2.1 Participants

The study participants included Rehabilitation Council of India (RCI) certified SLPs working in India, having a minimum work experience of 2 years, who employed the telepractice mode of service delivery for children with ASD. Participants for this study were recruited using purposive sampling by reaching out to SLPs working in speech therapy clinics across various regions of India, through email and social media notifications. SLPs who were recently not working with children with ASD and trainee or student SLPs were not included in the study.

2.2 Procedure

The study protocol was reviewed and approved by the Institutional Research Committee and the Institutional Ethics Committee (IEC2:271/2023). The study was registered under Clinical Trials Registry-India (CTRI/2023/10/058440). A semi-structured interview guide (Appendix A) was developed and validated for the study, including two subject experts.

The contact information of SLPs engaged in telepractice was then acquired through professional associations, alumni contacts and speech therapy centres. SLPs practising in India were contacted through flyers on social media and professional groups. Interested SLPs were sent a Google form to get their details and preferred time for the interview. A purposive sampling method was used to recruit SLPs for the study. Prior to the interview, oral consent was obtained from each participant. They were informed about the study objectives, assured of the confidentiality of the information shared and were provided with the structure of the interview. After obtaining participants’ consent, the primary investigator conducted in-depth interviews via a virtual video recorded meeting, scheduled at their convenience. The interview was conducted using questions from the prepared interview guide. Based on the SLP's responses, additional probes were used to obtain in-depth information. Additional questions were asked based on the SLPs’ answers to confirm their response. Each interview lasted for approximately 35–40 min. All interviews were conducted in English using an online audio-video platform (Google Meet and Zoom), while the ScreenRec application was used to record all interviews.

2.3 Coding and Analysis

The data obtained from all interviews was analyzed using an inductive thematic analysis approach. The 6-phase steps of analysis were followed (Barun and Clarke 2006). The collected data was anonymized to ensure confidentiality and privacy. The video recordings obtained were reviewed and transcribed by the primary investigator. The transcripts were reviewed and verified by co-investigators for accuracy and reliability. The transcripts were carefully reviewed and an initial set of codes was generated. SLPs' statements were interpreted based on the context and codes that shared a common meaning were combined. The first and corresponding authors conducted independent coding of the data. The codes obtained were compared and any discrepancies were discussed and resolved within the research team, resulting in the creation of a final code list. Subsequently, themes and sub-themes were derived from the code list and further refinement was achieved through discussions with co-investigators. The results were interpreted through discussions within the research team. In the final presentation of results, participant identities were anonymized. Any personal identifiable information, such as names, workplace details or location identifiers, was eliminated throughout the transcription process. SLPs were provided with anonymized labels (e.g., P1, P2) in place of their names. All data files were password-protected and were shared only within the research team.

4.1 Online Platform/Tools Used

While most SLPs reported online tools only for telepractice, some of the SLPs mentioned the use of both online and offline tools in their practice. SLPs elaborated on their preferred platforms for telepractice, with Zoom, WhatsApp and Google Meet as the most used, with a preference for Google Meet. One of the SLPs said: ‘I was using Zoom for a very long time, but then we had the issues with, 40-minute thing and everything. Now I use Google Meet. So, there's no time limit. Even though I still… do prefer Zoom over Google Meet because of the way the screen share and everything was way handier and easier, but still, I switched to Google Meet, I think a couple of months ago’ P(16).

Few of the SLPs reported use of the WhatsApp platform for telepractice. ‘One. Google Meet am using. And WhatsApp video call can be used now. Now screen sharing is there,… Google Meet, usually these tools, Zoom only rarely. One or two times only I have used’. P(10)

SLPs discussed numerous online tools that aided in engaging children with ASD during telepractice sessions. One of the participants said: ‘We use bamboozle, boom cards of course, YouTube is great and if the child loves reading…there are many reading websites that we use for world stories and then we have this voots, voots is great we've been using voots for reading out stories and Twink is amazing for worksheets and resources and then we also have story books. Canada, world wall, story sequencing .there's something called as tiny tap. okay. so we use, and we use a lot of individualized resources’. (P11)

4.2 Handling Technical Issues During the Session

The primary challenges experienced by SLPs and parents were related to technical issues. Most SLPs concurred that telepractice relies heavily on a robust internet infrastructure for both SLPs and parents. Where one of the participants said, ‘I do sometimes because the other side also they need to have the internet right. There shouldn't be any network issues and the same with me. So that kind of technical issues happens occasionally, not always… Apart from that, not really. Yeah, like audio issues or any kind of network problems. Those are mostly the technical issues’ P(14).

SLPs reported that if technical errors occur, compensatory sessions or a home plan were provided. ‘At times, if the network is not working, they will send me a prime message saying that, no, I wouldn't be able to do a session as such because the network is not good. But we try to see if we can give that session the next day or just, give another shot for that session.’ P(1)

4.3 Selection of Goals

SLPs expressed varied approaches towards the selection of goals for telepractice sessions. Some SLPs focused on goals achievable solely through telepractice, while others incorporated goals suitable for both offline and online modes. One of the SLPs reported, ‘It's very child specific. I cannot say it very generically to that. Whatever practice I take for a traditional or an offline session, the same goals I will apply here, I think, I don't think there's any change in that. Specific to teletherapy that I'll take? Nothing’ P(16).

Some SLPs reported that goals targeted offline can also be addressed in online mode. ‘I think you can start at any of the goals that you want. As in, you whatever you are doing in the in-person session, same thing can be targeted online, whether it's communication, reception, expression, all of that. Narration, anything. I think all the goals can be targeted, same thing that you are doing in-person’ P(12). Some other SLPs stated that all goals may not be attainable through online mode, depending on the child. ‘I don't think all the goals we can achieve through telepractice. It's again, it's based on which states that kids are in’ P(7).

4.4 Duration of Each Session

Many SLPs discussed the session duration, indicating that prolonged telepractice sessions can diminish the child's attention span. Therefore, sessions were often designed with activities assigned for the child for a specified time, followed by counselling and parent interactions. Another SLP reported that initially sessions were shorter, gradually increasing in duration over time. Other SLPs believed that session duration was customized according to the child, allocating time for both the child and the parents.

4.5 Need for Parent Training

Most of the SLPs emphasized that training parents is crucial in telepractice, on various aspects such as managing the child, operating the online platform and using online tools during telepractice. SLPs emphasized providing parent training either in a separate session or by integrating it during the online session. ‘Yes, that definitely helps because they need to know when to do things. So, initially, during my session, I counsel them. So, what has to be done, how it has to be done, how they have to stimulate, they have to follow my instructions. Sometimes, I might not hear what the child says, they must repeat it. So, these are some instructions that I'll give them during the first session itself’ P(5). Parents received training even during the session, ‘But after talking to the parents, if the child needs and sometimes if the child is not going to sit, I would end up talking to the parents and doing the parent training program more’ P(12).

4.6 Relative Role of Clinician Versus Parent

SLPs stated that, in telepractice, both the clinician and parents play important roles. While the clinician's role remains equally important in both offline and online modes, the parents’ role is significant and may outweigh that of the clinician in online mode. ‘They have the most important role in telepractice. They are doing the therapies seriously. They are the people, you know, people who are putting that into action. We are just guiding them, and they are putting that into action’ P(13). Parent involvement is more online when compared to offline, as they need to be present with the child. ‘I would say mothers, the parents' involvement is required much more than the offline. Here because offline most of the time, if during the session, the parents might be sitting outside and we just give them the last five minutes and just explain what is being done…So online requires much more parent involvement because they have to be there during the session. They must understand what is being taught and they have to incorporate the same thing all throughout the week for the child for the benefits’ P(9).

4.7 Future of Telepractice

SLPs stated that technological advancements for telepractice, especially for the ASD population, necessitates further modifications. It is beneficial for SLPs to possess adequate knowledge of existing tools and employ them creatively. ‘See, I would, in that way, if you see the suggestions, it is difficult to source materials for online. So if there is a platform wherein you can get materials done for online therapy, not the offline ones, For online therapy, you can get the materials or games online, which is there for, you know, or you can maybe a website where you can design your own game, things like that, keeping the child in mind, because every child is different’ P(1). Online mode offers ample tools, which SLPs need to explore further. ‘Apart from that I'm not sure because already there's a lot of resources. there's a lot of things that we can do online already that is you know we have explored a few, there are a few yet to be explored’ P(3). ‘I think most of the clinicians or SLPs are not making use of the technology and they are even reluctant to try that out’ P(7).

An SLP suggested that a unified speech platform with multiple items simplifies resource access. ‘I think our very speech or language-based app or a platform specifically made for this would be a very good idea because that would be nice instead of us going to multiple websites or multiple areas and multiple resources to get what we are trying’ P(15).

4.8 Pros and Cons of Telepractice

SLPs believed that patients would benefit from telepractice. Potential advantages for patients include cost and time savings, increased access, reduced waiting times and greater parent involvement. ‘Pros are convenience for both parties, because the kids are nowadays more inclined to technology, most of them will really work, you can engage with a screen if the therapist is creative. I guess the time that they spent and, you know, the money they spent, the participant, for those who cannot access their sessions, something is better than nothing, right, especially in this case’ P(7). In addition to these benefits noted by the SLPs, there were a few challenges associated with telepractice for children with ASD. SLPs mentioned some of the challenges, including lack of physical contact with the child, technical issues, lack of awareness for parents, social interaction and generalization and sensory challenges. ‘Cons would be first thing they can leave the session anytime anywhere they want okay they'll just go out it's not like an off-line where the child runs and you can go and get the child… network issues if it is there. yes definitely that's a con…other thing is you can't give them a physical approach. that is another con more sensory approach we can just guide them the parents will require a lot more, so if we are for a sensory approach and things like that at times the materials won't be available with the parents you'll have to ask them to get some of the materials, maybe trampoline or play-dough or things like that so material wise, yes for sensory needs kids, that would be a con I would say’ P(1).

5.1 Need for SLP Training

Few SLPs stated that incorporating training during academic years for SLPs would offer more benefits. ‘So, I feel that training should happen there and that should happen from the clinical side as well as from the academic side as well. So, what they've been done in the academic side is going to be shown clinically and clinical side when they have done an online session, if the students can sit and observe and also take part in the online session, they will get an idea’ P(9). Some SLPs believed that creativity is more important than attending formal training for telepractice. ‘I don't think training is required. I think if you're just creative and if your goals that you're planning and your activities are on point, depending on the child, I don't think you need any special training to give telepractice’ P(16).

Other SLPs, not being aware of specific training courses, still acknowledged the importance of training for SLPs before engaging in telepractice. ‘Actually, I really would want but, no, I have no idea about anyone who is. We are all, I mean, most of us just learned it ourselves, but I think, it would be a great idea to have something like that’ P(15).

5.2 Choice Between Online and Offline Modes

When working with children with ASD, many SLPs preferred offline sessions due to the ease of handling the child, more hands-on and better control of sensory issues. ‘Because I always think like if she or he was like with me, or if they are sitting near me, I could handle him properly. But now they are not sitting with me. So, that is the only thing I felt’ P(8). The SLP further added ‘Actually, we can't handle the child because of the less resources. Then, the connectivity issues and the unawareness of the parent, and they uh…like they won't be much cooperative’ P(8). Another SLP reported that progress was much faster in the offline session than online session. ‘I look for effective practice and for progress to be seen more rapidly, I think direct therapies are more feasible actually. Through online therapy in my observation, the progress is very slow, since we have a low technological advance during the scenario’ P(6). Another SLP explained the choice based on the expected outcome, ‘But equally, the outcomes are seen. It's not like there's no outcome seen at all, or it takes time to see the outcome. Nothing that way. How you work offline, how you work online, outcomes are equally fine. It's the way you work’ P(1).

5.3 Clinician Satisfaction

Most of the SLPs felt satisfied with their use of telepractice based on the feedback received from the parents. ‘Hmm…I think around 60 to 70%’ P(1) also let us know why ‘because as I said few clients you just feel that you know they need a more in-person touch uhh…because tele-therapy (can't give you can't I wouldn't say) you can give it for all the ASD kids. If the child has a severe ASD or you know has a lot of behavioral issues with than it's difficult to manage online. They would want an offline first and then go for online… or they would want a more sensory approach first because to get them regulated and then for the online, just to work on few aspects’ P(1).

6.1 Criteria for Selection of Children for Telepractice

Some SLPs followed criteria for selecting children with ASD for telepractice, such as age or pre-linguistic skills as a criterion, ‘Generally, ASD children with better prelinguistic skills, they deserve a better improvement through telepractice. This is what I have observed and learned’ P(6). She further added, ‘Actually it would be more helpful, more successful if they come three years and after. Before two years it's okay, it's fine, no problem. It's very playful also, I have seen some cases, it's very nice’ P(6). Other SLPs preferred not to set any criteria for selecting children with ASD for telepractice. They were willing to work with the child through telepractice regardless of their condition or age, ‘No, uh.I don't have any. Before I used to, if you were asking me this one year back, maybe I would have said yes, I would want the child to have a little attention, maybe a little sitting tolerance and everything. But right now, I'm open with all the, like you know, I'm not considering any factors or any checklist, nothing’ P(3).

6.2 Frequency of Sessions

The majority of the SLPs recommended a frequency of two to three telepractice sessions per week for each child with ASD. These sessions are mostly scheduled on alternate days rather than consecutive days. Another SLP supports the idea that session frequency should depend on the child, noting that continuous sessions can lead to a loss of interest ‘It's based completely, it's maximum two to three, nothing more than that’ P(15) and added ‘It's alternate. I choose alternate because I believe that if they are continuous, they are going to lose interest, or it will get too boring for them’ P(15).

6.3 Rapport Building

A few SLPs discussed the approximate amount of time for a child with ASD to adapt to telepractice or to build rapport, emphasizing that this varies for each child. ‘Um…I would say it depends on the child's level. So maximum three, minimum two’ P(9). Adaptation also varied with each child and how well the child knew about the technological aspects ‘Uh…It all depends upon the child I would guess. See for some children who have got you know used to a tab or a laptop, they tend to get adapted much quicker… than children who are kind of new to technology. All of it, kind of varied. But I would say roughly maybe around three sessions or so, okay two to three sessions, they should get adapted because the children now are quite quick’ P(9).

6.4 Child's Ability/Skills

SLPs discussed the impact of various skills of children on telepractice, including minimally verbal children with ASD and those with behavioural issues. They emphasized the importance of parental involvement and the involvement of other professionals such as behavioural therapist or an occupational therapist. Additionally, they suggested incorporating more play-based activities and visually engaging activities. When it comes to a child who has behavioural issues, ‘In that case, all the parents should be along with it. We need the behavioral therapist's support for these children, and they need speech therapy also’ P(4). Another SLP added about scheduled activities for such children, ‘If the child is very restless, its difficult for the child to sit, breaking the sessions into smaller slots would be helpful,. So maybe just making the child to sit for 5 minutes and make him just, look at a particular picture or look at a short video, where he just has to,. look and then point or tell what he has seen and then have the session, you know, after a while. .giving shorter breaks, work on a certain, or part of the goal, till the point where his attention and hyperactivity reduces to a level where he can just sit for 10 minutes and then can work. And then the rest of the goals can be worked at home’ P(9). Non-verbal or minimally verbal child can primarily benefit from online AAC or online communication board, ;We can guide parents have parents’ involvement for those who are non-speaking. we can have AAC,. we can have different modalities, we can provide them or ask the parent to download it,. right positioning, location customization support, different modalities that the child will use AAC, maybe a white board or a communication board’ P(11).

6.5 Need for Breaks During the Session

Some SLPs reported providing sensory breaks during online sessions for the child, while others opted for continuous sessions with no breaks, although using engaging activities during the session. Majority of the SLPs provided breaks, although some did not. ‘Yeah for many children we do need to provide them sensory breaks, if the child, of course for autistic children we can't expect them to interact or sit for too long so we provide sensory breaks, asking the parents to. kind of take the child around, walk around, jump and get back. so of course there are breaks in between’ P(11) further added, ‘so 30 minutes–35 minutes with the child 5 minutes break and then with the parent’ P(11). Schedule based activities where breaks were not provided for the child, ‘Like three goals are like 15–15 minutes each divided. But we will not give up, if he gets frustrated or anything, we will leave for 2 minutes and come back. Or otherwise, we will do the continued session like 45 minutes’ P(10).

While other SLPs offered breaks only when the child became frustrated or bored, utilizing this time for counselling sessions with parents. ‘If needed, if I feel the child is getting too bored or is getting too disinterested or he doesn't want to do a certain activity, I try to insert certain interactive game or I give them… go for a break’ P(9).