'In the circumstances I think we've all managed really well' an exploration of the impact of the COVID-19 restrictions on a Child Development Advisor (Portage) Service.

Background: The Child Development Advisor (CDA)  (Portage) service provides developmental support to children with significant developmental delays and emotional support for their families through fortnightly home visits. However, the onset of the COVID-19 pandemic and subsequent restrictions imposed to control its spread prevented services from providing face-to-face sessions with families and caregivers, thus removing the CDA (Portage) service's primary means of supporting children and their families. This article aims to explore the impact of those changes on a team of CDAs.
Methods: Semi-structured interviews were conducted with six CDAs representing the CDA (Portage) service within one NHS Health Board. Findings: The CDAs expressed feeling an initial negative impact of the COVID-19 restrictions on the service, but in the longer term they noticed a number of positive impacts, including caregiver empowerment and improved working with other professionals.
Conclusion: Despite having their primary means of providing support removed as part of the COVID-19 restrictions, the service has been able to adapt to continuously support families and promote child development throughout the pandemic and inadvertently developed a service offer that may be more beneficial for both families and professionals in the future.

INTRODUCTION

The Portage approach

Portage is an early intervention approach that aims to promote the development of children aged birth to three with developmental delay, and support their families, using play‐based strategies (Shearer & Shearer, 1972). Child Development Advisor (CDAs) often have experience in child development or education, and may also have a background in Health support, such as an Occupational Therapy Assistant. Developmental delay is established through developmental assessment, as a basis for understanding a child's needs (Shearer & Shearer, 1972) The Portage service supports families through regular home visits, structured using the Portage Model (National Portage Association, 2019a, 2019b), which consists of three elements (see Figure 1).

Figure 1

The Portage Model (National Portage Association, 2019a) [Color figure can be viewed at wileyonlinelibrary.com]

Child‐led play

The CDA spends time observing and interacting with the child through play to develop an understanding of their strengths, interests and what motivates them.

Family focus

The CDA provides emotional support and promotes families and caregivers to take an active role in their child's development (Nunkoosing & Phillips, 1999).

Structured teaching

The CDA completes a developmental checklist through an observational assessment to establish the child's current level of development. This allows the CDA to set achievable short, medium and long‐term developmental targets with the families and caregivers and provide strategies to help the child move towards these targets in small attainable steps. The CDA will reassess the child every 6 months using the same checklist to identify developmental progress and set new targets.

The CDA uses play‐based strategies to promote development to ensure the child enjoys and engages with the strategies and sessions, while maintaining a structured teaching element to the sessions, teaching parents how to perform the strategies so that they can continue them when the CDA is not present. The emphasis on each element to the model will vary between sessions and families as the CDA will tailor each session to fit the current needs of the child and family.

Evidence base for the Portage approach

Research suggests that the Portage approach is effective in promoting child development. Kohli (1990, cited by Brue & Oakl, 2001), found children who had received support demonstrated a statistically significant improvement in all developmental areas (social, language, self‐help, motor, and cognitive), regardless of how long they had received Portage support. More recently, Sarouphim and Kassem (2020) found the Portage approach had a statistically significant positive effect on all areas of child development investigated (social, language, motor, sensory and exploration) when compared to the child's developmental abilities at the beginning of the study. In addition, Russell (2007) reported 82% of 136 parents who had received Portage support felt Portage was the most useful support service out of all the services they had received.

However, the individualised approach of Portage makes it difficult to develop empirical studies (R. J. Cameron, 1997). Brue and Oakl (2001) concluded their literature review expressing a need for more empirical studies that address the methodological issues found during their review, specifically a lack of control group. However, research has since attempted to address the concerns raised by Brue and Oakl (2001). Both D. L. Cameron (2020) and Liu et al. (2018) investigated the impact of the Portage approach compared with a control group and found the support had a positive impact on overall child development.

Qualitative research with CDAs and parents or caregivers can provide an insight into the wider workings of the Portage approach in promoting child development. For example, Nunkoosing and Phillips (1999) interviewed 12 CDAs and found the CDAs perceived themselves to adopt various roles such as friend and advocate throughout their support, which allowed them to develop strong relationships with families and work in partnership with parents when promoting child development.

Sarouphim and Kassem (2020) interviewed parents who had received Portage support and found some of the key benefits of the service included: emotional support for the parents, increasing the parent's knowledge around their child and providing the intervention within the child's natural environment. The researchers suggested these categories explained the improvements in child development. Overall, there is both quantitative and qualitative evidence of the effectiveness of the home‐based intervention method Portage provides. The current study will use a qualitative approach as it aims to fully capture the unique experiences of the CDAs throughout the COVID‐19 pandemic and how the restrictions impacted their service offer.

Impact of COVID‐19

The COVID‐19 pandemic had an unprecedented global impact, causing major disruption to daily life (Aishworiya & Kang, 2021). Over the course of a few weeks, the COVID‐19 pandemic forced the closure of most businesses and services and required people to ‘lockdown’ in their homes except for essential travel.

Impact of COVID‐19 on families

The COVID‐19 pandemic negatively impacted all families, regardless of their background or current situations (Cresswell et al., 2021), yet reports suggest that families of children with additional needs were disproportionately affected (Asbury et al., 2021; Neece et al., 2020), as support networks families relied on were disrupted (Asbury et al., 2021). In the #LeftInLockdown report, 76% of 4074 respondents reported they lost short‐break provisions and around half of all parents surveyed reported a reduction in ‘extra support’ (Disabled Children's Partnership, 2020), which forced parents to take on support roles for their child that even the trained professionals can find challenging (Asbury et al., 2021; Neece et al., 2020), all while adjusting to the COVID‐19 restrictions themselves.

The increased pressure on families led to an increase in parental stress levels (Neece et al., 2020) and parents reporting a decline in their mental health (Asbury et al., 2021). These findings are concerning both for the parents themselves, but also for their children's development, as increased parental stress caused by social and economic disruption can increase unhelpful parenting behaviours such as hypervigilance (Freisthler et al., 2021).

Impact of COVID‐19 on child development

The restrictions imposed by governments also restricted children's opportunities for developmentally stimulating activities to those available within the home. There were limited interactions with both children and adults outside children's own households and access to ‘routine but essential’ services was prevented or limited (Eapen et al., 2021, p. 9).

A report about the experiences of approximately 5474 UK families' during the COVID‐19 pandemic found that only 11% of children under two had received a face‐to‐face visit from their health visitor, a primary service for identifying developmental delays (The Parent‐Infant Foundation, 2020). An inability to diagnose children throughout the pandemic may have led to children missing out on crucial support, which could harm their developmental potential, as research has found links between commencement of early intervention and developmental outcomes (Aishworiya & Kang, 2021). The COVID‐19 pandemic may therefore have significant longer‐term impacts on child development, having prevented access to early intervention services.

However, a potential positive impact of the restrictions on social contact is that of increased caregiver‐child interactions. A report by Weissbourd et al. (2020) found that 68% of 284 American fathers reported feeling closer to their children due to the COVID‐19 restrictions, as they were able to spend more time with them. Active caregiver engagement has been shown to positively affect child development in areas such as play, language and cognition (Mahoney et al., 1998) and thus, increased time spent together during lockdown may have had a positive impact on children's development.

Impact of COVID‐19 on ways of working

When COVID‐19 restrictions were in place, the home‐based intervention services (and thus face to face contacts) provided by the current team were required to cease, and the team offered support through telephone or video consultations instead.

Video consultations have several benefits, including a reduction in travel time and costs for clients and clinicians (Kilvert et al., 2020; Olsen et al., 2012; Wherton & Greenhalgh, 2020), and increased appointment flexibility (Kilvert et al., 2020). They have also been found to be suitable for a variety of clinical appointments (Hammersley et al., 2019; Johns et al., 2020).

However, there are several problems with video consultations, with technological issues being the most frequently reported throughout the literature. There are a wide range of potential technological issues when using video consultation, including freezing, poor picture quality and audio and video being out of sync (Johns et al., 2020). Research suggests that the frequency of technological issues during COVID‐19 restrictions varied between 73% of 37 consultations (Kilvert et al., 2020) and 24% of 139 participants (Wherton & Greenhalgh, 2020). However, consultations could often continue despite issues. For example, Hammersley et al. (2019) suggested that 52% of 40 clinicians experienced technological issues but only 15% were forced to end a call due to the issues. Within Wales (where the current team are based), a report by Ofcom stated that 10% of the country do not have access to 4G and 3% of Welsh households do not have access to ‘decent’ broadband (Ofcom, 2020), suggesting that technological problems within Wales could be exacerbated due to issues accessing high‐speed broadband.

CURRENT STUDY

The current CDA (Portage) service and the families they work with experienced significant disruptions due to the COVID‐19 restrictions. With their service offer being forced online and the families they work with undergoing significant challenges, there was concern about whether the CDAs could provide the same quality service as in pre‐COVID times. It was hoped that a greater understanding of the impact of the COVID‐19 restrictions could allow the service to make necessary adaptations to ensure they could provide a high‐quality service both for the remainder of the pandemic and going forward.

Therefore, the aims of the current study are:

To understand the impact of the COVID‐19 pandemic on the service provided by the CDA (Portage) service and

To consider how to build upon this understanding when planning for the future.

METHODS

Participants

The current study used a case‐study design to gain an in depth understanding of the experiences of one Portage team. For practicality, a pragmatic approach to sampling was taken whereby all CDAs within a team associated with both researchers were offered the chance to participate in the study and all seven of the CDAs agreed to take part. One CDA subsequently withdrew from the study due to personal circumstances. Therefore, the final sample size was six, consisting entirely of females of White ethnicity, with ages falling between 40 and 61 years and over 47 combined years of CDA experience between them.

Procedure

Participants were given an information and consent form, outlining the aims of the study, their role, potential risks of participating and the measures being taken to minimise those risks. Once participants had signed the consent form, they were invited to participate in one semi‐structured interview. Throughout the study, the researchers adhered to ethical standards as outlined by the British Psychological Society (Carpenter et al., 2021) and ethical approval was obtained from the Aneurin Bevan University Health Board Research and Development Team before the onset of the study.

Interview structure

Interviews were conducted over the Microsoft Teams platform. To protect their confidentiality, each participant was assigned a code at the beginning of the interview (e.g., J6N). All participants were asked five core questions during their interviews. These were:

What did your work look like before the COVID‐19 restrictions?

How has the service you offer families changed as a result of the COVID‐19 restrictions?

What in this new way of working has worked well for you, for parents/carers, and for children?

What have been the challenges of this new way of working for you, for parents/carers, and for children?

Looking to the future, what will you take away from this time and what will you hope to leave behind?

Subsequent questions were asked based on participants' responses and each interview culminated with the interviewer giving participants the opportunity to speak freely about any matters related to the research question that interested them and potentially uncover previously undiscussed impacts.

Interviews were recorded using the ‘record meeting’ function on Microsoft Teams to allow both verbal and nonverbal content to be captured.

Analysis

The researchers used a thematic approach to analysis, as outlined by Braun and Clarke (2006) to analyse the interview data (see Table 1).

Table 1

Process of thematic analysis (Braun & Clarke, 2006, p. 87)

Each interview was manually transcribed and read through before both researchers met to identify an initial set of codes using one of the interviews. The researchers then separately analysed the remaining interviews by hand to pull out extracts and any additional codes. Finally, the researchers met again to collate the 28 identified codes into five broad themes (see Table 2).

Table 2

Breakdown of themes generated

Themes
Journey: Child Development Advisor	Journey: Caregiver	Relationships	Child Development	Productivity and Wellbeing

FINDINGS

CDA journey

Before COVID‐19 restrictions, the role of the CDA aligned with that outlined by the Portage Model (National Portage Association, 2019a) and Shearer and Shearer (1972). The CDA's highlighted the importance of using a holistic approach within Portage. As one CDA summarised:

Portage is more than going in, assessing and giving them toys ya know I think we're there, and we support the family, emotionally as well as *shrugs* everything else… help ‘em with their housing support letters, help ‘em with all other stuff um… th, that if they haven't got all those things sorted, they can't concentrate on their child anyway, there's other, bigger worries, going on that we help them with. (R3P)

The change to virtual working forced the CDAs to learn a ‘completely different’ (H9L) way of delivering their service, as they were suddenly denied the ‘direct, hands‐on’ (N3B) approach to promoting child development they had grown so accustomed to over their years as CDAs. They reported experiencing feelings of ‘panic’ and ‘terror’ as a result, referring to the initial few months as a ‘baptism of fire’ (A8U).

An area that caused particular distress was the sudden reliance on technology. Every CDA described a lack of technological skills in the beginning, with one CDA going so far as to refer to themselves as a ‘technology dinosaur’ (A8U).

They were also concerned about the service they could provide to families and caregivers.

I don't feel like I'm doing our job for the children and the families… I'm not giving them… what they deserve and what they could have. (H9L)

However, as the pandemic progressed, the CDAs appeared to adapt to the changes imposed on them. They developed creative solutions to ensure they could still provide the service.

with… some of my… children for instance, that when I'm sending strategies to the parents, um… through emails, that if I'm asking them to do a physical exercise… then I tend to email them a little video as well, to show them exactly what I mean. (A8U)

When referring to more recent times, the CDAs reported feeling much more confident, with one CDA going so far as to say the current way of working felt ‘natural’ (O4P). The increase in confidence also applied to their feelings regarding the use of technology. One CDA showcased the drastic change in attitude towards the use of technology, stating:

The IT was the killer for me (I: Yeah)… and I and I feel we're, I feel it's become a real… real bonus. (R3P)

Each CDA recognised there were benefits to both ways of working and expressed an interest in alternating between providing fortnightly face‐to‐face and virtual sessions.

you can still have that hands‐on input so you can just… show, be with… um advise… nurture… in the way that we always have done. But then also… back up, with this… and, ya know, reassure parents that they are doing the right things or the things that you want them to do, and if they're not *gestures* give them a bit of a shove, ‘come on! What did we discuss when we saw each other?’ (Y9C)

The most positively anticipated benefit a hybrid service offer would provide was that of flexibility. The CDAs discussed how video consultations would allow them to provide their service even if a home visit was not possible, for example, if a sister was ill or a CDA was unable to travel due to weather conditions.

The CDAs also believed they would apply some of the different methods of conducting their sessions once they returned to in‐person visits, particularly in relation to caregiver engagement. They expressed feeling more confident to ask families and caregivers to engage more within sessions and that they would place a greater emphasis on empowering families and caregivers as the primary teacher for their child.

Caregiver journeys

CDA accounts suggested that families and caregivers appeared to undergo a similar developmental arc as the CDAs. The CDAs described families and caregivers as being in a ‘pickle’ (H9L) in the beginning of the pandemic, focussing on getting through daily life rather than engaging with the service. Families and caregivers also had to take a more prominent role during sessions in the absence of the physical presence of the CDA, something many families and caregivers were not used to.

However, not all families and caregivers were able to engage with the new style of working. CDAs reported that while they would attempt to break down play strategies into simple steps, families and caregivers could struggle to understand the instructions, causing them to interact with their child in a different way to what the CDA originally intended.

it's really 50/50 split with a lot of parents, and we're talking and they can be quite educated they just still don't get it. (H9L)

The use of virtual sessions also amplified existing inequalities within the local region. CDAs struggled to provide a service for families and caregivers where English was the second language, particularly during the first few months when the CDAs were solely working from home and lacked access to interpreters. Some families also lacked the technology to engage with the service over a virtual platform. The CDAs reported a need for families and caregivers to have access to high‐quality WIFI for sessions to run without interruption. However, they explained some families and caregivers were unable to afford the packages required for effective sessions, and in some cases, were unable to afford a device with video facilities to engage with the service at all.

I mean if they're on benefits that is a heck of a lot of money, and they haven't got it! So, ya know what do they do? They just stick to having a mobile. (R3P)

However, the CDAs reported that as restrictions were eased and understanding of the virus increased, they were now able to bring families and caregivers into the Children's Centres in certain circumstances, such as the two outlined above, in an attempt to reduce barriers to engaging with the service.

Despite initial struggles, the CDAs reflected that the change in service delivery empowered families and caregivers to take a more active role in their child's development. They understood the CDAs could no longer come to their house and ‘fix’ their child (H9L) and therefore they had to implement the strategies to support their child's development. Consequently, families and caregivers not only began to actively engage with the service during sessions:

he never used to like singing to his child. But I'm finding on this sort of status, on screen, they're more likely to do it!. (R3P)

But also, they felt confident to experiment with new toys and strategies beyond what the CDAs had asked them to work on, knowing they could return to the CDA for advice or reassurance:

I often get messages on here with parents… um showing me the activities that they've found and asking would this be suitable? Or would that be? Or pieces of equipment that they find. (R3P)

Relationships

The swap to virtual delivery of the Portage service forced the CDAs to take a step back with regard to their input during the sessions. They discussed a change in the dynamic of the sessions, with one CDA claiming their sessions now were more like ‘consultations’ with families and caregivers (O4P), as opposed to interactive sessions.

There were mixed views about the impact this change in service delivery has had on the ability to develop relationships with the children. One CDA suggested there had been a negative impact on the development of relationships, stating:

you don't get anywhere until the child is relaxed and smiling with you, comfortable with you, will come and sit with you or anywhere near you, depending on their presentation, and um *frowning* that's definitely changed, and it does, it's a *gestures barrier* barrier. *Remains frowning* It's very much a barrier… (Y9C)

Meanwhile, another CDA's account of their experiences with a particular child suggested there is still potential to develop a relationship with children over a virtual platform. They stated:

Soon as she comes on the screen she's, beaming and laughing… waiting ya know she knows, knows what's coming and she's really waiting… to interact and join in. (O4P)

Another area that produced mixed views from the CDAs was that of their relationships with the families and caregivers. Some CDAs expressed concerns about their ability to develop a strong relationship with families and caregivers over screen, particularly due to the inability to physically provide emotional support.

you do miss a lot and the personal touch and um being with in presence with someone is… much more *looking around* um you can get much more from it than over the video. There there there it's a barrier I'd say. (H9L)

Meanwhile, others felt they were still able to provide emotional support for the families and caregivers over the virtual platform, claiming families and caregivers were potentially more willing to ‘open up’ (A8U) over the screen.

A reccurring theme throughout the interviews was that the CDAs were able to provide consistent support for their families throughout the pandemic.

parents obviously know if there's anything significant they text me and I ring ‘em anyway *smiles*’. So, they've still got me at the end of the line. (R3P)

The use of virtual working also appeared to impact on the CDA's relationships with other professionals. According to the CDAs, there was an increase in multidisciplinary (MDT) working since the implementation of the COVID‐19 restrictions due to virtual meetings being easier to schedule into their days than in‐person meetings.

it's a lot easier to… click on to… ya know on screen. Whereas if you had to drive, leave an appointment, drive there, you wouldn't necessarily have time… to attend and fit all those things in. (O4P)

However, the use of virtual meetings also appeared to negatively impact the quality of professional relationships as it prevented the CDAs from ‘chatting’ more informally with other professionals and picking up on more subtle, nonverbal cues in meetings.

Throughout the interviews, the CDAs reflected on how MDT working allows them to deliver a higher quality service.

you actually get the real professional that's in with you… so I don't have to practise that bit myself, I can concentrate on some of the things like play. (A8U)

Child development

The CDAs expressed strong concerns about their ability to complete accurate assessments over the virtual platform, as part of their assessment process involves observing the child. They found they were unable to pick up on the subtle cues over a video session for several reasons, including delays in the technology and the child moving off screen.

if you're with a child, you're with that child. And you are watching every bit of it… or every bit of the child… Whereas… *wagging finger* over the, screen, ya know they've *extends arm* shot off… and you can't see what they're doing, and their mum will tell you what they're doing and then *gestures turn* turn the phone round and it's all over and done with and you've missed it. (Y9C)

The issue was particularly prominent over telephone calls, where the CDA had to rely on caregiver's accounts to complete their assessments, with one CDA saying that the experience was

like working with your hands tied behind your back kind of blindfold on a bit. (Y9C)

The true extent of the impact of the COVID‐19 restrictions on completing accurate assessments became apparent when the CDAs were able to begin video consultations instead of telephone consultations. They found what families and caregivers had been describing over telephone calls to be ‘quite different’ (N3B) to what they were able to observe over the video. Similarly, once the CDAs were able to invite certain families and caregivers into face‐to‐face meetings, they described feelings of ‘shock’ when observing the child as they presented differently to how they had been described.

Every CDA expressed their concerns about the impact of the COVID‐19 restrictions on children's development, specifically their social development. They discussed how there had been a lack of opportunities for children to interact with people outside of their household, which may have negatively impacted their social development.

a lot of children are coming in… um… being described as having Social and Communication problems, not giving any eye contact, not having any social development, and I wonder whether that's…. um because they haven't had that social contact. (A8U)

However, the CDAs acknowledged that there have been some positives to the COVID‐19 restrictions on child development. They found the restrictions had meant families and caregivers spent a ‘really concentrated length of time’ (H9L) with their children, and consequently families and caregivers had a greater understanding of their child's development and more time to practise strategies between sessions. Where this was the case, the CDAs felt the children had been able to develop as much, if not more than if they had received the service before the COVID‐19 pandemic.

Productivity and wellbeing

One positive consequence of the transition to virtual working was a significant reduction in travel time. Instead of spending a large portion of their day travelling between homes, the CDAs only had to travel to their office for the day or work from home. They felt this reduction in travel time allowed them to spend their time more efficiently and fit more into their working days.

The nature of the COVID‐19 restrictions also meant families were more accessible for appointments, with less families being ‘out’ and inaccessible during their scheduled appointments.

if they're not there, uh a home visit that's it I ring them, if they've gone out somewhere that's, whereas now if I ring them they're normally about, they've maybe just forgot or they've got a technical problem we can guide them to get them onto that appointment. (N3B)

Also, the CDAs commented that now they were able to continue working while they waited for a family to appear, whereas before the time would have been ‘wasted’.

Even if parents *shakes head* don't turn up for visits, on an Attend Anywhere ya know you can be getting on with something else… Whereas actually if you turn up at the home and they're not there it can be a complete and utter waste… of a whole hour. (A8U)

However, the CDAs frequently discussed occasions where their sessions had been disrupted or cancelled due to technological issues.

you can see a slight pause. And sometimes *leans in* you're watching very carefully what a child is doing *smiles*, if they're putting one brick on top of another, and you can actually… miss the actual action in a split second and not have seen it. (A8U)

While the technological issues were often resolved, one CDA claimed it was ‘hit and miss’ whether this was the case. When the CDAs were unable to solve the issues, they were forced to conduct their sessions over telephone conversations, a medium that was unanimously agreed to be unsuitable for the service as it did not allow the CDAs to see the child they were working with.

The COVID‐19 restrictions also meant that the CDAs were asked to work from home for the first time. Despite initial reservations, many of the CDAs reported working from home having a positive impact on their productivity and wellbeing, citing a lack of distractions and reduction in travel costs.

However, the positive response to working from home was not unanimous. A minority of the CDAs reported how working from home had negatively impacted on their productivity and wellbeing, citing the lack of clear boundaries between work and home life and the lack of an appropriate working space.

I look at the mountains as I'm driving home and its just like works done and now I'm gunna be home and that's lovely. And when you're just walking from the spare room, downstairs its grim!. (H9L)

Feelings of isolation were also reported by the CDAs due to working from home. They discussed how their jobs were naturally quite isolating and spending time at their respective place of work was often how they communicated with other professionals, and how they missed this element of their jobs.

you can become insular in your one area, and then if you're just working from home or if you're not meeting as a team I think that, that could possibly exaggerate. (H9L)

DISCUSSION

The aim of this study was to explore the impact of the COVID‐19 restrictions on the service provided by the CDAs. Previous reports showed that the COVID‐19 restrictions disrupted many families and caregivers' access to support services (Disabled Children's Partnership, 2020), however, the CDAs continued to provide an adapted service throughout restrictions.

The CDAs highlighted a negative impact on service quality within the first few months. Families were overwhelmed by the changes to daily life caused by the COVID‐19 restrictions (Asbury et al., 2021) which decreased their ability to engage with the service. During sessions, families and caregivers struggled to participate as they were forced to take on many aspects of the role of the Portage worker without prior training (Neece et al., 2020).

The dramatic change in service delivery also caused the CDAs to lose confidence as they adjusted to losing their primary methods of engagement. They felt they were unable to conduct accurate assessments over a virtual platform, particularly when using telephone sessions, where they were unable to observe the child and provide strategies tailored to the child's interests and strengths. Inability to complete accurate assessments may have resulted in inappropriate developmental targets being set (National Portage Association, 2019b), preventing the child from meeting their full developmental potential.

Yet, as the pandemic progressed, the CDAs and the families and caregivers they worked with adapted to the changes and developed solutions to initial problems. Families and caregivers were empowered to take a more active role in their child's development, both in and outside of sessions and the COVID‐19 restrictions allowed families and caregivers to spend more time with their children (Neece et al., 2020). The NPA Code of Practice (National Portage Association, 2019b) and Shearer and Shearer (1972) emphasises the importance of empowering families and caregivers to take a proactive role, and research has highlighted the benefits of active caregiver engagement for child development (Mahoney et al., 1998). Therefore, the changes may have positively influenced the quality of the service delivered by moving the service closer to the original Portage guidelines.

An area of interest going into the study was the impact of the increased use of technology, with the literature suggesting that there were several benefits and issues to using video consultations (Hammersley et al., 2019; Olsen et al., 2012). There was a concern technological issues would be more prevalent and disruptive during sessions. However, while there were reports of technological issues interrupting sessions, there did not appear to be significant concerns from the CDAs that technological issues prevented them from delivering their service. These results align with previous research that suggests, while technological issues may negatively impact client satisfaction with the service received, they do not prevent the service from being delivered (Olsen et al., 2012).

A concerning trend that emerged from the interviews was that of a digital barrier to accessing support. The CDAs made claims in line with previous research that a high‐quality internet connection was required for virtual consultations to be effective (Johns et al., 2020; Olsen et al., 2012), yet not all the families they worked with had access to basic, let alone high‐quality internet. The sole use of virtual consultations, therefore, resulted in some families being ‘cut‐off’ from accessing the service (Aishworiya & Kang, 2021), and potentially worsening health inequalities (Blackburn et al., 2020).

A positive impact of the increased use of technology is the opportunity to expand the service offer. The CDAs acknowledged that virtual working could not replace home‐based visits but expressed a desire to continue using virtual consultations alongside in‐person visits once the COVID‐19 restrictions are lifted. They felt a mixture of virtual and home‐based sessions would allow them to provide a higher quality service than a purely home‐based service offer, as it would allow them to assess the child and model strategies, while still empowering families and caregivers to take a more active role in their child's development. Overall, the findings suggest that the use of technology within the service offer will be beneficial for the service families and caregivers receive. However, consideration must be taken for those with limited access to technology, and alternative offers should be provided.

Technology can also be used to increase multi‐disciplinary team (MDT) working (Eapen et al., 2021). The CDAs were able to fit more appointments and meetings within their workdays and reported feeling more connected with other professionals within their workplace as they no longer had to spend large amounts of their day travelling. Increased MDT working can increase knowledge transfer and communication about children between professionals, improving the quality of care they can deliver (Ndoro, 2014). Going forward, a similar hybrid approach can be taken towards MDT working, whereby a virtual option is included for meetings so that more professionals are able to attend meetings regarding the child and professionals are able to receive the social contact needed to prevent feelings of isolation.

LIMITATIONS AND FUTURE RESEARCH

The current study captured the views of a small team of CDAs within one area of the United Kingdom. The small sample size and variations in service delivery between counties mean study generalisability is limited. Future research should aim to gather the perspectives of a larger number of Portage workers from a wider range of areas to gain a more detailed understanding of the impact of COVID‐19 on the Portage approach.

Johns et al. (2020) found that, in general, professionals had a more negative outlook on the use of virtual working than patients. Therefore, it is important to capture the views of families who received Portage support during the COVID‐19 in future studies to capture a more balanced viewpoint on the impact of the restrictions.

Where possible, future research may also wish to capture the viewpoints and experience of the children who received Portage support to assess their understanding of the support they receive and what aspects they found most enjoyable.

The implementation of a hybrid approach may present unique and potentially unforeseen challenges. Further research should explore the practicalities of adopting a hybrid Portage service offer.

CONCLUSION

The COVID‐19 restrictions significantly impacted the way the CDA service was delivered. This paper aimed to highlight the challenges faced by the CDAs during this pandemic, as well as how the changes made during the COVID‐19 pandemic can be used as a catalyst to enhance the Portage service offer going forward. The use of video consultation has proven to be effective in the Portage service, empowering families and caregivers to take a more active role in their child's development and allowing greater MDT working. However, the CDAs made it clear video consultations alone are not sufficient as they can lead to inaccurate assessments and risk poorer working relations. Going forward, it is suggested that a hybrid approach should be taken within both MDT working and session delivery, whereby the benefits of both video and home‐based services can be combined to provide a higher quality service offer than before the COVID‐19 pandemic.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.