Chapter 6 (Start)
The importance of critical reading
The quality of published information is variable
Info from research is used to make clinical decisions; we must check the validity and reliability
Critical review forces higher standards for research articles
Authors' recommendations for completing a good literature review
The best studies are the ones that compare and contrast different types of approaches, or ones that compare the effects of opposite groups, e.g. control vs treatment groups. Small sample size, is study applicable to your client?
Defined as: Repeatability of constancy of data
Control of variables (e.g. intelligence, age, etc)
quality and precision of measurement procedures (e.g. establishing a baseline, assessing generalization of skills vs learning effect)
Defined as: The appropriateness of assessment and observation in answering the questions posed by the study
Internal validity: the quality of control over variables. Most studies include a description of the participants' profiles.
External validity: how well the study and its results apply to the real world. Involves analysis of sample size, subject profiles/variables, and interpretation of results
Guidelines for critical review
Peer-reviewed journals are better
Review = both strengths and weaknesses
Be careful about info on the internet
Should receive training/practice in critical review of literature
Chapter 10 (Start)
Generalization and maintenance
Generalization consists of establishing new behaviors within different settings and with different communication partners over time
Maintenance is the last stage of therapy (and not generalization) is to make sure that whatever you’ve done with the client is maintained after you stop seeing them.
-Some regression of skills is natural
-Retention is not always automatic
-We must be sure that if we need to dismiss a client you must consider how to monitor a client to be sure that what they learned in therapy is continued
Generalization and maintenance procedures: Step 1
Select target behaviors that are likely to be used and reinforced in the client’s natural settings (and/or his or her family)
You may fail to teach your client skills that can generalize outside the clinic room if the parent is not reinforcing the behavior. For example, if you are using a picture-based system with a student and the family is not using it at home, then this system may be lost.
Generalization and maintenance procedures: Step 2
Begin to practice the target behavior within natural speech and language contexts (e.g., conversational speech or written narratives) as soon as possible.
You don’t necessarily have to go to the client’s natural context, but you can train people (OT, one-on-one aide, anyone else who works with student). This is because people who work with the student will also be communicating with the client and thus can address pragmatics, sequencing skills, intelligibility, etc.
Generalization and maintenance procedures: Step 3
Begin using an intermittent reinforcement schedule as soon as the target behavior has been established
In the beginning we give them positive reinforcement if they get it right, and give them immediate corrective feedback if they get it wrong.”Not quite”, “Almost”, “I heard that you made the ____ sound. Listen to me model and let’s try again.” When you’ve got the behavior fairly consistent, you want to start to use an interrmittant schedule, meaning you reinforce now and then or randomly per number of targets or per unit of time.
Generalization and maintenance procedures: Step 4
Use social reinforcers and a token system (i.e., conditioned generalized reinforcers) when possible; involve the parents (ask them what is reinforcing and train them to use the reinforcer)
Social reinforcers are the verbal reinforcers, “good job” or “correct”. This boosts the client’s confidence. Social reinforcers are the opposite of food reinforcers.
A token system is that the client must give the correct respond or show the correct behavior for a certain number of days to get a prize.
Generalization and maintenance procedures: Step 5
Establish association between the target behavior and various people and settings to facilitate generalization of skills)
For example, if you are working on the medial /th/ sound and you know your client’s brother’s name is Matthew, you should use that name. This answers the question, what words is the client likely to use? Refer to favorite movies, classroom curriculum, family, etc. Use material from the classroom and from the child’s home, so the child builds an association between the clinic and other environments.
Involve others (parents, classroom techers, one-on-one aides, etc.) to observe the sessions and attempt some of the activities and to complete some home activities. This the client begins to associate target behavior with people outside the clinic as well. Some clients may stop trying the target behavior outside the clinic.
Move the treatment outside the clinic (practice what the client will say, gradually increase physical distance bet yourself and client; increase complexity of the situation). We are more limited to do this because of limited time and resources.
Generalization and maintenance procedures: Step 6
Train parents to do as you do at home (i.e., to identify the error and its corresponding target, to elicit the behavior, and to provide appropriate feedback and reinforcement)
a) do not use technical jargon
b) model and provide many examples
c) provide parents with a copy of printed stimuli and directions
d) teach subtle ways to prompt; Often times students do not want a lot of attention brought to what they are working on, so if it is subtle and the student notices the cue, he will appreciate it if attention is not brought to his family.
e) teach the family how to provide corrective feedback
f) teach family member ways of increasing opportunities for communication (e.g., placing objects in sight but out of reach, presenting toys and foods bit by bit, and waiting for a response)
g) assess how the family is doing (through demonstration, audio and videotaping)
**Remember to take cultural differences into consideration when planning to train family members for home practice
Generalization and maintenance procedures: Step 7
Teach the client to self-monitor (i.e., to judge the accuracy of his/her own productions)
a) ask the client to chart their performance outside the clinic setting
b) teach the client different ways of using visual reminders/signals outside the clinic (e.g., a picture that cues the correct production of the target behavior posted on the client’s bedroom closet)
Generalization and maintenance procedures: Steps 8, 9, and 10
8. Teach the client to ask for reinforcement from others in the environment
9. Be sure to provide the client with sufficient treatment (e.g., assess correct production of the target behavior in naturalistic communication exchanges)
10. Provide booster treatment if the client experiences relapse (e.g., as in the case of some fluency clients)
Home Treatment Programs (Exam?)
Families strengthen behaviors a clinician has already establishes (client is taught the skills, client is stimulable, now client can work on it at home in an intervention program)
Families are trained to establish new behaviors under the guidance of clinician
Used primarily for infants who are at risk for developing speech and language delays or disorders (e.g. babies w/ hearing loss, cog impairments, syndromes)
Used also when services cannot be provided regularly by clinician (ex: If a family lives too far away)
A recommendation for a home tx program can be made only after the following criteria have been met (Exam?)
a) a thorough assessment of the client has been completed
b) the professional has developed a treatment program and assessed its effectiveness within a trial period
c) the parent has received sufficient training in implementing the home program and in keeping data
d) the professional has developed a plan for meeting with the parents form time to time to review data, assess progress and revise the program as needed
Follow-up assessments (Exam?)
An assessment of skills within conversational language or grade-level academic tasks (e.g., written assignments, reading comprehension)
A follow-up assessment should be scheduled before a client is dismissed from therapy
Usually the first follow-up is scheduled at three months post dismissal from therapy; the second is scheduled six-months later and third is scheduled one year after that
The purpose of the follow-up assessment is to test maintenance of skills and determine the need for booster treatment sessions
Chapter 2 (Start) Purpose of writing a clinical report
To inform the parent(s) and other professionals about the nature and degree of the delay/disorder, the recommended treatment plan, and the client’s progress
The language used must be understandable by the reader (i.e., contain minimal technical jargon and an ample number of examples)
Recommendations based on your impressions of what the client can and cannot do and what he may need to work on (this is not in the slide but she said it’s important). ex: Referral to counselor, assessment by OT, need for one-on-one aid in a mainstream classroom, the need for AAC device.
Writing skills are key: organization, content, and clarity.
Degree of severity: “Significant” is a term that insurance agencies want to hear. Average range, below average range, above average range Nature an type: Articulation, reading delay, phonemic awareness delay, voice disorder, fluency disorder, social-pragmatic difficulty, aphasia, traumatic brain injury. Recommendations: Could be to other professionals, not just SLP. Often include a statement about whether to continue treatment and if so how often and for how long Progress: A comparison of scores: pre- and post-treatment. Qualitative write-up of progress: whether the client continues to make the errors, whether the progress has been slow, or no progress at all. Whether or not the client has mastered the skill
General guidelines for writing a report
Use specific language, avoid ambiguous terms
Use a variety of language styles appropriate to the needs of the report, instead of stereotypical or standardized reporting.
Use specific accurate brief sentence, instead of verbosity.
Use language that conveys sincere professional attitude, instead of flippancy.
Use complete verb forms and correct punctuation.
Use positive statements that show what the testing has revealed instead of qualifiers and non-committal language.
Use personal pronouns when they convey a clear statement.
Use accurate descriptive language supported by fact.
Use the exact words to convey a concept or idea instead of misusing words.
Do use active verb construction when possible instead of passive verbs.
Write out the number one through nine, for numbers 10 and up, use digits.
General outline of a report
First sentence: _________ was referred to ____________ by ___________.
The second sentence reports the referral source.
The third sentences reports the primary concern and the reason for the referral.
The paragraph ends with a sentence that states the purpose of the report.
Chapter 8 (Start)
Defined as an agent of change…”a means of creating something that didn’t exist or changing something that did.”
As SLP’s, we create new behavior(s) or alter existing ones by presenting controlled stimuli, modeling or prompting a desired behavior, and responding to the behavior in a systematic way
To generalize skills to the client’s natural communication settings and partners, we train family members in all of the above
Basic components of treatment
I) Eliciting a target behavior
II) Establishing a new behavior
III) Increasing response frequency
IV) Strengthening and maintaining behaviors
V) Decreasing undesirable behaviors
I. Eliciting a target behavior: Providing Instructions
Guidelines for providing instructions:
Analyze the target behavior (e.g., how does it feel, sound, or look, when do you use it, why do you use it)
Break down the target behavior into smaller components (task analysis, objectives/benchmarks, prerequisite skills, shaping and approximation)
Use language that is comprehensible to the client (and/or caregiver)
Plan and rehearse the instructions
Provide the instructions in a natural conversational style
Check for comprehension
Repeat the instructions if the client does not understand
Provide new instructions when you change the plan
Analyze the error (e.g., /k/) and the target (e.g., /t/) and provide instructions
Provide instructions to a five year-old who omits the plural ‘s’; remember to show patterns and model instead of explaining the rules
Provide instructions for reducing vocally abusive behaviors
I. Eliciting a target behavior: Modeling and imitation
Decide whether to model live or to use a tape recorded model (what are the advantages and disadvantages of each?)
When appropriate (and possible), use the client’s own voice
Model often in the early stages of therapy, eventually fading modeling altogether
Reintroduce modeling each time you increase task complexity or when the client consistently fails to give a correct response
Request an immediate imitation
Reinforce a correct imitation
Model the target sound for a child who uses gliding
Ask a appropriate question and model a response for a client who substitutes the past tense with the present
Model an excessively high pitch and the target pitch for a female client with a hearing loss
I. Eliciting a target behavior: Prompting
Prompt: a reminder so it must be used before you elicit a target.
Guidelines for prompting effectively:
Provide a prompt immediately before or after the target response
As with modeling gradually fade the frequency of prompts to promote independence
Choose a subtle prompt
Train family members to use the same prompt outside the clinic setting
Note: visual prompts (as compared to verbal prompts) are more subtle (less intrusive) and easier to fade
Tactile – fade first
Verbal – fade verbal second – it’s more intrusive and interruptive
Visual – best, doesn’t interrupt client’s flow of communication
*Fading visual prompts and getting spontaneous production is easier than fading other types of prompts.
Explain how you would provide a hand signal for a client with a lateral lisp who is practicing generalization of skills to conversational speech
Demonstrate the use of vocal emphasis to elicit correct production of the personal pronoun within sentences
Explain the use of a visual prompt that reminds a stuttering client to use slow speech
I. Eliciting a target behavior: Using physical stimuli
Guidelines for using physical stimuli:
When appropriate, use pictures instead of objects
Ask client and/or caregivers to bring stimuli from home
Gradually fade the use of pictures and objects and increase the use of conversational speech in therapy
Use pictures to facilitate more complex expressive language skills (e.g., story retell, retell of a past event), but fade their use as soon as possible
Identify a toy you would use and a movement you would model for a client who has a limited inventory of nouns and is learning some basic verbs
Identify five pictures you would use to teach a client who uses stopping the target behavior
Identify five objects you might use to practice naming with an aphasic client
II. Establishing a new behavior
Successive approximations or shaping is reported to be an effective means of establishing new behavior
What is an example of a approximation of the correct /s/ sound for a client who speaks with a frontal lisp?
What is an example of an approximation of the correct use of the present progressive -ing for a client who produces the following sentence structure: “She walk”?
II. Establishing a new behavior: Shaping
Guidelines for shaping target behaviors
Analyze the behavior and know how to simplify it
Accept approximations in the beginning stages of therapy (even if you continue to model the correct response)
Gradually fade modeling an instructions
explain how you might manually shape the articulators for the correct production or the /u/ and /o/ vowels.
What is an acceptable verbal approximation of the high frequency word “dog” for a client diagnosed with DAS who has the following consonants in his phonetic inventory: /m,b,p,d/
III. Increasing frequency response
Is usually done through the use of positive reinforcement
A reinforcer must be something that the client finds motivating/reinforcing
The reinforcer may need to be changed from session to session
Reinforcers are of two kinds: a) primary (e.g., foods and drinks) and b) social or conditional (e.g., verbal praise, smile, pat on the back)
III. Increasing frequency response: Primary Reinforcers
Food and drink may be the most effective and sometimes the only reinforcers for some children
Schedule sessions during snack and lunch periods
If meeting with the client in a clinic setting, ask parents to refrain from feeding the child immediately before the session
Use healthy foods and drinks
Always ask about possible food allergies
III. Increasing frequency response: Token system
Known as a conditioned generalized system
May be quite effective for older children
Is a system whereby a certain number of tokens earned can be traded in for an agreed upon reward
*often used when patient doesn’t need immediate reinforcer but are working toward a bigger reward
*Used as part of a behavioral modification system
III. Increasing frequency response: Feedback
Immediate and accurate feedback can be a powerful tool for changing a client’s behavior (shaping a target behavior)
III. Increasing frequency response: Biofeedback
Provides visual information about the client’s production in comparison to a target production through the use of a device
Examples include Visi-Pitch, delayed auditory feedback, Video Voice, and Electropalatgraphy
EPG is very useful but very expensive - Requires building custom mode and uses electrodes to give feedback to the client regarding their sounds
IV. Strengthening and Maintaining Behaviors
Can be done through systematic changes in the reinforcement schedule (i.e., the use of a continuous schedule to establish behaviors in the early stages of therapy to the use of a variable reinforcement schedule to promote spontaneous productions and self-monitoring)
Establishing a baseline
Is a necessary first step in assessing progress (and the effectiveness of a treatment program)
Standardized assessment tools do not provide sufficient baselines; why?
To establish a reliable baseline, a sufficient number of behaviors need to be elicited
Baseline measurements need to be completed over a number of trials and/or within 2-3 sessions; why? *prioritize targets in terms of functional application for the patient
Number of target behaviors to teach
Depends on the following factors:
Most clients benefit from having structure in the early stages of therapy
Clients with a severe speech and/or language disorder also benefit from having structure in the session
Discrete trials (i.e., presenting a stimulus, asking a question to elicit a response, modeling, waiting for a response, and providing reinforcement and feedback) provide structure within clinical sessions
Probing for generalization
Generalization of a target behavior can be ‘probed’ by assessing its correct use within untrained stimuli and context (e.g., untrained position within a word or a more complex linguistic level)
When probing for generalization, do not model responses
The importance of data collection
“Data are your ultimate guiding principles” Data is used to determine whether or not a client is making progress, to evaluate the effectiveness of a treatment program, and to make the final decision of dismissal from services
Start with some data collection for first objective (perhaps 15 minutes), then move into more naturalistic interaction, then start data collection again when you begin a new goal. Do not stay on data collection the whole time
Chapter 7 (Start) Guidelines for selecting target behaviors
Can experiment with a few different targets before selecting one
Review past reports
Complete an assessment when necessary
Target functional skills
Target skills that may be reinforced in the client’s home environment
Target behaviors that expand the client’s existing communication skills (e.g., teaching verbs in preparation for expanding the client’s MLU)
Consider the client’s culture and primary language at all times
Selection of target behaviors
A target behavior is any skill you choose to teach a client
Some clients may have only one target behavior (e.g., correct production of all fricative sounds affected by a lateral lisp)
Most client will have multiple possible targets; address only a few at a time
Sequence targets and begin with those that make the biggest impact on functional communication skills
When creating goals ask yourself, “Does the client have the skills and concepts to do these tasks”, such as concepts of time that may be needed.
Complete task analysis and teach prerequisite skills when necessary (e.g., before addressing increased response accuracy to ‘where’ questions, determine if the student knows prepositions and other concepts of place)
Approaches to Target Selection
Two primary approaches include:
1) the use of age-based norms; remember to consider the client’s language age (e.g., with Down Syndrome clients). Focuses on cognitive age more than chronological age.
2) a client-specific approach that considers the immediate effect on the client’s individual communication needs as well as the client’s primary language and culture. Ask yourself, what does the client want and what is the immediate functional effect of the target?
Potential Targets - Articulation Disorders
Sounds not produced correctly - ask yourself which have the most neg impact on intellibility
Analysis is completed to determine type (i.e., substitution, omission and/or distortion) and frequency of error and the number of sounds produced incorrectly
clinicians are advised to learn about the child’s primary language to determine the appropriateness of potential targets; it’s important to compare and contrast the L1 and English phonetic inventories, sound positions, and sound combinations
Potential Targets - Phonological Disorders
Include simplification patterns used beyond expected ages (e.g., fronting, stopping, CR, FCD, gliding, and backing)
Clinicians can independently complete a voice, place and manner analysis, check for error consistency (e.g., how often the pattern is used and whether the pattern is consistent across word positions) when collecting a speech sample (and not relying on standardized assessment tool)
Children using multiple phonological patterns exhibit poor intelligibility (how does this compare with intelligibility ratings of a student with an articulation disorder?)
Choose 2-3 individual sounds that represent the class of sounds affected by the process
Choose a specific phonological analysis procedure (e.g., Cycles, Optimality Theory, developmental) when selecting the potential target(s) and deciding on their sequence
Choose words that are relevant to the client’s daily communication needs (e.g., foods, toys, activities, places, and people) and are highly motivating
Involve parents and teachers, when possible, in selecting a core list of words (e.g., as recommended within the Core Vocabulary approach)
Consider the client’s native language and culture (e.g., words related to American holidays may not be of priority)
Target concrete words (e.g., common nouns, verbs and adjectives)
Begin by teaching the combination of words the child knows
If the child speaks in one-word utterances, encourage the use of two-word utterances (children ma become overwhelmed when asked to produce simple sentences at this level)
Requests are often the easiest type of utterance to teach (they are often for something the child wants and therefore highly motivating)
Morphology and syntax
Should begin when the child can already produce phrases
Clinicians can use Brown’s stages of development to determine age-appropriate morphological targets (e.g., present progressive -ing, prepositions, regular plurals, regular past tense, and possessives)
Syntax can be taught through targeting additional morphological constructs such as questions and negative sentences
Take into consideration not just developmental norms but cultural and linguistic differences.
Examples: Turn taking, following directions, using convo repair strategies
In general, pragmatic targets begin in the more advanced stages of language development (exceptions include teaching children dx with Autism to establish joint attention and to seek an adult when making requests)
Functional units, also known as speech acts, include gaining attention, seeking or giving information, making a request, greeting others, responding to questions, following requests, initiating and maintaining a topic, turn taking skills and using conversational repair strategies when necessary
A behavior analysis perspective suggests that communication units are a cause-effect phenomenon; this perspective emphasizes the importance of understanding the antecedent event, the communicative behavior and the consequence;
How might this perspective be applied to target selection and development of the treatment program? Ex: If eye contact is something not important in a culture, you may not work on it.
Include reading and writing
The SLP’s scope of practice has expanded to include early intervention of preliteracy skills
Oral language skills are reported to have a strong correlation with later literacy development (there is also a correlation between a student’s L1 oral language skills and second language acquisition…)
Must consider prerequisite skills – such as, can the client see the letter, can the client connect the letter with a sound, etc.
What population of children are reported to be at higher risk for developing later delays in reading and writing skills?
Preschool children with oral language disorders.
Oral language skills are reported to have a strong correlation with later literacy development.