Exam 3 Flashcards
Treatment is:
- Application of variables that change behaviors
* What the clinician does, not the client.
Sequence of Treatment Components:
o Stimulus
o Response
o Reinforcement
• Short-Term Objectives:
o Things that can be trained in a relatively short period of time.
o Semester, such as on our treatment plan
o Hospital setting: few days, week
o Measurable, Objective
o So that you can chart their progress in tx
o Response recording is important so that you have the data to back your goal.
o Observable behavior
o Avoid words like think, assess
• Long-Term Goals:
o More broad
o What you want to achieve by the time they discharge
o Age appropriate communication skills
o Will always be changing
o Articulation or phonological skills that the child is expected to learn by the end of a specified treatment period (i.e., semester or year)
o STG help support the LTG
o Ultimate LTG:
Maintenance of the trained skill in the client’s natural environment across varied settings or situations
• Short-Term Objectives must address:
- Actual skill you are targeting
- Response mode: either production or discrimination
- Response level: word level, sentence level, convo level
- Quantitative criterion: 80% accuracy, etc.
- Setting: clinical, classroom, home, structured therapy setting
- Number of sessions: across three sessions
• STG for individual sounds:
o The client will produce the /s/ and /z/ phonemes in single words with 90% accuracy across 3 structured clinical therapy sessions.
o The client will produce the /r/ phoneme with 85% accuracy in conversational speech at the clinic, at school and in the child’s home across three speech samples
• In treating phonological skills, the goal may be:
o To eliminate certain phonological processes so that unstable word forms are eliminated
• Unstable word forms: ex: Save, sake, take, tav produces a variety of word forms for the same word.
o The child will decrease the PP velar fronting by producing k and g by with 80% accuracy across 3 structured clinical therapy sessions.
o Homonomy: Producing two words exactly the same, no contrast between the two words.
• STG for phonological skills:
o The client will reduce his use of final consonant deletion by producing /p/, /k/, /t/, and /m/ in word final position at the word level with 90% accuracy measured across three clinical sessions.
o The client will establish contrast between singleton and consonant clusters by producing the following /s/ + stop clusters in the initial word position with 80% accuracy measured across three consecutive sessions: /st/, /sp/, and /sk/.
Selecting the Initial Level and Sequence of Training:
- Generally, the higher the complexity you can start at, is most efficient.
- However, you don’t want to start too complex where the child will shut down and become frustrated.
- Take into consideration the child’s individual needs
- Look at each child and make sure the behaviors you are targeting are beneficial, meaningful in their home environment.
Hegde & Davis (2005) make the following recommendations:
- First, select behaviors that will make an immediate and socially significant difference in the communicative skills of the client.
• Social communication
• Academic achievement
• Occupational performance
• Includes sounds that are used highly in vocabulary first to improve speech intelligibility faster. - Second, select the most useful behaviors that may be produced and reinforced at home and in other natural settings
• Reinforced in the home. - Third, select behaviors that help expand the communicative skills
• Phrases and sentences that can be easily expanded. - Lastly, select behaviors that are linguistically and culturally appropriate for the individual client
• Find out what vocab is used culturally, pragmatics, language structures.
One criterion is to select treatment targets according to Developmental Norms:
- Select “age-appropriate” speech and language skills
- Target sounds that the child is misarticulating that are produced by younger, normally developing children first
- Treatment of sounds should follow from earliest-to-latest acquired sounds
- It is generally considered unwise to select sounds that are mastered at older ages than the child’s current age
- It has always been believed that skills mastered chronologically earlier are simpler than those acquired late
- Normative sequence of skills acquisition may be inviolable
- Individual sounds expected to be mastered by the age of the child, but which the child has not mastered, are targets
- Phonological processes that disappear by the age the child has attained but have persisted are targets for elimination
Problems with Normative Criterion:
- Children learn phonological skills at varying rates
- Individual differences are important
- A child’s unique and individual needs may not be met if developmental norms were used exclusively
- It is important to remember that developmental norms are a statistical representation of the average performance of an entire age group so don’t base treatment target selection solely on age-appropriateness
Select More Readily Taught Treatment Targets:
- Initially select targets that are easier to teach
- Treat targets that do exist, but not at the expected levels
- Sounds that have a low base rate of correct production should be treated first (between 20% & 40%)
- Treat sounds that are produced with visible articulatory movements (i.e., bilabials)
- From a phonological processes standpoint, treat processes whose frequency is less than 100%, processes that only occur in certain phonetic contexts, and processes that affect sounds that the child produces correctly elsewhere; treat unstable or inconsistent processes.
- Hodson & Paden (1991) recommend that if the frequency of a phonological process is less than 40%, it should not be treated
Reasons for treating sounds stimulable sounds or inconsistent sound or processes is:
- Initial treatment sessions may produce faster results
- Strengthen what is already taking place in the speech of the child
- Only problem: if the targets treated do not result in generalization to untreated error sounds
Select Targets That Produce Extensive Generalization
- Generalization is an indirect behavioral effect of tx.
- Generalized productions are a treatment goal, and positive changes in sounds not treated save much time and training effort
- An example: treating a few fricatives with generalization to the remaining fricatives without additional treatment
Select Targets That Affect Intelligibility The Most
- Select targets that affect speech intelligibility the most in children should be the initial treatment targets
- Select a phonological process that occurs frequently or the one that affects a large number of sounds since they might significantly reduce a child’s intelligibility
- Select treatment targets that result in homonymy (replacement of a single word for multiple words, resulting in loss of meaning)
- Another recommendation is to select any unusual, deviant, or idiosyncratic process (i.e., velarization, frication of stops or glottal replacement), which result in rapid improvement in intelligibility of speech
- Another recommendation: treatment should simultaneously target multiple sounds
- There is some limited evidence that when the treated words are of high frequency, better generalization may be obtained as opposed to the treatment of low frequency words
Summary of Guidelines on Target Behavior Selection
If immediate success in initial treatment sessions is more important than generalized effects, select as treatment targets:
- Easier to teach
- Stimulable
- Visible
- At least produced inconsistently
If the child can tolerate a somewhat delayed success in initial treatment segment that may result in more immediate generalized productions and marked positive effects on speech intelligibility, select:
Complex sounds that are produce consistently in error
- Non-existent in repertoire
- Processes that affect a greater number of sounds
- Processes that are idiosyncratic
- Reduce homonomy
- Processes that are exhibited in 100% of opportunities
- Phonemes that contain maximal phoneme feature contrast
- Sounds that contain multiple phoneme feature oppositions
Regardless of the initial success or generalization considerations, select:
Ethnoculturally appropriate
- Sounds that are in the child’s dialect
- Sounds most frequently used in the child’s language or home environment
Regardless of the target behavior selection strategy chosen, you should assess the effects of just completed treatment on untreated but potential targets
always be probing in therapy as they are getting success in therapy.
Deciding the Number of Sounds or Patterns to Teach at One time
- Motivation
- IQ
- Home Support/family support
- More targets you can target at one time the better
- If they can handle it target 4 or 5 at one time, if overwhelming, back down.
- Also know how much time you have, individual therapy is different than group therapy at school.
Planning & Developing a Treatment Program
- Prior to starting therapy
- Hospital: built into dx report
- Schools: IEP
- Clinic: actual PP
components of a TP:
- Identifying Information: name age address background
- Targets you will select in therapy
- General procedures, tentative sequence of training
- Listing goals
- May include dismissal criterion possibly
- Follow up
- Will vary based on place
Establishing Baselines
• Baselines: measured rates of behaviors in the absence of treatment
o First session gather baseline
o Will need to chart progress
o Get quantitative information, what level you are looking at first.
o Will help you establish accountability with yourself, with third party payers
Baseline Procedures: change numbers
1. Specify Treatment Targets in Measurable Terms: clinician must have a clear idea of what the intervention targets are before their baselines can be established—STG • Specify at what level (word level, etc.) 2. Prepare the Stimulus Items: • 20 items per target sound • Can also use these later in treatment • Make sure you document cues given 3.Prepare a Recording Sheet: • Record results • Good recording sheet that you can plug in whatever target you are working on 4. Administer the Baseline Trials: • Evoked procedures • Carrier phrase • Modeled trials • +/- • Gather a percentage
Treatment Continuum: 3 main steps
• Establishment:
o Teach the sound
o Elicit the target behavior
o Stabilize at whatever level you are at
• Generalization:
o Carrying over to different levels of complexity, different word positions, other situations, other sounds of the same process
• Maintenance:
o Stabilize or maintain retention of the behavior you taught
o Frequency or duration of therapy will lessen and decrease
o Client will take on self-monitoring role
Motor Learning Principles
Speech is a motor skill, start at a simple level and build on that.
Critical features in motor skill development:
3 main areas*
• Cognitive analysis:
o Client is able to understand mentally the placement of sounds, discriminate the right production and incorrect production.
o Learner’s ability to mentally evaluate their production.
• Practice: key variable thought necessary for mastery of any skilled motor behavior
o Artic is all about drill
o More reps the better
• Feedback: of great importance in the early development of a skill; as the error response is diminished, feedback becomes less important
o Tactile
o Verbal
o As they progress, feedback will decrease.
Clients who enter the treatment continuum at the establishment phase include:
o Have in repertoire but cannot produce in convo speech
o Those who do not perceive minimal pairs
o Those who have trouble with discrimination
o Those who produce a sound on demand but cannot produce in convo, syllable level or beyond. (Such as apraxia).
Discrimination/perceptual training may be used prior to direct production training
o Controversial
o Pair with production training
Production Training
4 methods commonly employed to establish production:
Imitation
Phonetic Placement
Successive Approximation
Contextual Utilization
Production Training: Imitation
• Imitation: initial instruction method for production training
o Look at you and do what you do
o Sound feels, looks
o Use auditory, visual and tactile cues that you can.
o Incorporating a mirror is helpful.
o May want to incorporate an auditory trainer
o Signal-Noise Ratio increase is good
o Incorporate a tape recorder to play back their production
Production Training: Phonetic Placement
• Phonetic placement:
o Using tactile cues, instruction to explain where to place articulators in mouth, getting in their mouth
o Mirror
o Mouth model
o Picture of mouth
o Sitting side by side
o Start with mouth gymnastics-oral motor placements
o Straw: Lateral lisp: move the straw around and wherever the sound is amplified is where the sound is leaking, useful for auditory feedback. Stabilizing the jaw
o Tongue depressors: pointing out placement
o Lemon swabs: tart swabs feedback
o Kool Aid or Fun Dip: placement
o Cheerio: hold it up on the alveolar ridge
o Peanut butter
Phonetic Placement: Successive Approximation
o Shaping a new sound from one they can already produce.
o Identify a sound that is similar t and s
o Graded steps: Ex:
Shaping for teaching /s/:
• Make [t]
• Make [t] with a strong aspiration on the release
• Prolong the strongly aspirated release
• Remove the tip of the tongue slowly during the release from the alveolar ridge to make a [ts] cluster
• Prolong the [s] portion of the [ts] cluster in a word like oats
• Practice prolonging the last portion of the [ts] production
• Practice “sneaking up quietly” on the /s/ (delete /t/)
• Produce /s/
• Also see examples from conference: stabilizing the sides of the tongue by beginning with I
Production Training: Contextual Utilization
o Deep testing
o After you have done assessment
o Any context that they can accurately produce the sound
• Lets say the child can accurately produce /s/ in the context of the word-pair “bright-sun” where the /t/ may be a facilitative context:
• Ask the client to say “bright sun” slowly and prolong the /s/
• Next ask the client to repeat “bright-ssssink, then hot-sssssea; other facilitating pairs may be used to extend and stabilize the /s/ production
• Ask the client to just say /s/ without the “lead-in”
• Rebecca example from conference
Things to note:
- Correct consonant productions may be observed in clusters when absent in singletons
- Curtis and Hardy reported that more correct responses of /r/ were elicited in consonant clusters than in consonant singletons.
- Williams reported when teaching /s/ in clusters, the sound generalized to /s/ in singletons
- Hodson supports this idea by suggesting the targeting of /s/ in clusters during treatment has the potential to facilitate widespread change within a child’s phonological system
Increasing & Strengthening Established Behaviors:
• Select potential reinforcers in initial treatment sessions until the reinforcing value is known
o Positive reinforcers:
events that increase the future probability of that response.
o Negative reinforcers:
responses that remove, postpone or reduce an aversive behavior.
o Primary Reinforcers:
those that do not rely on past learning. Ex: food, candy. Good initially, but not well continually and may not be preferred with the family. Works well with the beginning stages of therapy, the young, or intellectually disabled. Problem: not a natural consequence or something they will get outside of the treatment room. Should also be accompanied with a social reinforcer. Talk to the parents to find out what they like or what they are allergic to.
o Secondary reinforcers:
events or actions that increase behaviors because of social or prior learning. Needs to be immediate. With speech therapy, needs to be quick reinforcement and effective, but don’t spend a lot of time with the reinforcement.
Types include:
Social Reinforcers
Conditioned generalized reinforcers
• Social reinforcers:
eye contact, facial expression, and verbal feedback.
• Conditioned generalized reinforcers:
tokens, stickers, check marks, play money, and beads. Immediately give.
o Informative feedback:
lder, motivated, girls, competitive, you can show the chart to give feedback.
Schedules of Reinforcement
is the frequency with which the reinforcers will be delivered
Two Types
Continuous Reinforcement
Intermittent Schedule
- Continuous reinforcement:
Primarily, initially during therapy. Every correct production is reinforced. 1:1 reinforcement schedule.
- Intermittent schedule:
Ratio schedule:
b. Interval schedule: Period of time that goes by before you give reinforcement. Good for speaking rate and vocal quality, not so much speech sounds.
c. Fixed ratio (FR) schedule: Every 2 correct productions or every 4. After the sound is established, the reinforcement is backed off.
d. Variable ratio (VR) schedule: Constantly changing the amount of correct productions that receives a reinforcement. Can be an average of 5.
e.
Goal:
to wean the child off of the reinforcement. Generalization and carryover
Considerations regarding positive reinforcers:
- Do not assume the same reinforcement is going to work for all children
- Also do not assume that if it works one time that it will work every time.
- Immediate
- Eye contact don’t be looking down at your response sheet
- Unambiguous manner so that they know exactly what you are reinforcing
- Make sure reinforcement is very enthusiastic, they will relay on you verbal expression and gestures, keep the energy up with the child.
- Be consistent, true to your word and follow up on your promises
- Make sure the child knows why they are being reinforced•
Strategies to reduce undesirable behaviors:
Punisher
Corrective feedback
• Clarification request: “Did you mean to say wabbit or rabbit?”
• Mechanical feedback: using computer program or app, “Skip” program, if you say it correctly you get a happy face if you don’t you don’t get anything.
• Stimulus Withdrawal: Incorrect or unacceptable response occurs,
a. Time-out: Removal from what you are doing or a period where they can’t win any tokens.
b. Non-exclusion time-out: stop therapy for a second to help them realize that this behavior is not acceptable.
c. Response cost: Types include:
i. Earn-and-lose: give for correct response, take for incorrect.
ii. Lose-only: give the child so many tokens and with every incorrect response, you remove something from the child
If response-reducing methods are being used a lot, may want to ask yourself:
- Targeting something that is too difficult?
- Too difficult of a level?
- Targeting too many sounds at once?
- Does he understand the instructions and feedback?
- Reinforcements positive? Reinforcing to him?
- Sensory child: swinging, jumping on the trampoline before therapy, every 5-10 minutes do something active and then sit down, bear hug with deep pressure
- Session may be too long?
- Some of a group may not work well together in a school setting
Structuring the treatment session: 4 different Modes of Treatment (drill and drill play used most often)
Drill
Drill Play
Structured Play
Play
Drill
highly structured and efficient stimulus-response mode. Goal is as many reps as possibly. Good for trying to establish the sound, motor pattern
Drill Play
Add in a motivational event or activity, majority of speech therapy sessions. Incorporating a game (Chutes and Ladders), what ever number they get they have to say they word that many numbers of times, Go fish, after they ask they have to say the word so many times before getting the car.
Structured Play
Training stimuli are presented in play activities but you have structured the play activity, such as words that begin with the /k/ sound, good later on in therapy, for a more natural setting.
Play
free play, good for language sample, conversational therapy, good for the very end of therapy. Natural play sample,
2 variables help the clinician determine how treatment sessions should be structured
- Child or client
2. Stage of treatment they are at
Moving Through the Treatment Sequence
• When do I stop providing modeling or any other special prompting procedures?
o What ever your criterion is, when they reach that, start fading the model.
o Frequently probe, at least once a month with new stimulus words, or a new complexity level. If it’s a process bring out a new sound that has not been targeted in therapy.
o Don’t model or cue during probe
• How many target responses do I need to train before the client has learned the sound or phonological skill?
o When they have reached 90% accuracy, move on to the next sound.
Data Collection:
• To be completed every time because that is what is tracking progress.
Generalization
• Either a temporary production of a recently learned response in different contexts and situations, or the production of new (untrained) responses based on recent or remote learning
Types of Generalization: of Untrained Stimulus Items
- Learned response will evoke correct production in a target that you did not treat in therapy.
- Focused on /k/, but generalized to /g/ without targeting.
- Usually will happen with processes, but not all the time
Types of Generalization: Generalization across word positions
- Target one word position, and it generalizes to another word position.
- Probe to see after treatment of one position, if it has generalized to another word position.
Types of Generalization: Generalization across response topographies
- Targeting at word, might generalize to sentences naturally.
- Targeting at sentences, might generalize to conversation naturally.
Types of Generalization: Generalization within sound classes:
- Place, manner, voice
- Distinctive Feature
- Phonological Process
- Cognate Pairs
Types of Generalization: Generalization across sound classes
- Targeting /m/ and /s/ improves without targeting, random but it crosses the sound classes.
- Book, voiceless fricative /s/, later probed and /l/ had generalized. Same placement, but different manner and voice.
- Also improved final fricatives after teaching final stops.
Types of Generalization: Generalization across situations
• Target in therapy, see if it is generalizing outside of therapy.
Assessing Generalized Responses by probing untrained words, untrained phonemes, untrained positions, and untrained linguistic levels
- Discrete trial probes: No modeling, probing things you have not taught in therapy. No verbal feedback, no imitation.
- Conversational probe: collecting a speech sample, talking at the end of the session and listening for generalization.
