Cueing & Reinforcement

What is a cue or prompt?

• Both of these signal the degree of assistance given.

• Used to help teach, remind and support client’s ability to do a task or learn a new skill.

• Supports are frequent and high intensity to begin with.

• work within zone of proximal development

Cue

A signal (verbal or nonverbal) that tells the client when to produce the response;

• e.g., clinician says the first part of a sentence “a cup of…” (semantic cue)

• Signal, action, event

• use when prompt isn’t sufficient in supporting client

Prompt

A verbal or nonverbal hint, directive or minimal guidance that assists the client in producing a behaviour

• e.g., the clinician strokes his/her neck with a finger to remind the client with dysfluency to use easy onset, (tactile prompt)

• Reminder, points towards what the client should say or do

Hierarchies where you use different types of cues and prompts

Ways to provide support to our clients to help them to learn, succeed and self-cue (in some instances)

Puts cues in from least to most helpful

Hierarchy should typically be tailored to your client’s needs via the order you/whānau use

Exceptions: research and assessment protocol or specific treatment approach that has it’s own hierarchy

Visual prompt example

Ask client to try again “what’s this picture of?” (picture provided to support naming, no guide as to how to say the word)

Modelling how to make a sound

Imitation cue

• Ask client to copy you – may want to utilise mirror/placement cues again here

  • Immediate, delayed

Placement cue

Use metaphor

Ask client to “remember to keep the snake behind the gate” or “put your tongue behind your teeth” and try again/ look at the diagram

Semantic cues examples

• Superordinate: it’s something you drink

• Function/ location: you drink it at morning tea / you drink it from a cup

• Synonym/antonym: not coffee but….

• Rhyme: it rhymes with bee

• Word spelled aloud: t – e- a

• Sentence completion: pour me a cup of …

• Phonemic cue: It starts with a /t/ sound

• Visual cue (placement): Watch me....

• Imitation: It’s tea – say that after me tea

Verbal prompt examples

• “Ok lets do that 5 times”, “next word”

• “Where does your tongue need to be for the sound?”

• “What do you have to do to make the sound?”

• Step by step instructions –“first we will do x second we will do x”

Physical prompt

Pointing to the target word, or target letter in a word or where an object should go next

Placement prompt example

Instructing where to place articulators to make a sound

Written prompt examples

• Visual schedule

• Written instructions for the activity

• Written supports

Errorless Learning

Uses supports (usually from the therapist) to prevent the client from making mistakes.

Why?

• To increase enjoyment, confidence and motivation of learning.

• Some people may remember the error rather than the correct response when they make errors during learning.

• Some researchers say that error correction overloads the working memory system e.g. that was wrong, do this…

Errorless Teaching Strategies

• Breaking the task down into smaller steps ▪ Imitation (modelling, copy me)

• Tell client not to guess

• Anticipating errors and cueing immediately (using your hierarchy)

• Positive reinforcement for anything that is correct (social/tangible and specific)

• Slowly fading the prompts and cues (hierarchy

Type of cue or prompt used depends on

• client’s errors

• start where client is likely to have success

• then gradually decrease amount of support provided to enable client to produce the target spontaneously

Where would you document cues and prompts used pre-session?

Session plan

• therapist’s action to client’s response, or embedded in procedures

Where would you document cues and prompts used during the session?

Score sheet

• know how heavily you supported the client

Where would you document cues and prompts used post session?

SOAP/Clinical notes

Reinforcement

AKA feedback, teaching, support

• An item or activity offered after a behaviour to increase or decrease that particular behaviour.

• What you say and do matters!

Reinforcement frequency

can be:

• Continuous: Given for every correct target behaviour

• Regular: e.g. Given after every 2 responses

• Intermittent: Given at certain intervals e.g. end of task

Types of reinforcement

• Primary

• Secondary/tangible

• Social

• Natural

Primary Reinforcement

Biological necessity (food, water)

• Aotearoa context SLTs will not reinforce with food frequently….unless you have goals around feeding (dysphagia)

• E.g. You will not give a lolly/sweet for a correct response. BUT in some cases and client goals, food will be a relevant and useful reinforcement

Secondary/Tangible Reinforcement

Access to preferred object/toy/activity.

• Token –not typically valuable by self – value is that once collected, can be traded for another reinforcement e.g. 5 tokens = 1 sticker or 1 game at end (tangible)

• e.g. pop up pirate sword during the communication task= every time say 3 words with /s/ you get a sword to put in the pirate

Social Reinforcement

Praise, approval, attention “Good job keeping your tongue behind your teeth to make the sssss sound!”

Verbal Specific v non-specific verbal reinforcement

• Non specific –“good job”, “nice reading”

• Specific -“Well done, that’s a hissy /s/”

• Nonverbal e.g., a high five

• Visual e.g. visual schedule, crossing items off as you finish the task

Natural reinforcement

Naturally occurring consequence, -that the message being communicated is understood and responded to by the listener

• e.g. “ Oh nice, you said you went to the library? What book did you get out?”

Reinforcement in SLT

• use social, secondary/tangible and natural frequently

Reinfrocement can be:

• Used to keep client focused during the task

• Used to keep the client informed

• Used to teach the client what to do again to succeed

• Can also be a reward at the completion of a task

Knowing what motivates your client here is important to identifying a relevant and meaningful reinforcement

Manaakitangi

Made up of 3 parts:

• Mana = someone’s power or authority

• Aki = to uplift

• Ranga = part of Māori knowledge system of Matauranga Māori

Definition: the knowledge of how to uplift someone’s mana

• Changes depending on: support, care for others, showing respect, kindness

What does manaakitanga mean in relation to SLT?

Underpins how SLT’s should be working:

• Making sure client has all the info they need to make an informed decision

• Knowing clients holistically

• Using words to demonstrate building trust with and validating their client/whānau

• Acknowledging strengths, interests and identity

• Offering further support - e.g. training parents how to do therapy, offering more intensive therapy - give lots of options that fits with family well so they're more likely to engage and the best results are achieved

Examples of manaakitanga in simucase videos

Riley:

• “what a good word!”

• “good job”

• “that’s good thinking”,

• listing the words that the client came up with

• “good listening”

• “you did that all by yourself”

• Reminding client what he’d done “you found all the pictures start with /d/”

Leah:

• “Way to go!”

• “good idea, girl”

• “You know to press the button if you want it”

• “If you want it, you have to ask me”

• “Alright!”

• “smart cookie”

• “Yay, you popped the bubbles!”

Lincoln:

• Incorporating interest of bubbles into therapy as motivator and reward

• “good sharing”

• Validating mum’s concerns – making her feel heard and accepted, supporting her

• Giving support when he gags – telling him he was ok and continuing on as usual

Where would you document feedback/reinforcement pre-session?

Hui process section in session plan

Process plan - remember to ask about something - descriptive stuff about session - run sheet

Where would you document feedback/reinforcement during the session?

Score sheets - also for anything else you need to know

Where would you document feedback/reinforcement post session?

SOAP/Clinical notes, written reflection

Where would you document Manaakitanga pre-session?

Hui process section in session plan

Process plan

Where would you document Manaakitanga during the session?

Score sheet

Where would you document Manaakitanga post-session?

SOAP/Clinical notes, written reflection