HESP 415 Final Exam

Introduction to Intervention 8/28/24

Medical Model of Disability

• Deficit-based, biomedical perception of disability. Something is wrong with the body or the mind, we need to make it right to fulfill the ultimate quality of life.

Social Model of Disability

• Systemic structures, societal attitudes, and prejudices. Deficits are within society that impact quality of life for disabled individuals and solutions should focus on addressing those systems and attitudes.

The Risks of Ableist Practices

• Masking: Therapies and messaging that promote masking of neurotypes have significant consequences on mental health

• Suppression: Therapies that train suppression of behaviors can dampen important outlets for stress and dysregulation

• Denial of functional resources: Prioritizing neurotypical standards can result in reduced access to technology that can support functional goals

Principles of Intervention

• Dynamic (not static):

  • constantly providing stimuli and analyzing the results

• Client considerations:

  • what helps a participant perform best? How to adjust to their interests, sensory needs

• Functional strategies (not isolated skills)

  • Saying real sounds. Building on things that drive communication

• Emphasis on communication

• Emphasis on success

  • Choosing targets and implementing them in the therapy room

  • Challenge clients and push them out of their comfort zone

• Preparation for discharge

  • We want clients to develop skills and go out into the world without constant help/intervention

• Evidence-based practice

• Cultural sensitivity

  • Make sure what the cultural background of the client and their family.

  • What changes are needed in our therapy

Essential Clinical Skills

• Programming

  • How to program a session

  • Therapeutic programming of scheduling goals and how to treat them

• Behavior Modification

  • Emphasizing the trust and safety of a client

• Teaching Strategies

  • Skills that need to be supported

    • How to build upon these skills

• Session Design

  • How to plan our session

    • How is it structured

• Data Collection

  • Record and report on the client's progress in a session

9/4 - Building Rapport | Treatment Approaches for Articulation

The Clinician-Client Relationship:

Building Rapport and a Therapeutic Alliance

• Establishing Rapport

  • Data Collection

  • Programming

  • Behavior

  • Teaching Strategies

  • Session Design

Building Rapport

• The importance of therapist effects

  • Clinical factors

  • Therapist effects vs. intervention

• The importance of rapport

  • Trust, safety, comfort in the therapeutic setting

  • Session engagement

  • Motivation and agency

• It is the clinician's responsibility to build the relationship between client and therapist

• Three main elements:

  • Interpersonal bond

  • Agreement between clinician and client, family regarding long-term goals

  • Agreement between clinician and client/family regarding therapeutic tasks

Interpersonal Bond

• Striking the tone

• Therapeutic Relationship:

  • Not personal, is professional

• Personal interests

• Following leads and establishing boundaries

  • Building connections and trust

• Interest in person

  • Checking in every day

  • What are they looking forward to

• Body language

• Speaking style

• Feedback

Agreement on Long-Term Goals

• Solicit client priorities

  • Asking the client what they would like to accomplish

  • Seeing how the client interacts with their family (if nonverbal)

• Solicit family priorities

  • What are some challenges the client experiences

• Create goals that incorporate clinician expertise, the needs of the client, and the desires of stakeholders

Agreement on Treatment Activities

• Incorporate interests

• Consider client and family preferences

• Consistently establish expectations and review rationales

  • understanding why you are doing a treatment session

• Honor family requests

  • family understand why you are incorporating teaching strategies

  • listen to family requests - boundaries, preferences of language use, or types of play

Session Dynamics

• The pace of the session

  • Start-up of therapy is successful

• Material selection

• Proxemics

  • The client and the clinicians’ literal position from each other

  • How it allows you to maintain materials

Questions:

• When does rapport building start? When does it end?

  • It starts when you begin therapy and it is ongoing

• What are the risks of foregoing rapport-building?

  • Maintaining trust from therapists - mainly kids

  • Adults may not know why they are there

  • May be reluctant to change - adults

• How can rapport be restored?

  • Keeping consistent boundaries so it is easier to get back on track

  • Refresh the client's goals

Articulation and Treatment Approaches

Nature of Articulation Differences and Disorders

• Functional: No known pathology is causing articulation errors

  • Absence of: hearing impairment, intellectual differences, structural abnormalities, neurological dysfunction

• Organic: known physical causes of articulation errors

  • Presence of hearing impairment, structural abnormalities, neurological dysfunction

• Both

Treatment Approaches

• Traditional

• Motor Kinesthetic

• Distinctive Features

• Paired Oppositions

• Phonological Processes

• Cycles Approach

• Core Vocabulary

• Metaphon

Traditional (Van Riper, 1978)

• Sensory perceptual or motor-based approach

• Incorporates auditory discrimination, motor placement, and gradual increase in complexity

  • GILCU: Gradually increasing in length and complexity

Traditional: Sequence

1. Speech sound discrimination training

   a. Identification, isolation, and bombardment

2. Phonetic placement of the articulators

3. Producing the sound in isolation

4. Producing sound in nonsense syllables

5. Producing sound in initial, medial, and final positions

6. Producing sound in phrases and sentences

7. Producing sounds in conversation

Motor Kinesthetic

• Emphasizes development of movement patterns

• Clinician manipulation of articulators

• Prioritizes kinesthetic and tactile feedback

  • A lot of touch to stimulate feedback between the client

• Emphasis on the isolated sound

Distinctive Features

• Emphasizes the distinctive features of the targeted sounds for training

• Clinician selects a feature for training

• Discussion of feature

• Auditory discrimination activities

• Return to traditional speech production hierarchy (GILCU)

Paired Oppositions

• No explicit instruction on placement or production

• Minimal or Maximal Pairs

• Minimal Pairs: Differ on only one feature (/van/ vs /ban/)

  • Maximal Pairs: Difer on several features (e.g. /sad/ vs /bad/)

• Provide opportunities for natural consequences of mispronunciation and repair in functional activities

Phonological Processes

• Based on phonological simplification strategies that begin as typically developing

• Does not target individual phonemes but rather entire class of speech errors

Cycles Approach

• Intended for individuals with highly unintelligible speech

• Determine multiple phonological patterns to be addressed, individually, for a determined amount of time (cycle)

• Progression is based on cycle duration, not achieving mastery of speech sound

• Internalization of speech pattern even as clinician introduces new targets

Core Vocabulary

• SLP selects 50-70 “functionally powerful” words

• Up to 10 words are targeted simultaneously

• Emphasizes the ability to generate consistent motor plans for words

• Clinician provides detailed, specific feedback about the limited number of words

Metaphon

• “Philosophy” rather than program

• Provides client with explicit information, development awareness, and understanding of detailed aspects of speech sounds to facilitate accurate production.

• No specific or corrective feedback

• The environment is structure for repeated opportunities for intentional production and repair

Treatment Efficacy and Evidence-Based Practice

There is minimal consensus evidence to indicate one articulation approach is more effective than the other

How do we choose?

• Clinical expertise

• Client considerations

• Dynamic assessment and problem-solving

• Remember the importance of clinical factors

9/11 - Programming | CLD Considerations

Programming

• The selection and sequencing of specific behaviors for targeting in treatment

Programming Progression

• New behavior is introduced

• Behavior is taught with maximum structure and prompting

• Progress through hierarchy of difficulty and complexity

• Client demonstrates generalization of behavior

• Plan for discharge

Social Model of Intervention

• Does not focus on how to bring the client skills up to typical societal expectations

• Identifies ways to modify the attitudes and structures of society to accommodate the client's communication profile

• Focuses on reducing barriers to successful communication in the individual's environment or interpersonal relationships

• Providing support and modifications to address physical, environmental, and sensory barriers experienced by the client

Therapeutic Targets: First Steps

1. Analyze assessment data

   • Review diagnostic findings to determine areas for further investigation

2. Gather pre-treatment baselines (no prompting/teaching)

   • Provide a number of stimuli to determine a baseline accuracy

   • Under 75%…. Over 50%…. Lowest accuracy

3. Incorporate clinical judgement

Goals and Objectives

• Long-term goals: The determined communication behavior(s) to be acquired over the course of the treatment program

• Short-Term Objectives: The stepping-stones or collection of behaviors to achieve long-term goals

Selecting Therapy Targets

• Developmental/Normative Strategy

  • Known normative sequences of communicative behaviors are used to inform target selection

  • The earliest emerging behaviors are selected as the first therapy objectives

  • Most applicable for children

• Client-Specific Strategy

  • Consider the client's unique needs rather than norms

    • Frequency of a specific communication behavior in daily activities

    • Relative importance of the communication behavior

    • Client's potential mastery of the skill (stimulability)

      • Stimulability: The client's ability to achieve the communication behavior through imitation

    • Effective for both pediatric and adult populations

Sequencing Therapy Targets

• Developing a logical sequence of steps to accomplish each goal. Involves three factors:

  • Stimulus type

  • Task mode

  • Response level

• Stimulus Type: The more explicit and direct a stimulus, the greater the level of support from the clinician

  • Direct physical manipulation

  • Concrete Symbols

    • Objects

    • Photographs/color pictures

    • Black and white line drawings

  • Abstract symbols

    • Oral language

    • Written language

• Task Mode

  • Imitation

  • Cue/prompt

  • Spontaneous

• Response Level (GILCU)

  • Isolation

  • Syllable

  • Word

  • Carrier phrase

  • Phrase

  • Sentence

  • Text

Complexity Hierarchies

• Complexity hierarchies will vary based on population, skill, etc

  • Modifying level of support

  • Modifying level of complexity

• All should gradually build in independence and functionality

Use pretreatment baselines…

• Scores under 50% accuracy: begin at the level of difficulty just below the baseline stimuli

• Scores between 50% and 75%: Begin at the same difficulty level as baseline stimuli

• Branching: Modifying the difficulty level (branch up, branch down) to achieve a greater level of success

Generalization/Carryover

• Programming for transfer of a newly mastered communicative behavior to the everyday environment

• Should be incorporated throughout programming

• Build variation into therapeutic activities

  • stimuli

  • environment

  • audience

Termination of Therapy

• Discharge is based on clinical judgement

• Consider

  • Attainment of skills that are commensurate with chronological, developmental, or premorbid status

  • Attainment of communication skills that permit functioning in their daily environment

  • Lack of discernible progress beyond a predetermined time period

How many black/POC are in this field?

• About 3% black SLPs

Racial Concordance

• The matching of patient/client and clinician across cultural variables

• In primary care relationships, racial concordance is connected to increases in..

  • Client-clinician communication

  • client participation

  • information-giving

  • improved show-rates

  • overall satisfaction

In the absence of concordance

All clinicians need to be intentional about prioritizing:

• Cultural Competence

  • Ongoing self-assessment, continuous cultural education, openness to others’ values and beliefs, and willingness to share one's values and beliefs

• Cultural Responsiveness

  • Understanding and appropriately including and responding to the combination of cultural variables and the full range of dimensions of diversity that an individual brings to interactions

• Cultural Humility:

  • “A personal examination of one's own beliefs and cultural identities to better understand the beliefs and cultural identities of others”

Cultural Dimensions

• Family Life

• Child-rearing practices

• Education

• Employment

• Health Care Practices

• Value Orientations

• Verbal Communication

• Nonverbal communication

• Relational Communication Norms

Cultural Dimensions and the Individual

Cultural Dimensions exist on a continuum that will look different for each individual

• Emphasize ethnogenetic views: Groups, cultures, and their individuals are fluid and complex

• Being mindful of essentialism: Defining whole groups as essentially different, without regard for variations

Unlearning Ethnocentrism

Belief that your habits or viewpoints are superior

• Willingness to approach all beliefs with flexibility

• Acknowledging impacts of long-standing value systems

• Monitoring for microaggressions

Responsiveness vs. Stereotyping

• Consider how norms and values are uniquely shaped

• Monitor for preconceptions of a particular population

• Come prepared with cultural competence, adjust and nuance with cultural responsiveness

Difference vs. Disorder

A speech-language disorder..

• Impacts storage, retrieval, and/or execution of behaviors related to communication

• Results in a communication breakdown that is sufficient to negatively influence the effective communication in the language used by the speaker

A difference…

• Reflects a variation of the behaviors which are rule-based, not disordered

• May result from cultural variables impacting a variety of behaviors

• May vary in degree based on exposure, assimilation, and acculturation

Pursuing a Culturally Responsive Practice

• Solicit resources to build cultural competence

  • Differences across cultural dimensions in a particular population

  • Seek out support from other professionals who share concordance with your client

• Establish a sensitive and responsive rapport with your client to ask questions and receive feedback on cultural dimensions

• Mindful creation and modification of materials and therapeutic activities

9/18 - Behavioral Objectives

Goals vs. Objectives

• Long Term Goals (LTG)

  • Written with the overall skill in mind

  • May not have a stated criterion

• Short Term Objectives

  • The necessary sub-skills to achieve the LTG

  • May work in a gradual approximation of the LTG

  • May include a collection of steps in any order

Anatomy of an Objective

Given no more than verbal prompts, client will produce /s/ in initial position of words with 80% accuracy over two consecutive sessions

• Condition: what support will be provided (“Given Statement")

• Task: what will the client do

• Criterion: the success level and time element (timing is optional)

Importance of an Objective

• Allows the client and clinician to know

  • The exact therapy target

  • How it is to be accomplished

  • What defines successful performance

• Allows new clinicians to implement programming immediately

Condition

• The situation in which the target behavior will be performed

• Specifies…

  • When the behavior will occur

  • Where it will be performed

  • In whose presence

  • Materials to elicit the target

  • Prompting to elicit the target

• Important consideration for

  • generalization

  • independence

  • functionality

"Do” Statement

• The specific action the client is expected to perform

• Use terminology that is observable and measurable

  • Will I be able to tally when the behavior occurs?

• Determines the action that will be measured through data collection

Do's and Not Do's

• • Do's

    • Point

    • Say

    • Label

    • Write

    • Name

    • Ask

    • Vocalize

  • Not Do's

    • Learn

    • Know

    • Remember

    • Apply

    • Comprehend

    • Improve

    • Understand

Criterion

• How successfully the target behavior must be performed to achieve the objective

• May specify

  • Ratio/percentage of “correct” or successful responses

  • Minimum number of successful responses

  • Maximum number of errored responses

  • Within a given time period

• Examples

  • 99% accuracy

  • 8 out of 10 trials

  • Less than four errors over three consecutive sessions

  • 80% accuracy over two consecutive sessions

  • Continuously over a 2-minute period

SMART Goals

Good objectives with a snappy title

• Specific

• Measurable

• Achievable

• Relevant and Realistic

• Time based

Early Childhood Language

The Intentions of Early Intervention

• Emphasize family involvement and education

• Promote participation in the natural environment

• Integrate multiple disciplines and lanes of development

• Primary therapy strategies highlight authentic learning experiences and modeling/stimulation

Prelinguistic and Early Language skills

• Localization: turning toward and visually searching for the source of a sound

• Joint/Shared Attention: directing attention to a shared object, event, or individual

• Mutual Gaze: eye contact between child and caregiver

• Joint Action and Routines

  • A predictable play sequence with a clear progression of events

  • Facilitates anticipation by the child and increases the potential for successful interaction

  • Supports first interactions, turn-taking, role shifting

Communication Behavior Progression

• Intentional Gestures

  • Movement of the body with the intent to be understood

  • Head shake, reach, raising arms up

• Vocalizations

  • Reflexive → Cooing → Vocal play, laughter → Babbling → Jargon and Protowords

• Symbolic communication

  • Consistent, intelligible signing

  • Words or word-approximations

  • Other symbols (photographs, line-drawn symbols)

Communicative Intentions

The meaning that the speaker wishes to convey

• Preverbal

  • Attention Seeking

  • Requesting

  • Greetings

  • Protesting

  • Responding

  • Informing

• Single-Word Level

  • Naming

  • Commenting

  • Requesting (object, action)

  • Responding

  • Protesting

  • Attention seeking

  • Greetings

The Importance of Play

• Children learn and practice through play

• Development of social communication skills and natural language learning

• Nonsymbolic Play

  • Exploratory: dropping, mouthing, transferring

  • Functional: Using an item for its intended purpose as well as gross motor play

• Symbolic Play

  • Substitution of objects, assigning roles

First Lexicon

• Typical lexicons are based around social and physical events that are understandable and in the immediate environment

• Choosing targets:

  • Words that can be used in many different contexts within the child's day

  • Words that are important to the child

  • Words that represent references that can be acted on or manipulated

• Tier 1: Common, everyday words that most children known before entering school

• Tier 2: Academic vocabulary that is common across all topic areas, but not part of everyday social language

• Tier 3: Low-frequency, subject-specific words

Intervention for Birth-3 Intervention

• Capitalizing on natural contexts for skill development

• Creating natural contexts for skill development

• Utilizing predictable routines

• Imitating the child's behavior

  • Mirroring back vocalizations; playing their way

• Flooding of the target (vocabulary, skill)

• Incorporating family and key caregivers

• Supporting for necessary changes in caregiver behavior

Intervention for Infants, Toddlers, and Pre-K

• Focused Stimulation

• Incidental Teaching

• Floortime/Developmental Individual-Difference Relationship (DIR) Based

• Family Centered

Focused Stimulation

Clinician provides concentrated exposure to a linguistic target form in a variety of contexts

• High concentration throughout natural and meaningful interactions

• Child is not required to imitate or produce

• Can target vocabulary, grammatical morphemes, syntax

• Can be included as individual words, within sentences, or in short stories

Incidental Teaching

Naturalistic approach encourages child to initiate communication by arranging the environment to increase the likelihood they will produce the targeted behavior

• Verbal or non-speaking communication behaviors

• Natural consequences as rewards

• Clinician may respond to communicative attempts with models for expansion or elaboration

Floortime/DIR

Building foundations for social, emotional, and intellectual capacities

• Does not target isolated skills

• Emphasis on developmental milestones and individual differences

• Highlights relationship between child and others in the environment

• Family engagement is critical

Family Centered

• Trains parents and caregivers to foster development of language and communication in natural settings

  • Family members are the “agents of change"

  • Building and responding in mutually reinforcing communicative interactions

  • SLP is an indirect support during interactions with heavy focus on parent education

  • Can be utilized to target variety of speech and language skills

9/25 - Behavior Modification | School-Age Language

Behavior Modification Intentions

Intended for:

• Developing new speech, language, and communication behaviors

• Increasing likelihood of success

• Improving relationship and therapeutic alliance

Not intended for:

• Maintaining control

• Meeting NT expectations

• Keeping materials or space clean and tidy

• Establishing compliance

• Tolerating non-preferred tasks or environments

Terminology

• Operant Conditioning: Utilizing the relationship between a stimulus, response, and consequent event

• Stimulus: An event that precede and elicits a response

• Response: The behavior that is exhibited by the individual on presentation of the stimulus

• Consequence: An event that immediately follows the response

• Reinforcement: Consequences that increase the probability that a particular behavior will recur

Reinforcement and Punishment

• Positive Reinforcement: The addition of a reward consequence that it is intended to increase the likelihood of a behavior

• Negative reinforcement: The removal of an aversive consequence that is intended to increase the likelihood of a behavior

• Punishment: The addition of an aversive consequence or removal of reward consequence intended to decrease the likelihood of a behavior

Positive Reinforcement: Reinforcement

• Primary Reinforcers: Contingent events that are favorable due to the biological need or physiologic predisposition of the individual

• Secondary Reinforcers: Consequences that must be perceived or interpreted as rewarding

  • Social

  • Token

  • Performance feedback

Negative Reinforcement: Reinforcer Types

• Escape: Requires the presence of a condition that is perceived as aversive

• Avoidance: A performance of the behavior prevents the occurrence of an anticipated aversive condition

Punishment: Types

• Type I: Presentation of an aversive consequence after a unwanted behavior is exhibited

• Type II: Withdrawal of a pleasant condition after an unwanted behavior is exhibited

Reinforcement Schedules:

• Continuous: 1:1 reinforcement

  • Helpful for shaping new communication behaviors

  • Can be utilized for transitioning a skill to a greater level of difficulty

  • Not sustainable for long-term

• Intermittent: Lower density reinforcement based on number of executions or duration of a behavior

  • Effective in strengthening responses, promote maintenance

  • More sustainable in creating behaviors less susceptible to extinction

Intermittent Reinforcement: Types

• Fixed Ratio

• Fixed Interval

• Variable Ratio

• Variable Interval

Behavior Modification and ND Populations

• If expectations can be met without disconnection, set them!

• ND Populations present with variations in preferences, regulation, and past experiences

  • Do not withhold contingent rewards that are used/can be used to establish regulation

  • Be mindful token reinforcement systems

  • Analyze your session design and response styles to ensure you are serving the needs of your client, not the needs of the clinician

School-Age Language and Literacy

Characteristics of Students Ages 5-10

Oral Language Development:

• Vocabulary increases in size and depth

• Utterance length increases

• Changes in syntactic growth

• Metalinguistic awareness

Reading Development:

• Decoding: Knowledge of letter-sound correspondence

• Word Recognition and Fluency: Rapid, automatic identification of written words

• Comprehension: Processes by which print language is understood

Writing Development:

• Spelling: The forming of words from letters

• Written Composition: Writing at the text level

Writing Process Development:

• Planning: Generating and organizing ideas

• Drafting/Composing: Putting ideas into words/text

• Revising: Reviewing and evaluating text

• Editing: Polishing flow and format

Characteristics of Students Ages 10-18

• Early Adolescence (10-14): Promote communication skills for academic and personal-social purposes

• Mid-Adolescence (14-16): Promote communication skills for vocational purposes

• Late Adolescence (16+): Promote communication skills for career purposes

• Communication skills are refined

• Development of higher-order language abilities

• Growth in the metalinguistic area of figurative language

• Develop conversational maturity

• Increase the length of utterance

• Increased comprehension and production of complex sentences

• Advances in written language

• Development of metacognitive and executive functioning abilities

Language Learning Disabilities

• Overflow impact of language-learning differences in writing products, including:

  • Lack of planning

  • Reduced use of background knowledge

  • Lack of revision and editing

  • Reduced sense of audience

  • Reduced sentence complexity

  • Grammatical and punctuation errors

Intervention for School-Age and Adolescents

• Developmental → Functional

  • Goals and objectives will begin to transition to more functional application

  • Consider program goals that incorporate demands and expectations of the educational curriculum

• Oral Language x Literacy: As needs begin to impact academic progress, a greater focus on this relationship is necessary

• Service Delivery:

  • Pull-out | Push-in | Consultation and collaboration

  • Shocking: No one delivery model is best!

Treatment Approaches

When the transition is made from developmental programming to functional, treatment approaches will emphasize deeper interaction with content and planning; habit-building; and compensatory strategies

1. Previewing: Planning strategy for oral and written texts

• Examples of Oral Participation:

  • Topic identification; vocabulary; brief synopsis

• Examples for written text:

  • Section headings; captions

2. Predicting: Use of subject matter knowledge to:

   • Make predictions about content and vocabulary

   • Check comprehesion

3. Think-Aloud : Students engage in self-talk throughout the learning task to improve comprehension/monitoring of oral and written material

4. K-W-L Procedure : Focuses on comprehension of oral and written language

   • K = what we KNOW

   • W = What we WANT to know

   • L = What we have LEARNED

5. Metacognitive Stems : Students are provided with a structure to improve their organization for completion of an assignment

6. Discussion-Oriented Approach: Whole classroom or groups talk about word meanings in a conversational context

7. Social Stories :

   • Focus on improving pragmatic language skills

   • Clinician develops written or pictorial scripts that explain appropriate communication interaction behaviors in given social situations

8. Computer-Driven Therapy: Use of personal computers to present therapeutic stimuli and feedback

10/2/24 - Teaching Strategies | Autism

Teaching and Scaffolding Strategies

• Direct Modeling

• Indirect Modeling

• Shaping

• Prompts

• Fading

• Expansion

• Recast

• Negative Practice

• Target-Specific Feedback

Teaching Strategies: Direct Modeling

The clinician demonstrates a specific behavior to provide an exemplar for the client to imitate

• Beneficial for early stages of therapy

• Also utilized for shifting to a higher response difficulty

• Provides maximum support by the clinician

• Minimizes likelihood of errored responses

Teaching Strategies: Fading

The stimulus or consequence manipulations (e.g. modeling, prompting, reinforcement) are reduced in gradual steps while maintaining the target response

• Initiated once a client is able to produce some consecutive correct responses at imitation

• Process

  • Increase number of client productions following one model

  • Decrease length of model provided by clinician

Teaching Strategies: Prompts

The clinician provides additional verbal or nonverbal cues to facilitate a client's production of a correct response

• Attentional: Cues to improve performance by focusing a client's concentration on the task

• Instructional: Provide information directly related to the specific target behavior

  • Verbal reminders (“Remember to keep your tongue behind your teeth”)

  • Nonverbal reminders (A signal to adjust loudness)

Teaching Strategies: Shaping by Successive Approximation

A target behavior is broken down into small components and taught in an ascending sequence of difficulty

• Utilized when a direct model of a complete behavior is insufficient

• Each successive step moves progressively closer to the final form of the desired response

Teaching Strategies: Negative Practice

The client is required to intentionally produce a target behavior using a habitual error pattern

• Facilitates learning by highlighting contrasts

• Implemented after a client demonstrates capacity to produce the behavior consistently with imitation

• Powerful on a short-term basis

Teaching Strategies: Target-Specific Feedback

The clinician provides information regarding the accuracy or inaccuracy of a client's response

• Useful throughout all phases of therapy

• Three primary functions

  • Provides precise information regarding why or how a response was correct

  • Maintains client's awareness of the exact response being targeted

  • Maintains client's focus on the target during a therapy activity

Teaching Strategies: Indirect Modeling

The clinician demonstrates a specific behavior frequently to expose a client to numerous well-formed examples of the target behavior

• Can be employed at any stage in the therapy process

• Increase exposure to positive speech, language, or communication behaviors

• Not intended to elicit immediate responses

Teaching Strategies: Expansion and Recasting

The clinician reformulates a client's utterance into a more mature version (expansion) or difference sentence type (recasting)

• Primarily used in language and communicative therapy

• Increase exposure to positive speech, language, or communication behaviors

Teaching Strategies: Homework

Assigned to strengthen the response and facilitate generalization outside of the clinical setting

• Should target an existing skill

• Client should be able to evaluate their own performance

• Assigned in manageable amounts

• Assigned on a regular basis

• Should include written instructions

Autistic Learner: Sensory Processing

Basic Senses

• Auditory, Visual, Gustatory, Tactile, Olfactory

Invisible Senses

• Vestibular: Sense of body in motion across a variety of planes (via semicircular canals)

• Proprioceptive: Sense of body movements in relationship to one another (via stretch receptors in joints)

• Interoception: Sensations related to internal body states (via organs)

Threshold: The level of input at which the sensory system registers and/or responds

Low Thresholds: May result in over-reactivity, frequent responses to stimuli, frequent distraction or loss of regulation

High Thresholds: May result in missing important cues or information about the environment

Purposes of each sensory system

• Arousal (or alerting): To generate awareness

• Discrimination (or mapping): To gather information to make maps of self and environment

• Active Self-Regulation: The individual actively controls input to establish equilibrium

• Passive Self-Regulation: Allows changes to environment and responds

Common Sensory Characteristics:

• Sensitivity to touch, auditory, and oral sensory input

• Low registration of environment until threshold, then resulting in overwhelm

• Use of repetition and rituals to establish comfort to reduce triggering of lower thresholds

Interventionists (with the support of an OT) will need to learn the sensory profile of the individual to provide both alerting and calming stimuli to support trust, safety, and participation

Autistic Learner: Sensory Patterns

• Seeking: High thresholds, active self-regulation, independently incorporate movement, touch, sound, and visual stimuli in their activity.

• Low Registration: High thresholds, passive self-regulation. Do not actively seek changes to input, can appear withdrawn

• Sensitive: Low thresholds, passive self-regulation. Easily disrupted and distracted by change that does not go unnoticed

• Avoiding: Low thresholds, active self-regulation. Independently attempt to reduce input. May be resistant to participation

Autistic Learner: Cognitive Differences

• Memory for complex material (scenes, stories)

• Working memory (maintaining information for execution)

• Concept formation (insight, judgment)

• Face recognition

• Executive functioning

• Response to social consequences

• Managing abstract concepts, such as time, unspoken rules

Autistic Learner: Mental Health

• Reduce stress and demands by following the client's lead

• Allow ample wait time over the course of an interaction, a session, an episode of care, to build trust and opportunity for initiation

• Know your client's history with therapy and behavior interventions

Autistic Learner: Supports for Intervention

• Incorportation of preferred sensory input: Create an environment that is conducive to the seeker, not punitive

• Modulation of aversive sensory input: Monitor for aversive lighting, smells, auditory input. Prevent the need for avoidance

• Utilze visual supports: Support for receptive language differences, preparation and frontloading, social stories

• Utilize visual schedules: Support for impacted skills such as time-blindness, prediction, insight

Autistic Communicator: Social Differences

• Impacted joint attention

• Delayed pointing and use of gestures

• Stereotypical play

• Impacted perspective-taking (Theory of Mind)

Autistic Communicator: Language Development

Aberrant vs. Delayed: Language development may follows an atypical pattern

• Use of immediate and delayed echolalia

• Less-robust communicative intents

• Difficulty interpreting nonverbal communication

• Difficulty with higher-order language skills

  • Topic maintenance

  • Inferencing

  • Figurative language

  • Presupposition

Autistic Communicator: Echolalia

Echolalia: The partial or full repetition of the speech of others

• A hallmark characteristic to autism (although not unique to autism)

• May also be referred to as gestalts or scripts

• Noteworthy in their adherence to melody and intonation

• Characterized by timing:

  • Immediate: The repetition occurs immediately after perception

  • Delayed: The script is retained and produced at a later time

Autistic Communicator: Natural Language Acquisition

Natural Language Acquistion: The process of acquiring language in entire units, marked by natural boundaries (a breath, a pause, an end of an episode) and coded by experience

• Individuals exhibiting signs of NLA (Gestalt Language Processors) will be slow to respond to therapy techniques that are based in analytical language processes

At any given time, a GLP individual may utilize utterances that represent different a variety of stages

Supporting GLPs in Early Stages:

• Investigate the meaning of existing gestalts

• Acknowledge all gestalt use as meaningful, even during the investigative phase, to build trust and reciprocity

• Respond to current gestalts with a mitigated close relative

• Reuse mitigations with a variety of “chunks”

• Provide redundant models of new gestalts that are easily mitigated

• Utilize rich intonation and stimulating, emotional contexts to support imprinting

Allyship: Mind Your Language

• Rebuke deficit-based language and sweeping generalizations

• Be mindful of word-choice and messaging that implies blame, lack of effort, or a conniving nature of the individual

  • He can do it, he just won't

  • They're just being lazy

  • She's manipulating you

• Avoid “leveling” and functioning labels

Allyship: Disrupt NT Standards

• We can support autistic individuals to develop skills that will help them establish joyful communication and participation in predominantly NT communities, without:

  • Disrupting play preferences

  • Interpreting with self-regulation attempts

  • Enforcing uncomfortable boundaries

  • Rebuking special interests

• We can support NT communities to develop skills that will help them establish joyful communication and participation with autistic individuals

  • Provide counseling and support to families

  • Provide education to stakeholders on the micro and macro level

  • Encourage changes to environment and caregiver responsiveness

10/9 - Midterm Review

Sequencing Therapy Targets

Developing a logical sequence of steps to accomplish each goal. Involves three factors:

• Stimulus Type

• Task Mode

• Response Level

The therapy target is what you are taking data on

Stimulus type: the more explicit and direct a stimulus, the greater the level of support from the clinician

• Direct physical manipulation

• Concrete symbols

  • Objects

  • Photographs/color pictures

  • black and white line drawings

• Abstract symbols

  • Oral language

  • Written language

Task mode: how the therapy activity is designed

• Imitation: Client repeats what is said

• Cue/prompt: Provide an instruction/something that stimulates a behavior

• Spontaneous:

Response Level

• Length and Complexity (GILCU)

  • Isolation

  • Syllable

  • Word

  • Carrier Phrase

  • Phrase

  • Sentence

  • Text

• Response Latency: how long it takes for the client to give a response

10/23/24 - Materials Selection | Aphasia and TBI

Material Selection

• The vehicle of you therapeutic task

• The most-likely determinant of stimulus type

• Commercial materials

  • Therapeutic

  • Recreational

• Created materials

Materials Considerations

What You Use

• Consider client profile

  • Age

  • Developmental level

  • Language level

• Foster engagement

• Promote generalization

How You Use It

• Address the target

  • As is

  • With clinician mods

• Permit branching

• Promote high frequency of targets

• Can incorporate additional stimuli

Material Use

• How do we put materials to use to accomplish therapeutic targets:

  • Use as directed

  • Incorporate additional demands or stimuli

  • Create the materials we need

Material Use: Use as Directed

• Highlight the communication target that is naturally stimulated or easily prompted when interacting with the material

Material Use: Incorporating Additional Demands

• Earn Your Turn

  • After 10 accurate productions of /s/ at word level, take your turn in Trouble

• Incorporate a Target

  • Use past tense marker -ed to describe the turn (“You moved 2 spaces”)

• Support a Functional Target

  • Engineer opportunities to demonstrate a social target (advocacy sportsmanship, compliments, etc)

Material Use: Creation

• Create materials specific to the client's needs and preferences

Finding and Creating Materials

• ChatGPT

• Search Engines

• Pinterest

• Teachers Pay Teachers

• Interactive sites

• Closets

CLD Considerations

• Exercise cultural sensitivity

  • Do not assume holiday observations or traditions

  • Be mindful of current events

• Use materials and stimuli that are representative

  • Toys

  • Books and other media

  • AAC and visual supports

• Resist poor or stereotypical representations

The Last Word

1. Consider the pictured material:

2. Determine a use for the material in treatment

3. The last student to contribute wins

Aphasia and TBI

Aphasia

A language disorder due to brain damage that results in impaired comprehension and/or formulation of language

• Can impact both spoken and written modalities

• May co-occur with motor impairments

  • Hemiplegia or hemiparesis

  • Hemianopsia

Possible Etiologies

• Hemorrhage or blockage of blood flow to the brain

• Strokes/cerebrovascular accidents (CVA)

• Tumors

• Head trauma

• Certain disease processes

Classification of Aphasia Symptoms

• Nonfluent Aphasia: Poor verbal/written output with relatively spared comprehension

  • Reduced vocabulary

  • Agrammatism

  • Impairments of articulation, rate, and prosody

  • Labored and effortful production

• Fluent Aphasia: Impaired language comprehension with maintenance of normal melodic speech contour

  • Word-retrieval deficits

  • Paraphasias

  • Neologisms

  • Perseveration

  • Melodic, natural quality to speech production

Nonfluent Aphasias

• Broca's: Agrammatism, effortful articulation of short utterances, impaired prosody and intonation, apraxia of speech, good comprehension

• Transcortical Motor: Little to no initiation of spontaneous speech, but excellent imitation. Good comprehension

• Global: severe deficits in all areas of language comprehension and production

Fluent Aphasias

• Wernicke's: Fluent but meaningless speech articulation, intonation, and prosody are good. Comprehension is impaired.

• Conduction: relatively fluent speech, frequent phonemic paraphasias, marked difficulty with imitation. good comprehension

• Anomic: Significant word-finding difficulties with otherwise fluent and grammatical speech. good comprehension

Spontaneous Recovery

Occurs if at all, to the greatest extent during the first two to three months post injury/insult

• Influenced by several factors

  • Lesion characteristics (size, location, etiology)

  • Type and severity of initial aphasia

  • Age at onset

  • Overall premorbid health

• Prognosis is more favorable for younger clients without additional medical concerns

Neuroplasticity

The brain's ability to restructure its neural networks in response to internal and external stimuli

• Neural regions adjacent to the lesion may adopt functions of the affected area

• Right-hemisphere sites that parallel the affected left hemisphere may take over functions of the affected area

Neuroplasticity is a key theoretical underpinning to therapy and rehabilitation for patients with acquired neurological impairments

Intervention Timing

• Delayed option: initiating treatment once the effects of spontaneous recovery have likely run their course

• Early Intervention: Initiating treatment close to onset/injury to accelerate the natural process of spontaneous recovery

  • Delayed treatment has not been shown to improve treatment effects.

  • Most clinicians will recommend early intervention

Positive Indicators for Treatment

• Age: Individuals under 65 make greater gains in therapy

• Intensity: A total of 20-50 intervention hours resulted in better outcomes

• Duration: Continuation beyond a 4-week episode of care results in better outcomes

• Maintenance: longer-term gains were noted for individuals with milder aphasia symptoms and no deficits in executive functioning

Theoretical Orientations to Aphasia Treatment