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XXXClinical Methods


Data taken during each therapy session will be used to determine several things if the patient/client is making progress that the treatment techniques are appropriate when modifications need to be made and how to plan for future sessions.
The SOAP note is a staple of daily reporting on client progress it is an acronym Subjective Objective Assessment and Plan
SOAP notes are commonly used by medical and rehab staff and may appear frequently in medical charts
Subjective a description of the clients physical and emotional state including affect mood level of motivation attention and so on. May include direct quotes.
Mr. Jones was in a pleasant mood today and was eager to begin therapy subjective
Objective information regarding the behavior targeted during therapy includes session goals and data for each goal may include testing including the name of the test and the results and any info to support Subjective section
Client/pt will improve immediate memory by repeating eight-word sentences with 75% accuracy Mr. Jones only achieved 40% correct responses compared to 70% from last week due to his fatigue and lack of concentration Objective
Assessment includes an explanation of what your data means if necessary and description of how your client performed and factors that may have affected performance.
Client had difficulty with /f/ initial though she was stimulable for /f/ final in CVC. There also seems to be a facilitating context in that she could produce /f/ more easily if it followed the vowels /o/ and /i/. Assessment
Plan includes a statement about what is planned for the next treatment session
Continue to target /f/ sound initial and final and probe for stimulability for /f/ in the medial position of single words Plan
Primary tool for data reporting in the university setting for each session the SOAP note
Should be concise and detailed abbreviations OK sentence fragments OK SOAP note
SOAP notes are written for each session and at the end of the semester are used to write end of semester treatment or progress reports
SOAP notes must be written in a timely and accurate manner in order for them to be used to determine if true progress is being made
In a medical setting SOAP notes may contain medical terms including abbreviations and symbols see appendix J and FIM scores Functional Independence Measures
Inpatient Rehabilitative Facility Patient Assessment Instrument IRF PAI
IRF PAI measures patient’s current level of functioning develops goals measures progress and determines when a patient is ready to be discharged
Data on a patient in a medical setting including the SLP is gathered on a IRF PAI required for Medicare Part A IRF PAI also rates them on a FIM basis
Schools don’t use SOAP notes you may need to devise your own system or use school’s existing system of reporting data
Each child’s progress must be included in their IEP it is federally mandated
Patients who are in therapy for an extended period of time require long term progress reports and potentially discharge summaries
Final treatment report or progress report = Long term progress reporting in university setting a final report that includes data for all the clients goals for the entire term.
Long term progress reports from a university setting might be sent to child’s school and other professionals such as clinic supervisor psychologist physicians etc.
If child was referred it is standard practice to include with the long term progress report a thank you note for the referral of client
Short term and long term progress reporting is required by ASHA and third party payers helps maintain accreditation must be kept in a secured confidential location HIPAA
Short term and long term progress reporting is needed as clients may remain in therapy for several semesters even years and historical data is important when planning treatment each term
Adult patients end up in a university setting for treatment instead of a hospital as insurance companies often stop paying for hospital treatment after a determined number the patient has to pay out of pocket or find other treatment options
Patients end up at university settings often because fees are on a sliding scale basis can clinical staff needs clients to work with.
Short term and long term progress reports are needed because clients often have a new student clinician each semester depending on the circumstances.
Most universities expect student clinicians to work with a diverse population which is one reason why long term and short term progress reports are needed when clients transfer to a new clinician.
Short term and long term progress reporting is necessary because the client and/or parent or caregiver is provided with a record of progress. May motivate the client to continue with therapy.
Many times the long term progress report will also serve as a discharge summary which would usually be annotated in the Recommendations section of the report.
Patients are typically admitted to a Rehabilitative Facility for a pre-determined amount of time depending on the patients level of functioning Burden of Care and insurance coverage determine the amount of time
Persons aged 65 or older are covered under Medicare younger must rely on out of pocket or private insurance.
Average stay under Medicare is only 14 days but may stay longer with private insurance.
At end of stay in a rehabilitative setting one of these things happen discharged home
At times an SLP may discharge a patient from speech therapy before he/she is discharged from a facility if this happens write a discharge note on a specific form called a patient status form or patient update form and complete the Speech section on an interdisciplinary discharge form.
Upon discharge from Speech you may also have to fill out the patient education section that relates to any necessary home care
A patients stay in a hospital may be very limited acute care may only last a few days and then they may be moved to the skilled nursing wing of the hospital or discharged home.
In acute care patients generally do not have long term goals – it is the job of the professionals in this setting to get them medically stable so that they can participate in any therapies once they recover.
An SLP who sees a patient in a hospital setting may only be doing a bedside swallowing evaluation to determine if the patient is able to eat and drink food or if they need to be tube fed.
Once the patient has been transferred to another part of the hospital and out of acute care the SLP may be involved with speech
Once a doctor’s order for an evaluation is complete and the SLP evaluation occurs the SLP will begin to write goals for the patient and begin treatment.
Long term care or nursing home may be admitted here only long enough to recover and then return home once they recover adequate function.
Most patients who are admitted to a long term care facility or nursing home remain there for the rest of their life. Even though they are there for a long time they only get speech services for a specific amount of time.
Long term progress reports for a long term care facility or nursing home setting require long term progress reports - goals are often from a goal bank and objectives to support the goal goals must be functional for Medicare or 3rd party payers.
If not making progress then Medicare or 3rd party payers may stop paying for services. Long term goal is often written with time frame related to payment.
Public schools use a periodic reporting system! IEPs built in system for tracking progress benchmarks go along with long term goals and a time frame for each goal. Progress is reported to parent. It is more of a periodic reporting system at various intervals throughout the year with annual meetings.
Must report progress in order to know how clients are performing if they should continue on their course of treatment if treatment should be modified or if they should be discharged from therapy.
Long Term Progress Reporting 5 reasons required by ASHA and 3rd party payers historical data is important for long term care student clinicians likely change semester to semester the client or parent/caregiver is provided with a record of progress
Professional Correspondence report writing referral letters transmittal letters thank you letters emails memoranda
Professional correspondence speaks volumes about knowledge clinical competence organization and professionalism helps with credibility
2 types of professional writing: academic and clinical
Academic writing: research papers journal reviews answers to comprehensive test questions
Clinical writing: all the reports and other types of correspondence may differ in style
Professional writing organized easy to follow no typos or grammatical issues
Professional correspondence letterhead if a clinical facility dated at top inside address of recipient professionalrespectful greeting first para = basic info about the sender body convey reason in paras summary = reiterate purpose complimentary close signature degree position
What degree or position do I sign professional correspondence with student clinician
Four types of letters written in clinical setting: referral letters thank you letters transmittal letters and business letters
Referral Letter traditionally accompanies referral letter traditionally accompanies a diagnostic or treatment report referring a client for services outside scope of SLP services letter describes reason for the referral and introduces client
Thank you letter sent as a follow up when a client has been referred to you from another professional results in more referrals also to thank for complimentary materials toy donations when professionals donate their time to consult with you on a case
Thank you letters in exchange for time materials or finances
Transmittal Letter accompanies a diagnostic or treatment report sent to professional client parent or caregiver cannot just mail a report without a letter of explanation for document it is a cover letter essentially
Business letter to request a service or materials to correspond with insurance companies and businesses that provide administrative support such as office supplies copcying and clerical to let others know of clinical programs or establishment of new services by clinic
Letters require a specific format organization and professional communication
Memorandum or memo a business correspondence brief concise format pre-runner to email a usually brief written interoffice communication directive advisory or informative matter not intended for outside
We write memos to transmit information request information or requesting or enabling action
Check email daily it is the new memo for purposes of scheduling appointments or other tasks associated with clients well written and organized do not use text message speech abbreviations or slang
Emails may be not secure and can be hacked so don’t send client confidential information especially sensitive information be very careful
Tone of a document is the voice or attitude of a piece of writing voice can also refer to active or passive voice – use passive in professional documents
When writing to parents make sure letters are easy to understand yet professional no grammar or spelling errors and don’t trust spellcheck!
Three reasons you might contact the school SLP while working with a child at the clinic 1st to learn IEP goals 2nd how to coordinate your goals with school and 3rd to find out if the work you are doing is generalizing to the school setting 4th to find out what curricular materials might be used in your therapy for maximum generalization
School age language disorder protocol treatment activities incorporate some curricular material such as vocabulary and discussion topics so the child can receive an academic payoff in addition to the communicative gains
Professional verbal communication respect organization professional tone listening/understanding attending to the communicative context these are critical elements of interaction in all of your communications with professionals
CONTEXTS OF VERBAL COMMUNICATIONS WITH OTHER PROFESSIONALS: Consultations Staffings&Meetings Collaborations Solving Problems in Informal Daily Interactions Consultations Staffings&Meetings Collaborations Solving Problems in Informal Daily Interactions
Purpose of a Consultation to access additional information or a diff perspective on client that will assist you in your treatment program face to face allows for questions / clarifications or to consult with another prof for help specific to discipline/specialize in (ie: autism)
There is a difference between an informal consultation and a formal referral for an evaluation with the latter there are fees and often need administrative paperwork or doctor’s orders and are not done simply by professional courtesy
To involve another professional you must first obtain permission from the client or parent/guardian to protect confidentiality – a signed release before ANY consulting is done!
It is always a nice touch to provide feedback after a consultation everyone likes to know that their advice was followed and helped the situation and offer to help them in the future if you can be of any assistance
Staffings exist when there is a case that is of interest to multiple professionals the pulling together of multidisciplinary assessment information or they concern progress reports on a client who has been in treatment for a long time medical facilities and school systems
Staffings are multidisciplinary meetings chaired by the case manager where everyone must present current data towards goals relating to problem solving of difficult cases
Consultive model or collaborative model of treatment professionals from various disciplines work together to facilitate treatment progress in a particular client there are interdisciplinary multidisciplinary and transdisciplinary approaches to therapy
Of these interdisciplinary multidisciplinary and transdisciplinary approaches to therapy which has the most collaboration? Transdisciplinary has the most communication and cooperation among professionals. Close communication and collaboration.
In multidisciplinary approaches to treatment you are pretty much on your own with regard to assessing developing goals providing treatment and evaluating treatment progress.
Collaborating with other professionals takes time planning preparation and professional verbal communication
Interpersonal problems 3 major areas: mistakes misunderstandings/miscommunications crossing discipline boundaries
If you make a mistake learn from it and don’t make the same mistake again students are considered a ‘high risk’ population admit your mistake as soon as possible and explain the true nature of the situation
How to avoid mistakes? check and double check your work think about what you are planning to say before you say it think about saying it as professionally as possible
Once you perceive there may be a problem it is important to confront it ASAP negative feelings typically grow worse without bringing them out into the open communicate to the other person that you understand what they are feeling ‘let me see if I can clarify what happened’ ‘I am sorry for the misunderstanding.’
More good words: “I would never make statements to a family about something in your field. You are the expert on those issues and I value our working relationship.”
First Second and Third with Misunderstandings first validate the persons feelings about being upset then try to address the concern directly and put it in context of what actually happened and then use tone of respect to others expertise and role.
Be careful not to step on other professionals ‘turf’ diplomacy is very important “I’m not the authority on how to best deal with these behaviors but here is what I have been doing in language therapy.” Do not give advice on topics not of your specialty/area of expertise.
Verbal communications between students and supervisors: keep an open line of professional communication with your supervisors
Once you are working/practicum you see more clients schedule hectic deadlines are shorter less tolerance for mistake prof service delivery is expected and demanded and you will have more supervision initially as in closely scrutinized and more time talking together about cases
Once you are working/practicum there is also less time for supervisory conferences and thus less direction for the student less explanation and modeling to go by and elaboration on required paperwork
The degree of involvement by the supervisors decreases which leads to developing independence in the clinician leading to self-supervision you need to become more self-reliant and take more clinical responsibility for your cases
Sometimes a source of difficulty btw students and supervisors is a mismatch of expectations the expectations of supervisors steadily increases based on your past practicum experiences you need to independently plan know rationales research class notes for hints on how to handle client. Don’t be spoon fed!
Relationship btw practicum student clinical supervisor practicum student and client is a unique blend of service delivery clinical teaching and student learning
Most supervisors supervise more than the ASHA 25% mandate to ensure as much oversight as possible depending on capabilities of student and the complexity of the client’s disorder
Student Goals ethics know prefd practice patterns scope of practice policies/proceds HIPAA cultural respect evidence plan Dx/Tx methods test instruments therapy approach goals punctual accurate apply coursework good ?s self-eval good records prof good communication
Diffs btw students & supervisors credentials experience and perspective workload teacher-student relationship
Relationship between student and practicum supervisor should not get too friendly it is still one of teacher and student they are evaluating you. Make your interactions pleasant and friendly but make meaningful contributions to the teaching/learning relationship
There is still homework in a practicum setting they are expected to bring something to the table from their coursework and clinical experiences go back to class notes and look up information relevant to your cases read articles and books
Remember that all communication must be professional be respectful organized use professional terms listen and understand and pay attention to communicative context also organization professional terminology always be prepared have data be professional!
Issues can be resolved by acting professionally and using professional verbal communication
Your supervisor wants you to do things that were not addressed in your coursework read articles and handouts reconcile these with your existing knowledge need to put in the extra effort
Your supervisor does not allow you to do things that you learned in your coursework Ask your supervisor if you could add XXX goals to the therapy – most supervisors would be elated if a student suggested an addition to the treatment there is nothing wrong with asking
You only have your undergraduate training and are assigned a complicated case this likely will not happen but realize supervision will be intense do your part in terms of asking a lot of questions requesting frequent feedback and researching issues yourself in addition to info provided by supervisor
Inadequate supervision 25% is required by ASHA you can ask for more if you are organized and respectful about it
Oppressive Supervision you should have the opportunity to engage in problem solving developing strategies for selecting goals providing rationales and a role in planning again if you want something ask in an organized and respectful manner
Personality conflicts with supervisor teacher and student treat it as a learning experience be respectful and do what you are supposed to do
Differing criteria for clinical writing among supervisors find out from other prior students and shift appropriately
Differing criteria for grading ask what separates an A from a B focus on specific behaviors that will earn you the A ask for specific feedback
Supervisory conferences that run over time just say I am sorry but I have a class at this hour and I don’t want to be late
Don't do these complain to other students fail to clarify how evals will be done fail to discuss the issue with supervisor copy written materials from prior reports without thinking fail to take initiative or fail to progressivly assume more clinical responsibility
Don’t do these either be late for meetings and assignment deadlines say you understand when you don’t become frustrated with a lack of client progress or take too much initiative when you are uncertain how to handle the situation
Diagnostic Reports May be first things someone reads about a new client; must be concise yet detailed and relevant to patient's disorder
The number one thing that distinguishes professional from unprofessional written communication is organization - think alot before you begin to write or talk
Useful data to write a diagnostic report includes case history information prior tests and reports observation of client's behavior interview findings nonstandardized testing standardized testing all must be reconciled to arrive at a diagnosis
Upon writing a diagnostic report, an SLP may arrive at a diagnosis, prognosis, suggestions for further testing, clinical management suggestions, and a rationale for referral to other professionals if appropriate
Sections in a diagnostic report include identifying info background info biological bases of communication basic communication processes diagnostic test results clinical impressions summary and recommendations
What are the biological bases of communication? auditory acuity, structure and function of oral mechanism and cursory exam of neurological integrity hearing screening results oral peripheral exam/oral mech exam any neuro weaknesses: paralysis weakness, drooling, fine and gross motor skills seizures
What is meant by basic communication processes on a diagnostic report? Language articulation voice/resonance and fluency are they within normal limits? Have they been considered as an area of possible communication disorder? Could simply state: "no abnormalities were noted ... ..."
Diagnostic Reports must also focus on diagnostic testing relevant to the area of concern the most space and focus to the area of major concern
Diagnostic Reports contain clinical impressions: the clinician interprets the various test results and background information to arrive at a diagnosis and prognosis - can be longer if certain results are at odds with one another
A Diagnostic Report includes summary and recommendations: This is widely read by busy professionals summarize briefly and give specific recommendations for treatment. Treatment, no treatment or referrals are detailed here.
Things to avoid in writing style: redundancy, wordiness, lack of professional terminology, lack of objectivity and not separating fact from opinion, lack of organization and sequence, ambiguity, tense errors, spelling and typos, misuse of abbrevs, use of contractions and informal language
Diagnostic reports in these settings are often shorter and incorporate check boxes medical settings
Referral Testing by Multidisciplinary Team IEP Team meets to discuss Test Results Eligibility Determination IEP Goals Developed from referral to goals
In Behavior Management what does ABC stand for? Antecedent Behavior Contingency
Antecedent need to be concerned with and able to modify this end of BEHAVIORS
Antecedent = Stimulus Controls Attentional Prompts and Instructional Prompts
Attentional Prompts (stimulus controls) attention to task "watch my mouth" "Are you ready?" = helps with ADHD or cognitive impairments
Instructional Prompts (stimulus controls) prompts specifically related to whatever the target behavior is "remember to put your tongue up behind your teeth." "Look at me and see where my tongue is." (oral posture but also instructional)
With prompts both Attentional and Instructional which are part of stimulus controls, instructions should be clear, at age appropriate level may precede modeling or occur alone but better if both
Be sure client understands the terms within the terms if you ask that the client identify same and different, you need to verify they know the meaning of those terms
As a new clinician rehearse rehearse rehearse before opening your mouth
Stimulus Controls are: Prompting Modeling Shaping and Fading
Modeling: an antecedent and a stimulus control providing entire target to client prior to response modeling is good to use at start of task might use more with certain populations such as developmentally delayed individuals There is a difference btw modeling and imitation
Shaping is another stimulus control Shaping: successive approximations used when cannot imitate First step must be something the child can imitate at least with prompts
Shaping is what we use when even with very clear models the child cannot do the target behavior then we jump in with shaping and successive approximations whatever the target is we break it down into very small steps to provide stepping stones
Successive Approximations are used when the client cannot imitate target responses; target is broken into smaller steps of increasing difficulty each step moving closer to goal behavior may manually guide tongue depressor mirror chart diagram etc. move as approximations are somewhat stable
Don't overly reinforce intermediate steps
Feedback must be neutral reinforce what they are doing correctly but realize that neutral is what you need on those stepping stones so they don't get stuck there
Shaping is widely used in SLP because we often cannot get the ultimate target but we can take something a little bit closer and gradually get them to that point
Next Stimulus Control is FADING At a certain point you have to back off from all the support and allow generalization and independence. Gradually reduce models prompts etc.
Fading brings behavior more under the control of real-life situations makes it more under the client's control and makes them more independent
You have to have fading if you are ever going to have generalization and get maintenance - that the person will stay with that behavior that they don't need you for support
Initiate fading once the client can produce 5 consecutive correct imitations at that point start backing off make prompts and modeling less frequent move to a prompt or less complete model
Sometimes when you begin fading you need to go back to a more supportive role and then back off again - this is very client specific
Part B is the Behavior of the Antecedent Behavior Contingency thing
Part C = Reinforcement and Punishments Contingencies
Positive Reinforcer Occurs immediately after a behavior occurs is something ADDED and causes the behavior to INCREASE
You can't know for sure if something is a postive reinforcer until you use it because you can't tell if it is going to help the behavior INCREASE until you use it
How do you know what to use as a positive reinforcer if you cannot know in advance? You go by client history input etc. but you still don't know if the thing will be a positive reinforcer until you see it work.
Candy is NOT a reinforcer
If you use the same reinforcer over and over again it is no longer a positive reinforcer because of satiation
There are two types of Reinforcers Primary and Secondary
Primary Reinforcers are not learned they are need based food is the most common example of a primary reinforcer used more frequently with certain populations good to move toward secondary due to satiation
Primary Reinforcer Not learned; something that we need innately; effects not dependent on past experience
Billie says Candy is NOT a reinforcer and that she is 'SO not a fan of primary reinforcers...'
Primary Reinforcers have a limitation Especially if food - satiation - how much chocolate can you eat before it loses its appeal? Also have to wait for them to CHEW not good during speech therapy and also allergies, obesity, parents may object
Food as primary? You don't always get an M&M for doing something good in the world... doesn't transfer well to generalization and maintenance
Primary reinforcers are not good reinforcers for language Juice for juice yes, but in general saying something and getting food for it doesn't really make sense.
Secondary Reinforcers are learned - we learned at some point that these things are good in CMD we DO use these...
There are two types of Token use for 2ndary Reinforcers... Token Economy and High Probability
Token Economy: You get chips that have no value but you can trade them in for a coveted item
High Probability: Person gets all these chips and then you get to play with a coveted thing or preferred activity for 3 minutes
Must be very consistent with how tokens are traded in Must be very consistent with how tokens are traded in and 'stick to your guns.'
2ndary Reinforcers: are not satiable, do not interrupt session, are useful in fading a primary reinforcer
Token Economy: tokens themselves have no value but are used to gain a variety of 'true' reinforcers
Should have plenty of and a variety of back-up reinforcers stickers, prizes = don't need to know what that particular client likes - they get to pick
Token versus High Probability Token = chips with tangible reinforcer; High-Probability = chips in exchange for client preferred event (going to the movie going to the cafe taking a walk)
Adult clients could earn chips to go to the Activity Therapist This could be part of their activity with the Activity Therapist in their session
Don't always need a reinforcer with adults some just want to make progress, communicate with spouse, happy to see progress on a chart - but sometimes especially those with head injuries need something extrinsic to make progress
What are the strengths of a 2ndary reinforcer? Doesn't depend on deprivation, easy to administer, doesn't interrupt session, and even if it is food just get it at end of session.
Send a note home to parents asking to bring in toys that only cost a dollar or two to donate to a prize box with the understanding that they will be given away kids love seeing who got their stuff and getting a 'toy' that belonged previously to another child.
Performance Feedback is the other 2ndary reinforcer It is info to client regarding performance and progress
What are some examples of 2ndary reinforcers with regard to Performance Feedback? Graphs, percentage data, biofeedback = encourages development of intrinsic rewards (internal satisfaction and motivation)
Clients need to know how well they are doing want to know... you need to use performance feedback here charts, graphs, percentages of accuracy for performance across a session, biofeedback can be used with voice and fluency cases
If a client has a neurological condition using a graph for performance feedback is good, why? Because with a neurological condition you need to provide feedback that is easy to comprehend and doesn't require a lot of language to get the feedback
With regard to reading though, reinforcement should be intrinsic or extrinsic? The reward is that you can READ!! You don't want to be teaching them to read and the reward it time on the IPAD. The reward is that you are able to READ!!
Helps maintain target behaviors: seeing good results or seeing that they need to be making better progress or feedback compared week to week - keeps them working towards their goals. Visual feedback must be CLEAR!
Positive Contingency Behaviors Positive Reinforcers Primary and Secondary
Negative relates to Punishment
Punishment is: something negative added to the situation that DECREASES a behavior you don't want to occur; It is NOT something taken away - it is something ADDED that DECREASES a behavior...
There are two types of Punishment: Type I and Type II
Fading: Fading • gradual reduction of special stimulus conditions • brings target behavior more under control of real-life situations
DRO DRO - Differential Reinforcement of Other Behaviors • specify a behavior not reinforced • use to control uncooperative/ inattentive behaviors
Type I adversive consequence. Adversive consequence occurs IMMEDIATELY after undesired behavior to create a DECREASE in the behavior (no, we don't do that, frowning, etc.)
Type II Take something AWAY IMMEDIATELY after unwanted behavior... something the child wants is taken away immediately after the behavior occurs Time Outs Response Cost
Two Types of Type II Time Out and Response Cost
Time Out remove client in a minor way = take away clinician attention, sit in another part of the room where cannot participate with the group NOT standing in the corner
Response Co where the consequence occurs when a positive reinforcer already earned is taken away for a behavior. Child has already earned tokens but one is taken away for an undesirable behavior other than a speech behavior keep all your stars!
Positive Reinforcers are much more motivating and preschool kids don't have a lot of control over their behaviors hard for them to understand connections why something they earned is being taken from them.
DRO reinforce something good either in that child or in another child BEST POSSIBLE WAY TO GO Better than punishment Valuable. Effective. Good for getting kids on the right track.
DRO pick a good behavior that is NOT being reinforced and that is the OPPOSITE of the bad behavior. Use to control uncooperative and inattentive behaviors.
DRO DRO reinforces opposite behavior Differential Reinforcement of Other Behavior
DRO when the child you are working with does something CLOSE to the desired behavior reward IMMEDIATELY!
There are two main schedules: Continuous and Intermittent
Continuous means you are going to reward every single time the behavior occurs you reinforce it
Intermittent is when you reward a behavior on a schedule a number or a time period
Continuous Reinforcement originally you get a high rate of response. Use this only with NEW BEHAVIORS or WHEN CHANGING THE DIFFICULTY LEVEL.
Continuous Reinforcement is very susceptible to extinction due to satiation - also if you are giving it to me all the time and then you don't once, and then not again, the behavior gets extinguished.
Intermittant Reinforcement: 4 types of schedules: Fixed Ratio Fixed Interval Variable Ratio Variable Interval
Fixed Ratio and Fixed Interval reinforcement is predictable and right after client is reinforced may see a decline in correct response because they just got the reinforcer. People start to predict works early on...
Variable Ratio: every so many occurences every 1st, then every 7th then every 5th response gets reinforced
Variable Interval every so many minutes after every 3rd min every 5th, every 8th every 3rd minute for frequency to keep them on task.
Proxemics are the special arrangement between client and clinician
You have to do this while doing therapy collect data without it being distracting to client positioning should enhance record keeping
Assure that you can see the clients face during therapy and data collection especially with speech sounds you need to be looking at their face prior to recording the data
Seating arrangement should be in sync with the task/objective (reading versus phonology versus mirror) sitting kitty corner close by works well
If you are using a mirror you should BOTH be looking in the mirror
Keep client on non-writing side so that you can write
Reinforcement in a testing scenario needs to be ambiguous so that you don’t skew results or accidentally reinforce non-goal behaviors or decrease motivation
In therapy you do want to say things like “Your tongue was in the right position for /t/ very specific is GOOD in therapy. Don’t just say ‘good’ they need to know what they DID that is good.
Avoid discriminatory feedback if the client says something ‘wrong’ you need to tell them – your feedback cannot always be positive… “Aw – that was really slushy – let’s get that tongue tip up and try again.”
Lateralization wet sound and dry skinny air Linda Mood
With regard to reinforcement client should know requirements for tangible reinforcer prior to start of session as with a token economy – they need to know the rules and how to earn that reinforcer.
With regard to reinforcers you can’t change your mind or the rules mid session / mid game – if the client needed 50 tokens and they only are at 30 you can’t change the rules.
Don’t give a food reinforcer for a word juice for juice is more natural
Watch out for ‘OK Syndrome’ it’s when you have some stereotypical utterance that you say over and over again – filler or tag words can be very distracting in therapy – just don’t overuse something
5 Functions of OK: Conversational Filler Tag Question Providing Feedback Positive Reinforcer Answering Questions to Self none of these are good
5 Functions why not conversational filler – need rehearsing We are going to do this – OK? As feedback is not specific enough as Positive Reinforcer not firm enough reinforcer and as response to self We are going to play this game – OK? OK – lets go Not a good idea.
5 Functions how to stop them videotape yourself you will see what you do and then will be able to catch yourself
Don’t talk too much in therapy if you are talking the client isn’t and don’t step on what someone else is saying
Record and calculate percentage of time that you are talking versus client is talking let the client respond and silence is OK – often relates to processing time
Bloom Prescott Analysis 1972 an analysis piece where you score 5 items related to client and yourself relating to time
Remember your language level should be just above the client’s level you don’t talk in ten word sentences to a child who uses 2 word sentences
Adapt your language to suit client with regard to age cognitive level disability etc don’t talk to adults like children if they have cognitive impairments you use chunking of language for delivery of message instead of spewing out a whole pile of information
Fostering Dependency always work toward making the client more independent which leads to generalization and carry over more independence leads to earlier discharge.
Things that lead to independence give client assignments have them tell you how THEY think they did you want them to think about how they are doing they need to take responsibility for their disorder.
Be careful you may increase dependency by overhelping being in charge too much
Choice Constancy if they are choosing between five things and you take one away must put a fifth one back in the mix if you reduce the number of items it distorts the data collection too
Keep consistent with your requests point to the thing you write with point to the thing you drink with point to the thing you open a door with etc.
Reading Sequence always left to right and always top to bottom make sure it reads that way to the client same for presenting materials letters words or materials put them out in the direction we look at them natural way we look at things
Natural Elicitation of Responses go for natural way of saying things instead of saying ‘say the whole thing’ remember the idea is communicative effectiveness in normal conversation makes it more functional
Play is great for elicitation of responses because you can get the client to say what you want them to say in a natural setting natural responses = functionality get out the doll house the train set the store etc with kids
Don’t ask questions if you won’t accept the answer Don’t say “do you want to play this game?” cause they might say no. Child should always have choices just not about which activities. Use a Now/Next board and leave final activity off because that is usually the reinforcing activity. They can’t move that.
DON’T ASK QUESTIONS with OBVIOUS answers - there is no need to ask a question that the child and you both know the answer to. If you do this it becomes condescending and the client will be less engaged.
Be on eye level with a child decreases authority aspect and makes them more likely to engage.
USE CLEAR CONCISE DIRECTIONS: Beginning clinician – have a script. If you are giving a test there is likely already a script in the test packet. Have something right there – you don’t want to sound stilted but you need to be not talking off the cuff. Don’t want to be stumbling all over the place.
State in the declarative: You’ll do this you’ll do this you’ll do this.
Allow sufficient time for the client to respond don’t jump in too quickly or repeat it too quickly if the person has cognitive or comprehension issues you need to allow them time after being asked a question.
Focus on the Target Behavior not on the activity shouldn’t be too hard or too involved take too long to explain or too elaborate takes time away from the session from the focal behaviors.
Receptive Tasks MUST MEASURE GOAL need to keep other factors in the task constant keep other factors out that could be hints – don’t let there be key words in the stimulus that ‘help’ client respond – if you say put the pen on the table and then look at table they got ½ the answer.
Do Group Therapy not Therapy in Groups: allow for all clients to have opportunity to practice and for them to interact with each other not just you – build activity so that there is interaction between clients.
Group Therapy must consider size of the group smaller with new skill larger with maintenance large is OK at maintenance level because there are more individuals to interact with
How many kids in group 2 – 6 for kids
How many adults in a group? 7 – 12 0 can vary Dependent on purpose of group (skill learning support carry-over etc.)
GROUP COMPOSITION: Consider age gender disorder severity. Keep little ones closer in age. More successful with more homogenous groups. For kids should be within 2 – 3 years in age.
CLINICIAN’S ROLE: Clinician’s role in a group can be very directive or non-directive in style. For very young kids you have to be very directive but that doesn’t mean do drill cards. Rather
Directive versus non-directive Older kids you can be somewhat less directive. Can give them more choices let them make more decisions. Don’t let them change the direction of the therapy session. Older kids = self-help/ nondirective.
Age of clients makes a difference in agenda material selection what level of instruction what level of feedback.
Always be a mediator who is assuring progress of members in both directive and non-directive.
Watch your body language non-verbal behaviors positioning etc can convey boredom or nervousness no gum no yawning no nail biting no looking at the clock when keeping track of time has to be discreet
THE GAME: Make the target behaviors the focus. Don’t let the game be the focus. If you are doing one on one you need to be playing the game with the child. Don’t ever play the game without the child.
Kids can get very competitive. Assure responses are more important than the game. Competitiveness can be good but it should not just be about winning the game.
CARRY OVER = GENERALIZATION They need to be able to take that skill and use it in other settings. Don’t just do the self-monitoring process at the end of the session or therapy program. They need to learn to monitor for correct / incorrect responses – get them THINKING ABOUT IT.
Carry Over HW and self-monitoring are important. Homework starts RIGHT AWAY. Never give them something to do at home that they haven’t already shown they can do in therapy. Even if it is something very very minor it is the responsibility that creates independence.
HW WORK LOAD AND TIME COMMITMENT: Everybody is busy. MAKE SURE YOU TALK TO PARENTS – MAKE SURE IT DOESN’T TAKE MORE THAN 5 – 10 MINUTES Some people do homework in am in pm at dinner table you need to talk to the family if at all possible. Homework is NOT just for kids.
HW: Be sure assignments are reasonable (work load and time commitment.) When give assignments be sure to CHECK AT THE START OF THE NEXT SESSION!!!!! If you don’t they WON’T DO HOMEWORK!!!
Assignments Start early in tx not just carryover. things the client can do review best time of day with family member MAKE DATA COLLECTION EASY. YOU MUST COLLECT DATA ON HOMEWORK – including data even if collected in an easy manner makes for GREATER ACCOUNTABILITY.
Materials CLIENT CAN HELP SELECT STIMULUS ITEMS: makes them more responsible in working toward their goals.
Where are Materials Made? When? Clinician creates materials OUTSIDE. Helps client with the kind of things they want to work on -= progress towards their goals. Help me think of all the things need to play soccer – DON’T make the material DURING THERAPY though.
GET READY FOR CLOSURE: We need warning when time is almost over. Need some kind of a warning. At end of session work on something that they are having success with. Don’t let them go home discouraged. A little bit of time feeling successful before they leave is important.
Reasons for Self Supervision assess strengths needs develop skills understand interactions assure accountability to understand issues and be aware of resources
Strategies for Self-Supervision self-instruction problem solving modeling rehearsal self-determination of criteria self-contracting
Once you are aware of your own behavior you can improve performance
When good self-evaluation skills have been developed it is possible to become independent
In schools use curriculum based therapy therapy linked to IEP IEP linked to curriculum
IDEA Procedural Safeguards school setting Permission to Evaluate Procedural Safeguards Letter Procedural Safeguards Notice Evaluation Report Invitation to Participate in the IEP Team Meeting or Other Meeting IEP Notice of Recommended Edu Placement and Permission to Reevaluate
In schools there is a lot of paperwork that changes due to regulations and mandates
When implementing play therapy follow the child’s lead keep it fun and structure the unstructured keep record of responses have determined goals plan for session and guide client to meet goals visualize ahead of time situations
Holding the pen in your writing hand keeps, record keeping consistent
With a child who doesn’t want to be there, sit close to the door
Prior to the start of each session, check seating to ensure it is efficient for record keeping and client access
Keep verbal reinforcement, specific to task but also varied in lexicon makes clinician seem more involved in therapy session
Naturalistic reinforcement, juice for juice most effective when possible gaining and sustaining an adults attention getting desires and needs met engaging in pleasurable human interaction
Beginning clinicians often use unnatural presentation via emphasis or exaggeration, this complicates the task use accurate and correct models must be presented naturally
Clinicians must use and model grammar correctly, poor grammar is unacceptable if client misuses grammar respond in correct grammatical rephrasing
Keep your talking to a minimum in therapy, keep it relevant and necessary
With clients with an expressive language difficulty, keep your own use of language a step or two ahead of them do not model beyond their level
Encourage clients to take responsibility for both their problem and the therapeutic program, helps ease transition between clinicians for clients
Elicitation Techniques, Language use natural language expect natural language
Methods of eliciting articulation, manipulation of articulators placement cues visual and tactile imagery prosodic emphasis frequency of stimulus presentation model of presentation phonetic context contrasts minimal pairs
The type of cue or prompt depends on the client’s errors, start where success is likely when able to do it successively decrease support
To teach sign language begin with, the receptive modality it is important for the client to be able to ‘read’ signs
Sessions should begin with a statement of the goal by either the clinician or the client, if the client is capable they should take an active role in the opening and state what they are working on if just beginning therapy the clinician should state goal at beginning
Session close warning is important, because client may look forward to therapy and not want it to end deliver warning of close in terms the client can understand.
At close the goals should be reviewed, the client should take an active role in reviewing the goals if they are able to do so. Today you worked on /s/ at the end of words.
You can only audiotape or videotape if you have, an appropriate signed release form
Learn to be quiet and wait for a response, do not rush clients to respond
Do not name sounds by letter name, rather use phonetic sound sounds are what the client is working on!
Avoid a singsong voice when working with children, audiotape or videotape after obtaining a signed release to ensure you aren’t sing-songing
Self-observation techniques:, videotape audiotape be observed by a supervisor don’t forget the signed release form! Invite a supervisor or peer to observe you on videotape to give you feedback!
SOAP NOTES The type and length of reports varies greatly across settings. SOAP Notes are very useful in multiple settings.
Medical setting SOAP NOTES shorter short notes might be checklist based
We need to know everything that goes into a SOAP Note that is why they are so intense in the university setting.
SOAP notes progress notes in a therapy setting progress note written at end of every session with client in a therapeutic setting this is our documentation
We write SOAP notes everywhere except schools. Every setting including private schools just not public schools.
SOAP stands for subjective objective assessment and planning
When SOAP notes began they began in medical settings originally were very medically oriented was a way to chart things in medical chart
Public School Settings see so many kids so that we why we don’t use SOAP notes – use different form of documentation that is added in to IEP on a quarterly basis
SUBJECTIVE interview case history something perceived something said in interview something not hard and fast data something heard or observed patient’s perception “I am really tired today; Mom stating: “X is pretty wired today. I hope she settles down for you.”
SUBJECTIVE in SOAP NOTES you can put in a direct quote could also be just your opinion regarding relevant client behavior or status
OBJECTIVE in SOAP notes = test results or task data recorded from session something factual that can be seen or heard
ASSESSMENT in SOAP notes CONCLUSION based on Subjective/Objective Data take a look at actual data and make comment on why that data might have happened that way based on interpretation of data and Subjective/Objective input May compare to previous session
ASSESSMENT: Fading of clinician model may have been premature. Today’s results of X% reflect a decrease in accuracy compared to X-Data from two previous sessions.
SOAP Notes Assessment: the analysis of the data may be a reflection on the clinician’s choices of task or could be reflection on client’s subjective or objective input
PLAN in SOAP Notes: plan for next session – relate to THIS session. Based on this combination. Bring it all together the SOA part and come up with the P part.
PLAN can also include in SOAP Notes that the client may need more testing plan to administer a test in next session bring a diff kind of procedure
In SOAP Notes PLAN: you should be able to pick it up and know EXACTLY what you need to plan for the next session what you plan to do next therapy targets for next session. May state “pt will be seen again on what date” but don’t have to list this.
PLAN example continue to work on both tasks at same level but increase clinician modeling on plural task to a 2:1 ratio. Don’t need to restate the tasks.
IMPORTANT to have a DAILY NOTE SOAP Notes provide daily brief notation of what happened when it happened and the outcome.



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