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Baselines are clinician-designed measures that provide multiple opportunities for a client to demonstrate a given communicative behavior. A good rule of thumb is to include a minimum of 20 stimuli on each pretreatment baseline. The ratio of correct versus incorrect responses is calculated; the resulting percentage is used to determine whether the behavior should be selected as a therapy target. Ultimately, however, the selection of appropriate therapy targets relies heavily on clinical judgment.
Other clinicians argue strongly that behaviors with much lower baseline rates of accuracy may be the most appropriate choices based on individual client characteristics e. Often, clients present with several behaviors that qualify as candidates for remediation.
For individuals who demonstrate a large number of errors, clinicians may choose a broad programming strategy that attacks as many targets as possible in a given time frame.
Alternatively, clinicians may select a deep programming strategy for clients who demonstrate either relatively few or highly atypical errors. This strategy is based on known normative sequences of communicative behaviors in typically achieving individuals.
Therapy targets are taught in the same general order as they emerge developmentally. When two or more potential targets are identified from baseline procedures, the earliest emerging behaviors are selected as the first therapy objectives. Following are two examples that illustrate use of the developmental strategy.
A 5-year-old child with an articulation disorder produces the following speech sound errors on baseline procedures: 1. The plural marker is the next behavior to be targeted, followed by the regular past tense form. Therefore, intervention may not be warranted. The developmental strategy tends to be most effective for articulation and language intervention with children.
This strategy has less application for adults and disorders of voice and fluency. A developmental strategy for target selection should be implemented with careful consideration of at least two factors.
The sample population from which the norms were derived may have been too small to permit valid generalization of the findings to other populations. Moreover, the characteristics of the standardization sample e. The Client-Specific Strategy. This last factor addresses the notion of stimulability, which is typically defined as the degree to which a client can approximate the correct production of an error pattern on imitation.
Following are two examples that illustrate the use of the client-specific strategy. Max Asquith, a year-old computer programmer, demonstrates the following speech and language characteristics on pretreatment baseline procedures: 1. Distortion of vowels in all word positions 3.
Difficulty with the accurate use of spatial, temporal, and numerical vocabulary 6. An appropriate initial language target for this client would be vocabulary words that convey number concepts because his position as a computer programmer relies heavily on the use of this terminology. A 6-year-old child with an articulation disorder exhibits the following speech sound errors on baseline procedures: 1.
Unlike the developmental approach, a client-specific strategy can be implemented across a wide range of communication disorders with both pediatric and adult populations. In addition, a combination of the two strategies is often an effective way to approach therapy target selection for children with speech and language impairments. Sequencing of Therapy Targets Following therapy target selection and prioritization, programming involves the development of a logical sequence of steps that will be implemented to accomplish each objective.
Three major factors determine the progression of the therapy sequence: stimulus type, task mode, and response level. The following outline presents a hierarchy of complexity for each of these factors. Stimulus Type nature of input used to elicit target responses 1. Direct physical manipulation 2.
Imitation 2. Spontaneous Response Level degree of difficulty of target responses 1 1. Decrease latency actual time between stimulus presentation and client response The sequencing process starts with a decision regarding the most appropriate level to begin training on each target behavior.
Pretreatment baseline data for a given target are analyzed to determine the entry training level. In this example, therapy would begin at the word level of difficulty. Adherence to these procedures generally will result in a progression of targets at the appropriate levels of difficulty.
However, there may be occasions when a client does not perform as predicted; a chosen task turns out to be too difficult or too easy for the individual at this time. The clinician must recognize this situation when it occurs and immediately modify the task rather than persisting with the original plan.
This modification is known as branching and is achieved by increasing or decreasing the difficulty level by one step according to the therapy sequence hierarchies listed previously. Other response types such as gesture, sign, and writing, may require alternative hierarchies of difficulty.
Generalization is enhanced when intervention is provided in the most authentic, realistic contexts possible. Generalization should not be viewed as a distinct event that occurs only in the final phase of the therapy process.
Rather, it is an integral part of programming that requires attention from the very beginning. Three main factors can influence the degree to which successful generalization occurs. A variety of stimuli objects, pictures, questions should be used during therapy activities to avoid tying learning to only a small set of specific stimulus items.
Similarly, the clinician should vary the physical environment location in room, location in building, real-world locations in which therapy occurs as soon as a new target behavior has been established. Finally, clinicians should bear in mind that target behaviors frequently become attached to the individual who consistently reinforces them i. Therefore, it is important to vary the audience familiar adult, sibling, unfamiliar adult with whom therapy targets are practiced, to maximize the likelihood of successful generalization.
Termination of Therapy It is difficult to definitively state the point at which intervention services are no longer warranted. At the current time, there are no valid empirical data that can be used to determine appropriate dismissal criteria for any particular communicative disorder. Therefore, it is beyond the scope of this book to indicate realistic time frames for the duration of intervention. The authors strongly believe that the establishment of reliable treatment outcome measures is critical in the current climate of professional accountability in both the public and private sectors.
Within the past few years, the availability of efficacy data has increased significantly for a variety of communication disorders. This information will be presented throughout the book in pertinent chapters. In education settings, student progress is measured through benchmarks, which are sets of skills required to achieve specific learning standards. These objectives must be clearly delineated to ensure appropriate and effective intervention programming.
A widely used approach to task design is the formulation of behavioral objectives. A behavioral objective is a statement that describes a specific target behavior in observable and measurable terms. There are three main components of a behavioral objective: 1.
Condition 3. Thus, behavioral objectives should contain verbs that denote observable activity; nonaction verbs should be avoided. List 1 contains examples of verbs that are appropriate for inclusion in behavioral objectives; list 2 is made up of verbs that are unacceptable because they refer to behaviors that cannot be observed.
The condition portion of a behavioral objective identifies the situation in which the target behavior is to be performed.
It specifies one or more of the following: when the behavior will occur, where it will be performed, in whose presence, or what materials and cues will be used to elicit the target.
It can be expressed in several ways, including percent correct, within a given time period, minimum number of correct responses, or maximum number of error responses. The following examples illustrate how to formulate behavioral objectives. Example A 1. Condition: Given a written list of multisyllabic words 3. Criterion: With no more than four errors Behavioral objective: The client will verbally segment written multisyllabic words into their component syllables with no more than four errors.
Example B 1. Condition: Reading single sentences 3. Additional examples of behavioral objectives and worksheets are provided in Appendixes 1-B and 1-C at the end of this chapter. Appendix 1-D contains a sample Daily Therapy Plan that illustrates the following components of a single session: behavioral objectives, client data, and clinician comments. This is accomplished through application of the principles of behavior modification. Behavior modification is based on the theory of operant conditioning and involves the relationship among a stimulus, a response, and a consequent event Skinner, A stimulus or antecedent event is an event that precedes and elicits a response.
A response is the behavior exhibited by an individual on presentation of the stimulus. A consequence is an event that is contingent on and immediately follows the response. There are different types of consequent events. Consequences that increase the probability that a particular behavior will recur are known as reinforcement. Those that are designed to decrease the frequency of a behavior are termed punishment.
Types of Reinforcement There are two basic types of reinforcement: positive reinforcement and negative reinforcement. Both types are used to increase the frequency of a target response. Positive Reinforcement. Positive reinforcement is a rewarding event or condition that is presented contingent on the performance of a desired behavior.
These are contingent events to which a client reacts favorably due to the biological makeup or physiologic predisposition of the individual. Food is the most common example of a primary reinforcer.
This type of reinforcer is very powerful and is used most effectively to establish new communicative behaviors i. Low-functioning clients often respond well to the basic nature of primary reinforcers.
There are known disadvantages of primary reinforcement. First, it can be difficult to present the reinforcement immediately after every occurrence of the target behavior. Finally, skills that are taught using these contingent events are often difficult to generalize outside the therapy setting, because primary reinforcers do not occur naturally in the real world. These are contingent events that a client must be taught to perceive as rewarding. It is the most commonly used type of reinforcement in speech-language remediation programs.
Social reinforcers are extremely easy to administer after each target response and generally do not disrupt the flow of a therapy session. Token: This group of reinforcers consists of symbols or objects that are not perceived as valuable in and of themselves. However, the accrual of a specified number of these tokens will permit a client to obtain a previously agreed-on reward. Examples include stickers, checkmarks, chips, and point scores. These reinforcers are generally regarded as very powerful because they are easy to administer contingent on each occurrence of a target behavior and are relatively resistant to satiation.
Performance feedback: This category of reinforcers involves information that is given to a client regarding therapy performance and progress. Many individuals find it rewarding to receive information about the quality of their performance.
It is not intended to function as praise and need not be presented verbally. Feedback regarding client performance can be delivered in various formats, including percentage data, frequency of occurrence graphs, numerical ratings, and biofeedback devices. Negative Reinforcement.
This type of reinforcer requires the presence of a condition that the client perceives as aversive. Each performance of the target behavior relieves or terminates this aversive condition, thus increasing the probability that the specified behavior will recur. With this type of negative reinforcer, each performance of a target behavior prevents the occurrence of an anticipated aversive condition. This contingent event results in increased rates of performance of the desired response on subsequent occasions.
Use of negative reinforcement is relatively uncommon in the treatment of communication disorders because it repeatedly exposes clients to unpleasant or aversive situations. Use of positive reinforcement is the preferred method for increasing the frequency of desired responses.
An event is presented contingent on the performance of an undesired behavior, to decrease the likelihood that the behavior will recur. Type I. This involves the prompt presentation of an aversive consequence after each demonstration of an unwanted behavior. Type II. This type of punishment requires withdrawal of a pleasant condition contingent on the demonstration of an unwanted behavior. Time-out and response cost are the two most common forms used in speech-language intervention.
Time-out procedures involve the temporary isolation or removal of a client to an environment with limited or no opportunity to receive positive reinforcement. Response cost contingencies occur when previously earned positive reinforcers are deducted or taken back each time the undesirable behavior is demonstrated. This type of punishment can take various forms, including removal of stickers earned for previous correct responses or the partial subtraction of points already accrued by the client earlier in a therapy session.
Sometimes, the clinician may choose to give a client several unearned tokens at the beginning of a session or task to institute response cost procedures. Punishment should not be programmed in graduated levels of intensity; this creates the potential for client habituation to the punishing stimulus, thus reducing its effectiveness.
Punishment duration should be as brief as possible; lengthy periods of punishment call into question the strength of the chosen punishing stimulus. Punishment procedures should be employed with caution in the therapy setting because there are undesirable effects associated with their use. These may include client anger, aggression, a reluctance to engage in any communicative behavior with the therapist, and the avoidance or actual termination of treatment.
This phenomenon is known as extinction and is used in therapy to eliminate behaviors that interfere with effective communication. Extinction does not occur immediately. In fact, a temporary increase in emission rate may be observed when the behavior is initially ignored. Behaviors that receive reinforcement on a continuous basis are most vulnerable to extinction, whereas those that are only periodically reinforced over a long period of time are least susceptible to this procedure.
It is recommended that extinction procedures that are implemented for an undesired behavior e. The clinician should anticipate the possibility that a client may not pay attention or cooperate with the session plan.
The clinician must now focus on behavior management in addition to behavior modification. Currently, a system of positive behavioral supports PBS is recommended for dealing with challenging behaviors. PBS is a pro-active approach that uses interpersonal and environmental strategies to minimize opportunities for problematic behavior and encourages more socially useful behaviors.
Thus, PBS shifts the emphasis of behavior management from a reactive, aversive approach to one that is more preventative and positive in nature. A PBS plan can be developed for individuals, classrooms, school districts, or state-wide systems. Schedules of Reinforcement Once the appropriate type of reinforcer has been selected for a given client, the clinician must decide how often the reinforcer will be delivered.
The two main schedules of reinforcement are continuous and intermittent. Continuous Reinforcement. A reinforcer is presented after every correct performance of a target behavior. It is most commonly used to shape and establish new communication behaviors. It also can be used when transitioning an already established skill from one level of difficulty to the next e. The primary disadvantage of this schedule is that behaviors reinforced at such a high density level are very susceptible to extinction.
Intermittent Reinforcement. With this schedule, only some occurrences of a correct response are followed by a reinforcer. Intermittent reinforcement, often termed lower density, is most effective in strengthening responses that have been previously established. The four types of intermittent schedules are as follows. Fixed Ratio. A specific number of correct responses must be exhibited before a reinforcer is delivered e.
The required number is determined by the clinician and remains unchanged throughout a therapy task. This reinforcement schedule generally elicits a high rate of response. Fixed Interval. Reinforcement is delivered for the first correct response made after a predetermined time period has elapsed e.
The main disadvantage of this schedule is that response rate tends to decline dramatically immediately following presentation of the reinforcer, and therefore a fixed interval schedule may be an inefficient use of therapy time.
Variable Ratio VR. The number of correct responses required for the delivery of a reinforcer varies from trial to trial according to a predetermined pattern set by the clinician. For example, the pattern might be as follows: after the third response; then after the tenth response; then after the fourth response; then after the seventh response. This ratio, represented as VR: 3, 10, 4, 7, would be repeated throughout a therapy task. This schedule tends to be more effective than a fixed ratio schedule because the client cannot predict the seemingly random pattern of delivery and anticipates that every response has an equal chance of being reinforced.
Variable Interval VI. This schedule is similar to a variable ratio except that the clinician varies the time period required for reinforcement delivery rather than the number of responses.
For example, one interval pattern might be as follows: after 3 minutes; then after 10 minutes; then after 1 minute; then after 4 minutes. This pattern, represented as VI: 3, 10, 1, 4, would be repeated throughout a therapy task. In general practice, continuous reinforcement is used to establish a new target behavior. Intermittent schedules are introduced in subsequent stages of therapy to promote maintenance and generalization.
Indirect modeling: Clinician demonstrates a specific behavior frequently to expose a client to numerous well-formed examples of the target behavior.
Shaping by successive approximation: A target behavior is broken down into small components and taught in an ascending sequence of difficulty. Fading: Stimulus or consequence manipulations e. Negative practice: The client is required to intentionally produce a target behavior using a habitual error pattern.
This procedure is generally employed to facilitate learning by highlighting the contrast between the error pattern and the desired response. This type of feedback contrasts with generalized feedback or consequences. Direct modeling is the teaching technique most frequently used in the early stages of therapy.
It is also employed whenever a target behavior is shifted to a higher level of response difficulty, because this type of modeling provides the maximum amount of clinician support. Typically, clinicians augment direct models with a variety of visual and verbal cues to establish correct responses at the level of imitation. Direct modeling also minimizes the likelihood that a client will produce his or her customary error response.
Initially, a direct model is provided before each client response. Once a target behavior is established, continuous modeling should be eliminated, because it does not facilitate strengthening or maintaining a target response. Direct modeling can be terminated abruptly or faded gradually. Gradual fading can be accomplished in at least two ways. One requires a client to produce multiple imitations for each model demonstrated by the clinician e. The second method involves the progressive reduction of the length of the behavior modeled by the clinician.
In some cases, the stimulus alone is not sufficient to elicit the desired response. Prompts are extra verbal and nonverbal cues designed to help a client produce the target behavior.
Prompts can be categorized as attentional or instructional. Instructional cues provide information that is directly related to the specific target behavior being attempted. In such instances, procedures for shaping by successive approximation are usually instituted.
The simplification of a difficult target into a series of more manageable tasks fosters client success at each step. Each successive step moves progressively closer to the final form of the desired response. Target-specific feedback is a technique that is useful throughout all phases of the therapy process. It serves three main functions.
First, clients benefit from feedback that consists of more than simple accuracy judgments regarding their responses. Targetspecific feedback provides precise information about why responses are correct or incorrect e. Finally, this type of feedback assists clinicians in maintaining client focus on the communication behavior being targeted by a given therapy activity.
It is a particularly helpful strategy for beginning clinicians who may get too involved in the details or rules of an activity and lose sight of the true purpose of the therapy task. This procedure generally is implemented only after a client demonstrates the ability to produce a given target consistently at the level of imitation.
Negative practice is a powerful technique that is best used on a short-term basis. Devoting a significant amount of therapy to client practice on incorrect responses is of questionable value.
In addition to the specific training techniques just discussed, clinicians frequently use the general stimulation procedures of indirect modeling and expansion. These strategies can be employed at any stage in the therapy process.
They provide a client with increased exposure to instances of desirable speech, language, or communication behaviors but are not intended to elicit immediate specific responses. Homework Once a target communication behavior has been established in therapy using the teaching strategies specified in the previous section, homework assignments can be given to strengthen the response and facilitate its generalization outside the clinical setting.
Therefore, it should focus only on targets that have been solidly established in therapy. Homework should be instituted only after a client has demonstrated a basic ability to accurately evaluate his or her performance on a given target.
For example, activities that involve a daily commitment of 5 to 10 minutes may be more effective than those that require 30 to 45 minutes once a week. Homework should be assigned on a regular basis throughout the course of therapy. Homework assignments should always be accompanied by simple written instructions that specify exactly what the client is expected to do.
Review and check homework during the initial portion of the next therapy session. Homework activities can be supervised by a variety of individuals e.
The first decision to be made is whether treatment will be delivered in an individual or group setting. Session design for both of these formats requires consideration of the basic factors discussed in the sections that follow. Elements that are specific to design for a group session will be addressed later in this chapter. Basic Training Protocol Regardless of disorder type or severity level, speech, language, and communication therapy is carried out using the same basic training protocol.
This protocol is the distillation of the therapy process and consists of the following five steps see Table for guidelines on giving instructions : 1. Clinician presents stimulus. Clinician waits for the client to respond. Clinician presents appropriate consequent event. Clinician records response. Clinician removes stimulus as appropriate. This sequence represents a single trial for a given target and is repeated continuously throughout a therapy session.
The acceptable latency period between stimulus presentation and client response may vary according to disorder type as well as individual client characteristics.
For this reason, data recording should not delay the delivery of the consequence. Task Order Another important component of session design is the order in which tasks are conducted. Appropriate task order enhances the overall effectiveness of treatment. A session should begin with therapy tasks with which a client can be relatively successful without excessive expenditure of effort.
This could entail a review of completed homework assignments or nearly mastered targets from a previous session. The final segment should return to tasks that elicit fairly accurate performance with minimal effort. This task order increases the likelihood that a given therapy session will begin and end on a positive note.
This successoriented session design promotes high levels of client motivation even during difficult stages of the therapy process. Beginning clinicians may benefit from writing an actual script of instructions prior to a session. Directions that are presented indirectly in the form of requests e.
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