Riding the Rails to Treatment Success: Maximizing Client Participation in Speech-Language Therapy

Bypassing a behavior roadblock during treatment is challenging. Disruptive behaviors interrupt the progress of treatment and stall well designed treatment plans. However, every clinician and child can find successful solutions. When the road is blocked, hop on the train!

Consider the analogy of your intervention plan as a train track: the rails are treatment plan, the wooden ties are the evidence-based treatment principles supporting your plan, and the steel clamps holding the two together are research-based behavioral strategies.

Fork in the Road: SLP & Applied Behavior Analysis

“Applied behavior analysis is a discipline devoted to the understanding and improvement of human behavior.”³ Both applied behavior analysis (ABA) and speech-language pathology are committed to a shared focus; namely evidence-based practice and functional application.

As such, ABA and speech-language pathology have a shared history. In their 2006 article, Koenig & Gerenser provided an excellent historic timeline of the relationship between ABA and the field of speech-language pathology. Between 1950-1975, behavioral strategies were linked to the clinical work of speech-language pathologists and cited in our literature.⁶ References to the use of ABA principles can be found historically in the literature studying fluency (see Brookshire & Martin, 1967), articulation (see Sommers et al., 1966), voice (see Shriberg, 1971), and language (see Sailor & Tackman, 1972) therapies (Koenig & Gerenser, 2006).

So, what happened? Why the fork in the road? With the rise of generative grammar, theoretical linguistics, and cognitive psychology, the role of the speech-language pathologist became that of a facilitator eliciting language and speech development through indirect methodology versus through direct control of the stimuli, responses, and reinforcement contingencies.^6,8 However, recently, due to a renewed focus on social language use and the increased incidence of autistic spectrum disorders, ABA practitioners and speech-language pathologists have returned to collaboration.⁶ Given this shared history and use of evidence-based strategies, it is easy to see how the ABA principles can be applied to speech and language treatment.

Individualized Tracks

Chugging back to our train track analogy, each of our tracks needs to be highly individualized and client centered. Each track involves the unique goals, needs, vision, functional life activities, and medical/physical issues of our clients. As a result, before choosing your client’s individual track you must first ask yourself, what is the function of the disruptive behavior?

Different behavior functions call for different plans. There are four main functions of undesired behaviors; usually the student is trying to:

• Escape or avoid
• Gain a tangible
• Gain social attention; or,
• Receive sensory stimulation⁹

Each train track will have individualized and unique destinations!

Strategies to Keep Treatment on Track

There are a few overarching behavioral techniques that will provide the clamp between your treatment plan and evidence-based practice. Here are some strategies to consider implementing in your treatment to help get you and your client back on track riding the rails to treatment success:

1. Be Prepared!

Organize your treatment space and keep it free of distractions. Activities and any equipment should be prepared and readily available. Activities and items that are reinforcing should be out of your client’s reach. Being prepared and organizing your workspace can help prevent client distraction, downtime, and undesired behaviors.

2. Use Visual Supports⁵

Start your session with use of a visual schedule. This can be a symbol based schedule or just a written to-do list on a wipe-off board. A visual schedule provides your client with the expectations and organization of the treatment session. Indicating task completion by removing a symbol, erasing, or crossing out an activity is also naturally reinforcing.

3. Provide your Client with Choices

Choices can include the order of activities, the treatment or the break-time activities themselves (choice of two), or something as simple as choosing the color of the visual schedule.

4. Use Behavioral Momentum⁷

Use the ABA principle of behavioral momentum, especially before difficult or new learning tasks. Start your treatment with an easy task or item to gain momentum and then move toward the more difficult or unfamiliar work.

5. Schedule Breaks

Breaks and fun activities should be built into the client’s treatment session schedule. Be sure to pre-plan these breaks so you are not reinforcing any escape driven behaviors. Use timers, verbal warnings, and countdowns to help signal the end point of breaks and preferred activities. Using a timer helps to decrease the client’s view that it is your fault that the break is ending and it is time again for work.

6. Reinforce Activities and Items with Pairing and Correlation

Use these ABA principles to make sure that you have enough reinforcing activities. You will need a lot! Clients satiate on preferred activities or items quickly. To avoid aversive responses, your workspace, yourself, and your materials need to be paired with reinforcing items or activities.

7. Use “First Then” Statements

For example, “Work first, then play. Practice your target words first and then we can play basketball.” You can combine these statements with “work then _______” visuals to indicate treatment tasks followed by a fun activity.

8. Entice Versus Forced Compliance

Your client should want to participant in your treatment activities. Use enticing tasks to freely engage your client and maintain your client’s proximity to you and your treatment area. For example, before your client enters your treatment space have a highly-preferred activity visible in the area where you will work.

9. Be the Grandmom or Grandpop!

Use the Premack Principle⁴: Just like going to visit grandmom or grandpop, provide non-contingent rewards “just because”.

10. Use a Quick Rate when Possible^11,12

Using a quick rate during tasks and throughout your session will keep your client on his or her toes, facilitate attention, and eliminate time for undesired and off-task behaviors to occur.

11. Use the Appropriate Reinforcement Schedule³

Be sure the amount and magnitude of reinforcement matches the work demand. New or difficult tasks should start with an immediate and continuous reinforcement schedule. The clinician should move to a more delayed and intermittent schedule as soon as the client’s new skill becomes firm. If principles of reinforcement are not followed, you may inadvertently decrease your client’s use of the new skill!

12. Teach Replacement Communication Strategies for Undesired Behaviors

Many undesired or problematic client behaviors are the result of the inability to effectively and efficiently communicate. To remedy them, we need to assess the function of the behavior and teach a more acceptable communicative behavior. For example, if a client is hitting to protest or deny, teach the language to protest in a socially acceptable manner.

13. Consult and Collaborate with a Board Certified Behavior Analyst¹

Communication is behavior, and behavior is complex! As a speech-language pathologist you may not be able to develop effective behavior strategies on your own and behavior specialists may not understand the intricacies of communication and language. As disciplines, our work is mutually beneficial and only serves to increase our client’s performance.

Depending on your clinical environment, you may not have access to a behavior specialist or BCBA. In these cases, in order to meet your client’s needs, consult with the family and discuss the possibility of including behavior support. In a school setting, SLPs and behavior support should be working hand and hand.

Arriving at Your Destiniation

Riding the rails with these strategies will maximize our client’s participation in speech-language treatment sessions. As speech-language pathologists, we should collaborate with behavior professionals as well as continue to grow in our ability to use behavior strategies. For success in therapy, use behavioral strategies to clamp the rails of your treatment plan and tie together evidence-based techniques. All aboard! Stay on track and bypass behavior roadblocks!