Diagnostic Test 2 – Flashcards

1) Poor Sampling 2) Effect of Testing 3) Instrument Decay 4) Unreliable Measures

Sample Size -If the sample size is too small, then the unrepresentative people in the sample (the outliers) have a much bigger impact -If most of the people in the sample cluster around the sample (standard deviation on either side of the mean) 1) You could have one person with a score of 0 or someone who doesn't have the skill being tested. 2) If the sample size is 10 then that one person is going to drag down the mean a lot

Having already taken the test once is going to have an affect on the next administration of the test (the next time you take the test) -Easy to understand if the tests are taken close together in time (you would expect the scores to go up) -Even tends to happen when there is a span of time between the tests (not sure if the change has to do with therapy or just history) -When people take the GRE multiple times, the score usually goes up -People will do better on the second Diagnostic exam than the first (test format will be the same)

Has to do with not only technology but it is also true of observations -If the observer is the instrument -The first time you evaluate a kid or are using an evaluation then you are keeping track of every single behavior that you see -Over time there's a tendency to do that less and less and to just focus on the major behaviors that have affected kids in the past -happens a lot with articulation therapy -mark all the errors of the sounds and manage therapy and retest client, you can understand them better (you'll miss things if you aren't careful- you'll rate their intelligibility higher because you're getting more of the message) -You're not evaluating him like the kids in the norming sample got evaluated (you're judging intelligibility in a different way- not a valid way) -You can have someone else come in the room and see if they judge the perception the same way

-Reliability vs. Validity Idea -If your measures are not reliable, there are pretty good chances that your validity is going to be negatively impacted (many would argue that if your measures aren't reliable then they're not valid) -Spot evaluations that you fill out at the end of each semester are not reliable (if the answers change from administration to administration does that mean they're not valid? it's possible that the number that comes out of it will correlate to teaching effectiveness) chances are that validity isn't good for those things either -Unreliable measures negatively affect validity

Important in the management and diagnosis of clients -they tend to change as you gain experience -you become less worried about the technical aspects of what you're doing -your confidence of test administration will help rapport which will help your interpersonal skills -when the client sees that you know what you're doing, the interpersonal relationship will become easier

1) Competence 2) Motivation 3) Poise 4) Knowledge (without being condescending) 5) Personal Appearance

1) You feel as though you aren't truly in charge of your own session -you're the one with the client but you're subordinate 2) You feel threatened by being judged 3) The supervisor is one more thing to worry about during the session (in addition to what's going on with the client) 4) Multiple supervisors can lead you in multiple directions (we assign one supervisor per evaluation) 5) Criticism hurts: -it's their job to point out flaws -role of supervisors: "Here's what I observed" -the point of their criticism is to help you improve something -learn from your mistakes -sometimes criticism is a test to see if you react professionally 6) Over-reliance on supervisor: priorities switch from getting the grades to getting the skills to perform well on your own

1) Take chances -no session is going to be perfect -it's easy to observe a session and find something wrong -accept that you're not going to be equally competent in everything but you can be really good at everything if you use your feedback the right way 2) React to criticism professionally: -if criticism is unjustified in your mind, it is appropriate to explain yourself, just be careful about how you do it: 1) if you approach them and you're not willing to have a dialogue, that's not going to work 2) explain yourself professionally and even then you don't want to do that every time and if you don't agree you'll look insecure or like a know it all and you'll just be annoying -supervisor determines when you go off campus -as a clinician, behavior has major costs (work evaluations and you'll have strengths and weaknesses) 3) Be aware of your own strengths and weaknesses 4) Maintain a self-improvement program 5) Accept praise gracefully

Lowest item in a specified sequence of successful items -might be three correct items in a row -start the test at item number 5, get 5, 6, and 7 correct (items 5,6,7 are harder than 1-4 so if he can get those three then the four below should be correct) -everything below the basal is considered to be correct

-Highest item in a specified sequence of failed (unsuccessful) items -3 incorrect in a row or 4/8 -most consider the ceiling to be a more critical measure than the basal -ceiling is how a raw score is typically computed -subtract the items that are incorrect from the ceiling and that gives you the raw score

-Only exist when the test or items on a subtest increase in difficulty -Test manual lets you know what the number of incorrect/correct items is to be considered for a basal/ceiling (not always three, the test manual will give you the specific number -Why do they leave it up to the test manual? (that's how it was done with the norming sample) -Basals can be three while the ceilings are 5

-Time Savers (make the testing process more efficient) -Minimize client frustration (as a clinician you start to root against your client - your client might just start guessing)

Raw Score = Ceilings and the # of items scored as incorrect *REMEMBER THAT IT IS THE NUMBER OF ITEMS SCORED INCORRECT NOT JUST INCORRECT* (or Basal + the number of correct above basal) Always do what the testing manual says to be able to compare your client to the norms Basal value and the ceiling value are not as meaningful as the raw score (this is the actual number correct, which will be used to determine age equivalency, stanines, etc.) Basals and Ceilings are not established if there's not a sequence of 3 in a row (Raw score will just be the number added up to be correct)

1 2 + 3 + 4 + 5 - 6 + 7 - 8 + 9 + 10 - 11 - 12 - Basal: 2 Ceiling: 12 Raw Score: (12-5) = 7 *Anything below the basal is scored as correct!!!!!!*

1 2 + 3 + 4 - 5 - 6 + 7 + 8 + 9 - 10 - 11 - Basal: 6 Ceiling: 11 Raw Score: (11-3) = 8

1 - 2 + 3 + 4 - 5 - 6 + 7 + 8 - 9 - 10 + 11 - 12 - 13 + 14 - 15 - No basal & ceiling Raw Score: 6

Basal = 3 correct responses in a series of 5 and the ceiling is 3 incorrect responses in a series of 5: 1 2 + 3 + 4 + 5 - 6 + 7 + 8 - 9 + 10 + 11 - 12 + 13 + 14 - 15 - Basal: 10 Ceiling: 15 Raw Score: 12

Basal = 3 correct responses in a series of 5 and the ceiling is 3 incorrect in a series of 5: 1 2 + 3 + 4 - 5 - 6 + 7 + 8 - Basal: 3 Ceiling: 8 Raw Score: 5

Date of Evaluation - Date of Birth Rules: All months are 30 days 0-15 days, round down 16-30, round up -If it's off by a day or two it can skew results because the standard scores are based off of age and they're classified- When tests are normed, they still use the equation because there are a few rules that are used when determining CA

Eval: September 21, 2017 Birth Date: June 5, 2009 CA: 8 years, 4 months, 16 days (8;5)

Eval: October 24th, 2017 Birthday: September 4, 2005 CA: 12 years, 1 month, 20 days (12;2)

Eval: October 24th, 2017 Birthday: December 9, 1988 CA: 28 years, 10 months, 15 days (28; 10)

Eval: October 24th, 2017 Birthday: September 30th, 2008 CA: 9 years, 0 months, 24 days (9;1)

Eval: October 24th, 2017 Birthday: November 30th, 2000 CA: 16 years, 10 months, 24 days (16;11)

Assess FUNCTION and STRUCTURE -Labial -Lingual -Hard Palate -Velopharyngeal Mechanism -Teeth

Structure: -We can look at the symmetry at rest -Any asymmetry or possible paralysis -Scarring Function: -Ask for labial protrusion (pursing or puckering lips) (can you bring the lips forward?) -Smile for lip retraction -Protrusion and retraction together begin to see if there's any lack of coordination there -If they don't want to pucker or smile produce a long /o/ and a long /i/ "eeeee" -puffing the cheeks to hold air in the cheeks for 2,3 - 5 seconds to determine if labial closure is strong

~Mostly checking function though we do look at the tongue too~ Structure: -Does the tongue deviate from one side to the other -Lift the tongue and look at the frenum (is it short or holding back movement) Function: -Stick out your tongue out and point the tip (tongue protrusion) to see if the tongue is straight out How do you record this? (Very subjective) Does it look right/ do they have decent lingual control/ can they move the tongue as instructed -Lingual Grooving -Tongue lateralization: ~Will give you some idea of ability to move tongue on command ~Open your mouth wide, move your tongue from one corner to the other without tracking it on the lower lip and without moving the jaw ~Some will ask the client to lateralize as fast as they can ~Doesn't reproduce any speech movement at all but if the client can't keep those movements coordinated (might not impact speech but if you see other signs that lingual coordination is off then you have something else to base that conclusion on) ~Tongue Elevation: open mouth and put tongue on the roof of the mouth and stick out tongue and touch your nose (less like a speech sound but easier to see elevation) ~Tongue lowering: we don't lower our tongues a lot within the mouth and stick out your tongue and touch your chin with it ~Opening mouth and circling upper and lower lip with the tongue gives you some idea of lingual movement

Structure: -Does it look normal? -Is it abnormally high or abnormally wide or low? -If the palate is high and arched it could affect the aerodynamics of speech -Could affect some palatal sounds as well -If palate is low it will affect lingual movement

Soft Palate Assessment: -Make use of flashlight -Say "aah" to see if the palate moves up and back appropriately -we want to see what the velum looks like -Checking the gag reflex (can indicate a weakness in the VP if the gag reflex is absent) (can mean lack of sensitivity- maybe a neurological issue) (this is not normally done- people can have a sensitive gag reflex, not a fun test, not unimportant but most people don't deal with trying to trigger the gag reflex) Adenoids and Tonsils: -can restrict VP movement -are tonsils enlarged? -may or may not affect speech -can affect resonance and explain something that you're hearing -if tonsils are removed and you have a gap then the result would be hypo-nasality

(apart of velopharyngeal mech exam????) -Diadokinetic -Fancy word that means speed of alternating muscle movements -Generally expressed in number of movements over time (15 per 5 seconds) -looking at coordinated muscle movements -for the labial exam (protrusion and retraction as fast as you can until you tell them to stop) should be able to get at least 2 full protrusions and retractions per second -no standard scores for this measurement -repetitive productions of labial syllables are used for this as well as /pa/ or /ba/ (say syllable /pa/ as fast as you can until I tell you to stop)

-Moving tongue tip to either corner as fast as you can -Tongue tip movements -using syllables /ta/ or /ga/ -at least 3 per second Combined lingual and labial movements: -/pataka/ repetition -should average at least one per second 1) reliability issue with counting these productions: -all 5 of those answers would be 3 per second or more -should be able to accurately determine if the productions were abnormal or normal -maybe they weren't exact but the bigger question is if the alternating muscle movements can be done within normal range -if the client can't do 3 per second then they will be very easy to count and will be reliable 2) Second potential problem: -have to have maximum effort from the client -really helps to model but don't model too slow because the client will do what you do -if you have the client who doesn't care (the adult who thinks it's a silly task, the teen being a teen) (in that case you need to write in your report that there was not motivation for this task)

-Check to see if there are any missing teeth (missing, turned, chipped, anything out of the ordinary) -Identify which teeth you're talking about -Deciduous Dentition: -set of baby teeth, also called primary dentition, erupt around 6-8 months of age (a lot of variability here) -they're all there by age 2 -20 teeth -stay for a few years -Permanent Dentition: -start to erupt at 6 years -can take a while to come in -period of mixed dentition (time that you have both primary and permanent dentition 6-12 years) -from 12 years on you have your permanent teeth (32 of those if you count wisdom teeth)

The mouth is divided into four quadrants -Each arch is symmetrical Starting in front: 1) Central Incisor: 7.35 2) Lateral incisor: 8.45 3) Canine (cuspid): 11.35 4) First Premolar (bicuspid): 10.2 5) Second Premolar (bicuspid): 11.05 6) First molar (6 year molar): 6.3 7) Second molar (12 year molar): 12.25 8) Third Molar (18 year molar aka wisdom teeth): 17-21 -Primary dentition: everything from the central incisor to the bicuspids times 4 - these are the teeth you get a second set of (baby teeth) -Permanent dentition: you get new ones of all of these and your molars

-Affects aerodynamics and articulation -Can be indicative of other structural problems as well (occur in association with the hard palate)

Improper relations of opposing teeth when the jaws are in contact -Different classifications (Angle's Classification System) A) Normal Occlusion B) Class One Malocclusion C) Class Two Malocclusion D) Class Three Malocclusion Supraclusion/Supraversion Infraclusion/Infraversion

-Where the maxillary molars are about a half tooth width distal (backward) of the mandibular first molar -Maxillary slight behind mandible -Anterior cusp of the maxillary first molar fits into the buckled groove of the mandibular first molar

Neutroclusion: -There's a normal relationship between the first molars but there are individual teeth in the dental arch that are slanted or rotated or anything other than occluding normally with their counterparts above or below ~slanted and crooked teeth~

Distoclusion: -Mandibular first molar is distal or behind in its relationship to the maxillary first molar -Anterior teeth have the same relationship -You see an overbite but the malocclusion is not an overbite ~overbite~

Mesioocclusion: -Other teeth follow the lead of the molars -the mandibular teeth are outside of the maxillary teeth -mandibular are forward and the maxillary are behind ~underbite~

Seen with the class 2 -excessive overlap of the maxillary teeth over the mandibular teeth -probably not going to affect speech -might want it fixed for cosmetic reasons

-Referred to as an "open bite" -insufficient overlap of the teeth and the arches -either the teeth don't reach each other which is rare or the teeth always look like they're end to end

A screening should be completed with every evaluation that you do Oral motor exercises to help articulation and strengthening articulators -has been widely discounted (cleft palate article) -used to do a fair amount of it -exercising non speech movements to improve speech movements is not an efficient way to move articulators -that is not what an oral examination is Structure and function of the articulators (defined very broadly- talking about the voicing mechanism too) With kids you can make it into a game and make it fun for them (stick your tongue out at me) (open your mouth real wide and I can tell you what you had for breakfast too) With older kids and adults handle it more professionally : some clients that are older than grade school children don't like this part of the evaluation (they consider it silly, you're forcing them to make faces) while some see it more as a medical model (it's like the doctor telling me to open my mouth and say "ahh"

FUNCTION IS MOST IMPORTANT -more interested in seeing how the speech parts move than what they look like at rest -requires more cooperation on the client's behalf -within the realm of function, lingual function is the most important (if you have a client who doesn't want to participate, make sure that you get lingual function first) Structure: -looking at the symmetry and proportion of the face -drooping on one side or both sides -are things symmetrical -do the parts look of correct size

-Doing the exam with children (some kids have a tough time with this, 95% of them have no problem and you get cooperation) -Most oral motor exams will be completely normal (1/5 you'll probably see something that's noteworthy)

A regular part of a diagnostic evaluation -Doesn't happen every time but it's common -if a client had a recent hearing eval then you don't need to do the screen -Peds: sound field testing: sound comes through a speaker and the kid signals that they hear a sound (if they're uncooperative then the sound goes through a speaker and the light goes on) -Portable audiometer: if you have access, you should do a screening -if you don't have one you have to make some comment on the client's hearing (hearing appeared to be within normal limits based on ability to understand instructions given to them) -can make the rest of the evaluation question validity if you don't screen Hearing screening is usually done very early in the evaluation (sometimes before the history interview)

Simple Set intensity level at the outer edge of normal (can be 20, 25, 30 dB SPL) -if it's not a sound proof booth then setting it to 30 is a little bit safer Check different frequencies at this level, in particular speech frequencies (500, 1000, 2000 Hz) -short screening but if for some reason you're time limited then just do the speech frequencies -all you're recording is if there's a response at each frequency for each ear -if there's no response at a particular frequency it doesn't mean that the client has a hearing loss, it means that they failed a hearing screening (pass/fail) -a fail means a referral for an audiological evaluation or sometimes for a rescreening Client has to let us know if they hear the beep "When you hear the beep/tone let me know (say yes, raise your hand, do something) You have to check both ears so tell them to let you know if it's in their right or left ear Say "If you hear a tone, no matter how faint"

This is a STUPID IDEA Pure tone air conduction test -it will tell you more than a standard screen would Called a threshold screen because you get a hearing threshold at each frequency Put ear phones on the client (red phone on the right ear) Present the client a tone that's easy to hear so that you know what the client's response is going to be -if client hears the tone then you go down 10 dB -keep going past the level of hearing until the client can't hear a tone (then you go up in 5 dB steps) - if you get a response then you go down 10 -continue until you get 3 responses at 1 level and that's your threshold -this gives you a series of thresholds (of the frequencies that you test) if one of those thresholds is not in the normal limits then you're going to refer -a lot more work for the same purpose -only potential advantage for the screening (if there's a hearing loss that is going to interfere with the evaluation- threshold is 70 dB at all speech frequencies) -you have to make sure that there's a hearing aid in, use written instructions, etc. to make sure that they understand (it will give you more insight) -usually a waste of time (you can get the same results from a quick screening)

-Portable audiometers don't let you do this -measures the resistance of the middle ear -there's research indicating that you can pass a screening but have too much resistance in the middle ear so you should be referred for an evaluation anyways -a sound proof booth usually has one of these -if you have one of these then you can do this as part of a screen -recommend having an audiologist administer this

Another regular part of an evaluation What does speech sound like in conversation: -what kind of disfluent sounds or mispronounced sounds, voice characteristics -something that approximates everyday speech -sometimes have to listen to a lot of different things What does a speech sample measure? -voice and resonance evaluations tend to be involved -fluency: a different outside of normal disfluency -voice parameters -expressive language -listen for intelligibility -try to pick up individual error sounds -rate of speech (can impact intelligibility and fluency) The sample of spoken language gives the tester an opportunity to observe communication in a regular conversation The length of the sample needed depends in large part on what the SLP is looking for: -no standard length of speech sample -depends on why you're doing the speech -if listening for language forms then you do a lengthy speech sample until you hear the forms that you're after -if listening for speech at different levels (one word, sentence, conversation, story telling) then you gear the speech sample that way Pictures can be used to elicit a sample: -a way to get a speech sample without a conversation starter -a little bit less conversational (in the course of a day you're rarely asked to describe a picture) but if you want to get a running speech sample it can be useful stimuli -example in the slides is the Boston Sample (cookie jar picture) Can they describe details? The person will focus on different parts With an adult the speech and language sample is easy -sometimes you get an adequate sample just during the history interview -client is talking about family, a job, school or whatever and gives you a nice long sample of running speech -rate, language intelligibilty If the client gives you quick answers in his/her speech then you can pick up on history information with an open ended question -"Oh your job is ___ tell me about it!" -Talk about movies, sports, etc With children, this part of the eval is a challenge -kids don't understand the concept of a speech/language sample and what you're after doing the questions -"What'd you do in school today?" "Nothing." GOOD IDEA: -go into the evaluation with a set of conversation starters -if it's a smaller child, you will have to interview the parent to get info on what they want to talk about -if you know what the kid's favorite video is ("I've never seen the Lion King before, what is it about?")

Meet with a client get hearing screening take history information make observations do some formal testing (maybe some informal testing) oral motor exam listen to speech and language then should have a pretty good idea of what their communication sounds like, what the history of communication is, what the variability is, potential causes or if not causes then factors that impact communication We are accumulating this information and writing down notes in the margins. (Writing down inconsistencies- oral motor screen may go with what I'm hearing for intelligibility) At the end of this, give the client some recommendations.

Often involve therapy after a diagnostic evaluation (but not always) -If you did the eval and everything appears to be within normal limits then you don't have the basis for recommending therapy -if communication is different but not handicapping the client in any way then you might not recommend therapy (let's leave well enough alone) (yes you have an accent and with therapy you'll sound more American, but nobody has trouble hearing anything you're saying - it's a lot of time and money trying to tweak speech) -if prognosis is poor then it's hard to give therapy -sometimes there's a difference that needs to be corrected but it doesn't require regular sessions (we can make changes to a client's environment) -Sometimes you're not sure, just refer the client to another professional rather than recommending formal therapy More often than not, therapy is recommended after an evaluation -A parent comes in with his/her child and says that there's a difference in communication here, most of the time they're right -in those instances you want to be specific about the nature of the therapy you're recommending -treatment to improve communication is essentially meaningless to the client -treatment 3 times a week for 60 minute sessions to focus on productions of /s/ and /z/ (this gives the client tangible information and what they've been waiting to hear -"You think you can help me, what do I have to do" DO NOT MAKE GUARANTEES: -We're dealing with humans and all of their variability -Everything may be in favor of the client making progress but you never know for sure -In my professional opinion, this is the next step (or series of steps) that you need to follow -Not verbally but in written evaluation reports as well (should reflect what you told the client) Do you give complete information on recommendations? -Yes, usually you have a pretty good idea of what results will say/what the client needs to hear right now -sometimes you need to look at other information and see that you have to add something to therapy (add it to the report) -if you've only administered and not scored the test, you do have to give the client some sort of recommendation at the time of the evaluation (if for no other reason, that's what the client showed up for) It is considered UNETHICAL to recommend therapy when there's not some chance of improvement -We're going to work on certain skills but I really don't think the client will get any better (What are you really doing there? Having the client come in and give you money but you don't think there's hope for the client) -For clients with degenerative diseases: Maintenance therapy to maintain the skills that are there; done if they're better than they would be without therapy Be specific with your recommendations: -"Here's what we're going to work on" -Don't go overboard -Layman's terms should be used -"We had a little trouble with this so we're going to focus on that"

Prognosis isn't very good but there have been similar clients who have made miraculous recoveries If there's an outside chance that we can see some improvement here so we recommend a session or two -When there's some hope or you just really don't know -Have to be clear to the client and their family but if two weeks from now the level is still the same then ethically I can't have you keep coming in for sessions

Referrals are legitimate recommendations: -Talked about at the end of the session when you're giving recommendations -if you're going to refer, the client will probably want their information sent over to the other professional, which in that case they'll have to sign a release Be careful about how it's stated: -The people that you're talking to aren't well versed in our field -If you make a referral to a neurologist then explain why (coordination is off a bit so I'd like a neurologist to make an examination before we start taking any measures) -most people think a neurologist means that their kid is stupid "Client could benefit from psychological evaluation" - word it different so that the client doesn't freak out

Sometimes, not often, evaluations are done by a group of professionals Multiple professionals get involved if there are many possibilities for the etiologies -Cleft palate clinics and voice teams -done because there may be many different causes of the disorder and the treatment will include goals and tasks from a variety of professionals May need to exclude factors to determine the problem and what to do about it Groups should work as a team, with decisions made by all: -best evaluations come from a group working as a team -if there are a few members of the group that determine their discipline is most important, and they think other doctors should accommodate them, it's bad -might have to bring the parent in to decide best route of treatment that they want The role of the SLP can include informal or formal testing -Role of SLP on cleft palate team: -Formal testing (based on this normed test, here's what I have to say) -informal: how do nasality and articulation sound? -make recommendations based on your observations -don't be afraid to dispute the other team members if need be (whatever kind of client/team it is, communication is usually going to be the paramount issue unless there's another major health impairment) for the client and their family -know when to back off (these recommendations need to be followed but maybe not right away) Cleft Palate Team: -ENT, Plastic Surgeon, Audiologist, MD looking at general health, Dentist/Dental surgeon -Gross movement issues could result in a PT or an OT on board

~Keep this in mind when preparing clinical examinations that serve as a bridge from diagnosis to treatment -How does this communication problem affect this individual (if affects everything from history information that we get to the recommendations that we make) -Sometimes the diagnostic session itself is a huge help/benefit to the client -client comes to see you and you ask all the right questions and they seem to understand (for the first time their family has hope/ can be disappointing because they thought they could be fixed/ may react negatively/ think they'll recover from a stroke completely) --> say "In my professional opinion that is very unlikely" Diagnosis in a sense is the first phase of treatment (it's part of a bigger process) -it's not necessarily confined to a single session (it rarely is) -during therapy you'll accumulate more diagnostic information (tweak goals, tasks, things we would like to do in the initial diagnostic session) We're trying to get a working image of an individual (interview the individual and find out about him/her, examine, test the individual) so we bring in the client cognitive level, situational features -sometimes the clients we're evaluating have made their own adjustments to their communication issue through solving it or hiding it (might be defensive about those adjustments) -you may observe some things that are part of the problem but not really the primary problem -word finding deficits so the client pretends that he doesn't know (talking continuously to keep the listener from knowing that he can't retrieve words) - something you'll have to keep in mind with your recommendations but not be confused with the primary problem -A client might have a communication issue that they find embarrassing so they talk less and quietly -Secondary features to the primary issue can be quite significant (have to come up with recommendations to address those) -Regardless of how many evals that you do, keep in mind that it's the first one for the client (anxiety, scared)

-Purpose -What is the present complaint -Is there a language test that covers that -What do I know about this client -Sometimes recommended to give a battery of tests (real world: generally not enough time for that) -Validity of test: no test is going to be valid for all purposes and all clients -it's a good idea to take a look at the norms and to make sure that the client is represented in the sample -if client is in proper age range then it's probably okay -Recommendations are made to find a test where the client's age is around the middle of the norming sample as opposed to either extreme (an assumption, not based on research) -Standardize the assessment as much as you possibly can (read test beforehand and practice administering it -good idea to look and see how the tests are scored (WHY? Because you won't have done the formal scoring of the test at times of recommendations (Know what a raw score of ____ will lead to a particular recommendation -know if it will place child outside of normal limits -basals and ceilings are another good reason to read the test beforehand

AKA Therapy/Intervention -2 Goal Process: (you teach, they learn) 1) Teaching on your part 2) Learning on part of the client: how they absorb the information that you're giving them

Anything that a person does Involves a couple of things: 1) Behaviors that you can observe (over behaviors) 2) Behaviors that you can't observe (thoughts, feelings, covert behaviors, stuttering clients have a lot of covert behaviors) (engaging in something to avoid you seeing the stuttering and you don't pick up on it but it's still a behavior) "Anything that a living person can do that a dead person can not"

Any event that prompts or cues a behavior to occur What you use to get the desired behavior When you observe sessions you see clinicians using stimuli and materials in order to get a desired response from a client

Reaction to a stimulus Can be overt or covert as well You give a stimulus and think that a client is just thinking about it

Different ways of getting information to a client Demonstration of a behavior Can be direct or indirect Direct: -simply showing a client what you want him/her to do Indirect: -you engaging in a certain behavior that you want the client to pick up -indirect articulation therapy: not drill work, just fill the room with the sound and let the client listen to it -if it's an /r/ sound use auditory bombardment -while doing that you'll model the correct production of the /r/ but it's indirect because you're not telling them to watch you

Providing to the client what it is that you're doing or requesting Certain data, certain behavioral information from the client Can be goal or task specific Teaching information "I want you to slow your speech but I want you to slow it by adding pauses, not by slowing the movement of your mouth or prolonging any sounds" General information: How we use this term in everyday conversation (example: information about the treatment plan) Goals and tasks

Sometimes referred to as prompts or guidance A way of helping a client produce the right response Verbal Guidance: -a hint or a cue -"Remember it's the word that you told me at the beginning of the session" -can use gestures Phonemic Guidance: -giving a phoneme / the start of a target word Cueing with a CLOZE procedure: -a type of verbal guidance (when you're giving the client choices) -What color is that? "I don't know" "Well do you think it's blue or red?" -narrowing it down for the client Physical guidance: -used to be used in articulation therapy -hands on the client and showing how the lips are supposed to be when you make a certain sound -but if the client can't learn to cue himself that way when it's not meaningful or functional

The event that follows the response Contingent on the response A lot of our therapy is operant conditioning so it's stimulus, response and then a response to the response Can be positive or negative Can be a reinforcement or a punishment

A positive event that occurs after the desired behavior is performed Keep in mind: the positive event has to be positive from the client's perspective (must be rewarding to the client) Kiss Therapy: (An example of a reward that's only a reward from the clinician's perspective)

Negative event that occurs after a behavior Has to be penalizing to the client If you put the kid in time out and he says "great I don't have to work anymore" that's not penalizing the client, in fact it's rewarding (not a true punishment)

Refers to a manipulation of the stimulus Can be gradually withdrawn Fading: -an example of stimulus control -gradual removal of a stimulus -use the stimulus to get the desired behavior -once the behavior is there then we want to fade out the stimulus

Can learn through: 1) Observation 2) Traditional Methods courses: learning about treatment methods 3) Supervisory Classes: -taking classes as you're teaching -refining things that you're doing 4) Teaching: -getting in the room with the client and saying "Here's the information that you need to learn and I'm going to present it to you" -You learn the most by this method -you don't really learn until you're in there in front of the kids -When you're confronted with a real world situation it makes more of an impression on you (some background on how to teach is necessary before you're put in the real world) MUSTS: -basic understanding of how people learn -effective and efficient (how to make your teaching both of these)

Effective: -a client is learning what you're trying to teach -is the client learning how to produce /s/ (if so, then you're effective) Efficient: -are they learning it in a reasonable amount of time? -supervisors look for this when observing your therapy It's possible to be effective but not efficient if you're spending too much time on one goal (school that never made progress reports) It's possible to get a lot done in a session on paper (spend 5 minutes on each goal and get responses to everything) - yes that's efficient but the client didn't learn anything Need the balance between effectiveness and efficiency (your ability to do that is affected by your technical skills) IMPACTED IN LARGE PART BY CLINICIAN'S TECHNICAL SKILLS

Relationship marked by harmony, conformity, accord or affinity -not really definable -it's a "know it when you see it" -not measurable so not definable -supervisor can say rapport is lacking Establishing rapport is often neglected when beginning therapy: -you know you're being observed -you want real data so you want the client doing what they're there for -take some time to establish some rapport with your client -good time to make observations -make hte client feel comfortable which will improve the effectiveness of therapy -maintaining rapport is a very important skill, there's no set way to do it -Don't take entire first session to establish it (sometimes just takes a few minutes but it depends on the client) FIRST THING YOU DO WITH A CILENT

1) Mutual respect between client and clinician -if the client believes that you can/want to help, that's going to improve rapport -lack of respect from client, that's a barrier you have to get past to establish rapport 2) Enthusiasm: enthusiasm for what you're doing -you might not feel like sitting on the floor and playing cars but to establish rapport you have to be excited -appropriate enthusiasm isn't the same for every client (make judgment call) -show that you're interested in therapy and you like what you're doing and that you want to help 3) Competence: -as competence increases, respect from client increases -more than just projecting competence: they might not necessarily be giving good information -knowledge base is extremely crucial 4) Behavior Modification Techniques: -being able to focus on what they're doing well -giving positive feedback -being able to get them back on track -important enough that it's considered to be it's own technical skills 5) Attitudes and Motivation: -both on the client and clinician -a client may come into therapy unmotivated -a lot of your teen clients will -if you can make their attitudes more positive then rapport will be aided

A skill that requires you to establish it and maintain it Help client focus on the treatment objectives How is a client's attention to task Steps: 1) Establish attention to appropriate stimuli -Here's something I want the client to read or respond to in some way so I have to establish their attention to it 2) Prevent interferences: •If it's a visual stimulus with nothing in the way •With an auditory stimulus you want it quiet enough •Sometimes adults who have had a stroke or a head injury, some clients will attend to just about every sort of stimulus in the room •Overstimulating the room can interfere with attention as well •3 year olds have a short attention span so if the room is full with games and toys then the kid will just be looking at that the entire time 3) Maintain attention: •A lot has to do with keeping the task interesting •How? oFor adults it isn't that big of a problem because they're motivated to learn and get better oFor kids you might have to incorporate their favorite activities into the task •Kids tend to like games •The potential problem with games is that the game itself becomes the focus 4) Redirection as needed: If the client is looking or thinking about something else

1)Gross Attention: a. What we're doing sitting in class b. If you left this class and you were asked what you talked about in class ("therapy something, I know we mentioned rapport") c. Have a general idea of what's going on i. Its not that you're not attending, you just don't have our fine attention 2)Fine Attention: a. If Dr. Williams told us that we have a test today after material is covered then you're using fine attention b. You'll ask more questions instead of saying I'll worry about it later c. More learning takes place here d. You want your clients in that fine attending mode for as long as possible e. You want the cline to be in a condition for learning f. Hopefully the client isn't sick or distracted or uninterested g. Key their attention onto the specific tasks h. Attach a label to the task i. Call it something so that when a client hears a word they know what they're supposed to do i. Putting it into terms of what the client can understand "When you hear the /r/" j. Keep instructions simple and to the point but specific enough to where the client knows what he/she is supposed to be doing k. Give client specific feedback and tell the client what they did well i. Teach the client to do other things as well (the things that he didn't do so well) l. A lot of this just takes PRACTICE -You need to make the atmosphere conducive for learning •If you over stimulate the room then it becomes more difficult for learning to take place We have as many channels of attention as we have senses, but most of what our clients attend to during sessions comes through the auditory and visual channels

•Sense of touch (probably not much information going there) •Sense of smell (maybe interferes if wearing perfume) •Ask what channel it is that you're working in and it's almost certainly going to be visual or auditory (more so visual) •To establish and maintain attention you need to ask what the client wants to key into oThe instructions, the stimulus item oMay involve controlling other channels of attention, to make sure that the client's doing what you want them to be doing oAppearance can be something distracts the client through the visual channel oMaterials impact this •Non distracting •Are stimulating but not too stimulating •Interesting to the client oKeep the interest level up as you're proceeding through the task •Depends on the age of the client oLet the client experience some success can be helpful toward maintaining attention •If the client isn't experiencing any success they can get frustrated and will stop paying attention oWhat makes a good task? •Something that the client can do ~50-90% of the time •If you have a task that the client can maintain success at least half of the time then the client will stay interested •If it's 90-100% of the time then you don't have a good task (you're working on a skill that the client doesn't need oKeep the session moving •May include having a lot of stimulus materials oAppear interested in what you're doing oIf adults are aware of goals and know what progress they're working towards then their attention level stays high *****A lot of what you're doing is asking yourself "What motivates this client" Then attend to that in a way that makes the client attend to the goals

Feedback: what we say when we get a response from a client •Learning and maintaining desired behaviors vs. extinguishing undesired behavior •Cuing, teaching, reward, punishment •Based on learning theories oClassical and operant

Stimulus substitution, respondent conditioning o A form of learning in which a previously neutral stimulus (So) becomes a conditioned stimulus (CS) when presented together with an unconditioned stimulus • Does not do so randomly. Needs an unconditioned stimulus. • Called stimulus substitution because of the way we use 2 stimuli. • When the UCS paired with So enough times, So begins responding. Since it had to be paired with something to respond, that is why it's called a conditioned stimulus. • CS - initially neutral stimulus that is followed by an unconditioned stimulus. •UCS - stimulus that produces an unconditioned response •Pavlov •CS - bell, UCS - meat powder, UCR - salivation •UCR - response to unconditioned stimulus •When we compare bell to meat powder, bell causes same response of salivation. Salivation is a UCR as long as its paired with the meat powder. When the ringing of the bell results in salivation, now salivation is a conditioned response •If the UCR is contingent upon the conditioned stimulus, we have an SS contingency, a stimulus-stimulus contingency. oWhen bell loses neutrality, becomes a positive stimulus. •Electrical shock/tone experiment - stimulus initially neutral has now become a negative stimulus. Fear continues as long as the electric shock is present oAdd a light flash - becomes conditioned stimulus too. Higher order conditioning. When stimulus→another stimulus→ shock = response. •Stimulus stimulus bond - client has learned a negative response to something thru classical conditioning oTo get them to unlearn this response, use classical conditioning method oSystematic desensitization. Changing: •Phone (CS) linked to negative consequence (UCS)→ fear. •To S •So → Ro. •Bring in toy phone set on table. Bring real phone turned off. Real phone that is turned on that can start ringing. Moving step by step to point where client is hopefully ready to make a phone call. Think about the hierarchy.

Learning Curve •Strength of response Is going to increase with the number of pairings. The first time there is a tone and a shock, then light, as it continues response increases •Slope will change after a certain amt. of pairings and level off. If you stop pairing UCS with CS, i.e. tone without shock, slope will move downward. Referred to as extinction. oExtinction: process by which stim. loses ability to elicit the conditioned response. Phone example could be considered extinction •Terms oSpontaneous recovery - after a period of time post extinction, response can be elicited again. Response is likely to be not as string but it will be there oStimulus generalization - other stimuli similar to stim. Can elicit the response. •Using 1000Hz tone to play before shock, now play 900Hz tone. Not same but can elicit same response. •In practice - not using phone, going thru drive thru. With stim generalization - stim gen. gradient - the further away stim is from CS, the weaker the response.

Operant Conditioning •Instrumental conditioning - method of changing behavior in which the clinician waits for the response to occur after which the client is rewarded or punished. •Reinforcement and punishment can lead client to produce or withhold responses •Responses are not so much elicited as they are emitted and they are depended upon what happens after response •Reinforcement is a consequence of a certain behavior •Ways to alter a behavior is to reinforce it or to punish it. •Reinforcement oPositive - primarily used •Primary - is the use of something that the client doesn't have to learn to like. i.e. play time or candy. No conditioning was needed •Secondary - reinforcer that is conditioned - learn to respond to it. Ex: attention of clinician, use of tokens. Once he gets enough chips he gets a reward. Real prize oNegative - reversive stimulus, which when removed, will strengthen the response. Removal of negative stimulus. Ex: turn on fire alarm, we all stand up until everyone's done and fire alarm goes off. oVs. punishment •Punishment is aversive stimulus following a response. This must be viewed as aversive by the client. •Not very many punishments in sessions. •Not always easy to determine what is a punishment. •Can also be the case that punishment has to be increased in order to remain effective, will reach a point where it becomes excessive •Punishment may inhibit, rather than extinguish behaviors. oShocking for stutter treatment. Inhibiting overt instances of the behavior, but not actually extinguishing what was set out to be extinguished •Effect may only be temporary - may only be there as long as punishment is. •Too much punishment can lead to rebellion, big effect on learning, rapport. •Punisher can become a conditioned aversive stimulus. Client has negative reaction to you. Will have big reaction to rapport. •We need to tell client when things are wrong. oFirst reinforcers that you use can be very important. With kids think of variety of options. Attention on the client is important to this process •If child wants your attention, wants to please you, verbal reinforcement can be very effective. •People say verbal reinforcement - rogue reinforcement. oReinforcement can be continuant or intermittent •Continuant - reinforcing every correct response. Best schedule for learning an unlearned response. •Intermittent - feedback based on the schedule needed •Fixed interval - after time has past and response is present, then reinforce it oEvery minute, every 5 min, etc. •variable - time between reinforcement varies. •Fixed ratio - amount of responses between reinforcements. Every 5th instance of correct response. •Variable ratio - also based on number of responses, but number varies between reinforcements. Example: Reinforce every 4th or 5th instance. When it's more often, every 7th, less common lower. •Intermittent not used until high level of a task has been reached. oAt lower task levels, supervisors will expect continuous reinforcement, expect consistency. •Don't miss any items •Don't give a client list and let them zip through it.

Behavior modification / behavior management. •Attempt to modify behavior in beneficial manner •Trying to increase the occurrences of desired behaviors is in a sense behavior mgmt., way seen in field is getting rid of undesired behaviors. Establish and maintain alternate behaviors •Most behavior modification is with small children •First step establish need for behavior mod. •Have positive reaction when we get behaviors we want, when were not we may have to instruct them. Analyze behaviors. Is the behavior reinforceable? Is the unwanted behavior something I can deal with, something I want to get rid of? •With new clients, we don't anticipate behavior problems. We don't assume they will be awful, however we want to be prepared. Easier to avoid having behavior problem than it is to correct it once its there, although we can only do so many preventative measures. Keep environment non distracting. Don't have too much stuff within sight or reach. Keep level of task where kid is experiencing some success, but it isn't too easy. oHave materials that are interesting for the client oThink about pacing. Stimulus →response→feedback. Is it going too fast or too slow. Keep kid involved with task. keep yourself oriented with what you are doing