SLP client's behavior interfering with therapy
February 7, 2011 8:33 AM   Subscribe

Hi all, I'm an SLP grad student doing language-phonology clinic this semester and one of my client's behavior is getting in the way of therapy. She's 5.5 years old and is home schooled. It's quite clear there's no discipline at home and now I get to look totally incompetent for it. Any ideas about what I could do? This child spends most of the one-hour session mouthing off, spending 10 minutes on one sip of water to avoid work, pounding on the two-way glass (mom taps back, oy), and falling on the floor and telling me, "Me died." I've tried rewards but it seems she doesn't associate the rewards with anything. Just takes them and demands more.

Aaaaaaaaaand, since I'm here, any SLPs have any creative ways to teach children to answer questions with more than one word? I don't want to make the girl crazy with, "Let's hear that in a big, long sentence!" every time she says something. Help! Thank you all so much in advance, you were a huge help to me last time I had questions.
posted by RyG to Education (19 answers total)
One of the rationales behind clicker training animals is that the short, immediate "click!" makes it clearer to the animal what behavior is being rewarded. You do the click immediately, then give the reward. Giving a reward takes time -- you have to get it out of wherever it's stored, the recipient has to take it, then eat it, then swallow it -- so that by the time the reward cycle is completed, the association with the desired behavior is muted.

Plus, you can easily click multiple times in a short period. Also, once the click sound has a positive association, one doesn't necessarily have to give a food reward every time (at least with dogs; cats seem to be another matter).

You may be taking care of this verbally, but the click is less associated with the giver and seems more like a dispassionate, universal signal of good.

Maybe something to think about.
posted by amtho at 8:38 AM on February 7, 2011

Could you explain what SLP stands for?
posted by BozoBurgerBonanza at 8:40 AM on February 7, 2011

Speech Language Pathology.
posted by bilabial at 8:43 AM on February 7, 2011

From my time in the boyscouts, when helping to wrangle the cubscouts, the way to deal with it is to simply ignore the bad behavior (mouthing off), as it's an attempt to get attention, and avoid dealing with the work. Just give her a minute to perform her little tantrum, ignoring it completely, and then pick up right where you left off. Let her know there's no escape. Return every action and conversation to the subject matter. For example, if she says "Me died," just say, "No, you're still alive, you could only be dead if you say "I died." If she plays along, and says, "I died!" reward her by playing along, too - "Oh, no! She's dead!"

She actually seems pretty clever - once she picks up on the challenge of the work, as opposed to the challenge of avoiding the work and rattling the grownup, she'll settle in more.

Dealing with little kids requires lots and lots of patience... at 5 years old, I don't think it's really a discipline issue. It's just a spindizzy-sillyhead-donwanna issue. Repetition and consistency are your best tools... don't let her throw you off your gameplan.
posted by Slap*Happy at 8:48 AM on February 7, 2011 [1 favorite]

Hi --

Not a SLP (speech language pathologist), but I am a parent to that particular age bracket and I know that kind of behavior.

Two quick thoughts:

1. A one-hour session seems awfully long for a 5-year-old. Are they sitting the whole time? Is it possible to change this up -- play games, dance, play with toys, go outside? Change the "work" as much as possible within the limits of your program.

2. Try not to worry about "looking incompetent" -- people who know 5-year-olds know what you're dealing with, and what is your fault and what is not. You can't change what her home life is like.

Good luck!
posted by pantarei70 at 8:49 AM on February 7, 2011 [1 favorite]

Is there a prof or advisor in your program that you can discuss this with?
posted by cestmoi15 at 8:52 AM on February 7, 2011 [2 favorites]

If she's a bright and clever as well as a willful kid, as she seems to be, she might hate doing this therapy because it's being hard reminds her of the fact that she's not good at something that comes effortlessly to others. I don't have a specific technique to offer other than pantarei70s, but it might help your own sense how to proceed if you consider that maybe she's not just being a brat; maybe she is having trouble tolerating the awareness that she has a problem.
posted by Tylwyth Teg at 8:55 AM on February 7, 2011 [2 favorites]

its, not it's, sorry
posted by Tylwyth Teg at 8:55 AM on February 7, 2011

Yikes! I'm a school speech therapist and I was *not* a natural in structuring sessions and getting the most out of kids with behavior issues in grad school. It is still my least favorite part of the job--dealing with behaviors that interfere with learning (and drive you crazy).

I felt like I was in a Japanese tourture gameshow while I was in grad school clinic--with parents and supervisors watching on the other side of the glass, and the kid freaking out, and you (understandably) making some mistakes while learning how the whole therapy thing works.

I am all about positive reinforcement and modeling. If stickers aren't rewarding, what would be? Today I've used food rewards and high fives, lots of stickers, and tons of verbal praise. I also have a Yoda picture that I bring out with my boys who do a great job, and they work to see Yoda pop up and tell them "The force is strong with them." One of my students likes to use my ID badge to unlock the door to his classroom at the end of the session, so we use that. If your kiddo is all about the water, maybe you can take a break to get a drink, or keep the water out of reach and give her a drink when she "earns" it. This is weird, but she could "earn" food coloring drops in her water! I would say a sentence for that if I were 5. Does she have a favorite story or cartoon character? Maybe a picture of Hannah Montana (or whoever) can pop up and tell her "great job!" when she did something good.

I also try to build reinforcement into the activity. If you are playing memory or jenga, make her say a sentence or ask a question for a turn. I didn't like sentence imitation at first, but I think it is a good starting point for some kids.

Sometimes, though, negative reinforcement is a must. If you are playing a game, she loses a turn for not behaving. Hannah Montana pops up and says, "I'm disappointed in you." She loses a sticker.

If there is a game or story she really likes, she might be more into it. Ask mom about favorite TV shows or books, and have a lesson about that theme. Ask her questions about what she loves--if nothing else, it's a starting point.

With behavior problems, you can either coerce, or you can engage a child by using their interests. You can find a way to engage 99.9% of the time!

Most of all, give yourself permission to be a beginner. Memail me if you want to commiserate!
posted by shortyJBot at 9:02 AM on February 7, 2011 [4 favorites]

It's quite clear there's no discipline at home

Perhaps you have firm evidence of this, but don't make this presumption just based on your client's disordered behavior. Coincidentally, just before I read your post, I came across this article that names speech problems as a common comorbidity with ADHD.
posted by Wordwoman at 9:17 AM on February 7, 2011 [2 favorites]

I'm also not a SLP, but my sister does early intervention work in OT, and so I hear lots of stories. I AM a parent and a social worker, so lots of kid experience.

I would not assume there's no discipline at home unless you know for sure that's true. Five year olds are generally pretty whacky creatures. I do think it's completely appropriate to talk to the mom about ideas she might have for reinforcements/consequences that are enticing for her child, and also to ask her to not to reinforce her daughter's bad behavior (by doing things like tapping back).

My assumption is that if you continue to work with children, you will encounter kids with behavior like this, or much more challenging, all of the time. Many of the children you'll see will come from challenging backgrounds (like the child abuse victims I work with) or have other disabilities. Many of them will have parents who are not interested or not able to intervene in their child's bad behaviors themselves. I imagine your professors are looking to see how you handle a challenging kiddo-what tools can you pull out of your toolbox when things aren't going well? I think it would be completely appropriate to ask your professor for some guidance on strategies here.
posted by purenitrous at 9:54 AM on February 7, 2011 [1 favorite]

Seconding the suggestions to be clear with the mom about her inappropriate behaviors as your first step. She is an adult and should be able to make better choices.
posted by Sidhedevil at 11:18 AM on February 7, 2011

1. ASK YOUR SUPERVISOR(S) FOR HELP! This is what they're for.

2. It's quite clear there's no discipline at home and now I get to look totally incompetent for it.
But this is not about you and how you look; it is about helping a kid. A lot of kids act like kids, which it sounds like this particular kid is doing. If you are seriously trying to be an SLP (or really any person who works with kids!), you will need to just learn to roll with resistance and help encourage a kid to engage--you are only going to encourage the resistance by trying to find sneaky ways to make her do X, Y, or Z. So what does she like doing? What does she respond to? What is she able to do well? What are her strengths? These are the questions to start with, NOT why is she destroying the therapy? Why won't she listen to me and do what I want? etc.

3. Try to remember that she is 5 and a human. You're interpreting her behavior quite a bit here through your own assumptions about her intentions (in very negative ways, and imposing a "she's being horrible on purpose" picture onto it, which I would caution you VERY STRONGLY against), and you may not actually be accurate with the judgments you're making (and I think talking with your supervisor will help a LOT here). Remember that the way to have any kind of therapeutic process be successful is to let the kid guide the pace and process to a large degree. She can't respond the way you want her to because she's not ready or equipped with the necessary skills to do things the way you're trying to do them. It's a great opportunity for you to learn how to be super flexible and meet her where she's at.
posted by so_gracefully at 12:43 PM on February 7, 2011 [3 favorites]

I'm glad you asked us for help. Now ask your supervisor/advisor/coach for help. Asking for help is a good thing to do when you're struggling.
posted by exphysicist345 at 1:49 PM on February 7, 2011 [2 favorites]

Ah, the supervisor. Another issue entirely. Supervisor is always too busy, always off somewhere, and assumes we only require, say, 15 minutes of time when we really need an hour and half. Only response to my asking for help has been "be firm." This has gotten me nowhere.

There is no discipline. This I do know for sure. I won't go into the specifics as to how. My supervisor agrees with that much.

We've tried the playground, toys, favorite cartoon characters, stickers, being sneaky, not being sneaky, and so far met with little success. She makes it known what she will and won't do both verbally and physically. Like crumpling up books, pictures, whatever. I've definitely gotten some good answers from you guys (thanks!) but as far as suggestions to ask the supervisor--been there, done that.

And this is pretty irrelevant, but I intend to work with the geriatric population once (if!) I graduate, not children. I have worked with children in the past, though not in this capacity. This is just a necessary stop on the path. And I do know that ADHD is often comorbid with speech problems. This child's problems, however, stem from a too-small jaw.
posted by RyG at 2:13 PM on February 7, 2011

I am a parent of two children who have gotten speech and language therapy. My daughter is nearly five and is in her first year of preschool. My son is twenty months. Altogether, we have seen five different therapists, and liked all of them. For what its worth, in my pre SAHM life, I got a B.S. in public health, so I am not totally out of my depth with managing therapies.

I am not trying to be mean to you, at all, but I am going to say some things that might sting, and for that, I'm sorry.

Regardless of how you feel about this kid's mom, she's your boss. Very often, when dealing with a geriatric population, you will need to answer to the client's child, who is acting as a caregiver. Bedside manner is just as important in therapy as it is in a hospital. I think that the mom being on the other side of the glass is probably problematic, if she has to be there because you are a student, then this kid needs to see a full fledged therapist where the mom doesn't have to be there. It's tough to tell a parent to beat it, but it's part of the bedside manner thing- include the parent as part of the team, but the parent is the star when the team's home, and the therapist is the star when the team's away.

An hour per session is too long. If she needs 90 minutes a week, then have her come in three times a week. If she needs three hours per week, she needs to come five days a week. This therapy isn't about your schedule, or the mom's. Therapy is about meeting the child's needs on her level, and a hour and a half is way too long.

Whether or not this child is homeschooled is irrelevant and none of your business. If she has a physical problem that prevents her from being fully intelligible, her parents are not at all unreasonable for keeping her home.

Whether or not this child is undisciplined is irrelevant and none of your business. Disciplining a special needs child is damn hard. The parents might be in other therapy to address just that, or they might want to get speech out of the way and then start on that. It's your job as a professional to do your job despite outside difficulties. You must focus on what you can control, and not blame the home life. Therapists who do that don't practice very long. If you suspect abuse, you are a mandatory reporter in most states, and that's a different ball of wax, but if you just think the parents aren't stern enough, suck it up and get back to work.

At our pediatric therapy office, there are kids who have physical, mental or emotional difficulties, and combinations thereof. The parents range from the county pathologist who's in his fifties and has toddlers, to teen moms who live in public housing, to farmers with a tribe of foster kids. But there have been many vigorous waiting room conversations about how, "We switched to this therapy office because junior's previous therapist kept trying to tell me how to raise my kid." The parents who tolerate this the least tend to be older and well educated, within my unscientific observation. Asking a parent to do Beckman at home or require vocalization for a request is far, far different from saying, "You need to put her in school and discipline her more." That is in an utterly different category and will raise the hackles of most parents.

Just because her jaw is too small does not mean she may not have an ASD or learning problem. If a person is delayed in learning to speak for any reason, even a physical one, it may and often does affect the brain. And yes, speech delay has many mental co-morbidities, whether in pediatric or geriatric clients. More of your clients will be behaviorally challenging than not. You need to learn how to deal with that, and how to do your job in spite of it.

This kid sounds tough, and your supervisor sounds like an ass. To me, it sounds like your client needs to be in a room without glass, and without her mom nearby. I would go above your supervisor's head to make your concerns known, even if it means telling the kid's mom, "You need a real therapist."

Kids this age really crave consistency, repetition, and routine, so "Let's hear it in a big, long sentence!" thirty times per session will probably bug you more than it will her. If she's mouthing off to you, tell her, "We don't speak to [your name] like that," in a very, very stern voice, maybe with finger pointing and arm crossing. If she laughs or responds like it's a joke, take away something she likes- the water cup, her shoes, her coat, a toy, whatever. Kids who have no obvious attachment to their shoes will flip if you take them, because it's something of their own.

Have stickers or lollipops around as rewards, but hold her to a very high standard to get them. Or do levels- decent behavior gets one sip of water every two minutes, 15 minutes of decent behavior gets a sticker, an entire half hour session of goodness gets a sucker.

Behavior modification is hard. It takes consistency, patience, and both positive and negative reinforcement.

Don't be afraid to suggest having her evaluated for a behavior or learning problem if you truly think one exists.

I hope this was helpful to you.
posted by Leta at 3:29 PM on February 7, 2011 [3 favorites]

I will echo Leta's concerns above. I would differ, however, in that perhaps you should really fundamentally question (philosophically, academically and clinically) the use of rewards, the model of behaviour modification, and even the concept of verbal behaviour in a therapeutic context.

Perhaps looking into communication and experience sharing as motivators (e.g. following some of the Hanen methods), or placing your therapy in a context of play might be more effective than 'discipline', particularly for a 5 year old. But honestly, if you don't enjoy it, why would you expect her to?

Homeschoolers generally think that learning occurs through other activities, rather than as an activity per se. Perhaps you could use this as an interesting learning opportunity whereby you could see therapeutic goals being achieved through other activities rather than as the activity itself.

(I am not an SLP, but I am a clinician who works with children and other SLPs clinically, and I am the parent of children who receive speech therapy).
posted by kch at 3:56 PM on February 7, 2011 [1 favorite]

Well, it sounds like your supervisor sucks. It's now your responsibility (for the time being, as you have a very pressing matter to discuss) to get supervision or advice from someone else who is competent to do so. A professor, another supervisor on site, whomever you can find. You are still ethically bound to seek supervision when you don't know what to do, and it sucks that you will have to do some extra work for that, but wow, think of how much better you will be doing for your clients!

There is no discipline. This I do know for sure. I won't go into the specifics as to how.
But you should know because you did a thorough assessment that included looking at what this kid's life is like at home, at school, etc. What this actually sounds like when you talk about it is that you judged it based on some isolated piece of information you observed and then interpreted yourself subjectively "I won't go into the specifics as to how"?? The "how" should be because you asked, or because you observed at home, because it's important to understanding how to work with the kid. The "how" should not be because you assumed based on the mom acting poorly when her kid pounds on the glass, or because the mom seems to never be able to have her shit together, or any other completely subjective interpretation of potentially unrelated information.

I really think Leta's comments above are important to think about. Your tone and way of thinking about Kid's symptoms/presentation is potentially problematic because it sounds judgmental and not fully informed. I encourage you to plant yourself firmly in a position of being open and listening and learning, all the time, because you could miss a lot of opportunities to help this kid. I truly don't mean to be harsh or scolding, but you have a lot to learn here (just like any person early in their career/experience in any field), and there are a lot of people who don't know how much harm they're unintentionally doing by assuming they know things and not seeking out adequate support from supervisors or trainers. Pull your supervisor aside and tell her you need ___ minutes to consult with her about your client. If she doesn't respond accordingly, get someone else. Don't move forward without supervision.
posted by so_gracefully at 4:23 PM on February 7, 2011 [1 favorite]

RyG, you need to go back to your supervisor. It is her job and her responsibility to help guide you through this. I know because that's what I do for a living.

Also, please don't think that behavior management is a non-issue when working with adults. You will encounter dementia, traumatic brain injuries, cognitive changes following strokes, etc. Starting to get comfortable with behavior management techniques now will serve you well down the road.
posted by onepot at 4:47 PM on February 7, 2011

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