Thursday, March 24, 2016

Things SLPs should always say {NO, NOPE, STOP} The Importance of Punishment in Speech Therapy


Well, this is the flipside - except I couldn't narrow it down :) 

There are so many things we should always say, and this might surprise you, but we need to say more negative things!  We need to say, "NO," "NOPE," "Eh," "nuh-uh," "Stop that," "No way; try again," "That's wrong," "nah," and "no way." 


Before you think I've lost my mind and click away, let me explain myself.  By punishment, I certainly do not mean we should punish children, be rude or mean to children, or make them feel bad about themselves.  If you know me, I'm all about the peace and love with my students. 




  Simply stated, punishment (in the behavior world) is a consequence following a behavior that decreases the probability that a particular behavior will occur in the future. 

As SLPs we are fan-flipping-tastic about giving positive reinforcement! 
Good job!  Great talking! Nice sounds! Good work!! 
I love your effort! Good try! I love your good speech! Keep up the good work!
That sounded awesome! Wow, you're so smart! Super talking! 

Positive reinforcement is so important!! Providing positive reinforcement following a desired behavior increases the probability that the behavior will increase in the future.

Did you know that negative words are powerful, too?  
They're especially powerful when trying to change a behavior, and after all, isn't that what we try to do in therapy?  We try to shape dysfluent speech into fluency speech. We aim to shape new articulation and phonological patterns. We strive to change communication habits. That's our business! 

When trying to decrease a behavior (a lisp, an articulation error, a phonological process, vocal abuse, incorrect pronoun use, poor eye contact, spitting or biting, inappropriate social behaviors, etc.) punishment is important.  Using punishment decreases the likelihood of the behavior persisting.  Isn't that what we want? 

In fact, there's plenty of research out there supporting that using positive reinforcement along with punishment is more effective in changing speech patterns than using positive reinforcement alone. 

Costello and Ferrar (in 1976) compared progress between students who received punishment combined with positive reinforcement and students who received positive reinforcement alone for the reduction of incorrect articulation.  

They used 3 different "punishers" (a buzzer, response cost, and simple verbal "No!" Their results indicated that:
1) punishment in combination with positive reinforcement was more effective than positive reinforcement alone. 
2) introducing punishment did not cause disruptions for children nor did it cause children to become upset or off-task. In fact, disruptive and off task behavior increased when the punishment was taken away. 


Each time I get a graduate clinician from a local university or model therapy for new SLPs, I always get the same response...

Grad Student:  "YOU TELL THEM NO!?!" 
CF-SLP:          "You tell them it's wrong!?"
Me:                  "Well, yes, of course." 

It seems that somewhere along the line, it has become unpopular to tell students they are wrong. I see it in classrooms, too. When I was in grad school I had several wise professors who were adamant that we use a very firm, "NO" for all incorrect responses. It's just science; the child is less likely to make that same mistake again. I've refined my verbal punishment since then, and I provide more specific feedback that equates to "NO." Some are those are shown at the top in the speech bubbles :)  
Sometimes it's just the ole stink eye or grimace or a simple but firm "Uh-uh" or "Eh!" 

I mean, shouldn't we be honest with our students?  How will they know they are doing something incorrectly if we don't tell them?  If they were already capable of self- monitoring their speech, they wouldn't be therapy. If we don't tell them what they are doing wrong, how will they know what to change? 

Don't get me wrong, I would never plunge into therapy with a new student using punishment.  It's important to establish a relationship with a child and show him that therapy is a positive and safe place before using punishment.  It varies with each child, but that trusting foundation can be laid rather quickly.  Once the child understands that you're on his side, and you're there to help him/her, it's time to start being honest (but kind) with our feedback.  

Even though I use punishment (in the form of words or body language), I feel confident that my students still know I care about them. Additionally, they know to try something different than what they just tried.  

(I should note:  if you observe that punishment causes anger, sadness, aggression or self-esteem issues with any of your students, you should stop and consult with the rest of the child's IEP team or behavior experts at your disposal.  Also, never use strategies that may conflict with a child's behavior plan or established plan of reinforcement without consulting with the child's team.)

TIPS for using POSITIVE REINFORCEMENT & PUNISHMENT: 

1) Always use BOTH!!  How depressing would it be if a child only received punishment!? Therapy would be a beat down for both of you!  On the other hand, if you only use positive reinforcement, progress may be slower because your student may not have a clear understanding of what changes he/she needs to make with his/her communication. 

2) Always be sure to only positively reinforce behaviors (communication habits) that you want to strenghten! Likewise, always be sure to only punish behavior you want the child to decrease! Don't let any of those correct responses get by without at least a nod of approval, and don't let the belly flop responses get by without correction.  I see my fair share of SLPs doing drill silently-  tallying away but not giving feedback to the student.  All the while I think, "I wonder if they think they're doing well or not?"  How will they know what to KEEP doing if the therapist doesn't make it completely clear!?  How will they know what to STOP doing if they're not told!? 

3) Vary the type of positive reinforcement AND punishment! Saying "good job" 100 times will surely lose its impact on a student.  Likewise, "that's not right, try this" will also lose its mojo! Change it up to keep your reinforcement and punishment powerful! 

4) Consider each student! If verbal positive reinforcement isn't enough, pair it with high fives, stickers, tangibles, etc.  Positive reinforcement isn't reinforcement at all if it isn't something a child wants. Find out what motivates each child, and remember that reinforcers don't always maintain their power.  Some children lose interest in what you may be providing so you need to keep re-evaluating what's really reinforcing for a child.  In the same way, they may get "immune" to your stink eye or thumbs down punishers.  Change it up! Little Bee Speech got it right with its Articulation Station Pro app which allows SLPs to give a lovely "ding" sound when a child says a speech target correctly and an aversive buzzer-like "bomp" sound when he/she gets it wrong.  That's such a simple but effective form of punishment and positive reinforcement in one place.  (By the way, I don't get anything from that company for saying that! It's just my honest opinion) 

5) BE CONSISTENT and keep your expectations high.  Children thrive with consistent expectations. They will be less confused when you give them clear positive reinforcement for desired behaviors and clear punishment for undesired behaviors.  It's important for all of us not to lose sight of what the real desired behavior is. For example, if a child has a lateral lisp, and suddenly it is less distorted, it's very tempting for us to start packing on the positive reinforcement because...  

It's better!! Hooray!! 
Uh, Oh....

be very careful, because that behavior is likely to increase, and better doesn't mean correct. I recently observed a therapist who was marking all distorted /s/ productions as correct. Soon after, she told me how much better his lateral lisp now was.  Hmmmm, yes it's better, but now he thinks it's spot on! YIKES!  Let's keep our ears and brains finely tuned and expectations high- and let's communicate honestly with our students and clients. They deserve that. 

I admit, I am no expert on this subject; it's just something I have used in my practice for the past 20 years. If you want to read more from the real experts, check out this interesting 2010 article by Anne K. Bothe and Janic Costello Ingham about Using Responses Contingencies in Evidence-Based Treatements for Children's Stuttering. 

Do YOU say NO & NOPE in speech therapy, too?  I want to know that I'm not alone :) 

Be sure to click on the links below to read all about what my cohorts, The Frenzied SLPs, think SLPs should always say! 






2 comments:

  1. What a great post, Mia! Just like parenting, it's so important to combine positive reinforcement with the negative so our kids have that feedback.

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  2. Yes! I completely agree. Negative reinforcement is important - especially for increasing carryover in my experience.

    ReplyDelete

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