ILO 3 - Lesson 16: Intervention

Strategies: Clinician-Directed (CD)

Lesson Objectives
Describe some common activities used primarily in clinician-led sessions:
Drill
Drill play
Drill modelling
Describe some common strategies used in clinician-led sessions.
Clinician-directed modelling (complete and reduced model)
Expansion request
Repetition request
Self-correction request
Prompting
Today’s Lesson: Clinician-Directed Approach
1. Refresher on intervention approaches
2. Activities used in the Clinician-Directed intervention
3. Strategies used in the Clinician-Directed intervention
Refresher on intervention approaches
Do you remember the three management approaches?
Most language intervention programs under one of the following intervention
approaches:
Clinician-Oriented/Clinician-Directed Approach
Hybrid Approach
Child-Oriented/ Child-Directed/Child-Centred Approach
Clinician-Oriented/Clinician-Directed Approach
Widely used in pre-school and school settings.
The clinician selects the goals.
The clinician selects the treatment setting.
The clinician chooses the stimuli.
The clinician chooses the type and schedule of reinforcement.
Highly structured. Irrelevant stimuli is reduced/eliminated. Clear
reinforcement is provided by clinician.
Widely used in pre-school and school settings.
Textbook
 The clinician-oriented approach often uses behaviour modification to
teach a child new target.
The environment is highly structured.
The clinician controls/determines the materials, the order of activities,
the form of responses required, the types and frequency of
reinforcement and provides a certain number of opportunities for
repeated practice of the selected target
Child-Oriented/Child-Directed Approaches
The clinician follows the child’s lead - ‘simply playing with the child’
The clinician utilizes indirect language stimulation
techniques/strategies
The clinician uses more natural, everyday settings and activities to
stimulate language growth
The adult provides simple models of language that are within the child’s
Zone of Proximal Development. Said very simply the clinician respond to the
child’s language or behaviour by “providing a language model that is
appropriate to the child’s skill level”.
These approaches are typically used with young children or children with
established disabilities
Textbook
In the child-directed approach, the clinician focusses on following the
child’s lead and talking about what the child is doing or saying.
Hybrid Approaches
Similar to the child-centred approach, but the clinician retains some
control over the environment and may set the environment up to elicit
and prompt for certain language forms or targets.
Modelling remains indirect
Similarly to the child-centred approach, the hybrid approach is usually used
with young children or children with established disabilities.
Textbook
In the hybrid approach the clinician maintains more control than in child-
centred approach however language modelling remains indirect.
The child is encouraged to use the language targets in natural, realistic,
and functional contexts.
The clinician does this by eliciting and prompting language [expressive
language] and providing contingent modelling and expansion [receptive
language] while the child plays or conducts a familiar routine.
Intervention approaches: the ‘Continuum of naturalness’
Textbook
According to Paul and Norbury clinicians can choose to design
intervention sessions along a continuum from most natural to least
natural (see figure below).
The more natural the intervention feels to the child, the more it will
resemble their everyday life. This means it that the clinician will be
arranging the environment to create many opportunities for the child to
learn language targets, but this will not be taught using a direct teaching
approach.
Many of these sessions will use familiar everyday routines or play as
contexts to learn language.
If a clinician chooses less natural approach the session is going to be
more structured, and the child must complete several tasks (activities) in
which the primary purpose is to practice the language targets for the
session.
These sessions often make use of drill and or drill play activities and
clinician directed modelling (often using a puppet or other “helper” to
ensure that the child is clear about how to correctly complete the task)
and instructions (like request to repeat (or try again) from the therapist.

Which approach should I use? (We are not expecting you to know this at this
stage)
Consider the following factors:
Child (age, personality, behaviour, severity of language impairment)
Session aim (target)
Point in Tx (development/progress of aim)
 Resources (activities, materials, space)
Activities used in the Clinician-Directed approach
1. Drill
most highly structured
use of instruction, target stimuli to be imitated, prompts and fading of
prompts, shaping of behaviour and reinforcement of success.
Useful for speech production practice, but not often used for language
2. Drill Play
Drill play includes an activity in which the practice items are rewarded by
using a motivator, which is usually linked to a fun activity e.g., completion
of a jigsaw puzzle (motivating activity/antecedent) where the child’s
successful attempts are rewarded with puzzle pieces to add to the
puzzle (subsequent motivator).
This is one of the most common intervention strategies used in a
clinician-led therapy session.
3. Drill Modelling
Drill modelling (instead of imitating, the child first listens to a third
person (often toy/puppet) who models repeatedly, then the child tries
the target himself (alternating with the model), until he has a number
(usually 2 or 3 attempts correct).
Then the puppet’s input fades away, and the child is left to complete the
remaining practice items within the puppet’sassistance.
This is another common intervention strategy used in clinician-led
sessions.
Activities used in the Clinician-Directed approach 1. Drill
Most highly structured activity in the CD framework
Provides the highest rate of stimulus presentations and client responses
Challenge – Not very motivating. Clinicians and children don’t always enjoy
this approach
Activities used in the Clinician-Directed approach 1. Drill
How to do a drill activity:
1. Clinician teaches target and trains child in correct response
2. Clinician presents stimulus: child responds
If the child is CORRECT, SLP reinforces/rewards child
If the child in INCORRECT, SLP shapes the child’s response (corrects
it), then reinforces/rewards
3. SLP presents multiple stimuli for high levels of practice.
4. Reinforcement/reward is phased/faded out over time.
Activities used in the Clinician-Directed approach 1. Drill
What is reinforcement?
It is a reward to encourage/increase a particular behaviour.
Some examples:
Verbal praise: “Well Done!”, “Good Job”, “Excellent”
Tangible items: Stickers, stamps, puzzle piece, colour in a block
Reinforcing/motivating activities: High-five, shoot for hoops, pick-up-
sticks
Activities used in the Clinician-Directed approach 2. Drill play
Drill play makes the activity fun & enjoyable.
The antecedent is PLAY!!!! An antecedent is something that happens before
the target is drilled.
Gives the child an opportunity to play, have fun and enjoy the activity:
Fishing Game
Dress up doll(s)
Teddy Bears Picnic
PLAY IS NOT REINFORCEMENT!!!!
Activities used in the Clinician-Directed approach 2. Drill play
How to do a drill play activity:
1. Clinician teaches target and trains child in correct response.
2. Clinician presents stimulus and motivating event (antecedent): child
responds
If the child is CORRECT, SLP reinforces/rewards child
If the child in INCORRECT, SLP shapes the child’s response (corrects
it), then reinforces/rewards
3. SLP presents multiple stimuli for high levels of practice.
4. Reinforcement/reward is phased/faded out over time.
Activities used in the Clinician-Directed approach 3. Drill Modelling
Drill modelling makes use of a confederate or “third person” who provides
a model for what is expected in the activity - often a toy of puppet
How to do a drill modelling activity:
1. Clinician plays/act out the Drill or Drill Play activities with a
model/puppet: the model/puppet responds to stimulus as child would be
expected to. The child is a listener/observer.
2. After a few turns, the child joins the activity alongside the
model/puppet. The model/puppet and child then take turns responding
to the stimulus.
 3. When child gets three consecutive correct responses, the model falls
away. Now only child and clinician are included in the activity.
Strategies used in the Clinician-Directed intervention
NB: Note the difference between…
Approach: What learning/teaching style are you using?
Clinician-directed, Child-led or Hybrid?
Activity: What activity are you doing together?
Drill, drill play, drill modelling?
Technique / Strategy: Used within the activity to facilitate language
development.
Clinician-directed modelling (complete and reduced model),
expansion request, repetition request, self-correction request,
prompting

Clinician-Directed Strategies
Strategy Explanation
Models the target language (what you want the child
Modelling to say), so that the child can copy you. This modelling
Complete model can be complete (exactly what the child must say) or
Reduced model reduced (only part of the target response e.g. first 2
words)
Expansion request Asks for an expansion but does not present a model…
(“Tell me some more”/”Say the whole thing”)
 Repetition request “What did you say?” or “Tell me again”
Self-correction “Did you say it right?”
request
Prompting by the clinician alerts the child to the fact
that the clinician
Prompting expects a response. Prompting is usually described
in a hierarchy from indirect prompting to very direct
prompting.

Prompting
A verbal signal to the child to do or say something
Prompting occurs in a hierarchy from most to least direct/invasive. Always
prompt by using the least supportive and most appropriate strategy. Follow
through with more supportive prompts if needed.
Verbal prompts also have a hierarchy of direct/indirect prompts.
Open question (indirect): such as “tell me what the boy is doing in this
picture as if he has already finished doing it” or “what should the puppet
ask/say?”
More specific (or directed) “you need to add an -ed to the action word
if you want to let me know that it has already happened”
Most direct verbal prompts available to clinicians is the “say/model”
prompt. For instance, the clinician can say the following to the child
“look at this picture and say….[the boy walked to the shop].” In this
instance the adult tells the child exactly what to say.
Textbook
Together with these strategies we will often make use of feedback such
as prompting, and shaping, as well as reinforcement as additional tools
to help the child to be successful.
Shaping takes an incorrect or partially correct response and provides the
child with additional help to ensure that they can correctly complete the
task.
Prompting by the clinician alerts the child to the fact that the clinician
expects a response. Prompting is usually described in a hierarchy from
indirect prompting to very direct prompting.
We start off with indirect prompts such as “tell mewhat the boy is doing
in this picture as if he has already finished doing it” or “what should the
puppet ask/say?” If the child is unable to provide the correct answer, our
prompting can become more specific, (or direct), “you need to add an -
ed to the action word if you want to let me know that it has already
happened”.
One of the most direct verbal prompts available to clinicians is the “say”
prompt (which is very direct).
For instance, the clinician can say the following to the child “look at this
picture and say.... [the boy walked to the shop].” Offering reinforcers
tends to occur after a correct response by the child and acts as a
motivator for the child to continue trying throughout the session.