Thinking About “Dose” and SLP Practice: Part I

A debate arose on @wespeechies about whether cumulative intervention intensity concepts, especially dose, are “too medical model” for speech-language pathology practice. Several objections were raised and I am going to address them singly in independent posts. One point of discomfort was the sense that talking about dose implies that the SLP does something to a passive patient in a context that is incompatible with both the biopsychosocial model of health care provision and collaborative models of service provision in the schools. These objections have been raised before in print, for example by Alan Kahmi although in his commentary he does not actually discuss dose but rather scheduling of treatment sessions which is a different concept altogether.

I want to defend the importance of the dose concept recognizing that one can of course rename everything if “medacalese” offends you, my dear readers. Our patients have become clients and the dose may be referred to as a “teaching episode” or a “learning opportunity”. Nonetheless, as Lise Baker said, thinking about dose forces us to identify the essential active ingredients in our interventions and structure our efforts to ensure that the child is receiving those active ingredients in the right amounts at the right time. The analogy to medical (pharmaceutical) treatments does not preclude the application of the biopsychosocial model at all and may in fact enhance our effectiveness in that regard.

Consider as an example, a kindergarten aged child with unintelligible speech who finds himself in daily conflicts, sometimes physical, during craft time that is deliberately structured by the teacher to encourage sharing and cooperation by the children. The value of the biopsychosocial model is that it forces us to think beyond the impairment level. What factors contribute to the difficulties that the child is having during craft time? Besides his inability to express himself clearly he may be lacking in social strategies for solving the conflicts that arise, having so little experience with successful conflict resolution. He is also likely to be very anxious in this situation and lacking in self-esteem generally. The SLP may elect to bring in another professional to help the child with the anxiety and self-esteem issues (personal factors), council the teacher to change the environment during craft time to reduce the opportunities for conflict (contextual factors) and to engage a teaching assistant (TA) support the child during craft time, and to personally attend craft time weekly to encourage the child to use words such as “black, blue, glue, please” more accurately in the classroom. Now we have a collaborative model that appears to be compatible with the biopsychosocial framework but will these interventions achieve the goal of improving the child’s competence to verbally resolve social conflicts? Unless the TA, the teacher and the SLP all have a clear idea about the what the active ingredients of the treatment are, it is quite possible that the treatment will not be effective, regardless of the number of times that the TA is available to mediate the child’s experience during craft time.

An excellent document entitled Making Best Use of Teaching Assistants points out that TAs tend to prioritize task completion over other goals. Therefore it is likely that the TA will sort out the materials for the child during craft time and help him to assemble them thus avoiding any possibility for conflict. The teacher will be happier and the parents will receive fewer distressing reports but the child’s self-esteem and sense of isolation will suffer further and bullying by other children may actually increase. What would the active ingredient of the intervention program be and how would we count the dose? The active ingredient is not support by the TA and the dose cannot be counted as successfully completed crafts. Rather, the goal is successfully negotiated “sharing” of craft materials and therefore the dose should be counted as the number of opportunities to use new strategies to obtain materials from another child. The child will need a means of communicating his needs clearly, strategies for resolving conflict that do not involve grabbing or hitting, reinforcement for engaging appropriately with the other children, and supports from the entire class that do not isolate or stigmatize him further. My readers are more qualified than I to work out the details of the intervention but it should be clear that intervention intensity is not the number or duration of supports provided; rather it is necessary to document the number of times the child practices specific behaviors that will eventually result in satisfactory levels of independent participation. It is also necessary to teach the TA to specifically ensure that these learning opportunities occur and to support the child’s achievement of the necessary skills in an appropriate fashion. Thinking clearly about the active ingredients of the intervention facilitates the success of the consultation process.

My point is that the intervention is not the SLP’s conversations with other staff or even the child. Currently, IEPs are often written in terms of applying units such as the TA or SLP to children (or teachers) for specified periods of time rather than a specific description of what the child needs to do in order to achieve successful functioning in the school environment. We spend a lot of time determining what the child (or school) is entitled to and not what the child needs. The intervention for our imaginary child is the number of times the he uses the relevant sentences in appropriate communicative contexts, experiences error and self-corrects, initiates interactions, and verbally resolves conflicts. From this perspective, thinking about doses of intervention units is the antithesis of passive actions on the child – it is all about the child’s opportunities to practice and learn the skills necessary to participate in his every day environment. I will come back to the issue of how best to promote learning during these teaching episodes in another post.