Feedback Errors in Speech Therapy

I have been spending hours reviewing video of student SLPs (SSLPs) conducting speech therapy sessions, looking for snippets to take to my upcoming talks at ASHA2018. The students are impressively skilled with a very difficult CAS population but after this many hours of watching, repeated examples of certain categories of errors pile up in the provision of feedback to children about their attempts to produce the targets words, phrases and sentences. I am going to provide some examples here with commentary. In no way am I meaning any disrespect to the students because it is my experience that the average person becomes an idiot when a camera is pointed at them. I recall hearing about studies on the “audience effect” as an undergraduate – the idea is that when your skills are shaky you get worse when someone is watching but when your skills are excellent an audience actually enhances them. My social psychology prof said this even works for cockroaches! I can’t vouch for that but it certainly works for speech pathologists. I remember one time video-taping a session that was required for a course – I thought it went really well so I gave a copy to the parents and the course instructor. Later when watching it I could see clearly that for the whole half hour the child was trying desperately and without success to tell me that I was calling him by the wrong name (I had mixed him up with his twin brother whom I was also treating). I was oblivious to this during the live session but it was clear on the video. Anyway, these examples are not reflections on the students’ skill levels overall but they are examples of common feedback errors that I see in novice and experienced SLPs. Interestingly the clinical educators (CEs) who were supervising these sessions rarely mentioned this aspect of the students’ practice. Readers may find this blog useful as a template for reviewing student practice.

Category 1: No feedback

Child: [repeats 5 different sentences containing the target /s/ cluster words]

SSLP: [Turns to CE.] “What did you get?” [This is followed by 1 minute and 40 seconds of conversation about the child’s level of accuracy and strategies to improve it on the next block of trials.]

SSLP: [Turns back to child.] “You need to sit up. You got 2 out 5 correct. Now we’re going to count them on my fingers…”

Child: “Do we have to say these?”

Comment on vignette: In this case the SSLP did finally give feedback but too late for it to be meaningful to the child and after the telling the child off for slouching in her chair! Other variants on this are taking notes about the child’s performance or turning to converse with the child’s parent or getting caught up in the reinforcement game and forgetting to provide feedback. In CAS interventions it is common to provide feedback on a random schedule or to provide summative feedback after a block of trials. However, the child should be able to predict the block size and have information about whether their performance is generally improving or not. Even if the child does not have a count of number or percent trials correct, the child should know that practice stimuli are getting more difficult, reflecting performance gains. Sometimes, we deliberately plan to not provide feedback because we want the child to evaluate his or her own productions, but in these cases the child is told beforehand and the child is given a means of explicitly making that judgment (e.g., putting token in jar). Furthermore, the SSLP would be expected to praise the child for making accurate self-judgments or self-corrections. When the child does not get feedback or cannot track their own progress they will lose interest in the activity. It is common for SSLPs to change the game thinking that it is not motivating enough but there is nothing more motivating than a clear sense of success!

Possible solutions: Video record sessions and ask students to watch for and count the frequency of events in which the child has not received expected feedback. Provide child with visual guides to track progress indexed either as correct trials or difficulty of practice materials.

Category 2: Ambiguous feedback

SSLP: “Say [ska].”

Child: “[skak]”

SSLP: “OK, take the fish out.”

Comment on the vignette: In this case it is not clear if the SSLP is accepting the inexact repetition of her model. In our CAS interventions we expect the child to produce the model exactly because metathesis and other planning errors are common and therefore I would consider this production to be incorrect. Other ambiguous feedback that I observed frequently were “Good try” and “Nice try” and similar variants. In these cases the child has not received a clear signal that the “try” was incorrect. Another version of ambiguous feedback is to comment on the child’s behavior rather than the child’s speech accuracy (e.g., “You did it by yourself!” in which case the “it” is ambiguous to the child not clearly related to the accuracy of the child’s speech attempts).

Possible solutions: SSLPs really do not like telling children that have said something incorrectly. Ask students to role play firm and informative feedback. Have the students plan a small number of clear phrases that are acceptable to them as indicators of correct and incorrect responses (e.g., “I didn’t hear your snake sound” may be more acceptable than “No, that’s wrong”). Post written copies of the phrases somewhere in the therapy room so that the SLP can see them. Track the use of vague phrases such as “nice try” and impose a mutually agreed but fun penalty for exceeding a threshold number (buy the next coffee round for example). This works well if students are peer coaching.

Category 3: Mixed signals

SSLP: “Say [ska].”

Child: “[s:ka]”

SSLP: “Good job! Take the fish out.” [Frown on face].

Comment on the vignette: I am rather prone to this one myself due to strong concentration on next moves! But it is really unhelpful for children with speech and language delays who find the nonverbal message much easier to interpret than the verbal message.

Possible solutions: It would be better if SLP therapy rooms looked like a physiotherapy room. It annoys the heck out of me when we can’t get them outfitted with beautiful wall to ceiling mirrors. The child and SLP should sit or stand in front of the mirror when working on speech. Many games can be played using ticky tack or reusable stickers or dry erase pens. The SLP will be more aware of the congruence or incongruence between facial expressions, body language and verbal signals during the session.

Category 4: Feedback that reinforces the error

SSLP: “Repeat after me, Spatnuck” [this is the name of a rocket ship in nonsense word therapy].

Child: “fatnuck”

SSLP: “I think you said fatnuck with a [f:] instead of a [s:].

Comment on the vignette: Some SSLPs provide this kind of feedback so frequently that the child hears as many models of the incorrect form as the correct form. This is not helpful! This kind of feedback after the error is not easy for young children to process. To help the child succeed, it would be better to change the difficulty level of the task itself and provide more effective support before the next trial. After attempts, recasting incorrect tries and imitating correct tries can help the child monitor their own attempts at the target.

Possible solutions: Try similar strategies as suggested for ambiguous feedback. Plan appropriate feedback in advance. Plan to say this when the incorrect response is heard: “I didn’t hear the snake sound. Let’s try just the beginning of the word, watch me: sss-pat.” And when “spat” is achieved, plan to say “Good, I heard spat, you get a Spatnuck to put in space.”

Category 5: Confused feedback

SSLP: “Oh! Remember to curl your tongue when you say shadow.”

SSLP: “Oh! You found another pair.”

Child: “It’s shell [sʷɛo].”

SSLP: “Oh! I like the way you rounded your lips. Where is your tongue? Remember to hide your tongue.”

SSLP: Oh! You remembered where it was. You found another pair.”

Child: “Shoes [sʷuz].”

SSLP: “Oh! I like the way you rounded your tongue.”

Comment on vignette: In this vignette the SSLP is providing feedback about three aspects of the child’s performance-finding pairs when playing memory, rounding lips when attempting “sh” sounds, and in some cases anterior tongue placement when attempting the “sh” sound as well. One aspect of her feedback that is confusing when watching the video is the using of the exclamation “Oh!” Initially it appeared to signal an upcoming correction but it became so constant that it was not a predictable signal of any kind of feedback and was confusing. The exclamation had a negative valence to it but it might precede a correction or positive feedback. The SSLP confused her feedback about lips and tongue and it was not clear whether she was expecting the child to achieve the correct lip gesture, the correct tongue gesture or both at the same time.

Possible solutions: This can happen when there is too much happening in a session. The CE could help the SSLP restructure the session so that she can focus her attention on one aspect of the child’s behavior at a time, like this: “I want you to name these five pictures. Each time I am going to watch your lips. When you are done you can put the pictures on the table and mix them up for our game later.” If the child rounds the lips each time, switch to focusing on the tongue. When the ten cards are on the table play memory, modeling the picture names. In this way the three behaviors (rounding lips, retracting tongue, finding pairs) are separated in time and the SSLP can focus attention on each one with care, providing appropriate feedback repeatedly during the appropriate intervals.

Category 6: Confused use of reinforcement materials

SSLP: “Repeat after me, [ska].”

Child: “[θak]”

SSLP: [ska]

Child: “[θak]”

SSLP: “OK, take the fish out.”

SSLP: “Repeat after me, [ska].”

Child: [ska]

SSLP: “There you got it, take the fish out.”

SSLP: “Repeat after me, [ska].”

Child: [ska]

SSLP: “Good, and the last one, [ska].”

Child: [ska]

SSLP: “That’s good, take the fish out.”

Comment on vignette: In this vignette the child cannot tell if he gets a fish for correct answers or wrong answers or any answer. It is even worse if the child has been told that he will get a fish for each correct answer. Sometimes a student will say “Everything was going fine, we were having fun and then he just lost it!” When you look at the video you see exchanges such as the one reproduced here leading up to a tantrum by the child. The SSLP has broken a promise to the child. They don’t forgive that.

Possible solutions: This one is hard because it is a classic rooky mistake. Experience is the best cure. Reducing the number of tasks that the SSLP must do simultaneously may help. Therefore, in the early sessions the CE might keep track of the child’s correct and incorrect responses for the SSLP and allow her to focus on managing the materials and the child’s behavior. SSLPs would never think of this but it is possible to let the child manage the reinforcement materials themselves in some cases. One of our favorite vignettes, reprinted on page 463 of DPD2e (Case Study 9-4) involved an error detection activity in which the child could put toy animals in the barn but only when the SSLP said the names of the animals correctly. The child had the toys in his hands throughout the activity. He would not put them in the barn unless the clinician said the words correctly and would get annoyed if she said them wrong, telling her “you have to say cow [kau]!” SSLPs can learn that it is not necessary to control everything.

I put these here for students and clinical educators and speech-language pathologists and hope that you will have fun finding these feedback mishaps in your own sessions. If you come up with better strategies to avoid them than I have suggested here please share them in the comments.