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What is the purpose of this class?
- To learn practical application of previous knowledge of communication disorders
- Acquire clinical experience through observation and classroom learning
- Learn implementation of treatment (methods and materials)
- Learn how to bridge assessment to treatment planning
- learn documentation
Credentials needed vary from...
the state you work in and the work setting
What are the three different agencies that provide credentials?
- ASHA (Certificate of Clinical Competence)
- State Boards of Licensre (state licensure)
- State department of education (professional teaching standards board and teaching certificate)
What it stands for their definition and the mission
- American Speech Language and Hearing Association
- The professional, scientific and credentialing association for SLP/AUD in the US
- Mission is to "promote the interests of and provide the highest quality services... in audiology, speech-language pathology... and to advocate for people with communication disabilities.
What are the requirements to receive your CCC as an SLP and Audiology?
SLP: Masters or Ph.d from asha-caa certified program, 400 hours of observation and practicum, pass competitive praxis exam, evidence of knowledge and skills, supervised post graduate fellowship of at least 36 weeks.
Audiology: AuD or PhD from asha caa program, 4 year program (4th year is full time externship), pass competitive praxis exam, evidence of knowledge and skills
Describe the three components of the professional teaching standards board and state department of education.
- Need PTSB certificate to work in schools in wyoming.
- Masters degree or PhD in SLP
- Know US and WY constitutions
Describe the Wyoming board of speech pathology and audiology
- awards the state license needed to work in health care or private practice
- ASHA CCC
What are the three Laws, rules or regulations that are important to SLPs and AUDs?
- ASHA code of ethics
What is a bloodborne pathogen?
Pathogenic microorganism in humang blood that can cause disease in humans.
WHat are bloodborne pathogens found in?
- Amniotic fluid
- deep tissue fluids
- vaginal secretions
- anything visibly contaminated with blood.
What are bloodborne pathogens not typically found in?
Describe Hepatitis B virus
- Vaccine available- recommended for UW grad (externships require)
- 30% show no symtoms
- Risk of transmission is ~30%
Describe Hepatitis C Virus
- No vaccine
- 80% show no symptoms
- Risk of transmission is ~1.8%
- 70-80% progress to chronic
Describe the Human Immundoeficiency virus (HIV)
- Infected may show no signs or symptoms
- Risk for transmission is .3%
- No Vaccine
What are three occupational exposures?
- Pierces to skin
- touches inflamed skin, acne, skin abrasions
- touches mucous membrane
What are the 4 factors of disease induction
- Presence of pathogen with sufficient virulence
- portal of entry
- resistance of host
What is the exposure control plan?
- Plan that minimizes hazards of bloodborne pathogens
- minimize exposure
- universal precautions
- work practices
What are the universal precautions?
- assume that everyone is potentially infectious
- protect yourself
What are work practices for the exposure control plan
- disinfect work surfaces, equipment, materials
- wear gloves when necessary
- good personal hygiene
- be healthy or stay away from others
What is the proper way to wash your hands?
- Warm running water
- soap hands for 20 seconds
- rub hands vigorously
- dry with paper towel
- use towel to turn off knobs
- use lotion to control dry, irritated, cracked skin.
What is treatment/intervention?
Dynamic process that follows systematic progression of diagnosis, selection of tx targets, training procedures, mastery of tx targets.
Why do we do treatment?
To eliminate or modify the disorder
What are the 4 ups?
- Sign up
- show up
- write up
- button up
The ultimate goal of tx is?
to change behavior
Intervention, like research, should be based on scientific method and involve:
- *identification of problem
- *Review of existing knowledge re problem area
- Formulatio of hypothesis to solve problem
- manipulation of independent variables
- collection and analysis of data
- conclusion-evaluate process
What is speech and language intervention?
- A dynamic process that follows a systematic progression
- Begins with diagnosis
- Followed by selection of appropriate therapy targets
- Training procedures implemented to facilitate acquistion of target behaviors
- intervention process completed wen target behaviors are mastered.
What are the three main reasons for doing treatment?
- To eliminate the underlying cause of the disorder (drain fluid from ears, hearing aids)
- To teach compensatory strategies to improve functional communication (a device that speaks for a person with CP)
- To modify the disorder by teaching specific skills (Teach strategies for understanding multi-meaning words)
What is the major job of clinicians?
Change: to change the way communication takes place
What are the three ways we make change happen?
- We create communication
- we alter communication
- by manipulating or rearranging communicative relations between speakers and listeners.
When a disorder can't be cured, what do we do?
we provide treatment to modify the disorder by teaching skills or teach compensetory strateges if client cannot learn the skills necessary for easy communication
What 6 things do SLPs do?
- Evoke communicative behaviors that clients already have and
- increase use of existing communicative behavior (give lots of opportunities to greet, transition from one topic to another)
- Create non existing communicative behaviors (teaching certain sounds)
- Alter an existing communicative behavior (make a lisped s clear)
- Strengthen or sustain communicative behavior (transfer skills to classroom from speech)
- Control undesirable behaviors that interfere with communication(poor eye contact, interuptions)
How is intervention a dynamic process
SLP continuously assesses a clients progress and modifies when necessary.
Describe the Dance of Treatment
- SLP presents stimulus, listens to response, then responds accordingly
- SLP learns to predict what a client might do and what should be done next
- this is "client response/clinician adaption" from your observation sheet
What is the 6 things that intervention should be?
- Taught in a communicative context (realistic, menaingful, functional)
- Individually oriented
- Designed to ensure that client experiences consistent success
- promote client's knowledge one step beyond the current level
- based on research-based evidence
- sensitive to client's cultural and linguistic background.
Successful intervention requires ability to effectively integrate these into tx program
- behavior modification
- key teaching strategies
- session design
- data collection
What are the 8 parts of a semester treatment plan?
- Identifying information(initials, classification, facility, clinician, supervisor)
- Present level of performance
- Area of need
- short-term goals and objectives
- methods, materials, and procedures
- Rationale/ justification statement
- notice and agreement
What does present levels include?
- name and age of client
- brief history
- location and date of initial evaluation
- summarize diagnositic information
- dates and types of services
- present information in chronological order
- describe present levels from baselining information
- highlight overall current level of communication functioning
- state date of enrollment in current tx program
- include type, frequency, and duration of tx sessions
- include behavioral observations
The style and voice in professional writing is ____.
The vocabulary is ____
- more formal, straight forward and facts and interpretation only
- more precise, specific clear and appropriate
When writing professionaly you should avoid what?
when writing professionaly you should provide what? and what needs to be perfect?
- examples using clear language to explain or justify what you say.
- grammer, spelling, punctuation perfect
What are clinical reports and what is their purpose?
- Formal documents that must be written in appropriate technical style.
- Purpose: To summarize and interpret information regarding a client's performance or status.
- -to ouline intended intervention plan at beginning of tx (stp)
- -to monitor client performance on a session to session basis (SOAP)
- -To summarize client status eriodically (mid-term progress note) and at the end of the treatment program (final progress report)
What is just as important as a clinician's knowledge of communication disorders and their treatment?
the ability to communicate effectively in writing
What are ASHA's guidelines for clinical writing?
- Assessent names are capitalized only
- Assesments instruments are not appropriately called tests.. Use instrument, assessment, evaluation or measurement
- Do not use the word therapy in professional writing, use intervention remediation, programming or management or treatment
- Chronological ages written using semi colon
What does it mean by know your audience when clinically writing?
- use professional terminology but include simple explanations and clear examples.
- Make reports meaningful to family members and non-professionals and to other professionals
- Always keep a copy of your report, safely, according to HIPPA regulations
In clinical writing you should be ____ and avoid these terms.
Showed, given, worked on, pronounce, indicated, deomonstrated, administered, focused or taught, produce
What is critical in clinical writing?
Professional communication is important because....
- We need to share information (oral and written) with clients across the continuum of clinical services.
- It is how your present yourself to the client
What is the continuum of clinical services
- Interviewing and counseling clients
- report writing
- recording outcomes
- educating family members
- evaluation and treatment
Describe the key concepts with interviewing and counseling
- Explain the purpose of your discussion
- Match to the linguistic constructions and level of vocabulary of your audience as much as possible
- clear and complete
- repeat, rephrase, give examples as necessary
- allow listener to be active participant
- provide sufficient time for listener to process and react
- watch for nonverbal cues from listener.
What is meant by monitor your words and why is it important>/
- Words are powerful
- That was bad vs that was unfortunate
- that was the wrong thing to say vs perhaps that could have been expressed differently.
We also need to focus beyond our words, what does that mean we focus on?
- Nuaces added to spoken language
- suprasegmentals speak eloquently (stress, tone, intonation, length)
- non-verbal language.
Remember that you will be speaking to a person with a language disorder, therefore it is important to remember
- emphasis is subtle and hard for some people with language disorder to understan.
- Add facial expression, other non-verbal info
- Avoid rising intonation: makes you seem uncertain or like you are asking permission
- Watch out for extraneous movements.
How should you talk to a child, vs an adolescent, vs and adult
- Child: nurturing tone
- adolescents: similar to how you talk with your peers, not formal or authoritarian, friendly but not condescending
- Adults: more formal than with peers, professional yet supportive: avoid baby talk.
Describe intensity: what should you avoid? when does it happen? why do wee avoid it? how should it be?
- Avoid high pitch and exaggerated intonation
- Tendency to do this with very ill patients
- makes speaker appear incompetent or disrespectful
- speak quitely to minimize aggressiveness.
- Soft speech can soften a harsh message. Can you tell me why you decided not to do this?
_____ is the prerequisite to learning?
To gain a clients attention you should use ___ or ___. When is this important?
- preceding statement or alerter
- young clients, cognitvely impaired, second language learners
Use of attention getting is _______ but it is ______
- one of the simplest and most effective techniques
- not used often enough
What are the 4 ways to simplify your language?
- short clear statements
- avoid excessive talking
what are ways to use visuals? and when is it important?
- draw a picture
- use a graphic organizer
- important with some culture
- important with younger clients
- important with cognitively impaired clients
what are three examples of confirming?
- Now that i have explained what i want you to do, please do it for me just as i explained it
- I've suggested 3 things. Please tell me what you remember that i said
- show me that
What are the best types of questions?
do not ask questions when _________.
you mean to give a comand
Feed back is....
responses provided by the clinician to the client.
what is the most important thing needed to get the right resoponses and skills and that is most highly correlated with enhanced performanc?
Unless clients know how they are doing....
they can not change
Respect in the clinic setting means what 3 things
- cultural values
- do not assume that you know, ask
- design goals that are relavent and functional for life.
In all cases it is important to do what 4 things?
- use language that is specific
- avoid overstatement and exaggeration
- protect the dignity of the individual you serve
- keep the welfare of the client paramount
What are the 8 parts of a semester treatment plan?
- Identifying information
- present level of performance
- area of need
- short term goals and objectives
- methods, materials, and procedures
- rationale/ justification statement
- notice and agreement
Describe the present levels of performance?
- Brief background info/pertinent history-past tense
- PLOP written in present tense as appropriate
- Highlight clients overall current level of communication functioning
- include all areas--even those that may not be addressed this semester.
- State date of enrolement in current tx program
- type, frequency, and duration of tx sessions
- information from observations and data collected from baseline sessions
- include strengths
- include behavioral information
- Report sufficient information so that you can develop appropriate goals.
Describe a PLOP in terms of a school IEP
Need to include how disability affects student's educational performance.
Describe the Area of Need
- Based on present level of performance
- state the priority need for this semester
- state what you anticipate to accomplish by the end of the semester
- be realistic with time--think about number of sessions for your client before end of semester
- Guides choice of goals and objectives
Goals may be ____ or ____ depending upon the facility and need,
Long term or short term
All goals must have what 3 components?
- achievable (in time period)
- meaningful (functional)
what are the 3 incremental sequence of steps?
- Long term goals
- short term goals
- objectives as intermediary steps on way to meeeting the longer term goals
What are the 4 reasosn we write goals?
- 1. To know what you want to accomplish (basis of choosing procedures, materials)
- 2. To know when you have accomplished what needed to be done (tells you how the client is doing)
- 3. To enlist the cooperation of client and show respect for client (meta- not a secret, fucntional, explicit.)
- 4. Because you have to for (insurance companies, school districts, hospitals, rehab facilities, skilled nursing facilities)
where do you start when writing goals?
- with a good complete assessment to identify communication disorder areas and strengths
- Determine PLOP
- Prioritize needs - emphasize functionality
- Use a strategy: normative or client specific to do so.
What are the 3 components of a goal?
- 1: Performance ( what client will do)
- 2: Conditions (under what circumstances client does it)
- 3: Criterion (with what level of proficiency or how it will be measured
specific action the client is expected to perform
what are the two types of verbs and which one should be used?
- ***overt: things a client does that you an see count, hear, or otherwise measure
- Covert: performance can only be implied, not directly observed (mental, cognitive, internal)
When can you use a covert verb?
- when you add a direct way for client to show you
- ex: identify by pointing, recall by stating, respond by saying, demonstrate understanding by seperating into piles
Identifies the situation in which the target behavior is to be performed
three types of conditions
- can be place oriented (in the classroom, during play time)
- Can be person or partner oriented (when speaking with adults, when working with other children)
- can be with a level of assistance (given, withheld)
______ is assumed if a condition isnot stated.
independence and generalization to any context
In weekly goals, a condition can be oriented around what?
materials (given a list of written words or using pictures
Specifies how well the target behavior must be performed for the objective to be achieved.
correctly prodcue the /r/ phoneme is the____
in all word positions is a _____
with 80% accuracy is the _____
What is the performance, condition and criterion in
Mike wil produce closed syylables on spontaneously produced monosyllabic targt words in 90% of his attempts
- Performance: produce closed syllables
- Condition: on spontaneously produced monosyllabic target words
- Criterion: in 90% of his attempst.
write the objective
Use eye gaze to request an activity
given a field of two icons
Tim will appropriately use eye gaze to request an activity when given a field of two icons with 80% accuracy.
Which is the goal and which is the objective:
When given picture cards, Sarah will produce correct /l/ in initial position of words with 80% accuracy and moderate clinician support.
Sarah will independently produce correct /l/ in conversational speech with 80% accuracy.
Describe progress or final reports
- written at specific intervals throughout treatment or when services are terminal.
- Document client's mastery of goals and objectives in STP or IEP
What is the content of the progress reports?
- identifying information
- background information
- remediation process: (tx goal, objectives, plan, progress)
- clinical impresssions
Describe Daily treatment notes
- client performance must be documented after each session
- Enable the clinician to monitor tx program on continual basis and make changes as necessary
- provide info to others working with client
- another clinician can provied sercives
Treatment notes should be ______
- R- relavent
- S=Subjective (your opinion regarding relevant client behavior or status- give evidence not judgement
- O= Objective (data collected for each task during tx session
- A= Analysis or Assessment (interpret data from O or S and compare to previous performance. Analysis drives the plan)*most important
- P=Plan (identified proposed tx targets for next session and implies some form of action on your part)
What are maintaining factors, what can they affect? Directly? Indirectly?
- Factors that maintain the disorder (both limiting and supporting)
- Can affect communication and can impede rehabilitation of communicative disorder
- Can affect directly: make it more difficult for client to communicate
- Can affect indirectly: decreasing motivation is an example.
When should you consider maintaining factors?
- planning goals and procedures
- when developing prognosis
Maintaining factors can be used as ______
What are the 5 categories?
- a basis for determining which behaviors are contributing to a delay or disorders.
- cognitive, psychosocial, sensorimotor, health or medical, linguistic factors.
Describe the cognition related maintianing factors.
- Impairments in attention, short-term memory, organization, long term memory, reasoning, and problem-solving contribute to speech-language disorders
- Ex: (child learning pretend play relates to language skill of producing narratives. Adult with TBI and memory impairments relates to learnign strategy for producing grocery list)
Describe psychosocial factors related to maintaining factors.
- Ability to engage in and benefit from social interactions
- strategies for adapting to environmental demands
- Caregivers efforts to facilitate communication
- EX: Child with autism who does not seek social interactions, adult with dementia who is disoriented about location (long term care vs cruise ship)
- Family support
- Practice outside of treatment sessions (homework)
How would a clinician contribute as a maintaining factor?
- not providing tx that works for this client
- not providing a motivation that works for this client.
What are 7 behaviors that negatively affect learning?
- Non compliance
- Attention seeking
- Power and control
What are three results of poor behavior?
- client unavailable to learn
- client unable to complete tasks
- disrupts others learning
What are 8 predictors of poor behaviors?
- Inability to express self
- sensory challenges
- Lack of understanding of task
- uncomfortable emotional state
- peer rejection
- unfamiliar situations
- feelings of being misunderstood
What is best behavior management?
- Good planning
- Goals: written at correct level of difficulty
- Goals: functional and help client do what he or she needs to do
- Material: interesting and organized
- Have alternatives and more than you expect to need.
Discipline vs Behavior management
- Treatment that corrects or punishes
- a respectful way to help person function in a role.
What to do if child is seeking attention or aproval.
ignore poor behavior or praise good
what to do when behavior is due to power?
- withdraw from conflich
- Stay on message
- Never change your behavior, even if they don't comply keep doing work
- give choices, all ones you desire
what to do when behavior is revenge?
- avoid taking things personally
- maintain order
- take time and effort to build the relationship
- find things to praise.
What to do when behavior is because of inadequacy?
- Eliminate all criticism
- Encourage and recognize any attempts
- Focus on assets
- Don't be hooked into pity
- Maintain faith in the child
For behavior modification, it is important that....
you be consistent in your respones, know your consequences and follow through. if you are not prepared to do what you said then do not even start
Describe duratio of attention and how long children can last
- Younger childre: is often said to be equal in minutes to the child's age
- -2 year old can attend for two minutes
- -5 year old can attend for 5 minutes
- Older children: attention occurs in "waves"
- -Start: high attention, engagement, then declining attention and engagement after several minutes
- Each wave is smaller and shorter with most learning at beginning of the cycle.
What do SLPs do about attention?
- SLPs need to plan several activites to accomplish the same objective
- Child often doesn't realize he is working on the same skills because activity is fresh
- do a new activity every 5-8 minutes
What are two tips you can use for behavior?
- Mystery motivator,
- Yes no bag
What are the 5 parts of love and logic?
- 1. Set limits with enforceable statements
- 2. Demonstrate sadness or empathy vefore delivering consequences (oh no this is so sad, you did not finish your work today so i wont be able to give you your reward
- 3. Use delayed or anticipatory consequences (oh no, this is so sad, im going to have to do something about this, but not now, lwater. Try not to worry about it.
- 4. build a relationship with i notice statements
- 5. Build relationships with one sentence intervention (whisper one request in ear. )
What are some of Ms. Ross' tips for middle school?
- Dollar store grab bag for independently coming to speech on time
- get students to stand up and move often
- no hats, no hoods
- be friendly, but be in charge, set tone first day
- have a sense of humor and share it
- Surprise for fun.
- use independent work rubric and teach responsibility
- use visuals and pointing when possible
- know the school rules and school behavior plan.
What is incorporated into the methods, procedures, materials section of the STP?
- Teaching methods
- Regular procedures (usually elements of treatment)
- Examples are helpful
- Research - sources.
What is incorperated into the rational and justification section of an STP?
- Rationale for method and procedures
- Why did you schoos method--Evidence?
- Relate to priority need are and goals/objectives
What is incorporated into the prognosis section of the STP
- Your best assessment of client's outcome with intervention
- Include motivation, stimulability, family support, severtiy of disorder, maintaining factors, etc.
- An oderly set of actions based on an appraoch for intervention for a clients present level of performance
- EX: correct production of th/s/ phoneme in isolation will be accomplished by using a combination of phenetic placement and auditory stimulation based on Barbara Hodson's phonological approach
- The course of action that will turn goals and objectives into tangible activities
- Can include:
- Elements of treatment
- Family involvement
- Generalization plan-homework.
What do you need to consider when choosing materials?
- Interestin, motivational, functional, flexible
- Will materials provoke repeated target opportunities
- Will they allow you to take data
- Will allow explicit skill focus
- Call games activities.
Describe Lesson plans or tx plans.
- Can be daily or weekly
- Must have behavioral objectives based on semester treatment plan--but will be more specific incremental steps
- Some sites will require you to write rationale for each objective.
- SHOULD BE WRITTEN EXPLICITLY SO THAT IT COULD BE REPLICATED BY ANOTHER CLINICIAN
- of obective will change depending on activity/materials/procedures
- of objective will change depending on client's success in previous session
Lesson plans or tx plans should include...
- names of materials
- specific cues
- schedule of reinforcement
What are keys for planning/.
- Be flexible and plan for contingencies: client says he will bring some gardening articles to read- what if he forgets
- Thing about the session form the beginning to the end
- what wil you say?
- plan b and c?
How do you mantain accountability?
- Types of documentation
When or where do you collect data?
- Before an assesment
- during an assessment
- during treatment
- in situations for generalization
Data collection is
the recording of client responses
why do we collect data?
- we are a data driven society
- Numbers and information matter
- efficiency of treatment:time and money
WHat does data provide?
- Assesment of PLOP
- Treatment planning
- -changing meithods of treatment
- -changing steps of treatment-harder or easier tasks
- -to determine when to dismiss client
- -to decide to refer client
- to motivate client
- A way to justify treatmetn
What are clinical trials?
- Opportunities to take data
- Structured opportunities for client to produce a response during treatment
- usually provide multiple opportunities to practice the same skill
- may vary the activity, but the targets will be the same
What are naturalistic opportunities?
- opportunity to collect data
- careful observation during other speaking situations/play when client produces targets
- Depends on how you do treatment
- Set up enviornment to be sute the target behaviors will happen
Compare continuous data collection and intermittent or sampling data collection
- Continuous: All responses related to objectives are recorded. Better for some skills than others. Might interfere with the flow of session. Use data collection sheets when analyzing data and write your daily clinical note to summarize the session
- Intermittent: Take brief period and record all responses during that time. can have predetermined stimulus item on data sheet. When not predetermined- more writing si needed
What are 4 ways to take data?
- write during session
- on video or audio tape
- Use clickers or markers
- separate out the cards. pictures and count later
Describe quantitative data
- counting responses correct or incorrect
- often in terms of percentages correct
Compare horizontal and vertical quantitative data
- Horizontal: May not give enough detail (only good for correct or incorrect)
- Vertical: Tells first, second, third, etc. responses to same item. Can include prompts.
What would data collection for conversational level of articulation treatment be?
record errors per minute of speaking
What would pragmatic language treatment data look like?
Record correct uses of target per 5 minutes of play
What would early language development data look like.
Record occurences per day.
What are data graphs useful for?
To summarize and track inforamtion across multiple sessions, allows clinician to graph more than one objective
What is qualitative data?
Response rating scale (scale allowing clinician or client to rate the quality of clients responses, uses continnum of accuracy, usually 5 point scale
Qualitative data may be used with which clients?
What are the 5 elements of treatment?
- Behavior modification
- key teaching strategies
- session design
- data collection
What is programming?
- Selection sequencing and generalization of targets
- Developmental/normative strategy and client specific strategy
What is the developmental/normative strategy?
- based on developmental norms
- used more for childre with artic or language disorders
What is client specific strategy?
- based on individuals specific needs
- frequency which behavior occurs
- importance of behavior to client
- potential for mastery
Changing the task heirarchy is also known as? it is under what?
what are the three components of behavior modification?
What is positive reinforcement? Negative?
- Positive: primary, food. Secondary, social toaken performace feedback.
- Negative:Escape, avaidance
What are the types or reinforcement?
Continuous or intermittent
Continuous reinforcement is used to ....
establish new behavior
Intermitten schedules are used to
promote generalization and maintence
What are key teaching strategies?
- Negative practice
- Target specific feedback
- The clinician's production of the target response.
- Can be direct/immediate or indirect/ delayed
- Provides maximum clinician support
- Frequently used in early stages of learning new skill
- models are typically faded out over time
Describe shaping or successive approximation?
- Taking the client by little steps closer and closer to target- baby steps or bridge
- Shape behavior into desired behavior
- Analyze steps and find one to be imitated or assisted
- Moe a step closer to desired target
- Verbal or non-verbal cue to facilitate production
- of correct responses
- Partial stimulus
- gentle hint
- attentional or instructional
Modeling, prompting, reinforcements are reduced in gradual steps while maintaining target response.
- Clinician reformulates clients utterance into more mature or complete version
- Provides example of desirable communicative behavior
- Client becomes aware of error pattern
- Illustrates difference between old response and new target
- used after client is able to produce new target
Target specific feedback
- Provides precise information about why responses are correct or incorrect
- Be specific- not just "good" or "good work" but "good using 'he' in your sentance
- Helps maintain clients awareness of target response and helps clinician remember tx focus.
Describe session design
- Basic training protocol: clinician presents stimuls, waits for clients to respond, presents appropriate consequent event, records respones, removes stimulus
- Task order: Easy hard easy
- Dynamics of intervention
What are the 4 dynamics of intervention
- Clinician-client relationship
- Work efficiency/pace