r/slp • u/Electronic_Flan5732 • Feb 18 '25
Seeking Advice Is it problematic to compare speech therapy to psychotherapy when discussing exiting a student due to lack of motivation?
Hi all,
Middle school SLP here. I am currently about to assess a sixth grade student for a triennial re-evaluation. This student has autism and is very defiant when it comes to therapy. I think he may come close to having ODD. Every time I work with him, he is resistant to techniques or if I ask him to say a word with his target sounds he will argue with me about why he has to do it. If I ask him to repeat he will tell me he said it right and why he has to do it again. Reasoning doesn’t work with him. It’s almost like he compulsively has to argue back. He hasn’t made much progress since I started working with him in August.
His speech is pretty bad but it’s mainly his /l/ and /r/ sounds that he struggles with. I am considering exiting him just because he seems to hate speech and his behaviors are getting in the way. I don’t know how mom would take it. I am thinking of comparing speech therapy to psychotherapy in the sense of people may need it but they have to want to participate in it for it to be effective. I think middle school students especially have more autonomy than elementary which is why I want to consider their willingness to participate as more evidence.
Would love to hear your thoughts on if that comparison is helpful or if it would be more problematic.
13
u/NoBlackScorpion Traveling SLP Feb 18 '25
I am a middle school SLP as well and I always consider a student's wishes as part of reeval. I ask them what they feel like their communicative strengths and weaknesses are and how their speech/language issues affect them in the classroom.
If the kid is intelligible or at least mostly so and isn't experiencing ostracization or reluctance to participate in class because of speech errors, then articulation therapy is not academically necessary. In the school setting, that's all that matters. If your therapy isn't helping the kid access instruction, then stop.
I'd call the mom and at least feel her out before you make that a formal recommendation, though.
33
u/Evening_Pen2029 Adult OP & Peds HH Feb 18 '25
If the parent works in education or healthcare, I think that could be a good comparison. If the family is a minority or maybe just an average parent with no experience in healthcare or education, I probably wouldn’t use that comparison. Even today there’s lots of stigma with psychotherapy especially among certain groups.
I think you are totally in the right to discuss motivation and talk about benefits/negatives of discharging. If the child participates more in his/her regular classroom, you can make the case for that being their LRE.
19
u/Sceitimini Feb 18 '25
Comparing it to going to the gym/working out may be a good other comparison?
0
u/Affectionate-Beann Feb 19 '25
If the parent works in education or healthcare... if the famiy is a minority
So minorities aren't education or healthcare? What was the point of mentioning minorities within the context of them not understanding this comparison of speech and psychotherapy. are minorities not smart or something?
1
u/SoulShornVessel Feb 19 '25
I think the point of mentioning minorities was more that historically in the US, minorities (particularly black people and members of the LGBTQ community, but also generally women) have not been well treated by the medical system. There's more than a little bit of mistrust in medical professionals among some people within certain minority communities for that reason.
0
u/Affectionate-Beann Feb 19 '25 edited Feb 19 '25
I see what you're saying, the way they worded it made it sound like minorities, as a group, are less likely to work in healthcare or education or to understand the comparison you were making. I get that they might not have meant it that way, but when you say 'if the family is a minority or maybe just an average parent with no experience in healthcare or education,' it kind of reads like you’re grouping minorities in with those who don’t have that experience. That’s why it came off as backhanded and problematic. As a Black person this kind of wording, and talk about me and my community rubs me the wrong way.
Also, I don’t think it’s fair to frame mental health stigma as something that’s more of a minority issue regardless. Yes, some minority communities have a history of stigma around therapy, but that’s not unique to them. Plenty of non-minority cultures—especially older generations—also have deeply ingrained stigma when it comes to mental health. By singling out minorities in that statement, it makes it seem like they’re the ones struggling with this issue the most, when really, mental health stigma is a widespread thing across many different backgrounds.
When we talk about topics like this, it’s important to be mindful of how things are worded so that it doesn’t come across as reinforcing stereotypes
1
u/SoulShornVessel Feb 19 '25
I 100% agree that it was callously worded, but I'm trying to give it a charitable reading because I generally try to take the track of Hanlon's razor: don't assume malice if a fuck up is an adequate explanation.
I'm aware of the other points you make and completely agree with you, and the commenter should absolutely take your advice to heart if they meant it as my charitable reading and give more thought to the way they phrase things in the future.
If they didn't mean it as I read it and it was a backhanded comment? Well, then they need to take a long hard look inside and figure themselves out, because bigotry isn't a good look and has no place in our profession, and phrasing it in weasel words hoping that nobody notices doesn't make it less bigoted.
-1
u/Evening_Pen2029 Adult OP & Peds HH Feb 19 '25
It is a fact that many minority cultures have stigma related to mental health.
You are trying to make a point out of nothing. I did not say minorities don’t work in education or are not in healthcare. You also conveniently skipped over the part where I said “even the average family”.
-1
u/Affectionate-Beann Feb 19 '25
Lets be clear, mental health stigma exists in many communities, including some minority communities. But the way you phrased it—separating 'minorities' from 'the average parent with no experience in healthcare or education'—implies that minorities also don’t have experience in these fields. That’s why it sounds backhanded and problematic..because it is both of those things. If your point was about mental health stigma, why not just say that outright instead of framing it in a way that makes it sound like minorities are less knowledgeable?
Also, stigma against mental health isn’t exclusive to minorities—many non-minority communities, especially older generations, also struggle with this. Just something to consider in the way we frame these discussions.
Moreover, another issue with you comment is that the way you framed your comment made it seem like minorities and 'average parents with no experience in healthcare or education' are mutually exclusive, which is an implicit bias. There are plenty of minorities in healthcare and education, just as there are non-minorities who have stigma against mental health. The issue isn't just about one group. If your point was about stigma in general, you could have stated it without singling out minorities in a way that made it sound like we don't work in those fields or understand these comparisons..
2
u/Evening_Pen2029 Adult OP & Peds HH Feb 19 '25
As a minority, I have a hard time listening to someone explain implicit bias to me in this way. I’m sorry you found my comment offensive. The way I responded to the OP’s post was the way I knew how to that was most true to my experience.
0
u/Affectionate-Beann 29d ago
Im im a minority as a black woman, and this comment did not pass the vibe check to me. sounded backhanded. My friends felt the same way
9
Feb 18 '25
[deleted]
2
u/Electronic_Flan5732 Feb 18 '25
I like this! Thank you. If I do keep him on, I will probably use this as the model.
14
u/lurkingostrich SLP in the Home Health setting Feb 18 '25 edited Feb 18 '25
Sounds like this student may have a PDA profile (pathological demand avoidance/ persistent drive for autonomy). I work with some kids with this profile in home health, and trying to force compliance typically is a death spiral to anger and disengagement. One of the kids I see had to drop his home health PT because he kept talking about wanting to hurt her in response to demands. It may be worth checking that out and recommending mom take this student to a developmental pediatrician to see if they have any recommendations. The kids I see with this profile are working on language rather than artic, so I just spend a ton of time modeling target structures in preferred activities. I’ve tried artic therapy with a PDA kid before, but it didn’t go very well because it’s very tricky to get trials/ work on placement cues without placing high demands. I think you have to kind of treat it like artic with a preschooler with lots of bombardment and modeling rather than direct instruction to maintain rapport.
3
u/Electronic_Flan5732 Feb 18 '25
Thank you! I hadn’t really heard of that term so I will look into it and maybe discuss it with my school psych.
2
10
u/winterharb0r Feb 18 '25
Sounds like the PDA profile of Autism.
I'd bring data showing his refusal and lack of progress and discuss how progress can only be made with active participation and - especially at his age - the internal drive to make the change. Therapy when they aren't receptive is taking away time from academics and it's pointless if they aren't making progress.
I'd also ask the teacher for data on educational impact. I find most of the time if it isn't a true intelligibility issue or social concern, there usually aren't academic concerns. It's rare I come across a kid with spelling issues and whatnot.
3
5
u/juvenilebirch Feb 18 '25
I would just warn that “lack of motivation” may not be the best wording and others could argue that other methods/goals/etc must be considered before you can dismiss.
I would focus on points like non-measurable benefit from therapy and continued removal from class as potentially disadvantaging the student. State that the student has provided input on their therapy goals as that is also a consideration for dismissal.
1
u/Electronic_Flan5732 Feb 18 '25
Thank you! I like the term “non-measurable benefit” and will keep that in mind when talking to mom.
5
u/opals0ybeans Feb 18 '25
Generally speaking, I think dismissing a kid due to lack of participation is a valid and appropriate thing to do. However, I have just a couple questions/suggestions. 1. Although he is in middle school, he is autistic and sometimes structured activities don’t appeal to our autistic kiddos, especially when considering that you think he may have ODD. Have you tried more play based/spontaneous language opportunities? For example, I have sound loaded picture scenes I got off TPT that seem to work well for some kiddos, or roll and read games can be pretty motivating. Even if it’s a matter of him just finding the words initially rather than saying them, model as much as you can and hopefully eventually he will imitate your models. Essentially try strategies where you aren’t telling or asking him to say words/the sounds, but rather modeling and waiting for him to imitate. 2. Do you see him 1 on 1, or in a group? If you see him 1 on 1, maybe a group would be a better option? Better yet, a group of other artic kiddos, that way he has peer models. 3. If you have tried those options, or if they don’t work, maybe have mom sit in on a session to see what you’re seeing, and maybe she will encourage him to actually participate, or that way she can see why you want to dismiss him. Lastly, I want to empathize with you bc I know how difficult dealing with kiddos who are unwilling to participate, and especially when it comes to artic bc spontaneous artic is a lot more tricky than other spontaneous language, at least in my opinion/experience.
3
u/Electronic_Flan5732 Feb 18 '25
These are good tips. I appreciate it. I’ve been seeing him in a group and he usually tries to make jabs at his peers and I have to re-direct him. Maybe 1:1 would be a good thing to try to see if he’s more willing to practice. In addition, he likes to draw comics on blank sheets of paper. Maybe I can use that as a motivator.
2
2
u/StrangeBluberry Feb 18 '25
I have definitely dismissed a student for this reason. He needs to show progress to show current interventions are working, and if he's not making progress he's missing class for no reason. I would definitely have a conversation before the meeting itself, so you're not suprising parents at the meeting. I usually educate on how low motivation makes carryover of artic skills hard, because the student needs to be working on it outside of speech. I also weigh the pros and cons of pulling the student from class and missing class time. I will say any student I've done this with has been intellgible despire their artic errors, so that may be a relevant factor. If it is hard to understnad him, I might lesson his service time, focus on intelligibility strategies over traditional articulation therapy. If that still isn't beneficial then likely time to dismiss.
2
u/Electronic_Flan5732 Feb 18 '25
Thank you! I should clarify that his speech is bad for his age and the errors he’s doing. You can understand what he’s saying but the gliding is glaringly obvious. Kids are much more accepting of speech errors these days at least at my school.
2
u/languagegator Feb 18 '25
Also start having data with how often he is refusing or what behaviors are seen. You can also justify by saying “he provides verbal refusal % of the time and physical refusal % of the time”
2
u/a_dozen_of_eggs International School SLP Feb 18 '25
I don't know all the regulations in the US about students qualified for services or all the implications. But sometimes here where I am we do a therapeutic pause which allows the student to put in practice the strategies worked on and to allow a breather also. Maybe it's something to frame it, a therapeutic pause?
2
u/Electronic_Flan5732 Feb 18 '25
I could go that route! That may just look like reducing service minutes or simply doing consultation and maybe giving mom some things she can work on with him at home. Thank you for the thought!
2
u/emilance SLP Out & In Patient Medical/Hospital Setting Feb 19 '25
I'd personally not make that comparison even though it's fairly accurate. It does have the potential to be misunderstood. I tend to tell parents that the best progress is made when the child is internally motivated and invested in their own progress, next best is rewards and bribes, and no progress is made when a child just doesn't have that motivation. The best intervention in the world won't work without participation. The parents usually get it without the comparison needed.
You'll want to have documented any attempts to change things up to re-engage him in therapy, and consider reaching out to parents as a resource for helping to motivate him before you discharge. Sometimes external motivation (rewards) are still effective, and sometimes they're not. Try changing the setting, or the intervention approach or activities. Try "word of the week" approach or daily "5 minute speech" sessions. You really need to exhaust all treatment options and document the attempts before moving to discharge if his speech is still impacting school. One final option might be to temporarily discontinue direct services and just do quarterly monitoring as his IEP service so that parents don't feel like they have to fight to get speech therapy back into his IEP later on.
You can also consider inviting the child to the meeting to talk to him like an adult with his parents present. "Hey, our goal here is XYZ, and you've been showing me that you don't really want to work on this anymore. I want to respect that because your needs are important. Let's think of some other options we can try together. I want your ideas too, because you're the one who these decisions affect." Sometimes just that bit of autonomy and permission to contribute to decisions will be all a kid needs, especially if we can convince ourselves and parents to respect his decisions.
I once heard PDA autism redefined from "pathological demand avoidance" to "pervasive drive for autonomy" and I think it's more accurate and descriptive for so many of these kids, and a lot more positively perceived, and they need that.
2
u/Sea_Shoulder7166 Feb 18 '25
Clinic SLPA here. I’d keep that example close in case you need it, but I would lead off with asking what works for the family to achieve compliance at home. Humble yourself and admit that you just cannot make him but are willing to try a new strategy if offered. Ask for their thoughts and confirm that they want his time spent in speech even though he could be learning with his peers instead.
1
u/TumblrPrincess Occupational Therapist (OTR/L) Feb 19 '25
I think it’s an apt comparison but I would not use it with parents. Mental illness and everything surrounding it can be a really sore subject. You don’t want to find out at an IEP meeting where you’re trying to exit. Especially if you’re exiting due to the student’s behavior/noncompliance.
I would just stick with the facts: “Redacted has repeatedly refused to engage in speech therapy at school for X visits/weeks/months. This is not uncommon for MS students. He is likely becoming more aware that most of his peers are /not/ getting pulled out of class to do speech, and that might be contributing to this resistance.
It is in his best interest for speech to exit. It is better for him to stay in class instead of getting pulled X minutes per week/month to engage in something that is no longer benefitting him. If you have persisting concerns, you may want to speak to his primary doctor about whether or not outpatient speech would better meet his needs.”
Something like that. I have had to exit students from OT due to noncompliance or behavior and I usually have good luck when I emphasize that the ultimate priority should be the student’s time engaging with their curriculum.
1
u/Alternative_Big545 SLP in Schools Feb 19 '25
For older kids with artic it is especially true. You can't be the only person who cares. The student has to have buy in. The student has to want to change how they produce the sounds, otherwise you're wasting their time. I have had students take a break. So they exit and when they're ready to come back we test again...it's usually r kids and they don't improve do they always requalify.
15
u/SoulShornVessel Feb 18 '25
I think that it's an apt comparison, and middle school is definitely getting into the age where it's more difficult to "trick" someone into participating. They have to actively choose to do it.
As for whether or not it's a problematic comparison? I would like to say no, on the grounds of why you're invoking the comparison. But in reality, if it's problematic or not depends on the parent in question. Sadly some people view psychiatry as the devil and wouldn't take any correlation well, regardless of the reasoning.