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Why Do Children Refuse or Resist Participation in Speech Therapy?

Tracy Vail, M.S., CCC-SLP

I think it’s really valuable when professionals and parents make a shift in their thinking, where the question changes from “Why won’t my child participate in therapy?” to “What do I need to do to change the environment so the child wants to learn?” The responsibility for teaching any skill then becomes the responsibility of the professional and, realistically, it’s the only position to hold that gives us any power in the teaching situation.

Children only do what works for them or what we, as adults, have accidentally taught them in the past. If a child is sliding under the table and refusing to work and the parent takes him home, the child accidently learns how to get out of learning situations. If a child has many experiences with learning situations that result in failure, it’s not surprising that they would be motivated to escape learning situations. So, if a child is attempting to escape or avoid learning situations, we must do two things.

First, we have to make sure that the child’s behavior never results in escape again. How? At the beginning of any therapeutic relationship, it’s important to be careful of the demands we place on the child. We must avoid giving the child instructions to do anything that we are not willing or able to prompt them through doing. To start out, we figure out lots and lots of different things that motivate that child and give it to them unconditionally. These things that the child enjoys or is motivated for become potential reinforcers. Motivation is a critical part of teaching any skill. If the child is not motivated for anything, we have nothing to reinforce the skills we want to teach. If we are not reinforcing, we are not teaching.

Once the child is approaching the learning situation, and the therapist, we can begin placing small, easy demands on the child, but only those for which we are able and willing to provide follow through. If the child refuses, we prompt them through the task and reinforce their compliance. We want the child to quickly learn that, “good things happen when I comply with adult requests AND, I’m not going to escape doing it.” This is often difficult in speech therapy situations because the thing we are working on is talking and, no matter how hard we try, we can’t climb into the child’s mouth and prompt them to talk. So, even in speech therapy, it’s often helpful to start with small demands that you can prompt, such as asking the child to hand you something or put something away and then heavily reinforce compliance. It’s important to remember that in any given instance, we are teaching something. If we tell the child to say something, and they don’t, they are practicing NOT following directions. Once we have established many things the child is able and willing to do to gain access to their favorite toys/activities, we can being working on “talking”.

It’s also important to enroll the parents in the process and gain agreement for the importance of following this philosophy at home. If the parent asks their child to do something, they need to follow through to make sure it’s done. If they aren’t able or willing to follow through, then they should not give the instruction. For example, if the parent is running out the door to get everyone to school on time, it might not be a good time to ask the child to get their shoes because if the child doesn’t get his/her shoes on request, the parent needs to give them whatever prompting is needed to make sure that they get their shoes. Instead, in this time pressured situation, the parent might choose to get the shoes them self. Every interaction is a learning opportunity so be sure everyone is teaching the child what you want them to learn.

To increase the likelihood that the child will attempt what we are asking him to say, we can make sure we have a strong reinforcer visible and we can use “behavioral momentum.” Behavioral momentum occurs when we ask the child to do a couple of things which he can do easily then gradually make the requests more difficult. For example, we might as the child to stomp her feet, clap her hands, then, when she’s done those tasks successfully we can ask her to say something.

The second thing that we must do if a child is attempting to escape or avoid learning situations is that we make sure we are teaching the child in a way in which he can be successful. As human beings, we generally tend to enjoy doing things that we’re good at and avoid doing things that we’re not good at. When children have Apraxia of Speech, we are asking them to do something that is very difficult for them. The older that children are the more experience they’ve had with failure when attempting to talk. Children have a natural tendency to want to reach “parity” or to be able to imitate us. Thus, we have to provide models and prompts that they can successfully approximate and heavily reinforce every attempt that they make at the target sound or movement.

Each child is unique and part of the evaluation process is to determine what the child can already do successfully. We get an inventory of the sounds and syllable structures the child is able to produce successfully. These become our building blocks to start shaping this specific child’s speech. We also look at other skills the child has that might help us elicit specific sounds or words. For example, if a child can already drink through a straw or blow a horn, we might use this skill to help prompt lip rounding for vowels. Or, if a child can produce the “h” sound but has no other strident sounds, we could move from an “h” to an “h” with the teeth closed to get an approximation of “sh”. My speech therapy practice just recently had a child who could produce “m” but all of his plosive sounds became glottal. By holding his nose and asking him to say an initial “m’ syllable, we also got initial “b” syllables. This is the fun part of therapy! We get to figure out what the child can already do and how we can use that to teach them new skills in a way that they will be successful.

Another piece of the puzzle is to determine which type of prompting strategy to which the individual child responds best. There are many different programs out there with reported success, but after 30 years of practice, I can honestly say that none of them work for all of the children all of the time. It’s important for professionals to not be so attached to one prompting strategy that they will only use that with all the children with which they work. Some children might respond best to visual prompts for sounds. Others might respond best to tactile prompts. Still others respond best to auditory prompts. Others respond better to combined prompts. It really doesn’t matter which prompting strategy is used except that we use the one to which one the child responds best.

While it’s important to keep the child successful, it’s also important to make sure the child is progressing at an optimal rate. If we are continually teaching new skills, prompting in optimal ways and reinforcing success, the child should progress at their optimal rate. If at any time, progression slows, we need to examine our teaching procedures to make sure we’re doing everything possible to increase the rate of learning.

To summarize, whenever one of the therapists in my private practice has difficulty engaging a child, we look at the following:

  1. Are we using powerful enough reinforcers? Without motivation, we have no reinforcers and without reinforcers, we aren’t teaching. We need to find lots and lots of things that the child enjoys and deliver them contingent upon the types of responses we want.
  2. Are we reinforcing frequently enough? For some children, we need to start by reinforcing every attempt they make at performing the skill we’re teaching. Maybe we’re just reinforcing the movement of the lips toward the target vowel or even placing the tongue in the correct place to make a target sound. As the skills become easier for the child, we reinforce less frequently to strengthen the target skill.
  3. Are the skills we’re teaching possible for the child? This is often a big problem for children with apraxia as frequent failure at their attempts results in them wanting to avoid the teaching situation. For example, we might be asking a child to imitate an entire word and they just don’t have the motor planning skills for that. Instead, we could start with a movement, a vowel, or a single syllable…Whatever the child can produce successfully then teach the combined movements gradually.
  4. Are we using effective prompting methods? Different children do better with different prompting methods. Some do better with visual prompts such as hand signals or pictures. Others do better with tactile prompts such as PROMPT. Others do better with music or auditory prompts. We need to work with each individual child to know which prompting strategy works best for that child.
  5. Is everyone in the child’s life reinforcing the child for complying with adult requests and following through with demands placed? We want to make sure everyone works as a team to teach the child that good things happen when he/she complies with adult requests and that refusing is not an option.

The most important thing to remember when a child is attempting to escape or avoid any teaching situation is that it’s the teaching that’s the problem (NOT the teacher, but the variables involved in the teaching situation and the learning history of the child). First and foremost the problem is not the child.

[About the author: Tracy Vail is a Speech-Language Pathologist and co-owner of Let’s Talk Speech & Language Services in Raleigh, North Carolina. She has more than 25 years experience working with children with apraxia, autism, and other severe communication disorders.]