Q: I have heard you say that although most school districts seem to have excellent entrance criteria for therapy, they tend to have very poor exit criteria. Could you speak to this in regard to a client’s willingness to participate and in regard to cognitive level?

Because I have been in private practice for 25 years, I have not had to agree with anyone on exit criteria, and therefore I have taken it on a case-by-case basis. In all honesty, it is when I get that guilty feeling in my gut that says “You-should-not-be-charging-for-this-service-because-you-are-not-helping-this-child” that I talk with the parents and steer things in a different direction. However, I am sure that a guilty conscious is not the answer you are seeking.

Motivation

When it comes to motivation, I always figure that I can win over a little client, so I almost never let a young child go for that reason and I think I have won over just about every young client I have worked with. But when it comes to adolescents, I usually make a decision within 2-4 weeks. If I have not been able to establish rapport, and the client still is fussing about attending therapy, I would postpone our work until after the client had matured a little. I make sure to follow up so I can pick him up as soon as he is ready.

Cognitive Skills

So many clients with lower cognitive skills progress very slowly. Therefore I make sure that the parents understand what it may be possible to achieve, I spell out the child’s ability to “understand”, and I do not let the parents labor under the delusion that their child has a speech problem only.

I typically set up therapy in three-month intervals. I tell the parents that about every three months I am going to check in with them to see if this is worth continuing. When the time comes, I talk with them in an informal way on the phone or in person. I ask them if they are seeing enough progress to make this worthwhile in terms of time, travel, and financial commitment.

Most parents don’t really know what to say because they don’t want to give up. So I am very direct and say things like, “Well, you know that I cannot make this problem go away. Right? So given that, I think I could…” Then I outline what I think may be possible. I set concrete short-term goals like speaking up a little better, adding specific vocabulary words, or saying three-syllable words.

I find that if I set my goals very realistically, then I avoid that guilty feeling, and parents can see exactly what is improving during each three-month interval.