Spaced Retrieval in Pediatric Speech-Language Treatment

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Have you ever worked with a pediatric client who just can’t seem to remember what you’ve tried to teach them 5 minutes or 5 days later?

I know I have. And, it’s frustrating for everyone involved.

I’ve worked with pediatric clients who can’t remember what they’ve learned as the result of: pediatric in-utero strokes, pediatric strokes after birth, TBI, brain changes as the result of disorders like cerebral palsy, seizures disorders like severe epilepsy and Lennox-Gastaut syndrome, and severe ADHD/ADD. I’ve also worked with larger groups of children where we needed to make sure every child learned the same sequence (e.g., handwashing).

There is an effective teaching technique for this situation. It’s called spaced retrieval. It was developed initially for use with adults with dementia and it’s been around for a while. Here’s a link to a literature review on using spaced retrieval with individuals with dementia. It’s about 10 years old now, but it provides good background and the evidence-based practice for this technique.

There’s very little in the literature about using this technique with children or adolescents. I want to change that.

Spaced retrieval is a form of errorless learning. It taps into the implicit or procedural memory system rather than the more familiar episodic memory system (you know, where newly learned information first goes into the appropriate working [short-term] memory, processed, then is transferred to long-term memory). Implicit memory is an automatic memory system. In a nutshell, here’s how it works. You teach a new skill/new information, then ask the client to actively recall the skill/information over increasingly longer periods of time. As an example, an enterprising high school student and I used spaced retrieval to teach the CDC’s handwashing routine to 4- and 5-year old children attending a private school (Yemisrach & Bass, 2019; click on the link to access her Georgia State Science Fair poster). The student presented the 5 steps of the system with the associated pictures to children in groups of 2-3. Following the script we wrote together, she asked the children to immediately tell her the steps back using the picture supports. If they didn’t make any mistakes, then she set a timer and asked them in 15 seconds (a stopwatch or the clock function on your phone is must!) If they made mistakes, she reviewed the steps with them then immediately asked them to tell her the steps until they could do so error free. The time intervals were: 0 seconds, 15 seconds, 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, and 16 minutes. It took between 30-45 minutes to get each group to the 16-minute mark. As you’d expect, the 4-year-olds made more mistakes than the 5-year-olds initially. Most often, the 4-year-olds skipped a step in the retell. We conducted a post-test 1 week after the children got to the 16-minute mark without making mistakes. Nearly all of the participants were able to correctly recall all 5 steps 1 week later on the initial request.

Who knew the participants would really know how to wash their hands well a mere 6 months later? But, I digress.

Research shows you really only need to get your client to the 8-minute mark for them to have learned the new information. That’s great news, because you can teach new information through this errorless learning technique to the 8-minute mark in a 30-minute therapy session. How do I know? Because I use spaced retrieval in therapy.

I first began using spaced retrieval with a high school junior who had fried his brain on what we all believed to be “spice” (synthetic cannabis). A little background: I’d worked with the student when he was a sophomore. He was your garden variety “learning disabled student” whose learning disabilities really were rooted in a mild-moderate mixed receptive-expressive language disorder. (That’s a whole post in itself!) He was quiet, pleasant, and laughed at my jokes during therapy sessions. He had been living with his mom when their relationship went south. So, he moved in with his dad and changed schools because his dad lived in a different part of town. Fast forward a little over a semester. He came back to live with his mom because he’d gotten into “drugs” while living with his dad. The kid who came back was nothing like the kid who’d left only a few months before. He avoided eye contact. He had multiple motor tics. He mumbled. He no longer got jokes or hung out with his former friends. If he had access to an ink pen, he colored on his arms, legs, even the inside of his eye lids. When asked about his drug use, he stated adamantly to multiple people that he’d only smoked pot. I believe that’s exactly what he thought he was doing. I asked him why he colored on his skin with a pen. He said it felt good.

We held a new IEP meeting when he came to our school because his previous goals just weren’t appropriate any more. He’d changed that much. He stated he wanted to get out of high school and get a job. Ok. That gave me something to work with. I could work on the pragmatic skills through spaced retrieval. I ordered this book from Amazon and got to work. We started with making eye contact when you talk to other people. The prompt was, “Where do you look when people talk to you?” His version of the response became, “in the face.” In one 30-minute session, we were able to get to the 8-minute mark. And, it worked. When educators used the prompt, he began to make more eye contact with them. We also worked on, “When you’re at school or at work, where do you wear your pants?” (“Around my waist” was the response). I taught his primary teachers how to use spaced retrieval to help him with other parts of the school routine that just seemed to have been lost – things like not leaving class without permission, not coloring on the inside of his eye lids with a pen, etc.

I’ve since expanded the use of spaced retrieval to teaching the handwashing routine to early elementary school-age children with communication disorders (e.g., Down syndrome, autism, developmental delay; Summer 2021) and used it successfully to teach the consonants and vowels from the Lindamood Phoneme Sequencing Program (LiPS Program) to a 7-year-old with Lennox-Gastaut syndrome, a 6-year-old with severe ADHD, and a 7-year-old who was born at 23 weeks with history of in-utero strokes and several strokes/brain bleeds since birth. (I’m currently working with this client on recognizing these same associations when they are in text. She has vision issues related to her CP which complicate the process.) I also used spaced retrieval to successfully teach this client the days of the week in one 30-minute session and the months of the year in two 30-minute sessions – IEP goals that the school had been addressing for two years.

I’m in the process of developing some continuing education materials on this topic and several others I’ve posted about over the last year or so. In those CE materials, I’ll have sample benchmarks and goals for spaced retrieval. As we get closer to launch, I’ll post more information about how to access the courses for CEU credit.

As always, thanks for taking the time to read my thoughts. If you’d like to try spaced retrieval with your pediatric clients and would like some pointers, please feel free to get in touch with me.

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