© David Sponder, L.E.P., BCBA, Floortime C3c
Executive Director, Sponderworks Children’s Services

The Therapeutic Pause as an Indirect Prompt or a Replacement for Direct Prompting

The Therapeutic Pause technique is meant to foster independent thinking, as well as to reduce the amount of compensation others do for a child’s difficulties with aspects of independent thinking such as recollection, working memory, and motor planning.  Adults that use the technique minimize prompting overall, especially by eliminating prompts that are superfluous.  The Therapeutic Pause technique can be part of an overall prompt-reduction strategy.

This is not the same as “prompt-fading.” What we are talking about here is elimination of prompts rather than simply reducing the intensity or explicitness of prompts.

First, let’s analyze the functions of various prompts: Prompting can take many forms such as verbal reminders, gestures or signals (also includes “signs” such as rules on the wall; picture schedules; homework lists on the whiteboard, etc.), natural prompts (e.g. natural signs such as dirty dishes in the sink functioning as a cue to wash the dishes; wet pants as a cue to change clothes, etc.), embedded prompts (similar to natural prompts, but added to the environment for the purpose of prompting: e.g., a “TEACCH [DS10] style” row of boxes to help a student remember what assignments she has to do; arranging a child’s shoes in a special way as to help him remember which shoes goes on which foot, etc.), or… a therapeutic pause (STA) that can function as a cue for an action that you want a child to do (e.g., demonstrate a skill, reference you or someone/something else, etc.).

Prompting as Support for Memory

When we cannot remember something using only our own brains, we tend to make use external forms of storage.  Forms of external storage might include writing things down, recording them on tape or video, tying a string around our finger, taking pictures, asking someone else to remind us or relying on verbal prompting (using another person’s brain), etc.

A prompt should be thought of as external storage of memory.  It doesn’t contain all of the information; but it contains something that ignites the associated neural circuits that yield the rest of the information a person recalls (internal storage).

External storage is a compensation for what we cannot remember with our brains.  You will not remember every word you read here for instance, but you can keep it on your computer.  So in this case, external storage is an entirely normal and necessary compensation.

Example: The Anatomy of a Prompt

Let’s take one of the most common compensatory devices (prompts) that we use: the visual reminder (pictorial, visual symbol, or written schedules; rules on the wall; etc.).

As for myself, my career would be over if I had to rely on simply my brain to remember my schedule.  I absolutely rely on my calendar and my schedule to get by.  And because of my particular problem with something called visual-object memory, I need to have designated places where things go, or I will never find them.

But I don’t consider myself as seriously impaired as far as the mental skills that are required to understand, remember, or manage my schedule.  These skills include but are not limited to understanding concepts of date, time, and duration; understanding sequence and having some ability to change sequences around in my head, and; reasonable ability to remember things in the short, intermediate, and long term.  I also have a reasonable set of emotional skills that decide for me what is important and what isn’t.   But I can barely remember my schedule for a day, and I can remember that a certain event will happen where and when if it is important enough to me (Uh Oh, my Anniversary was yesterday.  Ah Jeez, I’m in trouble now).

Anything else will have to be stored externally.

If a particular memory process is weak (e.g., auditory memory, visual memory, short-term memory, working memory, sequential memory[2], long term memory, etc.), then there is an increased need for some form of external storage.  This is where something like a visual schedule might come in.

When we use picture or written schedules for kids with ASD, we must be careful in our assumptions regarding why they are necessary – if we ever hope to fade them.

We might use them because this is what we were taught in training: that kids with ASD do better with them.  It’s true.  Kids with ASD (or anyone else) can benefit, although we should have an idea of whether or not one is truly needed.  Common sense will tell you that if you can remember a few things easily in your head, it will slow down things unnecessarily to write them down.  It’s inefficient to make lists of things.

But as in any intervention, there are potential side-effects, so the willy-nilly application of this technique should be avoided.  For many with ASD, rigid thinking/inflexibility is a major feature of their clinical presentation.  Once a schedule is on paper, you may be in real trouble if you try to change it.  In other words, you would be in effect asking the person to ignore what the schedule on the wall says, which can be an intolerable cognitive dissonance for the most rigid thinkers.

Forms of memory a visual schedule might support:

Sequential Memory

Sequential memory is a temporal form of memory that has to do with remembering the order or sequence of things.  It helps us think forwards and backwards in time.

A lot of the time, it has to do with remembering the sequence of steps for actions, tasks, or routines, and then executing the actions in the correct order.  It also has to do with remembering the order of events: the order in which something was seen, heard, or otherwise noticed or perceived.  It also has to do with the remembering of the order in which ideas unfold.

People with autism have such difficulty with sequential thinking that they are often stuck in the “here and now.”  This is in line with the general characteristic of being [too] absorbed in their own actions (tunnel vision; keyhole perspective).  A form of this is being “stuck in time,” where the person dwells on events, but does not relate them to other events that occurred before or afterwards.

Visual [Sequential] Memory

This has to do with remembering the sequence of visual events.  Pictures or words on the schedule depict the order of events in a visual temporal display – usually from left-to-right or top-to-bottom.

Given that the schedule usually remains up on the wall or on the desk or whatever, the person does not have to commit any of this to memory.  As in the example of me and my calendar, it isn’t really practical to commit long lists to memory – so such a static visual reference is a beneficial compensation (for me).

However, lists and visual schedules do nothing to remediate visual memory.  Remediating visual memory might involve brief exposures to the schedule and providing frameworks (controlling for distractions, allowance of time and space to think and figure out what to do next, teaching referencing of others to track changes or clues in the environment that help one remember or that allow a person to follow others, etc.) that encourage the person to “do the work” of visual sequential thinking.

Overuse of static visual references (lists, calendars, social stories) teaches a person to adapt by not trying to remember, as what happens to our [auditory] memory of important phone numbers once we commit them to speed-dial.

Auditory [Sequential] Memory

Auditory sequential memory has to do with remembering what you’ve heard and the order in which you’ve heard it.  It is not exactly the same as remembering the order of events as described verbally to you.  It refers mainly to remember to the order in which sound or verbal information is perceived.

Common examples of auditory sequential memory have to do with remembering the order of numbers, things said, directions (“Right on Main; Left on Oak; Right on Maple; look for the yellow house on the left…”) etc.

In the human [neurotypical] brain, it is very hard to separate auditory and visual thinking as they generally go hand in hand, supporting each other and strengthening and stabilizing memory.  We tend to visualize the language we hear in order to remember it.

Here again, the overuse of static visual references teaches a person to adapt without having to make connections [integrations] between auditory, visual, and motor forms of memory.

Working Memory

This has to do with remembering what you’re doing while you are carrying out related or unrelated steps.  Working memory keeps you from “forgetting what you were doing in the first place.”

For instance: A person cooks dinner.  There are any number of steps and procedures involved in the task that one must execute in a certain order.  That order can be flexible of course, but only if working memory allows the person to remember the primary goal of the actions.  Distractions and unexpected events (uh oh – no carrots) can occur, without throwing the person off.

Due to underlying motor planning deficits that arise from slow or inefficient mental processing, people with ASD are notoriously deficient in many forms of working memory.   This accounts for the rigidity – any change can cause the forgetting of the original goal or sequence – so people with ASD do what they can to keep their worlds static.

Procedural Memory

Procedural Memory supports working memory by carrying out certain actions “automatically.”  Procedural memory is based primarily on motor memory, a process where carrying out actions becomes “implicit” or “second nature.”  Once a motor routine becomes a procedural memory (e.g., tying shoes, riding a bike), it no longer requires explicit thinking, which frees up explicit attention for thinking about other things at the same time.

A pathognomic trait associated with ASD is that individuals have poor retention of motor actions and even despite numerous repetitions of a motor sequence, still apply explicit thinking to those actions.  This leads to the trait of absorption by one’s own actions, just as we might be if we were learning a new dance or learning how to drive a stick-shift car.

The most common compensations for deficits in working and procedural memory are verbal or physical prompting.  Another way of compensating for poor working memory is to set up systems for task performance that lead and [visually] prompt someone through a series of steps, as is commonly done with TEACCH methods.

Using the Therapeutic Pause Technique Technique for Teaching 

The Therapeutic Pause Technique for Teaching depends a lot on proper framing of the activity.  The ultimate measure of proper framing has to do with increasing the potential for the individual to be able to figure out what to do on his or her own.

Remember, Therapeutic Pause Technique is really just a therapeutic pause.  If a person has trouble remembering a step, the Teacher pauses and allows time for the person to think.  The Teacher interrupts any actions that are distracting or that take the person of the course of the motor plan.  The Teacher controls for environmental distractions that interfere with the person’s concentration.  A good framework provides clear context and almost no other way to go.

Still, individuals undergoing teaching can become hopelessly stuck.  They may have indeed suffered a loss of working memory, and may need a little help.

In this situation scaffolding is necessary.  There are many ways to do this, but the best way to do this is to set the task up as a cooperative activity where each person has a role action to perform, and putting the individual in the position of following your lead.  The lead provides ongoing modeling, forward motion and pacing for the individual.  In this way, modeling becomes the essential form of cueing behaviors.

Why is not the same as prompting?  Technically, it could be similar.  But a real difference is that instead of having the person rely on verbal or physical directing or some other form of static reference – the person develops a habit of referring to other people’s actions as a means of adaptation.  Procedures of conventional prompting are typically used to speed up the performance of another person, which leaves inadequate time for the person do the work of figuring out what to do.  Framing and scaffolding techniques on the other hand can slow down and make use of therapeutic pausing, whereas conventional prompting procedures aim at speeding up performance or providing motivation that wouldn’t be there otherwise.

[1]     Sequential memory refers to remembering the sequence of things, such as what order things happened or will happen; the sequence of steps involved in a task, etc.