Interactive Learning with Fluency Specialists

The Center for Stuttering Therapy

Presenters

 Mary Wallace, M.A., CCC-SLP, BCS-F  Patty Walton, M.A., CCC-SLP, BCS-F  Whitney Noven, M.S., CCC-SLP  Matthew Goldman, M.A., CCC-SLP  Bethany Tileston, M.A., CCC-SLP  Kailey Silliman, M.A., CCC-SLP  Amber Rea, B.S., Graduate Intern

Introduction

 4 General Topic Areas  Assessment  Treatment and Therapy Strategies  Treatment Planning  IEP Goal Writing and Assessing Progress  Breakout Sessions

Assessment

 Preschool Diagnostic Guidelines  Early identification is critical-best prognisis  Differential diagnosis of typical vs. atypical disfluencies • • • • Stuttering Prediction Instrument (SPI) Danger/warning signs Risk factors Other indicators of concern

Stuttering Prediction Instrument (SPI) Riley,1984

  Assesses history Rates child’s reactions to stuttering  Measures part word repetitions based on # of RPI, schwa, tension and abruptness  Measures prolongations based on duration, phonatory arrest and articulatory posturing  Yields a frequency score (100 word sample)  Yields a severity rating for both chronic and non-chronic stuttering  Appropriate for children 3-8 years of age

Danger/Warning Signs

 Multiple part word repetitions  Schwa vowel  Prolongations  Struggle and tension  Pitch and/or loudness rise  Tremors  Avoidance  Moment of Fear  Difficulty initiating airflow and voicing

Risk Factors

 Family history of stuttering  Male gender  Sensitive temperament  Other speech language concerns  Time post onset  Parental concern  Negative awareness

Other Indicators of Concern

 Clustering  Ratio of typical/atypical disfluencies  Changes in cycles of stuttering  Mid utterance disfluencies  Multiple disfluencies per utterance  Sensory motor concerns

Diagnosis of School Age Stuttering

 Ages 7-12  No longer rely on danger signs and risk factors to assess stuttering, instead we need to consider:  What is the child doing physiologically when stuttering?

  How is the child reacting to moments of stuttering?

What are the child ’ s attitudes and emotions regarding stuttering?

 Formal vs. subjective assessment

Bennett, 2006

 Describes assessment of fluency in the school aged child as a “detailed, thought engaging process” where the goal of assessment is to understand thoroughly the client’s speech behaviors, thoughts, and feelings”  Portfolio approach (Yaruss 2013)

Formal Assessments

 Riley Stuttering Severity Instrument (RSSI-3); (RSSI-4) (2008)  Yields a severity rating  Only quantifies stuttering behaviors  Does not assess for more covert behaviors such as avoidance behaviors and postponement behaviors (uh, um)  Does not provide a basis from which to plan treatment

Test of Childhood Stuttering (TOCS)

 Logan, Gilliam and Pearson (2009)  Yields a severity rating  4 Subtests: rapid picture naming, modeled sentences, structured conversation, narration  Limitations:  based on reduction of linguistic complexity in the test items    awkward administration Only counts disfluencies in the first three words of an utterance Does not provide adequate information to plan treatment

OASES-S

 Overall Assessment of the Speaker’s Experience with Stuttering: Yaruss, Coleman & Quesal (2010)  For ages 7-12  Purpose of the tool is to assess the adverse impact that school age children experience as a result of stuttering  Administration time: 20 minutes   Scoring time: 5 minutes Results in an “ impact ” score based on a severity rating scale

Using the OASES in the School Setting

      Helps the SLP understand how the child responds to stuttering in general Determines the affective, behavioral, and cognitive reactions the child has to stuttering Assesses how stuttering affect’s the child’s ability to communicate in various settings: school, home and work.

Quantitatively determines how the stuttering is adversely affecting the child’s quality of life Provides pre/mid/post therapy data to assess progress Provides topics for discourse related to attitudes and emotions

Subjective Assessment

  Critical to planning treatment Based upon observation of the child’s speech in conversation and oral reading  What to look for:  Primary behaviors (nature and duration)  Secondary behaviors (linguistic or physical)  Tension (loci and degree)  Airflow management (including control of air pressure and adequate respiratory support)  Voice production (pitch, vocal strength, loudness)

Zebrowski 1997

 “The management of children who stutter depends not on a formula but on the decision making and problem solving skills that are part of the armory of every well trained clinician”

Breakout Session 1

 Assessment

Treatment and Therapy Strategies

 General Therapy Components • • • Increased length and complexity of utterance hierarchy Modeling Reinforcement  Importance of Combining Fluency Shaping and Modification Strategies  Fluency Shaping Strategies  Modification Strategies  Case Study

Using a Linguistic Hierarchy

• • • • • • • • • • • • • • Single Words Two Words Three Words Carrier Phrases Extended Carrier Phrases Prepositional Phrases Multiple Phrases Simple Sentences Complex Sentences Asking Questions Conversation Relating to a Structured Activity Spontaneous Conversation High-Level Demand Task Storytelling

How To Use the Hierarchy

     Start at easiest level and progress through each level after obtaining 95% success over multiple sessions Exception to this is jumping to carrier phrases quickly once the child gets the concept of the strategy Start sessions at a level below that obtained in previous session End sessions at a level where there is a high level of success Therapy sessions are designed for maximum success by moving up and down in hierarchy as needed

Modeling of Strategies

    Modeling of therapy strategies is critical Clinician models 100% of the time in initial stages of therapy Model is initially slightly exaggerated but produced with normal rhythm and prosody Rate of model increases over the course of therapy and exaggeration decreases

Reinforcement

    Reinforcement is constant and positive All attempts are praised and encouraged Encouraging praise is more effective than evaluative praise Reinforce the child’s use of strategies, not fluency

Combining Fluency Shaping and Modification Strategies

 Fluency Shaping Therapy   Helps the child speak more easily through a variety of strategies Strategies are chosen depending on the child’s age and the way they are stuttering  Modification Therapy  Helps the child stutter more easily, reduce struggle and tension and react less to moments of stuttering  The need and degree of modification strategies are dependant upon how negatively the child is reacting to stuttering

Fluency Shaping Strategies for the Young Child



Stretching or easy speech

   Stretch- slight prolongation of the initial sound or syllable in a word with a smooth transition into the vowel Used at the beginning of phrases or utterances Easy speech- incorporates several features which increase fluency • • • • • • Slower than normal speech rate Easy vocal onsets Soft articulatory contacts Sustained voicing Slight overarticulation Normal rhythm and prosody

Fluency Shaping Strategies for the School Age Child

 Stretching  Easy voice  Soft contacts (slides)  Continuous voicing  Sound blending (hooking-on)  Chunking and Phrasing  Overarticulation

Modification Strategies

  

Bouncing (also appropriate for the young child)

    Voluntary use of easy, effortless repetitions Produced with continuous voicing and light articulatory contacts Limit bounces to 2-3 repetitions per instance Bounces should be tension free and even in tempo

Pullouts

  Changing a stuttering moment by releasing tension and allowing the word to finish easier Can stretch or bounce out of harder moment of stuttering

Holding and Tolerating

 Staying in the moment of stuttering to decrease/prevent the negative response to stuttering

Voluntary Stuttering in Structured vs. Unstructured Therapy



Clinical Research Question:

 In the case of a four-year, nine-month-old boy identified with a severe beginning level stuttering pattern, is structured therapy implementing the stuttering modification technique of therapy?

“ bouncing, ” associated with marked decreases in the secondary stuttering behaviors of eye widening and vocal fold tremor, as compared with unstructured

Participant: Milo

      4 year, 9 month old boy Enrolled in preschool Diagnosed with a severe beginning level stuttering pattern Currently being seen at a university clinic for speech and language intervention Individual fluency therapy sessions twice a week for forty-five minutes Health concerns: asthma, enlarged adenoids and right side hypotonia. Participant receives dietary supplements to maintain daily nutrition and promote growth.

Technique

 Voluntary Stuttering (Bouncing)  Promotes tension reducing patterns that lessen sensitivity and avoidance of stuttering

Example from Walton & Wallace (1998) p. 38:

Clinician: “ What ga-ga-game do you want to play today?

” Child: “ I want to play Candyland.

” Clinician: “ Great idea, I like Candyland.

”  Constant model used by the clinician at the start of every utterance in both conditions

Intervention

  

Molecular Analysis

  Eye widening Vocal fold tremor

Conditions (Alternating Treatment Design)

  Unstructured therapy (15 min.): Child-centered conversation and play; clinician model of bouncing Structured therapy (15 min.): Clinician-directed activities and games; clinician model of bouncing; direct treatment approach at the 1-3 word level

Data Collection Procedure

   Data was collected over a six week period Obtained through video recording which was analyzed by the clinician Baseline and Final Data collected using an identical procedure for each condition

Quantitative Data

Qualitative Data

    

Questionnaire

Prior to study, Milo stuttered approx. 80% Since the start of the study, he stutters 50% of the time and much more smoothly Milo does not remain “ stuck ” at the beginning of a statement Presents fewer secondary behaviors such as eye widening, grimacing and slapping of leg Has begun to generalize his speech tools at home and in preschool    

Informal Interview

At the beginning of the study, Milo did not note any perceived difficulties with speech Near end of study, Milo began to discuss troubles of speech fluency When encountering hard or bumpy speech, Milo said “ he just can ’ t get it out ” Acknowledged how it feels when things are said “ easy ” vs “ hard ”

Conclusion

 In the case of a preschool-aged child identified with a severe beginning level stuttering pattern, both structured and unstructured therapy utilizing the stuttering modification technique of bouncing were evaluated. It was determined that structured therapy was more effective in reducing the presence of secondary stuttering behaviors of eye widening and vocal fold tremor.

Breakout Session 2

 Treatment and Treatment Strategies

Treatment Planning

Education & Identification

 The child knows something is wrong/not like other kids- what is it?

 Educating the child about stuttering will help them better understand that it isn ’ t their fault and that you can help.  Help the child identify his stuttering

Stuttering Iceberg

Addressing Attitudes and Emotions

   Drawings can be used to express     feelings (isolation, shame, embarrassment) beliefs (what I ’ m doing is bad and so am I) perceptions (people don ’ t want to/won ’ t listen) experiences (teasing, being talked for) Writing activities such as journaling allow them to write about their day, communication choices, feelings, etc. Writing stories about stuttering in general, specific experiences, how they imagine a specific event happening if they stutter Self Talk and Positive Affirmations  negative messages about themselves and their talking (I can ’ t say that, I can ’ t join that team/group/class because I stutter)  positive affirmations (I have choices, I can stutter my way, What I have to say is important)

Addressing Attitudes and Emotions

   Problem solving will help the child feel empowered and let them think about the situation based upon what they know is true  What actually happened?    What could I have done?

What would I rather do next time?

Can I make any changes to this situation now?

Letters to the teacher will educate the teacher about stuttering and the child ’ s needs – EMPOWERING–  allows them to introduce themselves as a person who stutters   explains what is difficult for them in class things that are helpful and not helpful for the teacher to do Gracie ’ s Letter

Working With Parents

    Accepting their child ’ s stuttering and at the same time letting their child know they accept them. What experience do the parents have with stuttering- is there a family history, positive or negative encounters Asking the parents what they expect from their child ’ s speech at home    Is it realistic?

Speech tools in the therapy room vs home Helpful vs Hurtful support at home Educating parents about stuttering    Myths vs facts What can they expect from therapy Experiences/feelings their child has about their stuttering (drawings and writings are very helpful)

What kids want their parents to know about stuttering

        Stop bugging me It ’ s ok to talk about stuttering I want to be called on more in class “ You heard me stutter twice when I got home I felt myself stutter all day and lived you can live too ” Stuttering is not FUN!!!

I can still be happy even though I stutter Everything is NOT about NOT Stuttering makes me, me!

Working With Teachers

   Increasing communication in the classroom  Student to teacher   teacher to student student in class Reduce stressors in classroom   Identify what they are: being called on, being called on alphabetically or in rows, reading aloud, substitute teachers (specific to each student) Problem solve together Generalization in classroom  When to integrate speech tools

Classroom Presentation

 Work with your student to make this their presentation    Talk about famous people who stutter Talk about the speech machine and how speech is produced Teach the children about what stuttering is     Talk about what friends can and cannot do to help the CWS Show the DVD “ Stuttering for Kids by Kids ” Teach all the children how to stutter on their their names-for candy!

www.stutteringhelp.org

and www.westutter.org

Friends Day!!!! April 18th

 FRIENDS: The National Association of Young People Who Stutter  Mission: To provide support for young people who stutter and their families  FRIENDS one-day conference April 18 th , Jefferson Academy  ASHA CEU ’ s for SLP ’ s  www.friendswhostutter.org

Breakout Session 3

 Treatment Planning  Working with Attitudes and Emotions

IEP Goal Writing and Assessing Progress

 Writing SMART fluency goals  Examples of goals  Fluency shaping  Modification  Identification, education, etc  Monitoring Progress

Specific

 Skills and techniques used in therapy  Increasing use of speech tools in specific setting • i.e. use of spontaneous easy speech during a game or other structured activity  Discussing stuttering with peers/adults, increasing disclosure • i.e. student giving a classroom presentation about stuttering, writing a letter to the student’s teacher  Increasing participation in the classroom • i.e. student voluntarily raising hand to answer a question, participating in discussions, sharing ideas with peers

Measurable

 Should involve an increase in the count/percentage of use of speech tools  i.e. Student will use his easy speech spontaneously in 8/10 opportunities  NOT reduction in stuttering  i.e. Student will not stutter during circle time

Achievable

 Goals should never target 100%  Should be scaffolded:  Increase in linguistic complexity • i.e. what level of the hierarchy is being targeted  Spontaneous vs. imitative responses • i.e. student repeating a model vs. student responding spontaneously  Across various situations for generalization • i.e. therapy room vs. hallway vs. classroom

Relevant

 Goals should be unique to the student  Based on their current level of performance  Decrease anxiety and increase participation  Promote positive social interaction in their learning environment

Time-bound

 Can be completed in a specific time frame  A goal should be challenging yet still attainable, to a degree that it could be completed within the IEP period.

 i.e. could move from single word level to carrier phrase or multi phrase level within IEP period, but less likely to go from single word level to conversational level within IEP period

Example Goals

 Fluency Shaping  Modification  Identification  Reduction of Secondary Behaviors

Fluency Shaping Goal

 In order to increase fluent speech, Timmy will use a fluency shaping strategy (stretches, easy onsets, voice on, etc.) without prompts to begin 80% of carrier phrases during a game, in the therapy room, while working 1-on-1 with the SLP.

 Baseline: Using fluency shaping strategies on 30% of 3-word utterances and 20% of carrier phrases in structured activities.

Modification Goal

 Susan will independently use a stuttering modification technique (bounces, pull-out, slide out, cancellation, etc.) 10 times during spontaneous speech, in a 30 minute therapy session with the SLP and one familiar peer.

 Baseline: currently producing 10 per session with frequent prompts (1 per minute).

Identification Goal

 In four consecutive meetings in the therapy room, Nicholas will identify a situation, sound, conversation partner or specific trigger that was a challenge to his fluency during the week, and will discuss how this affected his speech, as well as possible next steps.

 When prompted following a block of >.5sec. (or in a clinician-modeled block), Nicholas will correctly identify the trouble sound, location of the block, and type of sound (popping, blowing, buzzing, etc.), independently on 75% of opportunities to increase proprioception and gain awareness of speech mechanisms.

Reduction of Secondary Behaviors

 Alejandro will replace the use of “um” and “uh” as a secondary behavior by using a brief pause followed by a stretch or bounce to begin a phrase while speaking in the classroom during a structured activity, with SLP present, on 60% of utterances.

 Baseline: currently 95% in therapy room in conversation following a single prompt.

Monitoring Progress

 Moving up the hierarchy  i.e. carrier phrase level to question level  How the stuttering pattern changes   i.e. increase in part-word repetitions and decrease in prolongations, decrease in struggle and tension Student’s willingness to discuss stuttering  i.e. completion of worksheets for attitudes and emotions in the therapy room, discussing hard speech vs. easy speech

Breakout Session 4

 IEP Goal Writing and Assessing Progress