Interactive Learning with Fluency Specialists

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Interactive Learning with Fluency Specialists

• The Center for Stuttering Therapy

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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

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Introduction

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

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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

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Stuttering Prediction Instrument (SPI) Riley,1984

• Assesses history
• Rates childs 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

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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

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Risk Factors

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

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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

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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 childs attitudes and emotions
  regarding stuttering?
• Formal vs. subjective assessment

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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 clients speech
  behaviors, thoughts, and feelings
• Portfolio approach (Yaruss 2013)

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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

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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

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OASES-S

• Overall Assessment of the Speakers 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 impactscore based on a severity
  rating scale

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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 affects the childs
  ability to communicate in various settings
  school, home and work.
• Quantitatively determines how the stuttering is
  adversely affecting the childs quality of life
• Provides pre/mid/post therapy data to assess
  progress
• Provides topics for discourse related to
  attitudes and emotions

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Subjective Assessment

• Critical to planning treatment
• Based upon observation of the childs 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)

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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

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Breakout Session 1

• Assessment

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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

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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

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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

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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

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Reinforcement

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

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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 childs
  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

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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

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Fluency Shaping Strategies for the School Age
Child

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

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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

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

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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.

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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

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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

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Quantitative Data
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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 cant get it out
• Acknowledged how it feels when things are said
  easy vs hard

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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.

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Breakout Session 2

• Treatment and Treatment Strategies

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Treatment Planning
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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 isnt their fault
  and that you can help.
• Help the child identify his stuttering

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Stuttering Iceberg
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Addressing Attitudes and Emotions

• Drawings can be used to express
• feelings (isolation, shame, embarrassment)
• beliefs (what Im doing is bad and so am I)
• perceptions (people dont want to/wont 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 cant say that, I cant 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)

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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 childs 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
• Gracies Letter

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Working With Parents

• Accepting their childs 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
  childs 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)

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What kids want their parents to know about
stuttering

• Stop bugging me
• Its 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!

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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

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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

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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 18th, Jefferson
  Academy
• ASHA CEUs for SLPs
• www.friendswhostutter.org

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Breakout Session 3

• Treatment Planning
• Working with Attitudes and Emotions

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IEP Goal Writing and Assessing Progress

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

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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
  students teacher
• Increasing participation in the classroom
• i.e. student voluntarily raising hand to answer a
  question, participating in discussions, sharing
  ideas with peers

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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

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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

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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

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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

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Example Goals

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

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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.

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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).

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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 gt.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.

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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.

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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
• Students willingness to discuss stuttering
• i.e. completion of worksheets for attitudes and
  emotions in the therapy room, discussing hard
  speech vs. easy speech

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Breakout Session 4

• IEP Goal Writing and Assessing Progress