Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 1 CHAPTER 9 Facilitating...

1Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED.

CHAPTERCHAPTER 99

Facilitating Fluency for PreschoolFacilitating Fluency for Preschool and and

School-Age ChildrenSchool-Age Children


Indirect(Modify environment)

Direct(Modify Speech)


Treatment strategiesTreatment strategies

• Indirect Approach = Modify EnvironmentIndirect Approach = Modify Environment• Does direct intervention increase severity?Does direct intervention increase severity?

(1940s–1960s)(1940s–1960s)• Emphasis of treatment on preventing the child from Emphasis of treatment on preventing the child from

becoming aware that his speech was any different or a becoming aware that his speech was any different or a cause for concern (Bluemel, 1932)cause for concern (Bluemel, 1932)

• Parents and teachers instructed to avoid showing Parents and teachers instructed to avoid showing anxiety and using the word “stutter”anxiety and using the word “stutter”

• 1980s +1980s +• Direct modeling and encouraging easier speech; Direct modeling and encouraging easier speech;

Adjusting environmental factors in homeAdjusting environmental factors in home


Some basic approachesSome basic approaches

The Demands & Capacities Model (DCM)The Demands & Capacities Model (DCM)

(Starkweather, et al., 1987, 1997, 1999)(Starkweather, et al., 1987, 1997, 1999)

Decreasing demands while increasing capacities Decreasing demands while increasing capacities across 4 domains: motoric, emotional, linguistic, across 4 domains: motoric, emotional, linguistic, cognitive. Parents are trained to administer the cognitive. Parents are trained to administer the program. program.


Some basic approaches Some basic approaches (continued)(continued)

Lidcombe Program for preschool children Lidcombe Program for preschool children

Onslow, M, Packman, A., and Harrison, E., (2003) Onslow, M, Packman, A., and Harrison, E., (2003) The The Lidcombe program of early stuttering intervention: A clinician’s Lidcombe program of early stuttering intervention: A clinician’s guideguide. Austin, TX: Pro-Ed. . Austin, TX: Pro-Ed.

The child’s fluent speech is followed by praise or The child’s fluent speech is followed by praise or acknowledgment, disfluent speech by acknowledgment, disfluent speech by encouragement of a fluent correction or by encouragement of a fluent correction or by acknowledgement. Parents are trained to administer acknowledgement. Parents are trained to administer the program. the program.


Evidence of therapeutic changeEvidence of therapeutic changefor childrenfor children

Franken, C-M., Van der Shalk, K., Boelens, H., H. Franken, C-M., Van der Shalk, K., Boelens, H., H. (2005). Experimental treatment of early stuttering: A (2005). Experimental treatment of early stuttering: A preliminary study. preliminary study. J. Fluency Disorders, J. Fluency Disorders, 30, 189-30, 189-199199..

Purpose:Purpose:

to consider the feasibility of comparing the response of to consider the feasibility of comparing the response of two groups of preschool children who were randomly two groups of preschool children who were randomly assigned to assigned to The Lidcombe ProgramThe Lidcombe Program (n = 12) and the (n = 12) and the current standard treatment program in the Netherlands, current standard treatment program in the Netherlands, The Demands and Capacities-Based treatment programThe Demands and Capacities-Based treatment program (n = 15).(n = 15).


Evidence of therapeutic changeEvidence of therapeutic changefor children (continued)for children (continued)

Method:Method:

Stuttering frequencies and severity ratings were Stuttering frequencies and severity ratings were obtained immediately before and after treatment (12 obtained immediately before and after treatment (12

weeks).weeks).


Franken, et al. resultsFranken, et al. results

Results:Results:• Stuttering frequencies and severity ratings Stuttering frequencies and severity ratings

significantly decreased for both treatment groups. significantly decreased for both treatment groups.

• No differences between groups for either measureNo differences between groups for either measure

• Parents of children in both groups were cooperative Parents of children in both groups were cooperative and no differences were found on scales that and no differences were found on scales that measured their satisfaction with the two treatments.measured their satisfaction with the two treatments.

• Next:Next: analysis to determine contributions of analysis to determine contributions of treatment componentstreatment components


Common components for DCM and Common components for DCM and Lidcombe Programs Lidcombe Programs

(from Ratner & Guitar, 2006)(from Ratner & Guitar, 2006)

• Active role of the parents in the therapeutic processActive role of the parents in the therapeutic process• Parents levels of understanding, learning, & Parents levels of understanding, learning, &

commitment commitment • Parent’s active participation & resulting reduction of Parent’s active participation & resulting reduction of

anxietyanxiety• Parent’s increased parental locus of control Parent’s increased parental locus of control • Parents openly acknowledge and normalize Parents openly acknowledge and normalize

stutteringstuttering• Praise demonstrates the child has a choice about Praise demonstrates the child has a choice about

how they speakhow they speak


Common components for DCM and Common components for DCM and Lidcombe ProgramsLidcombe Programs

(from Ratner & Guitar, 2006) (continued)(from Ratner & Guitar, 2006) (continued)

• Bonding of the parent and child during treatment Bonding of the parent and child during treatment

takes place in the child’s everyday environmenttakes place in the child’s everyday environment

• Reduction in expressive language to more age-Reduction in expressive language to more age-

appropriate levels appropriate levels

• Focus on the child’s fluent speech may foster the Focus on the child’s fluent speech may foster the

development of an alternative story that is not development of an alternative story that is not

focused on stuttering. (Dilollo & Manning, 2006)focused on stuttering. (Dilollo & Manning, 2006)


Key qualities of a clinician treating Key qualities of a clinician treating younger speakersyounger speakers

• Understands the nature of stuttering; willing to help Understands the nature of stuttering; willing to help child experiment & vary forms of nonfluent speech.child experiment & vary forms of nonfluent speech.

• Provides supportive therapeutic experience, enabling Provides supportive therapeutic experience, enabling the child to become desensitized to their stuttering.the child to become desensitized to their stuttering.

• Allows child to understand and control the basic Allows child to understand and control the basic features of speech features of speech →→ effortless, forward-flowing effortless, forward-flowing speech.speech.

• Obtain the understanding and support of the parents Obtain the understanding and support of the parents and other important people in child’s life.and other important people in child’s life.


Treatment goals for young speakersTreatment goals for young speakers

• Reduce frequency and change the form of stutteringReduce frequency and change the form of stuttering

• Reduce negative feelings and thoughts about Reduce negative feelings and thoughts about

stutteringstuttering

• Decrease avoidanceDecrease avoidance

• Involve the parents in altering the child’s environmentInvolve the parents in altering the child’s environment

• Enhance the child’s abilities and enjoyment of Enhance the child’s abilities and enjoyment of

verbally communicatingverbally communicating


Choosing a treatment approachChoosing a treatment approach

• Be aware of many approaches & techniquesBe aware of many approaches & techniques

• Each approach will be different depending on Each approach will be different depending on

clinician—academic/clinical background, clinician—academic/clinical background,

experience, interactive styleexperience, interactive style

• Children will respond in different waysChildren will respond in different ways

• No one method works for all childrenNo one method works for all children


When I was climbing, my partner and I were giving each other advice about which way to go and which rock might be the best one to go to next. In learning to manage my stuttering, I have found that I need to find the things that work for me. I need to use my own best words to express myself, find my best chances or opportunities to talk, and discover which tools work best for me. Other people can guide me, but I have to find my own “right rocks.”

You just have to find the right rocks


When working with childrenWhen working with children

• Use basic and understandable termsUse basic and understandable terms

• Model targets (rather than tell)Model targets (rather than tell)

• Model slow and easy speechModel slow and easy speech

• Model slow and easy body movementsModel slow and easy body movements

• Reinforce child’s accomplishments and feelings Reinforce child’s accomplishments and feelings of self-worthof self-worth

(Ramig and Bennett, (Ramig and Bennett, 1995)1995)


Selected techniquesSelected techniques

• Parents’ rate, turn-taking, pausingParents’ rate, turn-taking, pausing

• Maybe fewer questionsMaybe fewer questions

• Communication disruptors (interruptions, Communication disruptors (interruptions,

over-talking, lack of interest in what the child over-talking, lack of interest in what the child

says, over- stimulation)says, over- stimulation)• Slowing parent’s rate of speechSlowing parent’s rate of speech——Mr. Roger’s Mr. Roger’s

speechspeech


Selected techniques Selected techniques (continued)(continued)

• Use analogies Use analogies (bumpy-smooth/stretchy, hose)(bumpy-smooth/stretchy, hose)

• Cursive handwriting for slow and easy speech

• Combining forms of play with sound

production

• Slowing down your own speech rate


Since we last met . . .Since we last met . . .

What have you learned about stuttering?What have you learned about stuttering?

• What new question do you have about stuttering?What new question do you have about stuttering?

• What action have you taken this week?What action have you taken this week?

• What new ways have you problem solved?What new ways have you problem solved?

• What would be a good next step for you?What would be a good next step for you?

→→ What are some of your “right rocks”What are some of your “right rocks”


SuperfluencySuperfluency(Guitar, 2006)(Guitar, 2006)

• Flexible rateFlexible rate—show child how to slow —show child how to slow only only the the initial syllables of a word or syllableinitial syllables of a word or syllable

• Easy onsetsEasy onsets—emphasize gradual onset of voicing —emphasize gradual onset of voicing and airflow.and airflow.

• Light contactsLight contacts—modeling easy articulatory —modeling easy articulatory posturespostures

• ProprioceptionProprioception—heightened feedback for —heightened feedback for articulatory movements and extent of contact articulatory movements and extent of contact Then, expand from three-word utterances to longer Then, expand from three-word utterances to longer sentencessentences


Indicators of successful therapyIndicators of successful therapy

• Slower rate of repetitionsSlower rate of repetitions

• Continuation of airflow and voicingContinuation of airflow and voicing

• Easy articulatory contactsEasy articulatory contacts

• Smooth transitions through sounds and Smooth transitions through sounds and syllablessyllables

• Child takes part in communicatingChild takes part in communicating


Recommended resourcesRecommended resources

• Chmela, K., & Reardon, N. (2002). Chmela, K., & Reardon, N. (2002). The school-age child who The school-age child who stutters: Working effectively with attitudes and emotionsstutters: Working effectively with attitudes and emotions. (Pub. . (Pub. # 5) Memphis, TN: Stuttering Foundation.# 5) Memphis, TN: Stuttering Foundation.

• Manning, W. (2004). Manning, W. (2004). Clinical decision making with Clinical decision making with adolescents who stutteradolescents who stutter. ASHA Continuing Education Series, . ASHA Continuing Education Series, Rockville, MD. (2 CDs)Rockville, MD. (2 CDs)

• Ramig, P., & Dodge, D. (2005). Ramig, P., & Dodge, D. (2005). The child and adolescent The child and adolescent stuttering treatment and activity resource guidestuttering treatment and activity resource guide. Clifton Park, . Clifton Park, NY: Thomson Delmar Learning.NY: Thomson Delmar Learning.

• Reitzes, P. (2006). Reitzes, P. (2006). 50 great activities for children who stutter50 great activities for children who stutter. . Austin, TX: Pro-Ed. Austin, TX: Pro-Ed.

• Ratner N, & Sisskin, V. (2002). Intervention strategies for Ratner N, & Sisskin, V. (2002). Intervention strategies for children who stutter. ASHA Continuing Education Series, children who stutter. ASHA Continuing Education Series, Rockville, MD. (2 video tapes)Rockville, MD. (2 video tapes)


Addressing desensitization and Addressing desensitization and cognitive restructuringcognitive restructuring

• Learn about stutteringLearn about stuttering• Learn about other people who stutterLearn about other people who stutter• Explore and learn to tolerate moments of stutteringExplore and learn to tolerate moments of stuttering• Change negative self-talkChange negative self-talk• Self-acknowledgement to friends, teacher, and Self-acknowledgement to friends, teacher, and

classmatesclassmates• Help parents to make stuttering an acceptable Help parents to make stuttering an acceptable

topic of discussion topic of discussion • Parent group meetings can be very useful (NSA, Parent group meetings can be very useful (NSA,

Friends)Friends)


Teasing vs. bullyingTeasing vs. bullying

• BullyingBullying—Conscious effort to hurt or control —Conscious effort to hurt or control someonesomeone

Negative effects: lowered self-esteem, Negative effects: lowered self-esteem,

depression, loneliness, anxiousness, depression, loneliness, anxiousness,

insecurities, social failure, academic issuesinsecurities, social failure, academic issues

• TeasingTeasing—Good-natured exchange between —Good-natured exchange between friends. No intention to harm someone.friends. No intention to harm someone.


Possible effects of teasing and Possible effects of teasing and bullyingbullying

• ShameShame——major affect on one’s overall self-major affect on one’s overall self-interpretationinterpretation

• Teasing is one way in which shame becomes Teasing is one way in which shame becomes attached to stuttering.attached to stuttering.

• Results in increased stuttering and a high Results in increased stuttering and a high degree of social inhibition.degree of social inhibition.

• 60% children who stutter (760% children who stutter (7––15 yrs) experience 15 yrs) experience this negative treatment.this negative treatment.

• The effects may continue into adulthoodThe effects may continue into adulthood


Developing effective responses to Developing effective responses to bullyingbullying

• Distinguish between hurtful and inquisitive Distinguish between hurtful and inquisitive commentscomments

• Instruct about the nature of bullying and those Instruct about the nature of bullying and those who do itwho do it

• Role-play activitiesRole-play activities


Role-playing activitiesRole-playing activities

• Provide child with opportunity to vent anger Provide child with opportunity to vent anger and frustrationand frustration

• Allow child to become desensitizedAllow child to become desensitized• Help child learn to defuse negative commentsHelp child learn to defuse negative comments• Possible responsesPossible responses

• Shrug: “I don’t care, So what.”Shrug: “I don’t care, So what.”• Broken Record: “Because I want to!”Broken Record: “Because I want to!”• Mighty Might : “You might be right.”Mighty Might : “You might be right.”• So?So?


When coexisting problems occurWhen coexisting problems occur

• Recognize that demands for phonological and Recognize that demands for phonological and grammatical processing compete with grammatical processing compete with resources that permit fluent speechresources that permit fluent speech

• Organize treatment hierarchyOrganize treatment hierarchy

• Structure intervention with minimum overt Structure intervention with minimum overt feedbackfeedback

• Determine whether the impairments should be Determine whether the impairments should be treated concurrently, sequentially, or cyclicallytreated concurrently, sequentially, or cyclically


Problems that reduce or impact Problems that reduce or impact fluencyfluency

• Co-occurring speech and language problems Co-occurring speech and language problems influence the clinician’s decision for providing influence the clinician’s decision for providing treatment for children who stutter, but there are treatment for children who stutter, but there are also a variety of neurological and behavioral also a variety of neurological and behavioral conditions.conditions.

• The more serious problems involve executive The more serious problems involve executive function or regulatory activities associated with function or regulatory activities associated with the basal ganglia.the basal ganglia.


Problems that reduce or impact Problems that reduce or impact fluency (continued)fluency (continued)

• Tourette’s Syndrome (TS)Tourette’s Syndrome (TS)

• Autism Spectrum Disorder (ASD) and Asperger Autism Spectrum Disorder (ASD) and Asperger SyndromeSyndrome

• Attention Deficit Hyperactivity Disorder (ADHD)Attention Deficit Hyperactivity Disorder (ADHD)

• Down SyndromeDown Syndrome


Tourette’s syndromeTourette’s syndrome

• A neurologic disorder with childhood onset and A neurologic disorder with childhood onset and is thought to be secondary to abnormal is thought to be secondary to abnormal metabolism of the neurotransmitter dopamine.metabolism of the neurotransmitter dopamine.

• By age 7, TS children exhibit motor, phonic, By age 7, TS children exhibit motor, phonic, and mental tics that are repetitive and involve and mental tics that are repetitive and involve rapid, involuntary movements or vocalizations rapid, involuntary movements or vocalizations (e.g., facial grimaces, eye-blinking, shrugging, (e.g., facial grimaces, eye-blinking, shrugging, head jerking, face-rubbing, lip-licking).head jerking, face-rubbing, lip-licking).

• Intelligibility is often impaired due to rapid Intelligibility is often impaired due to rapid speech problems.speech problems.


Tourette’s syndrome (continued)Tourette’s syndrome (continued)

• Most disfluencies are Most disfluencies are notnot SLDs typical of SLDs typical of developmental stuttering, but rather fillers, phrase developmental stuttering, but rather fillers, phrase repetitions, and sentence revisions.repetitions, and sentence revisions.

• Speech characteristics are similar to cluttering.Speech characteristics are similar to cluttering.

• Recommended intervention strategies:Recommended intervention strategies:

• focus on teaching the child to monitor speech focus on teaching the child to monitor speech during structured interactions and increase ability during structured interactions and increase ability to read social cues.to read social cues.


Tourette’s syndrome (continued) Tourette’s syndrome (continued)

• Recommended intervention strategies Recommended intervention strategies (Continued):(Continued):

• Speech rate addressed by emphasizing clear Speech rate addressed by emphasizing clear articulation with natural speech prosody. articulation with natural speech prosody.

• Other goals may include enhancing the child’s Other goals may include enhancing the child’s ability to comprehend abstract or figurativeability to comprehend abstract or figurative language, accurately process verbal language, accurately process verbal information, and formulate ideas.information, and formulate ideas.


Autism spectrum disorder (ASD) Autism spectrum disorder (ASD) including Asperger syndromeincluding Asperger syndrome

• Describes an assortment of developmental Describes an assortment of developmental problems including impairments in social problems including impairments in social interaction, communication, play and interaction, communication, play and imagination, and restricted interests and imagination, and restricted interests and activities.activities.

• Disfluencies, including SLDs, are common.Disfluencies, including SLDs, are common.• Asperger Syndrome is regarded as a milder Asperger Syndrome is regarded as a milder

form of autism and is characterized by no delay form of autism and is characterized by no delay in general language ability or cognitive in general language ability or cognitive development (they may score in the superior development (they may score in the superior range on standardized IQ tests).range on standardized IQ tests).


Attention deficit hyperactivity Attention deficit hyperactivity disorder (ADHD)disorder (ADHD)

• Hallmark of these children is “consistent Hallmark of these children is “consistent inconsistency” in two or more environments such as inconsistency” in two or more environments such as school, home, and other social settings and is school, home, and other social settings and is characterized by inattention, hyperactivity, and characterized by inattention, hyperactivity, and impulsivityimpulsivity

• Classified into 3 categoriesClassified into 3 categories

• Primarily hyperactive-impulsive(without inattention)Primarily hyperactive-impulsive(without inattention)

• Predominately inattentive type (without significant Predominately inattentive type (without significant hyperactivity)hyperactivity)


Attention deficit hyperactivity Attention deficit hyperactivity disorder (ADHD) (continued)disorder (ADHD) (continued)

• Classified into 3 categories (Continued)Classified into 3 categories (Continued)

• Combination of these twoCombination of these two

• Most children who stutter Most children who stutter do notdo not have ADHD have ADHD

• Medication has been found to increase disfluenciesMedication has been found to increase disfluencies


Down syndromeDown syndrome

• Stuttering more frequent for individuals of less Stuttering more frequent for individuals of less intelligence (30-40%)intelligence (30-40%)

• In the specific instance of the most common In the specific instance of the most common cause of intellectual disability, Down syndrome, cause of intellectual disability, Down syndrome, the occurrence of stuttering occurs with greater the occurrence of stuttering occurs with greater frequencyfrequency

• Characteristics of children who stutter with Characteristics of children who stutter with Down syndrome…Down syndrome…


Down syndrome (continued)Down syndrome (continued)

• Onset age 8–10 (sequencing 2–3 words)Onset age 8–10 (sequencing 2–3 words)

• Unaware initially, same avoidance laterUnaware initially, same avoidance later

• Many characteristics of cluttering (fast rate, Many characteristics of cluttering (fast rate, poor intelligibility)poor intelligibility)

• High frequency of whole and part-word reps High frequency of whole and part-word reps and prolongationsand prolongations

• Difficulty monitoring, poor motor coordination, Difficulty monitoring, poor motor coordination, word finding, and language formulationword finding, and language formulation


Classroom teachersClassroom teachers

• Create a workshop, S. Foundation video, handouts, Create a workshop, S. Foundation video, handouts, SLDsSLDs

• Basic message: Will not harm or make worseBasic message: Will not harm or make worse• Reinforce small & large victoriesReinforce small & large victories• Consult with SLP, child, parents, peersConsult with SLP, child, parents, peers

• Letter to teacher(s)Letter to teacher(s) (see p. 356)(see p. 356)• Observe basic techniques of treatmentObserve basic techniques of treatment• Be an advocate for the childBe an advocate for the child• Note Figure 9-1, Note Figure 9-1, Reardon’s Teacher ChecklistReardon’s Teacher Checklist


Classroom teachers (continued)Classroom teachers (continued)

• Participation & nonavoidanceParticipation & nonavoidance• Reward modification, open stutteringReward modification, open stuttering• Be calm and interested in child’s speechBe calm and interested in child’s speech• Call on child early; short answersCall on child early; short answers• Do not allow interruption by othersDo not allow interruption by others• Paraphrase (non)fluent speechParaphrase (non)fluent speech• Advertising/educating classmatesAdvertising/educating classmates

• Note Box 9-1Note Box 9-1, , Sample Letter to TeachersSample Letter to Teachers


Transfer and terminationTransfer and termination

• Critical to transfer skills to daily situationsCritical to transfer skills to daily situations

• Gradual transfer of self-cuing to the child and Gradual transfer of self-cuing to the child and parentsparents

• Relapse less likely with preschool childrenRelapse less likely with preschool children

• School-age children more likely to regress and School-age children more likely to regress and may need booster sessionsmay need booster sessions

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