Helping ParentsLearn to Facilitate Young

Children’s Speech Fluency

David W. Hammer, M.A., CCC-SLP

Children’s Hospital of Pittsburgh

J. Scott Yaruss, Ph.D., CCC-SLP

University of Pittsburgh

tuttering

CS enterof

estern ennsylvaniaW PA joint venture of Children's Hospital of Pittsburgh and the Department of

Communication Science and Disorders at the University of Pittsburgh

Purpose

• To present a model for teaching parents to facilitate their children’s development of normal fluency

– Based on reductions in interpersonal and communicative stressors

– Takes into account various aspectsof the child’s personality that may contribute to disfluency or stuttering

– Can be adapted to a variety of settings

Goals of Treatment

• The overall goal of treatment for preschool children who stutter is to eliminate stuttering while supportingthe child’s language development

• This treatment program focuses on one component of this overall goal… parental facilitation of the child’s fluency in real-world situations

Rationale for Treatment• Treatment is based on widely held

beliefs about the factors that affect children’s speech fluency, e.g.:

– Modifying aspects of the child’s daily interactions will help the child achieve fluency speech in that speaking situation

– The more time a child spends speaking fluently, the less likely the child will develop a chronic stuttering disorder

General Structure of Treatment

• Treatment consists of:– Two parent-only sessions for parental

counseling and overview of treatment– Four parent/child modeling sessions when

parents are taught modifications

• Treatment program is administered by itself or prior to more direct intervention with the child or family

Session #1

Overview of Stuttering

Interpersonal Stressors

Goals for Session #1

• Help parents understand the nature of stuttering and the factors that may affect their child’s fluency

• Provide an overview of the treatment process and outlook for the future

• Begin the process of identifying interpersonal stressors

Stressor Inventory (Handout #1)

• Prior to any discussion about modifying stressors, parentscomplete a stressor inventory– Provides background about factors that may

contribute to the child’s stuttering– Examines stressors within the child

and within the environment– Allows parents to see how they

compare in their view of the child

Stressors within the Child

• Is sensitive

• Tends to be perfectionist

• Has an “intense” personality

• Is competitive

• Demonstrates performance anxiety/fears

• Tends to become more disfluent when tired

• Tends to become more disfluent when ill

• Has other speech/language problems

Stressors within the Environment

• Hectic daily routines are commonplace

• Sibling rivalry is intense

• Limited free time or quiet time

• Others in the home talk fast or interrupt frequently

• Stressful situations have been present(e.g., divorce, death, etc.)

• Family members/relatives have stutteredor currently stutter

• High expectations are imposed by others

“Bucket” AnalogyPurpose

• Identifies factors that maybe associated with stuttering

• Helps parents understandthe multifactorial natureof stuttering

“Bucket” AnalogyFactors

• Factors interact• Cannot distinguish

influence of individual factors once they are in the bucket

STU TERING

T*

“Bucket” AnalogyGuidelines

• Begin at the bottomand work up

• Identify factors we havemore control over and factors we have lesscontrol over

STU TERING

T

• Purpose– Describes structure

& flow of treatment

• Guidelines– Begin at the bottom

and work up– Explain that not all

all steps may be necessary

Communication “Wellness” Analogy

Direct Child Intervention

Tre

atm

ent

Flo

w

ParentObservatio

n

Strategy

Practice

Parent Session

s

• “Normal” fluency in conversational speech

• Easy Talking– Conversational Level– Direct Model to Question Model

• Sentences • Phrases • Words

• Model & Practice– Delayed Response– Reduplication/Rephrasing– Decreased Questioning– Easy Talking

• Modify interpersonal stressors

• Chart home disfluencies

• Modify communicative stressors

• Discuss types of disfluencies

• Administer Stressor Inventory

Communication “Wellness”

Direct Child Intervention

Tre

atm

ent

Flo

w

ParentObservatio

n

Strategy

Practice

Parent Session

s

Discussing Types of Disfluencies

• Helps parents learn to distinguish between different disfluency types

• Helps parents understand how to view progress during treatment

• Reduces parental misconceptions– stuttering is just repetition– prolongations are “better” than repetitions

Increased Tension

Increased Fragmentatio

n

More Typical• Interjections• Revisions• Phrase repetitions• Multisyllabic whole-

word repetitionsCrossover Behaviors

• Monosyllabic whole-word repetitions

• Part-word repetitions• No tension/struggle• 1 – 2 iterations

Less Typical

• Part-word repetitions• 3 or more iterations

• Prolongations• Blocks

Continuum ofSpeech Disfluencies(adapted from Gregory, Campbell,

Hill, and others)

• Any type of disfluency withincreased tension or struggle• rise in pitch or loudness• tension in jaw or face

• Avoidance, fear about talking

Examining Stressors

• Compare stressor inventories completed by both parents– Parents may view situations differently

• Focus on interpersonal stressors first– Establish need for additional counseling

• Discuss ways to modify stressors– Parents take lead in finding solutions

Home Charting

• Increase parents’ awareness of– Situational factors that affect fluency – Their reactions to their child’s stuttering

• Helps parents focus their energy on helping the child rather than worrying

• Gives opportunity to assess parents’ commitment to treatment early in the therapeutic process

Home Charting

• Guidelines

– No “Aha!” expected

– Provide examples of successful charting(see handout)

– Parents should bring completed chartto next treatment session

Provide Supporting Literature

• Reassures parents that others have had similar concerns and questions

• Provides concrete examples of ways parents can help their children

• Additional opportunity to assess parents’ commitment to treatment

Examples of Supporting Literature

• Stuttering Foundation of America (SFA)– Stuttering and Your Child: Questions & Answers– If Your Child Stutters: A Guide for Parents

• National Stuttering Association (NSA)

• Stuttering Center Handouts

• Internet Resources– Stuttering Home Page

Session #2

Overview of FluencyEnhancing Strategies

Goals for Session #2• Additional opportunity for counseling to

to address parents’ concerns

• Further explore interpersonal stressors (when applicable)

• Begin the process of modifying communicative stressors

• Introduce next phase of treatment: parent/child modeling

Guidelines for Session #2

• First, Review Info from Session #1

– Review results from home charting

– Answer questions about booklets and supporting literature

– Address parents’ concerns about treatment and child’s fluency

– Continue discussion of interpersonal stressors and modifications

Fluency Enhancing Strategies

• Reducing parents’ speaking rates

• Reducing time pressures

• Reducing demand for talking

• Modifying questioning

• Providing supportivecommunicative environment

Preparing for Parent-Child Modeling Sessions (Sessions 3-6)

• Provide overview of session flow

• Explain the need to videotape sessions (have parents bring tape to next session)

• Briefly introduce Easy Talking asthe first strategy to be addressed

• Familiarize parents with wireless microphone system

“UseEasy

Talking”

Wireless Microphone System

(EasyTalking)

WirelessXmitter

(TelexTW-6)

WirelessReceiver

(TelexAAR-1)

Session #3

Easy Talking

Goals for Session #3

• Train parents to use Easy Talking

– Slower than parents’ habitual rate, but not too slow, choppy, or robot-like

– Introduce phrased speech as a preferred way to reduce speaking rate

– Explain that the goal for the parents’ speaking rate is somewhere in between the rate they will practice in treatment and the rate they used before treatment

Guidelines for Session #3

• Set up video equipment and wireless microphone system before session

• Review Easy Talking handout– Introduce phrasing as a preferred way to

reduce speaking rate– Explain that the goal for the parents’

speaking rate is somewhere in between the rate they will practice in treatment and the rate they used before treatment

Model and Practice Easy Talking

• Clinician models Easy Talking withthe child while parents observe

• One parent interacts with childwhile receiving on-line feedback

• Second parent interacts with childwhile receiving on-line feedback

• Discuss observations and importanceof reviewing videotape at home

Video Segment #1

Easy Talking

Preparing for Session #4

• When parents view the videotape, they should observe: – Their use of Easy Talking– The number and type of questions

they ask the child

• Discuss upcoming session’s focuson Modified Questioning

Session #4

Modified Questioning

Goals for Session #4

• Train parents to modify questions– Reducing the number of direct questions in

favor of more indirect comments– Goal is to reduce demands on child

• Parents cannot (and should not) eliminate questions completely– Provide “cheat sheet” for various

non-questioning starters

“Non-Question Starters”

• “I wonder…”

• “I think…”

• “I bet…”

• “I guess…”

• “Maybe…”

• “It looks like…”

Whatdoes Teddywant to do?

I wonderwhat Teddywants to do.

Model & Practice Modified Questioning

• Session has same structure as #3

• Clinician models Modified Questioningwith the child while parents observe

• One parent interacts with childwhile receiving on-line feedback

• Second parent interacts with childwhile receiving on-line feedback

• Discuss observations and importanceof reviewing videotape at home

Video Segment #2

Modified Questions

Session #5

Reduplication / Rephrasing

Goals for Session #5

• Train parents to use reduplication/ rephrasing strategy– Child can hear what he or she said

in an easier, more relaxed way

– Child knows that parents have heardwhat he or she said

– Gives parents the opportunity to providea good language/articulation model

• Session has same structure as #3, #4

Video Segment #3

Reduplication / Rephrasing

Delayed response

Session #6

Reducing Time Pressure

Review of All Strategies

Goals for Session #6

• Help parents incorporate all strategies into their interactions with child– Provide a summary of all techniques used in

treatment thus far– Discuss need to follow through with

techniques in home practice– Discuss plan for future treatment as

necessary

• Use the “refresher” handout

Refresher Handout

• Use Easy Talking at slowed rate…use phrased talking to keep it natural

• Delay Responding. Pause before answering• Modify Questions. Try “I wonder…”

“Maybe…” “I think”• Repeat and Rephrase both fluent and

disfluent speech to provide a good model and let child know you are listening

Follow-up• Phone contacts to monitor progress

– Parents’ use of strategies– Child’s response to strategies– Changes in child’s fluency

• Maximum 3 months before reassessment– Parents may opt for refresher sessions

prior to three-month timeframe

• May move right into fluency group or individual therapy

Evaluation andFuture Directions

Does any of this work?!?

Evaluating Treatment Outcomes• Recall that the goal of treatment is to help

parents facilitate children’s fluency in real-world situations

– To evaluate treatment, we evaluate parents’ ability to make these changes

• In treatment • Parent report from home

– We also monitor changes in children’s fluency to determine whether more direct treatment is necessary

• During treatment • At follow-up

So, does it work?• Anecdotal evidence and experience in

treatment shows that parents can make changes in treatment and at home– Many children do experience improvements in

fluency during the course of treatment– Changes may be related to treatment but may also

be related to natural recovery

• We are now more carefully documenting changes in parents’ communicationand children’s fluency during treatment

Case Presentations

  Diagnostic DataTreatment Process

Outcomes / Follow-up

JC (3;2) – from videotape• Diagnostic Results

– Signs of early stuttering (data)– Moderate speech sound disorder

• Treatment Process– 2 parent-only sessions (mother only)– 3 parent-child modeling sessions (both parents)

• Outcome– Phone contact 4 months post treatment revealed solid

fluency maintenance– Child will begin treatment for speech sound disorder

while fluency is monitored

LC (2;11) – Diagnostic Results• Child Factors

– Moderate to severe stuttering• Sound prolongations, secondary features• Frustration and avoidance

– Mild speech sound disorder– Sensitive, intense child

• Interpersonal Stressors– Fast-paced lifestyle– Parents’ perfectionistic tendencies

• Communicative Stressors– Father unsure how to play with child

LC (2;11) – Treatment/Outcomes

• Treatment– 3 parent-only sessions with both parents because of

complex home environment– 3 parent-child modeling sessions

• Outcomes– Follow-up parent session after 4 months revealed need

to refresh strategy usage– Follow-up visit after 6 months revealed

solid fluency maintenance– Returned to treatment for speech sound disorder;

fluency had stabilized

SH (4;6) – Diagnostic Results

• Child Factors– Moderate stuttering

• Multiple word/syllable repetitions; some blocks • Generalized facial tension and oral posturing

– Moderate expressive language deficits– Family history of stuttering– Intense, sensitive child

• Interpersonal Stressors– Minimal interpersonal stressors

• Communicative Stressors– Rapid parental rate of speech

SH (4;6) – Treatment/Outcomes

• Treatment– 2 parent-only sessions (both parents)– 4 parent-child modeling sessions

• Outcomes– 3-month follow-up revealed parents’

desire to refresh use of strategies – Child’s fluency continued to fluctuate during

parent-child sessions (every other week) – Child will be placed in parent/child fluency

treatment group

Adapting the Techniquefor Other Sessions

Practical Considerations

Current Implementation

• This treatment approach was developed at Children’s Hospital of Pittsburgh– Based on information from several sources,

including University Clinics

• Admittedly, these are idealized treatment settings– More flexible facilities

– Better access to families

– More control over timing and scheduling

Considerations

• Interaction with parents is critical for facilitating child’s fluency at home– Focus on parents helps them assess

the need for additional treatment

• It can be difficult to ensure parental involvement in certain settings– Manageable, short course of treatment (six

sessions over extended period of time) can facilitate scheduling, parent involvement

Modifications

• Wireless microphone system is helpful means of proving direct feedback to parents during sessions– Without wireless mic, clinician can provide

feedback right after parent session

• Observation room not necessary– Clinician can sit away from play area and

whisper instructions into microphone

Remember the Goal

• The goal of treatment is to help parents facilitate children’s fluency by modifying communicative and interpersonal stressors

• Technical details can be adjusted for different settings so the clinician can – Talk with parents to help them analyze

and modify stressors

– Model desired modifications

– Give parents chance for guided practice

Summary

• This treatment program helps parents make modifications to interpersonal and communicative stressors that may affect children’s fluency

– Provides an alternative to “wait and see” recommendations

– Can be used alone or in conjunction with more direct treatment

– Can be used in a variety of settings

Questions?Comments?

Let us know!

David W. Hammer, M.A., CCC-SLP

Children's Hospital of Pittsburgh2599 Wexford Bayne Rd.Sewickley, PA 15143Phone: (724) 933-3600Fax: (724) 933-3621Email: hammerd@chplink.chp.edu

J. Scott Yaruss, Ph.D., CCC-SLP

University of Pittsburgh4033 Forbes TowerPittsburgh, PA 15260

Phone: (412) 647-1367Fax: (412) 647-1370Email: jsyaruss@csd.upmc.edu

tuttering

CS enterof

estern ennsylvaniaW PA joint venture of Children's Hospital of Pittsburgh and the Department of

Communication Science and Disorders at the University of Pittsburgh