Working With Children who Stutter: Comprehensive Assessment and
Comprehensive Assessment and Treatment
Craig Coleman, M.A., CCC‐SLP, BRS‐FD
Clinical Coordinator, Children’s Hospital of Pittsburgh
Co‐Director, Stuttering Center of Western PA
What is Stuttering?
What is Stuttering?
So, What is Stuttering?
So, What is Stuttering?
• Interruption
Interruption in the forward flow of speech in the forward flow of speech
that may be accompanied by physical tension, secondary behaviors or negative reactions or
secondary behaviors, or negative reactions or decreased communication skills. The disorder has affective behavioral and cognitive
has affective, behavioral, and cognitive components (ABC)
Disfluency is…
Disfluency is…
• A disruption in the forward flow of speech
A disruption in the forward flow of speech
– All people have disfluencies, but not all people stutter
Types of Stuttering
Types of Stuttering
Cluttering
“Developmental”
Neurogenic
Psychogenic
Stuttering Myths…
Stuttering Myths…
• School‐Age
School Age Children can be Children can be “cured”
cured
• The only goal of treatment should be to eliminate stutteringg
• Stuttering is caused by being nervous
It is a good idea to tell people to “slow
slow down
down” when when
• It is a good idea to tell people to they stutter
• Changing words is a good practice to reduce g g
g
p
stuttering
g
y
g
• Stuttering is “normal” for young children
Stuttering Facts…
Stuttering Facts…
• Boys stutter 3‐4 times as much as girls do at school‐
y
g
age level (pre‐k ratio is 1:1)
• Stuttering is “caused” by a number of factors
– Genetics, Anatomy and Physiology, Environment, Temperament, Linguistic and Motor Factors, etc.
• Pre‐school
Pre school children can children can “outgrow”
outgrow disfluency, not disfluency not
stuttering
y
y
g
• We can identify risk factors for young children, but we do not have reliable predictors • About 1% of adults stutter Prevalence
• Prevalence
Prevalence relates to how widespread a relates to how widespread a
disorder is in the current population
• Approximately 1% of the adult population Approximately 1% of the adult population
stutters
Incidence
• Number
Number of people who stuttered at some of people who stuttered at some
point in their lives
• This is estimated to be approximately 5%
This is estimated to be approximately 5%
• What does the higher level of incidence tell us?
Age of Onset
Age of Onset
• Stuttering
Stuttering typically develops between the typically develops between the
ages of 2‐5
• Initially, there is often great fluctuation of Initially, there is often great fluctuation of
fluency in children, meaning that parents may have difficulty determining if an evaluation is needed
• Children who develop stuttering later are at great risk for chronic stuttering
The ABC’ss
The ABC
• Affective:
Affective: Feelings, attitudes, emotions
Feelings attitudes emotions
• Behavioral: Actions (Avoidance, tension, struggle); Stuttering
struggle); Stuttering
• Cognitive: Thought‐processes, self‐evaluation
Types of Stuttering
Types of Stuttering
• Repetitions
– Sound/Syllable
– Word
– Phrase
•
•
•
•
Prolongations
P
l
ti
Blocks
Interjections
Revisions
Theoretical Background
Theoretical Background
• Early theories of stuttering were based on:
Early theories of stuttering were based on:
–
–
–
–
–
–
–
Oral‐erotic gratification
Psychotic Disorder
y
Tic Disorder
Laryngeal Spasms
y g
p
Mini Convulsions
Perseverative Motor Response
Repressed Hostility
Current Theories
Current Theories
• Most
Most theories today suggest a complex theories today suggest a complex
interaction between linguistic development and motoric production skills combined with
and motoric production skills, combined with the influences of the child’s personality and multiple influences of the child’ss social and multiple influences of the child
social and
communicative environment. Why Do People Stutter?
Why Do People Stutter?
Neurophysiology
Genetics
Demands/Capacities
Environment
Temperament/Personality
Genetics: Role in Stuttering
Genetics: Role in Stuttering
• We
We know that there is a genetic component of know that there is a genetic component of
stuttering. We do not yet know enough to know exactly what specific genes are
know exactly what specific genes are consistently altered or if there is a genetic component for everyone
component for everyone
Clinical Implications
Clinical Implications
• Genetic
Genetic implications should be discussed implications should be discussed
• May ease the burden for some people who think they have caused stuttering
y
g
• May increase feelings of guilt for some if their family history is positive for stuttering
y p
g
• Discussion on genetics has the potential to alter viewpoint on stuttering from a disorder of emotion to a “medical” disorder
• Be
Be aware of family history and understand aware of family history and understand
that it is a powerful risk factor for young children who stutter
children who stutter
Clinical Case
Clinical Case
• A
A 4 y.o. presents with a strong family history 4 y o presents with a strong family history
of stuttering on mother’s side. Mother is very emotional and worried that her genes have
emotional and worried that her genes have caused her child to stutter – How do you handle this situation?
How do you handle this situation?
Neurophysiology
• Adult studies have found:
Adult studies have found:
– Reduced or abnormal activity in the auditory association areas
association areas
– Increased activity in the right frontal and left cerebellar regions
cerebellar regions
– Abnormal timing between primary motor and p
premotor regions in left hemisphere
g
p
– Increased activity in the left putamen, ventral thalamus, and inferior anterior cingulate Clinical Implications
Clinical Implications
• Neurophysiology
Neurophysiology also should be routinely also should be routinely
discussed, not because we know for sure if that particular child has a certain neurological
that particular child has a certain neurological profile, but to help educate people on causes of stuttering
of stuttering
• This can really help families and PWS to see that stuttering is a physiological disorder not
that stuttering is a physiological disorder, not emotional, or voluntary
Clinical Case
Clinical Case
• A
A parent of 3 y.o. you are evaluating is parent of 3 y o you are evaluating is
convinced that the child must have a neurological disorder because their stuttering
neurological disorder because their stuttering started abruptly. Parent states “Everything was fine and one morning he just woke up and
was fine and one morning he just woke up and couldn’t get a word out.”
Environment
• Stuttering
Stuttering tends not to be any more prevalent tends not to be any more prevalent
in children who grow up in abusive or neglectful homes
neglectful homes
• While environment likely does not cause a child to start stuttering it can have a
child to start stuttering, it can have a significant impact on the reactions – Allergies analogy
All i
l
Creating a Positive Environment
Creating a Positive Environment
• Modeling
Modeling both targeted speech patterns AND both targeted speech patterns AND
positive reactions to stuttering
• Reducing demands
Reducing demands
• Reducing time pressure
• Focus on content, not just manner
• Turn‐takingg
• Let go of perfection!
Clinical Case
Clinical Case • A
A parent states that they are concerned parent states that they are concerned
because their child is around another boy who stutters are preschool Prior to this their child
stutters are preschool. Prior to this, their child was not stuttering. They are concerned that their child is learning stuttering from the other
their child is learning stuttering from the other child at school.
Temperament
• Again
Again, while likely not a cause of stuttering, a while likely not a cause of stuttering a
child’s personality can play a role in how he responds to stuttering
responds to stuttering
– Perfectionism
– High sensitivity
High sensitivity
– Intense personality
– Competitive
Competiti e
– Reacts strongly Preschool Child: Evaluation
Preschool Child: Evaluation
• Purpose:
Purpose: To determine IF the child needs To determine IF the child needs
treatment. Is he likely to recover without treatment?
Parent Interview
Parent Interview
•
•
•
•
•
•
•
•
•
How long has child been stuttering?
Has stuttering changed over time?
What types of stuttering is the child exhibiting?
How much is the child stuttering? Is it improving or getting
How much is the child stuttering? Is it improving or getting worse?
Does the child have any tension when stuttering?
Does the child seem concerned?
Does the child seem concerned?
How are others reacting?
Is there a family history of stuttering?
D
Does the child have any other speech/language issues?
h hild h
h
h/l
i
?
More Parent Interview
More Parent Interview
• Are
Are there any other medical concerns? there any other medical concerns?
• How does the child interact with others? Are his interactions impacted on by his stuttering?
his interactions impacted on by his stuttering?
• Is the child in preschool/daycare? • Who else is involved in the child’s care on a regular basis?
Obtaining Speech Samples
Obtaining Speech Samples
• Have
Have the child begin the assessment by playing with the child begin the assessment by playing with
parents for a period of time
– Examine the child’s fluency (disfluency count)
– Examine the parents’ interactions
• Clinician interacts with the child
– Try to gauge fluency in various communication contexts (less pressure vs. more pressure)
– Begin to determine the child’s awareness and response to B i t d t
i th hild’
d
t
his stuttering
Other Factors to Consider
Other Factors to Consider
• May
May need to assess other speech/language need to assess other speech/language
areas
• Compare fluency during the assessment with Compare fluency during the assessment with
what parents usually see at home
Making Sound Clinical Decisions
Making Sound Clinical Decisions
• Need to evaluate several factors:
Need to evaluate several factors:
– Family History, gender, other speech/language skills, time since onset, reactions, overall communication
– Types of disfluencies, physical tension, secondary behaviors
Options for Treatment
Options for Treatment
• May
May begin treatment with 6
begin treatment with 6‐session
session parent/child treatment program
– More sessions may be recommended
More sessions may be recommended
• May monitor fluency over 3 more months and re evaluate
re‐evaluate
Case Study:
Case Study: • CASE STUDY: Jack is a 3 y.o. child who is exhibiting some speech disfluencies. You see him for an evaluation and have the following results: –
–
–
–
–
–
Disfluency rate = 6%
y
No physical tension or secondary behaviors
Jack’s father stutters
Jack has been stuttering for 9 months
g
Jack is a male
Jack’s parents (particularly his father) are very worried that Jack will stutter long‐term
g
• Would you recommend treatment for this child? Why or Why not? Setting the Stage for Treatment
Setting the Stage for Treatment
• Begin
Begin the process of individualizing the treatment the process of individualizing the treatment
plan for the child
• Begin educating and counseling the parents on g
g
g
p
stuttering
pp
y
• Help parents identify resources for information (National Stuttering Association, Stuttering Foundation of America, Stuttering Center of Western PA))
Goals of Treatment
Goals of Treatment
• The
The overall goal of treatment for preschool overall goal of treatment for preschool
children who stutter is to eliminate stuttering while supporting
pp
g
the child’s language development
• This treatment program focuses on one This treatment program focuses on one
component of this overall goal… parental f
facilitation of the child’s fluency in real‐world f
f
y
situations
What is Indirect Treatment?
What is Indirect Treatment?
• Involves
Involves making changes in environment, making changes in environment
rather than making any changes to the child’s speech
• Stuttering is not talked about with the child
• Very popular through the 1980’s, especially V
l h
h h 1980’
i ll
when diagnosogenic theory was thought to be true
Does it Work?
Does it Work?
• Despite
Despite decades of use, there is no
decades of use there is no published published
data to support the use of only indirect treatment with young children who stutter!
treatment with young children who stutter!
• This doesn’t mean that it is not effective, but when there is no data the pendulum
when there is no data, the pendulum often….swings…to….
Direct Treatment for Everyone?
Direct Treatment for Everyone?
• Direct
Direct treatment involves more specific treatment involves more specific
activities involving the child that target improving fluency or changing stuttering
• With the data compiled by the Lidcombe Program, direct treatment has become more popular in the last 2 decades, but many of these approaches are operant, not direct treatment
Time to Choose Sides…
Time to Choose Sides…
• The
The debate between those who support debate between those who support
indirect treatment and those that support direct treatment has been intense but is it
direct treatment has been intense…but is it really a necessary debate? So Many Choices….
So Many Choices….
• Indirect
– Child is not aware of, or frustrated by, his stuttering
– Child exhibits tension free stuttering without
free stuttering without secondary behaviors
• Direct
– Child is aware of, and/or frustrated by, his stuttering
– Child exhibits physical tension or secondary
tension or secondary behaviors associated with his stuttering
Common Misconceptions
Common Misconceptions
• Parents
Parents misperceive that misperceive that “Direct”
Direct means that means that
they are not actively involved in the treatment. treatment
• Parents incorrectly think that they may not need education and counseling in direct
need education and counseling in direct treatment. So, How Do We Treat These Kids?
So, How Do We Treat These Kids?
• Begin with short
Begin with short‐term
term indirect treatment indirect treatment
• Progress to direct treatment if needed
Parent/Child Treatment Program
Parent/Child Treatment Program • 6
6 sessions of parent training once per week sessions of parent training once per week
for children ages 2 through 6
• Depending on progress:
Depending on progress:
1. Monitor fluency over 3 more months and re‐
evaluate
l
2. Begin direct treatment
Rationale for Parent Training
Rationale for Parent Training
• Presents an alternative to “treatment / no treatment” binary options
– Useful for children who may meet some of the risk factors for stuttering
for stuttering
– Allows access to the child over a period of several weeks
– May be used as sole form of treatment, or beginning stage of more direct treatment
• Program is minimal in terms of cost and clinician time
• All children may not need to advance to direct treatment
General Structure of Treatment
General Structure of Treatment
• Treatment consists of
Treatment consists of:
– Two parent‐child training sessions for parental counseling and overview of treatment
counseling and overview of treatment
– Four parent‐child modeling sessions when parents are taught modifications
are taught modifications
• Combines aspects of both indirect and direct treatment methods
treatment methods
– Treatment plans are highly individualized
Goal for Session 1: “Stuttering 101”
• What is stuttering? (discuss theories and causes, at s stutte g? (d scuss t eo es a d causes,
teach about different types of disfluencies, answer parent’s questions, give literature)
• Provide an overview of the treatment process and outlook for the future
• Help parents gain an understanding of their role in treatment
• Parents complete Stressor Inventory
P
t
l t St
I
t
“Bucket” Analogy
gy
Factors
T
S UTTE
RI
NG
• Factors interact
• Cannot distinguish influence
of individual factors once
they are in the bucket
Home Charting
Home Charting
• Increase parents
Increase parents’ awareness of
awareness of
– Situational factors that affect fluency – Their reactions to their child
Their reactions to their child’ss stuttering
stuttering
• Helps parents focus their energy on helping the child rather than worrying
the child rather than worrying
• Gives opportunity to assess parents’ commitment to treatment early in the it
tt t t
t
l i th
therapeutic process
Goals for Session # 2
Goals for Session # 2
• Additional
Additional opportunity for counseling to opportunity for counseling to
address parents’ concerns
• Further
Further explore interpersonal stressors (when explore interpersonal stressors (when
applicable)
• Begin
Begin the process of modifying the process of modifying
communicative stressors
• IIntroduce next phase of treatment: t d
t h
ft t
t
parent/child modeling
Fluency Enhancing Strategies
Fluency Enhancing Strategies
• Reducing parents
Reducing parents’ communication rates
communication rates
• Reducing time pressures
• Reducing demand for talking
• Providing supportive
communicative environment
• Addressing negative reactions
Wireless
Microphone System
Wireless Microphone System
Goals for Session # 3
Goals for Session # 3
• Train parents to use
Train parents to use Easy Talking
Easy Talking
– Slower than parents’ habitual rate, but not too
slow, choppy, or robot‐like
,
ppy,
– Introduce phrased speech as a preferred way to reduce speaking rate
p
g
– 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
Tips for Session 3
Tips for Session 3
• Explain
Explain that goal is not
that goal is not to use this reduced to use this reduced
communication rate all the time, but to have it as a tool and use it consistently in intervals
as a tool and use it consistently
in intervals
• Help parents understand the need to address time pressure
time pressure
Model and Practice
Model and Practice
• Clinician
Clinician models Easy Talking with
models Easy Talking with
the child while parents observe
• One parent interacts with child
One parent interacts with child
while receiving on‐line feedback
• Second parent interacts with child
Second parent interacts with child
while receiving on‐line feedback
• Discuss observations and importance
Di
b
ti
di
t
of reviewing videotape at home
Goals for Session 4
Goals for Session 4
• Session has same structure as #3
Session has same structure as #3
• Clinician models Modified Questioning
with the child while parents observe
p
• One parent interacts with child
while receiving on‐line feedback
• Second parent interacts with child
while receiving on‐line feedback
• Discuss observations and importance
of reviewing videotape at home
Modified Questioning
Modified Questioning
•
•
•
•
•
•
•
•
II wonder…
wonder…
I think…
I bet
I bet…
I guess…
M b
Maybe…
It looks like…
Let’s see if…
Why don’t we try…
Goals for Session 5
Goals for Session 5
• Train parents to use recasting/ rephrasing a pa e ts to use ecast g/ ep as g
strategy
– Child can hear what he or she said
in an easier, more relaxed way
l d
– Child knows that parents have heard
what he or she said
what he or she said
– Gives parents the opportunity to provide
a good language/articulation model
• Session has same structure as #3, #4
Goals for Session 6
Goals for Session 6
• Help
Help parents incorporate all strategies into parents incorporate all strategies into
their interactions with child
– Provide a summary of all techniques used in Provide a summary of all techniques used in
treatment thus far
– Discuss need to follow through with techniques in Discuss need to follow through with techniques in
home practice
– Discuss plan for future treatment as necessary
Discuss plan for future treatment as necessary
Follow Up
Follow‐Up
• Phone contacts to monitor progress
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 i h i
fl
i di id l
therapy
How to Talk about Stuttering
How to Talk about Stuttering
• Each
Each child will differ in how they child will differ in how they “view”
view stuttering
• Some children may be more sensitive
Some children may be more sensitive
• Maintain encouragement and reinforce their d i
desire to communicate
i
• Avoid negative words (e.g., “That was a bad one. You are having a bad day.”)
Every Parent Should Know…
Every Parent Should Know…
• Stuttering is highly variable at this stage
Stuttering is highly variable at this stage
• Progress should be measured on many levels:
– Number of disfluencies
N b
f di fl
i
– Physical Tension
– Avoidance
– More prolonged periods of disfluency
– Stuttering becoming more situation‐specific
More Direct Treatment
More Direct Treatment
• Teaching Teaching “Turtle
Turtle Talk
Talk”
– Comparisons to “Rabbit, “Kangaroo,” “Snake”
• Hard vs. Easy “Bumps”
Hard vs Easy “Bumps”
– Targets physical tension
• Easy Starts
Case Study Breakout 2
Case Study Breakout 2
• You are seeing Alex (age 5) for treatment. Alex has gone through the parent training program and it is now time for more direct treatment. You have the following info:
– Parents have adapted well to strategies and are using them. p
g
g
– There is still a lot of competition for talking time, particularly with his sister, Mallory.
– Alex continues to exhibit rapid rate of speech. – Significant physical tension is noted during disfluencies, along with some negative reactions.
• What is your treatment plan for Alex and what goals would y
p
g
you set?
Purpose of School‐Age
Purpose of School
Age Assessment
Assessment
• For
For school
school‐age
age and adolescent children, the and adolescent children the
main purpose of the evaluation is determining if the child is READY for treatment
if the child is READY for treatment
Assessment Procedures
Assessment Procedures
• Many
Many of the assessment procedures are the of the assessment procedures are the
same as for Pre‐K children, except: – Child needs to be interviewed to determine:
•
•
•
•
•
Child’s readiness for treatment
Any differences in parent/child beliefs and reports
Child’s previous experiences in treatment
h ld’
Child’s emotional response to disfluency
Child’ss ability to use fluency strategies
Child
ability to use fluency strategies
ABC Assessment
ABC Assessment
• Affective
Affective and Cognitive domains can be evaluated and Cognitive domains can be evaluated
using indirect methods or OASES
• Behavioral
– Disfluency Counts
– Secondary behaviors
– Types of stuttering
• Remember, the behavioral domain is the most variable—sometimes from situation to situation. It’s also the easiest to change.
Who Cares About Attitudes and Emotions?
Who Cares About Attitudes and Emotions?
• Stuttering
Stuttering may be associated with a variety of may be associated with a variety of
attitudes and emotions for school‐age and adolescent children
adolescent children
• Overcoming negative attitudes and emotions toward speaking should be one of the central
toward speaking should be one of the central goals in treatment
Factors in Determining if Treatment is Indicated
di
d
• Does
Does the child want treatment?
the child want treatment?
• What are the child’s expectations for treatment?
• Can the clinician give the child and parents what they want?
h h
?
• What are the primary goals of the child and parents?
y
g
• Is the child ready to make changes?
Case Study Breakout 3
Case Study Breakout 3
•
CASE STUDY: Meredith is a 14 y.o. child who you are evaluating. You see her for an evaluation and have the following results
her for an evaluation and have the following results: – Disfluency rate = 14%
– Significant physical tension and secondary behaviors (eye‐blinking and head‐
nodding)
– Meredith’s mother and father want Meredith to be seen for treatment and would like her stuttering to be cured.
– Meredith does not want to be seen for treatment and thinks that therapy will be “boring.”
– You find that Meredith avoids speaking situations and activities because of her stuttering.
– After some counseling, Meredith agrees that you might not be that lame after all, and admits she might need help.
•
Would you recommend treatment for this child? Why or Why not? If so, what would you tell Meredith and her parents that the goals are for treatment? Introducing the Treatment Process
Introducing the Treatment Process
• Child
Child and Parents need to be made aware of several and Parents need to be made aware of several
things early on:
– Stuttering will likely not be cured
– Goals are to reduce stuttering, reduce tension, increase knowledge of stuttering, increase communication skills, reduce negative reactions to stuttering help child educate
reduce negative reactions to stuttering, help child educate others
– Parents will need to not only focus on fluency, but many other factors (Help them learn the ABCs)
Measuring Goals
Measuring Goals
• Progress
Progress is not measured only in terms of is not measured only in terms of
number of disfluencies
– Write goals that reflect the entire disorder
Write goals that reflect the entire disorder
• Children may be relieved, but parents may need help coming to terms with all objectives
need help coming to terms with all objectives and goals of treatment
– Acceptance that stuttering will not simply A
h
i
ill
i l
disappear
Common Misconceptions
Common Misconceptions
• Only
Only number of disfluencies can be measured
number of disfluencies can be measured
• Reduction of disfluencies is the only goal
• Criteria used in articulation/phonology can be Ci i
di
i l i / h
l
b
applied to stuttering (80% fluent speech)
• Affective responses will improve on their own, as the child’s fluency improves Appropriate Goals
Appropriate Goals
• Goals
Goals should address all aspects of the disorder, not should address all aspects of the disorder, not
just the number of disfluencies
• Goals should be geared toward increasing the overall g
g
communication skills of the person who stutters
– Is it better to speak freely and stutter or avoid situations/words that may be problematic?
• Target the “quantity” AND “quality” of stuttering • Goals should be individualized
Goals to Address Education
Goals to Address Education • Children
Children need to be educated about stuttering need to be educated about stuttering
(Empowerment)
• Education helps the child deal with stuttering Education helps the child deal with stuttering
long‐term rather than getting a “quick fix”
• Helps the child teach others, such as their H l h hild
h h
h
h i
peers, about stuttering
Sample Goals‐Education
Sample Goals
Education
• Johnny will increase his knowledge about stuttering by passing 3 quizzes on basic stuttering facts.
• Johnny will educate 2 friends about his stuttering treatment techniques.
• Johnny will give a presentation to his family members, peers, or teachers on stuttering.
• Johnny will participate in periodic stuttering trivia contests J h
ill
ti i t i
i di t tt i t i i
t t
that are held with other children who stutter.
• Johnny will be able to identify and explain the process of producing speech and the anatomical structures involved in this process through use of drawings and other illustrations.
Goals to Address “Quality”
Goals to Address Quality of Stuttering
of Stuttering
• These
These goals should target decreased physical goals should target decreased physical
tension during stuttering
• Kids can learn that they sometimes can
Kids can learn that they sometimes can’tt control “if” they stutter, but they can control “how” they stutter
• Goals here should also target reduction of secondary behaviors
• These are often stuttering modification techniques
Sample Goals‐Quality
Sample Goals
Quality of Stuttering
of Stuttering
• Johnny will demonstrate the ability to reduce physical tension during stuttering using the “easing out” technique, for 50% of disfluencies during various tasks.
• Johnny will use cancellation and pull
Johnny will use cancellation and pull‐out
out techniques for 75% techniques for 75%
of disfluencies in a structured conversational task.
• Johnny will be able to correctly identify location of physical tension during 80% of stuttering episodes in a structured task
tension during 80% of stuttering episodes in a structured task.
• Johnny will decrease the use of any secondary behaviors associated with his stuttering to less than 10% of disfluencies.
Goals to Address “Quantity”
Goals to Address Quantity of Stuttering
of Stuttering
• These
These goals are speech modification techniques
goals are speech modification techniques
• They target reduction of the number of disfluencies Important to note that “quantity”
quantity and and “quality”
quality are are
• Important to note that not exclusive goals‐one often ties in with the other
• Goals should be viewed in terms of reduction, not Goals should be viewed in terms of reduction, not
how often children can speak fluently
Sample Goals‐Quantity
Sample Goals
Quantity of Stuttering
of Stuttering
• Johnny
Johnny will demonstrate the ability to reduce the will demonstrate the ability to reduce the
number of disfluencies in his speech by using easy starts 85% of the time in a structured conversation.
• Johnny will decrease the number of disfluencies in a structured conversational task by 15%.
• Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by reducing rate of communication by 20%.
f
b
Goals for Targeting Overall Communication
Goals for Targeting Overall Communication
• These
These are the most important goals because are the most important goals because
they target communication
• Helping the child become a more effective Helping the child become a more effective
communicator is the primary goal of treatment
• Goals should heavily target avoidance or negative reactions to stuttering
i
i
i
Sample Goals‐Overall
Sample Goals
Overall Communication
Communication
• Johnny will decrease avoidance behaviors associated with his stuttering by entering 3 specific situations where he previously avoided stuttering.
• Johnny will demonstrate desensitization to stuttering by using Johnny will demonstrate desensitization to stuttering by using
5 pseudostutters during a conversation in the classroom.
• Johnny will increase participation in educational and social situations as noted on a weekly basis by his parents and
situations, as noted on a weekly basis by his parents and teachers.
• Johnny will use correct posture and eye contact 85% of the time in conversational speech with the clinician.
i
i
i
l
h i h h li i i
Targeting Education
Targeting Education
• Education
Education leads to empowerment
leads to empowerment
• Helps children educate others and takes the “mystery”
mystery out of stuttering
out of stuttering
– Identifying and drawing speech structures
– Discussing what happens when you stutter
Di
i
h h
h
– Types of stuttering
– Famous People who Stutter
– Stuttering Facts—TRIVIA!
Targeting Reduced Tension / Secondary Behaviors
• TTension and secondary behaviors are a i
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learned reaction. They often result from negative reactions toward stuttering
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– Desensitization
– Stuttering Modification
– Regaining control
Targeting Increased Fluency
Targeting Increased Fluency
• Don’t place too many of your eggs in this basket—it can be the most variable target
• RELAPSE is not really a word
• Toolbox
– Speech Modification
Targeting Negative Reactions / Teasing
Targeting Negative Reactions / Teasing
• Desensitization and education are critical
• Role‐playing
Role playing
• Opportunity to face situations that cause fear
Breakout • Practice
Practice all speech modification and stuttering all speech modification and stuttering
modification techniques The Great Debate
The Great Debate
• Have
Have your students your students
participate in debates with their peers‐‐or with you
• You can pretend that you are debating with the child to see who would make a better
would make a better Class President of their school
their school
• The
The “winner”
winner of the debate is decided by a of the debate is decided by a
points system, which rewards one point for each of the following:
each of the following:
– appropriate eye contact
– speech modification or stuttering modification speech modification or stuttering modification
strategies (e.g., easy starts, pausing and phrasing, o e e o u a ys u e g)
or even voluntarystuttering) – the content of the response.
• Each
Each participant in the debate is given their participant in the debate is given their
own turn to answer questions. This gives them a chance to talk without being interrupted In
a chance to talk without being interrupted. In addition to allowing the child to work on several objectives in a natural context this
several objectives in a natural context, this activity also promotes an awareness of time pressure and turn‐taking
pressure and turn
taking
Pick Your Team
Pick Your Team
• Children pick five to six players from professional sports teams that they want to include on their team
• They get to select their team name and make
team name and make uniforms
• Following the selection of players the child is told to
players, the child is told to pretend that each person on his team now stutters
• The
The child must come up with a list of team child must come up with a list of team
“rules” to facilitate communication on a team of players who stutter
of players who stutter
• Helps children verbalize their beliefs about stuttering
• Helps them learn appropriate behavior when i
interacting with those who stutter
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Sample Team Rules
Sample Team Rules
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•
•
•
•
•
•
Don t tease others who are stuttering
Don’t
tease others who are stuttering
If someone is teasing you, tell a coach
Use your speech tools
Use your speech tools
Maintain eye contact
Say what you want even if you stutter
Say what you want, even if you stutter
Have team meetings to learn about stuttering
Help people on the team if they are being teased by
Help people on the team if they are being teased by someone else
Stuttering Football
Stuttering Football • Helps
Helps children learn children learn
the facts about stuttering
• Children can play against others who stutter or against their parents
• Each
Each player starts at the goal line and tries to player starts at the goal line and tries to
make it 100 yards to the other end zone to score
• Each person takes turns selecting the number of yards they want to go for
of yards they want to go for. • The higher number of yards, the harder the question they are asked by their opponents!
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!
• If
If they get the question right, they get to move up they get the question right, they get to move up
that many yards
• If they get the question wrong, they do not advance yg
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and the other team gets their turn!
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• You can use this activity with a group of kids by dividing them into teams
• They can discuss the questions they will ask (and determine how much each question is worth)