1. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 1 CHAPTER 9 Facilitating Fluency for Preschool and and School-Age Children

2. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 2 Indirect (Modify environment) Direct (Modify Speech)

3. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 3 Treatment strategies Indirect Approach = Modify EnvironmentIndirect Approach = Modify Environment Does direct intervention increase severity?Does direct intervention increase severity?(1940s–1960s) Emphasis of treatment on preventing the child from becoming aware that his speech was any different or a cause for concern (Bluemel, 1932)Emphasis of treatment on preventing the child from becoming aware that his speech was any different or a cause for concern (Bluemel, 1932) Parents and teachers instructed to avoid showing anxiety and using the word “stutter”Parents and teachers instructed to avoid showing anxiety and using the word “stutter” 1980s +1980s + Direct modeling and encouraging easier speech; Adjusting environmental factors in homeDirect modeling and encouraging easier speech; Adjusting environmental factors in home

4. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 4 Some basic approaches The Demands & Capacities Model (DCM) (Starkweather, et al., 1987, 1997, 1999) Decreasing demands while increasing capacities across 4 domains: motoric, emotional, linguistic, cognitive. Parents are trained to administer the program.

5. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 5 Some basic approaches (continued) Lidcombe Program for preschool children Onslow, M, Packman, A., and Harrison, E., (2003) The Lidcombe program of early stuttering intervention: A clinician’s guide. Austin, TX: Pro-Ed. The child’s fluent speech is followed by praise or acknowledgment, disfluent speech by encouragement of a fluent correction or by acknowledgement. Parents are trained to administer the program.

6. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 6 Evidence of therapeutic change for children Franken, C-M., Van der Shalk, K., Boelens, H., H. (2005). Experimental treatment of early stuttering: A preliminary study. J. Fluency Disorders, 30, 189-199. Purpose: Purpose: to consider the feasibility of comparing the response of two groups of preschool children who were randomly assigned to The Lidcombe Program (n = 12) and the current standard treatment program in the Netherlands, The Demands and Capacities-Based treatment program (n = 15).

7. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 7 Evidence of therapeutic change for children (continued) Method: Stuttering frequencies and severity ratings were obtained immediately before and after treatment (12 weeks).

8. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 8 Franken, et al. results Results: Stuttering frequencies and severity ratings significantly decreased for both treatment groups.Stuttering frequencies and severity ratings 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 and no differences were found on scales that measured their satisfaction with the two treatments.Parents of children in both groups were cooperative and no differences were found on scales that measured their satisfaction with the two treatments. Next: analysis to determine contributions of treatment componentsNext: analysis to determine contributions of treatment components

9. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 9 Common components for DCM and Lidcombe Programs (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, & commitmentParents levels of understanding, learning, & commitment Parent’s active participation & resulting reduction of anxietyParent’s active participation & resulting reduction of anxiety Parent’s increased parental locus of controlParent’s increased parental locus of control Parents openly acknowledge and normalize stutteringParents openly acknowledge and normalize stuttering Praise demonstrates the child has a choice about how they speakPraise demonstrates the child has a choice about how they speak

10. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 10 Common components for DCM and Lidcombe Programs (from Ratner & Guitar, 2006) (continued) Bonding of the parent and child during treatment takes place in the child’s everyday environmentBonding of the parent and child during treatment takes place in the child’s everyday environment Reduction in expressive language to more age- appropriate levelsReduction in expressive language to more age- appropriate levels Focus on the child’s fluent speech may foster the development of an alternative story that is not focused on stuttering. (Dilollo & Manning, 2006)Focus on the child’s fluent speech may foster the development of an alternative story that is not focused on stuttering. (Dilollo & Manning, 2006)

11. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 11 Key qualities of a clinician treating younger speakers Understands the nature of stuttering; willing to help child experiment & vary forms of nonfluent speech.Understands the nature of stuttering; willing to help child experiment & vary forms of nonfluent speech. Provides supportive therapeutic experience, enabling the child to become desensitized to their stuttering.Provides supportive therapeutic experience, enabling the child to become desensitized to their stuttering. Allows child to understand and control the basic features of speech → effortless, forward-flowing speech.Allows child to understand and control the basic features of speech → effortless, forward-flowing speech. Obtain the understanding and support of the parents and other important people in child’s life.Obtain the understanding and support of the parents and other important people in child’s life.

12. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 12 Treatment 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 stutteringReduce negative feelings and thoughts about stuttering 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 verbally communicatingEnhance the child’s abilities and enjoyment of verbally communicating

13. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 13 Choosing a treatment approach Be aware of many approaches & techniquesBe aware of many approaches & techniques Each approach will be different depending on clinician—academic/clinical background, experience, interactive styleEach approach will be different depending on clinician—academic/clinical background, experience, 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

14. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 14 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

15. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 15 When 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 of self-worthReinforce child’s accomplishments and feelings of self-worth (Ramig and Bennett, 1995) (Ramig and Bennett, 1995)

16. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 16 Selected techniques Parents’ rate, turn-taking, pausingParents’ rate, turn-taking, pausing Maybe fewer questionsMaybe fewer questions Communication disruptors (interruptions, over-talking, lack of interest in what the child says, over- stimulation)Communication disruptors (interruptions, over-talking, lack of interest in what the child says, over- stimulation) Slowing parent’s rate of speech — Mr. Roger’s speechSlowing parent’s rate of speech — Mr. Roger’s speech

17. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 17 Selected techniques (continued) Use analogies (bumpy-smooth/stretchy, hose)Use analogies (bumpy-smooth/stretchy, hose) Cursive handwriting for slow and easy speech Combining forms of play with sound production Slowing down your own speech rate

18. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 18 Since we last met... 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”

19. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 19 Superfluency (Guitar, 2006) Flexible rate—show child how to slow only the initial syllables of a word or syllableFlexible rate—show child how to slow only the initial syllables of a word or syllable Easy onsets—emphasize gradual onset of voicing and airflow.Easy onsets—emphasize gradual onset of voicing and airflow. Light contacts—modeling easy articulatory posturesLight contacts—modeling easy articulatory postures Proprioception—heightened feedback for articulatory movements and extent of contactProprioception—heightened feedback for articulatory movements and extent of contact Then, expand from three-word utterances to longer sentences

20. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 20 Indicators 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 syllablesSmooth transitions through sounds and syllables Child takes part in communicatingChild takes part in communicating

21. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 21 Recommended resources Chmela, K., & Reardon, N. (2002). The school-age child who stutters: Working effectively with attitudes and emotions. (Pub. # 5) Memphis, TN: Stuttering Foundation.Chmela, K., & Reardon, N. (2002). The school-age child who stutters: Working effectively with attitudes and emotions. (Pub. # 5) Memphis, TN: Stuttering Foundation. Manning, W. (2004). Clinical decision making with adolescents who stutter. ASHA Continuing Education Series, Rockville, MD. (2 CDs)Manning, W. (2004). Clinical decision making with adolescents who stutter. ASHA Continuing Education Series, Rockville, MD. (2 CDs) Ramig, P., & Dodge, D. (2005). The child and adolescent stuttering treatment and activity resource guide. Clifton Park, NY: Thomson Delmar Learning.Ramig, P., & Dodge, D. (2005). The child and adolescent stuttering treatment and activity resource guide. Clifton Park, NY: Thomson Delmar Learning. Reitzes, P. (2006). 50 great activities for children who stutter. Austin, TX: Pro-Ed.Reitzes, P. (2006). 50 great activities for children who stutter. Austin, TX: Pro-Ed. Ratner N, & Sisskin, V. (2002). Intervention strategies for children who stutter. ASHA Continuing Education Series, Rockville, MD. (2 video tapes)Ratner N, & Sisskin, V. (2002). Intervention strategies for children who stutter. ASHA Continuing Education Series, Rockville, MD. (2 video tapes)

22. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 22 Addressing desensitization and cognitive 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 classmatesSelf-acknowledgement to friends, teacher, and classmates Help parents to make stuttering an acceptable topic of discussionHelp parents to make stuttering an acceptable topic of discussion Parent group meetings can be very useful (NSA, Friends)Parent group meetings can be very useful (NSA, Friends)

23. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 23 Teasing vs. bullying Bullying—Conscious effort to hurt or control someoneBullying—Conscious effort to hurt or control someone Negative effects: lowered self-esteem, depression, loneliness, anxiousness, insecurities, social failure, academic issues Teasing—Good-natured exchange between friends. No intention to harm someone.Teasing—Good-natured exchange between friends. No intention to harm someone.

24. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 24 Possible effects of teasing and bullying Shame—major affect on one’s overall self- interpretationShame—major affect on one’s overall self- interpretation Teasing is one way in which shame becomes attached to stuttering.Teasing is one way in which shame becomes attached to stuttering. Results in increased stuttering and a high degree of social inhibition.Results in increased stuttering and a high degree of social inhibition. 60% children who stutter (7–15 yrs) experience this negative treatment.60% children who stutter (7–15 yrs) experience this negative treatment. The effects may continue into adulthoodThe effects may continue into adulthood

25. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 25 Developing effective responses to bullying Distinguish between hurtful and inquisitive commentsDistinguish between hurtful and inquisitive comments Instruct about the nature of bullying and those who do itInstruct about the nature of bullying and those who do it Role-play activitiesRole-play activities

26. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 26 Role-playing activities Provide child with opportunity to vent anger and frustrationProvide child with opportunity to vent anger and 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?

27. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 27 When coexisting problems occur Recognize that demands for phonological and grammatical processing compete with resources that permit fluent speechRecognize that demands for phonological and grammatical processing compete with resources that permit fluent speech Organize treatment hierarchyOrganize treatment hierarchy Structure intervention with minimum overt feedbackStructure intervention with minimum overt feedback Determine whether the impairments should be treated concurrently, sequentially, or cyclicallyDetermine whether the impairments should be treated concurrently, sequentially, or cyclically

28. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 28 Problems that reduce or impact fluency Co-occurring speech and language problems influence the clinician’s decision for providing treatment for children who stutter, but there are also a variety of neurological and behavioral conditions.Co-occurring speech and language problems influence the clinician’s decision for providing treatment for children who stutter, but there are also a variety of neurological and behavioral conditions. The more serious problems involve executive function or regulatory activities associated with the basal ganglia.The more serious problems involve executive function or regulatory activities associated with the basal ganglia.

29. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 29 Problems that reduce or impact fluency (continued) Tourette’s Syndrome (TS)Tourette’s Syndrome (TS) Autism Spectrum Disorder (ASD) and Asperger SyndromeAutism Spectrum Disorder (ASD) and Asperger Syndrome Attention Deficit Hyperactivity Disorder (ADHD)Attention Deficit Hyperactivity Disorder (ADHD) Down SyndromeDown Syndrome

30. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 30 Tourette’s syndrome A neurologic disorder with childhood onset and is thought to be secondary to abnormal metabolism of the neurotransmitter dopamine.A neurologic disorder with childhood onset and is thought to be secondary to abnormal metabolism of the neurotransmitter dopamine. By age 7, TS children exhibit motor, phonic, and mental tics that are repetitive and involve rapid, involuntary movements or vocalizations (e.g., facial grimaces, eye-blinking, shrugging, head jerking, face- rubbing, lip-licking).By age 7, TS children exhibit motor, phonic, and mental tics that are repetitive and involve rapid, involuntary movements or vocalizations (e.g., facial grimaces, eye-blinking, shrugging, head jerking, face- rubbing, lip-licking). Intelligibility is often impaired due to rapid speech problems.Intelligibility is often impaired due to rapid speech problems.

31. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 31 Tourette’s syndrome (continued) Most disfluencies are not SLDs typical of developmental stuttering, but rather fillers, phrase repetitions, and sentence revisions.Most disfluencies are not SLDs typical of developmental stuttering, but rather fillers, phrase 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 during structured interactions and increase ability to read social cues.focus on teaching the child to monitor speech during structured interactions and increase ability to read social cues.

32. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 32 Tourette’s syndrome (continued) Recommended intervention strategies (Continued):Recommended intervention strategies (Continued): Speech rate addressed by emphasizing clear articulation with natural speech prosody.Speech rate addressed by emphasizing clear articulation with natural speech prosody. Other goals may include enhancing the child’s ability to comprehend abstract or figurative language, accurately process verbal information, and formulate ideas.Other goals may include enhancing the child’s ability to comprehend abstract or figurative language, accurately process verbal information, and formulate ideas.

33. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 33 Autism spectrum disorder (ASD) including Asperger syndrome Describes an assortment of developmental problems including impairments in social interaction, communication, play and imagination, and restricted interests and activities.Describes an assortment of developmental problems including impairments in social interaction, communication, play and imagination, and restricted interests and activities. Disfluencies, including SLDs, are common.Disfluencies, including SLDs, are common. Asperger Syndrome is regarded as a milder form of autism and is characterized by no delay in general language ability or cognitive development (they may score in the superior range on standardized IQ tests).Asperger Syndrome is regarded as a milder form of autism and is characterized by no delay in general language ability or cognitive development (they may score in the superior range on standardized IQ tests).

34. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 34 Attention deficit hyperactivity disorder (ADHD) Hallmark of these children is “consistent inconsistency” in two or more environments such as school, home, and other social settings and is characterized by inattention, hyperactivity, and impulsivityHallmark of these children is “consistent inconsistency” in two or more environments such as school, home, and other social settings and is characterized by inattention, hyperactivity, and impulsivity Classified into 3 categoriesClassified into 3 categories Primarily hyperactive-impulsive(without inattention)Primarily hyperactive-impulsive(without inattention) Predominately inattentive type (without significant hyperactivity)Predominately inattentive type (without significant hyperactivity)

35. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 35 Attention deficit hyperactivity disorder (ADHD) (continued) Classified into 3 categories (Continued)Classified into 3 categories (Continued) Combination of these twoCombination of these two Most children who stutter do not have ADHDMost children who stutter do not have ADHD Medication has been found to increase disfluenciesMedication has been found to increase disfluencies

36. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 36 Down syndrome Stuttering more frequent for individuals of less intelligence (30-40%)Stuttering more frequent for individuals of less intelligence (30-40%) In the specific instance of the most common cause of intellectual disability, Down syndrome, the occurrence of stuttering occurs with greater frequencyIn the specific instance of the most common cause of intellectual disability, Down syndrome, the occurrence of stuttering occurs with greater frequency Characteristics of children who stutter with Down syndrome…Characteristics of children who stutter with Down syndrome…

37. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 37 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, poor intelligibility)Many characteristics of cluttering (fast rate, poor intelligibility) High frequency of whole and part-word reps and prolongationsHigh frequency of whole and part-word reps and prolongations Difficulty monitoring, poor motor coordination, word finding, and language formulationDifficulty monitoring, poor motor coordination, word finding, and language formulation

38. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 38 Classroom teachers Create a workshop, S. Foundation video, handouts, SLDsCreate a workshop, S. Foundation video, handouts, SLDs 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) (see p. 356) Letter to teacher(s) (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, Reardon’s Teacher ChecklistNote Figure 9-1, Reardon’s Teacher Checklist

39. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 39 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 9-1, Sample Letter to TeachersNote Box 9-1, Sample Letter to Teachers

40. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 40 Transfer and termination Critical to transfer skills to daily situationsCritical to transfer skills to daily situations Gradual transfer of self-cuing to the child and parentsGradual transfer of self-cuing to the child and parents Relapse less likely with preschool childrenRelapse less likely with preschool children School-age children more likely to regress and may need booster sessionsSchool-age children more likely to regress and may need booster sessions