1. Welcome to Fluency Clinic!
Serving clients w Developmental Stuttering, Neurogenic Stuttering, Psychogenic Stuttering, & Cluttering

2. Use WHO-ICF to serve whole person
Describes all major structures & functions of human body
If person experiences difficulties = “impairment”
Clinical goals = reduce impact of impairment
Three Categories
Body Structure & Function
Activities & Participation
Personal & Environmental
ASHA (2001) specified our scope of practice “encompasses all components & factors in WHO framework”….we need to attend to WHO-ICF in our clinical practice!

3. Purpose of Assessment Pre- / Post-; Progress monitoring Session
Diagnosis; qualification; classify severity
Must record (video preferable!)
Fluency, Type, Duration, Tension, Rate
Inventory table
Severity
SSI-4; TOCS; other scales on tests
Session
Online data
%SS when applicable; accuracy of strategy-use
Structured (specific TX context) vs. Less structured

4. DX process similar across all ages
Intake/background/hx and Interview
Survey feelings, attitudes, beliefs
Other domains?
Describe disfluency patterns

5. Intake & Interview Fluency intake form (case history form) Interviews
HX of stuttering
Age on onset; In what situation was first noticed? Who noticed?
What was child’s speech like when first noticed? (give examples for easy ); Has frequency & type changed over time?
Family hx of stuttering? Who?
…..
Interviews
Client interview
Family interview (CWS’s cgs; PWS’s partnere)
Teacher survey

6. Feelings, attitudes, beliefs
Client
KiddyCAT (Vanryckeghem, Brutten, & Hernandez, 2005)
CAT; Communication Attitudes Test (Brutten & Dunham, 1989)
OASES; Overall Assessment of the Speaker’s Experience of Stuttering (Yaruss & Quesal, 2010)
A-19 Scale (Guitar & Grims, 1977)
Erickson S-24 Scale of Communication Attitudes (Andrews & Cutler, 1974)
Parent, family
ISPP; Impact of Stuttering on Preschoolers & Parents (Langevin, Packman, & Onslow, 2010)
Teacher, colleague
TASCC; Teacher Assessment of Student Communicative Competence (Smith, McCauley, & Guitar, 2000)

7. Other factors Hearing screening Oral motor Voice quality
Physical development
Social/emotional development
Cognitive development
Speech production; Phonology
Language

8. Describe pattern of disfluencies
Overall severity
Frequency (%SS)
Inventory & pattern
Tension
Rate of speech
Naturalness
What tools can you use to fulfill each of these diagnostic categories?

9. Starting treatment… Some of our resources: Guitar, 2014
Yairi & Seery, 2015
Guitar & McCauley, 2010
Zebrowski & Kelly, 2002
Chmela & Reardon, 2001

10. Two overarching goals of therapy Fanning, 1997
Awareness
Muscle Control
(tension management)

11. Let’s use strategies All about using a stretched speech sound!
Almost all strategies can be reduced to the single skill of being able to stretch a sound….!

12. Let’s use strategies Fluency Shaping Stuttering Modification
Single stretch
Slowed rate
Prolonged speech
Pause/chunk
Breath management
Conceptual Term: Controlled Fluency
Stuttering Modification
Cancellation
Full version
Reduced version (“easy redo”)
Pullout
Preparatory set
Pseudostuttering
Conceptual Terms: Open stuttering; Acceptable Stuttering

13. Across tx: Shared components
Positive therapy environment
Client motivation (look forward to thx time)
Client & family time (home program)
Family education, support, & data
Structured generalization, transfer, & maintenance
Hierarchical progression across targets

14. Across tx: Shared client goals
Decrease frequency of stuttering behaviors
Decrease tension related to stuttering
Increase client’s confidence as competent communicator
Increase client’s quality of life

15. Across tx: Shared clinician goals
Systematic criteria for moving forward with hierarchies
Data to inform tx decisions
Data from clinician (PBE)
Data from family (rating scales; observations)
Strong rapport w client & family
specialized coach vs lofty expert
Collaborate w all involved parties for maximum generalization
Even if simply supporting family to make connections

16. Intervention approaches
Parent-directed approaches
Lidcombe (preschool & school-age)
Palin Parent-Child Interaction (PCI)
Gradual Increase in Length and Complexity (GILCU)
Integrated approach
Preschool
School-age
Adult

17. Hierarchies we manage constantly
Linguistic (short to long; simple to complex)
Rate of speech (slow to fast)
Interest / excitement (low to high)
Modality / context
read, converse, monologue, picture descrip
narrative, expository
Sound / word (easy to hard sounds & words)
Settings / people (1:1; familiar to unfamiliar)
Cueing / support (max to min)
multisensory to visual cue
Independent use of cog org

18. Cognitive Behavioral Therapy (CBT)
Cognitive restructuring & desensitization
Towards reality: self-talk; self-perception messages
Discuss fluency barriers & related problems
PWS self-monitor w/speech journal; self-data & reflect
Role-play, discuss, reflect, plan for next
Relaxation techniques
Reflect on embarrassment & shame
Reframe trauma for deconditioning of fear reactions
PWS shares “aha moments” & new learning w/friends
Less reactive & more accepting; Reduce fears across all experiences, thoughts, perceptions
Intentionally & actively facing fears w/ positive consequences

19. Important CBT school issues
Bullying & teasing
the CBT at this level extends to peer issues
CWS needs support people readily available (peers, tchrs)
CWS needs survival routine (retort, response)
In combination w/fluency work:
assertiveness
advocacy
Teachers
need educating! Across challenge areas (p 392)
NSA, NSF pamphlets
Instruction
curriculum, testing, participation, presentation

20. Writing goals See handout w color-coded goals
Examples in WHO-ICF format

21. LTG 1 (speech fluency): CLIENT will demonstrate increased speech fluency across increasing linguistic hierarchies (e.g., …) by using an easy, relaxed approach to speech (child-labeled “…”) with 90% accuracy across 2 sessions this term amb clinician data.
STO 1.1: “Jelly Talk” Steps: Given diminishing support, CLIENT will use the following two-step approach to “easy talk”: 1) take a breath, 2) use a modified speaking pattern with 90% accuracy during structured activities in the clinic setting.
STO 1.2: Strategy Use: Given diminishing cues, CLIENT will demonstrate increased fluency by using preventive “easy talk” for utterances of 5-12 syllables during structured activities with 90% accuracy.
STO 1.3: Strategy Use: Given diminishing cues, CLIENT will demonstrate increased fluency by using preventive “easy talk” for utterances of syllables during structured activities with 90% accuracy.

22. LTG 1 (fluency strategy): CLIENT will demonstrate increased “controlled fluency” by using a variety of fluency enhancing strategies (e.g., …) to manage tension across tension events (….) in 9 out of 10 instances (…) with diminishing support across structured tasks (….) over two session probes in multiple settings (…).
STO 1.1 (controlled fluency): Given spontaneous non-structured speaking tasks, CLIENT will demonstrate independent “controlled fluency” (i.e., any combination of strategies: preparatory sets, cancellations, pull-outs, initial-word stretch, prolonged speech) across settings (people, café) as measured by >98% fluency.
STO 1.2 (pseudostuttering): Given spontaneous non-structured speaking tasks, CLIENT will demonstrate adept independent use of pseudostuttering and subsequent modification strategy (during, after) across settings (people, café) as measured by 95% accuracy.

23. Strategy Accuracy by cues
Linguistic Level
Strategy Accuracy by cues
Fluency rating
(1=low; 5=high)
Interest rating
Independent
( )
Minimum Cues
( Visual only )
Maximum Cues
(Verbal + Visual; Verbal)
No strategy
(— )
1 – 5 syll
6 – 10 syll
11 – 15 syll
16 – 20 syll
10 – 20 sec
21 – 30 sec

24. Strategy use Linguistic level (# syllables) Max cues Min cues No strat
fluency   /  /  
Strategy use
Fluency rating
(1=low; 5=high)
Interest rating
Indep
Max cues
(V+Vb; Vb)
Min cues
(V only)
No strat