Diagnosing and Treating Fluency Disorders in the Schools€¦ · Diagnosing and Treating Fluency...

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DiagnosingandTreatingFluencyDisordersintheSchools

LonnieG.Harris,Ph.D.,[email protected]

Disclosure

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Dr.Harrisreceivesnofinancialornon-financialbenefitbydiscussinganyproductsorprogramsduring

thisworkshop.

1.  PreschoolScreenerforDifferentiatingDevelopmentalDisfluenciesfromIncipientStuttering

2.  FluencyMatrix(RatingScale)

3.  TestofChildhoodStuttering(TOCS)4.  TeacherInterview:Fluency

5.  FluencyAssessmentSummary

6.  GILCUSequence

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Handouts SeeHANDOUT:

• TitleofHandoutinYourPacket

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1.  TipsforTeachers2.  FluencyFAQs3.  ClinicalCompetenciesforFluencyAssessmentandTreatment4.  FluencyAssessments5.  A-19Scale6.  ClutteringQuickScreen7.  HierarchyNumberLine8.  Similarities&DifferencesofFluencyShaping&StutteringModification9.  FluencyShapingStrategies10. TheBeachclozeactivity11.  Christmasclozeactivity12.  OrderofSoundsforEasyStarts13.  StutteringModificationStrategies14. WritingFluencyGoals15.  FiveMythsaboutBullies

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Handouts SeeELECTRONICHANDOUT:

• TitleofHandout

Whatcausesstu*ering?

BasicAssessmentGuideline

StandardizedTests

ThePreschoolScreener

TheFluencyMatrix(Ra6ngScale)

TheTeacherInterview

TheFluencyAssessmentSummary

Educa:onalRelevance5

TopicsCovered

Contextualvs.noncontextualspeech

Treatmentstrategies

FluencyShaping

Stu@eringModifica6on

DeterminingifProgressisBeingMade

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TopicsCovered

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KeyReminder

FluencyShaping

Stu*eringModifica:on

AddressingAJtudes

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TopicsCovered

1.Explainthecausesofstu*eringtoaparentorteacher.

2.Differen:atedevelopmentaldisfluenciesfromincipientstu*ering.

3.DemonstrateuseofavarietyofFSandSMtherapytechniques.

4.Writemeasureablefluencygoalsandobjec:ves.

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LearnerOutcomes

InteractiveWorkshop

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•  Research*showsthatparticipantsinaninteractiveworkshopremainmoreengagedinthetopicandretainmoreinformationcomparedtotraditionallecture-typeworkshops.

•  YourPowerPointhandoutwillhavewordsorphrasesmissingfromtheslides.Ablankwillappearintheplaceofwords.Themissingwordswillappearontheslideshighlightedinboldcolorsoyoucaneasilycompleteyourhandout.

•  Ifthereisn’tenoughroomtowritethewordsintheblanks,justusethelinedsectionsonthehandout.

*Skrabut,Stan(May5,2012).Engagingparticipantsthroughinteractiveactivities.TubarksWeekly.

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Whatcausesstuttering?

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GeneticEtiology

EnvironmentalEtiology


1.  Evidencethatstutteringisinheritedandismorelikelytooccurinboys.

2.  Identicaltwinshaveconcordancerateof60%,meaningthatifonetwinstutters,his/heridenticaltwinhasa60%chanceofstutteringatsomepoint. [Concordancediscussedonnextslide].

3.  Fraternaltwinshaveconcordancerateof20-26%,meaningthatifonetwinstutters,his/herfraternaltwinhasa20-26%chanceofstutteringatsomepoint.

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Whatcausesstuttering?GeneticEtiology

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Concordancestudiesareoftenconductedtoexaminetraitsintwins.

Itreferstotheprobabilitythatthepairwillhaveacertaincharacteristicifoneofthepair

hasthecharacteristic.

So,twinsareconcordantwhentheybothhave(orbothlack)agiventrait. 13

Whatcausesstuttering?GeneticEtiology

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GeneticEtiology



1.  Considercaseofadoptedchild.

2.  Others’reactions(particularlyfamilymembers).

3.  Stressfulspeakingsituations.

4.  Lifeeventsthataretraumatic.

15 SeeELECTRONICHANDOUTS:• TipsforTeachers• FluencyFAQs

Whatcausesstuttering?EnvironmentalEtiology

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GeneticEtiology







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LearnerOutcomes

CanStutteringBeCured?

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HavingaCure

•  Referstoanapproachorapplica:on.•  Thereiscurrentlynocureforcancer.

•  Thereisnocureforstu*ering.

BeingCured

•  Referstoanoveralloutcome.•  Manyhavebeencuredforcancer.

•  Stu*eringcanbecuredwiththerapy.


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•  StutteringCANbecured,bothwithandwithouttherapy.

•  Fluency“cures”refertonomorestutteringandnomemoryofstuttering.

•  Curesarecommoninyoungchildrenwhostutter,eventhosewhohavebeenintherapyforayearorso.

•  Ihaveevenseenafewcomplete“cures”inadultswhohavestutteredformanyyears.

ExplainingtheConceptofCurestoParents


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•  Nevertellclientsthatstutteringcategoricallycannotbecuredbecausewhoarewetoknowthefutureforeverysingleclient?

•  Itisappropriatetotellthethatcomplete“cures”arerareinchildrenandevenrarerinadults.

•  Letclientsknowthatitispossibletostillstutteronceinawhileandbasicallybestutter-freeortostutterlessfrequentlywithgoodmanagementstrategies(includingacceptanceofstuttering)whereinstutteringfadestothebackgroundofone’slife.

SuggestionstoSLPs

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Assessment:BasicGuideline

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AssessmentBasicGuideline

ThereshouldbeabsolutelyNOmodeling

ofanytechniqueduringassessment.

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Assessment:ThePreschoolScreenerfordifferentiatingdevelopmentaldisfluenciesfromincipientstuttering

24 SeeHANDOUT:• PreschoolScreenerDifferentiatingDevelopmentalDisfluenciesfromIncipientStuttering

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PreschoolScreenerTypeofdisfluency

InterjectionsI–uh–wanttogo.

Whole-wordrepsIwant-want-wanttogo.

Part-wordrepsIwanttog-g-g-goProlongationsIwanttogggggo

1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal

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PreschoolScreenerSizeofSpeechUnitAffected

SENTENCEI–wanttogo–Iwanttogo.PHRASEI–want–Iwant–Iwanttogo.

WORDIwant-want-wanttogo.

SYLLABLEIwa-wa-wanttogo.SOUNDIwanttog-g-g-g-go.


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PreschoolScreenerFrequencyofRepetitions

<2%

2%-5%

>5%


•  TheRepetitioncountincludesalltypes,fromsentencerepstosoundrepetitions.•  Wearecalculatingthepercentageofrepetitionsinoverallspeech.

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PreschoolScreenerFrequencyofProlongations

<1%

1%orgreater

1–ProbablyNormal 3–ProbablyAbnormal

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PreschoolScreenerFrequencyofOverallDisfluencies

<5%

5%-10%

>10%


•  Thedisfluencycountincludesalltypesofdisfluencies,includinginterjections.•  Wearecalculatingthepercentageofdisfluenciesinoverallspeech.

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PreschoolScreenerTypicalNumberofReiterationsperRepetition

<2I–Iwanttogo.

3–4I–I–I–Iwanttogo.

>4I–I–I–I–I–Iwanttogo.


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PreschoolScreenerAverageDurationofProlongations

<1second

1secondormore


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PreschoolScreenerAudibleEffort

Noneobserved

ObservedHardglottalattacksVocaltensionDisruptedairflowPitchrise


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PreschoolScreenerRhythm/Tempo/Speed

Slow/normalEvenlypaced

FastIrregular


•  Don’tconfusearapidratewithcluttering,whichhasacompletelydifferentdiagnosticprotocol.

33 SeeELECTRONICHANDOUT:• ClutteringQuickScreen

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PreschoolScreenerSchwaReplacement

Notobservedta-ta-tableda-da-da-daddy

Observedtuh-tuh-tableduh-duh-duh-daddy


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PreschoolScreenerAudibleLearnedBehaviors

Notobserved

ObservedCircumlocutionsAvoidancetacticsStarters


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PreschoolScreenerVisualEvidence

Notobserved

ObservedFacialGrimacingArticulationposturingHeadmovementsBodymovements


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13–16

17–21

22-39


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PreschoolScreenerScoreInterpretation

•  YouMAYreferfortestinginthe17–21therange.•  YouMUSTreferfortestinginthe22–39range.

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LearnerOutcomes

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Assessment:TheFluencyMatrix(RatingScale)

40 SeeHANDOUT:• FluencyMatrix(RatingScale)

•  Frequencyofdysfluencies

•  Type(s)ofdysfluencies

•  Phonatoryarrests&sustainedarticulatorypostures

•  Speechsoundprolongations

•  Schwareplacement

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AssessmentFluencyMatrix

•  Physicalconcomitants

•  Awarenessandemotionalreactions

•  Avoidancebehaviorsandpeerreactions

•  Adverseeffectoneducationalperformance

•  Fluencyrating

1.  PreschoolScreener–Useonlyforveryyoungchildrena.  IfFrequencyofOverallDisfluencies:>10%b.  “ProbablyAbnormal”(maynotspontaneouslyabate)

2.  FluencyMatrix/RatingScalea.  OverallSS/M:8-15%-moderateb.  Greaterthan15%-severe

3.  Researcha.   OverallSS/M:8%★ ★ ★ ★b.  Yairi&Ambrose,1999|Pellowski&Conture,2002

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AssessmentMakingSenseoftheNumbers

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1.  AssessmentofStutteringBehaviors

2.  StutteringPredictionInstrument(SPI)

3.  StutteringSeverityInstrument4(SSI-4)

4.  TestofChildhoodStuttering(TOCS)[Moreinformationlater]

5.  OverallAssessmentoftheSpeaker’sExperienceofStuttering(OASES)

6.  Cognitive,Affective,Linguistic,Motor,andSocialAssessmentModel(CALMS)

7.  AssessmentoftheChild’sAssessmentofStuttering(ACES)

8.  A19-PointScaleforChildrenWhoStutter

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AssessmentStandardizedTests

SeeELECTRONICHANDOUT:• FluencyAssessments

SeeELECTRONICHANDOUT:• ClinicalCompetenciesforFluencyAssessmentandTreatment

SeeELECTRONICHANDOUT:• A-19Scale

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The$mean$score$of$K.4th$graders$is$9.07$(S.D.=2.44)$for$children$who$stutter.$$For$children$who$do$not$stutter,$the$mean$score$is$8.17$(S.D.=1.8).$

Name:$_____________________________$ Date:$_______________$

A!19#Scale"I$am$going$to$ask$you$a$few$questions.$$Listen$carefully$and$tell$me$what$you$think.$$Just$tell$me$Yes$or$No.$$There$are$no$right$or$wrong$answers.$$I$just$want$to$know$what$you$think.$$1. Is$it$best$to$keep$your$mouth$shut$when$you$are$in$trouble?$ Yes$ No$

2. When$the$teacher$calls$on$you,$do$you$get$nervous?$ Yes$ No$

3. Do$you$ask$a$lot$of$questions$in$class?$$ Yes$ No$

4. Do$you$like$to$talk$on$the$phone?$$ Yes$ No$

5. If$you$did$not$know$a$person,$would$you$tell$you$name?$$ Yes$ No$

6. Is$it$hard$to$talk$to$your$teacher?$$ Yes$ No$

7. Would$you$go$up$to$a$new$boy$or$girl$in$your$class?$$ Yes$ No$

8. Is$it$hard$to$keep$control$of$your$voice$when$talking?$$ Yes$ No$

9. Even$when$you$know$the$right$answer,$are$you$afraid$to$say$it?$$ Yes$ No$

10. Do$you$like$to$tell$other$children$what$to$do?$$ Yes$ No$

11. Is$it$fun$to$talk$to$your$dad?$ Yes$ No$

12. Do$you$like$to$tell$stories$to$your$classmates?$$ Yes$ No$

13. Do$you$wish$you$could$say$things$as$clearly$as$the$other$kids$do?$$ Yes$ No$

14. Would$you$rather$look$at$a$comic$book$than$talk$to$a$friend?$$ Yes$ No$

15. Are$you$upset$when$someone$interrupts$you?$$ Yes$ No$

16. When$you$want$to$say$something,$do$you$jus$say$it?$$ Yes$ No$

17. Is$talking$to$your$friends$more$fun$that$playing$by$yourself?$$ Yes$ No$

18. Are$you$sometimes$unhappy?$$ Yes$ No$

19. Are$you$a$little$afraid$to$talk$on$the$phone?$$ Yes$ No$$$A$score$of$14$pts.$Is$1½$standard$deviations$below$the$mean$and$suggests$negative$attitudes$toward$communication.$$Stuttering$modification$therapy$may$be$a$viable$option$for$treatment.$$A$score$below$14$pts.$suggests$that$fluency$shaping$therapy$may$be$a$more$appropriate$way$to$begin$treatment.$$Total:$_______$ $Stuttering$Modification$ $Fluency$Shaping$$$The$clinical$decision$for$therapy$approach$should$take$into$account$the$A.19$score$and$all$other$diagnostic$information,$including$trial$therapy.$

1.  Testisnormedfrom4-12,butcanbeadministeredtochildreninthe2-6agerangeandresultscanbecomparedtothePreschoolScreener.

2.  Onlythefirst3wordsofanutterancearescored.

3.  Rapidpicturenamingtestsachildunderpressure.

4. Modeledspeech,structuredconversation,andnarrationareexamined.

5.  Thenormativedata(stats)arecorrect(notbackwardsastheSSI-4).

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AssessmentTestofChildhoodStuttering

SeeHANDOUT:• TestofChildhoodStuttering(TOCS)

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Assessment:TheTeacherInterview

46 SeeHANDOUT:• TeacherInterview:Fluency

•  Interpretresultsfromeachinterview.Ifchildhasmorethanoneteacher,usemostcommonratings.

•  ScoreTeacherInterviewontheFluencyMatrixunder“AdverseEffect.”

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AssessmentTeacherInterview

Assessment:TheFluencyAssessmentSummary 48 SeeHANDOUT:

• FluencyAssessmentSummary

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• Behavioralcomponents•  Thesecomponentscompriseobservedstutteredbehaviors•  Physicalconcomitantsareincludedinthissection.

• Affectivecomponents•  Student’sawarenesstohis/herstuttering•  Student’sreactiontohis/herstuttering

• Cognitivecomponents•  Avoidancebehaviors•  Peerreactionstostudent’sstuttering

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AssessmentFluencyAssessmentSummary

Assessment:EducationalRelevance(AdverseEffect)

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•  EducationallyRelevantisaphrasethatcomesfromIDEA1997andhasbeeninterpretedinmanydifferentways,mostofwhichdonotaccuratelyreflecttheintentofthelaw.

•  Thetermmeansthatgoalsmustaddressareasofimportanceintheacademicsetting.Thisdoesnotmean,however,thatgoalsmustfocussolelyonacademicissues.

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AssessmentEducationalRelevance

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•  Child#1stu,ersinfrequently,butrefusestoreadaloudinclassorrespondwhencalledoninclass.

•  Lowlevelofobservablebehaviors

•  Veryhigheduca:onalimpact

•  Child#2stu,ersfrequently,butreadsaloudinclassandiswillingtobecalledonbytheteacher.

•  Highlevelofobservablebehaviors

•  Lesseduca:onalimpact


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Toprovideabe*erdefini:onofeduca6onallyrelevant,wemust

rememberthatouroverallobjec?veintherapyistosupportthechild’scommunica?onsuccessesinthe

academicseBng.

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UsingHierarchies

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Representthehierarchyvisuallyinsomeway.

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HierarchiesCreatingHierarchies

SeeELECTRONICHANDOUT:• HierarchyNumberLine

Feelings Date:_____________________L J

1----------------2----------------3----------------4----------------5----------------6----------------7----------------8----------------9L J Speech

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Name:_______________________________________

Feelings Date:_____________________L J

1----------------2----------------3----------------4----------------5----------------6----------------7----------------8----------------9L J Speech

Feelings Date:_____________________L J

1----------------2----------------3----------------4----------------5----------------6----------------7----------------8----------------9L J Speech

Feelings Date:_____________________L J

1----------------2----------------3----------------4----------------5----------------6----------------7----------------8----------------9L J Speech

Feelings Date:_____________________L J

1----------------2----------------3----------------4----------------5----------------6----------------7----------------8----------------9L J Speech

Treatment:Contextualvs.NoncontextualSpeech 57

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Namingobjects

ShortPhraseresponse

Tellingastoryaboutapicture

Rela:nginforma:on

Answeringques:ons

Givinginstruc:ons

Contextual

Noncontextual

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TreatmentContextualvs.NoncontextualSpeech

•  Contextualspeechprovidesthechildwithvisualaidsthatcanbeusedtolimitspeakingdemands.

•  Forthisreason,askingthechildtodescribespeechs:muluspicturesmaynotresultinsa:sfactoryspeechsamplesbecausetheremaybeexcessivepoin?ngoruseofemptydescrip:vewords,suchasthisorthat.

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•  Badgeringorshortques:on-answerexchanges(e.g.,“What’sthis?”)shouldtypicallybeavoidedbecausetheyoaencausethechildtowithdraw.

•  Trytellingthechildwhattodoinsteadofaskinghimtoques:ons.

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Treatment:FluencyShapingvs.StutteringModification

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FluencyShaping•  Lessa*en:ontoreduc:onoffearandavoidance.

•  Therapyfocusesoncondi:oningandprogrammingprinciples

•  Morestructuredprogramsavailable,solessplanningneeded.

Stu*eringModifica:on•  Considerablea*en:ontoreduc:onoffear&avoidance.

•  Therapyfocusesonteaching/counselinginterac:on.

•  Therapyisunstructuredandlessdatacollectedformeasuringprogress.

TreatmentComparingtheTwoApproaches

SeeELECTRONICHANDOUT:• Similarities&DifferencesofFSandSM

5-pagehandoutcoveringoverviewofFluencyShapingandStu@eringModifica6on,aswellascombiningapproachesandwhentochangeapproaches.

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*Adaptedfrom:Guitar,B.andPeters,T.J.(2013).Stuttering:anIntegrationofContemporaryTherapies.Memphis,TN:TheStutteringFoundation.

SimilaritiesandDifferencesofStutteringModification&FluencyShapingTherapies*

FLUENCYSHAPINGTHERAPY

TherapyGoals

• Littleattentiongiventoreductionofspeech

fearsandavoidancebehaviors.

• Developmentofspontaneousorcontrolled

fluency.Clienttaughtstutter-freespeechin

clinicalandoutsidesituations.

• Maintenanceoffluencybymodifyingthe

mannerofspeakingand,ifnecessary,the

reinstatementoffluencybyrecyclingthrough

originalprogram.Managementof

contingenciesforstutteringandfluency.

ClinicalProcedures

• Therapystructureischaracterizedby

conditioningandprogrammingprinciples.

• Datacollectionintermsofobjectivedata

regardingclient’sspeech.

STUTTERINGMODIFICATIONTHERAPY

TherapyGoals

• Considerableattentiongiventoreductionof

speechfearsandavoidancebehaviors.

• Developmentofspontaneousfluency,

controlledfluency,oracceptablestuttering.

• Maintenanceoffluencybymaintaining

reductionoffearsandavoidancebehaviors.

Useofvarioustechniquestomodify

stuttering.

ClinicalProcedures

• Therapystructureischaracterizedbya

teaching/counselinginteraction.

• Datacollectionintermsofglobalimpression

ofclient’sstutteringproblem.

ProsandConsClient–PRO Client–CON

�Doesnotrequire �Needstoconfrontspeakingin andperformfear-

abnormalpattern. producingtasks.

Clinician–PRO Clinician–CON

�Therapytendsto �Therapyisbemorespon- nonstructured,and

taneousand moredifficult

enjoyable. decisionsneedtobe

made.

�Lessdatacollectedformeasuringprogress.

ProsandConsClient–PRO Client–CON

�Lessneedto �Mayrequirespeaking

confrontand inabnormalpatternfor

performfear- aperiodoftime.

producingtasks.

Clinician–PRO Clinician–CON

�Morestructured �Therapycanbeboring.programsavailable,

thuslessplanning

needed.

�Moredatakept �Morechartingofdata

keptformeasuring needed.

progress.

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CHANGINGAPPROACHESCHANGINGFROMASTUTTERINGMODIFICATIONAPPROACH

• Themostcommonproblemwithclientsinthestutteringmodificationtherapyprogramistheirresistanceinconfrontingtheirspeechfears.ThisisusuallymanifestedbythePWSeitherquittingtherapyorbyonlytokeninvolvementinthetherapyprocess.

• ItisimportanttoexplaintothePWSthatthisnewapproachwillwhittleawayathisspeechfearsinlittlesteps.Inthelongrun,hewillgettothesameplace,butwilltakeadifferentroute.

• Atthispoint,therapywillchangethefocustoaslowprolongedspeechprogramandworkupthroughahierarchy.

CHANGINGFROMAFLUENCYSHAPINGAPPROACHThemostfrequentproblemswithfluencyshapingprogramsarethattheyfailinthelaterstagesofgeneralizationorinthemaintenanceoffluency.Theproblemsseemtobeoftwotypes.

• ThefirstisthatthePWSstillhasconsiderablefearofcertainspeakingsituations,despitethefactthattheyhavealreadybeenapproachedthroughagradedhierarchyofsuccessivelymorefearfulsituations.Whenheapproachesthesesituations,hisfearbecomestoogreatandheisunabletomaintainfluency.

• ThesecondproblemisthatthePWSdoesnothaveanycopingtechniquestodealwithanticipatedoractualstutteringineverydayspeakingsituations.Hecanbeeitherfluentorhewillstutter.Hehasnowaytodealwithhismomentsofstuttering.

Treatment:FluencyShapingStrategies

65 SeeELECTRONICHANDOUT:• FluencyShapingStrategies

Reducethefrequencyofstutteredbehaviorswithoutincreasingtheuseofotherbehaviorsthatarenotpartofnormalspeechproduction.

•  Reducedspeechrate(ifrateisanissue)•  Easyonsetofvoicing(“easyspeech”)•  LightArticulatoryContact•  Continuousphonation•  Confidentialvoice•  Pausing/Phrasing/Chunking•  GILCU/ELU •  Eyecontact

FluencyShaping

66 SeeELECTRONICHANDOUTS:• BeachClozeActivity• ChristmasClozeActivity

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Fill in the blanks below with words from this box:

starfish shells waves surfing

volleyball sandcastle swimming

shore

suntan sunburn

snorkeling blanket escape

skin sunscreen

rays

beach sandy

summer towel

parasol breeze

driftwood

Going to the Beach One of the best ways to _____________ the heat of the ___________ months is to head down to the ____________. You can lie down in a soft __________ spot and feel the cool _____________ off of the ocean.

Sun Tanning A lot of people try to get a _____________ at the beach. To do this, they lie down on a _____________ and expose their _______________ to the sun’s _________________. After a while their skin turns brown. However, if they stay in the sun too long their skin turns red and they get a _____________. To prevent this, sunbathers should always put ________________ on their skin. To stay out of the sun many beachgoers use a ______________, which is a giant beach umbrella.

Beachcombing At the beach, it’s fun to search for things that wash up on the _____________. There are often brightly colored _______________ and crabs among the seaweed and ______________. There are also many curly ______________, which children like to collect.

Beach Activities To cool off, many people go ______________. And if the _____________ are high, some people even try _______________. Or, if there is a lot of interesting sea life, people can put on a mask and go _________________. When they are done in the water, they can use a _____________ to dry off and then build a ________________ in the sand or play beach _________________.

© 2006 www.bogglesworldesl.com

1.  Purpose:Toteachthespeakertobeincontrolofhisspeech.[Comparetodriving&skating]

167[Fluent]vs.123[PWS]WPM(Darley,1940)

2.  Method:a.  Speechshouldbeslowedtoabout1syllablepersecond(for

olderchildren)or2-3syllablespersecond(forveryyoungchildren).

b.   Graduallyincreaseratetothepointwherestudentisusingaroughlynormalspeakingrate,butstillmaintainingfluentspeech.

ReducedSpeechRate

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1.  Usedtotreatphonatoryarrests.

2.  Purpose:Tostartoutspeakingwithlessphysicaltensioninthespeechsothestudentcanstartasentencea“littleeasier.”

3.  Method: a.  Slightlyreducetherateofspeechandreducethephysical

tensioninthespeechmuscleswhenbeginningasentence.

b.  Graduallymoveintotherestofthesentenceusingregularspeech.

c.  Easystartscanbeusedasoftenasthestudentneedsinordertomanagehisspeech.

EasyOnsetofVoicing

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Whichspeechsoundsshouldbetaughtfirstwhenintroducing

EasyStarts?

EasyOnsetofVoicing

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1.  Nasals2.  Glides3.  Liquids

4.  Fricatives5.   Plosives

6.  Vowels

EasyOnsetofVoicing

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SeeELECTRONICHANDOUT:• OrderofSoundsforEasyStarts

•  First introduce Easy Onset with sounds that are easy to use with continuous airflow or movement.

•  Move to sounds that have some obstruction or stoppage of airflow. Affricates aren’t targeted, but they can be used as a bridge.

•  Introduce LAST because they are often initiated with a glottal stop.

1.  Usedtotreatsustainedarticulatorypostures.

2.  Purpose:Totouchpartsofthe“speechmachine”togethersoftlywithlessphysicaltensionsothestudentcankeephisspeechmoving.Thishelpschildproduceplosives.

3.  Method:a.  Lightcontactinvolvesusingsofterorlightertouchesofthe

articulators.

b.  Asthestudentisproducingasound,heneedstoberemindedtosimplytouchthearticulatorswithlesstensionbylightlytappingthearticulatorstogether.

c.  Trystartingwithplacementonlyandthenaddvoicing.Goodtousewith/m/,/t/,/f/andothervisiblephonemes.

LightArticulatoryContact

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1.  Purpose:Toreducethelikelihoodthattherewillbea“block”becausethecontinuousairflowenhancessmootherspeech.

2.  Method:a.  Speechshouldhavecontinuousvoicingexceptwhena

pauseisnecessarytotakeabreathorforlinguisticstress.

b.  Maintainnormalrateandprosodywhileusingcontinuousphonation.

c.  Slightlystretchthefirstsoundinthesentence.d.  Whenrecordingdatainatherapysession,fluent

speechthatisnotproducedwithcontinuousphonationisconsideredincorrect.

ContinuousPhonation

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1.  Purpose:Toreducethelikelihoodthattherewillbea“block”becausethecontinuousairflowenhancessmootherspeech.[SameasContinuousPhonation]

2.  Method:a.  Repeattheconfidentialvoicemodeltobesurethe

studentunderstandshowtoproduceit(asifnotwantingtowakeasleepingpersonnearby).

b.  Thetemporaryuseoftheconfidentialvoiceisexplained.Thisisusuallyafewweeks,butshouldbeuseduntiltheeffortfulvoiceisnolongerused.

c.  Establishtimeswhentheconfidentialvoicecanbepracticedwhilereading.

ConfidentialVoice

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3.  AdditionalInformation:a.  Thistechniquecanbeusedanytimetohelpthestudent

regaincontrolofhisspeech.

b.  AwhispershouldNEVERbeused.

c.  Researchhasfoundthat68%ofindividualswhowhisperdemonstrateincreasedhyperfunctionwithwhisperedvoice.

Rubin,AD,Praneetvatakul,V,Gherson,S,Moyer,CA,&Sataloff,RT.(2006)Laryngealhyperfunctionduringwhispering:realityormyth?JournalofVoice.20(1),121-127.

ConfidentialVoice

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1.   Phrasingsimplymeanssayingwordsthatgrouptogethernaturally.

2.   Pausingmeansleavingalittlebitoftimebetweenthosephrases(aswithcontinuousphonation).Thisalsohelpswithrate.

3.  Purpose:Allowsshortpausesinthespeechatnaturalpointswithintheconversation(e.g.,betweenphrasesorbreaths).Thisshouldbeusedwheneverstudentwantstoreducehowfasttheconversationisgoingsohehasmoretimetothinkaboutwhathewantstosayortopreparetouseothertechniques.

Phrasing/Pausing

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3.  Method:a.  Studentshouldspeakashewouldnormally.

b.  Whenhecomestotheendofaphrase,heshoulduseashortpause—aslongasheneeds,butnottoolong—andthencon:nuetothenextphrase.

c.  Duringthepause,hecanpreparetouseaneasystartorlightcontacttohelpreducetensioninthespeechmusclesbeforecontinuingtospeak.

Phrasing/Pausing

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1.  GILCU=GradualIncreaseinLengthandComplexityofUtterance.ELU=ExtendedLengthofUtterance.

2.  Purpose:Toenhancefluencyinahighlystructuredwayfromsinglewordstoconversation.

3.  Method:a.  Studentrepeatssinglewordsafteryou.Thenmoveto2

words,3words,4words,(5words),(6words).

b.  Studentrepeatssinglesentences.Then2sentences,3sentences,(4sentences).

GILCU/ELU

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3.  Method(cont.):a.  Studentreadssinglesentence.Then2sentences,3

sentences,(4sentences).

b.  StudentspeakswithSLPintherapyroominshortphrasesandthenprogressestolongerutteranceandconversation.

4.  AdditionalInformation:a.  Thisapproachallowsthestudenttobecomevery

awareofhisspeechearlyon.

b.  ThistechniqueMUSTbeusedwithContinuousPhonation.

GILCU/ELU

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1.  Purpose:Tolookatthelistenerduringconversation,aspartofnormalinterpersonalskills.

2.  Method:a.  Usinggoodeyecontactsimplymeansthatthestudent

looksatthelistenerwhenheisspeaking,orthathelooksatspeakerswhentheyaretalkingtohim.

b.  Thestudentcannotlookatpeopleallthetime,buthemaywanttomakesurethathedoesn’tletfearaboutstutteringcausehimtolookawaywhenspeaking.

c.  Heshouldstartoutbyusingeyecontactduringtimeswhenheisspeakingeasilyandthengraduallymovetowardmaintainingeyecontactduringmomentsofstuttering.

EyeContact

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Treatment:StutteringModificationStrategies

81 SeeELECTRONICHANDOUT:• StutteringModificationStrategies

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Reducetheseverity,duration,andabnormalityofstutteringbehaviorsuntiltheyare(orresemble)normalspeechdiscontinuities.

•  Cancellation(post-eventmodification)•  Pull-out(within-eventmodification)•  Preparatoryset(pre-eventmodification)

StutteringModification

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WhenShouldStutteringModificationbeImplemented?àWhenthefollowingareobservedorreportedbyPWS:

1.  Struggleand/ortension2.  Anticipationofstutteringevents.3.  Avoidance,suchascircumlocutions,situation

avoidances,orsimplynottalking4.  Fearoftalking5.   Linguisticsecondarybehaviorsareobserved,suchas

fillers(um),starters(Well,youknow),postponements(delayinsayingawordtodelaystuttering)

StutteringModification

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1.  Purpose:Takecontroloftensionafteramomentofstuttering.

2.  Method:Afterthestutteredword:a.   Pauselongenoughtofigureoutwherethetensionis.

b.   Releasethetensioninthespeechmuscles.

c.  Startthewordagainwithaneasystartoraneasystutter.DoNOTgobacktothebeginningoftheutterance.

d.  Studentcanstartpracticingthisinshortconversations,thengraduallymovetowardusingcancellationsinmorechallengingsituations.

Cancellation

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1.  Alsocalledslide-outoreasingout.

2.  Purpose:Toreleasetensionduringamomentofstuttering,theneasingintotherestofthewordorphrase.

3.  Method:a.   Identifywherethetensionisinthespeechmuscles.

b.   Reducethephysicaltensionalittlebitatatime.

c.  Continuespeakingtosaythewordandmoveontotherestofthephrase.

Pull-Out

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1.  Purpose:Usedatthebeginningofawordwherethestudentthinksheislikelytostutter.

2.  Method:a.  Speaknormally(withoutmodification)untilhefeelsthat

heiscomingtoawordwherehewillexperiencetension…andmostprobablydisfluentspeech.

b.  Beginthewordwithaneasystart(toreducephysicaltension)insteadoftensingmuscles.Anycombina:onoftechniquesusedforFluencyShapingcanbeusedhere.

PreparatorySet

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4.  Benefits:a.  Helpsreducethetensionandincreasefluencybeforethe

momentofstuttering.

b.  Mostappropriateforindividualswhodemonstrateanticipationofstutteredmoments.

5.  AdditionalInformation:a.  Easinginworkstogetherwithotherstutteringmodification

techniques(cancellationsandpull-outs)toprovidethestudentwiththreeopportunitiestochangethetensioninhisspeechmuscleswhenheexperiencesamomentofstuttering.Useinreverseorder.

b.  UseANYstrategytomaintaincontrolofthespeechasheanticipatesadisfluency.

PreparatorySet

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DeterminingifProgressisBeingMade

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•  Durationofstutteringmomentsareshorter.•  Articulatoryorlaryngealtensionisreduced.•  Secondarybehaviorsarereduced/eliminated.

•  Changesinprimarystuttering(e.g.,blocksarereplacedbyeasierprolongationsorrepetitions).

•  Frequencyofprimary/secondarystutteringisreduced.•  Increasedtalkingandrisktaking.•  Increasedfeelingsofself-worth.

•  Mayshowanincreaseinstutteringfrequency,butitwillultimatelydecrease.

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Progressisdeterminedwhen…





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LearnerOutcomes

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ProvideSupportforthePWSandFamily

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Provideinformationandguidanceto

clients,families,andothersignificantpersonsaboutthenatureofstuttering,normalfluency,and

thecourseoftreatmentandprognosisforrecovery.

ProvideSupport

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ProvideSupport

www.stutteringhelp.org

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ProvideSupport

www.westutter.org

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WritingGoalsforFluencyTherapy

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•  Goalscontainseveralcomponents:

• Whatyouwantthechildtobeabletodo

•  Howoftenyouwantthechildtodoit

• Whattaskandsettingthechildwilldoitin

•  Howmuchsupportthechildwillhave

•  Goalsmustbefocusedonthestate’slearningobjectivestofacilitatethestudent’seducational,social,&vocationalendeavors.

96

WritingGoalsKeyReminders

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• MethodofmeasurementisSLPobservation,teacherobservation,&studentreport.

•  “Whatthechildwillbeabletodo”isnotthesameas“whatthechildwillalwaysdo.”

• Weshouldmeasurewhatwehaveactuallytaughtthechildtodo(techniques),nottheby-productthatwehopewillresult(fluency).

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•  “Measureable”doesnotalwaysmean“percentages.”Itisnotappropriatetoexpectachildtoachieveanarbitraryfluencycriterion.

•  Youwillnoticeintheupcomingexamplesthattheyarenotframedintermsofpercentages,suchas“80%ofthe:me.”Percentagesareactuallynotrequiredbyfederallegisla?on.[Olson,E.&Bohlman,P.(2002).IDEA’97andchildrenwhostu*er:Evalua:onandinterven:onthatleadtosuccessful,produc:velives.SeminarsinSpeechandLanguage,23,159-164].

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Whenwearewritinggoals,rememberthattheultimategoalistohelp

personswhostuttersay

whattheywantwhentheywant

Towhomtheywant

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• Rememberthatthechilddoesnotactuallyhavecontroloverwhenhe/shestu*ersandwhenhe/sheisfluent.

•  Some:mes,childrenstu*ereveniftheyuseatechniqueappropriately(theyaredoingwhatwetrainedthemtodointherapy).

• Atother:mes,theywillnotstu*erevenwhentheyforgottousetechniques(beinglucky). 100

WritingGoalsFluencyShaping

Inreality,theonlythingthechildreallyhascontroloveriswhetherhea,emptstousethetechniques

taughtintherapy.

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•  Forachildwithar:cula:onconcerns,achieving80%successisoaenviewedasasignofsuccess.

• Achildwhois80%fluentiss:llexhibi?ngstu,eringon20%ofhiswords,whichisconsideredverysevere.

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SampleAnnualGoal

In36instructionalweeks,Joséwilldemonstratetheabilitytouselearnedfluencyshapingstrategies(e.g.,continuousphonation,lightarticulatorycontacts,confidentialvoice)invariousclassroomsituations,asreportedbythechildandteacheranddocumentedbychecklistsandtargetedobservations.

103


SampleBehavioralObjective

Joséwilldemonstrateabilitytouseavarietyoffluencyshapingtechniques(continuousphonation,lightarticulatorycontacts,andconfidentialvoice[WHAT]duringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessions[HOWOFTEN]inthetherapyroom[SETTING]with1-2verbalornonverbalprompts[SUPPORT].

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Ifyourdistrictrequiresatleasttwobehavioralobjectivesundereachannualgoal,youcanspecifyonedesiredbehaviorforeachobjective:

§  Reducedspeechrate(ifrateisanissue)§  Easyonsetofvoicing(“easyspeech”)§  Reducedarticulatorypressure(lightcontacts)§  Continuousphonation§  Slightlystretchingfirstsound§  Confidentialvoice§  GILCU/ELU

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Joséwilldemonstrateabilitytousecontinuousphonationduringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessionsinthetherapyroomwithminimalverbalandnonverbalprompts.

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Joséwilldemonstrateabilitytouseeasyonsetofvoicingduringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessionsinthetherapyroomwithminimalverbalandnonverbalprompts.

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SampleAnnualGoal

In36instructionalweeks,Joséwilldemonstratetheabilitytouselearnedstutteringmodificationstrategies(e.g.,cancellations,pull-outs,reducedphysicaltension)invariousclassroomsituations,asreportedbythechildandteacheranddocumentedbychecklistsandtargetedobservations.

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WritingGoalsStutteringModification

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Joséwilldemonstrateabilitytouseavarietyofstutteringmodificationtechniques(cancellations,pull–outs)[WHAT]duringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessions[HOWOFTEN]inthetherapyroom[SETTING]with1-2verbalandnonverbalprompts[SUPPORT].

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WritingGoalsStutteringModification

SampleAnnualGoal


Sampleannualgoalsandobjectivesforfluencyshaping,stutteringmodification,andaddressing

attitudesareonanelectronichandout.

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WritingGoalsAddressingAttitudes

SeeELECTRONICHANDOUT:• WritingFluencyGoals

BulliesareaPainintheBrainByTrevorRomainFreeSpiritPublishingwww.freespirit.comIntendedaudience:Ages8-13Book-$8.95DVD-$45.00(80min.,color,animated,liveaction)

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FiveMythsAboutBulliesByTrevorRomainFreeSpiritPublishingwww.freespirit.comIntendedaudience:Ages8-13Thisisatwo-pagefreedownloadatthewebsite.

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1.  Bullieshavelowselfesteem.

2.  Onlyboysarebullies.3.  Gettingbulliedisanormal

partofgrowingup.4.  Thebestwaytohandlea

bullyisbygettingevenorfightingback.

5.  Ifyouignorethem,bullieswillgoaway.

SeeELECTRONICHANDOUT:• FiveMythsaboutBullies

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Afteryearsofbeingteasedforhisstuttering,formerChicagoBearsrunningback,AdrianPeterson,decidedonagreatonelinerasaretort:“Istutter.Sowhat?”

Hesaiditsimplyanditendedtheinstigators’pathtobullying.

Theattainmentoftheseobjectivesmaybeverifiedbybothobservationandbythechild’sself-report.

§  Self-reportcontributesvaluableinforma:ontoourdatacollec:onthatwemaynotbeabletogaininotherways.

§  S:ll,self-reportcanonlybeavalidmeansofassessingtheoutcomesoftherapyifheisawareofthegoalsoftreatmentandifhe/shefullyunderstandsthebasisforthesegoals.

§  Thechildmustbeanac?vepar?cipantintherapyandself-reportedprogressisjustanotherexampleofwhyitisimportanttoensurethatthechildunderstandsthera:onalefortherapy.

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LearnerOutcomes

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Diagnosing and Treating Fluency Disorders in the Schools€¦ · Diagnosing and Treating Fluency...

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