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Interactive Learning with Fluency Specialists

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Interactive Learning with Fluency Specialists The Center for Stuttering Therapy Stuttering Prediction Instrument (SPI) Riley,1984 Assesses history Rates child s ... – PowerPoint PPT presentation

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Title: Interactive Learning with Fluency Specialists


1
Interactive Learning with Fluency Specialists
  • The Center for Stuttering Therapy

2
Presenters
  • Mary Wallace, M.A., CCC-SLP, BCS-F
  • Patty Walton, M.A., CCC-SLP, BCS-F
  • Whitney Noven, M.S., CCC-SLP
  • Matthew Goldman, M.A., CCC-SLP
  • Bethany Tileston, M.A., CCC-SLP
  • Kailey Silliman, M.A., CCC-SLP
  • Amber Rea, B.S., Graduate Intern

3
Introduction
  • 4 General Topic Areas
  • Assessment
  • Treatment and Therapy Strategies
  • Treatment Planning
  • IEP Goal Writing and Assessing Progress
  • Breakout Sessions

4
Assessment
  • Preschool Diagnostic Guidelines
  • Early identification is critical-best prognisis
  • Differential diagnosis of typical vs. atypical
    disfluencies
  • Stuttering Prediction Instrument (SPI)
  • Danger/warning signs
  • Risk factors
  • Other indicators of concern

5
Stuttering Prediction Instrument (SPI) Riley,1984
  • Assesses history
  • Rates childs reactions to stuttering
  • Measures part word repetitions based on of RPI,
    schwa, tension and abruptness
  • Measures prolongations based on duration,
    phonatory arrest and articulatory posturing
  • Yields a frequency score (100 word sample)
  • Yields a severity rating for both chronic and
    non-chronic stuttering
  • Appropriate for children 3-8 years of age

6
Danger/Warning Signs
  • Multiple part word repetitions
  • Schwa vowel
  • Prolongations
  • Struggle and tension
  • Pitch and/or loudness rise
  • Tremors
  • Avoidance
  • Moment of Fear
  • Difficulty initiating airflow and voicing

7
Risk Factors
  • Family history of stuttering
  • Male gender
  • Sensitive temperament
  • Other speech language concerns
  • Time post onset
  • Parental concern
  • Negative awareness

8
Other Indicators of Concern
  • Clustering
  • Ratio of typical/atypical disfluencies
  • Changes in cycles of stuttering
  • Mid utterance disfluencies
  • Multiple disfluencies per utterance
  • Sensory motor concerns

9
Diagnosis of School Age Stuttering
  • Ages 7-12
  • No longer rely on danger signs and risk factors
    to assess stuttering, instead we need to
    consider
  • What is the child doing physiologically when
    stuttering?
  • How is the child reacting to moments of
    stuttering?
  • What are the childs attitudes and emotions
    regarding stuttering?
  • Formal vs. subjective assessment

10
Bennett, 2006
  • Describes assessment of fluency in the school
    aged child as a detailed, thought-engaging
    process where the goal of assessment is to
    understand thoroughly the clients speech
    behaviors, thoughts, and feelings
  • Portfolio approach (Yaruss 2013)

11
Formal Assessments
  • Riley Stuttering Severity Instrument (RSSI-3)
    (RSSI-4) (2008)
  • Yields a severity rating
  • Only quantifies stuttering behaviors
  • Does not assess for more covert behaviors such as
    avoidance behaviors and postponement behaviors
    (uh, um)
  • Does not provide a basis from which to plan
    treatment

12
Test of Childhood Stuttering (TOCS)
  • Logan, Gilliam and Pearson (2009)
  • Yields a severity rating
  • 4 Subtests rapid picture naming, modeled
    sentences, structured conversation, narration
  • Limitations
  • based on reduction of linguistic complexity in
    the test items
  • awkward administration
  • Only counts disfluencies in the first three words
    of an utterance
  • Does not provide adequate information to plan
    treatment

13
OASES-S
  • Overall Assessment of the Speakers Experience
    with Stuttering Yaruss, Coleman Quesal (2010)
  • For ages 7-12
  • Purpose of the tool is to assess the adverse
    impact that school age children experience as a
    result of stuttering
  • Administration time 20 minutes
  • Scoring time 5 minutes
  • Results in an impactscore based on a severity
    rating scale

14
Using the OASES in the School Setting
  • Helps the SLP understand how the child responds
    to stuttering in general
  • Determines the affective, behavioral, and
    cognitive reactions the child has to stuttering
  • Assesses how stuttering affects the childs
    ability to communicate in various settings
    school, home and work.
  • Quantitatively determines how the stuttering is
    adversely affecting the childs quality of life
  • Provides pre/mid/post therapy data to assess
    progress
  • Provides topics for discourse related to
    attitudes and emotions

15
Subjective Assessment
  • Critical to planning treatment
  • Based upon observation of the childs speech in
    conversation and oral reading
  • What to look for
  • Primary behaviors (nature and duration)
  • Secondary behaviors (linguistic or physical)
  • Tension (loci and degree)
  • Airflow management (including control of air
    pressure and adequate respiratory support)
  • Voice production (pitch, vocal strength,
    loudness)

16
Zebrowski 1997
  • The management of children who stutter depends
    not on a formula but on the decision making and
    problem solving skills that are part of the
    armory of every well-trained clinician

17
Breakout Session 1
  • Assessment

18
Treatment and Therapy Strategies
  • General Therapy Components
  • Increased length and complexity of utterance
    hierarchy
  • Modeling
  • Reinforcement
  • Importance of Combining Fluency Shaping and
    Modification Strategies
  • Fluency Shaping Strategies
  • Modification Strategies
  • Case Study

19
Using a Linguistic Hierarchy
  • Single Words
  • Two Words
  • Three Words
  • Carrier Phrases
  • Extended Carrier Phrases
  • Prepositional Phrases
  • Multiple Phrases
  • Simple Sentences
  • Complex Sentences
  • Asking Questions
  • Conversation Relating to a Structured Activity
  • Spontaneous Conversation
  • High-Level Demand Task
  • Storytelling

20
How To Use the Hierarchy
  • Start at easiest level and progress through each
    level after obtaining 95 success over multiple
    sessions
  • Exception to this is jumping to carrier phrases
    quickly once the child gets the concept of the
    strategy
  • Start sessions at a level below that obtained in
    previous session
  • End sessions at a level where there is a high
    level of success
  • Therapy sessions are designed for maximum success
    by moving up and down in hierarchy as needed

21
Modeling of Strategies
  • Modeling of therapy strategies is critical
  • Clinician models 100 of the time in initial
    stages of therapy
  • Model is initially slightly exaggerated but
    produced with normal rhythm and prosody
  • Rate of model increases over the course of
    therapy and exaggeration decreases

22
Reinforcement
  • Reinforcement is constant and positive
  • All attempts are praised and encouraged
  • Encouraging praise is more effective than
    evaluative praise
  • Reinforce the childs use of strategies, not
    fluency

23
Combining Fluency Shaping and Modification
Strategies
  • Fluency Shaping Therapy
  • Helps the child speak more easily through a
    variety of strategies
  • Strategies are chosen depending on the childs
    age and the way they are stuttering
  • Modification Therapy
  • Helps the child stutter more easily, reduce
    struggle and tension and react less to moments of
    stuttering
  • The need and degree of modification strategies
    are dependant upon how negatively the child is
    reacting to stuttering

24
Fluency Shaping Strategies for the Young Child
  • Stretching or easy speech
  • Stretch- slight prolongation of the initial sound
    or syllable in a word with a smooth transition
    into the vowel
  • Used at the beginning of phrases or utterances
  • Easy speech- incorporates several features which
    increase fluency
  • Slower than normal speech rate
  • Easy vocal onsets
  • Soft articulatory contacts
  • Sustained voicing
  • Slight overarticulation
  • Normal rhythm and prosody

25
Fluency Shaping Strategies for the School Age
Child
  • Stretching
  • Easy voice
  • Soft contacts (slides)
  • Continuous voicing
  • Sound blending (hooking-on)
  • Chunking and Phrasing
  • Overarticulation

26
Modification Strategies
  • Bouncing (also appropriate for the young child)
  • Voluntary use of easy, effortless repetitions
  • Produced with continuous voicing and light
    articulatory contacts
  • Limit bounces to 2-3 repetitions per instance
  • Bounces should be tension free and even in tempo
  • Pullouts
  • Changing a stuttering moment by releasing tension
    and allowing the word to finish easier
  • Can stretch or bounce out of harder moment of
    stuttering
  • Holding and Tolerating
  • Staying in the moment of stuttering to
    decrease/prevent the negative response to
    stuttering

27
Voluntary Stuttering in Structured vs.
Unstructured Therapy
  • Clinical Research Question
  • In the case of a four-year, nine-month-old boy
    identified with a severe beginning level
    stuttering pattern, is structured therapy
    implementing the stuttering modification
    technique of bouncing, associated with marked
    decreases in the secondary stuttering behaviors
    of eye widening and vocal fold tremor, as
    compared with unstructured therapy?

28
Participant Milo
  • 4 year, 9 month old boy
  • Enrolled in preschool
  • Diagnosed with a severe beginning level
    stuttering pattern
  • Currently being seen at a university clinic for
    speech and language intervention
  • Individual fluency therapy sessions twice a week
    for forty-five minutes
  • Health concerns asthma, enlarged adenoids and
    right side hypotonia. Participant receives
    dietary supplements to maintain daily nutrition
    and promote growth.

29
Technique
  • Voluntary Stuttering (Bouncing)
  • Promotes tension reducing patterns that lessen
    sensitivity and avoidance of stuttering
  • Example from Walton Wallace (1998) p. 38
  • Clinician What ga-ga-game do you want to play
    today?
  • Child I want to play Candyland.
  • Clinician Great idea, I like Candyland.
  • Constant model used by the clinician at the start
    of every utterance in both conditions

30
Intervention
  • Molecular Analysis
  • Eye widening
  • Vocal fold tremor
  • Conditions (Alternating Treatment Design)
  • Unstructured therapy (15 min.) Child-centered
    conversation and play clinician model of
    bouncing
  • Structured therapy (15 min.) Clinician-directed
    activities and games clinician model of
    bouncing direct treatment approach at the 1-3
    word level
  • Data Collection Procedure
  • Data was collected over a six week period
  • Obtained through video recording which was
    analyzed by the clinician
  • Baseline and Final Data collected using an
    identical procedure for each condition

31
Quantitative Data
32
Qualitative Data
  • Questionnaire
  • Prior to study, Milo stuttered approx. 80
  • Since the start of the study, he stutters 50 of
    the time and much more smoothly
  • Milo does not remain stuck at the beginning
    of a statement
  • Presents fewer secondary behaviors such as eye
    widening, grimacing and slapping of leg
  • Has begun to generalize his speech tools at home
    and in preschool
  • Informal Interview
  • At the beginning of the study, Milo did not note
    any perceived difficulties with speech
  • Near end of study, Milo began to discuss troubles
    of speech fluency
  • When encountering hard or bumpy speech, Milo said
    he just cant get it out
  • Acknowledged how it feels when things are said
    easy vs hard

33
Conclusion
  • In the case of a preschool-aged child identified
    with a severe beginning level stuttering pattern,
    both structured and unstructured therapy
    utilizing the stuttering modification technique
    of bouncing were evaluated. It was determined
    that structured therapy was more effective in
    reducing the presence of secondary stuttering
    behaviors of eye widening and vocal fold tremor.

34
Breakout Session 2
  • Treatment and Treatment Strategies

35
Treatment Planning
36
Education Identification
  • The child knows something is wrong/not like other
    kids- what is it?
  • Educating the child about stuttering will help
    them better understand that it isnt their fault
    and that you can help.
  • Help the child identify his stuttering

37
Stuttering Iceberg
38
Addressing Attitudes and Emotions
  • Drawings can be used to express
  • feelings (isolation, shame, embarrassment)
  • beliefs (what Im doing is bad and so am I)
  • perceptions (people dont want to/wont listen)
  • experiences (teasing, being talked for)
  • Writing activities such as journaling allow them
    to write about their day, communication choices,
    feelings, etc. Writing stories about stuttering
    in general, specific experiences, how they
    imagine a specific event happening if they
    stutter
  • Self Talk and Positive Affirmations
  • negative messages about themselves and their
    talking (I cant say that, I cant join that
    team/group/class because I stutter)
  • positive affirmations (I have choices, I can
    stutter my way, What I have to say is important)

39
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40
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41
Addressing Attitudes and Emotions
  • Problem solving will help the child feel
    empowered and let them think about the situation
    based upon what they know is true
  • What actually happened?
  • What could I have done?
  • What would I rather do next time?
  • Can I make any changes to this situation now?
  • Letters to the teacher will educate the teacher
    about stuttering and the childs needs
    EMPOWERING
  • allows them to introduce themselves as a person
    who stutters
  • explains what is difficult for them in class
  • things that are helpful and not helpful for the
    teacher to do
  • Gracies Letter

42
Working With Parents
  • Accepting their childs stuttering and at the
    same time letting their child know they accept
    them.
  • What experience do the parents have with
    stuttering- is there a family history, positive
    or negative encounters
  • Asking the parents what they expect from their
    childs speech at home
  • Is it realistic?
  • Speech tools in the therapy room vs home
  • Helpful vs Hurtful support at home
  • Educating parents about stuttering
  • Myths vs facts
  • What can they expect from therapy
  • Experiences/feelings their child has about their
    stuttering (drawings and writings are very
    helpful)

43
What kids want their parents to know about
stuttering
  • Stop bugging me
  • Its ok to talk about stuttering
  • I want to be called on more in class
  • You heard me stutter twice when I got home I
    felt myself stutter all day and lived you can
    live too
  • Stuttering is not FUN!!!
  • I can still be happy even though I stutter
  • Everything is NOT about NOT
  • Stuttering makes me, me!

44
Working With Teachers
  • Increasing communication in the classroom
  • Student to teacher
  • teacher to student
  • student in class
  • Reduce stressors in classroom
  • Identify what they are being called on, being
    called on alphabetically or in rows, reading
    aloud, substitute teachers (specific to each
    student)
  • Problem solve together
  • Generalization in classroom
  • When to integrate speech tools

45
Classroom Presentation
  • Work with your student to make this their
    presentation
  • Talk about famous people who stutter
  • Talk about the speech machine and how speech is
    produced
  • Teach the children about what stuttering is
  • Talk about what friends can and cannot do to help
    the CWS
  • Show the DVD Stuttering for Kids by Kids
  • Teach all the children how to stutter on their
    their names-for candy!
  • www.stutteringhelp.org and www.westutter.org

46
Friends Day!!!! April 18th
  • FRIENDS The National Association of Young People
    Who Stutter
  • Mission To provide support for young people who
    stutter and their families
  • FRIENDS one-day conference April 18th, Jefferson
    Academy
  • ASHA CEUs for SLPs
  • www.friendswhostutter.org

47
Breakout Session 3
  • Treatment Planning
  • Working with Attitudes and Emotions

48
IEP Goal Writing and Assessing Progress
  • Writing SMART fluency goals
  • Examples of goals
  • Fluency shaping
  • Modification
  • Identification, education, etc
  • Monitoring Progress

49
Specific
  • Skills and techniques used in therapy
  • Increasing use of speech tools in specific
    setting
  • i.e. use of spontaneous easy speech during a game
    or other structured activity
  • Discussing stuttering with peers/adults,
    increasing disclosure
  • i.e. student giving a classroom presentation
    about stuttering, writing a letter to the
    students teacher
  • Increasing participation in the classroom
  • i.e. student voluntarily raising hand to answer a
    question, participating in discussions, sharing
    ideas with peers

50
Measurable
  • Should involve an increase in the
    count/percentage of use of speech tools
  • i.e. Student will use his easy speech
    spontaneously in 8/10 opportunities
  • NOT reduction in stuttering
  • i.e. Student will not stutter during circle time

51
Achievable
  • Goals should never target 100
  • Should be scaffolded
  • Increase in linguistic complexity
  • i.e. what level of the hierarchy is being
    targeted
  • Spontaneous vs. imitative responses
  • i.e. student repeating a model vs. student
    responding spontaneously
  • Across various situations for generalization
  • i.e. therapy room vs. hallway vs. classroom

52
Relevant
  • Goals should be unique to the student
  • Based on their current level of performance
  • Decrease anxiety and increase participation
  • Promote positive social interaction in their
    learning environment

53
Time-bound
  • Can be completed in a specific time frame
  • A goal should be challenging yet still
    attainable, to a degree that it could be
    completed within the IEP period.
  • i.e. could move from single word level to carrier
    phrase or multi phrase level within IEP period,
    but less likely to go from single word level to
    conversational level within IEP period

54
Example Goals
  • Fluency Shaping
  • Modification
  • Identification
  • Reduction of Secondary Behaviors

55
Fluency Shaping Goal
  • In order to increase fluent speech, Timmy will
    use a fluency shaping strategy (stretches, easy
    onsets, voice on, etc.) without prompts to begin
    80 of carrier phrases during a game, in the
    therapy room, while working 1-on-1 with the SLP.
  • Baseline Using fluency shaping strategies on 30
    of 3-word utterances and 20 of carrier phrases
    in structured activities.

56
Modification Goal
  • Susan will independently use a stuttering
    modification technique (bounces, pull-out,
    slide-out, cancellation, etc.) 10 times during
    spontaneous speech, in a 30 minute therapy
    session with the SLP and one familiar peer.
  • Baseline currently producing 10 per session
    with frequent prompts (1 per minute).

57
Identification Goal
  • In four consecutive meetings in the therapy room,
    Nicholas will identify a situation, sound,
    conversation partner or specific trigger that was
    a challenge to his fluency during the week, and
    will discuss how this affected his speech, as
    well as possible next steps.
  • When prompted following a block of gt.5sec. (or in
    a clinician-modeled block), Nicholas will
    correctly identify the trouble sound, location of
    the block, and type of sound (popping, blowing,
    buzzing, etc.), independently on 75 of
    opportunities to increase proprioception and gain
    awareness of speech mechanisms.

58
Reduction of Secondary Behaviors
  • Alejandro will replace the use of um and uh
    as a secondary behavior by using a brief pause
    followed by a stretch or bounce to begin a phrase
    while speaking in the classroom during a
    structured activity, with SLP present, on 60 of
    utterances.
  • Baseline currently 95 in therapy room in
    conversation following a single prompt.

59
Monitoring Progress
  • Moving up the hierarchy
  • i.e. carrier phrase level to question level
  • How the stuttering pattern changes
  • i.e. increase in part-word repetitions and
    decrease in prolongations, decrease in struggle
    and tension
  • Students willingness to discuss stuttering
  • i.e. completion of worksheets for attitudes and
    emotions in the therapy room, discussing hard
    speech vs. easy speech

60
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61
Breakout Session 4
  • IEP Goal Writing and Assessing Progress
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