helping parents learn to facilitate young children’s speech fluency david w. hammer, m.a., ccc-slp...
TRANSCRIPT
Helping ParentsLearn to Facilitate Young
Children’s Speech Fluency
David W. Hammer, M.A., CCC-SLP
Children’s Hospital of Pittsburgh
J. Scott Yaruss, Ph.D., CCC-SLP
University of Pittsburgh
tuttering
CS enterof
estern ennsylvaniaW PA joint venture of Children's Hospital of Pittsburgh and the Department of
Communication Science and Disorders at the University of Pittsburgh
Purpose
• To present a model for teaching parents to facilitate their children’s development of normal fluency
– Based on reductions in interpersonal and communicative stressors
– Takes into account various aspectsof the child’s personality that may contribute to disfluency or stuttering
– Can be adapted to a variety of settings
Goals of Treatment
• The overall goal of treatment for preschool children who stutter is to eliminate stuttering while supportingthe child’s language development
• This treatment program focuses on one component of this overall goal… parental facilitation of the child’s fluency in real-world situations
Rationale for Treatment• Treatment is based on widely held
beliefs about the factors that affect children’s speech fluency, e.g.:
– Modifying aspects of the child’s daily interactions will help the child achieve fluency speech in that speaking situation
– The more time a child spends speaking fluently, the less likely the child will develop a chronic stuttering disorder
General Structure of Treatment
• Treatment consists of:– Two parent-only sessions for parental
counseling and overview of treatment– Four parent/child modeling sessions when
parents are taught modifications
• Treatment program is administered by itself or prior to more direct intervention with the child or family
Goals for Session #1
• Help parents understand the nature of stuttering and the factors that may affect their child’s fluency
• Provide an overview of the treatment process and outlook for the future
• Begin the process of identifying interpersonal stressors
Stressor Inventory (Handout #1)
• Prior to any discussion about modifying stressors, parentscomplete a stressor inventory– Provides background about factors that may
contribute to the child’s stuttering– Examines stressors within the child
and within the environment– Allows parents to see how they
compare in their view of the child
Stressors within the Child
• Is sensitive
• Tends to be perfectionist
• Has an “intense” personality
• Is competitive
• Demonstrates performance anxiety/fears
• Tends to become more disfluent when tired
• Tends to become more disfluent when ill
• Has other speech/language problems
Stressors within the Environment
• Hectic daily routines are commonplace
• Sibling rivalry is intense
• Limited free time or quiet time
• Others in the home talk fast or interrupt frequently
• Stressful situations have been present(e.g., divorce, death, etc.)
• Family members/relatives have stutteredor currently stutter
• High expectations are imposed by others
“Bucket” AnalogyPurpose
• Identifies factors that maybe associated with stuttering
• Helps parents understandthe multifactorial natureof stuttering
“Bucket” AnalogyFactors
• Factors interact• Cannot distinguish
influence of individual factors once they are in the bucket
STU TERING
T*
“Bucket” AnalogyGuidelines
• Begin at the bottomand work up
• Identify factors we havemore control over and factors we have lesscontrol over
STU TERING
T
• Purpose– Describes structure
& flow of treatment
• Guidelines– Begin at the bottom
and work up– Explain that not all
all steps may be necessary
Communication “Wellness” Analogy
Direct Child Intervention
Tre
atm
ent
Flo
w
ParentObservatio
n
Strategy
Practice
Parent Session
s
• “Normal” fluency in conversational speech
• Easy Talking– Conversational Level– Direct Model to Question Model
• Sentences • Phrases • Words
• Model & Practice– Delayed Response– Reduplication/Rephrasing– Decreased Questioning– Easy Talking
• Modify interpersonal stressors
• Chart home disfluencies
• Modify communicative stressors
• Discuss types of disfluencies
• Administer Stressor Inventory
Communication “Wellness”
Direct Child Intervention
Tre
atm
ent
Flo
w
ParentObservatio
n
Strategy
Practice
Parent Session
s
Discussing Types of Disfluencies
• Helps parents learn to distinguish between different disfluency types
• Helps parents understand how to view progress during treatment
• Reduces parental misconceptions– stuttering is just repetition– prolongations are “better” than repetitions
Increased Tension
Increased Fragmentatio
n
More Typical• Interjections• Revisions• Phrase repetitions• Multisyllabic whole-
word repetitionsCrossover Behaviors
• Monosyllabic whole-word repetitions
• Part-word repetitions• No tension/struggle• 1 – 2 iterations
Less Typical
• Part-word repetitions• 3 or more iterations
• Prolongations• Blocks
Continuum ofSpeech Disfluencies(adapted from Gregory, Campbell,
Hill, and others)
• Any type of disfluency withincreased tension or struggle• rise in pitch or loudness• tension in jaw or face
• Avoidance, fear about talking
Examining Stressors
• Compare stressor inventories completed by both parents– Parents may view situations differently
• Focus on interpersonal stressors first– Establish need for additional counseling
• Discuss ways to modify stressors– Parents take lead in finding solutions
Home Charting
• Increase parents’ awareness of– Situational factors that affect fluency – Their reactions to their child’s stuttering
• Helps parents focus their energy on helping the child rather than worrying
• Gives opportunity to assess parents’ commitment to treatment early in the therapeutic process
Home Charting
• Guidelines
– No “Aha!” expected
– Provide examples of successful charting(see handout)
– Parents should bring completed chartto next treatment session
Provide Supporting Literature
• Reassures parents that others have had similar concerns and questions
• Provides concrete examples of ways parents can help their children
• Additional opportunity to assess parents’ commitment to treatment
Examples of Supporting Literature
• Stuttering Foundation of America (SFA)– Stuttering and Your Child: Questions & Answers– If Your Child Stutters: A Guide for Parents
• National Stuttering Association (NSA)
• Stuttering Center Handouts
• Internet Resources– Stuttering Home Page
Goals for Session #2• Additional opportunity for counseling to
to address parents’ concerns
• Further explore interpersonal stressors (when applicable)
• Begin the process of modifying communicative stressors
• Introduce next phase of treatment: parent/child modeling
Guidelines for Session #2
• First, Review Info from Session #1
– Review results from home charting
– Answer questions about booklets and supporting literature
– Address parents’ concerns about treatment and child’s fluency
– Continue discussion of interpersonal stressors and modifications
Fluency Enhancing Strategies
• Reducing parents’ speaking rates
• Reducing time pressures
• Reducing demand for talking
• Modifying questioning
• Providing supportivecommunicative environment
Preparing for Parent-Child Modeling Sessions (Sessions 3-6)
• Provide overview of session flow
• Explain the need to videotape sessions (have parents bring tape to next session)
• Briefly introduce Easy Talking asthe first strategy to be addressed
• Familiarize parents with wireless microphone system
“UseEasy
Talking”
Wireless Microphone System
(EasyTalking)
WirelessXmitter
(TelexTW-6)
WirelessReceiver
(TelexAAR-1)
Goals for Session #3
• Train parents to use Easy Talking
– Slower than parents’ habitual rate, but not too slow, choppy, or robot-like
– Introduce phrased speech as a preferred way to reduce speaking rate
– Explain that the goal for the parents’ speaking rate is somewhere in between the rate they will practice in treatment and the rate they used before treatment
Guidelines for Session #3
• Set up video equipment and wireless microphone system before session
• Review Easy Talking handout– Introduce phrasing as a preferred way to
reduce speaking rate– Explain that the goal for the parents’
speaking rate is somewhere in between the rate they will practice in treatment and the rate they used before treatment
Model and Practice Easy Talking
• Clinician models Easy Talking withthe child while parents observe
• One parent interacts with childwhile receiving on-line feedback
• Second parent interacts with childwhile receiving on-line feedback
• Discuss observations and importanceof reviewing videotape at home
Preparing for Session #4
• When parents view the videotape, they should observe: – Their use of Easy Talking– The number and type of questions
they ask the child
• Discuss upcoming session’s focuson Modified Questioning
Goals for Session #4
• Train parents to modify questions– Reducing the number of direct questions in
favor of more indirect comments– Goal is to reduce demands on child
• Parents cannot (and should not) eliminate questions completely– Provide “cheat sheet” for various
non-questioning starters
“Non-Question Starters”
• “I wonder…”
• “I think…”
• “I bet…”
• “I guess…”
• “Maybe…”
• “It looks like…”
Whatdoes Teddywant to do?
I wonderwhat Teddywants to do.
Model & Practice Modified Questioning
• Session has same structure as #3
• Clinician models Modified Questioningwith the child while parents observe
• One parent interacts with childwhile receiving on-line feedback
• Second parent interacts with childwhile receiving on-line feedback
• Discuss observations and importanceof reviewing videotape at home
Goals for Session #5
• Train parents to use reduplication/ rephrasing strategy– Child can hear what he or she said
in an easier, more relaxed way
– Child knows that parents have heardwhat he or she said
– Gives parents the opportunity to providea good language/articulation model
• Session has same structure as #3, #4
Goals for Session #6
• Help parents incorporate all strategies into their interactions with child– Provide a summary of all techniques used in
treatment thus far– Discuss need to follow through with
techniques in home practice– Discuss plan for future treatment as
necessary
• Use the “refresher” handout
Refresher Handout
• Use Easy Talking at slowed rate…use phrased talking to keep it natural
• Delay Responding. Pause before answering• Modify Questions. Try “I wonder…”
“Maybe…” “I think”• Repeat and Rephrase both fluent and
disfluent speech to provide a good model and let child know you are listening
Follow-up• Phone contacts to monitor progress
– Parents’ use of strategies– Child’s response to strategies– Changes in child’s fluency
• Maximum 3 months before reassessment– Parents may opt for refresher sessions
prior to three-month timeframe
• May move right into fluency group or individual therapy
Evaluating Treatment Outcomes• Recall that the goal of treatment is to help
parents facilitate children’s fluency in real-world situations
– To evaluate treatment, we evaluate parents’ ability to make these changes
• In treatment • Parent report from home
– We also monitor changes in children’s fluency to determine whether more direct treatment is necessary
• During treatment • At follow-up
So, does it work?• Anecdotal evidence and experience in
treatment shows that parents can make changes in treatment and at home– Many children do experience improvements in
fluency during the course of treatment– Changes may be related to treatment but may also
be related to natural recovery
• We are now more carefully documenting changes in parents’ communicationand children’s fluency during treatment
JC (3;2) – from videotape• Diagnostic Results
– Signs of early stuttering (data)– Moderate speech sound disorder
• Treatment Process– 2 parent-only sessions (mother only)– 3 parent-child modeling sessions (both parents)
• Outcome– Phone contact 4 months post treatment revealed solid
fluency maintenance– Child will begin treatment for speech sound disorder
while fluency is monitored
LC (2;11) – Diagnostic Results• Child Factors
– Moderate to severe stuttering• Sound prolongations, secondary features• Frustration and avoidance
– Mild speech sound disorder– Sensitive, intense child
• Interpersonal Stressors– Fast-paced lifestyle– Parents’ perfectionistic tendencies
• Communicative Stressors– Father unsure how to play with child
LC (2;11) – Treatment/Outcomes
• Treatment– 3 parent-only sessions with both parents because of
complex home environment– 3 parent-child modeling sessions
• Outcomes– Follow-up parent session after 4 months revealed need
to refresh strategy usage– Follow-up visit after 6 months revealed
solid fluency maintenance– Returned to treatment for speech sound disorder;
fluency had stabilized
SH (4;6) – Diagnostic Results
• Child Factors– Moderate stuttering
• Multiple word/syllable repetitions; some blocks • Generalized facial tension and oral posturing
– Moderate expressive language deficits– Family history of stuttering– Intense, sensitive child
• Interpersonal Stressors– Minimal interpersonal stressors
• Communicative Stressors– Rapid parental rate of speech
SH (4;6) – Treatment/Outcomes
• Treatment– 2 parent-only sessions (both parents)– 4 parent-child modeling sessions
• Outcomes– 3-month follow-up revealed parents’
desire to refresh use of strategies – Child’s fluency continued to fluctuate during
parent-child sessions (every other week) – Child will be placed in parent/child fluency
treatment group
Current Implementation
• This treatment approach was developed at Children’s Hospital of Pittsburgh– Based on information from several sources,
including University Clinics
• Admittedly, these are idealized treatment settings– More flexible facilities
– Better access to families
– More control over timing and scheduling
Considerations
• Interaction with parents is critical for facilitating child’s fluency at home– Focus on parents helps them assess
the need for additional treatment
• It can be difficult to ensure parental involvement in certain settings– Manageable, short course of treatment (six
sessions over extended period of time) can facilitate scheduling, parent involvement
Modifications
• Wireless microphone system is helpful means of proving direct feedback to parents during sessions– Without wireless mic, clinician can provide
feedback right after parent session
• Observation room not necessary– Clinician can sit away from play area and
whisper instructions into microphone
Remember the Goal
• The goal of treatment is to help parents facilitate children’s fluency by modifying communicative and interpersonal stressors
• Technical details can be adjusted for different settings so the clinician can – Talk with parents to help them analyze
and modify stressors
– Model desired modifications
– Give parents chance for guided practice
Summary
• This treatment program helps parents make modifications to interpersonal and communicative stressors that may affect children’s fluency
– Provides an alternative to “wait and see” recommendations
– Can be used alone or in conjunction with more direct treatment
– Can be used in a variety of settings
Questions?Comments?
Let us know!
David W. Hammer, M.A., CCC-SLP
Children's Hospital of Pittsburgh2599 Wexford Bayne Rd.Sewickley, PA 15143Phone: (724) 933-3600Fax: (724) 933-3621Email: [email protected]
J. Scott Yaruss, Ph.D., CCC-SLP
University of Pittsburgh4033 Forbes TowerPittsburgh, PA 15260
Phone: (412) 647-1367Fax: (412) 647-1370Email: [email protected]
tuttering
CS enterof
estern ennsylvaniaW PA joint venture of Children's Hospital of Pittsburgh and the Department of
Communication Science and Disorders at the University of Pittsburgh