Helping Parents Learn to Facilitate Young Children’s Speech Fluency

1. Helping ParentsLearn to Facilitate Young Children’s Speech Fluency David W. Hammer, M.A., CCC-SLPChildren’s Hospital of PittsburghJ. Scott Yaruss,Ph.D., CCC-SLPUniversity of Pittsburgh

2. 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

3. 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

4. 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

5. General Structure of Treatment • Treatment consists of: • Two parent-only sessionsfor parental counseling and overview of treatment • Four parent/child modelingsessions when parents are taught modifications • Treatment program is administered by itself or prior to more direct intervention with the child or family

6. Session #1 Overview of Stuttering Interpersonal Stressors

7. 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

8. 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 childand within the environment • Allows parents to see how theycompare in their view of the child

9. 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

10. 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

11. “Bucket” AnalogyPurpose • Identifies factors that maybe associated with stuttering • Helps parents understandthe multifactorial natureof stuttering

12. T T S Communicative Stressors U T E I R Negative response to disfluency Demanding questioning Frequent interruptions Competition for talking time Rapid rate of conversation N Interpersonal Stressors G Major life changes & traumatic events Marital & sibling conflicts Unrealistic demands Fast-paced / unpredictable lifestyle Child Factors Perfectionistic tendencies Highly degree of sensitivity Intense / driven personality Other speech/language disorders Predisposition to stutter “Bucket” AnalogyFactors * • Factors interact • Cannot distinguish influence of individual factors once they are in the bucket

13. T T S U T E I R N G “Bucket” AnalogyGuidelines • Begin at the bottomand work up • Identify factors we havemore control over and factors we have lesscontrol over

14. Communication “Wellness” Analogy Direct Child Intervention • Purpose • Describes structure & flow of treatment • Guidelines • Begin at the bottom and work up • Explain that not all all steps may be necessary ParentObservation StrategyPractice Treatment Flow Parent Sessions

15. Communication “Wellness” Direct Child Intervention • “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 ParentObservation StrategyPractice Treatment Flow Parent Sessions

16. 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

17. Continuum ofSpeech Disfluencies(adapted from Gregory, Campbell, Hill, and others) Increased Fragmentation Increased Tension • Any type of disfluency withincreased tension or struggle • rise in pitch or loudness • tension in jaw or face • Avoidance, fear about talking • More Typical • Interjections • Revisions • Phrase repetitions • Multisyllabic whole- word repetitions • Crossover 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

18. 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

19. 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

20. Home Charting • Guidelines • No “Aha!” expected • Provide examples of successful charting(see handout) • Parents should bring completed chartto next treatment session

21. 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

22. 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

23. Session #2 Overview of FluencyEnhancing Strategies

24. 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

25. 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

26. Fluency Enhancing Strategies • Reducing parents’ speaking rates • Reducing time pressures • Reducing demand for talking • Modifying questioning • Providing supportivecommunicative environment

27. 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 Talkingasthe first strategy to be addressed • Familiarize parents with wireless microphone system

28. Wireless Microphone System “UseEasy Talking” WirelessXmitter (TelexTW-6) WirelessReceiver (TelexAAR-1) (Easy Talking)

29. Session #3 Easy Talking

30. Goals for Session #3 • Train parents to useEasy 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

31. Guidelines for Session #3 • Set up video equipment and wireless microphone system before session • ReviewEasy 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

32. 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

33. Video Segment #1 Easy Talking

34. Preparing for Session #4 • When parents view the videotape, they should observe: • Their use of Easy Talking • The number and type of questionsthey ask the child • Discuss upcoming session’s focuson Modified Questioning

35. Session #4 Modified Questioning

36. 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 variousnon-questioning starters

37. “Non-Question Starters” I wonderwhat Teddywants to do. Whatdoes Teddywant to do? • “I wonder…” • “I think…” • “I bet…” • “I guess…” • “Maybe…” • “It looks like…”

38. 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

39. Video Segment #2 Modified Questions

40. Session #5 Reduplication / Rephrasing

41. Goals for Session #5 • Train parents to use reduplication/ rephrasing strategy • Child can hear what he or she saidin 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

42. Video Segment #3 Reduplication / Rephrasing Delayed response

43. Session #6 Reducing Time Pressure Review of All Strategies

44. 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

45. 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

46. 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 sessionsprior to three-month timeframe • May move right into fluency group or individual therapy

47. Evaluation andFuture Directions Does any of this work?!?

48. 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

49. 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

50. Case Presentations Diagnostic DataTreatment Process Outcomes / Follow-up