diagnosing and treating fluency disorders in the schools€¦ · diagnosing and treating fluency...
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9/5/17
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DiagnosingandTreatingFluencyDisordersintheSchools
LonnieG.Harris,Ph.D.,CCC-SLPLonnie.Harris@ebshealthcare.com
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
Whatcausesstuttering?
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
EnvironmentalEtiology
Whatcausesstuttering?
1. Considercaseofadoptedchild.
2. Others’reactions(particularlyfamilymembers).
3. Stressfulspeakingsituations.
4. Lifeeventsthataretraumatic.
15 SeeELECTRONICHANDOUTS:• TipsforTeachers• FluencyFAQs
Whatcausesstuttering?EnvironmentalEtiology
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GeneticEtiology
EnvironmentalEtiology
Whatcausesstuttering?
1.Explainthecausesofstu*eringtoaparentorteacher.
2.Differen:atedevelopmentaldisfluenciesfromincipientstu*ering.
3.DemonstrateuseofavarietyofFSandSMtherapytechniques.
4.Writemeasureablefluencygoalsandobjec:ves.
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LearnerOutcomes
CanStutteringBeCured?
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HavingaCure
• Referstoanapproachorapplica:on.• Thereiscurrentlynocureforcancer.
• Thereisnocureforstu*ering.
BeingCured
• Referstoanoveralloutcome.• Manyhavebeencuredforcancer.
• Stu*eringcanbecuredwiththerapy.
CanStutteringBeCured?
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CanStutteringBeCured?
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• StutteringCANbecured,bothwithandwithouttherapy.
• Fluency“cures”refertonomorestutteringandnomemoryofstuttering.
• Curesarecommoninyoungchildrenwhostutter,eventhosewhohavebeenintherapyforayearorso.
• Ihaveevenseenafewcomplete“cures”inadultswhohavestutteredformanyyears.
ExplainingtheConceptofCurestoParents
CanStutteringBeCured?
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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.
1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal
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PreschoolScreenerFrequencyofRepetitions
<2%
2%-5%
>5%
1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal
• TheRepetitioncountincludesalltypes,fromsentencerepstosoundrepetitions.• Wearecalculatingthepercentageofrepetitionsinoverallspeech.
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PreschoolScreenerFrequencyofProlongations
<1%
1%orgreater
1–ProbablyNormal 3–ProbablyAbnormal
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PreschoolScreenerFrequencyofOverallDisfluencies
<5%
5%-10%
>10%
1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal
• Thedisfluencycountincludesalltypesofdisfluencies,includinginterjections.• Wearecalculatingthepercentageofdisfluenciesinoverallspeech.
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PreschoolScreenerTypicalNumberofReiterationsperRepetition
<2I–Iwanttogo.
3–4I–I–I–Iwanttogo.
>4I–I–I–I–I–Iwanttogo.
1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal
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PreschoolScreenerAverageDurationofProlongations
<1second
1secondormore
1–ProbablyNormal 3–ProbablyAbnormal
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PreschoolScreenerAudibleEffort
Noneobserved
ObservedHardglottalattacksVocaltensionDisruptedairflowPitchrise
1–ProbablyNormal 3–ProbablyAbnormal
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PreschoolScreenerRhythm/Tempo/Speed
Slow/normalEvenlypaced
FastIrregular
1–ProbablyNormal 3–ProbablyAbnormal
• Don’tconfusearapidratewithcluttering,whichhasacompletelydifferentdiagnosticprotocol.
33 SeeELECTRONICHANDOUT:• ClutteringQuickScreen
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PreschoolScreenerSchwaReplacement
Notobservedta-ta-tableda-da-da-daddy
Observedtuh-tuh-tableduh-duh-duh-daddy
1–ProbablyNormal 3–ProbablyAbnormal
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PreschoolScreenerAudibleLearnedBehaviors
Notobserved
ObservedCircumlocutionsAvoidancetacticsStarters
1–ProbablyNormal 3–ProbablyAbnormal
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PreschoolScreenerVisualEvidence
Notobserved
ObservedFacialGrimacingArticulationposturingHeadmovementsBodymovements
1–ProbablyNormal 3–ProbablyAbnormal
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13–16
17–21
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1–ProbablyNormal 2–Questionable 3–ProbablyAbnormal
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PreschoolScreenerScoreInterpretation
• YouMAYreferfortestinginthe17–21therange.• YouMUSTreferfortestinginthe22–39range.
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1.Explainthecausesofstu*eringtoaparentorteacher.
2.Differen:atedevelopmentaldisfluenciesfromincipientstu*ering.
3.DemonstrateuseofavarietyofFSandSMtherapytechniques.
4.Writemeasureablefluencygoalsandobjec:ves.
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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
AssessmentEducationalRelevance
52
Toprovideabe*erdefini:onofeduca6onallyrelevant,wemust
rememberthatouroverallobjec?veintherapyistosupportthechild’scommunica?onsuccessesinthe
academicseBng.
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AssessmentEducationalRelevance
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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TreatmentContextualvs.NoncontextualSpeech
• Badgeringorshortques:on-answerexchanges(e.g.,“What’sthis?”)shouldtypicallybeavoidedbecausetheyoaencausethechildtowithdraw.
• Trytellingthechildwhattodoinsteadofaskinghimtoques:ons.
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TreatmentContextualvs.NoncontextualSpeech
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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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67
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
70
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
73
1. Purpose:Toreducethelikelihoodthattherewillbea“block”becausethecontinuousairflowenhancessmootherspeech.[SameasContinuousPhonation]
2. Method:a. Repeattheconfidentialvoicemodeltobesurethe
studentunderstandshowtoproduceit(asifnotwantingtowakeasleepingpersonnearby).
b. Thetemporaryuseoftheconfidentialvoiceisexplained.Thisisusuallyafewweeks,butshouldbeuseduntiltheeffortfulvoiceisnolongerused.
c. Establishtimeswhentheconfidentialvoicecanbepracticedwhilereading.
ConfidentialVoice
74
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
75
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1. Phrasingsimplymeanssayingwordsthatgrouptogethernaturally.
2. Pausingmeansleavingalittlebitoftimebetweenthosephrases(aswithcontinuousphonation).Thisalsohelpswithrate.
3. Purpose:Allowsshortpausesinthespeechatnaturalpointswithintheconversation(e.g.,betweenphrasesorbreaths).Thisshouldbeusedwheneverstudentwantstoreducehowfasttheconversationisgoingsohehasmoretimetothinkaboutwhathewantstosayortopreparetouseothertechniques.
Phrasing/Pausing
76
3. Method:a. Studentshouldspeakashewouldnormally.
b. Whenhecomestotheendofaphrase,heshoulduseashortpause—aslongasheneeds,butnottoolong—andthencon:nuetothenextphrase.
c. Duringthepause,hecanpreparetouseaneasystartorlightcontacttohelpreducetensioninthespeechmusclesbeforecontinuingtospeak.
Phrasing/Pausing
77
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
78 SeeHANDOUT:• GILCUSequenceinFluencyTherapy
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3. Method(cont.):a. Studentreadssinglesentence.Then2sentences,3
sentences,(4sentences).
b. StudentspeakswithSLPintherapyroominshortphrasesandthenprogressestolongerutteranceandconversation.
4. AdditionalInformation:a. Thisapproachallowsthestudenttobecomevery
awareofhisspeechearlyon.
b. ThistechniqueMUSTbeusedwithContinuousPhonation.
GILCU/ELU
79
1. Purpose:Tolookatthelistenerduringconversation,aspartofnormalinterpersonalskills.
2. Method:a. Usinggoodeyecontactsimplymeansthatthestudent
looksatthelistenerwhenheisspeaking,orthathelooksatspeakerswhentheyaretalkingtohim.
b. Thestudentcannotlookatpeopleallthetime,buthemaywanttomakesurethathedoesn’tletfearaboutstutteringcausehimtolookawaywhenspeaking.
c. Heshouldstartoutbyusingeyecontactduringtimeswhenheisspeakingeasilyandthengraduallymovetowardmaintainingeyecontactduringmomentsofstuttering.
EyeContact
80
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
82
WhenShouldStutteringModificationbeImplemented?àWhenthefollowingareobservedorreportedbyPWS:
1. Struggleand/ortension2. Anticipationofstutteringevents.3. Avoidance,suchascircumlocutions,situation
avoidances,orsimplynottalking4. Fearoftalking5. Linguisticsecondarybehaviorsareobserved,suchas
fillers(um),starters(Well,youknow),postponements(delayinsayingawordtodelaystuttering)
StutteringModification
83
1. Purpose:Takecontroloftensionafteramomentofstuttering.
2. Method:Afterthestutteredword:a. Pauselongenoughtofigureoutwherethetensionis.
b. Releasethetensioninthespeechmuscles.
c. Startthewordagainwithaneasystartoraneasystutter.DoNOTgobacktothebeginningoftheutterance.
d. Studentcanstartpracticingthisinshortconversations,thengraduallymovetowardusingcancellationsinmorechallengingsituations.
Cancellation
84
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1. Alsocalledslide-outoreasingout.
2. Purpose:Toreleasetensionduringamomentofstuttering,theneasingintotherestofthewordorphrase.
3. Method:a. Identifywherethetensionisinthespeechmuscles.
b. Reducethephysicaltensionalittlebitatatime.
c. Continuespeakingtosaythewordandmoveontotherestofthephrase.
Pull-Out
85
1. Purpose:Usedatthebeginningofawordwherethestudentthinksheislikelytostutter.
2. Method:a. Speaknormally(withoutmodification)untilhefeelsthat
heiscomingtoawordwherehewillexperiencetension…andmostprobablydisfluentspeech.
b. Beginthewordwithaneasystart(toreducephysicaltension)insteadoftensingmuscles.Anycombina:onoftechniquesusedforFluencyShapingcanbeusedhere.
PreparatorySet
86
4. Benefits:a. Helpsreducethetensionandincreasefluencybeforethe
momentofstuttering.
b. Mostappropriateforindividualswhodemonstrateanticipationofstutteredmoments.
5. AdditionalInformation:a. Easinginworkstogetherwithotherstutteringmodification
techniques(cancellationsandpull-outs)toprovidethestudentwiththreeopportunitiestochangethetensioninhisspeechmuscleswhenheexperiencesamomentofstuttering.Useinreverseorder.
b. UseANYstrategytomaintaincontrolofthespeechasheanticipatesadisfluency.
PreparatorySet
87
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DeterminingifProgressisBeingMade
88
• Durationofstutteringmomentsareshorter.• Articulatoryorlaryngealtensionisreduced.• Secondarybehaviorsarereduced/eliminated.
• Changesinprimarystuttering(e.g.,blocksarereplacedbyeasierprolongationsorrepetitions).
• Frequencyofprimary/secondarystutteringisreduced.• Increasedtalkingandrisktaking.• Increasedfeelingsofself-worth.
• Mayshowanincreaseinstutteringfrequency,butitwillultimatelydecrease.
89
Progressisdeterminedwhen…
1.Explainthecausesofstu*eringtoaparentorteacher.
2.Differen:atedevelopmentaldisfluenciesfromincipientstu*ering.
3.DemonstrateuseofavarietyofFSandSMtherapytechniques.
4.Writemeasureablefluencygoalsandobjec:ves.
90
LearnerOutcomes
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ProvideSupportforthePWSandFamily
91
Provideinformationandguidanceto
clients,families,andothersignificantpersonsaboutthenatureofstuttering,normalfluency,and
thecourseoftreatmentandprognosisforrecovery.
ProvideSupport
92
ProvideSupport
www.stutteringhelp.org
93
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ProvideSupport
www.westutter.org
94
WritingGoalsforFluencyTherapy
95
• 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).
97
WritingGoalsKeyReminders
• “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].
98
WritingGoalsKeyReminders
Whenwearewritinggoals,rememberthattheultimategoalistohelp
personswhostuttersay
whattheywantwhentheywant
Towhomtheywant
99
WritingGoalsKeyReminders
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• Rememberthatthechilddoesnotactuallyhavecontroloverwhenhe/shestu*ersandwhenhe/sheisfluent.
• Some:mes,childrenstu*ereveniftheyuseatechniqueappropriately(theyaredoingwhatwetrainedthemtodointherapy).
• Atother:mes,theywillnotstu*erevenwhentheyforgottousetechniques(beinglucky). 100
WritingGoalsFluencyShaping
Inreality,theonlythingthechildreallyhascontroloveriswhetherhea,emptstousethetechniques
taughtintherapy.
101
WritingGoalsFluencyShaping
• Forachildwithar:cula:onconcerns,achieving80%successisoaenviewedasasignofsuccess.
• Achildwhois80%fluentiss:llexhibi?ngstu,eringon20%ofhiswords,whichisconsideredverysevere.
102
WritingGoalsFluencyShaping
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SampleAnnualGoal
In36instructionalweeks,Joséwilldemonstratetheabilitytouselearnedfluencyshapingstrategies(e.g.,continuousphonation,lightarticulatorycontacts,confidentialvoice)invariousclassroomsituations,asreportedbythechildandteacheranddocumentedbychecklistsandtargetedobservations.
103
WritingGoalsFluencyShaping
SampleBehavioralObjective
Joséwilldemonstrateabilitytouseavarietyoffluencyshapingtechniques(continuousphonation,lightarticulatorycontacts,andconfidentialvoice[WHAT]duringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessions[HOWOFTEN]inthetherapyroom[SETTING]with1-2verbalornonverbalprompts[SUPPORT].
104
WritingGoalsFluencyShaping
Ifyourdistrictrequiresatleasttwobehavioralobjectivesundereachannualgoal,youcanspecifyonedesiredbehaviorforeachobjective:
§ Reducedspeechrate(ifrateisanissue)§ Easyonsetofvoicing(“easyspeech”)§ Reducedarticulatorypressure(lightcontacts)§ Continuousphonation§ Slightlystretchingfirstsound§ Confidentialvoice§ GILCU/ELU
105
WritingGoalsFluencyShaping
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SampleBehavioralObjective
Joséwilldemonstrateabilitytousecontinuousphonationduringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessionsinthetherapyroomwithminimalverbalandnonverbalprompts.
106
WritingGoalsFluencyShaping
SampleBehavioralObjective
Joséwilldemonstrateabilitytouseeasyonsetofvoicingduringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessionsinthetherapyroomwithminimalverbalandnonverbalprompts.
107
WritingGoalsFluencyShaping
SampleAnnualGoal
In36instructionalweeks,Joséwilldemonstratetheabilitytouselearnedstutteringmodificationstrategies(e.g.,cancellations,pull-outs,reducedphysicaltension)invariousclassroomsituations,asreportedbythechildandteacheranddocumentedbychecklistsandtargetedobservations.
108
WritingGoalsStutteringModification
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SampleBehavioralObjective
Joséwilldemonstrateabilitytouseavarietyofstutteringmodificationtechniques(cancellations,pull–outs)[WHAT]duringavarietyoftasksofincreasingcomplexity20consecutivetimesinthreesuccessivesessions[HOWOFTEN]inthetherapyroom[SETTING]with1-2verbalandnonverbalprompts[SUPPORT].
109
WritingGoalsStutteringModification
SampleAnnualGoal
SampleBehavioralObjective
Sampleannualgoalsandobjectivesforfluencyshaping,stutteringmodification,andaddressing
attitudesareonanelectronichandout.
110
WritingGoalsAddressingAttitudes
SeeELECTRONICHANDOUT:• WritingFluencyGoals
BulliesareaPainintheBrainByTrevorRomainFreeSpiritPublishingwww.freespirit.comIntendedaudience:Ages8-13Book-$8.95DVD-$45.00(80min.,color,animated,liveaction)
111
WritingGoalsAddressingAttitudes
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FiveMythsAboutBulliesByTrevorRomainFreeSpiritPublishingwww.freespirit.comIntendedaudience:Ages8-13Thisisatwo-pagefreedownloadatthewebsite.
112
WritingGoalsAddressingAttitudes
1. Bullieshavelowselfesteem.
2. Onlyboysarebullies.3. Gettingbulliedisanormal
partofgrowingup.4. Thebestwaytohandlea
bullyisbygettingevenorfightingback.
5. Ifyouignorethem,bullieswillgoaway.
SeeELECTRONICHANDOUT:• FiveMythsaboutBullies
113
WritingGoalsAddressingAttitudes
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.
114
WritingGoalsAddressingAttitudes
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1.Explainthecausesofstu*eringtoaparentorteacher.
2.Differen:atedevelopmentaldisfluenciesfromincipientstu*ering.
3.DemonstrateuseofavarietyofFSandSMtherapytechniques.
4.Writemeasureablefluencygoalsandobjec:ves.
115
LearnerOutcomes
116
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