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Children who stutter: Bilingual Issues in Assessment &

Treatment

Rosalee C. Shenker

CASLPA 2011

Why are you here?

Expectations from this session?

Why consider cultural & linguistic diversity in children who stutter?

S  50-70% SA children in Canada’s largest cities are children of immigrants

S  300,000 (7%) of all SA children in Canada are in some form of French immersion

S  Immigrant population is 19.8% of total

S  1/5 under 14 years old

S  20% of the Canadian population speak a home language other than English/French

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Bilingual Population

S  Immigrants to Canada come from 200+ countries speaking 150 different languages

S  4/5 are allophones ( those whose mother tongue is neither of Canada’s official languages)

10 most frequent languages

S  Chinese

S  Italian

S  German

S  Punjabi

S  Spanish

S  Arabic

S  Tagalog

S  Portuguese

S  Polish

S  Urdu

You will see these children!

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Some issues related to bilingualism/stuttering

S  Identifying stuttering in an unfamiliar language

S  Evaluating linguistic proficiency

S  Adjusting treatment to account for cultural beliefs & expectations

S  Evidence-based treatment

1. Identifying Stuttering in an unfamiliar language

S  Few guidelines

S  Stuttering can vary across languages

S  Different patterns are likely in children

S  Most research on bilingual adults

Einarsdottir & Ingham, 2009

S  SLPs unfamiliar with language

S  Reliable at identifying stuttering in 3-5 year old children

S  Consensus agreement

S  Rate in short intervals

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Tsai, Lim, Brundage, Bernstein Ratner ( 2011)

S  Provide examples of disfluency loci across major languages

S  Child Language Data Exchange System (CHILDES)

S  http://childes.psy.cmu.edu

Stuttering in an unfamiliar language

Can you pick out the unambiguous stutters?

2. Language Proficiency: Bilingual Children

S  May have uneven development across languages spoken

S  May have increased ambiguous disfluencies

S  Over-identification of stuttering may result

S  Delayed language may be misdiagnosed

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Bilingual children:

S  May change word order to preserve a grammatical rule of the stronger language

S  May code mix vocabulary of two languages

S  Not indicative of a speech avoidance or word retrieval problem

S  Use interpreters who can confirm proficiency

S  Detailed language history S  First exposure to each language

S  Course of language acquisition for each language

S  Other speech/language concerns

S  Where is each language used

S  Use perceptual rating scale for each language modality S  Roberts & Shenker, 2007

Evaluation of Linguistic Proficiency

Example

Language Proficiency/speaking

Poor Excellent

L1________ 1 2 3 4 5 6 7 8 9 10

L2________ 1 2 3 4 5 6 7 8 9 10

L3________ 1 2 3 4 5 6 7 8 9 10

Other_______ 1 2 3 4 5 6 7 8 9 10

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Conversational Sample languages spoken

q  Note disfluencies that could be related to reduced or developing proficiency

q  Include relevant, age-appropriate tasks including conversation, monologue, story retell, reading, picture identification

q  Probe increasing complexity

q Compare to established benchmarks

3. Belief systems

1 piece of advice you have heard about stuttering that reflects cultural beliefs?

Parent beliefs Waheed-Kahn (1997)

S  Parents coped with stuttering by: S  Praying for change

S  Telling their children to speak properly S  Completing their sentences

S  Changing the environment; sending them to live with someone else

S  Asking them not to talk in public

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Cultural Diversity: Implications for Stuttering

S  Adds another dimension of complexity

S  Children are coping with psychosocial issues

S  Placed in novel situations S  Introduction to a new language in school

S  Exposure to mixed linguistic input

To support our clients

S Need to view bilingualism with a new lens

S Not as a problem

S Understand cultural beliefs and practices

Retelling family stories

S  Encourages parents to identify hopes & concerns for treatment of stuttering

S  Consequences of loosing 1st language, e.g. loss of cultural identify, values, beliefs, communication with grandparents

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Retelling family stories

S  Values traditions, lifestyle practices, & linguistic heritage

S  Will have positive impact on treatment

S  Allows for assessment of pragmatic behaviors that may be culturally determined S  Rules for eye contact

S  How children are praised

S  Facial expressions, gestures that replace verbal comments

Establish role of family in treatment

S  Who will bring child to therapy?

S  Who will be the model in beyond clinic setting?

S  Other family members included in treatment?

S  What attitudes may impact treatment outcome?

Bilingualism

S  Does not mean speaking 2 languages perfectly

S  Case descriptions

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4. Treatment of Stuttering in bilingual children

What evidence do we have?

Eliminate one language Karniol 1992

S  Case study – English/Hebrew/Hungarian

S  Stuttering onset 2;1

S  Hebrew only >stuttering disappeared

S  No details of stuttering

S  Is this a case of natural recovery

S  Guttmann & Shenker (2006) – 4 bilingual preschoolers

Does fluency treated in L1 language generalize to L2?

Humphrey et al 2001

S  11-year old twins

S  English/Arabic

S  Treated in Arabic

S  Fluency increased in Arabic reading & transferred to English

Debney & Druce 1988

S  Intensive fluency shaping

S  No difference between bilingual/unilingual children in treatment outcome

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S  When family members: S  Attended therapy S  Learned treatment targets S  Reviewed lessons with child S  Modeled treatment targets at home S  Provided culturally appropriate materials S  Assisted in development of home program Outcomes improved

Using parents to provide treatment (Waheed-Kahn, 1996)

Lidcombe Program: A viable treatment for Bilinguals

Onslow, Packman, Harrison (2001)

S  Behavioral treatment

S  Parents provide verbal comments

S  Weekly clinic visits under guidance of SLP

S  Parents provide perceptual severity ratings to track progress

S  Can be easily adjusted for bilingual children

Case Studies

Shenker et al 1997

S  3 year old

S  Treatment first in L1(E)

S  L2(F) added at week 23

S  13.5%SS to 2.8%SS (L1)

S  9.9 – 4.4% (L2)

S  SR- 7-3.4

Roberts & Shenker 2007

S  3;11 year old

S  Stuttering onset > 18 months

S  Pre-treatment 5.6-9.8% (L1-2)

S  15 sessions in 23 weeks to Stage 2

S  <1%SS 88 weeks after discharge

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Case Studies

Harrison, Kingston, & Shenker (2010)

S  5 year old

S  Treatment in 2 languages

S  Pre-tx – 3.8-12%SS

S  8 sessions in 12 weeks to Stage 2

S  Post-tx – 0.4-1.4%SS

Rousseau (2005)

S  7 year old

S  Treated in French only

S  Pre-treatment 2-6% (L1,2)

S  41 visits over 51 weeks to Stage 2

S  Post-tx - <1%SS

Case Studies

Bakhtiar & Packman (2009)

S  8;11 male

S  Baluchi and Persian

S  12 sessions over 13 weeks

S  Maintained for 10 months

S  Baluchi at home; Persian in clinic

Treatment Outcomes: Bilingual Children

S Findlay & Shenker ( CASLPA 2011)

S  Median treatment time S  12 sessions to Stage 2

S  Consistent with benchmarks for monolingual children

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Case History

S  Age at onset of treatment – 5;0

S  Stuttering onset - 3 years

S  L1= English/French; L2 = Hebrew

S  Temperament – sensitive but warms up quickly

S  Expressive Language – WNL at assessment (French less complex development)

S  Family History – recovered (older sister, mother)

Case History, cont.

S  Previous treatment – none

S  Awareness – initially aware/unconcerned; recent increase in frustration; some abandonment of speaking, e.g., ‘I can’t say it’ .

S  Parent feedback – ‘slow down’, ‘take a breath’ when stuttering increases

Objective

S  Referring SLP – “severe disfluent speech with a high frequency of prolongations, blocks and first sound and syllable repetition”…some “secondary characteristics related to tension/anxiety…volume rises noticeably, loss of eye contact, turning of his head & neck to release a word…breathing becomes rapid & audible, turning to panting

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Objective

S  Speech - frontal lisp & fricatives substituted for sibilants

S  IC (pre-treatment) – 3%SS; SR=3

S  BC – 12%SS; SR – 7

S  poor eye contact

S  Expectation of Treatment – will respond to intervention and achieve standard LP Stage 2 criteria

Treatment

S  Stage 1 – visits 1-3 before holiday

S  Introduced SR

S  parents are reliable in verbal comments

S  Treatment provided in both English/French

S  Verbal contingencies for SFS introduced in structured speaking conversations

S  First telephone call (SR=2-3)

S  2%SS on taped sample

S  Initiating some spontaneous self corrections; less effort; more whole word, phrase reps.

Stage 2

S  Meets criteria in 8 visits over 12 weeks in both languages

S  Did not meet criteria for Stage 2 at first visit and subsequent 4 visits ( 5%SS; SR=4)

S  Parents resumed daily structured treatment conversations, mother trained to do ST measure

S  Discharged from Stage 2 after 12 months at 0%SS; SR =1

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What parents liked best about the treatment:

S  Being part of the solution for their son’s stuttering

S  Welcomed the opportunity to actively participate in treatment and gave high priority to attending sessions

S  Both were able to develop excellent problem solving and observational skills

0

2

4

6

8

10

12

14

1 16 31 46 61 76 91 106 121 136 151 166 181

%SS BC%SS IC-ESR-CE%SS-IC-F

Adjustments to traditional treatment

S  Culturally appropriate stimuli

S  Modified instructions to accommodate second language of the parent

S  Use audio/video exemplars in home language of child

S  Provide opportunities for practicing fluency in relevant contexts/activities

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Conclusion

S  More clinical studies with larger numbers of children

S  compare languages with different structures

S  early and later bilingualism

S  Bilingualism is not a ‘problem’

S  Important to assess in all languages the child speaks

S  Treatment is a collaboration between SLP & parent

S  Both stutterers and bilinguals are heterogeneous populations

Questions and discussion

Thank you!

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Rosalee C. Shenker, Ph.D. CCC-SLP

Bilingualism and Stuttering

Presented at CASLPA 2011