Helping Parents Learn 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

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 aspects of 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 supporting the 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

Overview of Stuttering Interpersonal Stressors Session #1 Overview of Stuttering Interpersonal Stressors

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, parents complete 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 stuttered or currently stutter High expectations are imposed by others

“Bucket” Analogy Purpose Identifies factors that may be associated with stuttering Helps parents understand the multifactorial nature of stuttering

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

“Bucket” Analogy Guidelines R I N G Begin at the bottom and work up Identify factors we have more control over and factors we have less control over

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

Communication “Wellness” “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 Modify interpersonal stressors Chart home disfluencies Modify communicative stressors Discuss types of disfluencies Administer Stressor Inventory Direct Child Intervention Parent Observation Strategy Practice Treatment Flow Parent Sessions

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 Fragmentation Continuum of Speech Disfluencies (adapted from Gregory, Campbell, Hill, and others) More Typical Interjections Revisions Phrase repetitions Multisyllabic whole- word repetitions Increased Fragmentation Crossover Behaviors Monosyllabic whole- word repetitions Part-word repetitions No tension/struggle 1 – 2 iterations Increased Tension Less Typical • Part-word repetitions • 3 or more iterations Prolongations Blocks Any type of disfluency with increased 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 chart to 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

Overview of Fluency Enhancing Strategies Session #2 Overview of Fluency Enhancing Strategies

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 supportive communicative 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 as the first strategy to be addressed Familiarize parents with wireless microphone system

Wireless Microphone System “Use Easy Talking” Wireless Xmitter (Telex TW-6) Wireless Receiver (Telex AAR-1) (Easy Talking)

Session #3 Easy Talking

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 with the child while parents observe One parent interacts with child while receiving on-line feedback Second parent interacts with child while receiving on-line feedback Discuss observations and importance of reviewing videotape at home

Video Segment #1 Easy Talking

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 focus on Modified Questioning

Session #4 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 what Teddy wants to do. What does Teddy want to do? “I wonder…” “I think…” “I bet…” “I guess…” “Maybe…” “It looks like…”

Model & Practice Modified Questioning Session has same structure as #3 Clinician models Modified Questioning with the child while parents observe One parent interacts with child while receiving on-line feedback Second parent interacts with child while receiving on-line feedback Discuss observations and importance of reviewing videotape at home

Video Segment #2 Modified Questions

Reduplication / Rephrasing Session #5 Reduplication / Rephrasing

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 heard what he or she said Gives parents the opportunity to provide a good language/articulation model Session has same structure as #3, #4

Reduplication / Rephrasing Delayed response Video Segment #3 Reduplication / Rephrasing Delayed response

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

Goals for Session #6 Use the “refresher” handout 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

Evaluation and Future Directions Does any of this work?!?

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’ communication and children’s fluency during treatment

Diagnostic Data Treatment Process Outcomes / Follow-up Case Presentations   Diagnostic Data Treatment Process Outcomes / Follow-up

JC (3;2) – from videotape Diagnostic Results Treatment Process Outcome 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 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 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

Adapting the Technique for Other Sessions Practical Considerations

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 Pittsburgh 2599 Wexford Bayne Rd. Sewickley, PA 15143 Phone: (724) 933-3600 Fax: (724) 933-3621 Email: hammerd@chplink.chp.edu J. Scott Yaruss, Ph.D., CCC-SLP University of Pittsburgh 4033 Forbes Tower Pittsburgh, PA 15260 Phone: (412) 647-1367 Fax: (412) 647-1370 Email: jsyaruss@csd.upmc.edu