1. 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

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 aspects of 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 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

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 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

6. Overview of Stuttering Interpersonal Stressors
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, 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

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 stuttered or currently stutter
High expectations are imposed by others

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

12. “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

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

14. 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

15. 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

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. 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

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 chart to 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. Overview of Fluency Enhancing Strategies
Session #2
Overview of Fluency Enhancing 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 supportive communicative 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 Talking as the first strategy to be addressed
Familiarize parents with wireless microphone system

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

29. Session #3
Easy Talking

30. 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

31. 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

32. 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

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 questions they ask the child
Discuss upcoming session’s focus on 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 various non-questioning starters

37. “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…”

38. 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

39. Video Segment #2
Modified Questions

40. Reduplication / Rephrasing
Session #5
Reduplication / Rephrasing

41. 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

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

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

44. 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

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 sessions prior to three-month timeframe
May move right into fluency group or individual therapy

47. Evaluation and Future 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’ communication and children’s fluency during treatment

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

51. 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

52. 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

53. 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

54. 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

55. 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

56. Adapting the Technique for Other Sessions
Practical Considerations

57. 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

58. 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

59. 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

60. 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

61. 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

62. Questions? Comments? Let us know!
David W. Hammer, M.A., CCC-SLP Children's Hospital of Pittsburgh 2599 Wexford Bayne Rd. Sewickley, PA Phone: (724) Fax: (724)
J. Scott Yaruss, Ph.D., CCC-SLP University of Pittsburgh 4033 Forbes Tower Pittsburgh, PA Phone: (412) Fax: (412)