Fluency Test 2

What should you incorporate when teaching a client about stuttering?

Educating the child, parents, and teachers.
o Identifying the core behaviors of stuttering.

What are two things that you can do when guiding a client to the stage of accepting stuttering?

talking and counseling

What are the two ways to help clients to communicate easily?

o Dealing with the environment
o Modifying stuttering and fluency

Explain the importance of early treatment.

o It is much easier to treat a child who stutters than it is to treat an adult who stutters
o Treat ASAP when disfluencies occur

Is intensity/gradual treatment more effective?

gradual

How many times a week should treatment be held (minimum)?

2 times per week

Should skills be learned immediately or gradually?

gradually

True or false: Treatment does not need to be integrated well to be maintained.

false

What type of treatment may be the best in achieving maintenance?

home treatment

Very intensive treatment produces striking ________effects but is/is not easily maintained.

initial

When is the best time for intensives to be held/attended?

What does indirect therapy intend to do?

attempts to create an environment that will enhance fluent speech

What does indirect treatment not include?

does not include direct manipulation of the child’s speech

What does indirect therapy focus on? (2)

What are parents taught when working to facilitate fluent speech by modifying aspects of the child’s environment? (3)

 reducing parental speech rate
 reducing interruptions
 limiting critical comments

What is the philosophy of indirect treatment?

The child should not be made aware of stuttering behaviors

When can indirect treatment be used?

can be used when children have little or no struggle or tension

When using indirect therapy should client’s experience negative feelings to use this approach?

no
Children receiving indirect treatment should also have no negative feelings associated with
their disfluencies

How long should an indirect approach be used before moving on to a more direct approach?

If indirect therapy is not effective in reducing stuttering after 8-10 weeks, then a more direct
approach should be used

What is direct therapy?

Treatment where disfluencies are directly addressed by teaching the child techniques such as easy speech and
modification

What does direct therapy focus on?

enhancing fluency by working directly with the child

When is direct therapy warranted?

warranted when mild and consistent disfluencies or moderate to severe
disfluencies are present in conjunction with any level of parental concern

What does research show about indirect & direct therapy?

Research indicates that both direct and indirect therapy approaches have merit in treating
young disfluent children and that neither approach has proven to be more efficient

What is direct questioning? Give an example.

requires the listener to answer the question immediately

-(e.g., What did you do in school today? How did you do on your spelling test?)

What is indirect questioning? Give an example.

designed to invite the child to communicate with the parents and then
stimulate open dialogue without contributing to communicative stressors that may affect the
child’s fluency
 (e.g., I wonder what you did in school today? Maybe you can tell me how your spelling
test was)

Who originally created the 6-week parent-child training program? Who modified the approach?

Coleman,
Hammer, and Yaruss in 2004 was modified by Santus and Tellis (2005) (e.g., Baselines)

Can it include a bit of direct therapy or is it only indirect therapy?

mostly indirect, but some direct therapy can be used

What are 6 aspects that are incorporated in th 6-week indirect approach?

(1) reducing specific and interpersonal stressors in the child’s life
 (2) reducing parents’ speaking rates
 (3) reducing time pressures
 (4) reducing demands for talking that may interfere with the child’s communication
 (5) modifying questioning
 (6) providing a supportive communicative environment

Explain the fluctuations of chronic stuttering.

(drawing in notes)

What is the goal of session 1? What questionnaires should be given?

The goal of Session 1 is to help parents understand the nature of stuttering and the
factors that may affect their child’s fluency

parent-only sessions for parental counseling and an overview of the
treatment program

parents are provided with an overview of the treatment process and then
begin the process of identifying the interpersonal stressors (Appendix B) for their child
who stutters

What is the goal of session 2?

parents explore interpersonal stressors and begin the process of modifying
communicative stressors
 Parents are also introduced to the next phase of treatment: parent-child modeling with
pauses between phrases

What is the goal of session 3?

During Session 3, parents are trained to use easy talking
 Easy talking (Appendix C) incorporates rates that are slower than the parents’
habitual rate
 During this session, parents begin to use the learned techniques of easy talking
with their child who stutters
 While the parent interacts with the child, the clinician uses a wireless FM
system to allow communication between the clinician and parents

What is the goal of session 4?

parents are trained to modify questions (Appendix D) by reducing the
number of direct questions in favor of more indirect comments
--Parents are taught strategies for delaying responses, decreasing demands, and home
charting methods
--Specific attention is given to Session 4 because indirect questioning is introduced and
modeled during this session

What is the goal of session 5?

parents are trained to use reduplication/rephrasing strategies so that their
children who stutter can hear what was said in an easier, more relaxed way

What is the goal of session 6?

the SLP helps the parents incorporate all the strategies into their interactions
with their children who stutter

When are parents instructed to implement indirect questioning (weeks)?

Throughout Sessions 4, 5, and 6, parents are instructed on the use of indirect questioning

What is the purpose of the bucket analogy?

Identifies factors that may be associated with stuttering
o Helps parents understand the multifactorial nature of stuttering

What are the 3 main factors that interact in the bucket analogy? Provide 3 examples of each.

Communicative Stressors (i.e., Negative response to disfluency, Demanding questioning, Frequent interruptions, Competition for talking time, Rapid rate of conversation)

Interpersonal Stressors (i.e., major life changes, marital and sibling conflicts, unrealizstic demands, face-pased/unpredictable lifestyles)

Clhild factors (i.e., perfectionist tendencies, high degree of sensitivity, intense/driven personality, other speech;language disorders, predisposition to stutter

What are the guidelines for the bucket analogy?

Begin at the bottom and work up
o Identify factors we have more control over and factors we have less control over

Explain the communication “wellness” analogy.

Purpose?

Describe structure and flow of treatment

Explain the communication “wellness” analogy.

Guidelines?

Begin at the bottom and work up
o Explain that not all steps may be necessary

Explain the communication “wellness” analogy.

Easy talking?

Conversational Level
o Direct Model to Question Model
 Sentences, phrases, and words

Explain the communication “wellness” analogy.

Model and practice?

Delayed Response
o Reduplication/Rephrasing
o Decreased Questioning
o Easy Talking

Lidcombe Program

a behavioral program that is administered by a parent in the child's
everyday environment

Is the Lidcombe Program a direct or indirect approach?

direct

What ages is it for?

3-6

What is the program?

Parents learn how to do the treatment during weekly visits to the speech-language pathologist

What happens during visits with the slp?

The SLP trains the parents by demonstrating various features of the treatment
 Observes the parents do the treatment
 Gives the parents feedback about how they are doing with the treatment

What is the scale for the parents used to rate the child daily?

The parent learns to measure the child's stuttering by scoring it each day out of 10, where 10 is "very
severe stuttering" and 0 is "no stuttering"

What are the two stages? Explain (Lidcombe)

o In Stage 1, the parent conducts the treatment each day and the parent and child attend the
speech clinic once a week
 This continues until stuttering either disappears or reaches a very low level
o The aim of Stage 2 of the program is to:
 Maintain the absence, or low level, of stuttering for at least one year
 Reduce the frequency of parental feedback and clinic visits provided that stuttering
remains at the low level at entry to Stage 2

Do you need to be certified?

Response Cost Therapy

A method in which:
o Desirable skills are positively reinforced with conditioned generalized reinforcers—tokens—
that are backed-up with other reinforcers (e.g., stickers, prizes, etc.)
o Each desirable behavior earns a token
o Each undesirable behavior loses a token
o Remember to reinforce with a token as soon as the child has a fluent utterance and stop the
child as soon as you hear stuttering and remove a token immediately (needs to be response
contingent)

RCT: Who should it be used with?

It is effective with young children for whom fluency shaping is not a good option

RCT: What does it not affect?

speech rate and speech naturalness

RCT: Is it easy or hard to administer?

easy

RCT: Explain the research behind it.

Response cost (RC) has been extensively researched in reducing various kinds of problem behaviors
with the highest level of evidence

RCT: What was found in the 60s and 70s? What was the issue with these findings?

In the 60s and 70s, RC was shown to be effective in treating stuttering, although the studies were
limited, with few participants and little or no follow-up (Halvorson, 1971; Kazvin, 1973)

Explain Hedge 2006

published promising results
40 preschoolers (34 boys, 6 girls); ages: 2.6 to under 6 years
o Sessions were held twice weekly
o Individual RC therapy was offered to each child for 30 to 35 minutes in individual therapy
rooms

Explain the first session of response cost therapy

the clinician introduces the RC procedure to the child by:
o Contrasting bumpy and smooth speech
o Reassuring the child that the clinician will help talk smoothly and that he or she can do it
o Showing plastic tokens and stating that if they collect 5 in a row for smooth speech, they will
get a sticker; and if they collect 5 stickers (25 tokens), they can play a game for a short while.
o Saying that a token will be taken away for bumpy speech

RCT: What happens when the child stutters?

Says something like “Oh no! That was bumpy! I am taking a token back!” and removes a
token from the child’s cup, drops it into her own cup (some parents and children do not like
this)
o Fluently models the child’s disfluent production, with normal rate and rhythm, for the child to
imitate
o Awards a token to the child if the imitated production is fluent
o Typically, the child’s imitated production will be fluent, quickly regaining the token

Should you administer response cost treatment during the reward?

NO!

Explain phasing out response cost therapy

 Initially, use the response cost procedure for every fluent utterance; however, once the child has very
high levels of fluency, you do not need to reinforce for every fluent utterance so that you can phase
out the tokens and change the reinforcement schedule; finally phase out the response cost procedure
when the child is completely fluent.

RCT Explain potential trouble 1: emotional reaction, for response cost therapy. How can toy troubleshoot this?

A child may react emotionally to the first token withdrawal and refuse to cooperate
 The child may stop talking, say “I don’t want to talk,” or fight tears


 The solution is role reversal
 Showing signs of disappointment is natural and nothing needs to be done
 More serious emotional reactions need to be handled promptly and sensitively

Explain token bankruptcy. How can you troubleshoot this?

Another potential problem is token bankruptcy—the child who is left with no tokens, which means no
gift at the end of the session
 More likely with highly disfluent children
 That, of course, should not happen; so avoid token bankruptcy at all costs
 Token bankruptcy means no reinforcement for fluency
 The child will react explosively! (And the method will not work)

What is reinforcing only fluency?

In the reinforcing fluency only program, use the same procedures as response cost; however, give
praise for fluent speech followed immediately by tokens and ignore stuttering

What is a potential problem with only reinforcing fluency?

One potential problem with this technique (reinforcing fluency only) is that some children will want
tokens every time they speak (even if they are disfluent); therefore, establish in the beginning that they
only will get tokens for smooth speech (model)

When should you use reinforcing only fluency?

end of the semester/school-year

How much of a session (min) should be used for parent education?

10

What are the parents given to use for at home carry-over?

Parents are given a progress chart (Appendix F) each week and are asked to spend at least 10 minutes
a day doing the therapy at home with the tokens and gifts for fluency (the gift could be something
really special that the child works towards)

How often should skills be practiced at home?

10 minutes per day

What is a system that is easy for data monitoring?

Data monitoring is very easy with the token system because a parent or clinician can easily count the
number of tokens that the child received for fluency as well as stuttering

What should the clinician remember when counting the tokens?

Remember, the number of tokens for fluency does not equal the number of words fluent but indicates
how many utterances were fluent (e.g., sentences, phrases, etc.)

What are three ways to treat stuttering & address child’s feelings & attitudes?

1.) Model Short, Easy Repetitions (Indirect Identification)
o 2.) Model Self-Corrections (Indirect Identification)
o 3.) Play Speech Cops games (Identification)
o 4.) Teach Easy Speech and Stretchy Talk
o 5.) Embrace Speech Villains (Walton and Wallace, 1998)

What is model short? What should you do when demonstrating it? Direct or indirect identification?

Be sure to demonstrate an easier, tension-free form of stuttering (Indirect Identification)
 Explain to the child that children and adults may have the same problems with their
speech
 Let the child observe that you experience these disruptions without struggle, tension, or
negativity

What should the clinician do when modeling easy repetitions? Should the clinician visibly react to the easy repetitions?

Make sure the repetitions are simple, that voicing is constant throughout the repetition, and
that no more than 2 repetitions are produced per instance
o Do not visibly react to the easy repetitions

What is “model self-corrections”? Direct or indirect identification?

Purposely insert disfluencies into your speech that are similar to the child’s speaking pattern
 Then, correct your disfluencies by repeating the utterance fluently (Indirect Identification)

Explain speech cops

Have the child point out to you when you are not saying a word the easy way (Identification)
o Best done as a structured activity, e.g., playing card or board games
 Have the child count the disfluencies by using chips or a peg board
 Put a limit on the number disfluencies used to no more than one per utterance
 Be aware that the majority of your utterances produced are fluent

What should the clinician do during the first session with easy speech?

During the first session with easy speech, tell the child that you will be practicing easy speech and
stretching together
o Greet the child at the door using easy speech and use it throughout the session and with the
parents

What is easy speech? What is stretched?

a minor prolongation “Stretch” on the first word (vowel or syllable) of a sentence
**vowel is stretched

What are the two things that easy speech includes?

o Easy vocal onsets
o Soft articulatory contacts

True or false: Minor voicing to reduce choppy speech during easy speech should not be used.

false

Explain the 3 pieces of using correct pausingand phrasing during easy speech.

o Slight overarticulation
o Normal rhythm and prosody
o No monotonous speech

What is the complexity ladder that the clinician should use for easy speech (hint: starts with vowels)

vowel--> conversation

True or false: The clinician should exaggerate easy speech is the client is having difficult with it.

true

What should the clinician be counseling the parents on?

Techniques such as:
- reducing interruptions
- modifying speaking rate may

facilitate the child’s fluency

What are 3 things that the clinician should tell the client’s parents to do when speaking to the child?

Pause 1 second between utterances
o Use shorter, simpler sentences
o Talk slower

What are 3 things that the clinician should discuss with the school teacher?

Peer ridicule
o Reinforcement of easy speech in the classroom
o Ways to increase the child’s success when talking in class
o Ask teachers not to cue for easy speech
o Reinforce the child in private, out of earshot of other classmates

What are the two most common types of direct treatment for stuttering?

o (1.) fluency shaping
o (2.) stuttering modification

Who should a direct treatment approach be used with?

adolesence and adults

Can a clinician guarantee a cure?

NO NO NO

Who created stuttering modification therapy?

Van Riper

Which is “non threatening” to clients?

fluency shaping

fluency shaping is based on... (2)

operant conditioning & programming principles?

Explain fluency shaping?

Fluency is reinforced and gradually modified to approximate normal conversational speech in
the clinic setting and eventually generalized to the individual’s daily speaking environment

Expand CHAIN

CHAIN = Inhalation, Exhalation, Onset, Rate Reduction (incompatible with stuttering)

What are the 4 target behaviors of the fluency chain reinforcement technique?

1.) Appropriate Air Flow Management
2.) Gentle Onset of Phonation, Continuous Phonation, and Soft Contact of the Articulators
3.) Overall Relaxed Posture
4.) Reduced Rate of Speech

How can we reduce the rate of speech?

Rapid rate of speech
o Increased syllable duration (preferred method)
o Increase pauses

What is the dismissal criteria for fluency shaping?

In clinic 98% fluency is expected
o Outside clinic, at least 95% fluency is expected

What is stuttering modification?

Therapy approach based on the theory that most of the speech problems of persons who stutter are a
result of avoiding or struggling with disfluencies, avoiding feared words, and/or avoiding situations

What does stuttering modification focus on?

Therapy focuses on reducing fears, avoidance behaviors, and negative attitudes towards speech