Evolving Communicative Competence in School-Age Children … · 2020-02-11 · From this workshop...

EvolvingCommunicativeCompetenceinSchool-AgeChildrenWhoStutter

KristinA.ChmelaM.A.CCC-SLPBCS-FOwner&Director,ChmelaFluencyCenter

DirectorofTraining&TherapeuticPrograms,

CampShoutOut

Chmela2019/AllRightsReserved 1

KristinChmela,M.A.,CCC-SLPBCS-F,spendsthemajorityofhertimeworkingwithindividualsofallageswithfluencydisordersatherclinic,ChmelaFluencyCenter,inthesuburbanChicagoarea.Sheisarecognizedlectureronthetopicofchildhoodfluencydisordersacrosstheworld.SheisCo-FounderandCo-DirectorofCampShoutOut,atherapeuticprogramforschool-agechildrenwhostutterandahands-ontrainingopportunityforprofessionalsandgraduatestudents.KristinwasformerChairoftheAmericanBoardofFluencyandFluencyDisorders,supervisesgraduatestudentsfromacrosstheglobe,providessmallgroupintensivetrainingsathercenter,andhasservedasadjunctfacultyatNorthwesternUniversity.Throughouthercareer,KristincollaboratedextensivelywiththeStutteringFoundationontrainingvideos,conferences,andpublications.Sheisleadauthoroftwopracticaltherapymanualsandprovidesongoingconsultationservicesforseveralareaschooldistricts.Asapersonwhogrewupstuttering,Kristinhasremainedpassionateabouthelpingpeoplewhostutterandthosewhoservethem,evenafter32yearsinthefield!Kristincanbepersonallycontactedatkristin@chmelafluencycenter.comorat847-383-5589. Chmela2019/AllRightsReserved 2

DisclosureStatement:KristinChmelaM.A.CCC-SLPBCS-F•  NonfinancialNonon-financialrelationshipstothecontentofthispresentationaredeclared. •  Financial

-BasicPrincipleProblemSolving:WorkingwithSchool‑AgeChildrenWhoStutter;Chmela,K.&Campbell,J.(2014)SuperDuperPublications;royaltypayments-FocusonFluency;SuperDuperPublications;royaltypayments-FluencyFlips;SuperDuperPublications;royaltypayments-DirectorofTrainingandTreatmentProgram;CampShoutOut;Holton,Michigan;onsitehonorarium

Fromthisworkshopparticipantswillbeableto:1)Assesscommunicativecompetencewithintheschool

settingforfluencycases2)DevelopDifferentialEvaluationandTreatmentplans3)Implement3strategiesacrosseachoftheFiveAreasof

FocusofCommunicativeCompetenceAswellas:-Atypicaldisfluencycases,makingdecisionsabouttherapyforpreschoolers,goalwriting,andmore

Ø  School-AgeStutteringiscomplicated

WhatcanwedoNOWtomakethispresentproblemevolveinapositivemanner? 5

Chmela2019/AllRightsReserved

-Whatcausesstuttering?(Smith&Weber2016)

“…Wearenowatapointintimewhentheanswertothisquestionnolongermustbe“wedon’tknow.”Itisnowwidelyacceptedthatstutteringisamultidimensionaldisorder.Itisalsowidelyacceptedthatstutteringisaneurodevelopmentaldisorder,whichmeansthatitarisesduringdevelopmentinchildhood…”(emphasisadded)

-Canweviewstutteringasanisolatedproblem?Briley,P.M.,&Ellis,C.(2018).Thecoexistenceofdisablingconditionsinchildrenwhostutter:evidencefromtheNationalHealthInterviewSurvey.JournalofSpeech,Language,andHearingResearch.

-Presenceofatleast1moredisablingdevelopmentalconditionwasatleast5.5timeshigher-Higheroddsforintellectualorlearningdisability,ADHD,seizures,autsim/Aspergers/pervasivedevelopmentaldisorder/otherdevelopmentaldelay-Existenceofotherdifficultiesshouldbeconsideredaspartoftheoverallmanagementplan

Chmela2019/AllRightsReserved7

-Dothecontributingfactorsmatter?MultifactorialDynamicPathwaysTheory(Smith&Weber,2017)

-Doestheapproachincludemorethan“speechtechniques?”Hughes,C.D.&Mahanna-Boden,S.(2017).Resultsfromastutteringclinicforschool-agechildrenwhostutter:apilotstudyusingacomprehensiveapproach.PerspectivesoftheASHASpecialInterestGroup.

Ø  School-AgeStutteringServices

-Ongoingproblemsolving:referencingandinterpretingtheBasicPrinciplesaccordingtocurrentknowledge,evidence,andresearch

-Identifyingschool-basedchallengeswithin

3areas:content,process,&integration(Chmela&Johnson,2018)

Dr.HugoGregory

Relationship

Counter-Conditioning,Desensitization

DifferentialEvaluation&Treatment

GuidedPractice

Modeling

Reinforcement-Self-Monitoring&SelfReinforcement

Generalization&Transfer

GradualDismissal&Ongoing

Maintenance

IntegrationofChild+

EnvironmentalFactors

Chmela&Campbell,2014;Gregory,1968;2003

Basic Principles help us guide the clinical process of positive change

BeaDifferentialThinker11

Family

EnvironmentThe Big Picture

Executive Functioning

MotorSocial Emotional

SensoryLanguageCognitive

What is the pattern of fluency?

What are the relevant potential contributing factors?

What are the strengths/weaknesses of the child’s overall Communication Profile?

Fluency Evaluation Options Formal Measures Informal Measures

Motor Ø  TestofChildhoodStuttering(Gillam,Logan,&Pearson,2010)Ages4-11

Ø  StutteringSeverityInstrument-4(Riley&Riley2009)Ages3-up

Ø  Formalarticulation,phonology,oralmotor,voice

assessmenttoolsifneeded

InformalOptions:seecontinuumnextpageØ RatingsofStutterLikeDisfluencies(Onslow&Packman,2003Ø RatingsofOtherDisfluencies/RateofInformationflowØ RatingsacrossvariousspeakingsituationsØ SystematicDisfluencyAnalysis(Campbell&Hill,2003)Ø Real-TimeAnalysis(Yaruss,1998)Ø On-line%StutteredSyllables(Onlsow&

Packman,2003)Ø Cursoryoralmotorandvoiceassessment

Contributing Factors

FormalOptions:Ø OverallAssessmentoftheSpeaker’sExperienceofStuttering(OASES)(Yaruss,Coleman,&Quesal,2010);ages7-12;13-17)Ø BehavioralAssessmentBatteryforSchool-AgeChildrenWhoStutter(BAB),(Brutten&Vanryckeghem,2006);ages6-15ANDØ Languageevaluationmeasures

Ø SinglewordReceptiveVocabularyassessmentand

Ø SinglewordexpressivevocabularyØ ShortSensoryProfile:caregiver/parent,teachers;childifageappropriateORSensoryProcessingMeasure

Ø  Detaileddevelopmental,medical,andacademichistory;reportofotherconcernsordiagnoses;culturalfactors

Ø  Informalanalysisofspontaneousspeakingsample

Ø  Informaldialogueregardingperceptions,

feelings,andexperiencesrelatedtotheproblemaswellasadverse

Ø  Pencil-PaperTasks;(Chmela&Reardon,2001)Ages8-TeensØ  Parent&TeacherChecklists(Chmela&

Reardon,2001;Reardon&Yaruss,2004)

Chmela,2019;AdaptedfromChmela&Campbell,2014 13

FluencyCaseSummary

Motor Social-Emotional

Sensory Language Cognitive

FluencyPattern&PotentialContributingFactors

ModerateStuttering;blocks,prolongations;tensereactionswithheadmovements

Significantfrustrationwithinblocks;Pragmatic-peerissues

Significant

RiskFactors VeryHigh

ExecutiveFunctioningSkills&OtherDiagnoses

q  Difficultiesobservedq  Diagnoses:HighFunctioningAutism;ADHDq Moderateimpactofstutteringproblem

PresentStudentNeeds:q  Communicationwithinsmallgroupinteractionsq  Increasedself-initiatedpeerverbalinteractionsq  Increasedeffectivenessofmessagescommunicatedviaeasierrelaxedapproachto

onsetofphonation,pausing;self-adjustmentsoftension;assertivenessregardingneedingincreasedtime;healthyreactionstocommentsregardingstuttering

q  Ongoingcommunicationregardingstatusofself-perceptionsoffluency

Informalcasesummaryworksheet:Gage9-3

DevelopingGOALSforStutteringTherapyØ Frequencyofcommunicationascomparedtosame-agepeersacrossacademicenvironment

-Measuredacrossratingscalescompletedbycaregiver/s,student,teacher/s,SLP-Mayleadtogoalfocuseduponincreasingcommunicationwithincertainspeakingsituations

Ø Competencyofcommunicationascomparedtosame-agepeers

-Measuredacrosscaregiver/sreport,studentreport,teacher/s,SLP-Mayleadtogoalrelatedtomodificationsofvariouscommunicativebehaviors(see5AreasofFocus)acrossvariousspeakingsituations

Ø ProgressindicatedacrossRubricsrelatedtowhatwilloccuracrossspecificsituationswherebyfrequency/competencyisbeingtargeted

-Utilizingrubricsaccountsforthevariabilityofstuttering

•  G.willdemonstratepresentengagement(self-regulatingbody,connecting,inhibitorycontrol)making2ormorerelevantcontributions(buildinguponothers’ideasorexpressinghisown)withincollaborativegroupdiscussionsasmeasuredbycorrespondingrubric(0-4RatingScale;with3asanoverallaverage)by…

•  G.willcommunicatewithinsmallgroupinteractionsandself-initiatedpeercommunicationswhilecommunicatinginvarioussettingswithafrequencyof3(basedupon0-4Rubric))completedbystaffobservationsby…

•  G.willdemonstrateavarietyofmodifications(Easier-RelaxedApproach-SmoothMovements-Phrasing;Pausing;Self-AdjustmentstoTension;TurntheQuestionAround)whilecommunicatinginvarioussettingswhileansweringquestionsanddemonstratingnarrativeswithafrequencyof3(basedupon0-4Rubric)asmeasuredbyacomparisonofhisself-ratingtostaffrating(75%correspondence)by...

BriefOverviewofTreatmentStrategies:Gage9-3Attentive

Awarenessofthoughts,emotions,&body;situation

&resultantactions

AssertiveInitiating,participating;advocatingforoneself

ConfidentBodylanguage;Voicevolume&strength

EffectiveCommunicatingwith

greaterease;intelligibility,

organization,&clarity

ProactiveEngaginginsetting

oneselfupforevolvingcommunicativesuccess

q  Breathawarenessq  Mindfulnessq  ReflectivelisteningExecutiveFunctioning:(Skillstargetedwithinacademicandhomeenvironment;reinforcedthroughoutspeechtherapy)q  Self-Regulationq  InhibitoryControlq  Shift-Sustainq  SensingTimeq  CognitiveFlexibility

q  SocialLanguage(Sociallanguagegoalsformulatedandarereinforcedwithinfluencytherapyandthroughouttheacademicday)

q  FirsttoApproachq  Talkingforyourselfq  TalkingMoreq  SayingAllWordsq  Nonverbal-Verbal

Notingq  Self-Advocacyq  Educatingothers

abouthiscommunication&stuttering

q  Coreseated&standingpostures

q  Handshakeq  Naturaleye

contactq  Bodylanguageq  Volume-powerof

q Varyingintent&expression

q Pausingwithvariationq Phrasingwith

variationq Expressive

Organization:Completesentences;Narratives;Answeringquestions(TTQA)

q Easier-Relaxed

Approachwithvariation

q SmootherMovementsq Self-adjustmentsof

tensionq Voluntarydisfluencyq Naturalstutteringw/

q  CorePracticesq  GuidedHierarchies

ofPracticeq  AccessingOngoing

Supportq  OtherDaily

PreparationBalancinginput-technology;physicalbody

FluencyCaseSummary

ModerateAtypicalDisfluency(finalsoundrepetitions)

Someself-regulatoryissuesreportedathome

Significantlyaboveaverage

RiskFactors Nofamilyhistory

q  Nonereported

PresentStudentNeeds:q  Communicationwithinvariouslevelsoflanguagecomplexityq  Communicationwithinfamilyconversationsq  Increasedeffectivenessofmessagescommunicatedviacounterconditioningoffinal

sounddisfluenciesq  Education&involvementofparentsintherapy;teacher

Informalcasesummaryworksheet:Tage11-6

BriefOverviewofTreatmentStrategies:Tage11-6Attentive

&resultantactions

q  Breathawarenessq  Mindfulnessq  ReflectivelisteningExecutiveFunctioning:q  Self-Regulationq  InhibitoryControlq  Shift-Sustainq  SensingTimeq  CognitiveFlexibility

q  SocialLanguage

abouthiscommunication&stuttering

variationq Naming&countering

atypicaldisfluency;Completesentences;Narratives;Answeringquestions(TTQA)

q Easier-Relaxed

q  CorePractices:BreathAwareness;Mindfulness

q  GuidedHierarchiesofPractice

q  AccessingOngoingSupport:parentwillprovidefeedbackduringdaily10minutespecialcommunicationtime

q  OtherDailyPreparationBalancinginput-technology;physicalbody

TherapyGoalsforTage11-6:

FluencyCaseSummary

SevereSLD;blocks,prolong;multipleinterjectionsnotedpriortoSLD

Instancesofbullying;Withdrawingfromtalkinginclassroom

Seekinginput;tactile-proprioceptive;historyofOT

Recept-Exprvocabdiscrepant

RiskFactors Veryhigh

q  Noneidentified;disorganizationathomenoted;parentconcernedaboutattention;veryimpulsive

PresentStudentNeeds:q  Communicationwithteacher(frequency&competency)q  Communicationwithinsmallreadinggroupsinclassroom(freq&comp)q  Increasedeffectivenessofmessagescommunicatedviareducingeffortassociatedwith

stutter;desensitizationoffearrelatedofstutteringmoment;attitudes&feelingsq  Education&involvementofparentsintherapy;teacherq  Self-advocacywithpeersq  Furtherexplorationof‘attention’concerns

Informalcasesummaryworksheet:Mage8-1

BriefOverviewofTreatmentStrategies:Mage8-1Attentive

&resultantactions

q  Breathawarenessq  Mindfulnessq  ReflectivelisteningExecutiveFunctioning:q  Self-Regulationq  InhibitoryControlq  Shift-Sustainq  SensingTimeq  CognitiveFlexibility

q  SocialLanguage

aboutcommunication&stuttering

variationq Completesentences;

Narratives;Answeringquestions(TTQA)

q Easier-Relaxed

q CorePractices:BreathAwareness;Mindfulness

q  GuidedHierarchiesofPractice

q  AccessingOngoingSupport

q  OtherDailyPreparationBalancinginput-technology;physicalbody

TherapyGoalsforMage8-1:

StutteringPersistencevs.Recovery

Preschool-1stgrade

2nd-4thgrade

5th-8thgrade

1yearpostonset: 63%recover2yearspostonset:47%recover3yearspostonset:16%recover4yearspostonset:5%recover

Themajorityofyoungchildrenbeginstutteringbetweentheagesof2-4.75%willrecoverwithin1yeariftheonsetofstutteringispriorto3.5yearsofage.

Ø  WhydoesfocusinguponoverallCommunicativeCompetencematter?

RiskFactorsAnalysisChart*PrimaryRankOrderedRiskFactors

FamilyhistorywithpersistenceGenderofchildTrendsinfluencypatternTimepersistedsinceonsetAgeatonset#andtempoofrepetitionunitsPresenceofprolongations/blocks

q  Who?q  Maleq  FlatorIncreasedtrendinfrequencyovertimeq  Continuedfor6-12monthsq  After3½yearsofageq  2-3ormoreunitsofrepetition;quickertempoq  PatternofSLDincludesBlocks-Prolongations

SecondaryRiskFactors

StutteringSeverityMovementsofhead,neckPhonologicalSkillsExpressiveLanguageSkills

q  Post1year,remainsinseverequantityrangeq  Post1year,remainfrequent&severeq  Belownormalinearlyphaseofstutteringq  Remainedadvancedovertime;weaknesses

OtherConsiderations

ChildReactionstoproblemChild’sTemperamentobservationsOtherParentReactionsOtherfamilyhistory

q  Frustration/Withdrawal/Avoidanceq  Lowersensorythreshold,higherreactivity;lower

adaptability,higherdistractibility,lowerattentionq  Otherdevelopmentalissuesq  Significantanxiety/negativemannerofreactingq  Speech/language,learning,anxiety,mood,attentiontic

orcompulsivedisorders;autism

ChmelaFluencyCenterReferencesincludeYairi&Ambrose,2005,IllinoisPredictionCriteria;Yairi&Seery,2015;Kraft&Yairi,2011

Ø The mindset of an Evolving Communicator Ø 5 Areas of Focus Ø Integration of speech pathology, psychology,

neuroscience, and occupational therapy Considers the integration of familiar approaches (Fluency Shaping & Stuttering Modification) and adaptations of “third-generation behavioral and cognitive therapies” (Hayes, 2004)

Ø  School-agestutteringtherapyfocusesuponevolvingCommunicativeCompetence

Key Concept #1: ² Communicative success is defined in multiple ways and is

within reach for all of us.

-Considers “The Big Picture” (the ongoing Differential Evaluation-Differential Treatment Processes)

-Willingness to keep learning and growing

Chmela2019CopyrightMaterialChmela2019/AllRightsReserved

Key Concept #2 ² Communicative competency is not perfect for anyone.

("The Concept of Communicative Competence." Handbook Of Communication Competence, ed. by G. Rickheit and H. Strohner. Walter de Gruyter, 2010)

-A historical topic -3 part definition -Accounts for relevance, variability, & motivation

Key Concept #3: ² Communicative abilities thread through most of what

matters to us. -Linking what we do (actions) to what matters to us (our values) -Helps us to identify behaviors that may no longer be helpful to us -Fosters healthier communicative attitudes- behaviors

5AreasofFocusof

EvolvingCommunicativeCompetence

AdaptedfurtherbyChmela,2018;three/fiveelementsdefinedoriginallybyChmela,expandedbyChmela&Campbell,2014;furtherexpandedbyChmela,Campbell,Eldridge,&Raynorthroughout

CampShoutOutcollaborationAllRightsReserved

How aware am I? Am I aware of my breath? Am I aware of what is going on around me? Am I aware of my thoughts? My emotions? What my physical body is telling me? Am I aware of listeners’ expressions and body language? Am I tolerant of waiting? Do I notice what I do when talking is harder? Do I notice when it is easier to speak? Do I hear it, feel it? Do I know what I do when I am trying not to stutter?

Thumb=Attentive

Counterconditioning&Awareness

Ø Wemayfocusupon:

q Breath awareness q Mindfulness q Reflective listening q Aspects of Executive Functioning -Self-Regulation -Inhibitory Control q Aspects of Social Language Chmela2019/AllRightsReserved 34

Do I talk if I want to? Do I say every word I want to say? Do I talk enough? Do I talk for myself? Do I self-advocate around communication if need be? Am I the first to introduce myself to someone new? Is the language I am using, voice tone and loudness respectfully appropriate for the situation?

Index=Assertive

q First to Approach q Talking for yourself q Talking More q Saying All Words q Nonverbal-Verbal Noting q Creating & Holding Space q Self-Advocacy q Educating others about communication &

stuttering

Confident: Do I have a strong body core? Do I sit with dignity? Stand like a majestic mountain? Do I connect with my eyes while communicating? Do I have a firm handshake and make a connection with my eyes when introducing myself? Is my voice from the start to the end of a phrase powerful? Do I feel a sense of ease in the pause?

ThirdFinger=Confident

Chmela2019CopyrightMaterialChmela2019/AllRightsReserved

q Core seated & standing postures q Handshake q Natural eye contact q Body language q Volume-power of voice

Effective: Do I communicate moving towards what I want to say? Can I create greater ease? Are my sentences complete? Is my message organized and clear? Does the manner of my speaking allow the listener to focus upon my message?

Fourth=Effective

Ø Wemayfocusupon:Varyingintent&expression

PausingwithvariationPhrasingwithvariationCompletesentences

TurningtheQuestionAroundExpressiveOrganization

Easier-RelaxedApproachwithvariationSmootherMovements

Self-adjustmentsoftensionVoluntarydisfluency

Voluntaryself-adjustmentsNaturalstutteringw/ease

Lessspecifictomorespecific

waysofm

odifyingspeaking

Proactive: Do I know how to set myself up for success as a communicator ? Do I have a team? Do they know how to help me? Do I know what my goals are? Do I know how to ask for feedback? Am I working on self-feedback? Do I do Core Practices? Am I learning how to Guide my own practice?

Pinky=Proactive

Ø  ExploringAttitudesandFeelings

4CategoriesofQuestionstoAskTeens

1.Desire-Whatdoyouwant?

2.Ability-Whatispossible?

3.Reasons-Whatarethebenefits?

4.Need-Howimportantisthischange?

Zebrowski(2018presentation)MotivationalInterviewing(Rollnicketal.,2008)

Whatisitthatyouwant?(DesireQuestions)•  Whatwouldyouliketoseedifferentaboutstuttering?•  Whatmakesyouthinkyouneedtochange?•  Areyouconcernedaboutyourstuttering?Areothers

concerned?•  Whydoyouthinkothersareconcernedaboutyour

stuttering?•  Whatideasdoyouhaveaboutwhatneedstohappen?•  Whatisyourtheoryaboutwhyyoustutter?•  Inwhatwaysdoyouseemeandthisprocesshelpfulin

attainingyourgoals?

43Zebrowksi Chmela2019/AllRightsReserved

•  Whatarethemostchallengingspeakingsituationsforyou(worriedyouwillstutter,avoidingtalking-stuttering;stutterthemost)?

•  What-wherearethecircumstanceswhen“doingsomethingwitha

stutter”isveryhardtodo?•  Howconfidentareyouinyourabilitytouseanewbehaviorand

remainengagedfollowingfailure(ona1-10RatingScale)?

•  Ofthemostchallengingsituations,whichonewouldyoubewillingtotakeonfirst?Whatwouldittaketocreateapositivechangeinthatsituationalcircumstance?

•  Acrossthe5AreasofFocus,wheredoyouseeyourself-yourstrengthsandareasofpossiblechangeorgrowth?

•  Whatareasmatterthemosttoyoutofacilitatechange?Why?

Whatdoyouseeyourselfdoing?(Ability)

44AdaptedbyChmela/Zebrowksi

•  Whatwouldbethegoodthingsaboutchangingsomethingabout

yourstuttering?Whatwouldbenotsogoodaboutchanging?•  Whatwillhappenifyoudon’tchange?•  Whatwillyourlifebelikeiftomorrowyouwokeupandnever

stutteredagain?Whatwouldyoubethinking,feeling,anddoingdifferently?Whatwouldyourteachersnotice?Yourparents?Siblings?Friends?

•  Howimportantismakingthischange?

Whyareyoudoingit?(Reason&NeedQuestions)

45Zebrowksi

q Core Practices q Guided Hierarchies of Practice (see

next) q Meet with teacher/other

RevisedChmela2019/CampShoutOut2015Campbell&Chmela/Campbell,2003

How many people?

Who are they? What input do I need?

Feedback What ACTIONS (Attentive, Assertive, Confident, Effective)

will I DO WHILE I am:

¨ 2-3 ¨ Peers I know ¨ Girl(s)/Boy(s)

¨ Sitting ¨ Standing ¨ Walking ¨ Other

Who will give Feedback? ¨ SLP ¨ Self ¨ Teacher ¨ Other

¨ 4-5 ¨ Peers I don’t know

¨ Girl(s)/Boy(s) ¨ Speech group

¨ Half class

¨ Whole class

¨ Authority Figures ¨ Familiar Adults ¨ Unfamiliar Adults

¨ Visually distracting

¨ Limited visual distractions

How? ¨ Whole

grade ¨ Whole

School

Other:

¨ Noisy ¨ Quiet

¨ Verbal Reminder

¨ Tactile Reminder

¨ Visual Reminder

Other:

*Allsituationsconsiderlanguagecontext,discoursestructure,andsemanticcomplexity.

Campbell,2003;Chmela&Campbell,2014

Guided Practice Chart

RevisedChmela2019/CampShoutOut2015Campbell&Chmela/Campbell,2003

How many people?

Who are they? What input do I need?

Feedback What ACTIONS (Attentive, Assertive, Confident, Effective)

will I DO WHILE I am:

¨ 2-3 ¨ Peers I know ¨ Girl(s)/Boy(s)

¨ Sitting ¨ Standing ¨ Walking ¨ Other

Who will give Feedback? ¨ SLP ¨ Self ¨ Teacher ¨ Other

¨ 4-5 ¨ Peers I don’t know

¨ Girl(s)/Boy(s) ¨ Speech group

¨ Half class

¨ Whole class

¨ Authority Figures ¨ Familiar Adults ¨ Unfamiliar Adults

¨ Visually distracting

¨ Limited visual distractions

How? ¨ Whole

grade ¨ Whole

School

Other:

¨ Noisy ¨ Quiet

¨ Verbal Reminder

¨ Tactile Reminder

¨ Visual Reminder

Other:

*Allsituationsconsiderlanguagecontext,discoursestructure,andsemanticcomplexity.

Campbell,2003;Chmela&Campbell,2014

Guided Practice Chart

MeetwiththeTeacherCreateanagenda&negotiatewhowilldothe

talking

1.  Thingsaboutmycommunicationskills:mystrengthsacrossthe5AreasofFocus&myareasofgrowthIamworkingtowards

2.  Factsaboutmystuttering3.  Factsaboutstuttering4.  Thingsgoingwellformeinyourclassroom5.  ThingsIworryaboutornoticerelatedtomy

communication6.  WhatIamworkingonthathelpsmygrowthasa

communicator7.  Waysyouandmypeerscansupportme

Thefollowingideasaresuggestionsfortheteacher,coach,orinstructorwhohasachildwhostutters

inherorhisclassroomorprogram.Stutteringisacomplex,variableproblemwithabasisinthewiringandfunctioningofthebrain.Itisnotcausedbynervesorlackofconfidence,althoughitmayincreasewithmomentsofanxiety.Stutteringwaxesandwanes,bothinquantityaswellasinseverityoftheactualmoments.Itconstantlychangesovertime.Somechildrenwhostutterhaveotherspeechand/orlanguageproblems.Somechildrenmayhaveattentionproblemsorstrugglewithanxiety.Stutteringrunsinfamilies.Eachchildwhostuttersisdifferent.

Childrenperceive,feel,andreacttostutteringdifferently.Somekeepontalkingnomatterwhat,andotherstalklessorsaylesswhentheydotalkbecausetheydonotwantotherstoseethemstutter.Somechildrenexperiencehighanxietywhenmeetingnewteachers,coaches,orpeersinschool,sports,orduringotheractivities.Othersdonot.Childrenwhostutterperceivespeakingsituationsdifferently.Somefeelgivinganoralpresentationisverychallenging,wherebyothersfeelisiseaserforthembecausetheyaretheonlyonesspeaking.Somelovetoreadaloud,andothersdreaditeverydayoftheschoolyear.

Helpfulreactionstostutteringincludewaiting,lettinghimorherfinishwhatisbeingsaid,keepingeyecontact,andifpossible,saying,“Iamnotinahurry,”or,“Ihavetimetolisten.”Ifpeersorotherschuckleorimitatethechild,itishelpfultosayverymatter-of-factly,“Wegiveeachothertimefortalkinghere,andwedonottalkabout,laugh,ormimicthewaysomeonetalks.”Ifit’snottheappropriatetimeforthechildtotalk,oryoucan’tbeavailabletolisten,it’sO.K.tosay,“Let’sholdthatideaforlater”or,“Ican’tbeagoodlistenernow.Abettertimewouldbe…”tothechild.

Letthechildknowinprivateyouhavetimetolisteniftheyfeeluncomfortableaboutanythingassociatedwithtalkinginyourenvironment.Youcanaskhimorherdirectlywhatyoushoulddowhentheyarehavingdifficulty.IthelpstoassurethemitisO.K.iftalkingiseasyanditisO.K.ifitisnot,andthatnomatterwhat,youwantthemtosharetheirideas!Sometimesspendingafewminutestalkingdailyorweeklywiththechildone-on-onecanhelphimorherbecomemoreatease.

Teachers,coaches,andotherscanhelpbyhelpingthechildfeelcomfortabletalking,demonstratezerotoleranceforbullying,andoffersupportandunderstanding.Bullyingiscommonplaceforchildrenwhostutter,andpositivecommunicativeexperiencesforthechildareessentialthroughouttheirdevelopment.Othersuggestionsarelistedonthenextpage.Ifthechildisinspeechtherapy,itmaybehelpfultoreachouttothechild’sspeech-languagepathologistforideasaswell.Othersuggestionsarelistedonthenextpage,aswellashelpfulresources.

Suggestions for Teachers, Coaches, & Others Interacting with Elementary-High School Students Who Stutter

ü Ifyouarehavingthechildrenintroducethemselves,itmaybeeasierforthestudenttostartfirst.ü Thestudentmayprefertositinacertainspot.Sometimesclosertothefrontoftheroomiseasier.ü Delayedresponse(waitpurposelyfortwosecondsafterbeingcalledonbeforeprovidingananswer)forallstudentstopracticereducesthefeelingoftimepressureduringlargegroupdiscussionsandparticipation.ü Askallstudentstoorallycommunicateincompletesentences,;whenansweringquestionsorally,teachthemTTQA(TurntheQuestionAround)atthestartoftheiranswer.ü Createasignalfororalparticipationtohelpachildbecomemorecomfortableifwarranted(ifthechildwishestospeak,he/sheraiseshis/herhandwiththefingersinanopenposition;ifthechildknowstheanswerbutdoesnotwishtospeak,he/sheraiseshis/herhandbutkeepsitinafist. ü Offertheinitialpartofthedesiredresponseasalead-intothechild’sanswer(i.e.“Tyrone,numberfivestatesthattheboy….”).ü Askthechildmoreclosed-endedquestionswithchoices,suchas,“Didtheboyfindthetreasureorwashestillsearchingforit?”ü Physicallyapproachachildwhenhe/sheiscalledupontospeak(sothatthecommunicativeexchangeisbetweenthe2ofyou).ü Provideawarningpriortobecalledupon(Samyouanswer#1andMaxwillbe#2).ü Allowtheclasstohaveoralreadingoptions(readingalone,orreadingchorallywithapartner).ü CreateaSubstituteCard,includingthestudent’spicture,informationregardingthestudent’scommunication,aswellasthebestwaystoreact.Letthestudentknowthatiftherewillbeasubstitute,heorshewillbeabletocarrythroughwhatyouhavebeendoingtosupporthimorher.

HelpfulResourceswww.stutteringhelp.orgTheStutteringFoundationprovidesfreeonlineresources,servicesandsupporttothosewhostutterandtheirfamilies,aswellassupportforresearchintothecausesofstuttering.(educationalmaterials,professionalreferrallist,teachervideoandbooklet)www.stutteringspecialists.orgHelpsconsumersandprofessionalslocatespeech-languagepathologistswhoareBoardCertifiedSpecialistsinFluency:professionalswhohavegonebeyondthebasicclinicalcertification(CCC-SLP)awardedbytheAmericanSpeech-Language-HearingAssociation(ASHA).www.friendswhostutter.orgFRIENDSisanationalorganizationcreatedtoprovideanetworkofloveandsupportforchildrenandteenagerswhostutter,theirfamilies,andtheprofessionalswhoworkwiththem.www.westutter.orgTheNationalStutteringAssociationprovidessupport,friendship,andinformationtothestutteringcommunity.TheNSAprovidesinformationaboutstuttering,increasespublicawarenessofstuttering,servesasasupportandadvocacygroup,andisareferralorganizationforspeechtherapysourcesthroughouttheUnitedStates. Chmela2019/AllRightsReserved 51

SELECTEDREFERENCELIST:School-AgeChildren•  BernsteinRatner,N.(2005).Evidenced-basedpracticeinstuttering:Somequestionstoconsider.JournalofFluencyDisorders,Vol.30,3,pp.163-188.

•  Bloodstein,O.&BernsteinRatner,N.(2008).Ahandbookonstuttering,6thedition.Clifton,NY:Delmar.•  Bothe,A.K.,Davidow,J.H.,Bramlett,R.E.,Franic,D.M.&Ingham,R.J.(2006).Stutteringtreatmentresearch1970-2005:II.Systematicreviewofincorporatingtrialqualityassessmentofpharmacologicalapproaches,AmericanJournalofSpeech-LanguagePathology,15,342-52.

•  Brutten,G.&Vanryckeghem,M.(2007).BehaviorAssessmentBatteryforschool-agechildrenwhostutter.SanDiego,CA:PluralPublishing,Inc.

•  Chang,S.E.,&Zhu,D.C.(2013).Neuralnetworkconnectivitydifferencesinchildrenwhostutter.Brain,136,3709–3726.•  Chang,S.E.,Zhu,D.C.,Choo,A.L.,&Angstadt,M.(2015).Whitematterneuroanatomicaldifferencesinyoungchildrenwhostutter.Brain,138,694–711.•  Campbell,J.H.(2003).Therapyforelementaryschool-agechildrenwhostutter,InH.H.Gregory(Ed.),Stutteringtherapy:rationale&procedures,(pp.217-262).Boston:Allyn&bacon.

•  Chmela,K.&Johnson,L.(2018).Howcanweovercomethechallengesofprovidingschoolbasedfluencyservices?SeminarsinSpeechandLanguage,Vol.39,No4.

•  Chmela,K.&Campbell,J.H.(2014).BasicPrincipleProblemSolving:Workingwithschool-agechildrenwhostutter.Greenville,SC:SuperDuper,Inc.

•  Chmela,K.(2006).Self&doublecharting:Aself-monitoringstrategyforschool-agechildrenwhostutter.PresentedattheInternationalStutteringAwarenessDay(ISAD)InternetOnlineConference;October1-22,2006,http://www.mnsu.edu/comdis/isad9/papers/chmela9.html

•  Chmela,K.&Reardon,N.(2001).Dealingwithschool-agechildrenwhostutter:Workingeffectivelywithattitudesandemotions.Memphis,TN:StutteringFoundationofAmerica.

•  Craig,A.,Hancock,K.,Chang,E.,McCready,C.,Shepley,A.,McCaul,A.,etal.(1996).Acontrolledclinicaltrialforstutteringinpersonsaged9to14years,JournalofSpeech&HearingResearch,39(4),808-26.

•  Donaher,J.,Soffer,S.,andHealey,E.C.,(2004).ADHDandchildrenwhostutter:considerationsforevaluation&treatment.PaperpresentedatAmericanSpeech-Language-HearingAssociationConvention.Philadelphia,PA.

•  Faber,A.&Mazlish,E.(1999).Howtotalksokidswilllistenandlistensokidswilltalk(20thAnniversaryed.).NewYork:AvonBooks.

•  Gregory,H.H.(2003).Stutteringtherapy:rationaleandprocedures,(pp.217-262).Boston:Allyn&Bacon.•  Gillam,RonaldB.;Logan,KennethJ.;Pearson,NilsA.:TestofChildhoodStuttering.http//www.proedinc.com/

Customer/productView.aspx?ID=4504•  Healey,E.C.,ScottTrautman,L.,&Susca,M.,(2004).Clinicalapplicationofamultidimensionalapproachforthe

assesmentandtreatmentofstuttering,ContemporaryIssuesinCommunicationandSciencesDisorders,31,40-48.•  Healey,E.C.,Reid,R.,&Donaher,J.(2005).Treatmentofthechildwhostutterswithco-existinglearning,behavioral,

andcognitivechallenges.InR.LeesandC.Stark(eds.)Treatmentoftheschool-agechildwhostutters.London:WhurrPublishersLtd.

•  Herder,Howard,Nye&Vanryckehgem(2006).Effectivenessofbehavioralstutteringtreatment:Asystematicreviewandmeta-analysis.ContemporaryIssuesinCommunicationScienceandDisorders,33,61-73.

•  Laiho,A.,&Klippi,A.(2007).Long-andshort-termresultsofchildren’sandadolescents’therapycoursesforstuttering.InternationalJournalofCommunicationDisorders,42,367–382.

•  Langevin,M.&Hagler,P.(2004).Developmentofascaletomeasurepeerattitudestowardchildrenwhostutter,InBothe,A.K.(Eds)Evidenced-basedtreatmentofstuttering:empiricalbasesandclinicalapplications.Mahwah,NewJersey:LawrenceErlbaumAssociates.

•  Murphy,W.P.,Yaruss,J.S.,&Quesal,R.(2007).Enhancingtreatmentforschool-agechildrenwhostutter:Reducingnegativereactionsthroughdesensitizationandcognitiverestructuring,JournalofFluencyDisorders,Vol.32,Number2,2007.

•  Murphy,W.,Yaruss,J.S.,&Quesal,R.(2007).Enhancingtreatmentforschool-agechildrenwhostutterthroughrole-playandself-disclosure,JournalofFluencyDisorders,Vol.32,Number2,2007.

•  Reardon,N.A.&Yaruss,J.S.(2014).School-AgeStutteringTherapy:Apracticalguide.StutteringTherapyResources.

•  Riley,G:SSI4:StutteringSeverityInstrument,4thEdition;www.pearsonassessments.com•  RileyG.,&Riley,J.(2000).Arevisedcomponentmodelfordiagnosingandtreatingchildrenwhostutter,ContemporaryIssuesinCommunicationScienceandDisorders,27,188-199.

•  Scott,L.A.(2009).DecodingIDEAeligibilityforchildrenwhostutter,aninstructionalDVDproducedbyStutteringFoundationofAmerica.Memphis,TN.

•  Sisskin,V.(2002).Therapyplanningforschool-agechildrenwhostutter,SeminarsinSpeechandLanguage,23,173-179.•  Smith,A.&Weber,C.(2017).HowStutteringDevelops:TheMultifactorialDynamicsPathwaysTheory.JournalofSpeech,Language,andHearingResearch•Vol.60•2483–2505•September2017•Copyright©2017AmericanSpeech-Language-HearingAssociation2483

•  Whitmire,K.&Scott,L.A.(2007,July).IDEA2004andspeech-languageservices:Keyissuesforchildrenwhostutter.ASHADivision4LeadershipConference,Minneapolis,MN.

•  Whitmire,K.&Reardon-Reeves,N.(2006,November).MeetingtheChallengesofStuttering:WritingIEPgoalsforschoolagechildren.ASHANationalConvention,MiamiBeach,FL.

•  Yaruss,J.S.,Coleman,C.E.,&Quesal,R.W.(2010).OASESforschool-agechildrenandteens.Minneapolis,MN:Pearson.•  Yaruss,J.S.,&Pelczarski,K.Evidence-BasedPracticeforSchool-AgeStuttering:BalancingExistingResearchwithClinicalPractice,EBPBriefs,2(4),pp.1-8.

•  Yaruss,J.S.,&Quesal,R.W.(2004).StutteringandtheInternationalClassificationofFunctioning,Disability,andHealth(ICF):Anupdate.JournalofCommunicationDisorders,37,35–52.

OtherHelpfulReferences:BoardCertifiedSpecialistsinFluencyDisorders:www.stutteringspecialists.orgStutteringFoundation:www.stutteringhelp.org1-800-992-9392;resources,education,researchfriendswhostutter.orgFriends:(supportgroupforschool-agechildren-teensandfamilies)conventions&workshops;support;volunteeropportunityforspeechandlanguagepathologistswestutter.org–NationalStutteringAssociationconventions&workshops,support;volunteeropportunityforspeech-languagepathologistsStutteringhomepage.com–resourcesandInternationalOn-Lineconference-sectionavailableforschoolcliniciansTheMindUPCurriculum:Brain-focusedStrategiesforLiving&LearningbyTheHawnFoundationcommunity.mindfulschools.orgWillard,Christopher(2016).GrowingUpMindful:EssentialPracticestoHelpChildren,Teens,andFamiliesFindBalance,Calm,andResilience.SoundsTrue.Boulder,CO.Cheasman,C.(2013).Embraceyourdemonsandfollowyourheart:AnAcceptanceandCommitmentTherapyapproachtoworkwithpeoplewhostammer.InStammeringTherapyfromtheInside:NewPerspectivesonWorkingwithYoungPeopleandAdults.Cheasman,C.,Everard,R.,Simpson,S.,(eds.).Pp267-302.J&RPressLtd.Croydon.Harris,R.(2009)ActMadeSimple:AnEasy-To-ReadPrimeronAcceptanceandCommitmentTherapy(TheNewHarbingerMadeSimpleSeries.)Saltzman,A.(2014).AStillQuietPlace.AMindfulnessProgramforTeachingChildrenandAdolescentstoEaseStressandDifficultEmotions.NewHarbinger:Oakland,CA.Sedley,B.(2015).StuffthatSucks:ATeen’sGuidetoAcceptingWhatyouCan’tChangeandCommittingtoWhatYouCan.Robinson

55Chmela2019/AllRightsReserved

Evolving Document: Research & Evidence in Support of 5 Areas of Focus in School-Age Fluency Treatment Page 1

Attentive Assertive Confident Effective ProactiveØ ManyCWScantalkabouttheirtalkingabilitiesandthemselvesastalkers(Clarketal.,2012;Vanryckeghemetal.,2005;Vanryckeghem&Brutten,2007)Ø “Speakingisdifficult”perceptionofCWSdifferentiatesCWS-CWNS(Clarketal.,2012)Ø CWSnoticestutteringmore;increaseswithage(Ambrose&Yairi,1994)Ø Comparedtonormallyfluentpeers,school-agechildrenviewedaslesspopular,andaremorelikelytoberejectedandbullied(Davis,Howell,&Cooke,2002;Langevinetal.,1998,2003;Stewart&Turnbull,2007;Bloodetal.,2010)Ø Increasedsensitivityandhighselfexpectations(Riley&Riley,2000)

Ø  Comparedtonormallyfluentpeers,school-agechildrenviewedaslesspopular,andaremorelikelytoberejectedandbullied(Davis,Howell,&Cooke,2002;Langevinetal.,1998,2003;Stewart&Turnbull,2007;Bloodetal.,,2010)Ø Negativeemotionalreactionsandavoidanceofspeakingsituations(Yaruss&Quesal,2010;Vanryckeghemetal.,2001;Stewart&Turnbull,2007)Ø Mindfulnesstechniquescanbeusefulfortreatinganxietysymptomsinschool-agechildren(Goodman,2005;Grecoetal.,2005;Semple,Reid,&Miller,2005)

Ø  Comparedtonormallyfluentpeers,school-agechildrenviewedaslesspopular,andaremorelikelytoberejectedandbullied(Davis,Howell,&Cooke,2002;Langevinetal.,1998,2003;Stewart&Turnbull,2007;Bloodet.al,2010)Ø Negativethoughtsandfeelingsregardingtheircommunicationdifficulties(Andrews&Cutler,1974;DeNil&Brutten,1991)

Ø  Bothe,A.K.,Davidow,J.H.,Bramlett,R.E,&Ingham,R.J.(2006):-Regulatedbreathingandairflow(deKinkelder&Boelens,1998;Ladouceur&Martineau,1982)-Formofstutteringmodification(Ryan&Ryan,1983)Ø  Ratner(2010)evidencereview-prolongedspeech(fluencyshaping);GILCU(GradualLengthandComplexityofUtterances,preferablywithparentsandwitheitheraDAFdeviceoranEMGdevice(Ryan&Ryan,1983,1995)Ø  Boey,(2008)SpeechLanguagemaybedelayedtypical,oradvanced;comparinglanguageasnormalCWStoCWNS:-syntactic,semanticandphonologicalprocessesdevelopslowerthanthoseofCWNS;

Ø  Thewholefamilyistheclient;allareimpactedbytheproblem;Majorityofsiblingswouldliketobemoreinvolvedintherapy.CWSfeellessclosetotheirparentsandtrustthemlessthanCWNSandwerefrustratedbyhowparentsmanagedtheirstuttering(Bielby,2014)Ø  Reinforcementfromother(s)impactstxsuccess(Harrison,Bruce,Shenker,&Koushik,2010;andKoushiketal.,2009;Rousseau,Packman&Onslow,2005;Koushik&Shenker,2005Lincoln,Onslow,Lewis&Wilson,1996;Rousseau,Packman&Onslow,2005;Ingham,1980;Ryan&Ryan,1983)

Research & Evidence in Support of 5 Areas of Focus in School-Age Fluency Treatment Page 2

Attentive Assertive Confident Effective Proactive

Ø Negativethoughtsandfeelingsregardingtheircommunicationdifficulties(Andrews&Cutler,1974;DeNil&Brutten,1991)Ø Negativeemotionalreactionsandavoidanceofspeakingsituations(Yaruss&Quesal,2010;Vanryckeghemetal.,2001;Stewart&Turnbull,2007)Ø  Preschoolchildren:• Higheractivitylevel(e.g.,Eggersetal.,2010;Embrechtsetal.,2000)• Negativeaffect(e.g.,Eggersetal.,2010)• Lessadaptabilitytochange(e.g.,Andersonetal.,2003)• Lowerinhibitorycontrol(e.g.,Eggersetal.,2010)• Lessabletoflexiblycontroltheirattention/shiftattention(e.g.,Karassetal.,2006)Ø  Donaher(2014)CWSwith

ADHD(4-26%)

Ø  CWSexhibitmore“unevenness”inthedevelopmentoflanguage,vocabulary,articulationØ  (Donaher,2014)CWSwithADHD(4-26%)maydemonstratepragmaticlanguageissues;lackofawarenessoflistenerperspective;timingandquantityofspeechissues:Initiatingpriortoformulatingideas,issueswithinterrupting,monopolizing,relevancyfiltering&respondingadequatelytoconversationalpartnercues;Higher-levellanguagecomprehensionandexecutivefunctioningSequencing,organization,andcohesionoflanguagePoortopicmaintenanceFollowingthroughwithadetailedormulti-stepplanØ  Alm&Risberg,2007:adultswhostutternotedhistoryaschildren;muchhigherthenthegeneralpopulation

Ø  Systematictransferoffluencyacrosssettingsispartofevidenced-basedpracticeforthispopulation(Shenker,2005;Andrewsetal,1980;1983;Cordes,1998;Thomas&Howell,2001))Ø  Langevin,Narasimha&Prasad(2012):positivebenefitsregardingastutteringeducationandbullyingawarenessandpreventionprogramforschool-agechildreninGrades3through6Ø Milleret.Al,(2007)ChildrenwithSPD-difficultyachieving-maintainingappropriaterangeofemotionalandattentionalresponsesØ  Executivefunctioning

difficulties:lackofsituationalawareness,forethought,planning,andexecution(Ward)

Research & Evidence in Support of 5 Areas of Focus in School-Age Fluency Treatment Page 3AttentiveØ  (Jonesetal.,2014)Reactivity(arousalofemotions,motoractivity,andattentions;secondarytoanovelstimuli)-morenegativeintheiremotions/affect-moreemotionallyreactive,higheranger/frustration,andhigherinmotoractivation;Self-Regulation(theabilitytomoderatetheabovetendencies;abilitytoshiftattentionfromnovelstimuli)lessabletomaintainorshiftattentionwhenappropriate;lesseffectiveatorientingattention;-lessabletoignoreirrelevantbackgroundstimuli;lessadaptivetotheirenvironment;lessabletoSelf-RegulateemotionØ Morereactivetoenvironmentalstimuliandlesslikelytoquicklyhabituate(regulate)tothestimuli(Schwenketal.,2007)Ø Morenegativeemotion(Johnsonetal.,2010;Ntourouetal.,2013)Ø Moreextremehighthanextremelowbehavioralinhibition(Choietal.,2013);correlateswithmorestutteringØ  Emotionalregulationstrategiesduringpriornon-speechtasksarepredictiveofstutteringduringsubsequentspeakingtasks(Arnold

etal.,2011;Johnsonetal.,2010;Ntourouetal.,2013)Ø  Kraft,S.J.,etal.,2018:helpchildrenwhostutterwithself-regulation;strategiesthatassistwithaspectsofeffortfulcontrolare

importanttoassistwithpositivetherapeuticchange

• MindfulnessSkillshavethe“potentialtoenhancechildren’s…”-attentionandfocus,memory,self-acceptance,self-managementskills,&self-understanding(Hooker&Fodor,2008;Burke,2009)Ø Mindfulnesstechniquescanbeusefulfortreatinganxietysymptomsinschool-agechildren(Goodman,2005;Grecoetal.,2005;

Semple,Reid,&Miller,2005)Ø  Someevidencesupportstheimpactofmindfulnessonqualityofattention(Rani&Rao,1996;Semple,2005)Ø Mindfulnessincreasesself-esteemandself-compassion(Saltzman,2016)Ø  CognitiveBehavioralTherapy(Beck,1995)hasbeenreportedintheliterature(Zebrowski&Wolf,2011)asameanstoassistschool-

agechildrenindevelopinghealthierattitudesandfeelingsregardingcommunication

DifferentialEvaluation-DifferentialTreatment:•  Wereallcomponents(childandenvironmentalfactors)addressedduringtheevaluation?•  Arethereanyotherconcernsordiagnosesoutsideofstuttering&aretheybeingmanagedsuccessfully?•  Didtheevaluationincludeformalandinformalmeasures?•  Aregoalsbasedupondesiresofallrelevantstakeholders?Cantheybemeasured?

Relationship•  Arerelationshipsbetweenallpartiespositive?•  Doesthechildlikecomingtotherapy?•  Isthechild’srelationshipwithhim/herselfpositive?•  Areweexploringfeelingsandvalidatingthem?Listeningandvaluing?Providinginformation?Assistingindeveloping

ormaintaininghealthyattitudeandfeelingsregardingcommunicationandstuttering?

Counterconditioning&Desensitization•  Isthechildstutteringwithlesstension?•  Iscommunicationfacilitatedwithmoreease?Iscommunicationmorecompetentacrossthe5AreasofFocus?•  Havewedevelopedandexecutedhierarchiesoffearedordifficultspeakingsituations?•  Isthechilddemonstratinglesssensitivitytospeaking?Tostuttering?•  Isavoidancereducingoreliminated?•  Isthechild’scommunicationpatternmoreeffective?

WhatshouldIdonow?ProblemsolvebyreflectingupontheBasicPrinciples&definingthemthroughlatest

evidencebasedresearch

Modeling•  Arewemodelingspeechthatistensefreewithpausesandincreasedlisteningtime?•  Arewemodelingstutteringandwaysofchangingstutteringinacomfortablemanner?•  Hasthechildtaughtotherswhatheorsheisbeingtaught?GuidedPractice•  Areweguidingpracticewithintherapyactivitiesbymanipulatingvariables(length,complexity,andcontextof

languageoutput,ourmodel,reinforcement,meaningfulnessoftopic,andothersensoryinputsuchaspeoplepresent,place,andlistenerreaction)?

•  Havewetaughttheconversationalpartnerwhattolookfor&howtogivefeedback?

Reinforcement•  Whatarewereinforcing?•  Isourreinforcementgearedtowardspositiveattitude-speechchanges?•  Isallreinforcementgiveninapositivemanner?•  Istherationaleofwhatisbeingreinforcedcleartothechild?•  Howisthechildrespondingtothereinforcement?•  Arewesystematicallyfadingthereinforcement?

Self-Monitoring&Self-Reinforcement•  Areweaskingthechildtoself-evaluate?•  Areweincorporatingvarioustypesoffeedback(audio&visual,audioorvisual)toassistwithself-monitoring?

Generalization&Transfer•  Areweawareofthenuancesoftheseskillsandwhatisgeneralizing?•  Areothersaware,suchastheconversationalpartner,ofwhattheseskillslooklikeinrealconversations?•  Areweusingaratingscaletogetfeedbackfromothers?•  Arewegivingfeedbackeachsessionduringanaturalisticinteraction?•  Arethegoalsoftherapyrelatedtowhatisobservableacrossdifferentconversationalinteractions(communicative

behaviorsaswellaschangeinreactionstostuttering..ie..shiftsinattitudesandfeelings)•  Areweinvolvingparents,teachers,others?

GradualDismissal,FollowThrough,&Maintenance•  Wasthereagradualdismissalfromtherapy?•  Didwemakeaplantocheckin?•  Didwetalkwiththechildandrelatedothersaboutrelapseandaplanofmaintenance?•  Isthereanopportunityforongoingsupport?•  Didwehelpthechildandrelatedothersknowwhenitmightbeimportanttocomebacktotreatment?•  Doesthechild-othersknowthatitisnormaltopossiblyneedmoretherapyasdevelopmentoccurs?

IntegratingChild-relatedandEnvironment-RelatedVariables•  Isthemannerinwhichthetherapistisconductingtherapycommensuratewiththechild’scognitiveability?•  Arebehavioralcomponents,bothspeechandavoidanceofspeech,beingaddressedaspartoftherapyasappropriate?•  Arenegativeattitudesandfeelingsbeingmonitoredandaddressed?•  Asthechild’sdevelopmenthasensued,doestherapyreflectthosechanges?•  Areenvironmentalfactorsbeingconsideredaspartofthetreatment?•  Arecontributingfactorsbeingaddressedintheappropriatemanner?

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