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Contributors

Jordanna M. Sevitz, MS, CCC-SLP, TSSLD-BEA

Teachers College Columbia University New York, New York

Casey Sheren, MS

Speech-Language Pathology Clinical Fellow Mount Sinai Hospital Mount Sinai Health System New York, New York

Lisa A. Simpson

Assistant Professor San Jose State University San Jose, California

Sarah Smits-Bandstra, PhD, SLP, Reg. CASLPO

Adjunct Professor Department of Psychology Social Science Centre, Room 7418 Western University London, Ontario, Canada

Chelsea Sommer, MS

Speech-Language Fellow Teachers College Columbia University New York, New York

Sarah Strathy-Alie, MHSc SLP (C)

Private Practice Toronto, Ontario, Canada

Jamie Swartz, BS

University of South Florida St. Petersburg, Florida

Casey Taliancich Klinger, PhD

Our Lady of the Lake University San Antonio, Texas

Tina M. Tan, MS, CCC-SLP, BCS-S

Supervisor, Pediatric Speech and Swallowing Services Department of Speech-Language Pathology Rusk Rehabilitation NYU Langone Health Hassenfeld Children’s Hospital New York, New York

John A. Tetnowski, PhD, CCC-SLP, BCS-F, ASHA-F

Ben Blanco/BoRSF Endowed Professor in Communicative

Disorders

Graduate Coordinator for Ph.D. Program in Applied

Language and Speech Sciences Board Certiﬁed Fluency Specialist and Mentor Special Interest Group in Fluency and Fluency Disorders

(SIG4) Coordinator Fellow, American Speech-Language-Hearing Association University of Louisiana at Lafayette Lafayette, Louisiana

Amber Thiessen, PhD, CCC-SLP

Department of Communication Sciences and Disorders University of Houston Houston, Texa

Sara J. Toline, MA, CCC-SLP

Clinical Specialist Cochlear Implant Center Rusk Rehabilitation NYU Langone Medical Center New York, New York

Mitchell Trichon, PhD, CCC/SLP

Assistant Professor Department of Communication Sciences and Disorders La Salle University Philadelphia, Pennsylvania

Michelle S. Troche, PhD, CCC-SLP

Associate Professor Speech-Language Pathology Program, and Director Laboratory for the Study of Upper Airway Dysfunction Department of Biobehavioral Sciences Teachers College Columbia University New York, New York

Shelley L. Velleman, PhD, CCC-SLP

Chair and Professor Communication Sciences and Disorders University of Vermont Burlington, Vermont

Judy P. Walker, PhD, CCC-SLP

Associate Professor Coordinator, Speech Therapy Telepractice Program Department of Communication Sciences and Disorders University of Maine Orono, Maine

xix

Contributors

Julie L. Wambaugh, PhD, CCC-SLP

Professor Department of Communication Sciences and Disorders University of Utah, and Research Career Scientist VA Salt Lake City Healthcare System Salt Lake City, Utah

Barbara D. Weinrich, PhD, CCC-SLP, ASHA Fellow

Professor Emerita and Research Associate Department of Speech Pathology and Audiology College of Arts & Science Miami University Oxford, Ohio, and Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Carol Westby, PhD

Consultant Bilingual Multicultural Services Albuquerque, New Mexico

Shane Wilmoth

Regional Adult Chapter Coordinator National Stuttering Association

Erin Yeates

Speech-Language Pathologist University Health Network Toronto Rehabilitation Institute Toronto, Ontario, Canada

Aaron Ziegler, PhD, CCC-SLP

Assistant Professor NW Clinic for Voice & Swallowing Department of Otolaryngology-Head & Neck Surgery Oregon Health and Science University, and Co-Founder, Co-President PhoRTE LLC Portland, Oregon

Jarrod B. Zinser, MS, CCC-SLP

School of Communication Science & Disorders Florida State University Tallahassee, Florida

Completely Normal Speech Is the Goal for a Child Born with Cleft Palate

1 Completely Normal Speech Is the Goal for a Child Born with Cleft Palate

Lynn Marty Grames

●

1.1 Introduction

An important concept, not often taught in our field, is that for the neurologically normal child born with a cleft, the goal is normal speech. Some children may present with maladaptive or compensatory articulations that require therapy, and these maladaptive/compensatory misarticulations are maladaptive motor patterns that require specific training at the phonetic level. A motor learning approach, in which the new motor pattern is practiced in increasingly complex motoric and linguistic functions, is an eﬀective means of facilitating transfer to spontaneous speech.

1.2 Clinical History and Description

MC was a full-term male born with cleft of the secondary palate (posterior to the incisive foramen) and micrognathia (small, retrodisplaced mandible), consistent with a preliminary diagnosis of Pierre Robin sequence. In addition, he presented with mild shortening of limbs and digits, hip dysplasia, and macrocephaly associated with enlarged ventricles. His mother was also born with a cleft palate. Genetic evaluation yielded no specific diagnosis, asserting that MC’s cleft was likely a unique presentation.

MC was admitted to the neonatal intensive care unit (NICU) at birth due to respiratory distress associated with his micrognathia, and feeding diﬃculties. The NICU followed an algorithm for conservative stabilization of his airway. When all conservative eﬀorts failed, he underwent a 15-mm bilateral mandibular distraction at 4 weeks of age. This surgical procedure is designed to gradually lengthen the mandible, thereby increasing the space between the base of the tongue and posterior pharyngeal wall. The airway improved significantly with distraction, and MC was discharged home at 2 months of age with a combination of oral and nasogastric tube feeding. He was gradually weaned from tube feedings to become a fully oral feeder over the course of 1 month at home. He received early intervention services in the home.

At 4 months of age, he underwent bilateral myringotomies with ventilation tube placement to treat chronic middle ear eﬀusion. Polysomnography (sleep study) at 12 months of age was normal. He underwent two-flap palatoplasty with repeat bilateral myringotomies and tubes at nearly 15 months of age.

1.3 Clinical Testing

Evaluation at 21 months of age yielded the following:

●

Normal hearing acuity.

●

Oral mechanism examination revealed intact palate with no evidence of fistula.

Voice quality, pitch, and intensity were within normal limits.

●

Resonance was diﬃcult to assess due to limited phoneme inventory, but significant aberrant nasal emissions were observed.

●

Articulation assessment via observation and imitation yielded a limited phoneme inventory. Consonants in the inventory included [m, h, ŋ], nasal stops, and both posterior and anterior nasal fricatives. Nasal stops and nasal fricatives are maladaptive articulations, believed to be compensatory, characterized by the supraglottal airstream being forced through the nose during speech and are frequently used as substitutions for oral pressure consonants. Vowel/diphthong repertoire was limited to [ɑ,æ,ʌ, ɛ, ɔ, ɑʊ]. Intelligibility of spontaneous speech was poor; MC’s mother expressed concern regarding limited intelligibility.

●

Language skills were assessed informally. MC used multisyllabic, but poorly intelligible utterances to request, negate, and comment. He exhibited age-appropriate social interactions and behaviors. The Bayley Scales of Infant Development-3rd Edition had been administered less than 2 months previously (chronological age 19 months) in his follow-up evaluation with the newborn medicine team (▶ Table 1.1).

1.4 Questions and Answers for the Reader

1. Does MC have a functional velopharynx? a) No. b) Yes. c) It is too early to tell.

Answer: c is correct. At present, his phonetic inventory consists of only vowels and consonants that do not require velopharyngeal closure. The addition of oral pressure consonants to his inventory will yield useful information about velopharyngeal function.

Table 1.1 MC’s developmental testing prior to speech-language evaluation

The Bayley Scales of Infant Development, Third Edition (administered at chronological age of 19 months)

Cognitive composite score = 100

Cognitive scaled score = 10 Age equivalent = 19 mo

Language composite score = 109

Receptive scaled score = 10 Age equivalent = 19 mo

Expressive scaled score = 13 Age equivalent = 24 mo

Motor composite score = 91

Fine motor scaled score = 12 Age equivalent = 23 mo

Gross motor scaled score = 5 Age equivalent = 14 mo

Completely Normal Speech Is the Goal for a Child Born with Cleft Palate

a and b are incorrect. Until his phoneme inventory increases to include attempts at oral pressure consonants, velopharyngeal function is unknown. The velopharynx should remain open for [m, ŋ]. It does not close for nasal stops and nasal fricatives, since the air is forced through the nose for those consonants. Vowels and diphthongs can be produced without velopharyngeal closure at this early stage of development, without pressure consonants.

2. The treating clinician may consider teaching [p, b] first, so as to learn more about his velopharyngeal function. Will [p, b] increase his intelligibility if he has a limited vowel inventory? a) No. b) Yes. c) It is too early to tell.

Answer: a is likely correct. A limited vowel inventory will limit the number of words he can produce intelligibly once he has [p, b]. Given his current vowel/diphthong repertoire, the following functional words may still not be intelligible even if he uses [p, b]: bye, baby, boat, boot, bite, big, pee, poo, pig, piece.

c is possibly correct. The therapeutic process is likely to pro-

vide the answer to this complex issue.

b is incorrect. Just as a limited consonant inventory limits one's intelligibility, so too does a limited vowel inventory. With a full vowel repertoire, we can expand the number of intelligible words a child can produce once we begin adding consonants.

3. It is atypical for children with cleft-related articulation disor-

ders to present with limited vowel inventory. Why might this child have a limited vowel inventory? a) He has apraxia. b) He has dysarthria. c) He maintains a posterior tongue carriage with pervasive

nasal stop and fricative use.

d) Any of the above.

Answer: d is correct. Only therapy progress will determine which of these options is correct. Given his history of enlarged ventricles and provisionally unique genetic diagnosis, one must be alert to the possibility of a neurologically based disorder, such as apraxia or dysarthria. Although he underwent mandibular distraction, which can result in stretching or severing of the inferior alveolar nerve, speech articulation deficits caused specifically by this are not reported. He also has a history of middle ear eﬀusions, which may mean that he had conductive hearing loss during critical periods for speech and language learning.

1.5 Description of Disorder and Recommended Treatment

Given his normal hearing, cognition, and receptive-expressive language skills, treatment was initiated with the hypothesis that this was a disorder of speech motor learning, characterized by maladaptive nasal stops and fricatives that likely entered his inventory prior to palate repair and then became adapted for use in linguistically meaningful ways. However, given his hydrocephalus and history of bilateral mandibular distraction, the possibility of a motor speech component, either apraxia or

dysarthria, was also possible, which, if present, would become apparent as treatment progressed.

A motor learning approach to therapy was initiated. Vowels were the initial target to improve intelligibility once consonants were added to the inventory. Using this highly structured therapy approach, the child must learn to imitate the therapist in a structured way. In addition, and also critical to therapy success, is the need for the child to enjoy therapy. “Mr. Potato Head,” or any construction toy or item with lots of pieces, is an eﬀective tool for the structured imitation approach. For example, MC was given the body of the potato and was instructed to imitate the therapist raising her hand. When it did not happen, the therapist showed him, hand over hand, what was expected on command, and when he did so (with help), he got an item for the potato, such as the eyes, coupled with enthusiastic praise. This process was repeated until MC imitated independently. It took only minutes for him to adapt to the imitation–reward paradigm. The clinician quickly transitioned from gross motor to oral motor movements to mouth shaping, at which point instruction on vowel production was initiated. Tactile assist for mouth shaping was used as needed, and each phoneme’s motor pattern, vowel or consonant, was given a new “name.” For example, [i] was the “smile” sound, [o] was the “surprise” sound, [ɔ] was the “cute puppy sound,” and [ɑʊ] was the “hit your thumb with a hammer” sound.

MC’s vowel repertoire increased rapidly and it no longer seemed likely that a motor speech component was present. Therapy proceeded with a motor learning approach to consonant production. Oral pressure consonants are essential for yielding information about velopharyngeal function; [p, b] (we called them the “quiet and noisy lip sounds”) were the first consonant targets. [p, b] are anterior, easy to see, and early developing. MC’s limited consonant inventory included [m], and one bilabial consonant can be used to teach others. In MC’s case, [b] was taught by plugging the nose as he produced repetitions of [ma]. Once the [b] was isolated, [p] was taught by whispering [b]. Multiple rapid productions of each isolated target were produced to establish the motor pattern. Once established, the motor pattern was practiced in increasingly complex patterns, so that it became habituated and could be easily called upon in rapid running speech. The progression of the therapy is shown in ▶ Fig. 1.1. However, some steps in the therapeutic process overlap, so that once a motor pattern becomes well established, the skill is addressed in multiple levels simultaneously, as shown in ▶ Fig. 1.2. Much early work was done in imitation, without pictures or objects, to establish the motor pattern. The addition of pictures or objects alters the task from imitation to word retrieval, and a child with normal language function may quickly revert to the undesirable motor pattern if the desirable motor pattern is not well established.

MC was weaned from the nose plugging after being consistently successful with all syllable imitation positions. Had he reverted to nasalization of [p, b] without nose plugging, it would have been clear that the distortion was obligatory in nature, due to velopharyngeal dysfunction, and he would have been referred for velopharyngeal imaging studies and management. However, MC was able to maintain good plosion on [p, b] without nasalization, nasal emission, turbulence, or grimacing. This observation strongly suggested that he was capable of nor-

Completely Normal Speech Is the Goal for a Child Born with Cleft Palate

Fig. 1.1 Illustration of the motor learning process for a consonant, or allophonic pair, from the initial teaching of the motor pattern in isolation through increasingly complex motor and linguistic levels to transfer to spontaneous speech.

Fig. 1.2 Illustration of the process by which syllables, words, and phrases can be addressed in imitative sequences, pushing the target consonant to the next level of complexity. This is only of value if the target is produced correctly at the simplest level. There is no value in attempting a more complex level if the target motor pattern is not produced accurately at a simpler level.

Completely Normal Speech Is the Goal for a Child Born with Cleft Palate

mal velopharyngeal function, but had not yet learned to use his velopharynx appropriately. Just as a child may need to be taught how to use other articulators, such as tongue and lips in sound production, it is also possible for a child to need to be taught how to use the velopharynx.

Although a brief section of each therapy session was devoted to teaching a variety of consonants in isolation, therapy focused primarily on one place of articulation at a time. When [p, b] were well established in spontaneous speech, attention was turned to lingua-alveolar place, with [n] being taught first, then using it to teach [d] by nose plugging, followed by [t], which was stimulated by whispering [d]. These lingua-alveolar consonants were then advanced through syllable and word imitation, etc., using the same process as had been used for [p, b]. [s, z] were addressed next, then [f, v], followed by [ʃ,tʃ,dʒ]. Simple home practice activ- ities that could be accomplished easily and quickly in a busy household were given each session, and follow-up was excellent. Weekly attendance was somewhat diﬃcult due to multiple med- ical issues and family schedule conflicts.

1.6 Outcome

MC was discharged from therapy with excellent intelligibility at the chronological age of 5 years, 8 months, the week before he began kindergarten. He received a total of 56 individual therapy sessions, most of them 1 hour in length. Articulation testing using the Goldman-Fristoe Test of Articulation-2 in his last session yielded the following scores:

●

Raw score: 2.

●

Standard score: 109.

●

Standard score projected range using the 95% confidence interval: 102 to 116.

●

Percentile score: 67.

●

Age equivalency: 6.3 years.

Spontaneous speech sampling revealed no concerns with regard to language skill. Voice quality, pitch, and intensity were within normal limits. Resonance was within normal limits. Following discharge, he performed well in an accelerated program at school. He participated in sports and functioned well socially. No further concerns with regard to speech production evolved and no further velopharyngeal management was indicated. He was scheduled for regular follow-up with his cleft palate team until facial growth is complete.

1.7 Key Points

●

Normal speech is possible, and expected, for a neurologically normal child born with a cleft palate, with or without cleft lip or other oral structural anomaly.

●

Nasal air escape during speech could be a function of articulation or of velopharyngeal dysfunction. This distinction must be made to provide appropriate treatment.

●

If a child presents with abnormal or maladaptive motor articulation patterns, a motor learning approach can be an eﬀective therapeutic program.

Suggested Readings

[1] Peterson-Falzone SJ, Trost-Cardamone J, Karnell MP, Hardin-Jones MA. The

Clinician’s Guide to Treating Cleft Palate Speech. 2nd ed. St. Louis, MO: Elsevier; 2016

[2] Zajac DJ, Vallino LD. Evaluation and Management of Cleft Lip and Palate:

A Developmental Perspective. San Diego, CA: Plural Publishing; 2016

[3] Hardin-Jones MA, Chapman KL, Scherer NJ. Children with Cleft Lip and Palate:

A Parent’s Guide to Early Speech-Language Development and Treatment. Bethesda, MD: Woodbine House; 2015

Assessment and Treatment of Preschool Fluency

2 Assessment and Treatment of Preschool Fluency

Sarah Smits-Bandstra

2.1 Introduction

J was a 4.1-year-old boy referred for fluency intervention by his parents after 17 months of therapy at another center where they considered his stuttering therapy to be unsuccessful. His parents were willing and able to participate in treatment.

2.2 Clinical History and Description

J’s birth and medical history was notable for a loss of fetal heart tones prior to delivery and admission to the neonatal nursery for approximately 2 hours for postpartum monitoring. At 2.5 years of age, J experienced myoclonic episodes after pertussis vaccines. He had no family history of stuttering, speech, or language disorders. J met most developmental, speech, and language milestones on time with the exception of gross motor skills. He received physical therapy 1 hour per week for 6 weeks. He was discharged from therapy approximately 6 months ago. J was in good health and had no significant medical illnesses, injuries, or concerns. J passed a hearing screening within 1 month of referral.

J lived at home with his mother, father, and younger brother (8 months old) with whom he reportedly got along with well. English was the only language spoken in the home. J was described as a br ight, imaginative, happy child. He began attending preschool 3 days per week 4 months ago. He also attended gymnastics, piano lessons, and swimming lessons on a weekly basis.

J began stuttering at around 18 months of age. He received clinician-directed stuttering therapy (parents were not trained in treatment) from the age of 2.5 to 4 years. Owing to insuﬃcient improvements, his parents sought alternate treatment.

2.3 Clinical Testing

Assessment included a stuttering-specific case history, parent and preschool teacher interviews, videos from home, observation of parent–child interactions, and a clinic visit. The parents also recorded a written diary over a 1-week period describing the stutter, reactions to the stutter, and the contexts in which the stutter was more or less severe.

J’s preschool teacher reported an increase in stuttering just prior to referral to the clinic. She noted that peers were kind and respectful and made no issue of the stuttering. She reported that his stuttering increased when asking a question, trying to get attention, or thinking of what to say. Informal assessment/screening of voice, articulation, receptive and expressive language, social skills, and resonance were unremarkable. Oral motor examination revealed mild limitations in range of motion for lip protrusion and retraction and occasional drooling.

A speech sample of 300 syllables was collected during unstructured play. During this sample, 5% of syllables were stuttered and 11% total disfluency (less than 10% is typical for

preschool-aged children) was noted. Total disfluencies include typical disfluencies (revisions, interjections, one or two repetitions of whole words, phrase repetitions) and atypical disfluencies (also known as stutters). Atypical disfluencies can be defined as part-word repetitions (mo- mo- mo- mom), tense/ rapid, and/or dysrhythmic whole- or part-word repetitions, prolongations, or blocks. In J’s sample, 43% of total disfluencies were atypical. It is considered normal for preschool-aged children to demonstrate less than 50% of total disfluencies as atypical. J’s disfluencies were most commonly slow, rhythmic part-word repetit ions at the beginning of phrases (e.g., “Whawha-wha-what is that?”). Revisions and whole-word repetitions were also common (e.g., “I-I-I-you go up there.”). Repetitions ranged in number from 2 to 10, with severe instances lasting 3 seconds in duration. No secondary behaviors (facial or body movements) were observed. J’s father indicated J’s speech during the sample was not representative and less severe than at home. J’s father provided three videos from home that he felt were more representative.

Analysis of these videos yielded the following data:

●

Sample 1 (151 s yllables): 8% syllables stuttered, 11% total disfluencies, 73% atypical.

●

Sample 2 (187 s yllables): 13% syllables stuttered, 17% total disfluencies, 75% atypical.

●

Sample 3 (162 s yllables): 12% syllables stuttered, 12% total disfluencies, 100% atypical.

Characteristics of atypical disfluencies included increases in pitch during a stutter, dysrhythmic repetitions, and repetitions ranging up to 16 units and 4 seconds in duration. J scored 6 on the KiddyCAT (Communication Attitude Test for Preschool and Kindergarten Children Who Stutter). This 12-item yes/no questionnaire for children younger than 6 years assesses a child’s awareness of their stutter and their attitudes toward speaking (e.g., “Is talking hard for you?”). A typical score for a child who stutters of J's age is 4.89, indicating J was aware of his stutter and had developed some negative attitudes toward speaking.

2.4 Questions and Answers for the Reader

1. What information indicates that J is at risk for persistent stuttering?

a) Stuttering for more than 12 months with no indication of

improvement. b) Family history of stuttering. c) Indications of language delays. d) Unawareness and limited reaction to stuttering.

Answer: a is correct. Research shows that children who stutter for longer than 12 months without indications of recovery are more likely to continue stuttering.

b is incorrect. J’s parents reported no family history of any

type of speech or language disorders or stuttering. Instead,

Assessment and Treatment of Preschool Fluency

there are indications that stuttering may be congenital (loss of fetal heartbeat, fetal seizures).

c is incorrect. J showed no evidence on informal assessment or screening of language delays; instead, he showed evidence of motor delays (physical therapy, weak lips, drooling).

d is incorrect. Results of the KiddyCAT assessment indicated that J showed awareness of his stutter and some negative reactions to his stutter. Awareness and negative reactions to stuttering are risk factors for persistent stuttering.

2. What important assessment information was obtained

outside of the initial clinic visit? a) Parent report/interview. b) Teacher report/interview. c) Parent–child interaction observation/video. d) KiddyCAT.

Answer: b is correct. Interviews with preschool teachers are usually done outside of the initial clinic visit due to diﬃculties with travel and scheduling.

a is incorrect. Although a case history can be completed at home or by telephone, a more detailed interview is typically done face -to -face (or through telepractice) with the clinician during a clinic visit.

c is incorrect. Although parent–child interaction observations or videos can/should be gathered from home, they are to supplement observations or videos taken during the initial clinic visit.

d is incorrect. Standardized stuttering assessments should be completed by a trained professional within a controlled setting to obtain valid and reliable results.

3. In addition to percent of syllables stuttered, what are the

other important and necessary assessments to measure stuttering severity and the impact of stuttering on the child’s life? a) Interviews with parents, teachers, and other significant

caregivers.

b) Child’s awareness of stuttering and attitude toward

speaking (e.g., KiddyCAT).

c) Description of the types (repetitions vs. blocks) and cate-

gorizations (typical vs. atypical) of disfluencies, durations of the disfluencies, and secondary behaviors.

d) All of the above.

Answer: d is correct. All of the aforementioned measures need to be incorporated to obtain a valid and comprehensive assessment of the impairments, activity limitations, and/or participation restriction associated with stuttering. Although it is important to speak directly to caregivers who spend time with the child, it is also important to administer assessment protocols directly with the child. It is also important to gather information from caregivers who spend time with the child and to directly assess/observe the child’s stuttering behaviors. Finally, it is critical to directly assess/observe the child’s stuttering behaviors as well as the child’s awareness of the stutter and their reactions to and attitudes about stuttering and gather information from caregivers who spend time with the child.

4. J’s previous therapy was not eﬀective. What therapies for

preschool children have the strongest evidence base? a) Treatment provided by a speech-language pathologist.

b) Treatment provided by the parents, where the parents

are trained by a speech-language pathologist.

c) Wait and see—t reatment is best provided after a child

enters school.

d) Treatment that focuses on having the preschool child self-

monitor and self-correct stuttering using fluency-shaping techniques.

Answer: b is correct. Current meta-analyses of clinical trials research suggest that the Lidcombe program has the largest body of research support. Lidcombe and Demands Capacity treatments were equally eﬀective. clinicians training parents to deliver the treatment at home. Comprehensive treatment includes parent training to ensure generalization and transfer.

daily parent-directed practice at home are more successful than those that are administered solely by a speech-language pathologist.

than school-age children. Early intervention is strongly recommended.

metalinguistic or metacognitive skills to formulate language and simultaneously self-monitor fluency and use of fluenc yshaping skills.

Both of these treatments are parent-directed with

a is incorrect. Treatments that include parental training and

c is incorrect. Preschool children are treated more eﬀectively

d is incorrect. Preschool children do not generally have the

However, one study has shown

2.5 Description of Disorder and Recommended Treatment

J presented as a child with beginning stuttering of moderate severity. Assessment information indicated several factors that put J at risk for persistent stuttering (congenital factors, stuttering for more than 12 months, and awareness/reactions to his stuttering). Therapy was recommended immediately. Therapy was provided by a st udent clinician with a clinical supervisor observing 75% to 100% of sessions. Therapy followed the Lidcombe Program, a stuttering treatment involving parent training in the clinic to provide the treatment to the child at home and other contexts. A detailed treatment guide can be freely downloaded from http://sydney.edu.au/health-sciences/asrc/ docs/lp_treatment_guide_2016.pdf. The clinician also modeled other known facilitative communication strategies such as slow rate of speech. The clinician observed parent attempts at indirect strategies in interactions with the child. The parents reported these strategies to be very helpful in daily interactions at home and reported that the strategies positively influenced severity ratings for structured times. These “indirect” strategies were added to the Lidcombe program to individualize the treatment to meet client needs and parent wishes. They were employed as needed and gradually extinguished over time.

For approximately 23 weeks, in weekly sessions, the clinician trained the parents in Lidcombe techniques for stage 1, including demonstrations. The clinician consulted with J ’s parents weekly for updates on J’s fluency patterns, progress, and areas of need outside of the clinic. Areas of need were discussed and problems were solved jointly between the clinician and parents.

Assessment and Treatment of Preschool Fluency

Table 2.1 Stuttering severity: visits 1 to 12 (Lidcombe stage 1)

Visit no. Visit date Severity

rating

1 January287 231567

2 February241219

3 February9319526

4 February16710327

5 February23510545

6 March 2 55235

7 March 23 48222

8 March 30 46116

9 April 6 59115

10 April 13 58221

11 April 20 44125

12 April 27 43115

Total disfluencies (%)

Syllables stuttered (%)

Atypical disfluencies (%)

Daily stuttering measures were taken by the parents to monitor fluency. Progress was measured through calculations of percentage syllables stuttered, ratings from the severity rating scale, reac tions to stuttering, and parent report (see ▶ Table 2.1 and ▶ Table 2.2). The rating chart is freely available and can be downloaded from http://sydney.edu.au/health-sciences/asrc/ docs/severity_rating_chart_2015.pdf.

2.6 Outcome

At the time of this report, J and his parents completed the first 13 weeks of stage 2 of the Lidcombe Program for childhood stuttering. J continued to show progress with fluent speech through stage 2. His most recent calculation of disfluencies in spontaneous speech was 0% syllables stuttered and 4.9% total disfluencies, 0% of which were atypical. He continued to respond positively to praise and showed no hesitations when asked to correct a disfluent utterance.

J’s parents demonstrated exceptional understanding and use of Lidcombe and indirect home-programming techniques through implementat ion during structured and unstructured activities. They self-reported the use of strategies in the home and community settings and reported decreased severity ratings when they were implemented. J’s stuttering decreased since his initial evaluation and his syllables were stuttered within normal limits for a 4-year-old across the last 13 consecutive weeks. J will continue to be monitored for the remainder of stage 2 (approximately 9 months).

Table 2.2 Stuttering severity: visits 13 to 23 (Lidcombe stage 1 continued)

Visit no. Visit date Severity

rating

13May64515

14May133401

15May2725110

16 June 10 2400

17 June 17 3400

18 June 24 44125

19 July 1 2300

20 July 8 1400

21 July 15 1409

22 July 22 14010

23 July 29 1500

Disfluencies (%)

Syllables stuttered (%)

Atypical disfluencies (%)

2.7 Key Points

●

Neither pre- nor posttreatment outcome measures are valid unless the representativeness of the clinic samples is determined and speech samples and reactions to stuttering are gathered across diﬀerent contexts, speakers, and time.

●

Parent-directed treatment is critical in fluency t reatment for preschool children to ensure optimal eﬀectiveness, generalization, and transfer.

●

Treatment programs, such as the Lidcombe Program, can be modified to meet individual client and family needs (such as supplementation with indirect techniques) as long as eﬀectiveness is monitored and maintained.

●

It is unethical to continue with treatment programs without evidence of progress in a reasonable time period. Therapists without experience or training in current evidence-based practice in stuttering therapy are ethically obligated to consult with a specialist and/or refer the client to a specialist if outcome measures do not indicate improvement within 6 weeks of beginning treatment (for indirect treatment) or 2 to 3 months (for more general types of treatment).

References

[1] Nye C, Vanryckeghem M, Schwartz JB, Herder C, Turner HM, III, Howard C. Be-

havioral stuttering interventions for children and adolescents: a systematic review and meta-analysis. J Speech Lang Hear Res. 2013; 56(3):921–932

[2] Franken MC, Kielstra-Van der Schalk CJ, Boelens H. Experimental treatment

of early stuttering: a preliminary study. J Fluency Disord. 2005; 30(3):189– 199

[3] Guitar BG. Treatment of Stuttering: Established and Emerging Interventions.

Baltimore, MD: Lippincott Williams & Wilkins; 2010

Working Collaboratively with a Young Child with Autism Spectrum Disorder

3 Working Collaboratively with a Young Child with Autism Spectrum Disorder

Ian Roth

3.1 Introduction

A 20-month-old boy is referred to a speech-language pathologist (SLP) because of red flags for autism spectrum disorder.

3.2 Clinical History and Description

WS was born following an unremarkable pregnancy and had what his parents—both of them pediatric medical professionals —described as a typical infancy involving a lot of babbling. At 16 months of age, they noticed a decrease in his babbling, which did not remit by the time he was seen for a speech and language assessment at 20 months. WS had a history of multiple ear infections, and had myringotomy tubes placed at 17 months of age. Audiological testing revealed no hearing loss at the time the tubes were placed.

3.3 Clinical Testing

A full case history was taken from both parents while WS played with toys in the room. This allowed him the opportunity to become familiar with the environment for 60 to 90 minutes and aﬀorded the SLP and SLP student time to observe WS’s play and spontaneous interaction skills. Two weeks later, the family returned for the more interactive components of the assessment. The Preschool Language Scales, 4th Edition (PLS-4)was attempted but was discontinued in favor of more informal assessment because WS did not follow instructions, with or without gestures. For this reason, it was diﬃcult to determine accurate receptive language abilities for WS. It was concluded that social communication deficits likely prevented him from responding to instructions, as opposed to responding incorrectly, which would be more indicative of a receptive language impairment.

WS moved around the room for much of the assessment, occasionally stopping to touch a toy, but rarely played in functional or conventional ways. The clinicians found success interacting with WS by following his lead. WS did stop moving to watch a spinning toy that was deployed. While watching, WS tensed his entire body and flapped his hands. He made intentional requests by handing the toy to the SLP who was down at his level and silent, but with an open hand. WS made other requests by pulling an adult’s hand toward objects he wanted/ wanted help with. After the SLP initiated a dyadic act ivity (i.e., no materials) that involved moving WS’s body side-to-side, when the SLP paused, WS moved his own body in a similar fashion to request the activity to continue.

WS was able to follow a point but he did not coordinate eye contact with gestures to request, and he did not initiate joint attention (i.e., a declarative gesture, such as pointing to show, while making eye contact). He was able to imitate some indi-

vidual words but he did not use speech to communicate (i.e., to send a message to another person) during the assessment. Most of his spontaneous utterances were vowel sounds and did not appear to be communicative. His parents reported immediate echolalia, which was not observed during the assessment. WS drooled throughout the assessment. Eating and drinking were described as safe and eﬃcient.

3.4 Questions and Answers for the Reader

1. Which of the following most closely approximates WS’s communication profile?

a) Receptive language delay, expressive language delay,

social communication impairment.

b) Apraxia of speech, expressive language impairment, social

communication within normal functional limits. c) Autism spectrum disorder (ASD). d) Social communication impairment, expressive language

impairment, receptive language unknown.

Answer: d is correct. Social communication is the primary impairment, given the low frequency of interactions, poor coordination of eye contact, and communication occurring primarily for the purpose of asking for help or other requests. WS’s expressive language is also delayed, given his extremely limited expressive vocabulary. However, his social communication deficit may be largely to blame for his impaired expressive language as evidenced by his not using conventional, symbolic gestures or vocalizations to compensate for delayed speech. Receptive language may in fact be impaired, but without responding to most instructions, it is diﬃcult to accurately assess WS’s receptive language skills.

a is incorrect. Though he is at risk of a receptive language delay, there is not enough information to determine whether receptive language is in fact delayed because WS did not respond to most instructions, which in the absence of hearing loss may be indicative of a social communication impairment .

b is incorrect. Apraxia of speech cannot be positively identified based on the current assessment. Social communication is impaired, as evidenced by his not initiating joint attention, minimally coordinating eye contact with requests, using people’s hands as tools, and not responding to his name or to simple instructions.

c is incorrect. ASD is not a communication profile. Children with ASD can present with a wide variety of communication profiles.

2. What referrals would you make to other health care/service

providers? a) Developmental assessment. b) Dolphin-assisted therapy. c) Chelation therapy. d) General practitioner/pediatrician to halt all future vaccines.

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