We are pleased to welcome Craig E. Coleman, MA, CCC-SLP, as our guest
host for the SLP chat tonight, Monday, February 21, 2005.  He will be
addressing the topic of Stuttering in the Pre-K Population.

Craig E. Coleman is a Clinical Coordinator at Children's Hospital of
Pittsburgh and Co-Director of the Stuttering Center of Western
Pennsylvania. He received his Bachelor's and Master's degrees at the
University of Pittsburgh. Craig is a member of the National Insurance
Advocacy Initiative and Chair of the National Stuttering Association's
Insurance Advocacy Committee. Craig also is an elected member of the
ASHA Legislative Council (PA).  In addition, Craig provides clinical
service to preschool, school-age, and adolescent children who stutter
and is involved in clinical research activities.

<Robin> Thank you all for being here tonight
<Robin> We are chatting tonight about the topic of Stuttering in the Pre-K Population with guest host
          Craig E. Coleman, MA, CCC-SLP.
<Craig Coleman> First, thanks to everyone for joining us tonight!
<Robin> Craig, please give us some background information about Stuttering in the Pre-K Population.
<Craig Coleman> For most children, stuttering begins between the ages of 2-5.
<Craig Coleman> As much as 80% of children between those ages will go through some form of disfluency as
          their speech and language skills expand.
<Craig Coleman> While we can't predict with 100% certainty which children will outgrow stuttering without
          treatment, a number of risk factors have been identified that we look for to determine if treatment
          is indicated.
<Craig Coleman> Some of those risk factors include family history of stuttering, male gender, physical tension
          or frustration associated with stuttering, length of time a child has stuttered, and environment.
<Craig Coleman> In terms of making recommendations for treatment, I tend to be on the conservative side and
          recommend at least some initial therapy for children who meet any of those risk factors that I just listed.
<Robin> How much greater is the incidence of stuttering in boys at this age?
<Craig Coleman> At the preschool level, the ratio is about 1:1 between boys and girls. By the time children reach
          school-age levels, the ratio rises to 4:1. This means that many more girls are recovering than boys.
<Rachel> why are boys more at risk for stuttering than girls?          
<Craig Coleman> Boys are really at more risk for any speech/language disorder. If you look at any speech/language
          disorder, boys have about a 4:1 ratio.
<AdrienneFSU> What about the environment would indicate treatment?
<Craig Coleman> As far as environment, constant time pressure and speaking demand may help to increase stuttering.
          In addition, less structured situations may contribute to increased stuttering.  
<Craig Coleman> It is important to note that those situations typically do not cause stuttering, they just may
          make it worse.
<AdrienneFSU> Thanks
<caslp> Is there a link between phonological disorders and stuttering or vice versa?
<Craig Coleman> Many children who stutter also exhibit articulation/phonological disorders.
<Craig Coleman> The presence of a co-occuring speech-language disorder is also another risk factor for continued
          stuttering, if no treatment is provided.
<Robin> Tell us about the typical child you would consider evaluating and how you would go about it.
<Craig Coleman> Honestly, I would consider evaluating any child whose parents are concerned about stuttering.
<Craig Coleman> To start with, you'll want to do a complete parent interview.
<Craig Coleman> This includes addressing all the potential risk factors that we discussed earlier.
<Craig Coleman> You'll also want to determine any medical history, any significant items from teachers and other
          family members that may help give a more complete picture of the child.
<Craig Coleman> Additionally, you'll want to begin assessing the awareness and concern on the part of the child
          and the parents.
<Craig Coleman> You'll want to determine if the stuttering appears to be getting better or worse.
<Craig Coleman> And what types of stuttering the parents are seeing (e.g. repetitions, prolongations, blocks).
<Craig Coleman> After the parent interview, I typically have the parents interact with the child while I observe
          to gauge the child's stuttering with someone they are more comfortable with.
<Craig Coleman> This also allows me to get a sense of how the parents are interacting with the child, and their
          communication patterns
<Robin> What if you are in the school setting (nursery school, day care, etc.) and this is not possible?
<Craig Coleman> Then I would talk with the parents before-hand and have them send me a tape (even audio is ok)
          of them interacting with the child.
<caslp> I work in I also observe the kids talking to their friends at recess.
<Craig Coleman> It's important to remember that at the preschool level, you will probably have some access to
          parents. It's a bit different for school-age kids.
<Craig Coleman> Following the parent-child portion of the assessment, I interact with the child and try to get
          a feel for how their stuttering is during less intense communication situations and situations with more
          time pressure.
<caslp> Please give an example of time pressure situation.
<Craig Coleman> Increased time pressure: Making the child answer questions quickly.          
<Craig Coleman> In all situations in the assessment, I want to get a disfluency count (I usually do this in words,
          not syllables). I also make a note of all secondary behaviors and physical tension.
<Robin> Craig, why count words and not syllables?          
<Craig Coleman> Syllable counts are not very practical in a clinical setting unless you go back and review it.
          Not many people can count syllables, track disfluencies, and other behavior at the same time.
<Craig Coleman> Once people get experience, they can usually do word counts on-line.
<diane> Only 15% of preschoolers'vocabulary is polysyllabic anyway...read that recently.
<Craig Coleman> Also, you'll want to track types of stuttering, parents reactions (both verbal and nonverbal),
          and the child's reactions.
<Robin> Are many children this age aware of their disfluencies?
<Craig Coleman> Children as young as 2 can be aware of their stuttering, and highly frustrated with it at times.
<Craig Coleman> Another thing to look for in the evaluation is how the child does in that session compared to
          what the parent sees at home.
<Craig Coleman> Stuttering at the pre-k level is so variable that the child may be having a day that is not
          consistent with what parents see at home.
<Robin> How do you determine if treatment is necessary?
<Craig Coleman> In terms of recommending treatment, I look at all those areas assessed during the evaluation
          as well as the risk factors identified during the parent interview.
<caslp> So if the stuttering is not variable but is consistent that is a red flag, right?
<Craig Coleman> Sure, consistent stuttering is usually more of a red-flag than situational stuttering or
          variable stuttering at this stage.
<Craig Coleman> Because I am in a "Stuttering Center," we typically don't see many people who do not need
          treatment. Usually they have come for good reason.
<Craig Coleman> It will be much more difficult at times in schools when kids can be sent to you without many
          indicators for treatment.
<caslp> Or when parents are surface compliant.
<Craig Coleman> Right--that's a good segue into treatment.
<Craig Coleman> For any pre-k child, no matter what approach you use, you NEED the parents involved or it
          simply won't work.
<Robin> What percentage of disfluencies raises a concern for a child this age?
<caslp> I wouldn't focus too much on percentage rather than the type of stuttering.
<Craig Coleman> Robin, to answer your question, number of disfluencies should be only one component of what
          you look at as should type of disfluencies.
<Robin> Please elaborate.
<Craig Coleman> A child could have all repetitions with a lot of tension or struggle.
<Craig Coleman> They could also have very few disfluencies with significant frustration.
<Craig Coleman> Each child reacts differently to stuttering. Temperament and personality are a huge component.
<Craig Coleman> For example, children with high sensitivty, perfectionistic tendencies, intense personalities
          may react much stronger to a much lower level of stuttering.
<Craig Coleman> I think we really miss the complete picture when we only talk about number of disfluencies.
<Robin> Thanks Craig
<Craig Coleman> In terms of treatment, we focus heavily on parent education and counseling at the beginning
          of treatment.
<AdrienneFSU> Craig, what if you think the parents are making too big a deal of it and actually increasing the
          stuttering occurances?
<Craig Coleman> Adrienne, good question. In these cases, the parents may need more "therapy" than the child. 
          Parents need to understand that their reactions, even nonverbal reactions, help shape the child's
          reactions.  They need to be counseled to respond positively and encourage the child to communicate.
          In short, they should focus on the content of the child's speech, rather than the manner in which he
          is saying it.
<Craig Coleman> We have a specific parent-child training program (PCTP) that consists of  sessions that we
          typically start with. A complete description, as well as handouts, is available on our website at
<Craig Coleman> I will try to give some detail here.
<Craig Coleman> We start with 2 parent-only sessions to work on education and counseling.
<Craig Coleman> Then, we do 4 parent-child sessions where we focus on helping parents learn strategies to
          facilitate fluency at home.
<Craig Coleman> These include reduced communication rate,
<Craig Coleman> Use of indirect prompts instead of rapid-fire questions,
<Robin> Can you give us an example of using indirect prompts?
<Craig Coleman> Recasting and rephrasing to help the child with a good model and also help them know they
          can still get their message across even if they stutter.
<Craig Coleman> Recasting: "I-I-I need milk." "Oh, you need some milk in your glass."
<AdrienneFSU> I think it's great you "facilitate fluency" as opposed to "get rid of the stuttering".
<Robin> Tell us about reduced communication rate.
<Craig Coleman> We help parents use a phrased speech approach that is similar to Mr. Rogers
<Robin> Increased pausing between phrases?
<Craig Coleman> Right Robin
<Craig Coleman> Mr. Rogers drives adults crazy but kids love him because he goes at a pace they are
          comfortable with.
<Craig Coleman> I want to go / to the store/ to get some ice cream. Phrased speech.
<diane> Craig, can I ask aquestion about bilingual homes?
<Craig Coleman> Yes, Diane, ask away.
<diane> I had a 3 year old boy with lots of sound repetitions and prolongations - mom speaks only German to
          him at home and dad only English.
<caslp> I have the same situation with a little boy who speaks exclusively Korean at home and English at
          school.  His mom states he does not stutter in Korean only English.  He stutters severely in English.
<diane> I asked mom to stick with one language one situation, and she's reluctant for fear once he knows she
          speaks English, he won't respond in German anymore...there is a lot of code switching being required
          when the whole family is together.
<Craig Coleman> This happens a lot in bilingual homes--if a child is more "fragile" from a speech and language
          standpoint, the extra demand may trigger more breakdowns in fluency.
<diane> He's equally disfluent in both languages.
<Craig Coleman> In these cases, I would usually recommend one language for the child until his system is
          more stable.
<Craig Coleman> The same recommendation is typically given for any child with a speech/language disorder.
          It is very difficult for those children to learn 2 languages at once when they are having trouble
          with one.
<Robin> It sounds like this may be a problem with parental compliance in these cases.
<diane> Families have been compliant, just really fearful of losing heritage and language of relatives...
<Craig Coleman> I'd make it clear that you can go back to the bilingual approach as his system matures and
          he can take the demand.
<diane> I understand their concern...I wonder if she could use English in prescribed situations/routines and
          German in others...would that discourage the child from German all together as she fears?
<Craig Coleman> I don't think the mom using German is the issue. I think it is asking the child to speak
          German. Mom can still do a story or something each night in German.
<diane> Ok - I'll try for that then. Thank you!
<Suzanne> Any advice for treating kids with concurrent fluency disorder and articulation/phonology disorder?
<Craig Coleman> Suzanne, I typically base this on severity in both disorders. I just wrote a whole newsletter
          on this topic (www.stutteringcenter.org).
<Craig Coleman> Typically, I think it is best to target both after the  initial parent training in stuttering has
          been carried out.
<Suzanne> Thanks, I'll take a look at the newsletter.
<wildcat> What about actual therapy techniques for the SLP to use?
<Craig Coleman> When working directly with the child, after the parent training is over, here are some things I do:
<Craig Coleman> Teach them a slow easy speech approach by using "Turtle speech." I typically contrast this with fast
          speech (rabbit), Bouncy speech (kangaroo) and slidey speech (snake).
<Craig Coleman> This helps children learn about disfluencies in a indirect way without making stuttering seem bad.
<Craig Coleman> Example: Child says "I--I-I-I need that one." The SLP may say "Wow, that was great kangaroo speech,
          maybe we can also try that one like a turtle.
<Craig Coleman> An example of Slidey Speech/Snake would essentially be a prolongation, such as
          "I lllllllike this game."
<Craig Coleman> Just help the child get comfortable with all types of talking.
<Craig Coleman> Another important issue is helping a child who is upset/frustrated.
<Craig Coleman> For this, you may say "oh that was a little bumpy, but that's ok, everyone has some bumpy speech.
          I really like how you told me what you wanted to say."
<Craig Coleman> Also, some purposeful stuttering with the child is a good thing to do.
<Craig Coleman> You can then say "See, I had some bumpy speech too."
<diane> Craig, what is your opinion of the Lidcombe Program?
<Craig Coleman> The Lidcombe program has the most data out there so it has to be taken into consideration.
<Craig Coleman> I worry about how some sensitive children respond because I have seen some respond negatively to it.
<Craig Coleman> I also wonder if there is anything else that is being lost. In any response-contingent program,
          you may extinguish the behavior but are you losing something else?
<Craig Coleman> For example, are children not talking when they should be if they think they will stutter. Are they
          using shorter less complex utterances...
<diane> Thank you.
<suezq> Do you recommend any particular programs to follow for therapy?
<Craig Coleman> I recommend doing our 6-session PCTP program as an initial phase of treatment. If more treatment
          is needed, then I would move into more direct treatment. It is important to note that more treatment may
          be needed for reasons related to the child or the environment.
<Robin> Craig, I have been instructed in the past to not discuss disfluencies (smooth or bumpy speech) in mild
          cases but to model smooth speech, phrased speech.
<Craig Coleman> I typically use this rule of thumb: if a child is not aware of or frustrated by his speech, it is
          ok not to address it.
<Robin> Ok, thanks...this particular child I am thinking about was not aware of her disfluencies.
<Robin> She had a lot to say all the time and was quite chatty.
<Craig Coleman> Sounds like in that case it may be that her language system was going faster than her motor
          system could handle.
<Robin> I think that was definitely the case!
<wildcat> That's what I originally thought about my student - who had oral motor problems - but this is my third
          year working on his speech and language and the stuttering is getting worse as his language skills improve.
<Craig Coleman>          Remember, while advanced language skills may be a positive prognostic indicator for stuttering,
          weak oral-motor skills are not a positive indicator since there is a large motor component to stuttering.
<Craig Coleman> If a child is aware of, or upset, by his stuttering, talking about it will not make it worse.
          He already knows he does it.
<Craig Coleman> In those cases, where the child is aware, not talking about it usually only adds to the "mystery".
<Craig Coleman> For a child with frustration, stuttering is not going away until you address this with the child.
<Craig Coleman> That has to be one of the first priorities of treatment.
<Robin> Craig, you have been chatting with us for nearly an hour! 
<Robin> Thank you for sharing your expertise with us Craig!
<Craig Coleman> I appreciate the great questions!
<Robin> Thank you all for joining us tonight.
<diane> I appreciate this session, Craig and Robin!
<Craig Coleman> It was my pleaure.
<luckyeagles> Thanks Craig. I've learned a few things tonight.
<wildcat> Thanks
<AdrienneFSU> Thanks for chatting!
<erin c> Thanks Craig.
<shaunda r> Thank you Craig
<wildcat> My student is now school age - anytime you would like to address that issue - great!
<ERS> Great job guys!
<Suzanne> Thanks, Craig.
<Robin> Thank you again Craig and thank you all for joining us tonight.
<Robin> Good night all!