We are pleased to welcome Adriana Digrande, MS, CCC-SLP and
Elena Caffentzis, MS, CCC-SLP, as our guest hosts for tonight's
chat on Monday, February 9, 2004. They will be addressing the topic
of Stuttering in the Early Intervention & Pediatric Populations.
Adriana DiGrande has been in private practice since 1997 and
continues to work exclusively with individuals who stutter.
She sees individual clients at her Lexington, MA office and
continues to conduct intensive stuttering therapy group
programs for school-aged children and adults in Boston. In
addition to her work with older children and adults, Adriana
has developed a pediatric fluency program where she treats
young disfluent children and their families. Adriana is a
clinical instructor at Boston University where she co-
facilitates a student-training program and adult fluency
group. She teaches graduate level courses in stuttering at
Emerson College and the MGH Institute of Health Professions
at Massachusetts General Hospital and has presented at
numerous conferences and workshops on the topic of stuttering.
Adriana also provides consultation services with regional
school systems and speech pathologists in the area of
stuttering. Adriana was selected to become a member of the
inaugural group of Speech-Language Pathologists who are
recognized as Fluency Specialists by ASHA's Specialty
Commission on Fluency Disorders.
Elena Caffentzis is the Coordinator of Children's Programs
at The American Institute for Stuttering in New York City.
Elena has worked with children and teens to treat speech
disorders ranging from fluency and articulation to language
delays and brain injury. Her personal philosophy supports a
holistic approach to treatment, working with families, friends,
teachers of her clients to provide continuous support beyond
the therapy room. Prior to joining the American Institute
for Stuttering in 1999, Elena worked as a speech-language
pathologist at the Massachusetts General Hospital in Boston
and trained at other Massachusetts-based medical and
rehabilitation centers as well as elementary schools. She
has treated hundreds of children and adults with speech,
language, cognitive and swallowing difficulties on both
outpatient and inpatient bases. Elena is a member in ASHA's
Fluency Disorder Special Interest Division, the International
Fluency Association and the National Stuttering Association
and Friends. She teaches the graduate level course in
stuttering at Seton Hall University and Touro College. Elena
is bilingual, allowing her to provide treatment in both English
<Robin> Welcome! Tonight we are chatting with Adriana_Digrande, MS, CCC-SLP and Elena
Caffentzis, MS, CCC-SLP, about the topic of Stuttering in the Early Intervention &
<Robin> Adriana & Elena, please give us some general info about tonight's topic.
<Adriana_Digrande> I'm really excited to present on this topic. Early intervention with this
population can be very successful.
<Elena_Caffentzis> Generally let's talk about children who are having their first experience
with dysfluency in the preschool years so as to keep things consistent!
<Elena_Caffentzis> I like to think about these kids...between the ages of 2-5 or so...
<Elena_Caffentzis> We can spend some time looking at the ways to evaluate and determine which of
these kids are at risk and then move to talking about the specifics of intervention.
<Adriana_Digrande> When evaluating young children it is important to determine their risks for
developing stuttering. Despite the popular thinking NOT all children outgrow stuttering. A fluency evaluation can help determine what children are at risk and the level of interve
<Adriana_Digrande> A fluency evaluation can help determine children who are at risk for
developing stuttering and the proper intervention strategy.
<Robin> What is the youngest age that you would do an eval?
<Adriana_Digrande> I would do a formal evaluation on a child 6 months post the onset of the
<Adriana_Digrande> However parent counseling should begin immediately when parents express
concern over their child's fluency development.
<Elena_Caffentzis> I would consider doing it sooner depending on family history and the child's
reactions to their dyslfuencies.
<Elena_Caffentzis> For example, I saw a child 4 months post onset because of extensive family
history and his own frustration.
<eileen> What kind of formal eval? and SSI (Stuttering Severity Index)?
<Adriana_Digrande> There are much better tools than the SSI to evaluate a preschooler. If you
like the SSI model, you could use The Stuttering Prediction Instrument (by the same
authors, Riley and Riley), however, I prefer the "Protocol For Differentiating The
Incipient Stutterer" from Rebekah Pindzola's Stuttering Intervention Protocol Program.
<Taslim> I learned about a weighted measure that can be used to "resolve ambiguity" about whether
the child stutters. Do you know more about this?
<Elena_Caffentzis> What is it called Taslim?
<Taslim> It was proposed by Ambrose and Yairi...I'm trying to find the name in my notes!
<Taslim> It is called "normative disfluency data for early childhood stuttering" in Journal of
Speech, Language and Hearing Research Vol. 42.
<Elena_Caffentzis> I am not certain of what it is exactly...so I can't say exactly.
<Robin> Elena and Adriana, tell us about determining the risks for developing stuttering.
<Adriana_Digrande> There are several risk factors to consider: I look at gender (males go on
to stutter at a rate of approximately 4:1), family history, type and frequency of
disfluencies, concomitant struggle behaviors, trend toward worsening in the pattern,
child's awareness, concern and/or avoidance behaviors, parental concern, concomitant
speech/language delays, and temperament.
<Elena_Caffentzis> Specifics...the types of dysfluencies I consider more risky are ones that are
tense, single sound repetitions, prolongations and blocks.
<Elena_Caffentzis> The frequency is also a consideration, greater than 10% or so.
<Elena_Caffentzis> The child's reaction is a consideration...and their awareness/concern.
<Adriana_Digrande> What's important to remember is that we should not use age as a factor to
evaluate and/or treat a child. Often times parents are counseled by SLPs or
pediatricians to take a wait and see approach or not to "worry" because the child is
3 or 4 and he will outgrow it. This advice is misguided at best. As we know, not all
children "outgrow" their stuttering and I believe we do have a window of time (between
the ages of 2.5 - 5) when this disorder can be treated easily and quickly.
<Elena_Caffentzis> true, very true
<Elena_Caffentzis> The Pindzola Protocol really outlines a lot of the risk factors and I find
it really useful.
<Taslim> So, basically we're not telling parents anymore that their child may outgrow the
<Elena_Caffentzis> Not necessarily...some MAY outgrow it but no one can know for certain, right?
<Adriana_Digrande> Yes, I think an SLP with expertise in stuttering can best determine who might
be at risk for developing stuttering and develop an appropriate plan of treatment, be it
direct or indirect.
<Elena_Caffentzis> So I want to educate them as to all of the possibilities...and have a
specialist really take a look at the specifics of the child and determine how at risk
<suezyb> What about environmental factors-don't they play a role?
<Elena_Caffentzis> They play a role for sure.
<Elena_Caffentzis> I don't think that they CAUSE stuttering per se...we can never really know
the influence...because I have seen kids come from environments that are not supportive
of fluency and those that are supportive and in the end, we still have a toddler who
<Elena_Caffentzis> BUT I do say that environment can play aHUGE role to enhance and support
<Taslim> What kinds of environmental factors would play a role?
<Adriana_Digrande> Environmental factors are ones that disrupt a child's ability to express
thoughts fluently. For example, a parent with an intense pattern of speech, ie: fast
paced or hard are modeling an approach to speech that the child may not be able to
handle. If the child tries to "keep up" with that model, fluency breakdowns are more
likely in the child who may be predisposed to stuttering due to genetic factors. Family
lifestyle can also place demands on the child's system. For example, many children today
are over programmed with a schedule that is hurried and full. Making changes in their
schedule that incorporate a more quiet/slower pace may be very helpful.
<Elena_Caffentzis> For example, changing the communication around the child and the pace and
the competition for talking, etc., can change the way that the child is dealing with
<linda> I want to talk about a 2.4 year old child I saw with moderate dysluencies including
prolongations, whole word and intial syllable repetitions. The child's mother suddenly
became quite unavailable due to work and the child's stuttering increased dramatically.
<linda> The mother asked me if I thought she should stop working. I also observed the child
engaged in activities that I felt were well above her age such as cutting, coloring,
and computer use. The child is quite verbal and has been for some time.
<Elena_Caffentzis> Have you educated the mother about some factors that may make it more
challenging for her child?
<linda> The mother wants me to tell her to stop working. How do you handle that?
<Adriana_Digrande> I don't like to make decisions that can affect the whole family like this
one that you present. Some day care situations are wonderful, they're small and
supportive. What's just as important is what happens in the home after daycare.
Do the parents spend quality time with the child, are they presenting fluency facility
communication models, have they tried to keep things as calm as they can given their
limitations? It's very important that we do not feed into parental guilt about their
child's disfluency. Parents do not create stutterers. If that were so, we would have
so many more children with this disorder.
<Elena_Caffentzis> I tell parents that I don't make decisions or recommendations for them...and
want to help them sort out what is best for them as a family.
<Elena_Caffentzis> Where is this child when she is not with mom?
<linda> At home with one nanny and her sibling with another nanny.
<linda> They also speak 3 languages in the home. The parents are quite educated.
<Elena_Caffentzis> Where do you see this child?
<linda> I have a private practice in L. A.
<Adriana_Digrande> It sounds like this child is under a lot of stress so simplification may be
in order here.
<Elena_Caffentzis> I would want to educate ALL people involved in her life.
<Elena_Caffentzis> And who brings her to you?
<linda> The mom brought her last week for the first time.
<linda> The parents have been concerned since the mother's work increased greatly.
<AdrienneFSU> Do you treat her with her mom or the nanny?
<Adriana_Digrande> It's not a bad idea to get the nanny on board since she is with the child.
<Elena_Caffentzis> Linda-you can work with the nanny...and I agree with Adriana about
<Elena_Caffentzis> It seems that there is a lot going on for them...
<Elena_Caffentzis> Think simplify and model for everyone who comes with her to show them what
they can be doing at home...
<Adriana_Digrande> The idea is to have as many people involved in the modification program as
<linda> I want them to use only one language and not encourage her to speak Italian (mother
reports she wants to learn the words in Italian)
<Elena_Caffentzis> Is this child aware?
<linda> Not aware
<Adriana_Digrande> I think the question of awareness is interesting. Often young children
are very aware but you need to look for the signs. Children will change words,
feared/difficult words, for easier ones, reduce the complexity of their language,
become more quiet, abort speech attempts when about to struggle. Parents report
a change in personality, "My child is less outgoing". My sense is that if a child
is experiencing tense disfluencies, they are probably aware of their disfluencies.
<Elena_Caffentzis> I agree with keeping things simple-meaning one language at a time...not
that the child cannot learn another language, but to add it in now is not necessary.
<Elena_Caffentzis> how is your rapport with the mom?
<linda> The rapport is only just starting. I think the mom trusts me and wants to do the
<linda> There is also a one year old sibling who is beginning to become mobile which I beleive
is also impacting the situation, although the mother denies it.
<Elena_Caffentzis> And do you see change when you spend time with her in your session?
<linda> I have only seen her once. I played with her on the floor.
<Robin> Adriana & Elena, what types of things do you suggest that linda do with this child?
<Adriana_Digrande> Given the child's age, an indirect program is suggested to include modeling
of fluency enhancing strategies. Parents are taught to reduce their speech rate,
increase pause time before responding to the child, they are taught to phrase more in
their speech, all of this to reduce pace of the interaction. Spending one on one time
with the child is also just as important.
<Elena_Caffentzis> I would model communication changes for the care givers.
<Elena_Caffentzis> For example, I would SHOW caregivers one change a time..for example, I would
show them how to communicate with slowed rate, increase pauses, limited questions,
decreased complexity and have them model as well...so that you can give them feedback
as to how they are doing with modifiying their own speech so that they can be effective
at home when they carry over the ideas from sessions to their own 'sessions' at home.
<Elena_Caffentzis> I actually WRITE down the things that I want parents to focus on.
<Elena_Caffentzis> So I have parents work for a week on pausing in their conversations/play with
their child one plus times a day for 20 minutes at a time.
<AdrienneFSU> Writing sounds like a good idea when there are multiple caretakers/communication
<linda> I like the idea of writing and specifics of home activities.
<Elena_Caffentzis> You can have them 'rate' the fluency of the child on a 1-5 scale...and have
everyone contribute to observing and effecting change.
<Adriana_Digrande> Parents provide the strongest models for their children and there are so many
misperceptions and myths about this disorder, so education the parent is very important.
<Elena_Caffentzis> How does this sound so far to you linda?
<linda> I like what you are saying.
<Elena_Caffentzis> The thing that I would like to stress is that you have to be sure that they
'get' it in your session so that they 'll carry it over at home the most productive way.
<linda> That's so hard to ascertain.
<linda> These parents, and most in my practice, are defensive and think they are doing it all
<Elena_Caffentzis> They just want the best for their child...and it's all they know how, linda...
so get them on your side but creating evidence IN the session that this stuff works...
and they'll be motivated to carry it over more.
<AdrienneFSU> Do either of you have experience going into homes for this interventions?
<Elena_Caffentzis> It helps me when I am dealing with parents that are having a hard time doing
<Taslim> Just another source of info that has a different take on environmental influences:
Chapter 2 from "Nature and Treatment of Stuttering, New Directions" (1997). The chapter
is called Home Environments and Parent-Child Interaction in Childhood Stuttering.
<Taslim> If you get your hands on a copy of that chapter, I think you will find it interesting,
because the new research is taking the focus away from the parents' speaking rates and
claiming that they aren't any different from parents of children who don't stutter.
<eileen> I also have a child that I am trying to figure out the best way to treat him. At what
age do you make treatment more direct?
<Adriana_Digrande> If the risk factors are present and the child has been disfluent for more
than 6 months, I would recommend direct treatment, keeping in mind that direct therapy
also involves the things we've discussed in an indirect approach.
<Robin> Eileen, how old is the child you are asking about?
<eileen> He turned 5 this past October.
<Adriana_Digrande> Then it seems that a more direct therapy would be needed.
<Elena_Caffentzis> Eileen-what have you done so far with this child?
<eileen> Well...this case is tricky.
<eileen> I inherited him, and mostly the previous work he'd been doing was speech. He's extremely
<eileen> I have been looking into the stuttering, and have been trying to indirectly target the
<eileen> I have tried to bring the parents in, but it's been a tough case. I only see him once
a week. Mom is now finally on board.
<Adriana_Digrande> I believe strongly that you can't treat a preschooler without parental
support. We are guides in the process, the parents are doing all the work. Without
parental support prognosis is poor.
<Elena_Caffentzis> Eileen-He is ? and what do you mean indirectly?
<eileen> Yes, he is. I have been slowing my rate of speech, increasing my pause time throughout
the session. The changes that were suggested earlier for parents.
<Elena_Caffentzis> How long has he been stuttering?
<eileen> He has been stuttering for a long time, more than 6 months. It has gone in waves.
<eileen> But, today I saw some serious secondaries for the first time.
<Elena_Caffentzis> Is he aware of what is going on?
<eileen> He became more fluent the past few sessions with me. I think he is starting to become
more aware. His parents have been waiting out his moments of dysfluency, and apparently
he has a supportive school environment, but I think he is getting frustrated.
<Elena_Caffentzis> Based on what I am hearing, I would look at more direct therapy.
<Robin> Elena and Adriana, can you give us some ideas for direct therapy approaches?
<Adriana_Digrande> When I treat young children using a direct approach, I use a
response/contingency program that reinforces fluency and "gently punishes" disfluency,
while parents are modeling fluency generating behaviors.
<Adriana_Digrande> I developed a program that is based on the Extended Length of Utterance
program by Janice Costello. It is very similar to the Lidcomb Program.
<Elena_Caffentzis> I like to use a hierarchical model where I establish discrimination skills
first, like the differences between hard and easy talking or smooth vs. bumpy.
<Robin> Any other direct approaches?
<Adriana_Digrande> There are lots of programs to choose from but basically you want to
model/teach a more easy relaxed approach to speech through modeling and play activities.
I like to do a lot of positive reinforcements of fluency with some attention to
disfluency. The Stuttering Foundation of America and The National Stuttering Association
also have materials for SLPs and parents.
<Elena_Caffentzis> For a specific approach you can look at Barry Guitar's book on stuttering
intervention...and look at the integrated therapy aproach.
<eileen> Thank you for your ideas. That's where I was thinking I would head.
<Elena_Caffentzis> Good, eileen...remember to keep it super friendly and not good or bad...
just maybe smooth or bumpy or hard vs. easy so that he is not developing the notion
that what he is doing is wrong!
<eileen> Right, Elena, thanks.
<hope> Sorry to get off the topic; but what is the difference between direct and indirect
<Robin> Good question, hope....Adriana & Elena, can you please explain?
<Adriana_Digrande> Direct therapy involves child and parent and indirect therapy primarily
involves working with the parents to change the communication environment.
<hope> Thank you
<ghb> I have been working with a now 4.5 year old boy in centerbased with direct approach for
the last 6 months. He started out with lots of pwr (part word repetition) and wwr
(whole word repetition), 2-3 repetitions per instance. We began stretching out first
sounds in sentences with easy onset, and have seen good progress.
<ghb> He just started adding fillers, um, that he didn't previously use. Any ideas to decrease
<Adriana_Digrande> The fillers may be starters, so it seems like teaching a more relaxed
approach would eliminate need for starters. If the rate of speech is rapid, rate
reduction is also helpful.
<Elena_Caffentzis> ghb -any other thoughts?
<ghb> If they are starters, would it help to analyze the next word or consonant after the filler?
I haven't noted any patterns to sounds or words stuttered on so far.
<Adriana_Digrande> Usually the next word is tense if it's a starter.
<Elena_Caffentzis> Maybe it's also there because of word finding...the fillers I mean.
<ghb> Word finding as in language? I have known him for awhile and think I can rule that out.
<Elena_Caffentzis> More like as he is searching for the word-formulation..not that there has to
be a language problem.
<ghb> I only have heard the starters when I place time pressures or demands on his talking.
Not in free play situations with his peers which he talks pretty relaxed in.
<Adriana_Digrande> Often when I hear frequent interjections or repetitions, they usually precede
a phonatory arrest.
<ghb> Please explain phonatory arrest.
<Adriana_Digrande> Phonatory arrest is a speech "block" indicating tension at the level of the
larynx, with a complete cessation of phonation and respiration. This may be subtle or
<Stephanie> I have a question here. I would like to know what is a good way to teach my 6 year
old student to recognize his disfluency.
<Elena_Caffentzis> Stephanie -can he recognize it in you if you modeled it?
<Stephanie> My student does not seem to be aware of his own stuttering.
<Elena_Caffentzis> I have kids try and decide if I am doing the word bumpy or smooth after a
discussion about how things, objects, words, are both smooth and bumpy
<Elena_Caffentzis> See if they can discriminate and then 'play' with it.
<Elena_Caffentzis> Have them do some smooth and some bumpy and see if you can guess
<Elena_Caffentzis> and also hard vs easy depending on how their own disfluencies are.
<ghb> Bumpy and smooth has also been very successful in my experience, easy for little ones to
<Stephanie> Should we talk about feelings at this age? (6 years old)?
<Stephanie>_ I am afraid to bring more attention if he is unaware of his bumpy speech.
<Elena_Caffentzis> Depending on the child's feelings and presentation...frustration, awareness,
<Elena_Caffentzis> I hear what you are saying Stephanie.
<Elena_Caffentzis> It depends on how you are doing.
<Adriana_Digrande> You don't need to worry about bringing anything to the child's awareness.
It is my strong belief that children who struggle with their speech are already aware
that they are having trouble speaking. Not addressing it in an open and natural way
only contributes to the shame that develops later on in this disorder.
<Elena_Caffentzis> Stephanie...that is why I have children discriminate in me and make a game
out of it.
<Elena_Caffentzis> It is sometimes a relief in a way that they can talk about this uncomfortable
'thing' that is happening in their bodies.
<ghb> But we can give them positive words in which to refer to their talking.
<Stephanie> Could you clarify about what type of game you play?
<Stephanie> Or suggest a reference/book that is good for kids at this age?
<Elena_Caffentzis> I make up the games.
<Elena_Caffentzis> Like, "Can you decide if I say it bumpy or smooth?" and I'll try and 'trick"
them and have them do the same.
<Elena_Caffentzis> When I say 'play' with it I mean experiment together and have fun...kids are
good at that and learn a lot more when you are both relaxed and having a good time with
it...just because they are stuttering, doesn't mean that you can't have a good time!
<ghb> Preschoolers LOVE to trick us!
<Adriana_Digrande> Just as with adults, we need to teach the child that "bumpies" are okay and
they are not to be feared.
<Stephanie> When I notice a lot of disfluencies, I am not sure if I should confront my student.
<Elena_Caffentzis> Maybe don't think of it as confronting, Stephanie, but asking him how his
<Stephanie> I see. thanks, Elena.
<travlpat> I agree. They need a validation.
<Elena_Caffentzis> Some 5-6 year olds do well with rating how easy or hard their talking felt.
<Adriana_Digrande> After age 5 or 6 the child develops the baggage that some older children/adults
<student> How do you work on rate without the often scary "slow down!"
<Adriana_Digrande> Don't instruct the child to slow down, model it and reinforce it.
<Elena_Caffentzis> I would model
<Elena_Caffentzis> take breaks in our talking, etc.
<ghb> I use "turtle talking" to refer to the slower rate.
<ghb> And I ask fast rate kids to keep their speech rabbit in their pocket.
<Stephanie> I usually just ask them to do it again using their turtle speech. Is this the right
way of doing it?
<eileen> Back a few steps...Adriana, do you model their utterance with slow speech, or just use
slow speech for the next thing you say?
<Adriana_Digrande> I model and have parents model slightly slower rate with pause times at
<gertiemae> Like Mr. Rogers!
<Adriana_Digrande> Mr. Rogers' rate wasn't that slow, but he used lots of pauses in his speech
and that made it appear as if his speech rate was slow. Parents find it easier to
insert pause times in their speech rather than slow down the rate of their syllables.
<Elena_Caffentzis> I am always modeling a slower rate during the whole session.
<travlpat> I agree. It is more difficult for us and the parents, but the child needs to be
immersed in a slower rate without time pressure.
<ghb> It is so hard I think to do slower talking for a whole session. I practice a lot.....
like reading road signs to myself while I'm driving, etc.
<travlpat> I use poetry.
<Elena_Caffentzis> We need to practice and keep practicing.
<Elena_Caffentzis> Have the kids try and remind YOU if you go faster.
<Elena_Caffentzis> They'll love 'catching' you!
<Adriana_Digrande> The main thing is to show that there is no time pressure in this interaction.
<Elena_Caffentzis> I agree-no time pressure.
<Robin> Great ideas.....thank you!
<student> Thank you
<Stephanie> Yes, thanks for the great ideas!
<katmc> Do you find that most of the children you see are mainly stutterers or do they often
have other disabilities as well?
<Elena_Caffentzis> It depends katmc...some and some.
<Elena_Caffentzis> I have some that are just fluency cases and some that have other issues.
<Elena_Caffentzis> We have a kid with CP and severe dysfluencies AND artic as well.
<katmc> How do go about therapy for a child with multiple disabilities?
<Elena_Caffentzis> Like what other diabilites?
<katmc> Like CP, MR/DD, Down's Syndrome etc.
<Adriana_Digrande> I have treated children with Down Syndrome and I believe that it is an
underserved population. The incidence of stuttering in this population is higher than
in the general population, yet there's a resistance on the part of some SLPs not to
treat the disfluency and thus witholding treatment during the early years when therapy
is most effective. There's the misperception that stuttering, it's part of the profile,
when in fact, it's not. I have had good success with a direct approach with children
as young as five.
<Elena_Caffentzis> What do you think is the issue that you are having with stuttering when there
is another disability?
<Adriana_Digrande> Many of the children that I see have concomitant phonological issues and/or
<Elena_Caffentzis> and others that are bright and clear and dysfluent!
<Robin> Elena and Adriana, is there anything else about serving this population that we should
<Adriana_Digrande> Yes, early intervention in this population is extremely successful.
<Adriana_Digrande> My success rate with children between 3.5 and 5 is excellent and relapse
is rarely an issue as is the case with older children and adults.
<Adriana_Digrande> When evaluating children it's important to take a careful case history,
videotape the child and really understand the risk factors involved to make a sound
clinical decision regarding type of intervention.
<travlpat> I came in late on this discussion. Do you have any references you recommend? I have
worked in early intervention for 20 years and would be interested in anything you
<Adriana_Digrande> The Stuttering Foundation, National Stuttering Association,
stutteringhomepage, etc. are some really good sources.
<Adriana_Digrande> Reference materials from SFA videos and books.
<gertiemae> Pindzola Protocol.
<travlpat> Thank you for the references.
<travlpat> Do you video tape or tape record your therapies?
<Elena_Caffentzis> Yes and yes...video and audio at times.
<travlpat> Thank you
<Robin> We have been chatting for nearly an hour now. Thank you to our guest hosts, Adriana
Digrande, MS, CCC-SLP and Elena Caffentzis, MS, CCC-SLP, for sharing their expertise!
<Stephanie>_ Thank you!
<Elena_Caffentzis> You're all so welcome!
<booms57> Thank you, very interesting chat.
<eileen> All of the ideas are much appreciated.
<ghb> Thanks for the great talk.
<travlpat> Thank you
<AdrienneFSU> Good tips!!
<suezyb> Thank you!
<Emily_Maren> Thank you!
<hope> Thank you all so much!
<gertiemae> Thanks much
<katmc> I enjoyed the session, thanks for the pointers.
<Elena_Caffentzis> One thing...be OK with the stuttering.
<Elena_Caffentzis> It matters to the child and family to know that you are all okay with where
they are at.
<Adriana_Digrande> Thanks and good night!
<Elena_Caffentzis> Good bye!
<Robin> Thank you again and goodnight!