Speech Therapy for Stuttering: First Sessions

You’ve scheduled your first speech therapy appointment for your child. Your focus is to help your child with stuttering. You want your child to learn more about how to speak clearly. What should you expect for your first few speech therapy appointments for stuttering?

You likely have questions.

What does speech therapy look like?
How can speech therapy help?
What will my child learn?
What types of activities will my child complete? 

Although speech therapy looks different for clients with different needs, there are some basics. If your child is beginning speech therapy for stuttering, there are a few areas he/she is likely to learn about.

This article outlines four common targets of first sessions with children who stutter. Specifically, these are targets for children who are 5 years old or older. Younger children may work on activities targeted more towards play.

Speech Therapy for Stuttering: First Sessions

1. Information about Stuttering

Speech therapy may (especially at first) focus on learning stuttering facts. Some examples:

What causes stuttering?
How many people stutter?
Do more boys or girls stutter?
Is there a cure for stuttering?
Who are some famous people who stutter? 

Why do we focus on this?

Honestly, many of my clients know very little about stuttering when they come to my clinic. Often, they don’t know anyone else who stutters. In addition, they aren’t sure why stuttering occurs or what they can do about it.

Depending on the client, we may spend more or less time on this topic. I typically do a pretest before starting this unit to determine how much my client already knows. That way, I can focus on specific areas that my particular client needs to learn.

But, really. Why focus on stuttering facts for those sessions? Why is it important?

Ultimately, how can you work towards improving something you know very little about? Although it can be tempting to skip this step, it’s essential to learn about stuttering in order to see growth in this area. In order to improve in any area, you need to learn more about it. This is typically something my clients don’t talk to others about very often, and they are curious to learn more.

It may take a session or two (or even more) to do this educational piece. For some of the older children I work with, we do a Jeopardy game at the end of this unit. Students love playing this game! Also, these clients can take the game home and have fun educating their families. Children build confidence as they realize how much they’ve learned as we wrap up the unit with Jeopardy. They also say it is fun to realize they know more than their families about this topic and they frequently win the game!

2. Educating Communication Partners

Another education piece is to provide resources for my client’s communication partners. These partners can include parents, classmates, friends and teachers.

I start by asking my client if anyone in their communication circle could use more information about stuttering, and if so how they’d like that information shared. A client may want to share stuttering information with a sibling, parent or teacher. If my client needs information, I’ll share a brochure, an information sheet, or links to helpful information online. This step focuses on basic information about how to be a communication partner for people who stutter.

Why is educating communication partners important?

My client won’t be communicating in a bubble. Because of this, it is important that his/her communication partners understand something about stuttering.

In most cases, I send home one sheet of basic helpful information. From there, I provide more resources to those who want more information.

3. Strategies

We will likely learn strategies for smoother speech, including:

– Determining the location of the tension during the stuttering event

– Learning more about types of stuttering and practicing them to increase awareness 

Strategies targeted depend on each particular client and their priorities. These strategies will be practiced in structured situations in the speech therapy room, and then in less structured settings outside the speech therapy clinic.

4. Identifying Avoidance Situations

In this step, we identify communication situations that are both comfortable/easy for your child as well as uncomfortable/difficult. Typically, we encourage our clients to identify what kind of language they’d like to use around these topics. We want to hear more about this from your child’s perspective, so they will identify and list out these situations with their SLP’s support.

I like to create a visual for this, so we may draw a ladder and at the bottom write speaking situations that feel easy (based on your child’s report) and go up the ladder to brainstorm increasingly difficult communication situations (again, from your child’s perspective). For example, a recent client put whispering to her mom at the bottom of the ladder (meaning that felt easiest) and answering questions when getting called on in class at the top of the ladder (meaning that was hardest for her). Towards the middle of the ladder, she put reading aloud and making phone calls.

This is done to first identify situations where speaking may be easier or harder for your child so that we can target speaking in those situations (including using strategies) so that those communication situations feel more do-able for children. It’s important that we have repeated practice in comfortable situations (those lower on the ladder) before we move on to more challenging situations. In addition, these more challenging situations will also be practiced quite a bit in the speech room before we move on to other settings (outside the speech room).

These are activities that may not be done in the first few sessions, but it’s important to be aware of what these activities are so you understand their purpose.

Speech Therapy for Stuttering: Essentials for Success

If you are working with an SLP, be sure to share your expectations for treatment as well. Share what you hope to gain from speech therapy. By doing this, you’ll be able to have a productive conversation and set expectations with your SLP. In addition, your SLP can share his/her expectations of your role in the process and will be able to let you know what sort of outcome is expected from speech therapy treatment.
Increasing awareness of stuttering, educating communication partners, learning strategies for smoother speech, and identifying when speech is easier versus harder and practicing (with support) in those situations helps clients have positive outcomes with speech therapy. While each child is unique (as are their needs), these skills provide an important foundation for early speech therapy sessions.

Further Reading

If you’d like to read more on stuttering, the American Speech-Language-Hearing Association has information on stuttering on their website. 

The Stuttering Foundation also has lots of parent information for both parents of school-age children and for parents of preschool-age children.

Another source for information is the Stuttering Source blog, which is written by a speech-language pathologist named Brooke Leiman. I recently took an excellent course on stuttering taught by Ms. Leiman, and I also enjoy reading her blog.

Telepractice Gone Wrong: 3 Scenarios and How to Deal

Are you an SLP? Do you want to learn more about telepractice? Are you already practicing in this setting, and do you want some tips to build your skills and get started?

If so, this article is for you.

Telepractice Gone Wrong: 3 Scenarios and How to Deal

I will share my three most common telepractice scenarios gone wrong, and what I do about them.

If you don’t know what telepractice is, you may want to check out my last telepractice-focused post.

Now, on to my top three scenarios!

Internet or Platform Connection Issues

Some internet connectivity and platform issues can’t be solved. (Note: a platform is the videochat program, such as Go To Meeting, Facetime, Zoom, or Skype).

There are many issues that come as a surprise, and come in the moment – and are impossible to predict.

Here are some I’ve run into, and some suggestions:

a) The Problem: Platform – a client not knowing how to operate the video/audio

How to Deal:

Depending on the platform used, there’s likely an option to switch video on and off as well as a way to turn off audio (mute). I’ve been asked if I give written directions on operating this to clients, and the answer is no. Why not? Honestly, it’s a visual task. It’s much easier to explain in real time. If you are meeting a client and just can’t figure it out in the moment, give your client a call and work through it together.

b) The Problem: Internet Connectivity

How to Deal:

Have the internet connection discussion before your first session. Let your client know that 4G or low strength wifi won’t support videochat, which requires a lot of bandwidth. If your client can use an ethernet cord to plug directly from a modem to their computer, bonus points (and huzzah!). More likely, know where the modem is if you are on wifi and make sure the signal is strong.

Behavior

Telepractice can make it more difficult to manage behavior challenges. Some new behavior challenges may even come up as a result of the telepractice service mode.

For example, a client may:

• videochat using a tablet or phone, and place the device face down so you cannot see each other

• roll back and forth in an office chair, which is distracting (and hello, motion sickness)

• choose a dark place in which to videochat, making the process difficult

• not listen to or follow the activity instructions

All the scenarios above have happened to me, and they do make things difficult.

A few pointers:

• It helps to prepare by letting your client know (whenever possible) that there needs to be an adult in the room or at least checking in and monitoring. This is especially true for younger children or older children who might not consistently follow directions

• It’s helpful to outline expectations for students at the start of each session, and again as needed. You can find these expectations on my instagram page or on the graphic below.

Needing to switch the lesson plan but not having plans/materials to do so

SLPs are known for being flexible and going with the flow when a lesson goes awry. In a live, in-person setting, if a session isn’t going according to plan, we can grab other materials pretty quickly and change the plan.

This can be harder with telepractice, especially when you need quick access to digital materials. But with some preparation, this can become second nature. To be honest, this was a big challenge for me when I started. Now, it’s rarely an issue.

Some ideas:

• overprepare so when this happens, you’ll be able to change activities easily.

• find a motivating online activity for those days when clients just can’t focus or need something reinforcing. Quia is my go-to in these circumstances.

Problems and Solutions

With technology, there can always be hiccups and problems to solve.

Also, with technology, there can be opportunities. Opportunities to serve more families. Families with many children or hectic schedules. Rural families without access to an SLP. Families who live in cities with long commutes and really don’t want one more long drive.

If you are interested in telepractice and begin seeing clients in this setting, there will be challenges. For SLPs willing to do their research, overprepare, clearly outline expectations, and problem solve; well, you just might be ready to dip your toes into the waters of telepractice.

Childhood Apraxia of Speech: Hierarchy of Support

Childhood Apraxia of Speech: Hierarchy of Support offers tips and tricks for helping children with CAS by giving consistent speech cues.

Using a hierarchy of support (consistent cues) has been one of my most used strategies for children with CAS. It is important to be intentional about the frequency and types of cues you are giving. By doing so, children have a consistent measure of support. This support fades as children’s speech production skills increase.

Before we begin, if you’d like to learn more about this series by reading my introductory post on CAS or scrolling to the bottom of the page for other posts on this topic.

Cueing: A Client Example

One of my recent clients with CAS came to me at age four. He made a variety of vowel and consonant sound errors. At that time, he was difficult to understand. In fact, I think his parents were the only people who could understand him. For those interested, I described more details about his story in my last post.

This client sometimes felt frustrated while speaking. He had started to notice that his speech was difficult to produce. He also noticed that people couldn’t understand him. Because of this, he was starting to talk less and less.

As a result, his parents and I developed a plan. We wanted him to increase his speech sound production skills. We also wanted to give him cues and pointers that were helpful. Our ultimate goal was that we wanted to hear this boy’s voice and what he had to say.

Thankfully with speech therapy, this client made a considerable amount of progress. Now, most people can understand what he says. He is still working on quite a few speech sounds, but speech no longer causes him a great deal of frustration. He likes to talk, and his parents and I like to hear him do so!

What worked?

So, how did we provide support? What plan did we develop? There were a variety of facets. We included regular speech therapy appointments and a homework program, gave this client opportunities to talk, and encouraged him by telling him what he said was important.

Over time, his speech sound skills increased. At first, he came several times a week for speech therapy. After his skills increased, he continued to come once a week to speech therapy.

Cues helped this child reduce his frustration level early on. Cues also helped him build his speech sound production skills. Over time, I was able to reduce those cues and he was still able to produce target sounds (even without cues).

Cues: A Definition

What are cues? A cue could be a sign, a prompt, or a reminder. There are many prompts you can give a child as you help her/him produce speech sounds. For example, you may ask a child to watch your mouth while you produce the sound. In addition, you may produce the speech sound together.

Chances are, you are already giving cues to your child. But how do we know that the cues we are giving are helpful? How can we cue children without giving too much or too little support?

As a child’s speech sound production skills increase, we need to give fewer cues. This increases independence and generalization because children are not dependent on our cues. In other words, we want to give a lot of support at first. As a child’s skills increase, we want to then reduce the support of cues. This will increase confidence and independence on the child’s part.

Childhood Apraxia of Speech: Hierarchy of Support

The hierarchy of support offers guideposts for those of us working with CAS to offer cues. It starts with offering the most help. This way, children can learn these skills with support and feel success. After that, the support decreases (in steps) as children’s skills increase.

Using this hierarchy of support is one of my most valuable tools in working with children with CAS. Giving supportive cues facilitates learning and independence in speech sound production.

Below, I’ll outline some of the steps in this hierarchy and examples of each. Also, the tasks in this hierarchy get more and more difficult. This is because as we see success on each step, we make sure to move forward to harder tasks. This is based on DTTC, a research-based approach to CAS; and is adapted for the order in which I use it in my clinic.

Steps in the Hierarchy of Support

1. Watch and Listen – Say The Word Together

This step offers the highest level of support.

For this step, I ask my client to watch me say the word. It is important my client is attending to my mouth movements. Then, we say the word together.

2. Watch and Listen – I Say, You Say (Watch my Mouth)

This step offers less support than Step 1. I begin this step once my client has a high level of accuracy with Step 1.

I will say the word, and then my client will say the word. Again, I make sure my client is attending to my mouth so she/he can see how I’m producing the sound.

3. I say, You Say (With Cues)

After Step 2, I reduce support even more for Step 3.

I’ll say the word and give a cue. I might give a visual cue, such as a picture of how the mouth should look for the sound. Another visual cue I might use would be my mouth puppet. This way, my client can manipulate the puppet and show me how to produce the sound. There are many other cues (besides visual cues).  Even so, for simplicity (and brevity), we’ll stick with this one for now.

With cues (such as a visual prompt), I’ll say the target word and then the child will say the target word.

4. Model, Repeat (No Cues)

This step is a simple model (I’ll say the word or sound), and then my client will repeat. I do not use other cues for this step.

In short, this step is I say it, you say it.

5. I ask A Question, You Answer (With Target)

Step 5 is an exciting step as we work away from using an initial adult model. This is an important step to increase generalization. When we reduce cues, children can work closer towards generalization. What is generalization? This is when children start using speech sounds in less structured settings. This is an important step to working towards using these sounds in conversational speech.

For this step, let’s pretend a child’s target word is “stop.”

My cue might be: “On a stoplight, green means go. What does red mean?”

A child could answer “stop,” and then we’d be ready for the next target word.

I ask a question (typically without the target word in it), and the client answers the question with the target word.

6. Target Utterances In Role Play in Games

Step 6 is for when children use their new speech sounds when answering questions (Step 5). It is important that there is a high level of accuracy on Step 5 before moving on to Step 6.

For younger clients, we might target sounds in role play or games. For older students, I might show them a picture loaded with target sounds and ask them to tell me about it. For students who are fluent readers, we might read a book together that has many of their target sounds.

To summarize, this steps involves using target sounds in less structured tasks (play, picture scenes, story retell).

Final Considerations for Parents

Although it isn’t necessary to follow this leveled support for all clients, I’ve found this is a helpful tool. In outlining these steps, I’ve removed some steps I don’t use. Therefore, other clinicians might have steps that look different than these. Ultimately there are many roads to a successful speech therapy session. Most of all, my goal in today’s post is to share one path that has worked well for my sessions.

Remember, these aren’t hard and fast rules. I may skip steps or not use these steps at all. Each child (and each speech pattern) can be quite different. As such, any good speech therapy plan will start with an evaluation of a specific child’s needs. After that, a speech language pathologist (SLP) will develop a plan targeting those areas.

If you are a parent of a child with CAS, I’d encourage you to talk to your child’s SLP about cueing. An SLP can provide helpful pointers on cues to use. If you are using cueing at home, it is important to check in with your child’s SLP. This way, you can make sure you use cues that compliment those used in speech therapy sessions.

Children with CAS can make significant gains in speech sound production skills. The best way to see progress is by using a combination of consistent speech therapy and practice at home. For parents with a child with CAS, an SLP can be one of your most important allies.

Recommended Reading

Please continue to scroll back for many, many more articles on CAS!

Answered: 5 Common Questions about Telepractice (School Setting)

For the past, I’ve provided telepractice service in the school setting. That means, I use videochat to work with clients who need speech therapy services. I currently work part time in a school contract, where I provide both telepractice and in person service. I spend most days videochatting from home. But I do visit the school for assessments and some meetings. At contracts where I’ve worked, I typically have a SLP-Assistant or SLP-Aide (titles vary by state). That means, I have access to a real live person onsite who can assist.

Telepractice in the Schools

Since I began telepractice, I’m often asked questions about how it works. Many speech-language pathologists (SLPs) are curious about this as a profession. I’ve compiled some of my most commonly asked questions here. Keep in mind, there are many companies out there that do telepractice only. I can’t speak to those, as I haven’t had a contract like that. I spend about 75% of my work time in telepractice and 25% of my time traveling to my telepractice site (a rural school). Therefore, I can comment about what it’s like to work in the hybrid service delivery model.

But first, I need to be completely honest. I am not unbiased. Since I began working in this setting, my work-life balance has drastically improved. I am confident that I do better work now, because I have the space and time to do it well. My work is focused. My days are more tied to home and family life, which I enjoy. Overall, telepractice was a great move for my career. That said, it isn’t for everyone. If you are curious about telepractice, read on for some great questions and honest answers of what it is like to work in this setting.

1. What are some challenges that are specific to the telepractice setting?

Some rural schools do not have access to a good internet connection. This is something that SLPs need to be willing to work with. Video may cut out or be jumpy in this case. Luckily for me, this is usually not the case. The districts I’ve worked with have had decent internet connections for the most part.

In my own experience, I’ve struggled occasionally with clients who don’t respond much to videochat. In those cases, I have some tricks that I’ve learned over the past four years for gaining engagement. That could be another blog post in and of itself. For young, wiggly clients, I make use of parents or paraprofessionals onsite. It also helps to switch up activities to maintain engagement. It’s a learning process, and I’m still working on getting better in this area.

2. Are there any specific clientele for whom telepractice is not a good fit? Are you able to work with a variety of people with varying diagnoses?

There are definitely challenges with all settings. This is an excellent question because it’s true – it’s not the best setting for every single client. I say that with a caveat.

First of all, I love providing telepractice. I love connecting with children who can’t come to speech because of distance or health issues. I also serve families with very busy schedules who don’t want to drive to another appointment. When approached by a new client, I do consider if telepractice really is the best fit.

You should have a system in place to determine if telepractice is a good fit for your client or student. Here are some examples of questions you may want to ask yourself:

• Does the student have the motor control needed to access and interact with the videochat program? Can the client hear you?

• Behaviorally, is the student able to attend to and interact with you? If not, is there an adult with them that can help? Is that enough?

• Can they benefit from your direct instruction? Are there cognitive concerns about the child’s ability to interact with videochat and benefit from the instruction?

• Do they need direct instruction? Is there a combination of consultation or other services that would better serve that child?

You may have even more questions than these, this is just a starting point. As the clinician, do your best to think through who could be seen via telepractice and how it would benefit your learners.

3. How flexible is the telepractice setting? Can you do telepractice while living/traveling abroad?

In order to do telepractice, you need high speed internet, a webcam, and a headset for high quality audio. I have done telepractice while traveling (within the United States) with my laptop. This requires looking ahead at the internet connection available to ensure I’ll have what I need. Streaming video takes a lot of bandwidth, so don’t assume you can work from anywhere with a wifi connection.

There would be some potential tricky aspects of living abroad and doing telepractice. It can be done, but you’d need to consider a few things first. Most importantly, do you have access to a good internet connection? Secondly, if you are somewhere with a different time zone, what would that look like for your own schedule? Is that something you are willing to do?

I do know of someone who worked from Mexico while house sitting for a friend. She had a great experience doing telepractice that way. I don’t know anyone who has done telepractice while extensively living abroad.

4. What do you like the most about telepractice? How does it compare to other work settings, such as schools or private practice?

This is a great question. This one could also be an entire blog post in and of itself. So that I don’t go on and on here (and I could), I’m going to answer a different question. I’ll talk about what I like more about telepractice than other settings, as well as some of the downsides.

Let’s start with what I like. I like helping children who might not receive services at all if it wasn’t for telepractice. That part is very rewarding. I like that I spend more time focused on therapy. This means less time spent on office politics or dealing with behavior situations. In the school setting, I was often interrupted from the work I needed to do for behavior emergencies. This didn’t allow me the time and concentration needed to do my work well. Also, I like the flexibility and how comfortable it is to be able to work from home and not commute. This has allowed me to enjoy more of my home life.

Some downsides are that it can be isolating, and you can feel like an outsider. This may be the case if you are contracting for a school. Also, sometimes you don’t get the hours you’d like to work. You may feel underemployed (because there aren’t more hours available to work). I did have one season where I really needed to work more hours, but they weren’t available. That was stressful. Thankfully, it was only a few months in the big picture of four years.

5. What does the market for telepractice look like currently? Is there a demand for SLP’s in the telepractice setting?

I’m honestly not sure on this one. I work for an organization that a friend worked for (and spoke highly of). So, I didn’t really have to enter the job market here – I just called a phone number my friend gave me, met the Chief Operations Officer, and then signed a contract. For other SLPs I know, I would say it wasn’t difficult for them to get hired in telepractice. However, they may not be working as many hours as they’d like. I do know other SLPs who would like more hours, but their contract companies don’t have any available. In other words, most people are employed, but some SLPs feel underemployed in this setting.

Telepractice: Challenges and Rewards

Telepractice has been a great experience that has given me more personal freedom. I am humbled to be the SLP for those who wouldn’t otherwise have one. However, this setting doesn’t come without unique challenges. If you want to know more about telepractice, or have anything to add, please find me on Instagram.

Four Useful Goals for Late Talkers

This post, Four Useful Goals for Late Talkers, is written for speech-language pathologists (SLPs). I hope this article provides you with some new ideas for writing specific goals for your toddler clients!

Four Useful Goals for Late Talkers

About three years ago, my work settings started to change. They focused on working with younger and younger children. Today, my private practice focuses mostly on helping children ages 2-5 communicate. My area of expertise is helping late talkers increase their communication skills.

As I began to work with toddlers, there was a steep learning curve. That said, working with toddlers and preschoolers is now one of my favorite things to do. I love working with this population!

One of the challenges of making this switch was finding goal areas that were specific to this age group. There were so many potential goals to choose from. I wanted to choose goals that would be the most helpful for my young clients. It was also important that these goals were measurable and realistic.

Heather Moore, Ph.D., and speech-language pathologist (SLP) is an expert in this area. The goals outlined below are heavily based on her work.

I last wrote about goals I was using for late talkers by scrolling back to previous posts. I still use goals outlined in that post today. However, I’ve switched things around a bit for my beginning communicators. This post focuses on young children who are just starting to communicate. For them, I’ve found these goal areas helpful.

1. Increasing Rate of Initiated Communication

How many verbal or nonverbal communication acts per minute is the child demonstrating?

For example, (child) will use:

4-6 nonverbal and verbal communication acts per minute across two routines.

2. Communicating For a Variety of Purposes

Why is the child communicating?

Note if the child is using communication to protest, request objects, request actions, or give items.

From there, work on increasing their repertoire.

For example, (child) will use:

communication to request objects, request actions, and protest across two routines.

3. Increasing Repertoire of Sounds and Gestures and/or Vocabulary

This might include gestures: shaking head yes, nodding no, hand to mouth (for “shhh!”), or a wave.

You might target a certain number of nouns, verbs, adjectives or prepositions.

Early pronouns to target might be “me,” “mine,” and “you.”

For example, (child) will use:

5 gestures across 2 settings.

3 pronouns, 5 verbs, and 25 nouns.

For this one, there is a high number of possibilities for goals, depending on where you’d like to focus.

4. Increase Sentence Length and Complexity

Examples for this area would be increasing vocabulary across word classes. It also includes using morphological endings and increasing utterance length.

There are many possibilities for creating goals that increase sentence length and complexity.

For example, (child) will use:

3-4 word utterances in at least 2 settings

plural /s/

present progressive verbs (with -ing) ending

Useful Goals For Late Talkers – Conclusion

By using these goals, I’ve found my six-month reviews progress more smoothly. These goals are targeted enough for data, but broad enough to have some wiggle room.

Remember, you’ll need to add your own accuracy levels and under which conditions to these if you are an SLP. Your specific goals should be based on the needs of your individual client.

From here, I hope you have some new goal ideas. I hope you’ve seen how you can make these ideas targeted, specific and measurable. I hope you’ll have goals for your toddlers that you’re glad you wrote when it comes to the six-month review.

If you live in the Rogue Valley, Oregon area, I have a private practice clinic that specializes in helping toddlers (and preschoolers!) communicate. I serve residents of the Ashland, Talent, Phoenix, and Medford Oregon areas.