110607 1 Children who stutter: Bilingual Issues in Assessment & Treatment Rosalee C. Shenker CASLPA 2011 Why are you here? Expectations from this session? Why consider cultural & linguistic diversity in children who stutter? 50-70% SA children in Canada’s largest cities are children of immigrants 300,000 (7%) of all SA children in Canada are in some form of French immersion Immigrant population is 19.8% of total 1/5 under 14 years old 20% of the Canadian population speak a home language other than English/French
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Children who stutter: Bilingual Issues in Assessment &
Treatment
Rosalee C. Shenker
CASLPA 2011
Why are you here?
Expectations from this session?
Why consider cultural & linguistic diversity in children who stutter?
S 50-70% SA children in Canada’s largest cities are children of immigrants
S 300,000 (7%) of all SA children in Canada are in some form of French immersion
S Immigrant population is 19.8% of total
S 1/5 under 14 years old
S 20% of the Canadian population speak a home language other than English/French
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Bilingual Population
S Immigrants to Canada come from 200+ countries speaking 150 different languages
S 4/5 are allophones ( those whose mother tongue is neither of Canada’s official languages)
10 most frequent languages
S Chinese
S Italian
S German
S Punjabi
S Spanish
S Arabic
S Tagalog
S Portuguese
S Polish
S Urdu
You will see these children!
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Some issues related to bilingualism/stuttering
S Identifying stuttering in an unfamiliar language
S Evaluating linguistic proficiency
S Adjusting treatment to account for cultural beliefs & expectations
S Evidence-based treatment
1. Identifying Stuttering in an unfamiliar language
S Few guidelines
S Stuttering can vary across languages
S Different patterns are likely in children
S Most research on bilingual adults
Einarsdottir & Ingham, 2009
S SLPs unfamiliar with language
S Reliable at identifying stuttering in 3-5 year old children
S Consensus agreement
S Rate in short intervals
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Tsai, Lim, Brundage, Bernstein Ratner ( 2011)
S Provide examples of disfluency loci across major languages
S Child Language Data Exchange System (CHILDES)
S http://childes.psy.cmu.edu
Stuttering in an unfamiliar language
Can you pick out the unambiguous stutters?
2. Language Proficiency: Bilingual Children
S May have uneven development across languages spoken
S May have increased ambiguous disfluencies
S Over-identification of stuttering may result
S Delayed language may be misdiagnosed
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Bilingual children:
S May change word order to preserve a grammatical rule of the stronger language
S May code mix vocabulary of two languages
S Not indicative of a speech avoidance or word retrieval problem
S Use interpreters who can confirm proficiency
S Detailed language history S First exposure to each language
S Course of language acquisition for each language
S Other speech/language concerns
S Where is each language used
S Use perceptual rating scale for each language modality S Roberts & Shenker, 2007
Evaluation of Linguistic Proficiency
Example
Language Proficiency/speaking
Poor Excellent
L1________ 1 2 3 4 5 6 7 8 9 10
L2________ 1 2 3 4 5 6 7 8 9 10
L3________ 1 2 3 4 5 6 7 8 9 10
Other_______ 1 2 3 4 5 6 7 8 9 10
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Conversational Sample languages spoken
q Note disfluencies that could be related to reduced or developing proficiency
q Include relevant, age-appropriate tasks including conversation, monologue, story retell, reading, picture identification
q Probe increasing complexity
q Compare to established benchmarks
3. Belief systems
1 piece of advice you have heard about stuttering that reflects cultural beliefs?
Parent beliefs Waheed-Kahn (1997)
S Parents coped with stuttering by: S Praying for change
S Telling their children to speak properly S Completing their sentences
S Changing the environment; sending them to live with someone else
S Asking them not to talk in public
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Cultural Diversity: Implications for Stuttering
S Adds another dimension of complexity
S Children are coping with psychosocial issues
S Placed in novel situations S Introduction to a new language in school
S Exposure to mixed linguistic input
To support our clients
S Need to view bilingualism with a new lens
S Not as a problem
S Understand cultural beliefs and practices
Retelling family stories
S Encourages parents to identify hopes & concerns for treatment of stuttering
S Consequences of loosing 1st language, e.g. loss of cultural identify, values, beliefs, communication with grandparents
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Retelling family stories
S Values traditions, lifestyle practices, & linguistic heritage
S Will have positive impact on treatment
S Allows for assessment of pragmatic behaviors that may be culturally determined S Rules for eye contact
S How children are praised
S Facial expressions, gestures that replace verbal comments
Establish role of family in treatment
S Who will bring child to therapy?
S Who will be the model in beyond clinic setting?
S Other family members included in treatment?
S What attitudes may impact treatment outcome?
Bilingualism
S Does not mean speaking 2 languages perfectly
S Case descriptions
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4. Treatment of Stuttering in bilingual children
What evidence do we have?
Eliminate one language Karniol 1992
S Case study – English/Hebrew/Hungarian
S Stuttering onset 2;1
S Hebrew only >stuttering disappeared
S No details of stuttering
S Is this a case of natural recovery
S Guttmann & Shenker (2006) – 4 bilingual preschoolers
Does fluency treated in L1 language generalize to L2?
Humphrey et al 2001
S 11-year old twins
S English/Arabic
S Treated in Arabic
S Fluency increased in Arabic reading & transferred to English
Debney & Druce 1988
S Intensive fluency shaping
S No difference between bilingual/unilingual children in treatment outcome
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S When family members: S Attended therapy S Learned treatment targets S Reviewed lessons with child S Modeled treatment targets at home S Provided culturally appropriate materials S Assisted in development of home program Outcomes improved
Using parents to provide treatment (Waheed-Kahn, 1996)
Lidcombe Program: A viable treatment for Bilinguals
Onslow, Packman, Harrison (2001)
S Behavioral treatment
S Parents provide verbal comments
S Weekly clinic visits under guidance of SLP
S Parents provide perceptual severity ratings to track progress
S Can be easily adjusted for bilingual children
Case Studies
Shenker et al 1997
S 3 year old
S Treatment first in L1(E)
S L2(F) added at week 23
S 13.5%SS to 2.8%SS (L1)
S 9.9 – 4.4% (L2)
S SR- 7-3.4
Roberts & Shenker 2007
S 3;11 year old
S Stuttering onset > 18 months
S Pre-treatment 5.6-9.8% (L1-2)
S 15 sessions in 23 weeks to Stage 2
S <1%SS 88 weeks after discharge
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Case Studies
Harrison, Kingston, & Shenker (2010)
S 5 year old
S Treatment in 2 languages
S Pre-tx – 3.8-12%SS
S 8 sessions in 12 weeks to Stage 2
S Post-tx – 0.4-1.4%SS
Rousseau (2005)
S 7 year old
S Treated in French only
S Pre-treatment 2-6% (L1,2)
S 41 visits over 51 weeks to Stage 2
S Post-tx - <1%SS
Case Studies
Bakhtiar & Packman (2009)
S 8;11 male
S Baluchi and Persian
S 12 sessions over 13 weeks
S Maintained for 10 months
S Baluchi at home; Persian in clinic
Treatment Outcomes: Bilingual Children
S Findlay & Shenker ( CASLPA 2011)
S Median treatment time S 12 sessions to Stage 2
S Consistent with benchmarks for monolingual children
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Case History
S Age at onset of treatment – 5;0
S Stuttering onset - 3 years
S L1= English/French; L2 = Hebrew
S Temperament – sensitive but warms up quickly
S Expressive Language – WNL at assessment (French less complex development)
S Family History – recovered (older sister, mother)
Case History, cont.
S Previous treatment – none
S Awareness – initially aware/unconcerned; recent increase in frustration; some abandonment of speaking, e.g., ‘I can’t say it’ .
S Parent feedback – ‘slow down’, ‘take a breath’ when stuttering increases
Objective
S Referring SLP – “severe disfluent speech with a high frequency of prolongations, blocks and first sound and syllable repetition”…some “secondary characteristics related to tension/anxiety…volume rises noticeably, loss of eye contact, turning of his head & neck to release a word…breathing becomes rapid & audible, turning to panting
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Objective
S Speech - frontal lisp & fricatives substituted for sibilants
S IC (pre-treatment) – 3%SS; SR=3
S BC – 12%SS; SR – 7
S poor eye contact
S Expectation of Treatment – will respond to intervention and achieve standard LP Stage 2 criteria
Treatment
S Stage 1 – visits 1-3 before holiday
S Introduced SR
S parents are reliable in verbal comments
S Treatment provided in both English/French
S Verbal contingencies for SFS introduced in structured speaking conversations
S First telephone call (SR=2-3)
S 2%SS on taped sample
S Initiating some spontaneous self corrections; less effort; more whole word, phrase reps.
Stage 2
S Meets criteria in 8 visits over 12 weeks in both languages
S Did not meet criteria for Stage 2 at first visit and subsequent 4 visits ( 5%SS; SR=4)
S Parents resumed daily structured treatment conversations, mother trained to do ST measure
S Discharged from Stage 2 after 12 months at 0%SS; SR =1
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What parents liked best about the treatment:
S Being part of the solution for their son’s stuttering
S Welcomed the opportunity to actively participate in treatment and gave high priority to attending sessions
S Both were able to develop excellent problem solving and observational skills
0
2
4
6
8
10
12
14
1 16 31 46 61 76 91 106 121 136 151 166 181
%SS BC%SS IC-ESR-CE%SS-IC-F
Adjustments to traditional treatment
S Culturally appropriate stimuli
S Modified instructions to accommodate second language of the parent
S Use audio/video exemplars in home language of child
S Provide opportunities for practicing fluency in relevant contexts/activities
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Conclusion
S More clinical studies with larger numbers of children
S compare languages with different structures
S early and later bilingualism
S Bilingualism is not a ‘problem’
S Important to assess in all languages the child speaks
S Treatment is a collaboration between SLP & parent
S Both stutterers and bilinguals are heterogeneous populations
Questions and discussion
Thank you!
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References
Au-Yeung, J., Howell, P., Davis, S., Charles, N., & Sackin, S. (2000). UCL survey on
bilingualism and stuttering. In H.-G. Bosshardt, J.S. Yaruss & H.F.M. Peters (Eds.)
Fluency Disorders: Theory, research, treatment and self-help (pp.129-132). Nijmegen, the
Netherlands, Nijmegen University Press.
Bakhtiar, M., & Packman, A. (2009). Intervention with the lidcombe program for a bilingual
school-age child who stutters in Iran. Folia Phoniatrica et Logopaedica, 61, 300-304.
Bernstein Ratner, N. (2004). Fluency. In B. Goldstein (Ed.), Language Development: A Focus on
the Spanish-English Speaker (pp. 287-310). Baltimore, MD: Brookes.
Bernstein Ratner, N. & Benitez, M. (1985). Linguistic analysis of a bilingual stutterer. Journal
of Fluency Disorders, 10, 211-219.
Cabrera, V., & Bernstein Ratner, N. (2000). Stuttering patterns in the two languages of a
bilingual child. Paper presented at the ASHA annual Convention, Washington, DC,
November 16–19.
Dale, P. (1977). Factors relating to dysfluent speech in bilingual Cuban-American adolescents.