Marisha: Hey there. Welcome to the SLP Now Podcast. It's Marisha, and today we have a very awesome guest, Amy Graham. She has been a speech language pathologist for 20 years, and she's the owner of Graham Speech Therapy, which is a private practice in Colorado Springs that specializes in speech sound disorders.

Marisha: She's listed on the Apraxia Kids Directory of SLPs with expertise in apraxia. And, she's also prompt trained and brings a wide range of expertise to the conversation that we're going to have today. And, she's also worked in a variety of settings. She's worked in public and charter schools, acute care, rehab, hospitals, audiology clinics, and now she's in her private practice. So, she's been in the trenches, she's seen all the things, and she has so many practical strategies and tips to share with us.

Marisha: And then, just before we dive in, if you don't follow Amy Graham on Instagram or any social media platform really, Facebook I guess would be the other one, you definitely should. She does an amazing job supporting and equipping SLPs with really practical strategies. I just love her video demonstrations on there. So, if you love this podcast episode and you want to learn more from her, that's definitely one place I would highly recommend, and I'm sure we'll talk about others throughout the podcast.

Marisha: So, without further ado, let's bring on Amy Graham.

Amy: Hi, Marisha. Thanks for having me today.

Marisha: Yeah, I am so excited to have this conversation with you because we have a lot of students on our caseloads. Like, we often work on articulation, and the oral-motor exam is something that we might not always do, if we're being real. It's something that I didn't always do a great job with. And, then I think it'll be really exciting just to dive into all of the pieces that we can look at in an oral-facial exam, and then also how we can use that to kind of work through our therapy. And, I've been getting several questions about it, and you are the perfect person to break that down.

Amy: Oh, good! Well, I'm happy to. I know, I've heard from quite a few SLPs myself just even through social media or who have reached out to me just saying that they're not confident giving and oral mech because they don't really feel like they had enough training on it, and so you're right. I think it's something that tends to be left out of our evaluations.

Marisha: Yes. And, then before we dive into all of those amazing tips and tricks, can you tell us a little bit more just about how you came to the field of speech language pathology and how you came to specialize in speech sound disorders?

Amy: Sure. Well, many, many years ago when I was a child, my sister actually had to have speech therapy. And, now looking back, I know exactly what she was working on. She had multiple phonological processes going on, so she had a phonological delay. And, she also had some residual articulation errors going on back then too. But, I was probably, gosh, 9 or 10, I guess. She was a little younger than I was. And, I had to go to all her speech sessions because we were homeschooled, and so I got to do all my homework in the waiting room while she was back with the speech therapist, the SLP. And, so I just remember as a kid, thinking, "Wow. This is kind of a cool office." They had a big fish tank. It looked pretty. It was a nice place to go, and so it was... That kind of planted the seed for what would later become my chosen profession.

Marisha: Yeah, I love that story. And, it's funny to hear how we all kind of end up in this space. And, you ended up working in a lot of different settings. How did you land on private practice and speech sound disorders given all the things it could've been?

Amy: Right, yeah. Yeah, I know, I changed my major a couple of times in college like we are all prone to do. And, then I eventually landed on comm disorders, communicative disorders, and then basically halfway through my... the undergrad found out you had to have a master's degree. And, man, that was a shock. I didn't realize that, but I'd already put some time in, so I just went with it.

Amy: And, I really think when I was taking those undergrad and graduate courses, the classes that just always jumped out at me were the motor speech classes, the child speech disorders classes. They've just always appealed to me. And, honestly, when I was a child, that's all I thought speech therapists did. I think that's all most people think speech pathologists do is just work on Rs and Ss. And, honestly, that's all I thought we did too. Which, surprisingly that is what appealed to me initially. So, that's after even going through all our training and all of our different... all of the places that I worked, I ended up landing on it.

Amy: I think I had so much experience in the schools as well because I did my CFY in the schools, and just working on all the different language, autism. I worked in special day classes. But, I just always came back to those speech sound disorders. I think, for one thing for me, when you do an assessment, I think it's so straightforward. I think you can hear immediately like, "Oof, yep. There's gliding going on there. Yep, there's a lateral lisp." And, for me, the assessment is super straightforward, so that appealed to me as well.

Amy: And, then I just have always loved that kind of mechanical nature of [inaudible 00:06:03]. If you know... If your tongue is hitting your alveolar ridge in the right spot, you know exactly what sound it's going to make if you've got the right breath support. And, so I just feel like it just came naturally to me. It just was curing underlying etiologies as well. Like, if you hear the hyponasality, the hypernasality, "Like, okay, there's something going on with the velopharyngeal mechanism." And, it just... just appealed to me, I suppose.

Marisha: Yeah, that makes so much sense, and it's funny because I feel like I was drawn to the field for a similar reason. And, it as kind of different. I was studying abroad, and I got to work with a speech language pathologist on accent reduction. But, at the time I was feeling, because I was a psych major and I was into all of the research and all of that, and it was just so... just so... It felt like such fluffy, big concepts. Whereas, she could tell me exactly where to put the articulator, and that systemic kind of nature to things was really interesting. And, I think as Type A... a generally Type A profession, I think that appeals to us.

Amy: Oh, I completely agree. I think just as I was working on kids and they have these language goals and vocabulary, I thought, "Okay, great. We're working on all these vocabulary words, but..." How do you truly measure somebody's vocabulary when they're 11 or 14? And, it's just... I just feel like you have to take a small, little sample, which with assessment and speech-sound disorders, it's like, "Yep, they're 90% on phrase level, and we're good, and let's keep going."

Amy: And, then also too, I think the treatment approaches. If you know what type of speech-sound disorder you're dealing with and you know evidence based practice, you're going to pick the most appropriate treatment approach and you just go with it. And, I feel like... Like, if you've got a phonological kid, I'm going to look at maybe cycles approach, minimal pairs, maximal oppositions.

Amy: If I have a child with obvious motor-speech issues that has childhood apraxia, I'm going to use principles of motor learning, and dynamic temporal and tactile cueing. And, I just feel like it's so much more clear-cut because there seems to be a decent amount of research at least right now. There can always be more. But, as far as what is the most... has the most evidence behind it as far as treatment too. So, that's also what I love about speech-sound disorders.

Marisha: Yeah. And, it's really amazing because I know a lot of us aren't feeling as confident about the oral-motor exams, but I feel like you have ... you're going to give us a way to make that more clear-cut and easy too.

Amy: I hope so! That's the whole plan.

Marisha: So, before we dive into all of those logistics around that, why is it important to do an oral mech Exam in the first place?

Amy: And, that is a great question. I think because we have to understand... In order to choose an appropriate intervention, you have to understand the nature of the disorder to begin with. And, I think part of doing that is either identifying or ruling out those structural and/or functional contributors.

Amy: So, like for example, I hear... I'll have SLPs contact me 'cause I have a decent following on Instagram, and so I get direct messages all the time, and I'll get questions like, "Gosh, I've got this kid who, he's just... he doesn't seem to have a speech problem, you know, when I give him an artic test, but man his intelligibility is just terrible in connected speech."

Amy: So, oftentimes, I'll ask them, "Well, what did the oral mech exam or the oral-facial exam show you?" And, so many times they're like, "You know, I'm not sure it was a really thorough one, so maybe I should do it again." And, so I'll ask questions like, "Well, was there any overall weakness of the articulators? That could maybe... You might want to think about dysarthria." And, so I think it can reveal a lot about the underlying issue.

Amy: Like, for example, maybe the oral mech exam is... Everything's within normal limits, and there are not issues, and the child has an obvious phonological issue, inaudible going to work on strength, strengthening or over articulation, basically, of those articulators. You're going to work on more of a linguistic approach.

Amy: So, excuse me, in other words, I just think it helps us rule in or rule out those structural and functional issues that we may have to address, that we would miss otherwise, and an articulation test is not going to show that.

Marisha: Yeah. Can you give us a couple concrete examples of maybe like a couple kid... maybe one or two kids that you've worked with?

Amy: Sure.

Marisha: Where you did the articulation test, but the oral-motor... or, oral mech exam revealed something that really helped you kind of change course or helped you clarify where you wanted to go.

Amy: Absolutely. I can think of one just a few months ago actually. This was a child who came to me, already had an IEP, and they were working on language, which there were obviously expressive language issues going on. But, the parents were just thinking that there's something else, she's just... it's not just that she's having a hard time putting sentences together, she's just really tricky to understand.

Amy: And, so basically all that was done previously was the Goldman-Fristoe, and you know there are not many multi-syllabic words on the Goldman-Fristoe. And, so really nothing much showed up. There was maybe... I think there were issues with a "T-H," but at her age it was like, "Okay. We should work on that, but that's probably not what's contributing so much to her un-intelligibility."

Amy: And, so as I did the oral mech exam, come to find out, she had incredible difficulty with volitional movements, just with non-speech volitional movements. So, you know, to me that's always a clue of, "Ooh. Are there some motor planning issues?" And, so that's all included in the oral mech exam, and so that's... Basically, that's not going to give me any diagnostic information, but it certainly is going to raise some red flags if children have issues with volitional non-speech and speech movements as well. And, so then my little question mark goes off in my head about, "Okay. Well, I'm going to consider childhood apraxia if speech is a contributor."

Amy: And, so then we did... went on to do the diadochokinetic rates, and boy were they jumbled up and just she had so much difficulty with the [putika putika putika 00:12:55] and the discoordination of those movements were kind of all over the place. And, she even told me, she's like, "Man, that's really hard to do!" And, then what that did is made me think, "Okay. We're not going to just look at a regular old articulation or phonology test. I need to do a motor-speech assessment with this child because that's what I suspect might be the underlying issue or at least a contributing factor."

Amy: And, we did that and there were obvious, obvious motor-speech issues. The longer and more complex utterances I gave her to produce, she had much, much more difficult time producing them. And, so things like that where you give the kid a straight artic test, "Oh, they're fine. You know, they're maybe borderline. We'll just work on "T-H." But, if you dig a little bit deeper, you might something else that is really contributing to their intelligibility.

Marisha: Yeah, that was such a great example. And, I feel like I've heard you talk about this before, but there's also structural components that might not be-

Amy: Absolutely.

Marisha: ... totally obvious. Can you give one example of something like that that came up in your practice?

Amy: Yes, absolutely. So, sometimes we'll get kids who sound a little hypernasal, and so that's really one of the parts of the oral mech exam too that we have to look at is you've got to look inside the kid's mouth, and not just how they're moving their tongue. We need to be looking at their palate and their velum, and seeing if there's any structural issues happening because oftentimes also I've gotten DMs from other SLPs and they're thinking, "Man, we've done therapy with this child. They're hypernasal and they just..." Or, sometimes I'll even hear, "You know, they have a substitution of they keep saying "M" for "B" or "N" for "D." And, of course that in my mind, my red flag is, "Well, that's hypernasality." So, how is that velopharyngeal mechanism working? Or, is there anything structural?

Amy: And, you would be surprised how many times I have found a bifid uvula, which can be an indicator of a submucosal cleft, which can really impact velopharyngeal insufficiency. Or, any kind of velopharyngeal dysfunction could be there. So, that's a child that really needs to be referred to a specialist and not just an ENT, but a team of specialists so that you have a craniofacial team or a cleft palate team. Here, in Colorado Springs, we have a VPI team that I refer to when I see that.

Amy: So, sometimes those things, they don't come up. You just might think, "Well, that's just an articulation substitution. It's no big deal." But, if a stop is changing to a nasal, that should be a little red flag that you need to consider that nasality might be an issue, and it could be structural, and we're not the ones that can rule that out. We need to send those kids to a team for that.

Marisha: Yeah, so helpful. And, I hope that we're all convinced that this is... that these are important things to look into when we're evaluating a student with speech sound disorders. And, so I'm curious, can you give us... 'Cause you touched on a lot of these things already, but can you give us a general overview of what you're looking for in the oral mech exam? Kind of like which components you go through. Like, do you have a process that like you always go through it in the same way or-

Amy: I do [crosstalk 00:16:23]. That's pretty much the reason I developed this particular checklist style format is because... And, what's the saying, "necessity is the mother of invention." Because I was looking for an easy-to-use, kind of a quick and simple, checklist style form that I could just take with me wherever I'm doing an assessment to go through. And, so I had to really think through, "Okay. Well, what all am I going to be looking for?"

Amy: And, really, it's everything that I was taught in grad school, and have learned through taking other Continued Ed courses just through the years about what we really need to be observing. So, for example, the first thing I go through is I'm just going to observe the child's face at rest. I'm looking for symmetry. Is there any drooping? Because sometimes, you might be surprised that some of the kids that we get might have some underlying neurological issues happening that parents aren't even aware of. And, we might be the first people to notice these things. Pediatricians miss this kind of stuff all the time. So, sometimes because we're looking so in-depth at their oral-facial structures, we might see things that nobody else will.

Amy: And, so I'm always looking, just observing symmetry, their tone of their face at rest. I'm looking if the child is mouth breathing. If you have a child that's come into... If I have one that's coming to me and they've got a pretty significant frontal lisp, there's a lot of distortions, and they're mouth breathing, and their mouth is open all time, that might be a child that we need to look at also how their feeding is, how their swallow function is because that could be a big issue as well.

Amy: I'm looking for how their jaw is moving. Do they have a good range of motion? Sometimes, I have kids who either their jaws are not opening sufficiently for speech. That's something we have to teach, about how to make those vowels better with good jaw grading. Is their jaw moving symmetrically when they're speaking?

Amy: I look at dentition. Sometimes, if children have crossbites, underbites, overbites, sometimes that can impact speech. However, I will say, as I go through this list, just because you notice something doesn't mean that, "Okay. Well, we can't work on anything until they get their braces on," or... Because I am always surprised at how kids can compensate for structural differences with their oral structures. But, it is always something good to note because if a child doesn't have good progress in therapy, you might want to go back and think, "Well, okay, well it could be because of these structural differences."

Amy: I'm looking at the pharynx. I'm looking to see how big their tonsils are, if they have tonsils, which is also why we need to do a case history because maybe they had their tonsils removed and that's why you don't see tonsils. And, if they had their tonsils removed and there is nasality in the child's speech, then that might be something you need to make a referral for as well. I've had that happen several times.

Amy: I'm going to look at the hard and their soft palate. There could be fistulas that have never been noticed. There could be submucosal clefts. So, I'm looking for all of these... I'm even looking at their soft palate to see what kind of movement I'm seeing with that soft palate when they're phonating. Is there lateral movement? Is it moving towards the center? Or, does it look it's moving up a little bit? We need to... And, sometimes if there are soft neurological signs, you might see some asymmetries in even the velar movements.

Amy: I look at their lips, how... Are they able to pucker their lips? This is another way to kind of check for oral, non-speech oral apraxia. Do they have a hard time doing what you're asking them to do? Like, can you pretend to blow bubbles for me? Can you pucker your lips like you're going to give mom a kiss? Do they have any issues with that? And, then do they have any strength issues? I use a tongue depressor, a lot of times, to have them push against my tongue depressor with their lips just to kind of gage how strong their muscles are. Not that you need a lot of strength for speech because we all know non-speech oral-motor exercises are not effective for improving speech if it is... if weakness is an issue.

Amy: But, it's just something that is good to note because if you ever have to refer inaudible to another specialist, it's something to have in your notes that we should all know about. So, there lots of things with the lips. I'm looking for rapid movements, for are they able to puff their cheeks out and hold their lips closed? Can they maintain that air in their oral cavity, or does it escape through the nasal cavity? Do you hear any air escaping, and is that maybe the velopharyngeal mechanism and are there issues there?

Amy: I'm looking at their tongue... Excuse me. I'm looking for range of motion. I'm looking for weakness. And, there are... We have ways, and I list them all out in my oral-facial exam on how to do that. But, I'm looking also for... As far as range of movement goes, I know it's kind of controversial right now in our profession about tongue-ties or shortened lingual frenums. But, I mean, if it's really restricted and that poor kid can't lift the tip of their tongue very far at all, then even though, okay, maybe you could get them to say a certain speech sound, it's going to be so effortful that in connected speech maybe that's going to be an issue. So, it's just something to note.

Amy: And, then I'm always looking at rapid side-to-side movements as well with the lingual movements. And, then at the very end after we kind of go through all of those oral-facial structures and their functions, I have the diadochokinetic syllable rates at the very end of the assessment sheet.

Amy: And, then 'cause I know I've heard from a lot of SLPs that, "Okay, great. I know how to assess strength, I know how to assess all this stuff, but what do I do with this information?" And, so I have a little section at the end too to kind of walk you through, "Okay. Well, if you're seeing these four things, then you might want to consider a referral here." Or, "If you see these three things, you might want to consider looking at feeding issues or tongue thrust assessment." Or, "You might want to consider a motor-speech assessment based on these findings."

Amy: So, I try to help walk through any SLP with whatever experience and SLP has. If you've taken your anatomy and physiology classes, you might have to go and review a little bit... and even neurology. But, I tried to make it as easy to use as possible.

Marisha: Yeah, and I personally love the checklist format, and it's been so helpful in just feeling confident. I know I looked at all of these different components, and then that gives me enough to go off of. Especially with those jumping-off points, that's such a helpful resource.

Amy: Right.

Marisha: And, then... 'Cause I think especially for a newer clinician, they might be like, "What is normal strength? What is it supposed to look like?" What would you suggest for someone who's still trying to figure that out?

Amy: Well, probably the best tip I can give is go assess about five or six typical developing kids that don't have a speech sound disorder. Because in order for us to be comfortable saying, "Yeah, that doesn't look right. That's kind of outside of the realm of typical development," we need to know what typical looks like. So, that would be my best advice is find a cousin, a niece, a daughter, a son, a nephew, a child of a friend where... that would... that you can just go and say, "Hey. I just have this little quick assessment. It won't take long. It's about 10, maybe 15 minutes at the very most. It'll be fun. Can I assess your child really quickly?" And, just have a good idea of what typical looks like, and the only way to do that is to assess typical kids.

Marisha: Yes, I love that, and I think it's a good way... Because it'll probably be easier to run through the assessment with a friend's kid versus a kid-

Amy: Right.

Marisha: ... in the therapy room.

Amy: [Inaudible 00:24:55].

Marisha: So, it could be a good way to get that flow down and kind of get the process.

Marisha: So, speaking of actually administering the assessment, what are your tips for make... like getting through... 'Cause there's a lot of different things that we're asking students to do. We work with a wide range of students who might have difficulty in several aspects of like following the directions and attending. Like, what are your go-to tips and strategies in terms of actually administering that?

Amy: Right. Yeah, the oral mech exam can be tricky, especially if a child maybe has bad experiences with medical professionals, and you're coming at them with a tongue depressor and a flashlight and he's like, "Whoa! I know what this is all about. I'm going to get a shot in a minute," or it just kind of... It can freak him out a little bit. So, I think we have to be really careful to understand a child's medical history so that we can be prepared for that.

Amy: So, what I recommend, one of my absolute best tips is I have a throat scope and I got it several years ago, I think, when it kind of first came out. And, it just changed the dynamic of doing an oral-facial exam because the minute you show that child that, "Oh, no, no, no. We're not going to stick this icky wooden thing in your mouth. Look at this, this is my light saber and that's..." I've talked to so many SLPs, and that's what they call it too because it is. It looks like a little light saber. It's a light-up flashlight, basically, that sticks on a plastic tongue depressor that basically lights up the whole tongue depressor.

Amy: So, when you stick it in the child's mouth, it just lights up the oral cavity. And, for one thing, it's better for us because I can see so much better. I don't have to have a tongue depressor in one hand and a flashlight in the other. It's now I'm only using one hand to hold, and then I can kind of help maybe hold the child's hand or kind of show them what I'm doing with my other hand. And, so it kind of frees me up to either write with one and do the assessment with the other. But, the kids love it.

Amy: I mean, sometimes I'll even have them practice with a little hand puppet themselves and say, "Here, why don't you do it first?" Especially if they're a little timid about initiating the oral mech exam. And, so I'll have them do it. That's another tip is have a little hand puppet on hand where they can practice doing it, and you give them the instructions like, "Okay. Tell them to open their mouth wide. Okay, now it's your turn."

Amy: And, so you can kind of have a little turn taking game that you're... You can kind of make it into a game, "Okay, now it's your turn. Oh, we're going to do something really silly now! I want you to move your tongue back and forth like this." And, so I think trying to make it as fun as possible. And, I even tell my kids, "I'm going to ask you to do some weird stuff right now. Are you ready? It's going to be so silly." And, so just to kind of make it a game.

Amy: Sometimes, though, if that's just not working, I will often just save it for the last thing that I do in my assessments. I will... We'll do the easy stuff like, "You're just going to name all these pictures I show you." And, then once we're kind of comfortable, we've maybe... I've gotten a good language sample because we're talking a little bit back and forth and they're comfortable with me now, then that's when I'll bring out my throat scope or my tongue depressor and say, "Hey, let's try something crazy now. Let's do something a little silly." And, then they're a little more comfortable sometimes if I hold it off to the very last thing.

Amy: But, then sometimes I think you have to be okay with doing it across multiple sessions. I've even told parents that that, "You know what? He is just not wanting to open his mouth for me today. So, I'll tell you what. Let's hold off on writing this report. Or, I'll write my report and say we're going to get this information later once more rapport is built between the client and myself."

Amy: And, so sometimes I will just either put it off down the road or I'll just say, "You know, we were only able to maybe get this first part of it where I just kind of observed their facial structures, but they weren't willing to stick their tongue out for me or have me kind of tip-toe that tongue depressor along their tongue. So, we're just... We're going to get the rest of it at a next session." So, I think sometimes we have to be okay with that. And, I think if we explain that to parents, they completely understand.

Marisha: Yeah, those are great tips. I also love the throat scope, like what an amazing invention that was.

Amy: Crosstalk fabulous.

Marisha: 'Cause it help us and it's super cool.

Amy: Oh, yeah.

Marisha: And, then yeah, I love the idea of using the puppet and making it a game, being silly around it, and just... I mean, we model it first just naturally when we're going through, but I think that it's nice because it is such a visual activity.

Amy: Mm-hmm (affirmative).

Marisha: Like, that we have built-in supports there even for a variety of students, so that's-

Amy: And, I even think explaining to the child what we're doing too. Because I think sometimes, we get so used to doing these assessments, we're just, "Okay, now do this, now do this." And, they're kind of thinking, "Well, what? Why?" But, so I will explain to them inaudible like, "Ugh, you know what? I need to look at your tongue because sometimes your tongue might move a different way than mine, so that's what I'm... I'm just looking to see how it's moving, that's all." And, so I think if we kind of give them a good explanation sometimes, especially if they're a little older, they're much more apt to go along and be cooperative during the assessment.

Amy: I thought of one more thing though. I had... I was speaking with Cari Ebert, a new friend of mine who's a fabulous apraxia expert, about how she can kind of get her really little ones 'cause she works with early intervention. And, so she will have the kids lay backwards on an exercise ball and have mom or dad there. And, as they roll them back, she says, "They always open their mouth really wide." So, you can get a good look inside their mouth when you do that, as you kind of roll them back just in a playful way on the exercise ball. So, that's another great tip that she gave me that I had to pass on.

Marisha: Ooh, that is genius! Crosstalk I love that one.

Amy: [Inaudible 00:31:05].

Marisha: That's like a little hack there. Oh, good. Okay, and so that's super helpful. I feel like we know why we want to administer these exams in the first place. We have a really good idea of what we're looking for and what we might do if we see certain components. And, then we also have a nice tool belt of different tricks that we can use if the student doesn't want to open his or her mouth or if we're just having some challenges there.

Marisha: So, then let's talk a little bit more about what we do once the exam is done and we have that data. Because I know sometimes, there can be some more controversial findings and it's not always super clear what the correct path is. So, can we talk... Like, one of the ones that came up, I think, is tongue-tie.

Amy: Right.

Marisha: So, what would you do if you find tongue-tie?

Amy: Well, I think we have to understand to what degree that tongue-tie might be impacting speech, and sometimes we don't really know. I think there's a tendency to go... to throw the baby out with the bathwater, so to speak, when there are SLPs out there and researchers who just automatically, "No, tongue-tie has nothing to do with speech. Don't worry about it. Maybe feeding, but not speech. The research doesn't show that it has an impact at all."

Amy: However, when you... When I read the research, and I'm sure I need to speak with an expert who has really read the research more than I have, but it's not that the... What I have found, anyway, is not that the... A tongue-tie, in general, doesn't impact speech. It's that when the tongue-tie is clipped or released, whatever you call it, that they haven't found that it has made an impact in speech improvement.

Amy: But, to me, there are so many variables of "haven't been looked at." I mean, have you looked to see if... What kind of therapy did they have beforehand or post? And, I feel like I, at least in my looking into that, the literature, I haven't... It hasn't answered that question for me. So, however though, there are other SLPs out there too who'd be like, "Oh, it's a t-... They have a tongue-tie? That's their problem. Let's clip it. That's it." I'm not there either because I don't think the research shows that, obviously.

Amy: So, what I do is I note the... to what degree that tongue is restricted. I think we should know it. I don't think we need to completely disregard it because I've seen kids who, oh my gosh, their tongue is so restricted that they can't even lick an icecream cone. They can't stick it past... stick their tongue out past their lips. And, if you don't think that's going to impact speech, then I wonder how many kids you've worked with with speech sound disorders because I've had kids who just... I mean, honest to goodness, they back everything because their tongue tip will not raise to that alveolar ridge in quick, connected speech. Now, you might be able to get them to do it at the single word level. But, as far as generalization goes, those kids are going to have probably a much harder time doing those movements quickly, and rapidly, and coordinated in connected speech.

Amy: So, for me, it's something I always note. However, I've had some kids that I've seen are not that... They are restricted, but not to the degree to maybe where they're... They can maybe stick their tongue out a little bit if they open their mouth wide and their tongue can reach... Or, it can at least get pretty close or halfway up to the palate. But, they don't have any issues with S's, or T's, or D's, or those alveolar sounds. Then, that's something I note for later.

Amy: However, I will say, I've had a few kids who I've noticed a, I would say, mild to moderate lingual restrictions. We've done therapy, and the issues have been an "R", actually, for the two that I'm thinking of. And, boy, we just couldn't get this "R" sound. I tried every tool in my tool box. We did it for a few months. Three or four months, I think, we did therapy for. But, I had back in my oral-facial exam that you know what? This restriction was noted. This lingual restriction was noted.

Amy: And, so I've gone back to the parent and I've said, "Okay, look. The research doesn't say "yes, if we get this tongue-tie taken care of, that her speech is going to improve and it's going to work." However, we've tried therapy for this long. I feel like she just is not able to elevate the back part of her tongue high enough to get it in the right spot to make that really good "R" sound. Because if you think of "R," I mean, you have to elevate the back of your tongue, you have to tense it. There's all these things you have to do. And, so in my opinion, I think you should consider it."

Amy: I never tell a parent, "You have to have this done." Because it's a medical procedure. I'm not a doctor. I'm not a pediatric dentist, which is who I refer out to for those kinds of referrals, those issues. And, so I'm not the one who's going to say, "Yes, this has to be done." But, I will share with a parent what I know. And, what I know is that we've done therapy, it's not work, there's a restriction. Research doesn't necessarily say it'll help, but you might want to consider it because I'm all out of my bag of tricks here." And, I've had two that I can think of that have had their tongue-tie clipped or whatever, their tongue-tie revised, whatever you want to call it, and we've made progress.

Amy: So, not that that's worth publishing, but I will say that I've had a couple times where that was the key to what helped them finally produce a particular sound accurately, consistently, and then they were able to actually generalize it much, much quicker. So, I guess I'm kind of, I don't know, agnostic as far as tongue-ties go because I think it's not something like I said before, we shouldn't be throwing the baby out with the bathwater just because the research doesn't show yet that it could be impacting speech. Or, maybe that research just hasn't looked at some specifics that we can see in clinical practice and maybe not in the research yet.

Marisha: Yeah, that's such a helpful case study, and it's really cool that you got to see that in action.

Amy: Yeah.

Marisha: That's so interesting.

Amy: Yeah.

Marisha: Have you seen any other factors? 'Cause that just peaked my interest. Have you seen anything else? 'Cause "R," I feel like, is one of the sounds that we... a lot of us struggle with.

Amy: Mm-hmm (affirmative).

Marisha: Have you seen any other factors that determine difficulty with "R" and kind of-

Amy: Yeah, absolutely. I think one thing that has, I think a lot of our kids with R's have trouble with proprioception, honestly. Because if you think about, when you tell them to make a "T" or a "D," what are you going to tell them? You put your tongue tip up, and you put it right here behind your teeth, and you just pop your tongue, "T-t-t-t," just like that. It's easy. It's visual. You can see exactly what to do.

Amy: Okay. Well, how do you explain what to do with your tongue for an "R?" Well, you kind of bunch it up in the back. Maybe you're going to tell them to curl their tongue if you're doing bunched or retroflexed versus bunched. And, so there's all these very kind of nebulous descriptors that we're trying to explain to this child to do. And, it's not like for bilabials, we can touch their lips and you can give them that tactile feedback. Well, that's a little harder with an "R" sound.

Amy: And, so I've found when I've given this oral-facial exam to kids who have those residual "R" errors, they are having a hard time telling where their tongue is in space. So, I feel like... I wonder if sometimes these kids with "R" problems who just can't ever quite get it, it almost always sounds even a little bit vowelized, they're just having trouble telling where their tongue is.

Amy: And, so if you have a child with proprioceptive issues, and really that can often come across in that oral-facial exam. You know, you tell them, "Okay. Don't look in this mirror. Just look at me. Copy what I do." And, you could see that they are not doing what you're doing. That might be a proprioceptive issue. It might be a motor planning issue. But, it also might be proprioception. And, so for me when I have... when I see a child with that deficit, I use a lot of tactile feedback.

Amy: And, so sometimes I will back up with those kids, and we will just get our little... my little swizzle sticks, and we will kind of touch the sides of the tongue and the tongue blade so that they can feel... As they're looking in a mirror, they can feel where their tongue is in space, and we practice moving your tongue in the context of speech a lot of times, but sometimes we just need to figure out where their t-... They need to figure out where their tongue is when they're moving it in a particular way. So, I think, yeah, that's another issue that that wouldn't... The only place that would come across is is really in an oral-facial exam, in an oral mech exam.

Marisha: That is so interesting. And, if you identify like the proprioception as a potential challenge, how... Like, I love the ideas and examples that you gave of what you could do in therapy. But, how would that fit into the general context? Would you... And, I know it varies for each student, but do you have kind of a general... Like, if you notice that, is there something that you generally do in terms of, "We just do it like a couple minutes at the beginning?" Or, do you spend a lot of time?

Amy: You know, like you said, it does... It's totally dependent on the child. Sometimes, they can get it pretty quickly if you give them a mirror and they get the visual feedback. Sometimes like, "Oh, okay. I see that my tongue is not going where I thought it was going." So, giving them a mirror helps almost initially. I've had some that we are working for weeks and weeks on trying to use tactile feedback along with visual feedback.

Amy: So, we've got a mirror and maybe a tongue depressor just to kind of say, "Okay. Do you see how we're curling our tongue? You're not curling your tongue, so let me help you with this tongue depressor," or this little Toothette or whatever you use for that tactile feedback with your kids. And, sometimes it takes a while with some kids. It just depends on the degree to which they have a deficit in that area.

Amy: And, sometimes you'll have a child who it's motor planning, plus proprioceptive, plus a few other things. So, I think if you have other... if there are other contributing factors going on, you might expect therapy just to take even a little bit longer.

Marisha: Yeah, that's so helpful. And, I think this is a good reminder too that we're not just looking in the mirror moving our tongue, we're looking in the mirror and doing all those different activities in the context of shaping those different speech sounds. So, it's always working towards that main goal. But, are there times when you would stray a little bit more away from that?

Amy: Stray from-

Marisha: Just like always having... 'Cause I guess we would break it down, and take a step back as we're shaping a new sound, and just practice some of those movement components.

Amy: Well, I try always, as quickly as possible, to put it into the... into speech. So, I mean, sometimes if we're inaudible what I might do is not even work on "R" for a little bit, but we'll work on another similar phoning like "L." And, we'll give a lot of tactile and visual feedback pairing "L" with vowels because they're very similar to the "R" sound. So, if we can put it in the context of speech, I think that... I mean, that's always the goal, right? We don't want to sit there and just, "Okay, we're just going to tap on your tongue. You feel that? Yep, that's right." Well, we've got to put that into the context of speech as soon as possible. And, for me, often it's on our first session.

Amy: And, so we might... Like you said, we might begin a session with, "Okay. Let's do a little feedback here. Touch this on your tongue." And, I know there are programs that actually focus a lot on that. I'm not a big program person. If it has a fancy name to it, granted I have some certifications and some trainings, I'm all for gaining knowledge in whatever area might help you working with your children, but I'm not a program person because I don't think there's one program that's going to... that's a one-size-fits-all.

Amy: But, I think we can definitely glean some helpful information or some therapeutic techniques from those, quote unquote, programs. But, we also have to balance that with what we do know about evidence based practice, and that is speech improves when you practice speech. And, so my goal is to always, even though I'm backing up and might be doing a few non-speech tasks to kind of build proprioception and sensory awareness, that kind of thing, my goal is to put that within the context of speech ASAP.

Marisha: Yes. Yeah, and I feel like I talk about that all of the time with... 'Cause I'm all about literacy based therapy, and it's always about putting it in context, putting it in context. And, I heard a really cool metaphor analogy from Dr. Ukrainetz who was talking about... Like, she compared... And, she was talking about language, but I think it applies really nicely to this too.

Marisha: So, we can teach... If we're a basketball coach and we're teaching students how to play basketball, we could have them just drop the ball on the floor 'cause that's a component of dribbling and that's a component of playing the game. But, if we... If that's all that we work on, if it's game time on Saturday and all they know is how to drop the ball, they're not going to be able to participate and be successful during that game. So, I think... I just really like that comparison.

Amy: That's a great [crosstalk 00:45:27]. I love that.

Marisha: So, awesome, and that was a super helpful breakdown of that.

Marisha: And, so I'm also curious in terms of... I feel like a lot of us are overwhelmed when it comes to motor-speech disorders, and if we... Can you just highlight again what we might see if a student does have difficulty with motor-speech, motor planning? Like, what would we see in the exam? And, what are some things that you would do based on that?

Amy: Right. So, initially if I see... Now, granted, this is not a speech, necessarily a speech test because you're looking at non-speech movements. But, if you see some groping with volitional movements during this oral-motor task... If you're asking them to stick out their tongue and move it side-to-side and you've already done a bunch of oral mech exams with typical developing kids, you're going to know what groping looks like.

Amy: And, typically, three-year-olds, four-year-olds, if we can stick our tongue out and move it side to side rapidly, there's no... Inaudible rhythmic movements, they're able to do pretty rhythmically. And, so if you see a child who has difficulty with that and they're groping, and they're kind of moving their whole head or they're moving their jaw along with it because they're having the hardest time getting their tongue to move quickly, rapidly, and you're just noticing a lot of difficulty with that, that's a red flag for apraxia.

Amy: And, then if they're only able to complete it upon imitation... It's better with imitation. Okay, well that's... That means that they need that extra support in order to do that movement. And, then also with the diadochokinetic syllable rates. If you're noticing all these issues like poor rhythmicity, coordinating, groping during those oral mech exam tasks and they're maybe more than 1.5 standard deviations outside the mean for those diadochokinetic rates, then to me those are really big red flags that I need to do a motor-speech assessment.

Marisha: And, I know we're not going into the full motor-speech assessment here, but what are some things that you would look at when you're doing that?

Amy: When I'm doing the motor-speech assessment?

Marisha: Yes.

Amy: So, you're going to look at... And, there are some really great guidelines. I know Edythe Strand, and I believe [inaudible 00:48:03], I don't have it right in front of me, have developed the DEMSS. And, gosh, don't ask me to say what it... Dynamic, Motor, Speech. I can't even tell you what it is, but that has come out recently and it has some... I just recently was at a talk, at the Apraxia Kids Conference, about how to conduct that assessment. And, basically, you're kind of walking the child through increasingly more difficult speech syllables, words, phrases, and you're assessing how accurate they are with different levels of prompting, the consistency of those productions.

Amy: And, there's a whole way to assess that basically, and there are some other... Even Jennie Bjorem has a really great assessment, an informal assessment, to help you kind of walk through what to look for for a motor-speech assessment. But, you're looking for accuracy, consistency specifically upon multiple repetitions of words that these child... that the children are given to repeat and how well they do as those words get increasingly more difficult.

Amy: Vowel production too, vowel distortions are another key component of apraxia, and as well as coordinating movements between sounds because these kids have difficulty with the motor aspect of speech and from going maybe from one syllable to the next. So, there might be some pauses, unusual pauses, poor rhythmic... What's the word I'm trying to come up with? I can't think of it off the top of my head. But, so there's many different aspects of speech that you're going to look at and too much for me to probably go into too much right here, but that's kind of a general idea.

Marisha: Yeah, that's super helpful, and I think it's... Maybe that'll have to be a whole other episode.

Amy: There you go.

Marisha: But, yeah, I love the... I got to learn about the DEMSS, and I just looked it up. It's the Dynamic Evaluation of Motor Speech Skill.

Amy: There it is.

Marisha: And, it's by Dr. Strand and Dr. McCauley?

Amy: Yes.

Marisha: I believe is how you say it.

Amy: Yep.

Marisha: But, I got to... Actually, a couple years ago I went to an intensive with Dr. Strand, and it was so incredibly helpful, and it's just I love... Like, this is all so systematic. They have like a nice framework around it, and it's a lot like the inaudible oral... oral exam that we've been talking about today. So, there are some really nice things that we could explore-

Amy: [Inaudible 00:50:47].

Marisha: ... and talk about more maybe in a future episode. But, that was a really helpful breakdown just to get us started and to know where to look for some resources. So, it was the DEMSS and Jennie Bjorem's resources-

Amy: Yes.

Marisha: ... to get started there.

Amy: Absolutely.

Marisha: Awesome. Well, I fee like I've walked away with a lot of good, practical tips and strategies and things to look for. I just love all of the practical suggestions and ideas that you shared. Is there anything else that you think is really important to share or something that you just wanted to end on?

Amy: I think that if you... Any SLP, if we don't do an oral mech exam, and I probably have said this before, with any child who has a suspected speech sound disorder, I think you're going to miss some things. So, I just think make sure... I'll reiterate. Make sure you always do one even if it's just, "Ah, this kid just has an "R" sound," or, "We just have a lisp, no big deal," always do an oral mech exam.

Amy: And, then if you're... Like I said, if you're unsure about how to interpret those findings and what to do with them or even just don't have confidence in your ability to understand what you're seeing, reach out to more experienced SLPs. I'm a sole practitioner, so I'm all by myself, so I have discovered that the social media outlet of finding other experts within the field has been so great with connecting me with other SLPs who have more experience and knowledge base than I do. So, I would say to anybody who's even new to giving oral mechs, reach out to an experienced SLP.

Marisha: Yeah, that is such a great strategy to use regardless of the area that we're working with.

Amy: [Inaudible 00:52:37].

Marisha: And, yeah, so valuable. And, where can... 'Cause I feel like everyone is going to want to learn even more from you, and check out your videos, and just learn all that you have to offer, so where can they find you if they want to find [crosstalk 00:52:54]?

Amy: So, yeah, my Instagram account is @grahamspeechtherapy, and Graham is G-R-A-H-A-M. And, I post... Like, I think you said earlier, I post real life therapy videos of me doing therapy with all my kids, whose parents have given me permission to do so. But, I record myself doing different therapy techniques. I have more information on how I administer my oral-facial exam on there in my highlights on my Instagram account.

Amy: I'm also on Facebook at Graham Speech Therapy. And, if you want to purchase the oral mech exam, the oral-facial exam is actually what I call it, that's on my website at www.grahamspeechtherapy.com.

Marisha: Awesome. And, we will share the link to the exam and all of the different resources that we mentioned throughout the podcast in the show notes, and that will be at slpnow.com/17. So, you can go there to find the link to, like I said, the exam, the DEMSS, the throat scope, all of the good things. Oh, and also Amy's social media platforms. So, let us know if you have any other questions about the oral-facial exams. But, I feel like... I think you did a pretty amazing job today, Amy.

Amy: Thank you.

Marisha: And, thank you so much for sharing your time and knowledge and expertise, and we'll talk to you soon.

Amy: Thanks. It was my pleasure.

Marisha: Hey, there. Welcome to the SLP Now podcast. I am so excited to be introducing our guest. Today. We are going to be diving into fluency strategies for some special populations. Our guest is Stephen Groner. He is a practicing speech language pathologist and person who stutters. He now speaks very fluently. I can't wait for him to share a little bit of his story with us.

Marisha: But he is on a mission to make stuttering therapy easy for everyone. He does that by sharing practical strategies. He has such an amazing way of breaking down stuttering and fluency therapy in a way that makes so much sense. I can't wait to hear all of the tips. Without further ado, let's chat with Stephen Groner.

Stephen: Hey, there. It's so good to be with you.

Marisha: Before we dive into all of the amazing tips and resources that I know you've got [crosstalk 00:01:04]-

Stephen: You would be right about that.

Marisha: What got you into the field of speech pathology, and how did you come to learn so much about stuttering? Can you tell us just a little bit about your story and your journey there?

Stephen: Yeah. Well, if you jump back with me, when I was six years old, I had to give a speech. It was a speech on my favorite animal horses. I got this book. I researched all kinds of facts. I wrote my speech down, and I decided to run through it with my mom. I stand up in front of her and my brother. I went to start. I couldn't say the word horses at that age. It just wouldn't come out of my mouth.

Stephen: I don't know how my mom kept a straight face as I tried to get through that word, but that was the first time when I knew that something was wrong, something was up. It continued from there. It was hard to say my name when I would meet new friends, hard for me to raise my hand and talk in class, hard for me to read out loud in front of class even though in like the fourth grade, I could read at a college level. Somehow, I got out of school-based speech therapy, I think, because I had really strong language skills.

Stephen: My stuttering was not impacting my academics, but it's because I would switch words. I had to work so hard to get any thoughts out. By the time I was 17 years old, I had had it. I was done. Talking was just too hard. I was just tired of not feeling like I was known being scared that I would never get a job, tired of like every single conversation being a hard one. I did what we all do.

Stephen: I hopped on Google. I found a two-week long intensive fluency shaping program in Virginia. Two and a half months later, I was there. For two weeks, I sat in a small room with a little box and a lot of workbooks. I was taught how to remake speech sounds in a more fluent way using fluency shaping techniques. It completely changed my whole life.

Stephen: I can still think to when I walked off of Main Street and walked into this little deli. I walked straight up to the counter and ordered lunch for the first time without stuttering like I ordered the exact sandwich that I wanted. I asked for exactly what I wanted on it. It came out. I got it. It was just so freeing. That changed my whole life. I wrestled for a few years wondering if I would ever make a good speech pathologist if I myself sometimes stuttered, but in the end, I decided and was shown that I actually might make a pretty good one because I'd been there in their shoes.

Stephen: It's been over 10 years now since I first went to that fluency shaping program. Every day since and all the years through graduate school and out of it, I have just been learning more and more and more about what we can do to help people like me to speak more fluently. I was pretty down cast when I got to graduate school though and found that fluency wasn't always taught very well or that a lot of students didn't feel like that they got what they needed from their grad school classes. Then, they were kind of thrown out into the field. It had no clue how to help these little kids who couldn't get their thoughts and words out.

Stephen: I felt bad because I knew so much and knew how much good that great therapy could give. I thought, "Well, you know what? I'm just going to make it nice and sweet and simple and easy for speech pathologists to learn how to do this well." That's why I'm here. That's how I got to be here.

Marisha: Oh my god. So many amazing nuggets and nuts for you. I wish you, guys, could see me because I was like, [inaudible 00:06:18].

Stephen: Thank you, Marisha.

Marisha: crosstalk see me. I hope you were [crosstalk 00:06:29].

Stephen: I was, yup, silently inside. crosstalk

Marisha: All the people who are listening because, oh my gosh, [crosstalk 00:06:38].

Stephen: Thank you.

Marisha: Now, let's just get-

Stephen: Let's begin.

Marisha: ... into all of the crosstalk good stuff. We're talking about two special populations today. I've gotten a lot of ... because listeners can submit questions to the podcast. This is one that I've gotten a lot about because like you've talked so much about stuttering and fluency, and we had a focus inside of the SLP Now membership on it too. They're like, "This is amazing like I've got the foundation." But what about this kid or this kid? A lot patterns that were coming up were like children with concurrent intellectual disabilities and bilingual children, and well, you've got lots of great things to share-

Stephen: I do.

Marisha: ... crosstalk on both of those. How about we start with some ... like can we treat stuttering in children with concurrent intellectual disabilities? If so, what does that look like?

Stephen: The answer there is maybe. The research is very ... Well, it's pretty sparse when it comes to fluency treatment, in general. But it is very desolate when it comes to fluency therapy in special populations. There's no agreement on whether or not direct fluency therapy is a good idea in children with ID. There are thoughts on both sides.

Stephen: What we do know and there have been a couple of papers really only three that I found, that I use, that I've drawn from for my own practice that talk about if we can and should do it and how. In the end, I would say,

Stephen: "Yes, we should try. If it doesn't work then, it doesn't work." But we can't not try.

Stephen: What I found, there's a really great paper by [Healy Reed 00:09:04] and [Donna Herr 00:09:08]. The copy that I have has no date, but they say that in a child with ID who has multiple disorders, the disorder that most negatively impacts communication should be treated first or should be given preference.

Stephen: If that is a language disorder, then then that should come first. If it's stuttering, then then that should be treated first, but they also say actually you can sort of blend the two. They say, "Maybe, don't stop all the other kinds of therapy just to give fluency therapy." You can sort of blend all of your goals into the same task. But we should definitely try.

Stephen: What's been found is that children with more mild ID do better when it comes to direct fluency treatment. There really isn't any research that I have found on children with more moderate to severe ID and fluency therapy with them, but Healy Reed and Donna Herr give a lot of tips for how we could and maybe should go about doing fluency therapy for children with ID.

Stephen: They say that you can still try. You can still use the same techniques that you would use with children who stutter, who don't have ID, but you're going to have to adapt them, of course, to your child. First, they say, "Of course, greatly simplify the language that you use to explain tasks and techniques and use of course multiple modalities to get it into them whether that's visuals." I mean use all of the things at your disposal, but make it very, very simple.

Stephen: The next thing, I think, is huge. That is it's been found that modeling a technique or a behavior instead of telling children with ID how to do it works far better. Show them what you want them to do. Don't tell them or talk at them. They also say, "Really, you want to train all of the adults and caregivers who that child spends time with." You want to train them on the techniques as well so they can sort of use it in their speech when they talk to this child so that the child gets that modeling of how we want them to speak or how they could speak to get their thoughts and words out better.

Stephen: That is huge. If you want there to be good carryover, you have to model and show it. The people who the child spends a lot of time with each day also need to model and show it. I know that's hard because we all have so much going on, but it's just been found to work in this population. They also say to reduce your own rate of speech which kind of goes along with that one.

Stephen: This one might be hard too, but they say that in children who have ID, generalization into everyday speech has not been found if they've only been treated in a clinical context, just like it's very hard even for a child or person who does not have ID to generalize fluency techniques outside of the therapy room. It is pretty much impossible for children with ID to do so.

Stephen: Therapy needs to take place in natural environments. You're pretty much going to waste your time if you're not doing therapy where they live and where they are. I know that can be hard, but really, that's just what has been found. Those are some general treatment considerations you can still try and use all of the same techniques that you would use for a child who does not have ID, but they have to be greatly simplified. They have to be shown and modeled not only by you but by other caregivers in that child's environment. Therapy has to take place in naturalistic environment. That's generally what has been found.

Stephen: There are two case studies of a young girl with Down's syndrome and a 21-year-old man with autism who have both been successfully treated for stuttering. You can pick which one I start with if you want to hear about them. Okay. Cool.

Marisha: [crosstalk 00:14:50].

Stephen: All right. Let's start with Sarah. She is or was an 8-year-old girl with Down's syndrome and a profound stutter. She stuttered on 54.7% of her syllables in conversation which is like off-the-charts. There's not even a chart for that, 29.8% of syllables in reading. She had an IQ of 69. That was mild intellectual impairment. Treatment lasted for 17 months. There was a total of 41 sessions in that month. Treatment consisted of teaching, fluency shaping techniques like stretchy speech, diaphragmatic breathing, gentle onsets, continuous phonation and light articulatory contacts.

Stephen: They also trained her in taking extra time so she could formulate her language. They trained her parents and adults at school to model a slower rate of speech as well as some of the techniques. Even though she was eight years old, they also trained the parents in giving verbal contingencies or responses like one would give in the Lidcombe Program, so praise for fluent speech and request for correction at between a 5 to 10 to 1 ratio, so 5 to 10 praises for fluent speech to everyone, request for correction.

Stephen: Last but not least, they included some training on how to respond to teasing and bullying. I don't believe that I mentioned their names at the start, but this is Harrison and Langevin 2012. The results at the end are pretty sweet if you ask me. She went from 54.7% syllable stuttered in conversation to 6.35% syllable stuttered. Then, get this. Four months' post-treatment, that had improved to just 0.8% syllable stuttered, less than 1% syllable stuttered down from 54.7%.

Stephen: It definitely can work that you can treat stuttering in clients who have ID, but this took a long time. It took a lot of buy-in from a lot of people. She had only mild ID, but I still think that that's pretty stinking sweet if you ask me. Isn't that awesome?

Marisha: Yes, that is amazing. I love that.

Stephen: That's Sarah. Do you want to hear about how stuttering was treated in a young man with autism? All right.

Marisha: Yes.

Stephen: They don't give his name. I guess we'll just call him Dude. Brundage, Whelan, and Burgess also in 2012 ... 2012 was a great year for research in fluency and special populations. It seems like it's like the only year where it was done, but there was a 21-year-old young man who had autism and a severe stutter. He had an IQ of 82 and deficits, of course, in receptive and pragmatic language. He stuttered on about 14-1/2% of his words in conversation.

Stephen: What is cool about this case is that he had very poor self-awareness of his stuttering which is something that I hear a lot when I get asked about how on earth do we treat stuttering in children with ID. It's like they're not aware of their disfluencies. How on earth can we help them to change them?

Stephen: They carried out a single subject [AB/AB 00:19:57] experiment. They blended it where they did it at the same time as the social pragmatic treatment that he was getting before they started treatment for fluency. Each session half of the time would be given to stuttering treatment. Then half of the time would be for pragmatic language.

Stephen: They did 43 sessions and condensed some fluency shaping rules to just three. They trained him on speaking slowly saying each word only once and saying each word short. Those were his fluency rules. Those were adapted from, I believe, Runyan and Runyan's 1986 fluency rules program. They had him write those rules down until he could state them by heart. Then, they were used in utterances of increasing length from single words all the way up to conversation. They would advance to the next level when less than 5% of his words were stuttered at the current length.

Stephen: At the end of that treatment which was 43 sessions long, of course, only half of the time in those sessions was dedicated to stuttering therapy. He had reduced his stuttering from 14-1/2% of his words stuttered to just 3% of his words stuttered. That two shows that ... Yes, he was 21 years old, but he still had very poor self-awareness of his stuttering and yet training him in these fluency rules still worked. That was really great to see that it can, in fact, be done.

Marisha: Yeah. That's pretty amazing given that he's a 21 year old plus the concomitant issues that [crosstalk 00:22:28]-

Stephen: Yeah. It's huge.

Marisha: ... made that amount of progress.

Stephen: It can be done.

Marisha: crosstalk encouraging.

Stephen: We just don't know a lot about how it gets done because there's not a lot of science that has been done on it, but what I would say ... Some folks say that we shouldn't do it because it'll be too hard for children with ID to learn these techniques or if they can't do them, then they'll only feel more shame about their speech.

Stephen: Basically, it's just too hard or it's going to harm them more if we try. While I think there are valid reasons for that thinking, I just don't think it plays out at least in the science that I have read. If things are adapted in the way that they have to be and there's a lot of buy-in from other stake holders, it can for sure be done at least for children with more mild ID. Definitely for them, you should do treatment. We don't know all that much about how well it works if you more moderate to severe stuttering, but I think that means that we have to try.

Stephen: Then, if it doesn't work then at least we know that it doesn't work for that child, but to not try I think we'll be doing them one of the greatest disservices in their lives. That's my thought on it from what I know. I'm sure that there's still a lot left that I have to learn. But that's all I had to say about that.

Marisha: inaudible That's so incredibly helpful. That gives us a little bit of license too to just start taking that action because there's not any resource telling us how it has to be done. We get to create or we just-

Stephen: Exactly.

Marisha: [crosstalk 00:24:32].

Stephen: We have brains. We have brains and we know good things and like when have we ever not tried something? I mean any child or client or patient who we have, we throw the book at them like we try every single thing out there that we know to try to help that and so like why would that be any different in stuttering?

Stephen: It's actually cool that we get to go where science has not gone yet. That means that we get to use our brains that we paid a lot of money to have filled with a lot of knowledge to try to help these kids. I think it's pretty sweet.

Marisha: Yes. [crosstalk 00:25:14].

Stephen: I love it. I love that.

Marisha: We get to fill in the science until crosstalk because crosstalk arriving eventually.

Stephen: Oh my gosh, yeah.

Marisha: [crosstalk 00:25:32].

Stephen: It will, but science is slow, right? Just like you said like we have to hold the beach until it gets there. Then, we can follow its lead. We can also help to make it too, but just to kind of surrender the fields because we don't know or it's too hard. That's not us. I mean that's not me. That's not you. Why would we do that?

Marisha: So good. What about crosstalk you have any moment [crosstalk 00:26:08]?

Stephen: Even though I hail from South Texas, Corpus Christi, just a few hours north of the border, I am not bi-lingual. It's one of the greatest regrets of my life that I am not. I know that there are a lot of other people who know more about this than I do, but here's what I know. That is that children who are known to be fluently speaking bilingual children, they produce mazes that sound like sound syllable or word repetitions at a far greater rate than their monolingual peers. They'll have more repetitions in their speech that is just typical as they navigate the formulation of language.

Stephen: 78% of them have greater than 3% of stuttered words in their speech mainly these repetitions that are seen as they formulate language. 78% of them who are known to be typical or fluently speaking, 78% of them run the risk of being diagnosed as stuttering if we use the monolingual standard of 3% word stuttered or more than 2% syllable stuttered.

Stephen: Courtney Byrd down at UT Austin has done a lot of really, really cool work with this population. She's who I go to. Byrd spelled B-Y-R-D, not bird like the flying creature. But she says this that we need to look for three things to know if a bilingual child who is exhibiting disfluencies is truly stuttering.

Stephen: The first is we need to look for if they have audible or inaudible sound prolongations in their speech. Fluently speaking bilingual children will not prolong sounds as they formulate language. If you hear those, then you have one check mark that this is probably actually real stuttering and not just mazes.

Stephen: Number two, we need to look if there is parental concern for stuttering. Usually, when parents come up and say, "Hey, I think that my child might be stuttering," it's usually warranted because they have seen it and heard it so much. They're not even experts, but they think that there's something wrong. You'll see that the parents of fluently speaking bilingual children are not concerned at all, that their children are stuttering. If you do see or hear about parent concern, then that's a second check that this actually might be real stuttering.

Stephen: Then number three, looking for any type of atypical tension. Fluently speaking bilingual children don't seem to exhibit tension in their repetitions. They're light. They're easy. They get through them quickly. If you see tension, then you know that there's struggle and that might be a third checkmark that this actually might be stuttering.

Stephen: That's the best way that we know how. That's from Byrd 2015 and Byrd 2018. I'm sorry. It was Byrd, et al 2015 and then just Byrd 2018. That's the best that we know that I currently know about how to sort of differentiate if they're just typically developing or if they actually stutter.

Marisha: Awesome. I'll also be sharing because you're throwing out lots of really good articles and resources there. I'll share the citations for those at slpnow.com/15 as well as some other resources if you're [crosstalk 00:31:18].

Stephen: Good.

Marisha: I'm taking notes for you guys. No worries. Just to recap, so we're looking for audible or inaudible sound prolongations, parent concern-

Stephen: Correct. Yeah. Nailed it.

Marisha: ... or atypical tension. The three red flags. Awesome. Then, any other tips for us? Is there anything that we would do differently if we like what would we do if we identified one, the red flags versus the three of the red flag crosstalk treatment.

Stephen: That was tough is that, again, we come to a place where there's not a whole lot of science at least not that I have found. If you know of one, please send it to me, but there's not a whole lot about, well, should we treat just their weaker language or should we treat in both languages or should we wait to treat until later or whatnot.

Stephen: Here, we sort of have to use our best judgment and say, "Basically, does their stuttering now, does it adversely impact their communication?" If it does, then we should treat it. if it doesn't or if it's new, then like maybe you could wait or if they're super young or they haven't been stuttering for very long then, of course, I would say, "Wait the six months to one year to see if it resolves on its own."

Stephen: But if you truly think that a bilingual child stutters then you should treat them, and, of course, you can only treat them in the language that you're fluent in. I think it would be great to treat it in both languages because, of course, there are different phonemes in each language. There are different syllable structures, different types of grammatical complexity.

Stephen: It would be great to get to treat all of that in both languages. But, of course, if you're only fluent in English, then ... If there is not a bilingual SLP who is well versed in stuttering treatment who you can refer them to, then it's going to fall on you. That, then, is the best that we can do, and that is to treat them in the language that we are fluent in.

Stephen: I think one thing to keep in mind as you ... I think we should just treat them normally from that point on except to know that their language formulation time might be longer than for one of their monolingual peers and just to give time for that. But besides that like, again, we're sort of on our own. We learn more about how we can best serve them.

Stephen: I think the best thing to do is to just treat them instead of not. Anything that you do will likely be better than doing nothing at all. Don't be scared of it. Just, of course, do the very best that you can just like we do every day.

Marisha: If we're taking our data, we're doing our best. We're being our own scientist until the research catches up. We're just testing different things inaudible one strategy. We have to. We definitely want to give it a fair try, but if we collect data for maybe a couple of weeks. I don't know. Do you have any feedback on how long you typically try something before crosstalk work?

Stephen: Yeah. I like to see them doing it in sentences before I say yay or nay because if they can use a technique in sentences without my help, then I know that they can do it if they choose to. If it still doesn't help, then we can move on.

Stephen: Sometimes, rarely, I've had somebody try something, I like hate this. This makes me feel stressed or tensed and tight. It's so hard. I don't like it. Then, I'll say, "All right. All right. Well, then, we don't have to do it." But if they're learning it, if they're trying to absorb it, I usually don't pull the plug on it until I see them at least try to do it in sentences and then make a decision from there.

Marisha: Just with the nature of stuttering, it sounds like because I feel like we've talked about this before, but I think you said in your own experience like crosstalk go through different strategies yourself crosstalk come out [crosstalk 00:36:33].

Stephen: I know like the back of my hand, I know easily 12 to 15 techniques that I could use at any given time to speak fluently or get through a moment of stuttering. I've definitely used different ones more at different times of my life. I couldn't tell you why that is. Perhaps, it's just me, but I find that, sometimes, some of them seem to come just a bit faster to me or they just seem to be working a little bit better.

Stephen: I'll lean on them. Then maybe, I'll remember one that I used to use more. I'll try it out. Then, it works for me. I'm always trying to find the easiest way to speak. Whatever that is, I'm going to do. Yeah. I sort of cycle through so like, currently, I am using the continuous phonation technique which is very hard for me to say still to this day, but I'm just trying to think to keep my voice turned on as I speak and trying to blend my voice through the borders of syllables.

Stephen: In that way, my voice won't have to turn off and then turn back on and put me at risk of stuttering. I mean, of course, there are some speech sounds that are voiceless. My voice will turn off, but the whole point of that technique is to try to keep your voice on as much as you can, but then as I as I come up to a difficult sound, I'm trying to use the light articulatory contacts technique where I just say it with a lot less force to help myself get through it.

Stephen: Then, I also currently love the attention shift technique. I think that this is going to be like the new wave of stuttering research. Harley 2018 wrote a really good article about the role of attention in stuttering and stuttering treatment. It's been known for a long time that children who stutter have poorer attentional functioning than their fluent peers. She wrote a lot about how instead of doing physical things to change our speech, what if we change what our attention is focusing on.

Stephen: Of course, we don't know what the cause of stuttering is in black and white, plain and dry. But there are some hypotheses that we who stutter relied too strongly on certain types of feedback in our speech and that maybe if we took our attention off of that and on to something else that we would be kind of freed up to speak more fluently.

Stephen: Anyhow, how that plays out for me in my own life and in my own practice is I like to ... As I'm speaking ... Well, before I start a sentence, I like to think in my mind or focus my attention on the single word of rewording because, for most of my life, speaking has not been rewording. I think that really, really strongly before I start to talk and taking my mind off of my physical speech actually lets it to come out more fluently which is kind of nuts especially because in my own story, it was really intense physical techniques where the first thing that allowed me to speak fluently.

Stephen: Then as I speak through my sentence, I flipped my mind back to that word I just try to think it in my head the single word of rewording. For some reason, the act of taking my mind off of what my physical articulator are doing actually helps them to work better. There's not a whole lot of research out on this yet, but I think it's going to boom here in the next few years or so.

Stephen: That's like one of my new phase that I use a ton. I think actually like it might be one of my favorite of all time, but back to what you asked me, yeah it. I love that. I know a ton of different techniques that I can pick and choose from. If I choose to put the work in to use them because they are work, but they're far less work than struggling through constant moments of stuttering.

Stephen: It's nice to have choice. We all like choice, right? It feels great to be armed with all these techniques so teach as many as you can. Then, let them pick. I don't think that you'll be sorry.

Marisha: Yeah. That's so helpful. I think that's important to keep in mind as we're trying these new techniques with these special populations crosstalk know what the data is supposed to look like. Stephen just gave us the okay to try a different strategy, some of them just won't work or they won't work right now, but you never know what it's going to be. We can give it a try.

Marisha: Then, also just with the nature of stuttering, it sounds like some days are much better than others, and so we're just naturally going-

Stephen: Oh my goodness.

Marisha: [crosstalk 00:42:53].

Stephen: I mean there are so many things that go into will it be a good speech day or a bad speech day. It's sort of like when you wake up, is it going to be a good hair day or a bad hair day. If I'm off of work and I'm really relaxed, then my speech is going to be more fluent than if I'm slammed at work have my huge caseload. My wife is sick. She needs my help. I have guests that are going to fly in and we have to get the house ready.

Stephen: With all that stress and movement, it's just going to naturally be more difficult for me to talk. It definitely fluctuates. The amount of reserve that I have to give towards my speech will change as well. Giving me and you giving your clients the most latitude and choice to try to face the fierceness of life. It is fierce. Trying to give them the most tools as you can is the best thing that you can do.

Stephen: It's fun because it means that you get to try a lot of things and then see which one works best. If you only try one thing and it doesn't work and you stop, then you've missed out on all the stuff that could work. Yeah. Never stop trying.

Marisha: I love that. Such good tips in there.

Stephen: I just talked and talked, yeah, and made you forget it. I tend to do that.

Marisha: We had another question. [crosstalk 00:44:44].

Stephen: [inaudible 00:44:44].

Marisha: crosstalk to it, but we'll come back because we've got a lot crosstalk to talk about. That was a super helpful overview of just, generally, how we're going to tackle students with concomitant disorders or intellectual disability, bilingual children. We've got some really great kind of suggestions and a little bit of help [crosstalk 00:45:07].

Stephen: [crosstalk 00:45:07].

Marisha: crosstalk perfect roadmap for us, but it was really cool to be able to hear it, the techniques that you're using for yourself. I thought we could take a couple of minutes to just go through kind of round-robin through a couple different techniques like what is your favorite technique for preschool children who stutter? If you have any ideas for how to modify it for those children with intellectually disabilities, bilingual [crosstalk 00:45:37].

Stephen: Oh my goodness. If you treat crosstalk with preschool children who stutter and you don't know about and don't use syllable timed speech yet, then you're not wrong. You're just, man, you're going to be so pumped when you hear this. The syllable time speech technique which is can be called the robot speech technique. It's also called the Westmead Program in Australia where it was developed is pretty simple, but daily practice with it for five minutes about five times per day for nine to 12 months can reduce stuttering by 96% in children who are already more than a year out from time of onset.

Stephen: For children who are past the horizon where most of them recover naturally, syllable time speech, practice daily for nine to 12 months can reduce their stuttering by 96%. How does that work? Well, you simply break up each of your words that you say into syllables and add a definite boundary around each one. If you hear me, I'm trying to still keep a natural kind of prosody and intonation as I do this. I'm not going very slowly like this. This is too slow.

Stephen: You try to stay at as fast of a speed as you can. Try to keep some natural intonation, but you do that for five minutes five times a day which means, yes, parents have to be involved, but they should be because their kids are in preschool. It's been found that doing that whether you look at pictures, whether you read a book, whether you're talking, while you drive in the car, it's been found that children who are past their best window to recover naturally doing that for five minutes about five times a day can reduce their stuttering by 95% after nine to 12 months.

Stephen: I start with that one always. Always, always, always, I start with that one. There was a phase two clinical trial. It's Trajkovski and Colleagues 2011, I believe. Yeah. That's my fave for those kiddos.

Marisha: Awesome. So helpful. It seems like-

Stephen: Definitely.

Marisha: [crosstalk 00:49:01].

Stephen: Exactly, but you just do it yourself crosstalk and try to get children with ID to copy you. You can even teach this, of course, to parents and teachers and have them try it as well. What it does is it facilitates the forward movement of speech. Even though you break each word up into syllables and add a slight pause as if you listen to me, my speech was plotting forward at a nice speed. It was more fluent than a child who stutters. Giving young children's brains basically access to fluency to what fluency feels like helps, I think.

Stephen: We're not quite sure, of course, because it's so hard to do research on young, young kids, but the thought is that it then helps to rewire their neuro speech circuitry to be more fluent. Definitely, definitely can be modeled well for sure. I like it.

Marisha: Pretty snazzy.

Stephen: Well, first, I'm just going to say crosstalk that syllable time speech can also be used for school-aged children up through their 11th year until they turn 12, at least that's what the research has found. The phase one, phase two trial, it was done by Andrews and Colleagues 2012 did the exact same thing with school-age children aged six through 11. They practiced syllable time speech for five minutes about five times a day for nine to 12 months. Their stuttering was reduced by 87%, so not quite as good as if they were in preschool, but still pretty darn good.

Stephen: What's great about syllable time speech is that it is not meant to be a technique that you use all the time whenever you speak whereas with fluency shaping techniques and with stuttering modification techniques, you're meant to employ those whenever you talk, whenever you choose to, but the thought is whenever you talk for the rest of your life, you may have to choose to use a technique to help you to speak more fluently.

Stephen: Syllable time speech is never meant to be a this is how you're going to talk for the rest of your life. It's a this is what we practice daily just like if we were working out so that our speech then in normal conversation will be more fluent. I love that. Definitely add that into your school-age repertoire as well. It can be as easy as a warm-up that you do at the start of your session.

Stephen: Then, of course, encourage them to do it at home as much as they can. That's probably the newest one that like I hadn't heard of until recently. I think until ... I didn't find it until last year. That's one that's not taught a whole lot for the school-age population, but if I had to pick like my next favorite one, it would be … Well, they sort of come as a bundle, but the cancellation pullout and preparatory set techniques that Van Riper talks about.

Stephen: Those would be my next favorite kind of my go-tos, but I think a lot more research is coming out that school-aged children can actually do a lot of fluency shaping techniques. It used to be said, "Well, fluency shaping techniques can't be used until you're 12." Then it was well maybe some children who were nine who have really good self-awareness and are really committed to therapy.

Stephen: Maybe, they can use it too and more and more research is coming out saying that actually even younger school-age kids can use the whole slew of fluency shaping techniques that can be taught to adults. Never think that you're kind of pigeon-holed to just one kind of therapy. That's what I would say about school-age kiddos. They're super fun.

Marisha: That does sound super fun. I inaudible because we have a variety of techniques that we can be teaching our students. I'm just curious how you use [crosstalk 00:54:26]. Do you target multiple like how many ... I know it really depends on the student, but what's the most techniques you would introduce in one session [crosstalk 00:54:41]?

Stephen: Yeah. I tend to only like to-

Marisha: ... to have any kind of default or [crosstalk 00:54:46]-

Stephen: ... train or to teach one technique per session until they're well versed in multiple techniques. If they have mastered multiple techniques at the sentence or conversational level, then we'll do tasks where they can switch back and forth if they can try to use them both at the same time, but whenever they're just learning techniques, I only teach one per session. Even, I'll spend a few sessions three or five or even eight sessions on just one technique until they've mastered it usually in sentences without my help before I'll move on to the next one.

Stephen: Then, as they learn more and master more at the sentence level, then we can start to do tasks that are more complex. They can choose to switch back and forth or use more than one. For preschool age kids, I teach syllable times speech straightaway. I also teach parents to slow down their rate of speech and to reduce their demands on their child's communication.

Stephen: Then lastly, after those three, I'll teach the verbal contingency technique where those responses that are taught in the Lidcombe Program for school-age kids. I also teach syllable time speech. First, teach them about the speech mechanism, teach them to identify their stuttering, go through the three cancellation pullout and prep set techniques, and also do some light [Bubba Bounces 00:56:47] where I have very light repetitions not ones that are super tense and tight.

Stephen: Then, I'll try out voluntary stuttering and self-advertising which if you had led with those when I was six years old say that you had me in therapy and you had the led with those two, I probably would never have come back to speech at all. I only teach those after I've given them actual physical ways to get through moments of stuttering. Then, I teach them how they can volunteer or share that they stutter which then, of course, does take a lot of the stress off of any conversation.

Stephen: But I don't ever start with that. For adults … Then, I'll even try out some of the techniques that I use more with adults because I think that they can actually work with school-age children who stutter. For adults, I start with the stretched syllable technique. Then, I pair that with me with the diaphragmatic breathing technique. Then, those kind of ... I wean off of the stretched syllable technique and teach gentle onsets, continuous phonation, light articulatory contacts.

Stephen: Then, I teach what I call what I've dubbed the attention shift technique which is the one that I talked about where I actually take my attention off of what I'm doing physically in my speech and put it on to something else. I like the word rewording. I teach them basically how they could have fluency without having to do any of the physical work that I just taught them how to do.

Stephen: That's normally what I what I do with those three age groups. Of course, it can be changed. It can be modified. If I think that a younger child could benefit from some of the techniques that I use more for adults, then I'll go ahead and try them. It's not going to hurt to try them. If they work, you've just discovered gold, so like why not dig and just see if it's down there. But I hope that helps when it comes to my mind when it comes to treatments planning. I'm sorry.

Marisha: Yeah. Super helpful. You just mentioned a lot of different techniques and unfortunately crosstalk time.

Stephen: Wow. I actually made exactly crosstalk what I would have wanted. When I was first learning about all these fluency techniques, I created a package called the Ultimate How to Treat Stuttering Package where I said, "You know what? I hear from a lot of people that they didn't get taught how to do all these techniques and how to teach them. I'll just make it super simple because we have no more time in our lives."

Stephen: I basically made videos of me doing every single one of the techniques that I knew. I wrote a handout for each one that you could give to clients or parents that breaks it down like step-by-step so that you just have to follow the steps, look at me as I model it. Then, you can teach it. You can actually give those to your clients to take home that they can have whenever they do their home practice.

Stephen: I would say, honestly, go there. It's going to give you the most knowledge in the fastest time in the simplest way then, if you tried to go out and search and find how to do all these techniques. That is up at slpstephen, S-T-E-P-H-E-N.com. Honestly, that's where I would go because I made it because it wasn't out there at least not that I had found. I just poured all of what I know into those modules. You get to hear me talk more which I hope has been nice for you. Really?

Marisha: Yeah. That's amazing and I actually got feedback from like someone else was telling me about how she was using these materials with the teenage boy. They were in a really rural area. I don't know if it was intended this way, but she ... Like you got to be the speech therapist for a part of this. It was really helpful for that teenage boy to see because he noticed like he noticed you using some of this [crosstalk 01:02:15]-

Stephen: That is so cool.

Marisha: ... and that was just really powerful.

Stephen: Oh my god. I love that. crosstalk Well-

Marisha: ... just like, "Oh," [crosstalk 01:02:23].

Stephen: Then, here's what I'm going to do. crosstalk I want to give you a promo code for 25% off. I'm just going to make it up in my head right now. I'll go put it in whenever we hang up, but let's make it SLP Now podcast rocks. If you use that, then you can get 25% off just because that story actually almost made me cry. I'm so glad to hear that.

Marisha: Awesome. Well, thank you so much for your time. I know-

Stephen: You are most, most welcome. crosstalk Thank you for all that you do. You know that we all love you too. To all of you who are going to go out and fight the good fight and treat stuttering even though it can be hard and scary like know that you have the power to change lives because I know how much it hurts to not be able to say my name or order the food that I want or say the town where I'm from or the school where I go to.

Stephen: I know that there need to be more of us who know what we're doing. The really cool thing is that we can. It just takes a little bit of courage and maybe a bit of a guide. I'm so glad that I could try to even be that for you tonight. Yeah. Glad to be on. Thank you so much. Bye, Marisha.

Marisha: Yeah. Thank you. Bye.