Introduction to Stuttering Treatment

Introduction to Stuttering Treatment

• Stuttering therapy can be long term or short term, intensive, weekly or individual and in groups
• Therapy is determined by assessment, severity of stuttering, phase of development, motivation to change, previous therapy, risk factors, and the therapist-client relationship
• The client must agree to therapy.
• The process and approach to intervention are determined by the phase of development.
• Long-term goals, short-term goals, and session goals are determined by the evaluation and assessment.
• Consider the client’s needs and what they desire to change
• The client must learn to manage speech and be open to desensitization.
• Attitudes, emotions, and cognition play a role in treatment as well as potential relapses, transfer, and maintenance.
• Self-determination is important.

Treating Children vs. Adults with Stuttering

• Children are still developing conceptual, linguistic, affective, and neuro-physiological skills.
• Therapy might focus on other concomitants first.
• Teasing and bullying are important considerations.
• Treatment is less direct compared to adults.
• Parents, teachers, and other professionals play a role in treatment.
• An asset-based approach is recommended.
• More likely to obtain fluency.

Preschool Stuttering Treatment

• The primary focus of treatment is the 3 Ps:
  • Prevent
  • Prepare
  • Promote
• Adapt the environment and involve the team.
• Intervention with parents and children is crucial.
• Provide groups and literature for parents.
• Model strategies for parents similar to the Hanen Program.
• Encourage slower speech rate, shorter utterances, reduced complexity, and pauses.
• Teach conversation strategies through pamphlets, videos, books, and websites.

Stages of Development for Stuttering

• Age: Preschool
  • Stage: Borderline
    • Core Behaviours: Phrase and some word repetitions, low level of tension, generally unaware.
    • Feelings/Attitudes/Awareness: Unaware of stuttering.
  • Stage: Beginning Stutterer
    • Core Behaviours: Word repetitions on initial sounds, prolongations, blocks, tension noticeable.
    • Feelings/Attitudes/Awareness: May begin to struggle, may have some awareness.
  • Stage: Intermediate Stutterer
    • Core Behaviours: More frequent and complex repetitions, prolongations, blocks, physical tension.
    • Feelings/Attitudes/Awareness: Aware of their stuttering; feelings of frustration, embarrassment, and anxiety.
  • Stage: Advanced Stutterer
    • Core Behaviours: Stuttering in all speech situations, blocks, physical tension, avoidance behaviors.
    • Feelings/Attitudes/Awareness: High levels of anxiety, fear, and avoidance of speaking.
  • Stage: Secondary Behaviours
    • Core Behaviours: Physical tension, facial grimaces, eye blinking, head movements.
    • Feelings/Attitudes/Awareness: Fear of speaking, social isolation.

Indirect (Parent Centered) Intervention for Preschool Children

• Focus: Working with parents, not the child, to improve fluency
• Techniques:
  • Adjust environmental factors that disrupt fluency.
  • Decrease speech demands.
  • Reward open, easy, and forward-moving speech.
  • Provide explanations, reassurance, and encouragement.

Three Stages of Parent Involvement

• Educational Counseling: Providing information to parents about stuttering.
• Facilitating Communicative Interaction: Teaching parents strategies to improve communication with their child.
• Parents as Observers and Participants: Parents learn to observe and participate in therapy sessions.

Rustin Family Interaction Therapy

• Focuses on parents’ interaction skills to:
  • Follow the child’s lead.
  • Give the child time to respond.
  • Gain the child's attention.
  • Improve positioning for communication.
  • Adjust their manner of interaction.
  • Provide reinforcement.
  • Ensure turn-taking.
  • Manage rate of speech.
  • Improve intelligibility.

Common Parent Behaviors That May Contribute to Stuttering

• Rapid speech rate.
• Interruptions.
• Asking too many questions without waiting for a reply.
• Over-directing in play and conversation.
• Parental passivity.
• Poor listening skills.
• Ambiguous non-verbal communication.
• Conversations unrelated to current activities.
• Parents are trained in therapy to modify these behaviors and implement them at home during special times.

Outcomes of Rustin Family Interaction Therapy

• Improvements should be noted within six weeks.
• Enter a maintenance program if the child shows improvement.
• If there’s no improvement, implement a direct strategy.

Direct (Child Centered) Intervention for Preschool Children

• Lidcombe Approach: Works with children through parents.
• Prognosis: Positive indicators for recovery
• Focus: Gently correcting, eliciting smooth/stutter-free speech, and parent training.
• Operant Conditioning: Positive reinforcement is used.
• Techniques:
  • Self-Monitoring: Children learn to monitor their own speech.
  • Lidcombe Programme (Onslow, 1995):
    • Does not involve non-involvement of the child; works with the child through the parents.
    • The treatment of choice for children under 6 years old.
    • Uses a direct approach, including self-monitoring, but does not teach a technique.
    • Employs operant conditioning/positive reinforcement.
    • Gently corrects stuttered speech, eliciting smooth/stutter-free speech, and parent training.
    • Extensive empirical data supports its effectiveness.

Lidcombe Programme (Onslow 1995)

• Parents learn how to:
  • Identify stuttered and fluent speech in their children.
  • Praise and correct in a natural way.
  • Take severity ratings every day.
  • Adjust treatment based on severity.
• Median Treatment Time: 11 sessions (11 weeks).
• Data: Over 2,000 children have been treated using this program.

Lidcombe Programme Instructions

• Provide information about stuttering.
• Describe the treatment to parents.
• Train parents on the severity rating measure (1-10).

Demands and Capacities Model

• Capacities:
  • Motor control (Rate of speech, stuttering behaviors, coarticulation, stress patterns, intonation, rhythm).
  • Linguistic (Language skills, syntax, semantics, phonology, and pragmatics).
  • Cognitive development (Moving, thinking, and feeling).
  • Socio-emotional (Emotional maturity, reactions to disfluency, the ability to move on despite fears, anxiety, and anger).
• Demands:
  • Communicative environment (Articulation/phonological plan, parents’ rate and communicative style).
  • Environmental demands placed on the individual.
  • Linguistic stressors (Words, sentences, and situations).
  • Socio-emotional demands impacting speech.

Intervention Approaches Based on Demands and Capacities Model

• Reduce demands: Parent counseling, education, skill development.
• Increase capacity.
• Employ fluency-shaping strategies.
• Work on social/emotional factors.

Fluency Enhancers for Stuttering

• Slow, stretched speech with normal intonation.
• Simple, short sentences.
• Frequent silent periods.
• Elimination of questions, interruptions, and demands for verbal performance.
• Slowed conversation turn-taking style.
• Self-talk and parallel play.
• Following the child’s lead in play.
• Producing disfluencies in conversation.

Therapy Goals

• Accountability:
  • Effectiveness
  • Eclectic approaches
  • Efficiency (Short term)
  • Integration
• Parent Training and Involvement: Parents must be educated and informed to change their behavior.
• Parents’ Role:
  • Parents do not cause stuttering, and they should not be “stuttering police.”

Factors Associated with Increased Concern for Stuttering

• Stuttering onset after 36 months.
• Relatively poorer speech/language performance.
• No family history or history of recovered stuttering.
• Female gender.
• Decrease in speech and language difficulties (SLDs) over 12 months.
• Early onset of symptoms.
• Strong speech and language skills.

Fluency Reinforcement

• Process: Conditioning and experiencing fluency.
• Stimulus: A cue or prompt.
• Response: Fluent speech.
• Reward: Positive reinforcement for fluency.

Fluency Reinforcement Examples for Children

• Lidcombe Programme:
  • Parents and therapists provide positive reinforcement for fluent speech and gentle corrections for stuttered speech, helping children experience fluency.
• Stocker Probe Technique: Focuses on prompting a child to produce a fluent repetition.
• Smooth Talking: Helps the child develop smoother speech by using gentle corrections and positive reinforcement.
• Easy Talker
  • Children learn to use easy talk techniques.
  • The focus is on reducing tension and increasing fluency.
• Fluency Rules: Teach children rules to use when they are likely to stutter, such as slowing down or taking a breath.

Common Fluency Reinforcement Programs:

• Palin PCI: A fluency shaping program that uses traditional fluency techniques and positive reinforcement to help children speak more fluently.
• Lidcombe Programme: A parent-administered treatment program that uses positive reinforcement to decrease stuttering in young children.
• Smooth Speech & CBT: Uses cognitive-behavioral therapy in addition to fluency shaping techniques.

Fluency Reinforcement Program Information

• Ages:
  • Palin PCI: Preschool (around 9 years old)
  • Lidcombe: Ages 3-6 years; 6-12 years.
  • Smooth Speech: Ages 9-14 years
  • Easy Talker: School age
  • Fluency Rules: School age
• Therapists:
  • Palin PCI: SLT, parents, and teachers.
  • Lidcombe: SLT and parents; teachers.
  • Smooth Speech: Clinician, parents, and teachers.
  • Easy Talker: SLT, parents, and teachers.
  • Fluency Rules: SLT, parents, and teachers.
• Frequency:
  • Palin PCI: 6/8 weeks
  • Lidcombe: 8-12 weeks.
  • Smooth Speech: Intensive 5 days in 5 weeks
  • Easy Talker: Weekly sessions over time.
  • Fluency Rules: Weekly sessions over time.
• Format:
  • Palin PCI: Individual and groups.
  • Lidcombe: Mainly individual.
  • Smooth Speech: Individual and groups.
  • Easy Talker: Individual and groups.
  • Fluency Rules: Individual and groups.

Stuttering Treatment Overview for Preschool Children

• Goals:
  • Improve fluency.
  • Help parents and teachers create a fluency-facilitating environment.
  • Help the child develop normal speech fluency by changing their speech patterns.
  • Maintain healthy, appropriate attitudes towards communication and speaking.