Treatment of Stuttering in Younger Preschool Children PDF

TREATMENT OF STUTTERING IN YOUNGER PRESCHOOL CHILDREN CDS 432 Fluency Disorders Dr. Fauzia Abdalla  2 YOUNGER PRESCHOOL CHILDREN ARE BETWEEN 2 AND 3.5 YEARS BORDERLINE STUTTERING An Integrated Approach  AN INTEGRATED APPROACH 4 G...

TREATMENT OF STUTTERING IN YOUNGER PRESCHOOL CHILDREN CDS 432 Fluency Disorders Dr. Fauzia Abdalla  2 YOUNGER PRESCHOOL CHILDREN ARE BETWEEN 2 AND 3.5 YEARS BORDERLINE STUTTERING An Integrated Approach  AN INTEGRATED APPROACH 4 Guitar Text Figure 11.1  RATIONALE FOR TREATMENT 5 Stuttering in younger preschool children (2 years–3.5 years) at the “borderline” level with loose and relaxed repetitions Treatment for them should be indirect, aimed at changing the environment. A few children may be more advanced in their stuttering; and are starting to add tension to their stuttering and may be aware of and frustrated by it. But best to refrain from direct treatment aimed at having them learn to change their speech. Almost all of these children between 2 and 3.5 years have been stuttering for less than a year, and many have a likelihood of natural recovery. Therefore, everything must be done to avoid interfering with natural recovery and instead to facilitate it. Also, most children between 2.5 and 3 years are not cognitively ready to learn from direct treatment how to change their stuttering Guitar Text  BORDERLINE STUTTERING 6 Two principles: work on environment to decrease stress work with child to increase fluency. Nature of Stuttering: Constitutional predispositions and the stresses resulting from developmental demands and the environment Guitar Text  7 TERMINOLOGY  8 CLINICAL PROCEDURE Indirect: Educate family to decrease stresses and foster fluency.  demonstrate facilitating style of communication interaction  guide family in their efforts  If no progress after 6 weeks or child's stuttering proves to be more advanced  Direct therapy Direct: assumes child aware of stuttering  use hierarchy of activities that focus on playing with stuttering and changing it to a milder form.  Change child's repetitions and prolongations.  9 CLINICAL PROCEDURE Fluency Goal Achieve spontaneous fluency –why? Spontaneous fluency = child’s natural fluency that occurs without work or thought on his part Feelings and Attitudes  behaviors of family  monitor child's feelings (deal directly with feelings of frustration if stuttering worsens). Maintenance stay connected with family (gradually fade) so they do not revert to old, stressful interaction pattern. Guitar Text  10 CLINICAL METHODS  Educate family –video-tape and reading material on nature of stuttering and how they can help.  Counsel family –listening, brainstorming & problem-solve – selecting what to modify in their interaction.  Collect data on child's speech and family's perception of his stuttering.  Support as stuttering decreases and maintenance of new styles of interaction. Guitar Text  CLINICAL PROCEDURE 11 INDIRECT TREATMENT Severity Ratings Designed originally for Lidcombe Explain to parents how to use.  CLINICAL PROCEDURE 12 INDIRECT TREATMENT Baseline Speech Measures Preliminary analysis of environment that makes vulnerable child more disfluent. At end of evaluation summarize findings about child's speech, conclude with description of borderline level of stuttering, help family decide how to facilitate child's fluency. Guidelines Materials to understand nature of stuttering and their role (watch video tape & discuss on 1st session). INDIRECT TREATMENT 13  INDIRECT TREATMENT 14 FAMILY INTERACTION PATTERNS  During evaluation Listen to descriptions of home environment  Tell family using appropriate vocabulary how research suggests that stuttering arises from an innate predisposition toward disfluency (you are not the cause). Child who is sensitive may be especially sensitive to certain speech pressures that are typical in normal home environment. Pressures trigger stuttering/make it harder to outgrow.  Other children improved when their families created environment that is helpful to fluent speech.  There is much you can do to help child overcome it.  INDIRECT TREATMENT 15 FAMILY INTERACTION PATTERN Guidelines  Recording of family interaction before evaluation (tape 10 minutes of typical conversation interactions with child when he is likely to stutter; if not possible use recording in clinic)  Transcribe 10–15-minute interaction and quantify the 8 variables making notes as when directly observed.  Note negative family interactions (normal in 'busy' homes but may put pressure on borderline stutterer).  Help family decide what aspects of interaction to consider for change. INDIRECT TREATMENT 16 TIPS FOR TALKING WITH A CHILD 17 WHO STUTTERS https://www.youtube.com/watch?v=DLlUN1OB_oU  TIPS FOR PARENTS 18 Parents of Children who Stutter: DOs and DON'Ts - YouTube INDIRECT TREATMENT 19  INDIRECT TREATMENT 20 Changing Conversational Interaction Patterns SLOWER SPEECH RATE WITH PAUSES  Teaching Slower Speaking Rate with Pauses  Trying Slower Rate with Pauses in the Clinic  Using the Slower Rate with Pauses at Home  Monitoring Parents’ Practice of Slower Rate with Pauses Guitar Text  INDIRECT TREATMENT 21 Changing Conversational Interaction Patterns MODELING INTERACTION  Family observes clinician play with child as he models 1 or 2 changes (e.g., slower rate of speech, increased pausing).  Let an assistant point out good/not so good examples of your interaction model.  Invite family to participate after observing 5 to 10 minutes. Pull back and let parent be primary player.  Observe as parent continues to practice. Rejoin interaction and provide further models of desired behavior.  Talk to family in private at the end –give positive feedback of their interaction (use 5:1 ratio of positive to corrective comments).  22 WORKING WITH OTHER ASPECTS OF THE PARENT-CHILD INTERACTION Changes in Family Routine Guitar Text EXPLAIN TO PARENTS 23 Guitar Text  INDIRECT TREATMENT 24 CHANGES IN FAMILY ROUTINE In addition to changing conversational interaction patterns a family may identify other stressors on the child that need to be changed Discuss changes in family routine.  Family may identify other stressors as well to do with busyness of family schedule.  Help family informally assess the effects of changes on child's fluency and overall adjustment (Significant change in child's stuttering is the REAL MOTIVATOR).  Parent-child interaction (one-on-one time 15 to 20 minutes with parent each day)–attention that child receives contributes to self-esteem which in turn affects fluency. Follow child's lead; nondirective play. Attentive play can become child-directed conversations as child grows older. Time to practice fluency-facilitating verbal interactions. If done in the morning –may help him carry over fluency achieved to remainder of day. Help family formulate plans for implementing changes  concentrate only one or two changes.  meet within 1 or 2 weeks to continue assessing, guiding and supporting their efforts  25 INDIRECT TREATMENT THE COURSE OF TREATMENT Guitar Text  INDIRECT TREATMENT 26 MAINTENANCE Help family develop a plan to deal with periods of increased stress that may prompt stuttering to reappear. Effective maintenance 1) help family to view child's stuttering more objectively, with less anxiety, guild or panic. 2) building family's confidence in their own ability to implement problem-solving skills they've learned to use when child's disfluencies increase. Relapse is possible and not abnormal –can return if help is needed.  27 CLINICAL PROCEDURES DIRECT TREATMENT  28 CLINICAL PROCEDURES DIRECT TREATMENT LIDCOMBE PROGRAM https://www.lidcombeprogram.org/fa milies-care-givers/stuttering-in-0-6-yrs/ 29  DIRECT TREATMENT 30 FOR MORE SEVERE BORDERLINE STUTTERING NON-LIDCOMBE DIRECT TREATMENT 31 FOR MILD BORDERLINE  Slightly aware, no extra efforts to "fight" their stutters.  fluent most of time and have capacity to develop entirely normal fluency.  focus on child's fluency.  train parents to respond positively to fluency with praise and ignore stuttering unless child is momentarily distressed by a stutter in which case parent can comment acceptingly on it.  train parent to use praise for fluency during daily one-on-one time with child (that was smooth talking; I like the way you said that). Decide how frequently to use positive reinforcement (ratio 1 for every 5 utterances –don't have to be consecutive utterances). NON-LIDCOMBE DIRECT TREATMENT 32 FOR MILD BORDERLINE  daily logs of overall fluency (1 to 10 severity ratings).  parent gradually replaces praise for fluency during daily one-on-one sessions with praise used occasionally during other activities.  weekly sessions to go over ratings, demonstrate procedure, discuss progress & problems.  simultaneously continue changes in interaction and family style.  NON-LIDCOMBE DIRECT TREATMENT 33 FOR SEVERE BORDERLINE  beginning to have negative feelings about their disfluencies but no displaying signs of physical tension or escape behaviors.  necessary to address their emotions without delay.  once a week session (45 minutes) with clinician.  continue to give encouragement and support to family to help make child's env more facilitating to fluency.  Treatment Hierarchy (progress to next step when child feels competent with previous –pace varies from child to child). Use context of games and activities that make focus on stuttering casual.  34 TERMINOLOGY NON-LIDCOMBE DIRECT TREATMENT 35 FOR SEVERE BORDERLINE Modeling Easy Stutters  begin indirectly during casual play with child by providing models of easy stuttering in your speech (if child's repetitions are fast/abrupt –model slow with gradual endings; if repetitions/prolongations are long –repeat only a few times or prolong sounds briefly).  insert them randomly 1 every two or three sentences (not immediately after child stutters).  after 10 to 15 minutes of this type of play, begin making accepting comments about them (I bounced a bit on that word, didn't I; that word stuck a little, but that's okay). Varying reactions from child (if he says 'don't do that or I don't like that' then proceed slowly with direct therapy to allow your acceptance & support during play activities to gradually counteract child's anxiety. Help child express his frustration.  occasionally may produce longer than usual stutter. Use this empathetic focus throughout the treatment. NON-LIDCOMBE DIRECT TREATMENT 36 FOR SEVERE BORDERLINE Active participation in "catch me“ move to this when child is comfortable with easy stuttering models. See if child will take part, Can you help me? Sometimes when I get stuck it goes on and on. Then I try to my stuck words real slow and loose and it helps me get unstuck. But sometimes I forget. If you hear me go on and on like thi-thi-thi-this, just, "There's one," and I'll try make it slow and loose. When child catches you, change a fast, tight repetition into a slow, loose one. Choose a style of stuttering that is similar to the child's. praise and use tangible rewards (small snacks, turns at a game) when child catches you (gives him a sense of competence over something he thought he had no control over). NON-LIDCOMBE DIRECT TREATMENT 37 FOR SEVERE BORDERLINE Active participation in play child follows clinician’s lead to playfully imitate disfluencies that are similar to his own. This is to desensitize child to the frustration. use play –let play saying sounds over and over. I bet I can say it five times. Watch me…can you do it five times? Use animals/puppets..hey this is zebragella. It goes lllllla (using prolongations). Then it jumps around (jump- jump-jump) and eats carpet (eat-eat-eat). gradually move to playing with repeated or prolonged sounds in conversation and then to child's actual stutters. NON-LIDCOMBE DIRECT TREATMENT 38 FOR SEVERE BORDERLINE Producing intentional stutters find opportunities to get child to produce a stutter intentionally. Pretend you are having difficulty producing slow, loose stutter and get child to show you how. Must be done intermittently and casually mixed with other activities. praise and reward to build confidence. let parent know in child's presence how he was able to teach you and get him to demonstrate intentional stutters to parents. This desensitizes both the child and parent to the stutter and models acceptance of child's stuttering for parents. NON-LIDCOMBE DIRECT TREATMENT 39 FOR SEVERE BORDERLINE Changing own real stutters  If child has not benefited from continued indirect treatment plus direct treatment then look for opportunities when child seems ready to modify his own stutters.  begin with accepting comments in response to a few of child's real stutters (oh, that was a bumpy one on 'my-my-my car') then return to business of playing.  model an easier and slower style of stuttering on the same word and comment positively about it. Ask child to imitate the easier stutter. Shape his stuttering to slow, relaxed style and praise for doing so.  look for slightly slower and easier stutters in child's speech and reward them.  after child can make the easier stutters in clinic, spontaneous generalization may occur.  If it does not occur automatically, work with family to make child's ability to play with and modify stutters a point of pride at home. Teach parents/sibling to stutter in clinic under guidance. Then train family to use positive reinforcement selectively to increase child's slow and easy stutters.