Stuttering Intervention Lecture Notes PDF

STUTTERING Presented by: INTERVENTION Dr Shabnam Abdoola  Long term or short term. THERAPY Weekly or CAN BE: intensive. Individual and groups.  Therapy is determined by the assessment: Intensity and severity of stuttering pattern presen...

STUTTERING Presented by: INTERVENTION Dr Shabnam Abdoola  Long term or short term. THERAPY Weekly or CAN BE: intensive. Individual and groups.  Therapy is determined by the assessment: Intensity and severity of stuttering pattern presenting (Phase of development) Motivation and need to change. Previous therapy. Risk factors. Therapist-client relationship. The client must give permission for therapy.  The process and approach of intervention is determined by phase of development. Refer to evaluation and assessment. Long term goals, short term and session goals. INTRODUCTION TO TREATMENT: Needs of client / what do they want? Presenting problem and choice of priorities. Client’s responsibility – learn to manage speech.  Desensitization. Attitudes, emotions and cognition. Relapses. Transfer and maintenance. TREATMENT Self determination. INCLUDES: Self help groups. (Remember to refer to the assessment and classification to help guide your decision making)  Still developing conceptual, linguistic, affective and neuro-physiological skills Might focus on other concomitants first TREATING Teasing and bullying CHILDREN VS Less direct compared with adults ADULTS: Parents, teachers, other professionals play a role / asset based approach More likely to obtain fluency MANAGEMENT: MAIN FOCUS 3 P’s Adapt the environment. Involve the team. Intervention with the parents and child Groups for parents. Literature for parents. Model strategies to parents (similar to Hanen Programme). Slower speech rate, shorter utterances, less complex and pauses. Teaching conversation strategies (pamphlets, video’s, books and website). PRESCHOOL Describe the stages of development according to: ▪ Age ▪ Stage ▪ Core behaviours ▪ Feelings/Attitudes/Awareness THERAPY Two approaches: (1) Parent (2) Child centered/focused centered/focused (Indirect Approach) (Direct Approach) NB: Level of awareness determines focus.  Borderline The child with phrase and some word reps, low level of tension, generally unaware ▪ Parents counselled and provided info regarding developmental nature of fluency (1) INDIRECT ▪ Most time spent working with parents vs. child (PARENT – CENTERED) INTERVENTION  Techniques: ▪ Adjust environmental factors that tend to disrupt his fluency ▪ Decrease speech demands ▪ Give rewards for open, easy, and forward-moving speech ▪ High degree of explanations, reassurance and encouragement (1) INDIRECT INTERVENTION FOR THE PRESCHOOL CHILD (CONTINUED…)  (1) Educational counselling 3 STAGES OF PARENT (2) Facilitating communicative INVOLVEMENT interaction (RAMIG, 1999): (3) Parents as observers and participants.  Based on multi-dimensional framework PRESCHOOL Intervention typically targets the parent’s STUTTERING interaction skills, with aim to modify: RUSTIN’S ▪ Following child’s lead FAMILY ▪ ▪ ▪ Giving time to respond Gaining child’s attention Improved positioning for communication INTERACTION ▪ ▪ Manner of interaction Reinforcement THERAPY ▪ ▪ Turn-taking Rate of speech ▪ Intelligibility  PRESCHOOL Use of video analysis to help parents identify areas to modify STUTTERING ▪ rapid speech rate ▪ interruptions RUSTIN’S ▪ asking too many questions without waiting for a reply FAMILY ▪ parental over direction in play and conversation ▪ parental passivity INTERACTION ▪ poor listening skills THERAPY ▪ ambiguous non-verbal communication ▪ conversation that is unrelated to current CONT. activity.  Parents trained to change these aspects in therapy and to implement at home during designated “special times” RUSTIN’S Improvements should be noted within 6 weeks and THERAPY enter maintenance programme If no improvement, may implement direct strategy work  (2) DIRECT (CHILD CENTERED) INTERVENTION Lidcombe Approach Demands and capacities ▪ Especially for children with speech and language HOW DIRECTLY SHOULD THE THERAPIST WORK. WHAT INFLUENCES THIS DECISION - THE PHASE OF DEVELOPMENT OF THE STUTTER AND THE INDIVIDUAL’S NEEDS. ⬥Prognosis with children? - indicators for recovery ⬥Transfer and maintenance. ⬥Relapses - warn parents and explain why. ◻ The Lidcombe Programme (Onslow 1995) advises against non-involvement of the child and works with him or her through the parents ◻ Parent centered. ◻ Treatment of choice for children under 6 years ◻ Direct approach including self monitoring, but does not teach a technique ◻ Behaviouristic – operant conditioning / positive reinforcement ◻ Gently correcting, eliciting smooth / stutter free speech, parent training. ◻ Not theoretically based, but has extensive empirical data LIDCOMBE PROGRAMME  LIDCOMBE PROGRAMME CONT. Parents learn to: ▪ Identify stuttered and fluent speech in their children ▪ To praise and correct in a natural way ▪ Take severity ratings every day ▪ Adjust treatment according to severity at any time Speech measures ▪ Severity ratings: all therapy decisions are made based on these! Median treatment time = 11 sessions i.e. 11 weeks Data on over 2000 children who have been treated using LP  LIDCOMBE PROGRAMME CONT. Give information regarding stuttering Describe treatment Train on severity rating measure ( 1- 10) Capacities Demands Motor control (rate of speech, Communicative environment or stuttering behaviours, the articulation/phonological coarticulation, stress patterns, plan, parents rate & intonation) communicative style DEMANDS & Rhythm Environmental (demands placed on the person) and he cannot CAPACITIES get transition MODEL Linguistic (language skills: syntax, semantics, phonology Linguistic stressors (words, sentences and situations) STARKWEATHER and pragmatics) Cognitive development Environmental stressors AND GOTTWALD (moving, thinking, feeling) (1990) Socio-emotional (emotional Socio-emotional demands which maturity, reactions to impact on speech. disfluency, the ability to move on despite fears, anxiety, anger etc) DEMANDS & CAPACITIES MODEL CONT. Intervention focuses on: ▪ Reducing demands: parent counselling, education, skill development ▪ Increasing capacity ▪ Primarily fluency shaping strategies ▪ May work on some of the social/emotional 21  THERAPY What can be done? Some fluency enhancers….. ▪ slow, stretched speech with normal intonation ▪ simple, short sentences ▪ many silent periods ▪ elimination of questions, interruptions and demands for verbal performance ▪ use of slowed conversation turn-taking style ▪ use of self-talk and parallel play ▪ following child's lead in play ▪ producing disfluencies in conversation.  Therapy should be: ⬥Accountable – effective – eclectic – efficient (short term) – integrated. ⬥Parent training and involvement. ⬥Parents need to be educated/informed to change their behaviour. ⬥Parents do not cause stuttering but not be “stuttering police” IN SUMMARY…….  ⬥Fun but not overshadow the aims ⬥Eliminating the fluency disruptors. ⬥Train the parents to manage the programme. TEACHERS – WHAT CAN THEY DO?  STOCKER PROBE TECHNIQUE Each programme SHINE: SYSTEMATIC has very FLUENCY TRAINING FOR YOUNG CHILDREN specific objectives CONTURE, Chapt 3: based on the Stuttering its Nature, Diagnosis and Treatment theory or approach: EASY Does it 1  GUITAR: Stuttering an integrated approach, Chapt. 13 & 14/ Shapiro: Chapt 9 & 10 LIDCOMBE: Mark Onslow (Tape, video and stopwatch.) SIP: Stuttering intervention programme; Rebecca Pinzola SMOOTH TALKING: Nola Radford Palin Child intervention (PCI) The school aged child who stutters: working with attitudes and emotions: Chmela, K.A and Rearden, N. (SFA)  Build up linguistic Experience complexity. fluency. THE BASIC OBJECTIVES OF THESE Establish fluency. Desensitize and PROGRAMMES resist fluency disruptors. ARE TO: Work on personal Transfer and constructs maintain. More concern Weighing the odds Family history of chronic stuttering Male Stable or increasing pattern of Stutter- Like Disfluencies (SLD's) over 12 mos. Stuttering onset after 36 months Relatively poorer speech/language performance No family history or history of recovered stuttering Female Decrease in SLD's over 12 months Early onset of symptoms Strong speech/language skills Less concern Fluency reinforcement FLUENCY REINFORCEMENT Process is conditioning / experiencing fluency: Stimulus Response Reward Examples for Children: Lidcombe Program Stocker Probe Technique Smooth Talking Palin PCI Lidcombe Smooth Speech Easy talker Fluency rules & CBT Preschool – 3-6; 6-12 years 9- 14 years School age School age about 9 years SLT, parents & SLT & parents; Clinician parents SLT, parents and SLT, parents and teachers teacher teachers teachers 6/8 weeks 8-12 weeks Intensive 5 days Weekly sessions Weekly sessions Follow ups in 5 weeks over time over time Individual and Mainly Individual and Individual and Individual and groups individual groups groups groups STUTTERING TREATMENT OVERVIEW: PRESCHOOL CHILDREN For preschool children (less than 5 or 6), the goal of treatment is to ▪ Improve their fluency ▪ Help parents and teachers provide a fluency-facilitating environment ▪ Help the child develop normal speech fluency by changing the child’s speech patterns ▪ Help maintain healthy, appropriate attitudes toward communication and speaking