B4L8 Fluency Assessment & Intervention.pdf

Stuttering Assessment Consistency Effect- consistent distribution in repeated readings; the particular sound that the person stutters with is consistent; regular and repeatable loci of stuttering Adaptation Effect- Stuttering decreases in frequency as over the course of several...

Stuttering Assessment Consistency Effect- consistent distribution in repeated readings; the particular sound that the person stutters with is consistent; regular and repeatable loci of stuttering Adaptation Effect- Stuttering decreases in frequency as over the course of several readings; flip side of consistency effect Adaptation effect- a person wth stuttering will roughly decrease from the initial reading evident by at least the fifth reading Case History Taking Start of the cognition (sudden and gradual onsets), (early or late onset) Effects on the quality of life Coping strategies Changes and fluctuations (ex. Feared words) Feelings and attitudes regarding stuttering Stuttering Severity Instrument (SSI) SSI-4 uses multiple (2-3) speech samples of at least 200 syllables each Comparing to norms regarding frequency, length, and severity of stuttering moments Only assesses motor components (primary behaviors) and not personal and subjective aspects and therefore need supporting assessments ○ Severity of motor components is not equal to severity of impact of stuttering to person’s life Can be used for adults and children Fluency Sample An informal assessment tool Having 2 samples is standard; there should be a conversation and reading sample ○ Why is reading Included? Person with stuttering cannot change the words which will show if the person is avoiding specific words ○ Can increase or decrease stuttering frequency Around 300-500 words or syllables (Yairi & Seery 2015; Manning and DiLollo 2018) 600-1200 for ‘less frequent stutterers’ Some references says a minimum of 200 syllable sample Minimum criteria for diagnosing stuttering: 2-3% stuttered syllables Information to obtain ○ Stuttered syllables- %SS Stuttering-like disfluencies (SLD)/Total Syllables x 100 ○ Stuttered words- %SW SLD/total words x 100 ○ Weighted SLD score- for obtaining severity rating of stuttering To get total number of words in sample, look for intended words in the sample (no repetitions or word revisions counted)  Very important to remember for obtaining %SS and %SW- to count every moments of stuttering only ONCE- no matter how severe or complex ○ Ex. ‘P-P-P-P-Pan’ is counted as one moment of stuttering Stuttering-like Disfluencies (SLD) ○ Part-word repetitions (sound or syllable) ○ Monosyllabic word repetition ○ Disrhythmic phonation Prolongations of vowels and/or consonants Blocks (marked by # in word boundaries) Broken words (marked by # within words) Other disfluencies (OD)/ Non Stuttering-like disfluencies (NSLD) ○ OD/NSLD are not counted when obtaining percent of stuttered syllables (%SS) and stuttered words (%SW) ○ Includes: Interjections (‘um’) Revision/abandoned utterances Multisyllabic phrase repetition Weighted SLD Equation and Cutoff Scores Weighted SLD Equation: [(PWR + SSWR) x RU] + (2 x DP) Note: Checklist for the child to identify their style of coping with sounds, words, and situations by using avoidance and escape behaviors. "yes" or "no" as to whether or not they use each of the 50 behaviors described by the clinician "to help the sounds or words come out."PWR = part-word repetitions; SSWR = single syllable word repetition; RU = the number of times a sound, syllable, or word is repeated prior to saying a word, divided by the number of words containing the repetitions. DP = dysrhythmic phonation. "Normally Fluent" 0-3.99 Mild Stuttering 4.00-9.99 Moderate Stuttering 10.00-29.99 Severe Stuttering >30.00 Advisable to tabulate %SS or %SW during both conversational speech and reading activities But these two percentages tend to be highly variable for a speaker due to anticipation and/or avoidant behaviors Depend on the situation and material Behavior Checklist (BCL) A Formal Tool  Checklist for the child to identify their style of coping with sounds, words, and situations by using avoidance and escape behaviors. Answering "yes" or "no" as to whether or not they use each of the 50 behaviors described by the clinician "to help the sounds or words come out. Tension Secondary behavior brought about by stuttering Measurement of tension: ○ including galvanic skin response (GSR), electroencephalography (EEG), and-most often-electromyography (EMG) (Van Riper, 1982). Perceptual identification of the sites of the degree of tension Greater degree of tension in an anatomical area = greater probability of a block VF occludes and airflow + voicing ceases (block) Other ABC Aspects Avoidance can negatively impact the person’s lifestyle more than the actual stuttering Perceptual ID of SLP when there are signs of avoidance Signs: ○ Hesitation before feared word (can be subtle) ○ Thinking (similar words & circumlocutions) ○ Using sounds (e.g., "ah") or words (e.g., "you know, let me see") to postpone or assist initiation (These are starting tricks) Ranges off behavior ○ Equal-interval scale for determining the current, average, and range of stuttering behavior during the assessment of adolescents and adults. Loss of control ○ Identifying loss of control in another speaker has yet to be demonstrated empirically. ○ Nevertheless, over the years authors have suggested that it is possible for experienced clinicians who become calibrated to their clients to be able to accurately identify such moments A19 ○ A formal tool assessing affect using a 19-item questionnaire ○ Measure a child’s attitude regarding communication ○ Higher score- more probability of negative attitudes regarding communication ○ Mean score of the K through 4th grade stutterers -> 9.07 (S.D. = 2.44), ○ 28 matched controls -> (S.D. = 1.80) S-24 Scale ○ A formal tool used for adults by Erickson (1969) ○ Scale for attitudes regarding verbal communication ○ 39 true-false items to differentiate person with stuttering (PWS) and person with no stuttering (PWNS) The OASES (Yaruss & Quesal, 2016) ○ Evaluate the impact of stuttering on a person's life  ○ Affective, behavioral, and cognitive factors of stuttering ○ For Adults and Children CAT and BigCAT is the adult form of Vanryckeghem and Brutten's Communication Attitude Test (2011; 2018). ○ It is a 35-item, self-report measure that has been normed on adults who stutter (AWS) and adults who do not stutter (AWNS) and aims to "determine what an individual currently thinks about his or her speech and speaking ability" Stuttering Intervention School age to adults Factors White Noise/ Masking ○ Reductions in stuttering frequency when speaking in the presence of loud noise e.g. near ocean surf, a waterfall, or a passing train. ○ Stutterers were unable to hear their own speech ○ "relatively free from the anxiety-producing cues involved" ○ Inference: the inability to hear one's own speech - rather than mere distraction - produced the effect. ○ Verified repeatedly and extensively Delayed Auditory Feedback ○ For many persons who stutter, speaking under DAF reduces stuttering frequency ○ In contrast, DAF tends to increase the frequency of disfluencies in typically fluent speakers ○ Whether feedback can create durable therapeutic improvements in fluency in spontaneous speech outside the research laboratory or clinic is still under investigation; not much generalization in natural context Video Self-modeling ○ Repeated exposed to the stutterer's error-free, target behavior ○ Editing video to select seaments portraying desired performance ○ Improves and reduces moments of stuttering Low Evidence Interventions Hypnosis & Suggestion Psychotherapy alone No pharmacological agent has yet been shown in a well-constructed study to dramatically improve fluency in AWS or alter its cognitive and affective features Pharmaceutical Therapy  Recent reviews, including that by LaSalle et al. (2021), emphasize that responses to medication by PWS can be idiosyncratic; none should be expected to completely remove stuttering symptoms. Most studies and reviews suggest that any pharmacological agent likely to be shown to improve fluency to some degree would have to be coupled with a behavioral treatment regimen in order to achieve meaningful increases in natural and fluent speech Stuttering Modification Voluntary Stuttering fluency enhancement through a change in the stutterer's manner of speaking Bring the problem out into the open and to be willing to stutter reduces the individual’s fear of stuttering Increasing acceptance of disfluency decreases breakdown in AWS Discuss stuttering freely and casually Willingness to enter difficult speech situations Refusal to use word substitutions or other tricks for avoiding stuttering Brynelson’s Therapy Very situational; Depends on the individuals feared situation and feared person Clients were taken outside the speech clinic, and challenged to maintain an objective attitude in feared situations Van Riper’s Cancellations, Pullouts, and Preparatory Sets Preparatory Sets ○ 1) Begin the word with the articulators in a state of rest ○ (2) Say the first sound as a movement leading into the next sound ○ (3) initiate voice or airflow immediately on the attempt ○ "easy onsets." Pullouts ○ If people began to stutter: Finishing the word with a smooth, controlled, gliding prolongation. ○ No frantic struggle to escape - immediate effect of increasing fluency Cancellations (Pausing) ○ When prolongations or pullouts fail = Pause, study their feelings and behavior, and immediately try the word again. ○ Goal is not to say the word fluently on the second attempt but to make some changes for the better in their way of stuttering. Modern application has reversed the order of the modifications to 1- cancellations, 2-pullouts, 3-preparatory sets Avoidance Reduction Therapy Reducing efforts to avoid showing stuttering Reducing efforts to conceal one's identity as a PWS  Fluency is achieved as a byproduct of self- acceptance and letting go of efforts to control speech Attempts to address: ○ Role conflict - most PWS could be perfectly fluent when speaking alone ○ Speaking fluently - expectations of continued fluency Lessen heightening anxiety and leading to reduced stuttering Desensitization Introducing the idea of stuttering on purpose: voluntary, intentional, or pseudostuttering Constant exposure to stuttering lowers the fear associated with it Until the speaker is able to decrease excessive levels of fear, they will have little success in the succeeding steps of treatment. Fluency Shaping/ Speech Restructuring Fluency enhancement through a change in the stutterer's manner of speaking Speech restructuring" techniques can reduce stuttering frequency by about 50% to 60% People who stutter tend to become fluent when they find themselves speaking in almost any way strange to them. When the speaker times each syllable to the beat, is a drastically reduced demand on motor planning, which comes at the cost of speech naturalness Possible Objectives Rate modification via prolonged syllables while maintaining natural prosody at first ○ Preventing increase in tension and disruptions in speech ○ Promotes flow and rhythm of speech Continuous voicing Easy onset of phonation & Gentle articulatory contacts ○ As little contact as possible, as easy contact as possible Work to normalize breathing if necessary (sudden inhalation and exhalation Prolonged Speech Prolong segments in spoken utterances Especially voiced components such as vowels, glides liquids (continuants) Other sounds (stops, fricatives) unnatural when prolonged Syllable Timed Speech Increased fluency when they time their speech to a rhythmic beat such as the ticking of a metronome Cue for the next sound Promotes rhythmicity Can serve as distraction to auditory feedback Operant Conditioning Punishment of stuttering and time-out Providing a signal that a stuttering behavior occurred Toy/light activates during moment of stuttering In adults: can be amorphous - Aversive for some, receptive for others Some benefited very little, while others benefited more extensively Fluency Reinforcement Ignoring the stuttering Reinforcements for fluent or stutter free utterances Tangible or Verbal rewards given Token economy Counting SS% in conversations Tokens either earned or lost in proportion to decreases or increases in their stuttering from session to session Additional Components Debates over treatments focused on acceptance versus treatments focused on modification Possible for individuals who stutter to work toward both of these goals simultaneously Can be complementary to one another Age considerations ○ Older People with Stuttering = Modifications would be prioritized than shaping Cognitive Behavioral Therapy CBT in combination with speech restructuring No improvements in speech fluency were observed with use of the CBT-Psych program alone Early Childhood Indirect Therapy Parent Counseling Manage or decrease any factors or conditions that appear to increase disfluency Rather than "directly" intervening with speech and fluency Managing speaking when: ○ Fatigued, excited, angry pressured, or in a competitive environment ○ Some immediate improvement in fluency may be achieved Common guidelines:  ○ slowing parental speaking rate, as a model to the child ○ reducing interrupting behaviors at home ○ reducing "simultalk" which increases moments of stuttering ○ expanding wait time between the child's utterances and parental responses to allow child to process better ○ acknowledging (rather than ignoring) the child's speech difficulty Direct/Mixed Therapy Lidcombe Program Good outcomes from a treatment regimen administered by parents First Stage ○ 15 min daily activities designed to maximize the child's opportunities for fluency ○ Under guidance of an SLP who meets with the family on a weekly basis to observe the child Second Stage ○ Defined as the maintenance stage ○ -› contingencies are fewer, and distributed throughout natural speaking situations ○ When fluent speeches exhibited: praise the child, ask for their evaluation and acknowledge ○ When stuttering is exhibited: Acknowledge and request self correction Demands and Capacities Model Components of indirect therapy, based on reducing motoric, linguistic, cognitive, and emotional stressors on children's fluency. Following initial weekly, hour-long sessions that involve the parent only, sessions are for both parent and child so that the therapist can observe how recommendations are being implemented and the child's response. Therapists also employ similar strategies in direct work with children, particularly issues of the child's response to stuttering, including desensitization strategies Family Centered Approaches: Parent-Child Interaction Therapy Parent-Child Interaction (Indirect Strategy) ○ Following the child’s lead ○ Conversational timing, pausing, and rate ○ Eye contact ○ Language Input ○ Use of commenting and graded difficulty of questions Family Strategies (Environmental & Speaking contexts) ○ Talking about stuttering ○ Building confidence  ○ Dealing with feelings ○ Managing turn-taking, routines, daily expectations ○ Family-specific issues Child Strategies (Direct strategies) ○ Open discussion ○ Building confidence ○ Learning about speech and stuttering ○ Desensitization and voluntary stuttering ○ Exploring emotions about stuttering ○ Speech modification ○ Language/Phonological Therapy as warranted