Fluency Exam Prep PDF - SLP 326
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2024
Dr Shabnam Abdoola
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This document is an exam preparation guide for a Fluency course (SLP 326). The exam will cover various aspects of fluency disorders, including stuttering, case studies, and assessment tools. The exam format will incorporate multiple-choice questions, true/false questions, short answers, and in-depth questions. The exam prep also includes topics on core behaviours, secondary behaviours, and attitudes related to fluency.
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SLP 326 Fluency Exam Prep When? Thu 12 December 2024 What time? 11:30-13:30 Where? E1-1027 General Types of Written vs Marks Total marks Weighting questions...
SLP 326 Fluency Exam Prep When? Thu 12 December 2024 What time? 11:30-13:30 Where? E1-1027 General Types of Written vs Marks Total marks Weighting questions typed MCQs 1-20 marks 100 marks Written 40% True/false per (paper- Short question based) questions/ answers Long questions/ answers Case study 3 MCQs & True/False Only one correct answer per question One mark per question Simple to complex Questions from ALL included sections Examples According to studies, stuttering is most common during which phase of development? a) Early adulthood b) Infancy c) Preschool years d) Adolescence What term describes recovery without intervention in children who stutter? a) Adaptation effect b) Neuroplasticity c) Spontaneous recovery d) Linguistic compensation Short questions/answers 1-10 marks Questions from ALL included sections Matching columns Examples Define secondary behaviors in stuttering and provide two examples. (3) Explain the difference between typical disfluency and stuttering in preschool children. (3) Explain the difference between the indirect (parent-centered) and direct (child- centered) approaches in stuttering therapy. (2) List the four phases of stuttering modification and briefly describe the purpose of each. (8) What is the purpose of using self-rating scales and cognitive activities in stuttering intervention for school-age children? (5) List and briefly describe two environmental factors and two developmental factors that may influence the onset or persistence of stuttering. (4) 7 Long questions/answers 10-20 marks Questions from ALL included sections 8 Examples Discuss the assessment of fluency disorders in the context of the WHO ICF framework (10) Discuss the differential diagnosis between stuttering and cluttering (20) Discuss the direct and indirect approaches of stuttering therapy. (20) 9 Case study General case Very little application Read the question carefully Consider the mark allocation 10 Example Sarah is a 9 year old girl, who has been stuttering for a few years. Her parents thought she was just shy but can now see that she is frustrated and is behaving aggressively as her stutter gets worse. She is in a new school and does not have many friends. 1. Describe the structure and components of the disfluency assessment. (10) 2. What assessment tools could be used in Sarah’s assessment? (5) 3. Once you complete the assessment, you diagnose Sarah with mild stuttering. Name and describe the therapy approach you would use for Sarah? (3) 4. What advice would you give Sarah’s teacher to improve her fluency in the classroom? (2) 11 What can I leave out? All the articles from the class activity Iceberg theory handout Bilingualism & stuttering powerpoint Stuttering & the Bilingual child handout (under lecture 12) Neurogenic stuttering powerpoint Disfluency count sheet & manual DSM 5 criteria Lecture 3- you need to know the overall age groupings, but not all the tables with the details at each stage. Lecture 5 (Intervention 1)- leave out slides 28-34 13 Good Luck! Dr Shabnam Abdoola Disorders of Fluency Introduction SLP326 Dr Shabnam Abdoola Prescribed textbook on Blackboard Additional: Guitar, B. (2019). Stuttering: An Integrated Approach to its Nature and Treatment. 5th edition. Lippincott Williams and Wilkens, Philadelphia. The Words We Use “People who stutter” preferable to: Stutterer PWS Disfluency “Disfluency” = either normal or abnormal “Disfluency” is preferable to “dysfluency” Types ❖ Stuttering ❖ Cluttering ❖ Psychogenic Stuttering ❖ Neurogenic Stuttering Definitions Fluency versus disfluent speech Definitions (cont.) Starkweather (1980, 1987) suggests that rate and effort are critical to fluency. Thus, a fluent speaker effortlessly produces speech at a rate comfortable to listeners. Stuttering: General Description Stuttering = abnormally high frequency and/or duration of stoppages in the flow of speech Stuttering also includes speakers’ reactions to stoppages These reactions include behavioral, emotional, and cognitive responses to repeated experiences of getting stuck while talking Need to distinguish between stuttering and typical disfluencies, as well as from neurogenic and psychogenic stuttering Core Behaviors of Stuttering Repetitions: may be single-syllable word or part-word repetitions Word or syllable may be repeated more than two times, li-li-li-like this. Prolongations: sound or airflow continues but movement of articulators is stopped Prolongations as short as one-half second may be perceived as abnormal. Core Behaviors of Stuttering (cont.) Blocks: inappropriate stoppage of airflow or voicing; movement of articulators may be stopped Blocks may occur at any level—respiratory, laryngeal, and/or articulatory. Blocks may be accompanied by tremors of lips, tongue, jaw, and/or laryngeal muscles. On average, people who stutter, stutter on about 10 percent of the words while reading. On average, stutters last about 1 second. Secondary Behaviors Secondary behaviors are learned behaviors that are triggered by the experience of stuttering or the anticipation of it. Escape behaviors occur when the speaker is stuttering and attempts to terminate the stutter and finish the word (e.g., eye blinks and head nods). Avoidance behaviors occur when the speaker anticipates a stutter and tries to avoid it by, for example, changing the word or saying “uh” just before the word. Feelings and Attitudes The experience of stuttering often creates feelings of embarrassment and frustration in a speaker. Feelings become more severe as the speaker has more stuttering experiences. Fear and shame may develop eventually and may contribute to the frequency and severity of stuttering. Attitudes are feelings that have become more permanent and affect the person’s beliefs. Beliefs may be about oneself or listeners. Functioning, Disability, and Health The disability of stuttering is the limitation it puts on individuals’ ability to communicate. This limitation is affected by the severity of stuttering as well as feelings and attitudes that people who stutter have about themselves and about how listeners have reacted to them. The handicap is the limitation it puts on individuals’ lives. This refers to the lack of fulfillment they have in social life, school, job, and community. International Classification of Functioning (ICF) Disorder of rhythm of speech…individual knows what he/she wants to say but cannot because of “an involuntary, repetitive prolongation or cessation of a sound”. Impairment: neuropsychological and neurophysiological events that immediately precede and accompany the audible and visible events of stuttering Disability: the audible /visible events that are the behavioural manifestations of stuttering Handicap: the disadvantages resulting from reactions of PWS and listener to the audible and visible events of a person’s stuttering International Classification of Function Model (ICF) Personal Factors Affective Behaviourial Cognitive Activity Impairment Limitation Presumed In Body Etiology Participation Function Restriction Environmental Factors Components of stuttering 1. Core behaviors 2. Secondary behaviors 3. Feelings and Attitudes 1. Core behaviours ❑ Repetitions (sounds, syllables, words) ❑ Whole-word and phrase repetitions in excess of 3 iterations ❑ Prolongations (voiced, voiceless) ❑ Blocks (stoppage of airflow, tension) ▪ Abnormal hesitations ▪ Broken words 2. Secondary Behaviours ▪ Unrelated to speech production ▪ Physical movements/Gross muscle movements ▪ Avoidance of feared words / substitution of another word. ▪ Interjected "starter" sounds and words, such as "um," "ah," "you know ▪ Repeating a sentence or phrase “jump start." ▪ Vocal abnormalities e.g. rising intonation ▪ Extraneous noises e.g., coughing, throat-clearing ▪ Not maintaining eye contact. ▪ Articulating an unrelated sound e.g. /t/ sound when trying to say /s/. ▪ Secondary behaviours may help you get around stuttering at first, but then lose their effectiveness 3. Feelings and Attitudes Typical feelings Feelings –attitudes –beliefs Role of conditioning Do these lead to dysfluency OR does dysfluency lead to feelings? The Iceberg of Stuttering (Sheehan) 16 Incidence vs Prevalence: ❑ Difficult to determine conclusively ❑ Incidence → those who have EVER stuttered ▪ Incidence is 5% of population worldwide ▪ 15% of individuals stutter for 6 months or less ▪ SPONTANEOUS RECOVERY ❑ Prevalence → those who have stuttering RIGHT NOW ▪ Prevalence is 1% of population ▪ Prevalence of those who stutter 6 months or less = 15% ▪ 2.4 % of all kindergartners, 1 % of school age children ▪ Less than 1% of adults Spontaneous recovery Possible, but percentages are unclear Range between 25% - 80% (Andrews et al.,1983) Approximately 65-80% of all children who begin stuttering will recover without intervention 3 to 5 years after onset (Yairi and Ambrose, 2005) 50% of kids between 8yrs to Teens (Howell et al, 2008) If problem continues into teen yrs., very small % Predictors/Risk Factors: ❑ Yairi and Ambrose (2005) predictors: ▪ Family history =less likely to recover ▪ Gender-Male = less likely to recover ▪ Age of onset-After age 3 ½ = less likely to recover ▪ Co-occurring developmental problems ▪ Learning disorder ▪ Type of stuttering displayed ▪ Length of time stuttering ▪ Environmental factors Interesting Facts ▪ Stuttering is universal ▪ Stuttering often genetic ▪ Disorder of early childhood ▪ Stuttering is cyclical ▪ Stuttering is more common among males than females ▪ Normally fluent when speaking in unison, whispering or singing ▪ Adaptation effect ▪ Stutter less when relaxed and rested verses being excited / fatigued ▪ 1% of the population stutters but 5% of people stutter at some time and recover spontaneously during childhood ▪ No two individuals who stutter, stutter in the same way Causes/Folklore What Causes People to Stutter? The causes of stuttering are not completely understood, but scientists believe these are important factors: Genetic and congenital influences Developmental influences Environmental influences Repeated negative emotional experiences with stuttering lead to negative feelings and attitudes. Factors Contributing to Stuttering Basic Facts and Their Implications Onset May start as gradual increase in normal childhood disfluencies or may start as sudden appearance of prolongations or blocks Often sporadic at outset, coming and going for periods of days or weeks before becoming persistent Onset may occur between 18 months and 12 years but most often between 2 and 3.5 years (average 2.8 years) Prevalence A measure of how many people stutter at any given time Prevalence is 2.4 percent in kindergarten, about 1 percent in school-age children, and slightly less than 1 percent in adults Basic Facts and Their Implications Incidence A measure of how many people have stuttered at some point in their lives About 5 percent Recovery from stuttering Somewhere between 70 and 80 percent of children who begin to stutter recover without treatment Basic Facts and Their Implications Children with these attributes have less likelihood of spontaneous recovery (Yairi & Ambrose, 2005): Having relatives who were persistent stutterers Being male Onset after 3.5 years Stuttering not decreasing during first year after onset Stuttering persisting beyond 1 year after onset Multiple unit repetitions (li-li-li-li-like this) Continued presence of prolongations and blocks Below normal phonological skills Basic Facts and Their Implications There is also evidence that recovery is associated with: Being right-handed Growing up in a home with a mother who is nondirective Having a slower speech rate and more mature speech motor system Basic Facts and Their Implications Some evidence of other factors influencing persistence versus recovery: Mothers of children who recovered used simpler language when talking to their children. White matter tracts in brains of children who recovered may be more developed/mature than those who persisted. Duration of breastfeeding was longer for children who recovered than for persistent children. Gender Ratio The sex ratio is almost even (1:1) at the onset of stuttering. However, girls start to stutter earlier than boys and recover more frequently so that by the time they are of school age, the ratio becomes three boys to every girl who stutters and continues at a 3:1 ratio. Girls begin to stutter earlier than boys and recover earlier and more frequently. Variability and Predictability of Stuttering In the 1930s, interest in stuttering turned from its medical or organic aspects to social, psychological, and linguistic aspects such as these: Anticipation: People who stutter can predict which words they will stutter on in a reading passage. Consistency: People who stutter tend to stutter on the same words each time they read a passage. Adaptation: People who stutter less each time they read a passage up to about six readings. Language Factors Brown showed that adults who stutter do so more frequently on: Consonants Sounds in word-initial position Sounds in contextual speech Nouns, verbs, adjectives, and adverbs Longer words Words at beginnings of sentences Stressed syllables Language Factors (cont.) Loci and frequency of stuttering are different in preschool children than in older individuals. Stuttering in preschool children occurs most frequently on pronouns and conjunctions (these occur frequently at the beginning of utterances in young children). Stuttering appears most frequently as repetitions of parts of words and single-syllable words in sentence- initial position. In summary, because stuttering in preschoolers tends to occur at beginning of syntactic units, the trigger seems to be linguistic planning and preparation. Fluency-Inducing Conditions Many conditions have been found which reduce or eliminate stuttering. These include speaking: When alone, when relaxed In unison with another speaker To an animal or infant In time or a rhythmic stimulus or when singing, in a different dialect While simultaneously writing, while swearing In a slow, prolonged manner Under loud masking noise, while listening to delayed auditory feedback When shadowing another speaker, when reinforced for fluent speech Fluency-Inducing Conditions (cont.) Fluency-inducing conditions have been explained as resulting from reduced demands on speech motor control and language formation (Andrews et al., 1982). In addition, recent brain imaging studies have made it clear that cortical and subcortical networks are impaired in people who stutter. Thus, fluency-inducing conditions may work because they help individuals compensate for the deficits in neural systems, by providing timing cues, slowing the rate of speech production, and/or allowing the person who stutters to focus total attention on producing fluent speech. A Model of Stuttering Stuttering is a neurodevelopmental disorder that usually appears in the preschool years when language development or the child’s environment create enough stress to trigger speech production discoordination that results in an excess of disfluencies. A Model of Stuttering (cont.) The child may regain fluency when stresses are reduced or the child learns to compensate. Some children recover completely. Other children persist in stuttering, because their neural pathways remain inadequate for fluency and/or because they react negatively to their early stuttering. Children who persist usually develop learned behaviors, making their stuttering more conspicuous. Class Activity Students work singly or in small groups to develop an explanation of stuttering that would be easy to understand when a parent asks. “What causes stuttering?” In pairs or groups of three, students role-play a clinician and a parent, answering the parent’s question about the cause of stuttering. Ethics regarding fluency disorders (stuttering) Rule of Ethics: ▪ To hold paramount the welfare of the persons we serve. ▪ Provide services competently. ▪ Shall fully inform the client on the nature and effects of the service. ▪ Evaluate effectiveness of services rendered and of products dispensed. ▪ Only dispense products when benefit can be expected. ▪ To maintain and secure records on assessment and treatment. ▪ Clinical competence not to be assigned to others. ▪ Shall not guarantee results of treatment. ▪ Statements to public will provide accurate information. Evidence based practice “The potentially devastating problem of stuttering demands state-of-the art evidence-based treatment if the most serious implications of the disorder are to be prevented.” Block, 2004 Best research (high quality) Clinical Client needs & expertise preferences “…the client and not the clinician is the guide” -Van Riper FACTORS ASSOCIATED WITH STUTTERING SLP 326 DR SHABNAM ABDOOLA FAMILY STUDIES Stuttering appears to be inherited. Stuttering best explained as interaction of several genes and the environment, including effect of epigenetics (factors that influence the expression of genes as specific behaviors). Children from families with persistent stuttering are more likely to have persistent stuttering themselves. IMPORTANT FINDINGS FROM TWIN STUDIES Stuttering in identical and fraternal twins Greater concordance among identical twins Twin studies confirm that genetic influence in stuttering is a major factor, with environmental influence being important but having a little less influence. CONGENITAL AND EARLY CHILDHOOD FACTORS 40 to 70 percent of stutterers have no family history of stuttering. Stuttering has been associated with: Brain injury before or soon after birth Premature birth Surgery Head injury Cognitive disability Intense fear SENSORY PROCESSING FACTORS IN STUTTERING Individuals who stutter show following deficits compared to individuals who don’t stutter: Poorer central auditory processing; poorer speech perception When listening to complex linguistic stimuli, they show longer latency and lower amplitude brain waves In dichotic listening, they show less left-hemisphere advantage, especially those with severe stuttering May be poorer at processing tactile, kinesthetic, and visual information SENSORIMOTOR CONTROL FACTORS IN STUTTERING Individuals who stutter show the following differences from their fluent peers: Slower reaction times, especially to linguistically meaningful stimuli Slower transitions, longer vowels, and delayed onset of voicing in fluent speech Slower in nonspeech sequencing tasks LANGUAGE FACTORS IN STUTTERING Stuttering onset often occurs during periods of rapid language acquisition in preschool years. Children who stutter appear to have slightly less robust language processing abilities. Language complexity influences stuttering: Longer and more complex sentences are associated with more stuttering. Whether or not a word is stuttered is influenced by class of word (noun, verb, etc.), length, and location in sentence. EMOTIONAL FACTORS IN STUTTERING Although some studies suggest that people who stutter are more anxious, most authors agree that this anxiety comes from repeated negative experiences when they stutter. Greater autonomic arousal (related to anxiety) has been found to be associated with greater amounts of stuttering. Many studies have shown that children who stutter have greater emotional reactivity than controls. This may affect level of physical tension in stuttering and susceptibility to conditioning. DEVELOPMENTAL FACTORS—PHYSICAL AND MOTOR DEVELOPMENT Rapidly developing motor skills may compete for neural resources so that language and speech production are affected. For example, rapidly changing size and shape of vocal tract may be a challenge for internal models used for speech. Another example of motor development competing for resources is the finding that: Most children master either walking or talking sequentially, but they don’t usually master both skills at the same time (they have the neural resources to master only one at a time). SPEECH AND LANGUAGE DEVELOPMENT Stuttering seems to have its most frequent onset when the child is mastering more complex language. Children predisposed to stuttering may have deficits in areas responsible for planning and production of speech and language (e.g., slowly developing white matter tracts). Rapid speech and language development may stress these weak areas, resulting in stuttering. Some children may develop stuttering as a response to extra difficulty because of a speech or language delay and the stress it puts on speech production. COGNITIVE DEVELOPMENT Intensive cognitive development may compete with fluency, especially for children with cognitive delays. The “ups” and “downs” in a child’s fluency may reflect spurts of cognitive development. As children develop cognitively, they may become more aware of their stuttering and may thus develop negative attitudes about their speech. SOCIAL AND EMOTIONAL DEVELOPMENT Emotional arousal increases stuttering and normal disfluency. Emotional stress during childhood may trigger or worsen stuttering. Some children who stutter—because of a sensitive temperament—may be more vulnerable to normal stresses of childhood. Individuals who stutter appear to be normal in terms of psychosocial traits. ENVIRONMENTAL FACTORS Environmental factors may interact with developmental factors to trigger or worsen stuttering. Parents Research: Mixed results about whether parents of stutterers are more anxious, etc. Theory: Children with vulnerable temperament may have inherited it from one or both parents, thus parents may be perfectionistic, anxious, etc. SPEECH AND LANGUAGE ENVIRONMENT Research unclear: Do families of kids who stutter have stressful speech and language models? Speculation about some variables causing stress for vulnerable children LIFE EVENTS Stressful life events may precipitate or worsen stuttering in some children TYPICAL DISFLUENCY AND THE DEVELOPMENT OF STUTTERING DR SHABNAM ABDOOLA NORMAL DISFLUENCY: AGES 2 TO 6 NORMAL DISFLUENCY: AGES 2 TO 6 (CONT.) BETWEEN 2 AND 6, MOST CHILDREN HAVE TYPICAL REPETITIONS, PROLONGATIONS, AND PAUSES. REPETITIONS ARE MORE COMMON IN YOUNGER CHILDREN; REVISIONS ARE MORE COMMON IN OLDER CHILDREN. TYPICAL DISFLUENCY: AGES 2 TO 6 (CONT.) TYPICALLY DISFLUENT CHILDREN DON’T REACT TO THEIR DISFLUENCIES; THEY SEEM UNAWARE OF THEM. FACTORS THAT MAY INCREASE NORMAL DISFLUENCIES: DEMANDS ON LANGUAGE ACQUISITION DELAYED SPEECH MOTOR SKILLS STRESS COMPETITION AND EXCITEMENT WHEN SPEAKING YOUNGER PRESCHOOL CHILDREN: BORDERLINE STUTTERING, AGES 2 TO 3.5 UNDERLYING PROCESSES: CONSTITUTIONAL SPEECH AND LANGUAGE DEVELOPMENT SOME LANGUAGE AND SPEECH SKILLS MAY BE MORE ADVANCED THAN OTHERS. INEFFICIENCIES IN SOME LANGUAGE PRODUCTION PROCESSES UNDERLYING PROCESSES: ENVIRONMENTAL COMMUNICATION STRESS MODELS OF FAST TALKING/FEW PAUSES INTERRUPTIONS, QUESTIONS, ETC. MODELS OF ADVANCED VOCABULARY AND SYNTAX COMPETITION TO BE HEARD PSYCHOSOCIAL STRESS CONFLICTS IN FAMILY BIRTH OF NEW SIBLING CHANGES IN HOME, MOVING, ETC. “OUTGROWING” BORDERLINE STUTTERING RESOURCE REALLOCATION TO COMPENSATE SPEECH AND LANGUAGE SYSTEMS MATURE CONFLICTS RESOLVE OLDER PRESCHOOL CHILDREN: BEGINNING STUTTERING, AGES 3.5 TO 6 UNDERLYING PROCESSES INCREASES IN MUSCLE TENSION AND TEMPO THESE INCREASES ARE SEEN AS A SIGN THAT STUTTERING IS WORSENING. THESE CHANGES MAY BE ATTEMPTS TO CONTROL OR ESCAPE FROM STUTTERS. EFFECTS OF LEARNING ON STUTTERING CLASSICAL CONDITIONING SPREADS THE EMOTION ASSOCIATED WITH STUTTERING TO MORE SITUATIONS; THIS MEANS MORE TENSION AND FASTER TEMPO. OPERANT CONDITIONING INCREASES FREQUENCY OF ESCAPE BEHAVIORS; THIS MEANS MORE EYE BLINKS, HEAD NODS, ETC. SCHOOL-AGE CHILDREN: INTERMEDIATE STUTTERING, AGES 6 TO 13 UNDERLYING PROCESSES CLASSICAL CONDITIONING CREATES MORE AND MORE TENSION IN STUTTERING IN MORE SITUATIONS. OPERANT CONDITIONING CREATES A MORE COMPLEX ARRAY OF ESCAPE BEHAVIORS. AVOIDANCE CONDITIONING CREATES EXTRA SOUNDS AND BEHAVIORS BEFORE THE FEARED WORD AND CAUSES CHILD TO AVOID MORE AND MORE WORDS AND SITUATIONS. A SCHOOL-AGE CHILD EXPRESSES HIS EMOTIONS ABOUT HIS STUTTERING THIS STUDENT SAID THE FIRST DRAWING SHOWED HIS CURRENT FEELINGS ABOUT HIS STUTTERING THE SECOND DRAWING, HE SAID, SHOWED HOW HE HOPED TO FEEL AFTER TREATMENT. OLDER TEENS AND ADULTS: ADVANCED STUTTERING, AGES 13+ UNDERLYING PROCESSES MINIMAL INFLUENCE OF ORIGINAL CONSTITUTIONAL, DEVELOPMENTAL, AND ENVIRONMENTAL FACTORS. LEARNING AND EXPERIENCE, HOWEVER, HAVE CHANGED BRAIN STRUCTURE AND FUNCTION. AVOIDANCE LEARNING HAS CREATED ENDURING STUTTERING PATTERNS. UNDERLYING PROCESSES (CONT.) COGNITIVE LEARNING CREATES NEGATIVE SELF-CONCEPT. THIS COMES FROM LISTENER REACTIONS FROM CHILDHOOD AND LATER. STUTTERERS ALSO PROJECT THEIR OWN NEGATIVE FEELINGS ABOUT STUTTERING ONTO OTHERS. THIS DRAWING IS BY AN ADULT WHO SAID IT DEPICTED HIS FEELINGS WHEN HE IS STUCK IN A MOMENT OF STUTTERING. Assessment SLP 326 Dr Shabnam Abdoola Family history Negative reactions towards own disfluency Physical tension or secondary behaviours When & Other speech or language concerns why do we Negative reactions from others assess? Difficulty communicating Parental concern Let’s expand on the different assessment areas… Medical history; General development; Speech and language development, including frequency of exposure to all languages used bythe child and the child's proficiency in understanding and expressing himself/herself in all languages spoken; Family history of stuttering or cluttering; Case Description of characteristics of disfluency and rating of severity; history Age of onset of disfluency and patterns of disfluency since onset (e.g. Continuous or variable, &changes over time) and other speech and language concerns; Previous treatment experiences and treatment outcomes; Information regarding family, personal, and cultural perception offluency; Thoughts/feelings for cause What else should you include in an assessment? consultation with family members, educators, and other professionals, including their observations of fluency variability (when disfluencies are noticed most and least) and impact of disfluency; real-time analysis or analysis based on review of a taped speech sample, if provided byaparent or teacher, demonstrating representative disfluencies beyond the clinic setting; review of previous evaluations and educational records; assessment of speech fluency (e.g., frequency, type, and duration of disfluencies; presence of secondary behaviors; speech rate; and intelligibility) in avariety of speaking tasks (e.g., conversational and narrative contexts); What else should you include in an assessment? stimulability testing in which the child is asked to increase pausing and/or decrease speech rate in some other way-a reduction of overall rate of speech typically assistswith a reduction in cluttering symptoms; assessment of the impact of stuttering or cluttering-including assessment of the emotional, cognitive, and attitudinal impact of disfluency-for information concerning speaking frequency and socialization; assessment of other communication dimensions, including speech sound production, receptive and expressive language development, pragmatic language, voice, hearing, and oral- motor function/structure; determination of individual strengths, coping strategies, and available resources that may facilitate the treatment process. Stuttering: (speech samples and reading samples) Type of core behaviours (spectrographic evaluation) – frequency, duration, tension Expanding and severity (Riley and Riley, SSI and van Riper’s profile) on assessing Associated motor behaviour (checklist) Avoidance and postponement (PSI) speech Consistency and adaptation (reading) Fears – words, sounds situations (checklist) fluency Personality traits (checklist e.g. Assertiveness Scale, S Scale-Erickson, Perceptions of Self or Self Efficacy Scale) OASES/KIDDYKAT/TOCS Speech Samples Throughout assessment looking for: Typesof disfluencies Severity (% of syllables or words stuttered) Secondary behaviours Escape/Avoidances Tempo / tension / flow Articulation / language/Cognition Stuttering Severity Instrument-4 (SSI-4) Systematic Disfluency Speech Samples Analysis (SDA) Reading Samples Oral Motor Assessment Scale (OMAS)-DDK What tools can we Hierarchy of Feared Situations use? Feelings and Attitudes Language & Articulation tests and checklists Stuttering Severity Speaking &ReadingTasks: Instrument4 *Frequency *Duration (SSI-4) *Physical concomitants (Riley, *Total Overall Score 2009) (Riley,Riley&Beckett,1985) “Theability to coordinate / produce Oral Motor alternating syllables (“puh”, “tuh-kuh”and “puh- Assessment tuh-kuh”) with atimed component. “Puh” “Tuh-Kuh” “Puh-Tuh-Kuh” Scale (OMAS) Model first what youwant from client: Diadochokinesis “Now I’m goingto askyouto saysome (DDK) funny sounds…The first one will go like this… Now sayas manyas youcanon one breath and I’ll let youknow when to stop.” Distortion or voicing Accuracy errors (b/p, d/t, g/k) What is being Missing, added, measured Flow repeated syllables when using the DDK? Uneven Rate flow Get a feel for variety of settings Hierarchy of Get a feel for variety of Feared listeners Situations (May have Have client rate to give difficult to easy concrete examples) Feelings and Attitudes VanRiper often told his students, “It’s not enoughto know the kind of disorder apersonhas, onemust know the kind of personwhohasthe disorder.” (J. Riley,2002) Tools to assess A-19 Scale for ChildrenWho Stutter (Guitar & feelings and attitudes Grims, 1977) in children: Communication AttitudeTest (CAT) (Brutten, 1985) Tools to assess feelings and attitudes in adults: Modified EricksonScale (S24) (Andrews &Cutler, 1974) Stutterers’ Self-rating of Reactions to SpeechSituations (Johnson et. al.,1952) Perceptions ofStuttering Inventory (Woolf,1967) Overall Assessment of the Speaker’s Experience of Stuttering (OASES) (Yaruss &Quesal, 2008) Scaleof 1-5 PWS rate the following: General Information YourReactions toStuttering Communication in Daily Situations Quality of Life Why the CELF-3/4 Subtests? Some children ❖Formulated Sentences who will have a Can be analysed for language concomitant content/use speech or Somewhat structured fluency language sample disorder. ❖Recalling Sentences Short term memory Additional fluency evaluation as client can not change the words (avoidances) Articulation GFTA-2 or Phonetic Inventory What have we learned? The questions we need to ask ourselves are (Zebrowski, 2002): Is the child stuttering or at risk for stuttering? Will the child experience Children: recovery? Describe and measure fluency/disfluency Determine child’s beliefs re talking in interview with the parents. What isthe nature of the stuttering? Is therapy warranted? What should the focus be? Adults: Determine the history Determine motivation Describe and measure speech Need to determine level of behaviour Determine the attitudes and beliefs. 2/3 plan + 1/3 practice/therapy Risk factors andnegative indicators. General questions? Is there aproblem and what is the problem? Who referred / or for whom isitaproblem? What are the expectations ofthe individual? Anyprevious help or other professionalhelp? What isthe impact ofthe problem? Does the client haveadisfluency problem? What iscausingthe problem? What are the areas of the deficit? What are the regularities and/or irregularities in the Questions client’s/ language performance? for the What canbe recommended for this client? Is intervention necessary? therapist: What isthe best approach? How will intervention be structured? What must the client learn? Is other professional help indicated? Sources consulted: ASHA, Ursula Zsilavecz (UP), DrAnniah Mupawose (WITS) That iswhat subtype or developmental phase? Classification Get to knowthe client. Identifyclient’s needs. of the Drawup anindividualized program. problem: Makeappropriate referrals. Involve members ofthe team. 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 and pragmatics) Linguistic stressors (words, sentences and situations) STARKWEATHER 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 STUTTERING Presented by: INTERVENTION 2 Dr Shabnam Abdoola THERAPY AIMS: SCHOOL-AGE CHILDREN Help child improve fluency as much as possible Help child develop healthy attitudes toward speaking, stuttering, and speech therapy Help parents/teacher develop supportive and accepting environment It’s important to recognize that progress is not measured only in terms of frequency or type of stuttered moments Ultimate goal is control over the stuttered moments SCHOOL AGE CWS An integrated approach Fluency Shaping Stuttering Modification Feelings/Emotions Teasing/Bullying AN INTEGRATED APPROACH (GUITAR, 2006) Stuttering Modification Fluency Shaping Modifying Stuttering Controlled Fluency Reducing Fear Cognitive Reframing Four Phases: Techniques: 1. Identification ▪ Rate Control 2. Desensitization ▪ Breathing (pausing and phrasing) 3. Modification ▪ Easy Onset 4. Stabilization/Generalisation/ ▪ Light Contact Maintenance ▪ Continuous Phonation, linking 4 FLUENCY SHAPING Management of surface features ▪ Aim to totally eliminate all stuttering events ▪ Little or no focus on attitudes ▪ Distinguish fluency from stuttering ▪ Desensitize , Establish fluency, Transfer & Maintain 1. Fluency first established in clinical setting 2. Reinforced with structured therapy 3. Gradually modified to normal sounding 4. New fluency generalized across tasks 5. Generalized outside clinical setting FLUENCY SHAPING CONTINUED… Therapy techniques: ▪ slow, rate controlled speech ▪ prolonged speech ▪ easy voice onset ▪ light articulatory contact ▪ as close to natural sound speech as possible Modifying moments of stuttering: ▪ Reduction and management of fear and avoidance ▪ Motivation - very aware thus discuss and plan aims together. ▪ Exploration, identification & learn control of stuttering pattern. ▪ Desensitization and working on attitudes and emotions. STUTTERING ▪ Incorporate the environment (parents, teachers, caregivers). MODIFICATION Modify the stuttering pattern with control techniques: ▪ pullouts, cancellations ▪ intentional, open, smooth and relaxed stuttering ▪ “acceptable” stuttering ▪ “pseudostuttering” (desensitizes, advertises) ▪ speaker learns to exert control over stuttering ▪ Decreasing the shame and fear ▪ Talk about stuttering STUTTERING ▪ Think about stuttering MODIFICATION: ▪ Express feelings about stuttering FEELINGS AND ▪ Learn about stuttering ATTITUDES ▪ Teach others about stuttering ▪ Own stuttering ▪ Accept stuttering (Yaruss, 2003) ▪ “Things I do when I stutter”: STUTTERING Repetitions, sound blocks MODIFICATION ▪ “Things I do because I stutter”: avoidances, anxieties, fears 1. “IDENTIFICATION” ▪ First step in self-management STUTTERING MODIFICATION 2. “DESENSITIZATION” ▪ Behaviours: Watch in the mirror, describe in detail, have SLP model ▪ Word avoidances: Say words, have competition for most use during session ▪ Situation avoidances: Talk about them, worst case scenario, act out, experience Learn easier way of “acceptable” stuttering: ▪ Cancellation: Stutter-Pause-Control STUTTERING (bounce) MODIFICATION ▪ Pullouts: Stutter-Catch-Use technique 3. “MODIFICATION” (easy onset, light contact) ▪ Preparatory Sets: Prepare ahead-use techniques ▪ Newly learned modification skills are practiced under more stressful conditions: STUTTERING 1. telephone calls MODIFICATION 2. public speaking 4. “STABILIZATION” 3. social introductions ▪ Techniques over learned to withstand increased pressure Children who stutter may exhibit the following: ▪ Fear of being teased ▪ Fear of reading aloud ▪ Fear of oral presentations ▪ (Ross & Deverell, 2004) May pretend the following: ▪ Disorganisation ▪ Illness ▪ Lack of knowledge ▪ Indifference IN THE CLASSROOM (Hartman, 1994) 1.Maintain eye contact 2.Pause (about 2-3 ENCOURAGE seconds) before responding to child’s TEACHERS TO statements / questions ALWAYS… 3.Rephrase child’s remarks to reaffirm the message has been delivered TEACHERS SHOULD BE ENCOURAGED TO ROUTINELY: 1.Reduce length and complexity of your sentences when child is stuttering 2.Speak at normal to slow normal rate Resist the urge to speak fast or rush your speech Teachers should never: 1. Finish a child’s sentence or fill in a word. 2. Tell a child to “slow down,” “Take a breath,” or “Relax.” (National Stuttering Association, 2006) HOW DO WE HANDLE TEASING & BULLYING Talk ▪ Acknowledge it before addressing it about it ▪ Learn about it – what, how we feel & why ▪ Establish a classroom environment that supports all children ▪ Handle with matter-of-fact positive but zero tolerance attitude ▪ May need to discuss teasing discreetly with child who stutters and parents ▪ Brainstorm about ways to react ▪ Teachers and parents to help address this ▪ Role play Stuttering is the result of multiple co-existing and interacting physiological, psychological and environmental factors. The end goal of therapy is feeling fluency control. Structuring PERSONALIZED Targeting FLUENCY Adjusting PROGRAMME – Regulating COOPER (1985): Multidimensional & Multidisciplinary team. HEALEY’S (1999) Characteristics: POINT OF VIEW ON ▪ Must be fun and motivating. THE CALMS ▪ Must endorse a holistic approach. MODEL: ▪ Nothing succeeds like success. C COGNITIVE ▪ Must work on hierarchy. A AFFECTIVE ▪ “No cookbook approach”. L LINGUISTIC ▪ Eclectic and suited to each individual. M MOTOR ▪ Linguistically and culturally diverse. S SOCIAL TRANSFER AND MAINTENANCE Role play Discourse Telephone Competition/disruption Home programmes Bring a friend Teach self monitoring and self correction – transfer and maintenance “Worry Ladder”, Chmela and Reardon (1997) Teachers and parents EMOTIONS/ATTITUDES Change parents: ❖Teach to: Listen actively Reflect back Discover the emotion Validate the feeling ❖Realistic expectations and discipline. ❖Don’t expect perfect! THE CHILD Find out about the child “Personal interview” Stewart and Turnbull (1995) What is true for you – I wish I could talk like other kids (t/f) Some people are hard to talk to I like to talk I gotten teased about my stuttering. Analysis: o Right hand - what you like about yourself o Left hand - what you do not like about yourself What pops into your mind? Most of all I want ………….. My family …………………… At school……………………. I get mad when…………….. Write a word picture about yourself. Count me out: Introducing myself to other persons Talking to friends Asking for a video Reading aloud COGNITIVE ACTIVITIES Self rating scales Reframing beliefs Being open about stuttering – the whole family is involved Be a problem solver – my problem is – how can I…..? How do I see my stuttering How do I want my parents/teachers to react or handle the situation I am my own manager Encourage and praise – see Chmela and Reardon. Conture (2001) Cooper (1985) Guitar (2006, 2013) EASY TALKER (Guitar) Shapiro, 2010 EASY DOES IT 2 Kully and Langevin (1999) Intensive Treatment for Stuttering Adolescents. In Stuttering and Related Disorders of Fluency, Chapter 8, p139. Manning (2010) Shapiro (1999) Zebrowski (2000) “Success comes in cans. I can do this. If you think you can, you can. And if you think you can’t you’re right.” IN SUMMARY… A comprehensive treatment approach for school-age children Many clinicians use an integration of and adolescents includes multiple approaches in order to achieve goals based on individual needs, optimal outcomes focused on increasing fluency as well as other goals It is the responsibility of the clinician to consider the entire impact of Please see the handout on disfluency on the child’s “Treatment Approaches: School-Age communication and life as a whole Children And Adolescents Who in order to develop a Stutter” comprehensive plan of treatment. STUTTERING Presented by: INTERVENTION 3 Dr Shabnam Abdoola Affective (feelings and emotions) Anxiety, fear, avoidance and anticipation Behavior (core ADDRESSING behaviors) THE ABC’S OF Fluency Shaping Stuttering Modification (SSMP) STUTTERING Cognition (Attitudes) Reframing and reorganizing our thoughts and ideas about stuttering and ourselves 2 Impairment Fluency Shaping (FS) Approach - Shaping is about relaxation and motor skills, emphasizing what happens during fluent speech. However, working on modifications and motor skills alone is not enough. Therapy must also address attitudes and emotions, which we’ll discuss last. Stuttering Modification (SM) Approach - is about stuttering more fluently - modifying, changing, or APPROACHES smoothing out a stuttering moment. Students need to look at and work with the moment of stuttering. This may involve negative practice and stuttering on TO THERAPY purpose. The integrated approach Both fluency and stuttering should be honored in therapy. Since most people who stutter will always stutter to some degree, recognizing and targeting fluency alone can be dangerous to self-esteem. Besides, no stuttering therapy approach is 100% successful. All people who stutter should be helped to feel that it’s OK to stutter. 3 SYNERGISTIC STUTTERING THERAPY: A HOLISTIC APPROACH (Bloom and Cooperman) – provides a good summary The synergistic model: ⬥Neuro-physiological demands – reduced speech motor control and language formulation ⬥Physical factors – genetics and possible brain activity ⬥Psycholinguistics – the interplay between language and disfluency ⬥Behaviour - learned ⬥Attitude and environment –self esteem, confidence = how readily they will express ideas and opinions ⬥Locus of control – inner self or external events. The therapist and client should strive to – identify needs especially the debilitating negative emotions Discuss the normal communication process. Motivate the client – show videos or play tapes. INTERVENTION/ MANAGEMENT Refer to websites. OF THE ADULT Keep note book or journal. Audio or video tape sessions regularly. THE PROCESS Combine modification with fluency shaping - an integrated approach (spontaneous controlled speech) Desensitise Vary and obtain control Use control techniques and modify the stuttering Cancellations Proprioception Transfer to outside situations as soon as possible Encourage to attend groups Must monitor self RELAPSES Discuss what these are Prepare Revisit fears Fake stutters Positive thoughts Discuss and use fears Help set realistic goals Therapy can be quite time consuming The therapist assists and supports the client in reality testing Conture (2001, p 293) “we are guides not magicians” Person- and Family-Centered Practice Consistent with a person- and family-centered approach to stuttering treatment, the SLP educates the individual who stutters and their family members about stuttering and communication and facilitates conversations between the individual and their family about the experience of stuttering, the individual’s communication expectations, their life goals, and how to holistically support communication CHANGING COGNITION “Our chief want in life is someone who will make us do what we can.” Emerson Motivational interviewing Techniques: ▪ Open-ended questions ▪ Feedback ▪ Reflective listening ▪ Affirmations ▪ Summarizing Basic principles to encourage positive self talk and emotions and attitudes ⬥create a safe house ⬥client and therapist establish objectives for therapy ⬥create opportunities for success ⬥heighten awareness of fluency ⬥encourage the use of techniques ⬥working on maintenance and carryover ⬥prepare for the outside world ⬥establish good communication skills (pragmatics?) ⬥in order to get a better understanding – therapist to “walk in PWS shoes” Clients need to know ⬥Stuttering is a point of view ⬥DISability or disABILITY? ⬥Have the paradigm of a stuttering – fluency can include stutter ⬥Focus on positive goals and behaviours WHAT MATTERS MOST IS HOW YOU SEE YOURSELF! Clients view stuttering as a barrier to life ⬥“Disorder of the spirit” ⬥Need to access new beliefs – find role models ⬥Against all odds ⬥Take control ⬥Stuttering creates more pain than the pain of therapy. ⬥Build a positive self image – feeling of competence ⬥Find other areas to achieve ⬥Ability to influence others Use the talents you possess. The woods would be very silent if no birds sang there except those who sang best. Henry van Dyke The individual who has low esteem reacts by “I can’t” Thus: ⬥we demean our own talents, ⬥feel others don’t value us, ⬥we are powerless and lack self confidence. In turn easily manipulated by others, becomes sensitive, easily frustrated and tends to blame others for own weaknesses. If the therapist (environment) can build up high self esteem and praise the action: the client will act independently in making choices, assume responsibility act promptly and confidently be proud of accomplishments approach new challenges with enthusiasm exhibit emotions and feelings without self consciousness tolerate frustration feel special to those they love, play with or work with feel capable of influencing others. Extent of impact Social aspects Vocational aspects Clinical process Themes of successful stuttering management RET (rational emotional therapy) or CBT (cognitive behaviour therapy). The client has a long history of loss of control – “fight or flight” Indoctrination of illogical, inconsistent unworkable values Attitudes from false interpretation of events A. Activating event E. Changing B. Person’s belief system irrational belief C. Emotional D. Irrational consequence belief A something unpleasant happens B we interpret the event C consequences – we get upset or “awfulize” the situation D you question and change your thinking about the event E irrational to rational TEACH POSITIVE AND NEW VALUES: Maslow quotes: “no psychological health is possible unless the essential care of the person is fundamentally accepted, loved and respected by others and himself.” Negative irrational self talk can also been seen as Bill Murphy (1997): The “stinkin thikin” which involves three levels of thinking/perception the descriptive level – I get the message making inference – I decide that the word are demeaning my cognition evaluates the comment and appraises. These beliefs can determine emotional health and in turn negative disturbed emotions so I start “awfulizing” “I’m bugged because I’m plugged” – a magical belief that becomes overly exaggerated (Emerick) Leads to F - false E - evidence A - appears R - real The aim is to control the products of primal processing (fear, self criticisms) → to learn more adaptive flexible behaviours. For example: You stutter→ the negative reinforcement → “I will never speak right” (this is an over generalization). A positive thought – “this was a momentary lapse on a good day what could I have done” or “I am making progress”. THE THERAPIST AND CLIENT SHOULD STRIVE TO – IDENTIFY NEEDS ESPECIALLY THE DEBILITATING NEGATIVE EMOTIONS. Break out New experience and positive Fear and anticipation Prediction and negative feedback Incident Stronger Getting Stuck Bogged Down Environmental feedback: Self fulfilling prophecy School – teachers Comparing with Work previsions – repeated Home – parents, history siblings A few simple tips: ▪ teach the client that he is not a bad person if he does not always achieve his goal ▪ perfection is not required to be a worthwhile person ▪ popularity and achievement are not necessarily related to being worthwhile nor is 100% ▪ teach the client that minor setbacks are not catastrophes. CBT steps: (See Emerick (1988), Bloom and Cooperman (1999) and Manning (2001) for an easy to follow programme). Information giving – a map of the therapy process and involve client to help set up objectives. Cognitive appraisal - the client summarizes in his own words the contents of the therapy programme and makes sure it suits his needs. Identify the self defeating thought patterns (identify the repertoire of negative thoughts). Thought reversal – reduce and eliminate the negative thoughts, “thought stopping”. Subject these “old” hypotheses to reality testing – the therapist helps by modelling, or role play. Substitute with self-enhancing language Coping skills Gerald Johnson (1985) 10 Commandments for long- term maintenance” uses the following 10 helpful steps: engage in an objective self analysis develop rational thinking work for philosophic change achieve spontaneity keep yourself healthy do not fall victim to the guru complex do not procrastinate achieve independence your choice – is positive self talk (Mental Health week task) MAP – monitor action and performance → your way to fluency. (similarly to sport = changing motor patterns) STARTING SELF-HELP GROUPS Rationale: The value of groups: ▪ support ▪ offer information and advice ▪ service delivery ▪ alternative therapy programme ▪ group activities FRAMEWORK OF A PROGRAMME Needs assessment Composition of the group Eliciting communication Choice of activities and topics Assessment Procedures Pre-Evaluation Procedures Pre-evaluation procedures are geared toward assessing basic risk factors associated with stuttering. These procedures are also used for multidisciplinary collaboration and determining previous experiences with speech treatment. Assessment Component Assessment Objective References General development, medical history Other speech/language concerns Time since onset, family history of stuttering (persistent or recovered) Ambrose, Yairi, & Cox Previous treatment (1997) Case history experiences Information regarding Yaruss, LaSalle, &Conture family/personal/cultural (1998) perception of fluency (e.g., perceptions of causes, what helps, etc.) Cultural viewpoints on stuttering/cluttering Concern of parent/child Observations of stuttering/cluttering variability and impact Consultation with other of stuttering/cluttering professionals (physicians, across various teachers, etc.) situations Previous evaluations, educational records Intra-Service Procedures Intra-service procedures focus on direct assessment of the affective, behavioral, and cognitive domains of stuttering across multiple communication contexts. Assessment takes into consideration the needs of the client and family, in addition to the communication environment of the person who stutters/clutters. Assessment Component Assessment Objective References Onset/development of Yairi, Ambrose, Paden, stuttering/cluttering &Throneburg (1996) Parent/Child Interview Perception of communication Yaruss et al. (1998) abilities Previous treatment, current outcomes, etc. Measurements of speech Brundage, Bothe, fluency (frequency type and Lengeling, & Evans (2006) duration of disfluencies, presence of secondary Logan, Byrd, Mazzocchi, behaviors) &Gillam (2011) Assessment of Speech Pellowski&Conture (2002) Fluency samples from out of clinic settings Riley (2009) samples that increase Yairi et al. (1996) in complexity from single word to Yaruss (1997, 1998) narrative samples Yaruss et al. (1998) Blood, Blood, Maloney, Meyer, & Qualls (2007) Blood, Boyle, Blood, &Nalesnik (2010) Boey et al. (2009) Assessment of negative (or Assessment of the Reactions positive) affective, behavioral, Davis, Howell, & Cooke of the Speaker and Listeners and cognitive reactions to (2002) stuttering/cluttering Mulcahy, Hennessey, Beilby, & Byrnes (2008) Vanryckeghem, Brutten, & Hernandez (2005) Yaruss&Quesal (2010) Beilby, Byrnes, &Yaruss (2012) Assessment of functional communication abilities (e.g., Chun, Mendes, Yaruss, difficulty experienced when &Quesal (2010) Assessment of Impact of communicating in daily Yaruss (2010) Stuttering situations); assessment of impact of stuttering on quality Yaruss, Coleman, &Quesal of life and satisfaction with (2012) communication Yaruss&Quesal (2006, 2010) Assessment of speech sound Blood, Ridenour, Qualls, & production, Hammer (2002) Assessment of Other receptive/expressive Paden &Yairi (1996) Communication Dimensions language development (including conversation, story Yairi et al. (1996) telling, and retelling), voice, hearing, oral-motor Yaruss et al. (1998) function/structure Documentation (test results) Recommendations/Treatment Treatment plan Preparation development, including long-/short-term goals Written report Post-Service Procedures Post-service procedures focus on providing information on stuttering to the client, family, and others in the child's communication environment. Consultation with/referral to other professionals as needed Provision of ongoing education about stuttering/cluttering to family, school personnel, and other significant people in the child's environment References Ambrose, N., Yairi, E., & Cox, N. (1997). The genetic basis of persistence and recovery in stuttering. Journal of Speech, Language, and Hearing Research, 40, 567-580. Beilby, J. M., Byrnes, M. L., &Yaruss, J. S. (2012). The impact of a stuttering disorder on Western Australian children and adolescents. Perspectives on Fluency and Fluency Disorders, 22, 51-62. Blood, G. W., Blood, I. M., Maloney, K., Meyer, C., & Qualls, C. D. (2007). Anxiety levels in adolescents who stutter. Journal of Communication Disorders, 40, 452-469. Blood, G. W., Boyle, M. P., Blood, I. M., &Nalesnik G. R. (2010). Bullying in children who stutter: Speech-language pathologists' perceptions and intervention strategies. Journal of Fluency Disorders, 35, 92-109. Blood, G. W., Ridenour, V. J., Qualls, C. D., & Hammer, C. S. (2002). Co-occurring disorders in children who stutter. Journal of Communication Disorders, 36, 427-448. Boey, R. A., Van de Heyning, P. H., Wuyts, F. L., Heylen, L., Stoop, R., & De Bodt, M. S. (2009). Awareness and reactions of young stuttering children aged 2-7 years old towards their speech disfluency. Journal of Communication Disorders, 42, 334-346. Brundage, S. B., Bothe, A. K., Lengeling, A. N., & Evans, J. J. (2006). Comparing judgments of stuttering made by students, clinicians, and highly experienced judges. Journal of Fluency Disorders, 31, 271-283. Chun, R. Y. S., Mendes, C. D., Yaruss, J. S., &Quesal, R. W. (2010). The impact of stuttering on quality of life of children and adolescents. Pró-FonoRevista de AtualizaçãoCientífica, 22(4), 567-570. Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic relationships between children who stutter and their non-stuttering classmates. Journal of Child Psychology and Psychiatry, 43, 939-947. Logan, K. J., Byrd, C. T., Mazzocchi, E. M., &Gillam, R. B. (2011). Speaking rate characteristics of elementary-school-aged children who do and do not stutter. Journal of Communication Disorders, 44(1), 130-147. Mulcahy, K., Hennessey, N., Beilby, J., Byrnes, M. (2008). Social anxiety and the severity and typography of stuttering in adolescents. Journal of Fluency Disorders, 33, 306-319. Paden, E., &Yairi, E. (1996). Phonological characteristics of children whose stuttering persisted or recovered. Journal of Speech and Hearing Research, 39, 981-990. Pellowski, M. W., &Conture, E. G. (2002). Characteristics of speech disfluencies and stuttering behaviors in 3- and 4-year-old children. Journal of Speech, Language, and Hearing Research, 45, 20-34. Riley, G. (2009). Stuttering Severity Instrument for Children and Adults. Austin, TX: PRO-ED. Vanryckeghem, M., Brutten, G. J., & Hernandez, L. M. (2005). A comparative investigation of the speech-associated attitude of preschool and kindergarten children who do and do not stutter. Journal of Fluency Disorders, 30(4), 307-318. Yairi, E., Ambrose, N., Paden, E., &Throneburg, R. (1996). Predictive factors of persistence and recovery: Pathways of childhood stuttering. Journal of Communication Disorders, 29(1), 51-77. Yaruss, J.S. (1997). Clinical measurement of stuttering behaviors. Contemporary Issues in Communication Science and Disorders, 24, 33-44. Yaruss, J. S. (1998). Real-time analysis of speech fluency procedures and reliability training. American Journal of Speech-Language Pathology, 7(2), 25-37. Yaruss, J. S. (2010). Assessing quality of life in stuttering treatment outcomes research. Journal of Fluency Disorders (Special issue: The Influence of Fluency Disorders on Quality of Life), 35, 190-202. Yaruss, J. S., Coleman, C. E., &Quesal, R. W. (2012). Stuttering in school-age children: A comprehensive approach to treatment [Letter to the editor]. Language, Speech, and Hearing Services in Schools, 43, 536-548. Yaruss, J. S., LaSalle, L. R., &Conture, E. G. (1998). Evaluating stuttering in young children: Diagnostic data. American Journal of Speech-Language Pathology, 7(4), 62- 76. Yaruss, J. S., &Quesal, R. W. (2006). Overall Assessment of the Speaker's Experience of Stuttering (OASES): Documenting multiple outcomes in stuttering treatment. Journal of Fluency Disorders, 31, 90-115. Yaruss, J. S., &Quesal, R. W. (2010). Overall Assessment of the Speaker's Experience of Stuttering. Bloomington, MN: Pearson Assessments. CLUTTERING & OTHER DISORDERS OF FLUENCY Dr Shabnam Abdoola Please study chapter 15 of the Guitar textbook CLUTTERING/TACHYPHEMIA: Definitions: “the verbal manifestation of a central language imbalance in the area of a verbal utterance” (Deso Weiss, 1964). “cluttering is a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular or both for the speaker.” (St Louis, et el.,2007) “a disturbance of fluency involving an abnormally rapid rate and erratic rhythm of speech that impedes intelligibility. Faulty phrasing patterns are usually present so that there are bursts of speech consisting of groups of words that they are not related to the grammatical structure of the sentence. The affected person is usually unaware of any communication impairment.” (APA 1987) CLUTTERING: NATURE Sudden bursts of rapid speech that is difficult to understand and somewhat disfluent. May have excess of normal disfluencies or co-occur with developmental stuttering. With effort and attention, speaker may be able to speak without cluttering. Cluttering often accompanied by disorganized language (mazing) as well as learning and neuropsychological problems. Recent research suggest cluttering may be associated with greater activity in premotor cortex bilaterally and presupplementary motor area, caudate nucleus, and putamen of basal ganglia. Reduced activity in lateral anterior cerebellum. “A CLUSTER OF SYMPTOMS” The syndrome of cluttering is often confused with stuttering, Tourette’s syndrome, ADHD – has a genetic predisposition and neurological imbalance and includes symptoms of language learning problems. HISTORICALLY: – Not recognized as a communication problem. – No universally accepted definition. – Myers and St Louis: “Cluttering a Clinical Perspective” – Myers and St Louis: “Managing cluttering and related fluency disorders” – Conference in Bulgaria, 2007 founded the ICA Confusion with disfluencies such as in: Autism Syndromes: Down’s Syndrome, Tourette Syndrome OT H E R D I S O RDE RS AN D THE C L UT T E RING ADD and ADHD S YN D ROM E Stuttering LLD ONSET AND DEVELOPMENT: Begins in late childhood - *deficits in speech rate seem to develop later later than stuttering *story telling and writing Onset gradual – tends to plateaux MAIN ASPECTS Problems with: – Initiation and sequencing of action – Inhibition of impulses – Attention, monitoring & correction behaviour – Selection of linguistic items – Monitoring of speech errors – Execution and timing of sequential behaviour MAIN SYMPTOMS: CENTRAL LANGUAGE IMBALANCE – Delayed speech and language acquisition. – Articulation errors. – Reading and writing problems. – Cluttering (disfluencies - repetitions). The most commonly agreed upon definition of cluttering represents basic criteria which all experts agree are found in all people who clutter to some degree. Under this definition, mandatory for a diagnosis of cluttering is that the speaker sounds fast to the listener at least some of the time. The concept is that even though the speaker may not be speaking faster than average, they are speaking at a rate that is too fast for their system to handle, resulting in communication breakdown. Under this definition, communication breakdown would appear in at least one of the following ways for a diagnosis of cluttering: Excessive moments of over-coarticulation, meaning that sounds and syllables are blended together “too much” so that it can sound like all sounds are syllables are not present (e.g., speaker says “ferchly” for “fortunately”). Excessive use of “normal disfluencies,” such as interjections (e.g. um, uh, er) and revisions (e.g., I would like to go—I was thinking about taking a drive). Pauses in places not expected grammatically, often making the speech sound “jerky” or “spurty" Disorder of musicality and rhythm. Disorderly and restlessness. MAIN SYMPTOMS CONT: Increased levels of inattentiveness Clarity of speech, thought processes and formulation. Other symptoms: (Silverman p 214) - Repetitions (words and part of words). - Excessive speed (tachylalia). - Drawling and interjections. - Monotone. - Articulation and motor abilities. - Respiration – not economic. - No tension or awareness. - Unorganized thinking. Other symptoms cont: - Reading disorders. - Writing disorders. - Grammatical errors. - Restless, impulsive. - Disorganized personality – sometimes chaotic. - Underachievers. The clinical picture of a typical cluttering problem would be enhanced if the person in question had any of the following: Little or no apparent physical struggle in speaking. Confusing, disorganized language or conversational skills. Limited awareness of his or her fluency and rate problems. Temporary improvement when asked to “slow down” or “pay attention” to speech (or when being recorded). Several blood relatives who stutter or clutter. Social or vocational problems resulting from cluttering symptoms. Learning disability not related to reduced intelligence. Sloppy handwriting. Distractibility, hyperactivity, or a limited attention span. Auditory perceptual difficulties Parents Teacher FOR WHOM IS IT A PROBLEM? Work area – work placement Usually affects others. DIFFERENTIAL DIAGNOSIS BETWEEN STUTTERING AND CLUTTERING: Symptoms Cluttering Stuttering Awareness Absent/ present Present Speaking under stress Better Worse Speaking a foreign language Better Better/Worse Calling attention to speech Better Worse Speaking in relaxed situation Worse Better Speaking after interruption Better Worse Short answers Better Worse/Better Reading a well known text Worse Better Reading an unknown text Better Worse Handwriting Hasty, repetitious Attitude toward own Careless Fearful speech Personality Outgoing Rather withdrawn Aptitude Underachiever Good – superior EEG Often diffused Usually normal dysrythmia Goal of therapy Directing attention to Diverting attention speech details to speech details COGNITION – Awareness: -listener perception -self-monitoring – Thought organization: -sequencing -categorization – Memory – Impulsivity LANGUAGE – Receptive: listening / directions; comprehension – Expressive: thought organization; poor sequencing of ideas; poor storytelling; language formulation; improper linguistic structure; word finding; improper pronouns; filler words and empty words; – Written: run on sentences; omissions and transposition of letters, syllables and words; sentence fragments Non verbal: poor eye contact, turn taking and poor processing of nonverbal signals. PRAGMATICS Conversations: poor topic maintenance; poor termination, verbose; lack of consideration of listener perspective. SPEECH – Disfluency – excessive repetition - part words and short words (no tension) – Verbal transposition – Interjections and interrupters Why the person has come What are the concerns IDENTIFICATION (WARD, 2011) Set mutual goals Give information of the fundamentals of the problem to client Video or audio analysis MONITORING AND SELF Identify why speech is AWARENESS difficult to understand Stress NB of self monitoring and explain the phases of how. Excessively fast speech Speech rhythm and intonation Over articulation (mumbling) MODIFICATION Language problems Narratives and sequencing of information Pragmatics DAF MAINTENANCE OF FLUENCY –Discuss relapse –Identify factors which may trigger relapse Full case history. Emphasis on academic and ASSESSMENT / scholastic performance. EVALUATION: Motivation and who referred & why? Speech – Oro-facial and DDK Articulation Assess Spoonerisms & difficult to produce words CLUTTERING: DIAGNOSIS AND EVALUATION For school students, a multidisciplinary approach is useful: SLP, teacher, special educator, psychologist, audiologist Case history and interview: Parents’ and teachers’ perceptions of problem How long cluttering as existed When and where it appears Background on student and family Reasons for seeking treatment now Other problems CLUTTERING: DIAGNOSIS AND EVALUATION (CONT.) Direct assessment of speech Videotape during a variety of speaking tasks Assess rate, especially during bursts of fast rate Separate counts of normal and stutter-line disfluency Ratio of syllables spoken in intended message to syllables spoken overall Percent intelligibility to unfamiliar listener Language assessment Assessment of cluttering characteristics (see Daly and Burnett-Stolnack, 1995) Assessment of coexisting disorders ASSESSMENT CONT. Language – receptive & expressive (form, content and pragmatics) Reading – familiar & unfamiliar; fluency word attack and type of errors Writing – creative writing & story grammar (sloppy writing) Spelling rules and sloppy errors Formulation Social ASSESSMENT ADHD / ADD CONT. Impulsivity Pragmatics CLUTTERING: TREATMENT Good candidates: ability to control cluttering on demand; motivation to improve Increase client’s awareness of rate Improve linguistic skills Facilitate fluency Increase client’s knowledge and awareness of cluttering ADDITIONAL IDEAS FOR TREATMENT Rather than ask client to slow down, use a device that will show clinician’s rate and ask client to match it. Record client using his best speech (e.g., on an iPad), and play it back to him; also have client visualize himself speaking clearly and slowly. Work on intelligibility and organization by beginning with short phrases and working up to longer and more complex utterances. Rate MANAGEMENT Motor Language Pragmatics MANAGEMENT CONT. MOTIVATION META AWARENESS – (SELF MONITORING, UNDERSTANDING, SELF PROPRIOCEPTIVE, “DELIBERATE MONITORING SKILLS & SELF SPEECH”, ANY FEEDBACK DEVICES) REGULATION SPEECH Speech and motor co-ordination : Rate, clarity, intonation and articulation Reduce disfluencies (DAF, reading through a ‘peephole’, counting backwards, economic breathing and pausing. Teach awareness and self monitoring – video and audiotape) Instruction to slow down – model and remind Prolonged speech – prolong the vowels, use continuous voicing, SPEECH SLT models CONT. Metronome – 90 beats per min., rhythmic tapping, finger tapping (also neurogenic) Pacing board LANGUAGE Language and language learning strategies. – Study methods – Auditory comprehension – Verbal expression – Written expression – Reading comprehension COGNITION AWARENESS THOUGHT REASONING PROBLEM ORGANIZATION SOLVING PRAGMATICS SUPPORT AND TRANSFER – Parents and family – Caregivers – Teachers – Employers – Significant others ROAD MAPS – R – rate – O – organization of language – A – articulation – D – disfluency – M – motivation – A – attention to detail – P – phonetic placement – S – self- monitoring OTHER FLUENCY DISORDERS Variety of problems that include disfluency as a characteristic – Cluttering – Neurogenic stuttering – Psychogenic stuttering – Tourette’s syndrome – Malingering Treatment Approaches: School-Age Children And Adolescents Who Stutter S. Abdoola 2019 Below is a list of approaches most commonly used with school-age children and adolescents who stutter. Approaches may vary for children and adolescents. Many clinicians use an integration of approaches in order to achieve optimal outcomes. All approaches should include a plan for generalization and maintenance of skills involved in activities of daily living. APPROACH/STRATEGY WHAT DOES IT ENTAIL? HOW DOES IT WORK? Increasing Speech Efficiency Increasing spontaneity in May initially exhibit more (Reducing Word Avoidance) communication surface-level stuttering Strategies For Reducing Desensitization: systematically Use of voluntary stuttering Negative Reactions (Personal desensitize themselves to their (sometimes called And Environmental Context) fears about speaking and "pseudostuttering," if the stuttering by facing those fears initiation of the activity involves in structured, supportive fake stuttering behaviors) environments Cognitive Restructuring: Identifying the assumptions designed to help speakers underlying their thoughts, they change the way they think can evaluate whether those about themselves and their thoughts are helpful (or valid) speaking situations and ultimately adopt different assumptions or thoughts. Self-Disclosure: involves communicating to others information that reveals one's identity as a person who stutters Support: valuable for improving Provide venues to practice
