Stuttering Intervention PDF

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

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