Practical Approaches to Treating Stuttering

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Practical Approaches to Treating Stuttering
South African Speech-Language Hearing
Association Suid Afrikaanse Vereniging Vir
Spraak-Taal-Gehoor October
27-29, 2003

• WHAT IS STUTTERING ALL ABOUT?
• The nature of stutteringwhat it means for therapy

A. Core Deficit
Brain Organization- for speech for temperament
Benefits of Right Hemisphere Dominance
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B. Other Factors That May Interact
In the child
In the environment
Others reactions
Family History
Gender
Family Communication Style
Expectations
Speech Language Skills
Life Events
Sensitivity
Reactions to Stuttering
Familys schedule
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C. Levels of Stuttering
Normal Disfluency
Borderline Stuttering
Beginning Stuttering
Intermediate Stuttering
Advanced Stuttering
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Small Group Activity
Develop an answer to a parents question What
causes stuttering?
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II. PRESCHOOL CHILDREN
Assessment
Case history form temperament questionnaire
Video or audiotape from home
Parent Interview
Parent-child interaction
Clinician-child interaction
SSI and other speech assessment
Exit interview
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Studying Family Interaction Patterns
Rates of speech
Rapid responses (no pauses)
Interruptions
Frequent open-ended questions
Frequent criticisms or corrections
Inconsistent listening
Advanced vocabulary or syntax
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Indirect Treatment
Listening time
Slow rate
Pauses
Positive comments
Comments instead of questions
Turn-taking
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DIRECT TREATMENT LIDCOMBE
General Principles Stage 1 Stage2
Severity Ratings by parent
SS by clinician
Stutters per minute by parent
Training of parent by clinician
Daily sessions - fluent praise only at first
Weekly clinic visits by parent
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Daily sessions - praise (51)
And.. after childs severity ratings are down
to 4s or 3s, start Requests for Corrections (1
per 5 to 10 praises)
When childs severity ratings show him or her to
be mostly 1s or 2s, taper off 1-on-1 sessions
with parent and begin to work in daily living
situations
Parent should chose varied situations for 15
minutes each day for praise and pickups.
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Parent keeps coming in weekly, doing severity
ratings, and doing daily unstructured sessions
until child is essentially fluent
Stage 2 Parent gradually fades treatment Activitie
s, but comes to clinic and increasingly Long
intervals once in 2 weeks, 4 weeks, 8 weeks, 16
weeks, etc.
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Clinician continues to measure SS and parent
keeps Severity Ratings.
If SS still mostly 1s and SRs are mostly 1s,
keep this schedule of fading.
However, if SS in clinic or SRs are elevated,
child resumes regular weekly visits.
Return to fading contact when SS SRs go down
to low levels.
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Small Group Activity
What level is the child on this Video
clip? Beginning escape behaviors
only Intermediate escape avoidance Advanced
severe self-concept as stutterer with shame
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School Children and Adolescents
I. Stuttering Modification Fluency Shaping

• What is Stuttering Modification?

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Here are the two major parts
1. Decrease fear
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2. Learn easy stuttering
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B. What is Fluency Shaping?
1. Learn to be fluent in easy context
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2. Maintain fluency in more and more difficult
(real life) contexts.
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II. Elements of Stuttering Modifiction
A. Key Concepts
1. Reduce avoidance
2. Make therapy fun
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3. Reduce shame
4. Stimulate approach, exploration, and
acceptance
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B. Steps in Therapy
1. Exploring stuttering
(a) Three principles for working with fear

• fearless clinician

• explore/approach feared object

• maximize time in contact with feared object

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(b) Explore childs beliefs and feelings about
stuttering
(c) Explore what child feels hes doing when in
a moment of stuttering ...increase positive
awareness
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2. Modifying Stuttering in Therapy Room

• Identify and practice the first sounds
• in words.

i. nonstuttered words
ii. stuttered words
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(b) Learn how to hold onto sounds you are
stuttering on, slow rate and reduce
tension, keep eye contact ... all
in voluntary stutters.
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(c) Learning how to do this with real stutters.

• cancellations

• pull-outs

• preparatory sets

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(d) Explore feelings about listener
reactions when working on the moment of stuttering
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3. Transferring
(a) Mastery in treatment situation
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(b) Begin with easy outside situation
(c) Clinician always models first
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(d) Always reward ANY progress
(e) After doing a transfer activity, discuss it.
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(f) Attempt gradually harder and harder situations
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4. Maintaining

• Help child develop a seeking out
• attitude.

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(b) Keep in contact with child as friend as
mentor
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c. fade formal therapy gradually
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III. Elements of Fluency Shaping
A. Key Concepts

• Use with younger children
• - those with little avoidance

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• Go from success to success

Use natural fluency in linguistic
hierarchy words ? phrases ? sentences ?
conversation
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• If natural fluency doesnt work,
• use fluency skills (see later slide)

• Examples of Fluency Shaping

Ryans GILCU
Programmed Therapy for Stuttering in Children and
Adults new and used copies available from
Amazon.com
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Costellos ELU,
Current behvioral treatments for children. In
Prins Ingham (Eds.) Treatment of stuttering in
Early Childhood Methods and Issues College-Hill
Press (1983)
Lidcombe
Onslow, Packman, Harrison (2003) The Lidcombe
Program of Early Stuttering Intervention Pro-Ed.
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B. Steps in Therapy
1. Establish Fluency
(a) Begin with lowest level needed to elicit
total fluency (e.g., single words)
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(b) After several sessions of success at lowest
level needed move to next level (e.g., short
phrases)
I love Bosco
I love Bosco
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(c) Keep going until you reach conversation
(d) If child starts stuttering at some
level, teach Fluency Skills (next slide) and
shape toward normal speech
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2. Teaching Fluency Skills
(a) Easy onsets
(b) Light contacts
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(c) Slow rate
(d) Proprioception
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3. Transferring Fluency
(a) Develop list of easy-to-hard situations
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(b) If child is willing, bring in parents
and involve them in home program
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(c) If home program help parents use a
Severity Rating scale to be shared with you
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(d) use appropriate rewards for each step
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(e) If child has difficulty maintaining fluency,
use stuttering modification to teach child to
deal with remaining stuttering
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4. Maintaining Fluency

• Once child is ok, fade sessions gradually

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(b) Keep in continued contact
(c) use child as mentor to younger children
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Adults Advanced Stuttering
I. Stuttering Modification
A. Identification An approach behavior
1. What are you doing when you stutter?
2. What are you not doing?
3. Areas to explore Core tensing, shutting
airway, speeding up Coping escape behaviors,
avoidances
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B. Desensitization reducing emotion
1. This decreases tensing and speeding
up (which are fight or flight responses)
2. Coping with fear
Model of clinician unafraid of stuttering
Exploring the stutter as its happening
Staying in the stutter
Reducing the impact of listener reactions via
voluntary stuttering
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C. Modification
1. Grooving the target
Practice slowing and proprioception and changes
in identified stuttering behaviors on non-feared
words.
2. Learning to modify stutters
Before (Preparatory Set)
During (Pull-out)
After (Cancellation)
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3. Using the modifications
With the clinician words, phrases, sentences,
structured conversations, unstructured
conversations
With familiar people
With strangers
On the phone to clinician
On the phone to stores
On the phone to others
Self-recording of various situations.
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II. Fluency Shaping
A. Key qualities
1. Slow
2. Easy onset of voice
3. Light articulatory contacts
4. Proprioception
5. Continuous Airflow
6. Normal Prosody
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B. Hierarchies
words sentences reading conversation
40 Syllables per minute (SPM) to 180 SPM in 5 or
10 SPM steps
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C. Generalization
1. Clinician and Client construct hierarchy
2. Client audio records samples of each step of
hierarchy clinician client analyze the tapes.
3. Mutually agreed upon criteria for success.
4. Client continues on hierarchy until she
reaches final stage successfully.
5. For some clients, success may
include stuttering modification techniques.
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D. Maintenance
1. Maintenance is an active process
2. Continue to measure fluency (criteria may be
adjusted to each client)
3. Client stays in contact at less and
less frequent intervals, as long as
fluency target is maintained.
4. If criteria are not met, client returns to
therapy until fluency is regained.
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The End