Overview of approaches to stuttering therapy

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Overview of approaches to stuttering therapy
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Research suggests that multiple therapy
approaches can be effective there is no one
solution for everyoneBasic Approaches to
Fluency Therapy
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Goals for Direct Therapy(see also Guidelines for
Practice in Stuttering Treatment , ASHA, 1995
Preferred practice guidelines for the profession
of speech-language pathology)

• Enhancing Fluency
• Modifying the Stuttering Pattern (Reduce
  Struggle)
• Changing Attitudes About Self and Stuttering
• Reducing Fear of Speaking
• Improving Skill as a Communicator
• Taking Responsibility for Change and Growth

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Individualizing the treatment plan strategies to
meet the goals
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Evidence-based practice

• Regardless of approach that is taken, the
  importance of evidence-based practice (EBP)
  should be kept in mind.
• Some assumptions (Sackett, et al., 1996)
• Clinical skills grow with the application of
  cutting edge data, not just personal experience
• Expert clinicians should seek new information to
  improve their effectiveness
• Clinicians should be data seekers, data
  integrators and application evaluators.

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Steps in evidence-based practice

• For a given clinical problem
• 1. Pose a clear and concrete question
• 2. Search the literature
• How does one do this appropriately and
  efficiently?
• 3. Critically evaluate the information you
  obtain
• Is it reliable,
• Valid, and
• Relevant to your question and case?
• 4. Integrate the information into your specific
  case, taking your clients specific concerns into
  account
• 5. Evaluate the result of your work.

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Approach 1 Fluency shaping or fluency
modification

• Historical roots
• Goldiamond (1965) use of Delayed Auditory
  Feedback (DAF)
• Brady (1968) timed speech using metronome
• Webster (1974) Precision Fluency Shaping use of
• gentle vocal onsets, prolonged speech, light
  articulatory contacts
• molecular approach, starting with phonemes,
  moving through longer units
• overlearning of targets via massed practice

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Techniques for fluency enhancement

• Slowed rate
• Continuous speech
• Easy onset of phonation (see video demonstration)
• Light articulatory contacts
• Airflow management
• These techniques have been shown to be effective
  in reducing the frequency of stutter events in a
  large number of studies. See a representative
  recent series of studies using these techniques
  by Craig and his colleagues (e.g., Craig, et al.,
  1996 Hancock, et al., 1998).

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Fluency Shaping Components

• For all components GILCU applies

GILCU Gradual increase in length and complexity
of utterance
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• Concepts in Fluency Shaping

• Rate modification It's hard!
• Achieved through prolonged segment durations
  (Prolonged Speech PS)
• Maintaining prosody
• Maintaining continuity
• Organizing targets by length (and by complexity,
  for children)
• Following rate reduction with gradual return to
  reasonable conversational rate
• Dealing with clients' self-perceptions of
  naturalness

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• Continuously moving speech

• Goal speech that is connected, avoids breaks and
  silences. Sometimes achieved through "continuous
  phonation."
• Paired with rate reduction
• Similar issues arise in need to encourage a
  natural prosody
• Similar issues arise in programming for task
  length, complexity and cognitive demand

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A more recent approach Reduction of short
phonation intervals (Ingham et al., 2001)

• Based on the premise that reducing short
  phonation intervals may be as effective as
  lengthening segments.
• Machine-assisted detection and feedback of SPIs
  (experimental).
• May produce more natural speech than other
  measures.

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Delayed Auditory Feedback and vocal modification

• What is DAF?
• Effects discovered by Goldiamond (1965)
• What are the effects of DAF?
• DAF is used in many programs to instill rate and
  continuous phonation.
• Through long lead DAF (e.g. 250 msec), gradually
  shaped through reductions in DAF latency and
  client learning of DAF-induced rate and
  continuity behaviors.
• Some clinicians (and clients) believe that the
  DAF works as a masker or distraction, as well.
• However, meta-analyses of the effects of DAF by
  Ingham (1984) and Perkins (1979) suggest that
  teaching prolonged speech and/or continuous
  phonation accomplishes the same ends, albeit less
  dramatically.

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• Easy onset of phonation

• Sometimes paired with pre-voice exhalation
• Building vocal intensity gradually
• Using a breath curve
• Early targets often involve vowels, /h/, nasals,
  liquids, glides.
• Programming phrases by length, complexity and
  cognitive demand

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• Light articulatory contacts

• Goal achieve consonantal closure using reduced
  effort and tension
• Usual first targets easily visible places of
  articulation, those high in proprioceptive
  feedback bilabials, dentals.

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Machine-assisted instruction

• Fluency shaping is sometimes augmented by
  computerized feedback programs that measure
  respiration, loudness, continuous phonation,
  amplitude rise, etc.
• Examples are CAFET, Dr. Fluency, etc.
• For an online, interactive demo of such programs,
  go to
• https//www.dfluency.com/registration/demoreg.asp
  
• What are the benefits and limitations of
  machine-assisted instruction?

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• Beyond the basics
• Getting cognitive

TARGET (i.e., slowed speech)
HOW?
WHY?
WHEN?
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Knowing a skill is not the same as using a skill

• How would you know if your client knew the
  skill?
• Developing metacognitive awareness
• What factors interfere with using new skills?

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Approach II Stuttering Modification
Hi, I'm Sam
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Stuttering modification

• Goals
• Analysis and modification of dysfluencies
• Reduction of fear and avoidance behaviors
• Van Ripers (1973) 3 stages of therapy
• 1. Identification
• 2. Densensitization
• 3. Modification

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Techniques to modify disfluencies and reduce
struggle

• Identifying the features of the stuttering
  pattern
• Reducing escape and avoidance behaviors
• Monitoring
• Open stuttering
• Reducing struggle behaviors
• Cancellation
• Pull outs
• Preparatory sets

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Components of Stuttering Modification
TOOLS

• from Van Riper

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Tools of stuttering modification

• Cancellation
• pausing deliberately following a stuttered moment
  to re-utter the word (in a different manner)
• Pull-outs
• slow motion escapes from dysfluency must be
  preceded by identification (aided by such tools
  as freezing)
• Preparatory sets
• pre-articulatory adjustments enabled by
  identification and modification phases.

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• Some Stuttering Modification techniques

• "Freezing"
• Benefits increased awareness of site of
  stuttering blocks and fixations
• Densensitization of moment of stuttering
• Cancellation finishing the stuttered word and
  repeating it fluently, or stuttering it
  differently
• Benefits increased awareness of moments of
  disfluency
• Reinforcement of successfully uttered word

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• Stuttering modification
• (continued)

• Pull-outs after freezing has been mastered, and
  client can identify bases for fixations
  ("clogs"), developing techniques for "sliding",
  "gliding", "moving forward" out of blocks.
• Preparatory sets after client identifies typical
  problem areas, such as utterance beginnings or
  problem words, using techniques as appropriate
  when moments of stuttering might be likely.

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Cancellations and pullouts
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Preparatory sets
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• Stuttering modification
• (continued)

• Dealing with affective and cognitive components
  of the disorder
• Fear of speaking
• Fear of stuttering
• Use of attitude checklists
• Practicing targets up a hierarchy of speaking
  difficulty (content, addressees, time pressure,
  etc.) as defined by the client.
• Desensitization through practice

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• Stuttering modification
• (continued)

• Progressive relaxation as useful and appropriate
• Developing a locus of control within the client

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Goals for Treatment

• Spontaneous Fluency
• Characteristic of the normal speaker.
• Effortless.
• Speaker more concerned with what is said than how
  it is said.
• Controlled Fluency
• Must monitor and adjust speech to maintain
  natural or normal sounding speech.
• Speaker must pay attention to how he is speaking.
• Acceptable Fluency
• Noticeable stuttering of less severity.
• Comfort in role of communicator, despite
  stuttering.
• Speaker makes adjustments to maintain an
  acceptable level of stuttering.

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Philosophical contrasts among approaches

• The ABCs can be used to contrast philosophies of
  these and other (e.g. operant) approaches to
  stuttering therapy.
• In many fluency shaping and operant approaches,
  the Bs (behaviors) cause the As and Cs
  (affects and cognitive states
• If you get rid of behaviors (e.g., stutters), you
  solve affective and cognitive components of the
  disorder.

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Contrasts (continued)

• However, in other approaches, such as stuttering
  modification and approach-avoidance, affective
  and cognitive components are seen as requiring
  their own therapy attention
• Because they can independently lead to
  disfluencies
• Because they interfere with use of shaping and
  modification strategies
• Because they impede generalization and transfer
• Because they have become entrenched beliefs and
  emotions that do not disappear spontaneously even
  when speech behavior changes.
• How you conduct therapy will depend on your view
  of the relationships among the ABCs,
  particularly in a given client.

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Changing attitudes and emotions
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Changing attitudes about self and stuttering

• Research suggests that changing the clients
  locus of control, knowledge about stuttering,
  and self-esteem can be an important factor in
  meeting a wide number of therapy goals (Blood,
  1995).
• Locus of control refers to the extent to which
  (an individual) perceives responsibility for
  their own personal problem behavior (Craig, et
  al., 1984).
• Identifying locus of control in the clients
  language about stuttering
• Research suggests that changes in locus of
  control and other affective components can reduce
  the risk of relapse (Craig, 1998).

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• Developing locus of control

All the strategies in the world won't work if you
can't use them. Learning to "steer your
stutter" Learning NOT ONLY to "avoid skids" but
how to get out of them. You can't drive well if
all you think about is not crashing.
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Techniques for enhancing self-esteem and locus of
control

• Improving knowledge about the nature of speech
  and stuttering
• Discussing fault and blame
• Responding to bullying and teasing
• Putting stuttering in perspective
• Tolerating disfluency
• Redefining success and failure
• Learning about self-help organizations

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Techniques to reduce fear of speaking

• Desensitizing speaking fears
• Voluntary stuttering
• Advertising
• Naturally, such tasks are enabled by prior work
  on cognitive restructuring reframing ones
  perceptions about stuttering.

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Techniques to improve communication

• Role playing
• Perspective taking
• Active listening
• Video self-analysis
• Group therapy

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Techniques to encourage responsibility and
initiative

• Learning to make choices
• Developing challenges
• Formulating assignments
• Problem-solving
• Identifying barriers to success

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The "One-Minute" Test
What would help me get more out of this?

• What is going right?

What needs to be changed?
Using your client as your guide Developing an
ongoing assessment of the goals and effectiveness
of your therapy
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• A few programs therapy resources available in
  the dept. and on the web

• Yaruss, JS Quesal, R. Identifying appropriate
  therapy goals. The ASHA Leader Online.
• Cooper Personalized Fluency Control Therapy (DLM)
• Shine Systematic Fluency Training for Young
  Children (Pro-Ed)
• Fosnot Woodford Fluency Development System for
  Young Children (CSB)
• Blood POWERR (for older children and teens)
  (CSB)
• Guitar Reville Easy Talker (CSB)