Additional Treatment Considerations

NZ Context

Māori understandings of communication conveyed through ancestral sayings

• interrelationship of natural, spiritual and human worlds

• communication from the environment

• spiritual involvement of language

• communication situated within interpersonal relationships and social dynamics

• not only oral communication (non-verbal)

Multilingual speakers

Regularly use 2 or more languages in daily life

• often different levels of proficiency and exposure of languages

• >40% of world’s population

• positive benefits of being bi/multilingual far outweigh any misperceived disadvantages

Bilingual children are more likely to be misidentified as

• having a language deficit

• being a child who stutters

• no evidence that bilingualism is a risk factor for developing stuttering

Cultural differences to be aware of in clinical practice

• hierarchy/talking to other gender

• expecting conversational interactions between parents and children

• interruptions in conversation (can be seen as active involvemenet)

• beliefs in cause of stuttering (spiritual, caused by parents etc)

Speakers of which languages can Monolingual English assessment guidelines be used for?

non-English monolingual speakers of Dutch, French, German etc, but not other languages such as Spanish

Can SLT’s identifying stutters in languages they don’t understand?

Yes, including identification of severity in bilinguals

BUT caution needed as can also identify non-stuttering children as CSW

What may bilingual children present with?

Typical and stuttered disfluencies exceeding conventional monolingual thresholds - but may not be considered stuttering in their language

How do you differentiate language-related disfluencies from stuttering?

Observe:

Affective features

• presence of tension

• struggle

• awareness etc of disfluencies

Cognitive features

• self-concept of speaking difficulty (attitude towards communication)

If bilinguals stutter they may have?

• similar amounts of stuttering in both languages

• more stuttering in 1 language

• inconsistent findings on why this is - grammatical complexity? linguistic uncertainty?

Linguistic uncertainty

A speaker whose linguistic knowledge is comprised of more than one language will have higher linguistic uncertainty.

Stuttering assessment

• Important to get comprehensive idea of client’s language history, function and proficiency during case study

• Check norms and cultural considerations for each test

Formal stuttering assessment

• complete OASES in different languages as impact of stuttering can vary depending on language and culture

• SSI-4 can be used if considering only those speech disfluencies produced with atypical timing and tension that are clearly indicative of stuttering

• KiddyCAT - complete in each language the child speaks, as you learn more about the child's cultures, you will become better at determining how their responses may be influenced by their culture, independently of stuttering

Informal stuttering assessment

• Need to combine formal and inform ax of stuttering to minimise cultural biases

• Greater cognitive demand placed on bilingual speakers as they navigate more than 1 language

• obtaining narrative and conversational samples in each of the languages the person speaks during the assessment process is an important step.

• by focusing less on the overall frequency and more on the types of disfluencies and especially the manner in which they are produced, the clinician can make a more accurate diagnosis.

Assessment of non-verbal behaviour

• cultural differences in making eye contact is critical to consider

• lack of eye contact could be misinterpreted as a secondary behaviour

• essential that the clinician familiarizes themselves with what is considered appropriate in that person's culture in order to determine whether the individual’s eye contact is related to stuttering or to cultural influences.

Stuttering treatment

• Most tx developed for monolingual speakers

• Treat all languages as much as possible (levels of stuttering may not been the same across languages)

• Use interpreter if needed

• Transfer between languages possible

• Resistance may be shown due to cultural differences e.g use of eye contact, speaking rapidly may be valued, nature of parental participation)

• take time to discuss rationale for approach

• sometimes intervention needs to be modified

Concomitant difficulties

• language impairment observed more frequently in CWS than in general population

• CWS can have co-occurring articulation/phonological difficulties and executive functioning difficulties

Treatment principles

Important to always consider impact from one domain to another

• e.g. increased language demand can negatively impact child’s ability to maintain fluency

• e.g. practicing speech sounds can lead to over-articulation and hard contacts

Treatment approaches

• Sequential

• Concurrent

• Cyclic

Sequential treatment

Address 1 difficulty before the other

• select the most significant area to target first

• move onto next difficulty when 1st one has been completed (target achieved)

• potential for untargeted areas to worsen or never get addressed (if stop treatment due to other factors)

Concurrent treatment

Work on multiple areas more or less in parallel

• may include combinations of direct and indirect treatment

• different portions of tx session address different difficulties

• 1 activity can address goals in multiple areas

• need to monitor effect of treating 1 area on other areas that require support

Cyclic treatment

Concurrent treatment, with set period of time to spend on goals in long-term plan

• differs from sequential which is based on predetermined level of accuracy vs time