Stuttering Treatment

history of stuttering treatment

• according to Lewis (1906), unhealthy and immoral lifestyles caused stuttering.

• years ago people suggested strange and sometimes dangerous treatment options for stuttering

things to consider for stuttering treatment

• time between onset and start of treatment

• rate and nature of stuttering progress

• indirect vs direct approach

• rational vs irrational concerns

• covert behaviors

• reframing and acceptance

indirect approach

no direct manipulation/modification of childs dysfluencies

direct approach

explicit instruction to modify speech

treatment for preschool/kindergarten children

• children 2-6 years old

• treatment approach - direct and/or indirect

• feelings and attitudes are affected by family

treatment goal for preschool children

fluent speech

The Lidcombe Program

• Onslow et al., 1990, 2003

• direct approach

• behavioral treatment of stuttering in preschool and kindergarten children

• based on operant conditioning

• providing verbal responses to stuttering

• use of pictures that represent stuttering

terms used in the lidcombe program

• stutter, bumpy, stutter-free, smooth

fluency shaping program

5:1 ratio of verbal responses for fluency to verbal responses for stuttering

examples of verbal responses for the Lidcombe program

• 5 responses, 3 for fluency, 2 for stuttering

  1. praise F

  2. acknowledgement of fluency (F)

  3. request for self evaluation (F)

  4. acknowledgement of stuttering (NF)

  5. request for self correction (NF)

praise example

that was nice smooth talking (F)

acknowledgement of fluency

that was smooth (F)

request for self evaluation

was that smooth? (F, only ask if fluent)

acknowledgement of stuttering

that was a little bumpy (NF)

request for self correction

can you say car without the bump? (NF)

lidcombe parent training

• learn verbal responses

• deliver responses as soon as possible after stutter free or stuttered speech

• use neutral tone of voice

• learn to rate stuttering severity using a 10 point scale (10 being extremely severe stuttering )

• rate stuttering severity every day

• establish severity agreement with SLP

stage 1 of lidcombe program

• weekly visits to clinic

• parent training

• SLP obtains PSS during every visit

• parent conducts treatment every day, first during structured then unstructured conversations

• parent records stuttering severity

criteria for stage 2

• PSS less than 1 for three weeks

• severity score of 0 or 1 for the same 3 weeks with at least 4 days at 0

stage 2 of lidcombe program

• maintenance stage

• gradual withdrawal of verbal responses

• less frequent clinic visits

treatment efficacy of Lidcombe

• median time - 17 clinic visits

• all children reach stage 2 after about 20 clinic visits

• long term effects show stuttering was near 0 levels

School age typical symptoms

• Tense repetitions and prolongations

• Use of escape devices

• Secondary characteristics

• avoidance strategies

• frustration

• embarrassment

• anticipation

School age treatment

• direct approach

• includes stuttering modification, fluency shaping techniques, and environment modification

• reducing negative feelings and attitudes

• reduce avoidance behaviors

treatment goal for school age children

controlled fluency, fluency mixed with very mild/mild stuttering

Cancellation

after a moment of stuttering, come back and modify the moment of stuttering by producing it again and changing the physical tension in speech

Pull out

easing out of tension during a moment of stuttering

Preparatory set

someone anticipates a stutter and prepares for it by starting out the word or sound with less tension and slightly prolonged

Light contact

encourages speakers to make minimal articulatory contact when producing sounds

Easy start

aims to reduce tension by initiating speech gently or more softly

Working with parents

• explain treatment program and their role (techniques, duration, difficulty)

• discuss possible causes if necessary (eliminating parental guilt)

• identify and reduce fluency disruptors (environmental factors)

• eliminate teasing

Working with teachers

• explain treatment plan and teachers role

• facilitate teacher talking to child about stuttering, acknowledging their stuttering, express help, etc

• work on classroom participation

• eliminate teasing

Adolescents and adults treatment

• client must be ready for treatment

• client has an active role in treatment

• fluency shaping and stuttering modification treatment

• addresses overt and covert characteristics

• address clients goals

treatment goal for adolescents and adults

modified stuttering

Techniques for establishing easier stuttering

adjusting timing and tension

adjusting timing

• selected rate reduction

• cancellations, pull outs, and preparatory sets

adjusting tension

• light articulatory contact

• phonatory adjustments (easy voice onset, speaking after exhalation has begun)

MIDVAS (Van Riper, 1958, 1978)

1. Motivation

2. Identification

3. Desensitization

4. Variation

5. Approximation

6. Stabilization

Motivation

• Support the client

• client needs to be motivated to start treatment

• goals of therapy

Identification

• education

  • Speech production

  • Primary behaviors

  • Secondary behaviors

  • Attitudes and emotions

desensitization

for stuttering dysfluencies and situations

Desensitization of stuttering dysfluencies

• support groups

• Watching videos of others who stutter

• Dysfluency imitation

• Watching self videos

• Voluntary stuttering/pseudostuttering

• Exaggeration

desensitization for situations

create hierarchies and start with the easiest to achieve success

Variation

• vary dysfluency types

• Attempt to modify stuttering dysfluencies into other stuttering dysfluencies

• Repeat every stuttering dysfluency but use different type

• Slow down and stutter in slow motion

• Stop every stuttering dysfluency before completion

• Exaggerate secondary behaviors or use atypical ones

Approximation

• Focus on primary characteristics

• Cancellations, pull outs, prep sets

Stabilization

Apply all learned situations that bring about pressure and stress

Data collection

• Obtain baseline data

• Consistently collect data during treatment

• Present client/parent with progress information