Stuttering Exam 3

When looking at the preliminaries to treatment, the clinician must have what attributes?

1. empathy

2. warmth

3. genuineness

4. preference for evidence-based practice

5. commitment to continuing education

6. critical thinking and creativity

The clinician attribute, empathy, means

the ability to understand the client’s feelings, thoughts, and behaviors

• learn to listen deeply and acceptingly

The clinician attribute, warmth, means

caring and unconditional acceptance that stimulates the client’s learning and unlearning

The clinician attribute, genuineness, means

• Being honest and self-accepting

• being able to be blunt with the client when needed

The clinician attribute, preference for evidence-based practice, means

• preferencing valid and reliable measures

• evidence for effectiveness of treatment

The clinician attribute, critical thinking and creativity, means thinking

• Will this approach work for my clients in my environment?

• What does this client need from me?

• How can I arrange it?

When looking at the preliminaries to treatment, what should we consider about the clinician’s beliefs?

1. What they are

2. How they affect evaluation procedures

3. How they affect treatment strategies

Clinician’s beliefs “What they are”

clinician should have a well-developed perspective on the etiology of stuttering and what causes some stuttering to become severe and persistent

Clinician’s beliefs “How they affect evaluation procedures”

Only with a detailed perspective about the onset and development of stuttering can the clinician effectively evaluate clients of all ages and counsel them and their families

Clinician’s beliefs “How they affect treatment strategies”

Treatment choice must be based on a good understanding of the dynamics underlying a particular client’s stuttering

Treatment goals for stuttering include:

1. reduce frequency of stuttering

2. reduce the abnormality of stuttering

3. reduce negative feelings about stuttering and speaking

4. reduce negative thoughts and attitudes

5. reduce avoidance

6. increase communication abilities

7. create a fluency-facilitating environment

8. increase freedom to speak

Treatment goals: Reducing frequency of stuttering

We must reduce the frequency of stuttering

• without creating extraneous behaviors

• reduction depends on the level

Treatment goals: Reduce the abnormality of stuttering

Reduce the abnormality of stuttering

• Depends on age and level

• Client has choice about how she stutters

Treatment goals: Reduce negative feelings about stuttering and about speaking

Reduce negative feelings about stuttering and about speaking

• Depends on age and level

• Change may occur as by-product of increased fluency or classical

  conditioning may be needed

Treatment goals: Reduce negative thoughts and attitudes

Reduce negative thoughts and attitudes

• Will affect amount and abnormality of stuttering

• Will affect behavior before starting to speak and after stuttering

Treatment goals: Reduce avoidance

Reduce avoidance

• Client needs to learn new behavior before reducing old behavior

(i.e., start by giving the client a tool to reduce stuttering).

• Reducing negative emotions reduces need for avoidances.

Treatment goals: Increase communication abilities

Increase communication abilities

• May be a major goal of some approaches

• Some clients may need more than others depending in part on level

Treatment goals: Create fluency-facilitating environment

Create fluency-facilitating environment

• Especially important for borderline and beginning

• Class environment (as well as home) important for school-age children

• Adults can change their own environments with help and support from clinician

When looking at therapy procedures and dealing with emotions associated with stuttering, with parents and preschoolers

It is critical to listen to, acknowledge, and accept feelings

• Let the parent know that y’all form a team to help the child

When looking at therapy procedures and dealing with emotions associated with stuttering, with older children and adults

The clinician must create an accepting atmosphere where feelings can be expressed by the client and accepted by the clinician

When looking at therapy procedures and dealing with emotions associated with stuttering, As clinician helps client explore and accept responsibility for his stuttering

The clinician’s curiosity and genuine interest in the client’s stuttering and his feelings are crucial

When looking at therapy procedures and dealing with emotions associated with stuttering, when working with school-age children, we use several activities to help reduce shame

1. Playing with the moment of stuttering to compete with the clinician for the longest and loudest stutter

2. Drawing pictures of stutters and talking about the stutters

3. Making music-enhanced videos of child’s work and play with his stutters

When looking at therapy procedures and dealing with emotions associated with stuttering, as client learns to stuttering openly and tolerate stuttering

The clinician helps client accept his feelings of frustration, fear, and vulnerability

When looking at therapy procedures and dealing with emotions associated with stuttering, as client learns to stutter in an easier way and stop rewarding tense stutters,

feelings of resistance, anger, and shame may arise

• The clinician can help by listening for these feelings and verbalizing acceptance of them

Therapy procedure and reducing frequency, for borderline stuttering,

The environment can be changed to become more fluency-enhancing

Therapy procedure and reducing frequency, for beginning stuttering,

an operant conditioning-based approach can be used, such as Lidcombe Program

Therapy procedure and reducing frequency, for intermediate and advanced stuttering,

reducing frequency, instead of reducing the abnormality of stuttering, should be reserved for only clients who have few negative emotions associated with their stuttering

Therapy procedure and reducing frequency, for these rare clients, a “fluency shaping” approach can be used:

establish fluency using low rate, easy onset, light contacts, proprioception, and pausing to shape normal-sounding speech

Therapy procedures and reducing abnormality of stuttering, we should first begin by,

reducing negative emotion associated with stuttering: (a) explore stuttering with much praise and acceptance as learns about his stuttering

(b) experiment with stuttering so client learns he isn’t helpless to change stuttering.

Therapy procedures and reducing abnormality of stuttering, we should secondly,

• guide client to stay in the moment of stuttering and reduce threat and fear associated with “stuckness.”

• Help client learn to produce appropriate sound associated with first sound of word that is being stuttered as he stays in stutter.

• Use rewards to make it a positive experience to stay in moment of stuttering

Therapy procedures and reducing abnormality of stuttering, we should lastly,

Guide client to ease out of stutter slowly and loosely AFTER TENSION IN STUTTER HAS SUBSIDED, and finish word.

Therapy procedures and reducing negative emotions, we should use

classical conditioning to decondition (associating stuttering with a neutral experience) or countercondition (associating stuttering with a positive experience).

Therapy procedures and reducing negative thoughts and attitudes: we should

• use cognitive therapy

• explain how thoughts affect feelings, which in turn affect behaviors

• explore and help client change things such as negative self-talk

Therapy procedures and reducing avoidances: we must

• teach new behaviors to old stimuli (like staying in the stutter, ending slowly and loosely, and feeling triumphant).

• these new behaviors will reduce fear and avoidance

• reward nonavoidance

• cultivate openness, seeking out, and receiving clinicians’ praise for doing it.

Therapy procedures and increasing communication skills: we must

• use instruction, modeling, role-playing, and video feedback of excellent communication examples of client

• guide client in learning turn-taking, topic maintenance, and repairing

• for school-age children have one or more teachers complete the TASCC, use that info to coach child in improving communication skills

Therapy procedures and creating a facilitating environment: preschool

• Involves parents and other family members

• Introduce one-on-one time between parent (or other caregiver) and child.

• Slower speech rate and very empathic listening are used during these daily times of about 10 to 15 minutes.

Therapy procedures and creating a facilitating environment: school-age

• Involves peers, teachers, parents

• Emphasis on helping child talk about his stuttering.

• Clinician should help parents accept the stuttering as is, so child can work on it.

• Clinician can help with teachers and peers by doing in-class presentation with child.

Therapy procedures and creating a facilitating environment: adolescent and adult

• Foster openness about stuttering

• Help the client figure out what to say and how to say it in talking about their stuttering

• Create a support group and have your teen and adult clients attend it

Younger preschool child: borderline stuttering includes

• between ages 2 and 3.5

• most repetitions and may have more than two iterations

• child not aware or minimally aware

In the integrated approach for preschool children (borderline, what does the author believe about the nature of borderline stuttering?

• results from the three factors: constitutional, developmental, and environmental

• if environmental factors are reduced, stuttering will fall off and become normal

• clinician’s role is to help family discover changes to make environment fluency-inducing

In the integrated approach for preschool children (borderline, what does the author believe about speech behaviors targeted for therapy?

aspects of family’s speech and nonspeech behaviors

In the integrated approach for preschool children (borderline, what does the author believe about fluency goals?

spontaneous fluency

In the integrated approach for preschool children (borderline, what does the author believe about feelings and attitudes?

we should work with family’s feelings, behaviors, and attitudes to keep child feeling positive about speech

In the integrated approach for preschool children (borderline), what does the author believe about maintenance procedures?

we should keep contact with family even after child has achieved fluency

• gradually taper off, remaining open to future contact if needed

Clinical methods for preschool children (borderline)

• educate (discussions, DVD, reading materials)

• counsel (support, problem-solving)

• collect data (parents collect SR, SLP collect %SS)

Clinical procedures for indirect treatment for preschool children (borderline)

1. clinician counsels parent

2. clinician models facilitation interaction

3. parents practice facilitating interaction at home

Measuring stuttering for preschool children (borderline)

• severity ratings

• baseline measure

Severity ratings used for measuring preschool children (borderline)

Use the Lidcombe Severity Rating Scale (1-10 scale)

• 1= typical fluency, 10= extremely severe stuttering

• parents use scale to report severity of child’s stuttering

• clinician may also use this in clinic session

Baseline measures us for preschool children (borderline)

clinician records for 10-15 minutes of each session and notes child’s SR for session and compares with parent’s SR

For preschool children (borderline), family interaction patterns such as one-on-one time with child include

• parents should use 10-15 minutes per day of one-on-one time with child to practice parent-child interaction changes

• best done at same time each day

• major characteristics: parent attending, good listening, child-directed

Looking at preschool children (borderline), slower speech rate with pauses includes:

1. clinician teaches family to use slower speech rate with pauses

2. parent/family benefits from practice with clinician

3. then, they can try with child in clinic and at home

4. Child never asked to slow down their speech rate

Looking at preschool children (borderline), commenting reassuringly on child’s speech includes:

• children who start to stutter may worry about what’s happening to their talking

• may also say “i can’t talk” or put hand over mouth

• if there is indication that they are aware, reassuring comments from parent may help

Looking at preschool children (borderline), commenting reassuringly on child’s speech includes also includes:

• not commenting very often, just occasionally when child seems very upset

• parents should vary their comments

• use relaxed accepting manner

• if child does not like comments, parents can just keep relaxed and accepting appearance and maintain relaxed eye contact

In preschool children (borderline), when should the clinician observe the parent-child interactions?

at the beginning of the session

In preschool children (borderline), the clinician should observe not only speech rate but also

request questions

In preschool children (borderline), when working on parent-child interactions, the clinician should

have parents watch video playback of parent-child interactions to brainstorm interactions that might stress the child (these may be normal but still might stress the child)

In preschool children (borderline), if the clinician used video playback when working on parent-child interactions, parents should

be praised for what they are doing well in the interaction

In preschool children (borderline), typical family interactions that may stress a vulnerable child:

1. high speech rates

2. rapid-fire conversational pace

3. interruptions

4. frequent open-ended questions

5. many critical or corrective comments

6. inconsistent listening to what child says

7. vocabulary above child’s level

8. advanced levels of syntax

In preschool children (borderline), to help parents develop more fluency-facilitating interactions, the clinician can

model for parent, then have parent try new behaviors with clinician observing and giving feedback

When continuing sessions for preschool children (borderline), the clinician’s role includes

• being deeply supportive

• listen well

• praise accurately

• help parents appreciate their good work

When continuing sessions for preschool children (borderline), it is important to

• measure changes in stuttering

• accept ups and downs

• brainstorm with parents about effective changes

For preschool children (borderline), maintenance includes:

• continued support for family

• fade contact after fluency is achieved

• prepare parents for possible return of stuttering under stress

• help family gain confidence in their skills

For preschool children (borderline), supporting data includes,

• when mothers speak slowly, children become more fluent

• demands and capacities therapy is effective

• when parents change interactions, the child becomes fluent

Clinical procedures: slightly more direct treatment for mild borderline stuttering (preschool) includes,

If child does not show improvement with indirect therapy after several weeks, the parents should continue to create a fluency-enhancing environment but add praise for fluency

• done during one-on-one times during the day

Clinical procedures: slightly more direct treatment for mild borderline stuttering continued (preschool) includes,

• praise for fluency is suited to what feels natural for the child and parent

• the clinician and parent work out frequency of parent comments and kind of praise given

• gradually praise for fluency beyond the one-on-one items

Slightly more direct treatment for more severe borderline stuttering (preschool) includes,

• Activities done by the clinician with parent observing and participating

• done in hierarchical order, the clinician and child ascend hierarchy as far as necessary to change stuttering into typical disfluency

When looking at slightly more direct treatment for more severe borderline stuttering (preschool) , the first approach in the hierarchal order is

The clinician models easy stuttering which is similar to child’s stutter but in slower easier style

• not done all the time, just once in awhile

• clinician occasionally comments on her easy stuttering

When looking at slightly more direct treatment for more severe borderline stuttering (preschool), the second approach in the hierarchal order is

The child participate in “catch me” when clinician models a hard stutter

• if child is willing to catch a hard stutter, clinician rewards child and changes hard stutter into an easy one

• if ok with child, then clinician catches one of child’s hard stutter and helps change it into easy

When looking at slightly more direct treatment for more severe borderline stuttering (preschool) , the third approach in the hierarchal order is

clinician helps child learn to “play” with stutter

• clinician and child have enjoyable competitions to see who can have longest pretend stutters

• pretend stuttering can reduce negative emotion

• give mostreward when child is able to do pretend stutters that are easy and loose

When looking at slightly more direct treatment for more severe borderline stuttering (preschool) , the first approach in the hierarchal order is

Clinician and parent develop a plan to generalize to home the “play with stutters” and easier stutters

• begin with single assignment to try at home

• parent keeps detailed notes on how child is responding to generalizing activities to home

The Lidcombe program is for

early stuttering intervention

The Lidcombe program of early stuttering intervention is designed for

children under age 6, but may be best suited for children ages 4-6 years old

the Lidcombe program can be applied to young school-age children

true

What is the goal of the lidcombe program?

stutter-free speech

The Lidcombe Program is strongly suggested that it be used

only by those who have been trained

Clinical procedures of the Lidcombe program

1. Parent delivered in-home operant program

• praise every fifth utterance

• gentle correction for unambiguous stutters, only once per 5 praises

2. Parent guided by weekly clinic visits

3. Initially structures, then unstructured sessions

4. Data guides changes in program

• parent collects daily severity ratings

• clinciian collects %SS or SR at clinic

Stage 1: first clinic visit of the Lidcombe Program involves

• clinician assesses child’s %SS or SR in 300 syllables of child’s conversational speech

• clinician teaches parents about SR on a 1-10 scale to rate child’s fluency every day

• to calibrate parent, clinician may ask parent to rate child’s speech in previous 300 syllable sample

Daily at-home sessions for the Lidcombe program

• clinician teaches parents to conduct daily treatment conversations at home for 10-15 minutes each morning

• keep child’s response fluent by adjusting length and complexity

• praise after every 5th fluent utterance

• praise must be specific

When corrections are introduced for the Lidcombe program

• once parent is comfortable with using praise, gentle corrections are introduced

• after 5 praised for fluency \, next stuttered word is commented on

• after parent is comfortable with using acknowledgments for a week, requests for self-correction are taught

• style of both praise and corrections can be adjusted to suit child and family

Contingencies for Lidcombe Program

1. praise (every 5th utterance, be specific)

2. request to self-evalaute (only for stutter-free speech, parent asks for child’s opinion)

3. acknowledge (that one was bumpy)

4. correct (after 5 praises then 1 correction, only for ambiguous stutter, aim in assistance, ask child to say stuttered word back)

Stage 1: Unstructured Treatment Conversation for Lidcombe Program

• when structured conversations are well and DR and %SS shows reduction, unstructured convos are introduced

• entails praise, acknowledgement of stutters, and requests for correction in everyday situations

• unstructured treatment to convos can start with only praise, and contingencies for stutters are introduced when appropriate

What are the goals for Subsequent stage 1 clinic visits for Lidcombe Program?

1. assess child’s speech

2. discuss SR and other indicators of progress

3. introduce new procedures when appropriate

What happens in the subsequent stage 1 clinic visits for the Lidcombe Program?

After the child’s speech is assessed, she plays by herself as parent and clinician openly discuss the child’s progress discuss progress

When does the family begin stage 2: maintenance of the Lidcombe program?

When the child meets criteria for three weeks in a row

• %SS in clinic is below 1% SS

• Weeks SR are 1 or 2, with at least 4 days being 1

What does Stage 2: Maintenance of the Lidcombe program consists of?

30-minute clinic visits scheduled at systematically increasing intervals as long as criteria are met

• 2 visits at 2 week intervals

• 2 visits at 4 week intervals

• 2 visits at 8 week intervals

• 1 visit at 16 week interval

When looking at stage 2: maintenance of the Lidcombe program, if criteria are not met

parent and clinician jointly decide among several possible options

• clinic visits increase

• weekly clinic visits

• reinstating either structured or unstructured clinic visits or both

When looking at stage 2: maintenance of the Lidcombe program, sometimes contingencies need to be adjusted.

True

Older preschool children: borderline stuttering is characterized by

• ages 3.5-6 years old and has stuttered for at least 9 months

• stuttering consists of repetitions with tension, tense prolongations, and some blocks

• escape behaviors and few avoidances

• feelings of frustration and embarrassment

Regarding older preschool children (borderline stuttering), what are the authors’ beliefs on the nature of stuttering?

• It arises from the interaction of sensory-motor deficits, vulnerable temperament, developmental factors, and environmental stress

• if child doesn’t recover naturally, they develop neural compensatory strategies to get fluency

• extensive experience speaking fluently at home with encouragement can help

Regarding older preschool children (borderline stuttering), what are the authors’ beliefs on speech behavior targeted for therapy?

should be both fluent speech and stuttering

Regarding older preschool children (borderline stuttering), what are the authors’ beliefs on fluency goals?

the goal should be typical disfluency

Regarding older preschool children (borderline stuttering), what are the authors’ beliefs on feelings and attitudes?

it is important to increase confidence about fluency

Regarding older preschool children (borderline stuttering), what are the authors’ beliefs on maintenance procedures?

there may be a need for a systematic program of gradual facing of contact