Young people who stutter

The preschool child who stutters Special Considerations

What is the status of the child? Not stuttering or at risk to stutter Not stuttering but at risk to stutter Currently stuttering with good chance of spontaneous recovery Currently stuttering with a likelihood of persistence

Prognosis for persistence: Primary factors Family history Family history of persistence predicts persistence Gender Boys more likely to experience persistence Age at onset persistence is associated with slightly higher age of onset Trend in stuttering behavior Persistence associated with stable (or less frequently a worsening) rates of SLDs over time, particularly in first year? Persistence is associated with continued presence of multi-unit repetitions over time Persistence is associated with a continued heightened tempo in repetitions (short intervals between units) Persistence is associated with an increasing proportion of prolongations and blocks over time. Duration of stuttering history Longer history of stuttering predicts persistence Yairi and Ambrose (2005)

Prognosis for persistence: Secondary factors Stuttering severity Only relevant when considered in relation to duration of stuttering history Head and neck movements Phonological skills Weaker phonological skills associated with persistence Expressive language skills No strong trends for diminished language skills being associated with persistence Considered a “complicating” factor Yairi and Ambrose (2005)

Prognosis for persistence: Considerations lacking empirical support Concomitant disorders Physical, emotional-behavioral, learning problems Awareness and affective reactions While not yet shown to be predictive for persistence, can help make decisions about intervention Yairi and Ambrose (2005)

Factors that may influence fluency development (Hugo Gregory) Child factors Genetics Development Temperament: sensitive, inhibited, anxious (little empirical support) Other concerns Communicative Environment (remember these are not causal factors) Limited response time Interruptions Simultaneous talking Negative reactions to speech General Environment Time Pressure Inconsistency Unpredictability Relational Issues Conflict Daily stress

Are therapeutic goals different for preschoolers vs Are therapeutic goals different for preschoolers vs. older children/adults? Generally, YES Major focus: Ameliorate the stuttering problem. Prevent stuttering or, at least, a progression of the problem. We don’t know all the factors that lead to recovery so we must assume we can move child in that direction. Less focus: Coping and managing the stuttering problem.

Decision Tree (Chmela, 2004)

Decision Tree (Chmela, 2004)

Decision Tree (Chmela, 2004)

Case 1 Bobby is a 3 year, 0 months old boy who has been exhibiting severe stuttering for three months. Stuttering characterized by approximately 12 SLDs per 100 syllables, has clear tension and some secondary behaviors. He has no family history of stuttering and otherwise exhibits normal speech and language development.

Case 2 Crystal is a 4 year, 6 month old girl who has been exhibiting moderate stuttering for about 16 months. Stuttering characterized by approximately 9 SLDs per 100 syllables. Features are mostly part word repetitions. Few secondary behaviors are observed. She has a father and uncle who stutter. Other speech and language skills are unremarkable.

Therapeutic Models Indirect: Direct: No direct discussion of fluency For example, model easy speech reduced time pressure Direct: Fluent speech Stuttered speech

Role of Parent Parent as client (direct recipient of treatment) Arose mainly out of diagnosogenic era not consistent with contemporary views of stuttering Parent advising Parent are recipient of advice on how to help child cope through environmental manipulations Commonly part of many treatment approaches Parent as co-clinician Parent carries out direct intervention e.g. Lidcombe program

Involving parent

10 pieces of advice for parents Seek professional help and obtain basic information about stuttering to correct unfounded assumptions and alleviate misplaced anxiety and guilt. Become informed about the prognosis of stuttering and factors that may facilitate or impede progress. Become informed about normal speech and language development and the differences between normal and abnormal disfluencies. Yairi & Ambrose (2005)

10 pieces of advice for parents Reduce general tension at home. This can be done through identifying and decreasing routine frictions in everyday parent-child relations. Reduce pressures directed toward the child who stutters. This can be done by analyzing their own expectations, demands and restrictions. Minimize situations likely to elicit pronounced stuttering in an effort to prevent frustration and growing fears of stuttering. Avoid negative comments or other types of verbal and nonverbal reactions that convey disapproval of child’s stuttering. Yairi & Ambrose (2005)

10 pieces of advice for parents Learn how to constructively handle moments of stuttering. Wait patiently without reacting, or kindly acknowledge the problem, assure the child, and suggest or demonstrate easy speech. Create a home atmosphere conducive to slow speech and fluency. Strive to reduce physical stimulation, excitement, and the pace of activities, and to maintain quietness. Facilitate fluency by providing the child with a model of uncomplicated language and slow speaking rate. Yairi & Ambrose (2005)

Use of Demands and Capacities Model (Chmela, 2004)

Regardless of specific approach… All communication (fluent and stuttered) is great and needs to be encouraged and rewarded with praise Resist time pressures for all activities (speech and non speech) Predictable routines in clinic and at home

Sample approaches for the pre-schooler Parent-Child Interaction Approach (PCI) Lidcombe program SP3 program (Chmela)

Palin Parent-Child Interaction Approach (PCI) Michael Palin Centre UK

Parent-Child Interaction Approach (PCI) Indirect, parent-mediated approach (with some flexibility)

Assessment Child Assessment Speech/language Fluency Interview to address Attitudes toward communication, social situation, school etc Home and family situation Aspects of speech problem Observe for behavioral issues such as Separation from parents Cooperation manner of engagement anxiety level

Assessment Child-Parent Interaction Parent Interview Video parents with child Evaluate interaction style Observe social communication variables Observe stuttering behaviors and when they occur Parent Interview Effect of stuttering on family Health History “Psychosocial” Interview Development history

Therapy outcome from assessment Low stuttering risk (no intervention) At risk for stuttering (delay intervention for reasons other than stuttering) At risk for stuttering (initiate intervention)

Treatment Focus Establish “strategies” to support natural fluency Interaction strategies Changes in rate, length & complexity of utterances Turn-taking, pausing and following child’s lead Family strategies Managing anxiety about stuttering Coping with sensitive children & confidence building Behavior management Child strategies May be included as appropriate Direct speech modification, fluency-enhancing strategies, language therapy, speech sound therapy

Aspects of Intervention Program Stage 1: Within-clinic Sessions 6 weeks of weekly one-hour sessions Session 1 Establish “Special time” concept Session 2-6 Discussion Video-taped play and review (video clip 4) Stage 2: Home-based Consolidation Period 6 additional six weeks implementing activities w/o attending clinic weekly Stage 3: Review Session and Clinical Decision Making Evaluation of child’s status and progress Considerations: monitoring only vs. direct therapy

Lidcombe Program

General Features Target Group: preschoolers Therapy Approach: Direct Operant Parent-Mediated Primary Therapy Goal: Reduce stuttering behavior < 1% SS

Program Components Behavioral Component Problem Solving Component Praise stutter-free speech (videos 2 & 3) “Correct” stuttering (modeling, stimulation and reinforcement) Positive reinforcement: punishment ratio ~ 5:1 Measure Speech Behaviors Programmed Maintenance (no formal transfer) Problem Solving Component Counseling to optimally integrate program into family environment etc.

Lidcombe: Randomized Clinical Trial Jones et al Lidcombe: Randomized Clinical Trial Jones et al. (2005) BMJ 331(7518): 659

SP3 Model (Chmela, 2004)

Treatment Activities Direct intervention approach for pre-school aged child Structured Direct Traditional therapy Clinician directed activities and behaviors Structured Indirect Guide parent to direct activities and behaviors Spontaneous Parent assumes role as director of activities and behaviors Problem Solving End-of-session review of success/problems Address emotions etc

Sample Therapy Approach SP3 (Chmela, 2004)

Sample Therapy Approach SP3 (Chmela, 2004)

Sample Therapy Approach SP3 (Chmela, 2004)

Sample Therapy Approach SP3 (Chmela, 2004)

Sample Therapy Approach SP3 (Chmela, 2004) Demonstrate and comment on disfluencies Stuttering can be ‘no big deal’

Modeling easy speech

Therapy example

Sample Therapy Approach SP3 (Chmela, 2004)

Talking about stuttering