1. Young people who stutter

2. The preschool child who stutters
Special Considerations

3. 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

4. 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)

5. 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)

6. 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)

7. 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

8. 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.

9. Decision Tree (Chmela, 2004)

10. Decision Tree (Chmela, 2004)

11. Decision Tree (Chmela, 2004)

12. 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.

13. 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.

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

15. 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

16. Involving parent

17. 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)

18. 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)

19. 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)

20. Use of Demands and Capacities Model
(Chmela, 2004)

21. 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

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

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

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

25. 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

26. 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

27. 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)

28. 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

29. 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

30. Lidcombe Program

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

32. 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.

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

34. SP3 Model (Chmela, 2004)

35. 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

36. Sample Therapy Approach SP3 (Chmela, 2004)

37. Sample Therapy Approach SP3 (Chmela, 2004)

38. Sample Therapy Approach SP3 (Chmela, 2004)

39. Sample Therapy Approach SP3 (Chmela, 2004)

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

41. Modeling easy speech

42. Therapy example

43. Sample Therapy Approach SP3 (Chmela, 2004)

44. Talking about stuttering