Treating Stuttering in School Age Children · Combined Stuttering Treatment: Evidence 6 boys; 1 girl – mean age 10.2 years 40 hours intervention

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Treating Stuttering in School Age

Children ROSALEE C. SHENKER, PH.D., CCC-SLP

MONTREAL FLUENCY CENTRE

SAC WEBINAR- NOVEMBER 2, 2016

ROSALEE C. SHENKER MONTREAL FLUENCY CENTRE 2016

Overview of webinarThe problemSummary of treatmentGoals for working with:◦Children◦Teachers◦parentsCase studies

ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016

Why are we concerned?As stuttering persists…

Chance of natural recovery decreases

Unlikely to recover without treatment

Perceived negatively by peers, rejected more often

Risk of self esteem issues

Risk of bullying/teasing increases


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Stuttering may interfere with success

Verbal expression needs increase◦Answer/asking questions◦Reading aloud◦Contributing to group discussions◦Debate teams◦Social/pragmatic needs


Children who cannot do this

May pay a social price

Start to develop negative reactions/fears

More likely to be bullied, rejected, less popular


Client Concerns about Treatment

◦Too long, too short

◦Too complex ➡� no buy‐in◦Client frustrated, demotivated◦Lack of generalization, follow‐up◦Treatment not completed◦Others???


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Clinician Concerns about Treatment

◦Large caseloads◦Long wait lists◦Not enough time◦Lack of confidence, training◦Little evidence to guide TX◦Other???


Clinical Trials Non‐trial Research Opinion‐based

Regulated Breathing Video Self modeling Practitioner expertise

Fluency Shaping (SpeechReconstruction)

Stuttering Modification Counseling based

Verbal Response Contingent Stimulation

Lidcombe Program (SA) Case studies

Combined Stuttering Treatment

CBT

Syllable Timed Speech


What works: 1. Fluency ShapingPositive Treatment Outcome…However…

◦Failure to maintain is common

◦Need for a new speech pattern

◦ Intensive format may not be practical


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What works: 2. Behavioral Change

Positive outcomes◦Socially valid◦Natural Sounding◦Simple treatment

However…◦Variability in Stage 2 (LP)◦ No attention to Cognitive issues


What works: 3. Affective

Counseling approach◦ focus on avoidance/acceptance

◦Can help to maintain fluency in comprehensive programmes

◦Can it stand alone as a treatment?◦ lead to increased fluency?◦Does everyone need it?


Treatment Goals: Child’s needsBefore/after treatment

◦ Impact of stuttering

◦Goals‐ short/long term

◦Prior Therapy Experience‐ what worked?

◦ Importance of parent/teacher support

◦Acceptance/inclusion


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Measures of Change

Objective◦Severity‐ pre‐post in all languages spoken◦Affect of other speech/language concerns◦Social validity post‐treatment◦Perceptual ratings of speech rate/naturalness,

Subjective◦Quality of life◦Avoidance/Anxiety Reduction◦Reduction in specific situations


Teacher’s Role

Supportive

Educative

Inclusive

Therapeutic?

Information available:◦SFA

◦Michael Palin Centre


Some viable treatments

Lidcombe Program

Combined Stuttering Programs

Rhythmic Speech- STS

Video Self-modeling


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Lidcombe ProgramApproach to Intervention

◦Behavioral◦Response Contingent Verbal Feedback◦Parents provide treatment beyond clinic◦No Cognitive aspects◦Adapted for school age children◦Stage 2 (Performance contingent)


Lidcombe ProgramService Delivery Model◦ Individual

◦ could be adapted to group, telepractice◦Changes for school age include◦More participation from child◦Still need parent, but maybe less…◦Specific feedback◦Alter criteria for Stage 2◦Child driven


Lidcombe Program: Evidence2 studiesSame results as for preschool◦12-16 hours to Stage 2More variability in Stage 2Parents involvedLong term results promisingWhen to add other strategies?◦Review after 6, 10, 15 session


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Combined Stuttering Treatment

Approach to intervention

◦Self Imposed Time-Out (SITO) combined with Prolonged Speech (PS)◦SITO first◦PS end of day 1◦Speech mission/excursions◦Cognitive/behavioral


Combined Stuttering TreatmentService Delivery Model

◦5 day intensive

◦7 week follow up visits – individual

◦ Individual/group problem solving

◦Deals with maintenance/follow up


Combined Stuttering Treatment: Evidence

6 boys; 1 girl – mean age 10.2 years

40 hours intervention◦ <1%SS in 4 conditions◦ Speech rate slightly increased 2 mos. Post-TX◦ OASES- less overall impact of stuttering in 4/6

Caters to individual needs

Lessens impact of stuttering in short term

Increased understanding of stuttering

No treatment manual


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Rhythmic Speech (STS) Approach to Intervention: Behavioral◦Stage 1◦Weekly visits, parent learns model◦Rate, pitch, intonation natural◦Praise for using STS optional◦Daily home practice; prompts to use STS

◦Stage 2 performance contingent◦Daily SR


Rhythmic Speech - STSService Delivery model

◦Individual and simple

◦Parent participation

◦Could be altered to group format?


Rhythmic Speech: EvidenceTwo studies 32 children (6-11)

50-82% reduction in 12 month follow up

Stuttering control may not be satisfactory to eliminate avoidance of some situations

Promising but needs more study


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Self-Modeling Approach to Intervention

◦Behavioral

◦Repeated observations of exemplar tape of fluency

◦3-5 minute videos in 6 occasions over 5 weeks


Self-modeling Service Delivery Model

◦ Individual

◦No parent participation necessary

◦Child needs to be self-motivated/mature


Self-modeling: Evidence3 males (13-17)

Can be used for generalization, may not be sufficient for stand alone treatment

Similar outcomes for larger study

Potentially valuable aid to treatment???


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Treatment goalsIs a behavioral treatment enough?

How much treatment dose is viable?

Can you provide a setting for problem solving?

Cognitive/affective goals

Parent/teacher role?

How will you provide for generalization/maintenance/follow‐up?

What evidence will you collect pre‐post‐follow up?


Case Study #1 Lidcombe Program: Stuttering onlyHistory: ◦Age 6 years; 10 months ◦Mild-moderate (mainly repetitions)◦SEV fluctuates through the day from 1-6◦Child not distressed-continues to talk ◦Above average receptive/expressive language ◦Rich spoken vocabulary


Case Study #1Why choose Lidcombe Program?◦No previous treatment for stuttering◦Parent involvement◦Licombe Program-best practice◦Window of Opportunity age wise


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Case Study #1Treatment Model◦Parent present during each TX session◦Clinician trained parent◦Parent gave feedback in structured and unstructured conversation at home/clinic

◦Weekly visits during stage 1◦Bi-monthly and monthly visits during stage 2◦Telephone calls


Case Study #1Progression of treatment and outcome◦Stage 1- 7 visits over 7 weeks

◦Stage 2- 6 visits-1 call over 5 months

◦6 month- 1 year follow up on telephone/email

◦Stutter-free 4 years post-treatment


Case Study #1Problems identified/solved◦ 1. Parent did not do TX at home during week1◦ Action: Brainstorm with parent on visit 2◦ TX became consistent at home

◦ 2. Child did not like praises ◦ Action: discrete feedback and non-verbal praises◦ Child/parent agreed on a minimum/maximum

◦ 3. Parent stopped TX completely at the end of stage 1◦ Action: praises reduced more gradually


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Weekly Severity Ratings

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1

2

3

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5

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7

1 2 3 4 5 6 7 8 9 10 11 12

Severity


Case Study 2: Combined Treatment11 years old at onset of TX

History◦De George Syndrome◦Phonology◦Learning difficulties◦Moderate/Severe stuttering


Case Study #2 Combined treatmentApproach to intervention◦Prolonged speech◦Self imposed time out◦Monitored BC by ‘self-modeling’◦SEV/NAT ratings daily◦Parent support as needed


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Case 2 Service Delivery Model◦Weekly clinic visits◦Home practice◦Parent involved initially◦Create new video for each visit using programmed criteria (SEV/NAT)


Case 2Progression of treatment ◦ Weekly sessions/gradual decrease◦ Support by video

Outcome◦ Fluency stable at SEV= 1-2; NAT= 2◦ Videos used for maintenance goals◦ Lack of confidence◦ Used videos to gain assurance◦ Ordering restaurants/ making phone calls


Case 2

Problems identified/solved◦ Needed something simple, quick◦ Some receptive language issues

◦ Initially watching video difficult◦ Only fluent videos

◦ Setting treatment goals◦ Client-driven


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Case Study 3: Rhythmic Speech: Stuttering & Language Difficulties

History◦9 years old at TX onset◦Hypotheses of language disorder◦Mild/moderate receptive; moderate severe expressive◦Low vocabulary◦ Immature Narrative◦Moderate stuttering; SR-4-6◦Family history of stuttering


Case Study #3: Intervention Lidcombe Program: 10 sessions◦ Parent not keeping SR accurately◦ Not using data to guide TX◦ Little praising/inaccurate feedback◦ Child becoming uninterested

◦ Rhythmic speech◦ Child leads TX◦ Less parent involvement◦ Complex sentences possible

◦ Stretchy starts◦ Used for specific situations like oral presentation


Case Study #3Service Delivery Model◦Parent present during sessions

◦Weekly/semi-monthly

◦Option for telepractice

◦Child leaves weekly message for practice

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Case Study #3Progression of treatment◦Lidcombe Programe (10 sessions over 2.5 months

◦Rhythmic Speech and Stretchy start◦Once every 2-3 weeks◦Rhythmic speech helpful for child with language concerns

Outcome ◦Video pre-post◦Client satisfaction


Case Study #3Problems identified/solved◦ Inconsistency at home

◦No generalization

◦Little ‘buy-in’

◦Other speech & language problems

Documents

Treating Stuttering in School Age Children · Combined Stuttering Treatment: Evidence 6 boys; 1 girl – mean age 10.2 years 40 hours intervention