ncshla fall 2014– gilcu program indirect therapy • managing the environment • teaching parents...

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Therapy for Preschool and School Age Children

who Stutter

–  Thank you!

–  [email protected]

–  828-262-2620

Goals for Today… Seriously

Participants will be able to: 1.  List three factors that make children

more likely to recover from stuttering 2.  Develop a treatment framework for

preschoolers who stutter. 3.  Develop a treatment framework for

school age children who stutter

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Causes of Stuttering •  ~70% of stuttering is genetic

•  ~30% is unknown, but children who stutter (CWS) have higher incidence of: – Anoxia at birth –  Instruments used at birth – Early head trauma – ADHD – Epilepsy – Cognitive impairment

Onset of Stuttering •  85% of CWS begin stuttering before age 3½

•  40% start stuttering in one to three days •  ~50% of CWS begin with repetitions only •  ~45% start with reps & prolongations •  ~5% start with prolongations & blocks

–  Yairi & Ambrose, 2004

Recovery from Stuttering

•  Chance of recovery for CWS = 75%. •  1 year post onset = 63%. •  2 years post onset = 47%. •  3 years post onset = 16% •  4 years post onset = 5%

• Yairi & Ambrose, 2004

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Predictive Factors

•  Family History is strongest predictor. –  If no relatives stutter, chances of recovery are

above 75% –  If relatives stuttered as children and recovered,

chances of recovery are 65% –  If relatives have continued to stutter into

adulthood, chances of recovery are 35%

Predictive Factors

•  Gender –  Girls are more likely to recover than boys

•  Age at Onset –  After 4th birthday, chances of recovery are lower

than children who start before age 3.

•  Other Speech/Language/Learning/Attention Disorders –  These children are less likely to recover

from stuttering

PRESCHOOL STUTTERING THERAPY

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Two Therapy Types for Preschoolers

•  Indirect Treatments: –  Demands and Capacities Model Therapy –  Parent-Child Interaction Therapy –  These treatments also have “Direct

Components” •  Direct Treatments:

–  Lidcombe Program –  GILCU Program

Indirect Therapy

•  Managing the environment

•  Teaching parents and teachers new ways to interact

•  Modeling a different way of talking

Demands & Capacities Therapy

•  Starkweather, Gottwald, & Halfond, 1990 •  Gottwald, 2010

•  Focuses on counseling and educating parents and decreasing the demands on the child, while letting his capacities naturally increase

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•  Counseling the family –  Provide support –  Provide (some) information –  Model problem solving –  Empower the parents


•  Reducing Speech Motor & Language Pressure –  Speech rate of family –  Pace of household –  Giving child time to initiate, respond, finish talking –  Matching language complexity with child’s abilities –  Following child’s lead –  More comments, less questions –  Positive comments


Things the Family CAN Do:

1. The parents can change their speaking style. –  Have parents model slow, easy whole word or

phrase repetitions at the beginning of utterances. –  Then see if parents can incorporate one factor

from previous slide.

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2. Have parents journal daily about stuttering. –  When does stuttering increase? –  When does stuttering decrease? –  Rate stuttering severity from 1 to 10 each day

•  1 = no stuttering •  2 = very mild stuttering •  10 = very severe stuttering



3. Child-led activity, one-on-one with a parent, for 15 minutes every day.

–  Child chooses the activity and topic –  Parents use a relaxed, slow rate of speech –  Lots of pausing –  Only positive comments –  Limited questions

Demands & Capacities Therapy •  There is no evidence that parent interaction styles

cause stuttering. •  The initial use of an indirect approach provides a

firm foundation for therapy and gives parents essential skills to support the child, even if direct approaches may be required later. – Millard, Nicholas, & Cook, 2008

•  I always start here with anyone 6 and under.

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Lidcombe Program

•  Jones, Onslow, Packman, O’Brian, Hearne, Williams, Ormond, & Schwarz (2008)

•  Onslow, Packman, Harrison (2003)

Lidcombe Program

•  Designed for Children under age 6

•  Goal: Stutter-free speech

•  Strongly suggested that it be used only by those who have been trained

Lidcombe Program

•  Clinician’s role in the treatment is to train the parent to deliver treatment safely and effectively

•  Parent is taught to accurately identify moments of stuttering / fluency

•  The Parent is then taught to praise fluency and change moments of stuttering.

•  A minimum of 5 praises must be given before a correction.

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Lidcombe Program

•  Praising: vary the wording

•  Acknowledge (“that was smooth”)

•  Request for Self Evaluation (“was that fluent/smooth/easy talking?” Answer is: “Yes!”)

Lidcombe Program

•  Request for Self-Correction: –  If in doubt, leave it out –  Only correcting blocks, prolongations, and part-

word repetitions (or single syllable word repetitions with more than three repetitions).

–  Aim is assistance, not punishment –  “C-C-C-C-an we go to the park?” –  “Oooh, that was bumpy. Say ‘Can’.” –  “Can we go to the park?” –  “Yes. Nice job.”

Lidcombe Program

•  So… •  5 to 10 praises for fluency •  1 Request for correction •  And repeat… •  Move from structured, 15 minute play time to every

day. •  Parent keeps 1-10 rating scale every day. •  Works best with 4 and 5 year-olds.

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Common Factors •  Clinician meets with parents & child once per week •  Clinicians are guides •  Preschool stuttering therapy should be delivered by

parents at home •  Counseling, including problem solving and

empowerment •  Stuttering is an open topic – no conspiracy of

silence •  Parents evaluate stuttering and journal

daily

Common Factors •  Daily, one-to-one parent-child interaction time •  Parents do lots of praising and supportive reactions •  Parents become educated about stuttering

–  Symptoms and cause –  Parents are not the cause of stuttering

•  Focus on demands on child’s speech and language •  Going from more to less structured

THERAPY FOR SCHOOL-AGE CHILDREN

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What are our goals, then?

•  Stuttering is not “curable” or “preventable” after 3 or 4 years since onset.

•  Think of stuttering like autism, hearing loss, apraxia, aphasia, etc.

•  Great stuttering therapy for school age kids is about management, coping skills, and fluency/stuttering modification, all rolled into one.

Increasing Knowledge: Identification

•  Rationale: 1.  Feeling “out of control” is scary 2.  Not knowing what you are doing is scary 3.  You need to know what you are doing to

change what you are doing 4.  Normalizes stuttering 5.  Decreases anxiety


•  Learning facts about stuttering •  Learning about famous people who

stutter •  www.stutteringhomepage.com •  Learning about talking •  Learning about one’s own stuttering

pattern -- tension

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•  Understanding that all people have disfluencies

•  Understanding that people who stutter can be effective communicators and still stutter: you play a big role here!


•  What does your child who stutters know about stuttering? About people who stutter? About his stuttering?

•  Does your child know what he does when he stutters?

Increasing Communication: Desensitization

•  Rationale: •  CWS need to participate in their classrooms

as much as other students •  Unless you are talking in class, you cannot

work on your stuttering in class. •  Fear of stuttering can only be reduced by

stuttering (using a hierarchy).

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1. Create a safe environment 2. Decrease fear of speaking/stuttering 3. Modify stuttering


•  Meeting with the classroom teacher – Child gets to talk openly with his teacher

about stuttering •  Child can relay his needs to the teacher

– Routine class participation – Special projects/presentations

•  Discuss Teasing/Bullying

Creating a Safe Environment

•  Goal: •  Mary will meet with her classroom

teacher to discuss her stuttering and list 3 things her teacher can do to facilitate talking in the classroom

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Creating a Safe Environment

•  Benchmarks: •  Mary will brainstorm with the clinician to

identify 5 things that would help her talk more in the classroom.

•  Mary will choose 3 of the 5 ideas to discuss with the classroom teacher.

Decrease Fear of Stuttering

•  Rationale: •  If you are afraid of snakes, the way to

become less afraid of snakes is to be around more snakes in a safe environment. Avoiding snakes only increases the fear for the next time.

•  Trying to be fluent does not make you less afraid of stuttering.

Desensitization

•  Gradually experiencing feared situations in a supportive environment using a controlled, systematic hierarchy – Van Riper, 1973 – Murphy, Yaruss, & Quesal, 2007

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Desensitization

•  Being open and honest about stuttering – Talking about “it” openly with you is the

first step – Inviting a friend (or parent) in for therapy

could be next – Talking to his teacher – Talking to his class

Desensitization

•  Freezing: holding onto a moment of stuttering – Using humor – Learning some easy releases

•  Voluntary Stuttering – In the therapy room – Outside the therapy room – Making stuttering “fun”

Desensitization

•  Does your child who stutters talk in her classroom?

•  Does she order what she wants for lunch?

•  Can she stutter without tension? •  Can she have a conversation with you,

with her parents, with her friends, about stuttering?

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Goals

•  Sarah will name 5 famous people who stutter and write down 2 facts about each person.

•  Roger will complete interviews about stuttering with 3 fluent speakers, and report on their answers in therapy to at least one other person who stutters.

•  Stephen will raise his hand ten times to ask a question in class during the month of November.

IEP Goals

•  John will give a presentation to his class about stuttering.

•  John will decrease his percent syllables stuttered by 25% during a classroom presentation.

Words are important

•  Use the word “stuttering” •  Good stuttering •  Interesting stuttering •  Hard stuttering, easy stuttering •  It’s okay to stutter, it’s okay to talk the way

you talk right now.

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Stuttering Support

•  Friends: for families & young people who stutter: www.friendswhostutter.org

•  National Stuttering Association – www.westutter.org

•  Camp Our Time: – www.campourtime.org – Hendersonville, NC – August 4-18, 2013 – Lots of scholarships available

Stuttering Information (and support)

•  www.stutteringhelp.org: Stuttering Foundation of America

•  www.stuttertalk.com: podcasts & information

•  www.stutteringhomepage.com

•  If you asked any of my students what was most important to them, it isn’t the amount of stuttering that they exhibit each day, it is the fact that Stuttering Does Not Define Them! They can relax knowing that they have permission to stutter! That their goal is to become better COMMUNICATORS! (not just kids who work hard not to stutter!) My kids have had so much growth! –  Terri Spencer, CCC/SLP –  Rumsey Station Elementary

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–  I want the PWS to stop saying "If I practiced more, I would have less stuttering” with very poor functional communication and a lot of stuttering and avoidance behaviors. I want them to… accept their stuttering, work on their avoidance behaviors, and advertise that they stutter. I want them to have functional communication for everyday life and have some stuttering. I want the SLP, especially in the schools, to stop apologizing for "not knowing what to I want them to stop feeling guilty when the "percentage of stuttering" does not drop and I want them to feel empowered when their students exhibit good functional communication with some stuttering and the students "say what they want, where they want, and when they want" with good pragmatic language skills. •  Judith Eckardt, M.S., CCC-SLP •  Tuscon, AZ

–  Thank you!

–  [email protected]

–  828-262-2620

ncshla fall 2014– gilcu program indirect therapy • managing the environment • teaching parents...

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