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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Children who cannot do this
May pay a social price
Start to develop negative reactions/fears
More likely to be bullied, rejected, less popular
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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???
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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???
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
10/24/2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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?
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Teacher’s Role
Supportive
Educative
Inclusive
Therapeutic?
Information available:◦SFA
◦Michael Palin Centre
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Some viable treatments
Lidcombe Program
Combined Stuttering Programs
Rhythmic Speech- STS
Video Self-modeling
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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)
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Combined Stuttering TreatmentService Delivery Model
◦5 day intensive
◦7 week follow up visits – individual
◦ Individual/group problem solving
◦Deals with maintenance/follow up
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
10/24/2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Rhythmic Speech - STSService Delivery model
◦Individual and simple
◦Parent participation
◦Could be altered to group format?
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
10/24/2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Self-modeling Service Delivery Model
◦ Individual
◦No parent participation necessary
◦Child needs to be self-motivated/mature
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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???
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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?
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Case Study #1Why choose Lidcombe Program?◦No previous treatment for stuttering◦Parent involvement◦Licombe Program-best practice◦Window of Opportunity age wise
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
4
5
6
7
1 2 3 4 5 6 7 8 9 10 11 12
Severity
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Case Study 2: Combined Treatment11 years old at onset of TX
History◦De George Syndrome◦Phonology◦Learning difficulties◦Moderate/Severe stuttering
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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)
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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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ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
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
ROSALEE SHENKER MONTREAL FLUENCY CENTRE 2016
Case Study #3Problems identified/solved◦ Inconsistency at home
◦No generalization
◦Little ‘buy-in’
◦Other speech & language problems