EXPLORING CLIENT-DIRECTED OUTCOMES-INFORMED (CDOI)THERAPY WITH AN ADOLESCENT WHO STUTTERS

Transcription

1 EXPLORING CLIENT-DIRECTED OUTCOMES-INFORMED (CDOI)THERAPY WITH AN ADOLESCENT WHO STUTTERS Haley Lewis & Lisa Scott School of Communication Science & Disorders Florida State University

2 TREATMENT PROGRAMS FOR ADOLESCENTS WHO STUTTER Few, if any, investigations have reported treatment protocols developed specifically for adolescents who stutter (Blood, 1995). Historically, studies reporting data for adolescents have been treatments designed either for schoolage children OR adults Adolescence is viewed as perhaps the last time that therapy may prevent development of chronic stuttering (Hearne, Packman, Onslow, & Quine, 2008)

3 CHARACTERISTICS OF ADOLESCENT DEVELOPMENT Rapid and diverse developmental changes occur physiologically, cognitively, and socially Cognitive/social changes that may influence stuttering treatment: Entering Piaget s stage of formal operations Abstract thinking Formulating opinions about benefits of treatment Development of sense of self (Kelly, 2007) Motivation Increased independence and psychological distancing from parents (Berk, 2002) Increase focus on peers, what others think

4 CLIENT DIRECTED, OUTCOMES INFORMED (CDOI) THERAPY (DUNCAN, MILLER, & SPARKS, 2004) Therapy approach developed in psychology Premise is that therapy should focus on the Client Client s preferences for change Outcomes of the client s perception of therapy Client is given responsibility for giving feedback to the clinician on The clinician s relationship with the client How goals and methods in therapy fit client s desires & vision How sessions are progressing

5 Use of very brief, visual analog scales Session and Outcome Rating Scales Available in both child and adult versions Session Rating Scales: end of every session Outcome Rating Scales: at beginning of every 10 th session Client makes a mark on a 10 cm line, clinician measures line Bring the SRS into the next session, discuss why client made ratings where he/she did, and what needs to change in order for mark to move to the right Brief visual analog scales have been determined to be both reliable and valid Change in response to medical treatments (c.f., Grunhaus, Dolberg, Polak, & Dannon, 2002), assessment and management of pain (c.f. Ger, Ho, Sun, Wang, & Cleeland, 1999), perceived quality of care (c.f., Arneill & Devlin, 2002), and health states preferences (Torrance, Feeny, & Furlong, 2001) CDOI scales: Miller et. al (2003)

6 PURPOSE Although CDOI has not been reported as part of therapy for individuals who stutter, it appears to be potentially useful as an adjunct to traditional approaches. Measures: Obtain direct feedback regarding whether therapy is meaningful/functional; Are quick, easy Are sensitive to small changes across time The purpose of the case study was to determine whether An adolescent who stutters would utilize session feedback to direct his treatment His ratings of functional outcomes would change as a result of CDOI implementation Any affective, behavioral, or cognitive changes might be observed These were not the primary focus of the case study, however

7 PARTICIPANT: G 19 year old male at time of intervention Diagnosed with stuttering at age 3 Referred to FSU Speech & Hearing Clinic at age 8 At time study began, he had participated in 2 hours of therapy per week most academic terms for 10 years Stuttering was rated as Severe on SSI 3 Characterized by blocks that were avg. of 3 sec in duration. Physical concomitants were minimal Despite many years of treatment, progress had been minimal As G progressed through adolescence, he desired to continue treatment but became less and less willing to complete functional activities (talking with peers, introducing himself to others, etc.)

8 Interviewed prior to start of the study, asked to recount all aspects of therapy he could remember He recalled working on: Easy beginnings, pseudostuttering, modifying secondary behaviors, relaxation techniques, and strategies for altering airflow His impression was that most of therapy had not worked for him He expressed dislike for pseudostuttering or relaxation, although these had been regular components of his treatment for the past 3 4 years He felt easy beginnings were most helpful He was able to demonstrate all techniques that he had named, and describe the rationale for each

9 INTERVENTION Semester 1: Pre CDOI 13 weeks Traditional fluency treatment, with goals focused on mastery (80% accuracy or greater) of: Easy beginnings Identifying moments of stuttering Modifying moments of stuttering through pull outs Decreasing secondary behaviors: body movements, increasing eye contact CDOI Semester: Same intervention, but CDOI measures were introduced 8 weeks

10 DATA ANALYSIS Affective, cognitive, and behavioral measures were made End of Pre CDOI Semester, End of CDOI semester, and 9 months post CDOI semester Stutters per minute of speaking time (SMST; Onslow, 2003) The OASES (Yaruss & Quesal, 2006) The Erickson S 24 (Andrews & Cutler, 1974) CDOI measures during CDOI semester only Session Rating Scales Outcome Rating Scales Sessions 1, 10, and 19

11 CDOI SESSION RATING SCALE: RELATIONSHIP

12 CDOI SESSION RATING SCALE: GOALS & TOPICS

13 CDOI SESSION RATING SCALE: APPROACH OR METHOD

14 CDOI SESSION RATING SCALE: OVERALL SESSION RATING

15 CDOI OUTCOME RATING SCALE: INDIVIDUAL OUTCOMES

16 CDOI OUTCOME RATING SCALE: INTERPERSONAL OUTCOMES

17 CDOI OUTCOME RATING SCALE: SOCIAL OUTCOMES

18 CDOI OUTCOME RATING SCALE: OVERALL OUTCOMES

19 STUTTERS PER MINUTE Intervention Semester Stutters in 5 min. sample Stutters per minute Pre-CDOI CDOI Nine months later

20 OASES& ERICKSON S-24 RESULTS OASES Overall Impact Scores Pre CDOI: 2.04 CDOI Semester: months post CDOI: 1.65 All of these impact scores equate to an impact rating of mild/moderate. Erickson S 24 At all points, G s Erickson scores fell within the range for normally fluent speakers Semester 1: 5 CDOI Semester: 4 9 months post CDOI: 7

21 DISCUSSION This case study was an exploration of whether giving an adolescent more control over the therapy he was participating in would yield positive changes Trends in the data are encouraging, and suggest that further investigation of CDOI as an adjunct to traditional fluency therapy is warranted CDOI measures all indicated positive change G s perceptions of functional outcomes improved, despite negligible change noted among affective, behavioral, and cognitive measures

22 Very brief, visual analog scales were useful in assessing Session to session outcomes G worked with clinician to modify his treatment; he finally expressed his dislike for pseudostuttering and the technique was dropped Client s perceptions of functional outcomes outside the therapy room CDOI may be useful in adolescent therapy due to the control it offers them in determining the course of treatment Allows the adolescent to express opinions Requires the client to take a more active, independent role Provides a quick snapshot of functional outcomes

23 FURTHER RESEARCH More participants in a controlled investigation Gathering data on SRS/ORS measures without implementation of CDOI Does being in treatment alone yield positive changes in ORS without implementation of CDOI Does clinician level of skill/confidence matter? Are the items rated good indicators of functional outcomes for communication?