Therapy for Preschool and School Age Children who Stutter

Transcription

1 Therapy for Preschool and School Age Children who Stutter Thank you! 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 1

2 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,

3 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 4 th 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 3

4 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 4

5 Demands & Capacities Therapy Counseling the family Provide support Provide (some) information Model problem solving Empower the parents Demands & Capacities Therapy 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 Demands & Capacities Therapy 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. 5

6 Demands & Capacities Therapy Things the Family CAN Do: 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 Demands & Capacities Therapy Things the Family CAN Do: 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. 6

7 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. 7

8 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 partword 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. 8

9 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 9

10 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 Increasing Knowledge: Identification Learning facts about stuttering Learning about famous people who stutter Learning about talking Learning about one s own stuttering pattern -- tension 10

11 Increasing Knowledge: Identification Understanding that all people have disfluencies Understanding that people who stutter can be effective communicators and still stutter: you play a big role here! Increasing Knowledge: Identification 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). 11

12 Increasing Communication: Desensitization 1. Create a safe environment 2. Decrease fear of speaking/stuttering 3. Modify stuttering Increasing Communication: Desensitization 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 12

13 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,

14 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? 14

15 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. 15

16 Stuttering Support Friends: for families & young people who stutter: National Stuttering Association Camp Our Time: Hendersonville, NC August 4-18, 2013 Lots of scholarships available Stuttering Information (and support) Stuttering Foundation of America podcasts & information 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 16

17 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! kleinjf@appstate.edu