Intervention Principles for Working with Preschool Children who Stutter Patricia M. Zebrowski, Ph.D. University of Iowa - PowerPoint PPT Presentation

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Intervention Principles for Working with Preschool Children who Stutter Patricia M. Zebrowski, Ph.D. University of Iowa

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Title: Intervention Principles for Working with Preschool Children who Stutter Patricia M. Zebrowski, Ph.D. University of Iowa


1
Intervention Principles for Working with
Preschool Children who StutterPatricia M.
Zebrowski, Ph.D.University of Iowa
2
Clinical Questions
  • What causes stuttering?
  • Is the child stuttering or normally disfluent?
  • Will the child outgrow stuttering?
  • What treatment options are available for
    school-aged children (elementary through high
    school?)

3
Clinical Questions
  • Should therapy be direct or indirect?
  • What approaches are best for young, preschool
    children?
  • What do we need to know about teenagers? What
    extras may help teens to make changes?

4
  • What Causes Stuttering?

5
What Do We Know About Early Stuttering ?
  • Onset of stuttering typically between 2-4 years
    of age
  • Probability of stuttering onset decreases with
    age
  • Lifetime incidence (in USA and Western Europe)
    approximately 4-5 of the population

6
  • Prevalence ranges from 0.5 to 1
  • Estimates of unassisted recovery or remission
    range from 32-89
  • Stuttering runs in families
  • More boys than girls develop chronic stuttering
    problems (31)

7
  • Theories of Stuttering Onset and Development
  • Diagnosogenic Theory (Johnson)
  • Communicative Failure/Anticipatory struggle
    (Bloodstein)
  • Demands and Capacities Model (Andrews Harris,
    1964 Adams, 1990)
  • Interaction Theory (Conture, 2001)
  • Communicative/Emotional Model (Conture, Walden,
    Karrass, Arnold, Hartfield Schwenk, 2005).
  • Multifactorial Model (Smith Kelly, 1997)

8
  • In essence, there is no
  • core factor(s) necessary for stuttering to emerge
    or persist
  • in young children

9
  • Rather, stuttering results from the complex
    interaction of a number of risk factors

10
  • Factors include
  • heredity speech motor function
  • language temperament
  • cognition environment
  • communicative context

11
  • Is the Child Stuttering or Normally Disfluent?

12
?
?
?
Question 3 Is therapy warranted and recommended?
Question 1 Is the child stuttering, or at risk
for stuttering?
Question 2 Will the child experience recovery
from stuttering will he outgrow it?
Objective 1 Describe and measure speech
(dis)fluency
Objectives 1, 2 3
Answers to Questions 1 2
Objective 2 Determine childs beliefs and
attitudes about talking
Objective 3 Interview the parents
13
  • CONSIDER STUTTERING WITHIN THE CONTEXT OF FLUENCY
    AND DISFLUENCY
  • FLUENCY
  • The smooth transitioning between sounds,
    syllables, and words
  • DISFLUENCY
  • A disruption in this process

14
CHARACTERIZING DISFLUENT BEHAVIOR
  • BETWEEN-WORD (aka Other Disfluencies Yairi et
    al., 1999)
  • Interjections
  • Revisions
  • Phrase repetitions

15
CHARACTERIZING DISFLUENT BEHAVIOR, (cont.)
  • WITHIN-WORD (aka Stuttering-Like Disfluencies
    Yairi et al, 1999).
  • Sound/syllable repetitions
  • Sound prolongations
  • (audible and inaudible)
  • Monosyllabic whole-word repetitions

16
  • STUTTERING IS A FORM OF SPEECH DISFLUENCY
    CHARACTERIZED BY A RELATIVELY HIGH PROPORTION OF
    WITHIN-WORD SPEECH DISFLUENCIES AND ASSOCIATED
    BEHAVIORS

17
  • AND
  • LISTENERS MORE FREQUENTLY JUDGE WITHIN-WORD
    DISFLUENCIES TO BE STUTTERING OR ATYPICAL AS
    COMPARED TO BETWEEN-WORD DISFLUENCIES.

18
MEASUREMENT OF DISFLUENCY AND RELATED BEHAVIOR
  • Frequency of speech disfluency
  • Relative proportion of disfluency types
  • (within and between)
  • Duration of within-word speech disfluencies
  • Associated (non) speech disfluencies

19
MEASUREMENT OF DISFLUENCY AND RELATED BEHAVIOR
  • Severity
  • Speech Rate (overall and articulatory)
  • Awareness and Emotionality
  • Attitudes About Speaking and Stuttering

20
  • Will the Child Outgrow Stuttering?

21
Patterns of Unassisted Recovery
  • Probability of recovery highest from 6-36 months
    post onset
  • Majority of children recover within 12-24 months
    post onset
  • Period of recovery marked by steady decrease in
    sound/syllable and word repetitions and prolonged
    sounds over time, beginning shortly after onset

22
  • Relatively brief beginning and ascending phase,
    and a relatively long declining phase
  • Subgroup of children presenting with severe
    stuttering at onset, with frequency of behaviors
    peaking at 2-3 months post onset and full
    recovery seen by 6-12 months

23

Recovery Predictors
  • Described by Yairi and associates (1992,1999,
    2005), and others (Conture, 2004 Pellowski
    Conture, 2002 Zebrowski, 1991)
  • Onset before age 3
  • Female
  • Measurable decrease in sound/syllable and word
    repetitions, and sound prolongations, overtime,
    observed relatively soon post-onset

24
  • No family history of stuttering or a family
    history of recovery
  • No coexisting phonological problems (and possibly
    language and cognitive problems?)
  • ALL ARE PROBABILITY INDICATORS

25
  • Indirect
  • Monitoring
  • Parent counseling
  • Providing models of specific speech
    characteristics with NO overt or deliberate
    attention paid to the childs speech or speech
    disfluency.

26
  • What are the Options for Treatment?
  • What Treatment Approaches are Available?

27
The Pre-School Child Who Stutters
28
We suspect that a child is either stuttering or
at risk for developing a stuttering problem if
(s)he meets BOTH of the following criteria
  • Produces THREE (3) or more WITHIN-WORD speech
    disfluencies per 100 words of conversational
    speech (i.e., sound/syllable repetitions and/or
    sound prolongations)
  • Parents and/or other people in the childs
    environment express concern that the child either
    stutters or is a stutterer.
  • After Johnson, Williams, Conture and others

29
  • Parent-Child Interaction Therapy (PCIT)
  • (Millard, Nicholas Cook, 2008)
  • Rooted in multifactorial model of early
    stuttering
  • Collaborative, flexible approach tailored to
    individual family
  • Stuttering is openly discussed and acknowleged
    with child
  • Tools based on (a) child assessment, (b) parent
    interview, and
  • (c) guided observation of videotaped parent-child
    play
  • to determine physiological, linguistic,
    environmental or
  • psychological factors

30
  • Parent-Child Interaction Therapy (PCIT)
  • (Millard, Nicholas Cook, 2008)
  • Session 1
  • - Clinician feedback from evaluation and
    discovery while
  • watching videotape.
  • - Management and Interaction tools are chosen.
  • - Special Time is negotiated.

31
Parent-Child Interaction Therapy (PCIT) (Millard,
Nicholas Cook, 200 Session 1 Management
Tools managing child and parent anxiety about
stuttering coping with sensitive
children confidence building behavior
management (e.g. sleeping, eating, turn-taking,
tantrums, etc.)
32
Parent-Child Interaction Therapy (PCIT) (Millard,
Nicholas Cook, 200 Session 1 Interaction
Tools Reduce speech rate Increase duration
of turn-taking pauses Reduce amount of talking
and length/complexity of utterances Decrease
language demands (i.e. vocabulary,
grammar, amount of talking, performance
requests)
33
  • Parent reduces time pressure in daily routine,
    and communicative time pressure in verbal
    interaction with child
  • Decrease time pressure in daily life

34
Parent-Child Interaction Therapy (PCIT) (Millard,
Nicholas Cook, 200 Session 1 Interaction
Tools During Play Follow childs lead during
play and verbal interaction (less physically
active role) Reduce instructions and questions
(use comments instead) Maintain attention
with eye contact, showing interest, encouragement
and praise Reduce language demands (i.e.
vocabulary, grammar, amount of talking,
performance requests)
35
Parent-Child Interaction Therapy (PCIT) (Millard,
Nicholas Cook, 2008) Session 2 Videotape
parent-child play and observe use of selected
interaction tools and their effectiveness Paren
t taught to observe relationship between child
stressors (internal and external) and fluency,
and modifies/manipulates when possible
Provide feedback sheets and schedule weekly
parent visits
36
Lidcombe(Onslow,Packman Harrison,
2003)Australian Stuttering Research Center
  • Parent provides treatment following training by
    clinician
  • Spontaneous fluency is reinforced, instances of
    stuttering are highlighted through parent request
    to say it easy. (Similar to cancellation?)
    Ratio of praise to request for do-over _at_ 51

37
  • Lidcombe (contd)
  • Parent provides treatment in daily intervals of
    increasing length and communicative complexity.
  • Parents taught to rate stuttering frequency and
    severity, and keep daily ratings of each for self
    and clinician.
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