Stuttering Therapy for School-Age Children: What Should Be Changed and Who Decides?

1. Stuttering Therapy for School-Age Children: What Should Be Changed and Who Decides? Patricia M. Zebrowski, Ph.D., CCC-SLP University of Iowa

2. Essential Clinical Skills • Modeling • Praising • Summarizing • Rephrasing • Putting the stuttering in your own mouth • Accepting • Checking in

3. Essential Clinical Skills • Telling child what’s coming next (we’re going to do this 3 times) • Questioning the child for understanding– do you understand why we’re doing this? • Knowing when and how to prompt • Asking permission: Is it ok if I interrupt you • Acknowledging the message/valuing communication • Using humor • Contrasting (saying hard/saying soft)

4. Making Choices • Changing speech and stuttering means understanding that there are choices for talking • Introducing choices needs to be done in a learning hierarchy

5. Making Choices • General steps in any hierarchy • Clinician models and child observes • Clinician and child practice together • Child tries the tool/teaches clinician how to produce it • Child practices the tool with clinician feedback • Child practices and rates own production with clinician guidance. • Child practices the behavior and self-monitors • Transfer activities and homework should correspond to and be co-occurring at each level of the hierarchy

6. Exploring Talking • Understanding and making choices about talking may be the most important piece of the therapy puzzle • In order to understand and feel what s/he does during stuttering, the child must know how we talk • Establishes common terminology between child and clinician • Develops understanding of how we coordinate respiration, phonation & articulation for speech • Reinforces that his/her speech system is “normal”; i.e. NOTHING NEEDS TO BE ‘FIXED’ • Rationale for this step • Starting treatment in a way that is removed from emotion: neutral and objective • Encouraging child to approach something that he/she fears and is used to avoiding

7. Exploring Talking Purpose of exploring talking and stuttering is to experiment with choices for: • Changing speech • Tools for changing airflow, tension, voicing, movement, rate WHICH LEADS TO… • New ideas about speaking, for example: • I don’t have to keep using the same patterns of speaking • I have options for speaking and for stuttering

8. Exploring Stuttering • Identify aspects of stuttering • In order to change behavior, need to know when andwhat to change • Use a hierarchy to experiment with change • Working through the change hierarchy helps the child to reduce worry and fear about speaking and stuttering (desensitization) • Exploring stuttering ties information from exploring talking to child’s own behavior/speech patterns

9. PROBLEM-SOLVING • Disfluency and stuttering represent difficulty in connecting sounds, syllables and words. Given that, • Attend to where you are “disconnecting” and what you are doing. What needs to be done to “move forward” and smoothly connect sounds, syllables and words while speaking? • The same principles are used to both initiate and maintain ‘easy’ speech, and to produce ‘easier’ stuttering

10. Tools For Change Changing Talking • Soft starts/easy onsets/light contacts • Changing rate Changing Stuttering • Voluntary stuttering • Holding & tolerating a moment of stuttering • In-block corrections/pullouts • Post-block corrections/cancellations

11. Changing TalkingSoft Starts/Easy Onset andLight Contacts • What are they? • Slower, physically relaxed speech initiation • Decreased muscle tension and less tense articulatory constriction (e.g. bilabial closure, tongue-alveolar contact) • Why use them? • Help initiate smooth airflow, voicing, and physically relaxed, smooth articulator movement • When to use them? - Beginning of phrases or utterances - Phrase boundaries

12. Changing Talking: Changing Rate • What is it? • Slower speech overall: fewer syllables or words per minute • Should sound smooth and connected, not choppy • Why use it? • It’s fluency enhancing because it… • Helps child attend to what he/she is doing • Gives more time to process • Gives child time to make changes in complex motor coordination • Helps child feel changes in muscle tension • How can rate be changed? • Stretching sounds or syllables • Phrasing and pausing • Combining stretches with phrasing/pausing

13. Changing Stuttering:Deliberate(orVoluntary) Stuttering • What is it? • The child stutters “on purpose”, choosing when and how • Why use it? • Can be used to teach any aspect of changing and varying stuttering • Assists in building awareness of stuttering moments • Decreases fear and avoidance of stuttering • Desensitizes to listener reactions • Creates a feeling of confidence in the ability to say feared words • Confront what might otherwise be avoided • When and how to use it? • Prelude to using “pullouts” • Begin teaching at the single word level with unfeared sounds or words • Begin using it in unfeared situations • Build to use on feared words or in feared situationss

14. Changing Stuttering:Holding & Tolerating A Moment of Stuttering • What is it? • Staying in a moment of stuttering • Child continues speech “movement” rather than stopping, “backing up”, or otherwise using “reactive” speech strategies • Why use it? • Increases child’s awareness of what he/she is doing during the stuttering moment • Helps reduce avoidances • Is desensitizing • When and how to use it? • After child can identify when and how he/she is stuttering • Clinician HAS to be supportive and encouraging as the child is holding the stuttering moment

15. Changing Stuttering: Pullout • What is it? • “Holding on” to the stuttering moment and “staying with it” • Helps to focus in on site of physical tension and cessation of movement so as to • Change the stuttering moment through reducing or “easing off” tension and slowly moving ahead into the next sound or word • Why use it? • Confront the stuttering moment and “take charge” (desensitization) • Release tension and keep speech moving forward • Reinforce a looser or “easier” way of stuttering

16. When and how to use it? • When the child experiences a high degree of emotionality or feels “stuck” in a moment of stuttering • After the child has learned to “hold onto” a moment of stuttering and tolerate it • Start with deliberate or “fake” stuttering at the single word level

17. Changing Stuttering:Cancellation • What is it? • Finishing a stuttered word then • Pausing for a moment to plan (e.g. pantomime or silently revisit the word) then • Stuttering on the word again in an easier way • Why use it? • The child learns to “cancel out” or replace hard stuttering with a looser, more controlled form of stuttering • Cancellation discourages avoidance behaviors such as recoiling, changing words, stopping in a block and backing up • Cancellation reinforces easier stuttering and build confidence

18. When and how to use it? • Child MUST complete the hard stutter before pausing and making it easier • If the child is unable to pullout or missed the opportunity to use a pullout, this will provide another opportunity to learn to stutter more easily and build confidence • Typically used in the therapy room only as a way of learning a strategy, not in the outside world

19. Disclosure • What is it? • Child chooses to openly acknowledges own stuttering to listeners • Why use it? • Allows the child to take control of the situation • It promotes openness about using techniques • Helps listeners know what to expect • Informs listeners what the client wants them to do • When to use it? • Like other tools, it should occur in a hierarchy (e.g., family, friends, group therapy, teachers/co-workers, strangers) • At the beginning of a conversation or presentation

20. The Great Therapy Debate: Different Fields, Same Questions. • What therapy approach “works best?” • What is the evidence? • Are there different kinds of evidence? • If so, do they receive equal weight in treatment planning? • How does evidence translate into clinical practice?

21. Evidence-Based Practice Evidence-based practice is the integration of the best research evidence with clinical expertise and client values. • ‘best research’ = ‘outcomes research’ or clinically relevant research into the accuracy,precision, and efficacy of diagnostic tests and treatments The Technique

22. Evidence-Based Practice • ‘clinical expertise’ = the ability to use our best clinical skills and past experience to identify delay or disorder, appropriate intervention, and the client’s personal values and expectations The Clinician

23. Evidence-Based Practice • ‘client-values’ = the unique preferences, concerns and expectations each client brings to the clinical experience The Client

24. What Can We Learn from Psychotherapy Research? • Numerous studies have compared the effectiveness of different therapeutic approaches for depression, anxiety, schizophrenia, etc. • Many of these investigations consisted of meta-analyses of the efficacy of various types of therapy (e.g. Wampold, Mondin, Moody, Stich, Benson & Ahn, 1997).

25. What Can We Learn from Psychotherapy Research? • With rare exception, research has uncovered little significant difference among different psychotherapeutic approaches. • This observation has been described as “the dodo effect”(e.g. Tallman & Bohart, 2004). “Everybody has won and all must have prizes” - Lewis Carroll

26. Explaining the “Dodo Effect” • Different therapy approaches use dissimilar strategies or processes to achieve the same outcome • Research methods may not be sensitive enough to detect differences in therapeutic effectiveness among approaches OR differences are so subtle that they cannot be observed using conventional between-group designs

27. Explaining the “Dodo Effect” Studies of treatment efficacy do not provide objective descriptions or operational definitions of therapy protocol (i.e., client-centered). Studies of treatment efficacy do not provide the quantitative information to allow for inclusion in meta-analysis There are common factors throughout all therapies that facilitate change or progress.

28. Explaining the “Dodo Effect” It is the similarities, rather than the differences, between approaches that account for the observation that all psychotherapeutic approaches are, in general, effective.

29. Explaining the “Dodo Effect” These similarities can be collapsed into four factors or elements that are common to all forms of psychotherapy: • Technique • Extratherapeutic Change • Therapeutic Relationship • Hope or Expectancy

30. The Common Factors • Techniques – factors or ‘strategies’ unique to different therapy approaches (e.g. “easy onset”, “voluntary stuttering”) • Extratherapeutic Change – characteristics of the client and his/her environment (e.g. temperament, social support)

31. The Common Factors • Therapeutic Relationship – characteristics of the clinician and client (and family) that facilitate change and are present regardless of clinician’s therapy orientation (i.e. ‘technique’). Components include shared goals, agreement on methods, means and tasks for treatment, and an emotional bond (Bordin, 1979). • Expectancy – Hope; sometimes thought of as “placebo”. Improvement that results from client (and clinician’s?) belief that treatment will help.

32. Explaining the “Dodo Effect” Further…. Lambert (1992) and Asay and Lambert (1999) reviewed the extant literature and concluded that these factors (separate and combined) account for most of the change observed in therapy.

33. Extratherapeutic Change 40% Therapeutic Relationship 30% Expectancy (Placebo) 15% Technique 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

34. The “Dodo” Effect in Stuttering Treatment Research? • Limited data available on efficacy of stuttering therapy for either children or adults. • Studies have shown that in general, treatment is better than no treatment. • Primary dependent variable is % stuttered words or syllables.

35. The “Dodo” Effect in Stuttering Treatment Research? • Treatment approaches with the most evidence of efficacy or effectiveness are: - response-contingent time-out - parent administered operant - GILCU and ELU - prolonged/smooth speech

36. The “Dodo” Effect in Stuttering Treatment Research? • Emerging evidence that between-treatment comparisons yield nonsignificant findings - Franken, Kielstra-Van Der Schalk & Boelens (2005) AND…..

37. The “Dodo” Effect in Stuttering Treatment Research? Recent meta-analysis of the results from 12 studies of behavioral stuttering treatment revealed that: - 6/12 yielded a significant effect size (treatment/no treatment; 0.91) - 6/12 yielded a nonsignificant effect size (comparison of two treatments; 0.21)

38. The “Dodo” Effect in Stuttering Treatment Research? “Results support the claim that intervention for stuttering results in an overall positive effect. Additionally, the data show that no one treatment approach for stuttering demonstrates significantly greater effects over another treatment approach.” Herder, Howard, Nye & Vanryckehgem (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta- analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73.

39. The “Dodo” Effect in Speech and Language Treatment Research? Robey, R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. JSLHR, 41, 172-187. Law, J., Garrett, Z., Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disorder: A meta-analysis. JSLHR, 47, 924-943.

40. The “Dodo” Effect in Speech and Language Treatment Research? Gillam, R., Loeb, D., Friel-Patti, S., Hoffman, L., Brandel, J., Champlin, C., Thibodeau, L., Widen, J., Bohmah, T., Clarke, W. (2005). Randomized comparison of language intervention programs. ASHA.

41. The “Dodo” Effect in Speech and Language Treatment Research? • Treatment better than no treatment • On average, treatment is effective • Different effect sizes most likely due to client characteristics, “age” or severity of problem, clinician skill-level, differences in social validity for individual clients, and so forth.

42. The “Dodo” Effect in Speech and Language Treatment Research? • Further research to support the conclusion that in general, “therapy works” would waste resources. • Future work should aim toward testing focused hypotheses (i.e., client characteristics + clinician skill + treatment approach). Robey, 1998

43. Extratherapeutic Change 40% Therapeutic Relationship 30% Expectancy (Placebo) 15% Technique 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

44. THERAPEUTIC RELATIONSHIP • Shared goals, agreement on methods, means and tasks for treatment, and an emotional bond (Bordin, 1979).

45. Child and Family Education and Preparation • Attending to the Child’s and Parent’s “Theory of Change” • Family Perception of Improvement in Therapy

46. Child and Family Education and Preparation • Limited understanding of clinical process OR mismatch between child and family expectations and realities encountered leads to poor therapeutic relationship AND • Puts child and family at greater risk for dropping out of therapy

47. Child and Family Education and Preparation • Child and family will respond positively to treatment when engaged in an exploration of various topics, including: - nature of stuttering - contemporary theories of etiology - why children come for therapy - the general structure of therapy - some specifics of behavior change

48. Child and Family Education and Preparation - what will be taught and why - the importance of active participation - self-expression - trust and confidentiality - child, parent and clinician roles and responsibilities - examples of positive outcomes and how they were achieved

49. Child and Family Education and Preparation Coleman, D. & Kaplan, M. (1990). Effects of pretherapy video preparation on child therapy outcomes. Professional Psychology: Research and Practice, 21(3), 199-203.

50. Attending to the Child’s and Parent’s “Theory of Change” “Within the client is a theory of change waiting for discovery, a frame-work for intervention to be unfolded and accommodated for a successful outcome” (Hubble, Duncan & Miller, 1999)