Stuttering Therapy for Children: What Makes Therapy Work?

1. Stuttering Therapy for Children: What Makes Therapy Work? Patricia M. Zebrowski, Ph.D., CCC-SLP University of Iowa

2. 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?

3. 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

4. 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

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

6. 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).

7. 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

8. 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

9. 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.

10. 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.

11. 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

12. 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)

13. 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.

14. 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.

15. Extratherapeutic Change 40% Therapeutic Relationship 30% Expectancy (Placebo) 15% The “Common Factors” in Treatment Responsiveness Technique 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

16. 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.

17. 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.

18. 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.

19. 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

20. 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.

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

22. The “Dodo” Effect in Stuttering Treatment Research? Recent meta-analysis of the results from 12 studies of behavioral stuttering treatment revealed 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).

23. Extratherapeutic Change 40% Therapeutic Relationship 30% Expectancy (Placebo) 15% The “Common Factors” in Treatment Responsiveness Technique 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

24. Treatment for School-Aged Children Who Stutter TECHNIQUE

25. Making Speech Change • Exploring Talking and Stuttering • Changing Talking • Changing Stuttering • Choosing Tools: What and When

26. Exploring Talking • 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 (i.e. “speech helpers”) • 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

27. 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

28. Exploring Stuttering • Identify aspects of stuttering • In order to change behavior, need to know when andwhat to change • Exploring stuttering ties information from exploring talking to child’s own behavior/speech patterns • Desensitizing

29. Exploring Stuttering: How do you stutter? • 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

30. 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

31. 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

32. 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

33. 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 situations

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Treatment for Pre-School Children Who Stutter TECHNIQUE

41. 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

42. 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

43. 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

44. 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****

45. 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 child’s environment express concern that the child either stutters or is a stutterer. • After Johnson, Williams, Conture and others

46. 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 acknowledged 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

47. 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.

48. 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.)

49. 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)

50. Parent reduces “time pressure” in daily routine, and “communicative time pressure” in verbal interaction with child Decrease time pressure in daily life