Comprehensive Stuttering Program for School-Aged Children (7-11/12 years)

Question 1

Considerations of Choosing a Tx

Answer 1

• evidence base
• known predictors of tx outcome
• child and parent reactions of therapy
• experience of SLP

Question 2

Comprehensive stuttering program for school-aged children (CSP-CS)

Answer 2

Integrated approach that addresses both stuttering behaviours, psychological, emotional and social consequences of stuttering.

Question 3

CSP-SC Treatment Goals & 3 phases

Answer 3

• speech related goals
• attitudinal/emotional goals
• self-management goals
• environmental goals

Phases: acquisition, transfer, maintenance

Question 4

Environmental Goals

Answer 4

• Cause & development of stuttering
• Process of speech/attitudinal change
• Managing environmental variables that facilitate or disrupt fluency (e.g. fast rate, questions, etc.)
• How to deliver therapy
• How to deal w/ regression/relapse
• Bullying management

Question 5

Self-management goals

Answer 5

• Develop problem solving skills
• Self-monitoring/evaluation/reinforcement
• Manage environment
• Plan practice activities

Question 6

Family Involvement

Answer 6

• heavy

- a lot of reinforcement, monitoring, decision making

Question 7

CSD-SC Speech-Related Goals

Answer 7

• Use fluency-enhancing skills (FS) in all speaking environments
• Manage residual stuttering
• Improve communication skills
• Praise for fluent speech achieved with or without fluency skills (when appropriate - from LP)

Question 8

CSP-SC Steps

Answer 8

• Establish fluency skills in continuous speech (systematically increasing rates) & training parents
• Ongoing cognitive-behavioural skills training
• Preparation for transfer
• Transfer
• Prep for maintenance
• Maintenance

Question 9

Acquisition

Answer 9

Speech processes
Fluency Enhancing skills
Training Each skill
Cycle Through skill sessions

Question 10

Acquisition: Speech Processes

Answer 10

Discuss speech processes
Discuss how speech is normally produced
Respiratory System Phonatory System Articulatory System
Discuss where stutters (i.e., bumps and sticks) occur – they identify their own
Discuss and demonstrate FS that replace the bumps and sticks (see in class handout)

Question 11

Acquisition: Fluency Enhancing Skills

Answer 11

Tension Modification
Prolongation (Stretch): Slow to slight stretch Easy Breathing (EB)
Gentle Starts (GS)
Smooth Blending (SB) (or Hooking/Linking)
Light Touches (LT)
Self-Corrections (SC) (or Fixes): Re-breathe
3T’s: Think, Take a Breath/Thumbs up, Talk
Rate Changes (or Changes)
Calm & Cool

Question 12

Clinical Strategies Critical to Client Success

Answer 12

Feedback
Careful sequencing (80% success)
Continuous prolongation
Instructions
Effective use of time
Maintain client individuality
Fostering responsibility
Involving family and friends

Question 13

Tension Modification

Answer 13

Practice audible prolongation of “T” in “Tim

Hold, slow release
Hold at level 10 tension, slow release
Hold at level 5 tension, slow release

TM in preparation for self-corrections and to help child cue in to tension and how to release it

Question 14

Prolongation (Stretch) Rates

Answer 14

Slow Stretch: 40-60 SPM (1-4 syllables per breath group) Welcome/ to Canada

Medium Stretch: 60-90 SPM (4-6 syllables per breath group) Welcome to Canada/ We hope you enjoy/ your visit here.

Slight Stretch: 90-120 SPM (6-8 syllables per breath group) Welcome to Canada/ We hope you enjoy your visit here.

Question 15

Easy Breathing (EB)

Answer 15

Comfortable diaphragmatic inspiration 
Comfortable expiration
Breath through mouth
Monitor abdomen (or not)
Individualize

Question 16

Gentle Starts (GS)

Answer 16

Glide voice on
Pre-voice expiration – older children only and only if need to specifically train it
Gradual increase in loudness
Applies to all sounds at the beginning of a word (or word in a phrase) regardless of place or manner of articulation

Question 17

Light Touches (LT) & Smooth Blending (SB)

Answer 17

LT – soft contacts…or normal amounts of tension on consonants within words…stops are not fricitivized

SB – sounds within words and phrases (breath groups)
are linked together

Individualize
May not teach LT – embed in SB
May teach LT in the beginning if needed but drop after SB well established

Question 18

Fixes (Self-corrections)

Answer 18

Re-breath
Pullout
Individualize

Question 19

Changes

Answer 19

Child taught to gear rate down to prevent or recover from stutters (taught at medium stretch)

Question 20

3 “Ts”

Answer 20

3 Ts used to resist time pressure and facilitate language organization if needed

Think…Take a breath…Talk using FS

Question 21

Calm & Cool

Answer 21

Incorporates 3 T’s, self regulation in terms of mind and body
– Calm and Cool Body
– Calm and Cool Mind – knows what he/she wants to say
– Calm and Cool Talking

Question 22

Self- and parent – Monitoring/Evaluation

Answer 22

Fosters awareness
• Use selfevaluation frequently
• Types
-Rating FS
-Tally paper - tally counter
-Thumbs up/down
-“Give me five” – evaluate 5 in a row
-Tally “Remembers” vs. “Forgets”

Question 23

Acquisition:

Cycle Through Skills Sessions

Answer 23

• each of the skills have been learned at word and phrase level, -begin to cycle through the skills that are relevant to the child (group)
• systematically increasing the length and complexity of utterance
• teach parents to lead session
• individualize

Question 24

Slow:
Medium:
Light:

Answer 24

Slow: Stretch, EB, GS, SB, LT, Fixes
Medium: Stretch, EB, GS, SB, LT, All skills, Fixes, 3T’s, Rate Changes
Slight: Stretch, EB, GS, SB, LT, All Skills, Fixes, 3T’s, Rate Changes

Question 25

Acquisition: Criterion Checks at the end of each stretch rate

Answer 25

* To check consistency/stability * Use criterion checks before completing each skill session and before moving up to next stretch rate * May need to decrease language level slightly in criterion check * May check 2 sets of 5 breath groups: 80%accuracy is generally required * Individualize

Question 26

Levels

Answer 26

* Words,phrases * Sentences (oral, reading) * Carrier phrases * Simple Q/A * Picture descriptions * Monologue * Paragraph reading * Topic Maintenance Q/A * Conversation * Presentations * Debates (if appropriate)

Question 27

Max level for slow

Answer 27

Picture descriptions

Question 28

Max level for medium

Answer 28

Topic maintenance Q & A

Question 29

Max level for slight

Answer 29

Presentations

Question 30

Acquisition: Incorporating Lidcombe components toward the end of acquisition

Answer 30

- Parents learn to deliver specific reinforcement for naturally occurring fluent speech (i.e., speech that is fluent with or without use of FS) - Used along with skill and rate practice if appropriate for client

Question 31

Transfers

Answer 31

- Use skills and rate control in real life situations applicable to them - Manipulate difficulty level - Parents taught how to guide - Start w/ pre-transfers (in clinic) - Create transfer hierarchy

Question 32

Transfer: Components

Answer 32

Plan Do Transfer Evaluate (play back recording)

Question 33

Maintenance: Home Practice

Answer 33

``` Fluency Skill practice: • Warm ups • Daily for 10-15 minutes • Target each rate and skill up to sentence level • Ongoing Practice • Planned Transfers • Severity Ratings (SR) ``` Attitudinal Emotional Issues: • Ongoing discussion as appropriate

Question 34

Treatment Outcomes: Kully and Boberg, 1991

Answer 34

Percent syllables stuttered (%SS) and parent report Stuttering reductions • 79-98% within-clinic at 8 to 18 months • 65-100% outside-clinic Stuttering is a relapse-prone condition • Need for ongoing maintenance

Question 35

CSP-SC: Treatment Formats

Answer 35

Intensive 4 week program (until 2010) ``` Intensive program (3 weeks 2011 to present) • 2 weeks individual intensive therapy (2 hours/day) followed by a 4 day transfer and consolidation camp ``` Extended therapy (1x per week; individual or group) Semi-intensive therapy (2 to 3 days followed by extended; individual or group) Telehealth delivery of treatment

Question 36

Teen/Adult CSP - Components

Answer 36

Integrates • Fluency Shaping, Stuttering Modification, and Strategies to Manage the Psycho-emotional and social consequences of stuttering Developed over more than 30 years Evidence-based

Question 37

CSP Evidence Base

Answer 37

Between 71- 86% of participants maintaining reduced stuttering at 1, 2, 5 or 10 years post- treatment. • self-report data clinically significant improvements in communication attitudes, perceptions of stuttering, and confidence in approaching speech situations. • CSP is efficacious in helping adolescents and adults achieve reductions in stuttering with speech naturalness being within normal ranges for typically fluent speakers.

Question 38

Treatment Phases

Answer 38

Establishment (Week 1 & 2) Transfer/Prep for maintenance: real world use of fluency and CBT skills (Week 3) Maintenance: After clinic

Question 39

Difference b/t children & teens/adults

Answer 39

Controlled rate/rate changes