Final Exam Fluency Flashcards
(107 cards)
1
Q
Main two questions to ask in assessment of preschoolers?
A
- Is it stuttering or not? Stuttering or normal child disfluency?
- Should we start treatment?
2
Q
Deciding whether it is stuttering or normal disfluency lies in a combination of these five factors:
A
- Speech behaviors (Monosyllabic repetitions, sound prolongations, tense pauses, 2 or more iterations in repetitions, prolongations more than 1 second long OR perceptual threshold)
- Accessory or concomitant features (physical, emotional, or cognitive struggle with speech)
- Child’s feelings/attitudes (Child’s belief that speech is difficult is often diagnostic in itself)
- Parent’s feelings/beliefs (Worried parents are usually correct)
- Others signs/predictors (Family history, child is not a young girl, speech getting worse over time)
3
Q
What is the main issue in decided whether to start treatment?
A
Spontaneous recovery- high percentage in much research
4
Q
What are the % of children recovered from Yairi and Ambrose’s 2002 presentation?
A
- 2 years post onset 31% recovered and 47% have chance of still recovering
- 3 years post onset 63% recovered and 16% had a chance of future recovery
- 4 years post onset 74% recovered and 5% had a chance of future recovery
- 5 years post onset 79% had recovered and 0% had a chance of future recovery
5
Q
What are 4 predictors of persistent stuttering?
A
- Later age at onset
- Male vs. female (Males recovered at a later age and showed a lower recovery rate)
- No reduction in SLDs (No reduction or no significant reduction in the 1st year or within 4 years)
- Family history of persistent stuttering
6
Q
What are some issues in preschool diagnosis
A
- Data don’t strongly support quick complete spontaneous recovery (4.5 years sometimes)
- Should we treat a disorder that will resolve itself? (Yes its impacting their life, you don’t know if there will be spontaneous recovery, stuttering could lead to other negative life changes)
- the ghost of Johnson!
7
Q
Many authorities recommend starting treatment __________ post onset
A
No more than 1 year
8
Q
Dr. Davidow suggests starting treatment for preschoolers if….
A
- Parents want it
- Child is at all upset
- Speech is not obviously getting much better quickly
- Reported time post onset is at least 2-3 months
9
Q
If you decide not to start treatment you should at the very least do what?
A
Monitor- collect data every 2 weeks or every week if possible
10
Q
What is one possible definition of assessment
A
Answering a series of questions about a client and about that client’s speech before, during, or after treatment
11
Q
What are general goals of assessment for stuttering?
A
- Identify and describe the speech itself
- Identify and describe all other relevant features related to the impairment, disability, and/or handicap of stuttering
- Guid management decisions including during and after treatment
12
Q
What information must you have when describing stuttered speech?
A
Frequency, quality, and speech rate
13
Q
How can you measure stuttering frequency?
A
%SS, %WS, % words disfluent, disfluencies per 100 words, Davidow recommends counting stutters and not disfluencies.
14
Q
You get more stuttering events from which stuttering measurement?
A
%SS
15
Q
How is naturalness measured?
A
1= highly natural 9= highly unnatural
16
Q
How is speech quality measured?
A
Naturalness
17
Q
How can you measure speech rate? (3 options)
A
- Transcribe and get out your stopwatch
- Dots and a stopwatch
- SMS type programs which also allow you to do stuttering frequency and naturalness
18
Q
What are questions you would ask in a case history for a child?
A
Time since onset, if they are aware of stuttering, if a parent or someone in the family stutters, reactions of child to episodes of concern
19
Q
What are questions you would ask in a case history for an adult?
A
How long have they been stuttering? When did it start? Any significant life changes? Medical history?
20
Q
Why assess attitudes, emotions, and cognitions in children?
A
Want to see what child’s reaction is to stuttered speech. Can be used as an outcome measure. How attitudes change from situation to situation (school, etc.)
21
Q
Why assess attitudes, emotions, and cognitions in adults?
A
- Most adults have specific situations they would like to do better in
- Counseling
- Many adults may not want or care so much about eliminating stuttering and may want to alter their feelings about stuttering.
22
Q
How might you assess attitudes, cognitions, emotions for stuttering?
A
Likert scale
23
Q
What should the goal for preschool children be?
A
Eliminate stuttering. Should be the only goal because it is possible.
24
Q
What should the goal for a school age child be?
A
Control and therefore decrease stuttering or decrease concomitant behaviors
25
What should the goal for adults be?
Decrease or control stuttering usually NOT to eliminate
26
What kinds of treatment probes would you try for children?
Maybe response contingent
27
What kinds of treatment probes would you try for adults?
Dunno, get answer somewhere
28
The combination of speech data, other data, probe data should allow you to develop a data based and specific
- Description of past and present stuttering
- Label the problem
- Plan for treatment options
29
A good assessment will include
- Case History
- Speech measures
- Other measures
- Speech change probes
- Goal setting
30
List a couple of findings about clinician confidence in treating persons who stutter
- Kelly et al. (1997) found that 52% of clinicians ranked their competence at 3 or below on a 5 point scale with 5 being the most competent and 1 being the least
- Brisk et al. (1997) found that 56% of clinicians agreed or strongly agreed that they were confident in choosing treatment goals for a child who stutters
31
General characteristics of indirect treatment
- methods do not include speech practice per se
- goals may or may not focus on child's speech/stuttering. Instead, might involve altering the parent's speech pattern or asking fewer questions to that child
32
General characteristics of direct treatment
- Methods include speech practice
| - At least one goal focuses on the child's speech/stuttering with or without the other goals
33
Four things that indirect treatments do
1. Do not draw attention to the unwanted behavior
2. Change the environment that maintains the behavior (motor, linguistic, cognitive, social emotional aspects)
3. Improve related related or prerequisite skills (motor, linguistic cognitive, social emotional aspects)
4. Improved related emotions or reactions
34
Summarize the study by Yaruss, Coleman, and Hammer (2006)
- Tested a treatment based on the demands and capacities model
- 12 boys and 5 girls
- Before Tx 16.4% mean stuttering frequency
- After Tx 3.2% mean stuttering frequency
Limitations: No extende baseline before Tx, reliability checks were not completed for the frequency count data, ---Samples we're of at least 200 words
- Stuttering frequency data were only at the end of treatment and not in follow up
35
Describe Palin Parent/Child interactions therapy
Goal: Achieve fluency within normal limits ( with child- a 5 minute play session where targets are worked on.
36
Problems with Millard, Nicholas, and Cook, and Millard, Edwards and Cook studies
- Not great data. Small sample size
37
List some methods for direct treatment for preschoolers
1. Feedback to identify correct and incorrect responses
2. Initial practice in motorically simpler units or at motorically simpler levels
3. Initial practice with exaggerated or hypercorrect response
38
How might you give feedback to identify correct and incorrect responses?
- Just reinforcement "that was good talking", praising a time period of fluency, praise each utterance
- Just punishment "stop" "try again" "slow down" uttered by clinician contingent on the moment of stuttering
- Punishment time out (Martin, Kuhl, and Haroldson)
- Use both punishment and reinforcement (Lidcombe)
39
Give some background of the Lidcombe program
- Direct treatment developed in Sydney suburb of Lidcombe by Onslow and colleagues
- Developed for children younger than 6
- Conducted by parents who provide verbal contingencies for stuttered and stutter free speech
40
What is the goal of the Lidcombe program stage 1?
Reduce stuttering to an insignificant level and maintain the reductions
41
Treatment protocol for Lidcombe stage 1
Weekly sessions 45-60 minutes
Parent and child visit the clinic each week (total 16-30 visits)
On the first visit, the parent learns to use the severity rating scale to rate the child 1= no stuttering 2= extremely mild 10= extremely severe
Clinician rates %SS
Clinician models and parent practices using the verbal contingencies
42
Lidcombe verbal contingencies for stutter free speech
- Acknowledgement ("That was smooth")
- Praise ("Lovely smooth talking")
- Request for self evaluation ("Was that smooth?")
43
Lidcombe contingencies for stuttered speech
- Acknowledgement (e.g. "There was a little bump there")
| - Request for self correction ("You had a bumpy word. Try again")
44
In the Lidcombe program, a decrease in severity usually occurs within the first ____ of stage 1
4 weeks
45
What happens when severity decreases during the Lidcombe program?
Clinician encourages the parent to use verbal contingencies during unstructured conversations
Structured conversations become less frequent and contingencies are given mainly during unstructured conversations
46
Criteria for entering stage 2 of Lidcombe are....
3 consecutive weeks of:
Clinician gives severity rating of 1 or 2 for whole clinic visit
Parent's severity ratings for the previous week are all 1 or 2 with at least four being 1
Below 1%SS within the clinic
47
Goal for Lidcombe Stage 2
Maintain the speech performance that was needed to enter stage 2
48
What happens in Lidcombe stage 2?
- Reduction in the number of verbal contingencies
- Child and parent attend the clinic less frequently if stuttering severity criteria are met
- Performance contingent schedule with less frequent visits
49
Interval of visits in Lidcombe stage 2
First 2 visits- 2 weeks apart
Next 2 visits- 4 weeks apart
Next 2 visits- 8 weeks apart
Next 2 visits - 16 weeks apart
50
What have results been with Lidcombe generally in studies?
- Generally children obtain stuttering frequency rates below 1% SS after stage 1 during, within, and beyond clinic speaking situations
- Long term studies found stuttering rates below 1%SS
- Speech rates are normal throughout the program
- Naturalness ratings of 1 or 2
51
What was important about Jones et all 2005 study on Lidcombe?
First study to show treatment wasn't due to natural recovery because there was a control group. Good data, with a follow up 9 months post treatment
52
Which preschool treatment program has more evidence than any other program?
Lidcombe!
53
What is the goal of the ELU program?
Facilitate children's spontaneous and automatic use of natural-sounding stutter free speech under all talking conditions in all settings, with all speaking partners, and with all audiences
54
Treatment protocol for ELU program
- Begin with the production of monosyllabic words and progress to 6 syllable utterances, various monologue lengths, culminating in 5 minute monologues and finally various lengths of conversation until a 5 minute conversation.
- Positive reinforcers (social and token) provided for each fluent response and "punishers" such as adult saying "stop" provided for each confluent response
- Contingencies faded during later stages of the program
55
What have results been like with the ELU program?
Children finish the establishment program between 1%SS and 2%SS and reductions remain throughout maintenance
56
Problems with ELU
More long term research is needed . Treatment appears effective for those who complete the program but more long term research is needed
57
What have results of the Gradual Increase in Length and Complexity of Utterance been like (GILCU)
- Post establishment phase data reveal stuttering rate around .5 stuttered words per minute
- For children completing follow-up measures, rates of 1.0 SW/M or below were reported
- Speech rates normal by the end of the program
58
What are some positives about the GILCU program?
- An experimentally evaluated program
- Sometimes transfer activities are incorporated into treatment from the beginning
- Older children have results comparable to younger children
- Addresses establishment, transfer, and maintenance portions of treatment
59
What are some criticisms of GILCU?
- Limited long term beyond clinic data
| - Subject attrition (not huge but noticeable)
60
What are some child terms for prolonged speech elements?
```
Slow rate- turtle speech
Smooth speech- satin ribbon
Gentle onset - feathers
Soft contacts- easy mouth
Continuous vocalization- keep the motor running
```
61
What are five challenges of treating children in the schools?
1. Get very little time with them- large caseloads, get child to and from class
2. Getting them services at all
3. No constant communication with parents
4. Infrequent treatment sessions
5. Limitations in budget
62
How can we increase practice time for fluent speech?
- Talk to teachers
- Summer or weekend therapy
- Homework
- Providing child with rules
- Ask parents to help
- Ask other staff members
- Make group therapy interactive
63
What is generalization?
Occurrence of a new behavior in non training conditions, with no programming or with substantially less programming than was required in training conditions
64
What are three options for generalization and maintenance of behavior change?
1. Train and Hope
2. Sequential Modification
3. Incorporate generalization from the start
65
What are stokes and Osnes' principles for generalization?
- Use client's natural environment and the reinforcers in it as much as possible so that the treatment is as close to real life as possible
- Select goals that people will notice and that the outside world will reinforce
- Make reinforcers in treatment similar to real world reinforcers
- Modify maladaptive environment (e.g. give reinforcer for going through with a phone call)
- Train diversely (different people, different therapy rooms, different signals for fluency)
- Incorporate salient social stimuli
- Incorporate self mediated physical stimuli
- Incorporate self mediated verbal/covert stimuli
66
What is maintenance?
Maintenance is the continuation of a new behavior in all relevant conditions after it has been established in and/or generalized to those conditions
67
What are some explanations for relapse after stuttering treatment attributed to the client?
- Failure to practice
| - Stutterer not becoming own therapist
68
What are some explanations for relapse attributed to the clinician?
- Bad procedures
- Goal mismatch
- No generalization/maintenance procedures
69
What is an active contingent maintenance plan?
Active: Client continues to do something that is consciously associated with treatment conditions
Contingent: Contingency for maintained success is increasing time between clinic visits; contingency for not meeting maintenance goals is more frequent visits
70
An example of an active contingency maintenance plan
```
Weekly for 4 weeks
If meeting (self-selected) goals , then every 2 weeks for 8 weeks, otherwise, return to weekly
If meeting (self-selected) goals, then every 4 weeks. Otherwise, return to two week schedule
```
71
What are some maintenance recommendations for children?
Fade contingencies during approximately 1 year of non stuttered speech
Continue assessing the child at monthly or so intervals to be sure that fluency remains
72
What are some before-treatment maintenance recommendations for adults?
- Determine desire for change. Are they willing to do what you ask them?
- Discuss the impact of speech change
- Match procedures to goals. Ask them their goals.
73
Recommendations for maintenance during establishment and transfer
- Use zero stuttering criterion to maintain non stuttered speech
- Use multiple generalization techniques
- Emphasize and over learn success
74
What are maintenance recommendations for adults during the maintenance phase?
- Active (client doing something associated with treatment conditions)
- Contingent
- Self-managed (maybe they rate naturalness, etc.)
- Support systems (support group)
75
Three big recommendations for pulling together entire treatment process (establishment-transfer-maintenance)
- Choose type of treatment that has been shown to be the most effective for the age group of client you are seeing
- Perform the treatment or have client practice their techniques in as many different places, with as many different people, and in as many different situations as possible
- Make a concerted effort to be sure that the gains the client has made during treatment remain
76
What are the four artificial and overlapping divisions in time for adult stuttering treatment
1. Pre 1940- Treatments directed at speech
2. 1920-1960- Speech change requires psychological change
3. 1960-mid 1980- Treatments directed at speech because of the "behavioral approach"
4. 1980-today - behavioral-cognitive or cognitive-behavioral or arguments!
77
What were some treatments for adults before 1940
Direct Modification of Speech
Thelwall used rhythm
In Francei n early 1800s, metronomes were sold as treatment devices
Aurelius Cornelius Celsus recommended respiratory exercises and economizing of breath during speech
Suggestion/hypnosis
Combination of those first 2
Stuttering schools
Speech devices
78
What were some treatment approaches from 1920-1960?
Indirect Treatment:
Freud Psychotherapy
Help client understand how the past determines how he/she behaves now
No evidence that this helped with stuttering
Travis: Mental Hygiene- Accept yourself and the social problem that seems to be the cause of your stuttering
No evidence that it improved stuttering
Webster (1977) tested an indirect psychological approach that didn't really work
79
Bryngelson developed what kinds of treatments in 1920-1960 psychological approaches
- Sidedness training (retraining the brain)
| - Voluntary stuttering
80
What did Johnson's treatment involve?
Go out and stutter, learn not to care about it
81
Van Riper's approach was based on the work of which two researchers?
Bryngelson and Johnson
82
Goal in Van Riper treatment is....
Fluent stuttering to replace abnormal symptoms
83
Four steps in the Van Riperian approach
1. Motivation - must be in place before you start anything
2. Identification-
3. Desensitization- Go out and intentionally stutter
4. Modification
84
What are the 3 kinds of modifications in the van riparian approach?
Cancellations: Occur after the stutter. If you stutter on a word, say it again
Pull-out: Relax articulators to help you through a word
Preparatory Set: If you notice a stutter is about to happen, prepare your articulators
85
What were some treatments developed since the 1960s?
```
"Behavioral Era"
Focused on speech
Try to make FIC permanent
Good evidence of substantial reductions in stuttering with related improvements in social, emotional, and other realms
con: accused of focusing just on speech
```
86
4 difficulties with use of a masker?
- Hearing loss with masker on
- Difficult to use on the telephone
- Effect disappears when mask is removed
- Some clients hesitate to wear in public
87
Summarize Brady's 1971 metronome study
-Start with desk metronome at 40-60 BPM- phase cleared when client can speak 100-160 words per minute with metronome. Move to pacemaster portable metronome. Systematically fade the pacemaster
Was effective in a study but didn't use speech rate or naturalness
88
Is rhythm a reasonable option?
- Not as a first choice
- Maybe for a client who can't do prolonged speech
- Maybe start doing with preschoolers who are too young for the Lidcombe program
89
Elements of prolonged speech
- Gentle onset of voicing
- Light articulatory contacts
- Blending words
- Easy breathing
- Extended voicing
- Exaggerated phrasing
- Stretching out words
90
Why should we use prolonged speech?
- Literature reveals that treatment programs using prolonged speech have produced the best reductions in stuttering frequency
- Social emotional, and cognitive variables improve as well. Some clients may need a lot of transfer activities and success to overcome these barriers
- Can be shaped to sound natural
91
8 things that may lead to improvements in social, emotional, and cognitive variables
1. Meeting others who stutter (support groups )
2. Practice somewhat difficult situations (e.g. telephone with a familiar person) early in treatment
3. Discuss feelings and thoughts after performing difficult activities
4. Accept clients for who they are- no judgements
5. Educate the client about stuttering
6. Group practice sessions
7. Self disclosure
8. Help client realize there is no "quick fix'
92
Some factors associated with the most successful prolonged speech treatments
1. Within-clinic practice of a slow prolonged speech program
2. Shaping this slow speech into a faster, normal speech rate
3. Performance contingent steps- criteria for proceeding in the program
4, A lot of practice with the new speech pattern in a variety of situations
5, Transfer tasks or homework assignments from the beginning of the program
6. Establishment of speech pattern can be during intense sessions or spaced
7. Measurements of stuttering frequency, speech rate, and naturalness within and beyond clinic
8. Maintenance stage
93
Weiss' definition of cluttering (1964)
Verbal manifestation of a central language imbalance
94
Daly's definition of cluttering (1992)
A disorder of speech and language processing resulting in rapid dysrhythmic, sporadic, unorganized, and frequently unintelligible speech
95
St. Louis' definition of cluttering (1992)
Abnormal fluency but not stuttering- rapid or irregular speech rate
96
Speech characteristics of cluttering
Rapid, variable, or accelerating speech rate
Disfluencies (vowel initial pauses, effortless multiple repetitions)
Articulation errors
Monotonous or nasal voice quality
97
Cognitive and language characteristics of cluttering
Short attention span, poor concentration, reading problems, writing problems
98
Other random characteristics of cluttering
- Lack of awareness of the disorder
- Slips of the tongue
- Physically immature or clumsy
- Poor musical/rhythmic skill
- Impulsive, fidgety, careless, untidy. Higher percentage of engineers, mathematicians, and programmers
99
Important case history elements for clutterers
Late onset of speech
| Disfluencies occurring at onset of language
100
Speech characteristics that may come up in evaluation for cluttering
Rapid rate
Slurred articulation
Child is always disfluent where stutterers have islands of fluency
No tension
101
What instrument is good for assessing cluttering?
Checklist for Identification of Cluttering- revised
102
What score on the Checklist for Identification of Cluttering is suggestive of cluttering
55 or higher
103
What might treatment of cluttering involve?
- Improvement of rate and prosody
- Syllable stress, practice simple and shorter utterances and work up to longer phrases
- Awareness
- Other (Help to focus on listener cues- is person understanding?)
104
How might you decide where to start treatment?
Ask the client what is most affecting intelligibility function day to day
105
What will treatment look like?
Articulation, language, stuttering, might call on several domains
106
What is adult onset dysfluency
Abnormal or unusual disfluencies begin to occur in a person who never stuttered or who has not stuttered since childhood. NOT those who just recovered - has to have been decades later at any age
107
Four ways of subdividing AOD
Recurrent- AOD in an adult who had stuttered previously
Psychogenic- AOD linked to emotional trauma or other psychological event
Pharmacological- AOD occurring as a side effect
Neurogenic- AOD occurring after known or suspected neurological damage
