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SPCH3107 > Management of fluency disorders > Flashcards

Management of fluency disorders Flashcards

1
Q

What are some features of advanced stuttering, and how does this guide therapy?

A

advanced stuttering:
- behaviours
- emotions
- cognition

therapy needs to be intense, long-lasting, provide long-term maintenance

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2
Q

List 5 key treatment concepts in treating adolescents and adults who stutter?

A
  1. treatment should be tailored to each client’s needs
  2. successful treatment requires focussed attention to speaking, especially when stuttering is anticipated
  3. successful treatment depends on increasing approach behaviours and reducing avoidance
  4. adults who stutter may continue to have speech processing deficits after treatment and may need to continue to compensate for them
  5. Measurement of progress and outcome
    a) SR
    b) %SS
    c) SSI-4
    d) Erickson Scale (S-24)
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3
Q

List some points to bear in mind when working with adolescents and adults who stutter.

A
  • make clients full partners in therapy
  • clarify locus of control and responsibility
  • increased emphasis on complex treatments (smooth speech), cognitive and affective aspects, participation factors, stress management, and counselling
  • make sure your treatment goals are mutual
  • make hard decisions if the client cannot be motivated
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4
Q

What is the ultimate goal of treating PWS?

A
  • true self-directed mastery over fluency - the person can control their fluency in whatever situation they so desire, whenever they so choose
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5
Q

List 7 considerations when developing goals for stuttering

A
  1. reduce the frequency of stuttering
  2. reduce the abnormality of stuttering
  3. reduce negative feelings about stuttering and speaking
  4. reduce negative thoughts and attitudes about stuttering and speaking
  5. increase overall communication abilities
  6. create an environment that facilitates fluency
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6
Q

List some long-term goals for PWS

A

(1-2 years)
- ability to manage fluency in particular situations at normal speech rates
- anxiety control
- reduce avoidances
- reduce the impact stuttering has on one’s life

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7
Q

List some short-term goals for PWS

A

(2-3 months)
- relaxation mastery
- establishment of diaphragm breathing
- gentle onset mastery
- smooth speech mastery in conversation 50SPM-100SPM-150SPM

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8
Q

List the 7 main classes of treatment

A
  1. speech restructuring
  2. operant reward/time-out therapies
  3. stuttering modification
  4. CBT
  5. assistive devices
  6. pharmacological treatments
  7. hybrid programs
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9
Q

List some important concepts underlying stuttering therapy

A
  • simple vs. complex treatments
  • programmed vs. non-programmed
  • speaking fluently vs. stuttering fluently
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10
Q

Define EBP

A

Evidence-based practice acknowledges that it involves the integration of the best research evidence with clinical expertise and the patient’s values and circumstances
Also requires the health professional to consider characteristics of the practice context in which they work

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11
Q

What are some Speech Restructuring programs?

A
  1. Smooth Speech
  2. Prolonged Speech
  3. Camperdown Program
  4. EMG biofeedback
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12
Q

Define speech restructuring.

A
  • use of novel speech pattern to reduce stuttering or eliminate stuttering while sounding as natural as possible
  • clients learn to speak initially with a slow, drawling speech pattern that is stutter free
  • speech pattern is then shaped toward a more natural stutter-free speech
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13
Q

What are the target speech behaviours in speech restructuring?

A
  • reduced speech rate
  • extended vowel production
  • light articulatory contacts
  • gradual onset of vocalisations (gentle onsets)
  • continuous breath flow during speech
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14
Q

What is Smooth Speech?

A
  • cognitive-behavioural approach to management of stuttering
  • systematic retraining of the speech mechanism via modifying the way in which one usually breathes, voices, articulates or phrases to produce smooth unbroken speech
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15
Q

List three smooth speech programs and features of them

A

Mater Smooth Speech Program:
- pre-course therapy
- instatement
- transfer
- maintenance
- bottom-up approach
LaTrobe Program:
- intensive phase
- maintenance phase
- review phase
BERL:
- breathe all air out
- ease into the phrase
- run all sounds and words together
- lengthen vowels and last words

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16
Q

How does Smooth Speech promote speech motor control?

A
  • the stuttering moment causes tension and/or inability for PWS to move forward in their speech
  • Smooth Speech normalises muscle tension levels and it provides a speech environment in which airflow and speech are continuous
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17
Q

What does Smooth Speech promote?

A
  • relaxation (mind and body)
  • breathing - relaxed diaphragmatic
  • gentle onsets
  • gentle contacts
  • continuous airflow
  • continuous smooth movements
  • natural sounding voice and prosody
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18
Q

Why are physical/mental relaxation foundational skills for fluency control and empowerment?

A
  • facilitates ability to monitor muscle tension
  • acts as a precursor to learning diaphragmatic breathing for smooth speech
  • develops into a means of anxiety control in general, and in specific speech situations, once practices
  • fosters a general sense of wellbeing
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19
Q

List some general relaxation points

A
  • acquired skills that needs practice
  • different ‘types’ of relaxation suit different people thus you will need to be flexible
  • meditation vs. visualisation vs. progressive muscle relaxation
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20
Q

Make two comments about relaxation and fluency management

A
  • relaxation has been proven to produce positive mental and physical health benefits for those who practice regularly
  • feeling relaxed generally has positive effects on a person’s fluency
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21
Q

List two reasons why it is important to understand the foundational role of relaxation in smooth speech, and its role more generally in fluency management?

A
  1. tension and relaxation are incompatible states
    - muscle tension is present in stuttering moment somewhere in speech mechanism
    - relaxation heightens awareness to muscle tension in the body
    - heightened awareness = earlier detection of muscle tension therefore enables you to use relaxation strategies to reduce tension = relax engaged muscles
  2. apply relaxation strategies on command
    - key to ultimate success in using fluency control techniques beyond the clinic is being able to apply relaxation strategies for fluency control and general anxiety management
    - intentional application of relaxation is important in fluency management and control
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22
Q

Describe the mechanics of smooth speech

A
  • breathing: slow controlled inbreath and slow smooth changeover to the outbreath
  • gentle onsets/slow smooth transitions into phrases
  • continuous smooth movement of the articulators
  • continuous airflow
  • normal intonation, stress patterns and voice quality
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23
Q

Why is planning an important feature of smooth speech?

A
  • use short phrases ‘chunking’ and longer pause times strategically
  • to facilitate relaxation
  • to allow time for planning
  • to allow time for monitoring
  • easier to articulate and more predictable in length = less respiratory control demand
  • the ‘pause-phrase-pause-phrase’ technique
  • allows time for the monitoring of a relaxed inbreath
  • facilitates better thought planning
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24
Q

Why is rate control important in smooth speech?

A
  • slower speech rates place less demands on the speech act
  • client needs to master control and monitoring of their speech rate
  • teach at slow speech rates initially
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25
Q

Why is attitude change important in smooth speech?

A
  • rational thinking
  • positive thinking
  • anxiety control
  • cognitive restructuring
  • self-discipline and self-reliance
26
Q

Discuss features of the LaTrobe Smooth Speech

A

Altering the speech pattern in the following ways:
- starting words gently
- stretching out words
- linking them smoothly
- pausing at the right places

27
Q

What are the 3 phases of LaTribe Smooth Speech Program?

A
  1. Intensive Phase = 5 days for 9 hours of treatment per day
  2. Maintenance Phase = 1/week follow up sessions for 2 hours/week for 7 weeks
  3. Review Days = 7 hours offered over the semester
28
Q

Describe the Intensive Phase of the LaTrobe program?

A

Days 1-3 - instatement: learning SS
60SPM-?80-100SPM->120SPM->150SPM->170SPM-> comfort rate
- key concepts taught (easy onsets, linking, elongating vowels)
- start with single vowels -> words (VC, CVC) -> multisyllabic words, phrase, sentences, reading, conversation to instate 60SPM
- at 60SPM clinician provides feedback every 15seconds
- at 120+SPM feedback is given every 1-2 minutes
- encouraged to se natural sounding speech at rates of 120SPM and higher whilst remaining stutter free using SS
- homework tasks assigned

29
Q

Discuss the transfer tasks involved in the LaTrobe program?

A
  • days 4-5 transfer: assignments
  • prepare the individual Hierarchy of Speech Situations
  • practise those speaking situations - rehearse, plan, role-play
  • actually implement those tasks
30
Q

Discuss the maintenance phase of LaTrobe program?

A
  • 2 hour sessions
  • measures of %SS in clinic
  • review of home practice activities
  • review of SS technique
  • problem-solving around generalisation and maintenance issues
  • last 1/2 hour = group interaction and practice
31
Q

Discuss the types of stuttering feedback you would provide to a client

A
  • need to discuss the moments of stuttering to increase PWS awareness and reduce the stigma
  • if there is a stutter - STOP the client, ask what happened and then start the exercise again
  • ask ‘did you feel that stutter?’ ‘What happened there?’ ‘What could you have done there?’
  • let them know that you were aware of the stutter - then problem solve through it
  • if they were able to problem solve give them positive reinforcement
32
Q

Discuss the specific Smooth Speech feedback you would provide a client

A
  • feedback on technique and rate for every 15-20 seconds during SS practice
  • errors in technique or rate only
  • if there is a breach in the technique or rate but then the next few phrases are perfect practice continue on
  • if there is a breach in technique 2 times in a row: then STOP client - identify what they did - demonstrate the breach if necessary - see if they can self-correct - model the correct technique if unable to self-correct - START exercise again
33
Q

Discuss features of prolonged speech (PS)

A

Treatment approach that teaches the behaviours of:
- continuous vocalisations (voiceless -> voiced)
- soft contacts (-> very loose -> slushy)
- gentle onsets (-> aspirated vowels)
. . . . in order to achieve continuous airflow

  • naturalness taught as a later layer, rather than at the outset
34
Q

What is the Camperdown Program?

A

Non-programmed speech restructuring model
- behavioural treatment program for adolescents and adults who stutter (>12 years of age)
- targets the stuttering behaviour directly
- based on earlier PS treatments
- requires less treatment time and gives client increased self-reliance in establishment, transfer and maintenance of controlled fluency

35
Q

Provide an overview of the Camperdown Program?

A
  • clients view a video demonstration of CP Training Model
  • clinician guides the client in using the speech pattern in the Training Model to develop an individualised fluency technique to reduce or eliminate stuttering in everyday speech AND to sound as natural as possible
36
Q

What is the Camperdown Program?

A
  • teaches PS without making reference to terms of traditional speech targets (such as ‘gentle onset’ and ‘soft contacts’)
  • clients are encouraged to use whatever features of the PS pattern they desire to control stuttering and are free to individualise their own behaviours
  • rate is slow at start, but set by individual in accordance with fluency level
  • helps people who stutter feel more positive about themselves as communicators
  • immediate shift of monitoring and control on to the individual, for them to work out ‘what aspects assist them most’
37
Q

What are the a) primary and b) secondary aims of CP?

A

a)
- reduce and control stuttering in everyday speaking situations
- does not aim to eliminate stuttering
b)
- to develop self-managed procedures
- similar to SS programs as it is learning a new speaking pattern -> Speech Restructuring

38
Q

Outline stage I of the CP (teaching treatment components)

A
  • overview of the program
  • learn to use the 9-point Stuttering Severity Scale
  • learn to control their stuttering using the Training Model with fluency technique of 7-8 during spontaneous speech
  • between 3-5 x 45-60 minute individual consultations
  • progression criterion to enter stage II
  • assign self scores with Stuttering Severity Scale that are similar to the clinician’s scores
  • consistently uses a fluency technique that approximates the Training Model to control stuttering, with a stuttering severity score of 0 and fluency technique score of 7-8
  • feel in control of their stuttering
39
Q

List 1 anxiety measure

A

The Subjective Units of Distress Scale (SUDS)
- 0-10 scale (0 = no anxiety, 10 = extreme anxiety)
- clients can record this on Situations Measurement Chart along with SR and fluency technique scores

40
Q

Outline Stage II of the CP (establishing stutter-free speech)

A
  • consolidate their imitation of the Training Model fluency technique
  • work with clinician to develop individualised, natural sounding fluency technique that they find acceptable for stuttering control
  • practise self-evaluation skills for stuttering severity and fluency technique
  • develop problem-solving skills to assist later generalisation of stutter-free speech to everyday speaking situations
41
Q

What is the progression criteria to enter Stage III of CP?

A
  • individualised fluency technique to control stuttering in conversation has been developed
  • stage III commences when clients can speak with the clinician for the entire session at SR 0-1 and a fluency technique score acceptable to the client
42
Q

Outline Stage III of CP (generalisation)

A
  • confirm they can use a fluency technique to control stuttering
  • compare their speech measures with those of the clinician
  • review and revise their fluency technique practice routine
  • report their stuttering severity, fluency technique and speech-related anxiety scores from everyday speaking situations
  • present and discuss recordings of their speech with speech measures in various everyday situations
  • interpret those speech measures with the clinician and plan strategies to resolve any problems
  • devise a hierarchy of everyday speaking situations to assist transfer of fluency technique
  • plan treatment changes for the coming week based on speech measures
  • modify measurement procedures if required
  • summarise treatment changes for the coming week
43
Q

What is the progression criteria to enter stage IV of CP?

A
  • stuttering and fluency techniques goals are met for 3 consecutive weekly consultations
  • goals for stuttering severity scores are to be 0-1 in most everyday speaking situations with no situation avoidance and fluency technique scores that the client find acceptable
44
Q

Outline Stage IV of CP (maintenance of treatment gains)

A
  • maintain stutter-free speech throughout the consultation
  • present acceptable stuttering severity and fluency technique scores for representative everyday speaking situations
  • confirm those scores with several audio recordings
  • demonstrate how variations of stuttering severity have been dealt with appropriately
  • booster programs
    -self-help groups
45
Q

What is the progression criteria for discharge from treatment in CP?

A

Negotiated between client and clinician when client can demonstrate:
- skills for monitoring their speech and control their stuttering
- an ability to address fluctuations in stuttering severity
- achievement of personalised goals for stuttering treatment

46
Q

List the strengths and weaknesses of CP

A

STRENGTHS:
- less time to learn the prolonged/smooth speech
- clinical hours are reduced: 20 clinical hours ca produce significant outcomes
- advantages in the video procedure: greater likelihood of effective learning, improves operations of the treatment process, participant imitates the exemplar on the video -> enhances self-management
- does not involve online judgement of stuttering movements
WEAKNESSES:
- does not involve programmed instruction and greater severity may indicate a more explicit teaching
- high attrition rates in initial research as high motivation required
- does not deal with self-esteem issues

47
Q

What is fluency shaping? List some features (strengths and weaknesses) of fluency shaping treatments.

A

Focuses on teaching the individual to speak more fluently
Strengths:
- Goal is to work with the speaker’s motor control capabilities and apply approaches to facilitate new speech production patterns
- establishes fluent speech in a controlled environment using positive and negative reinforcement
- transfer to normal conversational settings
Weaknesses:
- does not incorporate the individual’s feelings and reactions to the stutter
- speech can become monotonous and artificial

48
Q

What are operant therapies? Discuss some benefits of operant therapies

A
  • uses operant conditioning (i.e. rewarding fluency, time-out for stuttering)
    Helpful for adolescents if:
  • mild stuttering
  • person has not been stuttering for a long time
  • good application if rate control is the main contributory factor to stuttering
49
Q

What are assistive devices, and what does the research state regarding their effectiveness for PWS?

A

Devices that form part of a speech restructuring program and other fluency training programs:
- EMG feedback, breathing monitors, metronome
- devices that you wear: alter auditory feedback (i.e. DAF), the SpeechEasy

  • Research shows that assistive devices can decrease the severity of stuttering (on some people), however the effects can wear off
  • DO NOT ELIMINATE STUTTERING COMPLETELY
  • Evidence for decreased anxiety in people using these devices
50
Q

What are some drugs used in the pharmacological therapy of stuttering? What is the basis of the research as to why these drugs work?

A
  • haliperidol (antipsychotic drug - block receptors for dopamine)
  • olanzapine (dopamine antagonist)
  • pagoclone (dopamine antagonist)

Based on findings that there is underactivity in left striatum of the basal ganglia such that excess amounts of dopamine are present in the brain of many PWS

51
Q

Which of the drugs used in pharmacological treatment for PWS have the least side effects? List the side effects of the other drugs.

A

Pagoclone < Olanzapine < Haliperidol

(olanzapine - mild weight gain)
(haliperidol - side effects of drowsiness, sexual dysfunction, excess limb movement, risk of permanent neurologically based movement disorder)

52
Q

What are ‘stuttering modification’ treatments, and the goals of such treatments?

A
  • Based on Van Riper’s concept of modifying the stuttering moment and getting through it in a ‘more fluent’ manner

GOALS:
- modify the moments of stuttering so that stuttering is less severe
- reduce fear of stuttering and eliminate avoidance behaviours associated with this fear

53
Q

What are some limitations of stuttering modification treatments?

A
  • stuttering modification decreases avoidance behaviours BUT may increase frequency of stuttering moments
  • not as effective therapy as does not decrease impairment level (mentioned above ^ - stuttering frequency)
54
Q

What are the phases of stuttering modification treatment?

A
  1. Identification of own stuttering behaviours
  2. Desensitisation of person to their own stuttering (1. confrontation/accepting, 2. Freeze Core Behaviours, 3. Voluntary Stuttering)
    3.Modification Fluency Stuttering (pull-outs, preparatory set, cancellations)
  3. Stablisation (of speech gains)
55
Q

Outline a ‘recovery strategy’ a PWS can use according to stuttering modification treatment

A

Empower client to recover ASAP through modified ‘pull-out’ moment in the blocking moment:
- stop
- breathe out
- regroup and neutralise thoughts whilst breathing in slowly
- try again (more gently and slowly)

56
Q

What are cognitive therapies?

A
  • therapies that target the person’s anxieties, and their thoughts and reactions to stuttering
  • cognitive restructuring
  • identifying faulty beliefs and anxieties and changing these to be productive
57
Q

True or false: there is evidence to support cognitive restructuring can improve fluency outcomes when done either before or after speech restructuring therapy.

A

FALSE - can improve fluency outcomes when done AFTER a speech restructuring program, but no evidence for improving fluency outcomes when done BEFORE

58
Q

What is Self-Imposed Time Out Treatment? How is it implemented?

A

SITO:
- verbal response contingent stimulation
- when stuttering moment occurs, client stops speaking for a few moments then resumes speaking
- duration of SIT does not matter

  • starts with clinician imposing time-out
  • progresses to self imposed
  • signal to stop talking can be verbal or nonverbal
  • must stop talking
59
Q

What are the clinical advantages and implications of SITO?

A

Advantages:
- does not use an overt speech pattern
Implications:
- blocking as primary stuttering behaviour
- not a lot of evidence (i.e. not as much as speech restructuring)
- SITO is less effortful than speech restructuring BUT unclear as to how much effort clients use to sustain benefits in everyday speech

60
Q

List some reasons why you might do SITO with an adolescent or adult who stutters.

A

IF:
- client unable to learn speech restructuring
- cannot sound natural
- long history of unsuccessful treatment
- dislikes speech restructuring

61
Q

What are hybrid treatment? List some.

A

Incorporate speech restructuring (motor control) + address the cognitive-affective implications of stuttering
- Mater Smooth Speech Program
- LaTrobe Smooth Speech Program

62
Q

List some factors to consider when choosing a treatment option.

A
  • severity
  • rate of speech
  • length of time
  • family history
  • aetiology
  • level of anxiety
  • co-morbidities
  • fluency needs
  • availability
  • types of disfluencies
  • age
  • education and learning
  • response to other treatment
  • support systems
  • insight
  • motivation

SPCH3107 (4 decks)

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