Treatment adults and adolescents Flashcards
What is important about treatment?
Treatment needs to address:
- Behaviours
- Emotions
- Cognition
Treatment is most effective if it addresses all of these areas.
Treatment needs to intense, long-lasting and provide long-term maintenance.
What are some considerations when starting treatment?
Some adults seeking treatment will have never had intervention know little about research, view of stuttering
May have had little contact with other stutterers
Psychological barriers associated with embarrassment or shame can be entrenched
Conversely, others may have had treatment and present as disappointed and frustrated
Might believe that treatment is futile, worthless
What are the key concepts for treatment?
- Treatment should be tailored to each client’s needs.
- Successful treatment requires focused attention to speaking, especially when stuttering is anticipated.
- Successful treatment depends on increasing approach behaviours and reducing avoidance.
- AWS may continue to have speech processing deficits after treatment and may continue to compensate for them.
- Measurement of progress and outcomes - %SS, SSI-4 and Erikson
What is important when working with adults and adolescents?
Make clients full partners in therapy
Clarify locus of control & responsibility
Increased emphasis on complex treatments (smooth speech), cognitive and affective aspects, participation factors, stress management, and counselling
Make sure your goals are mutual - SMART goals
Develop real world practice targets
Make hard decisions if the client cannot be motivated
What is fluency shaping?
Focuses on teaching the individual to speak more fluently (Blomgren et al., 2005: Guitar, 1998)
Goal is to work with the speaker’s motor control capabilities & apply approaches to facilitate new speech production patterns Establishes fluent speech in a controlled environment using + and – reinforcement
Transfer to normal conversational settings
Does not incorporate the individual’s feelings & reactions to the stutter
Speech can become monotonous & artificial
Examples: Airflow Technique, Slow Rate, Light Artic. Contacts 12
What are the main classes of treatment?
- Speech Restructuring
- Operant reward/time-out therapies
- Stuttering Modification
- Cognitive-Based Therapies (CBT)
- Assistive devices
- Pharmacological treatments
- Hybrid programs (1 + 4 + 3) (5 + 1) - Used at UQ and best evidence based practice
What is speech restructuring?
Systematic retraining of the speech mechanism via modifying the way in which one usually breathes, voices, articulates, or phrases to produce smooth unbroken speech.
Good evidence for Smooth Speech, Prolonged Speech, Camperdown Program; EMG biofeedback, Modified Phonation Intervals
Research has shown these to be ‘best practice’ treatments for AWS (meta-analysis by Bothe et al., 2004
What are operant therapies?
Operant conditioning (e.g., rewarding fluency; time-out for stuttering)
Evidence-based research for children - Lidcombe Program+++ (gold standard treatment- RCTs)
Some research evidence that operant techniques may be helpful for adolescents, especially if:
mild stuttering
person has not been stuttering for a long time
Idea is to get person to stop speaking in the middle of stutter and eventually self-impose these timeouts. Can be very confronting and doesn’t suit everyone.
What is stuttering modification?
Based on Van Riper’s concept of modifying the stuttering moment and getting through it, in a more ‘fluent’ manner
Goals of stuttering modification:
1. Modify your moments of stuttering so that your stuttering is less severe.
2. Reduce your fear of stuttering and eliminate avoidance behaviours associated with this fear.
BUT… Stuttering modification decreases avoidance behaviours it may increase frequency of stuttering moments (Manning, 1999) WHO not effective Tx as does not decrease impairment level (stuttering frequency
What are the phases of stuttering modification?
- Identification of own stuttering behaviours to raise self-awareness of what happens in stutter.
- Desensitisation of person to their own stutter.
- confrontation/acceptance
- freeze core behaviours
- voluntary stuttering - Modification of fluent stuttering
- Stabilisation
What is involved in phase 3 of speech restructuring?
- Modification of fluent stuttering
Pull Outs – when a person begins to stutter, they purposely say the rest of the word with ease
Preparatory Set – when the person anticipates a word to be difficult the client looks ahead for words that they will stutter on and use “easy stuttering” on those words.
Cancellations – after stuttering, there is a pause and the word is said a second time using an “easy” stutter.
Surprisingly little evidence to support this approach, though many program incorporate aspects
What is involved in phase 4 of speech restructuring?
Seek to stabilize or solidify the speech gains
Goals:
Client has to become their own speech pathologist – take responsibility for making your own prescribed therapy activities “automatisation of preparatory sets & pull outs”
For the client to change their self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly
Explain cognitive therapies
Those therapies that target the person’s anxieties, and their thoughts and reactions to stuttering. Often used in conjunction with relaxation training.
Cognitive restructuring involves identifying faulty beliefs and anxieties and turning them into something more productive.
There is evidence that cognitive restructuring can improve fluency outcomes when done in conjunction with speech restructuring programs.
What are some assistive devices?
Devices that form part of a speech restructuring program and other fluency training programs
EMG feedback, breathing monitors [Computer Aided Fluency Establishment Trainer], metronome
Devices that you wear: alter auditory feedback (i.e., via masking, delayed feedback, shifted pitch frequency; rhythmical pulse). The SpeechEasy
Reduction in anxiety for people using these devices. Many people use these devices selectively, e.g., for oral presentations, on the telephone.
Often used as an adjunct to therapy.
What are options for pharmacotherapy?
Used as an adjunct to therapy.
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
Excess levels of dopamine are also present in people with Tourette’s Syndrome and schizophrenia. Hence, the same types of drugs have been trialled (but in smaller doses) with PWS
