Craig Coleman1, J. Scott Yaruss2, and David Hammer3
1Children’s Hospital of Pittsburgh Department of Audiology and Communication Disorders and the Stuttering Center of Western Pennsylvania, Corporate One Office Park, Building One, 4055 Monroeville Blvd, Monroeville, PA, 15146
2University of Pittsburgh Department of Communication Science and Disorders and the Stuttering Center of Western Pennsylvania, 4033 Forbes Towel; Pittsburgh, PA 15260
3Children’s Hospital of Pittsburgh Department of Audiology and Communication Disorders and the Stuttering Center of Western Pennsylvania, 2599 Wexford Bayne Rd., Sewickly, PA, 15143
Preliminary results are presented for eleven children ages 218-515 who participated in a six-session parent/child treatment program (Hammer & Yaruss, 1999) to improve speech fluency and communication attitudes. This program combines aspects of both indirect and direct treatment. Preliminary outcomes demonstrated significant changes in fluency for children in their home environment and new situations based on parent ratings and number of disfluencies in the clinical setting. Findings suggest the need for a prospective long-term study to determine the efficacy of the treatment program.
Differing views have been provided on the best treatment approach for young children who stutter. Some have favored a more direct therapy approach that focuses primarily on changing speech behaviors (Lincoln & Onslow, 1997). Others have favored a more indirect approach that focuses primarily on facilitating fluent speech through changes in the child’s environment and/or modifying parental speech patterns (Gregory, 1999). Some programs have combined aspects of indirect and direct approaches (Starkweather, Gottwald, & Halfond 1990).
Although some treatment approaches seem to have a growing body of evidence supporting their outcomes (Lincoln & Onslow, 1997), empirical evidence to support other types of treatment is sparse. This is particularly true for treatment programs that attempt to enhance fluency through indirect methods.
The purpose of this investigation is to provide preliminary data on the outcomes of a program that allows the clinician to monitor a child’s fluency over several weeks while providing parents 118 Theory, research and therapy infiuency disorders with strategies to enhance their child’s fluency in the home environment. This six-session program, described previously by Hammer and Yaruss (1999) combines aspects of direct and indirect treatment. Stuttering is addressed directly with the child in many cases, particularly in cases where the child exhibits negative reactions to stuttering. In addition to learning strategies that may enhance their child’s speech fluency, parents also learn strategies to address the emotional reactions of the child and others in the family.
The age group targeted by this approach is 3- to 6-year-olds, who may be referred to clinical, hospital, school, or university facilities with a range of stuttering severity. The primary focus of the early stages of treatment for these children involves the parents. Although it may be difficult in some settings for clinicians to find time to work with parents, we, like many other clinicians, feel that parent participation in the treatment process is essential for preschool and early school-age children who stutter. The benefits of working with parents are seen throughout the therapeutic process, in part because it fosters deeper communication between clinician and parents. Intervention plans are individualized to meet the needs of different families, but the core factors of parental understanding of stuttering, reducing environmental stressors, and demonstrated use of fluency enhancing strategies (not just reporting their use at home), are essential for achieving optimal change in this age group.
To achieve these objectives, four parent treatment strategies are targeted, including: (1) use and modeling of easy, relaxed speech (2) use of delayed response (3) modified questioning (4) and reflecting/rephrasing children’s responses. (Note: although research has not wholly supported the notion that reducing parents’ questioning improves fluency, it has been our experience that replacing direct questions with indirect statements such as “I wonder,” “ I think,” or “I guess” can facilitate the reduction of speaking rate, improved phrasing, and reduced talking demands perceived by the child.)
To establish these fluency-facilitating strategies, the treatment program used by the Stuttering Center of Western Pennsylvania entails a three-phase approach, including: (a) parent training and education, (b) parent/child modeling, and (c) formal child treatment (as necessary).
The initial parent training program consists of two sessions of parent education/counseling, three sessions of communication modification training, and one session of review/re-assessment.
The parent education/counseling sessions are “parent-only” sessions and the child is not involved in the session. During these sessions, we provide the parents with detailed information on the nature of stuttering, risk factors that are associated with stuttering, and various treatment options available for stuttering.
In addition, we use the first two sessions to develop a highly individualized plan of treatment with the parents based on the needs of the child as well as those of the family. For example, a “Stressor Inventory” is administered that identifies characteristics of the child and any environmental issues that may be contributing to the child’s stuttering. We then use this inventory to provide suggestions on how to adjust the environmental factors (e.g., negative response to stuttering by others, fast-paced schedules, competition for talking time, etc.) to better suit the child’s individual needs.
We also have parents chart their child’s stuttering at home and in other situations to help them identify any patterns in behavior or environment that may be associated with increased stuttering. More importantly, the charting often gives parents a chance to see that there is not one particular thing that “causes” their child to stutter. Instead, they typically see the variability in their child’s stuttering from situation to situation.
The three communication modification sessions, which target the four parent treatment strategies outlined above, allow parents to receive on-line feedback through a wireless FM system (Telex Sound Mate SR-lO0 16 Channel Personal Listening System). All sessions are videotaped for parental review.
These sessions typically begin with the clinician interacting with the child while the parents Watch the session through a two-way mirror. Each parent then has an opportunity to interact with the child while the clinician watches through the two-way mirror while providing on-line feedback through the wireless FM system.
Of the eleven children, six had a positive family history of stuttering. Four of the eleven children had additional speech and language concerns at the time of the evaluation. Of the eleven, three were females and eight were males. As a group, they exhibited an average disfluency rate of 14.9% (range: 8.5% to 28%) at their initial evaluation.
At the time of the initial treatment session, the mean age of these children was 3:7 (range = 2: 8 to 5:5). Their mean time from onset of stuttering until the first treatment session was 11.5 months (range = 2.25 months to 41 months). Children were three to 16 months post-treatment at the time that the questionnaires were completed.
- Not satisfied: 0
- Moderately satisfied: 1 (9%)
- Very satisfied: 10 (91%)
Table 1. Parents Rating of “helpfulness” of various components of treatment.
As evidenced above, parents were pleased with the overall program. Their responses highlighted that the wireless FM system was useful in providing on-line feedback and that their knowledge of stuttering increased “to a high degree” following treatment. After rating the above aspects of the program, parents were asked to rate their child’s fluency status in different situations pre- and post-treatment. The rating system was similar to that used by Campbell (1999) to describe outcomes of children with speech sound production deficits. Parents were asked to rate how often the child is able to speak without stuttering at home, at school, and in new situations, with the following rating scale used:
0 = never
2 = sometimes
3 = almost always 4 = always
A two-tailed paired t-test revealed a significant difference (p < .05) between the group of eleven children from pre-treatment to post-treatment in the home environment (p = .002) and in new situations (p = .002). Although there was a difference between the children pre- and post-treatment for the school setting (p = .09), this difference did not reach a significant level. Fewer responses were obtained for the children in school settings, as some children were not yet enrolled in school, or parents could not reliably estimate ;he child’s fluency in the school setting. Figure 1 highlights the increased ratings for the group following treatment.
Figure 1. Mean fluency ratings pre- and post-treatmem,”˜.
In addition to the fluency ratings aoove, disfluency rate measures were taken at the time of the initial evaluation, or the first treatment session that the child attended, and at the conclusion of the parent training program. Table 2 outlines pre- and post-treatment disfluency rates based on percentage of disfluencies per 100 words. Disfluencies were counted only if they consisted of sound syllablevrepetitions, word repetitions, prolongations, or blocks. This classification closely resembles that used by Conture and Meinick (1999).
Table 2. Disfluency rate per 1 00 words pre- and post-treatment.
As a group, significant improvements were noted in disfluency rates following treatment (p=.O00335; t=5.32600l). Individually, all of the children except one exhibited a reduced disfluency rate following treatment.
In cases where the child’s disfluency rate was between 4% and 9% following treatment (n=4), the child was also discharged from treatment and monitored through parental report and, in some cases, clinical re-evaluations. This recommendation was based on the fact that these children had made rapid gains in fluency (mean: 13% reduction in disfluency rate; range = 6% to 22%) in a very short period of time. Again, none of these children needed any additional sessions beyond the six session parent/child treatment program.
For two children (subjects 1 and 8), immediate additional treatment was recommended based on a number of factors: both had a positive family history of stuttering, both exhibited disfluency rates over 10% following treatment, and both had not demonstrated significant improvements following the initial treatment. In one subject, the disfluency rate had increased following treatment. Since the increase was only 1.5%, the change could probably be attributed to day-to-day fluctuations in disfluency in the absence of improved fluency skills.
For the two subjects who needed additional therapy, a significantly more direct treatment approach was implemented following the parent/child treatment program. Thus, one important use of the six session parent-child treatment program was to serve as a starting point for treatment in children who required more intensive long-term treatment.
For most children, the six session parent/child treatment program was sufficient to increase fluency in the clinical setting and increase parents’ ratings of their child’s fluency in environments outside the clinic. For this reason, and those outlined below, implementing this treatment approach may be beneficial to clinicians.
First, the program is minimal in terms of cost and clinician time. It provides an opportunity to provide initial treatment for children who stutter while closely monitoring their fluency over a period of time. This takes some of the “guesswor “ out of initial assessments for children who stutter when clinical decisions can often be made based on one moment of the child’s stuttering, rather than a broader picture that often is more representative of the child’s skills.
Second, for many children, the program may be enough to achieve normal or near-normal levels of speech fluency. There may be a subgroup of children who stutter who only need minor adjustments in their environment to achieve normal fluency. For these children, the parent/child training program may be sufficient. For those children who need more intensive long-term treatment, this program can still be very useful as a starting point for therapy. For example, parent counseling and education will still be necessary. This program accomplishes these initial steps of the treatment process.
Lastly, the parent/child training program provides an early intervention option for children whose prognosis is somewhat uncertain. Currently, we do not have a reliable set of prognostic indicators for determining whether young children will “spontaneously” recover without intervention. For parents, it may be somewhat comforting to know that a significant portion of young children who stutter may recover without treatment; however, that level of comfort is often overshadowed by their concern for their child, not a whole subgroup of children. Without a reliable set of prognostic indicators, we need treatment options for children whose skills may be at any level of risk for chronic stuttering. It may be reasonable to assume that some of these children would have recovered without formal treatment. Until reliable prognostic indicators for spontaneous recovery are firmly established, this program serves as a starting point for treatment, or a minimal set of sessions geared toward parent education and counseling.
This preliminary study provides enough evidence to indicate that a long-term prospective study examining this treatment approach is needed. Initial plans are already under way to conduct such a study. While the preliminary study provides evidence that the treatment program may be effective, a long-term prospective study is needed to provide further evidence of this approach. Data for this study were examined retrospectively to evaluate the treatment program. While evidence in this study demonstrates that the treatment program was successful in accomplishing the objectives it was designed to achieve, We would not recommend this six-session program as the sole source of treatment for children who may need more long-term treatment. For many children, additional treatment may be necessary.
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