2003 IFA Congress: Montreal, Canada

“Emotion and Speech” Treatment Approach for Young Children Who Stutter

Hiroaki Kobayashii1 and Mizokami Naomi2
1Facility of Education, Kanazawa University, Kakama-rnachi, Kanazawa-shi, Is/*tikawa-ken, 920-1192, Japan
2Graduate School of Education, Hiroshima University, Kagamiyama, Higashi-Hiroshima-shi, Hiroshima-ken, 739-8524, Japan

SUMMARY

The purpose of this study was to determine an approach to treatment that focused on an emotional components based on the U hypothesis (Uchisugawa and Hayasaka, 1988) in addition to a speech components. A preschool boy participated in this study. He visited at 3 year and 9 months old for treatment of stuttering. The result shows that the fragility in the emotional/speech areas that were seen at first session improved, and the number of stuttering-like disfluencies decreased. The adjustability and effectiveness of the “Emotion and speech” treatment approach with young children who stutter are discussed based on these results.

  1. Introduction
It has been proposed that speech-related variables are a factor in the onset and development of stuttering. Many researchers point out the possibility that children who stutter may have some problem with speech-related variables. For example, Kolk and Postma (1997) proposed that stuttering may occur because children covertly repair their incorrect phonological encoding. There are also a great number of studies that compare motor abilities in children who stutter with children who do not stutter (see the review of Guitar, 1998; and Kobayashi & Hayasaka, 2003). These researchers suggest that, although there are not consistent tendencies, children who stutter (or some of them) may have a problem with motor control.

Emotional variables are also considered to be a contributing factor in the onset and development of stuttering. Logan (1999) proposed that negative emotion plays an important role in aggravating stuttering. Logan assumed that negative emotions have a considerable influence on learning instrumental avoidance behavior and tonic/chronic block complexes of disfluent behaviours, and there is the possibility that these negative emotions and instrumental learning processes partly change the neurophysiologic structure. Guitar (1998) stated that several studies speculated that a person who stutters may have been born with an especially sensitive temperament. Guitar proposed the need to research the sensitivity of children just beginning to stutter, especially longitudinal studies that access the relation between sensitivity and the prognosis of stuttering to clear the relation between constitutional factors and the onset and development of stuttering.

This leads to speculation that there are two contributing factors for the onset and development of stuttering. One factor is some difficulty with speech, and another factor is difficulty with emotions. We consider that it is necessary that these two factors work together in the onset and development of stuttering. It is known that there are great differences between people who stutter, thus with different subtypes of stuttering the distribution of speech factors and emotional factors are dissimilar. However, we assume that both speech and emotional factors may be necessary to develop stuttering (at least severe stuttering). This suggests that stuttering treatment in young children who stutter should deal with both speech-related and emotional variables.

Kolk and Postma (1997) suggest that slow speech is effective in decreasing the load of phonological systems. Starkweather (1989) also suggest that it is effective to decrease the speech demand to enable the child’s limited capacity with the speech system. These ideas, that slow speech and decreasing speech demand are effective in decreasing stuttering problems, are widely acceptance, and applied by many therapists who treat stuttering (for example, Guitar, 1998). There are two ways to slow down the speech rate and decrease the speech demand. One is direct and the another is indirect. The direct way is to simply teach the children slow speech or a relaxed, short speech style (for example, Guitar, 1998, Lanyan, 1999). In the indirect way, people surrounding with the child speak in a slow, easy, relaxed speech style.

Uchisugawa and Hayasaka (1988) and Hayasaka and Kobayashi (1998) suggested a U hypothesis for a diagnosis/treatment system for young children who stutter. In the U hypothesis, factors related to the onset and development of stuttering are divided into three categories; (1) Aggravating factors, (2) Improvement factors, and (3) Persistence factors. Persistence factors are further two sub-categories, (3-a) personality characteristics and (3-b) neurological problems. The contents of these categories include speech, emotions, home environment, and comprehensive development (intelligence, motor, and so on) (Table 1). The U hypothesis includes emotional components, and makes it possible to identify emotional problems that aggravate stuttering and provide a way to reduce these problems.

The purpose of this study was to determine an approach for treatment that focused on emotional components based on the U hypothesis in addition to a speech components, and examine the adjustability and effectiveness of the “Emotion and speech” treatment approach with young children who stutter.

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Table 1. Components of U hypothesis

  1. Participant
A preschool boy participated in this study. He visited the University Speech Clinic at 3 years 9 months old for treatment of stuttering. He began to stutter at 3 years and 4 months old. The results of a mental development questionnaire test, audiometry, and electroencephalography showed that he had no mental development problems, hearing, and brain wave problems. He also had no history of clear physical, neurological or intellectual problems. The frequency of within-word disfluency in 15 minutes of child-mother interaction at the first session was 5.3% (22 disfluency/414 “basic blocks” of Japanese) (a “basic block” is approximately equivalent to an English “word”). He sometimes had rising oropharyngeal tension. He also sometimes avoided speaking, or said other things amid the rising tension. We inferred that with this behavior he was aware of his difficulty with speech.

  1. Clinical identification and decision for treatment policy
From an interview with his mother, observation of the child in free play, several tests (the Parent-Child Semantic Relationship Test (PCSRT, Uchisugawa and -Hyasaka, 1988), Parent- Stuttering Child Semantic Relationship Handy Test (PCSRHT, Uchisugawa & Hyasaka, 1988), and TS Child Personality Diagnosis Test (T-SCPDT, Takagi et al., 1997)), we conducted clinical identification based on the U hypothesis (Table 2).

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Table 2. Clinical identification based on the U hypothesis

Based on the U hypothesis, we aimed to (1) decrease aggravating factors, (2) increase improvement factors, and (3) prevent more aggravation and improve persistence factors. We decided on the following treatment policy:

Emotional components:

We attempted to alleviate a conflict between dominance and overprotectiveness and frustration at home and kindergarten to decrease aggravating factors and increase improvement factors. We also attempted to improve the child’s assertiveness to prevent more aggravation and improve persistence factors.

Speech-related components:

We attempted to reduce the load on speaking (adequate speech rate, taking turns with sufficient pauses between utterances, and adapting to voluntary stuttering) to decrease aggravation factors and increase improvement factors. We did not try to improve his speech components directly (i.e. direct speech training). The reasons are (l) he was not ready for speech training (e.g., experience with deskwork) and (2) he had several emotional problems and we considered that emotional problems must be given priority over speech problems.

  1. Treatment method
From 3 years and 9 months old to 6 years and 10 months old, 32 treatment sessions were carried out.

We attempted to realize a desirable home environment to improve the stuttering problem through guidance and counseling for the parents, as well as to reduce the parents’ anxiety and worry about their child’s stuttering. We consider that the parents play a critical role in our treatment in terms of alteration and maintenance of the home environment.

The guidance and counseling for the parents and play therapy for the child were divided into two components (emotional and speech-related).

Emotional components

We adopted the framework of the U hypothesis to improve his emotional components. In the U hypothesis, it is recommended that adults (parents and therapists) assume an child-centered manner to dissolution of conflict between dominance and overprotectiveness. It is also recommended that the adults assume a receptive response when the child displays the assertive behavior. Uchisugawa and Hyasaka.(l988) cited that these behaviors include assaultive behavior, for example, intemperate language, and physical attack. We paid special attention to interacting with him with an child- centered manner, and a receptive response to all assertive behavior in the play therapy. We also showed the parents play therapy with a video relay system as a model.

Speech-related components

We paid special attention to reducing the load on speaking. For example, we used a slow, short, relaxed speech style, refraining from excessive questions, and sometimes used voluntary stuttering. We also adopted the framework of INREAL (Wess, l984; Takeda and Satomi, 1994). In INREAL, it is recommended the adult interact with the child with reactive manners, and apply several psycholinguistic techniques, that is verbal monitoring and reflecting, modeling, self-talk, and so on. We used these speech styles and techniques in the play therapy. We recommended that the parents use these speech styles and techniques at home. The parents were shown the interaction style of the therapist in play therapy with a video relay system as a model.

  1. Evaluation of treatment effect We used the following tests and measurements to evaluation the effect of treatment.
Emotional components

A PCSRT (at 4 years old and 4 years and 4 months old) and a PSCSRHT were conducted. In examining the transition in the child’s personality, TSCPDT (at 4 years, 4 years and 4 months, and 6 years old) were also conducted.

Speech-related components

In examining the transition in the child-parent interaction, we checked the utterance ratio between the child and mother based on the number of “basic blocks” in child-mother free-play (at first for 5 minutes). In examining the transition for the number of the child’s utterances, we also checked on the number of the child’s utterances based on the number of “basic blocks” in child- mother free-play (15 minutes).

Speech disfluency In examining the transition of the frequency of within-word disfluency, we checked the frequency of within-word disfluency in 15 minutes of child-mother free-play.

  1. Result

(1) The course of treatment

From the beginning of treatment to 1 year later

Emotional components:The parent-child interaction changed into child-centered manners in concordance with the parents’ change. The parents reduced the demanded standard of upbringing, and attended to his utterances, especially utterances relevant to his own affection. His assertiveness also increased in concordance with the parents’ change. He could show aggressive behavior. For example, he hit a big rubber ball against his mother, beat the toy, and said “ball threaten to kill”, and “old codger” to members of the family or a family guest. He could also increase assertiveness in the kindergarten in addition to home. He built friendly relations with children in kindergarten and was in the cast of a school play.

Speech-related components: The parents used a slow, short, relaxed speech style and INREAL’s psycholinguistic techniques at home. He displayed slow articulation development at the start of the treatment, however, these problems disappeared in this period. He also said along, complex sentence include a phrase or condition.

From 1 year later to the last year

Emotional components: According to our treatment policy, the parent-child interaction was kept child-centered manner at home and his assertiveness was enhanced. However, his excessive aggressive behavior decreased, and he could express assertiveness in a more socialized manner. He hardly ever showed physical attacks or verbal abuse to his parents. His assertive behavior in kindergarten increased. His tendency toward hypersensitivity and anxiety, not being good at self- control, decreased in accordance with the increase in assertive behavior. He could act on something independently (without his parents). He was also seen as an athletic child his kindergarten teacher, carried out extra-curricular activities in- a positive way, and played a key role in a school.

Speech-related components: His incentive for speech developed, and he spoke to his parents about everything (for example, episodes in kindergarten). His ability for speech and discourse also developed. He could handle a long and complex utterance and had an effective discourse manner compared to the first period. He sometimes retold with a slow, relaxed speech style including voluntary stuttering when there was some oropharyngeal tension. However, the child’s incentive for speech and discourse developed rapidly, and indirect speech management as described above had not always been functioning effectively. In addition, the parents amount of speech for him increased according to his accretion of speech. For example, with the tendency for longer and more complex utterances, the more disfluency he displayed.

(2) Test results

Emotional components: The results of a PCSRT and a PSCSRHT indicated that (1) the result of the first test (4 years old) showed a tendency for the scores for “rejection”, “inhibition”, â_ training”, and “amenability” to be high (undesirable), (2) the results of the second and third tests (4 years and 4 month and 6 years old respectively) showed that all the scores, excluding “amenability”, decreased. These results indicate that a conflict between dominance and overprotectiveness and frustration at home were resolved. The results of the first and second TSCPDTS (4 years and 4 years and 4 months old, respectively) showed a tendency for “emotional instability”, “lack of self- control”, “dependence”, and “aggressive/impulsive” scores to be high. However, in the third test (6 years old), all the scores, excluding “lack of self-control” and “aggressive/impulsive”, decreased.

Speech-related components: The result of the utterance ratio between the child and mother in the former stages (from the beginning to 1 year later) showed that the utterance ratio between the child and mother in most sessions was close to 1. This indicates that the parent thought in a communication style that fit the number of adult utterances to the number of child utterances. However, the results in the latter stages (from 1 year later to last) showed that the utterance ratio fluctuated widely and was not close to 1. That is, there was a tendency for the adult utterance to be higher than the child utterance (Figure 1).

The result of the number of child utterances in the former stages showed that while some fluctuations depended on the type of play, there was a tendency for the number of “basic blocks” to gradually increase. This indicates that there were improvements in the positive attitude toward speech and/or language/speech ability. However, the results in the latter stages (from 1 year later to last) showed that the number to basic blocks did not exactly increase (Figure 1).

Speech disfluency: Although there was some undulatory transition, the transition of frequency of within-word disfluency in 15 minutes of child-mother interaction demonstrated that the frequency of stuttering-like disfluency decreased gradually, and stuttering-like disfluency was hardly seen at the last treatment session (Figure 2).

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Figure 1. Transmutation of speech style

EAST_f2.png

Figure 2. Transmutation of frequency of stuttering-like-disfluency

Note SSR1-2:Sound Syllable repetitions (1-2 times), SSR3- :Sound Syllable repetitions (over 3 times), ISP: Inaudible Sound Prolongations

  1. Discussion
(1) Emotional components

We aimed to (1) alleviate a conflict between dominance and overprotectiveness and (2) improve the child’s assertiveness as emotional components in this treatment. The parents understood and agreed with our trea :ment policy, and carried it out at home. As a result of treatment, the parents reduced dominance and increased child-centered manner. The results of a PCSRT and PSCSRHT showed the changes in parent-child interaction. He showed assertiveness excessively as aggressive behavior. However, his aggressive behavior decreased gradually and assertiveness increased in a more socialized manner in the latter period of treatment. His tendency toward hypersensitivity and anxiety, not being good at se1f-control, decreased in accordance with the increase in assertive behavior. These indicate that we achieved the first treatment target in emotional components with this treatment.

(2) Speech-related components

We aimed at reducing the load on speaking with this treatment. We selected the indirect method for it. The parents understood and agreed with our treatment policy, and carried it out as well. As a result of treatment, he gradually developed articulation, syntactics, and discourse. We attribute his development of these linguistic abilities to his own development rather our indirect treatment. However, our treatment may help to protect environmental demands beyond his Capacity to employ linguistics, and improve the learning environment for the linguistic domain. He also sometimes retold with a slow, relaxed speech style including voluntary stuttering when there was some oropharyngeal tension. These behaviors suggest that our treatment provided an available speech model for him. However our indirect speech management way had not always functioned effectively. These are shown by the utterance ratio in the child-parent interaction. The result in the former stages shows that the utterance ratio was close to 1. However, the latter stages showed that the utterance ratio was not close to 1. Furthermore, although the number of child utterances in the former stage gradually increased, in the latter stages, the number did not increase. As a matter of fact, the length of utterances gradually increased in the latter period, so it is not adequate to compare the change of utterances based on the number of utterances. It may be suggested that there is a limit in our indirect method from that perspective of effect of instructive induction.

(3) Efficacy of our treatment

We attempted a treatment approach that focused on emotion and speech components, and attained some positive results. Although some real problems are pointed out, our treatment not only enabled an improvement in the fragility in the emotional/speech areas, it was also effective in decreasing stuttering-like disfluency. This indicates that emotional components may play a critical role in aggravating or maintaining stuttering. Particularly, in the conflict between dominance and overprotectiveness, and assertiveness may be a considerable components in the mechanism of aggravation or maintenance of stuttering. Speech components may play a critical role in the aggravation or maintenance of stuttering well. We used the indirect method, environmental adjustment at home and play therapy, to improve these components. Our method was partly effective, and this may have contributed to his disfluency decrease. However, there are limitations to effective environmental adjustments only by our method. This is indicative of further speculative consideration and could include adoption of the direct method.

Starkweather (1988) proposed the Demand Capacity Model for the onset and development of stuttering. He suggested that stuttering occurs when the demand extremely exceeds the capacity, and it is necessary to decrease demand and increase capacity concomitantly. Our treatment can be divided into the following four matrices based on the demand capacity model (Table. 3). We speculate that these treatment components in the four matrices are all required, and adopt a treatment procedure in accordance with child’s condition of speech and emotion.

We will pay special attention to emotional components in addition to speech components, and we must add treatment to improve emotional components. We will accumulate clinical cases, and verify the validity of a treatment approach that focuses on emotion and speech components.

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Table3. Matrix of our treatment

References
Guitar, B. (1998) Stuttering. An integrated approach to its nature and treatment. Baltimore, Maryland, Lippincott Williams & Wilkins.

Hayasaka, K. & Kobayashi, H. (1998) Diagnosis and treatment of a speech-delayed infant stutterer based on U hypothesis. Japanese Journal of Logopedics and phoniatrics, 39, 383-387. (in Japanese)

Kobayashi, H. & Hayasaka, K.(2003)Manual Diadochokinetic Movements in Children with Stuttering and Phonological Disorders. Japanese Journal of Special Education, Vol.40, No.6, 649-662.

Kolk, H. & Postma, A. (1997) Stuttering as a covert repair phenomenon. In R. F. Curlee & G. M. Siegel (eds.) Nature and treatment of stuttering. New directions. Second edition. Allyn & Bacon, 182-203.

Logan, R. (1999) The three dimensions of stuttering: Neurology, Behavior and Emotion. Second edition. London, Whurr Publishers.

Ranyan, C. M. & Runyan, S. E. (1997) Therapy for school-age stutterers: An update of the fluency rules program. In R. F. Curlee (ed.) Stuttering and related disorders of fluency, Second Edition. Thieme Medical Publishers, 110-123.

Ranyan, C. M. & Runyan, S. E. (1999) Therapy for school-age stutterers: An update on the fluency rules program. In R. F. Curlee. (Ed) Stuttering and related disorders of fluency, 2nd edition.. New York, Thieme Medical Publishers, 110-123.

Starkweather, C. W. (1987). Fluency and stuttering. Englewood Cliffs, NJ H: Prentice-Hall.

Takagi, S., Sakamoto, R, Sonoyama, S., Kadota, K., Tanikawa, H., and Ito, M. (1997) The Manual of TS Child Personality Diagnosis Test. Tokyo, Kaneko Shobo (in Japanese).

Takada, K. & Satomi, K. (1994) INREAL approach. Tokyo, Nihonbunkakagakusha (in Japanese)

Uchisugawa, H., and Hayasaka, K. (1988) The study of diagnosis and treatment for young children who stutter. Tokyo, Kazama Shobo (in Japanese).

Weiss, R. (1981). INREAL intervention for language handicapped and bilingual children. Journal of the Division of Early Childhood, 4, 40-51.

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