Fluency Interventions in Speech-Language Therapy - Coursework Example

Fluency Interventions In Speech Language Therapy Stuttering type of fluency disorders are the most widely displayed disorder in early childhood. Though stammering is most commonly found in early childhood it becomes worrisome when it is predictable, persistent and gets carried to adult life. The characteristics of the dysfluent speech like frequency, the proportion, duration of dysfluency types and obvious physical manifestations differentiates stutter child from the normal child. Stuttering etiology involves the causes like cognitive processing abilities, genetics, sex of the patient, and environmental influences. The potential impact of stuttering on childrens development is severe and the problems outgrows as the child enters into adolescent stage affecting their self-esteem, self-image, and academic and occupational relationships. If speech and language disabilities identified and intervene at an early age, these disorders can display positive outcome. The treatment is often personalised and focus on the particular area of the speech, in which child is lagging behind like spoken language difficulties, articulation, pronunciation etc. There are mainly two types of speech therapy specifically for the adults who stutter: fluency shaping and stuttering modification therapy. Fluency shaping is conceptualized on operant conditioning techniques which relaxes the overstimulation and overactivity in stuttering to deliver fluent speech. Stuttering Modification Therapy emphasises on reduction of stuttering severity and not complete elimination of stammering. Both types of treatment are evidence based and showed positive outcome with self-management and modeling strategies. But success rate of both the treatments varies among stuttering population. Long term lasting effects of stuttering modification technique are not yet evidenced like fluency shaping therapy. Introduction Speech and language disabilities are the most widely displayed disorder in early childhood. It has been estimated that around 5-8% of children less than 6 years might show impaired speech and language function and 1.4 % of children less than 10 years show speech disfluency (Prasse & Kikano, 2008). Speech disorders are characterized by incorrect speech sounds and voice, and impaired articulation. The individuals who suffer from speech difficulties have stuttering problem, and can not pronounce the sound properly (Prelock, Hutchins, Glascoe, 2008). Language disorders make the children nonreceptive of other’s language and also they are not able to express themselves properly and adequately. The language obstacles involve impediments in signed/written language, grammar, phonology and semantics. Though stammering or stuttering is most commonly found in early childhood it becomes worrisome when it is predictable and persistent. The characteristics of the dysfluent speech like frequency, the proportion and duration of dysfluency types differentiates stutter child from the normal child. The behavioral symptoms like movements of eye (like eye blinking), head (like head-bobbing), and body (grimacing) might not be coherent with the speech in such children (Gordon, 2002; (Prelock, 2008). Their body language shows frustration or embarrassment. Stuttering started at the age of 3, though dies out uptil the age of puberty, sometimes it gets carried to adult life (Gordon, 2002). This speech developmental disorder has high occurrence among males (almost twice) than females (Prelock, 2008). The manifestations shown by stuttering include involuntary sound or syllable repetitions (e.g., w-w-what?, li-li-like), syllable prolongations (e.g., wwwwwwwwwhat?), an inaudible prolongation/block in the smooth flow of speech (e.g., a pause, inappropriate gap in a word or phrase), use of fillers or interjections (e.g.,) uh, er, um, “I um went um to um the um store.”). Also, it should be noted that when stuttering start in early childhood, the whole-word repetitions apart from syllable repetitions could be more common (Gordon, 2002). Causes Communication disorders have diverse range of causes including medical and nonmedical reasons. Medical reasons include autism spectrum disorder, brain injury, cerebral palsy, fetal drug or alcohol exposure, fluency disorder, mental disorder, hearing impairment and specific language impairment. Stuttering etiology involves the causes like cognitive processing abilities, genetics, sex of the patient, and environmental influences (Prasse & Kikano, 2008). Nonmedical conditions associated with communication impediments include psychosocial risk, abuse, social situations and neglect (Prelock, Hutchins, Glascoe, 2008). Stuttering is broadly classified into three types: developmental, neurogenic, and psychogenic stuttering. Developmental stuttering occurs due to lack of apt children’s speech and language abilities appropriate to their age which hamper verbal communication. This developmental disorder might be genetic, though exact genes involved in stuttering are not yet deciphered. Neurogenic stuttering might be due to accidental brain damage or head injury or stroke etc. Lack of coordination between the brain and nerves/or muscles due to improper signaling, and lack of harmony between different components of speech lead to stammering. Psychogenic stuttering is caused by emotional trauma or problems with cognition components like thought or reasoning (NIDCD, 2002; Prasse & Kikano, 2008). and very small percentage of population suffer from this type of stuttering. The potential impact of stuttering on childrens development Speech impairment hampers social and behavioral growth due to frustration, isolation from colleagues, and low self esteem. They display aggressive behaviour and mental health problems. These children suffer from emotional disturbances (like embarrassment and frustration) as well as physical effects (e.g., tense muscles) (Prasse & Kikano, 2008). These children suffer from anxiety disorder at later stages. Children having communication disorder can not develop literacy skills and often face academic failure resulting in more dropouts from the school. The problems outgrows as the child enters into adolescent stage affecting their self-esteem, self-image, and academic and occupational relationships (National Literacy Trust, 2009, Prasse & Kikano, 2008). Treatment If speech and language disabilities identified and intervene at an early age, these disorders can display positive outcome. The treatment is often personalised and focus on the particular area of the speech, in which child is lagging behind like spoken language difficulties, articulation, pronunciation etc (American Speech-Language hearing association, 2009). The speech-language pathologists might need to intervene for stuttering with multimodal, individualized and justifiable treatment using direct and indirect methods. The educators should train those areas purposefully and then plan to apply them in their daily activity. The learning outcomes for clients should be assessed routinely and accordingly changes should be made so that communication disorder could be overcome to possible extent. There are mainly two types of speech therapy specifically for the adults who stutter: fluency shaping and stuttering modification therapy. Fluency Shaping Fluency shaping is a type of direct speech therapy which focuses on the correction of fluency of a disfluent person. This fluency modification approach is also known as ‘speak more fluently’ approach. This is closely connected to rate control/rate reduction or prolonged speech therapies (Conture & Curlee, 2007, p. 244). This theory has neurological basis for correcting overactivity in stuttering like overtense, overstimulated respiration, vocal folds, and articulation (lips, jaw, and tongue) muscles (Kehoe, 2006, p. 28). Fluency shaping is conceptualized on operant conditioning techniques which relaxes the said overactivity in stuttering (Ward, 2006, p. 257). This therapy does not deal with psychological issues and secondary behavior originated from stuttering. This is because, it emphasises on fluent speech of a person who stutters which could become normal after the treatment, and all secondary traits (behaviors which are not related to speech production) would disappear. Motor learning and control plays an important role in correction of stuttering. Normal speech is fast, complex yet automatic and effortless which exercises open-loop motor control. While, to treat stuttering slow, attentive closed-loop speech motor control is utilized to learn and inculcate novel skills which stutterer has not tried before. This closed-loop speech motor control system intentionally relaxes respiration (stutterer breathes with their diaphragms), and slowly increases tension in vocal folds. This duration of onset of speaking of a word is increased by stretching vowels and consonants. The articulation (lips, jaw, and tongue) muscles are relaxed to form the correct sounds of each word without stuttering (Kehoe, 2006, p. 28-33). This tactic gives slow, monotonic but fluent speech. Once these skills are practiced and mastered, slowly speed can be increased. Once the desired inhouse (speech clinic) outcome is achieved in approximately three weeks intensive training in speaking, person has to use this technique on a daily basis. Camperdown program has effective and much shorter training schedule (Ward, 2006, p. 257-267). Fluency-shaping mechanisms are used in certain devices like, ‘delayed auditory feedback’ devices to improve upon stuttering. The stutterers words are repeated to understand the wording properly and correct it, which forcibly slows down the speech rate. These devices take care of stutterer’s speech to minimize distortions of the words and make it more fluent. The intensity of stuttering varies with the performance of the device (Prasse & Kikano, 2008). Evidence based studies to study the efficiency of Fluency Shaping Programs Some evidence based studies are summarized by Kehoe (2006) in his book. The Institute for Stuttering Therapy and Treatment (ISTAR) in Edmonton, Alberta, Canada conducted three-week Fluency Shaping Program on 42 stutter participants. The treatment involved slow, prolonged speech with initial speed of 1.5-seconds-per-syllable stretch and ending with slow but normal speech. Also, the training was given to the participants how to decrease fears and avoidance symptoms to openly accept the stuttering phenomenon and speak more in society. This was followed by a practice sessions at home for the clients. It was observed that there was about 20% reduction in stuttered syllables. It was concluded that after 2 years of post treatment, around 70% stutters regain normal fluency in the speech, 5% have reduced stuttering tendency partially, and in around 25% clients the therapy was not effective. In another study, it was noted that around 71-86% of graduates were benefited from ISTAR program. A program named Precision Fluency Shaping (a.k.a. Hollins therapy) involving three-week intensive program with one year post treatment follow-ups alleviated stuttering from 7.1% to 1.6%. It was concluded that after 2 years of post treatment, around 50% reduction in stuttering was observed (Kehoe, 2006, p. 56). Stuttering Modification Therapy The stuttering modification therapy is investigated by Van Riper in 1973 (Ward, 2006, p. 245). This is block modification therapy emphasises on reduction of stuttering severity and not complete elimination of stammering. In contrast to fluency therapy, it gives importance to regulation of cognition and, concentrates on psychological issues and secondary behavior like fear, anxiety, avoidance etc. originated from stuttering. This therapy believes that theses secondary symptoms increases disfluency in the speech. If these post stuttering symptoms could be abolished the speech could become more easier, and the person could become well conversant with less intensity stuttering. This therapy involves for consecutive steps: identification, desensitization, modification, and stabilization (Ward, 2006, p. 247-253). Identification of the factors which are associated with core traits (observable overt manifestations like repetitions, prolongations, blocks), feelings, attitudes and secondary behavior resulting from stuttering is the primary step of stuttering modification therapy. This aids in characterization of stuttering event by both the client and clinician. Desensitization technique is the process of freezing core behavior by removal of fear from the mind set of stutter about his stuttering trait. At the end of this step, the individual should able to be voluntary agree and be comfortable about his stuttering by experiencing a stuttering moment and communicating others that he is a stutter. Modification stage is the directional step to learn modification in stuttering by ‘easy stuttering’. Stuttering at ease is achieved after several attempts by cancellations (block dysfluency or confronting difficult sounds, take a pause for a moment, and try to repeat the same but correct word), pull-outs, or pulling out of a dysfluency into fluent speech, and preparatory sets. Unless the client perfects the word without stuttering, he is not supposed to move forward in the conversation. The client should make effort beforehand to know the words in conversation where he could make mistake and apply easy stuttering technique. At the end of the therapy, the person learns to stabilize himself by rehearsing the technique in daily conversation and practicing self made assignments. At the end, the person changes his own impression about himself from ‘a person who stutters’ to ‘a person who talks fluently with mild and sporadic stuttering’. Thus, in this intervention technique, the person is self responsible for the progress (Ward, 2006, p. 247-253). Disadvantages This technique basically deals with the approaches based on cancellation and desensitization which requires discipline, commitment, determination and positive attitude of the client beyond clinical settings. The client has to observe intentionally the self process of generation of speech and various aspects related to respiratory, phonatory, and articulatory system to produce a smooth flowing speech with less stuttering. Kinesthetic monitoring and openness is needed to check the progress in speech quality. Many times the person who stutters is not comfortable with outsiders to apply in practice these techniques due to inner shame and fear of unfavorable response from listener. Therefore, this technique is time consuming for the client which requires lots of persistence, patience, inner desire and self motivation from the adults who stutter (Conture & Curlee, 2007, p. 244). Long term lasting effects of stuttering modification technique are not yet evidenced. Combination of both the techniques is often useful to achieve full potential positive outcome resulting from both the interventions. Both the techniques increases the capacity of the client to self evaluate and monitor which he learns during the course. Stuttering modification technique makes the person aware of the stuttering moment and modifies it with less stuttering events in the conversation. Then the person should be exposed to voluntary stuttering in open atmosphere to check his desire to get over with stuttering. Such person when treated with fluency shaping technique it would help to smooth remaining stuttering moments at later stages (pre event and preparatory sets) to achieve 100% normal fluency (Conture & Curlee, 2007, p. 246). Finally, habituated and integrated steps in the intervention technique should be practiced persistently to have long term positive effects (Conture & Curlee, 2007, p. 246). Research studies Blomgren et al., (2005) applied multimodal assessment strategy to study the strengths and weakness of ‘Intensive stuttering modification therapy’ on adults. A successful intensive stuttering modification 3 weeks treatment program was studied in 19 clients, pretreatment, post treatment and 6 months later for 14 fluency and affective-based measures. The multimodal strategy contained stuttering frequency; the Stuttering Severity Instrument for Children and Adults, Third Edition (SSI-3); a self-rating of stuttering severity; the Perceptions of Stuttering Inventory (PSI); the Locus of Control of Behavior Scale; the Beck Depression Inventory; the Multicomponent Anxiety Inventory IV (MCAI-IV); and the State-Trait Anxiety Inventory. The researcher found that the program "was ineffective in producing durable reductions of core stuttering behaviors, such as stuttering frequency and severity." (2005). The clients having issues with perception of stuttering (the Avoidance and Expectancy subscales of the PSI) and affective functioning measures (like the Psychic and Somatic Anxiety subscales of the MCAI-IV) were only benefited (Blomgren, Roy, Callister, & Merrill, 2005). In 2008, Menzies et al. carried out an experimental clinical trial of a cognitive-behavior therapy package for chronic stuttering. The study was aimed at to calculate the stuttering population having social phobia, to investigate the consequence of speech restructuring treatment on social anxiety, and to inspect the outcome of a cognitive-behavior therapy (CBT) package for social anxiety on chronic stuttering. Speech structuring alone or in combination with CBT was studied in 32 participants randomly for speech and psychological measures prior to treatment, post treatment and 12 months later. It was concluded that 60% selected participants were suffering from social phobia. It was found that using only CBT strategy could result in positive psychological impact with unaltered speech outcomes. Speech restructuring alone could result in unaltered social phobia (Menzies, O’Brian, Onslow, Packman, St Clare & Block, 2008). The study conducted by Mulcahy et al. in 2008 focused on the interactions between anxiety, attitude toward daily communication, and stuttering symptomatology in teenagers. When trait and state levels of anxiety are compared in 19 stutter participants as compared to 18 fluent speaking controls, it was found that levels of anxiety are quite high in stuttering adolescents due to lack of proper communication in day to day life. The study concluded that all types of anxiety might not play significant role for stuttering surface behaviors but specific sub-types of anxiety might lead to stuttering disorder (Mulcahy, Hennessey, Beilby & Byrnes, 2008). Recent studies conducted by Clare et al. in 2009 centers on the development of comprehensive measures of stuttering which leads to social anxiety. The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) was used as a method to evaluate the levels of unhealthy thoughts and convictions in stuttering population which leads to social anxiety. UTBAS was divided into 66 parameters based on ten years study of cognitive-behavior therapy (CBT) for stuttering population to test the effect on cognitions linked with social anxiety. These parameters could differentiate between stuttering and nonstuttering population. Also, UTBAS showed favorable test-retest reliability and internal consistency. It is known that CBT makes positive changes in thoughts and beliefs. It was found that these changes leading to reduced social anxiety is a function of UTBAS (St Clare, Menzies, Onslow, Packman & Block, 2007). Prins and Ingham reviewed the literature to confirm the fluency disorder treatments like fluency shaping (FS) and stuttering management (SM) has strong foundation. He stated that FS focuses on the endproduct of the treatment, while SM evaluates the character of the stutter event. The results from FS show the validity of the treatment, while SM is originated from cognitive learning model of defensive behavior which can be linked with stuttering behavior. It was concluded that both types of treatment are evidence based and showed positive outcome with self-management and modeling strategies. But success rate of both the treatments varies among stuttering population (Prins & Ingham, 2009). Conclusions Widely displayed stuttering phenomenon in early childhood might have negative outcome in terms of personal, social, and occupational growth, if not treated at the right age. The speech-language pathologists might need to intervene for stuttering with multimodal, individualized and justifiable treatment using direct and indirect methods. This developmental disorder can be intervened in adults by two powerful techniques fluency shaping therapy and stuttering modification therapy. The learning outcomes for clients should be assessed routinely and accordingly changes should be made so that communication disorder could be overcome to possible extent. Fluency shaping is a type of direct speech therapy which focuses on the correction of fluency of a disfluent person to achieve normal fluency. In contrast to fluency therapy, stuttering modification therapy gives importance to regulation of cognition and, concentrates on psychological issues and secondary behavior like fear, anxiety, avoidance etc. originated from stuttering. Stuttering modfication therapy reduces stuttering. It was concluded that both types of treatment are evidence based and showed positive outcome with self-management and modeling strategies. But success rate of both the treatments varies among stuttering population. Combination of both the techniques is often useful to achieve full potential positive outcome resulting from both the interventions. Both the techniques increases the capacity of the client to self evaluate and monitor which he learns during the course. Stuttering modification technique makes the person aware of the stuttering moment and modifies it with less stuttering events in the conversation. Then the person should be exposed to voluntary stuttering in open atmosphere to check his desire to get over with stuttering. Such person when treated with fluency shaping technique it would help to smooth remaining stuttering moments at later stages (pre event and preparatory sets) to achieve highest possible normal fluency. . References Gordon, Neil (2002). Stuttering: incidence and causes. Developmental Medicine & Child Neurology, 44: 278-282. Prelock, Patricia A., Hutchins, Tiffany & Glascoe, Frances P. (2008). Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood. Medscape J Med. 10(6): 136. National Literacy Trust. (2009). http://www.literacytrust.org.uk/talktoyourbaby/impactofslds.pdf. American Speech-Language hearing association, 2009. Language-Based Learning Disabilities. http://www.asha.org/public/speech/disorders/LBLD.htm#four National Institute on Deafness and Other Communication Disorders (NIDCD) (May 2002). NIH Pub. No. 97-4232. Reviewed: October 2008 http://www.nidcd.nih.gov/health/voice/stutter.htm Kehoe, T. D. (2006). No Miracle Cures: A Multifactoral Guide to Stuttering Therapy (Fluency shaping). Illustrated, Casa Futura Technologies. Ward, David (2006), Stuttering and Cluttering: Frameworks for understanding treatment, Hove and New York City: Psychology Press. Conture, E. G. & Curlee, R. F. (2007). Stuttering and related disorders of fluency. 3rd edition, Thieme. Prasse, J. E & Kikano, G. E. (2008). Stuttering: An Overview. American Family Physician, 77(9): 1271-6. Academic Research Library database. (Document ID: 1468009541). Blomgren, M., Roy, N., Callister, T. Merril, R. (2005). Intensive stuttering modification therapy: A multidimensional assessment of treatment outcomes. Journal of Speech, Language, and Hearing Research, 48, p. 509-523. Menzies, R., O’Brian, S., Onslow, M., Packman, A., St Clare, T., Block, S. (2008). An experimental clinic trial of a cognitive-behavior therapy package of chronic stuttering. Journal of Speech, Language, and Hearing Research, 51:1451-1464 Mulcahy, K., Hennessey, N., Beilby, J., Byrnes, M., (2008). Social anxiety and the severity and typography of stuttering in adolecents. Journal of Fluency Disorders, 33: 306-319. doi: 10.1016/j.jfludis.2008.12.002 St Clare, T., Menzies, R., Onslow, M., Packman, A. & Block, S. (2007). Unhelpful thoughts and beliefs linked to social anxiety in stuttering: Development of a measure. International Journal of Language & Communication Disorders, 44(3): 338-351. Prins, D., Ingham, R. (2009). Evidence-based treatment and stuttering-Historical. Journal of Speech, Language, and Hearing Research, 52: 254-263. doi: 10.1044/1092-4388(2008/7-0111). Read More