Two Different Approaches to Stuttering Intervention - Research Paper Example

Abstract Stuttering is a complicated phenomenon that involves difficulty in speech production, intelligibility, emotions and cognitions. Hence, the main aim of stuttering intervention is to support the positive learning experiences and to develop the kinds of attitudes and beliefs that result in production of normal speech. Two methods of Speech Intervention are explained in the paper. Firstly, Self-modeling Intervention, that employs the observation on edited videotapes of oneself engaged in adaptive or exemplary behavior as there is considerable support for the notion that individuals can learn from observing and modeling themselves. Secondly, The Lidcombe Program, which is an operant intervention for early stuttering that is conducted in two stages. The goal of Stage 1 is for the sufferer to have no stuttering in everyday speaking situations; the goal of Stage 2 is for the sufferer to maintain that outcome for a long period. Treatment includes various behavioral and non behavioral components that are intended to eliminate stuttering in preschool-age children. Behavioral components include parental verbal contingencies for children’s stutter-free speech and stuttering, which parents use during conversations with children throughout Stage 1, and with decreasing frequency during Stage 2. Stuttering Intervention Introduction Stuttering is an intricate phenomenon that involves a mixture of characteristics together with extent of severity levels. Extent of Stuttering does not only rely on the amount of dis-fluencies in speech of an individual. But, it also takes in a multifaceted combination of problems in transparency, sentiments, production of speech and cognitions and all characteristics need to be assessed and intervened through an effective Stuttering therapy. (Hasbrouck, J. M., & Lowry, 2007) A number of these interventions are fairly popular. However, it is largely believed that the effect of intervention disappears after some time. The assessment of value of these interventions it is not without any problems: most of these procedures are quite time consuming. Purpose and Overview The objective of stuttering therapy is "To encourage the positive learning experiences and the kinds of attitudes and beliefs that result in normal speech." (Onslow, 2003) There are over one million stutterers in the United States and over fifteen million in the world. About eight out of every one thousand persons stutter. Many people do not understand the importance of speech therapy. Some believe it is a waste of time and money. Others say it is not effective until it perfects your speech problems not improve. However, educators emphasize the importance of speech development and the refinement of the speech process, for they recognize that successful learning situations, both within and outside the classroom, depend upon a child's ability to understand and use words. (Hewat, S., Harris, V. and Harrison, 2003) Physicians have obtained information about a child's speech development, realizing that such information provides major clues for predicting a child's total developmental schedule. Speech marks the time when a child first becomes an individual, separate from his mother, for it is through the use of speech for communication that a child first has ideas of his own and new way to express themselves. Stuttering Therapy is always purposeful. A clinician employs techniques because they are felt to be useful in guiding a person toward a particular end or goal. (Hasbrouck, J. M., & Lowry, 2007) The school system is a place where students are treated regularly for speech problems. Speech pathologist test students on a regular basis for speech disorders. Furthermore, just how effective is speech therapy. One particular weakness in stuttering treatments for school-age children who stutter is the lack of documented reports of long-term outcomes. Because of the problem of relapse, several researchers have suggested that follow-up periods of 2 to 5 years following treatment for stuttering are necessary to determine whether treatment effects are lasting. Stuttering Intervention programs are designed according to the standards and are determined to reach the goals as advised by the national service outline. Their target is to improve lives for young citizens in long run. Its main characteristics involve the Communication, Language and literacy (CLL) and individual, communal and emotional growth (PSE) of the sufferers. As these factors have a huge effect on learning life chances of children. Their main purpose is to give high-quality childcare and to recover sufferers of communication problems. In this paper two interventions for stuttering problem will be discussed. Self Modeling Intervention Self-modeling is defined as an intervention that employs the observation on edited videotapes of oneself engaged in adaptive or exemplary behavior (Dowrick, 1999). There is considerable support for the notion that individuals can learn from observing and modeling themselves. According to Dowrick (1999), over 150 studies have been published to date employing self-modeling as an intervention for a myriad of behaviors including athletic skills, academic issues, communication disorders, and personal and social adjustment. Dowrick (1999) asserts that the most beneficial and pronounced effects of self-modeling are apparent in studies that emphasize the image of future success in exhibiting novel skills or adaptive behavior within challenging contexts. Further, self-modeling, in comparison to other behavior or cognitive-behavior interventions, is perhaps the least intrusive in that it requires relatively less of the individual's time. Typically, the self-modeling intervention videotapes are only 2-4 minutes in duration (Dowrick, 1999) and are shown to the individual on six to eight occasions over a period of 4 to 6 weeks (Bray & Kehle, 2005). The first procedure prior to starting intervention is a formal diagnosis of fluency disorders by certified speech-language pathologists. Then, on one of the three components of the SSI-3 classification, frequency of stuttering in speaking, the mean percentage of stuttering is calculated. Direct observations. Two evaluations, 1 month apart, of the students' fluency are obtained by using a direct observation method during approximately 12-minute observation sessions. Each observation is conducted during a conversation with a school psychologist and is also videotaped for subsequent evaluation. The contents of the conversations used in the collection of these long-- term follow-up data are similar to those used in the original studies. Specifically, these conversations are focused on academic or social issues related to school experiences (e.g., plans after graduation, course work, teachers, etc.). Further, there is an attempt to keep conditions similar across students. The observations are made in the school psychologist's office or a vacant classroom. The percentage of stuttered words and rate of speech are directly assessed. Percentage of stuttered words is determined by dividing the total number of stuttered words by the total number of words produced. The rate of speech is determined by using the same data and dividing the number of words produced by the number of minutes that elapsed to produce them. Rate of speech is determined to assess whether fluency is due to a reduced rate of speech. The definition of stuttering used to determine the percentage of stuttered words and rate included single and multi syllabic word repetition, sound and syllable prolongations, and silent or audile bilabial or laryngeal blocking (Hasbrouck, J. M., & Lowry, F., 2007). Inter observer agreement. The raters used for all measures are one certified speech language pathologist. A frequency-within- interval method is used to calculate inter observer agreement for both speech rate and percentage of stuttered words data. Specifically, the procedure includes determining the average percentage of agreement on the frequency within each of the forty-eight 15-second intervals. An audiotape is used to insure calibration of intervals. This is done for 50% of the sessions, with an average inter observer agreement of .84, with a range of .81 to .88. Speech naturalness ratings. Speech quality is assessed by the experimenters during the long-term follow-up data collection. A speech naturalness rating index is used that employs a Likert-type scale that ranges from 1 to 9, where 1 equaled highly natural, and 9 equaled highly unnatural speech quality (Martin, R. R., Haroldson, S. K.,2007). This measure is employed as a measure of social validity and has a reported interrater reliability of .98 (Kuhr, A., & Rustin, L., 2003). There is evidence supporting the use of modeling as an effective intervention for stuttering (Jones, M., Gebski, V., Onslow, M. and Packman, A., 2002). Therefore, it is reasonable to make use of a type of modeling, self-modeling, as a treatment for this behavior. Bray and Kehle (2005) used a self-- modeling treatment and reported that all 3 individuals involved in the study, who initially had relatively higher percentages of stuttered words, evidenced a substantial reduction in stuttering that fell below baseline levels. Specifically, student 1 evidenced a decrease from an average of 45% at baseline to 8% stuttered words at follow-up; Student 2's stuttering decreased from an average of 52% to 13%, and Student 3 demonstrated a reduction from an average of 27% to 5%. Although none of the students achieved fluent speech (i.e., 4% or less stuttered words; Hasbrouck & Lowry, 2007), their relative treatment gains were maintained throughout an 18-, 15-, and 13-- month follow-up for Students 1, 2, and 3, respectively. At a 24-month follow-up, Student 1 had maintained his treatment gains, Student 2 evidenced an increase from 13% to 33% stuttered words, and Student 3 achieved the criterion for normal speech (less than 4% stuttered words). Similarly, in the Bray and Kehle (2005) replication it was reported that 3 of the 4 students achieved normal fluency by meeting the criterion of 4% or less stuttered words (Hasbrouck & Lowry, 2007). These 4 students initially evidenced relatively lower mean percentages of stuttered words than students in the previous study. The gains were maintained throughout 8-, 6-, 5-, and 4-week follow-ups for Students 2, 3, and 4, respectively. Student 1, who initially evidenced 5% stuttered words during intervention, improved to 3% at follow-up. Although these gains are maintained for some time, it is important to determine whether or not the treatment effects were sustained over a longer time period. The permanency of treatment effect is rarely considered in clinical studies and should be paramount with respect to determining the value of any particular treatment. The assessment of long-lasting change is considered an integral component of intervention research (Kingston, M., Huber, A., Onslow, M., Jones, M. and Packman, 2003). This is crucial to stuttering research because most studies have not employed follow-ups beyond 2 years with the vast majority reporting no longer than a 1-year follow-up, along with the finding that fluency usually declines relatively quickly after the cessation of treatment (Lincoln, M. and Packman, A., 2003). There are few studies in the literature, regardless of the type of treatment, that reported a 3-year or longer follow-up of fluency gains (Kingston, M., Huber, A., Onslow, M., Jones, M. and Packman, A., 2003). The long-term results of the implementation of self modeling stuttering intervention reveals that after 4 years, all 3 patients maintained their treatment effects. Specifically, some of them exhibited normal fluency by evidencing at or below 4% stuttered words. It should be noted that most of the times sufferers receive speech services subsequent to the 24-month follow-up. Similarly, after 2 years the long-- term results of self modeling intervention reveals that majority of the sufferers maintain their treatment effects and exhibit normal fluency by evidencing at or below 4% stuttered words. The evaluation of self-modeling as a treatment for stuttering represents one of the few long-term follow-up investigations in the literature. The results of the self-modeling treatments reveal that fluency is maintained for 2- and 4-year periods. It is not likely that the maintainance is due to maturation as spontaneous recovery from stuttering usually occurs by age 6 (Hasbrouck, J. M., & Lowry, F. 2007). Furthermore, older children who stutter are much less likely to experience spontaneous recovery. The interpretation of the relatively greater treatment effect for the initially more severe group is not understood and should be the focus of future investigations. Long-term follow-up is integral to evaluating the worth of the intervention. As mentioned previously, it is rare that follow-up evaluation extends beyond 1 year. This is undoubtedly due to the numerous inherent difficulties in conducting follow-up evaluations particularly after 2 and 4 years. However, school psychologists are uniquely situated to conduct such follow-ups given the availability and access to students throughout their school years. School psychologists are strongly encouraged to consider employing formal procedures for evaluating the long-term maintenance of treatment gains. In this way, lasting effects can be monitored and interventions reinstated in situations where it appears warranted. Lidcomb Intervention for stuttering Programme The Lidcombe Program is an operant treatment for early stuttering that is conducted in two stages. The goal of Stage 1 is for the sufferer to have no stuttering in everyday speaking situations; the goal of Stage 2 is for the sufferer to maintain that outcome for a long period. Treatment includes various behavioral and nonbehavioral components that are intended to eliminate stuttering in preschool-age children. Behavioral components include parental verbal contingencies for children’s stutter-free speech and stuttering, which parents use during conversations with children throughout Stage 1, and with decreasing frequency during Stage 2. Non-behavioral components include the incorporation of the parent–child relationship into treatment and the teaching strategies that clinicians use when training parents to conduct treatment. (Rousseau, I. and O’Brian, 2003) During weekly visits with their children to the speech clinic, parents learn how to conduct the treatment and measure their children’s stuttering severity. Clinicians supervise behavior and stuttering severity measures all through clinic visits and regulate the treatment to guarantee positive outcomes. There are good reasons to believe that the program is safe and produces clinically significant reductions in young children’s stuttering (Onslow and Packman 2001). The potential benefit in such research is that some treatment components may be eliminated, producing a simpler and more efficient treatment for early stuttering (Packman 2003). A process of dismantling the Lidcombe Program would be an extensive research effort, involving systematic manipulation of its treatment components as independent variables in order to assess their contribution to treatment outcome. The statistical inference in such a program of research would require many participants in order to achieve adequate power. This would have the likely effect that many children would, for clinically significant periods, receive a compromised version of a treatment that is currently thought to be best practice (Packman et al. 2003) and is known to have more immediate impact on stuttering than natural recovery (Harris et al. 2002). Without preliminary empirical justification, such a research program would not be ethical. It is therefore necessary first to establish whether or not such a project is viable with preliminary data. This could be accomplished by verifying the existence of any hypothesized effects and, if any such effects appear to exist, estimating their size in order to power adequately large-scale subsequent research. These contingencies are referred to as ‘punishment’ in behavioral terminology, although contemporary writers rarely use the term because of associated punitive connotations (Rousseau, I. and O’Brian, S., 2003). The reason for an assessment of their value in the Lidcombe Program treatment is that they are potentially harmful if used incorrectly: Of all behavioral techniques, punishment has the greatest likelihood of misuse. (Martin, R. R., Haroldson, 2007) Many people find it easier to apply punishment than to expand the effort to identify and apply positive reinforcement procedures for behavior incompatible with the undesired response. Punishment is also attractive because its impact is often more quickly visible than the effects of positive reinforcement. Finally, punishment can be a form of aggression and retribution, which are frequently the natural responses to the anger engendered by undesirable child behavior. (Yaruss, J. S., 2007) A potential clinical problem in the Lidcombe Program is that parental requests for children to self-correct stuttered speech momentarily exclude children from conversations with parents and return them to the interaction only after the child responds. Children could become puzzled or unhappy if parents—with the best of intentions—inadvertently replace normal conversation and unconditional approval with unremitting requests for improved speech. Indeed, during development of the Lidcombe Program, concerns were raised about the potential harm to children from the procedure (Jones, M., Gebski, V., Onslow, M. and Packman, A., 2002). Routine administration of the Lidcombe Program includes procedures to prevent unintended harm to children. ‘These procedures include, for example, ensuring that parental verbal contingencies for stuttering are neither constant, intensive nor invasive, that their use does not impair everyday communication between parent and child, and that parents use verbal contingencies for stutter-free speech at least five times more often than verbal contingencies for stuttering’ (Onslow 2003c). In fact, much of the clinical time during Stage 1 of the Lidcombe Program is spent teaching parents how to apply verbal contingencies for stuttering in the correct and safe manner. It may be that parental verbal contingencies for stuttering are necessary for Lidcombe Program treatment to be effective. In which case, the clinical time devoted to them would be justified. However, this has yet to be empirically determined. A second treatment process component worthy of interest in the Lidcombe Program is parental severity ratings (SRs). Parents rate children’s stuttering severity each day on a 10-point scale and report these ratings to the clinician each week, who records them graphically (Lincoln and Packman 2003). The measures are then used to guide treatment throughout Stages 1 and 2 (Hewat et al. 2003, Rousseau and O’Brian 2003). A recent investigation showed that SRs were the most common cause of difficulty when clinicians implement the program. Harrison et al. (2003) found that problems related to SRs accounted for 14% of requests for advice from a consultation service conducted by clinicians experienced in the Lidcombe Program. Therefore, it would be worthwhile to know whether the SR procedure is necessary in order to obtain the known clinical results of the Lidcombe Program. (Manual for the Lidcombe Program of Early Stuttering Intervention, 2002) Moral welfare is a highly contingent social construct based on political and social judgments and on objective or scientific data about what is best for individuals in an ideal society. Providing basic interventions for citizens has always been of crucial importance. Even though these interventions are made keeping every little aspect in view, to provide sufferers with the best intervention possible, but in some cases the special needs of sufferers might be ignored. However, these interventions make every effort to judge the reasonableness of the services offered to the sufferers. Many individuals with severe stutering problems are prone to face difficulties that will further endanger their survival in long run. Conclusion Early results from an extensive assessment implied that both the Self modeling and Lidcombe Stuttering Intervention programs did have the right direction of work. Researchers took regular feedbacks from parents, teachers and sufferers in order to make sure that the offered interventions were concentrating on the necessities of the individuals who were meant to avail them. Both the programs include parental presence in the setting. Moreover, these programs have been regularly evaluated from the time of implementation. In conclusion, both the self modelling and Lidcombe Procedure are effective in subsiding effects of stuttering problem in sufferers. However, it is needed that these interventions need to be assessed and sufferers need to be seen by their speech therapists at regular intervals, so that the effects of such interventions can be assessed accordingly. The basic aim of stuttering intervention programmes is to get rid of stuttering problem that leads to social exclusion, by giving desired help to sufferers and their family members by supporting them in nurturing and providing healthy learning ability to every individual from their early childhood. These interventions are popular, as they make sure to carry out every effort to eradicate stuttering problem from early childhood in individuals. These interventions prove the fact that nothing is impossible if someone decides to overcome their negative aspects by seeking help from experts. For the best interests of individuals, further researches will be needed to evaluate the efficacy of these interventions after several years of treatment completion. It will demonstrate, how much medical sciences have been successful in providing a sound stuttering intervention for individuals living currently with stuttering problem. Young children, who are still unable to communicate effectively unlike others should be given more consideration. So that the problem can be cured before it reaches severity. References Bray, M. A., & Kehle, T. J. (2005). ‘Self-modelling as an intervention for stuttering’. School Psychology Review. 13, Pg 206-215. Dowrick, P W. (1999). ‘A review of self modelling and related interventions’. Applied & Preventive Psychology, 8, 23-39. Hasbrouck, J. M., & Lowry, F. (2007). ‘Elimination of stuttering and maintenance of fluency by means of airflow, tension reduction, and discriminate stimulus control procedures’. Journal of Fluency Disorders, 14, 165183. Hewat, S., Harris, V. and Harrison, E., (2003), ‘Special case studies’. In M. Onslow, A. Packman and E. Harrison (eds), The Lidcombe Program of Early Stuttering Intervention: A Clinician’s Guide (Austin: Pro-Ed), pp. 119–136. Jones, M., Gebski, V., Onslow, M. and Packman, A., (2000), ‘Treating stuttering in children: Predicting outcome in the Lidcombe Program. Journal of Speech, Language, and Hearing Research’, 43, 440–1450. Jones, M., Gebski, V., Onslow, M. and Packman, A., (2001), ‘Design of randomized controlled trials: Principles and methods applied to a treatment for early stuttering. Journal of Fluency Disorders’, 26, 247–267. Jones, M., Gebski, V., Onslow, M. and Packman, A., (2002), ‘Statistical power in stuttering research: a tutorial. Journal of Speech, Language, and Hearing Research’, 45, 243–255. Kingston, M., Huber, A., Onslow, M., Jones, M. and Packman, A., (2003), ‘Predicting treatment time with the Lidcombe Program: Replication and meta-analysis. International Journal of Language and Communication Disorders’, 38, 165–177. Kuhr, A., & Rustin, L. (2003). ‘The maintenance of fluency after intensive in-patient therapy: Long-term follow-up’. Journal of Fluency Disorders, Pg 229-236. Lincoln, M. and Packman, A., (2003), ‘Measuring stuttering’. In M. Onslow, A. Packman and E. Harrison (eds), The Lidcombe Program of Early Stuttering Intervention: A Clinician’s Guide (Austin: Pro-Ed), pp. 59–69. Manual for the Lidcombe Program of Early Stuttering Intervention, (2002) (accessed 18 September 2002 from the Stuttering Unit, Bankstown Health Service website: http://www.swsahs.nsw.gov.au/stuttering/resources.htm). Martin, R. R., Haroldson, S. K. (2007). ‘Effects of vicarious punishment on stuttering frequency’. Journal of Speech and Hearing Research, Pg 21-26. Onslow, M., (2003), ‘Verbal response-contingent stimulation’. In M. Onslow, A. Packman and E. Harrison (eds), The Lidcombe Program of Early Stuttering Intervention: A Clinician’s Guide (Austin: Pro-Ed), pp. 71–80. Rousseau, I. and O’Brian, S., (2003), ‘Routine case studies’. In M. Onslow, A. Packman and E. Harrison (eds), The Lidcombe Program of Early Stuttering Intervention: A Clinician’s Guide (Austin: Pro-Ed), pp. 103–118. Yaruss, J. S., (2007), ‘Clinical implications of situational variability in preschool children who stutter’. Journal of Fluency Disorders, 22, 187–203. Read More