Focusing On Communication Intervention For School-Age Students Who Stutter

Focusing on Communication: Intervention for School-Age Students Who Stutter Ellen M. Kelly, PhD, CCC-SLP, BCS-F Kathleen A. O’Neal, MS Candidate Department of Hearing and Speech Sciences Vanderbilt Bill Wilkerson Center Vanderbilt University Medical Center

Disclosures Financial: – Kelly is employed by the Vanderbilt University Medical Center – Clinical research conducted by Kelly and O’Neal funded in part by a Malcolm Fraser Foundation gift Nonfinancial: – Nothing to disclose 2

Overview Focus on Communication The Stuttering Iceberg & the ABCs Assessing Affective and Cognitive Components – Assessment Tools: Students; Teachers – Interviewing and Goal Setting with Solution-Focused Brief Therapy (SFBT) Treating Affective and Cognitive Components – Cognitive Behavior Therapy (CBT) – Desensitization Big Finish: “Stuttering: Oh Yeah” 3

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Focusing on Communication Goals for assessment and treatment relate to whether or not our clients are achieving their communication goals in their relationships – Home – parents; siblings; extended family – School – peers; teachers; coaches – Social/Community – clubs; church; service whether they stutter or not. 5

Our Job Is Not to “Cure” Stuttering Most natural recovery from developmental stuttering occurs before age 7. Most children who are stuttering at age 7 and above, have been stuttering for more than 3 or 4 years (with onset between 2 and 4 years). Stuttering is natural for most of the schoolage students we see. (Yairi & Ambrose, 2013) 6

Stuttering and Role Conflict 7

Sources of Role Conflict “when children who stutter act in ways they are not used to, they feel conspicuous, ‘strange’ or ‘kind of funny’.” “it is not uncommon for children who stutter to prefer to act ‘like themselves’ and to just hope that they do not stutter.” “ for many children, it is more important to communicate thoughts and feelings ‘honestly’ than to say the words fluently.” (Williams, 2004, SFA, pp. 43-44) 8

Negative Attitudes Toward Communication Start Early Children as young as three years who stutter have more negative attitudes towards their speech than their nonstuttering peers Such attitudes: – become more negative with age – are not dependent on stuttering frequency (De Nil & Brutten, 1991; Vanryckeghem & Brutten, 1997; Vanryckeghem, Brutten, Hernandez, 2005; Clark, Conture, Frankel, & Walden, 2012) 9

Stuttering Impacts Communication Children who stutter report difficulty in: Group discussions Interpersonal conversations Interactions with strangers (Blood et al., 2001; Erickson & Block, 2013) Children who stutter exhibit: Increased communication apprehension Decreased communication competence 10

Communication Success Does the student who stutters: Say what he wishes to say? Do what he wishes to do? Become who he wishes to become? Vivian Sisskin (2018; ARTS) Is communication: Efficient? Comfortable? Spontaneous? Confident? Joyful? 11

Making Choices Vivian Sisskin (2018; ARTS) Road to Comfort Road to Struggle Showing Up Staying Home Saying All I Want Cutting It Short Avoiding Being Open Hiding My Stuttering 12

Stuttering Iceberg & the ABCs OVERT: Behavior: Observable aspects on the surface COVERT: Aspects hidden beneath the surface Affective: Emotions Cognitive: Thoughts, Attitudes, Beliefs (Sheehan, 1970; Sheehan, 2015) 13

Learning from the Experts (Michael Palin Centre for Stammering Children) http://www.stammeringcentre.org/ 14

ASSESSING AFFECTIVE AND COGNITIVE COMPONENTS 15

Overall Assessment of the Speaker’s Experience of Stuttering (OASES) 3 Versions – Ages: 7-12; 13-17; 18-adult 4 Sections: – General Information – Reactions to Your Stuttering – Communication in Daily Situations – Quality of Life Yields Impact Severity Ratings (Yaruss & Quesal, 2006; Yaruss, Quesal, & Coleman, 2010) 16

Children’s Attitudes about Talking-Revised (CAT-R) 32 items True/false response Examples of questions: – “Some kids make fun of the way I talk.” – “I am afraid words won’t come out when I talk.” – “I don’t talk right.” (De Nil & Brutten, 1991) 17

Connect with the Teacher Brief Questionnaires – Teacher Input – Fluency (State of TN, DOE, 2009) – Las Cruces Teacher’s Rating Scale http://www.mnsu.edu/comdis/kuster/stutter.html – Test of Childhood Stuttering Observational Rating Scales (TOCS ORS) (Gillam, Logan, & Pearson, 2009) Speech Fluency Rating Scale Disfluency-Related Consequences Scale 18

TN DOE (2009) 19

(Stuttering Homepage) 20

(Stuttering Homepage) 21

Speech Fluency Rating Scale: Does the child repeat, prolong, block? With whom does it happen? 22

Disfluency-Related Consequences Rating Scale: How does the child react to stuttering (physically? emotionally)? How do other children react? 23

How Teachers Can Help Give their unique perspective on the student in the classroom context Support the changes the student is making – Checking in – Compliments about communication – Supporting/assisting student’s class presentation(s) about stuttering Keep an eye out for teasing/bullying and respond accordingly 24

How Teachers Can Help “Notice” the child’s stuttering on particular days and respond accordingly – What’s going well in terms of communication? – Acknowledge frustration/difficulties “matter-of-factly” Consider (with the child’s input, if age appropriate): – Amount/level/context of talking requested – Individual versus group work Solo versus choral reading Small group versus whole-class discussion Individual versus group presentations Be a practice partner for the child 25

EXPLORING STUDENTS’ COMMUNICATION GOALS Solution-Focused Brief Therapy (SFBT) Interviewing 26

SFBT: Best Hopes Determine what is important to the client or family by asking for their “BEST HOPES” For each “hope,” (aka “goal”), ask questions like: – WHAT ARE YOUR BEST HOPES FOR ? – WHAT ELSE? WHAT ELSE? WHAT ELSE? – WHAT DIFFERENCE WOULD THAT MAKE? Best Hopes often yield LONG-TERM GOALS Follow-up questions yield SHORT-TERM GOALS or “SMALL STEPS” (e.g., Botterill, 2011; Botterill & Cook, 2009; Burns, 2005; Nicholas, 2015) 27

SFBT Case Study: Joseph BEST HOPES 28

Joseph’s Best Hopes What is your best hope for therapy? – The main thing would be not to stutter at all. That’s the best thing that could happen - ever. What difference would it make if you didn’t stutter at all? – I could communicate better with people. I could answer questions better and ask them better too. What difference ? – I would be seen as a more intelligent human being. What difference ? Who would notice? What would they notice? – I would be asking the questions, the right questions What difference would that make for you? – I would be more confident. 29

SFBT: Scaling Best Hopes 0 0 goal absent 10 10 goal achieved Client marks where he is now and where he would like to be over the long- or short-term. (Burns, 2005) 30

Sample SFBT Goals: Joseph LONG-TERM GOAL (Best Hope): – Joseph will increase his communication confidence from 3.5 to 8 on a scale from 0 no confidence to 10 complete confidence. SHORT-TERM GOAL (Small Step): – Joseph will increase how often he asks questions in class from 4 to 8 on a scale from 0 asking no questions 10 asking every question I have. 31

SFBT Interviewing: The Miracle Question If you wake up tomorrow, and your “best hopes” have been realized, what’s the first thing you will notice? – What else? What else? What else? – Who else will notice? What will they notice? What else? What else? – How will they respond? How will you respond to them? What else? What else? – What difference would that make? (Burns, 2005) 32

ASHA: Treatment Goals: Personal and Environmental Context Reduce negative emotional responses (e.g., anxiety, shame, frustration, fear, and apprehension) to stuttering and to communication in general. Increase self-confidence about, participation in, and enjoyment of communication. Increase knowledge about stuttering, take the initiative to educate others; advocate for appropriate accommodations. Retrieved from: amework/ 33

TREATING AFFECTIVE AND COGNITIVE COMPONENTS Cognitive Behavior Therapy (CBT) and Desensitization 34

Cognitive Behavior Therapy (CBT) Cognitions or Thoughts Affect Behavior or Feelings Physiological Responses (Beck, 2011) 35

CBT Cycle Stutter Change words Talk less Run away What I Do What I I can’t breathe. Think I wish I could talk. I look stupid. What I Feel in My Body How I Feel Stomach ache Fast heart beat Sweating Dry mouth Self conscious Angry Scared Rushed 36

CBT: Cognitive Restructuring Identify and minimize negative thoughts (Murphy et al., 2007) Change negative thoughts about stuttering 37

CBT: Changing My Thinking Helpful and Hurtful Thoughts – What do I think? – Are my thoughts hurtful? – Are there exceptions to what I think? – What are some more helpful thoughts? How could I test my hurtful and helpful thoughts (e.g., experiments)? 38

CBT: Changing My Thinking Hurtful Thinking Helpful Thinking 1. I am going to stutter if I answer this question. 2. Everyone will laugh when I stutter. 3. I always stutter when I read in class. 4. Nobody in high school will like me if I stutter. 1. I will answer this question by taking my time. 2. Most of my classmates will pay attention to my answer not my stuttering. 3. Sometimes I stutter when I read out loud. 4. I will have friends in high school like I do now. 39

Acknowledging Feelings Letting Feelings “Be” or “Holding Them Lightly” Discussing Feelings Openly – My Worry Dial – If my stuttering were an animal, it would be Building Confidence – Facing Our Fears – Expanding Our Comfort Zones 40

“Worrying is like sitting in a rocking chair. You’re doing something, but you’re not going anywhere.” (Jim Boeheim) (Lisa Scott, 2010) 41

Acknowledging Feelings: Drawing 42

Acknowledging Feelings: Drawing 43

Acknowledging Feelings: Drawing 44

Acknowledging Feelings: Drawing “I put a smiley face because I feel good about my stuttering.” 45

Desensitization Gradual exposure to feared situations (Murphy et al., 2007) Reduction of sensitivity associated with stuttering 46

Case Study: R.K. 3rd grade Refused to participate in therapy activities Rated communication effectiveness based on stuttering frequency 47

R.K.’s Desensitization Hierarchy (Sisskin, 2018) High Talking in front of the class Mid Talking during group therapy Low Talking at home with family 48

Self-Disclosure The acknowledgment of being a child who stutters Provides child with positive reactions Incorporated into – Mixed therapy groups – Motivating turn-taking games (Murphy et al., 2007; SFA, 2014) 49

Voluntary Stuttering Allows students to experience stuttering in a safe environment Improved confidence from –Imitating own stuttering –Using technique outside of therapy (Byrd et al., 2016; SFA, 2014) 50

Desensitization & Voluntary Stuttering (SFA, 2014; www.stutteringhelp.org) 51

Advocating for Myself Why advertise? – When you advertise, you take control of your stuttering. You don’t have to be nervous, waiting for someone to find out you stutter. How can you advertise? – When you introduce yourself, you can say, “I stutter” or “I stutter, so sometimes it takes me longer to speak.” You could add, “It’d be great if you could wait for me.” (Excerpted from NSA’s Advertising Challenge by Sarah Onofri) 52

Messages about Communication Keep on Talking No Matter What! – e.g., Giving a speech at school (Did you do it? How do you think it went?) The Power is Yours! – It is yours to keep (or to give away) – This is not acceptable! Model Being a Good Communicator – Be a good listener – Acknowledge & repair communication breakdowns 53