Direct or Indirect Treatment: When to Use What with Preschool Children Who Stutter

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>> Amy: Welcome to our Expert Seminar Series, "Direct or Indirect Treatment: When to Use What with Preschool Children Who Stutter" presented today by Dr. Corrin Richels. Dr. Richels earned her Ph.D. in Speech and Hearing Science from Vanderbilt University in Nashville, Tennessee in May 2004. She's an Assistant Professor at Old Dominion University in the Department of Communication Sciences and Disorders in Norfolk, Virginia. Her interests include the assessment, treatment and systematic study of language disorders, including childhood stuttering. Welcome Corrin and thank you so much for sharing your expertise with us today.

>> Corrin: Welcome, everybody. Good afternoon. As Amy said, I'm Corrin Richels, I'm an Assistant Professor at Old Dominion University. I wanted to talk to you about direct and indirect treatment and specifically about using those two things, one or the other, with preschool children. A lot of times it is more difficult to decide when you have very young children what kinds of techniques are going to be used. So the purpose of this presentation is to discuss the kinds of parameters you can use as clinicians to decide which type of treatment will work best for you, your client and your service delivery model.

Introduction and Overviews

So today we're going to do an overview of childhood stuttering in general. We're going to define indirect versus direct treatment. We're going to talk about the different characteristics of kids that benefit from indirect treatment. During that time I will also give you suggestions for therapy activities, different procedures that you can use to do indirect therapy, and we will do the same things for direct treatment.

We will discuss clients, procedures, therapy activities, and then we're going to conclude with how you would modify one or the other of those treatments to meet the needs of your service delivery option because clearly speech-language pathology is just as much art as it is science. We have to be adaptable depending on who we have in front of us and what we're trying to accomplish.

Childhood Stuttering

So let's talk about childhood stuttering in general. Stuttering is truly a disorder of childhood; unlike acquired disorders in speech pathology. It starts typically between 30 and 48 months old, so three and a half to four olds, which is the same timeframe that we see such a huge gain in speech and language skills. Not only are our kids developing an adult pattern of articulation, but they are adding in huge elements of grammar and there's a massive vocabulary spurt. So to me it has never been surprising that stuttering would see its onset during this critical period where you have so much going on that some things would get out of sync and result in disfluencies. In general, kids who are around 36 months old are highly variable anyway. So typically developing kids around the age of three have a major fluctuation in how fluent they can be.

So again, one of the difficulty things about childhood stuttering and preschool stuttering in particular is really being able to figure out what you have in front of you. Is this a period of normal disfluency or is this something that is going to persist into a lifelong problem? That's particularly problematic because we know that there's a huge rate of spontaneous recovery in kids who start to stutter before they are four. So the child who starts to stutter in this two and a half to four year old period, is a little bit more questionable. Are they going to recover without intervention or are they going to require our help? For kids who start stuttering after age four, their likelihood of recovering without our help actually declines. A recent study reported by Howell, Davis and Williams (2008) talk about different profiles of kids, when they start to stutter and which kids are more likely to persist, and they even had instances where kids started to stutter as late as 12 years old, which again is not typical.

When you have kids that are seven, I would say over seven years old for sure, that are just beginning to stutter, the odds of them recovering without your help really, really decrease.

Negative Prognostic Indicators of Recovery

What characteristics of kids fall into the category of kids who are going to need your help? The way I worded this was "negative prognostic indicators of recovery". Remember, these are the things that you are looking for that will tell you that it is time for you to intervene.

Time since the onset of stuttering: We figure that out by looking at a major milestone in the child's life. Let's say it is summertime and you are evaluating a child who is stuttering, you ask the parent to go back to Christmas time or the winter holidays. Was your child stuttering then? And they can say, "No, maybe not then." Well, then you use a birthday. Let's say the child's birthday was sometime around March and you ask the parent, "On his birthday - was he stuttering then?" They may say, "Yeah, we had started to notice it." Now you have narrowed your timeframe by about three months and can conclude that the onset of this stuttering was likely about three months ago. If you have gone through that process and you have realized that the child has actually been stuttering for more than 14 months, the odds of them improving without your help have gone down.

Positive family history of stuttering: children who stutter somewhere on the order of - at low end, 50% and upwards of 80% of people who stutter will have at least one other family member who stutters. It does not necessarily need to be an immediate family member.

Several years ago we did a project where we looked at family history, and we found that one of the other predictors and one of the other things we were seeing in families that had a child who stuttered was the presence of other speech and language disorders (e.g. articulation, language).

In fact, one of the really interesting things that we found was that if we had a child who stuttered, there was an increased likelihood that there was a family member with ADHD or learning disability. So family history of stuttering in particular is common but also look for other concomitant speech and language disorders in the child who stutters. Do they also have an articulation difficulty, language disability, any language delay, etc.
Children who have concomitant disorders are less likely to spontaneous recover. Upwards of 40% of children who stutter will also have an articulation or phonological problem.

Disfluency clusters: What does that mean? What you see is that usually disfluencies land at the beginning of an utterance. If you have a child who starts out and they are going to say, "Mom, I want that one." The example I have given is sound-syllable repetition with prolongation of the next word. So in the sentence, you hear "m-m-m-mom, I (prolongation) want that one." That's a different profile than kid that says, "Mom, mom, mom, mom, mom, I want that one." By clustering the two disfluencies together it tells you that this problem doesn't just land in that initial processing stage. There may be a little bit more going on.

High ratio of stuttering-like disfluencies to nonstuttering-like disfluencies: we will talk about those next and how to calculate that particular ratio.

Children with inhibited temperaments: Children with this type of temperament tend to not spontaneously recover. So what does that mean? Temperament is one of those things that is kind of the way you are wired. Some people tend to freak out about everything. I had a parent tell me that she couldn't wear her hair in a pony tail because her daughter absolutely would lose it. She would yell and scream and throw herself on the ground until her mom took her hair out of pony tail. That is a highly reactive sort of temperament.

When we talk about inhibited versus outgoing or extroverted, the child is the type that is very, very slow to warm up. They're the one that the parent is dropping the child off at daycare, they have to peel them off at the door, kind of scrape them off and run out before the kid can get a hand back on him. This is the child who, in a play situation at a birthday party, stays very close to their parent and then maybe after a period of time will mingle with the other kids.

The very reactive, the behaviorally inhibited types of children are also typically not...