transfer, maintanence, recovery & relapse of stuttering.pdf / kunnampallil gejo john

7/27/2019 TRANSFER, MAINTANENCE, RECOVERY & RELAPSE OF STUTTERING.pdf / KUNNAMPALLIL GEJO JOHN

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TRANSFER, MAINTANENCE, RECOVERY &

RELAPSE OF STUTTERING

FLUENCY AND ITS DISORDER

KUNNAMPALLIL GEJO JOHN, MASLP

KUNNAMPALLIL GEJO JOHNMASLP



Transfer/ Generalization of fluency:

Transfer refers to generalization of modifiedcommunication styles and speech techniques from withinthe clinic to settings and situations outside the clinic.

Transfer activities occur as an integral part of the therapy

process, under the guidance of clinician. This process laysthe foundation for subsequent long term maintenance ofmodified communication behaviors.

The difficulty of transfer activities is usuallyhierarchically structured to build the child’s confidence inhis ability to employ techniques across various settings,while benefiting from the clinician’s leadership andsupport.




Transfer during therapy:

• Although transfer of new speech behaviors to the child’sspeaking environment is important, it is not necessary tobegin this process immediately in therapy, before the newtechniques have been properly learned.

• Parents often expect homework after one or two sessions.To satisfy this desire, the clinician may assign somestuttering identification task instead. Indeed, homework

assignments should reflect as closely as possible theclinical activities taking place at that point in the therapyprocess.




• The transfer process is sequential and hierarchical, but

also iterative, as it builds momentum during the treatment

phases of identification, desensitization, modification andstabilization.

• The clinician can usually identify an environment or

situation in which the child is comfortable discussingstuttering.

• Such an activity would provide a more appropriate startingpoint for the process of transfer.




• In addition to the conscious transfer of behaviors,automatic transfer during the treatment process is alsopossible.

• This is particularly the case with very young , pre schoolchildren .

• This automatic transfer appears to follow from the child’sobservation of clinician modeling and practice with easierand less effortful speech in the clinic.




Transfer of identification:

• Consciously identifying stuttering behaviors andenvironmental factors begins an important aspect of thebehavioral change involved in the transfer of stutteringtherapy; changing stuttering from something that ishidden, unconscious and automatic to something that isexamined and modified in a conscious and deliberate way.

• This transformation is an essential aspect of anytherapeutic or change process, and it can actuallyundermine or mitigate the development of habitual fearsof sounds, situations and communication partners. Thischange in perspective is actually the foundation for thetransfer process.




Transfer of desensitization:

• Although the identification of stuttering behaviors isdesensitizing to some degree, it does not directlyconfront those aspects of stuttering to which childrenare more sensitive, the reactions, comments and

judgments of listeners.

Transfer of modifications:

• Generally, transfer of actual speech modificationtechniques (e.g. prolongations, easy onsets) is how mostpeople decline transfer.




• Without adequate attention to identification and

desensitization, however, it is unlikely that meaningfulgeneralization of modification skills will ever be adequatelyachieved.

• To ensure that the treatment process is one in which thechild experiences success, it is important to develop ahierarchy of speech situations in which to usemodifications.

• It is also important to document those situations in whichthe child is actually making or using modification.




Maintenance of fluency:

• Maintenance refers to a variety of after- therapyactivities that are applied to help clients keep intact thegains of a treatment program.

• It is the long term continuation of fluency in a widevariety of settings.

• Before the maintenance phase begins, the child has

experienced success in transferring techniques acrosssettings and has gradually learned to become his owntherapist.




• For maintenance to succeed, transfer must have become anatural part of the child’s experience.

• Maintenance is seen as an integral part of therapy and theclient experiencing the maintenance aspect of a therapy isstill in therapy.

- Ryan 1979.

• Andrews and colleagues (1980) found that a plannedmaintenance program is necessary for any stutteringtreatment to be successful




• Follow up is a post therapy evaluation of a clients longterm performance after a period of non clinicalintervention.

- Boberg et al (1979)

• Many clinicians believe that therapeutic gains are notlikely to be maintained without changes in some of thestutters feelings and attitudes.

• An increasing number of behavior therapy programs inrecent years have incorporated the so called maintenanceprocedure in an effort to cope with the possibilities forthe relapse following therapy.

E.g. of such procedures are periodic clinical contactsafter the termination of therapy, self- therapy assignments and work

on speech attitudes. KUNNAMPALLIL GEJO JOHNMASLP



• Perkins (1979) suggested that for some stutters, theproblem of maintaining fluency is largely one of identity,“when fluent, they feel like unwelcome strangers to

themselves…. They wish to feel like themselves, andstuttering is a part of that self image”




Goals of generalization and maintenance programs withfour main objectives by Ingham (1993)

• To have the client use therapy practices that reduce oreliminate stuttering in the absence of formal therapy.

• To have the client demonstrate that the factorsassociated with therapy (people or situations) are notnecessary for the client to evidence therapy benefits.

• To have others regard the client as a normally fluentspeaker.

• To have the client no longer “do things with his or her

speech” to sound fluent. KUNNAMPALLIL GEJO JOHNMASLP



Procedures to maintain gains:

By enhancing activities like• Daily self - monitoring activities: dismissal from

intensive therapy does not excuse a client from the needto purposefully engage in self monitoring activities of alltypes, ranging from monitored fluency to visualization.

• Regular clinic contacts: scheduling of periodic contacts ona decreasing frequency ranging from monthly to semiannually to yearly serve as maintenance ,markers for manyclients (Ryan et al 1971). Each visit allows clients to reviewimmediately past behavior and to analyze their fluencystatus.




• Refresher programes: if a client begins to show evidenceof loss of gains made in therapy it may be necessary to“recycle” appropriate segments of the previouslycompleted therapy program. (Ryan and Van Cirk 1974,Webster 1980, Boberg 1981).

• Self help groups: form a self help group or make him joinan existing one, often these groups are valuable forventilation, practicing therapy techniques or even

socialization. (Howie et al 1981).




Factors for poor maintenance:

• Boberg (1981) - if client does not spend considerable time and energy

in house activity and clinic visits.

• Dalton (1979) - if regular follow up therapy is not carried out.

• Ryan (1981) - extend of stuttering prior to therapy (for adults)

maintenance is better in children.

• Florence, Shanes (1980) - if not self monitorred .

• Guitar and bass (1978) - negative attitudes.

• Webster (1979) - inadequate initial learning fluency- producing skills.

• Fransella (1985) - self characterization of individual as a stutter




Recovery from stuttering:

• There has been considerable debate about the nature ofrecovery from stuttering, especially from its chronic form.(Coregory, 1979). Much of this debate appears to havebeen fueled by the long held belief that completerecovery is unlikely, if, not impossible, when stuttering

persist beyond childhood.

• There are views that elimination of stuttering, even if itwas possible, is a baseless outcome because reactions to

stuttering, such as fear and avoidance are the mostweakening features of disorder and thus a full recovery ispossible only if these problems are alleviated.

(Manning 2001).KUNNAMPALLIL GEJO JOHN

MASLP



Assisted and unassisted recovery from stuttering:

• A complete understanding of individuals who recover fromstuttering because of treatment and those who recoverwithout treatment is critical to be complete understandingof the nature and treatment of stuttering.

• The patterns of recovery have important implications forstuttering treatment because they would provide cliniciansand clients with empirically based treatment goals andrealistic expectations for treatment outcome.




• Finn (1997) found speech quality differences in adultswho have recovered relatively late in life as compared tocontrols who had never stuttered. However these

differences are not found among children who hadapparently recovered without assistance.

• These findings indicate that there seem to be a higherlikelihood that speech performance will differ from normalfor those who recover in adulthood, as opposed to thosewho recovered in childhood.

• Such a finding suggests that stuttering recovery mayhave interaction with neural plasticity and from a numberof other problems.




• There are well documented evidence of reorganization of

the neural system in response to developmental and

environmental demands, known as neural plasticity. Eventhe adult cortex is thought to undergo plastic changesduring the acquisition of new motor skills.

• Recovery from stuttering at different ages could becontrolled by or could result in different neuro-anatomicand neurophysiologic markers.

i.e. children showing early, complete and lastingrecovery from stuttering could be neurologically identicalto those who have never stuttered whereas thoserecovered as adolescents or adults are predicted tocontinue to differ neurologically .




• Neural changes after treatment with adults has also beenreported for stuttering. CBF imaging studies have beenused to study the effects of treatment.

• Kroll and Heule (2003) studied 13 adult stuttering speakers (20-25 years) and 10 controls. The stutteringspeakers received an intensive version of an establishedprolonged speech program.

• They reported that the initial lateralized bias (to theright hemisphere) for some areas shifted as subjects firstcompleted intensive therapy and subsequently themaintenance phase.




• Neumann et al (2003) similarly studied 5 adult male stutteringspeakers treated by prolonged speech. Using fMRI, they foundthat the over activations immediately after therapy were morewide spread and more bilaterally distributed than before.

And

At follow up, the majority of the over activations had shiftedback to the right hemisphere, but remained still more widespread than before therapy.

• Thus, Ingham, Finn and Bothe (2005) suggest that those who

have recovered could constitute a behavioral, cognitive andneurophysiologic benchmark for evaluating stutteringtreatment for adolescents and adults, while helping toidentify the limits of recovery from a persistent disorder




Based on the research findings on the hemispheric studies and neuro

linguistic explanations on stuttering and brain models, Webster (1998) made the following observations:

• Modern concepts of brain organization indicate clearly that , not onlyis brain activity the origin of the behavior, thought and feelings, but

behavior , thought and feelings are themselves in part the origin ofbrain activity.

• When speech motor control processes are brought under voluntarycontrol through the deliberate and systemic use of stuttering

modification and fluency shaping techniques, inevitably brainactivation is being focused more in the left hemisphere motor systemsand probably the supplementary motor area in particular.




• When cognitive or behavioral technique are used to bringfears under control and counter tendencies to avoid socialand speaking situations, inevitably right hemisphere activation is being kept under control.

• As clients practice their skills and become more proficientin an ever broadening range of social and speakingsituations, the skills become more automatic and requireless concentration.

• With the maintenance of this skill, altered state of brainactivation will also become more automatic.




Predictive factors of persistence and Recovery inchildren:

• Differentiating between beginning stutters who are at risk ofdeveloping a chronic disorder and those who are likely to recover hasbeen a central objective of investigators.

• According to Van Riper’s (1971) differentiation system, earlysymptomatology dominated by repetitions has a favorable prognosisfor recovery but if blocks and prolongations dominate, chronicstuttering is likely.

• Yairi et al (1996) indicates that language indexes, non verbalperformances, phonological skills, genetics and disfluencycharacteristics may all contribute to the prediction of persistentstuttering




• Age:one predictive factor is the effect of age of onset. Alater age of onset inturn may be related to slower

language / phonologic development.

• Disfluencies:

Disfluencies become more reliable predictors after 7 to12 months post onset. Considering the high rate ofrecovery during the early months of stuttering, whichcontinues until at least 15 months post onset, this timeperiod is an important indicator of chronicity or

recovery.




• Durational characteristics:the time interval between single unit repetitions couldemerge as a reliable predictive factor around 13 to 18months post onset of stuttering.

• Phonology, language and Non Verbal skills:

it has been reported that chronic stutters performpoorer than do recovered stutteres on phonology,language and non verbal skills. Phonological skills maybe below age norms at very early stages of stutteringin children with the potential of becoming chronic.Thus , this parameter may be especially useful forchildren who are being evaluated soon after onset




Relapse and its prevention:

• The term relapse is not well defined because it covers all formsof client regression from occasionally stuttered words to theresumption of speaking patterns to pre-therapy patterns .

• Silverman (1992) reports fewer than 50% of older children andadults who acquire normal sounding fluency during treatment areable to maintain fluency permanently.

• Martin (1981) - roughly one third of PWS appeared to achieve

lasting fluency, about a third relapsed significantly aftertreatment and the remaining third either dropped out oftherapy before completion or were not available for follow upevaluation.




• However, it is reported that relapse rate in whatever

way being measured, appears to be much lower forpreschool aged children (Starkweather, 1990).

• Craig and Calver (1991) found that the majority of

those who had suffered relapse related it to feelingunder pressure to talk faster while others reportedit due to embarrassment to use the new speechpatterns. It is suggested that maximum regressionoccurred with in the 6 months post treatment and

there is a need to follow up clients for 2-5 yearsperiod following treatment .




Some of the factors related to relapse include:

• slow decay due to similar stimuli encounteredoutside clinical set up which are not taken care ofduring therapy

• failure to practice .

• genetic factors.• chronicity and severity of the problem.

• neuro physiological loading in terms of demands(internal and self imposed) exceeding the

capacities of the individual.




• inadequate assumptions of responsibilities by theclient.

• attitude change.• lack of motivation and interest

• inadequate or insufficient guidance and treatment

with regard to establishment, transfer andmaintenence.

• achievement of false fluency.

• self efficacy doubts.

• poor self monitoring and self correction strategies.• Dissatisfaction with the new methods of speaking

introduced in therapy.

• BoredomKUNNAMPALLIL GEJO JOHNMASLP



Possible causes of relapse:

• Egan (1998) briefly discusses the idea of “entropy”

i.e. the tendency of things to break down or fallapart. Applied to humans who are attempting tochange, this may be thought of as the tendency togive up actions that have been initiated.

• The stutters may grow tired of talking with theintense concentration that the new way requires.Normal speech is free and spontaneous, as nearly allstutters know from their own periods of normalspeech.

• Sometimes the targets that are so easy to achieve inthe clinical environment are completely inaccessiblewhen the situation is difficult




Silverman (1981) suggested a number of possiblereasons for relapse.

• Clients who are especially likely to relapse are thosewho, following treatment, believe themselves to becured believing they have experienced a cure, theyare less likely to continue the rigorous process of selfmanagement.

• Other clients may regress as they come to loseconfidence in the treatment program. This is moreapt to occur if they have experienced relapsefollowing previous treatment experiences.




• Neurophysiological Loading:

Several authors have suggested that some of the

individuals with stuttering possess an underlyingphysiological or neurophysiological condition.

Clients with “genetic loading” who have a familyhistory of stuttering may have a greater chance of

relapse(Sheehan and Martyn, 1996, Cooper et al, 1972).

Starkweather (1990) suggested, the demand placedon the person’s capacities to produce speech, fluencybreak will be apt to occur. Treatment techniques mustfocus on enabling the clients to maintain appropriateself management abilities to compensate for thedemands placed on the speaker and the person’scapacities to produce speech.




Client Adjustment to a new role:

• As proposed by theories such as Personal ConstructTheory, in many important ways , the speaker mustevolve as a person beyond an individual who stutters,and form a new paradigm, a new view of himself andhis possibilities.

• As Dalton (1987) explains, the speaker makes a choiceto stutter, not because he prefers to do so, butbecause it is what is familiar and consistent with howhe understands his world.




• Kuhr and Rustin (1985) found evidences of minordepression in several fluent speakers duringmaintenance following formal treatment.

• Clients may state that they are not as comfortable asthey thought they would be with their fluency. Fromthe perspective of PCT, even when fluent, thespeaker is attempting to gain evidence of support fortheir new construct of themselves and their world.

KUNNAMPALLIL GEJO JOHN

MASLP



• Speaking in a non-habitual manner:

It has been argued by several clinicians that

treatment programs that bring about increasedfluency by encouraging the person to speak in a non-habitual manner tend o have only a temporary impacton a speaker’s fluency. (Bloodstein 1949, Boberg1986 and Van Riper 1990).

Changes in habitual speech production are difficult tochange in the long term. It takes concentration and agreat deal of effort to maintain what are clearly non-habitual, respiratory, phonatory and articulatorypatterns.

Some speakers are found to maintain their alteredways of producing speech. For others, use of theiraltered patterns eventually wears off.


MASLP



• Combinations of variables hold more promise of

predicting long term fluency.

• Relapse was shown to be related to a combination ofvariables such as pre treatment severity, speechattitudes, personality variables, locus of controls andself help factors.

• The other factors that needs to be explored areclinician-client relationship, the influence of maritalstability, the influence in the possible differences inthe stuttering subtypes, the influence of extremes inthe socio-demographic factors such as age, educationand unemployment.


MASLP



• All these factors have to be taken care of inachieving better outcome and maintenance of fluencyin PWS. Achieving good, natural sounding speech andmotivating the individual and his parents the need forgood practice, maintaining diary or daily log of goal

related activities and bringing out the necessaryattitude change in the PWS and significant others inhis environment is very crucial.


MASLP



Journal articles…


MASLP



Adults recovered from stuttering without formaltreatment: perceptual assessment of speechnormalcy. JSLHR vol 40, 1997

• Author: Patrick Finn

• Purpose of this study was to determine if the speechof adults who self-judged that they were recoveredfrom stuttering without the assistance of treatmentis perceptually different from that of adults whonever stuttered.

(in terms of speech naturalness and speech variablesas rate and fluency)


MASLP



• Method:

2 groups of adults participated in the study; 15 adultsrecovered from stuttering (URS) without assistanceand 15 normally fluent adults.

All speakers were video taped performing a five 10minute monologue on a self generated task.

URS speakers underwent a 2 step procedure – independent verification and self report evaluation.


MASLP



As reported by the URS speakers, the factors thatled to recovery were:

• Speech formulation• Speaking slowly• Speech breathing.

Judges viewed video taped speech samples of allspeakers and were instructed to decide whether aspeaker used to stutter or never stuttered.


MASLP



Results:

• It revealed that the speech of speakers who used tostutter was perceptually different from that ofspeakers who never stuttered.

• This difference was correlated with un naturalsounding speech and a high frequency of part word

repetitions.• Speech rate was also found to have contributed to

un- naturalness.


MASLP



Relapse following treatment of stuttering: a criticalreview and correlative data. JFD 2(3) 1998

• Author: Ashley Craig

• Aim: to provide a critical review of data based

research in which relapse after treatment forstuttering.

• Method: stuttering was investigated in eitherchildren or adults and also to provide correlative datainvolving long term predictors of relapse in 4 adultgroups treated for stuttering.


MASLP



• Conclusions: a critical review of research into relapsesuggests that, there is no single major course for

failure to maintain treatment gains.

• Pre treatment severity has been shown to be aconsistent but weak predictor of fluency outcome.

Generally, greater the severity, higher thevulnerability to relapse.


MASLP



Predictors of stuttering relapse one year followingtreatment for children aged 9-14 years: the relationbetween attitude change and long term outcome.

JFD, vol23, 1998

• Author: Hancock K; Craig. A.

• In order to enhance our understanding of the relapseprocess, the present study’s process was toinvestigate predictors of relapse in older children


MASLP



• Method:

subjects were 77 children and adolescents aged 9-14

years who were diagnosed as having stuttered for atleast one year.

• All successfully participated in treatment and were

assessed 12 months later. Possible determinantsinvestigated consisted of pre and post treatmentfactors, including demographic variables, severity ofstuttering and anxiety levels. A standard regression

analysis isolated factors that predicted thelikelihood of relapse.


MASLP

R lt



• Results:

Only pre treatment stuttering frequency measured by

percentage syllables stuttered and trait anxiety posttreatment significantly predicted stutteringfrequency one year post treatment.

Those having severe stuttering before treatment andwho were less anxious immediately post therapy werethose susceptible to higher levels of stuttering in thelong term. Although frequency of stuttering is not anexhaustive measure of relapse, the present study

offers an elementary ability to predict those childrenat risk of relapse following successful treatment.


MASLP



THANK YOU


transfer, maintanence, recovery & relapse of stuttering.pdf / kunnampallil gejo john

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