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Fluency Final ExamMaria HodappSarah BKelsey FPt #1: Beth is an 18 year old female who stutters. She would be classified as an advanced stutterer based on her age and her awareness of her disfluencies. This diagnosis would be appropriate due to Beth exhibiting fear or avoidance of most social situations (e.g., work, school). Beth has expressed feelings of helplessness and feeling ashamed after a stuttering moment. Previous assessments have focused on the Erikson Scale, which Beth received a score of 24. She was also given the Stutterer’s Self-Ratings of Reactions to Speech Situations, which she scored a 3.00. Further assessment has been recommended because of the great impact on her education and communication abilities.The following was assessed during evaluation: case history, perceptions of stuttering inventory (PSI), informal speech sample, reading sample, parent interview, employer interview, Stuttering Severity Instrument-4 (SSI-4), hearing screening, skilled clinical assessment of articulation, Clinical Evaluation of Language Fundamentals 5th edition (CELF-5), oral mechanism examination, and treatment probes. Based on these findings, the following is recommended for DIRECT THERAPY (due to her awareness, age, and identification of stutter/diagnostic level) using a combination of therapies/techniques: Treatment Rationale Stuttering Modification Therapy (PRIMARY FOCUS) Self-analysis (increase awareness of the type, severity, and loci of disfluencies along with any secondaries)Relaxation/Desensitization (Reduce anxiety and muscle tension related to stuttering) Three Stages: Cancellations (complete intended word, pause, mentally rehearse, relax then repeat word) Pull outs (stop in middle of stuttering moment or make adjustment during the stuttering using an enhancing technique then finish word) Preparatory Sets (anticipate stuttering moment and make adjustments so that stuttering does not occur) To reduce speech fears and negative attitudes associated with her stutter. Since Beth is characterized as an advanced stutterer, she exhibits learned behaviors that need to be addressed. Goal is to achieve spontaneous fluency, first, if not then controlled fluency. To improve communication, role playing, group therapy, and video self-analysis should be conducted. These techniques should be taught and mastered and then generalized to outside situations (e.g., work, school setting). Fluency Shaping (COINCIDE WITH MODIFICATION TECHNIQUES; inferior therapy) Light Contact (producing stop consonant by brushing the articulators together and keeping air flow going as the stop is produced) Easy Onset (easy or gentle contact of voicing) Decreased Speaking Rate (slowing down the production of a word) Continuous Phonation Awareness of Articulatory movement Since the stuttering is a learned behavior, the primary goal of fluency shaping is to eliminate disfluencies. Once fluency is established, it is modified gradually to sound natural. Goal is to achieve spontaneous fluency, first, if not then controlled fluency. Modified Erikson Scale of Communication Attitudes Reducing stuttering fear and negative feelings is critical if clients are going to be successful in using either controlled fluency or mild, acceptable stuttering. This will determine current progress and modified treatment outcomes, in regards to feelings and attitudes, depending on results. Positive Affirmations/Self TalkI like my self.I am composed.I speak clearly.Words are effortless for me.I speak relaxed.I love communicating.Speech is natural.Sentences form easily.I speak with confidence.I can manage my stuttering. Each session will begin a repetition of these sayings to improve self-confidence and maintain positive feelings and attitudes. Techniques to encourage responsibility and initiativeThe client needs to learn how to make choices, develop challenges. formulate assignments, problem solve, and identify barriers to success. Essentially, the client needs to become her own clinician. To document progress/current status the following will be measured each session: % of Syllables Stuttered, Modified Erikson Scale of Communication Attitudes, record any secondary behaviors. In order to be discharged: reduce types of disfluencies (change blocks to prolongations and repetitions) reduce frequency of disfluencies (from moderate stuttering to mild stuttering), reduce negative attitudes and feelings, and assure that Beth utilizes techniques taught in therapy and is capable of transferring them to outside situations and settings.Pt #2:Cody is a 4 year old stutterer. He would be classified as a beginning stutterer because of the type of disfluencies exhibited (i.e., repetition, prolongations), rise in pitch during a stuttering moment, as well as awareness of his stutter. It should be noted that since Cody is a male and has been stuttering for six months, this places him at a high priority for assessment. The following was assessed during evaluation: case history, KiddyCat, informal speech sample, parent interview: The Impact of Stuttering on Preschoolers and parents survey (ISPP), teacher interview, hearing screening, Stuttering Severity Instrument -4 (SSI-4), Clinical Evaluation of Language Fundamentals- Preschool 2nd Edition (CELF-P2), oral mechanism examination, and Structured Photographic Articulation Test II featuring Dudsberry (SPAT-DII). Based on these findings, the following is recommended for INDIRECT (due to his age and no secondaries or signs of awareness) THERAPY: Treatment Rationale Lidcombe Program Stage 1 consists of: weekly clinic visits, parent receives training, parent provides verbal contingencies in structured and unstructured conversation, and clinical measurement procedures implemented within and beyond the clinic Stage 1 concludes when child achieves near zero stuttering as documented with clinical speech measures within and beyond the clinic Stage 2 consists of: parents continue with treatment and are responsible for long term treatment, time between clinic visits increases, any departure from criterion speech performance is reviewed immediately. This approach uses operant conditioning procedures, administered by the parents, where they are trained, during conversations each day starting at structured and then moved to unstructured. Parents and client attends weekly therapy session. Every fifth utterance is followed by praise, acknowledgment of fluency, or request for self-evaluation, which is only used when the child is fluent. Parent counseling and education is provided during this program. It is also important to make sure clinician is properly trained in this program before implementing it to client’s family. To document progress/current status the following will be measured each session: The Lidcombe Program involves two stages. The goal of the first stage includes the child becoming normally fluent. In order to complete Stage 1, Cody must have three consecutive weeks where his parent’s severity rating averages are below 2 with at least four 1s. In addition, the clinician’s severity ratings for the entire sessions are 1s or 2s. When this occurs, Cody will progress to Stage 2, which is deemed the maintenance stage. Frequency of therapy sessions will be faded so that the client and clinician will meet in the sequence of two, two , four, four, eight, eight, and finally 16 weeks apart. Cody must meet all fluency criteria to continue on in this sequence. In order to be discharged: Parents should continue with the Lidcombe program to maintain non-stuttering disfluencies. If stuttering disfluencies arise, re-evaluation should occur at a later date. Pt #3 Brittany is a 3 year old girl referred for concern regarding possible stuttering by her parents. There is no family history of stuttering, and development has been within normal limits, according to physician. Brittany would be classified as a borderline stutterer because no evidence of frustration or secondary behaviors have been noted. Disfluencies can be connected to possible demands within the child’s environment (i.e., rate of speech, interruptions, family lifestyle). Previous assessment has determined Brittany is within normal limits for expressive and receptive language abilities, and articulation. Speech sample analysis has indicated that Brittany is currently stuttering on 4% of syllables. Observation of parents, siblings, and family members has shown that a fast rate of speech is used in the household. A consultation will be conducted due to her low risk factors (e.g., problem presented less than 12 months, 3 years old, female, child unaware, no other developmental issues, no history of stuttering in family). The following was assessed during evaluation: case history, oral mechanism examination, hearing screening, parent interview, and informal speech sample. Based on these findings, the following is recommended for INDIRECT (due to her age and no secondaries or signs of awareness) THERAPY: Treatment Rationale Parent Counseling and Educating Parents should be counseled to eliminate or reduce environmental demands, make speech enjoyable for child, desensitize child to fluency disrupting stimuli, and reward forward moving speech. Parents should be educated to: reduce rate of speech, pause before responding, become a good listener, and avoid interrupting child. Parents should set aside time daily to talk, listen, and communicate with the child and reinforce the techniques stated above. Siblings and relatives should also be educated on proper family conversations (e.g., listen while others talk, don’t talk for others, and don’t interrupt). To document progress/current status the following will be measured each session: Parents will continue to monitor and collect data on the frequency and type of disfluencies. Also, videotaping should occur, to document noticeable changes and disfluencies. In order to be discharged: Due to her normal disfluencies, parent counseling is the only therapy that should initially be conducted, to avoid bringing direct attention to the child’s disfluencies. In 6 months, informal reevaluation should be conducted to assess child’s current status. Pt #4Brian is a 12 year old boy who is displaying stuttering-like disfluencies (i.e., repetitions, prolongations, silent blocks). He would be classified as an intermediate stutterer because of his age, awareness, evidence of frustration, and introduction of blocks. Previous assessment using the Communication Attitude Test was conducted where Brian received a score of 70. It is impacting his social interactions in school and has been referred for further evaluation.The following was assessed during evaluation: case history, parent interview, teacher interview (TASCC), assessment of speaker’s experience (OASES), informal speech samples, skilled clinical assessment of feelings and attitudes, treatment robes , reading sample, SSI-4, hearing screening, CELF-5, oral mechanism examination, and a skilled clinical assessment of articulation. Based on these findings, the following is recommended for DIRECT THERAPY(due to his awareness, age, and identification of stutter/diagnostic level): Treatment Rationale Stuttering Modification Therapy (PRIMARY FOCUS) Self-analysis (increase awareness of the type, severity, and loci of disfluencies along with any secondaries)Relaxation/Desensitization (Reduce anxiety and muscle tension related to stuttering) Three Stages: Cancellations (complete intended word, pause, mentally rehearse, relax then repeat word) Pull outs (stop in middle of stuttering moment or make adjustment during the stuttering using an enhancing techniques then finish word) Preparatory Sets (anticipate stuttering moment and make adjustments so that stuttering does not occur) To reduce speech fears and negative attitudes associated with his stutter. Since Brian is characterized as an intermediate stutterer, he exhibits learned behaviors that need to be addressed. The goal is to achieve spontaneous fluency, first, if not then controlled fluency. To improve communication, role-playing, group therapy, and video self-analysis should be conducted. These techniques should be taught and mastered and then generalized to outside situations (e.g., work, school setting). Fluency Shaping (COINCIDE WITH MODIFICATION TECHNIQUES; inferior therapy) Light Contact (producing stop consonant by brushing the articulators together and keeping air flow going as the stop is produced) Easy Onset (easy or gentle contact of voicing) Decreased Speaking Rate (slowing down the production of a word) Continuous Phonation Awareness of Articulatory movement Since the stuttering is a learned behavior, the primary goal of fluency shaping is to eliminate disfluencies. Once fluency is established, it is modified gradually to sound natural. Goal is to achieve spontaneous fluency, first, if not then controlled fluency. Truth Envelopes “ People all stutter in different ways”“ I can educate people about stuttering”“ Stuttering doesn’t have to be a big deal”Every session will begin with this activity. Several statements will be placed in an envelop to be taken out one at a time. The client will read each statement in the beginning of each session to decrease negative attitudes towards stuttering. Modified Erikson Scale of Communication Attitudes Reducing stuttering fear and negative feelings is critical if clients are going to be successful in using either controlled fluency or mild, acceptable stuttering. This will determine current progress and modified treatment outcomes, in regards to feelings and attitudes, depending on results. Parent CounselingBug Balls This will be used to help provide parents with information about stuttering. This will attempt to explain the episodic nature and variability, factors that lead to higher fluency and encourage parents to talk openly about stuttering. It addition to parent counseling, Brian can write down bug balls-- things they want their parents to be doing (e.g., stop reminding me to use my tools, listen, correct my errors). These insightful tips can then be shared with his parents. DrawingsInitially, Brian will draw a picture to describe how he feels/what stuttering looks like to him. After targeting how his negatives attitudes are, he will draw a new picture on how he feels about stuttering. Brian and clinician can visually compare the two photos to see how their feelings have changed across therapy. To document progress/current status the following will be measured each session: % of Syllables Stuttered, Modified Erikson Scale of Communication Attitudes, record any secondary behaviorsIn order to be discharged: reduce types of disfluencies (change blocks to prolongations and repetitions) reduce frequency of disfluencies (from moderate stuttering to mild stuttering), reduce negative attitudes and feelings, and ensure that Brian utilizes techniques taught in therapy and is capable of transferring them to outside situations and settings.IEP GOAL: Targeting quality of stuttering: Given a structured or unstructured classroom setting, Brian will relax body and speech musculature as measured by clinician/teacher observation, other informal assessments and data collection.1. Brian will demonstrate the ability to reduce physical tension during stuttering using fluency modification techniques (e.g., pull out, cancellation), for 50% of the disfluencies during a 5-minute oral reading across three therapy sessions. Targeting quantity of stuttering: Brian will use fluency shaping techniques (e.g. easy onset, light articulatory contacts) to produce fluent speech during academically based expressive tasks (i.e. requesting, answering, describing, persuading) with 5 or less disfluencies per task across 4 out of 5 therapy sessions. Targeting fluency awareness/self-monitoring: Brian will increase awareness of own speech production by describing characteristics of fluent and disfluent speech by evaluating speech of self with 80% accuracy in a 5-minute language sample across 3 consecutive therapy sessions. Block = BlueRepetition= RedProlongation = PinkIt is with g g g great honor that I I I was able to teach you 2/14 X(block) f----luency this summer. I I I w---ish you all the 4/11 very best in all your inde de devours. B b best wishes in your 2/14 c c c careers as school based s-----speech language 2/8pa pa pa pathologists. X X X Please do not uh 2 /7 hesitate in c c c contacting me if if if you should ever n-----eed 3/14 p p p professional help or X X advice. Um, Best w----ishes and 3/12 X many b b b blessings in your f-----future. 3/8 # of syllables = __88____ # of disfluent syllables = ____21____ % of stuttered syllables = _____23.8%___Types: Repetitions: 9Blocks: 4Prolongations: 7 ................
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