Croatia Stuttering Symposium, day three

This week on the blog, we are continuing our summary of our trip to the Croatia stuttering symposium on the 19^th to the 22^nd of May. You can read a summary of day one here, and our guest bloggers entry about day two here. 

Sharon Millard, the research lead and clinical lead speech and language therapist at the Michal Palin Centre for stammering in London started the third day of the symposium. In her talk she gave a presentation of what she thought to be the five most important research findings to consider when treating pre-school children who stutter. These included findings that children can be impacted of stuttering from an early age, and that treatment effect vary. Children and parents respond differently to different treatments independent of which treatments. She also highlighted that varying degree of stuttering severity is normal in a trajectory of treatment and that treatment therefore needs to be flexible and closely monitoring the effect of the treatment over time. This lecture highlighted the growth in evidence in our field. Just during the last years more stuttering treatments studies have been conducted, with Millard being the one of the scholars adding to the evidence (Millard, Zebrowski & Kelman, 2018).

Like the other days, the second post of the day was master class demonstration dealing with speech pathology issues that occur in stuttering therapy. Elaine Kelman is a speech and language therapist and the head of the Michael Palin Centre for stammering. She presented video of cases and problems that can occur in treatment of preschool aged children who stutter. She emphasized the role of parents and how a client centered perspective can be used to help parents identify what they are already doing to help their children. She also showed examples of how to problem solve with parents and build confidence in ability to deliver treatment and support their child. For an introduction to the Palin PCI, see our blog post from the workshop that EST -team member Hilde attend earlier this year here.

The last master class of the day, clinical psychologist at the Australian Stuttering Research Centre Ross Menzies highlighted how cognitive behavioral therapy (CBT) can be used both with young children and their parents. Parents of children who stutter can be very anxious for their child and their child’s future. The child can pick up on this anxiety and will learn through the parents that stutter is something to be afraid off. Menzies argued that SLPs can help parents change their concerns and anxiety by using strategies from CBT. An easy introduction to CBT for speech and language pathologists is given in the paper Cognitive behavior therapy for adults who stutter: A tutorial for speech-language pathologists (Menzies, Onslow, Packman & O’Brian, 2009). Because anxious parents often complicate treatment by increasing fear and overprotecting the child, Menzies also highlighted that building confidence and knowledge in parents is very important.

After the formal presentations, all symposium delegates were divided into discussion groups led by a master clinician or researcher. Many challenging questions came up during this time. During a plenary discussion the presenters were able to answer question and engaging in discussions with all the clinicians in the room. Discussions centered around what to do when parents don’t want to do the treatment and how it is possible to use cognitive therapy with young children.

Attending a symposium, and one that is small and focusing on discussions especially, provides excellent opportunities for engaging in great conversation with some of the leading clinician and researchers in our field. We are very thankful for all the great people that took the time to talk to us about their research, that inspire us to make decisions moving forward in our own research project.

 

We really enjoyed our chat on the balcony with Elaine Kelman and Sharon Millard.

 

We would like to express our gratitude to our research group Compros and the EST-project for funding our trip and attendance to the conference. From the EST- team, Linn and Åse

 

References

Menzies, R. G., Onslow, M., Packman, A., & O’Brian, S. (2009). Cognitive behavior therapy for adults who stutter: A tutorial for speech-language pathologists. Journal of fluency disorders, 34(3), 187-200.

Millard, S. K., Zebrowski, P., & Kelman, E. (2018). Palin Parent–Child Interaction Therapy: The Bigger Picture. American journal of speech-language pathology, 27(3S), 1211-1223.

Croatia Stuttering Symposium, day two

The topic of the second day of the symposium was treatment of youth who stutter. This is a broad age group and clinicians treating this age group will meet many different challenges.  As on the first day we were given clinical insight through videos showing both speech pathology methods (Rosalee Shenker) and clinical psychology methods (Ross Menzies).

Associate professor at The University of Texas at Austin, Courtney Byrd, gave a historic backdrop in her lecture, focusing on some of the theories and ideas from Van Riper. Some of her key points was that stuttering modification reduces fear and avoidance, and that voluntary stuttering facilitates positive affective, behavioral and cognitive change. She emphasized that for voluntary stuttering to be effective in desensitization it needs to closely resemble the persons authentic stuttering, something Menzies later agreed on in the plenary discussions. Although there is little research done on the effects of voluntary stuttering, there is an abundance of evidence showing that being exposed to what you fear the most is desensitizing.  

Courtney Byrd highlighted the importance of non-apologetic self-disclosure, and that teaching kids who stutter to do this can be empowering. She talked about the risk of bullying and the negative effects this can have, and that educating the child about stuttering and developing their ability to handle bullying and stigmatization is an essential part of treatment. Lastly, she talked about communication, and that good communication can be achieved regardless of stuttering and is not defined by fluency alone.

Rosalee Shenker, Executive Director at Montreal Fluency centre, talked about the many challenges there is in treating youth who stutter. Negative feedback and social anxiety increases, past experiences with failed or incomplete treatment, difficulties with generalization to out-of-clinic settings and the resistance to changing speech in fear of sounding even more unnatural then they already do. She emphasized the importance of creating a positive therapeutic relationship, and that treatment must adapt to the child´s needs. We have to measure change, and treatment should reduce or eliminate stuttering in a reasonable time frame. Rosalee Shenker commented on the fact that youth are often said to be unmotivated for therapy. She was clear on the fact that effective treatment will motivate, and if treatment isn´t working we need to adapt and change, and that it is our responsibility to motivate our clients.

Ross G. Menzies talked about increased risks of anxiety and mental health issues for this age group, and that it is a critical age for positive change and successful treatment. If we do not handle these issues at this age, they will increase and become more severe in adulthood. The consequences of anxiety are enormous for education and social life. According to Menzies adolescents often deny or minimise their anxiety problems, and it can be challenging to get them to open up. Menzies states that cognitive-behaviour therapy (CBT) is the most supported treatment for reducing anxiety in young people. Youth who stutter experience bullying at high rates, which increases the risk of anxiety, and this must be dealt with in CBT.

Menzies explains that anxiety, fear and anger comes from our consciousness. And that consciousness, our inner voice, is our biggest enemy, but is camouflaged as a friend. In therapy he uses the metaphor of the wolf in sheep’s clothing. The goal of modern CBT is to change the relationship you have to your own consciousness, and get clients to realise that they should not trust their inner voice because a friend would never talk to them that way. The more proof you get that the “wolf” is wrong, the easier it is to ignore him. An exception to a feared situation will in most cases just give a feeling of relief, and will not make you any less anxious of the same situation the next time. Therefore, the idea of the untrusting wolf must be reinforced by explicitly saying again and again that the wolf was yet again mistaken.

This is a guest post written by Ragnhild Rekve Heitmann (UiB) and Ane Guldberg (Statped Vest).  Starting from the left side on the picture below you can see Åse, Ane, Ragnhild and Linn enjoying a typical evening in Cavtat with good food and lovely scenery. 

Croatia Stuttering Symposium - day one

One of the absolute perks of doing research is being able to travel and attend conferences around the world. Listening to some of the the great researchers in our field there is always lots to learn and be inspirited by. Last week two of the EST projects researchers Åse, PhD-student, and Linn, post doc, was fortunate to attend the Croatia Stuttering Symposium.

The symposium is the fourth of its kind, held every third year since 2010, in Cavtat, an ancient small town not far from Dubrovnik. The symposium is a joint effort between Croatian SLP and European Fluency Specialist Suzana Jelčić Jakšić, researcher and clinician Robyn Lowe and foundation director Mark Onslow, both at the Australian Stuttering Research Centre at the University of Technology Sydney.

Focusing on stuttering treatment, the symposium program was set up to give clinical insight in problem-solving through video of clinical settings. There were many opportunities to discuss clinical questions in groups consisting of clinicians and researchers from many different parts of the world.

 

The topic on the conferences first day was treatment of adults who stutter. For someone who normally focuses on the treatment of pre-school children, shifting the focus to the experiences of people with a life- long experience of living with stuttering, is a very healthy exercise. The lecturers reminded us that for many adults who stutter, stuttering isn’t just an acoustic disorder but one that may impact emotional and social wellbeing. For many adults, avoiding sounds, words or even speaking situations, is a big part of the disorder. Consequently, 60 % of adults presenting for treatment are diagnosed with social anxiety (Menzies et al., 2008).

Hans-Georg Bosshardt highlighted a finding by Iverach and collegues (2018): adults how stutter with and without a social anxiety disorder did not differ in self-reported stuttering severity. However, more dissatisfaction with one’s own speech, avoidance of speaking situations and significant psychological problems were reported in the group of adults who were socially anxious. The message we took home with us from this is that efficacious treatment and psychological treatment are very important and that impact may occur regardless of stuttering severity.

Each day, different speech language psychologist gave master classes for the age group of focus by showing videos from different treatment sessions and commenting on treatment choices that were made and particular challenges. The clinical psychologist at the Australian Stuttering Research, Ross Menzies, gave master classes in psychology each of the days. On day one he presented and exemplified the use of cognitive behavioral therapy (CBT) in treatment of anxiety in adults who stutter. Menzies emphasized that SLPs, who are experts on stuttering, can use CBT in their treatment of people who stutter. Importantly, he stated that the worst thing for anxious people is the all of the opportunities that are robbed from them when they avoid life. With CBT, the clinician can work with changing the client’s negative thoughts and expectations before situations and challenging the client to expose him/herself for situations and cease the opportunities in his/her life.

Susan O’Brian gave a master class on speech pathology methods for adults who stutter. We felt very lucky when joining her for lunch one of the days.  

CBT requires changing the negative thoughts appearing in everyday situations, and exposure for challenging situations. The same can be said for speech therapy, which aims to change the way people speak, in order to decrease stuttering. In her masterclass, associate professor Sue O’Brian showed through video how SLPs can work with adults who stutter to facilitate that the clients continue the work that is done in the clinic when they are outside clinic. The two key components in the last generalization phase was practice and problem-solving. Practicing speech techniques outside clinic should involve a lot of complexity and variation. Development of problem solving skills involved both finding solutions for how to incorporate practice in daily life and also which activities and level of technique that should be used during practice. She emphasized that this work needs to be incorporated into the daily routine of the clients. The time and energy needed to go through with stuttering treatment is interesting to consider when thinking about treatments for preschool children and their busy families as well.

Special for the Croatia Stuttering Symposium is the emphasis that is placed on plenary and group discussions. During the group sessions we got the opportunity to discuss the issues raised by the presenters with other SLPs. We learned a lot from these discussions across SLPs with differing experiences. Also, the three plenary discussions with different prominent researchers and clinicians in the panel was very exciting.

A big thank you to Compros- our research group for sponsoring our trip!

 

From the EST- team, Linn and Åse

References:

Iverach, L., Jones, M., Lowe, R., O’Brian, S., Menzies, R. G., Packman, A., & Onslow, M. (2018). Comparison of adults who stutter with and without social anxiety disorder. Journal of fluency disorders, 56, 55-68.

Menzies, R. G., O’Brian, S., Onslow, M., Packman, A., St Clare, T., & Block, S. (2008). An experimental clinical trial of a cognitive-behavior therapy package for chronic stuttering. Journal of Speech, Language, and Hearing Research.