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.

Public health nurses and language assessment in children at 2 and 4 year consultations.

The need to explore, experiment, absorb and learn, along with the pleasure of interacting with others, forms the basis for a normal language development. When mother, father and other caregivers puts words on what happens in different interaction situations, the child gets the best prerequisites for acquiring a large vocabulary and a good language (Sosial- og Helsedirektoratet 2006).


In the general health screenings at the child health centers in Norway, systematic observation of communication, language understanding and spoken language is recommended. The parents' assessment of the child's language is also essential. The public health nurse will refer the child to further language examination if there is suspicion of delayed language development or language difficulties. The Department of Special Needs Education at the University of Oslo, has prepared mapping materials for use at the health center's 2 and 4 year consultation. SATS and LANGUAGE 4 is used by the public health nurses for more systematic observation of children's language.

A normal language development at two years is characterized by a good language understanding. Regarding the spoken language, the normal variation is much greater.


SATS (Screening of Two-year-olds Language) focuses primarily on the child's language understanding, and consists of ten known objects from the child's everyday life (teddy bear, sock, bed, etc.), charting form, parental form and a guide. In the observation, the children are asked to play with the objects in different ways. In addition, interaction with the parents and environment are to be considered. If the child at the two-year consultation shows signs of linguistic delay, poor understanding or inadequate interaction with the environment, the child should be admitted to a new observation after a couple of months. The same applies if the parents express concern about the child's language development. In case of suspected linguistic abnormalities between the ages of 2.6 and 3 years, the child should be referred to further examination.


LANGUAGE 4 is a systematic observation that reveals significant features of four-year-old's language skills. LANGUAGE 4 consists of a simple picture folder, a tutorial and a mapping chart to be followed according to fixed procedures at the health center.


One of the most basic needs of a person's life is understanding and being understood. A delay in early language development may affect the child socially, emotionally and intellectually. It can also be a symptom of more complex difficulties, which can increase the risk of later reading and writing difficulties, learning disabilities and psychosocial difficulties.



Referanser
Sosial- og Helsedirektoratet (2006). Nasjonal faglige retningslinjer IS-1235. Retningslinjer for undersøkelse av syn, hørsel og språk hos barn.


Helsedirektoratet (2019). Nasjonal faglig retningslinje for det helsefremmende og forebyggende arbeidet i helsestasjon, skolehelsetjeneste og helsestasjon for ungdom. Tilgjengelig fra:https://helsedirektoratet.no/retningslinjer/helsestasjons-og-skolehelsetjenesten/seksjon?Tittel=helsestasjon-05-ar-3952. Nedlastet 13.03.19.

Written by Elisabeth H. Hansen

A weekend with stuttering in focus: Scott Yaruss visiting Oslo

Mid-March, the well-known professor Scott Yaruss travelled from Michigan to Oslo. The national organization for speech language pathologists (Norsk logopedlag, NLL) and the national stuttering interest group (Norsk interesseforening for stamming og løpsk tale, NIFS) collaborated on inviting Scott to two conferences that were held by the respective organizations that weekend. Also, the EST-team was very lucky to have a day discussing our project with him when he was here.

The topics Scott presented on the conferences was how to address bullying in children who stutter, treatment for school-aged children and treatment for all age groups. To sum up, it seemed that everyone, including parents of children who stutter, people who stutter “speechies” and the EST-group were amazed by Scott’s knowledge and dedication to enhancing treatment for people who stutter. He focused on making us SLPs more confident in how we assess and treat stuttering and how to address the challenges of living with a stigmatized difference. Through vivid story telling, examples, questions and exercises he enhanced the audience's understanding of the behavior and feelings that arises during the feeling of loosing control.

Scott emphasized that treatment success is much more than enhancing fluency and the importance of aiming to enhance acceptance of stuttering. One of the messages that I took home with me was that the gift of fluency has been wanted so badly by teachers, SLPs and parents that stuttering treatment has focused on teaching the children put much time, training and effort into using very difficult and unnatural techniques. Many children go through years of speech therapy focusing on learning to master techniques that they seldom use. SLPs should therefore not overpromise the effect of fluency techniques, but rather communicate that fluency techniques does not always work. Just as an umbrella in a heavy storm does not cover you from the rain, in some challenging situations fluency techniques will not work. Also, children have to learn that what they say is more important than how they say it. This does not mean that fluency techniques should not be included in stuttering treatment, but rather that stuttering treatment is much more than learning fluency techniques. One quote by Scott sums it all up: “treat the DISORDER, not just the BEHAVIOR”!

One of the EST-groups collaboration partner is the national interest group (NIFS). During the conference, they made a short video of Scott summarizing his presentation at the conference. If you want to look at this great video, click here: https://www.youtube.com/watch?v=_7ngc8uWu-w

Also, for all Norwegians, have a look at their web page and keep updated on all the activities they are arranging: http://stamming.no/

Inclusion criteria, design and assessment tools discussed over coffee and chocolate covered cherries from Michigan and Norwegian milk chocolate at the lovely Tøyen Hovedgård.

 
To Scott, thank you so much for your inspiration to do our very best as speech language pathologists working with people who stutter and researcher investigating stuttering treatment!  

Writing retreat at Engø Gård, Norway – March 2019

After a long, busy winter for the EST project with individual and skype meetings, we had finally managed to clear our calendars to join each other again for a writing retreat. 

We met the first week of March at Engø Gård, some of us for shorter, others for longer stays. Engå Gård promises you to “Find peace and tranquility” and so we did at this lovely historic hotel in the archipelago of Southern Norway. 

Despite spring time in the calendar, snow was in the air, covering the first flowering crocuses and snowdrops. Engø Gård can serve about 100 guests; however, we had the luxury to be the only guests at this time of the year. 

Even though being just a small group, the service was outstanding and the food delicious. Not to talk about the seemingly unlimited access to fruit and the perfect timed servings of homemade sweets in the meeting rooms during our long working days. 

For some of us, the mornings started at the gorgeous English conservatory style bath house, while others concluded the day’s work in the clear blue water of the swimming pool. A swim in the ocean on the other hand, we decided to save for a later stay. 

Linn, Åse and Kari-Anne pre-started the week by working all Sunday in Tønsberg, which resulted in some remarkable ideas and suggestions for the RCT. Monday morning, Melanie picked them up for the final drive to Engå Gård, where also Elisabeth and Hilde joined after driving form quite different parts of Norway. During this writing stay, the majority of us had the chance to meet Elisabeth in person for the first time and not just online, which was of great pleasure for all of us.

Hanne Næss Hjetland

Since we are working on several systematic reviews were we use the DistillerSR software, we also had invited Hanne Næss Hjetland (currently working at the Norwegian Institute for Studies in Innovation, Research and Education (NIFU)) to share her expertise and experience with DistillerSR in an evening session. For this session, we also had an additional visitor, Karine Bakken, Kari-Anne`s PhDs-student at the University of South-Eastern Norway.  It is so great to have good colleagues as Hanne, to spend their time and knowledge across projects. As so often, we concluded that we should have thought about that even earlier in the review process, but it was definitely not too late. Thanks to Hanne and Karine for their contributions and company.

Elaina joined in from Australia via skype for two long meetings on Tuesday and Thursday, unfortunately only participating in the work and discussions without the benefits of the social part. However, thanks to modern technology, she could save the time to travel that far, even though we missed her lively presence. On the other hand, Karoline and Ane from Statped were able to spend some days with us at Engø as well, completing the main project group with their practical–clinical insight and feedback.

From left going with the clock:
Karoline, Hilde, Åse, Linn, Elaina (skype), Elisabeth, Kari-Anne, Melanie and Ane

The time schedule at Engø covered both whole group meetings, sub-group working sessions and individual writing time. The EST project has many parallel ongoing activities, where the upcoming RCT was of course the main focus. Planning such a large clinical trial includes everything from preparing the protocol itself, discussing inclusion criteria, sketching screening interview questions, completing the ethics applications, designing information material and so on. Another working package of the project concerns future guidelines for health care professionals working with preschool children that stutter. Therefore, some of us are currently developing a survey for health care nurses, kindergarten teachers and speech-language pathologist to capture the state of art in Norway.  In addition, we had just received a detailed review of our Cochrane protocol that needed to be addressed. In other words: a very busy week with good progress for the EST project on several levels.  

PS: The next writing retreat is planned for the autumn semester, and Engø Gård is a strong candidate for a place to come back to.