|About the presenters: Richard Mallard is Professor in the Department of Communication Disorders at Texas State University in San Marcos, Texas. His bachelor's and master's degrees are from the University of North Texas and his Ph.D. is from Purdue University. Dr. Mallard is a Fellow of ASHA and holds Specialty Recognition in Fluency Disorders from the Clinical Specialty Board of ASHA. Dr. Mallard has conducted intensive stuttering programs for children and adults since 1976 and currently works with families of children who stutter in intensive, non-intensive, and email/Internet formats in both university and private practice settings.|
||Jill Green, M.S., CF-SLP, recently received her M.S. in speech-language pathology from Texas State University in San Marcos, Texas. She is working as a speech-language pathologist at Wilford Hall Medical Center at Lackland Air Force Base in San Antonio, Texas.|
The purpose of this report is to describe how we are using web camera technology is currently being used in our family stuttering program. As most of you know, there are relatively few clinics that provide specialized treatment for stuttering in America. The Stuttering Foundation of America (2005) identifies 36 speech-language pathologists (SLP) as specialized stuttering contacts on their referral list for the entire state of Texas. The Specialty Board on Fluency Disorders (SBFD) recognizes a total of 15 professionals in the state of Texas as having "gone beyond the basic clinical certification (SLP-CCC) awarded by ASHA" (SBFD, 2005).
Since 1986, the Department of Communication Disorders at Texas State University in San Marcos, Texas has provided a program of stuttering therapy for children modeled after the work of Lena Rustin and the staff at the Michael Palin Centre for Stammering Children in London, England. Given the specialty services for stuttering and the availability of a unique clinical approach, our clinic receives referrals from across the state of Texas, as well as from other states in America. Because of the extensive distance some families live from San Marcos, it has proved necessary with certain families to adopt a distance approach to treatment using electronic mail and other computer-assisted technology.
Our initial attempt at providing distant treatment procedures was developed in 1999. A case-study using a distance approach to treatment was described incorporating electronic mail (Mallard, 2002). This approach involved a family living 275 miles from San Marcos. Results indicated that over a period of two years the child's stuttering was brought under control with seven face-to-face therapy session and 59 electronic correspondences. As of this writing, this child continues to maintain control of her speech and is not in need of clinical services. Since the presentation of our initial trial, advances in technology have produced improved quality Internet web-camera equipment. This enhanced technology provides an effective synchronous telepractice option for stuttering treatment.
In the spring of 2004, the first author was contacted by a family in DeLeon, Texas, more than 200 miles from Texas State University. This family was referred for more specialized stuttering treatment by the speech-language pathologist who had worked with the child in the public school. When the initial telephone contact was made, their son had a "severe" stuttering disorder that had persisted for a period exceeding two years.
The family was seen for an initial meeting in March of 2004. The child was seven years old and in the second grade. He stuttered on 35% of his words in conversation and 52% of words in reading with blocks lasting up to 3 seconds. He also exhibited severe secondary features including head jerking, hand slapping, eye-blinking, and phonating during inhalation and attempting speech with an inadequate supply of air. The parents described their son's speech at that time as "very poor" stating there were times when they "couldn't even have a conversation with him because of the severity of his stuttering." The child received prior therapy in the public school for 3 months and in private therapy for 7 months.
The purpose of the first meeting was to describe the model of therapy and the expected outcomes. The family was given a three-week Talk Time assignment (Rustin, 1987a; Rustin, Botterill, & Kelman, 1996). A second meeting was scheduled in order to conduct a formal assessment and obtain a thorough case history (Rustin, 1987a; Rustin, Botterill, & Kelman, 1996).
We met with the family in San Marcos two additional times to begin treatment. It was during these two therapy sessions that the foundation for speech change was developed. The sequence of events which occur during the moment of stuttering was explained. A graphical model (see Figure 1) served as the foundation on which the moment of stuttering was identified, described, and later manipulated during therapy. The concept for this model came from Guyton (1976). He explained that voluntary motor movements are executed by the motor system following a stored sensory pattern called a "sensory engram." When a person wishes to perform a purposeful act, "Šhe presumably calls forth one of these engrams and then sets the motor system of the brain into action to reproduce the sensory pattern that is laid down in the engram" (p. 171). Thus, in order to modify a voluntary movement like talking, one must first change the sensory engram to a more desired pattern.
In Figure 1, the thick horizontal line between A and B represents a moment of stuttering. This dysfluency may be preceded and followed by periods of fluent speech which are represented by dashed lines both before and after the stuttering moment. A is the moment that the stuttering begins and B in the end of stuttering. The distance from A to B represents the time it takes for stuttering to run its course without the person doing anything to stop the stuttering moment.
C is used to represent the beginning of a movement that stops stuttering. C is not a fixed point, but may vary in time and position relative to the beginning and end of stuttering. For example, C may occur after a period of time from the onset of stuttering as is illustrated in this figure. It is possible that C may occur in conjunction with the onset of stuttering. As stuttering severity increases, C may move before A when an individual anticipates having difficulty. The person who stutters may choose to avoid stuttering altogether by changing words and/or not speaking, as illustrated by option D.
In order to control the stuttering moment, an individual must stop engaging in C and/or D. This leaves a stuttering pattern that is free of tension (maintaining control of the muscles from A to B) and ending without movements that stop stuttering (C and/or D). When C and D have been eliminated, it is then possible to gradually decrease the distance between A and B, thus reducing the duration of the stuttering moment. Therapy procedures outlined by Van Riper (1973) provided the foundation for speech modification.
During the second therapy session a summary was provided to the family describing the aforementioned therapy success which used electronic mail to supplement face-to-face meetings. The use of use of video and audio conferencing using web-camera technology was proposed as a possible adjunct to treatment. The family was receptive to this option and purchased a web-camera within days of the meeting.
Meetings were conducted using a Logitech QuickCam Orbit web-camera and the free internet messaging service provider Yahoo! Messenger Version 6.0. Weekly meetings were conducted with the family to monitor their ability to implement speech change, to answer questions which arose during the week, and to troubleshoot newly encountered problems.
At the writing of this paper, this family met face-to-face with clinicians twice for assessment and three times for treatment. Each session lasted an average of 2 hours. Following the two therapy sessions to instigate speech change, the third face-to-face session was conducted to introduce problem solving strategies described in detail by Rustin (1987a). In addition to the two face-to-face assessment sessions and the three face-to-face therapy sessions, there have been 19 contacts made via video conferencing and telephone contact. Each contact lasted an average of 22 minutes. The total treatment time has been 14 months.
A follow-up speech analysis revealed stuttering frequency decreased from 35% to 19% in conversation and from 52% to 22% in reading. Secondary behaviors such as head jerking, phonating on inhalation and speaking without adequate breath support were eliminated. Duration of the stuttering moments were typically less than one second with no block approaching the three second duration demonstrated in the initial evaluation.
A recent interview with the parents demonstrated the effects of incorporating the family therapy approach with video conferencing, as well as use of a graphical model to represent the moment of stuttering. The parents reported an increase in their son's willingness to communicate; in their ability to effectively target the elimination of secondary features; and an observed change in their son's level of confidence when talking. The parents further reported, "He understands what he is doing (with his speech) and what he needs to do to have more control." Regarding the Sequence of Events graph, they described how it aided their ability to understand the mechanics of stuttering and how it objectified the procedures used for speech change.
A parent critique of the video conference sessions revealed a positive satisfaction report. They described the use of videoconference as "... an excellent way to keep in contact, especially for quick updates and to quickly addresses problems that arise during the week." When asked to evaluate the incorporation of the web-camera and its effect on the therapy process, the parents reported use of the web-camera as cost-effective by saving them travel and long distance phone expense. They expressed the belief that several problems had been avoided because of the ability to address issues immediately using video-conferencing. They also indicated that use of web conferencing improved the accessibility they had to their clinician.
The positive therapy-satisfaction reported by this family mirror current clinical literature from speech-language pathologists and other health-care professionals which describe positive reports in client satisfaction with telepractice. Research in the field of health services has shown that evaluation results, satisfaction reports, and general service delivery via telepractice can be regarded as equivalent to that which is provided face-to-face (ASHA, 2005b). Successful use of telepractice has been reported throughout the field of speech-language pathology in areas of neurogenics, vocal rehabilitation, evaluation of swallowing disorders, and service delivery to children within rural areas (as cited in ASHA, 2005b).
Although this report demonstrates the successful use of telepractice in stuttering therapy with one family, it is important to stress that this model is not for everyone or every family. A thorough case history and assessment such as that used by Rustin, Bottrill, and Kelman (1996) is critical to determine if the client and/or family are good candidates for a family-based treatment approach. Wilson, Onslow, and Lincoln (2004) outlined potential problems with some families using a telehealth model. In addition, certain knowledge and skills are required for the provision of quality telepractice service (ASHA, 2005a, 2005b). Families must be able to provide support resources (i.e. appropriate environment, equipment, technology operation and troubleshooting ability). Individuals must be able to follow detailed instructions provided by clinicians in order to implement speech change. In addition, individuals must have access to high speed broadband internet connections with bandwidth speeds capable of supplying quality audio and video signals. Financial resources must be available to purchase necessary equipment including personal computers and web-camera equipment.
The results of this family demonstrate that the family-based approach to stuttering intervention (Rustin, 1987b; Mallard, 1998; Mallard, 2002) continues to be a powerful therapy design. Changes in speech control, as well as changes in attitude toward speech, illustrate the effectiveness of employing the family in the management of stuttering using a distance-treatment model.
American Speech-Language-Hearing Association. (2005a). Knowledge and skills needed by speech-language pathologists providing clinical services via telepractice knowledge and skills. Available at http://www.asha.org/members/deskref-journals/deskref/default.
American Speech-Language-Hearing Association. (2005b). Speech-language pathologists providing clinical services via telepractice: Technical report. ASHA Supplement 25, in press.
Guyton, A. C. (1976). Structure and function of the nervous system. .Philadelphia: W. B. Saunders.
Mallard, A. R. (1998). Using problem-solving procedures in family management of stuttering. Journal of Fluency Disorders, 23,.127-135.
Mallard, A.R. (2002, June). Expanding family intervention in stuttering through electronic media.. Paper presented at the Sixth Oxford Dysfluency Conference, Oxford University, Oxford, England.
Rustin, L. (1987a). Assessment and therapy programme for dysfluent children.. Tempe, AZ: Communication Skill Builders.
Rustin, L. (1987b). The treatment of childhood dysfluency through active parental involvement. In L. Rustin, H. Purser, & D. Rowley (Eds.), <Progress in the Treatment of Fluency Disorders. (pp. 166-180). London: Taylor and Francis Ltd.
Rustin, L., Botterill, W., & Kelman, E. (1996). Assessment and therapy for young disfluent children.. London: Whurr Publishers Ltd.
Specialty Board on Fluency Disorders. (2005). List of board recognized fluency specialists:. Texas. Retrieved April 1, 2005, from http://www.stutteringspecialists.org/index.html
Stuttering Foundation of America. (2005). Texas resource/referral list.. Retrieved March 13, 2005, from http://www.stutteringhelp.org
Van Riper, C. (1973). The treatment of stuttering.. Englewood Cliffs, NJ: Prentice-Hall.
Wilson, L., Onslow, M. &Lincoln, M. (2004). Telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention: Five case studies. American Journal of Speech-Language Pathology, 13,. 81-91.
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