Obviously individual speech and language therapists have different ways of working but these are features of their practice that are quite common.
The amount and type of therapy offered to young children will depend on the outcome of the assessment and the judgement of the therapist as to what level of support is required. Most therapists nowadays will endeavour to work closely with parents so they can become skilled supporters of their child's speech needs. The therapist would also try to use the lowest level of intervention in the first instance and this may involve one or more of the following levels of care:
1. Advice and information
This might be recommended when:
- the dysfluency has occurred only recently;
- the dysfluency is mild;
- parents are not anxious about the child's speech;
- there is no history of stammering in the family;
- there are no other speech and language problems;
- there are no other areas of concern.
What is this advice and information offered to parents?
This will vary with the therapist but is likely to include some or all of these:
- Information about the development of stammering and its effects on a young child.
- The importance of creating a supportive environment for the child's speech in the home: for example by managing family rules for turn-taking, pausing in speaking and allowing the child to finish what he wants to say without interruption.
- Making time in the home for parents to spend time with the child and ideas on how to use this time.
- Developing consistency within the household in appropriate routines and boundaries for behaviour.
- The BSA knows from parents that they sometimes worry if their child is not immediately offered therapy. They may feel let down in some way when only advice and information is offered. If you do feel like this then it is important to express your worries to the therapist at the time when s/he explains to you what is going to happen. You do need to feel reassured about the support you and your child are receiving, because if you continue to be anxious then your management of your child's speaking might be affected, and your child could sense your concern. If you still feel worried then contact the BSA:Helpline and discuss it with someone who understands.
2. Indirect therapy
This is likely to be recommended to parents who are concerned about their young child's speech, and although the dysfluency may be variable there is evidence that the child's speech shows tension and frustration. There might be extra vulnerability because of a family history or associated speech and language factors.
With younger children, indirect therapy is the method more commonly used, and is carried out through you as parents. You may be asked to attend appointments without your child, to discuss ways in which you can best provide support at home. Sometimes arrangements are made for parents to work together in small groups. The therapy focuses on family communication styles and will show the parent(s) how to identify some small changes that are likely to promote fluency.
Indirect therapy tends to be based on the demands and capacities model of stammering. According to this model, most children trip up over words, get stuck and repeat words or sounds when they first begin to talk. Usually, they work through this phase, although some may need extra help. At the same time as speech and language skills are developing, there are increasing demands on the child to communicate - these can include both external demands and internal demands (for example, to answer questions, express themselves, compete with siblings, etc.). When a child's skills keep pace with the demands, any difficulties are overcome fairly soon. However, when the demands are greater than the skills a child has acquired, difficulties can persist. The aim of indirect therapy is to achieve a better balance between the demands on the child to communicate and his or her developing capacities. The therapist will explore ways in which you can help reduce some of the pressures your child may be experiencing, as well as ways in which you can help increase their skills. They may also advise on how to ensure hat your child has a more relaxed life style so that he is not affected by too much rushing around. The BSA knows that nowadays it is often difficult to provide even young children with the time and space that they need to play as they wish at a pace that suits them. Parents can only do their best to deliver this, and even if only minor adjustments can be made they will help.
Parent Child Interaction Therapy
This is more likely to be offered to the older child and consists of six one-hour weekly sessions followed by a six-week consolidation period with additional appointments as necessary to monitor and review progress. The main aim of this therapy is to identify the 'interaction styles' within the family that may help the child towards more fluent speech. A key goal is to improve the family's confidence and skill in managing their child's problem.
Therapists know that children's fluency is highly variable and that periods of fluency can suddenly be disrupted by another phase of stammering. The task of the therapist and the parents is to identify the aspects that might be influencing the 'good' patches and the factors that may be less helpful at the moment.
The therapy sessions are set up in such a way as to make the child feel that it is a really fun playtime and he is videotaped playing with each parent in turn. Then the parents and the therapist (and the child if he wants to) watch a re-run of the play session. Next, the parents and the therapist consider aspects which might be useful to change a little, as these could influence fluency. Between the therapy sessions, 'changes' are practised during regular 5-minute 'special times' at home.
3. Direct therapy
For younger children (generally, those under 7 years of age), this specific form of direct therapy may be available in some areas. The therapist may wish to wait for some time before starting treatment, as there is evidence that children respond to this approach better, and go through the programme more quickly at around four years of age than when they are younger. This does not alter the fact that children should be seen by a speech therapist as soon as possible after stammering starts, so that they can be assessed and actively monitored.
Since the late 1990s, an increasing number of NHS and private speech and language therapists have trained in Lidcombe therapy, which was developed in Australia. It is a structured programme that takes a behavioural approach to the modification of a child's speech, the main 'therapist' being the parent. The therapist teaches you how to work directly with your child. You learn to recognize stammering and to measure its severity. For short periods each day, you will praise stammer-free speech, gently request that your child self-corrects stammered speech, and provide support. In the first instance, weekly sessions at the clinic are needed to guide you through the programme. Research indicates that this form of therapy is more effective than relying on natural recovery, but it will not be suitable for everyone. Parents should not attempt to use Lidcombe Programme techniques unless trained in them by a speech therapist and have the therapist's on-going support, as this could be harmful to their child's speech.
Therapy and your child
Therapists will always tailor their therapy approaches to the individual needs of the child and parents can be reassured that there is a not 'a one size fits all' approach to therapy. As children get older there may be more emphasis on the child's own understanding of his stammering and he may be taught techniques to help him speak more smoothly. Attention is likely to be paid to the psychological aspects of stammering, such as worrying thoughts. Problem solving and assertiveness sessions are often used to help the child manage situations that may be causing him stress, at school for instance.
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