Stuttering group

Eastside Stuttering Support group meeting 10/20/2010 People: SLPs Leslie, Maryam, Kate? PWS: Ruben, Rick (PhD) at UW

Interesting: NSA conference CDs, Lidcombe and Mark Onslow's research, Ruben's new teen stg group in Kent, school SLPs

Ideas for a group: opening, ice breaker, "what would you rather do/be?", discussion topic, expectations from the group

My first clinical encounter with 'Cluttering'

Fluency disorders has always been an area of interest for me professionally.  As a speech-language pathologist, practicing for 5 years, I've worked with many kids who present with 'Stuttering' or 'Stammering' (as it is called in the UK).  But only last week, did I have my first encounter with-- Cluttering, a fluency disorder, that SLPs learn about in school but very few have the privilege of experiencing clinically.  I evaluated a young girl, 8 years old, who was referred by her parents because she 'stutters'.  Did she have a fluency disorder of some kind, definitely!  But it wasn't stuttering. When I met her in the waiting area of the clinic, she responded to my greeting and immediately initiated a conversation about her playdate from that morning. I was pleasantly surprised by how outgoing she was and also a little alarmed about her social skills.

Assessment and Diagnosis

A great resource for Cluttering Assessment and Diagnosis is 'Online Resource on Cluttering- the Other Fluency Disorder' by Judy Kuster: http://www.mnsu.edu/comdis/ica1/papers/yvonne2c.html

I used the following tools:

1) The Stuttering Severity Instrument SSI-- very popular standardized test in the world of fluency disorders. Scores revealed sub-clinical to mild amounts of stuttering. But there were a significantly high number of non-stuttering like disfluencies, such as, interjections ("um", "but well", "well, then"), revisions (initiating phrases and then re-phrasing them over and over again), whole word repetitions and inappropriate pauses/breaths (taken in the middle of words).

2) The Stuttering Inventory-- not standardized, but this a great tool that looks into both stuttering and non-stuttering like disfluencies. Once again, scores demonstrated a high number of non-stuttering like disfluencies. Very few part-word repetitions, blocks, and prologations, which are all typical of stuttering.

3) Informal language and articulation assessment (I would recommend doing standardized language testing if you have time though)

4) Detailed case history (including information on academics)

I started suspecting Cluttering. My suspicion was confirmed by:

- history of mild reading challenges (she attended a reading group at school)

- writing difficulties (teacher described that student often started a topic but had a difficult time organizing her thoughts and completing her writing assignments)

- limited ability in maintaining conversations, poor self-monitoring, dominating conversations, going off on tangents, disorganized language

- student's lack of awareness of fluency issues

Definitions

American Speech-Language-Hearing Association (AHSA), described Cluttering as follow:

http://www.asha.org/docs/html/GL1999-00063.html#sec1.3.11

The Stuttering Foundation, also has helpful guidelines on Cluttering:

http://www.stutteringhelp.org/default.aspx?tabid=82

Management

Once again, the 'Online Resource on Cluttering- the Other Fluency Disorder' by Judy Kuster, is a  great resource for information on treatment-- http://www.mnsu.edu/comdis/kuster/cluttering.html

 Therapy was focused on increasing awareness through video and audio feedback. The student was very open to exploring the differences in her speech and came up with names to describe the various characteristics, such as, "breaking up the word" (inappropriate pauses), "adding words" (interjections), "speeding" and "doubling up" (word and sound repetitions).  Some other techniques I modified and enjoyed using are:

- http://www.mnsu.edu/comdis/ica1/papers/nuggets/myers2c.html-- we gave out speeding tickets.

http://www.mnsu.edu/comdis/ica1/papers/nuggets/potemrac.html-- we used 'dot talking' to slow down rate of speech.

- 'Talk bubbles' were helpful to keep track of conversations and encourage turn-taking. Each time someone starts a topic, write it their 'talk bubble'. Review the bubbles from time to time to see if they are fairly balanced, so that each person had a chance to intiate topics and take turns.

Feeding "picky eaters"

For most parents, feeding their child so that they are healthy and happy children is one of their top priorities!  My experience is that mothers are especially affected by their "picky eaters".  
For picky eaters, textures, tastes, smells and sizes can all interact in unexplainable ways to create sensory overload! 

During an experiment at a seminar, the person sitting next to me was suppose to "feed" me something out of a small snack size packet.  The packaging and logos were all in an Asian language unknown to me.  The color of this "food" was pink (like the insides of a living thing), the texture looked "chewy or rubbery" and it was squarish in shape.  My initial impressions of it were those of skepticism and uncertainty.  My partner then opened the package and brought this "food" close to my lips. The smell of it lead to a feeling of sheer disgust and an urge to push her hand away.  But in order to be polite and professional around this stranger, I simply moved my head away, managed to soften my expression of disgust and attempted a meek smile.  I was certainly not going to eat this with my own free will...it smelled, looked at felt inedible and caused my insides to pain.  To my surprise, several other individuals attending the seminar in the room were tasting this strange "food" and some even seemed to like it!  I later found out that the pink "food" inside the package was a squid snack sold commonly at Asian stores.  

In the above experience, I was lucky to be an adult who could speak my mind.  I am the master of my will with what I wish to eat and not.  For a child who is being fed and often times 'force fed' by a well meaning parent or adult, such experiences can significantly impact their relationship with food and the 'feeder' in a negative manner.

There may be several reasons for a child becoming a picky eater- medical, sensory, behavioral, or genetic/hereditary.  It is important to rule out any medical reasons causing children to refuse foods.  One very common one is--acid reflex (or acidity), where the child will be hungry but refuse to eat only after the few bites due to the resulting acid formation.  

Some simple and important points to consider when feeding picky eaters are:
- DO NOT 'force feed'
- continue to offer new foods (at least once per day)
- encourage being seated at the table with the family so that eating is a family event/experience rather that a race around the house
- always make a comfort/ favorable food available to avoid anxiety
- do not use the favorable food as a "reward" for trying/eating the new or disliked food
- take the child through the hierarchy/steps of:  1. having the new food in their plate, 2. touching and smelling the new food, 3. bringing the new food to the lips, 4. taking a "courtesy bite" of the new food and spitting it out (in a socially appropriate manner), 5.  taking a bite and swallowing it, and 6. eating the new food
- reminder: according to some research it takes up to 21 presentations before an individual and decide whether they truly like or dislike a food

What to eat and how much?

The healthy eating mantra is: eat well, not too much, mostly greens. 

Your diet is balanced if it includes- protein (daal, lentils, tofu, beans), carbohydrates (rice, wheat, pasta, bread, fruits, milk), fats (oil, ghee), vitamins and minerals (fruits and green leafy vegetables).   Portions sizes are often overestimated, especially for kids.  The portion of proteins and carbs each should be limited to the size of the individual’s fist and the amount of fat to the size of one’s thumb, it’s really that simple!  This applies to children too. It’s unfortunate that restaurants serving a healthy balanced mix of freshly prepared foods and the correct portions sizes are the ones that cost over $100 a meal.  It’s called fine dining!

 

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[Info obtained from the seminar ‘Mealtime Success for Kids on the Spectrum’]