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Discuss about the SPH306 International Journal of Telerehabilitation.

Use naturally occurring therapy agents

Procedure

Description

Example of use in Maintenance schedule

Use naturally occurring therapy agents

Incorporation of the food such as gooseberry, Black pepper, dried dates and cinnamon can be the naturally occurring fruits that are used for the reduction of things. This reduces the stuttering of the patient.

This therapy can be used for the patient who has the problem of moderate stuttering. The treatment can be implemented for the approximately three months.

Train in representative speaking situations

For the clinician groups, participants received the training prior to the treatment day to ensure that the training reduces the stuttering of the patient. It helps them to talk in front of everyone as the representative of others and being the voice of common problem. Eventually, it will boost the self-esteem.

The group of participants received this therapy for the 7hours in a week. For approximately 4 weeks. Parents are also involved in this therapy and treatment occurred in the non-clinical days. Especially, in school and colleges where individuals have low confidence due to the stuttering and surroundings (Ingham et al., 2015).

Minimize the possibility of discriminated learning

The minimization of a possibility of discriminating learning can is designed in the non-clinical setting, especially in the case of preschool patients. Learning in a group of other peers enhances their self-esteem, implant hope to learn new things without any difficulties (Soulakova,2017).

This minimization of a possibility of learning in the patient. Therefore it will be applicable in non-clinical settings such as schools, colleges and preschools within the age group of 2 years to 18 years. This decrease of discrimination will help them to acquire new information and sharing of information.

Purposefully discriminate learning

Purposefully discriminating the learning can be designed for the patients who are unable to be fluent in speech and reluctant to try it. In the preschool or school setting, the purposely discrimination can be designed for the specific period of time such as 2 hours a day (Joos et al., 2014).

This implementation procedure mainly used in preschool or adolescent for acquiring the new information. Even this can be implemented in the clinical setting or home setting for acquiring new information and patients will be willing to try the method.

Make feedback unpredictable

The altered auditory feedback can be designed for reducing the stuttering of the patient along with alternation in pitch upward or downward. It influences the fluency of the patient. A masking signal device can be used for the tracking during the conversation. The device involves a microphone held outside of the larynx with the strap along with headset. The masking unit attached to the belt. The altered auditory feedback can be designed for the recent controversial topic from the publication. The participants were measured beyond the clinic basis of three conversations and asking the question (Valentine, 2014).

This unpredictable feedback session can be used for 5 hours  a day. This can be implemented in the clinical setting for the teenager who has the speech stuttering during the pre-treatment with device (Joos et al., 2014)..

Mediate generalisation

Mediate generalization a, a type of generalization in which the conditioned response is elicited by a new stimulus that is different from the original one but associated with the original. The patient can be exposed to the certain fears or few materials that give the response of excitement.

This procedure can be applicable for the teenager of age in between 14 to 18 for particular time of the day.

Target generalisation

The target generalization can be designed for the individuals with the huge stuttering problem and it also implemented for the specific time of the day.

Time will be taken approximately 1 hour per day for teenager.

Sequential modification

A sequential modification can be implemented for the reduction of severity of stuttering and elimination of avoidance and cover behaviour to reduce the stuttering fear (Scharf, 2017).

The therapy is for the individual per week for the hour, group therapy is also implemented for 2hours and self-therapy daily.


This case study represents speech stuttering of  2; 11-year-old boy, James who came to the speech pathology clinic because of shuttering. During the session, the clinical measurement obtained were SR (severity rate) =3, 4.2 % SS, 150.5 SPM. The observed shuttering behaviours were part syllable and syllable repetition and the smaller number of fixed posture without audible airflow. Her mother reported that it was typical of his speech outside of the clinical setting. In such a scenario, the issues of timing are important to make the clinical judgment of clinicians. A time interval stuttering count procedure is usually performed by clinicians or observers where they note down whether the speech is for short period of time such as 10 second and free of stuttering or it will continue for the longer period of time with one or more stuttering movement (Kronfeld-Duenias et al., 2016). Sometimes in clinical measures, the most common syllable per minute is associated with SS% that allows the syllable per minute measure to be generated. If shuttering decreases after the treatment session, speech rate tends to increase and give an assumption to the clinicians to monitor the improvement of stuttering. In this case study, 150.5 SPM which is considered as the moderate speech rate in the case of the patient.

In order to make the recommendation relevant to the issues, there are few factors need to consider for reducing the stuttering. The first factor, Family history of the patient need to consider for understanding whether anyone the family has the speech impairment that gives rise to the speech impairment of offspring. The second factor is the severity rate of speech stuttering that is useful to understand how it affects the communication of patient. In the clinical setting four categories are described to understand the value of stuttering that affects communication.SR in between 1 to 3 considered as mild, SR 4to 5 considered as moderate, SR 6 to 7 considered as the severe and extremely severe is SR8. The patient, in this case, has SR 3 which moderate according to the severity rate category that affects the communication of the patient (Hasseltine et al., 2016). Moreover, the assigning SR score is also related to the communication, in such cases, reduced speech output is also part of the consideration in the clinical setting. Percentage of syllable shuttered also need to take in to consideration in order to make the clinical recommendation. In clinical practices, the percentage of stuttering can be measured the speech with the patient or watching doing the conversation with the child and parents (Onslow et al., 2018). The professional’s measure the percentage till the speech become a valid presentation of each day and device is used for measuring the percentage. However, the reliability problem exists in the session since the observations differ from one clinician to other clinicians. The patient shows the shuttering percentage is 4.2% which is moderate and can be controlled with proper clinical (Andrews et al., 2016). The posture of the child should be considered for the recommendation of children.  Fixed posture and inaudible is one of the most frequently shuttering movement observed in the clinical setting. In a majority of the cases, the shuttering movement displayed by the patient is repeated movement and very few patients show the fixed posture during the shuttering of speech. This behavior or change of posture mostly observed in case of monologue task (Constantino et al., 2016). Mostly these movements are observed during the language development and adaptation. During the consideration of posture, genetic influence of the posture and environmental influence of the posture need to consider for making the wise clinical judgment. These postures can be corrected by the oral motor exercise for the specific period of time to correct the posture of the child during talking.

Train in representative speaking situations

The case study represents the speech shuttering of a girl Isabella who is 4.4 years came to the clinical setting with her mother. During the appointment, a model of using verbal contingencies for shutter free speech during practice session has been recommended known as the lid combo program. However, after the session, it was observed that Isabella’s speech stuttering did not decrease. The Lid combo program is a technique that developed decade earlier where illuminated puppet has a conversation with the stuttering children and during the moment of stuttering the puppet disappears. This is an effective application of verbal response successfully controls the shuttering of preschool stuttering children. Parents are the essential part of this lid-combo program in order to reduce the stuttering of the patient. Parents do the limbo program with the assistance of the clinicians (Guitar et al., 2015). Parents give the verbal response contingent stimulation to their child for either shuttering of the child or not shuttering of a child. They usually provide the verbal response by involving themselves in natural conversation during the session purposely (Bridgman et al., 2016). This lid combo program is undergoes involving parents because a majority of the children are more comfortable with their parents than clinicians but sometimes caregivers provide the treatment.

The list of clinical reason behind the shuttering are follows:

  • Hearing impairments
  • Autism
  • Developmental language disorder
  • Apraxia
  • Brain mass atrophy
  • Down syndrome
  • Tied tongue ( Ankyloglossia)

The hearing is the essential part for developing the speech as well as how to read. The studies found that hearing impairment mostly observed in the case of children to be average of 10 months. Generally, hearing loss can cause by exposure to certain toxic chemical or medicines while children are in the womb or after birth. Infection can passes to the baby in the womb and that can damage the brain after birth. The infections are especially from viruses such as cytomegalovirus, herpes and rubella. Therefore hearing loss can affect the development of the children and language skills. When the child finds it difficult to hear sounds, the left frontal lobe of the language-dominant hemisphere tends to show slow development followed by the shutter of speech. Autism is considered as the communication impairment in children (Bridgman et al., 2016). Children with autism are often self-centered and tend to exist in their world. Children with autism tend to have the intellectual disability and lower IQ than other children. Consequently, specific area of the brain does not develop accurately and give rise to speech deficit. Developmental language disorder gives rise to the shutter of speech due to similar clinical syndromes such as autism or hearing problem. Development language disorder usually occurs with milder neurological development such as attention deficit hyperactivity disorder and other neurological syndromes (Stewart, 2016). Apraxia of speech is an acquired oral motor speech disorder observed in children affecting the ability of individuals to translate conscious speech plans into motor plans followed by the difficulty of speech. In Apraxia the damage of posterior parietal cortex damaged and individuals find it hard to connect the messages from the brain to mouth. The speech impairment can be observed due to brain mass atrophy due to any injury or sudden lesion. Sometimes spherical clumps accumulated in the nerve cells of frontal lobes and cells can die. Down syndrome give rise to speech impairment since the motor skills of individuals diminishes due to the genetic malfunction. In Down syndrome, the trisomy of 21st chromosomes observed due to non-disjunctions (Prabhaharan, 2016). It affects the mouth structures of the individuals and tongue sticks out of the mouth. Subsequently, stutter in speech observed in children. Tongue tie or ankyloglossia is the most common syndrome observed in children. A strong cord of tissues is tight in most of the children and give rise to the speech impairment (Jansson, 2015).

Minimize the possibility of discriminated learning

This case study represent moderate speech shuttering of a 8;9 years old boy. Considering the evidence-based practice there are three types of evidence need to consider for clinical decision making for suitable clinical approaches. As a health professionals, first evidences need to consider that why parents taken their child to the hospital. The problem can be behavioral and non behavioral. Shuttering due to psychological or behavioral problem can be resolved by specific interventions in clinical setting. Parents play an important part in speech impairment and resolve of speech impairment. For the children, whose parents share custody of the children usually experiences the psychological trauma in early age. They tend to neglect their child and child develops the speech stuttering in very early age. in such cases, the issues between parents can be resolved so that any one of the parent present in the clinical setting and involve with the clinicians during the treatment session. According to Swift et al. (2016), the treatment procedure can be lid combo program where illuminated puppet is involved in conversation with the children. It is a behavioral treatment which is designed to deal with the shuttering of children with the involvement of parents on the therapy .parents take part in this session with the clinical assistance for approximately minutes. In clinical visit, the clinicians usually demonstrate the correct procedure to involve in therapy session and making constructing comments. The first goal of the therapy is no shuttering and second goal of the therapy is that therapy should sustain for longer period of time. If any of the parent take part in the therapy, the improvement is usually visible if parents do it correctly since children are more comfortable with their parents rather than with the caregiver.

The second evidence as clinicians need to consider is the psychological aspect of the child and parental anxiety, genetic history, gender and motor skills of the child (Conture, 2016). Moreover, parents have any complexity of language and speech of parents that can give rise to the stuttering of children along with the environment where the children live. According to Millard & Davis,  (2016). In order to reduce the stuttering problem of the child, Palin parent-child interaction therapy can be implemented in the clinical setting. In this therapy, parents are advised to find a period during every day where parents need to give complete attention to the area of concern of their children in relax speech environment (Ratner, (2018). If the child becomes little more fluent compared to other time then ask the child to pronounce the problematic word. Reduction of parental speech rate and give time for answers to the child also advice to reduce the stuttering. Praising the actions of the child, taking care of adequate sleep and diet are also part of this therapy that significantly reduces the stuttering of children.

Purposefully discriminate learning

The third type of the evidence need to consider for decision making is that the type of shuttering child has, whether moderate or severe or problem with pronunciation of specific words. According to Hameed et al. ( 2016), the west mead process can be implemented in the clinical setting in order to reduce the stuttering of the child. It is also known as the robot talking during the specific time of the everyday. Parents prompt to use syllable time speech and in between parents praise their children for saying words correctly. There is no rule that it has to conduct in the specific time of the day but activity should occur for the reducing the stuttering of children with difficulty.

Andrews, C., O’Brian, S., Onslow, M., Packman, A., Menzies, R., & Lowe, R. (2016). Phase II trial of a syllable-timed speech treatment for school-age children who stutter. Journal of fluency disorders, 48, 44-55.

Bridgman, K., Onslow, M., O’Brian, S., Jones, M., & Block, S. (2016). Lidcombe Program webcam treatment for early stuttering: A randomized controlled trial. Journal of Speech, Language, and Hearing Research, 59(5), 932-939.

Constantino, C. D., Leslie, P., Quesal, R. W., & Yaruss, J. S. (2016). A preliminary investigation of daily variability of stuttering in adults. Journal of communication disorders, 60, 39-50.

Conture, E. G. (2016). Emotional contributions to the causal matrix of stuttering. The Biomedical & Life Sciences Collection.

Guitar, B., Kazenski, D., Howard, A., Cousins, S. F., Fader, E., & Haskell, P. (2015). Predicting treatment time and long-term outcome of the Lidcombe Program: A replication and reanalysis. American journal of speech-language pathology, 24(3), 533-544.

Hameed, A., Yu, T., Yuen, L., Lam, V., Ryan, B., Allen, R., ... & Pleass, H. (2016). Use of the harmonic scalpel in cold phase recovery of the pancreas for transplantation: the westmead technique. Transplant International, 29(5), 636-638.

Hasseltine, E. S., Black, S. F., Corcoran, T. M., DiPalma, D. L., Dixon, S. E., Gooch, A. T., ... & Secrist, C. (2016). Predicting Stuttering Severity Ratings by Timing and Tallying Dysfluencies Using Praat Software. Contemporary Issues in Communication Science and Disorders, 43, 106.

Ingham, R. J., Ingham, J. C., Bothe, A. K., Wang, Y., & Kilgo, M. (2015). Efficacy of the modifying phonation intervals (MPI) stuttering treatment program with adults who stutter. American journal of speech-language pathology, 24(2), 256-271.

Jansson, J. (2015). The Monster Behind the Smile: An Analysis of Nurse Ratched’s Character in Kesey’s One flew Over the Cuckoo’s Nest and Wasserman’s One Flew over the Cuckoo’s Nest: A Play in Two Acts.

Joos, K., De Ridder, D., Boey, R. A., & Vanneste, S. (2014). Functional connectivity changes in adults with developmental stuttering: a preliminary study using quantitative electro-encephalography. Frontiers in human neuroscience, 8, 783.

Kronfeld-Duenias, V., Amir, O., Ezrati-Vinacour, R., Civier, O., & Ben-Shachar, M. (2016). The frontal aslant tract underlies speech fluency in persistent developmental stuttering. Brain Structure and Function, 221(1), 365-381.

Millard, S. K., & Davis, S. (2016). The Palin Parent Rating Scales: Parents' perspectives of childhood stuttering and its impact. Journal of Speech, Language, and Hearing Research, 59(5), 950-963.

Onslow, M., Jones, M., O'Brian, S., Packman, A., Menzies, R., Lowe, R., ... & Franken, M. C. (2018). Comparison of Percentage of Syllables Stuttered With Parent-Reported Severity Ratings as a Primary Outcome Measure in Clinical Trials of Early Stuttering Treatment. Journal of Speech, Language, and Hearing Research, 61(4), 811-819.

Prabhaharan, R. (2016). The Thread of Parental Love as an Intricate Design in the Internal Working Model of the Select Characters in Karen Kingsbury’ s Novel Oceans Apart. Global Journal of Human-Social Science Research.

Ratner, N. B. (2018). Selecting Treatments and Monitoring Outcomes: The Circle of Evidence-Based Practice and Client-Centered Care in Treating a Preschool Child Who Stutters. Language, speech, and hearing services in schools, 49(1), 13-22.

Scharf, E. S. (2017). Exploring the Lived Experiences of Adults Who Stutter: A Qualitative Study. Ursidae: The Undergraduate Research Journal at the University of Northern Colorado, 6(3), 1.

Soulakova, J. N. (2017). Generalized confidence intervals compatible with the Min test for simultaneous comparisons of one subpopulation to several other subpopulations. Communications in Statistics-Theory and Methods, 46(19), 9441-9449.

Stewart, C. B. (2016). Effects of a Novel Right Brain Intervention on Stuttering Frequency in Unfamiliar Speech Tasks.

Swift, M. C., Jones, M., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2016). Parent verbal contingencies during the Lidcombe Program: Observations and statistical modeling of the treatment process. Journal of fluency disorders, 47, 13-26.

Valentine, D. T. (2014). Stuttering intervention in three service delivery models (direct, hybrid, and telepractice): two case studies. International journal of telerehabilitation, 6(2), 51.

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