راهکارهای درمانی خاص در درمان لکنت زبان کلینیک تخصصی لکنت کرج مهرشهر-کیانمهر- نبش میدان ولیعصر
allows the clinician to collect background data on the child’s development.
2 Clinician and child interview.
3 Assessment of child’s speech sample for speech rate and stuttering.
4 Assessment of parent-child interaction. Here the clinician observes the child at play with either one but preferably both parents or caregivers. Some clinicians do not collect formal data on the parent-child inter¬actions, whilst for others this procedure forms a considerable part of the assessment process. We look at parent-child interaction in the following chapter.
1 Introduction. Usually, we begin by asking the parents about the specific concerns that have brought them and their child to the clinic. This offers the parents an opportunity to present their perspective on the problem, together with a chance for them to explain their feelings about it. Only on rare occasions (perhaps when a parent is distressed that their child’s stuttering is all their fault) would we stop to discuss any concerns at this point. Instead, we acknowledge that we have understood their concerns. We then state that we will be returning to address them at the end of the assessment, when we have had a chance to gather some necessary information.
2 General development. We continue by asking about the child’s develop-mental milestones, beginning with pregnancy and birth, and moving on through motor development, asking how the child’s development has compared with his siblings, and how they see the comparison at present. Similarly, we enquire about the child’s language development. Although language and motor abilities are factors which we will assess with the child, it is often revealing to see how the parents’ perceptions match (or mismatch) with the abilities we see when we are one-to-one with the child.
3 Development of disfluency. Here, we ask when they first had concerns regarding their child’s fluency; how these fluency disruptions presented at that time and if they have now changed in what way. The purpose here is to discover whether these might be considered normal or stuttering-like disfluencies (SLD; see below). The latter may indicate a greater likeli¬hood of genuine stuttering and may be of relevance to the eventual prognosis. For example, noting the time elapsed since the appearance of SLDs may also be significant. Spontaneous recovery in stuttering is more likely when there is a decrease in stuttering moments over the first year. Empirical evidence tells us that it is also important to know if the parents identified any noteworthy events or changes going on with the family at that time such as family upsets, new birth within the family, death of a relative, or with the child away from the family problems at nursery such as bullying at school, experiencing a moment of shock (Rustin, 1991; Rustin et al., 1996; Van Riper, 1982).
4 Environment. We explore here how the disfluency is affected in differ¬ent circumstances. Are there any times or places where the fluency is improved (or even apparently goes completely), and does stuttering vary depending on who the child is speaking to? Relatedly, we ask about the family dynamics and how the child gets on with parents, siblings and his peers. Of interest here is whether there seems to be any association between fluency levels and favoured or disliked people. It is also import¬ant to ask whether the parents feel the child is aware of his stuttering. Is there any withdrawal? Is there any avoidance of words, situations or people? If the child is aware of stuttering, is this a subject that the parents have discussed with him, and if so what was the outcome of these discus¬sions? Information should also be gained as to the child’s general per¬sonality. Is he outgoing and happy-go-lucky, quiet, anxious, introspective? It is also important to know whether the parents have noticed any change in the child’s personality since the development of disfluencies. Answers to these questions help determine the significance of secondary factors in the stutter and, relatedly, the degree these will need to be taken into account in any subsequent therapy.
5 Concluding questions. We need to know whether the child has been seen for therapy, or has been assessed elsewhere. If there has been previous treatment, the clinician needs to know as much about this as possible. Being able to access the child’s clinical file from a previous therapist would obviously be of help when considering new treatment strategies. The parents’ thoughts too as to how effective they perceived that therapy to be and the reasons why it was not continued would also need to be taken into consideration. We conclude by asking if the parents feel there is anything we have not covered that is of relevance to their child and his fluency.
Clinician and child assessment
This is where the clinician has a chance to see at first hand the issues which have come to light in the case history. The clinician uses age-appropriate play materials to engage the child’s interest. A child who is quiet or nervous may initially be left to play on his own for a while before the clinician quietly joins in. An important objective is to ascertain whether the child is aware of his stuttering. The clinician must exercise judgement as to whether to actively pursue the issue, by asking whether the child knows why he has come today. Similarly, the clinician must be sensitive and adjust any termin¬ology appropriately. Usually terms like “bumpy speech” and “getting stuck” can be used to direct the child to the fact that everyone gets stuck from time to time, and that the child is not alone in his difficulties. The clinician will also use this opportunity to note the child’s motor speech and nonspeech motor control, as well as whether phonological and language skills appear age appropriate (see section below). During this session, the clinician will get some idea not only as to the child’s fluency, but also to his general style of interaction.
It is often useful to ask the parents after the session if they felt that their child’s behaviour and level and type of stuttering were typical. For example, a child may be going through a period of good fluency, but the parent might feel that there was increased stuttering at that session. (See next chapter for more discussion of these issues.) It is important to videotape (preferably) or audiotape this session. Video recordings often reveal significant but fleeting behaviours which can be missed on audiotape and allow the child’s speech to be used as the basis for the speech sample (see below). Additionally, a videotape serves as a snapshot of the child’s speech at that time (although we need to be aware of problems with reliability). It is therefore useful to keep this in the child’s file as pre-clinic assessment data. On the basis of the clinician-child assessment, the clinician may feel that further (formal) assessments are warranted.
Receptive and expressive language
Poor language skills may be associated with stuttering behaviour (Stark¬weather, 1997; Yaruss, 1999). These abilities may be tested using a number of the available standardized tests. Some commonly used examples in Britain include:
- Word Finding Vocabulary Scale (WFVS; Renfrew, 1988)
- British Picture Vocabulary Scales (BPVS; Dunn, Dunn, Whetton, & Burley, 1997)
- Derbyshire Language Scheme Rapid Screening Test (Masidlover & Knowles, 1982)
- Clinical Evaluation of Language Fundamentals (CELF; Wiig, Secord, & Semel, 2000)
- Reynell Developmental Language Scales (RDLS; Edwards, Fletcher, Garman, Hughes, & Sinka, 1997).
Some researchers and clinicians believe there is a link between disordered and delayed phonology and stuttering (Bloodstein, 1995; Louko, et al., 1990; Kolk and Postma, 1997), although the evidence at present seems equivocal (Nippold, 1990). Some clinicians automatically screen for phonological prob¬lems, but it is more common to informally assess these abilities through observation, and to save formal testing for when this raises any suspicion of phonological delay or disorder. Commonly used tests in Britain include the South Tyneside Assessment of Phonology (STAP; Armstrong & Ainley, 1989) and the more complex Phonological Assessment of Children’s Speech (PACS; Grunwell, 1985).