Direct Therapy Procedures – Fluency – Flashcards

Two critical elements: (1) Decrease the stutterer's speech fears and avoidance behaviors, and negative attitudes toward speech. (2) Teach the person who stutters to reduce tension. >Help the client to modify the form of his stuttering (lesser form of stuttering) >Cancellations, pullouts, preparatory sets - (especially for intermediate and advanced stutterers)

Operant Conditioning: successive approximations of a target response, use of reinforcement of appropriate response. >Establishment >Transfer >Maintenance phase >Stress maintenance of fluency >Spontaneous fluency >Controlled fluency >Acceptable Stuttering

establish fluency in stutterers' speech in the clinic in a controlled stimulus situation. Fluency is reinforced and gradually modified to approximate normal conversation speech in clinical setting.

transfer or generalize client's fluency to everyday speaking situations

retaining fluency over time.

by techniques such as slowing speech rate, monitoring speech carefully, or paying attention to easy onset of speech. Client expected to be as fluency as possible in a given stimulus situation.

normal level of speech flow that contains neither tension nor struggle behaviors, nor does it contain more than an occasional number of repetitions and prolongations. Person pays attention to his ideas. Fluency of normal speaker.

similar to spontaneous fluency except speaker must attend to his manner of speaking to maintain relatively normal sounding fluency.

level of speech flow where the speaker exhibits noticeable but not severe disfluencies and feels comfortable speaking despite his disfluency. Acceptable stuttering not a goal for many fluency shaping therapy adherents, this would be regarded as a program failure.

To achieve spontaneous fluency or controlled fluency. Modification therapy would strive for spontaneous fluency first, if not then controlled, if not then acceptable stuttering.

(1) Modification Therapy alone - when emotional component is present (2) Fluency Shaping Therapy alone - no emotional component (3) Combined Approach >Depends on the Age, Duration of Stuttering, (Significant) Attitudes and Feelings Trial therapy procedures to decide course of treatment.

Modification Therapy when he suffers a fair amount of penalty for stuttering. Life is miserable when he stutters. Others not overly accepting of his stuttering. Clinician impressions that he is uncomfortable with his stuttering and he feels it is holding him back from things he would like to do.

Modification may be indicated if the stutterer's severity or struggle behaviors become milder during stuttering modification trial tx procedures. Has difficulty producing fluent speech in fluency shaping trial. If slow prolonged speech is uncomfortable. Relatively strong negative feelings and attitudes toward stuttering.

>Relatively low communication attitude and avoidance scores. >Responds well to slow prolonged speech during trial fluency shaping therapy. (True regardless of severity of stuttering) >Minimal avoidance behaviors.

Benefit from both at some point. Suggested that fluency shaping is more efficient than stuttering modification for changing speech patterns. Stuttering modification therapy is more effective in reducing speech fears and improving speech attitudes for those clients who need it.

Child's feelings and attitudes appear to be a significant variable in the treatment approach. For many children, especially in the lower age range, our goal is spontaneous fluency. For children in the upper age range of this group, especially those with maladaptive attitudes, the goal more realistically is controlled fluency or acceptable stuttering. These positions are not proven. Based on Guitar and Peters's experiences.

If child shows marked improvement in stuttering modification trial therapy, this approach may benefit. If fluency shaping therapy is too structured or if he stutters considerably before reaching the spontaneous sentence level, he may be better suited to stuttering modification than fluency shaping.

Modification Therapy indicated if these are true: 1. very embarrassed or upset by stuttering, their home and school punishes it. 2. respond well to stuttering modification trial therapy. 3. they find it difficult to maintain fluency and interest in fluency shaping trial therapy.

If emotional component is strongly present or when obviously absent, the decision is clear cut. Most children it is not clear cut, lean toward a combined approach as potential feelings and attitudes are dealt with and an efficient procedure is used to establish fluent speech.

Trial Fluency Therapy: If child stutters on many of his responses (5 or more of 20), note if child is bothered. If so, best to move to some play activity in which the clinician does a lot of easy and relaxed speaking and the child gets to experience fluency. If child is still stuttering, clinician may want to try stuttering modification procedures. Model easier version of the child's stuttering, teach the child an easier form of stuttering. Goal of both modification and fluency shaping are similar in tx of preschool child. Achieve a basal level of fluency and generalize that to other situations. Modification therapy models a slow and easy form of speaking for the child to emulate. Aim is to modify the preschool child's stuttering so it is more like normal disfluency. Gradually outgrow these if they remain loose, slow, and easy. Do not need to teach modification strategies. Fluency shaping may begin with short fluent response and increase its length and complexity. First with clinician then to all other situations. Clinician provides the setting in which the young stutterer can be fluent, and then provides the conditions that will allow this fluency to generalize. From there Mother Nature will do the rest. Conditions that allow this fluency to generalize - use indirect therapy procedures to facilitate child's environment.

>ESPECIALLY FOR PRESCHOOL CHILDREN AND YOUNGER ELEMENTARY CHILDREN >BORDERLINE STUTTERING >BEGINNING STUTTERING IN ADDITION TO DIRECT THERAPY. *Providing suggestions for parents that can be used at home.

Work primarily through parents and caregivers. Little direct contact with child. Approach recommended for child who primarily shows repetitions of whole words or phrases, no secondaries or signs of awareness. This is the borderline and beginning stutterer. Goals: 1. Make speech enjoyable for child 2. Eliminate or reduce environmental demands 3. Desensitize child to fluency disrupting stimuli 4. Reward or encourage forward moving speech.

Increase child's capacities in the motor, language, emotional, and cognitive areas, while at the same time reducing the demands of the child's communicative environment through counseling and training the child's parents, siblings, teachers, day care workers, and others who have an influence on the child.

High rates of speech Rapid fire conversational pace Interruptions Frequent open ended questions Many critical or corrective comments Inadequate or inconsistent listening to what child says Vocabulary far above child's level Advanced levels of syntax.

Listening time set aside daily Slow Rate (Mr. Roger's speech) Pause before responding - don't rush the conversation Positive Comments about what child saying or doing Fewer Questions and instructions (follow child's lead) Be a good listener - attend to what is said not how it is said. Avoid negative reactions to disfluent speech Avoid interrupting child when he/she is talking *Role playing with the child - you become your dad or mom

>Listen while others talk >Don't talk for others >Don't interrupt others

Education >Provide information about stuttering in general and specifically about their child's -Talk about its episodic nature, variability, factors that might hinder fluency, things they can do to help >Align parents expectations with reality -Point out that most of speech is fluent -Can improve with treatment >Encourage parent to talk openly about stuttering >Try to relieve any guilt they may feel about their child stuttering. It is not your fault!

Background Program developed in Australia at Lidcombe Hospital in early 70's Oriented to preschool children (younger than 6) Focus is on behavioral treatment Goal is No Stuttering Program implemented by parents not by clinicians

Change occurs through parental verbal contingencies Parents respond to stutter free and stuttered speech Contingencies are: Acknowledging Praising Asking child to self-correct No other changes not even environmental Stuttering is looked at as an operant behavior that can be changed by its contingencies

Through out typical day a child will have both stutter free and stuttered speech. On some occasions parent will acknowledge that speech was either stutter free or stuttered. On some occasions parent may choose to ask child to repeat a stuttered utterance (ask child to self correct) On some occasions child is praised for stutter free speech RULE: At least five times more praise and acknowledgement of stutter free speech than there is acknowledgement and requests for self-correction.

Parent(s) and child visit clinician weekly Parent(s) are trained to deliver the verbal contingencies. Initially parent(s) are trained using very structured conversations and situations. Once parent and clinician are comfortable with how the contingencies are being delivered it gradually moves into unstructured situations Specific training depends on parent-child interaction

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Requesting Self-Correction That was bumpy. Do you want to try it again? See if you can say "dog" without the bump. You had a stuck word. Try it again Acknowledging Stutter-free and Unambiguous Stuttering That was smooth There was a little bump there I heard a stuck word No bumps.

For the child who is beginning to stutter we use a more direct approach. This child typically uses part word repetitions that are produced rapidly and with irregular rhythm. He may have some prolongations and there is usually some tension evident. If secondaries are present they are usually escape mechanisms such as eye blinds and head nods. The child is aware that he has some difficulty talking. Goal: Fluency Work directly with child and parents. Still use indirect methods to eliminate or reduce stressors in environment Target and reinforce child's fluent responses while gradually increasing length and complexity of speech. Would use a slowed speech technique initially to facilitate fluency and then fade it out In later stages if hard or tense moments continue would teach child how to stutter easily.

The intermediate stutterer is usually an older child between 6 and 13. He shows: Part-word repetitions Vowel prolongations Excessive tension Often has tense blocks Secondaries are common May use avoidance strategies (starter words, word substitutions, avoidance of speaking situations) Concept of self as a stutterer NOTE: This child may have a history of past treatment that must be considered in developing your treatment program. Goal: Fluency if possible and acceptable stuttering if not. Use a combined fluency shaping and fluency modification program. Teach Fluency Enhancing Behaviors (FEB) Slowed rate Gentle onset Soft or light contacts Awareness of feeling of movement of articulators Maintain fluency while gradually increasing length and complexity Help child understand and confront and accept the stuttering Desensitize child to the stuttering - decrease fear of it Modify hard stutters into easier ones Acceptable Stuttering Will vary from client to client. Ties in with tolerance and can be addressed in treatment program. Feelings and Attitude Almost always a part of the advanced PWS's intervention program. Must reduce fears (avoidances) in order to alter speech production. Confronting feared situations Systematic desensitization to fearful words & situations Stuttering Modification Learning to alter the stuttering moment. Identification, Modification (cancellation, pull outs, easy stutter) Fluency Shaping Learning to speak in a manner that promotes fluency. Becoming your own Clinician: Learning enough about stuttering to take over your own therapy.

GOALS: Spontaneous fluency in all settings at all times - normal speech? Be able to successfully apply skills to achieve controlled fluency. Fluency shaping Stuttering modification If cannot achieve controlled fluency then be able to use skills to achieve acceptable stuttering. If doesn't feel it is important to be fluent at a particular time then feel comfortable with acceptable stuttering. 1. Understand stuttering Basic information about nature of stuttering Identification of core behaviors, secondaries, attitudes/fears 2. Reduce negative feelings/attitudes and eliminate avoidances To become more open and accepting of disfluencies To eliminate speech avoidance behaviors (freezing, voluntary stuttering) 3. Use fluency enhancing skills and modifying moments of stuttering Slowed rate, easy onset, soft contacts. Might use DAF & structured program Stuttering easily (modification) 4. Maintaining Improvement Have client assume responsibility for his own therapy (give self assignments, use techniques, determine therapy needs) Development of realistic goals (hard work to constantly monitor speech so must develop an acceptance of stuttering)

Research suggests that changing the client's "locus of control", knowledge about stuttering, and self-esteem can be an important factor in meeting a wide number of therapy goals (Blood, 1995). Locus of control refers to "the extent to which (an individual) perceives responsibility for their own personal problem behavior" (Craig, et al., 1984). Identifying locus of control in the client's language about stuttering Research suggests that changes in locus of control and other affective components can reduce the risk of relapse (Craig, 1998).

Improving knowledge about the nature of speech and stuttering Discussing "fault" and blame Responding to bullying and teasing Putting stuttering in perspective Tolerating disfluency Redefining success and failure Learning about self-help organizations

Role playing Perspective taking Active listening Video self-analysis Group therapy

Learning to make choices Developing challenges Formulating assignments Problem-solving Identifying barriers to success

I like my self I am composed. I speak clearly. Words are effortless for me. I speak relaxed. I love communicating. Speech is natural. Sentences form easily. I speak with confidence. I can manage my stuttering

Explanation and Identification -

Awareness of control children learn that they can control their speech fast, slow, loud, soft clinician models first then child attempts Smooth talking- identification contrast bumpy and smooth speech clinician models child's common disfluencies clinician models easy speech (gentle onset and prolonged first vowel) child must be able to discriminate type of speech as heard in others Smooth Talking - child child is given option to use smooth or bumpy speech emphasis is on giving child choice have child teach clinician and parents how he stutters which helps desensitize child to stuttering may take turns with child determining how clinician will talk as well as how he shall talk. CATCH ME! start with simple linguistic tasks and gradually increase demands clinician at this point rewards deliberate production of speech choices not the fluency

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Tasks requiring the production of a set number of sentences Speaking for a predetermined period of time Asking and answering questions Telling past experiences/stories Problem solving/predicting what will happen Talking with others in therapy room Talking while clinician uses bumpy speech/disruptions Talking away from therapy room Talking with friends Telephoning Other targets identified as problem areas

Why others tease Why children react to teasing Why one should stop reacting to teasing How to stop reacting to teasing Role playing, discuss possible options, videotaping, learning to cope with difficult conversational partners.