Fluency: Treatment of Stuttering in Adolescents and Adults – Flashcards
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What is the nature of stuttering in this stage?
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Constitutional predispositions + developmental environmental influences ˇ Early stuttering (repetitions, prolongations, blocks + Learning ˇ Tension, hurry, escape, avoidance behaviors ˇ Negative emotions, negative beliefs
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What speech behaviors are targeted for therapy?
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• First focus of therapy is on stuttering - Emotions like fear of stuttering must be reduced - Then stuttering behaviors are changed: tension and hurry are decreased • Second focus of therapy is on fluency - New ways of speaking are learned when stuttering is expected or experienced - Avoidance is decreased; approach is increased
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What are fluency goals for this stage?
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• Ideally, spontaneous fluency is a goal • Realistically, spontaneous fluency in all situations is not achievable for many advanced stutterers
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What are three realistic goals for this stage?
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- Controlled fluency when fluency is important - Easy, mild stuttering when controlled fluency is not available - Acceptable stuttering when neither #1 nor #2 can be achieved • This is mild stuttering which is relaxed • There should be little avoidance of speaking • Good communication is also a vital element
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What feelings and attitudes need to be addressed in this stage?
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• Need to reduce fear (and avoidance) - Requires counterconditioning and deconditioning • Need to reduce shame - Requires openness, "advertising stuttering" • Need to reduce negative thoughts - Requires cognitive therapy activities
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What are maintenance procedures implemented in this stage?
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• Client must become her own clinician - Learn to evaluate own performance - Understand spontaneous fluency, controlled fluency, acceptable stuttering • Therapy must continue as long as client needs it • Therapy must be faded gradually
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What four clinical methods in this stage?
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exploring stuttering> learning controlled fluency>increasing approach behaviors>maintaining progress
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What does exploring stuttering aim to do?
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- Reducing fear of stuttering (in clinic and outside) - Increasing awareness of what one is doing that keeps words from coming out - Reducing fear of listener reactions (easy-to-difficult listeners
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How does the client learn controlled fluency?
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- Learning five elements of controlled fluency in clinic - Learning to replace stuttering with controlled fluency - Learning to use controlled fluency in outside situations
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What are key concepts to keep in mind at this stage?
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- Treatment usually takes a long time, requires high motivation, focus on many fronts - Treatment tailored to each client's needs - Successful outcome requires attention to speaking - Successful outcome requires increasing approach behaviors - Advanced stutterers may still have speech-processing deficits even after treatment • New responses to residual stuttering needed
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How are progress and outcomes measured?
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• Stuttering: SSI-4, %SS • Attitudes and emotions: Erickson S-24, OASES, self-ratings of reactions to speech situations
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What is addressed when beginning therapy with this stage?
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• Determine client's goals • Map out treatment plan - Decrease fear - Increase fluency - Transfer and maintain fluency and easy stuttering
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How can the client understand his/her stuttering?
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- Handout - Discuss elements of client's stuttering with her - Client is guided to feel what she's doing and describe her stutters
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How can stuttering be approached and explored in the treatment room?
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- Clinician models catching and holding stuttering - Client is guided to catch and hold her stutters - Client is guided to hold and reduce tension in her stutters*
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How can stuttering be explored outside the treatment room?
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• Clinician helps client develop a hierarchy of least-to-most difficult situations • Clinician models voluntary stuttering to strangers • Discussion of listener reactions to clinician's voluntary stutters • Client enters situations, studies her stuttering as it occurs • Discussion of feelings about her stuttering, listener reactions • Client enters situations, attempts to hold onto her stutters and reduce tension • Recording and later playback and discussion of how well client could hold stutters and reduce tension
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How can the clinician teach the client to evaluate and reinforce own behaviors?
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• Setting targets/goals • Observing her own behavior • Evaluating her own behavior • Reinforcing her own behavior
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What strategies are used for controlled fluency?
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- Flexible rate - Pausing - Easy onsets - Light contacts - Proprioception - Client can learn them individually and then combine or learn them as a single combined skill from clinical model
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How do you transfer controlled fluency into controlled speech?
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• Client practices using controlled fluency intermittently on words at beginning of sentences or within sentences
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How can client replace stuttering with controlled fluency in the therapy room?
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• Client learns to anticipate stutters and replace them with controlled fluency • Client learns to use "cancellations" for times when she is unsuccessful
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What are cancellations?
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after finishing stuttered word, say word again, but with controlled fluency
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How can the client transfer controlled fluency to anticipated stuttering?
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• Client works through a hierarchy of easiest to most difficult speaking situations, replacing stutters with controlled fluency • Hierarchy includes more support from clinician at first, and then support fades, so client is doing much on her own • Cancellations are used to help client learn to replace stutters with controlled fluency
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How should voluntary stuttering be implemented?
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• Give rationale (handout) • Model easy stutters; client imitates • Model harder and harder ones; client imitates • Client stutters voluntarily on her own • Transfer to outside therapy room, first with clinician guidance and support, then with less of that
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How should feared words and situations be handled?
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• Using feared words over and over with controlled fluency in many different situations will gradually diminish word fear • May need to help client solve residual problems with feared words, such as starting them too fast or jamming up at the start • Develop hierarchy of feared situations, along with a self reward system for clients • As with feared words, going into feared situations over and over will make them less and less feared
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How can improvement be maintained in this stage?
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• Using handout, clinician teaches client to become own clinician • Important for client to learn to set her own goals and develop her own assignments • Work on helping client become her own clinician gradually over the course of therapy
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How should long-term goals be established in this stage?
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• Review with client the various levels of fluency that may be available to her after therapy (handout) - Spontaneous fluency - Controlled fluency - Acceptable stuttering • Help client determine which goals are important to her • Help client understand the work required for various goals • Develop a plan for dismissal and continued contact with periodic assessment
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What areas does the CALMS model address?
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• Cognitive Domain • Affective Domain • Linguistic Domain • Motor Domain • Social Domain
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What does the cognitive domain address?
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1. Identification of stuttered moments (in reading, spontaneous speech, and from a clinician model) 2. An assessment of the child's knowledge of general facts about stuttering. 3. An assessment of the child's knowledge and understanding of previously learned techniques to reduce stuttering.
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What does the affective domain address?
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1. Assessment of how a child feels about his/her stuttering. 2. Assessment of words or terms that represent how a child feels about his/her stuttering. 3. Assessment of the child's attitudes about talking.
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What does the linguistic domain address?
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1. Measure of the relationship between the level of linguistic complexity of the speaking task and the child's the frequency of stuttering. 2. Informal measure of the child's general language skills. 3. Informal measure of the child's speech sound production skills.
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What does the motor domain address?
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1. Measurement of various characteristics of stuttering: a. types of disfluencies b. average number of unit repetitions per repetition c. tempo and regularity of repeated units d. average degree of tension, struggle, and effort exhibited during a stuttered moment 2. Calculation of the percentage of stuttering in spontaneous speech and during oral reading. 3. Measurement of the duration of typical moments of stuttering. 4. Measurement of the presence of secondary coping behaviors.
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What does the social domain address?
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1. Measurement of how often the child avoids words, people, and speaking situations 2. Measurement of how often stuttering occurs with various communication partners and in various social speaking situations. 3. Measurement of how often the child's stuttering affects friendships and interactions with peers.
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What does intervention look like with CALMS model?
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•Always helpful to start with a theme that incorporates student's interest •Analogies are very powerful •Lay the groundwork
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What do students like?
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• Video games (Mario Kart, Halo, Dance-Dance Revolution) • Sports (Soccer, football, baseball) • After school activities (Tae-Kwon-Do, Ballet, Yoga) • Hobbies (crafts, cooking, magic, baseball cards) • Popular books (Diary of a Wimpy Kid, Twilight) • Popular movies (The Avengers, Kung-Fu Panda, Frozen) • Comic books/graphic novels (Spiderman, Salamander Dream) • Animals (Horses, dogs, reptiles) • Trendy toys (Legos, Littlest Pet Shop, Zhu-Zhu Pets)
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ESTABLISHING COMMON VOCABULARY RE: SPEECH PRODUCTION & STUTTERING is part of what CALMS domain?
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Cognitive
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What are examples of ESTABLISHING COMMON VOCABULARY RE: SPEECH PRODUCTION & STUTTERING
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• Create a "Mr. Speech Dude" • Garden hose analogy • Create student-friendly definitions of stuttering behaviors • Repetitions= bumps • Prolongations= stretchy speech • Blocks= freeze frame
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REGULATING & CONTROLLING BREATH STREAM is part of what CALMS domain?
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control, motor
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What are examples of REGULATING & CONTROLLING BREATH STREAM?
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• Decrease/Eliminate •Speaking on exhausted breath •Rainbow arc analogy • Quick, shallow inhalations • Nasal emissions • Speaking on inhalation
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What parts of the CALMS model is ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI?
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Linguistic
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What are examples of ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI at the phrase level?
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• Pantomime Games • Analogies • Carrier Phrases • Memory Games • Peel & Stick Games • Tell me what you do with it • Role play ordering in a restaurant • Modify existing board games
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What are examples of ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI at the sentence level?
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• Verb Cards • Tag stories • Sequence Pictures • 20 Questions • Phone Calls • Q & A- many games work well (Trivial Pursuit, BrainQuest) • Description Activities
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What are examples of ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI at the disourse level?
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• Discourse Level- Story •Create stories • Felt board • Puppets • Computer generated • Story Retells • Recount Past Events • Barrier Games
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What are examples of densensitization?
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• Clinician pseudo-stutters & reacts without struggle, tension, or negative affect • Voluntary stuttering to demonstrate that child can stutter without tension or struggle • Negative practice- child imitates a stutter modeled by the clinician that becomes progressively more lax • Play "catch me" • Hold the stutter • Listen/watch audio/video recording of self • Pull-outs & Cancellations
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What are examples of identifying triggers?
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• Identify any feared sounds, words, and/or speaking situations • Create a "Worry Ladder" • Discuss a "zone of comfort" • Develop an "All About Me" book with student
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What are example of ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI at the word level?
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• Word Level • Memory games • Labeling (in the form of a game) • Grab Bag • Naming Games • Convergent • Divergent • Opposites
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What are examples of ESTABLISHING FLUENCY THROUGH INCREASINGLY LONG & COMPLEX STIMULI in the discourse level-conversations?
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• Role playing •Jokes • Debate • What would you do if • Authentic conversation •While playing with toys/coloring • Walk & talk
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What parts of CALMS model is VARY THE ENVIRONMENT AND SOCIAL PARTNERS?
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social
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what are examples of VARY THE ENVIRONMENT AND SOCIAL PARTNERS?
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• Move outside of the therapy room • Include others in the session • Begin with familiar listeners • Progress to unfamiliar listeners • Alter listener's reactions • Level of attention • Level of eye contact • Rate of speech •Introduce a time pressure or other fluency disruptors
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What part of the CALMS model is TEACHING LIGHT ARTICULATORY CONTACTS?
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motor
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WHat are examples of TEACHING LIGHT ARTICULATORY CONTACTS?
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•Auditory discrimination of hard & soft •Reduce rate & lengthen the first phoneme • Imagery- think of things that require a gentle touch • Tactile- feel the difference between hard & soft contacts • Contrast drills of hard & soft
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What part of the CALMS model is controlling rapid rate?
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motor?
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What are examples of controlling rapid rate?
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• Imagery- Turtle, Rabbit • Clinician model • Pacing board • With toys (cars) • Computer-assisted feedback
