Fluency Disorders – Flashcards
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Stuttering Modification
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Stuttering results from avoiding or struggling with disfluencies- created fear in speaking which created negative attitudes Fears-reduce these fears and avoidance behaviors negative attitudes -all therapies are based on stuttering modification, fluency shaping or combo of both -client is taught to be more fluent by modifying their speech
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stuttering modification- Attention is given to:
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Speech fears Avoidance behaviors Concentration on changing stuttering Gradually PWS acts as own therapist -teach client to be their own therapist so come up with stargeties to modify how they stutter
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Stuttering Modification goals:
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Spontaneous Fluency- trying not to have to think about their stutter and being fluent without thinking about it -Controlled Fluency- pretty fluent but they are controlling their speech and using strategies to control speech -Acceptable Disfluency- learn that it is okay to stutter --teach person to hcange pattern of speech and say they might be disfluent sometimes -except that their stutter may never go away but we can make it bet
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Fluency Shaping-These techniques tend to be used by therapists who believe:
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Stuttering is learned- old statement
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What is fluency shaping?
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No attempt to reduce communication Fears Avoidances Attitudes As person becomes more fluent: Fears Attitudes Positive social interaction take it's place --don't talk about what they are scared of and trying to avoid- once they become fluent this will all go away will have positive interaction with people -person is programmed for stutter free speech -fluency maintained by modifying their speaking -fluency varies each day
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More about fluency shaping
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Format is highly structured Typical of behavioral conditioning and programming Works with the surface structure of stuttering -look at SURFACE STRUCTURE- not underlying cause of it Ex.) turtle speech- talking really really slow
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fluency shaping Belief in
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Spontaneous Fluency Controlled Fluency Do not believe in Acceptable disfluency --not a goal for the person to accept their stutter
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Comparisons between stuttering modification and fluency shaping
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stuttering modification: Talk about fears in specific situations Act as own therapist Pseudo stuttering Van Riper's approach Fluency shaping: More structured Step by step approach Act as own therapist Slow speech (extremely slow speech Modification- fears taking that time what they are going to do to over come become own therapist, fake psedo stuttering= VAN RIPERS APPRACOCH , Fluency shaping- more step by step
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Combination allows the SLP to
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Pick and choose and combine approaches
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Pick and choose and combine approaches give some examples
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Van Riper's MIDVAS: Motivation (St. Mod.) Identification (St. Mod.) Desensitization (both)- spedo stuttering like fluency shaping, get to talk listen to themselves get use to that they stutter Variation (both)- start with word level say it over and over, phrase, sentences, conversation Approximation (both) Stabilization (both) -work on word level phrase level sentence level convo level= work on them all throughout the session DO NOT JUST WORK ON ONE (integrating) -lets talk about the weekend, lets do fake stuttering, lets say some words..ect --should step aside time to see how stuttering affects their lives -motivation- they are motivated if they are coming to therapy unless kid hsow them what they can do and what they can approve -establish some basetime can always be diagnostic always take a baseline, might be reading, dialonge, reading, -Identifiying- have them record listen to it and ask them what they did there and tehre
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Approximation includes for stuttering modification
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Cancellation:- when you mess up you go back and start over with that word or that phrase, if you say it a second time its good iiiii I start over iii I want to go to the movies Pull-Out: stuck in a stutter pull out of it (relax it a little more) iiiii I want to go to the movies Preparatory Set: not going to stutter prepare before speaking I want to go to the movies --always going back and forth
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Stabilization
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Full Breath-when someone stutters they try to get past it and run out of air tell them it needs to come from the diaphragm get a full breath and tell them speak on chunks or phrases Easy Onset- ex. Pull out and prepatory set easing into the phrase or word, easy speech Easy Speech—talking slower and getting everything out and getting more air in and not getting all bunched up --throat may feel dry and need water -even go for a walk it will help breathing
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A Note on: Feelings for stuttering modification and fluency shaping
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Warmth, empathy (St. Mod.) Straight forward etc. (Fluency Shaping)
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Clinician's TX Protocol
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What's the detailed plan for therapy Will you express your attributes of: Empathy- sorry to hear that, maybe you can work it out, its okay Warmth Genuineness Evidence-based practice (EBP)-external evidence, internal evidence and the clients values (what you see the baseline, what you keep track of) Critical thinking Clinician's beliefs Show them that you really care how the client feels -stuttering is affected by the emotional well being of the individual (like fatigue, sad, anger)
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Clinician's Attributes
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Empathy Warmth Genuineness Evidence-based practice (EBP) Critical Thinking Clinician's beliefs
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Treatment Goals
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Goals are determined by the clinician, the client and the client's family Frequent discussion will increase trust, motivation, and achievement of goals Reduce the abnormality of stuttering— Does the person prepare to stutter by creating facial grimacing (referred to as avoidance behavior- repetition of the "Uh" Escape behaviors head nods, eye blinks to stop blocks
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more goals:
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Reduce negative feelings about stuttering and speaking Can be a vicious cycle- negative feelings come and go Reduce negative thoughts and attitudes about stuttering and speaking Reduce avoidance Increase communication abilities Create an environment that facilitates fluency Help clients and families deal with emotions Reduce the frequency of stuttering- fluency shaping Reduce the abnormality of stuttering-stuttering modification Reduce Negative thoughts and attitudes (cognitive behavior therapy)- for the advanced stutterer Motor learning principles for treatment
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cover stutter
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hiding your stutter
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"People who stutter" preferable to:
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Stutterer PWS
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Disfluency
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Disfluency" = either normal or abnormal "Disfluency" is preferable to "dysfluency"
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Do All Cultures Have Stuttering?
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Yes. Stuttering is ancient and universal.
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What Causes People to Stutter?
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The causes of stuttering are not completely understood, but scientists believe these are important factors: Genetic and congenital influences Developmental influences Environmental influences Repeated negative emotional experiences with stuttering lead to negative feelings and attitudes
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Factors Contributing to Stuttering
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need this look at powerpoint
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Fluency versus disfluent speech
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look this up!! A lot of times people refer to reading fluencies- are two different things talking about reading not speech Rate, intonation have to do with fluency -Starkweather (1980, 1987) suggests that rate and effort are critical to fluency Thus, a fluent speaker effortlessly produces speech at a rate comfortable to listeners
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Stuttering
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abnormally high frequency and/or duration of stoppages in the flow of speech Stuttering also includes speakers' reactions to stoppages These reactions include behavioral, emotional, and cognitive responses to repeated experiences of getting stuck while talking Need to distinguish between stuttering and typical disfluencies, as well as from neurogenic and psychogenic stuttering
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Repetitions:
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May be single-syllable word or part-word repetitions Word or syllable may be repeated more than two times, li-li-li-like this
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Prolongations:
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Sound or airflow continues but movement of articulators is stopped Prolongations as short as one-half second may be perceived as abnormal
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Blocks:
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inappropriate stoppage of airflow or voicing; movement of articulators may be stopped Blocks may occur at any level - respiratory, laryngeal, and/or articulatory Blocks may be accompanied by tremors of lips, tongue, jaw, and/or laryngeal muscles On average, stutterers stutter on about 10 percent of the words while reading On average, stutters last about one second
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Secondary Behaviors
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Secondary behaviors are learned behaviors that are triggered by the experience of stuttering or the anticipation of it
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Escape behaviors
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occur when the speaker is stuttering and attempts to terminate the stutter and finish the word (ex. Eye blinks and head nods)
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Avoidance behaviors
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behaviors occur when the speaker anticipates a stutter and tries to avoid it by, for example, changing the word or saying "uh"
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Feelings and Attitudes
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The experience of stuttering often creates feelings of embarrassment and frustration in a speaker Feelings become more severe at the speaker has more stuttering experiences Fear and shame may develop eventually and may contribute to the frequency and severity of stuttering Attitudes are feelings that have become more permanent and affect the person's beliefs Beliefs may be about oneself or listeners
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Disability and Handicap
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The disability of stuttering is the limitation it puts on individuals' ability to communicate This limitation is affected by the severity of stuttering as well as stutterers' feelings and attitudes about themselves and how listeners have reacted to them The handicap is the limitation it puts on individuals' lives This refers to the lack of fulfillment they have in social life, school, job, and community
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Onset and whats the average
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May start as gradual increase in normal childhood disfluencies or may start as sudden appearance of severe blocks Often sporadic at outset, coming and going for periods of days or weeks before becoming persistent Onset may occur between 18 months and 12 years but most often between 2 and 3.5 years (average 2.8 years)
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Prevalence
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A measure of how many people stutter at any given time Prevalence is 2.4 percent in kindergarten, about 1 percent in school-age children and slightly less than 1 percent in adults
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Incidence
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A measure of how many people have stuttered at some point in their lives About 5 percent
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Recovery without treatment
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Somewhere between 70 and 80 percent of children who begin to stutter recover without treatment
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Children with these attributes have less likelihood of spontaneous recovery
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Having relatives who were persistent stutterers Being male Onset after 3.5 years Stuttering not decreasing during first year after onset Stuttering persisting beyond one year after onset Multiple unit repetitions (li-li-li-li-like this) Continued presence of prolongations and blocks Below normal phonological skills
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There is also evidence that recovery is associated with:
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Being right-handed Growing up in a home with a mother who is non-directive and uses less complex language when speaking to child Having a slower speech rate and more mature speech motor system
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Sex Ratio
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The sex ratio is almost even (1:1) at the onset of stuttering However, girls start to stutter earlier than boys and recover more frequently so that by the time they are of school age, the ratio becomes three boys to every girl who stutters and continues at a 3:1 ratio Girls begin to stutter earlier than boys and recover earlier and more frequently -Girls are more likely to correct themselves
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Variability and Predictability of Stuttering
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In the 1930s, interest in stuttering turned from its medical or organic aspects to social, psychological, and linguistic aspects
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Anticipation
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Stutterers can predict which words they will stutter on in a reading passage
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Consistency:
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Stutterers tend to stutter on the same words each time they read a passage
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Adaptation
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Stutterers stutter less each time they read a passage up to about six readings
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Language Factors-Brown showed that adults who stutter do so more frequently on:
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Consonants Sounds in word-initial position Sounds in contextual speech Nouns, verbs, adjectives, and adverbs Longer words Words at beginnings of sentences Stressed syllables Loci and frequency of stuttering are different in preschool children Stuttering in preschool children occurs most frequently on pronouns and conjunctions (these occur frequently at the beginning of utterances in young children) Stuttering most frequent as repetitions of parts of words and single-syllable words in sentence-initial position In summary, because stuttering in preschoolers tends to occur at beginning of syntactic units, the trigger seems to be linguistic planning and preparation
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Fluency-Inducing Conditions: Many conditions have been found which reduce or eliminate stuttering. These include speaking:
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When alone, when relaxed In unison with another speaker To an animal or infant In time or a rhythmic stimulus or when singing, in a different dialect While simultaneously writing, while swearing In a slow, prolonged manner Under loud masking noise, while listening to delayed auditory feedback When shadowing another speaker, when reinforced for fluent speech -Fluency-inducing conditions have been explained as resulting from reduced demands on speech-motor control and language formation
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The Facts about Stuttering Imply the Following
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Stuttering is an inherited or congenital disorder It first appears when children are learning the complex coordinations of spoken language It emerges in those children whose speech production system is vulnerable to disruption by competing demands of language, cognition, and emotion After it emerges, it becomes persistent in some children - perhaps those whose stuttering arouses substantial negative emotion which leads to a variety of learned behaviors
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A Model of Stuttering
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Disorder of neuromotor control of speech Influenced by language production Perpetuated by temperament and complex learning, and the response of their environment to their speech
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What are the main Causes Stuttering?
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- language abilities, genetics, phonological encoding difficulty, sensitivity/temperament, speech motor abilities, emotional development, environmental demands
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what is the goal of treatment
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accepting stuttering, improving speech attitudes, easier stuttering, normal fluency, eliminating stuttering, smooth speech
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which technique is best
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turtle speech, stuttering modification, cancellation, easier onsets, fluency shaping, pull-out, pause time, relation, post-block correction, voluntary disfluency
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Purpose
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To demystify stuttering so you will feel more confident working with children who stutter To reduce your own discomfort with stuttering so you will be better able to help your clients To discuss current strategies for helping preschool and school-age children who stutter Increase their fluency Change their stuttering Improve their communication attitudes
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Body Function and Structure:
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describes the major physiological and psychological functions of the body
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Observable Characteristics
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Common measures include frequency of disfluencies, type of disfluency, and severity Stuttering behaviors are highly variable Children may not stutter at all in some situations Collect speech samples in multiple situations As children grow older and as stuttering progresses, the observable characteristics tell less and less about the disorder
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Functioning and Disability:
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describes the major areas of people's daily lives
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impairments, limitations, restrictions
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Impairments in Body Function and Structure can lead to limitations in a person's ability to perform activities or restrictions in the person's ability to participate in life
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In stuttering, the link between impairment and the resulting negative consequences is largely mediated by the speaker's ____ to stuttering
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reactions Affective: Feelings, attitudes, emotions Behavioral: Actions (Avoidance, tension, struggle) Cognitive: Thought-processes, self-evaluation -The reactions of those in the speaker's environment also play an important role for many speakers
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Evaluating the Entire Disorder
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Since stuttering is so broad-based, we must assess several levels during an evaluation Etiology: Child's speech/language development, oral-motor development, and temperament Impairment: Observable characteristics of speech Child's Reactions: Affective, Behavioral, Cognitive Environmental Reactions: Communication model / Reactions of those in the child's environment Activity Limitation / Participation Restriction: Impact of stuttering on child's life
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Looking at Etiology - What Causes Stuttering
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Most clinical researchers now believe that stuttering arises due to multiple risk factors "multifactorial models" "complex interaction between child's abilities and environment" "interaction between motoric and linguistic factors" "different etiological risk factors for different speakers"
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What also Causes Stuttering?
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Stuttering arises due to an interaction among several factors that are affected by both the child's genes and the child's environment Motor Skills for producing rapid and precise speech Language Skills for formulating messages Temperament for reacting to disruptions in speech An interaction among factors contributes to the likelihood that the child will produce speech disfluencies and react to them
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Speech, Language, Oral-Motor Development and Temperament
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Multiple risk factors contribute to the initial onset and early development of stuttering For younger children, we examine these factors to estimate the child's risk for continuing to stutter These factors may also contribute to the maintenance of stuttering For older children, we need to determine whether there are concomitant problems that contribute to overall communication difficulties
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Summary of Diagnostic Goals- for preschoolers
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For preschool children, the primary diagnostic goal is to determine whether the child needs treatment This is mostly based on an estimation of the likelihood that the child will recover naturally without intervention
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Children's Reactions / Impact of Stuttering
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Documenting the child's reactions is difficult For preschool children, there are no standard instruments For school-age children, you can use Children's Attitudes about Talking-Revised (CAT-R) (DeNil & Brutten, 1991) There are also no instruments for documenting the negative consequences of stuttering; however, these are apparent from observation and interview This means we need to carefully document our observations to establish the need for treatment
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Documenting Reactions: Portfolio Assessment
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According to IDEA '01, we can establish a child's need for treatment through interviews with people important to the child's life... Parents, teachers, and...the child! Portfolio-based assessment is one way to document the child's reactions to stuttering As soon as a child is aware of stuttering, we can help them express their feelings about stuttering through drawing, interview, and role-play
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Environmental Factors
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For younger children, the speech/language model contributes to the demands placed on the child to communicate We evaluate these demands to see if changes can be made that may facilitate the child's fluency For older children we are also interested in the demands for perfection, or 'perfect fluency' We may need to help parents adjust expectations and the messages they give to their children
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Making Diagnostic Decisions
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Determining who needs treatment (who is likely to continue stuttering) is a matter of probability, not certainty Some children are clearly "at-risk" Other children are clearly not "at-risk" The majority are somewhere in the middle The best we can do is weigh the risks... and tolerate the uncertainty
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What are the at-risk factors?
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Family history of stuttering Preponderance of "stuttered" disfluencies Time since onset > 6 months Child is aware of or concerned about disfluencies Child is particularly sensitive to making mistakes Environmental reactions are negative or fearful Child has concomitant speech/language disorders Other Factors?
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To Treat or Not To Treat
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There is a significant debate about when to recommend therapy for preschool children Many children recover on their own, so some prefer to "wait and see"...I am not comfortable with this Because there is no simple way to determine who will "outgrow" stuttering... I prefer to help families that want help, even if it seems that the stuttering might ultimately resolve Of course, this does not mean that all children receive full, formal therapy
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INTERPERSONAL STRESSORS—
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Major life changes & traumatic events Marital & sibling conflicts Unrealistic demands Fast-paced / unpredictable lifestyle
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summary of diagnostic goals- school-age children
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For school-age children, the primary goal changes somewhat - we already know the child is stuttering Now, we also need to evaluate the impact of stuttering on the child's life, so we can determine whether now is the time for treatment and document our broader treatment goals Aspects to be assessed include functional communication, ability to participate in academic/social activities, and impact of environmental reactions to child's stuttering
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what is the goal of treatment for children under 7 and over 7
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The goal of treatment differs (in part) due to the child's age For most young children (younger than age 7 or so), it may be possible to eliminate stuttering For older children (older than age 7 or so), it may no longer be possible to completely eliminate stuttering so different goals are appropriate
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Stuttering Treatment Overview: Preschool Children
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For preschool children, the primary goal of treatment is to improve their fluency Help parents and teachers provide a fluency-facilitating environment Help the child develop normal speech fluency by changing the child's communication patterns Help the child (and family) maintain healthy, appropriate attitudes toward communication -have parents speak a little slower, increasing pause time in between stutters, have one on one time play when other siblings arent involved and play games
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A Fluency-Facilitating Environment- for parents and teachers
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Parents and teachers can change their own speech to help the child change his Slower speaking rate (b u t n o t t o o s l o w) Less hurried pace, easier interaction style Increased pause time between utterances Less hectic scheduling of daily life activities One-on-one time with child (for playing and interacting, not just for talking) Most important principle: SHOW, not tell...
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COMMUNICATION STRESSORS—
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Negative response to disfluency Demanding questioning Frequent interruptions Competition for talking time Rapid rate of conversation
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CHILD FACTORS
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Perfectionistic tendencies Highly degree of sensitivity Intense / driven personality Other speech/language disorders Predisposition to stutter
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Improving Fluency- concern
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Child may be attempting to use faster speaking rate, express more advanced concepts, or produce more complex utterances than he is able while still maintaining fluent speech
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improving fluency-guidelines
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: This reduced-demand model can be incorporated into treatment and used at home
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improving fluency- solution
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Solution: Identify specific factors (demands) that stress child's fluency, then work with parents to provide a model that minimizes those stressors
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Maintaining Healthy Attitudes- concerns
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Children who stutter are at risk for developing negative communication attitudes
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When Do We Talk About Stuttering with Preschoolers
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if the child is.. not aware/not = NO concerned, aware but not =MAYBE concerned, aware and concerned=YES!!
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maintaining healthy attitudes- solution
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Solution: Help parents learn to... Model appropriate attitudes and reactions Listen to children's concerns about speaking Talk to children about stuttering The goal is for the child to accept disfluencies as a normal part of learning to speakp
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Talking about Stuttering how do parents talk to their kids about stuttering?-concern and solution
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Concern: Child and parents do not have a way to discuss stuttering Solution: Introduce a vocabulary accessible to child and adult for discussing stuttering Use analogies for talking about disfluencies Repetition: "going over railroad" Prolongation: "going over a bridge" Block: "hitting a brick wall" Goal: Child and parents will be able to discuss stuttering in a matter-of-fact, accepting way
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Is It REALLY Okay To Talk About Stuttering ?!?
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YES! Talking about stuttering (in a supportive way) will not make stuttering worse One approach to treatment even encourage parents to point out a child's disfluencies and ask them to say the words again without "bumps" It's even okay to say the "S" word "Always use the proper name for things. Fear of a name increases fear of the thing itself."
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Summary of Preschool Treatment
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The goal of speech therapy with preschoolers who stutter is to eliminate the stuttering Create a fluency facilitating environment Help the child learn fluent speech patterns Develop/maintain healthy communication attitudes Efficacy studies are limited, but they indicate very high success rates (85 to 90%) BUT, it is difficult to differentiate from recovery rates for children without therapy
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Stuttering can be very stubborn...
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sometimes children don't get better
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Is This the ONLY WAY to Treat Preschoolers Who Stutter?
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Absolutely not! The Lidcombe program has been gaining popularity around the world This approach teaches parents to verbally reinforce fluent speech and verbally correct (punish) stuttering The punishments are gentle and appropriate A growing body of evidence demonstrates the efficacy of this approach...
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Treating Older Children: Specific Objectives
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Help child improve fluency as much as possible This is still an important goal, but it is no longer the only important goal Help child develop healthy attitudes toward speaking, stuttering, and speech therapy Help parents and teachers develop a supportive and accepting environment
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Some Consequences of these Treatment Goals
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For older children who stutter, treatment is not solely devoted to trying to eliminate stuttering
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Treatment must also focus on:
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helping the child become more accepting of his stuttering and speaking abilities helping the child learn to cope with stuttering in an appropriate manner
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more consequences
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Parents and teachers need to understand that progress is not measured only in terms of the frequency or type of disfluencies IEP goals should also reflect the fact that progress is not measured only in terms of the frequency or type of disfluencies To do this, we need to write treatment goals that focus on the entire stuttering disorder
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Treating the Entire Disorder
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Addressing Impairment Change speech production to improve fluency Addressing the Child's ABC Reactions Improve speech attitudes, acceptance of stuttering Reduce avoidance, tension, struggle, etc. Addressing the Negative Consequences (Activity Limitation / Participation Restriction) Focus on communication skills, not just fluency Addressing Environmental Reactions Educate others about stuttering to foster acceptance Help child learn how to handle teasing
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in other words.. what should the clinicians do
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Goals such as stuttering easily and feeling good about yourself are just as important as not stuttering and using easier beginnings Children are often relieved to hear this, though parents may have more difficulty accepting the fact that their child is (and will be) "a stutterer" To achieve these goals, clinicians must also become more comfortable with stuttering and with children who stutter
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You want me to do WHAT?!?
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The best way to teach acceptance of a child's stuttering is to model acceptance If the clinician seems uncomfortable when a child stutters, the child gets the message that he should be uncomfortable too How can we convince him that he should accept his stuttering if we cannot? How can we convince him that other people can accept his stuttering if he can see contrary evidence in our own faces?
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Some Exercises to Help You Become More Comfortable with Stuttering
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Stuttering on purpose in real-world situations Stuttering and talking in different ways Talking about stuttering with other people (These also make excellent therapy activities to desensitize the child to stuttering, too)
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Overall Goals of Treatment
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The overall goal is improved Communication Children should be able say what they want, when they want, how they want, to whom they want Simple fluency criteria are less relevant In addition to fluency, we address factors that interfere with the child ability to communicate Tension and struggle during stuttering Negative communication attitudes Negative consequences of stuttering Teasing, other environmental stressors
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Addressing Impairment: Improving Fluency / Reducing Stuttering, most techniques for improving fluency consists of
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Most techniques for improving fluency focus on changing timing or tension timing=Reducing Speaking Rate Increasing Pause Time Easier Beginnings tension=Easier Beginnings, "Easing In" Cancellation, Pull-out
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Changing Timing: Speaking Rate
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One of the most common techniques for improving fluency is reducing speaking rate For preschoolers, "turtle speech" can help children and parents slow their rate and facilitate children's fluency For school-age children, transition to a more "natural" type of slowed speech
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Guidelines for Reducing Speaking Rate
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Practice using slow rate before you attempt it — get a feel for too slow and not slow enough Use natural intonation and rhythm Do not use "choppy" or "robot" speech or s t r e t c h out all the words Slower (but still natural) speaking rates can be incorporated into all activities as a positive communication model for the child
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Changing Timing: Pausing
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Another helpful way to change timing is to increase pause time -- the length of time between words and phrases Pauses should occur at natural locations, e.g., between sentences and phrases Phrases should not be so long that the child feels uncomfortable with the silence (~1 sec) It may take some practice for the child (and you) to develop comfort with silence
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An Exercise: Changing Timing
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Read the practice passage at your normal rate 2) Re-read the passage using a slower rate First try stretching out all the sounds, then try slightly stretching some sounds and pausing Which one sounds more natural? 3) Re-read the passage going VERY slowly (so slowly you can't stand it!) 4) Return to the rate you used in #2. How does it sound now? Better, by comparison
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Changing Timing AND Tension
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Easier Beginnings: Reduce speaking rate and physical tension at the beginning of phrases Use phrasing and pausing to give multiple opportunities to reduce the physical tension Focus on naturalness throughout the phrase... only the beginning of the phrase is modified Requires lots of practice (for you and the child) Can also be used when the child knows he is about to stutter ("easing in")
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Exercise: Easier Beginnings
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Notice that the practice passage can easily be divided into phrases. 2) Read the passage again, using easier beginnings at the start of each phrase Be sure to change both the timing and tension of your speech at the beginning of phrases Make sure the rest of the phrase sounds natural What else changed about your speech when you used the easier beginnings?
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Techniques for Modifying Stuttering
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With fluency techniques, children do become more fluent (particularly in the therapy room). However, no fluency technique is perfect...even successful students will still stutter sometimes To improve communication further, we also need to help children stutter more easily Modifying tension during stuttering Reducing child's discomfort with stuttering
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Exploring Stuttering
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To help children change stuttering, we help them learn what they are doing when they stutter by staying in and exploring stuttering What are their "speech actors" or "speech helpers" (articulators) doing during stuttering? How can they move their speech actors differently to change the stuttering? This also helps desensitize children to stuttering They probably spend a lot of time trying not to stutter, leading to increased tension and struggle
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Exercise: Exploring Stuttering
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1) Pretend to stutter (pseudostutter) Try to imitate the type of stuttering one of your young students might exhibit If you can't do it, have your students teach you What kind of affective, behavioral, or cognitive reactions do you have during this exercise? This exercise helps your student (and you) overcome these negative reactions and reduces struggle 2) Consider what your muscles are doing and how this contributes to the physical tension
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Reducing Physical Tension
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Physical tension during stuttering is a learned reaction (part of the attempt to not stutter) Over time, it becomes an automatic part of stuttering, then tension and struggle increase Children require PRACTICE to learn how to reduce this tension and stutter more easily Practice reducing tension so the child can learn to control and modify tension Exercise: Pseudostutter with physical tension, then repeat the stuttering with less tension
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Easy Stuttering
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Children can use easy stuttering to help them learn they can change the way they stutter "Bouncing" and "gliding" or "stretching" are forms of pseudostuttering without tension Also reduces tendency to hide stuttering The more children try to hide stuttering, the more likely they are to stutter more If children are comfortable with stuttering, they can use voluntary stuttering to release tension in their muscles and prevent bigger blocks
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Exercise: Easy Stuttering
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Read a passage using easy (pseudo)stuttering Try to use both repetitions (bounces) and prolongations (stretches or slides) 2) Evaluate your ABC reactions and your ability to modify and control physical tension You and your students should be able to use easy stuttering without any negative reactions If your students still feel negative reactions or can't modify tension, they need more practice (and so do you)
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Techniques for Addressing Fluency AND Stuttering
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Cancellation: Replace stuttered speech with more "fluent" (controlled) speech After stuttering, repeat the stuttered phrase using less physically tense speech The repeated speech should not simply be repeated -- the point is to change the tension Pull-out: Reduce tension during stuttering to be able to continue speaking more fluently
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Exercise: Cancellation
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To practice cancellation, you will need to use some pseudostuttering (so you have some tension to modify) 1) Pretend to stutter in conversation or reading 2) Repeat the stuttered phrase using modified physical tension (not completely fluent) Don't rush through it Cancellation helps with tension and desensitization
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Planning Therapy
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Many times, I begin with techniques designed to modify stuttering If we work on fluency first, children are likely to become "too" fluent in the treatment room Then, there is little stuttering left to practice with and we have trouble with transfer I also start with techniques for modifying stuttering so we don't over-emphasize fluency After the child can modify stuttering events, I move to the fluency techniques
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Techniques for Improving Attitudes
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Techniques for changing stuttering also help improve the child's reactions to stuttering Talking about stuttering helps children understand stuttering and reduces anxiety about stuttering Easy stuttering helps children learn they can control their speech musculature Exploring stuttering and cancellation help to desensitize children to stuttering and reduces their tendency to struggle and avoid stuttering
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Addressing Reactions Directly
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Concern: The child's reactions to stuttering increase the severity of the disorder and reduce the likelihood of successful treatment Affective: Child experiences embarrassment, shame, isolation, fear, anxiety about speaking Behavioral: Child exhibits significant physical tension and struggle when speaking or stuttering; Child avoids speaking situations Cognitive: Child evaluates himself negatively as a communicator; does not understand stuttering
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Addressing Reactions
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Goal: Child will develop healthy attitudes toward himself and his communication abilities so he will not... Feel as bad about his stuttering (affective) Struggle with speech or avoid talking (behavioral) View himself as a poor communicator (cognitive) Helping the child develop healthy reactions to stuttering paves the way for greater success in treating the stuttering itself
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Addressing Affective Reactions ...feelings about stuttering
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Child experiences many difficult emotions connected with stuttering Stuttering is confusing, frightening Child feels uncertain about himself Child may feel embarrassed, ashamed Child needs to be able to express emotions SLPs can help, and very few other people can (particularly people who understand stuttering and can talk with the child)
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Addressing Affective Reactions ...expressing emotions
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When child is teased, he probably feels frustrated and angry Instead of lashing out, he can express his feelings in therapy, then work with you to find an appropriate response When a child stutters, he probably feels embarrassed or ashamed Instead of berating himself for not being fluent, the child can talk about his feelings
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Addressing Affective Reactions...reducing shame
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Shame is a feeling of failure in who we are...there's something wrong with us The way to reduce shame is to face the thing we're ashamed of Talk about it Think about it Express our feelings about it Learn about it Teach others about it Own it Become more comfortable with it Accept it
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Addressing Affective Reactions...reducing shame...
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I don't know why this is happening to me" "Nobody likes me because I stutter" "I stutter because I did something bad" "There is something wrong with me" "I know what I do when I stutter... I am the expert" "I can stutter and still have lots of friends" "Stuttering is not my fault!!!" "I stutter and I AM OKAY!!!"
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Addressing Behavioral Reactions
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Reducing Tension Allow production of easy disfluencies, without excess physical tension Help child reduce tension during stuttering using techniques such as cancellation, pull-out Reducing Avoidance Help child accept stuttering (affective/cognitive reaction) so he will not feel the need to hide his stuttering (thereby reducing behavioral reactions)
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Addressing Cognitive Reactions
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Understanding: Help child learn what stuttering is, and that he has some control over it Help child learn about speaking: What parts of the body are involved and how they work together Help child learn about stuttering: What happens to his "speech actors" when he is fluent, when he stutters, and when he changes stuttering Perceptions: Help child understand that some disfluencies are a normal part of speaking
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Addressing Cognitive Reactions continued
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Tolerance: "Normalize" stuttering...it is just something some people do when talking Many people stutter and still achieve their goals at school and in life Help child learn...IT IS OKAY TO STUTTER Support: Help child meet others who stutter through support groups...Join Friends or the National Stuttering Association
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Activity/Participation
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By addressing the child's impairment and ABC reactions, we can reduce the likelihood that he will experience negative consequences To reduce activity limitations directly, we also need to focus on generalization of treatment gains into real-world settings Also, we need to directly address aspects of the environment that may contribute to the child's negative experiences
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The Child's Environment ...teasing...
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People tease because they don't understand stuttering... Help child educate classmates about stuttering through class presentations Demystifies the disorder and the child Child becomes the expert about stuttering He can help others learn about stuttering Gives him power, value, strength, importance
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Modifying the Environment ...parents and teachers
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Just as the child needs to accept stuttering, parents and teachers need to accept it Child is OKAY, stuttering is just one aspect of child's abilities and development Recognition of broader goals of treatment Not just reducing stuttering... accepting stuttering Not just using techniques to change fluency... using techniques to change stuttering Not just being fluent...participating in life activities
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Techniques for Working with Parents
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Parents have no problem understanding and supporting techniques for improving fluency In fact, some parents "encourage" children to use fluency techniques all the time This can be helpful, but it can turn into nagging We can reduce nagging by helping the children teach their parents how to modify their speech When parents see how hard this is, they become more supportive/understanding of inconsistency
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You want my child to WHAT?!?
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Some parents have difficulty accepting techniques for working on stuttering Parents may still be hoping for complete elimination of stuttering ("a cure") Pseudostuttering and easy stuttering may not make sense to parents at first Parents must understand the purpose of these techniques: We practice stuttering to change stuttering and reduce the impact of stuttering on communication
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Complete Acceptance
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Parents' acceptance of stuttering is just as important as the child's acceptance Many children benefit from a "safe place" where they don't have to worry about their speech Parents can only provide this safe place if they completely accept the child's stuttering Parents can only help children deal with emotions about stuttering if they have already dealt with those emotions themselves
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Summary
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For preschoolers, our goal is to eliminate stuttering Modifying the child's environment to reduce stressors Modifying the child's speech to improve fluency Helping the child develop and maintain healthy attitudes When it seems that a child may continue stuttering, our treatment goals must be broader Improve fluency (through changes to timing and tension) Change stuttering (by changing tension and accepting stuttering) Improve attitudes (through understanding and acceptance) These strategies can help children cope with stuttering and become effective communicators
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Stuttering Organization
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National Stuttering Association www.WeStutter.org (800) We Stutter Friends: The Association for Young People Who Stutter www.friendswhostutter.org Stuttering Foundation of America (SFA) www.stutteringhelp.org (800) 992-9392
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The Lidcombe Program
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This program is one of the newer programs Parent Involvement The people who spend the most time with the child Clinician Support Parent has guidance Not many programs for early intervention (3 or 4 yrs to 6 yrs.) Talks about fluency Bumpy Speech Easy Speech Slow Speech
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The Lidcombe Program- lemented in two stages
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Stage 1 Goal-- No stuttering everyday speech It concludes when stuttering reaches predetermined low criteria Stage 2 Goal- continuing to measure the speech Is child continuing to maintain treatment benefits Family visits to clinic are less -Implemented in two stages Stage 1 the goal for child to have no stuttering in everyday spkg. Situations ``It concludes when stuttering reaches predetermined low criteria Always measuring Stage 2 continuing measuring
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stage 1
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Stage 1 Weekly clinic visits Clinician trains parents to do the treatment Parent provides verbal contingencies Clinical Measurement procedures implemented -Stage 1 Weekly clinic visits Clinician trains parents to do the treatment Parent provides verbal contingencies- in structured conversations( structured treatment) and in unstructured conversations (unstructured treatment) Clinical Measurement procedures implemented within and beyond the clinic
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stage 2
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Stage 2 Parent assumes responsibility Time between clinic visits increases Parents continue with treatment Any departure from criterion is addressed immediately -Stage 2 Parent assumes responsibility—for treatment in the long term and achieves independence from the clinician Time between clinic visits increases-- Parents continue with treatment- unstructured conversations as required Any departure from criterion speech performance, specified by clinical measures,is addressed immediately
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Typical Weekly Visit
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Clinician makes objective measure of severity (upon 1st visit) While talking to the child While watching parent talk to child And/or A combination of both Parent presents severity rating from everyday of previous week Parents and Clinician compare severity rating
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Discussion & Therapy
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Is the child's stuttering decreasing How has parent managed the treatment This is discussed extensively What problems exist Clinician needs to identify failure Parent demonstrates treatment Clinician gives feedback -Is the child's stuttering decreasing How has parent managed the treatment This is discussed extensively What problems exist Clinician needs to identify failure Parent demonstrates treatment - Progress is impeded if there are any problems that the clinician cannot identify. Clinician gives feedback - and demonstrates
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Key Concepts
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Goal- no stuttering Behavioral treatment program Treatment happens when the problem happens Agent for treatment— Praise for stutter-free speech Asking for self-correction Parental verbal contingencies are not Constant Intensive Or invasive Parents and children enjoy treatment Find sense of accomplishment Treatment done by parents Everyday situations Parents are taught new procedures each week Treatment helps parents become experts of their own children Treatment happens in structured conversation Clinical measurement is essential Goal of stage 1 NO Stuttering Goal of stage 2 Parents to maintain treatment for long term effects
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Program Development
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Developed in Sydney Australia Suburb of Lidcombe And developed in collaboration with researchers at the University of Sydney and professional clinicians at Stuttering Unit, Bankstown Health Service, Sydney It is used throughout the world (one of the first places to use it in U.S. - Minnesota)
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Historically
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In the early 20th century some writings encourage parents to use direct correction Somehow in the 1940s & 50s it changed & was believed that parents should not draw attention to stuttering. 1957- Glasner and Rosenthal found that 70% of parents corrected their children About half recovered -Van Riper—"the current belief so prevalent in this country that no therapist should work directly with a child who has just begun to stutter is probably based on the equating of direct therapy with punishment. This is a mistake: it is possible to deal directly with the child's speech in many ways without hurting him or focusing on stuttering as an evil. (Van Riper 1973,p. 385
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Van Riper believed
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Make the child's speaking pleasant again by Stimulating child with models of fluency which, when imitated, will increase the child's own fluency Provide activities that integrate & facilitate the smooth flow of utterance Program schedules of rewards & reinforcements for fluency that will enhance it
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Barry Guitar
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Clinician's Beliefs The Beginning PWS predisposing physiological factors interact with the development Similar to Oliver Bloodstein- it is possible to provide the beginning stutterer with fluent speaking situations Guitar believes you can provide the child with a hierarchy Parent counseling is important -The Beginning PWS predisposing physiological factors interact with the development & environmental influences to produce exacerbate repetitions and prolongations. Guitar believes you can provide the child with a hierarchy for establishing and transferring fluency Parent counseling is important- any developmental or environmental influences must be reduced if they perpetuate disfluencies
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Guitar's Fluency Hierarchy
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look at the powerpoint
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Guitar: Moment of Stuttering
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Modifying the moments of stuttering (optional) Giving the child a tool to use for residual stuttering Teaching how to stutter easily -Modifying the moments of stuttering (optional) Giving the child a tool to use for residual stuttering Teaching how to stutter easily- then child can practice his fluent easy speech pattern. ( this can be used during a tense moment)
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Intervention
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Outline what you believe to be the approach here Goals Objectives Rationale Transfer fluent speech
