School-Age Stuttering Treatment – Flashcards
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What are some of the goals of fluency therapy for children?
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• Gain understanding of the speech mechanism and stuttering • Enhance speech fluency • Manage stuttering that occurs • Deal with emotions and attitudes • Reduce fear of speaking and stuttering • Improve skill as a communicator • Address relapse
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What are our responsibilities in fluency therapy with children?
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• Explain how speech is produced • Relate the child's speech behaviors to speech physiology • Analyze the child's speech behavior to determine possible speech modification tools. • Select the appropriate speech modification tool(s) for the child to change speech • Explain the purpose of each speech modification tool to the child • Rate the child's ability to use a speech modification tool • Construct an appropriate systematic speaking hierarchy to practice the speech modification tools • Plan for transfer of skills to different environments
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What things should the child be able to do as a result of fluency therapy?
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• Understand how speech and stuttering are produced • Identify moments of stuttering a) modeled by clinician, b) produced in own speech • Label where tension is produced during moment of stuttering • Analyze own overt and covert communication behaviors • Produce different speech modification tools as instructed by the clinician • Rate a) own ability to use speech modification tools, b) personal preferences for using different speech modification tools • Employ speech modification tools to create easier, more fluent speech
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What are some essential clinical skills when working with children?
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Modeling - always take the first turn Praising - be specific Summarizing - 'what we just did was work on our easy talking to make our talking more smooth' Rephrasing - let the child know he has been heard Putting the stuttering in your own mouth Accepting Checking in - How does that feel? How does that sound? Telling child what's coming next (we're going to do this three times) Questioning the child for understanding - do you understand why we're doing this? Knowing when and how to prompt/branch Asking permission: Is it okay if I interrupt you? Acknowledging the message/valuing communication Using humor Contrasting (saying hard/saying soft)
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What do most techniques for improving fluency focus on?
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timing or tension (can also focus on linguistic length and complexity)
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In what ways can we focus on timing?
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Ø Reducing speaking rate Ø Pausing and phrasing Ø Reducing PACE
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In what ways can we focus on reducing tension?
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Ø Light contacts Ø Easy starts/easy onsets Ø Cancellations Ø Pullouts
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What are the two primary ways of doing fluency shaping treatment?
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1. Response Contingent (operant) - Reinforce fluency/correct stuttering & transfer (no alteration of child's natural speech). Data-keeping involves # of stutters (stuttering frequency -- %SS). 2. Fluency Enhancing Behaviors (FEBs) - Establish fluency using speech changes & transfer. Datakeeping involves # of times/how long used FEBS with periodic stuttering frequency (%SS) probes to see if stuttering is decreasing.
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What are some examples of fluency enhancing behaviors?
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Ø Systematic progression in length ; complexity of utterance Ø Reduced rate Ø Pausing and phrasing Ø Prolonged speech Ø Use of DAF to slow utterances Ø Easy onset of phonation Ø Light articulatory contacts Ø Regulation of breath stream (Airflow control) Ø Continuous phonation (connecting words across boundaries) Ø Easy Relaxed Approach-Smooth Movements (ERA-SM) Ø Syllable-timed speech treatment
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What are Response-Contingent programs like?
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Reduces stuttering directly without teaching specific fluency skills or modifying stuttering into less abnormal forms. May be programmed and structured OR nonprogrammed and naturalistic, depending on program Ø Praise for stutter-free speech and correction for stuttered speech Ø Can involve gradual increase in length and complexity of utterance and reduced rate Ø Must meet criteria before moving to next step in program; includes transfer ; maintenance. Published outcomes available.
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What are some examples of response-contingent programs?
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Ø Gradual Increase in Length ; Complexity of Utterance (GILCU) by Ryan Ø Extended Length of Utterance (ELU) by Costello-Ingham Ø Lidcombe Program for School Age Child by Onslow ; Packman
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How can we work on speech rate reduction?
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Ø Direct instruction and modeling (practice by way of linguistic hierarchy). Choose 1 or 2 of following: v Increasing syllable duration throughout entire utterance v Increasing pauses - both frequency ; duration v Stretching only the initial sound(s) after each pause (3-5 words) v Continuous voicing (gradual smooth transitions) to connect sounds ; words within each phrase v Levels of control or "speech gears" Ø Delayed Auditory Feedback (Ryan, 2001)
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What is the rationale for working on speech rate reduction?
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Facilitates the coordination of complex movements and timing associated with the respiratory, phonatory, and articulatory activity; helps decrease pace ; time pressure of overall conversation and reduces tension in speech muscles.
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Why might you use a semantic map?
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It is important that kids know what they are doing and why. A good way to teach this is to use semantic maps. Have the client help make the map.
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What is the purpose of pausing/phrasing?
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Ø Creates normal breath support Ø Can allow for decreased physical tension Ø Enhances formulation time
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What are the steps of pausing/phrasing?
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Ø A break in a message every 3-6 (or so) words Ø Normal breaks/silence within sentences when speaking or reading Ø No "deep breaths" allowed - keep it natural Ø May "mark" reading passages where child an clinician choose appropriate pausing
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Who is airflow (breath stream) control good for?
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those with broken words
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What is airflow (breath stream) control?
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Ø Teach timing of respiratory cycle. Emphasize full inspiratory breath coupled with slow, constant exhalation of air. Utilize "chunking" of words into phrases to facilitate adequate inhalation and exhalation cycles. Gradually increase length of utterances. Ø Identification of normal (belly breathing)/abnormal breathing patterns
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What is a good visual for teaching airflow control?
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can do by making a slide, regular inhale on up the ladder and slow exhale as you go down the slide and say your words have them trace it as they talk exhalation is longer than inhalation
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What is the rationale for using airflow control?
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Helps in coordinating speech breathing with the initiation and appropriate termination of speech for those children who have developed abnormal breathing patterns while talking as a response to the stuttering moment.
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What is easy onset of phonation?
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Ø Initiation of phonation with as little laryngeal or physical tension as possible v A s-l-o-w stretch at first, and gradual increase of intensity over time at the beginning of an utterance or after a pause v Speaking after exhalation has begun (sigh, /h/) v Smooth transition through phrase groups: Ease into first few sounds; let the rest go with continuous sound; pausing for control. EX: A---my, A---my and John, A---nnie and Matt // a---sked for directions.
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Who is easy onset of phonation good for?
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those who block
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What are some visual ways to teach easy onset of phonation?
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can teach by comparing and contrasting (hard hand, soft hand) or using a breath curve - have them trace ( like turning up a radio - gradually increase intensity over time)
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What is the rationale for easy onset of phonation?
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Reduction in laryngeal tension; reduction in physical tension of speech muscles; decreases pace of communication
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What are light articulatory contacts?
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Ø Minimize muscle tension (e.g., lips, tongue, velum) needed for articulatory contacts - teach/model "light touches" of the articulators with less tension Ø Use negative practice, compare/contrast.
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Who are light articulatory contacts good for?
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helpful for those with muscle tension in lips, tongues and/or teeth
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What is the rationale for light articulatory contacts?
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Decreases tension of speech muscles, reduces blockage of the airstream, lowers intra-oral pressure during stop consonant production, allows for smooth transitions between sounds, increases awareness of proprioception, increases ability to "monitor" tension
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What are some general principles for fluency shaping?
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• Reinforcement of choices, not fluency ex: play a game like go fish and let the kid choose if they want to talk fast or slow (remember, fast is not normal) reinforce them for talking how they choose (usually fast) • Awareness of control and purposeful change of speech • Discrimination of bumpy vs. smooth; talk about smooth talking; lots of practice at various linguistic levels • Rewarding smooth speech choices • Lots of practice in smooth speech utterances varied by temporal measures, linguistic difficulty, and situational difficulty • Generalization ; transfer
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What kinds of goals should you have to address the cognitive areas of stuttering?
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• Goal for helping the child develop positive thoughts, perceptions, and awareness of stuttering and fluency • Goal that focuses on what the child does or does not know and understand about his stuttering • Goal that explores the child's reactions to and perceptions of listeners to the stuttering.
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What is the purpose of having goals that address cognitive areas of stuttering?
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Develop a better awareness of the behaviors that need to change to speak more easily.
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How can we explore speech and help children become a speech detective?
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Anatomy and physiology Ø Ways our voice works Ø Choices in talking Ø Tight or loose muscles - start with other parts of your body like hands, then move to speech muscles Ø Playing with speech - scaling tension (tell them: say it with 100% tension, 50%, no tension)
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What are the steps of the "Speech Man"?
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Develop visual "Speech Man" by "playing with speech and having child make discoveries Discuss each part of the speech mechanism and how it helps to create speech
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What are some cognitive treatment activities you can do?
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Learning the facts Ø Facts/Myths - What is stuttering? Ø Famous People who Stutter Ø Cause of stuttering "Catch me" (and self) games (self-monitoring) - don't expect a child to catch every time they stutter, but they should be able to catch the hard stutters Changing thinking: List negative thinking and discuss a more positive way to look at each statement listed - ex: my speech is horrible vs I'm working on my speech or I'm not good at speech tools vs my eye contact is getting better Teaching others; developing problem-solving plans Developing hierarchies-identify difficult speaking situations and develop/execute steps using a speech hierarchy
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What are the steps for problem-solving?
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1. Name the problem: "The problem is..." 2. Fill in the blanks: "I feel __ because __ and I want __." 3. Brainstorm possible solutions: "Say/write anything." 4. Discuss consequences of each choice: "If __ , then __ ; choose one or more solutions." 5. Create a plan for follow-up.
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What are some goals for the affective part of stuttering?
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• Goal that deals with normalizing feelings, emotions, and attitudes about stuttering. • Goal that deals with an understanding of emotional reactions to stuttering • Goal that focuses on improving self-esteem and positive reactions to stuttering • Goal that focuses on being open about stuttering • Goal that focuses on reducing/eliminating avoidances
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What are the different ways to work on desensitization?
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-pesudostuttering/learning about tension -locating tension/staying in the stutter -negative practice/3 ways to say a word -voluntary stuttering
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What is the purpose of pseudostuttering/learning about tension?
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Model for child easier tension-free form of stuttering; play with stuttering; become more comfortable and less anxious about stuttering
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How can you work on desensitization with peseudostuttering/learning about tension?
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• Experiment with different types of pseudostuttering (with eye contact)—clinician first, then child; play with stuttering (slow, fast, hard, loose) in game format • Catch each other pseudostuttering; identify word and sound cln./child got stuck on; talk about what it sounded like; then move to catching real stutters • Begin to discuss/demonstrate speech areas where we get tight. SLP initiates a topic and signals when she feels tension -- discuss what happened. Child joins in catching, commenting, pseudostuttering.
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Why do locating tension/staying in the stutter?
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Child identifies the loci of moments of his own stuttering and where tension is in the stutter. (which word and which speech helpers)
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How is locating tension/staying in the stutter done?
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• Clinician does some pseudostuttering on a number of different words and sounds. Clinician ; child attempt to discover location of areas of clinician's tension (staying in the stutter; use visual cue). • Child does pseudostuttering (staying in the stutter; use visual cue) and clinician asks questions about tension (location/degree/speech helpers involved); feel how tension can travel while holding onto the block • Child repeats process on real stuttering with clinician help (staying in the stutter) to locate tension. - can use fist to show holding on to tension and loosening up
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What is the purpose of negative practice/3 ways to say a word?
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Emphasis is on feeling the contrast between tension levels & monitoring sensations both productions evoke. Provide successful experiences in tension reduction. Practice on feared sounds, words.
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What is negative practice/3 ways to say a word?
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• Negative Practice: Clinician and student produce a word in a hard way (100% tension) and then reduce the tension by 50%. Practice stuttering behaviors using varying degrees of tension. • 3 Ways to Say a Word: regular (fluently), easy stuttered way, hard stuttered way with tension & struggle
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Why do voluntary stuttering?
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Ø Doing what we fear. Desensitization (only do it on non-feared words. We don't want the voluntary stuttering to turn into real stuttering.) Ø Getting it out in the open (openness not hiding) Ø Decreases physical tension Ø Decreases avoidance of stuttering
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What are the steps to voluntary stuttering?
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Ø SLP demonstrates a purposeful "easy stutter" on a word Ø Child and SLP take turns putting moments of easy stuttering (bounces or slides) into speech during structured activities and then in "real life" Ø Learning to "play" with stuttering and teaching parents and others to stutter
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What are some affective (desensitization) treatment activities?
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• Pseudostuttering-play w/ stuttering/different ways to stutter • "Freeze" in a stutter • Discuss stuttering w/ others - teach how to stutter - grade • Teacher presentation/Classroom presentation (with cln.) • Teach selected individuals about therapy activities • Use classroom assignments to disclose stuttering • Voluntary stuttering (self-created hierarchy) • Stuttering "surveys" • Teasing (e.g., problem-solving plans, role-playing) • Reduce/eliminate avoidance (sounds, words, situations)
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What strategies are there for dealing with teasing?
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• Brainstorm ways to react (ANYTHING) • Categorize helpful/hurtful ways to react • Choose 1 or 2 helpful reactions (e.g., acceptance, acknowledgment) - 4 major ways to deal with teasing: 1-humor 2- ignoring 3- acknowledging 4 -educating • Role play the situations • Continue the problem solving process as incidents occur
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When should you use cancellations?
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After feeling tension in the speech muscles or after a stuttered word
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How are cancellations done?
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Immediately after the stuttered word, pause, release the tension, say the stuttered word again with a FEB or an easier stutter ("bounce" or "slide"). MUST change some aspect and say it again (easier but not necessarily fluently). - during stopping time, client needs to analyze stutter. Where was the stutter? What can they do to release the tension?
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Why do cancellations?
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Learns to recognize moments of stuttering more quickly to make changes, is an opportunity to take control of one's speech, decreases avoidance, increases confidence in managing tension & makes talking easier.
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When can you move to teaching pullouts?
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need 90% accuracy on cancellations before moving to pullouts
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What is a pull-out?
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Releasing tension in one's speech during a moment of stuttering, then easing into the rest of the word or phrase
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When should a pull-out be used?
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During a moment of stuttering or whenever tension is felt during speaking
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How do you do a pull-out?
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When one "catches" a moment of stuttering, identify where tension is, reduce physical tension gradually, ease on through word using a FEB or "bounce" or "slide" and continue speaking to finish the word ; move into rest of the phrase.
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What is the purpose of pull-outs?
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Helps reduce physical tension ; makes speaking easier, increases feeling of control of speech, decreases avoidance of stuttering, provides a choice about how to stutter (tense vs. easy), helps one change "involuntary stuttering" into "voluntary" speaking, keeps speech moving forward.
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When can you move to teaching preparatory sets?
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need 90% accuracy before moving to preparatory set
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What is a preparatory set?
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Using an easy start or other strategy to reduce physical tension and increase fluency before the moment of stuttering
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When can a preparatory set be used?
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Child speaks normally (without modifications) until he feels he is coming (prior) to a word where he will experience tension.
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How do you do a preparatory set?
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Rather than beginning the word by tensing his muscles, he begins the word using an easy start or other strategy for reducing physical tension.
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What is the purpose of preparatory sets?
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Reduces tension prior to stuttered word, most appropriate for children who demonstrate anticipation of stuttered moments as well as the higher skill of being able to recognize this part of their stuttering pattern.
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How should you create hierarchies for transfer of FS/SM skills?
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• Develop hierarchies for activities and assignments WITH child. Child must be a part of sequencing hierarchy. They bridge the gap between therapy room and real world (spontaneous use chart). • Change only one aspect at a time for success, then add another aspect; enhance child's chances for success
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What are some examples of hierarchies to consider with regard to practice of speech tools?
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Ø Location (where): therapy room, home, group therapy, playground, cafeteria, classroom... Ø Conversational partner (who): SLP, parents, friend, teacher, group of friends, stranger, person in authority, critical listener (bully)... Ø Linguistic level (what): word, sentence, question, monologue, conversation, classroom presentation... Ø Time (when): on phone, around bystanders, when hurried, when arguing, when nervous, in front of class...
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How can maintenance be achieved?
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• Increase self-monitoring and self-recording of performance • Maintenance: Reduce treatment to 1X/week for a month, 2X/month for a month, 1X/month, follow-ups for 12-24 months (obtain samples of speech, oral reading, & talk with child about how he has been talking in everyday speaking situations); relapse=usually re-enroll in treatment for "booster sessions"
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How can you prepare a child for relapse?
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• Explain what relapse is. Communicate that relapse NEVER equates with failure • Self-monitoring principle (can they problem solve, make modifications that help them?) • Voluntary disfluency • Keep working at reducing/eliminating avoidances • Use rating scales (looking at pre vs post rating scales can help them recognize their progress) • Teach child to be a problem-solver • Check back with child (even after dismissal) • Train parents to recognize changes that signal relapse (avoid picking up phone or other situations, not practicing their strategies, subtle signs of struggle)
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What are some examples of quantitative data you can take?
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Ø Frequency of stuttering produced in several contexts over time (%SS) Ø Types of stuttering produced, reduction in number and form over time Ø Number of times behaviors are exhibited Ø Number of times client self monitors and corrects a disfluent moment without prompting Ø Videotapes and/or audiotapes to document changes in behaviors Ø Changes in stuttering severity (SSI-4)
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What are some examples of qualitative data you can take?
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• Scores on scales (CAT, A-12), summary of comments & observations across sessions, improvements as indicated on the multidimensional treatment checklist, paper & pencil worksheets, rating sheets, & responses to questions like: Ø Is your stuttering under your control? Ø Do you think about your stuttering less than you used to? Ø Do you have more confidence in yourself and your speech? Ø Do you think the changes can be maintained? • Comments from child, parents, & teachers about successes and failures -- logged & dated • Child's verbal explanations of concepts learned in therapy • Products of therapy such as drawings, graphic organizers, ratings of performance, etc. • Observation of the child in a variety of communication environments and with other communicative partners
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What is included in an integrative treatment approach?
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• Become familiar with child ; his speech • Explore degree of child's emotional and intellectual awareness of fluency disorder • Discussion & analysis of speech behaviors associated with stuttering & fluency • Instruction of FEBs Ø Slower rate, gentle onset, light articulatory contacts, regulation of airflow, linguistic length/complexity, proprioception, etc. Ø DAF or 13-step hierarchy (see text) • Instruction of SM procedures (e.g., 3 ways to say a word, voluntary stuttering, cancellations, pull-outs) • Transfer & Maintenance
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What are some indicators of progress in therapy?
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• Increase in ability to self-monitor • Increase in ability to produce "open speech" • Decrease in frequency/duration of fluency breaks • Increase in normal speech formulation breaks • Metalinguistic changes—understanding stuttering • Increase in open decision-making/decreased avoidance • Increased sense of self-worth/self-esteem
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What are some things you should do in parent counseling with parents of school-age CWS?
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• Explaining the treatment program and parents' role • Explaining the possible causes of stuttering • Identifying ; reducing fluency disrupters • Identifying ; increasing fluency enhancing situations • Eliminating teasing
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What should a teacher do when a child stutters?
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maintain eye contact and wait for child to finish
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What should a teacher do when a child is having a difficult speaking day?
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reduce demands when possible
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What should a teacher do with regard to reading aloud in class?
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choral reading give plenty of time (oral presentations)
