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The ABCs of Stuttering

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									The ABCs of
 Stuttering
Shelly Wier, MS, CCC-SLP
 Easter Seals Outreach Program
        (501) 221-8415
   swier@ar.easter-seals.org
   Fluency Boot Camp
 July 11, 2002, Nashville
 Assessment Principles - E. Conture,
                             Vanderbilt University
 Fluency Shaping - M. Allen
         Center for Stuttering Therapy, Skokie, IL
 Modifying Stuttering - B. Murphy
                                Purdue University
 Modifying Attitudes - K. Chmela
           Private Practice, Hawthorne Woods, IL
 Therapy Planning - V. Sisskin
                           University of Maryland
     Basic Facts About
        Stuttering
 Prevalence      Nature of
                   Onset
 Gender Ratio
                  Speech at
 Familial         Onset
  Incidence
                  Spontaneous
 Onset            Recovery
 Temperament
  Basic Assumption #1
     Stuttering results from
      a complex interaction

     NATURE         NURTURE


between the person's environment
    and the skills and abilities
      that person brings to
       their environment.
 Understanding Stuttering
                            60
         Causation          mph

60
mph
       (deep structure)

         Behavior
       Manifestation        60
                            mph

60
      (surface structure)
mph

        Exacerbation
Parent-Child Conversational
Interactions that Exacerbate
 The longer the duration of mother-
      child utterance overlap, the
        more severe the child’s
               stuttering.
            (Kelly & Conture, 1992)



   The greater the disparity btw
    mom’s speaking rate and the
   child’s speaking rate, the more
    severe the child’s stuttering.
            (Yaruss & Conture, 1995)
   Important To Note

      COGNITION
            and

     LINGUISTIC
    FORMULATION
not just speech motor control
     Assumption #2
Variables thought to cause
 stuttering must change as
rapidly and continuously as
  instances of stuttering
      change during
  conversational speech.
   Assumption #3

Such variables probably
      also occur
        PRIOR
 to overt stutterings.
    Stuttering Does Not
     Exist in a Vacuum
A child known or suspected to stutter
  can, and often does, have subtle to
       significant OTHER speech,
      language, voice, hearing, or
   behavioral problems, and should
       receive the same thorough
    diagnostic battery as would be
           given to any child.
       Ultimate Goal of
         Assessment
 To distinguish children who do from
  those who don’t stutter.
 To base this distinction on
  information that can be replicated,
  reported, and understood by
  others.
 To provide the rationale for the
  type and amount of treatment.
      Common Problems
 Generic goals, like from a “goal
  bank”
 Too narrow in focus, only 1 of 3
  components (ABCs)
 Don’t easily generalize
 Do not reflect symptom variability
 Not related to “what matters”
 Performance is clinician-directed
          Purpose of
       Therapy Planning
 To identify features that are
  effective
 To use collaborative planning tools
  to formulate individualized goals
  and objectives
 To understand therapy planning as
  a problem solving process to help
  children achieve positive outcomes
Effective Therapy Goals
                 FEATURES


Functional      Individualized   Relevant
Outcomes


  Adequate        Needs Based    Meaningful
   Breadth                        Contexts


  Focus on          Reflect      Meaningful
Communication      Variability    Activities
        Collaborative
       Planning Tools
1. Assess and determine student’s
     needs.

2. Formulate goals and short term
     objectives or benchmarks.

3. Plan for evaluation of progress.
1. Assess and Determine
     Student Needs

 Consider contributing factors


 Wish Lists


 Identify milestones to recovery
   Milestones to Recovery

Affective          Behavioral              Cognitive
                 S.M.           F.S.
 Identify &    Identify &      Target       Identify &
              understand
understand    maladaptive
                             Production    understand
  negative     behaviors                   maladaptive
 emotions                                  cognitive
              Increased                    strategies
 Explore &      comfort;       GILCU            
  tolerate    Modification
                                            Positive
  feelings                       
               Increased                     choices
               fluency;                       
   Neutral    Comfortable    Spontaneous
  feelings     stuttering      fluency     Self-Therapy
 2. Formulate Goals and
       Objectives

 Hierarchies


 Goal content areas


 Sample objectives
     Sample Goal Content
           Areas
 Reduce frequency of stuttering behaviors
 Reduce severity, duration, or
  abnormality of stuttering behaviors
 Reduce escape/secondary behaviors
 Deal with co-existing problems
 Increase social activity and speaking
  behavior
 Improve self-esteem
 Reduce negative reactions to stuttering
 Provide information/counseling to others
   Curriculum Standards
 The student will participate in and
  report small group learning activities.
   3rd Grade: Ask and respond to
    questions from teachers and other
    group members.
   6th Grade: Communicate as leader
    and contributor.
   10th Grade: Evaluate one’s own role
    in preparation and delivery of oral
    reports.
 Sample Fluency Targets
                3rd Grade
 Ask and respond to questions in small
  group activities.
   Will maintain eye contact during
    disfluency while responding to questions
    in small group activities (behavioral)
   Will respond with factual information
    about stuttering when probed by peers in
    small group interaction (cognitive)
   Will use fluency shaping strategies on
    initial word when initiating a question in
    small group activities (behavioral)
 Sample Fluency Targets
                6th Grade
 Communicate as a leader and
  contributor.
   Will voluntary stutter to advertise as a
    person who stutters in academic and
    nonacademic small group activities, such
    as band, scouts, sports (affective)
   Will use stuttering modification strategies
    to move through blocks when contributing
    in discussion with peers (behavioral)
   Will write an article on stuttering for school
    newspaper to promote awareness
    (cognitive)
 Sample Fluency Targets
               10th Grade
 Evaluate one’s own role in preparation
  and delivery of oral reports.
   Will monitor word substitutions during bi-
    weekly presentation of current events
    (behavioral)
   Will formulate and carry out one speech
    challenge per month and evaluate own
    performance in terms of speech goals
    (cognitive)
   Will rate level of fear or desire to avoid
    during chalkboard problems in math class
    (affective)
  3. Plan for Evaluation
       of Progress

 Track all desired outcomes
 Include student and others in self-
  assessment
 Reconsider priorities
 Assess other factors influencing
  outcomes
      Suggestions for
      Implementation

 Multiple and alternative service
  delivery models

 Efficiency in sessions

 Network with school personnel and
  family
 Approaches to Therapy

 Stuttering Modification (SM)
  Approach

 Fluency Shaping (FS) Approach


 Importance of Integrating These
  Two Approaches
  Historical Perspective

 Cancellation - go back & change it

 Pullout - catch it during & change it

 Preparatory Set - feel it coming &
  fix it first
       Purposes of
 Stuttering Modification

 Break or relax tension

 Open up the point of stuttering,
  e.g. voicing, plosive

 Eliminate schwa or other vowel

 Move speech forward slowly
     Necessary Skills

 Identification


        Desensitization


                    Modification
    Modification Using
    Bounce and Slide

 Explain and model both techniques

 Focus student on a real stutter and
  overlay/replace it

 Signal the use of a technique

 Develop a hierarchy
Components of a School-
 Age Therapy Program
 Learning about Speaking
 Learning about Stuttering
 Understanding Your Stuttering
 Working with Your Stuttering
 Working with Your Fluency
 Working with Your Feelings and Ideas
 Strengthening & Sharing What You’ve
  Learned
Fluency Shaping
   Approach
  Relaxed Breath
 Stretched Speech
Smooth Movement
    Easy Voice
  Light Contact
     Linking
 Relaxed Breathing Target
        Rationale and Benefits

 Children may develop aberrant
  breathing patterns . . .

 This target:
   promotes proper breathing patterns
   provides a foundation for other targets
   promotes general body relaxation
  Stretched Speech Target
             Rationale and Benefits

 Stretching certain consonants helps
  the student to “hold on to” sounds in
  a steady, stable manner. /m, n, l, r, w, v, TH,
  y, j, z/

 This target:
    force & acceleration of muscle mvmts
    ability to notice & manage muscle mvmts
   improves timing of articulatory mvmts
    coordination of R, P, and A systems
 Smooth Movement Target
         Rationale and Benefits

 Rapid & abrupt articulatory
  movements may lead to stuttering
 This target:
   exaggerates the transition between sounds
   focuses attention on how articulators move
   allows student to slowly ease & relax their
    articulation, helping them gain greater
    control of their speech muscles
       Easy Voice Target
        Rationale and Benefits
 Muscles that control voicing move
  incorrectly during stuttering
 This target:
   helps children relax the movement of
    their vocal folds
   is the opposite of what occurs during
    vocal fry, glottal attacks, and/or
    laryngeal blocks
     Light Contact Target
        Rationale and Benefits
 Normal production of plosives and
  fricatives involves constriction, which
  involves tension, which may build
  and lead to stuttering
 This target:
   reduces articulatory pressure (tension)
   enables students to produce consonants
    in a light, relaxed manner
         Linking Target
        Rationale and Benefits
 Frequent restarting of the voice
  increases the likelihood of stuttering
 This target:
   connects syllables and words in a
    continuous way
   maintains a relaxed, continuous voice,
    which facilitates fluid, relaxed speech
   reduces number of vocal initiations
  Attitudes & Feelings
Stuttering more            Speaking more
easily                           fluently


  Developing and maintaining healthy
         attitudes and feelings

Improving general communication skills

   Incorporating support from others
       How Can I Be
      More Effective?

1. Create a communicative space
2. Explore attitudes and feelings
3. Document cognitive and affective
   goals
4. Implement strategies that
   develop healthier feelings and
   attitudes
  1. Creating a Healthy
  Communicative Space

 Improve how we listen, validate,
  and encourage - 6 concrete
  behaviors
 Partner with parents
 Use “encouraging” praise rather
  than “evaluative” praise
 Evaluating vs Encouraging
 Uses labels, like     Describes behavior
  “great” & “super”     Recognizes effort
 Judges correctness    Increases
 Expresses our          motivation
  values                Teaches belief in
 Increases              self
  dependence            Support self-
 Creates anxiety or     esteem
  confusion             Verbal snapshots
                        Internal
                         evaluations
   2. Exploring Attitudes
       and Feelings

 Three most common mistakes
 Look for them @ screening and
  evaluation
 Explore as an ongoing part of
  therapy
 Use a multi-task approach
      What To Look For
 Overall self-concept
 Awareness/Description of problem
 Reasons why stuttering happens
 Ideas about what helps
 Presence of worry or concern
 Reports of/Observation of avoidance
 Reports of fear and/or anxiety
 Concerns and perceptions of others
     Clinical Perceptions
Should be based on:
 Student’s description of problem &
  self

 Similarity of responses across tasks

 Behavior and body posture

 Parents’ and teachers’ reports
     3. Document and
    4. Implement Goals
 Create a Speech Binder

 Learn about Talking and Stuttering

 Educate and Involve Others

 Target and Discuss Meaningful
  Talking Topics

 Joint Problem Solving Plan
 Creating a Speech Binder
 May be a 3-ring binder or a floppy
  disc
 Use it as a working tool; implement
  strategies via the notebook
 Helps student understand what
  they are learning
 Enables them to teach others
 Helps clinician document what has
  been worked on
  Learning About Talking
      and Stuttering

 Draw, label, & discuss a diagram of
  the speech mechanism
 Relaxation activities
 Relationship of tension to stuttering
 Concept of communication
 Information about stuttering
 Educating and Involving
         Others
 Brainstorm what the student wants
  to share from his Speech Binder
  regarding stuttering, his stuttering,
  and what helps
 Develop an agenda or lesson plan
 Negotiate who will say what
 Meet with teachers or conduct
  lesson
 Follow-up with discussion
Meaningful Talking Topics

 Identify a concept or issue based on
  something you observe the student
  say or do

 Use one of three methods to
  highlight, explore, and relate the
  topic to progress in therapy
       Way to Explore
       Talking Topics
 Concept Map



        Flow Chart/Drawing



                      Rating Scale
   Joint Problem Solving

 A problem is identified and
  discussed in the Speech Binder


 This often follows discussion of a
  Talking Topic.
   Joint Problem Solving
          Process
1. Identify the problem
2. Discuss your feelings and needs
(I feel ___ because ___ and I want ___)
3. Student discusses his feelings/needs
4. Brainstorm solutions together
5. Discuss ones you like & don’t like
6. Choose one to follow through on
7. Make a plan to re-evaluate problem
       Final Comments
 Kids attitudes and feelings will
  change over time
 Respect where they’re at, let them
  be there, but know where you’re
  going
 Little signs can mean BIG GAINS
 Negative attitudes and feelings can
  keep kids “stuck” with stuttering

								
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