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The ABCs of Stuttering Shelly Wier, MS, CCC-SLP Easter Seals Outreach Program (501) 221-8415 email@example.com 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
"The ABCs of Stuttering"