The ABCs of Stuttering

1. The ABCs of Stuttering Shelly Wier, MS, CCC-SLP Easter Seals Outreach Program (501) 221-8415 swier@ar.easter-seals.org

2. Fluency Boot CampJuly 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

3. Basic Facts About Stuttering • Prevalence • Gender Ratio • Familial Incidence • Onset • Temperament • Nature of Onset • Speech at Onset • Spontaneous Recovery

4. Basic Assumption #1 Stuttering results from a complex interaction between the person's environment and the skills and abilities that person brings to their environment. NATURE NURTURE

5. Understanding Stuttering 60 mph Causation (deep structure) Behavior Manifestation (surface structure) Exacerbation 60 mph 50 mph 70 mph 60 mph 60 mph

6. 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)

7. Important To Note COGNITION and LINGUISTIC FORMULATION not just speech motor control

8. Assumption #2 Variables thought to cause stuttering must change as rapidly and continuously as instances of stuttering change during conversational speech.

9. Assumption #3 Such variables probably also occur PRIOR to overt stutterings.

10. Stuttering Does NotExist 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.

11. Ultimate Goal ofAssessment • 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.

12. 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

13. Purpose ofTherapy 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

14. Effective Therapy Goals

15. CollaborativePlanning Tools 1. Assess and determine student’s needs. 2. Formulate goals and short term objectives or benchmarks. 3. Plan for evaluation of progress.

16. 1. Assess and DetermineStudent Needs • Consider contributing factors • Wish Lists • Identify milestones to recovery

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

18. 2. Formulate Goals andObjectives • Hierarchies • Goal content areas • Sample objectives

19. 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

20. 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.

21. Sample Fluency Targets3rd 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)

22. Sample Fluency Targets6th 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)

23. Sample Fluency Targets10th 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)

24. 3. Plan for Evaluationof Progress • Track all desired outcomes • Include student and others in self-assessment • Reconsider priorities • Assess other factors influencing outcomes

25. Suggestions for Implementation • Multiple and alternative service delivery models • Efficiency in sessions • Network with school personnel and family

26. Approaches to Therapy • Stuttering Modification (SM) Approach • Fluency Shaping (FS) Approach • Importance of Integrating These Two Approaches

27. Historical Perspective • Cancellation - go back & change it • Pullout - catch it during & change it • Preparatory Set - feel it coming & fix it first

28. Purposes ofStuttering Modification • Break or relax tension • Open up the point of stuttering, e.g. voicing, plosive • Eliminate schwa or other vowel • Move speech forward slowly

29. Necessary Skills • Identification • Desensitization • Modification

30. Modification UsingBounce 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

31. 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

32. Fluency Shaping Approach Relaxed Breath Stretched Speech Smooth Movement Easy Voice Light Contact Linking

33. Relaxed Breathing TargetRationale and Benefits • Children may develop aberrant breathing patterns . . . • This target: • promotes proper breathing patterns • provides a foundation for other targets • promotes general body relaxation

34. Stretched Speech TargetRationale 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

35. Smooth Movement TargetRationale 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

36. Easy Voice TargetRationale 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

37. Light Contact TargetRationale 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

38. Linking TargetRationale 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

39. Attitudes & Feelings Stuttering more easily Speaking more fluently Developing and maintaining healthy attitudes and feelings Improving general communication skills Incorporating support from others

40. How Can I BeMore Effective? 1. Create a communicative space 2. Explore attitudes and feelings 3. Document cognitive and affective goals • Implement strategies that develop healthier feelings and attitudes

41. 1. Creating a HealthyCommunicative Space • Improve how we listen, validate, and encourage - 6 concrete behaviors • Partner with parents • Use “encouraging” praise rather than “evaluative” praise

42. Describes behavior Recognizes effort Increases motivation Teaches belief in self Support self-esteem Verbal snapshots Internal evaluations Uses labels, like “great” & “super” Judges correctness Expresses our values Increases dependence Creates anxiety or confusion Evaluating vs Encouraging

43. 2. Exploring Attitudesand Feelings • Three most common mistakes • Look for them @ screening and evaluation • Explore as an ongoing part of therapy • Use a multi-task approach

44. 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

45. 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

46. 3. Document and4. 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

47. 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

48. Learning About Talkingand Stuttering • Draw, label, & discuss a diagram of the speech mechanism • Relaxation activities • Relationship of tension to stuttering • Concept of communication • Information about stuttering

49. Educating and InvolvingOthers • 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

50. 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