Fluency- stammering

Stammering as a disability

Is a protected characteristic by law

Medical model

They can't do certain things normally
Reduced standards of living and social prospects
Aim is to make them fluent

Social model

Impairment and disability are different and separate
Disability is a process
Disability is due to physical structural and cultural barriers
Aim- possible future with reduced disability

Overt characteristics of stammering

Repetitions
Prolongations
Blocking
Associated physical behaviours
Associated breathing disturbances
Contemporary strategies- avoidance of swords , sounds, circumlocutions, filters, interjections

Overt stammering fro clinician view

Should clinicians be interested- no
What should we be asking- impact of steamer on them daily

Stammering characteristics

Part word repetition
Single syllable repetitions
Dysrhythmic phonations
Singe sound repetitions
Prolongations
Blocks
3-5 iterations
Faster iterations
Body movements concomitant features

Brain structure predisposing factors

Structural deficits n white matter
Differences in grey matter in Broca's area
Cerebral dominance
Over activation in right hemisphere
Deactivation in left auditory Cortes

Levels of neural structures coordinating for speech

Segmental and supra segmental

Models for speech

Multi factorial model- young children
Starkweathers Demands capacities model- children all ages
Iceberg analogy- children 9-adults

Stammer terminology

Client / service user
Therapy/ intervention

Initial consultations with children

Screening test for initial assessment
Screening of speech lang and communication difficulties
Child's view- awareness, feelings, reactions
Description of stammering behaviours

Full assessment - after screening

Assess tiger areas - language, social communication
Strengths and weaknesses in communication skills
Give longer speech assessment
See how environment affects stammer

Ways to assess

Blob tree
Draw how you feel
Sheehans Iceberg model
Pizza/ pie

Covert stammering

Cognitive- negative thoughts, beliefs, assumptions
Emotional- shame, embarrassment, anxiety
Behavioural- coping strategies and safety behaviours , avoidance, reticence, silence

Initial consultation with adult

Background whey now, whose idea
Current circumstances- personal, emolument, family, health
View of speech- stammer history, past therapy
Attitude

Therapy with adults

Solution focussed brief therapy
Motivational interviewing

Indirect approaches for children- working with family

Demands capacities
Parents child interaction
Parents counselling

Direct approaches working with child

Lidcombe programme
GILCU
Working on fluency

Demands capacity techniques

Pausing
Not finishing sentences
Not interrupting
Giving full attention
Ke6 child lead
Patience
Not reacting negatively
Allowing silence
Praise and confidence

Palin parent-child interaction model

To explain stammering
Increase parent knowledge
Interaction strategies in play time
Family

Stammering as a disability

Is a protected characteristic by law

Medical model

They can't do certain things normally
Reduced standards of living and social prospects
Aim is to make them fluent

Social model

Impairment and disability are different and separate
Disability is a process
Disability is due to physical structural and cultural barriers
Aim- possible future with reduced disability

Overt characteristics of stammering

Repetitions
Prolongations
Blocking
Associated physical behaviours
Associated breathing disturbances
Contemporary strategies- avoidance of swords , sounds, circumlocutions, filters, interjections

Overt stammering fro clinician view

Should clinicians be interested- no
What should we be asking- impact of steamer on them daily

Stammering characteristics

Part word repetition
Single syllable repetitions
Dysrhythmic phonations
Singe sound repetitions
Prolongations
Blocks
3-5 iterations
Faster iterations
Body movements concomitant features

Brain structure predisposing factors

Structural deficits n white matter
Differences in grey matter in Broca's area
Cerebral dominance
Over activation in right hemisphere
Deactivation in left auditory Cortes

Levels of neural structures coordinating for speech

Segmental and supra segmental

Models for speech

Multi factorial model- young children
Starkweathers Demands capacities model- children all ages
Iceberg analogy- children 9-adults

Stammer terminology

Client / service user
Therapy/ intervention

Initial consultations with children

Screening test for initial assessment
Screening of speech lang and communication difficulties
Child's view- awareness, feelings, reactions
Description of stammering behaviours

Full assessment - after screening

Assess tiger areas - language, social communication
Strengths and weaknesses in communication skills
Give longer speech assessment
See how environment affects stammer

Ways to assess

Blob tree
Draw how you feel
Sheehans Iceberg model
Pizza/ pie

Covert stammering

Cognitive- negative thoughts, beliefs, assumptions
Emotional- shame, embarrassment, anxiety
Behavioural- coping strategies and safety behaviours , avoidance, reticence, silence

Initial consultation with adult

Background whey now, whose idea
Current circumstances- personal, emolument, family, health
View of speech- stammer history, past therapy
Attitude

Therapy with adults

Solution focussed brief therapy
Motivational interviewing

Indirect approaches for children- working with family

Demands capacities
Parents child interaction
Parents counselling

Direct approaches working with child

Lidcombe programme
GILCU
Working on fluency

Demands capacity techniques

Pausing
Not finishing sentences
Not interrupting
Giving full attention
Ke6 child lead
Patience
Not reacting negatively
Allowing silence
Praise and confidence

Palin parent-child interaction model

To explain stammering
Increase parent knowledge
Interaction strategies in play time
Family and child strategies

Palin parent- child interaction - family strategies

Openness
N\=building confidence
Turn raking
dealing with feelings
Routine

Palin parent- child interaction - child strategies

Openness
Building confidence
Desensitisation
Increased pausing
Thoughts and emotions
Rate reduction

Lidcombe Program

Direct intervention
Operant conditioning based approach
A parent-administered treatment in which positive reinforcement is provided for stutter-free speech, and correction is used following stuttering.

Strengths to speak in more 'fluently'

Stammers can cause tension
Can help ease pain such as a block
Help prevent blocking airway
Can explore alternatives

Strengths of Stammer more fluency

Work on overt aspects
Confidence
Further understanding stammer
Encouraged to be themselves

Evidence based practice

research evidence
Clinical experience - shaping evince based practice and using it
Patient preferences - adapting outside pond the manual

Person centred goals

Evoking from the client what they want

Working with covert stammering - helping the client to

Change thoughts about themselves, their stammering and others' reactions to it
• Be open about stammering
• Desensitise to stammering
• Experiment with change
• Reduce struggle
• Reduce avoidance

Voluntary stammering \=

Stammeiring on purpose
Purposely ssssssslide of b b bounce

Acceptance and commitment therapyACT

· Through the use of metaphors, paradox, stories and other verbal techniques, the client learns that past attempts to control troublesome thoughts and emotions were unsuccessful and contributed to increase the frequency of those thoughts and emotions.
· Through mindfulness and acceptance exercises, the client learns to experience and nonjudgmentally embrace thoughts and emotions, including those that are troublesome.
· With ACT homework assignments are used not so much to promote cognitive restructuring of thoughts as with REBT or other forms of cognitive therapy, but to build more effective patterns of action towards the attainment of valued and identified goals.

Cognitive behavioural therapy CBT

Thoughts
Emotions
Physical feeling
Behaviour

Group therapy

For older children 8+ and adults
• Reduces isolation
• Provides support
• Motivation
• Reduced dependency on clinician
• Opportunities to practice

The Chimp Paradox

The Chimp -
Keeps us safe when we are in danger, but gets in the way. He controls the emotional part of the brain, thinks quickly and doesn't think about things too much

The Computer -
Stores away experiences and actions for later, it can be helpful... but it can save some things for easier recall than others and listens to the chimp!

The Human -YOU!
You can think things through and weigh up the evidence before acting.
You decide whether to listen to the chimp or the human

Sheehans theory of levels of avoidance

Word level- avoid a feared word
Situation level- to enter/not a feared situation eg in public
Feeling- to express/hide emotional content
Relationship- enter/ avoid interpersonal relationships
Self role/ego protective - accepting/rejecting role expectations eg for intellectual achievements

Phases of avoidance reduction

action therapy
self-acceptance phase
monitoring and exploring phase
initiative phase
modification of patterns phase
safety margins phase

Activities for phases of avoidance reduction

Establish eye contact
Discuss stammering openly
Explore stammering behaviours
Expose the iceberg
Stammer openly and easily
Resist time pressure
Pause - use of silence
Reduce struggle and move through stammering Voluntary stammering
Choose how and when to stammer

Openness and avoidance reduction

When a client is more open to stammering, they are less likely to try and hide it. The client will need to;
Allow others to see and hear their stammering
Approach rather than avoid stammering
Maintain eye-contact to see the listener's reaction rather than guess their reaction
Be able to tell other people about stammering
Therefore need to understand stammering
Questionnaires to members of the public
Be able to self-disclose stammering
Voluntary stammering
Participation in support groups Stammering interviews
Resist time pressures and be comfortable with silence
Not about being fluent

Dysfluency

Cluttering
Stammering
Word final dyfluency

Acquired stammering

neurogenic
- psychogenic
- pharmacological / pharmacogenic
- malingering

Neurological stammer

Comes from injury affecting brain- Parkinson's, brain tumour etc
Most common acquired stammer

Psychogenic stammering

Mental health link - psychiatric difficulties

Functional neurogenic disorder

Not due to organic causes
Is fir things happening that aren't for clear reasons

Malingering stammer

Do o put Rosie to avoid something you don't want to do eg presentation

Pharmacological stammering

Brough on by medicines eg-
Psychopharmaca
• Anticonvulsants
• Broncho dilatator theophylline

Cluttering characterised by

A speech AND language disorder characterised by:
• Abnormal fluency
• Apparent excessive and irregular speed of utterance
• Reduced intelligibility (co-articulations)
• The client's unawareness of his disorder

Cluttering includes

Fewer sound or syllable repetitions, prolongations or struggle
• More repeated utterances rather than repeated stoppages
• High level of word and phrase repetitions
• Dysfluency as a result of language formulation
difficulties
• More incomplete phrases, fillers, word repetitions and revisions
• No apparent momentary loss of control of speech
• Lack of awareness, no apprehension
• Locus of dysfluency can be mid or end of sentence, clause, phrase word or syllable; and on unstressed as well as stressed syllables

Cluttering articulation

Articulation
• • • • •
omission of sounds, syllable, whole words co-articulation
articulatory errors (e.g. blig blue book) Spoonerisms (e.g. kye make for my cake)
repetition of initial sounds at same rate as rest of speech

Cluttering