FLUENCY DISRODERS EXAM 3
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Last updated 1:11 PM on 4/5/23
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112 Terms
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goals for change
\-increasing fluency
\-improving communication
\-developing greater autonomy (agency)
\-improving communication
\-developing greater autonomy (agency)
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four principles of therapeutic change
\-move toward rather than away from the problem
\-assume the responsibility for taking action
\-restructure the cognitive view of the self & the problem
\-recruit the support of others
\-assume the responsibility for taking action
\-restructure the cognitive view of the self & the problem
\-recruit the support of others
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goals
\-goals will be derived from your evaluation of the client’s needs
\-usually more than one goal
\-the goals for therapy need to be communicated to the client
\-usually more than one goal
\-the goals for therapy need to be communicated to the client
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things to consider when establishing goals
\-the ease with which can be achieved (easier toward beginning)
\-how interested is the client in achieving your goal
\-the impact your goal will have on the severity of the disorder (ex. 8 sec to 1 sec)
\-what type of outcome you expect from goal
\-how interested is the client in achieving your goal
\-the impact your goal will have on the severity of the disorder (ex. 8 sec to 1 sec)
\-what type of outcome you expect from goal
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attainable vs. not so attainable goals
\-to “cure stuttering (level of disfluency within normal limits, has it been maintained for five years, client no longer believes they have a fluency disorder (who can attain this goal?))
\-to reduce the severity of the client’s fluency disorder (who can attain this goal?)
\-to reduce the extent to which the client is disabled and/ or handicapped by his or her fluency disorder (does handicap correlate with level of disfluency?)
\-to reduce the severity of the client’s fluency disorder (who can attain this goal?)
\-to reduce the extent to which the client is disabled and/ or handicapped by his or her fluency disorder (does handicap correlate with level of disfluency?)
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desirable treatment outcomes
to leave treatment with:
\-understanding & ability to use tools for speech management
\-to leave treatment with current understanding of the nature/ causes of stuttering
\-having educated family & friends about stuttering/ treatment
\-feeling at peace with stuttering & having reached a new level of acceptance & understanding
\-freedom, comfort, & ability to say what one chooses
\-being comfortable with stuttering & advertising the fact that one stutters
\-with a strengthened self-image & confidence
\-understanding & ability to use tools for speech management
\-to leave treatment with current understanding of the nature/ causes of stuttering
\-having educated family & friends about stuttering/ treatment
\-feeling at peace with stuttering & having reached a new level of acceptance & understanding
\-freedom, comfort, & ability to say what one chooses
\-being comfortable with stuttering & advertising the fact that one stutters
\-with a strengthened self-image & confidence
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assume responsibility for taking action
\-accept the self & the reality of the problem (in early 20s?)
\-practice: especially beyond the therapy environment
\-experiment with techniques
\-integrate the techniques/ develop expertise
\-increase internal locus of causality
\-practice: especially beyond the therapy environment
\-experiment with techniques
\-integrate the techniques/ develop expertise
\-increase internal locus of causality
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recruit the support of others
\-search for support from family & friends
\-make stuttering an “acceptable topic of discussion”
\-support groups (NSA, Friends, local groups)
\-make stuttering an “acceptable topic of discussion”
\-support groups (NSA, Friends, local groups)
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restructure the cognitive view of the self & the problem
\-broaden the understanding of stuttering
\-externalize the problem from the self
\-focus on self rather than the listener
\-acknowledge stuttering
\-inform the listener
\-humor as an indicator of cognitive change
\-externalize the problem from the self
\-focus on self rather than the listener
\-acknowledge stuttering
\-inform the listener
\-humor as an indicator of cognitive change
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transitional themes
\-support from others
\-successful treatment (no specific techniques or protocols)
\-self therapy & behavioral change
\-cognitive change (taking risks/ disclosing stuttering)
\-the development of counterplots
\-motivation & persistence
\-successful treatment (no specific techniques or protocols)
\-self therapy & behavioral change
\-cognitive change (taking risks/ disclosing stuttering)
\-the development of counterplots
\-motivation & persistence
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the meaning of therapeutic techniques
\-while specific therapeutic techniques are an important part of the treatment process, what is more important is the meaning of the techniques
\-clients don’t need to understand the theory behind what goes on in therapy but they need to understand the meaning of what they are doing
\-the clinician should have a rationale for what they are doing in therapy (or why they are not doing something)
\-clients don’t need to understand the theory behind what goes on in therapy but they need to understand the meaning of what they are doing
\-the clinician should have a rationale for what they are doing in therapy (or why they are not doing something)
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the shared meaning of therapeutic techniques
\-it is also often helpful to explain your rationale to the client
\-without a shared meaning of what is taking place in therapy the techniques are just techniques
\-if a client understands the rationale for what they are doing they are more likely to practice between sessions
\-a key trait of successful clinicians is their ability to motivate the client to practive between sessions
\-without a shared meaning of what is taking place in therapy the techniques are just techniques
\-if a client understands the rationale for what they are doing they are more likely to practice between sessions
\-a key trait of successful clinicians is their ability to motivate the client to practive between sessions
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stuttering modification therapy
\-used with avoidance, struggle, and fear
\-”stutter more fluently approach” or stuttering management approach
\-for example, Van Riper (MIDVAS: modification, identification, desensitization, variation, approximation, stabilization)
\-”stutter more fluently approach” or stuttering management approach
\-for example, Van Riper (MIDVAS: modification, identification, desensitization, variation, approximation, stabilization)
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fluency shaping
\-seeks to establish fluent speech through behavior modification
\-”speak more fluently approach” or fluency management
\-for example, monterey fleuncy program, GILCU
\-”speak more fluently approach” or fluency management
\-for example, monterey fleuncy program, GILCU
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stuttering modification therapy premise
stuttering results from avoidance, fear and negative attitudes
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fluency shaping premise
stuttering is learned
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behavioral treatment goals (stuttering modification therapy)
spontaneous fluency, controlled fluency & acceptable stuttering
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behavioral treatment goals (fluency shaping)
spontaneous fluency & controlled fluency are only acceptable/ evidence of stuttering indicates program failure
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spontaneous fluency
fluency characteristic of “normal” speaker; little effort
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controlled fluency
fluency characteristic of “normal” speaker; requires monitoring & adjustments
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acceptable stuttering
disfluency of relatively low severity & feels they are an effective communicator
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affective treatment goals (stuttering modification therapy)
identification & understand thoughts, feelings & attitudes related to communication
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affective treatment goals (fluency shaping)
no attempts are made to reduce communication related fears or attitudes/ feel it will happen on its own with improved fluency
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treatment procedures (stuttering modification therapy)
attention to reducing fears & avoidance/ taught techniques to modify moments of stuttering
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treatment procedures (fluency shaping)
use a behaviorally designed program to get stutter free speech/ taught to modify the manner of speaking
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treatment structure (stuttering modification therapy)
\-less structured
\-counseling like interaction
\-counseling like interaction
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treatment structure (fluency shaping)
\-highly structured
\-conditioning
\-conditioning
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diagnostic indicators (stuttering modification therapy)
\-hides stuttering
\-avoids speaking
\-personal penalty as consequence of stuttering
\-feels badly about self as communicator
\-avoids speaking
\-personal penalty as consequence of stuttering
\-feels badly about self as communicator
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diagnostic indicators (fluency shaping)
\-stutters openly
\-does not avoid
\-perceives annoyance rather than personal penalty
\-feels positive about self as communicator
\-does not avoid
\-perceives annoyance rather than personal penalty
\-feels positive about self as communicator
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basic stuttering modification strategies
\-aka non-avoidance/ Van Riparian
\-how to stutter easier & better (management)
\-deals with fear, avoidance, & struggle
\-more likely to involve counseling features
\-most speakers fit criteria for this approach
\-how to stutter easier & better (management)
\-deals with fear, avoidance, & struggle
\-more likely to involve counseling features
\-most speakers fit criteria for this approach
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it requires the speaker to
\-stay in the moment of stuttering (ex. freezing)
\-requires (some) desensitization
\-learn to play with the behaviors & attitudes
\-requires (some) desensitization
\-learn to play with the behaviors & attitudes
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goals of stuttering modification
\-we are doing more than creating easy stuttering, greater fluency is a realistic goal
\-changing behavior & decisions about communicating
\-dealing with helplessness & taking charge of stuttering events
\-changing behavior & decisions about communicating
\-dealing with helplessness & taking charge of stuttering events
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problems
\-more difficult to learn, many counseling components \[not as scripted\]
\-clinician must demonstrate & role play \[you have to be disfluent & vulnerable\]
\-involves more cognitive response than many fluency-shaping approaches \[more difficult for children\]
\-clinician must demonstrate & role play \[you have to be disfluent & vulnerable\]
\-involves more cognitive response than many fluency-shaping approaches \[more difficult for children\]
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stages of stuttering modification
\[motivation: do I want to do this\]
\-identification: acceptance & exploration
\-desensitization: staying in the moment, considering options
\-variation: experiment & play with behavior
\-modification \[approximation\]: before, during, after
\-stabilization: practice
\[you don’t have to complete one to move to the next\]
\-identification: acceptance & exploration
\-desensitization: staying in the moment, considering options
\-variation: experiment & play with behavior
\-modification \[approximation\]: before, during, after
\-stabilization: practice
\[you don’t have to complete one to move to the next\]
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motivation
\-convey your role & his or her in the process
\-be positive & optimistic
\-convey genuine interest, acceptance & understanding
\-replicate stuttering pattern in self
\-encourage the expression of feelings
\-be positive & optimistic
\-convey genuine interest, acceptance & understanding
\-replicate stuttering pattern in self
\-encourage the expression of feelings
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identification
\-”if a stutterer is to change, he must become aware of what to change”
\-involves developing a heightened awareness on ones own disfluencies, tensions, as well as mental expectations, fear and avoidances
can involve:
\-viewing oneself on video
\-tallying
\-freezing \[hanging onto a moment of disfluency instead of trying to get out of it\]
\-involves developing a heightened awareness on ones own disfluencies, tensions, as well as mental expectations, fear and avoidances
can involve:
\-viewing oneself on video
\-tallying
\-freezing \[hanging onto a moment of disfluency instead of trying to get out of it\]
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(identification) elements that can be identified
\-core behaviors
\-avoidance behaviors
\-postponement devices
\-timing behaviors
\-verbal cues
\-situational cues
\-loci of tension
\-recoil behavior
\-poststuttering reaction
\-feelings of frustration, shame, hostility
\-avoidance behaviors
\-postponement devices
\-timing behaviors
\-verbal cues
\-situational cues
\-loci of tension
\-recoil behavior
\-poststuttering reaction
\-feelings of frustration, shame, hostility
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desensitization
\-”approach rather than avoid & see what we can learn”
\-goal is to let stuttering out & reduce or eliminate avoidance
\-initially, this experience is difficult for clients bc it addresses stress
\-goal is to let stuttering out & reduce or eliminate avoidance
\-initially, this experience is difficult for clients bc it addresses stress
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(desensitization) make stuttering the object of study by watching themselves on video
\-discuss their approach to speech, quality of stuttering, patterns of eye movement (loci of physical tension)
\-characteristic disfluency types observed
\-discuss avoidance behaviors (struggle & escape behaviors)
\-discuss the presence of postponements, timing tricks, & starters
\-discuss thought & feeling before, during & after speaking situation
\-you can have them keep a record of stuttering by having them tally the stuttering behaviors & avoidance (they are stopping & catching themselves which is also useful)
\-characteristic disfluency types observed
\-discuss avoidance behaviors (struggle & escape behaviors)
\-discuss the presence of postponements, timing tricks, & starters
\-discuss thought & feeling before, during & after speaking situation
\-you can have them keep a record of stuttering by having them tally the stuttering behaviors & avoidance (they are stopping & catching themselves which is also useful)
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(desensitization) mirror work & freezing
purpose is to examine the moment of stuttering:
\-you can stop the client in a moment of stuttering by instructing them to freeze & hold the moment until they are told to let go (can use your fist as a visual indicator, ex. if the stutter was a repetition they would continue to repeat until they are cued to transition to the next sound)
\-the client then is asked to describe the disfluency by identifying the parts of the body that were affected & how they were affected
\-you can stop the client in a moment of stuttering by instructing them to freeze & hold the moment until they are told to let go (can use your fist as a visual indicator, ex. if the stutter was a repetition they would continue to repeat until they are cued to transition to the next sound)
\-the client then is asked to describe the disfluency by identifying the parts of the body that were affected & how they were affected
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(desensitization) voluntary stuttering\*\*\*
\-stutterer chooses and remains in “control”
\-you most likely have to model
\-you most likely have to model
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(desensitization) self-advertising or self disclosure
\-purpose is to overcome the shame & embarrassment of stuttering, eliminate fear, & communicate an attitude of confidence & comfort
\-provides an opportunity to educate others
\-should be viewed as a statement of fact not an apology
\-survey experience (go to strangers, introduce themselves & ask q ab stuttering: what do you think causes stuttering, what would you do if you had a child who stutters, what do you think a stuttered should do to overcome their problem, do you know anyone else who stutters)
\-provides an opportunity to educate others
\-should be viewed as a statement of fact not an apology
\-survey experience (go to strangers, introduce themselves & ask q ab stuttering: what do you think causes stuttering, what would you do if you had a child who stutters, what do you think a stuttered should do to overcome their problem, do you know anyone else who stutters)
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variation/ modification
\-the purpose of introducing variation is to break the client’s habitual pattern of stuttering (“we cling to the familiar even if it is unpleasant” )
\-we want the client to first recognize the way they characteristically stutter in terms of the way they think, feel and act
\-then they deliberately vary their stuttering behavior/ vary both the anticipatory & core stuttering behaviors (“breaking the rut”)
\-we want the client to first recognize the way they characteristically stutter in terms of the way they think, feel and act
\-then they deliberately vary their stuttering behavior/ vary both the anticipatory & core stuttering behaviors (“breaking the rut”)
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modification techniques
\-post stuttering (cancellation)
\-during stuttering (pull out)
\-before stuttering (prep step)
\-note: doing this to take charge-not to achieve fluency, particularly at the outset
\-during stuttering (pull out)
\-before stuttering (prep step)
\-note: doing this to take charge-not to achieve fluency, particularly at the outset
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steps when cancelling
\-stop after event (\~3s)
\-analyze old stuttering
\-pantomime easier/ smoother form
\-incorporates fluency shaping targets
\-(last chance to catch old stuttering, must be desensitized, takes much practice)
\-analyze old stuttering
\-pantomime easier/ smoother form
\-incorporates fluency shaping targets
\-(last chance to catch old stuttering, must be desensitized, takes much practice)
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the basics of fluency shaping
\-a history of behavioral modification
\-create & expand fluent speech
\-increase length & complexity
\-little focus on deep structure of change
\-tends to work well with young children
\-often works well during the later stages of stuttering modification
\-create & expand fluent speech
\-increase length & complexity
\-little focus on deep structure of change
\-tends to work well with young children
\-often works well during the later stages of stuttering modification
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parameters of forward moving speech
\-generate a consistent air flow from the lungs
\-create movement of the rib cage, abdomen, & articulators
\-achieving timing & coordination of respiratory, phonatory, & articulatory activities
\-initiate the onset of laryngeal moment for voicing making the transition between voiceless & voiced sounds
\-produce appropriate levels of muscular tension required for moving the articulators
\-create movement of the rib cage, abdomen, & articulators
\-achieving timing & coordination of respiratory, phonatory, & articulatory activities
\-initiate the onset of laryngeal moment for voicing making the transition between voiceless & voiced sounds
\-produce appropriate levels of muscular tension required for moving the articulators
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fluency shaping targets
\-slow rate (1 syllable/ second)
\-full breath
\-continuous airflow
\-gradual onset of phonation
\-continuous voicing
\-easy articulatory contacts
\-blending of all sounds & syllables (within & between words)
\-full breath
\-continuous airflow
\-gradual onset of phonation
\-continuous voicing
\-easy articulatory contacts
\-blending of all sounds & syllables (within & between words)
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easy onsets
\-refers to the easy or gentle onset of voicing
\-this is accomplished by starting speech with less physical tension in the speech musculature
\-(easier to use with words that begin with a vowel/ vowels following a voiceless consonant can be more difficult)
\-this is accomplished by starting speech with less physical tension in the speech musculature
\-(easier to use with words that begin with a vowel/ vowels following a voiceless consonant can be more difficult)
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light contacts
\-use of light articulatory contacts to prevent the stoppage of the forward flow of air
\-accomplished by touching parts of the speech mechanism togehter softly with reduced physical tension (plosives & affricatives will sound slightly distorted like fricatives, encouraging semi-closure)
\-often used in conjucntion with continuous voicing & airflow
\-can help increase awareness of the difference between tense & easy speech movements
\-can aid in the monitoring of tension
\-accomplished by touching parts of the speech mechanism togehter softly with reduced physical tension (plosives & affricatives will sound slightly distorted like fricatives, encouraging semi-closure)
\-often used in conjucntion with continuous voicing & airflow
\-can help increase awareness of the difference between tense & easy speech movements
\-can aid in the monitoring of tension
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reduced rate
\-thought that a slowed speaking rate may allow the client time to make the adjustments necessary for fluent speech production
\-some people who stutter increase their rate in response to stuttering
\-a slowed rate is often encouraged by having the client: prolong their vowels, make easy & relaxed transitions, through continuous phonation, DAF, phrasing/ pausing
\-some people who stutter increase their rate in response to stuttering
\-a slowed rate is often encouraged by having the client: prolong their vowels, make easy & relaxed transitions, through continuous phonation, DAF, phrasing/ pausing
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proprioceptive sensory awareness
\-it is believed that developing a proprioceptive awareness will aid in the training of motor skills (that is, one must break the motor components of speech down into its parts before they can learn new motor skills)
\-encouraging the client to become consciously aware of the sensory information provided by the articulators, you are asking the to essentially bypass the auditory system (want them to feel the movements of their lips/ jaw/ tongue ,can use DAF to interfere with self-hearing & have them close their eyes)
\-encouraging the client to become consciously aware of the sensory information provided by the articulators, you are asking the to essentially bypass the auditory system (want them to feel the movements of their lips/ jaw/ tongue ,can use DAF to interfere with self-hearing & have them close their eyes)
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continuous airflow (diaphragmatic breathing & breathing for speaking)
\-purpose: deeper, diaphragmatic breathing helps keep the throat muscles relaxed, the body relaxed, the mind clear, reduces adrenaline, & allows the intake of more air volume (which serves as the fuel for voice production)
\-awareness activity (want them to feel their body as they inhale & exhale/ provide some education on the breathing process & the movement of the diaphragm, where it is located & how it works)
\-awareness activity (want them to feel their body as they inhale & exhale/ provide some education on the breathing process & the movement of the diaphragm, where it is located & how it works)
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continuous airflow (sequence)
\-exhale any leftover air naturally & easily (inhaling before releasing the leftover air can cause more tension int he vocal tract)
\-then inhale in a comfortable & relaxed way (want them to maintain relaxed articulators/ instruct them to follow the airstream as the diaphragm descends & the ribs expand)
\-want them to maintain an openness of the vocal folds (you can then do some purposeful contrasting the feeling of openness versus the purposeful closure of the vocal folds & holding breath while mouth is open
\-then inhale in a comfortable & relaxed way (want them to maintain relaxed articulators/ instruct them to follow the airstream as the diaphragm descends & the ribs expand)
\-want them to maintain an openness of the vocal folds (you can then do some purposeful contrasting the feeling of openness versus the purposeful closure of the vocal folds & holding breath while mouth is open
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continuous voicing
\-the goal is simultaneous exhalation & voicing without hesitation (hesitation could result in closure of vocal folds)
\-begin with a neutral vowel (no activation of the articulators) (then move to the remaining vowels, its about the interaction of the breath stream & vocal folds/ want them to sustain each sound with constant pressure/ there should be no pitch or loudness change)
\-then shape the voicing into normal intensity change at the syllable level (soft-loud-soft pattern)
\-reconnect the syllables & progress throughout he hierarchy
\-begin with a neutral vowel (no activation of the articulators) (then move to the remaining vowels, its about the interaction of the breath stream & vocal folds/ want them to sustain each sound with constant pressure/ there should be no pitch or loudness change)
\-then shape the voicing into normal intensity change at the syllable level (soft-loud-soft pattern)
\-reconnect the syllables & progress throughout he hierarchy
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all techniques
\-require a lot of practice
\-are often non-intuitive
\-are often non-intuitive
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summary
\-fluency shaping for young children (continuous voicing does not work great for children)
\-most adolescents & adults need both stuttering modification & fluency shaping techniques
\-depends on what client needs from us & is capable of & willing to do
\-most adolescents & adults need both stuttering modification & fluency shaping techniques
\-depends on what client needs from us & is capable of & willing to do
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mindfulness & acceptance & commitment therapy
\-acceptance: the first step for change
\-mindfulness: paying attention without judgement
\-understanding & being in “A” in order to get to “B”
\-enhanced therapeutic alliance
\-decreased impact of stuttering
\-increased fluency
\-mindfulness: paying attention without judgement
\-understanding & being in “A” in order to get to “B”
\-enhanced therapeutic alliance
\-decreased impact of stuttering
\-increased fluency
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avoidance reduction therapy (ARTS)
\-fluency at the expense of spontaneity
\-focus on acceptance & desensitization
\-open or “clean” stuttering without avoidance or escape behaviors
\-easy, forward-moving speech In progressively more stressful situations
\-goal: saying what they want to whom they want comfortably, efficiently & spontaneously
\-focus on acceptance & desensitization
\-open or “clean” stuttering without avoidance or escape behaviors
\-easy, forward-moving speech In progressively more stressful situations
\-goal: saying what they want to whom they want comfortably, efficiently & spontaneously
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adolescents can be difficult cases because
\-many other interests, tx is a low priority
\-the hope that stuttering will go away
\-schooling often complicates matters
\-avoidance & substitution increase
\-may be a history of negative reactions (to fluency failure, to teasing, to treatment)
\-the hope that stuttering will go away
\-schooling often complicates matters
\-avoidance & substitution increase
\-may be a history of negative reactions (to fluency failure, to teasing, to treatment)
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and it also requires
\-involvement of the family
\-dependence on an adult
\-development of a trusting clinical relationship with often a female clinician
\-hard work for moths or years
\-lots of practice
\-dependence on an adult
\-development of a trusting clinical relationship with often a female clinician
\-hard work for moths or years
\-lots of practice
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basic messages to an adolescent
\-success is possible
\-stuttering is no one’s fault
\-a successful future is possible
\-find a good clinician when you are ready
\-you are not alone
\-stuttering is no one’s fault
\-a successful future is possible
\-find a good clinician when you are ready
\-you are not alone
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basic considerations with young children
\-children have conceptual, linguistic, affective, and neurophysiological factors that are in the process of maturation
\-there may be other communication, learning, & behavior problems
\-teasing & bullying may occur
\-parents & teachers have essential roles
\-less effort may be necessary to transfer & maintain treatment gains
\-it is possible to achieve natural & spontaneous fluency
\-relapse is less likely to occur than with adults
\-there may be other communication, learning, & behavior problems
\-teasing & bullying may occur
\-parents & teachers have essential roles
\-less effort may be necessary to transfer & maintain treatment gains
\-it is possible to achieve natural & spontaneous fluency
\-relapse is less likely to occur than with adults
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treatment directions (intervention direction)
\-indirect: parent training, ongoing monitoring, less frequent to intensive
\-direct: cognitive behavioral, parental involvement, intensive to less frequent
\-direct: cognitive behavioral, parental involvement, intensive to less frequent
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basic approaches
\-indirect approach: modify environment (does direct intervention increase severity?)
\-1940s-1960s: emphasis of treatment on preventing child from becoming aware that his speech was any different or a cause for concern, parents & teachers instructed to avoid showing anxiety & using the word “stutter”
\-1980s +: direct modeling & encouraging easier speech; adjusting environmental factors in home
\-1940s-1960s: emphasis of treatment on preventing child from becoming aware that his speech was any different or a cause for concern, parents & teachers instructed to avoid showing anxiety & using the word “stutter”
\-1980s +: direct modeling & encouraging easier speech; adjusting environmental factors in home
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treatment direction
\-indirect: attempt to change the child’s behavior by targeting the home environment/ relies on parental instruction
\-direct: tend to be response-contingent programs, fluency training or stuttering modification/ parents are also typically involved
\-direct: tend to be response-contingent programs, fluency training or stuttering modification/ parents are also typically involved
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some basic approaches (the demands & capacities model)
\-decreasing demands while increasing capacities across 4 domains: motoric, emotional, linguistic, cognitive
\-parents are trained to administer the program
\-parents are trained to administer the program
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some basic approaches (lidcombe program fro preschool children)
\-response-contingent program
\-childs fluent speech followed by praise or acknowledgement, disfluent speech by encouragement of a fluent correction or by acknowledgement
\-(“that was bumpy”, “I heard smooth speech”, trying to get tp 5:1)
\-(once 5:1 ratio met, begin to ask for repairs)
\-(drop off in disfluencies at the 10 wk mark)
\-(only use within a year of onset and children under 6)
\-parents are trained to administer the program
\-childs fluent speech followed by praise or acknowledgement, disfluent speech by encouragement of a fluent correction or by acknowledgement
\-(“that was bumpy”, “I heard smooth speech”, trying to get tp 5:1)
\-(once 5:1 ratio met, begin to ask for repairs)
\-(drop off in disfluencies at the 10 wk mark)
\-(only use within a year of onset and children under 6)
\-parents are trained to administer the program
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common components for DCM & lidcombe programs
\-active rile of the parents in the therapeutic process
\-parent levels of understanding, learning, & commitment
\-parent’s active participation & resulting reduction of anxiety
\-parent’s increased parental locus of control
\-parents openly acknowledge & normalize stuttering
\-praise demonstrates the child has a choice about how they speak
\-bonding of the parent & child during treatment
\-treatment takes place in the child’s everyday environment
\-reduction in expressive language to more age-appropriate levels
\-focus on the child’s fluent speech may foster the development of an alternative story that is not focused on stuttering
\-parent levels of understanding, learning, & commitment
\-parent’s active participation & resulting reduction of anxiety
\-parent’s increased parental locus of control
\-parents openly acknowledge & normalize stuttering
\-praise demonstrates the child has a choice about how they speak
\-bonding of the parent & child during treatment
\-treatment takes place in the child’s everyday environment
\-reduction in expressive language to more age-appropriate levels
\-focus on the child’s fluent speech may foster the development of an alternative story that is not focused on stuttering
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ASHA’s position concerning treatment for children
\-there is no current insufficient evidenve to support or refute the use of direct over indirect in the treatment of preschool-aged children with fluency disorders
\-at this time it is limited to one study(Franken et al., 2005) in which authors compared speech & parent outcomes of children randomly assigned to the Lidcombe (direct) with DCM (indirect) & no differences in stuttering freq & severity ratings found
\-at this time it is limited to one study(Franken et al., 2005) in which authors compared speech & parent outcomes of children randomly assigned to the Lidcombe (direct) with DCM (indirect) & no differences in stuttering freq & severity ratings found
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direct vs indirect treatment for preschool children who stutter: the RESTART randomized trial
\-age 3-6 August 2003-Dec 2011
\-direct (Lidcombe) program, n=99 CWS
\-indirect (DCM), n=100 CWS
\-> 3% SS, time since onset > 6 mo
\-measures at 3, 6, 12, & 18 mo post tx
\-direct (Lidcombe) program, n=99 CWS
\-indirect (DCM), n=100 CWS
\-> 3% SS, time since onset > 6 mo
\-measures at 3, 6, 12, & 18 mo post tx
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direct vs indirect treatment for preschool children who stutter: the RESTART randomized trial results
\-3 mo: significantly (p< .005) greater decline in % SS for Lidcombe program
\-18 mo: no significant difference for % SS
\-Lidcombe: %SS=1.2% (SD 2.1)
\-DCM: %SS=1.5% (SD 2.1)
\-no difference in the number of treatment sessions & hours
\-lidcombe had slightly better (non significant) scores for: severity ratings by parents, quality of life, speech attitude (KiddyCAT), emotional & behavioral problems
\-18 mo: no significant difference for % SS
\-Lidcombe: %SS=1.2% (SD 2.1)
\-DCM: %SS=1.5% (SD 2.1)
\-no difference in the number of treatment sessions & hours
\-lidcombe had slightly better (non significant) scores for: severity ratings by parents, quality of life, speech attitude (KiddyCAT), emotional & behavioral problems
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direct vs indirect treatment for preschool children who stutter: the RESTART randomized trial conclusions
\-at 18 mo clinical outcomes were comparable & both treatment protocols can be recommended
\-both protocols surpass expectations of natural recovery
\-both protocols surpass expectations of natural recovery
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key qualities of a clinician treating younger speakers
\-understands the nature of stuttering; willing to help child experiment & vary forms of non-fluent speech
\-provides supportive theraputic experience enabling the child to become desensitized to their stuttering
\-allows child to understand & control the basic features of speech-effortless, forward floeing speech
\-obtain the understanding & support of the parents & other important people in the child’s life
\-provides supportive theraputic experience enabling the child to become desensitized to their stuttering
\-allows child to understand & control the basic features of speech-effortless, forward floeing speech
\-obtain the understanding & support of the parents & other important people in the child’s life
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treatment goals for young speakers
\-reduce frequency & change the form of stuttering
\-reduce negative feelings & thoughts about stuttering
\-decrease avoidance
\-involve the parents in altering the child’s environment (consistency, understanding, support)
\-enhance the child’s abilities & enjoyment of verbally communicating
\-reduce negative feelings & thoughts about stuttering
\-decrease avoidance
\-involve the parents in altering the child’s environment (consistency, understanding, support)
\-enhance the child’s abilities & enjoyment of verbally communicating
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choosing a treatment approach
\-be aware of many approaches & techniques
\-each approach will be different depending on the clinician’s: academic/ clinical background, experience, interactive style
\-children will respond in different ways to same treatment
\-no one approach works for all children
\-each approach will be different depending on the clinician’s: academic/ clinical background, experience, interactive style
\-children will respond in different ways to same treatment
\-no one approach works for all children
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when working with children
\-use basic & understandable terms (bumpy, stretched, stuck)
\-model targets (rather than tell)
\-model slow & easy speech
\-model slow & easy body movements
\-reinforce child’s accomplishments & feelings of self-worth
\-model targets (rather than tell)
\-model slow & easy speech
\-model slow & easy body movements
\-reinforce child’s accomplishments & feelings of self-worth
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speech machine
explaining speech:
\-there are a lot of things that have to happen for us to talk
\-we think about what we want to say
\-we breathe (how in depth this depends on age of child)
\-we use our teeth, our lips, & our tongue
\-there are a lot of things that have to happen for us to talk
\-we think about what we want to say
\-we breathe (how in depth this depends on age of child)
\-we use our teeth, our lips, & our tongue
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learning about stuttering
getting the facts about stuttering:
\-types of disfluencies speakers produce (difference between normal & stuttered disfluencies)
\-prevalence of stuttering
\-current ideas about the cause
\-have them research stuttering (famous people who stutter)
\-types of disfluencies speakers produce (difference between normal & stuttered disfluencies)
\-prevalence of stuttering
\-current ideas about the cause
\-have them research stuttering (famous people who stutter)
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speech detective
helps increase self-monitoring skills:
\-have the child try & figure out where your speech machine is getting tight
\-then take turns being detectives
\-have the child try & figure out where your speech machine is getting tight
\-then take turns being detectives
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tight vs loose speech
learning the role of physical tension:
\-tense different parts of the body
\-throw a ball with & without physical tension
goal is for them to develop an awareness of what their muscles feel like when they are too tense or relaxed
\-also teaching them that they can modify the amount of tension in they have in their muscles
\-tense different parts of the body
\-throw a ball with & without physical tension
goal is for them to develop an awareness of what their muscles feel like when they are too tense or relaxed
\-also teaching them that they can modify the amount of tension in they have in their muscles
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selected techniques
decrease:
\-communication disruptors (interruptions, over-talking, distractions, over stimulation)
\-ask fewer (abstract) questions
increase:
\-parents’ slower rate (pausing), turn-taking
\-use analogies (bumpy-smooth/ stretchy, blocked/ open hose)
\-combining forms of play with sound production
\-communication disruptors (interruptions, over-talking, distractions, over stimulation)
\-ask fewer (abstract) questions
increase:
\-parents’ slower rate (pausing), turn-taking
\-use analogies (bumpy-smooth/ stretchy, blocked/ open hose)
\-combining forms of play with sound production
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since we last met…
what have you learned about stuttering:
\-what new question do you have about stuttering
\-what action have you taken this week
\-what new ways have you problem solved
\-what would be a good next step for you (what are some of your “right rocks”
\-what new question do you have about stuttering
\-what action have you taken this week
\-what new ways have you problem solved
\-what would be a good next step for you (what are some of your “right rocks”
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superfluency
\-flexible rate: show child how to slow the initial sounds of a word or syllable
\-easy onsets: emphasize gradual onset of voicing & airflow
\-light contacts: modeling easy articulatory postures
\-proprioception: heightened feedback for articulatory movements & extent of contact (expand from
\-easy onsets: emphasize gradual onset of voicing & airflow
\-light contacts: modeling easy articulatory postures
\-proprioception: heightened feedback for articulatory movements & extent of contact (expand from
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indicators of successful therapy
\-slower rate of repetitions
\-continuation of airflow & voicing
\-easy articulatory contacts
\-smooth transitions through sounds & syllables
\-more participation in communicating
\-continuation of airflow & voicing
\-easy articulatory contacts
\-smooth transitions through sounds & syllables
\-more participation in communicating
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addressing desensitization & cognitive restructuring
\-learn about stuttering
\-learn about other people who stutter
\-explore & learn to tolerate moments of stuttering
\-change negative self-talk
\-self-acknowlegement/ advertising to friends, teacher, and classmates
\-help parents to make stuttering an acceptable topic of discussion
\-parent group meetings are very useful
\-learn about other people who stutter
\-explore & learn to tolerate moments of stuttering
\-change negative self-talk
\-self-acknowlegement/ advertising to friends, teacher, and classmates
\-help parents to make stuttering an acceptable topic of discussion
\-parent group meetings are very useful
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teasing vs. bullying
bullying: conscious effort to hurt or control someone
\-negative effects: lowered self-esteem, depression, loneliness, anxiousness, insecurities, social failure, academic issues
teasing: good natured exchange between friends, no intention to harm
\-negative effects: lowered self-esteem, depression, loneliness, anxiousness, insecurities, social failure, academic issues
teasing: good natured exchange between friends, no intention to harm
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possible effects of teasing & bullying
\-shame: major affect on one’s overall self interpretation
\-teasing is one way in which shame becomes attached to stuttering
\-results in increased stuttering & a high degree of social inhibition
\-60-70% of children who stutter (7-15 yrs) experience this negative treatment
\-the effects may continue into adulthood
\-teasing is one way in which shame becomes attached to stuttering
\-results in increased stuttering & a high degree of social inhibition
\-60-70% of children who stutter (7-15 yrs) experience this negative treatment
\-the effects may continue into adulthood
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developing effective responses to bullying
-distinguish between hurtful & inquisitive comments
\-instruct about the nature of bullying & those who do it
\-role-play activities
\-instruct about the nature of bullying & those who do it
\-role-play activities
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role-playing activities
\-provide child with oppurtunity to vent anger & frustration
\-allows child to become desensitized
\-helps child learn to defuse negative comment
\-possible responses: shrug “I don’t care, so what”, broken record “because I want to”, mighty might “you might be right”, so!
\-allows child to become desensitized
\-helps child learn to defuse negative comment
\-possible responses: shrug “I don’t care, so what”, broken record “because I want to”, mighty might “you might be right”, so!
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when coexisting problems occur
\-recognize that demands for phonological & grammatical processing compete with resources that permit fluent speech
\-organize treatment hierarchy
\-structure intervention with minimum overt feedback
\-determine whether the impairments should be treated concurrently, sequentially, or cyclically
\-organize treatment hierarchy
\-structure intervention with minimum overt feedback
\-determine whether the impairments should be treated concurrently, sequentially, or cyclically
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background information you should obtain
\-environmental information
\-medical history information/ physiological functioning information
\-developmental information
\-psychological information
\-psychosocial information
\-academic information
\-medical history information/ physiological functioning information
\-developmental information
\-psychological information
\-psychosocial information
\-academic information
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environmental factors (background/ case history areas)
\-family composition (size, ages, single parent, extended family, etc.)
\-family history of communication/ other disorders (stuttering, phonology, language, ADHD, neurologic)
\-family interaction patters (communication environment-harmonious, hostile, rushed, inconsistent)
\-family attitudes towards stuttering (upset, intolerant, concerned, secretive, supportive)
\-family attitudes in general (high vs. low expectations, competitive, reward good performance/punish poor)
\-family history of communication/ other disorders (stuttering, phonology, language, ADHD, neurologic)
\-family interaction patters (communication environment-harmonious, hostile, rushed, inconsistent)
\-family attitudes towards stuttering (upset, intolerant, concerned, secretive, supportive)
\-family attitudes in general (high vs. low expectations, competitive, reward good performance/punish poor)
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medical/ physiological factors (background/ case history areas)
\-maternal health/ pregnancy (general health, Rh incompatibility, diabetes, drugs, toxins, trauma)
\-birth/delivery (prematurity, delivery difficulties, fetal hypoxia, Apgar scores)
\-diseases/ accidents (extended high fevers, convulsions, head trauma, head/ nech surgery)
\-motor or intellectual impairments (verbal dyspraxia, dysarthria, down syndrome, MD, CP)
\-developmental milestones (cognitive, motor, speech/ language)
\-birth/delivery (prematurity, delivery difficulties, fetal hypoxia, Apgar scores)
\-diseases/ accidents (extended high fevers, convulsions, head trauma, head/ nech surgery)
\-motor or intellectual impairments (verbal dyspraxia, dysarthria, down syndrome, MD, CP)
\-developmental milestones (cognitive, motor, speech/ language)
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psychological/ psychosocial factors (background/ case history areas)
\-general demeanor (happy, depressed, introvert or extrovert, perfectionistic)
\-distractibility (hyperactive, ADHD, impulsive, calm)
\-self-perception (low self esteem, confident, positive, hypercritical)
\-attitude towards failure (competitive, goal-setter, defeatist)
\-social interaction pattern (shy/ withdrawn, open/ out-going, reclusive, easily rebuffed, submissive, aggressive)
\-locus of control (internal control/ self-responsibility vs. external control/ denial of responsibility)
\-distractibility (hyperactive, ADHD, impulsive, calm)
\-self-perception (low self esteem, confident, positive, hypercritical)
\-attitude towards failure (competitive, goal-setter, defeatist)
\-social interaction pattern (shy/ withdrawn, open/ out-going, reclusive, easily rebuffed, submissive, aggressive)
\-locus of control (internal control/ self-responsibility vs. external control/ denial of responsibility)
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academic/ psycholinguistic factors (background/ case history areas)
\-performance in each academic area (reading, language arts, math, etc.)
\-communicative patterns in classroom (when reading aloud, presentations, asking questions, answering questions, voluntary attempts at speaking)
\-interpersonal communication patterns at school (loner, shy/ withdrawn, leader, etc)
\-special services (receiving special education sevices for any identified disability)
\-extra-curricular activities (number, type, activites, offices held, etc)
\-communicative patterns in classroom (when reading aloud, presentations, asking questions, answering questions, voluntary attempts at speaking)
\-interpersonal communication patterns at school (loner, shy/ withdrawn, leader, etc)
\-special services (receiving special education sevices for any identified disability)
\-extra-curricular activities (number, type, activites, offices held, etc)
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information you should obtain from direct examination/ assessment
\-oral mechanism function information
\-respiratory function information
\-phonatory (laryngeal) function information
\-phonological (articulatory) function information
\-language function information
\-fluency/ stuttering measures
\-stuttering awareness/ perceptual/ attitudinal information
\-be able to identify tests/ assessment instruments discussed in class (TOCS, SSI, CAT, OASES, S-24, PSI, & LCBSS)
\-respiratory function information
\-phonatory (laryngeal) function information
\-phonological (articulatory) function information
\-language function information
\-fluency/ stuttering measures
\-stuttering awareness/ perceptual/ attitudinal information
\-be able to identify tests/ assessment instruments discussed in class (TOCS, SSI, CAT, OASES, S-24, PSI, & LCBSS)
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oral mechanism evaluation (specific eval areas, info obtained from direct examination/ assessment)
\-presence/ absence of structural defects or anomalies (possible syndrome linkage)
\-diadochokinetic rate (for individual oral structures & sequenced in production of nonsense syllables)
\-overall range/ accuracy/ symmetry of motion
\-diadochokinetic rate (for individual oral structures & sequenced in production of nonsense syllables)
\-overall range/ accuracy/ symmetry of motion
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respiration (specific eval areas, info obtained from direct examination/ assessment)
(often assessed via reading passage/ monologue)
\-adequacy if respiratory support for speech (clavicular/ sternal pattern vs thoracic/ abdominal)
\-efficiency of breath management during speech (appropriate pause/ replenishment pattern, speaking on reserve air, ingressive phonation, etc)
\-loudness/ duration (monotone, monoloudness, excessive or inadequate intensity, excessive intensity variation, prosody/ intonation)
\-adequacy if respiratory support for speech (clavicular/ sternal pattern vs thoracic/ abdominal)
\-efficiency of breath management during speech (appropriate pause/ replenishment pattern, speaking on reserve air, ingressive phonation, etc)
\-loudness/ duration (monotone, monoloudness, excessive or inadequate intensity, excessive intensity variation, prosody/ intonation)
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phonation (specific eval areas, info obtained from direct examination/ assessment)
(often observed during a reading passage or monologue)
\-efficiency of laryngeal valving (overall adequacy of phonatory coordination with respiration, articulation, prosody, air wastage before initiation or during blocks)
\-vocal initiation pattern (hard glottal attacks, soft/ gentle or prolonged onset, etc)
\-vocal quality (presence of harshness, hoarseness, or breathiness, excessive perturbation/ variation)
\-pitch (appropriate for age/ sex or excessively high/ low, excessive variation, monopitch, correlation between pitch & tension/ anxiety)
\-intensity (loudness control throughout utterance)
\-efficiency of laryngeal valving (overall adequacy of phonatory coordination with respiration, articulation, prosody, air wastage before initiation or during blocks)
\-vocal initiation pattern (hard glottal attacks, soft/ gentle or prolonged onset, etc)
\-vocal quality (presence of harshness, hoarseness, or breathiness, excessive perturbation/ variation)
\-pitch (appropriate for age/ sex or excessively high/ low, excessive variation, monopitch, correlation between pitch & tension/ anxiety)
\-intensity (loudness control throughout utterance)
Note 
Flashcards (56)