Intensive instruction of speech modification skills helping clients who stutter make speech change
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Intensive Instruction of Speech Modification Skills: Helping Clients Who Stutter Make Speech Change. Lisa Scott, PhD CCC-SLP Florida State University [email protected] 2010 Kansas Speech-Language-Hearing Assocation Convention October 1, 2010

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Intensive instruction of speech modification skills helping clients who stutter make speech change

Intensive Instruction of Speech Modification Skills: Helping Clients Who Stutter Make Speech Change

Lisa Scott, PhD CCC-SLP

Florida State University

[email protected]

2010 Kansas Speech-Language-Hearing Assocation Convention

October 1, 2010

*Based on information from the Stuttering Foundation of America video , Basic Clinical Skills (2007) – information used with permission


Practice materials

Practice Materials

Draw a picture of the speech system that includes:

Diaphragm

Lungs

Trachea

Vocal cords/larynx

Tongue

Some teeth

Palate

Lips

Jaw

Eyes


25 words your interest s

25 Words: Your Interest(s)


Lisa scott phd ccc slp florida state university lscott fsu

100%

50%

25%


Williams normal talking model

Williams’ Normal Talking Model

  • Discussed/developed by Dean Williams

    • University of Iowa researcher and clinician

    • Was a student of Wendell Johnson

    • Stuttered

    • Very gifted clinician with children

  • Characteristic of University of Iowa clinicians

    • The faculty there, in the early days of the department, were trained as semanticists

    • Believed in power of words, as a result

    • Johnson, Williams, and others emphasized the use of “doing” language

      • What are you doing vs. what is happening

      • If you are doing something, you then have a choice to do something else


Making choices

Making Choices

  • Changing speech and stuttering means understanding that there are choices for talking

  • Introducing choices needs to be done in a learning hierarchy

    • General steps in any hierarchy (steps can be used for documentation)

      • Clinician models/client observes

      • Clinician and client practice together

      • Client tries the tool/teaches clinician how to produce it

      • Client practices the tool with clinician feedback

      • Client practices and provides own feedback together with clinician

      • Client practices the behavior and self-monitors

    • Transfer activities and any homework should correspond to and be co-occurring at each level of the hierarchy


Williams normal talking model1

Williams’ Normal Talking Model

  • Normal talking happens when:

    • Air from the lungs causes the vocal folds to vibrate (airflow)  

    • The vocal folds need to vibrate when airflow is started (voicing).

    • Proper tensing is necessary for normal speech (tension).

    • Proper timing between the speech systems is necessary for normal speech (timing).

    • Sounds are moved with smooth movements between sounds and words (movement).


Lisa scott phd ccc slp florida state university lscott fsu

  • Stuttering happens when the person who stutters does something that interferes with the normal talking process

    • If the person is doing something, there can be a choice to do something else

    • The trick is figure out is where the person is interfering


Step 1 exploring talking

Step 1: Exploring Talking

  • In order to understand what happens during stuttering, the client must understand how speech is produced

    • Establishes common terminology between client and clinician

    • Develops understanding of how respiration, phonation & articulation work together for speech

    • Reinforces that his/her speech system is “normal”


Lisa scott phd ccc slp florida state university lscott fsu

  • Rationale for this step

    • Starting treatment in a way that is removed from emotion: neutral and objective

    • Encouraging client to approach something that he/she fears and is used to avoiding


Lisa scott phd ccc slp florida state university lscott fsu

  • Possible activities for Exploring Talking

    • Use an age-appropriate diagram of the speech system

      • Google Images

      • Commercially available materials

      • Make a “speech machine” (Chmela & Reardon, 2001)

    • Discuss each component of the model

      • Customize to client’s age/level of cognitive development


Lisa scott phd ccc slp florida state university lscott fsu

  • Begin experimenting with change

    • Follow the hierarchy mentioned on the making choices slide (#3)

    • Concepts – too much, just right, too little

      • Make a strip with 10 squares and number 1-10

        • Helps develop awareness of different levels

      • Use a triangle -- Hard/as much as you can; half as much; half as much again

    • Discuss how it feels in your own body

    • Grade/rate one another


Documentation exploring talking

Documentation:Exploring Talking

  • Using a diagram, client will label at least 3 components of the speech production system

  • When prompted by the clinician, the client will describe the contribution of X components of the speech system to speech production

  • When modeled by the clinician (or prompted), the client will demonstrate at least 3 levels of variation in ________ (airflow, tension, voice onset, etc.)

  • After producing 10 target words, the client and clinician will rate (airflow, tension, voice onset, etc.) each production using a 1-10 scale and achieve at least 90% agreement.


Step 2 exploring stuttering

Step 2: Exploring Stuttering

  • Identify aspects of stuttering

    • In order to change behavior, the client needs to know when andwhat to change

  • Use the change hierarchy (slide #3) to experiment with change

  • Working through the change hierarchy helps the child to reduce worry and fear about speaking and stuttering (desensitization)

  • Exploring stuttering ties information from exploring talking to child’s own behavior/speech patterns


Lisa scott phd ccc slp florida state university lscott fsu

  • Clients begin to vary talking and stuttering as a basis for making choices

    • Begin to voluntarily manage speech by changing it in some way

    • It may never have occurred to the child that there’s a different way to stutter – his/her stuttering doesn’t have to occur in the same way it always has


Lisa scott phd ccc slp florida state university lscott fsu

  • Occurs through

    • Modeling

    • Implementing change hierarchies

    • Reducing worry and fear (desensitization)

  • Important to remember that this needs time and practice, and should reoccur throughout the entire course of therapy


Lisa scott phd ccc slp florida state university lscott fsu

  • Activities for this step:

    • Educate about the various ways to stutter

    • Discriminate how different types of stuttering fit the various aspects of the model

      • Play around with various types of stuttering

      • Discuss how it feels in my body/your body

      • Using the 1-10 strip

      • Strangest stutters

      • Grading/rating ability to stutter

      • Teach others to stutter


Documentation exploring stuttering

Documentation: Exploring Stuttering

  • When observing the clinician, the client will identify at least one way that he/she interferes with speech production that results in a stutter.

  • When prompted by the clinician, the client will vary X component of William’s Normal Talking Model to produce ______ (type of stuttering).

  • When prompted by the clinician, the client will vary (tension, airflow, movement, etc) during production of a __________ (type of stuttering).


Applying williams model to speech modification tools

Applying Williams’ Model to Speech Modification Tools

  • Changing Talking

    • Soft starts/easy onsets/light contacts

      • Components of the model addressed: ALL

    • Changing rate

      • Components of the model addressed: tension, movement, timing

  • Changing Stuttering

    • Voluntary stuttering

      • Components of the model addressed: ALL

    • Holding & tolerating a moment of stuttering:

      • Components of the model addressed: ALL

    • In-block corrections/pullouts

      • Components of the model addressed: tension, phonation, movement, timing

    • Post-block corrections/cancellations

      • Components of the model addressed: ALL


Changing talking soft starts easy onset light contacts

Changing TalkingSoft Starts/Easy Onset/Light Contacts

  • What is it?

    • Slower, physically relaxed speech starts

    • Decreased muscle tension: opposite of stuttering

  • Why use it?

    • Helps initiate smooth airflow and voicing

  • When to use it?

    • Beginnings of phrases or utterances

    • Phrase boundaries


Changing talking changing rate

Changing Talking:Changing Rate

  • What is it?

    • Slower speech overall: fewer syllables or words per minute

    • Should sound smooth and connected, not choppy

  • Why use it?

    • It’s fluency enhancing because it…

      • Helps client better attend to what he/she is doing

      • Gives more time to process

      • Gives client time to make changes in complex motor coordination

      • Helps client feel changes in muscle tension

  • How can rate be changed?

    • Stretching sounds or syllables, phrasing and pausing

    • Combining stretches with phrasing/pausing


Changing stuttering deliberate or voluntary stuttering

Changing Stuttering:Deliberate(orVoluntary) Stuttering

  • What is it?

    • The client stutters on purpose, choosing when and how

  • Why use it?

    • Can be used to teach any aspect of changing and varying stuttering

    • Assists in building awareness of stuttering moments

    • Decreases fear and avoidance of stuttering

    • Desensitizes to listener reactions

    • Creates a feeling of confidence in the ability to say feared words

    • Confront what might otherwise be avoided

  • When and how to use it?

    • Prelude to using pullouts

    • Begin teaching at the single word level with unfeared sounds or words

    • Begin using it in unfeared situations

    • Build to use on feared words or in feared situationss


Changing stuttering holding tolerating a moment of stuttering

Changing Stuttering:Holding & Tolerating A Moment of Stuttering

  • What is it?

    • Staying in a moment of stuttering

    • Keeps the sound going rather than stopping and backing up

  • Why use it?

    • Increases awareness of what client is doing during the stuttering moment

    • Helps reduce avoidances

    • Is desensitizing

  • When and how to use it?

    • After client can identify when and how he/she is stuttering

    • Clinician HAS to be supportive and encouraging as the client is holding the stuttering moment


Changing stuttering pullouts in block correction

Changing Stuttering: Pullouts (In-Block Correction)

  • What is it?

    • Hold onto the stuttering moment and stay with it

    • Focus in on where tension is and where movement is stopped

    • Then, change the stutter by reducing tension and moving ahead slowly into next sound or word

  • Why use it?

    • Take conscious control of and confront the stuttering moment (desensitization)

    • Release tension and keep speech moving forward

    • Reinforce a looser way of stuttering

  • When & how to use it?

    • When there is a high degree of emotionality or “trapped” feeling

    • After learning to hold onto a stuttering moment and tolerate it

    • Start with deliberate or “fake” (voluntary) stuttering at the single word level


Changing stuttering cancellation post block correction

Changing Stuttering:Cancellation (Post-Block Correction)

  • What is it?

    • Finishing a stuttered word

    • Pausing for a moment to plan (e.g. pantomime or silently revisit the word) then

    • Stuttering on the word again in an easier way

  • Why use it?

    • Learn to “cancel out” or replace hard stuttering with a looser, more controlled form of stuttering

    • Discourages avoidance behaviors such as recoiling, changing words, stopping in a block and backing up

    • Reinforces easier stuttering and build confidence

  • When and how to use it?

    • MUST complete the hard stutter before pausing and making it easier

    • If unable to pullout or missed the opportunity to use a pullout, this provides another opportunity to learn to stutter more easily

    • Typically used in the therapy room only, not in the outside world


Lisa scott phd ccc slp florida state university lscott fsu

  • How can Williams’ Normal Talking Model help you document change as a result of therapy?

    • Consider the type of stuttering the client is currently exhibiting

    • If the client is able to change the moment of stuttering, what is he/she adding in that wasn’t there before?

      • In other words, why might a prolongation or part-word repetition be a “better” type of stuttering for the client?

      • Why would you want to represent progress in this way?


Lisa scott phd ccc slp florida state university lscott fsu

  • Possible documentation

    • When prompted by the SLP, the child will name and describe at least 3 components of Williams’ Normal Talking Model.

    • When prompted by the SLP, the child will demonstrate varying levels of airflow (tension) (movement) and associate them with fluent and stuttered speech production in at least 5 opportunities.

    • When prompted by the SLP, the child will change a stutter to increase forward flow of speech by changing (airflow, tension, phonation, movement, timing) in 4/5 opportunities.


References

References

Chmela, K., & Reardon, N. (2001). The school-age child who stutters: Working effectively with emotions and attitudes…A workbook. Memphis, TN: Stuttering Foundation of America.

Cook, F. and Fry, J. (2006) Connecting stuttering measurement and management: III. Accountable therapy. International Journal of Language and Communication Disorders, 41, 379-394

Dell, C. (2000). Treating the school age child who stutters: A guide for clinicians (2nd edition). Memphis, TN: Stuttering Foundation of America.

Fraser, J. (Ed.) (2000). Stuttering therapy: Transfer and maintenance. Memphis, TN: Stuttering Foundation of America.

Gregory, H. H. (2003). Stuttering therapy: Rationale and procedures. Boston: Allyn & Bacon.

Guitar, C., & Fraser, J. (2007). Basic clinical skills (DVD). Memphis, TN: Stuttering Foundation of America.

Guitar, C., & Fraser, J. (2006). The genius of Dean Williams. Memphis, TN: Stuttering Foundation of America.

Ramig, P.R., & Dodge, D.M. (2005). The child and adolescent stuttering treatment and activity resource guide: Clifton Park, NY:Thomson/Delmar/Singular.

Sheehan, J. G. (1970). Stuttering: Research and therapy. New York: Harper & Row.

Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall.

Zebrowski, P. M., & Kelley, E. (2002). Manual of stuttering intervention. Clifton Park, NJ: Singular.


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