I received three calls in October and November from parents looking for help with cluttering. I had to tell them I have not treated cluttering per se, however, given my experience with stuttering and other speech/language issues I felt qualified to provide such treatment. Two of the callers moved on. One visited with me this week, which prompted me to review all the possible scenarios that might evolve when this new student walked through my door. For cluttering, there are many.
The ASHALeader article by St. Loius et. al. (11) describes assessment and treatment in a practical way for the clinician seeking to make the best use of the brief amount of time normally available for an evaluation. Cluttering can present with a constellation of symptoms to be teased apart in differential diagnosis. “One especially frustrating problem is that people with the disorder frequently do not clutter, for example, when they speak in a short screening evaluation.” (11, p.1) The SLP must select speech/language tasks that will reveal fluency, articulation, linguistic, and pragmatic problems that identify cluttering in particular. Conducting an evaluation in more than one session is recommended.
Knowing that “…rate problems are somehow central to cluttering” (11, p.2), it becomes important to video tape, transcribe, and calculate speech rates for a variety of speaking tasks. I happen to have the APAT (9) and therefore I chose a few tasks from this test. St. Loius et. al. recommend several tasks and provide data:
“Average conversational rates for normal preschoolers are reported to range from 110-180 SPM; for elementary aged children from 140-200 SPM; and for adults from 180 – 220 SPM.” (11, p.3) [see Sturm & Seery (10)] However, rate data alone must be supplemented by a description of pausing and phrasing. “While people who clutter sound like they are speaking too fast, the fact is they actually end up speaking slower than normal due to their rapid runs of speech being interrupted by long pauses.” (7, p.7) There is “…the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints…”(8) “Cluttering is fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rates may not exceed normal limits). (8)
Those of us well versed in stuttering issues will easily recognize the clutterer’s use of “an excessive number of disfluencies, the majority of which are not typical of people who stutter.” (8) Dewey lists these disfluencies in his personal story (5). I highly recommend Dewey’s well-organized, intimate essay as a take-home for parents as well as teen age students and adults. It can serve as an introduction to cluttering during an assessment and it could provide a point of reference throughout a treatment program.
Rapid rate (bursts of speech) and disfluency combine with articulation errors to result in speech which is difficult to understand. These errors will be familiar to the SLP. We have listened to a variety of articulation patterns that have been analyzed and re-analyzed according to the philosophies of the most popular university professors of the day. We’ve read debates over whether apraxia is a language or speech/language disorder, whether articulation disorders are functional, phonologically based or motoric in nature. SLPs are familiar with sound errors found in reading and spelling disorders. Analysis of the speech sample will not be unfamiliar. St. Louis, et. al. recommend using Systematic Disfluency Analaysis (11) which would result in a very detailed description. I imagine there are other methods of close transcription. Speech and writing samples generously shared by Peter Kissagizlis are found in his 2009 ISAD paper (8). We can listen to Dewey’s speech as well. (5)
Of course, as I read the latest news about cluttering, I question how many of my previous students presented with cluttering in addition to their stuttering. I have observed stuttering resolve by way of normal disfluencies and St. Louis makes note of this stuttering-cluttering relationship. “Moreover, cluttering is often noticed before the stuttering takes over during development of the disorders and after stuttering is treated successfully, but not while a person manifests significant stuttering.” (11, p.1) I have not recommended stuttering therapy in some cases of preschoolers who were very dysfluent but not stuttering and I’ve done a lot of language work with school children as part of their stuttering treatment. Maybe this is why.
I’m left wondering if treating cluttering may be easier than assessing it. My new client performed well for a variety of video taped speech samples. He completed the PCI with a score too low for a cluttering diagnosis. This leads us to a crucial aspect of cluttering and of cluttering assessment: “…the evaluation process must be long enough so the person doesn’t get that chance to consistently normalize. The clinician should carry out a number different speaking tasks in therapy, repeating them from time to time. Eventually, individuals will let down their guard, and the cluttering will appear. In addition, clutterers “are usually unaware of their disfluencies and misarticulations…” (3, p.1)
Given what we know about cluttering AND as a specialist who has been asked for a second opinion consult AND presented with somewhat good quality speech and language in a 60 minute initial visit AND a self report PCI score below 80 I DO NOT report that cluttering is not present in this case.
What next? Hopefully this student will be more spontaneous at the next visit as I challenge him with more complex linguistic material and ask for more in depth, extemporaneous opinions about familiar and unfamiliar topics in monologue and conversation. When I complete the PCI, it may score above 80. Assuming this student is coming to me for a diagnosis of cluttering and recommendations for speech therapy, it will be up to him to choose whether or not to reveal the communication problems that brought him to my door. Then we will discover it together by watching the video we make at his next session.
(1) Daly, D. (1993) “Cluttering: The Orphan of Speech-Language Pathology” American Journal of Speech Language Pathology, Vol. 2, pp 6-8
(2) Daly, D. (1996) The Source for Stuttering and Cluttering, East Moline, IL: LinguiSystems, Inc.
(3) Daly, D. (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10/daly10.html
(4) Daly, D. (2006) Predictive Cluttering Inventory (PCI) http://www.mnsu.edu/comdis/isad10/papers/daly10/dalycluttering2006R.pdf
(5) Dewey, J. (2005) “My Experiences with Cluttering” http://www.mnsu.edu/comdis/isad8/papers/dewey8.html
(6) Kleiman, L. (2003) Functional Communication Profile Revised: Assessing Commuicative Effectiveness with Clients with Developmental Delays, East Moline, IL: LinguiSystems
(7) Mosheim, J. (2004) “Cluttering: Specialists work to put it on the map of fluency disorders” advance for Speech-Language Pathologists & Audiologists, November 22, pp. 6-9
(8) Myers, F. & Kissagizlis, P. (2009) “Putting Cluttering on the World Map: Formation of the International Cluttering Association (ICA)” http://www.mnsu.edu/comdis/isad10/papers/myers10.html
(9) Ross-Swain, D. & Long, N. (2004) Auditory Processing Abilities Test (APAT), Novato, CA: Academic Therapy Publications
(10) Sturm, J & Seery, C. (2007) “Speech and Articulatory Rates of School-Age Children in Conversation and Narrative Contexts, Language, Speech, and Hearing Services in Schools, Vol 38, pp. 47-59.
(11) St. Louis, K. et al (2003) “Cluttering Updated” the ASHALeader, pp. 4-5, 20-22
(12) St. Louis, K. & Meyers, F. ( ) Cluttering www.stutteringhelp.org
(13) International Cluttering Association, http://associations.missouristate.edu/ICA/
11/26/09
10/17/09
FEAR
Rapid/shallow breathing, a ‘racing’ heart, light headedness, weakness in the legs, nausea, sweaty palms and fearful expression are physical symptoms created by the Sympathetic Nervous System (6). These symptoms occur when the body feels a need to fight or to run away. And this is called ‘the fight or flight response.’ Many of us experience these unpleasant symptoms during times of stress and fear.
Butterflies in the stomach and other symptoms of fear are the result of signals coming down the spinal cord from the Limbic System deep inside our brains (7). One of the brain structures within the Limbic System is called the amygdala. The amygdala “has long been associated with emotion, especially fear…nerve fibers from the amygdala project into the upper brain regions that control the release of stress hormones…when a person perceives a threat, alarms go off in the brain, causing arousal, hypervigilance…the fight or flight response.” (8)
The brain learns and remembers fear. “…research suggests that it takes only one terrifying experience for a lifelong emotional memory to be put into place that is extremely difficult to erase, because the ‘thinking’ part of the brain is ‘out of the loop’ when the fear-related memory is formed…many fearful situations are experienced, learned, and unconsciously committed to emotional memory without people being aware of the initial fear trigger…not being able to pinpointing the cause of their fear leads to a feeling of being weak and helpless.” (9)
Betty Horwitz, in her book Communication Apprehension, further describes several sources of fear. Innate fear are intrinsic reactions that cause an animal to withdraw, attack, become immobile or call for help. As an example she sites a fear of staring eyes and writes that disapproving looks can trigger innate fear. Conditioned fear is learned after repeated experiences in a specific circumstance, such as interactions with a critical authority figure. Unfamiliar event fear is somewhat self-explanatory. Freezing and avoidance are common fear reactions to unfamiliar situations. Fear of the unfamiliar transforms into anxiety with increasing age and social phobias can appear in adolescence.
What relevance does this all have to stuttering? Speech therapy for children includes activities intended to prevent and/or reduce communication apprehension – fear of speaking. Speech therapy for teens and adults includes activities intended to reduce communication anxiety already established by years of painful experience and avoidance behavior.
Recent research related to stuttering refers to two types of anxiety: “Trait anxiety refers to a person’s inherent level of anxiety and state anxiety, referring to a condition or situation-specific anxiety.” (2)
In any given situation, a person’s perception of danger and his ability to cope affects anxiety. One theory proposes four different types of situation anxiety: social evaluation, physical danger, ambiguity, and daily routines. A person may respond differently to each of these four kinds of situations. A person with a high level of trait anxiety may become exceedingly anxious in a situation of social evaluation, but feel quite capable of coping with a dangerous situation. This person would experience a higher level of situation anxiety in, let’s say, public speaking, than in conflict.
“The association between stuttering and anxiety has been robustly debated over the years…” (1) Some researchers have viewed anxiety as “the main cause of the disorder…as a mediating variable…as a by-product of stuttering…as a general stress trait…as a state condition related to communication in general and to speech communication in particular.” (3) Research into anxiety in persons who stutter has been done using self-report questionnaires. The Inventory of Interpersonal Situations, one such questionnaire, appeared in the appendix of one such study. (4)
Results suggest that many adults who stutter do have higher levels of trait anxiety than fluent speakers. Is this characteristic of some persons who stutter since childhood? I don’t think anyone knows the answer to that. However, trait anxiety can increase over time for the person who stutters. When I meet with a child who stutters who appears to have substantial trait anxiety, I immediately include conversation to address this issue in an attempt at prevention.
State anxiety is greater during social communication, which seems like a no-brainer. But, it was interesting to read one reason why: “Anxiety has an effect on human performance, which is expressed in qualitative changes in performance and strong muscle activation…Nonautomatic actions that need attention can be harmed by anxiety…In the process of producing speech there are automatic factors, such as the semantic selection, the syntax, and phonology. However, the phonetic stage that plans the articulation and the motor control are not automatic and require attention…All of these factors can explain the relationship between anxiety and stuttering severity…” (5)
Therefore, it makes sense to include treatment for anxiety as part of a total therapy program, even if that means referral to a specialist in anxiety disorders.
I would like to close with a more philosophical perspective. I am in chapter 2 of a book (10) that quotes Martin Luther King in his 1963 book The Strength to Love, “In these days of catastrophic change and calamitous uncertainty, is there anyone who does not experience the depression and bewilderment of crippling fear…?” King describes courage as “the strength of mind capable of conquering whatever threatens attainment of the highest good.” Fear has an insidious way of paralyzing us and we doubtless have justifications for this to be so. Persons who stutter have good reason to be fearful and clinicians perhaps need to reach beyond the physiological into the philosophical in order to be helpful.
Courage may need to be the topic of a new blog entry.
(1) Craig, A. et al (2003) Anxiety Levels in People Who Stutter: A Randomized Population Study, Journal of Speech, Language and Hearing Research, Vol. 46, p. 1197.
(2) Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, p.136.
(3) Ibid
(4) Kraaimaat, F.W., et al (2002) Stuttering and social anxiety, Journal of Fluency Disorders, Vol 27, pp 319-331.
(5) Ezrati-Vinacour, p.144
(6) http://faculty.washington.edu/chudler/auto.html
(7) http://health.howstuffworks.com/human-nature/emotions/other/laughter4.htm
(8) Betty Horwitz (2002) Communication Apprehension: Origins and Management, Albany, NY: Singular/Thompson Learning, p. 29-30
(9) Ibid. p. 31
(10) Rev. Scotty McLennan (2009) Jesus was a Liberal: Reclaiming Christianity for All, NY, NY: Palgrave MacMillan, p. 40.
Butterflies in the stomach and other symptoms of fear are the result of signals coming down the spinal cord from the Limbic System deep inside our brains (7). One of the brain structures within the Limbic System is called the amygdala. The amygdala “has long been associated with emotion, especially fear…nerve fibers from the amygdala project into the upper brain regions that control the release of stress hormones…when a person perceives a threat, alarms go off in the brain, causing arousal, hypervigilance…the fight or flight response.” (8)
The brain learns and remembers fear. “…research suggests that it takes only one terrifying experience for a lifelong emotional memory to be put into place that is extremely difficult to erase, because the ‘thinking’ part of the brain is ‘out of the loop’ when the fear-related memory is formed…many fearful situations are experienced, learned, and unconsciously committed to emotional memory without people being aware of the initial fear trigger…not being able to pinpointing the cause of their fear leads to a feeling of being weak and helpless.” (9)
Betty Horwitz, in her book Communication Apprehension, further describes several sources of fear. Innate fear are intrinsic reactions that cause an animal to withdraw, attack, become immobile or call for help. As an example she sites a fear of staring eyes and writes that disapproving looks can trigger innate fear. Conditioned fear is learned after repeated experiences in a specific circumstance, such as interactions with a critical authority figure. Unfamiliar event fear is somewhat self-explanatory. Freezing and avoidance are common fear reactions to unfamiliar situations. Fear of the unfamiliar transforms into anxiety with increasing age and social phobias can appear in adolescence.
What relevance does this all have to stuttering? Speech therapy for children includes activities intended to prevent and/or reduce communication apprehension – fear of speaking. Speech therapy for teens and adults includes activities intended to reduce communication anxiety already established by years of painful experience and avoidance behavior.
Recent research related to stuttering refers to two types of anxiety: “Trait anxiety refers to a person’s inherent level of anxiety and state anxiety, referring to a condition or situation-specific anxiety.” (2)
In any given situation, a person’s perception of danger and his ability to cope affects anxiety. One theory proposes four different types of situation anxiety: social evaluation, physical danger, ambiguity, and daily routines. A person may respond differently to each of these four kinds of situations. A person with a high level of trait anxiety may become exceedingly anxious in a situation of social evaluation, but feel quite capable of coping with a dangerous situation. This person would experience a higher level of situation anxiety in, let’s say, public speaking, than in conflict.
“The association between stuttering and anxiety has been robustly debated over the years…” (1) Some researchers have viewed anxiety as “the main cause of the disorder…as a mediating variable…as a by-product of stuttering…as a general stress trait…as a state condition related to communication in general and to speech communication in particular.” (3) Research into anxiety in persons who stutter has been done using self-report questionnaires. The Inventory of Interpersonal Situations, one such questionnaire, appeared in the appendix of one such study. (4)
Results suggest that many adults who stutter do have higher levels of trait anxiety than fluent speakers. Is this characteristic of some persons who stutter since childhood? I don’t think anyone knows the answer to that. However, trait anxiety can increase over time for the person who stutters. When I meet with a child who stutters who appears to have substantial trait anxiety, I immediately include conversation to address this issue in an attempt at prevention.
State anxiety is greater during social communication, which seems like a no-brainer. But, it was interesting to read one reason why: “Anxiety has an effect on human performance, which is expressed in qualitative changes in performance and strong muscle activation…Nonautomatic actions that need attention can be harmed by anxiety…In the process of producing speech there are automatic factors, such as the semantic selection, the syntax, and phonology. However, the phonetic stage that plans the articulation and the motor control are not automatic and require attention…All of these factors can explain the relationship between anxiety and stuttering severity…” (5)
Therefore, it makes sense to include treatment for anxiety as part of a total therapy program, even if that means referral to a specialist in anxiety disorders.
I would like to close with a more philosophical perspective. I am in chapter 2 of a book (10) that quotes Martin Luther King in his 1963 book The Strength to Love, “In these days of catastrophic change and calamitous uncertainty, is there anyone who does not experience the depression and bewilderment of crippling fear…?” King describes courage as “the strength of mind capable of conquering whatever threatens attainment of the highest good.” Fear has an insidious way of paralyzing us and we doubtless have justifications for this to be so. Persons who stutter have good reason to be fearful and clinicians perhaps need to reach beyond the physiological into the philosophical in order to be helpful.
Courage may need to be the topic of a new blog entry.
(1) Craig, A. et al (2003) Anxiety Levels in People Who Stutter: A Randomized Population Study, Journal of Speech, Language and Hearing Research, Vol. 46, p. 1197.
(2) Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, p.136.
(3) Ibid
(4) Kraaimaat, F.W., et al (2002) Stuttering and social anxiety, Journal of Fluency Disorders, Vol 27, pp 319-331.
(5) Ezrati-Vinacour, p.144
(6) http://faculty.washington.edu/chudler/auto.html
(7) http://health.howstuffworks.com/human-nature/emotions/other/laughter4.htm
(8) Betty Horwitz (2002) Communication Apprehension: Origins and Management, Albany, NY: Singular/Thompson Learning, p. 29-30
(9) Ibid. p. 31
(10) Rev. Scotty McLennan (2009) Jesus was a Liberal: Reclaiming Christianity for All, NY, NY: Palgrave MacMillan, p. 40.
9/5/09
Phonological Awareness: An ASHA How-To Journal Article
This is one of many articles published by the American Speech Language Hearing Association that make surfing the professional journals really worth my time. Phonological Awareness Intervention: Beyond the Basics (1) by C. Melanie Schuele and Donna Boudreau is the peer-reviewed article that speech-language patholgists (SLPs) need to guide and justify their instructional practices. This article is thorough in every sense of the word. There is background, justification for the role of the SLP in literacy intervention, definitions of terms, and step-by-step direction in how to teach phonological awareness skills. This article belongs in the personal reference materials of any SLP working with children.
This article is full of easy-to-read figures and tables that itemize key points. Table 8 on page 14-15 is a page and a half of an actual dialogue between adult and child ! There are 4 ½ pages of references for anyone looking for additional material.
There are so many jewels in this article; however, I will highlight only one here. An example of how this is an article about how to teach, here is a quote from page 10: “Learning is best characterized not by moving a child from 20% correct to 50% correct to 100% correct, but by moving a child from successful performance with maximal support to successful performance with little or no support.” This is so true for speech therapy for stuttering, in my opinion. Parents are eager to know when a child will become more fluent in the most excitable, linguistically challenging situations. Parents need to understand that this will only begin to happen when they provide maximal supports. They must take the initiative to CHANGE THE SPEAKING SITUATION - NOT CHANGE THE CHILD. This is maximal support.
In speech therapy for stuttering, we are looking to make speech and language more efficient. What are we going to actually do in a speech therapy session? Many years ago, we focused on the length and complexity of utterance. We trained speech tools at the syllable, then single word, then phrase, then sentence levels. Now, we can approach therapy activities is a more sophisticated way by embedding phonological awareness training and other literacy skills into our sessions.
“Several critical reviews of the general efficacy of phonological awareness instruction and intervention have provided conclusive evidence that phonological awareness can be improved through instruction and intervention, and improvement in phonological awareness leads to improvement in word decoding…reading researchers have called on practitioners to provide intervention to children with poor phonological awareness as early as kindergarten…to provide phonological awareness intervention to older students who demonstrate poor reading achievement in word decoding skills.” P. 3
Many of our students have additional difficulties, such as articulation and language delays/disorders and dyslexia. We can embed emergent literacy tasks nto our speech therapy activities for the sake of prevention as well as remediation for all of our clients at some point in their therapeutic journeys.
Thank you ASHA.
(1) Schuele, C.M. & Boudreau, D. (2008) Language Speech Hearing Services in Schools, Vol. 39, pp 3-20.
This article is full of easy-to-read figures and tables that itemize key points. Table 8 on page 14-15 is a page and a half of an actual dialogue between adult and child ! There are 4 ½ pages of references for anyone looking for additional material.
There are so many jewels in this article; however, I will highlight only one here. An example of how this is an article about how to teach, here is a quote from page 10: “Learning is best characterized not by moving a child from 20% correct to 50% correct to 100% correct, but by moving a child from successful performance with maximal support to successful performance with little or no support.” This is so true for speech therapy for stuttering, in my opinion. Parents are eager to know when a child will become more fluent in the most excitable, linguistically challenging situations. Parents need to understand that this will only begin to happen when they provide maximal supports. They must take the initiative to CHANGE THE SPEAKING SITUATION - NOT CHANGE THE CHILD. This is maximal support.
In speech therapy for stuttering, we are looking to make speech and language more efficient. What are we going to actually do in a speech therapy session? Many years ago, we focused on the length and complexity of utterance. We trained speech tools at the syllable, then single word, then phrase, then sentence levels. Now, we can approach therapy activities is a more sophisticated way by embedding phonological awareness training and other literacy skills into our sessions.
“Several critical reviews of the general efficacy of phonological awareness instruction and intervention have provided conclusive evidence that phonological awareness can be improved through instruction and intervention, and improvement in phonological awareness leads to improvement in word decoding…reading researchers have called on practitioners to provide intervention to children with poor phonological awareness as early as kindergarten…to provide phonological awareness intervention to older students who demonstrate poor reading achievement in word decoding skills.” P. 3
Many of our students have additional difficulties, such as articulation and language delays/disorders and dyslexia. We can embed emergent literacy tasks nto our speech therapy activities for the sake of prevention as well as remediation for all of our clients at some point in their therapeutic journeys.
Thank you ASHA.
(1) Schuele, C.M. & Boudreau, D. (2008) Language Speech Hearing Services in Schools, Vol. 39, pp 3-20.
6/7/09
Breathing
“Take a breath, slow down, relax…” What is it about stuttering that prompts this reaction in listeners? Stuttering does disrupt airflow. After all, breathing stops momentarily during a block and to breathe is to live. Prolongations and the repetitions of sounds and syllables alter speech rate. Stuttering often includes signs of tension in the face, neck and chest. And so, the empathic, and even the pragmatic, listener may feel that suggesting a stutterer ‘breathe and relax’ will be comforting and make perfect sense.
However, since the altered breathing and physical tension are symptoms – not the cause – of stuttering, this well meaning advice can make matters worse. Symptoms are clues. Clues help us solve mysteries, in this case, the mystery of stuttering. While treating the symptoms of a problem can ease our suffering, it may not promote healing. When I see a child whose repertoire of secondary behaviors includes quick gasps for air, eventually I also hear that he was instructed to ‘take a breath and relax’ as an immediate way out of his struggled speech. Like a bandage placed on an unwashed abrasion, this quick fix fails to really help at all.
My recent attention to breathing came about because of clues that led to impaired breathing as the cause of distress in two cases. Well, breathing was very near to the underlying causes. One was a member of my own family who contracted pneumonia. The other was an elementary school age client who suffers from allergies.
James L. Coyle, Ph.D., CCC-SLP, BRS-S co-presented “Dysphagia Practice: Aspiration Pneumonia and the Role of the Speech-language Pathologist” on May 2, 2009 for Northern Speech Services, Inc. I attended his enthusiastic and detailed presentation on the anatomy and physiology of the respiration system. Human beings breathe to feed the body with oxygen rid it of carbon dioxide. The lungs are loaded with tiny alveoli, like bunches of delicate grapes, which provide an enormous amount of surface area for this very purpose. Molecules of O2 inhaled pass from the lungs into the blood and molecules of CO2 leave the blood, go into the lungs and are exhaled. Damage to the alveoli impair breathing and create distress. In both cases, treatment of the underlying disease is the critical issue. Lawrence Hall Science, The University of California; Berkeley has a nice description of this for kids. (1)
Medical treatments for disease often involve medications. Antibiotics for pneumonia help cure the disease and therefore improve breathing. However, medications often have the side effects. And for the student I’m referring to in this blog, a switch from Allegra to Singulair to treat his allergies seemed to increase fluency substantially. Of course, medication changes should be done with medical supervision. The link betweeen medication and behvior may vary from person to person, and could be a valuable clue to anyone's stuttering mystery.
Human beings are adaptable. So, when faced with difficulty, we search for solutions. Given what we know at the time, we do the best we can. While it may seem obvious to increase air intake by expanding the lungs, it’s not that simple. A child who activates the muscles in his chest and shoulders to expand his lungs is increasing tension, not relaxation. The muscular work of breathing is the responsibility of the diaphragm. There is a simple animation of the diaphragm in a YouTube video called “3D view of diaphragm” (2). The narrative is quite complex, so I suggest the mute button for young children. However, there’s also a fun YouTube video called “Harmonica Playing for Beginners: diaphragmatic breathing” in a which a friendly instructor demonstrates how the diaphragm plays an important role in the breath support and relaxation while playing the harmonica (3). Therefore, unless the child is capable of self-monitoring such subtle muscle control, direct instruction to ‘breathe and relax’may be counterproductive.
For those interested in singing, a website called ‘The Singing Universe” has a section called “Breathing for Singing” which describes breathing exercises to help develop awareness of breathing from the diaphram (4) . I’m thinking of taking singing lessons to experience this instruction personally.
Take good care of your lungs.
(1) broken link
(2) http://www.youtube.com/watch?v=hp-gCvW8PRY
(3) http://www.youtube.com/watch?v=6qYigsgj68w
(4) broken link
However, since the altered breathing and physical tension are symptoms – not the cause – of stuttering, this well meaning advice can make matters worse. Symptoms are clues. Clues help us solve mysteries, in this case, the mystery of stuttering. While treating the symptoms of a problem can ease our suffering, it may not promote healing. When I see a child whose repertoire of secondary behaviors includes quick gasps for air, eventually I also hear that he was instructed to ‘take a breath and relax’ as an immediate way out of his struggled speech. Like a bandage placed on an unwashed abrasion, this quick fix fails to really help at all.
My recent attention to breathing came about because of clues that led to impaired breathing as the cause of distress in two cases. Well, breathing was very near to the underlying causes. One was a member of my own family who contracted pneumonia. The other was an elementary school age client who suffers from allergies.
James L. Coyle, Ph.D., CCC-SLP, BRS-S co-presented “Dysphagia Practice: Aspiration Pneumonia and the Role of the Speech-language Pathologist” on May 2, 2009 for Northern Speech Services, Inc. I attended his enthusiastic and detailed presentation on the anatomy and physiology of the respiration system. Human beings breathe to feed the body with oxygen rid it of carbon dioxide. The lungs are loaded with tiny alveoli, like bunches of delicate grapes, which provide an enormous amount of surface area for this very purpose. Molecules of O2 inhaled pass from the lungs into the blood and molecules of CO2 leave the blood, go into the lungs and are exhaled. Damage to the alveoli impair breathing and create distress. In both cases, treatment of the underlying disease is the critical issue. Lawrence Hall Science, The University of California; Berkeley has a nice description of this for kids. (1)
Medical treatments for disease often involve medications. Antibiotics for pneumonia help cure the disease and therefore improve breathing. However, medications often have the side effects. And for the student I’m referring to in this blog, a switch from Allegra to Singulair to treat his allergies seemed to increase fluency substantially. Of course, medication changes should be done with medical supervision. The link betweeen medication and behvior may vary from person to person, and could be a valuable clue to anyone's stuttering mystery.
Human beings are adaptable. So, when faced with difficulty, we search for solutions. Given what we know at the time, we do the best we can. While it may seem obvious to increase air intake by expanding the lungs, it’s not that simple. A child who activates the muscles in his chest and shoulders to expand his lungs is increasing tension, not relaxation. The muscular work of breathing is the responsibility of the diaphragm. There is a simple animation of the diaphragm in a YouTube video called “3D view of diaphragm” (2). The narrative is quite complex, so I suggest the mute button for young children. However, there’s also a fun YouTube video called “Harmonica Playing for Beginners: diaphragmatic breathing” in a which a friendly instructor demonstrates how the diaphragm plays an important role in the breath support and relaxation while playing the harmonica (3). Therefore, unless the child is capable of self-monitoring such subtle muscle control, direct instruction to ‘breathe and relax’may be counterproductive.
For those interested in singing, a website called ‘The Singing Universe” has a section called “Breathing for Singing” which describes breathing exercises to help develop awareness of breathing from the diaphram (4) . I’m thinking of taking singing lessons to experience this instruction personally.
Take good care of your lungs.
(1) broken link
(2) http://www.youtube.com/watch?v=hp-gCvW8PRY
(3) http://www.youtube.com/watch?v=6qYigsgj68w
(4) broken link
4/26/09
Stuttering is sort of like....
How can fluent speakers begin to appreciate what it is like to stutter? How can children who stutter find ways to express what it is like to speak? Luc Tielens wrote about metaphors for the 2004 International Stuttering Awareness Day online conference. * Since I own a box of 50 or so dominos and my students sometimes enjoy playing with them, here is a metaphore we came up with:
… when a chain of toppling dominos - stops. The smooth clickety-clickety sound of the dominos stops. The chain is broken. Like in a sentence when the smooth consonant-vowel-syllable sound of the words - stops.
Word fears, sound fears are like great big dominos you see ahead. You are on the lookout for them. When you spot trouble ahead – how do you feel ? What do you do? Maybe you think you know when the dominos could stop. If you think that the chain of dominos might stop falling at any time, your body might get anxious. Positive anxiety is called excitement. Negative anxiety is called fear. If the dominos feel out of control and frustration leads you to put them away, this is called avoidance. When talking gets too unpredictable and frustrating, sometimes children who stutter say, “Nevermind.” And they give up.
Finish this thought with your own ideas: Stuttering is sort of like…
… when a chain of toppling dominos - stops. The smooth clickety-clickety sound of the dominos stops. The chain is broken. Like in a sentence when the smooth consonant-vowel-syllable sound of the words - stops.
Word fears, sound fears are like great big dominos you see ahead. You are on the lookout for them. When you spot trouble ahead – how do you feel ? What do you do? Maybe you think you know when the dominos could stop. If you think that the chain of dominos might stop falling at any time, your body might get anxious. Positive anxiety is called excitement. Negative anxiety is called fear. If the dominos feel out of control and frustration leads you to put them away, this is called avoidance. When talking gets too unpredictable and frustrating, sometimes children who stutter say, “Nevermind.” And they give up.
Finish this thought with your own ideas: Stuttering is sort of like…
*http://www.mnsu.edu/comdis/isad7/papers/tielens7/tielens7.html
4/16/09
Down's Syndrome & Cluttering
One of my favorite tasks is searching the speech/language pathology journals for answers to specific questions posed by SLPs and by parents. I truly enjoy reading journal articles! I allow myself the luxury of wallowing in this kind of reading when I need to locate information regarding treatment choices for individual students.
A school-based SLP recently asked me about a student with Down’s syndrome. I could find only a few articles specifically about Down’s syndrome and stuttering with the kind of credibility necessary to support treatment decision making.
Judith Eckardt wrote an article for the International Stuttering Awareness Day online conference (1) in which she explained that her observation was that stuttering emerged around 8-10 years of age, about the same time these children were combining 2-3 word utterances and had rapid vocabulary development. This would be the time for “normal developmental stuttering” given the language delay. She also observed “shame of stuttering” in older Down’s students. She recalls, “I still remember the look of surprise and then a smile from the 17 year old, when I told her ‘It’s OK to stutter’ and ‘It’s NOT your Fault.’” (p.3)
There was also a presentation at the 2006 ASHA Convention specifically about stuttering and Down’s children. (2) I was not at the presentation, the handouts available on line make an explicit connection between Down’s and cluttering.
David Daley wrote an article for the 2007 International Stuttering Awareness Conference (3) in which he provides a checklist called the Predictive Cluttering Inventory. The checklist has 33 items divided into four categories: pragmatics, speech-motor, language-cognition, and motor coordination-writing problems. Each item is rated on a 7-point scale. He suggests that the higher the score on this inventory, the higher the probability that the speaker is a clutterer. Scores of “120 or more are quite rare. Typically, clients we have seen present with scores between 80 and 120. These scores we believe are indicative of a classification or diagnosis we call ‘Clutterer-Stutterer.’ One third of stuttering clients typically show some signs of cluttering.” (p.2) I have David Daley’s 1996 publication of The Source for Stuttering and Cluttering and in it he provides an extensive comparison of stuttering vs. cluttering.
The ASHALeader, an online publication of the American Speech Language Hearing Association, published an update on cluttering in 2003. (4) This article seemed to down play the role of language in the diagnosis. “Another vexing issue is the extent to which language planning and pragmatic problems are implicated in the diagnosis of cluttering. We do not currently include language difficulties in the definition because there appear to be at least a few clutterers for whom language problems are not evident.” (p.2) Rate problems are central to cluttering, says this article. “Clutterers also tend to slur or omit syllables of longer words, which compromise intelligibility during spurts of rapid speech.” (p.2) Many other optional symptoms include: lack of awareness of the problem, poor handwriting, confusing, disorganized language, temporary improvement when asked to ‘slow down,’ social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.
I think back upon 12 years of working exclusively with children and teens who stutter and realize that week after week, therapy activities often engaged my students in rate control, speech-motor practice, self-monitoring, educational counseling/mentoring, and language organization. These are relevant to both stuttering and cluttering. I recall how, eventually, so many of my students were found to have co-existing problems including Non-Verbal Learning Disorder, Attention Deficit, Sensory Integration Disorder, Dyslexia, Learning Disability and Temperamental Sensitivity. Others had family issues such as alcoholism, the birth of a sibling, moving to a new home, financial stress, and growing up in a multi-lingual environment.
I reflect on how experts in the field of stuttering have wondered aloud exactly why some treatment approaches seem effective with some individuals and not others. This has led to two stunning generalizations: 1. The client-clinician relationship matters more than the treatment approach; and, 2. Stuttering is a heterogeneous disorder with subtypes requiring different treatment approaches. Are these two concepts consistent with one another?!
All this causes me to pause and wonder, in the end, what separates me from the ‘snake oil salesman.’ All professional literature at my fingertips still leaves me with abiguity. Evidence Based Practice is not only literature based, but values clinician judgment. My judgments regarding client treatment are based on professional knowledge, ethical practice, and family feedback. Unlike 2+2, there is no single right answer in speech pathology.
(1) Judith Eckardt (2008) “Treating Down’s Children Who Stutter” http://www.mnsu.edu/comdis/isad11/papers/eckardt11.html
(2) Kurt Eggers & Chris De Bal (2006) Speech Dysfluencies in People with Down’s Syndrome Nov. 17, ASHA, Miami Beach (broken link)
(3) David Daley (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” (broken link)
A school-based SLP recently asked me about a student with Down’s syndrome. I could find only a few articles specifically about Down’s syndrome and stuttering with the kind of credibility necessary to support treatment decision making.
Judith Eckardt wrote an article for the International Stuttering Awareness Day online conference (1) in which she explained that her observation was that stuttering emerged around 8-10 years of age, about the same time these children were combining 2-3 word utterances and had rapid vocabulary development. This would be the time for “normal developmental stuttering” given the language delay. She also observed “shame of stuttering” in older Down’s students. She recalls, “I still remember the look of surprise and then a smile from the 17 year old, when I told her ‘It’s OK to stutter’ and ‘It’s NOT your Fault.’” (p.3)
There was also a presentation at the 2006 ASHA Convention specifically about stuttering and Down’s children. (2) I was not at the presentation, the handouts available on line make an explicit connection between Down’s and cluttering.
David Daley wrote an article for the 2007 International Stuttering Awareness Conference (3) in which he provides a checklist called the Predictive Cluttering Inventory. The checklist has 33 items divided into four categories: pragmatics, speech-motor, language-cognition, and motor coordination-writing problems. Each item is rated on a 7-point scale. He suggests that the higher the score on this inventory, the higher the probability that the speaker is a clutterer. Scores of “120 or more are quite rare. Typically, clients we have seen present with scores between 80 and 120. These scores we believe are indicative of a classification or diagnosis we call ‘Clutterer-Stutterer.’ One third of stuttering clients typically show some signs of cluttering.” (p.2) I have David Daley’s 1996 publication of The Source for Stuttering and Cluttering and in it he provides an extensive comparison of stuttering vs. cluttering.
The ASHALeader, an online publication of the American Speech Language Hearing Association, published an update on cluttering in 2003. (4) This article seemed to down play the role of language in the diagnosis. “Another vexing issue is the extent to which language planning and pragmatic problems are implicated in the diagnosis of cluttering. We do not currently include language difficulties in the definition because there appear to be at least a few clutterers for whom language problems are not evident.” (p.2) Rate problems are central to cluttering, says this article. “Clutterers also tend to slur or omit syllables of longer words, which compromise intelligibility during spurts of rapid speech.” (p.2) Many other optional symptoms include: lack of awareness of the problem, poor handwriting, confusing, disorganized language, temporary improvement when asked to ‘slow down,’ social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.
I think back upon 12 years of working exclusively with children and teens who stutter and realize that week after week, therapy activities often engaged my students in rate control, speech-motor practice, self-monitoring, educational counseling/mentoring, and language organization. These are relevant to both stuttering and cluttering. I recall how, eventually, so many of my students were found to have co-existing problems including Non-Verbal Learning Disorder, Attention Deficit, Sensory Integration Disorder, Dyslexia, Learning Disability and Temperamental Sensitivity. Others had family issues such as alcoholism, the birth of a sibling, moving to a new home, financial stress, and growing up in a multi-lingual environment.
I reflect on how experts in the field of stuttering have wondered aloud exactly why some treatment approaches seem effective with some individuals and not others. This has led to two stunning generalizations: 1. The client-clinician relationship matters more than the treatment approach; and, 2. Stuttering is a heterogeneous disorder with subtypes requiring different treatment approaches. Are these two concepts consistent with one another?!
All this causes me to pause and wonder, in the end, what separates me from the ‘snake oil salesman.’ All professional literature at my fingertips still leaves me with abiguity. Evidence Based Practice is not only literature based, but values clinician judgment. My judgments regarding client treatment are based on professional knowledge, ethical practice, and family feedback. Unlike 2+2, there is no single right answer in speech pathology.
(1) Judith Eckardt (2008) “Treating Down’s Children Who Stutter” http://www.mnsu.edu/comdis/isad11/papers/eckardt11.html
(2) Kurt Eggers & Chris De Bal (2006) Speech Dysfluencies in People with Down’s Syndrome Nov. 17, ASHA, Miami Beach (broken link)
(3) David Daley (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” (broken link)
(4) St. Louis, K, Myers, F.L., Bakker, K. (2003) “Cluttering Updated” (2003, Nov. 18) The ASHA Leader, pp 4-5, 20-22; (broken link)
4/7/09
Nonverbal Communication
Persons who stutter (PWS) face the challenge of ‘carryover’ from the very beginning of fluency therapy. The speech language pathologist (SLP) must offer guidance to the PWS regarding how to approach real life with new speech skills. One way to go about this can be to tap into the wealth of information available in the field of social-pragmatic communication. Research in the field of autism spectrum disorders provides detailed descriptions of social skills that will help in the design of carry over treatment goals. For example, I attended a workshop on Asperger’s Syndrome (2) in 2006 that included a 110 point Conversational Effectiveness Profile. Checklists such as this one provide the SLP and PWS with very specific choices from which to craft carry over goals.
Speech therapy for stuttering often emphasizes learning new speech skills along linguistic and speech-motor continuums. This means that practicing easy onset, for example, begins with syllables. Syllables are presumably easy to say because they are brief and have little/no semantic or syntactic demand. I suppose this would be similar to learning finger positions on an instrument. Gradually, the PWS practices his new speech skills in single words, then phrases, then sentences and longer speech tasks. This would be similar to learning chords, then short musical pieces and finally long, complex solos on an instrument.
The social-pragmatic literature draws our attention to the non-verbal aspects of communication that may be equally important in stuttering therapy. (3) Someone learning an instrument may want to play in a concert or jazz band, a string ensemble or perform solo in front of an audience. It seems to me that this requires more than musical talent and technical expertise. Likewise, the PWS wants more than fluency; he wants to communicate with others. He needs to appreciate the larger picture of effective communication. SLPs employed in multi-cultural settings also need to be sensitive to the different communication styles. (4)
Nonverbal communication is “body language.” A more encompassing, professional definition is “nonverbal communication includes those behaviors that are mutually recognized and socially shared codes and patterns with a focus on message meaning.” (1) Subtle and not-so-subtle behaviors communicate specific meanings to our listeners. A subtle raised eyebrow could indicate surprise. Hand waving could mean ‘Hi, I’m glad to see you.’ It depends on the situation, how these are combined with other gestures and perhaps what the speaker is also saying. PWS are sometimes extremely sensitive to the nonverbal signals being sent by listeners. They have seen "the look" so often, that they sometimes expect and percieve rejection from the subtlest of cues. Perhaps a greater understanding of nonverbal communication would help PWS gain a healthier, more resilianet perspective on listeners.
Speech therapy for stuttering often emphasizes learning new speech skills along linguistic and speech-motor continuums. This means that practicing easy onset, for example, begins with syllables. Syllables are presumably easy to say because they are brief and have little/no semantic or syntactic demand. I suppose this would be similar to learning finger positions on an instrument. Gradually, the PWS practices his new speech skills in single words, then phrases, then sentences and longer speech tasks. This would be similar to learning chords, then short musical pieces and finally long, complex solos on an instrument.
The social-pragmatic literature draws our attention to the non-verbal aspects of communication that may be equally important in stuttering therapy. (3) Someone learning an instrument may want to play in a concert or jazz band, a string ensemble or perform solo in front of an audience. It seems to me that this requires more than musical talent and technical expertise. Likewise, the PWS wants more than fluency; he wants to communicate with others. He needs to appreciate the larger picture of effective communication. SLPs employed in multi-cultural settings also need to be sensitive to the different communication styles. (4)
Nonverbal communication is “body language.” A more encompassing, professional definition is “nonverbal communication includes those behaviors that are mutually recognized and socially shared codes and patterns with a focus on message meaning.” (1) Subtle and not-so-subtle behaviors communicate specific meanings to our listeners. A subtle raised eyebrow could indicate surprise. Hand waving could mean ‘Hi, I’m glad to see you.’ It depends on the situation, how these are combined with other gestures and perhaps what the speaker is also saying. PWS are sometimes extremely sensitive to the nonverbal signals being sent by listeners. They have seen "the look" so often, that they sometimes expect and percieve rejection from the subtlest of cues. Perhaps a greater understanding of nonverbal communication would help PWS gain a healthier, more resilianet perspective on listeners.
A narrow view of carry-over, one based on linguistic and speech-motor continuums, is unsatisfactory. The field of social pragmatics is within the scope of practice for SLPs and can be a part of speech therapy for stuttering.
(1) Cicca, A.H., Step, M., & Turkstra, L. (2003, Dec 16). Show me what you mean: Nonverbal communication theory and application. The ASHALeader, pp. 4-5, 34.
(2) Kowalski, Timothy (2006) http://www.socialpragmatics.com/
(3) Volden, J. (2002) Nonverbal Learning Disability: what the SLP Needs to Know
(4) Cheng, L.R. (2007), May 29) Codes and contexts: Exploring linguistic, cultural, and social intelligence. The ASHA Leader, 12(7), 8-9, 32-33.
(2) Kowalski, Timothy (2006) http://www.socialpragmatics.com/
(3) Volden, J. (2002) Nonverbal Learning Disability: what the SLP Needs to Know
(4) Cheng, L.R. (2007), May 29) Codes and contexts: Exploring linguistic, cultural, and social intelligence. The ASHA Leader, 12(7), 8-9, 32-33.
4/1/09
Speech Development
Developmental disfluency emerges between 2 years and 6 years of age. This is a time of rapid speech and language growth. Research suggests that this growth is happening as the child’s brain and body mature. There is a sequence to this development. I was in a home this week where I observed a 5 year old ask his 17 month old brother to say “football.” While the younger boy may say something word-like to mean football, his ‘word’ cannot sound exactly like “football” because his oral-motor skills are too immature to pronounce the f-oo-t-b-a-ll sounds in just that way.
Yet we can listen to what a 17 month old child says and hear patterns common to child speech/language development. This blog entry is a brief review of speech development from birth – age 5. The information is adapted from a book by Ken M. Bleile. (1) The American Speech Language Hearing Association also provides information about speech/language development at http://www.asha.org/.
From birth to about 12 months of age, children begin to perceive the specific speech sounds of the language(s) they hear around them. When we talk, we create an acoustic signal, a sound wave full of information. The young child must decipher this signal. She has to find the individual ‘segments’ that are letter sounds and words. Imagine yourself listening to a language you don’t know; it sounds like a jumble of sounds, not an understandable sequence of words. “The acoustic signal of speech shows no distinctive boundaries that might mark where one segment ends and another begins, and the acoustic properties that can be associated with any particular segment are spread over fairly broad temporal regions.” (2) The young child listens to intonation patters, facial expressions, and watches his environment closely to discover the speech and language code hidden in the acoustic signal.
At the same time, brain and physical development are giving the child greater control over his body, including his jaw, tongue, lips, chest and lots of other muscles needed for saying sounds of his own. His babbling is his way of practicing these sounds. He tries out new sounds, combines them in different ways, hears his own voice and sees what affect it has on others. Gradually, he controls this babbling by starting and stopping it precisely enough that the people around him hear “words.” These beginning words don’t sound exactly like adult words. But they are close enough to give him a new kind of power. He can get what he needs with speech.
Once the child has figured out 1.) the acoustic signal actually made up of sound segments and 2.) she has greater control over saying sounds, she must learn the language rules of her community. A speaker of French must learn the rules of the French language. These rules are different than the rules of Spanish, or English, or any other language. And so the child must match her new physical ability to make sounds with a gradual understanding of how these sounds are combined in her native language. These two forces - the mechanics of speech and the rules of language – create some common “Error Patterns.” It is expected that children from the age of 2 years to 5 years will not speak like little adults! They will have natural, normal “error patterns” in their speech. A speech language pathologist listens carefully to a child and looks for these error patterns. It helps her decide if a child needs extra help learning to talk.
Note: “Regressions, small and large, occur commonly in speech development, especially during Stage 2, and may last from days to months. Parents sometimes notice larger, longer-lasting regressions, commenting that a child “used to say it correctly, but now doesn't” …Rather than proceeding in a straight line, speech development zigzags and sometimes even regresses… (3) While it may be normal to see regressions, we do want to take care that a child's regression is not due to hearing loss, environmental deprivation, or developmental delays. Consultation with the child's pediatrician, school district, or private clinician may be helpful.
(1) Manual of Articulation and Phonological Disorders: Infancy through Adulthood, 2nd Edition (© 2004, Clifton Park, NY: Thomson Delmar Learning, Inc.).
(2) Nittrouer, Susan (2002) From Ear to Cortex: A Perspective on What Clinicians Need to Understand About Speech Perception and Language Processing, Language Speech and Hearing Services in Schools,33, p. 238.
(3) Bleile p. 120
Yet we can listen to what a 17 month old child says and hear patterns common to child speech/language development. This blog entry is a brief review of speech development from birth – age 5. The information is adapted from a book by Ken M. Bleile. (1) The American Speech Language Hearing Association also provides information about speech/language development at http://www.asha.org/.
From birth to about 12 months of age, children begin to perceive the specific speech sounds of the language(s) they hear around them. When we talk, we create an acoustic signal, a sound wave full of information. The young child must decipher this signal. She has to find the individual ‘segments’ that are letter sounds and words. Imagine yourself listening to a language you don’t know; it sounds like a jumble of sounds, not an understandable sequence of words. “The acoustic signal of speech shows no distinctive boundaries that might mark where one segment ends and another begins, and the acoustic properties that can be associated with any particular segment are spread over fairly broad temporal regions.” (2) The young child listens to intonation patters, facial expressions, and watches his environment closely to discover the speech and language code hidden in the acoustic signal.
At the same time, brain and physical development are giving the child greater control over his body, including his jaw, tongue, lips, chest and lots of other muscles needed for saying sounds of his own. His babbling is his way of practicing these sounds. He tries out new sounds, combines them in different ways, hears his own voice and sees what affect it has on others. Gradually, he controls this babbling by starting and stopping it precisely enough that the people around him hear “words.” These beginning words don’t sound exactly like adult words. But they are close enough to give him a new kind of power. He can get what he needs with speech.
Once the child has figured out 1.) the acoustic signal actually made up of sound segments and 2.) she has greater control over saying sounds, she must learn the language rules of her community. A speaker of French must learn the rules of the French language. These rules are different than the rules of Spanish, or English, or any other language. And so the child must match her new physical ability to make sounds with a gradual understanding of how these sounds are combined in her native language. These two forces - the mechanics of speech and the rules of language – create some common “Error Patterns.” It is expected that children from the age of 2 years to 5 years will not speak like little adults! They will have natural, normal “error patterns” in their speech. A speech language pathologist listens carefully to a child and looks for these error patterns. It helps her decide if a child needs extra help learning to talk.
Note: “Regressions, small and large, occur commonly in speech development, especially during Stage 2, and may last from days to months. Parents sometimes notice larger, longer-lasting regressions, commenting that a child “used to say it correctly, but now doesn't” …Rather than proceeding in a straight line, speech development zigzags and sometimes even regresses… (3) While it may be normal to see regressions, we do want to take care that a child's regression is not due to hearing loss, environmental deprivation, or developmental delays. Consultation with the child's pediatrician, school district, or private clinician may be helpful.
(1) Manual of Articulation and Phonological Disorders: Infancy through Adulthood, 2nd Edition (© 2004, Clifton Park, NY: Thomson Delmar Learning, Inc.).
(2) Nittrouer, Susan (2002) From Ear to Cortex: A Perspective on What Clinicians Need to Understand About Speech Perception and Language Processing, Language Speech and Hearing Services in Schools,33, p. 238.
(3) Bleile p. 120
3/18/09
The Arm Bump
Here is a popular activity that helps fluent speakers understand a little bit about what stuttering is like. I led a group of about 20 teachers in this exercise in early March as it appeared likely to be the most effective way to engage such an audience in the topic of stuttering at the end of their work day.
I began by asking them all to take out their #2 pencils. :)
Seriously, everyone needed to write. Each chose a partner. One member of the partnership was asked to write her name several times. The partner was instructed to bump the writer's arm several times as she was writing. The bumping needed to vary in pressure and timing so that the writer could not predict when it would happen. The partners switched places in order for everyone to experience both roles. Teachers were laughing, talking, grumbling about messy writing....the first objective of the afternoon had been accomplished - they were engaged.
Facilitated discussion followed: how did they like the writing? How did their fingers, hands, wrists, arms, shoulders or any other parts of their body react to being bumped? How did they respond emotionally... any anticipation anxiety? Did their hands prepare for upcoming unpredictable bumps?
Generally speaking, this activity elicits physical tension in the fingers and hands. People tend to grip their pencils more tightly in anticipation of and in reaction to being bumped. They feel a range of emotions including annoyance, frustration, loss of control, and sometimes anger. One writer spontaneously grumbled, "I give up." People who stutter tend to do so on their own names, a very embarrassing event. This is why they were asked to write their own names. They write for several minutes so as to experience the relentless nature of the bumping. Yet, after the 5-10 minute activity, they have the luxury of returning to their original state of fluent writing. Facilitated discussion guides the conversation to how a person responds to stuttering.
In the 10 minutes reserved for questions, someone asked, "What can teachers do to help a child who stutters?" and I knew I had missed an important objective. The next presentation must include copies of Straight Talk for Teachers from the Stuttering Foundation of America for every teacher. We all still want a "How to..." list of directions. Please visit http://www.stutteringhelp.org/ for specific tips for the classroom.
1/31/09
Walking Together and Apart
I breathe a sigh of relief when I see ideas tossed around in conversation finally show up in print. To support my professional opinions (to myself, to my clients, or to others), it is helpful to refer to something published rather than my fading memory. So I was pleased to see the article "Accompanying a Client on His Therapy Journey" by Pelczarski and Yaruss in an August 2008 issue of Perspectives on Fluency and Fluency Disorders (Vol 18, pp 64-68). Talking about stuttering therapy as a life journey is an analogy one often hears at conventions for SLPs or for persons who stutter. Now here is an article describing that journey.
One task of the SLP as traveling companion is to consult the map often. The SLP is partly a tour guide who constantly wonders: Where are we now? Where have we been? Where are we going next? What do we need to prepare for the next leg of our trip? The novice SLP studies ways to measure different kinds of stuttering, as I once did. He or she has treatments at hand, preferably ones suggested by scientific research and supplemented by ideas from support organizations such as the National Stuttering Association. This is a good start and will get her as far as a single tank of gas will take a car.
Soon, she and the client encounter "bumps in the road," so to speak. The client does not become fluent after a few sessons. In fact, he discovers that "...the work of therapy is what happens in between therapy sessions." (p.65) He must experiment with generalizing skills from the speech therapy room to his life right away. The SLP quickly discovers that her words of wisdom do not yield instant change. Instead, her responsiblities include asking her student about his travels while they were apart. Did he do any 'homework?' If so, he's moved out of his comfort zone and will need meaningful praise and encouragement. In addition, the client's attempts at change will have uncovered additional issues. The SLP can choose which of these she feels comfortable pursuing, if any. She may decide to refer the client to someone else instead, suggesting he find another traveling companion. It's appropriate to take a break from speech therapy to work on other goals.
The experienced clincian will be curious about these detours to pursue other issues and may ask to go along. This SLP knows that progress is about much more than speech sounds. For a brief introduction to this widening scope of practice, an SLP might like to read "Early Intervention: Is Being a Good SLP Good Enough?' by Nancy Keenan-Rich (the ASHAleader online, 2002). Nancy walks the path of family centered therapy. "I had studied family systems and was now seeing first hand how this concept played out in the everyday lives of parents, children, and other caregivers. Family beliefs, values, and priorities became the backdrop for services...parent personalities, stress, boundaries, and the various pressures created by an extended family." (p.1) Nancy became a master at developing relationships and expanding her role to provide "information in areas that do not appear directly related to communcation such as parenting, behavior, and stress." She learned to make room for family input. "How do I collaborate with a parent who is angry with me...?" for example.
The well seasoned SLP, such as myself, has walked down many paths, tripped on her own feet, lost her way, read guidebooks, looked to the stars for direction, retraced her steps, and chatted with many other travelers. :) Therefore, I was delighted to find "Expanding the 'Ports of Entry' for Speech-Language Pathologists: A Relational and Reflective Model of Clinical Practice" by Geller & Foley (American Journal of Speech-Languag Pathology, Vol 18, pp4-21, 2009). This article is for the SLP who knows at the outset that she must invite each client to join her on a long voyage of change. This SLP "does not have a preconcieved agenda, or endpoint" (p.6). She's not even a tour guide. Rather, she comes to the relationship with the expectation that everyone walking participates equally in the travel plans. "...the role of the speech-language pathologist is to form a therapeutic alliance with the client and family in which conditions of safety are created...within this relationship, a range of problems can surface and be explored collaboratively." (p.6) Her role is not to teach nor lead, but to empower. She does not provide direction, but is reflective. "It is the expectation that the process of thinking-in-action, rather than just plowing ahead in implementing concrete goals and procedures, will allow intervention to be more successful." (p.9)
I take my son to piano lessons every week. Last week, I heard the piano teacher ask after students she had taught in the past. "Tell them I said hello," she said to a student finished with his lesson and heading home. In her voice was warm concern and curiousity. I recognized those feelings. I've been an SLP for 26 years and I still wonder about many of my previous students. Some students remain with me in spirit long after we had come to a fork in the road and parted company. I look up at the stars and wish them well.
Judy
One task of the SLP as traveling companion is to consult the map often. The SLP is partly a tour guide who constantly wonders: Where are we now? Where have we been? Where are we going next? What do we need to prepare for the next leg of our trip? The novice SLP studies ways to measure different kinds of stuttering, as I once did. He or she has treatments at hand, preferably ones suggested by scientific research and supplemented by ideas from support organizations such as the National Stuttering Association. This is a good start and will get her as far as a single tank of gas will take a car.
Soon, she and the client encounter "bumps in the road," so to speak. The client does not become fluent after a few sessons. In fact, he discovers that "...the work of therapy is what happens in between therapy sessions." (p.65) He must experiment with generalizing skills from the speech therapy room to his life right away. The SLP quickly discovers that her words of wisdom do not yield instant change. Instead, her responsiblities include asking her student about his travels while they were apart. Did he do any 'homework?' If so, he's moved out of his comfort zone and will need meaningful praise and encouragement. In addition, the client's attempts at change will have uncovered additional issues. The SLP can choose which of these she feels comfortable pursuing, if any. She may decide to refer the client to someone else instead, suggesting he find another traveling companion. It's appropriate to take a break from speech therapy to work on other goals.
The experienced clincian will be curious about these detours to pursue other issues and may ask to go along. This SLP knows that progress is about much more than speech sounds. For a brief introduction to this widening scope of practice, an SLP might like to read "Early Intervention: Is Being a Good SLP Good Enough?' by Nancy Keenan-Rich (the ASHAleader online, 2002). Nancy walks the path of family centered therapy. "I had studied family systems and was now seeing first hand how this concept played out in the everyday lives of parents, children, and other caregivers. Family beliefs, values, and priorities became the backdrop for services...parent personalities, stress, boundaries, and the various pressures created by an extended family." (p.1) Nancy became a master at developing relationships and expanding her role to provide "information in areas that do not appear directly related to communcation such as parenting, behavior, and stress." She learned to make room for family input. "How do I collaborate with a parent who is angry with me...?" for example.
The well seasoned SLP, such as myself, has walked down many paths, tripped on her own feet, lost her way, read guidebooks, looked to the stars for direction, retraced her steps, and chatted with many other travelers. :) Therefore, I was delighted to find "Expanding the 'Ports of Entry' for Speech-Language Pathologists: A Relational and Reflective Model of Clinical Practice" by Geller & Foley (American Journal of Speech-Languag Pathology, Vol 18, pp4-21, 2009). This article is for the SLP who knows at the outset that she must invite each client to join her on a long voyage of change. This SLP "does not have a preconcieved agenda, or endpoint" (p.6). She's not even a tour guide. Rather, she comes to the relationship with the expectation that everyone walking participates equally in the travel plans. "...the role of the speech-language pathologist is to form a therapeutic alliance with the client and family in which conditions of safety are created...within this relationship, a range of problems can surface and be explored collaboratively." (p.6) Her role is not to teach nor lead, but to empower. She does not provide direction, but is reflective. "It is the expectation that the process of thinking-in-action, rather than just plowing ahead in implementing concrete goals and procedures, will allow intervention to be more successful." (p.9)
I take my son to piano lessons every week. Last week, I heard the piano teacher ask after students she had taught in the past. "Tell them I said hello," she said to a student finished with his lesson and heading home. In her voice was warm concern and curiousity. I recognized those feelings. I've been an SLP for 26 years and I still wonder about many of my previous students. Some students remain with me in spirit long after we had come to a fork in the road and parted company. I look up at the stars and wish them well.
Judy
1/28/09
Audacity.sourceforge.net/download/ & the pause
“See the pause?” I ask my students as we sit facing a laptop examining speech on the screen. I am asking them to find moments of silence. This is a lesson about creating pauses and we are using a free download from http://www.audacity.sourceforge.net to see them. Silence is easy to locate; it’s represented by the absence of any speech waveform. It’s a straight line. Speech, on the other hand, takes a variety of shapes. And while this download is not so refined that I would expect scientists would use it in research, it serves us just fine. We can see pauses, easy onsets, voluntary stuttering, prolongations, repetitions, and even some blocks and hard articulatory contacts. We can even measure them. We are careful observers and we are having fun.
This blog is about pausing. You can read more about pausing in an article by Peter Reitzes, MA, CCC, SLP, “Pausing: Reducing the Frequency of Stuttering at (broken link). He also has a video to demonstrate pausing at “Peter Reitzes talking about speech tools he uses” http://uk.youtube.com/watch?v=g8biSBPsoeg. . I recently discovered these resources because one of my students likes pausing the best of all the speech tools. I was looking for a way that he could experiment with frequency, placement, and length of pauses at home. Speech can be difficult to monitor because it is invisible! Reading aloud was a way to monitor pauses at first. We could mark up a text with crayons to cue of when to pause. But it was time to shift to brief spontaneous narratives. Audacity gave us a tool for concrete, visual feedback.
I’d recently revisited principals of motor learning and found an intriguing concept: “attentional focus.” An internal focus is when we concentrate on what movement feels like. Speech language pathologists sometimes encourage internal focus so that students can find and reduce the physical tension they experience during a block, prolongation, or repetition. They request an internal focus again when teaching fluency enhancing skills. An external focus is when we concentrate on the effects of the movement. That is, does the movement achieve our goal? Reducing muscle tension and practicing speech tools are meant to make speech easier and increase self-confidence when communicating.
When my students say things like, “If I just think about what I want to say, my speech is easier.” it is time to shift focus of attention. Maybe this is what the “inner game” refers to, as in “Winning the Inner Game” by Winton Bates at http://www.mnsu.edu/comdis/isad9/papers/bates9.html . I read The Inner Game of Tennis by Timothy W. Gallwey and it seems to draw upon this concept of external focus of attention. A recent article in the American Journal of Speech Pathology says, “An external focus of attention…would allow for more automatically executed motor routines…” How this applies to speech motor control needs more research, as usual. In the mean time, when my students evidence a readiness to shift focus, professional judgment is good enough reason to try this route. Audacity shifts focus of attention to combine both auditory and visual goals. It may be a helpful tool for some students.
This blog is about pausing. You can read more about pausing in an article by Peter Reitzes, MA, CCC, SLP, “Pausing: Reducing the Frequency of Stuttering at (broken link). He also has a video to demonstrate pausing at “Peter Reitzes talking about speech tools he uses” http://uk.youtube.com/watch?v=g8biSBPsoeg. . I recently discovered these resources because one of my students likes pausing the best of all the speech tools. I was looking for a way that he could experiment with frequency, placement, and length of pauses at home. Speech can be difficult to monitor because it is invisible! Reading aloud was a way to monitor pauses at first. We could mark up a text with crayons to cue of when to pause. But it was time to shift to brief spontaneous narratives. Audacity gave us a tool for concrete, visual feedback.
I’d recently revisited principals of motor learning and found an intriguing concept: “attentional focus.” An internal focus is when we concentrate on what movement feels like. Speech language pathologists sometimes encourage internal focus so that students can find and reduce the physical tension they experience during a block, prolongation, or repetition. They request an internal focus again when teaching fluency enhancing skills. An external focus is when we concentrate on the effects of the movement. That is, does the movement achieve our goal? Reducing muscle tension and practicing speech tools are meant to make speech easier and increase self-confidence when communicating.
When my students say things like, “If I just think about what I want to say, my speech is easier.” it is time to shift focus of attention. Maybe this is what the “inner game” refers to, as in “Winning the Inner Game” by Winton Bates at http://www.mnsu.edu/comdis/isad9/papers/bates9.html . I read The Inner Game of Tennis by Timothy W. Gallwey and it seems to draw upon this concept of external focus of attention. A recent article in the American Journal of Speech Pathology says, “An external focus of attention…would allow for more automatically executed motor routines…” How this applies to speech motor control needs more research, as usual. In the mean time, when my students evidence a readiness to shift focus, professional judgment is good enough reason to try this route. Audacity shifts focus of attention to combine both auditory and visual goals. It may be a helpful tool for some students.
1/23/09
Principals of Motor Learning
Are you aware of what you look like when you walk, dance, talk on the phone or prepare a meal? Perhaps you sometimes recognize in yourself mannerisms you’ve seen your parents do! I can’t think of many other situations in which we take notice of our own behaviors. Activities such as a sports clinic, dance class, or public speaking course certainly increase our self-awareness. In training situations such as these, we observe our own behavior, compare it with that of the instructor’s model, and attend to feedback . The feedback might be a coach’s comments, our reflection in a wall of mirrors, a video of ourselves, or just looking down at our feet.
I recently read a fascinating article that describes how we learn new motor skills AND how normal learning processes may or may not apply to speech therapy. The article is called “Principals of Motor Learning in Treatment of Motor Speech Disorders” by Edwin Maas et.al. (American Journal of Speech-Language Pathology, Vol. 17, 277-298, August 2008). This article starts out by stating “the plasticity of the human brain, even in adults, is clear from animal research as well as human data…Critically for clinicians, behavioral treatments are known to promote brain reorganization and plasticity…”(p.277) Motor practice changes brain function.
However, “…it is unknown whether impaired motor systems are sensitive to the same principals of learning as intact motor systems…” So, while speech therapy uses well-known strategies adapted from normal motor learning processes, in fact, it would be more helpful if research told us how impaired motor systems learn best. Here are some concepts to think about:
Learning is a set of processes that result in a permanent change in the capability to perform. Learning is measured by how well a new skill is retained and transferred to a variety of situations. Performance is simply execution of the behavior. “…performance changes during practice do not predict retention or transfer…” Sound familiar? A common complaint in speech therapy is that transfer can be so difficult.
I won’t describe Schema Theory here. I confess to not understanding it fully myself. Nevertheless, the authors suggest that some aspects of motor learning are easier to change than others. And, critical to any learning is the ability to compare current behavior with the new behavior one is trying to learn. This requires conscious and unconscious accurate feedback. If any aspect of the feedback process impaired, then the learner will have difficulty learning. A learner must be able to detect his own errors. Which brings me back to the beginning of the blog: if we consider how unaware we can be about our own behavior, imagine how difficult it might be to discover, recognize, and then change something about ourselves if we are working with an impaired sensori-motor system!
There are many factors to consider in motor learning and this article does a thorough job of reviewing this material. The take-home message for this blog is that it is important to verify that effective feedback is taking place for a student in speech therapy. Also, different kinds of practice are appropriate for different kinds of speech behaviors. Treatment choices are not intuitive. For example, random practice can be more effective than blocked practice. An internal focus (attending to the tongue, lips, jaw, etc.) is the norm for many speech therapy activities, however, an external focus, “…a focus on acoustic output rather than speech articulators…” is recommended to promote movement automaticity, retention, and learning.
In summary, speech therapy for stuttering is partially about changing a speech motor behavior and this change process is quite complicated. One critical factor is accurate feedback, both the quality and type of feedback processes should be carefully considered. “Clinicians may need to consider using instrumental measures of performance to supplement perceptual measures…” At another time we can review how delayed auditory feedback, visual representations of speech as wave forms, and simple timers can become useful instruments to promote speech changes.
Judy
I recently read a fascinating article that describes how we learn new motor skills AND how normal learning processes may or may not apply to speech therapy. The article is called “Principals of Motor Learning in Treatment of Motor Speech Disorders” by Edwin Maas et.al. (American Journal of Speech-Language Pathology, Vol. 17, 277-298, August 2008). This article starts out by stating “the plasticity of the human brain, even in adults, is clear from animal research as well as human data…Critically for clinicians, behavioral treatments are known to promote brain reorganization and plasticity…”(p.277) Motor practice changes brain function.
However, “…it is unknown whether impaired motor systems are sensitive to the same principals of learning as intact motor systems…” So, while speech therapy uses well-known strategies adapted from normal motor learning processes, in fact, it would be more helpful if research told us how impaired motor systems learn best. Here are some concepts to think about:
Learning is a set of processes that result in a permanent change in the capability to perform. Learning is measured by how well a new skill is retained and transferred to a variety of situations. Performance is simply execution of the behavior. “…performance changes during practice do not predict retention or transfer…” Sound familiar? A common complaint in speech therapy is that transfer can be so difficult.
I won’t describe Schema Theory here. I confess to not understanding it fully myself. Nevertheless, the authors suggest that some aspects of motor learning are easier to change than others. And, critical to any learning is the ability to compare current behavior with the new behavior one is trying to learn. This requires conscious and unconscious accurate feedback. If any aspect of the feedback process impaired, then the learner will have difficulty learning. A learner must be able to detect his own errors. Which brings me back to the beginning of the blog: if we consider how unaware we can be about our own behavior, imagine how difficult it might be to discover, recognize, and then change something about ourselves if we are working with an impaired sensori-motor system!
There are many factors to consider in motor learning and this article does a thorough job of reviewing this material. The take-home message for this blog is that it is important to verify that effective feedback is taking place for a student in speech therapy. Also, different kinds of practice are appropriate for different kinds of speech behaviors. Treatment choices are not intuitive. For example, random practice can be more effective than blocked practice. An internal focus (attending to the tongue, lips, jaw, etc.) is the norm for many speech therapy activities, however, an external focus, “…a focus on acoustic output rather than speech articulators…” is recommended to promote movement automaticity, retention, and learning.
In summary, speech therapy for stuttering is partially about changing a speech motor behavior and this change process is quite complicated. One critical factor is accurate feedback, both the quality and type of feedback processes should be carefully considered. “Clinicians may need to consider using instrumental measures of performance to supplement perceptual measures…” At another time we can review how delayed auditory feedback, visual representations of speech as wave forms, and simple timers can become useful instruments to promote speech changes.
Judy
1/15/09
Journaling for Carryover
I am in the midst of designing a lesson plan for 2 teen age boys. My challenge is to create activities that are relevant to their individual speech therapy goals as well as meaningful in every day life. Typically, this means teaching a skill that will provide new communication challenges and be useful at school. I’ve chosen to discuss journaling.
“Lots of people keep journals to help them work through difficult things in their lives. For example, writing privately about something that has happened to you can help you get all your feelings on paper. As a result, you often feel better or at least understand what has happened a little more.” (125 Ways to be a Better Writer by Paul F. Johnson, LinguiSystems, 1996, p. 56. Journaling is a way to practice writing and writing is important to success in school. Journaling can be done in creative, unique ways without the limitations of a specific format. Finally, journaling observations about stuttering can lead to insights about one’s own therapeutic progress.
In order to make this process as painless as possible, I’ll be teaching the boys how to draw mindscapes. Mindscapes are picture representations of complex ideas and are described in the book Visual Thinking: Tools for Mapping Your Ideas by Nancy Margulies and Christine Valenza (Crown House Publishing, 2007). We will brainstorm ideas and “cluster” these thoughts quickly onto paper in the form of arrows, shapes, drawings and single words. We’ll record our observations by doodling with several different colored crayons. This lesson is not about composing grammatically correct complex sentences with accurate punctuation. Instead, it is about generating as many opinions and feelings as possible and then contemplating the relationships between them.
As a guide for thinking about stuttering, we will also refer to Making My Own Way a journaling workbook I co-wrote with Jackie Biagini in 2002. This is at http://www.mnsu.edu/comdis/kuster/TherapyWWW/butler.pdf . (It needs revision, so if anyone reading this blog would like to co-author a rewriting of this workbook, please let me know!! Perhaps it would look good on your college application or resume for employment.) The workbook has several “levels,” but, they don't have to be completed in a specific order. Each level simply offers a way to look at communication, stuttering, and behavior change.
Another handy reference for this kind of exercise is Diane Games' My Story: A PowerPoint Teaching Tool at http://www.mnsu.edu/comdis/isad9/papers/therapy9/games9.html. Diane explains: "The "My Story" framework provided a forum for each child/teen to comment on important personal issues with various speakers... The children and teens used this PowerPoint framework to develop and express their viewpoints in writing. Following the completion of the written story, the child/teen orally discussed their story and frequently provided alternative solutions or ideas for handling difficult situations. They also were empowered to evaluate their progress and to plan for future treatment."
Perhaps mindscaping and writing about stuttering will generalize to other academic tasks for my students. I know what it's like to stare apprehensively at a blank sheet of paper, wondering how to begin a report. Maybe you have too. Scribbling down ideas in the form of mindscapes may be an easy way to get the writing process started. Yes, each cluster of ideas must eventually become a paragraph of well written sentences. But, one can’t write sentences without first knowing what to say!
Judy
“Lots of people keep journals to help them work through difficult things in their lives. For example, writing privately about something that has happened to you can help you get all your feelings on paper. As a result, you often feel better or at least understand what has happened a little more.” (125 Ways to be a Better Writer by Paul F. Johnson, LinguiSystems, 1996, p. 56. Journaling is a way to practice writing and writing is important to success in school. Journaling can be done in creative, unique ways without the limitations of a specific format. Finally, journaling observations about stuttering can lead to insights about one’s own therapeutic progress.
In order to make this process as painless as possible, I’ll be teaching the boys how to draw mindscapes. Mindscapes are picture representations of complex ideas and are described in the book Visual Thinking: Tools for Mapping Your Ideas by Nancy Margulies and Christine Valenza (Crown House Publishing, 2007). We will brainstorm ideas and “cluster” these thoughts quickly onto paper in the form of arrows, shapes, drawings and single words. We’ll record our observations by doodling with several different colored crayons. This lesson is not about composing grammatically correct complex sentences with accurate punctuation. Instead, it is about generating as many opinions and feelings as possible and then contemplating the relationships between them.
As a guide for thinking about stuttering, we will also refer to Making My Own Way a journaling workbook I co-wrote with Jackie Biagini in 2002. This is at http://www.mnsu.edu/comdis/kuster/TherapyWWW/butler.pdf . (It needs revision, so if anyone reading this blog would like to co-author a rewriting of this workbook, please let me know!! Perhaps it would look good on your college application or resume for employment.) The workbook has several “levels,” but, they don't have to be completed in a specific order. Each level simply offers a way to look at communication, stuttering, and behavior change.
Another handy reference for this kind of exercise is Diane Games' My Story: A PowerPoint Teaching Tool at http://www.mnsu.edu/comdis/isad9/papers/therapy9/games9.html. Diane explains: "The "My Story" framework provided a forum for each child/teen to comment on important personal issues with various speakers... The children and teens used this PowerPoint framework to develop and express their viewpoints in writing. Following the completion of the written story, the child/teen orally discussed their story and frequently provided alternative solutions or ideas for handling difficult situations. They also were empowered to evaluate their progress and to plan for future treatment."
Perhaps mindscaping and writing about stuttering will generalize to other academic tasks for my students. I know what it's like to stare apprehensively at a blank sheet of paper, wondering how to begin a report. Maybe you have too. Scribbling down ideas in the form of mindscapes may be an easy way to get the writing process started. Yes, each cluster of ideas must eventually become a paragraph of well written sentences. But, one can’t write sentences without first knowing what to say!
Judy
1/14/09
Preschool Stuttering
Speech therapy for preschool disfluency is controversial. I'm not even going to try to address this topic completely. This blog entry is about my own perspective. It is based as much on experience as on published literature.
Some preschool children do stutter. That is, some 2-, 3-, 4- and 5-year olds experience blocks with struggle behavior, prolongations, and multiple sound and/or syllable repetitions. Some preschoolers respond to their stuttering by whispering, using their hands to pull on the tongue, reticence about talking, and gross motor movements such as hitting and jumping while stuttering. I've seen all of these reactions. These children need direct speech therapy, in my opinion. They need some kind of direct instruction and modeling to help them find more relaxed sound production. Preschoolers are often natural imitators, so that I can describe the slow-smooth way in which I am pronouncing words in an activity and they will imitate that style of speaking without needing repeated prompts to do so.
Preschool children love to play. Therefore, laying the groundwork for changing speech may need to be taught in play. These are the concepts I teach in play: empowerment, change, we learn from our mistakes, bumpy vs smooth, fast vs slow, and the child's ideas are important to me. I briefly describe each concept in a single page handout for parents. Role modeling for parents is an essential part of speech therapy with preschoolers.
When I appreciate a child's words and play, I signal that his input has value. If this child continues to stutter, he will need to value his own observations as he experiments with speech changes or stutters with peers. When I suggest that we change leggo building plans, change crayon colors, change playdo creations, change dramatic play scenarios, etc., I hope that my student is learning that change can be fun. If this child will eventually need to consciously change the way he talks to reduce articulatory tension, I want him to already be prepared for coping with the feelings of differentness that change brings. He may need to selectively change bumpy words into smooth words or perhaps reduce speaking rate. When I 'accidentally' knock over blocks, drop glue, and skip pages in a book, I model that making mistakes is a normal part of living. In fact, we need to make mistakes to learn what works for us and what doesn't.
I generally follow a treatment process described in "Treating Preschool Children Who Stutter: Description and Preliminary Evaluation of a Family-Focused Treatment Approach" by Yaruss, Coleman, & Hammer (Language, Speech, and Hearing Services in Schools, Vol. 37, 118-136, 2006 ). This is only one way to approach stuttering in preschoolers and a follow-up article, "Differing Perpectives on What to Do With a Stuttering Preschooler and Why" by Onslow & Yaruss can be found in the American Journal of Speech-Language Pathology, Vol. 16, 65-68, February 2007. Many SLPs are now trained in the Lidcombe Program of treatment. I opted not to do this training since it seemed to emphasize data collection, explicit correction of the child's stuttering, and training parents to assume the role of SLPs. I encourage parents interested in the Lidcombe Program to learn more specifics from SLPs who have completed its intensive training.
Helpful resources include an in-depth interview form called "When It Comes to Assessment Parents Know Best" by Janice Westbrook, Ph.D. http://www.mnsu.edu/comdis/kuster/gjohnson/parentsknowbest.html. I really like a coloring book called The Many Voices of Paws by Julie Dzewaltowski Reville and published by The Speech Bin (This fabulous book is likely out of print.) This is a simple, gentle story that introduces the very young child to the concepts of changing vocal output. Paws is a overweight, fluffy cat who experiements with making the sounds of other animals. "Our first talk about talking..." an oldie but goodie for young children at http://www.mnsu.edu/comdis/kuster/TherapyWWW/ourfirsttalk.pdf.
Parents willing to do some reading will benefit from "Stuttering Prevention: A Manual for Parents" by Starkweather, Gottwald, & Halfond at (broken link). The Stuttering Foundation http://www.stutteringhelp.org/ has an updated , now 7th, edition of if your child stutters: a guide for parents. Parents MUST actively participate in the preschool child's speech therapy. I no longer accept preschool children into speech therapy if both parents work full time and are not able to modify the child's daily environment or carryover therapy techniques at home. (I have a colleague who will not see any child who stutters unless both parents attend speech therapy sessions.)
A word about etiology: why does a preschool child stutter? This is the $64,000 question. Some children who stutter have a parent, grandparent, or other relative who stutters or who has recovered from stuttering. In this situation, it is tempting to presume that the young child has inherited stuttering. Some children have no known reletives who stutter. My observation has been that some of these children are eventually diagnosed with other problems. I would say that the vast majority of my students have had concerns in addition to stuttering: emotional sensitivity, dyslexia, sensory integration disorder, Down's Syndrome, learning disability, articulation disorder or delay, or gross-/fine-motor delay/disorders. Consequently, speech therapy for stuttering nearly always occurs in the context of larger therapeutic goals.
Judy
Some preschool children do stutter. That is, some 2-, 3-, 4- and 5-year olds experience blocks with struggle behavior, prolongations, and multiple sound and/or syllable repetitions. Some preschoolers respond to their stuttering by whispering, using their hands to pull on the tongue, reticence about talking, and gross motor movements such as hitting and jumping while stuttering. I've seen all of these reactions. These children need direct speech therapy, in my opinion. They need some kind of direct instruction and modeling to help them find more relaxed sound production. Preschoolers are often natural imitators, so that I can describe the slow-smooth way in which I am pronouncing words in an activity and they will imitate that style of speaking without needing repeated prompts to do so.
Preschool children love to play. Therefore, laying the groundwork for changing speech may need to be taught in play. These are the concepts I teach in play: empowerment, change, we learn from our mistakes, bumpy vs smooth, fast vs slow, and the child's ideas are important to me. I briefly describe each concept in a single page handout for parents. Role modeling for parents is an essential part of speech therapy with preschoolers.
When I appreciate a child's words and play, I signal that his input has value. If this child continues to stutter, he will need to value his own observations as he experiments with speech changes or stutters with peers. When I suggest that we change leggo building plans, change crayon colors, change playdo creations, change dramatic play scenarios, etc., I hope that my student is learning that change can be fun. If this child will eventually need to consciously change the way he talks to reduce articulatory tension, I want him to already be prepared for coping with the feelings of differentness that change brings. He may need to selectively change bumpy words into smooth words or perhaps reduce speaking rate. When I 'accidentally' knock over blocks, drop glue, and skip pages in a book, I model that making mistakes is a normal part of living. In fact, we need to make mistakes to learn what works for us and what doesn't.
I generally follow a treatment process described in "Treating Preschool Children Who Stutter: Description and Preliminary Evaluation of a Family-Focused Treatment Approach" by Yaruss, Coleman, & Hammer (Language, Speech, and Hearing Services in Schools, Vol. 37, 118-136, 2006 ). This is only one way to approach stuttering in preschoolers and a follow-up article, "Differing Perpectives on What to Do With a Stuttering Preschooler and Why" by Onslow & Yaruss can be found in the American Journal of Speech-Language Pathology, Vol. 16, 65-68, February 2007. Many SLPs are now trained in the Lidcombe Program of treatment. I opted not to do this training since it seemed to emphasize data collection, explicit correction of the child's stuttering, and training parents to assume the role of SLPs. I encourage parents interested in the Lidcombe Program to learn more specifics from SLPs who have completed its intensive training.
Helpful resources include an in-depth interview form called "When It Comes to Assessment Parents Know Best" by Janice Westbrook, Ph.D. http://www.mnsu.edu/comdis/kuster/gjohnson/parentsknowbest.html. I really like a coloring book called The Many Voices of Paws by Julie Dzewaltowski Reville and published by The Speech Bin (This fabulous book is likely out of print.) This is a simple, gentle story that introduces the very young child to the concepts of changing vocal output. Paws is a overweight, fluffy cat who experiements with making the sounds of other animals. "Our first talk about talking..." an oldie but goodie for young children at http://www.mnsu.edu/comdis/kuster/TherapyWWW/ourfirsttalk.pdf.
Parents willing to do some reading will benefit from "Stuttering Prevention: A Manual for Parents" by Starkweather, Gottwald, & Halfond at (broken link). The Stuttering Foundation http://www.stutteringhelp.org/ has an updated , now 7th, edition of if your child stutters: a guide for parents. Parents MUST actively participate in the preschool child's speech therapy. I no longer accept preschool children into speech therapy if both parents work full time and are not able to modify the child's daily environment or carryover therapy techniques at home. (I have a colleague who will not see any child who stutters unless both parents attend speech therapy sessions.)
A word about etiology: why does a preschool child stutter? This is the $64,000 question. Some children who stutter have a parent, grandparent, or other relative who stutters or who has recovered from stuttering. In this situation, it is tempting to presume that the young child has inherited stuttering. Some children have no known reletives who stutter. My observation has been that some of these children are eventually diagnosed with other problems. I would say that the vast majority of my students have had concerns in addition to stuttering: emotional sensitivity, dyslexia, sensory integration disorder, Down's Syndrome, learning disability, articulation disorder or delay, or gross-/fine-motor delay/disorders. Consequently, speech therapy for stuttering nearly always occurs in the context of larger therapeutic goals.
Judy
1/7/09
The 10,000 Hour Rule by Malcolm Gladwell
Malcolm Gladwell has a new book, Outliers: The Story of Success (Little- Brown, 2008). Chapter 2 is titled, The 10,000 Hour Rule. The theme of this chapter is that it takes at least 10,000 hours of practice to get really, really good at something. It also takes luck, talent, and opportunity. However, luck, talent and opportunity are not enough. " '...10,000 hours of practice is required to achieve the level of mastery associated with being a world-class expert - in anything," writes the neurologist Daniel Levitin. 'In study after study, composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again.'" (p.40)
Malcom Gladwell provides several examples. I'll share one with you now, the Beatles. "Lennon and McCartney first started playing together in 1957, 7 years prior to landing in America...In 1960, while they were still just a struggling high school rock band, they were invited to play in Hamburg, Germany...And what was so special about Hamburg?...It was the sheer amount of time the band was forced to play..." often eight hours a day, seven days a week. "All told, they performed for 270 nights in just over a year and a half...an estimated twelve hundred times...They were no good onstage when they went there and they were very good when they came back.'" (p.50)
Stuttering is a complex phenomenon and there is alot for a client to learn. When I began this private practice in 1991, I set out to provide intensive speech therapy. However, I discovered that very, very few clients made the time for or had the interest in this kind of committment. Consequently, I've learned to "meet the client where his is" as they say. I go with the client's level of motivation and do the best I can to provide information and guidance as to how to make speech changes given life's real constraints. Yet regardless of how much we understand the physiology of stuttering and the process of change during a session, it is actually DOING THE CHANGE outside the speech room that results in therapeutic success. I refer to Malcolm Gladwells' book in this blog to illustrate the importance of practice. 'How do you get to Carnegie Hall? Practice, Practice, Practice.'
In stuttering therapy, we are left with the question: Practice what? If a client were to practice 10,000 hours for speech change, what exactly would he be practicing? Here is when knowledge of stuttering and client preference become important. We know that stuttering is more than speech interruptions. It is also negative emotional reaction in a variety of forms. In the book Stuttering (Pro-Ed, 1997), Starkweather & Givens-Ackerman write, "First, most of the behaviors of stuttering are contained in the reactions of the child to the problem...Second, these reactions are accumulated through a development process that is unique to each person...there is no single etiology, but as many etiologies as there are stories of stuttering development." (p.24)
Consequently, it is the client's story that will reveal the focus of practice. For some clients, it will be overcoming avoidances - day after day of courageous attempts to initiate conversation, say those feared words and sounds, seek ways to change a stuttering mindset. For others, it may be speech-motor practice to find and rehearse a new way of sound production, including the carryover of speech tools. For still others, it may include learning social-langauge skills, coping with temperamental predispositions such as extreme sensitivity, unloading negative emotions, adopting a healthier lifestyle or becoming active in an NSA local chapter. In any case, it will take time and effort, time and effort, and more time and effort.
It's January and I've joined the hordes of adults joining gyms. I've made it to Planet Fitness about 3-4 days a week so far. At first, it was actually scary. The stark warehouse-like setting filled with machines was intimidating. Then I felt silly: an overweight woman in her 50's consulting a young personal trainer probably in his early 20's about designing a fitness program. Now, the novelty has worn thin and I just plain dislike going to the gym. I growl every time I drive into the parking lot. But I've been trying to slim down for 13 years and I finally realize it is going to take a much larger chunk of my life than I ever anticipated just to lose a few pounds!
Best to all of us looking for change. :)
Judy
Malcom Gladwell provides several examples. I'll share one with you now, the Beatles. "Lennon and McCartney first started playing together in 1957, 7 years prior to landing in America...In 1960, while they were still just a struggling high school rock band, they were invited to play in Hamburg, Germany...And what was so special about Hamburg?...It was the sheer amount of time the band was forced to play..." often eight hours a day, seven days a week. "All told, they performed for 270 nights in just over a year and a half...an estimated twelve hundred times...They were no good onstage when they went there and they were very good when they came back.'" (p.50)
Stuttering is a complex phenomenon and there is alot for a client to learn. When I began this private practice in 1991, I set out to provide intensive speech therapy. However, I discovered that very, very few clients made the time for or had the interest in this kind of committment. Consequently, I've learned to "meet the client where his is" as they say. I go with the client's level of motivation and do the best I can to provide information and guidance as to how to make speech changes given life's real constraints. Yet regardless of how much we understand the physiology of stuttering and the process of change during a session, it is actually DOING THE CHANGE outside the speech room that results in therapeutic success. I refer to Malcolm Gladwells' book in this blog to illustrate the importance of practice. 'How do you get to Carnegie Hall? Practice, Practice, Practice.'
In stuttering therapy, we are left with the question: Practice what? If a client were to practice 10,000 hours for speech change, what exactly would he be practicing? Here is when knowledge of stuttering and client preference become important. We know that stuttering is more than speech interruptions. It is also negative emotional reaction in a variety of forms. In the book Stuttering (Pro-Ed, 1997), Starkweather & Givens-Ackerman write, "First, most of the behaviors of stuttering are contained in the reactions of the child to the problem...Second, these reactions are accumulated through a development process that is unique to each person...there is no single etiology, but as many etiologies as there are stories of stuttering development." (p.24)
Consequently, it is the client's story that will reveal the focus of practice. For some clients, it will be overcoming avoidances - day after day of courageous attempts to initiate conversation, say those feared words and sounds, seek ways to change a stuttering mindset. For others, it may be speech-motor practice to find and rehearse a new way of sound production, including the carryover of speech tools. For still others, it may include learning social-langauge skills, coping with temperamental predispositions such as extreme sensitivity, unloading negative emotions, adopting a healthier lifestyle or becoming active in an NSA local chapter. In any case, it will take time and effort, time and effort, and more time and effort.
It's January and I've joined the hordes of adults joining gyms. I've made it to Planet Fitness about 3-4 days a week so far. At first, it was actually scary. The stark warehouse-like setting filled with machines was intimidating. Then I felt silly: an overweight woman in her 50's consulting a young personal trainer probably in his early 20's about designing a fitness program. Now, the novelty has worn thin and I just plain dislike going to the gym. I growl every time I drive into the parking lot. But I've been trying to slim down for 13 years and I finally realize it is going to take a much larger chunk of my life than I ever anticipated just to lose a few pounds!
Best to all of us looking for change. :)
Judy
1/2/09
Self-Regulation
Learning a new way of speaking is a learning process. That means it would be helpful to know about how people learn new behaviors. This blog is driven by my observation that some children learn and then carryover new speech skills more easily than others. While we do acknowledge the inherent worth and dignity of each and every speaker by saying "It's ok to stutter," students attend speech therapy to change how they think about, feel about, and actually produce speech. Children, teens, and adults come to speech therapy to become more fluent speakers. So let's take some time to review theories about learning.
SLPs who are members of ASHA will find an overview of learning processes in the article Constructivist Strategies in Phonological Intervention: Facilitating Self-Regulation for Carryover by Ertmer & Ertmer (Language, Speech, and Hearing Services in Schools (1998) Vol 29, 67-75). The topic here is learning new speech sounds, but the issues are the same as we find in learning more fluent speech sounds: "The relatiely slow attainment of carryover by some children suggests that specialized instruction is needed." (p.67) Anyone familiar with and honest about speech therapy for stuttering will tell you that changing speech in the clinic room is much, much simplier than changing speech in daily living. Yet, I've seen it happen. I've seen it happen when clients and I build hierarchies together as they discover how to adopt new fluency skills successfully one small step at a time, one speaking situation at a time.
Now I'd like to know how those success stories happen, because I'm stymied by the students that do not enjoy this progress, not even the luxury of moving 4 steps forward for every 2 steps back. One clue to this mystery is called self-regulation. Wikipedia defines self-regulation with respect to a variety of disciplines. The Social Cognitive Perspective looked most appropriate to my needs as an SLP. The 3 characteristics listed in Wikipedia appear in SLP research literature:
1. self-observation (monitoring one's activities)
2. self-judgement (self-evaluation of one's performance)
3. self-reactions (reactions to performance outcomes).
These 3 processes underlie Kristen Chmela's article Self & Double Charting: A Self-Monitoring Strategy for School-Age Children Who Stutter http://www.mnsu.edu/comdis/isad9/papers/chmela9.html . I really like this article, but, when week-after-week, an individual client is not showing enough progress for his efforts, then what? I've attended too many National Stuttering Association meetings in which I've heard adults complain in pain that their SLP accused them of not trying hard enough and of somehow personally falling short in the speech therapy process, that I must help us all - SLP & PWS alike - remove this yoke of blame and move forward toward success.
Ertmer & Ertmer review 3 learning theories and suggest when to apply each.
1. Behavioral approaches are based on stimulus-response-reinforcement principles. Simply put, the client is trained in the new behavior, e.g., 'easy onset', and then earns a reward every time he produces this new behavior. An obvious analogy is gambling. A slot machine provides tokens for the player and it does so just often enough to keep the player playing. In time, gambling becomes a new habit that can be exceedingly expensive and difficult to change.
2. Cognitive-linguistic learning theories rely on "active mental processing and problem-solving principles." (p.68) To my mind, this teaching technique gives us credit for being thinking human beings! Yes, we live in bodies that respond to motor practice and emotional cues, but we can also think, self-talk, and share ideas with others to benefit ourselves and society. In speech therapy, we learn about how personal and environmental influences affect speech. We build hierarchies, join support groups, read self-help literature, and write personal journals. We can think our way to good judgements and healthy lifestyles.
"Behavioral and cognitive instructional techniques are widely accepted methods for establishing correct targets and for transferring speech skills to a variety of linguistic contexts within the therapy setting." (p.68)
3. Constructivist approaches "allow children to create their own understanding of how to use speech skills in linguistically and socially complex situations." (p.69) This is the missing link I was looking for. It is the constructivist approach that is going to help us shift locus of control (personal responsibility) from the clincian to the student. I cannot continue to provide the structure, the feedback, and the reward and assume my clients will carryover new ways of talking into their own lives. While I have always known this, I see it now with new understanding. When a client returns with increased levels of stuttering, I've focused on retraining skills and rebuilding hierarchies. Now, there will be time in speech therapy "to facilitate discovery of the concept of generalization." (p.70) This is a shift to emphasize the development of self-regulated carryover.
Self-regulation is diagramed in a way that most clients will understand on pages 70 & 71 of Ertmer & Ertmer's article. Reflection is an important concept in this teaching technique. The SLP acts "to facilitate understanding ... by asking guiding questions, supplying needed information, directing activity, challenging answers, requiring logical evidence for conclusions, and most important, emphasizing the process of thinking, learning, and problem solving rather than the products (answers)." (p.71) I suppose this happens incidentally anyway in most speech therapy sessions. But perhaps it is time to include constructivist learning theory with more diliberateness as clients take their success in the clinic and experiment with it in the real world.
SLPs can find more information in What Are Executive Functions and Self-Regulation and What Do They Have to Do With Language-Learning Disorders? (LSHSS, Vol 30, 265-273, July 1999) and Self-Regulation and the Management of Stuttering (Facing the Challenge of Treating Stuttering in the Schools, Part 2. Seminars in Speech and Language, Vol 24, No. 1, 2003).
Judy
SLPs who are members of ASHA will find an overview of learning processes in the article Constructivist Strategies in Phonological Intervention: Facilitating Self-Regulation for Carryover by Ertmer & Ertmer (Language, Speech, and Hearing Services in Schools (1998) Vol 29, 67-75). The topic here is learning new speech sounds, but the issues are the same as we find in learning more fluent speech sounds: "The relatiely slow attainment of carryover by some children suggests that specialized instruction is needed." (p.67) Anyone familiar with and honest about speech therapy for stuttering will tell you that changing speech in the clinic room is much, much simplier than changing speech in daily living. Yet, I've seen it happen. I've seen it happen when clients and I build hierarchies together as they discover how to adopt new fluency skills successfully one small step at a time, one speaking situation at a time.
Now I'd like to know how those success stories happen, because I'm stymied by the students that do not enjoy this progress, not even the luxury of moving 4 steps forward for every 2 steps back. One clue to this mystery is called self-regulation. Wikipedia defines self-regulation with respect to a variety of disciplines. The Social Cognitive Perspective looked most appropriate to my needs as an SLP. The 3 characteristics listed in Wikipedia appear in SLP research literature:
1. self-observation (monitoring one's activities)
2. self-judgement (self-evaluation of one's performance)
3. self-reactions (reactions to performance outcomes).
These 3 processes underlie Kristen Chmela's article Self & Double Charting: A Self-Monitoring Strategy for School-Age Children Who Stutter http://www.mnsu.edu/comdis/isad9/papers/chmela9.html . I really like this article, but, when week-after-week, an individual client is not showing enough progress for his efforts, then what? I've attended too many National Stuttering Association meetings in which I've heard adults complain in pain that their SLP accused them of not trying hard enough and of somehow personally falling short in the speech therapy process, that I must help us all - SLP & PWS alike - remove this yoke of blame and move forward toward success.
Ertmer & Ertmer review 3 learning theories and suggest when to apply each.
1. Behavioral approaches are based on stimulus-response-reinforcement principles. Simply put, the client is trained in the new behavior, e.g., 'easy onset', and then earns a reward every time he produces this new behavior. An obvious analogy is gambling. A slot machine provides tokens for the player and it does so just often enough to keep the player playing. In time, gambling becomes a new habit that can be exceedingly expensive and difficult to change.
2. Cognitive-linguistic learning theories rely on "active mental processing and problem-solving principles." (p.68) To my mind, this teaching technique gives us credit for being thinking human beings! Yes, we live in bodies that respond to motor practice and emotional cues, but we can also think, self-talk, and share ideas with others to benefit ourselves and society. In speech therapy, we learn about how personal and environmental influences affect speech. We build hierarchies, join support groups, read self-help literature, and write personal journals. We can think our way to good judgements and healthy lifestyles.
"Behavioral and cognitive instructional techniques are widely accepted methods for establishing correct targets and for transferring speech skills to a variety of linguistic contexts within the therapy setting." (p.68)
3. Constructivist approaches "allow children to create their own understanding of how to use speech skills in linguistically and socially complex situations." (p.69) This is the missing link I was looking for. It is the constructivist approach that is going to help us shift locus of control (personal responsibility) from the clincian to the student. I cannot continue to provide the structure, the feedback, and the reward and assume my clients will carryover new ways of talking into their own lives. While I have always known this, I see it now with new understanding. When a client returns with increased levels of stuttering, I've focused on retraining skills and rebuilding hierarchies. Now, there will be time in speech therapy "to facilitate discovery of the concept of generalization." (p.70) This is a shift to emphasize the development of self-regulated carryover.
Self-regulation is diagramed in a way that most clients will understand on pages 70 & 71 of Ertmer & Ertmer's article. Reflection is an important concept in this teaching technique. The SLP acts "to facilitate understanding ... by asking guiding questions, supplying needed information, directing activity, challenging answers, requiring logical evidence for conclusions, and most important, emphasizing the process of thinking, learning, and problem solving rather than the products (answers)." (p.71) I suppose this happens incidentally anyway in most speech therapy sessions. But perhaps it is time to include constructivist learning theory with more diliberateness as clients take their success in the clinic and experiment with it in the real world.
SLPs can find more information in What Are Executive Functions and Self-Regulation and What Do They Have to Do With Language-Learning Disorders? (LSHSS, Vol 30, 265-273, July 1999) and Self-Regulation and the Management of Stuttering (Facing the Challenge of Treating Stuttering in the Schools, Part 2. Seminars in Speech and Language, Vol 24, No. 1, 2003).
Judy
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