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

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 http://www.journalofstuttering.com/1-2/Reitzes.2006.JSTAR.1.64-78.pdf . 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

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, http://www.linguisystems.com/) 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 http://www.speechbin.com/. 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 http://www.mnsu.edu/dept/comdis/kuster/Parents/starkweather.html . 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

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
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.