11/7/10

DIVA

Speech science offers clues to managing the problems of stuttering and cluttering.

Speech scientists study how we transform ideas into spoken words. They construct hypothetical models to explain these processes. A recent research development will change my speech therapy. It has to do with a computer model that can actually produce both fluent and stuttered speech. This model suggests that persons who stutter may not have accurate motor commands – feedforward commands – telling the oral motor system what to do. And, another related article proposes that inadequate feedback affects speech. (1) To my mind, this means speech therapy needs to spend a whole lot more time on whatever tasks elicit the most fluency instead of pressing onward to more difficult speaking tasks.

The speech model I am referring to is called the DIVA model. (2) Computer simulations of this model produced stuttered speech when manipulated in very specific ways. I cannot explain the mathematical calculations that caused the speech changes. However, the basic idea is easy to understand…

The DIVA model proposes that our brains issue motor commands to speak. The motor command seems to be for an entire sentence, so as to plan for “co-articulation.” Co-articulation refers to the slight changes we make when pronouncing an /i/, for example, based on what sounds come before and after it. The way we articulate /i/ in the word “mine” is slightly different that the way we articulate /i/ in “fight.” The DIVA model speculates that when a person mispronounces a sound, an internal “speech monitor” tries to correct the error by turning off the voice, “repositioning the articulators,” and starting over again. (3) This causes sound and syllable repetitions.

The ‘speech monitor’ depends on feedback. We rely on feedback for a variety of tasks. When I turn on the water to wash dishes, feedback from my hands tells me if the water is too hot or too cold. I use visual feedback while driving when I look at the speedometer to check how fast I am driving. And when speaking, I rely heavily on auditory feedback to be sure my speech is clear and my words express my message.

The Fall 2010 issue of The Stuttering Foundation newsletter refers to the DIVA model in a front page article, “Feedforward Strategy in Children.” (4) The author explains that he is going to study co-articulation skills in children who stutter to learn more about their speech motor planning skills. If children who stutter show poorer co-articulation skills compared to fluent children, then this would support the theory that inadequate feedforward commands could be to blame. In other words – if this theory is correct - children who stutter find themselves in mid-sentence having to change their articulation of sounds because of faulty motor planning at the very beginning of the sentence.

The April 2010 International Cluttering Awareness Day online conference includes a paper about the DIVA model. It even includes a diagram of the model. This paper suggests that a speaker’s “…feedforward mechanism may be relatively intact, so that he is aware of the appropriate sounds to produce…however, if the feedback system that includes both auditory [hearing] and somatosensory [touch] has not been providing the appropriate feedback, then the feedforward mechanism may be ‘faulty ‘ in that it may not be properly tuned.’” The article recommends a variety of ways to help the speaker increase awareness and improve feedback monitoring.

I’ll continue to experiment with new ways to provide feedback: digital video and audio recordings, delayed auditory feedback, and Audacity® in addition to traditional token reinforcement and verbal praise. But, now I will think in terms of practicing the correct output much more frequently.
also, I will be doing alot more modeling in order to provide the fluent model. Maybe this will help fine-tune the feedforward system. As usual, results will be different for each student. It will be interesting to see what session data reveals.

(1) Leahy, M. (2010) “Monitoring feedback as you speak: how DIVA contributes to explaining a part of the problem of cluttering, and to developing a therapy plan. http://www.mnsu.edu/comdis/ical/papers/leahyc.html

(2) Boston University Speech lab, http://speechlab.bu.edu/diva.hph (This link was broken today.)

(3) Civier, O. , et. al, (2010) “Overreliance on auditory feedback may lead to sound/syllable repetitions: Simulations of stuttering and fluency-inducing conditions with a neural model of speech production” Journal of Fluency Disorders, 35, p. 266

(4) http://www.stutteringhelp.org/portals/english/fall_newsletter_2010_web.pdf

9/25/10

Teaching is Finding Success

Children are demanding. They need fun, attractive games that hold their attention. While my speech therapy must be evidence-based and reference professional programs, it also has to be tailored to the needs of individual students. And so I’m always looking for commercially available games and then changing the rules of play so that they transform into speech therapy activities. Sometimes this is on the fly. During a speech therapy session, the parent, child, and I play around with changing game rules so that play is instructional as well as fun.

I recently purchased the game “Pickles to Penguins” (Imaginationgames.com, © 2009) because it looked like a colorful, child-friendly game that was reasonably priced. This blog is a description of how I will use this game to teach. Teaching means giving away the answers! Teaching means finding lots of ways to help a child discover/practice/play with the answers. Many games are packaged as competitive tests. There are time limits, scores, and demands for correct answers. I’ve listed some ways that the “Pickles to Penguins” game will become cooperative and informative.

It is my job to determine appropriate teaching goals through formal testing, observations, and collaborations with school staff and parents. Once goals are defined, I need to know how well the child performs these goals in a teaching activity. If the child performs well (based on a specific criteria), then the goal needs to be changed. There’s no point in teaching something the child already knows. So how will I know if a game is an effective method of teaching?

Before we play our very first game, my student will respond to what is called a “baseline” measure. He will perform the goal behavior without any hints or corrective feedback. I will record how well he achieves this task.
For one particular student, the baseline will be an audio recording (using a small digital recorder and clip mic) of his responses. The cards used for the baseline measure will not be the cards we play with. The cards used for the baseline measure are set aside and used at a later date to measure progress. Next, we will take a different deck of picture cards and begin to modify play based on the student’s responses. We play and play and play!! We change around the game rules and play again! (Don’t I have the best job in the world?)

After a period of time, we return to the cards used in the baseline. Once again, the child performs the goal behaviors without any hints or corrective feedback. If therapy was effective, the child will generalize his new skills to the baseline set of picture cards. His performance after therapy should be of better quality, include more examples of the goal behavior, than his performance at baseline.

Here are some ways we will play with the Pickles to Penguins game cards. I’m sure there are many more ways beside those I’ve listed. Specific fluency goals are added onto to each task, though not listed here.

• Modify the game as needed to achieve success.

o Slow down speech rate to slow the pace of the game
o Increase pause time to provide extra time for speech processing, coming up with ideas, word retrieval to express the ideas, sentence formation, speech production
o Consider bonus points for multiple responses. This will work only if it does not increase frustration or time pressure and if it does not increase competition.
o Use “personal best” scores as a way to be competitive. Encourage players to increase their own scores from previous times they have played.
o Select the number of cards per game based on the attention span and reward needs of the child. Several games using only 20 cards per game may be more fun for a child who needs to finish quickly and see scores improve across games asap.
o Use the same cards over and over again if needed to ensure success. E.g., play 3 times with the same 20 cards, then add 10 more new cards.
o Consider using a timer (like the hour glass or liquid drip timer) as an aid for increasing thinking time…e.g., 1 minute of thinking time is required before responding
o Team/cooperative play is a way to role model
o Plan to use the same answers you came up with together during the Review/Teach process. This will help with long term memory and with increasing success and confidence.


• Review/Teach the cards before playing.

o Spelling:
 Take turns holding a card out of sight of the other players, reading the word, asking each player to spell the word aloud or in writing on paper or in the air
 Take turns holding a card out of sight of the other players, spelling the word, asking each player to listen to the spelling and guess the word
 Sort through the cards together looking for a particular kind of spelling pattern. Be sure to take a few cards and write the words so that this is not just a flash card/recognition activity.
 Before reading a card, give a clue, e.g., “This word has the double vowel [ea] in it.” Remember, this is a teaching time and anything that helps correct repetitive practice makes playing fun and effective.
o Segmenting: take turns holding a card out of sight of the other players, read the word by omitting an initial or final sound (or a syllable) and ask the players to listen and guess the word by adding the missing sound
o Meanings: Take turns holding a card out of sight and talking about the picture and ask players to guess what the word is.
o Go through the cards and select which cards would be fun to play with. These will probably be cards that are most familiar and so the first several games should be successful. Be sure to include less popular, more difficult cards in later games.
o Talk about the cards:
 Word association: What single word(s) pop into your head when you read each card?
 Adjectives: What describing word(s) do you think of when you reach each card?
 Put each word in a sentence.
 Select 2 or more cards and make a story.
 Smell/touch/sound: Think of sensory experiences for each card (donkey feels soft, bean bag chair makes a squishing/crinkling sound when you sit in it)

There are lots of ways to play in multisensory ways. I haven't listed craft, role play, patomime, and music activities . Every teacher has personal preferences and talents that he/she brings to the lesson. Every parent does as well. Bring everyone's strengths to the teaching situation. Have fun!

Vocabulary Instruction for Children and Adolescents With Language Disorders, 2006, ASHA Professional Development Self-Study 7570

9/22/10

New Beginnings: Stress & Relaxation

A few of my students are beginning this academic year in new settings. Two are freshmen in college, one nearby and one quite far away. Two students are beginning middle school. And my own son began this year at a new school. The transition is stressful and can be downright frightening.

The middle school day is divided into periods. Students move from classroom to classroom, encountering a different teacher for each subject. Peers shuffle in the hallways, reconfiguring into distinct groups for each class. Time is limited to 5 minutes or less between classes during which padlocks on lockers must be opened, books retrieved, and quick friendly greetings exchanged if one is lucky enough to see friends passing by in the hall. Lunch is rushed and squeezed into a range of time slots so that it may be brunch one day and a mid-afternoon snack on another. When does one get to the bathroom!? And middle school means homework in several subjects to keep track of, including short and long term projects, quizzes and tests, and worksheets of various degrees of difficulty.

College takes all these changes and magnifies them. Now classes are in different buildings scheduled across days and include term papers and exams covering months of material. Peers may include students from other cities, other states, maybe even other countries. Living away from home requires multiple attempts at an independent healthy lifestyle: eating nutritious meals, getting enough sleep, managing time and making safe choices.

It’s all very exciting!

The adjustment process takes trial and error, success and failure, elation and pain, hard work, self-confidence and faith. I suppose there are lots of ways to approach dramatic changes such as these. Relaxation techniques may be helpful for some people. I mention this because a mom recently asked me if relaxation techniques would help her child’s speech. And so, I took a look around for some quick and easy suggestions.

There are different kinds of relaxation techniques that all seem to have the same general goal – to consciously and deliberately find a feeling relaxation to replace feelings of stress. Relaxation techniques take only 10 minutes or so and, with practice, can help us to relax almost any time we need to “calm down”, focus, think more clearly, and behave more carefully. Stuttering is not caused by stress, but, stuttering can be affected by stress. It can be easier to focus on speech and communication when we are more relaxed.

Here is a video of the famous Dr. Herbert Benson talking about the relaxation response.
http://abcnews.go.com/video/playerIndex?id=7392433 .

Here is a website that also describes the relaxation response. http://www.mgh.harvard.edu/bhi/basics/eliciting_rr.aspx.

A surf through YouTube revealed a few videos I happen to like….

Here is a simple video that describes how watching clouds can lead to a feeling of relaxation:
http://www.youtube.com/watch?v=P-ygq1W681A&feature=related

Here is a video of rain: http://www.youtube.com/watch?v=NgG4vDfcJek&feature=related

I liked this children’s meditation, even for middle schoolers: http://www.youtube.com/watch?v=7RmwNr5dSTg&feature=related

Here’s one that takes you through progressive relaxation:
http://www.youtube.com/watch?v=HFwCKKa--18

I make it a point to stop for about 15 minutes every day and just sit. When I’m lucky, I sit outside. Sometimes I write down the to-do list that perpetually crowds my thoughts. Released from this burden, I begin to hear the subtle sounds around me and then notice the more substantive ideas lurking between my ears. Back and forth I go: notice the rustle of leaves, eliminate a task I don’t reeeally need to do, feel the sun, re-prioritize projects, notice my breath, remember to write a friend, and relax into the important over the urgent.

I wish for my students to have faith in themselves and to act in new ways that will keep them to be healthy, safe, and successful.

8/3/10

Hope

“Experiences cause structural changes in the brain, sculpting synapses in profound ways. This ‘plasticity’ of the brain has been demonstrated by neuroscientists over the past decades.” (p. 189-190). This statement, which I have taken from the book The Anatomy of Hope,* is a crucial concept in speech therapy. It justifies the therapeutic process. There are times when the small step-by-step process of speech change seems to take so very long. But we persist because we expect to alter speech production pathways in the brain.

Let’s imagine, for the sake of simplicity, that neurons in the brain are organized like a road map. This is an analogy that children may understand. Some children spend a lot of time traveling short distances to sports and school events or long distances to vacation spots. Parents teach map skills by highlighting routes and talking about roadways, exit numbers, and geography. Stuttered speech is like driving on a bumpy road in rush-hour traffic! It can be uncomfortable, stressful, stop-and-go, include wrong turns, and involve some unpleasant interactions with others.

Speech therapy is road construction. The child, parent, SLP and other helpers, team up to build new roads along which a child’s ideas can travel through his brain to his mouth more easily. The new roads, the new neural pathways, take time to build and are constructed with care. During this construction phase, it is the expectation of a better road, the hope of an easier route, that helps us to be patient with the process.

In The Anatomy of Hope, the author seems to say that hope is essential to change. “Hope can arrive only when you recognize that there are real options and that you have genuine choices. Hope can flourish only when you believe that what you do can make a difference, that your actions can bring a future different from the present. To have hope, then, is to acquire a belief in your ability to have some control over your circumstances. You are no longer entirely at the mercy of forces outside yourself.” (p. 26)

Stuttering involves loss of control. Stuttered sounds seem to occur at random and then much later appear to be predictable on letters such as /b/, /s/, or /g/. This loss of control leads to struggle, anticipation anxiety, and avoidances. Listeners don’t understand what’s going on or know what to do and soon the person who stutters finds entire conversations out of his control. Some outside force, unknown even to the experts, wreaks havoc with speech and communication.

SLPs have no cure. Yet, they do offer hope in the form of speech therapy that encourages self-acceptance, behavioral changes, and ways to educate listeners. SLPs must convey the multiple messages: we can’t “fix” you (you are not broken) but we can give you reasons to hope for improvement. We cannot minimize the effort that will be required. We prepare for a speech therapy process that involves education, experimentation, trial and error, team work, persistence, and hope.

In The Anatomy of Hope, there is one cancer patient in particular who is also a cancer doctor. He selects an extremely intensive series of treatments that no doctor would ever recommend because of the debilitating side effects and uncertain results. This patient/doctor explains, “’I knew all the arguments made in cases like mine…I find these arguments patronizing…Most patients don’t really understand what’s happening to them… because they’re not clearly told the odds by their doctors…I, of course, had a crystal-clear understanding of my chances. And it was my right to choose what I did.” (p. 75)

This doctor was cured and later “he visited cancer patients in the hospital who were losing hope. He was an inspiration. His survival showed them that there is inherent uncertainty in the behavior of even the worst diseases…He sought to assist people in making choices that addressed their own particular needs, desires, and beliefs.” (p. 78)…To hope under the most extreme circumstances is an act of defiance that…permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.” (p. 81)

After much research into the concept of hope, Dr. Groopman suggests that realism plus positive physiological change is necessary to achieve positive emotional change. Therefore, he recommends that early treatment be designed to give patients some kind of immediate physiological improvement. With this in mind, I am spending more time encouraging my students to complete very simple, very successful speaking tasks at the beginning and at the end of every session whenever possible. I am relaxing my own, egocentric, need to see “progress” along any hierarchy, so that the student can experience speech success at whatever level that might be.

“Kindling and sustaining hope depend not only on images that may be conjured in the mind but also on how those images are brought into focus or blurred by the ongoing input of nerves from organs and tissues to the brain.” (p. 181) Students must experience success and understand how they were responsible for it. If SLPs push too hard, our students may experience more failure than success. Given the messages in The Anatomy of Hope, perhaps whatever cognitive therapy approaches we favor might be most effective when accompanied by carefully planned behavioral training that ensures speech change, even if that means slower “progress” along a hierarchy. Let’s remember that speech therapy is for the student’s benefit, not the SLP’s need to document professional competence.


*Jerome Groopman, M.D. (2005) The Anatomy of Hope: How People Prevail in the Face of Illness, NY, NY: Randomhouse, Inc.

7/25/10

Carryover at the Restaurant

Here is one way to go about carryover for ordering food:


• The numbers below are a rough scale estimate of how difficult each task is. For example, we know that talking at the same time that other people are talking is usually the easiest, so, “choral speech” is #1.

• Some places, such as the speech therapy room, are easy places to focus on speech goals. There are few fluency disrupters, little time pressure, and sensitive listeners at speech therapy. Other places have more time pressure, insensitive listeners or more difficult language demands. The ratings should be changed to reflect individual speech experiences. Then, beginning with the easiest choices, one can design carryover homework.

• The adult helper should prepare the child for each assignment. The adult talks about what will happen and rehearses the homework with the child.

• The adult is also responsible for resisting time pressure. To do this, the adult adds lots of pause time into the conversation, trying to make these delays as natural as possible. For example, when a waitress asks, “Can I help you?” the adult could say a friendly “uuuumm” while making it look like he/she needs just a few more seconds to decide what to order. Pauses like this deliberately slow down the pace of the conversation so that the child who stutters feels less time pressure. Then, a secret signal to the child indicates its time to talk. For example, after a few seconds, the adult might look at the child, smile and nod. After this special nod, the child and adult together look at the waitress and say their rehearsed lines.


Speech

#1. Choral Speech: The child and one or more others say the same words at the same time. For example, together they say, “I want a small ice cream cone, please.” Because the purpose here is to be successful at ordering something to eat, everyone doing this has to agree to order the same thing. Maybe the only person willing to help out is a parent who doesn’t mind getting the same ice cream as the child just so that the child can complete this homework assignment! If no one is willing to order the same thing as the child, then, immediately after ordering, the helper can change his/her mind and say, “Oh wait, I want a large ice cream.” This may also mean spending a few extra dollars for speech practice. An adult helper may not really want to order anything, but orders just to help the child have a successful speech experience.

#2. Choral Speech & fill-in-the-rest-of-the-sentence: The child and one or more others say the same beginning words of a sentence only. Then, child finishes the sentence alone. For example, the child and other(s) might say together, “I want a…” and then, the adult pauses naturally as if trying to decide while the child says all by himself “… small vanilla.”

#3. Changing the sentence: Use strategy #2 or #3 and say something different. For example, if you spent a week saying “I want a…”, then spend the next week saying “Do you have…? Of course, you may already know that the restaurant has what you are asking about. That doesn’t matter because what you are really doing is speech practice. If you are successful with saying “Do you have…?” for a week, trying using a different sentence each day of the following week. Note: you will be doing a lot of ordering so that you can do a lot of speech practice, so you might want to order something inexpensive!

#4. Imitated speech: The adult helper models the sentence; then, the child imitates most of the model to order independently. For example, an adult helper could say, “Do you want a vanilla?” and then the child looks at the waitress and says, “I want a vanilla.” Note: The adult needs to model whatever strategies the child uses. So, the adult might slightly slow down their speech rate and add easy onsets, continuous voicing and phrasing and ask the question like this, “Doooyouwant / aaavanilla?”


Most of all, try to have fun with this; that will help reduce anxiety!!!!

6/17/10

Wild Speech Monsters

It can be helpful for some children to illustrate their stuttering. This gives them a way to separate the behavior called stuttering from who they are as people. The child stutters - it is something that he/she does, not something that is inherently a part of who the child is. With this approach to therapy, the child takes the stuttering and puts it outside of him/herself in the form of a picture, sculpture, craft, or project. Some children may make friends with this depiction and negotiate a truce as his/her speech improves. Some children may benefit from releasing anger and frustration at it by destroying it in some way, such as smashing a playdo figure or ripping up a drawing. In both cases, children may experience a greater sense of control over their 'speech monster.' *

Where the Wild Things Are, the original cartoon version of the book, could be a helpful story when teaching this point of view. One simple description of the story is that a little boy finds a way to manage his angry emotions. They are monsters that he tames, plays with, and leaves behind. Perhaps in the same way, we can teach children to play with and tame their speech.**

*http://www.mnsu.edu/comdis/isad7/papers/shields7.html
**http://childrensbooks.about.com/cs/picturebooks/fr/wildthings

6/9/10

Scaffolding

"Scaffolding" is support. In education, scaffolding refers to the amount and type of supports children need to succeed. (1) In speech therapy for stuttering, scaffolding, to my way of thinking, is when a parent schedules time for speech homework, praises a child's efforts, looks for creative ways to practice speech goals, offers tangible rewards, asks about her child's feelings, helps him plan for speaking situations and educates others about stuttering.

Scaffolding occurs at every level of a hierarchy of goals. Practicing 'slow/gentle sounds' (my term for easy onset) at the one-word level is one step in a hierarchy. At the one-word level, a child completes a variety of speech therapy activities. Hopefully, the activities are designed to be games that parent and child play together. In my practice, these games include language processing tasks: auditory memory, phonological processing, word finding, vocabulary building, auditory comprehension and reading. There are many possible activities at each level of a hierachy.

The rules of each therapy game describe how the adult will provide scaffolding. Before a child responds, the adult gives a prompt. The prompt is a form of scaffold. The prompt may be a direct instruction like, "use slow/gentle beginning sounds." When the child is able to use slow/gentle sounds more automatically, instructions become less direct. The adult may only need to say something like, "Let's play a speech game." The fact that it is a speech game will cue the child to use whatever skill she is practicing. After a child responds, the adult gives some kind of feedback about the correctness of that response. The feedback is a form of scaffold. It is often a token. Tokens come in many forms: pennies, check marks, stickers. How much and how often a child earns tokens gradually diminishes and tokens are replaced by verbal praise.

Scaffolding should also increase empowerment and independence. For example, there will be times when the parent determines the time for speech homework and sits down with her child to compete activities together. Then, gradually the parent does something else, such as making dinner, while the child performs speech homework in the same room as the adult. (Stuttering varies with each speaking situation, so, homework should almost never be completed alone. The child needs to talk with someone while practicing speech skills.) Eventually the child should be responsible for approaching her parent and saying, "Let's play a speech game now." It is important for a child to learn to take responsibility for his own speech homework, because there will come a time when he will need to choose when to try out his new speech skills in everyday life.

This concept of scaffolding in my own life became apparent when I attended a student's graduation party. This young man's progress was accomplished with the assistance of other speech language pathologists in addition to myself. So, I was surprised to learn that I'd made an significant difference in his life and I was delighted to be invited to his family celebration. But I was also anxious because I am not a 'party person.' I really enjoy one-on-one and small group interactions, but fail at larger group gatherings. I typically hover at the fringe at such occasions and eventually meet other guests doing the same. An additional complication for this event was that I would need to avoid any break in patient confidentiality. After introducing myself, I would have to dodge any questions about what this student and I had done in speech therapy.

I was the first to arrive. That meant I could share his parents' pride right away. As more guests arrived, I soaked up the sunny afternoon in what was a beautiful location and sampled from a delicious buffet. After a while, it became apparent that the adults were distancing themselves from the teens by gathering on an elevated deck. I realized that finding my conversational partner(s) was going to be too much of a challenge with this arrangement. After some time, someone offered me the scaffolding I needed by bringing two guests over to chat with me. I appreciated this gesture and shared in several minutes of conversation. When these guests said their goodbyes so did I. This was a carefully prepared party, but I needed more scaffolding in order to mix with the other adult guests. But, then again, this was a family affair, and there really was no need for me to linger long. I left satisfied with my visit and gratified to have made a difference in someone's life. Its what all SLPs truly hope to do.

(1) http://condor.admin.ccny.cuny.edu/~group4/

3/30/10

Speech Therapy at the Mall

Occasionally, I can take speech therapy out of the clinic. I’d like to share a visit to the mall this weekend with one of my students that was unusually successful.Seven strangers initiated conversation with us in one hour. My student took the initiative for an eighth conversation that provided just the right amount of stretch and for which he could be proud. Luck is the meeting of hard work and opportunity and we had good luck on this outing.

I’ve taken speech therapy out of the clinic only a handful of times. When I did, the student had been with me for more than a year, made excellent progress in the clinic, had faith in the therapy process, and trusted me to present this new challenge carefully. These conditions must be met because so much therapeutic control is lost in the real world. Internal and external fluency disrupters present themselves often without warning. I always seem to underestimate the power of the internal, emotional influences that lurk unseen within my students. The student who can express his anxieties, concerns and perception of events on a speech therapy field trip is a priceless asset! His feedback helps me to modify expectations moment – to – moment.

Our first encounter was with an elderly gentleman pushing a walker and his friendly wife. They were looking for ‘the main entrance’ to the mall so that they might find their car. “Hey there young fella!” the gentleman called out to my astonished and unsuspecting student. I paused, waiting for his response. He looked at me, realized I was not about to ‘save’ him, and then gave the man directions to one of the mall entrances. As they shuffled off, I chuckled to myself about how these senior citizens had unknowingly broken through my student’s anticipation anxiety right off the bat. We were on a roll already and it was only 10 minutes into the session.

We walked through the crowd for about 5 minutes to observe non-verbal behavior. Then, we stood at the railing of the third floor as I pointed out the significance of specific nonverbal behaviors we had seen. I described a young vendor’s attempt to sell us jewelry. The vendor moved into our personal space, made friendly eye contact, spoke slightly loudly, asked us to look at the jewelry she was selling to benefit charity. All of these individual behaviors synthesized into a gestalt that my student would later recall to aid in his own personal assignment. My resource for this discussion came from a book about children with learning disabilities. (1) This book recommends “Social Scanning Skills” in which an adult assists the child in “observing and analyzing the social interactions of others.” Then, the child learns to recognize, reflect, and react: observe his surroundings, think about behavior options, and then choose responses thoughtfully.

We spoke with 4 people at a video game store. Two of these interactions were distinct and gave us plenty to talk about later. One of these interactions occurred with a teen who looked to be about the same age as my student. He walked up to us and casually commented on a special mouse my student coveted. “That’s not worth the money,” he said. I responded quickly, hoping to invite the teen to stay and chat. He did. He made inviting eye contact, left plenty of silence for my student to speak, asked for clarification, maintained topic, and then wandered off. He couldn’t have offered a more perfect peer experience. The second interaction occurred with an employee, a man perhaps in his 30’s. He was abrupt, spoke and moved rapidly, never asked us a question, showed us a notebook full of type too small to read, and left no time for us to talk! His eye contact was cold and he appeared to have many better things to do besides chat with us. The contrast between the 2 speakers was almost comical.

It was my student’s idea to engage a sales clerk in conversation about a specific product. And so we entered a Brookstone with this goal in mind. I decided it was time to encourage some independence and suggested he have this conversation without me by his side. I was surprised by his reluctance to follow through once we were in the store. Again, I had underestimated the internal drama that can rage within people who stutter. Twice I nudged him to approach a sales clerk, direct him to a specific product, and ask for more information. Finally, I pushed, informing him that we were nearly out of time and were not leaving the store until he had performed this task. It was time to test the trust we shared. I felt this was a task he could succeed at, despite his apparent sudden paralysis. Thank goodness this time I was right. As I purchased a small item for myself, I noticed that he had indeed found his courage and achieved his goal.


(1) Lavoie, Richard (2005) It’s So Much Work to Be Your Friend: Helping the Child with Learning Disabilities Find Social Success, New York, NY: Touchstone, Simon & Schuster, Chapter 12, “Appropriate Social Skills in Public Places” pp. 293-304.

(2) Another resource for social skills information can be found at www.socialpragmatics.com

3/9/10

Language Development & Stuttering

Developmental stuttering begins during a time of dramatic language learning. In this blog, I will share an article about vocabulary development and stuttering. (1) Many, maybe most, of my students seemed to have above average language skills. My students also often present with mild articulation errors, a history of articulation therapy, or were late talkers. My caseload over the years has featured children who were eager to grow linguistically while their speech motor systems appeared unable to keep up. It’s been hypothesized that “advanced language during early development may set the stage for fluency breakdown because language behavior is not synchronous with other aspect of development.” (p.62)

I offer parents the superficial hypothesis that some children may stutter because of a ‘mismatch’ between their language abilities and their speech-motor skills. Speech requires precise and extremely efficient coordination between several systems. “ …sentence production occurs incrementally, and as children begin to use more complex sentence structures, disruptions occur as a result of some ‘glitch’ in the formulation of the sentence.” (p.58) So, 3-year olds who have the language skills of 6 year olds may experience disfluency because ‘their mouths can’t keep up with their ideas,’ as the popular laymen’s explanation goes.

Nancy Hall’s article takes this hypothesis a step further by investigating vocabulary development specifically. Perhaps the ‘glitch’ is a child’s ability to get at the words he needs to express all those ideas in his head. Research has consistently found that children who stutter (CWS) “typically stutter on function words more often than on content words” (p.61) and that this corresponds with clause boundaries. Function words include articles (e.g., a, the) and conjunctions (e.g., and, but) and these tend to occur the onset of sentence parts. For the sentence, “I went / to the store / and bought / a new shirt”, we teach children to use easy onset and pausing at the slash marks because research tells us these are locations where stuttering most likely occurs. The words “to, and, a” are all function words.
However, this pattern changes over time. Children older than 6 begin stuttering more frequently on content words.

I like this puzzle: is stuttering a “delaying strategy” (p.61) while the child maps the syntax (grammar) of sentences OR retrieves the vocabulary he needs to express his thoughts? Children ages 2-6 learn the syntax of their native languages. They learn when to use “I” instead of “me”, work out noun-verb agreement, verb tenses, prepositional phrases, and what linguists call the “deep structure’ of language. Around age 6 years, the child begins school and its vocabulary development that becomes more intense as state curriculum frameworks emphasize English Language Arts in a formal way. Around 4th grade, lexical skills again leap ahead as children move from‘learning to read’ into ‘reading to learn.’ Multisyllable words require children appreciate derivational morphology to decode and comprehend more and more challenging academic material.

So, how do children learn vocabulary? Children learn some new words very quickly, after hearing them only a few times. The technical term for this is “fast mapping.” Other words are learned via “slow mapping”, in which children compare new words with those already in their vocabularies.

Consider the subtle differences between “succeed”, “achieve”, and “accomplish.” Children learn large categories of words (foods, feelings, objects) as well as syntactically different words (verbs, adjectives, multisyllabic word derivations). Researchers who study child language development have found several ways in which children make mistakes with words. This leads them to suppose ways in which insufficient lexical development might contribute to fluency breakdowns that serve a purpose. “The breakdowns…serve linguistic functions while the child attempted to revise of repair linguistic errors, or to buy formulation time while not relinquishing her conversational turn.” “These disruptions may result in the retrieval of a closely related but incorrect lexical item, or the presence of a place-holding disfluency, such as “um”, while a child attempts to retrieve a particular word. (p.58)
“It is the combination of a vulnerable speech production system and sensitivity to breakdown in CWS that sets the stage for overreactivity to glitches and subsequent tension in their attempts to repair the glitches.” (p.59)

This article does NOT suggest that CWS necessarily have a language delay or disorder. However, assessment and treatment need to take into account a child’s language development, perhaps ‘strengths and weaknesses’. “In particular, establishing the lexical/semantic level at which a child can maintain fluency or manage stuttering is important.” (p.65) And, there may be children for whom “…the clinician may need to include direct work on language competencies as well as the stuttering behaviors.” (p.65) This article supports language-based intervention for some children who stutter.

(1) Hall, Nancy E. (2004) Lexical Development and Retrieval in Treating Children Who Stutter, Language Speech, and Hearing Services in Schools Vol 35, pp 57-69.

3/1/10

Cause & Effect in Speech Therapy

Thomas W. Powell designed a comprehensive diagram to illustrate the many variables that effect progress in speech therapy. It took me several minutes to understand this graphic because it does include so many influences that the Client, Clinician, Environment, and Treatment method bring to the therapy situation. This diagram appeared in an article about oral-motor treatments for speech sound disorders. However, I think it can be adapted to speech therapy for stuttering.

"Cause and effect diagram illustrating selected sources of variance that may impact the outcome of intervention for children with developmental speech sound production disorders." Figure 1. page 376 in "The Use of Nonspeech Oral Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions", Language, Speech, and Hearing Services in Schools, Vol. 39, pp 374-379, July 2008

2/27/10

Appropriate, Effective Treatment

The conference title was “Unique Challenges and Common Themes in Stuttering Assessment, Treatment, and Research.” It was January 29-31, 2010 in Tampa, Florida. This was my 5th ASHA Special Interest Division 4: Fluency and Fluency Disorders conference and I was thrilled to attend. For 3 days I wallowed in workshops related stuttering. So did more than 100 other professionals equally interested in this esoteric topic. At home, I am the Sole Proprietor of a private practice that caters to stutterers exclusively. It can be a lonely career choice! However, at The National Stuttering Association and SID4 conferences, I meet with colleagues who are also fascinated by and committed to speech therapy for stuttering. I always return home refreshed and enthusiastic about new practice goals.

Jennifer Watson’s (1) presentation on Sunday morning was brilliant. She must have been paying close attention the previous 2 days because her topic drew directly from the presentations of Friday and Saturday. The title of her talk was “Research and Clinical Connections in Stuttering: Busting Barriers and Building Bridges.” I really appreciated her effort to review some reasons why it is difficult to translate current research immediately into therapy practice. She reviewed the current Framework for Evidence Based Practice (EBP) - a triangle, the three of points of which represent Current Best Evidence, Clinical Expertise and Client/Patient Values. Dr. Watson felt EBP should be represented by Venn diagram of interconnecting circles (rather than a triangle) to illustrate how important it is that research, clinician, and clients impact one another. There needs to be more communication between these three stakeholders in order to make progress in the field.

Dr. Watson recommends a “Deployment-Focused Model of Intervention Development and Testing.” I cringe at the military connotations the word ‘deployment’ has for me; nevertheless, her point is that all research and practice in the field of fluency and fluency disorders must has some genuine relevance to the real-life conditions in which speech-language pathologists work and persons who stutter live. The gems in her argument included:

•Improving client-to-treatment matching: Which treatment protocols work the best for which client profiles?
•Identifying change mechanisms: Are there key elements that promote and support client progress, for example, the concepts of “therapeutic alliance” or “stages of change.”
•Changing from a mentality of “best” treatment to “best fit.” It’s unlikely any one person is going to devise the “best” treatment for all persons who stutter. Clients are individuals and stuttering may be a heterogeneous disorder, which means, one-size will not fit all.

Walter Manning (2) had opened the conference with “Clinically Significant Change for Persons who Stutter” in which he statistical differences that indicate significant research findings are qualitatively different from clinical differences that indicate client satisfaction. Dr. Manning reviewed several ways to consider the client’s point of view. He emphasized that emotional and cognitive goals are equally as important, if not more so, than speech fluency goals in some cases. He recommended The Anatomy of Hope (3). He referred to a Contextual (or Common Factors) Model of therapy with the “therapeutic alliance” as a key ingredient to progress. Building such an alliance requires frequent, honest input from the client and Dr. Manning reviewed several methods for doing so. Constant client input ensures that the client is designing personal goals and taking ownership of the change process. It also detects any initial breakdown of the “alliance” so that immediate repairs can be made. One of his slides stated: “It’s not so much the presence of a positive relation but the absence of positive qualities that is strongly correlated with poor outcome. Thus, it is the negative feelings about therapy that need to be addressed.”

This conference highlighted the clinical relevance of research but I was incredulous when a speech-language pathologist challenged the relevance of Dr. Luc D’Nil’s brain imaging studies during a small group round table discussion. I thought the studies were fascinating, enjoyed reading articles by this particular researcher and felt her comments were disrespectful. Dr. D’Nil’s credibility and character only increased in my eyes when he graciously acknowledged the woman’s complaint and raised her issue again on Sunday when 5-minute summaries of each session were shared with the entire group. I find these conferences allow me a glimpse at the people behind the names I read in professional journals and faces I see on International Stuttering Awareness online conferences. I discover professionals in the field I really like and wish I could get to know better. They are the ones I rely on to guide my own clinical decision making. They are the names that are footnoted in my clinical reports.

I’m looking forward to the next time I can attend a SID 4 conference.



(1) Jennifer B. Watson, Ph.D., CCC-SLP, ASHA-F, Texas Christian University, Forth Worth, Texas.
(2) Walter Manning, Ph.D. The University of Memphis
(3) By Jerome Groopman, (2005) NY: Random House, Inc.
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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.