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


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.


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
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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.