12/30/11

Orton Gillingham: Ideas for Speech Therapy



I just learned another way to blend literacy with speech/language therapy. I just completed a 30-hour training course to become Certified in Orton Gillingham (O-G) (1). I was looking forward to learning this popular alternative to teaching reading and writing.  What I didn’t expect, was to come away from this O-G course with the realization that private speech therapy has become an alternative rather than a supplement to public education.

The O-G course was a week long, thoroughly pragmatic description of how to teach reading. Ten of the 12 participants were classroom teachers. One was a parent home-schooling her child and the other was me. The instructor was enthusiastic, patient and knew the material inside and out. There were frequent conversations about how lessons could be adapted for specific children and settings. I was completely satisfied with the class.

It seems to me that O-G has a step-by-step linguistic hierarchy that could be applied to learning fluency tools. Easy onset, reduced speaking rate, resisting time pressure, voluntary stuttering, and stuttering modifications could be taught in conjunction with a review of the rules of English reading and writing.  Speaking, reading, writing, listening, and literature would become a part of every speech therapy session right from the get-go at appropriate skill levels.  Literacy concepts could also be taught in combination with sessions on acceptance of stuttering, non-avoidance, desensitization, and self-expression. Multisensory experiences and practice drills could find a place in every lesson plan.

The practice drill has become more common in public education because of a teaching protocol called Response to Intervention (RTI). I attended a day-long workshop on RTI in 2008 (2). RTI protocol emphasizes drill and data collection.  The emergence of RTI foreshadowed the demise of special education. It permits children to qualify for extra help without undergoing lengthy and expensive team evaluations. Using an RTI intervention model, school districts can economize by assigning volunteers and assistants to complete practice drills with students who need help in small groups within the classroom. My O-G course instructor said the “beauty of O-G is that anyone can do it.” Highly structured programs such as O-G fit well into an RTI model.

I have concerns about RTI. I don’t understand how a child with an undiagnosed language or hearing impairment benefits from the RTI more-of-the-same approach. Does such a child need to fail at all three RTI levels before someone suggests an alternative? At the same time, I do wonder if my own speech therapy practice should place greater emphasis on simple speech practice drills. I provide guidelines for speech carryover practice and I grew up in a house where homework was top priority. But O-G class discussions made it clear that some students have limited opportunity for and assistance doing homework. “Race to Nowhere” (3) even suggests that homework can be harmful. Maybe simple speech drills that “anyone can do” deserve more respect.

How does O-G, reading, and writing fit with speech language pathology? The term “orthography” refers to the writing system of a language. A recent article published in an American Speech Language Hearing Association (ASHA) journal says that "Orthographic knowledge represents the information that is stored in memory that tells us how to represent spoken language in written form..." (4)  Two important concepts in this article seem especially relevant for any reading/writing program:

1.        Mental Graphemic Representations (MGR): This is "the stored mental representations of specific written words or word parts...when one has a clear mental image of a word, then ‘correct writing’(and reading) of that word should occur." (5)

2.        Orthographic Patterns: This refers to the letters representing speech sounds, how letters can be combined, and where letters may appear (positional and contextual constraints).

"MGR knowledge reflects memories of specific words, whereas orthographic pattern knowledge connotes an understanding of the patterns governing the symbol system. It is not word specific. "(6) O-G teaches non-phonetic “red words” in a different way than words which can be decoded phonetically.  Red words must be memorized, become mental representations. On the other hand, “green words” can be sounded out using rules of phonetics. Eventually, both “red” and “green” words must be memorized for fluent reading. More fluent reading enhances comprehension. Similarly, it has been speculated that fluent speech may also have a mental representation in the brain. (7)

 Some researchers feel that developmental stuttering is tangled up in language. "For more than half a century, language has been defined in part by Its components: phonology, morphology, syntax, semantics, and pragmatics ... This thinking however ignores a now well established principle that reading and writing are language skills...orthography must be included as one of the six, rather than five, components of language.” (8) Orthography and literacy are within the scope of practice of the SLP. I will be blending the acquisition of fluency enhancing techniques with the linguistic hierarchy provided by Orton-Gillingham for some students. I’ll be blending literacy into all of my lessons. My hope is that new fluency skills will become associated with literacy skills for the child and that better carryover will be one result.


Visit Blue Ribbon Readers at http://www.pspb.org/blueribbon/index.html for some fun literacy games.

A recent comprehensive text on dyslexia is Overcoming Dyslexia by Sally Shaywitz, M.D. http://dyslexia.yale.edu/book_Overcoming.html?gclid=CIfgnJWkqq0CFegSNAodoxPHng



(1)    Institute for Multi-Sensory Education, December 5-9, http://orton-gillingham.com/

(2)    Implementing a Response to Interventions Model, Dedham, MA, March 2008


(4)     Kenn Apel (2011) What is Orthographic Knowledge? Language, Speech, and Hearing Services in Schools, 42, p. 592.

(5)    Ibid, p. 593

(6)    Ibid., p. 594


(8)    Kenn Apel, p. 599-600

10/27/11

Fluency Enhancing Techniques: Phrasing


Within each child, there may be unique cognitive demands driving his/her verbal expression and complicating our assumptions about the amount of linguistic challenge he/she is experiencing.  If we know that language complexity affects stuttering, then we need to alert students to this issue explicitly. I think we need to tell children that language is a deliciously complicated code that could be affecting their efforts to carryover new speech skills. This idea evolved as I learned more about teaching literacy.  We can integrate our knowledge of fluency and literacy in our lesson plans. Early literacy lessons nowadays include explicit instruction in phonological and phonemic awareness.  School age children are routinely taught the rules of grammar and composition in native and foreign language classes. So perhaps it will be simple to include a more detailed understanding of linguistics as part of a child’s fluency treatment program.

Children learn fluency enhancing skills by playing speech/language games which gradually become more difficult. “For most children, fluency can be produced more easily when semantic and syntactic demands are lower... numerous activities can be implemented to first establish fluency at a simple level before increasing linguistic demands and expecting higher levels of fluency.” (1) This is familiar territory for speech language pathologists (SLP). These games are fun ways to control language complexity across single word-, phrase-, single- and multi-sentence, story-, and conversational- levels of linguistic challenge. In this blog entry, I’d like to suggest that paying closer attention to each child’s expressive language – rather than the structure of the speech game per se - may be one more way to help them move beyond the speech games into real life communication.

 For example, if reduced speaking rate could be more explicitly connected to language complexity, would it also be easier to use? A child can slow down his speech rate in several ways. For example, he can slow overall oral motor movement and use more frequent pauses. (2)  At a two-week Stuttering Foundation of America workshop I attended in 1992, pauses were combined with phrasing and Easy Relaxed Approach-Smooth Movement (ERA-SM) (3).  An example of phrasing can be found in the Parent Practice for Easy Talking handout on the website of the Stuttering Center of Western Pennsylvania (4). I’m going to refer to this collection of behaviors as “phrasing” since this blog is about paying attention to linguistics in stuttering.

My students have difficulty with phrasing because it interferes with powerful suprasegmental aspects of expressive language. Children’s words are woven together with intonation and emotion to become large parcels of ideas.  My students’ eyes glaze over when I explain that phrasing allows more time for speech-motor planning, word retrieval, and sentence formulation. To them, the mechanics of phrasing is a distraction and a challenge to working memory.

                So let’s say we approach his goal from a different perspective. What if we disguise the mechanics of phrasing with a costume of linguistic relevance? If phrasing could be made more explicitly meaningful, would it be easier to use. It’s time to remember our school language lessons!  Sentences are constructed to express “relationships among propositions or chunks of content.” (5) How?  By combining ideas in the form of several kinds of subordinate and coordinate clauses. And it turns out that SLPs familiar with literacy have a way to measure this. They measure children’s language complexity by counting these clauses.

I won’t go into detail here, but, a “T-unit” is a single independent clause “plus whatever other subordinate clauses or nonclauses are attached to, or embedded within, that one main clause.” (6)  Hypothetically speaking, if two children recalled the same story book with the same amount of information, the child using fewer T-units is likely to have done so with more complex language. She has communicated the information in fewer sentences by embedding it in more complex grammar.

I am becoming especially sensitive to the complexity of children’s spontaneous expressive language as they attempt activities beyond the speech games. The child using more complex language in his/her independent attempts to own the process of carryover, may be more dysfluent than the child who uses simpler language. Children who naturally use more complex language – or who have complex thoughts and reduced language skills – could be alerted to this possibility. As an SLP, there are times when I do not feel it best to simplify expressive language for the sake of fluency. There are times when I would want to nurture the interaction between complex thought and complex language, taking this time to observe rather than manage stuttering. Perhaps this could also be a child’s explicit personal goal as well.

  What if we could now teach phrasing as a strategy for expressing complex thoughts?  If phrasing was a  communication tool to assist listeners in comprehending complex syntax and to add power to the message perhaps it would feel more natural and easier to use. Phrasing allows listeners more time to digest complex language. It highlights the most important concepts being conveyed. Listen to any well-trained public speaker and you will hear this happening. Perhaps this is how the mechanics of speech production, [reduced rate + pausing + ERA-SM (or easy onset) + phrasing] might be disguised as simple communication competence. Maybe this would make fluency enhancing skills more relevant and accessible.

I had the privilege of coaching a student for the English portion of her Bat Mitzvah this month. [Pausing + phrasing + rate reduction+ easy onset] were particularly effective for this bright, energetic and charming young woman. One practice strategy was to select two sentences from anywhere in her presentation and record how long it took her to read them. She read the same two sentences several times over, changing how long it took to say them. The goal was flexibility, discovering the feeling of modifying speech rate at will.  She repeated this exercise several times with different pairs of sentences. But it seemed that an even more effective coaching tip was for her to think about what part of each sentence she wanted her audience to really get. She’d spent many hours thinking about her message, putting it into words, and editing it to her satisfaction.  It was critical that she consider how her delivery might convey that message most effectively. The mechanics of speech now had linguistic relevance. It was the message that mattered.

“Later language development is characterized by growth in the ability to communicate in flexible ways for diverse purposes.” (7) Our language is dependent upon the speaking situation. The language used to give a Bat Mitzvah speech or an oral report in science class is not the same as the language of conversation. Expository language is generally more complex than conversational language.  Research indicates that, in general, our conversational language becomes more complex as we get older. However, not expository language. “…even young school age children were able to use subordination [e.g., subordinate clauses] as frequently as middle aged adults, but young children require a task that is cognitively challenging to reveal their syntactic competence.” (8). This implies that when children who stutter present oral reports in class, participate in class discussions, or recall the events of an exciting day, they are challenged not only by the speaking situation (e.g., emotion, time pressure, listener reaction), but by more complex language demands as well.

Most children seem to acquire basic language skills in a magical sort of way. There is a developmental progression guiding the infant’s babbling to the first grader’s adult-like language. But studies suggest that “…later syntactic development is not primarily a matter of acquiring new grammatical structures. Rather, it seems to be more a process of learning how to use existing structures with greater efficiency and dexterity to communicate complex thoughts in a way that is clear and informative.” (9) This brings to mind the children I’ve met who appeared to be high potential learners.  These bright, gifted, and talented children are driven by an intellect beyond age and grade level expectations. (10) They have big ideas but lack the speech motor planning/execution skills and sentence formulation abilities to respond with the speed, precision, and efficiency required to reveal what they are thinking.

I’ve come to the end of another blog that, upon reflection, seems to state the obvious. Show children how the grammar lessons they tolerate in school may actually be relevant to their attempts at carryover of greater fluency. I listened to a radio interview couple weeks ago with an author who said that he writes stories to answer questions he has about the world. This is my new mantra. Perhaps this blog was my first experience walking my way through the question, “Why have I been attracted to literacy issues in my work as a fluency specialist?” The answer may only be new to me!



(1)      Peter R. Ramig & Darrel M. Dodge (2010) The Child and Adolescent Stuttering Treatment and Activity Resource Guide, NY: Delmar Cengage Learning, p. 147

(2)      Peter Reitzes, (2009) “Pausing and Stuttering”, http://www.mnsu.edu/comdis/isad12/papers/therapy12/reitzes12.html

(3)      Kristen Chmela  (2008) “Using a Reading Bucket Activity in School Age Stuttering Therapy”. Kristen refers to both ERA-SM and pausing/phrasing in this article. ERA-SM is somewhat similar to what others refer to as easy onset.


(5)      Cheryl M. Scott & Nickola Wolf Nelson (2009) Sentence Combining: Assessment and Intervention Applications, in Written Language Assessment and Intervention, American Speech Language Hearing Association Self-Study 8190.  P. 12

(6)      Ibid p. 14

(7)      Marilyn A. Nippold et. al. (2005) Conversational vs. Expository Discourse: A Study of Syntactic Development in Children, Adolescents, and Adults, Journal of Speech Language and Hearing Research, 48, p. 1048

(8)      Ibid. p. 1057

(9)      Ibid. p. 1058

10/5/11

APPs For Fluency Work





Balbus Speech, http://balbusspeech.com/  ,  launched an app today that may benefit some people who stutter. I was delighted to witness a demo of this iOS app, Speech4Good, last month. I don’t own an Apple product, so I cannot download the app. However, it looks very promising. It offers daf, speech waveform and ability to take notes which can be e-mailed to others.

This is the age of the “app.” An app is an “application” for mobile devices such as smart phones and tablet computers.  My nookcolor (1) has a small selection of apps. My husband’s Droid smart phone can access apps designed for the Android operating system (2). A few of my students have the iPhone and iTouch that access apps made for devices that use iOS (3). “apps… have introduced immediately accessible activities for use in treatment and at home. “ (4)

Mobile devices are everywhere.  Talking on a cell phone is common place. So using an app to practice speech can now appear as natural as anyone else who is using a phone. (Though I must admit, adults talking with a Bluetooth device (5) as they grocery shop still spook me!)

The Fluency Tracker (6) allows a speaker to count stuttered words, choose from a selection of feeling words, and take notes. This app raises the nagging question, “What is stuttering?”  Imagine if the speaker and a listener were both using this app. I wonder if their counts would be the same? Would the speaker record subtle moments of muscle tension and hesitations imperceptible to the listener? Would the listener record secondary behaviors of which the speaker was unaware?  The experience of stuttering from the perspective of the person who stutters vs the listener has been a long time topic for discussion.

The reliability of counting stuttered words is another critical concept to keep in mind.  Reliability refers to a person’s ability to count stuttered words across situations. So for example, if you count fewer stuttered words while talking to a friend in a restaurant as opposed to talking to a waitress, was it because you stuttered less or because your attention to counting was different? Speech characterized by clusters of dysfluency - multiple stuttered sounds and syllables across only a few words - would be difficult to count accurately and reliably in real time, I would think.

 I like how you can take notes and indicate emotional states with the Fluency Tracker. Otherwise, fluency counts could be meaningless.  A speaker’s thoughts and feelings in combination with environmental variables are all relevant to planning step-by-step behavioral change.

I think the Fluency Tracker would be handy for counting lots of other skills besides stuttering. A person could count fluency enhancing strategies (speech tools), self-talk and visualization, or specific behavioral goals. How fun it would be to see a graph showing increased use of easy onset, pausing, or cancellation across situations and over time! Or how about counting the kinds of visualization or self-talk used throughout a day?

The daf assistant (7) and the daf professional (8) are apps that provide delayed auditory feedback and frequency altered feedback. The speaker needs to wear a headset or earbuds with microphone. (9) These two apps have different features and may be useful for people who find that aaf improves their speech fluency.  This is not the case for everyone.  The same issues of accurate, reliable measurement as well as journaling thoughts, feelings, and environmental variables apply for this app as for the Fluency Tracker, IMHO.  Both apps could be part of a multi-faceted treatment program within a framework of  Evidence Based Practice.

The American Speech Language Hearing Association has resources for the SLP who would like to learn more about the appropriate use of apps in treatment. (10)  Apps for Speech Therapy (11) and Moms with Apps (12) are two Blogs cited by ASHA that look interesting.

 I have not seen any peer reviewed research about use of apps.  But I think that clinicians raise some of the questions that researchers ultimately study. I envision apps as a way to shift more power, control, responsibility and ownership of  carryover into the hands of the student/client. I look forward to research on the effectiveness of apps as a tool in speech therapy for stuttering.

Judy





(4)   DeCurtis, L. L.  & Ferrer, D, (2011, September 20) Toddlers and Technology: Teaching the Techniques. The ASHA Leader








10/2/11

Dear Parent of a First Grader


About once a month, I write long e-mail response to parents’ concerns. After writing such an e-mail today, it occurred to me that some of these e-mails would make good blog entries. Of course personal identification has been removed. This e-mail is about a first grader.



Hi Mrs. _____,



Thank you for sharing your concerns. I’m glad that _____ was talking so much on her play date. That is the real success story for any child who stutters.



If _____ is feeling more comfortable about her stuttering (this is called desensitization), she will be able to stutter with friends and participate confidently in other peer group activities. This also means she will feel fine about telling children who ask about her speech that sometimes she stutters and it’s no big deal. She will need support for the occasional situation in which she may be teased. It takes feeling comfortable about your speech and very confident about yourself to stand up to kids who tease.



Other listeners may be in a better position to judge word retrieval skills than I, since _____ doesn’t talk that much with me. So, I’m glad you feel this is not an issue for _____. Indeed, she performed exceptionally well on The Listening Comprehension Test 2 yesterday. I gave _____ stickers for answering the questions because I was afraid she wouldn’t talk for that long and tedious test. She did and she revealed a high level of listening skills. I waited until she was paying attention before presenting each item. I talked in a somewhat slower manner, which is how I talk most of the time anyway. If ______ appears to “lose her place in conversations sometimes” in other settings, it may be due partly to the many visual and auditory distractions of real life.



People in my position are in danger of jumping to the wrong conclusions about people who stutter when they do not talk. That’s why I suggested we do some testing.  Some adults who stutter recall being placed in special education classrooms as children because “professionals” misinterpreted their silence as an indication of some kind of special needs. A person who stutters has extra difficulty turning on her voice, which is called initiating voicing. That lag time can appear very unusual in a competitive world where fluent speakers respond very quickly. The definition of a person who stutters is someone who knows exactly what they want to say and cannot say it.



Research suggests that, for some children who stutter, organizing thoughts into precise and grammatically correct sentences is more challenging than for fluent children. A child who stutters can have a huge vocabulary but have some subtle difficulty getting it from their brains to their mouths in sentence form. In fact, some children and adults who stutter have extensive vocabularies so that they can substitute a word that is easier to say for the word they really want to say. This develops into a habit that can be difficult to change, which is why we try to desensitize children to stuttering – so they will not develop unproductive habits like word switching. For example, I recall the picture guessing game that _____brought in called Headbandz. Compared to other children who I’ve played similar games with, _____’s clues, guesses and language during that game made me wonder if she was having difficulty with talking, with word retrieval, or with following the language of the game. When she would whisper to herself in other games, I wasn’t sure if this was to make talking easier (which it does) or if _____ needed extra time processing the language of the game. I needed to wait and watch her language in future sessions.



The speech tools are the easy onset, pausing, a slower speaking rate, continuous voicing, bouncing, and cancellation that we have practiced in speech therapy. Some SLPs write the names of these strategies onto pictures of tools and put them in a tool box to get across the idea that these are sometimes called “speech tools.” _____ has done an excellent job of using easy onset (slow/gentle beginning sounds), bouncing and cancellation in single words.



I think she may be fluent in speech therapy because of the quiet one-on-one setting and because she speaks fairly slowly. Her responses to all the questions on the Listening Comprehension 2 test were spoken somewhat slowly (and I should calculate speech rate to document it). I heard two sound repetitions which she moved slowly through with no apparent reaction and this was really nice to see. In general, _____’s learning style seems to be somewhat slow and methodical in speech therapy, IMHO. She seems to take longer to understand and follow the rules of games and what she is expected to do, as if her language processing proceeds at 40 mph while the rest of the world is going 60-80 mph. Young children tend to move and play very quickly and I wondered if this might have something to do with _____ making friends. I wonder if she will gravitate toward the gentler, slower moving, and more thoughtful kinds of children?



On Saturday, we’ll do the Expressive Language Test 2. Would it be possible to record a speech/language sample with _____ at home? She could talk about a book she’s read, an art project she is working on, a family trip, whatever. It would be helpful for me to hear more spontaneous language. I suggest being proactive about asking the teacher for specifics about how _____ is doing at least twice a month. If there are questions by mid-year, you could ask for language testing in January (or sooner if you feel appropriate). Wait and see if any issues arise.



I’ll give you some specific things to watch for as _____ plays with peers, which is what pragmatic language is all about. All children need help with peer interaction, which is why her last homework was reading dialogue between characters in the book Friends. You already have the experience of raising two older siblings, so I’m sure you are already well versed in some of these issues!



I look forward to _____’s visits and I am happy to have her continue. I’m worried that there is something about speech therapy that is still intimidating her and maybe you can help me out with that. If you would like to try having her attend by herself, that’s fine. You can wait outside the door or run an errand. If she continues to test well, make friends, participate in class, and keep talking even when she’s dysfluent, then I think 2-3 times a month speech therapy is fine. I would like her to practice easy onset, pausing, and slower speaking rate in structured speech homework. This is like playing the piano in a way. She needs to practice a smoother way of talking, step by step in homework, even though daily life may be too demanding for her to be fluent. She has a young, developing brain in which we hope to establish pathways for fluent speech.

_____’s speech can be so hoarse that it would be unethical for me not to recommend an ENT consult, even if her pediatrician is denying a problem. (Pediatricians are still telling parents of toddlers who stutter to ignore it.)



My goodness, this is a long note and e-mail can be incomplete. I hope I responded to all your questions. Thanks again for your e-mail and let’s plan for all of us to be present for the Expressive Language Test next week. After that, we can have _____ attend by herself and I am going to increase the material we are working with to a 2nd and 3rd grade level. If _____ is a Gifted/Talented child, then this gives us a new way to view her behavior. You can visit www.nagc.org  and www.hoagiesgifted.org  for more information on this topic.



Thanks again,

Judy





Judith V. Butler, M.A., LLC

https://sites.google.com/site/judithvbutlermaccc/

Be The Change


9/19/11

Coarticulation and Timing

     One-hour speech therapy sessions pale in comparison to the many hours of dysfluency children experience in demanding, daily communication. This has always been a challenge for speech therapy. In 2011, I have been experimenting with my e-mail newsletter "Helping At Home", Skype, telephone calls, and digital recordings of speech therapy as ways to place 'new speech' in the home.

     After receiving permission from LinguiSystems, I burned CDs of myself demonstrating how to practice several of the activities in Easy Does It for Fluency: Intermediate (1) and gave these to my students who also purchased the workbook. My speech is very slow and my demonstration of the speech tools a bit exaggerated on this CD. I hope my model - as comical as it may sound - is a reminder of what speech therapy practice is. It is not speech as usual. It begins as a somewhat awkward sounding, very self-aware way of speaking. Only with practice and problem solving does it become more automatic and natural sounding.

     This past weekend, I recorded a CD of activities based on the picture book Friends by Helme Heine. (2) This CD, also free for my students, demonstrates how you can adapt your own books, games, and schoolwork to practice more fluent speech at home. Literature is educationally rich and a golden opportunity for carryover practice. Children apply multiple speech and language skills when working with fiction and nonfiction. In addition to books, I will be making speech homework CDs based on the lessons in Flash Skills Reading Comprehension books. These children's workbooks are available at any Barnes and Noble and, at $4 each, are quite affordable. Let me know your child's favorite literature and I'll add it to my CD collection.

     Children who stutter (CWS) are coping with a speech-language-motor system that is different from their fluent peers. Their speech is more sensitive to disruption and stuttering. We know that the fluent speech of young CWS is different from their fluent peers. Yes, the fluent speech. Children who stutter "have difficulties regulating the temporal/spatial programs of speaking, whether at a peripheral motor execution level or at a more central level before motor execution." (3) Speech therapy teaches "slow easy speech" to help CWS with motor planning, and motor execution. Now research indicates this may also contribute to more typical brain development.

     Please print this article and give it to your children's doctors, tutors, teachers, and counselors: "Using Brain Imaging to Unravel the Mysteries of Stuttering" by Soo-Eun Chang, Ph.D. This article, published 8/23/11, is a review of past research and a summary of "the only published study to date on the neuroanatomical bases of childhood stuttering."

     [Have you ever listened to a toddler babbling while lying in her crib before a nap? As the very young child chatters to herself, she plays with sound combinations she can feel and hear. I love listening to preschoolers learn new words as they try to match their own immature sound productions with adult models. An adult asks, "Can you say spaghetti?" and the very young child's first response may be, "eti!" Later, with improved coarticulation and timing skills, she may say three syllables, "ageti!" Eventually, she can pronounce the /sp/ with precision, "spaghetti!" The developmental sequence of speech and language is just plain fascinating to me.]

     A child's "fluid, effortless speech production is possible because of well-established connections among brain regions that support auditory processing, motor planning, and motor execution." (p. 3) There is a neurological 'superhighway' of white brain matter that connects the auditory processing, motor planning, and motor execution areas of our brains. It goes by the abbreviation SLF. This highway looks different in both children and adults who stutter compared to fluent speakers, primarily on the left side of the brain. (p. 4 & 6) Dr. Chang suggests that this may be related to an inherited predisposition for stuttering.

       This difference in the [SLF] "may mean that signals among the movement planning, execution, and sensory brain areas may not be transmitted in a sufficiently rapid manner to allow for fluent speech production." (p. 6, bold is mine)

     The brain is also made up of gray matter. (4) This is where the auditory processing, motor planning, and motor execution areas are located. Typical brain development shows more gray matter on the left side of the brain than the right side. Children who stutter show this typical gray matter distribution. However, brain scans of adults who stutter reveal more gray matter on the right side. Researchers speculate that this is the result of an adult brain that has been compensating for a weaker SLF on the left side. "The functional brain differences in stuttering children, when sustained, could result in structural brain changes, in turn resulting in abnormal laterality of auditory-motor interaction for speech processing - which is reported in stuttering adults." (p.10)

      Helping children become more fluent may nurture more typical brain maturation. The ongoing challenge of speech therapy for CWS is how to increase the amount of time they practice more fluent speech outside of the 'clinic.' The Lidcombe Program (5) requires that parents do the speech therapy at home. There are many issues to consider with respect to the Lidcombe method, but that is the topic of another newsletter. The point is, all speech therapy for stuttering must find ways to gradually transfer new, more fluent speech skills to daily life. I hope that home practice with Skype, telephone conversations, and homework CDs, as a supplement to other verbal recommendations, will help make this happen. I'll write about apps for speech therapy in a future newsletter.

(1) http://www.linguisystems.com/products/product/display?itemid=10044

(2) http://www.amazon.com/Friends-Helme-Heine/dp/0689710836/ref=sr_1_1?s=books&ie=UTF8&qid=1316393162&sr=1-1

(3) Soo-Eun Chang et al (2002) Coarticulation and Formant Transition Rate in Young Children Who Stutter, Journal of Speech, Language and Hearing Research, 45, 676-688.

(4) gray matter stained blue: http://www.sciencephoto.com/media/118722/enlarge

(5) http://www.stammering.org/lidcombe_info.html

(6) Olander, L. (2010) Evidence That a Motor Timing Deficit is a Factor in the Development of Stuttering, Journal of Speech Language Hearing Research, 53, 876-886

8/25/11

School Reading Lists

I am enjoying my students' school reading lists this summer: Walk Two Moons by Sharon Creech, Heat by Mike Lupica, and Hoops by Walter Dean Meyers. We are using summer reading to make fluency carryover work more meaningful and academically relevant.

It's been a couple of years since I "read" children's literature, beyond sharing books with my own son. The word read is in quotes because what I actually did was listen to children's stories on audio tape. It was my way to tolerate a work commute. I listened to most of the books on tape in the children's section of my local library. A childlike point of view on family, peers, school, and personal growth frequently caught me by surprise. Like, after listening to how ADHD made it impossible for a young boy to comply with adult expectations in Joey Pigza Swallowed the Key (1), my patience with children increased exponentially. Children's books offer parents a glimpse at how their own child may perceive the world.

My own justification for using literature comes from The Massachusetts English Language Arts Curriculum Frameworks (2). There are 10 Guiding Principles and several Standards for Reading, Writing, Speaking/Listening, and Language across the grade levels. As a whole, this document is overwhelming! However, by selecting only one or two standards per book, the task becomes more manageable. Parents of children in Massachusetts public schools are reminded repeatedly how classroom work and speech therapy goals correspond to the state educational frameworks.

As an example, Language Standard 5 for grades 6-8 is: "Demonstrate understanding of figurative language, word relationships, and nuances in word meanings." (p. 66). And the Speaking and Listening Standard 4 for grade 7 is "Present claims and findings, emphasizing salient points in a focused, coherent manner with pertinent descriptions, facts, details, and examples; use appropriate eye contact, adequate volume, and clear pronunciation." (p.62) These two standards support incidental work on vocabulary, language organization, narrative and conversation while simultaneously targeting fluency goals. This is how using school reading assignments in fluency work helps prepare children for classroom work too.

The three books listed above are called narratives; they are stories as opposed to non-fiction. "The structure of narrative text... is such that characters perform actions in response to problems that they wish to solve. Actions are causally linked to feelings, motivations, and goals directed toward solving those problems..." (3) So, work for fluency can also touch upon "comprehension strategies [for narratives...when children] listen for known words, generate predictive inferences, and periodically confirm whether predictions are accurate." (4) In addition, a method called "think aloud" (5) gives us even more to do. Think aloud is when children answer questions about what they are thinking as they try to make sense of what they are reading.

There's also note taking. Taking notes is a valuable addition to fluency lessons that use school reading lists. Since I am re-reading Executive Skills in Children and Adolescents (6), I am trying out the Cornell Method of note taking described on pages 92-93. But any kind of note taking, even drawing pictures about a story, is a way to actively engage with the narrative and give us something to talk about. An opportunity to talk is an opportunity to practice fluency goals.

While I enjoyed my students' reading, and taking Cornell notes, the time that it takes won't always be realistic. For Mr. Popper's Penguins by Richard and Florence Atwater, I turned to the internet for help. Many sites offer lesson plans for free or paid subscription. While it's important to read the books, it seems kind of silly to reinvent the wheel when teaching resources are available online. After all, I don't know what the school ELA teacher will choose to emphasize from each book. My goal, as an SLP, is to improve communication skills, including fluency.

Creating carry over activities for fluency has been dropped in the clinician's lap. Professional journals offer very little advice about this challenging aspect of stuttering therapy. The family and clinician must team up to find ways of managing language demand, communication setting, emotional reactions, and fluency enhancing strategies to help children experience easier speech. It's an ongoing process. School reading lists can serve to link family, teacher, and SLP in this carryover challenge.


(1) Joe Pigza Swallowed the Key by Jack Gantos, published by Harper Trophy, ©2000
(2) http://www.doe.mass.edu/frameworks/current.html
(3) Laing Gillam, Fargo, St. Claire Robertson (2009) Comprehension of Expository Text: Insights Gained from Think Aloud Data, American Journal of Speech Language Pathology, 18, p. 83
(4) Ibid
(5) Ibid p. 91
(6) Peg Dawson & Richard Guare (2010) Executive Skills in Children and Adolescents, Second Edition: A Practical Guide to Assessment and Intervention, NY,NY: The Guilford Press.

7/16/11

Medication Therapy

“…the use of medication continues to demonstrate results that are not merely promising but that may prove to be outstanding, even revolutionary.” Without Hesitation: Speaking to the Silence and the Science of Stuttering by Gerald A. Maguire, MD with Lisa Gordon Wither ©2010, p. 8

I am always delighted when one of my students can attend the National Stuttering Association (NSA) annual convention. I have attended five conventions and found them to be of consistently high quality with a balance of fun, intimate sharing, and informative workshops. One of my teen students attended the 2010 convention and brought me back the new book, Without Hesitation. This book describes the use of medication to treat stuttering. All proceeds from the sale of the book benefit the NSA. I recommend it without hesitation.

This is a thin book and an easy read because Dr. Maguire wrote it for the layperson. It includes a very succinct history of treatments for stuttering, description of brain research, several case studies, a review of medications, and message of hope. Dr. Maguire invites anyone and everyone to contact him for speech therapy at The Kirkup Center for the Medical Treatment of Stuttering, http://www.kirkupcenter.uci.edu.

In an earlier post, I referred to a theory of developmental stuttering in which a child is repeatedly unsuccessful at repairing a speech problem and that this can results in increasing tension, both oral-motor and emotional. Without Hesitation wonders why such a speech difficulty occurs and makes a crucial statement: “We consider stuttering to be a multifactorial disorder; which means it’s a condition that has multiple causes” such as: (p. 12)
• Genetics
• PANDAS – Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strptococcal Infections
• Brain development during childhood

My understanding is that most brain research is done with adults who stutter, not children. So, there is an ongoing debate over whether brain research reflects what happens to a brain that has spent a lifetime stuttering, or, what a brain looks like in childhood as well as adulthood. Given the theory that the brain is “plastic” and changes continuously in response to learning and environment, fMRIs of adult brains may represent how stuttering impacts brain function over time.

Brain research has revealed at least three major discoveries.
1. “…the striatum performs as the brain’s natural timer and initiator of speech. People who stutter most often have trouble with the beginning of a phrase or word, but the speech flows more easily once they overcome this verbal block.” (p.28)
2. “…the left-hemispheric speech areas in individuals who stutter are low in functioning compared to…the right hemisphere…increased activity within the right hemisphere may represent overcompensation…” (p. 29)
3. Persons who stutter “often have too much dopamine in the brain, which may affect the brain’s ability to initiate and time speech. This surplus…is related…to striatal hypometabolism, a condition in which the striatum functions at an abnormally low rate.” (p.29)

If a neurological cause can be identified, then perhaps a medication can be designed to target that specific neurological issue. Studies suggest that lowering dopamine levels in the brain improves fluency. Several of the medications described in Without Hesitation, act to reduce brain levels of dopamine and showed both positive results and negative side-effects.

Another avenue for drug research is a neurotransmitter called GABA, gamma-aminobutyric acid. A medication called pagoclone “has shown particularly hopeful outcomes.” (p.42) A large scale study of pagoclone was underway as of March 2009 (p. 48).

Chapter 7 describes case studies of children trying medication therapy. My impression is that this is experimental in nature and there is no FDA drug currently approved for the treatment of stuttering. Nevertheless, parents wrestle with difficult decisions about their children’s educational, social, emotional, and medical health all the time. There are not many easy, clearly defined answers anywhere, IMHO. For some children, stuttering has a dramatic impact on quality of life and experimental therapies may make sense.

Parents are also making serious medication choices for their children for other chronic conditions. I want to highlight ADHD in particular:


“We know that chemical substances called dopamine agonists can make stuttering worse by enhancing the brain’s dopamine activity and diminishing the brain’s ability to time and initiate speech. Central nervous system stimulants, such as methylphenidate, and amphetamines that are used to treat attention deficit disorder and narcolepsy, are examples of dopamine agonists.” (p.34)

We remind our children that stuttering is not their fault while at the same time encouraging them to learn self-management. I wonder if the parents of children who have other chronic conditions such as juvenile diabetes, asthma, and learning disabilities also wonder how to encourage empowerment in the face of such circumstances. It’s my pleasure to watch parents do the best they can and children’s confident smiles in response!

7/10/11

Games - A Big Picture Perspective

Today’s topic is games. There are more than 60 games in my basement including four versions of Monopoly, two versions of Clue, two versions of Stratego, both adult and junior versions of Pictionary and Labyrinth and both an original and travel version of Scrabble. We have 2 cloth bananas full of letter tiles, a game called Bananagrams, because the extremely bright and highly competitive members of my family need enough letters to make long words that, trust me, you would not encounter in everyday conversation. All the toys, boxes of K’NEX projects, Legos, Playmobile castles, dozens of picture cards, puzzles, art supplies and shelves full of books make my basement look like a children’s consignment store.

I have collected games ever since becoming a speech-language pathologist, 29 years ago. I’ve culled the collection over the years, so I can locate things without a filing system. Some games were gifts, others purchased at yard sales and consignment shops, a few came from catalogues, and some were scavenged from the Barnes and Noble clearance tables just about this time of year. I couldn’t resist buying a set of colorful children’s puzzles at BJ’s just this past Friday. Many of the games kept my growing, very active son occupied. Even now, family games are one way we share time during school vacations.

I have a reputation for changing the rules. My son and I made games more challenging. For example, instead of playing a Memory game with say 20 cards, we would play it with 30, 40 or more. Instead of circling the path of a game board once, we would do it twice to decide the winner. For students, I usually make games less challenging. One game of Candyland, in which a player can select a picture card that sends her back nearly to the beginning of the game, was enough to start me thinking of ways to make games more successful and fun. For example, sometimes we roll multiple dice instead of only one, so game pieces can get to the finish line faster. Instead of struggling to hold on to cards in our hands, we sometimes place them on the table, face-up in front of us during a game like “Go Fish”. My all-time favorites are teaching parents how to inconspicuously let their kids win sometimes and making games cooperative instead of competitive.

Why do I encourage changing the rules? A July 4th article in the New York Times highlighted the importance of fairness. The title of the article was “Thirst for Fairness May Have Helped Us Survive,” (authored by Natalie Angier.) She wrote, “…by the age of 6 or 7, children are zealously devoted to the equitable partitioning of goods, and they will choose to punish those who try to grab more than their arithmetically proper share of Smarties and jelly beans…” My students tend to experience the unfairness of life, so,when we re-design game play, the rules become more fair for them and therefore more fun.

Another aspect of game design is “feedback.” Feedback relates to how present behavior affects future behavior. So for example, when we walk, a feedback system is at work to help us maintain our balance and stay upright as we move along this smooth carpet or down the stairs and out across the uneven parking lot. Artificial intelligence is partially about computers learning based on feedback. My parents e-mailed me the link to a game in which an all-knowing genie could guess any famous character I was thinking of just by asking me several yes-no questions. You see, every time someone plays the game, it adds to data bases it has accumulated, or, it is learning the characteristics of the new person you are teaching it. If it didn’t guess the character you were thinking of, it gives you several choices of who it might be. Your answer is its lesson. My son says that the advertisements on his Facebook page change as he types, because a computer program is using feedback from his conversations to find ads that would interest him.

I work with children who stutter and research indicates that some children who stutter may hear their own speech differently than you and I hear our own speech. The auditory feedback that helps us to monitor how we talk by listening to ourselves, may not work adequately for some children who stutter. Also, children who can identify simple shapes just by feeling them in their mouths show better improvement in stuttering therapy than children who cannot identify shapes in this way. The sensory feedback from the mouth, which would suggest knowledge of how the tongue moves around in the mouth to make speech sounds, may be inadequate for some children who stutter.

What kinds of feedback are in games? Video games have children collecting virtual coins, special powers, and special tools that become useful at a later time. Board games allow players to collect sets of cards, money, opponents’ game pieces, and points as rewards for correctly spelling words, answering questions, drawing pictures, or solving a mystery. Some internal kinds of feedback are skill improvement, personal satisfaction, public recognition and companionship.

An article in the July/August issue of the Atlantic Magazine, “How to Land Your Kid in Therapy”, challenges my practice of changing games so that my students will receive generous amounts of positive feedback. Apparently telling a child “Great Job!” not just the first time a he puts on his shoes but every single morning, teaches him that everything he does is special. Likewise, children who earn stickers for “good tries” never get beneficial negative feedback on their performance. Growing up in a culture “…where everyone gets a trophy just for participating … is ludicrous and makes no sense when you apply it to actual sports games or work performance,” (p. 72) the article states.

The main idea of the Atlantic magazine article is to challenge those who believe children’s games should be designed to nurture happiness and build self-esteem. The argument in the article is based on research that shows “… predictors of life fulfillment and success are perseverance, resiliency, and reality-testing – qualities that people need so they can navigate the day-to-day.” – not happiness and self-esteem. (p. 76) Therefore, some children’s games should be difficult and allow for failure. Children need to fail so that that they can discover and develop their ability to survive hardship and emerge more competent.

I’m not too worried about this because most of my students have accumulated plenty of negative experiences already. New game rules give them a fair chance at finally winning. But, now I’m confused. Are we talking about play or are we talking about work?

I consider the “games” I play as an adult:

I have been playing an old game called ‘the on again, off again diet’ for decades. When I was growing up, the rules around eating were: finish everything on your plate and then you can have dessert. My mother made delicious dinners and scrumptious desserts. Feedback from the scale was always the same. However, when I was pregnant, the scale went to 200 pounds and it’s been a struggle to lower it ever since. The rules for eating changed when I wasn’t paying attention. The new rules include getting to the gym several days a week and nearly eliminating entire food groups – I believe chocolate is a food group. Fortunately, there is digital feedback on the treadmill telling me to keep walking or else feedback from my body would convince me to sit down!

I’m also playing a game called “talking with your teenager.” Where’s the rulebook when you need one? In this game, conversation can be interrupted by a phone text at any time, at which point I am to place an invisible conversational bookmark in my mind for as long as it takes for my son to complete his texted interaction; after which we can resume our conversation.

As I get older, I discover that there are many complex, high-stakes games being played all around me and it’s about time I paid more attention to them. The US Supreme Court ruled last month that banning violent video games for children was a violation of free speech. As a parent who has spent the last 10 years monitoring video game violence in my own home, I am very interested in reading this decision. And now I’m even more confused – video violence is fun?

Now I’m even more convinced that a valuable lesson learned with games is that it’s ok to change the rules. Living in a democracy, at least theoretically, grants me this priceless privilege. I can influence the rule-makers by contacting my government representatives and donating money to organizations that advocate for issues I support.

As my own personal playing piece gets closer to the finish, I’d like to sort out the difference between games that are play and games that are work and be sure I am spending at least some of my time just having fun.

7/2/11

What Do I Say?

One of the first questions that parents ask me is, “What should I say to my child when she stutters?” Parents are familiar with saying things to their children that are instructive, comforting, or otherwise helpful. Parents respond to children’s speech by imitating an infant’s babbling, teaching a toddler new vocabulary, and expecting ‘please’ and ‘thank you’ from teens. Consequently, it can feel quite natural to respond to stuttering by saying, “Slow down and take your time.; Think about what you want to say first.” When this response is not helpful, they wonder what to say instead.

Speech therapy approaches this problem by asking, “What does the child know?” Some children are not aware of their stuttering, so an adult’s advice to change how they speak can be confusing and frustrating. This goes for the preschooler with mild, typical disfluency and for the older child caught up in sharing ideas, momentarily oblivious to fluency. Indirect therapy dodges the question altogether. It “involves changes in the speech environment” (1): reducing communicative time pressures, modeling a new/easier way of speaking, and changing aspects of certain troublesome speaking situations, for example.

A child “may perform many repetitions, but may not be aware of the relationship of speech to the feeling that he is ‘stuck’ or that ‘something’ is holding him back. It is important to acknowledge this distinction. Although the child may not perceive his speech productions as distorted words, he is aware of a difficulty in speaking – specifically, of feeling stuck.” (2)

The speech language pathologist (SLP) needs to find a way to help the child understand what is going on and speak in a way that feels easier. “Incidentally, the emphasis on feeling here is intentional. The powerless feeling that results from a loss of control often concerns children more than the actual speech disfluencies.” (3). Friendly play and conversation are a part of every session to reveal a child’s learning style and interests, which eventually become woven into lesson plans.

Early lesson plans begin with the SLP voluntarily stuttering in the same way as the child (perhaps with less muscular tension) and then using stuttering modification to change the stuttered words into “easier” ones. If the child comments on this, a conversation about stuttering has begun. If the child does not notice the SLP stutter, then she will describe it and reward the child for noticing it. She might say something like, “When I get stuck, it sounds like this: ‘Th-th-th-the boy is walking his dog…Would you help me by telling me when I get stuck so I can get unstuck?” (4)

Every step of speech therapy involves teaching the child greater awareness AND options for change. “What do I say?” is very specific: praise for speech changes that the child learned how to perform in speech therapy. When the child learns light contacts and easy onsets (gentle beginning sounds), then the parent can praise the child’s use of these skills both in structured homework and in spontaneous conversation. When the child learns to resist time pressure by pausing within sentences (5), the parent can say “I like how you used pauses when you said…”

Note: the adult also uses everything the child is learning. This can be explicit as in, “Let’s play this game so we both can practice pausing.” or; the parent can focus on her own speech privately, pausing as frequently and naturally as possible during a game. For some children, “Disfluencies may be acknowledged with neutrality, compassion, or empathy…or gentle requests for repairs that are distributed at a rate that is considerably less than that for praise.” (6) For children who’s speech therapy program includes corrective feedback, praise must greatly outnumber corrections.

What can you say to your child who is stuttering? You have some choices.

1. Listen carefully to what your child is saying and respond to that content,and/or,
2. Resist time pressure, pausing before any response, and/or,
3. Imitate the stuttered words by using a speech technique to illustrate how they can be spoken easier, and/or,
4. Ask how she feels, ‘opening the door’ for some emotional support, and/or,
5. Manage the environment by scheduling some ‘down time’ instead of another planned activity.

We all experience varying success with children. We cannot expect to say the perfect thing all the time. I recently took a risk by asking about a young teen’s moment of stuttering only to have her burst into tears. Moments like this come with the territory. You know your child better than anyone else. Now you know a little more about stuttering therapy so that you can know what to say.

I recently joined a new blog about stuttering. You might appreciate the July 1 post written by a mom, It’s a Blessing to Raise A Child Who Stutters. (http://stutterguy.wordpress.com/)

1. Ramig, P.R. & Dodge D.M. (2010) The Child and Adolescent Stuttering Treatment and Activity Resource Guide p. 67
2. Ibid., p. 69
3. Ibid., p 70
4. Ibid. p. 71
5. P. Reitzes (2009) Pausing and Stuttering, http://www.mnsu.edu/comdis/isad12/papers/therapy12/reitzes12.html 6. Ibid., p. 71

6/23/11

Summer Support

Summer vacation is a chance to change communication habits and improve fluency. In the summer, you probably have more influence over the pace of life and content of your child’s day. The many stressors associated with school are replaced with days of sleeping in, reduced time pressures, fewer interruptions, greater control over diet, and more parent-child fun time. Let’s talk about that parent-child fun time. I encourage you to plan for moments of “down-time” so that you can talk with one another in fluency enhancing ways. Children often look forward to this special time, especially on the days when chaos overrides our best intentions.

“Down time” is can be an opportunity for reviewing speech therapy lessons. My lesson plans are often variations on games you can buy at the toy store, material from children’s magazines, arts and crafts, and home-made “let’s make up a game” activities that mix-and-match game boards, playing cards, and pieces from different games. This is so that parents can experience this process and take it home with them. If you understand the basic philosophy of treatment for stuttering, you can take a familiar family game and modify the rules: slow it down (remove the timer), make it cooperative to reduce the stress of competition (eliminate the rule that says “The first one to….wins”), and add your own content by drawing your own game board, playing cards, or score card. Enforce turn-taking and allow silence for thinking.

If you would like to purchase activities to foster language skills, you can shop the catalogues used by speech-language pathologists. I encourage my students to buy Easy Does It for Fluency: Intermediate by LinguiSystems .It is easy to read and includes a variety of attractive activities. I recently received copy write permission from LinguiSystems to use this workbook to record a practice CD or DVD for my students who also own the book.

LinguiSystems also has workbooks and materials that you could use for parent-child fun time. For example, there are “Quick Play Folder Games” for $15.95 each that practice word associations, categories, concepts, rhyming and vocabulary. There are “Early Social Behavior” books for ages 3-6 and “That’s Life” books, cards and game for middle- and high-school ages, for example. The “100%” workbooks are $43.95 and great for sitting together for 30 minutes of more structured focus. Spice up the activities by checking off each item on a page using colored markers or stickers. Share a snack and use the lessons for topics of conversation. Don’t feel like you need to do every item on every page. Have fun!

I do not have a financial interest in LinguiSystems – except that I spent a lot of money there! It is just one of many online opportunities that offer much more educational choice than you will find in the toy or book stores. I would love to know where your family finds online books, games, and other fun stuff.

Here is a list of things that can be helpful throughout the summer:*
• Minimize interruptions
• Speak slower
• Respect silence
• Minimize rushing & hurrying
• Ask one question at a time
• Avoid “show & tell”
• Talk about topics meaningful to your child
• Talk about stuttering
• Lessen conversation when there is more disfluency
• Insert short, easy, stutter-like mistakes in your speech
• Teach turn-taking
• Build self-confidence

*Ramig, P.R. & Dodge, D.M. (2010) The Child and Adolescent Stuttering Treatment and Activity Resource Guide , Delmar, Cengage Learning p. 15
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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.