Executive Function: Behavioral Inhibition

One of my students generously gave me the second edition of Executive Skills in Children and Adolescents (P. Dawson & R. Guare, 2010) which prompted me to re-think speech homework.

Executive skills develop throughout childhood. Let’s think about just one of them. “The cornerstone…is behavioral inhibition, which begins to emerge in the 5- to 12-month age range. This first executive function …helps us to think before we act and to decide when and if we will respond.” (p. 5) The three components of behavioral inhibition include the ability to:
1. delay or prevent a response,
2. stop ongoing behaviors,
3. manage distraction and interruptions.

At the beginning of direct speech therapy, a child is asked to prevent her usual pronunciation of sounds in favor of a pause followed by slower, gentler articulation. With lots of practice in very simple, repetitive games, children can learn to do this when everyone else is too. It is not easy bringing speech under conscious control like this.

Carryover activities add the demand of stopping familiar rapid or stuttered speech in situations that include distraction and interruption. As an example, let’s imagine going out for ice cream.

If the homework is to practice single words, then, the child and her mom might practice saying the names of ice cream flavors. Since the child has never used slower rate and gentler articulation in the ice cream store before, it is very likely that she will be able to do so on only some of the names, maybe 3 out of 6 names at first.

Practice with these 6 names means she needs to prevent saying “Minty Magic”, for example, with a normal “Minty” and say it after a pause and with loosely relaxed mouth and a slight prolongation as in “Mmmiiinty.” The child working on change will need to stop production of “M-m-minty” and either pull-out or cancel it with a pause, slightly slower speaking rate, and perhaps also loosening tension in the lips.

The parent’s role is to manage distraction and interruption by saying the ice cream names using a pause, gentle articulations and slower rate so the child can imitate the model. It is the parent who will make the entire 5-10 minute carryover opportunity a private affair, perhaps by placing an arm around the child or waiting until they are sitting with their ice cream away from the other customers.

Children look to their parents for direction. Most children are not likely to say, “When we get ice cream today, I want to practice easy speech.” I hope you can enjoy looking for times and places to show your child how easy speech can be fun to practice at the park, the ball game, the pool, the movies, on a walk, visiting the museum, working on a home project, and just hanging out together. Your encouragement and praise will help nurture your child’s courage and sense of personal accomplishment.


Transfer Step 2: Desensitization

Parents who call me for speech therapy are usually upset. Nine times out of ten, they are parents of elementary school age children denied school services or disappointed by them. The rest are frightened parents of preschoolers. My practice is one of many that do not accept insurance because the amount of time spent on paperwork and following-up denied claims is simply unmanageable. So everyone that steps through my door with a check in hand is emotionally invested in change.

The emotion that motivates families to make and keep appointments becomes a liability when it’s time to work on identification and behavior change. It is too frightening, embarrassing, or even disheartening for them to examine the stuttering closely. Children who fear stuttering have been known to cope in ways that increase emotional and physical stress, so turning down the emotional temperature is an important first step. A stuttered sound is pronounced with unexpected, excess physical tension and (often) a feeling of loss of control. To relax this articulatory tension, the child must slow down speech dramatically and find a new feeling of loose, deliberate articulation. And so step 2 in transfer is desensitization – reducing the emotional reactions.

Desensitization is what allows a child to CHANGE stuttered sounds instead of avoid, hide, or fight them. He can ‘play’ with the moment of stuttering to study just what in the world his mouth is doing and how to move his tongue, lips and jaw differently. Reducing the fear of stuttering gives a child permission to talk, express his thoughts and feelings, even if talking more means stuttering more. The more talking a child does, the more opportunities he has to transfer new skills. When a child will not talk in school because he would “rather be the quiet kid than the stuttering kid,” those lovely, loose stuttering modification techniques he performs in the speech room are a long way off from being transferred to the classroom.

A child needs to talk about stuttering with her teachers, friends, and relatives in order to set up a hierarchy of homework activities. Negative feelings can get in the way of this happening. It’s difficult to talk about issues that cause us to feel embarrassed or inadequate. Stuttering is one of those issues. Becoming aware of these feelings, talking about them, and investigating ways to reduce their powerful effects is another target of desensitization.

Ideas based on Peter R. Ramig & Darrell M. Dodge (2010) The Child and Adolescent Stuttering Treatment and Activity Resource Guide, 2nd ed., Clifton Park, NY: Delmar Cengage Learning.

Transfer Step 1: Identification

This blog entry is about transfer, learning to use new communication skills in everyday life. (1) Transfer is a long term goal. We must be careful not to blame the child for failure to transfer new speaking skills because there really is no such thing as failure. When the child, parent, teacher, and speech language pathologist (slp) design a transfer task, the outcome is always just another learning opportunity. Life is unpredictable, so transfer activities will probably not proceed exactly according to plan. But by understanding that many tiny little successes eventually add up to bigger, long-term accomplishments, we become better at recognizing and rewarding transfer success when we see it.

Transfer can begin immediately in the form of identification tasks. These are times when the parent and child observe what the stuttering behaviors look and feel like and when they occur. The role of the slp is to help the family talk about the “elephant in the room,” the stuttering. In a speech therapy session, the slp talks sensitively and without judgment about this frightening and confusing speech problem called stuttering. Hopefully, the child and parents become more comfortable talking about stuttering as a result.

This is an especially delicate process with very young children because parents are afraid that talking about stuttering will make it worse. In this situation, the slp may comment on her own voluntary disfluency and wait for the child’s response. In some cases, it will be appropriate to talk about bumpy speech with a preschooler. In other cases, it will not. With the older child, the slp models “an attitude of inquiry and curiosity about stuttering” (p.93) while at the same time demonstrating voluntary stuttering and sharing basic information about speech production. She chats comfortably about how every child experiences stuttering a little bit differently and how stuttering is no one’s fault. The first step in therapy involves discovering what kind of stuttering the child is doing, how it changes day-to-day, and if it is affecting the child’s thoughts and feelings about talking.

The child and parent may identify stuttering quite differently. I have observed young children block and react by pausing, whispering, and even raising a hand to the mouth while the parents insist he/she is unaware of a speech problem. I have listened to parents describe stuttered speech that their elementary school age child did not know was happening. And teens have described experiencing mild blocks accompanied by overwhelming anxiety that no one else seems to notice.

When everyone involved feels safe sharing their own perspective about stuttering, a more comprehensive picture of the problem can unfold. This identification process happens intermittently over the entire course of speech therapy, in my opinion. Every time a child makes progress, he/she must admit the need to keep moving forward. And this means identifying yet another problem area. With growing maturity and awareness, the child must identify not only the stuttering problem, but also the thoughts, feelings, and distractions that make transfer tasks difficult. For example, talking with teachers and peers about stuttering seems to be a gargantuan undertaking. Yet these are key people in a network of support necessary for transfer.

(1) Peter R. Ramig & Darrell M. Dodge (2010) The Child and Adolescent Stuttering Treatment and Activity Resource Guide, 2nd ed., Clifton Park, NY: Delmar Cengage Learning.
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.