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/

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