12/28/14

Counting Stuttered Words

I’m  watching a video of one of my students. I’m typing what he says and marking each stuttered word,  listening to some of his sentences over and over again to accurately label blocks,  prolongations, repetitions and secondary behaviors. I can think about a child’s speech more sensitively this way than if I try to take a frequency count in real time.

It takes several hours to transcribe and score a speech sample this way. I’ve been doing it for more than 20 years. In 1992, I learned a detailed protocol called Systematic Dysfluency Analysis (SDA) [1]. It introduced  me to careful listening. Eventually, I had to admit that SDA took too much time. In 2010, I bought the Test  Of  Childhood  Stuttering (TOCS)[2] which provided a simpler method. I knew that most speech language pathologists (SLPs) used the Stuttering Severity Instrument (SSI).[3]  However, as a specialist, I felt obliged to offer an alternative.  The Stuttering  Foundation has a continuing education video called Scoring Disfluencies,[4] an excellent resource for anyone interested.

In this blog post, I'd like to reflect on what speech analysis means. For starters, certain types of disfluency are considered stuttering and others are not. The distinction is especially relevant when considering whether or not a young child might be at risk for developing a chronic stuttering problem. Disfluency types can differentiate between stuttering and cluttering. And, sometimes, I see children show progress by gradually changing the type of disfluency they produce, even if frequency stays the same. The American Speech Language Hearing Association (ASHA) website has a thorough review of this information for SLPs in Clinical Topics: Childhood Fluency Disorders.  There is quite a lot of information for the public at the ASHA site as well.[5]

Any presence of physical tension is usually labeled stuttering.  One form of tension is a laryngeal block. This is when the vocal cords (located in the larynx) stop vibrating.  Speech  seems to be stuck in the throat. This may take a fraction of a second or up to several seconds.  Tension may also appear in the face and/or neck. It can spread through the torso. A change in timing, a prolongation, is another form of stuttering. It is a sound that lasts too long and  fails to transition quickly into the sound that follows. These two types of stuttering are called “disrupted phonation.” [6], [7]

Parents may not realize disrupted phonation in their child's speech could be stuttering. It's the repetitions that usually trigger concern. Friends, family and even pediatricians say ‘ wait and see’, maybe the toddler will pass through a common phase called developmental disfluency. Most young children do “outgrow” this. But the mystery remains; which children will develop normal speech and which children will stutter?

Research conducted in the 1990's identified disrupted phonation (blocks and prolongations) as associated with chronic stuttering. Disrupted phonation, whether it has a sudden or gradual onset is probably not normal. It turns out that some kinds of repetition are probably not normal either.  Atypical repetitions along with disrupted phonation are called  Stuttering Like Dysfluency (SLD).  A careful speech analysis will determine precisely what kinds of disfluency is occurring.  

            A special calculation called the "weighted stuttering like disfluency" has been found to discriminate between young  children who do and do not stutter. It combines repetitions and disrupted phonation in a mathematical formula .[8] In fact, a weighted SLD measure of 4 identified 97% of children (35/36 children ages 3 & 4 years) in one study.[9] It is important for parents to know that blocks and prolongations could be warning signs of chronic stuttering.

A careful speech analysis will count three types of repetition. Two types are associated with stuttering in young children: repeating parts of words (I w-w-w-want; I want pop-pop-popcorn.), and repeating single-syllable whole words (I want-want-want popcorn.)[10] In addition, the number of iterations is relevant. This is because the presence of a single repetition (I w-want) versus multiple iterations (I w-w-w-want) also distinguish between children who stutter (CWS) and children who do not stutter.[11] These guidelines have been revered for decades due to extensive research support.

For some children, stuttering apparently worsens with time.[12] One research team proposed that these children “may be encouraged, by a more positive listener reaction, to use increased physical tension to stabilize (or make less obvious) part word repetitions."[13] This didn't make sense to me. Rather, my intuition is that the older children's speech contain more SLDs  because it always did. By this I mean, children arriving at a clinic for evaluation at age four would be those who always had more disrupted phonation. But then I read The Genius of Dean Williams. [14] In chapter 9, he recalls the following: "One second grade boy reported that when he was in kindergarten and first grade he had repeated sounds a great deal. People called it 'stuttering.' Now, he tensed and 'pushed' to get the words out so he wouldn't 'repeat,' or 'stutter,' as he understood the meaning of the word." I was in awe that Dr. Williams could elicit such insights from a youngster.

Recording single-syllable whole word repetitions as stuttering is not universally accepted. "There is evidence...that children who recovered from stuttering showed a greater proportion of WWR than those who did not [and] ...Riley (1994) as creator of the SSI-3 asserts that WWRs should not be counted as moments of stuttering, as long as they are not disrhythmic."[15]  Why all the fuss over counting single syllable whole words? Well, we’re talking  about accurately diagnosing children at risk for persistent stuttering and recommending who should receive treatment. If we dismiss all childhood disfluency as something children outgrow, parents may not seek appropriate help. Or maybe the opposite. Maybe parents will be unnecessarily concerned.

It turns out that "...as a group, bilingual children produce higher levels of typical speech disfluency than their monolingual peers." [16] Repetitions ranged from 3-22% and number of iterations 4-8 in a recent study of Spanish-English speaking children. It may be that the guidelines for diagnosis revered for decades actually applies only to monolingual children.  Here is a danger of incorrectly labeling children at risk for stuttering. “…at present, researchers do not have a sufficient understanding of the disfluent speech of bilingual children who do not stutter. Thus, it is difficult to determine whether a bilingual child is in fact at risk for stuttering or if, perhaps, as a group, bilingual children produce higher levels of typical speech disfluency than their monolingual peers.”[17]

I began  this blog because I was working with a middle schooler. I didn’t find anything new in the ASHA journals for this age group. I did come across an article that validated a common phenomenon.  A group of children who stuttered ages 6 years old to 10 years and 5 months old, stuttered more in narrative than in conversation.[18] What’s the difference between having a conversation with someone versus recalling a story?

 A conversation is a shared experience. Speakers pay attention to one another. They interpret facial expressions, body language, tone and loudness of voice and changes in topic. There is time pressure to access language and speech/motor skills in socially acceptable ways. It matters who’s talking  and the speaking situation. Conversation can be challenging!   CWS in this study used shorter utterances in conversation than in narrative. Any surprise here? I’ve certainly seen this.

Okay, let's take a look at narrative. The speaker is completely responsible for all of the information, language, non-verbal messages, and listener reaction. It’s the speaker's job to keep a listener’s interest and ensure that he understands the message. Here’s two reasons a story telling activity would have been more difficult in this particular study. Reason number 1:  "...children [need] to hold a series of sequential intentions in memory while simultaneously planning and executing the motor movements required...” Reason number 2:  “…the utterances the CWS produced during narration were longer than the utterances they produced during conversation, thus creating the context for motor system instability…”[19]  Narrative is also quite challenging! This research suggests that narrative may be an efficient tool for gathering a speech sample.

The results of a speech analysis are combined with other information to help in the accurate diagnosis and  the selection of treatment for CWS. For the older child, I refer to lessons found in Easy Talker[20], my own workbook[21], and the Stuttering Treatment Guide. [22] I’m also taking another look at the workshop booklet from Dr. Dean Williams’ presentation I attended in 1993.[23]  School-Age Stuttering Therapy is another superb resource.[24] The Stuttering Foundation has many videos about treatment taught by highly respected experts.

This is just a personal reflection. I can only speak from my personal experience.  I’ve had 20+ years to form opinions and a clinician bias. I’m looking forward to retiring soon and hope to contribute to the field in ways other than studying speech samples. I’m looking forward to future generations of SLPs bravely taking on the challenge of stuttering therapy.

Thank you for reading,
Judy





[1] Systematic Disfluency Analysis Campbell, J. H. & Hill, D.G. (1987) Systematic Disfluency Analysis, Stuttering Therapy: A Workshop for Specialists, IL: Northwestern University
[2] R.B. Gillam, K.J. Logan, N.A. Pearson (2009) Test of Childhood Stuttering  Austin TX: pro-ed.
[3] G. D. Riley (2009) Stuttering Severity Instrument, Austin TX: pro-ed, inc.
[4] Diane Parris, Scoring Disfluencies, Stuttering Foundation DVD No. 6350. www.stutteringhelp.org
[6] E. Yairi and N. G. Ambrose (2005) Early Childhood Stuttering: For Clinicians By Clinicians, Austin, TX: pro-ed, p. 97.
[7] Let’s remember, too, that some speakers say they stutter when no dysfluency is evident to the listener.  This phenomenon is called covert stuttering.
[8] The  weighted SLD is "calculated by multiplying the number of part word (PW) and single syllable (SS) repetitions (PW + SS) per 100 words spoken by the mean number of repetition units (RU) and adding the result to two times the frequency of disrhythmic phonation (DP), thus yielding the following formula: ([PW + SS] x RU) + (2 x DP), as described by Ambrose & Yairi (1999, p. 899). 2002 p. 23."  M. W. Pellowski & E. G. Conture (2002) Characteristics of Speech Disfluency and Stuttering Behaviors in 3- and 4- Year Old Children, Journal of Speech, Language, and Hearing Research, vol. 45, 20-34.
[9] Ibid p. 26
[10] E. Yairi and N.G. Ambrose (2005) p. 96.
[11] M. W. Pellowski & E. G. Conture p. 26. “In general, findings indicated that the percentage of total disfluencies, percentage of stuttering-like disfluencies, weighted SLD measure, and mean number of repetition units significantly differed between CWS and CWNS, whereas the percentage of other disfluencies did not significantly differ between the two talker groups.”
[12] Ibid. p. 26 “…that increases in time since stuttering onset were associated with increases in the percentage of stuttering-like disfluencies for all CWS.”
[13] Ibid, p. 31.
[14]  Stuttering Foundation Publication No. 0425, p. 96.
[15] David Ward (2013) Risk Factors and stuttering: Evaluating the evidence for clinicians. Journal of Fluency Disorders, 38, p. 138.
[16] C.T. Byrd, L.M. Bedore & D.Ramos (2014) The Disfluency Speech of Bilingual Spanish-English Children: Considerations for Differential Diagnosis of Stuttering, Language, Speech, and Hearing Services in Schools, Dec. 10, p. 10.
[17] Ibid. p. 10
[18] C.T. Byrd, K.J. Logan, R.B. Gillam (2012) Speech Disfluency in School-Age Children’s Conversational and Narrative Discourse. Language, Speech, and Hearing Services in Schools, 43, p. 160.
[19] Ibid. p. 160.
[20] B. Guitar & J. Reville (1997) Easy Talker: A Fluency Workbook for School Age Children, Austin, TX: pro-ed pro-ed, 1997
[21] J. Butler (2014) Respecting the Communication Needs of Children Who Stutter, a free download at https://sites.google.com/site/judithvbutlermaccc/home/free
[22] The Child and Adolescent Stuttering Treatment and Activity Resource Guide, Second Edition, Delmar Cengage Learning, 2010
[23] D. Williams (1993) Stuttering Therapy for Children: Learning to Learn, University of Wisconsin-Milwaukee, School of Allied Health Professions, Office of Continuing Education
[24] N. Reardon-Reeves & J. S. Yaruss (2013) School-Age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering Therapy Resources, Inc. www.StutteringTherapyResources.com

10/31/14

POWERR: a treatment option

Thank you NSA! The National Stuttering Association sponsored another Family Fun Day in Boston this fall. Such a uniquely empowering event! Children who stutter meet one another, learn about stuttering and enjoy self-affirming activities. Parents learn about stuttering and share experiences. It’s a morning that takes hours and hours of volunteer planning. It was my privilege  to help facilitate the teen group again this year. It is so energizing to spend time with people who work at self-improvement and mutual support.

The National Stuttering Association (NSA) is a self-help group for people who stutter. It has local chapters across the United States. There are videos, podcasts, books, newsletters, brochures and merchandize on the NSA website.[1] The annual conference features programs for adults, families and speech language pathologists (slps). I’ve attended many of them, always returning home enlightened and enthusiastic.

The NSA annual conference is a ‘reality check’ for me.  People of all ages fill the workshops and hallways with a variety of viewpoints. The many voices at an NSA conference are like a cacophony of bird song at dawn. Some are louder than others. Some sound nearly identical. Most are emotional and sincere. Everyone has a story.

Wondering what I mean by ‘reality check?’  Take a look at the writings of Doreen Lenz Holte, parent of a child who stutters. Voice Unearthed [2] is her memoir.  Someone handed me a copy to read and then pass along. I was dismayed by the many pages of opinion presented as fact. But, I respected Ms Holte’s passion. Her arguments were no surprise. I’m familiar with the journey.

Let’s look at two of her comments.

One. Ms Holte challenges “the powers that be…to establish resources and support around indirect therapy, so parents have real options. If, as you tell us, ‘what works for one doesn’t work for everybody,’ then give us real choices beyond changing the moment of the stutter and minimizing speech errors.’”[3] I’ve watched the profession search for these options.  Perhaps this is why I learned way back in 1992[4] that differential diagnosis may be one key to designing treatment.  A workbook called The School – Age Child Who Stutters: Working Effectively with Attitudes and Emotions came out in 2001. Research suggests that stuttering is often accompanied by other issues such as differences in phonology, language and temperament and there may be subtypes of stuttering.[5] I’ve witnessed experts battle heatedly over early intervention. The debate rages on in a recent ASHASphere [6] and, quite frankly, I grow tired of the bitterness. Ms Holte is not alone in her confusion and frustration. [7]

May I suggest The POWERR Game[8] as an eloquent option. It costs $16.00 and has been around since 2003. It was created by Gordon W. Blood, Ph.D., CCC-SLP, a well respected expert in the field.  I presented this option to teens at the NSA conference in Atlanta and both NSA Family Days in Boston. The longer I stay in this profession, the more I appreciate this program. I really didn’t know how to access the depth and breadth of this resource in my younger days. The letters of POWERR represent Permission, Ownership, Well-Being, Esteem of Self, Resilience and Responsibility. What families need is this larger context in which to place stuttering treatment. This year, I designed new playing cards with many of the POWERR concepts represented as single words. For example, reaction, change, myth,  and outcome  fall under the category of Permission. The children in the NSA teen group selected from words like these and shared stories from their own lives. This became the preface for discussing speech and communication skills.

Two. Ms Holte was dissatisfied with several “rounds” of therapy (few details provided). Talk to many seasoned experts in the field of stuttering and you’ll hear this: It’s not the program that matters. It’s the relationship between the slp and the client.  In the spirit of placing treatment in a broader context, I digress with story of my own of how people make a difference. 

It is a bright, very warm, September afternoon at the soccer field. I sit with about 30 or so other parents in a single row of colorful folding chairs decorating a sideline. We watch our unique children become team players in a league sponsored by a local non-profit organization. I've watched  for many years and it fascinates me how every child, every coach, and every fan contributes to the experience.

It's 2:30 and players age 12 to 18  (all shapes, sizes, skill-levels, and personalities) take the field. The referee blows a whistle, glances at his watch and the game begins. Red team players laugh as they pass the ball around. Blue team players are more serious. A few strong players touch the ball most of the time. Many blue team members look like spectators embedded in the game. Like a flock of birds swirling through the sky, players run around the field.

To my left, two women share some play by play.  “She scored that goal from midfield! " To my right, a husband and wife catch up because he’s been on the road.  The red team players exchange friendly, supportive banter. "That's it!...way to be!...man on, man on!" Then, a  whistle. The game stops. A blue team player is called out for tripping.

Each person here adds to the joy of this moment. One angry parent could transform this pleasant community gathering into an anxious two hours. But I’ve never seen that happen. My only complaint is the aggressiveness of the blue team coach. The rules of soccer are the same for both teams. Yet coaches interpret the game differently and you can see it in how the children play. The blue team wins - again. And the fans politely congratulate everyone as we walk to the parking lot.  But I know that some parents will request their children be on the red team next year. Because soccer is fun, except when it's not.  It’s how you choose to play it.

Back to stuttering. This is not rocket science. Who do you choose as your friends? Who do you hire for projects? What religious community, social organization, or volunteer groups do you join? I bet you engage and employ people you feel good about. So here’s a problem. Public education provides one-size-fits-all programs. Students get “free” therapy with the only slp available. Health insurance covers a very limited course of treatment – if you’re lucky. An slp with additional training in stuttering may not be near you and tele-practice regulations make it difficult to access their services. I don’t accept insurance and I require parents participate in all treatment sessions. Consequently, I’ve always had few clients. I was glad to read that Ms Holt eventually found the “right” slp for her son.

            I believe frustration about treatment boils down to one simple concept. We cannot change another person’s behavior. Parents want me to fix their child’s speech. It can’t be done. A child is not a tablet needing the right app or an animal to be trained. And no matter how I present therapy, I see parents continue to blame children for stuttering. Ms Holte is right. There needs to be a revolution in how we provide treatment for stuttering. The disconnect between researcher, clinician,  and family hasn't been bridged. I for one will stop providing treatment in all but a very select few cases. Instead, I will offer family education and training as the only first option.

I wish you well on your journey with stuttering. When you are ready to change (I'm talking to parents and children) the National Stuttering Association and Stuttering Foundation are there to support and inform you.

p.s.

And here’s a brand new gem: Stuttering is Cool: A Guide to Stuttering in a Fast-Talking World.[9] This humble book filled with delightful drawings of Franky Banky & friends will validate the children, teens and even adults who stutter, especially someone far enough along on his personal journey to glimpse whole-picture thinking. [10] Mr Rossi gives us a modern version of the ‘reality check.’

Thanks for reading,
Judy










[2] Doreen Lenz Holte (2011) Voice Unearthed: Hope, Help, and a Wake-Up-Call for the Parents of Children Who Stutter.  no publisher listed.
[3] Ibid. p. 104
[4] A 2-week residential training program at Northwestern University sponsored by the Stuttering Foundation
[5] Nan Bernstein Ratner, Ed.D. (2012) Evidence Based Practice and Practice-Based Evidence: Closing the Gap, Nashville, TN: Stuttering Foundation No. 6720.
[6] Roger J. Ingham and Janis Costello Ingham (Oct.28, 2014) A Misleading Account of Research on Stuttering Treatment for Young Children
[7] I recently switched to Practical Intervention for Early Childhood Stammering: Palin PCI Approach (2008) for children through age 7. Written by Elaine Kelman & Alison Nicholas. Published by United Kingdom: Speechmark Publishing Ltd. This program requires and respects parent participation.
[8] Gordon W. Blood (2003) The PowerR Game: Managing Stuttering, Memphis, TN: The Stuttering Foundation publication no. 0250, www.stutteringhelp.org.
[9]Daniele Rossi (2014) Canada: Mischief, Mayhem and Mirth Publishing, www.stutteringiscool.com
[10] PowerR, p. 36

9/14/14

Classroom Presentation

           One of my courageous students presented  a slide show about stuttering to his 5th grade class.  I admit that I  was slow to  assist him in this ambitious project.  I expected his good intentions would  languish on  a wish list. Then he showed me a YouTube video he wrote and directed.  Here was proof that he was  a persistent  and competent young man, very likely to pursue any project to completion.

Wondering what my role would be, I recalled seeing an interview with Bill Belichick, coach of the New England Patriots football team. He said  quarterback Tom Brady knew it all and studied hard. He asked Coach Belichick so many tough questions that coaching him was very challenging. How was I going to coach my talented 5th grader?

I already had a few links to accounts of other children who  had spoken to their classes. [1] But I surfed the "just for kids" section of the Stuttering Home Page looking for inspiration.[2]  I chose only two articles in order to  prepare a thoughtful lesson within a week. This kept me occupied during a long, snowy evening.

I happened to be learning about Google tools and writing a talk for speech language pathologists at a nearby school.[3] I was multi-tasking in researching for my student' s assignment and for my own.  I found two YouTube videos to learn the basics of Google Slides.  One featured a teacher apparently in his home office. He spoke in a soft voice with the sweet sounds of a happy toddler in the background. Another YouTube video, this one intended for small business owners, gave  me a few more helpful tips. Im grateful to these two people who were so generous in sharing their knowledge on the internet.

The  two articles I chose from the Stuttering Home Page were written in very different styles. I read one written by Dr Bill Murphy called Class Presentations for Children Who Stutter. [4] It had an academic attitude and tight structure. It opened  with a premise followed by a lengthy list  of serious content. I took my time reflecting upon the parts of the article consistent with my clinical experience. How could this academic content  translate into a message my young student could quickly absorb?

The other article was FRIENDS Presentation Guide by John Ahlbach.[5] It had emotion,  intuition and humor. It affected me more now than when I read it many years ago. It suited my situation perfectly. John knew a child's perception of the world. His article addressed a  question hugely relevant to the child who stutters: Is it a good idea to hide ones' stuttering? The article  grabbed the readers attention immediately by proposing the issue this way: What if our hair turned green periodically? I read John's article with gratitude and a smile. It had the down-to-earth, friendly attitude I needed. It buoyed my spirits and gave me the energy to return to Dr. Murphy's article for more content.

            Brave children have taught others about stuttering in very public ways. Nate has a recent podcast Stuttering advice for parents, siblings and teachers at Stuttering is Cool[6]. He has a video of a recent class presentation[7] and one from four years ago[8].  (Also, take a look at Parker Mantells 2014 Commencement Speech.[9]) My student, his mother and I watched Nates videos during a speech therapy session. Nates model was absolutely priceless.

The final product was a true collaboration. Per his request, I emailed my template home for him to review and edit. [10] He deleted several of my slides and added his own. This entire process, which busied us for several sessions, fulfilled the requirements of a comprehensive treatment approach. We reviewed cognitive and affective components as we talked about what to put on each slide.  The behavioral goal (practicing speech change)  was satisfied as we rehearsed  the presentation. Im sure this project could meet requirements within the Common Core as well.

 Rehearsal was more difficult than I expected. My student began by denying any need to practice.  Consequently, I needed a way to transition from Nates videos to the present moment. So, I stood up and pretended we were in a classroom and that my student and his mom were students.  I made eye contact, resisted time pressure, reduced speaking rate slightly, paused at phrase boundaries, and talked. Yes , it was pretty humbling to stumble my way through this exercise. But perfection was never the goal. It was more important to have some fun with public speaking.  

            We made videos with my phone. I reviewed only three slides for Take 1.  I smiled alot  and played around with impromptu commentary. After giggling over the results, our attitudes brightened.  We used moms phone to video Takes 2. This time, I added loose, easy voluntary stuttering and modification techniques. I  held up a brochure about famous people who stutter and announced that everyone would  take one home. I had a laminated a poster of the movie The King's Speech[11] to hold up high for the entire class to see that I was in excellent company! My easy repetitions and mild blocks did not accompany any negative affect nor interrupt the flow of information. At this point in the session, my student was experimenting with the slow-motion feature and which made my videos became downright hilarious.  I thought this was a terrific because the project was no longer terrifying. It was great fun.

 Nate's YouTube video showed classmates asking questions.  We brainstormed around this possibility. Mother typed all of this into her laptop for future reference. I was delighted to watch mother and son work together. What success!



[1] J. Butler (8/26/13) Back To School Preparations for Children Who Stutter http://butlerspeechtherapy.blogspot.com/2013/08/back-to-school-preparations-for.html
[3]  J. Butler (3/8/14) Workshop Slides pdf  https://sites.google.com/site/judithvbutlermaccc/home/free
[4] As I edit this blog post on 9/14/14, I find that the link to Bill Murphys article is broken. The same content appears on the Stuttering Foundation site in the article  Teaching Others http://www.stutteringhelp.org/teaching-others
[7] Nates Stuttering Presentation with Questions (Nov. 30, 2013) https://www.youtube.com/watch?v=-0kxyzOxY3o
[8] Stuttering Presentation (May 8, 2010) https://www.youtube.com/watch?v=KKG2UM_5F_Y
[9] 2014 IU Commencement Speaker: Parker Mantell   https://www.youtube.com/watch?v=sTRAripodJY#t=154
[11] Stuttering Foundation , code 0074 www.stutteringhelp.org
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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.