3/8/14

Free Workshop for Schools


     This is the text for a 3-hour workshop for Speech Language Pathologists in the schools. The slides are "Workshop Slides" at https://sites.google.com/site/judithvbutlermaccc/home/free.
      Thank you very much for inviting me to your school to talk about stuttering. Let’s begin by watchingStuttering for Kids by Kids. There is a link to this video later in the side presentation.

 In 1997 my family and I moved and it was then that I decided to limit my private practice to stuttering. I was trying to continue in speech language pathology while learning to live in a new location and parent a toddler. I  became an ASHA Board Recognized Specialist in 2000. This new specialty was renewed every three years with continuing education credits and at least 100 hours/year of clinical work in stuttering. ASHA changed the name, requirements and renewal process in 2014. I am now called a Board Certified Specialist in Fluency and must renew every 5 years.

I am not a professor.   They know much, much more about stuttering than I do. What I hope to do in this brief, introductory workshop is to share a clinical perspective based on years of experience working with children who stutter. I have attended several National Stuttering Association conferences, published in the International Stuttering Awareness Day online conferences, read our ASHA journals and written a blog.  This is my present understanding of stuttering. I feel like the messenger. I'm hoping to  inspire you to learn more about stuttering and become more comfortable treating and advocating for the children who stutter who attend  your school.

Each student presents a new challenge. I revisit familiar material and look for research to support  all of my treatment recommendations. It almost never feels like I can use  a ‘one size fits all’ approach.  Because there were many days when I felt as if  I was reinventing the wheel, I started writing my thoughts down. In the beginning, these were published in Reaching Out, the newsletter of Friends: The Association for Young People Who Stutter.  I later compiled many of these articles in a self-published book called Becoming a Friend in 2002 and donated it to Friends. At that time, I was inspired by my friend Nancy Cohen and one of my students.  I felt the need to write again in 2008 and began a blog, Comments on Speech Therapy as a personal reference. It helped me to keep track of issues I wrestled with respect to different cases.  

Slide 3

This may be the most important concept in stuttering treatment. Stuttering is no one's fault. Stuttering appears to be a neurologically based disorder. Until a child develops anticipation anxiety, it can be fairly unpredictable. And so we need to be cautious about expectations for fluency. The moment of stuttering is something that we don’t understand. We do not know what causes the repetition,  prolongation or block. 

There is research linking  stuttering with length and complexity of spoken language, emotional reactivity, stability of the speech motor system and attention. Researchers think there may be subgroups of the disorder. Since I’m not the best person to talk about research studies, I’ll stop there and encourage you to choose a reference article that interests you from my blog  or from the references section of my therapy training manual.

Slide 5 

There are many valuable resources on the market. These are just the ones that I happened to use and are referenced in my own therapy manual. I just bought a brand-new therapy text by Yaruss & Reeves. It isn’t  listed here because I just haven't had a chance to read it yet.

 
Slide 6

Here are some additional excellent resources. The Stuttering Foundation produces a variety high-quality materials in multiple languages. Some are even available as free downloads. The National Stuttering Association is a support organization with chapters  throughout the United States. StutterTalk  is a podcast hosted by a speech language pathologist.  The Stuttering Homepage is a website with lots of materials and a link to the archived International Stuttering Awareness Day Online Conferences. Several years ago, I started a Google site as a personal resource. This is a link to one of the pages of that site. And finally, I write a blog called Comments on Speech Therapy .

Slide 7

I have been working on a speech therapy manual so that I can easily locate materials I find most helpful. Eventually, I hope to sell the workbook as a companion text for therapy and for school workshops. It needs alot more work before I can do that, so I’ve provided draft copies by email and on CD for free. There are many good books about stuttering on the market that stand alone as wonderfully thorough resources and I definitely defer to those texts.

I’ll be adding  a section about self advocacy to my manual soon because I recently created a classroom presentation. You can find it in the lesson ideas page of my website.  Students occasionally write a report about stuttering for school, but  never has one of my students been willing to make a presentation – until this year. One gifted and courageous student asked how to put one together for  a 5th grade class. We spent many sessions talking about it. He blended his own thoughts and style with some of my input to create a truly collaborative project.


Slide 8  - 10 minute group activity

Slide 9 (therapy manual page 40)

This slide reminds us that typically fluent speech is complex. 1.) When a person has an idea, the brain has so much to do!  2.) It selects words using the phonology (including the local accent) of a language. The words are organized in sentences using  the grammatical rules of the his language and situation.  And let’s not forget  intonation, loudness and turn-taking choices. All of this is presented in a socially appropriate manner. Nonverbal behavior such personal space, gesture and eye contact will accompany the verbal message.  3.) A motor plan will  program the body to produce pitch,  loudness, co-articulation and breath groups for phrasing, syllable- and word- emphasis ...all at a very fast speeds! 4.) The idea, the language and the motor plan will coordinate into an action sequence that can even withstand environmental interruptions!  5.) All of this is monitored within and without our awareness.
Of course many other important systems need  separate diagrams.  For example, listening skills  are important because some researchers feel auditory processing maybe implicated in stuttering.

Slide 10

Here are a few handy links for a review of speech production

Slide 11

This slide reminds us that stuttering is also complicated. On page 46, we see one theoretical basis for treatment. The point here is that stuttering is now considered a disorder influenced by many possible factors. As we think about the child sitting with us, we wonder how various parts of this model may apply to that child. Immediately, we begin to question if asking a child to reduce percentage of stuttering is realistic given that so many other variables influence the presence of stuttering.

Slide 12

 Let's think about how we can update therapy. Back when I was in college, we learned to count stuttered words and  praise children for reducing frequency of stuttering.  Now we must consider how this approach could foster guilt, fear and shame. Stuttering is a neurological in nature and potentially affected  by many other issues, some of which are clearly beyond our control. How often are we ourselves aware of co-articulation when we talk!

Yet, we ask children to change how they talk and thereby reduce stuttering.  In response, some children discover that  avoidance is an effective way to stop stuttering. You can’t stutter if you don’t talk.  Children can also avoid sounds and  words, by using synonyms or otherwise revising their message. Other children discover secondary behaviors that seem to make talking easier. The child with negative feelings about stuttering can find ways to hide it or fight it.

     On the other hand, if we encourage children to examine their speech and how it affects them, I believe we have the opportunity to prevent the development of a larger communication problem. We can teach children about speech and language, about stuttering in a non judgmental way, options for change and owning the process of improved communication.  What does this all mean?
Slide 13
Some people describe stuttering as an ice berg. Above the surface of the water we see a very small portion of the iceberg. This portion is the bumpy speech. Below the surface of the water is a much larger portion of the iceberg and represents the feelings and thoughts that are hidden from view but has the potential to become a significant portion of the stuttering problem. For the child who stutters, these feelings translate into behaviors such as avoiding class participation, avoiding the telephone and enduring teasing and bullying that an adult may or may not witness. Also below the surface are feelings of failure when parents ask why children will not use speech strategies in daily life. There is a parent who writes a blog called  Voice Unearthed who addresses these kinds of problems.
Slide 14
I'm not too sure why I placed this slide here. Perhaps it is because now that we have upgraded our understanding of stuttering, we can think about how we treat it from the very earliest years. We begin with genetics because research presumes there is a predisposition  to stutter. Furthermore, as with other conditions, environment plays a role. The child with speech language planning and production weaknesses, the child with greater emotional reactivity and difficulty with self regulation, the child who experiences difficulty with communication, and the child who reacts negatively to the stuttering may have a more difficult experience with stuttering.  Of course I am simplifying. Exactly how one or more of these factors influence one another is a mystery. We do not know the cause of stuttering but we have some ideas about how it might become a persistent and disabling condition for some children.
 
Slide 15
For additional information about treatment of  developmental stuttering in preschoolers, please refer to the pages listed on the slide. Please note that I have not included the Lidcomb Program.  I am not trained in that protocol and feel I should not comment it.
Slide 16
If we are not going to ask children to reduce stuttering what are we going to do? Well, teach them strategies to help reduce oral-motor tension, help them to understand their own communication needs and the process of change, and help them feel confident about saying what they need to say when they need to say it. By the way, this does not mean speech-language pathologists stop counting stuttered words. But it is no longer our sole or even our top priority. We pursue easier speech, positive affect and productive thinking regarding the child's communication needs. This means that we measure and treat speech-motor, cognitive  and affective issues in our therapy activities. 
Slide 17
demonstration of reduced rate, phrasing, easy onset, gentle voluntary stuttering, freezing, pullout, cancellation, natural prosody, non-verbal communication, confidence; comment that these strategies can feel more awkward than stuttered speech
Slide 18
Children 8 and older can talk about typical speech, stuttering, acceptance, avoidance and concomitant disorders in a more explicit way. You already do this in treatment for other communication problems. You take care to consider the unique needs of each individual student and you can do the same for children who stutter. Please refer to the many inexpensive and wonderful training DVDs produced by the Stuttering Foundation for more information. Also there are brand new books about teasing and bullying at the National Stuttering Association website.
 
Slide 19
You already know how to use a hierarchy for learning other speech language behaviors. I don't know of any skill that can be learned overnight and yet parents and teachers expect immediate carryover of new speech skills. Why is this?  I once had a conversation with a parent who worked as a school aide and who did not know I was a speech language pathologist. She said she thought speech therapy was a fraud because the children she saw were not improving speech skills in the classroom!! We need to remind others that any skill takes time to learn and it is no different for children in speech therapy.
Speech strategies and counseling are explained on Stuttering Foundation DVDs. Participation in social and academic settings can reference the literature on pragmatic language. If you read the stories children tell in (FREE) newsletters published by the Stuttering Foundation and the National Stuttering Association, you will learn about the recurring issues specific to children who stutter. If you are an ASHA Certified SLP, you can join Special Interest Division 4 for more information about stuttering. Please tell others about the free workshop you are attending right now. The slides and this text are post on my website.
You simply don't need to be a rocket scientist to understand and empathize with the child with a speech problem for which he/she has experienced teasing, bullying and communication breakdown.
Slide 20
Here are resources for addressing attitudes and emotions of children who stutter.
Slide 21
In conclusion I think we have a choice:  we can continue to focus on counting stuttered words and blame children for a neurological difference OR we can focus on the larger picture.
Thank you.   Judy
 
 
 
 




Creative Commons License
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.