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.
4/28/11
Treating More Than Stuttering
After 14 years of accepting only children who stutter, I am opening my practice to children with other language, reading and writing difficulties.
I treated a variety of pediatric speech/language disorders for many years prior to limiting my practice to stuttering. And I drew upon this experience often. My professional library grew to include books, continuing education materials, and therapy activities that assessed and addressed not only speech/language delay, but also voice production, articulation/phonological disorders, dyslexia, attention deficit, anxiety, executive functioning, auditory and visual processing, social/pragmatic skills and sensori-motor concerns. Most of my speech therapy for stuttering was combined with treatment for these other issues.
Now, I am looking forward to also working with children who do not stutter, but experience other language, reading, and writing difficulties. My speech/language therapy is based upon peer-reviewed professional publications and only supplemented by commercially published programs. Therapy sessions are designed with the needs and interests of each child and teen in mind. Parents are required to observe all sessions for elementary- and middle-school age children. Therapy is a family affair.
Our children and teens are facing increased academic pressures in the current climate of state-wide achievement testing. At the same time, shrinking budgets are restricting special education services. I specialize in working with the children who “fall through the cracks”, the children who do not qualify for special education at school, yet find academics a struggle.
I treated a variety of pediatric speech/language disorders for many years prior to limiting my practice to stuttering. And I drew upon this experience often. My professional library grew to include books, continuing education materials, and therapy activities that assessed and addressed not only speech/language delay, but also voice production, articulation/phonological disorders, dyslexia, attention deficit, anxiety, executive functioning, auditory and visual processing, social/pragmatic skills and sensori-motor concerns. Most of my speech therapy for stuttering was combined with treatment for these other issues.
Now, I am looking forward to also working with children who do not stutter, but experience other language, reading, and writing difficulties. My speech/language therapy is based upon peer-reviewed professional publications and only supplemented by commercially published programs. Therapy sessions are designed with the needs and interests of each child and teen in mind. Parents are required to observe all sessions for elementary- and middle-school age children. Therapy is a family affair.
Our children and teens are facing increased academic pressures in the current climate of state-wide achievement testing. At the same time, shrinking budgets are restricting special education services. I specialize in working with the children who “fall through the cracks”, the children who do not qualify for special education at school, yet find academics a struggle.
1/8/11
Cognitive Behavior Therapy
Speech therapy for stuttering takes many forms. I recently learned more about speech therapy as a process of discovery. This perspective is presented in the DVD Tools for Success: A Cognitive Behavior Therapy Taster by Frances Cook and Willie Botterill. (1)
Cognitive-behavior therapy (CBT) can be “readily adapted for working with the cognitive, affective, and behavioral aspects of stuttering” states handout accompanying the DVD. The premise of CBT is that thoughts, feelings, and behavior are inter-related and influence one another. An simple graphic illustrates thoughts, feelings, physiological responses and behavior in a circle. Initially, the relationship between these 4 aspects was explained as occurring in a clockwise direction: a person’s thoughts cause certain emotional reactions which in turn cause the body to respond which finally results in a specific behavior. Later, it was described as bi-directional. Towards the end of the DVD, a CBT approach is demonstrated during conversation with a group of children and a group of parents.
While I appreciated the therapeutic style and felt that the process could be a good fit for some of my students, I wondered about how CBT would affect real outcome. I recalled attending a workshop presented by the Albert Ellis Institute many years ago that espoused a similar approach to problems of depression, anxiety, relationships and addiction. The Albert Ellis Institute home page reads: “short term therapy, long term results” and I wonder aloud what evidence supports this claim. The Stuttering Hexagon (3) that John Harrison presents includes a diagram of the interaction between 6 different factors: behaviors, emotions, perceptions, beliefs, intentions and physiological responses. Does an appreciation for a multi-directional, multi-faceted mind-body relationship result in greater fluency?
Ms Cook and Ms Botterill, renowned therapists at the Michael Palin Center (4), report success using CBT with their clients who stutter. Slides 24 and 25 of their presentation define the commonly occurring reactions to stuttering as “Safety Behaviors.” These include specific speech behaviors such as “push harder” and “speak more quickly” as well as communicative choices such as “decide not to speak” and “pretend not to know the answer.” The premise is that when one changes a single factor of the Cognitive Model, then other factors also change because of their inherent interconnection. An SLP is to guide conversation with clients in such a way as to discover the specific thoughts, feelings, physiological responses and behaviors they experience. Then, reality checks, “cognitive reframing”, behavioral experiments, and problem-solving help to change unhelpful thought patterns and behaviors and therefore improve fluency.
In a way, proponents of a strictly behavioral approach to stuttering therapy made similar claims: improving speech fluency would positively influence cognitive and affective aspects of communication. I recall attending a Special Interest Division Conference in Boston, Massachusetts at which Bruce Ryan argued passionately that his systematic approach of increasingly difficult speech drills was successful. He even expressed regret that some of the younger SPLs may not have been exposed to his program, presumably because other training programs preempted his own. (5) Yet, the field of speech pathology has responded by drawing on principals of counseling therapy.
We now have a field divided. Research into genetics, assistive devices, temperament, self-monitoring skills and impulsivity, stages of change, quality of life, and evidence-based practice are overwhelming. Most SLPs choose not to keep up with the multitude of voices within the field of stuttering therapy. School districts propagate this state of affairs by refusing service to children who stutter in many cases. Insurance companies that deny coverage for stuttering therapy are accomplices.
Where are we now? Perhaps the recent National Public Radio interview with Kristin Chmela and Dan Slater (6) illustrates two answers to this question. Ms Chmela, an SLP, Specialist in Stuttering, and person who grew up stuttering, says that she has made a journey of recovery. (7) She seldom thinks, feels, or speaks like a stutterer. Mr. Slater talks about his continued internal anxiety and use of avoidance tricks. Ms Chmela eloquently describes stuttering and its management as something unique to every individual who stutters. This interview is a must-listen.
I will add principals of CBT to my speech therapy because it provides a framework for listening to the client. This is key to the therapeutic alliance, IMHO. The child, teen or adult who stutters is likely to have few, if any, sensitive listeners. Speech therapy may be the only place in which they talk. SLPs must allow plenty of time for careful listening and CBT allows for this.
(1) ©2009, www.stutteringhelp.org
(2) http://www.rebt.org/
(3) “How I Recovered from Stuttering” by John Harrison http://www.masteringstuttering.com/recovery-stuttering.htm
(4) I could find a webpage for this
(5) http://www.mnsu.edu/comdis/kuster/TherapyWWW/gilcu.html
(6) “The King’s Speech Passes Stutterers the Mic”, January 4, 2011, http://www.npr.org/2011/01/04/132653936/the-kings-speech-passes-stutterers-the-mic
(7) “Thoughts on Recovery” by Kristen Chmela, 1997, http://www.mnsu.edu/comdis/kuster/casestudy/path/chmela.html
Cognitive-behavior therapy (CBT) can be “readily adapted for working with the cognitive, affective, and behavioral aspects of stuttering” states handout accompanying the DVD. The premise of CBT is that thoughts, feelings, and behavior are inter-related and influence one another. An simple graphic illustrates thoughts, feelings, physiological responses and behavior in a circle. Initially, the relationship between these 4 aspects was explained as occurring in a clockwise direction: a person’s thoughts cause certain emotional reactions which in turn cause the body to respond which finally results in a specific behavior. Later, it was described as bi-directional. Towards the end of the DVD, a CBT approach is demonstrated during conversation with a group of children and a group of parents.
While I appreciated the therapeutic style and felt that the process could be a good fit for some of my students, I wondered about how CBT would affect real outcome. I recalled attending a workshop presented by the Albert Ellis Institute many years ago that espoused a similar approach to problems of depression, anxiety, relationships and addiction. The Albert Ellis Institute home page reads: “short term therapy, long term results” and I wonder aloud what evidence supports this claim. The Stuttering Hexagon (3) that John Harrison presents includes a diagram of the interaction between 6 different factors: behaviors, emotions, perceptions, beliefs, intentions and physiological responses. Does an appreciation for a multi-directional, multi-faceted mind-body relationship result in greater fluency?
Ms Cook and Ms Botterill, renowned therapists at the Michael Palin Center (4), report success using CBT with their clients who stutter. Slides 24 and 25 of their presentation define the commonly occurring reactions to stuttering as “Safety Behaviors.” These include specific speech behaviors such as “push harder” and “speak more quickly” as well as communicative choices such as “decide not to speak” and “pretend not to know the answer.” The premise is that when one changes a single factor of the Cognitive Model, then other factors also change because of their inherent interconnection. An SLP is to guide conversation with clients in such a way as to discover the specific thoughts, feelings, physiological responses and behaviors they experience. Then, reality checks, “cognitive reframing”, behavioral experiments, and problem-solving help to change unhelpful thought patterns and behaviors and therefore improve fluency.
In a way, proponents of a strictly behavioral approach to stuttering therapy made similar claims: improving speech fluency would positively influence cognitive and affective aspects of communication. I recall attending a Special Interest Division Conference in Boston, Massachusetts at which Bruce Ryan argued passionately that his systematic approach of increasingly difficult speech drills was successful. He even expressed regret that some of the younger SPLs may not have been exposed to his program, presumably because other training programs preempted his own. (5) Yet, the field of speech pathology has responded by drawing on principals of counseling therapy.
We now have a field divided. Research into genetics, assistive devices, temperament, self-monitoring skills and impulsivity, stages of change, quality of life, and evidence-based practice are overwhelming. Most SLPs choose not to keep up with the multitude of voices within the field of stuttering therapy. School districts propagate this state of affairs by refusing service to children who stutter in many cases. Insurance companies that deny coverage for stuttering therapy are accomplices.
Where are we now? Perhaps the recent National Public Radio interview with Kristin Chmela and Dan Slater (6) illustrates two answers to this question. Ms Chmela, an SLP, Specialist in Stuttering, and person who grew up stuttering, says that she has made a journey of recovery. (7) She seldom thinks, feels, or speaks like a stutterer. Mr. Slater talks about his continued internal anxiety and use of avoidance tricks. Ms Chmela eloquently describes stuttering and its management as something unique to every individual who stutters. This interview is a must-listen.
I will add principals of CBT to my speech therapy because it provides a framework for listening to the client. This is key to the therapeutic alliance, IMHO. The child, teen or adult who stutters is likely to have few, if any, sensitive listeners. Speech therapy may be the only place in which they talk. SLPs must allow plenty of time for careful listening and CBT allows for this.
(1) ©2009, www.stutteringhelp.org
(2) http://www.rebt.org/
(3) “How I Recovered from Stuttering” by John Harrison http://www.masteringstuttering.com/recovery-stuttering.htm
(4) I could find a webpage for this
(5) http://www.mnsu.edu/comdis/kuster/TherapyWWW/gilcu.html
(6) “The King’s Speech Passes Stutterers the Mic”, January 4, 2011, http://www.npr.org/2011/01/04/132653936/the-kings-speech-passes-stutterers-the-mic
(7) “Thoughts on Recovery” by Kristen Chmela, 1997, http://www.mnsu.edu/comdis/kuster/casestudy/path/chmela.html
11/7/10
DIVA
Speech science offers clues to managing the problems of stuttering and cluttering.
Speech scientists study how we transform ideas into spoken words. They construct hypothetical models to explain these processes. A recent research development will change my speech therapy. It has to do with a computer model that can actually produce both fluent and stuttered speech. This model suggests that persons who stutter may not have accurate motor commands – feedforward commands – telling the oral motor system what to do. And, another related article proposes that inadequate feedback affects speech. (1) To my mind, this means speech therapy needs to spend a whole lot more time on whatever tasks elicit the most fluency instead of pressing onward to more difficult speaking tasks.
The speech model I am referring to is called the DIVA model. (2) Computer simulations of this model produced stuttered speech when manipulated in very specific ways. I cannot explain the mathematical calculations that caused the speech changes. However, the basic idea is easy to understand…
The DIVA model proposes that our brains issue motor commands to speak. The motor command seems to be for an entire sentence, so as to plan for “co-articulation.” Co-articulation refers to the slight changes we make when pronouncing an /i/, for example, based on what sounds come before and after it. The way we articulate /i/ in the word “mine” is slightly different that the way we articulate /i/ in “fight.” The DIVA model speculates that when a person mispronounces a sound, an internal “speech monitor” tries to correct the error by turning off the voice, “repositioning the articulators,” and starting over again. (3) This causes sound and syllable repetitions.
The ‘speech monitor’ depends on feedback. We rely on feedback for a variety of tasks. When I turn on the water to wash dishes, feedback from my hands tells me if the water is too hot or too cold. I use visual feedback while driving when I look at the speedometer to check how fast I am driving. And when speaking, I rely heavily on auditory feedback to be sure my speech is clear and my words express my message.
The Fall 2010 issue of The Stuttering Foundation newsletter refers to the DIVA model in a front page article, “Feedforward Strategy in Children.” (4) The author explains that he is going to study co-articulation skills in children who stutter to learn more about their speech motor planning skills. If children who stutter show poorer co-articulation skills compared to fluent children, then this would support the theory that inadequate feedforward commands could be to blame. In other words – if this theory is correct - children who stutter find themselves in mid-sentence having to change their articulation of sounds because of faulty motor planning at the very beginning of the sentence.
The April 2010 International Cluttering Awareness Day online conference includes a paper about the DIVA model. It even includes a diagram of the model. This paper suggests that a speaker’s “…feedforward mechanism may be relatively intact, so that he is aware of the appropriate sounds to produce…however, if the feedback system that includes both auditory [hearing] and somatosensory [touch] has not been providing the appropriate feedback, then the feedforward mechanism may be ‘faulty ‘ in that it may not be properly tuned.’” The article recommends a variety of ways to help the speaker increase awareness and improve feedback monitoring.
I’ll continue to experiment with new ways to provide feedback: digital video and audio recordings, delayed auditory feedback, and Audacity® in addition to traditional token reinforcement and verbal praise. But, now I will think in terms of practicing the correct output much more frequently.
also, I will be doing alot more modeling in order to provide the fluent model. Maybe this will help fine-tune the feedforward system. As usual, results will be different for each student. It will be interesting to see what session data reveals.
(1) Leahy, M. (2010) “Monitoring feedback as you speak: how DIVA contributes to explaining a part of the problem of cluttering, and to developing a therapy plan. http://www.mnsu.edu/comdis/ical/papers/leahyc.html
(2) Boston University Speech lab, http://speechlab.bu.edu/diva.hph (This link was broken today.)
(3) Civier, O. , et. al, (2010) “Overreliance on auditory feedback may lead to sound/syllable repetitions: Simulations of stuttering and fluency-inducing conditions with a neural model of speech production” Journal of Fluency Disorders, 35, p. 266
(4) broken link
Speech scientists study how we transform ideas into spoken words. They construct hypothetical models to explain these processes. A recent research development will change my speech therapy. It has to do with a computer model that can actually produce both fluent and stuttered speech. This model suggests that persons who stutter may not have accurate motor commands – feedforward commands – telling the oral motor system what to do. And, another related article proposes that inadequate feedback affects speech. (1) To my mind, this means speech therapy needs to spend a whole lot more time on whatever tasks elicit the most fluency instead of pressing onward to more difficult speaking tasks.
The speech model I am referring to is called the DIVA model. (2) Computer simulations of this model produced stuttered speech when manipulated in very specific ways. I cannot explain the mathematical calculations that caused the speech changes. However, the basic idea is easy to understand…
The DIVA model proposes that our brains issue motor commands to speak. The motor command seems to be for an entire sentence, so as to plan for “co-articulation.” Co-articulation refers to the slight changes we make when pronouncing an /i/, for example, based on what sounds come before and after it. The way we articulate /i/ in the word “mine” is slightly different that the way we articulate /i/ in “fight.” The DIVA model speculates that when a person mispronounces a sound, an internal “speech monitor” tries to correct the error by turning off the voice, “repositioning the articulators,” and starting over again. (3) This causes sound and syllable repetitions.
The ‘speech monitor’ depends on feedback. We rely on feedback for a variety of tasks. When I turn on the water to wash dishes, feedback from my hands tells me if the water is too hot or too cold. I use visual feedback while driving when I look at the speedometer to check how fast I am driving. And when speaking, I rely heavily on auditory feedback to be sure my speech is clear and my words express my message.
The Fall 2010 issue of The Stuttering Foundation newsletter refers to the DIVA model in a front page article, “Feedforward Strategy in Children.” (4) The author explains that he is going to study co-articulation skills in children who stutter to learn more about their speech motor planning skills. If children who stutter show poorer co-articulation skills compared to fluent children, then this would support the theory that inadequate feedforward commands could be to blame. In other words – if this theory is correct - children who stutter find themselves in mid-sentence having to change their articulation of sounds because of faulty motor planning at the very beginning of the sentence.
The April 2010 International Cluttering Awareness Day online conference includes a paper about the DIVA model. It even includes a diagram of the model. This paper suggests that a speaker’s “…feedforward mechanism may be relatively intact, so that he is aware of the appropriate sounds to produce…however, if the feedback system that includes both auditory [hearing] and somatosensory [touch] has not been providing the appropriate feedback, then the feedforward mechanism may be ‘faulty ‘ in that it may not be properly tuned.’” The article recommends a variety of ways to help the speaker increase awareness and improve feedback monitoring.
I’ll continue to experiment with new ways to provide feedback: digital video and audio recordings, delayed auditory feedback, and Audacity® in addition to traditional token reinforcement and verbal praise. But, now I will think in terms of practicing the correct output much more frequently.
also, I will be doing alot more modeling in order to provide the fluent model. Maybe this will help fine-tune the feedforward system. As usual, results will be different for each student. It will be interesting to see what session data reveals.
(1) Leahy, M. (2010) “Monitoring feedback as you speak: how DIVA contributes to explaining a part of the problem of cluttering, and to developing a therapy plan. http://www.mnsu.edu/comdis/ical/papers/leahyc.html
(2) Boston University Speech lab, http://speechlab.bu.edu/diva.hph (This link was broken today.)
(3) Civier, O. , et. al, (2010) “Overreliance on auditory feedback may lead to sound/syllable repetitions: Simulations of stuttering and fluency-inducing conditions with a neural model of speech production” Journal of Fluency Disorders, 35, p. 266
(4) broken link
9/25/10
Teaching is Finding Success
Children are demanding. They need fun, attractive games that hold their attention. While my speech therapy must be evidence-based and reference professional programs, it also has to be tailored to the needs of individual students. And so I’m always looking for commercially available games and then changing the rules of play so that they transform into speech therapy activities. Sometimes this is on the fly. During a speech therapy session, the parent, child, and I play around with changing game rules so that play is instructional as well as fun.
I recently purchased the game “Pickles to Penguins” (Imaginationgames.com, © 2009) because it looked like a colorful, child-friendly game that was reasonably priced. This blog is a description of how I will use this game to teach. Teaching means giving away the answers! Teaching means finding lots of ways to help a child discover/practice/play with the answers. Many games are packaged as competitive tests. There are time limits, scores, and demands for correct answers. I’ve listed some ways that the “Pickles to Penguins” game will become cooperative and informative.
It is my job to determine appropriate teaching goals through formal testing, observations, and collaborations with school staff and parents. Once goals are defined, I need to know how well the child performs these goals in a teaching activity. If the child performs well (based on a specific criteria), then the goal needs to be changed. There’s no point in teaching something the child already knows. So how will I know if a game is an effective method of teaching?
Before we play our very first game, my student will respond to what is called a “baseline” measure. He will perform the goal behavior without any hints or corrective feedback. I will record how well he achieves this task.
For one particular student, the baseline will be an audio recording (using a small digital recorder and clip mic) of his responses. The cards used for the baseline measure will not be the cards we play with. The cards used for the baseline measure are set aside and used at a later date to measure progress. Next, we will take a different deck of picture cards and begin to modify play based on the student’s responses. We play and play and play!! We change around the game rules and play again! (Don’t I have the best job in the world?)
After a period of time, we return to the cards used in the baseline. Once again, the child performs the goal behaviors without any hints or corrective feedback. If therapy was effective, the child will generalize his new skills to the baseline set of picture cards. His performance after therapy should be of better quality, include more examples of the goal behavior, than his performance at baseline.
Here are some ways we will play with the Pickles to Penguins game cards. I’m sure there are many more ways beside those I’ve listed. Specific fluency goals are added onto to each task, though not listed here.
• Modify the game as needed to achieve success.
o Slow down speech rate to slow the pace of the game
o Increase pause time to provide extra time for speech processing, coming up with ideas, word retrieval to express the ideas, sentence formation, speech production
o Consider bonus points for multiple responses. This will work only if it does not increase frustration or time pressure and if it does not increase competition.
o Use “personal best” scores as a way to be competitive. Encourage players to increase their own scores from previous times they have played.
o Select the number of cards per game based on the attention span and reward needs of the child. Several games using only 20 cards per game may be more fun for a child who needs to finish quickly and see scores improve across games asap.
o Use the same cards over and over again if needed to ensure success. E.g., play 3 times with the same 20 cards, then add 10 more new cards.
o Consider using a timer (like the hour glass or liquid drip timer) as an aid for increasing thinking time…e.g., 1 minute of thinking time is required before responding
o Team/cooperative play is a way to role model
o Plan to use the same answers you came up with together during the Review/Teach process. This will help with long term memory and with increasing success and confidence.
• Review/Teach the cards before playing.
o Spelling:
Take turns holding a card out of sight of the other players, reading the word, asking each player to spell the word aloud or in writing on paper or in the air
Take turns holding a card out of sight of the other players, spelling the word, asking each player to listen to the spelling and guess the word
Sort through the cards together looking for a particular kind of spelling pattern. Be sure to take a few cards and write the words so that this is not just a flash card/recognition activity.
Before reading a card, give a clue, e.g., “This word has the double vowel [ea] in it.” Remember, this is a teaching time and anything that helps correct repetitive practice makes playing fun and effective.
o Segmenting: take turns holding a card out of sight of the other players, read the word by omitting an initial or final sound (or a syllable) and ask the players to listen and guess the word by adding the missing sound
o Meanings: Take turns holding a card out of sight and talking about the picture and ask players to guess what the word is.
o Go through the cards and select which cards would be fun to play with. These will probably be cards that are most familiar and so the first several games should be successful. Be sure to include less popular, more difficult cards in later games.
o Talk about the cards:
Word association: What single word(s) pop into your head when you read each card?
Adjectives: What describing word(s) do you think of when you reach each card?
Put each word in a sentence.
Select 2 or more cards and make a story.
Smell/touch/sound: Think of sensory experiences for each card (donkey feels soft, bean bag chair makes a squishing/crinkling sound when you sit in it)
There are lots of ways to play in multisensory ways. I haven't listed craft, role play, patomime, and music activities . Every teacher has personal preferences and talents that he/she brings to the lesson. Every parent does as well. Bring everyone's strengths to the teaching situation. Have fun!
Vocabulary Instruction for Children and Adolescents With Language Disorders, 2006, ASHA Professional Development Self-Study 7570
I recently purchased the game “Pickles to Penguins” (Imaginationgames.com, © 2009) because it looked like a colorful, child-friendly game that was reasonably priced. This blog is a description of how I will use this game to teach. Teaching means giving away the answers! Teaching means finding lots of ways to help a child discover/practice/play with the answers. Many games are packaged as competitive tests. There are time limits, scores, and demands for correct answers. I’ve listed some ways that the “Pickles to Penguins” game will become cooperative and informative.
It is my job to determine appropriate teaching goals through formal testing, observations, and collaborations with school staff and parents. Once goals are defined, I need to know how well the child performs these goals in a teaching activity. If the child performs well (based on a specific criteria), then the goal needs to be changed. There’s no point in teaching something the child already knows. So how will I know if a game is an effective method of teaching?
Before we play our very first game, my student will respond to what is called a “baseline” measure. He will perform the goal behavior without any hints or corrective feedback. I will record how well he achieves this task.
For one particular student, the baseline will be an audio recording (using a small digital recorder and clip mic) of his responses. The cards used for the baseline measure will not be the cards we play with. The cards used for the baseline measure are set aside and used at a later date to measure progress. Next, we will take a different deck of picture cards and begin to modify play based on the student’s responses. We play and play and play!! We change around the game rules and play again! (Don’t I have the best job in the world?)
After a period of time, we return to the cards used in the baseline. Once again, the child performs the goal behaviors without any hints or corrective feedback. If therapy was effective, the child will generalize his new skills to the baseline set of picture cards. His performance after therapy should be of better quality, include more examples of the goal behavior, than his performance at baseline.
Here are some ways we will play with the Pickles to Penguins game cards. I’m sure there are many more ways beside those I’ve listed. Specific fluency goals are added onto to each task, though not listed here.
• Modify the game as needed to achieve success.
o Slow down speech rate to slow the pace of the game
o Increase pause time to provide extra time for speech processing, coming up with ideas, word retrieval to express the ideas, sentence formation, speech production
o Consider bonus points for multiple responses. This will work only if it does not increase frustration or time pressure and if it does not increase competition.
o Use “personal best” scores as a way to be competitive. Encourage players to increase their own scores from previous times they have played.
o Select the number of cards per game based on the attention span and reward needs of the child. Several games using only 20 cards per game may be more fun for a child who needs to finish quickly and see scores improve across games asap.
o Use the same cards over and over again if needed to ensure success. E.g., play 3 times with the same 20 cards, then add 10 more new cards.
o Consider using a timer (like the hour glass or liquid drip timer) as an aid for increasing thinking time…e.g., 1 minute of thinking time is required before responding
o Team/cooperative play is a way to role model
o Plan to use the same answers you came up with together during the Review/Teach process. This will help with long term memory and with increasing success and confidence.
• Review/Teach the cards before playing.
o Spelling:
Take turns holding a card out of sight of the other players, reading the word, asking each player to spell the word aloud or in writing on paper or in the air
Take turns holding a card out of sight of the other players, spelling the word, asking each player to listen to the spelling and guess the word
Sort through the cards together looking for a particular kind of spelling pattern. Be sure to take a few cards and write the words so that this is not just a flash card/recognition activity.
Before reading a card, give a clue, e.g., “This word has the double vowel [ea] in it.” Remember, this is a teaching time and anything that helps correct repetitive practice makes playing fun and effective.
o Segmenting: take turns holding a card out of sight of the other players, read the word by omitting an initial or final sound (or a syllable) and ask the players to listen and guess the word by adding the missing sound
o Meanings: Take turns holding a card out of sight and talking about the picture and ask players to guess what the word is.
o Go through the cards and select which cards would be fun to play with. These will probably be cards that are most familiar and so the first several games should be successful. Be sure to include less popular, more difficult cards in later games.
o Talk about the cards:
Word association: What single word(s) pop into your head when you read each card?
Adjectives: What describing word(s) do you think of when you reach each card?
Put each word in a sentence.
Select 2 or more cards and make a story.
Smell/touch/sound: Think of sensory experiences for each card (donkey feels soft, bean bag chair makes a squishing/crinkling sound when you sit in it)
There are lots of ways to play in multisensory ways. I haven't listed craft, role play, patomime, and music activities . Every teacher has personal preferences and talents that he/she brings to the lesson. Every parent does as well. Bring everyone's strengths to the teaching situation. Have fun!
Vocabulary Instruction for Children and Adolescents With Language Disorders, 2006, ASHA Professional Development Self-Study 7570
9/22/10
New Beginnings: Stress & Relaxation
A few of my students are beginning this academic year in new settings. Two are freshmen in college, one nearby and one quite far away. Two students are beginning middle school. And my own son began this year at a new school. The transition is stressful and can be downright frightening.
The middle school day is divided into periods. Students move from classroom to classroom, encountering a different teacher for each subject. Peers shuffle in the hallways, reconfiguring into distinct groups for each class. Time is limited to 5 minutes or less between classes during which padlocks on lockers must be opened, books retrieved, and quick friendly greetings exchanged if one is lucky enough to see friends passing by in the hall. Lunch is rushed and squeezed into a range of time slots so that it may be brunch one day and a mid-afternoon snack on another. When does one get to the bathroom!? And middle school means homework in several subjects to keep track of, including short and long term projects, quizzes and tests, and worksheets of various degrees of difficulty.
College takes all these changes and magnifies them. Now classes are in different buildings scheduled across days and include term papers and exams covering months of material. Peers may include students from other cities, other states, maybe even other countries. Living away from home requires multiple attempts at an independent healthy lifestyle: eating nutritious meals, getting enough sleep, managing time and making safe choices.
It’s all very exciting!
The adjustment process takes trial and error, success and failure, elation and pain, hard work, self-confidence and faith. I suppose there are lots of ways to approach dramatic changes such as these. Relaxation techniques may be helpful for some people. I mention this because a mom recently asked me if relaxation techniques would help her child’s speech. And so, I took a look around for some quick and easy suggestions.
There are different kinds of relaxation techniques that all seem to have the same general goal – to consciously and deliberately find a feeling relaxation to replace feelings of stress. Relaxation techniques take only 10 minutes or so and, with practice, can help us to relax almost any time we need to “calm down”, focus, think more clearly, and behave more carefully. Stuttering is not caused by stress, but, stuttering can be affected by stress. It can be easier to focus on speech and communication when we are more relaxed.
A surf through YouTube revealed. . .
Here is a simple video that describes how watching clouds can lead to a feeling of relaxation:
http://www.youtube.com/watch?v=P-ygq1W681A&feature=related
Here is a video of rain: http://www.youtube.com/watch?v=NgG4vDfcJek&feature=related
Here’s one that takes you through progressive relaxation:
http://www.youtube.com/watch?v=HFwCKKa--18
I make it a point to stop for about 15 minutes every day and just sit. When I’m lucky, I sit outside. Sometimes I write down the to-do list that perpetually crowds my thoughts. Released from this burden, I begin to hear the subtle sounds around me and then notice the more substantive ideas lurking between my ears. Back and forth I go: notice the rustle of leaves, eliminate a task I don’t reeeally need to do, feel the sun, re-prioritize projects, notice my breath, remember to write a friend, and relax into the important over the urgent.
I wish for my students to have faith in themselves and to act in new ways that will keep them to be healthy, safe, and successful.
The middle school day is divided into periods. Students move from classroom to classroom, encountering a different teacher for each subject. Peers shuffle in the hallways, reconfiguring into distinct groups for each class. Time is limited to 5 minutes or less between classes during which padlocks on lockers must be opened, books retrieved, and quick friendly greetings exchanged if one is lucky enough to see friends passing by in the hall. Lunch is rushed and squeezed into a range of time slots so that it may be brunch one day and a mid-afternoon snack on another. When does one get to the bathroom!? And middle school means homework in several subjects to keep track of, including short and long term projects, quizzes and tests, and worksheets of various degrees of difficulty.
College takes all these changes and magnifies them. Now classes are in different buildings scheduled across days and include term papers and exams covering months of material. Peers may include students from other cities, other states, maybe even other countries. Living away from home requires multiple attempts at an independent healthy lifestyle: eating nutritious meals, getting enough sleep, managing time and making safe choices.
It’s all very exciting!
The adjustment process takes trial and error, success and failure, elation and pain, hard work, self-confidence and faith. I suppose there are lots of ways to approach dramatic changes such as these. Relaxation techniques may be helpful for some people. I mention this because a mom recently asked me if relaxation techniques would help her child’s speech. And so, I took a look around for some quick and easy suggestions.
There are different kinds of relaxation techniques that all seem to have the same general goal – to consciously and deliberately find a feeling relaxation to replace feelings of stress. Relaxation techniques take only 10 minutes or so and, with practice, can help us to relax almost any time we need to “calm down”, focus, think more clearly, and behave more carefully. Stuttering is not caused by stress, but, stuttering can be affected by stress. It can be easier to focus on speech and communication when we are more relaxed.
A surf through YouTube revealed. . .
Here is a simple video that describes how watching clouds can lead to a feeling of relaxation:
http://www.youtube.com/watch?v=P-ygq1W681A&feature=related
Here is a video of rain: http://www.youtube.com/watch?v=NgG4vDfcJek&feature=related
Here’s one that takes you through progressive relaxation:
http://www.youtube.com/watch?v=HFwCKKa--18
I make it a point to stop for about 15 minutes every day and just sit. When I’m lucky, I sit outside. Sometimes I write down the to-do list that perpetually crowds my thoughts. Released from this burden, I begin to hear the subtle sounds around me and then notice the more substantive ideas lurking between my ears. Back and forth I go: notice the rustle of leaves, eliminate a task I don’t reeeally need to do, feel the sun, re-prioritize projects, notice my breath, remember to write a friend, and relax into the important over the urgent.
I wish for my students to have faith in themselves and to act in new ways that will keep them to be healthy, safe, and successful.
8/3/10
Hope
“Experiences cause structural changes in the brain, sculpting synapses in profound ways. This ‘plasticity’ of the brain has been demonstrated by neuroscientists over the past decades.” (p. 189-190). This statement, which I have taken from the book The Anatomy of Hope,* is a crucial concept in speech therapy. It justifies the therapeutic process. There are times when the small step-by-step process of speech change seems to take so very long. But we persist because we expect to alter speech production pathways in the brain.
Let’s imagine, for the sake of simplicity, that neurons in the brain are organized like a road map. This is an analogy that children may understand. Some children spend a lot of time traveling short distances to sports and school events or long distances to vacation spots. Parents teach map skills by highlighting routes and talking about roadways, exit numbers, and geography. Stuttered speech is like driving on a bumpy road in rush-hour traffic! It can be uncomfortable, stressful, stop-and-go, include wrong turns, and involve some unpleasant interactions with others.
Speech therapy is road construction. The child, parent, SLP and other helpers, team up to build new roads along which a child’s ideas can travel through his brain to his mouth more easily. The new roads, the new neural pathways, take time to build and are constructed with care. During this construction phase, it is the expectation of a better road, the hope of an easier route, that helps us to be patient with the process.
In The Anatomy of Hope, the author seems to say that hope is essential to change. “Hope can arrive only when you recognize that there are real options and that you have genuine choices. Hope can flourish only when you believe that what you do can make a difference, that your actions can bring a future different from the present. To have hope, then, is to acquire a belief in your ability to have some control over your circumstances. You are no longer entirely at the mercy of forces outside yourself.” (p. 26)
Stuttering involves loss of control. Stuttered sounds seem to occur at random and then much later appear to be predictable on letters such as /b/, /s/, or /g/. This loss of control leads to struggle, anticipation anxiety, and avoidances. Listeners don’t understand what’s going on or know what to do and soon the person who stutters finds entire conversations out of his control. Some outside force, unknown even to the experts, wreaks havoc with speech and communication.
SLPs have no cure. Yet, they do offer hope in the form of speech therapy that encourages self-acceptance, behavioral changes, and ways to educate listeners. SLPs must convey the multiple messages: we can’t “fix” you (you are not broken) but we can give you reasons to hope for improvement. We cannot minimize the effort that will be required. We prepare for a speech therapy process that involves education, experimentation, trial and error, team work, persistence, and hope.
In The Anatomy of Hope, there is one cancer patient in particular who is also a cancer doctor. He selects an extremely intensive series of treatments that no doctor would ever recommend because of the debilitating side effects and uncertain results. This patient/doctor explains, “’I knew all the arguments made in cases like mine…I find these arguments patronizing…Most patients don’t really understand what’s happening to them… because they’re not clearly told the odds by their doctors…I, of course, had a crystal-clear understanding of my chances. And it was my right to choose what I did.” (p. 75)
This doctor was cured and later “he visited cancer patients in the hospital who were losing hope. He was an inspiration. His survival showed them that there is inherent uncertainty in the behavior of even the worst diseases…He sought to assist people in making choices that addressed their own particular needs, desires, and beliefs.” (p. 78)…To hope under the most extreme circumstances is an act of defiance that…permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.” (p. 81)
After much research into the concept of hope, Dr. Groopman suggests that realism plus positive physiological change is necessary to achieve positive emotional change. Therefore, he recommends that early treatment be designed to give patients some kind of immediate physiological improvement. With this in mind, I am spending more time encouraging my students to complete very simple, very successful speaking tasks at the beginning and at the end of every session whenever possible. I am relaxing my own, egocentric, need to see “progress” along any hierarchy, so that the student can experience speech success at whatever level that might be.
“Kindling and sustaining hope depend not only on images that may be conjured in the mind but also on how those images are brought into focus or blurred by the ongoing input of nerves from organs and tissues to the brain.” (p. 181) Students must experience success and understand how they were responsible for it. If SLPs push too hard, our students may experience more failure than success. Given the messages in The Anatomy of Hope, perhaps whatever cognitive therapy approaches we favor might be most effective when accompanied by carefully planned behavioral training that ensures speech change, even if that means slower “progress” along a hierarchy. Let’s remember that speech therapy is for the student’s benefit, not the SLP’s need to document professional competence.
*Jerome Groopman, M.D. (2005) The Anatomy of Hope: How People Prevail in the Face of Illness, NY, NY: Randomhouse, Inc.
Let’s imagine, for the sake of simplicity, that neurons in the brain are organized like a road map. This is an analogy that children may understand. Some children spend a lot of time traveling short distances to sports and school events or long distances to vacation spots. Parents teach map skills by highlighting routes and talking about roadways, exit numbers, and geography. Stuttered speech is like driving on a bumpy road in rush-hour traffic! It can be uncomfortable, stressful, stop-and-go, include wrong turns, and involve some unpleasant interactions with others.
Speech therapy is road construction. The child, parent, SLP and other helpers, team up to build new roads along which a child’s ideas can travel through his brain to his mouth more easily. The new roads, the new neural pathways, take time to build and are constructed with care. During this construction phase, it is the expectation of a better road, the hope of an easier route, that helps us to be patient with the process.
In The Anatomy of Hope, the author seems to say that hope is essential to change. “Hope can arrive only when you recognize that there are real options and that you have genuine choices. Hope can flourish only when you believe that what you do can make a difference, that your actions can bring a future different from the present. To have hope, then, is to acquire a belief in your ability to have some control over your circumstances. You are no longer entirely at the mercy of forces outside yourself.” (p. 26)
Stuttering involves loss of control. Stuttered sounds seem to occur at random and then much later appear to be predictable on letters such as /b/, /s/, or /g/. This loss of control leads to struggle, anticipation anxiety, and avoidances. Listeners don’t understand what’s going on or know what to do and soon the person who stutters finds entire conversations out of his control. Some outside force, unknown even to the experts, wreaks havoc with speech and communication.
SLPs have no cure. Yet, they do offer hope in the form of speech therapy that encourages self-acceptance, behavioral changes, and ways to educate listeners. SLPs must convey the multiple messages: we can’t “fix” you (you are not broken) but we can give you reasons to hope for improvement. We cannot minimize the effort that will be required. We prepare for a speech therapy process that involves education, experimentation, trial and error, team work, persistence, and hope.
In The Anatomy of Hope, there is one cancer patient in particular who is also a cancer doctor. He selects an extremely intensive series of treatments that no doctor would ever recommend because of the debilitating side effects and uncertain results. This patient/doctor explains, “’I knew all the arguments made in cases like mine…I find these arguments patronizing…Most patients don’t really understand what’s happening to them… because they’re not clearly told the odds by their doctors…I, of course, had a crystal-clear understanding of my chances. And it was my right to choose what I did.” (p. 75)
This doctor was cured and later “he visited cancer patients in the hospital who were losing hope. He was an inspiration. His survival showed them that there is inherent uncertainty in the behavior of even the worst diseases…He sought to assist people in making choices that addressed their own particular needs, desires, and beliefs.” (p. 78)…To hope under the most extreme circumstances is an act of defiance that…permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.” (p. 81)
After much research into the concept of hope, Dr. Groopman suggests that realism plus positive physiological change is necessary to achieve positive emotional change. Therefore, he recommends that early treatment be designed to give patients some kind of immediate physiological improvement. With this in mind, I am spending more time encouraging my students to complete very simple, very successful speaking tasks at the beginning and at the end of every session whenever possible. I am relaxing my own, egocentric, need to see “progress” along any hierarchy, so that the student can experience speech success at whatever level that might be.
“Kindling and sustaining hope depend not only on images that may be conjured in the mind but also on how those images are brought into focus or blurred by the ongoing input of nerves from organs and tissues to the brain.” (p. 181) Students must experience success and understand how they were responsible for it. If SLPs push too hard, our students may experience more failure than success. Given the messages in The Anatomy of Hope, perhaps whatever cognitive therapy approaches we favor might be most effective when accompanied by carefully planned behavioral training that ensures speech change, even if that means slower “progress” along a hierarchy. Let’s remember that speech therapy is for the student’s benefit, not the SLP’s need to document professional competence.
*Jerome Groopman, M.D. (2005) The Anatomy of Hope: How People Prevail in the Face of Illness, NY, NY: Randomhouse, Inc.
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