ADHD, Stuttering, and Executive Functioning

          ADHD “significantly impacts the ‘efficiency and fluency’ of speech” [1] Some of the dysfluency may be stuttering. Some may be “excessive typical” or “atypical”  dysfluency.  A detailed description of ADHD is beyond the scope of this article. [2] However, beginning with a few basics is essential to testing and treating dysfluency in the presence of ADHD.

           Joseph Donaher, Ph. D., describes ADHD as a condition in which a child focuses on too many things simultaneously.  A 13 year old student of his described ADHD like this: “I have a billion ideas bouncing in my head and I have trouble trying to figure out which one is most important.” Much of the information about ADHD in this article is taken from Dr. Donaher’s presentation in the Stuttering Foundation DVD No. 6700, ADHD & Children Who Stutter.  I highly recommend it for parents and professionals.

              The Huffington Post recently reported that “Children with ADHD produce more vocal repetitions or word fillers as they try to organize their thoughts, somewhat similar to a stammer…A response in the classroom may be along the lines of, ‘It’s a story abou…um…a story…um…um…it’s about…akidwhofliesakite...um.” In addition, these children “frequently struggle to find the right words and put thoughts together quickly and linearly in conversation. Errors in grammar as they compose sentences also may occur, because of planning difficulties present even when underlying skills in this area are intact.” The social use of language, called pragmatics, is also affected. Children with ADHD may blurt out responses to questions, interrupt, talk excessively, and speak too loudly. Distractibility, impulsiveness and poor executive function skills may make basic conversational rules too difficult for them to use. [3]

              Dr. Donaher reports that ADHD “can result in dysfluencies” for children who do not stutter and “exacerbates dysfluencies “ in children who do stutter. He lists the characteristics of ADHD Hyperactive/Impulsive and ADHD Inattentive types and, because both lists include difficulties with language, the dysfluency of ADHD resembles cluttering. Stuttering is characterized by part-word repetitions (p-p-p-play), prolongations (sssssoccer), and blocks (d-og). Cluttering, on the other hand, is characterized by whole-word and phrase repetitions, revisions ( I want to_ I think that…), and fillers (um, ah, mmm).

“Like stuttering, cluttering is a fluency disorder, but the two disorders are not the same. Cluttering involves excessive breaks in the normal flow of speech that seem to result from disorganized speech planning, talking too fast or in spurts, or simply being unsure of what one wants to say. By contrast, the person who stutters typically knows exactly what he or she wants to say but is temporarily unable to say it. To make matters even more confusing, since cluttering is not well known, many who clutter are described by themselves or others as "stuttering." Also, and equally confusing, cluttering often occurs along with stuttering.”[4]

              ADHD must be addressed prior to speech therapy for best results. Stimulant medications seem to have a greater impact on ADHD behaviors than non stimulant medications. Unfortunately, stimulants are also linked to “the onset and exacerbation of disfluencies and stuttering.” Behavior management of ADHD symptoms requires a lot of work collaborating professionals across settings and is most effective in combination with medication.  It looks to me like concepts of behavior management for ADHD may help almost any child working on speech change.

              “ADHD represents a deficit in executive function, a skill set that includes attention, impulse control…and far more. Seen as a disorder of self-regulation, ADHD potentially impacts anything that requires planning and coordination, from sleep and eating habits to laying out a long-term science project all the way to how someone speaks and listens in conversation.”[5]

That said, we can understand Dr. Donaher’s conclusion: children with ADHD are unable to do something without appropriate support.

            This concept of providing support, or “scaffolding,” is critical. A recent book dedicated to moving beyond “the absurdity of public school IEPs and their bizarre, fuzzy-wuzzy language,”[6] describes many ways for adults to support children so they may achieve short-and long-term goals. For children with ADHD, this is support for executive functioning skills. I will refer to concepts presented in the workbook Executive Skills in Children and Adolescents [7] now as I write about speech therapy goals.   

Dawson and Guare report that the first executive functioning skill to emerge in childhood is called behavioral inhibition. This skill begins to appear at 5-12 months of age and lays the groundwork for subsequent skills. Behavioral inhibition has 3 properties: 1. the ability to delay or prevent a response, 2. the ability to stop ongoing behaviors, and 3. the ability to manage distractions. Behavioral inhibition reminds me of a fluency enhancing strategy called pausing. [8]

Pausing appears in speech therapy for clients of all ages. Sheryl Gottwald lists pause time as a conversational strategy adults can use with young children who stutter.[9] Linda Cochran illustrates the value of wait time with a simple concise drawing anyone will understand. [10] Coleman and Weidner encourage adults to divide long complex sentences with  pauses when reading aloud to young children. [11]^,[12] I've also read about 'the power of the pause' in reference to public speaking. A short pause gives a speaker extra time to organize ideas, retrieve vocabulary, formulate grammatically correct sentences, create a speech motor program, and articulate intelligibly. It also provides time for listeners to process information.

In direct speech therapy, the student enlists behavioral inhibition to  find a new kinesthetic (sensory) feeling of easier speech. He or she pauses long enough to find this feeling while saying single sounds, syllables and then isolated words at first. Gradually, the student uses this new feeling of speech production on tasks of increasing difficulty, called a hierarchy. There is absolutely no expectation that a student can enlist behavioral inhibition in everyday conversation until much later in therapy. Everyday conversation is very demanding and will not provide enough support to ensure success. However, speech homework is different. Homework  games will have supportive rules, such as requiring pause time from every player.  

Wise adults know that children learn through imitation. Without launching into a discussion of nature vs. nurture, let's agree that modeling is one way we nurture our children. How fortunate that the speech language pathologist (SLP) demonstrates the behaviors she is training! When the SLP says, "Let me think…;" and, "I feel confident because...;" and, "First I'll make a plan…;" and "What if...;"[13] followed by a brief pause,  that SLP is modeling verbal mediation. Verbal mediation is about putting thoughts, feelings and choices into words – prior to, during, and after a behavior. Verbal mediation is essential to any kind of speech homework. To transfer a new skill, the parent and the child will need verbal mediation to decide when, where, and how to follow through with an agreed upon plan. Evidence based practice requires the family actively participate in this way. [14]

If you ask a child what he does in speech therapy, I can almost guarantee he will say something like 'I don't really know. We play games.' This anecdote represents what happens when children practice new speech skills. A child has to remember the new speech behavior as he is multi-tasking other communication demands. It seems to me that adult support frees up a child’s working memory so that he can be successful. This support can take the form of a linguistic hierarchy because one way to make a task easier is to simplify language. Also, controlling for pragmatic language leads to first practicing in choral speech, then immediate imitation, and delayed imitation before moving on to very simple elicited and spontaneous language tasks. Simple, repetitive homework games require minimal language processing and interruption so that a child can remember to use his new speech skill. Children find it easier to use a new skill when working memory is not overwhelmed.

Many small successes culminate in large achievements. Remember, the small successes take place in supportive situations. This is where the executive skill called planning comes in. Math curriculums plan addition and subtraction before multiplication and division. Similarly, SLPs plan speech work along a continuum of difficulty. To take this analogy further, we provide maximum instruction when introducing a new math concept and expect children to solve real-life mathematical problems only gradually. Similarly, we plan short- and long- term speech goals that respect the student's ability to inhibit behavior and juggle communication demands in working memory.

Once a lesson is presented, the student must do it. I find a child must pay careful attention to a specific activity for about 10-20 minutes at the very least. This is called sustained attention. During sustained attention, the student chooses the new behavior and remembers to use it repeatedly while relying upon the conditions set up for his success. The child cannot interrupt the planned activity by leaving his seat, talking about his favorite TV show, or giving up. He needs to engage his brain in feeling, hearing, experiencing and comprehending the consequences of a new behavior. Neurons in the brain need to record and retain the multi-sensory experience of a new way of speaking. “Concept cells link perception to memory…their elegant coding scheme allows our minds to leave aside countless unimportant details and extract meaning that can be used to make new associations and memories.” [15] Sustained attention is required at each step of a linguistic and transfer hierarchies.

Metacognition is the ability to observe one's own behavior. I find this an especially tricky concept in speech change because sounds are fleeting. Now you hear it - now you don't. Furthermore, the SLP does not see nor experience production of the new speech goal. She is unlikely to hear subtle moments of stuttering or appreciate the student’s  internal thoughts and feelings. This is problematic because the speaker needs feedback to know when she has made an appropriate change. Listening to an audio recording or observing digital analysis of her speech may help. This requires a sense of separateness, an ability to look at speech as something distinct from her inherent identity. Speech becomes something to study and manipulate.

Perhaps this next executive functioning skill should have come earlier : regulation of affect. A child needs to feel comfortable talking about stuttering before he can examine and experiment with speech change. Fear and embarrassment assume many disguises. For example, when a second grader crawled under the table as soon as I moved beyond introductory pleasantries and began talking about stuttering, I knew affect would be an important therapy issue. In the children's story Hooray for Aiden a young girl avoids school activities so that her peers will not hear her stutter. Her sadness and anxiety are overwhelming until a classroom visitor models self-respect and acceptance. A policeman visits her classroom to explain his job and as he talks, he stutters. Policeman Dave tells the class, “There’s n-n-nothing wrong with speaking the way that Aiden and I speak. When we get stuck on a word, it’s call stuttering. People who stutter are just r-r-regular people.” [16] The National Stuttering Association brings hope and empowerment to children and adults who stutter, their families, and professionals. Visit www.westutter.org for more information.

 To shorten the length if this article, I will group together the executive skills called  organization, time management & task initiation. All three apply to speech homework. I admit that I have never, in my 30 years as an SLP, been able to convince anyone to consistently complete homework . Finally I realized the obvious; this was not my job. I can talk with parents about playing speech games in the car, combining speech work with school work, arranging teacher conferences, requesting teacher feedback, completing take-home exercises, and on and on. Ultimately, it is the parent or child who organizes the family schedule to include speech homework - according to a lesson plan that respects the child's abilities and provides adequate scaffolding to ensure success. This is not easy given the pressures of our busy culture. But speech change does not happen without a commitment to work outside the SLP's office.

The final executive skills I’ll mention are goal-directed persistence & flexibility. I wish I could find another copy of a decorative wall hanging I've given as holiday gifts to two students. It was a simple painted sign that read "never, never, never give up." Stuttering is a peculiar condition. It is somewhat similar but always different from person to person. It seems to be affected by so many different factors and universally responsive to no single therapy method. "Progress" takes many forms [17] and therapy week-to-week is dependent upon the client's experience with previous lessons and homework. As quality of life improves, clients feel their communication skills are 'good enough' and they leave therapy. Or, they drop out for a variety of other reasons. So, I never really know how my students fare over the long haul. I can only hope to have given them something of what they needed at the time we worked together. Persistence and flexibility over many weeks, months, or years is one key to success.

It seems to me that concepts of executive functioning apply to speech therapy for children with and without ADHD. The latest catalogue from LinguiSystems arrived in my mail yesterday. I see there are four products for executive functioning and the Executive Functions Training workbooks are “Bestsellers”. [18]I’ll add them to my wish list! In the mean time, I see it’s a beautiful sunny though chilly February day. Time to stop typing and soak up some sun. As usual, I’ll need to rearrange my to-do list , and tap my executive functioning skills, to make this change in my plan for the day! Wishing you plans with flexibility!

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Judy

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[1] J. Donaher (2012) ADHD and Fluency Disorders in School-Aged Children, Case Studies in Fluency Disorders, Rockville, MD: American Speech Language Hearing Association Online Conference, May 9-12, slide 11.

[2] I recommend visiting websites such as Children and Adults with Attention Deficit / Hyperactivity Disorder (http://www.chadd.org/) for more information.

[3] M. Bertin, M.D. (January 16, 2013) That’s ADHD again? You Don’t Say! Listen Closely and Hear the Effects of ADHD on Communication, HUFFLIVE, HUFF POST PARENTS.

[4] The Stuttering Foundation: http://www.stutteringhelp.org/cluttering

[5] M. Bertin, (1/16/13)

[6] D. Twachtman-Cullen & J. Twachtman-Bassett (2011) The IEP from A to Z: How to Create Meaningful and Measurable Goals and Objectives, San Francisco, CA: Jossey-Bass, p. XV

[7] P. Dawson & R. Guare (2010) Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention, 2^nd Edition, NY, NY: The Gilford Press.

[8] D. Daley (2010) The Power of the Pause, http://www.mnsu.edu/comdis/ica1/papers/nuggets/dalyc.html 

[9] S. Gottwald (2010) Moving from Assessment to Intervention Planning , DVD No. 6300, www.stutteringhelp.org.

[10] S. Cochrane ( 2011 ) "Brain Time" - A clinical technique for children to aid in reducing impulsivity to speak and for a "preparation time" prior to speaking http://www.mnsu.edu/comdis/isad15/papers/therapy15/cochrane15.html

[11] C. Coleman (Nov 21, 2012) Working with Children Who Stutter and the Clinician’s Acceptance of Stuttering , StutterTalk, http://stuttertalk.com/working-with-children-who-stutter-and-the-clinicians-acceptance-of-stuttering-375/

[12] C. Coleman & M. Weidner (2009) Using Stories to Teach Fluency Strategies to Young Children, http://www.mnsu.edu/comdis/isad12/papers/therapy12/coleman12.html

[13] K. Chmela (2004 ) Working with Preschoolers Who Stutter: Successful Intervention Strategies, DVD No. 0162, www.stutteringhelp.org

[14] Evidence Based Practice http://www.asha.org/members/ebp/

[15] R. Q. Quiroga et al. (February, 2013) Brain Cells for Grandmother: Each concept – each person or thing in our everyday experience – may have a set of corresponding neurons assigned to it, NY, NY: Scientific American, pp. 31-35.

[16] Karen Hollett (2010) Hooray for Aiden, Yellowknife, NT, Canada: Hooray Publishing, broken link p.20

[17] J. S. Yaruss et. al. (2012) Stuttering in School-Age Children : A Comprehensive Approach to Treatment, Language, Speech, and Hearing Services in Schools, (43) pp. 536-548.

[18] LinguiSystems broken link

Human Voice: It's Beautiful

I can play an electric piano with the setting on choir and hear the digital sound of synthesized voices. It’s a pretty fun way to liven up tedious practice exercises. But it’s not nearly as beautiful as the sound of a real human voice.  The real human voice depends upon airflow instead of electronics.   Two tiny vocal cords tucked safely within the larynx vibrate to create the human voice. 

I brushed up on the basics of voicing when a young lady e-mailed me seeking voice therapy. She was experiencing vocal fatigue and hoarseness. I recommended that an otolaryngologist examine her vocal cords and that she follow through with any referral to a speech language pathologist (SLP) specializing in voice therapy. However, I also suggested we meet for a voice screening and a consultation regarding normal voice production and good vocal hygiene. At our first meeting, we talked about her concerns and completed both the Voice Activity and Participation Profile[1] and the Consensus Auditory-Perceptual Evaluation of Voice[2]. In subsequent sessions, we talked over her vocal history, demands currently placed on her voice, and some thoughts on change. I enjoyed these conversations.

Updating my knowledge of voice and voice therapy was a welcome change of pace. The American Speech Language Hearing Association studies that caught my eye questioned the usefulness of vocal warm-up[3], studied the significance of speaker temperament[4], and recommended ‘motivational interviewing’ as a method to support change[5].  YouTube had several relevant videos.  There were animations of laryngeal and related anatomy and physiology[6]. There was a 4-part power point presentation narrated in detail by Stephen M. Tasko, Ph.D., CCC-SLP.[7] Miriam van Mersbergen, Ph.D., CCC-SLP talked about the “Basics of Voice Training” in a video produced by LinguaHealth.[8]  The National Center for Voice and Speech had a tutorial explaining how researchers have come to understand vocal fold function.[9] And, there were lots of videos of the vocal cords recorded using videostoboscopy. It was all so fascinating that I also purchased a 6-hour continuing education course![10]

Here’s a very short synopsis.  Air from the lungs pushes the vocal cords apart, increasing the space between them. A combination of aerodynamics and vocal cord elasticity causes them to move back toward one another, closing the airway. It is a continuous stream of air from the lungs that separates the vocal cords again and again and again, resulting in a “non-linear mucosal wave.”  Puffs of air explode through the opening between the vocal cords and breeze through the throat, mouth and nose before leaving the body.  This air is shaped into speech sounds along the way.

I was happy enough with that review.  Except the continuing education course placed such emphasis on diaphragmatic breathing, that I researched this too.  A careful search of YouTube uncovered videos about breathing that seemed useful for a wide range of clients. How the body works: breathing was a delightfully simple animation with the sound muted. The narration is a bit technical and bland for children.[11]  A white board presentation by a young woman offered more complex information with friendly enthusiasm.[12] An authoritative and quite professional looking animation was available for studious teens and adults.[13]  Finally, that priceless podcast series, Stutter Talk, had at least two episodes devoted to breathing and speech.[14]^,[15] I assembled a new webpage for voice almost instantly![16]

Some occupations demand a clear, professional sounding voice. People who depend on their voice to earn a living include singers, politicians, broadcasters, actors, salespersons, customer service workers and teachers.  For these workers, vocal pathology is an occupational hazard.  They need to take excellent care of their voices and actually, many of them do even more. They study articulation (including accent reduction), intonation, loudness, pausing/phrasing, vocabulary, and the difference between explicit and implied meaning. SLPs treat a variety of voice disorders due to medical conditions. However, they also train use and care of the professional voice.

I have a renewed appreciation for the role of breath support in communication. I almost never talk about breathing with my students because they usually respond with effortful thorasic or clavicular breathing.[17]  Observe yourself taking “a deep breath.” What do you do? Do your shoulders rise up and your chest expand? They shouldn’t, at least not by much. It’s your abdomen that should expand as your diaphragm presses downward to make extra space for the lungs. How many of us ever learned this? A newspaper advertisement for a local performing arts school shows a little girl being taught diaphragmatic breathing as she sings.  This seemed exceptional. My curiosity got the best of me and I purchased a how to sing DVD by an internationally known singer. It instructed me in a series of fast-paced vocal exercises with slight reference to diaphragmatic breathing. I had to wonder how many viewers of this DVD damaged their voices by trying to sing using the laryngeal muscles instead of adequate breath support.

The concept is simple. Physical work requires effort and that effort can be misplaced. For example, I am learning to play the piano. My fingers are uncomfortable at the piano keys. With every missed note, my arms and shoulders stiffen and I hold my breath. Why?! I’m not entirely sure, but it happens. With the wisdom of an adult, I pay close attention to gentle breathing and upper body relaxation as I struggle to match music notes and piano keys and finger movements. I stop. I slow down. I attend to the feeling of my muscles. I have the time to do that. When voicing is difficult, speakers may compensate with extra effort in the neck, mouth, and face. It happens.[18] Conversation is fast paced and demanding so there is no time to stop, slow down, attend to the feeling of muscle movement and prevent inappropriate motor memories. (It can also be that differences in motor abilities affect this process.) Finding the feeling of relaxation under a variety of circumstances comes in handy. [19]

There it is: a brief description of voicing, which necessarily includes a review of breathing.  I am looking forward to learning alot more about the voice and voice therapies in the future.

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[1] This can be found in the Appendix of Estella P-M.Ma and Edwin M-L. Yiu (2001) Voice Activity and Participation Profile: Assessing the Impact of Voice Disorders on Daily Activities. Journal of Speech Language Hearing Research, 44, 511-524.

[2] This can be found as Appendix C in G.B. Kempster et. al. (2008) Consensus Auditory-Perceptual Evaluation of Voice: Development of a Standardized Clinical Protocol. American Journal of Speech Language Pathology, 18, 124-132. The authors give permission to photocopy it for clinical purposes. When I downloaded it, the lines used for severity ratings were only 95mm long, so I retyped the entire document and drew 100 mm lines as required.Appendix A and B describe the tool, administration, and scoring.

[3] Rochelle L. Milbrath and Nancy Pearl Solomon (2003) Do Vocal Warm-Up Exercises Alleviate Vocal Fatigue? Journal of Speech, Language, Hearing Research, 46, 422-436.

[4] M. Dietrich and K. Verdolini Abbott (2012) Vocal Function in Introverts and Extroverts during a Psychological Stress Reactivity Protocol. Journal of Speech, Language, and Hearing Research, 55, 973-987.

[5] Alison Behrman (2006) Facilitating Behavioral Change in Voice Therapy: the Relevance of Motivational Interviewing. American Journal of Speech Language Pathology, 15, 215-225.

[6] Cricoarytenoid Function AngleOne 4sec http://www.youtube.com/watch?v=nhVXgDEPu1E&feature=relmfu (this is one of them)

[7] Part 1 http://www.youtube.com/watch?v=A5uW4LcAemw (this is one of them)

[8] Speech Language Pathology: The Basics of Voice Training  http://www.youtube.com/watch?v=mC2b5PxGavM&feature=youtube_gdata_player

[9] National Center for Voice and Speech broken link

[10] Ellen N. Friedman (2012) Short - Term Voice Therapy. 6 hour CEU course, 

[11] How the Body Works: Breathing http://www.youtube.com/watch?v=gYSIWceGMxY&feature=related

[12] 8.6 Respiratory System Structure and Function http://www.youtube.com/watch?v=12ddbrqpZiQ&feature=related

[13] Respiratory System 3D broken link

[14] Stutter Talk:  Episode 263 The Anatomy and Physiology of Normal Speech Breathing as It Relates to Costal Breathing and Stuttering, 2/27/11,  http://stuttertalk.com/?s=breathing

[15] Stutter Talk: Stuttering and Breathing with Doctor Phillip Shneider,  Nov 8, 2008   http://stuttertalk.com/tag/breathing/

[16] --

[17] Breathing http://butlerspeechtherapy.blogspot.com/2009/06/breathing.html

[18] The Arm Bump http://butlerspeechtherapy.blogspot.com/2009/03/arm-bump.html

[19] http://butlerspeechtherapy.blogspot.com/2010/09/new-beginnings-stress-relaxation.html

Online Conference About Stuttering

The ISAD Conference is an interactive online event taking place from October 1 - 22.  Please take advantage of this remarkable chance to chat with the authors of several papers on stuttering. There is even an Office Hours – the Prof In link at which you can post any question about stuttering. Look for the ISAD conference link by visiting the Stuttering Home Page, www.stutteringhomepage.com. I have a Clinical Nugget  this year called Fluency Lessons for Window Shopping. It is co-written with a high school student and describes our visits to local retail stores as a method of carryover of new speech skills.

As I prepared to chat with people from around the world, I reflected upon my 30 years as a speech-language pathologist. Sixteen of them were almost exclusively working with children who stutter. Why? Well, let’s begin with a memory.

My paternal grandmother died of Parkinson's when I was about nine years old.   I can close my eyes and recall her dark green home, the small galley pantry, the living room where we watched Art Linkletter’s talent show, the screened porch that wrapped around  the front of the house, the push button light switches, and the toad who lived in a hole beside the foundation. And, I recall my grandmother’s slurred and stuttered speech. The connection between the warmth I felt in her presence and my decision to specialize in fluency therapy startled me one afternoon in the 1980’s during casual conversation with an elderly woman. Long lost memories of my grandmother flooded my mind and I experienced one of those ethereal moments when one’s life seems to make sense.

Early in my career and for far too many years, I counted stuttered syllables and tried to implement highly structured and apparently logical speech therapy. I basked in the glow of hard-earned diplomas from intense and expensive higher educational institutions. Over time, I discovered that therapy was very different from classroom work and research projects. When a dedicated student experienced relapse, I was forced to question my education and my attitude. Confused and humbled, I had learned that work with clients is not described well using logic or percentages.

For licensed, certified health care professionals, the client -clinician relationship is defined by the American Speech Language Hearing Association (ASHA) Code of Ethics. (1) There are ASHA publications on recommended best practice. Continuing education and clinical practice requirements for ongoing recertification and license renewal keep professionals current.  But sometimes one wonders what is real and what is paperwork.

In the past 20 years, my own therapeutic method has become more personal at the same time in which the profession of speech language pathology moved in a different direction. The profession has become more efficient. Data collection – for the benefit of insurance and educational institutions – seem to be paramount now.  Experts continue to press for large scale research studies in stuttering to accommodate the medical trend toward evidence based practice. (2)

What influences treatment method and outcome? Research suggests there may be subtypes of stuttering. Attention deficit, phonological disorders, dyslexia and other issues can co-occur with stuttering. The transfer of more fluent speech to daily life is still the lock without a key. While the latest research in genetics is promising, how does this change the lesson plan? (3) Every client comes to therapy as a unique individual. I worry about  demands for efficiency with an emphasis on data collection because therapy is not about stuttering – it’s about people. It seems to me that any data used to promote a treatment approach would need to include detailed descriptions of the individuals for whom it was “successful.” Will that happen?

My transition to a more personal treatment approach was nurtured by conventions of the National Stuttering Association and Friends: The Association of Young People Who Stutter. Attendees at these meetings expressed frustration with speech therapy. I was taken aback, discouraged and then grateful. I would come home and listen to my clients more carefully. My lesson plans changed to be more conversational and fun. But, new referrals to my practice were confused: why didn’t I have more rigorous demands for fluent speech? They were at the beginning of a journey that I and a few other SLPs had been traveling for a while. A small group of exceedingly dedicated SLPs (I was not one of them.) established the first ASHA Specialty Commission (4) and worked hard to address the multiple issues that make for a comprehensive approach to speech therapy for stuttering.  There’s no quick fix, only a personal path of ups and downs and variable results. (5)

Now I ask about my clients’ lives and share a little of my own. Students get small prizes for just showing up. Homework expectations are replaced by congratulations for any evidence of personal responsibility. I match the efforts of my clients. Those who attended regularly and reliably receive highly individualized lesson materials.  Attention to affective and cognitive issues equal that of speech motor change. Written reports are  lengthy and include footnotes (very inefficient and time consuming!) My role is one of giving my very best to the few who are invest the same. Is this effective? Clients decide. Informal, annual data collection and ongoing conversation keep us focused on collaborative goals. Unsatisfied clients move on to other service providers.

Fluency enhancing strategies haven’t changed for many years and dissatisfaction with them has become more public. (6) I feel the most significant change has been a lowering of expectations for fluency to avoid rewarding covert behavior. This therapy option coincides with a greater appreciation of the client’s perspective, exquisitely documented in the film Transcending Stuttering (7). Treatment methods are controversial to this day, as demonstrated by articles published in 2012 issues of the ASHA journal  Language Speech Hearing Services in Schools.

Talking is different from playing the piano, hitting a baseball, or learning to read, IMHO. Speech sounds are elusive and invisible. Listeners make snap judgments about a speaker’s competence, cultural identity, and eligibility for future relationships based on how they speak. It is societal expectations that drive clients into speech therapy. A Ted Talk titled The Disabled Listener (8) extols the profound value of respectful listening.  Watch it and ask yourself how you might become a better listener.

Now the client trumps any specific treatment approach. My clients assume complete responsibility for scheduling sessions. They are equal partners in treatment design and implementation. Quite frankly, this is a horrible business model, and so,  I continue studies in the field of literacy to expand my practice caseload. The warmth I felt listening to the stuttered speech of my grandmother returns whenever I put relationship before data and (illusions of) efficiency. My small contribution to the 2012 ISAD conference reflects this commitment to the individual.

Many grateful thanks to A. C. for his contribution to this effort.

Judy

(1)  broken link

(2)   Nippold, M.A. & Packman, A. (2012). Managing Stuttering Beyond the Preschool Years. Language  Speech Hearing Services in Schools (43) p. 340.

(3)   Rowden-Racette, K. (September 18, 2012). In Search of Stuttering's Genetic Code. TheASHALeader  broken link

(4)   Specialty Board on Fluency Disorders, now out of date

(5)   Schnieder, P. (2004) Riding the Fluency Instability Roller Coaster. http://www.mnsu.edu/comdis/isad7/papers/schneider7.html

(6)   Voice Unearthed: Hope, Help, and Wake-Up Call for the Parents of Children Who Stutter http://www.voiceunearthed.com/  

(7)   Schnieder, P. (2005). Transcending Stuttering: the Inside Story  http://www.mnsu.edu/comdis/isad8/papers/pws8/schneider8.html

(8)   Lansing, S. E. (June 8, 2011) The Disabled Listener: They can talk, they can hear, they just don’t listen. TEDxTalks http://www.youtube.com/watch?v=hrAxNijdJVY