One of my students generously gave me the second edition of Executive Skills in Children and Adolescents (P. Dawson & R. Guare, 2010) which prompted me to re-think speech homework.
Executive skills develop throughout childhood. Let’s think about just one of them. “The cornerstone…is behavioral inhibition, which begins to emerge in the 5- to 12-month age range. This first executive function …helps us to think before we act and to decide when and if we will respond.” (p. 5) The three components of behavioral inhibition include the ability to:
1. delay or prevent a response,
2. stop ongoing behaviors,
3. manage distraction and interruptions.
At the beginning of direct speech therapy, a child is asked to prevent her usual pronunciation of sounds in favor of a pause followed by slower, gentler articulation. With lots of practice in very simple, repetitive games, children can learn to do this when everyone else is too. It is not easy bringing speech under conscious control like this.
Carryover activities add the demand of stopping familiar rapid or stuttered speech in situations that include distraction and interruption. As an example, let’s imagine going out for ice cream.
If the homework is to practice single words, then, the child and her mom might practice saying the names of ice cream flavors. Since the child has never used slower rate and gentler articulation in the ice cream store before, it is very likely that she will be able to do so on only some of the names, maybe 3 out of 6 names at first.
Practice with these 6 names means she needs to prevent saying “Minty Magic”, for example, with a normal “Minty” and say it after a pause and with loosely relaxed mouth and a slight prolongation as in “Mmmiiinty.” The child working on change will need to stop production of “M-m-minty” and either pull-out or cancel it with a pause, slightly slower speaking rate, and perhaps also loosening tension in the lips.
The parent’s role is to manage distraction and interruption by saying the ice cream names using a pause, gentle articulations and slower rate so the child can imitate the model. It is the parent who will make the entire 5-10 minute carryover opportunity a private affair, perhaps by placing an arm around the child or waiting until they are sitting with their ice cream away from the other customers.
Children look to their parents for direction. Most children are not likely to say, “When we get ice cream today, I want to practice easy speech.” I hope you can enjoy looking for times and places to show your child how easy speech can be fun to practice at the park, the ball game, the pool, the movies, on a walk, visiting the museum, working on a home project, and just hanging out together. Your encouragement and praise will help nurture your child’s courage and sense of personal accomplishment.
5/10/11
Transfer Step 2: Desensitization
Parents who call me for speech therapy are usually upset. Nine times out of ten, they are parents of elementary school age children denied school services or disappointed by them. The rest are frightened parents of preschoolers. My practice is one of many that do not accept insurance because the amount of time spent on paperwork and following-up denied claims is simply unmanageable. So everyone that steps through my door with a check in hand is emotionally invested in change.
The emotion that motivates families to make and keep appointments becomes a liability when it’s time to work on identification and behavior change. It is too frightening, embarrassing, or even disheartening for them to examine the stuttering closely. Children who fear stuttering have been known to cope in ways that increase emotional and physical stress, so turning down the emotional temperature is an important first step. A stuttered sound is pronounced with unexpected, excess physical tension and (often) a feeling of loss of control. To relax this articulatory tension, the child must slow down speech dramatically and find a new feeling of loose, deliberate articulation. And so step 2 in transfer is desensitization – reducing the emotional reactions.
Desensitization is what allows a child to CHANGE stuttered sounds instead of avoid, hide, or fight them. He can ‘play’ with the moment of stuttering to study just what in the world his mouth is doing and how to move his tongue, lips and jaw differently. Reducing the fear of stuttering gives a child permission to talk, express his thoughts and feelings, even if talking more means stuttering more. The more talking a child does, the more opportunities he has to transfer new skills. When a child will not talk in school because he would “rather be the quiet kid than the stuttering kid,” those lovely, loose stuttering modification techniques he performs in the speech room are a long way off from being transferred to the classroom.
A child needs to talk about stuttering with her teachers, friends, and relatives in order to set up a hierarchy of homework activities. Negative feelings can get in the way of this happening. It’s difficult to talk about issues that cause us to feel embarrassed or inadequate. Stuttering is one of those issues. Becoming aware of these feelings, talking about them, and investigating ways to reduce their powerful effects is another target of desensitization.
Ideas based on 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.
The emotion that motivates families to make and keep appointments becomes a liability when it’s time to work on identification and behavior change. It is too frightening, embarrassing, or even disheartening for them to examine the stuttering closely. Children who fear stuttering have been known to cope in ways that increase emotional and physical stress, so turning down the emotional temperature is an important first step. A stuttered sound is pronounced with unexpected, excess physical tension and (often) a feeling of loss of control. To relax this articulatory tension, the child must slow down speech dramatically and find a new feeling of loose, deliberate articulation. And so step 2 in transfer is desensitization – reducing the emotional reactions.
Desensitization is what allows a child to CHANGE stuttered sounds instead of avoid, hide, or fight them. He can ‘play’ with the moment of stuttering to study just what in the world his mouth is doing and how to move his tongue, lips and jaw differently. Reducing the fear of stuttering gives a child permission to talk, express his thoughts and feelings, even if talking more means stuttering more. The more talking a child does, the more opportunities he has to transfer new skills. When a child will not talk in school because he would “rather be the quiet kid than the stuttering kid,” those lovely, loose stuttering modification techniques he performs in the speech room are a long way off from being transferred to the classroom.
A child needs to talk about stuttering with her teachers, friends, and relatives in order to set up a hierarchy of homework activities. Negative feelings can get in the way of this happening. It’s difficult to talk about issues that cause us to feel embarrassed or inadequate. Stuttering is one of those issues. Becoming aware of these feelings, talking about them, and investigating ways to reduce their powerful effects is another target of desensitization.
Ideas based on 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.
Transfer Step 1: Identification
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.
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
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