Developmental stuttering begins during a time of dramatic language learning. In this blog, I will share an article about vocabulary development and stuttering. (1) Many, maybe most, of my students seemed to have above average language skills. My students also often present with mild articulation errors, a history of articulation therapy, or were late talkers. My caseload over the years has featured children who were eager to grow linguistically while their speech motor systems appeared unable to keep up. It’s been hypothesized that “advanced language during early development may set the stage for fluency breakdown because language behavior is not synchronous with other aspect of development.” (p.62)
I offer parents the superficial hypothesis that some children may stutter because of a ‘mismatch’ between their language abilities and their speech-motor skills. Speech requires precise and extremely efficient coordination between several systems. “ …sentence production occurs incrementally, and as children begin to use more complex sentence structures, disruptions occur as a result of some ‘glitch’ in the formulation of the sentence.” (p.58) So, 3-year olds who have the language skills of 6 year olds may experience disfluency because ‘their mouths can’t keep up with their ideas,’ as the popular laymen’s explanation goes.
Nancy Hall’s article takes this hypothesis a step further by investigating vocabulary development specifically. Perhaps the ‘glitch’ is a child’s ability to get at the words he needs to express all those ideas in his head. Research has consistently found that children who stutter (CWS) “typically stutter on function words more often than on content words” (p.61) and that this corresponds with clause boundaries. Function words include articles (e.g., a, the) and conjunctions (e.g., and, but) and these tend to occur the onset of sentence parts. For the sentence, “I went / to the store / and bought / a new shirt”, we teach children to use easy onset and pausing at the slash marks because research tells us these are locations where stuttering most likely occurs. The words “to, and, a” are all function words.
However, this pattern changes over time. Children older than 6 begin stuttering more frequently on content words.
I like this puzzle: is stuttering a “delaying strategy” (p.61) while the child maps the syntax (grammar) of sentences OR retrieves the vocabulary he needs to express his thoughts? Children ages 2-6 learn the syntax of their native languages. They learn when to use “I” instead of “me”, work out noun-verb agreement, verb tenses, prepositional phrases, and what linguists call the “deep structure’ of language. Around age 6 years, the child begins school and its vocabulary development that becomes more intense as state curriculum frameworks emphasize English Language Arts in a formal way. Around 4th grade, lexical skills again leap ahead as children move from‘learning to read’ into ‘reading to learn.’ Multisyllable words require children appreciate derivational morphology to decode and comprehend more and more challenging academic material.
So, how do children learn vocabulary? Children learn some new words very quickly, after hearing them only a few times. The technical term for this is “fast mapping.” Other words are learned via “slow mapping”, in which children compare new words with those already in their vocabularies.
Consider the subtle differences between “succeed”, “achieve”, and “accomplish.” Children learn large categories of words (foods, feelings, objects) as well as syntactically different words (verbs, adjectives, multisyllabic word derivations). Researchers who study child language development have found several ways in which children make mistakes with words. This leads them to suppose ways in which insufficient lexical development might contribute to fluency breakdowns that serve a purpose. “The breakdowns…serve linguistic functions while the child attempted to revise of repair linguistic errors, or to buy formulation time while not relinquishing her conversational turn.” “These disruptions may result in the retrieval of a closely related but incorrect lexical item, or the presence of a place-holding disfluency, such as “um”, while a child attempts to retrieve a particular word. (p.58)
“It is the combination of a vulnerable speech production system and sensitivity to breakdown in CWS that sets the stage for overreactivity to glitches and subsequent tension in their attempts to repair the glitches.” (p.59)
This article does NOT suggest that CWS necessarily have a language delay or disorder. However, assessment and treatment need to take into account a child’s language development, perhaps ‘strengths and weaknesses’. “In particular, establishing the lexical/semantic level at which a child can maintain fluency or manage stuttering is important.” (p.65) And, there may be children for whom “…the clinician may need to include direct work on language competencies as well as the stuttering behaviors.” (p.65) This article supports language-based intervention for some children who stutter.
(1) Hall, Nancy E. (2004) Lexical Development and Retrieval in Treating Children Who Stutter, Language Speech, and Hearing Services in Schools Vol 35, pp 57-69.
3/1/10
Cause & Effect in Speech Therapy
Thomas W. Powell designed a comprehensive diagram to illustrate the many variables that effect progress in speech therapy. It took me several minutes to understand this graphic because it does include so many influences that the Client, Clinician, Environment, and Treatment method bring to the therapy situation. This diagram appeared in an article about oral-motor treatments for speech sound disorders. However, I think it can be adapted to speech therapy for stuttering.
"Cause and effect diagram illustrating selected sources of variance that may impact the outcome of intervention for children with developmental speech sound production disorders." Figure 1. page 376 in "The Use of Nonspeech Oral Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions", Language, Speech, and Hearing Services in Schools, Vol. 39, pp 374-379, July 2008
"Cause and effect diagram illustrating selected sources of variance that may impact the outcome of intervention for children with developmental speech sound production disorders." Figure 1. page 376 in "The Use of Nonspeech Oral Motor Treatments for Developmental Speech Sound Production Disorders: Interventions and Interactions", Language, Speech, and Hearing Services in Schools, Vol. 39, pp 374-379, July 2008
2/27/10
Appropriate, Effective Treatment
The conference title was “Unique Challenges and Common Themes in Stuttering Assessment, Treatment, and Research.” It was January 29-31, 2010 in Tampa, Florida. This was my 5th ASHA Special Interest Division 4: Fluency and Fluency Disorders conference and I was thrilled to attend. For 3 days I wallowed in workshops related stuttering. So did more than 100 other professionals equally interested in this esoteric topic. At home, I am the Sole Proprietor of a private practice that caters to stutterers exclusively. It can be a lonely career choice! However, at The National Stuttering Association and SID4 conferences, I meet with colleagues who are also fascinated by and committed to speech therapy for stuttering. I always return home refreshed and enthusiastic about new practice goals.
Jennifer Watson’s (1) presentation on Sunday morning was brilliant. She must have been paying close attention the previous 2 days because her topic drew directly from the presentations of Friday and Saturday. The title of her talk was “Research and Clinical Connections in Stuttering: Busting Barriers and Building Bridges.” I really appreciated her effort to review some reasons why it is difficult to translate current research immediately into therapy practice. She reviewed the current Framework for Evidence Based Practice (EBP) - a triangle, the three of points of which represent Current Best Evidence, Clinical Expertise and Client/Patient Values. Dr. Watson felt EBP should be represented by Venn diagram of interconnecting circles (rather than a triangle) to illustrate how important it is that research, clinician, and clients impact one another. There needs to be more communication between these three stakeholders in order to make progress in the field.
Dr. Watson recommends a “Deployment-Focused Model of Intervention Development and Testing.” I cringe at the military connotations the word ‘deployment’ has for me; nevertheless, her point is that all research and practice in the field of fluency and fluency disorders must has some genuine relevance to the real-life conditions in which speech-language pathologists work and persons who stutter live. The gems in her argument included:
•Improving client-to-treatment matching: Which treatment protocols work the best for which client profiles?
•Identifying change mechanisms: Are there key elements that promote and support client progress, for example, the concepts of “therapeutic alliance” or “stages of change.”
•Changing from a mentality of “best” treatment to “best fit.” It’s unlikely any one person is going to devise the “best” treatment for all persons who stutter. Clients are individuals and stuttering may be a heterogeneous disorder, which means, one-size will not fit all.
Walter Manning (2) had opened the conference with “Clinically Significant Change for Persons who Stutter” in which he statistical differences that indicate significant research findings are qualitatively different from clinical differences that indicate client satisfaction. Dr. Manning reviewed several ways to consider the client’s point of view. He emphasized that emotional and cognitive goals are equally as important, if not more so, than speech fluency goals in some cases. He recommended The Anatomy of Hope (3). He referred to a Contextual (or Common Factors) Model of therapy with the “therapeutic alliance” as a key ingredient to progress. Building such an alliance requires frequent, honest input from the client and Dr. Manning reviewed several methods for doing so. Constant client input ensures that the client is designing personal goals and taking ownership of the change process. It also detects any initial breakdown of the “alliance” so that immediate repairs can be made. One of his slides stated: “It’s not so much the presence of a positive relation but the absence of positive qualities that is strongly correlated with poor outcome. Thus, it is the negative feelings about therapy that need to be addressed.”
This conference highlighted the clinical relevance of research but I was incredulous when a speech-language pathologist challenged the relevance of Dr. Luc D’Nil’s brain imaging studies during a small group round table discussion. I thought the studies were fascinating, enjoyed reading articles by this particular researcher and felt her comments were disrespectful. Dr. D’Nil’s credibility and character only increased in my eyes when he graciously acknowledged the woman’s complaint and raised her issue again on Sunday when 5-minute summaries of each session were shared with the entire group. I find these conferences allow me a glimpse at the people behind the names I read in professional journals and faces I see on International Stuttering Awareness online conferences. I discover professionals in the field I really like and wish I could get to know better. They are the ones I rely on to guide my own clinical decision making. They are the names that are footnoted in my clinical reports.
I’m looking forward to the next time I can attend a SID 4 conference.
(1) Jennifer B. Watson, Ph.D., CCC-SLP, ASHA-F, Texas Christian University, Forth Worth, Texas.
(2) Walter Manning, Ph.D. The University of Memphis
(3) By Jerome Groopman, (2005) NY: Random House, Inc.
Jennifer Watson’s (1) presentation on Sunday morning was brilliant. She must have been paying close attention the previous 2 days because her topic drew directly from the presentations of Friday and Saturday. The title of her talk was “Research and Clinical Connections in Stuttering: Busting Barriers and Building Bridges.” I really appreciated her effort to review some reasons why it is difficult to translate current research immediately into therapy practice. She reviewed the current Framework for Evidence Based Practice (EBP) - a triangle, the three of points of which represent Current Best Evidence, Clinical Expertise and Client/Patient Values. Dr. Watson felt EBP should be represented by Venn diagram of interconnecting circles (rather than a triangle) to illustrate how important it is that research, clinician, and clients impact one another. There needs to be more communication between these three stakeholders in order to make progress in the field.
Dr. Watson recommends a “Deployment-Focused Model of Intervention Development and Testing.” I cringe at the military connotations the word ‘deployment’ has for me; nevertheless, her point is that all research and practice in the field of fluency and fluency disorders must has some genuine relevance to the real-life conditions in which speech-language pathologists work and persons who stutter live. The gems in her argument included:
•Improving client-to-treatment matching: Which treatment protocols work the best for which client profiles?
•Identifying change mechanisms: Are there key elements that promote and support client progress, for example, the concepts of “therapeutic alliance” or “stages of change.”
•Changing from a mentality of “best” treatment to “best fit.” It’s unlikely any one person is going to devise the “best” treatment for all persons who stutter. Clients are individuals and stuttering may be a heterogeneous disorder, which means, one-size will not fit all.
Walter Manning (2) had opened the conference with “Clinically Significant Change for Persons who Stutter” in which he statistical differences that indicate significant research findings are qualitatively different from clinical differences that indicate client satisfaction. Dr. Manning reviewed several ways to consider the client’s point of view. He emphasized that emotional and cognitive goals are equally as important, if not more so, than speech fluency goals in some cases. He recommended The Anatomy of Hope (3). He referred to a Contextual (or Common Factors) Model of therapy with the “therapeutic alliance” as a key ingredient to progress. Building such an alliance requires frequent, honest input from the client and Dr. Manning reviewed several methods for doing so. Constant client input ensures that the client is designing personal goals and taking ownership of the change process. It also detects any initial breakdown of the “alliance” so that immediate repairs can be made. One of his slides stated: “It’s not so much the presence of a positive relation but the absence of positive qualities that is strongly correlated with poor outcome. Thus, it is the negative feelings about therapy that need to be addressed.”
This conference highlighted the clinical relevance of research but I was incredulous when a speech-language pathologist challenged the relevance of Dr. Luc D’Nil’s brain imaging studies during a small group round table discussion. I thought the studies were fascinating, enjoyed reading articles by this particular researcher and felt her comments were disrespectful. Dr. D’Nil’s credibility and character only increased in my eyes when he graciously acknowledged the woman’s complaint and raised her issue again on Sunday when 5-minute summaries of each session were shared with the entire group. I find these conferences allow me a glimpse at the people behind the names I read in professional journals and faces I see on International Stuttering Awareness online conferences. I discover professionals in the field I really like and wish I could get to know better. They are the ones I rely on to guide my own clinical decision making. They are the names that are footnoted in my clinical reports.
I’m looking forward to the next time I can attend a SID 4 conference.
(1) Jennifer B. Watson, Ph.D., CCC-SLP, ASHA-F, Texas Christian University, Forth Worth, Texas.
(2) Walter Manning, Ph.D. The University of Memphis
(3) By Jerome Groopman, (2005) NY: Random House, Inc.
11/26/09
Cluttering Revisited
I received three calls in October and November from parents looking for help with cluttering. I had to tell them I have not treated cluttering per se, however, given my experience with stuttering and other speech/language issues I felt qualified to provide such treatment. Two of the callers moved on. One visited with me this week, which prompted me to review all the possible scenarios that might evolve when this new student walked through my door. For cluttering, there are many.
The ASHALeader article by St. Loius et. al. (11) describes assessment and treatment in a practical way for the clinician seeking to make the best use of the brief amount of time normally available for an evaluation. Cluttering can present with a constellation of symptoms to be teased apart in differential diagnosis. “One especially frustrating problem is that people with the disorder frequently do not clutter, for example, when they speak in a short screening evaluation.” (11, p.1) The SLP must select speech/language tasks that will reveal fluency, articulation, linguistic, and pragmatic problems that identify cluttering in particular. Conducting an evaluation in more than one session is recommended.
Knowing that “…rate problems are somehow central to cluttering” (11, p.2), it becomes important to video tape, transcribe, and calculate speech rates for a variety of speaking tasks. I happen to have the APAT (9) and therefore I chose a few tasks from this test. St. Loius et. al. recommend several tasks and provide data:
“Average conversational rates for normal preschoolers are reported to range from 110-180 SPM; for elementary aged children from 140-200 SPM; and for adults from 180 – 220 SPM.” (11, p.3) [see Sturm & Seery (10)] However, rate data alone must be supplemented by a description of pausing and phrasing. “While people who clutter sound like they are speaking too fast, the fact is they actually end up speaking slower than normal due to their rapid runs of speech being interrupted by long pauses.” (7, p.7) There is “…the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints…”(8) “Cluttering is fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rates may not exceed normal limits). (8)
Those of us well versed in stuttering issues will easily recognize the clutterer’s use of “an excessive number of disfluencies, the majority of which are not typical of people who stutter.” (8) Dewey lists these disfluencies in his personal story (5). I highly recommend Dewey’s well-organized, intimate essay as a take-home for parents as well as teen age students and adults. It can serve as an introduction to cluttering during an assessment and it could provide a point of reference throughout a treatment program.
Rapid rate (bursts of speech) and disfluency combine with articulation errors to result in speech which is difficult to understand. These errors will be familiar to the SLP. We have listened to a variety of articulation patterns that have been analyzed and re-analyzed according to the philosophies of the most popular university professors of the day. We’ve read debates over whether apraxia is a language or speech/language disorder, whether articulation disorders are functional, phonologically based or motoric in nature. SLPs are familiar with sound errors found in reading and spelling disorders. Analysis of the speech sample will not be unfamiliar. St. Louis, et. al. recommend using Systematic Disfluency Analaysis (11) which would result in a very detailed description. I imagine there are other methods of close transcription. Speech and writing samples generously shared by Peter Kissagizlis are found in his 2009 ISAD paper (8). We can listen to Dewey’s speech as well. (5)
Of course, as I read the latest news about cluttering, I question how many of my previous students presented with cluttering in addition to their stuttering. I have observed stuttering resolve by way of normal disfluencies and St. Louis makes note of this stuttering-cluttering relationship. “Moreover, cluttering is often noticed before the stuttering takes over during development of the disorders and after stuttering is treated successfully, but not while a person manifests significant stuttering.” (11, p.1) I have not recommended stuttering therapy in some cases of preschoolers who were very dysfluent but not stuttering and I’ve done a lot of language work with school children as part of their stuttering treatment. Maybe this is why.
I’m left wondering if treating cluttering may be easier than assessing it. My new client performed well for a variety of video taped speech samples. He completed the PCI with a score too low for a cluttering diagnosis. This leads us to a crucial aspect of cluttering and of cluttering assessment: “…the evaluation process must be long enough so the person doesn’t get that chance to consistently normalize. The clinician should carry out a number different speaking tasks in therapy, repeating them from time to time. Eventually, individuals will let down their guard, and the cluttering will appear. In addition, clutterers “are usually unaware of their disfluencies and misarticulations…” (3, p.1)
Given what we know about cluttering AND as a specialist who has been asked for a second opinion consult AND presented with somewhat good quality speech and language in a 60 minute initial visit AND a self report PCI score below 80 I DO NOT report that cluttering is not present in this case.
What next? Hopefully this student will be more spontaneous at the next visit as I challenge him with more complex linguistic material and ask for more in depth, extemporaneous opinions about familiar and unfamiliar topics in monologue and conversation. When I complete the PCI, it may score above 80. Assuming this student is coming to me for a diagnosis of cluttering and recommendations for speech therapy, it will be up to him to choose whether or not to reveal the communication problems that brought him to my door. Then we will discover it together by watching the video we make at his next session.
(1) Daly, D. (1993) “Cluttering: The Orphan of Speech-Language Pathology” American Journal of Speech Language Pathology, Vol. 2, pp 6-8
(2) Daly, D. (1996) The Source for Stuttering and Cluttering, East Moline, IL: LinguiSystems, Inc.
(3) Daly, D. (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10/daly10.html
(4) Daly, D. (2006) Predictive Cluttering Inventory (PCI) broken link
(5) Dewey, J. (2005) “My Experiences with Cluttering” http://www.mnsu.edu/comdis/isad8/papers/dewey8.html
(6) Kleiman, L. (2003) Functional Communication Profile Revised: Assessing Commuicative Effectiveness with Clients with Developmental Delays, East Moline, IL: LinguiSystems
(7) Mosheim, J. (2004) “Cluttering: Specialists work to put it on the map of fluency disorders” advance for Speech-Language Pathologists & Audiologists, November 22, pp. 6-9
(8) Myers, F. & Kissagizlis, P. (2009) “Putting Cluttering on the World Map: Formation of the International Cluttering Association (ICA)” http://www.mnsu.edu/comdis/isad10/papers/myers10.html
(9) Ross-Swain, D. & Long, N. (2004) Auditory Processing Abilities Test (APAT), Novato, CA: Academic Therapy Publications
(10) Sturm, J & Seery, C. (2007) “Speech and Articulatory Rates of School-Age Children in Conversation and Narrative Contexts, Language, Speech, and Hearing Services in Schools, Vol 38, pp. 47-59.
(11) St. Louis, K. et al (2003) “Cluttering Updated” the ASHALeader, pp. 4-5, 20-22
(12) St. Louis, K. & Meyers, F. ( ) Cluttering www.stutteringhelp.org
(13) International Cluttering Association, http://associations.missouristate.edu/ICA/
The ASHALeader article by St. Loius et. al. (11) describes assessment and treatment in a practical way for the clinician seeking to make the best use of the brief amount of time normally available for an evaluation. Cluttering can present with a constellation of symptoms to be teased apart in differential diagnosis. “One especially frustrating problem is that people with the disorder frequently do not clutter, for example, when they speak in a short screening evaluation.” (11, p.1) The SLP must select speech/language tasks that will reveal fluency, articulation, linguistic, and pragmatic problems that identify cluttering in particular. Conducting an evaluation in more than one session is recommended.
Knowing that “…rate problems are somehow central to cluttering” (11, p.2), it becomes important to video tape, transcribe, and calculate speech rates for a variety of speaking tasks. I happen to have the APAT (9) and therefore I chose a few tasks from this test. St. Loius et. al. recommend several tasks and provide data:
“Average conversational rates for normal preschoolers are reported to range from 110-180 SPM; for elementary aged children from 140-200 SPM; and for adults from 180 – 220 SPM.” (11, p.3) [see Sturm & Seery (10)] However, rate data alone must be supplemented by a description of pausing and phrasing. “While people who clutter sound like they are speaking too fast, the fact is they actually end up speaking slower than normal due to their rapid runs of speech being interrupted by long pauses.” (7, p.7) There is “…the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints…”(8) “Cluttering is fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rates may not exceed normal limits). (8)
Those of us well versed in stuttering issues will easily recognize the clutterer’s use of “an excessive number of disfluencies, the majority of which are not typical of people who stutter.” (8) Dewey lists these disfluencies in his personal story (5). I highly recommend Dewey’s well-organized, intimate essay as a take-home for parents as well as teen age students and adults. It can serve as an introduction to cluttering during an assessment and it could provide a point of reference throughout a treatment program.
Rapid rate (bursts of speech) and disfluency combine with articulation errors to result in speech which is difficult to understand. These errors will be familiar to the SLP. We have listened to a variety of articulation patterns that have been analyzed and re-analyzed according to the philosophies of the most popular university professors of the day. We’ve read debates over whether apraxia is a language or speech/language disorder, whether articulation disorders are functional, phonologically based or motoric in nature. SLPs are familiar with sound errors found in reading and spelling disorders. Analysis of the speech sample will not be unfamiliar. St. Louis, et. al. recommend using Systematic Disfluency Analaysis (11) which would result in a very detailed description. I imagine there are other methods of close transcription. Speech and writing samples generously shared by Peter Kissagizlis are found in his 2009 ISAD paper (8). We can listen to Dewey’s speech as well. (5)
Of course, as I read the latest news about cluttering, I question how many of my previous students presented with cluttering in addition to their stuttering. I have observed stuttering resolve by way of normal disfluencies and St. Louis makes note of this stuttering-cluttering relationship. “Moreover, cluttering is often noticed before the stuttering takes over during development of the disorders and after stuttering is treated successfully, but not while a person manifests significant stuttering.” (11, p.1) I have not recommended stuttering therapy in some cases of preschoolers who were very dysfluent but not stuttering and I’ve done a lot of language work with school children as part of their stuttering treatment. Maybe this is why.
I’m left wondering if treating cluttering may be easier than assessing it. My new client performed well for a variety of video taped speech samples. He completed the PCI with a score too low for a cluttering diagnosis. This leads us to a crucial aspect of cluttering and of cluttering assessment: “…the evaluation process must be long enough so the person doesn’t get that chance to consistently normalize. The clinician should carry out a number different speaking tasks in therapy, repeating them from time to time. Eventually, individuals will let down their guard, and the cluttering will appear. In addition, clutterers “are usually unaware of their disfluencies and misarticulations…” (3, p.1)
Given what we know about cluttering AND as a specialist who has been asked for a second opinion consult AND presented with somewhat good quality speech and language in a 60 minute initial visit AND a self report PCI score below 80 I DO NOT report that cluttering is not present in this case.
What next? Hopefully this student will be more spontaneous at the next visit as I challenge him with more complex linguistic material and ask for more in depth, extemporaneous opinions about familiar and unfamiliar topics in monologue and conversation. When I complete the PCI, it may score above 80. Assuming this student is coming to me for a diagnosis of cluttering and recommendations for speech therapy, it will be up to him to choose whether or not to reveal the communication problems that brought him to my door. Then we will discover it together by watching the video we make at his next session.
(1) Daly, D. (1993) “Cluttering: The Orphan of Speech-Language Pathology” American Journal of Speech Language Pathology, Vol. 2, pp 6-8
(2) Daly, D. (1996) The Source for Stuttering and Cluttering, East Moline, IL: LinguiSystems, Inc.
(3) Daly, D. (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10/daly10.html
(4) Daly, D. (2006) Predictive Cluttering Inventory (PCI) broken link
(5) Dewey, J. (2005) “My Experiences with Cluttering” http://www.mnsu.edu/comdis/isad8/papers/dewey8.html
(6) Kleiman, L. (2003) Functional Communication Profile Revised: Assessing Commuicative Effectiveness with Clients with Developmental Delays, East Moline, IL: LinguiSystems
(7) Mosheim, J. (2004) “Cluttering: Specialists work to put it on the map of fluency disorders” advance for Speech-Language Pathologists & Audiologists, November 22, pp. 6-9
(8) Myers, F. & Kissagizlis, P. (2009) “Putting Cluttering on the World Map: Formation of the International Cluttering Association (ICA)” http://www.mnsu.edu/comdis/isad10/papers/myers10.html
(9) Ross-Swain, D. & Long, N. (2004) Auditory Processing Abilities Test (APAT), Novato, CA: Academic Therapy Publications
(10) Sturm, J & Seery, C. (2007) “Speech and Articulatory Rates of School-Age Children in Conversation and Narrative Contexts, Language, Speech, and Hearing Services in Schools, Vol 38, pp. 47-59.
(11) St. Louis, K. et al (2003) “Cluttering Updated” the ASHALeader, pp. 4-5, 20-22
(12) St. Louis, K. & Meyers, F. ( ) Cluttering www.stutteringhelp.org
(13) International Cluttering Association, http://associations.missouristate.edu/ICA/
10/17/09
FEAR
Rapid/shallow breathing, a ‘racing’ heart, light headedness, weakness in the legs, nausea, sweaty palms and fearful expression are physical symptoms created by the Sympathetic Nervous System (6). These symptoms occur when the body feels a need to fight or to run away. And this is called ‘the fight or flight response.’ Many of us experience these unpleasant symptoms during times of stress and fear.
Butterflies in the stomach and other symptoms of fear are the result of signals coming down the spinal cord from the Limbic System deep inside our brains (7). One of the brain structures within the Limbic System is called the amygdala. The amygdala “has long been associated with emotion, especially fear…nerve fibers from the amygdala project into the upper brain regions that control the release of stress hormones…when a person perceives a threat, alarms go off in the brain, causing arousal, hypervigilance…the fight or flight response.” (8)
The brain learns and remembers fear. “…research suggests that it takes only one terrifying experience for a lifelong emotional memory to be put into place that is extremely difficult to erase, because the ‘thinking’ part of the brain is ‘out of the loop’ when the fear-related memory is formed…many fearful situations are experienced, learned, and unconsciously committed to emotional memory without people being aware of the initial fear trigger…not being able to pinpointing the cause of their fear leads to a feeling of being weak and helpless.” (9)
Betty Horwitz, in her book Communication Apprehension, further describes several sources of fear. Innate fear are intrinsic reactions that cause an animal to withdraw, attack, become immobile or call for help. As an example she sites a fear of staring eyes and writes that disapproving looks can trigger innate fear. Conditioned fear is learned after repeated experiences in a specific circumstance, such as interactions with a critical authority figure. Unfamiliar event fear is somewhat self-explanatory. Freezing and avoidance are common fear reactions to unfamiliar situations. Fear of the unfamiliar transforms into anxiety with increasing age and social phobias can appear in adolescence.
What relevance does this all have to stuttering? Speech therapy for children includes activities intended to prevent and/or reduce communication apprehension – fear of speaking. Speech therapy for teens and adults includes activities intended to reduce communication anxiety already established by years of painful experience and avoidance behavior.
Recent research related to stuttering refers to two types of anxiety: “Trait anxiety refers to a person’s inherent level of anxiety and state anxiety, referring to a condition or situation-specific anxiety.” (2)
In any given situation, a person’s perception of danger and his ability to cope affects anxiety. One theory proposes four different types of situation anxiety: social evaluation, physical danger, ambiguity, and daily routines. A person may respond differently to each of these four kinds of situations. A person with a high level of trait anxiety may become exceedingly anxious in a situation of social evaluation, but feel quite capable of coping with a dangerous situation. This person would experience a higher level of situation anxiety in, let’s say, public speaking, than in conflict.
“The association between stuttering and anxiety has been robustly debated over the years…” (1) Some researchers have viewed anxiety as “the main cause of the disorder…as a mediating variable…as a by-product of stuttering…as a general stress trait…as a state condition related to communication in general and to speech communication in particular.” (3) Research into anxiety in persons who stutter has been done using self-report questionnaires. The Inventory of Interpersonal Situations, one such questionnaire, appeared in the appendix of one such study. (4)
Results suggest that many adults who stutter do have higher levels of trait anxiety than fluent speakers. Is this characteristic of some persons who stutter since childhood? I don’t think anyone knows the answer to that. However, trait anxiety can increase over time for the person who stutters. When I meet with a child who stutters who appears to have substantial trait anxiety, I immediately include conversation to address this issue in an attempt at prevention.
State anxiety is greater during social communication, which seems like a no-brainer. But, it was interesting to read one reason why: “Anxiety has an effect on human performance, which is expressed in qualitative changes in performance and strong muscle activation…Nonautomatic actions that need attention can be harmed by anxiety…In the process of producing speech there are automatic factors, such as the semantic selection, the syntax, and phonology. However, the phonetic stage that plans the articulation and the motor control are not automatic and require attention…All of these factors can explain the relationship between anxiety and stuttering severity…” (5)
Therefore, it makes sense to include treatment for anxiety as part of a total therapy program, even if that means referral to a specialist in anxiety disorders.
I would like to close with a more philosophical perspective. I am in chapter 2 of a book (10) that quotes Martin Luther King in his 1963 book The Strength to Love, “In these days of catastrophic change and calamitous uncertainty, is there anyone who does not experience the depression and bewilderment of crippling fear…?” King describes courage as “the strength of mind capable of conquering whatever threatens attainment of the highest good.” Fear has an insidious way of paralyzing us and we doubtless have justifications for this to be so. Persons who stutter have good reason to be fearful and clinicians perhaps need to reach beyond the physiological into the philosophical in order to be helpful.
Courage may need to be the topic of a new blog entry.
(1) Craig, A. et al (2003) Anxiety Levels in People Who Stutter: A Randomized Population Study, Journal of Speech, Language and Hearing Research, Vol. 46, p. 1197.
(2) Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, p.136.
(3) Ibid
(4) Kraaimaat, F.W., et al (2002) Stuttering and social anxiety, Journal of Fluency Disorders, Vol 27, pp 319-331.
(5) Ezrati-Vinacour, p.144
(6) http://faculty.washington.edu/chudler/auto.html
(7) http://health.howstuffworks.com/human-nature/emotions/other/laughter4.htm
(8) Betty Horwitz (2002) Communication Apprehension: Origins and Management, Albany, NY: Singular/Thompson Learning, p. 29-30
(9) Ibid. p. 31
(10) Rev. Scotty McLennan (2009) Jesus was a Liberal: Reclaiming Christianity for All, NY, NY: Palgrave MacMillan, p. 40.
Butterflies in the stomach and other symptoms of fear are the result of signals coming down the spinal cord from the Limbic System deep inside our brains (7). One of the brain structures within the Limbic System is called the amygdala. The amygdala “has long been associated with emotion, especially fear…nerve fibers from the amygdala project into the upper brain regions that control the release of stress hormones…when a person perceives a threat, alarms go off in the brain, causing arousal, hypervigilance…the fight or flight response.” (8)
The brain learns and remembers fear. “…research suggests that it takes only one terrifying experience for a lifelong emotional memory to be put into place that is extremely difficult to erase, because the ‘thinking’ part of the brain is ‘out of the loop’ when the fear-related memory is formed…many fearful situations are experienced, learned, and unconsciously committed to emotional memory without people being aware of the initial fear trigger…not being able to pinpointing the cause of their fear leads to a feeling of being weak and helpless.” (9)
Betty Horwitz, in her book Communication Apprehension, further describes several sources of fear. Innate fear are intrinsic reactions that cause an animal to withdraw, attack, become immobile or call for help. As an example she sites a fear of staring eyes and writes that disapproving looks can trigger innate fear. Conditioned fear is learned after repeated experiences in a specific circumstance, such as interactions with a critical authority figure. Unfamiliar event fear is somewhat self-explanatory. Freezing and avoidance are common fear reactions to unfamiliar situations. Fear of the unfamiliar transforms into anxiety with increasing age and social phobias can appear in adolescence.
What relevance does this all have to stuttering? Speech therapy for children includes activities intended to prevent and/or reduce communication apprehension – fear of speaking. Speech therapy for teens and adults includes activities intended to reduce communication anxiety already established by years of painful experience and avoidance behavior.
Recent research related to stuttering refers to two types of anxiety: “Trait anxiety refers to a person’s inherent level of anxiety and state anxiety, referring to a condition or situation-specific anxiety.” (2)
In any given situation, a person’s perception of danger and his ability to cope affects anxiety. One theory proposes four different types of situation anxiety: social evaluation, physical danger, ambiguity, and daily routines. A person may respond differently to each of these four kinds of situations. A person with a high level of trait anxiety may become exceedingly anxious in a situation of social evaluation, but feel quite capable of coping with a dangerous situation. This person would experience a higher level of situation anxiety in, let’s say, public speaking, than in conflict.
“The association between stuttering and anxiety has been robustly debated over the years…” (1) Some researchers have viewed anxiety as “the main cause of the disorder…as a mediating variable…as a by-product of stuttering…as a general stress trait…as a state condition related to communication in general and to speech communication in particular.” (3) Research into anxiety in persons who stutter has been done using self-report questionnaires. The Inventory of Interpersonal Situations, one such questionnaire, appeared in the appendix of one such study. (4)
Results suggest that many adults who stutter do have higher levels of trait anxiety than fluent speakers. Is this characteristic of some persons who stutter since childhood? I don’t think anyone knows the answer to that. However, trait anxiety can increase over time for the person who stutters. When I meet with a child who stutters who appears to have substantial trait anxiety, I immediately include conversation to address this issue in an attempt at prevention.
State anxiety is greater during social communication, which seems like a no-brainer. But, it was interesting to read one reason why: “Anxiety has an effect on human performance, which is expressed in qualitative changes in performance and strong muscle activation…Nonautomatic actions that need attention can be harmed by anxiety…In the process of producing speech there are automatic factors, such as the semantic selection, the syntax, and phonology. However, the phonetic stage that plans the articulation and the motor control are not automatic and require attention…All of these factors can explain the relationship between anxiety and stuttering severity…” (5)
Therefore, it makes sense to include treatment for anxiety as part of a total therapy program, even if that means referral to a specialist in anxiety disorders.
I would like to close with a more philosophical perspective. I am in chapter 2 of a book (10) that quotes Martin Luther King in his 1963 book The Strength to Love, “In these days of catastrophic change and calamitous uncertainty, is there anyone who does not experience the depression and bewilderment of crippling fear…?” King describes courage as “the strength of mind capable of conquering whatever threatens attainment of the highest good.” Fear has an insidious way of paralyzing us and we doubtless have justifications for this to be so. Persons who stutter have good reason to be fearful and clinicians perhaps need to reach beyond the physiological into the philosophical in order to be helpful.
Courage may need to be the topic of a new blog entry.
(1) Craig, A. et al (2003) Anxiety Levels in People Who Stutter: A Randomized Population Study, Journal of Speech, Language and Hearing Research, Vol. 46, p. 1197.
(2) Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, p.136.
(3) Ibid
(4) Kraaimaat, F.W., et al (2002) Stuttering and social anxiety, Journal of Fluency Disorders, Vol 27, pp 319-331.
(5) Ezrati-Vinacour, p.144
(6) http://faculty.washington.edu/chudler/auto.html
(7) http://health.howstuffworks.com/human-nature/emotions/other/laughter4.htm
(8) Betty Horwitz (2002) Communication Apprehension: Origins and Management, Albany, NY: Singular/Thompson Learning, p. 29-30
(9) Ibid. p. 31
(10) Rev. Scotty McLennan (2009) Jesus was a Liberal: Reclaiming Christianity for All, NY, NY: Palgrave MacMillan, p. 40.
9/5/09
Phonological Awareness: An ASHA How-To Journal Article
This is one of many articles published by the American Speech Language Hearing Association that make surfing the professional journals really worth my time. Phonological Awareness Intervention: Beyond the Basics (1) by C. Melanie Schuele and Donna Boudreau is the peer-reviewed article that speech-language patholgists (SLPs) need to guide and justify their instructional practices. This article is thorough in every sense of the word. There is background, justification for the role of the SLP in literacy intervention, definitions of terms, and step-by-step direction in how to teach phonological awareness skills. This article belongs in the personal reference materials of any SLP working with children.
This article is full of easy-to-read figures and tables that itemize key points. Table 8 on page 14-15 is a page and a half of an actual dialogue between adult and child ! There are 4 ½ pages of references for anyone looking for additional material.
There are so many jewels in this article; however, I will highlight only one here. An example of how this is an article about how to teach, here is a quote from page 10: “Learning is best characterized not by moving a child from 20% correct to 50% correct to 100% correct, but by moving a child from successful performance with maximal support to successful performance with little or no support.” This is so true for speech therapy for stuttering, in my opinion. Parents are eager to know when a child will become more fluent in the most excitable, linguistically challenging situations. Parents need to understand that this will only begin to happen when they provide maximal supports. They must take the initiative to CHANGE THE SPEAKING SITUATION - NOT CHANGE THE CHILD. This is maximal support.
In speech therapy for stuttering, we are looking to make speech and language more efficient. What are we going to actually do in a speech therapy session? Many years ago, we focused on the length and complexity of utterance. We trained speech tools at the syllable, then single word, then phrase, then sentence levels. Now, we can approach therapy activities is a more sophisticated way by embedding phonological awareness training and other literacy skills into our sessions.
“Several critical reviews of the general efficacy of phonological awareness instruction and intervention have provided conclusive evidence that phonological awareness can be improved through instruction and intervention, and improvement in phonological awareness leads to improvement in word decoding…reading researchers have called on practitioners to provide intervention to children with poor phonological awareness as early as kindergarten…to provide phonological awareness intervention to older students who demonstrate poor reading achievement in word decoding skills.” P. 3
Many of our students have additional difficulties, such as articulation and language delays/disorders and dyslexia. We can embed emergent literacy tasks nto our speech therapy activities for the sake of prevention as well as remediation for all of our clients at some point in their therapeutic journeys.
Thank you ASHA.
(1) Schuele, C.M. & Boudreau, D. (2008) Language Speech Hearing Services in Schools, Vol. 39, pp 3-20.
This article is full of easy-to-read figures and tables that itemize key points. Table 8 on page 14-15 is a page and a half of an actual dialogue between adult and child ! There are 4 ½ pages of references for anyone looking for additional material.
There are so many jewels in this article; however, I will highlight only one here. An example of how this is an article about how to teach, here is a quote from page 10: “Learning is best characterized not by moving a child from 20% correct to 50% correct to 100% correct, but by moving a child from successful performance with maximal support to successful performance with little or no support.” This is so true for speech therapy for stuttering, in my opinion. Parents are eager to know when a child will become more fluent in the most excitable, linguistically challenging situations. Parents need to understand that this will only begin to happen when they provide maximal supports. They must take the initiative to CHANGE THE SPEAKING SITUATION - NOT CHANGE THE CHILD. This is maximal support.
In speech therapy for stuttering, we are looking to make speech and language more efficient. What are we going to actually do in a speech therapy session? Many years ago, we focused on the length and complexity of utterance. We trained speech tools at the syllable, then single word, then phrase, then sentence levels. Now, we can approach therapy activities is a more sophisticated way by embedding phonological awareness training and other literacy skills into our sessions.
“Several critical reviews of the general efficacy of phonological awareness instruction and intervention have provided conclusive evidence that phonological awareness can be improved through instruction and intervention, and improvement in phonological awareness leads to improvement in word decoding…reading researchers have called on practitioners to provide intervention to children with poor phonological awareness as early as kindergarten…to provide phonological awareness intervention to older students who demonstrate poor reading achievement in word decoding skills.” P. 3
Many of our students have additional difficulties, such as articulation and language delays/disorders and dyslexia. We can embed emergent literacy tasks nto our speech therapy activities for the sake of prevention as well as remediation for all of our clients at some point in their therapeutic journeys.
Thank you ASHA.
(1) Schuele, C.M. & Boudreau, D. (2008) Language Speech Hearing Services in Schools, Vol. 39, pp 3-20.
6/7/09
Breathing
“Take a breath, slow down, relax…” What is it about stuttering that prompts this reaction in listeners? Stuttering does disrupt airflow. After all, breathing stops momentarily during a block and to breathe is to live. Prolongations and the repetitions of sounds and syllables alter speech rate. Stuttering often includes signs of tension in the face, neck and chest. And so, the empathic, and even the pragmatic, listener may feel that suggesting a stutterer ‘breathe and relax’ will be comforting and make perfect sense.
However, since the altered breathing and physical tension are symptoms – not the cause – of stuttering, this well meaning advice can make matters worse. Symptoms are clues. Clues help us solve mysteries, in this case, the mystery of stuttering. While treating the symptoms of a problem can ease our suffering, it may not promote healing. When I see a child whose repertoire of secondary behaviors includes quick gasps for air, eventually I also hear that he was instructed to ‘take a breath and relax’ as an immediate way out of his struggled speech. Like a bandage placed on an unwashed abrasion, this quick fix fails to really help at all.
My recent attention to breathing came about because of clues that led to impaired breathing as the cause of distress in two cases. Well, breathing was very near to the underlying causes. One was a member of my own family who contracted pneumonia. The other was an elementary school age client who suffers from allergies.
James L. Coyle, Ph.D., CCC-SLP, BRS-S co-presented “Dysphagia Practice: Aspiration Pneumonia and the Role of the Speech-language Pathologist” on May 2, 2009 for Northern Speech Services, Inc. I attended his enthusiastic and detailed presentation on the anatomy and physiology of the respiration system. Human beings breathe to feed the body with oxygen rid it of carbon dioxide. The lungs are loaded with tiny alveoli, like bunches of delicate grapes, which provide an enormous amount of surface area for this very purpose. Molecules of O2 inhaled pass from the lungs into the blood and molecules of CO2 leave the blood, go into the lungs and are exhaled. Damage to the alveoli impair breathing and create distress. In both cases, treatment of the underlying disease is the critical issue. Lawrence Hall Science, The University of California; Berkeley has a nice description of this for kids. (1)
Medical treatments for disease often involve medications. Antibiotics for pneumonia help cure the disease and therefore improve breathing. However, medications often have the side effects. And for the student I’m referring to in this blog, a switch from Allegra to Singulair to treat his allergies seemed to increase fluency substantially. Of course, medication changes should be done with medical supervision. The link betweeen medication and behvior may vary from person to person, and could be a valuable clue to anyone's stuttering mystery.
Human beings are adaptable. So, when faced with difficulty, we search for solutions. Given what we know at the time, we do the best we can. While it may seem obvious to increase air intake by expanding the lungs, it’s not that simple. A child who activates the muscles in his chest and shoulders to expand his lungs is increasing tension, not relaxation. The muscular work of breathing is the responsibility of the diaphragm. There is a simple animation of the diaphragm in a YouTube video called “3D view of diaphragm” (2). The narrative is quite complex, so I suggest the mute button for young children. However, there’s also a fun YouTube video called “Harmonica Playing for Beginners: diaphragmatic breathing” in a which a friendly instructor demonstrates how the diaphragm plays an important role in the breath support and relaxation while playing the harmonica (3). Therefore, unless the child is capable of self-monitoring such subtle muscle control, direct instruction to ‘breathe and relax’may be counterproductive.
For those interested in singing, a website called ‘The Singing Universe” has a section called “Breathing for Singing” which describes breathing exercises to help develop awareness of breathing from the diaphram (4) . I’m thinking of taking singing lessons to experience this instruction personally.
Take good care of your lungs.
(1) broken link
(2) http://www.youtube.com/watch?v=hp-gCvW8PRY
(3) broken link
(4) broken link
However, since the altered breathing and physical tension are symptoms – not the cause – of stuttering, this well meaning advice can make matters worse. Symptoms are clues. Clues help us solve mysteries, in this case, the mystery of stuttering. While treating the symptoms of a problem can ease our suffering, it may not promote healing. When I see a child whose repertoire of secondary behaviors includes quick gasps for air, eventually I also hear that he was instructed to ‘take a breath and relax’ as an immediate way out of his struggled speech. Like a bandage placed on an unwashed abrasion, this quick fix fails to really help at all.
My recent attention to breathing came about because of clues that led to impaired breathing as the cause of distress in two cases. Well, breathing was very near to the underlying causes. One was a member of my own family who contracted pneumonia. The other was an elementary school age client who suffers from allergies.
James L. Coyle, Ph.D., CCC-SLP, BRS-S co-presented “Dysphagia Practice: Aspiration Pneumonia and the Role of the Speech-language Pathologist” on May 2, 2009 for Northern Speech Services, Inc. I attended his enthusiastic and detailed presentation on the anatomy and physiology of the respiration system. Human beings breathe to feed the body with oxygen rid it of carbon dioxide. The lungs are loaded with tiny alveoli, like bunches of delicate grapes, which provide an enormous amount of surface area for this very purpose. Molecules of O2 inhaled pass from the lungs into the blood and molecules of CO2 leave the blood, go into the lungs and are exhaled. Damage to the alveoli impair breathing and create distress. In both cases, treatment of the underlying disease is the critical issue. Lawrence Hall Science, The University of California; Berkeley has a nice description of this for kids. (1)
Medical treatments for disease often involve medications. Antibiotics for pneumonia help cure the disease and therefore improve breathing. However, medications often have the side effects. And for the student I’m referring to in this blog, a switch from Allegra to Singulair to treat his allergies seemed to increase fluency substantially. Of course, medication changes should be done with medical supervision. The link betweeen medication and behvior may vary from person to person, and could be a valuable clue to anyone's stuttering mystery.
Human beings are adaptable. So, when faced with difficulty, we search for solutions. Given what we know at the time, we do the best we can. While it may seem obvious to increase air intake by expanding the lungs, it’s not that simple. A child who activates the muscles in his chest and shoulders to expand his lungs is increasing tension, not relaxation. The muscular work of breathing is the responsibility of the diaphragm. There is a simple animation of the diaphragm in a YouTube video called “3D view of diaphragm” (2). The narrative is quite complex, so I suggest the mute button for young children. However, there’s also a fun YouTube video called “Harmonica Playing for Beginners: diaphragmatic breathing” in a which a friendly instructor demonstrates how the diaphragm plays an important role in the breath support and relaxation while playing the harmonica (3). Therefore, unless the child is capable of self-monitoring such subtle muscle control, direct instruction to ‘breathe and relax’may be counterproductive.
For those interested in singing, a website called ‘The Singing Universe” has a section called “Breathing for Singing” which describes breathing exercises to help develop awareness of breathing from the diaphram (4) . I’m thinking of taking singing lessons to experience this instruction personally.
Take good care of your lungs.
(1) broken link
(2) http://www.youtube.com/watch?v=hp-gCvW8PRY
(3) broken link
(4) broken link
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