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/
11/26/09
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
4/26/09
Stuttering is sort of like....
How can fluent speakers begin to appreciate what it is like to stutter? How can children who stutter find ways to express what it is like to speak? Luc Tielens wrote about metaphors for the 2004 International Stuttering Awareness Day online conference. * Since I own a box of 50 or so dominos and my students sometimes enjoy playing with them, here is a metaphore we came up with:
… when a chain of toppling dominos - stops. The smooth clickety-clickety sound of the dominos stops. The chain is broken. Like in a sentence when the smooth consonant-vowel-syllable sound of the words - stops.
Word fears, sound fears are like great big dominos you see ahead. You are on the lookout for them. When you spot trouble ahead – how do you feel ? What do you do? Maybe you think you know when the dominos could stop. If you think that the chain of dominos might stop falling at any time, your body might get anxious. Positive anxiety is called excitement. Negative anxiety is called fear. If the dominos feel out of control and frustration leads you to put them away, this is called avoidance. When talking gets too unpredictable and frustrating, sometimes children who stutter say, “Nevermind.” And they give up.
Finish this thought with your own ideas: Stuttering is sort of like…
… when a chain of toppling dominos - stops. The smooth clickety-clickety sound of the dominos stops. The chain is broken. Like in a sentence when the smooth consonant-vowel-syllable sound of the words - stops.
Word fears, sound fears are like great big dominos you see ahead. You are on the lookout for them. When you spot trouble ahead – how do you feel ? What do you do? Maybe you think you know when the dominos could stop. If you think that the chain of dominos might stop falling at any time, your body might get anxious. Positive anxiety is called excitement. Negative anxiety is called fear. If the dominos feel out of control and frustration leads you to put them away, this is called avoidance. When talking gets too unpredictable and frustrating, sometimes children who stutter say, “Nevermind.” And they give up.
Finish this thought with your own ideas: Stuttering is sort of like…
*http://www.mnsu.edu/comdis/isad7/papers/tielens7/tielens7.html
4/16/09
Down's Syndrome & Cluttering
One of my favorite tasks is searching the speech/language pathology journals for answers to specific questions posed by SLPs and by parents. I truly enjoy reading journal articles! I allow myself the luxury of wallowing in this kind of reading when I need to locate information regarding treatment choices for individual students.
A school-based SLP recently asked me about a student with Down’s syndrome. I could find only a few articles specifically about Down’s syndrome and stuttering with the kind of credibility necessary to support treatment decision making.
Judith Eckardt wrote an article for the International Stuttering Awareness Day online conference (1) in which she explained that her observation was that stuttering emerged around 8-10 years of age, about the same time these children were combining 2-3 word utterances and had rapid vocabulary development. This would be the time for “normal developmental stuttering” given the language delay. She also observed “shame of stuttering” in older Down’s students. She recalls, “I still remember the look of surprise and then a smile from the 17 year old, when I told her ‘It’s OK to stutter’ and ‘It’s NOT your Fault.’” (p.3)
There was also a presentation at the 2006 ASHA Convention specifically about stuttering and Down’s children. (2) I was not at the presentation, the handouts available on line make an explicit connection between Down’s and cluttering.
David Daley wrote an article for the 2007 International Stuttering Awareness Conference (3) in which he provides a checklist called the Predictive Cluttering Inventory. The checklist has 33 items divided into four categories: pragmatics, speech-motor, language-cognition, and motor coordination-writing problems. Each item is rated on a 7-point scale. He suggests that the higher the score on this inventory, the higher the probability that the speaker is a clutterer. Scores of “120 or more are quite rare. Typically, clients we have seen present with scores between 80 and 120. These scores we believe are indicative of a classification or diagnosis we call ‘Clutterer-Stutterer.’ One third of stuttering clients typically show some signs of cluttering.” (p.2) I have David Daley’s 1996 publication of The Source for Stuttering and Cluttering and in it he provides an extensive comparison of stuttering vs. cluttering.
The ASHALeader, an online publication of the American Speech Language Hearing Association, published an update on cluttering in 2003. (4) This article seemed to down play the role of language in the diagnosis. “Another vexing issue is the extent to which language planning and pragmatic problems are implicated in the diagnosis of cluttering. We do not currently include language difficulties in the definition because there appear to be at least a few clutterers for whom language problems are not evident.” (p.2) Rate problems are central to cluttering, says this article. “Clutterers also tend to slur or omit syllables of longer words, which compromise intelligibility during spurts of rapid speech.” (p.2) Many other optional symptoms include: lack of awareness of the problem, poor handwriting, confusing, disorganized language, temporary improvement when asked to ‘slow down,’ social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.
I think back upon 12 years of working exclusively with children and teens who stutter and realize that week after week, therapy activities often engaged my students in rate control, speech-motor practice, self-monitoring, educational counseling/mentoring, and language organization. These are relevant to both stuttering and cluttering. I recall how, eventually, so many of my students were found to have co-existing problems including Non-Verbal Learning Disorder, Attention Deficit, Sensory Integration Disorder, Dyslexia, Learning Disability and Temperamental Sensitivity. Others had family issues such as alcoholism, the birth of a sibling, moving to a new home, financial stress, and growing up in a multi-lingual environment.
I reflect on how experts in the field of stuttering have wondered aloud exactly why some treatment approaches seem effective with some individuals and not others. This has led to two stunning generalizations: 1. The client-clinician relationship matters more than the treatment approach; and, 2. Stuttering is a heterogeneous disorder with subtypes requiring different treatment approaches. Are these two concepts consistent with one another?!
All this causes me to pause and wonder, in the end, what separates me from the ‘snake oil salesman.’ All professional literature at my fingertips still leaves me with abiguity. Evidence Based Practice is not only literature based, but values clinician judgment. My judgments regarding client treatment are based on professional knowledge, ethical practice, and family feedback. Unlike 2+2, there is no single right answer in speech pathology.
(1) Judith Eckardt (2008) “Treating Down’s Children Who Stutter” http://www.mnsu.edu/comdis/isad11/papers/eckardt11.html
(2) Kurt Eggers & Chris De Bal (2006) Speech Dysfluencies in People with Down’s Syndrome Nov. 17, ASHA, Miami Beach (broken link)
(3) David Daley (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” (broken link)
A school-based SLP recently asked me about a student with Down’s syndrome. I could find only a few articles specifically about Down’s syndrome and stuttering with the kind of credibility necessary to support treatment decision making.
Judith Eckardt wrote an article for the International Stuttering Awareness Day online conference (1) in which she explained that her observation was that stuttering emerged around 8-10 years of age, about the same time these children were combining 2-3 word utterances and had rapid vocabulary development. This would be the time for “normal developmental stuttering” given the language delay. She also observed “shame of stuttering” in older Down’s students. She recalls, “I still remember the look of surprise and then a smile from the 17 year old, when I told her ‘It’s OK to stutter’ and ‘It’s NOT your Fault.’” (p.3)
There was also a presentation at the 2006 ASHA Convention specifically about stuttering and Down’s children. (2) I was not at the presentation, the handouts available on line make an explicit connection between Down’s and cluttering.
David Daley wrote an article for the 2007 International Stuttering Awareness Conference (3) in which he provides a checklist called the Predictive Cluttering Inventory. The checklist has 33 items divided into four categories: pragmatics, speech-motor, language-cognition, and motor coordination-writing problems. Each item is rated on a 7-point scale. He suggests that the higher the score on this inventory, the higher the probability that the speaker is a clutterer. Scores of “120 or more are quite rare. Typically, clients we have seen present with scores between 80 and 120. These scores we believe are indicative of a classification or diagnosis we call ‘Clutterer-Stutterer.’ One third of stuttering clients typically show some signs of cluttering.” (p.2) I have David Daley’s 1996 publication of The Source for Stuttering and Cluttering and in it he provides an extensive comparison of stuttering vs. cluttering.
The ASHALeader, an online publication of the American Speech Language Hearing Association, published an update on cluttering in 2003. (4) This article seemed to down play the role of language in the diagnosis. “Another vexing issue is the extent to which language planning and pragmatic problems are implicated in the diagnosis of cluttering. We do not currently include language difficulties in the definition because there appear to be at least a few clutterers for whom language problems are not evident.” (p.2) Rate problems are central to cluttering, says this article. “Clutterers also tend to slur or omit syllables of longer words, which compromise intelligibility during spurts of rapid speech.” (p.2) Many other optional symptoms include: lack of awareness of the problem, poor handwriting, confusing, disorganized language, temporary improvement when asked to ‘slow down,’ social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.
I think back upon 12 years of working exclusively with children and teens who stutter and realize that week after week, therapy activities often engaged my students in rate control, speech-motor practice, self-monitoring, educational counseling/mentoring, and language organization. These are relevant to both stuttering and cluttering. I recall how, eventually, so many of my students were found to have co-existing problems including Non-Verbal Learning Disorder, Attention Deficit, Sensory Integration Disorder, Dyslexia, Learning Disability and Temperamental Sensitivity. Others had family issues such as alcoholism, the birth of a sibling, moving to a new home, financial stress, and growing up in a multi-lingual environment.
I reflect on how experts in the field of stuttering have wondered aloud exactly why some treatment approaches seem effective with some individuals and not others. This has led to two stunning generalizations: 1. The client-clinician relationship matters more than the treatment approach; and, 2. Stuttering is a heterogeneous disorder with subtypes requiring different treatment approaches. Are these two concepts consistent with one another?!
All this causes me to pause and wonder, in the end, what separates me from the ‘snake oil salesman.’ All professional literature at my fingertips still leaves me with abiguity. Evidence Based Practice is not only literature based, but values clinician judgment. My judgments regarding client treatment are based on professional knowledge, ethical practice, and family feedback. Unlike 2+2, there is no single right answer in speech pathology.
(1) Judith Eckardt (2008) “Treating Down’s Children Who Stutter” http://www.mnsu.edu/comdis/isad11/papers/eckardt11.html
(2) Kurt Eggers & Chris De Bal (2006) Speech Dysfluencies in People with Down’s Syndrome Nov. 17, ASHA, Miami Beach (broken link)
(3) David Daley (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” (broken link)
(4) St. Louis, K, Myers, F.L., Bakker, K. (2003) “Cluttering Updated” (2003, Nov. 18) The ASHA Leader, pp 4-5, 20-22; (broken link)
4/7/09
Nonverbal Communication
Persons who stutter (PWS) face the challenge of ‘carryover’ from the very beginning of fluency therapy. The speech language pathologist (SLP) must offer guidance to the PWS regarding how to approach real life with new speech skills. One way to go about this can be to tap into the wealth of information available in the field of social-pragmatic communication. Research in the field of autism spectrum disorders provides detailed descriptions of social skills that will help in the design of carry over treatment goals. For example, I attended a workshop on Asperger’s Syndrome (2) in 2006 that included a 110 point Conversational Effectiveness Profile. Checklists such as this one provide the SLP and PWS with very specific choices from which to craft carry over goals.
Speech therapy for stuttering often emphasizes learning new speech skills along linguistic and speech-motor continuums. This means that practicing easy onset, for example, begins with syllables. Syllables are presumably easy to say because they are brief and have little/no semantic or syntactic demand. I suppose this would be similar to learning finger positions on an instrument. Gradually, the PWS practices his new speech skills in single words, then phrases, then sentences and longer speech tasks. This would be similar to learning chords, then short musical pieces and finally long, complex solos on an instrument.
The social-pragmatic literature draws our attention to the non-verbal aspects of communication that may be equally important in stuttering therapy. (3) Someone learning an instrument may want to play in a concert or jazz band, a string ensemble or perform solo in front of an audience. It seems to me that this requires more than musical talent and technical expertise. Likewise, the PWS wants more than fluency; he wants to communicate with others. He needs to appreciate the larger picture of effective communication. SLPs employed in multi-cultural settings also need to be sensitive to the different communication styles. (4)
Nonverbal communication is “body language.” A more encompassing, professional definition is “nonverbal communication includes those behaviors that are mutually recognized and socially shared codes and patterns with a focus on message meaning.” (1) Subtle and not-so-subtle behaviors communicate specific meanings to our listeners. A subtle raised eyebrow could indicate surprise. Hand waving could mean ‘Hi, I’m glad to see you.’ It depends on the situation, how these are combined with other gestures and perhaps what the speaker is also saying. PWS are sometimes extremely sensitive to the nonverbal signals being sent by listeners. They have seen "the look" so often, that they sometimes expect and percieve rejection from the subtlest of cues. Perhaps a greater understanding of nonverbal communication would help PWS gain a healthier, more resilianet perspective on listeners.
Speech therapy for stuttering often emphasizes learning new speech skills along linguistic and speech-motor continuums. This means that practicing easy onset, for example, begins with syllables. Syllables are presumably easy to say because they are brief and have little/no semantic or syntactic demand. I suppose this would be similar to learning finger positions on an instrument. Gradually, the PWS practices his new speech skills in single words, then phrases, then sentences and longer speech tasks. This would be similar to learning chords, then short musical pieces and finally long, complex solos on an instrument.
The social-pragmatic literature draws our attention to the non-verbal aspects of communication that may be equally important in stuttering therapy. (3) Someone learning an instrument may want to play in a concert or jazz band, a string ensemble or perform solo in front of an audience. It seems to me that this requires more than musical talent and technical expertise. Likewise, the PWS wants more than fluency; he wants to communicate with others. He needs to appreciate the larger picture of effective communication. SLPs employed in multi-cultural settings also need to be sensitive to the different communication styles. (4)
Nonverbal communication is “body language.” A more encompassing, professional definition is “nonverbal communication includes those behaviors that are mutually recognized and socially shared codes and patterns with a focus on message meaning.” (1) Subtle and not-so-subtle behaviors communicate specific meanings to our listeners. A subtle raised eyebrow could indicate surprise. Hand waving could mean ‘Hi, I’m glad to see you.’ It depends on the situation, how these are combined with other gestures and perhaps what the speaker is also saying. PWS are sometimes extremely sensitive to the nonverbal signals being sent by listeners. They have seen "the look" so often, that they sometimes expect and percieve rejection from the subtlest of cues. Perhaps a greater understanding of nonverbal communication would help PWS gain a healthier, more resilianet perspective on listeners.
A narrow view of carry-over, one based on linguistic and speech-motor continuums, is unsatisfactory. The field of social pragmatics is within the scope of practice for SLPs and can be a part of speech therapy for stuttering.
(1) Cicca, A.H., Step, M., & Turkstra, L. (2003, Dec 16). Show me what you mean: Nonverbal communication theory and application. The ASHALeader, pp. 4-5, 34.
(2) Kowalski, Timothy (2006) http://www.socialpragmatics.com/
(3) Volden, J. (2002) Nonverbal Learning Disability: what the SLP Needs to Know
(4) Cheng, L.R. (2007), May 29) Codes and contexts: Exploring linguistic, cultural, and social intelligence. The ASHA Leader, 12(7), 8-9, 32-33.
(2) Kowalski, Timothy (2006) http://www.socialpragmatics.com/
(3) Volden, J. (2002) Nonverbal Learning Disability: what the SLP Needs to Know
(4) Cheng, L.R. (2007), May 29) Codes and contexts: Exploring linguistic, cultural, and social intelligence. The ASHA Leader, 12(7), 8-9, 32-33.
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