Speech science offers clues to managing the problems of stuttering and cluttering.
Speech scientists study how we transform ideas into spoken words. They construct hypothetical models to explain these processes. A recent research development will change my speech therapy. It has to do with a computer model that can actually produce both fluent and stuttered speech. This model suggests that persons who stutter may not have accurate motor commands – feedforward commands – telling the oral motor system what to do. And, another related article proposes that inadequate feedback affects speech. (1) To my mind, this means speech therapy needs to spend a whole lot more time on whatever tasks elicit the most fluency instead of pressing onward to more difficult speaking tasks.
The speech model I am referring to is called the DIVA model. (2) Computer simulations of this model produced stuttered speech when manipulated in very specific ways. I cannot explain the mathematical calculations that caused the speech changes. However, the basic idea is easy to understand…
The DIVA model proposes that our brains issue motor commands to speak. The motor command seems to be for an entire sentence, so as to plan for “co-articulation.” Co-articulation refers to the slight changes we make when pronouncing an /i/, for example, based on what sounds come before and after it. The way we articulate /i/ in the word “mine” is slightly different that the way we articulate /i/ in “fight.” The DIVA model speculates that when a person mispronounces a sound, an internal “speech monitor” tries to correct the error by turning off the voice, “repositioning the articulators,” and starting over again. (3) This causes sound and syllable repetitions.
The ‘speech monitor’ depends on feedback. We rely on feedback for a variety of tasks. When I turn on the water to wash dishes, feedback from my hands tells me if the water is too hot or too cold. I use visual feedback while driving when I look at the speedometer to check how fast I am driving. And when speaking, I rely heavily on auditory feedback to be sure my speech is clear and my words express my message.
The Fall 2010 issue of The Stuttering Foundation newsletter refers to the DIVA model in a front page article, “Feedforward Strategy in Children.” (4) The author explains that he is going to study co-articulation skills in children who stutter to learn more about their speech motor planning skills. If children who stutter show poorer co-articulation skills compared to fluent children, then this would support the theory that inadequate feedforward commands could be to blame. In other words – if this theory is correct - children who stutter find themselves in mid-sentence having to change their articulation of sounds because of faulty motor planning at the very beginning of the sentence.
The April 2010 International Cluttering Awareness Day online conference includes a paper about the DIVA model. It even includes a diagram of the model. This paper suggests that a speaker’s “…feedforward mechanism may be relatively intact, so that he is aware of the appropriate sounds to produce…however, if the feedback system that includes both auditory [hearing] and somatosensory [touch] has not been providing the appropriate feedback, then the feedforward mechanism may be ‘faulty ‘ in that it may not be properly tuned.’” The article recommends a variety of ways to help the speaker increase awareness and improve feedback monitoring.
I’ll continue to experiment with new ways to provide feedback: digital video and audio recordings, delayed auditory feedback, and Audacity® in addition to traditional token reinforcement and verbal praise. But, now I will think in terms of practicing the correct output much more frequently.
also, I will be doing alot more modeling in order to provide the fluent model. Maybe this will help fine-tune the feedforward system. As usual, results will be different for each student. It will be interesting to see what session data reveals.
(1) Leahy, M. (2010) “Monitoring feedback as you speak: how DIVA contributes to explaining a part of the problem of cluttering, and to developing a therapy plan. broken link
(2) Boston University Speech lab broken link
(3) Civier, O. , et. al, (2010) “Overreliance on auditory feedback may lead to sound/syllable repetitions: Simulations of stuttering and fluency-inducing conditions with a neural model of speech production” Journal of Fluency Disorders, 35, p. 266
(4) broken link
11/7/10
9/25/10
Teaching is Finding Success
Children are demanding. They need fun, attractive games that hold their attention. While my speech therapy must be evidence-based and reference professional programs, it also has to be tailored to the needs of individual students. And so I’m always looking for commercially available games and then changing the rules of play so that they transform into speech therapy activities. Sometimes this is on the fly. During a speech therapy session, the parent, child, and I play around with changing game rules so that play is instructional as well as fun.
I recently purchased the game “Pickles to Penguins” (Imaginationgames.com, © 2009) because it looked like a colorful, child-friendly game that was reasonably priced. This blog is a description of how I will use this game to teach. Teaching means giving away the answers! Teaching means finding lots of ways to help a child discover/practice/play with the answers. Many games are packaged as competitive tests. There are time limits, scores, and demands for correct answers. I’ve listed some ways that the “Pickles to Penguins” game will become cooperative and informative.
It is my job to determine appropriate teaching goals through formal testing, observations, and collaborations with school staff and parents. Once goals are defined, I need to know how well the child performs these goals in a teaching activity. If the child performs well (based on a specific criteria), then the goal needs to be changed. There’s no point in teaching something the child already knows. So how will I know if a game is an effective method of teaching?
Before we play our very first game, my student will respond to what is called a “baseline” measure. He will perform the goal behavior without any hints or corrective feedback. I will record how well he achieves this task.
For one particular student, the baseline will be an audio recording (using a small digital recorder and clip mic) of his responses. The cards used for the baseline measure will not be the cards we play with. The cards used for the baseline measure are set aside and used at a later date to measure progress. Next, we will take a different deck of picture cards and begin to modify play based on the student’s responses. We play and play and play!! We change around the game rules and play again! (Don’t I have the best job in the world?)
After a period of time, we return to the cards used in the baseline. Once again, the child performs the goal behaviors without any hints or corrective feedback. If therapy was effective, the child will generalize his new skills to the baseline set of picture cards. His performance after therapy should be of better quality, include more examples of the goal behavior, than his performance at baseline.
Here are some ways we will play with the Pickles to Penguins game cards. I’m sure there are many more ways beside those I’ve listed. Specific fluency goals are added onto to each task, though not listed here.
• Modify the game as needed to achieve success.
o Slow down speech rate to slow the pace of the game
o Increase pause time to provide extra time for speech processing, coming up with ideas, word retrieval to express the ideas, sentence formation, speech production
o Consider bonus points for multiple responses. This will work only if it does not increase frustration or time pressure and if it does not increase competition.
o Use “personal best” scores as a way to be competitive. Encourage players to increase their own scores from previous times they have played.
o Select the number of cards per game based on the attention span and reward needs of the child. Several games using only 20 cards per game may be more fun for a child who needs to finish quickly and see scores improve across games asap.
o Use the same cards over and over again if needed to ensure success. E.g., play 3 times with the same 20 cards, then add 10 more new cards.
o Consider using a timer (like the hour glass or liquid drip timer) as an aid for increasing thinking time…e.g., 1 minute of thinking time is required before responding
o Team/cooperative play is a way to role model
o Plan to use the same answers you came up with together during the Review/Teach process. This will help with long term memory and with increasing success and confidence.
• Review/Teach the cards before playing.
o Spelling:
Take turns holding a card out of sight of the other players, reading the word, asking each player to spell the word aloud or in writing on paper or in the air
Take turns holding a card out of sight of the other players, spelling the word, asking each player to listen to the spelling and guess the word
Sort through the cards together looking for a particular kind of spelling pattern. Be sure to take a few cards and write the words so that this is not just a flash card/recognition activity.
Before reading a card, give a clue, e.g., “This word has the double vowel [ea] in it.” Remember, this is a teaching time and anything that helps correct repetitive practice makes playing fun and effective.
o Segmenting: take turns holding a card out of sight of the other players, read the word by omitting an initial or final sound (or a syllable) and ask the players to listen and guess the word by adding the missing sound
o Meanings: Take turns holding a card out of sight and talking about the picture and ask players to guess what the word is.
o Go through the cards and select which cards would be fun to play with. These will probably be cards that are most familiar and so the first several games should be successful. Be sure to include less popular, more difficult cards in later games.
o Talk about the cards:
Word association: What single word(s) pop into your head when you read each card?
Adjectives: What describing word(s) do you think of when you reach each card?
Put each word in a sentence.
Select 2 or more cards and make a story.
Smell/touch/sound: Think of sensory experiences for each card (donkey feels soft, bean bag chair makes a squishing/crinkling sound when you sit in it)
There are lots of ways to play in multisensory ways. I haven't listed craft, role play, patomime, and music activities . Every teacher has personal preferences and talents that he/she brings to the lesson. Every parent does as well. Bring everyone's strengths to the teaching situation. Have fun!
Vocabulary Instruction for Children and Adolescents With Language Disorders, 2006, ASHA Professional Development Self-Study 7570
I recently purchased the game “Pickles to Penguins” (Imaginationgames.com, © 2009) because it looked like a colorful, child-friendly game that was reasonably priced. This blog is a description of how I will use this game to teach. Teaching means giving away the answers! Teaching means finding lots of ways to help a child discover/practice/play with the answers. Many games are packaged as competitive tests. There are time limits, scores, and demands for correct answers. I’ve listed some ways that the “Pickles to Penguins” game will become cooperative and informative.
It is my job to determine appropriate teaching goals through formal testing, observations, and collaborations with school staff and parents. Once goals are defined, I need to know how well the child performs these goals in a teaching activity. If the child performs well (based on a specific criteria), then the goal needs to be changed. There’s no point in teaching something the child already knows. So how will I know if a game is an effective method of teaching?
Before we play our very first game, my student will respond to what is called a “baseline” measure. He will perform the goal behavior without any hints or corrective feedback. I will record how well he achieves this task.
For one particular student, the baseline will be an audio recording (using a small digital recorder and clip mic) of his responses. The cards used for the baseline measure will not be the cards we play with. The cards used for the baseline measure are set aside and used at a later date to measure progress. Next, we will take a different deck of picture cards and begin to modify play based on the student’s responses. We play and play and play!! We change around the game rules and play again! (Don’t I have the best job in the world?)
After a period of time, we return to the cards used in the baseline. Once again, the child performs the goal behaviors without any hints or corrective feedback. If therapy was effective, the child will generalize his new skills to the baseline set of picture cards. His performance after therapy should be of better quality, include more examples of the goal behavior, than his performance at baseline.
Here are some ways we will play with the Pickles to Penguins game cards. I’m sure there are many more ways beside those I’ve listed. Specific fluency goals are added onto to each task, though not listed here.
• Modify the game as needed to achieve success.
o Slow down speech rate to slow the pace of the game
o Increase pause time to provide extra time for speech processing, coming up with ideas, word retrieval to express the ideas, sentence formation, speech production
o Consider bonus points for multiple responses. This will work only if it does not increase frustration or time pressure and if it does not increase competition.
o Use “personal best” scores as a way to be competitive. Encourage players to increase their own scores from previous times they have played.
o Select the number of cards per game based on the attention span and reward needs of the child. Several games using only 20 cards per game may be more fun for a child who needs to finish quickly and see scores improve across games asap.
o Use the same cards over and over again if needed to ensure success. E.g., play 3 times with the same 20 cards, then add 10 more new cards.
o Consider using a timer (like the hour glass or liquid drip timer) as an aid for increasing thinking time…e.g., 1 minute of thinking time is required before responding
o Team/cooperative play is a way to role model
o Plan to use the same answers you came up with together during the Review/Teach process. This will help with long term memory and with increasing success and confidence.
• Review/Teach the cards before playing.
o Spelling:
Take turns holding a card out of sight of the other players, reading the word, asking each player to spell the word aloud or in writing on paper or in the air
Take turns holding a card out of sight of the other players, spelling the word, asking each player to listen to the spelling and guess the word
Sort through the cards together looking for a particular kind of spelling pattern. Be sure to take a few cards and write the words so that this is not just a flash card/recognition activity.
Before reading a card, give a clue, e.g., “This word has the double vowel [ea] in it.” Remember, this is a teaching time and anything that helps correct repetitive practice makes playing fun and effective.
o Segmenting: take turns holding a card out of sight of the other players, read the word by omitting an initial or final sound (or a syllable) and ask the players to listen and guess the word by adding the missing sound
o Meanings: Take turns holding a card out of sight and talking about the picture and ask players to guess what the word is.
o Go through the cards and select which cards would be fun to play with. These will probably be cards that are most familiar and so the first several games should be successful. Be sure to include less popular, more difficult cards in later games.
o Talk about the cards:
Word association: What single word(s) pop into your head when you read each card?
Adjectives: What describing word(s) do you think of when you reach each card?
Put each word in a sentence.
Select 2 or more cards and make a story.
Smell/touch/sound: Think of sensory experiences for each card (donkey feels soft, bean bag chair makes a squishing/crinkling sound when you sit in it)
There are lots of ways to play in multisensory ways. I haven't listed craft, role play, patomime, and music activities . Every teacher has personal preferences and talents that he/she brings to the lesson. Every parent does as well. Bring everyone's strengths to the teaching situation. Have fun!
Vocabulary Instruction for Children and Adolescents With Language Disorders, 2006, ASHA Professional Development Self-Study 7570
9/22/10
New Beginnings: Stress & Relaxation
A few of my students are beginning this academic year in new settings. Two are freshmen in college, one nearby and one quite far away. Two students are beginning middle school. And my own son began this year at a new school. The transition is stressful and can be downright frightening.
The middle school day is divided into periods. Students move from classroom to classroom, encountering a different teacher for each subject. Peers shuffle in the hallways, reconfiguring into distinct groups for each class. Time is limited to 5 minutes or less between classes during which padlocks on lockers must be opened, books retrieved, and quick friendly greetings exchanged if one is lucky enough to see friends passing by in the hall. Lunch is rushed and squeezed into a range of time slots so that it may be brunch one day and a mid-afternoon snack on another. When does one get to the bathroom!? And middle school means homework in several subjects to keep track of, including short and long term projects, quizzes and tests, and worksheets of various degrees of difficulty.
College takes all these changes and magnifies them. Now classes are in different buildings scheduled across days and include term papers and exams covering months of material. Peers may include students from other cities, other states, maybe even other countries. Living away from home requires multiple attempts at an independent healthy lifestyle: eating nutritious meals, getting enough sleep, managing time and making safe choices.
It’s all very exciting!
The adjustment process takes trial and error, success and failure, elation and pain, hard work, self-confidence and faith. I suppose there are lots of ways to approach dramatic changes such as these. Relaxation techniques may be helpful for some people. I mention this because a mom recently asked me if relaxation techniques would help her child’s speech. And so, I took a look around for some quick and easy suggestions.
There are different kinds of relaxation techniques that all seem to have the same general goal – to consciously and deliberately find a feeling relaxation to replace feelings of stress. Relaxation techniques take only 10 minutes or so and, with practice, can help us to relax almost any time we need to “calm down”, focus, think more clearly, and behave more carefully. Stuttering is not caused by stress, but, stuttering can be affected by stress. It can be easier to focus on speech and communication when we are more relaxed.
A surf through YouTube revealed. . .
Here is a simple video that describes how watching clouds can lead to a feeling of relaxation:
http://www.youtube.com/watch?v=P-ygq1W681A&feature=related
Here is a video of rain: http://www.youtube.com/watch?v=NgG4vDfcJek&feature=related
Here’s one that takes you through progressive relaxation:
http://www.youtube.com/watch?v=HFwCKKa--18
I make it a point to stop for about 15 minutes every day and just sit. When I’m lucky, I sit outside. Sometimes I write down the to-do list that perpetually crowds my thoughts. Released from this burden, I begin to hear the subtle sounds around me and then notice the more substantive ideas lurking between my ears. Back and forth I go: notice the rustle of leaves, eliminate a task I don’t reeeally need to do, feel the sun, re-prioritize projects, notice my breath, remember to write a friend, and relax into the important over the urgent.
I wish for my students to have faith in themselves and to act in new ways that will keep them to be healthy, safe, and successful.
The middle school day is divided into periods. Students move from classroom to classroom, encountering a different teacher for each subject. Peers shuffle in the hallways, reconfiguring into distinct groups for each class. Time is limited to 5 minutes or less between classes during which padlocks on lockers must be opened, books retrieved, and quick friendly greetings exchanged if one is lucky enough to see friends passing by in the hall. Lunch is rushed and squeezed into a range of time slots so that it may be brunch one day and a mid-afternoon snack on another. When does one get to the bathroom!? And middle school means homework in several subjects to keep track of, including short and long term projects, quizzes and tests, and worksheets of various degrees of difficulty.
College takes all these changes and magnifies them. Now classes are in different buildings scheduled across days and include term papers and exams covering months of material. Peers may include students from other cities, other states, maybe even other countries. Living away from home requires multiple attempts at an independent healthy lifestyle: eating nutritious meals, getting enough sleep, managing time and making safe choices.
It’s all very exciting!
The adjustment process takes trial and error, success and failure, elation and pain, hard work, self-confidence and faith. I suppose there are lots of ways to approach dramatic changes such as these. Relaxation techniques may be helpful for some people. I mention this because a mom recently asked me if relaxation techniques would help her child’s speech. And so, I took a look around for some quick and easy suggestions.
There are different kinds of relaxation techniques that all seem to have the same general goal – to consciously and deliberately find a feeling relaxation to replace feelings of stress. Relaxation techniques take only 10 minutes or so and, with practice, can help us to relax almost any time we need to “calm down”, focus, think more clearly, and behave more carefully. Stuttering is not caused by stress, but, stuttering can be affected by stress. It can be easier to focus on speech and communication when we are more relaxed.
A surf through YouTube revealed. . .
Here is a simple video that describes how watching clouds can lead to a feeling of relaxation:
http://www.youtube.com/watch?v=P-ygq1W681A&feature=related
Here is a video of rain: http://www.youtube.com/watch?v=NgG4vDfcJek&feature=related
Here’s one that takes you through progressive relaxation:
http://www.youtube.com/watch?v=HFwCKKa--18
I make it a point to stop for about 15 minutes every day and just sit. When I’m lucky, I sit outside. Sometimes I write down the to-do list that perpetually crowds my thoughts. Released from this burden, I begin to hear the subtle sounds around me and then notice the more substantive ideas lurking between my ears. Back and forth I go: notice the rustle of leaves, eliminate a task I don’t reeeally need to do, feel the sun, re-prioritize projects, notice my breath, remember to write a friend, and relax into the important over the urgent.
I wish for my students to have faith in themselves and to act in new ways that will keep them to be healthy, safe, and successful.
8/3/10
Hope
“Experiences cause structural changes in the brain, sculpting synapses in profound ways. This ‘plasticity’ of the brain has been demonstrated by neuroscientists over the past decades.” (p. 189-190). This statement, which I have taken from the book The Anatomy of Hope,* is a crucial concept in speech therapy. It justifies the therapeutic process. There are times when the small step-by-step process of speech change seems to take so very long. But we persist because we expect to alter speech production pathways in the brain.
Let’s imagine, for the sake of simplicity, that neurons in the brain are organized like a road map. This is an analogy that children may understand. Some children spend a lot of time traveling short distances to sports and school events or long distances to vacation spots. Parents teach map skills by highlighting routes and talking about roadways, exit numbers, and geography. Stuttered speech is like driving on a bumpy road in rush-hour traffic! It can be uncomfortable, stressful, stop-and-go, include wrong turns, and involve some unpleasant interactions with others.
Speech therapy is road construction. The child, parent, SLP and other helpers, team up to build new roads along which a child’s ideas can travel through his brain to his mouth more easily. The new roads, the new neural pathways, take time to build and are constructed with care. During this construction phase, it is the expectation of a better road, the hope of an easier route, that helps us to be patient with the process.
In The Anatomy of Hope, the author seems to say that hope is essential to change. “Hope can arrive only when you recognize that there are real options and that you have genuine choices. Hope can flourish only when you believe that what you do can make a difference, that your actions can bring a future different from the present. To have hope, then, is to acquire a belief in your ability to have some control over your circumstances. You are no longer entirely at the mercy of forces outside yourself.” (p. 26)
Stuttering involves loss of control. Stuttered sounds seem to occur at random and then much later appear to be predictable on letters such as /b/, /s/, or /g/. This loss of control leads to struggle, anticipation anxiety, and avoidances. Listeners don’t understand what’s going on or know what to do and soon the person who stutters finds entire conversations out of his control. Some outside force, unknown even to the experts, wreaks havoc with speech and communication.
SLPs have no cure. Yet, they do offer hope in the form of speech therapy that encourages self-acceptance, behavioral changes, and ways to educate listeners. SLPs must convey the multiple messages: we can’t “fix” you (you are not broken) but we can give you reasons to hope for improvement. We cannot minimize the effort that will be required. We prepare for a speech therapy process that involves education, experimentation, trial and error, team work, persistence, and hope.
In The Anatomy of Hope, there is one cancer patient in particular who is also a cancer doctor. He selects an extremely intensive series of treatments that no doctor would ever recommend because of the debilitating side effects and uncertain results. This patient/doctor explains, “’I knew all the arguments made in cases like mine…I find these arguments patronizing…Most patients don’t really understand what’s happening to them… because they’re not clearly told the odds by their doctors…I, of course, had a crystal-clear understanding of my chances. And it was my right to choose what I did.” (p. 75)
This doctor was cured and later “he visited cancer patients in the hospital who were losing hope. He was an inspiration. His survival showed them that there is inherent uncertainty in the behavior of even the worst diseases…He sought to assist people in making choices that addressed their own particular needs, desires, and beliefs.” (p. 78)…To hope under the most extreme circumstances is an act of defiance that…permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.” (p. 81)
After much research into the concept of hope, Dr. Groopman suggests that realism plus positive physiological change is necessary to achieve positive emotional change. Therefore, he recommends that early treatment be designed to give patients some kind of immediate physiological improvement. With this in mind, I am spending more time encouraging my students to complete very simple, very successful speaking tasks at the beginning and at the end of every session whenever possible. I am relaxing my own, egocentric, need to see “progress” along any hierarchy, so that the student can experience speech success at whatever level that might be.
“Kindling and sustaining hope depend not only on images that may be conjured in the mind but also on how those images are brought into focus or blurred by the ongoing input of nerves from organs and tissues to the brain.” (p. 181) Students must experience success and understand how they were responsible for it. If SLPs push too hard, our students may experience more failure than success. Given the messages in The Anatomy of Hope, perhaps whatever cognitive therapy approaches we favor might be most effective when accompanied by carefully planned behavioral training that ensures speech change, even if that means slower “progress” along a hierarchy. Let’s remember that speech therapy is for the student’s benefit, not the SLP’s need to document professional competence.
*Jerome Groopman, M.D. (2005) The Anatomy of Hope: How People Prevail in the Face of Illness, NY, NY: Randomhouse, Inc.
Let’s imagine, for the sake of simplicity, that neurons in the brain are organized like a road map. This is an analogy that children may understand. Some children spend a lot of time traveling short distances to sports and school events or long distances to vacation spots. Parents teach map skills by highlighting routes and talking about roadways, exit numbers, and geography. Stuttered speech is like driving on a bumpy road in rush-hour traffic! It can be uncomfortable, stressful, stop-and-go, include wrong turns, and involve some unpleasant interactions with others.
Speech therapy is road construction. The child, parent, SLP and other helpers, team up to build new roads along which a child’s ideas can travel through his brain to his mouth more easily. The new roads, the new neural pathways, take time to build and are constructed with care. During this construction phase, it is the expectation of a better road, the hope of an easier route, that helps us to be patient with the process.
In The Anatomy of Hope, the author seems to say that hope is essential to change. “Hope can arrive only when you recognize that there are real options and that you have genuine choices. Hope can flourish only when you believe that what you do can make a difference, that your actions can bring a future different from the present. To have hope, then, is to acquire a belief in your ability to have some control over your circumstances. You are no longer entirely at the mercy of forces outside yourself.” (p. 26)
Stuttering involves loss of control. Stuttered sounds seem to occur at random and then much later appear to be predictable on letters such as /b/, /s/, or /g/. This loss of control leads to struggle, anticipation anxiety, and avoidances. Listeners don’t understand what’s going on or know what to do and soon the person who stutters finds entire conversations out of his control. Some outside force, unknown even to the experts, wreaks havoc with speech and communication.
SLPs have no cure. Yet, they do offer hope in the form of speech therapy that encourages self-acceptance, behavioral changes, and ways to educate listeners. SLPs must convey the multiple messages: we can’t “fix” you (you are not broken) but we can give you reasons to hope for improvement. We cannot minimize the effort that will be required. We prepare for a speech therapy process that involves education, experimentation, trial and error, team work, persistence, and hope.
In The Anatomy of Hope, there is one cancer patient in particular who is also a cancer doctor. He selects an extremely intensive series of treatments that no doctor would ever recommend because of the debilitating side effects and uncertain results. This patient/doctor explains, “’I knew all the arguments made in cases like mine…I find these arguments patronizing…Most patients don’t really understand what’s happening to them… because they’re not clearly told the odds by their doctors…I, of course, had a crystal-clear understanding of my chances. And it was my right to choose what I did.” (p. 75)
This doctor was cured and later “he visited cancer patients in the hospital who were losing hope. He was an inspiration. His survival showed them that there is inherent uncertainty in the behavior of even the worst diseases…He sought to assist people in making choices that addressed their own particular needs, desires, and beliefs.” (p. 78)…To hope under the most extreme circumstances is an act of defiance that…permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.” (p. 81)
After much research into the concept of hope, Dr. Groopman suggests that realism plus positive physiological change is necessary to achieve positive emotional change. Therefore, he recommends that early treatment be designed to give patients some kind of immediate physiological improvement. With this in mind, I am spending more time encouraging my students to complete very simple, very successful speaking tasks at the beginning and at the end of every session whenever possible. I am relaxing my own, egocentric, need to see “progress” along any hierarchy, so that the student can experience speech success at whatever level that might be.
“Kindling and sustaining hope depend not only on images that may be conjured in the mind but also on how those images are brought into focus or blurred by the ongoing input of nerves from organs and tissues to the brain.” (p. 181) Students must experience success and understand how they were responsible for it. If SLPs push too hard, our students may experience more failure than success. Given the messages in The Anatomy of Hope, perhaps whatever cognitive therapy approaches we favor might be most effective when accompanied by carefully planned behavioral training that ensures speech change, even if that means slower “progress” along a hierarchy. Let’s remember that speech therapy is for the student’s benefit, not the SLP’s need to document professional competence.
*Jerome Groopman, M.D. (2005) The Anatomy of Hope: How People Prevail in the Face of Illness, NY, NY: Randomhouse, Inc.
7/25/10
Carryover at the Restaurant
Here is one way to go about carryover for ordering food:
• The numbers below are a rough scale estimate of how difficult each task is. For example, we know that talking at the same time that other people are talking is usually the easiest, so, “choral speech” is #1.
• Some places, such as the speech therapy room, are easy places to focus on speech goals. There are few fluency disrupters, little time pressure, and sensitive listeners at speech therapy. Other places have more time pressure, insensitive listeners or more difficult language demands. The ratings should be changed to reflect individual speech experiences. Then, beginning with the easiest choices, one can design carryover homework.
• The adult helper should prepare the child for each assignment. The adult talks about what will happen and rehearses the homework with the child.
• The adult is also responsible for resisting time pressure. To do this, the adult adds lots of pause time into the conversation, trying to make these delays as natural as possible. For example, when a waitress asks, “Can I help you?” the adult could say a friendly “uuuumm” while making it look like he/she needs just a few more seconds to decide what to order. Pauses like this deliberately slow down the pace of the conversation so that the child who stutters feels less time pressure. Then, a secret signal to the child indicates its time to talk. For example, after a few seconds, the adult might look at the child, smile and nod. After this special nod, the child and adult together look at the waitress and say their rehearsed lines.
Speech
#1. Choral Speech: The child and one or more others say the same words at the same time. For example, together they say, “I want a small ice cream cone, please.” Because the purpose here is to be successful at ordering something to eat, everyone doing this has to agree to order the same thing. Maybe the only person willing to help out is a parent who doesn’t mind getting the same ice cream as the child just so that the child can complete this homework assignment! If no one is willing to order the same thing as the child, then, immediately after ordering, the helper can change his/her mind and say, “Oh wait, I want a large ice cream.” This may also mean spending a few extra dollars for speech practice. An adult helper may not really want to order anything, but orders just to help the child have a successful speech experience.
#2. Choral Speech & fill-in-the-rest-of-the-sentence: The child and one or more others say the same beginning words of a sentence only. Then, child finishes the sentence alone. For example, the child and other(s) might say together, “I want a…” and then, the adult pauses naturally as if trying to decide while the child says all by himself “… small vanilla.”
#3. Changing the sentence: Use strategy #2 or #3 and say something different. For example, if you spent a week saying “I want a…”, then spend the next week saying “Do you have…? Of course, you may already know that the restaurant has what you are asking about. That doesn’t matter because what you are really doing is speech practice. If you are successful with saying “Do you have…?” for a week, trying using a different sentence each day of the following week. Note: you will be doing a lot of ordering so that you can do a lot of speech practice, so you might want to order something inexpensive!
#4. Imitated speech: The adult helper models the sentence; then, the child imitates most of the model to order independently. For example, an adult helper could say, “Do you want a vanilla?” and then the child looks at the waitress and says, “I want a vanilla.” Note: The adult needs to model whatever strategies the child uses. So, the adult might slightly slow down their speech rate and add easy onsets, continuous voicing and phrasing and ask the question like this, “Doooyouwant / aaavanilla?”
Most of all, try to have fun with this; that will help reduce anxiety!!!!
• The numbers below are a rough scale estimate of how difficult each task is. For example, we know that talking at the same time that other people are talking is usually the easiest, so, “choral speech” is #1.
• Some places, such as the speech therapy room, are easy places to focus on speech goals. There are few fluency disrupters, little time pressure, and sensitive listeners at speech therapy. Other places have more time pressure, insensitive listeners or more difficult language demands. The ratings should be changed to reflect individual speech experiences. Then, beginning with the easiest choices, one can design carryover homework.
• The adult helper should prepare the child for each assignment. The adult talks about what will happen and rehearses the homework with the child.
• The adult is also responsible for resisting time pressure. To do this, the adult adds lots of pause time into the conversation, trying to make these delays as natural as possible. For example, when a waitress asks, “Can I help you?” the adult could say a friendly “uuuumm” while making it look like he/she needs just a few more seconds to decide what to order. Pauses like this deliberately slow down the pace of the conversation so that the child who stutters feels less time pressure. Then, a secret signal to the child indicates its time to talk. For example, after a few seconds, the adult might look at the child, smile and nod. After this special nod, the child and adult together look at the waitress and say their rehearsed lines.
Speech
#1. Choral Speech: The child and one or more others say the same words at the same time. For example, together they say, “I want a small ice cream cone, please.” Because the purpose here is to be successful at ordering something to eat, everyone doing this has to agree to order the same thing. Maybe the only person willing to help out is a parent who doesn’t mind getting the same ice cream as the child just so that the child can complete this homework assignment! If no one is willing to order the same thing as the child, then, immediately after ordering, the helper can change his/her mind and say, “Oh wait, I want a large ice cream.” This may also mean spending a few extra dollars for speech practice. An adult helper may not really want to order anything, but orders just to help the child have a successful speech experience.
#2. Choral Speech & fill-in-the-rest-of-the-sentence: The child and one or more others say the same beginning words of a sentence only. Then, child finishes the sentence alone. For example, the child and other(s) might say together, “I want a…” and then, the adult pauses naturally as if trying to decide while the child says all by himself “… small vanilla.”
#3. Changing the sentence: Use strategy #2 or #3 and say something different. For example, if you spent a week saying “I want a…”, then spend the next week saying “Do you have…? Of course, you may already know that the restaurant has what you are asking about. That doesn’t matter because what you are really doing is speech practice. If you are successful with saying “Do you have…?” for a week, trying using a different sentence each day of the following week. Note: you will be doing a lot of ordering so that you can do a lot of speech practice, so you might want to order something inexpensive!
#4. Imitated speech: The adult helper models the sentence; then, the child imitates most of the model to order independently. For example, an adult helper could say, “Do you want a vanilla?” and then the child looks at the waitress and says, “I want a vanilla.” Note: The adult needs to model whatever strategies the child uses. So, the adult might slightly slow down their speech rate and add easy onsets, continuous voicing and phrasing and ask the question like this, “Doooyouwant / aaavanilla?”
Most of all, try to have fun with this; that will help reduce anxiety!!!!
6/17/10
Wild Speech Monsters
It can be helpful for some children to illustrate their stuttering. This gives them a way to separate the behavior called stuttering from who they are as people. The child stutters - it is something that he/she does, not something that is inherently a part of who the child is. With this approach to therapy, the child takes the stuttering and puts it outside of him/herself in the form of a picture, sculpture, craft, or project. Some children may make friends with this depiction and negotiate a truce as his/her speech improves. Some children may benefit from releasing anger and frustration at it by destroying it in some way, such as smashing a playdo figure or ripping up a drawing. In both cases, children may experience a greater sense of control over their 'speech monster.' *
Where the Wild Things Are, the original cartoon version of the book, could be a helpful story when teaching this point of view. One simple description of the story is that a little boy finds a way to manage his angry emotions. They are monsters that he tames, plays with, and leaves behind. Perhaps in the same way, we can teach children to play with and tame their speech.
*http://www.mnsu.edu/comdis/isad7/papers/shields7.html
6/9/10
Scaffolding
"Scaffolding" is support. In education, scaffolding refers to the amount and type of supports children need to succeed. (1) In speech therapy for stuttering, scaffolding, to my way of thinking, is when a parent schedules time for speech homework, praises a child's efforts, looks for creative ways to practice speech goals, offers tangible rewards, asks about her child's feelings, helps him plan for speaking situations and educates others about stuttering.
Scaffolding occurs at every level of a hierarchy of goals. Practicing 'slow/gentle sounds' (my term for easy onset) at the one-word level is one step in a hierarchy. At the one-word level, a child completes a variety of speech therapy activities. Hopefully, the activities are designed to be games that parent and child play together. In my practice, these games include language processing tasks: auditory memory, phonological processing, word finding, vocabulary building, auditory comprehension and reading. There are many possible activities at each level of a hierachy.
The rules of each therapy game describe how the adult will provide scaffolding. Before a child responds, the adult gives a prompt. The prompt is a form of scaffold. The prompt may be a direct instruction like, "use slow/gentle beginning sounds." When the child is able to use slow/gentle sounds more automatically, instructions become less direct. The adult may only need to say something like, "Let's play a speech game." The fact that it is a speech game will cue the child to use whatever skill she is practicing. After a child responds, the adult gives some kind of feedback about the correctness of that response. The feedback is a form of scaffold. It is often a token. Tokens come in many forms: pennies, check marks, stickers. How much and how often a child earns tokens gradually diminishes and tokens are replaced by verbal praise.
Scaffolding should also increase empowerment and independence. For example, there will be times when the parent determines the time for speech homework and sits down with her child to compete activities together. Then, gradually the parent does something else, such as making dinner, while the child performs speech homework in the same room as the adult. (Stuttering varies with each speaking situation, so, homework should almost never be completed alone. The child needs to talk with someone while practicing speech skills.) Eventually the child should be responsible for approaching her parent and saying, "Let's play a speech game now." It is important for a child to learn to take responsibility for his own speech homework, because there will come a time when he will need to choose when to try out his new speech skills in everyday life.
This concept of scaffolding in my own life became apparent when I attended a student's graduation party. This young man's progress was accomplished with the assistance of other speech language pathologists in addition to myself. So, I was surprised to learn that I'd made an significant difference in his life and I was delighted to be invited to his family celebration. But I was also anxious because I am not a 'party person.' I really enjoy one-on-one and small group interactions, but fail at larger group gatherings. I typically hover at the fringe at such occasions and eventually meet other guests doing the same. An additional complication for this event was that I would need to avoid any break in patient confidentiality. After introducing myself, I would have to dodge any questions about what this student and I had done in speech therapy.
I was the first to arrive. That meant I could share his parents' pride right away. As more guests arrived, I soaked up the sunny afternoon in what was a beautiful location and sampled from a delicious buffet. After a while, it became apparent that the adults were distancing themselves from the teens by gathering on an elevated deck. I realized that finding my conversational partner(s) was going to be too much of a challenge with this arrangement. After some time, someone offered me the scaffolding I needed by bringing two guests over to chat with me. I appreciated this gesture and shared in several minutes of conversation. When these guests said their goodbyes so did I. This was a carefully prepared party, but I needed more scaffolding in order to mix with the other adult guests. But, then again, this was a family affair, and there really was no need for me to linger long. I left satisfied with my visit and gratified to have made a difference in someone's life. Its what all SLPs truly hope to do.
(1) broken link
Scaffolding occurs at every level of a hierarchy of goals. Practicing 'slow/gentle sounds' (my term for easy onset) at the one-word level is one step in a hierarchy. At the one-word level, a child completes a variety of speech therapy activities. Hopefully, the activities are designed to be games that parent and child play together. In my practice, these games include language processing tasks: auditory memory, phonological processing, word finding, vocabulary building, auditory comprehension and reading. There are many possible activities at each level of a hierachy.
The rules of each therapy game describe how the adult will provide scaffolding. Before a child responds, the adult gives a prompt. The prompt is a form of scaffold. The prompt may be a direct instruction like, "use slow/gentle beginning sounds." When the child is able to use slow/gentle sounds more automatically, instructions become less direct. The adult may only need to say something like, "Let's play a speech game." The fact that it is a speech game will cue the child to use whatever skill she is practicing. After a child responds, the adult gives some kind of feedback about the correctness of that response. The feedback is a form of scaffold. It is often a token. Tokens come in many forms: pennies, check marks, stickers. How much and how often a child earns tokens gradually diminishes and tokens are replaced by verbal praise.
Scaffolding should also increase empowerment and independence. For example, there will be times when the parent determines the time for speech homework and sits down with her child to compete activities together. Then, gradually the parent does something else, such as making dinner, while the child performs speech homework in the same room as the adult. (Stuttering varies with each speaking situation, so, homework should almost never be completed alone. The child needs to talk with someone while practicing speech skills.) Eventually the child should be responsible for approaching her parent and saying, "Let's play a speech game now." It is important for a child to learn to take responsibility for his own speech homework, because there will come a time when he will need to choose when to try out his new speech skills in everyday life.
This concept of scaffolding in my own life became apparent when I attended a student's graduation party. This young man's progress was accomplished with the assistance of other speech language pathologists in addition to myself. So, I was surprised to learn that I'd made an significant difference in his life and I was delighted to be invited to his family celebration. But I was also anxious because I am not a 'party person.' I really enjoy one-on-one and small group interactions, but fail at larger group gatherings. I typically hover at the fringe at such occasions and eventually meet other guests doing the same. An additional complication for this event was that I would need to avoid any break in patient confidentiality. After introducing myself, I would have to dodge any questions about what this student and I had done in speech therapy.
I was the first to arrive. That meant I could share his parents' pride right away. As more guests arrived, I soaked up the sunny afternoon in what was a beautiful location and sampled from a delicious buffet. After a while, it became apparent that the adults were distancing themselves from the teens by gathering on an elevated deck. I realized that finding my conversational partner(s) was going to be too much of a challenge with this arrangement. After some time, someone offered me the scaffolding I needed by bringing two guests over to chat with me. I appreciated this gesture and shared in several minutes of conversation. When these guests said their goodbyes so did I. This was a carefully prepared party, but I needed more scaffolding in order to mix with the other adult guests. But, then again, this was a family affair, and there really was no need for me to linger long. I left satisfied with my visit and gratified to have made a difference in someone's life. Its what all SLPs truly hope to do.
(1) broken link
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