This is the text for a 3-hour workshop for Speech Language Pathologists in the schools. The slides are "Workshop Slides" at (this has been removed.)
Thank you very much for inviting me
to your school to talk about stuttering. Let’s begin by watchingStuttering for Kids by Kids. There is a
link to this video later in the side presentation.
In 1997 my family and I moved and it was then
that I decided to limit my private practice to stuttering. I was trying to
continue in speech language pathology while learning to live in a new location
and parent a toddler. I became
an ASHA Board Recognized Specialist in 2000. This new specialty was renewed every
three years with continuing education credits and at least 100 hours/year of
clinical work in stuttering. ASHA changed the name, requirements and renewal
process in 2014. I am now called a Board
Certified Specialist in Fluency and must renew every 5 years.
I am not
a professor. They know much, much more about stuttering than I do.
What I hope to do in this brief, introductory workshop is to share a clinical
perspective based on years of experience working with children who stutter. I
have attended several National Stuttering Association conferences, published in
the International Stuttering Awareness Day online conferences, read our ASHA
journals and written a blog. This is my present understanding of
stuttering. I feel like the messenger. I'm hoping to inspire you to learn more about stuttering
and become more comfortable treating and advocating for the children who
stutter who attend your school.
Each student presents a new
challenge. I revisit familiar material and look for research to support all of my treatment recommendations. It almost
never feels like I can use a ‘one size
fits all’ approach. Because there were many days when I felt as if I was reinventing the wheel, I started writing
my thoughts down. In the beginning, these were published in Reaching Out, the newsletter of Friends:
The Association for Young People Who Stutter. I later compiled many of these articles in a
self-published book called Becoming a
Friend in 2002 and donated it to Friends. At that time, I was inspired by
my friend Nancy Cohen and one of my students. I felt the need to write again in 2008 and
began a blog, Comments on Speech Therapy
as a personal reference. It helped me to keep track of issues I wrestled with
respect to different cases.
Slide 3
This may
be the most important concept in stuttering treatment. Stuttering is no one's fault. Stuttering appears to be a
neurologically based disorder. Until a child develops anticipation anxiety, it can
be fairly unpredictable. And so we need to be cautious about expectations for
fluency. The moment of stuttering is something that we don’t understand. We do
not know what causes the repetition, prolongation or block.
There is research linking
stuttering with length and complexity of spoken language, emotional reactivity,
stability of the speech motor system and attention. Researchers think there may
be subgroups of the disorder. Since I’m not the best person to talk about
research studies, I’ll stop there and encourage you to choose a reference
article that interests you from my blog or from the references section of my therapy
training manual.
Slide 5
There
are many valuable resources on the market. These are just the ones that I
happened to use and are referenced in my own therapy manual. I just bought a
brand-new therapy text by Yaruss & Reeves. It isn’t listed here because I just haven't had a
chance to read it yet.
Slide 6
Here are some additional excellent
resources. The Stuttering Foundation produces
a variety high-quality materials in multiple languages. Some are even available
as free downloads. The National
Stuttering Association is a support organization with chapters
throughout the United States. StutterTalk is a podcast hosted by a speech language
pathologist. The Stuttering
Homepage is a website with lots of materials and a link to the archived International Stuttering Awareness Day
Online Conferences. Several years ago, I started a Google site as a personal
resource. This is a link to one of the pages of that site. And finally, I write
a blog called Comments on Speech Therapy
.
Slide 7
I have
been working on a speech therapy manual so that I can easily locate materials I
find most helpful. Eventually, I hope to sell the workbook as a companion text
for therapy and for school workshops. It needs alot more work before I can
do that, so I’ve provided draft copies by email and on CD for free. There are
many good books about stuttering on the market that stand alone as wonderfully
thorough resources and I definitely defer to those texts.
I’ll be
adding a section about self advocacy to
my manual soon because I recently created a classroom presentation. You can
find it in the lesson ideas page of
my website. Students occasionally write
a report about stuttering for school, but
never has one of my students been willing to make a presentation – until
this year. One gifted and courageous student asked how to put one together
for a 5th grade class. We
spent many sessions talking about it. He blended his own thoughts and style
with some of my input to create a truly collaborative project.
Slide 8 - 10 minute group activity
Slide 9 (therapy manual page 40)
This slide reminds us that typically
fluent speech is complex. 1.) When a person has an idea, the brain has so much
to do! 2.) It selects words using the
phonology (including the local accent) of a language. The words are organized
in sentences using the grammatical rules of the his language and
situation. And let’s not forget intonation, loudness and
turn-taking choices. All of this is presented in a socially appropriate manner.
Nonverbal behavior such personal space, gesture and eye contact will accompany
the verbal message. 3.) A motor plan
will program the body to produce
pitch, loudness, co-articulation and breath groups for phrasing, syllable-
and word- emphasis ...all at a very fast speeds! 4.) The idea, the language and
the motor plan will coordinate into an action sequence that can even withstand
environmental interruptions! 5.) All of
this is monitored within and without our awareness.
Of course many other important
systems need separate diagrams. For example, listening skills are important because some researchers feel
auditory processing maybe implicated in stuttering.
Slide 10
Here are
a few handy links for a review of speech production
Slide 11
This slide reminds us that stuttering
is also complicated. On page 46, we see one theoretical basis for treatment.
The point here is that stuttering is now considered a disorder influenced by
many possible factors. As we think about the child sitting with us, we wonder
how various parts of this model may apply to that child. Immediately, we begin
to question if asking a child to reduce percentage of stuttering is realistic
given that so many other variables influence the presence of stuttering.
Slide 12
Let's think about how we can update therapy.
Back when I was in college, we learned to count stuttered words and praise children for reducing frequency of
stuttering. Now we must consider how
this approach could foster guilt, fear and shame. Stuttering is a neurological
in nature and potentially affected by
many other issues, some of which are clearly beyond our control. How often are
we ourselves aware of co-articulation when we talk!
Yet, we
ask children to change how they talk and thereby reduce stuttering. In
response, some children discover that
avoidance is an effective way to stop stuttering. You can’t stutter if
you don’t talk. Children can also avoid sounds and words, by using synonyms or otherwise
revising their message. Other children discover secondary behaviors that seem
to make talking easier. The child with negative feelings about stuttering can
find ways to hide it or fight it.
On the other hand, if we encourage
children to examine their speech and how it affects them, I believe we have the
opportunity to prevent the development of a larger communication problem. We
can teach children about speech and language, about stuttering in a non
judgmental way, options for change and owning the process of improved
communication. What does this all mean?
Slide 13
Some people describe stuttering as an
ice berg. Above the surface of the water we see a very small portion of the
iceberg. This portion is the bumpy speech. Below the surface of the water is a
much larger portion of the iceberg and represents the feelings and thoughts
that are hidden from view but has the potential to become a significant portion
of the stuttering problem. For the child who stutters, these feelings translate
into behaviors such as avoiding class participation, avoiding the telephone and
enduring teasing and bullying that an adult may or may not witness. Also below
the surface are feelings of failure when parents ask why children will not use speech
strategies in daily life. There is a parent who writes a blog called Voice Unearthed who addresses these
kinds of problems.
Slide 14
I'm not
too sure why I placed this slide here. Perhaps it is because now that we have
upgraded our understanding of stuttering, we can think about how we treat it
from the very earliest years. We begin with genetics because research presumes
there is a predisposition to stutter. Furthermore, as with other
conditions, environment plays a role. The child with speech language planning
and production weaknesses, the child with greater emotional reactivity and
difficulty with self regulation, the child who experiences difficulty with
communication, and the child who reacts negatively to the stuttering may have a
more difficult experience with stuttering. Of course I am simplifying. Exactly
how one or more of these factors influence one another is a mystery. We do not
know the cause of stuttering but we have some ideas about how it might become a
persistent and disabling condition for some children.
Slide 15
For additional information about
treatment of developmental stuttering in preschoolers, please refer to
the pages listed on the slide. Please note that I have not included the Lidcomb
Program. I am not trained in that protocol and feel I should not comment it.
Slide 16
If we
are not going to ask children to reduce stuttering what are we going to
do? Well, teach them strategies to help reduce oral-motor tension, help them to
understand their own communication needs and the process of change, and help
them feel confident about saying what they need to say when they need to say
it. By the way, this does not mean speech-language pathologists stop counting
stuttered words. But it is no longer our sole or even our top priority. We
pursue easier speech, positive affect and productive thinking regarding the
child's communication needs. This means that we measure and treat
speech-motor, cognitive and affective issues in our therapy
activities.
Slide 17
demonstration
of reduced rate, phrasing, easy onset, gentle voluntary stuttering, freezing,
pullout, cancellation, natural prosody, non-verbal communication, confidence;
comment that these strategies can feel more awkward than stuttered speech
Slide 18
Children 8 and older can talk about
typical speech, stuttering, acceptance, avoidance and concomitant disorders in
a more explicit way. You already do this in treatment for other communication
problems. You take care to consider the unique needs of each individual student
and you can do the same for children who stutter. Please refer to the many
inexpensive and wonderful training DVDs produced by the Stuttering Foundation
for more information. Also there are brand new books about teasing and bullying
at the National Stuttering Association website.
Slide 19
You
already know how to use a hierarchy for learning other speech language
behaviors. I don't know of any skill that can be learned overnight and yet
parents and teachers expect immediate carryover of new speech skills. Why is
this? I once had a conversation with a parent who worked as a school aide
and who did not know I was a speech language pathologist. She said she thought
speech therapy was a fraud because the children she saw were not improving
speech skills in the classroom!! We need to remind others that any skill takes
time to learn and it is no different for children in speech therapy.
Speech
strategies and counseling are explained on Stuttering Foundation DVDs.
Participation in social and academic settings can reference the literature on
pragmatic language. If you read the stories children tell in (FREE) newsletters
published by the Stuttering Foundation and the National Stuttering Association,
you will learn about the recurring issues specific to children who stutter. If
you are an ASHA Certified SLP, you can join Special Interest Division 4 for
more information about stuttering. Please tell others about the free workshop
you are attending right now. The slides and this text are post on my website.
You
simply don't need to be a rocket scientist to understand and empathize with the
child with a speech problem for which he/she has experienced teasing, bullying
and communication breakdown.
Slide 20
Here are
resources for addressing attitudes and emotions of children who stutter.
Slide 21
In
conclusion I think we have a choice: we can continue to focus on counting
stuttered words and blame children for a neurological difference OR we can
focus on the larger picture.
Thank you. Judy
