Stuttering

Report
Intensive Instruction of Speech
Modification Skills: Helping Clients Who
Stutter Make Speech Change
Lisa Scott, PhD CCC-SLP
Florida State University
[email protected]
2010 Kansas Speech-Language-Hearing Assocation
Convention
October 1, 2010
*Based on information from the Stuttering Foundation of America video ,
Basic Clinical Skills (2007) – information used with permission
1
Practice
Materials
Draw a picture of the
speech system that
includes:
• Diaphragm
• Lungs
• Trachea
• Vocal cords/larynx
• Tongue
• Some teeth
• Palate
• Lips
• Jaw
• Eyes
2
25 Words: Your Interest(s)
3
1
2
3
4
5
6
7
8
9 10
100%
25%
50%
4
Williams’ Normal Talking Model
• Discussed/developed by Dean Williams
–
–
–
–
University of Iowa researcher and clinician
Was a student of Wendell Johnson
Stuttered
Very gifted clinician with children
• Characteristic of University of Iowa clinicians
– The faculty there, in the early days of the department,
were trained as semanticists
– Believed in power of words, as a result
– Johnson, Williams, and others emphasized the use of
“doing” language
• What are you doing vs. what is happening
• If you are doing something, you then have a choice to do
something else
5
Making Choices
• Changing speech and stuttering means understanding that
there are choices for talking
• Introducing choices needs to be done in a learning hierarchy
– General steps in any hierarchy (steps can be used for documentation)
• Clinician models/client observes
• Clinician and client practice together
• Client tries the tool/teaches clinician how to produce it
• Client practices the tool with clinician feedback
• Client practices and provides own feedback together with
clinician
• Client practices the behavior and self-monitors
– Transfer activities and any homework should correspond to and
be co-occurring at each level of the hierarchy
6
Williams’ Normal Talking Model
• Normal talking happens when:
– Air from the lungs causes the vocal folds to vibrate
(airflow)
– The vocal folds need to vibrate when airflow is
started (voicing).
– Proper tensing is necessary for normal speech
(tension).
– Proper timing between the speech systems is
necessary for normal speech (timing).
– Sounds are moved with smooth movements
between sounds and words (movement).
7
• Stuttering happens when the person who
stutters does something that interferes with
the normal talking process
– If the person is doing something, there can
be a choice to do something else
– The trick is figure out is where the person is
interfering
8
Step 1: Exploring Talking
• In order to understand what happens during
stuttering, the client must understand how
speech is produced
– Establishes common terminology between client
and clinician
– Develops understanding of how respiration,
phonation & articulation work together for speech
– Reinforces that his/her speech system is “normal”
9
–Rationale for this step
• Starting treatment in a way that is
removed from emotion: neutral and
objective
• Encouraging client to approach
something that he/she fears and is
used to avoiding
10
• Possible activities for Exploring
Talking
–Use an age-appropriate diagram of the
speech system
• Google Images
• Commercially available materials
• Make a “speech machine” (Chmela & Reardon, 2001)
–Discuss each component of the model
• Customize to client’s age/level of
cognitive development
11
–Begin experimenting with change
• Follow the hierarchy mentioned on the
making choices slide (#3)
• Concepts – too much, just right, too little
–Make a strip with 10 squares and number 110
»Helps develop awareness of different
levels
–Use a triangle -- Hard/as much as you can;
half as much; half as much again
• Discuss how it feels in your own body
• Grade/rate one another
12
Documentation: Exploring Talking
• Using a diagram, client will label at least 3
components of the speech production system
• When prompted by the clinician, the client will
describe the contribution of X components of the
speech system to speech production
• When modeled by the clinician (or prompted), the
client will demonstrate at least 3 levels of variation in
________ (airflow, tension, voice onset, etc.)
• After producing 10 target words, the client and
clinician will rate (airflow, tension, voice onset, etc.)
each production using a 1-10 scale and achieve at
least 90% agreement.
13
Step 2: Exploring Stuttering
• Identify aspects of stuttering
– In order to change behavior, the client needs to know
when and what to change
• Use the change hierarchy (slide #3) to experiment
with change
• Working through the change hierarchy helps the
child to reduce worry and fear about speaking and
stuttering (desensitization)
• Exploring stuttering ties information from exploring
talking to child’s own behavior/speech patterns
14
• Clients begin to vary talking and
stuttering as a basis for making choices
– Begin to voluntarily manage speech by
changing it in some way
– It may never have occurred to the child that
there’s a different way to stutter – his/her
stuttering doesn’t have to occur in the same
way it always has
15
• Occurs through
– Modeling
– Implementing change hierarchies
– Reducing worry and fear (desensitization)
• Important to remember that this needs
time and practice, and should reoccur
throughout the entire course of therapy
16
• Activities for this step:
– Educate about the various ways to stutter
– Discriminate how different types of
stuttering fit the various aspects of the
model
• Play around with various types of stuttering
• Discuss how it feels in my body/your body
• Using the 1-10 strip
• Strangest stutters
• Grading/rating ability to stutter
• Teach others to stutter
17
Documentation: Exploring Stuttering
• When observing the clinician, the client will
identify at least one way that he/she interferes
with speech production that results in a stutter.
• When prompted by the clinician, the client will
vary X component of William’s Normal Talking
Model to produce ______ (type of stuttering).
• When prompted by the clinician, the client will
vary (tension, airflow, movement, etc) during
production of a __________ (type of stuttering).
18
Applying Williams’ Model to
Speech Modification Tools
•
Changing Talking
–
Soft starts/easy onsets/light contacts
•
–
Changing rate
•
•
Components of the model addressed: ALL
Components of the model addressed: tension, movement, timing
Changing Stuttering
–
Voluntary stuttering
•
–
Components of the model addressed: ALL
Holding & tolerating a moment of stuttering:
•
–
Components of the model addressed: ALL
In-block corrections/pullouts
•
–
Components of the model addressed: tension, phonation,
movement, timing
Post-block corrections/cancellations
•
Components of the model addressed: ALL
19
Changing Talking
Soft Starts/Easy Onset/Light Contacts
• What is it?
– Slower, physically relaxed speech starts
– Decreased muscle tension: opposite of stuttering
• Why use it?
– Helps initiate smooth airflow and voicing
• When to use it?
• Beginnings of phrases or utterances
• Phrase boundaries
20
Changing Talking:
Changing Rate
• What is it?
– Slower speech overall: fewer syllables or words per minute
– Should sound smooth and connected, not choppy
• Why use it?
– It’s fluency enhancing because it…
•
•
•
•
Helps client better attend to what he/she is doing
Gives more time to process
Gives client time to make changes in complex motor coordination
Helps client feel changes in muscle tension
• How can rate be changed?
– Stretching sounds or syllables, phrasing and pausing
– Combining stretches with phrasing/pausing
21
Changing Stuttering:
Deliberate (or Voluntary) Stuttering
• What is it?
– The client stutters on purpose, choosing when and how
• Why use it?
–
–
–
–
–
–
Can be used to teach any aspect of changing and varying stuttering
Assists in building awareness of stuttering moments
Decreases fear and avoidance of stuttering
Desensitizes to listener reactions
Creates a feeling of confidence in the ability to say feared words
Confront what might otherwise be avoided
• When and how to use it?
–
–
–
–
Prelude to using pullouts
Begin teaching at the single word level with unfeared sounds or words
Begin using it in unfeared situations
Build to use on feared words or in feared situationss
22
Changing Stuttering:
Holding & Tolerating A Moment of Stuttering
• What is it?
– Staying in a moment of stuttering
– Keeps the sound going rather than stopping and backing up
• Why use it?
– Increases awareness of what client is doing during the
stuttering moment
– Helps reduce avoidances
– Is desensitizing
• When and how to use it?
– After client can identify when and how he/she is stuttering
– Clinician HAS to be supportive and encouraging as the
client is holding the stuttering moment
23
Changing Stuttering:
Pullouts (In-Block Correction)
• What is it?
– Hold onto the stuttering moment and stay with it
– Focus in on where tension is and where movement is stopped
– Then, change the stutter by reducing tension and moving ahead
slowly into next sound or word
• Why use it?
– Take conscious control of and confront the stuttering moment
(desensitization)
– Release tension and keep speech moving forward
– Reinforce a looser way of stuttering
• When & how to use it?
– When there is a high degree of emotionality or “trapped”
feeling
– After learning to hold onto a stuttering moment and tolerate it
– Start with deliberate or “fake” (voluntary) stuttering at the
single word level
24
Changing Stuttering:
Cancellation (Post-Block Correction)
• What is it?
– Finishing a stuttered word
– Pausing for a moment to plan (e.g. pantomime or silently revisit the word)
then
– Stuttering on the word again in an easier way
• Why use it?
– Learn to “cancel out” or replace hard stuttering with a looser, more controlled
form of stuttering
– Discourages avoidance behaviors such as recoiling, changing words, stopping
in a block and backing up
– Reinforces easier stuttering and build confidence
• When and how to use it?
– MUST complete the hard stutter before pausing and making it easier
– If unable to pullout or missed the opportunity to use a pullout, this provides
another opportunity to learn to stutter more easily
– Typically used in the therapy room only, not in the outside world
25
• How can Williams’ Normal Talking Model help
you document change as a result of therapy?
– Consider the type of stuttering the client is
currently exhibiting
– If the client is able to change the moment of
stuttering, what is he/she adding in that wasn’t
there before?
• In other words, why might a prolongation or part-word
repetition be a “better” type of stuttering for the
client?
• Why would you want to represent progress in this
way?
26
• Possible documentation
– When prompted by the SLP, the child will name
and describe at least 3 components of Williams’
Normal Talking Model.
– When prompted by the SLP, the child will
demonstrate varying levels of airflow (tension)
(movement) and associate them with fluent and
stuttered speech production in at least 5
opportunities.
– When prompted by the SLP, the child will change a
stutter to increase forward flow of speech by
changing (airflow, tension, phonation, movement,
timing) in 4/5 opportunities.
27
References
Chmela, K., & Reardon, N. (2001). The school-age child who stutters: Working
effectively with emotions and attitudes…A workbook. Memphis, TN: Stuttering
Foundation of America.
Cook, F. and Fry, J. (2006) Connecting stuttering measurement and management: III.
Accountable therapy. International Journal of Language and Communication
Disorders, 41, 379-394
Dell, C. (2000). Treating the school age child who stutters: A guide for clinicians (2nd
edition). Memphis, TN: Stuttering Foundation of America.
Fraser, J. (Ed.) (2000). Stuttering therapy: Transfer and maintenance. Memphis, TN:
Stuttering Foundation of America.
Gregory, H. H. (2003). Stuttering therapy: Rationale and procedures. Boston: Allyn &
Bacon.
Guitar, C., & Fraser, J. (2007). Basic clinical skills (DVD). Memphis, TN: Stuttering
Foundation of America.
Guitar, C., & Fraser, J. (2006). The genius of Dean Williams. Memphis, TN: Stuttering
Foundation of America.
Ramig, P.R., & Dodge, D.M. (2005). The child and adolescent stuttering treatment and
activity resource guide: Clifton Park, NY:Thomson/Delmar/Singular.
Sheehan, J. G. (1970). Stuttering: Research and therapy. New York: Harper & Row.
Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall.
Zebrowski, P. M., & Kelley, E. (2002). Manual of stuttering intervention. Clifton Park,
NJ: Singular.
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