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Intensive Instruction of Speech Modification Skills: Helping Clients Who

Stutter Make Speech Change

Lisa Scott, PhD CCC-SLPFlorida State University

lscott@fsu.edu2010 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

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Practice Materials

Draw a picture of the speech system that includes:• Diaphragm• Lungs• Trachea• Vocal cords/larynx• Tongue• Some teeth• Palate• Lips• Jaw• Eyes

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25 Words: Your Interest(s)

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1 2 3 4 5 6 7 8 9 10

100%

50%25%

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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

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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

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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).

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• 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

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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”

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–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

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• 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

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–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 1-10»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

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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.

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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

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• 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

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• 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

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• 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

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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).

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Applying Williams’ Model to Speech Modification Tools

• Changing Talking– Soft starts/easy onsets/light contacts

• Components of the model addressed: ALL– Changing rate

• 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

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Changing TalkingSoft 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

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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

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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

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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

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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

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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

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• 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?

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• 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.

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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.