When Is Treatment for Stuttering ‘Completed’?

asianboy_89387926Both parents and speech therapists alike find themselves struggling to decide when treatment is complete for someone who stutters. Therapy for a child who has difficulty saying their “r”s has a distinct beginning and end (when a child meets criterion for 90 percent accuracy in conversation), however, stuttering is much more variable, by nature. In fact, once a child reaches the age of 8, it is much more likely that their stuttering is going to persist, in some form.

Does this mean that treatment will continue forever? The idea of treatment continuing indefinitely is daunting to both the therapist who has to continue to think of new and exciting activities and the parent who has to both make room in their schedule and in their budget!

Preschool age children
Many children go through a period of “temporary” disfluency as they begin to place more demands on their language system. Preschool children often have not developed the negative reactions to disfluencies that play a role in persistent stuttering that we see in older children and adults. As a result, for a child this age, it makes sense for a therapist (and parent) to aim to eliminate stuttering. I believe that a period of stutter-free speech is necessary to warrant dismissal from therapy for a young child (minimal “typical” disfluencies such as phrase repetitions or sentence revisions may persist).

Following a month or more of stutter-free speech, therapy should be slowly faded, going from weekly visits to monthly visits and finally entering into a monitoring period. This is a period where parents should keep in touch with their therapist to discuss how their child is doing at home and school. It is important to educate parents that stuttering is highly variable and that if a child does not stutter for weeks or even months, the parents should still continue to follow the program the therapist has set up for them and monitor changes in fluency so that they can quickly address a “reoccurrence,” should it occur.

School-age children/adolescents
As a child enters school and begins to demonstrate a more complex stuttering pattern, total elimination of stuttering may not be a realistic goal. Instead, it is more reasonable for a child this age to have a goal of improving their communication skills to include more forward-moving speech, although maybe not completely stutter-free. In addition a goal should be put in place to reduce the negative impact of stuttering on the child’s academic and social life. With these types of goals, it is much harder for a parent or therapist to assess when a child meets criterion for discharge from therapy.

A child should not be discharged unless a therapist determines that stuttering is no longer having a negative impact on how the child is participating in activities, interacting with others and communicating messages. Benchmarks for success cannot be solely based on frequency of stuttering, as a child who stutters on 50 percent of their syllables may be less impacted by their speech than a child who only stutters on 10 percent of syllables. The amount of impact is largely dependent on the severity of disfluencies (for example, blocks versus whole word repetitions), length of disfluencies (for example, fleeting versus 5 seconds), degree of secondary behaviors (for example, eye blinks, tension in lips, loss of eye contact), and child’s temperament.

Even a child who is not demonstrating any obvious disfluencies may be in great need of intervention. It takes a carefully observant therapist and parent to detect if the child that is seemingly fluent is actually masking disfluencies by avoiding words or situations. I suggest that therapy for school-age children who stutter be ongoing and, at the very least, be on a consult basis.

A child may comfortably get through fifth grade, with stuttering having relatively little impact on them, however, that same child may begin sixth grade, in a new school, and suddenly stuttering may play a very different role in their daily life. Having a speech therapist monitoring your child will allow for you to quickly catch any changes that may warrant more direct and intensive therapy.

Adults
With maturity, adults can decide for themselves if they are going through a period when speech has become a priority (for example, when interviewing for a job, gaining a new responsibility at work that involves speaking, dating, relocating, and so forth).

Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at National Speech Language Therapy Center in Bethesda, Md. Brooke hosts a blog focused on stuttering and stuttering therapy at www.stutteringsource.com. She can be contacted at Brooke@nationalspeech.com.

Distinguishing Cluttering from Stuttering

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Developmental stuttering affects 1 percent of the population and over 3 million people in the United States. However, there are other, lesser known fluency disorders that include neurogenic stuttering and cluttering. Telling the difference between stuttering and cluttering is often a point of confusion, so we take a closer look here at what, exactly, cluttering is—and the process of identifying and treating it.

The International Cluttering Association defines cluttering as “…a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular or both for the speaker. These rate abnormalities further are manifest in one or more of the following symptoms: an excessive number of disfluencies, the majority of which are not typical of people who stutter; the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints; and inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words. ”

So what does cluttering look and sound like?

1. Often people who clutter have what I (and many other speech-language pathologists) refer to as “machine-gun” speech. Their speech comes out in rapid bursts, which is described above as “irregular rate,” and may include pauses where it doesn’t feel appropriate.

2. A person who clutters may also demonstrate disfluencies that are unlike what we see in people who stutter. Some examples of disfluencies that are more typical of a person who clutters is excessive whole word repetitions, unfinished words and interjections (such as um and well). I have also noticed more atypical disfluencies, such as final part word repetitions (chair-air, bike-ike).

3. Coarticulation refers to when a person collapses or omits a syllable of a word (for example, “wuffel” for “wonderful”).

There is quite a bit of symptom variability, as well as co-existing conditions, that make this an even more confusing diagnosis. Below is a list of characteristics and co-morbid conditions that have been seen in people who clutter. (Note: Some people who clutter may have several of the below symptoms/co-existing conditions; some may have only one; and some may have none at all.)

  • Limited or no awareness of their irregular speech pattern unless someone draws their attention to it (very different from what we see in stuttering).
  • Sloppy handwriting.
  • Difficulty organizing thoughts; listeners easily get “lost.”
  • Learning disability.
  • Attention difficulties (i.e., ADHD).
  • Auditory Processing Disorders.
  • Asperger’s Syndrome/Autism Spectrum Disorder.
  • Stuttering (a person can clutter and stutter).

If you feel this diagnosis is hard to grasp, you’re not alone.  As a result, this condition goes largely misdiagnosed (as developmental stuttering) or undiagnosed (“I just speak too fast! I don’t have a “real” speech problem!”). For a helpful chart that breaks down the similarities and differences between stuttering and cluttering, see this brochure created by Kathleen Scaler Scott for the National Stuttering Association.

So what do you do if you think your child is cluttering?

Since this a relatively lesser known diagnosis, your best bet would be to find a speech- language pathologist who has experience working with fluency disorders. As you have learned, cluttering is a highly variable disorder. We cannot prescribe a “one size fits all” plan of treatment. There must be careful and continuous observation in order to create a treatment plan that is specific to the symptoms your child is displaying. Here are some common treatment objectives:

    • Self-Monitoring. One common characteristic among people who clutter is limited awareness of their own speech. It is important to heighten the client’s ability to monitor his or her disfluencies, rate, and/or mis-articulations. For a person who stutters, calling their attention to stuttering, although sometimes necessary, may initially cause an increase in disfluencies. However, for people who clutter, calling attention to their speech often helps them improve their rate and overall clarity (at least for a short bit).
    • Over-articulation. Another common characteristic among people who clutter is the collapsing or omitting of syllables. By practicing the over-articulation of sounds, it calls a person’s attention to all the syllables in a word, both stressed and unstressed. The speech of people who clutter may be monotone or “robotic.” Practicing over-articulation can be worked on in conjunction with exaggerating stressed syllables and inflection. Here is a useful video of an SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables:http://youtu.be/2AFygz-bxwQ
    • Pausing and Phrasing. Using this technique,  a person practices inserting more pauses into their speech, with attention to the proper placement of these pauses. For younger children, I will have them place pauses every one to three words, but as they get older, more attention will be paid to inserting pauses based on proper phrasing. I often will transcribe a client’s language sample, to include both the words they say and the placement of their pauses. I will then have them mark up the paper with where the pauses should have gone. Having a visual representation of speech is a helpful way to identify when there are way too many words being said between pauses (machine gun speech). Pausing is another too used in teaching a people to slow their rate, which is much more effective and constructive when compared with saying “slow down.
    • Provide strategies for “typical” disfluencies. As noted above, some people will demonstrate stutter-like disfluencies in addition to their cluttering characteristics. In this case, standard stuttering techniques should be addressed. These include cancellations, pull-outs and the like. SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables.

Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.

 

What Does a Fulbright Specialist Do?

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The Fulbright Specialist Program links U.S. academics and professionals and their counterparts at host institutions overseas. Qualified academics receive grants to engage in collaborative two- to six-week projects at host institutions in over 100 countries. International travel costs and a stipend are funded by the U.S. Department of State Bureau of Educational and Cultural Affairs. Participating host institutions cover grantee in-country expenses or provide in-kind services.

Communication sciences and disorders professionals are among those who participate in the program. In this post, I (Robert Goldfarb) and my colleague Florence Ling Myers recount our experiences in it.

Florence was a specialist in education and worked at the University of Hong Kong in 2011 for two weeks. She received approval for the five-year placement on the specialist roster. I was a specialist in applied linguistics/TEFL at Universidad Pedigogica Nacional in Bogotá, Colombia for six weeks, with the latter half of the commitment completed online after returning to the United States.

Our experiences were different enough to provide a sense of what a prospective Fulbrighter can expect.

Florence’s experience: Fluency disorders and returning to my roots

My mission in going to HKU was to reinforce the importance of fluency disorders in the family of speech-language pathologies. I gave workshops to students and professionals on cluttering, cluttering/stuttering, and stuttering. I met with academic and clinical faculty and reviewed curricula. Of particular interest was learning the problem-based learning paradigm used by faculty. The pedagogical philosophy is that students need to acquire critical thinking and problem-solving skills, to pose clinical hypotheses based on independent library research and come up with evidence-based therapy approaches for various case studies.

I had the pleasure of co-mentoring a senior thesis in stuttering. The student was bright, responsive and competent. HKU is definitely a high-power university, with great expectations for faculty and graduate students to publish in premier journals.

I also had a personal mission: to return to my roots and give back to my motherland. I escaped to Hong Kong as a refugee from mainland China in 1949 with literally nothing but the reassuring hands of my mother. I took not so much a “slow boat from China,” but a creaky leaky junk under the blackened nocturnal skies from Canton. I now wonder if I had been an illegal child alien. My dad was already in the United States to earn his doctorate in physics from the University of Missouri. Much has changed in Hong Kong since the 1940s, yet there is still this undefinable yet undeniable human spirit—to survive and thrive—among the people there.

Having been in the United States for nearly 60 years, I, too, have changed, though there is still very much a Chinese core in me. Whether or not one is from the East or West, the common bond that motivated me to return to my homeland as a Fulbright Specialist was a passion for cluttering and stuttering, and to instill this passion in the next generation of speech-language pathologists in China.

Robert’s experience: Helping with research methods/professional writing

I committed to teach two intensive graduate courses in research methods and in academic writing to advanced students working on thesis projects. In preparation for the visit, I arranged for my publisher to send some relevant books I had authored, and added others I thought might be useful. In addition, I prepared course packs in English and Spanish (with the help of a graduate student from South America) regarding local idioms. I learned, for example, that people in Colombia expressed something very positive as “the last Coca-Cola in the desert.”

Students also received feedback on their research projects in various stages, from proposals to data collection. Another commitment was a keynote address, called the Foro Fulbright, to local universities and other Fulbright scholars in the country. The students and young faculty were all bright, hard-working and dedicated, but their exposure to research design and international perspectives was provincial. Most students and faculty were open and eager to learn what the global academic community had to offer.

Not all experiences were positive. I was given Thursdays off, because it was known as “riot day,” when vigilantes stormed local universities. Sure enough, on the first Thursday of my visit and the Wednesday of the second week, I was ordered out of the office I shared with colleagues as vigilantes bombed the institution for hours. These events were followed by riot police storming the university. The tear gas they discharged lingered in the air for days.

Finally, on the Sunday before I left for home, I was robbed by a policeman while walking to the supermarket. The executive director of Fulbright Colombia called it a perfect storm of crime and civil unrest, and approved my decision to teach the remainder of my courses online.

Ongoing ties

Our students continue to keep in touch. I have helped several students write master’s theses of which they could be justifiably proud, and the thesis that Florence co-mentored was published the following year in the International Journal of Speech-Language Pathology.

Working as Fulbright Specialists allowed us to interact with colleagues and students abroad, while serving our country as ambassadors of scholarship. While there were some unwelcome experiences for me, we have many positive memories. We encourage you to apply to be on the roster, but note that you will need a bodyguard in some countries.

 
Robert Goldfarb, PhD, CCC-SLP, is professor of communication sciences and disorders at Adelphi University. He is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 4, Fluency and Fluency Disorders.

Florence Ling Myers, PhD, CCC-SLP, is professor of communication sciences and disorders at Adelphi University. She is an affiliate of ASHA SIG 4.

The Blame Game

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Although researchers are gradually learning more about stuttering and its cause/s, there is still a lot that remains a mystery. With “the unknown” comes room for parents to try and fill in the gaps with their own guesses as to what caused their child to begin stuttering. One of the questions I most often hear from parents is “Is it something I did?” The answer is a resounding “No!”

What We Know

According to the Stuttering Foundation, there are four factors that most likely play a role in the development of stuttering. It is hypothesized that a combination of these factors may result in a child with a predisposition for stuttering.

1. Genetics: Approximately 60 percent of people who stutter have a close family member that stutters as well. In addition, recent research by Dr. Dennis Drayna has identified three genes as a source of stuttering in families studied.

2. Neurophysiology: Brain imaging studies have indicated that people who stutter may process language in different areas of the brain than people who do not stutter.

3. Child development: Children with developmental delays or other speech/language disorders are more likely to stutter. (Note: By no means, is this implying that all people who stutter have delays in other areas. There is simply an increased likelihood of stuttering in children with developmental delays and language disorders.)

4. Family dynamics: High expectations and fast-paced lifestyles may play a role in stuttering.

Family Dynamics?? I Thought I Wasn’t the Cause??

You’re not! There are plenty of “fast-paced” families out there that do not have children who stutter. However, there are certain environments that may exacerbate disfluencies in a child who already has the increased propensity to stutter. This does not mean that you have to lower your expectations for your child or take them out of their extra-curricular activities. However, there are some changes that may help. Although I advise parents not to tell a child to “slow down” or “relax,” I do suggest slowing your own rate of speech and inserting more pauses. This decreases time pressure and models a more relaxed way of speaking. Indicate you are listening to your child with eye contact and by trying to set aside some time during the day that they have your undivided attention. Try your best to reduce interruptions. This can be easier said than done so don’t beat yourself up over this one, especially when there are siblings involved! On days that your child is having particular difficulty, reducing questions and language demands (i.e. “Tell grandma what we did yesterday.”) is a good idea. Let them initiate when they want to talk. Keep your expectations high, but give them a break on rough days!

If I’m Not To Blame, Then Why Does My Child Stutter More at Home And Around Me?

Although this is certainly not true of all children, many of my clients have stated that their child stutters more at home. Contrary to what most parents would believe, this is usually a positive thing and not a sign that they are doing something wrong. What these parents are witnessing is “open stuttering.” Open stuttering occurs when a child (or adult) speaks freely and without hiding, avoiding or “going around” words that they worry they may stutter on. Instead of feeling accountable for this increase in disfluencies, parents should be praised for creating a supportive environment that has allowed their child to be themselves and has encouraged their child to express themselves whether or not they stutter. At school or around peers your child may not stutter as frequently, however this may be a result of avoidance behaviors such as switching words or opting to speak less. These avoidance behaviors can be exhausting and frustrating. Home should be a place for your child to take a break from “avoiding” and say exactly what they want to say, when they want to say it (even if it means taking a little longer to come out!).

But What About The Techniques My Child Is Learning In Speech?

The strategies your child is learning with their speech-language pathologist are extremely valuable in giving them a way to regain some control over their speech, especially when entering a difficult speaking situation (i.e. reading aloud, oral presentation, introducing themselves, etc.) However, when it comes down to it, it is up to them when they choose to use their speech tools. They should be praised when they practice or use their techniques but also praised for open stuttering. It may not be easy, but resist the urge to feel (or express) disappointment when your child stutters. Instead, be proud that when they begin to stutter they are choosing to continue to speak and be heard.
Brooke Leiman, MA, CCC-SLP, is the Fluency Clinic Supervisor at National Speech Language Therapy Center in Bethesda, MD. Brooke hosts a blog dedicated to informing people on stuttering and stuttering therapy at www.stutteringsource.com. She can be contacted at Brooke@nationalspeech.com.

Healing the Stuttering Self

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It’s a question so simple, so common, yet so terrifying to someone who stutters:

“What’s your name?”

It’s the first chance to make an impression on someone, and you’re forced to perform the most difficult of tasks because there are no words to switch. Your name is your name. And sometimes it can be hard to say.

The “D” sound was problematic in my name because it began with a plosive. I blocked on the D, and built up so much muscular tension in my tongue tip that the word would get stuck. The more nervous I was, the more tension would develop. This happened hundreds of times throughout my life, each instance chipping away at my self-esteem and adding to my anxiety in social situations.

Facing that question is difficult for me even now, at the age of 44, long free of the burden of caring what others think of me. Even though I am a fully-licensed speech-language pathologist, the question,“What is your name?” still triggers an immediate response of fear, paralyzing my throat and stopping my breath. Sometimes, if I’m caught in the moment, unaware that my name will be asked, I can get it out easily, without thinking twice about it. My fluency is automatic now. However, it’s different when I’m anticipating that I will have to say my name—when my fear of speaking has the time to surface.

Stuttering runs in my family. I began to stutter at around four years of age.

At first, I don’t recall having any difficulty with my speech. I remember sharing a thought with my first-grade teacher one day, the content of which was not significant enough to recall. But I remember the feeling of spontaneously talking because it was one of the last times I would speak freely at school, or anywhere. My stuttering got progressively worse as I began to struggle against it.

The teasing started in second grade, when I was mimicked by classmates, and even my own friends. I would hear laughter when I struggled to get the words out when reading aloud in class. One time in third grade, I was teased about my stuttering by a girl in my class. I cried so hard that other kids came over to see what was wrong with me, thinking that I must be physically hurt because I was wringing my hands in anger.

On the first day of home economics class in my first year of high school, I was unable to say my name during the usual introductions. Every day after that, the table of football players mockingly chanted my name every time I walked into class. By my third year in high school, I spoke so infrequently that I was often asked, “Do you ever talk?”

I had gone through the Precision Fluency Shaping Program when I was 12. I remember the machine I had to speak into to learn gentle onset of voicing. A green light would illuminate when I got it correct. I did hundreds of drills with that machine. I also learned how to take a diaphragmatic breath and to prolong the first sound or syllable of a word. All these techniques finally gave me the tools to speak fluently, but they never dealt with the underlying fear of speaking that had built up over the years. Saying my name was always difficult.

As a graduate student in speech-language pathology, I was mostly fluent, but I still had episodes of stuttering. My fluency disorders professor told the others that I had “exquisite gentle onsets.” I was offered the job of answering the telephone in the department office as a way to practice my fluency techniques. Unfortunately, I had to say “department of communication disorders” when I picked up the phone. I blocked on the D sound, and soon realized that accepting the job was a huge mistake. There were professors and students in and out of the office, so it was hard to concentrate on my fluency techniques.

I had so much difficulty that I began having anxiety attacks. I was made to go into speech therapy, but not allowed to discontinue the job if I wanted to remain in the program. The pressure was too great, the stakes too high. Somehow I got through the semester, but I developed such a fear of the ringing phone that it was three years before I was able to answer the phone even in my own home.

As I learned about the causes and mechanics of stuttering in my course of study, I became aware of the feeling of discoordination between my breath and the muscles in my mouth. I increasingly gained control over my speech with the knowledge of the disorder, but the fear never went away. Since I never processed the fear, I suppressed it.

Now, when the fear grips me, it’s not fear of certain sounds or words, as it was when I was a child. It’s the fear of speaking itself. It’s not a simple discoordination that needs to come under conscious control by employing fluency techniques. The fear goes straight to my vocal chords and locks them.

What I’m finding helpful in those instances, is to take a diaphragmatic breath through my nostrils and exhale gently, then begin vocalizing. If I can do this, the words come out more easily. Another tactic I employ when I know I will be asked to say my name is visualizing myself doing it easily and successfully, over and over, before I actually go into the situation.

To process the feelings that have built up about stuttering, I have begun to examine some of the more damaging experiences from my past and think about them. I replay the situation in my mind, feeling the emotions that were present, then I imagine what I would say to my younger self in that moment. By reframing memories in this way, I can begin to heal them and let them go.

Most importantly, when entering a speaking situation that I suspect may be challenging, I tell myself, “I can do this.” This is what people who struggle with their fluency need to hear. They need to know that stuttering need not define them, and that the ability to gain control over their speech is within their grasp.

Donna L Marland, MS, CCC-SLP, is a pediatric speech-language pathologist who spent many years providing services in public schools. She specializes in language and fluency disorders in her private practice.