“Use Your Speech Tools!” Why Your Child Who Stutters May Not Be Using His Strategies

Stuttering Tools

When a child who stutters demonstrates the ability to change his speech during a treatment session, it seems obvious that he’d want to use the same strategies to improve speech outside the session as well.  Children, especially teenagers, rarely want to stand out in a way that stigmatizes them, provokes questions or increases the chances of teasing.   So the question arises, “Why aren’t they using their tools?!”

Speech and stuttering modification techniques are often learned quickly and easily within the treatment setting.  However, SLPs and parents often feel discouraged when these tools seem to disappear as soon as the client gets to his car.  Is it laziness on the part of the child?  Is it the fault of the family for not following through with home assignments?  Is the SLP not teaching the best strategies?

Instead of placing blame, consider the following three reasons a child may have difficulty generalizing his skills:

Reason # 1: These Techniques Are Too Hard! 

Making changes to one’s speech becomes exponentially harder when you introduce factors that often are not present in the session, such as interruptions, time pressure and feelings of embarrassment or shame associated with stuttering. Learned escape/avoidance behaviors and increased language demands may make it very difficult to use these tools.  Suddenly, what felt like an easy decision to use a new technique, becomes complicated by the person’s desire to be heard in a large group of chatty peers or by the need to formulate an excuse about why he doesn’t have his homework.

How Can I Help?

Children will be more likely to use speech/stuttering strategies if they are first introduced in safe and supportive environments (i.e. home, session room).  To help with this, create a hierarchy of speaking situations and use it to guide where the client practices the strategies.  If a child who stutters is not yet using speech tools in certain situations such as the classroom, it is probably because of where that situation is on his hierarchy. Work with your clients to determine where they would like to use their strategies , while also identifying those situations where they would prefer to concentrate on things other than using their tools.

Reason #2: These Techniques Make Me Sound Weird! 

There are several techniques that may be taught to a child who stutters. Some strategies involve prolonging the initial sound to ease into or out of a word with less physical tension or struggle.  Other techniques include inserting more pauses into speech.   All speech tools require a child to alter their speech in a way that is still different from how his friends sound.  Children may report that they have similar negative thoughts and feelings about using these strategies as they do about their stuttering.  This may play a role in why they are choosing not to use speech strategies outside their sessions.

How Can I Help?

Just as you might spend time trying to help reduce negative reactions to stuttering, you might also spend time desensitizing clients to hearing themselves use strategies through voluntary stuttering assignments.  Children can also benefit from improving their ability to handle listener reactions. This can be addressed by participating in role-playing activities that help the child create “scripts” for responding to curiosity/teasing.  For example: “Why do you sound like that?” “Sometimes I stretch my sounds like that to help me get out of a stutter.”  The more comfortable the child feels with his strategies and ability to respond to questions about his speech, the more prepared he will be to use these techniques outside the session.

Reason #3: These Techniques Aren’t Worth it!  

A cost-benefit analysis can be useful when trying to understand why a child may choose not to use speech/stuttering strategies.  At the surface, it may appear that there are many benefits of using strategies which include increased fluency and improved overall communication. However, SLPs and parents must be careful to consider the costs, as well.  Costs may include increased effort, difficulty concentrating on the content of message, the risk of showing more stuttering and the potential that the strategy doesn’t work.

How Can I Help?

Have discussions with clients about what they perceive as potential costs versus benefits of using strategies in a variety of different speaking situations.  As the child becomes more accepting of stuttering and is better able to tolerate both his feelings about stuttering and listener reactions, physical tension and struggles associated with speaking will decrease.  As this happens, tools become easier to use and costs may not feel so high.

The bottom line 

There are several strategies that may help reduce stuttering frequency and severity.  However, you often can’t offer these tools without first considering and incorporating goals that target how the client thinks and feels about his speech both while stuttering and while using tools.

Brooke Leiman, MA, CCC-SLP, is the Director of the Stuttering Clinic 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.

 

 

A Misleading Account of Research on Stuttering Treatment for Young Children

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A recent ASHA Leader article by Peter Reitzes on treatment for preschoolers who stutter makes claims to the efficacy of some treatments that are both misleading and not evidence based – at least as far as published research is concerned.  Reitzes refers readers to a study by Franken, Kielstra-Van der Schalk and Boelens (2005) that claims to have shown no difference between the results or outcome of the Lidcombe Program and a Demands and Capacities treatment approach.  That study, as Bothe, Davidow, Bramlett and Ingham (2006) reported in their systematic review of research on the treatment of stuttering, is fundamentally flawed, making the results uninterpretable.

A study by Jones et al. (2005) evaluating the Lidcombe Program, did so by comparing children who stutter that were treated by Lidcombe with a control group that did not receive treatment. Another study by Yairi, Ambrose, Paden and Throneburg (1996) made it clear that preschool children (especially those who have been stuttering for less than 15 months) have a very high rate of untreated recovery. Consequently, any treatment evaluation using that age group needs to be compared with an untreated control group so as to show that its beneficial effects exceed those that would occur without treatment.  In the case of the Franken et al. (2005) study there was no untreated control group.  Hence, Bothe, et al. (2006) concluded that “Franken et al.’s data are difficult to interpret without a no-treatment control group to confirm that their application of either treatment was actually effective” (2005, p. 331).  In fact, that is a very charitable comment because the data are not just “difficult to interpret” – they are impossible to interpret! There is nothing in this study that would show that any speech performance improvements (from Lidcombe or Demands and Capacities) exceeded those that might have occurred without treatment.

There is even more to be concerned about in the Reitzes article.  He describes a presentation by Franken at the 2013 NSA conference of another study that also compared Lidcombe Program with a Demands and Capacities treatments. This study (Franken, 2013) used a larger cohort (n =199; 3-6 years) and reported findings similar to those reported by Franken et al. (2005).  It was claimed that after 18 months there was no significant difference between the groups in terms of stuttering frequency and percentage of children recovered.  But this study simply repeats the design error identified by Bothe et al. (2006): yet again there was no untreated control group.  The importance of controlling for a natural rate of recovery is also underscored by the report that many of the study’s children may have been stuttering for between 6 and 15 months when they entered the study. It is now almost indisputable that a high rate of untreated recovery characterizes children in this bracket (Ingham & Cordes, 1999). The argument that some might raise that running an untreated control group would amount to unethically withholding treatment is not an excuse or defense. There are many alternative research designs that can offset this problem (see Kazdin, 1998). And if one is concerned about ethics in research, how can it be argued that it’s ethical to draw unwarranted conclusions about the effects of treatments for preschool children who stutter that are based on research designs that cannot support those conclusions?

The fact that the Bothe et al. (2006) review was not mentioned among the sources or references for this article is puzzling.  Either Reitzes was unaware of this critique of the Franken et al. (2005) study, or for some reason chose to ignore it. Or perhaps he is unaware of the high rate of natural recovery in this population and thus did not understand the threat that that fact posed to the usefulness of the Franken and colleagues’ findings. Nonetheless, readers should not be ignorant of the deceptive message conveyed within his article.

Roger J. Ingham and Janis Costello Ingham are professors in the Department of Speech and Hearing Sciences at the University of California, Santa Barbara. Roger Ingham is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders.

 

References

Bothe, A.K., Davidow, J.H., Bramlett, R.E., & Ingham, R.J. (2006).  Stuttering treatment research, 1970 – 2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and related approaches.  American Journal of Speech-Language Pathology, 15, 321-341.

Franken, M-C. (2013). Comparing a Demands and Capacities Model approach and the Lidcombe Program for preschool stuttering children: The RESTART randomized trial (Abstract). NSA Conference Presentation, Scottsdale, AZ.

Franken, M-C., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30, 189-199.

Ingham, R.J., & Cordes, A.K. (1999). On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. In N. Bernstein Ratner and E.C. Healey (Eds.), Stuttering Research and Practice: Bridging the Gap (pp. 211-230). Mahwah, New Jersey: Lawrence Erlbaum.

Jones, M., Onslow, M., Packman, A.,Williams, S., Ormond, T., Schwartz, I., et al. (2005). Randomized controlled trial of the Lidcombe Programme of early stuttering intervention [Electronic version]. British Medical Journal, 331(7518), 659.

Kazdin, A.E.  (1998). Research design in clinical psychology (3rd ed).  Boston MA: Allyn and Bacon.

Reitzes, P. (2014). The powered-up parent. The ASHA Leader, 19, 50-56.

Yairi, E., Ambrose, N.G., Paden, E.P., & Throneburg, R.N.  (1996). Predictive factors persistence and recovery: Pathways of childhood stuttering.  Journal of Communication Disorders, 29, 51-77.

 

Avoidance Reduction Therapy: A Success Story

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I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein.  Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist.  Ben also happened to be a person who stutters (PWS).    As the interview continued he shared that he was introduced to avoidance reduction therapy by Vivian Sisskin at the College Park campus of UMD.  I had already been applying aspects of avoidance reduction therapy with my clients,  however Ben helped solidify my feelings on this approach.  Ben was kind enough to answer some questions and walk me through his experience with avoidance reduction therapy, which is included below.

Avoidance reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients.  This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering.   The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.).  These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.

Avoidance reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering.   Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech.  Avoidance reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.

How do you incorporate avoidance reduction therapy into your sessions?  Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering.  Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations.  As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before.   Read on to learn about Ben Goldstein’s first-hand experience with avoidance reduction therapy.

Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?

Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.

Can you describe your stuttering pattern prior to beginning avoidance reduction therapy?  Do you feel like stuttering impacted your quality of life?   

Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.

In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter.  If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.

All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.

How were you introduced to avoidance reduction therapy?  

Ben:  After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic.  It was there that I was introduced to avoidance reduction therapy.

How would you define avoidance reduction therapy and the rationale behind this approach?  

Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life.  In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear.  If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process.  If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.

Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?  

Ben:  Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech.  Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”

Can you explain what a typical therapy session would look like?

Ben:  A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.

After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.

Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.

What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group? 

Ben:  I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.

How do you think your stuttering has changed?  Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?

Ben:  A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.

In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.

Do you think that there are individuals who would not benefit from this approach?  

Ben:  I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.

My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change.  The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.

If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.

Brooke Leiman, MA, CCC-SLPis 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

 

Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in Speech Pathology in the Fall of 2014.  Ben is a member of the Rockville Chapter of the National Stuttering Association and formerly served as it’s co-chapter leader.  He can be reached at bagoldstein@gmail.com.

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.

 

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.

Showing Our Stuttering Moves

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We may not know all the reasons for stuttering, but one thing’s for sure—children who stutter want to be heard!

People who stutter want to express themselves, but sometimes fear of potential embarrassment can overwhelm them. Luckily, movies like “The King’s Speech” and celebrities such as Lazaro Arbos from “American Idol” have put stuttering in the spotlight and can help inspire our kids. Together with information offered by the Stuttering Foundation on its website and in books, videos and conferences, the increased attention can help our students tackle the emotional side of stuttering and learn how stuttering can affect their lives in a positive way.

I am lucky that my school allows me to work once a week with a group of students who stutter. We work voluntarily during lunch time to tackle some of the emotional issues related to stuttering, with support from Margarita Torres, a student teacher from Adelphi University. I intend for the sessions to operate much like a support group—a forum in which students can discuss their feelings and thoughts about stuttering. I have tried to adapt desensitization and acceptance approaches outlined in Peter Reitze’s book “50 Great Activities for Children Who Stutter: Lessons, Insights and Ideas for Therapy Success” as I work with the students.

The group consists of two fifth-grade girls, a fourth-grade girl, a third-grade boy—and a fourth-grade boy who does not stutter but is friends with the other group members. One day as we were eating lunch and talking about famous people who stuttered, I shared with the group the story of Lazaro Arbos’ audition on “American Idol.” We showed the students the video and discussed his performance.

A few minutes later, one student broke out into song! He sang only one line, “I got the bounce like Darth Vader,” to the tune of Maroon 5’s “Moves Like Jagger.” We all giggled and were impressed with his musical talent. That one line stuck with me and my student teacher. Then I remembered the New York City United Federation of Teachers Speech Improvement Chapter’s Better Speech and Hearing Month Contest. My student teacher Margarita Torres, the students and I worked quickly to create a music video to submit for the contest.

The March 15 deadline was approaching fast and meeting once weekly was not going to be enough. So we decided to meet three times a week and work on modifying the rest of the song’s lyrics. We changed the lyrics to include information about stuttering (for example, famous people who stutter, including Darth Vader), tips for others when speaking to people who stutter, and feelings about stuttering. The group did an amazing job memorizing and working on the lyrics, and the script before the music video discusses why speech therapy is important.

Hopefully this experience has taught the students that being a person who stutters does not limit their potential. It only can enhance potential.

Kelly M. Enamorado, MS, CCC-SLP, is a bilingual speech-language pathologist at Public School 36 in New York City. She can be reached at Kenamorado@gmail.com.

Could Voice Therapy be a Remedy for Stuttering?

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Photo by edwin_young

It has been long known that stuttering, especially in severe cases with blocks, stops and interjections, could produce a real voice disorder as a post effect.

In most of these cases of severe stuttering, while the patient is blocking his speech we can see how much pressure is building below the closed vocal cords until they finally open for that interjection of speech production, causing the upper circulatory neck veins to be full of blood,well shown and causing a severe friction effect on the vocal cords themselves.

Thus, there is not much surprise in the clinical connection between stuttering and a secondary voice disorders. The voice of these stutterers is harsh, choppy, and very distinct.

Voice therapy might help with stuttering – really?

Speech pathologists who treated many stutterers throughout the years have seen numerous times that by treating the secondary voice disorder not only is voice quality improved but, surprisingly enough, the stuttering has become less severe and in some cases is gone completely!

This is actually not so surprising…any speech pathologist who has the specialty to treat stuttering will tell you that one of the best remedies clinically proven is to change the output pattern of the patient speech. Since voice therapy is doing just that…it may as well be a wonderful remedy for severe stuttering.

What would be the clinical procedure?

In the evaluation process I see many stutterers with a secondary voice disorde. While testing the voice and speech production of these patients I will decide which of the disorders to tackle first and which technique to use. Most probably if the patient’s voice is harsh and choppy I will choose to treat him with a technique that will try to solve both disorders or, rather, to do voice therapy that will decrease the vocal abuse secondary to his fluency disorder and improve his vocal production while working against his dis fluency behaviors by changing the speech production process all together.

What exactly do we do in voice therapy against stuttering?

There are typically a couple of very good techniques to choose from nowadays. While any voice therapy technique that will work to change the breath support pattern of the patient while advocating vocal cords relaxation physiotherapy is good and will have positive results on both the stuttering disorder as well as on the secondary voice hoarseness, I would much prefer to use state-of-the-art techniques that are more suitable for this complex combined situation of an Hoarse-Stutterer.

Let me briefly discuss 2 specially designed techniques for that:

WMD (Sonorantic) technique:

Introduced by Watterson,McFarlen and Diamond , features use of sonorants ( nasal consonants like /M/ and /N/ and liquids (half a vowel) like /Y/) in the teaching materials while implementing a change to abdominal breath support and emphasizing relaxation drills to the vocal cords. The idea behind this unique technique is that when we produce these sonorants , friction in the vocal cords is much reduced compare to using materials with ordinary common consonants – making this a best match to these stutterers!

MMSM (Minimal Movements Specialization Method) technique:

Introduced by Dr. Weiss, was designed as a voice coaching technique for singers and actors , then was implemented as medical voice therapy and has shown tremendous success with these actors that had dis fluency problems prior to treatment. Again, we see the power of changing the speech pattern in these patients. This relatively new fascinating technique may become a powerful weapon against stuttering since it features not one good voice but a thousand of good voices…the patient is learning how to control his vocal output using minimal movements of his speech muscles, making it possible to change the voice output in thousand different ways, so you could have a different speech pattern every day…which will most probably will have a vast positive effect on any stutterer’s speech outcome, and by decreasing the primary disorder will reduce voice abuse to solve the secondary voice disorder as well.

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.

The King’s Speech (Part 1): My Impressions

Poster for the movie "The King's Speech"

I was recently surprised to find an email in my inbox from Scott Squires of The Stuttering Foundation. Why would someone from The Stuttering Foundation be contacting me… after all, I’m a self-described “Voice Guy” with significant interest in adult language disorders. As it so happens, Mr. Squires, the foundation’s Director of Marketing and Communications, had read my posts for ASHAsphere and wondered if I’d like to interview the organization’s president, Jane Fraser, about the movie “The King’s Speech.” In the interest of conducting an informed interview with Ms. Fraser (which constitutes the upcoming “Part 2” of this post), I thought it best that I see the movie first. Because it was only in limited release at that time, my wife and I ventured from the wilds of Clarion two hours south to Pittsburgh and took in a showing.

The Kings Speech” is the story of King George VI’s attempt to overcome his stuttering as he ascends to England’s throne in the mid-to-late 1930s. Along the way, he is treated by an Australian speech therapist, Lionel Logue, who, through persistence and the application of various therapeutic techniques, convinces the future king that his stuttering can be cured. The movie culminates with King George’s speech to the British Peoples on September 3, 1939 announcing Britain’s entry into what would become World War II. (The actual speech can be heard here.)

During the movie I couldn’t help but be drawn to Geoffrey Rush’s portrayal of eccentric speech therapist Lionel Logue. Now I’m not a movie critic or a stuttering expert or a historian…what I am is an SLP who teaches in a university program responsible for the training of future SLPs. So it is from this perspective that I viewed Rush’s performance (and later “boned up” on the real Lionel Logue). What could I take from the movie to illustrate various facets of professional practice for my students? The movie was rife with examples, both of what to do and of what not to do as an SLP. I’ve chosen one from each category for brief discussion.

From the moment I first heard it, Logue’s promise to cure the future king’s stutter rankled me. And make no mistake, a cure is guaranteed in the movie (“I can cure your husband, but I need total trust”). I fully recognize that I’m viewing Logue’s promise of a cure within the context of contemporary ASHA practice standards. Maybe it was acceptable to guarantee a cure during the period depicted, a form of practitioner bravado or self-assurance designed to instill hope and confidence in one’s patients. Today, however, such an action would be foolhardy, potentially open the practitioner to litigation, and, most significantly, would violate the Code of Ethics to which we adhere as holders of ASHA’s Certificate of Clinical Competence. Specifically Principle I, Rule J: “Individuals shall not guarantee the results of any treatment or procedure, directly or by implication…”. Perhaps my discomfit is simply testament to the degree to which this tenet has been instilled in me by the organizational climate of the profession. And, for the sake of historical accuracy, the king was never “cured” despite Logue’s intervention, but rather continued to manifest a degree of disordered speech. In a December 2010 interview with Mark Medley of Canada’s National Post, Mark Logue (Lionel Logue’s grandson) described King George VI’s speech during a 1944 radio broadcast as manifesting the “watermarks of a speech impediment, signs in the hesitations and the pauses and the breathing.”

ASHA’s Code of Ethics states “individuals shall not reveal, without authorization, any professional or personal information about identified persons served professionally …” (Principle I, Rule N). When working with students in the clinical setting this is a stricture discussed over and over and over again. Logue practiced confidentiality to an admirable extent and could most definitely serve as a role model for students, both as depicted in the movie and in his actual life. At no point does he reveal his client to be the future King of England, not even to his wife and sons (though he, in one scene at the dinner table, is sorely tempted to do so). In fact, Logue’s family never finds out that his client is the king until George the VI shows up in their parlor and, in so doing, reveals himself. Imagine how hard it must be to keep something of this nature to oneself, not even confiding in one’s spouse…to strictly observe all that confidentiality explicitly and implicitly requires…especially when, like the future king, the client is sometimes exasperating and a source of professional discontent.

“The King’s Speech” might be the first exposure some in the general public have to the practice of speech therapy. As such, and despite being a “period piece”, the movie has the potential for shaping how the layperson views the practice of contemporary speech-language pathology. To this end, it behooves SLPs to critically look at the movie from a professional perspective, deciding what on the screen represents an accurate representation of today’s practitioner and what does not (historical differences notwithstanding). The above are but a few of my impressions. What did you like about the portrayal of SLPs? What didn’t you like? Please feel free to share your impressions in the comments section.


The next installment of my series reviewing “The King’s Speech” will share my discussion with Jane Fraser, President of The Stuttering Foundation.

You might find the following sources pertaining to Lionel Logue and “The King’s Speech” both interesting and informative (these were pieces I referred to as I prepared to write this post):

Bowen, C. (2002). Lionel Logue: Pioneer speech therapist. Speech-language-therapy dot com. Retrieved January 12, 2011, from http://www.speech-language-therapy.com/ll.htm

Dana. (2011, January 5). Review: The King’s Speech. Stimulated Boredom. Retrieved January 12, 2011, from http://stimulatedboredom.com/historical/review-the-kings-speech/#

Hallett, V. (2010, December 14). Surviving royal treatment: ‘The King’s Speech’ provides history of stuttering treatment. Retrieved January 12, 2011, from
http://www.expressnightout.com/content/2010/12/the-kings-speech-stuttering-treatment.php

Medley, M. (2010, December 13). As a speech therapist, he was fit for a king. National Post. Retrieved January 12, 2011, from http://arts.nationalpost.com/2010/12/13/as-a-speech-therapist-he-was-%EF%AC%81t-for-a-king/

The Stuttering Foundation. (2011, January 10). Stuttering and The King’s Speech. Retrieved January 12, 2011, from http://arts.nationalpost.com/2010/12/13/as-a-speech-therapist-he-was-%EF%AC%81t-for-a-king/

Kenneth Staub, M.S., CCC-SLP, is an Assistant Professor, Communication Sciences & Disorders at Clarion University of Pennsylvania. He will be a regular contributor to ASHAsphere and welcomes questions or suggestions for posts.

Stuttering Versus Cluttering – What’s the Difference?

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Photo by milgrammer

What is stuttering?

Stuttering is a disruption in the fluency of verbal expression characterized by involuntary, audible or silent, repetitions or prolongations of sounds or syllables. These are not readily controllable and may be accompanied by other movements and by emotions of negative nature such as fear, embarrassment, or irritation (Wingate 1964). Strictly speaking, stuttering is a symptom, not a disease, but the term stuttering usually refers to both the disorder and symptom. The stutterer is doing the opposite of what normal speaker would do: He is trying to talk on inhalation instead of after inhalation. He does this as a reaction to the fact that most of his air being exhaled BEFORE it can be used for phonation.

What is cluttering?

Cluttering is a disorder of both speech and language processing that frequently results in rapid, dysrhythmic, sporadic, unorganized, and often unintelligible speech (Daly, 1993).

How can we differentiate between stuttering and cluttering?

The clutterer vs. stutterer:

  • Talks BETTER under stress
  • Talks BETTER when interrupted
  • Talks BETTER on longer sentences
  • Talks BETTER in a foreign language
  • Reads BETTER unfamiliar texts
  • Doesn’t seem to care how he talks
  • Doesn’t have remissions in his speech disorder
  • Talks WORSE when calm
  • Doesn’t pay attention to what is said
  • Unaware of his speech

Can they co-exist? YES!

A patient may show symptoms of BOTH disorders together. Thus, he will be classified as clutterer-stutterer and will show: word-finding difficulty, poor reading abilities, poor memory, poor story-telling abilities and interestingly, superior skills in math and science (Daly, 1993).

How do we treat stuttering and cluttering?

Treatment for stuttering disorder is not easy – since we don’t really know the cause for sure, we try to manipulate the speech production using: mind control/attitudes, changing the speech patterns (clinically proven to help a lot of patients!), changing breathing patterns  (most beneficial to those patients that acquire hoarse voice due to their stuttering!), and teaching muscles relaxation.

Treatment for cluttering might be even harder and differs from treatment of stuttering. We typically will be working on awareness of the patient towards his speech problem , teaching oral-motor coordination exercises  (to stop the mumbling effect), teaching relaxation drills, emphasizing organizational language treatment, teaching memory strategies, teaching rate control techniques (clinically proven to help a lot of patients!).

Gal Levy M.Sc. CCC-SLP, has more than 21 years of experience in clinical treatments of Voice, Fluency, Articulation and Language. Gal is working as a school based SLP, Home health SLP and in his private practice at Frisco, TX. He also writes professional articles on various speech disorders and state of the art treatments on Google’s new Encyclopedia, Helium and AC writers websites. Gal participated on Community Focus radio monthly shows with Dr. Griffin advising KEOM 88.5 FM listeners on voice, fluency and tongue thrust clinical issues.