MANAGE STUTTERING STUTTERING MODIFICATION

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MANAGE STUTTERING/STUTTERING MODIFICATION
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KEY ELEMENTS

• Teach the individual to modify his moments of
  stuttering
• Reduce fear and anxiety
• These approaches manage neuromotor
  instability/inefficiency by teaching new
  stuttering patterns. Temperamental predis

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UNDERLYING THEORIES

• Charles Van Riper
• Disorder of timing from a breakdown in neuromotor
  processing
• Oliver Bloodstein
• Anticipatory struggle reaction manifested as
  tension and fragmentation

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UNDERLYING THEORIES, contd

• Richard Boehmler
• Disruption in the normal processes of speech
• David Prins
• Learned defensive reaction to perceived
  interruptions
• Joseph Sheehen
• Result of approach/avoidance conflict

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KEY ELEMENTS OF INTERVENTION APPROACH

• Modify moments of stuttering
• Reduce fear and eliminate avoidance behaviors
• Teaching/counseling approach
• De-emphasize data collection

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GOALS

• Spontaneous fluency not typically the goal
• Controlled fluency or acceptable stuttering
  usually the goal
• Theorists agree that some stutterers can achieve
  spontaneous fluency, but most will not

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STRATEGIES

• Identify and analyze
• Stutterer discusses stuttering accurately
• Identifies behaviors that interfere with speaking
  (Conture)
• Desensitize to stuttering
• Encourage self-disclosure

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STRATEGIES, contd

• Build tolerance for stuttering
• Freeze techniques
• Voluntary stuttering (Sheehan)
• Desensitize to listener reactions

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REDUCE NEGATIVE EMOTIONALITY

• Cognitive therapy strategies (Prins)
• Accepting self (Sheehan)

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MODIFY STUTTERING

• Teaching easy stuttering (Van Riper)
• Cancellation
• Pull-out
• Preparatory set
• Keeping speech moving (Bloodstein)

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MODIFY STUTTERING, contd

• Identify and relax tension
• Modifying speech prosody to sound more like
  normal speech (Boehmler)
• Reduce tension
• Speak slowly
• Improve phrasing

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MODIFY STUTTERING, contd

• Move easily from vowels to consonants
• Teaching a new motor response (Prins)
• Slide through dysfluency (Sheehan)
• Program for school-aged children (Dell)

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TRANSFER/STABILIZATION/MAINTENANCE

• Practice strategies in gradually more stressful
  speaking situations

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THERAPY PLAN
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IDENTIFY-DESENSITIZE

• Identify stuttering, study it, describe it
• Discuss attitudes and fears about it
• Identify aspects of stuttering in hierarchical
  order from most to least troubling
• Desensitize to stuttering
• Confront all issues about stuttering
• Build tolerance for dysfluencies
• Develop realistic ideas about listener reactions

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MODIFY

• Teach easy, more fluent ways to stutter
• Move slowly from vowels to consonants
• Slide through dysfluencies
• Initiate airflow prior to phonation
• Speak difficult words slowly
• Cancellations, pull-outs, preparatory sets
• Identify and relax tension in speech mechanism
• Keep speech going-slide or repeat through blocks
• Stutter openly in a relaxed fashion
• Chose strategies that match the stuttering pattern

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STABALIZE-TRANSFER-MAINTAIN

• Practice strategies in gradually more challenging
  environments
• Practice strategies in most difficult speaking
  situations
• Help individual become his/her own therapist
• Extinguish speech fears
• Change self-concept to have confidence in
  speaking ability
• Stutter on purpose to develop a margin of
  safety(Sheehan)

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FLUENCY SHAPING/MANAGE FLUENCY- goal is 100
fluency
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THEORIES ABOUT THE NATURE OF STUTTERING

• Neilson and Andrews
• Results from a reduced neural capacity for
  internal modeling
• Webster, Boberg, and Kully
• Disorder of timing and co-ordination
• Perkins
• Disorder of co-ordination of respiration,
  phonation, articulation
• Ryan
• Learned reaction to speech non-fluency

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UNDERLYING THEORIES, contd

• Shames and Florence
• Difficulty of speaking process exceeds persons
  ability to manage
• Iow self-concept is a factor
• Effective but have to follow the recipe exactly,
  and very intense
• Has to be a planned idea of what they are going
  to say, and have to generalize
• This one
• Shine
• -Result of central neurological integration
  difficulties
• Adams
• Difficulty coordinating and maintaining
  appropriate air flow
• Cooper
• Combination of anxiety and inefficient speech
  behaviors

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KEY ELEMENTS

• Fluency established in the clinic, reinforced and
  gradually modified to approximate normal sounding
  speech.- most anyone can be made fluent quickly
  by slowing them down or bring down their
  linguistic complexity
• Slow their rate with delayed auditory feedback?
• Leave the kids at an exceedingly slow rate, and
  this annoys the kids, so have to tweek the rate
  and move them up again to make them sound more
  normal
• Or DAF when you do this you automatically use
  continous phonation, automatically move from hard
  articulatory contact to easy contact on
• Little emphasis placed on reducing fear,
  avoidance, and anxiety.
• Data collection to track changes in dysfluency is
  stressed
• More imp than data connection is their
  descriptions on how they felt and if they are
  satisfied with their improvement, constantly
  counting fluency, figuring out when stuttering
  less than .5 of time and once they get this way,
  then move them up to the next level of speed they
  are using until they stutter and then work on
  that level
• Work on maintaining, generalizing, and
  transferring the new speech fluency pattern is an
  stressed

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KEY ELEMENTS, contd

• What you are doing is behavior modification if
  it is not continually rewarded, then it isnt
  going to stick
• Deal with feelings and emotions to enable the
  individual to be successful in learning
  strategies
• Develop a positive self-image.
• Focus on speaking in a new way to maintain
  fluency.
• Operant conditioning and programmed instruction
  often used in manage fluency approaches

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GOALS

• Spontaneous fluency (controlled fluency may have
  to be the goal with some individuals)
• Many believe there is no acceptable stuttering
• Strategies to manage relapse
• have to get them to keep practicing b/c they will
  relapse
• Have to figure out what works for that client
  when they do start to relapse

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STRATEGIES

• Determine baseline dysfluency
• Have to start with this in evaluation
• Use this info to compare changes to
• Problem with counting dysfluencies, it changes
  from day to day so have to look at it over time?
  changes from situation to situation and time to
  time
• Identify and analyze stuttering behavior
• Have to do this carefully with the client
  (managed stuttering did this to reduce the
  blocks)
• For managed fluency, we are doing this to figure
  out which strategies they use 100 of time

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STRATEGIES, contd- pick and choose which works
best for that client

• Establish fluency (may use one or several of
  these)
• Slow rate
• Breathy onset of phonation? think of this one
  when have blocks at larynx
• Relaxed phrase initiation
• Reduced phrase length
• Soft articulatory contact
• Slower transitions from vowels to consonants
• Reduce linguistic complexity
• Modify prosody
• Continuous phonation
• Often DAF (delayed auditory feedback)

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Procedures

• Fluency is established, reinforced, then
  practiced
• Hierarchies used for practice
• Gradual Increase length communicative utterance
  (GILCU)- work on this one beginning with one word
  responses until fluent, then onto 2 word phrases
  and move up to multi-word phrases
• Extended length of utterance (ELU)
• These are effective in helping the person
  remember what they need to do when start becoming
  dysfluent
• FIG (fluency initiating gestures)? a cartoon
  character that represents which strategies they
  will use and keep the cartoon characters at desk
  so can remember which ones you are working on
• Apple? draw an apple with a core and their you
  write the core behaviors that the client is
  working on and all around the apple then si the
  other small things client working on facial
  grimaces, fear of phone)
• Less than .5 stuttered words per minute before
  moving on to next step

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Transfer

• Once established, fluency is reinforced
• Goal of transfer is to generalize strategies to
  variety of speaking situations
• Practice in hierarchy of difficult speaking
  situations
• Gradually reduce cues and clinician input
• Encourage individual to self-monitor and modify
  independently- if they can self-monitor then this
  gives them the way to work on it when they are
  having trouble
• Interested in are they using the strategies we
  taught them and are they fluent

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MAINTENANCE

• Responsibility shifted from clinician to
  individual who stutters
• Individual must learn to independently
  self-evaluate and analyze speech
• Individual attempts to reduce the focus necessary
  to use fluency facilitating strategies
• They tell co-workers, therapist, etc I didnt
  get much sleep, so I am just not able to
  concentrate on my speech today as much as usual
• Individual learns to return to use of controls
  when necessary

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MAINTENANCE, contd

• Gradually wean individual from therapy- so dont
  discharge quickily 3 times a week, 1 time a
  week, 1 time every other week, 1 time month,
  monthly phone calls/emails, etc
• Follow-up strategies with clinician are planned
• Public speaking classes recommended
• Individual learns strategies to manage relapse
• So they know how to use these stategies on their
  own
• In later therapy stages, individual stops using
  controls until he stutters then practices
  independently to regain fluency skills

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Sample Treatment Outline

• Complete comprehensive stuttering analysis to
  gain baseline information all of these things
  are things to get in eval? a good assessment is
  needed need each of these things
• Stuttered words per minute
• Types of dysfluencies
• Description of dysfluencies
• Duration of dysfluencies
• Breath stream management
• Struggle behaviors
• Environmental issues
• Emotional issues

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Treatment outline continued

• Chose set of strategies to teach individual based
  on the nature of his stuttering patterns
• Practice each in gradual ELU using .5 stuttered
  words per minute as criterion
• Combine strategies in gradual ELU
• Have individual evaluate his use of each strategy
• Develop strategies for individual to self-cue
• With child, invite parents to learn
  strategies b/c parent needs to understand how
  hard this is for the child and what types of cues
  are necessary when the child is not being fluent
  encourage parent involvement

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Treatment outline continued

• Transfer strategies to gradually more difficult
  speaking situations
• Gradually reduce clinician cues and support
• Drop back to more simple utterances when use of
  strategies becomes difficult
• Have them start evaluating their own speech and
  once they start becoming dysfleutn in a reduced
  linguistic ability, then when getting fluent
  increase in your linguistic complexity
• Continue to encourage self-evaluation
• Strategies may be practiced one at a time or all
  at the same time
• Design this phase of therapy to ensure success
• Discuss emotional obstacles that interfere with
  individuals success- have to figure out what
  their fears are this is the one place where
  cognitive therapy enters in
• This is boring therapy and the gamiest b/c
  always trying to keep them interested? have to
  try to make it fun

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Treatment outline continued

• Modify (what they are doing for) speaking
  pattern to sound more normal-( so sit back and
  listent to them for a few minutes so you can
  modify their strategies to make it sound as
  normal as possible)
• Vary phrasing, speed, etc.
• Work together with individual to practice using
  strategies so speech sounds as close to normal as
  possible
• Help them become satisfied with the way speech
  sounds when using controls
• Practice these changes in gradually ELU and
  gradually more difficult speaking situations if
  necessary

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Treatment outline continued

• Prepare patient for relapse-b/c it will happen
• Help them develop sense of self as fluent speaker
• Encourage them to become their own clinician
• Gradually reduce frequency of therapy
• Provide practice strategies for them to use on
  their own.

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COMBINED APPROACHES
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UNDERLYING THEORIES

• Peters and Guitar
• Physiological predisposition for inefficient
  neurological processing of speech and vulnerable
  temperament interact with environmental factors
  to produce and/or exacerbate stuttering.
• Gregory
• Individual will only improve if he develops
  positive attitudes about himself and his
  stuttering. Work on speaking to strengthen
  fluency. Strategies used are individualized.
• Starkweather
• Result of multiple conditioning (believes it was
  conditioned and have to recondition them) and
  requires a behavioral approach to treatment.

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UNDERLYING THEORIES, contd

• Manning
• Individuals allow stuttering to put social,
  emotional, and occupational limits on their
  lives, and need to work on increasing
  opportunities and choices. Individuals must both
  feel more comfortable with stuttering and modify
  it to sound more normal.
• Whole time working on speech production, he is
  working on anxiety/fear simultaneously
• But, way too much focus on both and harps on
  others for not focusing on emotional factors
• Daly
• Expectations of success and belief in ability to
  become fluent is essential for success in
  therapy.
• He applies football to stuttering imagine
  yourself a fluent speaker, and you can be that

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KEY ELEMENTS

• Fluency enhancing and stuttering modification
  strategies compliment each other.
• Patient has ability to do either depending on
  situation.
• Individuals should feel no guilt.
• Deal with tension, anxiety, and negative feelings
  equally to their speech behaviors.
• Responsibility for fluency shifted to the
  individual who stutters.
• Ultimate goal is effective communication-
  whatever it takes! not fluency or expectable
  stuttering

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GOALS

• Ability to be fluent when necessary.
• Comfortable with acceptable stuttering but also
  be able to be fluent when they want to.
• Responsible for choosing strategies.
• Expert in modifying both stuttering and speaking.
• Develop realistic attitudes.
• Understand stuttering and relationship between
  strategies and fluency.
• Understanding stuttering needs to be put into an
  entire therapy plan if they understand the
  disorder they will by into the therapy procedures
  much easiermany have unrealistic goals about
  what they think stuttering is
• Help tehm understand what we know about the
  causes
• Understand rationale for using the strategies we
  use
• Need to understand strategies can work and that
  some wont work for them and why

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STRATEGIES

• Study, understand, and confront stuttering.
• Explore, clarify, and change negative attitudes.
• Discuss stuttering with others.
• Have to be honest about what is going on with
  their speech many kids in public schools get
  lost b/c they wont do this
• Sometimes the therapist never sees the stuttering
  b/c kid never opens up, so might have to let them
  go if never able to work on it
• Use voluntary stuttering.
• Use fluency enhancing behaviors.
• Stutter easily and in relaxed fashion.
• Learn to make wise decisions about strategies.
• Help stutterer become his own clinician.

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TRANSFER AND MAINTENANCE

• Combination of the transfer and maintenance steps
  of manage stuttering and manage fluency
  approaches.
• Similar to that of managed fluency just a bigger
  piece about managing anxiety and fears
• Generalize skills to all situations.
• Set realistic long term fluency goals.

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THEORISTS ASSOCIATED WITH COMBINED APPROACHES

• June Campbell-counseling and reducing anxiety and
  including self-confidence sees this as most
  affect/imp-over does it
• Peter Ramig- videos
• Eugene Cooper-cartoon
• Nan Ratner contributing most to other speech
  prob and stuttering role of subclinical lang
  impairments? dont qualify them on lang test, but
  break down the subtest and there is a group of
  these that they are having trouble with these
  areas on the test CELF or TOLD
• Lang along with fluency go together if have
  stuttering, will have lang probably
• Barry Guitar-class book
• Larry Molt- working on getting it so that the
  Speech Easy wont have to be purchased anymore

• Hugo Gregory
• David Daly
• Walter Manning
• Woodruff Starkweather

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THEORISTS, contd

• Theorists vary according to
• Behavioral vs. Counseling approaches
• Relative importance placed on emotionality
• Vary on Specific fluency enhancing strategies
  taught- we have to look at all choices available
  to us and we make choices based on that ind client

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THEORISTS, contd

• Wall and Myers
• Stress a language based approach because of
  synergistic nature of language and speech
  processing.
• Implemented Ratners work? program for lang and
  stuttering
• Coopers
• Personalized Fluency Control program. Developed
  FIG tree (fluency initiating gestures).
  Stuttering Apple and Monkeys on my
  Back-counseling approach
• Ratner
• Known for her program to help children who
  stutter and also have articulation and language
  problems. Deal with other issues first.
  Eventually, stuttering therapy coordinated with
  speech and language therapy.

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Therapy Outline

• Explore and reduce fear, anxiety, avoidance
• Demystify, desensitize-educate, educate and get
  them use to the way it sounds and get them use to
  the way it sounds
• Learn about speech production and stuttering, as
  well as their own ind pattern
• Build awareness of behaviors specific to
  individuals pattern
• Assume responsibility for producing speech
  patterns- make sure they know that magic is not
  pushing their tongue, they are! They are doing
  this and they are in control and teach them how
  to make themselves stop doing this/ways to manage
  it!
• Understand nature of fluent speech-relates back
  to understand the nature of stuttering lets talk
  about why your strategies are working so that
  they understand they can control it and they have
  the power to do it
• Explore perceptions and beliefs about anxiety and
  specific speaking situations

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Outline continued

• Personal beliefs and attitudes
• Discuss concept of personal constructs and how
  they influence behavior
• What about personality makes individual
  vulnerable to stuttering or lack of success in
  therapy
• How do attitudes about stuttering influence
  stuttering or success in therapy
• Explore strategies to modify personal constructs

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Outline continued

• Voluntary stuttering
• Directly attack and manipulate the thing you fear
  most
• Practice stuttering to better understand it
• Stutter on purpose to practice ways of
  controlling it
• Stutter on purpose to watch listener reactions
• Stutter so you can experiment with stuttering and
  strategies

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Outline continued

• Speech motor simplification
• Discuss normal speaking patterns
• Reduce rate-understand will begin with very slow
  rate but gradually increase
• Modify phrasing
• Use continuous phonation
• Reduce hard articulatory contact
• Use relaxed onset of phonation

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Outline continued

• Learn to alter the moment of stuttering
• Continue block or repetition until in control
• Modify to stutter in more relaxed way
• Learn to anticipate and substitute relaxed stutter

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Outline continued

• Learn self-management techniques
• Practice targets until effortless
• Self evaluate on criterion referenced scale
• Gradually fade clinician input and cueing
• Discuss need for continued (lifetime) monitoring
• Prepare for relapse

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Outline continued

• Plan strategies to use with dysfluency increases
• Use behavioral contracts to make strategic
  plans-determine reward/punishment
• Continually evaluate performance
• Plan actions before starting to speak
• Self-cue
• Rehearse plan

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Outline continued

• Employ tools used by expert speakers to enhance
  your communication
• Always be organized and prepared to reduce
  stress.
• Maintain contact with clinician and engage in
  life-long education about stuttering and fluency