Lisa Scott, PhD CCC-SLP Florida State University lscott@fsu

1. Intensive Instruction of Speech Modification Skills: Helping Clients Who Stutter Make Speech Change Lisa Scott, PhD CCC-SLP Florida State University lscott@fsu.edu 2010 Kansas Speech-Language-Hearing Assocation Convention October 1, 2010 *Based on information from the Stuttering Foundation of America video , Basic Clinical Skills (2007) – information used with permission

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

3. 25 Words: Your Interest(s)

4. 100% 50% 25%

5. Williams’ Normal Talking Model • Discussed/developed by Dean Williams • University of Iowa researcher and clinician • Was a student of Wendell Johnson • Stuttered • Very gifted clinician with children • Characteristic of University of Iowa clinicians • The faculty there, in the early days of the department, were trained as semanticists • Believed in power of words, as a result • Johnson, Williams, and others emphasized the use of “doing” language • What are you doing vs. what is happening • If you are doing something, you then have a choice to do something else

6. Making Choices • Changing speech and stuttering means understanding that there are choices for talking • Introducing choices needs to be done in a learning hierarchy • General steps in any hierarchy (steps can be used for documentation) • Clinician models/client observes • Clinician and client practice together • Client tries the tool/teaches clinician how to produce it • Client practices the tool with clinician feedback • Client practices and provides own feedback together with clinician • Client practices the behavior and self-monitors • Transfer activities and any homework should correspond to and be co-occurring at each level of the hierarchy

7. Williams’ Normal Talking Model • Normal talking happens when: • Air from the lungs causes the vocal folds to vibrate (airflow)   • The vocal folds need to vibrate when airflow is started (voicing). • Proper tensing is necessary for normal speech (tension). • Proper timing between the speech systems is necessary for normal speech (timing). • Sounds are moved with smooth movements between sounds and words (movement).

8. Stuttering happens when the person who stutters does something that interferes with the normal talking process • If the person is doing something, there can be a choice to do something else • The trick is figure out is where the person is interfering

9. Step 1: Exploring Talking • In order to understand what happens during stuttering, the client must understand how speech is produced • Establishes common terminology between client and clinician • Develops understanding of how respiration, phonation & articulation work together for speech • Reinforces that his/her speech system is “normal”

10. Rationale for this step • Starting treatment in a way that is removed from emotion: neutral and objective • Encouraging client to approach something that he/she fears and is used to avoiding

11. Possible activities for Exploring Talking • Use an age-appropriate diagram of the speech system • Google Images • Commercially available materials • Make a “speech machine” (Chmela & Reardon, 2001) • Discuss each component of the model • Customize to client’s age/level of cognitive development

12. Begin experimenting with change • Follow the hierarchy mentioned on the making choices slide (#3) • Concepts – too much, just right, too little • Make a strip with 10 squares and number 1-10 • Helps develop awareness of different levels • Use a triangle -- Hard/as much as you can; half as much; half as much again • Discuss how it feels in your own body • Grade/rate one another

13. Documentation:Exploring Talking • Using a diagram, client will label at least 3 components of the speech production system • When prompted by the clinician, the client will describe the contribution of X components of the speech system to speech production • When modeled by the clinician (or prompted), the client will demonstrate at least 3 levels of variation in ________ (airflow, tension, voice onset, etc.) • After producing 10 target words, the client and clinician will rate (airflow, tension, voice onset, etc.) each production using a 1-10 scale and achieve at least 90% agreement.

14. Step 2: Exploring Stuttering • Identify aspects of stuttering • In order to change behavior, the client needs to know when andwhat to change • Use the change hierarchy (slide #3) to experiment with change • Working through the change hierarchy helps the child to reduce worry and fear about speaking and stuttering (desensitization) • Exploring stuttering ties information from exploring talking to child’s own behavior/speech patterns

15. Clients begin to vary talking and stuttering as a basis for making choices • Begin to voluntarily manage speech by changing it in some way • It may never have occurred to the child that there’s a different way to stutter – his/her stuttering doesn’t have to occur in the same way it always has

16. Occurs through • Modeling • Implementing change hierarchies • Reducing worry and fear (desensitization) • Important to remember that this needs time and practice, and should reoccur throughout the entire course of therapy

17. Activities for this step: • Educate about the various ways to stutter • Discriminate how different types of stuttering fit the various aspects of the model • Play around with various types of stuttering • Discuss how it feels in my body/your body • Using the 1-10 strip • Strangest stutters • Grading/rating ability to stutter • Teach others to stutter

18. Documentation: Exploring Stuttering • When observing the clinician, the client will identify at least one way that he/she interferes with speech production that results in a stutter. • When prompted by the clinician, the client will vary X component of William’s Normal Talking Model to produce ______ (type of stuttering). • When prompted by the clinician, the client will vary (tension, airflow, movement, etc) during production of a __________ (type of stuttering).

19. Applying Williams’ Model to Speech Modification Tools • Changing Talking • Soft starts/easy onsets/light contacts • Components of the model addressed: ALL • Changing rate • Components of the model addressed: tension, movement, timing • Changing Stuttering • Voluntary stuttering • Components of the model addressed: ALL • Holding & tolerating a moment of stuttering: • Components of the model addressed: ALL • In-block corrections/pullouts • Components of the model addressed: tension, phonation, movement, timing • Post-block corrections/cancellations • Components of the model addressed: ALL

20. Changing TalkingSoft Starts/Easy Onset/Light Contacts • What is it? • Slower, physically relaxed speech starts • Decreased muscle tension: opposite of stuttering • Why use it? • Helps initiate smooth airflow and voicing • When to use it? • Beginnings of phrases or utterances • Phrase boundaries

21. Changing Talking:Changing Rate • What is it? • Slower speech overall: fewer syllables or words per minute • Should sound smooth and connected, not choppy • Why use it? • It’s fluency enhancing because it… • Helps client better attend to what he/she is doing • Gives more time to process • Gives client time to make changes in complex motor coordination • Helps client feel changes in muscle tension • How can rate be changed? • Stretching sounds or syllables, phrasing and pausing • Combining stretches with phrasing/pausing

22. Changing Stuttering:Deliberate(orVoluntary) Stuttering • What is it? • The client stutters on purpose, choosing when and how • Why use it? • Can be used to teach any aspect of changing and varying stuttering • Assists in building awareness of stuttering moments • Decreases fear and avoidance of stuttering • Desensitizes to listener reactions • Creates a feeling of confidence in the ability to say feared words • Confront what might otherwise be avoided • When and how to use it? • Prelude to using pullouts • Begin teaching at the single word level with unfeared sounds or words • Begin using it in unfeared situations • Build to use on feared words or in feared situationss

23. Changing Stuttering:Holding & Tolerating A Moment of Stuttering • What is it? • Staying in a moment of stuttering • Keeps the sound going rather than stopping and backing up • Why use it? • Increases awareness of what client is doing during the stuttering moment • Helps reduce avoidances • Is desensitizing • When and how to use it? • After client can identify when and how he/she is stuttering • Clinician HAS to be supportive and encouraging as the client is holding the stuttering moment

24. Changing Stuttering: Pullouts (In-Block Correction) • What is it? • Hold onto the stuttering moment and stay with it • Focus in on where tension is and where movement is stopped • Then, change the stutter by reducing tension and moving ahead slowly into next sound or word • Why use it? • Take conscious control of and confront the stuttering moment (desensitization) • Release tension and keep speech moving forward • Reinforce a looser way of stuttering • When & how to use it? • When there is a high degree of emotionality or “trapped” feeling • After learning to hold onto a stuttering moment and tolerate it • Start with deliberate or “fake” (voluntary) stuttering at the single word level

25. Changing Stuttering:Cancellation (Post-Block Correction) • What is it? • Finishing a stuttered word • Pausing for a moment to plan (e.g. pantomime or silently revisit the word) then • Stuttering on the word again in an easier way • Why use it? • Learn to “cancel out” or replace hard stuttering with a looser, more controlled form of stuttering • Discourages avoidance behaviors such as recoiling, changing words, stopping in a block and backing up • Reinforces easier stuttering and build confidence • When and how to use it? • MUST complete the hard stutter before pausing and making it easier • If unable to pullout or missed the opportunity to use a pullout, this provides another opportunity to learn to stutter more easily • Typically used in the therapy room only, not in the outside world

26. How can Williams’ Normal Talking Model help you document change as a result of therapy? • Consider the type of stuttering the client is currently exhibiting • If the client is able to change the moment of stuttering, what is he/she adding in that wasn’t there before? • In other words, why might a prolongation or part-word repetition be a “better” type of stuttering for the client? • Why would you want to represent progress in this way?

27. Possible documentation • When prompted by the SLP, the child will name and describe at least 3 components of Williams’ Normal Talking Model. • When prompted by the SLP, the child will demonstrate varying levels of airflow (tension) (movement) and associate them with fluent and stuttered speech production in at least 5 opportunities. • When prompted by the SLP, the child will change a stutter to increase forward flow of speech by changing (airflow, tension, phonation, movement, timing) in 4/5 opportunities.

28. References Chmela, K., & Reardon, N. (2001). The school-age child who stutters: Working effectively with emotions and attitudes…A workbook. Memphis, TN: Stuttering Foundation of America. Cook, F. and Fry, J. (2006) Connecting stuttering measurement and management: III. Accountable therapy. International Journal of Language and Communication Disorders, 41, 379-394 Dell, C. (2000). Treating the school age child who stutters: A guide for clinicians (2nd edition). Memphis, TN: Stuttering Foundation of America. Fraser, J. (Ed.) (2000). Stuttering therapy: Transfer and maintenance. Memphis, TN: Stuttering Foundation of America. Gregory, H. H. (2003). Stuttering therapy: Rationale and procedures. Boston: Allyn & Bacon. Guitar, C., & Fraser, J. (2007). Basic clinical skills (DVD). Memphis, TN: Stuttering Foundation of America. Guitar, C., & Fraser, J. (2006). The genius of Dean Williams. Memphis, TN: Stuttering Foundation of America. Ramig, P.R., & Dodge, D.M. (2005). The child and adolescent stuttering treatment and activity resource guide: Clifton Park, NY:Thomson/Delmar/Singular. Sheehan, J. G. (1970). Stuttering: Research and therapy. New York: Harper & Row. Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall. Zebrowski, P. M., & Kelley, E. (2002). Manual of stuttering intervention. Clifton Park, NJ: Singular.