SPA 461. SPA 461. Introduction to Introduction to Fluency Disorders Fluency Disorders

Fall Semester, 2003Fall Semester, 2003 M-W-F: 8:00-8:50M-W-F: 8:00-8:50

Stephen B. Hood, Ph.D.Stephen B. Hood, Ph.D.University of South AlabamaUniversity of South Alabama

Behavioral and Emotional Behavioral and Emotional DimensionsDimensions

R ep e tit ion sS ou n d /S yllab le

P ro lon g a tion sV o ic ed

V o ic e les s

B loc ksH ard C on tac ts

s ta rte rs /s ta lle rsIn te rjec tion s

reco ils

Typ e

D u ra tion

E ffo rt/ In ten s ity

F req u en cy

B eh avio rsO vert

S h am eG u ilt

V ic t imH elp les s

S cared /N ervou s

A n tic ip a tionE xp ec tan c y

A tt itu d es an d F ee lin g s

E m otion sC overt

S TU TTE R IN G

Sheehan’s Iceberg of StutteringSheehan’s Iceberg of Stuttering

Core Features Repetitions Prolongations Blockages

Secondary Features

Escape Avoidance

Attitudes & Feelings Fear Guilt Shame Denial

P re -D is ru ptio n F lue n c y D is rup tio n P o st D isr u pt io n

E m o t io n a l B e h a v io ra l B e h a v io ra l E m o t io n a l

A n t ic i p a t io n A v o id a n c e D is f l u en c y E m b a r ra s s m e n tE x p e c t a n c y P o s t p o n e m e n t F lu e n c y F a i lu re H u m il i a t io nF e a r W o rd S u b s t it u t io n S t u t t e rin g G u il tW o rry D is g u is e R e l i e fA p p re h e n s i o n A n t i e x p ec t a n c y A u d ib le - V o c a li z e d S h a m eA n x ie t y T i m e rs P a r t -W o rd R e p e t it i o n s W it h d ra w a lD re a d S t a r te rs W o rd R e p e t it io n s A n x i e tyW o rry P a u s e s P h ra s e R e p e t it io n s H o s t i l it yN e g a t iv e - C i rc u m lo c u t io n s S o u n d P ro lo n g at io n s F ru s t ra t io n E m o t io n B o d y M o v e m e n ts A u d ib le -N o n v o c a l i ze d P e n a lt yA b u li a R e fu s a l P a r t -W o rd R e p e t it i o n s D e n ia l( e tc . ) (e t c .) S o u n d P ro lo n g at io n s

D y s rh y t h m ic P h o n a t io n sIn a u d ib le - N o n v o c a li z e d

h a rd c o n ta c t st e n s e p a u s e ss il e n t b lo c k s

S t ru g g le - E s c a p eR e c o ilIn t e r ru p t e rsE f fo r t/ t r e m o r / s t ru g g le( e tc .)

> > - - - - r a t e c h a n g e s -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - > >> > - - - - - - - - s p e e d in g a n d t e n s in g -- - - - - - - - - - - > >> > - - - - - - - -h o ld in g b a c k - -- - - - - - - - - - - - - - - -- - > >

(A f t e r H o o d , 1 9 7 8 . A s s e s s m e n t o f F l u en c y D is o rd e r s )f il e : \ m o m en t o f .s t\ (9 9 )

Time Sequencing of Time Sequencing of EventsEvents

Episodic (VR- stages I and II)Episodic (VR- stages I and II) Chronic (VR- stages III and IV)Chronic (VR- stages III and IV) Intermittent -- alwaysIntermittent -- always ““Descriptive Language Framework” Descriptive Language Framework”

(Dean Williams)(Dean Williams) ““Normal nonfluency” -- “normal disfluency”Normal nonfluency” -- “normal disfluency”

easy, effortless, rhythmic, infrequenteasy, effortless, rhythmic, infrequent multiple word repetitions, multisyllable whole word repetitions, multiple word repetitions, multisyllable whole word repetitions,

revisions, interjectionsrevisions, interjections usually only one, or maybe two, reiterationsusually only one, or maybe two, reiterations

Key Terms and ConceptsKey Terms and Concepts

Key Terms and Concepts Key Terms and Concepts (continued)(continued)

““Stutter-like disfluency” (SLD)Stutter-like disfluency” (SLD) More fragmented: sound and syllable repetitions, More fragmented: sound and syllable repetitions,

single-syllable whole word repetitions, sound single-syllable whole word repetitions, sound prolongations and disrhythmic phonations, hard prolongations and disrhythmic phonations, hard contacts, tense pauses and silent blockscontacts, tense pauses and silent blocks

Reiterations of repetitions usually more than twoReiterations of repetitions usually more than two Overt features -- Covert featuresOvert features -- Covert features Escape behaviors -- Avoidance behaviors Escape behaviors -- Avoidance behaviors Predisposing, Precipitating, SustainingPredisposing, Precipitating, Sustaining

Key Terms and ConceptsKey Terms and Concepts (Continued)(Continued)

Incidence -vs- PrevalenceIncidence -vs- Prevalence ““Stutterer” -vs- “Person Who Stutters”Stutterer” -vs- “Person Who Stutters” Spontaneous RecoverySpontaneous Recovery Gender DifferencesGender Differences

Factors Related to FluencyFactors Related to Fluency

Melody/prosody/inflectionMelody/prosody/inflection PausesPauses Rate: speech rate -vs- articulation rateRate: speech rate -vs- articulation rate Amount of information flowAmount of information flow Effort: both physical and mentalEffort: both physical and mental FluencyFluency

PhonologicPhonologic SyntacticSyntactic SemanticSemantic PragmaticPragmatic

Historical Definitions of StutteringHistorical Definitions of Stuttering

Wendell JohnsonWendell Johnson Stuttering is an anticipatory, apprehensive, Stuttering is an anticipatory, apprehensive,

hypertonic, avoidance reaction.hypertonic, avoidance reaction. Stuttering occurs when speaker expects to stutter, Stuttering occurs when speaker expects to stutter,

dreads it, becomes tense in anticipation, and tried to dreads it, becomes tense in anticipation, and tried to avoid it.avoid it.

Diagnosogenic theory: “stuttering begins not in the Diagnosogenic theory: “stuttering begins not in the child’s mouth, but in the listeners ear.”child’s mouth, but in the listeners ear.”

X =speech characteristics, Y= listener reactions, X =speech characteristics, Y= listener reactions, Z = speaker reactions to listener.Z = speaker reactions to listener.

Historical Definitions of StutteringHistorical Definitions of Stuttering

Charles Van RiperCharles Van Riper ““Stuttering occurs when the flow of Stuttering occurs when the flow of

speech is interrupted abnormally by speech is interrupted abnormally by repetitions or prolongations of a sound, repetitions or prolongations of a sound, syllable or articulatory posture, or by syllable or articulatory posture, or by avoidance and struggle reactions.”avoidance and struggle reactions.”

These produce interruptions and breaks These produce interruptions and breaks in the rhythmic flow of speech. in the rhythmic flow of speech.

Historical Definitions of StutteringHistorical Definitions of Stuttering

Oliver BloodsteinOliver Bloodstein““Stuttering is an anticipatory-struggle reaction. It Stuttering is an anticipatory-struggle reaction. It

represents an exacerbation of the tensions and represents an exacerbation of the tensions and fragmentations that are common occurrences in the fragmentations that are common occurrences in the speech of normally developing children.”speech of normally developing children.”

““Stuttering develops readily in circumstances in which Stuttering develops readily in circumstances in which speech pressures are unusually heavy, the child’s speech pressures are unusually heavy, the child’s vulnerability to them is unusually high, or vulnerability to them is unusually high, or communicative difficulties are unusually frequent, communicative difficulties are unusually frequent, severe or chronic.”severe or chronic.”

Core Features (Guitar)Core Features (Guitar)Refer to Textbook, for developmental stagesRefer to Textbook, for developmental stages

Prolongations / Fixations (often develop second)Prolongations / Fixations (often develop second) Audible: Vocalized and Nonvocalized Audible: Vocalized and Nonvocalized Disrhythmic phonationsDisrhythmic phonations

Blocks (Usually develop last)Blocks (Usually develop last) Inaudible -- Nonvocalized Inaudible -- Nonvocalized Silent fixations of posture Silent fixations of posture Complete stoppageComplete stoppage

Repetitions (usually develop first)Repetitions (usually develop first) Sounds, syllables, single syllable whole wordsSounds, syllables, single syllable whole words Audible: Vocalized and NonvocalizedAudible: Vocalized and Nonvocalized Inaudible and NonvocalizedInaudible and Nonvocalized

Secondary FeaturesSecondary Features

ESCAPEESCAPE Escape behaviors develop prior to avoidance behaviors. At first, Escape behaviors develop prior to avoidance behaviors. At first,

these are probably random, but later serve to release the person these are probably random, but later serve to release the person from the stuttering moment.from the stuttering moment.

Later, become well learned through negative reinforcement.Later, become well learned through negative reinforcement. Prominent in Intermediate and Advanced Stages.Prominent in Intermediate and Advanced Stages.

AVOIDANCEAVOIDANCE Learned as response to anticipation of stuttering. May actually be Learned as response to anticipation of stuttering. May actually be

similar to escape behaviors, but now used to avoid prior to similar to escape behaviors, but now used to avoid prior to stuttering.stuttering.

Become maintained by positive reinforcement.Become maintained by positive reinforcement. May begin in Intermediate Stage, and highly prevalent in Advanced May begin in Intermediate Stage, and highly prevalent in Advanced

Stage.Stage.

Feelings and AttitudesFeelings and Attitudes

Feelings (Affective)Feelings (Affective) Refer to text for examples, relative to developmental Refer to text for examples, relative to developmental

stagestage Examples: frustrated, nervous, scared, upset, Examples: frustrated, nervous, scared, upset,

embarrassed, guilt, shame, denial embarrassed, guilt, shame, denial Attitudes (Cognitive)Attitudes (Cognitive)

Related more to your beliefs about stuttering and Related more to your beliefs about stuttering and stutters. Refer to text for examples related to stutters. Refer to text for examples related to developmental statedevelopmental state

e.g., that stuttering is bad, wrong, nasty, etc. That e.g., that stuttering is bad, wrong, nasty, etc. That stutterers are stupid, unworthystutterers are stupid, unworthy

Developmental and Developmental and Environmental InfluencesEnvironmental Influences

DevelopmentalDevelopmental PhysicalPhysical CognitiveCognitive Social-EmotionalSocial-Emotional Speech & LanguageSpeech & Language

EnvironmentalEnvironmental ParentsParents Speech & Language Speech & Language

EnvironmentEnvironment Life EventsLife Events

Diagnosogenic Theory: JohnsonDiagnosogenic Theory: Johnson

Johnson emphasized the overlap between Johnson emphasized the overlap between children beginning to stutter and children who children beginning to stutter and children who were normally nonfluent.were normally nonfluent.

Stuttering results from its (mis-)diagnosis.Stuttering results from its (mis-)diagnosis. ““Stuttering begins not in the child’s mouth, but Stuttering begins not in the child’s mouth, but

the listeners ear.”the listeners ear.” Johnson was wrong as to etiology, but correct Johnson was wrong as to etiology, but correct

with respect to “critical evaluations”with respect to “critical evaluations” Mary Tudor and the “Monster Study”Mary Tudor and the “Monster Study”

Communicative Failure and Communicative Failure and Anticipatory Struggle: BloodsteinAnticipatory Struggle: Bloodstein

Kids with communication difficulties (articulation, Kids with communication difficulties (articulation, language, word-finding) are more at risk for stuttering language, word-finding) are more at risk for stuttering to develop. When kids have a hard time being to develop. When kids have a hard time being understood, especially in a demanding environment, understood, especially in a demanding environment, then they are even more vulnerable.then they are even more vulnerable.

Early communicative failures lead to tension and Early communicative failures lead to tension and fragmentationfragmentation

Tension and Fragmentation can lead to anticipatory-Tension and Fragmentation can lead to anticipatory-strugglestruggle

Capacities and Demands: Capacities and Demands: StarkweatherStarkweather

1.1. The child’s capacity for fluency does not The child’s capacity for fluency does not equal environmental demands for it.equal environmental demands for it.

2.2. Reduced capacity may be caused by Reduced capacity may be caused by “organic predisposition.”“organic predisposition.”

3.3. It is the ratio of demands to capacities that It is the ratio of demands to capacities that is important. This becomes a focus of is important. This becomes a focus of therapy.therapy.

4.4. Components: Motoric, Linguistic, Components: Motoric, Linguistic, Emotional, Cognitive,Social-Pragmatic. Emotional, Cognitive,Social-Pragmatic.

The Development of StutteringThe Development of Stuttering

Van Riper’s 4-Stage model (Handout)Van Riper’s 4-Stage model (Handout) Douglass and Quarrington - Exteriorized Douglass and Quarrington - Exteriorized

Interiorized (Handout)Interiorized (Handout) Guitar (Borderline, Beginning, Guitar (Borderline, Beginning,

Intermediate, Advanced (Handout and Intermediate, Advanced (Handout and Text)Text)

Learning Theory: Brutten and Shoemaker. Learning Theory: Brutten and Shoemaker. Will be covered in Unit II. Will be covered in Unit II.

UNIT II: Learning Theory and AssessmentUNIT II: Learning Theory and Assessment

AssessmentAssessmentOvert-Behavioral FeaturesOvert-Behavioral Features

Learning Theory:Learning Theory:Emotional LearningEmotional LearningBehavioral LearningBehavioral Learning

Avoidance Avoidance EscapeEscape

Covert-Emotional FeaturesCovert-Emotional Features

Learning TheoryLearning Theory

Although there may be some debate as to Although there may be some debate as to precise etiology (organic-constitutional, precise etiology (organic-constitutional, psycho-emotional, environmental) there is psycho-emotional, environmental) there is strong agreement that once stuttering gets strong agreement that once stuttering gets started, learning theory plays a major role. started, learning theory plays a major role.

Learning theory may not explain predisposing Learning theory may not explain predisposing factors, but it helps explain precipitating and factors, but it helps explain precipitating and maintaining factors.maintaining factors.

Classical ConditioningClassical Conditioning

SynonymsSynonyms Classical, Pavlovian, Respondent, reflexiveClassical, Pavlovian, Respondent, reflexive

Contiguous PairingsContiguous Pairings UCS -----> UCRUCS -----> UCR NS -----> ?NS -----> ? NS---UCS -----> UCRNS---UCS -----> UCR CS ------> CRCS ------> CR

ExamplesExamples Audiology -- Galvanic Skin ResponsesAudiology -- Galvanic Skin Responses Students -- # 2 Pencils, and test sheetsStudents -- # 2 Pencils, and test sheets Stutterers -- The ringing of a telephoneStutterers -- The ringing of a telephone

Operant ConditioningOperant Conditioning

SynonymsSynonymsOperant, Skinnerian, Behavioral, InstrumentalOperant, Skinnerian, Behavioral, Instrumental

ContingenciesContingenciesResponse -> Consequence R---> CResponse -> Consequence R---> CR---- > Rf+ R---- > Rf+ positive reinforcementpositive reinforcementR---- > Rf- R---- > Rf- negative reinforcementnegative reinforcementR---- > NRR---- > NR no reinforcementno reinforcementR---- > P R---- > P punishment punishment

See Guitar Text. Pages 89-100See Guitar Text. Pages 89-100 See Class Handout BookletSee Class Handout Booklet

Brutten and ShoemakerBrutten and Shoemaker

Stuttering is a form of fluency failure which is Stuttering is a form of fluency failure which is the consequence of learned, antecedent, the consequence of learned, antecedent, negative emotion. Consistent because the negative emotion. Consistent because the emotion is learned.emotion is learned.

Fluency failures are the involuntary Fluency failures are the involuntary consequence of antecedent negative consequence of antecedent negative emotional. Sporadic because they are emotional. Sporadic because they are unlearned.unlearned.

See Diagrams in Class Handout.See Diagrams in Class Handout.

Conflict Learning Theory: Conflict Learning Theory: Sheehan (see class handout)Sheehan (see class handout)

Sheehan’s Double Approach-Avoidance Conflict Sheehan’s Double Approach-Avoidance Conflict Theory applies to precipitating and maintaining Theory applies to precipitating and maintaining factors. It is not a theory of etiology.factors. It is not a theory of etiology.

Levels of ConflictLevels of Conflict• approach-approachapproach-approach• avoidance-avoidanceavoidance-avoidance• approach-avoidanceapproach-avoidance• double approach-avoidancedouble approach-avoidance

Sheehan, ContinuedSheehan, Continued

Conflict HypothesisConflict Hypothesis• The stutterer stutterers when conflicting approach The stutterer stutterers when conflicting approach

and avoidance tendencies approach equilibriumand avoidance tendencies approach equilibrium Fear Reduction HypothesisFear Reduction Hypothesis

• The occurrence of stuttering reduces the fear that The occurrence of stuttering reduces the fear that elicited it, so that during the moment of stuttering elicited it, so that during the moment of stuttering there is sufficient reduction in fear-motivated there is sufficient reduction in fear-motivated avoidance to resolve the conflict and permit avoidance to resolve the conflict and permit release of the stuttered word.release of the stuttered word.

Sheehan, continuedSheehan, continued

The Fear of Both Speech and SilenceThe Fear of Both Speech and Silence• Speaking holds the promise of communication, but Speaking holds the promise of communication, but

the threat of potential stutteringthe threat of potential stuttering

• Silence temporarily eliminates the threat of Silence temporarily eliminates the threat of speaking and possibly stuttering, but at the speaking and possibly stuttering, but at the abandonment of communicating.abandonment of communicating.

• Guilt can be attached to both speaking and being Guilt can be attached to both speaking and being silent. silent.

Sheehan, continuedSheehan, continued

Sources of ConflictSources of Conflict• Speech -vs- SilenceSpeech -vs- Silence• Primary Guilt and Secondary GuiltPrimary Guilt and Secondary Guilt• Self as Stutterer -vs- Self as NonStuttererSelf as Stutterer -vs- Self as NonStutterer

– Role Acceptance -vs- Role DenialRole Acceptance -vs- Role Denial Levels of ConflictLevels of Conflict

• Word/Sound - specific sounds and/or wordsWord/Sound - specific sounds and/or words• Situation - time-pressure telephone, talk in class, to a groupSituation - time-pressure telephone, talk in class, to a group• Emotional Content - strong emotional valence to topicEmotional Content - strong emotional valence to topic• Role-Relationship - status-gap, authority figuresRole-Relationship - status-gap, authority figures• Ego Protective -- when ego being threatenedEgo Protective -- when ego being threatened

AssessmentAssessment

STUTTERING

BehaviorBehavior EmotionsEmotions

FrequencyFrequency AttitudesAttitudesIntensityIntensity FeelingsFeelingsDurationDurationTypeType

Disfluency AnalysisDisfluency Analysis

Key Concepts of ImportanceKey Concepts of Importance Obtaining valid samplesObtaining valid samples

rote automatic (count/days/months/poem, nursery rhyme)rote automatic (count/days/months/poem, nursery rhyme) picture descriptionpicture description monologue, telling story, relating an eventmonologue, telling story, relating an event reading (at age level)reading (at age level)

Number of meaningful words and syllables spokenNumber of meaningful words and syllables spoken Duration of speaking taskDuration of speaking task Molar Frequency CountMolar Frequency Count Molecular assessment of disfluency types.Molecular assessment of disfluency types. Speech Rate -versus- Articulation RateSpeech Rate -versus- Articulation Rate See disfluency analysis worksheet -- Class HandoutSee disfluency analysis worksheet -- Class Handout

Unit III: Prevention and TreatmentUnit III: Prevention and Treatment

Borderline-MildBorderline-Mild• Prevention and early Prevention and early

interventionintervention• Manipulation of Manipulation of

talking environmenttalking environment• Family InvolvementFamily Involvement

Intermediate-AdvancedIntermediate-Advanced• Direct focus on Direct focus on

stuttering: fluency stuttering: fluency shaping and stuttering shaping and stuttering modificationmodification

• Desensitization and Desensitization and copingcoping

• AcceptanceAcceptance• Attitudes & FeelingsAttitudes & Feelings

Explore your OptionsExplore your Options ComponentsComponents

• AttitudesAttitudes• FeelingsFeelings• BehaviorsBehaviors

– AvoidanceAvoidance– StutteringStuttering– EscapeEscape

Goals/ObjectivesGoals/Objectives• be fluentbe fluent• fluent stutteringfluent stuttering• manageable stutteringmanageable stuttering

EFFECTIVE EFFECTIVE COMMUNICATIONCOMMUNICATION

Look For Clues

Study Your Options

Final Outcomes from Therapy: Final Outcomes from Therapy: Goals, Options and ChoicesGoals, Options and Choices

H ig h S tim u lu s S p eec h

P u ll-O u ts , P rep ara to ry S e ts

P rio riocep tive M on ito rin g

"F lu en t S tu tte rin g "

M anaging S tuttering

B reath s tream M an ag em en t

E asy O n sets

F lu en cy E n h an c in g B eh avio rs

P rec is ion F lu en cy S h ap in g

M anaging Fluency

Hom e Free

Norm al Spontaneus Fluency

F in a l Th erap y O u tcom es

Realistic Outcomes: : for adults for whom stuttering has become for adults for whom stuttering has become

chronic and severechronic and severe

To be able to talk any time, any place To be able to talk any time, any place and to any bodyand to any body

And to be able to communicate And to be able to communicate effectively and efficientlyeffectively and efficiently

And to be able to do so with little more And to be able to do so with little more than a normal amount of negative than a normal amount of negative emotion.emotion.

Therapy Therapy For the Advanced StuttererFor the Advanced Stutterer

• Fluency Shaping ApproachesFluency Shaping Approaches• Stuttering Modification ApproachedStuttering Modification Approached• Combined ApproachesCombined Approaches• Traditional SchedulingTraditional Scheduling• Intensive ProgramsIntensive Programs

See Text. Pages 231-233, and 237.See Text. Pages 231-233, and 237.

Components of Therapy for Components of Therapy for Advanced (older) stutterersAdvanced (older) stutterers

BehavioralBehavioral IdentificationIdentification behaviors and behaviors and

emotionsemotions DesensitizationDesensitization

behaviors and behaviors and emotionalemotional

ModificationModification StabilizationStabilization

Emotional Being open, honest, Being open, honest,

acceptingaccepting Stuttering is really OK. Stuttering is really OK.

Be able to talk about it.Be able to talk about it. Reduce shame, guilt, Reduce shame, guilt,

denial denial I don’t need to chase I don’t need to chase

the “Fluency God”the “Fluency God”

Changing Stuttering Behaviors:Changing Stuttering Behaviors:(Additional Information in SFA Booklets)(Additional Information in SFA Booklets)

Fluency ShapingFluency Shaping• Slower rateSlower rate• Easy OnsetEasy Onset• Soft ContactSoft Contact• ProprioceptionProprioception

Stuttering ModificationStuttering Modification• Voluntary StutteringVoluntary Stuttering• CancellationCancellation

– erase and fixerase and fix• Pull-OutPull-Out

– freeze and releasefreeze and release• Proprioceptive Proprioceptive

monitoringmonitoring• Preparatory SetsPreparatory Sets

Changing Stuttering Behaviors Changing Stuttering Behaviors (continued)(continued)

Identification and understanding core behaviors, Identification and understanding core behaviors, secondary behaviors of escape and avoidance, and secondary behaviors of escape and avoidance, and attitudes and feelingsattitudes and feelings

Discussing stuttering openlyDiscussing stuttering openly Using feared words, and entering feared situationsUsing feared words, and entering feared situations Freezing, holding and gradually releasingFreezing, holding and gradually releasing Voluntary stuttering (and advertising in other ways)Voluntary stuttering (and advertising in other ways) Using FEBS (Fluency Shaping)Using FEBS (Fluency Shaping) Stuttering more easily (Stuttering Modification)Stuttering more easily (Stuttering Modification)

Cancellation, Pull-Outs, Preparatory Sets.Cancellation, Pull-Outs, Preparatory Sets.

Ideas from the InternetIdeas from the InternetAlong with other SourcesAlong with other Sources

I no longer need to chase the “Fluency God.”I no longer need to chase the “Fluency God.” I can live without constant fear.I can live without constant fear. I can speak well without scanning ahead for difficult words. I can speak well without scanning ahead for difficult words. I can speak for myself, rather than rely on others.I can speak for myself, rather than rely on others. I can explore and follow career opportunities that require talking.I can explore and follow career opportunities that require talking. I can make decisions in spite of stuttering, not because of it.I can make decisions in spite of stuttering, not because of it. I am not suffering or handicapped because of my stuttering.I am not suffering or handicapped because of my stuttering. I accept myself.I accept myself. I don’t feel guilty when I stutter, and I am not ashamed of myself. for I don’t feel guilty when I stutter, and I am not ashamed of myself. for

when I do sometimes stutter.when I do sometimes stutter. I have choices I can make that help me talk easily.I have choices I can make that help me talk easily. I communicate effectively, and feel comfortable doing so.I communicate effectively, and feel comfortable doing so. ““I’m really an o-k person” -- and I like being me.I’m really an o-k person” -- and I like being me.

Crucial Experiences: (Adapted Crucial Experiences: (Adapted from Van Riper and Czuchna)from Van Riper and Czuchna)

Stuttering can be deliberately endured, touched, maintained and Stuttering can be deliberately endured, touched, maintained and studied.studied.

Avoidance only increases fear, and must be reduced.Avoidance only increases fear, and must be reduced. Struggled, hurried escapes and recoils from stuttering make it worse Struggled, hurried escapes and recoils from stuttering make it worse

than it needs to be.than it needs to be. It is possible to build barriers to destructive listener reactions.It is possible to build barriers to destructive listener reactions. Society in general rewards the person who obviously confronts and Society in general rewards the person who obviously confronts and

attempts to deal positively and constructively with stuttering.attempts to deal positively and constructively with stuttering. Every effort must be made to build up your ego-strength, self-Every effort must be made to build up your ego-strength, self-

confidence and self-respect.confidence and self-respect. When the moment of stuttering occurs it can be studied, and its evil When the moment of stuttering occurs it can be studied, and its evil

effects erased as much as possible.effects erased as much as possible. It is personally more rewarding to stutter easily and stutter fluently than It is personally more rewarding to stutter easily and stutter fluently than

to stutter severely, and it is fun to be able to talk anywhere, even to stutter severely, and it is fun to be able to talk anywhere, even though you do stutter.though you do stutter.

Ways to Talk Easily -- (Which ImpliesWays to Talk Easily -- (Which Implieshelpful prerequisite attitudes)helpful prerequisite attitudes)

Post-It NotesPost-It NotesAVMAVM Air-Voice-MovementAir-Voice-MovementKYMRKYMR Keep Your Motor RunningKeep Your Motor RunningRTSERTSE Remember to Start EasilyRemember to Start EasilyNNTHNNTH No Need to HurryNo Need to Hurry

Speech Rate -vs- Articulation RateSpeech Rate -vs- Articulation Rate““Slow it down -- to speed it up”Slow it down -- to speed it up”““Gearing down and gearing up”Gearing down and gearing up”

Speeding Tickets (car) -vs- Talking Tickets (mouth)Speeding Tickets (car) -vs- Talking Tickets (mouth)Dealing With Time PressureDealing With Time Pressure

Ways to Talk Easily -- (which impliesWays to Talk Easily -- (which implieshelpful prerequisite attitudes)helpful prerequisite attitudes)

Self Talk and the Use of Language: action oriented verbsSelf Talk and the Use of Language: action oriented verbs Dean Williams: The language of self-responsibilityDean Williams: The language of self-responsibility““What Happened” -vs- “What am I doing”What Happened” -vs- “What am I doing”““Having a block” and “Getting Stuck”Having a block” and “Getting Stuck”““Little men are fighting in my throat”Little men are fighting in my throat”

NownessNowness

Superstitious BehaviorsSuperstitious Behaviors

Safety MarginsSafety Margins

Adjustment to easy talking and fluency. No more secondary gainsAdjustment to easy talking and fluency. No more secondary gainsOpenness: Advertising, Voluntary Stuttering, Pseudo-StutteringOpenness: Advertising, Voluntary Stuttering, Pseudo-Stuttering

Hood’s Hopefully Helpful HintsHood’s Hopefully Helpful Hints

Although you may not have a choice as to WHETHER you stutter, you Although you may not have a choice as to WHETHER you stutter, you have a choice as to how you stutter.have a choice as to how you stutter.

Attempting to hide, repress, conceal, avoid stuttering makes it worse Attempting to hide, repress, conceal, avoid stuttering makes it worse than it needs to be.than it needs to be.

Stuttering is something you do, not something that happens to you.Stuttering is something you do, not something that happens to you. The things that may have originally caused stuttering are not the same The things that may have originally caused stuttering are not the same

as the things that influenced its development -- and are not the same as the things that influenced its development -- and are not the same as the things that are now serving to maintain the problem.as the things that are now serving to maintain the problem.

Fluency is more than the absence of stuttering.Fluency is more than the absence of stuttering. It is important to understand the process of talking.It is important to understand the process of talking. The process of desensitization is two fold: both emotional AND The process of desensitization is two fold: both emotional AND

behavioral.behavioral. It is better to do more and more things to talk easily, than more and It is better to do more and more things to talk easily, than more and

more thingsmore things to try not to stutter. to try not to stutter.

Therapy for Intermediate StutteringTherapy for Intermediate Stuttering

Therapy is related to severity of Therapy is related to severity of stuttering, and Intermediate stuttering is stuttering, and Intermediate stuttering is highly similar to advanced stuttering, highly similar to advanced stuttering, although client is probably younger, and although client is probably younger, and has not been stuttering for as long. has not been stuttering for as long.

Therapy involves both fluency shaping Therapy involves both fluency shaping and stuttering modification. and stuttering modification.

Therapy Goals and Behaviors Therapy Goals and Behaviors Targeted for Therapy Targeted for Therapy (Intermediate)(Intermediate)

Fluency enhancing behaviors Fluency enhancing behaviors • slow rate, gentle onset, light contactslow rate, gentle onset, light contact

Stuttering modification Stuttering modification • cancellations, pullouts, preparatory sets and cancellations, pullouts, preparatory sets and

proproiceptive monitoring.proproiceptive monitoring. Desensitization: Desensitization:

• to understand, to understand, • to acceptto accept• to copeto cope

Clinical Procedures Clinical Procedures (Intermediate)(Intermediate)

Explore and understand stuttering momentsExplore and understand stuttering moments• reduce negative feelingsreduce negative feelings• increase acceptanceincrease acceptance• reduce/eliminate secondary behaviors of reduce/eliminate secondary behaviors of

avoidance and escape avoidance and escape • use of FEBS and modification techniquesuse of FEBS and modification techniques

–speech helpers, AVM, KYMR, etc.speech helpers, AVM, KYMR, etc.–Monitoring: gearing up and gearing down.Monitoring: gearing up and gearing down.

Clinical ProceduresClinical Procedures (Intermediate)(Intermediate)

Reducing negative feelingsReducing negative feelings Coping with teasingCoping with teasing Desensitization to fluency disruptersDesensitization to fluency disrupters Eliminating avoidancesEliminating avoidances Being open and accepting of stutteringBeing open and accepting of stuttering Maintaining eye contactMaintaining eye contact Being helpful to parents and teachersBeing helpful to parents and teachers

Therapy for Beginning StutteringTherapy for Beginning Stuttering

Whereas fluency shaping and Whereas fluency shaping and stuttering modification are quite different stuttering modification are quite different in Intermediate and Advanced levels, in Intermediate and Advanced levels, they is more overlap with beginning they is more overlap with beginning stuttering.stuttering.

Working to establish easy, ongoing, Working to establish easy, ongoing, fluent talking, and then transferring and fluent talking, and then transferring and maintaining it.maintaining it.

Therapy for Beginning StutteringTherapy for Beginning Stuttering

Make speech fun Make speech fun Make talking environment “fluency-friendly.Make talking environment “fluency-friendly. See Hood’s Handout on “suggestions to help children See Hood’s Handout on “suggestions to help children

talk fluently” for ideas to use with family.talk fluently” for ideas to use with family. Desensitize to fluency disrupters.Desensitize to fluency disrupters. Gradually increase the length and complexity of Gradually increase the length and complexity of

child’s fluent utteranceschild’s fluent utterances Other procedures are highly individualized, and will Other procedures are highly individualized, and will

be covered more in the graduate course.be covered more in the graduate course.

Therapy for Borderline StutteringTherapy for Borderline Stuttering

See Hood’s Handout on helping children See Hood’s Handout on helping children talk easilytalk easily

Work TOWARD easy, fluent talking, rather Work TOWARD easy, fluent talking, rather than away from stuttering.than away from stuttering.

Work with family to create positive talking Work with family to create positive talking environment for the child. Family environment for the child. Family counseling is important.counseling is important.

See page 371 and 372. Guitar text.See page 371 and 372. Guitar text.