Stuttering in Children and Adults

STUTTERING in Children and Adults: Selected Therapy Considerations

Possible Problem Areas to Explore
and
Possible Things to Do

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

INTRODUCTORY NOTE:

In thinking about fluency, disfluency and stuttering, consider the following levels.  For any individual child, which level, either alone or in combination with others, might be contributing to the problem:

1. Phonological fluency:  the ability to correctly and accurately pronounce long strings of syllables in unfamiliar combinations.  (Oral gymnastics and tongue twisters, etc.)
2. Syntactic fluency:  the ability to encode highly complex sentences representing a wide variety of complex content-form relations.
3. Semantic fluency:  the ability to have and use a large vocabulary.
4. Pragmatic fluency:  the ability to know what to say in a wide range of social situations. 

A. Fluency and Disfluency often relates to overall speech and language.

Often, we need to work more with overall speech and language, and less with disfluency and stuttering.  This is especially true for younger children, and for children whose stuttering is still in the early stages of developmental severity.

1. Delayed development of the speech and language with the accompanying pressures and feelings of communicative inability are frequently associated with developmental nonfluency, incipient stuttering, and the development of stuttering in children.
2. Articulation problems, with an accompanying increase in awareness of speech difficulties, often cause fluency problems.  Children who realize that listeners have difficulty understanding them, are under increased communicative and linguistic stress.  Therefore, they are vulnerable and susceptible to increases in disfluency.
3. Slow development of fine muscle coordination in the speech mechanism, generally inadequate motor functioning or inadequate oral perception, can have a detrimental effect on the development of fluency.
4. Feelings of failure in early reading experiences can be a problem, especially for children who are highly nonfluent and/or who stutter.  These children often need, and will benefit from help, in both silent and oral reading.
5. A Bilingual background with accompanying language confusions and word finding difficulty, often results in increased disfluency.
6. Attempts to model or produce excessively complex utterances are often associated with increases in disfluency.  Children who are expected to be verbally precocious are potentially "at risk" for fluency problems.
7. Disfluency differences in children with language and learning disabilities:  typically more inter-word that intra-word disfluencies.
8. Language and learning disabled children usually evidence pauses that are "semantically filled" rather than "semantically empty".
9. Linguistically advanced children may be more nonfluent that "average" talkers, but for a different reason.  They are "talking above their heads" and have disfluencies that are not highly fragmented.  Like the language delayed child, disfluencies tend to be inter-word rather than intra-word, and tend to be semantically filled rather than semantically empty.
10. Fluency is more vulnerable when speaker has increased communicative responsibility for the importance of the message (e.g., statement, request, question, clarification, etc), and expected reaction of the listener(s).
11. Children are more vulnerable to fluency breakdowns when there is the expectation of receiving negative listener reactions.

B. Fluency and Disfluency often relate to the child's speaking environment.

Modification of the child's speaking environment is often necessary:  at school, at home, in play situations, etc.

1. The vocabulary level and complexity of language structure to which the child is being exposed.
   People who talk to the fluency client should KISS:  Keep It Simple Stupid.

2. The rate of speaking of parents, siblings, and others with whom the child is often much too fast.  It is important to differentiate speech rate in terms of words spoken per minute (WPM) and articulation rate in terms of syllables spoken per second (SPS).
3. Rate Reduction by pausing between words is bad!
4. Rate Reduction by stretching syllables is good!

          "Smooth and slow"     "air - voice - movement"

          "keep your motor running"     "stretch and slide"

          "blending"     "exaggerated transitions"

3.  The degree to which the child is frustrated in his attempts to communicate, due to the frequency and/or intensity with which he is interrupted in his speaking attempts.   
4. The amount and kind of individual speech stimulation he has received.
5.  The circumstances surrounding the manner in which his articulation, word choice, or grammar are corrected by adults in his environment.
6. Time pressure:  the perceived need to say a lot in a short amount of time.
7.  Loss of listener attention.
8.  Demand speech:  Demands to respond to excessive questions.  Interrogation.
9. Display speech:  Verbal showing off.
10.  Excessive excitement.
11.  Maladaptive Pragmatic Interactions
    1. Speaker Dominance
    2. Verbal Turn Taking
       Interrupting
       Contradicting
       Pausing between turns
    3. Topic Maintenance
       appropriate to maintain (persistence)
       inappropriate to maintain (perseveration)
       as maintained by child
       as maintained by other person
    4. Topic Change
       appropriate times to change
       inappropriate times to change
       as changed by child
       as changed by other person
       how abrupt is the change?

12. Inappropriate prosodic models from others:  melody, inflection, intonation.  (The need to talk like Mr. Rogers).
    1. Speech Rate:  (Meaningful words spoken per unit time -- words or syllables per minute)
    2. Articulation Rate:  (Syllables spoken, when fluent -- syllables per second)
    3. Prosody
       The Importance of "MR. ROGERS."
       "Turtle Talking"
       Statements -vs- Demands -vs- Questions

C. Fluency and Disfluency often relate to social factors.

1. Marital problems or other interpersonal relationship difficulties within the family.
2. The lack of patience on the parts of parents in accepting the "childishness" of children.  Trying to act too old too soon is difficult, even for a bright child.
3.  The degree of compulsivity, impulsivity, and/or perfectionism exhibited by "significant others" with regard to the child's clothing, neatness, tidiness, untouchable objects and demands for excessive politeness.
4.  The emotional response of listeners to the disfluencies being exhibited by the child.
5.  Attempts on the part of parents to "pour a child into a mold" to make him what they think their son or daughter should be, instead of letting him be what he is.
6.  Emotional shocks or accidents that would only increase disfluency temporarily if they were handled well at the time, but if the parents continue to respond emotionally and constantly remind the child of his great misfortune or his unpleasant experience, the effect can be more lasting.
7.  Sibling rivalry and the need to compete for attention, possessions, and self- esteem.  Unrealistic or unfair comparisons with other children.
8. Family structure and discipline that is unfair, inconsistent and ineffective.
9.  Problems relating to the peer groups.

D. Fluency and Disfluency often relate to personality traits.

1. Compulsiveness may be evidenced in the child's attempt to be more fluent than his capacity will allow.  Often he is also trying to write more neatly, draw more perfectly or get higher grades than he can accomplish without undue pressure.
2. Hypersensitivity is a personality trait that often leads a child to try too hard to please the people around him.  His need for total acceptance and fear of rejection can make him more apprehensive and thus more disfluent.
3. Impatience with one's self builds tension in anyone, but if and impatient person becomes impatient concerning his communication skills and does not allow adequate pauses of sufficient time to formulate ideas, his speech will exhibit increased disfluency.
4. Unrealistic self expectations can result in embarrassment and frustration and unwarranted feelings of failure.  If a person tries to talk about something about which he knows very little, disfluency necessarily results.
5. Perfectionism.  The child does not want to make a mistake.
6. Frustration Tolerance.  Some children have low levels of coping with frustration.  Whereas some children are "generally frustrated", others show frustration primarily with respect to speech.
7. Poor Self-concept:  As a person in general, and as a speaker in particular.  Factors involving morale and ego strength.

E. Factors in Prevention and Early Intervention

1. Determining the Significant Others in the Child's Environment.
   1. CAUTION:  Correlation does not mean cause and effect.
   2. CAUTION:  Beta Weights of variables not always known.
2. See Handout:  "Suggestions to Help Children Talk Fluently"

F. Factors in Direct Modification

1. Selected Models:  What is Being Modified?
   1. Dean Williams: Modify the Talking
   2. Joseph Sheehan: Modify the Conflicts
   3. Gene Brutten: Modify the Negative Emotion
   4. George Shames and Cheri Florance: Be "Stutter" - Free
   5. Charles Van Riper: Stutter More Fluently
   6. Eugene Cooper: Fluency Initiating Gestures
   7. Ron Webster: Gentle Onsets
   8. Bill Perkins: Breathstream Management
   9. Ted Peters & Barry Guitar: Fluency Enhancing Behaviors & Stuttering Modification
2. What is the Target of Therapy?
   1. Modify the talking
   2. Modify the stuttering
   3. Modify the behaviors which result in talking or stuttering
   4. Developing strategies to COPE:
   5. Identification and Desensitization:
      Psycho-Emotional
      Behavioral
3. Ways of Looking at the Final Outcome of Therapy
   1. Spontaneous Normal Fluency
   2. Monitored Controlled Fluency
   3. Monitored Controlled Stuttering
4. The Question of VIGILANCE
   1. How hard must the client work to talk well?
   2. Is the price of monitoring worth it?
   3. Constant Monitoring of the mechanism?
   4. Monitoring only during anticipatory expectancy?
   5. Monitoring only during moments of tensing?

G. Helpful Hints and Other Goodies

1. The Need for Descriptive Language:  The Language of Self Responsibility
   1. What happened -vs- what are you doing.
   2. Action oriented verbs
   3. Verbs in the progressive tense
   4. Keeping the Language at the Client's Level
   5. Cancellation = Erase and Fix
   6. Approach-Avoidance Conflict = tug of war between the good guys who approach, and the bad guys who avoid.
   7. Easy speech and Teflon Talking
      1. Mr. Rogers' Speech
      2. Turtle Talking
   8. Speeding Tickets and Talking Tickets
   9. Picture Sequencing
   10. Post-It Notes
2. The Need for Environmental Therapy:  Working with Significant Others
   1. Advantages of school therapy:  access to teachers and peers
   2. Advantages of clinic:  access to parents and siblings
   3. Conclusion: Kids should get joint therapy from school SLP and from non- school clinic
   4. The need for external reinforcers
3. The Importance of the Clinician's Ability to MODEL the Target Response
   1. Keep your motor running
   2. Integrating A--V—M  (Air, Voice, Movement)
   3. Stretched syllables -vs- pausing between words
   4. Proprioceptive monitoring:  high stimulus speech
   5. SEQUENCES:
      
      Voiced Continuants: /r/l/z/w/y/
      Affricate: /dg/ (j) "jump"
      Voiced Plosives: /b/d/g/
      Voiceless Plosives: /p/t/k/
      Voiceless Continuants: /s/th/f/sh/
      
      Word--Phrase--Sentences
      
      GILCU:  Gradual Increase in the Length and Complexity of the Utterance
      
      Shadowing speech of others; radio monologue
4. The Need for "Nowness"
   1. You cannot change the past, or act in the future.  Monitoring of speaking behaviors must be NOW.
5. Reducing Superstitious Attitudes and Behaviors
   1. Clapping your hands to keep the elephants away.
   2. As long as superstitious avoidance occurs, the client will never know how he would have done if he had not avoided.
   3. Working with the Child's Beliefs Systems
      >> Two little men fight in my throat and won't let the words get out.
      >> Eye Blinks:  one before consonants and two before vowels.
      >> The reason the kid gives may seem stupid, but there is a reason.
      >> Trying to do -vs- trying not to do:
           --get on base -vs- not strike out
           --pass the test -vs- not fail
           --swim -vs not drown
           --be fluent -vs- not stutter
6. Therapy must be appropriately intensive
   1. Therapy -vs- glorified baby-sitting
7. The Safety Margin
   1. Remaining able to cope
   2. Doing the undoable, trying the untryable
   3. How to handle the problem of relapse
8. Adjustment to Improvement
   1. Giving up Secondary Gains
   2. Lag time in developing new self concept, and ability to believe it is the "new me".

H. The following basic experiences, based upon the ideas of Van Riper and Czuchna, often yield desirable outcomes when therapy is successful.

1. The child believes the clinician is competent and can be trusted.  This trust must be earned.
2. The child learns that he is responsible for his own behaviors, including stuttering.  He is also responsible for his talking and fluency.  He has choices.
3. The child learns that fear and avoidance reinforce each other.  Both can be reduced.
4. The child learns that stuttering can be deliberately endured, touched, maintained and studied, and that this will help develop a more objective attitude.
5. The child learns that struggling, hurried and abrupt escape reactions and recoils make stuttering more severe that it needs to be.
6. The child learns that it is possible to release himself voluntarily from moments of stuttering.
7. The child learns that the monitoring of normally fluent speech helps to reduce the frequency and severity of stuttering.
8. The child learns the self-suggestion of incoming stuttering can be resisted.
9. The child learns that it is possible to build barriers to destructive listener reactions.
10. The child learns that ambivalence, anxiety, guilt and hostility are to be decreased as much as possible.
11. The child learns that every effort should be made to build his ego strength, self confidence and self respect.

12. The child learns that in general, society rewards a person who obviously confronts and works on a problem rather than denying and avoiding it.