Basic considerations when treating young children
Immature system
May use less direct therapy
Parents, teachers, etc. may be needed
View other communication disorders as well
Spontaneous or automatic fluency is very likely
Better carryover
Less chance of relapse
Basic rules of therapy
Use understandable terms
Model rather than instruct
Use fluency inducing strategies in and out of therapy
REINFORCE positive feelings and self-worth
Parts of therapy
Explain the production system
Illustrate breakdowns
Show the child how to modify speech
Discuss strategies for responding to teasing, etc.
Train the child to guard against relapse
Schedule maintenance
Possible goals
Enjoy speaking
Involve parents
Improve self-confidence
Move to more complex utterances
Reward success
Teach “easy speech”
Modify fluency impacting behaviors in the environment
Desensitize the child to environmental disruptions
Make therapy fun
Use fluency facilitators
Approaches to Use with Children
Barry Guitar (integration of programs)
Fluency goals: normal fluency or spontaneous fluency
Feelings and attitudes: need not be addressed because they typically are not strong.
Maintenance: reevaluate over a period of years
Clinical methods: mostly fluency shaping, but can be in a structured or game playing format.
Integrated Approach
Therapy plan:
1) establish and transfer of fluency (use a systematic and gradual shifting of antecedent behaviors)
2) modify the moments of stuttering (optional)
3) maintaining improvement
**Associated with this program is a family counseling component.

Parent counseling
A) explaining the treatment program and parents’ role in it.
B) explaining the possible causes of stuttering.
C) identifying and reducing fluency disruptors.
D) identifying and increasing fluency enhancing situations.
Possible Hierarchies in Therapy
1) single word, slow speech, direct model
2) single word, slow speech, indirect model
3) carrier phrase + word, slow speech, indirect model
4) (clinician + parent) carrier phrase + word, slow speech, indirect model
5) (parent) carrier phrase + word, slow speech, indirect model
6) (parent at home) carrier phrase + word, slow speech, indirect model
7) sentence, slow speech, indirect model
8) sentence, normal speech, indirect model
9) 2-4 sentences, normal speech, indirect model
10) conversation, normal speech, no model
11) (clinician + parent) conversation, normal speech, no model
12) (parent) conversation, normal speech, no model
13) (parent at home) conversation, normal speech, no model

Specific Techniques For Children
1) DAF
2) metronome
3) prolonged speech
4) quiet speech
5) imagery
6) combinations
DELAYED AUDITORY FEEDBACK
Delayed auditory feedback (DAF) grew from feedback which was documented by sound engineers who worked for radio stations. 
Delay or reverberation was a problem which existed much to the dismay of "on-air" personnel. 
DELAYED AUDITORY FEEDBACK
Around 1950, a researcher named B.S. Lee (1950) reported the effects that this had upon the speech of the speaker.In its initial form, a DAF device was actually quite simple. 
It consisted of a tape loop where the playback head was in line after the record head. 
Thus, whatever was recorded, played back after a short period of delay.
Effects of DAF
The effects of DAF are very impressive.
When a speaker talks with a DAF unit, the following aspects of speech are altered:- rate- rhythm- pitch- intensity- pauses 
WHAT IS THE MOST EFFECTIVE USE OF DAF?
It should be noted that not all individuals are effected by DAF in the same manner.
It has been hypothesized that the effects are tied to how much dependence an individual places on their auditory feedback system. 
It is not the same for everyone. 
WHAT IS THE MOST EFFECTIVE USE OF DAF?
However, it has been consistently shown that the most effective level (will cause the greatest variance in speech patterns) is between 180-200 msec. delay for young adults. 
The most effective rate is longer for children.
Comparison of DAF Speech
DAF will cause most individuals to stutter, however, DAF stuttering can be perceptually differentiated from real stuttering (Neeley, 1961).
Langova and Moravek (1964) determined that although DAF improved the fluency of stutterers, it decreased the fluency of clutterers.
Comparison of DAF Speech
Wingate (1970) found that typical stuttering tended to occur during the first three words of an utterance, whereas, DAF stutterings were equally distributed throughout the utterance.
However, it has been shown that DAF has two effects upon speech patterns. 
1) increase in phonation duration
2) decrease in speaking rate
HOW CAN THIS BE IMPLEMENTED INTO THERAPY?
There are many programs which make use of DAF and it has been recommended as a treatment tool for many reasons.
HOW CAN THIS BE IMPLEMENTED INTO THERAPY?
Among them are:
it produces prolonged (not timed) speech and therefore is easier to shape back into normal sounding speech
it has very quick effects
it makes the user aware of production
it facilitates motivation and positive attitudes
it fits well into a total program
DAF
THERE ARE ALSO DISADVANTAGES
They are:
it can delay self-responsibility
it can cause over dependence on an instrument
it is somewhat expensive
SAMPLE DAF TASKS
fluency can be reinforced
can be used by the clinician to show the stutterer that anyone can stutter and they are not alone
with direction and instruction, the stutterer can be encouraged to concentrate on tactile and kinesthetic feedback from their own speech mechanism and reduce dependence on artificial fluency induction techniques.
MASKING
In a treatment program, masking has been used in at least two very different ways.
aversive stimulus to punish stuttering.  (WOULD THIS BE FLUENCY REINFORCEMENT OR STUTTERING MODIFICATION?)
gradually reducing the speaker's rate. (This is the most common use!)
Sample Masking Program
PHASE I: Establishment1) Select a masking level which will be acceptable to the client.2) Train the client how to use the device so that they cannot only turn it in and off, but they can get the masking level to start before the onset of an utterance.3) Use continuous five-minute masking periods in which the client completes reading, monologue and dialogue tasks.  Determine where the most fluency occurred.4) Concentrate on the speech mode which was the most fluent.  Practice until the client either reduces fluency by 90% from baseline measures or has less than 5 stuttered words in a 15 minute period.
Sample Masking Program
PHASE II: Refinement1) Repeat steps in the establishment mode, but reduce masking by 10 dB.2) Train the client to pay attention to loudness, rate, syllable duration while they are using the masking device.3) Practice until they have attained the same criterion established in the previous phase.
Sample Masking Program
PHASE III: Stabilization
1) Experiment to find the lowest masking level which will still bring about fluency; retain this as the "preferred masking level".2) Continue emphasis on self monitoring skills.3) Bring all other speech modes up to this level. (Reading, monologue, conversation)4) Meet the established criterion for all tasks.
Sample Masking Program
PHASE IV: Termination1) With masking level set at the preferred level, have the stutterer speak, until five minutes of stutter-free speech have been attained.2) With the earphones still in the speaker's ears, turn off the masker.  Instruct clients to:a) turn the unit back on when they anticipate stuttering.b) turn the masker back on after they have stuttered.  Leave it on until they feel ,that they have re-established their fluent speech pattern.3) Set criteria for success.4) The client will use the masker for the first five minutes of therapy, then take the unit off.These phases are then followed by a transition (limited use) and a separation stage (no masker used).
RHYTHMIC SPEECH
Rhythmic speech makes use of a metronome or some other timing device to aid in attaining fluency. 
Why rhythm works is not known for sure, but their are at least a few theories. 
One is that it is a distractor; the other is that it simplifies motor planning.
In therapy, the stages are similar to masking.
Example of  a Program for Children
Therapy for Pre-school Children
1) Onslow’s methods
2) Guitar’s methods
Lidcombe Program (Onslow and others)
I.) Clinical Evaluation, and,
II.) Case History
Clinical Evaluation
1) Within-clinic speech sample: clinician engages the child in conversation or play
or
2) With shy children, the parents play with the child
Clinical Evaluation
300 syllable sample is preferable
parents’ opinion of how this sample compares with samples at home
Measures:
% of stuttered syllables
Beyond-clinic Sample
300 syllable sample from home
Measures:
% of stuttered syllables
Case History
Prefereable to use an open-ended format.
Gathering of case history usually takes 1 - 1 1/2 hours
Case History
Information to be gathered:
1) Onset of stuttering
2) Type of stuttering/disfluency at onset
3) Changes since onset
4) Family history of stuttering
5) Previous speech therapy
Session ends with the clinician giving the family feedback about the information they provided.
Case Selection Criteria
If stuttering persists for more than 6 months after its onset, therapy begins.
Case Selection Criteria
Therapy does not begin when some of the following are met:
1) stuttering onset was less than 6 months past
2) stuttering consists primarily of rhythmic, syllable repetitions
3) child and parents are not frustrated by the stuttering
4) no family history of stuttering

Basic “Rules” of the Lidcombe Program
The child must enjoy therapy.
Any activity that the child reacts to in a negative fashion must stop.
All components are applied by the parents with flexibility.

Clinical Program
I.) Treatment procedures
II.) Fostering a working relationship
III.) Beyond-clinic speech measures
IV.) Within-clinic speech measures
V.) Therapy Activities
VI.) Maintenance
Lidcombe Program
Treatment Goals:
Eliminate stuttering in all speaking situations and maintain that level for 12 months (child).
Learn to conduct treatment and measurement activities sufficient enough so that they can get the child to achieve goal #1 (parent).
Assist parent in achieving #2 (clinician).
Lidcombe Program
Treatment Outcomes:
stutter-free speech in all situations for all times.

Treatment Procedures with the Lidcombe Program
Based upon weekly visits.
Must be attended by child and parent(s), or other caretaker.
This person must:
spend substantial time with the client each day
be willing to attend every clinic session with the client
Contingent based program.
Form a working relationship with parent (or other).
Maintenance.
Therapy Activities used with the Lidcombe Program
I.) Structured therapy games
II.) On-line
Therapy Activities used with the Lidcombe Program
I.) Structured therapy games
begin at a level where the child is operating
introduce games to elicit these responses
**Praise for stutter-free speech.**
possible reinforcers are “good speech”, “that was slow”, etc..
Stuttered utterances are ignored. (***there may be a few times when correction is required)

***If feedback is required, choose from,
1) parent repeats the word that the child stuttered on (no response from child required).
2) parents says, “that was bumpy” or other comment (no response from child required).
3) parents asks child to repeat one word that was stuttered, then reinforced if stutter- free.
4) parent interrupts child and asks them to fix the stuttered word (can be direct or indirect).
5) parent waits for child to finish talking, then asks them to repeat the sentence, but without the stuttering (“can you say that again without the bumping.”).
Therapy Activities used with the Lidcombe Program
In direct therapy, the clinician can use therapy games for 10-15 minutes, then let the parent use these techniques with the child.
Remaining session is used to discuss child and how things went at home.
Practice is done at home 10-15 minutes every day.
Therapy Activities used with the Lidcombe Program
When severity ratings are reduced to 4 or less, on-line activities replace structured therapy activities.
The parent learns to praise stutter-free speech on-line in all activities.
The parents still continues using structured therapy activities at home.
Structured therapy activities make use of the child’s favorite toys or games.
Therapy Measures
% SS in clinic activities
SR (severity rating) 10 point scale, where 1 is “no stuttering” and 10 is “extremely severe stuttering.
SMST (stuttering per minute of speaking time)
[know how to do all of these]
Therapy Activities used with the Lidcombe Program
Therapy continues until the client meets the criteria below over 3 consecutive weeks:
% SS is less than 1.0 within clinic
SR is less than 2.0 outside the clinic
SMST is less than 1.5 outside the clinic
When criteria is met, the child enters the maintenance phase.
Therapy Activities used with the Lidcombe Program
Maintenance:
parent continues with the program and child returns to clinic at intervals of:
2 weeks (x2)
4 weeks (x2)
8 weeks (x2)
16 weeks (x1)
Dismissal
*Criteria remains the same as noted earlier.
Naturalness Scale
Treatment Considerations with Older Students
Beyond the age of about 7-11.
This is when children have a better understanding of the world.
They can make some personal choices.
Operant conditioning (by itself) to eliminate stuttering has little support. 
Treatment Models
Fluency Shaping
modify all speech
collect objective data
response-contingent therapy
problem of carry-over
Stuttering Modification
modify only stuttered moments
eliminate fears
learn about stuttering and fears
problem of quantitative data
BUILDING A PROFILE
1) Does the client really stutter?
- disfluent?????
- other fluency disorder?????
2) How does stuttering change?
- with length?????
- with complexity?????
- with familiarity?????
- with context?????
BUILDING A PROFILE
3*) Can stuttering be modified under certain condition?
4) How are the clients “other skills”?
- language delay/disorder?????
- learning/attention disorders?????
- motor skills?????
5) Are there any neurogenic or emotional factors involved?
Fluency Induction Tasks
1) Instructional control
2) reduced speech rate
3) prolonged speech
4) rhythmic speech
5) shadowing or choral speech
6) DAF speech
7) masking
How a Profile Can Tell US What to Do and Where to Begin
Where does fluency break down?
Does fluency get better under any conditions?
What are these conditions?
Possible causes for “non-developmental” stuttering
Signs of fear and avoidance
Samples of Profiles
When is a stuttering modification program is appropriate?
when stuttering still persists after fluency induction techniques have been applied
when the client exhibits significant fear, and uses many postponement and avoidance behaviors
when consistency is high and adaptation is low
When is a fluency shaping program appropriate?
when stuttering can be easily eliminated with the use of fluency induction techniques
when the client exhibits very few fears and avoidances
when the client can not understand and/or monitor techniques used in stuttering modification therapy
When is a hybrid approach appropriate?
when some stuttering remains after fluency induction, but the client does not show significant fears
Historical Review of Stuttering Intervention with Older Students & Adults
“There is no such thing as the method for treating stuttering” (Johnson, 1939).
Our job is to select the most appropriate method for intervention.
Mix client needs with expertise of the clinician (Prins, 1997).

Specific Techniques used by Van Riper in Stuttering Modification Therapy
1) continuous phonation (“the mouth must be kept moving”)
2) loose articulatory contacts
3) the succeeding sound must be prepared for in the mouth (coarticulation)
This is all done to set up a new preparatory set.
Historical Review of Stuttering Intervention with Older Students & Adults
This is all done within the context of the stages of:
a) identification
b) desensitization
c) modification*
d) stabilization
* uses cancellations, pullouts, and preparatory sets
Historical Review of Stuttering Intervention with Older Students & Adults
The advantage of using cancellations, pullouts, and preparatory sets is that they can be used in a sequence for dealing with moments of relapse.
The true goal for therapy was to teach the PWS to “stutter more easily and briefly”.
Techniques used with Programmed Instruction
1) establish non-stuttered speech
a) soft contact
b) prolonged speech
c) gentle onset
2) progress to more natural sounding speech
40 spm
70 spm
100 spm
3) carryover
Established Programs/Techniques in FS for Older Students & Adults
Precision Fluency Shaping (Webster)
GILCU (Ryan)
ELU (Costello-Ingham)
Group Intensive vs. Individual Therapies
No differences
Efficacy and Tracking of Data
Outcomes: track your data.
Rely on at least two (or three) pieces of objective data:
1) correct use of technique or strategy
2) % of stuttering
3) naturalness

NOTES ON CLUTTERING

Cluttering
Cluttering is a congenital fluency disorder which is often confused with stuttering, and often co-occurs with stuttering.
Definitions of Cluttering
(Weiss, 1967) "cluttering is the verbal manifestation of central language imbalance".
(Webster's Dictionary, 1981) "a speech defect in which phonetic units are dropped, condensed or otherwise distorted as a result of overly rapid agitated speech utterance".
Definitions of Cluttering
(College of Speech therapists, London, 1959) "uncontrollable speech, which results in truncated, dysrhythmic, and incoherent utterances".
(St. Louis, 1993) "a speech-language disorder whose chief characteristics are: (1) abnormal fluency that is not stuttering and (2) a rapid and/or irregular speech rate".
Definitions of Cluttering
(Diedrich, 1984) "cluttering is a problem in maintaining sequential articulatory units with little self-consciousness about their difficulty".
Etiology
Their is no known cause, but most consider it to be congenital.
(deHirsch, 1970) congenital disorder that affects all levels of central investigation (motor, perceptual and verbal).
Etiology
(Arnold & Luchsinger, 1965) disability to formulate language that results in confused, hurried (tachyphemia) and slurred speech that results from a congenital and inheritable syndrome.
They say that it is an "organic, familial and dysphasia-like" language disorder.
Etiology
Froeschels (1946) an incongruity between speaking and thinking.
Tiger, Irvine and Reis (1981) a constellation of learning disabilities.
Etiology
Perkins (1978) the "microcosm of speech therapy".  He thought that the syndrome included grammatical deficiency, impaired reading, bizarre handwriting, poor musical ability and poor coordination. 
However, rate and rhythm were the major features of cluttering.

Etiology
Weiss' views are probably the most widely accepted. 
He states: "Cluttering is a speech disorder characterized by the clutterer's unawareness of his disorder, by a short attention span, by disturbances in perception, articulation and formulation of speech processes preparatory to speech and based on a hereditary disposition.  Cluttering is the verbal manifestation of Central Language Imbalance, which affects all channels of communication (e.g., reading, writing, rhythm and musicality) and behavior in general.
ASSESSMENT OF CLUTTERING
Quantitative:
1) speech rate (cluttering = rapid)
2) concentration and attention span (cluttering = poor and short)
3) locus of stuttering (cluttering = pauses before vowel initial words without signs of frustration)
4) # of repetitions (cluttering = 6, 8 or 10 repetitions of syllables, words or phrases are common)
ASSESSMENT OF CLUTTERING
Quantitative: (cont’d)
5) articulation testing (cluttering = several errors; /r/ and /l/ are common errors)
6) voice assessment (cluttering = monopitch/monotone)
7) reading assessment (cluttering = poor reading)
8) writing sample (cluttering = disorderly, poorly written, poorly integrated, uninhibited, full of repetitions and deletions)

ASSESSMENT OF CLUTTERING
Qualitative:
1) disorganized speech
2) frequent slips of the tongue (ex. "at this plant in time,...")
3) physically immature, clumsy and uncoordinated
4) poor musical ability
5) familial evidence ("Does anyone else in the family have speech problems similar to yours?")
ASSESSMENT OF CLUTTERING
Qualitative: (cont’d)
6) personality factors (impulsive, “figity”, hasty, hyperactive, careless, clumsy, untidy, sloppy, impatient, short tempered)
7) lack of awareness ("Do people ask you why you repeat?", "Do people ask you to slow down?")


Assessment
An experimental assessment set up by Daly (1991) is an attempt to validate cluttering.
 A score of 60 or higher usually validates cluttering. (*note: this test is not yet normed).

Assessment
Daly Checklist
Differentiation of stuttering from cluttering (Weiss, 1964)
Stuttering
High awareness of disorder
Speaks worse under stress
Speaks better in relaxed settings
Speaks worse when calling attention to speech
Speaks better when reading well-known text
Speaks worse with unknown text
Fearful attitude towards their own speech
Generally withdrawn
Academic achievement can be normal
Cluttering
Low awareness of disorder
Speaks better under stress
Speaks worse in relaxed settings
Speaks better when calling attention to speech
Speaks worse when reading well-known text
Speaks better with unknown text
Careless attitude towards speech
Generally outgoing
Academic underachiever

Treatment Variables for Cluttering
(1) age of the client
(2) the length of time that cluttering has been a problem
(3) whether cluttering and stuttering coexist
(4) nature and severity of the problem

Treatment for cluttering
Simply working on fluency is not enough!!
Documentation of success has been shown with clutterers, through use of the following therapy goals:
* Note: the younger the child, the more parental involvement is a good rule of thumb.

Goals/activities for therapy
CHILDREN
1) oral-motor exercises
2) training to increase memory span
3) work on a slow deliberate rate
4) sequencing activities
All goals need “awareness”.*

Goals/activities for therapy
1) reduce rate (they won't necessarily do this on their own; they have been told to slow down for all of their lives; see recommended task )
2) heighten awareness of their disorder and therapeutic techniques
3) pragmatic skills such as turn taking
4) mental rehearsal or imagery
5) DAF
Goals/activities for therapy
To reduce reading rate**, Burk suggests the following:
    a) read a passage five times, starting with a very slow rate and gradually increasing it until the fifth reading is as fast as the client can possibly read; audiotape the third reading which should be a normal rate and give it to the client to use as their "anchor".  Have them listen and refer to it many times.

Goals/activities for therapy
Awareness:
    Ex. Provide rationale for each activity.
    Ex. Utilize audio and video recordings.
    Ex. Negative practice
Goals/activities for therapy
Self-monitoring:
DAF
Self-rating (with feedback)
Goals/activities for therapy
Attention:
Redirection
Listening for comprehension, etc.
Goals/activities for therapy
Thought organization/formulation:
Story telling (details and completeness, i.e., more than surface meaning)
Oral
Written
Goals/activities for therapy
Speech production and motor skills:
Rate reduction (with DAF, deliberate phonation, overexaggeration, etc).
Breathing modification

NOTES ON OTHER FLUENCY DISORDERS

Stuttering Associated with Acquired Neurogenic Disorders (SAAND)
Can be associated with muscle weakness/incoordination, or,
Central language disorders
Motor speech impact
a) spastic dysarthria: tension may be too great at the beginning of an utterance.  Shallow respiration can affect motor control.
b) athetoid dysarthria: (twisting, writhing movements generally associated with cerebral palsy or lesions of the Basal Ganglia) involuntary movements of the larynx or tongue can cause dysfluency.
Motor speech impact
c) chorea-like dysarthria: (extrapyramidal tics; hyperkinetic movements) rapid, jerky movements of the articulators may not allow normal fluency.
d) flaccid dysarthria: (brain stem and below) slow, labored speech; muscles tire easily and fluency deteriorates.
Motor speech impact
e) ataxic dysarthria: (cerebellar damage) muscle tone is reduced and incoordination of the articulators can take place.
Stuttering associated with apraxia
Inability to produce purposeful movements in the absence of paralysis or weakness.
These clients struggle to produce speech and thus may sound like stutterers when their fluency breaks down. 
Stuttering associated with apraxia
These clients know what they want to say, but can not execute the appropriate movements necessary to produce the target utterance. 
The flow of speech and normal intonation patterns are affected, and since these individuals are aware of their problem, they struggle to correct errors and generally become very disfluent with a lot of whole word and phrase repetitions.
Dysfluency associated with aphasia
This type of dysfluency is again different. 
Confusion of ideas will frequently lead to speech characterized by hesitations, whole word repetitions, revisions and filled and unfilled pauses. 
Word retrieval deficits will also result in long pauses and word/phrase repetitions as well. 
The most common site of lesion in aphasics with fluency deficits are caused by frontal lesions associated with stroke or brain trauma.
Speech and Language Tasks Recommended for Diagnosing Stuttering Associated with Acquired Neurological Disorders (SAAND)
1) Standardized Tests:
    a) Aphasia Diagnostic Profiles
    b) Boston Naming test
2) Standard Speech Passages (repeated readings):
    a) "The Rainbow Passage”
    b) "The Grandfather Passage"
3) Automatic Recitations:
    a) Counting to 30
    b) Months of the Year
    c) "The Pledge of Allegiance”
4) Singing Familiar Songs
Speech behaviors noted with SAAND
1) no adaptation affect
2) repetitions, prolongations and stoppages are not restricted to initial syllables
3) stuttering can occur on grammatical as well as substantive words
4) the speaker may be annoyed but does not appear anxious
5) rarely are their physical concomitant behaviors associated with the moment of stuttering.
Treatment
Rate reduction
Rhythm (such as MIT)
Prolongation
Reports of success are limited****
At least three types of adult onset stuttering have been described in the literature.  They are:
(1) adult onset stuttering caused by head injury, stroke, degenerative disease of the CNS, brain tumor, brain surgery, and drug induced brain dysfunctions.
(2) emergence of stuttering that began during childhood (overt reaction to internalized stuttering or simply a relapse).
(3) as a result of emotional trauma.  This has also been referred to as "hysterical stuttering",or more appropriately, conversion reaction stuttering.
Conversion Reaction Stuttering
criteria for Conversion Reaction include the following:   
sensory or voluntary motor system involvement
atypical or bizarre quality of complaints
history of frequent minor health problems involving several organ systems
history of stress prior to onset of problems
presence of a model for the symptoms
a symbolic significance to the current conflict
no permanent organic change
la belle indifference (an unrealistic degree of indifference to, or complacency about startling or gross symptoms)
Symptoms associated with Conversion Reaction Stuttering
(1) the onset of stuttering is sudden
(2) the onset of stuttering is temporally related to a traumatic event
(3) the pattern of speech is primarily a repetition of initial or stressed syllables
(4) speech is not affected by choral reading, white noise, initial attempts at DAF, singing or different speech situations
Symptoms associated with Conversion Reaction Stuttering
(5) no "islands" or periods of fluency (including automatic, rote speech)
(6) initially, the client is not aware or interested in their stuttering symptoms
(7) no avoidances and no attempt to inhibit the stuttering
(8) same patterns of speech in reading or conversational speech.
Treatment for Conversion Reaction Stuttering
Eliminate the cause of the anxiety, and the stuttering typically goes away.
Fluency reinforcement, is another option.
See case studies:
Case Study # 1
44 year old male truck driver
trauma when a truck backed between him and his truck, crushing him between the two trucks.  He yelled for the truck to stop, however, his yelling was not heard.
the client was severely injured and lost consciousness
when he regained consciousness, his speech was very rapid, he stuttered on 80% of his initial phonemes and had a very high pitched voice
mental status examination was normal except for the speech disturbance
received treatment for 9 months to reduce rate and lower pitch
retained fluency as of 2 year post check
Case Study # 2
32 year old female admitted for inpatient treatment of a manic episode with psychosis
past history of conversion reactions including left paralysis and pelvic pain
repressed memories of physical abuse (when she began to verbalize about her physical abuse she discovered scars on her body which she had previously not notice in the past)
as her memories became clearer, she began to verbalize about her sexual abuse and began to stutter (no prior history of stuttering)
stuttering progressed over the next four weeks, from stuttering just while talking about abuse to other situations where it severely affected communication
the client was instructed to speak slower and to pronounce each word carefully
fluency returned in just a few weeks and remained fluent throughout further sessions
Case Study # 3
37 year old female with a history of severe emotional problems
involved in a physically and emotionally abusive marriage
separated from the spouse five years prior to treatment, but still remained in a sexual and emotional relationship with the husband.  Subsequently found out that her husband was in a relationship with another woman
became highly emotional in therapy, but realized that she must terminate her relationship with her husband
when she began to talk of her subsequent divorce, she developed severe prolongations which would be accompanied by severe physical concomitant behaviors
when asked to speak slowly and with clear pronunciation, her stuttering was largely resolved
soon, she terminated her relationship and marriage with the spouse and her stuttering was permanently resolved.
Conclusion
Please know how to separate these other fluency disorders from what we regard as “typical stuttering”, or what is sometimes referred to in the literature as “developmental stuttering”.
Know how to differentially diagnose these cases, and include it in your project.


GOAL WRITING ASSIGNMENT

PROJECT # 3 for Disorders of Fluency

 

Directions: The transcript below is from an imaginary (but real-life-like) client who came to our clinic for therapy.  Let's refer to this client by:

 

Name: Casimere Kulikowski

Address: 120 Cowing Street, Lancaster, NY 14086

Date of Evaluation: October 30, 2005

Date of Birth: April 30, 1993

 

Background:

- no history of stuttering in family

- stuttering began at age 4 1/2

- began as easy repetitions, developed into more severe stuttering

- in therapy since grade 1 with no success (8+ years total)

- average educational abilities (B/C student)

- likes art, music, phys. ed., science

- dislikes reading, English

- no significant birth history

- development is normal, with slight incoordination noted by parents

- language development "a little slow" as reported by parents (in comparison to older sister)

- lives at home with two parents, and one older sister (CA = 17.5)

- hobbies include "skateboarding" & "listening to music with friends"

- considered "shy" by both parents and teachers

 

                                                    SPEECH SAMPLE

 

TRANSCRIPTION KEY

............... = blockage (each dot represents 1/10 second; this example is equal to a 1.5 second blockage)

ssssssssuturee = prolongation (each extra letter repaeted represents 1/10 second; this example is equal to a .7 second prolongation)

p-p-p-p-picture = repetition (each syllable noted equals to the number of times the sounds/word/etc. was repeated)

 

Single Syllable Word Naming

 

b-b-b-ball

cat

……dog

ffffffoot

hat

lamb

m-m-m-man

p-p-p-p-ig

rat

b-b-bug

 

Single Syllable Word Repetition

 

Eat

Fish

b-bat

sit

shoe

mouse

hide

c-c-c-car

tie

hair

 

Single Syllable Word Reading

 

chew

act

d-d-d-disk

….van

sick

m-m-m-m-m-ake

cake

bite

fly

do

 

Multi-Syllable Word Naming

 

……….elephant

ffffffffffootball

m-m-m-onkey

p-p-p-icture

…….baseball

wishbone

………computer

……tv

c-c-c-c-candle

wwwwwwwindow

 

 

Multi-Syllable Word Repetition

 

p-p-pencil

gymnast

happy

c-c-c-ookie

racecar

shoeshine

…..jumping

cactus

easy

lightbulb

 

Multi-Syllable Word Reading

 

September

Radio

Fishing

Children

g-g-grumpy

active

pencil

…..kicking

easy

rootbeer

 

Sentence Formulation (from pictures)

 

He-he-he ……..is a b-b-big man.

Theeeeeee d-d-d-d-dog is whhhhhhhhhhhite.

Sh-sh-sh-she is rrrrrrrrunning.

Th-theeeeeeeeeee cat is b-b-b-lack.

…..He is strong.

………..The car is red.

The-the the fffffffffood llllllllooks g-g-g-good.

…..The t-t-t-tiger is ……eating.

……It is rrrrrrrrraining.

…..Heis g-g-g-etting a ………..haircut.

 

Sentence Reading

 

……Would you like to talk about it?

……..It never happened to me.

I like to go fishing.

You should see the beach.

The animals are eating.

Tom likes to eat candy.

K-k-k-kiick the ball as far as you c-c-an.

Always eat your vegetables.

Tell me where to g-g-go.

………Come over here, please.

 

 

 

Sentence Repetition

 

…….He will do a good job.

I like to eat potatoes.

She comes from the north.

Henry is Italian.

The boat tipped over in the water.

Children are always running around.

K-k-k-ken lives in the desert.

Run as fast as you can.

The night is c-c-cold.

I like ……computer ……games.

 

Reading a passage to clinician

 

W……………..ashington- P-p-p-part of the nnnnnnnation’s ffffffffuture oil ssssssssupply may lie within-within-within-within some e…….xtraordinary

o………..rganisms that have been called a “……..third form of life.”

A ………Colorado State ………..University mi-mi-mi-microbiologist reports ………..obtaining pure hy…….drocarbon that could be c-c-cconverted to

……..gasoline or llllllllubricating oils from …..several of the …….organisms.  The-the-the oily ssssssubstance is “…….energy-rich, d-d-d-efinitely a lubricant,

…….combustible, and isn’t ……soluble in water,” says the ……researcher, T-t-t-t-homas ……Tornabene.  ……And the oil is free of ……air-polluting

sulfur.

The-the-the d-d-d-discovery now ……..is only a lllllllllaboratory ….phenomenon; ……any commercial ……application isssss some time away.

“Right now…..right now…….right now we are c-c-concentrating on the orrrrrrrrrganisms’ basic ……..mechanisms,” …….Tornabene says.  “We have

two-we have two-we have two …….genetic engineers looking at them to-to-to find ways of …….getting them to …….grow faster and to ……..pump oil

faster.”

 

Adaptation and Consistency

 

Reading # 2

 

W……………..ashington- Part of the nation’s future oil ssssssssupply may lie within some extraordinary organisms that have been called a “third form of life.”

A Colorado State University mi-mi-mi-microbiologist reports ………..obtaining pure hydrocarbon that could be c-c-cconverted to gasoline or lubricating oils

from several of the …….organisms.  The oily ssssssubstance is “…….energy-rich, definitely a lubricant, combustible, and isn’t soluble in water,” says the

researcher, T-t-t-t-homas Tornabene.  And the oil is free of air-polluting sulfur.

The discovery now is only a lllllllllaboratory phenomenon; any commercial application isssss some time away.

“Right now we are concentrating on the orrrrrrrrrganisms’ basic mechanisms,” Tornabene says.  “We have two genetic engineers looking at them to find ways

of getting them to grow faster and to ……..pump oil faster.”

 

Adaptation and Consistency

 

Reading # 3

 

Washington- Part of the nation’s future oil supply may lie within some extraordinary organisms that have been called a “third form of life.”

A Colorado State University microbiologist reports obtaining pure hydrocarbon that could be c-c-cconverted to gasoline or lubricating oils from several of the

organisms.  The oily ssssssubstance is “energy-rich, definitely a lubricant, combustible, and isn’t soluble in water,” says the researcher, Thomas Tornabene.

And the oil is free of air-polluting ssssssulfur.

The discovery now is only a laboratory phenomenon; any commercial application is- you know- ssssssome time away.

“Right now we are concentrating on the organisms’ basic mechanisms,” Tornabene says.  “We have two genetic engineers looking at them to find ways of

getting them to grow faster and to pump oil faster.”

 

 

Conversation with Clinician

 

CK = Client

T = Clinician

 

CK: Why do they have a band, a band?

T: Because they play at uh, the football games, on Saturday night they they play football, and the band comes out during halftime and plays music they march

around the field.

T: Did you ever go to a football game?

CK: Yeah

T: Um hmm

CK: I go to it every Friday at at St. Anne’s but, but this time I’m not going, b-beecause I gotta go to my grandmas and I wanna go

T: Ah, do you like to go to your grandmas?

CK: Yeah

T: What do you do when you there?

CK: Um, I-I-I chase their dog

T: “Laughter”

CK: Its um its um ……… its um ………… its one of dose dogs that mff …………. do you know those dogs that they show up on T.V. at Taco Bell?

w-well

T: Ahh

CK: It’s one of those.

T: I know them, chiwawas, right?

CK: Yeah

T: Um hmm, let’s see, what’s his name?

CK: …………….Chico

T: Chico, that’s a funny name.  I happen to have a picture of one of my dogs right here.

CK: (laughter)

T: You ever seen one like that before?

CK: Uh huh

T: Umm hmm, yeah where?

CK: I see ssssssssome dogs on the street that ………walk

T: Aaah, I see, well let’s see, where do you live now?

CK: N-n-n-new York

T: Uh-huh

CK: 237 is my ………….address

T: Umm, how would you get there from here?

CK: Umm ……………… oh you would  …have to fffffly there

T: Why?

CK: It’s far,……….but I’ll t-t-t-t-t-tell you how to get there.

CK: Umm, ………… you just get out of Buffalo and drive out Laaaverack Road, and then yooooooou go down that-that-zat long road, it’s kinda like it’s- it’s

kinda like it’s-really like, three football fields put all together and umm, and the last house you stop and, and go in

T: Umm, ok, um, if  you were to leave in your house, how would you get to your school?

CK: I-I would back out of the driveway, go down the big long road and, I would, go straight ………. and um, then there is gonna be like this road that you

turn, turn, like like turn this way or yes, this way (motions right) you turn either, there is three roads, to get, to my school and and you’ll see, my big church

………sticking out.

T: Umm

CK: It’s-It’s like, its like five stories high and umm, and you and its bigger than all the other buildings so say say you can see the big ch-church just on top of the

umm, all de other buildings.

 

All Remaining Tasks are Fluency Induction

 

Single Syllable Word Naming (DAF)

 

bat

car

door

fist

jar

heart

mint

 

Single Syllable Word Naming (light articulatory contact)

 

b-b-b-boot

p-p-pen

....tape

snake

thumb

shoe

....milk

 

Single Syllable Word Naming (light articulatory contact + prolonged speech)

 

truck

cab

glass

light

pen

desk

red

 

 

Single Syllable Word Naming (prolonged speech)

 

box

stove

cup

dish

knife

green

 

 

Single Syllable Word Reading (DAF)

 

kick

wish

make

you

him

these

out

 

Single Syllable Word Reading (prolonged speech)

 

why

chip

drink

in

cold

rain

jump

card

 

 

YOUR TASK IS TO FILL OUT A PROFILE (as best as you can) AND GENERATE A REPORT (minus the exact therapy program, but you should at least list the type of program recommended and some beginning goals)

 

DURING ALL TASKS RELEVANT TO THE SSI, PHYSICAL CONCOMMITANTS ARE NOTED AS FOLLOWS:

 

eye blinking during stuttering

feet are moving about

lots of hand movements around the face

eye focus near the ground when stuttering

 

** Despite the obvious stuttering, his speech is very natural (except for the blockages, prolongations, repetitions, and circumlocutions).

 

 

 

***AS AN ADDENDUM, YOU CAN LIST ANY OTHER TOOLS AND TASKS THAT YOU WOULD NEED TO MAKE THIS ASSESSMENT MORE COMPLETE.

12-01-05 notes

Future Directions
We obviously do not have an answer to stuttering at this point.
Future directions in stuttering follow several directions due to recent advances.
These areas include:
Neuroimaging
Efficacy studies
Early identification
Improved methodologies
Works from the past
…..the reason that we bring these up is that they still influence theory despite the lack of conclusive, scientific evidence to support them.
Van Riper’s Tracks of Stuttering
Track I:
early onset of stuttering (2-3),following normal speech and language development in other areas
early characteristics include mostly syllabic repetitions
later development includes sound prolongations*, physical tension and strong emotional reactions
this group has a high rate of spontaneous recovery and the best prognosis in therapy.
*In Van Riper’s system, blockages are simply silent prolongations.
Van Riper’s Tracks of Stuttering
Track II
later onset than track I (ages 3-4)
articulation and language delay
early symptoms center on unorganized, syllabic repetitions (often confused with cluttering)
sound prolongations and physical tension are rare
minimal emotional reaction
little change in symptoms over time
Van Riper’s Tracks of Stuttering
Track III
sudden and late onset of stuttering (5-9)
normal articulation and language
symptoms include audible and silent prolongations (blocks)
physical tension, emotional reactions to stuttering and secondary characteristics are noted
Van Riper’s Tracks of Stuttering
Track IV
sudden and late onset of stuttering
no history of other speech and language problems
predominant symptoms are word and phrase repetitions and blocks (e.g., open jaw)
little emotional reaction to stuttering
little change in symptoms over time
The Impact of Van Riper’s Work
Many researchers today believe that there are several different “subtypes” of stuttering, including:
neurogenic “stuttering”
psychogenic “stuttering”
linguistic “stuttering”
motoric “stuttering”
not to mention cluttering
This has lead to….
More complete evaluations.
The building of diagnostic profiles.
Matching of treatment to symptoms.
Different treatment programs that look at “efficacy” (efficacy is measured across many vraiables).
More “naturalistic” assessments.
Consideration and studies that consider “co-morbidity” (e.g., phonological disorders, ADHD).
Where is the field going and what are some current critiques?
Neuroimaging studies:
How far has technology taken us? (some argue that current techniques used in neuroimaging studies only present an “average” of what is happening.  A snapshot of brain activity is only that, a snapshot.  Conversational speech takes many thousand neuromuscular events per second.  All of this is not captured in one image.
Neuroimaging studies have not been completed on children (when stuttering is just beginning). So, questions like, “Does activity change as the child develops different stuttering behaviors?” are still  unanswered.
Where is the field going and what are some current critiques?
Motor speech studies:
Stuttering begins well before the motor processes begin.
Lack of children in motor speech studies.
The technology required for motor speech studies precludes them from taking place in natural contexts.

Trends
The current trend with much of the literature and scientific study up to this point has not lead us to characteristics that are mutually exclusive to:
STUTTERERS
NON-STUTTERERS
We have still NOT been able to clearly separate the two groups on any symptoms.
This leaves us with efficacy!
Problems:
How do we measure non-observable strategies (such as emotions, feelings, fears, etc.)?
How do we reliably measure “observable” symptoms?
How do we measure efficacy without “placebo” or “non-treatment” groups?
The lack of “clinical databases” (there is still not an agreed upon method for transcribing a communication sample in stuttering).
Ways to measure success(in addition to decrease stuttering)
Decreased avoidance
Increased risk-taking
Improved self-image or self-concept
Others
What do we seem to know about stuttering that can help us in treatment? (just report the facts!!!)
Present reasons for importance:
Age of Client
Age of Onset
How long have they stuttered
Symptoms
Overt
Covert
Physical, social, educational, and developmental history
Time in therapy
Type of therapy now receiving
Goals
Clinician goals
Client goals
Prognosis (and why???)
For your exam
Know:
Major types of therapies and techniques
Differential diagnosis
What Manning has to say about intervention
Tools for diagnosis and intervention
Issues related to efficacy

REMEMBER: NEW EXAM DATE IS FRIDAY, DECEMBER at 7:30 a.m.-10.00 a.m.