fluency plus program - asha

Fluency Plus ProgramA Comprehensive Treatment for School Aged

Children

Robert Kroll, Ph.D.Marni Grotell, M.H.Sc.

Lea Ayuyao, M.Sc.Rachelle Vekris, M.H.Sc.

The Speech and Stuttering InstituteToronto, Canada

www.speechandstuttering.com

Presentation Outline

The Nature of Stuttering– Definitions and Characteristics

Treatment for Stuttering– Models and Principles

Treatment Efficacy Studies

The Fluency Plus Program– Fluency Skills (Targets)

Presentation OutlineTransfer

– Definition and procedures– Mental rehearsal– Types of fluency

Cognitive Restructuring– Issues during transfer– The stuttering mentality– Self-talk

Maintenance– Definition and procedures– Forms of practice

Therapy Formats– Groups vs individual– Associated factors

Stuttering

A complex multidimensional condition in which the flow of

speech or fluency is disrupted by involuntary speech motor events

Stuttering

ProblemPsychological StateAttitudeFeelingsEmotionsSelf ConceptSelf EsteemPsychological FactorsEtc

BehaviorDisfluency Form TypesBlocksRepetitionsProlongationsDisrhythmic PhonationContingent BehavioursEtc.

Types of Disfluency

• audible/ silent sound and syllable repetitions

• sound prolongations

• dysrhythmic phonations

• blocks

• intra-syllabic fragmentation

Stuttering Contingent Behaviours

• disordered breathing• glottal fry• lip pursing• eye blinks• facial grimacing• head jerks• abnormal body movements

may be observed at the respiratory, phonatory or articulatory levels of the speech mechanisms

Avoidance Behaviour

• specific sounds and words are often reported to result in increased stuttering

• scanning behaviour in order to predict stuttering

• avoidance strategies include word substitution, phrase revision, circumlocution, stopping the communicative process

• situational avoidance

WHO International Classification of Functioning, Disability and

Health (ICF)

Disorder

Body Structure/Function (Impairment)

Activity and Participation (Disability)

Environmental Factors (Handicap)

Body Structure and Function

Any loss or abnormality of psychological, physiological, or anatomical structure or function.

Stuttering in terms of the WHO Classification

Body Structure and Function• Frequency of stuttering behaviour• Duration of instances of disruption• Severity• Secondary behaviour

Activity and Participation

• Any restriction or lack of ability (resulting from an impairment) to perform a normal human activity.

• A disability is the functional consequence of an impairment.

Stuttering in Terms of the WHO Classification

Activities and Participation• Inability to say specific words/sounds• Difficulty communicating in specific

situations» Telephone» Groups» Answering specific questions» Formal Presentations» Authority figure

Environmental Factors

The social consequence of an impairment or disability defined by the

attitude and responses of others. Thus, the state of being handicapped is

relative to other people.

Stuttering in terms of the WHO Classification

Environmental Factors• Classroom discrimination• Teasing and bullying• Social, leisure and recreational

limitations• Issues of self confidence, self esteem• Effect on overall quality of life

Treatment Approaches to Stuttering

• stuttering modification

• fluency shaping

Stuttering Modification

• deals more directly with psychological aspects

• attitudes, feelings and emotions are addressed in therapy

• techniques include self-acceptance, attitude change, avoidance and anxiety reduction

• techniques employed to modify the moment of stuttering

Fluency Shaping• establishment of fluency within clinic setting• fluency is reinforced and gradually shaped to

approximate normal sounding speech• therapy procedures reconstruct the respiratory,

phonatory and articulatory gestures used in speech production

• no direct emphasis on fear or avoidance reduction

• transfer or generalization of skills is addressed

Behavioural Criteria for Successful Treatment

Outcome• significant, positive change in speech output

• generalization across speaking situations

• maintenance over time

Communication Criteria for Successful Treatment

Outcome• To be able to talk any time, any place and to any

body

• To be able to communicate effectively and efficiently

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

Summary of our clinical and research findings with adults and adolescents who stutter

(Kroll and Scott-Sulsky, 2010)

What did we learn?

The Two Year Follow-up Study

18

2

7

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101214161820

Pre Post Follow-up

Percent WordsStuttered

Kroll & De Nil, 1994

Mean percent words stuttered for 14 subjects pretreatment, post treatment and at two year follow-up

The Two Year Follow-up Study

Mean total scores on the Situation Checklist

0

20

40

60

80

100

120

140

160

Pre Post Follow-up

SituationChecklist Score

Kroll & De Nil, 1994

N=14

Current Maintenance DataMean percent disfluency, SSI, PSI and STAI scores for 13 subjects

7.071.61 3.46

15.38.15 10.3

48

18 21

34.829.5 31.7

0

10

20

30

40

50

60

Pretreatment Posttreatment Follow-up

Percent DisfluenciesStuttering SeverityMean PSIMean STAI

De Nil & Kroll, 2003

So ……

The Treatment ProgramMust:• be based on science• be comprehensive• focus on observable behaviours• also deal with attitudes, feelings and emotions• be intensive• stress over learning and exaggeration• limit response variability• allow for immediate feedback

The Client

• have age appropriate reading and learning ability

• have emotional stability• have a degree of objectivity• have adequate performance

on trial probes• have family support

• have valid reasons for seeking treatment

• have realistic expectations and goals

• have realistic perceptions of therapy

• have realistic perceptions of stuttering

• be self-reliant and work independently

Must:

The Fluency Plus Program

Based on our clinical work and research findings with older

individuals, we applied these principles and developed our treatment program

for school aged children.

Fluency Plus Program

1. Speech Presents Complex Behavior

2. Primary Focus on Observable Behavior

3. Intensification of Treatment

4. Over-learning5. Exaggeration of

Speech Responses

6. Small Response Units Taught Individually

7. Sequential Synthesis of Response Units

8. Reduction of Response Variability

9. Immediate Feedback• re: Response Accuracy

Principles


10. Clinician As Instructor11. Clinician As Therapist12. Client Self-Pacing and

Self-Reliance13. Fading14. Family Involvement

15. Transfer Component16. Follow-Up and

Maintenance Program17. Post-Treatment

Support Groups18. Refresher Programs

Principles


• Establishment• Transfer• Maintenance

Critical Phases of Therapy

Targets

Speech gestures employed in speech production which are characterized by one or more designated properties of position,

force, velocity or duration.

Definition


Fluency facilitating procedures- Targets -

• Full Breath• Stretched Syllable• Gentle Onset• Light Contact• Blending• Full Movement

Response ProgressionSpeech Responses

C-V CombinationsMonosyllabic WordsBi-syllabic Words

Polysyllabic Words

Short Self-Generated ChainsLong Self-Generated Chains

Syllable Durations

2 Seconds/Syllable1 Second/Syllable1 Second/Syllable-½ Second/Syllable½ Second Syllable-New NormalNew NormalNew Normal

Stretched SyllableRate Reduction Sequence

2 Second StretchMy Name Is Bob

2 ↑ 2 ↑ 2 ↑ 2

1 Second StretchMy name is Bob

2 sec ↑ 2 sec

Stretched Syllable

Response Progression continued…..

½ Second StretchMy name is Bob

2 sec

New Normal – Syllable durations are not timed.Normal prosody and inflection restored

Full Breath Target

Definition: A full and controlled inhalation/ exhalation cycle with the diaphragm as the major muscle contributor

Purpose: To correct learned faulty breathing patternsTo facilitate the reconstruction of voicing characteristics

3 Steps of the Full Breath Target

1. Take a slow, comfortable breath by movingthe diaphragm out.

2. Don't pause between inhaling and exhaling.3. Exhale by relaxing the diaphragm - don't

push.

Stretched Syllable Target

Definition: The duration of each syllable, and each sound within the syllable is exaggerated well beyond normal limits

Purpose: To enhance the client’s awareness of the specific motor movements of speechTo provide a foundation of fluent speech which can then be systematically shaped towards normal patterns.

The 4 Rules of 2 Second Stretched Syllable Target:1. Each syllable is stretched for 2 seconds (example:

zzzziip = 2 seconds)2. The first sound in the syllable is held for 1 full

second. Your mouth should keep still while holding the sound for one second (example: zzzziip, the "zzzz" is held for 1 second).

3. The rest of the syllable gets the other 1 second: "zzzz(1 sec)iiip(1 sec).

4. If you have a word with more than one syllable, you must pause for 1 full second in between syllables and take a Full Breath (the Full Breath target).

Unstretchables

• Referred to as “hissing” and “popping” sounds

• Consist of the voiceless fricatives and plosives

• These sounds are not stretched to avoid excessive air loss or to avoid the build up of articulatory pressure

Gentle Onset TargetDefinition: An initial low amplitude vibration of the

vocal folds followed by a steady and gradual increase in the strength of these vibrations

Purpose: To facilitate proper phonatory onsets. To reduce the abrupt, excessive tensioning of the vocal folds and the forceful expulsion of air characteristic of laryngeal block.

5 Steps of the Gentle Onset Target

1. Take a slow, full breath.2. Start the voice very gently, that is, very

softly.3. Raise the loudness of your voice very

gradually.4. Raise the loudness to your normal

conversational loudness level, or slightly louder if you speak softly.

5. Decrease your loudness back down to where you began the onset

Light Contact Target

Definition: A reduction of air flow through the vocal tract.

Purpose: To prevent excessive air loss on voiceless fricative sounds

To ensure correct initiation of voicing on subsequent sounds

Voiceless Fricative Sounds

Light Contact Target

Definition: Light contacts of the peripheral articulators

Purpose: To prevent excessive lip and tongue pressure build-up on plosive sounds

To ensure correct initiation of voicing on subsequent sounds.

Plosive Sounds

Stretched SyllableRate Reduction Sequence

2 Second StretchMy Name Is Bob

2 ↑ 2 ↑ 2 ↑ 2

1 Second StretchMy name is Bob

2 sec ↑ 2 sec

Blending TargetDefinition: Variation of the amplitude and

blending of syllables within the speech chain

Purpose: To facilitate the initiation of syllables embedded within the words and phrases

To improve speech flow and prosody

Blending Target• Constant voicing between syllables• Gentle Onset on each syllable

oooovvvveeeennnn

Paragraph Reading

My fa/vourite/ drink is/ iced tea./ I rea/lly en/ joy a/ cold drink/ on a/ hot day./ Sometimes/ my bro/ther likes/ his iced/ tea fla/voured with/ lemon./

Full Movement Target

Definition: The full and deliberate movement of the articulators from sound to sound within syllables

Purpose: To decrease physical tensioning in jaw and neck areas

To facilitate kinesthetic perception of other target behaviors

Stretched Syllable

Response Progression continued…..

½ Second StretchMy name is Bob

2 sec

New Normal – Syllable durations are not timed.Normal prosody and inflection restored

New Normal Speech

Definition: New normal is defined as that rate of speech which is stretched enough to feel the targets being completed accurately but natural enough to be able to transfer to all outside speaking situations.

Transfer

The voluntary or conscious application of learned or acquired behaviors

outside of the clinic situation.

Definition:

Transfer Procedures

1. Mental Rehearsal

2. Talking While Applying Targets

3. Objective Evaluation

Cognitive and Speech Motor Processes

Mental Rehearsal• The mental or preparatory set with

which the individual enters a speaking situation

• The first step of transfer• Should be positive as opposed to

negative

Evaluation

• Should be objective and in reference to target behaviours

• Should be written down• Should be used in subsequent transfers

Fluency Types

1. Lucky (Unmonitored)

2. Monitored

When is Transfer Introduced?

• Not too early in the program– Exaggerated forms of speech do not transfer

easily to natural speech situations.• Not too late in the program

– Delaying transfer may feed the child’s fears of specific speech situations. Emphasis should be placed on the fact that some forms of transfer have been accomplished earlier in the program.

What is the Major Problem Encountered During

Transfer?• The link between the clinic and the outside

world is not made• The transfer experience is not viewed as

an opportunity to practice• The client is waiting for fluency skills to

happen (the medical model)• The client is overcome by negative

emotion

The Stuttering Mentality

“I hope the teacher doesn’t call on me because I’ll blow it!”

“Maybe I’ll just pretend I don’t know the answer.”

“I hope they don’t ask me to introduce myself.”

“Uh-oh! Here comes a word that starts with a “D”. Let me pick another one - fast!”

“I know they are going to laugh at me if I stutter.”

“I don’t want to answer the phone, I might stutter.”

Monitored Speech Output

Broca’s Area

Premotor Area

(Motor Speech Area and message formulation)

Motor : execution Act of talking

Motor Planning of:

Negative Self-talkThe Limbic System

Cingulate Gyrus

AmygdalaHippocampus

Cognitive RestructuringDefinition- The alteration of attitudes, feelings, belief systems and emotions associated with the act of speech communication. This is accomplished by replacing faulty or irrational thought with more accurate and beneficial ones through supported self-realization and counseling.

Positive Self-talkSilent, internal messages regarding the

speaking situation or speaking performance.

Can be negative or positivePositive self-talk should serve as a mental

reminder to use target behaviours

“I will block for sure on my name”=>”Remember to use LC and GO”

“This person is in a rush, I better talk fast”=>”I will use SS and FM and I will be in control of how I speak”

Following Speech Hierarchies During Transfer• The danger here is encouraging the notion that

the situation is causing stuttering• The basic premise of fluency shaping therapy is

that violations of speech mechanics will ultimately lead to stuttering, not specific speech situations

• Thus, desensitization procedures are often not necessary, especially with children

What is the transfer process for younger children?

• In some cases transfer occurs spontaneously, depending on the age, sophistication and awareness level of the child

• The transfer process for older children exhibiting specific fears is very similar to that for adults

Maintenance

The continuation of the therapy program as the involvement of the clinician is gradually decreased.

Fluency maintenance is a long, gradual process of consolidation and stabilization of skills, and maturing of expectations by both the client and the therapist.

Definition:

What is the clinician’s role in maintenance?

• To provide on-going professional evaluative feedback during follow-up sessions

• To monitor practice schedules• To ensure that correct skills are being practiced

for appropriate lengths of time• To deal with psychological and behavioural

issues as they arise

When does the maintenance process begin?

• When the client can reliably transfer newly acquired speech skills in a variety of extra clinical situations

• When the stuttering mentality is replaced by a speech communication mentality

What are some of the challenges during maintenance?

1. Acceptance of modified speech pattern2. Constructive analysis of error patterns including

objective weighting of successes and failures3. Willingness to continually plus actively monitor speech4. Contingency plans to deal with anxiety and/or cognitive

demands of the dual speech process5. Acceptance of role and responsibility of fluent speech6. Acceptance of responsibility for the clinical process7. Possible alteration of perceived situational speech

difficulty8. Attitudinal and psychological changes

When is maintenance complete?

• When speech is no longer considered an issue

• Observed confidence and comfort level for communication

• Frequency and severity of disfluencies are minimal

Maintenance Practice Strategies

• Shaping• Structured transfer• Spontaneous transfer• Target review

Shaping• Daily practice of all targets and speech rates

to reinforce skill accuracy• Consists of reading aloud at each speech

rate, followed by a monitored conversation with a partner

1 minute full breath+ 3 minutes 2 second syllable stretch+ 4 minutes 1 second syllable stretch+ 6 minutes ½ second syllable stretch+ 6 minutes new normal= 20 minutes (reading) +10 minutes (conversation) = 30 minutes in total

Group vs. Individual Formats

• Group formats are ideal for children aged 7 and up

• Group activities encouraged• Reduces waiting time• Healthy competitive spirit ensures

program compliance• Children younger than 7 often not ready

for group

Group Therapy Formats

10 – 12 Year Olds:

• 26-28 weeks for establishment and transfers• “Speech partner” does not attend group

sessions• 5 children (maximum) per group

Group Therapy Formats7 – 9 Year Olds:

• 14-16 weeks for establishment and transfer• “speech partner” attends all group

sessions• 5 parent child pairs (maximum) per group• Rate reduction strategies replaced by

general instructions and modelling

The Role of the Parent/Caregiver

• To understand the nature of stuttering• To understand the goals of treatment• To serve as the child’s “speech partner”• To attend all parent meetings• To consult with SLP on a continual basis• To learn and model all speech targets• To carry out home practice with child• To create a home environment conducive to fluency• To educate family members• To liaise with the teacher

Home Practice• Instructions for practice should be clear

and formalized– Written down– Practice sheets provided– Recording devises used to:

• Provide samples of individual speech targets• Allow SLP to determine completeness and accuracy

of home assignments– Practice sessions conducted daily– Sessions should be 20-30 minutes in duration

Intensive Therapy• Can refer to in-clinic or extra-clinic

sessions• Eliminates spaced practice and retention

issues• Ensures experience of speech gain• Facilitates generalization of speech skills• Reduces client dependence on SLP• Challenges priorities and commitment• Builds in-home programming

Use of Video Recordings• Provides pre and post treatment fluency

count data • Visual record of stuttering and stuttering

contingent behaviours• Allows clients to examine their pretreatment

speech patterns • Allows for objective evaluation of target

behaviours during speech activities such as group presentations

The Younger Child• Children younger than 8 typically lack the

conceptual abilities for many of the details in Fluency Plus

e.g. Stretched syllables replaced by modeling “easy talking”

• Clinical materials and activities modified for this age group

• Parents attend all sessions• Parents assigned role of learning partner and

facilitator in clinic and at home

Pre/Post Data (Conversation)on 26 Children 9-12 years

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0-5% 6-10% 11-15%

16-20%

21-25%

26-30%

>30%

Pre-therapyPost-therapy

Percentage of dysfluency in conversation

Total Num

ber of Children

Pre/Post Data on 11 Children in the 7-9 Year Old Program

(

0

1

2

3

4

5

6

0-5% 6-10% 11-15%

16-20%

21-25%

26-30%

>30%



Total Num

ber of Children

Pre/Post Data on 8 Children in the 5-6 Year Old Program

00.5

11.5

22.5

33.5

44.5

5

0-5% 6-10% 11-15%

16-20%

21-25%

26-30%

>30%



Total Num

ber of Children

Questions, Discussion, etc.Robert Kroll, Ph.D.Executive DirectorThe Speech and Stuttering Institute2-150 Duncan Mill RoadToronto, Ontario M3B 3M4

Tel. 416 491 7771Email [email protected]

fluency plus program - asha

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