General Treatment Approaches to Change Speech/Stuttering Behaviors Stephen M. Tasko

Broad Frameworks for Intervention: “Alphabet Soup” ABC Principle (Various) A (affective) B (behavioral) C (cognitive) CALMS Model (Healey) C (cognitive) A (affective) L (linguistic) M (motor) S (social) Stephen M. Tasko

Stephen M. Tasko

CALMS Profile Stephen M. Tasko

Traditional Dimensions of Stuttering Therapy Establishment of techniques/fluency Transfer of techniques/fluency Maintenance of techniques/fluency Stephen M. Tasko

Behavioral Approaches to Stuttering Therapy Stuttering Modification (stutter more fluently) vs. Fluency Shaping (speak more fluently) Stephen M. Tasko

Stuttering Modification General therapeutic goals: is not fluency is easy stuttering focuses on making changes to the stuttering behaviors themselves Addressing fear and avoidance is an integral part of the behavioral changes Stephen M. Tasko

Stuttering Modification Theoretical underpinnings: More closely allied an anticipatory struggle viewpoint of stuttering However, is not inconsistent with other perspectives Stephen M. Tasko

Fluency Shaping General therapeutic goals: is to speak fluently Stuttering behaviors are not directly addressed Improved fluency is achieved by Reinforcing “natural” fluency in a highly structured response contingent program Systematically building a new pattern of speech production that is gradually “normalized” Addressing fear and avoidance behaviors is not integral to the actual fluency shaping procedures, but are often part of an overall program. Stephen M. Tasko

Fluency Shaping Theoretical underpinnings: Speech/stuttering is a behavior under operant control Stuttering is a speech motor control problem that is best controlled by Using a more motorically stable form of speaking re-coordinating the speech motor subsystems (i.e. respiration, phonation, articulation) Stephen M. Tasko

Stuttering Modification How to change stuttering Stephen M. Tasko

Stuttering Modification Highly interactive and client specific Focus on mastery and control of stuttering Heavy focus on proprioception Establishment and transfer are intermingled Typically makes use of voluntary stuttering Stephen M. Tasko

Stuttering Modification Role of voluntary stuttering Helps reduce fear and avoidance Helps reinforce a sense that the PWS has voluntary control over fluent and stuttered speech Provides a context for practice of techniques Stephen M. Tasko

Stuttering Modification Therapeutic approaches Post-block* modification (cancellation) Within-block modification (pull-out) Pre-block modification (altering preparatory set) *In this context a block refers to any stuttering moment Stephen M. Tasko

Cancellation What is a cancellation? A ‘do-over’ of a stuttered word The ‘do-over’ word is then produced in an easy, tension-free, continuous manner Stephen M. Tasko

Cancellation: Variant 1 Sequence: When stuttering has occurred Complete the moment of stuttering. STOP. DO NOT proceed to the next word Pause (2-3 seconds) Pantomime the stuttering moment* Silently repeat the word in a highly conscious manner* Whisper the word* Repeat the word loudly, slowly with a high degree of control *variations abound regarding which of these include Stephen M. Tasko

Cancellation: Variant 2 Sequence: When stuttering has occurred Complete the moment of stuttering. STOP. DO NOT proceed to the next word Pause (2-3 seconds) Replicate the stuttering block as realistically as possible but with ease and lack of tension. Repeat the word loudly, slowly with a high degree of control Stephen M. Tasko

Cancellation Goals of the Cancellation (according to Van Riper) Confront the disfluency (don’t run away from it) Practice for “fluent or easy stuttering” or pull-out behavior Desensitization: reduce emotional panic and struggle “Punishment” for stuttering *Many clinicians advocate only using the cancellation within the clinical setting Stephen M. Tasko

The Pull-Out What is a pull-out? A gradual shift out of the stuttering block toward fluency Conditions that typically necessitate a pull-out Excessive air pressure or lack of airflow Lack of movement Tight adductor laryngeal tension Inappropriate articulator posturing These motoric parameters must be altered to pull out of the block Stephen M. Tasko

The Pull-Out Typical pull-out sequence: Stop (“freeze”) while in the block Reduce inappropriate tension levels Initiate air Initiate voice Initiate gradual movement Stephen M. Tasko

Altering Preparatory Set What is a “preparatory set”? Van Riper’s term for what happens to a PWSjust prior to uttering a difficult word Components of a PWS’ preparatory set Elevates muscle tension Says first sound with a fixed articulatory posture (isolating first sound from the rest of the word) “Preforming” the first sound well ahead of uttering it Stephen M. Tasko

Altering Preparatory Set Replacing the “old” preparatory set with a “new” preparatory set relies upon good ability to anticipate problem PWS may have difficulty with anticipation, particularly early in therapy What is the “new” preparatory set? Articulators are in a state of rest (lack of tension) Initiate continuous movement from initial to following sound Immediately initiate airflow and sound Stephen M. Tasko

Fluency Shaping How to become fluent Stephen M. Tasko

Fluency Shaping Some common features of fluency shaping approaches Uses a strict hierarchy of task difficulty E.g. words – phrases – sentences – connected speech Total fluency is required before changing task difficulty (highly behavioral) Practice, practice, practice Focus on mastery of fluency Due to clear objective (total fluency), such treatment design lends itself to objective measurement Stephen M. Tasko

Fluency Shaping Natural fluency can be used in a highly structured response contingent (positive reinforcement) environment Fluency reinforced without discussion of how to speak Progress to next level contingent upon meeting strict fluency criterion If client “stalls” at a level, then specific strategies may be introduced Use of natural fluency more common with young children Stephen M. Tasko

Fluency Shaping More commonly, fluency shaping targets are introduced and integrated into the speech patterns of the client Client moves through hierarchy of task difficulty as well as individual target “degree” Establishment and transfer are often separated more in time Stephen M. Tasko

Common Fluency Shaping Targets Phonatory-based targets Easy voice onset Continuous voicing Respiration-based targets Full breath Abdominal breathing Pre-phonatory airflow Continuous airflow Stephen M. Tasko

Common Fluency Shaping Targets Articulation-based targets Easy/soft/light articulatory contact Full articulatory movements (proprioception) Higher-order targets Modified rate Rhythmic speaking Phrasing and pausing Blending Stephen M. Tasko