1. Selected Fluency Shaping Approaches and Issues

2. Fluency Shaping Approach Selected examples
Examples of “Prolonged Speech” Programs
Precision Fluency Shaping Program: PFSP (Webster 1975)
Fluency Plus Program (Kroll & Scott-Sulsky, 2010)
Camperdown Program (O’Brian, Packman & Onslow, 2010)

3. What is a “Prolonged Speech” Approach? (Ward, 2006)
General Features
Speech segments are “stretched”
Rate reduced to establish stretched speech
Possible Approaches
Stop watch
Clinician model
Delayed auditory feedback devices such as the Kay facilitator
Slows down client
Also requires increased proprioception
Highly structured hierarchy of rate increase to near-normal levels
Simultaneous introduction of “fluency enhancing” techniques during hierarchy
Progression through hierarchy will depend upon ability to maintain fluency level
Clinician’s role is primarily in providing feedback and monitor adherence to criteria
Often “intensive” (8 hours/day, 2-4 weeks)
Often “group-based”

4. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)
Program assumptions about effective stuttering treatment
Speech represents a complex behavior
Treatment techniques focus primarily on observable behaviors
Fluency skill training is supplemented by cognitive restructuring
Treatment must be intensive
Fluency skills must be overlearned and exaggerated
Reduction of response variability
Fading and client self-reliance
Transfer of fluency skills must be addressed
Maintenance programs must be incorporated
Post-treatment support groups provide a bridge
Refresher programs must be offered

5. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)
Group-Based
4.5 hours/day 5 days a week for 3 weeks
2-4 hours/day 7 days a week home practice over same 3 weeks
11 month maintenance phase (17 1 hour sessions)

6. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)
Stages of Program
Establishment of fluency-facilitating targets
Transfer and cognitive restructuring
Maintenance and staying connected

7. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)

8. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)

9. Fluency Plus Program (Kroll & Scott-Sulsky, 2010)
10 Tools for Avoiding Relapse
Achieve mastery of targets
Develop techniques which support positive preparation for speaking activities
Complete and evaluate practice activities daily
Systematically reduce fears and avoidance behaviors
Acceptance of the new speech pattern
Self-correction and evaluation of target behaviors
Establish a support network
Examine personal reasons for wanting to maintain speech gains
Work toward a lifestyle that accommodates change
Develop problem solving and self-reliance skills

10. Outcomes and Complications: An example
Walter Reed Army Medical Center Intensive Fluency Training Program
Intensive, Group Based Fluency Shaping Treatment Program
Intensive: 7 hours/day, 5 days/week for 4 weeks
Group-Based: 3-4 participants/group
Therapy Structure
Educational/informational
Normal speech production
Issues related to stuttering
Target establishment
Introduce targets
CAFET – computer assisted
Vary levels of “monitoring”
Transfer
Vary situations
Switching monitoring levels
Short group counseling sessions

11. Walter Reed Program Speech Targets
TECHNICALLY NOT A PROLONGED SPEECH PROGRAM
Diaphragmatic Breathing
Continuous Airflow
Slow Exhalation
Pre-Voice Exhalation
Initial Vowel Prolongation-Easy Onset
Continuous Phonation
Phrasing

12. Short-Term Treatment Outcomes10 20 30 40
pre-Tx SSI Score
comp-Tx SSI Score
0: Highly Natural
9: Highly Unnatural
Tasko et al. (2007)

13. Rhythmic Speech Therapy: An Example
Speaking at a uniform rhythm (relative time across syllables)
Rate may be fast or slow – typically start slow and then move toward a “normal” rate
Rhythm may be established with a metronome, finger tapping, imagined finger tapping
Slowly move toward naturalness while maintaining attention to rhythm

15. Thoughts and opinions of fluency shaping

16. A Two-Tiered (Hybrid) Approach to Stuttering Therapy J.M. Hanley

17. Two-Tiered Approach Target Population Two Components
Children
Adults
Two Components
Preventative (“fluency shaping”) focus on the development of speech behaviors.
Modification focus on disfluent speech behaviors.

18. Prevention vs. Modification: Where to spend the time
Emphasis will depend on
Severity of the problem
Client’s age
Client’s awareness or concern

19. Prevention vs. Modification
General Guidelines
Preventative measures
young children with less awareness, insight, tension, struggle and fear
Modification approach
child with tense repetitions, prolongations or tense pauses—and is concerned about the difficulty of speaking
Adults with well-entrenched patterns

20. Regardless of emphasis…
Key goals are to
Increase self-monitoring ability
Develop ability to use “negative practice”
To study
To identify
To desensitize
To practice new “controls”

21. “Hypothesis Approach”
Build and test hypotheses
Test your hypotheses to determine the effect of certain therapy strategies on fluency

22. Use understanding of speech production to prompt hypotheses
Is the disfluency voiced?
Is tension excessive?
Is movement stopped?
Is the sequel rapid? Slow?

23. Sample Hypotheses
Does language formulation have a systematic effect on the frequency, intensity, or duration of disfluency?
Do excited, hurried sentence onsets contribute to the occurrence of disfluent moments?
Does change of speech rate alter disfluent patterns?
Does easy voice onset (abducted vocal fold posture at initiation of voicing) increase fluency?
Does increased inter-sentence pause time reduce disfluency?
Does continuity of movement alter the disfluent pattern?

24. Six Preventative Tools
Airflow/air pressure
Voice Onset
Muscle Tension
Articulator Movement
Speech Rate
Speech Effort
Particularly with youngsters, always consider the role of language formulation as an interacting variable

25. General Goals Focus on sentence initiation
Initiate with appropriate tension levels
Gently initiate airflow or voice, whichever is appropriate for the phoneme being produced
Focus on maintaining continuous movement throughout the phrase, clause, or sentence unit
Maintain an appropriate speech rate
Monitor effort level

26. Endgame
Ideally, the end of the therapy experience would have the child
Initiating in an unhurried fashion,
Using an easy onset of air or voice (depending on the type of disfluency),
Exhibiting minimal tension levels,
Initiating and maintaining continuous movement,
Using minimal effort

27. Hurried vs. Unhurried Initiations
Excited and emotional onsets of speech are usually hurried
Result:
Maximum acceleration of movement
Quick inhalations are often noted
Pitch elevation is not unusual
Exaggerated head and neck movements are often observed.

28. Voice Onset
Difficulty with voicing onset is the most commonly observed difficulty
The most typical pattern involves an adducted, tense vocal fold posture and excessive subglottal air pressure is often involved.
The child may report “getting stuck.”
Therapy target is initiation with vocal folds abducted.
Fluency Friends
“Easy Eddie” vs. “Hard Harry”

29. Easy Voice Onset
Start with vowel initial words, gradually extending the complexity of the utterance to phrases, clauses, sentences, and combinations of sentences.
Using the glottal fricative (/h/)
If the child is having difficulty initiating voice from an abducted (open fold) position, initiation of airflow with an /h/ sound insures an open airway. Then the vibration for voicing can be initiated gradually.
Later, the audible /h/ phoneme can be changed to an inaudible airflow.

30. Voiced plosives
The phonemes /b/,/d/,/g/ have vocal folds adducted throughout oral closure
Establishing voice by linking nasal to plosive

31. Voiced vs. Voiceless sounds
Different relationship between airflow and voicing
voiceless repetition may be evidence of difficulty with voice onset
For voiceless sounds the target will be airflow followed by voice

32. Tension/Effort
Specific drills should be incorporated to adjust tension levels when indicated.
Contrastive activities work well here
Fluency Friends
“Tense Teddy” vs. “Relaxed Ralph”

33. Continuous Movement
Failure to maintain continuous movement often contributes to the occurrence of disfluency.
Fluency Friends
“Continuous Cal” vs. “Choppy Charlie”

34. Speech Rate In some cases, rate must be modified to enhance fluency.
Fluency Friends
“Fast Freddy” vs. “Slow Sammy” vs. “Just right Joe”

35. Introduce Speech Tools while
Managing situational complexity
Managing linguistic complexity

36. Situational complexity
Therapy room
Hallways
Waiting room
Telephones
Cafeteria
Shopping malls
School setting
Linguistic complexity