Clinical Nuggets

A special section in the newsletter for the ASHA Special Interest Division #4, Fluency and Fluency Disorders, was called Clinical Nuggets, where clinicians could share their therapy ideas in working with adults and children who stutter. The entire newsletter is available only to members of the Division. Joining the Division costs only $25 for ASHA members. But permission has been granted to duplicate portions of the Clinical Nuggets section on the Stuttering Home Page. Additional Nuggets appear in the newsletters. Anyone with more Clinical Nuggets is invited to share them for consideration to be included on this page. (a href="mailto:judith.kuster@mnsu.edu">judith.kuster@mnsu.edu

Volume 8, Number 2 - spring 1998

This issue inaugurated the "nuggets" section. Additional nuggets in this issue are by Nan Bernstein Ratner, Woody Starkweather, and Jennifer Watson and are available in the Newsletter.

Nan Bernstein Ratner - How to judge whether your clinical planning is working for your client

Take a moment to do the one-minute test: Ask your client to tell you: what is going right, what needs to be changed, what would help him/her get more out of this. Adapted from a teaching excellence tip, this "nugget" has allowed me to discover that the emphasis I may place on some aspects of a clinical session may not match the client's wishes. For instance, one client wanted more work on something they were really struggling with, and less work on the targets I had included to provide some positive experiences in therapy. It's also a great way to open a dialog with younger clients.

Walt Manning - Be a Tape Recorder

I suggest to my student clinicians that they should "Be a Tape Recorder". Using a tape recorder is often ineffecient and it can be difficult to adequately capture and play back the segment of speech that you would like to highlight. The tape recorder can disrupt the dynamics of the clinical exchange. Often it is difficult to record and play back the stuttered event quickly enough in order to be effective. Thus, rather than using a tape recorder to capture fluency breaks, I often mirror exactly what and how the person stuttered by speaking or stuttering exactly the way the client did. This enables the client to become conscious of the stuttered event in real time and to have the chance to identify and modify their behavior. It also demonstrates to the client that the clinician is unafraid of stuttering and willing to experiment and vary stuttered speech. After the clinician does this for awhile it becomes reflexive and almost automatic.

Bob Quesal - "Quiz client about therapy"

A useful idea is to periodically "quiz" your client about what you've been doing in therapy. Every two or three weeks, ask the client a question such as, "What have you learned in therapy the past few sessions?" or "Can you summarize what we've been doing over the past few sessions?" This is a good way to "calibrate" whether what you are telling your client is in fact what they are hearing. It can also be quite an eye-opening experience, when we find that what our clients are learning bears little resemblance to what we think they are learning. In this case, we can make adjustments in therapy and ensure that the process continues smoothly

J. Scott Yaruss - Stuttering for your client

One of the important messages our older school-age, adolescent, and adult clients may need help learning is that it is okay to stutter. We aren't likely to be able to convince them of that, though, just by talking about it -- it is an acceptance they will acquire with time and effort. We can help our clients achieve this important goal by showing them that stuttering is okay with us by using pseudostuttering or other voluntary stuttering technique to introduce disruptions into our own speech. This gives us an opportunity to model acceptance of disfluencies and show our clients that a person can stutter and still be an effective communicator. We can also use this technique if we take our client out into the real to show clients that other people can also be accepting of stuttering if we model some stuttering in our own speech in our everyday interactions in the real world while the client observes our reactions and the reactions of the listener.

Volume 8, Number 3 - August 1998

This issue's "nuggets" are from the1998 Special Interest Division 4 Leadership conference. Additional nuggets in this issue are by June Haerle Campbell, Kay Monkhouse, Barbara Dahm, and Sue Shirley and are available in the Newsletter.

Barry Guitar - Tips on Helping the Adult Client Vent and Using Metaphors to Convey Concepts

1. When a client is very resistant to working on his stuttering-especially if he has been working on it and this is a sudden change, emotion may be interfering with motivation. With a child, the clinician can break through this "block" by using activities that allow release of emotion, such as making clay images of stuttering and smashing them during moments of stuttering or throwing darts at balloons on which various hard words or situations are written. With an adult, the clinician needs to be able to verbalize the client's emotion (see Van Riper tapes, session #4) or otherwise help the client vent. In this situation the clinician must be sure not to take the client's emotion personally.

2. To help a child or adolescent (and some adults) grasp an important concept and remember it, use a metaphor from their experience. For example, to teach pullouts, demonstrate and have a child act out trying to open a door (the therapy room door) with your foot jammed against it, they become aware of your foot jammed against it, then slowly ease off your foot and open the door.

3. Or use a metaphor of "downshifting" a car with four-wheel drive, either when you are stuck or before you become stuck.

Bill Murphy - Tips to Aid in Desensitization and Reduce Teasing

1. To aid in desensitization for both child and parents regarding stuttering behavior, have the child client teach parents how to stutter and give parents "grades" according to how they are able to imitate different forms of stuttering. This technique also allows for easier family discussions on stuttering.

2. To reduce class teasing, aid in desensitization, and give others an understanding of stuttering, teach the client that self-disclosures of stuttering via talking about it can have a positive effect. The clinician and client can develop a classroom presentation regarding stuttering, the nature of stuttering, famous people who stuttered, tools we use, the class' perception of teasing and how it affects all children, and how the client wants classmates to respond to his/her stuttering. Once discussed in $he classroom, this normalization task also allows the speech-language pathologist to overtly help the child to manage speech during classroom activities (e.g., reading and class reports).

Howie Schwartz - Transferring Fluency Beyond Treatment

Transferring fluency beyond treatment is often an obstacle for adolescents. We use a number of activities that include notebooks, tape recorders, and telephone answering machines. For clients who are reluctant to carry a tape recorder, we encourage them to carry a small assignment notebook. These notebooks can fit in a purse, bookbag, or pocket. We ask our clients to pick one class, one person, or one time during the day where they will enter into the situation or conversation and put their full attention toward their speech. The client is asked to record the results of these situations in their notebooks. We expect the client to address their fluency, the reaction of others, and the client's feelings and emotions during this time. We expect clients to complete this activity on the days they are not attending treatment. We ask clients to bring their notebooks to the subsequent session so that we can discuss the client's ability to transfer fluency beyond the treatment room and discuss their feelings regarding the activity. When clients are willing to accept responsibility for their treatment program, we find that our program progresses much faster.

Patty Walton - A Helpful Note for Insurance Clients

For those insurance carriers who base payment of benefits for stuttering treatment on a physiological or "medically necessary" criterion, it is very helpful to enclose the brochure on stuttering from the National Institutes of Health. This details information on recent research that focuses on physiological aspects of stuttering. This is easily obtained by calling the NIH. They will send up to 50 brochures at no charge.

Volume 9, Number 1 - January 1999

ASHA granted special permission to include all "nuggets" from this newsletter.

Ken St. Louis - A Game for Young Children

Here is a little thing to try for a 3-4 year old who refuses to imitate easy stutterings or disfluencies. Draw or make some nonsense figures (e.g., friendly aliens) and build a story about them. One alien might be named "Mobe"; another might be named "M-mo-mobe" or "Mmmmmoooobe." By talking about them in the conversation, the youngster has lots of opportunity to practice easy repetitions and/or prolongations.

Dale Williams Tips on TV & Speech Model

Here are some things that recently struck me as interesting.

1. A preschooler receiving an indirect approach responded well to clinician modeling in the session, but poorly to the same type of modeling at home. His mother complained that he was "Just too wild" in the house. After lengthy interviewing, we determined that his wildness followed his usual TV watching time and that the shows he liked were quite violent. We asked the mother to limit the time he spent watching TV and also the types of shows. From that point on, he responded beautifully to the modeling in the home.
2. Another preschooler presented disfluency and a hoarse voice during an evaluation. Recommendations included indirect fluency therapy and a referral to an ENT. The child responded gradually to modeling. However, when the ENT report indicated vocal nodules, it was decided that indirect therapy was not an aggressive enough treatment. Using an easy speech model, direct voice therapy was administered (eliminating yelling, alternate behaviors, etc.). Interestingly, when the client decreased his overall loudness, there was a corresponding decrease in rate and tension. In other words, a model plus a voice therapy instruction facilitated the easy speech we were after.

Michelle Roberts and Judy Kuster Helping Children Who Stutter Become Their Own Advocates

Check out the Web site http://www.mnsu.edu/comdis/kuster/therapypics/pictures.html for Michelle and Judy's project for speech clinicians to use with some children in elementary school to help them educate their classmates and parents about stuttering. Bill Murphy writes, "It is important for children who stutter to learn how to talk about their stuttering and the classroom is a great place to begin to teach this process. In most cases, it is important to have the child be a part of the class discussion." (personal correspondence, September 24, 1998). Bill has also provided a helpful paper Class Visits for Children Who Stutter for additional information. If this an appropriate goal for your student, feel free to use the pictures at this Web site. Speech-language clinicians can use the pictures to suggest messages the student can share with others. The pictures are designed so that the possible message is seen only if you scroll down the Web page. That way you can brainstorm possible messages with your student if you want. At the bottom of the screen is a link that will lead to a full-page copy you may want to print out and have your student color before presenting the information to others. If you have other messages that you feel would be appropriate and could be easily illustrated, feel free to share your ideas (email to kuster@mnsu.edu. Also, please share any experience your students had using these pictures.

Volume 9, Number 2 - May 1999

Additional nuggets in this issue are by Woody Starkweather and Jacqueline Kaplan and are available in the Newsletter. Ms. Kaplan's idea, originally a post on a mailing list, is also available online.

Andy Floyd - Stuttering Modification and Stick-Shift Driving

Cancellation. It's when you're trying to start the car and either you let go of the clutch too fast or don't use enough gas and the car starts to shake and then stall. That part is like having repetitions on a word or blocking and then getting done with the stuttering moment. The car driver settles down (I know I was quite tense when I was stalling) and makes slower, more precise movements to ease the clutch and gas into perfect unison. Just like the person using a cancellation will calm down after the stuttering moment, go back and ease into the word, slowing things down and saying the word in an easy onset/prolongated manner.

Pull-out. When you're having trouble with the transition from the clutch to the gas pedal, you need to slow down and ease your way into the correct position.

Preparatory set. When you're preparing to have trouble with the transition from the clutch to the gas pedal, slow down and ease yourself into it.

Emotions. The first time you get in a stick shift car, it is very nerve-wracking. As other cars start to get near your car, you start to get more anxious, convinced that you'll do something wrong. This is very much lie the first time a person who stutters uses either stuttering modification or fluency shaping techniques. When persons who stutter first use such techniques outside of the clinic, they think they're going to mess up. The closer other cars get, the more they think something will go wrong and the more nervous they get. The same thing occurs with stuttering. A lot of negative thinking takes place in both circumstance.

Walt Manning - Two Tips

1. "Walking and talking" therapy. Often clients who are quite good at performing modication techniques in the treatment setting have considerably more difficulty when they are out of the treatment room and taking a walk with the clinician. So, although it sounds simple, I sometimes do "walking and talking" therapy, during which we do the same things we would be doing in the treatment setting as we are taking a walk inside or outside of the building. If necessary, small portable tape recorders (audio or video) allow you to document performance.
2. "The SEAL analogy." I've found this approach useful with some children or adolescents when discussing the concept of voluntary stuttering. I liken the experience to the desensitization and toughening process that Navy SEAL team members undergo during training. Stuttering moments can be likened to the scary sharks as, following the clinician's lead, we show them that it is possible to "swim among the sharks" as one or both of us produce stuttering on purpose. Together, we "swim" through a passage or short conversation and insert a variety of forms of stuttering. It is a process that takes time, but eventually the client finds that he or she can survive and even be intrigued by the process.

Volume 9, Number 3 - September 1999

Additional nuggets in this issue are by Beth McMillen and are available in the Newsletter.

Gerald Johnson - Motivational Trophies for Self-Help Groups

Many years ago, I attended a Toastmasters Club meeting in Lansing Michigan, home of Oldsmobile Cars. One of the awards given out that evening was a tie pin with a miniature spark plug attached. This was given to the person who "sparked and motivated" the meeting. Later in my career when I began to run an adult self-help group called AIMS: The American Institute for the Management of Stuttering (our logo was a broken arrow and our motto was: "AIMS Knows Stuttering") I was wracking my brain to find ways to additionally motivate the group. I remembered the spark plug and thought this might work. I bought a full sized spark plug and a 1 1/2 by 4 inch block of wood and drilled a hole to hold the spark plug. On the face of this "trophy" I burned into the wood with a hot soldering iron "spark plug award." I thought this would be great for the person who really got the group going, but what about the person who was striving for stuttering modification? It was not necessary for that person to be fluent, but rather to be showing exemplary effort toward hit/her goal. Having watched The Wizard of Oz with our kids for 100 times, I was hit by the idea of the oil can and the Tin Man oiling up the hinges of his jaw and his squeaking out his first rusty words. There was my ideas: get an old small metal oil can and embed the spout into another block of wood and burn into the side of the wood "The Tin Man Award." The members of the group at the end of the meeting would vote for the two persons who would "win" the awards and to be able to take them home with them until the next meeting. You can imagine the dynamics that took place during the meeting and at the recipients home afterwards. We had great fun and intrigue with these two trophies.

Volume 10, Number 1 - April 2000

An additional nugget in this issue by Tim Mackesey is available in the Newsletter.

Jerry Johnson - Wordless Picture Books

Great news for getting communication from preschoolers and non-readers. For many years, and stolen from my wife Maxine, a school speech-language pathologist, I have used wordless picture books by Mercer Mayer (and now co-authored by his wife Marianna). These little books are now in paperback and can be ordered from Amazon at a discount. The books are delightfully drawn and tell a short story that piques the imagination and encourages spontaneous story telling by the child. This method also encourages a wonderful verbal interchange between the speech-language pathologist and the child. Two that I particularly have enjoyed using are "A Boy, A Dog, and a Frog" and "A Boy, A Dog, A Frog and a Friend."

Wordless books allow the speech-language pathologist to be creative too and can defeat anxiety about the nonverbal child, because there are many ways to recite the story and they also allow for theatrical expression. In my experience, kids love these books. Sometimes kids don't want to talk, but when shown a non-threatening activity, no words to intimidate the child, most kids cooperate fully. Try it the next time you get stuck.

Volume 10, Number 2 - August 2000

Jerry Johnson - Torture Chamber Therapy

With some children who have achieved most of the fluency goals in therapy and who are approaching the stage of termination there comes a time when the kid might say, "What are we going to do today?" This rhetorical question might mean, "I'm getting a little bored with therapy." Sometimes the clinician too needs a break from the routine of therapy, or in some way or other needs to "spice it up" to keep the child's interest level.

Depending upon the emotional strength of the child and his/her sense of humor and an ability to handle a challenge, I will tell the child: "Today is the day! Today is Torture Camber day! Are you up to the challenge? Are you ready to show me what you can do when I try to throw you off?" I try to build the suspense and impending doom and gloom all in a humorous and sly, challenging manner. Unbeknownst to the child I have cleared this activity with the child's parent(s) and any administrator so there can be no question as to my intent or motivation and my rationale for doing the activity. Maybe this is a guy thing, and in our world of touchy, feel good behavior a clinician might not be comfortable doing this, but I have found that the carefully selected child really enjoys the Torture Chamber activity. However, for less emotionally intact children a scaled down activity could be used.

Into the therapy room I have brought all kinds of noise makers, soft Nerf balls, crunched-up paper, ear plugs (for me) and any other diabolical piece of nonsense equipment that I can find or manufacture including my own behavior and voice. The directions to the child are: "Do not stop talking no matter what happens." We have already established topics that the child really likes to talk about so he/she feels confident.

I offer the challenge: "Are you ready?" I ask, with a twinkle in my eye and a welcoming smile upon my face. "OK, start talking." As the child starts to talk the mayhem begins with ringing of bells, noise makers, asking the child to stand on one foot, walk backwards, rub tummy and pat head, Nerf balls flying around and. . . well, you get the idea. Be prepared for Nerf balls coming your way and bells ringing in your face, too. Kids have much fun with this and it gives me an opportunity to put their name on the Torture Chamber roll of honor and to give them an action hero pin of their choice to wear proudly. We talk about their meeting the Torture Chamber challenge with flying colors and what all this means in meeting their challenges in real life and that they were "the best I have ever seen at beating the Torture Chamber." Don't be surprised if they want to experience the Torture Chamber more than once.

ADDITIONAL CLINICAL NUGGETS from other sources