2003 IFA Congress: Montreal, Canada

School-Age Fluency Roundup: From Inception to Outcome

Alice Anne G. Farley1 and Judith H. Martin2
1Speech Pathology Practice and Steps to Fluency, 7436 Forest Court, Irmo, SC 29063
2Department of Comm. Sciences and Disorders. University of South Carolina, Columbia, SC 29208

SUMMARY

Inspired by presentations made at the 2002 SID#4 Albuquerque Leadership Conference, two fluency specialists from South Carolina were challenged to inaugurate an intensive gathering of school-age fluency clients that would also provide training for parents, students, and clinicians. The University of South Carolina offered the site and sponsorship for the continuing education project. Tuition support was obtained from the SC State Department of Education and the National Student Speech-Language- Hearing Association. The Roundup showcased Steps to Fluency © Farley, a color—coded treatment program, combining fluency shaping and stuttering modification. Two training days for SLPS / SLP students preceded the Roundup.

  1. Problem
A study by St. Louis and Durrenberger (1993) indicated that SLP clinicians preferred to treat articulation/phonological and language disorders and least preferred to work with fluency and voice disorders. Reasons given for their lack of preference for treating stuttering “included insufficient training and experience as well as lack of success in facilitating fluency.” The small number of individuals who preferred working with fluency and voice disorders tended to have more training and experience with them. A survey conducted by Sommers and Caruso (1995) affirms the need for more in service training opportunities for clinicians in the category of voice and especially fluency. Recently, academic and clinical requirements have been further reduced and compromised (Yaruss & Quesal, 2002) to the extent that many clinicians reach employment with little or no experience treating disfluency.

  1. Goals
Two fluency specialists from South Carolina resolved to develop an event that would result in a renewed interest in and an improvement of services to school-age children. Desired outcomes would include:

  1. Providing an intensive day of treatment for children and teens who stutter.
  2. Bringing together stuttering clients from around the state of South Carolina
  3. Acquainting parents with current information on stuttering
  4. Educating parents on appropriate responses to disfluent speech
  5. Facilitating knowledge of and practice of fluency targets from both the Speak More Fluently and Stutter More Fluently approaches
  6. Allowing an opportunity to practice fluency targets in a variety of formats
  7. Fostering family members’ interaction with families of others who stutter
  8. Assisting school therapists in formulating goals and objectives for each respective stutterer for the next school year
  9. Providing continuing education credit for practicing clinicians 10. Providing practicum experience for student clinicians
  1. Approach
A proposal was submitted to the SC State Department of Education (SCSDE) for an event to be scheduled just prior to the beginning of the next academic year. The event would involve an intensive day of therapy for children preceded by two days of training in the Steps to Fluency © Farley (STF) program for therapists. “Steps to Fluency”(STF) was selected because it is color—coded, concrete and sequential. It is easily understood, individualized and implemented. Sponsorship and site were secured from the University of South Carolina. The two specialists (Leaders) recruited four SLPs (Facilitators) to conduct breakout sessions. Grant proposals to the SCSDE and the National Student Speech—Language-Hearing Association (NSSLHA) underwrote tuition scholarships for school clinicians and graduate students. Publicity was generated by the SCSDE and the SC Speech—Language-Hearing Association (SCSHA). A poster session presented at the annual SCSHA conference stimulated interest. Continuing Education approval was received from the American Speech—Language-Hearing Association (ASHA) and the SCSDE.

Applications for participation were received from 35 school clinicians and 22 graduate students. Application required a commitment to a three-day schedule that involved Training Day One (Friday, April 11, 2003), Training Day Two (Friday, August 1, 2003) and the Fluency Roundup (Saturday, August 2, 2003). It also required commitment to master the STF program manual and the accompanying tape between training sessions. Facilitators attended two additional three—hour tutorials. Each participating clinician was expected to invite at least one child accompanied by one or two family members to the Saturday roundup. April’s Training Day One was attended by 26 SLPS /20 SLP students plus 6 Leaders/Facilitators. August’s Training Day Two attendance was 20 SLPs/ l6 SLP students plus 6 Leaders/Facilitators. The actual Roundup attendance totaled 99: 19 school clinicians, 18 school age children (grades 1 through 10); 36 family members; 16 SLP students; 6 Leaders/Facilitators and 4 helpers/ guests. Children and clinicians were divided among four breakout groups according to age/ability (Mustangs, Broncos, Appaloosas, Palominos). A Western theme prevailed.

AGENDA

Training Day One (7 Hours)
Welcome from State Director of Special Services — SCSDE
Overview/Purpose/Goals/Manual Distribution
Fluency Shaping/Stuttering Modification Reviewed
Steps to Fluency © Farley Tutorial I
Demonstration of Therapy Techniques
Small Group Breakout — Guided Practice with Facilitators
Assignments (tape practice)/Planning

 

Training Day Two (7 Hours)
Welcome from State Coordinator of Speech and Hearing — SCSDE Logistics
Review of Methodology
Discussion of Parent/Family Involvement
Case Study Presentations/Breakout Groups
Within—Group Assignments/Planning
Practice with experienced STF clients/parents
Final Logistics/Group Reports

 

Fluency Roundup (8 Hours)
Welcome: Chairman, Department of Communication Science & Disorders, USC
Morning General Session (All)
Breakout Sessions by Age—Group (children)
“Getting to Know You”
Assignment of Targets
Concurrent General Session (parents) (Leader 2)
Mini lecture on Stuttering Development
Questions and Answers
Breakout Sessions (children)
Bombardment of Techniques and Targets
Concurrent Parent Session
Stuttering Foundation Videos
Box Lunches Provided /Planned Activities
Afternoon General Session
Sing—Along with “SC Speech Ambassador”
Introduction of National Stuttering Association (NSA) Members
Rotation of Parents Through Computer Lab for Internet Access (NSA helpers)
Group Breakout (children) -
Parents present for half of time
Discussion of Teasing, Schoolwork, Family Communication
Breakout Group Presentation Planning
Final Parent Session — (Leader 1)
Final Presentations — Closing Session
  1. Methodology

Steps to Fluency © represents a combination of the fluency shaping and the stuttering modification methods for treating stuttering. Fluency shaping therapy elicits, promotes and reinforces fluency while stuttering modification therapy teaches block management and control.

The child needs to:

  • Understand stuttering
  • Understand his/her stuttering
  • Understand the process of speaking
  • Understand how his/her stuttering deviates from normal speaking
  • Learn techniques that will aid in the management of blocks
  • Become comfortable with a new way of speaking
  • Substitute new, easy speaking patterns for stuttering
  • Learn to “loosen up, lighten up and let go” during speaking

Understand the “colors of speech” and the progression to “earned green speech”

There are three ways for the child to achieve smooth speech:

  • Speak More Fluently SMF (Fluency Shaping) 
  • Stutter More Fluent._y - STMF (Stuttering Modification)
  • Combination Approach
The child learns that there are three (3) colors of speech. They are:

SAF_f1.png

When the child begins the program Steps to Fluency ©, he/she has two colors of speech: red and green. Early in the process of therapy he/she is taught orange speech targets, which will eventually replace red speech production. Orange speech becomes the new speech pattern, an exaggerated, regulated, heightened way of initiating and completing utterances. At the conclusion of therapy, he/she will want to retain some usage of orange speech to assure the gradual habituation of his/her new, fluent speech. Note the circles (Figure 1) as follows:

SAF_f1_1.png

Figure 1. Progression of Therapy

There are many aspects of stuttering that can be brought under Voluntary control. Initially, it is helpful, as well, to regulate the fluent or non-stuttered speech. In STF this act or procedure is called “speaking beneath the umbrella of orange speech”. Speaking under the “umbrella of orange speech” is the part of the program (Fluency Shaping) that teaches the child how to “get into speech, get through speech and get out of speech”: by using exaggerated, but natural, patterns of onset and continuity.

Usage of the targets “beneath the umbrella” should result in (Farley, 1995):


  1. Fewer blocks
  2. Less severe blocks
  3. Easier to manage blocks
In other "words, if the child is talking consistently (color orange) in a careful and regulated way (Figure 2) it will be difficult for him/her to stutter in the ways that he/she did previously. If block exits continue to require special handling to be smooth, usage of ST MF techniques is needed. A traditional Van Riper (Van Riper, 1973) approach is used along with “feigned block corrections” (Bailey et al., 1985) to encourage successful block management. In Steps to Fluency © (Farley, 1995), Van Riper “steps” and “techniques” are color-coded in keeping with the red, orange, green theme. Therefore, the student is able to move between SMF and STMF protocols to individualize the program.

Block corrections are all about learning how to loosen up, lighten up, and let go of tension during speaking. As the child uses block corrections and gains control of his/her speech mechanism he/she will gain confidence in becoming a fluent stutterer. For block exits to be correct, the person who stutters must not push out of a word but go through a period of adaptive stuttering. In Steps to Fluency ©, this process is called the “25—50—25 rule”. The stutterer must go through orange before coming out of the word. That is to say, that 25% percent of the word may be red, 50% must be orange and the exit may be up to 25%t green. Thus, the desired operant behavior receives the strongest practice response. The segue between the umbrella and Van Riper is often feigned block corrections (see Bailey, et. Al., 1985) a form of voluntary stuttering. In the Steps to Fluency © program, the child is able to move between stuttering modification (Figure 3) and fluency shaping protocols in order to tailor the program.

SAF_f2.png

Figure 2. Umbrella of Orange Speech (careful, regulated talking)

SAF_f3.png

Figure 3. Steps to control

Van Riper’s (l973) program is as follows with Steps to F laency © and SFA (Starbuck, 1972) phraseology added:

Steps to Fluency © is based on the assumption that the over-learning of correct and exaggerated speech patterns involving breathing, phonation, articulation and resonation, results in the habituation of integrated speech and the extinction of stuttered speech. Combining fluency shaping and stuttering modification assures that if fluency is not facilitated, strategies are in place to promote control of all speaking. In the training manual, an acronym (TEST) is used to describe the program. It is as follows: 
  • Teach the targets and techniques necessary to assure production of easy speech ° Elicit the newly learned targets in a variety of exercises
  • Strengthen the newly learned targets in a variety of settings
  • Transfer the newly learned and habituated skills to all speaking situations
If regression occurs at any phase of the program, the student is guided to resume practice protocols at the level below which he/she is functioning. The student is encouraged to develop correct speaking patterns, which may be rehearsed, adjusted, strengthened and generalized into daily speaking situations.

Lastly, the generalization process includes the involvement and cooperation of significant others. The parent training portion of Steps to Fluency © as well as other current available resources were presented at the Roundup and addressed during the two (2) training sessions. Topics of importance included:

  1. Creating a favorable environment (harmony and structure) for the child who stutters.
  2. Understanding. the progression and patterns of stuttering and therapy.
  3. Modifying adult speech patterns as an agent of positive change in the child’s speech.
  4. Exploring alternate ways of practicing with the child
  1. Results/Conclusion
Speech pathologists from seventeen school districts were introduced and trained in Steps to Fluency © as the result of the Roundup. Evaluation forms were distributed and tallied after each training session and on the day of the Roundup. Evaluation forms for SLPS, SLP students, and parents used five point scales running from “strongly agree” (5) to “strongly disagree (1). All adult forms asked for agreement/disagreement with eight or nine goal related statements. Children’s forms required circling YES or NO agreement to three, four or six goal related statements depending on age. Results are summarized in Table 1.

SAF_t1.png

One hundred percent of the school clinicians indicated strong agreement with the statement “I will enter the school year with a ‘jump start’ on my client’s goals and objectives and incorporate new information.” One hundred percent also strongly agreed with the statement “The Fluency Roundup was beneficial to my professional growth.” To date there are no data to support the use of the program with people who stutter but evaluation responses indicated an appreciation for its use as a training tool. The SC Department of Education has committed financial support for a second Roundup in 2004 and there are plans to document future therapy outcomes using Steps to Fluency ©.

References
Bailey, A.A.G. & Bailey, W. R. (1982). Managing the environment of the stutterer. Journal of Childhood Communication Disorders, 6, No. I, 26-39.

Bailey, A.A.G. (1977). Stuttering in children: Impasse or passage. Unpublished Therapy Manual, Columbia College: Columbia, SC.

Bailey, A.A.G., Bailey W. and Moore, S. (1985). Fluency is a choice, Summer Intensive Therapy Program. Columbia, SC.

Farley, A.A.G., (1995). Steps to fluency for the schoo1-aged stutterer ©. Unpublished Therapy

and Training Manual. Fraser, M. (1978). Self-therapy for the stutterer. Memphis: Stu :tering Foundation of America.

Gregory, H.H. (1979). Controversial issues: Statement and review of the literature. In H.H. Gregory (Ed.) Controversies about stuttering therapy. Baltimore. University Park Press.

Gregory, H., E Campbell, I. & Hill, D. (2003). Stuttering therapy: rationale and procedures. Boston: Allyn & Bacon.

Guitar, B. (1998). Stuttering: an integrated approach to its nature and treatment. Baltimore: Williams & Wilkins.

Luper, H. & Mulder, R. (1964) Stuttering: Therapy for children. Englewood Cliffs, N.J.: Prentice- Hall.

Sommers, R.K. & Caruso, A.J. (1995). Inservice training in speech-language pathology: Are we meeting the needs for fluency training? American Journal of Speech—Language Pathology, 4, No. 3, 22-28.

St. Louis, K.O. & Durrenberger, C. H. (1993) What communication disorders do experienced clinicians prefer to manage? ASHA, December, 23-31.

Starbuck, H. B. (1972). Advice to Those Who Stutter Memphis: Stuttering Foundation of America.

Van Riper, C. (1973) The treatment of stuttering. Englewood Cliffs, NJ: Prentice Hall.

Yaruss, J.S.& Quesal, R.W. (2002) Academic and clinical education in fluency disorders: an update. Journal of Fluency Disorders, 27, 43-63.

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