COMPONENT 1 ESTABLISHMENT OF FLUENCY THROUGH INCREASINGLY LONG AND COMPLEX LINGUISTIC STIMULI
Rationale: To provide a hierarchically based framework of application of principles for breathstream management, decreased speaking rate, oral motor planning, light loose articulatory contacts and self- monitoring.
As the child increases the length and complexity of his/her utterances they also increase the motor planning required to say these utterances The motor planning required to coordinate the respiratory, phonatory, and articulatory systems becomes increasingly complex. As the length of the sentences increase, we also see an increase in the semantic and syntactic complexity, as well as an increase in cognitive activity.
For the beginning speaker, language is a part of a complex array of developing skills, including linguistic and speech motor, which are essential to the production of fluent speech.
Research:
Conture (1990) - recommends intervention which moves from "simple" to "complex" behaviors along a continuum of speech behavior.
Costello (1983) - developed an operant therapy approach based upon extended length of utterance (ELU). Costello also advocates using nonsyntactic word strings to effectively increase the length of utterances while building fluency.
Perkins (1992) - reports that stutterers are more likely to be fluent when using short, simple utterances.
Peters (1991) - incorporates the use of linguistic hierarchies, moving from single word, to a carrier phrase + word, to a sentence, to two to four sentences, gradually moving into conversation. Manipulating clinician models, physical settings, and persons present are additional components to intervention with young school-age children.
Riley and - noted that their clients stuttered more during longer Riley (1983) and/or more complex sentences and that improving the child's sentence formulation skills through a gradual increased length of utterance program, proved successful in facilitating fluency.
Ryan (1984) - developed an operant therapy program (GILCU) based upon gradually increasing the length and complexity of utterances. Ryan reports a 100% success rate using this approach.
Shine (1980) - described stuttering as a discoordination of speech muscle and language encoding systems, such that muscle innervation is too slow to keep up with the language idea the child wishes to express. He feels that beginning therapy with simple responses and gradually moving toward the more complex aids the child in pre- organizing his motor-planning strategies.
Stocker (1980) - found that dysfluency in children increases with increased level of communicative demand placed upon the speaker. Stocker developed both a diagnostic and therapeutic approach based upon
Activities/Techniques:
1. Word Level:
a. Memory games are useful in eliciting single word responses. The child names each picture upon turning it over. The clinician models the same behavior, reinforcing the childŐs fluency.
b. Go Fish games, using pictures or words, will elicit single word responses which can be modeled and reinforced by the clinician.
c. Bingo/Concentration games - playing concentration/bingo games in which the client and clinician alternate turning over a card and naming the item can be successful at developing spontaneous fluency at the word level.
d. Secret Grab Bag games utilizing objects or picture cards, drawn from a box or a bag, are fun ways to elicit single word responses.
e. Classification games (where the child is asked to classify a number of different pictures or words) provides a more cognitively stimulating activity at the single word level. The clinician chooses a number of different categories, selected according to the childŐs age, and asks the child to put each response item into the correct category. Peabody language cards are helpful for this type of activity.
f. Naming opposites - The client is presented with picture cards and responds by naming the opposite.
g. Animal Farm - The clinician and the client take turns taking animals out of a box and putting them on a farm. The client names the animals as he/she puts them on the farm.
h. Sentence completion - The clinician presents incomplete sentences which the child completes using one word. For example:
2. Phrase Level:
a. Word Combinations - stringing words together in various ways is the color + noun, noun + noun, and number + noun, can be easily elicited through Uno, Trouble, Bingo, Concentration/Matching, and sentence building games.
b. Carrier phrases are easily elicited with games such as "Chutes and Ladders" and "Candy Land". The child is instructed to respond at each turn with "I have a ______" The clinician models this response throughout the game and reinforces the child for easy, fluent phrase responses.
c. Memory games - Modify the child's response to include a carrier phrase such as "I have a _______" "I have a match." "There is a ______" or "This is a _______" may be substituted or used in addition to "I have a _______"
d. Picture cards - (e.g. Winitz verb cards, Peabody Language Cards, activity pictures) can be used to elicit a wide variety of phrase level responses. For example, the clinician may have the client use the cards in a drill activity where a phrase response is required describing the activity in the picture. The level of difficulty may be increased by having the clinician ask questions such as "What is the boy doing?" to elicit a response.
e. "Tell me what you do with it" games - By utilizing pictures or words, the clinician can have the client describe what a variety of things are used for.
f. "Simon Says" can be modified to be used at a two-phrase level inserting a pause between "Simon Says" and "touch your toes". This activity is also helpful in modeling reduced linguistic complexity and appropriate pauses.
g. Game boards - The clinician prepares a game board that has various colored squares. As the child lands on each color, he/she is to pick the same colored card and read the phrase written on the back of it.
3. Sentence Level: Complex multi-sentence level
a. Verb cards - These can be used in several ways; the client can describe the action taking place in the picture, or two pictures can be placed side by side and a complex sentence may be elicited.
b. Picture books - The client is requested to provide a sentence about each picture. Clinician modeling during this task my be necessary to obtain the desired response. This task may be introduced initially where the child simply repeats back a sentence produced by the clinician.
c. Sequence pictures - The child is presented with sequence pictures and is asked to arrange them in the proper order while providing a sentence for each picture.
d. Fokes Sentence Builder - An excellent tool which can be utilized to gradually increase the length and complexity of the clientŐs sentences while providing visual stimuli. This may also be utilized to elicit nonsyntactic word strings of increasing length.
e. Guessing Games - The clinician and client can play guessing games using pictures or ideas, where clues are given describing a person, place or thing. For example, "It's an animal" or "It's something you eat." The other person must guess the secret thought.
f. Asking and Answering Questions - Activities which assist the child in maintaing one's fluency when asking and/or answering questions is pertinent to the school-age child who stutters. ("Brain Quest: Questions and Answers to Challenge the Mind" is an excellent, fun set of materials. Each box comes with two sets of questions and answers for preschool through 8th grade. Questions are divided into the categories of reading, math, vocabulary, social studies and science, and grab bag. These are a wonderful way to supplement the child's regular education curriculum while practicing fluency skills.)
g. Description activities - Using picture cards, the child is asked to describe a variety of attributes of the picture. "What does it look like", "What is it used for?", or "Where can it be found?" are questions which may elicit sentence length responses. ("Guess Who" is an excellent game for eliciting descriptive sentences using visual stimuli.)
h. Jobs/occupations - Provide the child with pictures of individuals depicting different occupations and instruct the child to explain what each does.
i. Sentence transformations - Instruct the child to form one sentence from two; e.g. "I have a coat. The coat is blue;" to, "I have a blue coat."
4. Story Level:
a. Recount past events:
b. Sequence cards
c. "What's Missing/Wrong Picture Cards" - The child describes in two to three sentences what is missing in the picture or what is wrong with the pictures. This language task, though higher level in complexity, still remains at a simpler level of complexity to ensure fluency success.
d. "What if Questions" - This task requires that the child propose answers to certain hypothetical situations requiring language reasoning skills ("What would you do if you saw smoke coming out of a building?")
e. Books with no words - These are especially effective for the very young child and the dysfluent child who is exhibiting delays in reading development.
f. Reading Riddles, short poems - For some children who stutter, reading may be a fluency facilitating task. Reading materials which incorporate predictable rhyme patterns can assist in learning how to phrase when speaking.
g. Felt board stories - These are common everyday stories which most children know. Linguistic complexity is easily manipulated with this type of material.
h. "All About Me Books" - Becoming more personal adds complexity to this sentence/story task.
i. "Retell the Story" - Incorporating Rebus type stories in which the child retells a story facilitates ease in language formulation and linguistic complexity necessary for fluent speech production.
j. Giving directions - Obtain a variety of shapes or small objects, two of each. One set is for the child and one set is for the clinician. A barrier is needed to put between the clinician and the client. The clinician will ask the client to describe, in detail, sentence by sentence how to place the shapes or objects Either a time limit or a certain number of sentences should be used. The clinician can make it more difficult for the client by shortening the time, increasing the number of sentences, or creating other fluency disrupters that would help the client use his tools for modification. For instance:
Clinician: "You need to make a picture with your objects. Now you need to tell me, step by step, how to put my shapes so that I can have a picture that looks exactly like yours." Client: "Okay. First, put the circle at the top." The client is expected to use his/her techniques throughout the game (i.e., stretching, easy onset of voicing, soft contacts). Response will be elicited through positive reinforcement by the clinician when the client uses his techniques.
5. Conversational Level: