Development

 

Over the past 15 years, researchers and practioners have recognized the necessity to develop an integrated approach to stuttering therapy based on models from whole language intervention (Norris & Hoffman) to demands/capacities (Adams; Starkweather & Gottwald) to multifactorial components ( Smith). Healey and Scott (2001) provide us with a model (and very good acronym) which pulls together domains for working with clients who stutter. The CALMS model allows us to integrate the five factors of complex interactions which include cognitive, affective, linguistic, motor and social components.

 

In working with Charles Healey, Jan Norris, and Lisa Scott, I began to look at incorporating the CALMS model as a framework for therapy with graduate students who work with my caseload of clients who stutter. Clients range in age from early elementary school to octogenarians. Because stuttering is a dynamic, rather than a static, disorder, influences in management must come from integrated, or blended, aspects of different treatment methods. Over the past ten years, graduate students have been incorporating the CALMS model to teach and explain information about stuttering and to correlate stuttering to topics of the client’s interest. As each person who stutters has a unique combination of characteristics. Each CALMS model is unique to the client/ graduate student relationship and interaction.

 

Assessment

 

The basic evaluation for a fluency disorder has been defined in a variety of resources (McAfee and Shipley, Gregory, Guitar). Specifically, tools including the Systematic Disfluency Analysis, or SDA,

(Gregory), the Stuttering Severity Index, or SSI, and the Cooper Assessment of Stuttering Syndrome- Adult/Adolescent or Child version , or CASS-A or C are used to obtain measurements of CALMS domains. We have also incorporated rating scales, parent/teacher assessments, and other perceptual criteria to evaluate the severity of the fluency disorder. Recently, Healey’s CALMS Rating Scale has been useful in organizing pre and post therapy comparisons. This scale is used primarily with school age children, but has been adapted with other age groups. Based on a 5 point rating scale, the CALMS assessment allows for subjective and objective measures of performance. From this assessment scale, directions for treatment design become apparent and support development of the individualized patterns and profiles which surface. As profiles emerge from this rating scale, clinicians may determine which areas of the CALMS model may need to be addressed specifically. If this is the client’s initial foray into therapy, all domains may need emphasis. If the client has previously participated in therapy, specific components may need more focus than others.

 

Topic Choice

 

Using the CALMS model for therapy, the clinician can provide the client with better understanding of stuttering, allow the client to discuss feelings and attitudes about stuttering, manage linguistic demands to improve fluency for the client, work with the client on speech skills of stuttering modification and/or fluency shaping, and use skills learned in a variety of realistic speaking situations with the client. All of this is then developed in the milieu of a topic of interest for the client.

 

How are topics chosen? In the interview or the initial therapy session, the clinician discusses with the client areas of interest including books, hobbies, celebrities, focus of study, games (card and video), sports, etc. These discussions are also components of speech sampling for monologue and/or dialogue to evaluate severity of stuttering, as well as for establishing rapport. Using this thematic intervention, the clinician and client maintain and develop a topic over time, encourage integrating skills and thinking, and refine speech and language skills continuously.

 

Topics that have been chosen are about as varied as one’s imagination and have included some of the following:

You are probably asking yourself, by now, how can these topics help one have a better understanding of stuttering? How do the graduate students know about these topics? Is this a static process? What do you do in a session? How do you get source material?

 

Many a clinician has brainstormed development of answers to these same questions with me. I have found that you can analyze any new task or idea using the CALMS model by breaking down the topic into the 5 domains. Remember, using this thematic approach allows a framework for therapy with specific objectives and activities developing over time. Source materials have come from the clients themselves, Internet research, and topic books like the Eyewitness series. Other useful materials include Fluency at Your Fingertips, Easy Does It – Fluency, the Source for Stuttering (various ages).

 

Treatment Principles and Goals

 

General treatment principles remain consistent. The relationship between client and clinician is important with clinician in roles as coach, counselor (as needed), and friend. The clinical must always be a good model for the client in showing different ways of thinking, feeling and reacting, and in demonstrating how to use the speech mechanism. The mutually chosen topic or theme should facilitate responses from the client at a level of both challenge and success. The clinician should be able to model desired activities for the client. Goals, as established, should be both meaningful and attainable for the client. While goals should be broad enough to include the multiple domains of fluency disorders, they also need to be individualized for the client and relevant in terms of education and communication.

 

Goals generally are divided into the five domains and may include:

 

Cognitive

• Increase the client’s understanding of stuttering
• Education about normal anatomy and physiology of speech production and mechanism
• Inform peers, family members, etc. about stuttering and its treatment (also Social)
• Develop consistent “language of fluency”, defining terminology of the communication system, of stuttering, of perceptions so that client and clinician are “on the same page.”
• Identify stuttering behaviors

 

Affective

• Decrease negative emotions and sensitivity to stuttering
• Decrease feelings of fear, anxiety and/or tension related to stuttering
• Increase ability to cope with negative responses by others, including teasing
• Improve areas of self-esteem and self-confidence
• Change negative thinking
• Observe, reflect, probe and validate feelings
• Increase ability to discuss stuttering with others (also Social)

 

Linguistic

• Increase linguistic complexity from concrete to abstract
• Increase length of utterance from single words to conversation, as level of smooth speech is defined
• Decrease word avoidance

 

Motor

• Identify speech modification and/or fluency shaping techniques
• Increase practice and use of techniques
• Define individual strategies for each client
• Increase awareness of self-monitoring skills (in all domains)

 

Social

• Increase social/pragmatic skills
• Increase verbal interactions in familiar and unfamiliar situations
• Increased number of opportunities for the client to use new skills in realistic speaking activities
•  

Treatment Activities

 

Ok, so let’s put this model to practice. Here is a sample form which is competed over the course of a semester between the client and the clinician.

 

Theme:

Domain	Stuttering Skills Targeted	Correlated theme activities
Cognitive
Affective
Linguistic
Motor
Social

 

In the “Stuttering Skills Targeted” column, the clinician will provide directed activities based on specific goals for stuttering. In the “Correlated theme Activities” column, the client and client will develop ideas that go along with targeted skills. Here’s how a form might look by the end of ten to twelve therapy sessions based on a theme of football.

 

Domain	Stuttering Skills Targeted	Correlated Theme Activities
COGNITIVE	Increase knowledge of normal speech production (must understand normal to identify differences Define stuttering terminology: disfluency types & fluency enhancing behaviors Develop self-monitoring skills with identification of instances of stuttering vs. fluency Use fo relaxation exercises for muscle awareness, tension vs. relaxation	Body parts used to play football Define football terms: player positions, plays, equipment, uniforms, stadium, etc. Keeping score: roles of coach & referees Stretching exercises in practice & before games
AFFECTIVE	Increase self- esteem Awareness & discussion of feelings of anxiety, tension: using materials from Chmela workbook (see bibliography)	Who are your fans? Why do they support teams? Who are your fans? How do you feel before a game? Feelings after a game?
LINGUISTIC	Increase length of utterance from single words to conversation Expand language skills: concrete to abstract, i.e. from labeling to 90% fluency in 3 minute conversation	Single word labeling of football terms/plays Discuss football plays: how they are developed Practice as if you were the play-by-play announcer for a game Analyze the outcome of a real football game
MOTOR	Easy onsets Rate reduction Deliberate phonation Cancellations	Practice these fluency enhancing behaviors (FEB) as you create & use football and speech rules Self-monitor & use cancellations to replace penalties for “offsides”, “blocks”, “do overs” (repetitions)
SOCIAL	Decrease avoidance behaviors Age appropriate social interactions and pragmatics through use of role plays, phone conversations, meeting with athlete or coach	Turn taking skills, i.e., the quarterback passes to the receiver OR offense vs. defense Be the quarterback calling plays or the coach discussing the outcome of the game with the media Call a local high school or college to arrange a conversation with an athlete Meet with an athlete or coach for interview

Graduate students have been creative once their clients decide upon a theme. Here are examples across the life span.

 

1. A preschool child had just initiated therapy following a family trip to ski in Colorado. He had learned to enjoy skiing and the clinician was able to associate fast/slow speech and smooth/bumpy speech with concepts of speed, smooth trails, feelings of fear and fun, ski equipment, and story books and storytelling about skiing.
2. A young adolescent chose the topic of reptiles and had much knowledge on the subject.

The clinician made connections between reptiles and stuttering. For example, a snake represented smooth speech, a turtle was equated with slow speech, a toad’s back suggested bumpy speech, and a lizard reminded him to use light contact. He then went with his clinician to a Natural History museum where he could interact with a docent. The clinician had arranged the visit and had discussed questions for the docent to ask. Back in therapy, the client had also done webbing and planning through role plays and question development to prepare for the museum visit. Once the client and clinician returned to the Clinic from the museum, they discussed and rated his speech to focus on self-monitoring.

3. A volcano theme was used with a 10 year old male. This was a relevant analogy, especially

in the area of Affective (feelings and attitudes). For the social component, the client researched and made a volcano with baking soda and vinegar. He did a presentation to other clients in therapy. The clinician and client also planned a visit to a geologist, at which time, fluency strategies were used and monitored in conversation.

4. A teen with Down’s syndrome chose a topic about Brittany Spears. The graduate student

learned about all of the celebrity’s songs and dances. She could correlate how Brittany choreographed, learned, and practiced dances with how the client could analyze fluency types and learn and practice fluency enhancing behaviors. The client also worked on planning, writing, and discussing both a fan letter to Brittany and a newsletter for the celebrity’s fans.

5. An adult client was in the process of obtaining his real estate license and wanted to work on his speech skills for future interactions. The graduate student worked on real estate terminology, feelings about buying a home, organizational strategies to look at types of homes or locations, and the step-by-step process of buying a home. Social interactions included role plays, phone calls to local real estate agencies, and, finally, meeting with an agent.
6. An octogenarian who wrote poetry used this theme which allowed the focus of therapy to be

on rate, rhythm, how to construct poems,, and how poetry could be used to elicit thoughts and feelings about stuttering.

 

Final Thoughts

 

The CALMS model approach to therapy has continued to be interesting, fun, and relevant for both clinicians and clients, and when appropriate, families and peers. It is a dynamic, multidimensional process that allows for the interaction of factors which maintain stuttering and for addressing those factors in an individualized way. Through this thematic construct of therapy, goals of treatment related to understanding the disorder, to feeling positively about self and speech, to being able to formulate the message, to managing stuttering and speech strategies, and to be feeling comfortable in a variety of speaking situations can be achieved over time.

 

Suggested Reference Materials

 

Stuttering Foundation of America: Pamphlets, Brochures & Videos

 

Chmela, K. and Reardon, N. (2001); Dealing with School-Age Children who Stutter: Working

Effectively with Attitudes and Emotions; Memphis, TN: Stuttering Foundation of America

 

Blood,G.W. (2003); Power-R Game ; SFA Pub.# 0250; Memphis, TN: Stuttering Foundation of America

 

RidgeH. and Ray;B. Fluency at Your Fingertips; Communication Skill Builders

 

Reardon, N. and Yaruss, S. (2004); The Source for Stutteriing: Ages 7 – 18; East Moline, IL:

Linguisystems

 

Ramig, P. and Dodge, D. (2005); The Child and Adolescent Stuttering Treatment and Activity

Resource Guide; Delmar Publications

 

Daly, D.; (1996) The Source for Stuttering and Cluttering; East Moline, IL:Linguisystems

 

Eyewitness series for thematic ideas

 

Bibliography

 

Conture,E. (2001) Stuttering: Its Nature, diagnosis, and treatment; Needham, MA: Allyn & Bacon

 

DeKemel-Ichikawa, K.(1996); Treating Motor, Linguistic, and Social Aspects of School-Age Stuttering;

Presentation, Annual Super Conference on Special Education; Baton Rouge, LA

 

Gregory, H.H. (2003); Stuttering Therapy: Rationale and Procedures; Boston, MA: Allyn & Bacon

 

Guitar, B.(1997); Stuttering: An Integrated Approach to Its Nature and Treatment; New York:

Williams and Wilkins

 

Healey, E.C. (2003, 2004); A Multidimensional Approach to Assessment and Treatment from

Stuttering Therapy: Practical Ideas for the School Clinician; Stuttering Foundation of

America workshop; Philadelphia, PA and Cincinnati, OH

 

Healey, E.C., Scott, L. and Susca, M. (2004); Clinical application of a multidimensional approach

For the assessment and treatment of stuttering; Contemporary Issues in Communication

Disorders, 31, pgs. 40 – 48

 

McAfee,J.G. and Shipley,K.G.(2004); Assessment in Speech-Language Pathology: A Resource Manual, 3^rd Edition; Clifton Park, NJ: Thomson/Delmar Learning

 

Norris, J. and Hoffman, P.(1993); Whole language Intervention for School-Age Children; San Diego,

CA: Singular Publishing

 

Smith, A. (1999); Stuttering: A Unified Approach to a multifactorial, dynamic disorder IN N.B. Ratner

& E.C. Healey, Eds; Stuttering Research and Practice: Bridging the Gap; Mahwah, N.J.: Lawrence

Erlbaum Publs

 

Starkweather, C.W., Gottwald, S.R., and Halfond, M. (1990); Stuttering Prevention: A Clinicial

Method; Englewood Cliffs, N.J.: Prentice-Hall Pubs.