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Fluency Final

Case Study 1: Michelle is a young lady of 18. Her father convinced her to seek
treatment for her stuttering since it was interfering with interactions at school and
her social life. She stutters with a great deal of facial contortions and even
protrudes her tongue on long blocks. Although there are situations where she could
talk easily, her stuttering is severe when she talks with her principal, her boss at her
part time job, or anyone else whom she perceives as an authority figure. She feels
totally helpless during moments of stuttering and deeply ashamed
afterwards. Michelle wants to be a teacher, but has decided not to apply to college
due to her stuttering issues. Michelles score on the Erickson Scale was 24 and her
mean score on the Avoidance section of the Stutterers Self Ratings of Reactions to
Speech Situations was 3.00. You are seeing Michelle from an outpatient setting
through a local rehabilitation hospital.

Treatment: Fluency Modification


o Rationale: Michelle demonstrated negative personal reactions to her
stutter. To help Michelle realize she has control over her stutter, fluency
modification techniques will be utilized. The goal of this technique is to
modify each disfluent moment by stuttering more easily to eliminate
struggle and avoidance behaviors.

Treatment: Fluency Enhancing


o Rationale: This treatment assumes stuttering is a learned behavior. The
primary goal is to eliminate disfluencies. First, fluency will be established,
then will be gradually modified so that it sounds more natural. Some
behaviors include easy onset, decreasing speak rate,light articulatory
contacts and awareness of articulatory movement. This is a more
structured therapy approach compared to the fluency modification
technique. Fluency enhancing behaviors will help Michelle prepare for
future disfluent moments. These techniques can be used to attempt to
refrain from stuttering.

Changes: In regards to feelings and attitudes, therapy will begin in situations that
Michelle identified as being less feared. As an increase in fluency is achieved in
this setting, therapy may change settings, but keep the same people (e.g., the
clinician will still be the communication partner). As Michelle feels more
comfortable in different situations, the communication will also change (e.g.,
family, boss, friends). Although the setting and communication partners change,
Michelle will be able to use the techniques she was taught to achieve more fluent
speech in these situations. Not only will the clinician record data on amount and
types of disfluencies, but Michelle will also be asked to self-evaluate. The
clinician will review Michelles data to determine accuracy and to discuss any
missed instances of stuttering.

Charting Progress: Because she is an advanced stutterer, it may be beneficial to


look at a decrease in severity in terms of a reduction in the number of repetitions

and/or a reduction in the length of prolongations instead of lowering the stuttering


index. To do this, not only would the number of syllables repeated be counted, but
the amount of repetitions within each disfluency would be documented. For
prolongations and blocks, the clinician may determine the length of each.
Charting progress in this manner will show Michelle more progress in the early
stages of therapy than looking for a reduction in the total number of disfluencies.

Ongoing Assessment: The clinician will be continuously assessing Michelles


fears and attitudes throughout therapy. Once these have reduced, we will move on
to fluency shaping strategies. Through the completion of therapy, the clinician
will be assessing Michelles performance. This will take place in the form of
formal probes. In these cases, Michelle will work on a therapy technique with the
clinician until Michelle becomes comfortable utilizing the technique. Then the
clinician will set up a situation for Michelle to utilize the techniques outside of the
therapy session (e.g., making a phone call, talking to an unfamiliar
communication partner, talking to a feared communication partner, etc.) These
situations will start from the least feared situations and move into more feared
situations as Michelle is capable of utilizing these techniques to increase her
fluency. The clinician will record the conversation and assess Michelles
disfluencies in terms of type, frequency, and duration. Secondary characteristics
will also be noted. The clinician will assess Michelles use of the desired
technique. The clinician will also assess Michelles feelings and attitudes
throughout their time in therapy. This will be done in the form of feelings and
attitudes checklists. When presented with a certain situation, Michelle will rate
how much anxiety she feels toward communicating in that situation. As these
situations are targeted in therapy, the clinician would expect to see a reduction in
the negative feelings and attitudes. Michelle and the clinician will then compare
the checklists before and after the situation has been targeted in therapy and
continue to work on any remaining negative feelings and attitudes.

Direct Therapy: Because Michelle is aware of her stutter and her stutter has
reached an advanced stage, direct therapy will be utilized during therapy. Direct
therapy involves the client working directly with the clinician. By using this type
of therapy, we want Michelle to be able to learn enough about stuttering to be able
to self evaluate and become her own therapist.

Fluency Shaping and/or Stuttering Modification:


o Stuttering Modification: Therapy would initially target having Michelle
identify moments of stuttering. She will make a tally mark every time she
demonstrates prolongations, blocks, repetitions, or secondary behavior.
This will help Michelle recognize what she is doing and will increase her
level of comfort with addressing her moments of stuttering. Therapy will
then target desensitization towards stuttering. Michelle is scared of talking
to authority figures. She will list this and any other feared situations. She
will then arrange the situations in a hierarchy. Next she will purposely
create and release tension during the session to help with relaxation.
Finally, Michelle will imagine using her relaxation techniques in various

feared situations. When Michelles anxiety towards stuttering is reduced,


therapy will begin to modify her stutter by progressing from cancellations
to pullouts and finally to preparatory sets. Since Michelle has already
gained awareness of her stutter in previous activities, she is ready to begin
modifying her stutter to make it more acceptable. The first step to doing
this is to bring a natural stutter to completion and then to pause and
analyze the areas of tension and furthermore to reduce this tension. After
pausing and analyzing the moment, Michelle will attempt the word again
with less tension. This will provide Michelle with a way to assert some
control over her stutter and assist in moving past her moment of stuttering.
When Michelle is able to complete a stuttering moment, go back, and
correct the moment, she will be taught to modify to initial moment of
stuttering by gaining control of her stutter and completing it in a controlled
disfluency pattern. She will prolong the disfluent moment, evaluate what
she is doing wrong, decide how to change the disfluency, and shift into the
change without stopping. This will help Michelle reduce tension
immediately and gain control right away. She will no longer have to repeat
her words, but control her speech when she recognizes the buildup of
tension. When Michelle is familiar with her disfluencies and is aware of
ways to modify her stutter once it starts, therapy will progress to fluency
enhancing techniques where Michelle will use techniques in an attempt to
prevent moments of disfluencies.
o

Fluency Shaping: A variety of fluency shaping techniques will be


introduced so Michelle can decide which strategies she benefits from most
and is most comfortable using. She will first be taught each technique at
the word level. Then therapy will progress to the sentence level and then
paragraph level and natural conversation. The techniques Michelle will be
taught include: easy onset, decreased speaking rate, light articulatory
contacts, continuous phonation, and awareness of articulatory movement.
Easy onsets are used at the beginning of phrases and phrase boundaries.
They are utilized to initiate smooth airflow and voicing. Easy onsets help
to decrease muscle tension when speaking and slow down and relax the
start of speech. This allows the air to come out easier. The easy onset
relaxes the speech mechanism and decreases the contact of the vocal folds
at the beginning of a word or phrase. This helps to release tension and ease
into the word or phrase. Decreased speaking rate is used to slow down the
rate of speech and to utilize fewer words or syllables per minute. This is
designed to increase fluency. It is key that the slowed rate does not sound
choppy, it should still sound smooth and natural. To change rate, you can
chunk portions together by phrasing and pausing. You can also achieve
this by stretching out sounds or syllables, or utilize a combination of both.
This is basically just slowing down the rate of speech. It almost makes the
client sound more thoughtful. The client can produce short phrases
inserting pauses into appropriate areas. Light contacts involves producing
a stop by lightly brushing the articulators together and maintaining the
airflow as the stop is produced. When a PWS anticipates difficulty with

certain sounds, it may cause his articulators to become stuck in a certain


position. Light contacts help prevent the stoppage of airflow and/or
voicing that can trigger stuttering (Guitar, 2006; p. 275) Continuous
phonation will be used to prevent Michelle from starting and stopping
speech. It will allow her to glide from one word to the next without
stopping her voicing. The goal is to reduce the buildup of tension when
initiating a new word from a silent pause. Pausing is another technique
that is sometimes used to help increase fluency. The difference here is that
voicing continues and the speech sounds natural because Michelle will not
produce choppy, robotic speech with unnatural pauses. Proprioception
refers to the sensory feedback from the muscles of the articulators. This
helps the speaker in controlling speech movements. By focusing on the
proprioceptive feedback instead of auditory feedback, the listener may be
able to become more fluent because some stutterers have difficulties that
originate from the auditory processing system.

Criteria for Discharge: When Michelle exhibits acceptable stuttering, no longer


demonstrates anxiety about her moments of disfluency, and is able to transfer her
skills to all settings she will be able to be discharged from therapy. It is abnormal
for an individual in an advanced stage of stuttering to be completely fluent, so
acceptable stuttering is a reasonable goal. It is also important that Michelle is not
only fluent in the therapy room with the clinician, but is able to generalize her
skills to all settings, especially her feared situations that are putting a handicap on
her life.

Case Study 2: Caleb is a 4 year old boy who has been stuttering for six months,
according to his parents. He stutters on approximately six percent of his spoken
words. His disfluencies are characterized by repetitions and a few
prolongations. He is aware of his stuttering. A few times his friends in the
neighborhood had teased him about his speech. Caleb does not exhibit many word
or situation avoidances, but he does use different ways of speaking to be fluent. For
example, he learned that if he spoke in a high pitched voice, he could be fluent, and
from time to time, he does this. During initial evaluation, he responded well to trail
therapy. He was fluent at the word, phrase, and sentence levels. You are seeing
Caleb in a preschool setting.

Treatment: Fluency Shaping


o Rationale: This treatment assumes stuttering is a learned behavior. The
primary goal is to eliminate disfluencies. First, fluency will be established,
then will be gradually modified so that it sounds more natural. Some
behaviors include easy onset, decreasing speak rate, light articulatory
contacts, and awareness of articulatory movement. This is a more
structured therapy approach compared to the fluency modification
technique. Fluency enhancing behaviors will help Caleb prepare for future
disfluent moments. These techniques can be used to attempt to refrain
from stuttering.

Treatment: Coping with Teasing


o Rationale: Due to the fact that Caleb is being teased for his stuttering,
therapy will work on what is an appropriate response to being teased and
how Caleb should deal with this. Caleb will be informed that the best way
to respond is to accept his own stutter and to openly admit to others that he
stutters. The clinician and Caleb will go through a series of things that
someone may say to Caleb when teasing him. They will come up with an
acceptable response to these types of comments that Caleb feels
comfortable utilizing outside of the therapy room. An example response
will be, I know I stutter, but Im working on it. Then Caleb and the
clinician will transition into role playing these situations where at first
Caleb will play the role of the bully. The clinician will model an
appropriate way to respond to this type of situation and then the roles will
be reversed. This will help reduce Calebs fears about being teased for his
stutter and will develop and appropriate way for him to respond.

Changes: If therapy progresses and the clinician notes that Caleb is developing
negative feelings and attitudes towards being teased and towards his stutter,
fluency modification techniques will be incorporated into therapy to address
these.

Charting Progress: Calebs progress will be charted through the assessment of


his ability to utilize the therapy techniques that are targeted in therapy. The
clinician will track data on Calebs use of these techniques. Progress will also be
charted through the analysis of the reduction in Calebs disfluencies. The clinician
will periodically take speech samples to obtain a Stuttering Index. The clinician
will then take the new data and compare it to the SI taken from the assessment.
Each type of disfluency will be charted on a line graph to give a pictorial
representation of Calebs progress.

Ongoing Assessment: Through the completion of therapy, the clinician will be


assessing Calebs performance. This will take place in the form of formal probes.
In these cases, Caleb will work on a therapy technique with the clinician until he
becomes comfortable utilizing the technique. Then the clinician will set up a
situation for Caleb to utilize the techniques outside of the therapy session (e.g.,
talking to a teacher, talking to a friend, etc.) The clinician will record the
conversation and assess Calebs disfluencies in terms of type and frequency. The
clinician will assess Calebs use of the desired technique. Throughout Calebs
time in therapy, the clinician will constantly be assessing if negative attitudes and
feelings are developing. If this is the case, the clinician will move to work on
some fluency modification techniques to reduce these fears and negative feelings.
In the event that this is necessary, Caleb will draw a picture about how he feels
when he stutters in certain situations. After the feared situation is targeted, Caleb
will draw another picture and compare the two. The clinician would expect to see
a decrease in these negative feelings.

Indirect Therapy: The clinician will implement some forms of indirect therapy.
The first of these will be to educate the parents on what it means to be a good
speaking model for Caleb. This will include informing them on how slowing
down their rate, using less complex language, and putting Caleb on the spot in
fewer situations could assist in increasing his fluency. They will also be educated
on how stressors in the environment can perpetuate the stutter and to eliminate
any of these, if possible. The parents will also be encouraged to reinforce fluent
responses and to refrain from dwelling on the disfluent moments. Another form of
indirect therapy will be to inform Calebs teachers of these same aspects and to
encourage them to enforce these tips in the classroom.

Fluency Shaping and/or Stuttering Modification:


o Fluency Shaping: Seeing as the clinician noted that Caleb sometimes uses
an accent to become more fluent, the clinician will address this and show
Caleb that there are more effective strategies to utilize. A variety of
fluency shaping techniques will be introduced so Caleb can decide which
strategies she benefits from most and is most comfortable using. He will
first be taught each technique at the word level, then therapy will progress
to the sentence level, paragraph level, and finally natural conversation.
The techniques Caleb will be taught include: easy onset, decreased
speaking rate, light articulatory contacts, continuous phonation, and
awareness of articulatory movement. Easy onsets are used at the beginning
of phrases and phrase boundaries. They are utilized to initiate smooth
airflow and voicing. Easy onsets help to decrease muscle tension when
speaking and slow down and relax the start of speech. This allows the air
to come out easier. The easy onset relaxes the speech mechanism and
decreases the contact of the vocal folds at the beginning of a word or
phrase. This helps to release tension and ease into the word or phrase.
Decreased speaking rate is used to slow down the rate of speech and to
utilize fewer words or syllables per minute. This is designed to increase
fluency. It is key that the slowed rate does not sound choppy, it should still
sound smooth and natural. To change rate, you can chunk portions
together by phrasing and pausing. You can also achieve this by stretching
out sounds or syllables, or utilize a combination of both. This is basically
just slowing down the rate of speech. It almost makes the client sound
more thoughtful. The client can produce short phrases inserting pauses
into appropriate areas. Light contacts involves producing a stop by lightly
brushing the articulators together and maintaining the airflow as the stop is
produced. When a PWS anticipates difficulty with certain sounds, it may
cause his articulators to become stuck in a certain position. Light
contacts help prevent the stoppage of airflow and/or voicing that can
trigger stuttering (Guitar, 2006; p. 275) Continuous phonation will be
used to prevent Caleb from starting and stopping speech. It will allow him
to glide from one word to the next without stopping her voicing. The goal
is to reduce the buildup of tension when initiating a new word from a
silent pause. Pausing is another technique that is sometimes used to help
increase fluency. The difference here is that voicing continues and the

speech sounds natural because Caleb will not produce choppy, robotic
speech with unnatural pauses. Proprioception refers to the sensory
feedback from the muscles of the articulators. This helps the speaker in
controlling speech movements. By focusing on the proprioceptive
feedback instead of auditory feedback, the listener may be able to become
more fluent because some stutterers have difficulties that originate from
the auditory processing system.
Criteria for Discharge: Caleb will be discharged when he exhibits spontaneous
fluency in all speaking situations and when he is comfortable utilizing and
transferring the techniques targeted in therapy to these situations.
Case Study 3: Beth is a 3 year old girl who has been referred to your services by her
concerned parents. Results of a case history indicate that there is no family history
of stuttering. Development, according to her pediatrician, has been normal and
without incident. An assessment of her speech and language indicate that she is at a
4 year level for receptive and expressive language and age appropriate for her
articulation and phonological abilities. A video tape from home and observation of
parent and child interaction in the clinic indicate that the childs parents speak at a
fast rate, siblings and other family members often interrupt, and the familys
lifestyle is very hectic. A speech sample analysis indicates that she stutters on 4% of
her syllables. Beth shows no signs of awareness of frustration. You are seeing Beth
in a clinical setting.

Treatment: Lindcombe Program


o Rationale: The Lindcombe Program is a treatment implemented by
parents that focuses on behavioral treatment. It is commonly used for
preschool-aged children who are beginning to stutter. In this approach,
stuttering is viewed as an operant behavior. This suggests that it is
something that can be changed by its contingencies. It is believed that the
stuttering is being reinforced, and that is why it is occurring. Therefore, to
eliminate it, we must stop reinforcing it. This program is implemented
throughout the childs day by the parents. Parents respond to both fluent
and stuttered speech. By the parents verbal contingencies, change will
occur. The contingencies include acknowledging, praising, and asking the
child to self-correct. No other changes, including any environmental
changes, need to be made. Throughout her day, Beth will have moments
of fluent speech and moments of disfluent speech. Beths parents will
sometimes acknowledge either stuttered or smooth speech, occasionally
ask her to repeat or self-correct a stuttered utterance, or praise her for
fluent speech. An important factor in this contingencies is that the parents
give praise and acknowledgement of fluent speech at least 5 times more
than requests to self-correct or acknowledgement of bumpy speech.

Treatment: Modifying the environment


o Rationale: In addition to the Lindcombe Program, it would be encouraged
that Beths parents modify the environment. Although this is not a
component of the Lidcombe Program, it would be added since Beths

parents tend to speak at an increased rate, siblings interrupt, and the


lifestyle is hectic. It is important for Beths parents to model appropriate
speech so Beth does not feel stressed when trying to talk. Trying to talk at
a fast past, or with people interrupting can add demands to talking, which
Beth may not have the ability to meet. This is another indirect approach
that, in addition to the Lidcombe Program, would likely have a positive
effect for Beth. The family would be encouraged to use speech rates that
closely matches Beths, pause between turns, eliminate questions requiring
detailed responses, and respond to Beth regardless of fluency.

Changes: To begin, the family will visit the clinician. The first meeting entails
assessing the childs stuttering, explaining severity ratings to the parents, and
teaching the caregiver how to conduct daily treatment conversation. To determine
the severity rating, the clinician will collect a speech sample and analyze the data
to obtain the frequency of stuttering. Initially, the parents are trained to provide
verbal contingencies during structured settings and conversations. This may
include focusing on bedtime or mealtime. Training will be specific based on
parent-child interactions. As the clinician, we will not provide the treatment, but
will model with the child how the parent should be responding. After the parents
feel comfortable with the contingencies in a structured setting, they will then
progress to providing these contingencies in an unstructured setting. As Stage 1 is
complete, Beth will enter Stage 2 which focuses on maintaining the fluency of
her speech.

Charting Progress: Every day, Beths caregiver (typically the parent) will use
the 10-point Severity Rating Scale to assess Beths stuttering throughout the day.
When this is discussed in the parent/clinician meeting, the clinician will ask
Beths mom to rate her speech currently and compare it to her own rating. This is
to ensure that Beths mom is using the scale appropriately. Any additional
comments should be included such as changes to the childs environment or
increases in stuttering. During the process, the clinician and parent regularly
discuss the childs stuttering and assess how the treatment is working. These
measures help to determine treatment decisions.

Ongoing Assessment: Ongoing assessment is conducted by the parents then


discussed with the clinician. Because this takes place at home, the clinician will
not be aware of exactly how well the parents are implementing the treatment
approach. The family will visit the clinician weekly. At this time, they will
discuss the SRR and determine Beths progress. Goals of the weekly meetings
include assessing the childs stuttering, discussing current progress, and
introducing new procedures when necessary. During this discuss between Beths
mother and the clinician, it is likely Beth will just be playing in the room. It is
okay if she overhears the conversation, but would not be required to sit and listen.
In regards to advancing the program, once verbal contingencies have been
exhibited in structured and unstructured conversations, and the child is fluent in
all situations, treatment will gradually be faded. A maintenance procedure is a key
factor of this program. Relapse is common, so it is stressed that the parents follow

through with stage 2 of the program. The time between each clinic visit is
gradually increased. Stage 2 still involves verbal contingencies, but less
frequently. Each meeting will involve discuss about whether the amount of verbal
contingencies should be decreased based on Beths progress. This stage typically
lasts about one year.

Indirect Therapy: This treatment would be considered an indirect therapy


approach. That is because the treatment is primarily through the parents or
caregivers. There would be little direct contact between the clinician and the
child. This approach is appropriate for Beth because she shows no secondaries or
signs of awareness. Indirect approach is typically used for borderline and/or
beginning stuttering. Goals of indirect therapy include making speech enjoyable
for the child, eliminating or reducing environmental demands, desensitizing the
child to fluency disrupting stimuli, and rewarding or encouraging forward moving
speech.

Fluency Shaping and Stuttering Modification: These are techniques used in


direct therapy, so they would not be used in Beths case. Fluency shaping assumes
the stuttering is a learned behavior and tries to prevent the stutter. The primary
goal is to eliminate disfluencies. Some behaviors include easy onset, decreasing
speak rate and light articulatory contacts. Stuttering Modification deals with the
here and now. The client is taught how to be more fluent in each moment of
stuttering. The three stages include cancellations, pull-outs and preparatory sets.
Because Beth is unaware of her stuttering, neither of these would be included in
the treatment. Instead, we would modify Beths environment. Examples of how
this would be done are included under the rationale section which discusses
environmental changes.

Criteria for Discharge: When Beth is fluent in all situations, treatment will be
faded in a gradual, systematic manner. By the time this program is completed, it is
unlikely that Beth will remember that she previously stuttered, and she will not
have to monitor her speech or work towards fluency.

Case Study 4: Brad is a 12 year old boy who stutters with repetitions,
prolongations, and silent blocks. Brad is starting to fear his stuttering and often
refuses to answer questions in class and does not volunteer answers. Results of the
Communication Attitude Test = a score of 70. Brad teacher indicates that his
stuttering affects his performance in class and his interactions with his peers, but
specific details are unknown. As a school-based speech-language therapist, Brad
has been referred to your services by his homeroom teacher. You also discover that
Brad is being teased and bullied by a classmate.

Treatment: Fluency Modification


o Rationale: Brad demonstrated negative personal reactions to his stutter.
To help Brad realize he has control over his stutter, fluency modification
techniques will be utilized. The goal of this technique is to modify each

disfluent moment by stuttering more easily to eliminate struggle and


avoidance behaviors.

Treatment: Fluency Enhancing


o Rationale: This treatment assumes stuttering is a learned behavior. The
primary goal is to eliminate disfluencies. First, fluency will be established,
then will be gradually modified so that it sounds more natural. Some
behaviors include easy onset, decreasing speaking rate, light articulatory
contacts and awareness of articulatory movement. This is a more
structured therapy approach compared to the fluency modification
technique. Fluency enhancing behaviors will help Brad prepare for future
disfluent moments. These techniques can be used to attempt to refrain
from stuttering.

Treatment: Coping with Teasing


o Rationale: If a client exhibits fluent speech or acceptable stuttering, but
attitudes and feelings are never addressed in therapy, the client is likely to
end up in therapy again. It is essential to address Brads feelings towards
stuttering and being teased while he is receiving therapy. It is impossible
to eliminate teasing, so therapy would target providing the correct
responses to teasing in order to provide Brad with the necessary tools to
face his classmates. Brad will first be taught to disclose to his peers that he
stutters; this will help increase their level of comfort and take pressure off
of Brad to speak perfectly. He will also be encouraged to accept the
stutter. If it does not bother him, then he will not mind when people
comment on his stutter, nor will he react to his peers when they tease him.
This will hopefully decrease his peers desire to tease Brad. In order to do
this, Brad will demonstrate positive reactions to his stutter and will
participate in role play activities with the clinician to help prepare for reallife situations involving teasing.

Changes: In regards to feelings and attitudes, therapy will begin in situations that
Brad identifies as being less feared. As an increase in fluency is achieved in this
setting, therapy may change settings, but keep the same people (e.g., the clinician
will still be the communication partner). As Brad feels more comfortable in
different situations, the communication partner will also change (e.g., family,
friends). Although the setting and communication partners change, Brad will be
able to use the same techniques he was taught to achieve more fluent speech in
these situations. Not only will the clinician record data on amount and types of
disfluencies, but Brad will also be asked to self-evaluate. The clinician will
review Brads data to determine accuracy and to discuss any missed instances of
stuttering.

Charting Progress: Because he is an intermediate stutterer, it may be beneficial


to look at lowering of the stuttering index or decreasing severity in terms of a
reduction in the number of repetitions and/or a reduction in the length of
prolongations. To do this, not only would the repetitions be counted, but the

amount of repetitions within each disfluency will be documented. For


prolongations and blocks, the clinician may determine the length of each. This
may help progress to be more easily noted than to just accept a change in the
stuttering index as the only progress being made.

Ongoing Assessment: An ongoing assessment of Brads fears and attitudes will


be completed throughout his time in therapy. Once these negative feelings and
attitudes have reduced, we will move onto fluency shaping strategies. Through the
completion of therapy, the clinician will be assessing Brads performance. This
will take place in the form of formal probes. In these cases, Brad will work on a
therapy technique with the clinician until he becomes comfortable utilizing the
technique. Then the clinician will set up a situation for Brad to utilize the
techniques outside of the therapy session (e.g., making a phone call, talking to an
unfamiliar communication partner, talking to a feared communication partner,
etc.) These situations will start from the least feared situations and move into
more feared situations as Brad is capable of utilizing these techniques to increase
his fluency. The clinician will record the conversation and assess Brads
disfluencies in terms of type and frequency. Secondary characteristics will also be
noted. The clinician will assess Brads use of the desired technique. The clinician
will also assess Brads feelings and attitudes throughout his time in therapy. This
will be done in the form of feelings and attitudes checklists. When presented with
a certain situation, Brad will rate how much anxiety he feels toward
communicating in that situation. As these situations are targeted in therapy, the
clinician would expect to see a reduction in the negative feelings and attitudes.
Brad and the clinician will then compare the checklists before and after the
situation has been targeted in therapy and continue to work on any remaining
negative feelings and attitudes.

Direct/ Indirect Therapy: Because Brad is aware of his stutter and his stutter has
reached an intermediate stage, direct therapy will be utilized. Direct therapy
involves the client working directly with the clinician. Along with direct therapy,
indirect therapy will also be utilized by educating his classroom teacher about
stuttering since Brad spends the majority of his time in this setting. His teacher
will be educated on the treatment program and what her role will be, how to
communicate with Brad about his stuttering, how to encourage Brads classroom
participation, and how to eliminate teasing among Brads peers.

Fluency Shaping and/or Stuttering Modification:


o Stuttering Modification: Therapy will initially target Brads ability to
identify moments of stuttering. He will make a tally mark every time he
demonstrates prolongations, blocks, repetitions, or a secondary behavior.
This will help Brad recognize what he is doing and will increase his level
of comfort with addressing his moments of stuttering. Therapy will then
target desensitization towards stuttering. Brad is scared of talking in class.
He will list this and any other feared situations. He will then arrange the
situations in a hierarchy. Next he will purposely create and release tension
during therapy to help with relaxation. Finally, Brad will imagine using

his relaxation techniques in various feared situations. Once Brads anxiety


towards stuttering is reduced, therapy will begin to modify his stutter by
progressing from cancellations to pullouts and finally preparatory sets.
Since Brad has already gained an awareness of his stutter in previous
activities, he is ready to begin modifying his stutter to make it more
acceptable. The first step in doing this is to bring a natural stutter to
completion and then to pause and analyze the areas of tension and
furthermore reduce this tension. After pausing and analyzing the moment,
Brad will try the word again with less tension. This will provide Brad with
a way to assert some control over the stutter and move past his moment of
stuttering. Once Brad is able to complete a stuttering moment and go back
and correct the moment, he will be taught to modify to initial moment of
stuttering by gaining control of his stutter and completing it in a controlled
disfluency pattern. He will prolong the disfluent moment, evaluate what he
is doing incorrectly, decide how to change the disfluency, and shift into
the change without stopping. This will help Brad reduce tension
immediately and gain control right away. He will no longer have to repeat
his words, but will be better equipped to control his speech when he
recognizes the buildup of tension. When Brad is familiar with his
disfluencies and is aware of ways to modify his stutter once it starts,
therapy will progress to fluency enhancing techniques where Brad will use
techniques in an attempt to prevent moments of disfluencies.
o

Fluency Shaping: A variety of fluency shaping techniques will be


introduced so Brad can decide which strategies he benefits from most and
is most comfortable using. He will first be taught each technique at the
word level. Then therapy will progress to the sentence level, then
paragraph level, and finally natural conversation. The techniques Brad will
be taught include: easy onset, decreased speaking rate, light articulatory
contacts, continuous phonation, and awareness of articulatory movement.
Easy onsets are used at the beginning of phrases and phrase boundaries.
They are utilized to initiate smooth airflow and voicing. Easy onsets help
to decrease muscle tension when speaking and slow down and relax the
start of speech. This allows the air to come out easier. The easy onset
relaxes the speech mechanism and decreases the contact of the vocal folds
at the beginning of a word or phrase. This helps to release tension and ease
into the word or phrase. Decreased speaking rate is used to slow down the
rate of speech and to utilize fewer words or syllables per minute. This is
designed to increase fluency. It is key that the slowed rate does not sound
choppy, it should still sound smooth and natural. To change rate, you can
chunk portions together by phrasing and pausing. You can also achieve
this by stretching out sounds or syllables, or utilize a combination of both.
It almost makes the client sound more thoughtful. The client can produce
short phrases inserting pauses into appropriate areas. Light contacts
involves producing a stop by lightly brushing the articulators together and
maintaining the airflow as the stop is produced. When a PWS anticipates
difficulty with certain sounds, it may cause his articulators to become

stuck in a certain position. Light contacts help prevent the stoppage of


airflow and/or voicing that can trigger stuttering (Guitar, 2006; p. 275).
Continuous phonation will be used to prevent Brad from starting and
stopping speech. It will allow him to glide from one word to the next
without stopping his voicing. The goal is to reduce the buildup of tension
when initiating a new word from a silent pause. Pausing is another
technique that is sometimes used to help increase fluency. The difference
here is that voicing continues and the speech sounds natural because Brad
will not produce choppy, robotic speech with unnatural pauses.
Proprioception refers to the sensory feedback from the muscles of the
articulators. This helps the speaker in controlling speech movements. By
focusing on the proprioceptive feedback instead of auditory feedback, the
speaker may become more fluent because some stutterers have difficulties
that originate from the auditory processing system.

Criteria for Discharge: When Brad exhibits acceptable stuttering, no longer


demonstrates anxiety about his moments of disfluency, and is able to transfer his
skills to all settings, he will be discharged from therapy. Acceptable stuttering is a
reasonable goal. It is also important that Brad is not only fluent in the therapy
room with the clinician, but is able to generalize his skills to all settings,
especially his feared situations.

Annual IEP goal with objectives for Brad


I.
Goal: Brad will increase positive feelings and attitude towards himself and his
stuttering.
A.
Objective 1: During a role playing situation in the therapy room, Brad will
produce an acceptable response to the teasing situation in 4 out of 5 opportunities across
the IEP cycle.
B.
Objective 2: Brad will utilize pull-outs in 60% of stuttering instances in 4 out of 5
sessions across the IEP cycle.
C.
Objective 3: Brad will pseudostutter (i.e., blocks, repetitions, prolongations) 6
times during a two minute timed conversation in 4 out of 5 sessions across the IEP cycle.
D.
Objective 4: Brad will identify stuttering like disfluencies (i.e., blocks,
repetitions, prolongations) in his speech during a 5 minute conversation with 80%
accuracy in 4 out of 5 sessions across the IEP cycle.
Please do a stuttering analysis on the following speech sample:
Underline intended message and identify types and amount of each disfluencies.
It is with g g g great honor that I I I was able to teach you
(14)
X f----luency this summer. I I I w---ish you all the
(11)
very best in all your inde de devours. B b best w--ishes in your
(14)
Ka Ka Ka Ka careers as school based s-----peech language pa pa pa (8)
pathologists. X X X Please do not uh (7)
hesitate in c c c contacting me if if if you should ever n-----eed (14)
p p p professional help or X advice. Um, Best w----ishes and
(12)
X many b b b blessings in your f-----future.
(8)
# of syllables = 88

# of disfluent syllables = 20
Repetitions: 11
Prolongations: 4
Blocks: 3
Cluster: 2 (1 block + repetition, 1 repetition + prolongation)
% of stuttered syllables (stuttering index): (20/88) = 22.7%

References
Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment (3rd
ed.). Baltimore: Lippincott Williams & Wilkins.
Stuttering: Basic Clinical Skills [Motion picture on DVD]. (n.d.). United States.