Stuttering; Fluency Shaping/Speech Modification

This post will focus on "fluency shaping," also known as "speech modification," as a treatment for stuttering.  This therapy seeks to teach behaviors that will lead to "normal" speech.

One component is management of airflow.  A child should have relaxed inhalations and exhalations, thus reducing tension in the body (specifically, the vocal tract).  Cue your child to take slow, deep breaths.  If she has labored inhalations, cue her to inhale through her nose as if she was sniffing a flower.  Provide her with a flower or other pleasant scent to sniff for practice in the initial stage.  If your child has labored exhalations, cue her to exhale through her mouth, as if she was blowing out a candle.

Additionally, a child should use an "easy onset" when speaking.  An easy onset is when one exhales a little bit before saying a sentence or before saying each individual word.  It is a way to encourage relaxation and a decreased rate of speaking, which have been shown to promote better speech.  A good way to begin teaching easy onset is to say words that begin with "H."  Words such as "hat" and "help" naturally occur with easy onsets since the "H" sound lets air flow freely.

Another component is to speak with "light articulartory contact."  This means that the child should produce gentle speech movements that are slow and deliberate.  For example, when making the /m/ sound, she should let her lips meet together lightly rather than pressing them together in a hard fashion; when making the /t/ sound, she should lightly tap her tongue on the roof of her mouth.  This is a way to reduce tension.

Reduced rate of speech is a key component in fluency shaping.  A child should speak slowly.  This can be accomplished by prolonging syllables.  For example, ask your child to say "father" by making sure that each syllable is said clearly, as in "fa-ther."  Another way to speak more slowly is to encourage prolongation of vowel sounds.  For example, cue your child to say "faaaaather;" in this case, the "ah" sound is prolonged so that rate of speech is slower.  It is also important for pauses to be used within and between sentences.

It is recommended that these strategies be trained individually.  Once a child has mastered the strategies, then it is time to practice using all of them together in speech.  Direct instruction, modeling of behaviors and positive reinforcement are all helpful in learning.  Also, encourage your child to monitor her own speech so that she will be independent.

One criticism of this treatment is that speech may sound unnatural or monotonous.  If this is the case, additional training may be incorporated to slightly increase rate, volume and intonation.

In order to habituate these strategies, practice will be essential - especially in a variety of environments.  One place to practice speech modification outside the home is at the Consol Energy Center while watching the Penguins play.

 

Image retrieved from http://en.wikipedia.org/wiki/Pittsburgh_Penguins.

Practice saying words first.  Cue your child as needed to "breathe easy," "speak slow," "speak gently," and use "easy onset."
One syllable words include: Goal, net, ref, skate, puck, ice, rink, win, lose, snack, pass, stick
Two syllable words include: Hockey, player, Penguins, Pittsburgh, defense, offense, helmet, trophy, award
Three syllable words include: Referee, goaltender, energy, national, injury, concussions, uniform, sportsmanship.

Next, move onto phrases.
Phrases include: Stanley Cup, Consol Energy Center, National Hockey League, Metropolitan Division, Eastern Conference, ice hockey, Pittsburgh Penguin, entry draft, Hall of Fame.

To stimulate sentences, as your child open-ended questions.  Examples include, "Who is your favorite player and why?" "What is your favorite part of the rink?" "What do you think is the hardest part about playing hockey?" "What concession foods do you like best?" "What's better: hockey or football?"  Cue your child to speak in full sentences.

To stimulate conversation, you may use the same questions as above but I recommend offering up your own opinion in order to generate a back-and-forth exchange.

Dysarthria: Prosody; PNC Park

This post will focus on how to manage prosody in children with dysarthria.  "Prosody" is a fancy term that reflects the degree to which speech sounds natural.  Ways to achieve natural-sounding speech include variations in loudness, pitch and duration.

To increase loudness, instruct your child to take a deep breath before each sentence.  This will allow her to have enough breath support to not only generate adequate volume for speech, but to have reserves in breath support for loud segments of speech.  Using more force when exhaling during speech will also help produce louder speech.  Practicing loud speech is an activity that most children enjoy.  Start by reviewing with your child the difference between "normal" volume and "loud" volume to emphasize a point.  For example, ask her to say her name in a normal voice and in a loud voice.  Once your child is familiar with using a loud voice appropriately, it will be time to practice using varying volume in speech.  I recommend beginning with emphasizing one word in a sentence.  Tell your child to save her loud voice for the most important word in a sentence.  For example, "I want cookies."  "Cookies" is the key word in this sentence, and thus should be said the loudest.  Practice with other sentences, such as "I like Sponge Bob," and "My brother's name is Tom." 

To have pitch sound more natural, it is essential to vary high pitch and low pitch.  Review with your child the difference between high and low pitches.  A low pitch can be demonstrated by humming, "Hmmmmmm."  Have your child touch her chest while humming "mmmm" to "feel" the low pitch/deep voice.  A high pitch is produced with more muscle tension in the throat.  It can be demonstrated by the "hmph!" noise.  Children may also conceptualize a high pitch with a "singing voice;" they can practice by singing "ah ah ah."  Have your child touch her voice box while practicing a high pitched voice so that she can "feel" the high pitch/high voice.  Once she understands the difference between a "deep voice" and a "high voice," practice saying words using different pitches.  Any words will do.  Once she is proficient in pitch alteration, it is time to practice sentences.  Again, the pitch should be varied for the most important word in a sentence.  Practice with the sentences, "I want cookies," "I like Sponge Bob," and "My brother's name is Tom."  Another good way to practice is by contrasting pitch differences in sentences that make a statement, and in sentences that ask a question.  When we ask a question, our pitch tends to be high at the end of the sentence.  Thus, practice a high pitch with sentences like, "Are you OK?" "We're going to grandma's, right?" and "Who is it?"  When we make a statement, our pitch tends to be low at the end of the sentence.  Thus, practice a low pitch with sentences like, "She lives in Florida," "It is five o'clock," and "You are nice."

Duration can be modified in speech through use of pauses.  Teach your child to pause at appropriate times in a sentence.  Syntax often dictates when it is appropriate to pause.  This may be difficult for younger children to understand.  Thus, I recommend telling them to pause after the most important part of a sentence.  Practice with sentences such as, "We went to art class...then had lunch," "I saw Joe...at school," and "Can we go now...Dad?"  Duration can also be modified by lengthening the production of sounds.  Practice with words such as "pleeeeease," "myyyyy" and "caaaaandyyyy."  In sentences, the most important word should be the one with the lengthened sound.  Practice with sentences such as, "That is mine," "It is Tuesday," and "What's on TV?"

For the most natural speech, use variations in loudness, pitch and/or duration all in the same sentence.  For example, "I like peanut butter...and jelly," "We went to McDonald's...then to the playground, didn't we?" and "I have piano lessons at four o'clock."

To practice natural sounding speech, ask your child to read aloud, have a conversation at the dinner table, or tell jokes or a story.

For practice outside the home, try going to a Pittsburgh Pirates game at PNC Park. 

Image retrieved from http://en.wikipedia.org/wiki/PNC_Park.

Topics to stimulate speech may include:
How are the Pirates doing this season?
Who are our biggest rivals in baseball?
What is your favorite sport?
What do you smell at the ball park?
Why is baseball the national pass-time?
What buildings can you see from the stadium?
Who is your favorite player?
Why is a parrot the team mascot?
What position would you like to play in baseball?
When was the stadium built?
Where do the Pirates go for a rest?
What do you like to eat during the game?

Hyponasality; Soergel Orchards

Resonance is defined as the modification of sound through the bodily structures that the sound passes through.  Disorders of resonance can be classified into two categories: hypernasality (covered in the previous post) and hyponasality.  What is an acceptable amount of nasality is often culturally defined.

Hyponasality is caused when too little air passes through the nose on nasal sounds like /m/, /n/ and /ng/ as in "sing."  Children often sound hyponasal when they experience a cold or allergies; this is temporary and does not require treatment.  Other children may experience persisting hyponasality.  This may be due to obstructions in the nasal cavity, enlargement of the tonsils and adenoids, or a deviated septum; in such cases, medical intervention may be required and one should consult an ear, nose and throat doctor.

There are behavioral treatments, though, to decrease hyponasality.  The first involves using a visual aid.  Place a tissue or mirror under your child's nose so that she can see appropriate nasal airflow while speaking.  The tissue should move and the mirror should fog up during nasal airflow.  An alternate method is for her to put her finger under her nose while she is speaking so that she can feel the air coming out of her nose.  You may demonstrate proper nasal air flow for her by letting her feel the air coming out of your nose, or by seeing the tissue moving/mirror fogging while you are speaking.  Nasal airflow is best taught with nasal sounds.  Practice saying the sounds /m/, /n/ and /ng/ in isolation.  Then, practice them in syllables.  Words with nasal sounds should then be practiced, such as "mom," "no" and "none."  Finally, move onto phrases, then sentences and finally conversation.  Humming can also help children reach the target amount of nasality, and therefore help them understand what their voice should sound like.  Children may start with a hum, then change the hum into a word.  For example, "Hmmmm, mmmmm, mmmmm, mom."

Another treatment is known as nasal-glide stimulation.  Children are prompted to say words with many nasal sounds and many "glide" sounds (/w/ and the "yuh" sound) in varying combinations.  This helps to direct airflow into the nasal cavity.  Some words with nasal sounds include, "meal," "knee," and "sing."  Words with glide sounds include "water," "yogurt" and "wheel."   Words that contain nasal and glide sounds include "swing," "yummy," "yam," and "lawnmower."

The final treatment option is known by a few different names, including "focusing," "masking" and "resonant voice therapy."  The idea is that one should increase vibration of the nasal and facial bones in order to facilitate increased resonance.  Prompt your child to exaggerate production of nasal sounds, and to feel the vibrations in her face/nasal area.  Once this is accomplished and you have identified an appropriate amount of resonance, use this strategy to practice nasality in words, phrases, sentences then conversation.  This treatment may be hard to conceptualize.  Here is a link for more specific instruction: http://www.everythingspeech.com/articles/resonant-voice-therapy/.  It also may be helpful to view YouTube videos so that one can see and hear exactly what this therapy is all about.  Please post below if you find an especially helpful video.  (I did a quick search and haven't found the perfect one yet.)

You may practice the above treatments anywhere.  A good starting point may be at Soergel Orchards (a family farm and country store) in Wexford.  It is a fun place in the springtime, and there are plenty of words with nasal sounds. 

Image retrieved from http://www.topworkplaces.com/frontend.php/regional-list/company/post-gazette/soergel-orchards

Nasal words to practice include:
country
home
garden
barn
family
farm
plant
planting
business
market
manage
growing
picking
plum
run
greenhouse
natural
landscape
indoor
Amish
corn
pumpkin
menu
tomatoes
lamb
riding
rent
furniture.

To practice nasal resonance at the phrase level, ask your child to describe some of the scenery or items at the orchard.  Targets may include, "big greenhouse," "red barn," and "pretty farm."  Another task is to ask your child what she would like to see more of, since "more" has a nasal sound.  Targets may include, "more horses," "more apples," and "more gardens."

To practice nasal resonance at the sentence level, ask your child what she wants to do at the orchard.  The target word "want" also has a nasal sound in it, so this will provide extra practice.  Targets may include, "I want to see the horses," "I want to smell the tomatoes," and "I want to shop at the gift barn."

To practice conversation, ask your child what she enjoyed doing at the orchard.  Any verb ending with "ing" provides practice since it has a nasal sound in it.  Targets may include, "I liked picking apples.  I also liked seeing the horses.  The barn was neat.  It was so giant.  Can we come back again?"

Dysarthria: Resonance; Pleasant Kingdom

This post will focus on how to manage resonance (specifically, hypernasality) in children with dysarthria.  According to expert literature, behavioral management is inferior to other methods such as surgical management and prosthetic management.  Thus, I recommend that you defer to your primary care physician for an appropriate referral for management.  However, if you are interested in behavioral management for mild cases, I will include a few tips.

Modifying the pattern of speaking can help decrease hypernasality.  One thing to do is to increase air flow out of the mouth, instead of air flow out of the nose which leads to hypernasality and air wastage.  Cue your child to open her mouth more when she speaks, which will direct more of the air out through the mouth instead of the nose.  Practicing speech in front of a mirror may be helpful for your child as it can provide visualization of airflow.  When the mirror fogs up, it means more air is coming out of the nose.  Practice a sentence like, "Buy Bobby a puppy," which doesn't include any nasal sounds.  Challenge your child to say the sentence in front of a mirror, with as little fogging up as possible.  (At first, it may be easiest to say one word at a time.)  Another fun way to measure nasal emissions is to put a spoon under her nose, and see how much that fogs up.  Or, ask her to put her finger under her nose to feel the air flow coming out.  Having her pinch her nose and listen to the difference with and without it pinched can also help build awareness.

Speaking more slowly, speaking more loudly and over-articulating have also been shown in studies to decrease nasality.  This is because those strategies lead to more precise speech movements, which help to direct airflow.  Simple cues like, "Speak slowly," "Talk louder," and "Exaggerate your words," are helpful.

Now that spring has sprung, I recommend going outdoors to get some exercise, and practice speech strategies.  One hidden gem is Pleasant Kingdom, located in Pleasant Hills.  It is a playground that looks like a castle, and even has a sprinkler feature in the summer.

 

 Image retrieved from http://curiouslittlekid.com/healthy-living/20-things-to-do-in-pittsburgh-for-under-20/.

Ask your child to use her "best speech" while playing at Pleasant Kingdom; use the cues provided above to remind her what to do.  *Nasal sounds are underlined.  Nasal sounds are /m/, /n/ and /ng/ as in "sing."

To practice at the word level, ask her to label features of the park that she sees as you are walking toward the playground.  Single words include:
slide (or sliding)
castle
swing
stairs
fairy tale
wood
run (or running)
jump (or jumping)
crawl (or crawling)
hide
sprinkler
water
trees
picnic
shade
park
bench
climb
play

To practice at the phrase level, ask your child what you should do while she is playing.  Targets may include:
"Sit down,"
"Watch me,"
"Read a book,"
"Check your phone."

To practice at the sentence level, ask your child what this unique park makes her imagine.  Targets may include, "I think I am a princess," "I imagine the animals talk to me," and "I can climb the castle and touch the sky."

To practice at the conversation level, ask your child how this park compares to other parks.  Targets may include, "I liked the castle.  I want to go to this park again because I can pretend to be a princess.  I want Katie to come next time.  She'd like the slide.  Oh!  Next time I want to have a picnic.  This park was fun!"

*Tip: Some nasality is normal, such as in words that contain a nasal sound. 

Pittsburgh Jokes

Although April Fools' Day has come and gone, I think it's important to use jokes frequently...even in speech therapy.  Joke telling is a great way to practice turn-taking and social skills.  Telling jokes is also a great way to practice articulation, stuttering strategies, language, voice strategies, abstract reasoning, reading...just about anything!  Here are a few Pittsburgh-themed jokes:

1. Why did the panther cross the road?  Because it was the chicken's day off!

2. What's black and white, black and blue, black and white, black and blue?  A Pittsburgh penguin slipping on the ice!

3. What did the Eat'n Park Smiley Cookie say when he felt sick?  I feel crummy.  I'm about to crumble!

4. Where do Pittsburghers keep their money?  In a river bank!

5. What did the frozen vegetables at Giant Eagle say?  Lettuce out, it's cold in here!

6. How can there be an Upper Saint Clair if there isn't a Lower Saint Clair?!

7. What is the nicest town in Pittsburgh?  Friendship!

8. Knock knock.  Who's there?  Pierogi.  Pierogi who?  Knock knock.  Who's there?  Pierogi.  Pierogi who?  Knock knock.  Who's there?  Pierogi who?  Knock knock.  Who's there?  Orange.  Orange who?  Orange you glad I didn't say Pierogi?!

9. What do lawyers wear to the Allegheny Courthouse?  Lawsuits!

10. Why did the computer go to UPMC?  Because it had a virus!

Please post below any Pittsburgh-themed jokes that are appropriate for children.

Dysarthria: Articulation; Western PA Miniature Railroad Museum

This post will focus on how to manage deficits in articulation in children with dysarthria.  Traditionally, precise and accurate speech sound production has always been at the heart of improving articulation.  Thus, I recommend that you cue your child to exaggerate production of sounds (particularly consonants).  Please go to the right sidebar and click on the sound/letter that your child is having difficulty with to review previous posts that include strategies on how to produce each sound.

Another strategy to improve articulation is to decrease the rate of speaking.  Simply slowing down one's speech helps improve articulation because it provides more time for the "voice box," tongue and lips to coordinate in order to make sounds.  A good cue to provide for your child is, "Speak slowly."  If your child has difficulty slowing down her speech even with the provision of verbal cues, there is an alternative cue.  Ask her to tap her hand on the table or on her knee with each syllable or word.  Instruct her to tap her hand slowly, so that her hand is the pacer; the rate of her speech should mimic the rate at which she taps her hand.  It is important to also encourage your child to use pauses appropriately in sentences.  Pauses are helpful to the speaker because they provide a break, and are helpful for the listener because they help to break up information.

Recording your child's speech and then playing it back to her can help increase awareness of speech errors.  Record your child during a conversation, or while she is reading.  Then, play it back to her.  Ask her to listen to her speech and identify what she did well (this is important for self-confidence) and what could be improved upon.  This will allow your child to hear what you hear, and to obtain ownership in management of her speech.

A fun place to practice articulation in Pittsburgh is the Western Pennsylvania Model Railroad Museum.

 

 Image retrieved from http://curiouslittlekid.com/healthy-living/20-things-to-do-in-pittsburgh-for-under-20/.

Practice articulation at the word level with these words:

One syllable: train, track, car, steam, scale, freight, show, seat, speed, house, shop, rail
Two syllable: railroad, western, model, Pittsburgh, hobby, journey, caboose, layout, curve, urban, indoor, tunnel, incline, member, engine, display, bridges, station, cargo, diesel, commute, transit, whistle
Three syllable: museum, Gibsonia, history, library, industry, collection, railroading, passenger, engineer, suburban, Mon-Valley, exhibit, conductor, electric, monorail, regional
Four syllable: miniature, Pennsylvania, education, transportation, locomotive.

Practice articulation at the phrase level by describing the trains and scenery.  Ask your child what kinds of trains she sees.  Targets may include, "Long trains," "City trains," and "Big trains."  Also, ask your child what scenery she sees.  Targets may include, "Trains in tunnels," "Train on bridges," and "Little houses."

Practice articulation at the sentence level by asking your child to describe the scenes she sees.  Targets may include, "I see a town," "I see a train on a big bridge," and "I see train tracks and trees."

Practice articulation in conversation by engaging in a make-believe task.  Ask your child where she would like to take a train to.  Target may include, "I'd like to take a train see Grandpa.  He would he happy to see me.  We would bake cookies," or "I'd like to take a train to Disney.  I could see the world.  Then, I could go on ride."  Or, ask your child what it would be like to take a long train ride.  Targets make include, "I think it would be fun.  I could hear the train whistle.  I could see trees.  I could sleep on a train!" 

Dysarthria: Phonation; Loews Movie Theater at the Waterfront

This post will focus on how to manage phonation (the vibration of the vocal cords, also known as "voicing") in children with dysarthria.  Behavioral strategies for managing phonation are similar to strategies for respiration because better breath support leads to a stronger voice.  This is because when one takes a deeper breath, it creates more pressure underneath the vocal cords which makes them vibrate better, giving the speaker a louder and stronger voice; it also provides more air to speak on for longer sentences.  Thus, cueing for better phonation is often the same as cueing for better respiration.  Instruct your child to "Take a deep breath before each sentence."  This will allow her to speak louder, and to speak longer on one breath.  (See the previous post "Dysarthria: Respiration" for more detail.)

If your child still has deficits in phonation, there are other behavioral strategies.  The first is to known as a "vocal cord adduction" technique.  Have your child sit upright on a chair with armrests, and put her arms on the armrests.  Then, tell her to push down on the armrests with her hands while she is speaking (starting with a deep breath, of course).  This is known as "bearing down" and it will help push the vocal cords together in order to get better vibration.  To be on the safe side, I recommend speaking with your child's doctor before implementing this strategy.

Another behavioral strategy for improved phonation is to instruct your child to begin speaking at the beginning of the exhalation.   It is true that we speak during exhalation, but many of use exhale for a little bit before starting to speak.  This can be detrimental to children with dysarthria because it can lead to air wastage.

If behavioral interventions fail, you may wish to speak with your SLP about the appropriateness of a speech amplifier.  There are also medical interventions available.  I recommend consulting with a specialized voice team including an ENT and SLP.  Here is a link for the UPMC Voice Center: http://www.upmc.com/services/ear-nose-throat/services/voice/pages/default.aspx.

I think a great place to practice phonation is at the movie theater...don't worry because you can talk during the previews!  Loews Movie Theater at the Waterfront is a good one to stimulate speech because it is so interesting looking inside and out.

 

 Image retrieved from http://www.cbre.us/o/pittsburgh/properties/the-waterfront/Pages/tenants.aspx.

Plus, the movie seats have armrests which allow your child to practice "bearing down."

Image retrieved from http://pittsburgh.cbslocal.com/top-lists/free-and-affordable-pittsburgh-129-music-movies-and-family-fun/.

A good way for your child to practice is to start by imitating short sentences, then longer sentences.  Remember to cue her to "Take a deep breath before each sentence," and maintain upright positioning; instruct her to "bear down" or begin talking at the start of the exhalation as needed.  Finally, let her move onto making up her own sentences, then participating in conversation all while monitoring her own speech.

Short sentences for repetition may include:
"It smells like popcorn,"
"I like movies,"
"There is a line."

Long sentences for repetition may include:
"I like to get popcorn and a soda when I go to the movies,"
"I wish I had a big movie screen at home,"
"I like funny movies because I like to laugh."

To stimulate your child to make up her own sentences, ask her questions.  Some may include:
"What is your favorite movie?"
"What is your least favorite movie?"
"Who is your favorite actor?"

Some topics for conversation may include discussing your favorite snacks at the movies, comparing movies, and talking about other things to do at the Waterfront.

Dysarthria: Respiration; Pittsburgh International Airport

Dysarthria is a collective name for speech disorders that arise from damage to the nervous system; it manifests as disturbances in muscular control of the speech mechanism, affecting respiration (breathing), phonation (vibration of vocal cords), articulation (modifying one's airstream to make speech sounds), resonance (hypernasality, hyponasality) and prosody (rhythm, stress and intonation of speech).  In the pediatric population, dysarthria is often caused by cerebral palsy, muscular dystrophy, Down's syndrome, traumatic brain injuries, etc. 

This post will focus on how to manage respiration in children with dysarthria.  The first step is to have proper positioning.  Sitting upright is optimal for many children as it allows for full lung expansion.  The next step is to make sure that your child is inhaling sufficiently.  The goal is to have sufficient breath support to complete a sentence, or to be able to say "ahhh" steadily for a minimum eight seconds.  If your child is having difficulty completing a sentence, it may be evident because she has to stop for a breath, she may become short of breath, or her voice may trail off toward the end of the sentence.  In this case, cue her to "Take a deep breath before each sentence."  You may be amazed at how well this cue works.  Once she has learned to take a deep breath before each sentence, she should have an idea of how long to make her sentences so that she can maintain adequate speech.  Once this is accomplished, you may then ask her to speak in longer sentences.  Through self-monitoring, she should be able to take deeper breaths and control her use of breath for longer sentences.  For older children having difficulty with breath support, instruct them to pause at appropriate times in sentences in order to take another breath.

A good way for your child to practice is to start by imitating short sentences, then longer sentences; remember to cue her to "Take a deep breath before each sentence," and maintain upright positioning.  Finally, let her move onto making up her own sentences, then participating in conversation all while monitoring her own speech.

If you live near the Pittsburgh International Airport (or just pass by it), it may be fun to watch the planes.  Use them as stimulus material for speech.

Image retrieved from http://www.cleveland.com/business/index.ssf/2009/11/pittsburgh_international_airpo.html.

Short sentences for repetition may include:
"I see a plane,"
"It is sunny,"
"The plane is flying."

Long sentences for repetition may include:
"There is a big, blue plane flying in the sky,"
"The pilot is flying the airplane through fluffy clouds,"
"The plane is up so high that it looks like a little speck."

To stimulate your child to make up her own sentences, ask her questions.  Some may include:
"Where do you think the plane is going?"
"How high to do you think the plane is flying?"
"What will the pilot do if it starts to rain?

Some topics for conversation may include discussing fun places to travel on a plane, comparing planes and trains, and thinking of ways to pass the time on a long flight.