Treating fluency disorders

After finishing the assessment and diagnosis it’s very important to develop a treatment plan.

The treatment plan includes the general goals and specific objectives. A treatment plan that's
successful studies all the aspects of the patient's disabilities. The treatment goals are collected
from the assessment data. This is why the assessment must address all relative aspects of
communicative functioning. Our assessment should be complete and all the communicative
aspects should be evaluated.

After we collect the data, and establish the results, we will understand which aspects we need to
target and what the priorities are because most of the times when we have a patient with any
language difficulties, the patient is a person and it’s very important to take into consideration
what he/she needs the most. For example, someone who stutters may also have difficulties
accepting stuttering, negative thoughts about it, acne, difficulties writing, etc.. The priority here
is their self-esteem and stuttering. Always think about the patient as a whole, as a human
being. Ask yourself: What’s more important? Focus on that.

In the classic treatment of stuttering, we teach the patient, through techniques, how to manage
her/his stuttering in the session but we don’t expect the patient to directly use these strategies in
their everyday life. They need time and this will improve their activity limitations. The types of
techniques we use are different from a person to another, some improve with technique A others
need another technique. For example, a patient who stutters in a group setting will need these
management techniques only when he/she is in a group cause that is where he/she stutters.
Others may only stutter at home and not outside and vice versa. The use of the intervention
techniques will be different from one patient to another.

Working from a comprehensive model of health functioning: The ICF model (The
International Classification of Function)

Yaruss, J.S., & Quesal, R.W. (2004). Stuttering and the International Classification of Functioning, Disability, and Health: an update. Journal of
communication disorders, 37 1, 35-52 . https://doi.org/10.1016/S0021-9924%2803%2900052-2
  this tool (ICF) is used by many healthcare workers as it helps identify the priorities of the
patient and general health sate .It helps us understand what the patient needs most.
 Some examples of the ICF component related to stuttering include:

-Body function and structure: here the treatment plan should remediate and compensate for
fluency impairment. a person who exhibits stuttering behaviors would be classified as exhibiting
an impairment of body function related to fluency of speech. Also, recent findings point to a
possible structural difference in the nervous system of adults who stutter.
-Activities and participation: Let’s say stuttering is affecting certain activities of daily living
(phone calls, ordering food, etc.). The most apparent component of activities and participation
that can be affected by stuttering is communication and specifically speaking
-Personal factors: includes ‘‘gender, race, age, other health conditions, fitness, lifestyle, habits,
upbringing, coping styles, social background, education, profession, past and current experiences
(past life events and concurrent events), overall behavior pattern and character styles, individual
psychological assets and other characteristics’’ (WHO, 2001)
-Environmental factors: A variety of environmental factors can influence the experiences of a
person who stutters including family, friends, certain attitudes or even communication contexts.

Considerations for the Treatment plan (TP):

We have two considerations for setting the TP

1. Some patients have specific activities of daily living that bother them in speaking like
speaking with parents during lunch time or at university or while presenting a project. So
we have to include goals that reduce and goals that remove all the negative feeling about
stuttering in this activity. From the assessment we must know which activities of daily
living bother the patient in order to target in the treatment those specific activities and
help reduce the negative feeling associated with it

2. We have to address the effort / how much the speaker speaks in these specific
bothersome activities. When there is a situation that bothers the patient he/she will reduce
his/her amount of speaking. So in the TP we target how much the speaker speaks and the
purpose is to help them say whatever they want to say. Our patient may have interesting
ideas and may want to give their personal opinion but they don't do because they want to
limit their stuttering occurrence. SO we encourage them to speak in these specific
situations. Hence, we include targeting speaking in these specific situations and give
them strategies and techniques accordingly.
The six principles of treatment

Many treatment approaches include one or more of these general principles:

1- Providing patient with feedback:

Providing the patient with feedback can be done naturally or through specific techniques. It
is when we give patients feedback regarding how we see their stuttering. We can ask them how
they found their speech in the sentence when they were talking, and then we give our feedback
(in my opinion, I noticed this and that however in the previous sentence there was this and that)
This will help the patient be more conscious about their stuttering and help them evaluate their
own speech.
- Approach 1: Feedback as means of providing behavior:
Here the feedback is for us to highlight the behavior. It can be stuttering related, secondary
behavior or it can be something we want them to do and whenever we give feedback we have to
be clear if it’s a good one or bad one. Meaning that we specify to the patient whether a certain
behavior should be used more or reduced. Feedback can be provided verbally or manually (as a
certain gesture, or mechanical noise like a knock on the table). We inform the patient that every
time they do an appropriate pause or use the technique correctly, we will knock on the table.

2-Regulating task complexity:

In stuttering there are variables that can affect the person’s speech like the number of syllables,
stress patterns, topic familiarity, if the content is rehearsed or not. There are also other variables
that are related to the behavior of the person they are talking to/receiver of speech (whether they
speak fast, if they interrupt the patient, and verbal and nonverbal reactions they provide). All
these behaviors of the receiver will affect the speech of the person (sender). Other variables are
related to the communication environment so if there is any background noise, the time available
to present the conversation (PS. Time pressure is detrimental for stutterers). It could be that the
patient may fear the person they are talking to like their teacher or parent so it will make the
conversation difficult. In the treatment plan the SLP will try to control these variables by limiting
them and little by little we include these variables during our sessions to make it more
challenging for the patient. First of all we remove these variables, then we start adding these
variables as a challenge for them to speak. We can put background noise or put on music that
makes it more complex for the patient to speak. We regulate the tasks provided to the patient
based on what the variables are. Eventually, we give out the proper strategies on how to speak in
more complex situations.

3- Building background knowledge:

It is very important to provide the parents, patient or adult we are working with with knowledge
about their fluency. When they understand the impairment they will accept it and understand it
and know how to react when it occurs.
 4- Altering Environmental Context:

Here we are talking about altering the environmental context and reducing the contexts that
increase fluency stressors like the audience size and composition, the familiarity of the people
and so on. We have to alter these environments (for ex a child who doesn't like to read in front of
his classmates cause they stutter when they read, and cause their classmates will laugh at them.
In this situation we can reduce this by telling or asking the director that when the teacher wants
to evaluate the reading skills she should take the student to another room where there is no
environmental stress for him). The idea is that we don't have to oblige the child to go through
these environmental stressors and whenever they are ready we do it, but we don't have to oblige
him/her because this will make them feel low and decrease their self-esteem.

5- Reinterpreting Personal Experience:

Addressing and including in the TP everything related to negative thoughts and beliefs about
stuttering are the SLP's job. According to ASHA, the speech therapist plays an important role
when it comes to counseling the patient about their beliefs in stuttering. However, if the SLP
doesn't have the capacity and expertise to do that, then she has to refer the patient to another slp
who is eligible to be doing this. Working with people who stutter is not the same as working with
other people with language impairments because the SLP should be able to counsel the patient
regarding their beliefs about their stuttering and emotions and all.

6- Desensitization:

The purpose of it is to help the patient be less sensitive and anxious towards their stuttering,
instead see it in a different way. It can be seen like the word or the letter is stuck. So by saying
this and thinking this way, we help the patients analyze what is happening when they are stuck in
their speech.

NOTE early intervention prevents the development of negative thoughts towards stuttering,
because a child who is affected by their stuttering and not treated, and they are not in a
supportive environment, they may develop problems and it can affect them. It is the SLP’s
responsibility because we know how important these factors are in regards to the fluency.
The stuttering problem may lead to social anxiety, so here we recommend the patient to see a
psychologist to help them with their anxiety and depression.

Approach 2: Deliberate manipulation of disfluency:

 As the patient is speaking, whenever he/she stutters the patient has to purposefully extend
this stuttering as long as possible , this creates laughter and a bit of positive emotions
towards stuttering. It also creates a way to control stuttering, the patient will feel that they
are in charge of their stuttering. Here stuttering comes naturally and we extend it/
elongate it.
Approach 3: Voluntary stuttering:

 Here the stuttering is on purpose. We tell the child to purposefully stutter and this will
make them feel like they control their speech, but it will also make them less fearful of
this behavior. We don't force the patients to do it if they don't want to. We should always
demonstrate the technique for them prior. Voluntary stuttering helps the patient produce
something they don’t want to produce/ fear to produce because it will cause them to
stutter. Hence, in this situation of voluntary stuttering, we will help the patient change
their perspective on it.

Regulating Speech production:

The techniques related to regulating speech production are mostly used by teenagers and pre-
adolescent ages. We don’t use them with children cause they are hard for them and include
advanced language components.

Why can I use them with children?

we don’t use them with children cause we are managing the parameters of the movement of
speech like time, force, pauses, or the air pressure that comes from the belly passing through the
larynx.. All these are hardly used by children. Also children at a younger age still lack such
awareness about the

Strategies that emphasize regulated articulation:

 Regulating Rate: Here one of the most common methods is to help the patient regulate
his articulation rate meaning that he will articulate each word in a slower pace , we start
very slow,, and when the patient comes comfortable we go less slower and. whenever
this technique is well done we do it slightly slower and so on until it is slightly slower
than the normal rate of speech. It is very important to make the patient have a natural
intonation, not robotic, when speaking slowly, and we shouldn't be slowing the
consonants, we slow the vowels.
 Regulation of phonetic transitions: we know that peope who stitter cansense when they
will stutter or when they are speaking they stop cz they feel that they will stutter. So here
this starategy is to regulate the rticulatory movement before stuttering occurs.

How is it done?
This is a technique very known( ERASM) an can be done in two ways:

 The first is to slow the rate of the articulatory movemnts in the syllable that come before
the syllable that there will be a disfluency. We dont use it as much as the second way.
 The second choice is: here the min idea is to articulate smoothly the ideas that come
before the anticipated disfluency. for example you will articulate less the phoneme that
 stutters . So i prepare the letter that comes after the sound ii will stutter on so the sound
that i stutter on will be said smoothly.

the one who is speaking will be doing management effort to manage their stuttering, but
the one who is hearing will not notice.
The essence of therapy is to manage the effort of the word, so that there is smoothness. Relaxed
way.
So instead of saying wwwwashington, the speaker prepares the sound (only the way it is
articulated, they dnt say the sound after ) after the /w/ which is /a/ and so they say it
{A}washington.
These techniques need training.It is not easy.

 Regulation of pauses: so here before we were regulating the articulation, the motor side.
here we are regulating the pauses so we want the speaker to use pauses in the correct
way. the way we do this is teach the patient that while speaking he/she can tap their
fingers. the idea here is to make the speaker aware of their pausing. So we have to let
them d more pauses but ofcourse the pauses should have their place.
 Regulation of speech breathing: here there are some techniques that use the breathing
to help the patient diminish the stuttering but these are specific fro breathing techniques.
Here we learn how to monitor the duration of breathing during inspiration and expiration.
We also do relaxation exercises and this helps alot. Realxation can really help the body to
release the stress so the stuttering will be less present.
 Regulation of Phonation: Also there are techniques that regulate the phnation of vowels
(parler chaud) where the patient is taught to exhale hot breath and then say the vowel, this
can be used for words that start with vowels like Amanda, arm, whatever. For example,
aleb.