Fluent Theory Manual
Thora Buckner
Developed and field-tested by Alice Anne Farley, Color Me Fluent is a fluency program that brings together the student, parent/caregiver, and speech-language pathologist as a team. Includes 160-page instructional activity manual with reproducible templates targeting fluency, 16 manipulatives to use with program and two educational posters. Printable CD-ROM. Grades PreK and Up.
Developed and field-tested by Alice Anne Farley, Color Me Fluent is a fluency program that brings together the student, parent/caregiver, and speech-language pathologist (SLP) as a team. Together they implement family education, learning theory, and behavior modification to make changes in the student's life and speech. The methods, activities, and materials in this program make it a versatile kit for any caseload, grades PreK and up.
Color Me Fluent promotes overlearning of correct and exaggerated speech patterns by focusing on breathing, phonation, articulation, and resonation. These strategies help the stutterer gain control of his/her speaking. The block management strategies in the program reduce fear and avoidance of speaking. Levels of speech fluency represented in colors provide visual cues to the student regarding his/her speech.
About the presenter: Anthony J. Caruso, Ph.D., professor, School of Speech Pathology & Audiology , Kent State University, has been actively involved in the clinical management of adults and children who stutter for over 17 years.. He has published several journal articles and book chapters on the physiological events associated with fluent and stuttered speech. Caruso (with E. Strand) co-edited a recent book entitled "Clinical Management of Motor Speech Disorders in Children" (Thieme).
While relatively few studies have examined processes of speech motor control in children who stutter, there is some evidence that children who stutter exhibit difficulty in the planning or programming of speech movements. In light of the limitation on the length of this paper, we refer the reader to Caruso et al., 1999 for a review of motor speech studies in children who stutter. In light of these findings, it seems reasonable to incorporate methods or strategies to improve multiarticulate serial movement with children who stutter. In the remaining portion of this paper, the utility of applying what is known about human neuromotor movements and factors that influence motor performance will be discussed relative to childhood stuttering.
Viewing childhood stuttering as a motor speech disorder has several benefits for clinicians. Indeed, one major assumption underlying this approach is that young children who stutter unless changes are made in articulatory dynamics as well as the coordination of those dynamics with respiration and phonation will not achieve fluency. Second, it facilitates development of treatment protocols based upon principles of motor learning (Schmidt, 1982). Thus, changes in, for example, oral motor events for speech which are necessary for fluency, can be supported by treatment planning that parallels or is consistent with established theories in neuroscience, motor learning and speech motor control. One question we are often asked by clinicians is "Where and how do I begin getting this child to be fluent?" Clearly, this theoretically based treatment approach provides a framework that can benefit clinicians in their development of a course of treatment for a particular client. Third, fluency treatment that is based upon motor learning theory is advantageous to clinicians--particularly those clinicians who determine that, due to a child's lack of progress, alterations in treatment are warranted. Based on our observations of both professional and student clinicians, often times the difficulty for these clinicians is not a failure to recognize that changes in the course of treatment are warranted. Rather, our observations suggest that the difficulty for many fluency clinicians is how to alter treatment and remain consistent with the goals of therapy and the accepted finding regarding neuromotor processes under fluent speech.
The purpose of this paper is to encourage clinicians to adopt a motor speech perspective on stuttering therapy. We will discuss some general strategies toward childhood fluency therapy that are consistent with the perspectives previously discussed in this paper. Note, however, a thorough discussion of fluency treatment, and techniques to facilitate fluency are beyond the scope of this document. There are several sources available re: stuttering treatment which provide both broad and detailed information in this area (cf., Conture, 1990; Max & Caruso, 1997; Yaruss, 1997). Moreover, several authors have discussed the benefits of applying motor learning theory to clinical management of children with motor speech disorders in a recently published book (see Caruso & Strand, 1999). Specific to fluency disorders, we have discussed our views on motor learning theory in previous publications (Caruso & Max, 1997 ; Max, Caruso & Vandevenne, 1997). Our focus here is to provide information on aspects of fluency therapy that, in our view, are consistent with a motor speech/learning perspective on stuttering in order to encourage others to adopt and implement this perspective in treatment.
As individuals learn novel tasks, or refine previously learned tasks, rate of performance has often been observed to be relatively slow in the beginning and speed up as skill level increases (Schmidt, 1988 ). One of the most robust findings in the stuttering treatment is that reduction of the client's speech production is an important variable in facilitating fluency. Although there are differing opinions as to why reduced rate of speech typically has a positive influence on fluency (cf. Ingham, 1990; Kalinowski, Armson & Stuart, 1995), there is general agreement that a slow rate permits more time for the speaker to program and/or execute speech movements and thus facilitates coordination for serial multiarticulate movements, respiration and coordination (e.g., Kent, 1984). It is interesting to note that stuttering, for most children, begins between 3 - 4 years of age, the same time of development that timing for speech typically becomes more refined (Netsell, 1981). It seems reasonable to suggest that children who stutter--i.e., children who are impaired in their abilities for speech timing and whose sensorimotor mechanism is still developing/evolving, would particularly benefit from a reduced rate of speech. The challenge to clinicians is that "slow" and "fast" are abstract concepts that may not be fully understood in young children near the onset of stuttering. Thus, some clinicians (see Conture, 1990) advocate pairing the abstract notion of "time" with concrete examples of "slow" and "fast"' and describe speech to the child as "turtle speech" or "rabbit speech."
It may be just as important to model a slow rate of speech for children who stutter as it is to have them reduce there own rate of speech. There is some evidence that disfluencies decrease when the communication partner's speech is slow (Guitar, Schaefer, Donahue-Kilburg & Bond , 1992). Moreover, this increase in fluency has occurred in conjunction with and increase in both the number of words per conversational turn and the number of conversational turns during the dyad (Caruso & Rolwing, in progress). Thus, it seems that children become more fluent as well as more verbal when speaking with a partner with a reduced speaking rate. One hypothesis regarding these results states that the partners model may provide a temporal model that the child who stutters utilizes in programming or planning speech movements (Caruso & Rolwing, in progress). For further information regarding different methods of rate reduction and the influence of the communication partner, see Logan & Caruso, 1997 and Max & Caruso, 1997).
It is generally acknowledged in the nonspeech literature, that practicing a single novel movement facilitates motor learning for complex (e.g., multiple movements) tasks (Schmidt, 1988). Relative to speech, individuals who stutter appear to have an easier time producing, e.g., single word utterances versus multi-word phrases and sentences. Many therapies advocate starting at a single word or short phrase level and gradually increasing length and complexity of the utterance. Although it has its roots in operant conditioning, the fluency treatment by Ryan is consistent with this factor in motor learning (Ryan, 1974). Another way to manipulate the number of speech movements by the child who stutters involves the use of different question types by the communication partner. Use of different questions (asked by a communication partner) is one way to manipulate the number or words spoken by a child. Thus, to facilitate motor learning, a communication partner to provide an opportunity for the child to practice speech movements during fluency could utilize "low level demand" question (e.g., questions that can be answered with a single word response). Clinicians should assess this relationship between length of response (i.e., number of movements) and disfluency (Conture & Caruso, 1987) to determine when fluent ("typical") movements breakdown as the demand for an increase in number of speech movements increases by asking more open-ended questions. Communication partners can be trained to modify their question types to facilitate fluency when talking with children who stutter (Logan & Caruso,1997).
Motor learning in general is known to be influenced by several factors: (1) the amount of repetitive practice; (2) feedback in the form of knowledge of results vs. knowledge of performance; (3) the schedule under which practice trials are performed, and, (4) motivation of the subject (see Caruso & Strand, 1999). Rarely have these variables been studied in stuttering. One notable exception is a study by Brutten and Dancer (1980) on the effect of two different types of practice on stuttering frequency. Their findings demonstrate that a greater reduction of stuttering occurred during blocked practice (each word repeated 5 times before proceeding to the next word on a list) than during random practice (the list was read in its entirety five times in succession). Unfortunately, however, this is one of the few studies on the principles of motor learning and stuttering. Needed are studies of the effects of any practice schedule on stuttering frequency during a retention task (designed to determine if a new skill was in fact learned vs. a temporary improvement in motor performance). Another important variable that needs to be addressed is the effect of speech rate during practice as well as retention tasks. Such studies are timely, particularly with children, as changes in health care bring increased demands to document effectiveness of treatment. Evidence that certain types of practice are effective with children near the onset of stuttering would have a valuable impact on clinical management of children who stutter.