Fluency Plus Program

A Comprehensive Treatment for School Aged

Children

Robert Kroll, Ph.D.

Marni Grotell, M.H.Sc.
Lea Ayuyao, M.Sc.
Rachelle Vekris, M.H.Sc.

The Speech and Stuttering Institute

Toronto, Canada

www.speechandstuttering.com
Presentation Outline
The Nature of Stuttering
– Definitions and Characteristics

Treatment for Stuttering

– Models and Principles

Treatment Efficacy Studies

The Fluency Plus Program

– Fluency Skills (Targets)
Presentation Outline
Transfer
– Definition and procedures
– Mental rehearsal
– Types of fluency

Cognitive Restructuring
– Issues during transfer
– The stuttering mentality
– Self-talk

Maintenance
– Definition and procedures
– Forms of practice

Therapy Formats
– Groups vs individual
– Associated factors
 Stuttering

A complex multidimensional
condition in which the flow of
speech or fluency is disrupted by
involuntary speech motor events
 Stuttering
Problem Behavior
Psychological State Disfluency Form Types
Attitude Blocks
Feelings Repetitions
Emotions Prolongations
Self Concept Disrhythmic Phonation
Self Esteem Contingent Behaviours
Psychological Factors Etc.
Etc
 Types of Disfluency

• audible/ silent sound and syllable repetitions

• sound prolongations
• dysrhythmic phonations
• blocks
• intra-syllabic fragmentation
 Stuttering Contingent
Behaviours
may be observed at the respiratory, phonatory or
articulatory levels of the speech mechanisms
• disordered breathing
• glottal fry
• lip pursing
• eye blinks
• facial grimacing
• head jerks
• abnormal body movements
 Avoidance Behaviour
• specific sounds and words are often reported
to result in increased stuttering
• scanning behaviour in order to predict
stuttering
• avoidance strategies include word
substitution, phrase revision, circumlocution,
stopping the communicative process
• situational avoidance
WHO International Classification
of Functioning, Disability and
Health (ICF)

Disorder

Body Structure/Function (Impairment)

Activity and Participation (Disability)

Environmental Factors (Handicap)

 Body Structure and
Function
Any loss or abnormality of
psychological, physiological, or
anatomical structure or function.
 Stuttering in terms of the
WHO Classification

Body Structure and Function

• Frequency of stuttering behaviour
• Duration of instances of disruption
• Severity
• Secondary behaviour
Activity and Participation

• Any restriction or lack of ability (resulting

from an impairment) to perform a normal
human activity.
• A disability is the functional consequence
of an impairment.
Stuttering in Terms of the
WHO Classification

Activities and Participation

• Inability to say specific words/sounds
• Difficulty communicating in specific
situations
» Telephone
» Groups
» Answering specific questions
» Formal Presentations
» Authority figure
 Environmental Factors

The social consequence of an

impairment or disability defined by the
attitude and responses of others.
Thus, the state of being handicapped is
relative to other people.
Stuttering in terms of the
WHO Classification
Environmental Factors
• Classroom discrimination
• Teasing and bullying
• Social, leisure and recreational
limitations
• Issues of self confidence, self esteem
• Effect on overall quality of life
Treatment Approaches to
Stuttering
• stuttering modification
• fluency shaping
 Stuttering Modification
• deals more directly with psychological
aspects
• attitudes, feelings and emotions are
addressed in therapy
• techniques include self-acceptance, attitude
change, avoidance and anxiety reduction
• techniques employed to modify the moment
of stuttering
 Fluency Shaping
• establishment of fluency within clinic setting
• fluency is reinforced and gradually shaped to
approximate normal sounding speech
• therapy procedures reconstruct the respiratory,
phonatory and articulatory gestures used in
speech production
• no direct emphasis on fear or avoidance
reduction
• transfer or generalization of skills is addressed
 Behavioural Criteria for
Successful Treatment
Outcome
• significant, positive change in speech output
• generalization across speaking situations
• maintenance over time
 Communication Criteria for
Successful Treatment
Outcome
• To be able to talk any time, any place and to any
body

• To be able to communicate effectively and

efficiently

• And to be able to do so with little more than a

normal amount of negative emotion.
Summary of our clinical and
research findings with
adults and adolescents who
stutter

(Kroll and Scott-Sulsky, 2010)

What did we learn?

 The Two Year Follow-up
Study
Mean percent words stuttered for 14 subjects pretreatment,
post treatment and at two year follow-up
20
18 18
16
14
12
Percent Words
10
Stuttered
8
7
6
4
2 2
0
Pre Post Follow-up
Kroll & De Nil, 1994
The Two Year Follow-up
Study
Mean total scores on the Situation Checklist

160
140
120
100
80 Situation
Checklist Score
60
40 N=14
20
0
Pre Post Follow-up Kroll & De Nil, 1994
 Current Maintenance Data
Mean percent disfluency, SSI, PSI and STAI scores for 13 subjects

60

50 48
40 Percent Disfluencies
34.8 Stuttering Severity
30 29.5 31.7
Mean PSI
20 21 Mean STAI
18
15.3
10 8.15 10.3
7.07
1.61 3.46
0
Pretreatment Posttreatment Follow-up
De Nil & Kroll, 2003
So ……
 The Treatment Program
Must:
• be based on science
• be comprehensive
• focus on observable behaviours
• also deal with attitudes, feelings and emotions
• be intensive
• stress over learning and exaggeration
• limit response variability
• allow for immediate feedback
 The Client

Must:
• have valid reasons for • have age appropriate reading
seeking treatment and learning ability
• have emotional stability
• have realistic
• have a degree of objectivity
expectations and goals
• have adequate performance
• have realistic on trial probes
perceptions of therapy • have family support
• have realistic
perceptions of stuttering
• be self-reliant and work
independently
 The Fluency Plus Program

Based on our clinical work and

research findings with older
individuals, we applied these principles
and developed our treatment program
for school aged children.
 Fluency Plus Program
Principles
1. Speech Presents 6. Small Response Units
Complex Behavior Taught Individually
2. Primary Focus on 7. Sequential Synthesis
Observable Behavior of Response Units
3. Intensification of 8. Reduction of
Treatment Response Variability
4. Over-learning 9. Immediate Feedback
5. Exaggeration of • re: Response Accuracy
Speech Responses
 Fluency Plus Program
Principles
10. Clinician As Instructor 15. Transfer Component
11. Clinician As Therapist 16. Follow-Up and
12. Client Self-Pacing and Maintenance Program
Self-Reliance 17. Post-Treatment
13. Fading Support Groups
14. Family Involvement 18. Refresher Programs
 Fluency Plus Program

Critical Phases of Therapy

• Establishment
• Transfer
• Maintenance
 Targets

Definition

Speech gestures employed in speech

production which are characterized by one
or more designated properties of position,
force, velocity or duration.
 Fluency Plus Program

Fluency facilitating procedures

- Targets -

• Full Breath
• Stretched Syllable
• Gentle Onset
• Light Contact
• Blending
• Full Movement
 Response Progression
Speech Responses
C-V Combinations
Monosyllabic Words
Bi-syllabic Words
Polysyllabic Words
Short Self-Generated Chains
Long Self-Generated Chains
Syllable Durations
2 Seconds/Syllable
1 Second/Syllable
1 Second/Syllable-
½ Second/Syllable
½ Second Syllable-
New Normal
New Normal
New Normal
Stretched Syllable
Rate Reduction Sequence

2 Second Stretch
My Name Is Bob
2 ↑ 2 ↑ 2 ↑ 2

1 Second Stretch
My name is Bob
2 sec ↑ 2 sec
 Stretched Syllable

Response Progression continued…..

½ Second Stretch
My name is Bob
2 sec

New Normal – Syllable durations are not timed.

Normal prosody and inflection restored
 Full Breath Target

Definition: A full and controlled inhalation/

exhalation cycle with the diaphragm
as the major muscle contributor

Purpose: To correct learned faulty breathing

patterns
To facilitate the reconstruction of
voicing characteristics
 3 Steps of the
Full Breath Target
1. Take a slow, comfortable breath by moving
the diaphragm out.
2. Don't pause between inhaling and exhaling.
3. Exhale by relaxing the diaphragm - don't
push.
Stretched Syllable Target

Definition: The duration of each syllable, and

each sound within the syllable is
exaggerated well beyond normal limits

Purpose: To enhance the client’s awareness of

the specific motor movements of
speech
To provide a foundation of fluent
speech which can then be
systematically shaped towards
normal patterns.
 The 4 Rules of 2 Second
Stretched Syllable Target:
1. Each syllable is stretched for 2 seconds (example:
zzzziip = 2 seconds)
2. The first sound in the syllable is held for 1 full
second. Your mouth should keep still while holding
the sound for one second (example: zzzziip, the
"zzzz" is held for 1 second).
3. The rest of the syllable gets the other 1 second:
"zzzz(1 sec)iiip(1 sec).
4. If you have a word with more than one syllable, you
must pause for 1 full second in between syllables
and take a Full Breath (the Full Breath target).
 Unstretchables
• Referred to as “hissing” and “popping”
sounds
• Consist of the voiceless fricatives and
plosives
• These sounds are not stretched to avoid
excessive air loss or to avoid the build up of
articulatory pressure
 Gentle Onset Target
Definition: An initial low amplitude vibration of the
vocal folds followed by a steady and
gradual increase in the strength of these
vibrations

Purpose: To facilitate proper phonatory onsets.

To reduce the abrupt, excessive
tensioning of the vocal folds and the
forceful expulsion of air characteristic of
laryngeal block.
 5 Steps of the
Gentle Onset Target
1. Take a slow, full breath.
2. Start the voice very gently, that is, very
softly.
3. Raise the loudness of your voice very
gradually.
4. Raise the loudness to your normal
conversational loudness level, or slightly
louder if you speak softly.
5. Decrease your loudness back down to
where you began the onset
 Light Contact Target
Voiceless Fricative Sounds

Definition: A reduction of air flow through the

vocal tract.

Purpose: To prevent excessive air loss on

voiceless fricative sounds

To ensure correct initiation of

voicing on subsequent sounds
 Light Contact Target
Plosive Sounds

Definition: Light contacts of the peripheral

articulators

Purpose: To prevent excessive lip and tongue

pressure build-up on plosive sounds

To ensure correct initiation of

voicing on subsequent sounds.
Stretched Syllable
Rate Reduction Sequence

2 Second Stretch
My Name Is Bob
2 ↑ 2 ↑ 2 ↑ 2

1 Second Stretch
My name is Bob
2 sec ↑ 2 sec
 Blending Target
Definition: Variation of the amplitude and
blending of syllables within the speech
chain

Purpose: To facilitate the initiation of syllables

embedded within the words and
phrases

To improve speech flow and

prosody
 Blending Target
• Constant voicing between syllables
• Gentle Onset on each syllable

ooo ovvv eeennnve n

 Paragraph Reading

My fa/vourite/ drink is/ iced tea./ I rea/lly

en/ joy a/ cold drink/ on a/ hot day./
Sometimes/ my bro/ther likes/ his iced/ tea
fla/voured with/ lemon./
 Full Movement Target

Definition: The full and deliberate movement of

the articulators from sound to sound
within syllables

Purpose: To decrease physical tensioning in

jaw and neck areas

To facilitate kinesthetic perception

of other target behaviors
 Stretched Syllable

Response Progression continued…..

½ Second Stretch
My name is Bob
2 sec

New Normal – Syllable durations are not timed.

Normal prosody and inflection restored
 Stretched Syllable

Response Progression continued…..

½ Second Stretch
My name is Bob
2 sec

New Normal – Syllable durations are not timed.

Normal prosody and inflection restored
 New Normal Speech

Definition: New normal is defined as that

rate of speech which is stretched
enough to feel the targets being
completed accurately but natural
enough to be able to transfer to all
outside speaking situations.
 Transfer

Definition:

The voluntary or conscious application

of learned or acquired behaviors
outside of the clinic situation.
 Transfer Procedures

Cognitive and Speech Motor Processes

1. Mental Rehearsal

2. Talking While Applying Targets

3. Objective Evaluation
 Mental Rehearsal
• The mental or preparatory set with
which the individual enters a speaking
situation
• The first step of transfer
• Should be positive as opposed to
negative
 Evaluation
• Should be objective and in reference to
target behaviours
• Should be written down
• Should be used in subsequent transfers
 Fluency Types

1. Lucky (Unmonitored)

2. Monitored
 When is Transfer
Introduced?
• Not too early in the program
– Exaggerated forms of speech do not transfer
easily to natural speech situations.
• Not too late in the program
– Delaying transfer may feed the child’s fears of
specific speech situations. Emphasis should be
placed on the fact that some forms of transfer
have been accomplished earlier in the program.
 What is the Major Problem
Encountered During
Transfer?
• The link between the clinic and the outside
world is not made
• The transfer experience is not viewed as
an opportunity to practice
• The client is waiting for fluency skills to
happen (the medical model)
• The client is overcome by negative
emotion
 The Stuttering Mentality
“I hope the teacher doesn’t call on
me because I’ll blow it!”
“Maybe I’ll just pretend I don’t
know the answer.”
“I hope they don’t ask me to
introduce myself.”
“Uh-oh! Here comes a word that
starts with a “D”. Let me pick
another one - fast!”
“I know they are going to laugh at
me if I stutter.”
“I don’t want to answer the phone,
I might stutter.”
 Monitored Speech
Output
Motor : execution
Premotor Area Act of talking
Motor Planning of:

Broca’s Area
(Motor Speech Area and
message formulation)
 Negative Self-talk
The Limbic System

Cingulate Gyrus

Amygdala
Hippocampus
 Cognitive Restructuring
Definition- The alteration of attitudes,
feelings, belief systems and emotions
associated with the act of speech
communication. This is accomplished by
replacing faulty or irrational thought with
more accurate and beneficial ones through
supported self-realization and counseling.
 Positive Self-talk
Silent, internal messages regarding the
speaking situation or speaking
performance.
Can be negative or positive
Positive self-talk should serve as a mental
reminder to use target behaviours

“I will block for sure on my name”

=>”Remember to use LC and GO”

“This person is in a rush, I better talk fast”

=>”I will use SS and FM and I will be in
control of how I speak”
 Following Speech
Hierarchies During Transfer
• The danger here is encouraging the notion that
the situation is causing stuttering
• The basic premise of fluency shaping therapy is
that violations of speech mechanics will
ultimately lead to stuttering, not specific speech
situations
• Thus, desensitization procedures are often not
necessary, especially with children
What is the transfer process
for younger children?
• In some cases transfer occurs spontaneously,
depending on the age, sophistication and
awareness level of the child
• The transfer process for older children
exhibiting specific fears is very similar to that for
adults
 Maintenance
Definition:

The continuation of the therapy program as

the involvement of the clinician is
gradually decreased.

Fluency maintenance is a long, gradual

process of consolidation and stabilization
of skills, and maturing of expectations by
both the client and the therapist.
 What is the clinician’s
role in maintenance?
• To provide on-going professional evaluative
feedback during follow-up sessions
• To monitor practice schedules
• To ensure that correct skills are being practiced
for appropriate lengths of time
• To deal with psychological and behavioural
issues as they arise
When does the maintenance
process begin?

• When the client can reliably transfer newly

acquired speech skills in a variety of extra
clinical situations
• When the stuttering mentality is replaced by
a speech communication mentality
What are some of the challenges
during maintenance?
1. Acceptance of modified speech pattern
2. Constructive analysis of error patterns including
objective weighting of successes and failures
3. Willingness to continually plus actively monitor speech
4. Contingency plans to deal with anxiety and/or cognitive
demands of the dual speech process
5. Acceptance of role and responsibility of fluent speech
6. Acceptance of responsibility for the clinical process
7. Possible alteration of perceived situational speech
difficulty
8. Attitudinal and psychological changes
 When is maintenance
complete?
• When speech is no longer considered an
issue

• Observed confidence and comfort level for

communication

• Frequency and severity of disfluencies are

minimal
Maintenance Practice
Strategies
• Shaping
• Structured transfer
• Spontaneous transfer
• Target review
 Shaping
• Daily practice of all targets and speech rates
to reinforce skill accuracy
• Consists of reading aloud at each speech
rate, followed by a monitored conversation
with a partner
1 minute full breath
+ 3 minutes 2 second syllable stretch
+ 4 minutes 1 second syllable stretch
+ 6 minutes ½ second syllable stretch
+ 6 minutes new normal
= 20 minutes (reading) +10 minutes (conversation) = 30 minutes in total
 Group vs. Individual
Formats
• Group formats are ideal for children aged
7 and up
• Group activities encouraged
• Reduces waiting time
• Healthy competitive spirit ensures
program compliance
• Children younger than 7 often not ready
for group
 Group Therapy Formats

10 – 12 Year Olds:

• 26-28 weeks for establishment and transfers

• “Speech partner” does not attend group
sessions
• 5 children (maximum) per group
 Group Therapy Formats
7 – 9 Year Olds:

• 14-16 weeks for establishment and transfer

• “speech partner” attends all group
sessions
• 5 parent child pairs (maximum) per group
• Rate reduction strategies replaced by
general instructions and modelling
 The Role of the
Parent/Caregiver
• To understand the nature of stuttering
• To understand the goals of treatment
• To serve as the child’s “speech partner”
• To attend all parent meetings
• To consult with SLP on a continual basis
• To learn and model all speech targets
• To carry out home practice with child
• To create a home environment conducive to fluency
• To educate family members
• To liaise with the teacher
 Home Practice
• Instructions for practice should be clear
and formalized
– Written down
– Practice sheets provided
– Recording devises used to:
• Provide samples of individual speech targets
• Allow SLP to determine completeness and accuracy
of home assignments
– Practice sessions conducted daily
– Sessions should be 20-30 minutes in duration
 Intensive Therapy
• Can refer to in-clinic or extra-clinic
sessions
• Eliminates spaced practice and retention
issues
• Ensures experience of speech gain
• Facilitates generalization of speech skills
• Reduces client dependence on SLP
• Challenges priorities and commitment
• Builds in-home programming
 Use of Video Recordings
• Provides pre and post treatment fluency
count data
• Visual record of stuttering and stuttering
contingent behaviours
• Allows clients to examine their pretreatment
speech patterns
• Allows for objective evaluation of target
behaviours during speech activities such as
group presentations
 The Younger Child
• Children younger than 8 typically lack the
conceptual abilities for many of the details in
Fluency Plus
e.g. Stretched syllables replaced by modeling
“easy talking”
• Clinical materials and activities modified for
this age group
• Parents attend all sessions
• Parents assigned role of learning partner and
facilitator in clinic and at home
 Pre/Post Data (Conversation)
on 26 Children 9-12 years

16
14
Total Number of Children

12
10
8
Pre-therapy
6
Post-therapy
4
2
0
0-5% 6-10% 11- 16- 21- 26- >30%
15% 20% 25% 30%

Percentage of dysfluency in conversation

 Pre/Post Data on 11 Children in the
7-9 Year Old Program
(
6
Total Number of Children

5
4

3 Pre-therapy
Post-therapy
2

0
0-5% 6-10% 11- 16- 21- 26- >30%
15% 20% 25% 30%

Percentage of dysfluency in conversation

 Pre/Post Data on 8 Children in the
5-6 Year Old Program

5
4.5
Total Number of Children

4
3.5
3
2.5 Pre-therapy
2 Post-therapy
1.5
1
0.5
0
0-5% 6-10% 11- 16- 21- 26- >30%
15% 20% 25% 30%

Percentage of dysfluency in conversation

Questions, Discussion, etc.
Robert Kroll, Ph.D.
Executive Director
The Speech and Stuttering Institute
2-150 Duncan Mill Road
Toronto, Ontario M3B 3M4

Tel. 416 491 7771

Email bobk@speechandstuttering.com