All About Fluency!

What goes into coordinating fluent speech?

  • Respiration- the process of using breath to create speech sounds.
  • Phonation- the process by which the vocal folds produce certain sounds
  • Articulation- the adjustments and movements of speech organs involved in pronouncing particular sound, taken as a whole.
  • Resonation The buzz created by the vocal folds resonates (vibrates) the air column and this in turn causes the structures above and around the larynx to vibrate/resonate as well.

If only one is “off,” there will be a breakdown in fluency.

What is Disfluency?

  • Various surface interruptions that occur in on-going speech, whole word/part word repetitions, irregular rhythm, sound prolongation, cessation of speech
  • “Normal nonfluencies,” occur is everyone’s speech- word finding, sentence formulation, distractions, interjections (like, um, you know)

Dimensions of normal speech fluency

  • rate (appropriate timing)
  • continuity (smooth connections)
  • tension effort (appropriate force)

The Major Components of Stuttering:

Core Behavior-what a Person Who Stutters does WHEN they stutter

  1. Repetition- When a sound, syllable, or word is repeated several times: b b b-aby or ba ba ba baby
  2. Prolongation- when a sound is held for a long time or just keeps coming: baaaaaaby
  3. Complete block- when the sound and airflow are completely stopped: b—–aby

Secondary Behavior– what a Person Who Stutters does BECAUSE they stutter

  1. eye blinking
  2. foot stomping
  3. head nodding
  4. face movements
  5. avoid talking
  6. add words
  7. change what was going to be said

Feelings and attitudes about stuttering: (anxiety, nervousness, fear)

Two Approaches For Treatment

Fluency Shaping: speak more fluently, which includes factors such as: speak with a slower rate, easy onsets, airflow management, intonation and phrasing management, continuous forward moving speech

Stuttering Modification: helps the person monitor the stuttered speech more fluently (stutter more fluently)- the Moment of stuttering is changed. Some techniques include:

  • Identification: understand core/avoidance behaviors understands feelings associated with stuttering learn about stuttering
  • Desensitization: address emotions toward stuttering, relax, teach person who stutters to tolerate moment of stuttering and reduce anxiety
  • Modification: Cancellation-finish stutter, make adjustments, and re-utter word
  • Pull-outs: examine, plan, change, finish word in an easier way
  • Preparatory set: before saying the word plan change, and produce the word more easily

Treatment Goals

Acceptable Fluency

  • Noticeable stuttering of less severity.
  • Comfort in role of communicator, despite stuttering.
  • Speaker makes adjustments to maintain an acceptable level of stuttering.

Controlled Fluency

  • Must monitor and adjust speech to maintain natural or normal sounding speech.
  • Speaker must pay attention to how he is speaking.

Spontaneous Fluency

  • Characteristic of the normal speaker.
  • Effortless.
  • Speaker more concerned with what is said than how it is said.

Thanks for reading! Contact one of our seven facilities if you suspect that you or a loved one may have a fluency concern. Happy Fall!

Amanda Weiner, MS CF-SLP TSSLD

Five Levels of Attention

Did you know? Individuals with cognitive-communication disorders (e.g., TBI, aphasia, and dementia) show marked difficulty with attention, memory, and executive functions. One frequent aspect of TBI secondary impairment is disordered attention.

Five Levels of Attention: 

Focused, Sustained, Selective, Alternating, and Divided

  1. Focused Attention: The ability to respond discretely to a particular visual, auditory, or tactile stimuli. Sometimes called “orienting” to stimuli. It is the lowest level of attention or alertness.
  2. Sustained Attention: The ability to sustain a steady response during continuous attention. On average, adults have an attention span of about 15-20 minutes.
  3. Selective Attention: The ability to maintain attention in the face of distracting or competing stimuli.
  4. Alternating Attention: The capacity for mental flexibility that allows the shift of focus between tasks. People with alternating attention deficits are slow to shift their attention from one task to another. This can also affect conversations. The person will have difficulty with switching conversational topics quickly.
  5. Divided Attention: The ability to respond simultaneously to multiple tasks or to do more than one activity at a time. People with divided attention deficits might have difficulty driving and holding a conversation or cooking and listening to the news.

Strategies for Maintaining Attention

  • Avoid areas near doors, windows, and traffic patterns
  • Provide opportunities to take breaks.
  • Use a written or picture schedule and check off progress
  • Schedule most important work for times of greatest concentration
  • Break assignments into smaller and shorter segments
  • Limit the amount of information you put into your brain
  • Repeat the information in your mind
  • Create and maintain a quiet and non-distracting environment
  • Break larger tasks into smaller ones & redirect your attention back to talook-a-squirrelsk when needed
  • Allow breaks during or between tasks to reduce fatigue from extended attending

Try the sustained/selective attention tasks below by scanning through the stimuli to find the number 2 (first link), and the word “sun” (second link).  These handouts are great resources for individuals with cognitive-communication deficits, and even may be used with our young ones with attention deficits! To make these exercises more challenging, add some background distractions (e.g., music, white noise) to increase the level of difficulty for which the individual needs to attend to. Thanks for reading!🙂

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Amanda Weiner MS CF-SLP, TSSLD

Picture Exchange Communication System (PECS)

The Picture Exchange Communication System or PECS approach was developed by Andrew Bondy and Lori Frost in 1985 and is a modified applied behavior analysis program designed for early nonverbal symbolic communication training. It is not a program designed to teach speech, although the latter is encouraged indirectly and some children begin to spontaneously use speech while enrolled in the PECS program.

PECS has been successful with a variety of populations including children with autism, those who have social-communicative and/or behavioral disorders, are non-verbal, and/or for those who are visual learners. It is important that from whatever target population the child belongs to, he or she can sit and attend to a two-dimensional stimulus and be able to physically hand each picture to his or her communication partner and establish joint attention.

The procedure for PECS intervention follows in a hierarchy of phases. PECS begins by teaching the child to give a picture of a desired item to a communication partner, who immediately honors the exchange as a request. The system goes on to teach discrimination of pictures and how to put them together to form phrases and sentences. In the more advanced phases, children are taught to respond to questions and spontaneously comment.

An outline of the phases are as follows:

pecs-2Phase I: How to Communicate- Students learn how to exchange single pictures for items or activities that they really want. It is important that the communication partner finds out what the child has interest in so that he or she isn’t prompted into asking for something they don’t like. We should never make PECS aversive.

Phase II: Distance and Persistence- Still using single pictures, students learn to generalize this new skill by using it in different places, with different people and across distances. This phase is also utilized for the purpose of expanding spontaneity from the child.

Phase III: Picture Discrimination- Students learn to select from two or more pictures to ask for their favorite things. These favorite things are placed in a communication book- a three ring binder with Velcro strips where pictures are stored and easily removed for communication.

Phase IV: Sentence Structure- Students seek out their PECS board, and learn to construct simple sentences on a detachable sentence strip using an “I want” picture followed by a picture of the item being requested. Students then seek out a communicative partner, and give him or her the sentence strip. Listeners read the strip back to the child, inserting a fixed time delay between the words “I want” and the item label. Additional social praise is added if a child independently provides the label during the delay.

*Attributes and Language Expansion* At this point, students begin to learn to expand their sentences by adding adjectives, verbs, and prepositions.

Phase V: Answering a direct question- Students learn to use PECS to answer the question, “What do you want?”pecs-1

Phase VI: Commenting- Now students are taught to comment in response to questions such as, “What do you see?”, “What do you hear?” and “What is it?” They learn to make up sentences starting with “I see,” “I hear,” “I feel,” “It is a,”etc.

Support provided by the clinician is included within each description of each phase; however, additional support and prompts may include:pecs-phase-4
Question Cues
: “What do you want?”

Hand Over Hand Cues: Helping to initiate the movement of putting the pictures from the communication board onto the sentence strip or by helping rip off the pictures.

Visual Cues: Pointing to the pictures on the communication board.

PECS is supported by evidenced based practice, and has demonstrated enhanced communication skills in a variety of populations. It is important to note that a therapist should be PECS trained before implementing the approach.

Clink the link below to watch how Phase 1 of PECS is used. Thanks for reading!

PECS Phase 1

References:

Ali, E., MacFarland, S. Z., & Umbreit, J. (2011). Effectiveness of combining tangible symbols with the picture exchange communication system to teach requesting skills to children with multiple disabilities including visual impairment. Education & Training in Autism      & Developmental Disabilities, 46(3), 425-35.

Ganz, J., Lund, E., Simpson, R. The Picture Exchange Communication System (PECS): A Promising Method for Improving Communication Skills of Learners with Autism Spectrum Disorders. Education and Training in Autism and Developmental Disabilities, 2012, 47(2), 176-186.

The Picture Exchange Communication System (PECS). (n.d.). Retrieved October 18, 2015, from http://www.nationalautismresources.com/picture-exchange-communication-system.html

Amanda Weiner M.S. CF-SLP, TSSLD

Back To School

With “back to school” right around the corner, everyone can benefit from strategies for increasing memory and retention of learned information. All of us, especially students, forget important information at times. This occurs when we do not transfer information from our short-term memory to our long-term memory. There are a variety of strategies that students, and adults, can use to improve their retention of important information.

memory

The strategies include:

  1. Chunking- breaking up large amounts of information into small chunks that are easily remembered
  2. Understanding- relate what you are learning to things you have already experienced to facilitate understanding.
  3. Graphic Organizers- organize information by using Venn diagrams, webs, cause and effect diagrams, or cycle organizers
  4. Visualization-see an image of what your learning in your head so it becomes more meaningful
  5. Association- connect each word or event with a person, place, thing, feeling, or situation
  6. Rhyming- make rhymes to help you remember key information
  7. Talking- talking about information promotes learning that information
  8. Storytelling- arrange learned information into a logical sequence so that each event in the story triggers the next event in your memory
  9. Writing Sentences/Acronyms- write sentences or words where the first letter of each word represents information you need to learn (e.g. the planets: “My Very Excellent Mom Just Served Us Nine Pizzas”)
  10. Rehearsing- practices it or it will fade by saying it, writing, it, drawing it, or singing it.  Rehearse the information in a variety of modalities.

 

Jessica Eberhardt M.S. CF-SLP, TSSLD

 

Melodic Intonation Therapy

During graduate school, I had the pleasure of working with an individual with severe non-fluent aphasia post stroke. My patient’s expressive output was limited to a few words, and he was outwardly frustrated by his limitations. One day, I decided to introduce music therapy into our sessions, and it was a success! By using the techniques from Melodic Intonation Therapy, my patient was able to spontaneously produce lyrics from some of his favorite tunes, including “New York, New York” by Frank Sinatra and “Take Me Out to the Ballgame.” Tears of pure joy fell from his face when he was able to so effortlessly produce speech again. It was so rewarding.

Singing, Is It Therapeutic? “Some patients can sing familiar songs, sometimes only the tune without intelligible words, but sometimes with the approximation of the lyrics, even when they cannot vocalize under other conditions.”

Music As Therapy: Music therapy has been used in rehabilitation to stimulate brain functions involved in speech. Musical structures and language structures have many similar features, which generates continuous research interest.

music-notes-clip-art-png-139835101453Developed in 1973 by Albert, Sparks, and Helm, Melodic Intonation Therapy (MIT) is a formal treatment program originally intended for patients with severe non-fluent aphasia. MIT uses the musical elements of speech (melody and rhythm) to improve expressive language by capitalizing on preserved function (singing) and engaging language-capable regions in the undamaged right hemisphere. Since the original publication, this technique has been researched and used by SLPs, music therapists, and music neuroscientists. Improvements of speech abilities in adults with non-fluent aphasia has led to new development of research aiming towards evidence of MIT on other individuals with communication disorders, such as apraxia of speech.

The Technique: MIT was designed to elicit speech from severely aphasic patients with little or no volitional speech. It places the patient in structured drills in which phrases are produced with exaggerated stress, rhythm, and pitch. The patient taps out the rhythm of each phrase while producing the phrase. The patient is trained to utter prepositional phrases and sentences using sung intonation patterns that are similar to the natural intonation patterns of the spoken phrases or sentences.

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Melodic Intonation Therapy continues to be a primary mode of treatment to facilitate production of communicative words and phrases. Click the links below to watch real-life examples of the effectiveness of MIT. Have a great Labor Day weekend and thanks for reading!

Link 1

Link 2

Amanda Weiner M.S. CF-SLP, TSSLD

ADHD? Don’t You Mean Sleep Disorder?

sleep disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a condition that affects millions of adults and children. ADHD is best characterized by problems with concentration, impulse control, organization, and memory. These symptoms are frequently accompanied by feelings of frustration, inadequacy, and isolation from others.

However, what if the individuals diagnosed with ADHD are, in fact, suffering from an entirely different disorder – sleep apnea? A little known fact is that symptoms of ADHD are closely related to symptoms of a sleep disorder. A list of behavioral traits for a child with ADHD includes:adhd-workingmemory-wordcloud

  1. Lack of Focus which includes difficulties listening, retaining information, paying attention, and organizing information
  2. Impulsivity which includes difficulty sitting still, remaining quiet, sharing, turn-taking, and talking when appropriate

These behaviors contribute to deficits in the areas of social interaction, cognitive development, and academic performance. The same behaviors discussed above are also found in children suffering from insufficient and inadequate sleep quality. A recent study found that children with obstructive sleep apnea were at higher risk to suffer from behavioral problems; specifically those that mirror ADHD. These children also demonstrated poorer academic performance.

Therefore in order to decrease the possibility of misdiagnosis, all children and adults being treated for ADHD should also be screened for sleep disorders.

Jessica Eberhardt M.S. CF-SLP, TSSLD

The Real Deal on Feeding Disorders in Children

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Does your child struggle with eating a variety of foods, consuming a variety of textures/consistencies, and/or gaining weight/growing? Then the SOS Approach to Feeding may be appropriate for your child. The SOS Approach to Feeding is a trans-disciplinary feeding program for assessment and treatment of children with feeding deficits from birth to 18 years of age. It incorporates a variety of factors including posture, sensory sills, motor skills, behavioral learning, medical, and nutritional components to understand how these cause and maintain feeding/growth problems. My experience in the field thus far has taught me that feeding disorders are rarely the result of an isolated issue. It is typically a combination of factors that cause this difficulty with feeding. It is our job as speech-language pathologists to thoroughly assess your child in order to determine what factors may be causing or maintaining the feeding dysfunction.

Children who eat a limited variety of foods are typically referred to as “Picky Eaters”; however, did you know there are specific distinctions between a picky eater and a problem eater. Typically, a picky eater eats 30 foods or more, stops eating foods due to “burn out” but will regain these foods after 2 weeks, can touch and taste new foods even though they’re nervous, and will add new foods to repertoire in 15-25 steps on the eating hierarchy. In contrast, problem eaters eat less than 20 different foods, foods that are lost due to food jag are NEVER re-acquired, has an emotional reaction such as crying to new foods, refuses an entire category of food textures, almost always eats a different food than the family, and acquires a new food in more than 25 steps on the eating hierarchy.

Here is a list of red flags from the creator of the program, Kay A. Toomey, PhD, to determine if your child is a candidate for referral:

  1. Ongoing poor weight gain (rate re: percentiles falling) or weight loss.
  2. Ongoing choking, gagging or coughing during meals
  3. Ongoing problems with vomiting
  4. More than one incident of nasal reflux
  5. History of traumatic choking incident
  6. History of eating & breathing coordination problems, with on-going respiratory issues
  7. Inability to transition to baby food purees by 10 months of age
  8. Inability to accept any table food solids by 12 months of age
  9. Inability to transition from breast/bottle to a cup by 16 months of age
  10. Has not weaned off baby foods by 16 months of age.
  11. Aversion to all foods with a specific texture
  12. Food range is less than 20 foods
  13. An infant who cries with arching back at majority of meals
  14. Meals are battles
  15. Child is difficulty for everyone to feed
  16. Child rarely meets weight goals.

If you answered “yes” to many of the above items, then you should contact one of our centers to be evaluated by a qualified Speech-Language Pathologist.

Jessica Eberhardt M.S. CF-SLP, TSSLD