Jon's mother called me in August of 1999 and asked if I would help him with his stuttering. In this paper I describe some of the events surrounding Jon's difficulties with speech and how helping him with some aspects of reading may have been useful in improving his fluency.
I met with Jon in August of 1999 to evaluate his fluency and determine if he might be a candidate for fluency therapy. Jon was six years old and the youngest of four children. Two older twin brothers, age eleven, had received speech therapy for articulation disorders as preschoolers. His sister, age eight, spoke early. Jon received speech therapy for articulation problems for two years at a university clinic and began having fluency problems between four and five years of age. The university personnel took a ‘wait and see' approach to Jon's disfluency initially but, when his disfluency seemed to increase, they began a process of fluency shaping which was described as "talking slowly" and "breathing" appropriately before and during talking.
Perhaps the best description of Jon's family is to say that it was "mother centered" and "mother driven." Jon's father was a quiet, professional man who was very active in amateur sports. Jon's mother was the nonstop family organizer, soccer mom, car pool driver, sports transporter, etc. Her speech matched her fast paced life style. For example, when she delivered Jon for his weekly half hour speech therapy sessions, she typically sped in with a car full of kids - hers and others - dropped Jon off and was off to do errands before returning to pick him up 30 minutes later. Jon also had piano lessons, soccer, and skiing or snowboarding, depending upon the season. There was always a lot going on at a rapid pace in this household and that was the way they enjoyed life.
Jon was a small six year old boy with dark hair and eyes. He was a very handsome boy, the "baby" of the family, and used his family position and coy mannerisms to full advantage, especially with his mother. In August of 1999 he demonstrated frequent initial sound repetitions and prolongations, silent blocks, word avoidances, and "frozen" postures during blocks. He had a few word specific articulation errors (e.g., shree for three) but his speech was quite intelligible. His spoken language appeared appropriate for his age. His standard score on the Peabody Picture Vocabulary Test - Revised was 101. He was about to enter first grade and was unable to read.
I met with Jon's mother and father, reviewed my assessment impressions, and provided them with some basic information regarding stuttering. I gave them some Speech Foundation of America booklets on stuttering and had them read some segments from Stuttering: An Integrated Approach to Its Nature and Treatment by Peters and Guitar (1991). Jon's mom did most, if not all, of the talking and she spoke with a rapid rate. There was some mention of fluency problems on the mother's side of the family but I did not pursue this topic. I agreed to begin working with Jon to see if I could help him with his fluency since he indicated to his mother that he did not want to return to the university clinic for treatment.
Over the next few months I learned more about Jon. He was having some difficulty learning to read. He avoided talking in class because of his stuttering and stated that he did not talk in class because of his speech problem. He used his "cuteness" to avoid speaking and to get what he wanted. For example, he would often feign a thoughtful expression and wait until another spoke to avoid speaking himself. His mother mentioned that he often "spoke with his eyes." He knew how to communicate without talking and took full advantage of his nonverbal skills to get what he wanted. He spoke without concern at home but avoided talking in other settings. I also noted that his speech was often quite disfluent during the first few minutes of each therapy session but relatively fluent five or ten minutes later.
My initial goal was to engage Jon in a therapy relationship that he found rewarding so he would be motivated to practice at home. Since his mother was going to be the primary tutor in the home and also Jon's primary communicative partner, I wanted some activities which might influence his mother's speech also. I selected tongue twisters as the devices to use to accomplish this goal. We used tongue twisters at a very slow rate of speech and then gradually increased the rate. I thought these exercises might also provide Jon with some speech activities that he could perform in the home which others could not. Although Jon and his mother seemed interested in the idea of tongue twisters, it was soon clear that they had better things to do. They had little time to practice tongue twisters because of their many other activities and they had numerous excuses for not completing speech assignments. Since I knew that 30 minutes of therapy once a week was going to do little to change fluency patterns, I wanted something that would cause Jon and his mother to invest time and effort in this enterprise.
Learning to read is what first grade is all about for many children and parents. Jon was enrolled in the first grade in a parochial school. His teacher used a "whole language" approach to teach reading and felt that "phonics" stifled children's desire to learn to read. Jon took home "good literature" books to practice reading. Unfortunately he did not have the reading skills required to read these books. His mother was concerned about this approach to reading and wondered if he shouldn't have some basic skills that would help him decode words. This concern and interest about reading by Jon and his mother meshed with my interest in language-learning abilities and provided a means of integrating some fluency enhancing procedures with developmental reading activities.
There is a large body of research which supports the view that phonemic awareness abilities are essential components in learning to read, especially for children with potential or actual reading problems (Brady and Shakweiler, 1991; Uhry, 1999; Catts and Kamhi, 1999; Moats, 2000). Phonemic awareness is the knowledge that speech is composed of words, syllables, and phonemes and the skill to manipulate these units (see Torgesen, 1997). Phonemic awareness develops gradually during the preschool years and may be aided by instruction in phonics whereby children recognize relationships between print and speech.
Phonemic awareness exercises seemed to pique the interest of both Jon and his mother and they were much more willing to practice these exercises at home since they were both concerned about reading. A variety of exercises were used, such as sound blending (e.g., "ssss...aaaa....mmm" = ?), sound deletion (e.g., if "ssss" is removed from "ssss..aaaa...mmm", what is left?), sound changes (e.g., if the "ffff" in "ffffaaaannnn" is replaced with "mmmm", what new word do you have?), and rhyming (e.g., cat, fat, hat, mat). Since phonemic awareness exercises do not have to involve letters, children do not have to be able to read to perform these tasks. These exercises may be adjusted for difficulty level by changing the rate, number of sounds in a syllable, position of the sound change (e.g., initial, medial, final, blend), by requiring the child to perform various functions (e.g., recognize a sound, produce a sound, produce a syllable, etc.). For purposes of fluency shaping, I was more interested in transitions between consonants and vowels and developed exercises which focused on prolonging initial consonant and vowels. Jon and his mother viewed these exercises more in the context of "reading therapy" while I felt that these exercises were useful for both developmental reading and fluency enhancement. The interested reader may find the phonemic awareness exercises outlined by Goldsworthy (1966) particularly helpful.
Although phonemic awareness exercises do not require knowledge of the alphabet, the exercises are much easier for nonprofessionals to use when the alphabet is used to represent sound patterns. Since knowledge of the alphabet and phonemic awareness competency are the two best predictors of reading potential in kindergarten and beginning first grade chilren (Snow, Burns, and Griffin, 1998), it is important to establish these competencies early. Thus, I began using letter patterns to represent speech sounds and demonstrated how letters could be mapped to speech. Nonwords were used intermittantly to ensure a focus on letter-sound relationships and to prevent guessing. For example, a sequence such as Ben, den, fen, hen, ren, sen, would be better than a Ben, den, hen, men, ten sequence. It should be noted that although these exercises have the appearance of reading drills, there is a great deal of emphasis on sound patterns and the clinician can engineer the exercises so a greater emphasis is placed on speech movements and sound transitions.
When Jon could read two and three sound words easily, short controlled sentences were developed (e.g., The pig is in the pen.). These exercises were not especially motivating but Jon did respond to competitive activities such as reading for time. A stopwatch was used to see how close he could come to producing a short sentence in a prescribed time. For example, "The pig is in the pen." would be targeted for five and three seconds. Since a five second target required an exceptionally slow speech rate, the sounds were stretched to hit the target. The slower rates were used initially and then faster reading rates. We targeted "front sounds" as the best place to "stretch" reading words. Jon enjoyed this type of exercises and participated in drills of this nature at home with his mother.
Jon's reading improved markedly over a six month period and his speech varied from considerable fluency to considerable disfluency. Due to a variety of scheduling conflicts and family activities, Jon was seen for a total of 20 half hour sessions between August of 1999 and March of 2000. In March we decided to terminate therapy since the family had a vacation planned and I was going to be gone a good part of May. Also the motivation for therapy was waning some since Jon was now reading well and his fluency was not seen as a major issue.
In early June Jon's mother called to say that he was having a terrible time talking and she asked if I would see him again - soon! We met three times during a two week span and used timed reading practice. Jon's reading ability was now much better and longer reading times of 10, 7, and 5 seconds were used to produce reduced speech rates.. In addition, Jon did some alternate reading with his mother (e.g., Mom reads a paragraph and then Jon reads a paragraph) with both reading at varied rates. They also discussed the content of the reading at reduced speaking rates. Jon was motivated to practice and he often asked his mother to work with him on his speech without coaxing. Jon's mother noted that this was the first time that Jon was the initiator of speech exercise practice.
Again our schedules were at odds so we planned on getting together in the fall, if needed. Jon's mother contacted me in late July to say that Jon had been quite fluent for the past month and that he was speaking fluently to his soccer coach. Jon usually avoided talking with adults. I doubt that Jon is out of the disfluency woods but he appears to being doing well at the moment and hopefully this will continue.
The relationships among reading disability or dyslexia, stuttering, and delayed speech are complicated (see Bloodstein, 1995, pp. 72-3). Whatever the relationships may be, there is a large body of research regarding what children need to develop competency in reading. Print awareness, phonemic awareness, the alphabetic principle, competency with phonics, and exercises to promote automaticity and fluency for reading are among the major elements which produce competent readers (Snow, Burns, and Griffin, 1998). Some of the principles and procedures important for the development of reading competency may be employed to increase fluency. In addition, some parents are motivated to work toward reading competency since reading exercises sometimes have a more structured and direct relationship to a specific objective. In the present case description, the mother's speech patterns were influenced, at least during the practice sessions. In some cases using phonemic awareness exercises and related reading instruction procedures may be useful in helping early elementary age children acquire reading competency and may also help improve fluency. The foregoing description was designed to reflect these possibilities.
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