#014: Where to Start with Fluency Therapy

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I was so excited to sit down and talk to the creator of the Busy Bee Speech blog (and fluency queen! 👑) Lauren LaCour Haines for this week’s episode of the SLP Now podcast.

Lauren is a graduate of Louisiana State University, and she has been a school-based speech-language pathologist in the Baton Rouge area for over 12 years. She is also the lead Special Education teacher at a local primary school, so she’s very much in the trenches with us and has so much practical experience to share!

I know I’ve found the prospect of working with students who stutter to be pretty daunting in the past, but Lauren did such a great job explaining how to work with the complexities of fluency, and it was super helpful to hear her process for working with students who experience disfluency.

It might be hard to believe, but she actually makes fluency therapy sound…fun!! 😂

So grab your beverage of choice (I’ll have an iced chai latte!) put your feet up, and listen in — there is so much goodness in here!! 👇

Key Takeaways

– Where to start when a student is referred to you for fluency concerns
– The 3 factors that help you to write effective fluency goals (Getting a good case history, Observing in the multiple environments, Taking the time to establish rapport)
– The types of red flags you would be looking for when you take a case history
– The importance of contextualized versus decontextualized conversations
– The 3 areas of communication to focus on when writing goals for fluency therapy (Counseling, Education, Stuttering modification)
– How Lauren structures her therapy sessions
– The difference between activities for preschool + school-aged children (that make fluency therapy fun and beneficial!)
– Monitoring progress in therapy when there are so many fluctuations (and Lauren’s tips for using a fluency journal)
– What Lauren wishes she knew when she first started working with students who stutter

Links Mentioned in the Podcast

The Communication Attitude Test
The CALMS Rating Scale
An article by Nina Reeves about how SLPs should get away for writing goals on percent fluency
– Apps for progressive relaxation and diaphragmatic breathing, like Calm, Headspace, or Pacifica.
Lauren’s interactive fluency binder
StutteringHelp.org
The Lidcombe program
Stuttering Therapy Resources by Dr. Scott Yaruss and Nina Reeves
Research from ASHA
Disfluency Index Counter (app)
– Lauren’s website BusyBeeSpeech.com → There are lots of fluency blog posts and resources there!
– If you sign up for her newsletter, she has several, free resources (including the stairs visuals that she mentioned!) that you can access right away.
Lauren’s store on Teachers Pay Teachers

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Transcript

Marisha: Hi everyone. I am so excited to be here with Lauren LaCour Haynes today. We'll just do a quick introduction before we dive into the juicy topic today, which is all about fluency. Lauren is a graduate of Louisiana State University and she has been a school based speech language pathologists in the Baton Rouge area for over 12 years. She serves as a speech language pathologist and lead Special Education teacher at a local primary school. So she is in the trenches with us. She has so much practical experience to share with us and she is also the author of Busy Bee Speech. She has a blog and she styles speech therapy resources on teachers pay teachers. I'm really excited to talk about fluency with her today. I've learned so much from her when it comes to practical strategies for fluency, and she also happens to have some pretty amazing resources to make that even easier for us to implement. So before we dive into all of the juicy tips and strategies, Lauren, can you tell us a little bit about yourself, your experience with stuttering and what led you to learn so much about this area?

Lauren LaCour H: Sure. I appreciate so much for you I'm having me here, but I did want to tell y'all that, well, I did stutter a little bit as a child. I can definitely remember that feeling of being stuck, of not being able to get your words out the way you want to. So, I've always kind of had a soft spot to my students who struggle with this and working with kids who stutter has always been one of my favorite aspects of the job. It can be a lot more challenging than some other types of cases, but I really like that about it. Most of my experience has been on the job learning and my own research, since like you said, I've been an SLP in the schools for about 12 years. I have almost always had fluency students on my caseload though. If that's the... Let's say student was referred a lot of times the other SLPs at my school would always send them to me because they knew that I enjoyed working with them, and they weren't very confident with treating stuttering themselves.

Lauren LaCour H: And then also in Grad school I ended up having more fluency cases than anyone else in my class, so many that my supervisor called me, the fluency queen. But I didn't mind all of that because, I really enjoyed it and I learned quickly that each student was different and the approach that I use might also be different for each student. So I did a lot of research and trying programs and strategies and even develop some of my own programs based on that research to help my students. And I found that there was really a lack of hands on resources for kids in the area of fluency, which is what led me to create my own.

Marisha: That's so amazing. And I love that story. I remember talking about this with you before, but it seems like there's a lot of us don't have many fluency kids on our case loads that might have, we might have one kid every few years or whatnot. We might have like an influx one year where we have a couple more, but I think it's interesting that for some reason they were all drawn to you. So it's super interesting.

Lauren LaCour H: I think it was meant to be.

Marisha: Yeah, you were meant to be the fluency queen. I love that. Okay, so let's dive into all of that good stuff.

Lauren LaCour H: Okay.

Marisha: So before we start with treatment, we want to figure out what we're... Where we're starting and do we even want to treat the student? Where do we want to start with an evaluation? What tips or strategies do you have?

Lauren LaCour H: When a student is referred for fluency concerns, I have found several things that have helped, whenever you're first starting off. So, the first thing would probably be to get a good case history. It's really important to know if there are family members with a history of stuttering, how long they have been stuttering, if there was any major trauma or neurological problems in their past that can contribute to stuttering and also what the environment is like in the home because, studies have pointed to factors that could lead to an increased risk for longterm stuttering so, if we know that is going in, the red flags can help us determine the severity of the case, and it can also help us when we go to make recommendations in our report especially if there need to be changes made to the whole environment.

Lauren LaCour H: Actually I had one student who had both parents who stuttered. So it was really helpful to know that going in because it meant that the student would likely have more of a tendency to deal with stuttering longterm, but also we can use that knowledge in therapy to help open the lines of communication between parents and their child to talk about what had worked for them in the past. I couldn't even send home activities for them to complete together and so on. So, it really was beneficial to have a good case history. So secondly, I also like to try to observe the student in multiple environments of possible. Fluency often has a tendency to fluctuate. I noticed that even in myself. So I feel like some days I can't string two coherent thoughts together to save my life or I have a serious of the case of interjections syndrome, and in other days it's smooth sailing and I'm fine. But that's the same way for your fluency gets to several factors can contribute to it and we don't always know what will cause it or what will be better or worse for them.

Lauren LaCour H: So they may be more disciplined at certain times of the day or with certain people are talking about certain topics. When a student is in the intervention or evaluation process, you don't know that yet. You don't know what the triggers are. So, I'd encourage you to pop into his or her classroom and take some data, ask them different types of questions on contextualized questions like talking about the here and now, like a picture versus decontextualized questions. Question is not about the here and now. Like explaining how to play a game or what happened last weekend. You could also talk to their teacher and ask them what situations might be more... That he'll be more likely to be fluent or disfluent, and that information would be really helpful for qualification purposes as well as for writing recommendations.

Lauren LaCour H: I know that in my state, in order to qualify for speech therapy services in the area of fluency, they strictly only go by percent of this fluency. So, you could pull a student into your classroom one on one and then they don't stutter at all, but then in the classroom they report that they stutter or at home they report that they stutter or maybe the next day they might stutter more. So, it could really affect the qualification. If you've spent some time observing and have that good case history, it could really help the student in the long run. And now I know that's not really feasible for everybody, so if you're on an eval team or in a clinic, you might not have access to the student and other environments, but you could still ask lots of questions during your parent student and teacher interviews or, you could even have them bring in recordings of the students speaking in other environments and observed that way.

Lauren LaCour H: So we talked about getting a good case history and then observing in the multiple environments, and then lastly, I really liked to take the time to establish rapport and get to know the student's attitude and feelings about speaking. I know this can really go for any student that we're evaluating, but it's really essential for students who stutter. We're looking to assess their reactions and emotions since that can be another risk factor for longterm stuttering. So we want to try to see if they are aware of their stuttering, if there are any avoidance behaviors, physical or arbitrary tension, or just their general feelings about communication. So, is he concerned about his speech or does she think something is wrong with her?

Lauren LaCour H: And if so, we can try to figure out if the concerns are leading to an increase in the severity of stuttering or not. But this again can be really helpful for goal writing later. And then, there are normed assessments like the communication attitude test for example, as well as more informal checklists like the comms rating scale. You can use those to assess those areas about attitudes and emotions. And so, those can also be really beneficial.

Marisha: Awesome. Those are some really great resources and suggestions to help us get started. I just had a couple follow up questions.

Lauren LaCour H: Okay.

Marisha: Because you mentioned some red flags and you were talking about family history, what other types of red flags would you be looking for?

Lauren LaCour H: Yes, so the red flags that I've mentioned where the family history, how long they have been stuttering, any major trauma or neurological problems and then, what the environment is like in the home. Like are there... Do they have a lot of demands being placed on the Child? Is it kind of a hectic and chaotic environment in the home? All of that can have an increased risk for longterm stuttering if we know some of those factors.

Marisha: Yeah, that is super helpful. And I have like a little checklist that I put in my folders just to keep track because I don't, I'm not the fluency queen and I don't get a lot of these kids. So it's really helpful just to remind myself of the different red flags to look out for and to help that inform the evaluation decisions.

Lauren LaCour H: Yeah.

Marisha: And then I just wanted to comment on this too. I love how you brought up the contextualized versus decontextualized conversations because I've had it happen with a couple of students where they're super fluent when they're talking about the here and now, but as soon as we talk about something that happened in the past or something that's going to happen, those disfluencies skyrocket. So it was just so interesting to see that happening.

Lauren LaCour H: Right. I agree. And I've had the same experience. A lot of times when they're talking about the here and now or something that's right in front of them, it's a little bit easier, but decontextualize are a little bit more linguistically demanding for them, so it can lead to more disfluencies.

Marisha: Yeah. And in that case, if you noticed that discrepancy, does that... Do you approach the goals and we're jumping ahead a little bit, but do you approach goals in treatment a little bit differently?

Lauren LaCour H: You can, especially if they're really fluent in one area and then if there's a big discrepancy in and they're not fluent in another area, you can target that in your goal. So I do that a lot. I'll say they will be fluent or they'll have this percent fluency or whatever in this type of situation, this can take decontextualize versus contextualized. And if they're still very disclosed in the contextualized, you should start there instead of something that's more demanding.

Marisha: Yep. Considering all of those factors and scaffolding from there, that's perfect. Okay. Awesome. So I feel like we've got pretty good handle on her evaluations now. I've got some good tools and strategies that we can pull out of our tool belt here. So once you have all of this data, how do you go through and what tips do you have for writing goals once that evaluation is complete?

Lauren LaCour H: Right. Okay. So we talked about how those aspects of the evaluation process can help you when they're writing those goals. And I know that states and districts often have different requirements when it comes to IEPs and go writing, so you're setting that you work in and then the ability to be flexible with your goals might play a part when you sit down to write then, because my state strictly goes by percent disfluency to enter or exit speech therapy. In the past, I almost always kept that as my main goal, but this was often really frustrating because of the variability and most students' day to day stuttering. So a student might "meet his goal" but then regress before I was even able to hold the IEP and write a new goal, just because of the nature of fluency and the variability there.

Lauren LaCour H: I recently read a really good article by Nina Reeves that talked about how SLPs should get away for writing goals on percent fluency, and focus more on what we are doing in therapy. So, if you have a district like mine and have a lot of requirements in place, I'd encourage you to reach out to your coordinator or supervisors, and maybe talk about reinventing the way you write fluency goals, which is what I'm in the process of doing. That being said, I've always been a fan of very specific goals and objectives. So when you're more specific in your objectives, it helps to streamline and structured therapy sessions a little more, because it helps you know exactly what you'll work on and how you'll collect that data. So in fluency therapy, I typically focus on three areas of communication. Counseling, education, and then stuttering modification or shaping.

Lauren LaCour H: And you can definitely write goals and objectives for any or all of these areas, depending on the needs of your student. Obviously not all students need to address all of the areas of stuttering treatment and goals will depend on a student's age and ability level as well, but I'll talk a little bit about targets for each area. The first area with counseling, and counseling has to do with a student's attitudes and emotions. Targets for this may look a little more social, like initiating conversations or speaking freely with peers or certain adults or making phone calls, ordering food at a restaurant, so if there are people or situations that they avoid, you can make a goal for that. You can even write objectives in a hierarchy of activities that are easier to more difficult for them. So in all of these cases, you may not necessarily be targeting how fluent they are, but just increasing their comfort level in participating in the activities.

Lauren LaCour H: An example of an overall annual goal might be that the student would exhibit effective communication skills during five out of five speaking situations on his hierarchy by the end of the year. That might be an overall one. And then an objective underneath it could be that they would initiate however many two conversations with a peer or another person during a play base activity or during recess or whatever situation that they find themselves that are more disfluent. So you could do that over three sessions. So that's mostly what I focus on for counseling. And then, you can also write goals for education, and education has to do with teaching your students about their speech anatomy and teaching them to identify instances of stuttering and types of stutters. So it's basically just educating students about stuttering. You can write goals that have to do with identifying so many parts of their speech machine or identifying eight out of 10 instances of disfluency in the clinicians' speech or even in their own speech, so they can learn to discriminate different rates of speaking or changes in detention.

Lauren LaCour H: If the students are old enough, I find that they usually enjoy that education part of therapy. So, goals for counseling, goals for education, and then finally you can write goals for them to make changes to their own speech by using fluency enhancing behaviors to release tension or change the timing. An example of this might sound like, when provided with visual cues, the student will use whatever fluency enhancing behavior like light contact or pausing, in nine out of 10 sentence trials over three sessions. Something like that. So the child will actually be practicing different strategies to make changes to the tension and timing of his own speech. And I can talk more about that later.

Marisha: Well that's amazing. I didn't think we were actually going to get real goals. We usually miss out on that part. That is amazing. Thank you so much for giving those examples because it's really helpful to be able to see how someone else does it. So then, okay, we have our goals and we know we want to work on these different areas. Do you have any ideas or suggestions on, like we just did the valuation, rewrote our goals, what's the first thing that we do when we start seeing a student? And I know it really varies on this depending on the student, but do you have any of your favorite initial activities or how you approach starting treatment?

Lauren LaCour H: Yeah, and that can be tricky sometimes if you don't know your student... Well, which is why getting that good information and getting good data during the eval process can really make life a whole lot easier, and can help you create a better program for the student. And like you said, where you start will depend on the child's age and severity. But in most cases, I like to start with the education aspect. In preschoolers, that typically means educating parents first. I try to communicate with them regularly and sent home handouts to teach them about stuttering so that they can make the necessary changes in the home environment. That might mean speaking at a slower rate. We do think demands and questions or responding a certain way to their child. You want to make sure that the child is in a supportive environment where they know that mistakes are okay.

Lauren LaCour H: So educating parents can be a great way to start for any age really, but especially for preschoolers. And then for school age kids, I typically start by teaching them about their speech machine as we like to call it, so that they can understand how everything works. Because if we eventually want them to be able to change the timing or the tension in their speech, they need to understand more about their mechanism and way or they are placing that tension. So after teaching them about their speech machine, I moved to identifying bumpy versus smooth speech in my speech and then identifying it in their own speech.

Lauren LaCour H: If they're old enough to understand, I also teach them about the different types of stutters and they can work on being able to label the different types of stutters that we identified in our speech. And then after that, we start practicing ways for the student to reduce tension or change the timing of their speech through the fluency enhancing strategy practice. That's where I typically start in the progression that I used. But like I said before, each case and situation is different. So it's best to use what you have and that data from the eval, as well as your own clinical judgment when deciding exactly where to begin.

Marisha: Yeah, that's really helpful. I love those ideas. And then... So once you've gone through some of the more initials stages of therapy, how do you structure your... Do you have a structure that you like to use for your sessions going forward? Do you have a mix of counseling and practice throughout all of them or how do you navigate between all of those different components and then all of the changes that are inevitable with fluency disorder?

Lauren LaCour H: Right. Well, frequency and duration of therapy will obviously depend on the student and the severity of the case. And I haven't really found a lot of research on that topic in relation to fluency, and what I found says just that. That it's based on severity and then the professional opinion of the SLP. So, in the past I've seen students for 15 or 20 minutes once a week or even 30 minutes, three times a week, depending on what the student needed. My coworker has seen success with 10 minute sessions four days a week for some of his fluency students, but I haven't really tried that yet. It just depends on what the student needs and what the data showing, parent involvement may play a factor in that decision as well. So that's kind of an up in the air and depending on the student. And then, so your sessions might look a little bit different depending on how long you have in a session.

Lauren LaCour H: But during my sessions I might do several different activities with the students depending on the group dynamic or if they are seen individually. So if they're seen in a group, a mixed group, it might look a little bit different than if they are just an individual student that I have with fluency. I have an interactive fluency binder for preschoolers as well as for school aged students, that I'll often work my way through with the student along with several other activities. So, my sessions are not always structured the same way each time, but I usually start with some type of progressive relaxation and diaphragmatic breathing. So there's some great apps that help with those techniques, like Calm or Headspace. I think the other one is Pacifica.

Lauren LaCour H: So if my students are old enough, we can do one of those little three to five minute exercises on the app together. And then if they're little, if they're younger, we might practice deep belly breathing together. So I have them... For that I had them lean back or lay down and put a bean bag on their belly and then they have to make it go up and down slowly while they breathe in and out. And then sometimes they laugh too much, but we always try it. And then we might, with the little ones, practice tightening and relaxing the muscles in our face too by making silly faces and then letting them go. So, I usually start with a little bit of relaxation and then we might do a worksheet or two from my binder, depending on what we're working on. So here is where I spent some time teaching them about their speech machine or types of stuttering or strategy that we're focusing on while we're doing those cut and paste activities.

Lauren LaCour H: And then after that we typically do some type of hands on activity or game and this gives them an opportunity to practice the skills that we're working on that day. So we might even role play situations or go outside of the classroom to finish up the session. It can really vary depending on what task that we're doing. So I kind of guess do a relax then teach or council in that area and then we'll practice it.

Marisha: Yeah, I love that. That makes a lot of sense to be able to combine all of those different components and then do ever, because you talked about communicating with parents and teachers, do you have them practice the relaxation in the classroom at all or what does the carryover look like with those pieces?

Lauren LaCour H: With the relaxation piece?

Marisha: Or any of the other pieces if you... Whatever you are sharing with parents and teachers would be awesome to hear about.

Lauren LaCour H: Yeah. So, with the relaxation, I typically practice it in the classroom and then if the parents are involved, if they come to therapy sessions too, some of my preschoolers are itinerant coming from home, so if the parents come into the therapy session, then we can practice it all together and they can learn it with us and they can do it at home too. Or if they're not, if they're a little bit older, I'll have the student just... I'll tell them to practice it at home. I don't really know if they do or not, but unless they'd let me know, but I don't have anything specific that they have to say, Oh yes, I'm doing all my relaxation exercises at home or anything like that.

Lauren LaCour H: But that's more of the initial thing that we can do in therapy. As far as their teachers, I do have some tips and handouts and things that I provide for the teachers. And I also have the students communicate with the teachers. I'll have them write letters or different things like that to their parents or to the teachers or classmates explaining what we're doing in therapy and how it's helping them.

Marisha: Yeah, I love those ideas. And do you have... What are your favorite handouts that you use to share?

Lauren LaCour H: There are some great handouts on stuttering therapy resources. I've also included some in my interactive fluency binder, there's also some on stutteringhelp.org, there are several online that you can print out and send home. I do though sometimes let the... if the students are older, I'll have them create their own handouts to send to their teachers.

Marisha: Oh, I love that idea. And that is really a cool way to increase that ownership and have them be involved in the process too. That's really awesome.

Lauren LaCour H: Yeah.

Marisha: Okay. Sweet. I love these ideas. And then do you have any other favorite therapy activities or go to's that you refer to when you're navigating the whole therapy process?

Lauren LaCour H: Yes, there are so many. There's so many that I love to do and sometimes it's difficult to make fluency therapy fun for the little ones since they're not a lot of products and resources geared towards fluency, but that's really one of my main goals in therapy. To make it fun yet beneficial for them. So, therapy can look different in versus school age students. So I'll talk a little bit about some of my favorite activities for both if that's okay. Let's talk about preschool first. A big part of physical therapy is like we talked about educating parents. So when working with parents and family, you want to teach them how to modify their environment and communication techniques. I tell them about the risk factors for stuttering and tips for their home environment, and then like we talked about, I send home letters or handouts and I even had these daily fluency trackers that I send home to help them implement those changes.

Lauren LaCour H: I even made a rules poster for parents as well as teachers to help with just good basic communication skills because, it's not always as common sense to everyone that it is to us. But with this, essentially we want parents to learn to slow their rate when speaking around the child and then to reduce the verbal demands that they place on them. We also want to teach parents how to respond appropriately when their child does stutter, and they want them to respond in a calm manner and model, effective responses to difficulties in general just so that they know that it's okay to make mistakes in life and in speaking. And then when the child is ready, you can also teach parents the verbal contingencies both for stutter free speech or smooth speech and for shuttering based on the Lidcombe program.

Lauren LaCour H: And if you don't know what those are, basically the Lidcombe Program says that in Sutter free speech, a parent can respond by praising the child speech by saying things like, that was good talking or that was really smooth, Or they can ask the child to evaluate themselves. Like, was that smooth? And then after a moment of stuttering, a parent can respond by acknowledging it. Hey, that was a little bumpy. Or by having the child correct it. Hey, can you try saying that again? And the Lidcombe program is a good research base technique for preschoolers and definitely worth exploring further if you haven't looked into it. That's really where I start with parents. In therapy, I do try to look at all three of the components that I mentioned earlier. I do use my binder a lot for both preschoolers in school age students actually, since it contains cut and paste and worksheet activities and all three of those aspects that we work on.

Lauren LaCour H: However, I do find that the majority of my preschoolers are not aware of their stuttering and it's not affecting them socially at this point. We usually don't spend a whole lot of time on the counseling piece at the preschool age unless I learned that they are starting to have negative thoughts and emotions and then in that case we definitely do address it. So, in therapy we play games to increase awareness in a safe, secure environment that is non demanding and low pressure. After doing a worksheet or activity to teach them the difference between bumpy and smooth for example, we might build a tower with Blocks or Legos, so I'll say a sentence, and then in order to earn Blocks they have to tell me if my speech was bumpy or smooth. Or if the child is more active, which a lot of my preschoolers, they're very active, I have these little circle mats that I placed around the room, so they can jump from Matt to Matt, but then before they jump, they have to listen to my sentence and tell me if it was bumpy or smooth.

Lauren LaCour H: You can also do this outside with chalk if the weather is nice or with any turn taking games. Once they get good at deciphering the difference between bumpy and smooth, we move on to identifying them in their old speech during play or games or craft activities. So, I typically acknowledge it for them at first like, that sounded a little bumpy. And then model what they said more smoothly. Sometimes we have a puppet show, and we point out when the puppets or bumpy or smooth, so once they are a little more aware of their own stuttering, I like to start teaching a few of those techniques to help them change the timing and the tension in their own speech.

Lauren LaCour H: However, with preschoolers who want to be careful that they don't overly exaggerate a slower pace or lose tension, sometimes it's hard for them to make that distinction if it's not super slow or super fast. We want them to know that needs to be somewhere in the middle, which is a great concept that I learned from a book called Stuttering Therapy Resources, actually I think it's a website called Stuttering Therapy Resources by Dr. Scott Yaruss. That concept is called too much, too little or somewhere in the middle. And you can use the Goldilocks and the Three Bears story to teach that since there are so many examples of too this or too that, like too hot or too cold, or just right. Or what we like to call it somewhere in the middle. You can then practice some non speech timing or tension activities with that concept to make sure that they understand what it means.

Lauren LaCour H: For example, like waiting too long to take a turn in a game or taking a turn too quickly, or walking like a turtle or running like a cheetah. You can also grab a ball or object with too much tension or too little tension or just the right amount of tension. And so once they understand that concept of too much and too little or just right or somewhere in the middle, you can draw that parallel between the tension and timing in speech production. Like when you use a speaking rate that's too fast or too slow. Or have physical tension that's too tight or too loose and we can then explain that talking too quickly or too tightly, might make it hard to say what we want to say, so we want to be somewhere in the middle. In my room and like to call it slow, easy speech or easy speech.

Lauren LaCour H: Most of the time the kids pace is too fast, so we practice slowing down to a rate that's "just right." I had them used pacing charts or move little counters while practicing phrases or sentences for pacing. I just want them to understand that we take our time to talk when we're using easy speech. And, we also practice pausing strategy, which is when we put brief pauses between groups of words or phrases while speaking. I like to teach that concept by playing red light, green light to make sure they understand a stop and go and explain the concept of pausing. So it's easy to practice it, those non speech tasks, and then with speech tasks, I like to do it using picture cards and carry your phrases. So, you can use the carrier phrases, I see or I like, and then have like three picture cards in a row and you can just place the pauses between the picture cards.

Lauren LaCour H: For example, like I see, a dog, a cat, and a rabbit. You can just place the pauses between each one. You can do this with picture books too. You just want to make sure that their sounding natural with that. To help with making changes intention, I like to explain that concept with my preschoolers using heavy and light. We talk about things that are heavy and things that are light. I have them try to pick up the table or pick up a piece of paper and then we talk about the difference. Things that are heavy make our muscles tense or steps and things that are light are easier on our muscles. They may practice tightening and loosening our different muscles in our body, and then once they understand those non speech examples, we move on to making our speech muscles tight and loose.

Lauren LaCour H: So I choose sounds and words that helped them feel tension in the different articulation placements like, PMB or FMV, or TND, to feel that tension versus loosening them up. And then if they can handle it, I also spent some time teaching them about their speech machine in general so that we can talk about the different places that tension happens. With all of this, I just want them to understand what easy speech means and that it has to do with making your speech timing and tension somewhere in the middle. And then once they have an understanding of easy speeches, it's easier to practice it in a variety of worksheets, games and activities. That's basically what I like to do with my preschoolers. Those are some of my favorite things.

Marisha: I love those activity ideas. Like the Goldilocks and the Three Bears is one that makes so much sense, but I never thought to use that. It's such a good way to teach that concept because a lot of times we have other concomitant issues going on and just being able to make sure that they understand that, even if they don't have language issues, although that is still a really great way to teach that concept, I love the idea of moving from non speech to speech related movements just to make sure that they understand the concept and to give them some really tangible understanding of what that means and what that looks like. That is... And I love all of the practical ideas. so helpful. And you have some ideas for school age too?

Lauren LaCour H: Yes, I do.

Marisha: Okay.

Lauren LaCour H: You can definitely do a lot of the activities that I mentioned before with the school age students to depending on their age. But for ones who are a little bit older, they most likely will already be aware of their stuttering, and in turn they might have some fears or attitudes in place. That need to be addressed. So you might spend a little more time with the counseling piece and have a more rounded approach in your treatment with the three areas that I mentioned before. I know I talked, we talked about goals in those three areas, so I'll go ahead and talk about some of my favorite activities and resources that we do in each of those for older kids. So for counseling, research from ASHA tells us that there are four different ways to target negative attitudes or emotions about stuttering.

Lauren LaCour H: So the first is desensitization, and that's when you help them become desensitized to their fears about speaking or stuttering. And then number two is cognitive restructuring, and that's when you change the way that you think about yourself in your stuttering. And then number three will be a disclosure statement, being able to intentionally tell people that you stutter in order to reduce anxiety, and then finally support groups or researching or meeting other people who also stuttered. So for counseling, here are a few of my favorite things that I like to do to address those areas. The first is making a hierarchy of situations that are easiest to hardest to participate in. They can list situations that they fear or feel the most astute and then rate them. Like from one to five or one to 10, however many activities that they come up with.

Lauren LaCour H: I think I have a free worksheet on my website that has a visual for this with stairs. You can then start with the easiest situation and work your way to the most difficult. I like to role play in a therapy room first before trying to get to the cities outside of it. And then to help with desensitization and cognitive restructuring, they can even voluntary Stutter or fake Stutter in the scenarios to help them see that stuttering is okay and it's not the end of the world if it happens to kind of desensitize them to that. Other activities I like to do would be writing letters to parents, friends or teachers. I think I mentioned that before. Once I had a student write a letter explaining things that he could do or not do that would help him stay smooth, and then things that his teacher could do or not do to help him stay smooth, and to make him feel more comfortable. That went over really well.

Lauren LaCour H: I also like to do different... Well actually it's an activity sheet that might help open the door for talking about vocabulary and situations that make them feel more or less fluent. So sometimes, there are a little bit hesitant to divulge what situations would make them more disfluent or they might not even know or understand. So, if you have like some questions or probes that would open the door to that, sometimes that helps. If the students are younger, I do try to play some games that will increase their feeling worth of vocabulary, because sometimes I don't always have the words to be able to say, oh, I feel this way. So, that way they're better able to express themselves when they're talking about how they feel to others. Emotion cards are great for this as well as social stories.

Lauren LaCour H: So that's what I like to do for counseling. For education, I mentioned before that I teach kids about their speech machine or speech mechanism, and I also want them to understand more about what stuttering is. So for this, we do things like, draw your speech machine. You can do this with paper or a worksheet or you can trace the outline of their body and chalk outside or like one of my coworkers did, you can do it on bulletin board paper and then hang them up in your classroom. And then after they do that and it can label the parts of their speech machine on the paper. You can also use Play-Doh or Paper Dolls or regular Dolls to talk about speech machine as well. Phonics books and Mighty Mouth. A little mouth that you use for articulation, those can also be good for talking about placement of articulators too, because they need to know those placements as well.

Lauren LaCour H: So I also like to teach them about the different types of disfluencies. And in the past, I've done this through representations. So what you do here is you take a topic that the student enjoys, like basketball or Harry Potter, and you make an aspect of that topic represent a type of disfluency. So for example, in basketball, dribbling might be repetitions or blocking might be a block. Then they draw or find pictures on the computer or something for each one and a glue them on an index card. I have them then write the meaning on the backs of the cards so that now they have cards that they can refer to and are reinforcing for them. This topic idea can even be carried over to when you're teaching them the different stuttering modifications are shaping strategies.

Lauren LaCour H: And then speech detective games are similar to what I was talking about with the preschoolers, are also good with school aged kids too when they're learning to identify bump day versus move speech in your own speech and then in their own speech. So you can read a book or play a game and they have to identify the times when you stutter, and then tell you what type it is. Sometimes I'll get them to drop a block in the bucket whenever they hear and then they'll have to let me know what type of it... What type of stuttering it is. So that's for education, and then a stuttering modification or fluency shaping strategies, are those techniques that we teach students to help change the timing intention? Like in preschoolers? There are several different strategies that research has shown to be effective.

Lauren LaCour H: For timing, I typically teach pacing and pausing. So pacing is like that slow or appropriate rate, and then pausing is putting those brief pauses in the correct places. I talked about a few of the activities that I do for those with the preschoolers but with older kids, I also like to spend some time teaching them why those techniques are helpful, and what exactly I mean by them. I use pacing boards, which you can easily make with a tongue depressor and stickers or you can use an app called Turtle Talk, and with the app you can set the pace they need to keep on the app, which is something that I really like about it. Rolling a ball back and forth is also great for timing. They have to roll the ball with you at each syllable or word while keeping a rhythmic beat.

Lauren LaCour H: So you're going back and forth to a certain beat, that gives them some more fluency. And there's also a metronome app that you can use to help with this too. Nursery rhymes or poems that they are familiar with that... But they also have a rhythm to them and those are good for teaching timing and helping students achieve some fluency. I think it's called the Time Syllable Technique. Those different techniques that when you put something to a rhythm, that you can say a syllable on each beat. When you're teaching then pacing or to slow their rate though, is to just important that they can get to a point to where they sound natural and not robotic. So that's for slower rate. And then for pausing, if their readers, I like using highlighter tape or Washi tape to make pauses in different places in a book. So then they can go back and read it, placing the brief pauses where they would naturally occur so that it sounds natural.

Lauren LaCour H: You can even use any conversational articulation activity and modify it by having them use their pacing and pausing. And I'll talk about a few of those conversational activities that I like to do in a minute. So, those are some strategies for timing. Now, strategies for decreasing tension in their speech, are things like cancellation, pullouts or light articulatory contact. For these you want to teach them how to release the tension that they've built up in their mouths. So cancellation is when, after a stuttered word, they wait a couple seconds and release the tension, and then say it again with less tension. You can get a stress ball and practice squeezing and releasing to help visualize decreasing detention. This is a good one to practice if they stutter even at the word level, they can play a game like memory and say the word on the picture and then say it again with less tension. They can even fix stutter on the word and say it again to practice feeling the difference in the tension.

Lauren LaCour H: The pullout strategy, I like to think of as freezing and sliding. So, during a stutter you ease yourself out by reducing tension. So you basically freeze the sound that's repeated or can't stop, and then relax the articulators that produce it. I have them catch the sound in their fists and then gradually open their hand to release it. And for this one, unless they are in a severe block or repetition, I feel like the hardest part is for them to recognize when their stuttering in the middle of it when they're younger. Sometimes it's hard for them unless they're really severe. So to practice this technique structure sentence or conversational tasks, if they're really structured, is better for this one when they're first starting out. If they're creating a sentence or answering a question, I feel like it's easier for them to pay attention to their fluency in this situation more than just play or a conversational tasks.

Lauren LaCour H: So cancellation, pullouts, and then light contact is another good strategy for keeping the tension in the mouth or looser. It's when you touch the articulators in your mouth together lightly and softly. And this one is also pretty fun to teach and practice. They can do things like light and hard hopscotch, where they hop lightly and then hop really hard to show the difference. They can throw a ball hard or throw it gently or squeezed something hard or squeeze it gently. Anything to show the contrast and tension. And then once they understand that, then they can practice with speech activities saying the words tense and then saying the words lightly and softly, so that they can get that feeling of producing words lightly and softly and eventually they can use the strategy during conversational speaking tasks to help keep the tension a little bit lower in general.

Lauren LaCour H: A few of those conversational activities that I like to do are things like, planning a pretend party together. They have to come up with everything they need for it, the people that they'll invite, and the activities that they'll do. So we planned this whole big party and they are talking the whole time, getting them going. That's great for conversation. Also, putting on a puppet show or play and that one's great for any strategy practice as well. Making it have to presentation, let them make slides and PowerPoint to explain how to do their favorite activity or make their favorite food or play a game. They can then explain it using all their fluency enhancing strategies. Also, I'm telling stories from funny stock photos or wordless books are also a great way to get them talking. So, those are a few of my favorite therapy activities for preschoolers and then for school age. I feel like it was a lot of information, but that's my favorite part about therapy.

Marisha: No, I love those. And I think that's what we need. It's really easy to find worksheets that explain the strategies or just the basic things that we started talking about at the beginning, but it's really helpful to have those ideas of actual activities that we can use. I love the funny stock photo idea and just some of the logistics too. Just the different apps that you mentioned, and we'll add those in the show notes as well as all of the other links, but that is so incredibly helpful to have those practical ideas, from an SLP in the trenches. It sounds like your kids have so much fun in the therapy room with you. I feel like I want to get fluency therapy now.

Lauren LaCour H: We have fun.

Marisha: It sounds like you guys have a blast, which is so cool and I love that. As listeners, we can take that into our own therapy rooms and implement that. So thank you for sharing all of those.

Lauren LaCour H: For sure.

Marisha: And I just had... I was also wondering too about monitoring progress. Do you have any tips or tricks that you found helpful? Because we're having a blast in therapy, but how do you keep track of how things are going especially with all of the ups and downs?

Lauren LaCour H: Yeah. So we're having a blast on therapy, but you still have to take data.

Marisha: All right.

Lauren LaCour H: Progress monitoring for me, it really depends on the goals and objectives that I've set in the beginning. So if we're setting good specific goals and objectives, then it's really a lot easier to take the data that you need. I have a tally sheet for each of my students and take data at nearly every session to monitor progress on their objectives. But I also really like the students to be involved in monitoring their own progress with, especially if they're older, since it gives them some ownership over how they're doing. So I'm trying to make sure and give them some goals that they can track, like, they can track how they're doing with labeling parts of the speech machine or explaining the different types of disfluency. Those are pretty easy for them to track.

Lauren LaCour H: And then they can also learn to recognize the times that they are using a strategy versus when they're just not paying attention. I have a self rating for them that they use, to talk about how they did with a certain activity. So that is helpful, and then fluency journals are also good for them to track how they're doing at home. Just speaking from experience, they're not going to complete those fluency journals unless you have some kind of reinforcement or reward system in place. So I will usually give them some type of reward if they'd completed their fluency journals for the week. That way they're tracking how they're doing and they can see their own progress.

Marisha: What do the fluency journals look like?

Lauren LaCour H: I'll have just the different little... I think I just have like a little rectangle of how they did... How they felt they did that day. So they can rate if their fluency was, I don't know, more severe or more light or they can just say if it was something, a situation was more difficult or was easier, so they'll just give me kind of one to 10. How is your fluency today? And then what situations made it a little bit more difficult to speak and what situations maybe a little bit easier. So maybe they had to give a presentation at school that day. That would be a little bit more difficult for them to, they might, their fluency might be more. So at least that way they know and I know what situations would cause that.

Marisha: Yeah, that's super helpful. That's like the information that you talked about gathering...

Lauren LaCour H: Right.

Marisha: Like during the evaluation, but it's those ongoing check ins and to figure out which context to help with. I love that.

Lauren LaCour H: Yes. So, for my own data though, I like to track their percent syllable stuttered weekly, even if I don't have that as a goal so that I can pick up on trends or situations that make him more or less fluent. So, he or she might have more difficulty with their fluency during the Christmas holiday season, or they might have more difficulty right at the beginning of school year, when they're getting to know new teachers and all of that. So, if I am tracking their percents syllable stuttered, it's weak, I can kind of make my own hypotheses and guesses on what is causing their fluency to fluctuate.

Marisha: Yeah.

Lauren LaCour H: I think-

Marisha: That extra data is amazing. Do you have... Do you collect the percent syllable stuttered in real time then?

Lauren LaCour H: I've gotten really good at it because I've done it for so long, so I do, but not all the time, depending on the case. If they are very fast talkers, then I'll just record them on a device, like my phone or a tablet and then take the data after the fact. There's an app called, I think Fluency Index Counter, that can help track their percent fluency for you and then keep the data in the app. You can just type... You'll just tap, and that makes it a little bit easier. I also monitor each goal or objective that we are currently working on, on each session and record it on their tally sheet just like I do with all my other students.

Marisha: Yeah. I love that. So helpful.

Lauren LaCour H: I'm glad.

Marisha: Do you have any... Does takeaways or things that you wish you knew when you were starting out, anything that you want anyone to know about fluency?

Lauren LaCour H: Well, I wish that I guess... I wish I would've known that you can't just do a one size fits all therapy approach with fluency. I mean, I guess it's like that in all areas of speech, that all cases might be a little bit different, but I feel like what's fluency, you just never know the reasons why they're stuttering and it's not gonna always be the same for every kid. So the counseling might look different, education might look different and then the activities might look different for each one. So you really have to get to know the kid and I guess, in the beginning I wish I would've known that I didn't have to approach it like, okay, well I'm going to do this first and this and this every single time. I wish I would have kind of gone into, okay, I'm going to spend some time getting to know the kid, asking them about their likes and dislikes, establishing that rapport because in the long run I think it really does help.

Marisha: Yeah, I agree. That's super helpful. And it is a challenging piece. It's something that... I think that's why so many of us do struggle or have a little bit of a fear of taking on those students because we don't get a lot of them. It's something we don't learn as much about in Grad school. And even if we do learn more, we don't get continued practice with it like we do with articulation or language. And then you add on that whole iceberg of all of the counseling and all of the underlying factors. There's so much going on there ant I just so appreciate you helping us break that down a little bit and making it that much more manageable.

Lauren LaCour H: No problem. I hope it helped.

Marisha: I am walking away. I've got my sticky note here with ideas to add to my little cheat sheet of like, okay, these are all these fun ideas you can use.

Lauren LaCour H: Those are good.

Marisha: I definitely walked away. And then, if people want to find out more about your resources and what you do, where can they find you?

Lauren LaCour H: Okay. You can find me at busybeespeech.com. I have lots of fluency blog posts and resources that I list there. If you sign up for my newsletter then I have several, free resources on my website that you can take home with you today. I also have a store on Teachers Pay Teachers under Lauren LaCour Haynes. I have several fluency resources there that I sell.

Marisha: Awesome. Well thank you so much. And, if you're listening, you can head to slpnow.com/14 and I'll put the link to Lauren's blog and her resources, her Teachers Pay Teachers store, all those freebies, all of the apps that she mentioned, all of that good staff. So if you want those links, had to slpnow.com/14 and we'll see you next time.

Lauren LaCour H: Thanks.

 

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Hi there! I'm Marisha. I am a school-based SLP who is all about working smarter, not harder. I created the SLP Now Membership and love sharing tips and tricks to help you save time so you can focus on what matters most--your students AND yourself.

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