We will be chatting tonight, Monday, March 24, 2003, with guest
chat host Lisa Scott Trautman, Ph.D., CCC-SLP.  Dr. Trautman
will be leading us in a chat about Fluency.  Dr. Trautman is
an Assistant Professor in the Department of Communicative
Disorders and Sciences at Florida State University where she
teaches courses in stuttering and counseling.  In addition to
her position at FSU, she works as a professional consultant to
the Stuttering Foundation of America, planning continuing education
and new publications in the area of stuttering. A Certified Fluency
Specialist, she has evaluated, treated, and/or consulted with over
150 school-age children who stutter, and many adults and preschool
children as well. In addition to her clinical work, she has made
presentations at district, state, and national meetings, and
co-authored several publications in the area of fluency disorders.

<Robin> Welcome!  We are chatting tonight with Lisa Scott Trautman, Ph.D., CCC-SLP
          about fluency.
<LisaTrautman> Hi everyone!
<Robin> Dr. Trautman, could you start with an overview about fluency/stuttering?
<LisaTrautman> Sure, an overview of fluency/stuttering...
<LisaTrautman> A lot of people consider stuttering to be one of the most difficult and
          least favorite disorders to treat.
<LisaTrautman> I personally think it's one of the most fun.
<AdrienneFSU> Most difficult because of recurrence?
<LisaTrautman> Most difficult I think because there are lots of folks who think that if
          clients are still stuttering, we're not doing our jobs properly.
<LisaTrautman> But it's like any other chronic disorder.
<Heidi_B> Is stuttering habitualized and is there a not-growing-out-of-it type (sorry)?
<LisaTrautman> A lot of stuttering is habituated, Heidi -- negative reactions and
          thoughts build up over time and those negatives often transfer to tension in
          the body.
<LisaTrautman> Van Riper used to say that a lot of stuttering happens from trying NOT
          to stutter.
<Heidi_B> I gave a short presentation on Van RIper method for stuttering this evening.
          Is this typically used as a whole approach or is it used piecemeal?
<LisaTrautman> Some people are very committed to one approach, like Van Riper's and use
          it in its entirety. I would say most people use it more piecemeal.
<LisaTrautman> You're fine, fire away with the questions
<LisaTrautman> I tend to use a lot of his stuff with clients who NEED it -- I don't
          just use it as a blanket approach for everyone.
<LisaTrautman> Not everyone is ready to do identification or pseudostuttering.
<Heidi_B> Do you typically use Van Riper for older clients?
<LisaTrautman> I use a lot of Van Riper's techniques for any client, any age, who is
          aware of his/her stuttering and has built up negative reactions/avoidances to it.
<LisaTrautman> For example, I worked with a 6 year old who we taught a lot of Van Riper
          stuff to because he really needed to develop different reactions to his stuttering
          moments before he could start focusing on fluency shaping tools.
<LisaTrautman> There is a lot of interesting new research coming out right now about
          preschool identification -- who will recover vs. grow out of it.
<LisaTrautman> There are researchers at University of Illinois--Ehud Yairi & Nicoline
          Ambrose -- that have published quite a few studies in recent issues of JSHR.
<LisaTrautman> They have given us guidelines to use when evaluating preschoolers, as far
          as likelihood that they will continue to stutter without treatment.
<LisaTrautman> Their main findings:
<LisaTrautman> 1. 75% of all children will spontaneously recover from stuttering with no
<LisaTrautman> 2. Children who are most likely to recover will be females, have no family
          history, have speech/language skills within normal limits, will have begun
          stuttering before age 3 1/2, and will show gradual improvement in their fluency
          over time.
<Robin> How long do they allow for spontaneous recovery?
<LisaTrautman> Spontaneous recovery can take as long as 3 years. Yairi and colleagues
          divide their kiddos into an early recovered, middle recovered and late recovered
<LisaTrautman> Early recovered is within first 18 months, middle from 18-24, and late from
          24-36 months.
<LisaTrautman> They believe the #1 predictor of kids who are more likely to persist are
          those who have family history.
<Robin> How large was their study?
<LisaTrautman> They have been following about 150 kids over the past 8 years.
<LisaTrautman> It's the largest longitudinal study ever conducted.
<Heidi_B> How much of a factor do you think reinforcement is in non-recovery?
<LisaTrautman> Heidi, can you explain what you mean by reinforcement? Do you mean how
          others respond to the stuttering?
<Heidi_B> I mean what Van Riper called "advantages of stuttering" i.e., not having to do
          group presentations, answer phone, etc.
<LisaTrautman> Ah
<LisaTrautman> I have to say that I only see clients who benefit that way about 1 in
          every 30 or so.
<Heidi_B> good
<LisaTrautman> I've worked with several clients who experience this "secondary gain"
          from their stuttering, but I would say it's the exception rather than the norm.
<LisaTrautman> Most clients are very troubled by their stuttering.
<LisaTrautman> But as clinicians we have to be really sensitive to that possibility.
<LisaTrautman> I worked with a boy who didn't mind getting teased by peers because it was
          the only way he was getting attention from them.
<LisaTrautman> So we had to work on his social skills and teach him how to make friends
          so that he wouldn't have to use stuttering as his method of getting peer attention.
<AdrienneFSU> Have you worked with any parents who are more upset with the stuttering than
          the kid is?
<LisaTrautman> Yes, Adrienne, lots of parents are more upset about it than their kids.
<LisaTrautman> And this is important to recognize the parent's anxiety in the problem
          because how the parent deals with the stuttering will have a big effect on how
          the child deals with it.
<AdrienneFSU> Do you just educate them a lot?  Have them talk to other parents?
<LisaTrautman> We do parent education, we do some counseling -- many parents have
          significant guilt and anxiety about the problem. They think they've caused it.
<LisaTrautman> Or sometimes they're really frustrated and think it should be something
          the kiddo should just "snap out of" or "try harder" at.
<LisaTrautman> And yes, talking to other parents.
<LisaTrautman> There is a great organization for kids that sponsors workshops all over
          the U.S. and a convention every summer -- www.friendswhostutter.org
<Heidi_B> Do you teach them that their anxiety can cause the child's anxiety which can
          facilitate the stutter?  Or is this not PC?
<LisaTrautman> We do talk about creating a "communicative environment" that is helpful.
<LisaTrautman> And we try to identify what they're thinking, what they're feeling. Many
          times if you just validate a parent's concern, they can let go of it. It's
          keeping the bad emotions in that creates the anxiety.
<Rhonda> It sounds like a class or two in counseling would benefit us as SLPs when
          dealing with these sensitive issues.  What do you recommend?
<Robin> Dr. Trautman also teaches a class in couseling.
<LisaTrautman> I do recommend reading anything on counseling that you can get your hands
          on, or taking a class. BUT, that being said, I think just paying good attention
          to the parent and listening well can serve you well too.
<Erika-OU> I have a client now who stutters, can I ask your opinion?
<LisaTrautman> Sure Erika, fire away.
<Erika-OU> He's 4 and a half, and his stutter is a strange inhalation stutter.
<Erika-OU> His language skills are at least average, he's quite a chatterbox and is
          completely unaware of his stutter.
<LisaTrautman> When you say inhalation stutter, does he hold onto the sound while he's
          inhaling or does he repeat it?
<Erika-OU> He takes an audible breath mid-word.
<Erika-OU> Where are y(breath)ou going.
<LisaTrautman> oh
<LisaTrautman> What kind of therapy are you doing with him?
<Erika-OU> Well, I've only seen him one time...we were modeling slow and easy speech with
<LisaTrautman> That kind of therapy approach is pretty common with preschoolers.
<Erika-OU> yeah...
<Erika-OU> and showing mom how to talk slow and easy.
<Erika-OU> but he had that stutter on 15 occasions in a one hour session.
<LisaTrautman> Yikes, he's really working hard to talk.
<LisaTrautman> That kind of stuttering is a lot about teaching the kiddos to really
          smoothe through that disfluency and keep all the sounds going.
<LisaTrautman> Does the kiddo like trains, by chance?
<Erika-OU>e probably likes trains...I haven't tried that.
<Erika-OU> We were going to implement some breathing exercises.
<LisaTrautman> There is a chapter by Runyan & Runyan in Curlee's book Stuttering & Related
          Disorders of Fluency.
<LisaTrautman> They talk about the fluency rules program they developed and one is keep
          talking smooth or something.
<LisaTrautman> Anyway, one thing you can do is have the kiddo use train cars and keep
          them going smoothly on the floor while he says words.
<LisaTrautman> We have words just like a train has cars, and we need to keep them all
          going together smoothly.
<Heidi_B> Is that type of stutter uncommon?  Seems difficult to do.
<LisaTrautman> I would say the inhalation stutter is less common.
<Erika-OU> We weren't sure if making him aware of his dysfluency was the way to go yet.
<LisaTrautman> For preschoolers, the part-word repetition is the hallmark disfluency,
          then probably audible prolongations, then maybe blocks.
<LisaTrautman> Phonatory arrest mid-word is a bit different but not unheard of.
<LisaTrautman> One way to check out whether he's aware is to model some disfluency
          yourself. If he looks at you or asks you what you're doing, that's a pretty good
          clue he's aware.
<LisaTrautman> If he ignores it, he's probably not.
<Heidi_B> Could you videotape him and play it for him?  If he discriminates it that is...
<LisaTrautman> Usually with little ones, I'm more inclined to not bring their attention
          to it until either (a) I know they are aware, or (b) indirect modeling of speech
          techniques isn't working.
<LisaTrautman> I don't usually video kids very often, it can be pretty frustrating for
          them. Even if they're aware they stutter, they usually don't know what they look
          like and sometimes that can work against you.
<LisaTrautman> But that's just me, other clinicans might do it differently.
<Erika-OU> Our resident neurology guy suggested he's doing it for diaphragmatic awareness.
<LisaTrautman> Hm, diaphragmatic awareness, that's interesting
<LisaTrautman> If you want to heighten his awareness, the important thing is just to be
          really neutral about bumps.
<LisaTrautman> Most people think awareness is a bad thing but sometimes kids need a more
          direct model.
<Erika-OU> We are at that crossroads now.
<Erika-OU> He's no showed twice now.
<LisaTrautman> So we might play a game where the goal is to put bumps in your speech,
          then put smooth in, etc. and you get points for CHANGING your speech -- then
          bumps aren't right or wrong, smooth isn't right or wrong, and you can say, You're
          so GOOD at changing your speech!
<LisaTrautman> Then just start shaping towards smoother speech once you know the kid can
          reliably  imitate and change.
<Robin> What type of therapy techniques do you use with older children?
<LisaTrautman> I use that same therapy technique with older kids.  Dean Williams who used
          to be at University of Iowa talked about letting kids "catch you".
<LisaTrautman> So I imitate and they do identification of my stutters, then we do
          imitation with them, then gradually work on them identifying their own disfluent
<LisaTrautman> We play games trying to change stutters around and make them really weird,
          really cool, really silly.
<LisaTrautman> Again, with the whole idea that you can change what you're doing.
<LisaTrautman> Heidi, does this sound familiar? It's identification + desensitzation--
          Van Riper for kids!
<Heidi_B> Yup!
<LisaTrautman> Then I teach them the speech modification tools I believe will match their
          disfluencies the best.
<Heidi_B> Modification!!
<LisaTrautman> Yes Heidi! Modification!
<LisaTrautman> And do a lot of real-talking sort of activities -- I do lots of stuff with
          themes in therapy.
<LisaTrautman> For instance, if the child plays a sport, try to think about how you can
          tie the sport to stuttering.
<LisaTrautman> For example, everyone has to learn new ways to kick, and then practice
          kicking to play soccer -- same with learning new ways to talk.
<LisaTrautman> and you have to practice a lot of different skills with different partners,
          on different fields before you can play a game -- just like you have to practice
          talking in different ways with different people before you're ready to go to the
          big leagues and let it rip along in the classroom!
<LisaTrautman> Tricia, do you want to add anything?
<LisaTrautman> Tricia is the fluency supervisor at UT-Dallas and a goddess at this stuff!
<Heidi_B> Wow, a two for one tonight!
<AdrienneFSU> How do you modify this approach of "not right or wrong, just different" to
          teens or adults?
<LisaTrautman> Not right/wrong with adults can be trickier because they have so many
          negative emotions built up and negative experiences.
<LisaTrautman> Usually with adults you start with the same principles of identification,
          then work on desensitization.
<LisaTrautman> And we talk a lot with adults about communicative effectiveness.
<Heidi_B> It goes along with the whole idea of "learning to stutter" more fluently.
<LisaTrautman> Yes, it does go along with learning to stutter more fluently.
<LisaTrautman> Also, it's important with adults to get away from the idea that you're
          only a good communicator if you're fluent.
<LisaTrautman> If they are evaluating communicative success on a binary system of
          "stuttered" or "fluent", it's difficult to move them away from those old negative
<LisaTrautman> and back to the earlier question about using Van Riper totally vs.
          piecemeal ----
<LisaTrautman> I think it's important for someone who stutters, especially adults, to know
          how to stutter easier.
<LisaTrautman> But then there's also an efficiency trade-off. So we would also introduce
          fluency shaping skills to improve their fluency as much as possible.
<LisaTrautman> In my ideal world, I want my clients to speak confidently, assertively,
          efficiently, and not be freaked out when stuttering happens because it might.
<LisaTrautman> But that doesn't mean you're not communicating exceptionally well. There
          are lots of fluent folks who are awful communicators.
<Heidi_B> Van Riper talks about teaching a "continuum of stuttering".  Can you elaborate?
<LisaTrautman> The continuum of stuttering, I believe (it's been awhile since I've read
          Van Riper so bear with me).
<LisaTrautman> It's that there is hard, tense, big bad stuttering. Then there is easier
          stuttering, then normal disfluency (ums, uh's, whole word repetitions, etc.) and
       then hyperfluency.
<Heidi_B> oh...
<LisaTrautman> For example, news reporters are hyperfluent.
<LisaTrautman> I'm a highly disfluent, fluent person.
<LisaTrautman> I have lots of revisions, whole word repetitions and interjections in my
<LisaTrautman> Does this make sense to what you were reading Heidi?
<Heidi_B> Yes, very much.
<LisaTrautman> And the deal is, a lot of adult clients especially come in with the
          expectation that therapy should take them to the hyperfluent end of the continuum.
<LisaTrautman> Van Riper advocated just moving them more towards normal disfluency.
<Tricia> Lisa-  Do you ever think that an individual will do better in an intensive
          therapy experience (i.e. SSMP) than in individual therapy?
<LisaTrautman> I think that people who do intensives end up having a better outcome if
          they follow up with some individual afterwards.
<LisaTrautman> I think that intensives like SSMP (Successful Stuttering Management Program)
          can offer nice opportunities that are hard to achieve sometimes in individual
<GL> Dr. Trautman, are you in favor of psychological oriented treatment or mechanical?
<LisaTrautman> I probably believe that the best therapy happens when there's a
          combination of both psych oriented + mechanical, so to speak, IF that's what
          the client needs.
<LisaTrautman> Do you have a preference for one approach over the other, GL?
<GL> Not  really....I tend to focus on breathing techniques and relaxation drills...and
          leave the soul to psychologists...
<LisaTrautman> I agree, psychologists are the best for soul work, GL. I do psychological
          approaches as they related directly to stuttering and communication, but not
          relationships, etc.
<GL> What technique is the most current now in the USA?
<LisaTrautman><GL>, I think most people in the USA do a combination of both or lean more
          toward mechanical than psychological.
<LisaTrautman> Many people are afraid to deal with psychological issues, don't want to
          harm the client, but this is rare really.
<rembuddyk> Dr. Trautman, are you familiar with Kristin Chmela's workbook for school-age
<LisaTrautman> Yes, I edited it!
<LisaTrautman> Do you like that workbook?
<rembuddyk> I haven't had the opportunity to use it yet.... have just finished graduate
          school after working in schools with a BS for 11 years.  Wish I would have had it
<rembuddyk> I can say that there are some activities that I used similar to these, and
          the couple of children I used it with responded very positively.
<Tricia> Lisa-  I would be curious if after your training with the Lidcombe program you
          are using it more than before?
<LisaTrautman> I haven't seen many preschoolers since the training but yes, I'm using it.
          I'm starting it with a 6 year old in a couple of weeks.
<LisaTrautman> I had a bad attitude about Lidcombe before I got trained but I have to say
          I'm a convert now.
<Robin> Dr. Trautman, tell us about the Lidcombe Program.
<LisaTrautman> Lidcombe is a preschool intervention program that was developed in Australia
          by researcher Mark Onslow and colleagues. It is a parent-administered intervention
          program. SLPs train parents to recognize disfluency, then design daily activities
          for their child that provide brief sessions where fluency is praised in a structured
          interaction. Once the child's fluency skills improve, corrections such as asking a
          child to "fix" a bumpy word -- e.g., "That word was a little bit tricky, can you
          fix it?" are introduced in a very scheduled, ratio-driven protocol.
<Tricia> When do you decide to use that type of approach rather than the more eclectic
          approach you talked about at the SFA workshop in Wichita?
<LisaTrautman> Well, Lidcombe folks would say you should always choose that approach but
          I don't have enough experience yet to always recommend that.
<LisaTrautman> I do it with families who are ready and willing to follow through on the
          daily practice as well as attend the therapy and STAY there with their kiddo each
          week rather than just drop them off.
<LisaTrautman> We do a mix of things, including breathing and relaxation.
<LisaTrautman> It's not that much different than Kristin's approach with preschoolers
          except for the praising/correction stuff.
<Tricia> Do you feel there is an optimal age range for it?  I am just not sure how I
          could get comfortable with the correction aspect.
<LisaTrautman> I think optimal is probably up to about age 7 or so.
<LisaTrautman> They are collecting data now doing it with older kids
<LisaTrautman> But I have reservations about it.
<rembuddyk> Dr. Trautman, one of my profs in grad school, Charles Healey uses an approach
          called CALMS that he authored (I guess you would say).
<LisaTrautman> I am a UNL grad and we developed it together!
<LisaTrautman> I do all my assessments and therapy according to CALMS.
<Robin> What does CALMS stand for?
<LisaTrautman> Cognitive, Affective, Linguistic, Motor, & Social.
<rembuddyk> I think it looks very good because it touches on every aspect of stuttering.
<LisaTrautman> Cognitive = how you think about the problem, what you believe
<LisaTrautman> Affective = how you feel
<LisaTrautman> Linguistic = your ability to use tools in varying linguistic contexts
<LisaTrautman> Motor = what the client is actually doing with their speech system that
          produces stuttering
<LisaTrautman> Social = how the problem handicaps them in terms of participation, etc.
<rembuddyk> What are your recommendations on texts for the CALMS approach?
<LisaTrautman> There aren't many texts out there with CALMS specifically, but I just read
          a book by Charleen Bloom & Donna Cooperman, Synergistic Stuttering Therapy:
          A Holistic Approach, that is very similar in ideas.
<LisaTrautman> We're going to present on it at ASHA this year with Anne Smith & Chris
<GL> In your experience what did the trick best?  Abdominal breath support or relaxing
          the laryngeal muscles?
<LisaTrautman> I think breath support is the basis for everything else. I find it
          difficult to have clients relax laryngeally.
<LisaTrautman> GL, I do work on relaxing the articulators, like using a more relaxed
          contact for tongue to teeth or lips together, etc.
<GL> For how long are you follow up your clients there after?
<LisaTrautman> GL-- follow up periods for maintenance?
<LisaTrautman> I'm still not sure I understand what you mean by following up. Do you mean
          how long to continue seeing the client after they have learned the techniques?
<GL> No-after you let them go...
<LisaTrautman> I usually try to keep in pretty regular contact for 3-6 months, then let
          them determine what they want for a follow up after that
<LisaTrautman> I also teach them what kinds of signs to look for in case of relapse, so
          that they don't wait until they have really gone "downhill" before they come back
<Robin> Dr. Trautman, you have been chatting with us for an hour!  Thank you so much for
          being here and sharing your expertise!!
<LisaTrautman> I appreciate everyone's participation tonight, this is always so much fun!
<Tricia>   Thanks for everything!
<Erika-OU> Thanks for helping me with my question.
<LisaTrautman> Erika, have FUN in therapy!
<Heidi_B> Thanks for all of your input.
<Rhonda> This has been very helpful for me. Thank you for your time. 
<LisaTrautman> Thanks again, this was fun!
<AdrienneFSU> Thanks!!!
<GL> Thank you so much !!!!
<rembuddyk>  Night everyone!
<becky> Thank you, goodnight!
<Robin> Thanks for joining us everyone!