Monthly Archives: January 2011

What’s up with this child? Listen to your instincts!

Please share this promotional video with anyone you think might benefit from it. It was inspired by all those well-meaning comments we parents heard, and by the courage of parents who said, “No, I think there’s something ‘off’ with my child and I’m going to explore that possibility.”

 

http://www.youtube.com/watch?v=wG4O2TV2smg

 

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The King’s Speech and Stuttering: Interview with Thomas David Kehoe

If you haven’t yet seen the marvelous movie The King’s Speech, I highly recommend it! It’s a wonderful true story about the man who helped the future king of England overcome his stutter, and features Colin Firth as “Bertie,” the future King George VI of England, and Geoffrey Rush as the unorthodox speech coach who must cure Bertie of  stuttering before Bertie takes the throne.

Excellent as Colin Firth’s acting is, his stuttering didn’t quite seem right to me. A childhood friend of mine, Thomas David Kehoe, had a severe stutter, so I well knew what a stutter sounded like. A few years ago, I came across the news that David (as I knew him then) had invented an anti-stuttering device to cure his own stutter after failing to benefit from a multitude of therapies. He’s also the author of No More Miracle Cures, a book that explores stuttering treatments and theories behind them. So, after seeing The King’s Speech, I thought I’d check in with my old friend and get his take on the movie and how it portrays stuttering. I also wanted David’s insights into stuttering treatment in history and today.

NP: So David, what was your take on the movie? Did you think it portrayed stuttering accurately?

TDK: There were a lot of things I liked about “The King’s Speech,” and one thing I didn’t like: that the stuttering wasn’t right.

Stuttering comprises repetitions (repeating a sound you can say that precedes a sound you can’t say), prolongations (drawing out a sound you can say that precedes a sound that you’re unable to say) and silent blocks. A silent block occurs when a stutterer has air in his lungs but locks his vocal folds, preventing the release of air. This usually is accompanied by secondary behaviors, such as eye blinking, jaw clenching, or head jerks.

When the stutterer gets a word out it can be incomprehensible. In my 20s, my most fluent speech was ten times slower than normal speech. I could block on a word for five or ten minutes.

As the movie "The King's Speech" portrays, King George VI of England stuttered

Colin Firth, the actor who played King George VI, silently trembled for a few seconds, then spoke clearly. My guess is that the director decided that real stuttering would have made the movie several hours longer and audiences would have needed subtitles to follow what the king was trying to say. Also, stuttering raises the blood pressure and induces other symptoms of stress in listeners. Audiences would have walked out theaters because it’s painful to watch severe stuttering.

There are mild stutterers. Mild stutterers can avoid certain words and sounds or substitute words or phrases they can say for feared words. For example, a mild stutterer might say “America’s favorite pastime” instead of “baseball.” But mild stutterers can usually hide their stuttering, so that wouldn’t make much of a movie.

NP: I remember you telling me that Winston Churchill stuttered, but in the movie he didn’t.

TDK. Near the end, Churchill tells the king, “My family has a speech impediment, too” but we never see it. In reality, Winston Churchill could speak fluently only by preparing his remarks in advance. He studied issues weeks in advance, and wrote out responses to any possible objection. This extra effort made Churchill more knowledgeable than other leaders.

As a young man, Churchill worried that his stuttering would have an impact upon his ambition to go into politics. But he didn’t believe in submitting to failure so he practiced and persevered. He both practiced his speeches and practiced nonsense phrases as he walked, such as “The Spanish ships I cannot see since they are not in sight.” When he was 23, he wrote, “Sometimes a slight and not unpleasing stammer or impediment has been of some assistance in securing the attention of the audience…”

NP: Wow. That’s inspiring!

Winston Churchill, the brilliant statesman and orator, stuttered

TDK: Aneurin Bevan, the Labour Party leader and Churchill’s political opponent, was also a stutterer. For a period of time the British king, prime minister, and opposition leader were all stutterers. Bevan found that he could speak fluently by making passionate speeches on behalf of British workers.

NP: The movie was set at a time when it seemed they didn’t really know how to treat stuttering. I had no idea there were so many crazy cures people tried. Were those real?

TDK: Yes. The movie opens with a speech therapist teaching the future king to smoke and stuffing marbles in his mouth — two useless treatments. I hadn’t heard of the smoking treatment, but I have read that a “manly” diet of beef and beer was recommended for stutterers by Charles Canon Kingsley (1819-1875), a Cambridge history professor, orator, and chaplain to Queen Victoria.

Anyway, Bertie gives up on these treatments then meets Lionel Logue, an Australian who treats “speech defects.” Logue first tries Freudian psychology, asking about Bertie’s early childhood memories. Then he successfully uses masking noise: Bertie speaks while listening to loud music in headphones. Masking noise is effective because stutterers have underactive auditory processing, and loud noise stimulates auditory processing.

NP: In a sense, waking up the auditory processing center, yes?

TDK: Yes. This treatment was later refined and became widely used in the 1980s with an electronic device called the Edinburgh Masker, which used a sine wave synched to the stutterer’s vocal fold frequency. A clinical trial found that the device reduced stuttering on average 50% for 18 adult stutterers, and eliminated stuttering for one of these adults.

Logue, an amateur actor, then tries elocution exercises for the theater. He has Bertie speak in a sing-song cadence (to the tune of “Camptown Races”), which was a widely used stuttering treatment at the time. He tries rhythmic arm swinging, which was also a widely used stuttering treatment in the 1920s. He has Bertie roll on the floor while speaking, anticipating a 1935 study that found that stutterers could speak fluently while crawling on all fours (which anticipated a current therapy for brain-injured children and adults).

Also, there’s a scene where the king has to do a radio address and he’s helped by having Logue silently mouth the words to him while he speaks with long pauses. The radio technicians could have set up a system in which Logue read the speech into the king’s headphones and the king spoke in unison with Logue, but this “shadowing” or “chorus reading” effect wasn’t known until 1956.

The future king’s speech gradually improves, although he still is unable to speak in a stressful situation and without spoiling the movie, he has to overcome an emotional block before he can control his stutter. This is accurate: stutterers can often speak fluently in “fight or flight” situations because adrenaline inhibits dopamine. Stuttering is a disorder of dopamine, as are Tourette’s, obsessive compulsive disorder, and tics.

NP: Dopamine—I know that’s a hormone that functions as a neurotransmitter in the brain, allowing the nervous system to work properly.

TDK: Stuttering, Tourette’s, OCD, and tics are associated with too much dopamine. Parkinson’s and ADHD are too little dopamine. The fact that there are five (at least) different disorders associated with too much dopamine (and an equally wide variety of Parkinson’s subtypes) suggests that different people have differing sensitivity to dopamine in various brain areas. For example, stutterers likely are oversensitive to dopamine in their speech motor control area, when Tourette’s patients are oversensitive in their gross motor control area.

NP: Of course, the movie takes place long before we knew about brain chemistry. So once the so-called experts got over the foolish notion that rolling on the floor or taking cigarette smoke deep into your lungs was going to cure stuttering, what did they figure out?

TDK:  Stuttering treatments can be divided into three eras. Stuttering treatment began in 1927 with the formation of the University of Iowa Speech Clinic.

The “Iowa Therapies” focused on accepting stuttering and reducing stutterers’ speech-related fears and anxieties. Because they couldn’t treat the core behaviors of stuttering, speech-language pathologists of this era managed the secondary symptoms associated with stuttering, to improve stutterers’ ability to communicate, despite stuttering.

The second era of stuttering treatment began in 1965 when Israel Goldiamond discovered that using electronic delayed auditory feedback (DAF), with which a user hears his voice in headphones delayed a fraction of a second, induced stutterers to speak slowly and fluently. Goldiamond and colleagues developed a stuttering treatment that began by inducing slow, fluent speech; then gradually increasing the speaking rate until the subjects spoke fluently at normal speaking rates. This “prolonged speech” or “fluency shaping” therapy reduces stuttering about 75% for about 75% of adult stutterers. The most fluent speech is produced in low-stress situations, and too often stutterers are unable to use fluency shaping therapy skills in high-stress situations.

The current neurological era of stuttering treatment began in 1992 with the first brain imaging study of stutterers. Two neurological abnormalities were associated with adult stuttering: overactivity in the speech motor control area, which was expected given the high speech muscle activity seen during stuttering; and underactivity in the auditory processing area, which was unexpected.

In 1993, Joseph Kalinowski and colleagues published a study finding that DAF and a newer technology called frequency-altered auditory feedback (FAF) reduced stuttering about 70% at normal and faster-than-normal speaking rates, without conscious effort or control. This challenged the belief of the fluency shaping era that slowing down was the key to fluent speech, and supported the brain imaging research finding that auditory processing was a significant issue in stuttering. In 1996 the three genes that control dopamine were associated with stuttering. In 1999 Gerald Maguire and colleagues published a study finding that the dopamine antagonist medication risperidone reduced stuttering.

So to summarize the three eras of stuttering treatment, in the first era (1927-1964) psychological effects (stutterers’ beliefs and attitudes) were treated because core stuttering behaviors couldn’t be treated. In the second era (1965-1991), the core physical stuttering behaviors were treated and stutterers were able to speak fluently, although this treatment wasn’t effective for every stutterer in every situation. In the third era (1992-present) we’re treating stuttering on a neurological level, using electronic devices or medications.

However, too often the neurological processes of stuttering are barely glimpsed or poorly understood and efficacy research lags years behind the technology, resulting in the media touting some “breakthrough” electronic devices or medications that later turn out to be ineffective.

The thesis of my book, No Miracle Cures: A Multifactorial Guide to Stuttering Therapy, is that each era of stuttering treatment has contributed to the field, that each has shortcomings and each treatment alone is insufficient, and that the successful treatment of adult stuttering requires combining treatments from all three eras.

Thomas David Kehoe

NP: What about treating children who stutter?

TDK:  The treatment of children who stutter also changed over the decades. In the “Iowa” era, parents were told that they caused their children’s stuttering by trying to correct their children’s normal dysfluencies (mistakes children make as they learn to talk).

NP: Similar to autism being blamed on “refrigerator mothers.” It’s so frustrating that people are quick to assume “it’s all mom’s fault!”

TDK: Parents were told to ignore their children’s stuttering and to do “indirect therapy,” which included the parents speaking slowly, pausing before answering the child’s questions, reducing the number of questions the parents ask the child, and slowing down the pace of family life. Twenty studies found indirect therapy to be useless, or even produce the opposite of the intended results, yet indirect therapy continues to be recommended today by the Stuttering Foundation of America, the National Institute of Deafness and Other Communication Disorders, and websites such as KidsHealth.org.

In the fluency shaping era, speech-language pathologists began using “direct therapy” with children who stutter. Today speech-language pathologists advocate treating children who stutter as soon as possible, as opposed to the older “wait and see if he outgrows it” advice.

NP: Years ago, the idea was “wait til he outgrows it” regardless of the developmental delay. So you’re saying that’s not the right advice?

TDK: In 2005 Ehud Yairi and Nicoline Ambrose published a longitudinal study examining young children soon after the onset of stuttering, and following the development of the disorder for five years or more. The results dispelled many myths, including that stuttering gradually develops from normal childhood dysfluencies. Yairi and Ambrose instead found that stuttering typically starts suddenly, over a few days or a week. The average age of onset is 34 months (two years and ten months old).

Yairi and Ambrose found that children who stutter are ahead of their peers in language development but behind in phonological development. Phonological development is the ability to perceive and produce speech sounds (phonemes). In other words, parents’ intuition that their child’s “mouth can’t keep up with his brain” turned out to be right.

Yairi and Ambrose found that most children recovered from stuttering without treatment within three years (usually by age six). However, 20% of the children stuttered more than five years, and these children never recovered, despite receiving speech therapy. The researchers then focused on the differences between the children who recovered from stuttering and the children whose stuttering persisted. They found that the children who rapidly recovered from stuttering also rapidly caught up with their peers in phonological development. The children who persisted in stuttering were slower to catch up in their phonological development. This suggests that in the future speech-language pathologists will focus on phonological development in young children who stutter.

By the way, in the movie, King George VI perceives that he always stuttered and that his first memory of stuttering was at age 4 or 5. Children become aware of their speech around 1st or 2nd grade. So if you ask any stutterer when they first remember stuttering it’ll be when they were between 5 and 7 years old. But they stuttered since 2 or 3, they just had no awareness or memory of their speech.

For children, the most popular direct therapy is the Lidcombe Programme. Developed in Australia, this treatment has been proven effective for pre-school stutterers in many studies. The therapy is simplified so that parents become the primary providers of speech therapy, instead of relying on speech-language pathologists to provide therapy.

NP: So where should you go to a therapist for help with your child’s stutter? And should you go when she is a preschooler?

TDK: Start with your school district. Federal law requires that schools provide (free) speech therapy starting at 3. Ask if the school district has a stuttering specialist, or ask for a referral to a private specialist. Board certified Fluency Specialists are listed at: http://www.stutteringspecialists.org/

My personal advice is: Go as soon as the child starts stuttering. Again, the onset is typically in days or a week. Don’t wait to see if the stuttering goes away.

(NP’s note: The American Speech and Hearing Association doesn’t specify when you should have your child evaluated but you can find an informational page about risk factors and other topics here: http://www.asha.org/public/speech/disorders/stuttering.htm )

NP: I know that your anti-stuttering device came about because you read professional journals from several different fields and got out there to speak to the female speech-language pathologists who are in the trenches helping kids to learn from them. Your perseverance and innovation led you to the breakthrough that resulted in your devices. What really touches my heart is that you’ve helped many, many parents figure out how to get the funding and get these devices to the kids who desperately need them, and traveled to places like Bosnia and Cuba trying to get the word out to therapists who treat stutterers. I like to think the universe rewarded you when you met a wonderful speech language pathologist at a conference in Cuba: Diany, whom you recently married!

TDK: I agree that I’m lucky on that count!

NP: Can you explain the anti-stuttering devices you manufacture and sell at Casa Futura Technologies, and how they work?

TDK: My company, Casa Futura Technologies, has made DAF and FAF devices since 1992. The devices have been proven effective in twenty clinical trials, both to reduce stuttering and to train stutterers to speak fluently over time and no longer need the devices. We’re developing a new device using a sensor worn on the neck to monitor vocal fold vibrations. The data is processed by an iPhone. The user sees a display of his or her vocal fold activity including amplitude, frequency, and the duration of phonated intervals. Stuttering is preceded by very short phonated intervals (vowels and voiced consonants delineated by voiceless consonants and silent pauses). The app color-codes these too-short phonated intervals red. Very long phonated intervals, produced with fluency shaping therapy techniques, are color-coded blue. Phonated intervals that are the right length to produce fluent speech at a normal speaking rate are color-coded green. The user immediately sees when his speech is too fast or too slow. The red phonated intervals make the iPhone vibrate, and switch on DAF in earphones to induce the user to slow down. When the user slows down and speaks fluently the DAF switches off. We believe that this new device will induce fluent speech, even in stressful speaking situations, while more quickly training the user to speak fluently and no longer need the device.

NP: I have to say, I wasn’t all that surprised that the kid who opted to do an oral report to our seventh grade class on the topic of integrated circuits, a subject I still don’t understand, would use his brilliance to solve such a frustrating puzzle as severe stuttering. I’m still utterly amazed at the results whenever we have a conversation.  David, thanks so much for your insights, and I’ll let people know that they can learn more about your anti-stuttering device and your new app for stutterers at http://www.casafuturatechnologies.com

And hey, are you impressed that I picked up on the stuttering in The King’s Speech being not quite right?

TDK: The real test of your movie perception skills is in Dances With Wolves. My mom {Dr. Alice Kehoe, a seminal anthropologist} was shocked that they cast a Saskatchewan Cree woman as a Lakota Sioux. Anyone could see she was Cree! 🙂

NP: OK, I readily concede that when it comes to detail, I will never be in your mom’s league! But it was fun talking to you about stuttering and The King’s Speech. Thanks for your remarkable insights!

TDK: You’re welcome!

The Small Talk (R) anti-stuttering device from Casa Futura Technologies

The information contained herein is provided as a public service. It is for informational and educational purposes only and should not be construed as personal medical advice. Although every effort is made to ensure that this material is accurate and up-to-date, it s provided for the convenience of the user and should not be considered definitive.

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60 first graders, 4 teachers, one open classroom = Sensory Hell

Do I laugh or cry at the misguided professionals who borrowed an idea from an elite private prep school to create a overpopulated first-grade classroom  for public school children, a group that includes kids with sensory processing issues?  According to the New York Times article, the class is held in an open area with 60 first graders and 4 teachers who can all hear and see what’s going on with the other groups. Transitions that involve a change of activity and moving the children to a different part of the room are a nightmare, which is frustrating for the teaching team.

Up to ten percent of children have sensory processing differences that make everyday sensations such as background noise or visual clutter incredibly intense experiences that are difficult for the brain to process, distracting, and anxiety provoking. Although we can be grateful our own kids aren’t in the sensory hell of 60 kids, 4 teachers, no walls, this story is a good reminder of how important it is to be aware of how sensory kids experience auditory and visual clutter.

Neurotypical people and children have the ability to automatically “turn down the volume” on sensory input that isn’t important and “turn up the volume” (that is, pay attention to) priority sensory input. Neurotypical children can usually tune out the sound of a truck rolling by a classroom, a dog barking outside, a chair scraping as someone pulls it out, or the squeak of a marker on a whiteboard isn’t important noise–unless they’re bored or antsy because they’re hungry or tired of sitting. However, most of the time they probably won’t notice the sound or, if they do, they automatically know it’s unimportant and they don’t instantly break their focus. Of course, younger children do get distracted by sounds they find especially interesting–the sound of money jangling in a bag, described in the article, would probably excite a six-year-old eager to see how much money it is. The sound of a dog barking outside a classroom door might elicit excitement (“Ooo, there’s a doggie in the building? Can I see him? Can I pet him?) or anxiety (“Oh no, a dog. I’m scared! My aunt’s dog bit me once!”).

Imagine, though, that your brain simply can’t block out the sound of children’s feet as they move across the room, or the teacher talking to a different class. Imagine that your brain is taking in the sight of 60 kids all moving, some of them moving suddenly, or bursting into giggles that pierce your ears because of your auditory sensitivities. Your brain can’t process all this information quickly enough and some of it is being processed as danger signals. Sudden high-pitched sound? Sudden movement to your right? Your body responds with panic: the fight or flight response. You start chewing your fingertips and rocking, shutting down and not hearing the teacher’s instructions. You feel yourself getting agitated, and when another child moves too close to you, you take a swing at her. You feel yourself so excited by all the stimulation that you start hand flapping and making silly noises–which the other kids laugh at, which makes you more excited, so you start bopping your head side to side and rolling on the ground. Fight, flight, sensory overload–these are not responses that will help you learn in this environment. And if you have poor self-regulation, which many sensory kids have much longer than neurotypical children do, you’re not going to come back to a calm and alert state simply because the teacher says, “Tommy, calm down now.”

Does this sound familiar? Are you seeing these behaviors and situations in a classroom of just 20-25 kids? If there’s a child with SPD in that classroom, and statistics tell us there is, the answer is “absolutely.”

So what’s a parent or teacher to do?

In general, kids with sensory issues function better in smaller classrooms because of the lower amount of stimulation. Any time you can reduce sensory stimulation and sudden transitions, it will be easier for all children, but especially those with sensory processing differences, to focus and remain calm and alert. Many parents have found that having their child with SPD in a private school classroom with 8 children is more supportive of him than a public school classroom with 30 children, but then there’s the issue of can you get special educational services (such as OT for sensory issues) paid for by the school district if your child is in private school? It’s very difficult.

Small private school classroom but no services, large public school classroom but services, including in-class services? It’s a tough call for many parents. Whatever choices you have before you, do check out the information on my website, SensorySmartParent.com, about helping your child at school (start HERE) and the chapter on Advocating for Your Child at School in Raising a Sensory Smart Child. There are MANY ways to make classrooms more user friendly for children with sensory processing issues, and many of the accommodations are simple, low cost, or no cost. You can begin to set up a sensory diet for your child today (hopefully, with the help of a sensory smart OT). No child should be put in “sensory hell.”

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Filed under anxiety, auditory processing disorders, autism and sensory issues, back to school for sensory kids, books on SPD, boys in school, schools, sensory diet at school, sensory integration dysfunction, sensory processing disorder, sensory processing disorder symptoms, sensory seeking, SPD and auditory, special education