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STUTTERING
 
MANUAL ON LOGOPEDIA
(speech-language therapy)
 
Dr. of Medicine, Professor
Lidia I. Beliakova,
Dr. of Logopedia, Associated Professor
Elena A. D'yakova
(319 p., 2nd edition, Moscow, 2001)
 
Part 1.
Basic mechanism of oral speech.


1.1.Anatomical and physiological mechanism of speech.
(page 8)
 
Breathing, phonic and articulatory parts of periferic speech apparatus. - Anatomy and physiology breathing; energy basis of speech. - Anatomy and physiology of phonic part; registers of voice, effect of resonance.- Anatomy and physiology of articulatory part. Articulation of vowels and consonants.- Conception of speech articulation.- Nervous system and functioning of speech apparatus.- Periferic_and central nervous systems.- Brain's structures connected with speech.- Right and left hemispheres.- Central nervous system; 3 blocks in the activity of brain.( A. K. Lurija)
1.2 Acoustical characteristics of oral speech.
(page 21)
 
Prosody.- Acoustical components of intonation.- Tempo- rithmic organization of oral speech.- Syntagma-elementary unit of prosody.-Fluent speech as unified articulatory complex of syntagms, pronounced at one expiration.- Pauses as necessary component of utterance.- Characteristics of pauses.
1.3 Functional system of the act of speech.
(page 26)
 
Speech articulation as psychomotoric and behavioral act.-Functional system of behavioral act, including afferent synthesis. Programming of action on the basis of phylo-and onthogenetical memory, emotions, orientation reflex, dominating motivation and bacuard afferentations.- Useful result of adaptation is as a system-forming factor. (Conception of P. K. Anochin ).- Influence of pathogenetic factors.- Kinestetic and hearing assotiations as organizing factors.- Philogenetic speech memory and inborn program of articulatory motions (first 6 months of life).- Ontogenetic speech memory connected with perseption of the phonems of mother tonque.- Stages of maturing of articulatory and breathing stereotypes.-Specific and nonspecific afferentations in the process of forming of functional system of speech.
1.4. Ontogenesis of speech.
(page 38)
 
Before-speech and after-speech periods in the life of child.- Mastering of words, phrases and monological speech.- Coordination between breathing, phonation and articulation.- Sensitive and hypersensitive grades of speech development-Peculiarities of oral speech of children.- 'Instability' and selective 'insecurity' of speech system under action of different damaging factors.
Part 2.
Stuttering


2.1. Phenomenology and symptomatic of stuttering.
(page 53)
 
Characteristics of facial spasms: type, location, degree.- Linguistic factors, leading to stuttering.- Speech breathing of stutterers.- Speech trikcs of stutterers.- Vegetativ reactions.- Logophobia.- Types of the evolution of stuttering.
2.2. Etiology Of Stuttering.
(page 69)
 
Factors preceding stuttering and contributing to its appearance. 1) age of child, 2) condition of central nervous system, 3) individual pecularities of the speech ontogenese process, 4) pecularities of the formation of functional brain asymmetry, 5) psychical trauma, 6) genetical factor, 7) sex demorphism.
2.3. Clinical, psychological and pedagogical characteristics of stutterers.
(page 75)
 
Two clinical forms of stuttering - neurotical and pseudoneurotical .- Neuroses-psychogenic, reactive and functional illness, appearing under the influence of stress factor of different strength and continuance.- Stinging and chronic psychical traums.- Pseudoneurotical conditions as consequence of the organic damages in central nervous system.

2.3.1. Characteristics of stutterers with neurotic form of speech patology.
(page 76)
 
Early speech development and presence of developed phrase speech before the beginning of stuttering.- Presence of characterological pecularities: impressibility, state of uneasiness etc.- Chiefly psychogenetic beginning of speech pathology: acute or chronic psychic traumatism, even in the age of 2- 6 years.- Greater dependence of the heaviness of spasmodic stutterings on the emotional state and conditions of speech intercourse.- Possibility of fluent speech in special conditions (loneliness, emotional comfort, when attention is turned off from speech process etc.)
2.3.2. Characteristics of stutterers with pseudoneurotic form of stuttering. (page 90)
 
Retarded speech development.- Different degrees of pathology in motoric functions of organism.- Appearance spasmodic stummering in the age of 3 - 4 years.- Gradual evolution of stuttering independently of any psycho-traumatic situation. Attention to the process of talking facilitate the speech , physical or psychical tiredness makes the speech worse. Mixed forms of stuttering.

2.4. Phsycholinguistical analysis of the speech of stutterers
(page 105)
 
Children with neurotic form of stuttering.- Discrepancy between high level of speech and low level of using it in different situations of intercourse.- Children with quasineurotic form of stuttering.- Difficulties in the transmission by speech the sense program of text.- Limited word resource.- Sentences are structurally incomplete, grammatical connections are limited.- Phonematic perception and articulation are of disartric type.- Disturbances in forming of monologic speech, connected with deficiency of language capability.- Common psycholinguistic characteristics of adult stutterers of neurotic and pseudoneurotic type.- Preferance to high-frequency words, repetitions; amourphousness of the structure of utterance , pecularities of intonation, uncorrect use of pauses.- Damages in process of inner-speech planning. Among the pseudoneurotic stutterers this features appear in a more rough form.
2.5. Pathogenetic mechanisms of stuttering
(page 111)
 
Clinical, psychological, psycho- linguistic investigations of stuttering.- Neurotic stuttering.- Reaction on stress.- Appearance of depression center in structures of brain, connected with emotions.- Innate inclination to pathologic reactions.- High level of the development of language and inadequate development of articulatory ( motoric ) means.- Pathological functional system of speech (FSS) suppresses normal FSS, and stuttering appears.- Intensification of emotional exitation contributes to strengthening of pathologic FSS.- In conditions of emotional comfort pathologic FSS may be suppressed by normal FSS; and the speech becomes fluent.- For teenagers this picture is complicated by the appearance of logofobia, i. e. secondary emotional dominant.- Stutterers with pseudoneurotic form of speech pathology are discerned by the presence of residual traces of early diffuse organic affection of brain.- Motoric weakness,(discoordination, damaged sense of temp and rythm, frequent hyperkineses), low level of active attention and memory.- Pathological activity in strio- polidaric structures of brain and relaxing influence of big hemispheres.- Retardation of speech development , the pronounciation is incorrect-Spasmodic stummerings firstly appeare in connection with the development of phrase speech, i. e. when the speech- language task is complicating.- Evidences of decompensation of regulating mechanisms of brain. The therapy of stuttering is conducted in accordance with these mechanisms of disorder.
Part 3.
The main trends in complex psychological and pedagogical rehabilitation of stutterers.

 
Presently in Russia a complex approach is used to overcome stuttering. This approach is based on a system of strictly differentiated but coordinated work of different specialists : speech therapist, psychologist, physicians of different profiles (including the obligatory psychoneurologist for children and psychotherapist for adults), logorithmist, educator (for children), specialist of physical activity and some other specialists.

The complex approach concerns three basic issues:

The first issue is forming of the habit of the stable fluent speech. We define a fluent speech as the possibility to pronounce each sintagma in the time of single expiration, without pauses and repetitions, in the process of a continual articulation. The forming of the habit of fluent speech is mainly carried out by speech therapist. It involves the using of number of special techniques, mainly during the speech training lessons or logorithmic lessons.

The second issue is the upbringing of personality of the stutterer. It is mainly carried out by psychotherapist, and also by psychologist, in the course of psychotherapy, psychological training and functional training. The specialists aim to form the social activity of the stutterer while changing his attitude to himself as a personality and as a partner in communication as well as changing of his attitude to his speech defect.

The third issue is the prevention of relapses of stuttering. It requires the general medical and health-sustaining work and the maintenance of stable fluent speech by the repeated courses of rehabilitation.

In Russia there are several systems of rehabilitation of stutterers [Vlasova, 1983; Nekrasova, 1975; Arutyunian, 1993; Schklovsky, 1994; Beliakova & D'yakova, 1998; etc.] .

Each system offers it's own way in solving above-mentioned problems.

The share of each technique is specified by speech therapist, depending on the results of assessment of stutterers.
3.1. Psychological and pedagogical assessment of stutterers
(page 130)
 
Complex assessement by therapist, speech pathologist and logorithmist.- General and speech anamnes state of intellect, general motorics, movement of fingers of hands ; mimical and articulatory motorics.- Speech assessement.- Pecularities in assessement of children, teenagers and adults.
3.2. Different techniques information of fluent speech among stutterrers
(page 145)
 
(Proceedings of the Third World Congress of Fluency Disorderes in Nyborg, Denmark, 2000)
1 .SPARING SPEECH REGIME
 
As a rule, speech therapy begins with using so-called " sparing speech regime", directed to the suppression of pathological speech stereotypes. It includes general health-supporting measures and "speech limiting regime" or "mute regime". The stutterers are protected from all physical and psychical overloads. We also try to limit the verbal production of stutterers. Concerning children, only very simple forms of speech not leading to stuttering are used: whisper, one-word questions and answers, speech conjugated with adult speech. Teenagers and adults during these regimes may practice total silence, using nonverbal means of communication (gesticulation, facial expression etc.). The different games to develop non-verbal means of communications are used. This period may have different duration according to the system of rehabilitation: from 2-3 days to 2-3 weeks.
2. FORMING OF THE CORRECT SPEECH BREATHING
 
This includes the following stages:

1) widening the physiological possibilities of breath apparatus, i.e. training of the diaphragmal breath;

2) forming the prolonged phonic expiration. Training begins with prolonged pronouncing of vowels. This teaches the stutterers to accurately distribute the expiring air, to regulate consciously the duration of expiration. This is the first step to the forming of speech breath.

3) Forming of speech breathing. The exercises include specially selected syllables, words and plirases. This work is directed to the creation of coordination between the apparatus of breath, voice and articulation. The work on breath - forming has to be systematic and prolonged.
3.FORMING OF RATIONAL HABITS OF VOICE-SUSTAINING AND VOICE- ATTACK
 
This technique is directed to the taking off local tensions in the voice apparatus and disphonic disorders and to the forming of coalescent or noninterupted articulation.

The stutterers are taught the rational form of voice - attack, i.e. how to start "softly" using the voice and involve the low -breast resonator in speech. As a result, the tension from the vocal cords is taken off, the voice becomes sonorous and resonant, rich in obertones. These exercises, combined with diaphragmatic breathing, helps to "fix" and support the voice.

Then the stutterers are taught the voice - sustaining i. e. how to pronounce the long row of vowels in a noninterupted manner, incessantly articulating and using one expiration. This habit is further transferred into the noninterupted pronunciation of syntagma.
4. DEVELOPMENT OF PROSODIC QUALITY OF SPEECH
 
The stutterers learn to express different kinds of intonations. In the beginning they use only gesticulation and facial expressions, then add voice, using a gradually prolonging raw of vowels. The vowels are pronounced with different modulations (silent-loud, lower-higher, imitating the intonations of question, exclamation etc.). Then this training is transferred into syllables, words, and phrases. The next step is to teach stutterers how to devide the text into the rhythmical - intonatation groups . This division leads to forming of articulatory -breathing cycles (according to the syntagmatic division of text).
5. DEVELOPMENT OF COORDINATION AND RHYTHMIZATION OF MOVEMENTS.
 
This logopedic technique is devoted to the normalization of motoric functions of stutterers. It includes:

1) The development of coordination and exactness in the movements of hands and legs, of fingers and articulatory movements; 2) The development of the tempo-rhythm sense, while performing speech and non-speech movements. The movement exercises are combined with speech and musical accompaniment. Rhythmization of movements reflects positively on the rhythm of speech. One of the important methods is working out of rhythmic speech articulations in combination with additional stimulation (by movements of hand). It is well known that rhythmization of movement changes biorithmical activity of brain, which, in its turn, positively influences the synchronizing activity of speech apparatus. Especially effective to the creation of the habit of fluent speech is to use rhythmic movements of the leading hand ore fingers in combination with rhythmic pronunciation of syllables or words. Rhythmization of speech may be intensified by using acoustical and/or visual stimulation. Velocity and tempo of speech articulations have to be chosen for each stutterers individually and bring the sense of comfort.
6. REGULATION OF EMOTIONAL STATE
 
The basic method of regulation of the stutterer's emotional state is the method, based on arbitrary changing of muscle tension, i.e.autogenes training (AT), created by J.H. Schultz . The foundation of AT is muscle relaxation and arbitrary regulation of vegetative functions of nervous system. In Russia the specialized variants of AT for stutterers are used. As a rule the method of conducting AT essentially depends on stutterer's age. Children of a preschool age, are taught only the basics of muscle relaxation; to teenagers and adults the full course of AT is recommended. At the background of AT the active speech correcting work is carried on. As a result, the bilateral connection based on reflexes, between the emotional state of relaxftion and fluent speech, is created. The habits of relaxation and fluent speech, acquired in the process of AT, are fixed by special functional training in the process of real communication.

We also use manual relaxating massage of muscles, connected with articulatory, vocal and breathing apparatuses, and massage of biological active points.
7. DEVELOPMENT OF INTRASPEECH PLANNING.
 
The work connected with the development of the planning function of speech, is also included in the correctional process. Such a work begins with teaching the stutterers to say phrases mutely (in a silent manner, without a voice). This "inner speech" gives to the stutterer the possibility to choose the strategy of utterance, the necessary words and grammatical constructions, before they use the loud speech. They are taught not only to "hold the pauses" in sintagmatically correct places, but also actively formulate the following part of utterance.

The exercises with gradually complicating language material are used here. These are conjugated speech (i.e a speech, articulated together with speech-therapist ), reflected speech (i.e. repetition of phrases, articulated by speech-therapist); answers to the questions, connected with some pictures, descriptions of some pictures or subjects, related to some situation. The final stage is spontaneous and monologues speech of stutterer in situation of a game, and further - in the situation of a real communication.

All the enumerated logopedic techniques have one aim: to work out a fluent speech. These techniques are taught almost simultaneously, they are directed to the coordination and unifying of psycho - physiological parameters, which constitute oral speech. In such a way, dynamics of the teaching of fluent speech consist not in a successive application of this or that technique but in a gradual complication of speech exercises: from pronouncing of isolated sounds to the context speech.

All the techniques, described above, are used in rehabilitation course with stutterers in different combinations. It is evident that there can't be the one system of application of logopedic techniques with predomination of this or that techniques and the succession of their application, recommended to all stutterers. But in all cases the work with all stutterers as a rule begins with practice of sparing or mild regime, and ends with the development of the planning function of speech.

The volume of work with each technique and methodic depends on the age of a stutterer and clinical form of stuttering. In Russia the concept of stuttering as of a systematic psycho- neurological disorder is spread. In accordance with clinical symptoms of this disorder two main forms are distinguished: neurotical and pseudo- neurotical This determines the clinical content of pathology, character of fluency disturbances, the level of speech development of the children, psycholinguistic characteristics of speech, possibility of communication, the peculiarities of personality and the specification of correctional work.

The up- to- date ideas about functional system of speech permit to select the main link of pathogenetic mechanisms, which lead to stuttering. For neurotical form of stuttering this link structurally and functionally is connected with mechanisms of (human) emotions. For pseudo- neurotical form of stuttering the main link is connected with disturbances of basic mechanisms of speech function formation, as a result of some organic defect in central nervous system. This concept concerning two different forms of stuttering, determines the direction, character and efficiency of each of the proposed above rehabilitation measures.

Stutterers with neurotical form of stuttering quickly master the above techniques. Switching attention on intonation essentially improves the fluency of their speech. One of the most effective techniques with neurotical stutterers is regulation of the emotional state of patients. But automatic use of new habits of speech demands from the stutterers long training and strict succession of exercises. In the opposite case the good result may quickly disappear.

When the stuttering is pseudo- neurotic, the habits of fluent speech are mastered also with difficulty. In the process of exercises it is necessary not only to explain but to show many times how to do them, using different kinds of control (acoustical, kinestethic- by hand, visual, using of computer program "Visual speech" etc.), especially when training the speech rhythms. The working out of the new speech stereotypes has to be systematic and long. As for pseudo-neurotic stutterers the most important is the development of the planning function of speech.
3.3 Correction of the personality of stutterer
(p. 196)
 
Stuttering essentially reflects on the personality of stutterer.- Pathological forms of behavior.- General psychotherapy.- Particular psychotherapy .- Suggestive psychotherapy.- Autogenic training.- Collective psychotherapy.- Games.
3.4. Systems of complex psychological and pedagogical rehabilitation.
(p. 206)
 
Complex systems of rehabilitation for preschool children, teenagers and adults.
3.5. Preventing of stuttering.
(p. 224)
 
Preventing of the appearance of stuttering.- Prevention of chronification and relapses in stuttering.- Prevention of the disturbances of cotial adaptation.

Part 4.
'Stuttering'- organization of the learning process for students.


4.1. Business games.
(p. 240)

4.2. Assessement by speech therapist of stuttering child.'.- 'Logopedic lesson with stutterers'.- 'Conversation with mother of stuttering child' etc.

4.3. Independent work of students. (p. 242)

4.4. Control questions to the course 'Stuttering'. (p.254)

Appendix. Practical materials, used in work with stutterers.
Appendix 1. Methods of activization of nonverbal intercourse. (p.252)
Appendix 2. Specialized autogenic training for adults. (p.259)
Appendix 3. Exercises on the formation speech breathing for children, teenagers and adults. (p. 270)
Appendix 4. Specialized (paradoxical) breathing gymnastics. (p.275)
Appendix 5. Exercises for the trainihg of voice. (p. 281)
Appendix 6. Exercises for the logarithmic lessons. (p. 286)
Appendix 7. Special logopedic massage for stutterers. (p.297)

Literature.
(p.312)

© Дьякова Е.А. Текст и фотоматериалы, 2006-2014.
© Блосфильд Е.О. Дизайн и разработка, 2006-2014.