University of Michigan Childhood Stuttering and Related Disorders Discussion - Nursing Essays
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University of Michigan Childhood Stuttering and Related Disorders Discussion

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March 22nd, 2024
Home Nursing Questions University of Michigan Childhood Stuttering and Related Disorders Discussion

At the end of each Module, use this forum to discuss what you have found interesting from the module.  Right a page of reflection each on each model.Three models in total and expecting three pages. A component of the Final Project is a final reflection paper and this discussion forum may help you reflect on your knowledge development for our student learning outcomes.

The following Student Learning Outcomes may be used as trigger questions for discussion postings – but feel free to discuss any topic related to our course or raise questions and/or comment on content.   Also if you find a helpful resource that you would like to share (i.e., website, book) please share here.

Describe the onset and development of childhood stuttering ASHA IV-C, V-B

Describe and be able to support the factors that contribute cause or promote stuttering. ASHA IV-C

  • Instruct a set of interview questions to be used during the collection of a child’s case history and anticipate the relevance of potential client answers. ASHA IV-D
  • Correctly differentiate normal from abnormal disfluencies during a live conversational speech sample. ASHA IV-C, IV-D
  • Construct an evaluation outline/table for a child with a suspected fluency disorder. Include how each listed procedure may lead to a diagnosis of “normal”, “stuttering-like” speech or other fluency disorders. ASHA IV-D
  • Measure both qualitatively and quantitatively normal and abnormal disfluencies contained in a conversational speech sample ASHA IV-D
  • Construct a treatment plan (outline) for a child who stutters. Include information appropriate to share with family members and other caregivers/teachers.   ASHA IV-D, IV-F
  • Demonstrate the following primary fluency facilitating techniques: easy, relaxed approach – slow movement (easy onsets, soft touches, smooth transitions and reduced rate) along with stutter more fluently techniques. ASHA V-A, V-B

    • Chapter 6
    Theories about Stuttering
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Theories about Stuttering: Overview
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    Theoretical Perspectives about
    Constitutional Factors in Stuttering
    • Stuttering as a disorder of brain organization
    – Orton & Travis (1931): lack of hemispheric dominance
    leads to mistiming of muscle activation = stuttering
    – Geschwind & Galaburda (1985): left-hemisphere delay,
    right-hemisphere dominance → inefficient for speech =
    stuttering
    – Webster (1983): left-hemisphere SMA, responsible for
    initiation, planning, and sequencing of movement, is
    vulnerable to disruption = stuttering
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    Stuttering as a Disorder of Timing
    • Van Riper (1982): disruption of timing of muscle
    sequencing = stuttering
    • Kent (1994): deficit in central timing that regulates
    speech production and integrates left-brain segmental
    and right-brain supra-segmental aspects of speech
    production; this deficit produces stuttering
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    Stuttering as a Reduced Capacity for
    Internal Modeling
    • Neilson & Neilson (1987):
    – Children learn to talk by hearing the sounds of their
    language and developing a “model” of how to move their
    articulators to make the sounds they desire
    – They use auditory feedback as they babble and talk to
    update their internal model as their speech mechanism
    changes size as they grow
    – Stuttering is thought to result from a weakness in using
    the internal model to transform the child’s plans for the
    sounds of a word into motor commands leading to
    movements producing speech (see next slide)
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    Stuttering as a Reduced Capacity for
    Internal Modeling (cont’d)
    Weakness here in
    transforming desired
    perceptual (auditory) targets
    into motor commands
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    Stuttering as a Language Production
    Deficit
    • Wingate (1988); Perkins, Kent, and Curlee (1991); and
    Kolk and Postma (1997) have suggested stuttering
    results from deficits in planning and assembling the units
    for language production
    • Kolk and Postma have a very specific model
    – Language production is monitored internally
    – If problem in phoneme plan is in error, production halts
    – Repetitions, prolongations, and blacks can all be explained
    by different responses to an error
    – Analogy can be made of a bicycle production plant (see
    next slide)
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    Kolk & Postma (1997) Analogy
    Analogy to putting together the
    components of language production
    Analogy to internal checking of
    language components before word or
    sentence is produced
    Stuttering results here if internal
    checkpoint detects error, and speaker
    retries, prolongs, or pushes ahead
    despite error
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    Stuttering as a Multifactorial, Dynamic
    Disorder
    • Anne Smith and her colleagues (e.g., Smith & Kelly,
    1997) suggest there is no one cause of stuttering, but an
    array of factors contributing to it
    • The problem is to find the relevant factors and discover
    how they interact
    • They see stuttering as “dynamic” because behaviors
    (repetitions, prolongations, blocks) are only surface
    features of an ever-changing process
    • Examples of the underlying factors are linguistic load,
    speech motor instability, emotional stress, etc.
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    Stuttering as a Multifactorial, Dynamic
    Disorder (cont’d)
    • Physiological tremor: A factor that may make the initial
    disorder more severe
    – A number of researchers (Fibiger, 1971; Smith, 1989; Van
    Riper, 1982) conclude that tremors are an important
    element in more advanced stuttering
    – Kelly, Smith, and Goffman (1995) found tremors in older
    children who stuttered, but not younger children
    – They further suggested that tremors may be evoked or
    amplified by emotion
    • Thus, tremors may develop when speech or stuttering is
    associated with emotion. This may occur when stuttering
    has been associated with fear, embarrassment, or other
    negative emotions
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    Theoretical Perspectives on
    Developmental and Environmental Factors
    • Diagnosogenic Theory
    –
    Wendell Johnson (Johnson et al., 1942) proposed that stuttering may
    result when parents misdiagnose their child’s normal disfluencies as
    stuttering
    –
    Johnson thought children who were misdiagnosed by their parents or
    other listeners developed tension and hesitation in their speech in an
    effort to avoid disfluencies
    –
    Collected data to try to prove his theory:
    • Directed a master’s thesis by Mary Tudor that used children at an orphanage to
    test the hypothesis that normal-speaking children who were misdiagnosed as
    stutterers would develop stuttering (Tudor, 1939)
    • Interviewed parents of normally disfluent children and parents of stuttering
    children to show that their first disfluencies (at onset) were very similar
    • Other researchers (e.g., McDearmon, 1969) interpreted the same data to
    suggest normally disfluent children and stuttering children had very different
    disfluencies at onset
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    Diagnosogenic Theory
    • Disfluency types (at onset) of children thought to be
    normally disfluent versus children thought to be
    stuttering
    Are the disfluencies
    of the nonstuttering
    children different
    in type than the
    disfluencies of the
    stuttering group?
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    Communicative Failure and Anticipatory
    Struggle
    • Oliver Bloodstein (1987; 1997) proposed that in many
    cases, stuttering begins when a child finds talking
    difficult
    Table 6.2 Experiences That May Make Some Children Believe
    Speaking is Difficult
    1. Normal disfluencies criticized by significant listeners
    2. Delay in speech or language development
    3. Speech or language disorders, including articulation problems, word-finding
    difficulty, cerebral palsy, and voice problems
    4. Difficult or traumatic experience reading aloud in school
    5. Cluttering, especially if listeners frequently say “slow down” or “what?”
    6. Emotionally traumatic events during which child tries to speak
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    Communicative Failure and Anticipatory
    Struggle (cont’d)
    • Anticipated difficulty in talking produces tension and
    fragmentation of speech
    • This leads to more frustration and failure in
    communication, which increases anticipation of difficulty
    More anticipation
    of difficulty
    More stuttering
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    Capacities and Demands
    • Sheehan (1970, 1975); Andrews et al. (1982); and
    Starkweather (1987): stuttering may emerge when
    child’s capacities for fluency are overwhelmed by
    demands
    • Examples
    – Capacities: Child’s ability to plan and program for
    language while making fast, coordinated movements for
    speech
    – Demands: Some children’s advanced conceptual and
    linguistic abilities; models of rapid and complex speech
    and language in environment; emotional stress on child
    from environment
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    Capacities and Demands (cont’d)
    • Capacities and demands theory leads to treatment based
    on reducing demands and, when possible, increasing
    capacities
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    An Integration of Perspectives on
    Stuttering
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    An Integration of Perspectives on
    Stuttering (cont’d)
    • Two-stage model of stuttering
    – Stuttering may often develop in two stages
    – Primary stage is simpler disfluencies that are the result of
    how the brain handles speech and language production
    – Secondary stage is a more complex pattern that is the
    result of the child’s and environment’s reaction to
    disfluencies
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    A Perspective on Primary Stuttering
    • Evidence reviewed in Chapters 2 and 3 suggests that
    stuttering often emerges from deficits in left-hemisphere
    processing for speech and language
    • Such deficits may result in primary stuttering because
    neural circuits for speech and language may be:
    – Working in an “underdeveloped” area
    – Reorganized and moved to an area not naturally suited to
    rapid speech and language functions (e.g., right
    hemisphere)
    – Reorganized so that major functions are at some distance
    from each other
    – Slower in processing because of less dense pathways
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    A Perspective on Primary Stuttering
    (cont’d)
    • Any of these arrangements may make these circuits both
    inefficient and vulnerable to disruption
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    A Perspective on Primary Stuttering
    (cont’d)
    • How does this inefficiency lead to primary stuttering?
    • Many existing theories suggest dyssynchrony, at some level, is
    responsible for repetitions, prolongations, or blocks (e.g., Kent,
    1984; Perkins, Kent, & Curlee, 1991; Webster, 1997; Van Riper,
    1982)
    • Dyssynchrony may mean that units for rapid speech and language
    production are not assembled accurately or rapidly enough
    • Repetitions may result from repeated utterance of unit that is
    ready, while waiting for next (transitional) element that is not
    ready
    • Prolongations may result from maintaining voice or airflow of first
    unit while waiting for next (transitional) element that is not ready
    • Blocks may result from attempt to go ahead despite next
    (transitional) element not being ready
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    Perspectives on Secondary Stuttering
    • Some children who begin to stutter may have more “reactive”
    temperaments
    • This reactivity may cause them to respond to unpleasant or
    threatening stimuli by increasing tension, speeding up, escaping,
    and/or avoiding (cf. Gray, 1987, re: behavioral inhibition)
    • These reactions may constitute the components of secondary
    stuttering (i.e., increased tension, escape, and avoidance)
    • These temperament traits may be (like the predisposition to
    primary stuttering) the result of inheritance or brain injury
    • Because a reactive temperament causes emotional arousal, events
    that caused the emotion will be more deeply learned (learning is
    enhanced by emotion)
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    Perspectives on Secondary Stuttering
    (cont’d)
    • Therefore, children who react to primary stuttering with increased
    tension, escape, and avoidance behaviors will be more likely to
    continue these secondary behaviors long term (cf. Brutten &
    Shoemaker, 1969)
    • Behaviors associated with high emotion are likely to be retained
    permanently (Ayres, 1998)
    • Therefore, treatment of those with secondary stuttering may be
    most effective if coping skills are taught (e.g., gentle onsets, slow
    rate, light contacts)
    • Emotional conditioning may result in cognitive changes so that
    cognitive therapy (examining habitual thought patterns) may be a
    useful adjunct to behavioral therapy
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    Two (or More) Predispositions for
    Stuttering?
    • Primary stuttering may be the result of an anomalous
    organization of speech and language networks in the
    brain, which can resolve via maturation or reorganization
    • Secondary stuttering may be the result of additional
    factors – perhaps a predisposition for a reactive
    temperament
    • Some support for the existence of two predispositions
    come from genetic research
    • Persistent and recovered stutterers have similar genetic
    makeup; possible that persistent stutterers have some
    additional genetic predisposition (Ambrose, Cox, & Yairi,
    1997)
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    Interactions with Developmental Factors
    • Interaction with speech and language development
    – Child with primary stuttering may be able to recover if
    speech and language demands are low or language ability
    is strong
    – Another child with primary stuttering may not recover so
    easily if language development demands are high or child
    is not strong in speech and language
    • Interaction with brain maturation
    – Some individuals will recover early because they have
    greater neural plasticity
    – Females appear to have greater organizational plasticity
    and more widely distributed language centers
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    Interactions with Developmental Factors
    (cont’d)
    • Interactions with social-emotional development
    – As social-emotional development creates stress on
    children, those with more inhibited temperaments may be
    more likely to have more negative reactions to difficulty
    with speech
    – Children who manifest primary stuttering may develop
    secondary stuttering as social-emotional pressures
    increase (e.g., beginning school)
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    Interactions with Environmental Factors
    • Primary stuttering/anomalous neural networks
    – An environment that is slow-paced and accepting may be
    more likely to give children freedom to develop fluency at
    their own pace
    – An environment that is fast-paced and demanding may be
    more likely to delay recovery
    • Secondary stuttering/reactive temperament
    – Families can help reactive child develop skills to manage
    stress, thus decreasing likelihood of stuttering becoming
    persistent
    – Some life events (e.g., divorce, hospitalization) can
    increase vulnerable children’s reactivity, thus increasing
    likelihood of stuttering becoming persistent
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    Implications for Treatment
    • Models of speech and language with slow rate and
    pausing may facilitate fluency in child with primary
    stuttering (Guitar et al., 1992)
    • Families can encourage less inhibited temperament by
    encouraging approach behaviors (Calkins & Fox, 1994)
    • Fluency skills-oriented therapies appear to reorganize
    networks for speech and language production (De Nil et
    al., 2003; Neumann et al., 2005)
    • More research needed on brain changes associated with
    relapse versus fluency maintenance after treatment
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    Accounting for the Evidence
    • Stuttering in all cultures; human biology implicated
    • Stuttering is low-incidence disorder: depends on cooccurrence of several factors
    • Evidence about stuttering at onset
    – Onset occurs beyond the one-word stage, when more
    complex sentences are being produced
    – This may be the case because the anomalous, inefficient
    neural networks for speech and language are not taxed to
    the breaking point by single words; however, complex
    utterances require the time-dependent integration of
    phonology, syntax, semantics, and prosody, which may
    stress the system
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    Accounting for the Evidence (cont’d)
    • Evidence about stuttering at onset (cont’d)
    – On rare occasions, onset is characterized by tension,
    struggle, and avoidance; this may occur in children whose
    temperament is more reactive
    – The characteristics of stuttering: repetitions,
    prolongations, and blocks may be the result of attempting
    to push ahead with speech production despite the fact that
    some required components are not ready in a timely
    fashion
    • Evidence about stuttering as it develops
    – Course of development of stuttering may be in part
    determined by development of emotional reactivity,
    changing environmental situations, and changing internal
    and external speech and language production demands
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    Accounting for the Evidence (cont’d)
    • Evidence of ameliorating conditions:
    – Many of these conditions provide increased time or
    external stimulus which could help the brain coordinate
    the components of speech and language production (e.g.,
    singing, speaking in time to a metronome)
    – Some conditions may create an environment in which the
    stutterer’s nervous system is less reactive and hence
    secondary reactions to expectations of stuttering are less
    (e.g., speaking when alone, speaking to a child, speaking
    when relaxed)
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    Accounting for the Evidence (cont’d)
    • Evidence about deficits in stutterers’ performance
    – The evidence that many stutterers perform more poorly
    than nonstutterers in tests of reaction time, speech
    perception, temporal perception, sequencing, and
    tracking, as well as on school achievement tests, may
    reflect inefficient sensory-motor processing
    – Inefficient sensory-motor processing may be the product
    of the anomalous neural network organization that is
    hypothesized to be the basis of primary stuttering
    – Individuals who stutter may have a range of sensorymotor processing ability, from very great deficits to mild
    deficits; this may be reflected in the wide range of
    performances in any large group of stutterers assessed on
    sensory or motor tasks
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    Chapter 4
    Developmental, Environmental, and Learning
    Factors in Stuttering
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    Overview
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    Developmental Factors
    • Children must deal with limited neural resources handling
    a multitude of tasks
    • Physical and motor development
    – Motor and cognitive development compete for cerebral
    resources
    – Rapid developmental changes in vocal tract stress the
    development of speech
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    Speech and Language Development
    • Stuttering seems to have its most frequent onset when
    the child is mastering more complex language
    • Children predisposed to stuttering may have deficits in
    areas responsible for planning and production of speech
    and language
    • Rapid speech and language development may stress
    these weak areas, resulting in stuttering
    • Some children may develop stuttering as a response to
    extra difficulty because of a speech or language delay
    and the stress it puts on speech production
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    Cognitive Development
    • Intensive cognitive development may compete with
    fluency
    • The “ups” and “downs” in a child’s fluency may reflect
    spurts of cognitive development
    • After age 3, children may be self-conscious enough to
    have negative emotions about stuttering
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    Social and Emotional Development
    • Emotional arousal increases stuttering and normal
    disfluency
    • Emotional stress during childhood may trigger or worsen
    stuttering
    • Some children who stutter—because of a sensitive
    temperament—may be more vulnerable to normal
    stresses of childhood
    • Individuals who stutter appear to be normal in terms of
    psychosocial traits
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    Environmental Factors
    • Environmental factors may interact with developmental
    factors to trigger or worsen stuttering
    • Parents
    – Research: Mixed results about whether parents of
    stutterers are more anxious, etc.
    – Theory: Children with vulnerable temperament may have
    inherited it from one or both parents, thus parents may be
    perfectionistic, anxious, etc.
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    Speech and Language Environment
    • Research unclear: Do families of kids who stutter have
    stressful speech and language models?
    • Speculation about some variables causing stress for vulnerable
    children:
    Table 4.1 Possible Speech and Language Stresses
    Stressful Adult Speech Models
    Rapid speech rate
    Complex syntax
    Polysyllabic vocabulary
    Use of two languages in
    home
    Stressful Speaking Situations for Children
    Competition for speaking
    Hurried when speaking
    Frequent interruptions
    Frequent questions
    Demand for display
    speech
    Excited when speaking
    Loss of listener attention
    Many things to say
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    Clinical Implications
    • Children who stutter may be helped by making
    communication easier.
    – More one-on-one time when parent can listen
    – Slower speech rate
    – Language complexity not too far above child’s level
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    Life Events
    • Stressful life events may precipitate or worsen stuttering
    in some children
    Table 4.2 Stressful Life Events That May Increase a Child’s Disfluency
    The child’s family moves to a new house, a new neighborhood or a new city.
    The child’s parents separate or divorce.
    A family member dies.
    A family member is hospitalized.
    The child is hospitalized.
    A parent loses his or her job.
    An additional person comes to live in the house.
    One or both parents go away frequently or for a long period of time.
    Holidays or visits occur which cause a change in routine, excitement, or
    anxiety.
    A discipline problem involving the child.
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    Learning Factors: Classical Conditioning
    Begins with two things naturally
    associated
    Then a neutral stimulus is added.
    After repeated associations,
    previously neutral stimulus elicits
    response
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    Classical Conditioning of Stuttering
    • Stuttering elicits feelings of dread and tightening of
    speech muscles
    • Stuttering (with accompanying dread and muscle
    tension) occurs repeatedly on the phone (previously
    neutral)
    • Phone elicits dread and muscle tension
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    An Example of Classical
    Conditioning and Stuttering
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    Operant Conditioning
    • If behavior is followed by reward, it increases
    –
    Example: Parent says “good talking” after child says five fluent
    sentences; child’s fluency will increase
    • If behavior is followed by punishment, it decreases
    –
    Example: Parent says “Can you say ‘truck’ again?” after child
    stutters; child’s stuttering will decrease
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    Operant Conditioning (cont’d)
    • If a behavior reduces negative stimulation, it is “negative
    reinforcement” or escape, and it increases the behavior
    “I went to N-N-N…the Big
    Apple”
    In this example, the young man “escapes from the stutter
    on “N-N-N” by substituting “the Big Apple” for “New York;”
    head nod is also an escape
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    Avoidance Conditioning
    • Anticipating a stutter and doing something to keep it
    from happening
    “I went to um…um…um…New York.”
    • In this case, he avoids stuttering on the feared word,
    “New York,” by saying “um” several times.
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    Clinical Implications
    • To deal with classical conditioning, you need to:
    – Decondition (associate behavior with neutral stimulus) and
    • Have client keep stuttering until fear is gone (no negative
    stimulus)
    – Countercondition (associate behavior with positive
    stimulus) what has been classically conditioned
    • Have client stutter and receive praise for keeping it going
    (positive stimulus)
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    Clinical Implications (cont’d)
    • To deal with operant conditioning, you need to:
    – Stop reward for unwanted behavior
    • Have client not release (reward denied) word immediately
    after tense squeeze, head nod, eye blink, or other escape
    behavior
    – Start reward for wanted behavior
    • Have client stutter to easy prolongation before release
    (reward given)
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    Clinical Implications (cont’d)
    • To deal with avoidance conditioning, you need to:
    – Decrease fear of stuttering
    • If client avoids by using “um” as in “My name is
    um…um…umBarry,” have client practice staying in stuttering
    on “Barry” (reward this) and also learn to reduce tension and
    release word easily
    – Reward non-avoidance
    • Have client practice saying “My name is Barry” without the
    “um” but with an easier stutter on “Barry” (reward this
    emphatically!)
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    Language Factors
    • Brown showed that adults who stutter do so more
    frequently on:
    – Consonants
    – Sounds in word-initial position
    – Sounds in contextual speech
    – Nouns, verbs, adjectives, and adverbs
    – Longer words
    – Words at beginnings of sentences
    – Stressed syllables
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    Language Factors (cont’d)
    • Loci and frequency of stuttering are different in preschool
    children
    • Stuttering in preschool children occurs most frequently
    on pronouns and conjunctions (these occur frequently at
    the beginning of utterances in young children)
    • Stuttering most frequent as repetitions of parts of words
    and single-syllable words in sentence-initial position
    • In summary, because stuttering in preschoolers tends to
    occur at beginning of syntactic units, the trigger seems
    to be linguistic planning and preparation
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    Fluency-Inducing Conditions
    • Many conditions have been found which reduce or
    eliminate stuttering. These include speaking:
    –
    When alone, when relaxed
    –
    In unison with another speaker
    –
    To an animal or infant
    –
    In time or a rhythmic stimulus or when singing, in a different
    dialect
    –
    While simultaneously writing, while swearing
    –
    In a slow, prolonged manner
    –
    Under loud masking noise, while listening to delayed auditory
    feedback
    –
    When shadowing another speaker, when reinforced for fluent
    speech
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    Fluency-Inducing Conditions (cont’d)
    • Fluency-inducing conditions have been explained as
    resulting from reduced demands on speech-motor control
    and language formation (Andrews et al., 1982)
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    The Facts about Stuttering Imply the
    Following
    • Stuttering is an inherited or congenital disorder
    • It first appears when children are learning the complex
    coordinations of spoken language
    • It emerges in those children whose speech production
    system is vulnerable to disruption by competing demands
    of language, cognition, and emotion
    • After it emerges, it becomes persistent in some children
    – perhaps those whose stuttering arouses substantial
    negative emotion which leads to a variety of learned
    behaviors
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    A Model of Stuttering
    • Disorder of neuromotor control of speech
    • Influenced by language production
    • Perpetuated by temperament and complex learning, and
    the response of their environment to their speech
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    Chapter 1
    Introduction to Stuttering
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    The Words We Use
    • “People who stutter” preferable to:
    – Stutterer
    – PWS
    • Disfluency
    – “Disfluency” = either normal or abnormal
    – “Disfluency” is preferable to “dysfluency”
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    Do All Cultures Have Stuttering?
    • Yes. Stuttering is ancient and universal.
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    What Causes People to Stutter?
    • The causes of stuttering are not completely understood,
    but scientists believe these are important factors:
    – Genetic and congenital influences
    – Developmental influences
    – Environmental influences
    • Repeated negative emotional experiences with stuttering
    lead to negative feelings and attitudes
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    Factors Contributing to Stuttering
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    Definitions
    • Fluency versus disfluent speech
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    Definitions (cont’d)
    • Starkweather (1980, 1987) suggests that rate and effort
    are critical to fluency
    • Thus, a fluent speaker effortlessly produces speech at a
    rate comfortable to listeners
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    Stuttering: General Description
    • Stuttering = abnormally high frequency and/or duration
    of stoppages in the flow of speech
    • Stuttering also includes speakers’ reactions to stoppages
    • These reactions include behavioral, emotional, and
    cognitive responses to repeated experiences of getting
    stuck while talking
    • Need to distinguish between stuttering and typical
    disfluencies, as well as from neurogenic and psychogenic
    stuttering
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    Core Behaviors
    • Repetitions: May be single-syllable word or part-word
    repetitions
    – Word or syllable may be repeated more than two times,
    li-li-li-like this
    • Prolongations: Sound or airflow continues but
    movement of articulators is stopped
    – Prolongations as short as one-half second may be
    perceived as abnormal
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    Core Behaviors (cont’d)
    • Blocks: inappropriate stoppage of airflow or voicing;
    movement of articulators may be stopped
    – Blocks may occur at any level – respiratory, laryngeal,
    and/or articulatory
    – Blocks may be accompanied by tremors of lips, tongue,
    jaw, and/or laryngeal muscles
    – On average, stutterers stutter on about 10 percent of the
    words while reading
    – On average, stutters last about one second
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    Secondary Behaviors
    • Secondary behaviors are learned behaviors that are
    triggered by the experience of stuttering or the
    anticipation of it
    • Escape behaviors occur when the speaker is stuttering
    and attempts to terminate the stutter and finish the word
    (ex. Eye blinks and head nods)
    • Avoidance behaviors occur when the speaker
    anticipates a stutter and tries to avoid it by, for example,
    changing the word or saying “uh”
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    Feelings and Attitudes
    • The experience of stuttering often creates feelings of
    embarrassment and frustration in a speaker
    • Feelings become more severe at the speaker has more
    stuttering experiences
    • Fear and shame may develop eventually and may
    contribute to the frequency and severity of stuttering
    • Attitudes are feelings that have become more permanent
    and affect the person’s beliefs
    • Beliefs may be about oneself or listeners
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    Disability and Handicap
    • The disability of stuttering is the limitation it puts on
    individuals’ ability to communicate
    • This limitation is affected by the severity of stuttering as
    well as stutterers’ feelings and attitudes about
    themselves and how listeners have reacted to them
    • The handicap is the limitation it puts on individuals’ lives
    • This refers to the lack of fulfillment they have in social
    life, school, job, and community
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    Basic Facts and Their Implications
    • Onset
    – May start as gradual increase in normal childhood
    disfluencies or may start as sudden appearance of severe
    blocks
    – Often sporadic at outset, coming and going for periods of
    days or weeks before becoming persistent
    – Onset may occur between 18 months and 12 years but
    most often between 2 and 3.5 years (average 2.8 years)
    • Prevalence
    – A measure of how many people stutter at any given time
    – Prevalence is 2.4 percent in kindergarten, about 1 percent
    in school-age children and slightly less than 1 percent in
    adults
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    Basic Facts and Their Implications
    (cont’d)
    • Incidence
    – A measure of how many people have stuttered at some
    point in their lives
    – About 5 percent
    • Recovery without treatment
    – Somewhere between 70 and 80 percent of children who
    begin to stutter recover without treatment
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    Basic Facts and Their Implications
    (cont’d)
    • Children with these attributes have less likelihood of
    spontaneous recovery (Yairi & Ambrose, 2005):
    –
    Having relatives who were persistent stutterers
    –
    Being male
    –
    Onset after 3.5 years
    –
    Stuttering not decreasing during first year after onset
    –
    Stuttering persisting beyond one year after onset
    –
    Multiple unit repetitions (li-li-li-li-like this)
    –
    Continued presence of prolongations and blocks
    –
    Below normal phonological skills
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    Basic Facts and Their Implications
    (cont’d)
    • There is also evidence that recovery is associated with:
    – Being right-handed
    – Growing up in a home with a mother who is non-directive
    and uses less complex language when speaking to child
    – Having a slower speech rate and more mature speech
    motor system
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    Sex Ratio
    • The sex ratio is almost even (1:1) at the onset of
    stuttering
    • However, girls start to stutter earlier than boys and
    recover more frequently so that by the time they are of
    school age, the ratio becomes three boys to every girl
    who stutters and continues at a 3:1 ratio
    • Girls begin to stutter earlier than boys and recover earlier
    and more frequently
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    Variability and Predictability of Stuttering
    • In the 1930s, interest in stuttering turned from its
    medical or organic aspects to social, psychological, and
    linguistic aspects
    • Anticipation: Stutterers can predict which words they
    will stutter on in a reading passage
    • Consistency: Stutterers tend to stutter on the same
    words each time they read a passage
    • Adaptation: Stutterers stutter less each time they read
    a passage up to about six readings
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    Language Factors
    • Brown showed that adults who stutter do so more
    frequently on:
    – Consonants
    – Sounds in word-initial position
    – Sounds in contextual speech
    – Nouns, verbs, adjectives, and adverbs
    – Longer words
    – Words at beginnings of sentences
    – Stressed syllables
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    Language Factors (cont’d)
    • Loci and frequency of stuttering are different in preschool
    children
    • Stuttering in preschool children occurs most frequently
    on pronouns and conjunctions (these occur frequently at
    the beginning of utterances in young children)
    • Stuttering most frequent as repetitions of parts of words
    and single-syllable words in sentence-initial position
    • In summary, because stuttering in preschoolers tends to
    occur at beginning of syntactic units, the trigger seems
    to be linguistic planning and preparation
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    Fluency-Inducing Conditions
    • Many conditions have been found which reduce or
    eliminate stuttering. These include speaking:
    –
    When alone, when relaxed
    –
    In unison with another speaker
    –
    To an animal or infant
    –
    In time or a rhythmic stimulus or when singing, in a different
    dialect
    –
    While simultaneously writing, while swearing
    –
    In a slow, prolonged manner
    –
    Under loud masking noise, while listening to delayed auditory
    feedback
    –
    When shadowing another speaker, when reinforced for fluent
    speech
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    Fluency-Inducing Conditions (cont’d)
    • Fluency-inducing conditions have been explained as
    resulting from reduced demands on speech-motor control
    and language formation (Andrews et al., 1982)
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    The Facts about Stuttering Imply the
    Following
    • Stuttering is an inherited or congenital disorder
    • It first appears when children are learning the complex
    coordinations of spoken language
    • It emerges in those children whose speech production
    system is vulnerable to disruption by competing demands
    of language, cognition, and emotion
    • After it emerges, it becomes persistent in some children
    – perhaps those whose stuttering arouses substantial
    negative emotion which leads to a variety of learned
    behaviors
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    A Model of Stuttering
    • Disorder of neuromotor control of speech
    • Influenced by language production
    • Perpetuated by temperament and complex learning, and
    the response of their environment to their speech
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    Chapter 7
    Normal Disfluency and the Development of
    Stuttering
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    Overview
    • Chapter describes changes that often occur as stuttering
    develops
    • Information will help clinicians design therapy to deal
    with the nature of a client’s stuttering
    • The developmental stages of stuttering are organized by
    age and level of severity, as shown in the next slide.
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    Overview (cont’d)
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    Developmental/Treatment Levels
    Table 7.1 Developmental/Treatment Levels of Stuttering
    Developmental/Treatment
    Level
    Typical Age Range
    Normal disfluency
    1.5-6 y, although a small amount
    of normal disfluency continues in
    mature speech
    Younger preschoolers: Borderline
    stuttering
    1.5-3.5 y
    Older preschoolers: Beginning
    stuttering
    3.5-6 y
    School-age: Intermediate
    stuttering
    6-13 y
    Older teens and adults: Advanced
    stuttering
    14 y and above
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    Developmental/Treatment Levels (cont’d)
    • Many exceptions to these levels of development
    • Four levels of stuttering development useful to determine
    treatment approach
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    Normal Disfluency: Ages 2-5
    Table 7.2 Categories of Normal Disfluencies
    Type of Normal Disfluency
    Example
    Part-word repetition
    “mi-milk”
    Single-syllable word
    repetition
    “I…I want that”
    Multisyllabic word repetition
    “Lassie…Lassie is a good
    dog”
    Phrase repetition
    I want a…I want a ice-ceem
    comb”
    Interjection
    “He went to the…uh…circus”
    Revision-incomplete phrase
    “I lost my…where’s Mommy
    going?”
    Prolongation
    I’m Tiiiiiiiiimmy Thompson”
    Tense pause
    “Can I have some more (lips
    together, no sound) milk?”
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    Normal Disfluency: Ages 2-5 (cont’d)
    • Between 2 and 5, most children have normal repetitions,
    prolongations, and pauses
    • Repetitions are more common in younger children;
    revisions are more common in older children
    Table 7.3 Characteristics of Normal Disfluency in the
    Average Nonstuttering Child
    1. No more than 10 disfluencies per 100 words
    2. Typically one-unit repetitions, occasionally two
    3. Most common disfluency types are interjections, revisions, and
    word repetitions. As children mature past age 3, they will show a
    decline in part word repetitions
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    Normal Disfluency: Ages 2-5 (cont’d)
    • Normally disfluent children don’t react to their
    disfluencies; they seem unaware of them
    • Factors that may increase normal disfluencies:
    – Demands on language acquisition
    – Delayed speech motor skills
    – Stress
    – Competition and excitement when speaking
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    Younger Preschool Children: Borderline
    Stuttering, Ages 2-3.5
    Table 7.4 Characteristics of
    Borderline Stuttering in a Younger
    Preschool Child
    1. More than 10 disfluencies per 100
    words
    2. Often more than two units in
    repetition
    3. More repetitions and prolongations
    than revisions or incomplete phrases
    4. Disfluencies loose and relaxed
    5. Rare for child to react to his
    disfluencies
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    Underlying Processes: Constitutional
    • Speech and language development
    – Some language and speech skills may be more advanced
    than others
    – Inefficiencies in some language production processes
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    Underlying Processes: Environmental
    • Communication stress
    – Models of fast talking/few pauses
    – Interruptions, questions, etc.
    – Models of advanced vocabulary and syntax
    – Competition to be heard
    • Psychosocial stress
    – Conflicts in family
    – Birth of new sibling
    – Changes in home, moving, etc.
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    “Outgrowing” Borderline Stuttering
    • Resource reallocation to compensate
    • Speech and language systems mature
    • Conflicts resolve
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    Older Preschool Children: Beginning
    Stuttering, Ages 3.5-6
    Table 7.5 Characteristics of Beginning
    Stuttering in an Older Preschool Child
    1. Signs of muscle tension and hurry appear in
    stuttering. Repetitions are rapid and irregular
    with abrupt terminations of each element
    2. Pitch rise may be present toward the end of a
    repetition or prolongation
    3. Fixed articulatory postures are sometimes
    evident when the child is momentarily unable to
    begin a word, apparently as a result of tension
    in speech musculature
    4. Escape behaviors are sometimes present in
    stutterers. These include, among other things,
    eye blinks, head nods, and “ums”
    5. Awareness of difficulty and feelings of
    frustration are present, but there are no strong
    negative feelings about self as speaker
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    Underlying Processes
    • Increases in muscle tension and tempo
    – These increases are seen as a sign that stuttering is
    worsening
    – These changes may be attempts to control or escape from
    stutters
    • Effects of learning on stuttering
    – Classical conditioning spreads the emotion associated with
    stuttering to more situations; this means more tension
    and faster tempo
    – Instrumental conditioning increases frequency of escape
    behaviors; this means more eye blinks, head nods, etc.
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    School-Age Children: Intermediate
    Stuttering, Ages 6-13
    Table 7.6 Characteristics of Intermediate
    Stuttering in a School-Age Child
    1. Most frequent core behaviors are blocks in
    which the stutterer shuts off sound or voice. He
    may also have repetitions and prolongations
    2. Stutterer uses escape behaviors to terminate
    blocks
    3. Stutterer appears to anticipate blocks, often
    using avoidance behaviors prior to feared
    words. He also anticipates difficult situations
    and sometimes avoids them
    4. Fear before stuttering, embarrassment during
    stuttering, and shame after stuttering
    characterize this level, especially fear
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    Underlying Processes
    • Classical conditioning creates more and more tension in
    stuttering in more situations
    • Instrumental conditioning creates a more complex array
    of escape behaviors
    • Avoidance conditioning creates extra sounds and
    behaviors before the feared word and causes child to
    avoid more and more words and situations
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    A School-Age Child Expresses His
    Emotions about His Stuttering
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    Older Teens and Adults: Advanced
    Stuttering, Ages 13+
    Table 7.7 Characteristics of Advanced
    Stuttering in Older Teens and Adults
    1. Most frequent core behaviors are longer, tense
    blocks, often with tremors of the lips, tongue, or jaw.
    Individual will also probably have repetitions and
    prolongations
    2. Stuttering may be suppressed in some individuals
    through extensive avoidance behaviors
    3. Complex patterns of avoidance and escape behaviors
    characterize the stutterer. These may be very rapid and
    so well habituated that the stutterer may not be aware
    of what he does
    4. Emotions of fear, embarrassment, and shame are
    very strong. Stutterer has negative feelings about
    himself as a person who is helpless and inept when he
    stutters. This self-concept may be pervasive
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    Underlying Processes
    • Minimal influence of original constitutional,
    developmental, and environmental factors
    • Learning and experience, however, have changed brain
    structure and function
    • Avoidance learning has created enduring stuttering
    patterns
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    Underlying Processes (cont’d)
    • Cognitive learning creates negative
    self-concept
    • This comes from listener reactions
    from childhood and later
    • Stutterers also project their own
    negative feelings about stuttering
    onto others
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    Table 7.8 Characteristics of Five Developmental/Treatment Levels
    Developmental
    /Treatment
    Level
    Core Behaviors
    Secondary
    Behaviors
    Feelings and
    Attitudes
    Underlying
    Processes
    Normal disfluency
    10 or fewer disfluencies
    per 100 words; one-unit
    repetitions; mostly
    repetitions, interjections,
    and revisions
    None
    Not aware; no concern
    Stresses of
    speech/language and
    psychosocial
    development
    Borderline
    stuttering
    11 or more disfluencies per
    100 words; more than two
    units in repetitions; more
    repetitions and
    prolongations than
    revisions or interjections
    None
    Generally not aware;
    may occasionally show
    momentary surprise or
    mild frustration
    Stresses of
    speech/language and
    psychosocial
    development interacting
    with constitutional
    predisposition
    Beginning stuttering
    Rapid, irregular, and tense
    repetitions may have fixed
    articulatory posture in
    blocks
    Escape behaviors such as
    eye blinks, increases in
    pitch, or loudness as
    disfluency progresses
    Aware of disfluency;
    may express frustration
    Conditioned emotional
    reactions causing
    excess tension;
    instrumental
    conditioning resulting in
    escape behaviors
    Intermediate
    stuttering
    Blocks in which sound and
    airflow are shut off
    Escape and avoidance
    behaviors
    Fear, frustration,
    embarrassment, and
    shame
    Above processes plus
    avoidance conditioning
    Advanced stuttering
    Long, tense blocks; some
    with tremor
    Escape and avoidance
    behaviors
    Fear, frustration,
    embarrassment and
    shame; negative selfconcept
    Above processes, plus
    cognitive learning
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    Chapter 2
    Constitutional Factors in Stuttering
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    Constitutional Factors in Stuttering
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    Biological Background
    • Hereditary factors
    • Family studies – What is the pattern of stuttering in
    members of one family?
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    Important Findings
    • Stuttering appears to be inherited
    • Single gene for transitory stuttering; two or more genes
    for chronic stuttering
    • Factors that predict natural recovery:
    – Female
    – No family history of persistent stuttering
    – Early onset
    – Good language, articulation, and intelligence
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    Clinical Implications
    • Parents should be told that stuttering is often inherited,
    not a result of bad parenting
    • Prognosis for natural recovery is related to number of
    recovery factors
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    Twin Studies
    • Stuttering in identical and fraternal twins
    • Greater concordance among identical twins
    • Twin studies show that whether stuttering occurs is 2/3
    genetics and 1/3 environment
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    Clinical Implications
    • Environment should be made as fluency-facilitating as
    possible
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    Adoption Studies
    • Research on families of stutterers who were adopted
    soon after birth
    • Adoption studies provide evidence for both genetic and
    environmental factors
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    Clinical Implications
    • Fact that a relative has persistent stuttering does not
    assure that stuttering will occur
    • Environment should be made as fluency-friendly as
    possible
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    Genes
    • Looking for genes and the chromosomes on which they
    are located
    • Genes associated with stuttering have been found on
    chromosomes 1, 7, 9, 12, 13, 15, 16, and 18
    • Persistent and recovered stuttering is associated with
    chromosome 9; persistent stuttering is only associated
    with chromosome 15
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    Genes (cont’d)
    • Studies in very different cultural groups have identified
    chromosome 12 as significantly related to stuttering
    • Mutations of three different genes on this chromosome
    have been associated with stuttering
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    Clinical Implications
    • New research may lead to early identification and
    prevention
    • This research shows that parents’ behavior does not
    cause stuttering
    • Parents who are concerned about passing on stuttering
    genes should know that they pass on many desirable
    traits as well
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    Congenital and Early Childhood Factors
    • 40 to 70 percent of stutterers have no family history of
    stuttering
    • Stuttering has been associated with:
    – Brain injury before or soon after birth
    – Premature birth
    – Surgery
    – Head injury
    – Mental retardation
    – Intense fear
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    Clinical Implications
    • Clinician should explore child’s early health history and
    events surrounding onset of stuttering
    • Clinician should be aware that one purpose of
    determining factors associated with stuttering is to
    relieve parents’ guilt
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    Brain Structure and Function
    • No matter what the etiology of stuttering, brain structure
    and/or function would be affected
    • Early EEG studies showed more right-brain activity
    during speech compared to nonstutterers
    • Early studies showed activity during speech shifted to left
    brain after treatment
    • Brain imaging studies show:
    – Overactivation of several right-hemisphere areas during
    speech
    – Deactivation of left auditory cortex during stuttering
    – Anomalous symmetry of planum temporale
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    Brain Structure and Function (cont’d)
    • Less dense fibers in white matter tracts of left
    operculum. These fibers are thought to connect sensory
    planning and motor areas for speech
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    Brain Structure and Function (cont’d)
    • This finding has been replicated, and the superior
    longitudinal fasciculus is less dense in the left
    hemispheres of stutterers
    • This is a bidirectional pathway between sensory
    integration and motor planning areas
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    Brain Structure and Function (cont’d)
    • After therapy, right-brain overactivations are reduced;
    left-brain speech, language, and auditory areas are more
    activated
    • Two years after therapy, some right-brain overactivation
    has returned
    A= before therapy; B = immediately after therapy; C = two years after
    therapy
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    Clinical Implications
    • Evidence that treatment changes neurological function
    • May suggest that treatments restore effective
    sensory-motor control of speech
    • Research needed on brain changes that accompany
    effective versus ineffective treatments
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    Caveats about Differences
    • Differences between stutterers and nonstutterers may be
    a result of stuttering, not a cause
    • Findings may be inconsistent:
    – May be sub-groups of stutterers
    – Methods of research may differ between studies of same
    phenomenon
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    Sensory and Sensory-Motor Factors
    • Sensory processing deficits in stutterers:
    – Poorer central auditory processing, especially for temporal
    information
    – Auditory evoked potentials have longer latencies and lower
    amplitudes, especially for linguistically complex stimuli
    – Less right-ear (left-brain) advantage in processing
    linguistically complex sounds
    – Stutterers may be poorer at processing tactile and visual
    information
    – Masking and other changes in auditory feedback decrease
    stuttering
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    Sensory and Sensory-Motor Factors
    (cont’d)
    • Sensory-motor control deficits in stuttering:
    – Slower reaction times
    – Slower speech during fluency
    – Slower on nonspeech sequencing
    – Slower at tapping at a comfortable rate, but faster and
    more variable at a fast rate
    – Not as able to focus on left-hemisphere motor control
    – Poorer at auditory-motor tracking
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    Clinical Implications
    • Because they process more slowly, slower speech may
    facilitate fluency
    • Because of sensory processing deficits, masking, DAF,
    attention to kinesthetic feedback may be helpful in
    treatment
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    Language
    • Stuttering onset sometimes associated with rapid
    language development
    • Stuttering more likely with more linguistically complex
    utterances
    • More linguistically complex stimuli result in poorer
    sensory and sensory-motor tasks
    • Clinical implication: Decreasing linguistic load on children
    starting to stutter, may improve fluency
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    Emotion
    • Emotion may increase stuttering, and stuttering may
    increase emotion
    • Important findings
    – Stutterers are not more anxious than nonstutterers, but
    more anxiety produces more stuttering
    – Autonomic arousal associated with stuttering
    – Stutterers may have more inhibited temperaments; may
    be more emotionally conditionable
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    Clinical Implication
    • Many stutterers, especially chronic stutterers, may be
    helped by treatment that facilitates unlearning of fearbased stuttering behaviors
    More detailed and in-depth analysis of constitutional factors
    can be found in Chapter 3.
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    Chapter 12
    Treatment of Stuttering in Older Preschool Children:
    Beginning Stuttering
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    Older Preschool Children: Beginning
    Stuttering
    • Child is between 3.5 and 6 years old and has been
    stuttering for at least nine months
    • Stuttering consists of repetitions, often with tension, as
    well as tense prolongations, and some blocks
    • Escape behaviors; may be some avoidances
    • Feelings of frustration and embarrassment
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    Author’s Beliefs
    • Nature of Stuttering
    – Stuttering arises from interaction of sensory-motor
    deficits, vulnerable temperament, developmental factors,
    and environmental stress
    – If children do not recover naturally as the brain matures or
    develops compensatory strategies, treatment is needed
    – With this level of stuttering, extensive experience speaking
    fluently at home with parents’ encouragement and support
    can replace stuttering with fluency
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    Author’s Beliefs (cont’d)
    • Speech behavior targeted for therapy
    –
    Both fluent speech and stuttering
    • Fluency goals
    –
    Normal (typical) fluency
    • Feelings and attitudes
    –
    Important to increase confidence about fluency
    • Maintenance procedures
    –
    Need systematic program of gradual facing of contact
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    Clinical Procedures: Lidcombe Program
    • Overview
    –
    Parent delivered in-home operant program praise about every
    fifth utterance
    –
    Gentle correction for unambiguous stutters, only once per five
    praises
    –
    Parent guided by weekly clinic visits
    –
    Initially in structured sessions, then in unstructured sessions
    –
    Data guides changes in program
    • Parent collects daily Severity Ratings (SRs)
    • Clinician collects %SS (or SRs) at clinic visits
    –
    Systematic maintenance program, guided by data, conducted for
    one year after child becomes fluent
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    Overview of One Child’s Lidcombe
    Program
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    Clinical Procedures (cont’d)
    • Stage 1: First Clinic Visit
    – Clinician assesses child’s %SS or SR in 300 syllables of the
    child’s conversational speech (standard for every clinic
    visit)
    – Clinician teaches parents about using SRs on a 1-to-10
    scale to rate child’s fluency every day
    – To calibrate parent, clinician may ask parent to rate child’s
    speech in previous 300 syllable sample; parent’s and
    clinician’s ratings then compared and discussed
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    Clinical Procedures (cont’d)
    • Clinician teaches parent to conduct daily treatment
    conversation at home for 10-15 minutes each
    morning
    –
    Conversation must be fun for child
    –
    Keep child’s response fluent by adjusting its length and complexity
    –
    Praise after every fifth fluent utterance: e.g., “That was really smooth!”
    –
    Praise must be specific to speech (“smooth talking!”) rather than general
    (“good!”)
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    Subsequent Clinic Visits
    • Three goals
    – Assess child’s speech
    – Discuss SRs and other indicators of progress
    – Introduce new procedures when appropriate
    • After child’s speech is assessed, she plays by
    herself as parent and clinician openly discuss
    child’s progress
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    Subsequent Clinic Visits (cont’d)
    • Once parent is comfortable with using praise,
    gentle corrections are introduced:
    – After five praises for fluency, the next stuttered word is
    commented on, acknowledging stutter: “That one was a
    little bumpy,” using a non-negative inflection in the voice
    – After parent is comfortable with using acknowledgments
    for a week, requests for self-correction are taught
    • “‘Truck’ was a little bumpy. Can you try that again?”
    • If child says the word fluently, parent then praises: “Nice job
    of making that word smooth!”
    – Style of both praise and corrections can be adjusted to suit
    the child’s and family’s preferences
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    Stage 1: Introducing Unstructured
    Treatment Conversations
    • When structured conversations have been going well and
    the child’s SRs and %SS show a reduction, unstructured
    conversations are introduced
    • This entails the use of praise, acknowledgment of
    stutters, and request for correction in everyday situations
    such as when child and parent are in the car or doing
    various activities around the house
    • Unstructured treatment conversations can start with only
    praise and contingencies for stutters introduced when
    appropriate
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    Stage 2: Maintenance
    • Family begins Stage 2 when child meets criteria for three
    weeks in a row
    – %SS in clinic is below 1%SS
    – Week’s SRs are all 1 or 2, with at least four days being 1
    • Stage 2 consists of 30-minute clinic visits scheduled at
    systematically increasing intervals as long as criteria are met:
    – Two visits at two-week intervals
    – Two visits at four-week intervals
    – Two visits at eight-week intervals
    – One visit at a 16-week interval
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    Stage 2: Maintenance (cont’d)
    • If criteria are not met, parent and clinician jointly decide
    among several possible options:
    –
    Clinic visits increased in frequency to previous level
    –
    Weekly clinic visits
    –
    Reinstating either structured or unstructured clinic visits or both
    • Sometimes contingencies need to be adjusted
    –
    Ex. When child rarely stutters, praise for fluency is sometimes
    forgotten and parent only using requests for correction; praise
    needs to be used whenever corrections are used
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    Problem Solving
    • Although the program usually runs smoothly and
    produces normal fluency for all children in all families,
    there can be minor problems
    • Sometimes a family forgets the details of the program
    and their use of praise, corrections, and treatment
    conversations needs to be examined and changed
    • Clinician and family brainstorm the problems together
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    Outcome Data
    • 42 children treated with Lidcombe showed near-zero
    levels of stuttering four to seven years after treatment
    (Lincoln & Onslow, 1997)
    • 12-week randomized control trail of Lidcombe (n=10)
    versus no treatment (n=13) showed that the treated
    children had significantly less stuttering than untreated
    (Jones et al., 2000)
    • Randomized control trial of Lidcombe (n=29) versus
    control (n=25) showed significantly greater improvement
    in Lidcombe treatment (p=0.003; effect size = 2.3%SS)
    (Jones et al., 2006)
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    Chapter 10
    Preliminaries to Treatment
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    Clinician’s Attributes
    • Empathy: The ability to understand the client’s feelings,
    thoughts, and behaviors; learn to listen deeply and
    acceptingly
    • Warmth: Caring and unconditional acceptance that
    stimulates client’s learning and unlearning
    • Genuineness: Honest and self-acceptance; being able to be
    blunt with client when needed
    • Preference for evidence-based practice: Valid and reliable
    measures; evidence for effectiveness of treatment
    • Commitment to continuing education
    • Critical thinking and creativity: Will this approach work for
    my clients in my environment? What does this client need
    from me, and how can I arrange it?
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    Clinician’s Beliefs
    • What they are
    • How they affect evaluation procedures
    • How they affect treatment strategies
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    Treatment Goals
    • Reduce frequency of stuttering
    – Without creating extraneous behaviors
    – How much reduction depends on level
    • Reduce the abnormality of stuttering
    – Depends on age and level
    – Client has choice about how she stutters
    • Reduce negative feelings
    – Depends on age and level
    – Change may occur as byproduct of increased fluency or
    classical conditioning may be needed
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    Treatment Goals (cont’d)
    • Reduce negative thoughts and attitudes
    – Will affect amount and abnormality of stuttering
    – Will affect behavior before starting to speak and after
    stuttering
    • Reduce avoidance
    – Client needs to learn new behavior before reducing old
    behavior (i.e., start by giving the client a tool to reduce
    stuttering)
    – Reducing negative emotions reduces need for avoidances
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    Treatment Goals (cont’d)
    • Increase communication abilities
    – May be a major goal of some approaches
    – Some clients may need more than others depending in
    part on level
    • Create fluency-facilitating environment
    – Especially important for borderline and beginning
    – Class environment (as well as home) important for schoolage children
    – Adults can change their own environments
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    Therapy Procedures: Dealing with
    Emotions Associated with Stuttering
    • With parents of preschoolers, critical to listen to,
    acknowledge, and accept feelings. Let parents know you
    and they form a team to help the child
    • With older children and adults, clinician must create an
    accepting atmosphere where any feelings that arise as
    client is learning about his stuttering can be expressed
    by client and accepted by clinician
    • As clinician helps client explore and accept responsibility
    for his stuttering, clinician’s curiosity and genuine
    interest in the client’s stuttering and his feelings about it
    are crucial
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    Therapy Procedures: Dealing with
    Emotions Associated with Stuttering
    (cont’)
    • As client learns to stutter openly and tolerate stuttering,
    clinician helps client accept his feelings of frustration,
    fear, and vulnerability
    • As client learns to stutter in an easier way and to stop
    rewarding tense stutters, feelings of resistance, anger,
    and shame may arise. The clinician can help by listening
    for these feelings and verbalizing acceptance of them
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    Therapy Procedures: Reducing Frequency
    • Operant conditioning often used (reward and
    punishment)
    • For beginning stuttering, use fluency versus stuttering
    • For intermediate and advanced stuttering, use “fluency
    shaping” (establish fluency using slow rate, easy onset,
    light contacts, proprioception, and pausing to shape
    normal sound)
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    Therapy Procedures: Reducing
    Abnormality of Stuttering
    • Use operant procedures to reduce tension/struggle
    • Do this in context of reducing negative emotion
    • These procedures are “stuttering modification”
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    Therapy Procedures: Reducing Negative
    Emotion
    • Use classical conditioning to decondition or
    countercondition
    – Ex. Stay in the stutter and relax
    – Ex. Stutter voluntarily
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    Therapy Procedures: Reducing Negative
    Thoughts and Attitudes
    • Use cognitive therapy
    • Explain how thoughts affect feelings, which in turn affect
    behaviors
    • Explore and help client change such things as negative
    self-talk
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    Therapy Procedures: Reducing Avoidances
    • Must teach new behaviors to old stimuli
    • Reward non-avoidance
    • Cultivate openness, seeking out
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    Therapy Procedures: Increasing
    Communication Skills
    • Use instruction, modeling, role playing, and video
    feedback
    • Teach turn-taking, maintaining a topic, and repairing
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    Therapy Procedures: Creating a
    Facilitating Environment
    • Preschool: Parents
    • School-age: Peers, teachers, parents
    • Adolescent, adult: Sense of humor, openness
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    Motor Learning Principles for Stuttering
    Treatment
    Principles of Motor Learning
    (Verdolini & Lee, 2004
    Application to Stuttering Treatment
    In the first stages of motor learning, feedback is
    important, but then the client must evaluate his
    own performance for long-term change.
    When teaching a technique such as easy onsets or pullouts, the
    clinician should let the client know when he has done well, but
    gradually diminish feedback and replace it with asking client to
    evaluate how he felt his easy onsets and pullouts were. A 1-10
    scale could be used for rating them.
    Rather than instructing the client, the clinician
    should facilitate the client’s own discovery of new
    behaviors that work. In doing so, the clinician
    should utilize the client’s sensory processes to
    discover helpful changes.
    As the client is trying to change old habits of tension and struggle,
    he should be urged to feel, hear, or see what he is doing as he
    searches for ways to change. An example is Dean Williams’s
    (2004) question to clients: “What are you doing to interfere with
    talking?” and his admonition to “feel what you’re doing.”
    As new habits are acquired, old habits must be
    suppressed by conscious inhibition.
    Prior to speaking, a client should pause and tell himself not to use
    an old habit (such as tensing larynx, lips, and/or jaw) and be
    aware of how that change feels.
    In order for responses to become automatized
    (and therefore stable in the face of distracters),
    the client needs to consistently use the new
    behaviors in relevant stimulus situations.
    Clients need to consistently use new behaviors such as easy
    onsets in place of habitual tense stuttering behaviors in order to
    build up automaticity in their use so they will be available under
    stress.
    Clients should use variable practice with different
    stimuli and in different environments.
    Clients should practice new behaviors (e.g., light contacts or slow
    rate) with a wide variety of words and sentences, in different types
    of speech tasks, and outside the clinic room as well as on the
    telephone in the clinic.
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    Chapter 13
    Treatment of School-Age Children:
    Intermediate Stuttering
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    School-Age Children: Intermediate
    Stuttering
    • Child is between 6 and 13 and has been stuttering for
    several years
    • Stuttering consists of repetitions, prolongations, and
    blocks
    • Escape and avoidance behaviors
    • Feelings of frustration and embarrassment
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    Author’s Beliefs
    • Nature of Stuttering
    – Constitutional + developmental + environmental
    factors
    – Tension, escape, and avoidance behaviors are
    learned and can be unlearned
    – Negative emotions and beliefs can be decreased via
    positive speaking experiences, reinforcement for not
    running away from stuttering, and activities which
    increase feeling “in control” of stuttering
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    Author’s Beliefs (cont’d)
    • Speech behavior targeted for therapy
    –
    Both stuttering and fluent speech
    • Fluency goals
    –
    Fluent speech, controlled stuttering, and acceptable (mild
    stuttering)
    • Feelings and attitudes
    –
    Important to reduce negative feelings and attitudes
    • Maintenance procedures
    –
    Need systematic program of gradual facing of contact
    • Clinical methods
    –
    Stuttering modification and fluency shaping
    –
    Work with parents and teachers as well
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    Clinical Procedures
    • Key Concepts
    – Fear and avoidance keep stuttering “hot”
    – Therapy must reduce these, increasing approach attitudes
    and behaviors
    – Struggle must be reduced
    – Shame must be reduced…by openness
    – Therapy must be fun
    – Clinician should do any task first
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    Clinical Procedures (cont’d)
    • Beginning therapy
    – Get to know child
    – Explain and discuss the sequence of therapy
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    Exploring
    • Exploring goals of therapy
    • Exploring beliefs about stuttering
    • Exploring core behaviors
    – Clinician must be unafraid of stuttering
    – Teach about speech helpers
    • Explore how they work in fluency
    • Explore what happens in stuttering
    • Holding onto stutters and feeling what is happening
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    Exploring (cont’d)
    • Exploring secondary behaviors
    – With much acceptance, help the child study what he
    does and why when he uses escape and avoidance
    behaviors
    • Exploring thoughts and feelings (ongoing)
    – Helps a lot to talk about feelings, but sometimes it’s
    hard to get kids to talk
    – See Chmela and Reardon (2001) about working with
    attitudes and emotions, available from the Stuttering
    Foundation
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    Exploring (cont’d)
    • Having students draw their feelings and talk about
    the drawings can be very helpful
    This drawing shows a student’s feelings about his stuttering now, and
    what he hopes it will be like after therapy.
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    Teaching Fluency Skills
    • Can be taught separately or combined
    • Specific fluency skills
    – Flexible rate
    – Pausing
    – Easy onsets
    – Light contacts
    – Proprioception
    – Combine all into “superfluency”
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    Replacing Stuttering with Superfluency
    • Practice superfluency with three-word sentences
    • Practice long and short sentences beginning with various
    sounds
    • Practice in conversation with clinician modeling
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    Transferring Superfluency to Structured
    Situations
    • Learn to downshift when stuttering is expected
    • Develop hierarchies to transfer superfluency into more
    real-life situations
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    Desensitizing the Child to Fluency
    Disrupters
    • Determine what disruptions are difficult
    • Role play disruptions while maintaining superfluency
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    Scaffolding
    • Scaffolding is providing extra support for the child as he
    works up a hierarchy of difficulty
    • Example: Telling a stranger that you and the child are
    working on your speech; using signals to communicate
    support as the child is speaking
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    Reducing Fear and Avoidance
    • Use metaphors to help child understand (ex. scary dog)
    • Help child learn that feeling fear and making mistakes
    are OK
    • Lots of practice on feared sounds, words, and situations
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    Coping with Teasing
    • Work on child’s acceptance of his stuttering
    • Help child learn a response to teasers, like “So?!”
    • Help child find support in other children who stutter or
    friends; role play
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    Being Open about Stuttering
    • Help child develop casual comments about his stuttering
    • Help child talk to teachers and classmates about
    stuttering
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    Maintaining Improvement
    • Continue assessing child (fluency and communication)
    • Gradually fade contact, but bring child back into regular
    therapy if he had trouble
    • Ask child for his help with other children who stutter
    • Develop an ongoing support group
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    Clinical Procedures: Working with Parents
    • Explaining treatment program and parents’ role
    • Explaining possible causes of stuttering
    • Identifying and reducing fluency disrupters
    • Identifying and increasing fluency-enhancing
    situations
    • Eliminating teasing at home (and responding to it at
    school)
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    Working with Classroom Teachers
    • Explain treatment program and teacher’s role
    • Facilitate teacher talking with student about stuttering
    • Help teacher and child work out child’s participation in
    class
    • Help teacher eliminate teasing in school
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    Progress and Outcome Measures
    •
    •
    •
    •
    %SS
    SSI-4
    Measure of attitude: CAT or A-19
    Teacher Assessment of Student’s Communicative
    Competence (TASCC)
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    Chapter 9
    Assessment and Diagnosis
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    Assessment of Stuttering: Overview
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    Preschool Children
    • Preassessment
    – Clinical questions
    • Stuttering or normal disfluency?
    • If stuttering, what are the disfluencies like in various
    situations, and how does it change over time?
    • What are the child’s responses? Emotions?
    • What are the family’s concerns, expectations, etc.?
    • Treatment options – none, waiting, indirect, direct?
    • Language, articulation, and voice age-appropriate?
    • Any issues for which referral needed?
    • Initial Contact
    –
    –
    –
    –
    Usually on telephone
    Listen carefully and respond to level of concern
    Make appointment as appropriate
    Provide suggestions to give parents useful ways to start
    helping child
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    Preschool Children (cont’d)
    • Case history form sent to family several weeks before
    evaluation
    • Informs clinician about family’s perception of current
    stuttering as well as history and development
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    Case History Form
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    Case History Form (cont’d)
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    Case History Form (cont’d)
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    Audio-Video Recording
    • Helpful to get video of child speaking spontaneously at
    home
    • 5-10 minutes of parents playing with child is usually
    adequate, unless stuttering is highly variable, in which
    case, more than one sample may be needed
    • Provides important sampling of stuttering that may be
    worse at home than at clinic
    • Parents can leave camera on stand for several days to
    get child used to it before filming
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    Assessment
    • Parent-child interaction
    – Done first to get unbiased sample
    – Opportunity to observe child’s stuttering and awareness of
    it
    – Opportunity to observe parent’s style of interacting with
    child
    – What are key elements to observe?
    – Video record for later analysis
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    Assessment (cont’d)
    • Parent interview
    – Interview with child present or not – what are the pros
    and cons of each?
    – Let parents know the overall flow of the evaluation
    – Begin with open-ended questions about what parents’
    concerns are
    – Careful, nonjudgmental listening is important
    – Leave time at end of parents’ questions
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    Assessment (cont’d)
    • Gather information about
    – Child’s birth and development
    – Family history (stuttering and other disorders)
    – Onset of stuttering and changes over time
    – Child’s awareness and response to his stuttering
    – Parents’ response to child’s stuttering; their ideas about
    the cause
    – Previous treatment
    – Child’s personality and environment
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    Child-Clinician Interaction
    • Opportunity to observe child’s stuttering and his response to
    various stimuli
    • If child is quite fluent, clinician may speak rapidly and ask many
    questions to see if stuttering appears
    • If child is stuttering, clinician may experiment with fluency
    facilitating interaction, such as speaking slowly
    • If child is aware, discuss with parents the benefit of talking to
    child about stuttering
    • Clinician can ask child if he ever gets stuck on words or has
    trouble talking
    • Children usually relieved by open, reassuring discussion of
    stuttering
    • If child is reluctant to talk or play with clinician, it’s important not
    to push; clinician can play with an appealing toy and talk to self,
    and eventually child may join
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    Speech Sample
    • Obtain sample from home and sample from clinic – at
    least 200 (300 if possible) syllables each
    • General observations:
    – Frequency of disfluency
    – Types of disfluency
    – Nature of repetitions, prolongations, and blocks
    – Starting and sustaining airflow and phonation
    – Physical concomitants
    – Word avoidances
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    Speech Sample (cont’d)
    • SSI-4: Assess child’s severity (see Chapter 8)
    • Speech rate: syllables per minute (see Chapter 8)
    • Feelings and attitudes
    –
    –
    –
    –
    Ask parents
    Observe child’s reactions to his stuttering
    Talk to child directly about his stuttering
    Feelings and attitudes can range from being totally
    unaware to highly frustrated and afraid
    – May change from time to time
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    Other Speech and Language Behaviors
    • Parents reports and observations of child’s speech and
    language may reveal other problems
    • Formal tests for phonological or language problems may
    indicate need for treatment concurrent with or following
    stuttering treatment
    • Compare syntax with vocabulary scores; disparity may
    be of concern
    • Also observe speech-motor and other fine motor skills
    • Hoarse voice may indicate laryngeal tension associated
    with stuttering
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    Other Factors
    • Physical development
    • Cognitive development
    • Social-emotional development
    • Speech and language environment
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    Diagnosis: Determining
    Developmental/Treatment Level
    • Typical disfluency: >10 disfluencies per 100 words;
    multisyllable word and phrase repetitions; >3 iterations
    in reps that are slow and regular temple; child unaware
    • Borderline: More than 10 disfluencies per 100 words;
    part-word and whole-word repetitions; more than two
    iterations in many repetitions
    • Beginning: Tension and hurry in stuttering; awareness
    and frustration; escape behaviors; possibly some
    avoidance
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    Risk Factors for Recovery versus
    Persistence
    • Factors that may be associated with persistence of
    stuttering:
    – Stuttering does not decrease during 12 months after onset
    – Stutterer is male
    – Relatives who have not recovered from stuttering
    – Below-average nonverbal intelligence scores
    – Sensitive temperament
    – See Table 9.1 (p. 194) Risk Factors for Persistent
    Stuttering or Extended Treatment
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    Drawing the Information Together
    • Some information is available for closing interview: e.g.,
    home video, case history and interview, observations of
    child’s stuttering
    • Other information will be available later for report: e.g.,
    analysis of clinic video
    • Need to develop hypothesis about:
    – Child’s current developmental/treatment level
    – Important risk factors
    – Treatment approach
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Closing Interview
    • Describe positive aspects of child and parents’ response
    to stuttering
    • Describe stuttering in appropriate, clear terms
    • Discuss treatment options
    • Respond to questions and implied concerns
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Recommendations for Child with Typical
    Disfluency
    • Give information about normal disfluency
    • If parents are concerned, set up another appointment in
    several weeks to reevaluate if disfluency persists or
    worsens
    • If needed, recommend changes in environment that may
    help all children: e.g., turn-taking, careful listening,
    appropriate speech rates
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Recommendations for Child with
    Borderline or Beginning Stuttering
    • Use risk factors and duration of stuttering since onset to
    determine if treatment should be direct or indirect
    • Teach parents to use severity rating (SR) scale (see
    Chapter 8), and have them begin to use it
    • Borderline (usually younger preschool children):
    – Discuss with parents option of indirect treatment or
    watchful waiting
    – Provide video Stuttering and the Preschool Child (SFA
    #70)
    – Have parents share weekly results of SR scale
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Recommendations for Child with
    Borderline or Beginning Stuttering
    (cont’d)
    • Beginning (usually older preschool children)
    – Discuss indirect versus direct treatment
    – Have parents begin to use SR scale and share with you on
    a weekly basis
    • For both levels: Answer questions and provide contact
    information so parents can stay in touch if needed before
    next appointment
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    School-Age Children: Preassessment
    • Clinical questions
    – What are characteristics of student’s stuttering?
    – What are student’s feelings and attitudes about speaking?
    – How does it affect him at school and home?
    – Is he eligible for services, according to state regulations?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Public School Considerations
    • Individuals with Disabilities Education Act (IDEA) and
    state laws set procedures for evaluation and treatment of
    students who stutter
    • When child is referred for stuttering, SLP makes discreet
    observation in classroom; confers with teacher and
    special education administrator
    • Child’s parents are contacted, permission for an
    evaluation is obtained, and evaluation is carried out
    • Team of SLP, teacher, special education administrator,
    and parents discuss treatment options
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Initial Contact with Parents
    • In school setting, telephone to get permission to evaluate child
    –
    Describe how student was identified and what characteristics of student’s
    stuttering are
    –
    Let parent know schools desire to help student become a more effective
    communicator
    –
    Find out if family has noticed stuttering
    –
    Maintain a caring, accepting attitude
    –
    Explain evaluation process
    –
    Ask them to fill out a case history form
    –
    Try to obtain a video from home (may be more effective to wait until SLP
    obtains permission from child)
    • In clinic setting, a telephone call to the family can let them know
    what to expect in the evaluation
    –
    Let them know you’ll be sending a case history and perhaps other forms to
    complete
    –
    May be helpful to talk to the student on the phone to describe the procedures
    and obtain permission for a home video
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Case History Form
    • See Slides 5-7
    • Important information
    – Changes in stuttering since onset
    – Student’s own reaction and family’s reaction to stuttering
    – Past treatment
    – Impact of stuttering on school performance
    • Video recording may be more stuttering at home or
    school than in clinic, so this is an important sample
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Assessment: Parent Interview
    • Let parents know you support them and their child
    • Fill in gaps from case history (see section on areas to
    discuss with parents of preschool child)
    • Ask about how stuttering affects student in school (e.g.,
    participating, teasing, teacher responses, etc.)
    • Try to determine if there are factors that would hinder
    recovery (e.g., parent’s anxiety or negative attitude
    about stuttering, student’s sensitivity, motivation, etc.)
    • Convey acceptance of family; comment on positive things
    they have done
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Assessment: Teacher Interview
    • Make an alliance with the teacher
    • Find out about child’s communication in class, if
    stuttering interferes with communication, how teacher
    responds to child’s stuttering, and if other children tease
    child about his stuttering
    • What information might you want to give to the teacher
    about stuttering?
    • Classroom observation
    – Arrange a time with teacher to unobtrusively observe
    student when he may be talking in class
    – Note how much he talks, to what extent he avoids, and
    how others react to his stuttering
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Assessment: Student Interview
    • Get to know student first – his likes, dislikes, family, etc.
    • Discuss stuttering in a direct but accepting manner
    – Explore when he stutters the most, least
    – What he does when he stutters (have him teach you)
    – His feelings about his speaking
    – Others’ reactions, teasing, parents’ responses
    – Avoidances
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Speech Sample
    • Preliminaries
    – Ask student’s permission to video record
    – Record 300-400 syllables of student’s conversation (10
    minutes)
    – Obtain 200-syllable reading sample
    • Pattern of disfluencies: Observe degree of tension,
    struggle, escape, avoidance, and estimate
    developmental/treatment level
    • SSI-4
    • Speech rate: compare with normal for age (see Table
    8.5)
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Trial Therapy
    • Stuttering modification
    – Have student catch clinician’s pretend stutters
    – Have student put in pretend (or real) stutters, and have
    clinician catch student and reward him
    – Have student control length of clinician’s pretend stutter
    – Roles reverse, and clinician signals student to make
    stutter longer
    – Can student hold onto stutter, reduce tension, and release
    stutter slowly?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Trial Therapy (cont’d)
    • Fluency-shaping/superfluency (see Chapter 13 for
    details)
    – Teach student to model easy onset, light contact,
    and flexible rate
    – Can student follow model?
    – Does he respond well to coaching to improve his
    superfluency?
    – Does he become more fluent?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Feelings and Attitudes
    • Methods of assessing:
    – Informally by observation and discussion with student
    – Informally with materials (e.g. “worry ladder” from
    workbook by Chmela & Reardon, 2001)
    – Use formal assessment with discussion: CAT or A-19
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Other Concerns
    • Observe articulation and language; test if needed
    • Physical: Are there motor problems? Delay?
    • Cognitive: Learning disability? Attention/activity
    problem? Intelligence?
    • Social-emotional: Able to make friends? Highly sensitive
    or anxious?
    • Academic adjustment: Academic performance problems?
    Reading problems?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Diagnosis and Closing Interview
    • Diagnosis
    – Developmental/treatment level
    – Factors influencing persistence
    • Closing interview in clinical setting
    – Begin with positive aspects of child and family
    – Be clear and direct when describing level of stuttering and
    implications for treatment
    – Address family’s concerns about student’s future
    – Discuss treatment options including family’s role
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Public School Setting
    • After evaluation, clinician writes brief report in lay terms
    • Report should discuss affective, behavioral, and cognitive
    aspects of student’s stuttering and school performance
    • IEP team meets to consider the severity of child’s stuttering
    and its impact on education including extracurricular
    activities
    –
    Does student participate fully in school activities, or does
    stuttering limit him or her? (Consider using TASCC to assess
    student’s communication abilities in class, Fig. 8.9)
    –
    Can student meet school’s curriculum objectives, especially
    those related to speaking?
    • If IEP team determines child is eligible, measurable goals
    and short-term objectives are developed
    • Services to meet these goals and objectives are determined
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Adolescents and Adults: Preassessment
    • Clinic versus school assessment
    • This evaluation described as though it is in a clinic
    • When evaluation is in school, IEP process is followed
    • IEP process gets input from students when they are 14
    or older and eventually involves not only school-based
    treatment, but transition plans as well
    • Case history form sent to adults several weeks prior to
    evaluation
    • Adolescents in school can fill out themselves with help
    from parents
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Case History Form
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Case History Form (cont’d)
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Preassessment
    • Attitude questionnaires
    – Sent to client several weeks before evaluation so they can
    be analyzed prior to interview
    – Typically used: S-24, SSRSS, Locus of Control, OASES
    (see Chapter 8 for details)
    • AV Recording
    – Crucial to have recordings from out of clinic; best if
    difficult situation, like talking on the phone
    – Analyze prior to evaluation
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Assessment: Interview
    • Begin by letting client know what will take place in the
    evaluation
    • Ask open-ended question like “Why don’t you begin by telling
    me about your stuttering?”
    • After client has finished an initial description of concerns, ask
    about onset, development, and early experiences
    –
    How would you elicit this information?
    • Ask about current stuttering and how it affects social,
    occupational, and academic situations
    • Explore feelings – use results of questionnaires (S-24, etc.) as
    a basis to explore further
    • Explore client’s awareness of current stuttering including
    escape and avoidance behaviors
    • Does client have questions?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Speech Sample
    • Use video recording of client talking about a familiar topic
    such as school of work, 300 syllables or more
    • Reading sample at appropriate level
    • Also sample from outside clinic; if none available, record
    client making a phone call
    • Analyze with SSI-4
    • Speech rate
    • Pattern of stuttering
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Trial Therapy
    • Stuttering modification
    – Have client freeze a moment of stuttering, maintaining
    posture and tension; this may require some coaching,
    especially on stop sounds
    – Have client become aware and describe what he’s doing to
    hold back speech as he stutters
    – Have client stay in posture but reduce tension and slowly
    produce first sounds of word and then rest of word
    normally
    – See if client can do this on his or her own after some
    clinician-guided practice
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Trial Therapy (cont’d)
    • Fluency-shaping
    – Use word list, then phrases
    – Teach gentle onsets, light contacts, flexible rate
    – Teach proprioception
    – In phrases, teach pausing
    – Teach client to put it all together in a new overall pattern
    of speaking (sometimes called “controlled fluency” or
    “prolonged speech”)
    – Can client do this on his own in brief conversational
    phrases?
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Other Speech and Language Behaviors
    • Informally screen language, articulation, voice
    • If needed, give formal tests
    • Screen hearing
    • Other factors
    – Intelligence
    – Academic adjustment (in adolescents)
    – Psychological and vocational adjustment
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Interview with Family of Adolescent
    • Convey sincere acceptance of family’s viewpoint and
    concerns
    • Give family opportunity to express their concerns and
    emotions and to get their view of the adolescent’s
    stuttering
    • Give some time for adolescent to express views and
    feelings privately
    • In closing interview with adolescent and family, give
    principle role in treatment to adolescent, but involve
    family as much as adolescent is comfortable with
    Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
    Diagnosis
    • Determine if this is “developmental” stuttering rather
    than normal disfluency, cluttering, neurogenic, or
    psychogenic stuttering
    • How do you differentiate these?
    • Intermediate stuttering
    –
    Younger than age 14
    –
    Blocks, repetitions and prolongations
    –
    Escape and avoidance behaviors
    –
    Negative attitudes about speaking
    • Advanced stuttering
    –
    14 years or older
    –
    Symptoms as above but more entrenched
    Copyright © 2013 Wolters Kluwer Health | Lippincott…

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