Differential Diagnosis and
Treatment for Individuals Who
Jaime Hannan, MS, CCC-SLP
Rob Reichhardt, MA, CCC-SLP
Cincinnati Children’s Hospital Medical Center
Michigan Speech-Language Hearing Association
March 28, 2014
*We have no financial or non-financial relationships to disclose.
What is Stuttering?
The Basic Principles
– Preschool
– School-age
– Adolescents
• Stuttering defined:
– Van Riper: Stuttering occurs when the forward flow of
speech is interrupted by a motorically disrupted
sound, syllable, or word or the speaker's reactions
– Stuttering Foundation of America: Stuttering is a
communication disorder in which the flow of speech is
broken by repetitions (li-li-like this), prolongations
(lllllike this), or abnormal stoppages (no sound) of
sounds and syllables. There may also be facial and
body movements associated with the effort to speak.”
• National Stuttering Association: People who stutter often
experience physical tension and struggle in their speech
muscles, as well as embarrassment, anxiety, and fear
about speaking. Together, these symptoms can make it
very difficult for people who stutter to say what they
want to say, and to communicate effectively with others.
• Core Behaviors
Part-word repetitions (c-cat)
Monosyllabic whole-word repetitions (on-on)
Prolongations (lllllike)
Blocks (inaudible; audible)
May have multi-component disfluencies
• Secondary Behaviors:
– Facial grimace, poor eye contact, arm and leg movements,
variations in rate and pitch, use of interjections
• Typical Disfluencies (not representative of stuttering)
Repetition of multi-syllabic words (because-because)
Repetition of phrases (I want-I want)
Interjections (um, uh)
• *Consider - are interjections being used to avoid stuttering moment?
• Incidence
– As many as 15% of children will have a period of
disfluency (Bloodstein, 1995)
– 5% will have a period of disfluency lasting longer
than 6 months (Andrews et al, 1983)
• Prevalence
– 1% of US population; over 3 million people
(Bloodstein, 1995; Andrews et al, 1983).
***Other sources have similar findings
Onset Patterns and Recovery
• Onset for most between ages 2-5
• Children who begin stuttering before age 3;6 are more likely
to outgrow stuttering.
• Children with onset before age 3 have better chance of
recovery within 6 months (regardless of severity)
(Yairi & Ambrose, 1992, 1999, 2005)
• Recovery Rates
• 74%
(Yairi & Ambrose, 1999)
– 84 children
– 4 years post onset
• 71%
(Mansson, 2000)
– 51 children
– Within 2 years of onset
Key Risk Factors
• We can never “guarantee” that a child will recover from
stuttering; however, several risk factors exist that enable
us to predict persistence vs. recovery
(Yairi & Ambrose, 1992, 1999, 2005).
Time since onset
Age of onset
Pattern since onset
Family history
• ½ of all children who stutter have a family member who stutters;
less risk if the family member outgrew stuttering as a child.
– Gender
– Other speech and language deficits
Theories About Stuttering
• The next several slides detail a historical
perspective on the causes of stuttering.
• Some theories have since been abandoned,
while others continue to contribute to
current clinical work with individuals who
Theories About Stuttering
• Constitutional Factors
– Disorder of brain organization
• Cerebral dominance
(Geswind & Galaburda, 1985; Webster, 1993a)
– Disorder of timing
• Timing functions for speech are less efficient;
vulnerable to interference during moments of
increased emotion (Van Riper, 1982; Kent, 1984)
– Disorder as reduced capacity for internal
• Have difficulty making sensory-to-motor and motorto-sensory transformations; predisposition
(Neilson & Neilson, 1987; Max et al, 2004)
Theories, cont.
– Language production deficit
• Stuttering often increases as load on language
functions is heaviest (e.g., conversation vs. single
words) (Bloodstein, 2002)
• Covert repair hypothesis – stuttering results as
correcting the phonological errors detected in the
phonetic plan before they are spoken (Kolk & Postma, 1997)
• Dyssynchrony of two components of language
production; left (linguistic) and right (paralinguistic)
hemispheres (Perkins, Kent, & Curlee, 1991)
– Additionally, person must experience time pressure and a
feeling of “loss of control.”
Theories, cont.
– Physiological tremor
• Some stutters are characterized by rapid,
rhythmic, oscillatory neural input to the muscles of
speech so that they are contracting in a tremorlike way (Smith, 1989)
Theories, cont.
• Developmental/Environmental Factors
– Diagnosogenic theory
• Stuttering evolves from normal fluency breaks to
which others mislabel as “stuttering” (Johnson et al, 1942)
– Communicative failure and anticipatory struggle
• Stuttering emerges from a child’s experiences of
frustration and failure when trying to talk
(Bloodstein, 1987, 1997)
– Demands and capacities
• Disfluencies emerge when a child’s capacities for
fluency are not equal to speech performance
demands (Starkweather, 1987)
Theories, cont.
• What do we know today
– No exact “cause” for stuttering.
– Two-stage etiological model (Guitar, 2006)
• Primary stuttering - results due to some
dyssynchrony at some level of the speech and
language development process.
• Secondary stuttering - result of a separate
constitutional factor - a reactive temperament that
triggers a defense response.
Characteristics of PWS
• We will explore each of the following
characteristics on the next few slides.
– Neuropsychological
– Linguistic
– Phonological/Motor
– Temperament
– Sensory
Neurophysiological and Linguistic
• Brain Differences
Greater activation of right hemisphere (for adults)
Inhibited activity in auditory cortex bilaterally
Novel activation patterns
Chang et al. 2008 (subjects age 8-12), reduced left side
gray matter in speech area; no increase in right side
activation (reinforced over time); reduced left side white
matter integrity in motor regions of face and larynx
• Linguistic Factors
• Mixed findings
• “The most recent findings dispel previous reports that
children who begin stuttering have, as a group, lower
language skills. On the contrary, there are indications that
they are well within the norms or above. Advanced
language skills appear to be even more of a risk factor for
children whose stuttering persists” (Yairi & Ambrose, 2005).
Phonological and Motor Skills
• Greater difficulty with phonological
• Difficulty using proprioceptive feedback to
control and coordinate motor tasks
• Reduced coordination for articulation/oral motor
• Reduced coordination in finger tapping and hand
• A temperamental bias refers to a distinctive profile of
feelings and behaviors that originate in the child’s biology
and appear early in development (Rothbart, 1989).
• CWS showed higher emotional reactivity, lower emotional
regulation, and lower attention regulation
(McDevitt & Carey, 1978).
• Characteristics of highly sensitive children
• Have greater physical tension, especially in laryngeal area
in response to new or threatening situations
(Kagan & Snidman, 1991)
• Are more sensitive, reactive to external stimuli, and less
adaptive to change (Anderson et al, 2003).
• PWS (preschool) have higher levels of gross motor
behaviors and impulsivity; decreased attention, focus, and
inhibitory control (Embrechts & Ebben, 2000).
Temperament, cont.
• Anxiety
• As stuttering persists, increased likelihood that
individual will react with increased anxiety.
• If persists into adolescence, increased Trait (long-term)
and State (momentary) anxiety.
• As many as 60% of adults who stutter present with
clinically significant levels of anxiety.
• Sensory processing is an overarching term that refers to
the method the nervous system uses to receive,
organize, and understand sensory input (Miller & Lane, 2000).
– In PWS: Differences exist in the neurological networks that
process sensory information (Ludlow & Loucks, 2003)
– The Auditory Cortex is underactive during speech and stuttering
in PWS, indicating a tendency for deficient auditory sensory
feedback (Yairi & Seery, 2011)
– Supporting the sensory system in therapy!
Learned Behavior
• Operant Conditioning
• Negative Reinforcement: behavior removes an
unpleasant experience; secondary behaviors - this
is why they grow.
• Classical Conditioning
• Associations over time; phone ringing=anxiety.
• Avoidance Conditioning
• A behavior that prevents an unpleasant
experience: interjections, word changing, not
participating in class - these are reinforced
because you AVOID the negative experience.
• People who stutter may be classified as
covert or overt.
– Overt
• Stutter openly
– Covert
• Try to hide stuttering
• Change words
• Avoid situations
The Iceberg Analogy of Stuttering
(Joseph Sheehan, 1970)
The Basic Principles
• What are they?
– Developed by Hugo Gregory (1968, 1975, 2003)
– A way of “clinical thinking” that assists SLPs in the
ongoing application of evidence based practices.
• Assists SLPs with varying levels of experience explore,
create, and implement success-driven solutions.
• Applies to various locations and types of service through
appropriate interpretation.
• Recognizes the unique temperament and experiences of each
individual, and focuses on positive relationship between
relevant parties engaged in process.
– Continuous process; principles are simultaneously
• Other research contributed to framework
of this process.
– General scientific logic set
(Tilly, 2008)
• Analyze problem, determine plan, and evaluate
– Various similar thinking processes, Heartland
Method (Reschly-Ysseldyke, 1995)
• Framework for defining a problem; conversational
– Framework similar to (DIR): Developmental,
Individual Difference, Relationship-Based
• Intervention based on child and family’s unique
Basic Principles
• Level 1
– Initial referral, diagnostic planning and
evaluation processes; diagnosing, and
developing goals and objectives
• Level 2
– Executing treatment objectives and
monitoring progress in a consistent, ongoing
• Goals for therapy
– Identify discrepancies, determine objectives,
plan outcomes
What are the Basic Principles?
• Differential evaluation – differential treatment
– Addresses the complexities of a problem, considering
both subject and environmental variables in an
ongoing manner.
• Relationship
– Addresses the manner of interaction between all
individuals collaborating to assess and, if necessary,
treat the presenting problem.
– Starts from the first moment you meet child.
– Respect/listen to child’s opinions and ideas.
– Shapes what will be done in therapy.
Components of an Evaluation
• Case history
– Medical history/Development history
• Milestones: gross motor, fine motor, speech/language,
feeding, sensory, behavioral, academic performance, past
– Fluency history
• Is there a family history of stuttering?
• At what age did your child start stuttering (try to pinpoint to
a specific month)?
• Has the stuttering behavior increased/decreased/remained
the same since onset?
• Describe your child’s stuttering (e.g., primary/secondary
• Do you think that your child is aware of his/her stuttering?
Evaluation, cont.
– Does your child’s stuttering change in certain situations? Around
certain people?
– What do you do when your child stutters?
– Describe your child’s personality in a few words.
– Describe your family dynamic (siblings at home; competition for
talk time, etc.).
• Fluency Samples
– Play/conversation sample with caregiver (especially in preschoolage children)
– Conversation sample with clinician
– Oral reading sample
– Pressure situations
• Stuttering Analysis
Stuttering Severity Instrument
SDA (Systematic Disfluency Analysis) (Gregory)
Illinois Clinician Stuttering Severity Scale (Yairi)
Real-time/online sample
Evaluation, cont.
• Attitudinal Measures
– Preschool-Age Clients
• KiddyCAT
• Informal measures (pseudo-stuttering)
– School-Age/Adolescent Clients
• CAT (Communication Attitudes Test)
• A19
• OASES (Overall Assessment of the Speaker’s
Experiences of Stuttering; different versions for
different ages)
• Informal measures (pencil and paper exercises;
Chmela and Reardon)
Evaluation, cont.
• Formal/informal testing of: speech skills;
language skills; voice; oral motor
structures; pragmatic skills; behavior;
attention; sensory skills
• Discuss findings/recommendations
– Therapy
– Referrals
– Considerations for schools
Evaluation, cont.
• REMEMBER: The most important aspect of
an evaluation is developing a solid picture
of the whole child.
– Think CALMS model
• Cognitive, Affective, Linguistic, Motor and Social
Assessment (Healey et al, 2004)
Let’s Review…
• Differential evaluation – differential treatment
– Addresses the complexities of a problem, considering
both subject and environmental variables in an
ongoing manner.
• Relationship
– Addresses the manner of interaction between all
individuals collaborating to assess and, if necessary,
treat the presenting problem.
– Starts from the first moment you meet child.
– Respect/listen to child’s opinions and ideas.
– Shapes what will be done in therapy.
Back to the Basic Principles
• Counter conditioning, deconditioning,
– Results in more productive behavior,
thoughts, and feelings.
• Modeling
– The most powerful and efficient teaching
procedure; is essential.
– Needs to be done in a variety of contexts
(e.g. location, audience, listener reaction).
– Both clinician and caregivers can provide
Basic Principles
• Guided practice
– Involves rehearsal of desired changes along
hierarchies of difficulty.
– Varying levels
– Why? How?
• Reinforcement
– Administered in a positive manner; provides
consequences for behavioral change.
– Be specific - remember your target.
– Spontaneous reinforcement – be a great observer.
• Self-monitoring, self-reinforcement
– Develops the client’s ability to assess more adaptive
behaviors and perceptions.
– Self cueing, visual reinforcement, family support
Basic Principles
• Generalization
– Results in learned behaviors occurring in similar situations or in
longer responses.
– Continual check-in on client’s motivations and goals.
– Client vs. caregiver goal.
• Transfer
– Is supported by systematic guided practice while manipulating
meaningful variable.
– Client ownership.
• Gradual dismissal, follow through, and maintenance
– Involves planned review and support to aid in preventing
– “The door is always open” – changes in communication
pressures and dynamics.
Basic Principles
• Consideration and integration of motor,
social-emotional, sensory, and cognitive
– Assists with planning and facilitating relevant
and functional treatment, ongoing problems
solving, and maintenance of progress.
• Now that we’ve talked about evaluation
and using the Basic Principles – let’s look
at some possible treatment activities for
our preschool, school-age, and adolescent
Treatment - Preschoolers
• Parental involvement
• Indirect Therapy
– Fluency-enhancing strategies
– Turn-taking
– Listening
• 5 Ps
Pointing out
• Lidcombe Program
• Easy Relaxed Approach - Smooth Movements (ERA-SM)
• Bunny/Turtle Speech
Treatment - School-Age
• Fluency Shaping – speaking fluently/speech
Modifying rate (pausing and phrasing)
Easy onsets
Continuous phonation
Easy Relaxed Approach – Smooth Movements
• Stuttering Modification – stuttering fluently
– Identifying stuttering; catching moments of stuttering;
modifying moments of stuttering
– Desensitization to moments of stuttering
– Post-stutter (cancelation), during-stutter (pull-out) and
pre-stutter (preparatory set) modifications
• Combination of both types
Treatment - School-Age Cont.
• Attitudes
– Explore feelings/fears about stuttering
– Informal tools (pencil/paper tasks)
• Speaking Situations/Fears/Hierarchy
• Operant programs
– Lidcombe
• Parental involvement
Treatment - Adolescents
• Many of the treatment approaches
mentioned previously for school-aged
clients are used for adolescents.
Adolescents: Special Considerations
• Already formed notions about therapy
• What do they want?
• Change speech?
• Change how they feel about stuttering?
• Parental involvement?
• What place does stuttering occupy in their lives
• Interactive writing
– Clinician initiates conversation on paper
– Continue on “paper”
• Set parameters
• They are involved in choosing goals
• Decision to have parents observe
Adolescents: Special Considerations
• 6 types of teen reactions when faced with stressful
situations, but have not yet integrated their identity with
societal demands/expectation (Elkind, 1998)
Anxious: worrying and not “doing”
Conforming: doing what other expect instead of what the teen
Self-punishing: negative self-talk, rejecting opportunities,
limiting of self
Obsessively competitive: gauging own performance against
others, putting others down, have to be the best
Angry: acting out verbally or physically, defiance
Fearful: avoiding, experiencing intense physical reactions
Adolescents: Special Considerations
• A Few Life Skills for Coping with Stress
(Schmitz & Hipp, 1995)
– Recognizing stress and understanding its physical and
emotional impact
– Differentiating coping from stress management
– Engaging in physical activity
– Learning methods that lead to relaxation
– Developing assertiveness
– Building supportive relationships
– Engaging in life planning
– Using positive self-talk
Cognitive Behavioral Therapy
• Developed from the work of Bandura, Ellis, Beck, Adler,
Meichenbaum, and others.
• Explores the relationship between the Cognitive,
Affective and Behavioral components of stuttering; helps
the patient to gain a clearer understanding of their
• Helps provide clarity to a complex experience for patient.
• Helps to objectify a patient’s experience and reactions to
• A great way to measure a cognitive shift/progress
toward being a more effective communicator.
“Acceptance and Commitment
Therapy” (Hayes, Strosahl, & Wilson, 1999)
• Form of CBA treatment
• ACT has been used for individuals who have survived trauma
(Follette & Pistorello, 2007)
• When people survive trauma, they often try to hide their pain
or hide from it (avoidance)
• Can living with stuttering be a traumatic experience?
• Steps to acceptance and moving forward
• Awareness to coping strategies/emotion response/thoughts
• Develop compassion/acceptance for self
• Psychological flexibility
» Mindfulness
» “Two sides of the coin can be true”
» Rational mind (thinking)
» Emotional mind (feeling)
» Wise mind (interaction of both)
Treatment Pointers
• Exploration of stuttering
• Understand their physical behavior: what are they doing to interfere
with forward flowing speech
• Cognitive Behavioral Analysis
• Desensitization (patient/parent)
• The feared “S” word
• Education
• Advertising
• Guided Practice
Vary degrees of modeling
Understanding the WHY and HOW; Changing behavior
Client-lead hierarchy
Transfer activities/Parent support
• Affective Communication
• Think big picture!
• Exploring pragmatics of language (eye contact, contributions to a
Treatment Pointers, Cont.
• Reinforcement: Keep it specific
• Be descriptive in your observations (appropriate for age)
• Lead client to reflect on own success
• Positive behavioral changes
Stuttering in a different/easier way (tight-loose)
Using an approach that promotes forward flowing speech
Client specific!!
Real-life situations
• An atmosphere where it’s okay to share feelings
• Don’t minimize, validate
Group Treatment
• Advantages
Opportunity to work on maintaining changes
Combat isolation
Open discussion of stuttering in safe environment
Monitor transfer of skills in social setting
Sense of community/support
Learn through observing the success of others
• Group Leadership Skills
• Active listening
• Reflecting
• Summarizing
• Facilitating
• Questioning
• Linking
• Supporting
• Terminating
**Not a full list**
(Corey, 2008)
Communicative Competence:
Become an Powerful Communicator
• Assertive
– Willingness to communicate with others.
• Confident
– Appropriate eye contact and posture when meeting
and greeting new individuals.
• Effective
– Manner of communication: verbalizing in complete
sentences; ability to initiate onset of phonation and
smooth movements into and between sounds, and
between words; phrasing; rate of information flow;
social language skills, etc.
• “Conversational Box”
Determining Goals
• Conversational discrepancies
– Difference between environmental
(or personal) expectations and what an
individual does
– Create “Talking Pie” to help determine
– Think specifics – what?, where?, with whom?
– Consider what is most important to the child!
Open Discussion
• Why do clients stop coming to therapy?
– Let’s discuss.
Helpful Resources
• Stuttering Foundation
– http://www.stutteringhelp.org/
• National Stuttering Association
– http://www.nsastutter.org/
• Stuttering Home Page
– http://www.mnsu.edu/comdis/kuster/stutter.html
Helpful Resources
• Fluency Team at Cincinnati Children’s
Hospital Medical Center
– Jaime Hannan, MS, CCC-SLP
• [email protected]
– Robert Reichhardt, MA, CCC-SLP
• [email protected]
• Board Recognized Fluency Specialists
– Look up for your area:
• http://stutteringspecialists.org/
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Hannan & Reichardt Differential Diagnosis & Treatment for