Interactive Learning with
Fluency Specialists
The Center for
Stuttering Therapy
Presenters
Mary Wallace, M.A., CCC-SLP, BCS-F
 Patty Walton, M.A., CCC-SLP, BCS-F
 Whitney Noven, M.S., CCC-SLP
 Matthew Goldman, M.A., CCC-SLP
 Bethany Tileston, M.A., CCC-SLP
 Kailey Silliman, M.A., CCC-SLP
 Amber Rea, B.S., Graduate Intern
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Introduction
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4 General Topic Areas
Assessment
 Treatment and Therapy Strategies
 Treatment Planning
 IEP Goal Writing and Assessing Progress
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Breakout Sessions
Assessment
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Preschool Diagnostic Guidelines
Early identification is critical-best prognisis
 Differential diagnosis of typical vs. atypical
disfluencies
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Stuttering Prediction Instrument (SPI)
Danger/warning signs
Risk factors
Other indicators of concern
Stuttering Prediction Instrument
(SPI) Riley,1984
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Assesses history
Rates child’s reactions to stuttering
Measures part word repetitions based on # of
RPI, schwa, tension and abruptness
Measures prolongations based on duration,
phonatory arrest and articulatory posturing
Yields a frequency score (100 word sample)
Yields a severity rating for both chronic and
non-chronic stuttering
Appropriate for children 3-8 years of age
Danger/Warning Signs
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Multiple part word repetitions
Schwa vowel
Prolongations
Struggle and tension
Pitch and/or loudness rise
Tremors
Avoidance
Moment of Fear
Difficulty initiating airflow and voicing
Risk Factors
Family history of stuttering
 Male gender
 Sensitive temperament
 Other speech language concerns
 Time post onset
 Parental concern
 Negative awareness
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Other Indicators of Concern
Clustering
 Ratio of typical/atypical disfluencies
 Changes in cycles of stuttering
 Mid utterance disfluencies
 Multiple disfluencies per utterance
 Sensory motor concerns
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Diagnosis of School Age
Stuttering
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Ages 7-12
No longer rely on danger signs and risk factors
to assess stuttering, instead we need to
consider:
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What is the child doing physiologically when
stuttering?
How is the child reacting to moments of stuttering?
What are the child’s attitudes and emotions
regarding stuttering?
Formal vs. subjective assessment
Bennett, 2006
Describes assessment of fluency in the
school aged child as a “detailed, thoughtengaging process” where the goal of
assessment is to understand thoroughly
the client’s speech behaviors, thoughts,
and feelings”
 Portfolio approach (Yaruss 2013)
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Formal Assessments
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Riley Stuttering Severity Instrument
(RSSI-3); (RSSI-4) (2008)
Yields a severity rating
 Only quantifies stuttering behaviors
 Does not assess for more covert behaviors
such as avoidance behaviors and
postponement behaviors (uh, um)
 Does not provide a basis from which to plan
treatment
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Test of Childhood Stuttering
(TOCS)
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Logan, Gilliam and Pearson (2009)
Yields a severity rating
4 Subtests: rapid picture naming, modeled
sentences, structured conversation, narration
Limitations:
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based on reduction of linguistic complexity in the test items
awkward administration
Only counts disfluencies in the first three words of an
utterance
Does not provide adequate information to plan treatment
OASES-S
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Overall Assessment of the Speaker’s Experience
with Stuttering: Yaruss, Coleman & Quesal (2010)
For ages 7-12
Purpose of the tool is to assess the adverse impact
that school age children experience as a result of
stuttering
Administration time: 20 minutes
Scoring time: 5 minutes
Results in an “impact”score based on a severity
rating scale
Using the OASES in the School
Setting
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Helps the SLP understand how the child responds to
stuttering in general
Determines the affective, behavioral, and cognitive
reactions the child has to stuttering
Assesses how stuttering affect’s the child’s ability to
communicate in various settings: school, home and
work.
Quantitatively determines how the stuttering is adversely
affecting the child’s quality of life
Provides pre/mid/post therapy data to assess progress
Provides topics for discourse related to attitudes and
emotions
Subjective Assessment
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Critical to planning treatment
Based upon observation of the child’s speech in
conversation and oral reading
What to look for:
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Primary behaviors (nature and duration)
Secondary behaviors (linguistic or physical)
Tension (loci and degree)
Airflow management (including control of air
pressure and adequate respiratory support)
Voice production (pitch, vocal strength, loudness)
Zebrowski 1997
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“The management of children who stutter
depends not on a formula but on the
decision making and problem solving
skills that are part of the armory of every
well-trained clinician”
Breakout Session 1
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Assessment
Treatment and Therapy
Strategies
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General Therapy Components
• Increased length and complexity of utterance hierarchy
• Modeling
• Reinforcement
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Importance of Combining Fluency Shaping and
Modification Strategies
Fluency Shaping Strategies
Modification Strategies
Case Study
Using a Linguistic Hierarchy
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Single Words
Two Words
Three Words
Carrier Phrases
Extended Carrier Phrases
Prepositional Phrases
Multiple Phrases
Simple Sentences
Complex Sentences
Asking Questions
Conversation Relating to a Structured Activity
Spontaneous Conversation
High-Level Demand Task
Storytelling
How To Use the Hierarchy
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Start at easiest level and progress through each level
after obtaining 95% success over multiple sessions
Exception to this is jumping to carrier phrases quickly
once the child gets the concept of the strategy
Start sessions at a level below that obtained in previous
session
End sessions at a level where there is a high level of
success
Therapy sessions are designed for maximum success
by moving up and down in hierarchy as needed
Modeling of Strategies
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Modeling of therapy strategies is critical
Clinician models 100% of the time in initial stages of
therapy
Model is initially slightly exaggerated but produced with
normal rhythm and prosody
Rate of model increases over the course of therapy and
exaggeration decreases
Reinforcement
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Reinforcement is constant and positive
All attempts are praised and encouraged
Encouraging praise is more effective than evaluative
praise
Reinforce the child’s use of strategies, not fluency
Combining Fluency Shaping
and Modification Strategies
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Fluency Shaping Therapy
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Helps the child speak more easily through a variety
of strategies
Strategies are chosen depending on the child’s age
and the way they are stuttering
Modification Therapy
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Helps the child stutter more easily, reduce struggle
and tension and react less to moments of stuttering
The need and degree of modification strategies are
dependant upon how negatively the child is reacting
to stuttering
Fluency Shaping Strategies for
the Young Child
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Stretching or easy speech
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Stretch- slight prolongation of the initial sound or syllable in a
word with a smooth transition into the vowel
Used at the beginning of phrases or utterances
Easy speech- incorporates several features which increase
fluency
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Slower than normal speech rate
Easy vocal onsets
Soft articulatory contacts
Sustained voicing
Slight overarticulation
Normal rhythm and prosody
Fluency Shaping Strategies for
the School Age Child
Stretching
 Easy voice
 Soft contacts (slides)
 Continuous voicing
 Sound blending (hooking-on)
 Chunking and Phrasing
 Overarticulation
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Modification Strategies
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Bouncing (also appropriate for the young child)
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Pullouts
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Voluntary use of easy, effortless repetitions
Produced with continuous voicing and light articulatory contacts
Limit bounces to 2-3 repetitions per instance
Bounces should be tension free and even in tempo
Changing a stuttering moment by releasing tension and allowing the
word to finish easier
Can stretch or bounce out of harder moment of stuttering
Holding and Tolerating
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Staying in the moment of stuttering to decrease/prevent the negative
response to stuttering
Voluntary Stuttering in Structured
vs. Unstructured Therapy
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Clinical Research Question:
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In the case of a four-year, nine-month-old boy
identified with a severe beginning level
stuttering pattern, is structured therapy
implementing the stuttering modification
technique of “bouncing,” associated with
marked decreases in the secondary stuttering
behaviors of eye widening and vocal fold
tremor, as compared with unstructured
therapy?
Participant: Milo
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4 year, 9 month old boy
Enrolled in preschool
Diagnosed with a severe beginning level stuttering
pattern
Currently being seen at a university clinic for speech and
language intervention
Individual fluency therapy sessions twice a week for
forty-five minutes
Health concerns: asthma, enlarged adenoids and right
side hypotonia. Participant receives dietary supplements
to maintain daily nutrition and promote growth.
Technique
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Voluntary Stuttering (Bouncing)
 Promotes tension reducing patterns that lessen sensitivity
and avoidance of stuttering
Example from Walton & Wallace (1998) p. 38:
Clinician: “What ga-ga-game do you want to play today?”
Child: “I want to play Candyland.”
Clinician: “Great idea, I like Candyland.”
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Constant model used by the clinician at the start of every
utterance in both conditions
Intervention
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Molecular Analysis
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Conditions (Alternating Treatment Design)
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Eye widening
Vocal fold tremor
Unstructured therapy (15 min.): Child-centered conversation and play;
clinician model of bouncing
Structured therapy (15 min.): Clinician-directed activities and games;
clinician model of bouncing; direct treatment approach at the 1-3 word
level
Data Collection Procedure
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Data was collected over a six week period
Obtained through video recording which was analyzed by the clinician
Baseline and Final Data collected using an identical procedure for each
condition
Quantitative Data
Qualitative Data
Questionnaire
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Prior to study, Milo stuttered
approx. 80%
Since the start of the study, he
stutters 50% of the time and
much more smoothly
Milo does not remain “stuck”
at the beginning of a statement
Presents fewer secondary
behaviors such as eye
widening, grimacing and
slapping of leg
Has begun to generalize his
speech tools at home and in
preschool
Informal Interview
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At the beginning of the study,
Milo did not note any
perceived difficulties with
speech
Near end of study, Milo began
to discuss troubles of speech
fluency
When encountering hard or
bumpy speech, Milo said “he
just can’t get it out”
Acknowledged how it feels
when things are said “easy”
vs “hard”
Conclusion
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In the case of a preschool-aged child identified
with a severe beginning level stuttering pattern,
both structured and unstructured therapy
utilizing the stuttering modification technique of
bouncing were evaluated. It was determined that
structured therapy was more effective in
reducing the presence of secondary stuttering
behaviors of eye widening and vocal fold tremor.
Breakout Session 2
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Treatment and Treatment Strategies
Treatment Planning
Education & Identification
The child knows something is wrong/not
like other kids- what is it?
 Educating the child about stuttering will
help them better understand that it isn’t
their fault and that you can help.
 Help the child identify his stuttering
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Stuttering Iceberg
Addressing Attitudes and
Emotions
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Drawings can be used to express
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feelings (isolation, shame, embarrassment)
beliefs (what I’m doing is bad and so am I)
perceptions (people don’t want to/won’t listen)
experiences (teasing, being talked for)
Writing activities such as journaling allow them to write about their
day, communication choices, feelings, etc. Writing stories about
stuttering in general, specific experiences, how they imagine a
specific event happening if they stutter
Self Talk and Positive Affirmations
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negative messages about themselves and their talking (I can’t say that, I can’t
join that team/group/class because I stutter)
positive affirmations (I have choices, I can stutter my way, What I have to say is
important)
Addressing Attitudes and
Emotions
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Problem solving will help the child feel empowered and let them
think about the situation based upon what they know is true
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Letters to the teacher will educate the teacher about stuttering and
the child’s needs – EMPOWERING–
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What actually happened?
What could I have done?
What would I rather do next time?
Can I make any changes to this situation now?
allows them to introduce themselves as a person who stutters
explains what is difficult for them in class
things that are helpful and not helpful for the teacher to do
Gracie’s Letter
Working With Parents
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Accepting their child’s stuttering and at the same time letting their
child know they accept them.
What experience do the parents have with stuttering- is there a
family history, positive or negative encounters
Asking the parents what they expect from their child’s speech at
home
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Is it realistic?
Speech tools in the therapy room vs home
Helpful vs Hurtful support at home
Educating parents about stuttering
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Myths vs facts
What can they expect from therapy
Experiences/feelings their child has about their stuttering (drawings and writings
are very helpful)
What kids want their parents to
know about stuttering
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Stop bugging me
It’s ok to talk about stuttering
I want to be called on more in class
“You heard me stutter twice when I got home I felt
myself stutter all day and lived you can live too”
Stuttering is not FUN!!!
I can still be happy even though I stutter
Everything is NOT about NOT
Stuttering makes me, me!
Working With Teachers
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Increasing communication in the classroom
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Reduce stressors in classroom
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Student to teacher
teacher to student
student in class
Identify what they are: being called on, being called on
alphabetically or in rows, reading aloud, substitute teachers
(specific to each student)
Problem solve together
Generalization in classroom
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When to integrate speech tools
Classroom Presentation
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Work with your student to make this their
presentation
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Talk about famous people who stutter
Talk about the speech machine and how speech is produced
Teach the children about what stuttering is
Talk about what friends can and cannot do to help the CWS
Show the DVD “Stuttering for Kids by Kids”
Teach all the children how to stutter on their their names-for
candy!
www.stutteringhelp.org and www.westutter.org
Friends Day!!!! April 18th
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FRIENDS: The National Association of
Young People Who Stutter
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FRIENDS one-day conference April 18th,
Jefferson Academy
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Mission: To provide support for young people
who stutter and their families
ASHA CEU’s for SLP’s
www.friendswhostutter.org
Breakout Session 3
Treatment Planning
 Working with Attitudes and Emotions
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IEP Goal Writing and Assessing
Progress
Writing SMART fluency goals
 Examples of goals
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Fluency shaping
 Modification
 Identification, education, etc
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Monitoring Progress
Specific
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Skills and techniques used in therapy
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Increasing use of speech tools in specific setting
• i.e. use of spontaneous easy speech during a game or
other structured activity
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Discussing stuttering with peers/adults, increasing
disclosure
• i.e. student giving a classroom presentation about
stuttering, writing a letter to the student’s teacher
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Increasing participation in the classroom
• i.e. student voluntarily raising hand to answer a
question, participating in discussions, sharing ideas
with peers
Measurable
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Should involve an increase in the
count/percentage of use of speech tools
 i.e. Student will use his easy speech
spontaneously in 8/10 opportunities
NOT reduction in stuttering
 i.e. Student will not stutter during circle time
Achievable
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Goals should never target 100%
Should be scaffolded:
 Increase in linguistic complexity
• i.e. what level of the hierarchy is being targeted
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Spontaneous vs. imitative responses
• i.e. student repeating a model vs. student
responding spontaneously
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Across various situations for generalization
• i.e. therapy room vs. hallway vs. classroom
Relevant
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Goals should be unique to the student
Based on their current level of performance
Decrease anxiety and increase participation
Promote positive social interaction in their
learning environment
Time-bound
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Can be completed in a specific time frame
A goal should be challenging yet still
attainable, to a degree that it could be
completed within the IEP period.
 i.e. could move from single word level to
carrier phrase or multi phrase level within IEP
period, but less likely to go from single word
level to conversational level within IEP period
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Example Goals
Fluency Shaping
 Modification
 Identification
 Reduction of Secondary Behaviors
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Fluency Shaping Goal
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In order to increase fluent speech, Timmy will
use a fluency shaping strategy (stretches, easy
onsets, voice on, etc.) without prompts to begin
80% of carrier phrases during a game, in the
therapy room, while working 1-on-1 with the
SLP.
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Baseline: Using fluency shaping strategies on
30% of 3-word utterances and 20% of carrier
phrases in structured activities.
Modification Goal
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Susan will independently use a stuttering
modification technique (bounces, pull-out, slideout, cancellation, etc.) 10 times during
spontaneous speech, in a 30 minute therapy
session with the SLP and one familiar peer.
 Baseline: currently producing 10 per session
with frequent prompts (1 per minute).
Identification Goal
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In four consecutive meetings in the therapy room,
Nicholas will identify a situation, sound, conversation
partner or specific trigger that was a challenge to his
fluency during the week, and will discuss how this
affected his speech, as well as possible next steps.
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When prompted following a block of >.5sec. (or in a
clinician-modeled block), Nicholas will correctly identify
the trouble sound, location of the block, and type of
sound (popping, blowing, buzzing, etc.), independently
on 75% of opportunities to increase proprioception and
gain awareness of speech mechanisms.
Reduction of Secondary
Behaviors
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Alejandro will replace the use of “um” and “uh”
as a secondary behavior by using a brief pause
followed by a stretch or bounce to begin a
phrase while speaking in the classroom during
a structured activity, with SLP present, on 60%
of utterances.
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Baseline: currently 95% in therapy room in
conversation following a single prompt.
Monitoring Progress
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Moving up the hierarchy
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How the stuttering pattern changes
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i.e. carrier phrase level to question level
i.e. increase in part-word repetitions and
decrease in prolongations, decrease in struggle
and tension
Student’s willingness to discuss stuttering
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i.e. completion of worksheets for attitudes and
emotions in the therapy room, discussing hard
speech vs. easy speech
Breakout Session 4
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IEP Goal Writing and Assessing Progress