Assessment and Treatment of
School-Aged Children Who
Stutter
Presentation to Newton Speech-Language Department
January 10, 2008
Christine LaFleur, MS, CCC-SLP, BRS-FD
Definition
• Stuttering is a disorder of neuro-motor
control of speech, influenced by the
interactive processes of language
production and intensified by
temperament and complex learning
processes.
Components of Stuttering:
• Core Behaviors
• Secondary Behaviors
• Feelings and Attitudes
Components of Stuttering:
• Core Behaviors
– Overt speech behaviors associated with
stuttering
– Repetitions, Prolongations, and Blocks
Secondary Behaviors:
Reactions to Core Behaviors
– Learned vs. involuntary
– 2 categories: Escape and Avoidance
Escape Behaviors
A way of getting a word out
– Examples: eye blinks, head nods,
interjections of extra sounds (um, like, uh),
movements of the extremities
– Happens during MOS (moment of stutter)helps a person escape the stuttering, get
the sound out
Avoidance Behaviors
Postponing or avoiding a stutter
– Examples: avoiding words, situations, use of
postponements, starter devices
– Precedes stuttering
– Conditioned (learned) behaviors: speaker anticipates
stuttering, recalls negative experience and resorts to
behaviors previously used to escape MOS and gain
emotional relief
– Behaviors become habituated and resistant to change
Feelings and Attitudes
• Feelings
– Emotional reaction (overt or covert) to stuttering
• Feelings feed stuttering: may increase effort and tension that
exacerbate stuttering
• Attitudes
– Feelings that have become pervasive, based on
years of experience, and have become part of a
person’s beliefs
• Begin to inform and shape negative perception of self and
communication
• “I can’t…….
• Project attitudes on listener—develop a set of beliefs about
them, what they think @ PWS (weird, nervous, stupid…)
• May have a significant impact on daily activities
Iceberg Analogy
Talking to Kids about Stuttering
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Reduces distress about stuttering
Reduces fear and avoidance
Decreases feelings of guilt and shame
Establishes open and honest communication
De-mystifies what’s happening
Use concrete, neutral, kid-friendly terms:
– bumpy/smooth
– rabbit/turtle
– frog/snail
The Purpose of a Fluency
Assessment
• To Determine:
– The presence of a stuttering disorder
– The type and severity of the disorder
– The impact of stuttering
– Profile of risk/precipitating factors
– Potential benefits of speech therapy
Components of a Fluency
Evaluation
• Review of Background Information
– Case History
– Client Interview
– Client’s purpose in seeking evaluation
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Speech Sample Analysis
Assessment of Feeling and Attitudes
Speech and language testing
Stimulability/Trial therapy
Diagnostic Considerations
• Classroom Observation
• Teacher Interview
– How is child communicating in
school?
– Participation?
– Teasing?
– How does teacher react to
stuttering?
Diagnostic Considerations…
• Student Interview
– “Talk about talking”
– Do they think they have trouble talking?
• Where? When? How?
– Can they “show me” their stuttering?
– Any avoidances?
– Have they been teased?
– Feelings and attitudes?
Background Information
• Significant medical history
• Family history of stuttering and/or other speechlanguage difficulties
• Developmental history
• Stuttering history and current speech patterns
– Onset, development, length of time stuttering, changes in
types of stuttering, etc.
• Educational history and current performance
• Social/Emotional Information
– Temperament
– Reactions to speech
– Social/pragmatic skills
Speech Sample
• 300 to 500 syllables of conversational
speech
• 200 syllables of reading passage
– at or below student’s reading level
Components of Speech Sample
Analysis
1.
Frequency of Disfluencies
typically expressed as % of stuttered syllables or words
each syllable or word can be stuttered only once
2.
Types and Frequency of Stutters
e.g. part word repetitions, monosyllabic whole-word
repetitions, prolongations, blocks
3.
Ratio of Stutters to Total Disfluencies
4.
Pattern of Disfluencies
e.g. clusters
5.
Duration of Disfluencies
Average length of 3 longest blocks or stuttering events
Components of Speech
Sample Analysis, cont..
6. Rate of speech
7. Physical concomitants/Secondary behaviors
e.g. physical movements, extra sounds, breathing
irregularities, or vocal changes
8. Escape and avoidance behaviors
Formal Fluency Assessment
Tools
• Stuttering Severity Instrument for Children &
Adults-3rd Edition (SSI-3) G. Riley, 1986; ProEd
• Stuttering Prediction Instrument (SPI) G.
Riley, 1981, Pro-Ed
• Protocol for Differentiating the Incipient
Stutterer (SIP program) Pindzola, 1987, Proed
Assessment of Feelings and
Attitudes
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Feelings about Stuttering
Struggle Behaviors
Escape Behaviors
Avoidance Behaviors
Beliefs about Stuttering
Formal Assessment of Feelings and
Attitudes
• Modified Erikson Scale of Communication Attitudes (S24)
• Communication Attitude Test
• A-19 Scale for Children Who Stutter
• Stutterer’s Self-Rating Scale of Reactions to Speech
Situations
• Teacher Assessment of Student Communication
Competence
• Perceptions of Stuttering Inventory (PSI) Locus of
Control Behavior Scale (adult)
Informal Assessment of Feelings
and Attitudes
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Direct and indirect questions
Observations
Pencil and paper tasks
SFA publication:
– Chemela & Reardon, The School Age
Child Who Stutters: Working Effectively
with Feelings & Attitudes
Trial Therapy
• Attempting therapy techniques during
assessment to
– Determine stimulability for changing motor speech
behaviors
– Assist in prognosis
– Guide treatment recommendations
– Possibly provide information for differential
diagnosis of possible neurogenic stuttering
• Clinician explains, models, then guides
Making a Diagnosis
• Is student stuttering?
• What are the risk factors present for
persistent stuttering?
• How is stuttering impacting this student, and
to what extent?
• What is the severity level?
• Is therapy recommended?
• What are the goals and objectives?
Making a Prognosis
• What are positive prognostic factors?
– Family and school support
– Stimulable to trial therapy
– Solid speech and language skills
– Little to no risk factors
– Little to no awareness or reaction to stuttering
• What are complicating prognostic factors?
– Significant risk factors
– Speech and language or learning difficulties
– Significant reactions to stuttering
– Length of time stuttering
– Lack of family support/willingness to change
– Presence of other disabilities
Special Education and
Stuttering
Eligibility process
1. Is there a disability?
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Determined by evaluation
2. Is the child making effective progress?
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E.g. participation, reading, etc..
Holistic view of child as a learner
Ability to access the academic curriculum
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Including social curriculum
3. Does the student require specialized instruction?
Treatment Considerations
• Spontaneous recovery is unlikely
– Most spontaneous recovery occurs within 1
year and/or by the age of 6-7
• Goal is Improved Communication
– Being able to say what they want when they
want, how they want, to whom they want
• Individualized, broad approach vs. a
singular focus on fluency
Treatment Considerations, cont…
• Helping CWS and family accept and deal with “chronic”
nature of stuttering
• Therapy needs to be fun
• Enlist children in creating goals and objectives
– Make them partners in therapy
– Draw on their expertise
• Engage Teachers
• Parent/family involvement
• Transferring newly acquired skills to new settings
Treatment:
General Goals and Procedures
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Reduce Frequency of Stuttering
– Often referred to as Fluency Shaping
– Appropriate for all levels
– Obtained through a variety of methods
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May involve use of DAF, reduced speech
rate, monitoring, etc.
– Degree to which frequency can be
reduced is varied
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Depends upon a number of factors
Treatment:
General Goals and Procedures, cont…
• Reduce the Abnormality of Stuttering
– Also known as Stuttering Modification
• Modify long and tense stutters into more easy
and relaxed ones
• Reduce influence of negative emotions and
attitudes
– Techniques include: identification,
cancellation, pull-outs, pseudo-stuttering,
advertising, slide-ins
Treatment:
General Goals and Procedures, cont…
• Reduce Negative Feelings about
Stuttering and about Speaking
– Intent is to counter-condition negative
feelings and associations with stuttering,
thereby diminishing their impact
– Associate stuttering with neutral or positive
experiences
– Counseling is also a component, allowing
client to express feelings about stuttering
Treatment:
General Goals and Procedures, cont…
• Reduce Negative Thoughts and
Attitudes about Stuttering and about
Speaking
– Working on attitudinal/cognitive aspects
• Helping students examine their beliefs and
thought processes
• Explore how what their thinking influences their
feelings and actions
Treatment:
General Goals and Procedures, cont…
• Reduce Avoidance
– Entails directly addressing fears surrounding
stuttering
– Techniques may include tallying, freezing,
confrontation of feared situations, and pseudostuttering in a supportive environment
– Need to teach new responses to situations—
counter-condition maladaptive response
Treatment:
General Goals and Procedures, cont…
• Increase Overall Communication Abilities
– Address pragmatic skills (if necessary)
• eye contact, turn-taking, interrupting, initiating
– Client’s habits may be family habits
– Group therapy is an excellent forum for practicing
these skills
• Educate family, teachers and others about
nature of stuttering and treatment
General Goals and Procedures, cont…
Transfer skills to familiar, novel and feared
contexts
– Crucial in establishing long-term changes
– Need to get client out of the therapy room and into
functional situations
– Introduce fluency disruptors
Clinical Procedures:
Beginning Therapy
• Cultivate environment of acceptance and
exploration
• Talk about the speech mechanism and
stuttering
Mr. Speech Guy
• Explore stuttering together
– Goal is to desensitize, de-”awfulize”
• Build child’s tolerance for talking about and “staying in”
stutters
– Ask child to teach you how to stutter
– Comment on stuttering in a neutral, accepting
manner
– Play with different kinds of stuttering: hard, easy,
etc.
• Explore Secondary Behaviors
• Explore Feelings and attitudes
– Use words, pictures, any medium of interest to
child
– Important to communicate acceptance and that
reactions are normal and understandable
Improving Fluency
• Easy Onsets
– Speech begins from a place of reduced muscle tension in the
vocal tract
– Gentle onset of voicing
– Start with voiced continuants and vowels, move to fricatives and
stops
• Light Contacts
– Produce consonants with relaxed articulators
– Contrast “light” contacts with “hard” ones
• Flexible Rate/Easing in/Easy Beginnings
– Combine easy onsets and light contacts
– Focus on the first vowel sound in a word
– Initial consonant is lightly articulated and production of
the first syllable is stretched
» Ex:
m
o
nkey
– Does not need to be applied to whole utterance, just
points where stuttering occurs
• Typically the first word of a sentence and natural
pauses
• Can also be applied to feared words
Improving Fluency…
• Proprioception
– Focusing on how speech “feels” rather than
how it “sounds”
– Tuning into sensory feedback from speech
muscles
• Contrast stuttered speech with easy speech—how
does it feel?
– Remember—stuttering is a disorder of muscle
tension
Putting it all together….
• Combining flexible rate, easy onsets, light contacts and
proprioception…
– Give it a name: e.g. Superfluency, Easy Speech, Smooth
Speech
• Hierarchical approach
• Begin with imitation of the clinician
gradually shift to spontaneous production
• Focus on transferring skills to new contexts and desensitizing to fluency disruptors right away
Reducing Severity of Stuttering
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Stuttering Modification approach
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Goal is improved fluency, improved communication,
and increased confidence in ability to manage
speech
Techniques
– Saying words in 3 ways
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Regular, Easy, Hard
Locating tension
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Confront and explore stuttering
Increase proprioception
Reducing Severity of Stuttering…
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Cancellations
– Complete stuttered word, then say it again fluently
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Pull-outs
– Begin by having child “stay in” MOS--keep repeating
or prolonging, modify to an easy stutter and release
rest of word
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Voluntary stuttering
– Inserting stuttering into real speech
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Transfer and Independence
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SFA Publication:
–
Dell, C. (2000)Treating the School-Age Child Who Stutters
Other Treatment Approaches
• ERA-SM: Easy Relaxed Approach with
Smooth Movement
– June Campbell and Hugo Gregory
– ERA-SM Technique
• Slower rate of speech with smoother transitions from word to
word
• Changes occur at the beginning of a word, do not continue
for the entire sentence
• Speech is “chunked” into phrases using appropriate pausing
• Also uses a hierarchical approach
ERA-SM continued…
• Also includes use of stuttering modification
techniques to reduce severity of residual
stuttering
• Parents are taught ERA-SM and encouraged
to model it at home
• Teachers are counseled on how to support
student
• Once child exits therapy, 12-18 months of
monthly “check-ups” are recommended
Practice…
Paperclip
Bicycle
Cupcake
Youkilis
Varitek
Autograph
Lowell
Raspberry
Eyelashes
Mountain bike
Telephone
2007 World Champions.
Time is of the essence.
Climb every mountain.
Smooth speech takes practice.
Read ‘em and weep.
I like monkeys.
Friday is my favorite day.
Elvis has left the building
When is summer vacation?
My mother is a nurse.
Cats are fuzzy and friendly.
Published
Treatment
Programs/
Guides
Addressing Feelings and Attitudes …
• Allow child to talk, write or draw about them
• Validate and acknowledge feelings
• Educate kids about time pressure and that they can
manage it
• Rank order speaking situations from easiest to
scariest—
– Tackle each situation using new tools, including
pseudo-stuttering
– Lots of positive feedback every time a CWS confronts
a feared situation!!!
Before Therapy
One Year into Therapy
Reframing Thoughts and Attitudes
• Modify
distorted/negative
beliefs via successive
experiences
• Contrast beliefs with
reality
• Reframe thoughts in
more positive, but
realistic manner.
Dealing with Teasing/Bullying
• Clinician’s role:
– Try to minimize teasing as much as possible in child’s
environment by counseling and educating parents,
siblings, teachers, etc.
– To support CWS
• Teacher’s role:
– Establish a classroom atmosphere of acceptance of
differences and zero tolerance for teasing and
bullying
– Discuss teasing episodes discreetly and ask the child
who stutters what he or she needs from you
However, we cannot eliminate all teasing…
• The student being teased needs:
– Strategies/defenses to help them feel empowered to
speak up for themselves
– Options to pick what feels most comfortable for them
– Validation—words do hurt
– Education
• Teasing is not about them—it is about the person who teases
• May help “de-personalize” teasing
– Practice
• Role play different responses, find what works
Strategies for Dealing with Teasing
• Responses vs. Reactions
– Acceptance
• “I know I stutter, but I’m working on it…”
– Confrontation
• “That hurts my feelings, stop it.”
– Humor
• “You call that stuttering? Here, let me show you…”
• “I stutter—what’s your problem?”
– Education
• Classroom presentation
– Takes on role of “expert,” a role with value, strength and
importance
QuickTime™ and a
AVC Coding decompressor
are needed to see this picture.
Resources for teasing
• National Stuttering Association Publication
• http://www.mnsu.edu/comdis/kuster/journal/roth.html
• http://www.stutterisa.org/CDRomProject/teasing/tease_b
ully.htm
• http://www.parentpals.com/gossamer/pages/Detailed/63
2.html
Working with Teachers
• Teachers can be allies and partners
• SLP role is consultative and supportive
• Classroom suggestions:
– Model pauses, turn-taking and “think time”
– Have a 1:1 conversation with the student about needed
accommodations in the classroom (e.g. being called on, reading
aloud)
– Expect the same quantity and quality of work as for all students
– Focus on content of student’s message versus speech
– Don’t tell the student to “slow down” or “relax”
– Don’t complete words or talk for him or her
Treating Concomitant
Speech& Language Issues
• Conture, Luoko and Edwards
– Treat phonological errors and stuttering at the same time
• direct treatment for stuttering
• indirect treatment for phonological errors
• Diane Hill
– Work on fluency first
– Use of hierarchical approach naturally incorporates language
remediation tasks
– Once fluency is established at sentence level, introduce
phonology or language targets in low-key approach
– While continuing to work on fluency, introduce one activity per
session to target concomitant problem
– Models pauses for word-finding
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Nan Bernstein Ratner…
– Concurrent treatment
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Fluency is treated simultaneously with other disorder
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Blended Model
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Child practices fluency only with mastered
language/speech structures
Language/speech targets are practiced with slow rates,
gentle onsets, relaxed movements, ample pauses and
turn-taking
As new targets are mastered, they are practiced with
more “normal” speech
Cyclical Model
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Alternates fluency with speech-language targets
Provides children with initial bursts of new skill
acquisition followed by opportunities for transfer and
generalization
Helpful Web Sites
• The Stuttering Home Page, Minnesota State
University, Mankato
• The National Stuttering Association
• Stuttering Foundation of America Home Page
• Division 4, Fluency and Fluency Disorders
• Specialty Board on Fluency Disorders
• www.childhoodstuttering.com
• Stuttering Center of Western
Basic Facts about Stuttering
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Onset
– Most likely between 2-5 years of age (range is 18 months to 12
years)
– Often coincides with a period of rapid expansion of speech and
language skills
Prevalence
– approximately 1%
Incidence
– approximately 15%
Spontaneous recovery
– approximately 50-75%
Gender
– 3:1 ratio girls to boys
Genetics
– Research is pointing to an inherited, genetic predisposition
Conditions that Reduce
Stuttering Severity
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Speaking in a non-habitual manner
Choral reading
Shadowing
Singing
Using a Metronome
DAF
Reduced Speaking Rate
Speaking while alone and to animals and small children
Not trying to hide stuttering
Playing a “role”
Adaptation
Conditions that Exacerbate Stuttering
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Telephone
Saying one’s name
Telling jokes
Repeating a misunderstood message
Waiting to speak
Speaking to authority figures
Public speaking
Trying to conceal stuttering
Excitement
Fatigue
Illness
Famous People Who Stutter
(a partial list)
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Tiger Woods
Johnny Damon
Nicholas Brendon
James Earl Jones
Winston Churchill
Bruce Willis
Julia Roberts
Bill Walton
John Updike
Jimmy Stewart
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Lewis Carroll
Carly Simon
Prince Albert of Monaco
Marilyn Monroe
U.S. Senator Joseph
Biden
Dominick Dunne
Tom Sizemore
Charles Darwin
King George VI
Jack Welch