A Review of Stuttering Intervention
Approaches for Preschool-Age and
Elementary School-Age Children
Aimee Sidavi
Renee Fabus
Brooklyn College, Brooklyn, NY
T
his article summarizes the literature regarding
different stuttering intervention approaches that
have been used with preschool-age and early
school-age children. The following information for each
approach is presented: name, purpose, components, and
limitations.
Stuttering treatment is a contentious issue for speech-language pathologists (SLPs) and has posed a pressing challenge in the field of speech-language pathology for decades
(J. C. Ingham & Riley, 1998; Yaruss, Coleman, & Hammer,
2006). There are many treatments for stuttering; however,
there is little agreement as to which should be used and
when treatment should begin (especially for preschool- and
school-age children). Treatment for stuttering includes
ABSTRACT: Purpose: This article describes different intervention approaches for preschool and school-age children
who stutter, including the name of the approach and its
components and limitations.
Method: A review of the literature was conducted to
summarize and synthesize previously published research
in the area of stuttering treatment. The goal of this literature review was to increase the clinician’s knowledge
base about different intervention approaches that are
used with children who stutter. If a clinician has an extensive understanding of intervention techniques, then he
or she can conduct well-developed therapy sessions.
Conclusion: Despite the increasing size of the literature
in the area of stuttering, there remains a dire need for
evidence-based intervention approaches.
KEY WORDS: stuttering, intervention approaches, preschool children, school-age children, literature review
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various techniques and methods: indirect and direct (R. J.
Ingham & Cordes, 1998), stuttering modification (Guitar
& Peters, 1980; Peters & Guitar, 1991), fluency shaping
(Blomgren, Roy, Callister, & Merrill, 2005; Guitar, 1998),
Lidcombe Program, altered auditory feedback (Armson
& Stuart, 1998; Hargraves, Kalinowski, Stuart, Armson,
& Jones, 1994; Howell, Sackin, & Williams, 1999; Van
Borsel, Reunes, & Van den Bergh, 2003), self-modeling
(Webber, Packman, & Onslow, 2004), and regulated breathing (Andrews & Tanner, 1982; Ladouceur, Cote, Leblond,
& Bouchard, 1982; Woods & Twohig, 2000). Understanding the various treatment approaches can pose a challenge
for clinicians. To properly select the appropriate treatment
method, clinicians must have access to all of the treatment
options. The purpose of this article is to review the various
treatment methods used by clinicians to help treat preschool- and school-age children’s stuttering.
A review of existing literature serves many functions,
including summarizing findings, identifying consistencies
and inconsistencies in the research available, and identifying implications for future research and practice (Bothe,
Davidow, Bramlett, Franic, & Ingham, 2006). A literature
review provides clinicians with some of the information
necessary for evidence-based practice (Bothe et al., 2006;
Yaruss et al., 2006). Moreover, assessing treatment methods
has helped researchers establish new approaches for the
design and conduct of more rapid clinical studies.
Initiating Treatment
There is much controversy regarding when intervention
should begin for preschool- and school-age children who
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stutter. The matter is complicated because of the high
percentage (approximately 70%) of children who recover
spontaneously (e.g., Finn, 1996; Peters & Guitar, 1991).
Yairi and Ambrose (1999) stated that 74% of children who
stutter recover naturally within the first 2 years of onset. The controversy concerning when to begin treatment
reflects different philosophies regarding the nature of the
disorder. Curlee and Yairi (1997), for example, suggested
“active monitoring” for 2 years postonset rather than active
intervention.
There are many variables that affect treatment time;
therefore, knowledge of the variables is essential to determine when treatment for preschool-age children should
begin (Rousseau, Packman, Onslow, Harrison, & Jones,
2007). Although guidelines have been developed for the
timing of several treatment programs (e.g., the Lidcombe
Program; Packman, Onslow, & Attanasio, 2003), it is important to identify the child’s concomitant disorders (e.g.
language and phonology) in order to predict treatment time
and decide when to begin treatment for early intervention
(Rousseau et al., 2007).
Treatment Reliability
An important aspect of assessing various treatment programs is whether the treatment was administered correctly.
This aspect determines whether the treatment was effective as reported in the literature (Conture & Guitar, 1993).
Siegel (1990) stated that replication is the most rigorous
test of reliability. In a number of studies, researchers have
reported that replication in treatment efficacy research
has been overlooked (Attanasio, 1994; Meline & Schmidt,
1997; Muma, 1993; Onslow, 1992). Muma (1993), for example, surveyed 1,712 studies in the Journal of Speech and
Hearing Disorders and the Journal of Speech and Hearing Research. Based on statistical analysis, he claimed that
Type I (false positive) and Type II (false negative) errors
were likely to be found in 50–250 findings. In addition,
Onslow (1992) reviewed the literature on stuttering intervention and reported that few studies have been replicated.
These findings could be misleading the development of
treatment in the field, indicating the necessity for further
replication studies.
Indirect and Direct Approaches
Indirect approaches to treating stuttering involve modifying
the child’s environment rather than working directly with
the child (R. J. Ingham & Cordes, 1998; Richels & Conture, 2007). Indirect therapy approaches are often implemented when the child is not aware of, or is frustrated
by, his or her stuttering. The aim of indirect therapy is to
facilitate fluent speech through changes in the environment
and modifications to parents’ speaking patterns. Indirect
methods target children’s attitudes, feelings, fears, and
language in daily interactions (e.g., pragmatics), and may
result in a reduction of the child’s speaking rate (Conture,
2001; Gottwald & Starkweather, 1995; Guitar, 1998; Shapiro, 1999; Starkweather, Gottwald, & Halfond, 1990). This
is directly related to the diagnostic theory of stuttering,
which states that stuttering is a result of parental attention
to the child’s disfluencies (Bernstein Ratner & Tetnowski,
2006). R. J. Ingham (1993) noted that many clinicians favor indirect approaches because they place less pressure on
the child; however, she claimed that these practices were
not supported by evidence. Furthermore, she noted that indirect treatments have too many variables and are difficult
to measure objectively.
Direct approaches, on the other hand, target the child’s
individual speech behaviors (R. J. Ingham & Cordes, 1998;
Richels & Conture, 2007). Direct therapy approaches are
often implemented when children are aware of and/or
frustrated by their stuttering, as well as when they exhibit
secondary behaviors (Coleman, Yaruss, Butkiewicz, &
Roccon, 2005). Direct treatment may be professionally
directed or parent directed; that is, either the SLP or the
parent may target the child’s speech disfluencies. Behavior
modification techniques have yielded positive results in
various studies (e.g., Onslow, Andrews, & Lincoln, 1994;
Onslow, Packman, Stocker, van Doom, & Siegel, 1997).
Some examples of direct treatment include modeling reduced speaking rate, increasing pauses during turn taking,
allowing the child to finish his or her statement without
interruption, and relaxed breathing techniques (Hill, 2003;
Kelly, 1995; Walton & Wallace, 1998; Zebrowski, 1997;
Zebrowski, Weiss, Savelkoul, & Hammer, 1996). Specific
programs include the Lidcombe Program (Onslow, 1997)
and Gradual Increase in Length of Complexity of Utterance
(Ryan & Ryan, 1983). Onslow (1995), however, noted a
decline in the effectiveness of behavior modification techniques after 5 years of age.
Some clinicians favor direct approaches to eliminate
stuttering behaviors (Adams, 1984; Prins & Ingham, 1983;
Shine, 1984). Bernstein Ratner (1997) indicated that clinicians have favored indirect approaches for early stuttering
(e.g., Cooper & Cooper, 1985; Cooper & Rustin, 1985).
She stated that direct treatment may not be suitable for
children with an average age of 2;6 (years;months). Nonetheless, it has become increasingly popular to begin shortterm indirect treatment and proceed, if necessary, to direct
treatment (Coleman et al., 2005).
Family-Focused Treatment,
Counseling, and Support Groups
For treatment of preschool children who stutter to be
successful, parental intervention is essential (Lawrence &
Barclay, 1998). There are two major components involved
in parental intervention: (a) parental knowledge and feelings about stuttering in general, their child who stutters,
and themselves, and (b) parental behaviors with their child
while stuttering and without stuttering (Shapiro, 1999). Parents are advised not to criticize the child, not to constantly
remind the child to speak slower, and not to repeat words
that were said disfluently (Lawrence & Barclay, 1998).
Moreover, Peters and Guitar (1991) and Van Riper (1973)
suggested diminishing time pressure, interruptions, rapid
speech rates, hectic or unpredictable schedules, punishments, and guessing what the child intends to say. Parents
need to be educated about what they can contribute to the
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development of their child’s communication and fluent
speech (Shapiro, 1999).
Yaruss et al. (2006) described a family-focused treatment
approach for preschool-age children (between the ages of 2
and 6) who stutter. The treatment included parent-focused
strategies to help parents alter their speaking patterns and
reduce their anxiety about stuttering and child-focused
strategies meant to help children modify their behaviors
and communication attitudes. Overall, the treatment method
targeted improved speech fluency, effective communication
skills, and healthy communication attitudes for both parents
and children. The efficacy of the treatment was validated
with a preliminary study examining the outcomes of treatment for 17 preschool-age children. All children demonstrated gains in fluency and maintained the gains at the
long-term follow-up.
Treatment groups for both children and parents can also
be implemented to help the child achieve fluency (Richels
& Conture, 2007). Richels and Conture (2007) explained
that whereas child treatment groups help the child achieve
fluency, parent treatment groups prepare parents for their
child’s therapy expectations and goals. To increase participation from all members, child groups should be limited to
5 children. Throughout the session, the SLP should use a
slow rate of speaking and syntactically appropriate utterance lengths and should not interrupt the child or modify
the child’s speech. The session should begin with a conversation so the clinician can monitor the child’s disfluencies
within a 100-word sample. The disfluency count allows the
clinician to monitor the child’s progress.
The parents in Richels and Conture (2007) were advised
to purchase a book, Stuttering and Your Child: Questions
and Answers (Conture, 2002), and a video, Stuttering and
Your Child: A Videotape for Parents (Conture, 1997). In
addition, the parents were given various strategies and
suggestions to facilitate their child’s fluency: use slower
rates of speech, use shorter sentences, do not interrupt your
child, avoid correcting your child, and avoid reprimanding
your child for producing disfluencies (Richels & Conture,
2007).
Counseling is another important aspect to the treatment
of children who stutter that can help both parents and
children deal with the necessary emotional adjustments.
Rollin (2000) defined counseling as “a dynamic process
that involves a complex interaction between and among
people” (p. 2). Furthermore, Luterman (2001) stated that
counseling is “a clinician trying to help a client manage
change” (p. 9). Counseling, however, has received minimal
attention in the stuttering literature (DiLollo & Manning,
2007). Luterman and Shames (2000) suggested that perhaps
it is the clinician’s discomfort with counseling children and
their parents that has contributed to the scarcity of research
in this area.
Counseling children, especially preschool- and schoolage children, may be a difficult task (DiLollo & Manning,
2007). The SLP can begin by listening to a narrative, or
story, which often reflects the child’s anxiety, tension,
and fear (Payne, 2002). The narrative can then be used to
externalize the problem, making the stuttering a separate
identity. In this way, the stuttering does not become an
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internal trait; that is, the disorder does not become a point
of identification for the child (Payne, 2002; White &
Epston, 1990).
Parents of children who stutter may face many emotional
reactions (Crowe, 1997). Counseling parents should initially
focus on the emotional adjustments such as grief, fear, anxiety, guilt, isolation, denial, and depression (Crowe, 1997;
Kubler-Ross, 1969; Manning, 2001). Clinicians begin by
listening and acknowledging the emotional responses. The
clinician refocuses the parents’ energy, perhaps by making
them more active in the treatment process (e.g., Lidcombe
Program) or by encouraging them to join support groups.
Support groups and self-help groups are playing a larger
role in the recovery process of individuals who stutter
(Bradberry, 1995; Krall, 2001; Ramig, 1993; Yaruss, Quesal, Reeves, et al., 2002). Support groups provide members
with newsletters, literature, and other information about
stuttering (e.g., treatment programs). Members may also
be provided with advice about treatment programs. These
factors play an important role for both the SLP and the
individual who stutters. The information received from the
support group may play a large role in the attitudes and
beliefs the individual may have toward a certain treatment
option. The SLP must therefore become an active member
in these groups and become acquainted with the information distributed to the members (Yaruss, Quesal, & Murphy,
2002).
The National Stuttering Association (NSA; http://www.
nsastutter.org) is the largest self-help support group in the
United States for individuals who stutter. The NSA-Kids
division has many chapters for both preschool- and schoolage children. They have several local support groups and
have NSA Youth Days for children and their families. NSA
Youth Days are events that bring individuals who stutter
together in a supportive environment. FRIENDS (http://
www.friendswhostutter.org) is another national organization
by the National Association of Young People Who Stutter
that helps children, teenagers, and their families cope with
stuttering. FRIENDS has a bimonthly digest titled Reaching
Out that provides information based on the experiences of
young people who stutter. In addition, the association holds
conferences and annual conventions so families and friends
can share their experiences. These are just a few ways that
parents, children, and therapists can become active members in children’s treatment process.
Stuttering Modification
Versus Fluency Shaping
There are two therapeutic techniques used when treating stuttering—stuttering modification and fluency shaping. Stuttering modification aims to reduce speech-related
avoidance behaviors, fears, and negative attitudes (Guitar &
Peters, 1980; Peters & Guitar, 1991). The goal of stuttering
modification is to modify stuttering moments by decreasing
the tension so the stuttering is less severe and the fear or
avoidance behaviors of stuttering are eliminated (Blomgren
et al., 2005; Guitar, 1998). This may be accomplished by
reducing struggle behaviors, tension, and the rate of stuttering (Guitar & Peters, 1980). Underlying this approach is
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the notion that stuttering results from various avoidance behaviors and feared situations (Guitar & Peters, 1980; Peters
& Guitar, 1991). Stuttering modification approaches have
been referred to in various ways in the literature: “stutter
more fluently” (Gregory, 1979, p. 2) and “those that manage stuttering” (Curlee & Perkins, 1984, p. iii). Manning
(1999) contended that although stuttering modification may
decrease avoidance behaviors, it may in turn increase the
frequency of the stuttering moments. This follows a logical
pattern because as the individual relinquishes avoidances,
the number of speaking opportunities increases. The World
Health Organization (WHO, 2001) would therefore not
consider the treatment effective because it does not reduce
the impairment level (e.g., stuttering frequency). Moreover,
Blomgren et al. (2005) stated that any stuttering modification program in its purest form (i.e., without fluency
enhancing techniques) will not be effective in reducing an
individual’s stuttering or core behaviors.
Fluency shaping, on the other hand, focuses on teaching the individual to speak more fluently (Blomgren et al.,
2005; Guitar, 1998). The goal of fluency shaping is to work
with the speaker’s speech motor control capabilities and apply various approaches to facilitate new speech production
patterns (Blomgren et al., 2005). This technique establishes
fluent speech in a controlled environment using both positive and negative reinforcement (Guitar & Peters, 1980;
Peters & Guitar, 1991; Shapiro, 1999). Fluency is eventually generalized to normal conversational settings through
successive approximations (Shapiro, 1999). A drawback of
this method is that it does not incorporate the individual’s
feelings and reactions to the disorder (Blomgren et al.,
2005). Furthermore, Guitar and Peters (1980) stated that by
using this method, speech becomes monotonous and artificial as the client strives for fluent speech.
Stuttering modification. Stuttering modification may
be targeted through Van Riper’s (1972, 1973) exemplar
termed MIDVAS: motivation, identification, desensitization, variation, approximation, and stabilization. According
to Van Riper, motivation is the first, and most important,
phase. During this phase, the SLP becomes a guide and
shares positive information about the treatment process with
the client. It is essential for both the client and clinician
to become comfortable and to share feelings and emotions regarding the disorder. The SLP must stress the fact
that being an active participant in treatment is vital to
achieve fluency. Following this phase, Van Riper (1973)
describes the identification phase, where the individual
identifies stuttering moments that are unique to his or her
speech. The rationale behind the identification of traits is
that once awareness is attained, the habit may be changed.
Goals include diminishing denial and identifying stuttering
behaviors.
The third phase, desensitization, “implies stress” (Shapiro, 1999, p. 197). During this phase, the client’s negative
feelings and emotions toward the disorder are addressed.
Some techniques include relaxation, pseudostuttering, adaptation, and anxiety reduction by modifying stuttering (Van
Riper, 1973). Following desensitization, the SLP may begin
modifying the individual’s stuttering (e.g., modifying anticipated behaviors) in the fourth phase, called variation. As
the client begins to learn new responses to diminish stuttering moments, he or she enters the approximation phase.
During this phase, the SLP continues to modify the client’s
speech to attain fluency. Some approximation techniques
include cancellation, pullouts, and preparatory sets (Van
Riper, 1973). Treatment is reduced during the stabilization
phase. As the client gains a positive self-image, he or she
begins to self-monitor the stuttering. Treatment may be
terminated in this final stage (Van Riper, 1973).
Because stuttering modification focuses on desensitization and reducing the individual’s anxiety, it is difficult to
obtain outcome measures and quantify the efficacy of the
technique (Blomgren et al., 2005). The Successful Stuttering Management Program (SSMP; Breitenfeldt & Lorenz,
1989) is an example of a stuttering modification treatment; there is, however, no evidence of its effectiveness
(Blomgren et al., 2005; De Nil & Kroll, 1996; Ham, 1996).
The SSMP is a 3-week program that is based on stuttering
modification techniques advocated by Van Riper (1973)—a
combination of desensitization techniques and avoidance
reduction therapy (Sheehan, 1970). Breitenfeldt and Girson
(1995) described positive changes in individuals’ attitudes
toward stuttering and secondary behaviors following this
program. Eichstadt, Watt, and Girson (1998) also reported
positive changes; however, no pretreatment baselines were
obtained (Blomgren et al., 2005).
Stuttering modification: Measuring attitudes and beliefs.
In creating a treatment plan for individuals who stutter, it
is not sufficient to count the number of disfluencies or the
frequency of stuttering moments. Assessing attitudes, emotions, self-esteem, and environmental factors is an essential
aspect in preparing treatment goals. Sheehan (1970) stated,
“Stuttering is like an iceberg, with only a small part above
the waterline and a much bigger part below” (pp. 184–185).
Because the overt aspects of stuttering account for only
10% of the problem (Hicks, 2003), it is important to evaluate the attitudes and emotions of the person who stutters,
or 90% of the disorder, using the various scales available.
Self-measurement, self-monitoring, and self-observations
are considered direct measures of behavior (Cone, 1999);
however, they may also include many personal biases
(Gilovich, 1991). The main purpose of self-measurement
is to serve as a therapeutic intervention (Foster, LavertyFinch, Gizzo, & Osantowski, 1999). Individuals who stutter
develop belief systems over time that include attitudes
about their individual abilities to speak and the effect of
situations and listeners on their speech and fluency. Negative emotional reactions and avoidance behaviors are two
measurable types of covert characteristics of stuttering.
Building a sense of confidence and self-worth is another
central aspect in the treatment of stuttering. According to
the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965),
self-esteem is a broad concept that is used to measure
a person’s “global” or “unidimensional” self-evaluation
(Gray-Little, Williams, & Hancock, 1997). McCarthy and
Hoge (1982) stated that the scale has been found to be
valid and reliable among students in Grades 7–12. The
RSE includes 10 statements that are scored using a 4-point
Likert scale ranging from 0, strongly agree, to 3, strongly
disagree. Cooperman, Bloom, and Klein (2007) adopted
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Rosenberg’s scale for children by simplifying the statements
and the Likert scale. The Self-Esteem Scale—Modified for
Children also contains a 4-point scale; however, 1 represents Yes, I think this is true, and 4 represents No, I never
think this is true.
Other scales are used to assess children’s attitudes and
perceptions toward the disorder, such as the Communication
Attitude Test (CAT; Brutten, 1985) and the Communication
Attitude Test—Revised (CAT–R; Brutten, 1985). The CAT
consists of 35 true and false questions that are used to assess the child’s perception of stuttering. The CAT has been
translated into various languages and has been researched
in 15 countries (Brutten & Vanryckeghem, 2003, 2007;
De Nil & Brutten, 1991; Vanryckeghem & Mukati, 2006).
De Nil and Brutten (1991) and Vanryckeghem and Brutten
(1992) have found significant test–retest reliability, high
correlations, and interitem reliability for the CAT–R
(Brutten & Dunham, 1989).
There have been high correlations between negative
speech-associated attitudes and emotions among children
who stutter and those who do not stutter. Moreover, there
is a relationship between the negative beliefs about the
speech, attitudes, and emotions of children who stutter and
the anxiety associated with their communication
(Vanryckeghem, Hylebos, Brutten, & Peleman, 2001). It is
important, therefore, to determine a child’s attitudes toward
his or her disorder at an early age. Vanryckeghem (1995)
found that parents do not accurately convey their child’s
belief systems. For this reason, there has been extensive
research with the KiddyCat (Langevin, 2007), a communication attitude test for preschoolers and kindergartners who
stutter (Ambrose & Yairi, 1994; Vanryckeghem & Brutten,
2007; Vanryckeghem, Brutten, & Hernandez, 2005). Researchers found that children who stutter develop negative
attitudes toward their speech as early as 3 years of age.
A more comprehensive scale, the CALMS Rating Scale
for Children Who Stutter (ages 7–15), is based on Healey,
Scott Trautman, and Susca’s (2004) multidimensional model
of stuttering. The scale addresses five key factors: cognitive, affective, linguistic, motor, and social. Each item on
the scale is rated from 1 to 5, with 1 representing normal
and no concern and 5 representing severe impairment and
extreme concern. By computing the total value of all of
the items and dividing it by the number of items scored, a
mean score for each component is obtained. The average
score is used to create a CALMS profile (Healey, 2007;
Healey et al., 2004).
Coleman and Yaruss (2004) devised an alternative instrument, the Assessment of the Child’s Experience of Stuttering (ACES), to assess the overall impact of stuttering
on the child’s life from the child’s perspective. The ACES
was adapted from an adult scale, Overall Assessment of
the Speaker’s Experience of Stuttering (OASES; Yaruss &
Quesal, 2004), to assess stuttering in children 7 to 18 years
of age. The ACES is divided into four sections: general
information about stuttering, reactions to stuttering (affective, behavioral, and cognitive), communication in daily
situations, and impact of stuttering on quality of life. The
instrument evaluates (a) the child’s perception of speech
fluency, speech naturalness, and speech therapy techniques;
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(b) the child’s affective, behavioral, and cognitive reactions
to stuttering; (c) the child’s difficulty in communicating at
school, at home, and in social situations; and (d) the impact
of stuttering on the child’s overall quality of life (Coleman
& Yaruss, 2004). The questionnaire consists of 100 items
that can be completed in 15–20 min. After gathering the
necessary information, the clinician can create a more individualized treatment plan for the child.
Fluency shaping. Aside from working on desensitization
of stuttering, increasing the fluency of stuttering may be
targeted by implementing two fluency shaping programs,
Programmed Conditioning for Fluency (Ryan & Van Kirk,
1971) and Programmed Therapy for Stuttering in Children
and Adults (Ryan, 1974). Fluency is established through
one of four techniques: gradual increase in length and complexity of utterances (GILCU), delayed auditory feedback
(DAF), programmed traditional, and punishment (Shapiro,
1999).
GILCU is a 54-step program that directs the client to
produce fluent speech (Shapiro, 1999). It begins with
single-word responses and is increased to six words. The
client’s speech is gradually increased from 5 min of passage reading to monologue speech, ending in conversational
speech with normal speaking rates (Ryan & Ryan, 1995).
The method has been found to be effective and efficient
(Costello, 1980, 1983; Rustin, Ryan, & Ryan, 1987; Ryan
& Ryan, 1995; Shine, 1984). Costello (1980) used a more
defined GILCU approach called the Extended Length Utterance (ELU) program. The ELU program is similar to
the GILCU program; however, instead of beginning with
words, it uses syllables. It is completed in 20 steps, beginning with monologue and ending in conversational speech
(Costello, 1980).
Traditional programs identify an individual’s stuttered
words and then shape fluent responses using Van Riper’s
techniques, cancellation, pullouts, and preparatory sets
(Shapiro, 1999). Punishment, on the other hand, reduces the
frequency of stuttering by presenting an aversive condition
(Shapiro, 1999).
Lidcombe Program
The Lidcombe Program is a behavioral parent-directed
treatment for stuttering in preschool children that was developed by the Faculty of Health Sciences at The University of Sydney and the Stuttering Unit of the Bankstown
Health Service in Sydney, Australia. Using this program,
the SLP teaches the parent to deliver treatment to the child
and to use a 10-point Likert scale to measure the severity
of the child’s stuttering in his or her everyday environment
(Onslow, Packman, & Harrison, 2003; Rousseau et al.,
2007).
There are two stages to the program. In Stage 1, the
parent and child meet with the SLP on a weekly basis for
the parent to deliver treatment in the child’s environment
daily (Onslow et al., 2003; Rousseau et al., 2007). The
SLP measures the percentage of syllables that are stuttered
(%SS), and the parent monitors the child’s speech using a
10-point scale where 1 represents the absence of stuttering and 10 represents extremely severe stuttering (Rousseau
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et al., 2007). Once the child’s stuttering decreases, Stage
2 (maintenance stage) begins, where the parent and child
attend sessions less frequently, and treatment is decreased
(Onslow et al., 2003).
Kingston, Huber, Onslow, Jones, and Packman (2003),
as well as Jones, Onslow, Harrison, and Packman (2000),
found that children with more severe stuttering took longer
to complete Stage 1; however, those who had been stuttering longer completed Stage 1 faster than those who had
been stuttering for a shorter period of time. Based on the
authors’ retrospective file audits, the median treatment time
was 11 visits. Rousseau et al.’s (2007) findings, however,
indicate a median treatment time of 16 visits. The exact cause of the discrepancy is unclear; Rousseau et al.
suggested that possible demographic differences may be
responsible.
Rousseau et al. (2007) investigated the effect of language and phonology as predictors of treatment time using
the Lidcombe Program. Knowing the relationship between
language and phonology and whether it affects the timing
of intervention is important for clinician decision making
during the time of assessment (Rousseau et al., 2007). The
authors did not find a relationship between phonological
development and the time it takes to complete the first
stage of the Lidcombe Program. They did, however, find a
relationship between language and treatment time; that is,
the higher the child’s mean length of utterance, the shorter
the treatment time, and the higher the child’s receptive
scores on the Clinical Evaluations of Language Fundamentals (Semel, Wiig, & Secord, 2003), the longer the treatment time.
Because the Lidcombe Program does not require programmed instructions, nor does it require the child to
change his or her manner of speaking, it is currently the
first choice for treatment in preschool-age children (Conture
& Curlee, 2007). Because of the social anxiety associated
with stuttering at the school-age level (Conture & Curlee,
2007), there is a need to investigate the efficacy of the
Lidcombe Program for older children (i.e., between 7 and
11 years of age). Rousseau, Packman, and Onslow (2005)
began investigating the efficacy of the Lidcombe Program
on school-age children. They investigated how well the
children responded and how long it took them to respond.
There is some data that suggest that the Lidcombe Program
may be effective for school-age children (Lincoln, Onslow,
Lewis, & Wilson, 1996); however, Conture and Curlee
(2007) stated that based on the data from Rousseau et al.
(2005), there are compelling reasons to believe that the
program may not be suitable for school-age children.
Altered Auditory Feedback
Altered auditory feedback (AAF) is a term that is used to
encompass altering the speech signal electronically so that
the speaker perceives his or her voice differently. There are
several types of AAF, including DAF, frequently altered
feedback (FAF), and masking auditory feedback (MAF).
AAF techniques have been found to reduce stuttering by
decreasing the child’s rate of speech (Armson & Stuart,
1998; Hargrave et al., 1994; Howell et al., 1999; Van
Borsel et al., 2003). Kalinowski, Armson, RolandMieszkowski, Stuart, and Gracco (1993) and Hargrave et
al. (1994), however, found that a reduction in speech rate
is not necessary for the production of fluent speech using
AAF programs.
DAF, or prolongation, has been studied extensively to
reduce stuttering in adolescence and in adults who stutter
(Boberg, 1980; R. J. Ingham & Andrews, 1973; Ryan &
Ryan, 1995; Ryan & Van Kirk, 1974; Webster, 1980). DAF
occurs when there is a 50–100 ms delay in the arrival of
the voice signal to the speaker’s ear. In the early stages
of DAF, a long delay was used (250 ms), which produced
slow and prolonged speech (Ryan, 1974; Ryan & Ryan,
1995). There are 25 steps to the program. The least amount
of time needed to complete the program is 110 min (Ryan,
1974; Ryan & Ryan, 1995; Ryan & Van Kirk, 1974). The
aim of the DAF program is to produce slow, paced speech:
a total of 40 words or less produced per minute (Ryan &
Ryan, 1995). Current research indicates the effectiveness of
the treatment with short delays (50 ms). In this manner, the
person can continue a fast-paced speech while maintaining
fluency (Kalinowski, Stuart, Sark, & Armson, 1996). The
goal of DAF is to prolong the speaking rate so the client
can produce fluent speech (Ryan & Ryan, 1995; Shapiro,
1999).
FAF alters the frequency of the individual’s speech (either up or down) between ¼ to 1 octave, affecting the perceived pitch of the person’s voice (Hargrave et al., 1994;
Howell, El-Yaniv, & Powell, 1987). Howell et al. (1987)
found that study participants using FAF produced fewer
disfluencies than those using DAF. Several studies have
reported a decrease in stuttering using 1-, ½-, and ¼-octave
increasing or decreasing the frequency of speech (Hargrave
et al., 1994; Howell et al., 1987; Kalinowski et al., 1993;
Stuart, Kalinowski, Armson, Stenstrom, & Jones, 1996);
nonetheless, the most consistent results have been found
using the 1-octave increase and decrease (Hargrave et al.,
1994). DAF, however, has been consistently reported to
be more effective than FAF in reducing stuttering (Stuart,
Kalinowski, & Rastatter, 1997; Zimmerman, Kalinowski,
Stuart, & Rastatter, 1997).
Masking noise delivered via headphones or electronic
devices has been used to help control stuttering in everyday
situations (Armson & Stuart, 1998). The results regarding
the effectiveness of masking studies are inconclusive (R. J.
Ingham, Southwood, & Horsborough, 1981). This method,
however, is now rarely employed because DAF and FAF
have been found to be more effective than masking noise at
reducing stuttering (Howell et al., 1987; Kalinowski et al.,
1993).
Overall, AAF, specifically FAF, has been found to increase speech naturalness and reduce the degree of stuttering in difficult speaking situations (White, Kalinowski, &
Armson, 1995). Lincoln et al. (2006) reviewed the literature
over the past 10 years to assess the effect of AAF on different speaking situations. The authors concluded that in
the laboratory, clinic, or classroom, AAF results in reduced
stuttering during oral reading for those who stutter. The
studies, however, did not suggest the reduction of stuttering
in conversational speech. The authors concluded that the
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19
true efficacy of the treatment cannot be determined until
the effects on conversational speech are examined (Lincoln
et al., 2006).
Yaruss and Gable (2005) reviewed the use of AAF
devices, specifically, the SpeechEasy device. SpeechEasy
is a fluency enhancing device for people who stutter who
use DAF, FAF, or a combination of the two. Kalinowski,
Stuart, and Rastatter invented the device after reviewing the
effects of AAF on people who stutter. The device resembles
a hearing aid and was designed for monaural use. There
are three main models: behind the ear, in the canal, and
completely in the canal. There are no published studies
regarding the efficacy of the devices, and no studies have
been reported regarding the use of the device with children.
Only temporary fluency gains have been reported when
using the device. Additionally, because the device is placed
in one ear, there may be competing signals in the other ear,
causing disruptions in communication.
Recently, Saltukaroglu and Kalinowski (2005) proposed
that AAF may be a promising treatment option for schoolage children. Howell et al. (1999) and Stuart et al. (2004)
studied participants between 9 and 12 years of age and
found that children did not respond as well as adults to
AAF conditions. No conclusions can therefore be made
regarding the effects of AAF devices on children. There is
no evidence in the literature that suggests the use of AAF
in children under the age of 9 years. Lincoln et al. (2006)
stated that altered auditory input on children developing
speech and language may create further complications.
Monterey Fluency Program
The Monterey Fluency Program (Ryan & Van Kirk, 1978)
is a structured therapy program for preschool- and schoolage children. The program is often combined with the
token economy system (Dalton, 1983). This program was
designed to provide two alternative schedules for fluency:
GILCU and DAF (Bloodstein & Bernstein Ratner, 2008).
The GILCU program is based on operant conditioning principles where there is an established structured program for
reinforcement of utterances. The DAF program is used with
older children and helps the client to read and speak in a
slow manner where all the words are prolonged.
Fluency Rules Program
The Fluency Rules Program (FRP; Runyan & Runyan,
1993, 1999) was designed for preschool- and school-age
children. Originally, the program was named “Rules for
Good Speech” and consisted of 10 fluency rules. The
program was expanded, however, to include three sections:
universal rules, primary rules, and secondary rules. It was
realized that not all children who stutter need the 10 rules.
Universal rules, therefore, are rules that all children who
stutter use. These rules include reduce the rate of speech,
say each word once, and say it short. Reducing the rate
of speech allows children to monitor their speech. Slow
speech was reported by SLPs to have a calming effect
on children who stutter (Runyan & Runyan, 2007). Using symbolic therapy materials (e.g., turtle or snail) may
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assist children in establishing a slow speech rate (Runyan
& Runyan, 1986) The second rule, say the word once,
reduces the number of repetitions (e.g., whole-word repetition, part-word repetition, single syllable repetition). The
third universal rule, say it short, was designed to decrease
prolongations (Runyan & Runyan, 2007).
If airflow and/or laryngeal difficulties are present, primary rules are enforced. These rules include use speech
breathing and “start Mr. voice box running smoothly.”
Speech breathing, or speaking on exhaled air, is illustrated to the child (Runyan & Runyan, 2007). In addition,
children are taught to begin vocal fold movement smoothly,
also referred to as easy onset (Bennett, 2006; Schwartz,
1999; Zebrowski & Kelly, 2002).
Lastly, when concomitant behaviors are present, two
additional, secondary, rules are implemented: “Touch the
speech-helpers lightly” and use only the “speech-helpers”
to talk. The “speech-helpers” (e.g., tongue, lips, teeth) are
depicted using cartoon characters. Children are taught to
“touch the speech-helpers lightly” because if they close the
articulators too tight, they will stop speech breathing, and
speech production will cease (Runyan & Runyan, 2007).
Runyan and Runyan (1985) pilot tested the FRP in a
public school on 9 children who stuttered (3–7 years of
age) to determine its efficacy in a public school setting
in school-age children. The results indicated, as per the
Stuttering Severity Instrument—3rd Edition (SSI–3; Riley,
1972), that the frequency of stuttering, as well as the
severity of the blocks, decreased. Additionally, the children
remained fluent 1–2 years after treatment.
Comprehensive Stuttering Program
for School-Age Children
Attitudinal and emotional aspects of stuttering and overt
stuttering are addressed with the Comprehensive Stuttering Program for School-Age Children (CSP-SC; Boberg
& Kully, 1985). The CSP targets four main goals: speechrelated goals, attitudinal–emotional goals, self-management
goals, and environmental goals. Teaching fluency enhancement skills, addressing attitudes and emotions, and incorporating the family into therapy address the targeted goals
(Langevin, Kully, & Ross-Harold, 2007).
Speech-related goals are achieved by teaching fluency
enhancing skills in various environments with normal rate
and prosody, managing residual stuttering, and improving
communication skills (Langevin et al., 2007). Fluency enhancing skills include prolongations, easy breathing, gentle
starts, smooth blending, light touches, and tension modification. Feelings, attitudes, and emotions are addressed as
well. Attitudinal–emotional goals include creating positive
attitudes toward communication; comfort with fluency enhancing skills; comfort with stuttering; and ability to manage fear and anxiety, recognize relapse, and improve social
skills (Langevin et al., 2007).
Self-management goals include problem-solving techniques, self-monitoring, self-evaluation, and the ability to
manage the environment. Lastly, environmental goals target
parental understanding of the disorder. Environmental goals
include the etiology and development of stuttering, how to
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deliver therapy, and how to deal with relapse (Langevin et
al., 2007).
Regulated Breathing
Regulated breathing is designed to help individuals who
stutter become aware of their stuttering moments. Using
this technique, the SLP teaches the client to interrupt or
prevent the occurrence of stuttering by completing responses that involve regulating airflow during speech. The
technique includes awareness training, relaxation training,
motivational training, and generalization training (Watson
& Skinner, 2004). Researchers have shown that regulated
breathing is an effective technique for increasing fluency
in both children and adults. Reports regarding regulated
breathing have indicated a decrease in stuttering without a
reduction in speech rate (Andrews & Tanner, 1982;
Ladouceur et al., 1982; Woods & Twohig, 2000).
Ladouceur et al. (1982), as well as Andrews and
Tanner (1982), replicated the study done by Azrin and
Nunn (1974) on the treatment of stuttering using regulated breathing training. The authors repeated the study
for various reasons, including the various methodological
limitations of the study, the lack of a definition of stuttering, and the fact that the measures of stuttering were based
solely on self-reported estimates. Furthermore, Andrews and
Tanner stated that no other accounts of the efficacy of the
treatment method had been published.
Self-Modeling
Self-modeling has been described in the literature as selfas-a-model (Hosford, 1981) and as self-observation (McCurdy & Shapiro, 1988; Shear & Shapiro, 1993). Selfmodeling includes training an individual using self-exposure
of error-free behaviors to promote change (Webber,
Packman, & Onslow, 2004). Dowrick (1999) defined selfmodeling as an intervention approach in which the individual views a 2- to 4-min edited videotape of him- or herself
engaging in exemplary behaviors. Through self-modeling,
an individual learns the target behavior by observing himor herself engaging in positive behaviors from prerecorded
and pre-edited videotapes (Murphy, 2001).
According to Dowrick (1999), individuals can learn by
observing their own behaviors. The efficacy of selfmodeling has been reported to be successful: Meharg and
Woltersdorf (1990) reviewed 27 articles, all of which indicated positive outcomes using the treatment method. Furthermore, Bray and Kehle (1996) found a reduction in stuttering
and maintenance of treatment gains using self-modeling
for the 3 students involved in their study. Bray and Kehle
(2001) examined the long-term effects of self-modeling over
2 and 4 years of treatment. The authors found that the study
participants’ fluency was maintained for the two periods under investigation. Webber et al. (2004) investigated whether
their aims could be attributed to the watching of selfmodeling videotapes. The authors found that self-modeling
can reduce stuttering; however, they suggest incorporating
the technique into other treatment methods.
There are several limitations to this intervention approach. First, it may be difficult to edit an acceptable
behavior(s) into or out of the videotape to indicate the
target behavior(s). In addition, the actual editing of the
videotape is difficult, and the equipment may be expensive
(Clark & Kehle, 1992). Second, the child’s interpretation of
the behavior may not be in accordance with the clinician’s
interpretation of the behavior (Clark & Kehle, 1992). Last,
the client’s age and cognitive capacity need to be taken
into account because the videotapes represent a behavior
that will appear in the future. The child may or may not
be able to self-reflect on his or her own abilities (Clark &
Kehle, 1992).
Synergistic Stuttering Therapy
Bloom and Cooperman (1999) developed the Synergistic
Model of Intervention with children who stutter. This model
accounts for the integration of the physiological or speechlanguage factors (e.g., respiration, voice, articulation, and
hearing), attitudes and feeling components, and communication environment (e.g., social and pragmatic influences
of communication and family influences). The “treatment
principles of the synergistic approach are based on the same
principles that relate to normal speech production” (Bloom &
Cooperman, 1999, p. 117). Bloom and Cooperman stressed
the importance of teaching the mechanics of normal speech
production so that clients could learn about the general
processes of respiration, phonation, and articulation using
visual devices. They then use various activities to help the
client increase his or her awareness about the stuttering
moment. Afterward, the client is taught the respiratory, phonatory, and articulatory targets of normal speech production. The treatment principles for the speech-language factors encompass using the target skills during four phases:
identification phase, modification and establishment phase,
stabilization phase, and transfer and maintenance phase.
Bloom and Cooperman indicated that feelings and attitudes
encompass three main areas: self-esteem, locus of control,
and assertiveness. The last main domain is environmental
aspect of the stuttering.
Implications for the Treatment
of Preschool Children Who Stutter
For children younger than 6 years, response-contingent
approaches (e.g., Martin, Kuhl, & Haroldson, 1972) to
treating stuttering were most effective (Bothe et al., 2006).
Response-contingency approaches may be delivered immediately after a stuttering moment or as part of a structural
performance-contingent maintenance program (R. J. Ingham,
1980). Martin et al. (1972) achieved near zero stuttering in
the home by using response contingencies in therapy: The
authors shut the light on the puppet stage for 10 s contingent on stuttering for two preschool boys. Reed and
Godden (1977) provided the verbal contingency “slow
down” and found a dramatic decrease in the percentage
of words stuttered. Onslow, Costa, and Rue (1990) found
that verbal contingencies provided by parents reduced the
frequency of stuttering as well.
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According to Bothe et al.’s (2006) systematic treatment
review of stuttering treatment, the Lidcombe Program (Onslow et al., 2003) is the best response-contingent approach
for preschool children who stutter. Lincoln and Onslow
(1997) provided follow-up treatment for children 2 to 7
years posttreatment, with results indicating a mean stuttering below 1%SS. In addition, children’s psychosocial levels
increased after Lidcombe treatment (Woods, Shearsby,
Onslow, & Burnham, 2002).
One important impediment in treating preschool children who stutter is the spontaneous, or natural, recovery
(Bothe et al., 2006). R. J. Ingham (1993) and R. J. Ingham
and Cordes (1999) estimate that 30% to 50% of preschool
children recover without treatment. The solution is to have
continuous assessments over time (J. C. Ingham & Riley,
1998).
Bernstein Ratner, N. (1997). Leaving Las Vegas: Clinical offs and
individual outcomes. Journal of Speech, Language, and Hearing
Research, 15, 296–302.
Bernstein Ratner, N., & Tetnowski, J. (2006). Stuttering treatment in the new millennium: Changes in the traditional parameters of clinical focus. In N. Bernstein Ratner & J. Tetnowski
(Eds.), Current issues in stuttering research and practice (pp.
1–16). Mahwah, NJ: Erlbaum.
Blomgren, M., Roy, N., Callister, T., & Merrill, R. M. (2005).
Intensive stuttering modification therapy: A multidimensional
assessment of treatment outcomes. Journal of Speech, Language,
and Hearing Research, 48, 509–528.
Bloodstein, O., & Bernstein Ratner, N. (2008). A handbook on
stuttering. Clifton Park, NY: Thomson Delmar Learning.
Bloom, C., & Cooperman, D. (1999). Synergistic stuttering therapy: A holistic approach. Boston, MA: Butterworth Heineman.
Boberg, E. (1980). Intensive adult therapy program. Seminars in
Speech, Language, and Hearing, 1, 365–374.
CONCLUSION
Boberg, E., & Kully, D. (1985). The comprehensive stuttering
program. San Diego, CA: College-Hill Press.
In developing a treatment program for children who stutter,
one must consider many variables and decide on an appropriate outcome measure: The measures should include both
overt and covert behaviors. Bennet (2006) has written about
the ABCs of stuttering, which include affective, behavioral,
and cognitive components of stuttering. A treatment program should integrate all of these aspects of the disorder.
For these reasons, the clinician’s task consists of choosing
a well-developed, evidence-based assessment instrument
that meets the client’s needs and goals.
Bothe, A. K., Davidow, J. H., Bramlett, R. E., Franic, D. M., &
Ingham, R. J. (2006). Pharmacological approaches to stuttering treatment: Reply to Meline and Harn. American Journal of
Speech-Language Pathology, 17, 98–101.
ACKNOWLEDGMENT
Thank you to Ciara Leydon for reviewing this manuscript before
submission.
Bradberry, A. (1995). The role of support groups and stuttering
therapy. Seminars in Speech and Language, 18, 391–399.
Bray, M. A., & Kehle, T. J. (1996). Self-modeling as an intervention for stuttering. School Psychology Review, 25, 358–369.
Bray, M. A., & Kehle, T. J. (2001). Long-term follow-up of self
modeling as an intervention for stuttering. School Psychology
Review, 30, 135–141.
Breitenfeldt, D. H., & Girson, J. (1995). Efficacy of the Successful Stuttering Management Program workshops in the United
States of America and South Africa. In C. W. Starkweather & H.
F. M. Peters (Eds.), Proceedings of the First World Congress on
Fluency Disorders (pp. 429–431). Nijmegen, The Netherlands:
Nijmegen University Press.
Breitenfeldt, D. H., & Lorenz, D. R. (1989). Successful stuttering
management program for adolescent and adult stutterers (1st ed.).
Cheney, WA: Eastern Washington University.
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This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.
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