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Effective communication as a part of therapy for students who stutter

• Learning how to make small talk

• The discovery of the positive uses of one’s voice

Ready for speech therapy?

• Who wants the treatment?

• Is the pain of the stuttering (staying the same) greater than the pain of change? (Scott Yaruss)

• Ready to take risks?

• Ready to look directly at the stuttering?

N’s story

• One visit only

• Not at all ready or able to handle looking directly at stuttering

AA’s story

E’s story A’s story

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S’s story School age Resources

• Lew, Gail Wilson (2015) Jeremy and the Hippo: A Boy’s Struggle with Stuttering.

• Reardon-Reeves, N. and Yaruss, J.S. School-Age Stuttering Therapy: A Practical Guide. McKinney, Texas: Stuttering Therapy Resources (2013

• Reitzes,P. 50 Great Activities for Children who Stutter. Austin, Texas: pro-ed (2006).

• The Girl who Stutters. Stuttering Foundation e book.

• Vawter, Vince (2013). Paperboy. New York: Random House Children’s Books

Treating teens and adults who stutter

Working with teens and adults who stutter

• Treatment can be productive and enjoyable and positive changes can occur

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Pseudo stuttering

Stuttering behavior done deliberately by the clinician and resembling real stuttering– To identify with the client– To show a genuine desire to learn– Necessary for client practice at identifying

stuttering– To demonstrate the clinician is not afraid of

stuttering– To continue moving toward openness about

stuttering

Voluntary Stuttering

• Voluntary Stuttering: deliberate easy repetitions done by the client on words where stuttering would not usually be expected– To do what one fears (desensitization)– To get the behavior out in the open– To decrease physical tension– To decrease avoidance of stuttering– To teach control of stuttering– To decrease the amount of real stuttering– To challenge the assumption that listeners react negatively to all

stuttering

Clinicians must put stuttering in their own mouths

Why:

• To increase comfort and familiarity with stuttering

• To develop the ability to use stuttering with clients

• On-purpose stuttering by the clinician is a useful tool as client and SLP investigate stuttering together

Basic assumptions

• Stuttering is a physical disorder with the potential to result in negative thoughts and emotions

• Treatment must deal with both surface speech behaviors and resulting thoughts and emotions

The CALMS model: (Charles Healey and colleagues,2004)

• Cognitive: thoughts, perceptions, awareness, understanding

• Affective: feelings, emotions, attitudes

• Linguistic: language skills, language demands

• Motor: sensori-motor control of speech movements

• Social: effects of type of listener and speaking situation

The CALMS model: Treatment

• Cognitive– More realistic thinking about stuttering, better

understanding

• Affective– Reduce negative feelings and attitudes

• Linguistic– Work toward controlling and shifting linguistic

demands to improve fluency

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The CALMS model: Treatment

• Motor– Focus on speech skills that enhance fluency

and those skills that modify stuttering

• Social– Use of new speech skills in realistic speaking

situations that are gradually increased in degree of difficulty

Let’s talk about avoidances

• Word substitutions• Added unnecessary phrases• Interjections (um um um); can function also as

postponements)• Replacing what you want to say with what you

can say• Pretending to forget• Vocations• Social situations• Relationships• Class participation

Avoidances

• Removing avoidances usually decreases the amount of actual stuttering

• Avoidance phrases are part of the stuttering– “well actually what I mean is …”

• Clinicians need to learn to spot avoidances

• Reducing avoidances, daring to stutter, is essential to long-term progress; the JG example

• Much effort is required to avoid

Avoidances as a treatment target

• Learn to be an avoidance detective– word substitutions– Circumlocutions– Conversation steering– Pretending to forget

• Be open and matter of fact about looking for avoidances: “Oh, did you just switch a word there?”

Assessment considerations

• Frequency; core, secondary behaviors• Avoidances, postponements, anything unusual

(excessive ums; atypical stuttering)• Rate and EVENNESS of rate: look for blurts• Attitude toward stuttering• Motivation: ready for therapy? • Who wants the therapy; what does the client

want• Is there a willingness to take risks?

Assessment Considerations: three horizontal lines

• Severity of stuttering from one (no stuttering) to ten (severe)

• Willingness to talk about stuttering: open (one) to closed (ten)– OPENNESS PERHAPS THE KEY IN

TREATMENT– The nurse whose patients healed faster when

they looked at the wound

• Thoughts and emotions: healthy, non-hindering (one) to unhealthy, hindering (10)

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Assessment Considerations: two vertical lines

• Severity of the actual stuttering on the left line, from low to high (mild to severe)

• Severity of the person’s reaction to the stuttering on the right line, from low to high

• A very mild severity rating and a very severe reaction rating suggests covert stuttering

Thinking about treatment: three philosophies

• ONE: It’s simple: the goal is fluency and no more stuttering

• TWO: It’s not simple. Fluency never to stutter again may not be possible. The tendency to stutter is hard-wired in the individual and will likely persist. The goal is to learn to manage stuttering, to make it as least-annoying as possible, and to develop a healthy attitude toward communication

• THREE: (often voiced by adults who have had experiences with therapy) Leave my speech alone! Stuttering is not who I am. Stuttering is ok. I am not broken and don’t need fixing. Stuttering is society’s problem

Possible goals for adults in speech therapy for stuttering– To increase fluency

– To move toward acceptance

– To improve the ability to effectively communicate

– To give the individual greater autonomy; to give individuals the courage and ability to act for themselves, speak for themselves, and do what they want to do when they want to do it.

Weybright: two goals

• Teaching speech management tools if the person so desires

• Helping the person accept stuttering as part of who they are and moving on with their lives– Tell their story (openness)

– Dare to take risks: disclose, order, talk

– Listen to others’ stories about stuttering

– Share their reshaped story; teach others

Two goals, said another way

• One, to reduce the amount of stuttering or the obviousness of the effort required in stuttering

Two goals, said another way, continued

• Two, to lead the client to view stuttering in a different light:– To see it as others do (almost always as less

of a problem)

– To see it as a speaking difference not a barrier to communication

– To see it as less than the most important thing in one’s life, to move it to a lower rung on the ladder (Thanks Portland NSAer Jim)

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Speech: Approaches to Treatment

Speech: approaches to treatment

• Fluency shaping

• Stuttering modification

• An integrated approach

Fluency Shaping

• Easy onsets

• Cursive speaking

• Light articulatory touches

• Pauses and phrasing

Stuttering modification

• Assumes there may always be some stuttering

• Modify the moment of stuttering• Deal with avoidances and fears• Reduce and hopefully eliminate secondary

behaviors• Acceptable stuttering is an appropriate

goal

Treatment: speech tools (stuttering modification)

• Cancellation (resets)

• Pull outs

• Preparatory sets

• Voluntary stuttering

• Bouncing

An integrated approach

• Combines elements of fluency shaping and stuttering modification: teach fluency but deal with stuttering moments

• An approach advocated by Barry Guitar Stuttering: An Integrated Approach to its Nature and Treatment. Lippincott Williams & Wilkins (2006; 2013)

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Other speech tools

• DAF (delayed auditory feedback)• The Rate-o-meter• The speech machine and the concept of a

“loose” speech machine• Use their own words and the words of others:

inspirational quotes• Attack avoidances• Severity ratings

Other speech tools

• The speech notebook

• Various hierarchies to use when teaching tools, including situational, listener, and foundation (Reeves, N., One-day workshop on treating children who stutter. Portland: 2006

Other speech tools

• Always have a rationale

• When using speech tools at home, encourage parents to set limits for reminders. You can’t use speech tools all the time. (Hamilton, S., Western Workshop. Seattle: Stuttering Foundation 2002)

Other Speech Tools

• Stuttering is something I do, not who I am• For teens, create and deliver a talk about

stuttering to a class• The concept of careful speech• “Two-part” sounds• Altered fluency, naturalness• The Weirdness Scale (Elyse Lambeth)• Barry Guitar’s concept of downshifting, gearing

down (2006)

Other speech tools

• Make a video about who you are and what stuttering is

• Develop rules for good talking: for example:– Before you talk, think ahead: make a plan– When you talk, speak a little slower– Start out talking slow and smooth– Remember to make your speech flow like

water– Say each word just one time

Other speech tools

• FYI-ing, disclosure

• Self-advocacy

• Ambasador-ship; see oneself as an educator

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Tricks and tools

• Tricks– Blinking before saying the word

– Saying “uh” or “ah” before the word

– Saying a little phrase “and another thing is” before every hard word

– Substituting an easy word for the hard one

– Not saying what you really mean

– Getting a “running start” with other words

Some important tools for teens and adults who stutter

• Meeting other people who stutter. SLPs, facilitate that; start a support group if none exists

• Learn to see yourself as a useful expert for others to learn about stuttering

• Be aware of on-line support groups

• Encourage listening to Stuttertalk and other podcasts about stuttering produced by people who stutter

The Seven Step Treatment Outline

A seven step treatment outline

• Introduction• Exploration of speech• Exploration of stuttering• Facing the stuttering• Modification

SpeechThoughts and emotions

• Stabilization and transfer• Maintenance

Strategies for success used by adults in speech therapy

• Plexico, L., Manning, W., & DiLollo, A. A Phenomenological Understanding of Successful Stuttering Management. Journal of Fluency Disorders, 30, (1), 1-22 (2005)

Strategies for success used by adults in treatment for stuttering

– The adults got support from friends and family

– They had successful treatment programs

– They practiced self therapy and made behavioral changes

– They made cognitive changes, took risks, and disclosed stuttering

– They developed life counter-plots

– They exhibited motivation and persistence

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Walt Manning: Agentic behavior

From a presentation titled “Working with Adults who Stutter” given to the 2013 Oregon Speech and Hearing Association conference, Salem, Oregon

Walt Manning: Agentic behavior

• What is agency: acting and speaking for oneself

• Improving fluency and communication within an agentic lifestyle

• The therapeutic alliance

Agentic behavior

– No longer chasing the fluency god

– Speaking without scanning for feared words

– Initiating conversations rather than choosing to be silent

– Speaking for myself rather than relying on others

Agentic behavior

– Choosing to speak even if I believe I may stutter

– Selecting leisure and career options that require talking without worrying about the possibility of stuttering

– Stuttering gently without avoidance or shame

– Living without constant fear of uncontrolled stuttering

Agentic behavior

• Four principles of therapeutic change:– Move toward rather than away from the

problem

– Assume responsibility for taking action

– Restructure the cognitive view of the self and the problem

– Recruit the support of others

Scripts

• Well thought-out, humorous if possible, well-practiced short explanations that are very useful for disclosure, and for answering standard questions like “Why do you talk like that?”

• Example for disclosure: “I wanted to let you know before we start that sometimes when I talk, I stutter. Don’t worry, it’s not contagious.”

• “Just so you know, sometimes I stutter when I talk. I’m not any more nervous than you would be, I just have a stutter. We’ll be fine.”

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Scripts, continued

• Sometimes I stutter. It’s not because I am nervous or don’t know my material. It’s just because I have a stutter. It doesn’t bother me so don’t let it bother you.

• That’s just the way I talk

Phone practice

• Making and receiving phone calls very challenging and fear-inducing for some people who stutter.

• May just be practice on “hello” many times without phone near, then with “dead” phone, then very carefully with “live” calls from SLP, then on to calls from others.

Phone practice, continued

• Can be used to practice stuttering modification tools (especially voluntary stuttering) or fluency shaping tools

• Businesses can be asked “What time do you close” or “Do you carry _____”

• Teens: These are NOT prank calls

• GW’s phone story

Treatment: Thoughts and Emotions

Counseling?

• “But I’m not a psychologist or psychotherapist!”

• From ASHA’s scope of practice (2007): “counseling individuals, families, coworkers, educators, and other persons in the community regarding acceptance, adaptation, and decision making about communication and swallowing”

Yes, counseling

• We are in the best position to help people who stutter deal with attitudes and emotions occurring as a result of the stuttering and to help them see themselves in a different light

• Of course, when there are other issues like depression or an anxiety disorder or another mental illness, we will refer to the appropriate specialist

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Treatment: tools for managing thoughts and emotions

• Disclosure (FYIing)

• Cognitive behavior therapy

• Mindfulness

• Solution focused brief therapy

• Acceptance and Commitment Therapy

• Facing fear

• The gift of imperfection (Brown)

• The three zones

Disclosure

• Why disclose?– Takes the pressure to hide stuttering off,

which often produces less stuttering

– Lets your listener(s) relax

– Lets you be yourself

What is cognitive therapy

• Cognitive therapy is an approach that encourages people to tune in to the automatic thoughts we all have, challenge them if necessary, and reap the results in anxiety reduction

• The goal is anxiety reduction

Stuttering: Thoughts, Emotions, Physical Responses and Actions

• Thoughts (cognitions) about stuttering– Can become a closed loop

– Learn to challenge thoughts

• Emotions (feelings) come from thoughts

• Physical responses: sweaty palms, etc

• Resulting actions: AVOIDING

Cognitive behavior therapy

• Objective: to identify and monitor thoughts, assumptions, beliefs, and behaviors that are related to or that accompany debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful and to replace them with more realistic thoughts, which will serve to change emotions.

Cognitive behavior therapy

• Cognitions are thoughts or perceptions• These thoughts create our feelings• Thoughts may be untrue, unrealistic, or

unhelpful• Thoughts can be changed, which will produce

changes in feeling and mood• From Burns, David, Feeling Good: the New

Mood Therapy (revised, 1999). New York: Avon Books

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Thoughts

• Examples– “This (presentation) is going to be horrible”

– “They won’t be interested”

– “Someone will ask me a question I can’t answer and I will look foolish”

Emotions, feelings

• Examples– Afraid, worried

– Nervous

– Jittery

– Anxious

Physiological responses

• Hot, flushed face

• Sweaty palms

• Nervous stomach

• Rapid breathing

• Heart rate up

• Tense

Safety (escape) behaviors

• Avoid content areas that might generate questions I can’t answer

• Fake a sickness at the last minute to get out of the situation

• Come six hours early to make sure everything is ready

• Be “busy” the next time I am asked to present

Some thoughts are not helpful

• The idea is to become aware of these “automatic” thoughts and then open them up to scrutiny and questioning

• Our thoughts about an event, our assumptions, which we may hold as fact, influence how we feel

• Cognitions that do not help us can be called NATs (Negative Automatic Thoughts)

Unhelpful thinking patterns (types of NATs)

• All or nothing thinking

• Catastrophising/fortune telling

• Mind reading

• Over-generalization

• “should” and “must” statements

• Labeling

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Steps in the process

• Elicit the NAT

• Challenge the NAT: test it – “people will think you are weird if you stutter:

they will laugh, run away, look at you strangely, or make fun of you”

– Do an experiment to test this NAT

• Replace the NAT

Steps in the process

• Methodical NAT- challenging is hard!

• Why do we teach clients to make the effort – because the payoff is reduced anxiety about stuttering and reduced anxiety may result in less tense stuttering, less avoiding, and more freedom in speech

Again, what is the goal of cognitive therapy?

• Reduced anxiety. Anxiety comes from the stuttering and from anticipating , it did not cause it. Reducing anxiety will make the speaking situation easier and more enjoyable

Mindfulness

• Purposeful and non-judgmental attention to, and awareness of, the moment– Focus on your breathing– When a distracting thought intrudes, gently bring your

attention back to your breathing– Scott Palasik, PhD, SLP, PWS begins every speech

treatment session for students who stutter with a focus on six breaths

• Dealing with negative thoughts and emotions in a mindful way: recognize them, even label them, sit with them, and then…. Move on toward your goal

Acceptance and commitment therapy (ACT)

• A mindfulness-based psychotherapy approach beginning to be used by SLPs who treat teens and adults who stutter, especially in group settings

• The client works on Accepting what is out of his/her control and Committing to taking action to move forward

Acceptance and Commitment Therapy (ACT) and stuttering

• Study the work of Carolyn Cheasman and Rachel Everard, speech language pathologists specializing in stuttering at City Lit in London, England

• Scott Palasik, PhD, University of Akron

• Dan Hudock, PhD, speech language pathologist and director, Northwest Center for Fluency Disorders, Idaho State University

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Brave and courageous

Facing fear and doing it anyway

Scare yourself to death

Acknowledge fear, put it in the back seat and keep going

The gift of imperfection

• What we view as flaws, those things we are ashamed of and don’t want anyone to know about, those things may turn out to be very valuable assets

• Brown, Brene, The Gifts of Imperfection. Center City, Minnesota: Hazelden (2010)

The three zones

• Comfort zone

• Learning, stretch zone

• Panic zone

• Developed by German educator Tom Senniger

• Encourage clients to move into the learning zone

The importance of validating feelings

Beaver sticks: mementos, reminders, and metaphors

Case studies: Adults who Stutter

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Natalie’s story: Full circle

• Once seen as an affliction, now seen as a gift

• The most helpful advice or instruction she received from all her speech therapy

Case studies: Adults in treatment: J.

• Resolved to “hide stuttering at all costs” and did so for twenty years

• Covert stuttering

• Quit his job and researched stuttering for six months at home, then started speech therapy

• Main tool turned out to be voluntary stuttering, then letting real stuttering out

J., continued

• Benefited greatly from the NSA; helped start our Portland NSA chapter

• “I’m still carrying baggage but it is getting lighter”

• The amazing email to friends and family

• What is covert stuttering

Case Studies: Adults in treatment: FH

• Wife made initial appointment

• Two years weekly sessions, then once every other month

• A great self-assigner

• Changed jobs; new career requires much more public speaking

• Uses speech tools but dares to stutter

• His amazing YouTube disclosure

FH, continued

• Describing a self-assigned speech task: “I deliberately stepped up against the butcher’s case so I was too close to point.”

• “All the advice about stuttering, all therapy, can be condensed to two points: Get stuttering ‘out there’ (attitude) and work on speech flow (tools and techniques).

Case studies: Adults in treatment: D

• What I got out of my speech therapy for stuttering– A transformation: before, I fought stuttering

and did not understand it

– Two results: improvement in using tools to address the stuttering, BUT more important, coming to terms with stuttering and becoming more confident in myself as a person who stutters

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Case studies: Adults in treatment: O.

• Many tools presented

• Did not move toward disclosure or openness about stuttering

• Did not take risks to use tools outside the therapy room

• Just wanted it to go away

Case Studies: Adults in Treatment

• Jima

Case study: Mike Turner and his movie

• The Way We Talk

Case studies: Adults in treatment: N.

• Healthcare professional

• Four months once weekly therapy

• Reviewed tools

• Biggest help was validating her responses to stuttering and presenting acceptance as a major goal in therapy

• Stuttering not her only challenge

N, continued

• Her disclosure statements when speaking to students in healthcare: “I didn’t want you to think I’m nervous. I’m not nervous; I just have a stutter.”

• And, referencing The King’s Speech, “The one thing I have in common with royalty: sometimes I stutter.”

K’s story

• My stuttering helped me get remembered after job interviews

• The scanner and the editor

• Toastmasters

• Ice in Anchorage

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Approaches and Challenges to Treating Teens who Stutter

Elyse Lambeth on working with teens who stutter

• Developing an authentic voice

• The weirdness feeling

• The weirdness scale

• Questions and scaling

• Functional goals

• Bravery

An authentic voice

• Could be one using speech tools

• Could be one where stuttering has been declared to be OK

• Will be a voice the person uses without apology

The weirdness feeling and the weirdness scale

• Learning a new speech tool like easy onset, will produce a feeling of weirdnesswhen you first do it. You have to travel through the weirdness. The tool feels weird but you have to go through a period of feeling unnatural.. It’s a motor skill and motor skills take time to develop. The weirdness feeling is normal.

Weirdness

• An eighth grade boy with mild stuttering: “I would rather stutter than use my speech tool (a slower rate) because my friends would think I was weird.”

The weirdness scale

• Used in conjunction with learning speech tools

• Establish the scale– A “1” is a way of talking not weird at all and a

“10” is unbearably weird and would never get used

• Agree on a weirdness number where a new voice might be used (let’s say 3)

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The weirdness scale, continued

• Now modify the voice (reduce stretch or ease into just the first word of the phrase) and have the teen rate that.

• Continue this process until you are at “3”, a voice that will get used

Questions and scaling

• Define the problem

– “I don’t talk to girls because I think I might stutter”

• Establish the scale

– Let’s say talking to girls whenever you want is a 10 and the opposite is 0: where are you now (let’s say 3)

Questions and scaling

• Establish the scale (continued)– Now let’s say when you wake up this morning

the number has risen to 4

• Questions to ask– What would have changed? What would you

be doing different to communicate? What would people notice that is different?

Questions and scaling

• Help the teen notice the things they are already successfully doing and help them identify things they could do more of

Functional goals

• Giving a report in school

• Talking to a boy (or girl)

• The class ring story

Bravery

• Acknowledge bravery

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Remember to validate! Effective Communication

Camp More The Camp More story

• The purpose of Camp More

• Daily schedule

• Group therapy

• Invited speakers

• The closing campfire

• “I found my people”

D’s wisdom from Camp More

• When things go wrong, accept it and see where it takes you. It can provide an opportunity.

• Adversity builds earth movers

• Saying “I stutter” is just an observation, not a value judgment

• If you are just waiting for the other person to be done talking so you can talk, that is not listening

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More wisdom from D.

• Stuttering is not about speaking perfectly fluently but about saying what you want to say

• To be myself, I have to allow other people to see the real me and that includes stuttering

• Speaking privilege is a lot of privilege

Case Studies: Teens J’s story

J’s story

• The head shake

• Bravery before school starts; own initiative

• Go-to tool: slowing down when a word that he will stutter on comes up

• Mom observation re fatigue

• The Bermuda Triangle of stuttering

S’s story

• Very atypical. No stuttering in conversation but significant stuttering in out loud reading

• Once weekly therapy for four months

• Cursive speaking (continuous phonation) go-to tool in reading

• Background as actor in high school plays; stand up comedy is vocational goal.

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E’s story

• Brave and weirdness-tolerant enough to use a speech tool with friends

• In phone practice, deliberately chose fake stuttering over the less intrusive starts with easy onsets

• His mom says: E is moving toward becoming at peace with stuttering

S’s story

• The treatment session in the lobby: the importance of moving therapy to the real world

• GIBIGY

Other topics related to treating stuttering

Atypical Stuttering

Electronic fluency aids

• Speech Easy– By far the most well known. DAF and FAF

together. Around $3500 to $5000. Peter Ramig says useful about one-third of the time. There are some in drawers in Portland and some being used effectively. There may be side effects and the fluency may not last.

Self help and support groups for people who stutter

• Friends: The National Association for Young People Who Stutter (friendswhostutter.org)

• The National Stuttering Association (westutter.org)

• Stuttering Foundation (stutteringhelp.org)• StutterTalk• Stuttering Home Page

(stutteringhomepage.com)• Toastmasters• TOPS (in Portland; Krisitn Mangan)• KOPS (in Portland; Sarah Herr)

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Resources for Adults and their SLPs

Resources

• Cheasman, C., Everard, R., & Simpson, S. Stammering Therapy from the Inside: New Perspectives on Working with Young People and Adults. J.&R. Press, Ltd. (2013)

• Gomez, J. (2017) When I Stutter. Full length documentary about stuttering

• Retizes, P. (ed) (2013). Stuttering: Inspiring Stories and Professional Wisdom

• Turner, M. (2015) The Way We Talk. Full length documentary about stuttering

ConclusionBeyond the skill set: the three

intangibles• Relationship

• Vulnerability

• Gratitude

• YOU CAN MAKE A DIFFERENCE!!

Acknowledgements

• To the preschoolers, school agers, teens and adults AND parents I have worked with who have taught me so much

• To Robert Casteel PhD, my speech therapist and university professor

• To Cliff Goldman, my first mentor in stuttering

• To Elyse Lambeh, a very stutter friendly SLP in Seattle, for her work with teens and for turning me on to the weirdness scale.

• To the members and leadership of the Portland chapter of the National Stuttering Association. Thank you for your bravery

• To Jane Fraser and the Stuttering Foundation

• I have benefited greatly from the work of Barry Guitar, Peter Ramig, Kristin Chmela, Susan Hamilton, Scott Yaruss, Nan Bernstein Ratner, Vivian Siskin, Charles Van Riper, and Walt Manning

References

• Bernstein Ratner, N. (2004). Caregiver-child interactions and their impact on children’s fluency: implications for treatment. Language, speech, and Hearing Services in Schools, vol 35, pp 46-54

• Byrd, C. (2018). Best practices for developmental stuttering: balancing evidence and expertise. Speech, Language, Hearing Services in Schools, vol 49 (1).

• de Sonneville-Koedoot, C., Stolk, E., Rietveld, T., & Franken, M. (2015). Direct versus indirect treatment for preschool children who stutter: The RESTART randomized trial. PloS One, 10 (7), e)133758.

• Gottwald, S.R. (2010). Working with preschoolers who stutter and their families: A multi-dimensional approach. In B. Guitar and R. McCauley (Eds.),Treatment of stuttering: Established and emerging interventions. Baltimore, MD: Lippincott, Williams, & Wilkins

• Mansson, H. (2000). Childhood stuttering: incidence and development. Journal of Fluency Disorders, 25 (1), 47-57.

• Millard, S. & Cook, F. (2009). Parent-child interaction therapy: Adding to the evidence. International Journal of Speech-Language Pathology, 11 (1) 6 1-76.

• Yairi, E., & Ambrose, N.G. (1999). Early childhood stuttering1: Persistency and recovery rates. Journal of Speech, Language, and Hearing Research, 42)5), 1097-1112)