Assessment and Treatment of School-Aged Children Who

StutterPresentation 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 BehaviorsPostponing 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– 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

Feelings and Attitudes

Iceberg Analogy

Talking to Kids about Stuttering• 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

• 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 speech-

language 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 Disfluenciestypically expressed as % of stuttered syllables or wordseach syllable or word can be stuttered only once

2. Types and Frequency of Stutterse.g. part word repetitions, monosyllabic whole-word

repetitions, prolongations, blocks

3. Ratio of Stutters to Total Disfluencies

4. Pattern of Disfluenciese.g. clusters

5. Duration of DisfluenciesAverage length of 3 longest blocks or stuttering events

Components of Speech Sample Analysis, cont..

6. Rate of speech

7. Physical concomitants/Secondary behaviorse.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; Pro-Ed

• Stuttering Prediction Instrument (SPI) G. Riley, 1981, Pro-Ed

• Protocol for Differentiating the Incipient Stutterer (SIP program) Pindzola, 1987, Pro-ed

Assessment of Feelings and Attitudes

• Feelings about Stuttering

• Struggle Behaviors

• Escape Behaviors

• Avoidance Behaviors

• Beliefs about Stuttering

Formal Assessment of Feelings and Attitudes

• Modified Erikson Scale of Communication Attitudes (S-24)

• 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

• 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?• Determined by evaluation

2. Is the child making effective progress?• E.g. participation, reading, etc..

• Holistic view of child as a learner

• Ability to access the academic curriculum– 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

• Reduce Frequency of Stuttering– Often referred to as Fluency Shaping – Appropriate for all levels– Obtained through a variety of methods

• May involve use of DAF, reduced speech rate, monitoring, etc.

– Degree to which frequency can be reduced is varied• 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 pseudo-stuttering 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 onkey

– 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 de-sensitizing to fluency disruptors right away

Reducing Severity of Stuttering

• Stuttering Modification approach– Goal is improved fluency, improved communication,

and increased confidence in ability to manage speech

• Techniques– Saying words in 3 ways

• Regular, Easy, Hard

– Locating tension• Confront and explore stuttering• Increase proprioception

Reducing Severity of Stuttering…• Cancellations

– Complete stuttered word, then say it again fluently

• Pull-outs – Begin by having child “stay in” MOS--keep repeating

or prolonging, modify to an easy stutter and release rest of word

• Voluntary stuttering – Inserting stuttering into real speech

• Transfer and Independence

• 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…PaperclipBicycleCupcakeYoukilisVaritekAutographLowellRaspberryEyelashesMountain bikeTelephone

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 buildingWhen 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 aAVC 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/

632.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

• Nan Bernstein Ratner…– Concurrent treatment

• Fluency is treated simultaneously with other disorder– Child practices fluency only with mastered

language/speech structures

– Blended Model– 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– 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• 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

• 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

• 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)

• Tiger Woods• Johnny Damon• Nicholas Brendon• James Earl Jones• Winston Churchill• Bruce Willis• Julia Roberts • Bill Walton• John Updike• Jimmy Stewart

• 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