Practical Treatment Strategies for Preschool and Young School-Age Children Who Stutter: Ages 2 to 6. J. Scott Yaruss, Ph.D., CCC-SLP, ASHA Fellow

Practical Treatment Strategies for Preschool and Young School-Age Children Who Stutter: Ages 2 to 6 J. Scott Yaruss, Ph.D., CCC-SLP, ASHA Fellow Board-Recognized Specialist and Mentor in Fluency Disorders Associate Professor, Communication Science & Disorders, University of Pittsburgh Director, Stuttering Center of Western Pennsylvania 4033 Forbes Tower, Pittsburgh, PA 15260 Phone: (412) 383-6538 Fax: (412) 383-6555 Email: jsyaruss@pitt.edu / speech@yaruss.com Stuttering Center: www.stutteringcenter.org / Presentations and Seminars: www.yaruss.com Practical Stuttering Therapy Guides: www.stutteringtherapyresources.com S enter tuttering Disclosures: Financial relationships with Pearson Assessments (royalties) and Stuttering Therapy Resources (royalties and ownership). Non-financial relationships with StutterTalk (advisory board) and National Stuttering Association (volunteer) C W of P estern ennsylvania I. Most Important Fact #1: You can and should treat preschool children who stutter, and YOU are the best person to do it. #1 II. Purpose A. To reduce your fears about working with very young children who stutter 1. To help you realize that you won t hurt the child or make stuttering worse through treatment 2. To help you feel confident that you are using appropriate diagnosis and treatment strategies 3. To help you respond to and minimize concerns of parents and others in a child s environment B. To discuss current strategies for helping preschool and young school-age children who stutter by 1. Improving children s speech fluency through a variety of data-based techniques 2. Reducing tension & struggle during stuttering so children can communicate freely and effortlessly 3. Minimizing the development of negative reactions (e.g., fear, concern) to stuttering by the child 4. Minimizing negative reactions of parents, teachers, peers, and others in the child s environment III. Where Do We Start? Defining Stuttering A. The first question we often need to answer is whether the child is actually stuttering 1. Many children go through a period when they exhibit an increased number of speech disruptions 2. Not all of these disruptions are instances of stuttering, but we want to look carefully to make sure we don t let kids who are at risk fall through the cracks 3. To answer this question, we need a definition of stuttering so we know what to look for 4. Unfortunately, numerous definitions have been offered over the years, and this has contributed to clinicians confusion about the diagnosis and treatment of the disorder B. What Is Stuttering? It can be defined as both a speech behavior and as a speech disorder 1. Behavior: A specific type of disruption in the forward flow of speech ( speech disfluency ) 2. Disorder: A communication problem typically (but not always) characterized by the production of certain types of speech disfluencies 3. Children can produce disfluencies without stuttering and without having a disorder (Indeed, all children are disfluent to some extent) J. Scott Yaruss 1

C. What Are Stuttering Behaviors?!? 1. There are many definitions of stuttering, and many opinions about what should be counted as stuttering behavior a) Stuttering typically refers to certain types of speech disfluencies (e.g., sound or syllable repetitions, prolongations, blocks) b) Note that these disfluencies typically involve disruptions within the word unit, but not all withinword disfluencies are stuttering, and not all stuttering involves within-word disfluencies c) Stuttering behaviors may also be accompanied by tension or struggle, but not always 2. Stuttering is often accompanied by a speaker s feeling that he cannot continue speaking even though he knows exactly what he wants to say a) Often referred to as a feeling of a loss of control (Perkins, 1990) b) We must recognize the speaker s perception when trying to identify stuttered events D. So Is This Child Stuttering? It is relatively easy to determine whether a preschooler is exhibiting stuttering behaviors. We do this by counting the disfluencies that the child exhibits. We also gather information from parents and others about those behaviors in other settings. IV. How do we count the stuttering behaviors? A. There are several basic measures of disfluencies: 1. Frequency of Disfluencies. How often disfluencies occur in a sample; Typically represented as the percentage (out of 100) of disfluent words or syllables. 2. Types of Disfluencies. Helps distinguish normal interruptions from stuttered interruptions; Provides indication of the development of the disorder (especially in preschool children) 3. Duration of Disfluencies. The number of seconds a repetition, prolongation, or block lasts or the number of iterations in a repetition (e.g., li-li-li-like contains 3 stuttered and 1 fluent iterations) 4. Severity of Disfluencies. Describes the physical behaviors during stuttering (e.g., tension, struggle). Severity measures combine several aspects of the behavior into a single number or score. In doing so, you lose some of the detail in the data you collected, but severity ratings are widely used. a) Often obtained through measures such as the Stuttering Severity Instrument (Riley, 1994) or Stuttering Prediction Instrument (Riley, 1981), but b) (Note that the reliability of these instruments is not ideal) B. Measurement Procedures. Measures can be collected in real-time or based on a transcript 1. Real-time analyses collect and analyze data at the same time, while the client is speaking (or offline from a videotape). These measures are fast and efficient, but limited in the amount of data that can be collected at one time 2. Transcript-based analyses require that you record data and analyze it later, often based on a detailed verbatim transcript of the client s speech. These measures are time-consuming, but allows much more detail to be considered in analyses C. Real-Time Analysis: Quickly and reliably obtain the frequency and types of disfluencies 1. Watch a speech sample (live or from a videotape) and keep track of whether each word or syllable was produced fluently or disfluently. Count the disfluencies to obtain your data. a) Make sure your sample is large enough to be representative of the client s speech J. Scott Yaruss 2

D. Count Sheet: To facilitate data collection, you can use a count sheet (Conture, 2001; Yaruss, 1998) 1. The sheet contains a series of blank lines representing the words or syllables produced by the client 2. A tally section is also included to facilitate tabulation of different types of disfluencies 3. Count sheets can be designed to follow the coding conventions used in any clinic) a) Use a dot or a dash to indicate a fluent word; Use abbreviations to identify the types of disfluencies that occur (using one of the various categorization schemes that were mentioned) b) This takes practice, but ultimately you will be able to identify the types of disfluencies (To begin, you can mark disfluencies with an X (or use S for stuttered and N for normal)) 4. The biggest concern about real-time analysis is keeping up with the child a) Children can speak quite quickly, and real-time analysis requires rapid judgments b) Still, stuttering reduces overall speaking rate and this actually makes it easier for you to keep up once you get good at making stuttering judgments 5. For More Information: see my CE course on stuttering measurement at www.onlineceus.com E. With practice, you can learn to make reliable judgments of the overall frequency of disfluencies in a sample. Still, it is not entirely straightforward because #2 1. Stuttering Varies from situation to situation, day to day, listener to listener. Thus, we cannot base decisions on measures taken in just one speaking situation 2. Some factors that affect variability: a) Conversational tasks (Conversation, Picture description / Story Retell, Monologue, Reading) b) Conversational setting (both in and out of clinic, at home, in the classroom, on the playground) c) Conversational partners (Parents, clinician, peers, siblings, playmates, others) 3. Still, If you practice (to achieve reliability) and are cautious in interpretation (because stuttering varies), you can get a reasonable indication of whether the child is stuttering and, if so, how much F. For preschool children, the question Is this child stuttering? isn t as important as you think... #3 #4 1. The parent would not have brought the child in if she hadn t had some reason to be concerned about the child s speech, AND preschool children can still recover even if they stutter severely (and children who stutter mildly may still be at serious risk!) 2. Initial Severity Does Not Predict Chronicity G. The more important question is Is This Child Likely to Continue Stuttering? because most Preschool Children Recover from Stuttering 1. Studies show that as many as 75-80% of preschool children who stutter will recover a) The majority of these children will recover within the first 6 to 12 months b) Recovery is still observed up to 2, 3, and even 4 years post-onset 2. This recovery can be aided (with the help of treatment) or unaided (without any intervention at all) 3. This is good because we want children to recover, but it s bad because it makes our job harder (There is no single factor that we can point to that absolutely differentiates children who will recover from children who will persist) H. For very young children who stutter, the primary goal of the diagnostic evaluation is to determine whether the child is at risk for continuing to stutter 1. If the child is at high risk, then treatment is definitely indicated 2. If the child is at low risk, then we may not need to be as urgent in our intervention, though I rarely send families home empty-handed! J. Scott Yaruss 3

I. Recent research has sought to determine what risk factors make it more or less likely that a child will recover from stuttering. These risk factors can be divided into two broad categories: 1. What s going on within the child? (Etiologic factors that create disfluencies 2. What s going on within the child s environment? (Contributing factors that exacerbate disfluencies) J. Focusing on Etiology What Causes Stuttering? 1. Most clinical researchers now believe that stuttering arises due to multiple risk factors (genetic & environmental factors including language abilities, motor abilities, temperament) 2. Many current theories of language formulation and speech production are based upon a set of related modules where messages are built through a series of interacting processes (Speech disfluencies represent disruptions in the planning or production process) 3. What s Going On in the Child? a) What are the child s Language Skills? (You already know how to evaluate children s language) b) What are the child s Motor Skills? (You already know how to evaluate young children s speech sound production, though evaluating speech motor control may not be as easy) c) What is the child s Temperament? (You may not have used tests of temperament before, but you can assess reactivity and regulation ability through observation and parent interview) #5 4. So what are we looking for in the child? a) A mismatch between Language Skills and Motor Skills (This can be any type of mismatch -- advanced language skills & typical/lower motor skills, advanced motor skills & typical/lower language skills, or anything) b) A sensitive/reactive Temperament (1) Reactivity to what goes on within/around the child (fears, cries easily, strong reactions to noise) (2) Regulation difficulty for changing responses (Difficulty stopping crying, changing activities) c) The etiology of stuttering is within the child In other words, Stuttering Is Built-In! (it is a neurological dysfunction involving the child s language skills, motor skills, & temperament systems) K. What s Going On in the Child s Environment? #6 1. For years, people believed that stuttering was caused by the child s environment a) The diagnosogenic theory stated that parental misdiagnosis of normal disfluencies led to increased concern about the child s speech ( Stuttering begins in the ear of the listener, not the mouth of the speaker ) b) This theory was the source of the fear about drawing attention to stuttering and was the foundation for indirect treatment approaches c) But The diagnosogenic theory was WRONG! The child s environment does not cause stuttering 2. Still, this does not mean the environment plays no role in the child s stuttering a) Parents are still extremely important in the child s daily experience of the disorder and the child s experiences contribute to the disorder b) We can help parents make changes that support the development of more fluent speech (If the child weren t susceptible to some change in his environment, then no treatment would work) 3. So what are we looking for in the environment? a) A speech or language model that is too advanced (This does not cause stuttering, but it can make it harder for the child to communicate successfully) (1) Children are more likely to stutter on longer, more complicated utterances (adult language model) (2) Stuttering severity is related to dyadic speaking rate (the difference between the parent s and child s rate) b) Strong (fearful, anxious) reactions to stuttering on the part of parents or others (Again, this does not cause stuttering, but it may convey that stuttering should be feared) J. Scott Yaruss 4

L. What Causes Stuttering? Stuttering arises due to an interaction among several factors that are affected by both the child s genes and the child s environment 1. Language Skills for formulating messages 2. Motor Skills for producing rapid and precise speech 3. Temperament for reacting to disruptions in speech 4. An interaction among factors contributes to the likelihood that the child will produce speech disfluencies and react to them M. What Risk Factors contribute to the likelihood that a child will continue stuttering? 1. Family history of stuttering 2. Preponderance of stuttered types of disfluencies 3. Time since onset > 6 months 4. Child is aware of or concerned about disfluencies 5. Child is highly reactive to mistakes or disfluencies 6. Parental reactions are negative or fearful 7. Child has concomitant speech/language disorders 8. Others? Research is ongoing N. How does all this relate to the diagnostic evaluation? To gain an full understanding of these risk factors, our evaluation will include: 1. Parent Interview: Family history, confirmation of behaviors in other settings, temperament, development of stuttering 2. Observation of Child: Surface behaviors of stuttering in clinical setting, reactivity and regulation 3. Speech/Language/Motor/Temperament Testing: Language/Motor Mismatch, Reactive Temperament, Presence of Concomitant Disorders O. To Treat or Not To Treat There is (still) a significant debate about when to recommend therapy for preschool children 1. Many preschoolers recover on their own, so some prefer to wait and see. a) I am not comfortable with this because I don t want children to fall through the cracks 2. Because there is no simple way to determine who will outgrow stuttering a) I prefer to help families that want help, even if it seems that the stuttering might ultimately resolve b) Of course, this does not mean that all children receive full, formal therapy that s what we ll discuss next P. Summary of the Evaluation. When evaluating preschool children who stutter, remember 1. Determining whether they stutter is easy (and not particularly interesting); determining whether they are likely to continue stuttering is the question of interest, for that is what helps you decide if therapy is indicated 2. The evaluation is based on finding risk factors a) Etiologic factors (within the child) b) Contributing factors (within the environment) J. Scott Yaruss 5

V. What s Next? TREATMENT! #7 A. What s the Primary GOAL of Treatment for Preschool Children? To eliminate the stuttering! B. How Do We Do That? There s more than one way 1. Treating Preschool Children Who Stutter the OLD Way. Historically, treatment for preschool children who stutter has been indirect (Based on the (incorrect) diagnosogenic theory) a) No instructions were provided to the child about how to modify speech or improve speech fluency (In fact, no mention of speech was made at all, for fear that the child would get worse or become aware of his stuttering ) b) This is old news! Times have changed! 2. Treating Preschool Children Who Stutter Some NEW Ways. Over the past 10 to 15 years, researchers and clinicians have moved toward providing direct treatment for preschool stuttering a) Direct discussion of fluency-enhancing speech strategies and appropriate communication attitudes, combined with environmental modifications to minimize fluency disruptors b) Direct correction of stuttered speech and praise for fluent speech (Lidcombe program) VI. A Family-Focused Treatment Approach for Preschool Children Who Stutter Yaruss, Coleman, & Hammer (2006) Language, Speech, and Hearing Services in Schools A. For young children who stutter, the first goal of therapy is to improve their fluency B. Still, our therapy is not focused entirely or exclusively on fluency 1. We also work to ensure that children develop effective communication skills 2. We want to ensure that children develop appropriate attitudes toward their speaking and stuttering C. Fortunately, we have several effective tools to help us accomplish these broad goals! Improved Speech Fluency Effective Communication Skills Healthy Communication Attitudes Parent-Focused Treatment (Parent-Child Training Program) Child-Focused Treatment (Direct Treatment) Parent Communication Modifications Parent and Child Understanding and Acceptance of Stuttering Child Communication Modifications Easy Talking Model Increased Pause Time Reduced Demands Reflecting / Rephrasing Parent Counseling Education about Stuttering Identification of Stressors Communication Wellness Education about Speaking and Stuttering Desensitization (as appropriate) Speech Modification Stuttering Modification Communication Skills Concomitant Disorders J. Scott Yaruss 6

VII. Part 1: Parent-Focused Treatment A. Parent Communication Modifications: (A Fluency-Facilitating Environment). Parents can change their speech patterns to help the child achieve more fluent speech, e.g.: 1. Slower speaking rate (n o t t o o s l o w!) a) Easier interaction style. Increased pausing both within and between utterances 2. Less hurried daily pace / lifestyle (Less hectic scheduling of daily life activities, one-on-one time with child) B. Focus on the Parents Communication Style and the Child s Fluency 1. Children do not slow when parents slow, and they do not pause when the parents pause a) Improvements in fluency are not related to changes in the child s speaking style b) Children just tend to become more fluent when parents change their speaking style 2. Why? Nobody performs at their best when under pressure to act quickly C. Why Do We Do These Things? (and why should they work, if they do?) 1. The rationale is NOT because parents talk too fast or demand too much a) For years, researchers have sought a consistent difference in the parenting and communication styles of parents of children who stutter, compared to parents of children who do not b) It s just not there parents of children who stutter are no faster or slower or more demanding or whatever than parents of children who do not stutter 2. The rationale for changing the environment IS based on the finding that when parents speak more slowly, children become more fluent a) The evidence for this is thin, and more research is needed so, why do we do it? 3. I think the key variable is time pressure a) Slower rate, increased pausing, reduced activity these aren t as important as giving the child the time he needs to plan and produce speech b) As we minimize time pressure, we increase communication success #8 4. The Bucket Analogy identifies multiple factors involved in stuttering and helps parents understand the rationale for parent-focused aspects of treatment a) Water in the bucket represents risk factors contributing to the child s stuttering b) Treatment aimed at modifying the communication environment addresses those aspects of the child s water bucket that can be modified (1) We can t easily change the genetic component of stuttering, temperament, family conflicts, etc (2) We can help the parents reduce time pressures the child experiences in key situations c) The rationale for parent-focused treatment is simply to lower the water level where you can d) In therapy, we change the things we can change! D. How Can We Help Parents Do All These Things?? (and do them consistently) 1. Rule #1: SHOW, not tell You can t just tell parents to slow down a) They ll try, but they can t do it without help b) And if they can t, they ll feel (even more) guilty 2. You need to train them about how to slow down, when to slow down, and what to expect when they do slow down a) The same is true for all the other strategies we re going to help the parents use in order to support their children s speech development J. Scott Yaruss 7

VIII. Helping Parents Learn to Facilitate Children s Speech Fluency ( Parent-Child Training Program ) A. Goal is to help parents learn and use strategies for facilitating fluency at home and in other settings B. Based on current evidence about factors that affect children s speech fluency: 1. Modifying aspects of daily interactions can help child achieve fluency in specific situations (even if the child does not directly change his own communication patterns) 2. The more time a child spends communicating successfully, the less likely he is to develop severe stuttering C. Approx. 6-to-8 session treatment program 1. 2 to 4 parent-only sessions for counseling/education about stuttering and communication in general 2. 3 parent-child sessions when parents learn and practice fluency-facilitating communication modifications 3. 1 to 2 review and problem-solving sessions where the need for further treatment is assessed 4. Training is administered by itself or prior to more direct intervention with child or family 5. Focus (for now) is on parent behaviors we will discuss child-focused treatment next D. Communication Wellness Analogy: Describes flow of treatment so parents will understand the treatment structure (this and other handouts at www.stutteringcenter.org) IX. Parent Session 1: Overview and Identification of Stressors Parent Observation Direct Child Intervention Parent Sessions Strategy Practice A. Goals of Session 1: 1. Help parents understand the nature of stuttering and the factors that may affect their child s speech 2. Provide an overview of the treatment process 3. Begin identifying interpersonal stressors B. Step 1: Stressor Inventory. Provides background about factors that may affect child s speech and helps parents understand What s Going On in the Child and in the Environment 1. Prior to any discussion about modifications, both parents complete a stressor inventory a) Provides background about factors that may contribute to the child s stuttering b) Examines stressors within the child and within the environment c) Allows parents to see how they compare with one another in their views about the child 2. Possible Stressors in the Child a) Is sensitive e) Demonstrates performance anxiety/fears b) Tends to be perfectionist f) Tends to become more disfluent when tired c) Has an intense personality g) Tends to become more disfluent when ill d) Is competitive h) Has other speech/language problems NOTE THAT THESE DO NOT CAUSE STUTTERING BUT THEY MAY CONTRIBUTE TO DISFLUENCY 3. Possible Stressors in the Environment a) Hectic daily routines are commonplace e) Stressful situations have been present b) Sibling rivalry is intense f) Family members/relatives who stutter c) Limited free time or quiet time g) High expectations are imposed by others d) Others at home talk fast/interrupt frequently NOTE THAT THESE DO NOT CAUSE STUTTERING BUT THEY MAY CONTRIBUTE TO DISFLUENCY (Stressor Inventories are attached to the end of the handout) J. Scott Yaruss 8

4. Interpreting Stressor Inventories a) Help parents understand that the goal is not to change the child s personality, but rather, to identify those factors that are contributing to the child s overall communication difficulty b) Keep in mind some parents may be reluctant to identify stressors in the environment c) Have both parents complete the inventories separately then compare them d) Give parents the chance to brainstorm ways to minimize personal and environmental stressors C. Step 2: Help Parents Understand Different Types of Disfluencies (See Disfluency Chart) 1. Helps parents distinguish between disfluency types and understand progress during treatment 2. Reduces misconceptions about disfluency types (prolongations are not better than repetitions) D. Step 3: Home Charting Exercise 1. Increase parents awareness of: a) Situational factors that affect fluency b) Their reactions and the child s reactions to stuttering 2. Helps parents focus their energy on helping the child rather than worrying 3. Gives opportunity to assess commitment to treatment early in the therapeutic process (Parents bring completed chart to next session) 4. The purpose is NOT for parents to keep track of how many times the child stutters E. Step 4: Provide Supportive Literature 1. Support helps parents deal with stuttering, and this helps them help their child 2. Reassures parents that others have had similar concerns, questions, and feelings 3. Provides concrete examples of ways parents can help their children 4. Examples: Booklets and brochures from SFA, NSA, Friends, Stuttering Home Page, etc. a) Beware PIO (Parental Information Overload) b) Keep in mind that counseling is not the same as teaching F. Summary of Session 1 1. Provides an overview of the process of treatment (Communication Wellness Analogy) 2. Helps parents understand the nature of stuttering (Stressor Inventories, Bucket Analogy) 3. Gives parents the opportunity to discuss their concerns in a supportive atmosphere 4. Gives clinician the opportunity to assess commitment and plan further treatment X. Parent Session 2: Overview of Fluency-Enhancing Strategies A. Primary Goals of Session 2 1. Review topics from Session 1 2. Prepare parents for communication modification sessions a) Describe structure of modeling sessions b) Explain wireless microphone system (if available) c) Introduce Communication Modifications J. Scott Yaruss 9

B. Step 1: Review Session 1 1. Begin by giving parents an opportunity to continue discussions from Session 1. Many parents will have thought about the stressors and have questions. Now is the time to address those issues 2. Some families may need more time on these aspects of treatment. If so, additional parent counseling sessions are scheduled prior to initiating communication modifications sessions C. Step 2: Describe Structure of Modeling Sessions 1. Communication Modification Sessions are designed to teach parents how to use skills a) Clinician first models the target strategy with the child while the parents observe b) Next, one parent interacts with child while receiving on-line feedback through wireless microphone c) Next, the other parent interacts with child while receiving feedback d) The session is videotaped so parents can review the session at home and observe the changes in detail D. Step 3: Describe the wireless microphone system (if available) Use Easy Talking Wireless Xmitter (Telex TW-6) Wireless Receiver (Telex AAR-1) (Easy Talking) E. Step 4: Introduce Communication Modifications. Make sure parents understand the rationale for the communication modifications 1. Reinforce that the goal is not to correct parental behaviors that cause stuttering, but to make the changes we can make to minimize time pressure on the child s speech (review bucket analogy) 2. Also, reinforce the importance of providing a supportive communication environment 3. Help parents reduce their concerns about the child s stuttering so they can model appropriate reactions XI. Parent and Child Sessions 3, 4, and 5: Fluency-Enhancing Strategies A. Several strategies can be introduced as necessary to enhance child s fluency if these factors are judged to affect a child s speech 1. Reducing parents speaking rates (Easy Talking) 3. Reducing demand for talking (if demand is high) 2. Reducing time pressures (Delaying response) 4. Modifying questioning (if and only if necessary) (Note: Providing a supportive environment is important no matter what other tools are being used) B. Easy Talking: Smooth, slightly slower speech that provides a model of a speaking style the child can use while reducing time pressure 1. Slower than parents habitual rate, but not too slow, choppy, or robot-like 2. Introduce phrased speech as a preferred way to reduce speaking rate 3. The goal for the parents speaking rate is in between the rate they practice in treatment and the rate they used before treatment C. Modifying Questioning: IF a parent uses frequent, rapid questions, and IF this cause problems for the child, the parent can learn to COMMENT rather than QUESTION 1. I wonder 3. I bet 5. Maybe 2. I think 4. I guess 6. It looks like Parents should not just eliminate all questioning J. Scott Yaruss 10

D. Reduplication / Rephrasing. Gives child opportunity to hear what he or she said in an easier, more relaxed way (easy speech) 1. Also gives parents the opportunity to provide an appropriate language/articulation model 2. Child knows that parents heard what s/he said 3. Similar to the active listening strategy that clinicians use in counseling interaction 4. Listener reflects and expands upon speaker s utterance, but adds modeling of easy talking XII. Parent and Child Session 6: Review and Evaluation A. Help parents incorporate all strategies 1. Discuss need for home practice and follow-up plan 2. Discuss plan for future treatment as necessary B. A Refresher handout can facilitate generalization (available at www.stutteringcenter.org) 1. Use Easy Talking at slowed rate with phrasing 2. Delay Responding to reduce time pressure 3. Modify Questions. I wonder Maybe I think 4. Repeat and Rephrase both fluent and disfluent speech to provide a good communication model XIII. How Can I Do All that Stuff Where I Work? ( Adapting the Parent-Child Training Program to Other Settings) A. Common Adaptations: Scheduling 1. Many clinicians have difficulty meeting with parents on a regular basis in school settings a) Still, this is somewhat easier to do in many Early Intervention or Preschool settings b) Note that the program is designed to minimize contact between clinician and parent (6 sessions) while maximizing parents treatment of children 2. We typically schedule sessions every other week to give parents the opportunity to try strategies at home before they learn new ones B. Common Adaptations: Observation/Modeling 1. We have found success using the wireless microphone to provide feedback in real-time a) The system is relatively inexpensive and easy to implement in most settings b) Does not require an observation room, since you can sit in the corner of the room and speak quietly into the mic to provide feedback 2. If you don t have access to such a system, you can still provide feedback off-line (after a parent practice session) or while watching videotape J. Scott Yaruss 11

XIV. What about Talking to Kids about Stuttering? (Focusing on Parent and Child Acceptance) A. Is it REALLY okay to talk about stuttering? YES! It really is okay to talk about stuttering. 1. Talking about stuttering (in a supportive way) will not make stuttering worse a) The Lidcombe Program even encourages parents to point out a child s disfluencies and ask them to say the words again without bumps (more about that later) 2. It s even okay to say the S word! B. Parent-Child Focused Treatment: Maintaining Healthy Attitudes 1. Concern: Children who stutter are at risk for developing negative communication attitudes 2. Solution: Help parents learn to... a) Model appropriate attitudes and reactions b) Listen to children s concerns about speaking c) Talk to children about stuttering 3. The goal is for the child to accept disfluencies as a normal part of learning to speak C. Talking about Stuttering 1. Concern: Child and parents do not have a way to discuss stuttering 2. Solution: Introduce a vocabulary accessible to child and parents for discussing stuttering 3. Use analogies for talking about disfluencies a) Repetition: going over railroad b) Prolongation: going over a bridge c) Block: hitting a brick wall 4. Goal: Child and parents will be able to discuss stuttering in a matter-of-fact, accepting way D. When Do We Talk About Stuttering with Preschoolers? If the child is Not Aware / Not Concerned Aware but Not concerned Aware and Concerned Parent Counseling Education about Stuttering Identification of Stressors Communication Wellness Parent and Child Understanding and Acceptance of Stuttering Then will we talk about stuttering? No Maybe Yes! Education about Speaking and Stuttering Desensitization (as appropriate) XV. Summary of Parent-Focused Components of Treatment A. A short course of therapy designed to teach parents strategies they can use to facilitate children s fluency at home and in other settings B. Recall that this is not the entire treatment it is just one component, the component that addresses parental communication patterns C. Still, some children require no more that this many children recover following only these parent-focused aspects of treatment D. Next, we decide if more treatment is needed! Parent Communication Modifications Easy Talking Model Increased Pause Time Reduced Demands Reflecting / Rephrasing Parent-Focused Treatment (Parent-Child Training Program) Parent Counseling Education about Stuttering Identification of Stressors Communication Wellness Parent and Child Understanding and Acceptance of Stuttering Education about Speaking and Stuttering Desensitization (as appropriate) J. Scott Yaruss 12

XVI. Direct Follow-Up A. Follow-up is critical, not only because it is a basic responsibility of clinicians using any treatment 1. Although many children recover following only the parent-focused treatment, not all do a) Some children need more direct, child-focused treatment after the parent/child training program b) Follow-up is the only way to know if the child has improved you can t rely on parent report only 2. Because success is based on the parents use of techniques, you can t just teach the strategies and assume this will be enough. You must check! #9 B. The key decision is how long to try this stuff before giving up and trying something else? 1. If Indirect Therapy Is Going to Work, It Will Work Quickly 2. Don t Wait Too Long I rarely stay only with parent-focused treatment for more than 3 months (6 sessions, every other week) If the child isn t better by then, move on! XVII. Part II: Child-Focused Treatment A. Improving Fluency Directly 1. If the child continues to stutter following the parent-focused treatment, then it s time to begin direct child-focused treatment Parent and Child Understanding and Acceptance of Stuttering Child-Focused Treatment (Direct Treatment) Child Communication Modifications 2. Now, the goals of treatment are the same as they would be for older children who stutter Education about Speaking and Stuttering Desensitization (as appropriate) a) To improve the child s fluency through direct modification of the child s communication skills b) To ensure that the child develops and maintains appropriate communication attitudes Speech Modification Stuttering Modification Communication Skills Concomitant Disorders B. Communication Modifications 1. Many techniques for improving fluency have been discussed; most focus on changing timing or tension 2. Changing Timing: Reducing Speaking Rate, Pausing and Phrasing, Reducing Pace, Easy Starts 3. Changing Tension: Light Contact, Easy Starts / Easing In, Pull-out / Easing Out, Cancellation C. Changing Timing: Speaking Rate 1. One of the most common techniques for improving fluency is reducing speaking rate 2. Turtle speech can help children slow their rate to facilitate fluency 3. I strongly prefer a more natural styles of slower speech (easy talking) 4. Guidelines for Reducing Speaking Rate a) Practice using slow rate before you teach it get a feel for too slow and not slow enough b) Use natural intonation and rhythm c) Do not use choppy or robot speech or s t r e t c h out all the words d) Slower (but still natural) speaking rates can be incorporated into all activities as a positive model for the child, but don t go too slow! D. Changing Timing: Pausing 1. Increase pause time -- the length of time between words and phrases 2. Pauses should occur at natural locations, e.g., between sentences and phrases 3. Pauses should not be so long that the child feels uncomfortable with the silence (~1 sec) 4. It may take some practice for the child (and you) to develop comfort with silence J. Scott Yaruss 13

E. Changing Time: PACE 1. Rather than encouraging children to slow down or pause, I teach them to manage their pace a) If their pace is too high to maintain control, they can try slowing or pausing b) Sometimes, they will need to manage their pace; Other times, they won t 2. Again, the goal is successful and effective communication F. Changing Physical Tension 1. Physical tension is a learned reaction to stuttering (or the anticipation of stuttering) (It is the child s attempt to not stutter, but it rapidly becomes part of the stuttering pattern) 2. Most of what you see on the surface is the child s reaction to stuttering (The real core of stuttering is under the surface; Children must become desensitized to that core if they are reduce their reactions) 3. We can blend desensitization with tension reduction to help children stutter more easily 4. Children can learn to change tension by exploring different ways of speaking and stuttering a) Pseudostuttering (easy bouncing or stretching) helps the child understand what happens when he gets stuck in his speech b) The child can explore using more tension and less tension to learn to change his stutters 5. These activities are fun and desensitizing and they prepare the child for advanced techniques like easing in, easing out, and cancellation G. Exploring Stuttering. To help children change stuttering, we help them learn what they are doing when they stutter by staying in and exploring stuttering 1. First, they need to learn about their speech machine 2. Next, they learn about how their articulators move during both stuttered and fluent speech 3. By staying in the block, they can explore how to move their articulators to change stuttering 4. This also helps to develop necessary self-monitoring skills and desensitizes children to stuttering H. Easy Stuttering 1. Easy stuttering helps children learn that they can change the way they stutter ( Bouncing and gliding or stretching are forms of pseudostuttering without tension) 2. Also reduces tendency to hide stuttering a) The more children try to hide stuttering, the more likely they are to stutter more b) If children are comfortable with stuttering, they can use voluntary stuttering to release tension in their muscles and prevent bigger blocks I. Helping the Child Develop Healthy Communication Attitudes 1. Desensitization is just one part of therapy that supports the development of healthy attitudes 2. Viewing stuttering in an open, matter-of-fact manner, in which the child is praised for his communication success (not just his fluency), is another way to ensure that the child learns that what he has to say is valuable and worthy even if it sometimes comes out bumpy 3. Parents must come to terms with stuttering if they are going to be able to do this effectively J. Can Little Kids Do All this Stuff? SURE! But, you may need to take your time. J. Scott Yaruss 14

XVIII. Brief Summary of Family-Focused Treatment A. The Family-Focused Treatment Approach is designed to help preschool children achieve and maintain normal speech fluency B. Treatment involves parent-focused and child-focused strategies that are designed to: 1. Help parents make communication modifications to indirectly facilitate children s fluent speech 2. Help parents and children develop and maintain healthy, appropriate communication attitudes 3. Help children make communication modifications to directly improve their speech fluency XIX. Next What is the Lidcombe Program? (Onslow and colleagues) A. Overview 1. An operant treatment program in which parents reinforce fluent speech and (gently) correct stuttered speech a) In Stage I, parents engage in daily treatment sessions at home (and attend treatment in a clinic once a week) until the child reaches a set criterion level for fluent speech b) In Stage 2, parents reduce the frequency of sessions, while maintaining feedback for at least a year 2. Parents also provide regular judgments of the child s stuttering severity, so ample data are kept B. Proceed with Caution! 1. More and more, I hear of clinicians who say they use a modified Lidcombe approach 2. If you are seeking to apply the principles of evidence-based practice, this cannot be done a) As soon as you modify the Lidcombe program, you re no longer operating within the evidence b) I am deeply troubled when I hear of children who are on Lidcombe for 9 months or a year (or more) that s not how it was designed to be used 3. Don t try to combine it with indirect therapy! C. Use As Directed 1. If you re interested in using the Lidcombe Program, that s fine, of course 2. But I encourage you to get the proper training and then use it as it was designed (and tested) 3. For More Information, go to: http://www3.fhs.usyd.edu.au/asrcwww/treatment/lidcombe.htm XX. So Which Approach Should I Use? A. Consider the evidence: Lidcombe has lots 1. Ample evidence supports the Lidcombe program, with many publications over the past 20 years a) Many children receiving the full Lidcombe program do indeed improve their speech fluency 2. We know absolutely nothing about children who receive only part of the Lidcombe program a) Commenting on children s speech does not make them more concerned about their speech b) Recovery rates for children receiving Lidcombe are higher than those for children not receiving treatment, and recover time is faster than natural recovery J. Scott Yaruss 15

XXI. Summary B. Consider the evidence: Other therapy has less 1. Although it has been widely used, very few studies have examined the effects of pure indirect therapy a) There may be no formal studies of indirect therapy 2. There is a wealth of anecdotal evidence, but nothing (yet) with the rigor of the Lidcombe research a) Starkweather reported high success rates for indirect treatment C. Note that what we re doing isn t only indirect we directly address attitudes and speech fluency a) Rustin and colleagues have written books showing success from a family-centered approach (indirect and direct) D. Still Times Are Changing. Yaruss et al. (2006) present preliminary data from the family-focused treatment program described in this presentation 1. All 17 of the first 17 children enrolled in this program showed significant gains in fluency (and all but one reached normal fluency by the end of treatment) 2. Fluency improvements were maintained throughout long-term follow-up of more than 2 years 3. Many children (2/3) required only the parent-focused components of treatment 4. The other children also received some child-focused treatment (ranging from 3 sessions to a full year for one child) E. And the data are promising (there s more than one way to skin a cat) 1. Success rates from Yaruss et al. (2006) are very similar to those reported for Lidcombe a) Further, the mean duration of treatment (12 sessions) was identical to that reported for Lidcombe (and 75% of participants required 11 sessions or less) 2. Franken et al. (2005) presented the first direct comparison of the Lidcombe program and traditional indirect/direct therapy a) Every comparison revealed identical results from the two treatment approaches A. When working with preschool children who stutter, the primary goal is to help them eliminate their stuttering 1. There are at least two research-supported approaches to treatment that help children do this 2. In addition to addressing fluency, treatment should ensure that the child develops appropriate communication attitudes. a) This will minimize the likelihood that he will struggle with his speech b) It will prepare him for the future in case he does keep stuttering and needs more advanced treatment #10 B. Most Important Fact #10a: You CAN Help Preschoolers Who Stutter C. Most Important Fact #10b: YOU Can Help Preschoolers Who Stutter XXII. And if it doesn t work remember the Most Important Facts for children who continue to stutter: Stuttering Is More Than Just Stuttering, and Treatment for Stuttering Is More Than Just Treatment for Stuttering J. Scott Yaruss 16

XXIII. Key Stuttering Organizations and Resources A. Stuttering Foundation of America (SFA) 1. www.stutteringhelp.org -- (800) 992-9392 2. Publishes many helpful booklets and videotapes for clinicians, people who stutter, and their families 3. Provides numerous CE workshops for SLPs B. National Stuttering Association (NSA) 1. www.westutter.org -- (800) We Stutter (937 8888) 2. Publishes helpful booklets for children who stutter and their families 3. Supports more than 80 local chapters for adults who stutter, as well as several new local chapters for children and families nationwide 4. Provides CE workshops for SLPs as well as workshops for people who stutter and their families 5. Hosts an annual conference with 3-day youth program C. Friends: Association for Young People Who Stutter 1. www.friendswhostutter.org 2. Hosts an annual conference bringing together people who stutter from around the country D. Our Time 1. www.ourtimestutter.org 2. Nonprofit organization helping children who stutter through the arts E. Specialty Board on Fluency Disorders 1. www.stutteringspecialists.org 2. Recognizes specialists in fluency disorders; provides information to consumers and professionals F. The Stuttering Home Page 1. www.stutteringhomepage.com 2. Contains a tremendous amount of helpful information about stuttering, including essays about stuttering, course syllabi, and links to other stuttering pages G. Stuttering Therapy Resources, Inc. 1. www.stutteringtherapyresources.com 2. A publishing company (owned by the presenter and colleague Nina (Reardon) Reeves) dedicated to providing high-quality, affordable books and resources to help speech-language pathologists help people who stutter J. Scott Yaruss 17

I. Understanding Stuttering Some of the Presenter s Recent Papers on Stuttering Yaruss, J.S. (1998). Describing the consequences of disorders: Stuttering and the International Classification of Impairments, Disabilities, and Handicaps. Journal of Speech, Language, and Hearing Research, 49, 249-257. Yaruss, J.S., & Quesal, R.W. (2004). Stuttering and the International Classification of Functioning, Disability, and Health (ICF): An update. Journal of Communication Disorders, 37, 35-52. II. Assessment and Diagnosis Yaruss, J.S. (1997). Clinical measurement of stuttering behaviors. Contemporary Issues in Comm. Science & Dis., 24, 33-44. Yaruss, J.S., LaSalle, L.R., & Conture, E.G. (1998). Evaluating stuttering in young children: Diagnostic data. American Journal of Speech-Language Pathology, 7(4), 62-76. Yaruss, J.S. (1998). Real-time analysis of speech fluency: Procedures and reliability training. American Journal of Speech- Language Pathology, 7(2), 25-37. III. Treatment Preschool and School-age Children Logan, K.J., & Yaruss, J.S. (1999). Helping parents address attitudinal and emotional factors with young children who stutter. Contemporary Issues in Communication Science and Disorders, 26, 69-81. Murphy, W., Yaruss, J.S., & Quesal, R.W. (2007). Enhancing treatment for school-age children who stutter I: Reducing negative reactions through desensitization and cognitive restructuring. Journal of Fluency Disorders, 32, 121-138. Murphy, W., Yaruss, J.S., & Quesal, R.W. (2007). Enhancing treatment for school-age children who stutter II: Reducing bullying through role-playing and self-disclosure. Journal of Fluency Disorders, 32, 139-162. Reardon-Reeves, N., & Yaruss, J.S. (2013). School-Age stuttering therapy: A practical guide. McKinney, Tx: Stuttering Therapy Resources. Yaruss, J.S. (2010). Evaluating and Treating School-Age Children Who Stutter. Seminars in Speech and Language, 31, 262-271 Yaruss, J.S., & Reardon, N.A., (2003). Fostering generalization and maintenance in school settings. Seminars in Speech and Language, 24, 33-40. Yaruss, J.S. (2004). Documenting Individual Treatment Outcomes in Stuttering Therapy. Contemporary Issues in Communication Science and Disorders, 31, 49-57. Murphy, W.P., Quesal, R.W., & Reardon-Reeves, N., & Yaruss, J.S. (2013). Minimizing Bullying for Children Who Stutter. McKinney, Tx: Stuttering Therapy Resources, Inc. Yaruss, J.S., Quesal, R.W., & Reeves, P.L. (2007). Self-Help and Mutual Aid Groups as an Adjunct to Stuttering Therapy. In E.G. Conture & R.F. Curlee (Eds.). Stuttering and related disorders of fluency (3 rd ed.) (pp. 256-276). New York: Thieme. Yaruss, J.S., Quesal, R.W., & Pelczarski, K. (2010). School-age children who stutter: Treating the entire disorder. In B. Guitar & R. McCauley, Treatment of stuttering: Conventional & controversial interventions. Baltimore: Lippincott Williams & Wilkins. Yaruss, J.S., & Quesal, R.W. (2010). Overall Assessment of the Speaker s Experience of Stuttering (OASES). Bloomington, MN: Pearson Assessments. Other Helpful Resources (Note: This is just a selection. There are many resources available to help clinicians improve their confidence in helping people who stutter) Bloodstein, O., & Bernstein Ratner, N. (2008). A Handbook for Stuttering (6 th ed.) New York: Thompson-Delmar Publishing. Chmela, K. & Reardon, N. (2001). The school-age child who stutters: working effectively with attitudes and emotions. Memphis, TN: Stuttering Foundation of America. Conture, E.G. (2001). Stuttering: Its Nature, Assessment and Treatment. Needham Heights, MA: Allyn & Bacon. Conture, E.G., & Curlee, R.F. (Ed.) (2007). Stuttering and related disorders of fluency (3 nd ed.). NY: Thieme Medical Pubs. Curlee, R.F., & Siegel, G. (Eds.), (1997) Nature and treatment of stuttering: New directions (2 nd ed.). Needham Heights: Allyn & Bacon. Gregory, H.H. (2003). Stuttering therapy: Rationale and procedures. Boston, MA: Allyn & Bacon. Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment (3 rd ed.) Baltimore: Williams & Wilkins. Manning, W.H. (2010). Clinical decision making in fluency disorders. (3 rd ed.). New York: Delmar-Cengage. Shapiro, D.A. (2011). Stuttering Intervention: A collaborative journey to fluency freedom (2 nd ed.). Austin, TX: Pro-Ed. Yairi, E., & Seery, E. (2011). Stuttering: Foundations and clinical applications. Needham Heights, MA: Allyn & Bacon. J. Scott Yaruss 18

Factors Potentially Associated with Childhood Stuttering S T U T T E R I N G Original version published in: Yaruss, J.S., Coleman, C., & Hammer, D. (2006). Treating preschool children who stutter: Description and preliminary evaluation of a family-focused treatment approach. Language, Speech, and Hearing Services in Schools, 37, 118-136. Revised March, 2009. Copyright 2009. All Rights Reserved. The Stuttering Center of Western Pennsylvania. S tuttering C enter of estern ennsylvania W P A joint venture of Children's Hospital of Pittsburgh and the Department of Communication Science and Disorders at the University of Pittsburgh

"Non-Stuttered" Disfluencies Hesitations (pause) Interjections (um, uh, er) Revisions ("I want-i need that") Repetitions of phrases ("I want- I want that") Disfluencies occur more frequently Understanding Different Types of Speech Disfluencies Repetitions of multisyllabic whole words ( mommymommy-mommy let s go. ) Reactions to disfluencies increase Repetitions of monosyllabic whole words ( I-I-I want to go. ) Tension or struggle increases Tension during "nonstuttered" disfluencies Duration (length) of disfluencies increases NOTE: "Non-stuttered" disfluencies can be used to avoid or postpone stuttering (e.g., I um, you know, uh I want to um, g-g-g-o with you. ) Secondary characteristics (eye blinks, head movements, etc.) From Yaruss & Reardon (2010), Young Children Who Stutter: Information and Support for Parents. New York: National Stuttering Association (NSA). "Stuttered" Disfluencies Repetitions of sounds or syllables ("li-li-like this") Prolongations ("llllllike this") Blocks ("l---ike this")

Speech Disfluency Count Sheet 2/ 15/ 2003 Name: Overall Frequency / Severity: DOB: DOE: Age: Stuttered Disfl. %: Types: Situation: Clinician: Non-stutt. Disfl. %: Types: Type # Type # I I Rv Rv Rp Rp Rw Rw Rs Rs P P B B O O % % Type # Type # I I Rv Rv Rp Rp Rw Rw Rs Rs P P B B O O % % Notes: "Nonstutt." Disfl. "Stuttered" Disfl. # NonStutt Stutt I Interjection Rw Word rep. 1 Rv Revision Rs Sound/syllable rep. 2 Rp Phrase rep. P Prolongation 3 O Other (Specif B Block 4