Fluency and Stuttering

1. Fluency and Stuttering By Ann Blau, MS, CCC-SLP

2. Participant Learning Objectives • Define a fluency disorder • State defining characteristics, secondary behaviors, and risk factors for stuttering • List the important components to include in an assessment of stuttering • Become familiar with various tools and techniques used in the treatment of stuttering • Know how to educate parents regarding their role in stuttering intervention

3. What is a Fluency Disorder? • Fluency is speech that: • moves at an appropriate rate • has an easy rhythm • is fluid and smooth • is effortless • is automatic • Disfluency occurs when there is: • an unusually high rate of stoppages or blockages that disrupt the flow of communication • a disturbance in the normal fluency and timing patterns of speech

4. Types of Disfluencies • Interjections • (examples: "uh," "er," "well"). • Revisions of wording • (example: "I was - I am going"). • Repetitions of whole words • (example: “I I was going”). • Repetitions of phrases • (example: "I was I was going"). • Part-word repetitions (repetition of sounds or syllables) • (example: “I was go- go- going”) • Broken or interrupted words • (example: "I was g-(pause)-oing home"). • Prolonged sounds • (example: "I sssssaw him"). • Unusually long pauses between words • (example: "I was.....going home").

5. Normal Disfluency vs. Abnormal Disfluency • Normal disfluencies occur between the ages of 18 months and 7 years as many children pass through stages of speech disfluency associated with their attempts to learn how to talk. • Children with normal disfluencies between 18 months and 3 years will exhibit repetitions of sounds, syllables, and words, especially at the beginning of sentences. • Children with normal disfluencies may exhibit: • increased disfluencies when tired, excited, upset, or being rushed to speak • Increased disfluencies when they ask questions or when someone asks them questions • an increase in frequency of disfluencies which may occur for several days or weeks, disappear for a time, and then occur weeks or months later • Typically, children with normal disfluencies appear to be unaware of them, showing no signs of surprise or frustration. Most parents will not notice their child’s disfluencies or will treat them as normal. • Abnormal disfluencies that are cause for concern include: • repetition of sounds (b-b-book) • prolongation of sounds in words (sssssssoup) • the child seems "stuck" and cannot get his words out • exhibits facial tension during speech, and/or • expresses feelings of frustration or embarrassment towards communication

6. So, what is a fluency disorder (also known as stuttering)? • An abnormal disfluency described as an interruption in the forward flow of speech that may be accompanied by physical tension, secondary behaviors, negative reactions, or decreased communication skills. The disorder has affective, behavioral, and cognitive components.

7. Defining Characteristics of Stuttering • Core Features • ‘Stutter-Like’ Disfluencies • Secondary Features • Escape behaviors • Avoidance behaviors • Feelings and Attitudes • Causes and Risk Factors • Predisposing factors • Precipitating factors

8. Core Features • Core features: primary characteristics of stuttering • Part-word repetition: sound or syllable is repeated 2 to 4 times • Single-syllable word repetition: two or more times • Sound prolongation: duration of speech sound is lengthened • Block: articulators and airflow completely stop during the production of a sound • Any combination of the above

9. Secondary Features • Secondary features: emerge in response to the core behaviors • Escape behaviors: response to moments of stuttering • Head jerks, eye blinking, leg slapping, looking away • Avoidance behaviors: avoid moments of stuttering • Verbal avoidances • rising pitch of the voice during repetitions and prolongations, use of extra sounds like “um,” “uh,” or “well” to begin a word on which the child expects to stutter • Avoidance of specific situations • Feelings and attitudes: negative feelings towards communication • Fear, embarrassment, shame • Negative attitudes, such as worrying about speaking, viewing speaking as difficult

10. Causes and Risk Factors • Predisposing: factors that increase the risk of stuttering • Family history of stuttering • Age of onset – stuttering that persists after 3 1/2 years of age • Time since onset – stuttering that lasts 6-12 months or longer • Gender – males are at higher risk than females • Presence of other speech production concerns (speech sound errors or trouble being understood) • Language skills that are advanced, delayed or disordered • Precipitating: environmental factors that can worsen stuttering • Stressful adult speech models: children exposed to adult speech that is too sophisticated for their own speech, language, and cognitive abilities • Stressful speaking situations for children: competing or hurrying to speak, having too many things to say • Stressful life events: moving, divorce of parents, loss of family member, illness, accident or trauma (violence)

11. Stuttering FAQs • More than 70 million people worldwide stutter, which represents about 1% of the population. • Affects children between the ages of 2 and 10 years at the highest rates • Males are affected at a higher rate than females (approximately 4:1) • Approximately 5% of all children go through a period of stuttering that lasts six months or more. Three-quarters of those will recover by late childhood, leaving about 1% with a long-term problem. The best prevention tool is early intervention. • There is a relatively high rate of speech and language problems that exist in combination with a fluency disorder (articulation and phonological disorders are more common than language disorders)

12. How is Stuttering Diagnosed? • A comprehensive assessment should include: • A thorough case history • Evaluation of speech fluency • Physiologic variables to consider: • perceptions of tension and secondary features (physical tension of jaw, lips, vocal folds, articulators is a sign of loss of control), conversational style, speaking rate • Observable characteristics of speech disfluenciescan vary from situation to situation so assess a variety of contexts (play, monologue, conversation, different conversation partners and settings) • Distinguish “non-stutter” or normal disfluencies (phrase repetitions, revisions, interjections, hesitations) from “stutter-like” or abnormal disfluencies (repetitions of words/sounds/syllables, prolongations, blocks) • Measure types of stuttering by frequency, duration, and severity • Monitor presence of cluster behaviors (more than one type of disfluency in one moment of stuttering), secondary behaviors (visual & auditory), and avoidances • Evaluation of the negative impact of stuttering on the child’s life • How does it affect the child’s functional communication/quality of life? • Does stuttering affect their ability to… • Say what they want to say? Do what they want to do? • Be who they want to be? Interact with peers, family members, and teachers? • Evaluation of the child’s reaction to stuttering through observation, talking to the child, parent interview/questionnaire, reflective drawings from the child • Affective (beliefs and feelings about stuttering itself; is there fear or shame?) • Behavioral (is there tension behavior, struggle, avoidance of speaking situations?) • Cognitive (is their self-esteem or self-confidence affected?) • Evaluation of the environment (others’ reaction to stuttering) • Adults: Parents & Teachers • Children: Peers & Siblings • Evaluation of speech and language skills

13. How to Evaluate Speech Fluency? • In order to analyze speech fluency: • Determine if the quality and/or quantity of disfluencies significantly differ from normal • Quantity: two common metrics • Average # of disfluencies per 100 words • Average # of disfluencies per 100 syllables • Quality: • Normal: interjection and revisions predominate • Disordered: repetitions, prolongations, and blocks predominate • Severity: • characterize as mild/moderate/severe (various scales look at percentage of typical vs. atypical disfluencies to make this determination) • Positive diagnosis is more likely if there are: • At least 10 total disfluencies per 100 words • At least 3 total core disfluencies per 100 words • Physical escape behaviors • Verbal avoidance behaviors

14. Assessment Protocol • You should be able to answer the following questions: • Is the child stuttering or at-risk for stuttering? • Does the child exhibit other communicative risk factors or disabilities? • Is therapy for stuttering warranted? • Consider whether the child is negatively reacting to the stuttering • What therapy approach would be most beneficial?

15. How is Stuttering Treated? • Borderline Stuttering • Early intervention versus “wait and see” approach is generally taken with pre-school age children • Indirect treatment: • goal of treatment is to help parents and teachers provide a fluency-facilitating environment • Beginning Stuttering • Direct treatment • Goal of treatment is to eliminate core disfluencies (secondary behaviors are not apparent yet) • Current approaches include: • Stuttering modification therapy: teaching about stuttering and how to work through it • Fluency shaping therapy: teaching smooth/fluent speech • Intermediate and Advanced Stuttering • Secondary features now characterize these levels • Incorporate direct treatment approaches, emphasize knowledge about and acceptance of stuttering, reduce negative feelings associated with stuttering, employ techniques in specific communication situations

16. Preschool Children Who Stutter • For very young children who stutter, the primary goal of the diagnostic evaluation is to determine whether the child is likely to continue to stutter: • If the child is at high risk, then treatment is definitely indicated • Consider the risk factors that contribute to the likelihood that a child will continue to stutter: • Family history of stuttering • Child is aware of or concerned about disfluencies • Time since onset > 6 months • Stuttering that persists after 3.5 years is cause for concern • Child is highly reactive to mistakes/disfluencies • Large number of “stuttered” disfluencies • Parental reactions are negative or fearful • Co-occurring speech and/or language disorders • Most preschool children recover from stuttering • Studies show that as many as 75-80% of preschool children who stutter will recover • The majority of these children will recover within the first 6 to 12 months • Recovery is still observed up to 2, 3, and even 4 years post-onset • This recovery can be aided (with the help of treatment) or unaided (without any intervention at all)

17. Preschool Children Who Stutter:Treatment • Since we do not know who will ‘outgrow’ stuttering, it is best to intervene early by beginning with an indirect, family-focused treatment approach • Goals of treatment in parent/family-focused program: • Ensure that children develop effective communication skills • Develop health, appropriate attitudes toward their speaking and stuttering

18. Parent/Family-Focused Treatment • Helps parents learn and use strategies for facilitating fluency at home and in other settings • Based on current evidence that: • 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) • the more time a child spends communicating successfully, the less likely he is to develop severe stuttering • Children who stutter are at risk for developing negative communication attitudes • Starts with parent-only sessions for counseling/education about stuttering and communication in general to: • help parents understand stuttering and give them a chance to discuss concerns • identify stressors in the child’s life that may worsen stuttering • Parents are taught to practice fluency-facilitating modifications as needed, such as • reducing parents’ speaking rates naturally or reducing time pressures (delaying their responses) • reducing demand for talking (if demand is high) and modifying questioning (if necessary) • providing a supportive communication environment • Training is administered by itself or prior to more direct intervention with child or family

19. Preschool Children Who Stutter:Treatment • If the child continues to stutter following the parent/family-focused treatment, then it’s time to proceed with child-focused treatment. • Goals of treatment in a child-focused program (same as for school-age/older children who stutter): • To improve the child’s fluency through direct modification of the child’s communication skills • To ensure that the child develops and maintains appropriate communication attitudes

20. Child-Focused Treatment • Focuses on modifying the child’s stuttering by: • Changing Timing • Reducing speaking rate, pausing and phrasing, easy starts • Changing Tension • Physical tension/struggle 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. • Most of the disfluencies observed are the child’s reaction to stuttering. The “core” of stuttering is under the surface; Children must become desensitized to that core to reduce their reactions. • Combine desensitization with tension-reducing techniques to help children stutter more easily.

21. Child-Focused Treatment • Help the Child Develop Healthy Communication Attitudes • Desensitization (to the fear and expectancy of the stuttering moment) is just one part of therapy that supports the development of healthy attitudes • 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’ • Parents must come to terms with and accept the stuttering if they are going to be able to do this effectively

22. Suggestions for Parents of Young Children Who Stutter • Minimize the time pressure a child may feel when speaking • Pause for one to two seconds before answering your child’s questions. This gives your child the time he or she needs to ask and answer questions, and it helps teach him not to rush into responding during his own speaking turns. This technique shows the child how to take enough time before speaking to formulate his answers more fully. It also helps children learn to take turns when speaking. During normal conversation, turn-taking usually involves only one person speaking at a time. If two or more people are competing to talk at the same time, or if one person interrupts another, there is a tendency for the rate of speech to increase and for the speakers to feel pressure to get their message out quickly. This is particularly difficult for children who stutter. So, it is best to take turns when talking. Each person gets an opportunity to speak without fear of being interrupted and without the need to hurry. You can demonstrate this in your own speech by not interrupting your child (a part of pausing between speaker turns) and by managing the talking turns of other children so each child gets their turn to talk.

23. Suggestions for Parents of Young Children Who Stutter • Respond to stuttering in an accepting manner • No parent wants their child to have a stuttering problem; however, it is important for you to demonstrate complete acceptance of your child, including acceptance of his or her stuttering. Children’s self-esteem and self-acceptance are very dependent upon the acceptance of others, particularly their parents. If you convey the message that stuttering is bad, or something to be ashamed of, then it is more likely that your child will believe that he is a source of embarassment. As a result, his shame will increase. The child’s negative reactions to stuttering determines whether he will be held back by his speech problem, While children can learn to be more fluent in treatment, they will not be successful if they have already developed negative attitudes about themselves and their speech.

24. What Parents Can Do to Help Children Develop Normal, Healthy Communication Attitudes • model a calm and objective response to children’s stuttered speech • listen to children’s concerns about speaking and focus on their message, rather than on the way they are talking • When appropriate, talk with children about stuttering in a matter-of-fact, supportive way so they will understand what is happening when they have difficulty talking.

25. What Teachers Can Do To Help • When having the class read aloud, try to avoid calling on each child to take a turn reading aloud. A more random style of turn taking often helps minimize the anxiety of this speaking situation. • Encourage turn-taking for the entire class. Limit verbal interruptions and try to NOT reward those who call the answers quickly in class. • Be patient. Allow plenty of time for the child who stutters to talk and answer questions. Remember that you set the tone for how the rest of the class will respond to the child’s stuttering. • Wait for a brief period of 1-2 seconds before answering a question. This shows the child that there is not a lot of pressure to answer the question immediately. It reduces time pressure. • Try to treat the child who stutters no different than the other children in class. If you do, other children will be able to sense that.

26. Case Study • David is a 7-year-old boy who has been stuttering since he was 3 years old. He has never had speech therapy. David’s parents became concerned when their son suddenly began to stutter more severely and his personality began to change. Although David was once a popular young boy, he no longer enjoys spending time with other children and prefers to play by himself. He has become much quieter and less interactive at home. His parents also noticed that he has started to have trouble “getting his thoughts out” when trying to communicate. They mentioned that David’s father used to stutter as a child.

27. Results of the Assessment:Breaking It Down • Are there any are risk factors for continued stuttering? • Age of onset • David has been stuttering since the age of 3. Typically, children who have not outgrown stuttering beyond the pre-school years (ages 2-6) will likely continue to stutter. • Family history of stuttering • David’s father stuttered as a child (David’s parents always thought he would ‘grow out of’ his stuttering with time as his father did) • Gender bias • Stuttering is 4 times more prevalent in males (such as David) than females. • Are the majority of disfluencies considered “stutter-like”/abnormal or normal? • A fluency analysis was conducted and revealed a high percentage of core stuttering behaviors, including sound prolongations, blocks and repetitions • How does the child react to his stuttering? (Are there any negative reactions?) • David has started talking less at home and now prefers playing alone rather than with friends. His parents believe that this change in behavior (or negative reaction) is related to an increase in the amount of teasing and bullying that he has experienced recently. • Are there any secondary behavior or avoidances? • Significant physical tension is noted during disfluencies, along with avoidance of speaking situations (as described above). • Are there any accompanying speech or language impairments? • David exhibited word finding difficulties resulting in poor word selection. Although his sentences were long enough and had appropriate word order (syntax), the words he chose did not quite communicate his meaning (semantics). The listener had to work extra hard at decoding the message. • In short, David’s stuttering is being influenced by affective, behavioral, cognitive and environmental factors.

28. Treatment: Where to Begin? • For school-age children, the goal of treatment expands to address both fluency AND stuttering • Working on fluency: helps children learn to speak more fluently so they stutter less often • Working on stuttering: helps children manage stuttering so it does not affect communication • The goal is for children to be able to say what they want, when they want, to whom they want • Communication is what matters

29. Treatment:School-Age Child • Therapy must address: • Others’ reactions to stuttering (Environment) • Adverse impact on child’s life (Participation/Restriction) • Child’s reactions to stuttering (Reactions) • Speech disfluencies (Impairment) • Let’s talk in more detail about how to approach the school-age child who stutters.

30. Treatment Objective #1: Addressing the Environment • Change the environment (how others react to stuttering) • David should demonstrate knowledge of stuttering by teaching others about stuttering (how speech is produced, facts about stuttering, types of stutters, famous people who stutter, etc.) • David should also learn strategies for minimizing bullying • Suggestions responding directly to a bully’s comments • Sample responses: The bully says, “You stutter!” The child who stutters says… • “Yup, I do.” or “I know…” or “Did you just notice?” • “You told me that yesterday. It’s still true.” • “I don’t like it when you say that” • “That’s really not nice of you to say. I wish you’d stop.” • “Huh?” “I can’t hear you” or “So” repeatedly • “I know, now are you still playing this game?” • Together, these and other activities can help David and his peers see that stuttering is not something to be afraid of; it is just one of the many characteristics that make people unique. As David internalizes this important message, his fears about stuttering will diminish, and he will find it easier to successfully regulate and minimize (desensitize) his negative reactions to stuttering.

31. Treatment Objective #2: Addressing the Adverse Impact on Participation • Minimize adverse impact of stuttering on the child’s life to enable increased participation in social activities and reduce avoidance of speaking situations • David can discuss the stuttering disorder with his peers and educate them about his speaking difficulties. Of course, talking openly about stuttering can initially be quite difficult for children, so David and his clinician might start with role-play activities to help him plan his responses to his peers. • Direct role-playing: the child who stutters plays himself and the therapist plays the bully • Reverse role-playing: the child plays the bully and the therapist plays the child who stutters • Working with the teacher and clinician, David can develop a classroom presentation in which he can, for example, provide facts about stuttering, engage his classmates in a trivia contest about stuttering, or discuss differences between individuals in general.

32. Treatment Objective # 3:Addressing the Child’s Reactions • Decrease negative reactions associated with stuttering to promote greater acceptance • As an intermediate stutterer, David is learning to fear and avoid stuttering (i.e., develop negative reactions) to stuttering. As such, physical tension associated with speaking has begun to develop. This is a learned behavior due to negative reactions associated with stuttering. If David can take the hurt and anxiety out of moments of stuttering, the physical symptoms of struggle (physical tension) and avoidance will also diminish. • Help David view stuttering in an open, matter-of-fact manner, in which the child is praised for his communication success (not just his fluency), to ensure that the child learns that what he has to say is valuable • Help him become more comfortable with his stuttering by practicing voluntary (fake) stuttering. • Give him the opportunity to ‘play with’ different types of stuttering behaviors: • a) Long stutters / short stutters c) Loud stutters / quiet stutters • b) High stutters / low stutters d) Bouncy stutters / stretchy stutters • These activities reduce the child’s sensitivity to disfluencies in general while helping him learn more about how his speech mechanism works

33. Treatment Objective #4:Addressing the Actual Impairment • Reduce the severity of David’s stuttering by addressing the actual impairment • Techniques to modify stuttering and improve fluency: • Change Timing: reduce speaking rate, increase pause time • Pause as needed before starting to speak • Pause as needed during ongoing speech • Slightly reduce speaking rate • If the child allows more time for language planning and speech production, he is more likely to be more fluent • Change Tension: before, during or after the moment of stuttering • Changing tension helps the child move his articulators more smoothly and easily. • When a child’s muscles are too tense, it is harder to speak. • How to stutter with less physical tension? (It takes a lot of practice!) • Easy or voluntary stuttering, which caninvolve • Light bounces “li-li-like this” • Easy prolongations “lllllike this”

34. Treatment Objective #5:Addressing the Language Disturbance • Let’s not forget . . . the co-existing language problem, that may also be further contributing to the disorder and affecting the child's performance and participation in daily activities.  • Improve word retrieval and selection skills to remediate the language problem • Sample activities (with accompanying graphics): • Ask the child to think of five words that might describe the physical characteristics of an apple (what you can see, hear, smell, touch, taste) • Ask the child to think of five words that might describe how someone feels when smiling • Continued . . .

35. Additional Word Retrieval Activities • Category Naming: Give three or four items belonging to the same category (e.g. drum, flute, guitar and piano) and then ask the child to identify the category. You can then reverse this naming game and give the category first, then have the child name three or four items belonging to that category. To make this activity more challenging you ask the child to name as many items as possible in one minute. Write down their answers and try to beat their previous score each time you practice. • Antonyms: Naming opposites. Choose a word and try to come up with the opposite of that word. • Synonyms: Naming words that have the same, or almost the same meaning. This activity tends to be more difficult than naming opposites. However, it is a great practice tool for strengthening word retrieval skills. For more of a challenge, try to name two synonyms for each word. • Fill in the Blank: Say a familiar phrase and leave the last word out. Try to supply the missing word. When phrases become mastered you can move on to sentences, for example: “open the ______ (door).” • Similarities: Choose two words within a category and describe how they are the same. For example: How are a car and a bus the same? This activity encourages the child to think about word associations. This cognitive ability can be used as a strategy to aid in word retrieval. • Differences: This activity tends to be more challenging than describing similarities between words. Using the same example as above: How are a car and a bus different? This exercise encourages the child to remember specific details that make similar objects different from one another. • Odd one out game: The child is presented with three or four items and one of the pictures / object / written words is from a different category. The child must identify the odd one out and discuss why. Encourage the child to use category words e.g. banana, apple, cherry and carrots we would like the child to identify that the first three are types of fruit and carrots are a type of vegetable. • Sorting games: Cut up pictures relating to two different categories e.g. fruit and vegetables. The child then sorts the pictures into the correct category. • Word association games: The child is given a word and has to think of an associated word. For example: pilot goes with….(plane), taxi goes with…..(driver). • Sentence completion: for example “a banana is something you eat, tea is something you…… (drink)”.

36. Video Clip (double click to play) • http://www.stutteringhelp.org/content/stuttering-kids-kid

37. Testimonials from Kids Who Stutter (Stuttering Foundation of America)

38. More Testimonials • Hi. My name is Jonathan. I am 9 years old and live in New Haven, CT. Today I met someone who stutters. It felt very good. It made me also realize that I am not alone. Sometimes I don’t care that  I stutter. It felt very good not to care about stuttering. If you don’t care about it, then it feels like you don’t stutter.-Jonathan, 9, New Haven, CT • Speech therapy changed my life forever! Imagine that you did a project that you worked so hard on for days. It was perfect, and you practiced and practiced your presentation for a long time.  Then, when you presented it to the class, you stuttered on almost every word you tried to speak.  This is what happened to me. Speech therapy is life changing to me because I speak more fluently, I have tools to help me overcome stuttering, and I have more confidence.  -Ben, 12, Palm Harbor, FL • Advice for teens who stutter: • Don’t quit trying to use strategies. • Teach other people about stuttering. • Don’t be scared to talk to someone about stuttering. • Don’t think about stuttering that much – it will get easier if you practice. What I have learned from stuttering: • That people are different and it is fine to be different. -Duron, 14, Worcester, MA

39. Resources • The Stuttering Foundation of America website • National Stuttering Association website • American Speech-Language-Hearing Association website • Stuttering Center of Western Pennsylvania website