Assessment and Treatment of Fluency Disorders in Bilingual Children

1. Assessment and Treatment of Fluency Disorders in Bilingual Children Kerry Danahy, M.A., CCC-SLP University of Minnesota dana0007@umn.edu

2. Introduction • There is very little research examining fluency disorders in bilingual speakers. • BUT that doesn’t mean we are lost in assessing and treating this population: • We can use what we know about fluency and about bilingualism, as well as cultural influence, to work with bilingual children with fluency disorders.

3. Why do children stutter? • Most current models of stuttering are multifactorial. • Factors that interact to cause stuttering include: genetics, environment, language skills, motor skills, and temperament. • This information gives us some insight into bilingual speakers who stutter.

4. Factors for bilingual children • In bilingual children, genetics, motor skills, and temperament will be constant across languages. • It is extremely unlikely that a bilingual child will stutter in one language and not the other (e.g., Van Borsel, Maes, & Foulon, 2001).

5. Factors for bilingual children • Language skills and environment (including home vs. school environments, cultural beliefs associated with one language, etc.) may differ significantly between languages. • It is common for children to stutter more frequently in one language than the other (e.g., Nwokah, 1988).

6. Stuttering Prevalence in Bilingual Speakers • It has been estimated that about 1% of the world’s population stutters (Bloodstein, 1995). • Many authors have claimed that stuttering is more prevalent among bilinguals than among monolinguals (e.g., Karniol, 1992; Nwokah, 1988). • However, the evidence for this conclusion is questionable (Van Borsel et al., 2001).

7. Stuttering Prevalence in Bilingual Speakers • Evidence that eliminating bilingual input to preschool children improves fluency is very limited and has been disputed (see Bernstein Ratner, 2004; and Van Borsel et al., 2001, for reviews). • No support exists for reducing bilingual input to disfluent speakers older than preschool. • As in other disorders, the child’s need for bilingual proficiency to meet environmental needs is paramount.

8. Assessment • Bilingual children may present additional assessment challenges, because difficulty formulating utterances due to limited proficiency in either a first or second language can look like disfluent speech. • However, we can rely on key features of true stuttering to distinguish children with fluency disorders (Watson and Kayser, 1994): • Stuttering will be present in both languages. • Stuttering is usually accompanied by self-awareness. • Secondary behaviors often accompany stuttering.

9. Assessment • Core areas to assess are the same for bilingual and monolingual children: • Disfluencies • Secondaries • Child’s beliefs and emotions about stuttering • Other speech and language skills • Parents’ beliefs about stuttering • Developmental history

10. Assessing Disfluencies • Measurement of disfluencies is similar for monolingual and bilingual children: • collect language samples from conversation and oral reading • calculate frequency and duration of disfluencies. • English behavioral stuttering assessment tools (e.g., SSI-3; Riley, 1994) may be adapted as criterion-referenced measures for other languages (Bernstein Ratner, 2004). • Word-based (rather than syllable-based) counts of stuttering frequency may be more accurate across languages.

11. Assessing Disfluencies • Specific types of atypical and typical disfluencies may vary in frequency across languages. • Atypical disfluencies include blocks, prolongations, sound and syllable repetitions, and broken words. • Typological features of the language may affect where these occur, and how often. • Typical disfluencies include hesitations, filler words, revisions, word and phrase repetitions. • Cultural factors may affect how often and where speakers use these (Bernstein Ratner, 2004).

12. Assessing Disfluencies • However, atypical disfluencies have similar characteristics across languages: • Struggle • Loss of eye contact • Avoidance behavior • Disruption in the typical forward flow of speech • These features have been shown to be prominent enough for people to identify disfluencies in a language they do not speak.

13. Assessing Secondary Behaviors • Types of secondary behaviors look the same in different languages, and are distinct signs of fluency disorders. • May involve: • Eyes • Lips • Cheeks/other facial muscles • Arms or legs • A child could have different secondary behaviors in different languages.

14. Assessing Behaviors: Things to Remember • When assessing frequency and severity of disfluencies and secondaries, remember that stuttering is highly variable across environments. • Variability is even more pronounced in bilingual children because stuttering can also vary across languages. • Important to get a representative picture of child’s speech across environments.

15. Assessing Behaviors: Things to Remember • Word and situation avoidances can be difficult to catch in monolingual children. • Bilingual children can also use code-switching to avoid stuttering. • This makes identifying avoidances even more difficult, because there are many other reasons to code-switch, and appropriate code-switching may be difficult to identify.

16. Assessing Beliefs and Emotions • Cognitive and affective factors are central to stuttering and important to assess. • Cultural factors will impact the child’s beliefs and emotions (e.g., Nwokah, 1988). • Bilingual children may show greater situational variation in their reactions to stuttering due to differences in culture between home and school environments.

17. Assessing Beliefs and Emotions • Questionnaires are available to assess this area for school-aged children (e.g., ACES, available through http://www.stutteringcenter.org). • May need to modify questionnaires to account for: • Limited English proficiency. • Differences in cultural beliefs across environments.

18. Assessing Other Speech and Language Skills • Language and/or articulation proficiency may affect stuttering frequency and severity (also reviewed in Van Borsel et al., 2001) : • Stuttering may be more prevalent in weaker language: • Increased stress in weaker language may increase stuttering. • More difficult motor demands (e.g., unfamiliar sounds) may increase stuttering. • Stuttering may be more prevalent in stronger language: • Slower speech rate and simpler utterances in weaker language may increase fluency. • Experiences in stronger language may increase disfluencies.

19. Assessing Other Speech and Language Skills • It is also important to remember that children who stutter are much more likely to have another speech or language disorder (or even another fluency disorder, such as cluttering) than children who do not stutter.

20. Assessing Parent Beliefs & Developmental History • Interviews with parents and other family members can give valuable insights into cultural beliefs about stuttering that affect the child. • Asking broad, open-ended questions that allow the parent to describe his/her views often give the most information. • Parents’ descriptions of how the fluency problem began often reflect views of why children stutter.

21. Treatment • Central goal of therapy for school-aged children is to manage stuttering (e.g., Reardon-Reeves & Yaruss, 2004). • We do not currently have a “cure” past the preschool years. • Several sub-goals may be important components of stuttering management for the child: • Reduced frequency and severity of disfluencies • Knowledge of techniques to manage moments of stuttering • Acceptance of self, including stuttering

22. Treatment: Fluency Shaping • Fluency shaping techniques are designed to reduce the frequency of disfluencies. • All of them modify speech in some manner. • It is important to remember that there is a tradeoff between naturalness and fluency benefits: the more the child modifies her speech, the less likely she is to be disfluent, BUT the more unnatural she will sound.

23. Treatment: Fluency Shaping • It is also important to remember that it is HARD to use fluency shaping techniques in conversational speech. • It is not reasonable to expect children to use fluency shaping all the time, because of difficulty and unnaturalness. • Goal should be for children to learn effective techniques so that they can choose when to use them.

24. Treatment: Fluency Shaping • Fluency shaping techniques include: • Slowed rate (typically through prolonged speech with continuous phonation) • Easy onsets • Light articulatory contacts • Easy prolongations or repetitions to begin utterances • Fluency shaping techniques can be used in any language.

25. Treatment: Fluency Shaping • The application of fluency shaping techniques will be different in different languages due to different typologies. • Children may not be able to apply techniques to their other language without explicit instruction and practice. • Cultural impact of using fluency shaping techniques may vary.

26. Treatment: Stuttering Modification • Stuttering modification techniques are typically used to reduce the severity of disfluencies and to give the child increased control in stuttering moments. • Stuttering modification has been traditionally been used with children who stutter more severely. • BUT these techniques can be useful for all children who stutter, particularly if they demonstrate shame or avoidance.

27. Treatment: Stuttering Modification • Stuttering modification includes techniques for: • Recognizing a stuttering moment • “Cancelling” or “pulling out” of it • Continuing to speak (perhaps with the help of fluency shaping techniques)

28. Treatment: Stuttering Modification • Stuttering modification also usually includes desensitization. • Desensitization work overlaps with cognitive and emotional treatment. • Basic goal of desensitization is to make the child less afraid of stuttering.

29. Treatment: Desensitization • Activities to achieve desensitization include: • “Freezing” in a stuttering moment • Describing the stuttering moment • Pseudo-stuttering, in increasingly difficult situations • Manipulating length and severity of pseudo-stutters • Desensitization effects are likely to be situation-specific. • It may be particularly difficult for bilingual children to become more comfortable with stuttering in their home/community environments.

30. Treatment: Attitudes and Emotions • Most children who stutter benefit from a basic understanding of stuttering, including: • The normal speech production process. • Changes to the process that produce stuttering. • Potential causes of stuttering. • The existence of other people who stutter, including successful adults. • This education will be similar for monolingual and bilingual children, except that adult role models may be different.

31. Treatment: Attitudes and Emotions • Identifying core beliefs about stuttering is an important goal for most children who stutter. • Negative beliefs often lead children to avoid stuttering at all costs. • Negative beliefs can be restructured to be more reasonable.

32. Treatment: Attitudes and Emotions • For example: • If the child believes, “No one will want to listen to me if I stutter,” • It is more accurate to say that some people may not want to listen, but others will still want to hear what you have to say. • Rewriting this belief with the child may help him become more accepting of stuttering. • Bilingual children may have language-specific beliefs, such as believing they will not stutter in a new language.

33. Treatment: Attitudes and Emotions • Many children benefit from making connections with other children who stutter. • Online groups include the National Association of Young People Who Stutter http://www.friendswhostutter.org, and postings on Judith Kuster's Stuttering Homepage: http://www.mnsu.edu/comdis/kuster/stutter.html • International Stuttering Association spans countries but uses English (http://www.stutterisa.org)

34. Treatment: Generalization • Generalization is always an important consideration in fluency therapy. • Bilingual children need to generalize skills to multiple languages and cultural environments. • Limited evidence exists to show that therapy can be successful in one language and not generalize to another (Humphrey, 1999, as cited in Bernstein Ratner, 2001).

35. Treatment: Generalization • Setting up specific plans for the child to use skills such as fluency shaping, stuttering modification, and desensitization in both languages and different environments is essential. • Generalization of cognitive and emotional changes may be easier, if beliefs associated with both cultures are addressed in therapy.

36. Summary • Bilingual children who stutter present us with several challenges. • But we have the tools to meet them. • Remember basic principles: • Bilingual children who stutter will stutter in both languages. • We need to consider behaviors across languages and environments during assessment. • We need to address both languages in treatment.

37. Summary • There is a critical need for additional research on bilinguals who stutter to support clinical practice in this area. • Current additional information is available online at http://www.stutteringhelp.org/Default.aspx?tabid=55

38. Additional Language-Specific Resources • Stuttering Foundation of America has pamphlets and videos translated into Spanish and French. • Online store can be accessed through http://www.stutteringhelp.org • Stuttering Foundation of America has also created a website in Spanish (http://www.tartamudez.org)

39. References • Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual children. In B. Goldstein (ed.). Language Development: a focus on the Spanish-English speaker. Baltimore, MD: Brookes. (287-310). • Bloodstein, O. A handbook on stuttering. London: Chapman & Hall. • Humphrey, B. (1999, November). Bilingual Stuttering: Can treating one language improve fluency in both? Paper presented at the American Speech-Language-Hearing Association Annual Convention, San Francisco, CA. • Karniol, R. (1992). Stuttering out of bilingualism. First Language, 12, 255-283.

40. References • Reardon-Reeves, N.A., & Yaruss, J.S. (2004). The source for stuttering. East Moline, IL: LinguiSystems. • Riley, G. (1994). Stuttering Severity Instrument for Children and Adults (3rd ed.). Austin, TX: PRO-ED. • Nwokah, E. (1988). The imbalance of stuttering behavior in bilingual speakers. Journal of Fluency Disorders, 13, 357-373. • Van Borsel, J., Maes, E., & Foulon, S. (2001). Stuttering and bilingualism: A review. Journal of Fluency Disorders, 26, 179-206. • Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural adults who stutter. Seminars in Speech and Language, 15, 149-163.