“Stuttering 101”: Referrals, Eligibility, Treatment & Support Lisa R. LaSalle, Ph.D., CCC-SLP

1. “Stuttering 101”: Referrals, Eligibility, Treatment & Support • Lisa R. LaSalle, Ph.D., CCC-SLP • Communicative Disorders Dept. / Truesdail Center for Communicative Disorders

2. High priority assessment techniques for “stuttering/fluency” referrals 5:30-6:00 pm

3. Assessment priorities depend upon age and with time since onset • If child is “stuttering” and is a 2- to 4-year-old, he/she is: • Often within two years time since onset, presenting a “sensitive period” or opportunity for prevention: • Average age of onset is 33 mos of age, 95% begin stuttering < 48 mos of age (Yairi & Ambrose, 2005) • Oftenunaware of stuttering (both of his/her own stuttering and unaware of stuttering in peers, e.g., Mancuso, 2011) • At risk to persist in stuttering if he/she shows: • consistent stuttering with no remission in ~1 yr post-onset; • a family history of persistent stuttering; • averages > 3-4 units per repetition (based on Yairi & Ambrose, 2005 longitudinal data), later age at onset; concomitant sp/l/h disorders, etc.

4. On the phone or by email with the parent: • Get onset of “stuttering” information. Imitate “stutters.” • Is there / might there be a concomitant “disorder”? • 30-40% of children who stutter have a phonological disorder • ~ 10% may have a language disorder • Children who are late talkers or ESL may be “catching up” rapidly, which is positive for communication, but this process can negatively affect fluency • What have the caregivers been doing “to help”? (Get all the related details.) Do you think this has made a difference (yet) in your child’s speech? Why/why not? • Plan an assessment.

5. Assessment priorities with 2- to 4-yr-olds • Get the “most-likely-to-be-dysfluent” sample, for example: • Spontaneous, especially narration; “One-upmanship” play; Include broken or interesting toys to elicit initiations . • Arrange a parent interaction (free play with toys) so you can credit/replace parental behaviors that are potentially facilitative or exacerbating of child’s fluency • While parents are interacting, observe & code disfluencies online. • Yaruss(1998) has shown that real-time analysis can be almost as good as offline, but we tend to miss “disfluency clusters” (LaSalle & Conture, 1995) • Collect frequency and type for severity (Stuttering Severity Instrument, SSI-4, Riley, 2009): • Note that prolongations are more advanced types than repetitions; Duration of stutters often do not vary beyond 0.5 to 1.5 seconds • Note average number of units of iterations (i.e., “b-b-b-b-big” is worse prognostically than “b-big”)

6. If the child is a 5- to 13-year-old (Kindergarten thru Middle School): Time since stuttering onset is often 2+ years. We have an opportunity to prevent him/her from developing negative communication-related attitudes, but stuttering will likely persist into later childhood and beyond. He/She is aware that “I stutter,” but not often how I stutter or why I stutter, presenting other opportunities (education; speech production tasks; pseudostuttering, etc.)

7. Our assessment priorities with Kindergarteners – Middle Schoolers (cont’d): • Collect dis/dysfluency frequency and type and duration of three longest blocks for severity. Rate “secondary behaviors” on SSI-4 • Consider grade-level reading. • Note if stutters per 100 words or stutter duration is higher in reading than in spontaneous speech - might indicate sound/word avoidances. • Learn about favorite topics, esp. those related to curriculum. Reading “fluency” can be a bridge to spontaneous fluency, if you do choral/DAF-assisted reading, ask varying levels of questions (What  What do you think?)fade-out use of DAF, etc.

8. Our assessment priorities with Kindergarteners – Middle Schoolers (cont’d): • Test of Childhood Stuttering (Gillam, Logan & Pearson, 2009; 4- to 12-year-old norms; Pro-Ed): • Rapid picture naming, modeled sentences, structured conversation, narration; Parent/Teacher Observational Rating Scale (fluency & consequences) • Collect attitude scales (e.g., Behavioral Assessment Battery [BAB], Brutten & Vanryckegham, 2009; Plural Publishing) • The CALMS (Cognitive, Affective, Linguistic, Motor, Social) Rating Scale (Healey, 2006) http://www.unl.edu/fluency/pdfs/calmsrate.pdf - incorporates score from the Communication Attitude Test from BAB

9. For the 14- to 18-year-old teen (Highschooler) who stutters: We have an opportunity to help this teen prevent stuttering from becoming a roadblock for socialization, college, jobs, careers, etc. Information that we obtain about the stuttering should be functional, developmental, and academic in nature. Learn the degree of concern about the problem from the teen’s, parents’ and teachers’ perspectives. History of successful vs. unsuccessful therapy matters, from each perspective.

10. Our assessment priorities with Highschoolers: SSI-4, but this is never enough, as the 2nd S is for severity, and eligibility can not be based on one measure Overall Assessment of the Speaker’s Experience of Stuttering (OASES™; 7-12; 13-17; 18+yr-olds; Yaruss & Quesal, 2010; Pearson) Trial therapy – “what works?” ala Fluency Shaping (Speak more fluently) and Stuttering Modification (Stutter more easily) approaches

11. Establishing eligibility for school-age children who stutter according to IDEA guidelines 6:00 – 6:30 pm

12. Issues with Establishing Eligibility: We and the caregivers are often the primary advocates for kids who stutter. Sometimes the primary advocate is the kid who stutters, him or herself (www.stutteringhomepage.com > Just for Kids > Jeopardy game). Service plans (private schools) or Individualized Education Programs (IEPs) (public schools) are just that – plans/programs, with appropriate supports and accommodations, and with a beginning and an end.

13. California • California is participating in a 26-state consortium: the Partnership for the Assessment of Readiness for College and Careers (PARCC). • Fluency and open stuttering matters for this goal! • California’s Race to the Top …frameworks & timeline • Mathematics (2012-14) and English-Language Arts (January 2014-16)

14. Eligibility Issues Continued: Common Core State Standards: http://www.corestandards.org/assets/application-to-students-with-disabilities.pdf In order for students with disabilities to meet high academic standards and to fully demonstrate their conceptual and procedural knowledge and skills in mathematics, reading, writing, speaking and listening (English language arts), their instruction must incorporate supports and accommodations… and challenges!

15. What does this mean? • http://www.scoe.net/castandards/agenda/2010/ela_ccs_recommendations.pdf • Grade 2 > #1 > Fluency during reading: Q’s about reading • Grade 5 > p. 10 Fluency and Naturalness in Oral Reading • http://www.scoe.net/castandards/agenda/2010/math_ccs_recommendations.pdf • Page 6 > even Kindergarteners could count / measure behaviors: How many bumpy/stuck words in fast vs. slow speech. What does this mean?

16. What about adverse educational impacts? • Confidence of the student to participate? • Attitude scales; Parent/Teacher reports • Self-efficacy of the student • Efficiency of the student to communicate? • Frequency, duration of blocks, ability to modify stuttered moments, prevent stutters but still use relatively exact words with relatively exact timing when necessary • Understanding of the nature of stuttering, even if basic (no known cure, no known cause, but lots of known “healthy coping strategies”, famous people who stutter, King’s Speech, etc.)

17. What supports, accommodations, or challenges are already being made? • For example, DIBELS accommodation: • Dynamic Indicators of Basic Early Literacy Skills • Series of quick tests, reading-based, e.g., How many letters or how many CVC words can you name in one minute? • Not appropriate for students who stutter, according to the authors of DIBELS; Norms shouldn’t be used; design your own criteria

18. Eligibility Issues Continued: • Eclecticism is a non-random, purposeful blend of approaches that make sense for the individual student who stutters, clutters, or has another type of fluency disorder (late onset; neurogenic; atypical types): • Indirect/Demands-Capacity vs. Direct/Lidcombe-like, Response Contingent Stimulation Approaches for preschoolers who stutter • Stuttering Modification/Stutter more easily vs. Fluency Shaping/Speak more fluently Approaches for school-agers who stutter

19. What Service Delivery Models (Pull-out, inclusion, consultation)? • Monitor without a Service Plan or an IEP • Teach the teachers; aides; mentors; buddies, etc. • Parents may fear regression without 2-3x week, 20+ min pull-out therapy sessions, but parents and students may not have been educated enough about: • Stuttering/fluency variability • “becoming one’s own clinician” • Referrals across the country (www.stutterhelp.org) • Support groups and self-help groups! “Homework”

20. “Covert, Open, and Plus Cases:” Fluency Shaping - Stuttering Modification Blends 6:30 - 7:00 pm

21. “Covert stuttering” Sensing the stuttering (i.e., literally not being able to move through the planned word); yet not producing the surface stutter (i.e., repetitions or a block) “Getting a running start” phenomenon occurs This is not (often) a word-finding problem! This is a problem of increasing rapport, comfort with discussing the stuttering, allowing the covert stuttering student to know that he/she is not alone My experience: more females than males are covert (ASHA Leader special issue on stuttering, 2-14-12)

22. What strategies work to overcome “Covert stuttering”? Document the negative attitudes about speaking, the sound, word, speaking situation avoidances Use podcasts, youtubeclips of Emily Blunt; stuttertalk.com or ISAD talks; (www.schneiderspeech.com> Stuttering) Goal #1 is to continue through the stuttered word on 4/5 occasions, by self-report and observation. Goal #2 is to pseudostutter (“buh-buh-bounce” might provide easier “buy-in” than tense stutters) Goal #3 is to approach instead of avoid…

23. Review of Stuttering Modification approach • “Stutter more easily” • Humanist-based; developed by those who stuttered (e.g., Van Riper) • To change locus of control; pre-Tx – stutters control you; now you control stutters - when and where and with whom you will stutter • With covert stuttering, caution against too much too fast (there are reasons that the stuttering has gone underground)

24. Stuttering modification: Ideas for building open stuttering Fake stutter when esp. fluent Use pullouts immediately or later Cancel out stutters Fake stutter; Make it turn real Cancellations Cancel out avoidances

25. “Open stuttering” Stuttering openly and “being cool with it”…on the surface; Yet there are still negative attitudes and low self-efficacy in students who show open stuttering. Thinking ahead to college and career, when do I want to speak more fluently? Disfluency frequency and type could and should decrease from baseline, as opposed to covert stuttering, where stuttering frequency/duration increase is actually progress, because freedom of communication has increased.

26. What strategies work to prepare someone who openly stutters? Help him/her increase self-advocacy and resiliency for encountering stigma Help him/her decide when controlled fluency is desired Use controlled fluency as needed (follow student’s plan) Fluency shaping building blocks, first, with formative feedback! Then return to stuttering modification building blocks.

27. Review of Fluency shaping approach • “Speak more fluently” • Behaviorist-based, hierarchical, intensive-basis (e.g., Webster’s Precision Fluency Shaping, 1970s; newer ones) • Naturalness (prosody, duration of elongations, loudness, etc.) and Generalization/carry-over activities are key ingredients! • If you use this approach exclusivelywith a client who avoids certain sounds, words, and situations, you are giving tacit permission to continue to avoid. • But, because many individuals tend to avoid speaking situations/words due to their stuttering, they often want to know from us how to speak fluently.

28. Fluency shaping: Ideas for building stutter prevention Van Riper’s “preparatory sets” Pause Easy onset on V-initial words Light contact on C-initial words Decelerate How slow do you have to go? When you do, does it work? How do you know when to?

29. The client will use the“Buh-buh-bounce”tool and Van Riper’s three stutter modification tools with 80% accuracy at varying levels: Cancellations: repeating an actual stuttered word fluently the second time, as a way of “cancelling-out” the physical tension: “g-g-g-going [pause] going like this” Other labels: “Re-do’s” Pull-outs: reducing physical tension and making the involuntary nature of the stutter voluntary within the boundaries of the word: “g-g-g-go [regain control] oooooing like this” Other labels: “Go-on’s”; “Ease-outs” Preparatory sets:easing into the word before a stutter is ever produced “speaking along and [pause] going like this” Other labels: “Easy starts”; Light contacts” (C); “Easy onsets” (V)

30. “Stuttering-plus” cases • Concomitant disorder cases are the “name of the game” in fluency disorders: • 30-40% of children who stutter also have a phonological disorder • But Blood, Ridenour, Qualls & Scheffner Hammer (2003) found in a large survey ~ 65% of K-12 students who stutter have at least one concomitant disorder! • Articulation (33%); Phonology (13%); Language (expressive) (14%); Language (receptive) (12%); Learning disabilities (11%); literacy disorders (8%); Attention deficits (6%); Auditory processing (4%); Neuropsychological (3%); behavioral (2%) sensory deficits (2%)

31. What strategies work with “Stuttering plus” cases? • Determine priority goal areas, through consideration of critical/sensitive periods, e.g., • From longitudinal evidence, ~47% of children who stutter will recover two-years post onset, but consider the odds. • The highly unintelligible child who stutters? • Does “too much phonological work” exacerbate stuttering? (ala Covert Repair Hypothesis, Postma & Kolk, 1993; Limited Capacity Processor models) • Or, if we treated the phonology, would the child feel greater self-efficacy/confidence as a communicator and can that in itself facilitate fluency (Anticipatory Struggle Hypothesis, Bloodstein, 1987)?

32. I’m not so good at speaking…I’ll have trouble if I talk now… Tell everybody how we bake a cake, honey… I…I…I…um W-w-w-we bate duh t-tate… Anticipatory Struggle Hypothesis (Bloodstein, 1987)

33. Determine if you want to to be cyclical or simultaneous with goal areas (Logan & LaSalle, 2003) : • Preschooler examples: • Say carrier phrases including phonology target words OR Increase stimulability for target sound; use slow rate, recast, comment on “smoothness” of speech (Simultaneous) • Treat stuttering for several activities, sessions, or weeks because it is more severe, then return to phonology targets or v.v. if stuttering is mild (Cyclical) • School-ager examples: • Identify stuttered words during a targeted oral reading in recorded playback mode; Modify 4/5 stuttered words in utterances containing targeted morphemes, etc.(Simultaneous). • When would Cyclical make sense in the case you have?

34. Per goal area, determine if the child needs to be in a relatively active or passive role: • Preschooler examples: • Identify/smooth-out bumpy words; say a carrier phrase (fluency-active); auditory bombardment (phono-passive), OR • Differentiate minimal pairs (phono-active); Model a slow rate; recast stuttered utterances (fluency-passive) • School-ager examples: • Identify stuttered words; Modify 4/5 stuttered words (fluency-active); re-iterating your instructions in both a visual and auditory manner (LD-passive) OR • Request a reiteration of the purpose/steps of a task (LD-active); Model pseudostutters+modification with student’s permission as a “sideline reminder” (fluency-passive)

35. Strategies for increasing the socio- emotional support for those who stutter 7:00 - 7:30 pm

36. Tx: Support vs. Self-help groups • Support groups are those led or facilitated by a speech-language pathologist • I have followed what I call the “critical mass” philosophy – in any given year, I might form a group for parents of CWS; a group of TWS or a group of AWS • Self-help groups are initiated and maintained by the people who stutter themselves and do not necessarily include an SLP leader • A combination: SLP gives prompts to a mentor; the mentor then tells new clients his/her experiences and the new clients ask, “compare notes”, etc.

37. Computers, smartphones, ipad™ apps! • Websites! youtube; www.stutteringhomepage.com • www.stutterhelp.org (streaming video: “Swish” & beyond) • www.westutter.org (more of a Stuttering Modification focus; acknowledging stuttering & community of others who stutter • www.stuttertalk.org (Peter Reitzes’ ~ 300 podcasts!) • www.speecheasy.com etc! (Fluency Coach – example of one of many free-download DAF devices) • DAF (Delayed Auditory Feedback) for portables, e.g.: DAF/FAF (Frequency Altered Feedback) Assistant: From www.artefactsoft.com • Logging / Tracking apps – Notes – Recording apps • Speech4good ipad app

38. Re-cap: Can you…? And Q/A time! • List and demonstrate high priority assessment techniques for a typical student referred to you for “stuttering/fluency.” • List strategies for establishing eligibility for school-age children who stutter according to IDEA guidelines. • List and demonstrate an effective blend of fluency shaping and stuttering modification techniques for a student who represents each of these three subgroups: • covert stuttering • open stuttering • concomitant S/L/H disorder with stuttering • List strategies for helping children and teens who stutter get support and learn that they “are not alone”

39. References: My current set of stuttering/fluency resources: http://db.tt/T6PE5LiT Commercially available tests cited on slides Blood, G., Ridenour, V., Qualls, C. & Scheffner Hammer (2003). Co-occurring disorders in children who stutter. Journal of Communication Disorders, 36, 427-448. Bloodstein, O. (1987) A handbook on stuttering. (4th ed.) Chicago:National Easter Seal Society. LaSalle, L.R. and Conture, E.G. (1995). Disfluency clusters of children who stutter: Relation of stutterings to self-repairs. Journal of Speech and Hearing Research, 38, 965-977.

40. References continued: Logan, K.J. and LaSalle, L.R. (2003). Helping children with concomitant communication disorders. Seminars in Speech & Language, 24, 13-20. Mancuso, J.R. (May, 2011) Thesis, University of Four- and five-year-olds’ awareness of stuttering in a peer. Wisconsin-Eau Claire. Postma, A. & Kolk, H. (1993) The covert repair hypothesis: Prearticulatory repair processes in normal and stuttered disfluencies. Journal of Speech and Hearing Research, 35, 1024-1032. Yairi, E. & Ambrose, N. (2005). Early childhood stuttering. Austin, TX: Pro-Ed. ” (LaSalle & Conture, 1995) Yaruss(1998) Real-time analysis of speech fluency procedures and reliability training.American Journal of Speech-Language Pathology, 7, 25-37.