UNIT 3 – MANAGEMENT OF STUTTERING

COUNSELLING
Stuttering, like many complex human conditions and behaviours, results from a complex
interaction of a number of innate and environmental factors. For most children and adults
who stutter, these factors include the speech behaviours that characterize stuttering (e.g.,
sound and syllable repetitions and sound prolongations), as well as the thoughts and emotions
that develop in reaction to the experience of stuttering. For families, especially the parents of
children who stutter, coping with their emotions and reactions to the child or adult who
stutters is often a key issue. It is this piece of the stuttering puzzle, the thoughts, beliefs and
emotions surrounding stuttering that are the focus of the counselling process in treatment.

In general, counselling can be viewed as a helping relationship in which the clinician, or

counsellor, guides the individual toward finding "their own answers, to experience an internal
sense of control, and to leave with new perspectives and the confidence that they can care for
themselves (Riley, 2002). According to Luterman (2001) the goal of counselling should be;
the forging of a relationship that is based on the assumption that people can make themselves
happy.

According to Luterman (2001), suggests an approach to counselling our clients, one that is
rooted in a process of listening and valuing their stories, thoughts, emotions, and concerns.
Through listening and valuing, we assume that clients and their families are competent to
solve their problems without our explicit instructions. It is emotion, what the client and
family do both consciously and unconsciously to cope with and adjust to the problem (Beck,
1995) not rational thought, that most strongly influences behaviour. The clinical significance
is that without helping the client and family to uncover the way they feel about the problem,
and how these emotions contribute to their actions, it really doesn't matter what therapy road
we persuade them to follow; they will not be fully on board. What we advise and suggest will
be less powerful than what the client and family feel in determining their actions.

Purpose of counselling:
1. to share information – regarding the nature and severity of the problem, cause/s,
preventive measures if any
2. To offer advice – type/s and duration of treatment required, prognosis, options/
alternatives, cost, facilities available & addresses
3. To assist care givers and significant others in understanding and coping up with the
problem
4. Catharsis – to provide opportunity to ventilate feelings

Counselling parents of children who stutter:

Hill (2006) and Ramig and Dodge (2010) state that parent counselling should be a key
element of any approach to treating children who stutter. The way parents think, feel, and
behave contributes to the child’s environment and influences treatment progress. The severity
of stuttering exhibited by a child often influences the degree of parental concern. The four
main goals of counselling parents of children who stutter are to help them:
● Express their feelings, thoughts, and beliefs about the problem.
● Make the connection between their emotions and actions
 ● Manage their emotions through activities that transform free floating emotions into
positive actions
● Provide educational information about the problem of stuttering and how the parents
can make changes to support the therapy process.

The long term goals of counselling are to assist parents in coming to accept their child’s
stuttering and their feelings about the problem and to cope positively with their child and her
stuttering.
Ramig and Dodge (2010) explained that the parents need to know the number of factors
which helps in achieving fluency for their child, such as, minimizing interruptions, speaking
slower, respecting silence, minimizing rushing and hurrying, asking one question at a time,
teaching turn taking, and building self-esteem etc.
Nelson (2006) emphasizes a variety of recommendations for family members that can be
incorporated into the counselling:
● A child who stutters should be treated as a “regular kid” – a child who happens to
stutter.
● Children who stutter take more time to talk and, therefore, needs patient listeners.
● Do not let brothers or sisters imitate or tease the child about his stuttering.
● People involved in the child’s life should be instructed to listen to what the child
says, not how he says.
● When children who stutter feel pressured, their stuttering can be aggravated.
● If fatigue increases a child’s stuttering, make sure he gets plenty of rest.
● Family members should avoid correcting the child’s stuttering- it does not help.

Counselling children who stutter:

The form of style of counselling children who stutter varies significantly with the age of the
child: preschool, school- age, and adolescent.
Preschool Children Who Stutter
Most evaluations and therapy with preschool-age children are done in a play atmosphere,
usually without the young child knowing the purpose of his new adult playmate. The child’s
psychosocial abilities and ease with a stranger are observed. It is helpful for the parents to
observe the clinician’s interactions with the child so that clinician can model techniques of
listening and interacting that parents can use to enhance their child’s fluency. Most of the
direct therapy to help a preschool age child is with the parents.
School-Age Children Who Stutter
Williams (2006) and Ramig and Dodge (2010) emphasise that the purpose of talking with a
child who stutters is to discuss frankly and openly what he believes is wrong, what he
believes help him talk better, and what his feelings are about talking. However, before the
clinician can talk to a child about his feelings, the clinician must first earn the child’s trust.
This can be best accomplished by using Roger’s (1953) principles of acceptance,
unconditional positive regard, genuineness, and congruence in the clinician’s words, voice,
facial expressions, and body language. Children are masters at detecting phoniness in adults.
The primary feelings many children have about their stuttering is that it makes them feel
“bad” or “sad” and frustrated. Embarrassment, shame, and guilt about their stuttering and fear
of talking often begin in the late preschool years when children become cognitively mature
enough to compare themselves to others. These feelings can increase if they remained
concealed and unexamined (Guitar & Reville, 2006). Eventually feelings of helplessness and
hopelessness may develop. The clinician’s micro skills and ability to ask questions in a non-
threatened manner are essential in helping children reveal their feelings about their stuttering.
● Children’s Beliefs about Stuttering: Helping a child develop new and healthier
beliefs and ability to be aware of what he is physically doing when he stutters helps
reduce the mystery of his stuttering. Further, better understanding of stuttering leads
to realistic expectations about increasing normal fluency.
● Children’s Feelings about Stuttering: Van Riper (2006) emphasised that “children,
particularly those who stutter, hurt badly, and they show it”. Clinicians need to be
aware that stuttering is a very sensitive, emotional issue for children and painful
emotions may surface. It is essential that children develop trust in their clinician in
order to be willing to talk honestly and openly about their feelings.
Van Riper (2006) describes a technique in which he tries to mirror the child’s
feelings, by saying “I think I’ve learned what you do when you stutter, and may be
you have too. Now let’s see if I can understand how you feel at the time you stutter or
just before or afterwards. I’ll try to act out what I think your feeling is and if I’m
wrong, let me know. Van Riper demonstrated the child’s feelings as:
✔ When a child was feeling helpless- droop his body or whimper
✔ If the child seemed hostile- bang the table
✔ Gesture of shame- cover his face

This technique also helped the child learn how to verbally describe his/her feelings and talk
about them.
Another procedure that Van Riper used involved projective drawings of the feelings evoked
by stuttering. Both the child and Van Riper drew and labelled their own pictures representing
anger, fear, helplessness, sadness, shame and others. After the drawings on the cards were
made, they were laid on the table. Then while the child was talking and had a moment of
stuttering, the child picked up that she felt best reflected her feelings at the moment, and Van
Riper picked up a card that he had drawn that he thought represented the child’s feelings.
They compared the card to see if the child and Van Riper picked up the same card.
Adolescents who stutter
Zebrowski (2006) discusses the challenges that the adults face when attempting to teach,
guide, instruct, and advice adolescents. Adolescents undergo many cognitive, emotional and
physical changes. A major developmental task during the teenage years is the individuation,
or becoming more independent from parents and developing a separate identity.
Consequently, teens are frequently resistant to or uninterested in what adults have to teach
them. Thus, the way that teens present themselves to clinicians can result in appearing
unmotivated.
When working with adolescents, it is important to ask them about their experiences and to
“treat them as the expert” rather than to “preach” them. Luterman (2008) encourage clinicians
to listen and value the adolescent and view him as competent to make good clinician.
Curlee (2008) talks about self-defeating thoughts and behaviours that teenager who stutters
often use. People can change their beliefs by changing their behaviours, and they can change
their behaviours by changing their beliefs. Adolescents may believe that they cannot do
something, but once they work on it they discover they can do it and they change their beliefs
about it. Many people need to believe that they can accomplish something long before they
accomplish it.
Williams (2008) mentioned that many parents do not talk to their children about their
stuttering because:
● They are afraid it would upset their child if they showed disappointment in the way
their child talks
● They feel their child’s stuttering is not a big issue to them
● Their child does not like to talk about personal things
● They just do not know enough about stuttering and they do not know what to say

Hence, a cycle of communication avoidance is created.

In order to help teens and their parents initiate conversations about stuttering. Williams offers
few suggestions:
● Select a good time and place to talk
● Be aware that parents are likely to feel awkward, too, and may be too embarrassed.
● Remember that it is the teen’s responsibility to start the conversation and to set the
tone for it.

Counselling Adults who stutter

Most authorities on stuttering emphasise that therapy with adults who stutter is a step-by-step
process involving both attitude and speech changes (Aten, 2008; Bloodstein & Bernstein
Ratner, 2008). Breitenfeldt (2008) states that severe chronic stuttering remains a problem for
most adults and, therefore, they need to learn to live successful, fulfilling lives in spite of this
constant, unwanted companion. Because stuttering is both a communication problem and a
problem of living, the clinician needs to work with the person who stutters, not just the
stuttering.
● Adult Stuttering can Coexist with Psychological Disorders

Adults who enter therapy for their stuttering problem may have other problems that become
apparent as therapy progresses. Stuttering and anxiety are commonly intertwined and
interrelated. When a clinician becomes aware of such symptoms or other significant
psychological or emotional concerns that are outside the scope of practice, it is appropriate
and ethically responsible for the clinician to suggest or recommend that the person seek help
from a mental health professional.
Principles of counselling for adults who stutter
Cooper (1997) describes stuttering in adults as a syndrome that consists of multiple,
coexisting and interactive affective, behavioural, and cognitive components coalescing over a
period of years. Each of these three major components of stuttering needs to be addressed n
therapy, and counselling is an essential part of any therapy that works with the entire person
and not just the stuttering behaviours.
Sheehan (2008) offered several principles for counselling people who stutter, with emphasis
on the feeling level:
● Create a relationship and an atmosphere in which the person is able to express
whatever he feels. Help him understand that he is never wrong on the feeling level,
and never tell the client, “You shouldn’t feel that way.”
● Help the person realize his potential for growth and development and self-realization.
● Begin where the client is, not where the clinician is. Give him room to feel
comfortable about the way he feels.
● Respect the person’s feelings of frustration, fear, anger, shame, guilt, and so on as
being valid.
● Help him discover that the more guilt, shame, and hatred he attaches to his stuttering,
the more he holds back and try to hide his stuttering, results in even more stuttering
● Deal with the here and now. Emphasise the possibilities of the future, not the mistakes
of the past.
● Let the person know that you are interested in more than just the stuttering, that you
are interested in him as a person, what he thinks and feels, and that you have
unconditional positive regard.
● Every client should be encouraged to develop initiative and independence of the
therapist by learning how to recognise which assignments he needs to work on for the
maintenance of his improved speech.

Direct and Nondirect Counselling Skills

● Directive counselling requires the clinician to control and direct the therapy sessions.
There are times when clients are in "choice overload" or "ignorant" of the right
information. They may need the therapist to tell them exactly what to do, and for how
long. This type of direction usually occurs during the first phases of therapy. The
clinician acts as an instructor, not a coach, cheerleader, or mentor. The directive
approach provides the client with accurate facts and reassurance. It is an easy method
of counselling. The clinician clearly directs the therapy. Clinicians label their opinions
and provide direct answers to questions asked. Statements like these would be
representative: 1) that’s not quite what you wanted to do. Slow it down and get an
easy onset; 2) Good, that was much better; 3) So you felt that people were making fun
of you; 4) Did you get up and explain to the person what you wanted? 5) It sounds
like you should have been more assertive, doesn't it?
● Nondirective counselling deals with stimulating growth and letting clients "discover"
the answers to their questions. It assumes that change can occur with introspection,
examination, and discussion. This nondirective approach leads to increased self-
responsibility. Clinicians try not to interrupt the client, often "repeat or rephrase" what
has been said, and do not provide advice about what to do. This technique is also
called "mirroring". Comments like these would be representative: 1) would you like
to talk some more about that? 2) That sounds interesting to you. 3) So you're saying
that people who do not stutter are less personable.

GROUP THERAPY
Fluency disorders are multidimensional commonly including a sense of isolation, and
negative thoughts and feelings (Liddle, James and Hardman, 2011). Group therapy has
certain qualities that can help address these aspects of the disorder. In particular, group
therapy provides an opportunity for peer support which has been found to reduce
victimisation and anxiety around bullying, increase self-confidence, and reduce feelings of
isolation. In addition Williams and Dugan 2002, suggest that child in a group setting is
motivated by his/her peers success and becomes empowered by the peer support.
Need/ Goals of group therapy:
● To promote group interaction
● Facilitate socialization & communication in social context
● Competitiveness and better learning
● Develop a sense of self reliance
● Transfer and generalize the skills
● Promote emotional support
Better utilization of clinician’s time

Pre-requisites:
● Group homogeneity with respect to age, disability, capability, language
● Adequate no. of children/adults; ideal group size is about 7 people, but can have as
many as 12-13 and as few as 2-3.
● Timings, Keep a fixed day and time per week

Group Therapy for Children who stutter:

Guitar and Reville (2006) and Ramig and Dodge (2010) mentioned the purposes and benefits
of group therapy for school-aged children who stutter. Group therapy is a safe environment
where the children feel free to be themselves and to talk freely despite their stuttering. They
can practise and improve their fluency and communication skills by watching, listening and
talking to each other.
Group Therapy for Adult who Stutter:
Adults who stutter can share past as well as present experiences, feelings, attitudes and
beliefs with other adult who stutter, who share the same concern. The group provides a
sheltering atmosphere where by adults who stutter can say what they want to about their
problems and their feelings and the others will at least listen, even if they do not always
agree. Through a group adult stutterers come to learn that they are not alone with this
problem.
Client reluctant to participate in group therapy:
Conducting group therapy for adults who stutter is however not always an easy task. First and
foremost the disorder itself interferes with the very medium clinician need to use in group
therapy: talking. There are periods of discouragement when it appears no one wants to
contribute to the group talk.
● Some adults who stutter have strong fears about their stuttering that they may be
reluctant to deal with and explore in a group
● Some seem reticent to see themselves in others; and they resist to face the reality
● Some may deny or avoid facing the reality that their feelings, beliefs and attitudes
may be contributing to their problems
 ● Some seems to believe that by seeing and hearing others who stutter will make their
problem worse or stutter more

Advantages and disadvantages of individual vs. group Therapy

Advantages
Individual Group therapy
● Can target needs ● Provides natural communication
environment
● Paced to match needs ● Awareness that others have similar
problems facilitates participation
● Safe & secure to practice skills ● Can learn from each other
● Appointments can be flexible ● Range of comm. model
● Easier to plan and monitor progress ● Competitiveness
● Range of activities, skills &
opportunities
● Better generalization
● provide a supportive network for
parents and children
● More economical
Disadvantages
Individual Group therapy
● Creates artificial environment ● Some clients too shy and inhibited
● Parents have reduced contact with ● Less time for individuals
others
● Generalization beyond one-to-one ● May have personality clashes with
may not occur others
● More time consuming ● May learn bad habits
● Total attention can be threatening ● Requires more time for planning,
organization and resources
● Difficult to maintain confidentiality
● Comparisons may upset some
functioning at low levels

THERAPY FOR CHILDREN WHO STUTTER

Treatment approaches for children who stutter include:

Indirect
Indirect treatment focuses on counselling families about how to make changes in their own
speech and how to make changes in their child’s environment. These modifications are used
to facilitate speech fluency and may include reducing communication rate, using indirect
prompts rather than direct questions, and recasting/rephrasing to model fluent speech
(Millard, Nicholas, & Cook, 2008; Yaruss et al., 2006).

Direct
Direct treatment focuses on changing the child's speech in order to facilitate fluency. Direct
treatment approaches may include speech modification and stuttering modification strategies
to reduce disfluency rate, physical tension, and secondary behaviours (Hill, 2003). Direct
treatment also can target children's communication attitudes (Yaruss et al., 2006).

1. Contour (1990) – Analogies for children with stuttering

Analogies are used to help the child understand what a child must do to increase the speech
fluency indicating that speech involves a smooth continuous movement from one sound to
another.

Analogies to understand fluent speech production:

1. Garden Hose Analogy:

Steps:
● Showed the similarity between the hose and the larynx.
● Larynx – Faucet | Throat and Tongue – Garden Hose | Lips – Nozzle
● Permit the water to flow out of the hose
● Minimize the water flow
● Stuttered speech is like pressing for too long with too much force between the thumb
and the opposing fingers (prolongation), or repeatedly contacting the thumb with the
finger (repetition)
● Deep breath and hold it with the mouth – air flow is stopped with the faucet
● Deep breath and hold it with the lips closed and cheeks buffed out – air flow stopped
with nozzle

2. Blown up Balloon Analogy :

Steps:
● Similar to the pressure created by air pressure and vocal tracts
● Free flow of air through balloon represents free flow of air through larynx
● Squeeze the sides of the balloon and feel the changes in pressure on the sides of the
balloon
● Hold the neck of the balloon and feel the pressure against the fingers – when air to
stopped at the level of larynx there is an aerodynamic back pressure felt below larynx

Analogies to practice fluent speech production:

3. Lilly Pad Analogy :

Steps:
● Draw Lilly pad bridge
● Ask the child to pretend like a frog
● The frog should hop from the bank to the 1st lilly pad and so on
● While doing so child should say one syllable per pad.
 ● If he stand to long on a pad – Prolongation | Jumps too hard on a pad – Hard contact |
Hop up and down on the same pad – repetition | If he gets wet, go to the bottom or
climb out again

4. Barrel Bridge Analogy :

Similar to Lilly pad

● The boy should hop from one barrel to the other and so on
● While doing so child should say one syllable per barrel.
● If he stand too long on a barrel – Prolongation | Jumps too hard on a barrel – Hard
contact | Hop up and down on the same barrel – repetition | If he gets wet, go to the
bottom or climb out again

5. Thumb and Opposing Finger Analogy :

Steps:
● Each finger is the letter or the sound of the short word
● Thumb represents tongue ‘used to produce each letters’.
● Fluent speech is like having the thumb move smoothly and easily from one finger to
another
 ● Stuttered speech is like pressing for too long with too much force between the thumb
and the fingers (prolongation)
● Repeatedly contacting the thumb with the finger (repetition)

6. Closed-fist-to-relate-hand Analogies :

Steps:
● As the hand relaxes, it moves from a fist to an open palm.
● Through repeated demonstrations with or without speech, the child learns smooth
release of tension in the hand.
● The person who stutters must learn to unclench his tongue as he unclenches his fist

2. Time Out and Response Cost

Time-out is a simple operant procedure. The client pauses (i.e. takes a “time-out”)
immediately after he or she stutters. Because these “time-outs” are triggered by stutters,
the treatment is sometimes called “response-contingent time-out” (e.g. Franklin et al.,
2008).

● Time-out treatments have been used to treat stuttering since at least the late 1950s
(James, 2007). There are two main kinds:
● Speech pathologist-led time-outs: The speech pathologist presses a button whenever
the client stutters, which illuminates a light or makes a noise, or simply says “stop”.
When this happens, the client stops talking.
● Self-administered time-outs: Clients monitor their own speech and impose a time-
out on themselves whenever they stutter.
● One of the more recent versions of time-out uses a combination of these
techniques: the speech pathologist initially imposes the time-out, and then trains the
client to do it (Hewat et al., 2006).

● Time-out is usually considered a stuttering treatment for teenagers and adults (e.g.
Hewat et al., 2006). However, it has been used with pre-schoolers (e.g. Martin, Kuhl
& Haroldson, 1972); and school-aged children (e.g. Onslow et al., 1997).
● Time-outs need to happen when the person stutters (and not at other times or for other
reasons).
 ● Self-imposed time-outs seem to help clients achieve real world gains more than
speech pathologist-imposed time outs
● Results seem to be best when combined with rate control and/or prolonged speech
treatments.
● It doesn’t seem to matter whether the client thinks it will work!
● The duration of the time-out seems irrelevant: short (1-5 second) time-outs seem to
work as well as longer ones.
● Time-out is an option with some clinical evidence to support it – particularly for teens
and adults.

Response cost for pre-schoolers (2003, M.N. Hegde)

Response cost is an attractive alternative to fluency shaping. It is effective with young
children for whom fluency shaping is not a good option. It does not affect the speech rate and
speech naturalness. It is easily administered; clinicians are readily trained in its use. Parents
accept it and therefore it has high social validity.

Administration of response cost: Token award

during the individual response cost therapy:
● The clinician uses toys, story books, puzzles, selected games, activities, and so forth to
evoke speech from the child.
● For every fluent production (a word, a phrase, or a sentence), the clinician places a token
in the child’s container.
● The clinician also praises the child for smooth speech as she places the token in the
child’s cup (e.g., Says, “That was smooth speech! Here is a token for you”)

Administration of response cost: Token withdrawal

● When the child stutters, the clinician says something like “Oh no! That was bumpy! I am
taking a token back!” and removes a token from the child’s cup and places the removed
token in his/ her own cup
● The clinician fluently models the child’s stuttered production for the child to imitate and
awards a token to the child if the imitated production is fluent.
● Initially, withdraw a token with announcement (“That was bumpy, I am taking a token
back”)
● Later, take a token back without announcement.
● While showing pictures and evoking controlled responses, interject brief conversational
episodes

Progression across response complexity

● As with other procedures, advance the child from isolated sentence level to more
continuous speech.
● From continuous speech, advance the child to narrative speech.
● From narrative speech, advance the child to conversational speech.

Trouble shooting
● Occasionally a child may react emotionally to the first token withdrawal and refuse
cooperation.
● The child may stop talking, fight tears, leave the seat, or ask for Mommy
● Showing signs of disappointment is natural and the clinician needs to do nothing
● Serious emotional reactions need to be handled promptly and sensitively.

● Role reversal is invariably effective in completely eliminating the children’s

unfavourable reactions to the initial token withdrawal.
● The clinician plays the child’s role, and asks the child to give and take tokens for smooth
and bumpy speech (and produces many bumps).
● Children gleefully withdraw tokens from the clinician!
● When the treatment is resumed, children have no problem with token withdrawal.

Token bankruptcy
● Another potential problem to be handled is token bankruptcy—the child who is left with
no tokens, which means no gift at the end of the session.
● That, of course, can’t happen; the clinician should avoid token bankruptcy at all cost.
● Token bankruptcy means no reinforcement for fluency.
● The child will react explosively if there is token bankruptcy.
● Clinicians monitor the number of tokens the child has at any moment
● When the child’s token collection is precariously low, the clinician can award two tokens
for fluent and longer production
● Extend the session by a minute or two so the session ends with surplus tokens for the
child.

Parent training
● Parents must be trained in the administration of response cost at home.

3. Lidcombe program

● The Lidcombe Program is a behavioural treatment for children who stutter who are
younger than 6 years. It may be suitable for some older children. The program takes
its name from the suburb of Sydney where the Australian Stuttering Research Centre
was located.
● The treatment is administered by a parent or carer in the child’s everyday
environment. Parents learn how to do the treatment during weekly visits to the
speech-language pathologist. During these visits, the speech-language pathologist
teaches the parent by demonstrating various features of the treatment, observing the
parent do the treatment, and giving parents feedback about how they are going with
the treatment. This parent training is essential, because it is the speech-language
pathologist’s responsibility to ensure that the treatment is done appropriately and is a
positive experience for the child and the family.
● The treatment is direct. This means that it involves the parent commenting directly
about the child’s speech. This parent feedback needs to be generally positive. The
parent comments primarily when the child speaks without stuttering and only
occasionally when the child stutters. The parent does not comment on the child’s
speech all the time, but chooses specific times during the day during which to give the
child feedback.
● As well as learning how to give feedback effectively, the parent also learns to
measure the child’s stuttering each day with a scale from 0 to 9, where 0 is no
stuttering, 1 is extremely mild stuttering, and 9 is extremely severe stuttering. At each
clinic visit, the speech-language pathologist and the parent discuss at these severity
ratings for the previous week to see what effect the treatment is having outside the
clinic. This is an essential process to ensure that the treatment works properly.

The Lidcombe Program has two stages.

● During Stage 1, the parent conducts the treatment each day and the parent and child
attend the speech clinic once a week. This continues until stuttering either is gone or
reaches an extremely low level.
 ● Stage 2 of the program – or maintenance starts at this time and lasts around a year.
The aim of Stage 2 is to keep stuttering from returning. The use of parent feedback
during Stage 2 is reduced, as is the number of clinic visits, providing that stuttering
remains at the low level it was at the start of Stage 2. This maintenance part of the
program is essential because it is well known that stuttering may reappear after a
successful treatment. All children and families are different, and the speech-language
pathologist takes this into account when supervising the treatment. While the essential
features of the treatment as set out in the Lidcombe Program treatment guide are
always included, the way they are implemented is adjusted to suit each child and
family

4. Parent – Child Interaction Therapy (PCIT)

Principles of Palin PCI Therapy

● Stuttering is heterogeneous, therapy needs to be individually tailored
● Focus is on understanding each child’s skills and needs
● Parent involvement is central to the process of change (both parents unless a lone
parent family)
● Parents of CWS are not different from parents of CWNS (Kelly & Conture 1992;
Kloth et al 1995; Yaruss & Conture 1995; Miles & Bernstein Ratner 2001).
● Interaction is a two way process (Meyers & Freeman 1985; Kloth et al 1999)
● Parental interaction styles may influence a child’s fluency (Stephenson-Opsal &
Bernstein Ratner 1988; Newman & Smit 1989; Guitar et al 1992; Winslow and Guitar
1994)
● Interaction styles can be modified – change in one may influence many others
(Bernstein Ratner 1992).
● Focus on strengths, what parents are already doing
● Collaborative - therapist facilitates, supports, reinforces
● Stuttering openly acknowledged and discussed

Overview of Palin PCI Kelman & Nicholas, 2008

● Identify the physiological / linguistic / environmental / emotional factors
● Enhance and develop those that support fluency
● Combination of indirect (interaction and family strategies) and direct methods
(fluency enhancing strategies)

Candidates for therapy

● All CWS aged 2-5 years
● Any time post onset

Including children who:

● Are unaware of stuttering
● Don’t have metalinguistic skills to modify speech
● Are sensitive to any mention of stuttering
● Have reduced attention and listening skills
● Have reduced language skills
 ● Have learning difficulties or autistic spectrum disorder

Palin PCI Sessions

● Screening assessment
● Consultation assessment – child assessment – case history
● Six clinic sessions (one hour each)
● Six week home consolidation period
● Review 6 weeks, 3 months, 6 months, 1 year post therapy

Clinic Sessions
● Session 1
- Set up Special Time
- Make interaction video
● Sessions 2-6
- Review home tasks
- Interaction videoed and observed
- Parents identify interaction target
- Family strategy introduced

Rationale for choosing therapy goals

● Interaction strategies
- Parent identifies target and rationale
- Parents can make changes to interaction
- Changes can impact on fluency
● Family strategies
- Children function in context of family
- Environment can influence development
- Need to generalise outside clinical environment

Interaction Strategies
● Increasing pauses between turns
● More equal balance of turns
● Matching complexity of language to child’s abilities
● Reducing speech rate
● Altering the balance of questions: comments
● Following child’s lead in play
● Increasing eye contact

Family Strategies
● Praise (Faber & Mazlish, 1988)
● Confidence building
● Behaviour management
● Family turn taking
● Establishing routines
● Other family support
Measuring Progress
● Stuttering frequency (%SS)
● Parent questionnaire (Millard 2002; Millard et al., 2009)
● Parent report

Parent Rating Scales (Millard et al., 2009)

How worried are you about your child’s stammering?
0 (as worried as 10 (not at all)
I possibly could be)

How worried is your child about his stammering?

0 (as worried as 10 (not at all)

He possibly could be)

THERAPY FOR ADULTS WHO STUTTER

Fluency Shaping
In the 1970s, fluency shaping was another approach to stuttering treatment. The goal of this
new therapy was to replace stuttering completely with a new way of talking that allowed the
person to talk without stuttering. The goal of this “Fluency Shaping” therapy was not to
stutter more easily, but to “speak more fluently”.
The program usually started with the production of a very slow unnatural sounding
prolonging of sounds and syllables – but during this time the client did not stutter. Next, the
rate and other factors were shaped gradually in steps to sound like normal, natural-sounding
speech. All the while, the client is still not stuttering.
After the stutter-free speech was established in the clinic, the client was carefully exposed to
outside clinic situations. They started with the easiest speaking situations and gradually
progressed to more difficult situations until the client was able to speak without stuttering to
anyone all day long.

Purposes:
- Obtain fluent speech outside of stuttering behaviours, or before stuttering
events.
- The aim to prevent the intensity or frequency of stuttering behaviour.
- Allow for success in achieving fluency so to increase confidence.
- To decrease negative reactions to stuttering — so to promote fluent speech.
- Alter speakers’ articulation, speech rate, breath patterns, voice productions and
other aspects of communication to reduce vulnerabilities to disfluencies.
- These are strategies to utilize when communicating in a general capacity, not
just in the targeted moments of stuttering. Using these strategies will allow for
the best chance at a communication environment that will be more fluent,
thereby reducing the occurrence of the need to utilize stuttering modification
strategies.
Fluency-enhancing techniques are attempts at promoting fluency in a generalized way:
- Light contact: producing the initial sounds of words that are plosives in
manner — /b, p, d, t, g, k/ — these sounds are produced very gently. Light
productions improve fluency due to less tension being involved.
- Slower speech rates: slowing down the rate of speech may improve fluency.
- Relaxed breath patterns: reducing tension globally via focusing on reducing
tension in breath patterns can also improve fluency.
- Slow/stretched speech: Prolonged productions of speech sounds in a general
capacity to encroached fluency.
- Easy onset: producing initial sounds of words that are not plosives (vowels,
fricatives /z, s, v, v/ nasals /n, m/ and liquid /l/ also in an easy and gentle way.
- Pausing and chunking: This technique involves creating. Natural breaths,
allowing for pausing that is indicated for improving fluency.

Stuttering Modification
Charles Van Riper developed “Stuttering Modification” techniques in the 1930s. Clinicians
wanted to teach clients to “stutter more easily”. They taught techniques to reduce tension by
training muscle relaxation during the moments of stuttering. Some of these procedures are
“pull-outs” (reducing tension during the stuttering moment) and “cancellations” (completing
the stuttering moment and then going back over it with less tension). All of these were
somewhat effective in reducing the severity of the stuttering moment, but the stuttering
remained.

Purposes of stuttering modification strategies:

- To increase awareness of physical tension
- Reduce physical tension
- Reduce struggling behaviours/unlearn secondary behaviours
- Reduce negative reactions of the speaker
- Increase feelings of self-control
- Increase awareness of speech that is disfluent
- Approach stuttering in a relaxed way
- Reduce feelings of sensitive about disfluencies
- Increase feelings of openness and acceptance

The classic stuttering modification therapy was developed by Charles Van riper in the middle
of 20th century. Since then many clinicians have improvised on Van ripper’s basic stages and
strategies. The stages of Van Ripper’s therapy can be summed up in the acronym MIDVAS:

Motivation: the person who stutters needs to assess his/her motivation for seeking therapy
and the speech language pathologist needs to help the person build and maintain the
motivation necessary for successfully changing speech behaviours and attitudes.

Identification: in the identification stage the client and clinician identify all of the
behaviours, feelings and attitudes that go along with the persons stuttering. They identify the
core behaviours, secondary behaviours, physiological components, such as changes in heart
rate, feelings of fear, anxiety, shame, guilt and hostility, and avoidances. Identification can be
very difficult for people who stutter because it exposes their shame and feelings of
inadequacy.
 Desensitization: after the emotionally draining word of identification, the person who
stutters moves into the desensitisation stage. Van Riper designed this stage to help drain away
the negative emotions, the fears and the anxieties associated with the act of stuttering. These
negative feelings gives stuttering its power over the individual. The most common strategy
used in desensitisation phase is called “voluntary stuttering”. In which the person stutters on
purpose. By choosing when and how to stutter, the individual begins to gain control over the
stuttering and the fear and anxiety begin to diminish.

Variation: once some of the negative emotions have drained away from the act of stuttering
the individual is able to change how he/she stutters and changes his/her reactions to
stuttering. Much of a stutterer’s behaviours and reactions are engrained to the point of being
stereotyped. The same stimulus (e.g. ringing telephone) will set off the same chain reaction of
feelings and behaviours in the person. Varying these stereotyped responses weakens their
power over the individual and helps the individual continue gaining control over the fears and
the stuttering.

Approximation: once the stereotyped pattern of stuttering has been broken up, the individual
can learn specific strategy to smooth out and minimise the moments of stuttering. The 3
common strategies for altering the stuttering are; cancellation, in which the person stutters all
the way through the word, stops immediately, and then repeats the stuttered word in a
different way, Pull outs; in which the person gains control over a moment of stuttering while
it is happening and smooth’s it out and preparatory set, in which the person prepares for a
moment of stuttering before it happens, starts gently and glides through it smoothly.

Stabilisation: after successfully moving through the previous phases of therapy with the
close guidance of clinician, the person who stutters needs to become his/her own clinician. In
the stabilisation phase the individual uses the new stuttering controls in more and more
situations of daily life.

Steps in the treatment of stuttering:

The management of fluency disorders involves three stages:

1. Establishment of fluency:
Establishment of fluency is easy and can be achieved using a variety of fluency shaping or
stuttering modification approaches. Many PWS do not exhibit stuttering or exhibit less severe
problem in the clinical set up because they do not try to suppress the problem. Many novel
ways of speaking reduce disfluencies.

The method and mode of therapy varies with children and adults who stutter, as the demands
and capacities vary in children and adults. For young children various analogies are adopted
to make it enjoyable and fun. For older children and adults different approaches are combined
to provide a comprehensive treatment plan, which include:

a. Traditional approaches: Following are a few of the traditional techniques being used for
decades with varied success: Voluntary stuttering/ stutter fluently techniques, prolongation or
many of its variants, cancellation, pull out, soft/loose contacts, relaxation, airflow therapies,
and shadowing.
b. Cognitive approach/Cognitive restructuring: Developing an understanding about the
production of speech in general and fluent speech in particular is essential part of any
therapy. Even young children are encouraged to understand the same using various analogies
(Garden hose/Blown up balloon analogies). PWS are made to realize how and why the
stuttering problem varies and how can they get a control over it. This would reduce their
dependency on the clinician and gradually make them more confident in getting control over
their problem. Maintenance of a diary would facilitate this.

c. Behaviour therapy approach: Although the cause of stuttering is not very well
understood, recent theorists emphasize nurture or environmental factors to contribute as
maintaining factors in stuttering. Appropriate reinforcement procedures to facilitate fluency
and punishment strategies like the Time out and Response cost to reduce disfluencies could
aid in achieving fluent speech. Further, in clients with anxiety traits, progressive relaxation
combined with systematic desensitization procedures could be very effective.

d. Emotional or effective approaches: Using varieties of psychotherapy and counselling,

positive changes in emotional or affective states of the individual need to be brought about.
Stuttering is a disorder which evokes unusual reactions from the peers parents and public.
These negative reactions are unpleasant and speaking situations may be traumatic to PWS,
who will start avoiding them. Hegde (1990) opines that if the attitudinal changes are not
brought about during the therapeutic management, the unchanged maladaptive attitudes will
soon wipe out the temporary and shaky fluency generated by the treatment procedure.

e. Instrumental approach: Mechanical and electronic devices and various equipment’s are
available for establishing fluent speech in the clinical set up such as, metronome, EMG
Biofeedback, Masking, DAF, FAF, Dr. Fluency. Some portable bone conduction hearing aids
are also available which provide noise to mask auditory feedback, delayed or frequency
shifted feedback. School DAF, Telephone fluency system, pocket fluency, desktop fluency
system, and voice changer are some of the other devices used in the management of PWS.

f. Supportive approach: Periodic counselling and guidance to the parents, relatives, friends,
teachers, employers or significant others in the social environment of PWS is very important
for bringing about long lasting maintenance of the fluency that is achieved. It is necessary for
PWS to get support and encouragement from these people to overcome their negative
feelings and attitudes and proper motivation to control the fluency achieved.

2. Transfer/ Generalization of fluency:

Once the fluency is established in the clinical set up the clinician should start activities to
transfer these skills to outside situations in a gradually graded manner. Situational hierarchy
ratings obtained during pre-therapy assessment would help in this exercise. Maintenance of
log books or diary is necessary to monitor progress achieved in day-to-day practice. PWS
should be encouraged to self-monitor and self- correct to reduce dependency on the clinician.
A close friend or a family member could be assigned to assist the client in this process
initially.

3. Maintenance of fluency:
PWS have to be prepared for any relapses that could occur during the treatment or later so
that it does not come as a shock if he suddenly encounters situation where he is not able to
maintain the fluency achieved. After intensive and extensive practice sessions, the frequency
of treatment sessions should be gradually reduced to make follow up or booster sessions to
monitor the maintenance of fluency.
Following are the therapy techniques for adults who stutter:
∙ Prolonged speech therapy
∙ Airflow based therapy techniques
∙ Shadowing
∙ Habit rehearsal techniques
∙ DAF
∙ Masking
∙ Camper-down program
∙ Systematic Desensitization
∙ Cognitive- behaviour therapy for adults who stutter

RELAPSE AND RECOVERY FROM STUTTERING

1. Recovery From Stuttering

● Recovery is restoration to a former or better condition.
● There are two forms of recovery Spontaneous recovery and recovery following
treatment.
● Spontaneous recovery of stuttering is more common in young children and it is a rare
occurrence in adults.
● Some stop stuttering spontaneously for reasons even the experts cannot determine
with any certainty
● Changes in speech and desire to improve can lead someone to declare himself or
herself recovered
There are few longitudinal studies where investigators reported the percentage of individuals
who were recovered from stuttering are:
Authors Year Recovery
percentage
Andrews and Harris 1964 79.1%
Panelli 1978 80%
Ryan 1990 65%
Yairi and Ambrose 1992 70-80%

Recovery following treatment:

Authors No. of subjects Findings
Yairi and Ambrose (1992) 27 preschool-aged CWS. Results indicated that for the
two subgroups there was a
18 of the 27 CWS received a
marked deceleration over
few speech treatment
time in the mean frequency
sessions, whereas 9 children
 did not receive direct of stuttering-like disfluency.
treatment
Finn (1996) 11 of 15 PWS self-reported as recovered
when continued to practice
speaking with a modified
speech pattern
Finn (1997) using many of the same Stated that they still had a
subjects, 9 of 15 recovered tendency to stutter.
subjects

Factors related to recovery in stuttering:

● Stuttering recovery and gender: The incidence of stuttering- higher in males than in
females. Also, female PWS tend to recover earlier than male PWS. Sex type is the
significant variables in the distributions of recovery and persistence of stuttering.
(Seider, Kidd & Gladstien, 1983).
● Stuttering recovery and age: It appears from all available findings that some degree of
recovery may occur at any age. Study on recovered adults PWS by Martyn & Sheehan
(1968) showed there was a considerable tendency for recovery between the ages 13 and
20 years. Seider, Gladstein, & Kidd (1983) showed a decreasing probability of recovery
with age. However, they reported that the ages of recovery ranged from 3 to 38 years
● Other recovery related factors: The speech modifications, along with motivation to
change, speaking more slowly, self-evaluation, acquiring new attitudes towards self or
speech problem were reported as the biggest factors in the recovery of the subjects
(Quarrington, 1977; Finn 1996, 1997)
● The one factor that seemed to make a difference is the severity of stuttering. The more
severe cases tended to be more persistent presumably because recovered PWS had less
severe problems and hence, had less often received formal speech therapy (Dickson,
1971)

2. Relapse in stuttering
● Relapse is defined as the recurrence of symptoms after a period of improvement
(Webster, 1989)
● In other words, relapse is defined as a return of considered symptoms that therapy
either had replaced or brought under control
● Relapse has been called the “Achilles Heel” of stuttering intervention (Kuhr & Rustin,
1985)

Factors related to relapse:

● Silverman (1981) suggested a number of possible reasons for relapse. Clients who are
especially likely to relapse are those who, following treatment, believe themselves to
be cured. Believing they have experienced a cure, they are less likely to continue the
rigorous process of self-management. Other clients may regress as they come to lose
confidence in the treatment program. Relapse is also more likely to occur if clients are
released from treatment too soon, although how soon is “too soon” may be difficult to
assess.
Some of the common factors contributing to relapse as given by Sheehan (1966) and
supported by other authors (Boberg, 1979; Kamhi, 1982) are:
● Client’s difficulty in adjusting to a new role as a fluent speaker or dissatisfaction of
the client with the new speech mode
● Weak establishment and transfer of new speaking modes
● Failure to develop or more likely to use, self-monitoring adequately
● Failure to eradicate social avoidance behaviour
● False fluency: Client is not fluent but in response to suggestion and pressure is
persuaded into a false fluency
● Self-efficiency doubts: over dependence on the clinician and the therapy program,
rather than develop confidence in their own capacities
● Jost’s law: when two approximately equal responses compete, the older response
will, over time, tend to displace the new one. The less sure, firm, acceptable the new
response is, the sooner relapse will occur
● Boredom: behaviours that have to be worked on and nurtured can become boring and
lose their appeal
● Penalty of fluency: Many PWS obtain gains from disfluency. Some find the
responsibility and penalties of fluency just not rewarding enough to maintain

Helping Events to Manage Relapse

● Client’s first experience with relapse is traumatizing. Therefore, one of the first things
a clinician should do is to reassure individual that relapse happens and it’s no body’s
fault. Clinicians should learn to listen to their strong feelings and acknowledge them.
● One thing that has to be noted with relapse is that relapse does not mean that the client
has forgotten everything learned before.
● Re-evaluation of the problem with respect to frequency and severity is very important.
Some structured practice and refinement of stuttering or fluency shaping skills will
help the person regain the skills that they temporarily lost.
● Cognitive behaviour therapy is particularly very helpful as it will help them to cope
with the demands and also provide some self-management skills.

MEASUREMENT OF THERAPY PROGRESS & NATURALNESS RATING

During a diagnostic evaluation clinician needs to carefully measure a client’s speech fluency
and other behaviours in order to make an appropriate judgement of whether the client is
stuttering, whether the client require treatment and what nature of treatment should be. Later,
during treatment, clinicians needs to measure changes in their clients speech to document
their response to treatment and to help with planning future treatment. Clinicians need to be
able to distinguish day-to-day or situation–to-situation fluctuations from changes associated
with treatment.

Client’s behaviours that can be measured:

1. Characteristics of speech disfluencies
- Frequency of disfluencies
- Types of disfluencies
- Duration of various types of disfluencies
- Audible or visible tension during disfluencies
 - Non speech behaviours associated with disfluencies
- Severity of individual instances of disfluency
2. Factors that may affect the occurrence of disfluencies
- Linguistic contexts in which disfluencies occur
- Situational contexts in which disfluencies occur
- Overall speaking rate (i.e. number of words per minute of talking time)
- Articulatory speaking rate (i.e. number of syllables produced per second, with
pauses, hesitations and disfluencies removed)
- Response time latency (i.e. the pause between the end of the conversational
partners utterance and the beginning of the clients utterance)
3. Client factors
- Reaction to disfluencies or different speaking situations
- Attitudes and feelings about speaking, stuttering and self
- Avoidance of sounds, words or speaking situations.
4. Response to treatment
- Use of modification techniques
- Effect of modification techniques on speech disfluencies
- Naturalness of fluent speech

Speaking tasks and situations to measure the progress:

1. Conversational tasks
- Reading
- Describing a picture
- Speaking in a monologue
- Speaking in a conversational dialogue
- Speaking in a conversational dialogue with increased conversational pressures
- Retelling a story

2. Conversational settings
- In the clinic
- At home
- In the classroom (children)
- On the playground (children)
- In the work place (Adult)
3. Conversational partners
- Clinician
- Peers
- Parents (children)
- Siblings (children)
- Spouses (Adult)
- Co-workers (Adult)
How often to measure the therapy progress:
Frequency of measuring the stuttering depend on factors such as client’s stage in treatment
and the rate of change, and specific behaviour to measure. Thus, the clinician should develop
a flexible schedule in which some measures (e.g., frequency and type of disfluencies or use of
modification techniques) are made on a regular basis and other (e.g., speech attitudes or
linguistic contexts affecting fluency) are made on a less regular, but still consistent basis
based on the specific needs of the client.

Naturalness of speech can be defined as the speech output that sounds normal or natural to
the listener (Parish, 1951).The impetus for studying the speech naturalness of individuals
treated for stuttering came from observations that many people who had undergone
successful treatment continued to sound unnatural. Their speech was perceived as effortful,
uncomfortable to listen to and contained auditory or visual features that prevented the listener
from fully attending to the content of the message. Despite an otherwise successful treatment
experience, many speakers found that they were still unsatisfied with their speech and were
still regarded by others as having a problem. Tasko, McClean and Runyan, 2007 found, for
example that of 35 adults who reduced their stuttering severity during ass intensive fluency
shaping program (mean SSI-3 score reduction from 29 to 9.3), the speakers who showed the
greatest success in decreasing the severity of their stuttering were also determined to be the
most unnatural-sounding. Tasko et.al suggested that decreased naturalness ratings may have
resulted from the effort the successful participants had to put forth in order to execute the
behavioural therapeutic targets (e.g., increased abdominal breathing, continuity of airflow,
pre-voiced exhalation, easy articulatory and phonatory onset, and continuous phonation). The
authors also acknowledge that the increased inspiration and monitoring of speech movements
required of the speakers may have also contributed to decreased speech naturalness.

In 1984, Martin, Haroldson and Triden began the development of a reliable scale for rating
speech naturalness. The scale consisted of a 9-point Likert scale, with 1 equivalent to highly
natural sounding speech and 9 equivalent to highly unnatural sounding speech. This scale was
subsequently used in many investigations of speech naturalness. Martin et.al, found that mean
naturalness ratings for the speakers who stuttered was 6.52, while normally fluent adult
speakers averaged 2.12.

The naturalness of speech is recognised as an important consideration in determining the

success of treatment. The scale developed by Martin, Haroldson and Triden appears to be
reliable for either oral reading or spontaneous speech.

-----------------------------------------------ALL THE BEST------------------------------------------