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A Multidimensional Approach to the Assessment and
Treatment of School
-
Age Children Who Stutter


Part I

Kansas Speech and Hearing Association
Conference

September 29, 2012


E. Charles Healey, Ph.D
.

University of Nebraska
-
Lincoln

204 Barkley Memorial Center

Lincoln, NE 68583
-
0738

402
-
472
-
5459

chealey1@unl.edu

www.unl.edu
/fluency


A Conceptual Framework

For Stuttering
Assessment That Leads To Treatment


Stuttering is
a multidimensional
problem which
suggests that

m
any
factors can contribute to each
child’s stuttering in different ways, at different times,
with different communicative partners
.


An assessment should

be geared toward assessing
multiple aspects of the child, not just his or her
stuttering.


What we discover from the assessment can provide
some direction on what to address in treatment.

A Conceptual Framework for
Stuttering
Assessment and Treatment


Each child who stutters has a
unique set

of characteristics. No two
children are alike so an assessment should discover these
unique characteristics.


The
variability

of the disorder is one of its most striking features,
which means that improvements in speech might be slow.


Children who stutter
change

across time and the focus of their
treatment might need to change as well.


Many factors
have to be addressed and re
-
addressed in order for a
child to effectively manage his/her stuttering.


What
Standardized

Measures Are Available
For Assessing Stuttering in Children?

Stuttering
Severity Instrument 4
th
-

Edition

(SSI
-
4; Riley, 2009
)


The
Behavior Assessment Battery for School
-
Age Children
Who Stutter
(
Brutten

&
Vanryckeghem
, 2007
) Included is
the
Communication Attitudes Test (CAT)
.


Test
of Childhood Stuttering

(
Gillam
, Logan, & Pearson, 2009
)


Overall
Assessment of the Speaker's Experience of Stuttering
(OASES™)
by
Yaruss

and
Quesal

(2010)

What are we trying to accomplish in
the assessment?

1.
Establish and verify that a child has a fluency disorder

2.
Determine the severity of the disorder

3.
Determine the variability of the disorder across
different situations and settings

4.
Examine the emotional reactions a child has to
his/her stuttering

5.
Determine adverse effect on academics, social
-
emotional functioning, independent functioning and
overall communication.

6.
Use assessment data to plan treatment

What Measures Should We Obtain?

T
raditional measures of stuttering include the
frequency and duration of stuttering as well as
evidence of secondary coping behaviors.


We also need to examine thoughts, awareness,
understanding, feelings, attitudes, reactions,
and changes in stuttering based on what is said,
who it is said to, and in what situation.

Assessing awareness, knowledge, and understanding of
stuttering

Have the child:


Identify stuttering events while reading (% correct)


Identify stuttering events while speaking spontaneously (% correct)


Identify stuttering events produced from clinician model (% correct)



(Awareness and self
-
monitoring assessment)



Test a child’s

knowledge

of simple facts about stuttering (e.g.,
boy/girl ratio, % of people who stutter, causes of stuttering, etc.)



Test a child’s knowledge

and
understanding

of techniques or
strategies that have been used in therapy. How well do they know
and understand what they have been taught to do? And, does
he/she use those techniques? If not, why?

Assessing reactions, feelings, and attitudes
toward stuttering


• Determine level of
negative reaction
s the child might have as a result
of being a child who stutters. Ask “how often” they feel certain ways
(
e.g.,feel

bad about stuttering, being made fun of, talking to
someone you don’t know, etc.) on a rating of “never, a little,
sometimes, a lot, or always.


• How often are
emotional label
s tied to stuttering ( e.g., worried,
afraid, sad, mad, etc.) Use same ratings as above.


• Presence or absence of
negative attitudes

a child feels about talking
(Communication Attitudes. Simply yes or not questions like
:

I don’t
like the way I talk, I’m afraid to speak, I have a hard time saying my
name, talking is hard for me, mom and dad worry about how I talk,
etc.)

Assessing the impact of speech and
language skills on stuttering



Test the impact of increasingly complex linguistic speech tasks on stuttering
frequency.

Use

s
imple to complex speech contexts (Automatic speech, sentence repetition, picture
description, picture sequence, story retell, script narrative, expository narrative)


Stuttering is strongly linked to the length and complexity of the message (
Bernstein
Ratner

&
Sih
, 1987)



• Assess language function (formally or informally)

• Assess speech sound production ability (formally or informally)


Language and/or
a
rticulation disorders coexist with stuttering in about 1/3 of all
children who stutter

(Arndt & Healey, 2001)

Assessing specific aspects of the
stuttering behavior

Obtain measures of the:

• Types of
disfluencies

• Average number of units per repetition

• Tempo and regularity of repetitions

• Degree of struggle and effort

• Percentage of stuttering in spontaneous speech

• Percentage of stuttering in reading
(can also be used
to assess adaptation and consistency effects)

• Duration of a typical stuttering moment

• Presence of secondary coping behaviors

Assessing the social and situational
variability of stuttering


• Determine how often stuttering leads to
avoidance

of people
and words/events. Provide examples of people and
situations (teachers and peers

certain words, talking in a
group setting, etc.)


• Determine how frequently the child stutters with various
people and in various social situations



(how stuttering is impacted by the type of listener and speaking
situation
-
give examples)


• Determine how often stuttering affects
friendships

and
interactions with peers
.

0
1
2
3
4
5
Student #1
Student #2
Student #3
Student #4
Student #5
Student #6
A Multidimensional Approach to the Assessment and
Treatment of School
-
Age Children Who Stutter


Part II


E
. Charles Healey, Ph.D.


Bridging the Gap Between Assessment
and Treatment


An analysis of the data collected during
the assessment can produce a profile of
skills/deficits that can assist the clinician
in knowing where to focus attention in
treatment.



Treatment goals are accomplished by
developing activities that include
cognitive, affective, linguistic, motor, and
social factors as much as possible.


0
1
2
3
4
5
Example of Item Profile

Possible treatment Goals Relative to
the
S
ample Assessment Profile


Increase identification, awareness, and
understanding of fluency and stuttering.


Increase understanding of previously learned
speech strategies.


Decrease negative emotional reactions to and
attitudes toward stuttering and being a person
who stutters (Desensitization and stuttering
openly)





Treatment Goals (
con’t
)


• Increase management of stuttering through the use of the
“Big 5” strategies (easy onsets, light contacts, slowed rate,
pullouts, and cancellations)

• Increase self
-
management of stuttering through the
manipulation of linguistic length and complexity of
utterances.

• Learn self management skills

problem solving, self
monitoring and willingness to practice strategies outside of
therapy.

• Increase use of new speech skills in a variety of realistic
speaking situations.

Examples of Treatment Goals and Activities

Goal #1: Increase awareness and understanding of
stuttering


Activity 1
:
Explore and discuss the differences between normal fluency, normal


nonfluencies
,

little stutters and big stutters by using a piece of paper
divided

into 4 sections




Discuss
feelings

associated with each. Use voluntary stuttering that mirrors the
child’s stuttering pattern. Use
simple linguistic contexts
for this task.



Question for each category of speech,

1. What is happening with your air (breath), voice, tongue and lip movements?

2. How do you feel when you talk that way?

3. How hard to do have to think or work to speak when talking that way?

Treatment Activities for Goal #1 (continued)

Activity 2
:
Practice using
Voluntary Stuttering/
Pseudostuttering
--

learning
and feeling what it’s like to stutter on purpose without tension or
struggle. Can also help desensitize the child to the fear of stuttering or
covering it up.

Convey to the child that “Its OK to Stutter!” so let’s learn
about what you do when you stutter.



Identify stuttering moments
and learn what is happening when you stutter.
Learn to stutter
in different
ways (real
vs

faked and versions of each).



Discuss

feelings

that go along with the purposeful

stuttering
as well as the

speech changes (motor skills
)
that are taking
place between
real and
faked stuttering. Hold on to the stutter and

slowly
release it
.


Stutter purposefully with a variety of listeners
(Desensitization).


Treatment Activity for Goal #1 (continued)

Activity 3
:

Understand how the speech
mechanism works
-

focus on how physiology of
speech is impacted by thoughts and feelings.




a)
Diagram of speech system



normal

function


b)

Note which part of the system is

disrupted when negative

emotions


occur


c
)

How does the speech mechanism

function change when you feel

anxious, nervous, etc ? (with

certain people and/or

speaking

situations
)

Goal #2:
Decrease negative emotional reactions to and
attitudes toward stuttering and being a person who stutters
(Desensitization and stuttering openly)


Activity 1:

Use visual materials to represent
stutters and emotional
reactions


-
Develop a concrete representation of
stuttering through drawings. What
does the stuttering “look like to you?” (see next two slides)


-
Have
child

create clay or play dough figures of to represent stutters and
create a play dough “
stutter
monster.” Create play dough figures that
represent emotions that are attached to the “monster.”


-
Write word about a feeling or an emotion connected to stuttering on a
piece of paper. Toss paper at target to release feeling or emotion.


-
Could
also use clay representations of stuttering and related emotions
.






Activity #2:

Changing Negative Self Talk to Positive Self Talk

1.
People think I’m stupid because I
stutter.

2.
Nobody likes me because I stutter.

3.
I stutter so I must be doing
something wrong.

4.
I wish I could stop stuttering.

1.
I’m not stupid, stuttering is just
something I do.

2.
I have friends who don’t seem to
care that I stutter.

3.
Stuttering is not my fault and
there is nothing wrong with
me
.

4.
I am learning how to talk in an
easier way and sometimes what I
do doesn’t work but I’m still
trying.

Treatment Activity for Goal #2 (continued)

Goal #3: Strategies for Improving
Fluency/Modifying Stuttering

Activity 1:

Ways of making

talking easier
--
less
stuttered and/or more fluent



There are a few ways to make talking easier that
can reduce effort, force and tension as well as
improve timing, coordination, and rate of
speech


Ways to make talking easier

Five Key Strategies (The “Big 5”)


1. Easy onsets of phonation

2. Light
articulatory

contacts

3. Slowed speech rate through continuous phonation

4. Pullouts

5. Cancellations




Easy onsets”, “easy starts”, “easy voice”, “easy on” or “easing in



Two
ways to create an easy onset or easy start



emphasize increased airflow or gradual voicing onset




(
e.g.,
hhhheeeeach

or
eeeeeach
)



Draw a “hill or mountain” to represent breathing & voice pattern








h

h

h

h

e
a
s
y
h

h

h

e
a
s
y
h

h

e
a
s
y
e
a
s
y
Ways to make talking easier


Light Contacts, Pullouts, Cancellations to Reduce Effort/Tension:



a. Use light contacts to reduce tension and effort during
sound placement

lighten contact by using more airflow
during the contact



b
. Pullout or “ease out” of a stutter



c
.
Cancel

a stutter slowly and easily and then
change

to make
the next attempt less stuttered or fluent.



d
. Rate any muscle tension during stuttering on a scale of 1
-
10



Ways to make talking easier

Reduce rate and transitions between words
:


a. prolonged method or “stretched speech”
(Onslow et al., 1996)



b
. pause and stretch short phrases to reduce
overall pace of a verbal interaction.


** Set up practice of specific strategies outside
of therapy to facilitate generalization with
other listeners
--
keep it simple


Learn self management skills

problem solving, self monitoring
and willingness to practice strategies outside of therapy.

• Strategies are a plan for improvement

• Have to be used voluntarily

• Client must be aware of what to do and have
confidence strategies will work

• Client has to think about them and learn them

• Fluency clients might develop only limited use
or skill given the level of stuttering and motor
stability

Six Steps in Developing Self Regulated
Strategies
(Reid &
Lienemann
, 2006)

1.
Develop and define the skills needed.

2.
Discuss the strategy: “Sell it” and have client
“buy in”

3.
Model the strategy: See the “expert” do it.


Knows what to do, why it is being used, how to do it,
recognize they know that they are doing it, and what
needs to happen to keep it going

4.
Have child memorize the strategy

5.
Support the strategy

shift responsibility for use
of strategy to the client, decrease prompting

6.
Develop independent performance


Goal #4: Increase self
-
management of stuttering through the
manipulation of linguistic length and complexity of
utterances.

Activity:

Manipulating the length and complexity of
responses while using selected speech strategies.




-

Begin with
contextualized

materials concerning a theme
or topic the child enjoys talking about. Information can be
found on the internet and/or the child can bring
information to therapy that is familiar to him or her.



Materials Include:


• pictures



• drawings



• written materials of any kind







Suggested linguistic complexity sequence
coupled with strategy use




1. Labeling and short description of terms. Oral reading first then
repeat content using eye contact with listener



2. Longer description of terms and concepts
-

some from
material/some from personal experience.



3. Use questions that require an inference or an interpretation of
information.



4. Story telling that is scripted



5. Unscripted story telling or topic discussion that is
decontextualized
.


Examples of linguistic complexity sequence coupled
with strategy use

Topic is Baseball

Labeling


--
pitcher, catcher, first baseman, second
baseman, home plate, foul lines, outfield, etc.

Short Description


--

Double play
: when two outs are made before 2
runners reach base.


--

Slide
: when a player slides on the ground to
touch the base.




Examples of linguistic complexity sequence coupled
with strategy use

Topic is Baseball

Longer descriptions and concepts

--

Tell me three ways a “strike” can occur
. (client repeats
all three ways listed below)


a. the batter swings and misses the pitch


b
. the batter hits the fall foul
(
outside the lines of first
and third base).



c
. the batter tips the ball and it’s caught by the catcher.

--
What is an “inning?”


The part of the game when on team bats and has three
outs and the other teams bats and has three outs. The
bottom of the inning is always given to the home team.

Examples of linguistic complexity sequence coupled with strategy
use

Topic is Baseball

Inference and Interpretation


--

Why is it difficult for pitchers to get strikeouts?



--

If there is a runner on first base and the batter hits the ball on the ground,
what might happen next?


--

What happens when a runner tries to steal a base?


Scripted story telling



--

read short stories about baseball or professional base ball players and have
the child retell the story.


Unscripted story telling/Conversation



--

Have child tell personal story about a baseball game that he played in or
attended as a fan.





--

Have a conversation about baseball or something that happened recently
in the news about baseball.


Picture Description

C

“Tell me
what you are thinking

about before you say the first
phrase
.”

A

“Tell me
how you are feeling

before
or during the time you say
something about the picture.”

L


What you are going to say
?”
(How
long and complex is it?)

M


How are you going to say it
? Use

a
strategy when
you tell me about
the picture.”

S

Who are you talking to
? (Client talks
to clinician, another person in
therapy or take home to parents)


Treatment example of how the linguistic context can
be used to support cognitive, affective, motor, and
social domains

SPEECH MATERIAL



1. Baseball is a game that is played on a field
shaped like a diamond.



2. The long boundary lines of the field go from
home plate in a line to the first and third base
sides of the field.



3. A foul ball occurs when the the ball is hit
outside of the lines of the playing field.



4. The object of the game is to get more
runners to cross home plate than the other
team during a nine inning game.




5. All the players sit in dugouts while their
team is at bat. Everyone sits in the dugout
while one person bats and another player gets
ready to become the next hitter.


CLINICIAN FOCUSES ON:


Selection of 1, 2, or 3 strategies to
practice

even include some voluntary
stuttering.


What is the child going to use and does he
understand how and why the strategy
works?


If there there is any emotional or physical
tension present before or during speech
practice?


Monitoring

performance and wait for a
couple of seconds to give feedback. How
did that feel? How did that work? What
changed? What didn’t change?


Having child rate performance on a scale
of 1
-
5.


Having child read the phrases and then
say phrases using eye contact with
clinician. Say it again to another listener (if
possible)


Have child make comments or answer
questions about the topic so that it is
more difficult and challenging.


What types of data do I need to
collect to
document outcomes?

Documenting progress (or lack thereof) in treatment
involves both
quantitative

and
qualitative

measures.
Use a portfolio approach to documenting changes
.



Not all goals or processes achieved in therapy have to
be quantified.
Qualitative

data such as:


1) comments from the child, parents, or teachers, 2)
drawings, diagrams, and a transcript of explanations
of concepts that relate to any cognitive, affective,
motor, or social component being treated.

Quantitative Measures


• Reductions in stuttering frequency and severity (% of stuttered
words or syllables and improvements in SSI
-
4
score)

• Speech rate within normal limits (conversational or narrative
speech rates for children 7
-
11 ranges from 110
-
190 syllables
per minutes).

• Naturalness of speech (rated on a scale of 1
-
9; 1= highly
natural and 9=highly unnatural).


Improvements in cognitive, affective, linguistic, and social
measures obtained during the assessment, using objective
data across multiple occasions to show change

Concluding
Thoughts

• Approach therapy as a dynamic,
multidimensional process. Many
factors interact to maintain the
disorder and multiple factors need to
be addressed in therapy
. Consider
therapy as a journey not a
destination.



Use a multidimensional assessment
that includes more than just a
measure of stuttering in order to
tailor
the therapy to the needs of the
child.

• Children who stutter need to see that
they should not hide from their
stuttering, that it’s OK to stutter, and
with time and a little work, they can
learn to talk in an easier way.


References



Arndt, J. & Healey, E.C. (2001). Concomitant disorders in school
-
age children who stutter.


Language, Speech, Hearing Services in Schools, 32
, 68
-
78.


Bernstein
Ratner
, N. &
Sih
, C. (1987). Effects of gradual increases in sentence length and complexity on
children’s
dysfluency
.
Journal of Language Speech and Hearing Disorders, 52
, 278
-
287.



Bloodstein
, O. & Bernstein
Ratner
, N. (2008).
A handbook on stuttering. 6
th

Ed.
Clifton Park, NY: Delmar
Learning.


Bothe, A. K.,
Davidow
, J. H.,
Bramlett
, R. E., & Ingham, R. J. (2006). Stuttering treatment research 1970
-
2005: I.
Systematic review of incorporating trial quality assessment of behavioral, cognitive, and related
approaches.
American Journal of Speech
-
Language Pathology
,
15

(4), 321
-
341.



Brutten
, G. and
Vanryckeghem
, M. (2007).
Behavior Assessment Battery for School
-
Age Children Who


Stutter
. San Diego, CA: Plural Publishing.




Healey, E.C., Scott
Trautman
, L., and
Susca
, M. (2004). Clinical applications of a



multidimensional model for the assessment and treatment of stuttering. Special Issue on


fluency disorders in
Contemporary Issues in Communication Disorders, 31, 40
-
48.




Healey, E.C., Scott
Trautman
, L. &
Panico
, J. (2001). A model for manipulating linguistic


complexity in stuttering therapy.
International Stuttering Awareness Day Online


Conference
, Mankato State University, Mankato, MN.








References

Ingham, J. and Riley, G. (1998). Guidelines for documentation of treatment efficacy for young


children who stutter.
Journal of Speech
-
Language
-
Hearing Research. 41
, 753
-
770.



Manning, W. H. (2010).
Clinical decision making in fluency disorders
. Clifton Park, NY: Delmar,
Cengage

Learning.


Maas, E., Robin, D., Hula, S, Freedman, S,
Wulf
, G, Ballard, K, & Schmidt (2008). Principles of motor learning in
treatment of motor speech disorders.
American Journal of Speech
-
Language Pathology, 17
, 277
-
298.


Onslow, M., Costa, L., Andrews, C., Harrison, E., & Packman, A. (1996). Speech outcomes of a prolonged
-
speech
treatment for stuttering.
Journal of Speech and Hearing Research, 39
, 734
-
749.



Reid, R. &
Lienemann
, T. O.


(2006).


Strategy instruction for students with learning disabilities.


New York:
Guildford.


Smith, A. (1999). Stuttering: A unified approach to a
multifactorial
, dynamic disorder. In N.
Ratner

and E. C.
Healey (Eds.)
Stuttering research and practice: Bridging the gap.

Mahwah, New Jersey,
Lawerance

Earlbaum

Associates, Publishers.



Starkweather
, C. W. & Givens
-
Ackerman, J. (1997
) Stuttering.

Austin, TX: PRO
-
ED, Inc.



Yairi
, E. &
Seery
, C. (2011). Stuttering: foundations and clinical applications. Upper Saddle River, NJ: Pearson.


Internet Resources


Major resource and links to other websites about stuttering:



Stuttering information for professionals and consumers

www.stutteringhomepage.com


Stuttering Foundation of America:

www.stuttersfa.org


National Stuttering Association

www.westutter.org



UNL Fluency Center

www.unl.edu/fluency