Enhancing treatment for school-age children who stutter I. Reducing negative reactions through desensitization and cognitive restructuring

This paper describes several treatment strategies that clinicians can use to address negative affective, behavioral, and cognitive reactions that school-age children who stutter may experience as part of their disorder. Specific strategies include desensitization to stuttering, cognitive restructuring, self-acceptance, purposeful self-disclosure, and a combination of both fluency enhancing and stuttering modification approaches. To facilitate clinicians' application of these techniques, the strategies are presented in the context of a case study involving a 9-year-old boy who participated in a comprehensive treatment program for stuttering. Following treatment, the child exhibited improved communication attitudes and a reduced frequency and severity of stuttering, combined with reduced concern about stuttering, as indicated through formal and informal assessments. Findings suggest that clinicians can help children overcome the negative reactions associated with stuttering through a number of treatment strategies that can be applied in a variety of clinical settings. Educational objectives: After reading this article, participants will be able to: (1) define desensitization and cognitive restructuring and provide two arguments in favor of using these strategies in treatment for school-age children who stutter; (2) describe two treatment strategies for helping school-age children achieve desensitization through stuttering therapy; (3) describe two treatment strategies for helping school-age children engage in cognitive restructuring in the context of therapy.     

Parent perceptions of an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering

PurposeRecent research has identified approximately half of children who stutter present with self-regulation challenges. These manifest in elevated inattentive and/or impulsive behaviours, aligned with attention deficit hyperactivity disorder (ADHD) symptoms. These symptoms have been found to influence the child’s responsiveness to their stuttering treatment, and may exacerbate the psychosocial consequences of stuttering for them and their families. Early stuttering intervention identifies parents as key agents of change in the management of their children’s stuttering. This study sought feedback from parents regarding their experiences with an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering, addressing the child’s self-regulation challenges.MethodEight parents of children who stutter who had co-occurring self-regulation challenges completed the integrated program. This incorporated the Triple P--Positive Parenting Program adapted for the developmental stuttering population, and the Curtin University Stuttering Program (CUSP). Semi-structured qualitative interviews were conducted to capture parents’ reflections on, and experiences with, the integrated program.ResultsThematic analysis identified several major themes regarding the parents’ experiences with the integrated program: emotional impact on parents, child self-regulation, link between stuttering and behaviour, parent self-regulation, impact on family dynamics, and overall positive perceptions of the integrated program. All of the parents indicated they would recommend the program to future parents of children who stutter.ConclusionThis study provides insights into parents’ perceptions regarding an integrated intervention approach for early stuttering and behavior management. It also indicates how adopting a holistic approach to stuttering intervention is positive and has social validity.     

Enhancing treatment for school-age children who stutter II. Reducing bullying through role-playing and self-disclosure

This paper describes several treatment strategies that clinicians can use to help children who stutter who are experiencing bullying and other negative reactions from their peers. Specific strategies include problem-solving activities designed to help the child develop appropriate responses to bullying and a classroom presentation designed to educate peers about stuttering. To facilitate clinicians' application of these techniques, the strategies are presented in the context of a case study involving a 9-year-old boy who participated in a comprehensive treatment program for stuttering. Following treatment, the child exhibited an increased ability to respond to bullying experiences in a constructive fashion. In addition, negative comments by the child's peers diminished following the classroom presentation. Findings suggest that clinicians can help children overcome bullying and other negative reactions associated with stuttering through a number of well-supported treatment strategies that can be applied in a variety of clinical settings. Educational objectives: After reading this article, participants will be able to: (1) define bullying and teasing and explain the difference between the two experiences; (2) describe two strategies for helping children who stutter successfully manage bullying experiences at school and in other settings; and (3) explain two strategies for educating children about stuttering and about bullying.     

Coordinated interpersonal timing in the conversations of children who stutter and their mothers and fathers

Coordinated interpersonal timing (CIT) is a measure of "conversational congruence," or "attunement," and refers to the degree to which the temporal aspects of the vocal behaviors of co-conversationalists are correlated over the course of a conversation [Jasnow, M., & Feldstein, S. (1986). Adult-like temporal characteristics of mother-infant vocal interaction. Child Development, 57, 754-761]. In the present study, CIT was examined in a group of children who stutter (CWS), and a matched group of nonstuttering children (CWDNS; children who do not stutter), during conversations with either their mother or father recorded in two separate sessions (i.e., mother-child, father-child). Separate audio signals for both the child and parent (mother or father) were analyzed using AVTA software, which allowed for the quantification of sound and silence patterns in simultaneous speech. Squared cross-correlations (i.e., coefficients of CIT) for the durations of five vocal behavior states were obtained for each subject, through time series regression analysis using lag procedures. Vocal state behaviors within conversational turns included: vocalization, pauses, turn switching pauses, and interruptive and noninterruptive simultaneous speech. Results indicated that CWS and their parents showed mutual influence (i.e., CIT in both directions, child to parent and parent to child, or bi-directional influence) for more vocal state behaviors than did CWDNS and their parents. In addition, the CWS exhibited CIT with their parents for the durations of more vocal state behaviors than did the CWDNS (i.e., unidirectional influence). Findings suggest that children who stutter may be more easily influenced by the subtle timing aspects of conversation. Taken further, some of these children may perceive conversations with their parents as either challenging or difficult because of an element of unpredictability brought into conversations by the production of stuttering, the social skills of the child, and the nature of the parent-child relationship. Consequently, these children may be engaging in more pervasive coordination of the temporal characteristics of their speech to those of their conversational partner, as a mechanism by which to more effectively manage verbal interaction. EDUCATIONAL OBJECTIVES: After reading this paper, the learner will be able to: (1) describe the phenomenon of coordinated interpersonal timing (CIT); (2) summarize research findings in CIT as they apply to the verbal interactions of children and their parents; (3) summarize research findings in parent-stuttering child interaction, especially those related to the temporal aspects of both parent and child conversational speech, and (4) discuss the applicability of the findings from the present study to the treatment of childhood stuttering.     

Evidence-based treatment of stuttering: II. Clinical significance of behavioral stuttering treatments

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.     

Perspectives of stuttering treatment: Children,adolescents, and parents

PurposeResearchers investigated whether children who stutter (CWS), adolescents who stutter (ADWS), and their parents preferred treatment focused on changing speech or communicating regardless of stuttering.MethodsTwenty-four parents and their CWS (n = 11, ages 8;0–12;11) or ADWS (n = 13, ages 13;0–17;11) answered questions about their preferences for stuttering treatment via an internet-based survey; an additional 11 surveys were filled in only by parents without responses by their child/adolescent. The researchers compared responses of the parents and their children, as well as between the two age groups and years in treatment (less than five years versus five or more years).ResultsViews tended to be mixed without any clear trends based on age. Just over half of the CWS, ADWS, and parents of CWS indicated a general tendency for therapy satisfaction; however, less years of treatment were associated with more satisfaction. When presented with a specific scenario, a higher proportion of parents expressed focus on their child saying what they want to say, regardless of stuttering. Otherwise, preferences were mixed on therapy goals of speaking freely vs. speaking more fluently.ConclusionsPreferences for treatment goals do not predictably vary based on age or years in treatment; given the small sample size, these findings should be considered with caution. Given the variability in responses, it is evident that stuttering treatment for school-age children and adolescents should be individualized. These results also emphasize the importance of communication, education, and applying a person-centered approach when providing stuttering intervention to children, adolescents, and their parents.     

An experimental treatment using verbal punishment with two preschool stutterers

A multiple base-line experimental treatment was conducted with two preschool stuttering children. Each child conversed 20 min with the experimenter for 20 sessions. Treatment consisted of the presentation of the verbal stimulus “slow down” contingent upon a stuttering response. The percentage of words stuttered by both children decreased during the treatment sessions. Probe tape recordings conducted in each child's home revealed a decrease in stuttering frequency.     

A component model for diagnosing and treating children who stutter

Nine components of stuttering and their distribution among 54 children who stutter are described. The components are arranged into a model that includes four neurologic components (attending disorder, auditory-processing disorder, sentence-formulation disorder, and oral-motor disorder) and five traditional components (high self-expectations, manipulative stuttering, disruptive communication environment, unrealistic parental expectations, and abnormal parental need for the child to stutter). Diagnostic and treatment usefulness of the model are discussed. Thirty-two of the children have been followed through component-based treatment and 12 mo post termination. Results indicate that treatment was successful with 27 (84%) of the 32 children. Only one child regressed during the 12 mo after treatment ended. These results suggest that treating the neurologic and traditional factors which disrupt fluency improves maintenance and carry-over.     

Stuttering treatment for a school-age child with Down syndrome: A descriptive case report

BackgroundLittle is known about optimal treatment approaches and stuttering treatment outcomes for children with Down syndrome.Aims and methodThe purpose of this study was to investigate outcomes for a child with Down syndrome who received a combination of fluency shaping therapy and parent delivered contingencies for normally fluent speech, prolonged speech, and stuttered speech.ResultsIn-clinic speech measures obtained at post-treatment and at 4 months follow-up reflected improvements in fluency of 89.0% and 98.6%, respectively. The participant's beyond-clinic follow-up sample reflected an improvement of 95.5%. Following treatment, the participant demonstrated improved self-confidence, self-esteem, and improved participation and functioning at school.ConclusionsFindings suggest that fluency shaping with parental contingencies may be a viable treatment approach to reduce stuttering in children with Down syndrome. Future research using an experimental research design is warranted.Educational objectives: Readers will be able to describe (a) prevalence estimates of stuttering in individuals with Down syndrome, (b) the main components of a fluency shaping program for a child with Down syndrome who stutters and has co-occurring speech and language delays, and (c) speech and parent-, teacher-, and self-report treatment outcomes.     

Childhood stuttering and speech disfluencies in relation to children's mean length of utterance: a preliminary study

The purpose of this study was to examine the influence of utterance length and complexity relative to the children's mean length of utterance (MLU) on stuttering-like disfluencies (SLDs) for children who stutter (CWS) and nonstuttering-like disfluencies (nonSLDs) for children who do not stutter (CWNS). Participants were 12 (3;1-5;11, years;months) children: 6 CWS and 6 age-matched (+/-5 months) CWNS, with equal numbers in each talker group (CWS and CWNS) exhibiting MLU from the lower to the upper end of normal limits. Data were based on audio-video recordings of each child in two separate settings (i.e., home and laboratory) during loosely structured, 30-min parent-child conversational interactions and analyzed in terms of each participant's utterance length, MLU, frequency and type of speech disfluency. Results indicate that utterances above children's MLU are more apt to be stuttered or disfluent and that both stuttering-like as well as nonstuttering-like disfluencies are most apt to occur on utterances that are both long and complex. Findings were taken to support the hypothesis that the relative "match" or "mismatch" between linguistic components of an utterance (i.e., utterance length and complexity) and a child's language proficiency (i.e., MLU) influences the frequency of the child's stuttering/speech disfluency. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to: (1) compare different procedures for assessing the relationship among stuttering, length and complexity of utterance, (2) describe the difference between relative and absolute measures of utterance length, (3) discuss the measurement and value of mean length of utterance and its possible contributions to childhood stuttering, and (4) describe how length and complexity influence nonstuttering-like disfluencies of children who stutter as well as the stuttering-like disfluencies of children who do not stutter.     

Zones of Proximal Emotional Development — Psychotherapy Within a Neuroaffective Perspective

This article outlines a conceptual framework for assessing personal and emotional functions of a person’s zone of proximal emotional development. The framework is based on the integrative theory Neuroaffective Developmental Psychology (NADP), which brings together attachment theory, neuropsychology, developmental psychology, and trauma theory. Within the NADP framework, this article describes a way of understanding children’s normal emotional mental organization and of examining how this mental organization may be developed or disturbed by relational issues. It also describes how a child’s mental organization can be disturbed and thus, without intervention, disturb the child’s personality development on a lifelong basis. The article presents three case vignettes, describing three children growing into adolescence with three different attachment patterns and suggested individually tailored intervention plans for each of them, relevant and useful for clinicians working with vulnerable children and families. Because the nervous system retains its plasticity throughout life, attachment is not necessarily an unchangeable pattern. That is why we as clinicians should develop psychotherapeutic methods and a research-based way of determining “what works for whom” by assessing the zone of individual proximal emotional development. The text outlines the characteristics of NADP and how it can be used to structure an intervention plan.     

Group play therapy for Japanese children who stutter

Twenty-one sessions of group play therapy were conducted with children who stutter in order to improve their stuttering and to promote their development in social adaptation. Follow-up surveys were made 6 mo and 5 yr after therapy.As therapy progressed, a definite process of change was observed in each child, from periods of anxiety, appearance of aggressive behavior, frequent occurence of aggressive behavior, to a decrease in aggressive behavior. After the appearance of aggressive behavior, a fluctuation in stuttering occured as cooperative play with other children was established. This was followed by a decrease in stuttering. The appearance of aggressive behavior during therapy is thought to be of major significance for the disappearance of stuttering and for interpersonal relationships.A follow-up survey showed that both stuttering and social adjustment had improved, indicating the effectiveness of therapy.     

Elevated attention deficit hyperactivity disorder symptoms in children who stutter

PurposeThis study described the proportion of children who stutter who exhibit Attention Deficit Hyperactivity Disorder (ADHD) symptoms, manifesting in inattentive and hyperactive/impulsive behaviours. Children who stutter with these challenging behaviours may not respond as quickly and successfully to stuttering treatment. A preliminary exploration of differences in treatment responsiveness for children with and without ADHD symptoms was undertaken.MethodParticipants were 185 preschool children who stutter who had completed stuttering therapy within 3 months prior to study commencement. Differences between groups of children who stutter with and without elevated ADHD symptoms were investigated, in terms of pre-treatment stuttering features (stuttering severity and typography), demographic variables (age at onset, time between onset and commencement of therapy, family history and sex) and treatment data (post-treatment stuttering severity and number of sessions to achieve discharge criteria).ResultsOne-half (50%) of participants exhibited elevated ADHD symptoms. These children required 25% more clinical intervention time to achieve successful fluency outcomes than children without elevated ADHD symptoms. Findings suggest that more ADHD symptoms, increased pre-treatment stuttering severity, and male sex were associated with poorer responsiveness to stuttering treatment.ConclusionThe large proportion of children exhibiting elevated ADHD symptoms, and the increase in clinical contact time required in this subgroup to achieve successful fluency outcomes, is suggestive of the need for clinicians to tailor stuttering intervention to address these concomitant behaviour challenges. Findings support the use of careful caseload management strategies to account for individual differences between children, and strengthen prognostic information available to parents and clinicians.     

Applicability of the Impact on Family Scale for assessing families with behaviorally difficult children.

The present paper reports a series of studies on the potential usefulness of the Stein and Riessman Impact on Family Scale for assessing the effects of behaviorally difficult children on their families. Subjects were parents of 54 clinic and 76 nonclinic children who completed a child behavior or child temperament questionnaire in addition to the Impact on Family Scale. Findings suggest that, while the scale was developed for assessing the influence of a physically ill child on the family, this general assessment approach may also have value in assessing family-related changes associated with having a child who is difficult to look after.     

Bilingual children who stutter: Convergence,gaps and directions for research

PurposeThe aim of this systematic review is to examine the early interactions between bilingualism and stuttering to synthesize knowledge that could inform diagnosis and treatment for bilingual children who stutter.MethodScopus, Science Direct, PubMed, ERIC Ebsco, and Google Scholar were searched with no limits placed on the year of publication. Search terms consisted of: (“stuttering” [MeSH] OR “stutter”) AND (“child” [MeSH] OR “children”) AND (“multilingualism” [MeSH] OR “bilingualism”). Inclusion criteria were children who stutter, bilinguals who stutter, empirical research articles, and published in peer review journals. Exclusion criteria were studies that reported on only adults, only monolinguals, or were not published in English.ResultsA total of 50 articles met the criteria. There was convergence with monolingual studies reporting sexually dimorphic and familial trends in the prevalence of stuttering and rates of recovery. Findings surrounding language proficiency, cross-linguistic stuttering severity, and development were ambivalent. Results point to the difficulty in identifying stuttering in bilingual children, and the need for culturally competent research and interpretations.ConclusionCurrent findings offer a fragmented view of bilingual development and echoes a recurring theme, i.e., the current understanding of bilingualism and stuttering is limited and more research is warranted.     

Disfluency data of German preschool children who stutter and comparison children

This study compared the disfluencies of German-speaking preschool children who stutter (CWS, N = 24) with those produced by age- and sex-matched comparison children who do not stutter (CWNS, N = 24). In accordance with Yairi and Ambrose's [Yairi, E., & Ambrose, N. (1992). A longitudinal study of stuttering in children: A preliminary report. Journal of Speech and Hearing Research, 35, 755-760] guidelines the CWS group had a narrow age range (2-5 years) and were seen close to the reported time of their stuttering onset (average of 8 months). Furthermore, over 95% of the CWS group had not received any type of speech therapy intervention. Consistent with previous findings for English-speaking preschool children, 'stuttering-like' disfluencies (prolongations, blocks, part- and one-syllable word repetitions) were significantly more frequent in CWS (mean = 9.2%) than in CWNS (mean = 1.2%), whereas no significant group differences occurred with respect to 'normal' disfluencies. The number of iterations in stuttering-like disfluencies was also significantly higher in CWS (mean = 1.28 iterations) than in CWNS (mean = 1.09 iterations). In contrast to previous findings, a sub-group of children who have been stuttering for a shorter time (1-5 months) did not differ from a sub-group who had stuttered for a longer period (8-22 months). EDUCATIONAL OBJECTIVES: The reader will be able to: (1) describe how German-speaking preschool children who stutter and who do not stutter display stuttering-like and normal disfluencies including number of iterations; (2) explain how powerful classification measures for the diagnosis of stuttering are for German-speaking preschool children; (3) discuss how disfluency patterns of native English- and German-speaking children close to onset of stuttering differ.     

The association between stuttering, Brown''s factors, and phonological categories in child stutterers ranging in age between 2 and 12 years

Though the phonological difficulty of a word might reasonably be supposed to influence whether a word is stuttered, it has recently been reported that the incidence of stuttering does not depend on this factor in child stutterers. This conclusion is reexamined in the current report. Data are employed that were obtained from groups of child stutterers (and their controls) who vary in age and severity of their disorder. First, it is shown that the measure of phonological difficulty reveals differences in phonological ability for children of different ages (stutterers and fluent controls). The properties of words with regard to whether they are function words or content words, their position in the sentence, their length, and the phoneme that they start with vary between phonological categories (referred to as “Brown's factors”). Since these factors could influence whether words are stuttered in their own right, they may led to apparent differences in stuttering between words in different phonological categories that are spurious. Alternatively, these factors may disguise influences that phonological categories have on stuttering. It is shown in the next analysis that the words in the various phonological categories differ with regard to Brown's factors. In the final analysis, the proportion of words stuttered for words in each phonological category are analyzed so that any influence Brown's factors might have are removed by treating the factors as covariates. No dependence of stuttering on phonological category is observed for age group, stutterer's severity, or word types (stuttered word or word following the stuttered word). Thus, phonological difficulty as measured here and elsewhere does not appear to be a major factor governing the incidence of stuttering in children.     

Dual Diathesis-Stressor Model of Emotional and Linguistic Contributions to Developmental Stuttering

This study assessed emotional and speech-language contributions to childhood stuttering. A dual diathesis-stressor framework guided this study, in which both linguistic requirements and skills, and emotion and its regulation, are hypothesized to contribute to stuttering. The language diathesis consists of expressive and receptive language skills. The emotion diathesis consists of proclivities to emotional reactivity and regulation of emotion, and the emotion stressor consists of experimentally manipulated emotional inductions prior to narrative speaking tasks. Preschool-age children who do and do not stutter were exposed to three emotion-producing overheard conversations—neutral, positive, and angry. Emotion and emotion-regulatory behaviors were coded while participants listened to each conversation and while telling a story after each overheard conversation. Instances of stuttering during each story were counted. Although there was no main effect of conversation type, results indicated that stuttering in preschool-age children is influenced by emotion and language diatheses, as well as coping strategies and situational emotional stressors. Findings support the dual diathesis-stressor model of stuttering.     

Primary-school stutterers: Have attitudes changed?

How concerned are primary-school-aged stuttering children about their communication problem? What are the clinical implications of this concern?Fifteen years ago, Silverman (1970) suggested that primary-school-aged children who stuttered were not concerned about their disfluencies. A clinical implication of that report was that the interpreted lack of concern might negatively affect the children's motivation and desire for change in therapy. Scant research exists to support or refute this implication. While research is available on reactions to stuttering, pretherapeutic attitudes—especially those of children—have not been systematically reported. Guitar (1976) measured the pre-treatment attitudes of 38 adult stutterers and reported that, “those stutterers with more negative attitudes measured just prior to treatment, were most likely to have high levels of stuttering a year later, even though all subjects left therapy entirely fluent.” In related areas, research by Kolb, Winter, and Berlen (1968), McFall (1970), and McFall and Hammen (1971) has indicated that clients who are more motivated do better in behavior modification programs.Whether or not these findings may be generalized to children, in the midst of a developmental process, is purely speculative.