Fluency Disorders: Stuttering, Cluttering, and Related Fluency Problems [2 ed.] 1635501474, 9781635501476

Table of contents :
Preface
Acknowledgments
Reviewers
Section I. Foundational Concepts
1. An Introduction to Fluency Disorders
Chapter Objectives
Introduction
Speech Fluency Versus Language Fluency
Fluency as an Integral Component of Social and Communicative Functioning
Fluency in the Context of Speech-Language Pathology
Speech-Language Pathology as a Profession
Developing a Framework for Clinical Practice
Fluency in the Context of Service Delivery Domains
Fluency in the Context of Professional Practice
Viewing Fluency as a Component of an Individual?s Health Functioning
Functioning, Performance, and Capacity
Activities and Activity Limitations
Participation and Participation Restrictions
Impairment and Disability
Environmental and Personal Factors
Facilitators and Barriers
Fluency Disorders: A First Look
The Concept of Disorder
Stuttered Speech
Cluttered Speech
Providing Clinical Services to People Who Have Fluency Concerns
The Rewards of Being a Fluency Clinician
Developing the Necessary Knowledge
Developing the Necessary Skills
Developing Competencies for Interprofessional Practice
Engaging in Evidence-Based Practice
Establishing Effective and Valued Working Relationships With Clients
Summary
Questions to Consider
2. Conceptualizing Fluency
Chapter Objectives
Context and Historical Perspective
Fluency: A Multidimensional Construct
The Dimensions of Fluency
Fluency Dimensions: Speech Continuity
Fluency Dimensions: Rate and Rhythm
Fluency Dimensions: Effort and Naturalness
Fluency Dimensions: Talkativeness
Fluency Dimensions: Stability
Organizing Fluency Dimensions Into a Clinical Model of Fluency
Fluency in the Content of a Speech Production Model
Modeling the Speech Production Process
Conceptualizing a Message
Transforming a Preverbal Concept Into a Corresponding Linguistic Form
Transforming Linguistic Representations to Articulatory Movements
Summary
Questions to Consider
3. Conceptualizing Disfluency
Chapter Objectives
Defining Disfluency
Identifying Disfluent Segments
The Structure of Disfluency
The Moment of Interruption
The Reparandum
The Original Utterance
The Editing Phase
The Repair Phase
Labeling Disfluency
Characteristics of Common Disfluency Types
Revisions
Pauses
Interjections
Repetitions
Prolonging and Blocking
Variations in Disfluency Form
Variations in the Editing Phase
Variations in the Repair Phase
Nested Errors
Repetition of Final Segments in Words and Utterances
Limitations of Disfluency Labeling Systems
Limitation 1: Lack of Standard Terminology
Limitation 2: Lack of Comprehensive Terminology
Limitation 3: Inconsistent Relationship Between Labels and Structure
Limitation 4: Continued Dependence on Listener-Based Judgments
Summary
Questions to Consider
4. Speech Fluency in Typical Speakers
Chapter Objectives
Characteristics of Typical Fluency
Quantitative and Qualitative Perspectives on Fluency
Speech Continuity in Typical Speakers
Disfluency Frequency in Children With Typical Fluency
Disfluency Frequency During Adulthood
Types of Disfluency
Context Effects: Where Does Disfluency Occur?
Utterance Locations That Are Prone to Disfluency
Syntactic Forms That Are Prone to Disfluency
Speaking Tasks That Elicit Disfluency
Is It Typical for Young Children to Be Highly Disfluent?
Rate in Typical Speakers
Articulation Rate
Speech Rate
Rhythm in Typical Speakers
Disfluency Duration
Effort in Typical Speakers
Perspectives on Effort
Naturalness in Typical Speakers
Talkativeness in Typical Speakers
Talkativeness in Relation to Conversational Participation
Talkativeness in Relationship to Communicative Functions
Stability of Fluency in Typical Speakers
Summary
Questions to Consider
Section II. Neurodevelopmental Stuttering
5. Stuttering: Characteristics and Etiology
Chapter Objectives
Terminology
Historical Perspective
Defining Stuttering
Early Attempts to Define Stuttering
Contemporary Definitions
Characteristics of Stuttered Speech
Continuity Characteristics of Stuttered Speech
Rate and Rhythm Characteristics
Effort and Awareness
Compensation and Concealment Strategies
Performance Variability
Effects of Speaking Task, Setting, and Conversational Partners on Speech Fluency
Effects of Linguistic Complexity on Speech Fluency
Summary
Questions to Consider
6. Stuttering: Correlates and Consequences
Chapter Objectives
Historical Perspective
Correlates of Stuttering
Genetic Correlates of Stuttering
Approaches to Researching Genetic Factors
Neuroanatomical Correlates of Stuttering
Gray Matter Volume and Hemispheric Asymmetry
White Matter Integrity
Neurophysiological Correlates
Early Studies of Brain Activation and Hemispheric Dominance for Language
Electroencephalography (EEG) Findings
Neuroimaging Findings
Motor Correlates of Stuttering
Manual Movements
Reaction Time and Speech Initiation
Speech Motor Coordination and Movement Control
Motor Learning
Linguistic and Cognitive Correlates
Syllable, Word, and Utterance Properties That Precipitate Stuttering-Related Disfluency
Effects of Syntactic and Phonologic Complexity
Assessments of Language Functioning in Speakers Who Stutter
Developmental Disorders that Co-Occur with Stuttering
Studies of Phonological Encoding
Cognitive Functions and Stuttering-Related Disfluency
Psychological and Social-Emotional Correlates
Life Experiences of People Who Stutter
Anxiety and Related Disorders
Personality Characteristics
Temperament Characteristics
Emotions and Autonomic Nervous System Functioning
Environmental Correlates
Listener Behavior
Summary
Questions to Consider
7. Stuttering: Epidemiology, Development, and Etiology
Chapter Objectives
Epidemiology
Age of Onset
Fluency Characteristics Near the Time of Onset
Incidence and Prevalence
Lifetime and Cumulative Incidence
Prevalence
Stuttering Prevalence in Males Versus Females
The Developmental Course of Stuttering
Persistent Versus Transient Stuttering
Patterns of Recovery From Stuttering During Childhood
Predictors of Recovery From Stuttering
Recovering From Stuttering After Childhood
Age- and Stage-Based Approaches to Describing Persistent Stuttering
Primary Versus Secondary Stuttering
Progressing From Repeating to Prolonging/Blocking as a Primary Symptom
Relationships Between Age and Stuttering Frequency
Relationship Between Age and Stuttering-Related Disability
Age, Disability, and Quality of Life
Attempts to Explain Stuttering: Theories and Models of the Disorder
Early Explanations: Psychological and Learning-Based Explanations
The Move Toward Viewing Stuttering as a Symptom of Speech Production ?Breakdown?
Multifactorial Models of Stuttering
Summary
Questions to Consider
Section III. Other Types of Fluency Disorders
8. Acquired Stuttering
Chapter Objectives
Introduction and Background
Characteristics of Acquired Stuttering
Terminology and Subtypes
Disfluency Characteristics
Epidemiological Data
Disfluency Profiles
Rate Characteristics
Facilitative Contexts and Response to Treatment
Associated Behaviors and Emotional Reactions
Summary
Questions to Consider
9. Cluttering
Chapter Objectives
Background and Historical Perspective
Defining Cluttering
Approaches to Defining Cluttering
The Evolution of Cluttering Definitions
Fluency Characteristics of Cluttered Speech
Speech Continuity in Cluttered Speech
Effort and Naturalness Characteristics of Cluttered Speech
Talkativeness Characteristics of Cluttered Speech
Performance Consistency/Stability in Cluttered Speech
Speech Articulation Characteristics of Speakers Who Clutter
Coarticulatory Characteristics of Cluttered Speech
Speech Sound Accuracy in Cluttered Speech
Syntax and Discourse Characteristics of Cluttered Speech
Epidemiological Characteristics of Cluttering
Incidence and Prevalence of Cluttering
Onset and Developmental Course of Cluttering
Gender and Familial Patterns of Cluttering
Disorders That Co-Occur With Cluttering
Etiology of Cluttering
Early Views on Etiology
Contemporary Views on Etiology
Public and Professional Views Toward Cluttering
Summary
Questions to Consider
10. Disfluency Patterns in Other Clinical Populations
Chapter Objectives
Fluency in Children With Specific Language Impairment
Frequency and Types of Disfluency in Children With Language Impairment
Language Development, Language Demands, and Fluency Performance
Disfluency Variability in Children With Language Impairment
Fluency in Individuals With Intellectual Disability
Fluency in Individuals With Genetic Syndromes
Fluency in Individuals With Down Syndrome
Fluency in Individuals With Fragile X Syndrome
Fluency in Individuals With Prader-Willi Syndrome
Fluency in Individuals With Tourette Syndrome
Fluency in Individuals With Neurofibromatosis Type 1
Fluency in Individuals With Autism Spectrum Disorder
Other Cases of Atypical Disfluency
Word-Final Repetition in the Context of Ostensibly Typical Development
Atypical Disfluency in the Context of Other Communication Disorders
Palilalia: Repetition of Utterance Final Words
Summary
Questions to Consider
Section IV. Clinical Practice: Assessing Fluency Disorders
11. Assessment Protocols and Data Collection
Chapter Objectives
Assessment Goals and a Framework for Assessment
Assessment Goals
A Framework for Fluency Assessment
Eliciting Background Information: Case Histories and Client Interviews
Administering a Case History Form
Interviewing the Client and/or Caregiver
Eliciting Speech Samples
Clinician-Designed Tasks: Conversation
Clinician-Designed Tasks: Narration
Clinician-Designed Tasks: Oral Reading
Clinician-Designed Tasks: Sentence Production Tasks
Other Sampling Conditions
Norm-Referenced Tests for Assessing Stuttering
The Stuttering Severity Instrument?Fourth Edition (SSI-4)
The Test of Childhood Stuttering (TOCS)
Tests for Assessment of Language Fluency
The Controlled Oral Word Association Test (COWAT)
Tests of Speech-Language Functioning in Adults With Neurological Impairment
Rating Scales and Questionnaires for Assessment of Stuttering and Related Disorders
Rating Scales for Stuttering
Scales for Assessing Temperament, Anxiety, and Self-Concept
Rating Scales for Cluttering
Open-Ended, Written Responses
Designing Assessment Protocols
Summary
Questions to Consider
12. Describing Client Performance
Chapter Objectives
Historical Context
Obtaining Rich Descriptions of Client Performance
Describing the Client?s Perspective on Fluency Impairment
General Considerations
Perspectives on Fluency Impairment
Describing Speech Continuity
Measurement Options
Formats for Analyzing Continuity Data
Reporting Summary Statistics
Disfluency Measures Versus Stuttering Measures
Describing Speaking Rate
Articulation Rate
Speech Rate
Rate Deviations
Describing Rhythm
Time-Based Measures of Disfluency Duration
Restart Attempts During Repetition
Evaluating the Rhythmic Structure of Repetitions
Describing Effort
Objective Measures of Effort
Subjective Ratings of Effort
Acoustic and Visual Correlates of Effortful Speech
Describing Naturalness
Describing Compensatory and Concealment Strategies
Motor-Based Compensations for Fluency Impairment
Other Strategies for Circumventing, Postponing, or Concealing Fluency Difficulty
Describing Performance Variability
Describing Emotions, Feelings, Thoughts, and Beliefs
Describing Participation and Participation Restrictions
Verbal Output Within Tasks
Situational Involvement
Analyzing Communicative Flexibility
Summary
Questions to Consider
13. Linking Assessment Data to Intervention
Chapter Objectives
Assigning Diagnostic Classifications
Normal Fluency Functioning
Developmental Fluency Disorders and Atypical Fluency Patterns
Acquired Fluency Disorders
Rating Disorder Severity
Formulating and Presenting General Recommendations
Recommending Dismissal
Recommending Reevaluation
Recommending Intervention
Making Referrals
Other Considerations When Making Recommendations
Making Intervention Recommendations for Preschoolers Who Stutter
Making Recommendations When Parents and Children Disagree on the Need for Intervention
Developing Comprehensive Intervention Plans
Working From Assessment Results
Clarifying the Purpose of Intervention
Taking a Collaborative Approach to Goal Development
Developing Goals Within a Comprehensive Framework of Functioning
Designing Intervention Plans That Encompass Multiple Service Delivery Domains
Planning for Incremental Evaluation of Progress
Other Planning Considerations
Summary
Questions to Consider
Section V. Clinical Practice: Intervention Approaches
14. The Clinician’s Roles and Responsibilities in Intervention
Chapter Objectives
Background
Clinical Practice and the Code of Ethics
Ethical Principles
Fluency Intervention: Clinician Roles and Responsibilities
Roles That Fluency Clinicians Are Likely to Assume During Intervention
Fluency Intervention: Independent and Evidence-Based Clinical Judgment
Using External Scientific Evidence
Locating Scientific Evidence and Implementing It in Practice
Using Clinician-Generated Data and Clinician Expertise
Incorporating the Perspectives of Clients and Their Caregivers
Clinical Expertise Revisited: Understanding the Intervention Landscape
An Overview of Intervention
Behavioral Treatments
Other Approaches to Treatment
Counseling as an Intervention Component
Prevention as an Intervention Component
Direct Versus Indirect Interventions
Summary
Questions to Consider
15. Intervention Principles and Strategies for Helping People Who Stutter
Chapter Objectives
Historical Perspective
A Principle-Based Approach to Improving Communication Functioning
Intervention Principle 1: Develop the Client’s and Others’ Knowledge of Stuttering, Speech Production, and the Treatment Process
Overview and Rationale
Implementation
Intervention Principle 2: Build an Environment That Is Supportive and Accepting of Stuttering
Overview and Rationale
Implementation
Intervention Principle 3: Build a Communication Environment That Facilitates Speech Fluency
Overview and Rationale
Implementation
Intervention Principle 4: Provide Systematic Feedback About Fluency Performance
Overview and Rationale
Implementation
Intervention Principle 5: Help the Client Discover and Build on Existing, Productive Responses to Stuttering
Overview and Rationale
Implementation
Intervention Principle 6: Help the Client Develop Skills That Reduce Stuttering Frequency
Overview and Rationale
Implementation
The Speaker’s Experience of Speech Regulation
Intervention Principle 7: Help the Client Develop Skills That Modify Unproductive Responses to Stuttering
Overview and Rationale
Implementation
Intervention Principle 8: Develop the Client’s Ability to Apply Stuttering Management Skills in Natural Settings
Overview and Rationale
Implementation
Intervention Principle 9: Develop the Client’s Ability to Maintain Stuttering-Related Improvements after Intervention Ends
Overview and Rationale
Implementation
Summary
Questions to Consider
16. Counseling People Who Stutter
Chapter Objectives
Historical Perspective and Overview
An Overview of Counseling Approaches
Counseling and the Scope of Practice in Speech-Language Pathology
Counseling in Speech-Language Pathology: Overview
Emotions That May Accompany Stuttering
Emotions That Parents May Experience
Ways of Interacting With Clients During Therapy Activities
Engaging in Active Listening
Using Empathic Highlights
Using Probes and Summaries
Presenting Challenges and Disputations
Application of Counseling Practices in Stuttering Intervention
Targeting Self-Limiting Beliefs and Self-Talk: Research Outcomes
Applying Counseling Practices in the Broader Context of Stuttering Treatment
Summary
Questions to Consider
17. Sample Intervention Programs for Children Who Stutter
Chapter Objectives
Introduction
A Recap of Intervention Concepts Discussed Thus Far
Individualized Intervention: Introductory Comments and Preliminary Considerations
Case 1: Preschooler With Mildly Disfluent, but Typical Fluency Performance
Background Information
Summary of Speech-Language Assessment Protocol and Results
Relationship Between Recommendations and Intervention Principles
Measuring Outcomes
Contingency Plans
Case 2: Preschooler With Moderately Severe Stuttering
Background Information
Summary of Speech-Language Assessment Protocol and Results
Relationship Between Recommendations and Intervention Principles
Measuring Outcomes
Contingency Plans
Case 3: Early Elementary Grade Student With Moderate Stuttering
Background Information
Summary of Speech-Language Assessment Protocol and Results
Relationship Between Recommendations and Intervention Principles
Case 4: Intervention With Children Who Have Concomitant Disorders
Summary
Questions to Consider
18. Intervention With Older Children, Teens, and Adults
Chapter Objectives
Initial Considerations: Clinical Outcomes Research for Stuttering
A Framework for Organizing Intervention Approaches
Applying Intervention Research to Clinical Practice
Intervention With Older Versus Younger Clients: What Are the Main Differences?
Behavior Modification Approaches to Treating Stuttering
Use of Time-Out as a Primary Intervention Strategy
Speech Motor Approaches for Treating Stuttering
Using Regulated Articulation Rate and Syllable-Timed Speech as Primary Intervention Strategies
Explanatory Mechanisms
Developing the Client’s Ability to Use a Motor-Based Strategy
Examples of Intervention Protocols
Other Strategies That Involve Alteration of Speech Motor Behavior
Speech Motor Strategies in the Context of General Intervention Principles
Structure of a Typical Clinical Session
Feedback and Technology Interventions
The Basics of Delayed Auditory Feedback
The Basics of Frequency Altered Feedback
Explanatory Mechanisms
Intervention Protocols When AAF Is the Primary Intervention Strategy
AAF in the Context of General Intervention Principles
AAF Research Outcomes
Combined/Multiple-Component Interventions
Van Riper’s Stuttering Modification Therapy
A Framework for Designing Combined or Multicomponent Interventions
Evaluating Client Progress and Intervention Outcomes
Intervention for Cluttering
Summary
Questions to Consider
References
Index

Citation preview

fluency disorders

Second Edition

Stuttering, Cluttering, and Related Fluency Problems

Li ke

kenneth J. logan

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y words

She was alway- he w as a

then n e If- if - th I- um st- stutter- stutter

- many- uh many t- ti- times

y don’t understand me e h t d n a run together

lways saying that

FLUENCY DISORDERS Stuttering, Cluttering, and Related Fluency Problems Second Edition

FLUENCY DISORDERS Stuttering, Cluttering, and Related Fluency Problems Second Edition

Kenneth J. Logan, PhD, CCC-SLP

5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Website: https://www.pluralpublishing.com Copyright © 2022 by Plural Publishing, Inc. Typeset in 10.5/13 Garamond by Flanagan’s Publishing Services, Inc. Printed in the United States of America by Integrated Books International All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publisher will gladly make the necessary arrangements at the first opportunity.

Disclaimer: Please note that ancillary content (such as documents, audio, and video, etc.) may not be included as published in the original print version of this book. Library of Congress Cataloging-in-Publication Data: Names: Logan, Kenneth J., author. Title: Fluency disorders : stuttering, cluttering, and related fluency problems / Kenneth J. Logan. Description: Second edition. | San Diego, CA : Plural Publishing, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2020039402 | ISBN 9781635501476 (paperback) | ISBN 1635501474 (paperback) | ISBN 9781597569200 (ebook) Subjects: MESH: Speech Disorders Classification: LCC RC424.7 | NLM WL 340.2 | DDC 616.85/5--dc23 LC record available at https://lccn.loc.gov/2020039402

Contents Preface xvii Acknowledgments xix Reviewers xxi

Section I.  Foundational Concepts

1 An Introduction to Fluency Disorders



2 Conceptualizing Fluency

3 Chapter Objectives 3 Introduction 3 Speech Fluency Versus Language Fluency 4 Fluency as an Integral Component of Social and Communicative Functioning 4 5 Fluency in the Context of Speech-Language Pathology Speech-Language Pathology as a Profession 5 Developing a Framework for Clinical Practice 7 7 Fluency in the Context of Service Delivery Domains Fluency in the Context of Professional Practice 11 12 Viewing Fluency as a Component of an Individual’s Health Functioning Functioning, Performance, and Capacity 13 Activities and Activity Limitations 14 14 Participation and Participation Restrictions Impairment and Disability 15 15 Environmental and Personal Factors Facilitators and Barriers 16 Fluency Disorders:  A First Look 16 16 The Concept of Disorder Stuttered Speech 16 Cluttered Speech 18 Providing Clinical Services to People Who Have Fluency Concerns 18 The Rewards of Being a Fluency Clinician 18 Developing the Necessary Knowledge 19 Developing the Necessary Skills 20 Developing Competencies for Interprofessional Practice 20 Engaging in Evidence-Based Practice 21 Establishing Effective and Valued Working Relationships With Clients 22 Summary 23 Questions to Consider 24 25 25 25 25

Chapter Objectives Context and Historical Perspective Fluency:  A Multidimensional Construct v



vi Fluency Disorders

The Dimensions of Fluency 27 Fluency Dimensions:  Speech Continuity 27 Fluency Dimensions:  Rate and Rhythm 31 Fluency Dimensions:  Effort and Naturalness 33 Fluency Dimensions:  Talkativeness 34 39 Fluency Dimensions:  Stability Organizing Fluency Dimensions Into a Clinical Model of Fluency 39 Fluency in the Content of a Speech Production Model 41 Modeling the Speech Production Process 41 Conceptualizing a Message 42 43 Transforming a Preverbal Concept Into a Corresponding Linguistic Form Transforming Linguistic Representations to Articulatory Movements 45 Summary 49 Questions to Consider 49



3 Conceptualizing Disfluency



4 Speech Fluency in Typical Speakers

51 Chapter Objectives 51 51 Defining Disfluency Identifying Disfluent Segments 52 The Structure of Disfluency 52 53 The Moment of Interruption The Reparandum 54 55 The Original Utterance The Editing Phase 55 The Repair Phase 55 56 Labeling Disfluency Characteristics of Common Disfluency Types 60 Revisions 60 Pauses 61 Interjections 63 Repetitions 64 Prolonging and Blocking 66 69 Variations in Disfluency Form Variations in the Editing Phase 69 Variations in the Repair Phase 70 Nested Errors 70 Repetition of Final Segments in Words and Utterances 71 Limitations of Disfluency Labeling Systems 72 Limitation 1:  Lack of Standard Terminology 72 Limitation 2:  Lack of Comprehensive Terminology 73 Limitation 3:  Inconsistent Relationship Between Labels and Structure 73 Limitation 4:  Continued Dependence on Listener-Based Judgments 73 Summary 74 Questions to Consider 75 Chapter Objectives Characteristics of Typical Fluency Quantitative and Qualitative Perspectives on Fluency

77 77 77 77

Contents vii

Speech Continuity in Typical Speakers 78 Disfluency Frequency in Children With Typical Fluency 80 Disfluency Frequency During Adulthood 82 Types of Disfluency 83 Context Effects:  Where Does Disfluency Occur? 85 85 Utterance Locations That Are Prone to Disfluency Syntactic Forms That Are Prone to Disfluency 86 Speaking Tasks That Elicit Disfluency 87 Is It Typical for Young Children to Be Highly Disfluent? 88 Rate in Typical Speakers 90 90 Articulation Rate Speech Rate 92 Rhythm in Typical Speakers 93 Disfluency Duration 94 Effort in Typical Speakers 96 Perspectives on Effort 96 97 Naturalness in Typical Speakers Talkativeness in Typical Speakers 98 Talkativeness in Relation to Conversational Participation 99 99 Talkativeness in Relationship to Communicative Functions Stability of Fluency in Typical Speakers 100 Summary 101 Questions to Consider 101

Section II.  Neurodevelopmental Stuttering

5 Stuttering:  Characteristics and Etiology



6 Stuttering:  Correlates and Consequences

105 Chapter Objectives 105 Terminology 105 Historical Perspective 106 Defining Stuttering 107 107 Early Attempts to Define Stuttering Contemporary Definitions 107 Characteristics of Stuttered Speech 109 Continuity Characteristics of Stuttered Speech 110 Rate and Rhythm Characteristics 115 Effort and Awareness 120 Compensation and Concealment Strategies 123 Performance Variability 127 Effects of Speaking Task, Setting, and Conversational Partners on Speech Fluency 127 Effects of Linguistic Complexity on Speech Fluency 129 Summary 129 Questions to Consider 130 Chapter Objectives Historical Perspective Correlates of Stuttering

133 133 133 134

viii

Fluency Disorders

Genetic Correlates of Stuttering 134 Approaches to Researching Genetic Factors 134 Neuroanatomical Correlates of Stuttering 140 Gray Matter Volume and Hemispheric Asymmetry 140 White Matter Integrity 141 143 Neurophysiological Correlates Early Studies of Brain Activation and Hemispheric Dominance for Language 144 Electroencephalography (EEG) Findings 144 Neuroimaging Findings 145 Motor Correlates of Stuttering 147 147 Manual Movements Reaction Time and Speech Initiation 148 Speech Motor Coordination and Movement Control 149 Motor Learning 151 Linguistic and Cognitive Correlates 152 Syllable, Word, and Utterance Properties That Precipitate Stuttering-Related Disfluency 153 Effects of Syntactic and Phonologic Complexity 155 Assessments of Language Functioning in Speakers Who Stutter 158 Developmental Disorders that Co-Occur with Stuttering 160 162 Studies of Phonological Encoding Cognitive Functions and Stuttering-Related Disfluency 162 163 Psychological and Social-Emotional Correlates 164 Life Experiences of People Who Stutter Anxiety and Related Disorders 166 168 Personality Characteristics Temperament Characteristics 169 170 Emotions and Autonomic Nervous System Functioning Environmental Correlates 171 Listener Behavior 171 Summary 173 Questions to Consider 174



7 Stuttering:  Epidemiology, Development, and Etiology

175 Chapter Objectives 175 Epidemiology 175 Age of Onset 175 Fluency Characteristics Near the Time of Onset 179 Incidence and Prevalence 180 Lifetime and Cumulative Incidence 181 Prevalence 182 Stuttering Prevalence in Males Versus Females 184 The Developmental Course of Stuttering 185 Persistent Versus Transient Stuttering 185 Patterns of Recovery From Stuttering During Childhood 187 Predictors of Recovery From Stuttering 190 Recovering From Stuttering After Childhood 192 Age- and Stage-Based Approaches to Describing Persistent Stuttering 193 Primary Versus Secondary Stuttering 193 Progressing From Repeating to Prolonging/Blocking as a Primary Symptom 194

Contents ix

Relationships Between Age and Stuttering Frequency 194 Relationship Between Age and Stuttering-Related Disability 194 Age, Disability, and Quality of Life 196 Attempts to Explain Stuttering:  Theories and Models of the Disorder 198 Early Explanations:  Psychological and Learning-Based Explanations 199 The Move Toward Viewing Stuttering as a Symptom of Speech Production “Breakdown” 199 Multifactorial Models of Stuttering 202 Summary 204 Questions to Consider 206

Section III.  Other Types of Fluency Disorders

8 Acquired Stuttering



9 Cluttering

211 Chapter Objectives 211 Introduction and Background 211 Characteristics of Acquired Stuttering 212 Terminology and Subtypes 212 213 Disfluency Characteristics Epidemiological Data 214 218 Disfluency Profiles Rate Characteristics 222 Facilitative Contexts and Response to Treatment 222 223 Associated Behaviors and Emotional Reactions Summary 224 Questions to Consider 225 Chapter Objectives Background and Historical Perspective Defining Cluttering Approaches to Defining Cluttering The Evolution of Cluttering Definitions Fluency Characteristics of Cluttered Speech Speech Continuity in Cluttered Speech Effort and Naturalness Characteristics of Cluttered Speech Talkativeness Characteristics of Cluttered Speech Performance Consistency/Stability in Cluttered Speech Speech Articulation Characteristics of Speakers Who Clutter Coarticulatory Characteristics of Cluttered Speech Speech Sound Accuracy in Cluttered Speech Syntax and Discourse Characteristics of Cluttered Speech Epidemiological Characteristics of Cluttering Incidence and Prevalence of Cluttering Onset and Developmental Course of Cluttering Gender and Familial Patterns of Cluttering Disorders That Co-Occur With Cluttering Etiology of Cluttering Early Views on Etiology

227 227 227 228 228 228 231 231 237 237 238 238 238 240 240 241 241 242 242 243 244 245



x Fluency Disorders

Contemporary Views on Etiology 245 Public and Professional Views Toward Cluttering 247 Summary 249 Questions to Consider 249

10 Disfluency Patterns in Other Clinical Populations 251 Chapter Objectives 251 Fluency in Children With Specific Language Impairment 251 Frequency and Types of Disfluency in Children With Language Impairment 252 Language Development, Language Demands, and Fluency Performance 254 Disfluency Variability in Children With Language Impairment 255 256 Fluency in Individuals With Intellectual Disability Fluency in Individuals With Genetic Syndromes 257 Fluency in Individuals With Down Syndrome 257 Fluency in Individuals With Fragile X Syndrome 259 Fluency in Individuals With Prader-Willi Syndrome 260 Fluency in Individuals With Tourette Syndrome 260 261 Fluency in Individuals With Neurofibromatosis Type 1 Fluency in Individuals With Autism Spectrum Disorder 262 Other Cases of Atypical Disfluency 264 264 Word-Final Repetition in the Context of Ostensibly Typical Development Atypical Disfluency in the Context of Other Communication Disorders 265 267 Palilalia:  Repetition of Utterance Final Words Summary 269 Questions to Consider 269

Section IV.  Clinical Practice:  Assessing Fluency Disorders 11 Assessment Protocols and Data Collection Chapter Objectives Assessment Goals and a Framework for Assessment Assessment Goals A Framework for Fluency Assessment Eliciting Background Information:  Case Histories and Client Interviews Administering a Case History Form Interviewing the Client and/or Caregiver Eliciting Speech Samples Clinician-Designed Tasks:  Conversation Clinician-Designed Tasks:  Narration Clinician-Designed Tasks:  Oral Reading Clinician-Designed Tasks:  Sentence Production Tasks Other Sampling Conditions Norm-Referenced Tests for Assessing Stuttering The Stuttering Severity Instrument–Fourth Edition (SSI-4) The Test of Childhood Stuttering (TOCS) Tests for Assessment of Language Fluency The Controlled Oral Word Association Test (COWAT) Tests of Speech-Language Functioning in Adults With Neurological Impairment

273 273 273 273 274 277 277 278 278 279 282 283 284 285 291 291 292 293 293 294

Contents xi

Rating Scales and Questionnaires for Assessment of Stuttering and Related Disorders 294 Rating Scales for Stuttering 295 Scales for Assessing Temperament, Anxiety, and Self-Concept 299 Rating Scales for Cluttering 301 Open-Ended, Written Responses 302 303 Designing Assessment Protocols Summary 303 Questions to Consider 303

12 Describing Client Performance 307 Chapter Objectives 307 Historical Context 307 Obtaining Rich Descriptions of Client Performance 307 Describing the Client’s Perspective on Fluency Impairment 309 General Considerations 309 Perspectives on Fluency Impairment 310 311 Describing Speech Continuity Measurement Options 312 Formats for Analyzing Continuity Data 317 322 Reporting Summary Statistics Disfluency Measures Versus Stuttering Measures 324 327 Describing Speaking Rate Articulation Rate 327 Speech Rate 328 329 Rate Deviations Describing Rhythm 330 330 Time-Based Measures of Disfluency Duration Restart Attempts During Repetition 331 Evaluating the Rhythmic Structure of Repetitions 333 333 Describing Effort Objective Measures of Effort 334 335 Subjective Ratings of Effort 335 Acoustic and Visual Correlates of Effortful Speech Describing Naturalness 336 Describing Compensatory and Concealment Strategies 336 Motor-Based Compensations for Fluency Impairment 336 Other Strategies for Circumventing, Postponing, or Concealing Fluency Difficulty 337 Describing Performance Variability 337 Describing Emotions, Feelings, Thoughts, and Beliefs 338 Describing Participation and Participation Restrictions 339 Verbal Output Within Tasks 339 Situational Involvement 340 340 Analyzing Communicative Flexibility Summary 342 Questions to Consider 344 13 Linking Assessment Data to Intervention Chapter Objectives Assigning Diagnostic Classifications

345 345 345

xii

Fluency Disorders

Normal Fluency Functioning 346 Developmental Fluency Disorders and Atypical Fluency Patterns 348 Acquired Fluency Disorders 352 Rating Disorder Severity 353 Formulating and Presenting General Recommendations 353 354 Recommending Dismissal Recommending Reevaluation 354 Recommending Intervention 355 Making Referrals 355 Other Considerations When Making Recommendations 355 356 Making Intervention Recommendations for Preschoolers Who Stutter Making Recommendations When Parents and Children Disagree on the Need 360 for Intervention Developing Comprehensive Intervention Plans 360 Working From Assessment Results 360 Clarifying the Purpose of Intervention 361 365 Taking a Collaborative Approach to Goal Development Developing Goals Within a Comprehensive Framework of Functioning 367 Designing Intervention Plans That Encompass Multiple Service Delivery Domains 370 371 Planning for Incremental Evaluation of Progress Other Planning Considerations 372 Summary 372 Questions to Consider 373

Section V.  Clinical Practice:  Intervention Approaches 14 The Clinician’s Roles and Responsibilities in Intervention 377 Chapter Objectives 377 Background 377 Clinical Practice and the Code of Ethics 377 Ethical Principles 378 379 Fluency Intervention:  Clinician Roles and Responsibilities Roles That Fluency Clinicians Are Likely to Assume During Intervention 379 Fluency Intervention:  Independent and Evidence-Based Clinical Judgment 390 Using External Scientific Evidence 390 Locating Scientific Evidence and Implementing It in Practice 392 Using Clinician-Generated Data and Clinician Expertise 392 Incorporating the Perspectives of Clients and Their Caregivers 393 Clinical Expertise Revisited:  Understanding the Intervention Landscape 394 An Overview of Intervention 394 Behavioral Treatments 395 Other Approaches to Treatment 399 Counseling as an Intervention Component 401 Prevention as an Intervention Component 401 Direct Versus Indirect Interventions 402 Summary 403 Questions to Consider 404

Contents xiii

15 Intervention Principles and Strategies for Helping People Who Stutter 405 Chapter Objectives 405 Historical Perspective 405 A Principle-Based Approach to Improving Communication Functioning 407 408 Intervention Principle 1:  Develop the Client’s and Others’ Knowledge of Stuttering, Speech Production, and the Treatment Process Overview and Rationale 408 Implementation 408 Intervention Principle 2:  Build an Environment That Is Supportive and Accepting 411 of Stuttering Overview and Rationale 411 Implementation 411 Intervention Principle 3:  Build a Communication Environment That Facilitates 418 Speech Fluency Overview and Rationale 418 Implementation 419 Intervention Principle 4:  Provide Systematic Feedback About Fluency Performance 424 Overview and Rationale 424 Implementation 425 Intervention Principle 5:  Help the Client Discover and Build on Existing, Productive 427 Responses to Stuttering Overview and Rationale 427 Implementation 427 Intervention Principle 6:  Help the Client Develop Skills That Reduce Stuttering Frequency 430 Overview and Rationale 430 Implementation 430 The Speaker’s Experience of Speech Regulation 435 Intervention Principle 7:  Help the Client Develop Skills That Modify Unproductive 435 Responses to Stuttering Overview and Rationale 435 Implementation 436 Intervention Principle 8:  Develop the Client’s Ability to Apply Stuttering Management 442 Skills in Natural Settings Overview and Rationale 442 Implementation 442 Intervention Principle 9:  Develop the Client’s Ability to Maintain Stuttering-Related 443 Improvements after Intervention Ends 443 Overview and Rationale Implementation 444 Summary 445 Questions to Consider 446 16 Counseling People Who Stutter Chapter Objectives Historical Perspective and Overview An Overview of Counseling Approaches Counseling and the Scope of Practice in Speech-Language Pathology Counseling in Speech-Language Pathology:  Overview

447 447 447 448 462 462

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Fluency Disorders

Emotions That May Accompany Stuttering 465 Emotions That Parents May Experience 469 Ways of Interacting With Clients During Therapy Activities 470 Engaging in Active Listening 470 Using Empathic Highlights 471 472 Using Probes and Summaries Presenting Challenges and Disputations 472 Application of Counseling Practices in Stuttering Intervention 476 Targeting Self-Limiting Beliefs and Self-Talk:  Research Outcomes 476 Applying Counseling Practices in the Broader Context of Stuttering Treatment 476 Summary 477 Questions to Consider 478

17 Sample Intervention Programs for Children Who Stutter 479 Chapter Objectives 479 Introduction 479 A Recap of Intervention Concepts Discussed Thus Far 479 Individualized Intervention:  Introductory Comments and Preliminary Considerations 481 484 Case 1:  Preschooler With Mildly Disfluent, but Typical Fluency Performance Background Information 484 486 Summary of Speech-Language Assessment Protocol and Results Relationship Between Recommendations and Intervention Principles 489 Measuring Outcomes 490 490 Contingency Plans Case 2:  Preschooler With Moderately Severe Stuttering 491 491 Background Information Summary of Speech-Language Assessment Protocol and Results 491 Relationship Between Recommendations and Intervention Principles 495 495 Measuring Outcomes Contingency Plans 497 497 Case 3:  Early Elementary Grade Student With Moderate Stuttering Background Information 498 Summary of Speech-Language Assessment Protocol and Results 498 Relationship Between Recommendations and Intervention Principles 502 Case 4:  Intervention With Children Who Have Concomitant Disorders 504 Summary 505 Questions to Consider 505 18 Intervention With Older Children, Teens, and Adults Chapter Objectives Initial Considerations:  Clinical Outcomes Research for Stuttering A Framework for Organizing Intervention Approaches Applying Intervention Research to Clinical Practice Intervention With Older Versus Younger Clients:  What Are the Main Differences? Behavior Modification Approaches to Treating Stuttering Use of Time-Out as a Primary Intervention Strategy Speech Motor Approaches for Treating Stuttering Using Regulated Articulation Rate and Syllable-Timed Speech as Primary Intervention Strategies

507 507 507 508 509 511 512 512 519 520

Contents xv

Explanatory Mechanisms 521 Developing the Client’s Ability to Use a Motor-Based Strategy 522 Examples of Intervention Protocols 525 Other Strategies That Involve Alteration of Speech Motor Behavior 529 Speech Motor Strategies in the Context of General Intervention Principles 531 532 Structure of a Typical Clinical Session Feedback and Technology Interventions 533 The Basics of Delayed Auditory Feedback 533 The Basics of Frequency Altered Feedback 534 Explanatory Mechanisms 535 535 Intervention Protocols When AAF Is the Primary Intervention Strategy AAF in the Context of General Intervention Principles 536 AAF Research Outcomes 536 Combined/Multiple-Component Interventions 538 Van Riper’s Stuttering Modification Therapy 538 A Framework for Designing Combined or Multicomponent Interventions 543 544 Evaluating Client Progress and Intervention Outcomes Intervention for Cluttering 545 Summary 546 Questions to Consider 548

References 549 Index 589

Preface The second edition of Fluency Disorders: Stuttering, Cluttering, and Related Fluency Problems provides professionals and students who are in the field of speech-language pathology with a thorough, up-to-date examination of the nature of speech fluency, the characteristics and etiologies of fluency disorders, and assessment and treatment practices that speech-language pathologists use when working in clinical settings with people who have fluency disorders. These issues are approached from the author’s experiences as a researcher, clinician, graduate program director, and person who stutters. Like the first edition, the content in the second edition of the book deals mainly with neurodevelopmental stuttering (childhood onset fluency disorder); however, cluttering, acquired forms of stuttering, and disfluency patterns associated with other clinical populations are discussed at length as well. Readers who are familiar with the first edition of Fluency Disorders will find a number of substantial changes in content, format, and organization in this second edition of the book. New features of the second edition include the following: • Expanded coverage of treatment/intervention concepts.  In the first edition of the book, these concepts were addressed in two primary chapters and presented in the context of six general intervention principles. The second edition of Fluency Disorders features five chapters that pertain directly to treatment/intervention concepts. The chapter on intervention principles has been revised substantially  — nine general principles now are described, each with accompanying descriptions of practical implementation methods. Along with this, there are new chapters that are devoted to intervention approaches for young children who stutter, intervention approaches for older children, teens, and adults who stutter, xvii

and counseling practices for clients of all ages. There also is a new chapter devoted to the roles and responsibilities of the clinician when working with people who stutter. Overall, readers should find that the second edition of Fluency Disorders will provide them with a clear, well-rounded, and practical understanding of how to design, implement, and evaluate individualized intervention programs for clients of varying ages and degrees of severity. In short, upon reading the book, readers should develop a sense that they know what to do when working with people who stutter, and how to go about doing it. • A new introductory chapter and reorganization of chapters that were in the first edition.  The second edition of Fluency Disorders begins with a new introductory chapter, which provides readers with an overview of concepts that will be addressed in later portions of the book. Included in the first chapter are definitions of basic terms, and a discussion of the importance of establishing a “therapeutic alliance” between the clinician and client. In addition, several chapters from the first edition have been substantially revised and reorganized. As a result, some of the lengthier chapters from the first edition have been re-arranged into separate, shorter chapters, and/or merged with the content of other chapters, and the chapters themselves now are organized into five main sections (the first edition had four main sections). Readers should find that information in this edition of Fluency Disorders is presented in a clear, wellorganized manner. • Updated content and many new figures and tables.  The professional literature on fluency disorders continues to grow at an ever-accelerating rate. Consequently, content

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Fluency Disorders

has been updated throughout the book to capture recent research findings and current clinical practices. The book features a mix of new sections (with new content) and updated content in most of the sections that were retained from the first edition, with many new figures and tables. With these revisions comes a fresh perspective on issues related to the nature, assessment, and treatment of fluency disorders and their impact upon people. • New pedagogical elements within chapters and an expanded table of contents. Each of the chapters in the second edition of Fluency Disorders features introductory learning objectives and boxes that are embedded within chapter text to highlight topics of special interest. Each of the chapters closes with both a chapter summary and a “Questions to Consider” section in which readers are invited to consider various queries and to complete an assortment of “hands on” activities that are designed to consolidate and extend knowledge. In addition, the table of contents has been expanded so that it now provides readers with an outline of the first- and second-level headings from each

chapter. The latter change will help readers locate information in the text easily. • Revised and expanded ancillary resources. The second edition of Fluency Disorders features PowerPoint slides that have been revised from the first edition so that they correspond to the book’s updated content and organization. The slides provide instructors and students with a clear, easyto-follow outline of important concepts in the book. The PluralPlus companion website also offers a core set of exercises and materials that are intended to build key clinical skills that pertain to assessment and treatment. Some of the exercises are linked to the “Questions to Consider” sections that are presented at the end of the book’s chapters. As is evident from the information above, the second edition of Fluency Disorders: Stuttering, Cluttering, and Related Fluency Problems features many updates and improvements to the first edition and, overall, the book provides professionals and students in speech-language pathology with a robust context for developing the knowledge and skills that are essential to building effective, productive working relationships with clients in clinical settings.

Acknowledgments Many people assisted me during the process of writing the second edition of this book. I specifically would like to acknowledge the many students who have been enrolled in my undergraduate course, Introduction to Speech Disorders, and in my graduate course, Stuttering, at the University of Florida. Their questions, comments, and observations have shaped my thinking on fluency and fluency disorders in ways that otherwise would not have been possible. Drs. Sharon Millard and Lisa Scott provided helpful suggestions in their 2017 reviews of the first edition of Fluency Disorders. I also want to acknowledge Christina Gunning, Project Editor at Plural Publishing, Inc., for coordinating the writ-

ing and production process (and for keeping me on schedule), and Valerie Johns, Executive Editor at Plural Publishing, Inc., for offering many helpful suggestions during the planning phase of this edition. Also, I extend a big thank you to KathieJo Arnoff, Copy Editor, whose superb attention to detail played an important role in polishing the final version of the manuscript, and to Martin Flanagan for his role in the book layout during the final stages of production. And last, but certainly not least, I thank my family — and especially my wife, Nancy — for all of the unwavering patience and support throughout the project.

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Reviewers Plural Publishing, Inc. and the author would like to thank the following reviewers for taking the time to provide their valuable feedback during the development process: Craig Coleman, MA, CCC-SLP, BCS-F, ASHA-F Chair, Department of Communication Sciences and Disorders Board-Certified Specialist in Fluency Disorders ASHA Fellow Edinboro University Edinboro, Pennsylvania Chip Hahn, MS, AuD, CCC-A/SLP Clinical Associate Professor Department of Speech Pathology and Audiology Miami University Oxford, Ohio

Eileen M. Savelkoul, PhD, CCC-SLP Assistant Professor, Special Contract Department of Communication Disorders Minot State University Minot, North Dakota Michelle A. Veyvoda, PhD, CCC-SLP Assistant Professor, Department of Speech and Communication Studies Iona College New Rochelle, New York

xxi

To all of those who devote their time, energy, and talents toward improving the well-being of people who stutter.

SECTION

I

Foundational Concepts

1 An Introduction to Fluency Disorders

piece. Dictionary definitions for fluency typically include descriptors such as ease, effortlessness, and proficiency. Each of these qualities, as well, has relevance to how individuals perform during communication activities such as reading, writing, and speaking. The focus in this book is on speech fluency and fluency disorders. The act of speaking fluently is dependent on the integration of both language and speech motor processes. Given the inherent complexities in speech production, it is perhaps surprising that more people do not experience difficulties with speech fluency. Fluent speech is commonplace during most daily activities, such that most people take little notice of this aspect of communication performance. At times, an individual’s speech fluency proficiency can be quite impressive. Consider, for example, the rapid-fire remarks from an auctioneer or a radio announcer’s brisk, lively descriptions of the action occurring in a basketball game. Marked difficulty with speech fluency is uncommon and unexpected. Thus, when a speaker’s fluency deviates significantly from the norm, it literally can turn the heads of those who are within earshot of what is being said. Seemingly everyone wants a glimpse of the disfluent speaker. When fluency difficulties occur often enough and/or deviate too far from typical performance, a range of problems and challenges can ensue for the affected individual. In such cases even the relatively mundane activities of everyday

Chapter Objectives After reading this chapter, readers will be able to: • Describe the concepts of fluency and fluency disorder. • Describe how fluency relates to communicative and social functioning. • Describe how fluency fits into the scope of practice and clinical certification standards in speech-language pathology. • Describe how the World Health Organization’s ICF model applies to clinical practice in the area of fluency disorders. • Describe basic types of fluency impairment and their speech characteristics. • Describe the attributes and skills that are needed for clinical service provision in the area of fluency.

Introduction The term fluency is derived from the Latin word fluere, which means fluid. Consider, for example, the smooth and seamless movements that a gymnast makes while performing a routine on the parallel bars or the sweeping finger movements that a pianist makes while playing a classical music 3



4 Fluency Disorders

life — ordering a cup a coffee, saying one’s name, or inserting comments into a conversation with a group of friends — can be significantly challenging. In such cases, speech-language pathologists (SLPs) can play an important role in helping the individual overcome these challenges and, in so doing, help an individual push his or her fluency difficulties from their spot on the top of the list of one’s difficulties to well into the background.

Speech Fluency Versus Language Fluency As stated earlier, the focus of this book is on speech fluency — that is, fluency as it occurs when an individual is talking aloud. Speech is one of several modalities people use to express language codes; writing, typing, and manual sign production (as in American Sign Language) are examples of others. Speech is a complex motor activity, in that it requires the functional organization of more than 100 muscles distributed across the abdomen, chest, neck, larynx, pharynx, velopharynx, tongue, mouth, and face regions (Behrman, 2007). Thus, from a movement perspective, speech fluency pertains to the fluidity and ease with which an individual executes these coordinated movements while talking. Speech fluency, however, encapsulates more than just movement. Specifically, it is reflected in the three main components of message production: (1) an individual’s ability to arrive at communicative intentions that he or she wishes to express; (2) the individual’s linguistic fluency (i.e., the person’s knowledge of his or her language plus ability to retrieve and assemble the language codes that correspond to specific communicative intentions promptly and accurately); and (3) the individual’s ability to convert the assembled language codes into sequential vocal tract movements that correspond with the linguistic codes and result in an acoustic representation (speech) that other people can hear and understand. In this way, speech fluency constitutes the “end product” of an individual’s communicative efforts, and difficulties that a speaker has with any one of these three processes are manifested in the form of delays, hesitations, retraces and repetitions, and so forth. Breakdowns

or disruptions in speech fluency such as these are termed disfluencies. The term linguistic fluency refers to the smoothness, effortless, and proficiency with which a speaker selects and assembles the linguistic symbols that correspond to a message being conveyed. A speaker’s linguistic fluency depends not only on the moment-to-moment selection and assembly of linguistic codes, but also on his or her knowledge of the language’s lexicon (i.e., vocabulary) and rules for ordering words and phrases (i.e., syntax), sound units (i.e., phonemes), and meaning units (i.e., morphemes) within utterances. Sometimes the source of the disfluency is possible to discern — that is, whether the disfluency is indicative of difficulty in arriving at an intention to be conveyed, in formulating the linguistic codes that correspond the intention, or in executing the motor movements that convert a linguistic representation into a corresponding acoustic representation. Knowing the source of a disfluency can be useful in a treatment setting, as it may provide a clinician with information about the parts of the message production process that need to be addressed.

Fluency as an Integral Component of Social and Communicative Functioning Speakers who routinely produce disfluent speech at greater-than-normal frequencies often find it challenging to communicate the spoken messages that are essential for participation in daily activities. These challenges can affect not only the execution of the articulatory movements that are used to convey a spoken message, but also the words that a speaker selects for inclusion in the spoken message. Speakers with fluency impairment sometimes cope with their situation by settling for what they think they can say, rather than saying what they want to say. In such instances, speakers may end up saying words that, from a pragmatic perspective, are only marginally appropriate for the situation. Speakers with impaired fluency also often find that the quality of their communicative interactions is disrupted or diminished by the ways in which conversational partners interact with them. For instance, an individual with highly disfluent



1.  An Introduction to Fluency Disorders

speech may find it difficult to initiate spoken messages with the promptness that is needed to obtain a conversational speaking turn, or the individual may find it difficult to complete a speaking turn if the conversational partner attempts to finish the speaker’s disfluent words by guessing at what the speaker might be attempting to say. Consequently, in clinical settings, it is critical for SLPs to look beyond the linguistic and speech motor aspects of fluency to consider how the difficulties that go along with fluency impairment can impact an individual’s communicative functioning and, more broadly, social functioning during daily activities.

Fluency in the Context of Speech-Language Pathology The American Speech-Language-Hearing Association’s (ASHA’s) Scope of Practice in SpeechLanguage Pathology (2016a) is a comprehensive document that includes a formal delineation of the areas and types of activities that an SLP performs. As such, the document is useful to SLPs in helping them communicate their roles and responsibilities to others. It also helps SLPs’ in their endeavors to provide evidence-based clinical practice, conduct research, and participate in pre-professional educational training.

Speech-Language Pathology as a Profession In the United States, the roots of speech-language pathology go back nearly 100 years. According to its website (www​.asha​.org), ASHA, the modern-day professional organization for SLPs and audiologists, traces its origin back to 1925 and an organization called the American Academy of Speech Correction. By 1927, the Academy had transformed into the American Society for the Study of Speech Disorders. Members of these two early organizations came from a variety of academic fields and professional backgrounds, including psychiatry, otolaryngology, state-level educational policy organizations, and university and public-school settings. As suggested by the organizations’ titles, their members shared an interest in speech production and speech disorders. What is less obvi-

ous from these titles is the fact that much of the interest in “speech correction” centered on service provision to individuals with speech sound disorders and to individuals who stuttered. The profession of speech-language pathology evolved further with the advent of clinical certification under the American Speech and Hearing Association in 1952 (which was later known as the American SpeechLanguage-Hearing Association). The development of a formalized process of clinical certification led to standardization in the content, scope, and quality of the educational and clinical experiences and corresponding areas of knowledge and skill that individuals had to have in order to engage in clinical practice in the field. The scope of practice for speech-language pathologists (SLPs) encompasses the areas of communication and swallowing (ASHA, 2016a). Since the inception of clinical certification, SLPs in the United States have worked under an evolving set of national standards and an accompanying certification process, both of which are overseen by ASHA. The process leads to the Certificate of Clinical Competence in Speech-Language Pathology. Accordingly, SLPs are the primary providers of the services included under the Scope of Practice in Speech-Language Pathology. This means that SLPs decide which services to provide, when to provide them, and whom to provide them to. SLPs provide clinical services across nine unique service delivery areas, which are described in Table 1–1. Each area constitutes an aspect of human functioning that is within the purview of SLPs to address as part of intervention. It is incumbent upon the SLP to know which types of clinical activities fall outside the scope of practice in speechlanguage pathology and thus warrant referral to professionals from other fields who are fully qualified to provide such services. As indicated in Table 1–1, fluency is one of the service delivery areas within the scope of practice in speech-language pathology, and it is the primary focus in this book. Beyond being an autonomous profession, speech-language pathology also is a dynamic profession (ASHA, 2016a). Consequently, the roles and responsibilities of SLPs change over time and, at times, they overlap with the scopes of practice from other professions. As a result, SLPs commonly engage in collaborative practice with professionals from fields such as psychology, neuropsychology,

5



6 Fluency Disorders

Table 1–1.  Service Delivery Areas Within ASHA’s (2016a) Scope of Practice in Speech-Language Pathology Examples

Service Delivery Area

Relevant Variables

Disorders/Diseases/Conditions

Fluency

Speech continuity, rate, rhythm

Stuttering, cluttering

Speech sound production

Motor planning, speech articulation

Developmental speech sound delay, childhood apraxia of speech; Down syndrome

Language

Spoken/Written; content, form, use, Literacy; Paralinguistic communication; Prelinguistic communication

Specific language impairment; dyslexia; aphasia; anomia; psychiatric disorder

Cognition

Attention, memory, problem-solving; executive functioning

Traumatic brain injury; dementia

Voice

Phonation quality, pitch, loudness

Vocal nodules, alaryngeal voice, vocal fold paralysis

Resonance

Hypernasality, hyponasality, nasal emission

Cleft palate; velopharyngeal dysfunction

Auditory habilitation/ rehabilitation

Communication and listening skills impacted by hearing impairment; auditory processing

Sensorineural hearing loss; conductive hearing loss; Auditory processing disorder

Feeding and swallowing

Swallowing phases; atypical eating patterns (e.g., food selectivity/refusal)

Dysphagia, oromyofunctional disorders; chronic cough

Elective Services

Speech, language, communication

Transgender communication, business communication; accent/dialect modification; professional voice use; preventative vocal hygiene.

medicine, counseling, education, audiology, special education, and social work, as well as individuals from the areas of education and health care. As detailed later in this book, fluency difficulties sometimes co-occur with other forms of difficulty, which

can lead to a range of limitations in areas beyond communication, including academic, work-related, and social functioning. In such cases, SLPs are likely to engage in interprofessional collaborative practice to best address patient needs. Thus, it is critical for

Fluency in the Context of Clinical Service Delivery Fluency is one of the nine major clinical service delivery areas within the Scope of Practice in Speech-Language Pathology (ASHA, 2016a). It also is featured in the clinical competence standards set by the Council for Clinical Certification (CFCC) in Audiology and Speech-Language Pathology of ASHA (2018). Standard IV-C in the current version of the speech-language pathology certification standards states that candidates for the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) must “have demonstrated knowledge of communication and swallowing disorders and differences, including the appropriate etiologies, characteristics, anatomical/physiological, acoustic, psychological, developmental, and linguistic and cultural correlates in the [area of] . . . fluency and fluency disorders.”



1.  An Introduction to Fluency Disorders

SLPs to develop professional competencies with implementing intervention in the context of interprofessional practice.

Developing a Framework for Clinical Practice ASHA’s Scope of Practice in Speech-Language Pathology includes two substantial sections that delineate the activities that SLPs perform and the professional roles that they assume. The first of these sections, “Service Delivery Domains,” consists of eight essential areas of clinical practice in which SLPs engage when providing services to individuals. Each of these has relevance to clinical practice provided to people who have fluency difficulties. In contrast, the “Professional Practice Domains,” deal with activities beyond provision of

direct clinical service. These domains are outlined in Figure 1–1. After glancing at the figure, one can envision some of the ways that fluency and problems that affect fluency interface with activities and roles included in ASHA’s Scope of Practice in Speech-Language Pathology.

Fluency in the Context of Service Delivery Domains ASHA (2016a) delineates eight domains of service delivery in its Scope of Practice document. Taken together, the eight domains listed in Figure 1–1 encompass the types or levels of clinical services that SLPs provide. In the remainder of this section, each of the eight service delivery domains is discussed, including examples of how they can apply to clinical service provision to clients with fluency impairment.

Figure 1–1.  Domains of service delivery and professional practice that come under the scope of practice for speech-language pathology for certified clinicians in the United States. Service delivery entails the activities that SLPs perform in day-to-day service with clients. Professional practice entails activities beyond service delivery that assist and inform clients, the general public, professional colleagues, and future SLPs.

7



8 Fluency Disorders

Terms to Use When Referring to People Who Receive Clinical Services What term should an SLP use to refer to the people who receive speech-language pathology services? In a private practice setting, it might be client or consumer. In a hospital setting, patient is the most likely choice, and in a school setting, student or pupil is used often. Another option is the term individual, which ASHA uses in its most recent official documents. This text uses each of these terms interchangeably, along with other terms (e.g., person and people), based on which one seems most appropriate for the topic under discussion. Regardless of which term is used, it always should be presented in a format in which the person is mentioned before the disorder, disease, or disability; for example, person who stutters or individuals with impaired fluency. In the context of stuttering and other fluency disorders, person-first terminology conveys the important message that there is much more to an individual than the fluency difficulties that he or she experiences when talking.

Collaboration Collaboration involves the act of working cooperatively with other individuals toward the attainment of a common goal. In speech-language pathology, one main goal of collaboration is to enhance the value of the services that a clinician provides. In other words, through collaboration with others, the SLP seeks to improve or strengthen the quality of the services that he or she provides to a client by gaining access to the expertise and talents that others possess. Collaboration implies that at least some portion of the clinical services that a client receives are provided by a team of professionals who coordinate their efforts toward the goal of optimizing the client’s functioning. At a minimum, clinical practice involves collaboration between a patient and an SLP. Because communication disorders do not exist apart from other facet’s of an individual’s life; however, it often is worthwhile to involve other people (e.g., family members, other types of professionals) in intervention efforts as well. The success of a collaborative approach to intervention depends greatly on the effectiveness of communication among team members. In the case of communication disorders, the SLP assumes responsibility for communicating regularly and clearly with the other team members and for working with them in ways that lead to decisions and actions that are likely to maximize the client’s functioning. In the context of fluency impairment, the SLP usually assumes a central or

lead role on the intervention team. Engagement in collaborative practice also means that the SLP has a responsibility to educate stakeholders about the principles and competencies associated with interprofessional education (IPE) and interprofessional practice (IPP). In later chapters, examples are provided of how SLPs engage in collaboration as part of clinical service provision to individuals who have fluency concerns.

Counseling Counseling activities include the provision of education, guidance, and support (ASHA, 2016a). In the area of fluency, the SLP’s counseling efforts usually are directed toward the client; but depending on the client’s age or circumstances, efforts also may be directed toward the client’s family members or caregivers. Counseling efforts typically are designed to help clients attain the following: (1)  decisionmaking skills, particularly with respect to issues associated with fluency functioning and related clinical services; (2) accurate knowledge about communication challenges or concerns; (3)  ability to self-advocate for one’s needs; and (4) ability to minimize the negative effects that self-limiting thoughts, feelings, and emotions can have on communicative functioning in daily life activities. When a client’s impairments, challenges, or other issues fall outside the scope of practice for speech-language pathology, the SLP refers to qualified professionals who can assist. The importance



of counseling activities to professional practice in speech-language pathology has long been recognized, and numerous authors have explored the principles and practices of counseling as they pertain to speech-language pathology (e.g., Crowe, 1997; Luterman, 1996; Murphy, Quesal, ReardonReeves, & Yaruss, 2013; Tellis & Barone, 2018). In Later chapters, the specific strategies, methods, and materials that SLPs can use when counseling individuals who have impaired fluency are discussed.

Prevention and Wellness The term prevention carries several connotations. Lay people are likely to think of prevention in terms of reducing the incidence (i.e., the number of new cases) of a specific disorder. This type of prevention (i.e., primary prevention) is, at present, not feasible for many communication disorders, particularly those that have a genetic or neurodevelopmental basis. Thus, in speech-language pathology, and particularly with disorders that affect speech fluency, prevention practices are more likely to focus on secondary or tertiary aspects of a disorder. Included under the latter are activities that promote early detection of disorders and those that are designed to mitigate the predictable future consequences of a disorder. For example, a clinician anticipates that a fourth-grade boy who stutters will face a growing risk of being bullied and thus takes preemptive steps. These might include a classroom education program about stuttering, engagement with the school’s anti-bullying campaign, and instruction within the context of a school support group for students who stutter for a child to learn strategies for responding to bullying. Prevention efforts also many be aimed at a client’s thoughts and emotions related to stuttering. As clients receive negative, hurtful, or unpleasant reactions to their disfluent speech from others, they may begin to form self-limiting thoughts and self-defeating behaviors that exacerbate their communication difficulties. For instance, a child might restrict his or her participation in conversation as a way of coping with anticipated negative reactions from others about speech disfluency. In scenarios like this, an SLP’s prevention efforts would be focused on helping the child to develop constructive, self-affirming thoughts and positive, proactive

1.  An Introduction to Fluency Disorders

behavioral responses to the challenges that disfluency presents. Outcomes of this sort are likely to have a positive impact on an individual’s quality of life and general sense of well-being. Prevention efforts often are rooted in activities that are designed to educate people about nature and characteristics of communication disorders and that promote awareness of the attributes and experiences of individuals who are affected by the disorders. Prevention activities of this type often involve campaigns that are directed at the school, community, and/or societal levels. An example of the latter is ASHA’s long-running May Is Better Hearing and Speech Month campaign, which targets specific aspects of speech, language, hearing, and swallowing over the course of the month. ASHA (www​.asha.org) has an assortment of materials (e.g., pamphlets, posters, press releases, video recordings) available for download in support of prevention efforts. In later chapters, the specific strategies, methods, and materials that SLPs use to promote prevention and wellness are discussed.

Screening Early identification of communication difficulties is a central component of prevention efforts in speechlanguage pathology. Screening is an efficient means of achieving early identification of a disorder. Screenings are brief assessments that are designed to identify individuals in a population who are need of a comprehensive assessment. They are particularly useful when the goal is to identify individuals with fluency impairment because pertinent symptoms often can be detected in relatively brief samples of speech. In later chapters, specific screening-related activities that SLPs use to identify individuals who possibly exhibit impairment in fluency are discussed.

Assessment SLPs use the process of assessment to arrive at differential diagnoses of communication disorders. The assessment process is designed to provide information about an individual’s functioning with respect to body structure (i.e., anatomy) and function (i.e., physiology, kinematics, proprioception, other related processes) across the activities that an individual performs during daily life. Through assessment, the clinician aims to capture how well

9

10

Fluency Disorders

the individual performs during daily activities, the extent to which the individual participates during daily activities, as well as the extent to which factors in the individual’s personal life and surrounding environment facilitate or hinder functioning. In Chapters 11, 12 and 13, the components, materials, and procedures that SLPs use to assess speech fluency are discussed at length.

Treatment Treatment consists of speech-language services that are conducted to optimize an individual’s communication (or swallowing) abilities, and in turn, improve quality of life (ASHA, 2016a). As ASHA indicates, treatment activities are designed to help individuals develop skills or abilities that enable them to correct or compensate for whatever deficits they may exhibit. In the context of fluency disorders, treatment goals and associated activities are directed mainly toward improvement of an individual’s communication-related functioning, how the individual and/or family members cope with or react to disorder-related limitations, and how to address aspects of the environment (e.g., listener behavior) that appear to precipitate, perpetuate, or aggravate the effects of the disorder. SLPs are responsible for designing and implementing evidence-based treatment plans. This means developing treatment approaches that are likely to help clients successfully address issues of primary concern to them, and to do so in an efficient manner. Treatment plans of this sort incorporate practices or principles that are supported by empirical research and then modified as necessary based on both the preferences/desires of the individual being treated as well as other pertinent data that the clinician considers (e.g., the presence of concomitant communication disorders). The specific strategies, methods, and materials that SLPs use to treat disorders that affect speech fluency are discussed in the final section of this book.

Modalities, Technology, and Instrumentation With some clinical populations, assessment and treatment activities require the use alternate communication modalities, advanced instrumentation,

and technologies. In the context of fluency disorders, speech usually is the primary mode of communication (even when fluency is impaired severely). Clinicians may incorporate technology to assess specific aspects of speech (e.g., a digital speech analysis system to measure disfluency duration) and/or to supplement treatment (e.g., an electromyograph instrument that provides the client with feedback on the activation level of lip and jaw muscles during speech). Concepts pertaining to this aspect of clinical practice are discussed further in the assessment and treatment sections of the book.

Working at Population and Systems Levels Communication disorders, including those that affect speech fluency, exist within broader contexts that affect not only individual clients but also others who care for and interact with them. For this reason, SLPs are charged with working to understand the population-level context in which communication disorders exist. Although this may sound daunting, there is much that the clinician can do at family, school, community, and state levels to identify and then alter or remove barriers to an individual’s communicative functioning and well-being (Coleman, 2018). Examples of such barriers include local practices or policies that limit clinicians’ ability to provide treatment in an optimally effective or efficient manner and local conditions that foster unfavorable or hostile attitudes and actions toward individuals who have fluency difficulties. In such instances, clinicians can take any number of actions, including the following: analyzing communication environments and, if necessary, taking steps to improve them; coaching teachers and early intervention providers in how they can facilitate children’s speech and language development and performance; collaborating with school administrators and faculty to promote policies and practices that promote efficient scheduling for special services or that facilitate access to the curriculum for individuals who have communication disorders; and working with state-level speech-language-hearing organizations and legislative bodies to enact policies that promote the provision of optimal treatment practice for individuals with communication disorders.



1.  An Introduction to Fluency Disorders

Fluency in the Context of Professional Practice ASHA (2016a) identifies five professional practice domains, each of which pertain to professional roles that go beyond the activities that deal with direct clinical provision (see Figure 1–1). As can be inferred from the figure, the activities associated with these professional practice domains help to advance the profession of speech-language pathology and increase its visibility among the general public. Each professional practice domain has relevance to the work that SLPs do with people who have fluency difficulties. Accordingly, they are described in the text that follows.

Advocacy and Outreach According to ASHA (2016a), advocacy involves activities that are designed to promote and facilitate individuals’ “access to communication, including the reduction of societal, cultural, and linguistic barriers.” Included in advocacy are undertakings in the political arena such as providing expert advice to legislators and policy makers; promoting and marketing professional services; encouraging involvement in state, local, and national professional organizations; serving as an expert witness during legal proceedings; working with businesses to promote improved and open access to services for individuals with communication disorders; and speaking out for fair and equitable services for all individuals.

Clinical Supervision SLPs have a responsibility to supervise clinical experiences for clinical fellows, student clinicians, and other personnel, such as speech-language pathology assistants. ASHA (2016a) describes supervision as a complex activity that entails clinical as well as administrative and technical competencies. Many skills are required for effective supervision, including the abilities to educate, counsel, encourage, and support other people. SLPs who supervise the clinical activities of others must demonstrate that they have completed the appropriate amount and type of training in the area of supervision.

Educational Activities Another role for SLPs involves education. Typically, education activities occur in the context of working with university-level students who are enrolled in the study of communication sciences and disorders. Opportunities for education also exist through the provision of continuing education activities through which the SLP offers learning opportunities for other professionals. Such activities are common at regional, state, or national conventions of SLPs, as well as through local continuing education events such as clinical grand rounds seminars that take place in some work settings. In addition to these activities, SLPs sometimes provide in-service education to coworkers, including colleagues from other professions. The aim of in-service activities often is to inform others about topics such as recent advances in the understanding of a disorder’s etiology, recent changes in treatment practices for specific communication disorders, and recent approaches to interdisciplinary practice within specific clinical populations. Education activities can extend beyond the workplace to include community service organizations, local or regional self-help groups, local parent or senior citizen groups, and the like. Presentation content for audiences such as these often is designed to improve public awareness of communication disorders and their symptoms, symptoms that suggest the presence of a communication disorder or the need for assessment, the types of services and treatments that are available to address specific communication disorders, the role of SLPs in educational or health care settings, and so forth.

Engagement in Research Clinical practice is rooted in research. SLPs ​— even those who do not hold a research doctorate — are eligible to conduct or facilitate research in any of the service delivery areas included within the Scope of Practice. Most contemporary research activities are conducted in partnership with professional colleagues and in settings such as schools or hospitals, where students or patients are recruited for research participation. The research activities must be performed in accordance with the employers’ policies regarding data privacy, ethical and safety

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standards, and (in medical settings) delineation of billing and reimbursement procedures for medical services that may overlap with activities that are performed in the research protocol. Most hospitals and school districts have formal review boards (i.e., institutional review boards or IRBs) that evaluate research proposals, particularly with respect to ascertaining the extent to which a study’s methods comply with state and federal laws pertaining to protected health information, educational records privacy, records retention, benefits and risks associated with the research, and so forth.

Administration and Leadership Roles Some SLPs pursue jobs in which their duties, in part or in full, pertain to administration and/ or leadership. Positions like these are found in school/educational settings, hospital and related health care settings, corporations that provide speech-language pathology services to entities such as schools or nursing homes, state speechlanguage-hearing associations, and state boards for licensing and credentialing, as well as ASHA. Administrative positions typically involve activities that deal with the managerial aspects of clinical practice (e.g., caseload management, cost efficiency of clinical services, employee productivity, regulation and quality control for clinical practice, adherence to legal statutes). SLPs who work in positions like this may have opportunities to provide input into policies or practices that improve the quality, cost, access, or effectiveness of clinical services and related measures such as patient satisfaction. Within ASHA, clinicians can join Special Interest Group 4 (Fluency and Fluency Disorders) and get involved with colleagues who share a common passion for working to improve the lives of people with fluency concerns.

Viewing Fluency as a Component of an Individual’s Health Functioning The World Health Organization’s (WHO, 2001) International Classification of Functioning, Disability, and Health (abbreviated as ICF) is a clinical tool that SLPs and other health care providers can use to generate comprehensive descriptions

of an individual’s health functioning. According to WHO (2001), health is is more than just the presence or absence of disease or impairment. That is, it is a principle aspect of an individual’s overall well-being. The ICF is a tool for capturing what a person does (irrespective of whatever impairment the person has) and does not do (disability) in various health-related domains. ASHA (n.d.) states that the ICF framework is particularly useful in the context of interprofessional collaborative practice and as a mechanism for fostering person-centered care. The ICF framework has been used for many years with people who have fluency difficulties (e.g., Logan, 2005; Yaruss, 1998; Yaruss & Quesal, 2004). Prior to delving into the details concerning the characteristics of fluency disorders and associated assessment and intervention practices, it first is useful to review the ICF framework more closely. Doing so will be helpful in establishing a conceptual basis and a common language for talking about the effects that communication disorders have on individuals’ overall health. The remainder of this section is a discussion of 13 concepts that are central to the ICF framework. Clinicians are likely to encounter the ICF framework regularly during clinical practice. In fact, ASHA (n.d.) states that the ICF has been adopted as “the framework for the field . . . of SpeechLanguage Pathology.” Clinicians who are well versed with these concepts are well positioned to think, speak, and write coherently about the individuals they serve.

ICF-Related Resources Available Through ASHA ASHA’s website offers an assortment of ICF-related resources that are useful to SLPs in planning and conducting clinical activities. The website also features links to ASHA-produced webinars that deal with the use of ICF in speech-language pathology, occupational therapy, and physical therapy. Beyond the website, there is substantial literature on the applicability of the ICF framework to the assessment and treatment of fluency disorders.



The ICF framework offers clinicians a common conceptual structure and set of terms to use when describing clients, clinical intervention, and other related issues. The use of a common conceptual framework and terminology facilitates the accuracy, precision, and scope of clinical reporting within and among clinicians. The ICF also offers a system for organizing each bit of information that a clinician collects about a client, and it provides a structure around which assessment and treatment protocols can be constructed and treatment outcomes can be assessed. Essential components of the ICF framework are illustrated in Figure 1–2. As shown the figure, the ICF framework is concerned with the following: (a) the interplay between functioning and disability, (b) the things that a person does in everyday life, (c) the extent to which these things are done in a manner that

1.  An Introduction to Fluency Disorders

is comparable to most people in the population, (d) and the ways in which factors that are internal (personal) and external (environmental) to the person affect what the person does. In the remainder of this section, these concepts and several others that feature prominently in the ICF framework are discussed.

Functioning, Performance, and Capacity The terms functioning, performance, and capacity are similar in that each of the terms deals with activities that an individual does. The term functioning is the broadest of the three terms, as it refers to (a) the structure of an individual’s body (i.e., anatomy), (b) the functioning of body structures

Figure 1–2.  Essential concepts in the World Health Organization’s (2001) ICF model. In the ICF framework, functioning pertains to a person’s body structures and how they function, activities they perform, and the extent to which they participate in those activities. Disability is the inverse of functioning. It pertains to impairment in body structure or function, activity limitations, and participation restrictions. Both functioning and disability are inextricably related to the personal and environmental factors that are unique to the individual and comprise the broader context of the person’s life.

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(i.e., physiology, psychophysical functions), and (c) how an individual uses body structures and functions to perform daily activities. In the ICF framework, the notion of functioning is intended to identify what a person does (rather than what a person does not do). Over the years, researchers with an interest in speech-language pathology have developed an assortment of methods for describing fluency functioning. The term performance pertains to how an individual behaves or acts within his or her current environment. The notions of performance and functioning are similar in that both deal with what an individual does during daily activities. Performance is a narrower concept than functioning, however, as it excludes matters related to body structure and function. Thus, when describing performance, a clinician is focused on what an individual does when engaged in daily activities, including the extent to which the individual engages in those activities. Capacity refers to “the highest probable level of functioning that an individual may reach” within a uniform or standard environment (WHO, 2001, p.  20). In the context of fluency disorders, the uniform or standard environment for determining capacity often is a clinical context such as the SLP’s office. Many individuals who experience fluency difficulties report that their “within-clinic fluency” often is substantially better than their “real-world” fluency; and because the individual likely will be returning to the clinical setting many times in the future, the individual’s within-clinic fluency constitutes an appropriate environment for estimating the individual’s highest probable level of functioning.

conversation, narrative storytelling, talking on the telephone, and asking questions to obtain information). However, there is a host of activities (e.g., lecturing, joke telling) that are performed only by some people or only on rare occasions. Further, across individuals, communication activities can assume an almost limitless number of permutations. Conversations, for instance, can vary in terms of the number of participants involved, the level of familiarity among the participants, the physical proximity of the participants, the amount of background noise during the conversation, the participants’ familiarity levels with the topic, and so forth. Each of these variations has the potential to affect a speaker’s communicative performance. In addition, some infrequently occurring activities (e.g., reciting wedding vows) are possibly ones that are of the utmost importance to an individual. The term activity limitation refers to a problem or difficulty that an individual has when performing an activity. Thus, activity limitation has a negative connotation. In the context of speech functioning, activity limitation refers to how a client’s performance falls short when compared to the performance of other speakers. As explained in later chapters, speakers with impaired fluency commonly exhibit situational difficulties; that is, they exhibit little or no limitation when performing one type of activity but marked limitations when performing another type of activity. Consequently, when designing intervention activities, it is critical for clinicians to consider information about the manner and extent with which a client’s speech fluency varies across daily speaking situations.

Activities and Activity Limitations

Participation and Participation Restrictions

The term activity refers to a task or action that an individual performs. In the context of fluency intervention, it is important to identify the types of communication activities an individual performs, how often the person performs the activities, and the level of importance the person assigns to the activities. On the surface, identification of an individual’s communication activities may seem to be a straightforward task. After all, there is considerable overlap in the communication activities that people perform (e.g., nearly everyone engages in

Participation is an index of an individual’s breadth and depth of engagement in life’s activities. The concept of participation has a positive connotation in that it refers to what an individual does, regardless of how it compares to the participation characteristics of other people. Participation encompasses both the number of activities in which an individual is engaged as well as the degree to which the person is engaged in a particular activity. For activities that offer opportunities for speaking, verbal



1.  An Introduction to Fluency Disorders

output (e.g., number of words spoken) is one way to measure participation; the number, type, and variety of speaking activities engaged in is another. In assessments with people who stutter, it is common to find clients who participate verbally in a modest number of daily activities; but within those activities, the amount of talking the client does is extensive. As with daily activities, “participation profiles” vary greatly across clients who have fluency difficulties. The term participation restriction refers to limitations in an individual’s involvement in daily activities, which, in the context of fluency impairment, are activities that entail speaking. As with activity limitations, participation restrictions are determined by comparing an individual’s participation patterns against the participation patterns of typically functioning individuals. Participation restrictions commonly exist in individuals who have fluency impairment. Consequently, they represent another way in which an individual’s communicative functioning can be limited. The extent of an individual’s participation restrictions often is commensurate with his or her activity limitations. That is, individuals with severe activity limitations in talking activities often also present with severe participation limitations in these activities. Nonetheless, there are cases where the severity levels of an individual’s participation restrictions and activity limitations are dissociated, such that an individual who speaks disfluently when performing a particular task engages in that task as often and as extensively as a person without fluency impairment. A range of personal factors (e.g., the individual’s feelings and beliefs about fluency impairment and expectations for personal performance) and environmental factors (e.g., the extent to which others accept the individual’s fluency impairment) seem to contribute to the differences in participation profiles that exist across individuals (Yaruss, 1998; Yaruss & Quesal, 2006).

Impairment and Disability In the ICF framework, the term impairment implies the presence of structural or functional deviations or a limitation in an individual’s body. These differences are viewed in relation to what is typical in the general population. Each of the fluency dis-

orders discussed in this text are associated with deviations in neuroanatomy and/or neurophysiology that limit the ability of individuals to speak at fluency levels that are commensurate with the general population. In the ICF framework, disability is a broad concept. That is, it refers to the impairments, activity limitations, and participation restrictions a person exhibits. Disability refers to what an individual does not do. In contrast, functioning focuses on what an individual does do. As such, disability essentially is the inverse of functioning. Like impairment, disability is defined in reference to how an individual without a specific health condition such as stuttering, would function in an activity.

Environmental and Personal Factors WHO (2001) defines environmental factors as the “physical, social, and attitudinal (context) in which people live and conduct their lives” (p. 12). The concept is a broad one in that it includes not only physical features of the world but also societal roles, attitudes, values, social systems and services, as well as policies, rules, and laws. Clinicians typically have little control over societal-level environmental factors; however, they often are able to alter or influence certain proximal environmental factors, such as how a classroom teacher responds to a student’s disfluent speech. In this way, a clinician helps to create an environment around a person that helps the individual function optimally. In contrast, the term personal factors refers to intrinsic characteristics that can affect an individual’s functioning, such as age, gender, or religion as well as an individual’s feelings, beliefs, and thoughts about the self and, more specifically, experiences associated with communication impairment. Personal factors can have profound effects on functioning. For example, a teenage boy who stutters may experience shame when stuttering around other people. The emotional intensity of the shame may lead the teenager to avoid participation in verbal interactions at school and elsewhere and, over time, the stuttering may have increasingly negative effects on not only the person’s communication but also his or her quality of life and sense of well-being.

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Facilitators and Barriers

The Concept of Disorder

The term facilitator refers to features of the environment that improve an individual’s functioning and thus reduce disability. As such, the term has a positive connotation. In the context of fluency impairment, facilitators can be features of the physical environment, such as the presence or absence of background noise, or, more commonly, behavioral characteristics of people who interact with the speaker who has impaired fluency. For example, a conversational partner acts as a facilitator when consciously refraining from interrupting a person who stutters after noticing that verbal interruptions tend to worsen the severity of the person’s fluency difficulties. Barriers, in contrast, are aspects of the environment that limit or hinder an individual’s functioning and, in doing so, negatively impact the severity of the individual’s disability. As such, the term has a negative connotation. Barriers can assume a variety of forms. Some barriers are financial (e.g., an individual’s lack of financial resources to cover the cost of fluency intervention). Other barriers have to do with access to convenient or reliable transportation, which can hinder a person’s ability to travel to a speech-language pathology clinic. Health insurance access can be another barrier to patient functioning (e.g., access/availability to a health insurance plan, the extent to which speechlanguage pathology services are covered under an insurance plan). Other barriers are multilayered, such as in the case of a school system that lacks qualified personnel to provide effective fluency services and that has challenges in recruiting such individuals because of other factors, such as salary or benefit structure.

ASHA’s (1993) Ad Hoc Committee on Service Delivery in the Schools defined a communication disorder as “an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems (para. 2).” For the most part, the terms impairment and disorder are used interchangeably throughout this book, although impairment as defined in the ICF is narrower in scope than disorder. That is, the focus of impairment is on body structure and function); whereas, in ASHA’s definition, impairment also encompasses elements of activity limitation. ASHA (1993) states that communication disorders may affect hearing, language, or speech processes and that an individual may have more than one type of communication disorder at the same time. In some cases, the communication disorder can be the primary source of the individual’s communication disability, and, in other cases, the disorder and its associated areas of disability occur secondary to other impairments the individual has. For example, a child with autism may also experience fluency difficulties that affect speech. A fluency disorder is classified as a subtype of speech disorder, although as noted earlier in the chapter, difficulties in language formulation also can be manifested “downstream” in speech in the form of pauses, hesitations, word repetitions, utterance revisions, and so forth. Definitions of specific types of fluency disorders are explored at length later in the book. For now, however, the introductory discussion is limited to reviewing the prominent symptoms associated with two common types of disordered fluency: stuttering and cluttering.

Stuttered Speech Fluency Disorders:  A First Look This section presents an overview of several fundamental concepts and terms that pertain to fluency disorders and explores some of the requirements for becoming an effective clinician in this area of clinical practice.

Stuttered speech is the most familiar type of impaired fluency. It is characterized primarily by frequent disruptions in speech fluency that result in the following disfluency types: (a) repeated speech, particularly repetitions of parts of words (e.g. a little b- b- boy); (b) audibly prolonged speech sounds (e.g., the l in a llllllittle boy), and/or (c) blocks in speech sound production in which a speaker holds



the posture of a speech sound for an atypical length of time and/or with an atypical amount of physical tension, with little or no sound forthcoming (e.g., silently holding posture for the b in a little boy for 2 seconds). In addition to occurring frequently (i.e., several to many times per 100 words), instances of stuttering-related disfluency also can last for a relatively long time and thus consume time that the speaker otherwise would spend in productive communication. Stuttered speech is observed in two different types of fluency disorder — one that typically has its onset during childhood, and one that typically has its onset during adulthood.

Symptom Onset in Childhood Most often, the onset of stuttered speech occurs in the preschool years, in the absence of any frank neurological injury, trauma, or illness. In such cases, symptom onset often coincides with speech and language development. This type of stuttering, which traditionally has been assigned labels such as stuttering, childhood stuttering, or developmental stuttering, is characterized by an atypical pattern of disruption in the flow of speech (i.e., disfluencies). The primary disfluency types for the childhood onset form of stuttering are those that were mentioned earlier (i.e., part-word repetition, sound prolongation, and blocked speech sounds). Over time, these disfluencies may be accompanied by associated behaviors that the speaker uses either to facilitate fluency or to conceal or avoid impending disfluency. Affected individuals also may exhibit social anxiety, particularly in the context of activities that involve speaking, as well as reduced participation in social/communication activities. The American Psychiatric Association (2013) adopted the label childhood onset fluency disorder as part of its revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). This label was introduced as a replacement for the traditional, but less specific term stuttering. Alternately, WHO (2018), in its recently revised International Statistical Classification of Diseases and Related Health Problems (ICD-11) used the label developmental speech fluency disorder when referring to stuttering and classified it under the broader heading of neurodevelopmental disorder.

1.  An Introduction to Fluency Disorders

As explained in later chapters, there is now considerable evidence that neurodevelopmental anomalies are commonly present among individuals whose stuttered speech emerged during childhood, in the absence of other potentially explanatory events such as acute illness, head trauma, and anoxia.

Symptom Onset in Other Types of Stuttering The childhood form of stuttering is contrasted with a nondevelopmental form of stuttering. Traditionally, the latter form of stuttering has been regarded as acquired stuttering, meaning that after a substantial period of demonstrating typical fluency, the individual develops stutter-like speech under one of the following scenarious: secondary to acquired neurological damage (neurogenic stuttering), exposure to certain drugs (pharmacogenic stuttering), or, less common, acquired or adultonset psychiatric illness (psychogenic stuttering). The term neurogenic stuttering is used today, particularly in cases where stuttered speech emerges soon after an individual experiences neurological insult (e.g., following stroke or closed-head injury) or when the onset of stutter-like speech occurs in the context of certain neurodegenerative conditions, such as Parkinson’s disease. Pharmacogenic (or drug-induced) stuttering is a label that is used for stuttered speech that begins in conjunction with the introduction of certain pharmacological agents and then resolves when their use is discontinued. In the most recent iteration of the ICD (ICD11, WHO, 2018), acquired forms of stuttering most often would fit under the label adult onset fluency disorder. ICD-11 also includes alternative diagnostic labels that would apply to fluency disorders of this sort, such as fluency disorder (stuttering) following cerebrovascular accident, which would apply in cases where an individual begins to stutter following a stroke or other documentable injury that affects cerebral blood flow. The term fluency disorder in conditions classified elsewhere also is available and would be appropriate for cases in which stutter-like speech emerges as a secondary symptom of a more primary disease, such as Parkinson’s disease. The latter label also would be

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appropriate to use in cases where children with well-established histories of typical fluency begin to exhibit atypical fluency, including stutter-like speech that is secondary to acquired brain lesions. Aram, Meyers, and Eckelman (1990) reported on 33 such cases and found that the children demonstrated a number of quantitative and qualitative differences in their fluency when compared to a group of children with typical neurological functioning. Procedures for diagnosis and labeling various types of fluency disorder are discussed later in this book.

Cluttered Speech Cluttered speech is another type of disfluent speech pattern. It is characterized primarily by a rapidsounding rate of speech articulation, intermittent bursts of rapid and/or unintelligible speech (particularly in conjunction with multisyllabic words), excessive production of certain disfluency types (particularly revision of previously spoken words), and interjection of meaningless filler. For example, revision might sound like this: She wants, I mean, She ne- She needs to, like she has to find another person who. And interjection of meaningless filler, which may be mixed in with the revision, might sound like this: She um um like um She can’t find a job she’s qualified for. Stutter-like disfluencies may occur in conjunction with cluttered speech, but in such cases, they usually are not the predominate form of speech disruption. If symptoms of both cluttering and stuttering are prominent enough, however, an individual would be diagnosed with both cluttering and stuttering. The diagnostic terminology used with cluttered speech is more straightforward than it is with stuttering. For example, at present, a distinction between developmental and acquired forms of cluttering is not routinely made, nor is there a routine differentiation between childhood and adult-onset cluttering. Thus, the label cluttering seems to suffice as a descriptor for speech that is characterized by the rate, intelligibility, and fluency anomalies described earlier. Additional details about cluttering are presented later in the book; but for now it suffices to say that the range of symptoms that have been associated with cluttering is much broader

than that for the various of types of stuttering. The reasons for this is that the impairment underlying cluttering seems to affect both the speech and the language production systems.

Providing Clinical Services to People Who Have Fluency Concerns Speech-language pathologists provide a range of clinical services to people who have fluency disorders. The topic of clinical service provision with this population is addressed extensively in this book.

The Rewards of Being a Fluency Clinician Many clients and clinicians find their participation in a speech fluency intervention program to be a rewarding experience. As described later in this book, fluency disorders can result in marked difficulty with spoken communication, which in turn, can lead to other difficulties, such as social isolation and self-limiting thoughts and beliefs. One of the greatest joys for a clinician who works with this population is to hear clients describe the important changes they have made in their lives through participation in a fluency intervention program. The changes that clients describe often go beyond those associated with speech mechanics to include improvements in situations that, from the client’s perspective, were loaded with personal risk and/ or stoked with unpleasant feelings and emotions. For instance, after many months of avoiding certain important speaking activities because of anticipated difficulties with speaking fluently, a woman who stutters might decide at last to attempt these activities regardless of how fluent her speech is. A young man who stutters might report that after years of berating himself about his limitations in speech fluency, the skills and concepts he has learned during treatment have helped him reach a point where he now accepts that everyone has areas of relative strength and areas of relative weakness, and that one can feel satisfied about having communicated effectively, even if not per-



fectly fluently, in a given situation. Though speaking more smoothly is certainly an understandable and worthwhile goal for many clients to pursue, changes that affect one’s level of social engagement and sense of self-acceptance are likely to be truly transformative in a person’s life. SLPs are the professionals who are most qualified to assist clients in bringing about these transformative changes. Historically, however, not everything has been positive in the world of providing clinical services in the area of fluency. In fact, research shows that SLPs have tended to view clinical service provision in the area of fluency with trepidation. For example, clinicians have ranked the fluency disorder stuttering lower than many other communication disorders in terms of the extent to which they feel confident about and comfortable with providing services (Cooper & Cooper, 1985, 1996; Sommer & Caruso, 1995; St. Louis & Durrenberger, 1993). In past decades, clinicians’ attitudes toward providing services in this area have been linked to limitations in the breadth and depth of preservice (i.e., academic) and in-service (i.e., postdegree continuing education) training that clinicians have received (Crichton-Smith, Wright, & Stackhouse, 2003; Kroll & Klassen, 2007; Sommer & Caruso, 1995; Yaruss et al., 2017; Yaruss & Quesal, 2002). Although preservice training seems to have improved in some respects over the past 20 years, there still is considerable unevenness across academic programs and room for improvement in the United States in areas such as degree of expertise across instructional faculty and the extent to which fluency-related concepts and skills are addressed in academic and clinical curricula (Yaruss et al. 2017). Another important contributor to clinicians’ apprehension about providing services to clients with fluency difficulties is that quite often the clinicians with limited preservice training also have an incomplete or inaccurate understanding of basic issues, such as those that pertain to the nature of fluency disorders (e.g., Why do certain people produce so many disfluencies when talking?), procedures for arriving at a diagnosis (e.g., How does one distinguish between typical and disordered fluency?), factors that affect the developmental course of fluency disorders (e.g., Why do fluency problems resolve in some children but not others?), key treatment-related matters (e.g., What constitutes a

1.  An Introduction to Fluency Disorders

successful treatment outcome, and what is best way for helping my client attain that outcome?), and perhaps most important of all, the impacts that fluency disorders have on individuals’ quality of life. It is no wonder that a clinician who is wrestling with how to answer these basic questions would feel unsure about providing clinical services to individuals who have disordered fluency. The good news is that, in recent decades, a dedicated group of professionals around the world has been hard at work studying these and other important aspects of fluency disorders. Their efforts have resulted in a proliferation of information about fluency disorders, which in turn, has led the community of scientists and clinicians who work in this area to develop a much more accurate and complete understanding of these disorders and how they impact people. Certainly, there remains much more for scientists and clinicians to discover about fluency disorders. Nonetheless, because so much has been learned and so many insights have been gained, it is fair to say that there has never been a better time in history to become a clinician who specializes in working with people who have impaired fluency. The information in this book is designed to provide readers with the opportunity to develop their baseline knowledge and clinical skills in ways that are necessary for providing competent services to clients of all ages who have fluency concerns.

Developing the Necessary Knowledge It is well recognized that to become an effective clinician in a clinical practice area, one must develop a rich, accurate understanding of the characteristics and the causes of the specific disorders in that clinical practice area. One also must have a solid understanding of the ways in which each disorder impacts the lives of the affected individuals. With a robust knowledge base in place, a clinician is then well positioned to implement the accompanying set of relevant clinical skills he or she has developed for the purpose of administering effective intervention programs. The integration of a robust knowledge base and the ability to perform key clinical skills forms the core of the standards that ASHA has developed

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for its Certificate of Clinical Competence. In the most recent version of these standards, the CFCC in Audiology and Speech-Language Pathology of ASHA (2018) details an assortment of content areas in which clinicians must demonstrate knowledge, including the following: • Statistics and biological, social/behavioral, and physical sciences; • Normal bases of speech fluency; • Etiologies, characteristics, and correlates of fluency disorders and differences; • Current principles and methods of prevention, assessment, and intervention for persons with fluency disorders; • Standards of ethical conduct; • Research methods and the role of research in evidence-based practice; • Contemporary professional issues that affect clinical practice; and • Professional certification and licensure credentialing, as well as regulations and policies that affect service provision.

Developing the Necessary Skills CFCC (ASHA, 2018) also specifies general standards that must be met with respect to clinical skills. These include the following: • Demonstration of communication skills with the client and other relevant individuals that allow for competent professional practice; • Demonstration of essential skills that pertain to client evaluation; • Demonstration of essential skills that pertain to client intervention; and • Demonstration of essential skills that pertain to the clinician’s personal qualities and interactions with others. Table 1–2 provides more detail about the specific clinical skills that pertain to evaluation, intervention, and personal qualities and interactions with others in the most recent version of the CCC standards. These standards for professional practice provide a framework for what a competent SLP must be able do. When working with people

who have fluency concerns, however, there are a number of disorder-specific principles and skills that clinicians must acquire. Specific skills that pertain to assessment are discussed in Chapters 11, 12, and 13, and specific skills that pertain to intervention and the clinician’s skills in the areas of professional communication, interpersonal interactions, and intervention practices are discussed in Chapters 14 through 18. Although the requisite skill set is fairly wide ​ — ranging from the skills associated with specific motor speech skills to the skills that go along with offering counsel to clients about their fluencyrelated emotions, feelings, thoughts, and beliefs — it is one that is quite feasible to develop, and there are many clinicians around the globe who have done so. Some clinicians have gone so far in pursuing their interests in treating people who have fluency disorders to gain recognition as a Board Certified Specialist in Fluency (BCS-F) by the American Board of Fluency and Fluency Disorders.

Developing Competencies for Interprofessional Practice Clinical service provision in speech-language pathology takes place in an interprofessional context. Thus, when providing clinical service to individuals who have fluency difficulties, SLPs are likely to interface not only with the client and the client’s family, but also with a host of individuals from other professions. These include teachers, educational and counseling psychologists, occupational and physical therapists, and perhaps physicians and related medical personnel. For this reason, ASHA states that, beyond professional knowledge and skills, certified SLPs also must demonstrate a core set of attributes and abilities that are central to professional practice in an interprofessional setting. These include the following: • Accountability (i.e., demonstrating mutual respect for and shared values with professionals with whom you engage); • Effective communication (i.e., communicating with professionals, clients, and other individuals involved in intervention in a manner that is responsive, responsible,



1.  An Introduction to Fluency Disorders

Table 1–2.  Summary of Skills Included in ASHA’s 2020 Clinical Certification Standards for Speech-Language Pathology Communication Skills, Interaction Skills, and Personal Qualities (Standards V-A and V-B-3)

Evaluation Skills (Standard V-B-1)

Intervention Skills (Standard V-B-2)

Conduct screening and prevention activities.

Collaborate with clients (and others1) to develop settingappropriate intervention plans.

Use appropriate clinical and professional communication (oral2, written, and other modalities) interactions with clients (and others).

Collect case history information; integrate the information with other information.

Develop and implement intervention plans, while involving clients (and others1) in the process.

Communicate effectively with the client and other relevant individuals.

Select and administer appropriate evaluation procedures.

Select/develop and use appropriate materials and instrumentation for prevention and intervention.

Manage the client’s care to ensure use of interprofessional, team-based collaborative practice.

Adapt evaluation procedures to meet the client’s (and others’1) needs.

Measure and evaluate client’s performance and progress.

Provide counseling to client/ patient, family, caregivers, and relevant others.

Process data to develop diagnoses and make appropriate intervention recommendations.

Modify intervention plans, strategies, materials, or instrumentation as appropriate to meet the client’s needs.

Adhere to ASHA (2016b) Code of Ethics and behave professionally.

Complete all administrative and reporting functions that are necessary to support the evaluation. Refer individuals as necessary for appropriate services. 1

The term and others refers to the client’s family members and other relevant individuals who are involved in treatment. CCC applicants must demonstrate oral language skills consistent with ASHA’s current position statement on Englishspeaking competence.

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and supportive of intervention team goals); • Professional duty (i.e., having an understanding of how an interprofessional approach to assessment and treatment works and how it benefits clients, and having the ability to implement it effectively to coordinate speech-language pathology with other services the individual may be receiving); and • Collaborative practice (i.e., having an understanding of the values and principles

that are central to interprofessional practice; when appropriate, being able to effectively plan and implement team roles beyond those immediately associated with speech-language pathology, in a safe, timely, efficient, effective, and equitable manner).

Engaging in Evidence-Based Practice Clinicians who have a well-developed knowledge base about fluency disorders, an appropriate set of

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clinical skills, as well as other key professional practice competencies are well positioned to engage in high-quality clinical practice. Evidence-based practice (EBP) is a concept that has gained widespread attention in professions such as speech-language pathology over the past 20 years. ASHA (2005) stipulates that principles of evidence-based practice must be incorporated as completely as possible into the clinical decisions that SLPs make. Contemporary models of evidence-based practice include three components: (1) evidence that comes from current, high-quality research pertaining to assessment and treatment practices; (2) evidence that comes from the SLP’s professional expertise in the area of practice (e.g., how a specific client is responding to an intervention, how similar clients have responded to an intervention in the past); and (3) preferences and values of a fully informed client (or, in some cases, informed parents). Knowledge about which clinical practices are and are not well supported by evidence from the current research literature is an excellent starting point for selecting an assessment or treatment approach. Clinicians who possesses such information are likely to spend most of the time in treatment engaged with the client in activities that are likely to be effective, and less time in activities that are either marginally effective or ineffective. Because research-based evidence is external to the client, however, the SLP must supplement it with internal, patient-specific data (Dollaghan, 2007). Internal evidence includes things such as the clinician’s records about client performance within and across treatment sessions and the clinician’s accumulated knowledge from past clients about matters such as whether a particular treatment’s effectiveness is affected by the client’s age or presence of concomitant communication disorders. Such information is important to incorporate into clinical practice because treatments that have been shown to be effective for many people are not necessarily going to be effective for the client who the clinician currently is serving. Patient preferences and values also are important to incorporate in an intervention plan. This component of evidence-based practice is important to address because, after all, the client is the one who lives his or her fluency disorder every day and is, therefore, the expert when it comes to

how his or her disorder is experienced (Dollaghan, 2007; Zebrowski & Wolf, 2011), People who stutter often possess their own distinct impressions of and feelings toward fluency intervention. Their views typically are based on their past experiences in daily life and, in some cases, with fluency therapy (Yaruss, Quesal, & Murphy, 2002). Accordingly, nearly all clients will have opinions about what it is that they hope to accomplish in treatment and whether the clinician’s treatment recommendations seem like a suitable way to approach these goals.

Establishing Effective and Valued Working Relationships With Clients As suggested in the preceding section, a critical component of evidence-based practice is the incorporation of the client’s preferences and values (and, when appropriate, parents and other family members) in the therapeutic process. In this way, clients and other involved individuals have opportunities to shape the content and scope of intervention in ways that align with their values and goals, and in doing so, develop a sense of ownership in the intervention process and a sense of shared responsibility with the clinician for how the intervention will transpire. There is a large and long-standing body of research literature in the area of counseling psychology, and more recently in speechlanguage pathology, with respect to factors that affect how clients feel about the relationship they have with their clinician throughout the intervention process. The term therapeutic alliance is used to describe this construct, and it has been argued that client perceptions regarding the strength of this alliance plays a critical role in determining treatment outcomes. Bordin (1979) argued that therapeutic alliance is based on a sense of emotional attachment or bonding between the client and clinician. As such, it goes beyond having the client become acquainted with the clinician or the clinician asking the client to provide input into treatment design and goals. Some contend that the strength of the therapeutic alliance may play a bigger role in client change than the formal treatment approach that is often used (Wampold et al., 1997). Plexico, Manning, and DiLollo (2010) examined responses from 28 adults who had partici-



1.  An Introduction to Fluency Disorders

pated in treatment for stuttering. The participants, whose lengths of therapy participation ranged from 6 months to 12 years responded in writing to a set of four standard prompts, which were designed to identify characteristics of clinicians who they felt were effective or ineffective in promoting successful changes in their ability to communicate. The participants also were asked to describe how they felt about each type of interaction, and the common content themes they expressed were identified and summarized. The participants described effective clinicians as having the following attributes: • Passionate and committed, believing in the therapeutic process and in the client’s ability to change; • Making clinical decisions based on the client’s needs, capabilities, and personal goals. • Having a professional, confident demeanor and demonstrating understanding of the nature of stuttering and its treatment; • Being able to build a trusting relationship with the client; • Being an active listener and demonstrating a patient, caring demeanor; • Encouraging client participation and agency (i.e., a person’s ability to take the actions that are necessary to secure a desired outcome [Bandura, 2000]); and • Acknowledging and/or promoting the client to realize cognitive change (e.g., thinking about fluency and communication in more positive and constructive ways). As can be surmised from this list of characteristics, effective clinicians go beyond academic knowledge and speech-based technical skills in ways that put the person above the fluency disorder. Effective clinicians are invested in developing a rich understanding of what each client’s communication challenges are like, including making an attempt to ascertain the client’s unique perspective on the affective (feelings and emotions) and cognitive (thoughts, beliefs) elements that are associated with their communication challenges. They engage with clients in ways that convey a sense of caring for, listening to, and promoting the client’s goals. Accordingly, such clinicians are able to help clients

change not only their ability to communicate but also, more broadly, their lives. This type of outcome is much more encompassing and likely to be much more functional than an outcome that aims only to help a client reduce the frequency with which he or she produces disfluency. As such, it is likely to be an outcome that, once attained, will be one that clients recognize, value, and greatly appreciate.

Summary This chapter introduced the topic of fluency disorders and, along with it, an overview of the many and varied roles that SLPs assume when working with individuals who have impaired communication and/or swallowing. The term fluency was defined and discussed within the context of communication and as a contributor to an individual’s overall health and sense of well-being. It was emphasized that fluent speech is best understood by examining with the broader contexts of speech production and human communication. The roles and responsibilities of the SLP in the realm of fluency disorders were discussed within the context of the service delivery domains and professional practice domains described in ASHA’s (2016a) Scope of Practice in Speech-Language Pathology. It was emphasized that professional practice with individuals who have impaired fluency goes well beyond the core assessment and treatment activities that many pre-service and beginning clinicians are familiar with, to include elements such as counseling, collaboration, prevention, advocacy, engagement in research, and assisting pre-service individuals and less-experience professional colleagues who are in the process of developing expertise in this area. Essential concepts from WHO’s (2001) International Classification of Functioning, Disability, and Health (ICF) were presented. These concepts constitute one of the major organizational frameworks for the discussion of information in this book. A brief overview of fluency disorders and associated terminology was provided. Each type of fluency disorder is discussed at length in later chapters. One major point of emphasis is the importance

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of viewing the surface-level characteristics of a person’s fluency disorder within the broader context of his or her unique personal and environmental setting, and the importance of adopting a broad view of the purpose for intervention — one where the focus is on the client’s communicative functioning and overall social/emotional well-being rather than on simply the number of disfluencies he or she produces in conversation. The chapter concluded with discussion of several components that are necessary for the provision of evidence-based clinical services in the area of speech-language pathology. Areas of knowledge and clinical skill that are essential to clinical service provision in the area of fluency disorders were outlined, along with competencies for interprofessional practice. These elements provide a platform for evidenced-based practice, wherein clinicians combine high-quality scientific data about intervention practices with their professional expertise, empirical data they have collected about the client, and input from the clients regarding what they hope to attain from clinical services, their priorities in intervention, and their preferences for how to attain them. The chapter concluded with a discussion of the clinician qualities that contribute to clients’ feeling that they have a strong therapeutic alliance and productive working relationship with

their clinician. These qualities go beyond the basic elements of evidence-based practice to include several key interpersonal skills as well as basic human qualities and attributes such as conveying a sense of respect for the client and a firm commitment to working toward the fulfillment of the professional duty that a clinician assumes when entering into a therapeutic relationship with a client.

Questions to Consider • In which social contexts is it most important for people to speak in a highly fluent manner? • In which social contexts is it least important for people to speak in a highly fluent manner? • Are there social contexts where it is expected that people will speak with less than perfect fluency? • Are there social contexts where it is expected that people will speak very fluently? • In what ways can a lack of fluency hinder a person’s social interactions? Ability to communicate? Self-esteem?

2 Conceptualizing Fluency

in aspects of typical and/or disordered communication have parsed the construct of fluency into subcomponents such that fluency is viewed as a multidimensional construct.

Chapter Objectives After reading this chapter, readers will be able to: • Describe seven primary dimensions of fluency and a model that shows their interrelationship. • Compare/contrast language fluency versus speech fluency. • Describe the main components of the speech production process and how these components relate to speech fluency. • Explain why it is necessary to have a clear conceptualization of fluency prior to working with individuals who have impaired fluency.

Fluency: A Multidimensional Construct

Context and Historical Perspective As discussed in Chapter 1, the notion of fluency is observed in the range of human activity, including human communication, wherein one can describe the fluency with which people read, write, sign, and speak. Related to this, the term fluency also connotes the notions of mastery and competence (e.g., the fluency with which one speaks a language). Over time, professionals who are interested

A clinician’s ability to assess and treat individuals is enhanced significantly by having a solid understanding of what fluency is. In this book, fluency is viewed as an index of both language functioning and speech functioning. As such, it is examined within a multidimensional framework. The concepts discussed in this section mainly originated in the 1960s through the 1980s, a period when a substantial amount of research was conducted to describe normal or typical communication processes in greater detail. The information in this section is largely derived from the influential work of Fillmore (1979) and Starkweather (1987), each of whom proposed frameworks for use in the study of fluency.

Fluency as an Index of Language Functioning Fillmore (1979) primarily discussed fluency as it pertains to the general population and individual

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differences in fluency performance. Fillmore viewed fluency from a linguistic orientation. Consequently, he considered a speaker’s fluency performance to be a reflection of his or her underlying language abilities. As discussed later, Fillmore’s approach to conceptualizing fluency overlaps to some extent with contemporary concepts such as pragmatic functioning and social communication. Fillmore (1979) noted that it is important to differentiate between “how people speak [a] language and how well people speak [a] language” (p. 93). He argued that the “how” of language is manifested through language-specific rules that govern syntax, morphology, and phonology, and that fluency is a measure of how well people implement their knowledge of language during everyday settings. Fillmore (1979) proposed four fundamental fluency abilities: • “The ability to talk at length with few pauses” (which is discussed here using terms such as talkativeness, verbal participation, and verbal output); • “The ability to talk in coherent, reasoned, and ‘semantically dense’ sentences” (which is discussed here using terms like succinctness, conciseness, and communication efficiency; • “The ability to have appropriate things to say in a wide range of contexts” (which is discussed here using the term linguistic flexibility); and • “The ability . . . to be creative and imaginative in . . . language use” (which is discussed here using the term linguistic creativity). (p. 93)

Fluency as an Index of Speech Functioning Starkweather (1987) extended Fillmore’s (1979) language-oriented approach to fluency competence by proposing additional dimensions of fluency, each of which pertained primarily to physical aspects of speech production. Starkweather defined speech fluency as “a normal level of skill in the 1

production of speech” (p. 12). Like Fillmore, he proposed four primary dimensions of fluency: • Continuity (i.e., the connectedness of sounds, syllables, and words in a spoken message); • Rate (i.e., the speed at which a spoken message is delivered); • Rhythm (i.e., prosodic patterns or rhythmic characteristics in a spoken message); and • Effort (i.e., the amount of energy a speaker expends when speaking). Starkweather noted that continuity, rate, and rhythm are associated with aspects of speech timing, and that each is subordinate to effort. In other words, utterances1 that a listener (and, most likely, the speaker) perceive to be unusually effortful often are those that feature atypical continuity, rate, and/or rhythm characteristics. There are two other qualities of speech production that have been linked to fluency: speech naturalness and talkativeness. Speech naturalness (Nichols, 1966; Parrish, 1951) is a construct that researchers in speech-language pathology began to study in earnest during the 1970s and 1980s. At that time, researchers began to use naturalness as a means of evaluating the quality of speech in individuals who had participated in treatment programs for stuttering (e.g., Ingham & Packman, 1978; Martin, Haroldson, & Triden, 1984; Runyan, Bell, & Prosek, 1990). In such studies, researchers were interested in comparing the posttreatment speech of speakers who stuttered to the speech of speakers who did not stutter (i.e., typical speakers) to determine the extent to which individuals in the two groups sounded similar. The thinking at the time was that, ideally, a person who completes a treatment program for stuttering will attain speech that sounds as natural as that of a typical (unimpaired) speaker. Measures of speech naturalness have become relatively common in studies of treatment efficacy with speakers who stutter (e.g., Riley & Ingham, 2000; Teshima, Langevin, Hagler, & Kully, 2010), and some authors

An utterance is a string of words or clause that communicates an idea and is bound by a single intonational contour (e.g., Logan & Conture, 1995, 1997; Meyers & Freeman, 1985). Utterances often are set apart by pauses, as well. An utterance can consist of a single word (e.g., me) or multiple words (e.g., In the morning). All sentences are utterances, but not all utterances are sentences.



2.  Conceptualizing Fluency

have recommended that they be adopted as a standard treatment outcome metric (Ingham & Riley, 1998). Like effort, naturalness seems to function as a superordinate dimension of fluency in that it reflects the combined characteristics of other fluency dimensions (i.e., continuity, rate, rhythm, and effort).

The Dimensions of Fluency Seven primary fluency dimensions are described in this section. Table 2–1 provides an overview of these fluency dimensions.

Fluency Dimensions: Speech Continuity

Fluency as an Index of Performance Stability Stability is another dimension of fluency. In the context of this book, the term stability pertains to performance consistency over time within the domain of speech fluency (Kleinow & Smith, 2000; Smith & Goffman, 1998; Van Riper, 1971; Yaruss, 1997). Stability is studied through repeated measurements of an individual’s speech performance. For most speakers, the speech production system functions in a stable manner. For example, a typical speaker is expected to exhibit essentially the same manner and degree of fluency when asked to say the same sentence 10 times in succession or when asked to speak in the same situation day after day. Variability is a construct that is closely associated with stability. An unstable speech system yields more variable performance than a stable speech system.

The term continuity refers to the connectedness with which a person speaks. More specifically, continuity concerns the extent to which a speaker articulates the sounds within syllables, the syllables within words, and the words within utterances in a seamless, ongoing manner. In another sense, one can view continuity as the extent to which spoken utterances are free from disruptions or breaks in the flow of information. Breaks in the continuity of speech occur in all speakers, even speakers who are regarded as having “normal” or “typical” levels of speech fluency. There are several scenarios under which breaks or disruptions in speech continuity can arise. Some of these scenarios are more relevant than others to clinical practice in the area of fluency disorders. Nonetheless, it is important

Table 2–1.  Overview of Speech Fluency Dimensions Dimension

Description

Continuity

The extent to which spoken utterances are free from unintended breaks or interruptions that arise from problems in speech planning or execution.

Rate

The speed with which linguistic information is expressed during a spoken utterance.

Rhythm

Prosodic patterns in speech that arise from the durations of pauses and syllables, and the speech sound segments that comprise syllables.

Effort

The amount of physical or mental energy a speaker expends when producing a spoken utterance.

Naturalness

The extent to which spoken utterances sound like those of typical speakers in terms of their continuity, rate, rhythm, and/or effort.

Talkativeness

Includes (a) the amount of speech produced (verbal output), (b) conciseness and creativity in conveying information through speech, and (c) breadth of participation across life activities.

Stability

Pertains to the consistency (or variability) of continuity, rate, rhythm, effort, and naturalness over time and across tasks.

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for fluency clinicians to have a broad understanding of the conditions that lead to breaks or disruptions in speech fluency, and the differences between types of fluency disruption that tend to be of clinical concern.

Continuity Breaks Caused by Conversational Partner Interruptions Some continuity breaks arise when person in a conversation does something that causes another person in a conversation to stop speaking temporarily. The term conversational partner interruption is used to describe this type of continuity break. Typically, it arises when one participant in a conversation talks at the same time as another participant in the conversation who currently is talking. This results in the person who currently is speaking to choose between yielding the speaking turn to the conversational partner or continuing to speak. If the speaker opts to yield the speaking turn, his or her ongoing utterance, of course, will be discontinued. Factors that can influence a speaker’s decision on whether to yield a speaking turn include the speaker’s social status relative to that of the partner and the perceived importance of the partner’s utterance relative to the speaker’s utterance. Continuity interruption that results from verbal interruption is important to note when assessing fluency. This is because speakers who have fluency difficulties are prone to having their utterances interrupted by others (Meyers & Freeman, 1985) and because verbal interruption has the potential to exacerbate the communication difficulties that speakers with fluency disorders experience (Kelly & Conture, 1992; Millard, Nicholas, & Cook, 2008; Starkweather, Gottwald, & Halfond, 1990).

Continuity Breaks Associated With Basic Physiological Functions Speech breathing is the most common physiological event that leads to breaks in speech continuity. Continuity breaks of this sort occur when a speaker’s air supply is inadequate to support the amount of speech that the speaker is attempting to produce. Usually, speech breathing results in brief periods of silence or near silence — often lasting less than one-quarter second — as the speaker inhales enough air to meet basic physiological

needs as well as the demands associated with the upcoming segment of speech. There are a host of less commonly occurring nonspeech behaviors that are associated with basic biological functions or with emotional expression also disrupt speech continuity. Examples of these include the following: sneezing, sniffing, yawning, laughing, hiccupping, burping, panting, grunting, and coughing (Kent, 2015). Most often, these behaviors are extraneous to the utterance within which they occur. Because these behaviors typically do not have a communicative function, they usually are not relevant to speech fluency assessment. Exceptions are rare but include instances when a clinician judges that a speaker produces the behavior deliberately to conceal, circumvent, or postpone difficulties associated with fluency impairment. Clinicians, even inexperienced ones, are typically adept at detecting inauthentic yawns, coughs, and so forth, and in such cases will find it straightforward to document their occurrence.

Continuity Breaks Associated With Utterance Prosody The term prosody is a phonological concept that refers to the rhythmic and intonational properties of a spoken utterance (Kent & Read, 1992). As such, the term encompasses the metrical properties of spoken utterances, including phenomena such as the duration of speech sound segments, word duration, and pause duration (Ferreira, 1993, 2007; Selkirk, 1984). It is thought that, during utterance planning, a speaker specifies the metrical (i.e., timing) properties associated with the individual words that comprise what is about to be said (Selkirk, 1984). Speech scientists and psycholinguists regard metrical planning as a primary source of the final syllable lengthening phenomenon — that is, the tendency for a syllable to be longer in duration when it occurs in an utterance-final context than it is when it occurs in other (nonfinal) utterance contexts (Ferreira, 1993; Fon, Johnson, & Chen, 2011; Klatt, 1974, 1975; Snow, 1994, 1997). Other aspects of speech that have a prosodic basis include the syllable stress and sound segment lengthening associated with the conveyance of certain communicative intentions. For example, a speaker can convey equivocation through vowel lengthening, as in the lengthening of the vowel [ε]



2.  Conceptualizing Fluency

in the word “well” (Well, it’s complicated). Pausing is an aspect of prosody that has relevance to both verbal communication and the assessment of speech continuity. Speakers use pauses intentionally for a variety of purposes. Chief among these is to mark syntactic boundaries (e.g., Our dog eats from this dish [pause] but our cat eats from that dish). Speakers also use pauses to convey communicative intentions such as suspense (e.g., The winning number in this week’s Lucky Lottery drawing is [pause] 1528) and equivocation (e.g., Speaker 1: Is it a little dent? Speaker 2: Well [long pause] that depends on what you mean by “little.”) Other aspects of prosody include fundamental frequency and intensity, aspects of speech that yield information about the intonation of an utterance (Kent & Read, 1992). Although the intonation pattern of an utterance is not directly associated with its continuity, it can provide information about speech effort, a dimension of fluency discussed later in this chapter. A clinician might show interest, for example, when a speaker’s vocal pitch changes in an atypical manner because such a pattern probably was not part of the speaker’s original speech production plan and, instead, is indicative of excessive laryngeal tension that occurred during

the course of saying the utterance. Speakers who stutter sometimes produce sudden upward shifts in pitch while talking, a behavior that coincides with the buildup of excess subglottal air pressure and the abrupt release of excessively tense adducted vocal folds upon syllable initiation.

Continuity Breaks Associated With Abandoned Communicative Goals Disruptions in speech continuity also can occur when a speaker shifts his or her attention away from the communicative intention at hand in order to pursue another behavioral goal. The main pattern is that the speaker suddenly attends to something that he or she regards as either more interesting or more important than the current message, and in doing so, discontinues the ongoing utterance. For example, a woman who is engaged in conversation with a friend at the grocery store might interrupt an utterance in midstream after remembering that she left a candle burning at home near an arrangement of dried flowers. In instances like this, the individual’s goal shift results in a prompt cessation of speech, and it is not always clear whether the speaker will resume the utterance or not. When the

Distinguishing Between A Speaker’s Planned and Unplanned Speech Behaviors When assessing fluency, it is necessary to distinguish between those metrical events that a speaker appears to produce as part of the communicative intention that is being expressed and those that are produced for reasons that are indicative of fluency impairment. Usually, continuity interruptions that appear to be planned (e.g., a vowel that is lengthened to convey equivocation, a pause of typical duration at the end of a major grammatical unit) will be unnecessary to note in a clinical fluency analysis, but continuity interruptions that are associated with fluency impairment will need to be noted. This may seem like a daunting task, but, in practice, identification of this type of atypical behavior usually is straightforward to do, especially when the clinician collects information about related aspects of the speaker’s behavior, such as the frequency, location, and duration of the pauses or lengthened speech sounds, or when the clinician observes the amount of muscle tension in the speech articulators during vowel lengthening. The presence of the latter types of behavior would suggest that the speaker’s pauses and/or lengthened speech sounds are not associated with the expression of communicative intent, but rather with difficulties in planning or producing upcoming portions of the utterance. Methods for identifying the symptoms of fluency impairment are discussed in later sections of the book.

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speaker does not resume the utterance promptly, it is considered an abandoned utterance. Analyses of conversational speech samples from typical speakers show that continuity breaks that involve utterance abandonment are uncommon and thus usually not of clinical concern in most cases. However, in cases where a person is referred for assessment of speech-language concerns, a clinician typically will want to note where and how often utterance abandonment occurs. Doing so will help the clinician to ascertain whether these disruptions in speech are symptomatic of communicative impairment. For example, in cases of severe stuttering, recurring instances of utterance abandonment could arise when a speaker essentially gives up on saying specific utterances because of the amount of effort it takes to produce them. In other cases, frequent instances of utterance abandonment could be symptomatic of utterance formulation difficulties.

Continuity Breaks Associated With Utterance Planning Problems As noted in the previous section, a common source of disruption in speech continuity involves problems in planning what is about to be said. Speech production is a complex process that requires the generation and assembly of discreet representations of linguistic and articulatory information. All utterances, even superficially simple ones, take some amount of time and multiple steps to plan. Although some utterance planning seems to take place during the pauses that occur at syntactic boundaries and between utterances, some of it also seems to take place as a person is actively speaking (Ferreira, 2007). When pauses occur at major syntactic boundaries, it can be challenging to determine how much of the pause reflects aspects of an utterance’s prosody (i.e., planned pausing) and how much of the pause reflects activities associated with planning of upcoming segments of the utterance (i.e., planning pauses). Continuity interruptions that are associated with utterance planning are of primary interest in fluency analysis. The factors that lead a speaker to take an unusually long time to plan upcoming speech often are covert, meaning that they are not outwardly observable. As indicated earlier, pauses

may be judged to be indicative of problems in utterance planning when their duration lasts for longer than the norm or when the silence is accompanied by other behaviors (e.g., evidence of “struggle” such as excessive physical tension or dysrhythmic inhalation of air) that are symptomatic of impairment in speech fluency. In some instances, the speaker may be able to describe the source of the usual pause in speech; but in instances when the speaker is unable to do so, the clinician is left to rely on his or her judgment about what has occurred. Planning-based continuity disruptions are identifiable with a much higher level of confidence in instances where a speaker says a portion of an utterance, and then stops, backtracks, and changes some aspect of what was previously said (i.e., revises the utterance). This occurs when the speaker determines that the content of something that just has been said is mismatched with what the speaker intended to say. If a speaker detects the deviation and elects to repair it by revising what he or she has just said, the speaker’s error becomes overt. In other words, the incorrect or mismatched portion of the utterance can be heard by both the speaker and the listener. Every speaker exhibits at least some overt errors when talking. In the general population, these errors usually are linguistically based, meaning that they are rooted in errors that affect the syntactic, morphologic, or phonologic form of an utterance and/or the words (i.e., lexical items) that the speaker selects for inclusion in an utterance. During fluency assessment, clinicians will want to note continuity breaks that are associated with linguistic formulation errors. These types of continuity breaks are of significance clinically when they deviate significantly from the norm with respect to their frequency, duration, type, or structure. The main objectives in a clinical setting are to document the occurrence of such disruptions in fluency as they occur, the conditions under which they occur, and the extent to which they limit the speaker’s communicative functioning.

Continuity Breaks Associated With Speech Motor Control Problems Motor control problems constitute another potential source for continuity breaks in speech. Some individuals, particularly those who stutter, are



2.  Conceptualizing Fluency

likely to report experiencing difficulties with initiating and maintaining continuous production of the sequenced articulatory movements that comprise spoken utterances. In such cases, the speaker typically will report that he knows precisely what he wants to say (which suggests that the linguistic content and form of the utterance have been planned) and how he wants to say it (which suggests that suprasegmental aspects of the utterance such as stress and pause patterns have been planned), but at that moment, he is unable to produce the articulatory movements that are needed to execute the speech sounds that constitute the utterance. Motor-based continuity interruptions of this sort are a hallmark of the fluency impairment that results in stuttered speech. As such, a clinician surely will want to note this type of continuity interruption during a fluency assessment.

Continuity Interruptions Versus Disfluencies As noted in the previous section, not all interruptions in speech continuity are indicative of fluencyrelated communication problems. This leads to the question of whether one needs to record all instances of continuity interruption — regardless of their source — when describing a speaker’s fluency. The answer to this question largely depends on an examiner’s objectives for assessment, the extent to which the examiner deems the continuity interruptions to be relevant to the client’s fluency functioning, and the level of behavioral detail about the client’s functioning that the examiner wishes to capture.

Fluency Dimensions: Rate and Rhythm The constructs of rate and rhythm both deal with temporal (i.e., time-based) information. Thus, in the context of fluency, the two are closely intertwined and inextricably related to speech continuity. That is, breaks in speech continuity not only disrupt the rhythm of an ongoing utterance, but they also slow the rate of informational output by consuming time that a speaker might otherwise spend in productive communication.

Speaking Rate The term speaking rate pertains to the speed at which a speaker conveys information while talking (Logan, Byrd, Mazzocchi, & Gillam, 2011). There are two general approaches to measuring the rate of speech. The first approach, termed articulation rate, is computed using stretches of speech that are free from interruptions in continuity. Some clinicians base their articulation rate analysis on complete utterances, while others base it on a speech unit called a run, which they define as some minimum number of consecutive syllables (usually at least four or five) within an utterance that a speaker produces without a break in continuity. Thus, a run can constitute either an entire utterance (see Example 2–1) or a portion of an utterance (see the underlined segment within Example 2–2). Example 2–1:  The storm dumped 12 inches of rain. rain Example 2–2:  The [ss-] storm dumped 12 inches of rain. rain Articulation rate is computed by dividing the total number of syllables sampled across all fluent utterances (or runs) by the total amount of time taken to articulate each of the fluent utterances (or runs). Speech-language pathologists usually compute articulation rate by analyzing a predetermined minimum number of utterances or runs (e.g., 10 or 20) that they select randomly from some larger speech sample. The goal is to obtain a valid estimate of the speaker’s customary articulation rate. Because articulation rate is based on perceptibly fluent stretches of speech, the measure provides clinicians with a sense of how rapidly a speaker talks at times when the speech production system is functioning optimally. Adult speakers attain increases in articulation rate, in part, by increasing the amount of coarticulatory overlap across adjacent speech sound segments rather than by simply increasing the velocity of articulatory movements (Gay, 1978; Gay, Ushijima, Hirose, & Cooper, 1974). Coarticulation refers to the extent to which the articulatory movements for one speech sound segment carry over into the production of an adjacent speech sound segment (Nicolosi, Harryman, & Kresheck, 1989)

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Fluency Disorders

A second measurement approach, speech rate, involves the analysis of both fluent and disfluent utterances. When assessing speech rate, an examiner elicits a series of utterances from a speaker and then randomly selects a subset of those utterances (e.g., 10 or 20) for analysis. The number of syllables (or words) within each utterance is tallied and then summed across all sampled utterances. A key difference between articulation rate and speech rate is that with speech rate, disfluent utterances are permitted to be included in the set of utterances that the clinician samples for analysis. For the disfluent utterances, any speech sounds, syllables, or words that occur within disfluent segments of speech are included in the timing of utterance duration but are excluded in the count of how much productive speech the individual has spoken. The total number of syllables or words in the sample (excluding those that occur within disfluent segments of speech) then is divided by the total time spent speaking across each of the utterances (including the time spent during disfluent segments of an utterance). Because the syllables from disfluent segments of an utterance are included in the utterance timings but not in the counts of how much speech has been spoken, speech rate usually will be slower

than articulation rate. Similarly, a highly disfluent speaker usually will have a slower speech rate than a speaker who is rarely disfluent. This is because speech disfluency consumes time that a speaker would otherwise spend in productive communication (i.e., fluent speech). Speech rate is a particularly good measure to use when the goal is to quantify how a speaker’s disfluency characteristics change over time. A speaker who exhibits a decrease in the number and the duration of disfluencies over time almost always will exhibit an increase in speech rate. The effect of disfluency on speech rate and the difference between it and articulation rate are illustrated further in Table 2–2. The expected articulation and speech rate values for a speaker vary according to variables such as the type of task the speaker is performing, the speaker’s familiarity with the speaking topic, and the type of communicative intention that the speaker is conveying. In general, listeners tend to view the use of a brisk speech rate favorably. For instance, speech rate values correlate positively with ratings of a speaker’s competence, intelligence, and truthfulness (Apple, Streeter, & Krauss, 1979; Brown, Giles, & Thakerar, 1985; Smith, Brown, Strong, & Rencher, 1975). Nonetheless, listeners do not always view rapid speech favor-

Table 2–2.  Examples of Articulation Rate and Speech Rate Computation in Fluent and Disfluent Utterances

Line

Spoken Utterance

1

She sold the kayak in Cedar Key last weekend.

2

She saw [ma- ma-] manatees in the bay near the refuge. refuge

# of Syllables

Speaking Time (in seconds)

Articulation Rate (syl/s)

Speech Rate (syl/s)

12

2.8

4.3

4.3

10 in run

2.1 in run

4.8 (in run)

3.5 (in utt)

12 in utt

3.4 in utt

3

The [um] manatees swam [be- be-] beside [the-] the startled tourists.

12

3.9

—

3.1

4

She [um] hoped to [um] see some [um] dolphins, but [um] they [um] were not there.

12

5.2

—

2.3

Note.  Underlined text indicates a run of 5 or more continuous syllables within a disfluent utterance. Utt = utterance, syl = syllable. Articulation rate cannot be computed for lines 3 and 4 because neither utterance contains 5 consecutive syllables that are uninterrupted by disfluency. Disfluent speech is excluded when tallying the number of syllables per utterance. Note that the speech rates for utterances 2, 3, and 4 (the disfluent utterances) are slower than that for Utterance 1, even though each of the utterances contains 12 syllables when the disfluencies are removed. This is because disfluencies consume time that speakers otherwise would spend in productive communication.



ably. For example, listeners tend to regard speakers who use a moderate speech rate as being more benevolent than those who use a rapid speech rate (Smith et al., 1975). Starkweather (1987) noted that most speakers use a habitual rate that falls toward the upper end of their rate range. In other words, people tend to talk about as fast as they can talk, but not so fast as to compromise the intelligibility or accuracy of their spoken message. A third way to view rate is in terms of how promptly a speaker can initiate an utterance following a cue to begin speaking. Researchers use terms such as speech initiation time and speech onset latency when referring to this behavior. As explained further in Section II, speakers who stutter tend to have longer speech initiation times than speakers who do not stutter — even during utterances that listeners might perceive as fluent. Speakers who stutter also commonly report that they produce disfluencies more often during speaking contexts in which they feel obligated to initiate speech promptly, such as when saying “hello” after answering a phone call. For this reason, issues related to utterance initiation rate often have relevance in clinical settings.

Speech Rhythm Rhythm is an aspect of prosody that pertains to variations in syllable, segment, and pause duration throughout the course of an utterance. Rhythm is characterized as a suprasegmental aspect of speech because its effects are realized across syllables, words, phrases, and sentences (Bauman-Waengler, 2016). Some authors use the term tempo instead of or in addition to rhythm because it also captures the notion of speaking rate. An utterance’s rhythm differs from its intonation, with the latter referring to the pitch contour and stress patterns that extend over an entire utterance (Kent & Read, 1992). Multiword utterances are comprised of a combination of stressed and unstressed syllables. In English, the distribution of stressed syllables is unevenly spaced, meaning that the number of unstressed syllables occurring between stressed syllables is variable (Huggins, 1972). Thus, speech rhythms are not fixed in the same sense that musical rhythms are. A speaker can express the same sequence of words via a variety of rhythmic pat-

2.  Conceptualizing Fluency

terns (Kent & Read, 1992), and in doing so, alter the meaning that is being conveyed (e.g., YOU want that? versus You WANT that? versus You want THAT?). In clinical settings with individuals who have fluency concerns, the primary focus has been on stress patterns within words and phrases, with research consistently showing a higher tendency for speakers to produce stuttering-related disfluency on syllables that carry primary stress (Wingate, 1988).

Fluency Dimensions: Effort and Naturalness The next fluency dimensions to be discussed are effort and naturalness. In the context of speech production, a clinician can examine effort from either a mental or physical standpoint (Starkweather, 1987). Mental effort refers to the amount of thought or attention a speaker expends while talking, whereas physical effort refers to the amount of muscular exertion a speaker expends while talking (Hoit, Lansing, & Perona, 2007). Both areas have received considerable attention in speech production research throughout the years; and as technological advances allow for increasingly precise inquiry into the neurophysiological correlates of various cognitive processes, the relationships between objective measures of neural and muscular activity and subjective perceptions of mental and physical activity are becoming better understood (e.g., Schmidt, Lebreton, Cléry-Melin, Daunizeau, & Pessiglione, 2012). The physical properties of speech sounds are well documented. One widely used objective index of physical effort during speech sound production is intraoral air pressure. A variety of studies have examined differences in intraoral air pressure values across age levels, sound classes, linguistic contexts, and articulation rates (e.g., Klatt, 1974; Oller, 1973; Prosek & House, 1975; Subtelny, Worth, & Sakuda, 1966; Umeda, 1977). Both subglottal and intraoral air pressures have been used as indices of effort (e.g., Hixon, 1973; Prosek & House, 1975). Prosek and House reported a significant linear relationship between the amount of intraoral air pressure that is present during speech production and a speaker’s perception of speaking

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Fluency Disorders

effort. Other physical indices of speaking effort include electrodermal activity, peripheral blood flow, oxygen saturation levels, blood pressure, and heart rate (Craig et al., 1996; Hoit et al., 2007; van Lieshout, Starkweather, Hulstijn, & Peters, 1995; Weber & Smith, 1990). Variations in perceived mental effort during speech production have been assessed across an assortment of tasks as well. Methods for documenting mental effort include the use of multipoint rating scales, adjective listing, and narrative description (e.g., Hoit et al., 2007; Ingham, Warner, Byrd, & Cotton, 2006). Clinicians may use such methods with the goal of determining whether a speaker feels that he or she needs to attend closely to the mechanics of speech production while talking. It is interesting to speculate about the effect that careful, deliberate self-monitoring has on speech production processes. Results from some studies in nonspeech domains, such as ball throwing and free throw shooting, reveal that the use of consciously mediated control strategies (i.e., shifting attention focus to movement execution) for activities that ordinarily are executed without such attention focus can result in poorer performance, greater variability in movement coordination, and changes to movement dynamics and timing (Higuchi, 2000; Schücker, Hagemann, & Strauss, 2013). However, others (e.g., Geeves, McIlwain, Sutton, & Christensen, 2014; Toner, Montero, & Moran, 2014) have argued that, in the sporting and music domains, conscious cognitive activity plays an important role in supporting continued motor skills improvement in individuals who show expert level functioning.. It may be that task-specific anxiety (e.g., associated with fear-of-negative evaluation) may be a key moderator of the effects that self-focus has on performance by utilizing cognitive resources that otherwise might be allocated to movement selfconsciousness (Malhotra, Poolton, Wilson, Uiga, & Masters, 2015; Schucker et al., 2013) Another dimension of fluency that has clinical relevance is naturalness. Researchers often use the construct of naturalness when assessing posttreatment outcomes that occur in conjunction with the use of treatment strategies that require the use of regulated or controlled speech articulation. Although many speakers who stutter produce fewer disfluencies through application of articulation rate regulation strategies, it is possible for

the resulting speech pattern to sound mechanical (i.e., unnatural) when compared to the speech of speakers who do not stutter (e.g., Ingham, Gow, & Costello, 1985; Onslow & Ingham, 1987). Encouragingly, though, speakers who stutter can improve speech naturalness when provided with feedback from a clinician about their current naturalness levels (e.g., Ingham, Martin, Haroldson, Onslow, & Leney, 1985). Speech naturalness ratings seem to function as a proxy for other aspects of speech, as listenerbased naturalness ratings correlate strongly with both a speaker’s speech rate and disfluency frequency (Logan, Roberts, Pretto, & Morey, 2002; Martin & Haroldson, 1992). In research studies, raters usually are not given a precise definition of naturalness. Thus, it seems to be assumed that a listener will know a natural utterance when he or she hears one. This appears to be the case, as naturalness ratings have proven to be quite reliable within and among raters (Martin et al., 1984). Naturalness ratings are not fixed, however, because within an individual listener, ratings can vary depending on the mode of stimulus presentation. For example, seeing and hearing a person speak disfluently yields less favorable naturalness ratings than only hearing a person speak disfluently (Martin & Haroldson, 1992). This finding provides additional support for the idea that individuals base their naturalness ratings on multiple factors, including perhaps visual information about the speaker’s appearance while talking. Figure 2–1 illustrates the relationship between an individual’s speech rate and the naturalness ratings that listeners assign to the individual’s speech. As shown in the figure, which is based on findings from Logan et al. (2002), adult raters’ perceptions of speech naturalness are tied to the speakers’ articulation rates. Accordingly, it seems likely that deviations in speech rhythm and/or effort would affect a rater’s perceptions of naturalness similarly, as well.

Fluency Dimensions:  Talkativeness Fillmore (1979) observed that verbal output is an essential component of fluency. Although Fillmore did not use the label talkativeness in reference to the amount of speech one produces, the term seems appropriate as it fits with his criterion



2.  Conceptualizing Fluency

Typical rate Moderately slow

Very slow

Fair to good naturalness rating

Very good to excellent naturalness rating

Poor naturalness rating

Figure 2–1.  An illustration of the relationship between speakers’ speech rate and listeners’ ratings of speech naturalness. In research studies, these variables tend to be strongly correlated, with r values exceeding 0.90. This means that if one knows the speech rate of an utterance, he or she can predict, within a narrow range, the naturalness rating that listeners are likely to assign to that utterance.

of talking at length, and it is consistent with terminology used by researchers who specialize in studying issues related to verbal output and participation (e.g., Leaper & Ayres, 2007; Leaper & Smith, 2004). Given the many communicative functions that speakers convey through talking, talkativeness carries many advantages. Of course, the amount of verbal output a speaker produces does not necessarily correspond with how effectively he or she communicates. Thus, in clinical settings, a clinician must weigh a speaker’s verbal output against the extent to which the amount of output meets the needs and expectations of conversational partners as well as the speaker’s personal communication goals.

Verbal Output and Participation Several measures of verbal output have been reported in the research literature, including the following measures: • The total number of syllables, words, or utterances a speaker produces in an interaction; • The total number of syllables or words a speaker produces per unit of time;

• The average number of syllables or words a speaker produces per utterance, speaking turn, or narrative; and • The total amount of time a speaker spends talking in an interaction. Talkativeness also relates to the concepts of participation and participation restriction, each of which figures prominently into assessments of communicative functioning. Within the sphere of verbal communication, participation pertains to matters such as the number and variety of social contexts in which a speaker makes verbal contributions as well as to the depth and breadth of a speaker’s verbal contributions during specific situations. In contrast, the notion of participation restriction pertains to the absence or lack of participation relative to speakers who do have impaired fluency and the ways in which the participation restrictions limit or hinder a person’s ability to function within the context of daily activities. Thus, the basic goal when measuring verbal output and participation is to capture how much talking a person does in various situations, and then to evaluate the adequacy of that participation in relation to performance levels in the general population as well as to the

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Fluency Disorders

individual’s unique needs and desires. Additional details about the clinical assessment of verbal output are presented in Section III of this text.

Communicative Efficiency In clinical settings, patients who consistently include superfluous detail in their conversational utterances or who consistently veer off-topic with their remarks, may be regarded as demonstrating atypical functioning in social and pragmatic aspects of language. Such issues can arise in conjunction with fluency impairment as well. For example, a person who stutters might either circumlocute (a form of talking excessively) or say very little (a form of restricted participation) in an attempt to cope with or conceal anticipated fluency difficulties. Thus, by limiting the functionality of utterances a person contributes, fluency impairment has the potential to negatively affect a speaker’s communicative competence, as well. In Fillmore’s (1979) model, the term succinctness was used in reference to the ability to speak in logically organized and semantically dense sentences such that ideas are expressed efficiently. For example, a speaker who is skilled in this dimension of fluency may be able to communicate in eight words what another speaker takes 15 words to communicate. Fillmore (1979) conjectured that one’s ability to speak succinctly is associated with both the person’s general linguistic aptitude and his or her background knowledge of a particular topic. Succinctness also can reflect the amount of experience a speaker has with conveying a particular story, concept, or procedure to others. In this view, the succinctness of a message should improve as a speaker rehearses content or practices information delivery over time. Other terms that are relevant to the notion of communicative efficiency and succinctness are coherence and circumlocution. The term coherence refers to a speaker’s ability to present information in a logical, unified manner. In clinical settings, clinicians assess coherence by examining a person’s topic maintenance skills. Coherence deficits are found in an assortment of disorders that affect functioning in cognition or language. These disorders include the following: developmental language impairment (Ketelaars, Hermans, Cuperus, Janso-

nius, & Verhoeven, 2011); dementia (Dijkstra, Bourgeois, Allen, & Burgio, 2004); aphasia (Rogalski, Altmann, Plummer-D’Amato, Behrman, & Marsiske, 2010); and cluttering (St. Louis, Myers, Faragasso, Townsend, & Gallaher, 2004; van Zaalen-op ’t Hof, Wijnen, & DeJonckere, 2009). In such cases, succinctness of message delivery is reduced or lost, as the speaker strays toward topics that have only marginal relevance to the established topic. Within the context of fluency disorders, the term circumlocution is used to describe instances in which a speaker inserts semantically acceptable but communicatively unnecessary or inefficient words into an utterance. Some speakers who stutter use circumlocution to cope with the expectation of being unable to smoothly produce the motor movements associated with upcoming syllables. Circumlocution is presented here in the contrast between Example 2–3 and 2–4. Example 2–3:  Max is stopping by tonight. (Succinct) Example 2–4:  That guy who is grandma’s brother is stopping by tonight. (Circum­ locution around Max) An utterance like Example 2–4 might occur when a speaker expects disfluency on the word Max and reacts to it by substituting alternate and less precise words (e.g., the guy who is my grandmother’s brother). In this case, circumlocution resulted from the speaker’s attempt to avoid or postpone a word (Max) in the originally intended version of the utterance. For people who stutter, circumlocution seldom is a reliable strategy for coping with anticipated disfluency, and when it is used, the speaker ends up filling speech with imprecise or unnecessary words. Thus, in the context of stuttering, circumlocution often creates more communication problems than it solves, as the unclear wording may confuse listeners, thereby triggering them to ask an assortment of clarifying questions. As noted, problems with coherence, circumlocution, and lack of succinct expression occur in conjunction with various types of language impairment. These problems also are seen in cluttering, a communication disorder that often features evidence of impairment in both speech and language



2.  Conceptualizing Fluency

(see Chapter 9 for additional details). Speakers who consistently and substantially exceed the verbal output requirements that are customary within a particular situation or who consistently report information that is irrelevant often are labeled as having a pragmatically based communication impairment (Douglas, 2010; Philofsky, Fidler, & Hepburn, 2007). Thus, in the realm of communication, it is functional to be talkative but dysfunctional to be so talkative that others become annoyed, distracted, confused, or disinterested by what is being said.

Communicative Flexibility In clinical settings, intervention programs typically are designed to help patients establish functional

Utterance Number Utterance Mom 1 Look at this! Child 1 It’s a toy farm! Mom 2 What should we do now? Child 2 Play with it! Mom 3

Do you want this cow?

Child 3

Yep.

Mom 4

Tell me what’s next.

Child 4 Child 5 Mom 5 Mom 6 Mom 7 Child 6

Let’s put the cow and the chicken in the barn. Wow! I like what you did. Here’s a toy salamander. Say “salamander.” Salamander.

communication — that is, the ability to use speech to communicate competently and comfortably across the range of daily activities. Fey (1986) developed a system for classifying the functional characteristics of conversational utterances. The analysis is rooted in Searle’s (1975) concept of the speech act. With Fey’s speech-act analysis, each conversational utterance is described in terms of the communicative function that the speaker accomplishes by uttering it. The main categories of Fey’s speech-act analysis are shown in Figure 2–2 and accompanied by examples of various types of speech acts as they would be coded in a conversation between a mother and a child. As is illustrated in the figure, each conversational utterance can be described at an utterance level and at a discourse level.

Communicative Function Utterance Level Assertive — Comment Assertive — Comment Assertive —Request information Respond to request for information Assertive —Request information Respond to request for information Assertive —Request information Respond to request information Performative Assertive —Statement

Discourse Level Initiate Extend

Assertive — Comment

Extend

Assertive —Request imitation Respond to request for imitation

Extend

Extend Extend Extend Maintain Extend Extend Maintain Extend

Maintain

Figure 2–2.  Utterance- and discourse-level categories included in Fey’s (1986) speech act analysis, which is used to describe the communicative functions that a client expresses during conversation. Utterances are analyzed at two levels: (1) in relation to the function of the immediately preceding conversational utterance (i.e., utterance-level analysis), and (2) in relation to the role of the utterance in the conversational topic development (i.e., discourse level analysis). At the discourse level, an utterance can initiate a topic, maintain a topic, or extend a topic. At the utterance level, utterances can be assertive, responsive, imitative, or performative. Assertive acts can be further specified (e.g., comments, statements), as can responsive acts (e.g., responses to requests for information, requests for imitation, requests for clarification).

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Fluency Disorders

The Role of Social Expectations in Listener’s Reaction to Disfluency Speakers who stutter commonly report that it is more challenging to speak fluently in some situations than others. One of the factors that seems to influence this phenomenon concerns the social expectations that go along with how promptly people will speak in certain communication contexts. To get a sense of what this is like, try doing the following over the course of the next few weeks: Think of upcoming situations that you expect to participate in, during which you are likely to be asked to provide information about yourself such as your name, age, cell phone number, e-mail address, physical address, and so forth. After being asked to provide such information, purposefully delay the start of your response for several seconds, such that you remain silent. If it is a face-to-face interaction, be sure to look at your communication partner during the delay so that the person can see you are paying attention. Observe how the person reacts to your delay: Observe the person’s facial expressions, what the person says to you at this time, and the tone of the person’s voice. How did the listener’s reaction affect you? How do you think a similar reaction might affect a speaker who stutters?

At the utterance level, the clinician describes the role of a client’s utterance within the conversation, based on its functional relationship to the previous utterance in the conversation. At the discourse level, the client’s utterance can be described further, based on how it relates to the development of the topic of conversation. This approach allows the speech-language pathologist to discover the types of communicative functions that the client conveys most and least often, and when paired with an analysis of speech fluency, which communicative functions the client produces most and least fluently. Speakers who stutter often report that certain types of speech acts are particularly challenging for them to perform fluently. These include speech acts that obligate the use of relatively long or complex utterances, and those that obligate prompt response initiation (e.g., saying the word “hello” when answering a telephone call).

Speaking in Creative or Entertaining Ways The fourth dimension of fluency that Fillmore (1979) identified pertains to the spontaneous expression of ideas in novel, clever, or distinctive ways during discourse. As Fillmore noted, speakers who are highly proficient in this dimension of fluency not only are able to express ideas clearly in a variety of settings, but they also do so in ways

that others’ consider to be creative, pleasing, entertaining, or amusing. Examples of this type of fluency include the abilities to generate puns, jokes, alliterations, or metaphors spontaneously during conversation. Speaking in this manner surely requires proficiency with language (i.e., linguistic fluency); however, for activities such as joke telling, a speaker also needs to be adept with timing the spoken components of an utterance in ways that maximize the impact of the spoken words on the listener. For many people with impaired fluency, the ability to talk in the creative way that Fillmore (1979) described might be regarded as “icing on the cake”— that is, a level of proficiency beyond what is necessary for functional communication. While the ability to speak in creative or entertaining ways may not rank as a high priority within a treatment plan for a person with impaired fluency, performative speech acts such as the production of witty asides, playful banter, and joke telling are integral components of social interaction and thus patients may value them highly when choosing intervention goals. Speech acts like these certainly contribute to a speaker’s sense of being fully participatory in a conversation, and the absence of these communicative functions in a speaker’s repertoire can leave one feeling as if he or she is on the margins of social interactions with other people. Many people who stutter report



2.  Conceptualizing Fluency

that it is challenging for them to speak fluently within time-constrained speaking contexts such as joke telling or inserting verbal asides (Bloodstein & Bernstein Ratner, 2008). Thus, although creative, entertaining remarks may constitute only a very small percentage of everything an individual says, the inability to make these remarks can have an outsized contribution to one’s sense of social engagement, and with it, one’s experience of communicative disability.

Fluency Dimensions: Stability The term stability refers to the consistency with which a particular activity is performed. Within the context of fluency, one can look at an individual’s consistency of performance across fluency dimensions such as continuity, rate, rhythm, effort, naturalness, and talkativeness. At a group level, speakers with disordered fluency perform much less consistently (i.e., their performance is more variable) than speakers with typical fluency do in each of these aspects of fluency.

Within-Task and Between-Task Perspectives The constructs of variability and stability can be studied from both within-task and between-task perspectives. The within-task perspective refers to the extent to which a speaker performs in a similar manner when asked to perform the same task multiple times in succession. Each attempt at the task is called a trial, and a researcher or clinician compares the speaker’s fluency performance across successive trials. Trials can be performed in one sitting (e.g., reading a paragraph aloud five times in a row during a clinic visit) or over time (e.g., reading a paragraph aloud over the course of five consecutive days). Either way, this approach provides information about the extent to which a speaker’s fluency behavior changes as a function of practice and task familiarity. In contrast, the between-task perspective deals with the extent to which a speaker performs in a similar manner across different types of speaking tasks. For example, a clinician might compare a speaker’s performance during a sentence production task, a reading task, and a conversational

task, or when engaging in a one-on-one conversation versus delivering a lecture before a large audience. In this way, one can answer questions such as whether a speaker’s disfluency frequency or speech rate changes as a function of the linguistic properties of an activity, social contexts, and so forth. Both the within- and between-task perspectives are important to consider if a clinician is to obtain a complete understanding of a person’s fluency functioning.

Quantifying Performance Variability Variability is a statistical concept that can be captured through measures such the range and standard deviation for a given set of data The more variable a speaker’s performance is on a task, the larger the range and standard deviation values for that task will be. In general, speakers who stutter show greater variability than speakers who do not stutter on most measures of fluency. As such, performance variability provides the clinician with a sense of a client’s functioning and extent of disability in the area of speech fluency. People who stutter generally exhibit much greater variability in disfluency frequency, both within and between tasks, when compared to typical speakers. This concept is illustrated further in Table 2–3 using fictitious data from a typical speaker and a speaker who stutters. Imagine that a speech-language pathologist had analyzed each person’s fluency over 15 consecutive conversational speech samples. As shown in the table, disfluency frequency for the typical speaker remains below 4 per 100 syllables in each of the samples; but for the speaker who stutters, disfluency frequency is about five times greater and about 2.5 times more variable. Research data show greater performance variability in other fluency-related domains as well, particularly those associated with speech motor control.

Organizing Fluency Dimensions Into a Clinical Model of Fluency A model provides clinicians with a framework for understanding how certain concepts relate to one another. In Figure 2–3, the fluency dimensions discussed in this chapter have been combined into a

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Fluency Disorders

Table 2–3.  Disfluency Frequency Data That Would Be Expected From Two Types of Speakers

Speaker Type

Overall Frequency

Disfluency Frequency By Session Numbera 1

2

3

4

5

6

7

8

9

10

11

Person With Typical Fluency

4

2

0

4

1

0

3

1

Person Who Stutters

12

13

9

6

6

11

15

15

12

13

14

15

2

3

14

7

M

SD

4

1

2

3

4

2.27

1.44

6

14

13

12

16

11.27

3.58

Note.  M = Mean; SD = Standard Deviation a Disfluency frequency is expressed as percent of disfluent syllables.

Continuity

Rate Rhythm

Stability

Effort

Naturalness

Talkativeness (Verbal output and participation; communicative efficiency and flexibility)

Figure 2–3.  A multidimensional model of speech fluency. Continuity, rate, and rhythm are depicted as interrelated constructs that contribute to speechrelated effort. Utterances that are free from continuity interruption and feature typical rate, rhythm, and effort are likely to sound natural to listeners. Speakers who consistently produce natural sounding utterances are likely to be talkative, meaning that they will say as much as they desire to say, using the words they want to use, in a range of life activities. Further, they will do this in a consistent, stable manner (i.e., day after day).

model of fluency. The model constitutes an attempt to illustrate how the various fluency dimensions relate to one another. As shown in the model, rate,

continuity, and rhythm are depicted as partially overlapping concepts, meaning that although they share common features, they are not interchangeable. For example, speech rate is inextricably linked with the number of breaks in speech continuity a person has, such that many continuity interruption can result in an typical speech rate. Yet, a speaker who uses a speech rate that is half that of the general population despite having no continuity interruptions also can be judged to use an atypical speech rate. In the model, continuity and rate also overlap, in part, with rhythm. This is because both rate and disfluency affect the metrical structure of spoken utterances and, consequently, listeners’ perceptions of the normalcy of speech rhythm (Logan et al., 2002; Martin et al., 1984). However, perception of speech rhythm is not based entirely on a speaker’s speech continuity and speaking rate; syllable duration patterns play a role too. For example, when a speaker times his or her speech to the beat of a metronome, the constituent syllables tend to have similar durations, which creates the impression of a staccato or relatively fixed beat to speech. This pattern too would yield speech that, although continuous, still would be judged as atypical. Speech-related effort is presented in the model as having relevance to continuity, rate, and rhythm. Speakers who exhibit marked differences in any of these fluency dimensions would likely be perceived as speaking with greater effort in comparison to speakers who exhibit typical fluency (see, e.g., Ingham et al., 2009). In the model, naturalness is depicted as reflecting a speaker’s effort, conti-



2.  Conceptualizing Fluency

nuity, rate, and rhythm. Atypicality in any of those four fluency dimensions can result in the perception that speech production is unnatural (Hodgman & Logan, 2013). The next component in the model is talkativeness, which pertains to the speaker’s verbal output and participation in speaking activities, as well as to qualities of communicative efficiency and flexibility (i.e., the range of communicative functions a speaker expresses during daily speaking activities). In the model, talkativeness is represented as being influenced by an individual’s functioning in each of the other fluency dimensions. The final fluency dimension, stability, appears on the side of the model as an enclosing bracket. It is depicted this way to show that it is determined through repeated observations of an individual’s performance in the other fluency domains. Information about the stability of a client’s speech fluency is crucial for clinicians to consider during assessment and treatment, as it provides information about how an individual’s current fluency performance compares to how the client has performed at other points in time.

Fluency in the Content of a Speech Production Model Ordinarily, when speaking, it seems as if one only has to open his or her mouth and a stream of words springs forth. One might interpret the relative ease with which most people talk as evidence that the process of fluent speech production is simple and straightforward. This, however, is not the case, as even the casual remarks a person says during conversation result from a series of neurophysiological events that he or she must perform accurately and integrate precisely if fluency is to occur. Considering this complexity, it perhaps is surprising that fluency impairment is as uncommon as it is. Scientific research into speech production has a long history. In the past 3 decades, the development of increasingly sophisticated computerbased tools for imaging, measuring, and modeling neuroanatomical structures and neurophysiological events has resulted in a markedly more accurate and detailed description of the speech

production process and, with it, a better understanding of the system and processes that underlie speech fluency.

Modeling the Speech Production Process Findings from several lines of research — including analyses of speech errors in typical speakers, the speed at which different types of linguistic information is retrieved, response dissociations in individuals with neurological injury and disease ​ — ​have led to insights into specifying the core components of speech production. Most models developed since the 1970s represent the speech production process as a series of stages or steps within which specific aspects of an utterance are created, selected, and/or arranged (e.g., Bock & Levelt, 1994; Dell, 1986; Fromkin, 1971; Garrett, 1975, 1984; Levelt, 1989; Levelt, Roelofs, & Meyer, 1999). In this section of the chapter, the discussion focuses primarily on a model by Levelt and colleagues (e.g., Bock & Levelt, 1994; Levelt, 1989, 2001; Levelt et al., 1999; Roelofs, 1997, 2000, 2003; Roelofs & Meyer, 1998), who have engaged in a large and long-term research program to understand the process of speech production. Figure 2–4 illustrates the main elements from Levelt’s (1989) well-known speech production model, along with associated information about the temporal characteristics of each stage of production. Levelt’s (1989) model presents speech production in three main stages: conceptualization, formulation, and articulation. In the model, the act of encoding a word or phrase for speech production involves a series of cascading neural processing events that take place over a very brief amount of time. Research findings suggest that the events involved in word production — from conceptualizing what will be said through the initiation of articulation — take place in about six tenths of a second (600 ms), with some subcomponents of the process such as phonological code retrieval taking less than one tenth of a second ( initiation times than NS at ages 5, 9, and adult; initiation time decreases with age in both groups.

Cullinan & Springer (1980)

C

“ah”

S > initiation times than NS; effect present only in participants with stuttering and concomitant disorders.

Hand & Haynes (1983)

A

“ah,” key press

S > initiation times than NS for both targets; manual condition > vocalization condition.

Watson et al. (1992)

A

“ah,” “Oscar,” sentence starting with “Oscar”

S > initiation times than NS, especially in participants with atypical cortical blood flow; stimulus complexity (but not stuttering severity) associated with initiation times.

Maske-Cash & Curlee (1995)

C

1 and 4 syllable words and nonwords

S > initiation times than NS in all conditions and with all response types; effect strongest in participants with stuttering and concomitant disorders.

T, A

Sentences

S > initiation times than NS for 3 of 4 sentence types; stuttering severity not associated with initiation times.

A

Sentences

S > initiation times than NS for all sentence types; syntactic complexity and initiation time correlated for both groups.

Logan (2003)

Tsiamtsiouris & Cairns (2013)

Note.  S = individuals who stutter, NS = individuals who do not stutter, C = children, T = teenagers, A = adults.



6.  Stuttering: Correlates and Consequences

stutter are slower than people who do not stutter in their ability to initiate speech-based responses (e.g., Cross & Olson, 1987; Dembowski & Watson, 1991; Logan, 2003; Starkweather et al., 1984). In many of these studies, the average initiation time of speakers who stutter lags that of speakers with typical fluency by roughly 150 ms, and response complexity further exacerbates the extent of the lag (Tsiamtsiouris & Cairns, 2013; Watson, Pool, Devous, Freeman, & Finitzo, 1992). Lags in speech initiation also have been documented for tasks that measure onset of nonspeech targets like throat clearing (Starkweather et al., 1984), vocal termination time (Adams & Hayden, 1976; Cullinan & Springer, 1980), and tasks that permit participants to rehearse the target response many times prior to performing the test trial (Adams & Hayden, 1976). Initiation lags also have been demonstrated in both adults and children who stutter (Anderson & Conture, 2004; Bishop, Williams, & Cooper, 1991; Cross & Luper, 1979; Cullinan & Springer, 1980; McKnight & Cullinan, 1987), which suggests that lags in response initiation are not simply the result of a speaker’s anticipated difficulty in speaking fluently or compensations for stuttered speech that develop over time. In a study of adults who stuttered, Watson et al. (1992) found that slow laryngeal reaction times were observed mainly in a subgroup of participants who exhibited reduced cerebral blood flow to left hemisphere areas associated with speechlanguage processing. Others (e.g., McKnight & Cullinan, 1987) have reported that slow initiation times were present mainly in a subgroup of children who presented articulation and/or language disorders concomitantly with stuttering.

Speech Motor Coordination and Movement Control Another approach to studying the role of motoric factors in stuttering is to compare speakers who stutter to speakers with typical fluency in terms of their ability to coordinate and control speech movements. Conture and colleagues (Caruso, Conture, & Colton, 1988; Conture, Colton, & Gleason, 1988) examined this issue by studying children’s temporal coordination of muscles in the respiratory, laryngeal, and articulatory systems during

fluent repetitions of simple target sentences. They found no significant difference in the sequence of muscle activation across the systems between children who stuttered and children with typical fluency during fluent responses. In utterances that contained stuttered speech, the coordination of the respiratory, laryngeal, and articulatory muscle systems again was like the coordinative patterning seen in the typical children during fluent trials in terms of the sequence in which muscle systems activated. During stuttering trials, however, the children who stuttered initiated the onsets of key words within the target sentences significantly earlier than children with typical fluency did during fluency trials. Thus, the children’s timing structure for the stuttering trials was subtly different from that of typical, fluent speech, even though the gross pattern of coordination was normal. Other researchers have uncovered differences between speakers who stuttered and typical speakers in the relative sequence of upper-lip, lower-lip, and jaw muscle activation during lip closure for [p] within the context of target nonsense words like sapapple (e.g., Caruso, Abbs, & Gracco, 1988; Gracco & Abbs, 1985). Speakers with typical fluency showed a predictable activation sequence when speaking at habitual rates: upper lip → lower lip → jaw; however, speakers who stuttered were less likely than fluent speakers to produce the lip-closing gesture in this sequence (Caruso et al., 1988). Whether this coordination difference is the direct consequence of fluency impairment or, instead, a compensation for impairment remains to be determined (Namasivayam & van Lieshout, 2008). A variety of other motor system differences have been discovered in speakers who stutter when compared with fluent controls. These include the following: • Differences in the timing structure of consonant-vowel transitions during perceptibly fluent speech (Bauerly, Jones, & Miller, 2019; Bauerly & Paxton, 2017; Dehqan, Yadegari, Blomgren, & Scherer, 2016; Howell, Sackin, & Rustin, 1995; Zebrowski, Conture, & Cudahy, 1985); • A greater magnitude of error in tasks that involve tracking the movement of a stimulus using lip movement (Howell et al., 1995);

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• Differences in the relative speeds with which the tongue and lower lip move in relation to the jaw during speech (McClean & Runyan, 2000). (The tongue and lip moved with excessive velocity while the jaw moved with insufficient velocity. Velocity disparities were greatest in speakers who stuttered severely); and • Evidence of tremor in lip muscles during disfluent speech (McClean, Goldsmith, & Cerf, 1984). Smith and colleagues (Denny & Smith, 1992; Smith, 1989; Smith, Denny, Shaffer, Kelly, & Hirano, 1996; Walsh & Smith, 2013) examined patterns of lip, jaw, and neck muscle activation using electromyography (EMG) in samples of fluent and stuttered speech. They found evidence of characteristic tremor-like oscillations during muscle activation in speakers who stuttered that none of the typical speakers exhibited. The frequency characteristics of the tremor-like oscillations all fell within a restricted range (5 to 15 Hz), which suggested that they resulted from a common neural source (Smith, 1989). Not all stuttered disfluencies exhibited the atypical EMG activation, however, and some segments of fluent-sounding speech showed evidence of the tremor-like oscillation that was present during stuttered speech. Furthermore, the tremor-like oscillations were present to differing extents across speakers. Thus, there was no single common physiological pattern that characterized all stuttered disfluencies, and there was evidence of abnormality during speech that sounded fluent. The source of the tremor across speech-related muscles was unclear, but Smith (1989) speculated that it might pertain to speech-related anxiety or autonomic nervous system arousal. Results from other studies showed no differences in the EMG activity of preschool and early elementary school-aged children who stuttered (Kelly, Smith, & Goffman, 1995; Walsh & Smith, 2013); however, tremor-like oscillations was detected in the speech of 10- to 14-yearold children who stuttered, which suggests that tremor is an emergent feature of stuttered speech (Kelly et al., 1995). In another line of studies, Smith and colleagues compared the stability (i.e., coordinative variability) of motor movements in speakers who stuttered

with those of fluent controls (see, e.g., Kleinow & Smith, 2000, MacPherson & Smith, 2013). In typically developing adults, the spatiotemporal variability of articulatory movements reduces from early- through mid-adulthood, after which it stabilizes (Dromey, Boyce, & Channell, 2014). In Smith and colleagues’ research paradigm, studies were conducted to examine the timing and spatial characteristics of lip and jaw movements during repeated productions of target utterances that featured multiple bilabial consonants (e.g., Buy Bobby a puppy). In these studies, variability in the spatial and temporal aspects of articulatory movement was combined mathematically into a single numerical value (the spatiotemporal index or STI). In some of the studies, the target utterance had been embedded in longer and/or linguistically complex contexts. In other studies, the researchers used nonword response targets (e.g., mabshibe, mabfieshabe). The general finding from this research is that the articulatory movements of speakers who stutter show significantly greater spatiotemporal variability compared to movements that fluent speakers produce (e.g., Kleinow & Smith, 2000; Smith, Goffman, Sasisekaran, & Weber-Fox, 2012; Smith, Sadagopan, Walsh, & Weber-Fox, 2010). The utterance productions of typical speakers generally are quite stable; that is, in trial after trial, the articulatory movements of the typical speakers are nearly the same in terms of their spatial properties and temporal patterning, as measured by markers such as the time and manner in which lip closing occurs on target bilabial consonants across successive trials of a target utterance. With the speakers who stutter, however, the articulatory movements are much less stable, meaning that the spatiotemporal organization can be noticeably different (when measured with sufficiently sensitive equipment) across successive trials in a series of repeated productions of the target response. Although these repeated productions all sound fluent, they all are significantly different from those of fluent speakers in terms of their coordination profile, and therefore, they are characteristic of stuttering. Children who stutter show significantly more movement variability than typical children in syntactically simple sentences, whereas the two groups perform similarly in syntactically complex



6.  Stuttering: Correlates and Consequences

Is a Speaker Who Stutters Ever Truly Fluent? Based on research studies that have compared the spatiotemporal coordination of fluent-sounding utterances produced by speakers who stuttered and typical speakers, one can argue that most, and perhaps all, utterances a speaker who stutters produces — including those that “sound fluent”— are atypical and indicative of the impairment that results in stuttered speech. In this view, stuttered speech is any speech that a speaker who stutters produces, regardless of whether the speech contains overt instances of stutter-like disfluency. The discrepancy between the sound of an utterance and its underlying coordination characteristics can create difficulties in the assessment and treatment of stuttering. That is, an utterance can sound fluent to a clinician, but it can feel stuttered to a client. Thus, one must be mindful that listener-based acoustic measures of speech disfluency offer only a limited sense of motor system functioning in speakers who stutter (Smith & Kelly, 1997; Smith & Weber, 2017).

sentences (MacPherson & Smith, 2013). STI has potential significance for predicting the developmental course of stuttering in preschoolers. For example, in one study, spatiotemporal variability in the aperture of lip movements during sentence production tasks accurately differentiated between children who eventually met criteria for persistent stuttering and children who eventually recovered from stuttering (Usler, Smith, & Weber, 2017).

Motor Learning Other research studies have examined the motorlearning abilities of people who stutter. In this research, speakers who stutter and speakers with typical fluency repeat target utterances numerous times in succession. This generally reduces the frequency of stutter-like disfluency across trials and, consequently, it increases speech rate. In the stuttering literature, the improvement in fluency across immediate, repeated productions of the same stimulus has been termed the adaptation effect. Initial explanations for adaptation revolve around presumed changes in a speaker’s beliefs or anxiety about stuttering-related disfluency (see, e.g., Williams, Silverman, & Kools, 1968). Since then, however, researchers (e.g., Frank & Bloodstein, 1971; Max, Caruso, & Vandevenne, 1997) have demonstrated that the effect most likely results from massed practice at producing the articulatory movements.

The study of motor learning goes beyond immediate changes in performance, however, to include examination of whether long-lasting changes in performance occur. Thus, in some studies of speech motor learning, participants are asked to say target utterances dozens, if not hundreds, of times in succession, and then leave the research laboratory and return hours or days later to perform the task again. If a speaker can resume the task during these follow-up sessions at a level that is substantially better than his or her baseline performance from the first session, then motor learning is said to have taken place. Several representative studies from this part of the research literature are summarized in Table  6–6. As shown, in each of the studies presented in the table, speakers who stuttered exhibited evidence of motor learning. In all but two of the studies, the improvements were demonstrated during a retention task that occurred well after the initial practice phase. Importantly, however, speakers who stutter do not seem to attain a comparable degree of improvement in the speed and/or coordination of motor movements as speakers with typical fluency do (Bauerly & De Nil, 2011; SmitsBandstra, De Nil, & Rochon, 2006; Smits-Bandstra, De Nil, & Saint Cyr, 2006) and, even after practice, speakers who stutter continue to exhibit anomalous movement patterns (Namasivayam & van Lieshout, 2008). So, although motor learning takes place in speakers who stutter, the learning is not sufficient to result in normalized speech motor functioning.

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Table 6–6.  Findings From Selected Studies of Motor Learning in Speakers Who Stutter Study

Method

Results

Frank & Bloodstein (1971)

Paragraph reading.

Similar stuttering frequency in Trial 6 of both conditions.

Condition 1:  solo, 6× in succession.

Solo:  gradual frequency decrease in Trials 1 to 5.

Condition 2:  Trials 1 to 5 chorally; Trial 6 solo. Max & Caruso (1998)

Choral, frequency ~ 0 in Trials 1 to 5.

Study 1:  replication of Frank & Bloodstein (1971). Study 2:  like Study 1 but multisyllable target words embedded in text.

Consecutive reading yields:  decreased stuttering frequency; decreased word, vowel, and CV transition duration; and reduced movement duration for labial closure.

Max & Baldwin (2010)

Read paragraph 5× in succession over three sessions. In Trials 2 & 3, half of the sentences were unchanged, half were novel from trial to trial.

Unchanged sentences showed more fluency improvement than novel sentences after first 5 readings, and again after 5 more readings 2 hours later. After 24 hours, unchanged sentences retained evidence of motor learning; novel sentences did not.

Namasivayam & van Lieshout (2008)

Repeat nonsense words at fast and slow rates in three sessions (sessions 1 & 2 on same day; session 3 one week later).

After practice, speakers who stuttered were similar to controls on several motor measures, but showed larger amplitude for upper lip movements, trends toward more variable lip movement, and less coordinated movements.

Bauerly & De Nil (2011)

Day 1:  100 repetitions of 10-syllable-long nonsense word sequence (baz dob jeb zot gak vud daf bup jeg tup).

Speakers who stuttered:  longer production durations than controls on both days.

Day 2:  50 more repetitions.

Effect limited to subgroup of participants. Retention of practice effects on day 2.

Smits-Bandstra De Nil, & Rochon (2006)

30 repetitions of 10-syllablelong nonsense word sequence (ta ba pa ta ga pa ga ta pa ba).

Speakers who stuttered showed less improvement than controls, including no change in response initiation time.

Smits-Bandstra, De Nil, & St. Cyr (2006)

Typing number sequences (e.g., 4 2 1 3 1 2 4 1 3 4) on a response pad.

Speakers who stuttered:  less decrease in reaction time and less improvement after practice; less retention of reaction time gains.

The latter finding is consistent with the view that stuttered speech is, principally, a manifestation of impairment in the speech motor system.

Linguistic and Cognitive Correlates Researchers have studied the linguistic and cognitive correlates of stuttering extensively. Regarding

linguistic correlates, much of the research addresses issues related to how people who stutter compare to typical speakers in language development and performance, and the effects that linguistic context and complexity have on fluency performance. Regarding cognitive variables, comparisons have been made between people who stutter and typical speakers on various aspects of cognitive functioning as well as the effect that cognitive load has on the frequency of stuttering-related disfluency.



6.  Stuttering: Correlates and Consequences

Syllable, Word, and Utterance Properties That Precipitate Stuttering-Related Disfluency Many studies have attempted to identify word types and word locations within an utterance that are most likely to feature stuttering-related disfluency. In the earliest studies of stuttering, researchers hoped that the description of the loci (i.e., locations) of stuttering would lead to insights about the nature of the disorder. The general finding from this line of research is that stuttering-related disfluency is not a random event. Rather, it appears that some types of words and some types of linguistic contexts are more prone to stutter-like disfluency than others (Brown, 1945; Logan & Conture, 1995; Taylor, 1966). Included among the linguistic factors that have been studied are the following: word position in an utterance, word and syllable stress characteristics, word length, and word frequency, as well as word grammatical class and phonological form.

Word Length Word length typically is measured in syllables per word, and it affects the probability that the word will feature stutter-like disfluency. The main effect is that a syllable has a higher probability of featuring stuttering-related disfluency when it occurs in a multisyllable word context compared to a monosyllable word context. For example, Wingate (1967) asked adults who stuttered to read two types of word lists. One list contained pairs of one-syllable words (e.g., fan, sea), and the other list contained two-syllable words that were composed of the syllables in the one-syllable word pair condition (e.g., fan and sea were combined to form the target word fancy). Overall, 22% of the two-syllable targets featured symptoms of stuttering versus only 9% of the one-syllable targets. The word length effect occurs independently of the phonemes within the word; and in long utterances, the effect occurs independently of where the word is positioned in the utterance. Within multisyllable words, word-initial syllables generally have a higher probability of featuring stuttering-related disfluency than noninitial syllables do.

Word Position in Spoken Utterance It is well established that words in utterance-initial contexts are particularly prone to featuring stutterlike disfluency. Most researchers (e.g., Bloodstein & Grossman, 1981; Logan & LaSalle, 1999) have interpreted this phenomenon as reflecting the elevated demand that this utterance context places on the speech production system. That is, in this context, the speaker is articulating the beginning stages of an utterance while he or she simultaneously is planning or holding in memory upcoming portions of the utterance. Simultaneous engagement in both activities promotes instability in the speech production system, which is manifest as stutter-like disfluency ( Jayaram, 1984; Logan, 2001; Tsiamtsiouris & Cairns, 2013). Another, and not necessarily incompatible view, is that the biomechanical characteristics of syllables that occur in utterance-initial contexts differ from those of utterance-final syllables. Thus, a string of syllables may be more coordinately demanding to produce when it occurs in an utterance-initial context than it is when it occurs in an utterance-final context. (van Lieshout, Starkweather, Hulstijn, & Peters, 1995).

Word Frequency Researchers (e.g., Soderberg, 1966, 1967) also have found that low-frequency words evoke stuttered speech more often than high-frequency words. It has been proposed (Cykowski et al. 2010; Max et al., 2004) that when speakers produce low-frequency words, they rely on auditory monitoring and corrective auditory feedback more so than when they are saying high-frequency words. Presumably, this is because low-frequency words require construction of motor plans on an as-needed basis (i.e., “on the fly”). Because the motor plans of lowfrequency words are less practiced than those of high-frequency words, there is a need for greater moment-to-moment sensory-motor feedback/guidance as the word is being articulated. Impairment in either the motor planning process, the sensory feedback process associated with evaluating and updating the status of an ongoing motor plan, or both would render low-frequency words particularly vulnerable to featuring stutter-like disfluency. Low-frequency words also appear to place more subtle demands on speech motor control

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by triggering changes in the prosodic structure of ongoing speech. That is, speakers tend to modify the prosodic pattern of a word if it is (a) rare, (b) mentioned for the first time, or (c) phonologically similar to other words in a language. This tendency is an apparent effort to increase the word’s saliency for the listener (Fowler & Housum, 1987; Wright, 1979). Speech adjustments include increasing vowel duration and fundamental frequency. To the extent that these changes differ from the duration and frequency characteristics of surrounding speech, they may tax an impaired speech motor system in ways that induce stutter-like disfluency. Low-frequency words appear to be demanding in other ways. For instance, Munson and Solomon (2004) found that the density of a word’s phonological neighborhood affects vowel duration as well, such that low-neighborhood-density words feature a more restricted vowel space (i.e., more precise articulation) than high-neighborhooddensity words do. (Neighborhood density refers to the frequency of those words that are phonologically like a target word, e.g., dog → hog, bog, log.). Anderson (2007) found that children tended to stutter on low-frequency words and on words that have a low-neighborhood-density frequency. Thus, lexical frequency and phonologic neighborhood density appear to have distinct effects on fluency, and overall, it appears that it is more than lack of practice that makes low-frequency words prone to featuring stuttering-related disfluency. Adults show a similar effect: more stuttering on low-neighborhood-density words (Tsai, 2018).

Grammatical Class The grammatical class of a word is another language-based factor that researchers have examined extensively in relation to stuttered speech. The traditional view has been that, with adults and older children, stuttering-related disfluency occurs more often in conjunction with the production of “content” words (i.e., nouns, verbs, adjectives, adverbs) than it does in conjunction with the production of “function words” (i.e., pronouns, prepositions, conjunctions, articles). For example, Brown (1937) examined disfluency location during an oral-reading task with adults who stuttered. The median

stuttering frequency percentages for most types of content words were greater than 7%, while the median stuttering frequency percentages for function words were each less than 2.5%. Verbs fell between these two groups, with a median stuttering frequency of 3.75%. In contrast, preschoolaged children appear to exhibit a relatively high percentage of stutter-like disfluency in conjunction with function words (Bloodstein & Gantwerk, 1967; Bloodstein & Grossman, 1981). Some authors (e.g., Bloodstein & Grossman, 1981) have argued that the function-word effect is confounded with sentence planning effects (i.e., many of children’s stuttered function words occur in sentence-initial contexts), and thus may reflect sentence planning demands rather than word-based demands. As children develop competence in syntax and morphology, it may be that the distinction between content words and function words becomes less meaningful in analyses of stuttered speech. This is because in the domains of speech prosody and speech motor planning, unstressed function words are said to attach to host content words to form prosodic units call phonological words. For example, the utterance the nation is represented grammatically as Determiner + Noun, but the motor plan and any pauses that might precede or follow it are built around the phonetic sequence [ðəneIʃən]. From this perspective, the syllable [ðə] constitutes the first syllable of a three-syllable phonological word. Au-Yeung, Howell, and Pilgrim (1998) examined the content-word versus functionword distinction using Selkirk’s (1984) concept of a phonological word. They found that preschoolaged children exhibited relatively high levels of function-word disfluency only when the function word led off a phonological word. For instance, the word after would have a higher probability of being produced with stutter-like disfluency in Example  6–1a where it initiates a phonological word than in Example  6–1b where it terminates a phonological word. (The underscores indicate phonological word boundaries.) Example 6–1a:  Janine looked after school ended. Example 6–1b:  Janine looked after her little brother.



Syllable and Word Stress Word and syllable stress patterns have been well documented in speech. Syllable stress is part of the prosodic pattern of a spoken utterance. Stressed syllables within words are typically longer and louder than surrounding syllables (Kent & Read, 1992). As such, their production requires momentto-moment adjustment in the speech and force of articulatory movements. From the standpoint of communication, the function of stress is to highlight key semantic concepts in an utterance — the added emphasis makes a word “stand out’ from surrounding words and/or from other words with which it might be confused. Several authors have examined the association between linguistic stress and stuttered speech (Klouda & Cooper, 1988; Prins, Hubbard, & Krause, 1991; Wingate, 1984b). A main finding from this body of research is that stutteringrelated disfluency coincides with stressed syllables more often than it does with unstressed syllables (e.g., Bergmann, 1986; Klouda & Cooper, 1988; Natke, Grosser, Sandrieser & Kalveram, 2001; Prins, Hubbard, & Krause, 1991). This effect appears to be common among speakers who stutter, as most, and sometimes all, participants in published studies exhibited the group-level pattern (cf. Bergmann, 1986; Brown, 1938; Prins et al. 1991), and the effect has been documented in both children and adults who stutter (Natke, Grosser, Sandrieser, & Kalveram, 2002; Natke, Sandrieser, van Ark, Pietrowsky, & Kalveram, 2004). The effect also appears to be independent of syllable location, as it has been documented in initial and noninitial positions of both words and sentences (Bergmann, 1986, Brown, 1938; Natke et al. 2002); and in a given a sentence, the probability that any one syllable will be stuttered can be altered by shifting the word in the sentence that receives primary stress (Klouda & Cooper, 1988). It is plausible that the articulatory adjustments associated with the execution of syllable stress necessitate the need for greater situational reliance on somatosensory feedback. In this view, speakers who cannot readily or fully integrate somatosensory feedback into a running speech motor plan due to impairment in the speech production system are at risk to produce stuttering-related disfluencies in linguistic contexts that carry syllable stress.

6.  Stuttering: Correlates and Consequences

Weighting Linguistic Factors at the Word Level Some researchers have attempted to determine which linguistic factors have the strongest effect on the occurrence of stuttering-related disfluency. The results of these efforts have yielded mixed conclusions (cf. Hubbard & Prins, 1994; Soderberg, 1967; Taylor, 1966). Ultimately, it perhaps is most productive to adopt a view like the one that Brown (1945) held. That is, the probability that a speaker will produce stuttering-related disfluency at any particular point in an utterance is the product of multiple factors (e.g., a word’s frequency, stress characteristics, syllable length, and position within a sentence or phrase); and words that feature relatively many of the triggers for stuttered speech are more likely to feature stuttering-related disfluency than words that have relatively few of the triggers. This approach is illustrated in Examples 6–2a and 6–2b, where the syllable that has the highest probability of being stuttered is underlined. Weighting considerations are listed after the word pair. Example 6–2a:  Wash vs. Wa Washington (stressed, word-initial syllable in multi­ syllable word) Example 6–2b:  High vs. Hy Hydrocarbon (stressed, word-initial syllable in low-frequency, multisyllable word)

Effects of Syntactic and Phonologic Complexity The effect of linguistic complexity on stutteringrelated disfluency is another area that researchers have studied extensively. Research has focused mainly on the notions of syntactic and phonologic complexity. Examples of research approaches used to examine this issue are described next.

Syntactic Complexity of Utterances In some studies, researchers have defined syntactic complexity from a developmental perspective. With this approach, early emerging syntactic forms

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are considered less complex than late-developing syntactic forms. In other studies, researchers have defined syntactic complexity in quantitative terms by counting the number of syntactic elements in an utterance. Examples of the latter approach include analysis of either the number of clauses or the number of syntactic phrases (i.e., clause constituents such as noun phrase, verb phrase, and adverbial phrase) in an utterance. An utterance that contains relatively many syntactic elements is considered more complex than an utterance that contains relatively few syntactic elements. Syntactic complexity effects have been examined in a variety of contexts: sentence imitation, sentence modeling, conversation, and narration. With sentence modeling, a participant attempts to produce a novel sentence that matches a syntactic form, but not the content, of a stimulus sentence an examiner models (e.g., Examiner: The boy gave the girl a pencil. Child: The girl gave the boy a crayon. Picture stimuli are used to elicit the sentences. In Table 6–7, findings are presented from several representative studies of the effect of language complexity on the fluency of people who stutter. As shown in the table, the syntactic complexity effect is robust in studies with children, regardless of how one defines complexity. In studies with adolescents and adults who stutter, the effect seems less robust. Silverman and Bernstein Ratner (1997), for example, found no difference in the frequency with which teens who stuttered produced stuttering-related disfluency while imitating sentences that featured syntactic forms of varying difficulty but a similar number of syllables. Syntactic complexity did affect the frequency with which both speaker groups produced interjections and revisions, however. Logan (2001) — not shown in Table 6–7 ​— also found no effect for syntactic complexity on stuttering frequency in a speech-initiation time study where teens and adults who stuttered memorized and then promptly reproduced sentences when cued to do so. The sentences varied in the number of syntactic constituents within the subject-noun phrase. Tsiamtsiouris and Cairns (2013) did find evidence that syntactic complexity affects stuttering-related disfluency using target sentences that were much more complex than those used in Logan (2001).

Phonologic Complexity of Words Researchers also have examined phonologic complexity as a possible precipitator of stuttered speech. Throneburg, Yairi, and Paden (1994) defined phonological complexity in terms of syllable shape, phonemic content, and word length. In their study, phonologic complexity was defined in relation to whether syllables within a word contained consonant clusters and/or late-acquired phonemes, and whether a word had more than one syllable. Words were assigned weighted scores based on the number of these characteristics they contained. Throneburg et al. found no significant effect for phonological complexity — at least when defined using their method — on the frequency with which children produced stuttering-related disfluency on words during conversation. Howell and Au-Yeung (1995) defined phonological complexity in the same way as Throneburg et al. (1994) while also controlling for other word-level factors, such as grammatical class, which can influence stutteringrelated disfluency. They too found no evidence that the phonological complexity of a specific word affected the likelihood of stuttering-related disfluency on a word. Anderson and Byrd (2008) used an alternate definition of phonological complexity. They reported that children who stuttered were more likely to produce whole-word repetition when saying words that contained either low-frequency speech sound segments or low-frequency sequences of speech sounds. However, these phonotactic word properties were not associated with other stuttering-related disfluency types, such as partword repetition or sound prolongation. As noted earlier in the chapter, Anderson (2007) found that children stuttered more often on low-frequency words and on words that have a low neighborhood-density frequency. These findings suggest that although developmental conceptualizations of phonological complexity do not seem to hold much predictive value for determining which words will be stuttered, other non-developmental metrics of phonological structure do seem to have an effect, particularly those related to the frequency with which phonological constituents within a word occur within a language.



6.  Stuttering: Correlates and Consequences

Table 6–7.  Findings From Selected Studies of Utterance Length and Syntactic Complexity Effects on Stuttering-Related Disfluency Complexity Focus

Complexity Measure(s)

CWS; CWTF

S; L

Sentences ranked on developmental difficulty and number of syllables per utterance.

Late-developing sentence forms elicited more stutteringrelated disfluency than early-developing sentence forms; syntactic complexity correlated more strongly with disfluency than utterance length complexity.

Gaines et al. (1991)

CWS

S

Language complexity scorea and number of words per utterance.

Stuttered utterances had more words and more complex language than fluent utterances.

Logan & Conture (1995)

CWS

S; L

Language complexity scorea and number of syllables per utterance.

Stuttered utterances had more syllables and more complex language than fluent utterances.

Logan & Conture (1997)

CWS; CWTF

S; L

Syllable structure and complexity; number of syntactic phrases per utterance.

Stuttered utterances had more syntactic phrases than fluent utterances.

Silverman & Bernstein Ratner (1997)

TWS; TWTF

S

Syntactic complexity of sentences.

Sentences with complex syntax elicited more interjections and revisions, but not more stuttering-related disfluency, than simple sentences.

Tsiamtsiouris & Cairns (2013)

AWS; AWTF

S

Syntactic complexity in sentences.

High-complexity sentences elicited more disfluency than low-complexity sentences.

Yaruss (1999)

CWS

S; L

Syllables, words, morphemes, syntactic phrases, and clauses per sentences.

Stuttered utterances had more syllables, words, and grammatical elements than fluent utterances. Syllables per sentence was strongest predictor of stuttered speech.

Zackheim & Conture (2003)

CWS; CWTF

S, L

Number of syllables and morphemes per utterances.

Utterances above a child’s mean utterance length elicited more disfluency than utterances below mean utterance length; long, complex sentences elicited the most disfluency.

Study

Groups

Bernstein Ratner & Sih (1987)

Findings

Note.  CWS = children who stutter, CWTF = children with typical fluency; TWS = teens who stutter; TWTF = teens with typical fluency; AWS = adults who stutter; AWTF = adults with typical fluency. S = syntax and L = length. a Language complexity scores are based on Lee’s (1974) Developmental Sentence Scoring procedure.

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Assessments of Language Functioning in Speakers Who Stutter Researchers have had a long-standing interest in studying the language functioning of speakers who stutter. For the most part, results from these studies suggest that, as a group, children who stutter perform more poorly in this aspect of communicative functioning than children with typical fluency.

Performance on Formal and Informal Language Assessments One way to examine children’s language-related functioning is through administration of formal, norm-referenced tests. Researchers have used this approach extensively in studies with children who stuttered and have detected evidence of substandard performance in many different facets of language. For example, Westby (1974) reported that kindergarten and first-grade children who stuttered scored significantly lower than age-matched children with typical fluency on formal tests of vocabulary comprehension, expressive sentence complexity, and semantic skills. Ryan (1992) administered a battery of formal language tests to preschoolers who stuttered and found the group’s mean score on 7 of 8 measures to be below that of age-matched children with typical fluency. In a review of diagnostic data from nearly 100 preschoolers who stuttered, Yaruss, LaSalle, and Conture (1998) reported that significant percentages of the children scored below normal limits in the following areas: tests of receptive language performance (15% of the children), tests of expressive language performance (29% of the children), and tests of speech sound development (37% of the children). Several researchers have reported anomalous performance among speakers who stuttered on tests that involved nonword repetition. In several studies, children who stuttered made more errors than children with typical fluency during nonword repetition tasks (Anderson & Wagovich, 2010; Anderson, Wagovich, & Hall, 2006; Hakim & Bernstein Ratner, 2004; Pelczarski & Yaruss, 2016; also see Ofoe, Anderson, & Ntourou, 2018, for a

meta-analysis). Adults who stuttered displayed similar accuracy to typical adults during nonword repetition; however, kinematic data revealed atypical variability in articulatory coordination when saying the nonwords, and the articulatory movements of the speakers who stuttered became more variable as the length and complexity of the nonword targets increased (Smith, Sadagopan, Walsh, & WeberFox, 2010). In more complex processing conditions involving real-word recall, however, adults who stuttered demonstrated poorer verbatim recall of phonological information than typical speakers as time from stimulus presentation increased (Byrd, Sheng, Bernstein Rater, and Gkalitsiou, 2015); poorer performance on identifying, producing, and implementing elision with 7-syllable nonwords (Byrd, McGill, & Usher, 2015); and poorer, slower performance at monitoring word-medial phonemes (Howell & Bernstein Ratner, 2018). Ntourou, Conture, and Lipsey (2011) conducted a meta-analysis of language-related findings from 22 studies in which language performance data were reported for young children who stuttered. The researchers computed effect sizes for mean performance differences (children who stuttered versus children who did not stutter) across the 22 studies. The results of their analysis showed that the receptive vocabulary scores for children who stuttered were 0.52 standard deviation units below those of children with typical fluency, which translated into 70% of the children who stuttered having a lower receptive vocabulary score than the average child with typical fluency. Similarly, the expressive vocabulary scores for children who stuttered were 0.41 standard deviation units below those of children with typical fluency, which translated into 66% of the children who stuttered having a lower expressive vocabulary score than the average child with typical fluency. Lastly, the overall language performance scores (receptive + expressive language) for children who stuttered were 0.48 standard deviation units below those of children with typical fluency, which translated into 68% of the children who stuttered having a lower overall language performance score than the average child with typical fluency. Children’s language skills at the time of stuttering onset are challenging to assess. In one



recent prospective study of 66 children who were tracked on three occasions within 1 year after stuttering onset, 83% of the cohort demonstrated mild to very mild stuttering, and overall, the group demonstrated expressive language skills that were age appropriate (Watts, Eadie, Block, Mensah, & Reilly, 2017). The role of stuttering recovery also has been considered with respect to children’s linguistic performance. For example, Watkins and Yairi (1997) examined children’s language performance around the time of onset for stuttering symptoms and found that children who stuttered seem to perform similarly to, if not better than, children with typical fluency. However, Watkins and Yairi noted that preschoolers who ultimately were classified as having persistent stuttering displayed more variable language performance than the children who ultimately were classified as having recovered from stuttering. In a similar longitudinal study, children who went on to exhibit persistent stuttering had poorer scores on standardized language tests (and greater variability in articulatory movements) than children who went on to recover from stuttering (Ambrose, Yairi, Loucks, Seery, & Throneburg, 2015). Considering this finding, it may be that a relatively large percentage of the children studied in Ntourou et al.’s (2011) analysis were on track for persistent stuttering. This interpretation seems plausible because, in nearly all of the 22 studies included in Ntourou et al.’s analysis, the average age of the children who stuttered was 48 months or older. If one assumes a typical age of onset for the children, this means that many of them had stuttered long enough to meet criteria for “persistent stuttering” or at least to be “at risk” for doing so. In summary, results from studies of languagerelated functioning on norm-referenced instruments suggest that children who stutter tend to perform more poorly than children with typical fluency. Of course, group data are built from averaging the scores of many children. This means that some children who stutter score better on these measures of language functioning than the average child who does not stutter. Based on Ntourou et al.’s (2011) analysis, the percentage of stuttering children who perform better is roughly 30% to 35%.

6.  Stuttering: Correlates and Consequences

Performance During Narrative Production Narrative production is a form of oral discourse in which the speaker constructs an extended account of an event or a series of interrelated events (Liles, 1993). Narrative discourse emerges during the preschool years, and children gradually develop the ability to produce increasingly elaborate stories. By the start of elementary school, children can construct stories that contain both background setting information and multiple story episodes. With age, the episodes within children’s stories gradually increase in complexity such that they eventually feature structural elements such as an initiating event; the character’s physical, emotional, and cognitive responses to the initiating event; the character’s attempts to resolve a problem or challenge; and the effects of the character’s actions (Stein & Glenn, 1979). Beyond these structural elements, narrative discourse is regarded as a relatively complex form of oral communication because it requires a speaker to reference information clearly across sentences through adept use of pronouns, pronoun referencing, and prosodic marking. Children who present with delays in aspects of sentence structure often also exhibit delays with aspects of story grammar (Paul & Smith, 1993). Furthermore, both children who stutter and children with specific language impairment produce more disfluency than children with typical fluency do during narrative production (Byrd, Logan, & Gillam, 2012; Guo, Tomblin, & Samelson, 2008). Several authors (e.g., Byrd et al., 2012; Trautman, Healey, & Norris, 2001) have reported that children who stuttered produced more stutter-like disfluency during narrative tasks than they did during other forms of speech, such as conversation and sentence production. In addition, certain types of narratives (e.g., story retelling) elicited more complex language and evoked more disfluency than other types of narratives (e.g., story generation) from children who stuttered (Trautman, Healey, Brown, Brown, & Jermano, 1999). Given the tendency for children who stutter to perform more poorly than children with typical fluency on various norm-referenced tests of language

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performance, one would expect children who stutter to exhibit deficits in the linguistic aspects of narrative production as well. Several researchers (e.g., Nippold, Schwarz, & Jescheniak, 1991; Trautman et al., 1999; Weiss & Zebrowski, 1994) have examined this issue and, to date, have uncovered relatively few differences between the groups. For example, Weiss and Zebrowski (1994) reported that children with typical fluency produced longer, more elaborate narratives than the children who stuttered, but the difference was apparent only in a condition where the children interacted with listeners who were unfamiliar with the content of the narrative. Both Nippold et al. (1991) and Trautman et al. (1999) reported that children who stuttered produced narratives that were like those of children with typical fluency in terms of structural complexity and use of cohesive devices. One limitation of these studies is that most have featured relatively small sample sizes and, with that, accompanying limitations in statistical power. Because of this and the evidence of language performance deficits in other types of studies with children who stuttered, narrative production is an area that may warrant additional examination in the future.

Developmental Disorders that Co-Occur with Stuttering Briley and Ellis (2018) examined 6 years of data (2010 to 2015) from the National Health Interview on 1,231 children who stuttered to examine the extent to which various “disabling conditions” coexist with stuttering. They found that children who stuttered were 5.5 times more likely than nonstuttering children to have a coexisting developmental disorder. Odds ratios for some specific conditions were as follows: seizures (7.5 times as likely); intellectual disability (6.7 times as likely); autism/Asperger/pervasive developmental disorder (5.5 times as likely); learning disability (5.5 times as likely); attention deficit hyperactivity disorder (3.1 times as likely). Many published reports have noted a tendency for children who stutter to exhibit coexisting difficulty with speech sound production. In studies based on analysis of children who participated

in research studies, the estimated percentage of cases with co-occurring fluency and speech sound production difficulties ranged from 20 to 40% (e.g., Louko, Edwards, & Conture, 1990; Yaruss, LaSalle, & Conture, 1998). Another approach has been to survey school-based speech-language pathologists about characteristics of children on their caseloads (Table 6–8). The main finding from these studies was that many of the children who received treatment for stuttering in school settings also met local criteria for other speech-language disorders. As shown in Table 6–8, data from Blood and Seider (1981) and Arndt and Healey (2001) indicated most children who stutter had some type of accompanying disorder, including disorders that affected functioning in language, speech sound production, or both. Blood, Ridenour, Jr., Qualls, and Hammer (2003) reported that articulation disorders were more likely to co-occur with stuttering (33% of all cases) than were voice disorders (2% of all cases) or cluttering (1% of all cases). About 13% of the children who stuttered met school district criteria for language impairment that affected semantics and/or syntax, and 10% met criteria for language impairment that affected syntax. If one expands the focus to include any type of accompanying disorder, the percentage of affected cases jumps to more than 60% (see Table 6–8). This is, of course, much higher than what one sees in the general population. The picture is not entirely clear, however, because other studies featuring direct testing of preschool-aged children have reported no significant difference between stuttering and typical fluency groups on their articulation test scores (Clark, Conture, Walden, & Lambert, 2015. Thus, it may be that children who end up on school-based caseloads constitute a subgroup that goes on to exhibit stuttering and speech sound disorders that persist from the preschool years into the school years. Another issue to exam is whether the presence of a concomitant communication disorder results in patterns of speech production that are substantially different from those that are observed when a disorder exists in isolation. Louko et al. (1990) reported that children who stuttered were more likely to exhibit phonologically based speech



6.  Stuttering: Correlates and Consequences

Table 6–8.  Percentage of Children Who Stutter With Concomitant Disorders Percent of Cases Both speech sound disorder and language disorder

Speech sound disorder only

Language disorder only

Any type of accompanying disorder

Blood & Seider (1981)

11

16

10

68a

Arndt & Healey (2001)

14

14

15

67b

Blood et al. (2003)c

—

—

—

63a

Study

a

Includes all types of communication disorders plus other developmental communication- and non-communication-based disorders.

b

Includes confirmed disorders of speech sound production and language functioning, plus other suspected or confirmed communication- and non-communication-based disorders. c Data were collected for specific types of speech sound production and specific areas of language disorder. Because individual cases could present with more than one of these problems, it is not possible to complete the first columns in this table.

sound disorder than children in a control group with typical fluency (40% versus 7%, respectively). The children who stuttered exhibited a greater variety of phonological processes, and some of the phonological processes that the children who stuttered produced (i.e., glottal replacement, backing, lateralization) were not produced at all by the children in the control group, and some more common processes, such as cluster reduction, occurred much more among children in the stuttering group than they did among children in the control group. Wolk, Edwards, and Conture (1993) compared speech sound production and fluency characteristics of children who stuttered, children with disordered phonology, and children who exhibited both disorders. They found that the presence of disordered phonology in combination with stuttering did not affect the frequency or duration of stuttering-related disfluency, stuttering severity, or speaking rate. The only difference between the two groups was that the children who exhibited both stuttering and disordered phonology had a significantly greater proportion of sound prolongations in their disfluency profiles (37% of all disfluencies) than the children who only stuttered (19% of all disfluencies). Further, the presence of stuttering did not markedly alter the symptoms of the phono-

logical disorder. That is, children with both stuttering and disordered phonology performed similarly to children with only disordered phonology in terms of phonetic inventory, percent of consonants correct, percent of process occurrence, and most frequent types of processes produced; vowelization, gliding, cluster reduction, and velar fronting were the most common. Logan, Louko, Edwards, & Conture (1995) compared the phonological skills of mild and severe cases of childhood stuttering using many of the same measures that Wolk et al. (1993) used. They reported no difference in the number or types of phonological errors produced across the two levels of stuttering severity. Clark et al. (2015) reported similar findings for a much larger sample of preschoolers who stuttered. On this basis, the presence of coexisting fluency and phonological disorders does not seem to result in performance patterns that are markedly different from those that occur when either disorder exists in isolation. The presence of concomitant communication disorders among children who stutter has led some authors (e.g. Seery, Watkins, Mangelsdorf, & Shigeto, 2007; Yairi, 2007) to search for subtypes of stuttering. Yairi (2007) reviewed several decades of research studies and identified five factors with

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potential relevance to the development of a framework that would facilitate identification of stuttering subtypes: 1. Co-occurring disorders (e.g., presence or absence and type of a co-occurring disorder); 2. Speech characteristics (e.g., disfluency types produced, disfluency frequency, effects of responsiveness of disfluency frequency to speech motor rehearsal); 3. Biological characteristics (e.g., gender, brain morphology, genetic traits and family history); 4. Response to drugs (e.g., presence or absence of a fluency response, type of fluency response [positive, negative, neutral]); and 5. Developmental course of disorder symptoms (e.g., age of symptom onset, changes in symptom presentation over time, eventual outcome of stuttering symptoms).

Studies of Phonological Encoding Several studies have examined the language performance of speakers who stuttered during tasks that involve word or sentence production. Most of these studies have focused on functioning in the area of phonological processing. In one study, children who stuttered performed similarly to children with typical fluency with respect to response initiation times on a naming task that included words from low-density and high-density phonological neighborhoods (Arnold, Conture, & Ohde, 2005). Despite this finding, Byrd, Conture, and Ohde (2007) reported evidence of immaturity in phonological encoding among children who stuttered. In the study, 3- and 5-year-old children who stuttered increased naming speed only for one-syllable words when presented with a phonological model of a holistic prime, which corresponds to acoustic information associated with nearly all of a syllable rime. In contrast, 5-year-old children in the control group showed a developmental change in the type of phonological prime that facilitated their response initiation times. At age 3, they benefited from holistic primes; however, at age 5, their naming speed increased when they received incremental primes, which corresponds to acous-

tic information associated with the syllable onset and a small portion of the phonetic transition into the vowel.

Cognitive Functions and Stuttering-Related Disfluency Studies of children who stutter have revealed that as a group they perform more poorly than nonstuttering children on forward digit-span tasks (Ofoe et al., 2018). Results from numerous other studies have indicated that people who stuttered experienced an increase in stuttering frequency when asked to perform a concurrent cognitive task while speaking. For example, Bosshardt (2002) found that adults who stuttered became significantly more disfluent when asked to repeat a series of three words at the same time they performed either a reading or a memorization task. Interestingly, exacerbation of fluency was observed only when the concurrent task featured words that were phonologically similar to the words the participants were repeating. Adults with typical fluency showed no difference in fluency between the concurrent- and single-task conditions of the study. Bosshardt hypothesized that, in speakers who stutter, the functioning of the phonologic and/or articulatory systems is prone to disruption when attentional resources are diverted toward other goals. In another study, Bosshardt (1999) examined the effect of a concurrent mental addition task on speech fluency during a word-repetition task. He found that speakers who stuttered demonstrated a temporary improvement in speech fluency immediately after receiving a cue that the mental addition task was about to be presented, but speakers’ fluency then worsened when they performed the simultaneous tasks. Nonstuttering controls showed no change in fluency during the experimental task. In this study, the increase in disfluency was limited to a subgroup of participants. As in the 2002 study, findings demonstrated that stuttering behavior is affected by the extent to which the speaker’s attentional resources are diverted from speaking. Jones, Fox, and Jacewicz (2012) also found evidence of an interaction between phonological and cognitive processing demands in a study with



adults who stuttered. In this study, the participants made rhyme judgments and recalled letter strings of varying lengths. Although the adults who stuttered performed as accurately as the nonstuttering controls in the rhyme judgments at all levels of cognitive load, their response times were on average about 250 ms (i.e., one-fourth second) slower than those for the control group, and response lags were greatest in conditions that involved the most cognitive load. Caruso and colleagues (Caruso, Chodzko-Zajko, Bidinger, & Sommers, 1994) used the using the Stroop Color Word Test to examine the effects of cognitive load on the performance of adults who stuttered. In their study, participants produced speech samples during tasks in which they either read printed words (i.e., “red,” “yellow,” “blue,” and “green”) or stated the ink color in which the color words were printed. In one condition, the ink color was congruous with the color word (e.g., the word “red” was printed in red ink); in another it was neutral (all words were printed in white font against a black background); and in another condition, the ink color was incongruous with the color word (e.g., the word “red” was printed in blue ink). Tasks were performed under speeded and self-paced conditions. Caruso et al. measured the participants’ cardiovascular responses, speech motor timing and coordination, and fluency across the conditions. Results showed that the cognitive stress condition (e.g., naming incongruous ink colors under time pressure) had significant effects on heart rate, word and vowel duration, speech rate, and response latency for the speakers who stuttered. In another study, Weber-Fox, Spencer, Spruill, and Smith (2004) found that adults who stuttered had slower response initiation times than fluent controls during the most complex conditions of a rhyme judgment task in which the experimenters manipulated phonologic and orthographic congruency (e.g., thrown-own; cake-own; gown-own; cone-own). In that study, the adults who stuttered also showed an anomalous cognitive-processing strategy, characterized by greater right hemisphere activation than what was observed in the control group. Similarly, children who stuttered perform slower (Coalson & Byrd, 2015; Sasisekaran & Basu, 2017) and less accurately (Coalson & Byrd, 2015)

6.  Stuttering: Correlates and Consequences

than children with typical fluency in studies that examined executive functioning through phoneme monitoring tasks. In addition, children who stuttered receive poorer parental ratings in the areas of working memory performance and general executive function performance when compared to children with typical fluency (Ntourou, Anderson, & Wagovich, 2018).

Psychological and Social-Emotional Correlates Having discussed the many communication-related differences and deficits that people who stutter present, the next issue to consider relates to stuttering-related emotions, feelings, thoughts, beliefs, and attitudes. As Johnson and Associates (1959) noted many years ago, stuttering is a dynamic disorder, and a speaker’s experience of the disorder is shaped by four main factors: (1) the speech behaviors that characterize the disorder; (2) how the speaker reacts to his or her stuttered speech; (3) how listeners react to the speaker’s stuttered speech; and (4) how the speaker reacts to the listeners’ reaction to his or her stuttered speech. Stuttering can have a marked negative impact on a person’s ability to communicate; however, the extent of a person’s speech fluency disability is not always an accurate indicator of the broader effects that the disorder has on a person’s psychological and social-emotional functioning. For example, a person who exhibits what appears to be relatively mild stuttering symptoms in speech may report experiencing intense emotions (e.g., shame, anxiety) surrounding the fluency impairment and, with those emotions, significant reductions in quality of life and well-being. Such an individual is likely to experience significant participation restrictions in at least some life activities, and the backdrop may interfere with speech motor control in ways that aggravate the symptoms of fluency impairment (Bauerly et al., 2019). An illustration of how feelings, thoughts, and emotions become intertwined with self-evaluative thoughts and speech motor behavior and speech fluency is presented in Figure 6–2. For most individuals

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1. Speaker stutters.

2. Listener reacts negatively, e.g., laughs.

3. Speaker reacts to listener reaction (e.g., shame, anger).

6. Speaker tries to conceal stuttering, e.g., word avoidance.

5. Speaker becomes fearful of stuttering openly and anxious about future interactions with listener.

4. Speaker links emotions with evaluative thoughts, e.g., “Stuttering is bad.”

Figure 6–2. Illustration of the cyclic events that lead to extension of stuttering-related disability from the domain of speech fluency to broader aspects of functioning, particularly communicative functioning, emotional well-being, self-concept and general health. With young children, the entry point into the cycle is in box 1, i.e., the production of stuttering-related disfluency. As children’s social cognition and self-awareness develop, listener reactions to stuttered speech become increasingly influential in shaping how one responds to and evaluates their stuttered speech. Repeated exposure to listeners’ negative/disapproving responses to stuttered speech can lead to the development of emotions, thoughts, and concealment strategies, which when repeated (dashed arrow) can disrupt or limit one’s speech fluency, emotional well-being, participation in social interaction, and general quality of life.

who stutter, this process begins during childhood and progresses in the manner suggested in the figure. That is, the speaker’s stuttering elicits a response from the listener (e.g., laughter, a sarcastic comment, a look of concern, pity, or alarm) that is upsetting to the speaker, thus triggering an emotional response and corresponding feelings such as anger, embarrassment, humiliation, frustration, or diminishment. These feelings become mixed with evaluative thoughts (e.g., “This feels bad. Stuttering is bad. I can’t let others hear me stutter”), which after many repeated occurrences can crystalize into firmly entrenched beliefs about how future speaking interactions will transpire and, with those beliefs, speech-related anxiety and fear (i.e., social anxiety) and associated physiological symptoms. Approaching new speech situations against this backdrop is likely to exacerbate the effects that the individual’s fluency impairment has on his or her speech fluency and can lead the speaker to withdraw from social interactions or attempt to conceal stuttering-related disfluency. The scenario depicted

in Figure 6–2 is not uncommon among people who stutter. In one study of children who stuttered and who were aged 3 to 18 years, results indicated that they had poorer attitudes toward communication in comparison to children who do not stutter; and the disparity in communication attitudes between groups increased with cohort age (Guttormsen, Kefalianos, & Næss, 2015). When clients present evidence of poor communication attitudes, negative thoughts, disruptive emotions, and communication avoidance, the treatment plan must incorporate intervention activities that target one more of these elements and, in doing so, help the client break this unproductive, unhealthy cycle of events.

Life Experiences of People Who Stutter Several large-scale community cohort studies have been conducted over the past 2 decades to examine general health and developmental characteris-



tics during childhood. McAllister (2016) reported on findings from the Millennium Cohort Study in the United Kingdom. Data from children who stuttered were examined for areas of “difficulty,” which included aspects of behavioral, emotional, and social development, and addressed issues such being “nervous or clingy” or “fidgety or easily distracted” and having peer relationship problems (e.g., bullying). Results indicated that, based on parental reports, children who stuttered presented with more “difficulties” than children who did not stutter at ages 3, 5, and 11 years. In another study that was based on the National Child Development Study in the United Kingdom, Helena and colleagues (Helena, McAllister, & Skinner, 2016) examined alcohol and tobacco use among people who stuttered at seven points between the ages 16 and 55 years. They found no difference in consumption rates of either substance compared to rates observed in the general population. Iverach et al. (2010) reported similar findings for a cohort of 92 Australian adults who sought treatment for stuttering. Other researchers have used qualitative research methods that incorporated standardized interviewing to learn about how people who stuttered experienced stuttering during daily activities. The researchers then analyzed the content of participant responses systematically using methods that are designed to extract themes that recur across participants. For example, Corcoran and Stewart (1998) conducted a qualitative study of eight adults who stuttered that centered on the participants’ common emotional themes. Four interrelated themes emerged among the participants: shame, helplessness, fear, and avoidance, which together added up to an overall portrait of suffering. Corcoran and Stewart discussed the relationship between feelings of shame and the stigma that becomes attached to stuttering through an assortment of negative cultural connotations of stuttered speech and people who stutter. The researchers noted that the experience of suffering, in medical spheres, often is accompanied by feelings such as a lack of control over the situation, lack of understanding of the situation, and a sense of feeling overwhelmed at the prospect of experiencing dire or unrelenting negative outcomes.

6.  Stuttering: Correlates and Consequences

Plexico, Manning, and DiLollo (2005) used qualitative methods to identify the processes that are involved in learning to manage stuttering successfully. They conducted in-depth interviews with seven adults who stuttered. Each of the adults had developed the ability to manage stuttering well enough that the disorder no longer resulted in significant communication disability. In Plexico et al.’s study, the participants discussed their speech and general experiences from childhood through adulthood. The common themes that the participants mentioned with regard to those periods in life when they did not manage stuttering successfully included the following: experiencing negative emotions; experiencing negative reactions from listeners; leading a restrictive lifestyle, avoiding social and communicative situations; developing gradual awareness of communication disability; and receiving inadequate speech therapy. Based on comments from the participants, Plexico et al. (2005) also identified the “essential structure” of stuttering at three periods in the participants’ lives: the period when stuttering was not successfully managed, the transition period toward successful management, and the (current) period when stuttering was successfully managed. The essential structure consisted of a concise narrative that captured the seven participants’ common core experience. The essential structure that Plexico et al. reported for unsuccessfully managing stuttering included the following elements: (1) experiencing significant “struggle” and “suffering” due to the challenges associated with stuttering; (2) enduring negative reactions toward stuttering from people within and beyond the immediate family; (3)  attempting to conceal stuttering from others either by avoiding participation in social situations or by implementing coping strategies in order to minimize or prevent stuttering-related symptoms; and (4) experiencing a range of unpleasant and disabling emotions (e.g., helplessness, anxiety, poor self-esteem). Daniels, Gabel, and Hughes (2012) completed a qualitative study in which 21 mainly middle-aged adults who stuttered recounted their stutteringrelated experiences during the school years. Experiences that the participants reported included the following:

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• The use of physical (finger tapping), linguistic (word avoidance), and socialinteractional (situational avoidance) coping strategies (86% of participants); • Physiological consequences such as physical illness (e.g., vomiting from anticipation of public speaking), muscle tension, and anxiety (67% of participants); • Psychological consequences such as feelings of hopelessness (33% of participants); • Academic consequences such as limited verbal participation in learning activities and limited attention to lectures because of stuttering-related anxiety (90% of participants); • Speech therapy that focused mostly on speaking techniques and rarely on speechrelated feelings and emotions (76% of participants); and • Persistent fear of speaking following completion of school and development of a stuttering self-identity (81% of participants). Clearly, in cases of chronic stuttering, the memories of communication-related difficulties from childhood remain vivid into adulthood, and they seem to color a person’s life experiences well after the school years end. Research with older adults who stutter indicates that speakers may continue to experience negative feelings concerning social interactions, concern about negative reactions from listeners, and diminished satisfaction with their general health state (Bricker-Katz, Lincoln, & McCabe, 2009). These experiences seem to extend to people in a variety of cultural settings. For example, South African adults who stuttered reported similar histories of negative listener reactions and similar stuttering-related limitations for their academic and occupational performance as adults from other countries who have participated in studies of stuttering-related experiences (Klompas & Ross, 2004). As an aside, student speechlanguage pathology clinicians who are required to complete pseudo-stuttering activities as part of their clinical training report many of the same reactions and experiences to talking in a stutter-like manner as speakers who stutter (McKeehan, 1994; Rami, Kalinowski, Stuart, & Rastatter, 2003).

Anxiety and Related Disorders According to the American Psychological Association (APA, 2020a), anxiety is “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure” (para. 1). APA stated that people with anxiety disorders also may present recurring intrusive thoughts or concerns and situational avoidance, which is rooted in worry about how a situation will unfold, along with physical symptoms such as “sweating, trembling, dizziness, or rapid heartbeat” (para. 2). Included under the umbrella of anxiety disorders are conditions such as social phobia, generalized anxiety disorder, panic disorder, and obsessivecompulsive disorder (Iverach et al., 2010). Anxiety has been included as a variable in many studies of stuttering, where its role as a potential cause and/ or consequence of stuttering has been examined. In psychology, a distinction is made between state anxiety and trait anxiety (Spielberger, Gorsuch, Lushene, & Vagg, 1983). The notion of state anxiety refers to how a person experiences anxiety within specific situations or settings. Trait anxiety, in contrast, refers to a person’s background level of anxiety across all activities — that is, the level of anxiety that one experiences chronically or, perhaps, that is intrinsic to one’s personality. Researchers that have examined state and trait anxiety have consistently detected differences between speakers who stutter and speakers with typical fluency. For instance, Ezrati-Vinacour and Levin (2004) reported that adults who stuttered had higher trait anxiety scores than fluent controls and that severe cases of stuttering had higher state anxiety scores than mild cases of stuttering. Craig (1990) examined anxiety ratings for a large sample of adults who stuttered in the context of recorded telephone conversations before and immediately after participation in a stuttering therapy program. Data were compared to anxiety ratings from a control group of typical speakers. In the pretreatment assessment, both the state and trait anxiety scores for the speakers who stuttered were significantly greater (more severe) than those for the fluent controls. Craig interpreted the high pretreatment trait anxiety scores for the speakers who stuttered as a consequence of having had a



speech handicap for many years and the elevated state anxiety as a consequence of the speakers’ repeated exposure to negative reactions from conversational partners in this context and their expectation of receiving such reactions again in the future. For the speakers who stuttered, pretreatment state anxiety was significantly correlated with stuttering frequency as well. Following the treatment, which resulted in marked reduction of stuttering-related disfluency during the phone calls, the trait anxiety scores were comparable to those of the control group and were not correlated to stuttering severity in either the pre- or posttreatment conditions. Thus, after the speakers developed skills for managing speech fluency more effectively, their anxiety scores improved markedly. On this basis, Craig suggested that anxiety is more likely a consequence of stuttering than a cause of stuttering. In some studies, researchers have failed to detect differences in either state or trait anxiety between speakers who stutter and speakers with typical fluency, but they have found evidence of anxiety-related differences between the groups using other measures. For instance, Blood and colleagues (Blood, Blood, Bennett, Simpson, & Susman, 1994) reported that adult speakers who stuttered showed higher levels of salivary cortisol (a hormone that is involved in glucose metabolism and the body’s response to stress) than nonstuttering controls during self-rated “high stress” sessions in the experiment. Both groups reported comparable increases in state anxiety scores during the “high stress” condition relative to a baseline condition, but the groups did not differ in the amount of anxiety they reported. Comparisons of cortisol and alpha-amylase (another bio-stress marker) levels in children who stuttered versus children with typical fluency have yielded negative findings, however (Ortega & Ambrose, 2011). Other research has supported the notion that the elevated anxiety found in many speakers who stutter is primarily socially based. Messenger, Onslow, Packman, and Menzies (2004) administered a comprehensive anxiety rating scale to both adults who stuttered and matched controls who did not stutter. They found that the stuttering group exhibited elevated scores only on portions of the scale that pertained to social evaluation and partici-

6.  Stuttering: Correlates and Consequences

pation in new or unfamiliar social situations. Scale items dealing with other anxiety-provoking contexts (i.e., exposure to physical danger, participation in certain daily routines) did not differentiate the groups. In a similar study, Mahr and Torosian (1999) found that speakers who stuttered had higher (less favorable) ratings on a scale of social anxiety than a fluent control group did; but when the speakers who stuttered were compared to a group of people with social phobia, they scored lower (more favorably) with regard to social distress, avoidance, and fear of negative evaluation. The most common fears reported by speakers who stuttered dealt with speech-related issues. Findings from other research with adults who stuttered showed that they identified more daily activities as being stressful than speakers with typical fluency did, and they exhibited higher levels of stuttering on self-reported “high stress” days than on low stress days (Blood, Wertz, Blood, Bennett, & Simpson, 1997). Elevated anxiety ratings also have been reported in studies with adolescents who stutter (Blood, Blood, Maloney, Meyer, & Qualls, 2007; Mulcahy, Hennessey, Beilby, & Byrnes, 2008). Although self-reported ratings of self-esteem for adolescents who stutter do not seem to differ from those for typically fluent adolescents, the selfesteem scores are significantly correlated with selfratings of anxiety, suggesting that highly anxious teens who stutter tend to have poor self-esteem (Blood et al., 2007). There is growing recognition that the prevalence of social anxiety disorder is much higher among people who stutter than it is in the general population. In one study, Blumgart, Tran, and Craig (2010a) administered a battery of tests to 200 adults who stuttered and 200 fluent controls. As in other studies, they found evidence of elevated trait anxiety and social anxiety among the speakers who stuttered. In addition, 40% of the adults who stuttered met criteria for social phobia, and these individuals were judged to be at risk for a generalized phobia. Examples of fears that differentiated the groups included the following: “public speaking,” “saying stupid things in a group,” “asking questions in a group,” “business meetings,” and “social gatherings or parties.” Iverach et al. (2009)

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used a statistical modeling approach to estimate the extent to which adults who seek therapy for stuttering are at risk for various anxiety-related disorders. Based on their analysis, 22% of adults seeking treatment met diagnostic criteria for social anxiety, and people who stuttered had a 6 to 7 times greater chance than nonstuttering controls of meeting a 12-month diagnosis for some type of anxiety disorder. The risk for social phobia was particularly high (16 to 34 times greater than the fluent controls), and there also was significantly higher risk for developing generalized anxiety disorder (4 times greater risk than the fluent controls) and panic disorder (6 times greater risk than the fluent controls). More recently, Iverach et al. (2018) examined a large sample of adults who stuttered using a computer-based interview protocol and found that 30% of the participants met criteria for social anxiety disorder. The subgroup of participants with social anxiety disorder were younger than the subgroup with no social anxiety disorder (~30 years versus ~35 years), and while they did not differ in stuttering severity, those participants with social anxiety disorder reported more avoidance, less speech satisfaction, more psychological problems, as well as a greater negative impact from stuttering on their daily life. In another study, Iverach et al. (2010) found that people who stuttered were two times as likely as nonstuttering controls to meet criteria for mood disorders (e.g., major depression). These findings differ from those in some other studies, wherein speakers who stuttered were found to exhibit a similar degree of depression as nonstuttering controls (Bray, Kehle, Lawless, & Theodore, 2003; Miller & Watson, 1992). Sample sizes in the latter studies were smaller than those in the Iverach et al. (2010) study, however. Self-reported mood rating data over a 6-month period from adults who stuttered indicated that about 40% of individuals showed elevated mood states in the areas of interpersonal sensitivity, depressive mood, or anxiety, and that mood states like interpersonal sensitivity were associated in part with self-perceptions of vitality, control over life events, and social fears (Tran, Blumgart & Craig, 2018). The concept of self-stigma has received an ever-increasing amount of attention among pro-

fessionals who study and work with people who stutter. Boyle (2018) explained that self-stigma develops when a person who stutters internalizes negative beliefs about stuttering and people who stutter that are held by the general public. As a speaker who stutters becomes aware that stuttering is stigmatized, he or she gradually adopts the public views and applies them inwardly. Self-stigma has negative consequences for one’s mental health, physical health, and health care satisfaction, and it can exacerbate the effects that fluency impairment has on one’s communication and general quality of life (Boyle, 2015b; Boyle & Fearon, 2018).

Personality Characteristics Bloodstein and Bernstein Ratner (2008) summarized numerous studies that were conducted in the mid- to late-1900s in which the research focus was on the personality, personal adjustment, and mental well-being of speakers who stutter. Based on this review, they concluded that the average person who stutters does not show evidence of severe maladjustment or neuroticism, nor does the person show evidence of a specific “character structure” or personality profile. With respect to personal adjustment, the researchers concluded that people who stutter show marked variability — some people are very well-adjusted both to their communication impairment and to general life activities, while others clearly are not, and that there is considerable overlap between the two speaker groups in terms of their adjustment adequacy. They held that, on average, people who stutter “are not quite as well adjusted as are typical normal speakers” (p. 209). This premise was based on findings from many studies in which people who stuttered showed a tendency toward lower self-esteem and reduced willingness to take risks compared to typically fluent speakers. Still, Bloodstein and Bernstein Ratner suggested that the differences between people who stutter and typical speakers is a matter of degree, not type. Thus, people who stutter may score lower than typical speakers on measures of personality and emotional health, but usually not so much lower as to create a categorical difference and the labeling of a disorder.



6.  Stuttering: Correlates and Consequences

The personality characteristics of speakers who stutter continue to receive researchers’ attention. Iverach et al. (2010) examined five personality domains in speakers who stuttered compared to speakers with typical fluency and found that the speakers who stuttered were well within the normal range for all five domains (neuroticism, extraversion, openness, agreeableness, and conscientiousness); however, these same speakers had less favorable ratings than controls for three of these domains (neuroticism, agreeableness, conscientiousness). Manning and Beck (2013) also examined personality factors in a sample of 50 adults who were undergoing treatment for stuttering. They found that only 10% of the participants met criteria for personality disorder and suggested that personality disorder is no more common among people who stutter than it is in the general population. It also appears that when speakers who stutter exhibit strong social support networks, healthy social relationships, and a high degree of “self-efficacy” (i.e., the belief that one can exert influence over circumstances in their life), they are much less likely to experience adverse psychosocial effects compared to those individuals who lack these markers of resilience (Craig, Blumgart, & Tran, 2011).

Temperament Characteristics Temperament has been defined as “biologically based individual differences in behavioral characteristics or reactions that are present in infancy and are relatively stable across contexts and over time” (Anderson, Pellowski, Conture, & Kelly, 2003, p. 1221). The construct typically is conceived of as a collection of hereditable traits or dimensions pertaining to reactivity, sociability, self-regulation, agreeableness, positive or negative emotionality, and adaptability (Eggers, De Nil, & Van den Bergh, 2009; Rothbart & Bates, 1998; Seery et al., 2007). According to estimates, roughly 20% to 60% of the individual variation in temperament can be attributed to genetic factors, with the remainder attributable to environmental factors (Eggers et al., 2009). In recent decades, researchers have examined the temperament of children who stutter in an attempt

to clarify its role in the development and expression of stuttering. In some studies, researchers have measured children’s temperament using parental responses on formal rating scales of temperament (e.g., Anderson et al., 2003; Eggers et al., 2009; Karrass et al., 2006; Kefalianos, Onslow, Ukoumunne, Block, & Reilly, 2014). In other studies, researchers have examined children’s verbal and nonverbal behaviors during experimental situations that are designed to elicit positive and/or negative emotions (Arnold, Conture, Key, & Walden, 2011; Johnson, Walden, Conture, & Karrass, 2010). In the Arnold et al. (2011) study, behavioral measures were supplemented by electrophysiological measures of brain activity. The general pattern of research findings indicates that although children who stutter and children with typical fluency show similarities in temperament profiles, in most studies, at least some differences have been detected between the groups (Seery et al., 2007). The nature of temperament differences between groups varies across studies, however, and the relationship between the group differences and stuttered speech sometimes is unclear. For example, some researchers (Kefalianos et al., 2014) have found that children who stutter are less reactive to environmental stimuli than children with typical fluency; others have found that they are more reactive (Karrass et al., 2006; Schwenk, Conture, & Walden, 2007); and still others have the two groups reacting similarly (Arnold et al., 2011). In several studies, children who stutter have been found to be more likely to manifest reduced attention and/or task persistence in comparison with children with typical fluency (Anderson et al., 2003; Karrass et al., 2006; Kefalianos et al., 2014). Schwenk et al. (2007) examined children’s reactivity and distractibility by observing how participants reacted to movements of a remotely controlled video camera while experimenters collected data. They found that when the camera moved, the children who stuttered were nearly three times as likely as the nonstuttering children to reorient attention toward it and, consequently, away from the toy or person to which they had been attending. The children who stuttered also showed a trend toward orienting more quickly toward the camera movement than the

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nonstuttering children did. In community cohort studies of 2- to 4-year-old children, however, no obvious relationships between temperament profiles and stuttering severity have been reported (Kefalianos, Onslow, Ukoumunne, Block, & Reilly, 2017). Differences between children who stutter and children with typical fluency in emotional regulation also have been reported. For example, when presented with an undesirable gift in an experimental setting children who stuttered produced more nonverbal expressions of negative emotion than children with typical fluency and, at such times, their speech became more disfluent (Johnson et al., 2010). Children who stutter also were less apt than children with typical fluency to implement overt emotional regulation strategies such as distraction (i.e., shifting attention toward another event or activity), self-stimulation (i.e., seeking comfort from another person), or cognitive restructuring (i.e., requesting more information about a situation) when engaging in communication contexts that are associated with discomforting emotions (Arnold et al., 2011, Eichorn, Marton, and Pirutinsky, 2018). In a recent meta-analysis of research in this area, Ofoe et al. (2018) reported that children who stuttered had lower parental ratings on measures of inhibition and attention focus/persistence than children with typical fluency; yet on behavioral measures of these constructs, the two groups perform similarly. Kefalianos et al. (2014) examined aspects of temperament in preschool-aged children for the presence of traits that are associated with anxiety. Among other variables, they examined whether children who stuttered were more reluctant to approach novel stimuli and novel social situations than children with typical fluency and whether they showed a greater tendency toward being viewed by their parents as being difficult to deal with. Neither variable differentiated the two groups of children — a finding that was consistent with other research (Anderson et al., 2003; Eggers et al., 2009). Based on these findings, Kefalianos et al. concluded that anxiety is not likely to be a causal factor at stuttering onset. Rather, it seems to be an emergent feature of stuttering and develops after preschool following accumulated nega-

tive experiences with speaking. Given the nature of the findings in the temperament literature, Seery et al. (2007) proposed that there is not a single, common “stuttering temperament,” but rather that temperamental differences are present to varying degrees in subgroups of children who stutter.

Emotions and Autonomic Nervous System Functioning One way of studying the physiological correlates of stuttering is to examine autonomic nervous system (ANS) functioning. The ANS is a branch of the nervous system that regulates body activities that are largely “involuntary” in nature (e.g., heart rate, vasoconstriction, digestion, sweat secretion). Several researchers have examined ANS functioning in speakers with typical fluency and speakers who stutter through examination of variables such as heart rate and pulse volume. One of the main findings is that high levels of autonomic arousal characterize speech production for all speakers — regardless of whether they stutter (Weber & Smith, 1990). The relationship between autonomic arousal and stuttered speech is complex, however. For example, Weber and Smith (1990) reported that high levels of autonomic nervous system activation were present prior to, during, and just after overtly stuttered speech; however, levels of autonomic arousal were not strongly predictive of stuttering severity or disfluency frequency. Further, speakers who stuttered did not show more autonomic arousal than speakers with typical fluency. In more recent research, however, children who stutter have been found to have heightened emotional reactivity compared to typical children when viewing unpleasant pictures (Zengin-Bolatkale, Conture, Key, Walden, & Jones, 2018); also, heightened sympathetic nervous arousal in preschoolers near the onset of stuttering is a marker for stuttering persistence (Zengin- Bolatkale, Conture, Walden, & Jones, 2018); and difficulty in regulating sympathetic nervous system arousal has been linked to increased frequency of stutterlike disfluency ( Jones, Walden, Conture, Erdemir, Lambert, & Porges, 2017). Further, heightened levels of autonomic nervous system arousal have



6.  Stuttering: Correlates and Consequences

been detected regardless of whether adults who stutter are in a stressful situation; and heightened levels of autonomic arousal in combination with self-reported anxiety are associated with instability in speech motor movements (Bauerly, Jones, & Miller, 2019).

Environmental Correlates Elements of the general environment, particularly those associated with listener/speaking partner behavior, also have relevance to the expression of stuttering.

Listener Behavior As noted in the previous section, many people who stutter report having received negative responses from listeners. Some of these responses undoubtedly result from the listener’s failure to recognize stuttered speech as it is occurring. For example, a speaker who hesitates to respond when asked “What is your name?” may be met with a remark such as “Oh, that’s a tough question, huh?” or “Yeah, I’ve had a long day too” or perhaps a facial expression that conveys impatience, confusion, concern, or incredulity. Listener responses such as these may not be delivered with a malicious or hurtful intent, and the responses may not seem particularly problematic on the surface; however, when a speaker who stutters is met with these responses multiple times per day, for weeks and months, he or she is likely to view these responses negatively and to become apprehensive or anxious about how the next listener will respond when the speaker stutters.

Bullying APA (2020b) stated that bullying “is a form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort” and that it can take the form of “physical contact, words, or more subtle actions” (para. 1). In most cases, the person being targeted

for bullying cannot defend himself or herself easily and has done nothing obviously wrong or threatening to the bully. A person who is being bullied may withdraw from social interaction and experience low self-esteem, as well as physical symptoms such as difficulty sleeping, loss of appetite, and anxiety. Research into the bullying experiences of people who stutter is limited, but data suggest that it is a significant problem for this population, and negative effects from being bullied in childhood can persist into adulthood in the form of poorer self-ratings of psychosocial functioning (Blood & Blood, 2016). In one retrospective study, about 89% of participants with a history of stuttering reported having been bullied during their school years (Hugh-Jones & Smith, 1999). In a study of adolescents, 44% of those who stuttered reported that they had been bullied, while only 14% of the control group did (Blood et al., 2011). Davis, Howell, and Cooke (2002) interviewed school-aged children individually regarding their views about classmates. The researchers showed the children a class roster and asked them to nominate the three children they liked most and least. Then they asked the children to pick three classmates who best fit each of the following eight adjectives: shy, assertive, cooperative, bully, bully victim, disruptive, leader, and uncertain. The results showed that peers rejected children who stuttered more often than they did nonstuttering peers and that children who stuttered were less likely to be viewed as popular or as leaders and more likely to be characterized as victims of bullying and as seeking help. Similar findings have been reported in studies that examined classmate nomination patterns for preschool-aged children with other types of speech-language disorders (Gertner, Rice, & Hadley, 1994). Langevin (2009) found that about 17% of 10-year-old children expressed somewhat negative to very negative attitudes toward two stuttering children who they viewed on video. However, the participants who reported knowing someone who stuttered had more favorable attitudes toward the children on the video recordings than the participants who reported not knowing someone who stuttered. This suggests that educational programs that are geared toward building school-aged children’s knowledge of stuttering

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may be an important component in programs that are designed to prevent bullying in schools.

Listener-Based Stereotypes and Attitudes The issue of listener attitudes toward stuttering and people who stutter has been studied extensively (Bloodstein & Bernstein Ratner, 2008). One widely used approach to elicit listener perspectives on stuttering has been to present adults who do not stutter with pairs of contrasting adjectives such as outgoing and withdrawn and then ask them to use the adjectives to rate a hypothetical person who stutters and a hypothetical person who does not stutter. In many studies of this type, the hypothetical speaker who stutters ends up being assigned less favorable or less desirable characteristics than the hypothetical fluent speaker. In other studies that have used this general methodology, subgroups within the population (e.g., teachers, nurses, prospective employers) are presented with descriptor-based rating scales and again are asked to rate hypothetical speakers. In these studies as well, hypothetical people who stutter tend to be rated less favorably than hypothetical fluent speakers. One limitation of the “rate the hypothetical person who stutters” method is that there is no control over who the raters are using as a reference point. Consequently, it is possible that the ratings some participants make are based on an amalgamation of all people who stutter, while the ratings of other participants are based on their experiences with one person who stuttered — and that person may have stuttered mildly, severely, or at a level between these extremes. Logan and Willis (2011) attempted to address this methodological weakness by exposing raters to multiple samples of speech containing varying degrees of stuttering-related disfluency. They found that when ratings are made under more controlled conditions, raters’ perceptions of people who stutter are no longer uniformly negative. In the study, the raters demonstrated to the ability to empathize with types of communicative difficulties that speakers with varying degrees of stuttering severity are likely to experience, as demonstrated by their assignment of ratings about the speakers that varied in scale with their perceptions of stuttering severity for the speech samples.

Studies of employers have suggested that they tend to view people who stutter as being less capable or less likely to be promoted than people who do not stutter (Bloodstein & Bernstein Ratner, 2008). Interestingly, studies with people who stutter tend to show similar findings; that is people who stutter sometimes report that their stuttering limits their performance in work settings (Logan & O’Connor, 2012). When speakers with typical fluency are asked to provide career advice to a person who stutters, they are much more likely to recommend occupations with low speaking demands over occupations with high speaking demands. In contrast, their occupational advice for speakers with typical fluency is primarily based on the raters’ perceptions of the academic or training requirements associated with an occupation (Logan & O’Connor, 2012). People who stutter are sometimes faced with the dilemma of whether to overtly acknowledge their stuttering when interacting with other people. Results from some studies have suggested that listeners react to a speaker who stutters more favorably when the speaker acknowledges his or her fluency impairment compared to when the impairment is not acknowledged (Collins & Blood, 1990; Schloss, Espin, Smith, & Suffolk, 1987). Also, a listener’s attitudes toward stuttering are influenced by the amount of background knowledge and firsthand experience that he or she has interacting with people who have the disorder (Walden & Lesner, 2018). Not surprisingly, study findings have indicated that many of the people with whom speakers who stutter interact — including medical personnel, and teachers have only limited knowledge about the disorder (St. Louis, et al. 2014). This lack of basic knowledge about stuttering among the general public may help to explain why stuttering is often depicted in a negative light in contemporary films and in a distorted or simplistic manner in fictional literature (Logan, Mullins, & Jones, 2008).

Other Environmental Factors Over the years, various authorities on stuttering have proposed that parents of children who stutter are, through their speech behaviors or expectations for the child, somehow the cause or trigger of their child’s speech disfluency. Research find-



6.  Stuttering: Correlates and Consequences

ings have not supported this proposal, however, as parents of children who stutter have been found to perform similarly to parents of typically fluent children when assessed on variables such as disfluency identification (Zebrowski & Conture, 1989); the type of verbal input they provide to their child (Miles & Bernstein Ratner, 2001; Nippold & Rudzinski, 1995); and their judgments about their child’s communicative functioning (Bernstein Ratner & Silverman, 2000). In addition, parents of children who stutter seem to use speech rates and turn-taking patterns that are similar to those observed in parents of typically fluent children (Kelly & Conture, 1992); and they express similar pragmatic functions during conversation (Weiss & Zebrowski, 1991). Meyers and Freeman (1985) found that mothers of both children who stutter and children with typical fluency talked more rapidly when interacting with a child who stuttered severely than they did when interacting with children who stuttered less severely or with children who did not stutter. Thus, there may be some aspects of stuttered speech that alter or disrupt the typical temporal course of conversation. Beyond this, however, studies of prenatal, developmental, and medical factors have failed to uncover any consistently compelling differences between the home lives of stuttering and nonstuttering children (Cox, Seider, & Kidd, 1984).

Summary This chapter focused on the correlates of stuttering. As indicated in this review, researchers have examined stuttering from many perspectives. In the past 20 years, scientific understanding of the nature of stuttering and its characteristics has progressed at a dizzying pace. It is now widely accepted that genetic factors play a significant role in one’s predisposition to develop the disorder. This has been demonstrated through the comparisons between the incidence of stuttering within affected families and the rate at which the disorder affects the general population. In current models, environmental factors are seen as having a supporting role in the expression of the disorder. A main focus of current research is to identify chromosomes and, eventually, genes that are asso-

ciated with stuttering. This work is likely to provide a clearer understanding of the biological basis of stuttering. Work of this type is underway, and it has led to insights into which chromosomal regions (and in some cases, which genes) are relevant to the disorder. In current models, genetic factors are seen as influencing neurodevelopment, particularly in structures that mediate speech production. The following quote from Etchell and colleagues’ (Etchell, Civier, Ballard, & Sowman, 2018) systematic review of neuroimaging research with people who stutter summarizes the current state of what has been learned through this work: There are widespread abnormalities in the structural architecture and functional organization of the brains of adults and children who stutter. These are evident not only in speech tasks, but also non-speech tasks. (p. 6)

Current evidence suggests that stuttered speech is associated with breakdowns in the development of white matter tracts — particularly those that are involved in connecting brain regions that are involved in speech motor planning and the process of integrating somatosensory information, in the form of feedback, into motor plans that direct speech articulation. An impairment of this sort might explain why speakers who stutter show patterns of anomalous (and, presumably, compensatory) neural activation in right hemisphere regions and particular difficulty when saying lowfrequency words and multisyllable words fluently. An impairment of this sort might also explain why many people who stutter experience more disfluency when engaged in dual-task activities, wherein they presumably must divert attention away from speech execution toward some other task. It also might explain some of the motoric deficits that people who stutter exhibit, particularly those that relate to the lags in response initiation, instability in speech motor coordination, and the poorer retention of newly practiced motor patterns. People who stutter also commonly experience deficits or disability in aspects of communication beyond speech fluency, including domains related to syntactic, phonologic, and semantic performance. Surprisingly, language-related differences have been noted in people who stutter for both

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receptive and expressive language activities. In studies of school-based speech-language pathology caseloads, a substantial percentage of children who stutter are identified as having concomitant language and/or articulation difficulties. The role, if any, for these “peripheral” communication problems in the etiology and expression of stuttering is unclear at present. Beyond its impact on speech fluency, chronic stuttering can affect the thoughts, feelings, and emotions of an individual. The affective and cognitive components of the disorder can negatively impact not only one’s attitude toward communication but also one’s sense of self-worth and value. More and more studies are finding evidence of elevated anxiety among people who stutter, particularly with regard to speech-related tasks and social interaction. The consensus is that anxiety and other related “negative” emotions are an emergent feature of the disorder. Fortunately, speech-related anxiety seems amenable to change through cognitive behavioral therapy and, indirectly, through motor-based speech therapy. Nonetheless, it is critical for clinicians to understand that stuttering can have a serious negative impact on an individual’s quality of life, including one’s ability to attain and maintain quality social interactions with friends, family members, teachers, and employers. Research evidence suggests that the deleterious effects of stuttering may persist across the life span and influence the most basic activities of daily life, including when and where a person chooses to speak and the type of occupation that one chooses to pursue. Based on this review, it should be apparent that stuttering is much more than simply a case of a person being “nervous” or “tense” while communicating. There is a physical basis for stuttering; and as the details about the physical nature of the disorder become increasingly well understood, insights into how to improve treatments for the disorder should emerge as well. In the meantime, it is important to remember that many people who

stutter possess resources for managing the effects of stuttering. They can learn strategies for coping with and compensating for fluency impairment in ways that substantially reduce stuttering-related disability, and they can learn how to recognize and modify the disruptive feelings and thoughts that often accompany the speech symptoms. These latter topics are explored in following chapters.

Questions to Consider 1. The concordance for stuttering among monozygotic twins is not 1.00. What does this finding suggest about the roles of genes and the environment in the expression of stuttering? 2. How might information from research on the linguistic contexts in which stuttering-related disfluency is most likely to be produced be used to influence assessment and treatment practices with individuals who stutter? 3. Based on the surface characteristics of stuttered speech, which aspects of language (i.e., syntax, morphology, phonology, syntax, pragmatics) do you think would be most relevant to understanding factors that contribute to stuttering? Which do you think would be least relevant? 4. Think about other communication disorders that affect people. To what extent do those disorders negatively affect the psychological wellbeing of individuals who have the disorders? 5. From what you have read in this chapter, how does the level of psychological distress among people who stutter compare to that of people who have other communication disorders? 6. Based on your experience, to what extent and in what ways do your thought processes and emotions influence how well you perform a task? To what extent are your experiences similar to the experiences that people who stutter have? To what extent do they differ?

7 Stuttering: Epidemiology, Development, and Etiology

Chapter Objectives After reading this chapter, readers will be able to: • Describe epidemiological statistics pertaining to neurodevelopmental stuttering. • Describe factors associated with onset of stuttering and recovery from stuttering. • Describe relationships among age, communication disability, and quality of life. • Describe the evolution of etiological models of stuttering.

Epidemiology Epidemiology involves the study of how diseases or, in this case, disorders are manifested in a population. Some areas of concern in epidemiological research include the following: (a) how often a particular disorder occurs in a population, (b) patterns of persistence and recovery for a disorder, (c) factors that affect disorder frequency and outcome, and (d) whether a disorder affects some segments of the population more than others (Coggon, Rose, & Barker, 1997).

Epidemiological data for stuttering have been reported in a number of studies. Data such as these are helpful on many levels, such as determining whether stuttering is more or less common than other speech disorders, examining whether the disorder is more common among some populations than others, and examining whether the disorder has become more or less common over time in a population. In this section, some of the main findings about the epidemiology of stuttering are reviewed.

Age of Onset It is widely agreed that the symptoms of stuttering first appear during childhood. Indeed, the diagnostic descriptor for stuttered speech that emerges during the context of a child’s early development is referred to as childhood onset stuttering. A number of researchers have attempted to identify when in childhood the symptoms of stuttering are most likely to appear. This has proven to be a bit more difficult to do than one might think.

Cumulative Frequency Data One can collect age-of-onset data via either retrospective or prospective methods. Typically, the

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development of 1,142 babies who were born in the city during May and June of that year, tracking them from birth through 16 years of age. A team of trained health care workers and speech clinicians met regularly with the children and their caregivers and reported their findings in a series of publications (e.g., Andrews, 1984; Andrews & Harris, 1964; Morley, 1957). During the course of the study, 43 children showed symptoms of stuttering. The researchers collected data such as how old the children were when stuttering symptoms first appeared, whether the symptoms eventually resolved, and, if they did resolve, how long the symptoms had been present before they finally resolved. Selected results from this research are presented in Table 7–1 where they are compared with data from several retrospective studies. In the table, the data represent cumulative percentages. This means that the number in each column of the table reflects the percentage of cases that began to stutter by a particular age. So, in the Andrews and Harris (1964) study, 58% of all cases of stuttering in

onset data are part of a broader project in which the researcher also explores the prevalence, incidence, and/or recovery rates for stuttering. Onset data that come from prospective studies are considered more accurate than those that come from retrospective studies, because the prospective approach allows for documentation of the date of onset to occur relatively close in time to when the symptom onset actually occurred (Yairi & Ambrose, 1992b). The prospective approach also reduces the risk of selection bias that might arise through collecting data only from individuals who seek clinical services after the onset of the disorder has commenced. To date, however, there have been only a few prospective studies into the epidemiology of stuttering. Most likely, this is because such studies are both time and resource intensive and expensive to conduct. Perhaps the best-known prospective study of stuttering epidemiology took place in England beginning in 1947, in a city named Newcastle upon Tyne. Researchers attempted to follow the speech

Table 7–1.  Cumulative Frequency Data (Percent of Cases) for Age of Stuttering Onset Agea Study

Sampleb

Designc

2

3

4

5

6

7

8

9

10

11

12

Andrews & Harris (1964)

Persist (n = 9)

P&R

14

42

58

70

77

82

88

92

95

96

100

6

22

50

70

79

91

98

100

—

—

—

Dickson (1971)

Seider et al. (1983)d

Recover (n = 34) Persist (n = 164)

R

16

41

59

74

88

92

95

97

97

98

100

Recover (n = 196)

R

19

50

73

86

92

96

98

99

100

—

—

Persist (n = 269)

R

5

26

43

65

72

80

92

95

95

98

99

Note.  The number in a cell represents the percentage of all stuttering cases in a particular study that had experienced stuttering onset by a particular age. For example, 14% of the persistent cases reported in Andrews & Harris (1964) began to stutter at age 2, and another 28% of cases began to do so by age 3, bringing the cumulative total to 42% of all cases. The percentages in this table are estimates that were derived from figures presented in the original manuscripts. Shaded cells represent the age at which at least 70% of the participants in the study had begun to stutter. a

Age is reported in years. Persist = participants whose stuttering persisted throughout the duration of the study; Recover = participants whose stuttering symptoms eventually resolved (i.e., they “recovered” from stuttering). c  P = prospective design; R = retrospective design. d Data are for male participants in this study only. b



7.  Stuttering:  Epidemiology, Development, and Etiology

that study evidenced symptoms of stuttered speech by age 4, and 77% of all cases did so by age 6. There were no cases in that study with a reported onset after age 12. Based on these data, Andrews (1984) concluded that virtually all of the risk for an individual to develop stuttering has passed by age 12 years. In other words, if a person has yet to exhibit symptoms of childhood onset stuttering by age 12, it is very unlikely that he or she will do so in subsequent years. Most often, researchers have used retrospective research strategies to determine the age of onset. With a retrospective approach, a researcher identifies a group of people who stutter and then asks each of them (or their parents/caregivers) when stuttering symptoms first appeared. This method works best when each of the participants under study has passed the age when the risk for developing symptoms of stuttered speech has largely passed (~12 years). Several retrospective studies like this have been conducted. One such study was conducted by Andrews and Harris (1964) using a different set of participants than those who participated in their prospective study. Age-of-onset data from their retrospective study appear in Table 7–1. As shown in the table, the age-of-onset patterns for Andrews and Harris’s retrospective and prospective studies generally were consistent.

Dickson (1971) conducted a retrospective study of stuttering in which questionnaire responses were examined for 3,923 elementary and junior high school-aged students from Williamsport, New York, USA. Of these participants, 360 were reported to have shown symptoms of stuttering. Age-of-onset data for these participants are presented in Table 7–1 as well. These data are mostly consistent with findings from the other studies. All of the students in Dickson’s cohort who ever stuttered had begun to do so by the age of 12 years, and there were no cases with a reported age-of-onset after age 10 among students who eventually recovered from stuttering. The upper limit for stuttering onset in Dickson’s study is somewhat younger than the age that Andrews and Harris (1964) reported but still is consistent with the idea that few cases of stuttering will feature an onset after childhood and, in most cases, onset occurs early in childhood. The third study listed in Table 7–1 (Seider, Gladstien, & Kidd, 1983) consisted of a retrospective examination of stuttering patterns in males and females who had either recovered from or persisted with stuttering. The data shown in the table are from the 269 males with persistent stuttering, and the general pattern of findings for their ages of onset is like those in the other studies. Also consistent with the studies in Table 7–1 is a report

Clients Who Report Stuttering Onset During Adolescence The author has evaluated several college-aged clients who reported that the onset for their stuttering symptoms occurred during early to mid-adolescence (e.g., ages 13 to 16 years). Each of these cases exhibited what the author would regard as classic symptoms of stuttering. Still, given how uncommon it is for stuttering onset to occur so late in development, it is prudent to carefully consider the possibility of an acquired form of stuttering. Thus, with such cases, it is important to inquire indepth about the client’s neurological functioning and overall health, and about any changes that have occurred regarding stuttering symptoms or other aspects of functioning over time. If there is any suspicion that the client presents with an acquired form of stuttering, then a medical referral is warranted. One limitation with relying on client or caregiver reports for information about stuttering onset is that the informant may fail to recognize subtle symptoms of the disorder that existed prior to what they regard as the age of onset. Thus, it is possible that in cases of so-called “late-onset stuttering,” some or most of these individuals exhibited symptoms of stuttering much earlier in life, but the symptoms were not severe enough to attract the notice or concern of anyone but a speech-language pathologist.

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from Wingate (1964b), who collected data from 50 persons who stuttered, age 17 and older. Most of these participants (79% males, 61% females) reported stuttering onset to be before age 7, and all but one participant reported an onset between the age range of 2 and 13 years. This is not to say that the onset for stuttering never is detected after a child reaches 10 to 12 years. After all, not every person who has ever stuttered was included in these studies. However, based on these studies, it is safe to say that such a scenario is highly uncommon — so uncommon in fact that, based on data from the Newcastle upon Tyne study, Andrews (1984) proposed that cases with an onset beyond age 12 be classified as “acquired stuttering.”

Mean Age of Onset Another way to think about onset is in terms of the average age when children begin to stutter. Table 7–2 presents age-of-onset statistics from several studies. In all of the studies, the data come from retrospective reports. In some retrospective studies (Ambrose & Yairi, 1999; Yairi & Ambrose, 1992b), the data were collected very near the age

of reported onset — an approach which presumably yields more accurate information than, say, a study such as the one by Seider et al. (1983), wherein adults were asked about the age of onset for their stuttering. As shown in Table 7–2, the mean ages of onset in 3 of the 4 studies are roughly 30 months for females and 36 months for males. Reilly et al. (2013) reported prospective data related to the cumulative incidence of stuttering, based on a sample of 1,619 children from Melbourne, Australia. Although the authors did not report data for stuttering in terms of mean age of onset, their data on cumulative incidence indicated that a large majority of the 181 children who eventually developed stuttering began to do so between the ages of 24 and 36 months. Because the Reilly et al. (2013) study reported only on children through age 48 months, new cases that might emerge later in life are not captured in the data. This is a limitation of the age-onset values in many other studies, particularly those in which the researchers’ focus is on young children who stutter. For example, in the Yairi and Ambrose (1992b) study, the focus was on cases with stuttering onset before age 6. In the Reilly et al. (2013), it was on children between birth and age 48 months. In such studies, there obvi-

Table 7–2.  Mean Ages of Onset and Associated Standard Deviations for Stuttered Speech in Several Studies of Children Who Stutter Reported Age of Onset (in Months) Male

Female

Male + Female

Author(s)

Sample

M

SD

M

SD

M

SD

Ambrose & Yairi (1999)

N = 90 (59 males, 31 girls); Age range: 23–59 mos.; M age: 37 mos. (SD = 9 mos.)

34

8

33

9

34

8

Yaruss et al. (1998)

N = 100 (85 males, 15 females); M age: 55 mos.

36

11

30

10

35a

—

Yairi & Ambrose (1992b)

N = 87 (59 males, 28 females); Age range: males = 20–69 mos.; females = 21–43 mos.

34

9

29

6

33

8

Seider et al. (1983)

N = 305 (223 adult males, 82 adult females) with persistent stuttering

62

—

57

—

—

—

Note.  Dashes indicate data that were not reported in the original study. a  Mean was computed by present author based on reported data from original source.



ously is no opportunity to incorporate cases with later ages of onset into the statistics. This may not be a major limitation, however, as both Yairi and Ambrose (1992b) and Reilly et al. (2013) remarked on the apparent diminution of new cases beyond roughly 40 to 48 months. This view is supported by data in Table 7–1, where only about 10 to 20% of all cases of developmental stuttering began after age 6. Obviously, when these cases are factored into the age-of-onset calculations, the mean would be somewhat higher than it would when the cases are excluded. Results from the Seider et al. (1983) study bear this out as well. That study was based on retrospective reports of adults who stuttered (a method that allows for inclusion of late-onset cases), and the reported mean ages of onset for both males and females were closer to age 5. In the prospective study by Andrews and Harris (1964), stuttering onset for more than 70% of cases occurred by age 5. So, in all, based on these data it seems safest to say that symptom onset for stuttering most often occurs during early childhood, at or before age 5; and for many of those cases, onset occurs between the ages of 30 and 40 months. Yairi and Ambrose (1992b) questioned 87 parents of children who had experienced onset of stuttering symptoms during the previous year. The parents characterized stuttering onset as “gradual” in 56% of the cases and as “sudden” in 44% of the cases. In 57% of the cases, stuttering onset reportedly did not occur in the context of unusual or excessive physical or emotional stress, whereas in 43% of the cases, it reportedly did. In most (70%) of the cases, the parents characterized their child’s stuttering severity as mild at the time of onset. In the remainder of cases, it was moderate or severe. In 66% of the cases, there was a positive family history of stuttering — that is, there were others who stuttered in the family beside the child in the study. Overall, the most common profile (25% of all cases) was for a child to exhibit gradual onset of stuttering in the context of a positive family history and the absence of marked physical or emotional stress. Before concluding this section, it is important to remember that age-of-onset data reveals only about when the symptoms associated with stuttering are first overtly manifested in speech. Thus, the reported age-of-onset for a case does not necessarily correspond to the age at which the underlying

7.  Stuttering:  Epidemiology, Development, and Etiology

cause of the disfluent speech first developed. For instance, a child may present with subtle neurodevelopmental abnormalities well before the onset of stuttered speech, but these abnormalities do not impact speech production until the child’s cognitive and linguistic skills develop enough to allow for the production of relatively long syntactically based utterances. Advances in neuroimaging approaches are likely to provide information about this possibility soon. In this view, it is possible that many, if not all, children who stutter effectively “have” neurodevelopmental markers of childhood onset fluency disorder well before the overt symptoms of the disorder become apparent to listeners. As discussed in the previous chapter, speech that sounds fluent is not necessarily fluent or normal in terms of its underlying neurophysiology or movement coordination characteristics.

Fluency Characteristics Near the Time of Onset Research from Yairi and colleagues’ University of Illinois Stuttering Research Program (for a summary, see Yairi & Ambrose, 2005) has included several analyses of fluency characteristics of preschool children at or near the time of stuttering symptom onset. Among the findings to emerge from this work are the following findings, which were reported by Yairi et al. (1993) and Yairi and Ambrose (1992a, 1992b): • Gradual symptom onset (56% of cases) is more common than sudden onset (44% of cases); • The proportion of boys and girls with sudden onset of stuttering symptoms is similar; • In most cases (70%), stuttering severity is mild near the time of onset (other cases are either moderate or severe); • The most common profile for stuttering is gradual onset of stutter-like disfluency in the context of a positive family history of stuttering and no obvious or overt stress in the child’s life; and • In the weeks immediately following onset of stuttering symptoms, a substantial number of children present with relatively

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high stuttering frequency scores; however, a child’s stuttering frequency score from the weeks immediately following symptom onset is not a good predictor of whether the child’s stuttering will persist. Other researchers have attempted to capture the variations in behavioral presentation around the time of symptom onset for stuttering. For example, Van Riper (1971, pp. 103–117) proposed a four-part classification system to describe the various symptom profiles that children who stutter most often present in the earliest stages of the disorder. The four “tracks,” or developmental pathways, for stuttering development came from a review of 300 files from patients he had assessed. All but 69 of those cases (23% of the total) fit into one of the four tracks. Some of the main characteristics associated with each of the tracks are summarized here. As can be seen, Track 1 is the most common onset scenario and, of the four tracks, it corresponds most closely to the scenario that Yairi and Ambrose (2005) encountered most often. Track 3, in contrast, seems to correspond most closely to the cases of stuttering onset that Yairi and Ambrose encountered in which symptom presentation was relatively severe from the very earliest stages of the disorder (although trauma was not a necessary characteristic of this type of onset). • Track 1:  gradual onset between ages 2;6 and 4;0, following earlier period of perceptibly fluent speech; primary characteristics = effortless part-word repetitions on utterance-initial function words; symptoms wax and wane in severity over time; little awareness of stuttered speech; little sign of speech-related frustration or fear. • Track 2:  gradual onset in the context of delayed development of syntax and speech sound production and rapid articulation; prior to stuttering onset, speech fluency was never particularly smooth; primary characteristics = effortless repetitions of syllables and words, revision, and “gaps” scattered throughout content words; little awareness of stuttered speech; little sign of speech-related frustration or fear.

• Track 3:  sudden onset after development of syntactically based utterances, often following trauma. Primary characteristics = slow rate; effortful inaudible prolongations and blocks, particularly in sentence-initial contexts; keen awareness, frustration, and fear toward the fluency difficulties. • Track 4:  sudden onset after age 4 following an earlier period of fluent speech; primary characteristics = excessive repetition of words and phrases; long, behaviorally complex disfluencies; stuttering symptoms change little over time; keen awareness of disfluent speech, but no frustration or fear. As Van Riper (1971) noted, a limitation of highly delineated classification approaches like the one just described is that individual clients can present some, but not all, of the characteristics of a track or characteristics from more than one track. The latter scenarios make it challenging for a clinician to decide which track is most appropriate to assign. Although Van Riper’s tracks are not used widely in clinical practice today, they nonetheless offer a general sense for some of the more common symptom patterns a clinician is likely to encounter as well as a reminder that surface-level symptom presentation sometimes appears quite different across cases.

Incidence and Prevalence Incidence is an epidemiological statistic that captures the number of unique or newly diagnosed cases of a disorder within a population during a particular time frame. Prevalence, in contrast, is an epidemiological statistic that captures how many cases of a disorder exist within a population at a specific time. As such, depending on the time frame one uses, prevalence statistics can include both recently diagnosed cases and long-standing cases. The relationship between incidence and prevalence is affected by several factors, including the following: (1) the developmental course of a disorder (i.e., age-of-onset patterns for the disorder; whether the disorder usually is transient or chronic); (2) the cohort under study, (i.e., does



7.  Stuttering:  Epidemiology, Development, and Etiology

the analysis focus on a narrow demographic segment of the population or on a broad segment?); and (3) the time frame that the researcher is interested in (i.e., does the analysis focus on the entire life span or on a shorter time span, such as the past year?). In the stuttering literature, researchers most often have examined lifetime incidence (i.e., how many people have stuttered at some time during their life) and point prevalence (how many people stutter now). As will be seen, many cases of stuttering are transient, meaning that the speech-related symptoms of a person’s disorder do not persist throughout the person’s entire life but instead remit or resolve. In cases where the symptoms of stuttering persist, the symptoms usually first appear during childhood and remain with the person for some significant length of time, perhaps even throughout the life span. Remission (or recovery, as it often is called) of stuttering symptoms is most likely to occur during childhood. This means that the lifetime incidence for stuttering (i.e., how many individuals have stuttered at some point during life) will be greater than the point prevalence for stuttering (i.e., how many individuals stutter right now), because some individuals who formerly presented symptoms of the disorder no longer do.

Lifetime and Cumulative Incidence Data for the lifetime incidence of stuttering are most accurate when the participant pool includes individuals who are past the age at which new cases of stuttering are likely to arise. Because the onset of stuttering seldom occurs after about age 10 to 12, incidence data that are based on reports from individuals who are older than this are most appropriate, at least when a retrospective design is being used. Other factors that can affect the reporting of incidence statistics include the following: how the researcher has defined stuttering; how well the researcher has conveyed his or her definition of stuttering to participants; the length of time that has elapsed between when a participant showed the symptoms of stuttering and when a participant is being asked to report on those symptoms; the size and representativeness of the

participant sample; and the extent to which the researcher can corroborate a participant’s report of stuttering. Differences in these factors across research studies probably account for much of the variance in reported lifetime incidence rates for stuttering across research studies. Overall, estimates of the lifetime incidence for stuttering have ranged from about 3% to 6%. For example, Sheehan and Martyn (1970) reported 2.9% incidence; Cooper (1972) reported 3.7% incidence; and Porfert and Rosenfield (1978) reported 5.5% incidence. Andrews and Harris (1964) reported a lifetime incidence rate of 4.8% in their retrospective study of adults from Newcastle upon Tyne, England. The incidence rate from that study was very similar to the one reported in their prospective study, 4.9%. In turn, the incidence rate in Andrews and Harris’s prospective study was similar to the reported lifetime incidence, 5.1%, in a prospective study by Månsson (2000), which included more than 1,000 children who were natives of the same Danish island and were followed from birth through about age 10. Although lifetime incidence rates are within the 3% to 6% range in most studies, others have reported somewhat different results. For example, Craig and colleagues (Craig, Hancock, Tran, Craig, & Peters, 2002) interviewed a randomized and stratified group of individuals from New South Wales, Australia, to obtain information about incidence, prevalence, and recovery rates for stuttering across the lifespan. In that study, the incidence rate for the entire sample was 2.2%, which is below the mean reported in most other studies. As expected, incidence rates varied depending on the age of the person who was being analyzed. In Craig et al. (2002), incidence rates for subsets of the overall sample varied as follows: • 2.8% • 3.4% • 2.2% • 2.1%

for for for for

ages ages ages ages

2 to 5 years, 6 to 10 years, 10 to 20 years, and 21 to 50 years.

At the other end of the continuum, Dickson (1971), in a large sample of students from Williamsport, New York, USA, reported incidence rates of 10% for elementary school-aged students and

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8% for junior high school students. As noted, such differences may arise due to methodological differences such as the way in which stuttering was defined in a particular study or the challenges associated with collecting such data retrospectively. Reilly et al. (2013) reported data on the incidence of stuttering in a sample of 1,619 children. Reilly et al. tracked the children longitudinally from age 7 months through age 4. They reported that 181 children (11.2% of the total sample) developed stuttering prior to age 4. Unlike many other studies, speech-language pathologists confirmed the diagnoses of stuttering through direct observation of the children and then subsequently monitored the children’s fluency performance through monthly visits. Reilly et al.’s (2013) reported incidence of 11.2% is substantially higher than percentages reported in most of the other studies reviewed in this section. It is possible that the use of speechlanguage pathologists in identifying cases of stuttering explains some of this difference, as they presumably would be more attuned to the symptoms of stuttering and thus more likely to recognize children who have the disorder and to possess a stricter definition of what stuttering is compared to parents or affected individuals. In contrast to the studies mentioned earlier, some researchers have investigated stuttering incidence rates in specific subpopulations. This approach leads to quite different results than studies based on general population samples. For instance, Seider et al. (1983) examined patterns of stuttering in relatives of individuals who were diagnosed with stuttering. They reported lifetime incidence rates of 13% among relatives of the male participants who stuttered and 18% among relatives of the female participants who stuttered — findings that support the notion that stuttering tends to “run in families.” Similarly, MacFarlane, Hanson, Walton, and Mellon (1991) reported an incidence rate of 14% for stuttering in a 1,200-member, fivegenerational family from the western United States. Along these same lines, Kloth, Kraaimaat, Janssen, and Brutten (1999) examined the incidence of stuttering in a prospective study of children who had a parent who stuttered. Overall, 28% of the children developed symptoms of stuttering during the 6-year course of the study. Such results are interpreted as reflecting the role of genetic factors

in shaping one’s predisposition for stuttering — an issue that is discussed later in this section. Overall, these incidence data suggest that stuttering is not a rare disorder, at least when examined over the lifespan and when compared to some other developmental disorders. On the other hand, these data argue quite strongly against the view ​ — often held by laypeople — that “everybody stutters.” As described earlier, everybody does not stutter; if that were true, the incidence of stuttering would be 100%. It is true that nearly everyone produces stutter-like disfluencies on occasion, but that is very different from being diagnosed with the speech disorder called stuttering. To reiterate, current best estimates are that 2% to 6% of the general population will present with stuttering at some time during the lifespan, with the risk for ever having stuttered increasing in segments of the population that are at a unique risk for the disorder.

Prevalence As noted, prevalence involves the percentage of a population that currently exhibits a disease or disorder. As with incidence data, estimates of prevalence for stuttering vary depending on the age and representativeness of the research participants and assorted other methodological factors such as how stuttering is defined, who is making the primary diagnosis of stuttering, and whether reports of stuttering are corroborated by researchers. Results from several studies that have examined the prevalence of stuttering are presented in Table 7–3. Perhaps the most comprehensive of these studies, Craig et al. (2002) conducted telephone interviews with a large and stratified sample of individuals from one Australian state. The interviews included corroborative conversations with the people who were reported to have stuttered. The prevalence of stuttering was highest among the cohort of preschool-aged children (1.40%) and then gradually decreased during the school-aged years (0.90%) and into adulthood (0.37%). Such a pattern is expected, given the observation that some people who stutter go on to discontinue producing the symptoms sometime after onset. The overall prevalence for stuttering across all age levels in the Craig et al. (2002) study was 0.72 %. Thus, slightly less



7.  Stuttering:  Epidemiology, Development, and Etiology

Table 7–3.  Prevalence (as a Percentage of the Sample) of Stuttering at Various Age Levels Age Level Study

Sample

Preschool

School

Adult

All

Proctor et al. (2008)

N = 2,223; Illinois, USA; preschoolers

2.52

—

—

—

McKinnon et al. (2007)

N = 10,425; Sydney, Australia; kindergarten to 6th grade

—

0.33

—

—

Van Borsel et al. (2006)

N = 21,027; Belgium

—

0.58

—

—

Craig et al. (2002)

N = 2,553; New South Wales, Australia; all ages

1.40

0.90

0.37

0.72

Okalidou & Kampanaros (2001)

N = 1,113; Patras, Greece; kindergartners

—

1.71

—

—

Brady & Hall (1976)

N = 18,420; Illinois & Pennsylvania, USA; kindergarten to Grade 12

—

0.35

—

—

Gillespie & Cooper (1973)

N = 5054; Tuscaloosa, AL, USA; Grades 7 to 12.

—

2.12

—

—

Andrews et al. (1964)

N = 7,358; Newcastle upon Tyne, England

—

—

—

1.20

Note.  Dashes indicate that the authors did not examine the age interval.

than 1% of the population exhibited active stuttering at the time the researchers conducted the study. Findings from several other studies are roughly consistent with those from Craig et al. (2002). That is, the highest prevalence rates tend to be reported among preschool-aged cohorts (e.g., Proctor, Yairi, Duff, & Zhang, 2008), and the reported prevalence rates among school-aged children tend to be lower (e.g., McKinnon, McLeod, & Reilly, 2007; Van Borsel et al., 2006) than those for preschoolers. Not every study has yielded prevalence estimates that fit within this pattern, however. For instance, Gillespie and Cooper (1973) sampled more than 5,000 junior and senior high school students in Tuscaloosa, Alabama, USA, and found a 2% prevalence rate for stuttering, which is roughly twice as high as that in other studies. It is difficult to assess the extent to which methodological factors contributed to this unusual finding, as neither the criteria for diagnosis of stuttering nor the qualifications of the examiner(s) who made the diagnoses were detailed in the published report of the study. It is

possible (though unlikely) that the prevalence of stuttering was particularly high in that community. As with the incidence of stuttering, the prevalence of the stuttering varies from the general population mean when certain subgroups of people are examined. For example, Montgomery and Fitch (1988) surveyed 77 residential/specialized schools regarding children with hearing impairment and obtained data on the fluency performance of more than 9,900 students. Based on survey responses, only 12 of the students (0.12% of the total) exhibited symptoms of stuttering. Each of the 12 students had at least severe hearing loss. Six of the 12 students stuttered while using manual communication; five stuttered during both oral and manual communication modes, and one stuttered only during oral communication. In contrast, Cooper (1986) summarized findings from 14 studies of stuttering prevalence among individuals with intellectual disability. In 8 of the 14 studies, the prevalence estimate fell in the range of 2% to 8%; and in three other studies, it fell between 10% and

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20%. Similarly, Van Borsel and Tetnowski (2007) summarized research on stuttering characteristics associated with various genetic syndromes. In the studies they reviewed, the prevalence of stuttering among people with Down syndrome ranged from 15% to 48%, although in some studies (e.g., Otto & Yairi, 1975), the authors argued that the stutterlike speech patterns were not entirely consistent with those seen in stuttering. Proctor et al. (2008) examined the prevalence of stuttering among more than 3,000 preschool-aged American children of European and African descent. Data were collected using teacher and parent reports and clinician screenings. Results indicated the prevalence of stuttering for both groups was similar (2.6% for African-American children; 2.44% for EuropeanAmerican children); thus, race was not a significant predictor of stuttering (the child’s sex was, however, with males being more likely to stutter than females). Finally, in a study of school-aged children from Belgium, Van Borsel et al. (2006) reported a stuttering prevalence rate of 2.28% for a sample of children who were enrolled in a special education

setting but a prevalence rate of 0.58% for children who were enrolled in regular education.

Stuttering Prevalence in Males Versus Females It is well accepted that males are more likely to exhibit symptoms of stuttering than females. The ratio of males to females who stutter is not fixed, however. Instead, it varies somewhat depending on the age of the cohort under investigation. For example, Yairi and Ambrose (1992a, 1992b, 1999) reported information on the age of onset and stuttering remission patterns in a large group of preschoolers. They found that girls began to stutter at an earlier age than boys and that girls demonstrated recovery from stuttering symptoms more often than boys did. Given this, one would expect the ratio of males to females who stutter to be smaller among a cohort of, say, 2- to 3-year-old children than that of a cohort of older children. As Figure 7–1 shows, this is precisely what research-

5

Males Females

Number of male cases per female case

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4

3

2

1

0 2;1 to 3;7

1;8 to 5;9

2;0 to 5;11

Yairi (1983)

Y & A (1992b)

6;0 to 10;11

11;0 to 20;11

21;0 to 50;11

Craig et al

Participant Age Ranges Within Research Study Figure 7–1.  Ratio of male to female cases of stuttering by age (years;months) of participant cohorts in three studies: Yairi (1983), Yairi and Ambrose (1992b) and Craig et al. (2002). The number of male cases relative to female cases increases steadily from early childhood through early adulthood, and then by middle adulthood, decreases toward values that more closely approximate those observed during childhood. Y & A = Yairi & Ambrose. (Craig et al. reported data for an adult cohort, age 51 and older, which is not shown this figure.)



7.  Stuttering:  Epidemiology, Development, and Etiology

ers have found. As shown in the Figure 7–1, Yairi (1983) reported a male:female ratio of 1 to 1 for children who were in the 2- to 3-year range. However, Yairi and Ambrose (1992b) reported a substantially greater male-to-female ratio (2.1 males to 1 female) for a cohort of children who ranged from age 1;8 to 5;9. Craig et al. (2002) found a similar pattern when they examined the sex ratio for stuttering in preschool- and school-aged children (see Figure 7–1), along with a steady increase in the ratio through early adulthood. Somewhat unexpectedly, however, they also reported a decline in the magnitude of the ratio with older segments of the population (e.g., 1.4 males to 1 female for ages 51 years and older). MacFarlane et al. (1991) reported similar findings (1.8 males to 1 female) in a study of stuttering patterns that occurred in a 1,200-member, multigeneration family living in the western United States. As discussed in Chapter 6, explanations for why males appear to be at greater risk for stuttering than females has centered on genetic factors. With that, strong forms of environmental explanations (e.g., factors such as societal and cultural expectations for males vs. females) have fallen into disfavor (Kidd, Kidd, & Records, 1978; Yairi & Ambrose, 2005). Support for genetic-based explanations of the sex ratio data come from examination of stuttering patterns within families. For example, Kidd et al. (1978) examined epidemiological patterns of stuttering among the immediate relatives of the probands (i.e., research participants who are the direct focus of study and lead to the study of other family members) and concluded that stuttering is a sex-modified trait. Their findings included the following: • Male relatives of probands who stuttered were nearly three times as likely to stutter as female relatives of probands (Ratio = 2.9 males:1 female); • Male probands who stuttered had more than twice as many sons who stuttered as they did daughters who stuttered (Ratio = 2.3 sons who stuttered:1 daughter who stuttered); and • Female probands who stuttered were more than twice as likely to have a daughter who

stuttered than a son who stuttered (Ratio = 2.4 daughters who stuttered:1 son who stuttered).

The Developmental Course of Stuttering Both researchers and clinicians have studied how the symptoms of stuttering change over time. Such information is useful when counseling clients and their family members and when making decisions about when to assess and treat clients.

Persistent Versus Transient Stuttering At a basic level, one can think of stuttering as a disorder where the symptoms can be present either for a long time (persistent stuttering) or a relatively short time and then resolve (transient stuttering). That is, with persistent stuttering, stutter-like disfluency and other associated symptoms during childhood, usually before age 5, continue for a significant length of time in an unabated manner so as to indicate chronic impairment. The classic profile of persistent stuttering is for a person to begin to stutter during childhood (childhood-onset stuttering) and continue to do so throughout the remainder of his or her life span. With transient stuttering, stuttering symptoms also appear during childhood, but then they subsequently resolve sometime later. In such cases, the individual is said to have recovered from stuttering; once recovery has taken place, the individual would then regard himself or herself as a typical speaker. The dichotomy between the persistent and transient paths for stuttering suggests a degree of order and certainty in clinical outcomes that, unfortunately, is not always present in real life. The main challenge is that it often is difficult for a clinician to be confident about which path a child (and to a lesser degree, a teen) is traveling and thus where the client will ultimately land. This ambiguity is because the process of recovery from stuttering occurs on varying timescales across individuals.

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Figure 7–2 illustrates the different time frames during which recovery from stuttering can occur; and the characteristics of each are briefly elaborated on here: • Early Recovery:  In some cases, recovery from stuttering occurs relatively soon after onset, and thus relatively early in life. In such cases, stuttering symptom expression is measurable in terms of as little as weeks or months and extending to roughly 2 years from symptom onset before resolution of stuttering symptoms and normalization of speech fluency occur. Among all the cases of recovery from childhood-onset stuttering symptoms, this pattern occurs most often (Ambrose & Yairi, 1999; Andrews, 1984). • Intermediate Recovery:  In other cases, recovery from childhood-onset stuttering symptoms occurs on a more protracted

timescale, occurring anytime from more than 2 years after onset to the start of adolescence. Other researchers have noted this pattern of recovery often as well; but based on Andrews (1984), it is less common than the early recovery scenario described earlier. • Late Recovery:  Lastly, there are cases where recovery from childhood-onset stuttering symptoms occurs many years after onset — that is, during adolescence or adulthood. When stuttering has persisted for this long, it seems questionable to consider the stuttering in such cases as being transient in any conventional sense of the word. This is because the experiences associated with being a person who stutters for years or decades will undoubtedly shape an individual’s life in the years after symptom resolution has taken place.

Stuttering resolves within 24 months of onset

Early Recovery

Stuttering resolves more than 2 years after onset, but before adolescence

Intermediate Recovery

Stuttering resolves during adolescence or adulthood

Late Recovery

Stuttering never resolves

Persistent Stuttering

Preschooler Who Stutters

Figure 7–2. Diagram illustrating possible paths for stuttering. Among children who begin to stutter during the preschool years, if symptoms resolve, they often will do so relatively soon after onset. The clearest cases of persistent stuttering are those in which symptoms continue throughout the life span. Cases in which stuttering symptoms resolve many years after onset can be regarded either as “late recovery” or as a variant of persistent stuttering, given the potential for a long-standing history of stuttered speech to impact the speaker even after recovery occurs.



7.  Stuttering:  Epidemiology, Development, and Etiology

Defining and Using the Term Recovery The term recovery has been used inconsistently in the fluency disorders literature. In most instances, the term has been used in reference to cases where the speech fluency of a person who stutters improves over time to such an extent that it appears that the person no longer stutters. That is, it appears as if all traces of fluency impairment and fluency-related disability are gone. When using the term recovery in this way, it is critical to define the length of time that stuttering symptoms must be absent before one can say with confidence that speech fluency has truly normalized, and stuttering symptoms will not return at some point in the future. For example, in the Ambrose and Yairi (1999) study of developmental pathways for preschoolers who stutter, the symptoms of stuttering had to have been absent for at least 1 year in both clinical and home settings before a case was classified as recovered. Obviously, the longer the symptoms of stuttering remain absent, the more confident one can be in the use of the label recovery. For cases where stuttering persists from early childhood into early adolescence and then appears to resolve, it might be prudent to adopt an even longer time frame (e.g., absence of symptoms for 2 or 3 years) before applying the label recovery. Some clinical researchers have used the term recovery in a less restrictive way so that it includes cases where the speech fluency of a person who stutters improves significantly over time; however, evidence of stuttered speech is still apparent when the person talks. That is, it appears as if most or all of the communication disability has resolved, but evidence of fluency impairment still remains. With such cases, it is of course possible that the person’s stuttering symptoms will completely resolve at some point, but for now they remain. This book, to facilitate clarity, uses the term recovery in reference to cases where markers of stuttering-related impairment and evidence of stuttering-related disability are no longer apparent in an individual who previously had stuttered. In contrast, this book uses terms such as significant improvement and absence of communication disability in reference to cases where an individual perceives stuttering-related disfluency and associated communication disability to have markedly improved, however evidence of stuttered speech remains in the individual’s speech in at least some activities of daily living.

Patterns of Recovery From Stuttering During Childhood It has long been known that a significant portion of the children who begin to stutter during early childhood eventually stop doing so (e.g., Andrews & Harris, 1964; Martin & Lindamood, 1986; Sheehan & Martyn, 1970). As noted, researchers usually have referred to this process as recovery. Authors also have used the term spontaneous recovery in reference to cases in which symptom resolution occurs in the absence of formal intervention. Vari-

ous colloquial expressions exist as well among laypeople to describe this phenomenon (e.g., outgrowing stuttering and getting over stuttering). One focus of researchers who are interested in the epidemiology of stuttering has been to determine the percentage of children who do in fact experience resolution of stuttering symptoms. Such data have important implications for clinical intervention practices (Andrews, 1984; Martin & Lindamood, 1986). For instance, if a large percentage of children do indeed recover from stuttering, this raises questions about whether clinicians

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should treat stuttering during childhood and, if they do, which children should be treated and when treatment should be provided (Andrews, 1984; Martin & Lindamood, 1986). Accurate information about recovery rates also facilitates the interpretation of treatment outcomes research with young children who stutter (Curlee & Yairi, 1997; Saltuklaroglu & Kalinowski, 2005). That is, if a child’s stuttering resolves following a course of treatment, how is one to know whether the improvement resulted from the treatment, from developmental processes unrelated to treatment, or some of both? Researchers have examined recovery rates for stuttering both retrospectively and prospectively. Data from large-scale retrospective surveys of college students during the 1960s and 1970s (e.g., Sheehan & Martyn, 1966, 1970) have suggested that stuttering symptoms resolve in up to 80% of cases. Results from these studies also have suggested that individuals who had stuttered severely at some time in the past have a lower chance of recovery (about 50% less) than those with mainly manifested milder, less severe stuttering. In Dickson’s (1971) retrospective survey of nearly 4,000 parents, approximately 70% of all children with a history of stuttering had reportedly experienced recovery by ninth grade. Survey data also indicated that most cases of stuttering were relatively brief ​ — lasting 2 years or less, with recovery most likely to take place early in life, usually before age 7. Wingate (1964b), in contrast, used a definition of recovery that appeared to encompass both cases where stuttering symptoms resolved and cases where stuttering symptoms improved significantly. Not surprisingly, under that definition, participants indicated that recovery occurred on a more protracted scale. Some authors (e.g., Martin & Lindamood, 1986; Young, 1975) expressed concerns with this retrospective research on recovery, citing the limitations associated with retrospective research and the possibility that caregivers’ comments about their speech to children who stutter may have therapeutic benefits. They questioned whether the recovery process for stuttering truly was as “spontaneous” as it often was made out to be and, consequently, whether spontaneous recovery rates actually are as high as data from retrospective survey research has

suggested. These concerns were addressed to some degree by findings from several prospective studies (discussed later), each of which found that resolution of stuttering symptoms is indeed common. One such prospective study (i.e., Andrews & Harris, 1964) tracked the speech performance of a large cohort of infants (1,142 at the time the study began) from birth through age 15. During the 15-year course of the study, 43 participants showed symptoms of stuttering at one time or another, and the findings pertaining to their recovery rates were similar to those from the retrospective studies cited earlier. That is, 34 of the 43 children (79%) demonstrated resolution of stuttering symptoms prior to the conclusion of the study (i.e., before the children reached age 16). For many of these cases, stuttering proved to be a short-lived phenomenon. That is, for 24 of the 34 cases (about 71% of the total), symptom resolution occurred within 1 year of onset. Less commonly (6 of 34 cases; 18% of the total), symptom resolution occurred 2 or more years after onset, including one case (3% of the total) in which symptom resolution occurred 11 years after onset. There were 9 of the 43 cases who stuttered at any time during the course of the study (21% of the total) who continued to stutter at the conclusion of the study. Andrews (1984), in a review of his earlier study, noted that some of these long-standing cases eventually may have remitted as well in the years after the conclusion of the study. If so, this would put the remission rate somewhat higher than 79%. However, based on the pattern of progressively diminishing recovery up through age 11, it also is possible that stuttering persisted across the life span for all 9 individuals. Another main source of information about recovery from stuttering comes from Yairi and colleagues (e.g., Yairi & Ambrose, 1999), who conducted a series of studies during a long-running project at the University of Illinois that focused primarily on recovery patterns in cases of early childhood stuttering. They used a longitudinal design to follow the fluency performance of youngsters who had begun to stutter prior to age 6. The researchers evaluated the children at 6-month intervals, with the initial evaluation occurring within 6 months of stuttering onset (and for many cases, much less than 6 months). Yairi’s team published numerous



papers summarizing various facets of the research. Some of that work is summarized here.1 Yairi et al. (1996) examined changes in disfluency patterns during the first few years after the onset of the children’s stuttering and found that by 7 to 12 months post-onset, the children who eventually recovered from stuttering showed a clear divergence in terms of the number of stutterlike disfluencies they produced when compared to the children whose stuttering eventually persisted. In other words, for most children, a trend toward recovery was evident within 1 year of onset. On this basis, children who do not show this trend during the year following stuttering onset might be considered “at risk” for persistent stuttering. Also, Yairi et al. (1996) found that at the time of the initial evaluation for the study, the children who eventually recovered from stuttering had a higher frequency of stutter-like disfluency than the children who eventually exhibited persistent stuttering. On this basis, they concluded that disfluency frequency at or near the time of onset is not a useful predictor of whether stuttering symptoms eventually will resolve. This conclusion fit with findings from Yairi, Ambrose, and Niermann (1993), who reported that some cases with very severe stuttering at the time of the initial evaluation went on to recover. Other markers of persistent stuttering that Yairi et al. (1996) reported included the percentage of a child’s relatives who exhibited persistent stuttering. In that study, children whose stuttering persisted over the course of the study had a greater percentage of relatives who exhibited persistent stuttering than the children who recovered from stuttering over the course of the study, with the difference being about 1 to 5.5% of relatives. In contrast, children who recovered from stuttering had more relatives who had recovered (about 4.5%) than the persistent children did (about 1.5%).2 Finally, both the persistent and recovered cases exhibited more movements of the head and facial muscles while talking than children in a control 1

7.  Stuttering:  Epidemiology, Development, and Etiology

group did. In both stuttering groups, the movements were apparent near the time of stuttering symptom onset; thus, they did not appear to be an emergent feature of the disorder, nor did their frequency of usage appear to be a good predictor of recovery. In a subsequent study, Ambrose and Yairi (1999) reported on 84 children with childhood onset stuttering whom they had observed for at least 4 years. Overall, 74% of children demonstrated recovery from stuttering symptoms during the study. Each of the children had met the researchers’ recovery criteria for at least 12 months, and most (92%) had met the criteria for 18 months or longer. Criteria for recovery were detailed by Throneburg and Yairi (2001) and included demonstration of the following three characteristics over a period of at least 12 months: • Researcher and parent judgments that indicated the child’s use of stutter-free speech, • Researcher and parent ratings of less than 1 on multipoint stuttering severity rating scales, and • Production of fewer than 3 stutter-like disfluencies per 100 syllables of conversational speech. In a related study, Finn, Ingham, Ambrose, and Yairi (1997) examined the perceptual assessments of speech normalcy using samples of speech produced by children who had recovered from stuttering as well as children who had never stuttered. Three types of judges (sophisticated, unsophisticated, experienced) rated the participants in terms of speech naturalness. Across all three judging groups, the children who recovered from stuttering received comparable ratings to the children who had never stuttered. Thus, the speech of children who were labeled as having recovered from stuttering was perceptually indistinguishable from the speech of children who never had stuttered.

 airi and Ambrose (2005) published a detailed summary of the primary project outcomes in a textbook. Readers who are interested in Y reading more about the project should consult that source in addition to the various individual research publications they authored. 2  The latter finding is consistent with results from Kloth et al. (1999), who reported that recovery from stuttering took place in only 62% of children who had a parent who also stuttered.

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Yairi and Ambrose (1999) also found that girls were significantly more likely to demonstrate resolution of stuttering symptoms than boys (85% of girls versus 69% of boys; ratio of 1.22 girls: 1 boy). Although both boys and girls demonstrated varying amounts of time between the onset of stuttering and attainment of symptom resolution, with most cases, recovery took place within 24 to 30 months of onset, and in many cases, it was much sooner than that. Interestingly, the children who exhibited persistent stuttering showed a trend toward decreased stuttering during the course of the study, as well; however, the magnitude of their decrease was not nearly as marked as that of the children who recovered. The latter finding and a similar one by Throneburg and Yairi (2001) with a smaller group of children go against the notion that stuttering gradually worsens in severity as the time from symptom onset increases. Rather, the data suggested that children who showed no reduction or only minimal reduction in stuttering symptoms during the first year or two after onset were less likely to resolve stuttering symptoms than the children who showed substantial reductions over that time period. Yairi and colleagues’ research yielded important insights into the nature of recovery processes in childhood stuttering. The scientific process is based on replication of research findings, and consequently, other studies of recovery patterns have been conducted since then. For example, Reilly et al. (2013) also examined patterns of recovery in a longitudinal study of Australian children from birth to age 4. In their study, only 6.3% of the children who stuttered demonstrated recovery within 12 months of onset. In addition, recovery was more likely to occur within this time frame among boys than it was among girls, and the initial parent ratings of stuttering were lower (more favorable) for cases that did recover than for cases that did not. Interestingly, none of the 54 girls included in the analysis showed recovery from stuttering within 12 months of onset. The findings from Reilly et al. are different in some respects (e.g., recovery rates for boys vs. girls) from those reported by Yairi and colleagues (e.g., Throneburg & Yairi, 2001; Yairi & Ambrose, 1999). The reasons for these differences are not entirely clear but may reflect differences in

the timescales and age ranges under study by the two research groups.

Predictors of Recovery From Stuttering Findings from the University of Illinois research studies pointed toward several factors that appeared to be relevant to generating reasonable predictions of which cases of stuttering would persist and which would recover. These factors included the following: 1. The child’s sex (males appear to have greater risk of having stuttering persist); 2. Longitudinal trends in severity in the months following stuttering onset (cases that persist show little or no improvement during the 12 months following onset); 3. Time since onset (when recovery occurs, it most often happens within a roughly 2-year window following onset); and 4. Family history (the presence of multiple relatives with active stuttering seems to increase the risk that a child’s stuttering will persist). Additional research has uncovered several other variables that are promising with respect to their ability to predict the eventual course of a preschooler’s stuttering. These are discussed next.

Lexical and Grammatical Development As the basic epidemiological characteristics of recovery began to emerge, Yairi and colleagues also conducted several studies in which they examined the role of various speech-language factors in predicting recovery from stuttering. One such study (Watkins, Yairi, & Ambrose, 1999) examined the extent to which a child’s expressive language performance predicted recovery. Watkins et al. analyzed 84 children’s conversational speech in terms of structural complexity and lexical diversity. They found that both the children who recovered and the children who did not recover exhibited average to above-average skills in expressive language. However, a subgroup of children who began to



stutter between the ages of 2 to 3 years exhibited expressive language skills that significantly exceeded age-level expectations. Watkins et al. concluded that expressive language performance was not a strong predictor of which children recovered from stuttering; however, it did offer insight into factors that might precipitate stuttering onset. In their view, precocious language development during the early years of life may be something of a double-edge sword: advantageous for rich and varied communication but a potential liability for communication fluency because of the demand that complex utterances put on the speech planning and speech motor processes. Reilly et al. (2013) reported a similar finding in their prospective study of 1,619 children from birth to 4 years. At the end of the study period, children who had begun to stutter exhibited significantly better scores on standardized tests of language development and nonverbal cognition than children who never stuttered. In contrast with Watkins et al. (1999), however, the children’s language development at age 2 was not a strong predictor of which children began to stutter prior to age 4, and language performance at age 4 was not a good predictor of recovery from stuttering. In another longitudinal investigation, Leech and colleagues (Leech, Bernstein Ratner, Brown, & Weber, 2017) compared growth in syntactic and lexical performance in children who recovered from stuttering and children who persisted with stuttering between the ages of approximately 4;9 and 7 years of age. They found a significant positive relationship between children’s pace of syntactic maturation over the course of study. That is, children who advanced the most in terms of the syntactic complexity of the utterances they produced had much higher odds of recovery than children who advanced the least. Performance on a test of speech sound production also was associated with recovery from stuttering. Growth in vocabulary diversity, however, was not associated with the likelihood of recovery. It may be that accelerated growth in syntax places acute demands on a child’s developing speech motor system, a scenario that might precipitate the occurrence of stuttered speech. Interestingly, children’s semantic processing performance at age 5 during listening tasks also

7.  Stuttering:  Epidemiology, Development, and Etiology

has been found to predict eventual stuttering recovery status. Kreidler, Wray, Usler, and Weber (2017) conduced electrophysiological measurements of children via electroencephalography (EEG) as they listened to semantically anomalous sentences and semantically sensible sentences. They found that children who eventually recovered from stuttering showed significant differences in two components of the EEG waveform when compared to children who did not recover. Both the Kreidler et al. and Leech et al. (2017) studies provided evidence of neural maturation in language-related systems. It is interesting to speculate whether more widespread neural maturation, particularly in the language and the speech motor systems, occurs concurrently among children who recover from stuttering.

Speech Sound Development and Speech Motor Coordination Paden, Yairi, and Ambrose (1999) examined the role of phonological development in recovery from stuttering in a study of the same 84 children included in the Watkins et al. (1999) study. Analysis of data from the children’s initial evaluations showed that the children who eventually recovered from stuttering exhibited phonological skills that were superior to those of the children who persisted. Leach et al. (2017) found a similar pattern in a study of slightly older children, with the children who eventually persisted with stuttering obtaining an average standard score of 82 (below normal limits) on a test of speech sound production, while children who eventually recovered obtained a standard score of 97 (within normal limits). In the Paden et al. study, the types of errors that all of the children who stuttered (recovered and persistent) made were similar to those of typically developing children. Thus, children who stuttered seemed to be following the same developmental course as typical children, but some children who stuttered (i.e., those who eventually exhibited persistent stuttering) developed at a slower-than-typical pace. These concerns about phonological development were short-lived, however, because in a follow-up study of the children, Paden, Yairi, and Ambrose (2002) found that within 1 year after stuttering onset, the children who eventually exhibited

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persistent stuttering effectively “caught up” with the children who eventually recovered from stuttering in terms of phonological development. Thus, phonological development distinguished the two subgroups of children who stuttered near the time of symptom onset but failed to do so in later stages of the disorder. Other researchers have examined aspects of consonant-vowel coarticulation as potential predictors of recovery from stuttering during childhood. Results from some of these studies have suggested that motor-based measures of speech production possibly can distinguish between children who will and will not recover from stuttering. Brosch, Häge, and Johansenn (2002) analyzed aspects of speech such as voice onset time, vowel duration, fundamental frequency, jitter, and articulation rate in target utterances that children produced. When the mean scores of the two groups were compared, the children who eventually persisted with stuttering showed greater variability for many of these measures — especially for voice onset time — than the children who eventually recovered from stuttering. Subramanian, Yairi, and Amir (2003) measured the duration and frequency changes associated with second formant (F2) transitions during children’s perceptibly fluent productions of specific CV syllables.3 In the study, the children who persisted with stuttering showed smaller frequency shifts than the children who recovered from stuttering, suggesting that the persistent stuttering group used relatively restricted or constrained movements when shifting from one vocal tract configuration to another during syllable production. CV transition duration, in contrast, did not differ between the two groups of children. More recently, Usler, Smith and Weber (2017) measured variability in lip aperture and fluency at age 5 as children repeated target utterances that contained several bilabial consonants. Analysis of the perceptibly fluent responses showed that the children whose stuttering was found in subsequent assessments to persist through age 8 exhibited greater spatiotemporal variability in this aspect of articulatory movement than children who went on to recover from stuttering. 3

Recovering From Stuttering After Childhood As noted earlier in the chapter, the term late recovery, when used in a narrow sense, refers to cases in which the symptoms of childhood onset fluency disorder resolve in adolescence or adulthood. When used in a broader sense, it also can include cases where symptoms of childhood stuttering have improved substantially by adolescence or adulthood. There are data from several studies, most of them retrospective in nature, that examine this phenomenon. Wingate (1964b) studied 50 individuals who reported having stuttered earlier in life and then experiencing resolution or marked improvement. Participants ranged in age from 17 to 54 years (mean age = 34 years). Half of the participants described themselves as “normally fluent,” while the other half reported that they usually spoke with normal fluency, however in some stressful situations, they still exhibited minimal stuttering, which they reported usually being able to control. Across all participants in the study, onset most often occurred before age 7, and significant stuttering symptoms were present for an average of 12 years. Among males, the age at time of recovery/marked improvement ranged from 9 to 26 years, and for 60% of the males these changes occurred during adolescence. Among females, the age at time of recovery/marked improvement was more variable, and only 28% of the females experienced these changes between 14 and 20 years of age. Individuals attributed their changed fluency functioning to factors such as attitude change, speaking practice, symptomatic speech therapy, and environmental change. It is difficult to compare results from Wingate’s (1964b) study with results from the studies by Yairi and colleagues because Wingate included many participants whose stuttering still was apparent in some situations. Accordingly, it perhaps is safer to think of Wingate’s data, at least in part, as providing information about the ages at which speakers who stutter perceive stuttering as no longer being an area of significant disability.

A formant is a pattern of vocal tract resonance, and during vowel production, F2 provides information about anterior-posterior tongue movement (e.g., front vowels are associated with relatively high F2 frequency values; back vowels are associated with relatively low F2 frequency values).



7.  Stuttering:  Epidemiology, Development, and Etiology

Other studies of recovery from stuttering have featured participants that are similar in fluency functioning to those in Wingate’s (1964b) study (e.g., Anderson & Felsenfeld, 2003; Finn, 1997; Shearer & Williams, 1965; Sheehan & Martyn, 1966). Finn, Howard, and Kubala (2005) reported on 15 cases of “unassisted recovery” from stuttering. Overall, 7 of the 15 participants reported that they no longer stuttered at all. The remaining 8 participants reported that they still stuttered on occasion; however, stuttering no longer presented a significant handicap for them. In a previous study, Finn (1997) compared speech samples from these recovered speakers with speech samples from speakers who never had stuttered. Raters assigned lower naturalness ratings to the recovered group, and naturalness ratings correlated moderately with speech rate and part-word repetition frequency. In 11 of the cases, unassisted recovery occurred at or after age 15. In five of those cases, recovery happened between age 20 and 26 and in one case, at age 42. It is unclear the extent to which these findings are representative of the overall population; however, data such as these underscore the fact that although complete resolution of stuttering symptoms seems to become increasingly unlikely as one ages beyond childhood, recovery from stuttering does occur, as does near-complete recovery and, in the latter cases, a person may be quite satisfied with his or her level of functioning despite

having speech that sounds somewhat different than someone who never has stuttered.

Age- and Stage-Based Approaches to Describing Persistent Stuttering Experts in stuttering have long had an interest in presenting the developmental course of persistent stuttering in terms of stages or phases. Several of those approaches are summarized in this section.

Primary Versus Secondary Stuttering Some of the earliest efforts in this regard came from Bleumel (1932), who distinguished between “primary” and “secondary” forms of stuttering. Bleumel used the term primary stuttering in reference to the stuttering-related disfluency that a child produces prior to becoming aware of or concerned about it. In contrast, he used the term secondary stuttering in reference to the patterns of speech that a person who stutters produces after he or she has become aware of and concerned about stuttering. As such, secondary stuttering incorporates stuttering-related disfluency plus whatever other behaviors the speaker uses to cope with the disfluency and/or conceal it from others (e.g., fluency

Which Factors Do Teens and Adults Who Stutter Attribute to Improved Speech Fluency? Several of the studies cited in this chapter contained information about participants’ impressions of factors that led to their improvement in (and, in some cases, recovery from) stuttering. Common themes that participants mentioned included the following: changes in confidence and motivation, making a conscious decision to change, making overt or explicit changes in speech (e.g., talking slower, thinking before speaking) either within or apart from speech therapy, and remaining focused or vigilant about speech fluency over time. Some authors (e.g., Plexico, Manning, & DiLollo, 2005) have examined this issue via interviews with adults who stuttered and isolated factors such as persistence/motivation, participation in speech therapy, support from others, drawing upon personal experiences and areas of strength, and developing more accurate/constructive thoughts and beliefs about stuttering and being a person who stutters as being key to improved speech fluency..

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facilitation strategies; avoidance, postponement, and concealment strategies).

Progressing From Repeating to Prolonging/Blocking as a Primary Symptom As noted earlier in the chapter, many cases of childhood stuttering begin in what has been described as a gradual manner that includes a progression from repeating to prolonging/blocking as a primary symptom of stuttering. Conture (1990) proposed an account of this progression in his alpha-delta hypothesis, which was designed to capture changes in stuttered speech during the years immediately following symptom onset in early childhood. He proposed that the earliest symptoms of stuttered speech (alpha behavior) consist of brief inefficiencies in speech production. These inefficiencies were hypothesized to be brief “laryngeal catches,” most of which are imperceptible to listeners. Conture proposed that speakers attempt to compensate for the laryngeal glitches by producing oscillatory articulator behavior, which manifests as part-word repetition (beta behavior). Over time, the speakers’ reactions to and attempts to compensate for repeated speech lead to rigid, fixed articulatory postures that manifest as sound prolongation/ blocking (gamma behavior) and the emergence of various other coping or reactive responses to the preceding forms of disfluency (delta behavior). There is some support for the idea that sound prolongations are an emergent aspect of stuttering. For example, Pellowski and Conture (2002) reported that the proportion of “disrhythmic phonations” (a category that includes sound prolongation) a child produces is positively correlated with the amount of time that has elapsed since the onset of stuttering symptoms.

Relationships Between Age and Stuttering Frequency Several researchers have examined the relationship between a speaker’s age and/or time since stuttering onset and a quantitative measure of stuttering such as disfluency frequency. Andrews

and Harvey (1981) conducted repeated measurements of adults who stuttered as they waited for treatment during a period of several months. During the first 3 months on the wait-list, stuttering showed modest but significant improvement; and after that period, it remained stable. Thus, with those adults, the passage of time did not necessarily correspond to a worsening of speech disfluency. Yairi and colleagues (Yairi et al., 1996) reported a similar pattern among the preschool-aged children whom they followed over time but did not enroll in active treatment: Stuttering frequency remained relatively stable or in some cases improved somewhat. Similarly, based on the author’s experience with developing norms for the Test of Childhood Stuttering (Gillam, Logan, & Pearson, 2009), there was no significant correlation between a child’s chronological age and his or her stuttering severity. Longer-term trends in stuttering severity are less well studied. For example, there is relatively little research on the stuttering-related experiences of older adults. In one study (Manning, Dailey, & Wallace, 1984), older adults who stuttered showed similar communication-related performance and attitudes as younger adults who stuttered, but they perceived stuttering as being less handicapping than the younger adults did. Together, these findings suggest that although gradual worsening in stuttering severity certainly may happen with some individuals, it is by no means a universal feature of the disorder.

Relationship Between Age and Stuttering-Related Disability There seems to be a general agreement that in cases of chronic or persistent stuttering, the severity of the disorder and/or its consequences gradually worsens as the length of time from symptom onset increases. In other words, the longer one stutters, the more severe its consequences become. Clinical authorities have presented this position in several ways. One well-known approach is the one that Bloodstein outlined (see Bloodstein & Bernstein Rater, 2008), in which he proposed four phases of stuttering, each of which is organized around the type, manner, and frequency of disfluency produced, the speaker’s reactions to disflu-



7.  Stuttering:  Epidemiology, Development, and Etiology

ency, and the contexts in which stuttered speech most often occurs. Bloodstein described the symptoms at stuttering onset in a manner consistent with Van Riper’s (1982) Track 1 stuttering and claimed that as stuttering symptoms persist, the speaker’s awareness of stuttering and its social consequences increases. Consequently, the speaker’s concern with communication disability and being a “person who stutters” increases as well, which leads the speaker to more frequent and demonstrable use of strategies for actively concealing, avoiding, and coping with stuttering-related fluency impairment. Van Riper (1971) outlined a similar progression for the disorder in his track-based approach to describing stuttering over the life span, and Guitar (2014) developed a continuum based on a combination of length of time stuttering and severity of stuttering symptoms (i.e., beginning, intermediate, and advanced stages of stuttering). The bulleted list that follows combines some of the primary concepts from these stage-based approaches to provide a sense of the progression that an individual with moderate or severe stuttering and significant communication-based disability might go through as stuttering persists beyond childhood: • Stuttering in early childhood (approximately ages 2 to 6):  episodes of speech that at first are largely situational in nature, but gradually become increasingly consistent across daily activities and speaking partners; stutter-like disfluency often includes part-word repetition, but may also include sound prolongations/blocks, and most of these disfluencies occur in conjunction with the initiation of major grammatic units (e.g., utterances, clauses, phrases). Excessive articulatory effort may emerge in the form of physically tense disfluency. Part-word repetitions will sound dysrhythmic. Most children will develop awareness of speech disfluency over this time period, but most will exhibit either relatively little concern or situational acknowledgment/concern about speech disfluency (e.g., I can’t say it, Mommy.). • Stuttering during the elementary school years (approximately ages 7 to 12):

Stuttered speech becomes chronic and may become more severe than typical in situations that entail public or group speaking, time pressure, excitement, the need to communicate information rapidly. Most stutter-like disfluency occurs in conjunction with the initiation of major grammatical units; however, as utterance lengths increase, stutter-like disfluency is likely to occur elsewhere, such as in conjunction with syllables that carry primary linguistic stress within a phrase. The child is likely to gradually develop a self-concept of being a “person who stutters,” yet the level of concern about stutter-like disfluency can vary widely across individuals. Some children may implement compensatory strategies (e.g., rhythmic movements of non-speech body parts, word substitution) to cope with anticipated stutter-like disfluency. Excessive articulatory effort may be present in the form of physically tense disfluency and muscle tremor. Emotional and cognitive components are likely to increase as awareness of listeners’ reactions to stutter-like disfluency increases. • Stuttering during adolescence and early adulthood (approximately ages 13 to 22): Stuttering symptoms are likely to continue to vary in frequency and severity across situations; however, the speaker is likely to progressively view some words and some types of speaking tasks as being harder to say or do than others. Individuals who lack effective strategies for managing imminent disfluency may increasingly resort to avoidance or delay tactics such as word substitution and/or circumlocution; and speakers who are embarrassed about stutterlike disfluency or anxious about listener reactions to stuttered speech will begin to limit participation in specific speaking situations, particularly those in which unfavorable listener responses are more likely. Concern about stuttering generally increases as the individual comes to realize the social and, possibly, economic costs of stuttering and related communication disability. Some individuals may seek out

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speech therapy. Sometimes this happens in the context of important life events, such as the need to improve communication in social, school, or work settings, or to participate in a job interview; and at other times, it stems from having reached a point of fatigue or intolerable dissatisfaction with having to struggle to speak, worry about listener reactions, and feel speech-related anxiety embarrassment or shame. Other individuals may be unenthusiastic about participating in therapy for reasons such as embarrassment that others will find out about the therapy, hope that stuttering will somehow resolve on its own, or a desire to “fix the problem” independently without having to rely on others’ help. Cost and access to services also can be a barrier. • Stuttering during adulthood: Most individuals will be acutely aware of their stuttered speech and will often be able to anticipate when stuttering is most apt to occur. Individuals who have not “come to terms” with being a person who stutters through accepting that their impairment is not their fault and is but one part of the many other things that make up who they are will be likely to continue use of the various concealment and avoidance strategies that they developed earlier in life. Speakers are likely to find that concealment and avoidance strategies often either backfire (e.g., the person ends up stuttering even more severely than they would have if they had simply said the target word) or require so much effort to execute that they become an additional source of dissatisfaction for the speaker. At such points, individuals may seek professional assistance for dealing with stuttering more effectively. Other individuals essentially will develop stuttering management strategies through self-therapy, and as noted earlier, some will reach a point where they are able to manage stuttering to their satisfaction and in ways that allow them to communicate effectively enough to meet the needs of their daily activities.

Although stage-based conceptualizations of stuttering such as the ones described here offer a general sense for how the expression of stuttering evolves over time, this approach has somewhat limited clinical application because there always will be clients who fit some, but not all, of the characteristics that are attributable to any particular stage. As Bloodstein and Bernstein Ratner, 2008) noted, these phases are best regarded as “typical” patterns rather than as “universal” patterns.

Age, Disability, and Quality of Life As discussed in Chapter 6, issues pertaining to the effects of stuttering on an individual’s quality of life have been studied for a long time and have received a growing amount of attention over the past 2 decades. The interplay between an individual’s (1) speech fluency skills, speaking, and social environment (e.g., listener reactions), (2) societalcultural context (e.g., the extent to which stuttering is “understood” versus stigmatized in a culture), and (3) person feelings, emotions, beliefs, and expectations about stuttering and being a “person who stutters” combine to create one’s “experience of stuttering.” In light of the many findings regarding the life experiences of people who stutter, it is not surprising to learn that, on a group level, adults who stutter report having a lower quality of life than speakers who do not stutter (Craig, Blumgart, & Tran, 2009; Yaruss & Quesal, 2006). Craig et al. (2009) found that stuttering affects life domains that go beyond verbal communication to include arenas such as physical vitality, social functioning, emotional functioning, and mental health status. They also found that the quality of life differences exhibited by people who stutter were similar in magnitude to those seen in people with chronic disorders such as spinal cord injury, heart disease, and diabetes. They also reported that individuals with severe stuttering were more likely than speakers with mild or moderate stuttering to report limitations in quality of life. In teens, stuttering increases the risk of being teased and bullied (Blood & Blood, 2004; Erickson & Block, 2013). Also, teens who stutter see their speech impair-



ment as something to keep hidden from others, and they perceive their skills in communication to be below average and a source of apprehension (Erickson & Block, 2013). With adults who stutter, higher ratings of self-stigma (i.e., the extent to which one internalizes negative public beliefs that are held about a specific condition) are significantly correlated with lower ratings of overall health and health care satisfaction, and increased ratings of perceived stress during daily life activities (Boyle & Fearon, 2018). Stuttering can have economic consequences as well (Blumgart, Tran, & Craig, 2010b; Gabel, Hughes, & Daniels, 2008; Gerlach, Torry, Subramanian, & Zebrowski, 2018), and it influences the occupational choices that people who stutter make (Gerlach et al., 2018; Hayhow, Cray, & Enderby, 2002; Klein & Hood, 2004) as well as the types of occupations that others deem to be suitable for people who stutter (Gabel, Blood, Tellis, & Althouse, 2004; Logan & O’Connor, 2012). Blumgart et al. estimated the lifetime cost of stutteringrelated services for people who stutter in Australia for adults to be about $5,500, and they found that individuals with high social anxiety (individuals who arguably are most in need of services) tended to spend less on treatment than people with low social anxiety, possibly because of their discomfort with confronting stuttering-related issues. In the United States, Gerlach et al. (2018) reported that males who stuttered showed a gap in earnings of approximately $7,600 to $10,700 compared to males who did not stutter; and for females who stuttered, the earnings gap was approximately $7,100 to $18,700 in comparison to females who did not stutter. In addition, males were about 8% less likely to participate in the workforce than males who did not stutter, and women who stuttered were about 23% more likely to be underemployed than women who did not stutter. In work settings, adults who stutter expect to be stigmatized because of their communication limitations; they see their speech difficulties as limiting opportunities for occupational advancement, and they experience elevated fear of being negatively evaluated (Bricker-Katz, Lincoln, & Cumming, 2013). Self-stigma, however, appears to contribute less to earnings discrepancies in males who stutter than the occupation itself

7.  Stuttering:  Epidemiology, Development, and Etiology

(Gerlach et al., 2018). Clearly, the consequences of stuttering for teens and adults who stutter can be quite significant. With preschoolers, researchers have reported mixed results with respect to the impact that stuttering has on quality of life. In some studies, preschoolers who stuttered have scored within normal limits on measures of health-related quality of life (Reilly, et al., 2013; de Sonneville-Koedoot, Stolk, Raat, Bouwmans-Frijters, & Franken, 2014). However, in other studies, preschoolers who stuttered showed less favorable communication attitudes (Vanryckeghem, Brutten, & Hernandez, 2005) and were at greater risk of being teased, bullied, rejected, and/or excluded from social/schoolrelated activities (Gertner, Rice, & Hadley, 1994). With school-aged children who stutter, a host of studies have found evidence of increased risk for teasing, bullying, exclusion, and rejection (Blood, Blood, Tramontana, Sylvia, Boyle, & Motzko, 2011; Davis, Howell, & Cooke, 2002; Hugh-Jones & Smith, 1999; Langevin, Kleitman, Packman, & Onslow, 2009) as well as a higher likelihood of meeting criteria for social anxiety and subclinical generalized anxiety disorder (e.g., Iverach, Jones, et al., 2016); and parents reported that the challenges and uncertainties that came with knowing how to respond to and assist with their child’s stuttering created stress within the household (Erickson & Block, 2013). The quality of life differences in people who stutter of course are related to the presence of disability in the area of spoken communication. Although there generally is a significant inverse correlation between the severity of one’s stuttering and the person’s assessment of their quality of life (Craig et al., 2009), there are those cases in which the severity of the fluency impairment does not clearly correspond to the social and emotional consequences experienced by the individual. In some individuals, speech that is characterized by “mild” stuttering is accompanied by relatively high levels of emotional distress and participation restriction; and in other individuals, speech that is characterized by “moderate” or “severe” stuttering is accompanied by a relatively favorable attitudinal outlook and relatively little emotional distress. In one study with adults who stuttered (Carter, Breen,

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Yaruss, & Beilby, 2017), ratings of self-efficacy (i.e., the extent to which one thinks he or she can take actions to achieve a desire outcome) showed a strong association with quality of life ratings, whereas the stuttering frequency was only moderately associated with quality of life ratings. Thus, clinicians must remember that disability in people who stutter does not always correspond directly to the number of surface-level interruptions a persons produces in speech; and these surface level interruptions and the limited fluency that results often are less consequential to an individual’s overall function than the challenges the person experiences in areas such as communication participation and social-emotional well-being. Figure 7–3 summarizes the information in this section by presenting a graphic illustration of the progression of events that might lead an individual with moderate or severe stuttering and significant communication-based disability to pursue speech

therapy. The milestones in the figure are representative of what often plays out over the course of childhood, or on a longer time scale, from childhood through adolescence and/or adulthood.

Attempts to Explain Stuttering:  Theories and Models of the Disorder Stuttering is a speech disorder that, until the past few decades, has essentially defied explanation. There are multiple reasons for this: Technological limitations have surely been a primary obstacle to explaining the disorder, but the nature of the disorder’s symptomatology (an onset that occurs after a period of ostensibly normal development, variable symptom severity across tasks, the observation that stuttering symptoms are transient for some but per-

1. Impaired fluency, Stutter-like disfluency, Activity limitations 2. Awareness of stutter-like disfluency, Activity limitations, Emerging concern over others’ reactions to disfluent speech 3. Use of compensatory strategies, Use of avoidance & concealment strategies

4. Social anxiety, Unproductive/ disruptive feelings, thoughts, beliefs about speaking

5. Participation restrictions, Lowered self-esteem, shame, feeling stigmatized

6. Seeking treatment Figure 7–3. Progression of events that occur commonly in individuals with longstanding moderate to severe stuttering. A profile like this is consistent with significant communication-based disability and would be likely to lead an individual to pursue speech therapy



7.  Stuttering:  Epidemiology, Development, and Etiology

sistent for others, the fact that stuttered speech seems to be totally absent in speaking conditions like choral reading, the inconsistent effects that emotional states have on fluency performance) surely have posed obstacles to developing an accurate theory of the disorder as well. These closing pages of this chapter review several early attempts to account for stuttering and then turn to a review of contemporary models of the disorder, which are getting ever closer to offering an accurate account of the etiological elements in stuttered speech and explaining why some people are more prone than others to develop the disorder. Most models of stuttering are aimed at explaining the fundamental impairment that people who stutter present (i.e., the disfluency types that characterized childhood onset fluency disorder). As will be seen, these models have become increasingly sophisticated over the years and increasingly linked to the intricate processes that go into speech production. Still, many of these theories have revolved around a single “key factor” that is offered as an explanation for stuttering-related disfluency (Conture, 2001; Smith & Weber, 2017). The number and scope of such theories is, in retrospect, rather remarkable. Key factor and single deficit approaches have been found to be unsatisfactory for one of the following reasons: They could not adequately account for the many features of stuttering; they were completely divorced from models of speech production, and/ or they could not be tested scientifically.

Early Explanations:  Psychological and Learning-Based Explanations Several early theories of stuttering attempted to account for stuttered speech using psychological constructs, wherein stutter-like disfluency was said to be a manifestation of (a) an individual’s repressed needs and/or suppressed feelings or thoughts (e.g., see Coriat, 1943; Travis, 1971); (b) momentary conflicts arising at the intersection of an individual’s desire to speak and desire to hold back from speaking (Sheehan, 1958); (c) an individual’s desire to avoid causing parents concern over one’s speech fluency ( Johnson et al., 1942); or (d) the belief that speaking is difficult

to do (Bloodstein, 1958). Still other theories have attempted to account for stuttering using concepts from learning theory. For example, Brutten and Shoemaker (1967) proposed a “two factor theory” wherein it was claimed that young children learn to associate speaking with negative emotion through classical conditioning such that, over time, the act of speaking becomes linked with the disintegration of cognitive and motor processes that are necessary for fluent speech production. It was further claimed that once the link between disfluency and negative emotion is established, the child’s speech disfluency is shaped further through operant conditioning mechanisms (e.g., reinforcement, punishment) to include secondary symptomatology. At first glance, this may seem like a compelling model; however, many young children have little awareness of their disfluent speech (Ezrati-Vinacour, Platzky, & Yairi, 2001); and in such cases, it is difficult to account for how disfluency would become linked with “negative emotion” during the earliest stages of the disorder. Further, studies of motor and autonomic nervous system activation of speakers who stuttered have shown that heightened muscle activation or heightened autonomic nervous system arousal does not always accompany stuttered speech (Denny & Smith, 1992; Kelly et al., 1995; Smith, 1989; Weber & Smith, 1990).

The Move Toward Viewing Stuttering as a Symptom of Speech Production “Breakdown” In other early theories, stuttered speech was explained as being a symptom of “breakdown” or dysfunction in one or more of the steps in the speech production process. For example, several models proposed that discoordination in the neural or neuromuscular processes involved in speech production were the source of stutter-like disfluency (e.g., Travis, 1931, Van Riper, 1982; West, 1958). From the late 1980s through the early 2000s, several authors proposed explanatory models for stuttering that were rooted in psycholinguistic processes or their interaction with aspects of speech planning. Some of the more prominent models of this type are described next.

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Stuttering as a Symptom of Breakdown in Utterance Planning In the Covert Repair Hypothesis (Postma & Kolk, 1993), stuttering was modeled as an impairment that affected phonological encoding. It was proposed that individuals who stutter take longer than normal to select the phonemes that are unique to a lexical item, which makes these individuals prone to selecting incorrect phonemes during phonological encoding. In this model, stutter-like disfluency is symptomatic of the speaker’s attempts to repair the effects of a hypothesized lag in phoneme selection. Repair strategies include use of “restart” (repetition) and/or “postponement” (i.e., prolongation) of the affected phonological segments of a word. In Perkins, Kent, and Curlee’s (1991) neuropsycholinguistic theory of stuttering, stutter-like disfluency also was modeled mainly as a breakdown in phonological encoding. In the model, stuttering was said to be symptomatic of a lack of synchrony between the segmental (phonemic) and the prosodic (e.g., the metrical properties for a string of consecutive syllables) components of an emerging utterance. In the model, a speaker experiences this lack of synchrony as “stuttering” only when it is accompanied by a feeling of time pressure. More recently, Howell (2004, 2011) described the execution and planning model (EXPLAN) of stuttering. In this model, disfluency (particularly stutter-like disfluency) is viewed as a symptom of lack of synchrony between the language and motor components of the speech production system. In this model, if a speaker attempts to generate the motor output for a word prior to completing the linguistic planning for the word, it results in “fragmentary” types of speech such as part-word repetition, sound prolongations, and blocks. Like their characterization in the Covert Repair Hypothesis, such disfluencies are viewed as a means of “stalling” until synchrony between the two components of the system is reestablished. In the EXPLAN model, linguistically complex utterances, which take longer to plan, exacerbate the effects of any motor system deficit that a speaker exhibits. In this way, both the language system and the motor system are said to be integral to stuttered speech. Although none of these theories has gained universal acceptance as being the complete, stand-

alone account of why certain people stutter, each of them brings the causal mechanisms of stuttering into focus by highlighting areas of difficulty/ impairment that people who stutter experience when talking. That is, the general notion of stuttering as a symptom of impairment or inefficiency in utterance planning processes, particularly in the phonological/phonetic realm, has gained wide acceptance among contemporary researchers, and it is incorporated in most other modern explanations for stuttering.

Stuttering as a Symptom of Breakdown in Motor Speech Processes Several motor-based accounts for stuttering have been proposed during recent decades, and this perspective has received growing emphasis during the past decade in light of emerging findings from neuroimaging about the motor system functioning of speakers who stutter. Some of the most recent “motor models” are multifactorial in the sense that the motor system is seen as interacting with other neural systems such as those involved in the processing of language, cognition, and/or emotion. Howell’s (2004, 2011) EXPLAN model, which focuses on interactions between the language and speech motor systems, is one such example. The idea that stuttering might be fundamentally a motor-control problem is by no means new. One idea that underlies several theories — old and new — is that stuttered speech is symptomatic of a speech motor control system that is ill-equipped to regulate and/or produce the precisely timed sequential motor movements that are necessary for smooth, continuous speech. In the early 1930s, Samuel T. Orton and Lee Edward Travis proposed that stuttering results from asynchronous neural input to bilaterally innervated speech musculature (Travis, 1931). They proposed that the breakdown in the delivery of synchronous neural input to the right and left sides of the body results from a failure to establish the cerebral dominance that is necessary to keep neural input to the muscles properly timed. It was hypothesized that this lack of integrated timing results in paired speech muscles on the right and left sides of the body receiving neural input at slightly different times — a situation that they claimed would cause disfluency. Since then, a



variety of other motor-based explanations for stuttering have been proposed. Packman and colleagues (Packman, Onslow, Richard, & Van Doorn, 1996) noted that people who stutter speak very smoothly when employing either prolonged speech or syllable-timed speech. They noted that each style of speaking tends to reduce the amount of variability in the duration of the syllables a speaker says. Typical speech, however, with its complex patterns of stressed and unstressed syllables, requires speakers to articulate syllable sequences in which individual syllables are much more variable in their timing; and when such syllable sequences are attempted by people who stutter, they are executed with much less fluency. Thus, in Packman et al.’s model (the Variability model or V-model), stutter-like disfluency was viewed as a symptom of motor breakdown that occurs in the context of having a deficit in the ability to produce variably timed speech gestures. Zimmermann (1980) took a somewhat different approach, proposing that people who stutter exhibit excessive variability in the velocity or spatial-temporal positioning of the speech motor movements they produce (a hypothesis which subsequently has been supported in some other studies). In his model, when movement variability exceeds critical thresholds, it is detected via sensory feedback. This triggers corrective action in the form of motor reprogramming, which ultimately creates instability in the motor system that is manifested in the form of either oscillatory movements (i.e., repetitions) or static posturing (i.e., sound prolongations). Other models of stuttering have centered on the speaker’s ability to mesh sensorimotor information with the motor plans that form the basis of speech-related movements. In several models, stuttered speech is seen as a symptom of problems in updating movement plans with momentto-moment information about the status of an ongoing articulated utterance. Such updating is needed to fine-tune an utterance’s motor plans (i.e., the gestural score) to the dynamic conditions that are present during an ongoing utterance. Along these lines, Neilson and Neilson (1987) viewed stuttering as a failure or a weakness in the ability to utilize adaptive feedback control. In their model, adaptive control refers to events that

7.  Stuttering:  Epidemiology, Development, and Etiology

establish a relationship between motor commands and the “sensorimotor motor consequences” that motor commands create, as well as the verification or modification of motor commands based on sensorimotor information. Sensorimotor factors continue to play a prominent role in contemporary models of stuttering. For example, Max et al. (2004) presented a model of stuttering that was closely aligned with principles and concepts from the DIVA model (Guenther, 2006; Ghosh, Tourville, & Guenther, 2008). In Max et al.’s model, it is proposed that stuttered speech can result in one of two ways: (1) The speaker’s internal motor models or sensory models for movement goals are either unstable (i.e. they do not remain activated for a sufficient length of time) or insufficient (i.e., they do not activate completely); or (2) the speaker relies too heavily on afferent (somatosensory) feedback, which creates instability in the speech production system due to the amount of time that it takes to incorporate the afferent feedback into the ongoing articulatory movements. Max et al. (2004) noted that their model accounts for specific instances of stuttering-related disfluency but not necessarily for how certain people come to have the disorder. The authors offered several possible mechanisms that could lead to a person developing stuttering. They suggested that abnormal levels of dopamine in the basal ganglia system could lead to problems in both motor planning and programming, along with difficulties in motor learning and sensorimotor integration. They also cited several studies in which speakers who stuttered had been found to exhibit atypical patterns of cortical activation in brain regions that are involved with speech production, particularly those associated with motor planning and sensorimotor aspects of spoken sounds, syllables, and words. Such atypical activation might be a consequence of the decreased motor and/or sensory models that the authors hypothesized. Tourville and colleagues (Tourville & Guenther, 2011; Tourville, Reilly, & Guenther, 2008)) outlined and tested a mechanism for stutter-like disfluency in which poor performance in the “feeding forward” of motor plans leads to excessive and anomalous auditory monitoring in an attempt to correct errors in the motor plan. In the model, error detection leads to interruption (i.e., disfluency) in the motor production

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of a syllable, which a speaker could then repair using either a restart (repetition) or delay (prolongation) strategy. In summary, there are several “breakdown theories” of stuttering that seem at least to be “in the ballpark” with respect to specifying the core deficits that lead to stuttered speech. It is rather remarkable that some of the very early accounts, such as Van Riper’s (1973) claim of impaired sensorimotor functioning during speech motor execution and Orton and Travis’ (Travis, 1931) claim of overactivation in right hemisphere regions during speech production, have turned out to be remarkably prescient in light of recent findings regarding the types of neuroanatomical and neurophysiological anomalies that commonly are observed in studies of people who stutter. However, as Smith and Weber (2017) have stated, although it seems quite apparent that impairment in speech-related sensorimotor processes is at heart of the disfluency that speakers produce, there also is evidence of “breakdowns”/impairment in aspects of the language planning and processing systems, as well as differences in emotional regulation and behavioral inhibition systems that also are relevant to speech. More generally, there is growing recognition (e.g., Smith & Weber, 2017; Smits-Bandstra & De Nil, 2007) that the consequences of speech production breakdown are not confined to discreet moments in speakers who stutter, but rather are apparent throughout the course of spoken utterances; and because that multiple systems that seem to be involved in stuttering and the functioning of and interactions among these systems changes over time, a multifactorial, dynamic model is needed to account for the nature of the disorder.

Multifactorial Models of Stuttering The notion of multifactorial models of stuttering became increasingly attractive during the 1980s and 1990s as the limitations of key-factor theories became more and more apparent. Several authors (e.g., Smith & Kelly, 1997; Starkweather, Gottwald, & Halfond, 1990; Van Riper, 1982) offered accounts of stuttering that included multiple variables that interacted with one another. Two such models are the focus in this section.

The Communication Emotional (C-E) Model Conture and colleagues (Conture et al., 2006; Richels & Conture, 2010) proposed a multifactorial Communication Emotional Model (C-E model) for stuttering that attempts to capture which persons are likely to stutter and, once the person is stuttering, which factors contribute to overt instances of stuttering-related disfluency. The model is organized around two main components: the distal contributors and the proximal contributors to stuttering. In the C-E model, the distal contributors are factors that play a role in determining which people will stutter. This distal component of the model consists of two factors: (1) genetics (i.e., a person’s inherited a propensity for inefficient speech-language functioning; and (2) environment (i.e., the social, communicative, and emotional variables that can influence the expression of one’s genetic predisposition for speech-language performance). In the model, the proximal contributors to stuttering are those factors that have an immediate impact on the expression of stuttering. These include the speaker’s functioning in the planning and production of speech, a speaker’s life experiences, and a speaker’s emotional functioning, particularly regarding emotional reactivity and regulation. Consistent with contemporary psycholinguistic models, in the C-E model, speech-language planning is conceptualized as an incremental process. That is, utterances develop through a series of separate, staged representations that allow for conversion of a preverbal semantically based intention into morpho-phonologic and then phonetic representations. This process is hypothesized to be inherently inefficient in speakers who stutter due to genetic influences on the development of the speech production system. In the C-E model, experience consists of a speaker’s accumulated life experiences and a history of interactions between genetics and the environmental interactions. Speakers who communicate in an environment that features frequent fluency stressors such as conversational interruption or requests to speak quickly may develop stuttering-related behaviors that a child who was reared in a demand-laden environment would not exhibit. In the C-E model,



accumulated exposure to fluency stressors is presented as having the potential to exacerbate whatever speech-language planning problems the speaker presents. The C-E model also incorporates the notions of emotional reactivity, which refers to the frequency or intensity of emotional arousal, and emotional regulation, which refers to the act of controlling the expression of feelings and emotions and their underlying physiological substrates. In the C-E model, emotional reactivity and emotional regulation are hypothesized to influence stutteringrelated disfluency. The occurrence of stutter-like disfluency is considered a proximal factor as well. In the model, it is hypothesized that the speaker’s experiences with stuttered speech act in a “bottom-up” manner to influence his or her emotional functioning, interactions with other people, and speech-language planning.

The Multifactorial Dynamic Pathways Theory Smith and Weber (2017) proposed a multifactorial dynamic pathways theory of stuttering that attempts to characterize the conditions under which the onset of stuttering occurs during the preschool years as well as its developmental course through the start of the school years, a time span in which many cases of stuttering either resolve or persist. Smith and Weber’s theory extends earlier work by Smith and Kelly (1997): the “dynamic, multifactorial model” of stuttering. A main premise of that model was the notion that multiple factors contribute in a dynamic manner to the phenomenon of stuttering. The Smith and Kelly model featured five factors intrinsic to the speaker (genetics, emotions, language, cognition, and (speech) motor), and one extrinsic factor (environment); and it was argued that explanations of stuttering onset and maintenance over the life span are not dependent on any one single key factor that is common to every case. Instead, different factors contribute in differing degrees to the disorder across individuals, and, within individuals, different factors contribute in differing degrees to the disorder at different phases of the life span. Another main premise of the Smith and Kelly model is that the factors associated with stuttering interact in a nonlinear manner.

7.  Stuttering:  Epidemiology, Development, and Etiology

For example, a slight change in the status of one factor (e.g., grammatical development) can result in small changes in another factor (e.g., the stability of the speech motor system) at one age, but, at another age, can result in very large changes. Smith and Weber’s (2017, p. 2485) multifactorial dynamic pathways theory updated the earlier model and is based on at least four key tenets: (1) Stuttering now is clearly recognized as a neurodevelopmental disorder; (2) stuttered speech results from impairment in sensorimotor processes involved in speech production, however, emergence, persistence, and severity of the disorder over the life span is “strongly conditioned by linguistic and emotional factors,” (3) the emergence of stuttered speech occurs within a fairly short time window in early childhood during which the neural systems that underlie several critical systems (i.e., the motor speech system, the language system, the emotional/self-regulatory system) are undergoing intensive development and developing at different trajectories, which means these systems can interact in different ways at different points in development to result in either recovery from stuttering or its persistence; and (4) stuttering emergence and its eventual course are best explained as a dynamic process wherein speech motor instability (and with it, stutter-like disfluency) is the product of ever-shifting interactions among the system interactions, but are not found in individual subcomponents of the system. In the 2017 version of the model, Smith and Weber model stuttering from a neurodevelopmental perspective, which emphasizes the interplay between an individual’s genes (i.e., DNA segments present at birth), environment, and epigenetic patterns (i.e., “the timing and intensity of gene expression throughout life” (p. 2487). As with the earlier model, impairment in the speech motor system (i.e., development of poor speech motor programs and “muscle synergies for speech”) is seen as a primary factor in stuttered speech, leading to atypical instability in speech motor movements that is present even in the speech that sounds fluent. As in other contemporary models, speech motor impairment is viewed as a product of neuroanatomical (e.g., degraded connectivity between key processing centers involved in speech production) and neurophysiological (e.g., reduced and anomalous

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activation in key processing centers involved in speech production) differences between speakers who stutter and speakers with typical fluency. Another critical factor in the model is the language system, and, in particular, children’s manner and rate of maturation in the language domain ​ — in particular with respect to the robustness and efficiency with which an individual (a) processes linguistic input, (b) represents/stores linguistic information, and (c) accesses and assembles linguistic codes when formulating the form and content of messages that are to be spoken. Children who stutter have demonstrated an assortment of deficits in these areas, and attempts at producing linguistically complex utterance often are sufficient to destabilize speech motor system functioning in children who stutter in ways that lead to the production of stutter-like disfluency. The remaining critical component of the model concerns emotional factors. Smith and Weber discussed the potential impact that social anxiety, which seems to be particularly prevalent among people who stutter, has on functioning in speech-language domains. However, they noted that the role of emotional factors and related constructs such as an individual’s temperament is, for now, unclear with respect to the expression of stuttering due to conflicting results from research studies in this area.

The Impairment, Disability, and Context Model of Stuttering Figure 7–4 shows the author’s model of stuttering that incorporates some of the main concepts presented in Chapters 5, 6, and 7 with respect to the nature and characteristics of stuttering. As shown in the figure, genetic factors play a primary role in predisposing an individual to stuttering, and genetic factors (shaped by environmental influences) affect neurodevelopment, with the main area of interest being neuroanatomical and neurophysiological development in the speech production system (particularly the structure and functioning of language and speech motor control systems). Impairment in speech motor control and, for some individuals, concomitant inefficiencies in the language formulation system leads to instability and slowness in speech production and ultimately stutter-like disfluency, which becomes

more likely as task demands (e.g., linguistically complexity, time constraints on utterance production) increase. Depending on factors such as the severity of one’s fluency impairment and how the speaker and others respond to the fluency impairment, this can lead to varying degrees of disability (activity limitations and participation restrictions) in speech-based communication, as well as distressing emotions/feelings and thoughts, and selflimiting beliefs that negatively can affect one’s quality of life.

Summary The focus in this chapter was on the correlates of stuttering. As demonstrated, researchers have examined stuttering from many perspectives. As scientific inquiry of stuttering progresses, researchers begin to develop an increasingly clear and detailed picture of what stuttering is. Stuttering seems to be a disorder that is rooted in genetic factors. Some people have a greater predisposition to develop the disorder than others, as evidenced by the high familial incidence of stuttering in comparison to the general population. In current models, environmental factors are thought to play a role in determining whether one’s genetic predisposition to stutter will be expressed and, if so, how it will be expressed. A focus of current research is to identify chromosomes and, eventually, genes that are associated with stuttering. Work of this nature is underway, and it has led to some initial insights into chromosomes and genes that might be relevant to the disorder. After stuttering-related genes are reliably identified, the next step is to determine their relationship to speech-language development and speech production. It is possible that genetic factors are linked to certain neurodevelopmental differences in the speech production system that are key to stuttering. Preliminary evidence suggests that stuttered speech is associated with breakdowns in the development of white matter tracts — particularly those that connect brain regions that are involved in phonetic planning and the sensorimotor guidance of ongoing spoken utterances. An impairment of this sort might explain why speak-



7.  Stuttering:  Epidemiology, Development, and Etiology

Predisposition to develop stuttering, e.g., • Genetic factors (Genes, Gene Expression, Interactions with environment) • Sex (male, female) Altered neurodevelopment • Neuroanatomical differences (e.g., dysmyelination) • Neurophysiological differences (e.g., anomalous neural activation) Altered functioning in speech production system • Neuromotor (sensorimotor) system differences, e.g., • Excessive spatiotemporal variability in speech motor movements • Slowness in speech initiation • Neurolinguistic system differences, e.g., • Processing inefficiencies Speech fluency impairment

(Task demands)

Disability

• Disfluent speech • Atypical frequency, atypical type • Atypical duration, atypical rhythm • Atypical effort Personal factors, e.g.,

Participation restrictions

• Speaker’s thoughts, beliefs, emotions related to stuttering Environmental factors, e.g.,

Context

Activity limitations

• Listener responses to stuttering; Treatment availability; Societal views toward stuttering

Figure 7–4. The author’s multicomponent model of stuttering depicting factors associated with the predisposition to develop stuttering as well as etiological mechanisms, shown at both the biological level (e.g., neuroanatomy, neurophysiology) and the behavioral level (e.g., motor system coordination, language processing efficiency, speech disfluency characteristics). Impairment that affects the ability to speak fluently can be shaped by personal (e.g., reactions to and interpretations of fluency impairment) and environmental (e.g., listener behaviors) factors, and often, but not always, leads to communication disability (i.e., activity limitations and participation restrictions).

ers who stutter show patterns of anomalous (and, presumably, compensatory) neural activation in right hemisphere regions and why they have particular difficulty saying low-frequency words and

multisyllable words fluently. A deficit of this sort also might explain why many people who stutter experience more disfluency when engaged in dual-task activities, wherein they presumably

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must divert attention away from speech execution toward some other task. This impairment also might explain some of the motoric deficits that people who stutter exhibit, particularly those that relate to the speed of response initiation, stability in speech motor movements, and the ability to learn new motor patterns. Clearly, further research is needed to examine these possibilities. People who stutter also seem prone to deficits or disability in aspects of communication beyond speech fluency, as evidenced by findings related to syntactic, phonologic, and semantic processing. Surprisingly, language-related differences have been noted in people who stutter for both receptive and expressive language activities. In studies of school-based speech-language pathology caseloads, children who stutter are routinely found to present concomitant language and/or articulation difficulties. The association, if any, between these seemingly “peripheral” communication problems and the etiology and expression of stuttering is unclear at present. Beyond its impact on speech fluency, chronic stuttering can affect the attitudes, feelings, and beliefs that a speaker has toward communication and, more broadly, his or her overall identity. Several studies have reported evidence of elevated anxiety among people who stutter, particularly regarding speech-related tasks and social interactions. The consensus is that “negative” emotions like these are an emergent aspect of the disorder, although an individual’s temperament may render some people more prone than others to develop or experience them. Fortunately, speech-related anxiety seems amenable to change through professional treatment. Still, stuttering can have significant negative consequences on an individual’s quality of life; it can interfere with social interactions with friends, teachers, and employers. Indeed, research evidence suggests that the deleterious effects of stuttering can persist across the life span and influence the most basic activities of daily life, including when, how often, and how much one communicates, as well as the type of occupation that one chooses to pursue. Based on this review, it should be apparent that stuttering is much more than simply a case of a person being “nervous” or “tense” while com-

municating. There is a physical basis for stuttering; and as the physical nature of the disorder becomes better understood, it should lead to the development of increasingly effective treatments. In the meantime, it is important to remember that many people who stutter possess resources to learn strategies for coping with and compensating for fluency impairment in ways that substantially reduce stuttering-related disability. The latter topic is explored in the following chapters.

Questions to Consider 1. How do you think a teen or adult who stutters would react to learning that stuttering has a heritable component to it? Do you think this type of information would be upsetting to the individual, or would that person be relieved to learn it? 2. How do you suppose a teen or adult who stutters might react to learning that impairment or inefficiency in the speech motor control system is the source for many of the breaks in his or her speech continuity? Do you think this type of information would be upsetting to the individual, or would the individual be relieved to learn it? 3. What type of informational counseling do you think a speech-language pathologist should provide to the parent of a preschooler for whom recovery from childhood onset fluency disorder (stuttering) is still a possibility? 4. Laypeople sometimes have difficulty appreciating the magnitude of the communication difficulties that people who stutter experience. Try using pseudo-stuttering (i.e., simulated stuttering) in at least three consumer settings this week (e.g., restaurants, stores, utility companies). As you talk with the worker(s) at the sites, produce a mix of part-word repetitions and moderately tense sound prolongations or blocks. How did the workers react when they heard stuttering in your speech? How did you feel when producing stuttering in your speech? What insights did you develop about social anxiety disorder as a result of completing this activity?



5. Review information from consumer websites for organizations like the Stuttering Foundation, the National Stuttering Association, and Friends (the Association of Young People Who

7.  Stuttering:  Epidemiology, Development, and Etiology

Stutter). Based on what you find, to what extent do you think it is possible to be both a person who stutters and a person who has a positive quality of life?

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SECTION

III

Other Types of Fluency Disorders

8 Acquired Stuttering

Chapter Objectives After reading this chapter, readers will be able to: 1. Discuss the conditions that are most associated with acquired stuttering. 2. Discuss the primary subtypes of acquired stuttering. 3. Discuss how the fluency profiles of neurodevelopmental and acquired forms of stuttering differ. 4. Discuss how acquired stuttering impacts communicative functioning.

Introduction and Background The focus in this chapter is on acquired forms of stuttering. The fluency difficulties discussed in this chapter differ in several ways from those seen in the neurodevelopmental form of stuttering (childhood onset fluency disorder). Although acquired stuttering is less prevalent than neurodevelopmental stuttering, clinicians are likely to encounter cases with this type of fluency difficulty, particularly in health care practice settings that serve adults. The main purpose of this chapter is to present essential information about the characteristics and etiologies of

acquired stuttering and its impact on the communicative functioning and quality of life of affected individuals. Issues concerning the assessment and treatment of acquired stuttering are addressed in the treatment section of the book (Section IV). One main difference between the two types of stuttering concerns the conditions that are present at the time the symptoms of fluency difficulties appear in speech. Although both types of stuttering stem from impairment in the neural systems that support speech-language production, the impairment associated with neurodevelopment stuttering typically occurs in the context of system development and maturation, whereas the impairment associated with acquired stuttering typically occurs secondary to damage in an already matured and normally functioning speech-language production system. Thus, the speech disfluencies that characterize neurodevelopmental stuttering are viewed as a consequence of using an underdeveloped or abnormally developed neural system, whereas the speech disfluencies that characterize acquired stuttering are viewed as a consequence of using an injured or damaged neural system. From the perspective of parents and caregivers, the symptoms of neurodevelopmental stuttering seem to “come out of nowhere.” That is, usually there are not any obvious injuries, illnesses, or diseases that a parent or clinician can identify confidently as the precipitator of speech disfluency,

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nor is there typically any unequivocal evidence of environmental factors that have harmed the child’s fluency. However, with acquired stuttering, symptom onset occurs in individuals who, after having established a substantial history of producing typical fluency, experience onset of stutter-like symptoms that are closely linked in time or associated with some specific, precipitating event that affects functioning of the speech-language production system (e.g., traumatic brain injury, neurodegenerative disease, cerebrovascular accident).

Characteristics of Acquired Stuttering In the following sections, a range of studies that have examined acquired stuttering are reviewed. Reports of acquired forms of stuttering date back to the earliest days of speech-language pathology. Overall, however, the research literature on acquired stuttering is not as extensive as the literature on neurodevelopmental stuttering, particularly with respect to the number of group level studies that have been conducted. For example, Cruz, Amorim, Beça, & Nunes (2018) conducted a PubMed and Scopus search for the purpose of performing a systematic review of research studies published between 2000 and 2016 on stuttering subsequent to acquired neurologic dysfunction and identified a total of 33 qualifying papers. Many published articles are single-subject case reports, and the patterns of symptom presentation tend to be more heterogeneous in comparison to the research literature on neurodevelopmental stuttering. Still, most reports on acquired stuttering include extensive descriptions of the participants’ fluency and background medical information, as well as information about participant reactions to fluency impairment and changes in fluency performance and general functioning across speaking tasks and over time. In addition, the number of studies and pace of publication has grown steadily over the past 4 decades. As data on acquired stuttering accumulate, an increasingly detailed and accurate picture of acquired stuttering has begun to emerge.

Terminology and Subtypes Authors have used a wide range of terms to describe stuttered speech that results from nondevelopmental processes (De Nil, Jokel, & Rochon, 2007; Logan, 2018a). Many authors use the term acquired stuttering as a superordinate descriptor for any form of stuttering that occurs after establishment of a mature speech production system and, with it, a substantial history of typical speech fluency functioning. The previous edition of this book used the term nondevelopmental stuttering synonymously with acquired stuttering in contexts where it was helpful to provide a contrast with the childhood onset form of stuttering (i.e., neurodevelopmental stuttering). This edition of the book continues to use both terms. In the ICD-11 (World Health Organization, 2019), the term speech dysfluency is used to refer to the stutter-like symptoms and associated communicative impairment that develops outside of the development period. Another widely used term in this literature is neurogenic stuttering. This label mainly has been used to describe stuttering that is acquired in the context of neurological trauma/brain injury. One limitation with the term neurogenic stuttering is that the speech disfluency associated with neurodevelopmental stuttering is neurogenic as well; thus, it can be argued that the term is not sufficiently precise. Rosenbek (1984) made a similar point when he suggested that professionals who are interested in speech fluency should declare a moratorium on the use of the term neurogenic stuttering because it is not sufficiently contrastive with disfluency that occurs secondary to neurogenic communication disorders such as aphasia. In addition, the term pharmacogenic stuttering has been used for cases where stuttered speech develops in the context of drug use. Because pharmacological agents can affect neurotransmitter levels in the central nervous, this type of stuttering also fits under the broad heading of stuttering patterns that are associated with neurological functioning. De Nil et al. (2007) noted that (acquired) neurogenic stuttering has been contrasted with psychogenic stuttering in the fluency disorders literature, with the latter term usually referring to cases of adult-onset stuttering that occur in the absence



8.  Acquired Stuttering

of measurable neurological disfunction. De Nil et al. cautioned, however, that the occurrence of acquired stuttering in the absence of obvious neurological impairment does not necessarily mean that there is no neurological impairment. They supported this caution with a reference to a case study by Lebrun, Retif, and Kaiser (1983) wherein adult onset stuttering was the first symptom of what eventually was diagnosed as motor neuron disease. Another potential pitfall that comes with making a distinction between psychogenic and neurogenic stuttering is that it can leave the impression that psychological states and psychiatric disorders are somehow “not neurological” or that they lack a physical or biological basis. In summary, it is useful to operate from the premise that all disfluency — even that produced by healthy speakers — is, in some sense, neurogenic. Thus, use of the term has the potential to convey the incorrect impression about the nature of disfluency in other disorders. One potential solution to this problem is to use terms that clearly state the conditions under which stuttering has been acquired. The ICD has used this terminology approach in the past, for example, referencing fluency disorder (stuttering) following cerebrovascular disease or fluency disorder in conditions classified elsewhere.

Disfluency Characteristics In most published accounts of acquired stuttering, the authors attempt to compare the extent to which the speaker’s disfluency patterns are like those seen in cases of developmental stuttering. In some early reports (e.g., Canter, 1971), it was stated that the speech characteristics of speakers with acquired neurogenic forms of stuttering are markedly different from those observed in neurodevelopmental stuttering. In many subsequent reports, however, researchers have emphasized the many similarities between the two types of stuttering (De Nil et al., 2007; Helm, Butler, & Canter, 1980; Lebrun, Leleux, Rousseau, & Devreux, 1983; Rosenbek, Messert, Collins, & Wertz, 1978). In terms of the types of disfluency that are produced, it seems that the two forms of stuttering are similar. That is, as with neuro­

developmental stuttering, speakers with acquired forms of stuttering typically exhibit excessive production of part-word repetitions, sound prolongations, and “blocks” in speech continuity. Jokel, De Nil, and Sharpe (2007) conducted a detailed analysis of the frequency with which “less typical” (i.e., stutter-like) and “more typical” (i.e., non-stutter-like) disfluencies occurred in the speech of six adults with acquired stuttering following traumatic brain injury and six adults with acquired stuttering following stroke. They found a mix of both categories of disfluency for both speaker subtypes. With the stroke group, the proportion of the more typical disfluency types was somewhat greater than that for less typical disfluency types; however, with the traumatic brain injury group, the opposite pattern was observed: a greater proportion of less typical disfluency types. The relative proportion of both categories of disfluency varied across groups, depending on the nature of the speaking task. Also, the participants with traumatic brain injury had a greater frequency of total disfluency during conversation than participants with stroke did. In several case studies (Burch, Kiernan, & Demaerschalk, 2013; Tani & Sakai, 2010), however, some speakers with acquired stuttering appeared to produce only stutter-like disfluency. Thus, the presentation of disfluency types may vary across cases. Clinicians also should be mindful of the possibility of other types of fluency problems among patients with neurologic disease. For example, patients with various types of non-Alzheimer’s dementia may exhibit deficits on language-based tests of semantic and phonemic fluency (see, for a review, Reilly, Rodriguez, Lamy, & Neils-Strunjas, 2010). Relatively little is known about the extent to which listeners can differentiate the speech fluency patterns associated with developmental and acquired forms of stuttering. In one study (Van Borsel & Taillieu, 2001), researchers asked experienced speech-language pathologists to evaluate samples of speech that had been produced by adults with neurodevelopmental stuttering and adults with acquired stuttering. The clinicians were not easily able to differentiate the two types of speakers. The clinicians demonstrated 100% accuracy at categorizing the speech samples from only one of four

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speakers with acquired stuttering and only two of four speakers with neurodevelopmental stuttering. Although the clinicians’ judgments for most of the other speakers tended toward the correct diagnostic classification, the clinicians did not make clear, categorical distinctions between the two types of speech samples. Thus, it appears that the disfluency patterns associated with developmental and acquired forms of stuttering can sound quite similar. Still, there are many published reports in which the disfluency patterns of specific speakers with acquired forms of stuttering are markedly different from those of speakers with neurodevelopmental stuttering in terms of structure, frequency, or severity (e.g., Van Borsel, Van Lierde, Van Cauwenberge, Guldemont, & Van Orshoven, 1998). Recent reports of symptom presentation in cases of psychogenic stuttering are infrequent. In one review, the following characteristics were listed as “red flags” for functional (psychogenic) stuttering: (1) excessively consistent stuttering (e.g., stuttering on every syllable, sound, or word); (2) marked variability in stuttering frequency from day to day; (3) stress assignment errors; and (4) an absence of concomitant speech-language disorders such as dysarthria, aphasia, or apraxia of speech (Chung, Wettroth, Hallett, & Maurer, 2018). The extent to which these are unequivocal red flags is unclear as most of the aforementioned symptoms of acquired stuttering have been noted in case studies of individuals who have been diagnosed with frank neurological pathology. Mattingly (2015) described a case of a service member who presented with acquired stuttering, comorbid posttraumatic stress disorder, and mild traumatic brain injury (TBI) secondary to multiple exposures to explosive blasts. In this study, the speech-language pathologist attributed the stuttering to the effects of post-traumatic stress; however, given that several other studies have demonstrated relationships between TBI and acquired stuttering, one could argue that it is difficult to rule out effects related to neurological damage.

Epidemiological Data Epidemiological data for acquired stuttering are limited. Data on its occurrence in males versus

females, at various points of the life span, and in conjunction with specific types of neuropathology are discussed here.

Male-to-Female Ratio Acquired stuttering is more likely to occur in males than in females. Overall, the male-to-female ratio for acquired stuttering appears to be like that for neurodevelopmental stuttering. Survey data from speech-language pathologists have yielded maleto-female ratios that range from 2.23:1 to 3.76:1 (Market, Montague, Buffalo, & Drummond, 1990; Theys, van Wierignen, & De Nil, 2008). Market et al. (1990) suggested that males may be more susceptible to acquired stuttering than females because they are more likely to engage in the types of behavior that can cause brain injury. Theys et al. (2008) reported that the maleto-female ratio for acquired stuttering varies with the associated neuropathology. They reported that males were far more likely than females to acquire stuttering in conjunction with both traumatic brain injury (ratio = 10:1) and neurodegenerative disease (ratio = 8:1); however, the male-to-female ratio for acquired stuttering following stroke was much smaller (ratio = 1.9:1). In contrast, females were more likely than males to acquire stuttering in association with conditions such as epilepsy, encephalitis, and use of medication (ratio = 2:1). The sample sizes for all but the stroke subgroup ranged from 9 to 11 participants; thus, these ratios would likely differ with larger sample sizes.

Age Characteristics On average, acquired stuttering appears to occur in middle-aged and older adults much more often than it does in children, teens, and young adults. Market et al. (1990) reported a mean age of 43.7 years (median = 43 years; range = 36 to 93 years) for their sample of 81 adults. In contrast, Theys et al. (2008) reported a mean age of 69 years (range = 16 to 86 years) for their sample of 58 adults with acquired neurogenic stuttering. That said, there are several published reports of children who have acquired stuttering following neurological injury (e.g., Aram, Meyers, Ekelman, 1990; Meyers et al., 1990). The distributional patterns of acquired stut-



tering across the life span are undoubtedly influenced by the fact that older adults have a greater risk than young adults to experience the kinds of neurological events (e.g., stroke, neurodegenerative disease) that precipitate acquired stuttering. Theys et al. (2008) reported the mean ages for various participant subgroups based on survey data from 58 adults with acquired stuttering. The mean age of people with stroke-related acquired stuttering was 69 years; and for acquired stuttering following neurodegenerative disease, the mean age was 72 years. In contrast, the mean age for people with stuttering following traumatic brain injury was 46 years. The age characteristics of the traumatic brain injury group are most likely a reflection of the fact that younger people typically are more active than older people and thus more likely to be in situations where traumatic brain injury (and, with it, acquired stuttering) can result.

Incidence, Prevalence, and Relationship to Comorbidities Relatively little is known about the extent to which individuals with brain injury or neurodegenerative diseases are at risk for acquiring stuttering. In one report (i.e., Theys, van Wieringen, Sunaert, Thijs, & De Nil, 2011), researchers tracked 319 adult stroke patients to see how many of them subsequently began to stutter. Of the total, 5.3% met criteria for a diagnosis of (acquired) neurogenic stuttering during the study, and 2.3% of the total exhibited symptoms of stuttering for at least 6 months. Thus, it appears that approximately 43% (i.e., (2.3/5.3) × 100) of the cases eventually exhibited persistent forms of acquired stuttering. Individuals who developed aphasia following stroke were at a greater risk for acquiring stuttering than individuals who did not develop aphasia. In contrast, neither dysarthria nor cognitive impairment following stroke was associated with an increased risk for acquiring stuttering. Theys et al. (2011) cited data indicating that 17% to 35% of people who experience stroke will develop aphasia. Thus, overall, it seems that the acquisition of stuttered speech following stroke is not a common outcome. Based on results from their large-scale survey of clinicians’ experiences with acquired stuttering, Theys et al. (2008) estimated that about 27% of the clinicians they had

8.  Acquired Stuttering

contacted about the study had provided clinical services to at least one patient with acquired stuttering during the 5 years preceding the study. Although the presence of aphasia may increase the risk for acquiring stuttering, it is not uncommon for acquired stuttering to occur in the absence of other communication or cognitive disorders (Ardila & Lopez, 1986; Bhatnagar & Andy, 1989; Lebrun et al., 1983; Ludlow, Rosenberg, Salazar, Grafman, & Smutok, 1987). Ludlow et al. (1987) found that the severity of brain-injured patients’ aphasia was not useful in predicting the stuttering severity. In addition, Meyers et al. (1990) found that speech disfluencies did not parallel the course of word-finding difficulties in a 7-year-old boy with a history of stroke, and the researchers concluded that the two disorders were independent. Theys et al. (2008) did, however, report a significant positive correlation between the number of concomitant disorders a person had and the frequency with which he or she stuttered. Thus, the additive effects of concomitant disorders may be an important factor to consider in clinical settings. In a recent retrospective study of more than 309,000 U.S. military veterans who were deployed in Iraq or Afghanistan, Norman and colleagues (Norman, Jaramillo, Eapen, Amuan, & Pugh, 2018) examined the roles of traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and prescribed medications to determine the chances of being diagnosed with acquired stuttering. Overall, 235 individuals (0.8% of the total sample) had a diagnosis of acquired stuttering. Among those with acquired stuttering, 6% had only TBI as a diagnosis, 31% had only post-traumatic stress disorder (PTSD) as a diagnosis, 43% had concomitant diagnoses of TBI and PTSD, and 20% had neither TBI nor PTSD as a diagnosis. Those who had a diagnosis of TBI and/or PTSD were more likely to have been diagnosed with acquired stuttering than those without a history of either TBI or PTSD, and individuals with only a PTSD diagnosis had a lower chance of being diagnosed with acquired stuttering than individuals with a concomitant diagnosis of TBI and PTSD. There was no difference between individuals who were diagnosed with only TBI versus only PTSD in their chances for being diagnosed with acquired stuttering. In addition, 66% of individuals who were diagnosed with acquired stuttering

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also had been prescribed medications that, in previous research, had been shown to affect speech production. One final consideration is that some participants in studies of acquired stuttering have had histories of recovery from childhood onset fluency disorder. In such cases, it is unclear whether the stuttering that appears during adulthood represents a resurgence of the person’s childhood stuttering or, instead, is an independent occurrence. In many cases, the speech behaviors of the adult stuttering are unlike those that the person exhibited during childhood, which suggests that the fluency problems are unrelated (Theys et al., 2008). Further research is needed to examine this issue.

Types of Neuropathology Associated With Acquired Stuttering Several researchers have reported data on when the onset of acquired stuttering occurred in relation to the time of neurological insult. Market et al. (1990) reported results from a survey of 81 people with acquired stuttering. In 81% of the cases, stuttering onset began within 1 month of the neurological event; and in 93% of the cases, stuttering onset began within 3 months. Theys et al. (2008) reported that 69% of their 58 study participants began to stutter within 1 week of experiencing a stroke; and in 73% of those cases, the onset was sudden. In some reports, onset of stuttering occurred within the context of recovery from a coma (e.g., Abe, Yokoyama, & Yorifuji, 1993; Van Borsel et al., 1998), and in others, recovery from stroke (Ardila & Lopez, 1986; Grant, Biousse, Cook, & Newman, 1999; Meyers et al., 1990). Acquired stuttering has been observed in conjunction with an assortment of neurologic conditions, including the following: • Left hemisphere lesions following stroke or head trauma (Grant et al.,1999; Osawa, Maeshima, & Yoshimora, 2006; Rosenbek et al., 1978; Turget, Utku, & Balci, 2002; Van Borsel et al., 1998) and brain abscess (Sudo, Dutake, Yokata,, & Wantanabe, 2018); • Right hemisphere lesions following stroke or head trauma (e.g., Ardila & Lopez, 1986; Balasubramanian, Max, Van Borsel, Rayca, &

Richarson, 2003; Burch et al., 2013; Lebrun & Leleux, 1985; Rosenbek et al., 1978); • Diffuse cortical damage following stroke or traumatic brain injury (e.g., Aram et al., 1990; Ludlow et al., 1987; Mattingly, 2015; Penttilä, Korpijaakko-Huuhka, & Kent, 2019; Rosenbek et al., 1978); • Lesions that impact white matter tracts at cortical and subcortical levels (e.g., Burch et al., 2013; Ludlow et al., 1987); • Inflammatory demyelination of the corpus callosum associated with multiple sclerosis (Decker, Guitar, & Solomon, 2018); • Basal ganglia, thalamus, and brain-stem lesions (Abe et al., 1993; Balasubramanian et al., 2003; Bhatnagar & Andy, 1989; Tani & Sakai, 2010); • Cerebellar lesions (Ludlow et al., 1987; Theys, van Wieringen, Tuyls, & De Nil, 2009); and • Neurodegenerative disease (Lebrun et al., 1983; Louis, Winfield, Fahn, & Ford, 2001; Silbergleit, Feit, & Silbergleit, 2009); • Aseptic meningitis in conjunction with West Nile virus (Mickail, Klein, & Cunha, 2011) and immune-mediated encephalitis (Dinoto et al., 2018); and • Multiple system atrophy associated with Parkinson’s disease (Kikuchi et al., 2018). As shown in the preceding list, acquired stuttering has been linked to neurological damage in the left and right hemispheres, assorted white matter tracts, the cerebellum, basal ganglia, thalamus, and various brain-stem regions. Given the possibility that only the most severe or unusual cases are submitted for publication, the case reports do not necessarily provide an exhaustive list of the types of neuropathology that lead to acquired stuttering, nor do they indicate the extent to which any particular neurological condition is associated with acquired stuttering or the types of fluency problems that speakers with acquired stuttering will present. Survey studies offer a potential solution to this problem. With a survey study, researchers potentially can compile information about many cases of acquired stuttering and subsequently obtain a more accurate sense of the characteristics of the clinical population. In this chapter, results are



8.  Acquired Stuttering

reviewed from two survey studies dealing with neurologically based forms of acquired stuttering. Market et al. (1990) contacted more than 100 speech-language pathologists in the United States, which resulted in data for 81 cases of acquired stuttering. Later, Theys et al. (2008) contacted more than 200 clinical sites in northern Belgium, which resulted in data for 58 adults who had acquired stuttering in the context of neurological injury or disease. In both surveys, the researchers inquired about the medical histories, speech-language characteristics, social and emotional characteristics, and treatment experiences of the individuals who stuttered. A comparison of findings from the two studies regarding the suspected etiologies for the acquired stuttering is presented in Figure 8–1. As shown, in both studies, acquired forms of stuttered speech were most associated with either stroke or traumatic brain injury. Although the proportion of stuttering cases associated with the two conditions differed between the two studies together, these conditions were much more likely to be associated with acquired stuttering than other neurological events were. The relatively wide range of neuropathology associated with acquired stuttering shows that the

Unknown 6%

Emotional 3%

disorder cannot be readily localized to any one region of the central nervous system. For instance, in studies that have documented left hemisphere lesions in conjunction with acquired stuttering, lesion sites have included the temporal lobe, the parietal lobe, the inferior frontal lobe, and the supplementary motor area (Grant et al., 1999; Osawa et al., 2006; Rosenbek et al., 1978; Turget et al., 2002; Van Borsel et al., 1998). Grant et al. (1999) reported on a case of acquired stuttering in conjunction with a left occipital lobe infarction and concomitant right homonymous hemianopia. In this case, the role of the infarction in stuttered speech is unclear, as the occipital lobe typically is not implicated in speech fluency impairments. Theys et al.’s (2008) survey revealed that, among 29 adults who began to stutter following stroke, 17 had left hemisphere lesions, five had right hemisphere lesions, and five had bilateral cortical lesions (data were not available for the remaining two individuals). Among 11 adults who began to stutter following traumatic brain injury, four (36% of the total) had bilateral cortical lesions, and two had no detectable lesions. The findings from research on normal speakers and speakers with acquired forms of stuttering have suggested

Percent of Cases

Percent of Cases

Drug 6%

Neurodegenerative disease 15%

TBI 38%

Other 10%

Other 16%

TBI 19%

Stroke 37%

A

Stroke 50%

Market et al. (1990)

B

Theys et al. (2008)

Figure 8–1.  A comparison of frequency-of-occurrence data from two survey studies that examined suspected etiologies associated with the onset of acquired neurogenic stuttering in adults. Findings from Market et al. (1990) (A) and Theys et al. (2008) (B) suggest that most cases of acquired stuttering occur in the context of stroke or traumatic brain injury. A range of other neurological events are associated with the remaining cases.

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that many neural areas are critical to the attainment of fluent speech. Speech production, even during seemingly simple tasks like producing single syllables, entails an extensive network of neural activation (Ghosh, Tourville, & Guenther, 2008). To the extent that this is true, speech fluency then can be conceived of as an index of the overall functioning of this neural network. As noted, the brain injuries that follow stoke and head trauma often are diffuse, and this complicates researchers’ attempts to identify specific nervous system regions that are critical to the occurrence of stuttered speech. The study of relatively focal lesions, therefore, is a potentially fruitful approach for gaining insight into the neural basis for stuttered speech. Ludlow et al. (1987) conducted a study in which they examined 10 adults who had received relatively discrete penetrating missile wounds during the Vietnam War. Each of the participants exhibited acquired stuttering and concomitant rate disturbance, which was characterized occasional bursts of rapidly-produced speech that comprised speech unintelligible The participants’ speech continuity was characterized by frequent repetitions and prolongations and lengthy, effortless pauses. Statistical analysis of neuroimaging data showed that the participants who stuttered differed from both a fluent control group and a group of speakers who had a history of head-injury, but no stuttering, on the extent of lesion involvement in the internal and external capsules, inferior frontal lobe white matter tracts, and the caudate and lentiform nuclei. Most of the participants with acquired stuttering had unilateral lesions that affected one or more of these areas. In five cases, the lesions were right lateralized; in four cases, they were left lateralized; and in one case, they were bilateral. Interestingly, the group with acquired stuttering and the group with head injury but no stuttering showed no differences in the frequency of presenting lesions in Broca’s area, the supplementary motor area, or the primary motor area — each of which has been linked to neurodevelopmental stuttering in other research. Based on their findings, Ludlow et al. suggested that the motor system plays an important role in a speaker’s ability to attain and maintain normal levels of speech fluency.

Pharmacogenic Stuttering Several authors have documented acquired forms of stuttering that result from the use of pharmacological agents. This has led to the use of terms such as pharmacogenic stuttering and drug-induced stuttering. McClean and McLean (1985) reported on a case of adult-onset stuttering in association with a drug-based treatment for seizures that occurred following a head injury. The patient’s seizures developed about 3 months post injury, at which point the drug phenytoin was introduced to manage the seizures. At the initial speech evaluation, which took place several months after the introduction of phenytoin, the patient exhibited frequent disfluencies (about 20 to 30 per 100 syllables), most of which consisted of part-word repetitions. At this time, the patient showed symptoms of phenytoin toxicity, and, consequently, he gradually was shifted to an alternate anti-seizure medication, carbamazepine. McClean and McLean monitored the patient’s speech fluency across roughly a 1-month period during which the change in medications occurred. During this time, the patient’s fluency improved markedly, as shown by a decrease in stuttering frequency from about 25% syllables stuttered while taking phenytoin to about 12% syllables stuttered while taking carbamazepine. Use of carbamazepine, however, was associated with an increase in the proportion of sound prolongation in the patient’s overall disfluency profile. Similarly, Makela, Sullivan, and Taylor (1994) reported a case of stuttering onset in an adult upon introduction of sertraline to treat work-related anxiety. The patient’s stutter-like speech featured excessive silent blocks in speech, each of which lasted from 1 to 3 seconds. The patient’s disfluent speech pattern resolved completely within 2 days after use of sertraline was discontinued. Case reports like this suggest a link between emotions, neurotransmitters, and speech fluency.

Disfluency Profiles It is reasonable to consider whether the behavioral symptoms of acquired stuttering might differ according to the nature of the underlying neu-



ropathology. Many of the published reports on acquired stuttering have examined this issue, and results from several such studies are summarized in Table 8–1.

Disfluency Frequency and Type As shown in Table 8–1, stuttering frequency varies widely across study participants. In some studies, adults with acquired stuttering exhibited stuttering frequency scores that are consistent with mild severity in cases of neurodevelopmental stuttering. Sometimes, the fluency deviations are even subtler. For example, in a study of children with localization-related epilepsy (Steinberg, Bernstein Ratner, Gaillard, & Berl, 2013), the children with epilepsy displayed a higher overall frequency of disfluency and a higher proportion of sound prolongations than the typically fluent children did. The mean frequencies of total disfluency for both groups were not exceptionally high (epilepsy group: 6.0 per 100 words; control group: 4.6 per 100 words) but still of statistical significance. The difference between the groups in the frequency of stutter-like disfluency approached statistical significance as well. In other studies, participants have exhibited frequency scores that correspond with profound impairment. The patient in the study by Van Borsel et al. (1998) reportedly produced stutter-like repetitions on 100% of the syllables during all speaking tasks except reading. The participant in the study by Abe et al. (1993) also had high stuttering frequency scores during both conversational discourse (>50% syllables stuttered) and picture naming (>25% syllables stuttered). Theys et al. (2008) reported considerable inter-subject variability across the 58 participants in their study. For participants with a history of stroke and traumatic brain injury, stuttering frequency ranged from 3% to 50% of syllables; and for participants with a history of neurodegenerative disease, the stuttering frequency extended beyond 50% of syllables. Repetitions of sounds, syllables, and parts of words seem to be the predominate type of disfluency noted in many of the studies of acquired stuttering. This is true of the studies outlined in Table 8–1 and also of a host of other studies (e.g., Grant et al., 1999; Lebrun et al., 1983; Meyers et al.,

8.  Acquired Stuttering

1990; Osawa et al., 2006; Silbergleit et al., 2009). Because repetitions are observed in cases with widely varying areas of neurological impairment, they do not appear to arise from a specific lesion type or location. Atypical types of repetitions have been reported as well. For example, Kikuchi et al. (2018) reported the presence of both traditional stutter-like disfluencies and palilalia-like disfluency (i.e., repetition of utterance final words) in a 72-year-old man with multiple-system atrophy secondary to Parkinson’s disease. Penttila et al. (2019) examined clustering of speech disfluency in 20 adults with traumatic brain injury (10 with neurogenic stuttering and 10 without neurogenic stuttering), and the two groups produced the same number and average length of disfluency cluster, although individual disfluencies in the nonstuttering group were the longest in the study (e.g., one participant produced a cluster that contained 14 descriptive units. Speakers with acquired stuttering seem to produce sound prolongations less often than partword repetitions (Aram et al., 1990; Ardila & Lopez, 1986; McClean & McLean, 1985; Meyers et al., 1990; Theys et al., 2008). In some reports (Cipolotti, Bisiacchi, Denes, & Gallo, 1988; Marshall & Neuburger, 1987), prolongations were not observed at all. Aram et al. (1990) compared the fluency characteristics of 20 children with unilateral left hemisphere lesions and 13 children with unilateral right hemisphere lesions and found that both groups of children produced more total disfluency and more sound prolongations than normally fluent controls. Children with left hemisphere lesions exhibited more effortful speech production as well. Further research into the types of disfluency that accompany specific patterns of brain injury or dysfunction is needed before any firm conclusions can be drawn regarding the effect, if any, of lesion site on disfluency profiles. It is interesting to consider whether the structural form of a disfluency correlates with certain types of neuropathology. In cases of acquired stuttering, the production of stutter-like disfluency appears to be independent of interjection and revision production (i.e., the disfluency types that typical speakers produce most often). Meyers et al. (1990) reported on a 7-year-old boy who began to stutter following

219

220 Pons, orbital surface of RH frontal lobe.

Adult male

Balasubramanian et al. (2003)

1 w/ none, 3 w/ aphasia, 1 w/ aphasia + apraxia, 1 w/ language disorder & dysarthria, 1 w/ suspected language & intellectual impairment. Normal language functioning; severe loss of verbal automatisms (songs, poems); dress apraxia, déjà vu phenomena, depersonalization, episodic amnesia.

Part-word repetition most common for 6/7 cases; 6/7 cases exhibit prolongations. Sound and syllable repetition most common, word repetition noted but less frequent; repetition in all word positions.

8% to 70% of words stuttering; mostly word initial, but 6/7 stutter on noninitial syllables.

Part-word repetitions, prolongations (ratio not reported).

History of childhood stuttering with subsequent recovery for several decades.

Mild comprehension deficits for abstract content and in reading; mild word finding difficulty; stuttering onset occurred about 2 months post stroke. Mainly sound or partword repetitions, occasional prolongations. No other disfluency types.

100% syllables stuttered in all tasks except reading, where 70% to 82% of syllables were stuttered; disfluency impairs speech intelligibility. ~5% syllables stuttered in solo and unison reading; ~6% to 8% under AAF.

Mild disorientation, memory impairment (recent memory, visual memory).

Syllable repetition (no word or phrase repetition).

58% of syllables stuttered in spontaneous speech, 28% in naming, 9% in reading, 5% in sentence repetition.

Stuttering increased as a function of task demands (e.g., 37% of words during counting, 52% of words in conversation).

Concomitant Problems

Types

Frequency/Distribution

Note.  RH = right hemisphere, LH = left hemisphere, SMA = supplementary motor area, AAF = altered auditory feedback, w/ = with.

Stroke affecting LH SMA, subarachnoid bleeding above corpus callosum, in coma for ~3 days.

Adult male

Infarcts in the paramedian thalami and midbrain; 3 months post coma.

Right temporal lobe infarct following stroke.

Van Borsel et al. (1998)

Adult male

Ardila & Lopez (1986)

5 w/ LH stroke, 1 w/ RH stroke, 1 w/ diffuse stroke.

Adult male

7 adult males

Rosenbek et al. (1978)

Neuropathology

Abe et al. (1993)

Participant(s)

Study

Stuttered Disfluency

Table 8–1.  Neurological, Speech Fluency, and Concomitant Disorder Characteristics of Adults With Acquired Stuttering



a cerebrovascular accident that affected a diffuse region of the left hemisphere along with portions of the putamen, caudate nucleus, globus pallidus, and internal capsule. Meyers et al. had access to recorded samples of the boy’s speech prior to the brain injury and thus could compare pre– and postmorbid frequencies for various disfluency types. They found that the frequency of the boy’s stutterlike disfluencies increased dramatically following the stroke; however, the frequency of interjections and revisions remained almost constant. This pattern is consistent with data from several other studies reviewed in this chapter in which data for interjections and revisions are reported. In several studies, those disfluency types constitute a minority of all disfluencies that the speakers produced and, in some cases, interjections and revisions were not produced at all. Of course, not all cases follow this pattern. For example, Marshall and Neuburger (1987) reported on a person with acquired stuttering following traumatic brain injury. The participant presented frequent whole-word and phrase repetitions, as well as prominent interjections and repetitions of sounds and syllables. As noted earlier, Jokel et al. (2007) reported frequent production of non-stutter-like disfluency such as revision and interjection in adults who acquired stuttering subsequent to stroke or traumatic brain injury.

Disfluency Location Helm-Estabrooks (1986) reviewed several studies that were published between the 1960s and early 1980s and concluded that speakers with acquired stuttering “always” produced stutter-like disfluency in conjunction with word-initial phonemes, and “often” produced stutter-like disfluency in conjunction with word-medial phonemes. This pattern of disfluency is consistent with the results from the studies that are summarized in Table 8–1, as well as with findings from survey studies that included data from scores of speakers with acquired forms of stuttering (i.e., Market et al., 1990; Theys et al., 2008). Canter (1971) suggested that speakers with acquired forms of stuttering are prone to wordfinal stuttering (e.g., pavement t- t- t), a behavior that is not characteristic of neurodevelopmental stuttering. This claim has not been strongly supported by findings from subsequent research, how-

8.  Acquired Stuttering

ever. For example, Rosenbek et al. (1978) studied seven patients with acquired stuttering secondary to brain injury and found that none of them exhibited repetitions of word-final syllables or sounds. Although several authors who reported detailed summaries of disfluency types apparently have not observed this disfluency type (e.g., Aram et al., 1990; Helm-Estabrooks, 1986; Ludlow et al., 1987), Theys et al. (2008) reported that 5 of 58 (9% of the total) participants with acquired neurogenic stuttering produced stuttering-related disfluency in conjunction with final sounds. In that study, final sound disfluency was noted in 2 of 29 (7% of the total) participants with a history of stroke, 1 of 9 (11% of the total) participants with degenerative neurological disease, and 2 of 11 (18% of the total) participants with traumatic brain injury. Three other studies included in the present review mentioned instances of word-final repetition. Two of these cases had histories of stuttering onset following right temporal lobe stroke (Ardila & Lopez, 1986; Helm-Estabrooks, Yeo, Geschwind, Freedman, & Weinstein, 1986). Of course, the participants in these studies exhibited repetition in the word-initial and word-medial positions as well. Van Borsel et al. (1998) reported a single instance of final sound repetition in a case of very severe stuttering after left supplementary motor area damage. That participant produced sound repetition in conjunction with 100% of the syllables spoken during all tasks except reading. Despite this extraordinarily high occurrence of stutter-like disfluency, virtually all of the participant’s disfluencies involved difficulty in moving from the onset to the rime of a syllable, rather than perseverative production of the coda consonant. Another variable that has been studied often is the grammatical class of stuttered words. Researchers accomplish this by comparing the proportion of function words (e.g., prepositions, articles) and content words (e.g., nouns, verbs) that feature stutter-like disfluency. Study results consistently indicate that speakers with acquired forms of stuttering exhibit stutter-like disfluency on both word classes (Market et al., 1990; Theys et al., 2008), and stuttered speech occurs in conjunction with a variety of speech sounds (Theys et al., 2008). Overall, however, most stuttered speech can be expected to occur in conjunction with content words (Jokel et al., 2007).

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Variations in Disfluency Frequency Across Speaking Tasks Speakers with neurodevelopmental stuttering often exhibit variation in disfluency frequency across speaking tasks. The main pattern is that tasks with relatively high language formulation demands (e.g., conversation, narration) usually feature more disfluency than tasks such as oral reading, sentence repetition, counting, and alphabet recitation, wherein the content is fixed or predetermined. Several researchers have examined variations in disfluency frequency across tasks with speakers who have acquired stuttering following neurological injury. In Helm-Estabrooks’s (1986) review of studies, she found that speakers who began to stutter following stroke, head trauma, and extrapyramidal disease “always” exhibited disfluencies in conversational speech and “usually” exhibited stuttering during tasks such as sentence repetition and rote or automatic speech. Ludlow et al. (1987) studied 10 individuals with chronic acquired stuttering and found that stuttering frequency was greatest during conversational speech. In a case study of stuttering following a right hemisphere stroke, Ardila and Lopez (1986) reported that disfluency increased as a function of the formulation requirements associated with the task. For example, the participant in that study stuttered on 32% of the words during recitation, 37% of the words during counting, 42% of the words during reading, 44% of the words during sentence repetition, 46% of the words during picture description, and 52% of the words during conversation.

Rate Characteristics Relatively few studies have reported rate data for speakers with acquired forms of stuttering, and when rate information is provided, it usually has consisted of subjective verbal descriptions. Meyers et al. (1990) reported numerical data in their case study of a child with acquired stuttering following a left hemisphere stroke. A comparison of the child’s pre- and post-morbid speech rates showed that his articulation rate had increased from 3.17 syllables per second to 4.37 syllables. Interestingly, the time

period when the child stuttered most was marked by increases in his use of syntactically complex utterances and a gradually increasing speech rate. Ardila and Lopez (1986) reported findings similar to those of Meyers et al. (1990) for a patient with acquired stuttering following a right hemisphere stroke. As the man recovered from the stroke, he began to produce longer and more complex sentences, and he began to speak at a progressively faster rate. His speech became increasingly disfluent at this time. Ardila and Lopez introduced a metronome to help the subject use a slower speech rate, but this approach was unsuccessful. As is the case with typical speakers and speakers with neurodevelopmental stuttering, speaking rate does not have a fixed affect on fluency. For instance, Aram et al. (1990) reported that children with unilateral left hemisphere lesions used a slower speech rate than both children with right hemisphere lesions and normally fluent children in a control group, yet both of the groups with brain injury were comparably disfluent. In one report (Dinoto et al., 2018), stutter-like speech, accompanied by slowing of speech and general motor movements, evidence of language and cognitive impairment, and electroencephalography abnormalities in the frontal cortex and sensorimotor networks, was reported in a 71-yearold male during the acute and post-acute phases of immune-mediated encephalitis. The symptoms eventually resolved following corticosteroid methylprednisolone.

Facilitative Contexts and Response to Treatment Typical speakers and speakers with neurodevelopmental stuttering have been observed to adapt (i.e., produce increasingly fewer disfluencies) when asked to say the same material repeatedly (Bloodstein & Bernstein Ratner, 2008). In addition, certain conditions (e.g., choral reading, rhythmic speech, singing, whispering, delayed auditory feedback) usually result in complete or near complete elimination of stuttering-related disfluency in cases of neurodevelopmental stuttering (Andrews et al., 1983). Although some individuals with acquired



stuttering do show favorable responses during adaptation tasks, research data suggest that speakers with acquired forms of stuttering are less likely than speakers with neurodevelopmental stuttering to show fluency improvement in this condition. For instance, Market et al. (1990) found that 35 of 76 participants (46.1% of the total) in their survey did not show significant fluency improvement under the adaptation paradigm; and Theys et al. (2008) reported a percentage that was even greater (55% of the total). It also is important to note that in these studies, some participants are unable to attempt adaptation tasks due to concomitant impairments. Failure to realize the adaptation effect has been noted in conjunction with several types of neuropathology, including stroke and brain-stem infarction (Ardila & Lopez, 1986; Balasubramanian et al., 2003; Bhatnagar and Andy, 1989; Jokel et al., 2007; Theys et al., 2008). Other conditions that are highly effective at enhancing fluency in individuals with neurodevelopmental stuttering also seem less likely to yield comparable improvements on a consistent basis in speakers with acquired stuttering. McClean and McLean reported dramatic reduction of disfluencies in one person with acquired stuttering (from approximately 30% of words stuttered to 5% of words stuttered) during choral reading and delayed auditory feedback conditions. Facilitative effects have been reported in some individuals with acquired stuttering during singing and serial speech as well (Rousey, Arjunan, & Rousey, 1986). However, Ardila and Lopez (1986) reported severe stuttering across all contexts for a patient with a history of right hemisphere stroke in the following tasks: singing, choral reading, and metronomepaced speech. Similarly, Balasubramanian et al. (2003) reported a lack of fluency adaptation during choral reading, delayed auditory feedback, and frequency-altered feedback in an adult with lesions of the right hemisphere and the pons. Thus, overall, speakers with acquired forms of stuttering are less likely than speakers with neurodevelopmental stuttering to benefit from repeated speaking practice and access to choral speech models (Balasubramanian et al., 2003; Market et al., 1990; Tani & Sakai, 2011; Theys, et al., 2008; Turget, Utku, & Balci, 2002).

8.  Acquired Stuttering

Associated Behaviors and Emotional Reactions Associated Behaviors In neurodevelopmental stuttering, stuttering-related disfluency sometimes is accompanied by a variety of accompanying behaviors such as eye blinking, facial and limb movements, abrupt pitch changes, physical tension in the speech musculature, and disrupted speech-breathing patterns (Bloodstein & Bernstein Ratner, 2008). These behaviors typically indicate that the speaker is aware of and reacting to his or her fluency difficulties. Researchers have examined the extent to which associated behaviors are present in the speech of speakers with acquired forms of stuttering. There has been speculation that speakers with acquired forms of stuttering are less likely to exhibit secondary behaviors than speakers with neurodevelopmental stuttering. Some case reports support this idea. For example, Bhatnagar and Andy (1989) reported the absence of associated behaviors in a patient with brainstem dysfunction, and Ludlow et al. (1987) described several of their participants’ stuttering-related disfluencies as “effortless.” However, group data suggest that associated behaviors are relatively commonplace among people with acquired stuttering. Market et al.’s (1990) survey results indicated that 31.6% of individuals with acquired stuttering displayed associated behaviors with some regularity, while Theys et al. (2008) reported that 55% of participants did so. In a study of 12 adults with acquired stuttering, Jokel et al. (2007) concluded that the participants did not always seem aware that they produced associated behaviors, but the majority of them clearly exhibited them. When associated behaviors do occur, they seem to resemble the behaviors that occur in neurodevelopmental stuttering (Ludlow et al., 1987). Examples of such behaviors include foot tapping as a strategy for timing speech initiation and the use of stereotypical interjections and phrases to start speech. Marshall and Neuburger (1987) reported muscle fixations, irregular breathing, and loss of eye contact that accompanied the disfluencies

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Fluency Disorders

of an adult with acquired stuttering. Ardila and Lopez (1986) observed that part-word repetitions in an adult with acquired stuttering sometimes were accompanied by visible muscle tension in the speech articulators that resulted in blockage of speech.

Emotional Reactions Another focus in research involves participants’ emotional reactions to acquired stuttering. In Market et al.’s (1990) survey, 67.1% of the participants with acquired stuttering were characterized as “annoyed but not anxious” about their speech. Other patients have been described as “discontent but not anxious” (Ardila & Lopez, 1986) and as “stuttering easily” with “little overt anxiety” but yet expressing “concern” about speech (McClean & McLean, 1985). Ludlow et al. (1987) characterized 10 adults with chronic-acquired stuttering as “annoyed” and “surprised” by their disfluent speech and as making little effort to change speech because, as one patient expressed, “it’s a problem that we can’t control.” Ludlow et al. used a behavior rating scale to compare patients’ affective expression with that of patients with brain injury who did not stutter and speakers with typical fluency and found no differences among the groups. In other studies, participants have had stronger reactions than those described to their stuttered speech. Patients have been reported as being “quite anxious” (Rosenbek et al., 1978) and as displaying “a great deal of fear and avoidance of speaking situations” (Rousey et al., 1986). In a few of the cases reviewed in this chapter, the onset of stuttered speech happened in conjunction with stressful life events that occurred in the weeks and months after the neurological event. For example, Nowack and Stone (1987) reported a case of acquired stuttering wherein the symptoms markedly worsened during a period of great family stress and then markedly decreased following resolution of the family stress. Jokel et al. (2007) administered a communication attitudes scale to adults with acquired stuttering and found that the responses were like those seen in speakers with neurodevelopmental stuttering. Whether a person reacts to acquired stuttering may depend on the type of neurological event. Theys et al. (2008) reported that about 80% of

individuals with a history of traumatic brain injury showed emotional reactions to their stuttered speech versus about 60% of individuals with a history of stroke and 33% of individuals with neurodegenerative disease. In light of such findings, clinicians should be mindful of the fact that, in some cases, a person’s feelings and emotions about acquired stuttering can contribute as much to his or her communication disability as the stutter-like interruptions in speech do (De Nil et al., 2007).

Summary Based on this review of the literature, it appears that the disfluency patterns associated with acquired stuttering are similar in several respects to those associated with neurodevelopmental stuttering. Some of the characteristics that the two disorders share include the following: (1) Part-word repetitions, prolongations, and blocks tend to be the predominate type of disfluency produced; (2)  these stutter-like disfluencies are most commonly associated with word-initial syllables but are sometimes produced in conjunction with word-medial syllables; (3) the stutter-like disfluencies are not constrained by phoneme class; and (4) the stutterlike disfluencies generally are most frequent during speaking contexts that require relatively high language formulation demands (e.g., conversation, narration). For both developmental and acquired types of stuttering, the stutter-like disfluencies may be accompanied by excessive physical tension and/ or the use of associated behaviors such as rhythmic movement of nonspeech body parts or head jerking. From a perceptual standpoint, the speech of some speakers with acquired stuttering sounds very similar to that of speakers with neurodevelopmental stuttering; however, other speakers present stuttering symptoms that are much more severe than those seen in cases of neurodevelopmental stuttering. Many speakers with acquired stuttering seem aware of their fluency impairment, and those who are aware may express concern, frustration, or other similar emotions in response to it. Not all comparisons yield similarities between developmental and acquired forms of stuttering,



however. For example, as a group, speakers with acquired forms of stuttering appear to be less likely than speakers with neurodevelopmental stuttering to exhibit fluency improvement during adaptation tasks, and they seem to be less likely to exhibit fluency facilitation during conditions such as choral reading, repeated reading of the same material, singing, use of delayed auditory feedback, and the production of rote or serial speech. As noted, some cases of acquired stuttering are characterized by severely disfluent speech. This fluency pattern perhaps is not surprising, given the extent to which individuals with acquired stuttering present with comorbidities such as communication disorders and/or medical conditions that have the potential to exacerbate the effects of fluency impairment. Indeed, the presence of concomitant problems appears to increase one’s risk for developing acquired stuttering. Acquired forms of stuttered speech have been documented in conjunction with a wide range of conditions that impact neurological functioning. Preliminary evidence suggests that some characteristics of acquired stuttering may vary with the type of neuropathology that is present. For example, speakers who acquire stuttering in conjunction with degenerative neurological diseases may be less likely to show emotional reactions to speech disfluency than speakers who acquire stuttering in conjunction with stroke. Acquired stuttering has

8.  Acquired Stuttering

been associated with a wide variety of lesion locations. This finding underscores the extent to which the processes that are integral to speech fluency are distributed throughout the nervous system.

Questions to Consider 1. To what extent do the neurological lesions with acquired stuttering overlap with neurological lesions that have been identified in developmental stuttering? 2. In what ways do you think the social consequences of stuttering would differ in individuals with acquired stuttering versus developmental stuttering? 3. In addition to a speech-language pathologist, what other professionals would be important to have on a patient’s medical services team when assessing an individual with acquired stuttering? 4. What do you think some of the primary challenges would be when providing treatment to a person with acquired stuttering? 5. With acquired stuttering, is the primary goal for intervention likely to involve helping the person compensate for the effects of his or her impairment or helping the person completely remediate the effects of the impairment? Why?

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9 Cluttering

Chapter Objectives After reading this chapter, readers will be able to: • Describe how the definition of cluttering has evolved over time. • Describe the fluency, articulation, and language characteristics of cluttered speech. • Compare the epidemiological characteristics of cluttering to those of stuttering. • Describe current views on the correlates and etiology of cluttering.

Background and Historical Perspective The word “clutter” evokes images of messiness and disorganization. The term cluttering has a similar connotation in the field of speech-language pathology. A precise definition of cluttering is presented later in this chapter, but for now it suffices to say that the term refers to a communication disorder that leads to messy and disorganized speech. That is, cluttered speech may be excessively fast and more disfluent than what is typical, and listeners may have difficulty deciphering the speaker’s intention because speech sometimes is unintelli-

gible, and ideas are presented in a disorganized or tangential manner. In his classic textbook, Cluttering, Weiss (1964) offered an overview of how cluttered speech has been conceptualized throughout the centuries. He noted that reports of clutter-like speech date back to ancient Greece and Demosthenes, a statesman who was said to have spoken indistinctly, with misarticulated words and difficulty maintaining conversational topics. Weiss also discussed several texts from the Middle Ages, which contained descriptions of speech problems that, in retrospect, seem consistent with contemporary notions of cluttering. According to Weiss, scholarly writing about clutterlike speech patterns increased in frequency during the 18th and 19th centuries, at which time, symptom description also became increasingly refined. He noted, for instance, the writings of Bazin, who in 1717 documented a subgroup of speakers who spoke rapidly and in a manner that suggested that several thoughts at once were “fighting for expression.” Weiss also mentioned the writings of Colombat, who in 1830 distinguished between speech disorders that featured excessive rate (which is consistent with contemporary notions of cluttering) and speech disorders that featured excessive hesitation (which is consistent with contemporary notions of stuttering). Despite these and other writings from the late 1800s and early 1900s, clutter-like speech did not

227

228

Fluency Disorders

attract much scholarly attention until Weiss (1964) published his textbook. The book was part of a series called the Foundations of Speech Pathology, which was edited by the eminent speech-language pathologist (SLP) and expert on stuttering, Charles Van Riper. Despite the publication of Weiss’s book, in the subsequent decades, cluttering continued to get limited attention from scientists who conducted research on fluency disorders. The status of cluttering during this era is exemplified by the title of Daly’s (1993) review article on the disorder, in which he tagged cluttering as the “orphan of speech-language pathology.” Later, Scaler Scott, Grossman, and Tetnowski (2010) reported results from a survey that they distributed to faculty of academic programs in speech-language pathology within the United States, Canada, and Europe. They found that although more than 90% of the programs included cluttering in their academic curriculum, the instructional time allotted to studying the disorder averaged only 100 minutes. It is no wonder that contemporary authorities on cluttering (e.g., Myers, 2010) continue to argue for extending the research base and professionals’ awareness of and interest in the disorder. Although scientific understanding of cluttering has progressed slowly since the 1960s, SLPs’ interest in the disorder seems to be on the upswing in recent years as evidenced by an increased frequency of international collaborations among SLPs and increases in the number of textbooks and research papers that focus on cluttering. Efforts to expand professional awareness of cluttering and energize the research agenda for the disorder seem to have had some success, as well. This success is exemplified by activities such as the establishment of the International Cluttering Association (ICA) in 2007 at the First International Cluttering Conference, and the subsequent merging of ICA activities with the World Congress of the International Fluency Association in Hiroshima, Japan, in July 2018.

Defining Cluttering Long ago, Wingate (1964a) noted that a wellwritten definition should provide a succinct summary of the essential, observable features and

properties of a disorder; and, when such information is known, a statement of the disorder’s etiology. Such a definition is critical for scientific advancement in any area of clinical science, as it essentially provides guidance on what is important to study and increases the likelihood that research participants across studies are, in fact, all members of the same clinical population. To date, experts in speech-language pathology have found it challenging to define cluttering.

Approaches to Defining Cluttering Over the past 15 years, experts in cluttering have worked to attain consensus on a valid definition of the disorder. Reaching this goal has not been easy. Part of the difficulty lies in the array of symptoms that have been associated with cluttering. As St. Louis et al. (2010) noted, if cluttering is defined too narrowly, many legitimate cases of the disorder will be missed. Alternately, if cluttering is defined too broadly, it is possible that the disorder will be over-identified. Broad definitions also can lead to a scenario where two clinicians each claim to be treating a person who clutters, yet the symptom presentation for the two cases is completely different (Myers & St. Louis, 1996).

The Evolution of Cluttering Definitions Table 9–1 presents several defining characteristics of cluttering. As shown in the table, Weiss’s (1964) definition is the earliest one, and it portrays cluttering as a multifaceted impairment, with some elements related to communication (i.e., impaired oral and written language, speech rate, speech articulation), other elements related to cognition (i.e., impaired attention, planning, problem awareness), and still other elements related to temporal and motor functioning (i.e., impaired rhythm generation, impaired musical performance). In the complete form of the definition, Weiss did not indicate which — if any — of these symptoms he considered most essential to the diagnosis of cluttering. In the diagnostics chapter of Weiss’s textbook, however, he suggested that lack of problem awareness, exces-

9. Cluttering 229



Table 9–1.  Evolution of Definitions for Cluttering Author Weiss (1964)

Definitional Characteristics • Lack of problem awareness, short attention span • Disturbances in speech perception, articulation, and formulation • Excessive speed of delivery • A disorder of thought processes preparatory to speech • Hereditary disposition • A verbal manifestation of a “Central Language Imbalance” affecting all channels of communication (e.g., reading, writing, rhythm, musicality)

Daly (1992)

• A disorder of both speech and language processing • Rapid, dysrhythmic, sporadic, unorganized, and unintelligible speech • Accelerated speech (tachylalia) not always present • Impairments in formulating language almost always are present

St. Louis et al. (2003)

• Syndrome characterized by abnormally fast and/or irregular speech rate • Speech affected by: • Failure to maintain normally expected sound, syllable, phrase, and pausing patterns; and/or • Greater than expected frequency of disfluency (most of which are unlike those observed in people who stutter

St. Louis et al. (2007)

• Rate perceived to be abnormally rapid, irregular, or both • Rate abnormalities are manifest as: • Excessive non-stutter-like disfluency • Atypical pause locations and prosodic patterns • Inappropriate (usually excessive) coarticulation of sounds, especially in multisyllable words

St. Louis & Schulte (2011)

• A fluency disorder • Segments of conversation perceived as too fast, too irregular, or both • Segments of rapid and/or irregular speech rate are accompanied by one or more of the following: • Excessive frequency of non-stutter-like disfluencies • Excessive collapsing or deletion of syllables • Abnormal pause locations, syllable stress, or speech rhythm

sive speaking rate, and excessive or atypical speech disfluency were the core symptoms of cluttering. Weiss’s definition included a claim about etiology, which stated that cluttering is a manifestation of “central language imbalance” (p. 63). Unfortunately, the construct of central language impairment was not well specified then and has not been subject to extensive scientific scrutiny since then. Several decades later, Daly (1992) published a definition of cluttering that was narrower than Weiss’s (1964). Daly described cluttering as a

speech and language disorder that affects the rate, rhythm, and intelligibility of speech as well as linguistic organization. Interestingly, the notion of excessive disfluency was not mentioned explicitly in Daly’s definition, although perhaps it is captured indirectly under the concept of impaired rhythm. Like Weiss, Daly characterized cluttering primarily as a language disorder, a position that appeared to be based on his observation that neither impaired speech rate nor reduced intelligibility was present in all cases of cluttering.

230

Fluency Disorders

St. Louis, Raphael, Myers, and Bakker (2003) developed a definition for stuttering that was more speech-based than previous definitions. That is, they defined cluttering primarily in relation to rate, rhythm, and disfluency characteristics. In contrast to Daly (1992) and Weiss (1964), St. Louis et al. did not mention the notion of language disturbance in their definition of cluttering. Subsequently, St. Louis and colleagues (i.e., St. Louis, Meyers, Bakker, & Raphael, 2007; St. Louis & Schulte, 2011) refined the St. Louis et al. (2003) definition by designating rate impairment as the primary characteristic of cluttered speech and describing whatever disfluency and rhythm abnormalities a speaker might have as secondary to the rate impairment. St. Louis and colleagues (St. Louis et al., 2007; St. Louis & Schulte, 2011) also added the concept of impaired coarticulation to the definition of cluttering. In their view, impaired coarticulation underlies the other primary characteristics of cluttered speech — that is, excessively fast, unintelligible speech. Interestingly, none of the definitions that St. Louis and colleagues presented explicitly mentioned language-related deficits. Thus, these contemporary definitions for cluttering are quite different from the initial definition for cluttering that Weiss (1964) put forth. To validate the St. Louis et al. (2007) definition, St. Louis and Schulte (2011) summarized the details of a doctoral dissertation that Schulte conducted in 2009. Schulte studied 15 persons who previously had been diagnosed with cluttering by other SLPs. Among other things, Schulte examined how the behavioral profiles of the speakers who had been identified as cluttering matched the characteristics contained in St. Louis et al.’s (2007) definition of cluttering. Schulte’s analysis revealed that each of the 15 individuals who had been diagnosed as cluttering exhibited a rapid speaking rate (defined in the study as anything greater than 250 syllables per minute); however, only 5 of the 15 (33%) individuals exhibited irregular speaking rate (i.e., bursts of accelerated speech within an utterance). The combined frequency of interjections and revisions, which Schulte termed “normal disfluencies,” was excessive in 6 of the 15 (40%) participants. Perceptions of overly coarticulated speech also were noted for 6 of the 15 (40%) participants. Interestingly, none of the 15 participants in Schulte’s (2009) study showed evidence of atypi-

cal pause use or atypical prosodic patterns in speech — characteristics that are included in St. Louis et al.’s (2007) definition. Also of note, 2 of the 15 (13%) participants who had been diagnosed with cluttering by an SLP exhibited only one of the symptoms from the St. Louis et al. (2007) definition (in both cases, the symptom was abnormally fast speaking rate). Given the findings from Schulte’s (2009) study, it appears that SLPs use the label “cluttering” in reference to a rather heterogeneous group of individuals. An excessively fast speaking rate clearly was the most identified symptom. After that, however, the behavioral profile of identified individuals diverged, such that other definitional characteristics of cluttering were present only in subsets of speakers. Although St. Louis et al.’s (2007) definition since has been used as the basis for a number of studies and discussions about cluttering, not everyone agrees that it is the best way to define cluttering. For instance, van Zaalen-op’t Hof and De Jonckere (2010) argued that cluttering fundamentally is a language-based problem and that the many symptoms commonly associated with the disorder arise from language-related difficulties. The latter view is consistent with the definition that Weiss proposed in 1964. Indeed, it appears that contemporary professionals who have experience working with people cluttering continue to maintain a model of the disorder that includes a wide range of factors — namely, speech intelligibility, rate regularity, overall rate, articulatory precision, speech fluency, language organization, and discourse management — as having relevance to the identification of cluttering (Myers & Bakker, 2014). Some experts (e.g., Bretherton-Furness & Ward, 2012; Ward, 2006, 2011) have suggested that part of the difficulty in delineating the definitional symptoms of cluttering may be because cluttering is a spectrum disorder, meaning that an individual can have varying degrees of symptoms associated with the disorder, or that motoric and linguistic subtypes of cluttering exist. Whatever the case may be, the challenges that clinical authorities have experienced in defining cluttering are not unique to the disorder. For example, in recent decades, experts have struggled, and continue to struggle, with how to define developmental forms of speech apraxia (i.e., childhood apraxia of speech).

9. Cluttering 231



Fluency Characteristics of Cluttered Speech The primary fluency characteristics of cluttered speech are reviewed in this section. The speech of individuals who clutter can be examined in terms of its continuity, rate, rhythm, effort, naturalness, talkativeness, and performance consistency/stability.

Speech Continuity in Cluttered Speech Although excessive disfluency in speech was not mentioned in Weiss’s (1964) definition of cluttering, it is featured as a diagnostic marker of cluttering in several later definitions (i.e., St. Louis et al., 2003, 2007). It is widely accepted that speakers who clutter exhibit a disfluency pattern that is dis-

tinct from the pattern seen in speakers who stutter. That is, unlike stuttering, wherein repetitions, prolongations, and blocks are the predominant type of disfluency, speakers who clutter tend to produce interjections, revisions, and “false starts” (i.e., abandoned segments of speech) more often than other types of disfluency, and the frequency of these disfluency types may be greater than what is observed in the general population. Thus, the disfluency pattern seen in cluttering is, in a sense, the inverse of the pattern seen in stuttering. Along with this, the disfluencies that occur with cluttered speech are likely to sound distinctly different from those that occur with stuttered speech. An example of the expected disfluency profile for a hypothetical speaker who clutters and speaker who stutters are illustrated in Figure 9–1. As with cases of stuttering, the frequency of speech disfluency in speakers who clutter seems to vary across tasks. For example, van Zaalen-op’t Hof,

Intj + Rev + FS

Rep + Pro + Blk

Speaker who stutters

Speaker who clutters

0

20

40

60

80

100

Percent of Total Disfluencies Figure 9–1.  Stacked bar graph showing typical ratios of non-stutterlike disfluency types such as interjections (Intj), revisions (Rev), and false starts (FS) to stutter-like disfluency types such as partand whole-word repetitions (Rep), sound prolongations (Pro), and blocks (Blk). As indicated, most of the disfluencies for a speaker who clutters would be expected to consist of interjections, revisions, and false starts (80% of the total in this hypothetical case). The inverse pattern would be expected with most speakers who stutter. In this hypothetical case, 20% of all disfluencies consist of interjections, revisions, and false starts, and 80% involve repeating, prolonging, and blocking.

232

Fluency Disorders

Wijnen, & De Jockere (2009) found that, among speakers who cluttered, the combined frequency for interjections, revisions, hesitations, and other “non-stutter-like” disfluency types was about six to eight times greater than the combined frequency of “stutter-like” disfluencies such as part-word repetitions and prolongations during a monologue task and a story retelling task but similar during an oral reading task. Overall, in the van Zaalen-op’t Hof et al. (2009) study, 75% of the speakers who cluttered produced at least three times as many of the “non-stutter-like” disfluencies as they did “stutterlike” disfluency. Several authors (e.g., Bretherton-Furness & Ward, 2012; Myers & St. Louis, 1996; Preus, 1996) also have noted the tendency for speakers who clutter to produce maze-like disfluency. As noted in Chapter 3, authors have used the term maze behavior in different ways. In some cases, it is used as a synonym of any type of disfluency that a speaker produces, and, in other cases, it refers to instances of linguistically based disfluency. In this book, the term maze is used in a restricted sense — that is, to signify disfluent segments that feature multiple and varied unsuccessful attempts to move past a break in speech continuity within an utterance. As such, mazes have a convoluted or complex quality, as is evident in Examples 9–1 and 9–2. Example 9–1:  [He his f-, no wait, um the decis- ] My brother decided to hire my father. Example 9–2:  [um well, you know like– it’s like– it’s the governme– um] it’s one of those patronage deals. Notice that the disfluencies in Examples 9–1 and 9–2 lack the elements of part-word repetition, sound prolongation, and blocking that characterize stuttered speech. Instead, they consist solely of editing terms and speech attempts that are either abandoned (“false starts”) or subsequently revised. This pattern of disfluency conveys a sense of disorganized or impaired linguistic formulation, characterizations that are included in some definitions of cluttering (e.g., Daly, 1992; Weiss, 1964). The maze-like disfluencies of cluttered speech also may contain elements of stutter-like disfluency (e.g., part-word repetition, sound prolongation); however, in cases of so-called “pure” cluttering, the

interjections, revisions, and false starts will be the most prominent types of disfluency. Daly and Burnett (1999) stated that excessive repetitions may be present in cluttered speech as well, but they added that the repetitions in cluttered speech differ from those seen in stuttered speech in the following ways: (1) repetitions in cluttered speech are not effortful, but those in stuttered speech are; (2) repetitions in cluttered speech usually span longer linguistic units (e.g., phrase and word repetitions) than those in stuttered speech (part-word repetitions); (3) repetitions in cluttered speech reflect difficulty in word retrieval or sentence formulation, whereas repetitions in stuttering do not; and (4) speakers who clutter generally are unconcerned about these lengthy repetitions, while speakers who stutter are concerned. Based on data from more recent group-based studies of cluttering (e.g., van Zaalen-op’t Hof et al., 2009), it seems that repetition-based disfluencies like those that Daly and Burnett (1999) noted can occur, but they are not common in cases of pure cluttering. As with developmental stuttering, disfluency frequency can vary considerably across speakers who clutter. In fact, if one adopts a definition of cluttering like the one proposed by St. Louis et al. (2007), which is based on excessive speaking rate, it is possible for a speaker to be diagnosed with cluttering without exhibiting an excessive amount of disfluency. An example of the latter scenario is illustrated in Williams and Wener’s (1996) study of an adult male who exhibited accelerated articulation rate, poor intelligibility, and poor cohesion during narration as primary symptoms of cluttering. The speaker’s speech continuity, in contrast, fell into the normal range during conversation, with only 2 disfluencies per 100 words. A similar amount of disfluency was reported for the speaker during oral reading. In the latter context, however, the speaker blinked his eyes in conjunction with sound prolongations and syllable repetitions, a behavior consistent with stuttered speech. So, although disfluency frequency was within normal limits, other qualitative features of disfluency were indicative of fluency impairment. Group-level disfluency data for speakers who stutter have been reported in numerous published studies. From this research, it is known that the combined frequency of disfluency that features

9. Cluttering 233



repeating, prolonging, and blocking can range from as little as 1 or 2 disfluencies per 100 syllables to as many as 40 or 50 per 100 syllables. In the area of cluttering, unfortunately, there are few largescale group studies of disfluency frequency. Still, reviews of smaller scale studies provide a sense for what the disfluency profile is like in this population. In an analysis of eight adults who cluttered, Bretherton-Furness and Ward (2012) reported that pauses, fillers/interjections, repetitions, and revisions were the most common disfluency types during two narratives tasks. Similarly, Myers, Bakker, and St. Louis (2012) reported on 18 teens and adults who cluttered and found that interjection was the most common disfluency type in cluttered speech (it comprised about 55% of the total), followed by revision (about 23% of the total) and word repetition (about 12% of the total). The frequencies for these disfluency types were similar to those for a comparison group of typical speakers: about 10 per 100 syllables for interjections, 3 per 100 syllables for revisions, and 1 per 100 syllables for word repetitions. Other disfluency types were present in both groups, but they occurred infrequently. The cluttering group did produce disfluency clusters (i.e., maze-like disfluency) such as Interjection + Revision significantly more often

than the control speakers; however, the observed frequency was relatively low (i.e., less than 3 per 100 syllables). Published case studies are another potential source of insight into how disfluency frequency is distributed in the population of speakers who clutter. The disfluency data from four of the casebased reports on cluttering in the Journal of Fluency Disorders (1996, Volume 21, Issues 3 and 4) are presented in Table 9–2. Although disfluency frequency values were not provided for individual disfluency types in three of the four studies, and one of the studies (Teigland, 1996) reported only the observed numbers of disfluency, it still is possible to get a general sense for the severity of these cases. As shown in Table 9–2, the overall disfluency frequencies reported by Lees, Boyle, and Woolfson, (1996) and Williams and Wener (1996) are not excessive in relation to normative data on fluency from typical speakers, and these frequencies are roughly consistent with group-level data reported by Myers et al (2012). Although disfluency frequency for many speakers who clutter may not be particularly high in an absolute sense, it still is possible for a speaker who clutters to be perceived as atypically disfluent if many of the speaker’s disfluent segments are

Table 9–2.  Disfluency Frequency Results From Case Studies of Speakers Who Clutter Study

Cases

Disfluency Data

Myers & St. Louis (1996)

12-year-old male

• Total disfluency = 8 per 100 syllables; 75% of total are interjections, revisions, or unfinished words.

11-year-old male

• Total disfluency = 4 per 100 syllables; 71% of total are interjections, revisions, or unfinished words.

15-year-old male

• Reading = 9 per 100 syllables, including interjections and wholeand part-word repetitions.

Lees et al. (1996)

• Conversation = 10 per 100 syllables, including interjections, wholeand part-word repetitions, and revisions. Williams & Wener (1996)

Young adult male

• Reading = 4 per 100 words, including prolongations, single-syllable repetitions, interjections, and multisyllable repetitions. • Conversation = 2 per 100 words, including prolongations, single-syllable repetitions, and interjections.

Teigland (1996)

3 adolescents who clutter; 3 matched controls

• Cluttering speakers produced three times as many revisions of grammatical errors as the speakers who did not clutter. • Speaking turns with grammatically based disfluency = cluttering, 19%; control, 7%.

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maze-like in nature. In addition, it is important to remember that some speakers who clutter clearly are excessively disfluent. Figure 9–2 presents an excerpt from a transcript from an adult who cluttered. When reading the transcript, it is apparent that the speaker is highly disfluent and that many of the disfluent segments are maze-like in form, such that they mostly consist of interjections along with bits of speech that are either abandoned or subsequently revised. (What the transcript does not capture is that the speaker also was perceived to talk very rapidly.) The composition of the mazelike disfluency in Figure 9–2 (i.e., many convoluted revisions to utterance content and syntax) suggests that these fluency interruptions are symptomatic of language formulation difficulties. Other

Line 1 2 3 4 5 6 7 8 9 10 11 12

authors (e.g. LaSalle & Wolk, 2011) have noted the occurrence of disfluency in speakers who clutter in conjunction with produced phonologically complex words that reside in phonologically sparse neighborhoods.

Rate Characteristics of Cluttered Speech Cluttered speech often is perceived as sounding excessively fast, rapid, rushed, or hurried (St. Louis & Hinzman, 1986; St. Louis, Myers, Faragasso, Townsend, & Gallaher, 2004). This seems to be a longstanding observation about the disorder, as each of the six definitions listed in Table 9–1 mention rate disturbance. In recent years, rate dis-

Utterance [it's like she doesn't make a co-] she probably doesn t make a lot of money but… [It s like it s prob- it s sort of- like you know] it s [like] something that she loves. [Like at lea-] she acts like she loves it. [She doesn t- she doesn t- like the- she- I mean] Sorry, but this is the first time that I m sharing this story. So [it s like har-] I need a [s-]second to think about it! But [it s like- well- see-] her husband acts like he doesn t want the clothing store. But [it s like- it s something that- and she s jus-] it s kind of [her best- the-] her dream job. I mean [it s like- it s like she s- like] the lady loves vintage clothing. And it s interesting that [like I- I kind of- it s like she- It s like she doesn t ev-] she doesn t arrange clothing by sizes. [She does it very crea- like categorizes-] I think she arranges it by [pause[ color. Or [like by- I thi- she-] she organizes [it-] some by fabric. So she displays it really [in her bes-] in her own special way.

Disfluent Segments 1

Syllables 13

2

6

1 1

6 15

2 1

11 14

2

7

1

10

1

16

2

10

2 1

10 13

Totals 17 Adjusted frequency (disfluencies per 100 syllables) = (17/131)

131 100 = 12.98

Figure 9–2.  An excerpt from a transcript of a narrative by a speaker who clutters. The story deals with the speaker’s trip to a secondhand clothing store. The core content of each utterance is shown in bold text, and disfluent segments are shown in non-bolded text. Disfluency frequency (12.98 disfluencies per 100 syllables) is only moderately high in a quantitative sense, but speech sounds very disfluent because of the many lengthy, maze-like disfluent segments. Most of the disfluent segments consist of clustered interjections (particularly “like”), stereotypical phrases (particularly “it’s like”), plus words or parts of words that subsequently are revised or abandoned. In addition to the disfluencies, the speaker’s rate sounded excessively fast.

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turbance has emerged as a cardinal symptom of cluttered speech (see Table 9–1). In three of the definitions for cluttering that St. Louis and colleagues developed (St. Louis et al., 2003, 2007; St. Louis & Schulte, 2011), rate disturbance is characterized as the primary or essential characteristic of cluttered speech. The fact that cluttered speech is commonly perceived to be excessively fast might lead one to assume that speakers who clutter exhibit abnormally high articulation rates during all sorts of speaking tasks or that they exhibit an extraordinary capacity to articulate rapidly. Research does not support either assumption. Consider, for example, the results from Bakker, Myers, Raphael, and St. Louis (2011), who compared articulation rate patterns across three speaker groups: (1)  adult females with typical fluency (control); (2) adult females who cluttered; and (3) adult females with exceptionally rapid speech but no cluttering. Group articulation rates were compared across four tasks — diadochokinesis (DDK), recitation of nursery rhymes, oral reading, and sentence repetition — and across four rate conditions. During the DDK, nursery rhyme, and oral reading tasks, the researchers asked the participants to speak at a “comfortable” rate, a maximum rate, and a “maximum 2” rate, during which participants attempted to exceed their initial attempt at a maximum rate. The main findings from the study regarding rate were as follows: • Both the cluttering group and the exceptionally rapid rate group spoke faster than the control speakers when using a “comfortable rate” during the oral reading and nursery rhyme recitation tasks. (Oral reading task: Cluttering = 7.59 syll/s; Control = 6.26 syll/s. Rhyme recitation task: Cluttering = 6.01 syll/s; Control = 5.60 syll/s.) • Both the cluttering group and the exceptionally rapid rate group spoke faster than the control speakers when attempting to match the experimenters’ “slow rate” during sentence imitation. (Cluttering = 0.89 syll/s faster than the experimenters’ model; Control = 0.45 syll/s faster than the experimenter’s model.)

• There were no rate differences across the three groups during DDK production or during either of the maximum rate conditions in the oral reading and nursery rhyme recitation tasks. Bakker et al. (2011) attributed the lack of group differences in the maximum rate conditions to physiological constraints; that is, the speech articulation system can move only so fast. Interestingly, however, group differences were apparent only when the speakers used their customary rates during oral reading and rhyme recitation. Thus, it may be that the speech production system is “tuned’ differently in individuals who clutter, such that their default setting is to use articulation rates that are faster than other speakers. In this view, when one’s habitual rate is tuned at an excessively fast setting, other facets of speech, such as speech intelligibility and speech fluency, will be affected and may be affected adversely (Alm, 2011; Bakker et al., 2011). Bakker et al. also remarked that the lack of rate differences across the groups during the DDK tasks supports the notion that rate disturbance in cluttering is most apparent — and perhaps only apparent — during tasks that require linguistic formulation. When one computes effect size statistics for Bakker et al.’s data, it is apparent that the differences between speakers who clutter and typical speakers, particularly during tasks like oral reading and sentence imitation (both of which require linguistic formulation), are large in magnitude and thus likely to be noticeable to most listeners. A final point worth mentioning is that none of the tasks in the Bakker et al. (2011) study examined rate production during spontaneously formulated connected speech. Some authors (e.g., van Zaalenop’t Hof & De Jonckere, 2010) have suggested that the symptoms of cluttered speech are more apparent during tasks that require spontaneous formulation of linguistic information than they are during tasks such as reading or rhyme recitation, wherein linguistic content is provided for the speaker. If this is so, then one would expect the rate differences between typical speakers and speakers who clutter to be greater during spontaneous conversation than they were in the tasks used in the Bakker et al. (2011) study. This possibility can be examined using results from van Zaalen-op’t Hof et al. (2009).

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Van Zaalen-op’t Hof et al. (2009) compared speakers who cluttered, speakers who stuttered, and speakers with both cluttering and stuttering on several variables (including articulation rate) during monologue, oral reading, and story retelling tasks. In the group of speakers who cluttered, articulation rate was faster during monologue than during reading, although only moderately so (the computed effect size was d = 0.67). As expected, articulation rate for speakers who cluttered was significantly faster than that of speakers who stuttered but only during the monologue, the task that presumably featured the greatest degree of selfformulation. Overall, the articulation rates for 56% of speakers who cluttered were more than 1 standard deviation above the average articulation rate for all participants in the study. On this basis, the rate disturbance that characterizes cluttered speech seems to be most apparent in tasks that entail linguistic formulation, particularly those tasks that involve spontaneous linguistic formulation. Other rate-based difficulties have been associated with cluttered speech. For example, some authors (e.g., Weiss, 1964) have mentioned festination (i.e., the tendency to articulate at a faster and faster rate the longer one talks) as a symptom of cluttering. In addition, several authors (e.g., Daly & Burnett, 1999; St. Louis et al., 2007; Weiss, 1964) have mentioned atypical variability in articulation rate as another key symptom of cluttered speech. The main pattern is for the speaker who clutters to exhibit transient accelerations in articulation rate in ways that are atypical or unexpected within the context of the spoken utterance. This speaking pattern leads to the perception that cluttered speech contains intermittent bursts of rapid speech. Articulation rate variability is discussed further in the following section on rhythm and in a later section on speech sound articulation.

Speaking Rhythm In disorders such as stuttering and cluttering, speech rhythm is disrupted by factors such as the frequency and duration of disfluency within an utterance as well as aspects of speech rhythm such as pause frequency, pause duration, and syllable duration.

Empirically derived data on speech rhythm in speakers who clutter are limited. As noted earlier in this chapter, several experts have listed maze behavior as a symptom of cluttered speech (see Examples 9–1 and 9–2). To date, there is little information on the duration of such disfluencies during cluttered speech; but based on orthographic transcription alone, one would surmise that a mazelike disfluency is likely to last considerably longer than, say, a single-iteration word repetition (e.g., [we-]we) or a simple interjection (e.g., uh). Thus, maze-like disfluencies are likely to disrupt speech rhythm noticeably, particularly when a speaker produces this type of disfluency frequently. Several authorities on cluttering include pause abnormalities as a symptom of cluttered speech (e.g., Daly & Burnett, 1999; St. Louis et al., 2007; Van Riper, 1982). Some authors have stated that, in cluttered speech, the pauses within running speech are absent, too brief, or misaligned with the syntactic or semantic properties of an utterance (St. Louis et al., 2007). Other authors (e.g., Daly & Burnett, 1999) have stated that inappropriately long pauses (“silent gaps”) may be present in cluttered speech and that they are associated with impaired word retrieval or sentence formulation. More recently, van Zaalen-op’t Hof et al. (2009) found support for the claim of minimal pausing during cluttered speech in a study of speech samples from 42 speakers who cluttered. Interestingly, however, neither van Zaalen-op’t Hof et al. (2009) nor any of the authors cited in Table 9–2 reported observing excessively long pauses in the samples they analyzed. This finding suggests that if excessively long pauses (hesitations) are observed in speakers who clutter, they are present only in a minority of cases and are less commonly observed than very brief pauses are. The latter point is supported by the observation that many of the treatment-related publications for cluttering (Daly, 2010; Daly & Burnett, 1999; Logan, 2010) have discussed the utility of teaching speakers who clutter to pause more frequently and for a longer length of time than they customarily do. Obviously, there is need for additional empirical investigation of pause behavior in speakers who clutter. Issues that warrant study include the following: (a) the percentage of cluttering speakers who exhibit pause abnormalities,

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(b) the frequency with which speakers who clutter typically produce atypical pauses, and (c) whether excessively short pauses are more common than excessively long or misplaced pauses. Speech rhythm also can be influenced by variations in articulation rate. Van Zaalen-op’t Hof et al. (2009) examined rate variability in speakers who cluttered by measuring articulation rate in five fluent utterances that each contained at least 10 syllables. Variability was defined as the difference between fastest and slowest articulation rates across the five sentences. Based on this definition of variability, there was no difference in rate variability across speakers who cluttered, speakers who stuttered, and speakers who both cluttered and stuttered. However, in the cluttering literature, rate variations typically are described using terms such as “spurts” or “bursts.” Thus, additional research is needed to assess rate variability across intra-utterance linguistic units, such as syntactic phrases or phonological words. The latter approach seems better suited to detecting spurts of rapid-sounding speech.

Effort and Naturalness Characteristics of Cluttered Speech Speaking Effort in Speakers Who Clutter Speech-related effort has not been studied extensively with speakers who clutter. Most available information comes from case reports and anecdotal observations. In contrast to the pattern seen with stuttering, the consensus is that physically tense instances of disfluency are not commonly observed in speakers who clutter, nor are overt signs that the speaker is fearful of speaking (e.g., Daly & Burnett, 1999). These characterizations of speaking effort are consistent with the observation that speakers who clutter seem to have limited self-awareness of their communication difficulties (St. Louis et al., 2007). One can assume that a speaker first must have awareness of his or her communication impairment before attempting to compensate for it or conceal it from others. Of course, compensation and concealment each require action and sustained

attention to implement, and, in that sense, they are effortful. It seems plausible that as a patient attempts to self-monitor speech more frequency or in greater depth, the patient’s sense of speaking effort would increase accordingly. This possibility has not been well studied in speakers who clutter, but warrants investigation.

Speech Naturalness in Speakers Who Clutter Nearly all of the research on speech naturalness comes from studies of people who stutter, and most of that research concerns the perceived quality of posttreatment speech patterns. To date, there has been little systematic research on treatment outcomes with speakers who clutter, let alone the naturalness of their posttreatment speech. Thus, the status of posttreatment speech naturalness among speakers who clutter is unclear. Because of the overlap in treatments for stuttering and cluttering, one could imagine that people who clutter would exhibit many of the same naturalness limitations that are found in people who stutter (see, e.g., Reichel, 2010). This issue needs to be studied, however. St. Louis et al. (2004) examined listeners’ perceptual ratings of cluttered speech samples that came from two speakers. Listeners rated both the naturalness and the rate attributes of the cluttered samples less favorably than they rated the language, articulation, and disfluency attributes. In one sense, this is not surprising because naturalness ratings seem to be correlated with other dimensions of speech production (Chakraborty & Logan, 2013). Thus, there is a need for comparisons between pre- and posttreatment samples of speakers who clutter, which then are compared to speech samples from control speakers.

Talkativeness Characteristics of Cluttered Speech Talkativeness encompasses variables such as verbal participation, message coherence, and communicative flexibility. Regarding verbal participation, clinical authorities seem to be in agreement that

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speakers who clutter are prone to talking excessively (Daly, 1993; Scaler Scott, 2011; Ward, 2006; Weiss, 1964). This is in contrast to the profile for speakers who stutter, for whom verbal output may be less-than-typical due to the speaker’s desire to conceal his or her fluency impairment from others and/or the amount of effort that is takes to produce utterances. Speakers who clutter also are prone to exhibiting difficulty with informational organization, particularly within narrative contexts, while speakers who stutter typically do not display difficulty in this area (Daly, 1993; Scaler Scott, 2011; Ward, 2006; Weiss, 1964). Among those cluttering speakers who exhibit disorganized thought expression, additional research is needed to determine the nature and extent of the organizational difficulties. Application of standard discourse analysis procedures to cluttered speech samples would be an important first step to address this gap in the research literature.

Performance Consistency/ Stability in Cluttered Speech As with many other aspects of cluttered speech, relatively little is known about the extent to which cluttering symptoms vary over time, across tasks, or across situations. Based on the author’s clinical experience, it seems that cluttering-related variables such as disfluency frequency, articulation rate, language organization, and speech intelligibility show relatively little variability from day to day. Thus, a speaker who exhibits moderately fast speech at an initial evaluation is likely to exhibit moderately fast speech at a follow-up evaluation 1 week later. However, as noted earlier in this chapter, cluttering symptoms do seem to fluctuate across speaking tasks. For instance, nonmeaningful utterances such as those produced as part of DDK assessment are less likely to show evidence of cluttering compared to the meaningful utterances that occur during narration and sentence production tasks (Bakker et al., 2011). Additional research is needed to determine the extent to which cluttering symptoms vary with contextual factors such as speaking partner (e.g., speaking with a friend vs. speaking with an

employer). It has been claimed that the symptoms of cluttering are most apparent when a speaker is relaxed or comfortable (Daly & Burnett, 1999; Weiss, 1964). Perhaps this is because, at such times, the speaker’s self-monitoring of speech production is presumably less than it would be in other contexts. Additional group-level research is needed to examine the extent to which the symptoms of speakers who clutter diminish when they are instructed to attend more closely to speech production and whether symptom severity varies with factors such as speaking partner and topic familiarity.

Speech Articulation Characteristics of Speakers Who Clutter Impairment in speech articulation also is a commonly reported characteristic of cluttered speech. At least two areas of difficulty have been reported: (1) excessive coarticulation, a problem that affects the timing of speech sound segments; and (2) errors in the accuracy with which specific phonemes are produced.

Coarticulatory Characteristics of Cluttered Speech The term coarticulation refers to the extent to which the articulatory movements associated with contiguous phonemes overlap with one another during speech production (Behrman, 2007). Although coarticulation most often is conceptualized as an aspect of speech articulation, some authors (e.g., Starkweather, 1987) have discussed coarticulation within the context of speech fluency as well. Either way, coarticulation is a suprasegmental construct, meaning that its effects span the boundaries of individual speech sound boundaries within a spoken utterance. Most contemporary definitions of cluttering (e.g., St. Louis et al., 2007) identify excessively coarticulated speech as a core symptom of the disorder. Daly & Burnett (1999) used the term telescoped speech to describe this aspect of cluttered speech. That is, just as the segments of a telescope tube are nested so that they can slide into one another

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and decrease the overall length of the instrument, the gestural postures associated with contiguous speech sounds can overlap to varying degrees; and in speakers who clutter, it appears as if the gestural postures for individual speech sound segments sometimes overlap too much (St. Louis et al., 2007). Although the speaker may be producing the appropriate consonants and vowel sequences, the temporal characteristics of the transitions between the sound segments are atypical. Experts are in general agreement that the coarticulation difficulties of speakers who clutter are especially apparent during production of multisyllable words (Bakker et al., 2011; and see Examples 9–4 and 9–5 in the next section) and that overly coarticulated speech results in reduced intelligibility when it occurs. An excerpt from a speech sample from an adult who demonstrated this type of speech is shown in

Figure 9–3. During the underlined portions of the sample, speech sounded as if it was being said in rapid bursts or spurts, a pattern that many authors have documented in conjunction with cluttering (e.g., Daly & Burnett, 1999; St. Louis et al., 2007). As indicated in the figure, perceptibly rapid (and, presumably, excessively coarticulated) speech occurred regularly; and when it occurred, it usually spanned entire phrases or clauses. At these times, the speaker’s intelligibility was reduced, often to the point of becoming unintelligible. Other authors have reported similar patterns. For example, in a study of three teenagers who cluttered, Teigland (1996) found that 18% of their speaking turns contained rapidly accelerating bursts of speech, and 8% of their speaking turns (versus 0% and 2% in control cases) contained speech segments that were minimally intelligible or unintelligible.

1. I’ve had a problem for a long time [uh] enunciating and having people clearly understand what I’m trying to say. 2. [uh um] Some of the worst problems are [uh] when I’m saying my major. 3. No one hardly ever understands xx xx xx. 4. And I just can’t get it out so they understand xx xx xx, which gets discouraging. 5. And [uh- w- a-] I’m taking a class in xx xx xx xx, and I sometimes have to present projects. 6. And when I’m up in front of the class talking, [uh] I have no problem being comfortable. 7. The problems are when I’m thinking the same time as I’m talking and not xx xx xx xx xx. 8. But if they ask me something that I don’t know, I xx xx xx xx and my speech gets worse.

Figure 9–3.  An excerpt of cluttered speech from an adult who produced speech that was perceived as containing spurts of very rapid speech (indicated by underlined words). At such times, speech intelligibility was marginal to poor, possibly because the speaker coarticulated speech sound segments excessively or articulated the sounds incompletely. In some portions of the sample (indicated by xx), speech was unintelligible. The speaker’s comments throughout the sample suggest selfawareness of communication difficulty.

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Speech Sound Accuracy in Cluttered Speech Many clinical authorities have noted that speakers who clutter are prone to reducing or deleting syllables within multisyllable words, a speech pattern that also results in the perception of “compressed” or “hurried” speech. St. Louis et al. (2007) offered the following examples to illustrate this phenomenon: Example 9–3:  explanation → [EkspleIʃən] Example 9–4:  inability → [InbIət] The error in the word explanation is interesting in that the speaker fuses the two word-medial syllables. That is, the target form (i.e., [spləneI]), which features one unstressed and one stressed syllable, is merged into one new stressed syllable (i.e., [spleI]), which includes constituents from the two original syllables. In contrast, the error on the target word inability features deletion of one unstressed syllable (i.e., [ə]) and reduction of another unstressed syllable (i.e., /lə/ → [ə]). Errors like these and the ones in Figure 9–3 point to phonological problems that extend beyond the boundary of a syllable. Whatever the source for these errors may be, the resulting speech is not indicative of systematic difficulty in saying specific sounds or syllable types (as would be the case in young children who exhibit systematic error patterns or phonological processes). Rather, the errors seem to reflect a nonsystematic (intermittent) problem with encoding metrical information — and perhaps segmental information as well — within phonological words. Alm (2011) proposed that the atypical coarticulation seen in speakers who clutter results from impairment at the speech planning level when the durations of consonant and vowel segments are specified. As suggested earlier, if speech coarticulation and syllable realization are sufficiently aberrant, speech intelligibility can be compromised. Deficits in speech intelligibility are routinely mentioned in the professional literature on cluttered speech, which bolsters the idea that cluttering is a disorder that affects both fluency and articulation. Group-level data are needed on matters such as the

average percentage of unintelligible words among speakers who clutter and the extent to which unintelligible segments of speech correspond to phonological word boundaries. The relationship between articulation rate and speech sound coarticulation needs to be explored further as well to gain better insight into factors that cause speech to sound as if it is being spoken in a “hurried” or “rushed” manner. Information about speech-language development in young children who clutter is very limited. Some authors (e.g., Daly & Burnett, 1999; Weiss, 1964) have stated that children who clutter exhibit delays in phonemic development that lead to systematic error patterns in speech sound production (e.g., substitutions, omissions, additions, distortions). Daly and Burnett (1999) characterized the speech sound production of speakers who clutter as “baby talk,” but elsewhere in their book chapter they suggested that the speech sound production difficulties in this population are most associated with incorrect production of liquid and sibilant sounds. Systematic sound production errors are not mentioned in contemporary definitions of cluttering, and there is very little clinical data about the early articulation development of speakers who clutter. In the adolescent and adult speakers who clutter, as seen in clinical practice, most individuals do not display systematic difficulty in producing specific phonemes, phoneme sequences, or syllable types accurately. In contrast, nonsystematic difficulties in speech sound accuracy that appeared to occur secondary to difficulties in articulatory timing were commonplace. In summary, for now, it probably is best to regard systematic speech sound production problems as one of several speechlanguage impairments that a speaker may exhibit concurrently with cluttering but also to realize that speakers who clutter do not seem to have such difficulties routinely.

Syntax and Discourse Characteristics of Cluttered Speech Researchers and clinical authorities (e.g., Bretherton-Furness & Ward, 2012; Daly & Burnett, 1999; St. Louis, Hinzman, & Hull, 1985; Teigland, 1996; Ward, 2006) have noted an assortment of language-

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related difficulties in speakers who clutter. These include the following: • Producing syntactically complex utterances; • Establishing and maintaining linguistic cohesion; • Expressing information concisely and in a well-organized manner; • Maintaining conversational topics; • Retrieving lexical items and completing sentences promptly; and • Recognizing and repairing unsuccessful communication attempts. These language difficulties are consistent with the disfluency profile that is characteristic of cluttered speech, wherein interjections, revisions, and false starts predominate and widely are viewed as being symptomatic of language formulation difficulties. In Figure 9–2, the disfluencies in the speech sample, most of which involve message reformulation, are consistent with this view.

Epidemiological Characteristics of Cluttering In contrast to the research on stuttering, relatively little is known about the epidemiology of cluttering at a population level. Until such information becomes available, one must be content with having only a rough sense of issues such as how common cluttering is and the trajectory of the disorder’s expression over time. Based on what is known, the epidemiological characteristics of cluttering do appear, in most ways, to be distinct from the characteristics of stuttering.

Incidence and Prevalence of Cluttering Several authors have reported diagnostic classification statistics for patients with fluency concerns. These provide information about matters such as whether cluttering is less common than stuttering and how often the two disorders co-occur. In most of these reports (i.e., Daly, 1993; Freund, 1952;

Howell & Davis, 2011; Preus, 1992), cases of pure stuttering have outnumbered cases of pure cluttering and cases of cluttering-stuttering. The reported ratios of stuttering-only cases to cases with cluttering-only and/or cluttering-stuttering are quite variable, however, ranging from 1.2:1 (Daly, 1993) to 4.6:1 (Howell & Davis, 2011). To complicate matters, Weiss (1964) reported the opposite pattern; that is, cases of cluttering-stuttering outnumbered cases of pure stuttering and pure cluttering, each by a ratio of approximately 2:1. Howell and Davis (2011) studied cluttering epidemiology by presenting four judges who were experienced in fluency analysis with a series of speech samples obtained from children that the authors had evaluated previously for fluency concerns. Two speech samples were available for each of the 96 children. One sample was recorded at approximately age 10, and the other was recorded at approximately age 14. Howell and Davis provided the judges with criteria for identifying cluttering (i.e., evidence of fast speech, evidence of poor or disorganized thinking, and evidence of a short attention span). They then asked the judges to assign each of the speech samples into one of four categories: (1) only stuttering; (2) only cluttering; (3) stuttering and cluttering (with more stuttering than cluttering); and (4) stuttering and cluttering (with more cluttering than stuttering). Howell and Davis then validated the judges’ classifications by presenting the speech samples that a majority of judges had labeled only cluttering or stuttering and cluttering to two authorities on cluttering. Howell and Davis retained the speech samples that both authorities had labeled as cluttering for further analysis. Overall, 12% (23/192) of all speech samples in the Howell and Davis (2011) study were labeled as cluttered. Among the 96 individuals from whom speech samples were elicited, 18% (17/96) had at least one sample that met the criteria for cluttering, while the remainder (82%) met criteria for only stuttering. Only 6 of the 96 (6.25%) individuals with fluency concerns presented evidence of cluttered speech during both of their speech samples; and of these cases, all of the cluttered samples came from the “age 10” assessments. Thus, there were no newly developed cases of cluttering during early adolescence, and some cases of cluttering at age 10

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had resolved or improved substantially by age 14. Findings from this study suggest that cluttering is indeed less common than stuttering, with the ratio being about 4.6 cases of only stuttering for every 1 case of either only cluttering or stuttering and cluttering. On this basis, the observed occurrence of cluttering is somewhat less than that reported in several earlier studies such as Preus (as cited in Daly, 1986), Freund (1952), and Weiss (1964).

Onset and Developmental Course of Cluttering Data regarding the age of onset for cluttering are limited, in part because of the apparently low incidence of pure cluttering. Some sources (e.g., Diedrich, 1984) have contended that the onset of cluttering occurs much later than that of stuttering, while others (e.g., Van Riper, 1971; Weiss, 1964) have suggested that cluttering can transform into stuttering — a scenario that would put cluttering onset earlier than stuttering onset. In contrast, in Howell and Davis’s (2011) study of 17 children who cluttered, the average reported age of onset for cases of stuttering (about 49.5 months) was similar to that of the reported ages of onset for both children who cluttered and children who both cluttered and stuttered (about 53 months). Howell and Davis’s longitudinal assessments of fluency outcomes for the children who cluttered showed that 29% (5/17) attained normalized fluency by age 14, while the remainder (71%) persisted with cluttered speech. Howell and Davis’s longitudinal investigation of children’s impaired fluency revealed that cases of cluttered speech can transform into stuttered speech over time — a pattern noted in several earlier sources (e.g., Van Riper, 1971; Weiss, 1964). However, according to Howell and Davis, this pattern is uncommon (i.e., less than 30% of the cluttering cases in their study demonstrated it). Van Riper (1971) analyzed clinical records from 300 patients with impaired fluency, which resulted in his identification of four tracks or manifestation patterns of stuttering. One of the four tracks (Track  II) consisted of speakers who exhibited “hurried and irregular” repetitions of whole words, along with “more abortive beginnings, more revi-

sions, (and) more revisions” (p. 109) than cases of classic stuttering. Individuals who were classified as Track II also exhibited unorganized speech and frequent articulation errors but minimal frustration about and self-awareness of their communication difficulties. Van Riper summarized his discussion of the Track II category by saying that the speech pattern “is the early cluttering-like speech delineated by Weiss (1964)” (p. 109). Other aspects of Van Riper’s Track II category were not consistent with contemporary views on the symptoms of cluttered speech, however, and suggested that the Track II pattern perhaps is more consistent with cases that present both stuttering and cluttering.

Gender and Familial Patterns of Cluttering Like stuttering, cluttering seems to affect males more often than females. Howell and Davis (2011) reported that 88% of their participants who either cluttered or cluttered and stuttered versus approximately 81% of the participants who only stuttered were male. The male-to-female ratio for cluttering in Howell and Davis study is similar to that reported by St. Louis (1996) for the series of case studies within the Journal of Fluency Disorders’ special issue on cluttering (i.e., 86% male to 14% female). Regarding familial patterns, Weiss (1964) concluded, “We have found that hereditary is a basic factor in cluttering” (p. 50). He continued by saying, “In virtually every case (of cluttering), we discover that at least one other member of the family has had a speech disorder” (p. 51). Weiss’s conclusion was based, in part, on data such as that from Freund (1952), who reported that more than 90% of cluttering cases had a positive family history of speech-language impairment. More recent accounts differ from this view, however. For example, in St. Louis’s (1996) summary of data from the Journal of Fluency Disorders’ special issue on cluttering, only 7 of 18 (39%) speakers who cluttered had a positive family history of articulation or language disorders. Howell and Davis (2011) reported that 47% (8/17) of their participants who cluttered had a positive family history of impaired fluency. The latter statistics suggest that the role of hereditary factors in cluttering may be subtler and perhaps

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more complex than it was originally thought to be. Overall, the genetics of cluttering are not understood nearly as well as the genetics of stuttering, and there is a need for additional research into this aspect of the disorder.

Disorders That Co-Occur With Cluttering Based on clinical observation, it appears that clutter-like speech often occurs in the context of other disorders. The list of disorders that have been linked with cluttering is lengthy. Some disorders that co-occur with cluttering affect oral expression and were discussed earlier in this chapter (i.e., stuttering, impairments in expressive language, atypical articulation performance). This section reviews stuttering and some other disorders that have been reported to co-occur with cluttering.

Stuttering It is possible for a speaker to exhibit symptoms of both stuttering and cluttering. As noted in previous chapters, these disorders are characterized by distinct disfluency profiles. In cases where the disorders co-occur, patients exhibit evidence of both stutter-like disfluency (e.g., part-word repetition, sound prolongation, blocking on speech sounds) and clutter-like disfluency (e.g., interjection, revision, and maze-like disfluency), and the two classes of disfluency at times may be intertwined. A maze-like disfluency that features both stutter-like and clutter-like disfluency is shown at the onset of the sentence in Example 9–5. A second, mazelike disfluency consisting of clutter-like disfluency precedes the word hire. Disfluent segments in speakers who clutter are not always convoluted or maze-like in their form, however. Note, for instance, that the sentence in Example 9–5 also contains two “simple” disfluent segments (an interjection preceding my, a part-word repetition in conjunction with father). Example 9–5:  [H-He- his ffa- fath-, no wait, um the um mm-m-]my brother decided to [um well he, it’s kind of well] hire [um] my [f-]father.

It also is possible that some reported cases of pure stuttering are misclassified, such that they actually include evidence of cluttering. For example, Stager, Freeman, and Braun (2015) found that some of the fluency patterns in individuals with Down syndrome that family members had regarded as “stuttering” instead were classified as “cluttering” by expert raters. Similarly, in another report, about half of 18 adults with intellectual disability who, according to referral sources, had evidence of stuttering were instead classified as presenting either pure cluttering or stuttering and cluttering by expert evaluators (Coppens-Hofman, et al., 2013).

Learning Disability According to the National Institute of Neurological Disorders and Stroke (NINDS, 2019), “learning disabilities are disorders that affect the ability to understand or use spoken or written language, do mathematical calculations, coordinate movements, or direct attention.” They usually are first diagnosed during the school years. Although the precise etiology of learning disabilities is unknown, central nervous system dysfunction is assumed to be present. Hereditary factors appear to be a predisposing factor for some, and perhaps many, cases. It also is possible that exposure to teratogenic agents (e.g., a virus, drugs, chemicals) may affect neurodevelopment in ways that result in learning disabilities. Peripheral sensory deficits (e.g., hearing loss, vision loss) and intellectual disability (mental retardation) may be present in individuals who have a learning disability; however, by definition, these conditions are not a primary cause of an individual’s learning disabilities. Social and cultural differences and/or economic disadvantages may be present as well; however, by definition, these characteristics are not a cause of the learning disability either. Learning disabilities assumed a prominent role in Weiss’s (1964) classic writings on cluttering; however, others (e.g., St. Louis et al., 2007) have noted that many individuals who clutter do not present concomitant learning disabilities. As discussed earlier in this chapter, an assortment of oral language deficits has been noted in speakers who clutter. It is unclear whether these oral language deficits and the reading and writing deficits

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typically found in learning disabilities arise for common reasons.

Attention Deficit/Hyperactivity Disorder Attention deficit/hyperactivity disorder (ADHD) is “a brain disorder characterized by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development (National Institute of Mental Health [NIMH], 2019). St. Louis et al. (2007) briefly reviewed reports from several authors who described symptoms consistent with attention deficit/hyperactivity disorder among speakers who clutter. Based on their review, St. Louis et al. cautioned that research data regarding the extent to which the two disorders overlap is limited and that, in their experience, cluttering is not present in most people who meet definitional criteria for ADHD.

Auditory Functioning and Central Auditory Processing Disorder Central auditory processing disorder (CAPD) arises from dysfunction in the central auditory nervous system. The disorder can lead to a variety of difficulties with tasks such as understanding speech in the presence of background noise, processing rapid speech, processing sound patterns, and following verbal directions (American Academy of Audiology, (AAA) 2010). CAPD falls within the scope of practice of audiology, and test batteries typically include listening tests such as Gap Detection, Frequency Patterns, Dichotic Digits, and Competing Sentences, which tap into an individual’s ability to resolve, integrate, and/or order auditory stimuli (American Speech-Language-Hearing Association [ASHA], 2005). Although performance on measures of language and cognitive functioning show weak to moderate correlations with performance on some central auditory tests, most of the variance in CAPD tests scores is attributable to other, as-yetunknown factors (Brenneman et al., 2017). Disordered processing in the central auditory system has been mentioned as a condition that co-occurs with cluttering (e.g., Daly & Cantrell, 2006). To date, however, there has been relatively little scientific study with regard to auditory system functioning in speakers who clutter. Molt (1996) compared three individuals who cluttered to three

typical speakers in terms of their performance on several central auditory processing and electrophysiological (i.e., auditory evoked potentials) measures. In contrast with the typical participants, all three of the individuals who cluttered performed atypically on at least two of the four tests of central auditory processing that they completed. In addition, each of the three speakers who cluttered showed abnormalities in auditory evoked potentials, particularly over the frontal lobe region. The speakers who cluttered also presented with attention deficit disorder, which made it difficult to determine the extent to which their responses on the experimental tasks were associated with cluttering. With respect to basic audiometric findings, Howell and Davis (2011) reported data on several measures of auditory functioning in a group of 96 children with impaired fluency. The participants with cluttered speech (n = 17) did not differ from participants with stuttered speech with respect to having a history of otitis media with effusion (OME) or their pure-tone thresholds during three masking conditions.

Autism Spectrum Disorder There is limited research on the occurrence of stuttering in individuals with autism spectrum disorder (ASD). Scaler Scott (2011) summarized findings from her 2008 dissertation in which she examined the speech characteristics of 12 children with ASD (they had been diagnosed with Asperger syndrome). She found that three of the children met definitional criteria for either cluttering or cluttering-stuttering. A main characteristic of cluttering in the three children was abnormalities in speech rate (i.e., their rates were judged as being rapid or irregular). Scaler Scott (2011) also discussed evidence of excessive coarticulation and atypical pause patterns among individuals with autism spectrum disorder.

Etiology of Cluttering Although views on the cause of cluttering have slowly evolved since the 1960s, some new models of etiology, each rooted in neurophysiology, have been proposed in recent years.

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Early Views on Etiology In his classic text on cluttering, Weiss (1964) offered what was, at the time, the most extensive exploration of cluttering etiology. When he published his textbook, understanding of the neurological and psycholinguistic bases of normal and disordered speech production was much more limited than the current knowledge bases in these areas. Thus, his views on etiology must be interpreted within the context of how speech-language functioning was understood at the time. Weiss (1964) viewed cluttering as a hereditary disorder. Although data on the epidemiology of cluttering were very limited in the 1960s (and still are today), he noted that many of the clients he treated for clutter-like concerns reported having other family members, including parents, who spoke similarly. Weiss (1964) noted that although people who clutter do not present with frank signs of neurological impairment, the disorder nonetheless has an “organic flavor.” He noted that a speaker who clutters often can alleviate the symptoms of cluttering by attending more closely to the speech production process; and when a speaker does not attend to how he or she talks, the symptoms worsen. Such a profile, he claimed, is more consistent with an organic (i.e., biological) base for the disorder than it is with a psychological base. Weiss stated that cluttering is best conceptualized as being a manifestation of “inborn weakness” in the ability to communicate, and as such, the disorder represents an intermediate point along a longer continuum of functioning that ranges from normal fluency at one end to complete dysfunction at the other end. Weiss (1964) also proposed that cluttered speech results from central language imbalance, which he defined as a deficiency in a speaker’s “sense of harmony in language functions” (p. 9). He asserted that this condition could give rise to a host of problems, including delayed speech, disorders of reading and writing, disorders in musicality, and, of course, cluttering. He proposed that among individuals who clutter, the extent of central language imbalance varied from person to person. Weiss (1964) readily acknowledged that the underlying mechanisms of his central language imbalance hypothesis could not be studied with the technology of his era. Consequently, he specu-

lated on what the source of a central language imbalance might be. These speculations included the following: • Dysfunction in the striatum (a region of the basal ganglia) that is the result of microscopic lesions in this area; • Neurodevelopmental immaturity, which reflects an extended period of neuroplasticity; • Dysfunction in brain regions that are involved in speech planning and regulation. Weiss cited data showing that electrical stimulation of the thalamus results in acceleration of speech rate and that electrical stimulation of Brodmann’s area 6 (the premotor and supplementary motor area) on the mesial surface of the brain elicited repetitions in speech; and A deficit in the ability to utilize proprioceptive feedback from articulatory structures and/or auditory feedback during ongoing speech. Interestingly, this proposed mechanism is quite like what one finds in contemporary etiological models of stuttering. In some respects, Weiss’s (1964) ideas about the etiology of cluttering and fluency impairment, in general, were remarkably prescient, as subsequent research has provided support for the roles of neurodevelopment, basal ganglia functioning, proprioception, and auditory feedback in the attainment of normally fluent speech and in the symptoms of stuttered speech.

Contemporary Views on Etiology Since the year 2000, several updated views of cluttering etiological models have been proposed.

Neurological Frameworks for Cluttering Impaired neurological functioning has been implicated in cluttering for some time. For instance, Luchsinger and Landolt (cited in Weiss, 1964) reported electroencephalographic (EEG) abnormalities in nearly all of the individuals who clutter that they studied. Drawing upon research findings

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like this as well as contemporary research into the neurophysiology of speech production, Alm (2011) proposed a neurological framework for explaining cluttered speech. Alm argued that although the core of cluttered speech appears to be fast and dysrhythmic speech, the disorder more accurately is viewed as a constellation of symptoms. That is, there are numerous symptoms of cluttering, but few clients present all of the possible symptoms. According to Alm (2011), the core symptoms of cluttering are consistent with dysfunction in cortical regions located along the medial wall of the left frontal lobe. Alm noted that this area has been linked to several functions, including the motivation to speak, sentence planning (especially aspects of syntax and phonology), execution of sequential motor activities, and monitoring of speech output. Cluttered speech is characterized by deficits in each of those aspects of performance. In Alm’s model, specific areas within the region that have particular relevance to cluttering include the following: • Anterior cingulate cortex (ACC): Alm (2011) stated that this area has an executive function (e.g., it is associated with the initiation of voluntary movements as well as willful attention and error monitoring). He noted that the ACC is involved in volitional control, including the suppression of behavior, making decisions under conditions of uncertainty, and the maintenance of willful attention for tasks such as error monitoring; and the ACC has been implicated as an area of dysfunction in cases of attention deficit disorder. Consistent with these functions, Alm noted that the ACC receives input from a variety of areas, including the limbic, motor, and auditory systems. Accordingly, Alm characterized the ACC as a “hub” or an integration center. • Supplementary motor area (SMA): In Alm’s (2011) model, the SMA is viewed as an “assembly center.” In other words, it is associated with retrieving linguistic information from lateral regions of the left temporal and frontal lobes as well as with controlling the timing of articulation through inputs from the basal ganglia and

cerebellum and with the monitoring of utterance production via inputs from the auditory cortex. Alm noted that, like the ACC, the SMA has cognitive, affective, and motor divisions. • Pre-supplementary motor area:  Alm noted that the pre-SMA has been linked with aspects of phrase assembly such as word selection, word form selection, and word sequencing. It also has been linked to speech error detection. • Basal ganglia:  The basal ganglia have a variety of functions, but with regard to cluttered speech, Alm (2011) emphasized the role of this region in word selection and regulation of speech timing. Alm (2011) proposed that the symptoms of cluttering are consistent with dysfunction (i.e., hyperactivation, dysregulation) of the medial wall of the frontal lobe, which occurs secondary to a lack of inhibitory input to this region from the basal ganglia due to a hyperactive dopamine system. In other words, many of the key symptoms of cluttering (i.e., excessive drive to talk, disrupted message sequencing, mistimed message delivery, and a reduced ability to sustain attention and monitor performance) are consistent with the presence of excessive amounts of the neurotransmitter dopamine (i.e., a hyperdopaminergic state). This hypothesis leads to the question of why a hyperdopaminergic state exists. Researchers have not yet offered answers to that question in relation to cluttering; thus, it remains to be seen whether factors such as disease or genetic variation might be the underlying source. Despite this limitation, models such as the one that Alm developed offer a useful, well-detailed roadmap that others can use to guide future research efforts. Recent neuroimaging data are consistent with a neurophysiological basis for cluttering (Ward, Connally, Pliatsikas, Bretherton-Furness, & Watkins, 2015). In Ward et al.’s research, adults who cluttered exhibited greater neural activation during speech production than controls cortically in the lateral premotor cortex, bilaterally and in the pre-supplementary motor area, and subcortically in regions of the caudate nucleus and the putamen. They also exhibited less neural activation in



the lateral anterior cerebellum. Over-activation in the right ventral premotor area and in the right anterior cingulate cortex appeared to be unique to the participants who exhibited both cluttering and stuttering. Ward et al. stated that these patterns were consistent with a model of stuttering as a motor control disorder that incorporates the basal ganglia and frontal lobe regions that receive its output.

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4. Impairment in speech motor execution: Inclusion of this component in Ward’s model of cluttering is based on the similarities that exist between cluttered speech and speech patterns seen in some forms of dysarthria (particularly hypokinetic dysarthria, which is associated with Parkinson’s disease), such as shorter voice onset times than normally fluent speakers and speakers who stutter during consonant-vowel (CV) sequences within conversational speech.

Language Formulation and Speech Motor Control Perspectives on Cluttering Data on the speech motor performance of speakers who clutter are limited. Hartinger and Moosehammer (2009) examined the spatiotemporal characteristics of articulatory movements in three speakers who cluttered. The researchers detected evidence of speech motor control deficits in the speakers who cluttered during the articulation of multisyllable words. In the study, the speakers who cluttered exhibited greater variability in the amplitude and duration of their tongue blade movements as well as reduced range of movement. In a different study, Ward (2011) noted the similarities between the motor performance of the speakers who cluttered and the expected performance of individuals with Parkinson’s disease. Ward (2011) discussed a multifactor model of cluttering that is consistent with Alm’s (2011) view on the nature of cluttering. Ward’s model included four potential areas of impairment that could account for cluttering symptoms: 1. Impairment in linguistic planning: Inclusion of this component in a model of cluttering is based on the substantial number of cluttering speakers with deficits in language formulation in areas such as pragmatic, syntax, semantics, and phonology. 2. Impairment in motor planning: Inclusion of this component is based on the nonsystematic speech sound sequencing errors that some speakers who clutter exhibit. 3. Impairment in speech motor programming: Inclusion of this component in Ward’s model of cluttering is based on the substantial number of speakers who clutter that manifest imprecision in the execution of speech movements.

Public and Professional Views Toward Cluttering Results from studies of people in a range of countries, including the United States, Bulgaria, Turkey, and Russia, suggest that the general public seems to be aware of cluttering — at least when researchers provide them with a definition of the disorder ​— and that many people say that they have interacted with people who clutter (St. Louis et al., 2010b). Providing raters with only a written definition may affect the accuracy with which cluttering is identified, however, as college students who received only a written definition reported knowing more people who clutter than students in a comparison group who had access to both the written definition and a video clip of cluttered speech (Farrell, Blanchet, & Tillery, 2015). In recent years, there has been a growing emphasis on conducting research into public views and attitudes toward people who clutter. St. Louis and colleagues (St. Louis et al., 2010a) developed a multi-item rating scale called the Public Opinion Survey of Human Attributes (POSHA) for this purpose, and the instrument (and various modified versions of it) has been used extensively with research participants around the world. Based on this work, it appears that laypeople tend to hold attitudes toward cluttering that are similar to, though somewhat less positive, than the attitudes that they hold toward stuttering (St. Louis, Sønsterud, Carlo, Heitmann, & Kvenseth, 2014). Some of the items on the POSHA-E require responders to rate cluttering and other conditions in terms of how much they would want to have each condition. Raters have rated the cluttering item less favorably

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than items such as using a wheelchair, having a mental illness, and being overweight (St. Louis, 2010a). The type of exposure that one has to the disorder also seems to matter, as college students who saw a video clip of cluttered speech reported greater reluctance to hire a person who clutters in comparison to college students who did not see the video clip (Farrell et al. 2015). With respect to the perceived impact of fluency disorders, it seems that both raters with typical fluency and raters with fluency impairment consider stuttering to have a greater adverse impact on affected individuals than cluttering (Sovani Kelkar & Mukundan, 2016). It has been more than 3 decades since St. Louis and Rustin (1986) surveyed SLPs in the United States and the United Kingdom with regard to their awareness of cluttering. The results from that study uncovered reluctance on the part of clinicians in both countries to treat people who clutter — an attitude that seemed to be driven, at least in part, by the clinicians’ limited knowledge of the disorder. Although recent attempts to improve professional awareness and knowledge of cluttering may have improved this situation somewhat, on the whole, it is quite possible that professionals’ views toward cluttering are not markedly different today than they were in 1986. It is interesting to consider why cluttering has not attracted more attention from researchers and clinicians. There are at least three factors that may account for this situation. First, authorities have found it difficult to construct a suitable definition for cluttering (St. Louis, 1992; St. Louis & Schulte, 2011; Ward, 2011). The initial attempts to define cluttering (e.g., Weiss, 1964) included numerous symptoms, many of which applied to other disorders as well. This created questions about whether cluttering was a distinct disorder or, instead, merely a subset of some other disorder. The lack of a suitable definition for cluttering likely has affected researchers’ and clinicians’ attempts to study the disorder systematically. For example, how can one study a phenomenon if he or she is unable to state precisely what the phenomenon is? Epidemiological factors also seem to have influenced the amount of research and clinical attention that cluttering has received. Although epidemiological data for cluttering are scarce, authorities generally agree that it is a low-incidence disorder and

that it is less prevalent than stuttering. Accordingly, it is challenging for individual research laboratories to conduct the kinds of group-level research studies that are useful for advancing scientific understanding of a disorder (Craig, 2010). The situation does seem to be improving, however. For instance, with the establishment of the International Cluttering Association, SLPs, speech scientists, and related professionals now have a formal venue through which they can forge collaborative research efforts, and with that, an efficient and effective way to conduct group-level research studies that in result in population-level inferences about the nature and treatment of cluttering. There also is widespread acceptance among authorities that cluttering can co-occur with stuttering. Given the relative prominence of stuttering as a communication disorder, it is possible that clinicians and researchers will become more attuned to clutter-like elements in the speech of some individuals, and as a result, arrive at observations about cluttering that previously may have been overlooked (Craig, 2010). A third factor that seems to affect the standing of cluttering is the quality of the research base on the disorder. Notwithstanding the challenges associated with researching low-incidence disorders, the quality of cluttering-related research literature has been characterized as being weak in comparison to the research base for other disorders (Craig, 2010; Curlee, 1996). Up until the mid-1990s, much of the data on the etiology and characteristics of cluttering was derived from anecdotal reports. Although such information has a place in any research literature, it is regarded as a very weak form of evidence and certainly not suitable for being the primary source of knowledge for any disorder. Anecdotal case reports have a host of shortcomings, including the following: lack of control over observer bias and other extraneous variables; the inability to test hypotheses and make statements about causeeffect relationships; and the inability to generalize information to a broad population (in this case, people who clutter). Craig (2010) argued that there is a need for more robust forms of research, such as (a) well-controlled cohort studies (i.e., longitudinal designs and cross-sectional studies in which participants are well matched across groups on critical variables); (b) randomized controlled clinical trials (RCTs); and, ultimately, (c) systematic reviews of

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RCTs. Fortunately, studies of this sort have become increasingly commonplace in recent years. As this work continues to build in breadth and quality, the scientific understanding of cluttering will undoubtedly advance beyond its current level.

Summary Cluttering has long been recognized as a disorder that negatively impacts verbal communication. Although cluttering traditionally has been categorized as a fluency disorder, given current conceptualizations of the disorder, some might argue that it could just as well be classified more broadly as a speech motor control disorder that affects both articulation and fluency, or perhaps as a disorder with subtypes that affect speech motor functioning and/or language functioning, or perhaps as a spectrum disorder that affects fluency, articulation, and/or language functioning in varying degrees. The many and varied symptoms that are associated with cluttering have complicated efforts to generate a standard definition for the disorder. The lack of a standard definition in combination with the disorder’s relatively low incidence may explain why the research base for cluttering is more limited than that for stuttering and many other communication disorders. Much of what was known about cluttering up until the 21st century came largely from anecdotal reports, authoritative assertions, case reports, and retrospective reviews of patient records. In recent years, however, scientists have amplified the call for group-level cohort studies that feature comparison groups (e.g., cluttering vs. typical fluency) and experimental manipulation of and control over key variables. The fluency characteristics of cluttered speech have been adequately described. It is widely agreed that the disfluency types seen in cluttering differ from those seen in stuttering. Although disfluency frequency in cluttered speech may not be high in a numerical sense, speech still can sound very disfluent because of the tendency for speakers who clutter to produce lengthy, maze-like disfluencies. Stuttering and cluttering sometimes coexist, and when they do, a speaker’s disfluency pattern can be expected to feature disfluency types that typify

both disorders. Excessively rapid articulation rate has emerged in recent years as a primary (and to some authors, obligatory) symptom for diagnosing cluttering. The perception that cluttered speech contains bursts of rapid-sounding speech has been attributed to excessive coarticulation across speech sound segments — a speech pattern that reduces speech intelligibility. The continuity and rate qualities of cluttered speech disrupt speech rhythm and naturalness. A counter position to the “cluttering as a rate disorder” view is that cluttered speech fundamentally is a symptom of language impairment. Concomitant difficulties in language, particularly in the areas of syntax and pragmatics, result in the breakdowns in message formulation and organization that are seen in many patients and help to reinforce this view of the disorder’s nature. Epidemiological data on cluttering are limited, but it generally is accepted that the disorder is less prevalent than stuttering and that, when cluttering is present, it may co-occur with symptoms of stuttering. There also is evidence that the two disorders sometimes unfold consecutively, such that clutterlike speech during childhood gives way to stutterlike speech by adolescence (Howell & Davis, 2011; Van Riper, 1971). Another area that needs additional research involves the effect that cluttering has on the quality of life. To date, there are few systematic, firsthand personal and caregiver accounts that describe the effects of cluttering-associated disability on daily life (e.g., Dewey, 2010; Wong, 2010). The information that is available suggests that the effects of the disorder can be significant, particularly when combined with the effects of coexisting disorders that a person might present (e.g., learning disability, ADHD). In other sections of this text, issues related to assessment and treatment of people who clutter are discussed. Clearly, much progress has been made, but much work remains to be done with regard to advancing the understanding of cluttering.

Questions to Consider 1. Make a grid that is based on the fluency dimensions model described in Chapter 2 of this book, and then enter the fluency characteristics

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of cluttering and stuttering. How does the fluency of the two disorders compare? 2. Cluttering usually is discussed under the heading of “fluency disorders.” What do you think the rationale is for placing it under that heading rather than under the heading of language disorders or articulation disorders? 3. For the next week, listen to the people around you as they speak. How often and in what situations is their speaking rate unusually fast? Is their speaking rate ever so fast that speech becomes unintelligible? 4. Select a short story (about 100 syllables long) to read aloud. Find a friend or classmate to read the story. First, ask the person to read the story silently, so he or she can become familiar with

it. Next, time the person as he or she reads the story aloud at the person’s typical rate. Then, time the person again as he or she reads the story at what the person considers to be a fast rate. Finally, ask the person to read the story yet again using a rate the person considers to be twice as fast as the person’s fast rate. Time that version of the story as well. Compute the articulation rates in syllables per second for each version of the story (formula: Total syllables in passage/Total number of seconds to read passage). What are the articulation rates for each condition? How do the person’s fast rates compare to the fast rates that your classmates obtain for other speakers?

10 Disfluency Patterns in Other Clinical Populations

tioning. As such, the disfluency patterns discussed in this chapter often are not the client’s most pressing concern.

Chapter Objectives After reading this chapter, readers will be able to: • Summarize the fluency characteristics that are observed in children with neurodevelopmental disorders other than stuttering and cluttering. • Describe the concept of atypical disfluency types, particularly in terms of their expected frequency, structure, and distributional properties in spoken utterances. • Describe the fluency characteristics that are expected in individuals with various genetic syndromes and conditions. The focus in the preceding chapters has been on two well-known fluency problems: stuttering and cluttering. In this chapter, the discussion shifts the focus to disfluency patterns that are associated with other clinical populations. For the most part, these disfluency patterns are distinct from those seen in stuttering and cluttering. Many of the fluencyrelated behaviors discussed in this chapter occur in conjunction with some other developmental condition or impairment that adversely affects language, speech, cognitive, and/or intellectual func-

Fluency in Children With Specific Language Impairment This section concerns the fluency patterns that are observed in conjunction with developmental impairments that specifically affect language. According to the American Speech-Language-Hearing Association (ASHA), when impairment affects only the speaking and listening modalities, it is termed specific language impairment (SLI). ASHA states that SLI is regarded as a primary disorder —  that is, it is not accompanied by comorbidities such as intellectual impairment, autism spectrum disorder, or traumatic brain injury. In some older publications, the term language learning disability (LLD) was used to refer to this disorder. In more recent research publications and textbooks (e.g., Boscolo, Bernstein Ratner, & Rescorla, 2002; Guo, Tomblin, & Samelson, 2008), it has been labeled specific language impairment, which is the term used here. Like neurodevelopmental stuttering (i.e., childhood onset fluency disorder), the symptoms

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of SLI emerge in the context of neurodevelopment during the preschool and early school years. Children with SLI present with delays in the development of language form, content, and use. SLI can affect performance in all aspects of language form (i.e., phonology, morphology, and syntax). As such, it can affect speech intelligibility and the informational complexity and specificity of spoken utterance. Lexical development can be affected as well, leading to deficits in vocabulary inventory as well as related problems such as the ability to use linguistic and environmental context to infer the meaning of novels words and the ability to rapidly retrieve lexical items during sentence formulation. The latter difficulty can lead to breaks in speech continuity, which listeners would perceive as disfluency. Beyond this, children with SLI may exhibit deficits in metalinguistic performance, leading to problems performing tasks that entail grammaticality judgment and/or manipulation or analysis of phonological structure, and, in the school years, performance deficits in literate language (i.e., reading, written expression). A common inclusion criterion for SLI in research studies is that participants must score significantly below age-level expectations on at least one and, usually, several formal measures of language performance. As is the case with assessments for suspected stuttering, in most studies, analysis of speech fluency has addressed the frequency and types of disfluency that speakers produce. In some studies, however, researchers have examined variables related to verbal output.

Frequency and Types of Disfluency in Children With Language Impairment Although findings from the research literature have been mixed, the overall pattern of results suggests that children with SLI are, on average, less fluent than children who exhibit typically developing language. This is not to say that children with language disorders routinely stutter or clutter, but they do appear less adept at achieving the relatively seamless continuity of speech production that children with proficient language skills exhibit.

The amount of literature on fluency performance in children with SLI is much less than the literature on fluency in children who stutter. Nonetheless, a number of detailed studies have been conducted over the years to examine this issue. MacLachlan and Chapman (1988) examined fluency characteristics in a group of seven children with specific language learning disability during both conversation and narration. The children in the language impairment group were 9 to 11 years old, with normal nonverbal intelligence. Each of the children exhibited deficits in more than one aspect of language-related functioning. Deficit areas included language comprehension, language production, word retrieval, reading, verbal reasoning, and auditory memory. The fluency performance of the children with language impairment was compared to the fluency performance of seven chronologically age-matched controls and seven language age-matched controls. The groups were compared on the frequency with which they produced four types of disfluency: (1) stalls (defined in the study as interjections and part-word, wholeword, and phrase repetition); (2) repairs (i.e., revisions of syntactic, semantic, and phonologic errors); (3) abandoned utterances; and (4) other types of disfluency. MacLachlan and Chapman hypothesized that the children with language impairment would exhibit higher levels of disfluency in narration than in conversation, because narration features more complex syntax and greater organizational requirements than conversation, and during narration speakers are less able to draw upon discourse support from a speaking partner than they are during conversation. MacLachlan and Chapman (1988) found significant differences in the frequency with which the children produced stalls and repairs. Overall, all children were more disfluent during narration than during conversation, and disfluency frequency increased as a function of utterance length. Unlike the two control groups, the children with language impairment showed a trend toward a proportionally greater difference in disfluency frequency during conversation than during narration. In addition, the ratio of interjections to repetitions in the language impairment group was significantly greater than it was in the language age-matched control



group. Thus, when children with language impairment “stalled” in speech, they did so by producing interjection more often than the younger, language age-matched controls did. MacLachlan and Chapman (1988) reported disfluency data in terms of disfluencies per utterance, and data were subdivided according to utterance length. It is not possible, therefore, to compare their disfluency frequency data to those from most studies in the fluency disorders literature. Still, it is possible to approximate the “per 100 words” disfluency frequency based on the information they presented. It appears that during conversation, the combined frequency of stalls and repairs for the language impairment group was between 3.00 and 6.00 per 100 words, depending on the utterance length. During conversation, however, the combined frequency of stalls and repairs for the language impairment group was between 8.60 and 11.50 per 100 words, again depending on the utterance length. The disfluency frequency scores for the language impairment group during narration were about 70 to 90% greater than those in the two control groups. Given the small sample size in the study and variations in disfluency across participants within groups, these frequency scores should be interpreted cautiously. In several other studies, researchers have examined fluency performance in speakers with specific language impairment. Children in these studies presented deficits in communication that were limited to language usage, particularly expressive language usage. Boscolo et al. (2002) examined fluency performance during a basic narrative task with 22 pairs of 9-year-old children. In each pair, one of the children had a history of specific expressive language impairment and the other had a typical language development history. The children with a history of SLI produced narratives that were significantly less complex in structure than the narratives from the children with typical fluency. The researchers also compared the groups on total disfluency frequency, the frequency of “stutter-like disfluency” (defined in the study as part-word repetitions, sound prolongations, blocks, and “tension pauses”), and the frequency of “normal disfluency” (defined as whole-word and phrase repetitions, revisions, and interjections). The children in the

10.  Disfluency Patterns in Other Clinical Populations

language-impaired group produced significantly more total disfluency and significantly more stutterlike disfluency than children with typical language development did. Overall, the observed disfluency frequencies for both groups were relatively low for both groups. For total disfluencies, the control group produced 3.3 disfluencies per 100 words, and the language-impairment group produced 4.56 disfluencies per 100 words; for stutter-like disfluencies, the control group produced 0.33 disfluencies per 100 words, and the language-impairment group produced 0.76 disfluencies per 100 words. Thus, the frequency of stutter-like disfluency in the children with SLI was less than what is typically seen as a minimum amount of disfluency among children who stutter, but it was nonetheless greater than what children in the control group produced. Boscolo et al. suggested that the greater disfluency in the children with a history of expressive language impairment might be evidence of “persistent subtle difficulty with language formulation” (p. 48). In another study with school-aged children, Guo et al. (2008) examined fluency performance in 60 fourth-grade children: 20 children with SLI, 20 typically developing children who were matched to the SLI children by chronological age (CAmatched), and 20 typically developing children who were matched to the SLI children by language age (LA-matched). Guo et al. compared the groups on the number and duration of silent pauses produced and also on the frequency of what they termed “vocal hesitation rates.” The latter consisted of familiar disfluency types such as filled pauses (e.g., “um”), interjections (e.g., “well”), wholeword repetitions, part-word repetitions, and revisions. The findings revealed that the children with SLI produced more total fluency disruptions than the children who were matched for chronological age but not more than the children who were matched for language age — a finding that supports the idea that disfluency in language-disordered children is related to linguistic formulation and a child’s relative level of development in that area. There were no significant differences among the groups in the frequency of vocal hesitations, and the total frequency of disfluency for all three groups was modest (i.e., 4 per 100 words for the CAmatched group, and 5 per 100 words for both the

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SLI group and the LA-matched group) and less than what would expected for a group of children who stutter. Guo et al. (2008) also examined four categories of silent pauses, which were defined by duration — that is, 250 to 500 ms, 500 to 1000 ms, 1000 to 2000 ms, and greater than 2000 ms. The SLI group differed from the CA-matched control group only in the frequency of 500 to 1000 ms pauses. Also, the SLI group was much more likely than the CA-matched group to produce speech disruptions at the start of syntactic phrases. The two groups did not, however, differ in the frequency with which they produced silent pauses before words, clauses, or sentences. For all three groups in their study, the 500 to 1000 ms silent pauses occurred most often and pauses more than 2000 ms occurred least often. Guo et al. again interpreted these results as supporting the idea that, with SLI, a child’s speech disruptions are related to his or her language ability. The relatively high frequency of intermediatelength pausing in the SLI group and the positioning of these pauses at the start of phrases were posited to be symptomatic of a deficit in activating the syntactic frame and/or associated lexical items for an upcoming utterance. As noted earlier, Boscolo et al. (2002) studied fluency patterns in typically developing children and children with specific language impairment. The two groups did not differ in their frequency of “normal disfluency” types (typical group: 3.3 per 100 words; SLI group: 3.8 per 100 words), and analysis of the frequency for individual disfluency types failed to differentiate the groups as well. There were some subtle differences between the groups, however. For example, 78% of the children in the SLI group produced one or more stutter-like disfluency (versus 52% of the children in the typical language group). The frequency of stutter-like disfluency was quite low for both groups (0.76 per 100 words for the children in the SLI group, 0.33 per 100 words for the typical group) but still significantly different in a statistical sense. Although the SLI group produced more stutter-like disfluency than the typical group, none of the children in the SLI group were judged to exhibit neurodevelopmental stuttering. Given the absence of excessive physical tension during the stutter-like disfluency, Boscolo et al. speculated that these disfluency

types were associated with processes related to language formulation. Examples of the kinds of speech samples a clinician would expect to obtain from a typical school-aged child and a school-aged child with SLI are presented in Table 10–1. In these hypothetical samples, the same utterances are transcribed with respect to how each child might produce them. The child with typical language development produces 6 instances of disfluency per 100 syllables (1 revision, 2 interjections, 3 pauses) with no instances of stutter-like disfluency. The child with SLI, in contrast, produces 14 disfluencies, including 12 nonstutter-like disfluencies (4 revisions, 2 interjections, 6 pauses) and 2 stutter-like disfluencies. Although the stutter-like disfluency does not pass the threshold of 3 per 100 syllables that is often used in research for qualifying participants who stutter, it still occurs more frequently than it does among the typical child, and the child with SLI produces more total disfluency than the typical child.

Language Development, Language Demands, and Fluency Performance Merits-Patterson and Reed (1981) examined fluency performance in 27 children who were between 4 and 6 years old to examine the effects that language intervention had on children’s speech fluency. Nine of the children had been diagnosed with language delay, as evidenced by low scores on formal tests of language development, and were enrolled in language therapy. Another nine children similarly had been diagnosed with language delay but had not yet commenced language therapy. The remaining nine children had normal language functioning and served as a control group. Merits-Patterson and Reed elicited speech samples from the children using a combination of picture description and play-based conversation. Analysis of the speech samples revealed that the children with language delay who were receiving therapy were significantly more than twice as disfluent (6.6 total disfluencies per 100 words) than children with language delay who were not receiving therapy (3.08 total disfluencies per 100 words) and children with typical language, who comprised the control group (3.36 total disfluen-



10.  Disfluency Patterns in Other Clinical Populations

Table 10–1.  Example of the Subtle Disfluency Pattern Differences in a 100-Syllable Sample From a School-Aged Child With Typical Language Development and a School-Aged Child With Spoken Language Impairment (SLI). Row

Typical

SLI

1

He’s going to be mad at the alien.

He’s going to be mad at the alien.

2

[it will] He will crash into the bike.

[it will-] He will crash into the bike.

3

[uh] They’re landing on the red bike which is owned by Spencer.

[uh] They’re [l-] landing [pause] on the red bike [pause] which is owned by Spencer.

4

I think they’re gonna get crushed.

I think [he’s-] they’re gonna [pause] get crushed.

5

The spaceship’s not crushing her bike.

The [pause] spaceship’s not crushing her bike.

6

You crushed [pause] my friend’s bike.

You crushed [pause] my friend’s bike.

7

Because they’re scared of aliens.

Because they’re scared of aliens.

8

One has one eye and [um] the other has two eyes.

One has [two-] one eye [um] and the other has two eyes.

9

They’re gonna faint!

They’re gonna faint!

10

The boys wanna get out of town.

The boys [have t-] wanna get out of town.

11

One is yellow and the other’s [pause] red.

One is yellow and the other’s [pause] red.

12

Because [pause] she’s getting on something like a snowboard.

Because [pause] she’s [g-] getting on something like a snowboard.

cies per 100 words). Additional analysis showed that the children with language delay who were receiving therapy produced significantly more whole- and part-word repetitions than the other two groups did. Merits-Patterson and Reed suggested that the elevated disfluency frequency in the language therapy group might have reflected the children’s incomplete mastery of recently learned linguistic forms or, possibly, “communicative pressures” that arise during language therapy activities. Rispoli’s (2003) study of speech disfluency in typically developing children provides additional support for a link between a child’s fluency and the types of syntactic forms he or she is attempting to produce. Rispoli analyzed data from children who ranged from 22 to 48 months old. He found a moderate, positive correlation between a child’s level of grammatical development and frequency of sentence revisions. Specifically, he found that as children’s grammatical proficiency increased, they attempted to say increasingly complicated utterances; and when doing so, the frequency with which

they produced revisions increased as well. Disfluency types that involved “stalling” (e.g., interjecting, repeating) were not significantly correlated with grammatical development and thus were viewed as arising from the formulation or production of a specific utterance rather than from the child’s background level of language proficiency.

Disfluency Variability in Children With Language Impairment Hall, Yamashita, and Aram (1993) examined the fluency performance of 60 preschool-aged children (mean age = 4;5) who had developmental language disorders. Each of the children showed a discrepancy of at least one standard deviation between their nonverbal intelligence score and their global language functioning score. Analysis of group data revealed the presence of a subgroup of 10 children who produced substantially more disfluency than the remaining 50 children in the group. While the

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typical fluency subgroup of 50 language-impaired children produced only 3.59 disfluencies per 100 words, the high disfluency subgroup produced an average of 14.39 disfluencies per 100 syllables. Although most of the disfluency in the high disfluency subgroup was “non-stutter-like” in nature, the average number of stutter-like disfluencies in the high disfluency subgroup (4.59 per 100 words) was substantially higher than that seen among both typically developing children and the typical fluency subgroup of language-impaired children. Post hoc analysis showed that the high disfluency subgroup was significantly older than the other children in the study and that they also scored significantly higher on formal tests of receptive and expressive vocabulary. Given the small sample size in the high disfluency subgroup, the findings should be viewed cautiously, but they are suggestive of a link between children’s language competence and their speech fluency. Hall (1999) compared the number and nature of speech fluency disruptions in two groups of children with SLI. One group of children presented with only SLI; the other group presented with SLI plus disordered phonology (DP). In this study, the total frequency of disfluency for the two groups was comparable (about 10.00 per 100 words). Children in the SLI+DP group did, however, exhibit about twice as much variation in the total frequency of disfluencies they produced as the children in the SLI-only group. In addition, when subcategories of disfluency were examined, children in the SLI+DP group exhibited a significantly greater frequency of “stutter-like disfluency” than children in the SLIonly group (i.e., 3.11 per 100 words vs. 0.33 per 100 words, respectively). As with total disfluency frequency, the frequency of stutter-like disfluency was more variable in the SLI+DP group than it was in the SLI-only group. Other researchers (e.g., Prelock & Panagos, 1989) have documented fluency differences between children with language impairment and typically developing children during production of sentences of varying syntactic complexity. Similar to findings with children who stutter, children with language impairment showed a disproportionate increase in disfluency frequency relative to typically developing children during production of grammatically complex sentences. In a study of

four Spanish-speaking “disphasic” children who ranged from 6;0 to 8;10 in age, Navarro-Ruiz and Rallo-Fabra (2001) reported findings that were consistent with those from English-speaking, language-impaired children: The children produced more disfluency during narration than conversation, and they demonstrated greater use of stutterlike disfluency such as word repetition. In addition, the language-impaired children in the study were less likely to repair language errors and more likely to completely abandon utterances than the normally functioning children were.

Fluency in Individuals With Intellectual Disability Several researchers have studied the speech fluency performance of individuals with intellectual disability. According to the American Association on Intellectual and Developmental Disabilities (AAIDD, 2019), intellectual disability is a developmental disability that originates before age 18 and is characterized by “significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills (para. 1).” The research literature on fluency performance in individuals with intellectual disability spans many decades. Bloodstein and Bernstein Ratner (2008) reviewed results from 15 studies that were published between 1912 and 1978. Consistent with societal policies of that era, most of the studies reported on individuals who lived in institutional settings. Thus, the sample sizes were generally large, often exceeding 200. One purpose in many of these studies was to determine the prevalence of stuttering among individuals with intellectual disability. Data in this regard were quite variable, with many researchers reporting prevalence rates in the 1 to 3% range (e.g., Chapman & Cooper, 1973; Sheehan, Martyn, & Kilburn, 1968), but others reporting prevalence rates of 10% or more (e.g., Schlanger & Gottsleben, 1957). Cooper (1986) reviewed many of these same studies and concluded that stuttering severity tended to worsen with an individual’s degree of intellectual disability. Another issue of interest concerns the extent to which the stutter-like patterns observed among



individuals with intellectual disability are consistent with those observed in cases of neurodevelopmental stuttering. Bonfanti and Culatta (1977) noted that many of the participants in their study were severely disfluent and that repetition tended to be the predominant type of disfluency. Many of the participants seemed aware that they stuttered but not particularly concerned about it, as evidenced by a relative lack of word substitution, word avoidance, and other symptoms that would suggest attempts to cope with impaired fluency. Other research has demonstrated that individuals with intellectual disability exhibit improvement in speech fluency when asked to say the same utterance several times in succession (i.e., the adaptation paradigm), but they are less likely than speakers who stutter to report expectancy for upcoming stuttering-related disfluency (Chapman & Cooper, 1973). Naremore and Dever (1975) examined language and fluency characteristics of spoken narratives produced by a group of children who had intellectual impairment (their IQ scores ranged from 74 to 84) and two comparison groups of typically developing children — one of which was matched for mental age and the other for chronological age. Regarding fluency, the children with intellectual disability showed a disfluency profile that was characterized by a higher frequency of repetition compared to the children in the control groups. The children in the control groups, however, exhibited a higher frequency of filled pauses (i.e., interjections) and false starts (i.e., revisions) than the children with intellectual impairment did. More recently, Coppens-Hofman et al. (2013) examined conversational disfluency in 28 adults with mild to moderate intellectual disability and poor speech intelligibility. The context of intellectual disability varied, with 11 participants having Down syndrome, four with a history of hypoxia at birth, three with “chromosomal deficiency,” and the remainder with Fragile X syndrome, Turner syndrome, or an acquired brain injury. The authors studied disfluency frequency and type, instances of articulatory “telescoping” (overly coarticulated speech), and articulation rate. On average, non-stutter-like disfluencies (M = 17.47 per 100 utterances) were about four times as frequent as stutter-like disfluencies (M = 4.71 per 100 utter-

10.  Disfluency Patterns in Other Clinical Populations

ances). Fluency, rate, and articulation analyses suggested that 7 participants (25% of the total) had no fluency disorder, but 8 (28.5%) met the criteria for cluttering-stuttering, 6 (21%) met the criteria for cluttering, and 7 more (25%) for cluttering without evidence of rapid articulation rate. No cases of pure stuttering were observed.

Fluency in Individuals With Genetic Syndromes There are several genetic syndromes that have been studied for their potential to influence aspects of speech-language fluency.

Fluency in Individuals With Down Syndrome Prevalence data suggest that about 1 out of every 700 newborns (0.15%) have Down Sydrome (DS), which makes it the most common chromosomal condition in the United States (Parker, Mai, Canfield et al., 2010). Kent and Vorperian (2013) published a comprehensive review of the literature that deals with speech characteristics associated with DS. Specific aspects of speech included in the review were articulation, phonology, voice, prosody, intelligibility, and fluency. The authors concluded that, at a group level, people with DS have difficulties in each of these domains and that, at an individual level, it is not uncommon for a person to show impairment in multiple domains. Based on this finding, Kent and Vorperian (2013) stated that individuals with DS face “serious challenges in spoken communication, which may substantially interfere with their participation in social, educational, and vocational activities” (p. 189). Fluency characteristics of individuals with DS have been studied since at least the 1950s. In several of these older studies, the reported prevalence rates for stuttering among people with DS are greater than 30% (Gottsleben, 1955; Preus, 1972; Schlanger & Gottsleben, 1957). On this basis, it has long been held that stutter-like speech seems to be much more common among people who have DS than it is among the general population.

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Recent research continues to support this view: Eggers and Eerdenbrugh (2018) in a study of 26 children with DS ranging in age from 3 to 13 years, reported that about 30% of their participants met a criterion for stuttered speech of 3 or more stutterlike disfluencies per 100 syllables, with frequencies of stutter-like disfluency ranging from 0 to 10.88 across participants. Some researchers also have reported very high prevalence rates for cluttering among people with DS. For example, Preus (1972) reported that nearly 32% of the participants with DS in the study met criteria for cluttering. More recently, Van Borsel and Vandermuelen (2008) assessed for the presence of cluttering using the Predictive Cluttering Inventory (PCI; Daly & Burnett, 1999) and reported that nearly 80% of the participants with DS met the PCI’s criterion for “possible cluttering.” In contrast, Eggers and Van Eerdenbrugh (2018), in their study of children with DS, did not find sufficient evidence of cluttering markers, such as excessive rate, overly co-articulated (“telescoped”) speech, or abnormal pause patterns, to diagnose any of the participants with that disorder. Several of the classic stutter-like types of disfluency have been noted to occur at relatively high frequencies in individuals with DS (Harasym & Langevin, 2012; Otto & Yairi, 1974; Preus, 1990). Otto and Yairi (1974) reported that individuals with DS produced significantly more part-word repetitions, dysrhythmic phonations (e.g., sound prolongation), and physically tense disfluencies than the fluent controls did. In contrast, the speakers with typical fluency produced significantly more interjections than the individuals with DS did. In that study, the overall disfluency frequency scores (i.e., total disfluency) for the two groups were not significantly different (DS group: M = 8.78, SD = 5.72; Control group: M = 6.48, SD = 2.14). As in cases of neurodevelopmental stuttering, disfluencies involving repetitions, prolongations, and blocks were the predominate type observed in the DS group. Eggers and Eerdenbrugh (2018) reported slightly lower group means for stutter-like disfluency, with children ages 3 to 7;11 years producing an average of 1.58 stutter-like and 2.79 non-stutterlike disfluencies per 100 syllables, and children ages 8 to 12 years producing an average of 3.00 stutter-like and 1.98 non-stutter-like disfluencies per 100 syllables. Sound prolongation was the most

common stutter-like disfluency type observed. Silent pauses were common as well, but their distribution within utterances appeared to be typical. Ten of the 26 children produced more stutter-like disfluency than non-stutter-like disfluency; and among the children who met criterion for stuttering, only 5 of 8 did so. Individual cases can be quite severe, however. For example, Harasym and Langevin (2012) reported profound stuttering in an 8-year-old girl, with stutter-like disfluency present on nearly 30% of syllables in reading and 55% of syllables in conversation. However, Coppens-Hofman et al. (2013) found evidence of stuttering only when it co-occurred with cluttered speech in a study of adults with intellectual disability, including some with DS. Several authorities have questioned whether the repetitions and prolongations that individuals with DS produce truly are like those seen in people who stutter. For instance, Lebrun and Van Borsel (1990) described the speech-language functioning of a 17-year-old girl with DS who showed deficits in both language comprehension and production, as well as an assortment of speech sound errors. The girl also exhibited stutter-like disfluency (i.e., sound prolongations, blocks, and phrase, word, syllable, and sound repetitions). Overall, 15.5% of her words were spoken disfluently. However, of these disfluencies, 19% involved repetition of word-final sounds. The word-final repetitions were limited to voiceless stops and fricatives. Some of the repetitions featured a brief pause between iterations of the repeated consonant. A disfluency pattern of this sort is not typical of neurodevelopmental stuttering. The extent to which individuals with DS use compensatory and associated behaviors (e.g., avoidance, rhythmic movements to facilitate fluency) has not been studied extensively. Preus (1990) reported that about 30% of studied individuals with DS exhibited such behaviors. Eggers and Eerdenbrugh (2018) reported that 6 of the 8 children in their study who met criterion for stuttering displayed associated behaviors such as facial grimacing, head movements, and distracting sounds. Harasym and Langevin (2012) reported the presence of excessive physical tension in the lip musculature and pre-posturing of articulatory movements in conjunction with stutter-like disfluency. Some authors have noted atypical types of disfluency as well. For example, Stansfield (1995) reported on four adult speakers who had a history



10.  Disfluency Patterns in Other Clinical Populations

Atypical Types of Disfluency Part-word repetition and sound prolongation are characteristic disfluency types in the speech of speakers who stutter, and typical speakers produce them occasionally as well. These disfluency types have a similar structure in that each involves a break in speech continuity between the syllable onset and rime. For example, in the following disfluency on the word “kick,” k- k- k- kik, speech is interrupted at the point where the speaker attempts to make the articulatory transition from syllable onset to syllable rime. Acoustically, a listener would hear either the [k] in isolation or the [k] plus a small part of the phonetic transition into the following vowel, but not a fully articulated vowel. Similarly, in the following sound prolongation on the word “sack,” ssssack, speech again is interrupted at the transitional point between the syllable onset and the syllable rime. Disfluency that entails repetition of syllable-final elements is much less common in both the general population and speakers who stutter or clutter. These atypical types of disfluency are observed with regularity in conjunction with certain neurodevelopmental disorders, particularly autism spectrum disorder, and they also have been documented in some cases that apparently have no other formally diagnosed disorder, disease, syndrome, or condition. Structurally, these disfluency types most often involve repetition of either the entire syllable rime (e.g., “sack” → [sæk æk]) or repetition of only the consonant in the syllable coda position (e.g., “sack” → [sæk k k]) for syllables in which the coda position is filled. Repetitions of this sort can occur in word-final positions, as in the last example, or in word medial positions (e.g., “napkin” → [næp – æpkin]). Even less common than these disfluencies are ones that feature mid-vowel continuity interruption with resumption of speech from the point of interruption (sometimes termed “broken words”), with or without insertion of an extraneous speech sound (e.g., “sack” → [sæ- æk] or [sæ- hæk]).

of “learning difficulties,” “mental handicap,” and/or DS who each presented with word-final disfluency. (See Box: “Atypical Types of Disfluency”). Across the four cases, disfluency frequency ranged from 6 to 19% of words. For these cases, the word-final repetition constituted a minority of their disfluencies — ranging from 8 to 33% of their total number of disfluencies. In three of the four cases, wordfinal repetition constituted more than 20% of the speaker’s disfluencies.

Fluency in Individuals With Fragile X Syndrome According to the Centers for Disease Control and Prevention (CDC, 2019) Fragile X syndrome (FXS) is a genetic sydrome that affects the body’s ability to produce a protein that is associated with brain development. Common characteristics of individu-

als with FXS include delayed attainment of developmental milestones, difficulties and differences in social communication functioning and in behavioral functioning (e.g., anxiety, attentional deficits), and intellectual disability (CDC, 2019). Data suggest that FXS is more prevalent among males (1.4 per 10,000) than among females (0.9 per 10,000; Hunter, Rivero-Arias, Angelov, Fotheringham, & Leal, 2014), and that autism spectrum disorders may co-occur with FXS (CDC, 2018). Van Borsel and Tetnowski (2007) reported that individuals with FXS typically present with a range of speech and language deficits, including problems with speech sound production, prosody, and phonation, as well as with social/pragmatic language functioning. The literature on fluency performance in individuals with FXS has been mixed, with some studies noting fluency differences and others not (Van Borsel, D’or, & Ronal, 2008). It has been reported in a number of studies that fluency

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difficulties, including stutter-like disfluency, occurs more often among people with FXS than it does in the general population, but less so than it does among people with DS. In some reports, the fluency profile in FXS shares similarities to neurodevelopmental stuttering in terms of the types of disfluency produced most often; however, in some reports, some of these disfluencies also diverge from those seen in neurodevelopmental stuttering (e.g., disfluency in word- and sentence-final positions). Based on Van Borsel et al.’s review, the average frequency with which stutter-like disfluency occurs among individuals with FXS seems to fall roughly in the range of 3 to 5 per 100 words, which is greater than that seen in the general population, and when compared to neurodevelopmental stuttering, indicative of mild stuttering. Van Borsel et al. (2008) examined disfluency patterns in nine speakers, aged 10 to 22 years, with FXS. Their total disfluency frequency ranged from 5.42 to 22.62 per 100 syllables, and interjections were, by far, the most common type (about 50% of the total). Revisions and repetitions of phrases and words accounted for about 13% of all disfluencies. Stutter-like disfluency types comprised less than 5% of the total. Disfluency frequency was similar across conversation, narration, sentence repetition, and automatic serial speech. On this basis, the authors concluded that stuttered speech was a common characteristic of this population. Kover and Abbeduto (2010) compared a range of expressive language measures in 15- to 16-yearold males, 20 with FXS, 8 with FXS plus autism, 8 with DS during conversation and narration. The FXS and FXS+autism groups performed similarly on most measures, other than intelligibility, where FXS+autism performed more poorly. All three groups demonstrated better performance in narration than in conversation. With respect to fluency, each of the groups demonstrated disfluency in 22% of the utterances they produced during conversation, and 14 to 20% of utterances during narration; none of the differences were statistically significant due to relatively large variations in fluency performance in each group. Disfluency types assessed in the study mainly included those associated with linguistic formulation and repair (e.g., revisions, mazes), and stutter-like disfluency was not mentioned as a prominent feature in the speech samples.

Fluency in Individuals With Prader-Willi Syndrome According to the National Institutes of Health (NIH, 2020), Prader-Willi syndrome is a genetic condition that most often is caused by a deletion of particular paternal genes in a region of chromosome 15, but also can occur when two copies of the maternal version of these genes are present or when translocation or mutation of the critical paternal genes occurs. Prader-Willi syndrome affects 1 in 10,000 to 1 in 30,000 people globally, and most cases of Prader-Willi syndrome appear to be due to random genetic events; thus, the syndrome is not heritable (NIH, 2020). Some of the characteristics that typically are present include hypotonia, feeding difficulties, hyperphagia, mild to moderate intellectual impairment, learning disabilities, and behavioral problems such as temper outbursts and stubbornness (NIH, 2020). Speech and language problems, including excessive disfluency, have been reported in studies that include individuals with Prader-Willi syndrome. In several studies, the disfluency types that are less characteristic of stuttering (e.g., interjections, revisions) seem to be predominate; however, stutter-like disfluency is routinely noted as well. Defloor, Van Borsel, and Curts (2000) reported that all 15 participants in their study exhibited excessive disfluency, with interjections comprising more than half of the total number of disfluencies produced. The participants were most disfluent during conversation and monologue and much less disfluent during tasks involving stimulus repetition and automatic speech. With regard to disfluency types, repetitions constituted about 30% of all disfluencies, and prolongations, blocks, and broken words constituted about 5% of all disfluencies.

Fluency in Individuals With Tourette Syndrome According to the National Institute of Neurological Disorders and Stroke (NINDS, 2018), Tourette syndrome is “a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics.” NINDS stated that Tourette syndrome appears to be a hereditable dis-



10.  Disfluency Patterns in Other Clinical Populations

order that affects males three to four times more often than females. According to NINDS, symptom onset usually occurs between ages 3 and 9 years and peaks in severity during early adolescence. The tics can be simple (e.g., throat clearing, eye blinking, grunting) or complex (e.g., touching objects, hopping) and, less often, self-harmful (e.g., punching oneself) or inappropriate (e.g., coprolalia); and individuals usually present with associated neurobehavioral problems, including attention deficit hyperactivity disorder, academic problems, and obsessive-compulsive symptoms. Other communication-related difficulties that have been noted include delayed receptive and expressive language skills, social/pragmatic interaction difficulties, and use of a rapid speech rate (Donaher, 2006). Van Borsel and Tetnowski (2007) noted that in older literature, stuttering often has been mentioned as one of many behavioral concomitants associated with Tourette syndrome; however, they stated that much of the older research literature is difficult to interpret due to inconsistent terminology for disfluency analyses and/or poorly specified research methodologies. More recent research, however, has failed to support the idea that people with Tourette syndrome are prone to stuttering, as stutter-like disfluency constitutes a minority of all disfluency types produced (e.g., Van Borsel, Goethals, & Vanryckeghem, 2004; Van Borsel & Vanryckeghem, 2000). Consistent with this finding, stutter-like speech is not mentioned as a characteristic of Tourette syndrome on NINDS’ most recent “fact sheet” for the disorder. Evidence of excessive production of other, non-stutter-like types of disfluency has been noted, however (De Nil, Sasisekaran, van Lieshout, & Sandor, 2005). In addition, Van Borsel and Tetnowski noted that several researchers have reported the presence of atypical disfluency such as word and sentence-final repetitions in some individuals with Tourette syndrome.

Fluency in Individuals With Neurofibromatosis Type 1 Neurofibromatosis type 1 is a genetically based disorder that is characterized by a cluster of symptoms including tumors (usually benign) that grow along nerves in the brain and in other parts of the body, as well as characteristic changes in skin color (café-

au-lait spots) and freckling in the underarm and groin regions (NINDS, 2018). According to NINDS, an assortment of other symptoms may be present, including larger-than-typical head circumference, short stature, cardiovascular problems, poor language and visual-spatial skills, and low academic performance. Fluency-related research with neurofibromatosis type 1 is limited. Cosyns and colleagues (Cosyns, Mortier, Janssens et al., 2010) reported on the occurrence of word-final disfluency in 21 adults with neurofibromatosis type 1. They observed relatively high mean disfluency frequencies for the participants in their study during conversation and monologue tasks (11% and 9% of words, respectively), with several of the participants exhibiting 16 or more total disfluencies per 100 words during a monologue task. Disfluency frequency during conversation and monologue was greater than it was during oral reading, stimulus repetition, and automatic speech — each of which featured disfluency frequencies of about 3%. Interjection and revision were the most common disfluency types, and both were produced more often than any of the classic stuttering-related disfluency types. The mean frequency for stutter-like disfluency was relatively low (1.82 per 100 words), and 19 of the 22 participants produced fewer than 3 stutterlike disfluencies per 100 words. Stutter-like disfluency was noted in word-initial and word-final positions more often than in word-medial positions. There was no effect for sentence position or grammatical class on distribution of stutter-like disfluency, and the participants showed no evidence of speech-related struggle when repeating or prolonging. Some participants presented complications of the central nervous system as a result of tumor growth. However, their disfluency levels were like those of participants who did not exhibit central nervous system complications. In sum, the authors did not find evidence that the individuals with neurofibromatosis type 1 routinely presented stutter-like speech. In a follow-up study, Cosyns, Mortier, Corthals, Janssens, and Van Borsel (2010) reported on a man with neurofibromatosis type 1 who produced word-final sound prolongations on 9% of words he produced. The disfluencies accounted for 11% of his total talking time and occurred most often on multisyllabic words.

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Fluency Disorders

Fluency in Individuals With Autism Spectrum Disorder During the past 2 decades, speech-language pathologists have shown an increased interest in studying fluency functioning in individuals who are diagnosed with autism spectrum disorder (ASD). Although the nature, symptoms, and effects of ASD in general functioning and social communication have been studied extensively, the fluency research literature in this area still is emerging. Scaler Scott (2011) summarized past research on disfluency patterns associated with ASD and reported consistent mention of the occurrence of both classic types of disfluency (e.g., repetitions, interjections, prolongations, revision) as well as uncommon forms of disfluency such as repetition of word-final sounds and mid-vowel interruptions in fluency (termed “broken words” in the Williams, Darley, and Spriestersbach [1978] taxonomy, upon which many contemporary disfluency classification systems in studies of stuttering are based). Several authors have reported the presence of uncommon disfluency types in children diagnosed with ASD (or with the older diagnostic label

of Asperger syndrome/disorder). Basic fluency data from several of those studies are reported in Table 10–2. Some studies reported group data, while others reported data for individual cases. One of the first group-level studies into fluency patterns in individuals with ASD was conducted by Shriberg and colleagues (Shriberg et al. (2001). They studied conversational speech and prosody characteristics in 15 males with high functioning autism, 15 males with Asperger syndrome (AS), and 53 males with typical speech. Utterances were coded for the presence of one or more than one instance of familiar disfluency types (e.g., part- and whole-word repetition, revision). On this basis, most (67%) of the individuals with AS and 40% of individuals with high functioning autism demonstrated nonfluent phrasing on more than 20% of their utterances, with utterances containing part-word repetition, whole-word repetition, and revision being the most common in the autism group, and utterances with part-word repetition and whole-word repetition plus revision being most common in the AS group. On average, about 86% of utterances in the typical fluency group were spoken fluently compared to only 75 to 76% of utterances in the ASD and AS groups.

Table 10–2.  Fluency Data From Several Studies of Individuals With Autism Spectrum Disorder Disfluency Frequency Typical Structure Study Plexico et al. (2010)a Scaler Scott et al. (2014)b Brundage et al. (2013)b

NonStutter-Like

Stutter-Like

Atypical Structure

2.3

1.6

0.4

N = 8; M frequency = 4:1

10.5

2.4

0.2

N = 11; WFD in 8/11 participants

NR

Baseline: 14.6

NR

Case report of 21-year-old male

Post1: 3.95

Other Details

Post2: 3.00 Sisskin & Wasilus (2014)b

Pre-tx: ~2.4

Pre-tx: ~4.7

Pre-tx: ~12.7

Post-tx: ~1.0

Post-tx: ~1.0

Post-tx: ~1.5

Note. NR = not reported, WFD = word-final disfluency, tx = treatment a frequency reported per 100 syllables b frequency reported per 100 words

Case report of 7-year-old male



Plexico, Cleary, McAlpine, and Plumb (2010) reported disfluency characteristics of 8 children who were diagnosed with ASD (see Table 10–2). They observed a mix of disfluency forms including traditional part- and whole-word repetition, sound prolongation, interjection, and revision, as well as uncommon types involving repetition of final sounds and syllables, within-word breaks (broken words), and between syllable sound insertions. Overall, the total mean disfluency frequency for the 8 children was relatively low (about 4.5 per 100 syllables) and, unlike findings from some case reports, atypical disfluency types such as repetition of word-final sounds were observed infrequently (M frequency = 0.4 per 100 syllables), and across the 8 participants, they occurred less often than either non-stutter-like disfluency or stutter-like disfluency. Each of the children produced enough stutter-like disfluency to obtain a severity rating, with four categorized as “very mild,” three as “mild,” and one as “moderate.” Scaler Scott, Tetnowski, Flaitz, & Yaruss (2014) compared disfluency profiles in 11 children with AS, 11 children who stuttered, and 11 children with typical fluency (see Table 10–2). Overall, 8 of 11 children with AS produced instances of atypical disfluency types (i.e., word-final repetition, broken words with and without sound insertion). However, mean frequency of atypical disfluency types across the 11 children was very low (less than 1% of words) and not statistically different from frequencies for the other two groups. They found that non-stutter-like disfluency was the most frequent type for all three groups. The groups did not differ statistically in production frequency for nonstutter-like disfluency; and descriptively, children with AS (about 11%) produced this disfluency type less often than children who stuttered (about 13%), but more often than children with typical fluency (about 8%). The children with AS produced stutterlike disfluency at a frequency of about 75% less than that of the children who stuttered (i.e., 2.37 per 100 words vs. 8.74 per 100 words). Nonetheless, 3 of 11 children met the criterion of a classification of at least very mild stuttering on the Stuttering Severity Instrument, and three also met criteria for cluttering. Sisskin (2006) reported on two individuals who were diagnosed with AS (one was age 7 years,

10.  Disfluency Patterns in Other Clinical Populations

the other age 17 years) and found it necessary to add two disfluency categories to the classification taxonomy that speech-language pathologists typically use with cases of neurodevelopmental stuttering: final part-word repetition and mid-syllable insertion. In the 17-year-old case, 90% of the disfluencies were non-stutter-like. Final part-word repetition and mid-syllable insertion (e.g. “see-hee” for the word “see”) were the most common types of disfluency (50% and 30% of the total, respectively). The case of the 7-year-old showed a similar profile: 50% of the disfluencies were not stutter-like, with mid-syllable insertions constituting 33% of the total disfluencies and final part-word repetitions constituting 25% of the total. Relatively little has been written on treating fluency problems in individuals with ASD. Brundage, Whelan, and Burgess (2013) addressed this gap in the literature with a report on treatment outcome for a 21-year-old male with a diagnosis of AS at age 16 and a diagnosis of ASD at age 19. Fluency data were collected over a time span of well over 1 year. During the first year, treatment focused on social communication skills and, when stuttering had begun to significantly limit communication, it was incorporated into the treatment plan as well. Frequency data for stutter-like disfluency are presented in Table 10–2. Pretreatment stuttering was rated as severe. After a 10-week intervention that focused on application of three core fluency management rules, stuttering severity decreased to approximately 4 words per 100, and then to approximately 3 words per 100 following a second block of treatment sessions. Sisskin and Wasilus (2014) reported treatment outcomes for a 7-year-old with a diagnosis of AS. The boy’s fluency was characterized by frequent repetition of word final sounds (i.e., syllable codas) and phrase repetitions that began with a retrace to a syllable coda in the word prior to the location of the point of continuity interruption (e.g., “cause I don’t . . . ” → [kɔz aI- ɔz aI dont]. The atypical disfluency types occurred at a frequency of approximately 8.4 per 100 words pretreatment, and accounted for approximately 75% of all disfluencies. Pretreatment word-final repetitions were characterized by as many as 8 iterations. Following treatment, atypical disfluency had decreased to approximately 1.2 to 1.5 per 100 words. Following

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a treatment program that incorporated strategies to increase the child’s ability to identify instances of disfluency and later to modify them using a disfluency cancellation strategy, which involved reproducing disfluent words in a fluent way. Stutter-like disfluency frequency decreased from about 5 per 100 words pretreatment to about 0.5 to 1 per 100 words posttreatment.

Other Cases of Atypical Disfluency As noted in the previous sections, disfluencies that feature repetition of word-final sounds and/or syllable rimes and disfluencies that feature mid-vowel breaks in speech continuity (“broken words”) are uncommon in the general population, but apparently more common in some clinical populations, particularly ASD. There are a number of other published reports on cases that present these and other uncommon forms of disfluency in conjunction with other medical diagnoses. There also are reports where these uncommon disfluency types seem to occur in the absence of comorbid disorders, and as such, are the primary presenting symptom of speech disorder. There also are a handful of reports where these atypical disfluency types occur in children who have been diagnosed with neurodevelopmental stuttering.

Word-Final Repetition in the Context of Ostensibly Typical Development Most of the early reports of atypical disfluency types were case studies, and several of these documented the phenomenon in children who had no diagnosed communication disorder or other diseases or syndromes. For example, Rudmin (1984) reported the presence of word-final repetitions in a longitudinal case study of his daughter. She repeated word-final voiceless stop consonants from age 16 to 29 months. After the word-final repetition resolved, the girl exhibited sound prolongation on liquid and glide consonants for about 4 months, after which the latter disfluency type resolved. Rudmin speculated that the disfluency pattern may have been caused by a failure to termi-

nate speech motor programs associated with segments of speech. A few years later, Mowrer (1987) reported on a case of final consonant repetition in a 2-year-old boy. Like many 2-year-olds, the boy exhibited systematic use of final consonant deletion, and the boy’s mother reported that she had attempted to teach him to produce word-final consonants by emphasizing and demonstrating final consonants in her speech. The boy reportedly often imitated his mother’s models of word-final consonants and sometimes repeated the final consonants several times, with emphatic aspiration. Over time, however, the frequency of the boy’s final consonant repetition increased markedly and no longer appeared to become involuntarily. The mother subsequently sought professional assistance, which led to Mowrer’s case study. At the initial evaluation, the boy produced 3.28 final consonant repetitions per 100 syllables. The next most frequent disfluency type, interjection, occurred only 1.31 times per 100 syllables, and the frequencies for other disfluency types were less than this and within normal frequency expectations. The boy also exhibited noticeable aspiration on many of the word-final stop consonants that were not repeated. During the 12-month study, the frequency of word-final consonants gradually diminished and eventually resolved. Following the initial speech assessment, Mowrer provided the child’s parents and caregiver informational material on how to reduce environmental demands that might negatively impact the child’s fluency. The extent to which this information led to the changes in the child’s word-final repetition was unclear. Camarata (1989) documented word-final repetition of voiceless stop consonants (i.e., /p/, /t/, /k/) in a preschool-aged boy. The repetitions were first noted at age 2;1 but seemed to resolve after about 1 month and did not return throughout the course of the study, which ended at age 3;5. Other than the word-final repetition, the child’s communication development appeared to be within normal limits, and the child showed no evidence of stuttering. The boy exhibited several phonological patterns that are common at age 2, including final devoicing and stopping. Thus, when the child encountered a word that featured a word-final voiced consonant, he routinely devoiced the con-



sonant (e.g., “tub” was pronounced as [tp]), and when the child encountered words that featured a voiced word-final fricative, the child devoiced it and then substituted a stop sound (e.g., “buzz” was pronounced as [bt]). Interestingly, words that featured devoicing of a voiced final consonant never featured word-final repetition. The word-final repetition occurred only on words that naturally feature voiceless word-final sounds. Thus, “but” and “bus” were produced as [btt], however, “buzz” was produced as [bt]. On this basis, Camarata (1989) hypothesized that the boy’s final consonant repetition was phonologically motivated — that is, it was used to prevent homonymy. In other words, without the use of final consonant repetition, minimal pairs such as “beat” and “bead” would have sounded the same in the child’s speech. The use of final consonant repetition enabled the boy to contrast the two words. The child’s repetition pattern always contained two iterations of the target consonant (e.g., pet- t). Camarata noted that double consonant use has been documented in some languages, where it serves a phonemic function. Camarata also argued that Mowrer’s (1987) case of final consonant repetition was likely phonological in nature as well, because the repetition patterns in the two studies shared many similarities. Teitler, Ferré and Dailly (2016) reported data on 8 French-speaking children, each of who exhibited repetition of word-final segments, but no concomitant communication disorders (including no evidence of stuttering) or other signs of impairment. The authors recruited the participants by contacting 122 French professionals with training in speech fluency. Overall, 10 children were referred for participation, and of these, 8 displayed evidence of word-final disfluency during data collection for the study. The children produced a total of 128 word-final disfluencies (M = 16), and across the individuals, word-final disfluencies were produced on 0.7% to 5.1% of their syllables. Similar to some other studies, multisyllable words were more likely to feature word-final disfluency than monosyllable words, and the atypical disfluency mainly occurred on word-final syllables and most often involved relatively effortless repetition of the syllable nucleus (in open syllable contexts) or syllable rime (in closed syllable contexts). There was no

10.  Disfluency Patterns in Other Clinical Populations

systematic pattern to the onset consonants in syllables that featured these repetitions. Coda consonant repetition seldom occurred, which the authors attributed in part to characteristics of French phonology. One participant exhibited atypicality in the editing phase and repair phases of some syllablefinal repetition. That is, the participant inserted a glottal stop at the midpoint of otherwise silent editing phrases and inserted an extraneous glottal voiced fricative at the start of the repair phase.

Atypical Disfluency in the Context of Other Communication Disorders Lebrun and Van Borsel (1990) reported wordfinal repetition of stops, fricatives, and /r/ in an 8-year-old boy. The boy also presented with a rapid articulation rate, “numerous phrase, word, syllable, and sound repetitions,” and some sound prolongations. The final sound repetition almost always consisted of reiteration of the final sound in the word, although on a few occasions the final two sounds in a word were reiterated. During reading, the word-final repetitions occurred on 8.25% of words. The frequency of word-final repetition remained constant in all but the middle trial of an adaptation task in which the child read a passage five times in succession. Thus, the frequency of word-final repetition did not clearly improve with repeated practice across the adaptation trials, as it would be expected to do with stuttered speech. In conversational speech, 16% of the boy’s words featured disfluency, but there was only one instance of word-final repetition in the 320-word sample, which translates to an adjusted frequency of 0.31 word-final repetitions per 100 words during conversation. McAllister and Kingston (2005) reported on word-final, part-word repetition during conversation, reading, and sentence repetition in two school-aged boys. In each case, the repetition pattern featured reiteration of some portion of the rime from the final syllable of the word (e.g., “breakfast” → [brEfIst -Ist]. The frequency of these disfluencies was relatively low for each child, with both boys producing about 3 per 100 words. The repetitions occurred on content words and function words. The first child (age 8;0) had a history

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of phonological disorder and stuttering, each of which had resolved by age 6;8. Shortly thereafter, at age 7;4, word-final part-word repetitions emerged in the child’s speech. The second child began to produce word-final, part-word repetitions at age 5;11 and continued to do so through age 7;6 (when the study was completed). The boy’s older brother reportedly had exhibited similar repetitions from age 5 to age 9. McAllister and Kingston reported that the word-final, part-word repetitions obeyed the following phonological constraints: • Child 1 exhibited repetition of the last syllabic nucleus of the final word, plus any consonants that were in the coda. For instance, “army” would have featured repetition of the word-final vowel /i/ and “poke” would have featured repetition of the vowel /o/ plus the /k/ from the coda (i.e., [ok]). • Child 2 exhibited repetition of the last syllabic element in a word, unless the word contained a diphthong, in which case the off-glide of the diphthong was repeated along with any consonants that were in the coda. For instance, “army” would have featured repetition of the word-final vowel /i/; the word “then” would have featured repetition of the word-final /n/, and the word “light” would have featured repetition of the off-glide [I] along with the final consonant (e.g., /laIt/ → [laIt-It]). McAllister and Kingston (2005) proposed both motoric (e.g., a type of compulsive action, a symptom of palilalia) and psycholinguistic (e.g., a symptom of sentence planning problems) explanations for these disfluencies. They also questioned whether repetitions such as these, when produced infrequently, should be regarded as evidence of a communication disorder. Van Borsel, Geirnaert, and Coster (2005) reported on a 12-year-old boy who developed word-final disfluency following a bout of migraine headaches that led to lowered consciousness, aphasia, convulsions, and progressive right-sided paresis-paralysis, followed by gradual recuperation. Referral for speech concerns occurred about

6 weeks after the episode, at which time the boy presented with disfluent “robot-like” speech and atypical voice quality. Assessment revealed disfluency that ranged from 0% (reading) to 11% (picture description) of syllables, and word-final partword repetition as the most common disfluency type (about 32% of all disfluencies). It occurred most often in tasks with relatively high linguistic complexity (conversation, narration, picture description) and rarely or not at all in simpler or nonspeech tasks (e.g., automatic speech, word repetition, singing). Most other disfluencies were nonstutter-like in nature; stutter-like disfluency was infrequently produced. Most word-final disfluency occurred with the final syllable of multisyllabic words and most (80%) involved VC rime repetition; the remainder involved repetition of either only the nucleus (V) or coda consonant. Conversational disfluency frequency decreased in the context of treatment from 9.25% of syllables to 3.08% of syllables over 5 weeks, along with complete elimination of the word-final repetitions. MacMillan, Kokolakis, Sheedy, and Packman (2014) reported on word-final disfluency in 12 children, 9 of whom were from four families, in each of which the father either currently stuttered (3) or previously had stuttered (1). Two of the children were also diagnosed with ASD, one with general anxiety disorder with compulsive behavior and one with mild phonological disorder. Food intolerances also were reported in several children. Similar to other studies, the disfluency most often involved relatively effortless repetition of the syllable nucleus (in open syllable contexts) or syllable rime or coda (in closed syllable contexts). MacMillan et al. conducted acoustic analyses of the word-final repetitions and found that the repeated syllable elements were produced with less intensity than the original syllable elements. Instances of sound prolongation/blocking on the coda consonants also were noted occasionally. In addition, 3 of the 12 children produced a total of six broken words. In contrast with most of the previous reports, 10 of the 12 children presented with concomitant developmental stuttering. The authors speculated that word-final repetition may be caused by a breakdown in the sensorimotor signaling process that indicates that completion of syllable articulation is imminent.



10.  Disfluency Patterns in Other Clinical Populations

Palilalia:  Repetition of Utterance Final Words Palilalia is a speech pattern that is characterized by compulsive repetition of a sentence, phrase, or word (Duffy, 1995). Unlike neurodevelopmental stuttering, the reiterations in palilalic speech typically are produced at the end of an utterance (e.g., She likes to play tennis, play tennis, play tennis, play tennis). The successive reiterations that characterize palilalic speech are produced often, but not always, with increasing rate and decreasing loudness (Kent & LaPointe, 1982), and they are more common during spontaneously generated speech than they are during rote or serial speech (LaPointe & Horner, 1981). Although patients generally are aware of and sometimes bothered by the reiterations, they typically do not appear to make any obvious effort to prevent their occurrence (Boller et al., 1973). Palilalia generally is considered to reflect bilateral basal ganglia dysfunction, and the disorder is reported most often in patients who have a history of postencephalitic Parkinson’s disease, dementia, pseudobulbar palsy, or Tourette syndrome (Duffy, 1995; Williams, 1978). Palilalia has been noted in conjunction with idiopathic Parkinson’s disease as well (Boller et al., 1973). Although most authors have not considered palilalic speech to have communicative value, in one report researchers presented conversational utterance examples of palilalic speech from a 16-yearold female with ASD, which they interpreted as having communicative purpose, specifically as a turn holding device during conversational speech. Boller et al. (1973) reported on a case of familial palilalia, in which both a mother and her son exhibited palilalic speech, as well as evidence of dementia, chorea (involuntary, purposeless movements), and “extensive intracerebral calcification.” The mother exhibited excessive repetition of utterance-final linguistic elements and instances of producing sequences of silent speech-like articulatory movements. X-ray images showed evidence of calcification in the basal ganglia, cerebellum, and cerebral gyri. Utterance-final repetition was observed during tasks that involved serial speech, such as counting and reciting the days of the week. Verbal output during conversation was quite limited. The

woman’s son exhibited more marked symptoms of palilalia, often repeating either an entire sentence or several of the final words from a sentence several times in succession. The reiterative speech fit the definitional criteria of palilalia in that speech rate tended to accelerate, and speech intensity tended to trail off. Palilalic reiterations also were noted during serial speech such that upon completing a recitation of the alphabet, the days of the week, or the months of the year, the man then restarted the series from the beginning. Palilalic reiterations were noted occasionally in writing, as well. Other deficits also were noted, including use of simplistic expressive language and limited verbal memory. The man exhibited calcification patterns similar to those seen in his mother. Boller et al. speculated that palilalic speech might be related to chorea. In other words, just as chorea reflects impairment in movement inhibition, palilalia seems to reflect impairment in speech inhibition. LaPointe and Horner (1981) reported descriptive data for a 29-year-old male who showed symptoms of palilalic-like speech. The cause of the speech disturbance could not be determined definitively; however, the man had a history of barbiturate abuse, phenobarbital addiction was suspected, and a previous psychiatric evaluation had resulted in a tentative diagnosis of simple schizophrenia. Overall, 38% of the man’s running speech consisted of palilalic speech. The maximum number of reiterations in the palilalic repetitions varied across tasks: 28 reiterations during spontaneous conversation, 14 reiterations during picture description, and 6 reiterations during sentence reading. When explaining the meaning of the proverb “look before you leap,” however, the speaker produced a total of 52 iterations during a single repetition. The mean number of iterations for these tasks, of course, was less than the maximum: 2.8 reiterations during spontaneous conversation, 3.1 reiterations during picture description, and 1.8 reiterations during sentence reading. Verbal formulation tasks like the proverb explanation evoked the longest repe­ titions — an average of 5.0 reiterations per trial. Kent and LaPointe (1982) reexamined acoustic properties of data from LaPointe and Horner ‘s (1981) study and found that the reiterative speech did not conform to classic characteristics of palilalic

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speech. That is, upon examining the rate and loudness of the reiterations, they found that the reiterative segments of speech did not get progressively faster, and, in fact, the last iteration in a series often had a longer duration than earlier ones. Similarly, the final iteration often was produced with greater intensity than the others. The authors concluded that the speech pattern might have been indicative of some reiterative speech problem other than palilalia and/or a variation of palilalia that resulted from neurological impairment other than that seen in most cases of palilalia. Logan and Maren (1998) reported a case study of a 6-year-old child who presented both stuttering and a form of whispered perseverative speech that was similar to palilalia. Case history information revealed that the child had begun stuttering at age 3. In the months leading up to the child’s speech assessment at age 6, there was a progressive worsening of the stuttering along with the emergence of whispered repetitions of entire sentences (or significant portions thereof). During the speech evaluation at age 6, the child produced 9.6 speech disfluencies per 100 syllables of conversational speech, with part-word repetition, phrase repetition, and sound prolongation as the most common disfluency types, and results from the Stuttering Severity Instrument–3 (Riley, 1994) indicated “moderate” stuttering. Several instances of palilalic-like repetition were noted during the evaluation. The palilalic-like reiterations usually were verbatim whispered repetitions of entire utterances or large portions of utterances that the child initially had

said with normal intensity, voicing, and rate. In addition, the child sometimes silently “mouthed” the articulatory movements associated with the just-completed utterances. Phonological development and other aspects of expressive and receptive language developmental were within normal limits. Results of a comprehensive neurodevelopmental assessment that was conducted elsewhere following the initial speech assessment indicated deficits in fine motor coordination but were otherwise inconclusive. The child’s performance was monitored across a 2-year period (age 6 to 8) in the context of a fluency treatment program and associated follow-up. Data on the child’s speech fluency at that time are summarized in Table 10–3. As shown in the table, palilalic-like repetitions occurred on about one quarter of all utterances, and, when combined with the silent, mouthed repetitions, about one third of all utterances featured repetition of final portions of an utterance. The palilalic-like speech and mouthed repetitions fluctuated in frequency during the year following the initial speech evaluation, after which they declined steadily until they eventually seemed to resolve. The role of treatment in the resolution of these behaviors was unclear, as the child showed very little awareness of when the palilalic-like behaviors occurred, even in the context of treatment activities. The frequency of the palilalic-like speech decreased steadily during the observations despite an increase in stuttering frequency during the middle stages of the treatment program, and palilalic-like speech occurred with equal frequency

Table 10–3.  Frequency of Palilalic-Like Repetitions, Mouthed Repetitions, and Stutter-Like Disfluency Across a 27-Month Span in a School-Aged Child (Logan & Maren, 1998) Observation Point

Behavior Palilalic-like repetitions Mouthed repetitions Stutter-like disfluency

1

2

3

4

5

6

Initial Evaluation

+6 months

+12 months

+18 months

+24 months

+27 months

25

16

9

4

250 ms. • Interjections: Locate places within or before an utterance where speech continuity is interrupted by semantically empty filler (e.g., um, uh).

Revisions

• Locate places within an utterance where the speaker corrects (i.e., repairs) a previously spoken part of the utterance.

1. He found a[>250ms of silence] cat. cat kitten. 2. You have a[ um ]kit We had a dog. 3. [Um- like- um]We hawk. 4. A[350ms of silence um]hawk

1. [He-]She She found a cat. have a kitten. 2. You [had-]have 3. The [tog-] dogs have a toy. 4. [My dog-] My cat likes dogs. 5. The [dog are-] dogs are cute.

Complex disfluency

• Locate places within an utterance where speech continuity is interrupted by instances of consecutive or nested disfluency types.

1. He [wa- um]found a penny. 2. [Y- You got-]You have a dime. 3. [Mike um- like um- ]Mark has a dime. bank. 4. [On my- In my- In- ]In my bank

a

Right-facing brackets ([) indicate disfluency onset; left-facing brackets (]) indicate disfluency offset. The dash after a typed character indicates a point at which the speaker interrupts (i.e., stops) speech production. A sequence of three consecutive typed letter characters (e.g., “sss”) indicates speech sound that is prolonged audibly for an excessive amount of time. A typed letter character followed by three consecutive dashes (e.g., “d---”) indicates that the articulatory posture for a speech sound is being held with little or no sound forthcoming for an excessive amount of time. Underlined text indicates the point at which the speaker advances an utterance beyond the point at which it originally was interrupted.



12.  Describing Client Performance

Table 12–2.  Factors to Consider When Attempting to Identify Instances of Stuttering Factor

Description and Comments

Does the disfluency involve short-element repetition?

If so, the disfluency is likely to be judged as an instance of stuttering.

Does the short-element repetition sound dysrhythmic?

If so, the disfluency is likely to be judged as an instance of stuttering.

• People who stutter produce all types of repetition more often than typical speakers do; however, repetitions of short elements of speech (i.e., sounds, syllables, parts of words, monosyllable words) discriminate between the two speaker groups more powerfully than other repetition types. • Short-element repetitions are more likely to be judged as instances of stuttering when they sound dysrhythmic and/or rapidly paced versus when they sound rhythmic and slow-paced. • That said, a short-element repetition does not have to sound dysrhythmic or rapidly paced to be judged as an instance of stuttering.

Does the disfluency involve prolonged or blocked speech sounds?

If so, the disfluency is very likely to be judged as an instance of stuttering.

How long do the repetitions, prolongations, and blocks last?

The longer an instance of repeating, prolonging, or blocking last, the more likely it is to be judged as an instance of stuttering.

• People who stutter produce prolonged or blocked speech sounds much more often than typical speakers do. Typical speakers rarely produce prolongations or blocks. Producing 1 or 2 of these per 100 syllables is considered atypical. • Even brief instances of these disfluencies are likely to be judged as “stuttered” when accompanied by excessive physical tension.

• In typical speakers, disfluencies usually last less than 1 second, and most shortelement repetitions feature only one extra iteration of the repeated element (b- boy). • Multi-iteration repetitions are common in people who stutter and are frequently judged as stuttering (e.g., b- b- boy). • As the duration of a repetition, prolongation, or block extends beyond 1 second, it more apt to be judged as stuttering.

Does the speaker slow articulation rate in ways that sound unnatural or effortful?

If yes, that part of the utterance may be an instance of stuttering.

Do syllable stress patterns in utterances sound unnatural?

If yes, the affected syllables may be an instance of stuttering.

Does the speech appear or sound effortful?

If yes, the affected speech is likely to be judged as an instance of stuttering.

• Some speakers who stutter slow their articulation rate in advance of an upcoming word that is expected to be stuttered. • The slowing may be extensive enough to be perceived as sound prolongation (see row 2 above), to be perceived as unnatural, and/or to give the sense that the speaker uses excessive effort to speak smoothly. • Some speakers who stutter produce syllables with roughly equal stress, giving speech a mechanical quality. Speaking in this way sounds unnatural and gives the sense that the speaker is talking in this way to maintain speech continuity. • Excessive physical effort may manifest visually (e.g., as tight or tremulous muscles, as extraneous bodily movement, as brief catches in initiation of speech sounds that most people produce smoothly) or acoustically (e.g., as noise bursts during the release of stop sounds or as strained sounding phonation during vowel production), or as appearing to struggle with coordination articulation, phonation, and speech breathing. continues

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Table 12–2.  continued Factor

Description and Comments

Does the speaker use extraneous movement to initiate speech or maintain speech continuity?

If yes, the affected part of the utterance is very likely to be judged as an instance of stuttering.

Does the speaker produce multiple instances of stutter-like disfluency in the sample?

As the frequency of stutter-like disfluency increases in a speech sample, any individual instance of stutter-like disfluency is more likely to be judged as being stuttered.

• Compensatory behaviors such as timing syllable initiation with the rhythmic beat of a nonspeech movement such as finger tapping are indicative of stuttered speech.

• For example, the repetition of “he” in [He-]He went home is more apt to be judged as “stuttered” in a speaker who produces 10 other similar disfluencies during a 200-syllable speech sample than it is in a speaker who produces no other instances of stutter-like disfluency during a 200-syllable speech sample.

Stuttering Frequency:  Computational Steps 1. Listen to a brief stretch of the client’s speech (e.g., a phrase, clause, short utterance, or sentence); 2. Within the stretch of speech, (a) Identify the words that comprise the speaker’s target message; (b) Identify any syllables in the target words that feature symptoms of stuttering; and (c) Identify instances of disfluency that are not symptomatic of stuttering. a. For example, in the following sentence, the six underlined words constitute the target message and the three bracketed areas constitute instances of stuttering: The [b- b- b-] boat [ssss]sailed sailed [by- by- ] by the um dock dock. The interjection um is not underlined or bracketed because it is judged to be disfluent but not stuttered. Thus, this example features 3 instances of stuttering within a sample of 6 (target) words, plus 1 instance of disfluency (which is not indicative of stuttering). 3. Repeat Steps 1 through 3 until a predetermined minimum number of target words (or syllables) has been analyzed or until the end of the sample has been reached. 4. Divide the total number of stuttering instances by the total number of target words and then multiply the quotient by 100. This yields the number of stuttering instances per 100 words. (Disfluencies that are not judged as stuttering are not included in the stuttering frequency score.) a. For example, if a speaker produces 20 instances of stuttering while saying 365 target words, the number of stuttering instances per 100 words is: (20/365) × 100 = 5.48 5.48. b. When syllables are used as the unit of reference, the term “syllables” replaces the term “words,” and the result can be expressed either as “number of stuttering instances per 100 syllables” or as “percentage of syllables stuttered”).2

2 

 ote, however, that “percentage of words stuttered” is not interchangeable with “number of stuttering instances per 100 words” because N of the possibility of stuttering on more than one syllable in a word. For example, when the word calculator is produced as [c- c-]cal[c-] culator, there is 1 stuttered word, but two stuttered syllables. If this occurred in a speech sample, “percentage of words stuttered” would yield a different score than “number of stuttering instances per 100 words.”



12.  Describing Client Performance

Table 12–3.  Identifying the Boundaries of Stuttering Instances Stuttering Structure

Procedure

Examplesa

Repetitions

• Locate places where speech continuity is interrupted by stuttering-related repetition.

1. He [f- ]found a penny. 2. She [f- f- f-]found a dime. 3. [You-]You have a dollar. 4. [We- we- we-]We had a nickel. 5. [He w- He w-]He went shopping.

Prolonged or Blocked Speech Sounds

• Locate places where speech continuity is disrupted by stuttering-related sound prolongation or blocking.

1. He [fff]ound a penny. 2. W[eee] had a dime. 3. We had a [d---]dime. 4. [O---]ur mom went shopping.

Complex Disfluency

Other StutteringRelated Behavior

• Locate places where speech continuity is interrupted by consecutive or nested disfluencies, some of which involve short-element repetition, sound prolongation, or blocking.

1. He [f- f- um f-]found a penny.

• Extraneous sounds or movements prior to utterance initiation or during utterance production.

1. [A, , A] Two pennies.

2. [YYY- yyy-]You have a dime. 3. [Mmmike- ]Mark has a dime. 4. [In m- In my- in m-]In my bank.

2. [rhythmic finger tapping] Two pennies. 3. We had a [ni]ckel. (head jerk) 4. I [have a dollar]. (audible effortful exhalation throughout bracketed part of utterance)

a

 ight-facing brackets ([) indicate onset of stuttering-related behavior; left-facing brackets (]) indicate offset of stutteringR related behavior. The dash after a typed character indicates a point at which the speaker interrupts (i.e., stops) speech production. A sequence of three consecutive typed letter characters indicates speech sound that is prolonged audibly for an excessive amount of time and is judged to be symptomatic of stuttering. A typed letter character followed by three consecutive dashes indicates that the articulatory posture for a speech sound is being held with little or no sound forthcoming for an excessive amount of time and is judged to be symptomatic of stuttering.

Formats for Analyzing Continuity Data Traditionally, clinicians have used either orthographic transcripts or code-based transcripts to arrive at disfluency scores and stuttering scores. Orthographic transcripts yield verbatim written accounts of what a speaker has said, whereas, with code-based transcripts, the speaker’s output is represented using non-word symbols. Examples of each type of transcription are presented here. With either orthographic or code-based transcription, data can be input live (i.e., as the client speaks) or by replaying a recording of the speaker. Live data entry is more time efficient; however, it can be challenging to do accurately when a

speaker is highly disfluent, talks rapidly, and/or is very talkative. Also, the attention required to complete real-time data entry and analysis can interfere with the clinician’s ability to interact naturally with the client and observe client behaviors that are relevant to assessment. For these reasons, clinicians who are new to computing disfluency frequency scores are advised to base their analyses on recorded speech samples.

Orthographic Transcription Figure 12–2 presents an example of a verbatim transcript of an excerpt from an oral narrative. In this example, disfluencies in speech are categorized under either “Repetitions, Prolongations, and

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Utt Numa 1

Utterance Okay, well, in this [p---]picture here we have a lot going on

Syllables

RPBs

ODs

15

1

0

2

[There’s, let's see-, um] we have a boat.

4

0

1

3

And the boat is coming in [t- t-]to the dock. There is a crane, actually a few cranes, and they’re loading stuff on the boat.

10

1

0

18

0

0

One of the cranes is loading a big [b---]box. Another is loading what looks to be a train car or maybe a school bus or something.

10

1

0

22

0

0

6

0

0

15

3

1

18

4

0

28

2

0

13

2

0

4 5 6 7 8 9

And there's another crane. It’s loading a giant [t---]truck, but [it’s g- i- i-] it’s going [t- t-]to miss [uh] the boat. There are some [p--]people on the boat and they’re [d--]directing the crane [www]where [t-]to go.

11

One of the guys is about to get hit [b--]by an aero[p--]plane that looks like it is about to crash into the boat. There's also a guy dropping in on a [p---]ara[shshsh um shshsh]cute.

12

I'm not sure where he’s going [t- t-]to land.

9

1

0

13

On the dock there are a lot of workers.

10

0

0

14

They’re all very busy.

6

0

0

184

15

2

10

TOTALS

Frequency of Repetitions, Prolongations, and Blocks per 100 Syllables: (15/184) x 100 = 8.15 Frequency of Other Disfluency Types per 100 Syllables: (2/184) x 100 = 1.09 Disfluency Frequency (any type) per 100 syllables: (17/184) x 100 = 9.24

Note: Utt Num = Utterance Number Figure 12–2. An example of an orthographic transcript of an oral narrative produced during administration of the Stuttering Severity Instrument-4 (Riley, 2009). In this example, a verbatim record of the speaker’s utterances was created, with disfluencies separated from target words in each utterance to facilitate the syllables per utterance counts. Disfluencies were assigned to one of two categories. The first category, “Repetitions, Prolongations, and Blocks” (see RPB column) captures disfluencies that feature any form of repeating and/or prolonging or blocking of speech sounds. Recall that these disfluency types are characteristic of stuttered speech. The second category, Other Disfluencies (see OD column), captures disfluencies that feature only interjecting, revising, and/or pausing. Recall that these are disfluency types that people who stutter and typical speakers tend to produce with similar frequency.

Blocks” (see RPB column) or “Other Disfluencies” (see the OD column). As shown in the figure, the sample size is determined by counting only syllables in the words that comprise the target message in each utterance; speech from disfluent segments of each utterance are excluded from the count. The syllables and disfluencies are counted in each row and then summed, which allows for calculation of disfluency frequency statistics.

For speech samples that involve oral reading, computation of disfluency frequency is simpler. The first step is to determine the total number of words and/or syllables in the passage. As the client reads the passage aloud, the clinician codes a copy of the passage for the following types of information: (a) the location and types of any disfluencies (or stuttering instances) that occur, and (b) the location of any uncorrected reading errors



12.  Describing Client Performance

make on a copy of a reading passage to capture this information. Disfluency frequency is computed by dividing the total number of disfluencies by the adjusted passage length (in words or syllables), and then multiplying the quotient by 100.

that increase or decrease the original length of the passage. If desired, the location of any misread words that do not alter the length of the passage also can be documented. The clinician then tallies the number of disfluencies (or stuttering instances) and adjusts the original passage length as necessary to account for all reading errors that resulted in adding or subtracting words (or syllables) from the total in the original passage. Figure 12–3A illustrates the types of notations that a clinician would

Coded Transcription In Figure 12–3B, an example of a coded transcript is presented. The coded transcript is based

A

Coded Transcript of Client Sample A B C D E F

1 Sent1/ -

- S - - -

2 S Sent2/ -

- - -

3 - - - - -

4 S - - - S

5 - - - - -

6 - - Sent3/- - -

7 - - - - -

8 - - - - -

9 - - - - -

10 - - S Sent4/ -

-

Note: Each cell corresponds to one syllable. The sample contains 4 sentences, 51 syllables, and 5 instances of stuttering. Stuttering frequency score: 9.80 per 100 syllables (i.e., 9.8% of syllables are stuttered B Figure 12–3. Panel A shows markup of a passage that a client who stuttered read aloud. Three disfluency types are indicated by the notations: part-word repetition (twice), audible sound prolongation (twice) and inaudible “blocking” (once). Each of these disfluency types is characteristic of stuttered speech (i.e., these are “stutter-like disfluencies”). The observed number of stutter-like disfluencies (5), when adjusted for the length of the passage in syllables, translates to a stuttering frequency score of 9.80 per 100 syllables. In Panel B, the content of the reading passage has been mapped to the grid (one cell per syllable in the original passage). Syllables that featured stutter-like disfluency are coded with “S” to indicate they were judged to be symptomatic of stuttering, and syllables that were produced without stutter-like disfluency are coded with a dash. Each of the “S” codes could have been coded instead to indicate the type of disfluency produced. For example, cell A2 (which corresponds to the first syllable of “children” in row 1 of the story) could have been coded as “PWR” to indicate that a part-word repetition had occurred.

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on an oral reading sample. To illustrate how the coded transcript corresponds with the content of the speech sample, the figure (see Figure 12–3A) also shows the original passage and how the passage looks when it includes transcription of the stuttering-related disfluency. In this example, the oral reading sample upon which the coded transcription was based did not contain any disfluencies that were judged as non-stuttered. Had such disfluencies occurred, these could be entered into

the scoring grid, if desired, and marked with a different code, such as “D” (for “disfluent, but not stuttered”). Note that coded transcription typically would not be needed for analysis of oral reading samples because the clinician already has access to an orthographic transcript of what was being said (Figures 12–3A and 12–4). The coded transcription approach is most useful when analyzing spontaneously produced speech, such as the narrative sample shown in Figure 12–2 or conversational utterances — 

Figure 12–4.  Example of the types of notations that would be made as part of a disfluency analysis for a sample of oral reading. As it is originally printed, the passage contains 151 words and 250 syllables. Notations are made for reading errors that affect passage length. The client produced 12 instances of stuttering (indicated by shaded portions of words), which when divided by the number of syllables in the passage, translates to 4.8% of the syllables. Reporting frequency scores that are adjusted for sample size makes it possible to compare a client’s performance among oral reading samples that are obtained from passages of differing lengths.



12.  Describing Client Performance

contexts where a prepared orthographic transcript would not be readily available and would be time consuming to create.

Computer-Assisted Approaches to Measuring Fluency FluCalc.  Some software programs that were designed originally for analysis of children’s language production can be used to generate statistics about speech fluency, as well. Programs like this are particularly useful when assessing children, an age range where clinicians may be interested in thoroughly evaluating both fluency and language performance. The most extensive of computer-assisted approaches is FluCalc, a computational tool that is part of the FluencyBank project (https://fluency.talkbank.org). FluencyBank is part of the larger TalkBank project, which has been funded by the National Institutes of Health and the National Science Foundation and has been operating since 2000 (Bernstein Ratner & MacWhinney, 2018). TalkBank grew out of the Child Language Data Exchange System (CHILDES), which Brian MacWhinney and Catherine Snow founded in 1984 to promote and improve upon the study of child language development. In its current form, a main project goal for FluencyBank is to develop a large, sharable database that researchers can use to study aspects of speechlanguage development and disorders and that professionals and students can use to learn about typical development as well as various speech-language disorders (Bernstein Ratner & MacWhinney, 2018). The FluencyBank website resources are free to use. Individuals who wish to make use of the research-related data first must become a member of the FluencyBank consortium group, a process that also is free. FluencyBank also includes a free, open access teaching section, which is useful for developing fluency assessment skills. The data analysis tools in the TalkBank/FluencyBank systems operate on transcripts that are developed in CHAT (Codes for Human Analysis of Transcripts), which is an open-access, Web-based 3 

system for coding. Coding conventions are straightforward to use, and symbols used to code behaviors of interest, such as specific types of speech disfluencies, are applicable across languages. Once a CHAT-formatted transcript has been prepared, it can be analyzed automatically using one or more of the tools (e.g., Eval, KidEval, FluCalc) included in the Computerized Language Analysis (CLAN) module. With the Eval and KidEval tools, a clinician or researcher can obtain rich, highly accurate morphosyntactic descriptions of a speaker’s transcript. Much of the morphosyntactic information is generated automatically via parsing of regular typed text — that is, without the need for annotating transcripts with additional specialized codes. The FluCalc tool yields information about the frequency with which various types of disfluency are produced (the disfluency labels used largely are consistent with those used in this book). Observed instances of disfluency are counted, along with sample-size-adjusted frequencies (i.e., proportions that are referenced against the number of words or syllables in the speech sample). FluCalc also generates a weighted stutter-like disfluency score, which is useful for differentiating a sample of typical speech fluency from samples of stuttered speech.3 To generate the fluency data, the transcript must first be annotated using the CHAT codes for specific disfluency types (e.g., ≠ is the code for blocking). Audiovideo recordings of speech samples can be uploaded to FluencyBank, and when this is done, the CHATcoded transcription can be linked to the audio-video media on an utterance-by-utterance basis. FluencyBank’s website features a free downloadable manual that is tailored to speech-language pathologists (i.e., A Clinician’s Complete Guide to CLAN and PRAAT (Bernstein Ratner & Brundage, 2019) and provides an overview of the CLAN coding process. FluCalc output can be merged into a Microsoft Word template for clinical reporting. Systematic Analysis of Language Transcripts (SALT).  Systematic Analysis of Language Transcripts (SALT; Miller, Chapman, & Nockerts, 1998)

 he weighted stutter-like disfluency (SLD) score generated by FluCalc is based on Yairi and Ambrose’s (1999) weighted SLD score, T which is a weighted composite score. The clinician first computes the total frequency of short-element repetitions, sound prolongations, and blocks produced. Weighting is attained by multiplying short-element repetition frequency by the average number of iterations per repetition and by multiplying the prolongation/block frequency by a factor of 2.

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is a computer program that was designed primarily for analysis of children’s language, but that also can be applied to fluency analysis. With this program, the clinician generates a written transcript of what a speaker has said. When coded properly, the program generates statistics for basic indices of language performance such as mean utterance length in morphemes and number and types of grammatical morphemes used. It also captures aspects of lexical diversity (e.g., type/token ratio, number of different words). Disfluent speech (“mazes” in the parlance of the SALT manual) also can be coded within the transcripts by putting parentheses around disfluent segments, for example, (He) He went home. Using this and other transcription conventions, the program will tally instances of various disfluency types. If additional specificity in disfluency description is needed, descriptive codes can be placed after any word, and these are automatically tallied during data analysis, as well. Computerized Scoring of Stuttering Severity. The Stuttering Severity Instrument–4 (SSI-4; Riley, 2009) features a software tool — the Computerized Scoring of Stuttering Severity (CSSS-2.0; Bakker & Riley, 2009) — that can be used to measure either disfluency frequency or stuttering frequency. Data entry can be done either live, as the client talks, or while listening to an audio recording of the client’s speech. To measure instances of stuttering or disfluency with this tool, the clinician listens to a running sample of speech and presses a specific computer key each time a syllable in a target utterance is produced fluently. The clinician presses another specific key each time a syllable in a target utterance is produced with evidence of disfluency or stuttering. The software tallies both types of key presses to generate a frequency score (e.g, number of disfluencies per 100 syllables, percentage of syllables stuttered). Stuttering Measurement System. The Stuttering Measurement System (SMS; Ingham, Ingham, Moglia, & Kilgo, n.d.) is a program that has been available for download via a website at the University of California, Santa Barbara (see http:// www.speech.ucsb.edu/roger.htm). The program is designed to measure stuttering frequency (i.e.,

percentage of syllables stuttered) and speech naturalness. The software is accompanied by a training manual (Ingham & Ingham, 2011), which provides users with information on how to develop their competence at calculating these measurements. Completion of a training protocol associated with the SMS improves scoring accuracy of stuttering measurement by approximately 34%, which is superior to having no training (Bainbridge, Stavros, Ebrahimian, Wang, & Ingham, 2015).

Reporting Summary Statistics After completing the preceding analyses, it is customary to summarize the results in a table. This section describes how to do this for both the disfluency frequency scores and stuttering frequency scores.

Summarizing Data from a Disfluency Analysis When conducting a disfluency analysis, it is customary to report statistics for individual disfluency types and/or for disfluency subgroups (e.g., “stutter-like disfluency types”). Figure 12–5 contains examples of reporting formats for summarizing frequency data for disfluency types in these two ways, respectively. Both reporting formats are adapted from a format presented by Conture (2001). In Figure 12–5, data are reported for seven disfluency types. Two frequency scores (i.e., number of disfluencies per 100 syllables and number of disfluencies per 100 words) are reported. In practice, clinicians usually would report only one of the two frequency scores. For most clients, the “per 100 words” value will be a greater number than the “per 100 syllables” value. This is because most speech samples contain more syllables than words; thus, the divisor for “per 100 syllables” will be greater than it is for “per 100 words.” Also, most clients mainly will produce one disfluency per word; thus, the number of stuttered words and the number of stuttered syllables often is similar within a given speech sample. As shown in the lower half of Figure 12–5, disfluency data from rows 1, 2 and 4 in the table were summed into a single category (“stutter-like disflu-



12.  Describing Client Performance

Observed frequency 6

Adjusted frequency (disfluencies per 100 syllables) (6/457) x 100 = 1.31

Syllables = 457 Words = 402 Adjusted frequency (disfluencies per 100 words) (6/402) x 100 = 1.49

2. Word repetition

3

(3/457) x 100 = 0.66

(3/402) x 100 = 0.75

3. Phrase repetition

5

(5/457) x 100 = 1.09

(5/402) x 100 = 1.24

4. Prolongation/Blocking

19

(19/457) x 100 = 4.16

(19/402) x 100 = 4.73

5. Interjection

8

(8/457) x 100 = 1.75

(8/402) x 100 = 1.99

6. Revision

4

(4/457) x 100 = 0.88

(4/402) x 100 = 1.00

7. Pausing

12

(12/457) x 100 = 2.63

(12/402) x 100 = 2.99

57

(57/457) x 100 = 12.47

(57/402) x 100 = 14.18





Sample Size: Summary Table



Disfluency types 1. Part-word repetition

Total Summary Statistics

Disfluencies per 100 syllables: (57/457) x 100 = 12.47 Disfluencies per 100 words: (57/402) x 100 = 14.18 Stutter-like disfluencies per 100 syllables (1.31 + 0.66 + 4.16) = 6.13 (See rows 1 + 2 + 4): Repetitions, prolongations, and blocks per (1.31 + 0.66 + 1.09+ 4.16) = 7.22 100 syllables (See rows 1 + 2 + 3+ 4): Percent of all disfluencies that feature (6.13/12.47) x 100 = 49% stutter-like disfluency: Other (non-stutter-like) disfluencies per 100 (1.75 + 0.88 + 2.63) = 5.26 syllables (Rows 5 + 6 + 7): Figure 12–5.  This figure shows summary statistics and associated disfluency frequencies for various disfluency types that were observed in a speech sample that contained 457 syllables and 402 words. Disfluencies were labeled during data analysis, and tallied to yield the numbers in the “Observed Frequency” column. The number of observed disfluencies for each type of disfluency then was divided by the sample size to yield two sample-size-adjusted frequency scores: the number of disfluencies per 100 words and number of disfluencies per 100 syllables. Various summary statistics are reported in the lower half of the table, including a frequency score for stutter-like disfluency.

ency”) because the frequencies with which these disfluency types are produced reliably differentiate speakers who stutter from speakers with typical fluency. The frequencies for interjection, revision, and pausing also were collapsed into one category (“other disfluency”), as these disfluency types dif-

ferentiate speakers who stutter from speakers with typical fluency less reliably. The number of repetitions, prolongations, and blocks per 100 syllables also was computed, as that would be likely to differentiate speakers who stutter from speakers with typical fluency.

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Disfluency Measures Versus Stuttering Measures The preceding sections have reviewed one approach to describing speech continuity that is based on analysis of instances of disfluency and another that is based on instances of stuttering. Questions often arise regarding which of the approaches is better and when it is most appropriate to select one approach over the other. These issues are addressed in this section.

Pros and Cons of Measuring Instances of Disfluency There are at least three pros associated with disfluency-based measures. First, because all people produce disfluency, disfluency-based measures can be used with any client, regardless of whether he or she stutters. Perhaps it is for this reason that the web-based fluency research consortium FluencyBank bases its fluency calculations on disfluency types rather than on “instances of stuttering.” Disfluency frequency scores are particularly useful when a direct comparison between a typical speaker and a speaker with fluency impairment is needed because it captures a class of behavior that both speaker groups produce. For example, the use of disfluency-based measures on the Test of Childhood Stuttering (Gillam, Logan, & Pearson, 2009) allows for direct comparisons between typical children and children who stutter on the frequency with which they produced part- and whole-word repetitions, prolongations, and blocks. This comparison forms the basis of diagnostic decision-making on the test. Second, disfluency-based measures are flexible: Categories can be added to or removed from an existing taxonomy of disfluency types as necessary to capture unique disfluency forms that a client produces. Discreet disfluency categories can be bundled to emphasize the types of disfluency that characterize certain clinical populations (e.g., repetitions, prolongations, and blocks are typically bundled in assessment of individuals who stutter; interjections and revisions can be bundled in assessments of individuals who clutter or who have certain types of language disorder).

A third advantage of disfluency-based measures is that disfluency identification is mostly an objective process. The structural properties associated with disfluency categories make examplars of each category relatively easy to identify. Measurement problems can arise, however, particularly with the identification of sound prolongation, where clinicians sometimes face the challenge of deciding whether the duration of a sound is sufficiently elongated to be regarded as “prolonged.” Also, the distinction between part- and whole-whole repetition sometimes can be challenging to discern when repetition occurs on one-syllable words such as “I,” or “a.” The clinician’s challenge here is in determining whether a speaker has repeated the entire word or only part of it. Lastly, behaviorally complex disfluencies (e.g., the speaker prolongs while repeating) can be challenging to label (e.g., Does it constitute one disfluency or more than one disfluency?). In the author’s experience, each of these measurement challenges can be addressed satisfactorily by establishing clear, detailed methods for how to conduct the analysis.

Pros and Cons of Measuring Instances of Stuttering The concept of “stuttering instance” differs from that of “disfluency” in several ways. One main difference is that identification of stuttering behavior involves a subjective judgment about not only the type of disfluency produced, but the rhythm, duration, and effort characteristics of the disfluency. In other words, the goal is to determine whether speech has been interrupted in a way that is symptomatic of the disorder stuttering. Another difference is that stuttering judgment often goes beyond the primary fluency dimensions discussed here to include consideration of extraneous behaviors, some of which come under the domain of nonspeech behaviors that are produced in reaction to the expectation of an instance of stuttering in order to compensate for or conceal the effects of fluency impairment. One limitation of describing continuity in terms of stuttering instances is that the measure can be used only with people who stutter or who are suspected of stuttering. This is because the behavior stuttering, by definition, is something that



only people who are diagnosed with the disorder “stuttering” do. This limitation becomes an advantage when the measure is applied to this clinical population, however, as stuttering instances link directly to metrics of stuttering severity. Thus, the measurement of stuttering instances in assessments with people who stutter has strong face validity: It is a measure of the speech behavior that is the primary concern of individuals who are seeking treatment for the disorder. Although the stuttering measurement procedure outlined earlier in the chapter may seem relatively straightforward to do, in clinical practice, it does not always turn out this way. Research has shown that both laypersons and experts sometimes disagree on whether specific instances of speech should be classified as “stuttered” (Cordes & Ingham, 1994; Curlee, 1981; Ingham & Cordes, 1992; Kully & Boberg, 1988; MacDonald & Martin, 1973; Martin & Haroldson, 1981). Fortunately, both experienced and inexperienced judges show improved measurement reliability when they are asked to evaluate larger units of speech such as a spoken narrative, an entire utterance, or a 4-second segment of speech for the presence or absence of stuttering (Armson, Jenson, Gallant, Kalinowski, & Fee, 1997; Chakraborty & Logan, 2018; Ingham, Cordes, & Gow, 1993). Reliability also is improved when raters are asked to make global judgments about whether a speaker is or is not a person who stutters (Bloodstein & Bernstein Ratner, 2008). Also, although raters may not always agree on exactly where an instance of stuttering has occurred, their summary statistics (e.g., percentage of syllables stuttered) tend to be similar (Curlee, 1981; Yaruss, LaSalle, & Conture, 1998). Still, experienced raters tend to identify more instances of stuttering than inexperienced raters do (Brundage, Bothe, Lengeling, & Evans, 2006); thus, it is important for clinicians who are new to the stuttering judgment process to be knowledgeable about the kinds of behaviors highly experienced clinicians identify as “stuttered.” Training materials to assist with the process can be found along with the automated fluency analysis software that Ingham and colleagues developed (e.g., Ingham & Ingham, 2011; Ingham et al., n.d.). Materials in FluencyBank (FluencyBank.org) and in the online resources for this book are useful for training, as well.

12.  Describing Client Performance

Another issue that arises with stuttering measurement is conceptual in nature. That is, many authorities have questioned the validity of thinking of stuttering as something that can be quantified in terms of discreet “events” or “instances” The “event-based” view of stuttering can give the impression that stuttering is a form of speaking that a speaker moves in and out of while talking. The work of Smith and colleagues, however, calls this view of stuttering into question. Their research has demonstrated, among other things, that markers of stuttering are present in speakers’ speech breathing patterns and autonomic nervous system activation during segments of speech that precede overt “instances” of stuttering during speech that, from an acoustic perspective, sounds fluent (Denny & Smith, 1992; Smith & Kelly, 1997; Weber & Smith, 1990). In a series of other studies with people who stutter, Smith and colleagues demonstrated that samples of speech that sound normal from an acoustic perspective actually look disordered when one examines patterns of spatial-temporal coordination in connected speech (e.g., Kleinow & Smith, 2000; Smith, Sadagopan, Walsh, & WeberFox, 2010). The main pattern is that speech-related movements of speakers who stutter during ostensibly “fluent” speech show much greater spatial-temporal variability than the movements of non-stuttering speakers. Differences between the speech of people who stutter and typical speakers during perceptibly fluent samples of speech have been demonstrated by other researchers as well (e.g., Smits-Bandstra & De Nil, 2009; Zebrowski, Conture, & Cudahy, 1985). Other researchers have reached similar conclusions based on other types of analyses (e.g., Armson & Kalinowski, 1994; Lickley, Hartsuiker, Corley, Russell, & Nelson, 2005). Research findings such as these suggest that, rather than thinking of stuttered speech as something that occurs at certain moments or in discrete instances, it is more accurate to think of stuttered speech as any speech that a person who is diagnosed with the disorder “stuttering” produces. From the latter perspective, it is important to realize that the widely used practice of using acoustic data to make judgments about stuttered syllables yields only a partial picture of the fluency difficulties that speakers who stutter experience (Smith & Kelly,

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1997). That is, by analyzing “stuttered instances,” clinicians are likely identify only the most obvious or aberrant points of dysfunction in an individual’s speech. Meanwhile many other relevant, but more subtle, symptoms of fluency impairment are likely present in speech; however, these symptoms of stuttering are much more subtle and detectable only with sensitive instrumentation that evaluates aspects of speech production beyond what is found in the acoustic signal. Despite the conceptual problems associated with the measurement of stuttering instances, this metric nonetheless does offer clinicians a convenient, “low-tech” method of capturing the extent of fluency impairment a speaker has. For this reason, measurement of stuttering today mostly remains organized around the quantification of discreet moments in time when a person’s speech behavior obviously looks or sounds symptomatic of the disorder called stuttering.

Measuring Disfluency Versus Measuring Stuttering: Which One to Use? As noted, both disfluency- and stuttering-based measures have advantages, and one can make a case to support either approach for specific clinical purposes. The author has found that disfluencybased measurement is a good starting point for clinicians who are new to fluency assessment because it requires only a statement of how the speaker was disfluent, not why the speaker was disfluent (as is the case with stuttering-based measurement). Also, it is an approach that one can use with any type of client, and thus is useful to know. The level of detail associated with disfluencybased measurement is not necessary for all clinical activities, however. Thus, binary coding (disfluent/ fluent) often may suffice in settings such as treatment activities. Stuttering-based measurements are particularly useful with clients whose disfluencies consist mainly of unambiguous exemplars of stuttering behavior. With clients who produce disfluencies that are more difficult to differentiate (stuttered or non-stuttered), a disfluency-based analysis may be preferable, as the clinician simply needs to label the types of disfluency that have occurred without

the need for additional step of making a qualitative judgment about whether it is symptomatic of stuttering. In such cases, a common practice is to separate disfluency types into those that are “stutter-like” and those that are “non-stutter-like.” The use of stutter-like disfluency in the assessment of people who stutter works best when clinicians remember the following: • Clearly define which disfluency types will be considered “stutter-like.”  In the professional literature, definitions of “stutter-like” range from narrowly inclusive (i.e., only part-word repetitions and prolongations/ blocks), to moderately inclusive (i.e., only part- and whole-word repetitions and prolongations/blocks), to broadly inclusive (i.e., any type of repetition and prolongations/blocks). Each can be backed by a defensible rationale. Prior to coding stutterlike disfluency, a clinician must decide which of these definitions he or she will use and be able to explain why it is acceptable to define stutter-like disfluency in that way. • Remember that some instances of “stutterlike disfluency” may not sound like “instances of stuttering.”  This statement may seem contradictory; however, it makes sense when one remembers that the concept of stutter-like disfluency is rooted in disfluency-based assessment, and it is derived from labeling disfluency types. Research shows that, at a group level, people who stutter produce certain types of disfluency significantly more often than people who do not stutter. Specifically, people who stutter produce prolongations, blocks, and all types of repetitions more often than typical speakers do (see, e.g., Ambrose and Yairi, 1999). As noted, however, the process of stutteringjudgment is distinct from the process of disfluency labeling. Stuttering identification is multidimensional and thus broader than the process of disfluency labeling. Thus, it possible that, because of their perceived rhythm, duration, or effort, some instances



12.  Describing Client Performance

of “stutter-like disfluency” (e.g., a slow and rhythmically paced monosyllable word repetition) may sound “disfluent, but not stuttered” to the clinician. • Remember that the category “stutter-like disfluency” may not capture all “instances of stuttering.”  This statement also may seem contradictory; however, as with the preceding bullet point, it makes sense when one remembers that the concept of stutterlike disfluency is rooted in disfluency-based assessment, and it is derived from labeling disfluency types. For most clients who stutter, most of their instances of stuttering will be manifested through disfluency that features repeating, prolonging, or blocking. However, some instances of stuttering may be manifested in other ways, e.g., in the form of extraneous nonspeech movement or through the production of a “non-stutterlike” disfluency, such as when a speaker says “um” to postpone the start of a word upon which an instance of stuttering is expected.

Describing Speaking Rate Speaking rate is another dimension of fluency that commonly is analyzed. Rate-based measures provide information about the speed or pace at which a speaker communicates information. Highly disfluent speakers usually take more time than speakers who produce few disfluencies to communicate a given amount of information. This is because disfluencies consume time that otherwise could be spent communicating productively. There are two primary rate-based measures reported in the literature on fluency disorders: articulation rate and speech rate. Either measure can be used with any client who speaks in intelligible, multiword utterances.

4 

Articulation Rate Articulation rate is defined as the number of linguistic units (usually syllables or words) a speaker produces per unit of time during perceptibly fluent stretches of speech (Logan, Byrd, Mazzocchi, & Gillam, 2011). The measure provides information about how quickly a speaker communicates when the speech continuity is uninterrupted. Computation of articulation rate is straightforward when a speaker produces relatively little disfluency because there will be many utterances available for measurement that are free of disfluency. In conversational samples, it is advisable to exclude 1- and 2-word utterances from the analysis because these utterances occur often and are likely to contain recurring content (e.g., Yeah, No). Oversampling of such utterances could distort the assessment in ways that reduce the validity of the measurement as an index of communicative productivity. For speakers who are very disfluent, it may be necessary to base the analysis on a unit of speech called a run, which is defined as a string of consecutive syllables (usually at least 4 or 5) that are spoken without continuity interruption. A run may constitute an entire utterance, but it also can consist of part of an utterance.4 Examples of runs that consist of at least 5 consecutive fluent syllables are shown in Example 12–1 (a and b). The runs are indicated by the underlined words, and disfluency boundaries are marked with brackets. Example 12–1a:  [Uh-] They met for lunch yesterday. yesterday (7 consecutive fluent syllables) Example 12–1b:  We [m-]met for [b-]brunch at the new restaurant. restaurant (6 consecutive fluent syllables) There is no agreed upon minimum number of utterances or runs that must be analyzed to yield

 any disfluencies are positioned at or near the onset of utterances or clauses. When run-based analyses of articulation rate are used M with highly disfluent speakers, there is a risk of oversampling the “tail end” of utterances. This may be problematic because articulation rate is not uniform over the course of an utterance (Starkweather, 1987). Rather, speakers tend to articulate relatively quickly near the start of utterances and then gradually decrease articulation rate as an utterance’s end approaches. Thus, analysis of noninitial runs may yield articulation rates that are slower than articulation rates that are based on all parts of an utterance.

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a valid estimate of rate. In clinical practice and research studies, articulation rate usually is based on a minimum of 10 or more perceptibly fluent utterances or runs (e.g., Kelly & Conture, 1992; Logan et al., 2011; Logan, Roberts, Pretto, & Morey, 2002; Meyers & Freeman, 1985). The specific steps involved in computing articulation rate are presented in the box below.

Speech Rate Speech rate is defined as the number of linguistic units (usually syllables or words) that a speaker produces per unit of time. Unlike articulation rate, it is based on both fluent and disfluent utterances. A set of randomly selected utterances from a speech sample is likely to contain both fluent and disfluent utterances. Speech rate yields information about the rate at which the speaker typically conveys information. In addition to capturing information about the speed of articulatory movements, speech rate also captures information

about disfluency frequency and disfluency duration. For this reason, speech rate is likely to be a more informative measure than articulation rate in clinical settings. The steps involved in comput-ing speech rate are presented in the box below. An example of a speech rate analysis, based on data from the Modeled Sentences subtest of the Test of Childhood Stuttering (Gillam et al., 2009), is presented in Figure 12–6. Computation of speech rate during tasks such oral reading and narration is easier to do than it is within conversational tasks because the speech sample consists of consecutive utterances, and the clinician can time the entire reading passage or narrative. If the speaker produces no disfluency during oral reading and narration, articulation rate can be computed using the same method. However, if the speaker produces disfluency, the clinician will need to analyze individual sentences (or runs) using the method for computing articulation rate in conversational speech described in the box below.

Speaking Rate:  Computational Steps Computation of the two speaking rate measures (articulation rate and speech rate) are similar. When measurement of rate is based on speech from a conversational sample, the procedure is as follows: 1. Record a sample of speech from the speaker. 2. Randomly select at least 10 utterances from the speech sample. a. For articulation rate, limit selection to fluent utterances, or with highly disfluent speakers, 10 perceptibly fluent runs. b. For speech rate, select any type of utterance, fluent or disfluent 3. Tally the amount of speech (i.e., syllables or words) in each of the utterances (or runs). Syllable (or word) tallies are based on the target utterance; thus, speech produced during disfluent segments is excluded from the tally. 4. Sum the number of syllables (or words) that are spoken across all selected utterances (or runs) to obtain the total number of syllables (or words) in the sample. 5. Use a stopwatch to time the duration of each selected utterance (or run). 6. Obtain the articulation rate or speech rate in words or syllables per second by dividing the total amount of speech produced by the total amount of talking time (in seconds). Multiply the quotient by 60 to convert the rate to words or syllables per minute. For example, 150 syllables produced in 30 seconds of talking time equals 5 syllables per second and 300 syllables per minute.



12.  Describing Client Performance

Time Line

(in Words Syllables seconds)

Utterance

1 [Th-]Three kids are making a snowman.

6

8

2.93

2 The boy is polishing the shoes.

6

8

2.75

3 [T-T-] Two kids are washing the car.

6

7

2.83

4 The kids are taking naps.

5

6

2.34

5 [Is the girl-] Is the dog [um] pulling the girl?

6

7

3.44

6 Is the girl cleaning the tub?

6

7

2.93

7 Are the children [brush-]brushing their teeth?

6

8

3.09

8 Is the boy giving the girl some ice-cream?

8

10

3.11

9 The girl is getting off the boat.

7

8

2.65

10 The boat has [um] a flag on it.

7

7

2.74

11 The vegetables are on top of the table.

7

11

3.32

12 The children are riding on the train.

7

9

3.12

12

13

3.47

14 When the boy [was-] did a handstand the girls clapped.

9

10

3.25

15 When the boy paid his [mmm-] money he got [i-]ice-cream.

9

11

3.51

107

130

45.48

13

[When- When the- um] When the dog barked at the cat, the cat got very scared.

S ums

Syllables per second = 130/45.48 = 2.86 Syllables per minute = 2.86 x 60 = 172 Words per second = 107/45.48 = 2.35 Words per minute = 2.35 x 60 = 141 Figure 12–6.  Analysis of speech rate based on 15 responses from the Modeled Sentences task of the Test of Childhood Stuttering (Gillam et al., 2009). Word and syllable counts are based on analysis of target utterances; thus, they exclude speech from disfluent segments. Utterance timings were determined using a computer-based spectrogram.

Rate Deviations The term rate deviation refers to transient fluctuations in articulation rate during running speech that a listener judges as being unusually faster or slower than the rate of the surrounding speech. Deviations in articulation rate often are regarded as a primary symptom of cluttered speech (St. Louis, Myers, Bakker, & Raphael, 2007). The main pat-

tern of rate deviation in cluttering is when brief stretches of excessively fast-sounding speech occur within the context of speech that otherwise seems to be articulated at a typical rate. In the context of cluttering, the affected segments of speech typically are relatively short, spanning either a single phonological word or phonological phrase. Speech during these portions of an utterance may be unintelligible to the listener.

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Speakers who stutter may manifest the opposite pattern: brief stretches of unusually slow articulation rate. The reduction in rate appears to be a compensatory response to the anticipation of stutter-related disfluency on an upcoming syllable. If either type of rate deviation occurs consistently during a speech sample and detracts from communication, it is worth documenting its frequency and other characteristics such as the number of syllables spanned. In clinical settings, it will suffice to document instances of rate deviation by simply listening to a speech sample and tallying each perceived occurrence. These tallies can be referenced against the number of syllables or words in the speech sample to obtain a frequency score. If desired, the length of each identified segment of rate deviation can be described in terms of its length (e.g., syllables, words) as well. An example of how to document segments of rapidly articulated speech from a speaker with cluttering is shown in the chapter on cluttering (see Figure 9–3).

Describing Rhythm As discussed in Chapter 1, rhythm is an aspect of prosody that arises from variations in the duration of syllables, sounds, and pauses during a spoken utterance. Rhythm is a paralinguistic component of communication; variations in speech rhythm can add or refine the meaning of the words a speaker says. English is regarded as a stress-timed language. Utterances are composed of stress groups, each of which consists of a stressed syllable and one or more unstressed syllables (Hixon, Weismer, & Hoit, 2008). In an utterance or across a series of contiguous utterances, the duration of these stress groups is roughly equivalent, even though individual stress groups may differ in the number of syllables each contains (Lehiste, 1973). In large part, speech rhythm reflects the effects of prosodic planning, though the biomechanical properties of the speech production system play a role as well in influencing the duration of speech sound segments in certain phonetic contexts (Behrman, 2007; Selkirk, 1984).The presence of disfluency in an utterance disrupts rhythm by interrupting the expected time course of the linguistic constituents in speech.

Consequently, disfluent utterances are perceived as being dysrhythmic, and a speaker who frequently is disfluent is likely to be regarded as speaking less rhythmically than a speaker who rarely is disfluent. This section discusses two quantitative analyses that pertain to speech rhythm. The first involves the measurement of disfluency duration — that is, the length of time a disfluency lasts. Disfluency duration factors into some metrics of stuttering severity (e.g., Riley, 2009), and duration, along with measures or estimates of time spent speaking fluently, have been explored as measures of communicative productivity (Amir, Shapira, Mick, & Yaruss, 2018; Starkweather, Gottwald, & Halfond, 1990). The second analysis pertains to the duration and rhythmic structure of repetitions — specifically the number of attempts a speaker requires to repair breaks in speech continuity and the temporal patterns associated with those repair attempts.

Time-Based Measures of Disfluency Duration Measurement of disfluency duration involves identifying and then timing the portions of an utterance that are disfluent. The analysis is straightforward to do when using a stopwatch, which measures time in hundredths of second (i.e., seconds are measured to 2 decimal places). Duration also can be measured using a digital speech analysis tool, such as a spectrogram, which will take much longer to do than the stopwatch approach. Measurement of disfluency duration using a spectrogram is illustrated in Figure 12–7. As shown in the figure, the computer software allows for marking the boundaries of the disfluent segment, which results in automated calculation of duration. Another option for disfluency duration measurement is to use a software tool such as Computerized Scoring of Stuttering Severity (CSSS-2.0, Bakker & Riley, 2009), which is a component of the Stuttering Severity Instrument–4 (SSI-4; Riley, 2009), or the Stuttering Measurement System (SMS; Ingham et al., n.d.). With both programs, disfluency duration is measured by pressing a specific computer key at the onset of a perceived disfluency and releasing the key at the offset of the disfluency. The steps involved in computing disfluency duration are presented in the box below.



12.  Describing Client Performance

Figure 12–7.  Spectrographic image of the phrase after the s- s- s- sunrise. The disfluency boundaries were identified using criteria described in Table 12–1 and marked on the spectrogram by clicking the cursor at the onset (i.e., the left-most edge) of the disfluency and then by dragging it to the offset (i.e., right-most edge). Upon doing this, the computer program displayed the corresponding duration. This disfluency lasted approximately 1.133 seconds. The spectrogram was created using the Wavesurfer software program (Sjölander & Beskow, 2006).

Disfluency Duration:  Computational Steps 1. Record a sample of speech from the speaker. 2. Select a minimum of 10 disfluencies at random from the recording. If desired, the type of disfluency selected can be restricted (e.g., stutter-like disfluencies, clutter-like disfluencies). 3. Identify the boundaries of each instance of disfluency, and then time how long the disfluency lasts. 4. Sum the durations from each of the measured disfluencies to obtain the total time disfluent. Divide the total time disfluent by the total number of disfluencies measured to obtain the average duration for the sampled disfluencies. For example, if the sum duration of 10 disfluencies is 25 seconds, the average duration per disfluency is 2.5 seconds.

Accurate measurement of disfluency duration depends on the clinician’s ability to begin timing at the onset of a disfluency, and end timing at the offset. Clinicians may find this challenging to do when timing disfluency duration in running speech; thus, it is advisable to complete self-training activities prior to attempting to measure disfluency duration with clients. Some clinicians have adopted the method of timing each disfluency multiple times and then taking the average of the timings as the

duration for the disfluency (e.g., see Pindzola, Jenkins, & Lokken,1989; Sturm & Seery, 2007). This approach presumably reduces measurement error and is worthwhile to consider.

Restart Attempts During Repetition Another way to examine speech rhythm is by counting the number of repeated speech sounds

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or syllables that occur within a disfluency. As described in Chapter 4, three main methods have been described in the fluency disorders literature: • Counting the total number of attempts taken to produce a target syllable or word; • Counting the number of unsuccessful attempts taken to produce a target syllable or word; and • Counting the number attempts needed to repair the underlying problem that triggers the repetition. The distinctions among these three approaches are illustrated in Example 12–2, where the total number of attempts needed to successfully produce the word Mike are underlined (there are four total attempts), the unsuccessful attempts at producing Mike are marked with the superscript “U” and numbered to indicate their sequential position (there are three unsuccessful attempts), and the repair initiations are marked with the superscript “R” and numbered to indicate their sequential position (there are three repair initiations). In this example, the descriptors are applied to a sound that is repeated. The same descriptors can be applied to repetitions of syllables, words, or phrases. As noted in Example 12–2, analysis of the number of repair initiations and the number of unsuccessful attempts yields the same answer (three, in this case), and the number of total attempts (four, in this case) is always one greater than those counts. Example 12–2:  MU1- M-U2/R1 M-U3/R2 MikeR3 walked home.

Any of the three methods is acceptable to use in clinical practice, provided the same approach is employed each time the measure is performed. The method outlined in the following box involves computing the average number the unsuccessful attempts (i.e., the repetition units) produced within disfluencies than involve syllable or word repetition. Examples of part-word, whole-word, and phrase repetition are presented in Example 12–3 (a–d) to illustrate the concept further. Unsuccessful attempts at advancing the utterance beyond the original point of interruption in the utterance are marked with a superscript “U” and numbered to indicate sequential position. Example 12–3a:  KayU1KayU2 Kayla moved to New Jersey. (2 unsuccessful attempts) Example 12–3b:  NewU1 NewU2 NewU3 New York won. (3 unsuccessful attempts) Example 12–3c:  Uncle StanU1 Uncle Stan hired three cashiers. (1 unsuccessful attempt) Example 12–3d:  Can weU1 Can weU2 Can we get candy? (2 unsuccessful attempts) Repetition unit analysis provides insight into the speaker’s ability to repair problems in speech production that affect speech fluency. Unfortunately, it is not possible at present to say why some disfluencies feature multiple unsuccessful repair attempts and others feature only one. The assumption is that an underlying problem — most likely a problem with either language formulation or

Repetition Unit Analysis:  Computational Steps 1. Record or listen to a sample of the client’s speech. 2. Select a minimum of 10 repetitions at random for analysis. (When repetition unit analysis is used with individuals who stutter, sampling usually is restricted to part-word repetition and monosyllable word repetition.) 3. For each disfluency, count the number of unsuccessful attempts at producing the target syllable or word. 4. Sum the total number of unsuccessful attempts across all analyzed repetitions and then divide by the number of repetition disfluencies sampled to obtain the average number of unsuccessful attempts per disfluency.



12.  Describing Client Performance

speech motor control — is present, and some problems are more challenging for speakers to repair than others.

Evaluating the Rhythmic Structure of Repetitions Another way to describe speech rhythm is to examine temporal patterns within disfluencies that involve repetition. With this approach, the main goal is to distinguish between those repetitions that preserve the rhythm of fluent speech that surrounds the disfluency and those that do not (Pindzola & White, 1986; Van Riper, 1971). Repetitions of the latter sort sound choppy, uneven, or irregularly paced to a listener.

Scale-Based Ratings of Rhythmicity Pindzola and White (1986) described a two-category rating approach to analyzing repetitions produced by children who stutter. With their approach, the clinician classifies each repetition as either “slow/ normal; evenly paced” (which corresponds to the type of repetition that a speaker who does not stutter would produce) or “fast, perhaps irregular” (which corresponds to atypical fluency performance, such as that observed in speakers who stutter). Pindzola and White’s (1986) approach can be expanded by using a multipoint, Likert-type rating scale that features terms such as “highly rhythmic” and “highly dysrhythmic” at each end point. The latter approach has the potential to yield more refined ratings of disfluency rhythm than a binary typical ​— atypical rating yields.

of the overall disfluency duration in comparison to repetitions that children who do not stutter produce (Throneburg & Yairi, 1994). Disfluencies with this temporal pattern are likely to be perceived as “rushed,” “hurried,” or dysrhythmic in relation to surrounding fluent speech. In the Throneburg and Yairi (1994) study, the mean duration for the silent interval within singleunit, part-word repetitions (e.g., b- boy) among the children who did not stutter was about three times longer than it was for the children who stuttered (i.e., 418 ms versus 136 ms, respectively). A similar disparity was noted between the groups for single-unit, whole-word repetitions (e.g., My- My dog). In two-unit repetitions (e.g., b- b- boy), the first silent interval lasted longer than the second for both groups; however, children who stuttered again exhibited shorter silent periods than children who did not stutter. The children who did not stutter showed greater between-subject variability in the duration of silent periods than the children who stuttered. Further analysis showed that a child’s diagnostic classification (i.e., stuttering vs. non-stuttering) could be predicted based on the temporal properties of the editing phase within repetitions with 72% to 87% accuracy, depending on the disfluency type analyzed. The duration of the editing phase (i.e., the silent period) within single unit, whole-word repetitions had the best predictive value of a child’s diagnostic status. Examples of excerpts from two phrases, each with multi-iteration, part-word repetitions of the sound [s] in the phrase after the sunrise, are shown in Figure 12–8. One example illustrates the rhythmic structure common among speakers who do not stutter, and the other, the rhythmic structure common among speakers who stutter.

Time-Based Measures of Rhythmicity Some researchers (e.g., Throneburg & Yairi, 1994; Yairi & Hall, 1993) have compared the temporal characteristics of part- and whole-word repetitions produced by children who stutter and children who do not stutter by comparing the duration of repeated speech units in a repetition to the duration of the silent intervals (i.e., the editing phases) that occur between the repeated units in a repetition. The editing phases of children who stutter are briefer, and they occupy a smaller proportion

Describing Effort The construct of effort in speech production has been measured both subjectively and objectively and from listener and speaker perspectives. The focus in this section is on physical aspects of effort (e.g., excessive muscle tension, extraneous movement) that occur concomitantly with stuttered speech. Some of the effortful behaviors discussed

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Figure 12–8.  In this figure, excerpts from two phrases, each with multi-iteration, part-word repetition within the phrase after the s-s- sunrise, are shown. The rhythmic structure of the repetition in the phrase on the left (solid-line oval) is like what would be observed in a child who does not stutter. It features relatively long silent periods (i.e., editing phases) between iterations of [s]. About 55% of the total disfluency duration is spent in silence (i.e., editing). The rhythmic structure of the repetition on the right (dashed oval) is characteristic of a child who stutters. It features relatively short editing phases between iterations of [s], and a smaller proportion of the total disfluency duration (about 44% in this example) is spent in editing. The spectrogram was created using the Wavesurfer software program (Sjölander & Beskow, 2006).

in this section fit under the headings of what have been called “secondary behavior” or “associated behavior” in the stuttering literature.

Objective Measures of Effort The construct of effort can be assessed using instrumental measures that measure physical characteristics of speech production, including aerodynamic events, muscle activation levels, and movement velocity, range, and force. These types of measurement typically require the use of specialized equipment that is likely to be found only in research laboratories. Thus, this section focuses the discussion mainly on electromyography, as it is plausible that this equipment would be available in a range of practice settings.

Measures of Muscle Activity Electromyography (EMG) provides information about the electrical activity that is present within a muscle. As such, it offers insight into the health of muscles and the neurons that innervate them.

There are two main types of EMG: intramuscular and surface. Intramuscular EMG requires the insertion of an electrode into muscle tissue via either a hypodermic needle or hooked insertion (Behrman, 2007). The electrode can detect electrical activity within specific regions of a muscle when the muscle is at rest and when the muscle is active. Resting muscles typically feature very little electrical activity. Contracted muscles, in contrast, feature greater levels of electrical activity, and activity increases as a function of how much contraction occurs. Intramuscular EMG has been used to document effort in numerous research studies involving people who stutter (e.g., Freeman & Ushijima, 1978; Guitar, Guitar, Neilson, O’Dwyer, & Andrews, 1988; Smith, Denny, Shaffer, Kelly, & Hirano, 1996; Travis, 1934). Surface EMG is performed by affixing disklike electrodes to the skin in locations that correspond to muscles. As with intramuscular EMG, the surface electrodes collect data about electrophysiological events within muscles; however, surface EMG typically offers less sensitive assessment of specific muscles in comparison to intramuscular EMG. Because surface EMG is less invasive than intramuscular EMG, it is more apt to be used in



12.  Describing Client Performance

clinic-based fluency intervention activities and in basic research and treatment studies with children (e.g., Conture, Colton, & Gleason, 1988; Kelly et al., 1995). Indeed, several research studies have been conducted to examine the effects of EMG-based biofeedback at reducing stuttering frequency (e.g., Craig & Cleary, 1982; Craig et al., 1996; Hancock et al., 1998; Hanna, Wilfling, & McNeill, 1975). In such studies, the surface EMG instrument is configured to provide auditory or visual feedback (e.g., a tone, a color) that changes, proportionately, in response to changes in the amplitude of the EMG signal. The speaker attempts to alter muscle activity using the feedback about muscle activity. Results from these studies suggest that speakers who stutter can reduce stuttering frequency significantly when provided with feedback about the activity level in speech-related muscles.

Subjective Ratings of Effort Subjective ratings of effort are straightforward to do: a rater is presented with a sample of speech and a rating scale and then is asked to use the scale to quantify his or her perception of the amount of effort being expended by the speaker. Ratings typically are based on relatively brief samples of speech such as individual sentences or minute-long narratives (e.g., Ingham et al., 2009; Ingham, Warner, Byrd, & Cotton, 2006) or specific instances of disfluency (Weber & Smith, 1990). The ratings can be performed either by the speaker (e.g., Ingham et al., 2006) or by a listener (e.g., Young, 1981). Ratings are typically made using multipoint, Likertstyle scales that feature either 7 or 9 intervals. The scale end points often are labeled with contrasting terms such as “very effortless” and “very effortful” (e.g., Ingham et al., 2009; Ingham et al., 2006; Weber & Smith, 1990). Several of the formal rating instruments used in stuttering assessment contain items that pertain to speaking effort. Examples of such instruments include the Perceptions of Stuttering Inventory (PSI; Woolf, 1967), the Behavior Assessment Battery (adult and school-aged versions; Brutten, 1975; Brutten & Vanryckeghem, 2007), and the Overall Assessment of the Speaker’s Experience of Stuttering (OASES, Yaruss & Quesal, 2016). An example of a

listener-based rating is the Observational Rating Scale on the Test of Childhood Stuttering (TOCS, Gillam et al., 2009).

Acoustic and Visual Correlates of Effortful Speech Many speakers who stutter show observable signs of excessive physical effort during at least some portions of their spoken utterances. Excessive physical effort tends to be most noticeable during moments of stuttering-related disfluency, where, it sometimes can be expressed as muscle tremor, or as tight, pursed articulatory postures. Tremor-like oscillations during speech are most apt to occur in older children, teens, and adults who stutter (Kelly et al., 1995) are often are visably noticeable. Acoustic markers of excessive physical tension often are detectible as well. Examples include the following: strained/strangled sounding phonation in conjunction with stutter-related disfluency; abrupt changes in pitch or prominent bursts of aspiration upon the release of stutter-related disfluency; abrupt, audible inhalation or exhalation prior to utterance initiation; and variation in vocal loudness over the course of a stuttering-related sound prolongation. The excessive physical tension that sometimes accompanies stuttered speech is not the root cause of the disorder itself; however, its presence is likely to affect disorder presentation (e.g., by causing the duration of a stuttering-related disfluency to be longer than it might have been had excessive physical tension not been present). The occurrence of excessive physical tension can be coded on a speech sample transcript easily. A clinician can indicate via written codes which syllables or words are affected by observable excess physical tension, tremor, or acoustic markers of excessive effort. If desired, numerical ratings of degree of effort can be added as well. The inclusion of effort in an analysis of speech fluency may allow the clinician to document symptoms of stuttering that cannot be captured through disfluencyor stuttering-frequency scores. A method for coding speech-related effort is illustrated in Example 12–4. In the example, the effort dimension is represented on a tier above

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the sound segments that comprise the spoken utterance. As shown in Example 12–4, evidence of fluency difficulty, in the form of abrupt, audible exhalation, is apparent before phonation begins. Evidence of excessive effort continues over the course of the entire spoken utterance in the form of extraneous movement (twisting movement of the torso) and progressive loss of vocal intensity secondary to the exhalation of air prior to utterance initiation. An analysis like this captures symptoms of speech-related disability beyond those that are included in traditional category of disfluency. Example 12–4: Time → {abrupt, forceful audible exhalation}

{twisting of torso → → → → } {audible exhalation + progressive drop in vocal intensity →} He mailed it last week.

Describing Naturalness Naturalness seems to be a multidimensional construct that includes elements of continuity and rhythm (Martin, Haroldson, & Triden, 1984), rate (Logan et al., 2002), and prosody and effort (Hodgman & Logan, 2013; Ingham et al., 2006). Over the past 2 decades, several authors have argued for expanded use of naturalness as a component in fluency assessment, particularly in the context of evaluating treatment outcomes (Ingham & Riley, 1998). In research studies that have examined its use, the construct of naturalness typically is left undefined for raters and is measured using a 7- or 9-point Likert-style scale. For any rating of naturalness, the rater typically is presented with one or more excerpts of speech from an individual who stutters and is asked to assign the samples a naturalness rating. The Stuttering Severity Instrument-4 (SSI-4; Riley, 2009) features an informal assessment of naturalness, which is based on a 9-point scale. On the scale, a rating of 1 corresponds to “Highly Natural Sounding Speech,” and a rating of 9 corresponds to “Highly Unnatural Sounding Speech.”

At an initial assessment for a client who stutters, a time when a client typically is not managing stuttering effectively, one would expect the naturalness rating to be relatively poor and probably strongly correlated with the individual’s stuttering severity rating. Thus, naturalness ratings are limited in their usefulness at this stage of intervention. They become more useful after treatment commences, particularly when the treatment incorporates motorbased management strategies in which the client is asked to continuously talk at a slower-than-customary articulation rate. As the client is learning to regulate articulation rate, the clinician provides the client with intermittent feedback about his or her speech naturalness using a Likert scale like ones described in the preceding paragraph. Such feedback is designed to prevent the client from speaking in a way that sounds mechanical while using the stuttering management strategy. Research findings demonstrate that when a clinician provides clients with intermittent feedback about speech naturalness, clients are capable of making the necessary adjustments in rate, prosody, inflection, or other aspects of speech to alter their speech such that it sounds similar to the speech that speakers with typical fluency produce with respect to its naturalness (Ingham, Martin, Haroldson, Onslow, & Leney, 1985; Ingham, Sato, Finn, & Belknap, 2001).

Describing Compensatory and Concealment Strategies As children become increasingly aware of their stuttering-related disfluency they appear to become increasingly likely to implement behavioral compensations that are designed to facilitate speech fluency and conceal the symptoms of fluency impairment from others. Methods for identifying client’s use of such strategies are described in this section.

Motor-Based Compensations for Fluency Impairment Some speakers who stutter exhibit extraneous movements of nonspeech body parts in conjunction with speech. These typically are used to facili-



12.  Describing Client Performance

tate speech fluency, and in doing so, also have the potential benefit of preventing negative responses to stuttering-related behavior from communication partners. When a speaker produces extraneous movements, the goal typically is to time the production of a specific articulatory movement (e.g., the initiation of the first sound in a word) to coincide with an upcoming beat in the sequence of rhythmic nonspeech movements. Although the use of these extraneous movements does sometimes facilitate speech continuity, clinicians generally discourage clients from using them in the context of treatment programs for stuttering because their fluency facilitating effects are limited in scope, and they also tend to be conspicuous, which means they can detract from the speaker’s communication more than they facilitate it. Because such strategies also are used to hide stuttering from others, they may perpetuate the anxiety that many people who stutter experience during social interactions and limit their ability to respond positively to treatment (Helgadóttir, Menzies, Onslow, Packman, & O’Brian, 2014; Lowe et al., 2017).

Other Strategies for Circumventing, Postponing, or Concealing Fluency Difficulty Fluency disruption and listeners’ reactions to it can be emotionally painful for clients. Consequently, some speakers who stutter go to great lengths to mask symptoms of their impaired fluency from others. Clinicians should be alert to behaviors that clients may use extemporaneously or situationally to circumvent anticipated instances of stutteringrelated disfluency. Examples of these intentional behaviors include the following: • Sound substitution or omission (e.g., saying “eace” rather than “peace” during a religious service during anticipated disfluency on the [p] sound in peace.) • Word substitution (e.g., wanting to say “Doctor Ferraro” but instead saying “Professor Ferraro” because of anticipated stuttering-related disfluency on doctor) • Rearranging word order (e.g., planning to say “The chili is too spicy,” but rewording

it to “It’s too spicy, the chili” because of anticipated stuttering-related disfluency if chili had been spoken near the start of the utterance) • Feigning forgetfulness or temporary inability to retrieve words (e.g., responding to a question by saying “I don’t know” or “I can’t remember” to avoid or delay saying a word upon which stuttering is anticipated) • Circumlocution (e.g., planning to say “Chelsea” but saying “that neighborhood that’s south of Penn Station” instead because of anticipated stuttering-related disfluency on “Chelsea”) • Word postponement (e.g., engaging in a nonspeech activity such as adjusting one’s shirt collar, feigning a cough, or clearing one’s throat in advance of a word upon which stuttering is anticipated) Many other concealment and circumvention strategies have been identified in studies of people who stutter (Helgadóttir et al., 2014; Lowe et al., 2017; Van Riper, 1971), and most clients will demonstrate at least some of these strategies either situationally or at certain points in time. The presence of these strategies demonstrates that many clients, even those who are very young, have at least an implicit understanding of the nature of their fluency impairment and the types of adjustments in speech that mitigate the effects of fluency impairment. Some speakers who stutter demonstrate remarkable proficiency with the use of strategies like word substitution and circumlocution to conceal the overt symptoms of stuttering. Such individuals are likely to report, however, that use of these strategies can be mentally exhausting, and when this is the case, that they would like to attain the ability to say the words they want to say in a way that requires less mental effort.

Describing Performance Variability Performance variability is another aspect of fluency functioning that often is challenging for some speakers who have impaired fluency. Some clients report that they experience large fluctuations in

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fluency performance from one communication context to the next or from one conversational partner to the next. Others report that their fluency performance waxes and wanes over time, with some weeks or months characterized by tolerable amounts of stuttering and other weeks or months characterized by intolerable amounts. Variability also occurs on a more immediate level. For example, a speaker who is presenting a lecture might say the term environment smoothly in some sentences, but with lengthy, physically tense disfluency in others. For these reasons, speech production can seem like an unpredictable endeavor to many people who stutter. The lack of assurance about how an activity will turn out can induce anxiety; and when anxiety-inducing events recur in social settings, they can be generalized beyond individual words or situations to the entire act of verbal communication. It is difficult for clinicians to replicate the dynamics of real-world communication situations in a clinical setting. The many permutations of realworld interactions, such as who is participating in an interaction with the client, what types of time constraints the participants are under, what kind of day the participants have had, and whether the participants have ever interacted with someone who stutters, present clients with an almost limitless mix of communicative challenges that are difficult for clients to anticipate and even more difficult to manage. At the least, is helpful for the clinician to collect information about the extent to which a client’s fluency varies with speaking tasks and across communicative settings. With respect to variability within speaking tasks, clinicians can note whether significant fluctuations exist in the frequency of disfluency at various points within in a task (e.g., start of the conversation, end of the conversation), and if so, form hypotheses about what contributes to the fluctuations (e.g., changes in linguistic complexity, changes in time constraints for initiating utterances, topic familiarity or content) With preteens, teens, and adults, the clinician can ask the client for his or her impressions of what accounted for the fluency fluctuations. With respect to variability across settings, clinicians can train parents and/or clients to make self-ratings of stuttering severity during various

predetermined speaking contexts and report the information back to the clinician. Many clinicians use a multipoint, Likert-style rating scale for this purpose (e.g., see Lincoln & Onslow, 1997; Onslow, Andrews, & Lincoln, 1994), and the ratings correlate well with clinician based scores of stuttering frequency (O’Brian, Packman, & Onslow, 2004a; Tumanova, Choi, Conture, & Lambert, 2018). Data like these can be used to construct task-difficulty hierarchies, which then are used to plan for the generalization of treatment strategies to real-world settings later in the intervention process. Selection of beyond-clinic speaking activities can be facilitated through construction of an “ecological inventory” that is based on client documentation of typical speaking situations that are encountered each week.

Describing Emotions, Feelings, Thoughts, and Beliefs Although formal diagnosis of emotion-based conditions such as social anxiety disorder is outside the scope of practice in speech-language pathology, clinicians can nonetheless make observations about the emotions, feelings, thoughts, and beliefs that surround a client’s fluency impairment. As indicated in Chapter 11, several stuttering-oriented rating scales contain items that address these issues, and there are instruments specifically developed to assess anxiety constructs. As shown in Chapter 11, writing prompts can be an effective way to identify the thoughts and beliefs that a client holds about a specific speaking activity. The client data can then be analyzed for the presence of inaccurate or distorted perceptions of how listeners/audience members are likely to think or feel when they hear the client stutter. As will be discussed in Chapter 16, clients can learn to identify inaccurate or distorted thoughts and beliefs, and then construct alternative interpretations that are more accurate and thus less likely to provoke emotionally intense reactions that interfere with fluency performance. Clients who stutter can present with a variety of stuttering-related emotions. Some of these, such as embarrassment and anger, are familiar to everyone and experienced by most people at least



12.  Describing Client Performance

occasionally. Among people who stutter, common feelings like embarrassment seem to be experienced more often and sometimes more intensely than is the case in the general population, with listener responses to stuttered speech often triggering the feeling. Thus, clinicians will want to mine the client’s verbal comments about his or her stuttering experiences as well as item-responses on assessment tools the client has completed to ascertain how pervasive and disruptive the client considers these feelings and emotions to be. Other feelings and emotions that coincide with stuttering include the following: • Anxiety, which according to the American Psychological Association (APA, 2020a) is “an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure . . . sweating, trembling, dizziness or a rapid heartbeat.” The APA adds that recurring intrusive thoughts or concerns are present in individuals with anxiety disorders, along with worry-induced avoidance of specific situations. • Shame, like embarrassment, is categorized as a “self-conscious emotion,” meaning that it comes about following self-reflection and self-evaluation in the context of having committed a moral transgression (Weir, 2012). The emotion involves painful exposure of one’s self (rather than one’s behavior), along with a sense of unworthiness, incompetence, or being defective. Also associated with shame are feelings of diminishment,

worthlessness, and powerlessness (Tangney, Miller, Flicker, & Barlow, 1996). • Self-stigma, which occurs when a person who stutters internalizes negative listener assumptions and stereotypes about people who stutter. The process of internalizing these assumptions and stereotypes can negatively affect an individual’s psychological well-being and self-perceived levels of stress and physical health (Boyle & Fearon, 2018). Table 12–4 presents symptoms associated with social anxiety, which, as indicated in Chapter 6, is present in a significant percentage of people who stutter.

Describing Participation and Participation Restrictions Chapter 2 introduced the term talkativeness and described how it captures aspects of fluency such as verbal output/participation, succinctness, situational flexibility, and communicative creativity. This section discusses strategies for obtaining information about functioning in these areas.

Verbal Output Within Tasks At its core, talkativeness pertains to verbal output ​— that is, how much a speaker says. Verbal output has been examined in a variety of clinical

Table 12–4.  Symptoms Associated With Social Anxiety Disorder Physical

Interpersonal

Feelings

Participation

• Blushing

• Eye gaze aversion

• Embarrassment

• Sweating

• Acting self-consciously

• Worry that actions and behaviors will be evaluated negatively by others

• Self-imposed participation restrictions

• Trembling • Racing heart • Nausea

• Discomfort interacting with/ talking with others (particularly strangers)

Note.  Information adapted from National Institute of Mental Health (2016).

• Withdrawal from social interactions

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populations. It has been used as a diagnostic marker for disorders such as schizophrenia, bipolar disorder, depression, and dementia; as an indicator of personality style; and as a dependent variable in studies of the effect that certain drugs have on verbal behavior (Barch & Berenbaum, 1997; Wardle, Cederbaum, & de Wit, 2011). Still, the task of identifying the appropriate amount of verbal output for a person is a challenging undertaking because the amount of talking one does is affected by an assortment of factors, and more talking does not necessarily lead to better communication. Examples of factors that affect verbal output include the following: topic familiarity (e.g., high/ low familiarity); linguistic proficiency (e.g., extensive/limited); social conventions (e.g., amount and type of talk); the physical setting (e.g., conducive/ not conducive to talking); relationships among communication partners (e.g., familiar/unfamiliar, equal status/unequal status, same gender/different gender); and individual factors (e.g., temperament, motivation, physical stamina). Verbal output has been measured in relation to language-, time-, and task-based units (see Leaper & Ayres, 2007; Leaper & Smith, 2004 for thorough reviews). These approaches are discussed next. Numerous language-based approaches to measuring verbal output have been reported in the research literature (Leaper & Ayres, 2007; Leaper & Smith, 2004). This measurement typically is accomplished by determining the number of linguistic units that are nested within other linguistic units, such as the number of words within an utterance, a conversational turn, or an entire conversation. Measures that are lexically based (e.g., number of words per utterance, number of words per conversational turn, number of utterances per conversation) align more closely with conventional notions of verbal participation than do measures that are grammatically (e.g., number of morphemes or clauses per utterance) and phonologically (e.g., number of syllables per utterance) based. Other alternatives are to report the number of linguistic units produced per unit of time (e.g., words per minute, syllables per second) or to examine the amount of time that one spends talking. In timedelineated activities such as a class period or a business meeting, the latter approaches are useful for gathering information about the percentage of time the client “has the floor.”

Situational Involvement A complementary measure to verbal output is the assessment of situational involvement. In this case, the focus is on the number and variety of communication contexts in which the client engages. Several of the rating instruments that are designed for use with people who stutter (see Chapter 11) include items that address situational involvement and related aspects of participation. Information from these rating instruments offers a good starting point for describing a client’s current status in this important domain of functioning. The Self-Efficacy Scaling by Adult Stutterers (SESAS; Ornstein & Manning, 1985) yields a relatively detailed examination of situational involvement. Scale items cover 50 unique speaking situations. When necessary, however, a clinician can design client-specific data collection tools (see the next section for more information on this). For school-aged children, a tool would capture activities and situations that are common in the school settings (e.g., participation in lunchroom conversation, playground games, talk surrounding class projects, oral reading in class or small group settings); whereas for an adult, the inventory would focus on job-specific routines that involve talking.

Analyzing Communicative Flexibility As discussed in Chapter 2, in the section on talkativeness, communicative flexibility refers to the ability to produce utterances that accomplish a range of communicative functions. With stuttering, this ability may be limited by the amount of fluency difficulty a client experiences in specific pragmatic contexts. In Chapter 2, Fey’s (1986) speech act analysis was presented as a helpful framework for analyzing the types of communicative functions a speaker expresses. Although Fey applied the framework to the analysis of children’s language samples, it can be extended for use with individuals of other ages who have impaired fluency to determine whether a speaker demonstrates use of a full range of communicative functions and whether some communicative functions are performed more fluently than others. With the speech act analysis, the functions of a speaker’s conversational utterances are classified at



12.  Describing Client Performance

both the utterance level and at the discourse level. (See Figure 2–2 for an example of how utterances are classified.) Utterance-level analysis pertains to the communicative function of one utterance in relation to the preceding utterance. In this chapter, three utterance classifications are discussed: assertive acts, responsive acts, and imitative acts. • Assertive acts are utterances that are unsolicited. Thus, these are utterances such as statements, comments, and requests, that a speaker initiates without being obligated to do so by another person. • Responsive acts, in contrast, are verbal remarks that are solicited by another person via questions and requests to which the speaker is obligated to respond. Various subtypes of responsive acts can be specified (e.g., responses to requests for information, responses to requests for clarification). • Imitative acts are utterances that copy the content of a conversational partner’s preceding utterance. Discourse-level analysis pertains to how an utterance functions in relation to the conversational topic. As noted in Chapter 2, utterances can introduce, maintain, or extend a topic. In clinical assessments, it is useful to make observations about fluency performance across these categories also. Clients who cope with fluency impairment by withdrawing from verbal communication are likely to exhibit a discourse profile that features few utterances that initiate or extend conversation, relying instead on utterances that merely maintain conversation (e.g., “uh-huh,” “yeah,” “sure” or equivalent nonverbal gestures). Individuals who exhibit this passive pattern of discourse are likely to feel frustrated with their communication involvement, as they essentially surrender control of the content and structure of a conversation to their conversational partner. With such cases, an appropriate treatment goal is to help the individual become a more active communicator by increasing the use of remarks that initiate or extend conversations, regardless of how fluently the remarks are produced. Analysis of the effect that utterance function has on a speaker’s fluency and communicative style can be done informally using a form like

the one shown in Figure 12–9. The form is structured such that a clinician can tally the number of fluent and stuttered utterances a client produces within a speech sample with respect to various utterance-level and discourse-level categories. The data shown in Figure 12–9 correspond to a passive style of communication in which the client largely follows the lead of the conversational partner, and most of the client’s fluent utterances consists of simple responses. The client’s comments and statements, utterance types that would be complete sentences, occur infrequently, and when they do occur, the client tends to produce them disfluently. Information from this form suggests that the client could improve communicative functioning by increasing the number of assertive utterances produced during conversation (regardless of how fluently they are produced) and by developing stuttering management strategies that increase the frequency with which comments and statements are produced fluently. Lastly, Table 12–5 presents an example of a data collection form that a clinician can develop to collect information about the client’s perceptions of fluency performance across various communicative roles. The client rates communication performance in terms of frequency of engagement in the situation and, once engaged, the amount of speech produced and the client’s level of satisfaction with his or her speaking performance. Forms like this can be tailored to capture the specific speaking activities within which the client most often engages or that are most important to the client. Information from a data collection form like the one in Table 12–5 can be a good starting point for identifying a client’s participation restrictions. Ultimately the “right amount” of participation is a level that the client determines, and that “right amount” of participation in any situation is based on the difference between what type of participation the individual would like to have and what type of participation the individual currently has. For a person who stutters, participation decisions often are complicated by how fluently the individual thinks he or she will speak in the situation. Many SLPs (e.g., Bielby & Yaruss, 2018; Sheehan, 1970; Sisskin, 2018; Van Riper, 1973) argue that one of the more powerful ways for a client to reduce stuttering-related communication disability is to embrace the idea that attainment of “normal speech

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Assertive

Utterance-Level Analysis Requests (e.g., for information, clarification) Comments (e.g., remarks about observable events) Statements (e.g., remarks about what one is thinking or feeling) Disagreements (e.g., contradicting what another person has said)

Number of Utterances Fluent Disfluent 0 0 4

12

2

4

0

0

Performatives (e.g., jokes, warnings)

0

0

Responding to requests for information

0

0

Responding to requests for clarification

0

0

Simple response to another person’s assertive utterances (e.g., “Okay,” “Yep”)

40

2

Imitation of preceding utterance

0

0

46

18

Initiates a topic

0

4

Maintains a topic without adding new content (e.g., “Okay”)

40

2

Extends a topic by adding new content

6

12

46

18

Responsive

Imitative

Total Discourse-Level Analysis

Total

Figure 12–9.  Form for classifying the fluency of a client’s utterances according to their communicative function. Each utterance in the sample is analyzed at the utterance- and discourse-levels. In this example, most of the client’s fluent utterances are simple responses to remarks the conversational partner has made. At the discourse level, this means that the client frequently maintains the conversational topic but seldom extends the topic by adding new information. The overall profile suggests that the client is a passive participant in the conversation. The client produces relatively few comments and statements, and when comments and statements do occur, they tend to be disfluent.

fluency” is not a precondition for conversational participation or effective communication; that is, one can stutter and be satisfied with the amount and quality of his or her spoken communication.

Summary A wide range of approaches for describing fluencyrelated performance in individuals with stuttering or other types of fluency impairments were presented. When describing a client’s performance in the fluency arena, it is important to start with

information about the client’s perspective on what he or she currently is doing and is not doing. This type of information can be gathered from client interviews and from various rating scales that elicit information about communication-related attitudes and general quality of life. The client perspective provides a context for interpreting other types of quantitative data that are available. The main focus of the present chapter was on options and procedures for describing the various dimensions of speech fluency. Toward that end, options and procedures for data analysis in the areas of speech continuity, speech rate and rhythm, speech effort and naturalness, and communicative



12.  Describing Client Performance

Table 12–5.  Self-Rating Scale for Documenting Participation Restrictions and Activity Limitations Directions:  Rate yourself in terms of how often you speak, how much you speak, and how fluently you speak in the following situations.

SPEECH SITUATIONS

Performance Rating: [1 = strongly disagree; 5 = strongly agree] I am satisfied with how often I engage in this situation.

I say as much as I would like to say in this situation.

I am satisfied with how well I speak in this situation.

Responding to . . . Requests you can answer in a word (e.g., Do you like it?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requests you can answer in a few words (e.g. Where’s Tim?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requests you can answer in a few sentences (e.g., What’s on their menu?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requests that you need many sentences to answer (e.g., Tell me about your trip.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requests that require you to repeat what you said. (e.g., What did you say? I couldn’t hear you.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requesting information from others (e.g., Do you want to go to the gym later? Where is the shoe department?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Asking questions in order to keep a conversation going (e.g., And what did you do next?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Requesting others to clarify what they said (e.g., Tell me more. Can you explain it further?)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Commenting on daily events (e.g., My watch is broken.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Remarking on personal feelings (e.g., I feel really tired.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Expressing disagreement (e.g., No, that’s not what happened.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Introducing yourself (e.g., Hi, I’m ___and I work at ____.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Telling entertaining stories or jokes

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Asserting yourself by. . .

participation were described. Also presented were options and procedures for describing the adaptive and maladaptive compensatory strategies that

clients may use, as well as the thoughts and emotions that accompany their stuttering. The chapter concluded with an overview of options and

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Fluency Disorders

procedures for describing how a client’s fluency performance varies across situations and over time. The clinical measures described in this chapter are necessary for documenting client status at the start and end of intervention, and at various intermediate checkpoints. While it will not be necessary to use all types of data analysis described in this chapter with an individual client, it is important to capture the client’s fluency performance using a broad lens in which the information that is gathered goes beyond speech continuity and the severity of speech-based stuttering symptoms, to capture the functional impact of speech disfluency on the client’s everyday activities, psychological well-being, and general quality of life.

Questions to Consider 1. Of the analyses described in this chapter, which of them would provide the most insight into the functioning of a person who appears

to use avoidance as a frequent strategy for responding to stuttering? Which would provide the least? 2. Do an Internet search for recorded samples of speakers who stutter. Listen to the samples and then conduct a stuttering frequency analysis of the first 50 words in the sample. Do the analysis using the verbatim transcription approach first, and then the coded transcription. What are your impressions of each approach? How long does it take to do each analysis? Which parts of the analysis are most challenging to do? Which parts of the analysis do you most need to practice? 3. Using the same speech samples, use the stopwatch feature on your cell phone to time the duration of the first 10 instances of stuttering in the speech sample. Write down the time of each stuttering instance and then compute the average. What are your impressions? How long did it take to do the analysis? Which parts of the analysis are challenging to do? Which parts do you most need to practice?

13 Linking Assessment Data to Intervention

Chapter Objectives After reading this chapter, readers will be able to: • Describe the characteristics of diagnostic classifications that can be assigned following fluency assessment. • Describe methods for formulating and presenting recommendations following fluency assessment. • Describe factors that influence the decision to implement a formal intervention program with a client. • Describe principles and practices associated with developing a comprehensive intervention plan that corresponds to assessment results and client concerns/preferences. The process of linking assessment data to treatment includes several activities, some of which occur at the conclusion of an initial assessment and others at the start of whatever follow-up intervention is recommended. As described in the preceding chapter, upon completing a fluency assessment, data are analyzed and interpreted to determine whether and how communication is impaired, and how the impairment impacts the client. The next steps, described in this chapter, are to assign the

client into a diagnostic category that corresponds to the assessment data, and then to make recommendations for whatever next steps, including intervention, should be taken. These actions set the stage for the specific recommendations that the clinician makes to the client. When intervention is recommended, the clinician works with the client (and/or caregivers and other relevant individuals) to design an intervention plan that includes general goals and specific objectives that state what will be done to help the client maximize his or her communicative functioning.

Assigning Diagnostic Classifications Integration of assessment data leads naturally to diagnosis, which is a descriptive label that captures the client’s current status. The most familiar diagnostic labels for fluency impairment are stuttering and cluttering; however, there are several other diagnostic classifications that can be assigned, and of course, there is the possibility that the client is functioning within the normal range. In the remainder of the section, classification terminology is organized into three categories: (1) normal functioning; (2) developmental disorders; and

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Fluency Disorders

(3) acquired disorders, with primary symptoms and considerations for categorical inclusion discussed. Fluency functioning — normal or disordered — is defined in relation to the fluency dimensions that were outlined in Chapter 2.

Normal Fluency Functioning The notion of normal fluency functioning is consistent with the concept of “typical fluency,” a term that has been used in other chapters in this book. The broad classification of normal fluency functioning is used to describe individuals whose overall frequency for all types of disfluency (stutter-like and non-stutter-like) is relatively low (e.g., fewer than 10 total disfluencies per 100 syllables), and interjections, revisions, and pauses are the predominate disfluency types. In addition, speech rate, rhythm, and effort are within normal limits, and there are no fluency-based activity limitations or participation restrictions. In this section, three subtypes of normal or typical fluency functioning and their characteristics are discussed.

Normally Developing Fluency The term normally developing fluency is appropriate for use with children who are between the ages of 1 to 12 years. This is the stage of life at which children are acquiring adult-like proficiency with their language and speech production. This also is the age window within which neurodevelopmental stuttering (i.e., childhood onset fluency disorder, stuttering) emerges. So, for example, although a 5-year-old child may show no signs of stuttering during a fluency assessment, it is prudent to remember that the child is still within the age range in which symptom expression of stuttering can occur. The label “normally developing fluency” reflects this possibility. As discussed in Chapter 4, fluency performance for some children can be relatively volatile between the ages of 2 and 3 years old (Colburn & Mysak, 1982a, 1982b; Wijnen, 1990; Yairi, 1981, 1982); thus, the notion of developing proficiency with fluency is particularly apt for clients who are in this age range. As described in Chapter 4, disfluency spikes that occur during the preschool years

in conjunction with the acquisition of language (and that are not characterized predominately by short-element repetitions, sound prolongations, and blocks) are often considered “normal” because a sizeable percentage of children in the general population exhibit the behavior. The symptom profile that characterizes stuttering, in contrast, is not classified as “normal” because that type of speech pattern (frequent production of disfluency that consists predominately of short-element repetitions, sound prolongations, and blocks) is observed in only about 5% of the population. Because the label “stuttering” corresponds to a disorder, it implies the presence of an impaired or atypical speech production system. As such, it is not “normal” to stutter or to be a person who stutters in either a statistical or developmental sense. Normally developing fluency is not an appropriate term to use for a child who currently exhibits stuttered speech but could possibly recover from it at some time in the future. Rather, this type of case most appropriately is labeled as “stuttering” for as long as the stuttered speech is present. Should the child someday recover, he or she then would be reclassified into “normalized fluency” (see next section), provided stuttering symptoms have been absent for a substantial length of time.

Normalized Fluency The label normalized fluency is appropriate to use with cases in which a speaker now exhibits typical functioning across all dimensions of fluency, but had, at some point in the past, experienced impaired or disordered fluency. The term normalized fluency is consistent with the concept of “recovery from stuttering” when the latter term is used to refer to cases where the symptoms of stuttered speech resolve such that the client’s speech now is indistinguishable from that of unimpaired speakers and has been like this for a significant length of time (see, e.g., Yairi & Ambrose, 1992a, 1999). Among children who begin to stutter during the preschool years, girls are more likely to attain normalized fluency than boys (Yairi & Ambrose, 1999). The speech patterns of children who meet the criteria for recovery described in the box that follows are indistinguishable perceptually to both lay and professional listeners from speech samples



13.  Linking Assessment Data to Intervention

Documenting Recovery From Stuttering Clinicians can feel most confident about using the classification normalized fluency when they have access to high-quality longitudinal data on a client’s fluency. Such data allow the clinician to establish that the client did indeed demonstrate impaired fluency but now no longer does so. To date, there is no standard criterion regarding how long a speaker must exhibit the absence of disordered fluency before he or she appropriately can be regarded as having “normalized.” Obviously, the longer the time frame, the more confident one can be in the classification. Yairi and Ambrose (1999, p. 1103) set a criterion of 1 year of symptom-free speech before classifying preschoolers as having recovered from stuttering. Additional criteria that Yairi and Ambrose used to determine fluency normalization were as follows: • Both the clinician and the parent judge, overall, that the child no longer stutters; • The clinician’s and the parent’s average ratings of the child’s stuttering severity over the year are less than 1 on a 0 to 7 scale (0 = “normally fluent,” 7 = “very severe stuttering”); • The child’s combined frequency of part-word repetitions, monosyllable whole-word repetitions, and “dysrhythmic phonations” (e.g., prolongations, blocks) remains at less than 3 per 100 syllables; and • Neither the clinician nor the parent mentions stuttered speech in reports on the child’s speech for at least 12 months.

produced by children who have never stuttered (Finn, Ingham, Ambrose, & Yairi, 1997). The diagnostic label normalized fluency also can be used with teens and adults who report having fully recovered from stuttered speech that was present in the remote past but since has resolved. Use of the term in this context should be done with caution, because retrospective reports on fluency functioning are prone to error due to distortions or lapses in memory and the possibility that clients define stuttering differently than clinicians do. Finn and colleagues (Finn, 1996, 1997; Finn, Howard, & Kubala, 2005) described a procedure for validating adolescent and adult speakers’ reports of recovery from stuttering that had been present earlier in life. The procedure consisted of the following: (1) having a long-term acquaintance of the speaker answer questions about the speaker’s past and current status (e.g., Did the person ever have a speech problem? Did the person ever stutter? Is the person now a normally fluent speaker?); (2) asking the speaker to complete a checklist that included items about the characteristics of stuttered speech; and

(3) analyzing the content of the speaker’s verbal descriptions of their past and current speech for the presence of statements that were consistent with past stuttering and current absence of stuttering. Through this procedure, Finn et al. (2005) identified two types of self-described recovery. The first type consisted of individuals who reported they no longer had any tendency to stutter, and the second type consisted of individuals who reported that their fluency improved substantially but that they still occasionally stuttered. In the context of the present discussion, the first group fits the definition of normalized fluency more completely than the second group. Finn et al. (2005) speculated that, for the second group, the sense of feeling recovered while still stuttering occasionally might occur because these individuals no longer viewed stuttering as a handicap. Other researchers have used similar methods to validate speaker reports of past stuttering and current recovery. For example, Cooper (1972) interviewed young adults who reported they had fully recovered from stuttering. Among other things,

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Cooper asked the participants to describe and to demonstrate how they used to stutter, and to indicate whether they ever currently anticipated stuttering or used strategies like word substitution in response to the expectation of stuttering. Affirmative response to such questions suggested that the individual’s fluency disorder had not fully normalized.

Normal Fluency Speakers who exhibit normal fluency are those who show no sign of impairment in speech continuity, rate, rhythm, effort, or naturalness during any daily activities and no evidence of fluencyrelated disability such as expectancy of stuttering, word avoidance, or stuttering-related participation restrictions. The individual speaks as often and as much as he or she desires and is a fully engaged conversationalist. This label can be applied most confidently to those speakers who have passed the upper bounds for when the onset for stuttering is likely to occur — that is, at roughly age 10 to 12 years. Data for age of symptom onset with cases of cluttering are lacking, but suggest that symptoms of this disorder usually are apparent by early adolescence (Howell, 2011).

Developmental Fluency Disorders and Atypical Fluency Patterns Several classifications exist for describing cases that present with fluency disorders or atypical fluency patterns. Descriptions of these classifications are presented in this section.

Neurodevelopmental Stuttering/ Childhood Onset Fluency Disorder The characteristics of speech that characterize neurodevelopmental stuttering (childhood onset fluency disorder, stuttering) were discussed at length in Chapters 5, 11, and 12. As mentioned, there are 1

numerous markers of the disorder, many of which are readily observable visually and/or acoustically, and they often are produced in such a way that a listener easily can identify them as being outside the realm of typical speech disfluency (e.g., producing numerous dysrhythmic part-word repetitions; producing instances of long, physically tense sound prolongations). In such cases, diagnosis of the disorder is relatively straightforward. Indeed, many teen and adult clients come to their initial assessment already knowing that they stutter. There are cases, however, where diagnosis is less clear-cut. In the author’s experience, this is most likely to occur with young children, particularly those who are limited in their ability to describe and self-reflect on their fluency difficulties, and in whom the expression of fluency difficulty is marginally noticeable or has a limited impact on spoken communication.1 To facilitate accurate diagnostic decision making with such cases, the author developed a form that features questions about various behaviors that are related to stuttering. Upon completing the form in Figure 13–1, clinicians should find that they feel more confident in their diagnosis as to whether stuttering is present or not. As noted in Figure 13–1, not every listed symptom needs to be present to arrive at a diagnosis of stuttering. Most individuals who stutter exhibit the first three characteristics listed (i.e., the frequencies of part-word and whole-word repetitions, sound prolongations, and blocks total more than 3 per 100 syllables of speech; one of those disfluency types is the most common type of disfluency the individual produces; and the individual’s combined frequencies for those disfluency types is greater than the combined frequency of interjections and revisions). In addition, it is possible for an individual to exhibit only the first three characteristics listed in Figure 13–1 and be diagnosed with stuttering. It also is possible for an individual to demonstrate only one or two of the first three behaviors and still be diagnosed with stuttering, particularly when other listed characteristics are present. For

 ncertainty about whether to diagnose stuttering can occur occasionally following assessment with older clients, as well. Examples U include cases wherein an individual reports producing stuttering-related disfluency in very specific situations, and stuttering-related disfluency is not observed during the assessment; and in some cases of “covert stuttering,” wherein an individual presents no overt markers of stuttering-related behavior during assessment, but reports being able to conceal or cope with all anticipated instances of stuttering-related disfluency though strategies such as word substitution and reordering words.



13.  Linking Assessment Data to Intervention

Client __________________________ DOB __________ Evaluation Date ____________ Age _______ Symptom Presentation Summary: Complete the fluency assessment. Then answer the questions below.

#

Variable

Normal range/ Typical behaviors

Question

Client’s performance

1.

Disfluency frequency

How many (short element) repetitions, prolongations, and/or blocks does client produce per 100 syllables?

Total = 0 to ~3.0

2.

Ratio of RPB frequency to total frequency

What percentage of the client’s total disfluency frequency involves disfluencies with short-element repetition, prolongation, and/or blocking?

3.

Most frequent disfluency type

What type of disfluency does the client produce most frequently?

4.

Disfluency distribution

Does client produce consecutive part-word repetitions, sound prolongations/blocks (e.g., g- get o- out)?

very rare

5.

Disfluency duration

What is the average number of repetition units in partword and monosyllable whole-word repetitions?

~1.2 or less

6.

Disfluency duration

On average, how long do the client’s part- or wholeword repetitions, prolongations, and/or blocks last?

~0.75 sec or less

7.

Disfluency complexity

Are there multiple or marked instances of behaviorally complex disfluency that include repeating, prolonging, or blocking? (we- we- w- um wwwe like um w- we can)

very rare or never

8.

Client’s perception

Does client report being unable to initiate words due to anticipated repetition, prolongation, or blocking?

very rare or never



9.

Client’s perception

Does the client avoid specific words because of anticipated repetition, prolongation, or blocking?

very rare or never



10.

Are there multiple or marked instances of excess Physical tension physical tension (“struggle”) in the respiratory, laryngeal, or supralaryngeal systems during speech?

very rare or never

11.

Bodily movements

Does the client use extraneous (rhythmic) movements to facilitate speech fluency?

rare or never

12.

Repetition tempo

Do part- or whole-word repetitions routinely sound rushed or rapidly paced or dysrhythmic in tempo?

typical pace, rhythmic

13.

“Starter” vocalizations

Does the client systematically use stereotypical vocalizations (e.g., “um well like,” vowel-like sounds) to initiate utterances?

very rare or never

< 50% revisions, interjections







Clinical Impression: Evaluate client’s performance in the above areas and make a diagnosis. A client does not have to exhibit all symptoms above to be diagnosed with stuttering. Most persons who stutter perform outside of the normal range on items 1, 2, and 3. Items 4 through 13 may or may not be areas of concern. Sympton onset for stuttering typically occurs between ages 2;6 and 5;0, but not later than age 12;0.

Does the client stutter? YES _____

NO _____

If yes, how severely?









If no, is there evidence of another type of fluency impairment? _______ If yes, describe.





Figure 13–1.  A form for documenting symptoms that support a diagnosis of stuttering.

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example, the following profiles would be indicative of a person who is diagnosed with stuttering: • A client who produces 2.8 sound prolongations per 100 syllables, with several of the prolongations lasting for 2 seconds or longer, and sound prolongation is the most frequent type of disfluency produced. (Sound prolongations are uncommon in the general population, and sound prolongations that last longer than 1 second are highly unusual among typical speakers.) • A client who produces fewer than 3 stutterlike disfluencies per 100 syllables, but several of these are unambiguous instances of stuttering-related behavior; the client reports being unable to initiate words due to anticipated stutter-like disfluency; and the client copes with instances of stutteringrelated behavior by using strategies such as word substitution and “starter” vocalizations.

Cluttering As discussed in Chapter 9, the definition of cluttering has shifted over the past few decades and may not be completely settled today. The contemporary view is that the essential symptoms of cluttered speech include the following: (1) a fast and/ or irregular articulation rate; (2) reduced intelligibility of speech that results from coarticulatory imprecision; and (3) excessive disfluency, particularly excessive production of revisions, interjections, and phrase repetitions (St. Louis, Raphael, Myers & Bakker, 2003). Some authorities add poor language organization, pausing irregularities, and poor self-awareness of communication deficits to this list (van Zaalen-op’t Hof, Wijnen, & De Jonckere, 2009); and still others note deficits in language complexity, message cohesion, and topic maintenance (Myers, 1996). From this perspective, cluttering features elements of fluency, articulation, and language disorder. Although conditions surrounding symptom onset for cluttering are not well understood, it appears that cardinal features of the disorder are observable between late childhood and adolescence, and that case history information is more consistent with a neurodevelopmental model of etiology, as opposed to cluttering being a

condition that is acquired (e.g., secondary to neurotrauma or disease). Despite the seemingly clear-cut list of symptoms for cluttering, the reliability with which clinicians diagnose the disorder remains questionable. For example, van Zaalen-op’t Hof et al. (2009) asked two experienced speech-language pathologists (SLPs) to subjectively assign one of three diagnostic labels (i.e., stuttering, cluttering, or stuttering+cluttering) to 54 disfluent speakers after listening to several samples of their speech and found that the SLPs assigned a common diagnostic label to only 27 of the 54 cases (50% of the total). Diagnostic agreement improved to about 80%, however, when the SLPs were given objective criteria pertaining to the rate, disfluency, and articulation accuracy characteristics of each disorder. In a follow-up analysis, van Zaalen-op’t Hof et al. (2009) evaluated the samples from 27 cases that the SLPs had rated consistently. Overall, van Zaalen-op’t Hof et al.’s (2009) findings were mostly consistent with the characteristics of cluttering that St. Louis et al. (2003) described. Among these 27 cases, the following characteristics were identified: • The articulation rate for more than half of the speakers who cluttered was more than 1 standard deviation above the group mean for all disfluent speakers during spontaneous speech. During oral reading and story retelling, however, fast articulation rate was not observed as consistently across speakers who cluttered. • On average, the combined frequency of revisions, interjections, and multiword repetitions among the speakers who cluttered was more than 6 times greater than the combined frequencies of their part-word repetitions, monosyllable word repetitions, and sound prolongations. Overall, 75% of speakers who cluttered fit this pattern. Conversely, 80% of the speakers who stuttered showed the inverse pattern of disfluency. • On average, speakers who cluttered produced about 10 times as many errors in articulatory accuracy as the speakers who stuttered and the speakers in the control group.



13.  Linking Assessment Data to Intervention

As with stuttering, the more cluttering-related characteristics a client presents, the more a clinician can feel confident about a diagnosis of cluttering. With respect to etiology, the occurrence of frequent revisions is consistent with language formulation and organization deficits (van Zaalenop’t Hof & DeJonckere, 2010), and the rate-based disturbances are consistent with impairment in the speech motor-control system (Alm, 2011).

Stuttering-Cluttering A third category under the heading of neurodevelopmental fluency disorder is stuttering-cluttering (or cluttering-stuttering, depending on one’s perspective). Whether this is a distinct diagnostic classification or, instead, a situation where two disorders coexist independently within an individual is unclear. Criteria for this classification, of course, includes evidence of both stuttered speech and cluttered speech. Research is needed to identify the extent to which symptoms of stuttering and cluttering co-occur and to determine whether such co-occurrence is indicative of a distinct disorder.

Stuttered Speech or StutterLike Disfluency Co-Occurring With Another Disorder This diagnostic classification pertains to cases wherein stuttered speech or stutter-like disfluency occurs secondary to some other primary disorder

such as expressive language impairment, autism spectrum disorder, intellectual impairment, or Down syndrome. As explained in Chapter 10, fluency in children with specific language impairment appears to differ significantly, at least in a statistical sense, from fluency seen in typically developing children. The main pattern is that children with specific language impairment exhibit more total disfluency and, in some studies, more stutterlike disfluency than children with typical fluency (Boscolo, Bernstein Ratner, & Rescorla, 2002; Guo, Tomblin, & Samelson, 2008; MacLachlan & Chapman, 1988). Both the observed frequency and the magnitude of the difference in disfluency frequency between the two groups tend to be small, however. For example, in one study (Boscolo, et al., 2002), the average frequency of stutter-like disfluency for children with specific language impairment was about 1 per 100 syllables. Although this was greater than the frequency observed in a control group of children with typical fluency, it still is below the average minimum frequency for stutterlike disfluency seen in studies of speakers who are diagnosed with stuttering, and, barring observation of other behavioral markers for stuttering, would be insufficient to warrant a diagnosis of that disorder. It also would be unlikely to have significant practical consequences. In this scenario, a child’s language difficulties would most likely be a much high priority in treatment, and fluency may not be treated directly at all. Additional disfluency profiles are described in the following box.

Other Disfluency Profiles • Atypical disfluency types.  Atypical disfluency types sometimes are present in individuals who either do or do not have another co-occurring condition. As discussed in Chapter 10, atypical disfluency types have been noted in several published reports of speakers who have a primary diagnosis of autism spectrum disorder. Examples of these atypical disfluency types include repetition of word-final sounds (e.g., “kite” → [kɑIt t t], and mid-vowel interruptions (also known as “broken words”) that are accompanied by sound insertion (e.g., “stay” → [ste- heI]. Disfluencies like these usually are not observed in individuals who stutter or clutter or in typical speakers, and thus are likely to be conspicuous in speech, even when they are not produced frequently. The impact of these atypical disfluencies on communication is likely to be much less than the impact of other impairments that are present

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(e.g., impaired social communication functioning in individuals diagnosed with autism spectrum disorder). • Late-onset stuttering.  There is no widely agreed-upon definition of late-onset stuttering. This book has used the term when referring to clients who exhibit symptoms of stuttering that, according to client report, began after age 12 years and in the absence of any identifiable precipitating event (e.g., traumatic brain injury, illness). Although the upper age bounds for stuttering onset appears to be in the 9- to 12-year-old range (e.g., Andrews, 1984), it is possible that a later-onset variant of stuttering exists for cases with reported onset after age 12. Caution is advised when making this interpretation because of published reports indicating that late onset stuttering is an initial symptom of underlying neuropathology such as a brain tumor (see, e.g., Lebrun, Retif, & Kaiser, 1983). Clinicians should be alert to this possibility and collect more information from the client about symptom presentation and the presence of any other changes in performance, and based on this information, decide whether a referral to a medical specialist is needed.

Acquired Fluency Disorders The third major classification category involves nondevelopmental or acquired forms of fluency impairment.

Acquired Stuttering With acquired stuttering, the onset of fluency impairment can be linked to the occurrence of one or more specific events that impact neurological structure or function in ways that cause the speaker to produce repetitions (particularly part-word repetitions), sound prolongations, and/ or blocks more frequently than normal and more frequently than he or she had prior to the precipitating event. Examples of events that have been linked to acquired forms of stuttering include the following: stroke, traumatic brain injury, neurodegenerative disease, use of certain medications, migraine headaches, epilepsy, and acute psychological stress and/or mental illness (see Chapter 8 for a detailed review). With supporting medical records, a classification of acquired stuttering can be specified further, e.g., acquired stuttering, secondary to traumatic brain injury, acquired stuttering secondary to stroke/CVA.

Acquired Cluttering The question of whether clutter-like speech can emerge in the context of neurological injury or disease has received little attention in the research literature. One example of this classification comes from Lebrun (1996), who discussed rate disturbance in individuals with Parkinson’s disease under the umbrella of “acquired cluttering.” Lebrun described two cases with idiopathic Parkinson’s disease, each of whom presented with rapid rushes of speech along and poor speech intelligibility. Lebrun likened the speech to the rate and intelligibility disturbances observed in the developmental form of cluttering. At present, there is insufficient documentation of acquired cluttering as a distinct category of fluency impairment.

Other Acquired Deficits in Fluency Several authors have described poor performance on verbal fluency tasks among patients with various forms of non-Alzheimer’s dementia. The Controlled Oral Word Association Test (COWAT; Benton, Hamsher, & Sivan, 1994) and other similar, informal tasks have been used to examine phonemic, semantic, and generative action naming fluency in adult speakers. Similar formal word generation tasks have



13.  Linking Assessment Data to Intervention

been developed for use with children. With such tasks, speakers are given a constraint (e.g., words that start with “s”) and then attempt to generate as many unique words as possible in that category within a specific time (usually 1 minute). Deficits in phonemic fluency have been reported in patients with vascular dementia (e.g., Jones, Laukka, & Backman, 2006), and deficits in generative action naming fluency have been reported in patients with Parkinson’s disease dementia (Henry & Crawford, 2004).

Rating Disorder Severity Traditionally, severity ratings for stuttering mainly have focused on the degree of speech fluency impairment that is present. Instruments such as the Stuttering Severity Instrument–Fourth Edition (SSI4; Riley, 2009) and the Test of Childhood Stuttering (TOCS, Gillam, Logan, & Pearson, 2009) feature norm-referenced metrics of severity that are based on analysis of speech samples that are elicited from the client. With the SSI-4, the client’s speech performance is compared to other people who stutter, and in the Speech Fluency Measure portion of TOCS, the client is compared to other people who stutter and to speakers with typical fluency on the frequency with which stutter-like disfluency is produced. Informal, Likert-style rating scales also have been used extensively with speakers who stutter to obtain holistic ratings of speech impairment (see, e.g., Karimi, Jones, O’Brian & Onslow, 2014; Logan, Byrd, Mazzocchi, & Gillam, 2011; O’Brian, Packman, & Onslow, 2004a; Yairi & Ambrose, 1999). The latter approach also is potentially useful for rating the severity of cluttering, a disorder for which normed referenced severity tools are lacking. Although severity statements that focus on speech fluency performance certainly provide a sense of how much difficulty a speaker experiences, it nonetheless is useful to supplement these ratings with other measures that capture the extent to which stuttering impacts the client’s daily life. As described in Chapter 11, there are a variety of published rating instruments that yield insight into the consequence of stuttering (e.g., activity limitations, participation restrictions, environmental hin-

drances; along with feelings, beliefs, and attitudes that hinder communication and reduce wellness and quality of life). Examples of such instruments include the following: Behavior Assessment Battery for School-Age Children Who Stutter (Brutten & Vanryckeghem, 2007); Overall Assessment of the Speaker’s Experience of Stuttering (OASES; Yaruss & Quesal, 2016); the Self-Stigma of Stuttering Scale (4S; Boyle, 2015); Test of Childhood Stuttering (TOCS; Gillam et al., 2009); and the S-24 Scale (Andrews & Cutler, 1974). When data from instruments like these are combined with quantitative measures of speech impairment severity and the client’s own verbal reports of severity, it provides the clinician and client with a multifaceted perspective on problem severity. This approach is consistent with Egan (2002), who in his textbook on counseling, conceptualized problem severity as the product of three terms: (1) the client’s current level of distress, (2) the extent to which the client sees the problem as being uncontrollable, and (3) the frequency with which the client encounters the problem. For example, a client who feels very distressed by being a person who stutters and feels powerless to control or manage stuttering-related disfluency, and experiences instances of stuttering on 25% or more of spoken words, would be viewed as having a severe problem.

Formulating and Presenting General Recommendations Following an assessment, the clinician may present several possible recommendations to the client. These are depicted in Figure 13–2. Each of the recommended actions is presented in the context of clinical counseling, wherein the clinician not only explains what he or she thinks should be done but also presents data that support the recommendation, describes how the recommended actions can be accomplished, provides the client with pertinent educational literature or resources, and solicits questions and comments from the client and/ or the client’s family members. The most common general recommendations to be presented following assessment are described next.

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Dismissal Recommendation Options



Referral(s) Re–evaluation Intervention

Figure 13–2. General recommendation options to present to clients and/or caregivers following assessment. Referral(s) can be made for any client, regardless of what other recommendations are made. Dismissal is mainly used as a recommendation when the client’s functioning is within normal limits. Reevaluation is recommended in cases where more information is needed to determine whether a client has a fluency impairment and in cases where a young child stutters but appears to be unaware of stuttering and at low risk for persistent stuttering. Intervention is recommended for clients who exhibit persistent stuttering, who are judged to be at risk for persistent stuttering, or who are distressed, frustrated, or concerned about stuttering.

Recommending Dismissal A recommendation for dismissal following an initial evaluation is most likely to occur when the assessment results indicate that the client is functioning within normal limits in all aspects of communicative functioning, and the client does not exhibit any speech-language behaviors that warrant reexamination. A recommendation for dismissal also is likely to occur in the context of reevaluation, when results indicate that the client’s fluency functioning has been within normal limits for a significant period of time (e.g., about 1 year), and all other aspects of speech-language performance are within normal limits as well. The latter scenario occurs in cases where speech fluency impairment has normalized either through unassisted recovery or participation in speech-language intervention. In such cases, the clinician again must explain to the client and/or the client’s caregivers the evidence that supports a judgment of normalized fluency performance. In cases where a caregiver continues to express concern about a child’s fluency development even though the fluency assessment results clearly point toward normal performance, one or more of the following steps usually are helpful: (1) Obtain

additional information about the caregiver’s concern; (2) obtain additional data about the child’s performance in beyond-clinic settings (e.g., a parent can submit recordings of home-based speech samples to the clinician); (3) provide the caregiver with additional information on the symptoms of fluency impairment; and (4) schedule a follow-up that includes a date for reevaluation, plus offer the option for the caregiver to meet with the clinician sooner than that should the child seem to need to be seen more urgently.

Recommending Reevaluation A recommendation for reevaluation most often occurs when the clinician is uncertain about whether the client’s fluency (or other aspects of speech-language performance) will remain within normal range in the months following the evaluation and thus should be monitored. A decision to reevaluate the client might come about in situations where the client currently functions in the normal range but has exhibited evidence of isolated fluency difficulty in the recent past or when it is questionable whether an aspect of the client’s current fluency performance is in the normal range. A rec-



13.  Linking Assessment Data to Intervention

ommendation for reevaluation implies that neither the client nor caregiver (when the client is a child) currently expresses or exhibits significant fluencyrelated distress and that other aspects of communicative functioning are within normal limits. When a reevaluation is recommended, the client’s progress is monitored during the interval between the just-completed assessment and the reevaluation that is scheduled in the future. As part of the monitoring plan, the clinician may engage in telephone consultations with the client (or the client’s caregiver) on an as-needed basis should questions or concerns about fluency functioning arise. A typical time frame for reevaluation is 3 to 6 months following the initial evaluation. Scheduling for the reevaluation is driven by factors such as the extent to which the clinician and/or client are uncertain about the normalcy of the client’s fluency, the amount of time that has elapsed since the client’s most recently experienced fluency difficulties, and the nature and severity of the client’s most recently experienced fluency difficulties. If the client’s fluency performance remains in the normal range at the reevaluation, the client then would be dismissed or scheduled for another (optional) reevaluation. If the client’s performance at the time of reevaluation suggests the presence of fluency impairment, then the clinician most likely would recommend that the client enroll in treatment.

may be possible to conduct semi-intensive treatment (e.g., 3-hour sessions for 5 consecutive days) at the front-end of treatment, and then transition to less intensive contact (e.g., 30-minute sessions, twice a week; 1-hour sessions, once a week). In other settings, intensive treatment may be scheduled (e.g., 6 hours per day for 1 week) with less intensely scheduled follow-up sessions.

Recommending Intervention

As indicated earlier, a clinician typically recommends intervention in situations where the client exhibits impaired fluency and the client (or the client’s caregiver) expresses a desire for professional assistance in addressing the impairment and its associated effects on daily life. In most cases of disordered fluency, the decision to recommend treatment is straightforward. After the clinician confirms the diagnosis of stuttering, he or she presents the client with the recommendation that the client commence an intervention program, which typically includes enrollment in formalized treatment that is administered by a speech-language pathologist. Although this is what commonly happens, there are scenarios where a recommendation for treatment is not clear-cut. Two such scenarios are discussed next.

A recommendation for intervention is made in situations where the client exhibits impaired fluency and wishes to address it (or, with children, the caregiver). Intervention involves a range of options, including prevention activities and direct and indirect forms of treatment. Usually, a recommendation for treatment involves regularly occurring appointments, which are held across a series of weeks (e.g., weekly 60-minute sessions over a 15-week period). At the end of the treatment period, fluency performance is reevaluated, and the clinician and client then consider the need for additional treatment sessions. In certain work settings, other treatment scheduling options may be possible. For example, in some practice settings, it

Making Referrals A fourth type of recommendation involves referrals to other professionals. Referrals come about when the clinician suspects that the client presents additional areas of concern, and those areas are beyond the clinician’s expertise or scope of practice. The nature of the referral depends, of course, on the nature of the areas of concern. Examples of professionals to whom referrals might be made include the following: a bilingual speech-language pathologist, a family practice physician, an otolaryngologist, a neurologist, a psychologist, or an audiologist. Referrals are presented in conjunction with recommendations for dismissal, reevaluation, or treatment.

Other Considerations When Making Recommendations

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Making Intervention Recommendations for Preschoolers Who Stutter Decisions about whether and what type of treatment program to recommend for preschoolers who stutter can be complicated by the possibility that a child’s stuttering can resolve without formal treatment, a process that some (e.g., Martin & Lindamood, 1986) have termed “unassisted recovery.” Findings from contemporary research suggest that roughly 75% of all preschoolers who stutter eventually attain normalized fluency in the absence of participation in formal speech therapy sessions (Yairi & Ambrose, 1999, 2005). At present, it is not possible to state with absolute confidence which children will persist with stuttering and which will not. This creates the possibility that a clinician will provide treatment to a child who is on a path toward unassisted recovery from stuttering.2 This section describes two approaches that clinical authorities have taken when making recommendations for how to proceed with preschoolers who stutter. The approaches are adapted from Adams and Webster’s (1989) discussion of “case selection” options. The first approach is termed the differential approach for recommending treatment, and the second approach, aptly, is called the nondifferential approach for recommending treatment. The main difference between the approaches involves the extent to which a clinician is inclined to adopt a “wait and watch” stance prior to recommending that a child who stutters commence enrollment in the clinician’s active caseload to participate in formal treatment sessions.

Differential Approach to Recommending Treatment With the differential approach to recommending treatment, the speech-language pathologist bases the decision on whether to recommend a child for treatment on assessments of how stuttering affects the child’s speech-related feelings and emotions, and on the extent to which the child appears to 2 

be at-risk for persistent stuttering. In cases where immediate treatment is recommended, other intervention elements, such as prevention activities or educational counseling, may be introduced; however, the primary focus is on treating the child’s stuttering. In cases where the recommendation is to defer treatment, other intervention elements, namely educational counseling, are likely to be introduced at the time recommendations are presented; however, no formal treatment activities are conducted. Counseling topics might include an overview of communication behaviors or contexts that are likely to stress fluency in speakers who stutter, how to respond to stuttered speech or children’s inquiries about stuttering, and other general topics. A decision tree that illustrates the two approaches to making recommendations, along with criteria for determining which recommendation to make, is illustrated in Figure 13–3 and discussed next. Children Who Are Distressed, Frustrated, or Concerned About Fluency Difficulty. Clinical authorities generally agree that some form of active treatment is warranted in cases where a preschooler who stutters is distressed, frustrated, or concerned about his or her ability to communicate due to difficulties with speech fluency. Thus, even when a child presents no or very few risk factors for stuttering persistence (see discussion of risk factors that follows), the presence of stuttering-induced participation restrictions and/or negative feelings, emotions, or thoughts about communication or one’s identity as a person who stutters would outweigh whatever indicators of recovery/persistence a child might manifest, and thus “tip the scales” in the direction of recommending treatment. Children Who Are At Risk for Persistent Stuttering. With a differential approach to recommending treatment for a preschooler who stutters, another main criterion is risk for stuttering persistence. Here, the clinician attempts to estimate the extent to which a young child who presently is stuttering is at risk for persistent stuttering. Chil-

 he extent to which preschoolers’ recovery from childhood stuttering truly is “unassisted” has been questioned by some researchers T (e.g., Martin & Lindamood, 1986), who argue that the informal, day-to-day comments and suggestions that parents make to a child about stuttering constitute a form of treatment. This issue continues to be studied.



13.  Linking Assessment Data to Intervention

Nondifferential Approach

Treatment Recommendations Following Assessment

Does child stutter?

No Counsel & Dismiss

Yes Recommend Treatment

Differential Approach

Does child stutter?

No

Yes

Counsel & Dismiss

Is child distressed by it? No

Is child at-risk for persistent stuttering? No Counsel, Monitor, & Re-evaluate

Yes

Recommend Treatment

Yes Recommend Treatment

Figure 13–3.  Flow chart showing the decision-making processes associated with a nondifferential (i.e., “treatment for all”) approach to making treatment recommendations for preschoolers who stutter and a differential approach. As shown, with the latter approach, clinicians sometimes recommend deferring treatment if a young child who stutters does not appear to be negatively affected by the stuttering and appears to be at low risk for persistent stuttering.

dren who have several or many risk factors are recommended for immediate enrollment in treatment, regardless of whether they show signs of being distressed, frustrated, or concerned about stuttering. In contrast, a recommendation to defer treatment is made for children who have no or few risk factors (i.e., if they show no signs of being distressed, frustrated, or concerned about stuttering). The length of time for treatment deferral from the time of assessment is influenced by factors such as the child’s age, the amount of time since the onset of stuttering symptoms, stuttering severity, and emergence of negative reactions to stuttering. A typical time frame for reassessment would be 3 to 6 months, assuming none or few of the risk factors are present. Yairi and colleagues’ (see Yairi & Ambrose, 2005, for a summary) longitudinal

research with preschoolers who stuttered led to several insights regarding factors associated with stuttering persistence. These factors (and supporting evidence and background considerations) are discussed next. Since their research was reported, many other studies have examined factors associated with the persistence of or recovery from stuttering. The primary factors associated with persistence of stuttering are described next and are illustrated in Figure 13–4. • Family History of Stuttering Yairi and Ambrose (2005) stated that family history of stuttering is “one of the most powerful risk predictors” for persistent stuttering, and that a child’s risk for persistent stuttering is particularly great if the child has other relatives who had or currently

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Age at Onset

Sex

Time Since Onset

Family History

Severity Trend

Risk for Persistence

Language & Speech Sound Skills

Figure 13–4. Factors to consider when estimating a preschooler’s risk for persistent stuttering. Several factors that have been studied are potential predictors of stuttering persistence in preschool-aged children who stutter. With respect to intervention, these factors are considered by clinicians who take a differential approach to recommending treatment for preschoolers who are relatively near (e.g., within 12 to 24 months) to the onset of stuttering symptoms. Each of these factors has been shown to differentiate children with persistent stuttering from children who recover from stuttering.

have persistent stuttering. Yairi and Ambrose stated that the risk for persistent stuttering decreases, but still warrants attention, if the child’s family includes other individuals who recovered from stuttering. Singer, Hessling, Kelly, Singer, and Jones (2020) reported the results of a meta-analysis that was designed to identify evidence-based clinical markers for stuttering persistence. In their analysis, family history did indeed turn out to be one of the stronger predictors of persistence; however, unlike Yairi and Ambrose’s findings, children who had any family history of stuttering had nearly twice the risk of persisting with stuttering in comparison to the children who stuttered but had no family history of stuttering. • Longitudinal Trends in Stuttering Frequency/Severity Yairi and Ambrose (2005) reported that most children who eventually met criteria for having recovered from stuttering showed a clear and continuing trend toward improved fluency in the weeks and months following onset of stuttered speech. In their research, many children who eventually

recovered from stuttering showed clear trends toward recovery within the 12 months following symptom onset. (On this basis, stuttering that is present for 12 months or longer might place a child at risk for persistent stuttering.) Children who did not recover during the course of their research study showed either a trend toward more frequent stuttering-related disfluency (i.e., the stuttering became more severe over time) or a stable pattern in the months following onset (i.e., stuttering frequency neither markedly increased nor decreased). Interestingly, in their research, a child’s frequency of stuttering-related disfluency near the time of stuttering onset did not seem to be a strong predictor of whether the child eventually recovered from stuttering. Severity at later stages of the disorder (e.g., a few years post onset) was, however, viewed as a poor prognostic indicator for eventual recovery. In Singer et al.’s (2020) meta-analysis of studies that examined factors affecting persistence, stuttering frequency was a significant predictor of recovery from stuttering. Yairi and Ambrose in addition reported that children who recovered from stuttering also showed



changes in the rhythmic structure of stutteringrelated disfluency. That is, the duration of the “silent interval” (i.e., the editing phase) between iterations of short-element repetitions became progressively longer over time in children who recovered. Children whose stuttering persisted, however, did not show this pattern. In addition, the number of sound prolongations produced as a proportion of total disfluency gradually decreased in the children who were on a path toward recovery. Beyond this, children who were on a path toward recovery from stuttering also showed a gradual decline in the frequency of extraneous nonspeech movements such as head and neck movements while speaking. • Time Since Onset of Symptoms Based on their longitudinal data, Yairi and Ambrose (2005) concluded that the longer a child exhibited stuttered speech, the less likely the child’s stuttered speech was to resolve. For example, assuming all other factors were equal, a child who had been stuttering for 12 months had less likelihood of recovery than a child who had been stuttering for 3 months. In turn, a child who had been stuttering for 24 months had less likelihood of recovery than a child who had been stuttering for 12 months, and so on. In their view, if a child has been stuttering for 2 years or longer, that alone would be grounds for enrolling a child in treatment, regardless of the child’s status on other risk factors for persistence. Importantly, the recommendation to treat for children who have stuttered 2 years or longer is made independently of the frequency with which a child produces stuttering-related disfluency. For example, a child who has consistently produced 4 to 5 stutteringrelated disfluencies per 100 syllables (this would likely be perceived as “mild” stuttering) for 28 consecutive months still would be seen as being at significant risk for persistent stuttering (or, indeed, already exhibiting persistent stuttering) and a candidate for enrollment in a treatment program. • Sex Yairi and Ambrose (2005) reported that girls were more likely to exhibit recovery from stuttering than boys, and in girls, recovery took place sooner in relation to stuttering onset than it did with boys. On this basis, males were seen as having a greater risk for persistent stuttering, were less likely to

13.  Linking Assessment Data to Intervention

recover from stuttering than girls, and the total amount of time that they spent stuttering prior to recovery usually is more than it is with girls. This finding appears to be generally true across studies that have examined persistence rates in male and female children who stuttered. For example, in epidemiological studies of stuttering, males who stuttered outnumbered females who stuttered by ratios of 2, 3, or 4 to 1 at different stages of the life span (Craig, Hancock, Tran, Craig, & Peters, 2002; Yairi & Ambrose, 1992b). Overall, results from Singer et al.’s (2020) meta-analysis indicated that stuttering was about 1.5 times more likely to persist in male children who stuttered than it was in female children who stuttered. • Age at Symptom Onset Yairi and Ambrose (2005) stated that the effect of “age of stuttering onset” on stuttering persistence was less clear than that of other variables; however, they stated that the persistence risk appeared to increase as a child’s age at time of stuttering onset increased. For example, a child who experienced onset of stuttered speech at age 4 would be considered at greater risk of persistence than a child who experienced onset of stuttered speech at age 2;6, assuming all other relevant factors were equal. Yairi and Ambrose speculated that self-awareness of stuttered speech, which tends to become more common and more developed past the age of 4 years, may play a role in the eventual outcome of the stuttering. In the meta-analysis by Singer et al. (2020), children who went on to exhibit persistent stuttering had a significantly older age of stuttering onset (40 months) than children whose stuttering did not persist (34 months). • Language and Speech Sound Production Skills Yairi and Ambrose (2005) reported that children who went on to exhibit persistent stuttering had poorer phonological skills at or near the time of stuttering onset in comparison to children who eventually recovered from stuttering. Singer et al.’s (2020) meta-analysis also reported this finding. In the latter study, children whose stuttering persisted also scored lower than children whose stuttering resolved on tests that examined expressive and receptive language skills. With the latter finding, however, the mean standard scores for the persisting

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children were well within normal limits in both the receptive and expressive language domains. Nondifferential Approach to Recommending Treatment (Treatment for All). Not all clinicians agree with taking a differential approach to recommending treatment for preschoolers who stutter, however (see, e.g., Jones et al., 2008; Millard & Davis, 2016; Onslow, Packman, & Harrison, 2003). For those who adopt a nondifferential approach to recommending treatment, the main criterion for recommending treatment is that a child has been diagnosed with neurodevelopmental stuttering. In other words, if the child stutters, he or she will be recommended for prompt enrollment in a formal treatment program that focuses on reducing the severity and impact of the child’s stuttering. The recommendation to treat is made regardless of whether the child demonstrates signs of distress, frustration, or concern, and regardless of whether the child appears to be at risk for persistent stuttering. For this reason, Adams and Webster (1989) referred to this approach to clinical caseload selection as “treatment for all.” When treatment is recommended, other intervention elements, such as prevention activities and educational counseling, may be introduced; however, the primary focus is on treating the child’s stuttering. When treatment is not recommended, education counseling (e.g., information about warning signs for stuttering) would likely be presented in the context of presenting a treatment recommendation. Descriptions of treatment approaches that are appropriate for young children who stutter are described in the Chapters 15 and 17. Rationales for this approach include the following: Stuttered speech is inherently disruptive to communication; it is not “normal” at any age to exhibit symptoms of the disorder stuttering; and it is not possible to determine conclusively whether specific cases of stuttering will or will not eventually realize recovery.

Making Recommendations When Parents and Children Disagree on the Need for Intervention Another situation in which the decision to recommend treatment may be unclear occurs when there is

disagreement between parents and children regarding the need for fluency therapy. In the author’s experience, differences of this sort are most likely to arise in the middle school and high school populations. Conflict can arise in scenarios where a parent expresses concern about the current or future impact of stuttering on the child’s life; however, the child indicates that he or she is not concerned about stuttering and expresses disinterest in attending fluency treatment. Discrepancies like this can be challenging to resolve. Potential responses to parent-child differences on the need for fluency therapy include the following: (a) Defer treatment and then reintroduce the idea at a time when either the undesirable consequences of stuttering or the potential benefits of participating in treatment become more apparent to the child; or (b) implement treatment on a trial basis in the manner that is agreeable to the child, yet not diluted so much that it is unlikely to be beneficial. Upon completion of the trial period, the clinician, child, and family members can reassess where things stand and adjust the intervention plan accordingly at that point.

Developing Comprehensive Intervention Plans When assessment culminates in a recommendation for intervention, the next step in the process is to work with the client (and/or the client’s caregiver) to develop an intervention plan. Key steps and considerations in intervention planning are discussed in this section.

Working From Assessment Results Assessment data are the main source of information for establishing treatment goals. If the assessment has addressed all relevant aspects of communicative functioning and disability, including the client’s perspective on his or her communicative challenges, the clinician should have a clear sense of what type of intervention plan will help the client improve functioning in the areas of fluency and communication, and result in a better quality of life. When developing intervention plans, it is essential for the clinician to consider the data both



13.  Linking Assessment Data to Intervention

from clinician-based observations about the client and from the client’s firsthand reports of his or her experiences. This reduces the likelihood of overlooking or underweighting key problems or areas of concern during intervention. Client reports usually are a good source of information about communication disability and associated feelings, emotions, thoughts, and beliefs, and, possibly, additional areas of impairment that are not detected via clinician-administered procedures during the assessment. At the very least, clinical assessment activities should screen for potential areas of communication impairment beyond fluency. It is not uncommon for children who are being assessed for stuttering to exhibit concomitant problems with speech sound production and/or language comprehension and production. Similarly, many speakers who clutter present problems with fluency, articulatory accuracy, and speech intelligibility, and some clients also present deficits that affect expressive language formulation and organization.

Clarifying the Purpose of Intervention Before specifying the details of the intervention plan, it first is useful for the clinician and client to discuss their perspectives on issues such as what the purpose of the intervention program will be and how success will be defined. The purpose of intervention gets into identification of the longterm goal(s) for the intervention program, as well. Based on client reports, the intervention process for stuttering often requires considerable time, effort, struggle, and expense (Blumgart, Tran, & Craig, 2010b; Craig, Blumgart, & Tran, 2009; Plexico, Manning, & DiLollo, 2005). Against this backdrop, a clear, concise statement of the long-range goal is needed so that a client will have a reference point for aligning intervention efforts and measuring progress.

How Do Clinicians Define Success? Curiously, when it comes to treating stuttering, clinicians are not always in agreement regarding what the purpose and long-term goals should be nor are they in complete agreement on how clinical success should be defined.

Historically, one main source of disagreement concerns the extent to which clinicians believe that speakers who stutter should strive to attain highly controlled speech production, and with it, the ability to eventually become, or at least sound like, a normally fluent speaker. Professional differences on this matter are exemplified by statements that Cooper (1987) and Shames and Florance (1980) made about treatment outcomes. Cooper (1987) stated that normalized fluency is “an unrealistic goal” for many clients and that clinicians do clients a disservice when they pursue the “simplistic notion” that every client can develop fluent sounding speech if they work hard enough to attain it (p. 381). In contrast, Shames and Florance (1980) stated that the primary goal of their treatment program was “to establish speech that is free of stuttering” and to help the speaker attain the selfperception of being “someone who no longer stutters” (p. 19). Although Cooper (1987) and Shames and Florance (1980) made their remarks years ago, differences in opinion about the long-term goal for therapy with speakers who stutter continue in contemporary clinical practice (e.g., compare Nippold, 2011; Yaruss, Coleman, & Quesal, 2012). So, what is the long-term goal for intervention? Stuttered speech now is widely viewed as being symptomatic of impairment that affects functioning in the speech production system. As discussed in Chapter 6, researchers have uncovered an assortment of speech-related differences and deficits in people who stutter. Given the mounting evidence for motor-system dysfunction in speakers who stutter, it is reasonable to think of stuttering as a type of movement disorder. The implications for how one classifies stuttering are not trivial, as views about the nature of a disorder are apt to influence the types of treatment goals and treatment techniques that one implements (Bernstein Ratner, 2005). For example, a clinician who regards stuttering as a movement disorder would likely implement many treatment activities that focus on motor-based skills and that are rooted in principles of motor learning. When writing about treatment outcomes, Rosenbek and LaPointe (1985) made the following observation about dysarthria: Only if a dysarthric patient’s nervous system returns to normal will speech return too. The return to normal — either because of natural or

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physiologic recovery or because of medical treatment — is a rare circumstance indeed. Therefore, the aim of all dysarthria treatment is compensated intelligibility. (p. 104)

Rosenbek and LaPointe’s (1985) remarks about dysarthria seem apropos to cases with persistent neurodevelopmental stuttering (and to cluttering, as well). Because stuttered speech is a symptom of impaired or underdeveloped functioning in the speech motor system, it can be argued that a realistic long-term goal for many affected individuals is some form of compensated fluency. Attainment of this goal is dependent on a client’s ability to develop and apply speaking strategies that enable the individual to maximize functioning (and thereby reduce disability) by speaking as fluently as he or she is capable, in as many situations as possible, and for as long as possible, given the limitations of his or her speech production system. The goal of being able to effectively compensate for fluency impairment is quite different from goals such as attaining normalized fluency or “remediating” stuttering. This is because effective compensation implies that even though the client will likely continue to manifest signs of impaired fluency at times, after intervention these residual fluency issues will have much less impact on communication than they did at the start of intervention, and ideally they will become inconsequential during the individual’s daily life activities.

Although there are aspects of stuttered speech that are remediable (e.g., helping the clients to eliminate his or her reliance on finger tapping to initiate words fluently), the remediation of all stuttering symptoms in many older children, teens, and adults who stutter is a much less certain outcome. (See the following text box.) In contrast, compensated fluency is a long-term goal that is realistic and attainable for most individuals with persistent stuttering. It is a realistic long-term goal because it acknowledges that the person who stutters is operating with an impaired or underdeveloped speech production system that limits the extent to which normal levels of fluency can be attained or sustained. It is an attainable long-term goal because success is defined in terms of achieving “good enough” fluency — that is, fluency that is acceptable to the client in terms of how it sounds and how much effort it takes to achieve. It is fluency that allows for effective communication, as opposed to perfect or normalized speech fluency. “Good enough” fluency is likely to feature significantly less overt disfluency than the client’s pretreatment fluency, and the overt disfluency that does remain will be produced with significantly less effort and for shorter durations than the client’s pretreatment disfluencies. The notion of compensated fluency deals only with speech production, however. The disability that people who stutter experience often goes beyond the mechanics of talking. As will be

The Effect of Motor-Based Treatment on Neurophysiology With adults who stutter, neuroimaging data suggest that systematic, intensive practice on rate-based stuttering management strategies leads to changes in patterns of central nervous system activation. For instance, frontal and temporal lobe regions proximal to those involved in speech production (see, e.g., De Nil, Kroll, Lafaille, & Houle, 2003; Neumann et al., 2005) show increased activation following treatment. Although these changes are consistent with the idea of normalized functioning, they do not seem to be equivalent to eliminating fluency impairment, because in studies like these, speakers who stutter often continue to demonstrate neural activation anomalies that were present in other parts of the central nervous system prior to treatment. Also, in adults who stutter, treatment-induced changes in neural activation tend to revert toward anomalous pretreatment activation patterns in the months after the treatment ends (De Nil et al., 2003).



13.  Linking Assessment Data to Intervention

seen here and in the following chapters, for many older children, teens, and adults who stutter, the notion of compensated fluency fits into a broader notion of success: effective management of stuttering. The latter concept encompasses compensated fluency and thus also is oriented toward effective communication. It is a broader conceptualization of success, however, in that it includes not only improvement in speech continuity, but positive changes in communicative participation; positive changes in stuttering-related feelings, emotions, and thoughts; and a sense of improvement in one’s quality of life. These ideas are illustrated in Figure 13–5, where effective stuttering management is depicted as a process that includes the establishment of (compensatory) skills that lead to (1) meaningful improvement in speech fluency, as evidenced by fewer and less disruptive instances of stutter-related disfluency, (2) meaningful reduction in communication disability (e.g., fewer activity limitations, less restricted participation); (3) meaningful positive changes in communication-related feelings, emotions, and thoughts; and (4) a sense of having an improved quality of life.

Ineffective management of stuttering

Skills for improving speech fluency/managing stutteringrelated disfluency

Skills for altering stuttering-related thoughts and emotions

Reduced stutteringrelated disability

Improved quality of life Figure 13–5. A model of a successful intervention outcome for a client with persistent stuttering. In this model, improved fluency functioning is viewed as a step toward a complete, fulfilling outcome that includes reduced disability in communication, improvements in affective and cognitive correlates of stuttering, and an overall sense of having an improved quality of life.

How Do Clients Define Success? At the start of an intervention program, clients often have a sense of what they hope to accomplish. This information typically is disclosed during the client interview or during the presentation of post-assessment recommendations. Some clients begin intervention with the goal of managing stuttering more effectively. Thus, their definition of success is likely to be consistent with the clinician’s definition. However, it is not uncommon for clients’ long-term goals for intervention and their conceptualizations of success to be misaligned — often in unproductive or unrealistic ways — with those of the clinician. Although absolute agreement on these matters is not necessary to commence treatment, if left unaddressed, marked differences in perspective can result in the clinician and the client working at cross-purposes during treatment. It is the clinician’s job to bridge gaps in this area when they are present. Examples of unproductive and/ or unrealistic long-term goals that clinicians are likely to hear in one form or another from clients at the start of an intervention program include the following: • “I want to be rid of stuttering.” • “I want to sound normal.” • “I want to learn how to talk so that nobody will know I stutter.” Clients who express a desire to be rid of stuttering or to sound normal are, understandably, hoping to attain the sort of fluency that speakers with typical fluency experience. Guitar (2014) referred to this type of outcome as spontaneous fluency. In individuals who demonstrate spontaneous fluency, all facets of the fluency are within normal limits, and normally fluent speech is attained without the need for intentional use of fluency management techniques. The terms normalized fluency and recovery are consistent with the notion of spontaneous fluency. Implicit in concepts like spontaneous fluency, normalization of fluency, and recovery is the idea that the underlying impairment that caused the person to stutter either has resolved substantially or has been compensated for to such an extent that overt symptoms of impairment no longer are observable (Neumann et al., 2005). As

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noted in previous chapters, for cases with onset during the preschool years, recovery from stuttering is most likely to take place during childhood, particularly within the first 2 years following symptom onset. The longer an individual has stuttered, the less likely this outcome is to be realized. In this view, it would seem that teenage or adult clients who have stuttered since childhood and define success in terms of being able to “get rid of stuttering” may be setting themselves up for frustration or disappointment. Issues like these will likely need to be discussed after treatment commences. Regardless of which stage of intervention the client is at, clinicians should refrain from telling clients that recovery from stuttering is an impossible outcome, for that is unknown, and there are documented cases of speakers who attain normalized fluency long after the onset of stuttering symptoms (Wingate, 1964b). Still, given the many uncertainties about if or when recovery will occur, the author’s stance is that clinicians work to encourage teen and adult clients to strive first toward intermediate outcomes associated with “effective stuttering management” that are realistic and attainable. These outcomes are, in a sense, destinations on the road to recovery. At these destinations, one’s success is defined in terms of being able to speak freely (though not necessarily “stutter-free”), being able to minimize communication disability, and reducing the disruptive and sometimes painful feelings and emotions that can accompany stuttering. In short, success becomes a place where stuttered speech no longer is the primary determiner of what a person does, thinks, or feels. In the author’s experience, those clients who reach this point feel as if they have become quite successful. Client-based goals that convey the desire to conceal stuttering from others also are understandable, but generally unproductive. As noted in previous chapters, clients’ efforts to conceal stuttering typically consist of self-devised strategies such as word substitution, word avoidance, and circumlocution, which are limited in their effectiveness, effortful to implement, and as likely to hinder communication as they are to help it. Beyond this, some authorities argue that use of concealment strategies perpetuates the fears of negative listener evaluation that motivate people who stutter to use the strategies in the first place (Helgadóttir, Men-

zies, Onslow, Packman, & O’Brian, 2014; Lowe et al. 2017). Clinicians also should be alert to the possibility that clients who have an overarching goal of “not letting anyone know about stuttering” also may attempt to use the stuttering management strategies that are introduced during intervention as another way of concealing stuttering from listeners. Clients who are anxious about the possibility of receiving negative listener reactions to their stuttering may set out to speak in a controlled manner (e.g., at a target articulation rate while monitoring phonetic transitions) as much as possible in daily situations. Clients who have relatively high self-defined expectations for fluency performance may feel similarly. Most people who stutter — even adults — find it quite difficult to control fluency at all times. This means that symptoms of stuttered speech are likely to be apparent at least some of the time that the person talks, despite how much or hard they try to control speech. Thus, when a client states the desire to implement controlled fluency on a “24/7” basis, the clinician can immediately validate the client’s push for excellence. Eventually, however, it will be advisable to counsel the client about the practical difficulties associated with that goal, and when the goal is fueled by a desire to conceal stuttering, to inform the client about the negative effects that a goal of concealment can have on one’s long-term satisfaction with progress. When treatment commences, the clinician’s job in such cases is to invite the client to alter his or her perspective on success. This likely will mean that the clinician introduces activities that are designed to promote the client’s understanding of his or her fluency impairment and any disability that stems from it. The notion of understanding does not in any way imply that the client should feel resigned to a life of communication disability. Rather, it simply is intended to help the client develop a more accurate view of the current limits of his or her speech production system and to embrace the idea of learning to use the speech production system as effectively as possible. The clinician also is likely to introduce activities that develop the client’s ability to disclose stuttering in various ways to other people. Such activities, over time, are likely to help the client to shift their view of success away from concealing stuttering toward effective management of stuttering. Clients



13.  Linking Assessment Data to Intervention

can be very slow to shift from a “hide stuttering” perspective to perspectives that embrace “managing stuttering effectively,” “communicating more competently,” “reducing disability,” and so forth. Implicit within each of the latter perspectives is a willingness on the part of the client both to acknowledge that he or she has impaired fluency and to allow the symptoms of stuttering to be on display for others to see and hear. Some clients find that very difficult to do.

Taking a Collaborative Approach to Goal Development Collaboration is one of the core domains of service delivery in speech-language pathology. In the context of fluency disorders like stuttering, collaboration mainly entails actions related to involving the client and, when appropriate, parents and other relevant individuals in the goal-planning process. Some clients may be receiving services from other professionals (e.g., a psychologist, an occupational therapist, a physician) for concomitant problems that fall outside the scope of practice for speechlanguage pathology. A collaborative approach to intervention is called for in such circumstances, particularly if the concomitant problems have the potential to affect a client’s fluency functioning and/or response to fluency treatment. More often, however, the clinician is collaborating with the client (and/or caregiver and other relevant individuals).

Involving Clients and Caregivers in Intervention Planning After identifying the need for intervention and specific areas that, from the clinician’s perspective, should be targeted in intervention, it is advisable to specify or personalize the intervention plan further to ensure that it reflects the client’s unique circumstances and concerns. To do this, the clinician collaborates with the client and/or other appropriate individuals to solicit their perspectives on which aspects of health functioning should be incorporated into the intervention plan and how these should be incorporated (see the next section for information on the use of the ICF framework for

this purpose). This approach provides clients (and, when appropriate, others) with the opportunity to shape the intervention plan so that it reflects goals that have personal significance to them. The client’s role in the collaborative relationship is to offer information about issues such as the specific fluency challenges that he or she faces in daily life, which challenges matter most, which aspects of a speaking activity are most concerning, and the extent to which he or she is willing to reveal the fluency impairment to others while attempting to attain the goal. In turn, the clinician can offer input on the types of treatment activities that are likely to help the client with his or her individual concerns and can help the client to subdivide a personalized goal into discrete, attainable steps. Through this process, the clinician and client essentially coauthor an intervention plan that is tailored to fit the client’s unique experience of stuttering. The process of personalizing treatment goals is illustrated in Figure 13–6. As shown, treatment goals can serve two broad functions. Some treatment goals deal with building the prerequisite skills for managing stutter-related disfluency (i.e., capacity-oriented goals). Other treatment goals deal with broader outcomes, such as reducing disability in the activities of daily life (i.e., performanceoriented goals). As stated previously in the book, the notion of capacity deals with a person’s optimum level of functioning as measured in a standard setting such as the treatment room. Capacity-building goals are addressed in controlled settings, and they tend to address generic skills or concepts that are applicable to many people who stutter (e.g., motor-based strategies for reducing stuttering-related disfluency, strategies that are likely to minimize stuttering severity in situations that involve time pressure). While goals of this sort certainly have a place in an intervention plan, in the author’s experience, clients often see them as being one step removed from what they really want, which is to change fluency performance in the real-world settings they regard as being most challenging or distressing. Thus, it is critical for clinicians to work with clients to develop goals that address the client’s disability as it exists in everyday life. Such goals will involve the application of a skill or concept to those activities

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Collaborate with client to develop intervention plan and associated goals.

•Build capacity •Develop base skills •Generic goals and activities •Extend to personalized goals

Real-World Fluency •Build performance •Apply skills •Client-specific goals and activities

Therapy Room Fluency

•Effective management of stuttering •Improved fluency •Reduced disability •Improved affective and cognitive functioning

Outcome

IMPROVED COMMUNICATION & QUALITY OF LIFE

Figure 13–6.  An illustration of the goal-setting process for the treatment of fluency disorders. The clinician and the client collaborate to identify intervention goals, including goals that have personal significance for the client. Many initial goals in treatment typically are aimed at building a speaker’s capacity to speak with improved fluency under ideal conditions, such as in a therapy room setting. The activities involved in building capacity are generic in the sense that they consist of tasks most clients will do when developing basic competencies in fluency management skills. After the speaker establishes the capacity to use fluency management skills, the focus of treatment shifts toward goals that deal with fluency performance in real-world settings, particularly areas of personal significance to the client. The focus for these goals is on the specific activity limitations, participation restrictions, personal factors, and environmental factors the client faces. When possible, performance-based goals are addressed concurrently with capacity-building activities. Attainment of these goals leads to an outcome. Given the nature of fluency disorders and the limitations of present treatments, it is suggested that an appropriate initial outcome for most clients with persistent stuttering is to develop the ability to manage the symptoms of fluency impairment so that fluency-related disability is markedly reduced or eliminated.

or experiences in the client’s daily life that are highly significant to him or her. Clients, of course, are likely to view the clinician as the expert who can assist them with overcoming their communication disability and related concerns. Consequently, it is common for clients to defer to the clinician’s judgment regarding which types of intervention goals and activities are most likely to help. In such cases, it is advisable for clinicians to resist the temptation to rush in to fill the informational void. While it is true that most clients will lack information about which treatment strategies are likely to help them most, they are the experts on matters such as which stutteringrelated symptoms are most difficult to manage and which aspects of stuttering-related disability they regard as most important to change. Clinicians need to take full advantage of clients’ expertise on these matters.

When it comes to real-world functioning, clients’ fluency concerns can vary widely and usually reflect multiple aspects of the ICF model. Examples of individualized concerns that a client might express include the following: • Impairment concerns (e.g., “I’d like to talk without repeating sounds and words so often.”); • Activity limitations concerns (e.g., “It’s really hard for me to introduce myself to customers at work. I stutter a lot when I do it.”); • Participation concerns (e.g., “I want to join the conversation when I’m at my book club meeting, but I rarely do.”); • Concerns about personal factors (e.g., “I worry that people think I’m strange when they hear me stutter.”); and



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• Concerns about environmental factors (e.g., “When I stutter, my boss always has this ‘hurry up’ look on his face and then I stutter even more.”). The process of melding generic fluency management skills with individualized activities that are aimed at reducing the client’s speech disability during real-world settings requires regular, indepth discussion between the clinician and the client. Effective clinician-client communication is likely to increase the client’s sense of “buy in” to the treatment process because it leads to treatment activities that are of personal significance to the client (Bothe & Richardson, 2011; Plexico, Manning, & DiLollo, 2010).

Developing Goals Within a Comprehensive Framework of Functioning The effectiveness of an intervention plan is influenced by the extent to which it addresses all aspects of a client’s current status in terms of functioning and disability. Thus, it is essential to construct an intervention plan that is sufficiently comprehensive.

Working From a Comprehensive Model of Health and Wellness As indicated in the assessment section of this book, the American Speech-Language-Hearing Association (ASHA) uses the International Classification of Functioning, Disability and Health (ICF; World Health Organization [WHO], 2001) as a framework for clinical practice. Several authors have described the use of the ICF framework in the development of comprehensive intervention plans for people who stutter and for people with other communication disorders (Blake & McLeod, 2018; Logan, 2005; Yaruss, 1998; Yaruss & Quesal, 2004). The ICF framework consists of five primary components. Three of the components pertain to client functioning (i.e., impairment, activity limitations, participation restrictions) and two pertain to the context in which the client functions (i.e., personal factors, environmental factors). These five components provide clinicians with an organizational

structure for organizing assessment results, identifying areas to address in intervention, and generating corresponding goals. Examples of the types of goals that follow from the components of the ICF model are shown in Table 13–1. The most basic intervention goals are those that deal with improving the client’s capacity for speaking fluently. In the ICF parlance, the term capacity refers to the client’s optimal or maximal level of functioning as measured in a standard or controlled setting, such as the clinician’s office. With older children, teens, and adults, capacity goals usually will target the various fluency management skills that the client will learn to develop. These skills, when implemented, are expected to help the client improve fluency functioning and reduce associated communication disability. Nearly all intervention plans include goals that address the client’s capacity for speech fluency. The rationale for this is straightforward: If a client is unable to implement fluency management skills successfully under optimal, controlled conditions, it is unlikely he or she will be able to do so under the oftenunpredictable conditions associated with realworld activities. Intervention typically is structured sequentially. In other words, as a client develops the capacity to manage fluency in a controlled setting, he or she then attempts to transfer the newly developed capacity to other, naturalistic settings — particularly those settings where activity limitations are present. The activities that are targeted for intervention vary from person to person. For some clients, communication disability is present in many daily activities. For others, it is present only in specific activities. The client’s primary activity limitations should be uncovered during the initial assessment; however, additional areas of limitation are likely to be identified once treatment commences. As the client develops competence at managing fluency across various activities of daily living, the extent of his or her communication disability will diminish gradually. Thus, it is common for treatment plans to include goals that are aimed at reducing specific activity limitations that the client presents. Participation restrictions are another aspect of the communication disability that many speakers who stutter exhibit. A participation restriction occurs when a speaker talks less than he or she

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Table 13–1.  Examples of Goals Associated With Components of the ICF Instrument (WHO, 2001) ICF Component

Potential Goals to Target in Treatment

Impairment (and associated loss of function)

• Remediate and/or compensate for fluency impairment:  Improve the client’s capacity to speak fluently through the use of various fluency management skills.

Activity limitations

• Reduce disability:  Reduce the number and severity of the client’s activity limitations.

Participation restrictions

• Reduce disability:  Increase the client’s verbal participation within and across daily activities.

• Improve/normalize speech continuity, rate, rhythm, effort, and naturalness. • Improve the client’s fluency functioning in specific activities of daily living.

• Improve the extent to which the client participates verbally in specific situations. • Improve the number and variety of communicative contexts in which the client participates. Personal factors

• Reduce disability:  Reduce the impact of personal factors on the client’s fluency functioning. • Develop constructive, realistic, and/or accurate attitudes toward impairment and therapy. • Improve the accuracy with which the client interprets internal and external events that are associated with fluency impairment. • Develop strategies for managing feelings/emotions that disrupt speech fluency.

Environmental factors

• Improve functioning:  Reduce the impact that environmental factors have on the client’s fluency functioning. • Develop supportive or facilitative listener reactions to the client’s fluency impairment. • Reduce the occurrence of listener demands for rapid, fast-paced, or complex communication if such demands hinder fluency.

Note.  ICF = International Classification of Functioning, Disability and Health.

would like to talk. There are many triggers for participation restrictions. Examples include the amount of effort it takes a person to speak and the emotions that a person experiences when he or she stutters. Goals that deal with participation often are aimed at increasing the amount of talking that a client does in specific situations and/or the number and variety of situations within which the client speaks. The long-term goal is not for a client to talk for the sake of talking but rather for a client to say as much as he or she would like to say within any given situation. Participation goals often intersect with personal factors such as the client’s stuttering-related feelings, emotions, thoughts, and beliefs. Thus, prior to pursuing participationrelated goals, it first may be necessary for a client to address affective (feelings, emotions) and cognitive (thoughts, beliefs) components of stuttering,

particularly when these elements seem to be the source of the participation restriction. Personal factors and environmental factors constitute the context within which the client functions. These contextual factors either can facilitate or hinder a client’s fluency functioning. As such, they can be targeted in an intervention plan, as well. Overall, the main objective is to reduce or eliminate those personal and environmental factors that hinder the client’s fluency functioning and to promote those personal and environmental factors that facilitate fluency functioning. Assessment activities (e.g., checklists, inventories, discussions) enable the clinician and client to identify the personal and environmental factors that most affect the client’s fluency functioning (see Chapters 11 and 12 for examples of pertinent assessment tools). Goals that address personal factors often are



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aimed at how the client thinks about specific stuttering experiences as well as about being a person who stutters. Treatment activities of this sort come under the heading of cognitive behavioral therapy, an approach that has been used with increasing frequency in treatment programs for teens and adults who stutter. As explained in subsequent chapters, targeting distorted or inaccurate thinking can have a significant, positive impact on the feelings and emotions that people who stutter experience while talking and in general. There is a wide assortment of environmental factors that have the potential to hinder a client’s fluency. Some factors (e.g., family members’ responses to stuttered speech) are easier to address than others (e.g., strangers’ responses to stuttered speech). Either way, intervention plans for speakers who stutter commonly include at least some goals that target this aspect of functioning. Examples of goals that fit under the heading of environmental factors include the following: • A goal that addresses the frequency with which a sibling interrupts the client during conversation. (This goal is aimed at one of the client’s communication partners. Attainment of this goal is likely to facilitate the client’s functioning by decreasing the client’s exposure to a behavior that causes the child to feel angry and frustrated and that has the potential to stress the child’s speech fluency); and • A goal that addresses the client’s ability to produce assertive statements when coworkers interrupt his or her stutter-related disfluency. (This goal is aimed at how the client responds to environmental stressors. Attainment of this goal is likely to facilitate functioning by reducing the extent to which the client feels angry with coworkers and by increasing feelings of self-efficacy such as the sense that “I can affect what happens when I stutter.)3 3

Working From a Comprehensive Model of Fluency As discussed in Chapter 2, fluency is a construct that can be described multidimensionally — that is, in terms of continuity, rate, rhythm, effort, naturalness, talkativeness, and performance stability/ variability. The use of a multidimensional fluency model during intervention planning provides the clinician and client with a mechanism for ensuring that all relevant aspects of a client’s fluency functioning are addressed. Dimensional aspects of fluency, in turn, align easily with components of the ICF model, particularly those that pertain to functioning/impairment, activities limitations, and participation restrictions. As discussed earlier in this section, there is a long-standing practice in speech-language pathology of evaluating the success of stuttering treatment programs based primarily on improvements in speech continuity. From this narrow perspective, cases that attain “0% syllables stuttered” or something near that are considered successful outcomes, and cases that exhibit higher posttreatment stuttering frequency scores are not. The main problem with weighting speech continuity so heavily when evaluating treatment outcomes is that it overlooks other dimensions of fluency that also may be relevant to perceptions of success. Cooper (1986) referred to the overreliance on disfluency frequency data as a metric of intervention success as the “frequency fallacy.” He argued that clinicians should use a variety of clinical measures when evaluating whether an intervention plan has been successful. Research data on speakers’ perceptions of fluency outcomes, with or without treatment, support Cooper’s argument. For example, there are numerous reports of speakers who relate feeling satisfied with their communication abilities even though their speech fluency has not entirely normalized (Anderson & Felsenfeld, 2003; Boberg & Kully, 1994; Cooper, 1986; Plexico et al., 2005; Pollard, Ellis, Finan, & Ramig, 2009). As one of the

 ssertive statements consist of three components: (a) telling the communication partner what he or she is doing (e.g., “I noticed that A you interrupt me when I block on a word.”); (b) informing the communication partner how this behavior affects the speaker (e.g., “This usually leads me to block on sounds longer and harder.); and (c) informing the communication partner what the speaker would like him or her to do instead (e.g., “I’d prefer it if you wait until I finish saying the word.”). Schloss, Espin, Smith, and Suffolk (1987) examined the effects of a training program in which adults who stuttered learned to produce assertive behavior like that described. The participants received more favorable interview ratings when using assertive behavior than they did when not making such comments.

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participants in Plexico et al.’s (2005) study said, “95% of the time or more stuttering is not an issue . . . it’s there and it’s part of who I am, but it’s not an issue in terms of decisions I make or . . . what I’ve achieved” (p. 15). The participant went on to comment that stuttering no longer dictated the day-today choices that the person made. Comments like this are a reminder to both clinicians and clients that speech disfluency and effective communication are not mutually exclusive concepts. As indicated earlier, the multidimensional fluency model presented in Chapter 2 illustrates that improvements in a client’s fluency can be documented in multiple ways. For example, one client might attain only a modest reduction in stutteringrelated disfluency following intervention yet still feel pleased with his fluency outcome because of significant reductions in disfluency duration (an aspect of rhythm) and speech-related effort. Another client might show only modest reduction in disfluency frequency following a course of treatment yet still feel satisfied with the substantial increase in verbal participation (an aspect of talkativeness) that she has attained. Although these clients may wish to continue to work at improving speech continuity and other dimensions of fluency, it nonetheless also is possible that they will choose to discontinue the quest for normalized fluency at this point, and instead find sufficient satisfaction in the changes they have made in other dimensions of their fluency. In short, when clinicians and clients think of fluency as a multidimensional construct, it leads to an assortment of potential intervention goals and outcome measures that would not be possible when the focus is placed only on speech continuity. This notion seems to be one that is applied with increasing frequency, as demonstrated by the use of participation-based metrics (Mendes, Dacakis, Block, & Erickson, 2015; Lee, Robb, Van Dulm, & Ormond, 2016) as well as measures that aim to capture holistic aspects of speech performance such as speech efficiency (Amir, Shapira, Mick, & Yaruss, 2018).

Designing Intervention Plans That Encompass Multiple Service Delivery Domains Six of the eight clinical service delivery domains described in ASHA’s Scope of Practice in Speech-

Language Pathology (2016a) incorporate activities that can be conducted following assessment. It is useful to review these service delivery domains when designing intervention plans to avoid overlooking intervention activity types that may be helpful to the client.

Incorporate Prevention and Wellness Practices As discussed earlier, in contemporary practice, intervention for stuttering and other fluency disorders is framed within the broader context of health functioning. Inherent in this viewpoint are the concepts of prevention and wellness, which in the context of this chapter, pertain to goals that deal with preventing predictable consequences of fluency impairment (e.g., the risk that classmates will bully a child or teen who stutters) as well as to goals that pertain to reducing the severity or the impact of disability associated with fluency disorders.

Incorporate Collaborative Practices According to ASHA (2016a), “Collaboration requires joint communication and shared decision making among all members of the team, including the individual [the client] and family [the client’s family], to accomplish improved service delivery and functional outcomes for the individuals served.” As described in Chapter 1, collaboration involves educating and consulting with other professionals as needed and, for some cases, serving as the manager or coordinator for activities associated with clinical care in the context of interprofessional practice.

Incorporate Counseling Practices Most intervention plans incorporate at least some elements of counseling. According to ASHA (2016a), professional activities in this area come under the headings of education, guidance, and support. While most counseling activities are directed toward the client and family members, some activities, particularly those that pertain to education and awareness, may be directed toward the client’s community (e.g., teachers in the client’s school, students in the client’s school). Certain skills, such as those related to self-advocacy and to the evaluation and altering of negative thoughts about com-



munication disorders come under the counseling domain as well. If a client’s counseling needs fall outside the scope of practice in speech-language pathology, a reference to a qualified professional will be necessary. Such referrals may be incorporated into the intervention plan as well.

Introduce Appropriate Treatment Strategies According to ASHA (2016a), treatment is the service delivery domain that deals with activities that are designed “to optimize individuals’ ability to communicate and swallow.” Treatment goals address the concepts and skills that a client will learn or develop to address the symptoms that characterize his or her stuttering-related disability. Thus, treatment activities assume a prominent role in most intervention plans. Clinicians must deliver only treatments that come under the scope of practice in speech-language pathology. ASHA’s Scope of Practice (2016a) specifies that treatment activities (and the goals upon which they are based) must be culturally and linguistically appropriate, consistent with elements of evidence-based practice, and specified and delivered in accordance with “best available practice appropriate to the practice setting.” Also included are details about how treatment effects will be measured and how treatment data will be used to guide decisions about continued use of a treatment.

Consider the Use of Technology and Instrumentation As will be discussed in subsequent chapters, intervention plans for individuals with impaired fluency sometimes will include the use of specialized technology and instrumentation, with the aim of improving communicative functioning through the speech modality.

Populations and Systems: Seeing the Big Picture This service delivery domain deals mainly with aspects of practice above the level of a client (e.g., activities that are designed to improve the efficiency with which treatment services for stuttering are delivered within a large school district).

13.  Linking Assessment Data to Intervention

Individuals with impaired fluency may benefit indirectly from these activities; however, it is unlikely that these activities would be written into an individual’s intervention plan.

Planning for Incremental Evaluation of Progress Management of stuttering is a process that for many clients continues long after the conclusion of formal treatment (Plexico et al., 2005). Indeed, some clinicians (e.g., Shapiro, 2011) have likened the process of stuttering management to a journey. Although treatment may help a client improve significantly in his or her ability to manage stuttering, many individuals will find that intervention does not make stuttered speech disappear. Rather, situational challenges will continue to arise after the conclusion of formal treatment, and at these times the client will be called upon to employ his or her “management strategies.” At these moments, the client’s goal is to mitigate the fluency difficulties that occur to an extent where, even though speech contains stuttering-related behavior, the speaker is satisfied not only with speech fluency, but with communicative competence as well. Given that stuttering management often is a protracted process, it is helpful to encourage clients to think of success in terms of short-, middle-, and long-term outcomes. With this approach, the outcome that a client works toward in the near term (e.g., 3 months from now) will differ from that for the middle-term (e.g., 1 year from now), which in turn will differ from that for the long-term (e.g., 3 to 5 years from now). For example, for an adult client with moderately severe stuttering, the clinician and the client might decide that the following goals are appropriate: • 12-week goal:  Develop the ability to minimize the severity of instances of stuttering-related disfluency consistently (e.g., >85% of instances) during spontaneous conversations with the clinician and during preplanned conversations with a family member; • 1-year goal:  Develop the ability to manage most (e.g., >90%) instances of stutteringrelated disfluency during five frequently occurring daily activities; and

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• 3-year goal:  Develop the ability to manage nearly all (e.g., >95%) instances of stutteringrelated disfluency, no matter what the situation. An approach like the one outlined here is consistent with adult reports about the pathway to successful stuttering management. As suggested in the preceding goals, many clients will find that their speech motor patterns change relatively quickly within controlled clinical settings; however, consistent realization of these changes in authentic life situations usually unfolds gradually and requires commitment to practice. In the author’s experience, clients’ stuttering-related emotions, feelings, and unproductive thoughts change more slowly than the motor dimensions of the disorder. It is important for clients to understand that the protracted timescale of stuttering management is neither good nor bad — rather, “it just is.” Adoption of the short-, middle-, and long-term perspective for interpreting success not only embraces the realities that come with having a neurodevelopmentally based speech disorder, but also helps clients to gauge the pace of their journey toward successful stuttering management on a timescale that is commensurate with that of many other people who stutter.

Other Planning Considerations Intervention plans need to reflect the unique performance profiles and needs of the client. In other words, they need to be individualized. Other factors that affect the content and organization of intervention plans include the practice setting and the client’s age.

Intervention Plans Across Practice Settings The setting within which a clinician works is likely to affect the types of intervention activities he or she can conduct. For example, in school-based settings, clinicians have direct access to people (e.g., the client’s peers) and situations (e.g., class presentations) that a clinician in a private practice or hospital setting is not able to access directly. Thus,

when designing intervention plans, consideration must be given to the types of activities that are and are not feasible to incorporate directly into the plan. When communication partners or key practice contexts are not easily accessed directly, it is likely that the clinician and client can devise workarounds, such as the use of recorded activities, telehealth supplementation of in-clinic services, and recruitment of therapy adjuncts (e.g., a teacher).

Intervention Plans Across Age Levels A client’s age also is a primary influence on the composition of an intervention plan. Although there are numerous contrasts that can be made, the following examples provide a sense of the types of differences that exist. For instance, many of the stuttering management strategies that are used with older school-aged clients, teens, and adults require the ability to self-monitor one’s speech behavior for extended lengths of time, the ability to reflect upon and self-analyze motor behavior, and understanding of various meta-communicative concepts. These characteristics render many of these treatment strategies too demanding for use with preschoolers and younger school-aged children who stutter. Alternately, young children who stutter generally are less likely to present with the disruptive feelings and emotions that accompany stuttering in many older clients. Consequently, intervention plans for this age level are more likely to encompass goals that deal with preventing the emergence of affective correlates of stuttering, whereas intervention plans for older clients are likely to incorporate treatment activities that target these aspects of functioning directly.

Summary The present chapter addressed issues related to the diagnosis of fluency impairment. Several categories of normal and disordered functioning were discussed. In clinical settings, clients often have a good sense of the type of disorder they have, even before they undergo a fluency evaluation. In some cases, clients know that a fluency disorder exists,



but they are uncertain about the nature of the disorder. For example, a client may state that he or she stutters when, in fact, the client clutters. People in the general public and some health professionals may dismiss childhood stuttering as “normal” behavior and state that “everybody stutters.” While it is true that many people produce isolated instances of stutter-like disfluency, only a small percentage of the population consistently exhibits the unique disfluency profile that characterizes the disorder known as neurodevelopmental stuttering. Epidemiological data indicate that only about 5% of the population will exhibit this disorder over the life span. On this basis, relatively few people ever stutter. The diagnosis of stuttering sometimes is challenging with preschool-aged children. At this age, children generally are unable to describe their fluency experiences in detail. Consequently, a clinician is unlikely to hear a preschooler report, “I know what I want to say, but I can’t say it” or “I want to say this word, but I feel stuck.” Such verbal comments about stuttering phenomenology are common in older children, adolescents, and adults, and when present, they are useful in diagnosing stuttering in those cases where speech symptoms alone may be insufficient to arrive at a diagnosis. In the absence of such information, clinicians may need to consider the use of qualified diagnostic labels such as “possible stuttering” until the nature of the client’s fluency functioning becomes clear. Another area of potential uncertainty following a fluency evaluation concerns the issue of when to recommend a preschooler who stutters for enrollment in a formalized treatment program with a speech-language pathologist. At this age, it is possible that the child might recover from stuttering in the absence of formal fluency intervention. Some clinicians address this issue by making differential recommendations for treatment based on estimates of whether the child appears to be at risk for persistent stuttering or is distressed or concerned about stuttering. Ongoing research has led to improved understanding of risk factors for persistent stuttering. Although these indicators offer a sense of whether a child’s stuttering will persist, they are not yet developed enough to be

13.  Linking Assessment Data to Intervention

100% predictive of a child’s eventual outcome. For this reason, a case can be made for commencing treatment with any preschooler who stutters. The chapter concluded with a discussion of intervention planning. In this process, it is important to base an intervention plan on assessment results and to clearly define the purpose and expectations for intervention. Clinicians and clients may think differently with respect to what will be accomplished through intervention, and any differences in perspectives need to be reconciled prior to or in the early stages of treatment. Contemporary principles of evidence-based practice call for involving the client (or caregiver) in the process of intervention planning. Clients are the experts on how fluency impairment affects their daily lives, and clinicians should turn to their expertise often during treatment. Development of a comprehensive intervention plan is most likely to result when clinicians use the ICF model, a comprehensive model of fluency, and ASHA’s model of service delivery domains as the basis for planning.

Questions to Consider 1. Following an assessment, it sometimes is difficult to be completely confident about whether a child should be diagnosed as stuttering. In such cases, what do you think are the most prudent types of recommendations to make to a parent? 2. The intervention goals that a client arrives at sometimes can differ markedly from the intervention goals that the clinician thinks are best suited for the client. What is the best course of action in such situations? What are some potential ways that you could respond? 3. Interprofessional practice is highly valued in contemporary clinical practice. What would an interprofessional practice approach look like when treating stuttering in a high school setting? Who else besides the speech-language pathologist would be involved in intervention? How would they be involved? Under which circumstances would you work to involve these individuals?

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V

Clinical Practice: Intervention Approaches

14 The Clinician’s Roles and Responsibilities in Intervention

Chapter Objectives After reading this chapter, readers will be able to: • Describe the roles that a clinician can assume when working with people who stutter. • Describe fundamental responsibilities of a fluency clinician. • Describe a framework for evidence-based practice. • Describe a general framework and principles for organizing fluency intervention programs.

Background Clinical practice in speech-language pathology is a dynamic enterprise. The scope of practice for today’s profession is broad, encompassing nine service delivery areas, eight service delivery domains, and five additional professional practice domains. Together, these elements constitute the speech-language pathologist’s (SLP’s) professional parameters. That is, they indicate which types of people the SLP can work with and, broadly, what

the SLP can do while working with them. However, as anyone who has ever observed or conducted a clinical session knows, SLPs also operate on a much narrower, personal level with the individuals they serve. That is, the practice of speech-language pathology plays out directly during regularly scheduled clinical sessions wherein the clinician and client engage with each other, either in a faceto-face manner or, as is becoming more common now, via some form of telecommunication. Either way, these interactions are the “front lines” of clinical practice, and the manner in which clinicianclient interactions transpire can affect the amount and type of progress a client makes as well as the client’s perceptions of the extent to which intervention is meeting his or her personal needs. This chapter focuses on this aspect of clinical practice, examining it from the perspectives of clinician roles and responsibilities and the establishment of effective working relationships.

Clinical Practice and the Code of Ethics As noted at the outset of the book, clinical service provision is rooted in standards of integrity and principles of ethical conduct. All individuals who

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are members of the American Speech-LanguageHearing Association (ASHA), all individuals who hold the Certificate of Clinical Competence (CCC), and all individuals who are applying for membership in ASHA and/or for the CCC are bound by ASHA’s Code of Ethics (2016b). Adopted formally in 1952, and applicable to the fields of audiology and speech-language pathology, the Code of Ethics is a statement of ASHA’s professional values. As such, in the context of speech-language pathology, it provides individuals with “a framework of common principles and standards of practice” that they can use to guide personal conduct and decisionmaking in professional settings. The Code of Ethics has evolved over the years in response to the changes in the landscape of clinical service provision as well as in the broader cultural and societal context with which service provision occurs. ASHA’s most recent update to the Code of Ethics occurred in 2016. ASHA (2016b) stated that its Code of Ethics is “partly obligatory and disciplinary and partly aspirational and descriptive in that it defines the professional’s role.”

Ethical Principles As stated in the document, the main purposes of ASHA’s (2016b) Code of Ethics are to (a) ensure the welfare of individuals who receive clinical services and who participate in research, and (b) “to protect the reputation and integrity of the professions.” The Code of Ethics is organized around four main principles, each of which is accompanied by an associated set of rules that pertain directly to the principle. As stated by ASHA, these principles address concepts related to professional duty, accountability, responsibility, and fairness. Readers are encouraged to visit ASHA’s website where the Code of Ethics can be accessed and read it in its entirety. Principle I of the Code of Ethics addresses the clinician’s responsibility to put the welfare of the individuals they serve professionally above all other competing considerations. The parameters of Principle I are specified through 20 accompanying “Rules of Ethics.” These 20 rules encompass a range of day-to-day elements of clinical practice. As such, it is incumbent on clinicians to review them

regularly so that they can be implemented always. Among the 20 rules are stipulations for providing clinical services in a competent manner — one in which the clinician draws upon all available resources, including referrals to other professionals and engagement in interprofessional collaboration, to ensure that quality services are provided. Among other things, the rules associated with Principle I call for practitioners to use “independent and evidence based clinical judgment” that puts the best interests of the client above all other considerations, to evaluate the effectiveness of the clinical services that are provided, and to provide only those services for which a realistic expectation of benefit is expected for the individual who is being served. Practitioners also should be knowledgeable about the outcomes that can be reasonably expected from treatment and to refrain from guaranteeing positive treatment outcomes to any client or client’s caregiver. Among the rules associated with Principle of Ethics II is the stipulation that SLPs engage in only those aspects of the profession “that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.” This ethical rule pertains not only to one’s competency in treating issues related to speech fluency but also to associated issues that many people who stutter experience with respect to how they think and feel about talking and about having a speech impairment. Related to this is the requirement that certified practitioners engage in continuing education for the purpose of enhancing and refining their professional competence. Principles of Ethics III and IV include rules pertaining to an assortment of professional practice matters that intersect with personal qualities such as honesty, integrity, diligence, and respect; the need to establish and maintain harmonious professional relationships with colleagues within and beyond the profession; and the need to prevent one’s financial and nonfinancial activities from conflicting with the duty to hold paramount the welfare of individuals served. The matters addressed in Principles of Ethics I, II, III, and IV constitute the base of quality clinical service provision. Adherence to the Code of Ethics is taken



14.  The Clinician’s Roles and Responsibilities in Intervention

seriously. Adjudication of alleged ethics violations for a range of matters, including those related to deception, misrepresentation, negligence, harassment, abuse of power, and discrimination, are overseen by ASHA’s Board of Ethics. ASHA’s website contains a wealth of resources to help professionals develop their base knowledge of professional ethics and to obtain guidance on how to deal with ethical dilemmas that arise in different working settings and at different stages of service provision.

Fluency Intervention:  Clinician Roles and Responsibilities This book uses the term clinical roles in reference to the ways the clinician interacts with a client at any stage or moment during treatment, and the underlying reasons that lead to those manners of interaction. In a sense, the term is captured by the familiar analogy of “wearing different hats” depending on what type of job is needed at any moment. The notion of responsibilities refers to the quality of the clinician’s interactions with the client, especially to the interlocking concepts of ethical behavior, evidence-based practice, and the clinician-client relationship. Taken together, an understanding of one’s clinical roles and responsibilities is an important frame of reference from which to commence intervention for any client. Skilled clinicians act responsibly during intervention, and they can shift readily from one interactional style to another while engaging with a client. These shifts can occur within a single treatment activity, during different portions of a clinical session, and/or at during different phases of an intervention plan, with the role a clinician assumes at any one moment driven by his or her assessment of the client’s current actions or words in conjunction with an understanding of what the goals for the session or activity are, and more broadly, what the client’s long-term goals are. As will be seen, the clinician’s interactions with the client may not always engender feelings of warmth or comfort from a client, but the interactions always are done with the goal of helping the client make the changes that are necessary to reach the goals of intervention.

Roles That Fluency Clinicians Are Likely to Assume During Intervention The interactional styles that a clinician assumes during intervention are difficult to capture fully; however, this section discusses several roles that clinicians are likely to take with most individuals who have impaired fluency. An overview of these roles is presented in Figure 14–1.

The Clinician as Authority­–Expert Of the many roles that a clinician can assume, the role of “authority” or “expert” is one that probably comes to mind immediately for most readers. Indeed, the notion of clinical expertise is captured in rule IA of ASHA’s (2016b) Code of Ethics in speech-language pathology: Individuals shall provide all clinical services and scientific activities competently. The ability to provide services competently implies that the clinician has develop a rich knowledge base and a broad clinical skill set. The related concepts of competence and expertise are represented in several other rules within the Code of Ethics, as well (e.g., making use of all appropriate services, being able to use independent and evidence-based clinical judgment, being able to make reasonable statements of prognosis), and they are intrinsic to the seven clinical roles discussed in this section. Primary areas of fluency-related knowledge and skill that are essential to the provision of competent clinical services for people with impaired fluency are presented in Table 14–1. The information presented in this table is an extension of the general requirements for the Certificate of Clinical Competence that were present earlier in the book, in Table 1–2. As suggested there, and as shown in Table 14–1, competency is dependent on a thorough understanding of both the normal bases of fluency and the nature and characteristics of impairment in fluency, as well as the ability to integrate knowledge and previous experiences into a range of assessment and intervention practices. The importance of having a rich knowledge base and a proficient skill set in each of these areas

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AuthorityExpert TeacherCoach

Advocate

Intervention Process Consultant

Model

Manager

Counselor

Figure 14–1. Roles that clinicians can assume when conducting fluency intervention. The roles of authority-expert, teacher-coach, model, and counselor most often are assumed during the course of clinical sessions with the client. Within a session, and sometimes within an activity, the clinician may move from one role to another, depending on what the situation calls for. Authority-expert is a role assumed when planning clinical sessions and when engaged in informational counseling. Teacher-coach and model are roles the clinician assumes when working with clients on developing skills for stuttering management. Counseling is likely to be integrated with skill-building activities, particularly at times when clients are needing to address affective and cognitive factors associated with stuttering. Managing, consulting, and advocating roles take place outside treatment, but still have the ability to support the client’s stuttering management.

cannot be overemphasized. The more one knows about fluency, fluency impairment, and options for intervention, the better positioned he or she is to respond to the unique circumstances and challenges that a client presents. Clients form impressions quickly as to whether their clinician has a rich grasp of fluency disorders and the significance of the client’s communication disability. Having the ability to respond to clients’ questions about the nature and treatment of fluency disorders, and the ability to explain and teach contemporary intervention strategies go a long way toward building

clients’ confidence that the clinician has the competence needed to help them attain their long-term goals. Development of a thorough understanding of information from chapters in this book and the associated practice activities following the chapters is an excellent way to make this happen. There is no doubt that the SLP’s competency matters greatly in clinical practice. That said, clinicians should be cautious about assuming that their expertise will carry them through all that is encountered in intervention. While it is true that SLPs, by virtue of their academic study and clini-



14.  The Clinician’s Roles and Responsibilities in Intervention

Table 14–1.  Core Knowledge and Skills Associated With Competence in the Ability to Provide Fluency Intervention Area The nature of fluency The nature of disfluency

Competency (Being able to . . . ) • Describe fluency as a multidimensional concept. • Describe how fluency occurs in the context of the speech-language production system. • Describe how disfluency occurs in the context of the speech-language production system. • Describe the characteristics of common disfluency types, including their structure and factors that can trigger their occurrence.

Characteristics of typical and atypical fluency functioning

• Describe normative data pertaining to disfluency frequency (by types), disfluency duration, and speech rate. • Describe the characteristics of stuttered, cluttered, and other types of atypically disfluent speech. • Describe the epidemiological characteristics of fluency disorders. • Describe the effects that impaired fluency can have on one’s functioning. • Describe the genetic, biological, motoric, linguistic, psychological, and cultural corelates of stuttering, cluttering, and other fluency impairments.

Assessment

• Describe, administer, and interpret formal and informal procedures that are used to evaluate fluency functioning, make a diagnosis, and determine the severity of fluency disorders. • Integrate assessment data to make reasonable statements of prognosis. • Develop and present appropriate recommendations and intervention goals.

Intervention

• Describe intervention approaches for stuttering, cluttering, and other fluency impairments, including their rationale, characteristics, expected effects, and potential limitations. • Integrate knowledge about the nature of fluency and disfluency and characteristics of typical and atypical fluency functioning into intervention practices. • Demonstrate application of evidence-based intervention principles, including: • Selection and competent administration of appropriate intervention principles/strategies and associated outcome measures; • Employment of evidence-based judgment to adjust intervention practices as necessary in response to ongoing assessment of a client’s response to intervention and client preferences; and • Implementation of strategies for generalizing and maintaining functional changes.

cal training, should be able to provide accurate answers to many of the client’s fluency-related questions, and are likely to have a good sense of what type of intervention approach is best suited to the client’s current speech profile and long-term goals, it also is true that some of the questions clients ask about their fluency impairment cannot be answered definitively (e.g., “Will I ever stop stut-

tering?”), and some of the challenges a client faces will not have a clear-cut “best answer” (e.g., “I’m stuttering a lot during the ‘meet and greets’ I have to do with customers at work. What should I do?”). For questions like these, it is helpful to welcome the client’s participation in arriving at answers by asking questions such as, “What have you imagined happening with your fluency in the future?”

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or “Is there any small part of these ‘meet and greet’ interactions that you think you might be able to grab ahold of and change?” Thus, rather than feeling driven to construct “authoritative responses” to every question a client asks, even the unanswerable questions, the clinician instead takes advantage of the client’s expertise — drawing upon the individual’s firsthand knowledge about his or her experiences to construct responses. In this way, the clinician avoids imposing ill-fitting professional expertise on the client. An approach like this is consistent with the broader aim of intervention, which is to help clients develop the ability to manage their stuttering-related challenges effectively and independently — that is, to help clients improve their ability to help themselves (ASHA, 2016b; Egan, 2002).

The Clinician as Teacher-Coach A main role of the SLP in fluency intervention is to teach clients concepts and skills that they currently lack. Part of the teaching role concerns identification of what the client needs to know. Academic knowledge about fluency impairment and related assessment and treatment options, plus practical experiences with previous clients, enables the clinician to shape the intervention goals that will be addressed and to build out the content of the intervention program (e.g., which intervention components are important to include, which treatment concepts or skills are important to introduce to the client). Another main portion of the teaching role concerns instructional design — that is, the organizational format of clinical activities that the clinician will introduce to the client. Numerous approaches to instructional design have been developed for use in educational settings. An approach to lesson plan (i.e., learning activity) design that has been applied widely in educational settings is the one developed by Russell and Hunter (1976; Table 14–2). Although not every clinical activity needs to be structured exactly in the manner described in Table 14–2, the framework shown there at least offers a useful starting point for considering which elements to include when treating a client (Hunter, 1989; Wolfe 1987). As shown in Table 14–2, treatment activities are intended to unfold in an orderly manner, that

allows for structured incremental development of a knowledge concept or skill. Although knowledge concepts typically can be developed relatively quickly (i.e., in few sessions, after a limited amount of practice), attainment of stuttering management skills, particularly those that entail changes in speech motor behavior and changes in how one thinks about speech and stuttering-relating behavior, often require much more time and many practice trials before the client reaches the desires level or type of performance. Thus, practice activities are a key component of fluency therapy and, within any one session, they are likely to consume most of the time that is allotted to treatment activities. Specific instructional strategies are explained in greater detail in subsequent chapters; however, for now it suffices to reiterate the point made in Chapter 13: Because people who stutter are operating with an impaired or, at best, inefficient speech motorcontrol system, it cannot be assumed that copious amounts of practice will lead to normalized speech motor performance. Even after hundreds of practice trials, it is not at all unusual to hear a client say that he or she still needs to devote conscious attention to aspects of speech such as movement velocity and movement force when articulating an utterance. Nonetheless, speakers who stutter do improve at being able to realize relatively smooth, connected motor movements when talking. For this reason, a critical aspect of the teaching role is the creation of practice contexts that are structured according to principles of learning (particularly principles of motor learning). In the following box, several fundamental principles of motor learning are described. Research into the effects of implementing different practice regimes into motor-based clinical interventions for childhood apraxia of speech and speech sound disorders has been conducted with growing frequency in recent years (e.g., Allen, 2013; Namasivayam et al., 2015; Preston, Leece & Maas, 2017; Preston, Maas, Whittle, Leece, & McCabe, 2016; van der Merwe & Steyn, 2018), and factors affecting motor learning in people who stutter during laboratory tasks have been examined in numerous studies as well (Kleinow & Smith, 2000; Max & Baldwin, 2010; Max, Caruso, & Graco, 2003; Namasivayam & van Lieshout, 2008; Smits-Bandstra, De Nil, & Rochon, 2006).



14.  The Clinician’s Roles and Responsibilities in Intervention

Table 14–2.  Russell and Hunter’s (1976) Elements of Lesson Plan Design as Applied to an Intervention Activity for a Client Who Stutters Component

Description

Example

Anticipatory Set

The clinician introduces materials to spark the client’s interest or expand the client’s insight into the learning activity that is about to occur.

The clinician presents the client with an excerpt from a general interest newspaper article on the effects of time constraints on human performance. They discuss how the content of the article pertains to feelings of time pressure the client has been experiencing when making telephone calls. They conclude that it is common for most people to experience a drop in performance when they feel pressured to do something quickly.

Objective and Purpose

The clinician explains the objective of the activity and the criterion for success.

“As we discussed at the last session, we’ll be making several telephone calls today. The objective is purposefully to block your speech on the first sound in the word “hello” and to hold that sound for as long as you need until the feeling of being rushed dissipates. The purpose of this exercise is to change how you react when you stutter in time-constrained contexts.”

Input

The clinician presents pertinent background information, materials, and instructions.

The clinician explains how emotional arousal and distorted thinking (e.g., I have to hurry.) can amplify the severity of stuttering-related disfluency. The clinician presents a list of telephone numbers to call along with instructions on how to make the calls.

Modeling

The clinician demonstrates what the client is expected to do.

The clinician makes a sample telephone call, blocking on the word “hello” as described above.

Checking for Understanding

The clinician provides a chance for the client to ask clarifying questions and asks the client to repeat the purpose of the activity.

The client successfully explains the purpose of the activity. The client then asks several “What if the person does ___” questions, which the clinician answers.

Guided Practice

The client practices with accompanying feedback from the clinician, and the clinician prompts for self-evaluations. Trial procedures are modified as necessary (e.g., add reminder cues) depending on the client’s performance.

Fifteen calls are placed. The clinician uses a stopwatch to time how long the client holds “hello” and then asks the client to complete a self-rating on the amount of “time pressure” the client felt at the start of the call and when the call ended. The clinician and client exchange their data after each call.

Independent Practice and Application of Principles

The client extends use of the skill to a setting where the clinician is not present.

The client and clinician decide on how many telephone calls per day the client will make at home during the upcoming week and design a self-evaluation form.

Closure

The clinician and client recap the main concepts.

The client applies the skill to settings other than the telephone.

The clinician, with the client’s participation, summarizes the objective, purpose, method, and outcomes associated with the activity.

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Motor Learning Parameters to Consider When Designing Practice Activities for Motor-Based Treatments With People Who Stutter (Adapted from Maas et al., 2008): 1. Prepare the learner for practice. Implement preparatory instructions or activities to ensure the client understands what he or she will be doing and is motivated to do it. Check whether the individual can produce the target movement/movement pattern. 2. Consider the amount of practice. Historically, motor-based treatments for stuttering have featured large amounts of practice (i.e., many practice trials, across many sessions) using a variety of practice stimuli. (Some research suggests that practicing the same stimuli over and over can result in poorer transfer of skills to other settings.) 3. Consider the distribution of practice. Historically, motor-based treatments for stuttering have featured massed practice (e.g., many trials at once), with some treatments also incorporating closely bunched sessions (e.g., daily for 2 weeks.). At present, it is unclear how this type of treatment schedule compares to distributed practice (e.g., spacing out practice sessions over a long period of time) when applied to speakers who stutter. 4. Consider the movement variability associated with practice stimuli. Existing motor based treatments for stuttering have featured elements of both variable and constant practice. Practice with stimuli that are phonetically the same or highly similar (constant practice) is more likely to be done in the early stages of treatment, and practice with stimuli that are phonetically different (variable practice) is more common in the mid- to late-stages of treatment. 5. Consider the practice format (i.e., random vs. blocked stimulus presentation). Similar to the preceding, it is unclear the extent to which stimulus presentation must be manipulated such that a learner either (a) is able to predict what the movement pattern will be in an upcoming trial, or (b) is unable to predict what the movement pattern will be in an upcoming trial.

6. Consider attentional focus. Historically, some motor-based treatments for stuttering have featured an internal attentional focus, wherein the speaker concentrates on body movements including kinematic and somatosensory information (e.g., the force of articulatory movement at the place of articulation), whereas others have featured an external focus (i.e., the focus is on the effect of the movements, such as when a speaker aims globally to attain a target speech rate, such as 1 syllable per second). 7. Consider the complexity of practice stimuli. Motor plans for speech are thought to range in length from single syllables (e.g., toast), to multiple-syllable word units (e.g., toaster), to phonological phrases (e.g., in the toaster). To the extent that any of these represent a complete, generalized motor program, they each would be regarded as a complex target. Simple targets, in contrast, would consist of part of a generalized motor program (e.g., part of a syllable, or one syllable in a multisyllable motor program). Historically, motorbased treatments for stuttering have featured complex targets. 8. Consider the type, frequency, and timing of feedback. Two types of feedback are described in the motor learning literature. Knowledge of results is a type of feedback that is provided after the completion of a practice target. It includes information about whether a movement’s outcome matched the movement goal. This type of feedback typically consists of simple statements (e.g., “You missed the target.”). Knowledge of performance, in contrast, is a more specific form of feedback — one in which the clinician offers more specific details to the learner (e.g., “Your rate was about 25% faster than the goal for that sentence.”). Both types of feedback have been used in motor-based treatments for stuttering. To date, however, it is unclear whether



14.  The Clinician’s Roles and Responsibilities in Intervention

one type of feedback offers advantages over the other for effective stuttering management through motor-based control strategies. Feedback frequency and immediacy also can be manipulated. Maas et al. (2008) noted that some studies have reported reduced fre-

The coaching role is similar to the teaching role in that both are oriented toward improving performance. Within clinical sessions, the “clinician as coach” role is particularly relevant during practice activities, wherein the focus often goes beyond merely completing a set number of trials to include the element of pushing the client, within reason, to perform at a level that the clinician feels the individual can attain, but that the client is not yet demonstrating consistently. Across clinical sessions, the “clinician as coach” also aims to help clients maintain maximal motivation toward accomplishing intervention goals in real-world settings. The latter portion of intervention can be challenging for clients because contemporary treatment strategies for stuttering are not guaranteed to yield high levels of fluency at all times in naturalistic contexts. As such, it is not unusual for clients to become discouraged with the pace or extent of progress they are making. At times like these, it is helpful for the clinician to step into the coaching role. Hall and Simeral (2008) listed several characteristics of effective coaches. These include the following: • Self-reflection.  In the context of treatment for fluency disorders, this includes self-analysis of the clinician’s roles and responsibilities in helping the client attain his or her intervention goals. Included in self-reflection is clarification of which responsibilities belong to the client in intervention and which belong to the clinician. Self-reflection also implies analysis of what parts of guided and independent practice are working well for the client and what parts are not working well, and the underlying reasons why.

quency of feedback and delayed presentation of feedback; each are associated with better motor-learning outcomes in individuals with disorders such as apraxia of speech and hypokinetic dysarthria.

• Establishment and maintenance of trustworthy relationships.  In the context of treatment for fluency disorders, trustworthiness can be established through consistent demonstration of empathy for the client’s experiences and through consistent implementation of treatment activities and realism with respect to performance expectations. • The ability to recognize the client’s strengths, abilities, and beliefs.  In the context of treatment for fluency disorders, this characteristic is a product of systematic assessment of all relevant facets of the client’s fluency functioning, and careful, nonjudgmental observation of what the client says and does when talking about his or her fluency experiences. • The ability to demonstrate patience.  In the context of treatment for fluency disorders, this characteristic requires that the clinician have a thorough understanding of the change process in individuals who have long-standing histories of stuttering. Change often occurs slowly (perhaps on a time scale that will exceed the number of clinical sessions you will be able to conduct with the client) and incrementally. Knowing and accepting this reality will help the clinician remain enthusiastic about those changes the client does make and convey that enthusiasm to the client. In maintaining enthusiasm, the clinician as coach is conveying messages to the client such as “This is just as it is supposed to happen,” and “Keep going . . . you are on the track that’s typical with stuttering treatment.” Messages like these are helpful in maintaining a client’s motivation at times when it begins to wane.

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• Ongoing assessment of one’s impact on the client.  In the context of treatment for fluency disorders, the clinician as coach consistently reassesses the effect that his or her efforts have on the client, and in doing so, considers the extent to which meaningful changes are occurring and whether the clinician has helped the client develop new skills and expand existing strengths to manage stuttering more effectively when the time comes to do so independently.

The Clinician as Model As noted in the preceding section, modeling is a component of teaching. It is separated here because the kinds of modeling that an SLP is called on to do during intervention for fluency disorders often goes beyond what might typically occur in educational settings or in clinical service provision with other disordered populations (e.g., speech sound disorders). As will be explained further in the remaining chapters, some intervention strategies for stuttering entail having the clinician model behavior that are straightforward to do (e.g., longer or more frequent pauses, a slower-than-usual speaking rate). Other intervention strategies, such as emulating the types of stuttering-related behavior the client produces, are likely to be perceived as more challenging to do. The rationale for modeling stuttering behavior for clients is threefold: first, it helps the clinician understand the motoric/physiologic aspects of the stuttering-related behaviors; second, it creates the potential for the clinician to demonstrate alternatives to the client’s current behavior that are more consistent with concepts such as “reducing disability” and “improving communicative competence”; and third, it creates a context that allows a client to analyze stuttering behavior that is like his or her own, but occurs at a “safe distance.” Clinicians who are new to providing intervention for stuttering often find it challenging to emulate the client’s stuttering-related behavior. Indeed, in people who do not stutter, the simple act of listening to stuttered speech triggers significant physiology changes, such as increased skin conductance, reduced heart rate, and subjective self-

ratings of negative emotion such as unhappiness, nervousness, and discomfort (Guntupalli, Everhart, Kalinowski, Nanjundeswaran, & Saltuklaroglu, 2007; Rami, Kalinowski, Stuart, & Rastatter, 2003). When emulating stuttering, feelings of embarrassment arise, along with concern over how the client might respond. In the author’s experience, after a relatively modest amount of practice, clinicians can learn to produce simulated stuttering (i.e., pseudostuttering) in a calm, authentic manner. As for the matter of client reactions to the clinician’s pseudostuttering, this issue usually is addressed easily by explaining the rationale for doing so. A more challenging task than in-clinic modeling of stuttering-related behavior involves modeling pseudo-stuttering in genuine out-of-clinic contexts (Ham, 1990; Hulit,1989). A clinician might do this in an activity that is designed to help the client analyze the communication dynamics of a situation that currently is very challenging for that individual (e.g., making a telephone call to a local business, ordering a sandwich at a restaurant). Pseudo-stuttering activities appear to increase empathy in typical speakers for people who stutter. In a treatment context, the client stands back and watches/listens as the clinician produces simulated stuttering behavior, and the listener reacts to it. Activities like this offer the potential for helping clients develop a perspective on the dynamics of a speaking situation that likely would be more difficult to achieve if the client were to be the one engaged in the interaction.

The Clinician as Counselor Another role that clinicians assume during intervention with people who stutter is that of counselor. According to ASHA’s Scope of Practice in Speech-Language Pathology (2016a), clinicians fulfill this role in the following way: SLPs counsel [the individuals they serve] by providing education, guidance, and support. Individuals, their families and their caregivers are counseled regarding acceptance, adaptation, and decision making about communication, feeding and swallowing, and related disorders. The role of the SLP in the counseling process includes interactions related to emotional reac-



14.  The Clinician’s Roles and Responsibilities in Intervention

tions, thoughts, feelings, and behaviors that result from living with the communication disorder, feeding and swallowing disorder, or related disorders.

As is clear from this description, the counseling role is broad and includes elements of providing clients with information, providing clients with support, and helping clients to make decisions and take actions that will help them respond to their communication-related challenges more effectively than they presently are doing. In the role of informational counselor, the clinician typically draws on his or her professional expertise (i.e., knowledge about the nature and characteristics of stuttering and its treatment) to help clients develop factually accurate understandings of their experiences, options, and challenges. Behind many queries for facts, however, are emotional underlays, such as coming to terms with one’s limitations and developing effective problem management skills to address one’s struggles, obstacles, and challenges. As will be discussed in Chapter 16, the role of counselor requires a skill set that is different from the role of being a clinical teacher. The process of counseling requires the ability to listen empathetically to clients as they talk about their experiences, but also the ability to probe and question clients in ways that help not only the clinician to understand the client, but the client to understand himself or herself better. The latter is akin to a therapeutic dialogue. The role of counselor intersects a bit with the coaching role described earlier, in that part of counseling is helping clients develop the ability to become unstuck and move forward in their progress with a particular task by identifying underused opportunities and resources they have, by identifying and reconfiguring inaccurate or distorted beliefs they have about their situation, and by challenging them to act on the plans they develop for tackling stuttering-related challenges, feelings, and emotions. All of this is done to help clients to help themselves, and in doing so, improve their sense of well-being by alleviating general distress and, in some cases, resolving crises. In the clinician-as-counselor role, it is critical for the SLP to grasp the depth of difficulty that some clients who stutter experience. As noted, informational counseling is a typical component of inter-

vention. With this type of counseling, the SLP uses his or her expertise to provide clients (and, when appropriate, parents and other caregivers) with accurate and appropriate information to advance understanding of the disorder, the intervention process, and specific facets of treatment. (See Chapters 15 and 16 for additional details about informational counseling.) Although this type of counseling can be useful for many clients, clinicians often need to go beyond facts and figures about the disorder to address the many and varied social and emotional consequences that can accompany the speech symptoms of the disorder. This is where the clinician-as-counselor role comes in. Many people who stutter find it quite difficult to deal with the limits that stuttering places on their ability to communicate. They find it challenging to experience disability in an arena where most of the population has no problem at all, and to have an impairment that limits one’s ability to function in ways that are difficult for typical speakers to grasp. A backdrop like this can trigger a range of feelings and emotions in the person who stutters, including feelings of embarrassment, helplessness, vulnerability, frustration, anger, and shame, as well as an assortment of ineffective, partially effective, and self-limiting coping responses such as avoidance of speaking, word substitution, circumlocution, and use of rhythmical nonspeech movement to facilitate speech initiation. As stuttering-related speech difficulties persist, one’s sense of being able to manage the speech difficulties is likely to decrease. In this scenario, these negative feelings and coping responses tend to grow in frequency and intensity, sometimes to such an extent that they become as much a part of the person’s stuttering-related communication disability as the disfluent speech. Beyond the client’s fluency impairment and reactions to the fluency impairment, a third source of distress for many people who stutter is how others respond to their speech difficulties. People who stutter often report that they routinely experience situations in which their conversational partners respond to stuttered speech in suboptimal ways. Some partner responses (e.g., filling in or guessing at a word while the individual is producing a stuttering-related disfluency) have the effect of aggravating stuttering severity and reducing the speaker’s sense of self-efficacy. Partner responses

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that convey a sense of pity for the person who stutters (e.g., “Oh, you poor darling.”), that are overtly hostile or demeaning (e.g., laughing at, imitating, or making hurtful remarks about the individual’s fluency difficulties), or that are designed to exclude the person who stutters from participating in an activity can lead the individual who stutters to have a diminished sense of self-worth. Stuttered speech can evoke an assortment of more subtle responses from conversational partners, as well. Many of the latter responses are nonverbal, and they seem to run the gamut of human emotion, ranging from looks of surprise or being startled, to looks of confusion, curiosity, or discomfort, as well as to actions that suggest impatience with the amount of time the person who stutters is taking to communicate. Although partner responses like these are most apt to occur when a person who stutters interacts with a stranger or someone who they seldom encounter (e.g., children encountered during playground activities, store clerks, participants in social gatherings or meetings), it is possible for speakers who stutter to receive responses like these in almost any setting. Interactions with strangers and marginally familiar people occur regularly during daily life for most people, including people who stutter. Thus, they are not avoided easily. In contrast, some people who stutter have reported that the absence of partner response to stuttering also can have significant negative effects. For example, when a person’s stuttering is seldom acknowledged or discussed within his or her family, that person may conclude that stuttering is a taboo topic and a shameful thing to do. To typical speakers, partner responses like those noted in this chapter might not seem particularly problematic; however, for many people who stutter, such responses occur often enough to create a communication landscape that, in some respects, is chronically unpredictable in terms of how successful one’s attempts at speaking smoothly will be and how others will respond when the speaker’s speech is not smooth. In other respects, a partner’s response is very predictable due to the person who stutters having experienced recurring fluency difficulties and/or suboptimal partner responses in specific situations (e.g., when reading aloud in class, when speaking on the telephone, when conducting a team meeting at work). Over time, when

recurring uncertainty about communication outcomes and listener responses mix with recurring situational fluency difficulties and negative partner responses, a speaker’s reactions to stuttering can transform from basic concern and unease into more intense emotional responses such as fear, panic, and anxiety. In recent years, some researchers have reported that symptoms of social anxiety are present in a substantial percentage of people who stutter, including those in the preschool age range. When present, social anxiety has the potential to affect functioning negatively in a variety of ways, such as (a) interfering with one’s ability to apply stutteringmanagement strategies successfully in real-world situations; (b) reducing one’s willingness to participate verbally in daily activities; and (c) diminishing one’s self-perceptions of health and quality of life. Clients are not the only ones who can benefit from the SLP’s counseling efforts. Parents of children who stutter also may experience a variety of feelings that, when left unchecked, can interfere with their ability to participate in intervention activities effectively. For instance, parents may feel anxious about the disorder and how the label “person who stutters” will affect their child’s achievement, socialization, and self-esteem over time. They may feel guilt over having done something to have caused their child to stutter or over not having sought professional services to help their child sooner. The SLP can help parents address feelings like these through informational counseling and, when necessary, through more advanced forms of counseling that are aimed at helping parents adjust to and focus on their child’s present situation and identify concrete steps that are likely to help their child communicate more effectively now and in the future.

The Clinician as Manager The role of clinician-as-manager is regarded as one that involves elements of coordination, supervision, collaboration, and personal development. As a case manager, the clinician may assume a lead role in coordinating interdisciplinary services that a client receives. In such cases, the clinician is responsible for monitoring what these services are, how they impact the client, and how they might interact with one another. When appropriate, another respon-



14.  The Clinician’s Roles and Responsibilities in Intervention

sibility is to facilitate ways in which the various professionals can coordinate their efforts for the maximum benefit to the client. For example, if a client who stutters also receives services from a psychologist for treatment of social anxiety disorder, the clinician can, with the client’s permission, collaborate with the psychologist to identify ways that each professional can reinforce the other’s work. In school settings, SLPs may have the opportunity to coordinate and/or direct other school personnel (e.g., school counselors, office staff, special education teachers, classroom teachers, classroom aides and assistants) in ways that promote a consistent, integrated approach to intervention. Because of the nature of their job duties, these individuals often are in prime positions to be involved with facilitating, monitoring, or implementing prevention activities that are included in the student’s intervention plan (e.g., an anti-bullying program). Some clients may elect to invite family members, peers, or other important individuals in their lives to participate in treatment activities that take place either in the SLP’s office or in real-world settings at home or at school. In the role of manager, clinicians also can be alert for “beyond clinic” opportunities that may be useful to the client. For example, the clinicians can connect the client with local consumer groups that provide support not only for stuttering but also with aspects of general personal development such as public speaking. In that way, the clinician helps the client to network with organizations and key individuals who may serve as adjuncts to the specific activities that transpire in fluency therapy.

The Clinician as Consultant Clinicians are most likely to engage in the role of consultant after the client’s participation in formal treatment ends. In this role, the clinician serves as a resource to the former client, helping the individual to troubleshoot challenges that arise in daily life long after one-on-one sessions with the SLP end. Examples of situations that could prompt a former client to consult with the clinician include the following: The client is seeking advice for how best to handle a situation in which he or she stutters much more severely than in other situations, seeking the clinician’s advice on whether it is wise to disclose

one’s status as a person who stutters in an upcoming job interview, or seeking the clinician’s advice on how to best respond when the former client’s child has begun to stutter. The author has encountered each of these scenarios and others in clinical practice. Clinicians should find that former clients are quite grateful for having a trusted professional to consult in times of difficulty.

The Clinician as Advocate One other role that clinicians may assume and that can impact the intervention experiences of people who stutter is that of advocate. According to ASHA’s Scope of Practice in Speech-Language Pathology (2016a), clinicians fulfill their role in advocacy and outreach in the following way: SLPs advocate for the discipline and for individuals through a variety of mechanisms, including community awareness, prevention activities, health literacy, academic literacy, education, political action, and training programs. Advocacy promotes and facilitates access to communication, including the reduction of societal, cultural, and linguistic barriers.

Advocacy and outreach activities often take place at levels well beyond the clinician-client dyad (e.g., working to help a state speech-languagehearing association collect data about caseload sizes for presentation to a state legislature). Nonetheless, there are several activities under this heading that, in certain contexts, can impact individual clients more directly. For example, an SLP’s efforts to educate an elementary school’s staff and students about stuttering could have immediate, positive benefits for children in the school who are being teased about stuttering (Murphy, Yaruss, & Quesal, 2007b). Similarly, an SLP who works to broaden the local school district’s eligibility criteria for children who stutter to be enrolled in individual therapy sessions could immediately impact access to treatment for children in the school district. SLPs have an obligation to be alert for opportunities to advocate for the profession and for individuals who the profession serves. Another role that fits, at least partly, under the notion of advocacy is that of an ally. Gerlach, Constantino, and Kennedy (2017) compiled ideas that

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attendees at the 2017 National Stuttering Association Annual Conference shared regarding the qualities of a person who acts as an ally for individuals who stutter. The ideas were organized under five main points on an informational flyer titled What Does It Mean to Be an Ally to People Who Stutter? The five broad qualities noted on the pamphlet were as follows: • Shows interest in and asks questions about a person’s stuttering; • Respects that individuals who stutter have differing views when it comes to how they feel about their stuttering, how fluently they wish to speak, and how much they wish to participate in therapy; • Assumes responsibility for becoming knowledgeable about basic characteristics of stuttering and about what people who stutter think, feel, and experience. • Models “best practices” for others on how a communication partner should respond when a person who stutter is speaking; • Is willing to stand up for people who stutter even when it is discomforting to do so (e.g., standing up to people who bully, tease, or mock people who stutter). Clinicians would be wise to do an honest selfappraisal prior to commencing intervention with a person who stutters to determine whether they meet the criteria for being an ally to people who stutter. Once this has been verified, they are then in a position to commence treatment and to train others to fulfill this important role.

Fluency Intervention: Independent and Evidence-Based Clinical Judgment As acknowledged briefly in Chapter 1 of the book, one of the more significant changes during the past 25 years regarding the treatment of communication disorders has been the recognition that clinical services need to be based on evidence-based practices (EBP). Indeed, ASHA’s (2016b) Code of Ethics calls on clinicians to use independent and

evidence-based clinical judgment when providing services to clients, and to do so in a manner that holds the client’s welfare as the overriding priority ​ — that is, as something that ranks above all other considerations. This section discusses this aspect of ethical practice in greater detail. According to ASHA, EBP features the integration of (a) external scientific evidence, (b) clinical expertise/expert opinion, and (c) the perspective(s) of the client and/or caregiver. ASHA stated that the integration of these three components results in “informed evidence-based decisions and [the provision of] high-quality services [that reflect] the interests, values, needs, and choices of individuals with communication disorders.” Dollaghan (2007) described this three-part model of evidence-based practice at length in her textbook on the use of evidence-based practice in speech-language pathology. The essential features of Dollaghan’s description of the EBP components are described next.

Using External Scientific Evidence The term external scientific evidence refers to data that originate beyond a clinician’s professional practice setting (Dollaghan, 2007). In the EBP literature, external scientific evidence is ranked in terms of its quality. In such rankings, randomized controlled trials (RCTs) are regarded as a robust form of evidence. RCTs are research studies that feature active manipulation of an independent variable and random assignment of participants to the groups. For example, where individuals are assigned randomly to either an experimental treatment group or a group that receives a placebo, the study is classified as an RCT, and “treatment type” is an independent variable. When implemented with sufficiently large participant samples, randomization provides an effective means of controlling for any effect that extraneous variables might have on participant performance in the study activities. The use of a control group allows for the groups to be compared based on whether they received the experimental treatment or not. An alternative to the RCT is the quasi-experimental design, which features precise matching of research participants across two or more groups. The aim of participant matching is to make the



14.  The Clinician’s Roles and Responsibilities in Intervention

composition of the groups as similar as possible with respect to potentially confounding variables such as participant age, gender, disorder severity, or any number of other factors. Because of the difficulties inherent in matching participants on all potentially relevant variables, participant matching is regarded as a weaker research design than the RCT. Single-subject experimental research also is afforded less weight than the RCT in most rating systems. With this design, a participant is measured repeatedly throughout stages of the experiment (e.g., the baseline stage, the treatment stage, the withdrawal of treatment stage). In this way, the participant essentially acts as his or her own control for an assortment of confounding variables that would be present when a group design is used (e.g., education level, prior treatment history). A limitation of the single-subject experimental design, however, is that the results cannot be readily generalized to a broad population. Nonetheless, this approach is appropriate to use when examining a novel or previously untested treatment, each of which is a situation where it is sensible to test the effects of the treatment on a small scale prior to launching a resource-intensive group-level investigation. Systematic reviews are another option to consider when collecting external evidence. ASHA (2020) defined a systematic review as “a formal assessment of the body of scientific evidence related to a clinical question [that] describes the extent to which various diagnostic or treatment approaches are supported by the evidence.” In other words, a systematic review is a study of studies. Systematic reviews differ from a book chapter such as this in that they feature a formal method, in which the researchers develop and implement procedures for conducting their literature search, including criteria they apply to identify published studies that are sufficient in quality and scope to be included in their review. When treatment outcomes are the focus of the systematic analysis, the researchers then synthesize data from the selected studies to arrive at general conclusions about the effectiveness of the treatment(s), and, perhaps, about the quality of the research designs of the selected studies. Some systematic reviews (i.e., meta-analyses) are conducted in a manner that enables a researcher to combine and then conduct statistical analyses

on data from multiple individual studies. In this way, the results from a single study are merged with results from other similar studies to yield a summary of statistically based findings on a single treatment or on a group of similar treatments. When applied to treatment research, this approach has the potential to yield overarching statistical conclusions about the state of treatment effectiveness with a disorder population. Data from contemporary systematic reviews in the area of fluency disorders can be accessed through the Practice Management section of ASHA’s website. Other sources of evidence, such as case studies and expert opinion, typically are ranked as being weaker than those described thus far because of their lack of experimental manipulation and the greater potential for being affected by author biases. Despite the limitations of case studies, they do have a role in the evidence-building process (e.g., as a first step in examining the effect of a novel treatment). Expert opinion also plays a role in the evidence-building process, such as when several experts are assembled to function as a committee or when a clinician draws on his or her previous experiences in clinical treatment with a client population to arrive at decisions about treatment practices for a current client. In addition to the research-driven evidence described thus far in this section, clinicians can access consensus-based guidelines. These function similarly to systematic reviews; however, rather than containing information that is based on research studies that meet a predetermined threshold of quality, they contain information that reflects the consensus (i.e., group-level agreement) of individuals who are recognized for their expertise in a topic area (e.g., the treatment of stuttering with adult clients). Consensus-based guidelines are useful for jump-starting the process of evidencebased practice; however, clinicians must be mindful of limitations that are inherent in the process of constructing group-level guidelines. Such limitations include (a) the types and extent of compromise the committee members have had to make in order to arrive at a final document, and (b) the tendency for the more assertive and/or the more senior members of a committee to make outsized contributions to the guidelines that the committee ultimately puts forth.

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Locating Scientific Evidence and Implementing It in Practice Clinicians can access treatment research more easily today than at any time in history due to the electronic storage of scholarly information and the ease with which that information can be accessed through the Internet. Dollaghan (2007) provided a detailed description of how to implement evidencebased practice in either assessment or treatment contexts. (Similar information is summarized on the Evidence-Based Practice section of ASHA’s website.) Dollaghan (2007) explained that the process begins with the formulation of a question that helps the clinician focus on the type of evidence he or she hopes to assemble. The focusing question (abbreviated as PICO) consists of four components: (1) the target population (e.g., children who stutter); (2) the intervention being considered (i.e., stuttering modification therapy); (3) a comparison or alternative option to the intervention being considered (e.g., no treatment, another type of treatment); and (4) the outcome one seeks to attain (e.g., improved fluency, reduced communication disability). The clinician then searches for the relevant information on various websites that publish or archive research studies and, after conducting a rigorous assessment of the information, arrives at a decision regarding how clinical practice should proceed. This process can be time intensive, particularly when the PICO question deals with an area for which systematic reviews and/or meta-analyses have not yet been conducted. Thus, if the characteristics of one’s work setting allow, it is helpful to assemble a team of professionals to conduct the review of scientific evidence.

Using Clinician-Generated Data and Clinician Expertise Dollaghan (2007) used the term internal evidence in reference to data that a clinician amasses through systematic, empirical interaction with a client or a cross set of similar clients. Consequently, a clinician’s internal evidence base is closely linked to the amount of firsthand experience he or she has working with a client (e.g., one session’s worth of

data vs. 20 session’s worth of data) or with a clinical population (e.g., experience with two previous clients who stutter vs. experience with 20 previous clients who stutter). As a clinician amasses clinical data, he or she becomes increasingly able to use what has transpired in the past to shape what he or she will do or should happen in the future with respect to a client’s treatment activities. In the context of treating stuttering, clinicians aim to collect data about the client’s fluency performance in clinical and in real-world settings through assessments that are based on the tests and speech sample measurements described in Chapters 11 and 12. Clinicians also can design informal assessments that are designed to capture information about relevant, client-specific areas of performance (e.g., performance during a unique treatment activity, performance during a specific stage of skill development). For each client, clinicians are charged with maintaining accurate, ongoing records about the client’s performance. This means that data are collected at the initial assessment and at regular intervals (usually during every session) throughout the course of intervention. In this way, the clinician can track incremental changes the client makes toward the attainment of his or her treatment goals. When it appears that all treatment goals have been met or that the client is satisfied with his or her progress, posttreatment assessment data are collected. The latter data are compared to pretreatment assessment data to provide the clinician and the client with a sense of the magnitude of the changes/improvements that have been made. Internal evidence works best when the clinical measures that the SLP is making are closely aligned with variables that the client regards as important. For example, in one recent study by Cooke and Millard (2018), school-aged children who stuttered, aged 9 to 13 years, were surveyed on what they regarded as optimal clinical outcomes for stuttering intervention. Among the survey items rated most favorably were the following: improved fluency, increased confidence, greater independence, listeners who are knowledgeable about how to support people who stutter, and the ability to communicate with others more easily. An important part of evidence-based practice is ensuring that the intervention being provide matches well with what the client hopes to attain. This issue is discussed further in the next section.



14.  The Clinician’s Roles and Responsibilities in Intervention

Incorporating the Perspectives of Clients and Their Caregivers In the ASHA EBP model, the perspectives of the client (and in some cases, the caregiver) are an essential component of the treatment process. These perspectives include the choices that a fully informed client (or caregiver) makes about the content and scope of treatment (Dollaghan, 2007). According to Dollaghan, determination of client preferences emerges through ongoing dialogue between the clinician, the client, and, when appropriate, parents and other relevant individuals such as teachers. Such dialogue usually begins at the initial assessment, where discussion typically revolves around the client’s (or caregiver’s) perceptions of his or her impairment and disability and the extent to which the client (or caregiver) wishes to participate actively in making treatment decisions. Chapter 13 discussed the process of collaborating with clients when developing intervention goals. That topic is again discussed here, as this process of collaboration is one that extends beyond the intervention planning stage into all stages of treatment and even into posttreatment monitoring. To expand on points raised in Chapter 13, the inclusion of client/caregiver preferences in the treatment planning process is not trivial. Findings from research with speakers who stutter indicate that clients’ perceptions of treatment effectiveness are influenced not only by the fluency changes they make or their perceptions of clinicians’ general knowledge about stuttering but also by their perceptions of how well clinicians understand the impact that fluency impairment has on the client (Plexico, Manning & DiLollo, 2010). That said, clinicians may find it challenging to get clients or their caregivers to offer their perspective on how they would like the treatment program to transpire or on what they specifically would like to accomplish. Sometimes this is because of the client’s age. Young children typically have limited awareness of their speech fluency performance and the impact that stuttered speech has on their communication. Older children, teens, and adults usually have a much better developed awareness of their fluency experiences and the impacts of stuttering on functioning during daily activities; however, at the start of the treatment process their knowledge about stuttering and what can be done

to treat it typically is quite limited. Caregivers often present with this limitation as well. Thus, even after the clinician has explained treatment options, clients (or caregivers) still may find it difficult to state specifically how they would like therapy sessions to proceed, and/or they may continue to state their goals for treatment in only the most general terms (e.g., “I want to talk better.” “I don’t want to stutter anymore.”). Consequently, clients (and their caregivers) often look to the clinician for leadership and guidance regarding how to proceed with treatment and what types of outcomes are likely to be most feasible based pm the client’s current status. Given the benefits that come with having clients and caregivers become actively engaged in formulating and executing the treatment plan, however, clinicians should resist the urge to jump into the role of “treatment director” too eagerly. In the author’s experience, clients (and their caregivers) often arrive at their perspective on treatment gradually; thus, clinicians should allow time and create opportunities for this to happen. One helpful way for clinicians to gather information about clients’ (or caregivers’) perspectives on the intervention process is to listen empathically during clinical sessions to the stories (i.e., personal narrative accounts) they tell about fluency impairment and the effects it has on daily life. According to Egan (2002), empathic listening is the process of identifying key messages and feelings in what the client says and then attempting to (a) understand how the events in the story fit into the broader context of the client’s life, and (b) identify any gaps, distortions, or inconsistencies between what the client has said in the story and what else the clinician has learned about the client through other assessment activities. Storytelling is a form of shared personal experience in which clients translate what happens in daily life into words (Egan, 2002). In this way, storytelling functions as a type of self-disclosure — an activity many contemporary clinical authorities view as an important component in a treatment program for stuttering (Mancinelli, 2018; and see Amster & Klein, 2018). Egan stated that storytelling offers several potential benefits to clients, including the following: gaining clarity/insight into one’s problem situations, identifying unexploited or underused opportunities for change or growth, and developing new perspectives on how to cope with present problem

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situations. In this way, personal storytelling has the potential to engage clients more fully in identifying their treatment preferences and goals, and thus constructing a more-fully developed perspective on the therapeutic process.

Clinical Expertise Revisited: Understanding the Intervention Landscape The chapter concludes with a very general overview of intervention options that are available to clinicians for the treatment of fluency disorders. The information presented is intended as an introduction to more detailed discussion of intervention issues in Chapters 15 through 18. The primary reason that most people with impaired fluency seek out the services of an SLP is to enroll in intervention that will improve their communicative functioning and overall quality of life. Thus, it is important for clinicians to develop a thorough understanding of this aspect of clinical practice. Most of the treatment-related information in the area of fluency disorders pertains to neurodevelopmental stuttering. Thus, the focus in this section and in the treatment-related chapters that follow

is largely on intervention approaches for stuttering. Nevertheless, some of these approaches also are applicable to treating cluttering and acquired forms of stuttering. The latter topics are discussed in subsequent chapters as well.

An Overview of Intervention The terms intervention and treatment sometimes are used interchangeably; however, in some sources, the terms are considered separately. For example, in ASHA’s (2016a) Scope of Practice in Speech-Language Pathology, the term intervention is used sparingly, and treatment is the term used to refer to activities that are aimed squarely at improving client functioning. In this book, the term intervention has been used in a broader sense than the term treatment, which seems consistent with the approach taken in ASHA’s (2016a) Scope of Practice document. The diagram in Figure 14–2 illustrates the relationship between the two concepts. As shown in Figure 14–2, intervention is conceptualized as an overarching concept that captures six main elements in clinical service: assessment, treatment, counseling, prevention and wellness, advocacy, and collaboration and management. Treatment, prevention and wellness, and counsel-

Intervention Activities

Assessment

Treatment

Counseling

Prevention & Wellness

Advocacy

Collaboration & Management

Figure 14–2. Elements of intervention. Assessment provides information about the client’s functioning and areas of disability, which in turn, influences the types of activities a clinician implements as part of treatment, counseling, prevention and wellness, advocacy, and collaboration/management efforts that are implemented to improve the client’s communicative functioning.



14.  The Clinician’s Roles and Responsibilities in Intervention

ing are the main elements used to optimize an individual’s communication and, thus, improve quality of life. Assessment activities generate the information about the client that is needed to conduct treatment, prevention, and counseling activities. For this reason, the term assessment, unlike the other terms, appears in an unshaded box in Figure 14–2. The terms counseling, collaboration and management, and advocacy were defined earlier in the book. According to ASHA’s (2016a) Scope of Practice in Speech-Language Pathology, treatment is that element of practice that “establishes a new skill or ability or remediates or restores an impaired skill or ability” for the purpose of improving an individual’s functional outcomes. Lastly, in the context of fluency therapy, prevention is used mainly to refer to efforts or activities that are conducted to decrease the severity or impact of communication disability caused by fluency impairment. In Figure 14–3, these intervention elements are sketched out further, as an overview of the intervention landscape. Major components of intervention are presented in the second row of the figure and under each of those are listings of the types of variables that can be targeted in intervention. For most clients who stutter, a fluency intervention program will include one or more treatment elements, and depending on case characteristics, also may include prevention, counseling, advocacy, and case management elements. Assessment (not shown in Figure 14–3) is conducted on a continuing basis with all clients, which enables the clinician to update the types of intervention activities that are done over time and to determine whether such activities need to be initiated, continued, or discontinued.

Behavioral Treatments As suggested by the layout of Figure 14–3, most contemporary approaches to treating stuttering are behavioral in nature. That is, they focus on helping the client (or those around the client) develop skills that lead to changes such as improved fluency functioning, improved ability to compensate for the persisting effects of fluency impairment, and the development of healthier, more constructive ways of thinking about and responding to fluency impairment. Behavioral treatments for stut-

tering vary in their focus and purpose. For instance, some behavioral treatments focus on changing the speech motor behavior of the person who stutters, others focus on the day-to-day verbal and nonverbal behavior of people who interact often with the person who stutters, and still others focus on the specific types of responses (i.e., contingencies) that follow fluent and stuttered speech. For clients who are beyond the preschool years, most intervention plans for stuttering include treatment strategies that focus on teaching the client new skills that either change or modify characteristics of the client’s speech. As shown in Figure 14–3, these treatments are directed toward various facets of speech, with some being directed toward changing articulatory behavior (e.g., articulation rate, attention to kinetic and proprioceptive aspects of articulatory movement), others being directed toward phonatory and speech breathing behavior (e.g., voicing parameters; phonation continuity, coordination of speech breathing with phonation onset), and still others with rhythmic (e.g., syllable-timed speech) and self-regulation of excessive muscle tension during moments of stutter-like disfluency. Lastly, task complexity (e.g., number of syllables produced, developmental difficulty of syntactic structures used) can be manipulated either independently or in conjunction with any of the facets of speech noted earlier. As indicated in Figure 14–3, other behavioral treatments are directed toward the individuals who interact with the person who stutters. Parents and other individuals (e.g., teachers) are taught speech styles and communication-interaction strategies that have the potential to reduce the extent to which the client speaks under conditions that tax speech production. These individuals also may be taught ways of reacting or responding to stuttered speech that also limits demands on the client’s speech production system, while also conveying support and acceptance for the client. As Neumann and Euler (2010) discussed, data from recent neuroimaging studies has indicated that some behavioral interventions — specifically those that entail intensive practice of regulated articulation rate — result in new patterns of neural activation that approximate those that are observed in normally fluent speakers. Neumann and Euler

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Self-Efficacy

Risk Taking

Problem Solving

Cognitive Restructuring

Assertiveness

Disclosure

Desensitization

Mindfulness

Education

Counseling

Public Awareness

General Health & Wellness

Intervention Allies

Early Detection & Intervention

Education

Prevention & Wellness

Team Management

Collaboration

Advocacy

Other Activities

Figure 14–3.  Overview of options that SLPs have available when providing intervention to people who stutter. Behavioral treatments are the most common form of intervention and often are supplemented with counseling and prevention and wellness activities. Advocacy, collaboration, and team management typically occur in the background, but can influence the content and quality of treatment and counseling activities in which the client is engaged.

General Situational Characteristics

Responses to Stuttering

Turn Taking

Linguistic Behavior

Speech Rate

Partner's Speech

Utterance Complexity

Muscle Tension

Breathing

Pharmacological

Altered Frequency

Stress/Rhythm

Phonation

Delayed Feedback

Auditory Feedback

Other Treatments

Rate/Velocity

Client's Speech

Behavioral Treatments

Intervention Landscape



14.  The Clinician’s Roles and Responsibilities in Intervention

explained that these treatment-induced changes in neural activation provide evidence that certain types of behavioral interventions facilitate “repair” of an impaired speech production system in ways that enable speakers who stutter to communicate more fluently than they otherwise would.

The Role of Learning Theory in Behavioral Treatments for Stuttering Versions of behavioral treatments that were developed for stuttering during the 1960s through mid-1990s remain in use today. Most behavioral treatments from that era were intertwined with principles from operant learning theory. A main tenant of operant learning is that an individual’s future behavior is shaped by the consequences (i.e., response contingencies) that follow current behavior. Certain types of response contingencies (i.e., reinforcement) make a behavior more likely to occur in the future, and others (i.e., punishment) make a behavior less likely to occur in the future. Three response contingencies that have been examined extensively in relation to stuttering treatment are the following: • Positive reinforcement is a form of reinforcement that features the introduction of a response contingency that subsequently increases the frequency (or intensity, duration, and so forth) of a behavior over time. For example, a woman who receives a supportive response from a listener after reluctantly disclosing to the listener her status as being “a person who stutters” is more likely to issue similar self-disclosure about stuttering in the future. • Negative reinforcement is a form of reinforcement wherein the removal of a response contingency increases the frequency (or intensity, duration, and so forth) of a behavior over time. For example, reducing the number of times a client’s classmates snicker while the client is reading aloud in class is likely to increase the percentage of fluent syllables the client produces in that context. • Punishment is any response contingency that decreases the frequency (or intensity,

duration, and so forth) with which a behavior occurs. In the context of operant learning, the term punishment does not necessarily imply that an aversive contingency such as electrical shock is applied to stuttered speech. As will be seen, the “time-out” contingency (i.e., having a person stop speaking for 5 seconds when cued to do so by the clinician following a moment of stuttering) has been shown to reduce stuttering frequency markedly. Thus, in an operant condition framework, time-out is considered a punishment; however, when queried about their time-out experiences, speakers who stutter may report that they find them helpful, affording a chance to regroup in speech. Although contemporary treatment approaches for stuttering are less closely wed to traditional operant terminology than they were 40 to 50 years ago, the underlying principles of operant conditioning remain in the background of many contemporary treatment approaches. (See, e.g., the discussion of feedback in the context of motor learning principles in the box found earlier in this chapter.)

Manualized and Programmed Behavioral Treatments One hallmark of behavioral treatments for stuttering is that they feature detailed instructions for how the treatment is to be administered. Some clinical authorities have developed treatments that are administered via stepwise procedures and/or standard activities (e.g., Ingham, 1999; Ryan, 1974; Shames & Florence, 1980). Treatments like these are akin to a curriculum through which all clients proceed. Such treatments often are labeled as “programs” or “programmed instruction,” and some of the programs offer formal training on treatment administration through participation in continuing education activities offered by SLPs who are certified as instructors for the program. Manualized or programmatic treatments offer the advantage of providing standard treatment protocols to all clients. These are particularly valuable in treatment outcomes research, where it is critical for all participants in a study to have highly similar

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treatment experiences. In clinical settings, however, standardization can become a drawback if a treatment program is applied so rigidly that it results in a one-size-fits-all approach to intervention. As seen in preceding chapters, clients who stutter are a rather heterogenous group with respect to both the severity of their fluency-related disability and how they react to the disability. In addition, many formalized treatment protocols emphasize preplanned treatment activities or levels that center around speech motor skills. Such activities may be an important ingredient for success for many clients, and client performance can be tracked easily; however, some clients may need additional or alternative treatment components to attain maximum improvement in functioning. While inexperienced fluency clinicians may find comfort in the structure that these programs offer, and the programs themselves may be effective at improving surface-level aspects of speech fluency (e.g., by reducing the frequency of stuttering-related disfluency), clients who complete such programs may remain dissatisfied with their treatment outcomes because the treatment has not led to substantial change in the distressing feelings and thoughts that they have developed in response to their fluency impairment and related communication difficulties. Thus, a manualized treatment that is highly effective for one client may be only moderately effective or ineffective, particularly with respect to affective components of the disorder, for another client. For this reason, the author feels strongly that it is important for fluency clinicians to acquire the knowledge and skills that are needed for developing individualized intervention plans — intervention programs that are tailored to meet a client’s specific needs. Manualized activities certainly may play a role in such intervention plans; however, in many cases, a more eclectic approach is necessary. The process of developing individualized intervention plans is discussed at length in Chapter 15.

Technique-Based Behavioral Treatments Some clinicians have developed treatment approaches that are organized around a set of circumscribed treatment techniques that clients attempt to learn and then implement strategically when speaking (e.g., Gregory, 2003; Ramig & Bennett, 1997). When

describing these approaches, clinical authorities sometimes use the analogy of providing clients with a “toolbox” of stuttering management techniques that clients can implement as needed when faced with real-life fluency-related challenges. The “toolbox of techniques” approach to treatment offers clients the advantage of developing a repertoire of fluency management methods as well as opportunities to discover which of these methods they deem most effective or most desirable to use in everyday settings. When specific techniques are introduced as a package, it offers clients the prospect of seeing stuttering management as a dynamic process in which the methods one uses can vary by situation or circumstance. Scientific research into the extent to which clients like, value, or benefit from one treatment “tool” versus another is lacking. In the author’s experience, a drawback of the “many tools at once” approach is that clients can become overwhelmed by the number of options available. To simplify their stuttering management experience, such clients may end up employing only a small subset of the newly introduced tools or techniques they have learned, and/or they may revert to using stuttering management methods that were part of their pretreatment repertoire. Also, in the author’s experience, most clients are less appreciative than clinicians are of the often-subtle distinctions between one technique and another. Clinicians should not be at all surprised to hear a client, when asked to explain what her or she is doing to manage stuttering, generate a response that is amiss in either its accuracy or depth. An alternative to introducing fluency management tools in one big bundle is to introduce the fluency management tools to clients on an asneeded basis (one can think of this as a “just in time” approach). In this way, the clinician exposes clients only to those strategies and skills that, in the clinician’s judgment, are most likely to be beneficial at helping the client address the speech communication challenges they face. Whether fluency management tools are introduced as one big package or selectively, clinicians still face the risk that clients will have varying levels of proficiency when it comes to understanding and implementing the tools, as well as the possibility that the collection of motor-centric techniques still may fail to address



14.  The Clinician’s Roles and Responsibilities in Intervention

ways that create a systematic shift in the frequency characteristics of the wearer’s own speech upon playback (e.g., the speaker hears his or her voice at a frequency that is 0.5 octaves higher than its Other Approaches to Treatment actual frequency). The research base for FAF is much smaller than that for DAF, and its utility as a Several other approaches to treatment have been stand-alone form of fluency facilitation remains to used to treat stuttering. Two of these approaches ​ be determined. — ​assistive technology and pharmacological agents ​ — ​are introduced in this section. Pharmacological Interventions the breadth and depth of the client’s communication disability adequately.

Scientists have long been hopeful of finding effective drug-based treatments for stuttering. That said, Assistive devices are tools or instruments that a pharmacological approaches for stuttering remain speaker uses to enhance his or her communicative largely experimental, even after several decades of functioning. Devices that alter what a person hears research. Saxon and Ludlow (2007) conducted a while talking (e.g., masking devices, delayed audi- thorough review of the pre-2007 literature in this tory feedback devices, metronomes) have received area. Part of their review focused on the strength the most attention with regard to their potential as of the research designs for studies in this area. treatments for stuttering. With some treatments for They identified a total of 75 published reports that stuttering, the client is provided with an assistive dealt with drug-based treatments for stuttering device, and after receiving basic training on how and found that none met criteria for Class I quality to use it, turns it on and begins talking — with the (i.e., randomized assignment to a control group, expectation that speech fluency will be improved objective and blinded data collection and analysis, significantly immediately or soon after the device use of a large prospective design). According to is in operation. (With some interventions, a behav- Saxon and Ludlow, Class I studies yield informaioral treatment strategy, often one that involves tion for determining whether a treatment is benself-regulation of articulation movements, is intro- eficial or not. Only 4 of the 75 studies met criteria for Class II quality (i.e., use of a matched control duced in combination with the assistive device.) In contemporary practice, the most common group as well as blinding and a small prospective type of assistive device is one that presents the design). Saxon and Ludlow explained that Class speaker who stutters with some form of altered II studies allow a professional who is reading the auditory feedback (AAF). Delayed auditory feed- research to conclude whether a treatment is probback (DAF) is one type of altered auditory feed- ably beneficial or not. The remaining studies were back. With this type of assistive device, speakers classified as either Class III (i.e., use of a control who stutter wear a hearing-aid-like device, which, group; independent, but not blinded, data analysis; unlike a standard hearing aid, delays the playback crossover design) or Class IV (i.e., uncontrolled of acoustic signals the microphone on the device study, used client reports as outcome measures, receives. Playback delays generally are brief (e.g., case series design). Saxon and Ludlow stated that between 0.05 and 0.1 second). With this amount of Class III studies allow a professional who is readdelay, the wearer perceives his or her speech as an ing the research only to conclude whether a treatecho. For many speakers who stutter, this type of ment is possibly beneficial, and Class IV studies do auditory feedback is sufficient to induce changes not allow for conclusions about the suitability of a in the speech production process (e.g., slowing drug for treatment. Historically, researchers have been interested of articulation rate) and improvement in speech in evaluating the effects of drugs that target the continuity. Another type of altered auditory feedback ​— ​ neurotransmitter dopamine because of its actions frequency altered feedback (FAF) — involves elec- in the basal ganglia, a region involved in the control tronic processing of incoming speech signals in of motor movements. After reviewing the results

Assistive Devices

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from these studies, Saxon and Ludlow (2007) concluded that pharmacological agents that directly affect the dopamine system (i.e., dopamine receptor blockers) are “probably beneficial” in treating stuttering. They noted that one drug in this category, haloperidol, which is used customarily in the treatment of psychosis, has the potential for very serious side effects (e.g., tardive dyskinesia) and, thus, can be excluded as a viable treatment option. They also noted that pimozide, another drug that acts as a dopamine receptor blocker, has been linked with side effects such as depression and the development of mild parkinsonism in studies with speakers who stutter. Saxon and Ludlow reported that some other dopamine receptor blockers (i.e., tiapride, risperidone, clozapine) have fewer side effects and thus warrant further research. Based on their review, Saxon and Ludlow (2007) concluded that norepinephrine reuptake inhibitors used in the treatment of depression (i.e., imipramine, desipramine) and calcium channel blockers (e.g., verapamil) are “possibly not beneficial.” They also concluded that the study designs used to evaluate the use of selective serotonin reuptake inhibitors (SSRIs) such as clomipramine, paroxetine, and fluoxetine (typically used to treat depression) limited the conclusions one can make about their effects. They added that this might be a moot point because the reported side effects associated with certain SSRI drugs for some research participants (e.g., suicidal thoughts, depression) may be “prohibitive.” Saxon and Ludlow also noted that because most of the studies in their review took place across a relatively short time frame, more data are needed on the long-term effects of using medications to treat stuttering. Bothe and colleagues (Bothe, Davidow, Bramlett, Franic, & Ingham, 2006) also evaluated the research literature for pharmacological approaches to treating stuttering. Their systematic review examined studies that were published between 1970 and 2005. The studies included in their systematic review were analyzed according to their methodological robustness and treatment outcomes. Bothe et al. found that none of the 31 studies included in their review met more than three of the five methodological criteria they had specified (i.e., use of an experimental design; blinding during data collection; multiple data points for speech performance,

including “before” and “after” measurements; data from beyond-clinic settings; and data on speech rate, speech naturalness, and observer agreement for these measures). In 4 of the 31 studies, stuttering frequency decreased by more than 50%, and only one study reported a posttreatment stuttering frequency of less than 5% syllables stuttered. In addition, evidence of short-term improvement in social, emotional, or cognitive variables was evident in only 4 of the 31 studies. Among the studies with the strongest research design, none yielded unqualified evidence of favorable improvements in speech fluency or associated affective behaviors. Based on these findings, Bothe et al. questioned the wisdom of continuing to use the pharmacological agents reviewed in their study in the treatment of stuttering. Maguire et al. (2010) examined the effects of the drug pagoclone on stuttering-related behaviors in the context of a randomized, multisite clinical trial. As Maguire et al. explained, pagoclone is an agonist for GABA, which is a neurotransmitter that is widely distributed in the brain and primarily acts to inhibit neuronal activity. GABA appears to modulate dopamine levels (e.g., higher concentrations of GABA are associated with lower concentrations of dopamine). In a previous paper, Wu et al. (1997) proposed that stuttered speech may be a symptom of excessive dopamine with resulting hyperexcitability in the speech motor system. Thus, pagoclone, a GABA-A selective receptor modulator, appeared to offer a way to reduce levels of dopamine without incurring the negative side effects of other dopaminergic drugs. In their clinical trial, Maguire et al. (2010) treated 132 participants during an 8-week double blind, placebo-controlled, multicenter study (88 participants received pagoclone, 44 received a placebo). Results showed that participants in the pagoclone group showed significantly better performance than those in the placebo control group on a number of fluency-related measures. Following the treatment phase of the study, participants could opt to enter an “open label” phase, during which they knew they were taking pagoclone. At 12-months post-baseline, participants who continued with pagoclone showed a 40% reduction in stuttering frequency relative to baseline and no serious or harmful side effects. Other measures indicated improvements in social anxiety and



14.  The Clinician’s Roles and Responsibilities in Intervention

speech naturalness as well. Ingham (2010) subsequently raised several concerns about methods and interpretation of results from the Maguire et al. (2010) study, including the following: (1) use of relatively short, in-clinic speech samples to assess treatment effects; (2) lack of evidence showing that the reported treatment effect for the drug exceeded natural variations in disfluency frequency associated with the disorder; (3) substantially less magnitude of fluency improvement through the use of medication than that reported for behavioral treatments of stuttering that emphasize regulated speech production; and (4) limited experience with stuttering measurement for data collectors at some research sites. Given these issues, Ingham concluded that trials such as this “contribute little” to the treatment of stuttering. Overall, it appears that considerably more research is needed with drugbased treatments before such an approach can be considered as a safe and viable alternative to behavioral treatments. Additional research also is needed to examine the role of drug-based treatments as an adjunct to traditional behavioral treatments. In a systematic review of studies that examined applications of pharmacotherapy to children and adolescents who stutter, Boyd, Dworzynski, and Howell (2011) found only 7 studies that met their inclusion criteria, and of these, only one study was designed sufficiently to be regarded as strong evidence. That study, which was conducted with 25 participants, showed that clonidine was ineffective as a treatment for stuttering at these age levels.

Counseling as an Intervention Component The role of clinician-as-counselor was discussed earlier in this chapter. In most intervention programs, counseling activities are conducted in conjunction with one or more of the treatment approaches shown in Figure 14–3. Some counseling approaches are behavioral in nature (e.g., cognitive behavioral therapy). Thus, like the speech-based treatments for stuttering described earlier, these approaches involve elements of unlearning old behavior (in this case, old ways of thinking about personal experiences) and implementing new behavior (in this case, new ways of thinking about

or evaluating personal experience). Figure  14–3 contains a list of concepts and skills that are applicable to intervention plans for speakers who stutter. Some of these are narrow in scope (e.g., being able to disclose stuttering to other people) and feasible to develop on a short-term horizon, within a fixed time span, while others (e.g., self-efficacy, self-acceptance) are more complex and likely to change on a protracted time scale. Further discussion of these topics follows in Chapter 16.

Prevention as an Intervention Component As indicated earlier in the chapter, intervention plans often incorporate prevention activities, which the speech-language pathologist implements to accomplish a range of outcomes (ASHA, 2016a). The term primary prevention refers to actions that will reduce the incidence of a disease or disorder (e.g., vaccinations, elimination of exposure to toxic metals). Because the genetic and neurodevelopmental mechanisms that lead to stuttering still are being sorted out, this type of prevention is not used currently in clinic-level treatment programs for stuttering. Instead, in the context of stuttering intervention, if prevention activities are introduced, clinicians will implement either secondary forms of prevention (e.g., activities that promote early identification of a fluency disorder) and/or tertiary forms of prevention (e.g., educational activities that inform parents, teachers, classmates, and others about stuttering). Secondary and tertiary prevention activities have the potential to limit the severity of a client’s stuttering-related disability in areas such as speech fluency and communication participation, as well as to facilitate the client’s development of healthy, constructive thoughts and beliefs about the act of speaking and being a person who has impaired fluency. The SLP’s prevention activities often are educational in nature and can be directed toward the client and his or her family, as well as to larger audiences (e.g., an entire school, a classroom). Broadly, these prevention activities are conducted with the aim of altering how the client’s family members and others (e.g., classmates, the general public) think and act when engaging with people

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who stutter. The intention is to optimize the communicative functioning of people who stutter by limiting the amount and/or intensity of their exposure to environmental stressors that aggravate stuttering severity and by fostering an environment that promotes their sense of wellness and acceptance, and the experience of a positive quality of life.

Direct Versus Indirect Interventions Another way to think about intervention is in terms of how changes in the client’s speech fluency are expected to occur. Some interventions seek to induce changes in the client’s fluency-related functioning indirectly by changing what happens in the environment that surrounds the individual’s speech production system. Other interventions, in contrast, seek to reduce stuttering-related disability directly — that is, by requesting the client to make active changes in how they talk (or perhaps in how they think about talking). Such changes can be realized in various ways — for example, by developing a new skill that increases the likelihood of speaking smoothly or by discontinuing the use of an ineffective coping strategy.

Indirect Intervention As will be discussed in greater detail in Chapter 15, some intervention approaches target stuttering-related behavior indirectly by focusing on characteristics of the client’s communicative environment and the extent to which it is conducive to fluent speech and supportive of the person who has impaired fluency. With an indirect intervention approach, clients are not asked or expected to make explicit changes to how they speak. For example, clients are not asked to talk slower than they currently are talking, nor are they expected to make active attempts to alter the tension of their speech muscles or to modify aspects of their phonation or speech breathing. Rather, the clinician, and often other significant individuals around the client, work to create a speaking environment that is, at once, conducive to influencing the client’s speech in ways that enhance fluency and consistent in its support for and acceptance of the client

as a human being. Intervention approaches like this are based on the hypothesis that modifications or alterations of these environmental elements will reduce or eliminate stressors and barriers that contribute to or trigger the client’s stuttering-related disfluency. The expectation is that removal of these environmental elements will result in improved fluency functioning, and thus less stuttering-related disability. Indirect intervention can be delivered in several ways — that is, via treatment, counseling, prevention, or advocacy activities. Treatment targets such as those listed under “Partner’s Speech” and “Response Contingencies” in Figure 14–3 are consistent with the idea of indirect approaches to treating stuttering.

Direct Intervention In clients who are school-aged or older, direct forms of intervention are likely to constitute the primary elements of an intervention plan. Far more common are interventions that involve having clients make explicit changes to how they approach speech, and more broadly, communication. For this reason, they are regarded as forms of direct intervention. With such approaches, the clinician and client discuss the client’s stuttering-related behaviors and disability in open, age-appropriate ways, and the client assumes responsibility for changing current approaches to speaking through the implementation of various evidence-based strategies and techniques. The success of most direct stuttering management techniques is dependent on the client’s ability to engage in sustained self-monitoring of how he or she is speaking (with some approaches, this is done on a syllable-by-syllable basis) at the same time that he or she is attending to what is being said. This way of speaking is likely to be quite different from how the client typically speaks, and it certainly differs from how speakers who do not stutter behave when talking. Clients may find it effortful to maintain the dual responsibilities of planning what to say and controlling speechrelated movements for extended time periods, and they may express that they feel as if their speech lacks the spontaneity that exists in their typical stuttered speech. Success also is dependent on the



14.  The Clinician’s Roles and Responsibilities in Intervention

client’s motivation to implement his or her newly learned stuttering management skills often and in a range of settings. Clinicians must be mindful that preschoolers and primary grade school children will be much more limited than older clients in their ability to proactively apply most stuttering management techniques consistently in natural settings. In addition, they are likely to have a limited grasp of meta-linguistic concepts such as the syllable or the speech sound. For these reasons, direct forms of intervention should be used judiciously with young children, and when employed, should be accompanied by ample support from the clinician or parent, and with tempered expectations from both concerning the extent to which the preschoolers will apply stuttering management techniques independently. Indeed, many teens and adults who stutter report that it is challenging and effortful for them to “restructure” the way they speak on a day-to-day, hour-by-hour basis. If it is challenging for these mature individuals to implement certain stuttering management techniques independently, then the clinicians’ expectations for young children to make these changes to their speech independently should remain relatively modest. In Figure 14–3, the treatment targets listed under “Behavioral Treatments, Client’s Speech,” “Other Treatments,” and “Counseling” are regarded as forms of direct intervention.

Summary The present chapter addressed four main topics: (1) fluency intervention in the context of ASHA’s (2016b) Code of Ethics in speech-language pathology; (2) the roles and responsibilities of the SLP when conducting fluency intervention; (3) the application of evidence-based practices to fluency intervention; and (4) an overview of intervention options that are available as a framework for clinicians when implementing fluency intervention. The Code of Ethics makes clear the expectations that ASHA has for the breadth and depth of competencies the clinician will possess, the importance of placing client welfare above all other competing concerns, the types of services that the clinician

and those who work under the clinician will offer, as well as personal qualities and interpersonal relationships that the clinician demonstrates. ASHA’s Code of Ethics and its Scope of Practice in Speech-Language Pathology also indicate the roles that the SLP assumes in intervention. Seven roles were discussed in this chapter. During clinical sessions, the clinician moves between four of these roles (expert, teacher-coach, model, and counselor) while interacting with the client during intervention activities. The three remaining roles (manager, consultant, advocate) are engaged in outside of clinical sessions, but nonetheless have the potential to influence the quality or characteristics of what transpires during clinical sessions. Clinicians have an assortment of options to choose from when the intervention program commences. A wide range of treatment options exist — ​ some of which target the client’s fluency concerns directly and others which target them indirectly. Treatment activities can be supplemented by counseling and prevention/wellness activities, and all of these activities may be integrated with other services the client receives from other professionals. Although the information outlined in this chapter provides a general sense of what has been done with respect to intervention in the area of stuttering, it does not necessarily provide a clear sense of what should be done with an individual who is recommended for intervention. Evidencebased research offers general guidance about the types of outcomes the clinician and client can expect to attain when a particular type of treatment is administered properly. Although such treatments may improve fluency-related aspects of a client’s stutter-related disability, there is no guarantee that fluency-related improvements will translate into improvement in other aspects of the client’s stuttering-related disability, particularly those pertaining to affective components of the disorder. For this reason, the author favors an approach where intervention programs are individualized — designed in ways that meet the unique needs of a client. To do this, the clinical roles, intervention elements, and specific intervention areas outlined in this chapter can be placed within a framework of basic evidencebased intervention principles. This approach is the focus of the next chapter, Chapter 15.

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Questions to Consider 1. Multiple roles were discussed for the clinician who works with people who stutter. To what extent do clinicians assume these same roles when working with other clinical populations? Are there some roles that a clinician might assume more often when working with people who stutter than when working with other populations? 2. Another area of focus in this chapter was

evidence-based practice. Visit the ASHA website and review the resources that are available there for evidence-based practice. Which of these resources would be applicable to your clinical practice in general and in work with people who stutter? 3. Visit the ASHA website and review the practice portal. Which of the resources shown there would be applicable to planning intervention programs for people who stutter? Which would be applicable when implementing intervention programs with people who stutter?

15 Intervention Principles and Strategies for Helping People Who Stutter

Chapter Objectives After reading this chapter, readers will be able to: • Describe how contemporary management strategies fit into historical context of fluency management. • Describe the rationales and implementation strategies associated with general principles of intervention. • Distinguish between direct versus indirect intervention strategies for stuttering. • Describe challenges that clients commonly face during the intervention process.

Historical Perspective The speech patterns that characterize stuttering have been noted in writings that span more than 2000 years. Over that time, individuals with an interest in stuttering have proposed a remarkably diverse range of ideas for ameliorating the symptoms of the disorder. Since the emergence of speech-language pathology as a recognized profession in early to mid-1900s, there has been considerable debate about which treatment practices are

most appropriate for treating stuttering. Included in this discussion have been matters such as what the primary emphasis of treatment should be, when treatment for stuttering should commence, the extent to which stuttering symptoms should be acknowledged directly, and which clinical measures are most appropriate to use when assessing treatment outcomes. As will be seen in this chapter, there are a variety of thoughts on these matters, and ultimately it is up to the clinician, with input from the client, to determine the best course of action to follow. In the opening chapters of his classic textbook, The Treatment of Stuttering, Van Riper (1971) provided a thorough, entertaining, and informative overview of many of the early treatment approaches for stuttering. Table 15–1 outlines the main treatment categories and specific techniques Van Riper reviewed. It is important to remember that the etiology of stuttering was poorly understood when these treatments approaches/techniques were developed. Consequently, some of the approaches/ techniques were based on only the developer’s intuitions about what would be helpful to people who stutter, while other approaches/techniques were based on untested or inadequately tested models of etiology — most of which are now regarded as being inaccurate. Given these limitations, it is not surprising that many of the early

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Table 15–1.  A Historical Overview of Categories and Approaches to Stuttering Treatment as Reviewed by Van Riper (1973) Treatment Category Suggestion, Distraction, and Persuasion Therapies

Therapy Approach • Direct suggestion (e.g., hypnosis, auto-suggestion) • Oral prostheses and appliances • Distraction via novel ways of breathing, phonating, accenting, and so forth • Persuasion (e.g., “stuttering is nothing more than a habit to break”) • Chewing method (i.e., producing chewing movements while talking) • Semantic therapy (e.g., altering the language one uses when talking about stuttering)

Relaxation Therapies Rhythmic, Timing, and Rate-Control Therapies

• Massage therapies; sleep therapies • Relaxation in the context of behavior therapy (e.g., systematic desensitization) • Rhythmic speech; metronomic or syllable-timed speech • Other timing methods (e.g., voluntary bounce [rhythmic syllable repetition]; timing syllable release with body movements like jumping, stepping, or hand gestures) • Breathing rituals (e.g., inhaling deeply before speaking) • Vocalization rituals (e.g., saying “aahh” to get speech started) • Lengthening phonation intervals by reducing pause frequency • Progressively shaping singing into fluent speaking • Talking in unison with or shadowing another person’s speech • Rate-control therapy

Punishment and Reinforcement Therapies

• Corporal punishment • Pairing adverse consequences with instances of stuttering (e.g., electrical shock, loud bursts of noise) • Operant conditioning principles (i.e., reinforcing fluency, punishing stuttering-related behavior)

Folk Remedies

• Ice baths, liquid potions, specialized diets • Surgeries (e.g., clipping lingual frenum, tonsillectomy, bloodletting) • Appliances (e.g., mouth inserts to stimulate articulation, neck bands to stimulate phonation)

Servotherapy (Feedback)

• Altered auditory feedback (e.g., talking under auditory masking, delayed auditory feedback) • Electrolarynx speech

Psychotherapies, Drugs, and Group Therapies

• Psychoanalysis • Gestalt therapy • Counseling • Group therapy and self-therapy groups • Assertiveness training behaviors in context of anxiety reduction • Humor • Drug therapya

Note.  Bolded text indicates therapies (or elements thereof) that continue to be used commonly in contemporary clinical practice. a  This type of therapy is not widespread in contemporary practice but continues to be explored experimentally.

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15.  Intervention Principles and Strategies for Helping People Who Stutter

therapies that were proposed to treat stuttering turned out to be ineffective or, at best, less effective than hoped. Accordingly, most of them no longer are used. Not all the older treatment approaches/techniques for treating stuttering have been discarded, however. As indicated by the bolded text in Table 15–1, several older approaches/strategies, or variations thereof, are still used in contemporary clinical practice. The narrowing of approaches to treating stuttering has occurred in the context of improved scientific understanding of the nature of stuttering and the more widespread implementation of evidence-based practice. Consequently, contemporary treatment approaches for stuttering tend mainly to focus on speech motor system functioning, characteristics of the client’s communication environment, and the client’s feelings, emotions, thoughts, and beliefs about stuttering and being a person who stutters. Nonetheless, some of the old, unsupported therapy practices linger on. For instance, just few years ago, the author encountered a case where a family physician had clipped a child’s lingual frenum in the hopes that it might help alleviate the child’s stuttering.

A Principle-Based Approach to Improving Communication Functioning In this chapter, contemporary intervention practices for stuttering are introduced within a framework of general intervention principles. Nine intervention principles are described. As shown in Figure 15–1, some intervention principles are indirect in nature in that they pertain to the environment or context within which a client speaks, and others involve direct forms of intervention wherein clients work actively to change aspects of their speech or how they perceive or react to their speech. Most intervention principles pertain to activities that occur while the client is enrolled on the clinician’s caseload; however, some pertain to activities that occur after formal intervention ends — a time when clients are charged with managing stuttering-related issues independently. Some intervention principles pertain to prevention and counseling concepts, while others pertain to treatment concepts. Overall, the intent is for clinicians to use this principle-based framework (in

Figure 15–1.  An overview of intervention principles that are useful to adhere to when providing services to people who stutter.

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consultation with clients or their family members) to design comprehensive, client-specific intervention plans that target not only speech fluency functioning, but general communicative competence, and clients’ thoughts, feelings, and beliefs about their communicative competence, as well. Because the aim is to create individualized intervention plans, not every one of the intervention principles described in this chapter will apply to every case. Clinicians must evaluate each case carefully and then decide whether a specific principle is applicable to the case, and if so, how the principle is realized in practice.

Intervention Principle 1:  Develop the Client’s and Others’ Knowledge of Stuttering, Speech Production, and the Treatment Process • This principle is applicable at any point in intervention. • This intervention principle is most appropriately used with clients who are aware they stutter and who are capable of grasping stuttering-related concepts. • Activities associated with this principle are implemented in the context of a larger intervention plan — one that incorporates other intervention principles as well.

Overview and Rationale Intervention Principle 1 deals with the development of the client’s, parents’, and other key individuals’ knowledge of stuttering, speech production, and the treatment process. Activities associated with this principle are introduced as part of a broader effort to create a communication context that is maximally facilitative of the client’s speech fluency and ability to establish healthy, constructive attitudes toward speech communication and fluency impairment. At the start of treatment, most people who stutter, and most parents, teachers, and other adults have a very limited understanding of stuttering, speech production, and the treatment process. This limitation can foster the develop-

ment of inaccurate or distorted views of stuttered speech and people who stutter, and it can hinder treatment-related communication. Issues like these have the potential to limit the effectiveness with which client, parents, teachers, and others participate in the treatment process. In contrast, an accurate, well-developed knowledge base helps clients and caregivers communicate with the clinician about treatment-related issues more effectively. It also helps clients and caregivers develop an objective perspective on stuttering — a perspective that serves as a counterpoint to emotions such as helplessness, concern, anxiety, and frustration that clients (and parents) may experience in response to stuttering. Although objectivity does not displace the negative emotions that can surround stuttered speech immediately, it is aligned with the establishment of a fact-based, problem-solving orientation toward stuttering and its management.

Implementation It is neither expected nor necessary that clients, parents, teachers, or other caregivers develop an expert-level understanding of fluency disorders. That said, some inquisitive clients and parents do indeed approximate this level of knowledge. For most cases, however, the objective is simply to help these individuals to be “on the same page” as the clinician regarding issues that are central to the client’s intervention plan. Usually, this means that the clinician strives to help these individuals develop a basic understanding of issues such as what stuttering is, how speech is produced, or how stutteringrelated disfluency arises during speech production. Examples of the types of information a clinician can address during intervention are provided in Table 15–2. As shown in Table 15–2, there are a host of specific topics and issues for a clinician to address regarding the nature of stuttering. Information about stuttering can be presented at both a population level and at a client level. The term population level is used here to indicate general facts about stuttering and the population of people who stutter, and the term client level to indicate knowledge that pertains specifically to the individual who is being treated. Exploration of stuttering-related



15.  Intervention Principles and Strategies for Helping People Who Stutter

Table 15–2.  Examples of Topics to Explore When Building Clients’ and Parents’ Understanding of Stuttering General Concepts

Specific Concepts

Nature of fluency impairment

• Current views on etiology

Normal bases of speech production

• Speech breathing, phonation, and articulation

• Current epidemiological facts • Speech sound production, syllable types, and structure • Basics of articulatory phonetics (e.g., speech sound characteristics and classifications) • Common types of disfluency in typical speakers, factors that contribute to disfluency

Common symptoms of the fluency disorder

• Characteristics of stuttered speech • Common reactions to fluency impairment (e.g., feelings, thoughts) • Common compensatory (secondary) behaviors • Factors that commonly contribute to situational variability in stuttering severity • Common activity limitations and participation restrictions in people who stutter • Conditions that usually enhance fluency in people who stutter

Impact of the fluency disorder

• Ways in which fluency impairment can affect academic or work performance • Common listener reactions to stuttered speech • Impact of fluency impairment on general quality of life (health, wellness)

Stuttering in society

• Famous people who stutter • The depiction of characters who stutter in film and literature • Changes in how stuttering has been viewed over time • How stuttering treatment has evolved over the ages • Common societal attitudes and stereotypes about people who stutter

Note.  Similar topics can be explored to build knowledge of cluttering.

information with parents and teachers may have the added benefit of promoting dialogue between the client and his or her parents or teachers about stuttering and its treatment. As noted earlier, in some families, stuttering is a neglected or taboo topic of discussion (Logan & Yaruss, 1999; Rustin & Cook, 1995). Although initial conversations about stuttering may be awkward or uncomfortable for both the client and his or her parent or teacher, in the author’s experience, such feelings lessen over time as the client’s and others’ concerns about discussing such issues dissipate and appreciation of the opportunity to talk about stuttering-related experiences grows. Other topics to address include common myths and misperceptions about stuttering and people who stutter, as well as the ways in which stuttering can impact not only one’s ability to communi-

cate but also one’s overall quality of life. In addition, if such information has not already been addressed at the conclusion of the initial assessment, it also is important to discuss treatment options, the estimated time and cost of intervention, the benefits and limitations associated with treatments for stuttering, and anticipated intervention outcomes. Fortunately, high-quality informational materials about stuttering are readily available to clinicians, parents, and teachers through a variety of venues today. The clinician’s main responsibility is to direct these individuals to these resources and to guide them through the content, as necessary. Clinicians can access an assortment of print and video materials for free or at nominal cost through several professional, government, and consumer-based organizations (Table 15–3). Most organizations have

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Table 15–3.  Examples of Sources for Information About Stuttering Source Type

Source

Associations

American Speech-Language-Hearing Association Australian Speak Easy Association British Stammering Association Canadian Stuttering Association European League of Stuttering Associations Indian Stammering Association International Fluency Association International Stuttering Association Irish Stammering Association

Government

U.S. National Library of Medicine U.S. National Institute on Deafness and Other Communication Disorders

Consumer

Friends: The National Association of Young People Who Stutter (friendswhostutter.org) National Stuttering Association1 Stuttering Foundation1 Stuttering Association for the Young (SAY)

Blogs and Podcasts

• Stuttering is Cool (http://stutteringiscool.com) • StutterSocial.com (http://stuttersocial.com) • Stutter Rock Star (https://stutterrockstar.com) • The Stuttering Foundation’s Blog (https://www.stutteringhelp.org/blog?page=1) • The Stuttering Brain (http://www.thestutteringbrain.com/p/why-support-me.html) • Katherine Preston.com (http://katherinepreston.com/blog) • Stuttering Student (https://stutteringstudent.blogspot.com) • StutterTalk (http://stuttertalk.com)

Data Bases

• Fluency Bank • The University College London Archive of Stuttered Speech

Note. These sources are presented for illustrative purposes only. The associations, organization, universities, and government agencies feature websites through which clients and consumers can access information. The list is not exhaustive, and the inclusion of a site in this table does not imply that the author endorses the website, its sponsor, or its associated content. 1 Also has resources for speech-language pathologists

well-developed websites that offer free or low-cost published materials and/or downloadable materials. Of course, clinicians also can draw upon their expertise to create individualized informational materials. This approach is useful in cases where a client’s unique clinical profile calls for the provision of information that goes beyond standard topics addressed in most consumer materials. In addition to print-based material, several people who stutter operate Internet forums that are

devoted to stuttering. Some of these forums provide opportunities for online chatting with other people who stutter and/or for listening to recorded lectures, interviews, and discussions that deal with stuttering. In the context of treatment, clinicians can encourage or assign clients, parents, other caregivers, and teachers to access and review such information, after which follow-up activities can be conducted to integrate the information into the clinician’s intervention plan.



15.  Intervention Principles and Strategies for Helping People Who Stutter

Intervention Principle 2:  Build an Environment That Is Supportive and Accepting of Stuttering • This intervention principle is applicable to any case and at any point in treatment. • Activities associated with this intervention principle are implemented in the context of a larger, more comprehensive intervention plan that incorporates other treatment principles.

Overview and Rationale Intervention Principle 2 concerns the extent to which the client feels accepted and supported in his or her efforts to communicate. Activities associated with this intervention principle are aimed at reducing the negative effects that one’s feelings, emotions, and thoughts can have on fluency functioning. This intervention principle typically is addressed as one part of a more comprehensive intervention plan that includes stuttering management strategies that are aimed at improving the client’s speech fluency, communicative functioning, and/or sense of well-being. This principle rests on the assumption that clients who feel accepted and supported by others spend less time and energy being concerned about whether others are evaluating them negatively, and thus have more time and energy to allocate toward stuttering management efforts. In this way, support and acceptance act as counterweights to the negative feelings and emotions (e.g., helplessness, anxiety, fear, and shame) that clients often experience when they lack the capacity to manage stuttering effectively. With children who show no outward signs of feeling unaccepted or unsupported, this intervention principle still applies. In this case, the goal is to prevent the emergence of negative feelings, emotions, thoughts, and beliefs about stuttering, speech communication, and self-concept. Alternately, with children who do show signs of feeling negatively about stuttering, intervention activities that follow from this treatment principle typically are focused on the parents and, when appropriate, other key adults such as teachers who inter-

act regularly with the client. In such cases, the main goal is to help these individuals consistently interact with the individual who stutters in ways that demonstrate (a) acceptance of the individual regardless of how fluently he or she speaks, and (b) appreciation of the content of the individual’s spoken remarks (rather than directing the focus primarily toward evaluation of the fluency with which the remarks are delivered). At the start of treatment, most parents and teachers have a limited understanding of stuttering and its consequences. Thus, work in this area usually is coordinated with concepts from Intervention Principle 1, which addresses general knowledge about stuttering and its impact on affected individuals. With teens and adults who report feeling unaccepted because they stutter or are unsupported in their efforts to cope with stuttering, some of the same strategies that are used with children apply. With older individuals, particularly those who no longer live in their parents’ household, the clinician can work with them to identify, engage, and/or develop treatment adjuncts or allies (i.e., individuals who can be relied upon to support the client, particularly during the early to mid-stages of an intervention program, when the client is attempting to transition from ineffective to effective stuttering management. (See Chapter 14 for more information on the concept of treatment allies.) With teens and adults who are seeking treatment for stuttering, long-standing experiences with stuttering often means that their associated negative feelings, emotions, and thoughts are intertwined more thoroughly with their communication difficulties than would be the case with preschool and elementary school-aged children. Consequently, teen and adult clients also are likely to benefit from intervention activities that are aimed directly at the affective-cognitive components of stuttering. Intervention strategies for the latter issues are addressed under Intervention Principle 6, which deals with counseling principles.

Implementation Speech-language pathologists (SLPs) use an assortment of strategies to facilitate the creation of a supportive, accepting communication environment for

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the individual who stutters. Several of these strategies are reviewed in this section. An overview of these strategies is shown in Figure 15–2. Although the focus here mainly is directed toward children and teens, many of the strategies described next can be modified for use with adults who stutter.

Involve Parents and Others in Intervention Activities When possible, clinicians should involve those around the client in the intervention process. As noted in Chapter 13, two common ways to do this are to involve parents of children who stutter in developing the intervention plan, and to involve them in treatment and prevention activities that take place within and/or beyond the treatment room. Parent and teacher participation in interven-

tion has the potential to greatly expand the amount of time per week a client is exposed to a supportive, accepting social environment, and it also increases the amount and scope of opportunities for a client to practice stuttering management skills in an environment that is emotionally supportive and facilitative to speech fluency. Engagement of parents and teachers in intervention activities has the added benefit of providing support to the client at the times it is most needed — that is, in authentic, real-world settings. When working with older children and teens, particularly those who are sensitive about disclosing stuttering to others, it is helpful to involve the client in the process of determining how parents (or others) will be involved in intervention. Among the issues to be discussed beforehand with clients are matters such as when and how the parent(s)

Figure 15–2.  An overview of strategies that are useful for helping to develop a supportive, accepting environment for people who stutter.



15.  Intervention Principles and Strategies for Helping People Who Stutter

will be involved. Clinicians must be careful not to force parent involvement during treatment upon a client if the client expresses discomfort with that happening. For example, with teen-aged clients, it can be helpful to set up preliminary activities wherein the clients are assigned jobs such as describing the treatment goals they have set for themselves to their parent, debriefing the parent about what transpired in therapy sessions, or designing intervention-related activities that ease the parent into the intervention process. Clinicians can facilitate this process, as well, through activities where the spotlight is not on the client, but on other people who stutter (e.g., the clinician, teen, and parent watch a video together about stuttering and then discuss it).

Help Parents and Others Learn to Talk About Stuttering Clinicians have discussed the “conspiracy of silence” that seems to surround stuttering in many families of children who stutter (Logan & Yaruss, 1999). In the author’s experience, most parents want to talk about stuttering with their child who stutters, but they are concerned they might say “the wrong thing,” and in doing so, will aggravate the child’s fluency difficulties. Research shows that many children develop awareness of stuttering gradually during the preschool years, and most will do so by the lower elementary school grades (Ambrose & Yairi, 1994; Boey et al., 2009). Children demonstrate their awareness of stuttering in different ways. Some do so via verbal comments (e.g., “I can’t say it, Mommy”), others via coping strategies such as word avoidance, and still others via nonverbal means (e.g., foot stomping, assuming a slumped body posture that suggests dejection). Contexts such as these offer opportunities for parents and children to talk about stuttering. The act of “talking about stuttering” can assume various forms. The author recommends that remarks like the ones that follow be presented judiciously. In the author’s experience, it is helpful to introduce them selectively, that is, at times when the child or teen appears to be reacting most strongly to stuttering-related difficulties. Clinicians can collaborate with parents (and others) to refine

the wording of these remarks in ways that fit the client’s age and types of stuttering-related reactions. Examples of remarks that address stuttering include the following: • Content responses to questions about stuttering.  Children and teens who stutter may question parents (or others) about why they stutter, if their stuttering always will be as severe as it is now, and so forth. Educational materials such as those described under Intervention Principle 1 are useful in helping parents develop basic information that is needed to address such questions. The clinician can collaborate with parents (or other appropriate individuals) to shape response content in ways that fit the client’s age and informational needs. • Probes to elicit emotions that underlie questions about stuttering.  The surfacelevel content of questions that individuals who stutter ask about their stuttering may mask underlying feelings, emotions, beliefs, or concerns about stuttering (Luterman, 1996). For example, when a teen asks, “Am I going to have to practice my new speech skills?” rather than seeking information about the exact amount of practice minutes per day that is expected, he or she actually may be saying, “I feel really uncomfortable with having my parents and my friends watching me while I am learning how to talk in this new, different way.” Luterman suggested that the best way to respond to such questions is with a confirmation question — that is, a verbal probe that is designed to check for underlying client concerns. In the scenario just described, examples of appropriate confirmation questions include, “What is it that you would like to do when you practice?” or “What type of practice do you think would be most helpful to you?” • Verbal acknowledgments that objectively describe and/or convey empathy for stuttering-related difficulty.  Statements of this sort are called for when feelings such as frustration, embarrassment, or anger

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are present in conjunction with stuttered speech. The clinician works with the parent (or other individuals) to develop accurate, matter-of-fact descriptions of physical behavior (“I can see you worked hard to say that.” “Yes, your speech was stuck briefly on that sound.”), as well statements that highlight the child’s current feelings (e.g., “Yes, you feel frustrated when talking takes a lot of work.” “You feel mad when sounds stretch out like that.”). • Statements that offer reassurance and provide perspective.  Statements of this sort are called for when signs of distress accompany stuttered speech. The clinician works with the parent (or other individuals) to develop straightforward statements that put the client’s present speech difficulties and/or feelings into a broader context of long-term development and life span changes. Toward this end, reassurance can be offered through matter-of-fact statements that highlight the temporary or focal nature of the difficulty (e.g., “Yes, you sometimes get stuck for longer than you like on some words.” “Yes, your lips were very tense on that word. I noticed that most of the other words were not tense at all.” “You know, I noticed that you used to have a lot of long stutters like that, but now you hardly ever do.”) Other statements can be presented to acknowledge the current behavior and then counter that with the possibility that fluency may not always be as difficult as it is now (e.g., “Yes, I see that was difficult. That happens sometimes when kids are learning to talk.” “Yes, it is hard to say things now, and you’re learning ways to deal with that. Let’s see what happens later.”). When presenting comments like this, it is important to do so in ways that do not negate the client’s feelings (e.g., “Oh, you shouldn’t feel like that. You talk really well.”) or minimize the client’s level of distress (e.g., “Oh, you didn’t stutter that badly.”). • Statements that convey unconditional love or acceptance.  Statements of this sort can

be made at any time and are particularly apt when feelings such as concern, frustration, anger, or disappointment are present in conjunction with stuttered speech (e.g., “I like listening to what you have to say no matter how you say it.” “We love you no matter how you talk.” “I will wait for you to finish, even when it takes a while.”). • Statements that reinforce client qualities that are likely to facilitate long-term, successful stuttering management.  Statements of this sort acknowledge and support qualities such as persistence and resilience that the client demonstrates in the face of stuttering-related communication challenges (e.g., “Yes, you stayed with that word and said just what you want to say.” “You didn’t let stuttering stop you. You got your message across to them.”). Comments like these broaden the focus of evaluation from fluency competence to communication competence. Although fluency may be the client’s primary concern now, the long-term success of intervention must eventually be linked to communicative functioning.

Help Parents (and Others) Respond to Stuttering Constructively Parents can convey acceptance and support for children who stutter by becoming more aware of their verbal and nonverbal responses to stuttered speech and by learning about the nature of stuttering and factors that affect its expression. A first step is for the clinician to help parents identify how they currently react to their child’s stuttering. • What are the parent’s verbal reactions? Do the reactions tend to facilitate or hinder the child’s fluency? Verbal behaviors such as guessing at or supplying a word for a child who is currently stuttering are generally discouraged because they are contrary to intervention goals such as reducing communication-related time pressure and building the client’s sense of self-efficacy. • What are the parent’s nonverbal reactions? Do the reactions tend to facilitate or



15.  Intervention Principles and Strategies for Helping People Who Stutter

hinder the child’s fluency? For example, nonverbal behaviors that suggest impatience or concern (e.g., furrowing the eyebrows at moments when the child is stuttering, abruptly shifting eye gaze to the child’s mouth when stutterrelated disfluency occurs) are contrary to intervention goals such as reducing communication-related time pressure and developing the client’s ability to view stuttering objectively — as a behavioral puzzle to be solved rather than as a behavior to be feared. • What is the parent thinking and feeling? It is not uncommon to hear parents say that as their child is stuttering, their mind shifts to “big picture” thoughts about how stuttering will affect their child’s life (e.g., Will it interfere with success in school or at work? Will it lead to hardships such as teasing and bullying?). It also is not uncommon for parents to report feeling concerned or anxious about what stuttering will mean for their child’s future. Other parents may express frustration or, perhaps, impatience over why their child speaks smoothly in some situations but not in others. Parents also may report feelings of embarrassment or helplessness when their child’s stuttering is severe enough to draw the attention of strangers. The aim here is not to judge whether these responses are “good” or “bad,” rather it is simply to invite parents to consider whether the responses are likely to be facilitative of the child’s communicative functioning and attempts to manage stuttering. Thus, the aim is to help parents, as much as possible, to model calm responses to stuttering-related behavior that convey a sense of “This is going to be okay.”

Create Opportunities for the Client (and Parents) to Learn About and Interact With Other People Who Stutter Clients who are school-aged or older often benefit from learning about and interacting with other

people who stutter. This can occur through activities such as the following: reading autobiographies and Internet blogs written by people who stutter; watching or listening to podcasts, movies, Internet videos, and other similar media that feature firsthand accounts of stuttering experiences by people who stutter; as well as face-to-face (direct) inter­actions with people who stutter that take place in settings such as support group meetings and group therapy sessions. Interactions like these are likely to facilitate the client’s functioning in a variety of ways. First, they are likely to help clients put their experiences with stuttering into context by enabling them to see how “their stuttering” compares to that of others. Often, this leads clients to realize that their communication challenges and associated feelings and emotions are not unusual or a sign of weakness, but rather are very much like what other people who stutter experience. For clients who feel deeply embarrassed or ashamed about being a person who stutters, these realizations are likely to bring a sense of relief or catharsis, and with it, a foundation upon which self-forgiveness or self-acceptance of stuttering can perhaps be established eventually. Second, interactions with other people who stutter can provide the client with insight into the process of stuttering management, such as strategies that others have used to cope with or overcome specific communication challenges and/or stuttering-related emotions, the amount of effort required to realize significant change, and the timescale in which significant change occurs. Third, these interactions can provide clients with models of how people who stutter have come to terms with their fluency limitations and have learned not only to survive, but also to thrive while still being a person who stutters. Clients who are particularly uncomfortable with embracing the identity of a “person who stutters” are likely to express discomfort or, at least, uncertainty about interacting directly with other people who stutter; thus, for these individuals in particular, it is helpful to interact with people who stutter less directly (e.g., by reading what they have to say, by listening to and/or watching them talk about stuttering).

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Address Bullying The basic characteristics of bullying and its impact on individuals who are targeted for bullying were discussed in Chapter 6. As reported there, the American Psychological Association (APA, 2020b) defined bullying as “a form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort,” and the APA stated that it can take the form of “physical contact, words, or more subtle actions.” Although bullying may be regarded as something that affects only children and adolescents, bullying behavior also occurs among adults in workplace settings. According to the Workplace Bullying Institute (WBI, 2019), bullying is a form of abusive conduct (and not a “rite of passage” or a type of interpersonal conflict) that is threatening, humiliating, or intimidating, and as such, it goes well beyond acts of incivility and disrespect. Hughes (2014) noted that, in school settings, at least four types of bullying are described in the literature: physical bullying (e.g., hitting, shoving); verbal bullying (e.g., threats, name calling); cyber bullying (i.e., abusive conduct in online settings, particularly those that involve social media); and relational bullying (e.g., spreading rumors or gossip about a person, deliberately excluding or ostracizing a person from a social group). In workplace settings, bullying behavior may also include acts of commission (doing things to others) or omission (withholding things from others) that sabotage work efforts or prevent work from being done (WBI, 2019). As noted in Chapter 6, students with disabilities, including students with communication dis­ orders, are more likely to be targeted for bullying than students with typical communication functioning. Children who stutter seem particularly vulnerable to being targeted for bullying, with some studies showing more than a fourfold risk in comparison to children in the general population (Blood et al., 2011). According to the National Academies of Science, Engineering, and Medicine (2016), a range of significant biological and psychological consequences have been linked to being bullied, including the following:

• Somatic disturbances (sleep disturbance, gastrointestinal concerns, headaches); • Changes in stress response systems that can lead to emotional dysregulation, mental health, and cognitive problems; • Increased risk for anxiety, depression, and alcohol/drug use in adulthood; and • Increased risk of contemplating or attempting suicide. Attempts to address bullying have become a high priority in school and work settings. Such consequences are serious. This has led to the development of laws, policies, and various strategies and practices that are designed to prevent bullying from occurring and, when it does it occur, to stop it immediately. When children are being bullied for stuttering or for any other reason, it is essential for the clinician, parents, and other individuals in the child’s life (e.g., teachers, school counselors, school administrators, peers) to take steps to address it. The first step as a responder is to become familiar with local school or workplace policies, resources, and practices that pertain to bullying. Prevention approaches for bullying fall into three categories: (a) universal prevention (efforts that are aimed at reducing risk and strengthening skills for all youth in a community or school); (b) selective prevention (efforts that are aimed at individuals who are at risk to perpetrate bullying or become a target of bullying); and (c) indicated prevention (activities that are aimed at individuals who are actively bullying or being targeted for bullying) (National Academies of Science, Engineering, and Medicine, 2016). A variety of prevention programs have been developed to address individual, peer, and community audiences. The effectiveness of universal prevention programs has been researched more than other types of prevention, with results suggesting that they are moderately successful at achieving their intended aims (National Academies of Science, Engineering, and Medicine, 2016). Blood (2014) stated that SLPs are well-suited to provide support to students who are targets of bullying because they often work with students



15.  Intervention Principles and Strategies for Helping People Who Stutter

individually. He stated that clinicians must listen carefully as students talk about their experience, thank them for having the courage the share the information, and to remind them that they have done nothing to deserve the bullying and that the SLP and others at the school will help. Later, the SLP can discreetly follow up with the student to inquire as to whether the bullying has lessened or changed in positive ways. As for workplace bullying, Law (2017) recommended that the person who is being targeted (a) immediately begin to document the perpetrator’s behavior when a problem is sensed; and then (b) immediately inform workplace administrators of the perpetrator’s behavior. Law (2017) described several proactive and preventative steps to address workplace bullying, as well: Prioritize civility among colleagues; address incivility when it occurs; conduct activities that foster relationships among colleagues; and establish group norms for how employees will interact with one another and with administrators. The National Academies of Sciences, Engineering, and Medicine (2016) published a webinar presentation dealing with the state of bullying prevention efforts in the United States. Included in

the presentation is information about practices that are recommended and not recommended when attempting to address bullying in school settings. This information is summarized in Figure 15–3. The nonrecommended practices in the figure are approaches that have been shown to be ineffective or counterproductive, while the recommended approaches are promising with respect to their effects thus far. In addition, a U.S. Department of Health and Human Resources website contains a wealth of information about bullying, including links to various Internet-based sources that provide information on promising approaches to addressing bullying. Included among the latter are the Stop Bullying.gov website, which features information on bully prevention that is tailored to a variety of audiences (e.g., parents, students, educators), plus information on state-level bullying laws. The site also links to the Source of Strength program, which is a peer-leadership training program directed at adolescents. The aim of the program is to enlist adolescents to help “change social norms that promote risky and unhealthy behaviors including bullying, substance use, and suicide.”

Figure 15–3. Recommended and nonrecommended approaches for addressing bullying in school settings. (Source: National Academies of Sciences, Engineering, and Medicine, 2016).

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Other Resources for Responding to Bullying Self-help organizations like the National Stuttering Association and The Stuttering Foundation publish resource materials and workbooks that clinicians can use to help children who stutter learn about bullying and develop strategies for responding to it. Clinical resource books such as Minimizing Bullying for Children Who Stutter (Murphy, Reeves, Reardon-Reeves, & Yaruss, 2013) offer clinicians a wealth of practical ideas, strategies, and resources for assisting school-aged children who stutter. Other authors (Langevin & Prasad, 2012; Murphy, Yaruss, & Quesal, 2007a) offer detailed descriptions of classroom presentations and educational activities that inform school-aged students about stuttering and best practices for responding to stuttered speech when it occurs. Blood (2014) described a six-point process, captured by the acronym STOP-IT, that SLPs can implement when instances of bullying occur at school. It consists of the following: 1. Stop the bullying immediately; 2. Tag (label) the bullying behavior immediately (e.g., “You just pushed him.”); 3. Offer assistance and social support to the person who is being targeted; 4. Present the immediate, appropriate consequences for bullying (e.g., tell the individual who is bullying that the behavior is unacceptable and will be reported); 5. Instruct witnesses/bystanders by telling them that bullying behavior is not allowed at school and that they should report instances of bullying to school personnel if they witness it); and 6. Teach bullying intervention strategies to students, personnel, parents, and friends.

Intervention Principle 3: Build a Communication Environment That Facilitates Speech Fluency • This intervention principle is applicable for any case and at any point in treatment. • Often, it is used as one component in a larger, more comprehensive intervention plan. • With some preschoolers who stutter, it may be introduced either as a form of prevention or as the primary intervention strategy.

Overview and Rationale Stuttering severity can vary, sometimes significantly so, from task to task. There are a host of variables that have the potential to influence the likelihood of stuttering in a specific utterance or situation.

Some of the variables that affect speech fluency are intrinsic to the utterances a speaker produces (e.g., the number of syllables or syntactic units within an utterance, the stress pattern within a phrase, topic familiarity). Other variables are associated with the speaker’s communication partner (e.g., the partner’s speaking rate, interruption frequency, verbal or nonverbal reactions to stuttered speech). Still other variables are associated with physical characteristics of the communication environment (e.g., the number and nature of distracting stimuli, the amount of time the client has available to complete an utterance or a turn in a conversation, the extent to which there is competition for speaking turns in a conversation). These factors and others often coexist in a communicative interaction and can interact dynamically to create ever-shifting landscapes of communicative demand for the speaker who stutters. Because variables such as these can impact stuttering-related behavior, SLPs usually attempt



15.  Intervention Principles and Strategies for Helping People Who Stutter

to control the extent to which they are present during treatment activities. The aim is to create talking environments that are appropriately challenging — not too easy, yet not too difficult — in relation to a client’s current level of fluency functioning. When practice tasks are designed to regulate demands in this way, the result usually is that the client spends a greater amount of time working within his or her current capabilities, and thus a greater amount of time engaged in successful fluency management. Most intervention programs that incorporate motor-based treatments for stuttering incorporate this principle. As such, practice activities associated with such treatments typically are organized hierarchically (e.g., short utterances to long utterances; simple language forms to complex language forms; limited time pressure to extensive time pressure).

Implementation What to Manage In the early and mid stages of treatment, clinicians often work closely with clients in one-on-one activities to help them develop skills that will improve speech fluency and thus increase their capacity for more effective stuttering management. At this point in treatment, clinicians typically attempt to design treatment activities in ways that limit or control the number and/or intensity of communication-related fluency stressors that are present. The specific aspects of communication to be managed will vary from case to case. Variables that commonly are regulated include the following: • Competition for obtaining speaking turns (conversational pace):  The clinician can manage this aspect of communication by regulating variables such as the following: the number of utterances produced by conversational participants per minute (fewer utterances = slower pace = less demand); the duration of pauses that occur between the end of the child’s utterance and the start of the adult’s following utterance (longer pauses = slow pace = less demand); the number of conversational

utterances in which participants are talking simultaneously (fewer overlapping utterances = less need to fend off interruptions = less demand). • Competition for maintaining a speaking turn:  This can be managed by manipulating/regulating variables such as the following: the frequency with which speaking partners interrupt the client’s speech (fewer interrupted utterances = less need to finish utterances quickly = less demand); the frequency with which speaking partners attempt to fill in words when the client is experiencing stutteringrelated disfluency (fewer filled-in words = less need to finish stuttered words quickly = less demand). • Partner’s verbal and nonverbal responses to the client’s disfluency:  This can be managed by manipulating/regulating variables such as the following: the frequency with which a speaking partner conveys impatience toward disfluent speech (fewer impatient moments = less perceived need to speak more quickly = less demand); the extent to which the listener shows interest in the content of the client’s utterances versus the fluency with which the utterances are delivered (less focus on disfluency = less time being concerned about negative reactions to stuttering = less demand). • Communication setting:  Audience size (smaller audience size = less demand); audience composition (e.g., acquaintances vs. strangers); physical settings (e.g., public space vs. private room). Audience composition and physical setting seem to affect fluency functioning idiosyncratically. • The way in which the partner engages the client in conversation:  A partner’s use of open-ended requests (e.g., Tell me all about the movie!) obligates the client to produce a greater proportion of long utterances and/ or multi-utterance responses (long utterances = greater coordinative and language formulation demands = greater likelihood of stuttering). In contrast, use of closed-ended requests (e.g., What was the name of the movie?) obligate much shorter,

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less complex responses, which are likely to increase the client’s chances for speaking smoothly and perhaps managing instances of stuttering successfully (short utterances = less communicative demand = fewer instances of stuttering).

Where, When, and How to Manage Management/regulation of task complexity is easiest to accomplish during in-clinic activities. In this setting, clinicians can design activities that help the speaker who stutters develop his or her ability to apply stuttering management skills in a controlled setting that is conducive to success. In most motorbased treatments for stuttering, practice activities feature multiple, consecutive trials (massed practice). Practice activities tend to be ordered such that task demands progress incrementally, from less difficult to more difficult. It is also possible, though more challenging, for clinicians and caregivers to regulate aspects of task complexity during real-world activities (Gottwald, 2010; Logan & Caruso, 1997; Starkweather, Gottwald, & Halfond, 1990). Given the dynamic nature of events in real-world settings, however, it is seldom possible to control all relevant task complexity variables to the extent that is possible within-clinic. Determination of an appropriate level of complexity for a practice activity is based on a both clinician- and client-generated assessment data, which for the client portion may be based on a mix of objective data (e.g., stuttering frequency scores) and subjective rankings (e.g., from “easiest” to “hardest”). In the treatment literature for fluency disorders (e.g., Ingham, 1999; Ryan & Ryan, 1995; Shames & Florance, 1980), the aim generally has been to begin with tasks in which the client can apply a treatment strategy with a relatively high level of success (e.g., 70% or greater) and continue until mastery is demonstrated (e.g., 95% or greater accuracy for three consecutive sessions). When a client meets mastery criteria for the use of a stuttering management skill at one task complexity level, subsequent (more challenging) practice activities are introduced. This continues over time, such that practice activities unfold in a stepwise, easy-to-difficult progression.

SLPs often attempt to control linguistic complexity of utterances that clients produce during in-clinic practice activities in the initial stages of treatment. Linguistic complexity can be defined in several ways (Table 15–4). As shown in the table, phonologic complexity is defined often in terms of the number of syllables per response. This variable is relatively easy to control at the word and phrase levels. However, as the number of syllables per utterance increases, it is likely that the number of words and syntactic constituents per utterance will increase as well. Thus, clinicians should be aware that the “syllable length” of an utterance often is confounded with these other variables. Task complexity also can be managed by attending to the pragmatic function of an utterance. Research studies of interactions between parents and their children during play-based conversation (e.g., Logan, 2003; Weiss & Zebrowski, 1992) show that parents often present “close-ended requests” to their children. These are requests that typically obligate nothing more than a word or two as response (e.g., Parent: What color is it? Child: Blue). Brief responses like these have a higher probability of being spoken fluently than responses that consist of fully developed sentences or several sentences in succession. The latter types of responses are more likely to occur in response to “open-ended requests” (e.g., Parent: Tell me about the movie. Child: Oh mom, you should have seen it. It was really good. There was this one part in the middle where I was really scared and . . . ). Some clients who stutter report that responses to requests for clarification are more difficult to produce fluently than responses to requests for information. This is illustrated in Example 15–1, where the response to the request for clarification contains stuttering, but the initial production of the utterance, in which the speaker responded to a request for information, does not. The fluency difference between the utterances may arise because the speaker is expected to initiate the response to the request for clarification promptly and without the slightest bit of disfluency (because the speaker just said the sentence fluently a few moments before). Example 15–1: Parent:  Where are you going after school?



15.  Intervention Principles and Strategies for Helping People Who Stutter

Table 15–4.  Types of Variables to Target When Controlling Task Complexity in Practice Activities Category

Variable

Examples

Phonologic

Number of syllables (e.g., per word, phrase, or utterance)

Word:  Ann (1) versus Angelo (3)

Number of syntactic units per utterance

John bought pizza (S+V+O = 3) versus

Phrasal elaboration

Walter versus Uncle Walter versus Dear old Uncle Walter

Developmental difficulty

The boy is napping. (early developing) versus

Syntactic

Phrase:  In the Den (3) versus In the Denver Zoo (5) Utterance:  She found a can. (5) versus She found a candidate. (7) John ate pizza quickly today (S+V+O+Adv+Adv = 5)

After he eats lunch, the boy is napping. (late developing) Pragmatic

Speech act type

Assertive utterance versus Responsive utterance Responding to request for information versus Responding to request for clarification

Temporal

Setting

Number of utterances spoken per minute

Few turns per minute versus Many turns per minute

Time allotted for response completion

Brief time limit window versus Long time limit versus No time limit

Formality

Business meeting versus Casual conversation

Audience characteristics

Few versus Many audience members Familiar versus unfamiliar speaking partners Patient versus Impatient speaking partner

Clinician Support

Amount, frequency

Continuous prompting, Occasional prompting, No prompting Continuous encouragement versus Intermittent encouragement With cueing versus Without cueing

Note.  Numbers in parentheses indicate the number of linguistic units within a word, phrase, or utterance. Underlined text denotes syntactic constituents.

Child:  Over to Kaci’s house. (fluent utterance) Parent:  What? Where are you going? Child:  O- o- over to K- K- Kaci’s house. (same utterance, but stuttered) Over time, as a client’s capacity for managing stuttering-related disfluency improves, a clinician can systematically incorporate fluency stressors like this in treatment activities so that the client gains experience with managing speech fluency in a variety of discourse contexts. During the generalization phase of treatment, when the client is attempting to apply newly developed fluency management skills to real-world settings, environmental stressors are less predictable,

and thus more difficult to control. Nonetheless, clinicians can take steps to minimize their occurrence in family, classroom, and work settings by training key people in those environments to alter their communicative behaviors in ways like those described here. The basic idea is that by minimizing the extent to which the client encounters communication stressors while interacting with “communication allies” such as family members, teachers, and friends, the clinician and client can create semi-controlled practice contexts within real-world settings. Such contexts act as a bridge between the client’s highly facilitative speaking environment in the clinic and the rough-and-tumble communicative situations that the client is certain to encounter when dealing with random communication part-

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ners who, in their enthusiasm to communicate, sometimes show little regard for the rules of communication etiquette or the challenges that people who stutter face in obtaining and maintaining conversational turns.

Complexity Management as a Primary Intervention As noted, the interventions associated with complexity management aim to alter the environmental context in which children who stutter speak. As such, they can be implemented in a preventative manner (i.e., to prevent the occurrence of communicative situations that might aggravate stuttering severity) or as a type of treatment (i.e., as a method for improving fluency functioning in individuals who are stuttering). Either way, when this intervention principle is applied to preschool-aged cases, it will be aimed at the parents of children who stutter rather than at the children themselves (Botterill & Kelman, 2010). The parent attempts to create a communication environment that largely “fits” with the child’s current speech production functioning and, in doing so, attempts to minimize the extent to which the child is exposed to fluency stressors that increase the likelihood of stuttering (or of stuttering in a more severe manner). As such, it is considered an indirect approach to stuttering management. Common goals in intervention plans that use complexity management as a primary treatment strategy are to educate parents about the communication environments that tend to precipitate or aggravate stuttering symptoms in young children and to inform them about recommended ways of responding to a child’s stuttering or stutteringrelated frustrations and concerns (Botterill & Kelman, 2010). Treatment programs like this usually also include parent-oriented training modules that are designed to help parents interact with children in ways that minimize the risk of precipitating or aggravating stuttering or that possibly may facilitate speech fluency (Gottwald, 2010). In this way, the treatment is likely to change some aspects of what parents currently do when interacting with their child and to have parents continue or expand on other aspects of what they currently do (Botterill & Kelman, 2010). It is easy to see how a supportive speaking environment would be advantageous to a child

who stutters. The question becomes whether treatments that are oriented exclusively or primarily toward regulating environmental stressors are powerful enough to yield fluency improvements that are comparable to those seen with other treatments for childhood stuttering. At present, research data are not available to answer this question unequivocally. For instance, Baxter et al. (2016) conducted a systematic review of treatment studies for stuttering that were published between 1990 and 2014 and identified 111 total reports that met their inclusion criteria. Among those studies, however, only five studies fit into the category of indirect, parent administered interventions. Millard, Nicholas, and Cook (2008) reported on results of treatment for six preschool-aged children who stuttered using a single-subject experimental design. The treatment featured six parent-training sessions and six home-based, parent-led sessions. The clinicians developed semi-individualized treatment programs for the children based on assessments of parent-child interaction patterns. Common features in all or most of the treatment plans included the provision of praise for target behaviors, directions for parents to follow the child’s lead during play, and directions for parents to use comments more than questions when interacting with their child. Other directions that were applied to some cases included directions for parents to reduce their speech rate and alter or attend to their family members’ turn-taking behaviors. Millard et al. reported significant reductions in stuttering-related disfluency in four of the six cases. In a follow-up study that added untreated control cases, four of six children who received the treatment showed improvement in stuttering over a 1-year period compared to only one of four untreated children. Yaruss, Coleman, and Hammer (2006) developed a family-focused intervention for 17 preschool- to early elementary-aged children that incorporated communication management techniques like those described earlier in this section. The program consisted of two to four education/ counseling sessions and three sessions wherein parents were trained to modify their communication using approaches such as “easy talking,” “increased pause time/reduced time pressure,” “reduced communicative demands,” and “reflecting/rephasing” the child’s utterances. Some (seven of 17) children also learned communication modi-



15.  Intervention Principles and Strategies for Helping People Who Stutter

fications that targeted stuttered speech and general communication. Posttreatment data showed that all 17 children (including 10 who received only the parent-based treatment) improved speech fluency (pretreatment mean = 16.3% syllables stuttered; posttreatment mean = 3.2% syllables stuttered). Additional data of this nature are needed for this type of intervention to assess how treatment outcomes for parent-oriented interventions compare to those from other interventions such as feedbackoriented approaches like the Lidcombe program. Both Ryan (1974) and Ingham (1999) provided detailed descriptions of treatments that featured regulation of task complexity as a primary intervention component. With Ryan’s (1974) program, termed Gradual Increase in Length and Complexity of Utterance (GILCU), the clinician develops a series of practice activities in which task demands start out simply and become progressively more difficult over time. The client progresses through the task hierarchy by meeting preset performance criteria. When applied to school-aged children, the GILCU treatment begins with oral reading at the one-word level. The client is directed to read single words fluently. After demonstrating mastery at this level, the client progresses to reading two-word sequences fluently, and then three- to six-word sequences fluently, one- to four-sentence sequences fluently, and then eventually to reading fluently for progressively longer time intervals (e.g., 30 seconds, 1 minute, 2 minutes) up through 5 minutes of fluent reading. After attaining mastery within reading, the treatment cycles back to spontaneously formulated words, from which it progresses to spontaneously formulated phrases, sentences, monologue, and eventually to conversation. At all stages, the treatment uses a step-by-step structure. If a child is unsuccessful at a step, the clinician is directed to model the correct (i.e., fluent) response for the client, which the client then imitates. If a child does not meet outcome criteria at the end of an entire sequence of steps, the clinician starts the step-sequence again from the beginning (e.g., at the one-word target level). Although the GILCU treatment was originally presented as a “stand-alone” treatment, the treatment’s approach to complexity management easily can be adopted as an organizational framework within which the client can practice specific motor-based stuttering management strategies (e.g., regulated articulation rate).

Ingham (1999) outlined a step-based treatment protocol, similar to GILCU, for use with young children who stutter. The program contains 21 steps, and for each step, Ingham specified the treatment materials that are to be used (she termed them “discriminative stimuli”), along with the child’s expected response to the materials (e.g., one stutter-free word), a description of the desired consequences that will follow (i.e., fluent) and undesired (i.e., stuttered) responses, and the criteria that the child must meet to proceed to the next step (e.g., 10 consecutive stutter-free responses). Step complexity within the program is like that in Ryan’s GILCU treatment, with target responses increasing by the number of syllables per response and, eventually, at the monologue and conversational levels, by the time spent talking. It is difficult to separate the contributions of the regulated complexity in these programs from those of the response-contingent feedback that children receive. In both programs, the feedback is evaluative (e.g., “Great!” “Right!” “Not quite”) and/ or directive (e.g., “Stop!”). Clients are given little to no explicit instruction on how to talk fluently. As Ryan (1974) stated, the program relies “heavily on the client’s performance and the clinician’s evaluation of the performance” (p. 54). When instructions are given, they are quite general (e.g., “Try to talk as smoothly as possible” “Try to talk with no stuttering”). In this respect, the treatment is like both the time-out and Lidcombe approaches described under Principle 4. That is, the client is essentially left to access and use whatever internal resources for stuttering management he or she possesses independently during the activities. Peer-reviewed treatment outcome data on the effects of regulated response complexity as a treatment strategy are less extensive than those for time-out and the Lidcombe approaches. Ryan and Ryan (1995) compared treatment outcomes in children and teens who stuttered. Children in one group received a treatment that used GILCU principles, while children in a second group completed a treatment that used delayed auditory feedback (DAF) to establish a target articulation rate. Overall, 96% of the children showed improvement in fluency, and the average time needed to establish the skills was 7.9 hours. In a transfer and maintenance phase that followed the active treatment phase, the children in the two groups again demonstrated a

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similar degree of fluency improvement. Among the children who completed all phases of study, mean stuttering frequency decreased from about eight stuttered words per minute at pretreatment to less than one stuttered word per minute 14 months later. In a similarly designed study, Riley and Ingham (2000) compared treatment outcomes for a speech motor training therapy against those for an extended length of utterance therapy. For elementary school-aged participants, both treatments resulted in statistically significant reductions in stuttering frequency upon completion of 24 treatment sessions. For the speech motor training, the median reduction in stuttering frequency was 36.5%, and for the extended length of utterance treatment, it was 63.5%. The speech motor training therapy resulted in significant increases in vowel duration and stop-gap duration between pre- and posttreatment measures. Children in the extended length of utterance treatment showed no changes in speech timing, and their speech timing resembled that of a control group of children who did not stutter. Thus, changes in speech rate/timing did not appear to be a common factor in the treatment outcomes. Bothe, Davidow, Bramlett, and Ingham’s (2006) systematic review of stuttering treatment research featured only two regulated utterance complexity studies that met their inclusion criteria (one of these was Ryan and Ryan [1995], which was discussed earlier). Both studies reported treatment outcomes in which stuttering frequency was less than 5% syllables stuttered and the participants were able to maintain the treatment gains at a 6-month followup. Baxter et al.’s (2016) review added research from two other studies in which motor-based treatment skills (“smooth speech”) were introduced to teens who stuttered in the context of a GILCU-like framework (von Gudenberg, 2006; von Gudenberg, Neumann, & Euler, 2006), both of which reported significant improvements in fluency posttreatment.

Intervention Principle 4: Provide Systematic Feedback About Fluency Performance • This intervention principle is applicable for any case and at any point in treatment. • Activities associated with this intervention principle usually constitute one component

of a larger, more comprehensive intervention plan. • Feedback is a primary strategy in some approaches to stuttering treatment.

Overview and Rationale In the context of stuttering intervention, feedback is the process of providing clients with information about what they do (or do not do) during speaking tasks. In the early stages of intervention and in treatment activities that are oriented toward the development of new skills, feedback often is provided on a moment-to-moment basis. In latter stages of treatment or in activities that involve established skills, however, feedback usually is provided less often and is merged with the goal of developing clients’ ability to self-evaluate performance. The rationale for providing feedback in a therapeutic setting is straightforward: It will be difficult for a client to function in some new or different way if the client does not know how he or she currently functions. Feedback addresses this situation by helping the client develop awareness of what he or she is doing and, possibly, how well he or she is doing it. Results from numerous studies indicate that, over time, the systematic delivery of feedback immediately following stuttering-related disfluency leads to decreased frequency of stuttering-related disfluency (e.g., Onslow, 1996; Prins & Hubbard, 1988). In stuttering treatment programs, SLPs usually are the first persons to provide clients with systematic feedback about their performance. Over time, however, parents and other individuals may be taught to do so, as well (Onslow, Packman, & Harrison, 2003). In some approaches to stuttering intervention, particularly those used with preschoolers who stutter, the provision of systematic feedback is the primary intervention strategy (e.g., Onslow, 1996; Onslow, et al., 2003), particularly during the early to mid-stages of treatment, when the clinician is attempting to help the client build his or her capacity for speaking more fluently and/ or stuttering less severely. When implemented over time, a clinician’s feedback to the client can provide the client with a model for how to self-evaluate speech



15.  Intervention Principles and Strategies for Helping People Who Stutter

Table 15–5.  Types of Feedback Presented in Conjunction With Stuttering-Related Behavior Type

Description

Feedback Examples

Highlighting

Clinician informs client that client produced a behavior of interest (e.g., stuttering).

• Client:  “my c- c- c- coffee and . . .”

Client is not asked explicitly to alter speech but may do so anyway. Evaluating/ Describing

Clinician informs client about how client performed in relation to task criteria. • Knowledge of results (KR), that is, simple feedback indicating whether target goal was met or not • Knowledge of performance (KP), that is, detailed feedback regarding what or how client behavior aligned with goal Client is not asked explicitly to alter speech but may do so anyway.

• Clinician:  (presents highlighting signal) • Mechanical (e.g., rings bell) • Gestural (e.g., raises hand, clears throat) • Verbal (e.g., “There’s one.”) • Client:  “and my c- coffee and . . . ” • Clinician:  feedback indicating correct/incorrect application and treatment strategy (KR) • Gestures, for example, thumb up (correct); thumb down (incorrect) • Verbal remark, for example, “Yes,” “Good,” “Correct,” “Not quite” • Client:  “G- g- g- get that out of here.” • Clinician:  “That sounded bumpy.” (KP) • Client:  “He put that one over there.” • Clinician:  “That was smooth talking.” (KP) • Client:  “He fixed the bicycle.” • Clinician:  “Good, you blended ‘the’ and ‘bicycle’.” (KP)

Directing

Clinician explains to client what client should do when the clinician presents feedback (e.g., “Whenever I signal you, you are to stop speaking for 5 seconds. Then resume speaking.”).

fluency. As clients develop self-evaluation skills, clinician- or caregiver-initiated feedback to the client usually can be reduced in frequency and ultimately discontinued after the client reaches certain fluency performance benchmarks. Table 15–5 contains three categories of feedback that SLPs use when treating clients who stutter. As shown in Table 15–5, feedback can vary in its detail and purpose. Additional information about the application of various types of feedback is presented next.

Implementation Use Feedback to Highlight Behavior The most basic type of feedback is that which highlights the presence of a behavior. The clinician’s

• Client:  Produces lip tremor on [p] in pie • Clinician:  Administers mechanical, gestural, or verbal signal • Client:  Stops saying [p], pauses for 5 seconds, restarts pie (hopefully without tremor)

aim simply is to signal to the client that a behavior of interest has occurred. Feedback of this sort can be delivered in many ways (i.e., vocally, gesturally, mechanically), via any type of signal that is salient to the client. Examples of behaviors that a clinician might highlight include instances of stuttered speech, instances of fluent speech, and instances when a client either applies a treatment strategy or a self-devised maladaptive strategy in response to anticipated stuttering-related behavior. The clinician’s main challenge when attempting to highlight client behavior is to present the feedback signal in close temporal proximity to the behavior of interest. This sometimes is hard to do because specific behavioral markers of stuttered speech can be fleeting, thus difficult to “tag” promptly. By the time the clinician presents a highlighting signal, the client may have advanced the utterance by several syllables. At this point, the feedback is

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no longer precisely linked with the behavior that the clinician intended to highlight, which creates scenarios wherein a client may think the clinician is highlighting a behavior other than the one the clinician intends to highlight. Prins and Hubbard (1988) reviewed experiments that examined the effects of various response contingencies on stuttering frequency. In experiments where aversive stimuli (i.e., electrical shock, loud tones, noise) were paired with stuttered speech, nine studies reported a decrease in stuttering frequency, three reported mixed results, and four reported no effect. In experiments where neutral stimuli (i.e., light, digital counter, pure tone) were paired with stuttered speech, one study reported a decrease in stuttering frequency, two reported mixed results, and two reported no effect. In studies where highlighting of stuttering-related behavior led to positive changes in speech fluency, the findings suggest that, as a group, speakers who stutter possess intrinsic resources for managing their stuttering-related disfluency and can implement such resources when prompted to do so and in the absence of didactic instruction on how to talk.

Use Feedback to Evaluate, Describe, or Direct Behavior Another use of feedback is to evaluate or describe what a client has done. With evaluative feedback, the clinician not only highlights a behavior that a client produces, but simultaneously comments on its accuracy, appropriateness, or desirability in relation to some predetermined standard or expectation. Evaluative feedback is, of course, a staple of learning in all sorts of domains. Teachers provide evaluative feedback to students on examinations; coaches provide evaluative feedback to athletes during practice drills; and parents provide evaluative feedback to their children during activities such as coloring and dressing. As noted in the discussion of motor learning principles in the previous chapter, evaluative feedback can be simple in both form and content (e.g., “good,” “not quite,” “uh-oh”). Such feedback provides the client with knowledge of results, but not the details of what aspects of their speech were right or wrong, good or not good. In Prins and

Hubbard’s (1988) review of response contingency research, there were two studies that reported significant reductions in stuttering frequency in conjunction with positive evaluative feedback (i.e., “good”) and no studies with negative findings. Among studies that used aversive forms of evaluative feedback (e.g., “no,” “not good,” “wrong,” and laughter), nine studies reported a significant decrease in stuttering frequency, one study reported mixed results, and one study reported no effect. Unexpectedly, in two other studies, presentation of an ambiguous word (i.e., “tree”) resulted in a significant decrease in stuttering frequency (Cooper, Cady, & Robbins, 1970; Daly & Kimbarow, 1978). Thus, it may be that almost any type of verbal contingency that is linked with stuttered speech can prompt a client to recruit internal resources that lead to a reduction in stuttering frequency. In other studies, researchers have paired descriptive labels with the client’s speech production. Feedback of this sort constitutes a primary intervention strategy in the Lidcombe program (Onslow et al., 2003) — a well-researched treatment used primarily with preschoolers who stutter. With the Lidcombe approach, clinicians and, eventually, caregivers deliver descriptive comments about a child’s fluency during circumscribed intervention activities. The adults primarily make descriptive remarks about the child’s fluent speech (e.g., “That sounded smooth”). However, they also occasionally remark on the child’s stuttered speech (e.g., “That sounded bumpy”). Clinicians and parents typically present these comments on a preset schedule. Initially, feedback is provided often (and during therapy activities, perhaps even continuously), but over time it is faded and presented intermittently. Although there is more to the Lidcombe treatment than the clinician’s and parent’s verbal feedback to the child, the descriptive feedback is a main feature of the intervention. The provision of descriptive feedback to young children seems to be powerful, based on the many published accounts of positive treatment outcomes with the Lidcombe approach (Femrell, Avall, & Lindstrom, 2012; Jones et al., 2005; Jones et al., 2008; Lattermann, Euler, & Neumann, 2008; Lewis, Packman, Onslow, Simpson, Jones, 2008; O’Brian et al., 2013). Interestingly, with the Lidcombe program, clinicians devote little or no time to didac-



15.  Intervention Principles and Strategies for Helping People Who Stutter

tic instruction in speech production. Rather, the child is essentially left to figure out how to change “bumpy speech” into “smooth speech” on his or her own. To the extent that young children succeed at doing this, it again supports the idea that people who stutter possess internal resources such as reallocation of attention or adjustment of speech motor movement kinematics such that, when implement, enables them to reduce stuttering-related disfluency and accompanying communication disability. When clinicians work with older children, teens, and adults, they can, of course, present more detailed forms of descriptive or evaluative feedback. Feedback of this sort typically occurs after completing a speaking task. (This in contrast to administering feedback in as close temporal proximity as possible to an instance of stuttering.) Detailed evaluative feedback provides clients with a critique of what they did either in a specific practice trial or upon completing a practice activity (e.g., what did or did not go well during a classroom presentation and how that compared to predetermined criteria for performance). In addition to providing clients with data on how they are progressing in treatment, feedback of this sort offers models that may promote their ability to self-evaluate their stuttering-related behavior in the future. Feedback also can be used in activities that are designed to direct the client to do something that differs from what he or she currently is doing. When implementing feedback in this manner, the clinician administers a signal (e.g., a tone, a hand signal, a verbal remark such as “stop”) that is contingent upon a specific behavior, such as a client’s instance of stuttering. The clinician attaches a contingency (e.g., “stop talking for 5 seconds”) to the signal, which the client then implements immediately after the clinician presents it. The clinician delivers the feedback to the client in “real time” — ​ that is, during or immediately after the behavior of interest. Several studies have examined the effects of this type of feedback using single-subject experimental designs (e.g., James, 1981; James, Ricciardelli, Rogers, & Hunter, 1989; Martin, Kuhl, & Haroldson, 1972), and each has demonstrated the effectiveness of this approach in experimental settings at reducing stuttering frequency during speaking tasks.

Intervention Principle 5: Help the Client Discover and Build on Existing, Productive Responses to Stuttering • This treatment principle is most applicable to clients who are capable of self-analyzing aspects of speech fluency and actively modifying aspects of their speech production. • This treatment principle is applicable at any point in treatment. • Activities associated with this treatment principle typically constitute one component of a larger, more comprehensive intervention plan.

Overview and Rationale Prior to commencing treatment activities that target stuttering management skills, clinicians should find that many clients already demonstrate stretches of speech where they respond to instances of stuttering in relatively constructive ways, either through the attitude they exhibit toward speaking or in the actual speech-language behaviors they produce. At these times, the client’s response to stuttering approximates or, perhaps, even matches the result that the clinician is seeking to help the client attain through treatment. At the pretreatment stage, however, clients are unlikely to be producing these responses intentionally or systematically. Rather, they simply are an implicit feature of the client’s speech. Thus, the clinician’s task is to highlight and reinforce constructive behavior like this so that clients increase their awareness and appreciation of their existing capacity for managing stuttering effectively.

Implementation Highlight and Reinforce Existing Personal Qualities That Are Likely to Facilitate Stuttering Management Nearly all clients enter treatment possessing personal qualities, such as persistence, resilience,

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patience, and motivation, that are likely to facilitate stuttering management. During treatment, the clinician’s job is to recognize instances when the client demonstrates these qualities, and then highlight their occurrence and reinforce their importance to the stuttering management process. In this section, examples of how clinicians can highlight and reinforce instances of persistence and resilience are presented. Highlighting and Reinforcing Persistence. Speaking is an intrinsic part of daily life for all people. However, for many people who stutter, speaking is a challenging task. The act of producing speech often is effortful, and listener reactions to stuttered speech can be unpleasant or hurtful and hinder the client’s efforts to communicate. Given this, one might understand if some people who stutter choose to give up on talking. This rarely, if ever, occurs, however. Instead, most people who stutter “soldier on” — that is, they continue talking to others throughout an assortment of life activities, even though their speech may be very disfluent and effortful for them to produce. Clients who “soldier on” demonstrate persistence, meaning that they continue to engage in speech despite its difficulty and associated hardships. Persistence is a personal quality that is present in adults who report having developed the ability to manage stuttering successfully after having had considerable stutter-related disability at earlier stages in life (Plexico, Manning, & DiLollo, 2005). Thus, persistence is a personal quality that clinicians need to identify and reinforce throughout the intervention process. The following exchange, modeled after information presented by Egan (2002), illustrates how clinicians can do this.

Client:  . . . and its [www- www- um wwwwww- um like well um www- www]wasteful. Clinician:  That one lasted a while. Are your stutters that long in other settings? Client:  Yeah, a lot of times . . . S- sometimes I feel like quitting w- what I’m saying. Clinician:  You feel like quitting. Client:  Well, just stop t- talking to the person. Yeah, but I mean, I don’t quit.

Clinician:  You keep going — even when talking is difficult. Let’s talk about how your “keep going” approach might help you to reach the speech goals that you set for yourself. Highlighting and Reinforcing Resilience. The American Psychological Association (2020c) defined resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.” The APA notes that, in essence, resilience is the ability to bounce back from adversity. Resilience is an important quality for people to have, and it is particularly important for people who lack effective strategies for managing stuttering because they regularly face adversity in the communication arena — often many times per day. The clinician’s job is to identify and reinforce instances when clients demonstrate the ability to “bounce back” from difficult stutteringrelated experiences. The following exchange illustrates how clinicians can do this.

Client:  My presentation on Tuesday didn’t go well. I stuttered a lot, and I really struggled to talk. Clinician:  It sounds like it was difficult for you. Client:  Yeah, I felt bad about myself for about a half-hour afterwards . . . just really embarrassed. I have another presentation tomorrow. I’m going to do this one with slides because I think it will help if I have the content set up beforehand. Clinician:  Sounds like you have a thoughtful plan for getting where you want to go. Client:  Yeah, I mean I know it’s going to take time to get my stuttering under control in these presentations. It’s hard but I’ve told myself to just keep at it. A little at a time. Clinician:  Yes, it’s a big task you’re undertaking with some setbacks along the way. It sounds like you’ve come right back from this latest setback — and you’re ready to try out a new strategy to keep moving forward. I have a feeling your ability to



15.  Intervention Principles and Strategies for Helping People Who Stutter

bounce back from setbacks will help you progress in the long run. Client:  Yeah, me too.

Highlight and Reinforce Speech Behaviors That Facilitate Stuttering Management Prior to introducing activities that target stuttering management skills, clinicians should find that many clients already demonstrate speech behaviors that are similar to and consistent with speech patterns that the clinician will be helping the client to develop and produce consistently via treatment. At the pretreatment stage, however, clients are unlikely to grasp the importance of such behaviors (or, even realize they exist). Thus, the clinician’s job is to highlight their occurrence, reinforce their use, and then help the client build off them as formal treatment strategies are introduced. Highlighting and Reinforcing Productive Adjustments to Expected Stuttering. When examined closely, some instances of stutteringrelated disfluency can be understood instead as moments where clients are demonstrating productive responses to the expectation of impending stuttering-related disfluency on an upcoming syllable. Consider the following disfluency:

. . . and th[eee] basketball. (0.5 s prolongation of [ə]) In the preceding example, the speaker prolongs the vowel in the word the for about one-half second while saying the phrase and the basketball. When discussing this disfluency with a speaker who stutters, it would not be surprising to hear the speaker say that the prolonged vowel in the was not the main fluency problem in the phrase. Rather, it was the first syllable in basketball. The speaker also might say that he or she did not even realize the vowel in the was prolonged, or if the speaker was aware of it, he or she might report that it was not prolonged intentionally or strategically — it was something that “just happened.” From the clinician’s perspective, however, the client’s slight stretch on the schwa vowel offers an example of an adaptive response to anticipated

stuttering. With this particular adaptation, the client is essentially “downshifting” articulation rate, which alters the rhythm of the utterance slightly. The adjustment in articulation rate in this phrase is similar to what a client would learn to do in a therapy context where regulation of articulation rate is introduced as a treatment strategy. Slight adjustments like this in speech timing often enable speakers who stutter to “slide through” areas of anticipated stutter-related disfluency within an utterance with minimal disruption to speech continuity, thus preventing the occurrence of what might otherwise have been a much more disruptive instance of disfluency on basketball. Clinicians can highlight and reinforce the use of speech behavior like this using language similar to that presented earlier in the sections on persistence and resilience. As treatment progresses, clinicians can work toward helping clients develop the ability to respond in this manner intentionally and consistently to instances of anticipated stuttering. Highlighting and Reinforcing Instances of “Clean Stuttering.” In many clients who stutter, instances of stuttering will vary in their presentation. The term “clean stuttering” is used to refer to stuttering-related disfluencies that, for a specific client, are relatively simple in their structure (e.g., ma- ma- marathon vs. ma- um um maum like — marathon), relatively free of excessive muscle tension, and feature no extraneous nonspeech sounds (e.g., audible, dysrhythmic inhalation) or physical movements (e.g., eyerolling, finger-tapping). Clean stuttering is minimally disruptive to communication, and thus consistent with the notion of effective stuttering management. As clinicians interact with clients who stutter, they can look for, and then highlight and reinforce instances of clean stuttering. The following exchange, which takes place during a conversational activity that is designed to develop the client’s ability to self-identify and describe instances of stuttering, illustrates how clinicians can do this.

Client:  I’m not sure what we’ll do. [Ththth] there’s a chance of rain this weekend. Clinician:  Another rainy day . . . Let’s talk about the prolonged [ð] sound in the word “there’s.” Did you notice that?

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Client:  Yeah. Clinician:  What do you think? What was that like? Client:  Well, that bit of stuttering lasted a little while, but it wasn’t nearly as tight and tense as most of the ones we talked about so far today. Clinician:  Yes, and you didn’t tap your finger on table to get the word started, like you have done on some other words. You just went right into the word. Even though there was some stuttering, it was “clean” and uncomplicated. What do you think your speech would be like if more of your stuttered words were like this one?

Intervention Principle 6:  Help the Client Develop Skills That Reduce Stuttering Frequency • This intervention principle is appropriate for clients whose speech continuity is interrupted frequently by stuttering-related disfluency. • It is most appropriate for clients who have the capacity for actively regulating and monitoring their speech for extended periods of time. • Skills associated with this intervention principle are commonly used with clients who are school-aged and older, and they often are the primary component around which an intervention program is built.

Overview and Rationale Treatment strategies discussed in this section deal with helping speakers who stutter to develop speech motor skills that, when implemented, are likely to reduce the frequency of stuttering-related disfluency. The main objective is for speakers to improve speech fluency through the self-directed, deliberate regulation and monitoring of one or more speech production parameters.

In the context of this treatment principle, the term regulation refers to intentionally altering, controlling, and/or monitoring the motor movements that one makes while talking. Strategies that incorporate regulated speech are used widely for the treatment of stuttering. Treatment strategies for stuttering most often focus on articulatory parameters; however, treatments that focus on aspects of speech rhythm/prosody, phrasing, phonation, and speech breathing also have been described and studied. Clinicians commonly use these strategies with individuals who are in the preadolescent, adolescent, and adult years (Guitar & McCauley, 2010). This is because independent use of most of the strategies requires the ability to understand, analyze, and attend to specific aspects of speech production. Young children typically are quite limited in their ability to do these things; thus, it is not reasonable to expect them to independently employ strategies like those described in this section. That said, there are simplified forms of some motor-based strategies for stuttering management that have been implemented in circumscribed ways during treatment with preschoolers who stutter. These are discussed briefly next.

Implementation Develop the Client’s Ability to Regulate Articulation Rate Regulation of articulation rate is one of the most used and most well-researched strategies for treating stuttering. Most descriptions of this treatment strategy require the client first to learn to speak consistently at an articulation rate that is much slower than normal. Because articulation movements are produced in slow motion, speech output sounds are prolonged or stretched out. Target articulation rates in some intervention approaches (e.g., Shames & Florance, 1980) can be as slow as 2 seconds per syllable (30 syllables per minute), whereas a typical articulation rate is on the order of 0.2 seconds per syllable. Most speakers who stutter produce little if any stuttering-related disfluency while speaking in this way, and they will report that the expectancy of stuttering on upcoming syllables is greatly diminished as well.



15.  Intervention Principles and Strategies for Helping People Who Stutter

Unnatural-Sounding Speech Is Not the End Goal of “Prolonged Speech” Intervention strategies that incorporate regulation of articulation rate often are referred to as prolonged speech. Although use of the prolonged speech strategy involves copious amounts of talking at a rate of speech that is slower than one’s habitual rate, use of the strategy does not mean that the desired treatment outcome is for the client to speak in a slow, unnatural-sounding speech. Rather, in nearly all cases and with nearly all motor-based treatment approaches, the long-term goal is for clients to develop speech that sounds natural in terms of its rate, rhythm, and other aspects of speech. Although speakers may be asked to use a very slow rate of speech or unnatural sounding speech rhythm, outputs like these typically are attempted only during the early stages of skill development, and they usually are not intended to be implemented during activities beyond the clinical setting. When regulated speech is used in connected speech with speakers who stutter, it typically results in fewer continuity interruptions, and with it, increased speech rate, improved rhythm, and speech output that appears less effortful and sounds more natural when compared to pretreatment speech (Logan, 2005). With many cases, the use of strategies that are based on regulation of speech motor behavior result in rapid and very noticeable improvement in speech fluency (e.g., Boberg & Kully, 1994). In cases with moderate to severe stuttering, these improvements in fluency also are likely to result in marked reduction of maladaptive coping strategies for stuttering, such as circumlocution and word avoidance strategies and improved communicative participation in daily activities. Proficient application of regulated speech during daily activities also results in much less variable fluency performance; that is, speakers begin to demonstrate similar levels of improved fluency across most communicative activities (Logan, 2005).

After the client meets predetermined criteria for mastery at the slowest target articulation rate, the clinician introduces an articulation rate that is slightly faster than the base rate (e.g., progressing from 2 seconds per syllable to 1 second per syllable); and after the client meets performance criteria for the second rate target, the clinician introduces additional articulation rate targets that become progressively faster until eventually the client is asked to produce an articulation rate that is within the normal range. Additional details and examples of using regulated articulation rate as a stuttering management strategy are presented in Chapter 18.

Develop the Client’s Ability to Make Smooth, Controlled Phonetic Transitions This treatment strategy involves the use of regulated articulatory movements while making specific

phonetic transitions within a spoken utterance. This strategy is like regulated articulation rate in that it typically involves slowing articulation rate. However, unlike the regulated articulation rate strategy, where articulation rate is regulated across all syllables within an utterance, the speaker who stutters regulates articulation rate only in focal portions of an utterance. In addition, the speaker is encouraged to attend to proprioceptive sensations, particularly those pertaining to the positioning and movement of key speech articulators (i.e., the lips, tongue body, tongue blade, lips, and jaw) during transitions between syllable boundaries and perhaps also during transitions between the syllable onset and syllable rime. Both utterance locations are particularly prone to stutteringrelated disfluency. Development of this skill provides clients with a strategy for reacting effectively to instances when the client senses that stuttering-related disfluency

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is impending. When applied proactively, it provides the client with a strategy for reducing the risk of stuttering-related disfluency in utterance locations that are particularly prone to that type of disfluency (e.g., syllables in utterance-initial positions, syllables in clause-initial positions; onset-rime transitions in syllables that carry primary linguistic stress). Application of this strategy to instances of anticipated stuttering is considered in Example  15–2. In the example, the speaker anticipates part-word repetition on the words Washington and Baltimore, and in each instance, manages the anticipated stuttering by regulating articulatory movements that precede each of the points of expected stutteringrelated disfluency as well as the syllables within which stuttering-related disfluency was anticipated (see parentheses in the following example). The client’s adjustments prevent the expected partword repetitions from occurring. Van Riper (1973) referred to this strategy as preparatory set. Others have used terms such as smooth transition (Shames & Florance, 1980) and easy, relaxed approach with smooth movements (Gregory, 2003) to describe this stuttering management strategy. Example 15–2: Planned sentence:  We’re going to Washington and Baltimore. Anticipated disfluency:  We’re going to [WW- w]Washington and [BB- b- b-] b- Baltimore. Locations of strategy application: We’re going t(oo Wwaa)shington a(ann BBal) timore. The speaker essentially has two options for managing these anticipated disfluencies (described next). Each of the strategies is likely to differ from the approach that the client has been using prior to commencing treatment. Preventing Impending Stuttering by Modifying Articulation Rate and Attending to Proprioceptive Feedback. The first option entails both modification of articulatory movement and attention to proprioceptive feedback through the syllable transition. So, the speaker, while saying the word going, detects that stuttering-related disflu-

ency is likely to occur during the word Washington (with the expected point of continuity interruption being between the onset and the rime of the first syllable in Washington). In this instance, the speaker slows articulation rate in the word to by prolonging the vowel slightly and while doing so, attends to proprioceptive feedback related to the articulatory transition that occurs between the /u/ in to and lip closure associated with the production of the [w] in Washington. The speaker’s primary objective is to approach the point of maximal lip closure for [w] in a slower-than-typical, controlled, intentional manner. In this example, use of rate adjustment in combination with proprioceptive monitoring increases the likelihood that the speaker will produce this portion of the utterance seamlessly and without excessive muscle tension. This outcome is likely to be much less disruptive to communication that the alternative, which was anticipated to be a part-word repetition. The speaker uses a similar approach for Baltimore. In this case, the speaker increases the duration of the syllable [æn] (the [d] in “and” most likely is lost to coarticulatory effects) and while doing so attends to proprioceptive feedback related to the articulatory transition that occurs between the /n/ in an’ and the lip closure associated with the production of the [b] in Baltimore. Thus, this portion of the utterance is said seamlessly as follows: aannBBaltimore (where the consecutive “B” characters indicate slow, deliberate lip closure on the [b] sound. Preventing Impending Anticipated Stuttering by Attending to Proprioceptive Feedback. A second approach to managing these disfluencies would be to forego slowing of articulatory rate and instead simply attend to the articulatory movements that occur at the transitions leading into the initial syllables of both Washington and Baltimore. With this approach, the speaker would maintain the articulation rate from the first half of the sentence but simply would observe (i.e., self-monitor) movement velocity associated with vocal tract closure for the [w] and [b] in the two words. With this second approach, the listener would be unaware that the speaker had managed instances of anticipated stuttering-related disfluency. The speaker would, of



15.  Intervention Principles and Strategies for Helping People Who Stutter

course, be very aware of the management effort, because the essence of the treatment strategy is directed attention. Managing anticipated disfluency in this manner would likely follow extensive practice with the first approach (management of anticipated disfluency using slowed articulation and proprioceptive monitoring). Slow transitions are progressively shaped into transitions that occur at the speaker’s habitual or natural articulation rate, and throughout the process, the speaker monitors aspects of movement velocity, articulator location (proprioception), and, perhaps, force at the point of vocal tract constriction. Targeting Utterance Locations That Are Prone to Stuttering-Related Disfluency. As noted, speakers who stutter also can regulate articulatory movements at utterance locations that are prone to stuttering-related disfluency (e.g., syllables at the start of each breath group, stressed syllables in utterance-initial prosodic phrases). With this approach, the speaker deliberately reduces articulation rate at these utterance locations and then returns to using a typical articulation rate throughout the remainder of the utterance. In the paragraph in Example 15–3, the underlined text indicates the locations where the speaker would deliberately reduce articulation rate, regardless of whether stuttering-related disfluency was anticipated. In each of the sentences, the underlined text corresponds to the transition into the stressed syllable of the phonological word that leads off each sentence as well as the stressed syllable itself (e.g., “The children” = [ðə.tʃIl.dZrIn]). In each case, the speaker would slightly prolong the vowel in “the” and then monitor articulatory movement associated with the approach to the place of articulation for following consonant (e.g., “the family” would sound like theeefffamily).

Example 15–3: The children chi begged their parents for a new dog. The family fa looked all over to find the perfect one. The dad was hoping to get a dog that was not too big and not too small. The family fa wanted a smart dog that was good with children.

Develop the Client’s Ability to Modify Pause Frequency and Duration Although regulation of articulation rate is used commonly as a treatment for stuttering, there are other treatments that entail regulation of speech production (Bothe et al., 2006). This section discusses how clients can modify pause behavior intentionally to facilitate stuttering management. As discussed in Chapter 2, pauses are disfluencies that are characterized by a gap of silence that occurs within the boundary of an utterance or between two consecutive utterances and exceeds some predetermined duration (e.g., >250 ms; >333 ms). Although pausing is indicative of disfluency, pausing usually is not indicative of stutter-like disfluency. Clinicians can teach speakers who stutter to modify pause frequency and/or duration intentionally to facilitate fluency functioning. Using Pausing to Reduce Speech Rate and Alter Phrasing Patterns. The paragraph in Example 15–4 contains four sentences, each of which contains more than 10 syllables. Most adult speakers would read the paragraph using a pause after each of the first three sentences (see the [pause] inserts in the following example). Thus, the typical phrasing for this paragraph when read aloud would consist of four relatively long runs of speech. Clients who stutter can modify the phrasing pattern of the paragraph by intentionally inserting pauses at ends of some syntactic phrases within these sentences (see the ^ inserts in the example). In doing so, clients reduce speech rate (which is likely to facilitate speech fluency) and phrase length (which is also likely to facilitate speech fluency).

Example 15–4: The children begged their parents ^ for a new dog. [pause] The family ^ looked all over ^ to find ^ the perfect one. [pause] The dad ^ was hoping to get a dog ^ that was not too big ^ and not too small. [pause] The family ^ wanted a smart dog ^ that was good with children. Pause insertions like these can be practiced first with reading passages — clinicians or clients can

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mark the pause locations and then read the passage aloud. After the client becomes familiar with the strategy and implements it consistently, practice activities can be extended to narratives and to conversations of varying lengths. Using Pausing to Slow Conversational Pace. Clients also can practice deliberately increasing the duration of turn-switching pauses that occur between the end of the partner’s utterance and the start of the client’s following utterance. Speaking in this manner slows the pace of the conversation, and in doing so, may facilitate fluency by tempering the effects of temporal constraints on the client’s application of stuttering management skills. This skill first should be practiced in structured activities within the treatment setting (e.g., clinician-client conversations) and then systematically applied to real-world settings.

Develop the Client’s Ability to Regulate Syllable Timing Patterns With this stuttering management strategy, the speaker focuses on regulating the rhythm of syllables within a spoken utterance. In contemporary practice, it has been used as a “stand-alone” treatment (Andrews et al., 2012; Andrews et al., 2016; Ingham, Sato, Finn, & Belknap, 2001; Trajkovski et  al., 2011). Syllable-timed speech (also referred to as rhythmic stimulation) sometimes first is established by asking a client to speak in time to a metronomic beat (or to some other type of periodic beat). The beat may be relatively slow at first (e.g., 70 beats per minute) and, then, after the client establishes the ability to time syllable production to the beat, the pace of the metronome is increased (e.g., 140 beats per minutes). When the skill is well established, the metronome is withdrawn, and the speaker attempts to generate and maintain the syllable-timed style of speaking independently in contexts such as oral reading, narration, and conversation. Andrews et al. (2012) reported favorable preliminary treatment outcomes when using a syllable-timed speech approach with school-aged children who stuttered. The children had learned to produce the speech pattern after being presented with a clinician-provided model. In a follow-up study with 19 school-aged children

who stuttered, Andrews et al. (2016) reported on a parent-administered treatment that incorporated syllable-timed speech in combination with verbal contingencies for stuttered speech and stutter-free speech. Overall, stuttering frequency decreased by nearly 80%, and more than half of the participants reduced situational avoidance. Other studies have demonstrated that when adult clients are provided with clinician feedback on their speech naturalness, they can shape syllable-timed speaking patterns, which sound unnatural at first, into natural sounding speech (Ingham et al., 2001).

Interventions That Target Speech Breathing and Phonation The strategies described in the preceding section focused largely on speech articulation. With other strategies; however, the focus in on speech breathing and/or phonation. Interventions That Target Speech Breathing. Regulation of speech breathing also has been used to treat stuttering (e.g., Blood, 1995b; Elliott, Miltenberger, Rapp, Long, & McDonald, 1998; Gagnon & Ladouceur, 1992). The strategy relies largely on teaching the speaker who stutters to monitor and/ or alter temporal aspects of speech breathing or the position of the chest wall or the abdomen while inhaling or exhaling during speech. On the expiratory portion of a breathing cycle, the goal is to maintain a steady, smooth return to resting level over the course of the utterance. There is some evidence to support the use of treatments that involve regulated breathing (Bothe et al., 2006); however, some of these treatments (e.g., Azrin & Nunn, 1974) appear to incorporate fluency management strategies that go beyond breathing regulation, which makes it challenging to evaluate the contribution of the breathing component in the participants’ fluency improvement. Interventions That Target Phonation. Other treatment approaches incorporate regulation of vowel duration as a means of improving fluency with speakers who stutter. With some approaches, the aim is to increase vowel duration. Such approaches are similar to regulated articulation rate, described earlier, because vowel duration is inextricably tied to articulation rate. The intended effect



15.  Intervention Principles and Strategies for Helping People Who Stutter

of both treatments is similar: slower speech. Still other treatments have targeted the amount and type of vocal fold contact being made. Some older approaches attempted to have speakers initiate phonation in a breathy manner (e.g., Schwartz, 1977). Approaches like this are essentially targeting the temporal relationship between the onset of expiration and the onset of phonation for speech. For vowel-initial words (e.g., on, apple), vocal rise time also can be targeted, with the goal being for the speaker to gradually increase the intensity of phonation — a goal that entails coordination between speech breathing and vocal fold tension and approximation. The evidence base for use of the latter techniques as a primary treatment for stuttering is lacking. Further, there is little evidence to support the idea that speakers who stutter routinely present with unusually excessive tension in lip, jaw, or neck musculature or, necessarily, during all instances of stuttering-related disfluency (Denny & Smith, 1992). In contrast, Ingham and colleagues (Ingham et al., 2001; Ingham, Ingham, Bothe, Wang, & Kilgo, 2015) reported improved fluency with speakers who stuttered following a treatment that entailed computer-based feedback, which helped speakers to reduce the frequency with which they produced short intervals of phonation and, instead, sought to maintain a continuous stream of phonation over multisyllable segments of speech.

The Speaker’s Experience of Speech Regulation To people who do not stutter, the act of regulating speech production may seem straightforward. This is reflected in the advice that well-meaning parents often dispense to children who stutter: “Just slow down”. For the speaker who stutters, however, the act of consistently monitoring speech, hour by hour, day after day, can be quite taxing. A rough analogy of the experience is to ask a person to begin walking about 10% slower than he or she normally does. This request may not be so difficult to fulfill in a quiet work setting with few distractions or during a solo leisure activity. However, it becomes much more difficult to do when the walker is required to maintain the slow pace during all activities and throughout the duration

of the activity — when crossing busy streets, when attempting to catch buses that are about to leave, and when joining an exercise partner for a daily fitness walk around the neighborhood. Not only is this type of self-regulation difficult to maintain, but it feels unnatural to do, as well. The challenges associated with “just walk slowly” are quite apparent in this example. The process of regulating speech production is very similar to the “just walk slowly” example described in the preceding paragraph. It can seem effortful to do, difficult to maintain in all situations, and can feel unnatural (Finn & Ingham, 1994). In cases of persistent stuttering, the need to regulate speech production continues across the life span (Anderson & Felsenfeld, 2003; Plexico et al. 2005). Although implementation of stuttering management strategies may become easier after extensive practice, it is critical for clinicians, parents, teachers, and indeed even the client to understand the challenges associated with implementing stuttering management strategies. Inattention to this aspect of treatment can lead to unrealistic expectations of what a client should be able to accomplish via regulated speaking approaches. That said, a speaker may tolerate some types of regulated speech (e.g., modified phonation intervals, syllable-timed speech) better than others (e.g., prolonged speech); thus, clinicians should routinely engage clients in discussion about their perceptions of and experiences with the stuttering-management strategies that they are learning to use.

Intervention Principle 7: Help the Client Develop Skills That Modify Unproductive Responses to Stuttering Overview and Rationale For those who lack effective skills and strategies for managing the effects of fluency impairment, the act of speaking often is effortful — so much so that some individuals may regard certain utterances as being nearly impossible to say. Many individuals also find stuttering to be embarrassing or shameful, and anx-

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iety provoking, in large part because the reactions they receive from their communication partners can be quite discomforting. Of course, many individuals are not deterred because speaking is effortful, embarrassing, shameful, or anxiety provoking. Rather, they enter therapy having discovered their own solutions for making speaking less effortful and less emotionally distressing. These solutions are essentially the client’s responses to stuttering. The problem that most clients encounter, however, is that their self-devised responses to stuttering are, at best, only partially effective. This can lead clients to become anxious about whether their self-devised stuttering management response will “work” in a given situation; and when it does not “work,” it can trigger feelings such as helplessness, confusion, and panic, which are likely to exacerbate the effects of fluency impairment. Some client-devised responses to stuttering, particularly those that involve attempts at concealing fluency impairment from communication partners through strategies such as word and situational avoidance, are simply unproductive; although they may shield the client temporarily from experiencing intense negative emotions, they create more problems than they solve by adding to the client’s communication disability. For these reasons, many intervention plans for people who stutter include treatment activities that are designed to help clients identify and then modify current responses to stuttering that either are ineffective or unproductive, and hence exacerbate or maintain the client’s stuttering-related disability.

Implementation Develop the Client’s Ability to Identify, Describe, and Evaluate Current Stuttering Behavior In Van Riper’s (1973) classic text, The Treatment of Stuttering, identification of stuttering-related behavior is one of four central stages or intervention components. The concepts that Van Riper described revolve around strategies for helping clients modify how they stutter, with the overarching goal being the reduction of communication disabil-

ity (as opposed to the reduction or elimination of stuttering-related disfluency). The essence of Van Riper’s intervention approach is this: “It’s not a matter of if you stutter, but rather how you stutter.” Van Riper’s intervention concepts and practices remain in use today, and they constitute the basis of the discussion here. The primary goal behind stuttering identification is for clients to develop the ability to label and describe their current stuttering-related behavior accurately and objectively. In doing so, the client acquires a precise understanding of how he or she currently stutters, and in doing so, can develop insight into which aspects of his or her stuttering behavior can be modified to improve overall communicative functioning. As noted earlier under Intervention Principle 1, the ability to describe stuttering-related behavior objectively serves to counter the sometimes intense negative emotions that surround a client’s stuttering. Van Riper organized the identification of stuttering-related behaviors around three subobjectives: (1) identification of fluent speech and “easy stuttering”; (2) identification of avoidance/concealment behaviors; and (3) identification of behaviors that constitute “core” stuttering-related disfluency. Examples of each category of behavior can be gathered in the context of informal, in-clinic conversations. If necessary, the client can first identify the behaviors in the clinician’s speech, and then the clinician and client can work toward identifying them in the client’s speech. These activities then are extended by having the client record examples of his or her speech in situations beyond the clinic, for the purpose of identifying fluent (non-stuttered) segments of speech, easy stutters, avoidance behavior, and core disfluencies. Van Riper cautioned clinicians that activities that require clients to confront their stuttering-related behavior directly can unleash intense, uncomfortable emotion. Thus, the clinician should proceed thoughtfully, deliberately, and respectfully when conducting such activities, particularly when the clinician is asking the client to listen to or watch recordings of his or her own stuttered speech. Self-observation of stuttered speech should be introduced gradually and with the full, informed consent of the client. Figure 15–4 illustrates the main structure and associated clinical methods for this aspect of treatment.



15.  Intervention Principles and Strategies for Helping People Who Stutter

Figure 15–4. Areas to focus on when helping people who stutter identify their current stuttering-related behaviors. Van Riper (1973) described these areas as part of the identification component of his intervention approach for stuttering.

Help the Client Reduce Sensitivity to Stuttering-Related Disfluency One approach to helping clients reinterpret their stuttering-related experiences is by helping them change how they react when stuttering occurs or is expected to occur. The main goal is to help clients move toward reacting to speech disfluency from an objective, problem-solving orientation, rather than from an emotional perspective (e.g., “Okay, my speech is stuck. Here is what I am going to do.” vs. “Oh no, I’m stuttering! What can I do?”). The use of desensitization in the treatment of stuttering is long-standing. For example, Van Riper (1973) devoted an entire chapter to desensitization in his text on treatment approaches for stuttering. Throughout the years, Van Riper and other clinicians (e.g., Beilby & Yaruss, 2018; Guitar, 2014; Sisskin, 2018) have described an assortment of methods that are effective for reducing client sensitivity toward stuttering. Examples of several such methods follow: Create a Context That Is Supportive of the Client’s Attempts to Communicate. At the beginning stages of treatment, many clients who stutter are likely to experience stuttered speech as something that is undesirable, unacceptable, or

shameful — in short, as something that is “not okay.” Clinicians, parents, and others who are involved in the intervention program can counteract this type of client sensitivity to stuttering by creating a supportive communication environment (see Intervention Principle 2) — one that is accepting of the client’s stuttering — and offering consistent demonstrations of calm, patient, empathetic responses to the client’s fluency difficulties. Clients are urged to stutter openly in the presence of the clinician (as opposed to concealing stuttering-related disfluency through strategies like word-avoidance) because open expression of stuttered speech provides the clinician with insight into the client’s fluency difficulties and fosters the clinician’s ability to assist the client in reaching his or her communication goals. Practice Deliberately Manipulating Stuttering-Related Disfluency. The goal here is to provide clients with the experience of producing stutter-like disfluency in a context of limited emotional arousal. After explaining the activity to the client, the clinician engages the client in conversation, and then, when an instance of stuttering-related disfluency occurs, signals the client to deliberately hold or extend the disfluency for many seconds, until it appears that any excessive physical tension and/or emotional arousal

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associated with the disfluency has dissipated. Clients sometimes signal that this has occurred by smiling or laughing after holding a disfluency for what seems like, to them, an absurd amount of time. As this activity is repeated often over time, clients accumulate experience with producing stuttering-related disfluency with minimal physical and emotional arousal. An extension of this activity is to have the client purposefully vary parameters of speech such as repetition rate, muscle tension, and vocal pitch while purposefully holding out the disfluency (Guitar, 2014). Such manipulations are designed to develop the client’s sense of control over the way disfluency is expressed. The establishment of an internal locus of control (i.e., one’s belief that “I am in control of this.”) has been associated with how favorably adults who stutter respond to the adversities that come with a lifetime of stuttering (Craig, Blumgart, & Tran, 2011). In addition to creating a more positive emotional context for talking, over time, such experiences are likely to facilitate the client’s use of other stuttering management skills. Purposeful extension and manipulation of stuttering-related disfluency functions as a precursor to more advanced skills such as “pseudostuttering” and “voluntary stuttering,” which some clinicians use to help clients become desensitized to stuttering. Develop the Clients’ Knowledge About Their Stuttering and About Other People Who Stutter. Activities that target the development of an accurate, fact-based perspective on speech production, fluency, stuttering, and the experience of other people who stutter are likely to help clients view stuttering objectively — as a problem to be solved rather than as a mystery to be feared (see Intervention Principle 1.) As described in previous chapters and earlier in this chapter, there are assorted ways to help clients build such knowledge. With teens and adults, discussion, reading activities, and Internet research are useful resources. Murphy, Yaruss, and Quesal (2007a) published a helpful case report on an 8-year-old boy who exhibited negative scores on a scale of communicative attitudes and expressed other concerns verbally about his stuttering. Murphy et al. designed a treatment plan that included both speech management strategies

and strategies that were designed to reduce the child’s sensitivity to stuttering. The plan included elements such as the following: (1)  opportunities to interact with other people who stutter via a pen-pal activity; (2) participation in a therapy group that includes other children who stutter; (3) opportunities to experience stuttering in the absence of emotional arousal via pseudo-stuttering with the clinician and by deliberately manipulating the characteristics of authentic stutters (e.g., purposefully making them longer, more tense, less tense); (4) labeling and discussion of the emotions that are present during instances of stuttering; and (5) opportunities to disclose stuttering to others and to challenge inaccurate or unproductive “selftalk” related to stuttering (e.g., “I’m dumb because I stutter.” vs. “Stuttering has nothing to do with how smart I am.”). Posttreatment data showed positive changes in both the child’s stuttering frequency and communication attitudes’ and at a 1-year follow-up assessment, he continued to participate regularly in class activities and felt confident about his ability to manage stuttering successfully. Teach Clients How to Assert Their Feelings and Wishes. With clients who are seeking to change how family members, friends, classmates, coworkers, and others respond to stuttering, it may be necessary to help the client develop the ability to assert his or her feelings and wishes directly in real-world settings (Schloss, Espin, Smith, & Suffolk, 1987). Many people, even those who do not stutter, find it difficult to engage in assertive behavior of this sort. With practice, however, clients can learn to express their feelings and wishes by (a) informing the communication partner what he or she is doing (e.g., “I noticed that you often interrupt me when my speech is blocked on a word.”); (b) informing the communication partner how this behavior affects the speaker (e.g., “This causes me to try to speak faster, which leads me to block longer and harder.); and (c) informing the communication partner what the speaker would like him or her to do instead (e.g., “I’d prefer it if you wait until I finish saying the word.”). Clinicians can help clients develop their ability to produce statements like this in role playing activities within the clinic, and then gradually extend the skill to situations where the client uses assertive statements with self-



15.  Intervention Principles and Strategies for Helping People Who Stutter

selected “safe communication partners,” and then eventually with other individuals at times when such statements are necessary to produce. Schloss et al. (1987) examined the effects of a training program in which adults who stuttered learned to produce assertive behavior like that described here. The participants received more favorable interview ratings when using assertive behavior than they did when not making such comments. Organize Practice Activities Hierarchically. The goal here is to help clients become desensitized to stuttered speech and listeners’ reactions to stuttered speech by organizing speaking tasks hierarchically so that they progress from “little stuttering–limited emotional reactivity” in the early stages of a therapy program to “more stuttering–a lot of emotional reactivity” in the later stages of therapy. In this way, clients are performing in situations that are not likely to be completely overwhelming to them in terms of the amount of stuttering or the intensity of emotional reaction to stuttering that occurs. As clients develop proficiency with communication in less challenging contexts, they gradually enter into more challenging contexts. Many factors can determine the extent to which a speaking task is perceived by a client as “more challenging” or “less challenging,” and clients’ predictions about what will be challenging are not always accurate. Nonetheless it is worthwhile to organize speaking activities in this stepwise fashion so that clients have a reasonable chance of reaching the specific stuttering management goals they are pursuing. Examples of factors around which to construct activity hierarchies include the following:

• Who the communication partner is (progress from less difficult partners to more difficult partners; partner difficulty may be based on an individual’s speech rate, how a communication partner responds when the client stutters, how fluently the individual expects the client to speak, and so forth); • How many communication partners are in the interaction (progress from one to a few to a small group to a large group); and • The amount of information that a communication partner is requesting (progress

from requests that can be answered in a few words to requests that require long responses). Help Clients Become More Open About Their Stuttering.  Other strategies for reducing clients’ sensitivity revolve around increasing the extent to which clients reduce the use of avoidance and concealment strategies, and increasing the extent to which they reveal their stuttered speech and status as a person who stutters to other people. Examples of two strategies that promote this goal are voluntary stuttering and disclosure. With voluntary stuttering, the client purposefully introduces stutter-like disfluency into speech during conversation. Initially, the voluntary stuttering is at a severity level that is milder than the client’s current performance; and then, as the client becomes more comfortable with speaking in this manner, he or she is encouraged to make the voluntary stutters approximate the client’s actual stuttering more closely. The rationale behind the technique is that purposeful production of a feared behavior (in this case, stuttering) will lessen the fear of it over time. When a client is less fearful of stuttering in front of others, he or she will be better able to employ fluency management skills. Self-disclosure entails briefly revealing one’s identity as a person who stutters. Self-disclosure can be accomplished in a variety of ways (e.g., through a statement on a T-shirt, through verbal comments such as “I stutter sometimes,” by telling others about one’s participation in stuttering therapy). Clients should be involved in setting the parameters for self-disclosure (e.g., who they will disclose to, in which setting disclosure will occur, how disclosure will be accomplished). In the author’s experience, clients generally find self-disclosure easier to do than voluntary stuttering. A primary benefit of self-disclosure is that it removes doubt in the client’s mind about whether the listener knows (or cares) that he or she stutters. In the author’s experience, self-disclosure almost always is met with a positive response from the communication partner, and as such, clients may report a sense of relief in knowing the partner is supportive and perhaps even eager to learn more about stuttering and what can be done to help people who stutter.

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Voluntary Stuttering: “You Want Me to Do What?” In the author’s experience, many speakers who stutter (not to mention, many clinicians) find voluntary stuttering very challenging to do, and many clients do not appreciate the rationale for the technique or its potential benefits, even after extensive explanation. A recent survey of 206 adults who stuttered confirmed this view (Byrd, Gkalitsiou, Donahur, & Stergiou, 2016). For these reasons, it is not advisable to push voluntary stuttering on a client who is uncomfortable with the approach; and if the strategy is to be used, it is best implemented after or in conjunction with other elements of the intervention plan, particularly those that focus on identification and modification of stuttered speech, and the thoughts, beliefs, and feelings that the client has about being a person who stutters. Murphy, Yaruss, and Quesal (2007a) used such an approach when they combined traditional desensitization and stuttering modification strategies with a cognitive restructuring treatment. A preliminary step to voluntary stuttering would be for the client to introduce pseudo-stuttering into his or her speech while talking with the clinician. Much of the data to support voluntary stuttering is anecdotal, case-based, or from self-reports in surveys. In survey results from Byrd et al. (2016), adults who used voluntary stuttering reported implementing it in a variety of ways (e.g., some only in-clinic; some in and out of clinic), and most individuals who reported using voluntary stuttering indicated that they did so sparingly (e.g., only a few times per week or month) and in conjunction with feared speaking situations. These individuals reported receiving benefits from voluntary stuttering across a range of contexts, including public speaking and speaking on the phone. Despite these encouraging reports, clinicians should monitor the client’s response to voluntary stuttering carefully if they are encouraging a client to use the technique.

Develop the Client’s Ability to Modify Instances of StutteringRelated Disfluency As noted earlier, many speakers who learn to produce controlled fluency using regulated speech continue to exhibit residual stuttering (and, sometimes, a lot of residual stuttering). This is not unexpected or a sign that the treatment “doesn’t work.” It merely underscores the limitations of using behavioral interventions to treat neurodevelopmental disorders like stuttering. Many contemporary treatment protocols incorporate goals that are aimed at helping clients manage instances of stuttering-related disfluency in ways that minimize their impact on communication. Three main strategies for modifying instances of stuttering-related disfluency are cancellation, which is essentially a purposeful, controlled “do over” of a stuttered disfluency; pullout, which is essentially a purposefully within-stutter shift to a voluntary, controlled from

of stutter-like speech; and preparatory set, which refers to fluency facilitating adjustments that a speaker makes in advance of an word upon which stuttering is anticipated.

Help the Client to Interpret StutteringRelated Experiences Constructively As noted elsewhere in this book, fluency impairment can lead to broad-based communication disability and associated problems such as social anxiety disorder, underemployment, and poor selfratings of health and quality of life (Bray, Kehle, Lawless, & Theodore, 2003; Craig, 1990; Craig, Blumgart & Tran, 2009; Mulcahy, Hennessey, Beilby, & Byrnes, 2008; Vanryckeghem & Brutten, 1996; Yaruss & Quesal, 2006). These issues can persist into adulthood even after an individual has completed speech therapy (Craig et al., 2011). Given the range of adverse effects that stuttering can have on an individual’s functioning, it is not



15.  Intervention Principles and Strategies for Helping People Who Stutter

surprising that clients who stutter also are at risk for developing thoughts and beliefs about stuttering that can distort their speaking experiences in ways that amplify the effects of fluency impairment and hinder response to treatment. Sheehan (1970) captured this scenario neatly by likening a speaker’s experience of stuttering to that of an iceberg, wherein the speaker’s speech disfluencies are above the surface and available for all to see, while the bulk of the problem — the speaker’s thoughts, feelings, and beliefs about stuttering, and tricks and false roles to hide stuttering from others — are hidden beneath the surface. The iceberg analogy reinforces a theme that is repeated in many places within this text: The sound of a person’s speech is not always a good indicator of how a person feels about his skills as a speaker or, more broadly, about his value as a person. Although improvements in speech fluency through participation in fluency therapy may help to improve some aspects of a speaker’s social, emotional, and cognitive variables (Bothe et al., 2006), clinicians should be alert to the possibility that large swaths of stuttering-related disability remain hidden below the surface. The SLP’s challenge is to help clients shift their thoughts about stuttering away from how stuttering feels toward a problem-solving orientation, in which the client’s main focus is on objectively evaluating communication performance in terms of its relationship to the client’s long-term communication goals. In contemporary clinical practice, social, emotional, and cognitive variables are not typically the sole focus in intervention plans that are designed for stuttering. As has been demonstrated in previous chapters, stuttering is not fundamentally an emotional or a psychological disorder. Nonetheless, social, emotional, and cognitive variables can contribute greatly to the communication-related disability clients experience. Consequently, issues such as these have received an increasing amount of attention in the treatment literature on stuttering. For example, in recent years, research studies have been conducted to examine the effects of treatments such as Cognitive Behavioral Therapy (CBT; e.g., Klein & Amster, 2018) and Acceptance and Commitment Therapy (Beilby & Yaruss, 2018) on the communicative functioning and psychosocial well-being of people who stutter. Such

treatments will be discussed in more detail in Chapter  16. For now, however, it suffices to say that clients’ thoughts and beliefs about stuttering are intertwined with their feelings and emotions about stuttering, and each of these are associated with the manner and extent to which clients react to their stuttered speech and their communication partners’ reactions to stuttered speech. Clients’ thoughts, feelings, and beliefs about stuttering are also predictive of how willing they will be to embrace the use of desensitization strategies such as self-disclosure, pseudo-stuttering, and voluntary stuttering. Simply put, clients who feel ashamed to be a person who stutters and who expect to receive negative reactions from their communication partners when they stutter are unlikely to embrace the use of strategies that require them to tell or show other people that they stutter. Thus, in intervention, it is helpful to tackle clients’ stuttering-related thoughts, stuttering-related feelings and beliefs, and approaches to stuttering management in tandem, with the idea that changes in any one of these elements will result in changes to the other elements. This concept is illustrated in Figure 15–5.

Figure 15–5. Areas to target when attempting to help clients who stutter interpret and respond to their stuttering-related experiences in a constructive way.

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Intervention Principle 8: Develop the Client’s Ability to Apply Stuttering Management Skills in Natural Settings Overview and Rationale All intervention activities are aimed ultimately at the complementary goals of improving communication functioning and reducing stuttering-related disability in real-world settings. These issues are discussed in this section.

Implementation This chapter and previous chapters have discussed factors that are important in helping clients translate skills and strategies they have developed in the therapy setting into changes in their speaking performance in real-world environments. Primary strategies for helping to bring this about include the following: • Help clients identify their routine daily activities that entail speaking, and then rank them in terms of perceived difficulty and importance.  Generalization of newly acquired stuttering management skills typically is arranged hierarchically. The daily activities that are targeted first for generalization tend to be those that the client considers to be relatively easy, either in terms of the amount that the client stutters and/or the intensity of emotions the client experiences in the setting. After rankordering daily activities, the clinician and client establish specific objectives the client will attempt to meet in the setting. • Help the client to remain focused on the primary intervention goals.  As indicated in previous chapters, for clients who are beyond the preschool years, the primary goals of intervention are generally to improve communication functioning and, by inference, reduce stuttering-related disability. For most clients, the objective of generalization activities should not be for

the client to speak in an entirely stutter-free manner (this is seldom attainable, at least in the early stages of generalization) or to speak in a way that conceals stuttering from the listener (this type of goal perpetuates negative emotions such as stuttering-related shame or anxiety). It is important for clients to understand that the goal of improving communication functioning differs significantly from the goal of “normalizing fluency.” The latter goal often is driven by stuttering-related shame and anxiety, feelings that are part of stuttering-related disability. As these feelings dissipate (and clients will want them to dissipate), clients will realize that a person can stutter and, at the same time, communicate effectively and experience little to no disability. From this perspective, the simple act of participating in an activity that the client has been avoiding for several month can be seen as a step toward “reducing stuttering-related disability,” regardless of how fluently the client speaks while participating. • Help clients select generalization activities that are important to them.  In the author’s experience, clients respond favorably to the generalization stage of intervention when at least some of the real-world activities that are targeted are ones that the client considers important to address now, regardless of how demanding they are. These activities may be quite narrow; for example, they might include how to deal with the severe disfluencies that arise when the client is reciting an employer’s required script for telephone greetings; how to stutter less severely when ordering food at a local fast food restaurant; how to manage a class presentation that is only a few weeks away. Activities like these are important to the client usually because of the frequency with which the client encounters them, the extent to which the client has received negative listener reactions previously in the setting, and the extent to which the client feels unable to remain in charge of his or her speech fluency while talking. Some clients



15.  Intervention Principles and Strategies for Helping People Who Stutter

have only a handful of the latter types of activities, so a general guideline is to target mainly activities that are appropriately challenging, but to also include one or two activities/situations that the client regards as very challenging yet very important to address. • Help clients learn how to dissect generalization activities into substeps or subcomponents.  Most clients find it difficult to step directly from the controlled environment of the clinic into real-world settings and apply their newly learned stuttering management skills with same degree of proficiency. Clinicians can help clients succeed at generalization by showing them how to dissect the activities that have been selected for generalization into smaller elements, each of which can be the focal point for intervention. For instance, for a client who is stuttering more severely than he or she would like when reciting an employer-required greeting script on the phone, the clinician can help the client identify one or two key syllable transitions that the client will attempt to modify in a way that leads to less severe stuttering (even if the modification does not result in perfectly fluent speech); or the clinician can demonstrate to the client how the use of a pause prior to initiating the script can counteract the client’s well-ingrained belief that he or she is essentially at the mercy of the speaking partner and must talk in the way that the client thinks the speaking partner wants the client to talk (e.g., by commencing speech promptly). An approach like this helps clients to see stuttering management as a series of incremental changes, as something that occurs gradually on a relatively protracted time scale. This perspective is useful, as it can help the client remain motivated to implement stuttering management strategies long after formal treatment ends. • Recruit communication allies who can support the client during generalization activities.  It is said that there is strength in numbers. Clients may find it less daunting

to complete certain generalization activities when they are accompanied by another person (e.g., another client who stutters, a “fluency buddy” from the classroom, their teacher) during the activity. The individuals can assume a variety of supportive roles (e.g., listening empathetically as the client conveys his or her trepidations about completing the activity; reinforcing personal qualities such as bravery, courage, and resilience) that are needed to complete such activities. • Help the client create and stay with a generalization plan.  As with fitness plans and dieting, implementation of generalization activities in stuttering intervention is not something that just happens. It requires dedication and planning on the part of the client and accountability to others (e.g., the clinician, other clients who stutter, one’s personal goals). For this reason, it is helpful to have clients create a system for planning and evaluating generalization activities. Systems like this can assume many forms: “activity logs,” “generalization calendars,” “speech diaries,” and so forth. In general, the simpler the system, the more likely the client is to use it regularly.

Intervention Principle 9:  Develop the Client’s Ability to Maintain Stuttering-Related Improvements after Intervention Ends Overview and Rationale Helping clients maintain the gains they have made in treatment has been an issue of long-standing interest in the stuttering treatment literature. The aim, of course, is to help clients expand upon the gains they have made in an intervention program so that in the months that follow, stuttering-related disability continues to gradually diminish, and communication functioning continues to improve. Relapse is a genuine concern, and it has been documented often in the treatment literature.

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Implementation Clinical authorities have devised a number of strategies to help clients maintain treatment gains after their regular treatment sessions end. These include the following: • Build in follow-up visits and opportunities to refresh stuttering management skills and collaborate with the clinician to troubleshoot fluency challenges.  As the client’s participation in formal, regularly scheduled treatment sessions winds down, clinicians can work with clients to set up follow-up visits and, perhaps, refresher sessions. Follow-up sessions can be conducted via telephone or in-person. In research studies, posttreatment follow-ups typically are scheduled at 6 and 12 months after formal treatment ends. These sessions provide the clinician with the opportunity to reassess the client’s functioning, to field questions that the client may have about ongoing stuttering management, and to offer suggestions. Clients are typically brought into the maintenance process by being asked to brainstorm potential solutions to fluency challenges, to analyze situations to identify obstacles to success, and to implement and evaluate the effects of new strategies to manage persisting challenges. • Help former clients establish a support network.  In the months that follow completion of a formal stuttering intervention program, former clients will likely to find it beneficial to meet periodically with other people who stutter. These individuals can provide support to former clients in dealing with the often-challenging task of maintaining communication changes independently. Establishment of a support network can be accomplished in many ways, including the following: participating in local self-help groups for people who stutter, attending conferences that are geared toward individuals who stutter, reading blogs that deal with stuttering, and watching and listening to podcasts that deal

with stuttering. Through activities like these, clients will find that stuttering management often continues well after formal treatment ends, and that many people who stutter are experiencing — and responding constructively ​— to the same challenges that they face. • Make referrals to other professionals, if necessary.  In the author’s experience, changes to stuttering-related feelings and emotions tend to occur on a more protracted timescale than changes in speech mechanics do. Although the activities included in an intervention plan can facilitate positive changes in how clients think and feel about stuttering, some clients may benefit by participating in psychosocial counseling, either while the intervention program is occurring or after it concludes. Topics that may be addressed through counseling are wide-ranging, but often include issues related to self-acceptance (e.g., giving oneself permission to be a person who stutters), management of stuttering-related anxiety (e.g., dealing with negative or hurtful listener reactions), and overcoming shame or depression that is intertwined with stuttering. • Welcome opportunities to consult with former clients.  Clinicians who specialize in working with people who stutter are likely to find that some former clients will reach out to them for advice on how to deal with challenges or concerns they are facing currently. While many of the inquiries deal with personal speech-related challenges, clinicians even have fielded inquiries from former clients about how to best respond to their preschool-aged child who has begun to stutter. • Encourage clients to support and advocate for people who stutter.  Maintenance of treatment gains can be facilitated for some clients when they make stuttering a central part of their lives. Organizations like the National Stuttering Association offer opportunities for individuals to serve as peer mentors to other people who stutter and to coordinate local support chapters for people who stutter.



15.  Intervention Principles and Strategies for Helping People Who Stutter

Summary The present chapter dealt with foundational issues related to the treatment of stuttering. Nine main intervention principles were presented, each with an accompanying description, rationale, and examples of implementation strategies. Clinicians can use the intervention principles outlined in this chapter as a starting point for designing treatment plans that meet the specific needs of individual clients. Implementation of a comprehensive intervention model reduces the likelihood of administering an intervention that focuses exclusively on the number of disfluencies that a speaker produces. Although impairment in speech continuity is an important contributor to disability in disorders such as stuttering, consideration of other fluency dimensions will target a much broader range of issues that are relevant to the client and his or her family. Organizing intervention around the ICF model (World Health Organization, 1981) provides a framework for developing an intervention plan that goes beyond the speaker’s fluency impairment to consider issues such as how the client performs in real-world activities and how the client’s feelings, attitudes, and beliefs and the actions of other people around the client may impact the client’s fluency functioning. Stuttering now is widely regarded as being a neurodevelopmental disorder that impacts motor system functioning. Thus, a treatment plan that consists solely of activities such as relaxation are unlikely to have as much positive impact on a client’s communication functioning as an intervention that is based on activities that directly target speech motor behavior. It also was suggested that an accurate understanding of the nature of stuttering will facilitate realistic views of treatment success. To date, none of the existing treatment methods for stuttering reliably lead to a normalization of the underlying neurological conditions that cause the disorder. Until such a treatment is developed, the best course of action is to help clients strive for compensated fluency and remediation of any existing maladaptive compensatory or coping strategies. From this perspective, the client’s goal is to function as well as possible given the limitations

of his or her speech production system. Clinicians can counsel clients with regard to issues related to developing realistic long-range goals for treatment and about setting meaningful interim goals, as well. When treatment does lead to normalized fluency, that outcome is, of course, to be celebrated. However, there are many other satisfactory treatment outcomes that clients can attain in which speech fluency is not entirely normalized, and these outcomes can be celebrated as well. Creating a supportive environment, helping clients to become informed consumers, and providing feedback to clients constitute an important foundation for behavioral treatments used with stuttering. As described, feedback is a primary treatment agent in some approaches for treating developmental stuttering. Most behavioral treatment approaches also incorporate the notion of regulating task complexity, at least during early stages of intervention when clients are establishing the capacity to produce basic fluency management skills. Eventually, of course, clients will need to deal with the complexities of real-world communication, and clinicians can help clients accomplish this by developing the client’s use of motor-based strategies that reduce stuttering frequency and help clients to manage stuttering effectively when it does occur. The client then must generalize these skills to daily life. Clinicians can facilitate this process by systematically introducing various fluency stressors into treatment activities. Such an approach, when accompanied by reassurances of a parent’s unconditional support and regard for the child, also may prevent the development of pervasive negative feelings and attitudes about stuttering. Part of creating a supportive communication environment involves the regulation of environmental factors that can hinder fluency functioning. Some of these factors are communication based and can be addressed as needed by working with supportive communication partners on creating a speaking environment that is conducive to the application of fluency management skills. Bullying is another environmental stressor that some clients who stutter encounter, and it can have long-term negative effects on individuals who are targeted. Children who stutter are at greater risk than average to be bullied. Thus, clinicians must

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be alert for evidence of bullying and be prepared to help clients and others respond to it if or when it occurs. Stuttering can have significant negative emotional and attitudinal impacts on affected speakers. Several approaches to helping clients reduce sensitivity to stuttering and reinterpret stutteringrelated experiences were discussed. These included methods of desensitization and basic principles of cognitive behavioral therapy (i.e., cognitive restructuring). Clinicians should be mindful that significant therapy-driven improvement in speech continuity is not always accompanied by comparable improvement in a client’s self-concept, feelings about speech, and communication attitude. For many clients, negative feelings and attitudes about speech communication are as much a part of the disability that comes with fluency impairment as the disfluent speech and thus need to be monitored closely at all points in treatment, including the posttreatment “maintenance” phase. Several approaches to helping clients regulate speech production were described. Skills in this area are a staple of most approaches to intervention for school-aged children, teens, and adults, and there are elements of these skills in some treatment approaches for preschool-aged children, as well. Most forms of speech regulation are targeted at speech articulation, particularly articulation rate. The use of slow articulation rate is a temporary strategy that is designed to introduce clients to the act of regulating speech movements. The long-range goal, however, is for clients to incorporate principles of regulated speech while using a normal rate of articulation and natural sounding speech. Principles of regulated speech often are applied with the goal of helping clients attain smooth, controlled fluency that sounds similar to that of typical speakers. Speakers who stutter also can apply the same or similar strategies to modify instances of stuttering-related disfluency so that these interruptions in speech continuity have less of an impact on a speaker’s communication. As the saying goes, however, “there is no such thing as a free lunch.” Speakers who stutter may find the act

of regulating speech production to be effortful and unnatural. Although this may improve with time, clinicians, parents, and clients should take this into account when setting treatment goals and evaluating treatment outcomes.

Questions to Consider 1. Some intervention practices for stuttering require parents to make lifestyle changes — that is, alterations in the ways that daily activities transpire. Think of times when you have attempted to make lifestyle changes (e.g., changes in your diet, changes in your physical activity level) and then describe how these efforts might be similar to what the parent of a child who stutters must do when trying to manage a communication environment. What parts of your lifestyle changes were difficult to do? How did you maintain your motivation to keep working at change? What role did other people, such as a fitness coach, play in the changes you made? 2. Spend an entire morning trying to speak with a slightly slowed articulation rate (aim for a target that is about 10% slower than your typical rate). Describe your experience. What did it feel like to talk this way? Were there parts of it that you liked or disliked? What would be most challenging about this style of speech if you were asked to implement it every day for several hours at a time? 3. Spend a few days observing the people who you come into contact with on a regular basis. As you observe them, make an attempt to note behaviors or personal qualities they present that would be helpful in times of adversity. What types of behaviors or qualities did you notice? How would these qualities be helpful during adversity? How did these people come to have these behaviors/qualities? Is it possible to help a person develop these qualities if they are not already present?

16 Counseling People Who Stutter

Chapter Objectives

Historical Perspective and Overview

After reading this chapter, readers will be able to: • Describe how counseling fits into intervention plans for people who stutter. • Describe prominent counseling theories and their related assumptions and methods. • Describe how counseling is incorporated into the scope of practice in speechlanguage pathology. • Describe emotions that people who stutter and parents of children who stutter may experience and how these emotions can impact functioning and treatment progress. • Describe basic skills that speech-language pathologists (SLPs) use when counseling clients, their, family members and caregivers. • Describe qualities and interactional skills that are essential to effective client counseling. • Describe ways in which counseling has been applied in treatment programs for people who stutter.

Counseling is one of five primary mental health disciplines  —  with the others being psychiatry, psychology, social work, and marital and family therapy (Sperry, 2010). In the opening chapter of his textbook, The Skilled Helper, Egan (2002) noted that although there is this core set of disciplines that are dedicated to facilitating people’s mental health and helping them manage life problems, there are a host of other disciplines (e.g., teaching, managing, medicine, nursing, pharmacology, occupational therapy, physical therapy, and speech-language pathology), wherein professionals regularly encounter people who are in emotional distress associated with areas of disability or other life challenges. Accordingly, it is important for “second line” professionals like these to demonstrate basic competencies in the counseling arena. In doing so, these professionals are able to engage with students/patients/clients in ways that help those individuals to feel understood and accepted, and perhaps to change their approach to how they respond to the difficulties and challenges they face, particularly in ways that promote self-enhancing

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behavior, a productive lifestyle, happiness, and satisfaction (Egan, 2002; Ellis & Harper, 1975). The roots of what is now called counseling psychology traces back to ancient times. For example, philosophers such as Plato and Aristotle explored psychological states and their effects on human behavior and on the characteristics and effects of interpersonal interactions. Philosophies such as Stoicism, Taoism, and Buddhism grappled with issues such as the relationship between thought and emotion (Ellis, 1989). According to Schmidt (2000), the field of counseling psychology evolved steadily, growing out of work from the fields of vocational guidance, psychometrics, and psychotherapy. The practice of counseling for the purpose of personal enhancement came into its own in the mid-1900s with the advent of Carl Roger’s (1951) person-centered therapy as well as other behaviorally and cognitively based approaches. This evolution has resulted in the development of various distinct approaches to counseling. Authoritative sources typically organize the approaches into categories that are based on their underlying assumptions about the nature of a people’s distress and methods for alleviating client symptoms and/or facilitate their growth (cf., American Psychological Association, 2020; Crowe, 1997; Luterman, 1996; Sperry, 2010). Although counseling approaches have been organized categorically, there still are general similarities both within and across counseling categories, which is the primary focus in this chapter. The practice of counseling as discussed in this chapter largely can be thought of as therapeutic dialogue; that is, it is conversation between the clinician and the client that is intended to help clients discover what matters most to them when it comes to managing stuttering, and what roadblocks stand in the way of helping them think and feel satisfied about their stuttering management efforts and outcomes. Therapeutic dialogue implies that clinicians assume the roles of listener and speaker. In the listener role, the clinician actively works to go beyond simply getting the gist of what a client says, to achieve a level of understanding that also incorporates how the client thinks and feels about what he or she says. In the speaker role, the clinician works intentionally to go beyond being merely a provider of facts and advice, to speaking

with clients in calculated ways that are likely to help the clients clarify their concerns and goals, and discover and implement resources that they possess but seldom use to tackle problems that they currently are avoiding, choosing to ignore, or are unaware of. As will be seen, listening and speaking in this way sometimes plays a critical role in helping clients develop a fresh mindset to go along with their emerging repertoire of stuttering management skills.

An Overview of Counseling Approaches There is no single, unified approach to counseling. Rather, numerous approaches to counseling/psychotherapy have been developed over time, each with its distinct set of methods and assumptions about the root cause(s) of a client’s distress. The American Psychological Association (APA, 2020d) identified five broad categories of counseling. This section briefly reviews these categories and their associated characteristics.

Psychoanalysis and Psychodynamic Therapies Psychoanalytic/Psychodynamic approaches (also called Dynamic approaches; Sperry, 2010), are oriented toward helping people change behaviors, feelings, and thoughts that create problems in life. From this perspective, psychopathology is viewed as resulting from “defensive reactions to anxiety, maladaptive schemas,” or internalization of interpersonal experiences stemming from childhood experiences or from recurring maladaptive relationship problems (Sperry, 2010, p. 39. With this approach, clients and clinicians work together closely in ways that help clients “learn about themselves by exploring their interactions in the therapeutic relationship.” (APA, 2020d). Psychoanalytic approaches to therapy often are closely associated with Freud’s (1901) work on the role of unconscious drives and conflicts in human behavior; however, several other prominent psychoanalytic therapies developed out of Freud’s classic psychoanalytic approach. Crowe (1997) summarized several of these approaches,



16.  Counseling People Who Stutter

including Adler’s (1964) individual psychology, in which therapy is viewed as an educational process wherein clinicians work with clients, helping them correct lifestyle “mistakes” that are a source of the distress or turmoil they are experiencing. Common lifestyle mistakes that might be addressed within Adler’s individual psychology approach include the following: • Making overgeneralizations (e.g., “Employers would never hire a person who stutters.” “People don’t want to listen to people who stutter.”); • Creating unrealistic goals (e.g., “I have to apply my stuttering management techniques at all times.” “I am never going to stutter in front of anyone again.”); • Developing misperceptions of life and life’s demands (e.g., “Life is so unfair.” “Life expects too much from me.”); • Minimizing or denying one’s worth (e.g., “No one really cares what I say.” “I’m not very good.”); and • Developing faulty values (e.g., “I must be better than others in all facets of my life.” “I have to show others that the things I do are better than the things they do.”). In the framework of individual psychology, the clinician works to help the client develop insights into his or her lifestyle by interpreting events from the client’s life in ways that help the client discover roadblocks to problem resolution and personal growth. These roadblocks can be cognitive (i.e., the client’s thoughts or beliefs about a situation), affective (i.e., the client’s feelings and emotional reactions to a situation), and/or behavioral (i.e., self-limiting or self-defeating actions). As the client gains insight into his or her mistakes and recognizes the roadblocks, the clinician helps the client to enact positive, purposeful “reorientation” in everyday activities. Crowe (1997) summarized the types of activities/exercises that are used to facilitate reorientation, including the following: 1

• Progressive approximation:  The clinician helps the client break down long-term goals into discrete, manageable steps that, when accomplished, lead gradually toward the long-term goal in a stepwise progression. • Negative practice:  The clinician encourages the client to perform the behavior (e.g., stuttered speech) in front of others in an intentional and exaggerated manner.1 Negative practice is intended to desensitize the client to the emotions (e.g., anxiety, fear) associated with the targeted behavior, which in this case, is stuttering in front of others, and in doing so, risking the possibility of receiving negative reactions from the listener. • Role enactment:  The clinician encourages the client to act in the manner he or she is striving toward. For example, the client imagines how a person who is comfortable with stuttering in front others would act, and then attempts to act that way in selected real-life situations. • Image creation:  The clinician helps the client create a mental image that contrasts with the client’s current misperception. For example, a client who currently says very little in social situations because of stuttering-related concerns might create an image of a gregarious motivational speaker prior to entering challenging speaking situations. The image is intended to create a humorous counterpoint to tension, fear, or anxiety that the client experiences in relation to the situation, and in doing so, shows the client alternative ways of functioning in that situation. • Self-monitoring and self-regulation: The client practices identifying unproductive behavior and modifying it to something more productive. The client is encouraged to approach this task lightheartedly (e.g., being able laugh at oneself after detecting an unproductive thought of self-defeating

This activity was discussed in Chapter 15 as part of the discussion of voluntary stuttering. Van Riper (1973) encouraged the use of voluntary stuttering as a means of helping clients become desensitized to their stuttering-related disfluencies and to the expectation of stuttering-related disfluency. In Van Riper’s approach, clients first practice producing voluntary stuttering using a milder form of their typical stuttering and then gradually work up to their typical degree of severity. Conversely, in Adler’s (1964) approach, clients begin with an exaggerated (i.e., more noticeable) form of the feared behavior (which, in this case, would be stuttered speech).

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behavior, rather than feeling guilty or disappointed about it). This approach also can be applied to develop emotional self-regulation (e.g., recognizing one type of emotion and then consciously shifting to another). • Homework assignments:  The skills/abilities outlined earlier are developed in the context of assignments that the client completes outside of the therapy sessions.

Cognitive Therapy Cognitive approaches to counseling target clients’ thoughts rather than actions (APA, 2020d). The main emphasis in cognitive therapy is on the identification and alteration of dysfunctional thinking that results in dysfunctional emotions or behaviors. With this approach, a primary focus of counseling is to help clients change their thoughts, and in doing so, also change their feelings and actions. Cognitive therapy grew out of Beck’s (1976) work with treating patients who were diagnosed with depression. According to Hollen and Beck (2000), a primary aim of the treatment is to identify instances of negative thinking and associated “maladaptive information processing styles,” which promote dysfunctional beliefs. The clinician works to help the client test the accuracy of his or her beliefs by comparing them to empirical (i.e., firsthand, observed) data from events in the client’s daily life. In other words, the process of subjecting one’s beliefs to systematic empirical testing is at the core of Beck’s cognitive therapy. The goal is not so much to change discreet thoughts, but rather to help clients construct a comprehensive, accurate cognitive scheme or “meaning framework” within which information from daily life is processed. Another focus in the therapy is to help clients differentiate their thoughts from their feelings, and to identify the thoughts that are most potent at triggering intense emotional arousal (Hollen & Beck, 2000). Sperry (2010) stated that the client’s main goal in cognitive approaches to therapy is to “unlearn unwanted responses and to learn new ways of responding to, evaluating, challenging, and modifying maladaptive beliefs and behaviors” (p. 28). According to Sperry, the clinician determines in advance what will be discussed during a session

and directs the session once it commences, inviting the client to participate in decisions about the session’s direction along the way. The clinician strives to teach clients skills that will help them to cope more effectively with significant life challenges. As with psychodynamic therapy, the clinician and client work to develop homework assignments that develop and reinforce such skills. Treatment tends to emphasize the client’s present and future challenges much more so than his or her past difficulties. Among the strategies used to alter dysfunctional thinking is the use of Socratic questioning techniques, wherein the learning environment provides opportunities for clients to identify and evaluate the evidence base for their negative thoughts and maladaptive beliefs (APA, 2020d).

Behavior Therapy According to the American Psychological Association (APA, 2020d), behavior therapy grew out of work by Thorndike in the early 1900s in trial-and-error approaches to learning. Behavior therapy rose to prominence in the mid-1900s. With behavior therapy, the behaviors that people produce are viewed from the perspective of learning, with emphasis on classical conditioning (i.e., associative learning) and operant conditioning (i.e., the roles of rewards and punishment in learning). A primary premise of behavior therapy is that learned behaviors, particularly those that are maladaptive, can be unlearned. Sperry (2010) described behavior therapy as: . . . a technical, problem-focused, presentcentered approach,” and he indicated that, when it was introduced, behavior therapy constituted a marked contrast compared to other therapies of the time (e.g., psychoanalysis, client-center therapy), which focused largely on the clinicianclient relationship and “the feelings and inner world of the client. (p. 29)

Behavioral learning theory has played a prominent role in the treatment literature for stuttering. For example, classical conditioning principles are at the heart of at least one staple strategy — desensitization  —  from Van Riper’s (1973) stuttering modification treatment; and operant conditioning



principles are the core of both the Lidcombe Program for Childhood Stuttering and various speech restructuring treatments (i.e., fluency shaping therapies) that are used commonly with older clients who stutter. In the APA’s (2020d) classification scheme, cognitive-behavioral therapy (CBT) is classified under the heading of behavior therapy, even though it also includes elements of cognitive therapy. In contrast, Sperry (2010, p. 30) described three “waves” of cognitive behavioral therapy, with the first wave being behavior therapy that was based on classical and operant conditioning principles; the second wave being cognitive (behavior) therapies such as Beck’s (1976) cognitive therapy and Ellis’s (1962) rational emotive behavioral therapy (REBT); and the third wave consisting of “reformulated” CBT approaches that use techniques such as mindfulness and acceptance to promote an orientation in which the individual becomes adept at being aware of life experiences without necessarily reacting to them (Sperry, 2010). For example, mindfulness is used to help clients develop the skill of detaching from negative thinking (rather that actively attempting to alter negative thinking), and in doing so, enable the client to prevent the spiral toward catastrophizing moments of adversity, challenge, failure, and so forth. Books such as Kabat-Zinn’s (2005) Wherever You Go, There You Are provide clear and easily accessible information and straightforward exercises on the application of mindfulness meditation in daily life. Approaches and practices like these have been incorporated in stuttering treatment as well, and their use has grown steadily in recent years. For example, Sisskin’s (2018) Avoidance Reduction Therapy for Stuttering approach includes acceptance of one’s thoughts (positive or negative) as a component of stuttering treatment. Beilby and Yaruss (2018) described the application of Acceptance and Commitment Therapy (ACT) to the treatment of stuttering. Main goals of the latter approach include developing skills for reacting to or resolving potentially disruptive thoughts, beliefs, or mental images; developing the capacity to accept situations for what they are (rather than trying to change, fix, avoid, or ruminate on them); and linking stuttering treatment and its outcomes to broader values that a

16.  Counseling People Who Stutter

person has (e.g., openness and honesty, integrity). Of course, these approaches are not entirely new to stuttering treatment, as elements of open and honest stuttering and embracing one’s identity as a person who stutters are present in older stuttering treatment frameworks for stuttering such as Van Riper’s (1973) stuttering modification therapy and Sheehan’s (1958) approach-avoidance conflict therapy, as well as in the perspective of long-standing support organizations for stuttering such as the National Stuttering Association (NSA) and the Stuttering Foundation. (Indeed, the name of the NSA’s long-running newsletter is Letting Go.) Rational Emotive Behavior Therapy. Ellis’s Rational Emotive Behavior Therapy (REBT; Ellis, 1962; Ellis & Harper, 1975) generally is recognized as being at the forefront of cognitive-behavioral approaches to therapy (Sperry, 2010). Ellis maintained that a person’s nonproductive, irrational behavior can be understood only if one understands how a person perceives, thinks, emotes, and acts (Ellis, 1989). In the REBT framework, emotions are described as being “ideogenic,” meaning that one’s thoughts are the source of one’s emotions (Crowe, 1997). Thoughts can assume the form of inner speech or “self talk.” Thus, for a person to change his or her emotions or self-defeating behaviors, the first step is to identify and then modify negative self-talk and irrational beliefs into messages that are more rational, self-enhancing, and productive. Crowe (1997) described REBT as being a “directive, and action- and discipline-oriented” approach to counseling. In therapy, the clinician’s methodologies include provision of advice, information, interpretations of the client’s thoughts and behaviors, and homework assignments. Clients are responsible for monitoring their thoughts and behaviors, and for practicing the act of changing unproductive, distorted thinking into productive, factual thinking. In the REBT approach, rational thinking is viewed as being conducive to happiness, while irrational thinking is viewed as fostering self-defeating behavior and a nonproductive lifestyle (Ellis & Harper, 1975). Emotional disturbance and self-defeating behavior are said to arise through a process of self-blaming, which is described as a faulty thought process wherein a

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person mistakenly treats his or her preferences (e.g., I would like to speak fluently.) as needs (e.g., I need to speak fluently.). Ellis (1962) identified 11 common irrational beliefs that are sources of distress for patients who seek psychotherapy. Ellis and Harper (1975) expand the list to 12 ideas, and other authors have modified this work in other ways. The information in Table 16–1, which is drawn from Ellis (1962), Ellis and Harper (1975), and Egan (2002), contains categories and stuttering-related examples of selflimiting beliefs that are commonly encountered in individuals who stutter, along with examples of corresponding statements that indicate more ratio-

nal, productive interpretations of stuttering-related challenges. In the original REBT framework, clients were trained to examine thoughts in an “ABC” framework, where A corresponds to an activating event (something that the client or someone else does), B corresponds to the client’s belief about the activating event (this can be either a rational or an irrational interpretation), and C corresponds to the consequence of the belief (e.g., self-defeating behavior, growth-oriented behavior). Thus, in this framework, irrational thoughts/beliefs have different consequences than rational thoughts/beliefs. In the context of stuttering therapy, activating

Table 16–1.  Irrational/Unhelpful Beliefs and Their Rational/Helpful Reformulations Irrational/Unhelpful Beliefs Nature of Unhelpful Belief

Irrational/Unhelpful Statement

Rational/Helpful Counterpoint “Most people seem to enjoy interacting with me and generally approve of what I do.”

1. Needing to be liked, loved, or approved of by every significant person in a community

“Everyone must like me.”

2. Needing to be highly competent, adequate, and achieving in all endeavors

“I cannot have any stuttering in my speech.”

3. Needing to have one’s own way, so that one’s plans always work out

“It was horrible! I practiced for this interview so much and yet I still stuttered.”

“I feel disappointed because, even after practicing, I had more stuttering than I wanted during the interview.”

Internally directed blame: “You stuttered during the presentation. You are so stupid.”

“Blaming myself is not going to help. I know I tried my best.”

4. Needing to blame and/ or punish someone when mistakes are made, particularly when the mistakes are hurtful

“I don’t want anyone to reject me.”

“I need to be better than everyone else at everything I do.”

Externally directed blame: “People always are interrupting me and don’t seem to respect me. They deserve to be yelled at!”

“Stutter-like speech ‘comes with the territory’ of the speech disorder stuttering. I sometimes stutter on words.”

“Yes, this is upsetting, but not catastrophic. I will not beat myself up over it. I will continue to work at reaching my goal.”

“There is nothing ‘wrong’ with stuttering.” “Stuttering management is a process that takes a while to master.” “I have worth/I am deserving of respect whether I stutter or not.” “Everyone, including me, makes mistakes sometimes.” “Most people don’t have experience interacting with people who stutter.”



16.  Counseling People Who Stutter

Table 16–1.  continued Irrational/Unhelpful Beliefs Nature of Unhelpful Belief 5 Making one’s happiness conditional on external factors

Irrational/Unhelpful Statement

Rational/Helpful Counterpoint

“I can’t be happy unless I am sure other people are going to react to me positively.”

“I am in charge of how I react to external events. I will decide how I feel about a situation. My decision is independent of what the other person says or does.”

“That situation was okay because the other person did not laugh at me.” 6. Being constantly concerned about and dwelling on dangerous or harmful things

“What if [negative or threatening event] happens when I make the presentation?”

“Worrying about things will not prevent from them occurring.” “If ___ occurs, I am capable of dealing with it at that time.” “I have prepared for what are likely to be the most challenging aspects of the situation. However, I cannot anticipate every possible thing an audience may say or do.”

“It feels frightening to let others hear me stutter. I will conceal my stuttering symptoms using word substitution.”

“I will not reach my goal of managing stuttering successfully by continuing to avoid words that I think I stutter on.”

8 Needing to rely or depend on others

“I usually stutter a lot in this situation, so I need someone to talk in my place.”

“This is my speech, and even though it is not perfect, I am capable of talking for myself.”

9 Being subjected to the tyranny of the past.

“I always have difficulty speaking fluently in this situation. This time will be no different.”

“This situation has posed challenges in the past; however, I am capable of changing little pieces or parts of my speech or how I feel about my speech today.”

“I can never say my name.”

“I have learned many new skills for managing my speech, and like other people who stutter, I now am beginning the process of applying these skills in real life.”

“I must plan every aspect of this presentation. I need to know exactly how it will go.”

“There is no specific or single way to approach this situation. I will make a plan that is based on general strategies, some things that sounds reasonable, and I will see how it goes.”

7 Avoiding difficulties rather than facing them

10 Needing to know the precise answer to every problem

Source:  After Ellis & Harper, 1975; Egan, 2002.

“Avoidance is associated with the shame I feel about being a person who stutters. I am learning that being a person who stutters is not something to feel ashamed of.”

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events that are addressed in treatment usually pertain to the client’s need to speak in a situation in which adverse, unfavorable, or threatening behavior is expected from the client’s communication partner(s) or the client’s active production of stuttered speech. Sperry (2010) explained that, in a therapy setting, there are several techniques that clinicians can use in the setting of therapeutic dialogue with the client that will help him or her to modify irrational, distorted, and thus self-limiting, beliefs. See Figure 16–1 for an overview. The specifics of these techniques are as follows: • Reattribution:  With this technique, the clinician helps clients challenge and change instances of unsupported personalization (i.e., instances wherein the client assumes responsibility for behaviors or events that are outside of his or her control or influence). For example, a client who stutters might assume responsibility for a communicative partner’s comfort level during conversation (e.g., I feel bad because stuttering makes other people feel uncomfortable.). With reattribution, the client examines those components of the interaction that he or she is responsible for

directly (e.g., My ability to control what a listener thinks about my speech is limited, or I can control what I tell the listener about my stuttering, but I cannot control how that person will respond to what I tell them.). • Redefining:  With this technique, the clinician helps clients move past statements that simply acknowledge the existence of a problem (e.g., I always have long, tense blocks whenever someone asks me what my name is.) to define their problem in more active, solution-oriented language (e.g., I am working at making any blocks that I produce when saying my name shorter and less physically tense.). • De-catastrophizing:  With this technique, the clinician helps clients prepare for experiences, such as speaking in tasks when stuttering is anticipated, through proactive management of self-talk and self-limiting beliefs. The goal is to help an individual who routinely envisions the worst possible outcome for a situation to brainstorm and entertain other less extreme, and more likely outcomes. The technique also can be applied after completion of an activity. In this way, the client practices revising

Client’s Self-Limiting Beliefs

Reattributing



Refining

Identifying what is and is not under one’s control

Decatastrophizing

Explaining problems in solution-oriented language

Decentering

Identifying alternatives to the “worst possible outcomes”

Recognizing that others are not as concerned as you think they are

Figure 16–1.  Overview of techniques that can be used to challenge irrational or distorted beliefs that limit a client’s functioning. Clinicians can present challenges to clients that facilitate their ability to see the inaccuracies or inconsistencies in their beliefs and the ways in which current beliefs may limit the client’s functioning in speech fluency and ability to apply stuttering management strategies as effectively as possible in real-world settings. The eventual goal is for clients to engage in self-disputation of nonproductive thoughts and beliefs as they occur prior to, during, or after speaking situations.



16.  Counseling People Who Stutter

unproductive self-talk that may follow an unsuccessful activity, and in doing so, creates opportunities to redefine unsubstantiated or inaccurate conclusions, to interrupt intrusive negative thoughts, to disengage from nonproductive cognitive behaviors such as self-blaming, and so forth. • De-centering:  With this technique, the clinician helps clients to assemble and take note of evidence that suggests that the client is not the center of everyone’s attention in every life situation. In the context of stuttering, the purpose is to help clients understand that, in most situations, most people do not care nearly as much about the client’s stuttering as the client thinks they do. As clients come to understand that “all eyes are not always on them when they stutter,” they should begin to feel less anxious about having others hear their stuttered speech. Other authors (and Ellis himself) expanded the original three-part ABC framework into a fivepart ABCDE framework. For example, in Seligman’s (1990) Learned Optimism approach, A corresponds to an adversity (i.e., a specific type of activating event); B to the person’s belief about the adversity; C to the consequences of the person’s belief; D to the person’s disputation of irrational, unproductive, or pessimistic beliefs (this is akin to decatastrophizing, described earlier); and E to the energization that results from revising self-limiting beliefs into growth-directed thoughts and subsequent action. In Seligman’s (1990) framework, individuals work primarily toward the identification and modification of pessimistic versus optimistic “explanatory styles” that occur in the context of depression. Nonetheless, general features of the approach have relevance to stuttering management. Three main parameters or dimensions to beliefs are explored: permanence, pervasiveness, and personalization. Permanence pertains to the temporal dimension of beliefs, and is indicated by descriptions of life events through the use of words such as always and never (e.g., I always stutter in that situation. My speech is never going to change. People never give me the time I need to talk.). Because

absolutisms like these distort the realities of the person’s experience, they are targeted for identification and disputation. Doing so helps people to see adversities and challenges more accurately, and thus more optimistically (i.e., as being less daunting and impenetrable than they seem to be at first glance). The goal is to help people evaluate adversities and challenges using terms such as sometimes, occasionally, and lately — explanatory terms that, in most situations, represent the realities of a person’s situation more realistically. In the context of stuttering therapy, the act of disputation creates a point-of-entry into fixed, inaccurate, long-held, self-limiting beliefs. The aim is to dispute these beliefs repeatedly, and eventually replace them with flexible, accurate, growth-facilitating beliefs. Pervasiveness pertains to the spatial dimension of a person’s belief — that is, the extent to which a person generalizes the consequences of an adverse experience in one’s life context into anticipated consequences in other life contexts. These generalizations are indicated when people describe failure through universal attributions (e.g., Everyone thinks I talk strangely.) This process is akin to the act of catastrophizing, which Ellis (1962) described as a process through which beliefs and feelings about a discreet setback come to permeate multiple arenas of the person’s life. Seligman (1990) described the effects of pervasiveness in the following way: People who make universal explanations for their failures give up on everything when a failure strikes in one area. [In contrast, people] who make specific explanations may become helpless in that one part of their lives yet march stalwartly on in the others. (p. 46)

The interplay between the permanence and pervasiveness dimensions is illustrated in Figure 16–2. In treatment scenarios, which, at first, would transpire in the context of therapeutic dialogue between the clinician and client and then later be applied independently by the client, the goal is to help clients to see their problems for what they almost always are: limited in duration and limited in scope. In the context of stuttering therapy, the aim again is to develop the clients’ ability to monitor

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Permanent My fluency is never going to improve.



Temporary It may take some time, but my fluency will improve steadily.

Pervasive I always stutter.



Limited I stutter a lot in this situation, but I stutter only a little in that situation.

Figure 16–2.  Seligman’s (1990) Learned Optimism framework. Clients are encouraged to examine their explanations (i.e., beliefs) about adverse events that occur in life. Beliefs that see adversity as permanent (left ) and pervasive (right ) in life can be disputed in ways that promote a more accurate, optimistic explanation of adversity as reflecting temporary challenges and as being limited in scope.

their thinking for the purpose of identifying and then disputing instances of universal attribution (i.e., overgeneralization), so that they eventually are replaced with interpretations that describe life experiences in specific, accurate terms. For example, a client who observes a concerned look on the face of a speaking partner following a physically tense instance of stuttering would work toward adjusting beliefs such as “Everyone thinks something is wrong with me” to more specific interpretations, such as “This person looks like she thinks something is wrong with me.” Statements like the latter can be disputed further because they imply that clients can read the minds of listeners. The speaker will not know what the listener is thinking without asking the listener directly. Thus, a statement such as “This person appears to be trying to figure out what is going on with my speech” presents a more objective, specific interpretation of the situation. Alternately, clients can be encouraged to apply universal attribution at times of successful or positive outcomes. For example, after speaking with a relatively high degree of fluency in a situation that previously had been very challenging, the interpretation “I am able to manage my stuttering successfully” is preferable to a more pessimistic take, such as “I got lucky in that situation,” or “For once in my life, I managed my stuttering well.” Personalization pertains to where a person assigns blame when things go wrong or poorly, and

to where the person attributes credit when things go right or well. For negative events, the options are to internalize blame (i.e., assign blame to oneself) or to externalize blame (i.e., assign blame to other people or to outside circumstances). Depending on the circumstance, both internal and external attributions can promote an optimistic, forwardlooking mindset for dealing with life events. For example, a client who blames her stuttering on communication partners (e.g., They are always making me stutter badly.) has avoided engaging in self-blame (e.g., My speech is so bad.), which when done repeatedly lowers one’s self-esteem. Both sides of the personalization coin come with caveats, however. For instance, in the preceding example, repeatedly blaming others for one’s speech performance can prevent the unpleasant emotional consequences that may accompany selfblaming, but can have undesirable consequences as well, such as leading a client to cede control of fluency to other people and for one to feel powerless in his or her ability to influence the dynamics of communicative interactions and to influence or control one’s stuttering symptoms actively. Seligman (1990) stated that although personalization affects how one feels about oneself, it is a less important dimension than either permanence or pervasiveness, because the latter dimensions have a greater effect on what a person does over time and in which situations. Nonetheless, the clinician



must monitor clients’ use of attributions and help clients to self-evaluate their performance in a way that is both accurate yet self-supporting.

Humanistic Therapy Humanistic therapy is recognized as another distinct approach to counseling (APA, 2020d). In this approach, the focus is on an individual’s attainment of his or her maximum potential by making rational choices. Humanistic approaches emphasize concern and respect for others to a greater extent than behavioral and cognitive-behavioral approaches. Sub-types of humanistic therapy include existentialism, which emphasizes the individual’s free will, self-determination, and search for meaning; gestalt therapy, which emphasizes “organismic holism, awareness of the here and now, and selfresponsibility”; and client-centered therapy (most closely associated with Carl Rogers, 1951), which emphasizes the quality of the clinician-client relationship, and the idea that the client is the expert on his or her inner self (Crowe, 1997). Assumptions associated with person-centered therapy include the following: the need for the clinician to create an atmosphere of trust and respect for the client in the therapy setting (e.g., trusting that clients have the capacity to progress toward reaching their full potential; trusting that clients have the ability to set appropriate therapy goals and choose how to attain them); the need for recognizing and incorporating the clients’ unique perspectives on their life experiences (i.e., phenomenology) into therapy; the need for recognizing that client behavior will be consistent with client self-concept (Crowe, 1997). According to Sperry (2010), person-centered therapy places great emphasis on the clinician’s personal qualities, with the key qualities being congruence (i.e., genuine interactions with the client), unconditional positive regard (i.e., a respectful, nonjudgmental approach toward the client), and empathy (i.e., the ability to experience the subjective elements of a client’s feelings and meanings). As summarized by Crowe (1997), personcentered therapy is much less clinician-driven than behavioral therapy or cognitive-behavioral therapy. In person-centered therapy, the client is provided a context for assuming responsibility for

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what transpires in the counseling relationship, and in the context of therapy explores feelings and attitudes, with the goal being to identify incongruity between feelings and behaviors. The client also seeks to identify attitudes that have been “denied” to consciousness, particularly those attitudes that are mismatched with the individual’s self-concept. This process is said to result in reorganization of self-concept such that one’s internal awareness matches his or her external experiences. In the context of stuttering, an example of a mismatch that SLPs are likely to encounter involves the relationship between how fluently a client is able to speak through the use of strategies learned in treatment (i.e., the client may sound just like or similar to a speaker who does not stutter) and how anxious the client feels about the possibility of stuttering should the strategies not “work” as well as they do in therapy settings. In person-centered counseling, outcomes are assessed in terms of changes in the client’s openness to experience changes in the client’s self-trust (i.e., embracing the adequacy/acceptability of one’s judgments and decisions); shifting from external standards of evaluation (i.e., mainly valuing what other people think about my performance) to internal standards (i.e., mainly valuing what I  think about my performance); and willingness to continue growing (Crowe, 1997). In scenarios where clients are speaking fluently but remain anxious about the possibility of not speaking fluently, personal growth would be said to have occurred when the client demonstrates the ability to enter a situation in which anxiety is likely to be experienced, and embraces the anxiety as part of his or her present self-concept, by making a statement such as “It’s okay if I feel anxious and if I stutter on some words in this situation.”

Integrative or Holistic Therapy The fifth category of counseling therapy, integrative or holistic therapy, features various combinations of the other four counseling-type categories. The integrative approach is commonly used in contemporary counseling practice (APA, 2020d; Egan, 2002; Sperry, 2010), as it offers the advantage of tailoring therapy to meet the client’s needs. The primary focus in this section is on Egan’s Skilled

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Helper approach to counseling. Egan (2002) presented the Skilled Helper approach within the context of positive psychology. In the author’s reading of the Skilled Helper approach, it appears to be eclectic, incorporating elements of person-centered therapy, cognitive therapy, and cognitive-behavioral therapy, along with principles of positive psychology. As the name implies, positive psychology emphasizes what is present, rather than what is absent — that is, what people do rather than what they do not do. Thus, clients are helped to build from existing strengths and skills and to develop opportunities that are available to them but not yet exploited. Although the theoretical roots of personcentered therapy and positive psychology differ, there are areas of common ground at the treatment level, which offers opportunities for integrating the approaches ( Joseph, 2015; Pomerantz, 2020). Thus, the need to balance pathology with positive elements of functioning is recognized. Overall, however, positive psychology is more closely aligned with the notion of promoting an individual’s functioning than it is with the notion of reducing or eliminating an individual’s disability or impairment (Egan, 2002). A full description of Egan’s (2002) Skilled Helper approach is beyond the scope of this chapter; however, the remainder of this section summarizes some of the main features of the approach. The Skilled Helper Approach. Egan (2002) offered several qualities of what counseling entails. He said that the fundamental aim of counseling is to help people “make and act on their own decisions.” In Egan’s model, the clinician’s role is to help the client. From this perspective, clinicians occupy a mid-ground when it comes to directivity. That is, counseling is an activity that falls between telling a person exactly what to do and leaving a person on his or her own to solve problems. Egan said that, in the context of counseling, helping is about changing the client’s “bad habits” and not about issues related to the individual’s sociobiological determinism. In the Skilled Helper approach, four attributes are identified as being essential to establishing a productive helping relationship with clients: respect for the client (e.g., demonstrating that you are on the client’s side, keeping the client’s agenda — not the clinician’s agenda — in focus throughout ther-

apy); empathy (i.e., the ability to understand clients as they are, and not as the clinician wishes them to be); genuineness (e.g., honest, non-defensive, spontaneous interactions with the client); and commitment to empowering the client (e.g., sharing the helping process with the client and respecting the client’s ability to make significant contributions to the process rather than seeing the client as helpless or as a victim). There are two main goals in Egan’s helping model: • Helping clients manage their life problems more effectively by developing their use of existing, but underutilized or overlooked, resources and opportunities. • Helping clients become more effective at helping themselves in everyday life. These goals align well with the general intervention principles outlined in Chapter 15 of this book; and the second half of this chapter provides examples of how the notion of “helping” clients melds with more traditional notions of stuttering treatment. For clients to attain these goals, they need to become actively engaged in solving their problems and to work at separating their feelings from their behaviors. In the Skilled Helper model, these actions go a long way toward helping clients become “unstuck” in their approach to dealing with problems, and in doing so, impose order and discipline to parts of life that currently are in disarray. According to Egan (2002), when these aims are met, clients are better positioned to live their life as fully as possible within the context of the life situations with which they are presented. As with several of the other categories of counseling, clinicians work with clients to clarify key issues that the client wishes to change, to clarify the outcomes that the client wants to attain, and to help the client develop strategies and skills for attaining the desired outcomes. Egan (2002) organized the Skilled Helper approach into three primary stages (Figure 16–3). In Stage 1, the clinician helps the client identify key issues that the client wishes to change. In the context of stuttering therapy, some of the key issues to tackle in treatment will have been identified at the conclusion of the initial assessment; however,



16.  Counseling People Who Stutter

•Help client tell stories. •Help client recognize “blind spots.” •Help client target high-impact goals.

2. Identify outcomes. •Sensible solutions. •Realistic yet challenging goals. •Weighing the costs versus benefits of goals. •Developing incentives for commitment.

1. Clarify key issues.

•Find “best-fit” strategies. •Craft implementation plans. •Take incremental steps. •Celebrate success. •Expect temporary setbacks. •Do the hard work.

3. Develop and enact strategies for attaining goals.

Figure 16–3. Stages of Egan’s (2002) Skilled Helper approach, which is designed to help clients manage problems and develop opportunities using resources that they currently possess or have access to. Stage 1 involves goal setting, which for this part of therapy would focus mainly on using or promoting a mindset (i.e., replacing unproductive thoughts and beliefs with productive thoughts and beliefs) and a skill set (i.e., replacing self-defeating behaviors with self-enhancing behaviors) that facilitate the client’s communicative functioning by improving participation and facilitating implementation of stuttering management skills. Stage 2 involves outcome determination, which in this approach is oriented mainly toward helping clients to think of success in pragmatic terms by developing adaptive goals that feature both ideal outcomes and acceptable outcomes. Stage 3 involves identification of and implementation of strategies that move the client toward his or her defined outcomes. To facilitate success, problems are tackled incrementally. Strategy implementation often involves hard work and temporary setbacks for which the client must also develop response strategies.

as treatment unfolds, clients are likely to encounter “sticking points” along the way. These sticking points often center on activities wherein the client’s stuttering-related thoughts, beliefs, feelings, and emotions clash with the speech-related goals the client is attempting to reach. For example, the client may be eager to implement a newly learned stuttering management skill that involves regulation of speech, yet at the same time, the client may experience intense anxiety that centers on the possibility of a speaking partner discovering that the client is “a person who stutters.” Conflicts like this are common in stuttering treatment, and they have long been recognized as a significant hindrance to clients in making progress in stuttering treatment. Sheehan (1958) described scenarios like this — ones that involve competing drives to “do” and to “not do” — as an approach-avoidance conflict. The presence of such conflicts are an ideal

context for clinicians to supplement traditional motor-based strategies for stuttering management with activities that fit under the helping/counseling umbrella. These activities also serve the function of helping clients gain clarity regarding which aspects of their stuttering problem, if successfully met, would have the biggest payoff in terms of life satisfaction and resolution of other life problems. Although clients may not realize it at the start of treatment, altering avoidance and concealment (strategies that are used to protect the speaker who stutters from hurtful listener responses) will turn out to be “high payoff” changes that will likely deliver a great amount of positive change. Clinician counseling, when done properly, can be used to lead a client to this discovery. Egan (2002) described client storytelling as a form of self-disclosure that offers an effective vehicle for (1) helping clients to uncover key issues in

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their present life; (2) helping clients to see the portions of their present experience that are driven by faulty logic but that they presently are unaware of; and, (3) helping clients discover extant resources and opportunities for solving key issues. Another approach for identifying problems is to use the Lazarus technique (Lazarus, 1981), which entails asking clients to describe their problem in just one word, to put that word into a phrase, and then to produce a sentence that states the main problem. In the context of stuttering, the Lazarus technique might yield the following: • The problem in one word:  stuttering • The problem word in a phrase:  feeling down about my stuttering • The problem in a sentence:  I’m feeling down about my stuttering, because stuttering makes talking very difficult and embarrassing for me. As the client describes present life experiences, clinicians are able to gauge the severity of the client’s problem situations by assessing the amount of distress the client is in, the extent to which the client feels helpless to control the situation, and the frequency with which the client encounters the distressing situation. Clinicians also search for any assets or resources that the client mentions, as these are likely to be helpful to the client in addressing his or her primary issues or concerns. Examples of assets/resources include instances or situations where the client describes behaviors that lead to effective communication, or instances where others demonstrate acceptance of stuttered speech, or when the client demonstrates personal qualities such as resilience or persistence that can be highlighted and reinforced for future use. Instances like these and the people or qualities embedded in these instances can be used as leverage points for future change. Egan (2002) indicated that clients must be involved in the process by being invited to respond to prompts such as the following: • What are my unused skills/resources? • Which opportunities do I let go by, and which do I want to develop?

• What could I accomplish if I put my mind to it? • Which role models could I be emulating? Egan (2002) stated that clients usually are more concerned with solving their current problems than they are with digging deep into their past to explore the roots of their current problems. To facilitate problem solving, clients are helped to word their goals as solutions and to develop their decision making skills by learning how to gather information about a problem, analyze the pros and cons of the information, and then chose a solution that is both rational (i.e., Will this choice (mostly) accomplish what I want to accomplish?) and in line with the client’s values (Will I accomplish the goal in a way that I am proud of?). Another part of a solution-focused process for dealing with problems is to help clients brainstorm possible solutions, and then to construct a “change agenda” in which the client specifies exactly what he or she wants and needs. As part of this process, clients also consider their level of commitment to accomplishing the goal, which for many clients comes down to determining how much one is willing to pay for what they want. For instance, a client who is tired of avoiding words upon which stuttering is anticipated may wish to use avoidance less often as a coping strategy for stuttering, and instead, say the words he or she intends to say. This is a fine goal; however, the client may not be willing to pay the cost that comes with it, which is the potential to feel embarrassment or shame by stuttering, perhaps severely, on these intended words. Although clinicians can help clients conduct cost-benefit analyses on issues like word avoidance, ultimately it is the client who must “opt in” to tackle a goal, despite whatever negative, near-term costs are associated with it. According to Egan (2002), a client’s level of commitment to tackling a counseling goal is a product of the client’s level of self-efficacy; that is, the extent to which the client believes that he or she has the ability to implement whatever steps are necessary to manage a situation successfully. A client’s sense of self-efficacy can be built up by providing models of the target behavior, by providing corrective feedback and encouragement, by



16.  Counseling People Who Stutter

helping the client reduce fear and anxiety that may interfere with success, and by developing the client’s ability to perform the necessary skill. As with cognitive-behavioral therapy, in the Skilled Helper model, clinicians help clients to differentiate their wants (i.e., things that would be preferred but that are not essential) from their needs (i.e., things that are essential). Clients also are asked to respond to future-oriented probes such as the following to identify a focus for therapy: • What would this problem look like if you were managing it better? • What would you be doing differently with the people in your life? • What current behavior patterns would you eliminate? • What accomplishments would you have that you do not have now? In Stage 2 of the Skilled Helper model, the focus is on helping clients identify goals and outcomes they want to attain. In the context of stuttering therapy, the client’s preferred goals should be stated clearly and specifically, and focused on changes that will lead to significant changes in life. Treatment outcomes likely will have been discussed at the conclusion of the initial assessment; however, as treatment unfolds, clients are likely to find that their understanding of success and desirable outcomes will shift as they experience the challenges associated with active stuttering management and the limitations of their currently available stuttering management strategies. Thus, after goal areas have been identified, clinicians can work with clients to create adaptive outcomes. These are outcomes that feature a range of possible results that are acceptable to the client. The “absolute best” outcome scenario forms one end of the continuum, but because this may not be realistic given the constraints that stuttering imposes on speaking performance, other points along the continuum are identified as alternatives that may be “good enough”— outcomes wherein instead of conquering stuttering completely, the client is seen as coping more effectively than in the past and as working toward keeping stuttering severity within a range that is acceptable to the client with respect

to its impact on communication functioning. Adaptive outcomes come under the broader concept of adaptive goals. These are goals with flexible outcomes, ranging from very high/normalized to adequate/functional. Examples of outcome continua are presented in Figure 16–4. Other authors, such as Sisskin (2018), have offered examples of how adaptive goal setting can be used in the context reducing the use of avoidance behaviors in clients who stutter. Although adaptive goal setting like this may strike some clinicians and clients as “settling for less” or “aiming too low,” Egan (2002) stated, “In many difficult situations helping clients cope is one the best things helpers can do.” As noted earlier, whichever outcome clients are aiming for, they will need to clarify how much they are willing to risk and how much energy they are willing to expend, because stuttering management can be a very challenging process, particularly when clients are attempting to confront long-held beliefs about their stuttering, how their listeners will react to their speech, the concepts of disability and ability, and the accompanying complex of feelings and emotions. In Stage 3 of the Skilled Helper model, as goals are implemented, clinicians work with clients to help them become effective tacticians — that is, individuals who can successfully adapt a plan to fit an immediate situation. As part of this process, clients also can develop and implement “actionfocused self-contracts and agreements,” which are written statements of specific actions that the client will complete. The plans typically are written in specific terms. When goals are written specifically and in ways that break big tasks into manageable increments, the actions the client will be taking should be ones that he or she is comfortable with and reasonably confident in implementing. To spur clients into action, clinicians can work with them to develop a list of agreed truths; that is, statements with which both the client and clinician agree. Examples of agreed truths that pertain to stuttering include the following: • “The only way to reduce my reliance on word avoidance is to say the words I am tempted to avoid (even if I stutter on them).”

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A

Current status: Same old stuttering

One or two things are better

Many things are better

Several things are better

B

Current status: Saying nothing

Making occasional remarks

Engaging in small talk

Conversing briefly

Everything is better

Conversing extensively

Figure 16–4.  Examples of adaptive goals. Panel A shows a continuum of outcomes related to stuttering management proficiency during work-related telephone conversations. Panel B shows a continuum of outcomes related to the amount and type of participation a client exhibits during conversations with friends. The client can assign self-ratings at different points in treatment (e.g., following a speaking situation, on a monthly basis) to measure the extent to which he or she is moving toward an optimal or ideal outcome. For some goals, clients may decide that they are satisfied with less than optimal performance.

• “By acknowledging my stuttering openly to others, I no longer need to worry about whether my listener knows I stutter.”

Counseling and the Scope of Practice in Speech-Language Pathology As discussed in previous chapters, counseling is one of eight domains of clinical service delivery included in the American Speech-Language-Hearing Association’s (ASHA’s, 2016a) Scope of Practice in Speech-Language Pathology. This section takes a closer look at counseling by describing how counseling has been applied in the field of speech-language pathology, and more explicitly

with people who stutter, in exploring unhelpful thoughts, unpleasant and disruptive emotions, and self-defeating behaviors.

Counseling in Speech-Language Pathology: Overview According to ASHA, the Scope of Practice in SpeechLanguage Pathology allows clinicians to provide counseling to clients and, when appropriate, to the client’s family members (particularly parents) and other caregivers who are included in an intervention plan. Figure 16–5 presents an overview of the counseling concepts that are included in the Scope of Practice for Speech-Language Pathology. As shown in the figure, the SLP provides services that are designed to educate, guide, and support



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The role of counseling in speech-language pathology also comes with the important responsibility of recognizing when the client’s counseling needs go beyond the realm of communicative functioning and/or the clinician’s counseling expertise. In such instances, the clinician is obligated to refer the client and his or her family to professionals who are qualified to help the client address these needs, challenges, and concerns.

Acceptance

Education, Guidance, and Support Decision Making

Educational Counseling

Adaptation

Figure 16–5.  Overview of counseling roles and responsibilities as described in ASHA’s Scope of Practice in Speech-Language Pathology (2016a). Clinicians offer clients and their family members education, guidance, and support, which facilitate the individual’s ability to participate in decision-making, adapt to the speechlanguage or swallowing impairment, and accept the disability that accompanies impairment.

individuals on matters related to accepting, adapting to, and making decisions about issues that surround fluency and fluency disorders. Counseling concepts have long been present in the treatment literature on stuttering, and in the past 2 or 3 decades have seen increasing application in clinical treatment. The core counseling activities  —  education, guidance, and support — are complementary, and clinicians are likely to engage in each of them at times during most intervention programs. These facets of counseling are embodied in a range of activities that are oriented toward helping clients (as well as parents and others) to become well informed about their communication disorder, feel empowered to make informed decisions about intervention, advocate for their needs and interests, feel supported in their stuttering management efforts, and develop skills for managing self-limiting thoughts, beliefs, feelings, and emotions associated with their communication-related challenges.

Preceding chapters briefly have discussed the educational aspect of counseling. For example, Chapter 13 described how educational counseling can be used when presenting the rationale for or characteristics of treatment recommendations and when providing the client with background information that will help him or her contribute to the development of personalized treatment recommendations and goals. That chapter also described how educational counseling is used in intervention plans that entail parent training (e.g., training parents about communicative behaviors that tend to affect conversational pace and complexity in ways that hinder children’s speech fluency). The rationale for educational counseling was described in Chapter 15 under Intervention Principle 1: Develop the Client’s and Others’ Knowledge of Stuttering, Speech Production, and Intervention Process. Various topics to address when attempting to build the knowledge base of individuals who receive services were described as well (see Table 15-2). In this domain of clinical service delivery, the SLP draws on expertise to provide the client and others with accurate, objective information about matters such as typical and atypical communication, intervention options, and the causes, characteristics, and consequences of communication disorders. As such, educational counseling has the potential to facilitate an individual’s ability to make informed decisions about important intervention matters, including those pertaining to the selection of treatment goals and treatment strategies, and the metrics that will be used to define successful performance. As an individual’s knowledge base grows, his or her perspective on the nature of stuttering-related challenges is likely to grow as well, and individuals are likely to improve their ability

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to engage in the sorts of strategic/tactical thinking that are necessary to manage specific communication challenges independently and effectively. A well-developed knowledge base also creates a favorable context for helping individuals to understand their present limitations in communication performance for what they are (i.e., the consequences of speaking with and adapting to an impaired speech production system) and to accept (or refuse to react to) any lingering limitations that might persist despite one’s best efforts to eliminate them through treatment. This knowledge is likely to leave individuals with an expanded sense of empowerment in terms of not only their ability to make informed decisions about treatment, but their ability to apply newly developed knowledge in the service of self-advocacy and to counterbalance disabling emotional reactions to communicative disability that may be present.

Clinicians can engage proactively in educational counseling by incorporating educational activities as a standard component in intervention plans. The SLP not only can provide clients, parents, and others with informational materials about stuttering, but also can provide information about how individuals can access peer-to-peer support networks that offer information, guidance, and support for people who stutter and their families. And, of course, clinicians also have opportunities to engage in educational counseling as they respond to questions that clients, parents, and caregivers raise periodically about stuttering, intervention, and related matters. As noted in Chapter 15, clinicians should be mindful that questions that appear on the surface to be straightforward requests for facts about stuttering (e.g., Do they know what causes stuttering?) instead may reflect fear or other emotions that the

Counseling Versus Interviewing In speech-language pathology textbooks, counseling and interviewing concepts and practices sometimes are bundled together, and in some cases, so much so that the terms are used interchangeably. Although there are some commonalities between the two — both entail interpersonal interaction, use of active listening techniques, and adoption of an empathetic and respectful orientation toward the client/parent/ caregiver — the two concepts are regarded distinctly in most contemporary sources. Tellis and Barone (2018) defined interviewing as “an informational giveand-take between [sic] therapist and client, client advocates, and adversaries. It is designed to capture client information in a structured manner” (p. 106). Interview protocols such as the one presented earlier, in Chapter 11, Table 11–1, are clinician designed and directed. As shown there, an interview protocol is based on a set of specific, comprehensive requests that are designed to elicit information the clinician regards as important. Alternately, the counseling activities described in this chapter feature very little of the one-sided questioning that occurs during clinical interviews. Instead, activities most often feature a mix of clinician- and client-directed discussion and use of two-sided conversations wherein the clinician works with the client, helping the client to construct, interpret, and/or develop solutions for the stuttering-related challenges he or she faces. In the latter roles, clinicians alternate between listening empathetically to what the client says, sharing empathic highlights with the client, probing for additional information, and challenging the client to consider or create alternative interpretations or actions that are likely to facilitate more effective, independent management of stuttering-related challenges and to engage in aspects of communication that he or she currently is either not engaged in or engaged in only minimally.



individual experiences in conjunction with stuttering (e.g., Did I do anything that caused my child to stutter?). Accordingly, Luterman (1996) recommended that, prior to launching into what might be a lecture-length response, clinicians first respond to client and parent inquiries about stuttering with confirming questions (e.g., What is it that you think may have caused the stuttering?). In this way, clinicians can identify whether any emotion-based concerns are embedded in the request, and if so, respond to the questions appropriately. Responses that address fear and other emotions that clients and parents experience are, in part, educational, but as will be seen in the following sections, they also will include content that offers empathy, guidance, and support to these individuals, and in doing so, helps them to navigate the emotional terrain of stuttering. An example of this sort of clinical dialogue was presented in Chapter 15 under Treatment Principle 1.

Counseling for Guidance and Support As shown in Figure 16–5, the SLP’s counseling activities can go beyond educational purposes to include activities that offer support and guidance to clients, parents, and caretakers. As noted in previous chapters, stuttering often has significant negative impacts on the functioning and psychosocial well-being of individuals who have the disorder. Some clients who stutter present with an assortment of self-limiting thoughts and beliefs that have developed over time in response to their repeated struggles to communicate and to their accumulation of negative responses from communicative partners to their stuttered speech. A client’s selflimiting thoughts and beliefs typically are accompanied by feelings and emotions that, at best, feel unpleasant or uncomfortable, and, at times, can be intense enough to exacerbate the severity of the client’s fluency impairment and limit the client’s ability to apply stuttering management strategies as effectively as possible. For these cases, counseling activities can play a key role in helping clients deal with challenging matters such as how to address unpleasant, uncomfortable, or disruptive emotions and thoughts related to stuttering, how to accept and adapt to one’s communication limitations, and how to deal with “real time” obstacles such as

16.  Counseling People Who Stutter

negative reactions from communicative partners that have the potential to disrupt communicative functioning significantly. Parents of children who stutter may experience negative or unproductive thoughts and emotions as well while grappling with issues such as what has caused their child to stutter, how stuttering might impact their child’s future success and well-being, and how they should respond when stuttering-related difficulties arise in their child’s speech. In such instances, SLPs, by virtue of their professional training, are well positioned to offer guidance and support to parents, and in doing so, help them to focus on those elements of the immediate communication situations that are most likely to facilitate their child’s development. Counseling is the service delivery domain in which issues like these are addressed.

Emotions That May Accompany Stuttering People who stutter report experiencing a variety of emotions when talking. Four of the more common, and most disruptive, emotions that coincide with stuttering are fear, anxiety, guilt, and shame. Essential characteristics of each of these emotions are shown in Figure 16–6, along with the correlates and the effects they have on functioning. Although other feelings and emotions may be present (e.g., disappointment, frustration, loneliness), the focus of this discussion is mainly on these four emotions, as they have received considerable attention in clinical and research literature on stuttering. In some clients who stutter, one or more of these emotions is present often enough and/or intensively enough to exacerbate the fluency and life participation difficulties that are associated with stuttering. Authorities generally consider anxiety and fear to be related emotions, in that each emotion is associated with a threat or danger. Similarly, authorities generally discuss shame and guilt together because each of these emotions involves self-directed scrutiny of oneself. Embedded within the shame quadrant in Figure 16–6 is a fifth emotion ​— ​anger — which may be present in clients who stutter as well. Of the emotions shown in Figure 16–6, anger tends to be most closely associated with shame (as part of

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Figure 16–6.  Characteristics of anxiety, fear (Beidel, 2000, Kowalski, 2000), shame, and guilt (Tangney, 2000). Although people who stutter can experience a wide range of emotions in conjunction with the challenges that stuttering presents, emotions that are most commonly experienced include anxiety, fear, shame, and guilt. These emotions tend to be emergent features of a speaker’s stuttering experience. In individuals who stutter, anxiety and fear stem from a real or imagined threat, while shame and guilt are emotions that arise from self-evaluation. With stuttering, anxiety is most likely to revolve around social interactions (social anxiety disorder).

a self-protective response to feelings of shame); however, clients certainly can experience anger in the absence of shame, as well, such as when a communication partner’s behavior toward the client (i.e., interrupting the client’s stuttered speech, showing impatience with the client’s disfluent speech) violates expectations that the client has about the manner in which communication partners should act. The remainder of this section discusses these emotions in more detail and explores how they are associated with stuttering and experienced by people who stutter. In clinical settings, one of the clinician’s main responsibilities is to note the presence of emotions as they are manifested through the client’s facial expressions, eye gaze patterns, body posture, gestures, and vocal tone and expressivity, and in the client’s verbal descriptions of his or her speaking experiences, wherein characteristics of these emotions may be described. It is not the clinician’s job to “talk clients out of” the emotions they feel or to convince clients to deny how they are feeling

through remarks such as the following: “Oh, you have nothing to be anxious about.” “Don’t worry, it won’t be that bad.” “Cheer up! Your stuttering is nothing to feel ashamed about.” “You shouldn’t feel anxious — everyone produces disfluencies.” “You’re not afraid of talking to them. You’re tougher than that.” Instead, the recommended course of action is to listen actively and empathetically to all that the client has to say about his or her feelings and to make simple remarks that serve to validate the client’s experiences with these emotions (Luterman, 1999). When presented in a caring, engaged manner, confirmatory utterances such as “Uh-huh” indicate to the client, “I have heard what you have said and accept your message as it is.” Empathy is a critical quality for SLPs to display toward their clients. Empathy implies that the clinician takes a nonjudgmental stance to what the client is saying. The clinician’s words, facial expressions, and body posture should convey the message, “I hear what you are saying, and your emotions are what they



are. They are not ‘good’ or ‘bad.’ They simply are a part of your present experience.”

Anxiety and Fear Anxiety and fear are two of the more common emotions that clients who stutter are likely to report experiencing in connection with their speech disorder. Fear is a reaction to a specific, imminent threat or danger, whereas anxiety is a fear-based reaction to a diffuse threat that is anticipated to occur at some point in the future (Heshmat, 2018; Horwitz, 2013; Kowalski, 2000). Anxiety has been studied extensively, including in the research literature on stuttering. Anxiety research has been conducted from four perspectives: psychodynamic, expressive-behavioral, biological, and cognitive (Kowalski, 2000). According to Kowalski when examining a client from a psychodynamic perspective, the focus is on uncovering the origins of the person’s anxiety, with the assumption being that anxiety is symptomatic of unresolved unconscious conflict(s), which often trace back to childhood and early developmental experiences. From an expressive-behavioral perspective, the focus mainly is on the role of evolutionary factors and the adaptive value that anxiety can have when experienced in moderation. From a biological perspective, the focus primarily is on the physiological correlates of the emotion. As shown in Figure 16–6, behavioral inhibition is a common physiological correlate of anxiety. The fourth perspective from which anxiety has been examined is cognitive, such as in work by Beck and Emery (1985), who proposed that anxiety stems from a two-stage appraisal process, wherein the individual first determines that an environmental threat is present, and then evaluates his or her capacity for managing the threat effectively. Anxiety arises when the individual judges that his or her capacity to manage the threat is inadequate. In this model, maladaptive anxiety arises when the appraisal process becomes distorted. Beidel (2000) described the symptoms of anxiety and characteristics of anxiety disorders. Anxiety is accompanied by physiological symptoms (i.e., the somatic component) such as heart palpitations, shaking, shortness of breath, abdominal distress, and numbness; as well as subjective distress, which consists of unwanted or obtrusive thoughts,

16.  Counseling People Who Stutter

images, or worries; and behavioral avoidance, which is characterized by evading those situations that create physiological and subjective distress. A panic attack occurs when four or more somatic symptomatic symptoms are present at once, or when fewer than four symptoms are present at once in conjunction with the fear of dying, losing control, or going crazy. The term anxiety disorder refers to a cluster of discreet disorders, each of which is based around feelings of fear, worry, or apprehension. Of these, phobias, defined as excessive distress elicited by the presence of or in anticipation of certain objects, situations, or events, are the most common. As explained at some length in Chapter 6, anxiety has been studied in various ways with both children and adults who stutter. One main area of focus has been to compare speakers who stutter with typical speakers in the extent to which they experience difference subtypes of anxiety. Many studies have examined Spielberger’s (1976) distinction between state and trait anxiety. State anxiety refers to the anxiety that a person experiences at a specific point in time or in a specific situational instance (e.g., I feel anxious now; I felt anxious when I woke up this morning). In contrast, trait anxiety refers to a person’s propensity to regard various life situations as threatening and then respond to those situations with state anxiety. Kowalski (2000) stated that people who score high on measures of trait anxiety are not necessarily chronically anxious. Rather, they simply have a tendency to experience anxiety more often than a person who scores low on measures of trait anxiety. As indicated in Chapter 6, there is evidence that people who stutter have elevated levels of both state and trait anxiety, and that anxiety levels can be lowered in conjunction with treatment for stuttering. Data from one meta-analysis that incorporated studies published through 2010 (Craig & Tran, 2014) reported an effect size of 0.57 for elevated level trait anxiety among individuals who stutter.

Social Anxiety Disorder In the past decade, researchers in the area of stuttering have shown increased interest in examining anxiety disorders, and in particular social phobia (i.e., an individual’s excessive fear that he or she will do or say something that the individual regards

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as embarrassing or humiliating in front others). As noted in Chapter 6, people who stutter appear to be more prone to experiencing social phobia (or social anxiety disorder, as it has come to be termed in recent years) than typical speakers, with prevalence rates among adults who stutter estimated to be between 22 and 60% (Iverach, Rapee, Wong, & Lowe, 2017). With school-aged children ages 7 to 12 years, research findings show a six-times greater risk for children who stutter to present social anxiety disorder, a seven-times greater risk to present subclinical generalized anxiety disorder, and a four-times greater risk to present any type of anxiety disorder (Iverach et al., 2016). In a study of adolescents seeking treatment for stuttering, participants’ anxiety and depression scores were within the normal range overall; however, there was a significant association between one’s stuttering severity and less favorable scores on measures of anxiety, internalization of problems (i.e., rumination), speech dissatisfaction, and quality of life (Iverach et al., 2017). Individuals who report a history of having been bullied score less favorably on social anxiety measures than individuals who report no history of being bullied (Blood & Blood, 2016). Craig and Tran’s (2014) meta-analysis offered a global assessment of research findings in this area and revealed a large effect size (0.82) for differences in measures of social anxiety between speakers who stutter and typical speakers. Correlates of heightened anxiety have been reported in preschool-aged children who stutter, as well. For example, Zengin-Bolatkale, Conture, and Walden (2015) found that 3-year-old children who stuttered exhibited higher sympathetic nervous system arousal in the context of a rapid picture naming task than both 3- and 4-year-old children with typical fluency. Although the source of the difference could not be determined, the authors speculated that cognitive, physiological, or attentional differences between groups may have accounted for the finding. In general, research findings are strongly supportive of biologically based differences in temperament as a predisposing factor for young children to subsequently develop elevated trait anxiety or social anxiety disorder (Alm, 2014). There is widespread agreement, however, that stuttered speech — even at the earliest stages of life — is met with a host of negative social and com-

municative responses and consequences, which when accumulated over time can lead speakers to become hypervigilant about the possibility of receiving negative/threatening responses from others and to develop a fear of being negatively evaluated by listeners (Brundage, Winters, & Beilby, 2017; Hennessey, Dourado, & Beilby, 2014). Nonetheless, it is likely that there are factors in addition to fear of negative evaluation that lead to and maintain social anxiety among speakers who stutter. In one recent model, an individual’s propensity for negative thoughts related to social-evaluation, self-focused attention, general attention biases, use of avoidance and concealment as responses to the anticipation of stuttering (and associated listener responses), and pre- and post-stuttering information processing patterns all were considered as playing a role in the maintenance of social anxiety in speakers who stuttered (Iverach et al., 2017). As will be discussed further later in the chapter, there are a range of treatments (e.g., cognitive behavioral therapy, desensitization activities) that are effective at helping clients learn to manage adversity, and in doing so, to reduce the extent to which anxiety and fear contribute to stutteringrelated disability.

Guilt and Shame Tangney (2000) reviewed the essential characteristics of guilt and shame. In that review, guilt is described as tension, remorse, or regret that one feels about having done something that is bad or wrong. As such, guilt tends to elicit corrective actions from a person, such as confessing or apologizing, or actions that are intended to undo the harm that the person has caused. Tangney described guilt as proactive and oriented toward future action; and, in many circumstances, it serves a constructive purpose. Tangney also stated that guilt-prone individuals generally are empathic individuals. The association between stuttering and guilt appears in many older counseling-oriented publications in the area of stuttering (see, e.g., Sheehan, 1958, 1994). In the context of stuttering, guilt can become nonproductive when the speaker who stutters engages in over-personalization — that is, the speaker assumes responsibility for the listener’s behaviors, thoughts, and feelings (variables that are



not under the speaker’s control). Occurrences like this can lead a speaker to apologize for his or her stuttering to a listener (e.g., My speech has caused the other person distress, thus, I should apologize; I am not cured of my stuttering after attending three months of therapy sessions, thus, I should apologize to my parents.) In such cases, one treatment goal is to help the client shift the frame of reference away from what others may need or want, and, instead, orient it toward what the client feels he or she needs or wants in a given situation. In this way, the client learns to evaluate performance in terms of how his or her actions or thoughts align with broader goals for improved communication and satisfaction with life. When guilt arises in conjunction with the client’s perceived failure to meet one’s own performance expectations (e.g., I should have been able to do better than that.), a treatment strategy is to conduct education activities that help the client develop an accurate concept of what “adequate performance” is for people who stutter. Shame, in contrast, involves instances wherein the individual engages in painful scrutiny of oneself (Tangney, 2000). With shame, one’s self-talk contains messages that revolve around themes of unworthiness, defectiveness, or incompetency (e.g., I am bad. I am worthless.). Individuals who are experiencing a shame episode may report sensations such as feeling reprehensible; feelings of shrinking or diminishment, of being or feeling small; or feeling worthlessness or powerless. Tangney stated that shame is accompanied by a desire to hide from others and from oneself — a desire to disappear — and in doing so, escape, separate, or distance oneself from the emotional pain he or she is experiencing. Shame that is induced externally (e.g., by a listener’s response to stuttering) has a significant negative impact on one’s psychological well-being, as it tends to promote self-criticism (Castilho, Pinto-Gouveia, & Duardo, 2017). In children, shame has been found to be associated with anxiety (Muris, Meesters, & van Asseldonk, 2018, as well as with “depressogenic thinking,” which in turn is associated with internalization of problems and development of anxiety and depressive symptoms later in life (Mills et al., 2015). Situationally related shame (state shame) also predicts an individual’s tendency to ruminate about negative social events well after the event has occurred (Cândea

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& Szentágotai-Ta%tar, 2017). Shame also can precipitate anger, which either may be directed at oneself or toward others for the purpose of regaining a sense of control over life activities (Tangney, 2000). Tangney (2000) added that in either case — withdrawal or anger — responses to shame tend to be nonproductive, as they tend to promote “self-oriented personal distress responses” and an “impaired capacity for other-oriented empathy.” As such, shame can interfere with interpersonal relationships in ways that guilt does not, and neither shame-driven withdrawal nor shame-driven rage are likely to rectify one’s perceived transgressions.

Emotions That Parents May Experience Parents of children who stutter understandably sometimes experience some of the same emotions that their children experience (Cooper, 1997; Zebrowski & Schum, 1993). For example, parents may feel concern or worry about how their child’s stuttering will impact other aspects of his or her life. They may feel guilty about whether their parenting behavior caused or aggravated their child’s fluency difficulties. They may feel helpless or angry over not knowing how to prevent or ameliorate their child’s disfluent speech. They may express feeling embarrassment and self-consciousness at times when the severity of their child’s stuttering in a public space causes people in the immediate vicinity to turn abruptly to discern what is going on. And parents may confess to feeling anger or impatience over their inability to help their child and to feeling guilty because they feel embarrassed or impatience about their child’s limitations. As with client’s emotions, these feelings essentially “are what they are,” and a clinician’s initial actions are to listen empathetically as parents describe their experiences and to validate the parents’ emotions. At the same time, the clinician’s job is to empower parents to become productive members of the intervention team. Ideas for how to accomplish this were discussed at length in Chapter 15, particularly under Intervention Principles 1 through 4. As parents become more knowledgeable about stuttering, and more skilled at implementing strategies that facilitate their child’s fluency performance

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and communication experiences, negative feelings and emotions such as those described earlier should begin to dissipate. Grieving, a process that commonly accompanies a significant loss, is another possible response to stuttering. Although grieving can be difficult to experience, it also “can strengthen one’s inner resolve to accomplish goals” (Crowe, 1997, p. 32). Luterman (1996) stated that much of the counseling he has conducted with parents of children with hearing loss is “grief counseling.” When preparing to counsel parents of children with communication disorders, Crowe (1997) stated that it is helpful to review the grieving process, as parents may be engaged in this process as they attempt to come to terms with what it means to have a child who has a communication disorder. A parent’s discovery that his or her child has “lost” typical communication can be a jarring realization. Kubler-Ross (1969, 1975) developed a fivestage model of the grieving process that has become well known. Clinicians operate under the hypothesis that active involvement of parents in the intervention process will facilitate their progress through the grieving process. Crowe (1997) stated that people tend to progress through the grieving stages in cycles rather than in a strictly linear manner. Thus, there is a chance that a parent (or a grieving child) will return to exhibit characteristics of a stage that he or she appeared to have left previously. Characteristics of each stage of the grieving process are as follows: • Denial (a defense mechanism designed to protect against painful emotion associated with life events); • Anger/Resentment (a “why me?” orientation as the realities of one’s situation reach conscious awareness); • Bargaining (an attempt to delay acceptance of one’s situation, to negotiate for a less severe problem situation, or to revert to a time in the past when the problem situation was not yet present or was less severe); • Depression (a reaction to the realization that denial, anger, and bargaining have not removed the problem situation, and one

is left with no alternative but to accept the problem situation); and • Acceptance (attained when one “has had the time, inner resources, and helping support to resolve the preceding stages successfully” [Crowe, 1997, p. 39]).

Ways of Interacting With Clients During Therapy Activities At all stages of intervention, it is important for clinicians to interact with clients and family members in ways that convey understanding and acceptance of their challenges and problem situations and in ways that help clients move from their current modes of thinking and behavior into new approaches that facilitate attainment of their goals. Included within this is the concept of demonstrating respect for the insight and experience that clients bring to the therapeutic interaction; the clinician knows a lot about stuttering, but the clients are the experts when it comes to their stuttering, what it involves, and how it affects them. Another part of showing respect for clients is trusting that they have the capacity to become empowered to manage the unique stuttering-related challenges they face. The clinician’s role is to point clients in the proper direction and then help them implement the skills and resources that either already are in place or are currently being developed. The remainder of this section summarizes characteristics of several ways that clinicians can engage with clients to make this occur. Information in this section is drawn from more extensive discussions of this topic in the following sources: Crowe (1997), Egan (2002), Luterman (1999), Seligman (1990), Sperry (2013), and Tellis and Barone (2018). Readers who wish to explore this topic in greater depth should refer to these sources.

Engaging in Active Listening Active listening is a foundational element of most counseling approaches. To listen actively, one must go beyond simply parroting back what the client



16.  Counseling People Who Stutter

has said, and instead attempt to enter the perceptual world of the client in order to see and feel life experiences from the client’s perspective. As noted, Egan (2002) discussed the value of listening to clients’ stories, as it provides a vehicle for the clinician to hear about the clients’ experiences and behaviors, as well as their feelings, emotions, and moods. Clients’ language usage in the stories they tell provides insights into areas that are ripe for change — areas that, once they are addressed, offer clients the potential to break through barriers or obstacles that block their ability to respond effectively to challenges, and to prevent reoccurrence of self-limiting thoughts and self-defeating behavior. Egan stated that, as clients talk about their experiences, they also are likely to reveal information about their points of view on various aspects of treatment (e.g., what they are and are not willing to attempt, what they do and do not care about accomplishing), decisions they already have made, and actions they intend to take in the future. Egan encouraged clinicians not only to listen carefully but also to observe nonverbal behavior that may confirm, deny, intensify, or conflict with spoken messages. While listening and observing, the clinician attempts to process the client’s bottomline meaning to identify not only the key messages but also the key feelings that the client is expressing.

Using Empathic Highlights Egan (2002) used the term empathic highlights in reference to concise statements that the clinician presents to the client. These statements communicate to the client that the clinician understands just what the client has said. Put another way, empathic highlights are inferences that the clinician makes about the client’s thoughts and feelings based on what the client has been saying. As such, they include not only the content of what the client has said, but also the emotions, feelings, and moods in which the content is embedded. Consider the following scenario: An adult male who stutters describes a recent job-related speaking presentation in which he stuttered more severely than usual and subsequently felt intense shame. Following the

talk, however, he received words of encouragement from a district supervisor. In this situation, the clinician might first communicate empathetic understanding of the client’s experience via a statement such as the following: You had a particularly difficult day speaking at work. So much so, that you felt like all eyes were on you and you felt like just shrinking up. That must have been difficult. Empathetic highlights like the one just described then can be followed with statements that reinforce strengths that the client has displayed in the situation and other statements that show how that strength might be applied to facilitate successful management of stuttering in the future. For example, On the other hand, you didn’t run away from the situation — you stuck with it — and it sounds like your supervisor is on your side. Perhaps you could enlist him as ally . . . you know, work with him to modify the format of these presentations temporarily, during this phase when you are getting a handle on your stuttering management skills. Empathetic highlights can be used to emphasize or communicate understanding of a range of things clients have said, including their key experiences, behaviors, and/or feelings, the decisions they have made, or the intentions they express (Egan, 2002). In the preceding example, the empathic highlight clarifies the client’s problem and presents resources/opportunities that may be available to the client for addressing the problem. Egan stated that empathic highlights can be used for other purposes as well, including the following: • To help the client evaluate options. For example, “You said you think you would be able to speak more smoothly and communicate more easily on phone calls if you practiced the sales script intensively. You also said you could speak more easily if you didn’t care so much about how fluent your speech sounded. Did you say which of

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these might work better? Or what it would look like if you put both ideas together? You know, mastering stuttering management strategies, while at the same time letting go of being upset with your stuttered words.” • To choose actions that are needed to accomplish goals.  You said you might be ready to do some activities where you disclose your stuttering to others. What steps or actions would you need to take before you go ahead and do it?

Using Probes and Summaries Clinicians can use probes to clarify information or obtain additional information from the client. These include direct questions, open-ended requests (e.g., Tell me more about how you reacted.), statements (e.g., I don’t understand which of these techniques you find to be most helpful.), and leading statements (e.g., You are hoping that the audience will . . . ). As noted in Chapter 11, open-ended requests tend to be more effective than narrowly focused questions. Egan (2002) stated that clinicians also can use probes as a means of prompting clients to consider a more balanced view of their challenges. For example, in a situation where the client focuses entirely on negative aspects of a situation, the clinician can counter with a probe such as, “I wonder if you see any positive aspects to this situation?” Egan (2002) stated that summarizing is a useful technique to use at the start of a session, as it provides a means of “catching the client up” on what transpired in the previous session; and it also is useful at times when there is a need to move the client through a roadblock in treatment, for example, when a client has made few, if any, changes over the past few sessions to address his or her lack of verbal participation during important life situations. At such times, the clinician can present the client with a recap of what has transpired during recent sessions and then follow with a probe, such as the following, “So, it sounds like things are more or less the same in terms of feeling like you are sitting on the sidelines during your classes. I wonder if during this time you discovered any obstacles that get in the way of raising your hand and jumping into the conversation?”.

Presenting Challenges and Disputations Using challenge statements is a core technique in both REBT and in Egan’s (2002) Skilled Helper model. Egan stated that “helpers are sowers of discord,” meaning that they sometimes present messages that are “somehow inconsistent . . . with [clients’] current theories of themselves and their circumstances” (p. 176). At first, the clinician issues challenge statements to the client; however, over time, clients are encouraged to issue challenges to themselves, and in doing so, come to question their thoughts, beliefs, and actions with respect to their accuracy and productiveness.

Start, Stop, and Continue Challenges Egan (2002) identified three different categories of challenges. Stop challenges are statements in which a client is presented with the suggestion to refrain from or discontinue thoughts or behaviors that seem to perpetuate the problems the client is experiencing. Examples of this in stuttering therapy include the following: (1)  stopping the practice of saying “um like um” before the start of an intended word in an utterance, and (2) catching instances of rumination on negative stutteringrelated social experiences and then shifting attention to neutral or positively oriented thoughts associated with active stuttering management. The second category, start challenges, are statements in which the client is encouraged to initiate the use of thoughts or actions that facilitate attainment of intervention goals. Continuing with the preceding example, a start behavior would be for the client to start the practice of going directly into the first sound of a word (without the “um um’s”), even if it means the word will feature stuttering-related disfluency. The third type of challenge, continue challenges, involves actions or thoughts that currently are working well for the client, with respect to facilitating effective management of current problems and/or the development of unused opportunities. An example of this would be to continue use of an existing practice wherein the client deliberately catches and then deliberately lessens the



physical tension in the speech articulators while blocking on speech sounds. Stop, start, and continue challenges also can be used to help clients develop a greater sense of openness about fluency impairment. Some people who stutter go to great lengths to hide their fluency impairment from others due to concern about how others may evaluate them. This leads to the use of assorted avoidance and postponement behaviors (e.g., word substitution, pretending to have forgotten what was to be said). Such strategies seldom are effective at hiding stuttering completely, and they divert cognitive resources away from stuttering management. These behaviors often have the counterproductive effect of diminishing communication and one’s sense of self-efficacy (Blomgren, 2010). In such instances, the goal is to nudge the client toward being more open about fluency impairment with others so that the client can devote more of his or her speech production resources toward fluency management. Blomgren noted that speakers can accomplish this goal by making simple, direct statements about their speech (e.g., I stutter.), humorous remarks (e.g., That’s easy for you to say!), or by bringing stuttering out into the open through the use of voluntary stuttering. Many clients, but particularly teenagers, find it quite difficult to acknowledge their stuttering to others (Blood, Blood, Tellis, & Gabel, 2003). Their expectations about receiving negative reactions to their stuttered speech fuel tendencies o conceal stuttering from others and avoid situations where the occurrence of stuttering is greatest. The author has found that, when addressing this issue, it is important for clinicians to first validate the client’s fears about how listeners may react and the client’s concerns about selfdisclosure of fluency difficulties, and, if possible, to provide opportunities for the client to interact with or read about other people who have had similar concerns. Clinicians also can model the act of self-disclosure during activities such as telephone conversations, in which they simulate stuttered speech. Empirical disputing (e.g., “Where is the proof that others will reject you if they know you stutter?”) and functional disputing (e.g., “How are you helping yourself manage stuttering more effec-

16.  Counseling People Who Stutter

tively by putting so much energy into hiding it from others?”) — techniques described by Nelson Jones (2002) — can be used to open initial dialogue on this topic and to explore the extent to which a client sees advantages and disadvantages in his or her present attempts to hide fluency impairment. The author also has found that “start” behaviors associated with openness work best when they are preceded by activities in which clients list the potential risks and rewards associated with being open about stuttering and then weigh the potential risks against the potential rewards. For many clients, the key question becomes, “Am I willing to risk the possibility that this listener will reject me in order to move closer to my goal of feeling in control of my speech fluency?” This is a question that only the client can answer, and the clinician should be prepared to support the client regardless of how he or she responds. Not every client will embrace the notion of taking communicative risks immediately. Even when a client initially declines to risk exposing himself or herself to potentially unpleasant listener reactions, the clinician still can play an important role in improving the client’s communicative functioning by “planting the seeds” for how one can begin the process of performing activities that are challenging, uncomfortable, or threatening to do.

Challenges to “Blind Spots,” Distorted Beliefs, and Pessimistic Thinking Egan (2002) stated that challenges typically are directed at the client’s “blind spots,” which are problem areas that the client does not recognize, or perhaps vaguely recognizes but does nothing about. Egan said that blind spots arise for different reasons, including simple unawareness, selfdeception, and disinterest in changing. Figure 16–7 illustrates examples of the types of blind spots clients may exhibit. As shown in the Figure, a client may present mismatches between what they do and what think or believe, mindsets that consists of rigid or fixed assumptions, beliefs, and preconceptions about other people or things, and/or self-defeating (i.e., self-limiting) behaviors such as avoidance of words or situations when stuttered speech is expected. When clients present blind spots in their thoughts, beliefs, and/or behaviors,

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Mindsets

Mismatches

Selfdefeating behaviors

Figure 16–7. Common blind spots that clients who stutter exhibit. Blind spots are aspects of one’s cognitive or behavioral repertoire that either are unrecognized, poorly understood, or intentionally ignored by the client. Blind spots can precipitate the emotions that the client experiences, and as such, are helpful to target in intervention.

the clinician (and eventually the clients) can challenge them. According to Egan (2002) mindsets typically involve overgeneralizations that distort or misrepresent the reality of events in the client’s life. They also can include preconceptions about what the client expects to happen in each feared or anxietyinducing situation. For clients who stutter, cognitive distortions and preconceptions that predict threatening or aversive outcomes can be significant enough to push an individual into catastrophizing events that most other people would regard as being no more than an annoying, unfortunate, or a nuisance. Related to mindsets are internal behaviors such as ruminating, worrying, rehearsing, and daydreaming. Each of these, when engaged in extensively, has the potential to limit client functioning, and thus are challenged to be discontinued or modified. A client’s self-defeating behaviors can be challenged as well. Examples of the latter include the following: apologizing to other people for one’s stuttering (doing this cedes the evaluative and approval process for one’s fluency to the listener),

including far too much content for a time-limited talk (the extra context creates time pressure on the speaker), and, as noted previously, avoidance of feared words or speaking situations. In recent years, clinicians increasingly have incorporated elements of cognitive-behavioral therapy (CBT) as a part of treatment for stuttering with adolescent and adult clients. As explained earlier in the chapter, CBT (e.g., Ellis & Harper, 1975; Nelson-Jones, 2002; Seligman, 1990) helps clients to develop a systematic process for analyzing how they interpret life events (particularly those that involve adversity), discovering the consequences of their interpretations, and then disputing/altering interpretations that are inaccurate, nonproductive, or self-limiting. Common self-limiting beliefs and accompanying productive revisions were presented in Table 16–1. Clinicians have implemented a variety of strategies/techniques to help clients identify and modify these self-limiting beliefs. As described earlier in the chapter, cognitive approaches incorporate Socratic questioning techniques that are intended to lead clients to productive insights about their maladaptive beliefs; and REBT approaches have used directed questioning and persuasion to accomplish this goal. Nelson-Jones (2002) described four “disputation” types that clinicians can present to clients for the purpose of challenging client beliefs that appear to be unsupported, distorted, and thus maladaptive and self-limiting. In contrast, in Egan’s positive psychology approach, clinicians are urged to challenge clients’ existing strengths and resources, as well as their unused or underused opportunities. Table 16–2 provides examples of Nelson-Jones’s and Egan’s challenge types. In the context of counseling, the term challenge is not meant to suggest an adversarial or confrontational approach. Instead challenges are presented in the context of sincere inquiry, genuine care for the client, and the promotion of clinician-client collaboration that is designed to help the client recognize and move past obstacles that prevent him or her from attaining goals. Challenges like these typically are combined with behavioral experimentation (see, e.g., Menzies, O’Brian, Lowe, Packman, & Onslow, 2016; Menzies et al., 2008; Seligman, 1990; Van Riper, 1973), wherein prior



16.  Counseling People Who Stutter

Table 16–2.  Challenges That Clinicians Can Present to Clients When Helping Clients to Modify Distorted Beliefs and Unproductive Self-Talk Challenge Type

Challenge

Functional Disputinga

• Is this (belief/rule/behavior) helping you? • How does/did this (belief/rule/behavior) affect you? What are/were the pros and cons? • How has avoidance of speaking in group settings helped you move closer to your goals?

Logical Disputinga

• How does it follow that because you want x to be true, it should be true? • How is it that you are forgiving of the disabilities that other people have, but you are not forgiving of disability in your own life?

Empirical Disputinga

• From what you have said, most people stay on the phone calls with you. Where is the proof that “everyone hangs up”? • Your classmates asked several questions about your report. How does this fit with your belief that “no one in your class listens to you”?

Philosophical Disputinga

• From my perspective, the question is whether you will allow yourself to be satisfied with your performance even though you might not speak entirely fluently. • Can you risk speaking in this situation even though you expect to feel anxious about what others may do or think if they hear you stutter?

Challenging Strengthsb

• You really seem to go “all out” during your half-marathon races. Is there any part of that “all out” approach you could apply to what we’re doing here with your stuttering? • Time and time again with me, you work your way out of stutters so that they last only a moment. What would it take for you to be able to do the same when you are talking with your friends?

Challenging Unused Opportunitiesb

• You said you mainly work at managing your stuttering when you’re around me and your parents. What is it about us that makes us good talking partners? Who else do you know who has some of these characteristics? • You say your speech is smooth when you talk with people who “understand” stuttering. Your upcoming weekend at the children’s camp gives you a chance to talk with new people who aren’t such a sure thing. That seems like just the type of goal that would take you to next level in managing your stuttering.

a

After Nelson-Jones (2002) After Egan (2002)

b

to entering a feared situation, the client who stutters describes or writes out anticipated fears or threats. After completing the activity, the client compares what he or she had expected would happen to what did happen. For clients who frequently engage in maladaptive cognitive sets such as over-

generalization, universal attribution, self-blaming, catastrophizing, personalization, and pessimistic thinking, the outcomes they anticipated often will be much worse than what does occur. In this way, behavioral experimentation creates a forum for the client to disconfirm expectations that exacerbate

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feelings of fear and anxiety and that interfere with communication performance.

Application of Counseling Practices in Stuttering Intervention In this section, findings from several studies that have incorporated counseling concepts with people who stutter are discussed, and several clinical scenarios that indicate a need for clinicians to incorporate counseling into an intervention plan are outlined.

Targeting Self-Limiting Beliefs and Self-Talk:  Research Outcomes Results from several recent research studies suggest that cognitive-behavioral therapy is a promising approach to treating social anxiety disorder in adults who stutter. For example, Menzies et al. (2008) administered a CBT program as part of a more comprehensive treatment for stuttering that included speech restructuring activities as well. The CBT treatment was administered over 10 weeks via individualized sessions, for a total of 15 hours. The CBT treatment contained three components: 1. Cognitive restructuring — activities where the participants were trained to identify and modify irrational thoughts related to anxiety; 2. Graded exposure — gradual and progressively more intense exposure to anxiety inducing situations; exposure was repeated until participants’ anxiety levels subsided significantly; and 3. Behavioral experimentation — participants compared their anticipated negative outcomes for the graded exposure activities to the actual outcomes. At follow-up, participants who completed the CBT program showed no signs of social phobia and reduced signs of avoidance behaviors commonly observed in stuttering. Participants in a comparison group that received only a speech

restructuring treatment showed no such changes. While the CBT treatment improved the participants’ anxiety and avoidance, it had little impact on speech fluency performance. In a follow-up study, Menzies et al. (2016) administered an online computer-based program (i.e., CBTPsych) as part of an international phase II clinical trial. Data from 49 participants showed significant improvement in a variety of measures, including the following: selfratings of depression, anxiety, and stress; fear of negative evaluation; stuttering avoidance; and the occurrence of unhelpful thoughts and beliefs about stuttering. Scheurich, Beidel, and Vanryckeghem (2019) reported improvements in social anxiety in a study of six speakers who stutter, aged 17 and older, using a 10-hour-long social anxiety treatment that consisted of graded exposure to anxiety-inducing stimuli. At a 6-month follow-up assessment, findings showed that all participants improved their affective, behavioral, and cognitive experience of stuttering; speech fluency, however, did not change significantly. Findings from Scheurich et al. (2019) and Menzies et al. (2008, 2016) are consistent with findings from Blomgren, Roy, Callister, & Merrill (2005), who examined the long-term effects of a treatment that primarily targeted variables such as “unhelpful thoughts,” hiding stuttering from others, and the avoidance of words. The treatment resulted in long-lasting improvements on measures of social anxiety and avoidance tendencies, but relatively little change in speech fluency. Based on these findings, if long-lasting changes in speech fluency are sought, it likely will be necessary for clinicians to target speech fluency directly and apart from a client’s social and emotional concerns.

Applying Counseling Practices in the Broader Context of Stuttering Treatment Counseling practices are particularly relevant in clinical contexts where clients are in need of accurate information pertaining to the challenges they are encountering, and in contexts where cognitive (i.e., thoughts and beliefs) and emotional factors are compounding the effects of fluency impair-



16.  Counseling People Who Stutter

ment on speech communication and/or interfering with a client’s response to treatment. When one reviews the treatment literature on stuttering, it soon becomes apparent that counseling activities have been implemented in several ways. In many older approaches to “speech restructuring,” treatment emphasis was placed squarely on speech motor training; and social, cognitive, and emotional components of a person’s stuttering-related disability either were untreated or treated minimally, with the assumption being that reductions in stuttering frequency would resolve any disabling stutteringrelated thoughts, beliefs, feelings, or emotions that were present. Although there is evidence that this sometimes occurs (Bothe, Davidow, Bramlett, & Ingham, 2006), in contemporary practice, it has become much more common to treat affective and cognitive aspects of stuttering directly in cases when concerns in these areas are present. As discussed thus far in the chapter, there are an assortment of circumstances within the course of a treatment plan that suggest the need for counseling-oriented activities. Examples of such circumstances include the following: • Cognitive and/or emotional factors associated with stuttering are present, with negative consequences on functioning.  These are situations wherein clients — through their overt behavior, responses on assessment measures, or verbal descriptions of their stuttering-related experiences — indicate the presence of intrusive thoughts, images, or ideas, feelings/emotions, and/or behaviors (e.g., attempts to avoid or conceal stuttering related behavior) that significantly impede their communication performance. • Difficulties in attaining success during generalization activities.  These are situations where the client demonstrates effective stuttering management in clinical settings and perhaps in some real-world situations, but demonstrates significant difficulty attaining the same level of success in other real-world settings. In the latter context, the communicative dynamics of

the situation in combination with client’s cognitive and emotional approach to the situation are likely explanatory variables for the difficulties the client is experiencing. • Frequent or demonstrable use of physical compensatory behavior, avoidance, or concealment behavior.  As indicated in Chapters 5 and 11, some clients who stutter demonstrate use of physical nonspeech behaviors (e.g., rhythmic finger-tapping, sudden head jerks) to facilitate initiation of speech. When such behaviors are present, clinicians can probe further with the client to identify the extent to which maladaptive beliefs about the consequences of overt stuttering and disruptive emotions are present and intertwined with the nonspeech behavior. As will be seen in Chapters 17 and 18, nonspeech secondary behaviors can be treated directly; however, in such cases, the client may realize more long-term benefit when the treatment centers instead on modifying maladaptive beliefs that may be driving the use of the behavior in the first place. The preceding list provides a sense for how and when counseling activities can be applied in stuttering treatment. In Chapters 17 and 18, this topic will be explored in greater detail, with specific examples related to instances of avoidance, concealment, and difficulties in generalization of stuttering management skills.

Summary This chapter focused on the role of counseling practices in the treatment of stuttering. The chapter began with an overview of counseling approaches. Principles and practices associated with psychodynamic, cognitive-behavioral, humanistic, and integrative approaches to counseling were reviewed, along with the idea that counseling approaches differ in their main points of emphasis, with some approaches being centered on what is missing or “broken,” and other approaches focusing on the cli-

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ent’s positive aspects (i.e., what is present and functional), as well as the idea that not everything that is broken has to be fixed. In other words, clients may find that some elements of their stuttering are acceptable just as they are. A range of interactional techniques were described. In treatment, these are used to help clients clarify the nature of the challenges they experience, identify the pros and cons of their current response strategies to adversity, and develop and implement strategies for managing current and future stuttering-related adversities. As clients develop a repertoire of strategies for managing the cognitive and affective components of stuttering, they should find it easier to apply motor-based stuttering management skills in everyday situations where the possibility of receiving disruptive responses from communication partners is always present. As clients improve their ability to manage all elements of their stuttering disability (the cognitive part, the emotional part, and the behavioral part), most clients should find themselves in a position to attain what they want most — that is, the feeling of being satisfied with how they communicate and how they are as a person.

Questions to Consider 1. Anxiety plays a role in stuttering for many people who have the disorder. Conduct an experiment where you slip pseudo-stuttering into your speech as you are ordering coffee or food in a restaurant. What feelings do you have before placing your order? During and after placing your order? How do you suppose your experience compares to that of people who stutter when they are in the same situation? 2. Think of examples from other communication disorders or other areas of life where anxiety affects an individual’s functioning. How does anxiety come about in these other situations? 3. Review the six types of challenges that are presented in Table 16–2. Based on what you have read about stuttering so far, can you think of other challenge statements that a clinician might present to a client who stutters?

17 Sample Intervention Programs for Children Who Stutter

Chapter Objectives After reading this chapter, readers will be able to: • Describe background factors that should be considered when designing an intervention plan. • Compare/contrast the options that are available for treating children who stutter. • Summarize the treatment characteristics and intervention design for various scenarios of treating preschoolers who stutter. • Summarize the treatment characteristics and intervention design for various scenarios of treating early to middle elementary grade children who stutter. • Summarize the treatment characteristics and intervention design for various scenarios of treating late elementary school to preschoolaged children who stutter.

essentially to pull this information together by reviewing a range of hypothetical clinical cases and published intervention programs, each of which offers unique examples of how to structure intervention, what to do with clients during sessions, and what to do after the clients move on from participating in a formal clinical program. This chapter deals with examples of intervention plans for use with young children who have fluency concerns, and Chapter 18 deals with intervention plans for use with older children, teens, and adults who have fluency concerns. The main focus in both Chapters 17 and 18 is on intervention with cases of stuttering; however, with modification, several of these approaches can be implemented with clients who present with cluttering, atypical types of disfluency, and acquired forms of stuttering as well. Before addressing the learning objectives for this chapter, some of the main concepts that have been introduced in the preceding treatment-related chapters from this book are briefly summarized.

Introduction

A Recap of Intervention Concepts Discussed Thus Far

A lot of information about fluency, stuttering, and clinical practice has been covered in the first 16 chapters. The goal for the last two chapters is

In Chapter 13, the focus was on matters related to differential diagnosis, the processes of making post-­assessment recommendations, and with that,

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•Build an environment that supports & accepts stuttering •Build a fluency facilitating environment



widely-used approaches that involve the use of assistive devices and pharmacological agents. Chapter 15 presented nine interlocking intervention principles, around which clinicians can develop intervention plans that are tailored to meet the unique needs and circumstances of each client. The rationale and purpose for each intervention principle was explained, along with associated implementation methods and examples of supporting research findings. The nine intervention principles, in a sense, offer clinicians a “menu of options” to consider when providing individualized services to clients. The notion of individualized intervention, of course, contrasts with the idea of a “one size fits all” approach to intervention. It also implies that not every intervention principle will be applicable to every client. Rather, it was suggested that clinicians must use their professional judgment, which is based on their synthesis of assessment results and clients’/parents’ input about their treatment-related preferences and aspirations, to arrive at an intervention plan that is well-suited for the individual. For some clients, this may mean an intervention plan that is based on just three or four principles and, for others, it may mean an intervention plan that is based on all nine principles. A summary of these intervention principles is presented in Figure 17–1.

•Provide systematic feedback •Develop existing strengths

Extend

•Develop knowledge base in client and others

Build

the process of deciding when and with whom to recommend intervention. The chapter also presented a collaborative approach to developing intervention plans and the development of intervention plans that not only focus on the client’s fluency performance but also consider broader themes in a person’s life such as the client’s communication performance and his or her perceptions of quality of life. Also discussed in Chapter 13 was the importance of clarifying the definition of “success” so that the clinician and client are oriented toward and enthusiastic about achieving the same outcome. In Chapter 14, the focus shifted to a discussion of the responsibilities and roles of the clinician when working with people who have fluency concerns. The importance of ethical and evidencebased practice was discussed, along with the notion that clinicians often are called upon to assume a range of roles when providing services to the clients with whom they work. These include familiar roles such as expert, teacher/coach, model, and counselor, and less familiar roles such as manager, consultant, and advocate. The chapter concluded with a bird’s-eye view of the intervention landscape, differences between direct and indirect approaches to intervention, and a discussion of the differences between behavioral treatments and other less-

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•Develop new skills to reduce stuttering frequency •Develop new skills to modify ineffective and maladaptive responses to stuttering

Figure 17–1.  Summary of intervention principles for use with people who stutter.

•Apply stuttering management abilities in daily contexts •Maintain stuttering management abilities over time



17.  Sample Intervention Programs for Children Who Stutter

Finally, in Chapter 16, several general counseling approaches were presented in the context of the way in which counseling fits within the scope of practice in speech-language pathology and, more specifically, within intervention programs for people who stutter. Common emotional responses that accompany stuttered speech were reviewed, as was the role that these emotions play in the establishment of self-limiting, nonconstructive thoughts, beliefs, and behaviors that have the potential to amplify the effects of an individual’s fluency impairment in ways that heighten communication disability, create the potential for social anxiety disorder and reduced self-esteem, and reduce one’s overall satisfaction with speech communication and quality of life. Specific strategies for listening to and talking with people who stutter were presented, including strategies for helping clients alter cognitive-behavioral components of their stuttering-related disability, and in doing so, break through some of the cognitively and emotionally based “logjams” that hinder their progress in stuttering management and, more importantly, the development of a positive view of one’s competency and worth as a communicator. So, it is against this backdrop that the final two chapters are presented. As noted earlier, the goal in this closing section of the book is to integrate information in ways that provide a sense for how to develop and implement individualized interventions that are effective at helping clients attain outcomes that they think they want to reach, and perhaps, outcomes that they did not think were possible or were unaware of.

Individualized Intervention: Introductory Comments and Preliminary Considerations The aim in this chapter is not to review all possible treatment approaches or all possible case scenarios that clinicians will encounter. Rather, the approach is to focus mainly on several case scenarios that clinicians are likely to encounter, and then to explore corresponding interventions. The case examples are not verbatim reports on intervention plans that transpired with individual clients. Instead, the approach here is to expose readers to structural elements that go along with different treat-

ment approaches and the underlying rationales for making specific decisions about the structure of treatment. The focus is mainly on broad elements of intervention (e.g., what to do, when and how often to do it), with occasional exploration of finer elements of intervention (e.g., how to teach a client to implement a particular treatment strategy; how to work through “sticking points” that clients may experience). The text then comments on how an intervention plan can be adapted if the client who is depicted in the case example were to present with a less typical performance profile. Of course, there is no one best way to treat each client. With that in mind, sometimes alternative approaches are also presented that a clinician may have been able to use with the case example.

Historical Perspective As indicated in Chapters 13 and 14, numerous intervention approaches have been described in the professional literature for treating childhood stuttering. In a broad sense, these approaches range from those that seek to alter the communicative environment in which a child functions to those that seek to help the child directly alter aspects of his or her speech in ways that promote more fluent speech and less severe stuttering symptoms. Beyond the approaches themselves, there even has been debate on the basic question of whether direct forms of treatment should be introduced to preschoolers who stutter (Martin, Kuhl, & Haroldson, 1972). The concern of some authorities was (and perhaps, for some clinicians, still is) that direct forms of treatment will increase children’s concern about their stuttered speech, and in doing so, lead to the development of various “secondary behaviors” (i.e., self-devised behaviors that are intended to conceal, avoid, and cope with the anticipation of overt stuttering) that only increase stuttering-related disability. (For an example of this line of thinking, see Johnson, 1949.) Aside from this concern, which subsequently has been determined to be unfounded, there also is the practical matter of whether preschoolers have the attention resources and meta-communication skills that are necessary to comprehend and then independently apply common stuttering management strategies. (The latter is a better-supported reason for questioning the extent to which direct

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intervention approaches should be introduced routinely to preschoolers who stutter, but even this is not supported in an absolute sense.) The consensus today is that early intervention for stuttering is helpful and that intervention approaches for preschoolers need not be complex to be effective. An assortment of direct and semidirect approaches to treating childhood stuttering have been examined and shown to be effective (Baxter et al., 2016; Bothe, Davidow, Bramlett, & Ingram, 2006). Indirect approaches, which center on regulation and management of a child’s communication environment also are widely used, but their effectiveness has not been studied as extensively as direct and semi-direct treatment types.

Informing Clients and Caregivers About What to Expect In intervention plans that involve preschool-aged children, it is customary to begin the intervention process by providing parents with an overview of how treatment will unfold — that is, how long treatment is anticipated to last, what the primary treatment strategies will be, and why they are expected to be helpful. It also is important to discuss with parents the ways in which they can be involved in the intervention process. In the author’s experience, most parents are happy to support the treatment process as they are able, and they are open to learning about how they can facilitate the clinician’s efforts during treatment sessions and during home-based activities. Beyond this, other helpful things to review with parents include those that follow. The nature of improvements in stuttered speech: Although exact trajectories of improvement are difficult to predict, treatment research data with children do indicate that in many cases, improvement in fluency should become apparent within the first five to 10 treatment sessions. To paraphrase Onslow, Packman, and Harrison (2003), if clinicians find that they are doing the same activities over and over with a child who stutters and have seen no signs of improvement, it probably means that it is time to examine ways of modifying the treatment approach. Parents also should be prepared to expect fluctuation in children’s fluency during treatment. Although a child’s overall trend

might be one of general improvement, it is not usual for a child to experience temporary, intermittent spikes in disfluent speech along the way. The sources for these “blips” in disfluency often are difficult to determine. Still, parents will appreciate knowing that their occurrence is not unexpected. What to say to children about “seeing a speechlanguage pathologist (SLP)”:  As a treatment program is about to commence, clinicians should be prepared for questions from parents such as, “What should I say to my child about coming to see you?” or “What should say if my child asks about where we are going?” There is not a single correct answer to these questions, but as a rule, parents should respond with an age-appropriate, accurate response. For preschoolers, the response might be, “We’re going to see a (lady/man) and you are going to talk with her/him and look at pictures and maybe play games.” For elementary school-age children, who most likely will already remember the SLP from the initial assessment, responses can be more precise, such as “We’re going back to see the clinician, as that is someone who is likely to be able to help you (learn ways of speaking more easily/learn how to work through those words that you are frustrated about.”). Parents may not always feel as if they have the perfect thing to say to their child, but in most instances, anything they say will be better than saying nothing. This is because, in the absence of information from parents, children will arrive at their own conclusions about what it means to receive services for their stuttering. Parental silence in this situation may lead the child to conclusions such as, “They can’t even talk about it. Stuttering must be really bad.” or “They didn’t say anything. There must be something seriously wrong with me.”

Treatment and Service Delivery Options Options for service delivery typically are constrained by an assortment of factors, such as the setting in which a clinician practices, and related factors such as size of the clinician’s caseload, access to and types of treatment space, the feasibility of scheduling clients for individual sessions, the feasibility of organizing group sessions, and so forth. The existence of constraints like these will



17.  Sample Intervention Programs for Children Who Stutter

influence elements of treatment such as the ease with which parents can participate directly in treatment sessions (e.g., it would be easier to do this in a private practice setting than in a school setting), treatment dosage (e.g., a clinician with a very large caseload may find it challenging to schedule a child for more than one session per week), and even the number of sessions the clinician can offer to the client (e.g., site administrators or insurance funding may provide support for fewer sessions than what the clinician feels is optimal for the client). Constraints like these mean that clinicians must be strategic and creative — designing treatment in ways that offer the potential of delivering the greatest impact given the resources that are available. Examples of such approaches are provided in some of the case examples that follow.

Clarifying Which Outcomes Are Valued Most Chapter 13 discussed at some length the importance of having a clear understanding of how the client and the clinician view the purpose of intervention and, related to this, what type of long-term treatment outcome each individual would like to see occur. As noted in Chapter 13, clients who are ashamed of their stuttered speech and/or anxious about how other people will react to it, are likely to aim for an outcome that involves concealing their identity as a “person who stutters” from other people. Clients who aim for this outcome are nearly always bound to experience disappointment and frustration (not to mention, continued shame and anxiety) because, for most individuals who stutter, it simply is not possible to hide the symptoms of stuttering all day, every day from other people. And even if it was possible, the amount of effort needed to accomplish the outcome is likely to result in dissatisfaction as well. For clinicians, the tension often centers around whether it is better to encourage clients to strive toward speaking in a more fluent way or whether it is better to encourage clients to strive for an open, less effortful, less impactful form of stuttering (Van Riper [1973] referred to this as “fluent stuttering”). Clinicians who are drawn to the latter outcome typically will argue that it is preferable to encourage clients to speak as fluently as possible because

open, fluent stuttering is essentially the opposite of the main problem for many clients, which is their strong drive to hide their stuttering from others. Clinicians who advocate fluent stuttering as an outcome also are likely to frown on encouraging clients to pursue “fluent speech” as a goal because, for cases with chronic stuttering, spontaneously fluent speech may not be a feasible outcome (i.e., fluency will not normalize unless the client’s underlying fluency impairment normalizes) and because speaking with controlled fluency often becomes yet another way for clients to attempt to conceal their identity as a person who stutters. Alternatively, other clinicians may encourage clients to strive toward improving speech fluency by making adjustments in speech motor movements (e.g., speaking slightly more slowly, monitoring articulation rate and/or articulatory movements more closely and continuously, attempting to speak while using a target speech rhythm).Talking in this manner usually results in fewer overt occurrences of stuttering-related disfluency. Attainment of controlled fluency, when motivated by a desire to communicate more efficiently and clearly and with relatively minimal effort, is a valid and productive outcome to strive for as well. These two outcomes — a minimal amount of disfluency on the one hand, and open, minimally disruptive stuttering on the other hand ​— sometimes are presented as “either/or” outcomes. In clinical practice, however, SLPs also have the option of using an integrated approach, where clinicians encourage clients to work toward both outcomes through the simultaneous development of strategies that result in fewer overt, stutteringrelated disfluencies in the client’s speech, as well as through the use of other strategies that enable the client to minimize the extent to which any residual stuttering-related disfluency disrupts speech communication. In this way, the client attains both outcomes: speech that is more fluent, and stuttering that is open, relatively effortless, and minimally disruptive. In an integrated, or eclectic, approach to intervention, a client’s stuttering-related beliefs and emotions can be targeted, if necessary, along with these speech fluency goals. These facets of stuttering can be presented to clients in various orders. The clinician uses his or her clinical judgment to identify the presentation format that seems best

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suited to the client’s needs. The interplay between these conceptualizations of stuttering treatment are discussed at greater length in Chapter 18.

Addressing Children’s Concerns About “Being in Speech Therapy” Another issue that may arise, particularly with school-aged children, involves instances when children express concerns about participating in fluency intervention. This situation can arise in several ways, but two of the more common scenarios are these: The scheduled time for the clinical sessions overlaps with other activities that the child would rather participate in; and the child is embarrassed about attending treatment and does not want his or her peers to know. Each of these is a valid concern. As such, they warrant the attention of the SLP and/ or the child’s parent. Scheduling conflicts sometimes are easy to resolve, but when they are not, it may be necessary to work out some type of allowance that accommodates the child’s competing interests (e.g., rescheduling a treatment session that overlaps with an activity that is of particularly high value to the child; in school settings, shortening the length of a session that conflicts with the other, high value activity and then adding a second session on another day). The challenges are greater in scenarios where the child’s embarrassment about stuttering leads the child to become concerned about revealing his or her stuttering or therapy participation to others. In the author’s experience, these situations take longer and are more complicated to improve. Counseling activities that are aimed at breaking down shame and/or anxiety are a good starting point, along with basic sensitivity toward and awareness of the child’s feelings and emotions. In school settings, when intervention is delivered through a “pull-out” method, clinicians must be alert to the possibility that a child who feels shame about stuttering is likely to have the sense that “all eyes are on him or her” when leaving the classroom to attend therapy. In the latter case, during the early stages of treatment, clinicians perhaps can use their understanding of the situation and the child to devise discreet ways for the child to exit the class. Later, as treatment-induced changes lead to shifts in the child’s “relationship”

with his or her stuttering, the goal would be for the child to eventually be capable of being more assertive in the classroom. With this type of outcome, a child would be able to inform others openly and calmly about where he or she was going and why, without feeling the need to apologize for it.

Case 1:  Preschooler With Mildly Disfluent, but Typical Fluency Performance This case example is built around a hypothetical 30-month-old male whose parents have concerns about recent changes in his speech fluency. The case example is used to illustrate a scenario in which the clinician’s analysis of assessment data indicates a diagnosis of stuttering is not warranted. Consequently, rather than commencing direct treatment with the child, the clinician and the child’s parent collaborate to develop a plan that includes completion of brief intervention modules that focus on parent education and practices related to the creation of a fluency facilitating environment, acceptance and support of the child’s developing communication skills, and other selected education and prevention topics. The clinician and parent also develop a plan for tracking the child’s progress in the coming months and, if necessary, reassessing his speech in the months following the initial assessment.

Background Information The child’s parent provided the information shown in Table 17–1 in response to questions on a case history form and during a clinical interview with the SLP. The parent’s report indicates that the spike in disfluent speech began as the child neared age 2;6. This is a typical age for children to experience a (temporary) decrease in speech fluency. For a male, this increase in disfluency, if it does occur, typically will occur closer to age 3. Thus, this child is younger than most males in terms of the age at which the increase in disfluent speech occurred. In typically developing preschoolers, a decrease in speech flu-



17.  Sample Intervention Programs for Children Who Stutter

Table 17–1.  Case Example 1:  Case History and Parent Interview Data Demographic Information Child’s age:

2;6 (30 months)

Child’s sex:

Male

Household structure:

Lives with mother, father, and 1 brother (age 0;3)

Parents’ education:

High school diploma (mother and father)

Other caregivers:

None (child is not in preschool or daycare)

Problem/Complaint Behavior(s) Primary problem/complaint:

Mildly to moderately disfluent speech, possible stuttering

Parents’ level of concern:

Moderate (per self-report)

Family history:

Paternal uncle with persistent stuttering

Age at problem onset:

2;4 (28 months)

Time since problem onset:

2 months (disfluency spike followed birth of a sibling)

Severity trend since onset:

Stable, slightly improved during past week

Disfluency type(s) noted:

Whole word repetitions (mono- and multi-syllabic words) most common; occasional part-word repetition

Disfluency duration:

Mostly one-iteration repetitions; some have two, rare >2

Associated behaviors:

None

Awareness/reactions:

Seems unaware/minimally aware, no obvious emotional reactions

Impact on functioning:

Very few activity limitations, no participation restrictions

Environmental factors:

Most disfluent during car rides, at bedtime, when excited

Parent responses/reactions:

Listens patiently during disfluency; no other active attempts to help; moderate concern that disfluency might persist

Previous services:

None (no previous speech-language services)

Other Aspects of Development/Other Concerns Medical history:

Unremarkable

Developmental milestones:

Within normal limits

ency typically coincides with advances in syntactic and lexical development, and concurrent increases in utterance length and complexity (and thus, greater demands on the speech motor system). On this basis, one might expect to see this child present with relatively advanced language skills for his age. Also, the disfluency spike followed shortly after the birth of a sibling. It is difficult to say what,

if any, effect this may have had with respect to changes in the child’s communicative routines at home or other variables that might have influenced the child’s fluency. With developmental disfluency, the onset of most cases cannot be linked to specific precipitating events such as the birth of a sibling (Yairi, 1981). That said, parents do sometimes report an association between the two.

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Summary of Speech-Language Assessment Protocol and Results The SLP completed a speech-language assessment. The assessment activities focused primarily on the child’s speech fluency performance. The clinician also assessed the child’s speech sound development and receptive and expressive language development via administration of age-appropriate, norm-referenced tests. The child’s parent had not expressed concern about functioning in these areas; however, the clinician assessed these areas because, as explained in Chapter 6, functioning in these areas has been associated in some studies with children’s likelihood of recovering from stuttering. The child’s functioning in these areas also may affect the types of treatment stimuli that are used, should treatment be recommended.

Assessment Procedures and Results The fluency assessment was based on elicitation and analysis of a 300-syllable-long conversational speech sample that transpired in a play-based setting between the child and his parent. Prior to the start of the conversational speech sample task, the clinician instructed the parent to interact with the child as she normally would and to speak in a natural manner (e.g., refrain from peppering the child with closed-ended questions, refrain from asking the child to recite nursery rhymes or other memorized information). The clinician sat off to the side as the parent and child played, and used coded transcription on a scoring grid like the one described in Chapter 12 to conduct a real-time analysis of the child’s fluency and to note the parent’s interactional style with the child. The online (i.e., real-time) analysis meant that the clinician would have preliminary data about the child’s fluency at the conclusion of the assessment. That data could be used as a basis for formulating a diagnosis and for making treatment recommendations at the conclusion of the assessment. The clinician had considered administering the Stuttering Severity Instrument-4 (SSI-4; Riley, 2004) but elected not to do so because the clinician’s online analysis of the conversational speech sample suggested that the child did not exhibit symptoms of stuttering; and the SSI-4 results are

only interpretable in cases where a client has been diagnosed with stuttering (i.e., one cannot have a “stuttering severity score” if one has not been diagnosed as a person who stutters). The Test of Childhood Stuttering (TOCS; Gillam, Logan, & Pearson, 2009) does have a diagnostic component in addition to a severity score component; however, the TOCS test norms start at age 4;0, and thus are beyond the child’s age. The assessment also included informal observations about other aspects of the child’s functioning (e.g., voice and resonance qualities; structure and function of the oral mechanism). Results from the most relevant assessment activities are shown in Table 17–2. The assessment and analysis procedures for fluency performance were consistent with the informal assessment procedures described in Chapters 11 and 12. As shown in Table 17–2, the child’s speech fluency appears to fall within normal limits. That is, the child’s combined frequency for repetitions, prolongations, and blocks (RPBs) is below 3 per 100 syllables, and the child’s most common disfluency type is wholeword repetition. According to research literature, most disfluencies that are judged to be instances of stuttered speech feature repeating, prolonging, and/or blocking. That said, the child’s most common disfluency type, whole-word repetition, differentiates children who stutter from children with typical fluency much less powerfully than does part-word repetition frequency or prolongation/ block frequency. In other words, the frequency of whole-word repetitions can be associated with stuttering, but it is less likely to be a quintessential marker of the disorder. Thus, the child’s use of whole-word repetition as the most common disfluency type, in combination with his low overall frequency score for RPB disfluency and the near absence of part-word repetitions and sound/prolongations block, are positive signs — ones that are indicative of typical fluency functioning during the speech sample. Beyond this, other markers of stuttered speech also were absent. For example, there were no instances where repetition, prolongation, and/or block occurred on consecutive syllables or words, no instances of RPB disfluency embedded within behaviorally complex disfluency, no dysrhythmic repetitions, and no evidence of effortful speech



17.  Sample Intervention Programs for Children Who Stutter

Table 17–2.  Case Example 1:  Summary of Data From the Clinician’s Speech-Language Assessment Fluency Performance Sample/sample size:

300-syllable conversation with mother

Disfluency frequency RPBs:

2.67 per 100 syllables (7/8 are monosyllable word reps)

Disfluency frequency IRs:

None observed

Most common disfluency type(s):

Whole-word repetitions (only 1 instance of part-word repetition, no sound prolongations/blocks)

Average duration of RPBs:

1.2 iterations per whole-word repetition

Severity rating (10-point scale):

1 (very little disfluency)

Complaint Behavior(s) Primary problem/concern:

Mildly to moderately disfluent speech, possible stuttering

Family history:

Paternal uncle with persistent stuttering

Age at problem onset:

2;4 (28 months)

Time since problem onset:

2 months

Severity trend since onset:

Stable, slightly improved during past week

Disfluency type(s) noted:

More than 80% are whole-word repetitions (rhythmic) of monoand multi-syllabic words; occasional part-word repetition

Disfluency duration:

Mostly 1-iteration repetitions; some with 2 iterations

Associated behaviors:

None (no evidence of concealing, postponing)

Other markers of stuttering:

None

Awareness/reactions:

Seems unaware/minimally aware; no obvious emotional reactions

Impact on functioning:

No significant activity limitations or participation restrictions. (Speech during car rides mildly limited.)

Environmental factors:

Most disfluent during car rides; when excited; hectic family routines

Parent actions/reactions:

Listens patiently during disfluency; uses typical rate, few interruptions; mix of open and closed requests

Previous services:

None (no previous speech-language services)

Other Aspects of Development/Other Concerns Medical history:

Unremarkable

Communicative milestones:

Within normal limits

Speech sound development:

Within normal limits (test score at 75th percentile)

Receptive/expressive language:

Within normal limits (test scores at 82nd & 73rd percentiles)

Oral mechanism:

Within normal limits

Note.  RPBs = repetitions, prolongations, and blocks; IRs = interjections and revisions.

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and/or speech disfluency. Although not related to the diagnosis of stuttering, the clinician also noted that the parent’s interactional skills with the child showed no systematic evidence of communicative behaviors (e.g., rapid articulation rate, frequent interruptions, frequent use of open-ended requests for information) that are likely to increase conversational pace and/or complexity, and thus put stress on the child’s speech-language production system in ways that might precipitate speech disfluency. Of course, it is possible that the child simply was having a “good day” when the assessment took place; however, the clinician asked the parent about the representativeness of the speech sample as the session was ending, and the parent indicated that the child’s speech, for the most part, was indicative of his recent performance. The parent reminded the clinician that the child’s main recent fluency difficulties have occurred during car rides and at times when the child’s speech coincides with positive excitement. The mother reported that, at those times, the child continues to produce repetitions, mostly of whole words, at a frequency higher than what was observed during the current assessment. She reminded the clinician of one instance, 2 weeks prior, when the child produced a repetition that featured “about 7 or 8” iterations while talking in the car. The latter was a source of moderate concern for the child’s mother at the time, and now, 2 weeks later, remains a source of mild concern. Although the latter information certainly indicates a need to monitor the child’s performance in these situations in the future, the absence of other indicators of stuttered speech in these settings and the very limited occurrence of significant fluency difficulty suggests, overall, that the child’s performance is consistent with a diagnosis of “typically developing fluency.” One final issue to consider is whether the child is at risk for persistent stuttering. The question of persistence is most relevant for children who already are diagnosed with stuttering. Because this child is not diagnosed with stuttering, one can argue that the persistence question is less relevant (or perhaps, irrelevant) in this case. If the clinician did entertain the question, he or she could say that “the child’s present speech fluency profile does not appear to add any risk that might otherwise

be present for him to develop persistent stuttering.” The child is a male (a risk factor for persistent stuttering), and the child does have one biological relative who stutters (another risk factor for persistent stuttering). Given the current state of research on predicting stuttering persistence, however, it is unclear how much weight one should assign to this information. The clinician determined that it was not cause for significant concern given that the child presently does not stutter.

Conclusions and Recommendations At the end of the assessment, the clinician’s primary conclusions were as follows: • The child exhibits typically developing fluency. • The child’s functioning in speech sound development and in receptive and expressive language development are within normal limits. • All other aspects of development related to communication appear to be typical. Recommendations included the following: • Individualized treatment is not recommended for the child at the present time. • Given the isolated instances of fluency difficulty that the child had recently and the parent’s level of concern about these difficulties, it also is recommended that: • The parent be provided with informational counseling regarding the nature and symptoms/characteristics of stuttering and be provided with printed informational materials regarding general practices for creating a home speaking environment that is conducive to fluency development and accepting and supportive of speech disfluency. (This information was disseminated following the assessment using ready-made materials the SLP had on hand.) • The parent be provided with training on the use of a 10-point rating scale to document the child’s daily fluency



17.  Sample Intervention Programs for Children Who Stutter

performance. (This also took place following the assessment, and the parent was provided with a reproducible form that contained seven rating scales [one for each day of the week]). • The parent be invited to attend a monthly 1-hour training seminar that the clinician offers to parents of preschoolers, which provides demonstration of and practice with concepts and skills that are designed to create a home speaking environment that is conducive to fluency development and accepting and supportive of speech disfluency. (The parent could attend this optional event if he or she felt it was necessary to do so.) • The parent should contact the clinician if symptoms of stuttering appear. • The parent can schedule a reassessment of the child’s speech within 3 to 6 months from the time of this assessment, if the child’s fluency remains a matter of concern to the parent.

Relationship Between Recommendations and Intervention Principles Table 17–3 shows how the recommendations that were presented earlier fit with the general intervention principles outlined in Chapter 15. As shown in the table, the intervention plan for this case of typically developing fluency mainly consists of informational counseling activities that are designed to improve the parent’s knowledge base about typical fluency development and the speech symptoms and other characteristics of neurodevelopmental stuttering. The module also includes information about how to support fluency development in young disfluent children through the management of conversational pace and complexity. Methods for managing these variables were explained in Chapter 15. If necessary, the clinician and parent also can brainstorm strategies for managing other fluency stressors related to interpersonal and life stress (e.g., hectic family routines, dealing with dominating conversational partners, dealing with relatives who comment about the child’s speech).

For a case like this one, reading materials and a brief clinician-led demonstration and/or roleplaying activity of the core concepts should suffice; but if necessary, parents can be scheduled to attend training sessions during which more detailed explanation and training of these concepts take place. In the previous section, a standalone, one-time per month group training session was suggested, which likely would be adequate for a parent of a typically developing child. Other authors (e.g., Hill, 2003; Sawyer, Matteson, Ou, & Nagase, 2017; Starkweather, Gottwald, & Halfond, 1990; Yaruss, Coleman, & Hammer, 2006) have conducted trainings for parents of children who stutter during a handful of clinical visits. In this case, the child’s fluency is in the typical range, and overall disfluency frequency is low prior to the start of any prevention activities. Thus, there is relatively little room for fluency improvement with this case during most of the child’s daily activities; and a semiintensive three-session training — although very appropriate for preschoolers who stutter — seems excessive given that this child is functioning in the normal range. In cases where speech is more disfluent and stuttering-related disfluency predominates, an intervention plan like this one still might be used, at least on a trial basis, to assess its effects on a child’s speech fluency. With either type of case — a typical child or a child who stutters — the parentadministered intervention mainly will influence the child’s fluency indirectly. That is, neither the parent nor the clinician will be asking the child explicitly to change how he or she is talking. Instead, any changes that occur in the child’s speech behavior will be induced indirectly, as demands on the child to talk in utterances that are highly time constrained and/or complex in terms of their length or language characteristics decrease. One of the main “problem contexts” for this child involves talking with his mother in the car. In the United States, state laws require preschoolers to be seated in the rear of a vehicle (and typically facing toward the rear of the vehicle). The physical setting makes eye-to-eye contact between speakers impossible. Settings like this often exacerbate any fluency difficulties an individual has, and this certainly appears to be so in this case. The informational counseling associated with Intervention

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Table 17–3.  Relationship Between Recommendations for Case and General Intervention Principles #

Treatment Principle

Concepts/Skills

1. Develop the parent’s knowledge base.

Informational counseling:  Materials on nature and characteristics of typical fluency development and of stuttered speech.

2. Build an environment that is supportive and accepting of stuttering.

Informational counseling:  Acknowledging and talking about disfluency/stuttering; verbal & nonverbal responses to disfluent/stuttered speech.

3. Build an environment that facilitates speech fluency.

Informational counseling: Ways to manage conversational pace and complexity that facilitate fluency; ways to manage interpersonal and life stress (e.g., hectic family routines, dominating conversational partners, others’ comments about child’s speech).

4. Provide systematic feedback about fluency performance.

—

5. Help the client discover and build on existing, productive responses to stuttering.

—

6. Help the client develop skills that reduce disfluency/stuttering frequency.

Accomplished indirectly through Principles 1 through 3.

7. Help the client modify responses to fluency/stuttering that are ineffective or unproductive.

—

8. Develop the client’s ability to apply fluency/stuttering management skills in natural settings.

Accomplished indirectly through Principles 1 through 3.

9. Develop the client’s ability to maintain fluency/stuttering-related improvements after intervention ends.

Accomplished indirectly through Principles 1 through 3 and 7.

Principle 2 can target this by helping parents brainstorm response strategies (e.g., if it is a short trip, it may be better to delay the conversation until after everyone is out of the car; or if the conversation must be held, the parent can provide support for the child by presenting some slow-paced, closed-ended requests for information that are likely to reduce the child’s utterance length and elicit whatever it is the child has to say in short, low complexity utterances).

Measuring Outcomes To assess outcomes associated with this plan, the clinician can offer the parent the option of sched-

uling a follow-up telephone “check-in” a month or two in the future to discuss the parent’s ongoing observations about the child’s fluency and the results of the disfluency ratings the parent has been making.

Contingency Plans Although it seems unlikely to occur, if the parent reported that the child did begin to stutter in the months following this clinic visit, the child would be scheduled for a reassessment, at which time the child’s diagnostic status and need for intervention would be reexamined.



17.  Sample Intervention Programs for Children Who Stutter

Case 2:  Preschooler With Moderately Severe Stuttering This case example is built around a hypothetical 42-month-old female whose parents have significant concerns about recent changes in her speech fluency. This case example is used to illustrate a scenario in which intervention commenced within a 3-month window following onset of stuttering symptoms. The clinician and the child’s parents designed an intervention plan that centered on Intervention Principles 2, 3, 4, and 7. Intervention primarily consisted of the four operant learning principles that were presented in the context of the Lidcombe program’s framework (Onslow, Packman, & Harrison, 2003): (1) mainly acknowledging and praising instances of stutter-free speech (e.g., “That was smooth talking.”); (2) occasionally acknowledging instances of unambiguous stuttering (e.g., “That was bumpy.”); (3) occasionally requesting self-evaluation of stutter-free speech (e.g., “Was that smooth?”); and (4) occasionally requesting self-correction of unambiguous stuttering (e.g., “That was bumpy. Try saying it again.”). Overall, the goals were as follows: (1) to help the child increase awareness (and eventually production) of stutter-free utterances; (2) to teach the parents strategies for responding to and helping their daughter modify instances of physically tense, effortful stuttering-related disfluency; and (3) to create a background environment that facilitated positive attitudes toward disfluent speech and minimal demands for fast-paced and/or complex utterances. As with Case 1, the clinician and parent also developed a plan for tracking the child’s progress daily throughout the early stages of intervention.

Background Information The child’s mother provided the information shown in Table 17–4 in response to questions on a case history form and during a clinical interview with the SLP. The parent’s report indicated that stuttered speech began around age 3;3. It occurred in the context of a family move across the country. Symp-

toms were subtle at first (brief part-word repetitions), but within a month, as the move occurred, the situation had progressed into physically tense sound prolongations and blocks. The average age for stuttering onset in females is typically before age 36 months; thus, onset for this case is slightly later than typical. In preschoolers, stuttering onset for most cases coincides with advances in syntactic and lexical development, and concurrent increases in utterance length and complexity (and thus, increase in demands on the speech motor system). Per the parent’s report, this child already had been speaking in very well-developed sentences for at least one and a half years prior to symptom onset for stuttering. On this basis, one would expect to see this child pre­sent with relatively advanced language skills for her age.

Summary of Speech-Language Assessment Protocol and Results The SLP completed a speech-language assessment. The assessment activities focused primarily on the child’s speech fluency performance. The clinician also assessed the child’s receptive and expressive language development via administration of ageappropriate, norm-referenced tests. Speech sound development was assessed informally through analysis of conversational speech. As with Case 1, the child’s parent had not expressed concern about functioning in these areas; however, the clinician assessed them because functioning in these areas has been associated with children’s likelihood of recovering from stuttering. Also, information about the child’s language and speech sound development can provide insight into the nature and type of treatment activities to develop, should intervention be advised.

Assessment Procedures and Results The fluency assessment was based on elicitation and analysis of a 400-syllable-long conversational speech sample that transpired in a play-based setting between the child and her parent. Elicitation procedures were like those for Case 1. An additional speech sample was elicited using the Stuttering Severity Instrument-4 (Riley, 2009). As with

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Table 17–4.  Case Example 2:  Data From Case History Form and Parent Interview Demographic Information Child’s age:

3;6 (42 months)

Child’s sex:

Female

Household:

Lives with mother, father, and 1 brother (age 20 months)

Parents’ education:

4-year college (mother and father)

Other caregivers:

None (child is not in preschool or daycare)

Problem/Complaint Behavior(s) Primary problem/complaint:

Moderate (sometimes severe) stuttering

Parents’ level of concern:

Moderate-to-high (per self-report)

Family history:

Father (active stuttering, persisting from childhood)

Age at problem onset:

3;3 (39 months)

Time since problem onset:

3 months

Severity trend since onset:

Recently stable but prior to that, steadily worsening

Disfluency type(s) noted:

Physically tense blocks and prolongations on syllable-initial consonants; occasional part-word repetition

Disfluency duration:

About 1 to 2 seconds with some up to 4 or 5 seconds

Associated behaviors:

Covers mouth with hand during long, physically tense stutters; pitch rises occasionally during vowel prolongations

Awareness/reactions:

Seems very aware and concerned

Impact on functioning:

Limits communication effectiveness; no participation restrictions

Environmental factors:

Onset occurred in context of cross-country move (With move recently completed, will stuttering stabilize or improve?)

Parent responses/reactions:

Parent listens patiently during disfluency

Previous services:

No previous speech-language assessments

Other Aspects of Development/Other Concerns Medical history:

Unremarkable

Developmental milestones:

Attained all gross motor, fine motor, and speech-language milestones early; “excellent language skills”

Case 1, the clinician sat off to the side as the parent and child played, and used coded transcription on a scoring grid (e.g., see Chapter 12) to conduct an online analysis of the child’s fluency and to note the parent’s interactional style with the child.

Based on the case history report information and observations made in the waiting room prior to the assessment, it was clear that the child would stutter during the assessment session. Thus, the “percent of syllables stuttered” measure was used



17.  Sample Intervention Programs for Children Who Stutter

to document the child’s stuttering-related behavior. Because the child was more verbal than Case 1, and thus produced longer utterances, the clinician audio-recorded the sample so that accuracy of the online analysis could be checked. Results from the most relevant assessment activities are shown in Table 17–5. The analysis procedures for fluency performance were consistent those described in Chapter 12. As shown in Table 17–5, the child’s speech fluency profile is much different than the profile from Case 1. That is, the child’s stuttering frequency was more than 8% (i.e., ~8 instances of stuttering per 100 syllables of speech.) Among the child’s stuttered syllables, most (about 88% of total stuttered syllables) were characterized by effortful blocking that resulted in inaudible prolongation of articulatory postures

for affected speech sounds. This disfluency type is uncommon among typically developing children, and its presence at this frequency (7.48 per 100 syllables), alone, is enough to warrant a diagnosis of stuttering. Other markers of stuttered speech that were present included the following: 7 instances of sound prolongation/blocking on consecutive syllables or words (this indicates “clustering” of stutter-like syllables, which is highly atypical in preschoolers who do not stutter); and visual and/or acoustic evidence of effortful speech on most sound prolongations/blocks (this also is highly atypical in preschoolers who do not stutter). Observation of the parent’s interactional skills with the child showed no evidence of behaviors (e.g., rapid articulation rate, frequent interruptions, frequent

Table 17–5.  Case Example 2:  Summary of Data From the Clinician’s Speech-Language Assessment Fluency Performance Sample/sample size:

400 syllables

Percent of syllables stuttered:

8.5% of syllables (34 of 400 syllables)

Most common type(s) of stuttering-related behavior:

Physically tense blocks (inaudible sound prolongation); 88% of stuttered syllables are this type (7.48 per 100 syllables)

Other markers of stuttering:

Clustering of stuttered syllables (e.g., H-h-he wwwent)

Average duration of stuttered syllables:

1.5 seconds (longest three = about 4 seconds)

SSI-4 severity rating

Moderate (total score = 25)

Associated behavior:

Extraneous extremity movement (hand covering mouth) and physical tension (lip and tongue pressing)

Awareness/reactions:

Associated behaviors suggest high awareness of stuttering

Environmental factors:

Stuttering severity consistent across tasks

Impact of stuttering:

Reduces communicative functioning; child is quite talkative, so no obvious impact on participation

Parent interaction style:

No obvious fluency stressing behaviors

Other Aspects of Development/Other Concerns Medical

Unremarkable

Speech sound development:

Within normal limits (glide substitutions on consonant /ɹ/ and distortion of /, 2/)

Receptive/expressive language:

Above normal limits (92nd percentile)

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use of open-ended requests for information) that might precipitate the child’s need to speak rapidly in order to gain or complete speaking turns, or to produce long, complex utterances (although though the child did produce many such utterances independently). The parent indicated that the child’s speech during the assessment tasks was indicative of her recent performance. The parent also stated that the child occasionally had instances of stuttering that were longer and more effortful than the ones produced during the current assessment. The overall conclusion was that both the parent-reported data and clinician-generated assessment data were consistent with a diagnosis of “stuttering” (neurodevelopmental stuttering). In contrast, the child presents a mixed picture regarding her risk for persistent stuttering. There is a family history of stuttering (a risk factor for persistent stuttering). On the other hand, the child is female (less of a risk factor for persistence than it is in males) and she has been stuttering for only a few months. Stuttering severity had been increasing, but lately appears to have stabilized. However, a more positive prognostic sign would be for the stuttering severity to be decreasing steadily, which it is not. Overall, there is reason to be concerned about the possibility of persistent stuttering in this case.

Conclusions and Recommendations Following the assessment, the clinician reached the following conclusions: • The child exhibits neurodevelopmental stuttering, with a severity rating of moderate. • Stuttered speech significantly limits the rate and naturalness of the child’s spoken communication. • The child’s functioning in speech sound development is within normal limits. • Functioning in receptive and expressive language appears to be above normal limits. • All other aspects of development related to communication appear to be developing typically.

Recommendations included the following: • Individualized treatment is recommended for the child in the form of weekly, 50-minute sessions. • Treatment will include clinician-directed activities with the child and parent, with the goal of eventually training the parent to administer the treatment. • The parent will be provided with information on the nature and symptoms/ characteristics of stuttering and training that results in the parent being able to recognize instances of stuttering reliably. • The parent will be provided with informational materials regarding general practices for creating a home speaking environment that is conducive to fluency development and accepting and supportive of speech disfluency. • The clinician will demonstrate and direct activities in which the parent learns to produce techniques for regulating conversational pace and complexity in interactions with the child. The parent will then implement these techniques during preselected “talking times” with the child at home. Talking times will involve one-on-one interactions in a quiet setting and will be organized around either a picture book, a simple age-appropriate game, or toys. • The parent will learn to administer “response contingencies” while interacting with the child during talking times. The parent will produce positive comments (e.g., “That was smooth talking”) following the child’s stutter-free utterances and occasionally will highlight stuttered speech using simple descriptive utterances (e.g., “There was bumpy speech.”). Positive comments will outnumber highlighting of stuttered speech by a large margin (e.g., a 10:1 ratio). • The parent also will learn how to comment occasionally on the child’s instances of relatively severe stuttering with simple remarks that acknowledge the child’s feelings/emotions about speech disfluency at that moment.



17.  Sample Intervention Programs for Children Who Stutter

• The parent will learn how to prompt the child to “cancel” one or two severely stuttered words produced during the talking time. That is, in addition to requesting the child to repeat some stuttered words, the parent will supplement this activity by modeling a briefer, less effortful model of disfluency immediately following an instance or two of the child’s longest, most physically tense disfluencies, and then asking the child to imitate the parent’s model. • The parent will learn to use a 10-point rating scale to document the child’s stuttering severity daily.

Relationship Between Recommendations and Intervention Principles Table 17–6 shows how the recommendations that were presented earlier fit with the general intervention principles outlined in Chapter 15. As shown, the intervention plan for this preschool-aged case with moderately severe stuttering incorporates several intervention principles. Standard materials and activities to develop background knowledge will be presented, along with information about and practice with behaviors that promote an environment that is supportive and accepting of stuttering, and facilitative of speech fluency. The main treatment strategy involves implementation of “response contingencies” like those described in the Lidcombe program (Onslow et al., 2003). In this case, prompted cancellation with a request to imitate a parent model of brief, less effortful stutter-like speech is introduced as a supplement to the standard Lidcombe techniques. This is done because the child has been experiencing lengthy, physically tense disfluency (some of which last for many seconds and lead the child to cover her mouth with her hands). The thinking is that, rather than passively observing as the child is becoming frustrated while engaged in an unproductive attempt at the word, it is better to intervene in a gentle, supportive manner, and show the child an alternative way to produce the word.

Given the child’s frustration with her disfluency, another key element of this intervention program involved having the parent occasionally comment on the child’s disfluency experiences in ways that help the child interpret them in a positive, accurate, and optimistic manner. This is accomplished through the use of comments that label immediate feelings (e.g., “Yes, you feel frustrated sometimes when words are stuck.”) and put the situation into an accurate context (e.g., “That word was bumpy. Most of your other words are smooth.” or “That word was bumpy. That’s okay. That happens sometimes when kids are learning to talk.”). Standard application of the Lidcombe program follows a delivery plan. In Stage 1 the goal is to stabilize/manage the child’s fluency. This is accomplished through in-clinic sessions involving the parent, child, and clinician; and as the parent’s proficiency with administering response contingencies develops, treatment activities in the home setting are introduced. These sessions continue until the child reaches a performance criterion (e.g., parent ratings show attainment of stuttering severity ratings of 1 or 2 (on a 9-point scale), daily for at least 3 weeks; and in-clinic assessment shows percentage of syllables stuttered scores of less than 1%. During Stage 2 of the treatment, the treatment largely shifts to the home environment. The parent returns to the clinic, weekly at first, but less often over time. The clinician continues to assess the child’s percentage of syllables stuttered scores and reviews the severity ratings that the parent assigns to the child. During in-clinic visits, the clinician assesses the parent’s accuracy with response contingency presentation and stuttering severity rating, and helps the parent troubleshoot problems in treatment administration that may arise. If the child relapses to previous levels of stuttering, it may be necessary to return to Stage 1 activities.

Measuring Outcomes In the standard application of the Lidcombe program, the primary outcome measure is percentage of stuttered syllables. That measure was incorporated in this case but supplemented with informal

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Table 17–6.  Relationship Between Recommendations for Case and General Intervention Principles #

Treatment Principle

Concepts/Skills

1. Develop the parent’s knowledge base.

Information on nature and characteristics of typical fluency development and of stuttered speech.

2. Build an environment that is supportive and accepting of stuttering.

Information and practice on listening to, acknowledging, and talking about instances of stuttering; building a repertoire of positive/facilitative verbal and nonverbal responses to stuttered speech.

3. Build an environment that facilitates speech fluency.

Information about and practice with slowing conversational pace, managing hectic family routines, and talking in ways that reduce the child’s obligation to produce long, complex utterances.

4. Provide systematic feedback about fluency performance.

Administering verbal reinforcement to stutter-free utterances, and occasionally highlighting instances of stuttering, requesting self-evaluation of stutter-free speech, and requesting “re-do’s” or “cancellation” of stuttered words during preselected parent-child talking times.

5. Help the client discover and build on existing, productive responses to stuttering.

—

6. Help the client develop skills that reduce disfluency/stuttering frequency.

Accomplished through Principles 1 through 4.

7. Help the client modify responses to fluency/stuttering that are ineffective or unproductive.

During parent-child talking time, prompt “cancellation” of instances of severe stuttering by asking the child to imitate a model of a briefer, less effortful stutter (e.g., “Try saying that word like this ____.”). [Parent demonstrates a slightly slowed, relatively effortless version of word.]

8. Develop the client’s ability to apply fluency/stuttering management skills in natural settings.

Accomplished indirectly through Principles 1 through 4.

9. Develop the client’s ability to maintain fluency/stuttering-related improvements after intervention ends.

Accomplished indirectly through Principles 1 through 4 and 7.

assessments of the child’s speech-related feelings/ emotions. For the latter, the parent was asked to monitor the frequency with which the child demonstrated frustration during instances of stuttering. The goal for delivering supportive, encouraging comments immediately after some instances of lengthy, physically effortful stuttering-related disfluency is to help the child develop alternatives to simply feeling frustrated. For example, the child might internalize the parent’s comments and self-administer them during future instances of stuttering. The author has heard, for example,

preschoolers say things like, “That’s okay. I’m just learning my words!” after physically challenging instances of stuttering. As with any treatment, the number of sessions needed to reach intervention goals for a case like this would be difficult to predict precisely at the outset. The clinician can look to the evidence base for “dosage” information associated with the use of response contingencies to narrow the estimate. In cases like this one, it might take 12 to 16 sessions to reach Stage 1 criterion; and then in Stage 2, which can be thought of as a highly structured follow-up



17.  Sample Intervention Programs for Children Who Stutter

stage, monitoring of the child’s fluency can continue for several months more. Some children will show remarkably quick responses to certain elements of treatment. For example, introduction of supportive acknowledgments (e.g., “That one was a bumpy. That’s okay. You are just learning to say your words!”) can be followed by a rapid reduction in the length and physical effort of speech disfluency.

Contingency Plans Three-year-old children will, of course, be limited in the extent to which they can actively employ speech motor control strategies for stuttering management. Because of this, a Lidcombe-based program with supplemental, parent supported “cancellation prompts” is very much within the capacity of a child this age. If such an approach proved ineffective, however, the clinician would need to consider implementing other strategies, such as clinician- or parent-directed requests to imitate slightly slowed speaking rate targets over the course of entire utterances. These would need to be administered during structured times and with support, and with very modest expectations for the child to begin speaking in this regulated manner spontaneously. Yaruss et al. (2006) described outcomes associated with a “family-focused” intervention approach for stuttering that is designed for use with children who are between the ages of 2 and 6 years. The intervention approach features both parentfocused strategies and child-focused strategies. Parent-focused strategies target communication modifications such as providing the child with a model of “easy talking,” using lengthened pauses between conversational turns, reducing demands for long, linguistically complex or fast paced utterances, and reflecting/rephrasing the child’s utterances to highlight smooth speech patterns. The latter strategy involves having the parent repeat or paraphrase a child’s disfluent utterance while using speech that is slightly slower and much smoother than what the child just said. In doing this, the parent models an alternative way to produce the utterance. The program also aims to improve both the parent’s and the child’s understanding and accep-

tance of stuttering. With parents, the SLP accomplishes this via parent counseling activities, by educating parents about stuttering, and by helping parents to identify fluency stressors in their current home environment and daily routines. For children, the understanding and acceptance of stuttering also is targeted — in this case via age-appropriate educational activities about stuttering and by facilitating parent-child discussions about stuttering (examples of strategies like these are presented in Chapter 15). Age-appropriate activities to help the child become desensitized to stuttering also are introduced (general desensitization methods are described in both Chapters 15 and 18). The final component of the intervention program features activities that are designed help the child modify his or her communication. Strategies here include speech modifications (e.g., regulated speaking rate), stuttering modification (e.g., age-appropriate responses to stuttering-related disfluency), targeting of other communication skills, and treating any concomitant speech-language disorders the child might present. An approach like this offers the flexibility to incorporate more direct forms of intervention that involve having the child gain experience with directly altering facets of his or her speech under the guidance and direction of the clinician and, after training, the parent. Yaruss et al. (2006) reported data for 17 children who participated in the intervention, with all achieving improved fluency. Parent evaluations of the intervention were positive as well.

Case 3:  Early Elementary Grade Student With Moderate Stuttering This case example is built around a hypothetical male client, age 8;6, whose mother contacted a private-practice clinician with concerns about recent worsening in her son’s stuttering. The spike in the boy’s stuttering severity followed a stretch of several months during which the boy demonstrated minimal stuttering. Unlike the previous two cases, this case example illustrates a scenario in which intervention commences several years after the reported onset of stuttering symptoms. As with Cases 1 and 2, the clinician and the child’s parent

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designed a plan that is built around several intervention principles. The boy provided input into the plan as well, helping to shape the activities that were designed to help him transfer newly developed stuttering management strategies into reallife settings. Given that the child had been stuttering for several years, and his stuttering had been worsening in recent months, it was felt that he would benefit from a treatment in which his stuttered speech was addressed in a more explicit and intensive manner than would be the case with either an indirect, parent-administered intervention (Case 1) or an intervention that targeted stuttering-related disfluency via verbally administered response contingencies and intermittent requests for active modification of stuttering-related disfluency (Case 2). Thus, for this case, a treatment program that emphasized principles of regulated task complexity and self-regulation of speech motor behavior in the context of massed practice was developed. In this example, the clinician tested this treatment approach near the conclusion of the child’s initial evaluation; this indicated that he could produce the desired treatment targets with relative ease and that the approach resulted in immediate and noticeable improvement in his speech fluency. Overall, the broad goals for Case 3 were as follows: (1) to establish the child’s ability to improve speech fluency through intentional use of a slightly slowed speaking rate; (2) to facilitate generalization of this newly learned stuttering management skill to the boy’s home environment by training his mother to develop and deliver treatment activities at home on the days between treatment sessions; (3) to help the boy develop strategies for managing stuttering during social settings in which his stuttering tended to be most severe; and (4) to encourage the child’s parents to continue practices they already had in place for establishing a home environment that facilitated positive attitudes toward disfluent speech and reasonable demands for conversational pace, competition for obtaining speaking turns, and the obligation to produce lengthy, complex utterances, particularly during time-constrained contexts. As with the previous cases, the clinician and parent developed a plan for tracking the child’s progress daily throughout all stages of intervention.

Background Information The child’s parent provided the information shown in Table 17–7 in response to questions on a case history form and during a clinical interview with the SLP. The mother’s report indicated that the boy’s stuttered speech had been present for about 5 years. Circumstances surrounding stuttering onset were unremarkable. Stuttering symptoms waxed and waned in severity during the first 2 years after onset, ranging from severity levels the parent estimated to be between “mild” and “moderate.” In recent months stuttering symptoms had worsened. The parents seemed comfortable with discussing stuttering with the child. Stuttering seemed to have minimal impact on communication participation; however, it was judged to limit the child’s communication effectiveness in some contexts.

Summary of Speech-Language Assessment Protocol and Results The SLP completed a speech-language assessment. The assessment focused primarily on the child’s speech fluency performance. The clinician also assessed the child’s receptive and expressive language development via administration of ageappropriate, norm-referenced tests. Speech sound development was assessed informally through analysis of conversational speech. As with Cases 1 and 2, the child’s parent had not expressed concern about functioning in these latter areas; however, the clinician assessed language and speech sound production functioning to obtain more information about the child’s skills in phonology, narration, and syntax, as these were likely variables to manipulate in treatment activities.

Assessment Procedures and Results The fluency assessment was based on elicitation and analysis of speech samples that transpired in the context of the Test of Childhood Stuttering (Gillam et al., 2009). An informal analysis of conversational interactions between the child and his mother, and then the child and his sister took place as well, to provide a sense for variability of stuttering symptoms and to assess conversational



17.  Sample Intervention Programs for Children Who Stutter

Table 17–7.  Case Example 3:  Data From Case History Form and Parent Interview Demographic Information Child’s Age:

8;6

Child’s Sex:

Male

Household:

Lives with mother, father, and 1 sister (age 6;7)

Parents’ education:

4-year college (mother); high school (father)

School:

3rd grade; performing satisfactorily in all academic areas

Social/temperament:

Outgoing, easygoing, popular with classmates

Problem/Complaint Behavior(s) Primary problem/complaint:

Mild to moderate stuttering (depending on setting)

Parents’ concerns:

Confused about why stuttering has worsened; seeking intervention so stuttering does not worsen further

Family history:

None

Age at problem onset:

3;0 (approximately)

Time since problem onset:

5 years (approximately)

Severity trend since onset:

Fluctuated between mild to moderate over several years; mild in past half year; moderate recently

Disfluency type(s) noted:

Primarily part-word repetitions; some sound prolongations

Disfluency duration:

About 1 second

Associated behaviors:

Nothing obvious

Awareness/reactions:

Aware of stuttering; talks about it openly with parents

Impact on functioning:

Sometimes limits communication effectiveness; no participation restrictions

Environmental factors:

Stuttering is most noticeable when he talks in group settings with peers (e.g., soccer practice)

Parent responses/reactions:

Parents talk openly with him about disfluency

Previous services:

Fluency therapy during 1st grade at school; mother unsure about details of treatment approach; dismissed from treatment following improved fluency

Other Aspects of Development/Other Concerns Medical history:

Unremarkable

Developmental milestones:

Gross motor, fine motor, and speech-language milestones met as expected; “always very verbal and outgoing”

interaction styles of these family members. For the latter interactions, the clinician sat off to the side and used coded transcription on a scoring grid like

the one described in Chapter 12 to obtain an online analysis of the child’s fluency. The “percentage of syllables stuttered” measure was used to document

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the child’s stuttering-related behavior. The clinician audio-recorded the sample so that accuracy of the online analysis could be checked. Results from the most relevant assessment activities are shown in Table 17–8. The analysis procedures for fluency performance were consistent with those described in Chapter 12. As shown in the table, the child’s speech fluency profile is much different than the profile from Case 1. That is, the child’s combined frequency of stuttered syllables was almost 6 per 100 syllables, which is much more frequent than what would be expected in the general population. Most syllables that were judged to be stuttered featured part-word repetition, a disfluency type that is highly characteristic of stuttered speech. The part-word repetitions fea-

tured an average of 1.7 iterations per repetition, which also is greater than what one would see in a typical speaker. Regarding other markers of stuttering, there were no instances of sound prolongation/blocking and no evidence of clustered stutter-like disfluencies. Stuttered syllables occurred most often near the start of a sentence, either on the utteranceinitial word or on the word in the subject/noun phrase that carried primary linguistic stress (e.g., The f- f- first alien). Part-word repetitions sounded dysrhythmic, with most featuring more than one iteration. The parent’s interactional skills with the child showed no behaviors that would need to be targeted specifically for intervention; however, the client’s sister frequently interrupted his utter-

Table 17–8.  Case Example 2:  Summary of Data From the Clinician’s Speech-Language Assessment Fluency Performance Sample/sample size:

308 syllables

Percent of syllables stuttered:

5.84% of syllables stuttered

Most common type(s) of stuttering-related behavior:

Part-word repetition (90% of stuttered syllables are this type; 5.26 per 100 syllables)

Other markers of stuttering:

None

Average duration of stuttered syllables:

0.90 seconds; 1.7 iterations per repetition

Test of Childhood Stuttering (TOCS)

• Speech fluency measure: