Stuttering

Stuttering An Integrated Approach to Its Nature and Treatment

SIXTH EDITION

Stuttering An Integrated Approach to Its Nature and Treatment

SIXTH EDITION

Barry Guitar, PhD Professor Emeritus Department of Communication Sciences and Disorders

University of Vermont Burlington, Vermont

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Sixth Edition

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Preface

A s Stuttering: An Integrated Approach to Its Nature and Treatment reaches its sixth edition, we have strived to retain features that the previous editions’ readers have found helpful and made some changes we believe can make it even better. As we have done for each new edition, we have made additions, deletions, and other changes to bring to you the latest research and treatment approaches dealing with stuttering and related disorders. Using updates from colleagues and library resources, including pow erful search engines, such as Ovid MEDLINE and Google Scholar, is vital because research, especially on the neurology of stuttering, as well as clinical research on treatment, is moving at a rapid pace. Although we have tried to be as current as possible, we still advise you to turn to the most recent literature to keep abreast of the newest developments in research and to turn to more popular sources, such as webcasts and stuttering support group outlets, to gain insights from the powerful of voices of people as they share their personal journeys. In keeping with efforts to stay current, we have included a brand-new chapter by Naomi Rodgers. Her chapter “Treatment of Adolescents: Advanced Stuttering” (Chapter 16) brings new perspectives to stuttering therapy with teens, acknowledging how important it is to let clients take the lead in deciding when to start therapy and to determine the pace of treat ment. Dr. Rodgers’ extensive experience with teens is reflected in the guidance and recom mendations she makes and enriched by her own experience as a teen who stuttered. Another change in this new edition is the use of gender-inclusive pronouns (they and them and themselves, in place of he or she or hers or his or herself or himself). This change reflects our effort to respect individuals’ gender identity and convey an accepting attitude toward all individuals no matter what gender they were born with or what gender they have chosen. As research on the nature of stuttering has progressed, it is clearer that differences in brain function in many who stutter may be permanent and even some of the learned behav iors may be difficult to unlearn. Thus, another change that we hope readers of earlier ver sions of this book will notice is an increasing emphasis on incorporating acceptance as an important component of treatment. This is especially true of therapy for school-age stut terers, adolescents, and adults. As you will see in the treatment chapters, individuals who stutter are guided to make peace with their stuttering, learn to be open with others about their stuttering, and reduce the tension and struggle that they have used to try not to stutter. This approach makes stuttering a minor problem that is no longer associated with shame, embarrassment, and fear. Some of us even look forward to moments of stuttering so that we can handle them smoothly and openly as well as experience the feeling of triumph that accompany a stutter well-handled—or not handled at all but still not allowed to take away the importance of what we are saying.

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Although we are emphasizing acceptance as particularly important for older individuals who stutter, we see stuttering in young children as a different issue. In my experience and according to my clinical data, early indirect or direct treatment of stuttering—rather than acceptance of it—is effective in eliminating stuttering or nearly so. Children younger than age 6, before they enter their first year of school, respond well to a parent- or caregiver based program of therapy managed by a dedicated stuttering clinician. Although we agree that clinicians need to stay alert for signs that a child’s feelings of shame, embarrassment, and fear that might in fact be triggered by a focus on fluency, we believe working on fluency does not make such feelings inevitable. Thus, we give wings to this new edition of our stuttering textbook, with hope that it will help many who stutter and many who work with them! B ARRY G UITAR Professor Emeritus, University of Vermont

Acknowledgments

I want to begin by thanking my clients and my students, who—over the last 6 decades—let me help them learn about the nature and treatment of stuttering. As much I as I may have taught them, they have taught me. Thank you also to my colleagues at the University of Vermont and around the world who were invaluable in helping me understand research, treatment, and the goodness of other people. Huge applause for my friends and editors at Wolters Kluwer. These heroes include Amy Millholen, Senior Development Editor, and Varshaanaa Muralidharan, Editorial Coordi nator, who have been generous with their time, endlessly patient, and deeply insightful. Lindsey Porambo, Acquisitions Editor, has been most benevolent in supporting this sixth edition, as well as responsive to issues that have come up as I have worked on this textbook. I would like also to bestow great thanks to all the staff at Wolters Kluwer who have taken this book through its many stages of production. Immeasurable thanks to Bot Roda, a gifted illustrator, who has the ability to transform my scrap art into vivid compositions that more than capture what I want to convey to the reader! He is amazing! Many thanks to Lydia Sack—a former student and now a full-fledged stuttering thera pist—for developing new quiz questions for Lippincott Connect and for creating an entirely new feature: Suggested Answers to Study Questions at the end of each chapter, for teachers to use with their classes. And thanks to Lydia and to Danra Kazenski for their very valuable help with many other digital assets on the website. In this sixth edition, we are indeed fortunate to welcome Naomi Rodgers who has writ ten an outstanding new chapter on Treatment of Adolescents who Stutter: Advanced Stut tering. She is internationally known as an expert in working with this sometimes puzzling and always entertaining group of individuals who stutter. As in each of the preceding five editions, Rebecca McCauley and Charles Barasch have given their valuable time and energy to reading every word and every punctuation mark of every chapter and suggesting changes that have made this edition sing. I also thank my Tibetian Terrier, Deano (named after the famous Dr. Dean Williams), who has taken me on many walks and nuzzled my face to keep me happy and healthy. And finally, I am endlessly indebted to my wife, Carroll, who has used her many talents to find, organize, and attach more than a thousand references—many of them hot off the press—for this edition. Moreover, she has managed the permissions, videos, and my time, allowing us to break a bottle of champagne over the bow of this sixth edition.

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5. Learning and Unlearning 99 Learning 100 Unlearning 108 6. Theories About Stuttering 114 Theoretical Perspectives About Constitutional Factors in Stuttering 117 Theoretical Perspectives on Developmental and Environmental Factors 127 Integration of Perspectives on Stuttering 130 7. Typical Disfluency and the Development of Stuttering 143 Overview 145 Typical Disfluency 147 Younger Preschool Children: Borderline Stuttering 152 Older Preschool Children: Beginning Stuttering 155 School-Age Children: Intermediate Stuttering 159 Older Teens and Adults: Advanced Stuttering 163 8. Atypical Disfluency 171 Overview 172 Acquired Neurogenic Stuttering 172 Stuttering as a Result of Stress and Injuries While in the Military 174 Functional (Previously Termed “Psychogenic”) Stuttering 175 Malingering 177 Cluttering 179 Contents

Preface v Acknowledgments vii

S e c t i o n I Nature of Stuttering 1. Introduction to Stuttering 3 Perspective 4 Overview of the Disorder 6 Definitions 7 The Human Face of Stuttering 13

Basic Facts about Stuttering and Their Implications for the Nature of Stuttering 13 2. Primary Etiological Factors in Stuttering 26 What Do We Know About Constitutional Factors in Stuttering? 27 Hereditary Factors 28 Congenital and Early Childhood Trauma Studies 37 Brain Function and Structure 39 3. Sensorimotor, Language, and Emotional

Factors in Stuttering 53 Sensorimotor Factors 54

Language Factors 63 Emotional Factors 65 4. Developmental and Environmental Factors in Stuttering 73

Developmental Factors 76 Environmental Factors 89

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x Contents

S e c t i o n I I Assessment of Stuttering 9. Preliminaries to Assessment 185 The Client’s Needs 187

Another Clinician’s Approach: Sheryl Gottwald 326 Treatment of Concomitant Speech and Language Problems 328 15. Treatment of School-Age Children:

Insurance Considerations 188 Clients’ Right to Privacy 189 Multicultural and Multilingual Considerations 190 The Clinician’s Expertise 194 Assessing Stuttering Behavior 194 Assessing Speech Naturalness 203 Assessing Speaking and Reading Rate 205 Using FluencyBank to Assess Stuttering Behaviors 206 Assessing Feelings and Attitudes 206 10. Assessment of Preschool Children Who Stutter 209 Steps in Assessment of Preschool Children Who Stutter 210 11. Assessment of School Age Children, Adolescents, and Adults Who Stutter 236 School-Age Children 237 Adolescent 252 Adult 264 S e c t i o n I I I Treatment of Stuttering 12. Preliminaries to Treatment 277 Clinician’s Attributes 278 Clinician’s Beliefs 281 Treatment Goals 282 Therapy Procedures 286 13. Treatment of Younger Preschool Children: Borderline Stuttering 295 An Integrated Approach 296 Other Approaches 305 14. Treatment of Older Preschool Children:

Intermediate Stuttering 333 An Integrated Approach 334 Approaches of Other Clinicians 357

Treatment of Stuttering Accompanied by Attention-Deficit/Hyperactivity Disorder (ADHD) 359 Treatment of Stuttering Accompanied by Autism 360 16. Treatment of Adolescents: Advanced Stuttering 364 Introduction 365 Background on Adolescence 366 Setting the Tone for Therapy 366 Stuttering With Greater Ease 368 Developing Healthier Thoughts and Feelings About Stuttering 371 Reducing Avoidance of Sounds, Words, and Situations 377 17. Treatment of Adults: Advanced Stuttering 381 An Integrated Approach 383 Other Approaches 399 18. Treatment of Atypical Fluency Disorders 404 Introduction 405

Acquired Neurogenic Stuttering 405 Functional (Psychogenic) Acquired

Stuttering 409 Malingering 412 Cluttering 413

Bibliography 421 Author Index 449 Subject Index 457

Beginning Stuttering 312 An Integrated Approach 313

Treatment of Adolescents: Advanced Stuttering Naomi H. Rodgers, Ph. D., CCC-SLP 16

Chapter Outline Introduction

Chapter Objectives After studying this chapter, readers should be able to: ■ Summarize the unique challenges and opportunities associated with stuttering in adolescence ■ Describe how to establish a trusting therapeutic alliance with adolescents who stutter ■ Summarize the steps to help adolescents stutter more easily ■ Explain methods for addressing difficult thoughts and feelings about stuttering

Background on Adolescence Setting the Tone for Therapy Creating a Safe Stuttering Space Focusing on “What’s Right” With the Client Codeveloping Goals Guided by the Client’s Readiness to Change Stuttering With Greater Ease Learning About the Speech Mechanism Identifying Moments of Stuttering Holding, Tolerating, Then Easing Out Using Hierarchies to Level Up Developing Healthier Thoughts and Feelings About Stuttering De-Mystifying Stuttering Through Education Reframing “Success” and Celebrating Small Steps Identifying “Thinking Traps” Accepting and Letting Go of Difficult Thoughts and Emotions Creating Affirmations Finding Community Reducing Avoidance of Sounds, Words, and Situations Talking Openly About Stuttering and Increasing Disclosure Expanding Comfort Zone Voluntary Stuttering

Key Terms

Acceptance: Letting internal experiences just be there without trying to get rid of them, avoid them, or replace them; one of the six principles of ACT Acceptance and commitment therapy (ACT): Learning to let difficult thoughts and feelings just be by staying in the pres ent moment, noticing what’s happening without trying to change those thoughts or feelings, and moving in the direction of what matters to the client

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Chapter 16 • Treatment of Adolescents: Advanced Stuttering 365

Adolescence: Period of development, roughly from 10 to 24 years of age, where brain-body-behavior changes are rapidly underway, which primes young people for learning, renders them highly sensi tive to social experiences, and promotes desire for independence Affirmations: Positive statements about the client’s characteristics or behaviors that help reinforce change behaviors Bibliotherapy: Using published literature about stuttering to help clients better understand their own experiences Change : Overt and covert behaviors that are personally important to the client; for many adolescents who stutter, it involves (1) learning ways to talk and stutter more easily, (2) developing more positive thoughts and feelings about stuttering, and (3) reducing avoidances Change journey: The process that a client goes through as they learn new ways to think about and act upon stuttering Cinematherapy: Using films about stutter ing to help clients better understand their own experiences Comfort zone: Situations in which one feels equipped to readily act and succeed; can be expanded by taking small steps just outside one’s comfort zone Defusion: Separating oneself from one’s thoughts by looking at thoughts rather than engaging or embodying them; one of the six principles of ACT Disclosure: Sharing with others the fact that one stutters Easing out: When in a moment of stut tering, releasing tension and gently and mindfully transitioning to the next sound Hierarchy: Stepwise progression through linguistic and situational contexts of increasing difficulty used to help clients generalize new behaviors Holding and tolerating: Volitionally con tinuing to hold tension in a moment of stuttering for longer than usual to de sensitize the person to difficult feelings that arise in that moment and to develop behavioral self-awareness in the moment Motivational interviewing: Strengthen ing the client's motivation for and com mitment to their goals by eliciting and exploring their own reasons for change

Mindfulness: Staying in the present mo ment and being nonjudgmentally aware of present moment experiences Safe stuttering space: A situation or con text in which the client feels that the environment is open to and accepting of stuttering Solution-focused brief therapy (SFBT): A style of counseling that focuses on the client’s strengths and resources for change that is important to them, rather than focusing on their problems Stages of change: Five discrete phases of readiness to change that people move through dynamically as they shift how they think about a target behavior Strengths: Personal attributes that help the client make value-driven decisions in their everyday life Struggle: Avoidance and escape behaviors that interfere with the speaker’s ability to move directly into, and stay easily within, stutters Therapeutic alliance: Unwavering rapport between the client and clinician that is based on a mutual trust and respect; it develops from the clinician’s curiosity about the client’s experience with stutter ing and showing that “it’s ok to stutter” through their mindful use of accepting verbal and nonverbal language Thinking traps: Processing information in a negative way where the person can feel “trapped” in a cycle of negative thinking Voluntary stuttering: When a stutterer or nonstutterer imitates a moment of stut tering; also known as pseudostuttering or stuttering on purpose

INTRODUCTION This chapter will introduce you to the unique aspects of stut tering therapy with adolescents. You have already learned some ways to establish a strong therapeutic relationship with your client, and this is arguably the most important aspect of adolescent stuttering therapy. Adolescents thrive on feel ing heard and validated, so your primary responsibility is to situate your adolescent client in the metaphorical driver’s seat as you listen deeply and validate their experiences from the passenger’s side. This foundation of unwavering rapport will help your adolescent client feel safe, valued, empowered, and socially connected. And from here, change is possible. Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

366 Section III • Treatment of Stuttering

In this chapter, once we establish common ground on the unique challenges and opportunities for young people, we will explore some therapy approaches and activities that are well suited for helping adolescents codevelop their therapy goals, learn ways to stutter more easily, develop healthier thoughts and feelings about themselves and stuttering, and reduce avoidance of sounds, words, and situations. This is all in service of helping adolescents cultivate responsibility and autonomy over their change journey —the process that an adolescent goes through as they learn new ways to think about and act upon stuttering. BACKGROUND ON ADOLESCENCE Adolescence has historically been thought to “begin in biol ogy and end in culture”—that it is bookended by the onset of puberty on one side, and the achievement of culturally expected milestones of adulthood on the other (things like marriage and gainful employment) (Conger & Peterson, 1984). Contemporary models of adolescence harness recent neuro biological evidence that reveals that puberty is starting earlier and earlier, and neurological development continues well into one’s 20s. This has inspired recent calls to expand the age range of adolescence to be 10 to 24 years (Sawyer et al., 2018). What makes adolescence such a unique period of one’s life that it warrants its own literature base, its own research questions and methods, its own approach to stuttering therapy? Because adolescents are not simply older children nor younger adults, so regarding them is a disservice to the exceptional challenges and possibilities that are unique to this period of great risk and opportunity. The challenges of adolescence stem from the drastic changes in social-emotional networks in the brain that ren der adolescents exceptionally sensitive to their social world. While highly active limbic regions are amplifying emotional experiences, the less mature prefrontal regions are still devel oping self-regulation abilities (Shulman et al., 2016). Dur ing this time, adolescents are shifting their dependence on their parents to their peers instead, and this shift toward peers happens at a time when social fears and worries natu rally escalate. In fact, social anxiety typically begins around 13 years of age (Kessler et al., 2007), and there is evidence that reveals higher rates of social anxiety among people who stutter than those in the general population (Bernard et al., 2022). Therefore, it is reasonable to expect the adolescent years to be a particularly vulnerable and tumultuous time for those who stutter. The common, intense desire to fit in is challenged by stuttering—a part of them that sets them apart from their peers. On top of the great lengths that many young people who stutter go to hide this part of themselves, they may not be particularly receptive to well-intentioned clini cians recruited to help them. Some young people view cli nicians as extensions of their parents— here is another adult telling me what to do —and this attitude of not needing or wanting help can strain a budding therapeutic relationship.

Adolescence is simultaneously a time of tremendous possibilities. Those same neurobiological changes that make adolescence a difficult time also prime them for learning, particularly self-directed learning. In fact, the surge in neu roplasticity we see during the adolescent years is second only to that observed in the first 3 years of life (Cohen Kadosh et al., 2013). It is a time when identities and lifelong habits take root as young people make sense of who they are and find their place in the world. This is a crucially pivotal time for young people to have supportive experiences that allow them to flourish and develop healthy ways of coping, because toxic environments and experiences can have long-lasting damag ing effects on their livelihood (Steinberg, 2014). Clinicians can help facilitate these positive experiences by working with adolescents’ natural tendencies for independence, novelty seeking, exploration, and peer connection. SETTING THE TONE FOR THERAPY From the outset of therapy, the clinician’s primary mission is to establish a strong therapeutic relationship that is based on mutual trust and respect. To earn an adolescent’s trust, take genuine interest in understanding what they like and care about—what they like and dislike about school, what they do in their time outside of school, what their family is like, who their friends are, what they’re looking forward to or nervous about. Take notes and use these details in conversations that follow, as that signals to the adolescent that you are invested in them, and you truly care about them as people.

Creating a Safe Stuttering Space Clinicians must not only set an honest tone that stuttering is ok but also demonstrate that this is true. There is underesti mated power in four simple words: “it’s okay to stutter.” Say this often and mean it by the intentional use of verbal and nonverbal actions. Keep neutral eye contact, facial expres sions, and body language, especially during moments of stut tering. Nod along naturally. It’s helpful not to remind them to use their “speech tools” when they are just sharing about their life and not intentionally practicing a new skill; offering such reminders sends the message that you are more concerned about how they talk rather than themselves as people. If they are practicing some sort of speech change during a structured activity later in the session, then that confined activity would be an acceptable time to offer guidance and reminders in a supportive, nonpunitive way. If, in conversation, you notice that the client is spontaneously fluent—that they are speaking easily and fluently without control or conscious effort—it is oft en not helpful to comment on this because the ease was not the result of anything they were doing intentionally. Regard less of how the client delivers their message and how much they stutter, it is always useful to praise them for sharing their ideas. Many young people come to avoid sharing what’s on Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Chapter 16 • Treatment of Adolescents: Advanced Stuttering 367

their mind—the little things that aren’t necessary like anec dotes, jokes, etc.—to minimize the cost: if I don’t talk, then I won’t stutter. If after a conversational turn with some tough stutters, you may offer some validation like, “I appreciate that you stuck with it. You have lots of great ideas and I want to hear them.” Together, these listening practices send the mes sage to the adolescent that you care about what they have to say and that you are not hyperfocused on how they say it. Ultimately, we want our adolescent clients to share whatever is on their mind and feel safe letting us in. As a clinician who stutters myself, I have found that stut tering openly and confidently can be one of the quickest and most powerful ways to establish a bond with teens who stut ters, many of whom have never met someone else who stut ters before. They may feel an instantaneous connection with you since there is an unspoken understanding that know what stuttering is like, and they may feel relieved to know an adult who stutters who survived adolescence. For all clinicians (those who do and those who don’t stut ter), you can show your client that it’s ok to stutter by con fidently putting stuttering in your own mouth. This is often called “ voluntary stuttering ” or “pseudostuttering.” First, ask the adolescent if it’s ok for you to try to voluntary stut ter like them, explaining that doing so will help you better understand how they stutter. Once the client has consented, have them teach you how they stutter and try to voluntary stutter in that way, learning their pattern by attending to where and how tension builds and how it can release. Even tually, you will model ways of stuttering more easily—easier bounces, easier blocks. As you try to help clients generalize a new communication skill outside the therapy room (whether it’s stuttering openly, maintaining eye contact while stutter ing, easing out of a stutter, or something else the client finds important), always offer to do it first and then offer to take turns while the skill is still new. This sends a clear message to the client that you’re not afraid of stuttering and that you are also willing to take the same risks that you are asking them to take. This inspires mutual trust and respect. Psychologist Kelly Wilson (2009) argued that clients are best served when they are valued as “a sunset to be appreciated rather than a problem to be solved” (p. 15). Clinicians can do a lot of good by focusing on the client’s strengths and values—those qualities that already reside within the client that motivate how they live their day-to-day and make choices. In line with positive psychology (Seligman, 2012), motivational interviewing (Miller & Rollnick, 2012), and solution-focused brief therapy (SFBT) (De Shazer et al., 2021), we can focus on “what’s right” with the client, rather than on their deficits or problems. Early in the therapeutic relationship, clinicians can ask their clients: “What do you think you’re good at?” and “What would your family and friends say you’re good at?” Another Focusing on “What’s Right” With the Client

way to tap into the client’s innate abilities is to prompt them: “I’d like you to think of another time in your life when you learned a new skill or made some sort of change. Perhaps you learned how to speak Spanish, or how to play basketball, or how to drive a car. What kind of skill have you learned? What happened? How did you manage to learn that new skill? What does that show you about yourself?” Clinicians may help clients recognize the incredible dedication and problem solving that already exists within them. This type of dialogue aligns with principles of motivational interviewing, where clients bring to conscious awareness their natural abilities that allow them to do hard things. To extend this conversation, you can also have the cli ent complete a “signature strengths” assessment to identify their top five character strengths (freely available at www. viacharacter.org). This facilitates the client’s self-knowledge and helps them focus on their positive attributes. Then, in conversations that unfold over your therapy sessions, you can help them identify times that they activated those character strengths. Week to week, as they share constructive shifts in their life, you can point out positive things about them that you’ve noticed (eg, “It seems like you care a lot about your friends,” “I can tell that you’re a hard worker,” “You figured out a way to take care of yourself.”). Sharing these observa tions often helps adolescents build their own ability to recog nize and appreciate these strengths within themselves. Goals and outcomes should be developed collaboratively between the clinician and adolescent. Involving young clients in the process sends the message that the clinician’s role is more facilitative than authoritarian, which bolsters the client’s autonomy, investment, and independence that are blossom ing at this time in their life. To do this, you pose open-ended questions to elicit what the adolescent wants to change. These open-ended questions can blend principles from SFBT and motivational interviewing to elicit the adolescent’s “best hopes” or “preferred future” (SFBT terms). Codeveloping Goals Guided by the Client’s Readiness to Change

In Table 16.1, when adolescents are asked what they want to be different, many of them will reply with something along the lines of “I want to be more fluent” or “I don’t want to stut ter as much.” This is an invitation to explore what meaning the client has attributed to fl uency on a deeper level. First, it’s important to validate their desire for talking to be easier through reflecting what they said and the underlying feeling. You can gently reframe the client’s language to help them start focusing on ease and communication over fluency. For exam ple, you may reply: “Stuttering can be really hard sometimes. It’s normal to want talking to be easier. I’m here to support you in exploring what easier talking sounds and feels like.” This sets the tone for the collaborative journey that lies ahead. Using the client’s language within SFBT-style questions can be useful to dive a bit deeper: “If you were more fluent (or if you weren’t stuttering as much), what would that look like? Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

368 Section III • Treatment of Stuttering

TABLE 16.1 Discussion Prompts for Identifying What and How Adolescents Can Make Changes That Are Personally Meaningful

Topic

Example Question to Ask

What they want to change

■ What would you like to see different about stuttering or how you live with it? I’m interested in what you want, not what you think your parents or teachers might want for you.

■ What are the pros or benefits of making this change? ■ What are the cons or drawbacks of making this change?

Why this change is important to them

■ What makes you think that this might be a good time to make this change?

How ready are they to make this change

■ The steps I plan to take in changing are… ■ The ways other people can help me are… ■ I will know that my plan is working if… ■ Some things that could interfere with my plan are… ■ What I will do if the plan isn’t working…

What steps they can take to make this change

change ) suggests that a person’s readiness to change hugely impacts their engagement in the change process and, ulti mately, how durable their change is over time. In this theory, as seen in Figure 16.1, there are five stages of change, rang ing from precontemplation (where the person is not at all ready to change) to maintenance (where they have stuck to a new behavior for at least 6 months). People tend to move through the stages dynamically or nonlinearly, meaning they can make progress, regress, and then progress again— multiple times over. As people re-cycle through the stages, they tend to move through the stages more quickly with each cycle and the change that results tends to be more durable. More information about the stages of change and its applica tion to adolescent stuttering therapy can be found in papers by Zebrowski et al. (2021) and Rodgers et al. (2021). Research has shown that it’s best to start a change journey with the tar get behavior that the client is most ready to change or finds most important to their well-being (Prochaska et al., 1994). Once they have started to make changes in that primary domain and start noticing signs of progress, they will likely feel more confident that they can address other domains that at first seemed too far out of reach. STUTTERING WITH GREATER EASE Most young people who stutter want talking to be easier. They may think that stuttering itself is what makes talking hard. But in reality, stuttering does not have to be hard nor does it have to make talking hard. Vivian Sisskin, a well-known stut tering specialist and pioneer of Avoidance Reduction Therapy for Stuttering (ARTS), distinguishes stuttering from struggle (Sisskin, 2023). Stuttering is not inherently struggled. Often, it is all the things that stutterers do to avoid stuttering that makes stuttering and talking struggled. For example, one

What would you be doing instead?” Perhaps they share that they would participate more in school, be more outgoing, or have better friendships. From these responses, you may say something like “It seems like participating in school is impor tant to you. Do you think it’s possible to participate more in school even if you still stutter?” This helps them focus on what’s important to them rather than on how fluent they are. It also plants seeds of acceptance where they start to consider that they can achieve what they want, with stuttering still a part of who they are. Additional SFBT-style prompts you can offer are: “What would more fluency/less stuttering mean to you? What difference would that make? How would you be different? How would your life be different?” These questions also open up possibilities that they can achieve their goals even if they still stutter (Rodgers et al., 2020). When confronted with the question about what they want to change, some adolescents may not know what they want or have difficulty expressing it. In this case, you can offer some evidence-based domains of change that Dr. Tricia Zebrowski and I have identified in our research (Rodgers et al., 2021; Zebrowski et al., 2021). Based on our interviews with adoles cents who stutter and stuttering specialists, we found three overarching behavior changes that are relevant to many teens who stutter: 1. Making speech changes to talk or stutter more easily 2. Developing more positive thoughts and feelings about stuttering 3. Reducing avoidance of sounds, words, situations The clinician can offer these three behavior changes and then ask them: “On a scale of 1-5, how important is each of these behaviors to you? Which one do you think you’re most ready to start with?” A prominent theory of behavior change known as the transtheoretical model (commonly known as the stages of

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Chapter 16 • Treatment of Adolescents: Advanced Stuttering 369

Figure 16.1 Five stages of change, which adolescents who stutter can move through dynamically.

teen that I worked with realized that he physically braced for upcoming stutters by pressing his lips together right before a target sound he knew he would stutter on, even if the target sound wasn’t produced bilabially. This often altered the tar get sound that came out and would impact his intelligibility. That’s an example of struggle. With this struggle versus stut ter distinction in mind, one of our aims when working with young people who stutter is to guide them in figuring out ways to reduce struggle so they can stutter with greater ease. They can do this by learning about the physiology of talking and stuttering, identifying when and how they stutter, and then figuring out ways to work with their speech mechanism rather than fight against it. Learning About the Speech Mechanism One of the most important precursors to making any sort of behavioral speech changes is to learn how the speech mecha nism works to produce talking and stuttering. A helpful way to start this discussion is to find or make an age-appropriate drawing of the speech mechanism that includes everything from the diaphragm up—lungs, vocal folds, articulators (tongue, teeth, lips, jaw), nose, and don’t forget the brain that decides what to say and directs parts of the speech mecha nism to move in certain ways. Creative clients may be inter ested in making a 3D model of the speech mechanism using modeling clay, Legos, origami paper, household objects, or other resourceful materials. Once a common vocabulary about speech anatomy has been established, it’s time to understand how the different parts work together. It’s useful to start by explaining how the parts work together seamlessly most of the time to produce

easy, fluent speech: The brain sends a signal to the body to inhale, which sends the diaphragm down to make room for the lungs to fill up with air. Once we’ve inhaled, we start talk ing as we exhale. The air moves up from the lungs into the windpipe and then through the vocal folds, which starts their vibration so that the voice can turn on. The air then moves into the mouth where the articulators shape the air to make different sounds. Once the teen understands the path of airflow, it’s help ful to explore with them where and how different sounds are made. Have them produce different sounds: labials /p, b, m, w, f, v/, alveolars /t, d, n, l, s/, velars /k, g/, and those that occur at the vocal folds including vowels and /h/. The clinician should model each one first, producing each of these sounds easily and then increase the tension by, say, 25% → 50% → 75%. When playing around with differ ent tension levels, this is a natural time to talk about and experiment with the three core behaviors of stuttering— repetitions, prolongations, and blocks. From single sounds, you can start producing single words and simple phrases with the same approach (first easily, then gradually add ing tension). In the spirit of Dr Dean Williams (one of the renowned giants of stuttering therapy at the University of Iowa from the 1950s to 1980s), prompt the client to really “feel what you’re doing”—recruiting their cognitive and physical attention so they are moving mindfully and inten tionally. This is educational, kinesthetic, and desensitizing as it builds their behavioral awareness of where and how they may get stuck when they stutter. Try to tap into your own curiosity and creativity to make this activity engaging and interesting for your adolescents; model the type of intrigue and excitement that the complexity of speech production

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370 Section III • Treatment of Stuttering

deserves! A video of Dean Williams working with a teen is available on Lippincott Connect. It is titled, “Dean Williams helps a student stutter more easily.” Identifying Moments of Stuttering Once the adolescent has developed a clear understanding of speech anatomy and physiology, and has experimented with modifying tension on different target sounds and words, it’s time to help them identify when and how they actually stut ter. Many young clients (and adults who are new to therapy, too) will initially have difficulty with identifying stutters on the fly, so we need to scaffold initial skill acquisition to help them become good observers. I usually start away from the client (understanding other people’s stuttering) and then gradually work toward their own real stutters. Perhaps you could watch YouTube videos of people who stutter and work together to identify stutters in their speech by raising your finger when you see one. Then, pause the video and you and the client both try to imitate the stutter, followed by brief description of where in the speech mechanism it was pro duced and what type of stutter it was (repetition, prolonga tion, block). Once the client has showed that they are able to identify moments of stuttering in these recordings of others and can describe where and how they are produced, the next step could be you producing pseudostutters in conversation with the client, prompting them to raise a finger when they notice you pseudostutter, and then describing where and how you pseudostuttered. You do not need to make your pseu dostutters really hard and struggled. I once had a 13-year-old client tell me that she was uncomfortable when her previous clinician pseudostuttered because the clinician did it with a lot of physical struggle; the client thought, “is that what I look like when I stutter?” So, before you pseudostutter with a client, it is helpful to gauge their comfort with you pseudos tuttering and if they give you the go-ahead, know that you can make your point by pseudostuttering confidently and without a lot of struggle. After the client has demonstrated success with identifying your pseudostutters, it’s time to move to the client’s own stut ters. Some clients are willing to be videorecorded in the ses sion and then watching it back right away with the clinician and identifying their own stutters offline. However, watching recordings of oneself can be confrontational and uncomfort able, even for people who don’t stutter. So, if the client does not want to do this step, then by all means skip it and move to the last step where the client tries to identify their own stutters as close to in real-time as possible. Have them try to raise their finger when they notice themselves stuttering. The type of stimuli you use to elicit a conversational turn from the client in this activity depends on how frequently they stutter. For clients who stutter very often, you may get real stutters by eliciting shorter phrases. For clients who stutter less fre quently, you may need to elicit longer responses or increase the communicative stress by having them explain something

complex or take a stance about a controversial topic. Ensure that the topics and stimuli are relevant to their life—their interests, hobbies, school topics. Two notes about semantics here. First, in the spirit Dean Williams, it is useful to talk about stuttering as something the speaker does, not something that happens to them . If stut tering is something they do, they can do something differ ent about it; if stuttering is something that happens to them, then they likely feel at the mercy of stuttering, which robs them of making any choices about it. This type of active language is not intended to blame the client for the stut tering, but rather to instill a sense of autonomy. Second, if you are not a person who stutters and you are stuttering on purpose during an activity, it is more accurate to call what you’re doing pseudostuttering or voluntary stuttering rather than stuttering. This sends a subtle signal to your client that you respect their stuttering experience as something that is unique to them and the stuttering community. Often, well intentioned listeners and clinicians will attempt to console people who stutter or normalize stuttering by saying things like, “everyone stutters sometimes.” Everyone is disfluent sometimes, but not everyone stutters sometimes. Holding, Tolerating, Then Easing Out Once the adolescent has demonstrated knowledge of when, where, and how they stutter, they can start to figure out ways to reduce tension in moments of stuttering to ease out gen tly. At this stage, it’s helpful to stay in stutters for longer than usual so that they have time to turn their attention inwards and focus on how it feels in the moment. Most people who stutter will do whatever they can to get out of stutters as quickly as they can; stuttering can feel uncomfortable, stress ful, embarrassing, and so of course they want to get out of it as soon as they can. But a big part of desensitizing oneself to those negative thoughts and emotions amid a stutter is to stay in it for longer than they have to. This act of progressive desensitization increases their comfort with stuttering, which in turn will help them stutter more easily. To stay in a stutter, the person is guided to volitionally keep the tension in that spot to keep the stutter going. Many teens find it helpful to close their fist as a visual and physi cal way of “catching the stutter” and then keeping their fist closed as they keep the stutter going. This is what I mean by “ holding and tolerating .” Then, as they slowly unfurl their fingers and open their fist, they slowly reduce the tension in their articulators and ease into the next sound. As they ease into the next sound, the teen is guided to really elongate this moment and focus their attention on how the smooth transition to the next sound feels. It’s as if they are putting this moment under a microscope so they can study it and understand it. I have found that learning how to hold, tolerate, and ease out works best when teens begin with voluntary stutters. Once they have gotten a hang of how to do it with fake stutters, they

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Chapter 16 • Treatment of Adolescents: Advanced Stuttering 371

can move to doing it with real stutters. If they miss a moment of real stuttering, they can go back into the target word using a voluntary stutter and practice it that way. At first, many adolescents will feel very uncomfortable with this activity. After all, they thought they were coming to you so they could learn how to stutter less and here you are telling them to stutter more . It’s important to offer a very strong rationale for why you are asking them to hold and tol erate. I may say something like this: “Our therapy room is a safe place to explore moments of stuttering—not by fighting them, but by learning how to work with them so that eventu ally they become less scary and easier to move through. So we’re going to try to hold onto stutters—both fake ones and real ones—for longer than we need to or longer than feels natural. Something like this [model an example, synchroniz ing your verbal model with your fist closing and opening as described in the previous paragraph]. By taking our time in these moments, we are giving our body and brain enough time to tune in and learn. It may feel odd or uncomfortable to stay in stutters longer than you’re used to, especially if you’re wanting them to be shorter not longer. But this is an important step in teaching your body and brain that you can be brave and courageous when stuttering. The more you do this, the less scary stuttering will be and in time, you’ll be able to make the stutters shorter.” The use of analogies can be particularly useful here. For example, it can be helpful to do something you’re afraid of (eg, flying without your parents, learning how to drive) by taking small steps toward it in a safe way. If there’s an example from the client’s own life that you can draw on, this would make the point more effectively. Using Hierarchies to Level Up For those who want to stutter more easily, the ultimate goal is to be able to do so across interactions and situations in the “real world.” But how does a new behavior become reliable and engrained? By systematically practicing it in situations of increasing difficulty. This applies to all populations that clini cians serve, not just those who stutter. In the world of stutter ing therapy, we often talk about “hierarchies” to help clients gradually work their way up to using new communication behaviors in more challenging situations. There are two types of hierarchies that are relevant for stuttering therapy: linguistic hierarchies and situational hier archies . A linguistic hierarchy is similar to that which is used in traditional articulation therapy where new sounds are acquired in isolation, then words, then phrases, then struc tured conversation, and finally unstructured conversation. A linguistic hierarchy is most useful within stuttering therapy sessions when clients are first learning to hold, tolerate, and ease out of stutters; it offers a structured roadmap for how to practice the new skill in increasingly complex utterances. While a common linguistic hierarchy is applicable to lots of people, a situational hierarchy is highly unique to each cli ent and therefore should be created together with the client

to ensure that it is personally relevant to them. A situational hierarchy is a list of social interactions that are ordered from easiest or least stressful, to hardest or most stressful. These can include certain people (eg, talking to specific family members, peers) or certain contexts (eg, talking in specific classes, giving class presentations, ordering at a restaurant, talking on the phone). A situational hierarchy is useful within and outside therapy sessions because the people and contexts on the hierarchy likely exist outside the therapy room (eg, talking to a teacher or coach, giving a class presentation). A savvy clinician uses both linguistic and situations hier archies to support gradual skill development in an inten tional way that feels safe to the teen. Both types of hierarchies are effectively visualized using a staircase or a ladder that can make the process concrete for teens. The process can also be gamified to make it more engaging for teens; once they have “beaten” a level, they move to the next level in their hierarchy. Over time, it’s likely that their comfort zone will expand and they will approach harder situations with a bit more confi dence. It’s important to tune into the client’s comfort level. While it’s appropriate to gently nudge when it is clear that the teen is capable and ready for a new challenge, do not ask teens to do something that is too stressful for them at that moment as that damages the trust you have worked so hard to establish. This is described in greater detail in the section “Expanding Comfort Zone” toward the end of the chapter. Across all challenges, always offer to model first either in a role play or real scenario as you shouldn’t ask your client to do something that you yourself are not willing to model. Also, always offer to be there as a support person as appropriate or feasible; your presence as a trusted partner can minimize the scariness of doing something new.

DEVELOPING HEALTHIER THOUGHTS AND FEELINGS ABOUT STUTTERING

Behaviors can be both overt and covert. There are behav iors that are visible to others, and there are behaviors that are invisible to others like thoughts, feelings, and memories (Ciarrochi et al., 2005). Thus, addressing how a young person thinks and feels about communication is a behavioral goal within our scope of practice (American Speech-Language Hearing Association, n.d.).

My perspective is that negative thoughts and feelings about stuttering are typical reactions to an atypical stressor—that they arise because young stutterers are learning how to navi gate a fast-paced society that is often unwelcoming to people who need more time to do anything, including talking. And this is unfolding at a period in their life when social approval is paramount to their well-being. Repeated experiences with being interrupted, teased, bullied, told to talk differently, or reminded to “slow down, think about what you want to say” when stuttering has nothing to do with fast speech rate or Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.