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Stuttering An Integrated Approach to Its Nature and Treatment


Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Stuttering An Integrated Approach to Its Nature and Treatment


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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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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vi Preface

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

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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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Preface v Acknowledgments vii 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 Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 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


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

Beginning Stuttering 312 An Integrated Approach 313 Bibliography 421 Author Index 449 Subject Index 457 Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Treatment of Older Preschool Children: Beginning Stuttering 14

Chapter Outline

Chapter Objectives After studying this chapter, readers should be able to: ■ ■ Describe the characteristics of a child who has beginning stuttering ■ ■ Describe the author’s beliefs about stut tering, targets in treatment, goals for treatment, how much to involve feelings and attitudes in treatment, and mainte nance procedures ■ ■ Delineate the procedures involved in the Lidcombe Program, the stages of therapy, and the criteria to complete each stage ■ ■ Describe the procedures for Stuttering Modification Treatment ■ ■ Explain how formal training may be obtained for using the Lidcombe Program ■ ■ Outline the components of Sheryl Gottwald’s “multidimensional approach” ■ ■ Describe a number of different approaches to working on stuttering co occurring concomitant speech or lan guage problems

An Integrated Approach Author’s Beliefs Nature of Stuttering

Speech Behaviors Targeted for Therapy Fluency Goals Feelings and Attitudes Maintenance Procedures Clinical Methods Clinical Procedures: Lidcombe Program Stuttering Modification Treatment Another Clinician’s Approach: Sheryl Gottwald Children Who Stutter With Minimal Struggle Children Who Stutter With Moderate to Severe Struggle Termination Supporting Data on Gottwald’s Multidimensional Approach Treatment of Concomitant Speech and Language Problems Modifying the Environment Modifying the Child’s Speech

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Evaluation Treatment

Sequential Model Concurrent Model Cycles Model


Chapter 14 • Treatment of Older Preschool Children: Beginning Stuttering 313

Key Terms

Concomitant speech and language problems : Difficulties with articulation/ phonology and/or difficulties with lan guage that sometimes accompany stut tering. When this occurs in some children who stutter, it poses the problem of which disorder to work on first. Several approaches have been used by experi enced clinician-researchers Demands and capacities : The perspective that the factors associated with the onset and persistence of stuttering are the demands placed on the child by her envi ronments, balanced (or not) by the child’s innate capacity for fluent speech Lidcombe Program (LP) : An operant con ditioning–based approach to stuttering treatment, delivered in the home by a parent or other caregiver and guided via weekly meetings with the clinician Older preschool children : Children be tween 3.5 and 6 years of age Operant conditioning : A type of behav ior modification that uses rewards and punishments to increase or decrease the frequency of a behavior Severity Rating (SR) Scale : A scale from 0 to 10 used daily by parents to assess a child’s stuttering. May be used by clini cian as well during weekly clinic sessions Stage 1 of the Lidcombe Program (LP) : The initial step of LP in which the child becomes normally fluent. Criteria for completing Stage 1 are 3 consecutive weeks in which (1) the parent’s weekly SRs are 0 to 1 during the week before the clinic visit and 4 of the 7 SRs are 0 and (2) the clinician’s SR for the entire session is 0 to 1 Stage 2 of the Lidcombe Program : When the child meets the fluency criteria to complete Stage 1, this maintenance stage is begun. Weekly clinic meetings are faded systematically so that the parent and child meet with the clinician in this sequence: 2, 2, 4, 4, 8, 8, and finally 16 weeks apart. The child must continue to meet fluency criteria Stuttering modification : A treatment approach that helps the client to AN INTEGRATED APPROACH Children with beginning stuttering are usually between 3.5 and 6 years of age. To distinguish them from children with milder, borderline stuttering, I refer to them as older pre school children . ey have probably been stuttering for at least several months, and their parents may well be con cerned that it is not a transient problem that will disappear on its own. What follows are some details on the core and secondary behaviors of their stuttering, as well as feelings and attitudes that o en characterize stuttering in this age group. ese children’s most common core stuttering behaviors are part-word repetitions that are produced rapidly, usually with irregular rhythm. Prolongations may also be present. Both the repetitions and prolongations may contain exces sive tension, which can be heard as abrupt endings to the repetitions and/or as increases in vocal pitch in repetitions and prolongations. Blocks may also be present, with evidence of tension and struggle. Secondary behaviors are typically escape devices, such as eyeblinks, head nods, and increases in pitch as the child tenses their vocal cords trying to get the word out. A few avoidance maneuvers may be observed, such as starting sentences with extra sounds like “uh” or chang ing words when a stutter is anticipated. In many cases, when the frequency of stuttering becomes high, these children may put their hands to their mouths to push words out or may momentarily avoid talking. Children with beginning stutter ing usually feel frustrated and sometimes panicked with their di culty in talking but have not yet developed a strong antic ipation of stuttering or learned to be ashamed of their speech. I will illustrate our approach with a description of Kath erine’s treatment. She is the 3-year-old child I introduced in Chapter 1. e course of her treatment is depicted in Figure 14.1. Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. decrease negative attitudes and feelings about their stuttering and guides them to stutter more easily. It may result in the elimination of stuttering as a problem or, at least, a reduction in the effort needed to talk Unambiguous stutter : A moment of stut tering that is so clear that the parent or the clinician has no doubt that it should be categorized as a stutter Verbal contingencies : Comments to the child made immediately after an event (eg, fluent utterance; stutter) that are intended to change the frequency of that event

314 Section III • Treatment of Stuttering

Case Example


child may experience as the result of moving, the birth of a sibling, or other life events. In some children, beginning stuttering emerges gradu ally a er they have gone through a period of borderline stuttering as younger preschool children. As these children get older and if stuttering continues, they begin to respond to negative experiences of repetitive dis uencies with increased tension. However, in some children, beginning stuttering appears suddenly, close to the onset of stutter ing. ey may be easily frustrated or highly distressed when many of their speech attempts result in repetitions or pro longations that feel out of their control. As these children respond, at rst nonconsciously, to these core behaviors, they increase tension and develop a variety of escape behav iors that are reinforced. eir eyeblinks, head nods, and pitch increases are rewarded because they o en result in the release of stutters. Gradually, classical conditioning in u ences when and where the child’s stuttering occurs. Spe ci cally, negative emotional experiences that are associated Seven years after therapy had been completed, we contacted Katherine and her parents to assess her status. She had been completely fluent ever since treatment ended and was highly verbal with only dim memories of ever having stuttered. Her parents have become a valuable resource for other parents of children who are beginning to stutter as they contemplate treatment. stuttering and then using verbal contingencies for stuttering and for fluency during natural conversa tions throughout the day. After several weeks went by, we saw notable im provement in Katherine’s stuttering, shown by both our weekly measures of her stuttering frequency in the clinic and her mother’s daily ratings of the se verity (SRs) of Katherine’s stuttering at home. The steady decline in Katherine’s stuttering continued, interrupted by an occasional spike upward when a stressful event occurred, such as a visit by relatives or a family trip. At one point, Katherine’s stuttering shot up for several days, and we worked with Katherine’s mother to figure out the source of the problem. We discovered that Katherine’s father, in his eagerness to help, began to use verbal contingencies without training when he was alone with Katherine and over dosed her with several hours of contingencies each day. Once that was resolved and Katherine’s father was trained to use contingencies judiciously, her stut tering continued to decline steadily. Katherine be came fluent after about 6 months of treatment. Over the following year, the clinicians continued to stay in touch, but Katherine and her mother came in to the clinic less and less frequently.

Katherine’s therapy began when she was 3 years old and stuttering severely—on 21% of her spoken syllables. As you may remember from our description of her stuttering in Chap ter 1, Katherine’s pattern was characterized by rep etitions, prolongations, and

Author’s Beliefs Nature of Stuttering As I’ve described in chapters in the “Nature of Stuttering” part of this book, I believe that beginning stuttering arises when children’s neurodevelopmental sensorimotor di cul ties related to speech production interact with their tempera ment and other developmental and environmental in uences to produce or exacerbate repetitions, prolongations, and blocks. is is essentially the position taken by C. S. Blue mel in his book e Riddle of Stuttering (1957). It was further articulated by Johnson and colleagues (1959), who suggested that the problem of stuttering arises as a result of interac tions among (1) the amount of the child’s dis uency, (2) the reaction of his listeners to the dis uency, and (3) the child’s sensitivity to his own dis uency and to listeners’ reactions. I would add to Johnson’s list of interacting factors any pres sures that a child may feel internally (eg, to speak quickly and in long, relatively complex sentences) and any anxieties the At the time she came in for an evaluation, two other clinicians and I had recently been trained in the Lidcombe approach—a treatment described in this chapter. Several weeks after the evaluation, we began Katherine’s therapy by training her mother in using verbal contingencies (praise) for Katherine’s fluent speech during daily, 15-minute practice ses sions at home. We also trained Katherine’s mother in making daily ratings of the severity of Katherine’s stuttering. During our weekly clinic meetings with Katherine and her mother, we measured the fre quency of Katherine’s stuttering in conversation at the beginning of each session. The rest of each ses sion was spent on problem solving any issues that came up during practice sessions and training Kath erine’s mother in the next steps of treatment. These next steps included using verbal contingencies for blocks, with a predominance of blocks with much struggle behavior. She had changed from bubbly and talkative to withdrawn and reluctant to engage in conversation.

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Chapter 14 • Treatment of Older Preschool Children: Beginning Stuttering 315

Figure 14.1 An overview of Katherine’s treatment with Katherine’s mother conducting most of the treatment at home.

with stuttering become etched into memory and associated with various contexts, such as the telephone, impatient listeners, or particular sounds and words. As stuttering spreads and becomes more pervasive and more consistently present, these children become aware of their stuttering, although at rst, they may have little shame about it and do not dread speaking situations. Because of the plasticity of the brain at this age, some children with beginning stutter ing develop better sensorimotor control of speech produc tion, and their stuttering goes out the door it came in. eir stutters diminish in frequency and severity and disappear or become a minor nuisance. Other children, perhaps those with more widespread sensorimotor de cits, a more sensi tive temperament, or larger doses of other developmental

and environmental stresses, continue to stutter and o en develop more advanced symptoms. Like Bloodstein (1975), I believe that if we can provide a child who has beginning stuttering a su cient number of positive, uent speaking experiences during treatment, u ency will replace stuttering. Bloodstein, whose 50-year career was focused on the nature and management of childhood stuttering, strongly advised treatment that would ensure that “the child experiences daily successful, pleasant, and reward ing speech with a minimum of stuttering” and that these daily experiences be created by the parent at home (Blood stein, 1975, pp. 61–62). Echoing Bloodstein, I believe that this may happen best when treatment is administered by the parent at home,

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316 Section III • Treatment of Stuttering

where it can be done many days a week. It also appears e ec tive if natural uency is elicited at rst in highly structured situations, systematically reinforced, and then carefully transferred to more and more real-life situations in which stuttering has been occurring. Speech Behaviors Targeted for Therapy Usually, intervention for beginning stuttering focuses on u ency, with the expectation that children at this stage are likely to respond well to techniques with that focus. Sometimes, however, when the child is beginning to experience fewer repetitions and an increasing number of very e ortful stut ters, the focus may expand to include not just uency but also methods of modifying dis uencies so that they are less e ort ful. Despite these goals as major targets for therapy, however, creating a context that is playful and therefore fun is also seen as crucial. Fluency Goals Almost all children who are treated with e ective therapy for beginning stuttering will gain or regain spontaneous, typical uency. In most cases, a year or two a er treatment ends, the children will have little or no recollection of having stuttered and will not have to monitor their speech or work at being uent. Some who are stuttering more severely at the beginning of treat ment may have mild stutters remaining that are hardly notice able and which do not interfere with communication. In rare instances, children with beginning stuttering may continue to stutter in ways that are noticeable. ese children (and their par ents) can learn to accept the remaining stuttering and develop attitudes that allow the children to communicate e ectively. Feelings and Attitudes As noted earlier, a child with beginning stuttering has occa sional frustration and intermittent concern about talking. ey have only mildly conditioned fears or avoidances of stuttering. us, it is typically unnecessary to focus directly on feelings and attitudes in therapy—in most cases—for a child with beginning stuttering. I do, however, work on feel ings if the child seems frustrated or ashamed of their stutter ing, as you’ll see in the later sections of this chapter where I talk about speci c techniques. e feelings and attitudes of these children are, however, in uenced by the family. e clinician teaches the family member providing the at-home treatment to be matter-of fact about the child’s “smooth” and “bumpy” speech. e clinician and family member openly discuss the child’s stut tering during their weekly meetings when the child is also present. ese aspects of treatment are intended to reduce any embarrassment or shame that was associated with stut tering and foster the child’s acceptance of stuttering as just a little slip-up, like bumping into a table or tipping over their For the past many years, I have been using the Lidcombe Program (LP) (Guitar et al., 2015; Onslow et al., 1990, 2003) to treat preschool children with beginning stuttering. I was initially trained in using this program in a workshop led by Rosalee Shenker in collaboration with the Montreal Fluency Centre. Subsequently, I developed more expertise through consultation and mentoring from Rosalee and my colleagues, Julie Reville, Melissa Bruce, and Danra Kazenski. Follow-up training with Elisabeth Harrison—one of the developers of LP—further sharpened my skills. For readers interested in using this approach, I urge you to obtain formal training at one of the many workshops o ered around the world by the Lidcombe Program Consortium. More information on LP is available at On this web site, the link to “Lidcombe Program Trainers Consortium” provides a brief video “lptc-an introduction” in which the program is described in a way that both families and clini cians can get a clear overview of the program and its exibil ity to adjust to di erent families and di erent children. On the website, there are also links to pages that provide infor mation in the following categories: Families and Caregivers, Speech-Language Pathologists, and Teachers and Health Pro fessionals. e information for Speech-Language Pathologists includes copies of materials needed for using the Lidcombe Program, including the treatment guide that can be found by clicking on the Research and Publications link. More infor mation about stuttering treatment can be found by connect ing with the Australian Stuttering Research Centre (ASRC), available through Google and other search engines. Moreover, an excellent chapter in Guitar and McCauley (2010), written by Harrison and Onslow, gives a detailed description of LP. Fourteen short video clips on Lippincott Connect (Chapter 14 videos) show Harrison (a master LP clinician) treating a preschool child using LP. Although LP is ever-evolving as its Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. tricycle. is is a far cry from the “conspiracy of silence” that formerly characterized the treatment of children who stutter. Maintenance Procedures Systematically fading contact with the child and their family is vital for maintaining uency. In my experience, if families leave treatment a er uency is achieved without having par ticipated in a maintenance program, stuttering seems more likely to return. us, it is important for clinicians to stress the importance of maintenance procedures at the outset of treatment. Moreover, the clinician and family should con tinue with careful data collection as contact is faded, so that the family can return to regular weekly meetings and discuss appropriate contingencies for uency and stuttering if any relapse occurs. Clinical Methods Clinical Procedures: Lidcombe Program

Chapter 14 • Treatment of Older Preschool Children: Beginning Stuttering 317

provides a gentle acknowledgment of the stutter (“ at was a little bumpy”) or a gentle request for self-correction (eg, “Say ‘truck’ again.”). Although in an operant framework, these latter comments are seen as mild punishments, I think that many parents and children will experience them as pretty innocuous. Table 14.1 lists verbal contingencies for uency and stuttering. e ratio of verbal contingencies for uency to verbal contingencies for stuttering is kept very high to make the program a positive experience for the child. In other words, the parent responds to the child’s stuttering only a er the parent has given an appropriate number of praises for u ency. e ratio is determined by the parent and clinician as they observe how the child responds to both kinds of con tingencies. As the child’s stuttering decreases during practice sessions, contingencies are also given during the natural con versations each day. e parent continues to provide verbal contingencies for uency and stuttering, but in more casual way, in natural situations of daily life, such as when the parent is talking with the child in the car, in the kitchen, or at a store. Once the child meets the established criteria for uent speech

developers continue to identify improvements through their research, the essentials of the interventions have not changed signi cantly, making these resources of continuing value. O VERVIEW e Lidcombe Program uses operant conditioning proce dures (ie, verbal response contingencies), which are admin istered by a parent in the home during brief one-on-one practice sessions and natural conversations each day and are guided by weekly meetings with the clinician. Treat ment begins in structured conversations—practice sessions designed to elicit a maximum of uent speech by the child so that the child receives mostly positive reinforcement. At the beginning of treatment, it is important to provide frequent praise, su cient to let the child know that they are uent (eg, “ at was really smooth talking!”), acknowledgment of uency (eg, a very low-key “ at was smooth”), or request for self-evaluation (eg, “Was that smooth?”), which is used only a er a uent utterance. A er the child becomes used to praise for uency, the parent begins to comment infrequently on the child’s stuttering. When the child stutters, the parent

TABLE 14.1 Verbal Contingencies for Fluent Speech and Unambiguous Stuttering

Examples of Verbal Contingencies

Fluent speech

■ Comments should be specific to speech (ie, “nice” or “very good” is too general, but “that was nice, smooth talking” is right on). ■ Always give at least as many praises for fluency before a contingency for stuttering. ■ Adjust the types of praise to those that the child seems to enjoy. Here are some examples: “That was smooth.” “Great, your words are smooth!” “Nice smooth talking!” “No bumps there, excellent.” “I didn’t hear any bumps.” “Wow, that whole story was totally smooth.” “Was that smooth?” (The answer should always be “yes” and followed up with another instance of praise.) ■ Also praise for spontaneous self-evaluation (ie, if the child says “I was really smooth today” or remarks on his own smooth or bumpy talking). ■ Use low-key friendly delivery and move quickly to a praise. ■ Use one request for correction after several praises. ■ Some children become so smooth during a session they do not need any contingencies for stuttering. This is okay because the goal is practicing stutter-free speech. ■ In early responses to stutters, some Lidcombe clinicians merely comment acceptingly on stutters rather than asking the child to re-do them: “Oops, I heard a little bump.” “That was a little bumpy.” “There was a bump.” “You got a little stuck there.” “You only need to say _____ once.” “Say _____ again.” (Use if child is comfortable with repeating stuttered word.) Remember only to praise smooth speech; it’s important not to praise bumps! However, praising the child’s willingness to continue talking after a bumpy patch supports communication and therefore warrants consideration.

Unambiguous stuttering

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318 Section III • Treatment of Stuttering

in all situations, the treatment is gradually faded in a system atic fashion during Stage 2, which is the maintenance stage of treatment. roughout the program, the clinician and parent regularly assess the child’s stuttering using the severity rating chart and use those measures to make treatment decisions and problem solve any barriers to progress. S TAGE 1: T HE F IRST C LINIC V ISIT Stage 1 of the Lidcombe Program begins with the rst clinic visit when the clinician meets with the parent (or other care giver) and child to accomplish three goals: (1) to explain severity ratings (SRs) to the parent, (2) to assess the child’s stuttering and overall ease of speaking, and (3) to teach the parent to conduct daily practice sessions. Stage 1 clinic visits are typically 1 hour in duration. Assessment of Stuttering Using the SR Assessment of the child’s stuttering is carried out primarily by using the Severity Rating (SR) Scale (see Chapter 9; Figure 9.4). is is a 0 to 10 scale that the clinician and parent use in each clinic meeting. In addition, the parent records SRs at the end of every day, re ecting their judgment of the child’s stut tering severity that day. e daily SRs are crucial data used to assess the child’s progress and make decisions about verbal contingencies. On the SR Scale, a 0 represents no stuttering, a 1 represents extremely mild stuttering that a casual observer would not notice, and a 10 represents extremely severe stut tering. 1 In the rst clinic meeting, a er discussing the scale in detail with the parent, the parent and I play and talk with the child to obtain an adequate, representative sample of the child’s stuttering. I then ask the parent to tell me what SR they would give the child’s speech in that sample, which I compare with my own judgment of the child’s SR. It is usually pos sible with only a little discussion to ensure that the parent is using the scale appropriately. On the rare occasion that the parent’s rating di ers from mine by more than 1 point plus or minus, I explain how I came up with my rating and then try to determine if the parent seems to understand my rationale and is likely to be accurate in their future ratings. I o en say to a parent if there is any stuttering, the score can’t be 0, and if you think about is the stuttering is mild, moderate, or severe, it will help you come up with a score that is in the lower, mid dle, or top part of the scale. If I have doubts, I use video clips of the child’s speech to help teach the parent how to use the scale. I typically ask the parents to make videos of the child’s speech at home during the rst few weeks of treatment so that I can continue to “calibrate” the parent’s ratings. Once I’m sure that the parent understands the scale, I ask them to rate the child’s speech at the end of every day and to bring the ratings to our weekly meetings. e standard Lidcombe

procedure has the parent bring in a chart that displays each day’s SRs of the child. I encourage the parent to add com ments to the chart if the child has gone through a period of increased stuttering, sickness, or other event that the parent feels may have an impact on severity or the child’s response to treatment. If it would be helpful to the parent, there is an online scale available from ASRC downloads. is can be lled out online and e-mailed to the clinician. Assessing the Child’s Percentage of Syllables Stuttered (%SS) e use of %SS to assess the child’s stuttering is optional because it simply assesses the frequency of the child’s stut tering, rather than characteristics of the severity of the stut tering. When I am conducting LP treatment, I usually assess the child’s %SS at the beginning of treatment and at other important points in the program such as when the child moves from Stage 1 to Stage 2. For a formal assessment using %SS, I typically video record the clinic session and later score the child’s stuttering from their speech in that sample, which should be at least 300 syllables. Teaching the Parent to Conduct Daily Practice Sessions A critical part of the rst clinic visit is to show the parent how to conduct the daily practice sessions. It is most important to create situations that not only are fun but also stimulate and encourage a lot of uent speech in the child. is enables the parent to begin treatment using a great deal of positive verbal contingencies for uency. To demonstrate for the par ent, I begin by using a picture book or picture cards with the child to elicit short, uent words. To keep the child’s interest, I talk with a lot of enthusiasm and move through the pictures quickly. I usually name a picture or two myself as a model for the child and then ask them to name some pictures. A er the child is engaged in the task and is producing a good deal of uent speech (because the task is designed to limit the length of the response and thus producing much uency), I praise the child’s uency immediately by saying something spe ci cally about their speech, such as “ at was really smooth talking!” or “You said that really smoothly!” It is important to make the praise directly relevant to the child’s uency , rather than general praise (ie, not “You are doing well!” but “You said those words really smoothly”). A er modeling for the parent, I ask them to work with the child, and I coach the parent if necessary.

1 e Lidcombe Program changed the 0 to 9 scale to a 0 to 10 scale in 2023, to make it similar to many scales that are 0 to 10. With children who have more severe stuttering, I may need to begin with single-syllable words or have the child repeat the word a er me. Children who have milder stutter ing can progress quickly from single words to carrier phrases (such as “I like _____”) and to short sentences of three or four words. Figure 14.2 shows a linguistic hierarchy that most children can quickly climb on the way to natural conversa tions in the beginning of Stage 1. It is important to keep in mind and share with the parent the idea that the point of the Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Chapter 14 • Treatment of Older Preschool Children: Beginning Stuttering 319

As I mentioned earlier, it is crucial that the parent make the practice sessions fun for the child. It may be helpful to suggest games and activities for the sessions. Table 14.2 lists some of the activities that parents can use with the child in these practice sessions. At the end of the rst clinic visit, I review the activities and tasks the parent will be doing over the coming week and respond to any questions they have. Some parents bene t from taking notes or being given a written description of things they will be doing; others like to have a follow-up con tact from me. In all cases, I encourage them to call or e-mail me if they have any questions or concerns during the week. S TAGE 1: S UBSEQUENT C LINIC V ISITS Most subsequent clinic visits have three goals: (1) to assess the child’s stuttering, (2) to discuss the current progress, and (3) to introduce new procedures when appropriate. Each ses sion begins with the clinician and parent assessing the child’s stuttering using the SRs. is assessment is made from the child’s conversational speech when talking with the parent and the clinician with no verbal contingencies given, until a representative sample of the child’s speech has been obtained (about 300 syllables or 10 minutes). e clinician determines in their own mind what SR rating to give the child’s speech and then asks the parent for their rating of that sample. Once the parent has announced their SR rating, the clinician then shares with the parent what the clinician’s rating is. If the par ent and clinician ratings di er by more than 1 point, a dis cussion ensues that helps the parent align their ratings with those of the clinician, or, in some cases, in uences the clini cian to change their rating. In some instances, the parent may be initially rating the child’s articulation or language instead of, or in addition to, their stuttering, so this must be clari- ed. Accurate parent SRs are essential to the integrity of the treatment program. ese ratings, along with the clinician’s ratings, determine whether treatment is progressing success fully and signal when to fade practice session conversations and transition to treatment in natural conversations. ey

Figure 14.2 Linguistic hierarchy used for practice sessions at the beginning of Stage 1 in the Lidcombe Program.

linguistic hierarchy is only to ensure that the child is produc ing many uent utterances and thus receiving frequent praise for uency. ere is no need to adhere to the linguistic hierar chy in obsessive way. As long as the child is producing plenti ful uency, the goal of therapy is being achieved. One of the mistakes parents o en make when they rst begin is to use positive verbal contingencies for uent speech that are too general. ey might say, for example, “ at’s good” or “You’re doing well.” In this case, I simply restate the need for speci c praise and observe the parents doing it. Another common error is for parents to let the child make longer responses than are appropriate, thereby allowing more stuttered than uent utterances to occur. Fortunately, a little discussion and lots of modeling will usually clear this up. For those children who need to start at the one- or two-word utterance stage, speci cally praising their use of one or two words will help keep them at this level until it is appropriate for them to move to longer utterances.

TABLE 14.2 Suggested Games and Activities for Structured Treatment Conversations

Grab bag

The parent puts interesting items into a large cloth bag or pillowcase, and the child guesses what each is by reaching into the bag and feeling the item.

Picture naming Using picture books or picture cards, the child names each picture. At the one-word level, the child only names the pictured object. As longer utterances are permitted, the child can use a carrier phrase such as “That’s a _____,” or she can name the item and its color, such as “red rabbit.” Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Reading a story

Parent and child look at a familiar book while the parent reads or tells the story. To elicit a word or phrase, the parent asks the child to complete a sentence, such as “Then Goldilocks said, ‘Somebody’s been sleeping in my _____.’”

Rhyme closing

Parent makes up a rhyme and leaves the last word blank, like “Once there was a man—he cooked his eggs in a frying _____.”

320 Section III • Treatment of Stuttering

also indicate when to move from Stage 1 to Stage 2 of the Lidcombe Program . A er the clinician and parent complete their ratings of the child’s speech, they discuss the week’s SRs and the prog ress of the home treatment. As they talk, the child usually plays by themselves in the same room, with some interac tion and encouragement from the parent and the clinician. e openness with which discussions of the week’s progress take place is a hallmark of the Lidcombe Program. ere is no attempt to keep the child from overhearing the parent and clinician discussion of the child’s stuttering. e matter-of fact manner in which the clinician and parent discuss the child’s speech seems to make it more likely that both the par ent and child will feel less anxious about the child’s stuttering and may reduce any shame the child might feel about their di culty. During the parent and clinician’s discussion, some children o en make noise to call attention to themselves. In my experience, this is not because the child objects to the dis cussion of their stuttering but is only an attempt to bring the focus back more obviously on themselves. At such times, it may be helpful if the clinician simply tells the child, “Right now, I want to talk to your mommy/daddy for just a minute; then we’ll play again!” or the parent may take a minute to play with the child. As the clinician looks over the parent’s weekly SRs, the cli nician may ask about the days in which ratings are higher or lower than average, or the clinician and parent may brain storm solutions to problems that may be indicated by lack of change in the ratings. is is o en a time when videos of the practice sessions from home are useful, so that the clinician can assess how they are being conducted. It is also essential that the parent demonstrate treatment during each clinic visit to show how they are conducting the treatment at home by doing a few minutes of a practice session with the child using the verbal contingencies (Fig. 14.3). When adequate progress is being made and home SRs and clinic assessments indicate that the child is becoming more uent, new treatment proce dures can be introduced.

Once a parent is appropriately and accurately reinforc ing uency, they may be taught to use mildly negative verbal contingencies for stuttering in practice sessions. e mildest such contingency is verbally acknowledging the occurrence of an unambiguous stutter . Only unambiguous stutters should be acknowledged because normal dis uencies should not be treated as stutters. e descriptions of normal dis u encies and stuttered dis uencies in Chapter 7 clarify this dif ference. I typically model an acknowledgment of stuttering for the parent, which is given a er several contingencies for uent utterances. It is important that the parent learn to use contingencies for uency several times before using a ver bal contingency for stuttered speech. When I demonstrate acknowledgment of stuttering, I use comments like “a little bumpy one there” or “that one was a little bumpy.” I make the statement quietly, immediately a er the stutter and without any negative in ection in my voice. Acknowledgment does not require a response from the child, although some chil dren will spontaneously repeat the word that was dis uent, and the parent should praise the attempt. A er I have mod eled how to acknowledge stutters, I ask the parent to try it, but only a er they have praised several of the child’s uent utterances. Most children hardly seem to notice the acknowl edgment, although some may stop momentarily and look at the parent when it is given. Typically, I ask parents to continue using contingencies for uency and begin using acknowledg ment of stuttering for a week before introducing further ver bal contingencies for stuttering. What I have described is my way of using the LP treatment. However, there is exibility in how verbal contingencies are delivered, and each clinician should decide on their own—a er they receive training in LP—exactly how to teach parents to deliver contingencies. In the following weekly meeting, I introduce requests for self-correction of unambiguous stuttering. is verbal con tingency asks the child to say the stuttered word again with a phrase such as (if the child has stuttered on “I”) “Can you say ‘I’ again?” Such requests are made in a positive, support ive manner , and it is important that the parent practice this contingency a er the clinician demonstrates it. Some parents may be hesitant to request a self-correction and may convey their concern to the child. Others may inadvertently use a slightly negative or impatient tone when asking for a correc tion. However, a clinician’s patient modeling and subsequent coaching can do wonders to shape parents’ responses into helpful, supportive requests. A er the child has repeated the word uently, the parent should praise the self-correction with comments like “Nice job of making that word smooth.” If a child ignores a parent’s request for self-correction or refuses to self-correct, the par ent just moves on. If the child says the word again but stutters again, the parent may say something supportive like “ at’s OK; sometimes those words are hard.” In the subsequent weeks, the clinician monitors the child’s progress and ensures that the parent is delivering verbal con tingencies e ectively. e clinician also checks to see that the

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Figure 14.3 Clinician observing a father demonstrating a practice session with his child.

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