330 Section III • Treatment of Stuttering

problems in beginning stutterers. One approach is to work on phonological and language problems at the same time as they work on uency, if other problem(s) are severe enough to warrant intervention. Bernstein-Ratner (1995) provided a good overview of how these children can be identi ed and how therapy can be designed so that it considers the whole of these children’s communication challenges. Guidelines are given for concurrent approaches for stuttering concomitant with phonological and language issues. Ratner presented the example of such an approach with phonological problems as described by Conture et al. (1993). ese authors used an indirect approach, avoiding the tra ditional “corrective” type of therapy and providing the child with plenty of models of target phonemes through extensive auditory stimulation and opportunities for improved pro duction. is is done in an accepting environment rather than correcting the child when they are wrong and asking the child to try again with more attention and e ort. Hill (2003) begins with receptive training and then follows with a sequence of working on phonological change, sound play, sound approximation, and rehearsal of correct sound pro duction in a few target sounds. If language is an issue, the clinician again begins with receptive training, followed by integrating practice with proper syntactic forms into the uency hierarchy of more and more complex language. For example, the clinician provides appropriate instructions and materials and has the child practice a speci c syntactic struc ture while using easy, relaxed speech. Another good example of the concurrent approach is given in chapter by Hall et al. (2022), describing therapy for a 3.6-year-old boy with stuttering and a severe phonological problem. is case example (Box 3.2 in their chapter) is par ticularly useful because of the details given about the assess ment, the treatment of the phonological problem, and the involvement of parents in indirect stuttering therapy. Cycles Model is approach alternates uency treatment with language or phonology therapy over the course of the year (Hod son & Paden, 1991; described in Bernstein-Ratner, 1995). Bernstein-Ratner points out that this provides children with initial periods of concentrated learning of new skills (for a speci ed amount of time irrespective of whether or not the client meets criteria for nishing the treatment), followed by opportunities for spontaneous generalization of these skills to other settings while the other treatment is cycled in. is alternation continues until one of the prob lems is resolved so that all attention can then be given to the remaining issue(s). Again, the chapter by Hall et al. (2022) provided an excel lent case example (Box 13.4). e child described here is 3.11 years old and has a receptive-expressive language disorder. A er several months of language therapy, the child begins to stutter and treatment then uses a cyclic (and concurrent)

approach to treating both issues. Both the child and his mother are involved in the treatment. To recap, in schools and clinics, as well as in private practice, it is not uncommon to assess and treat children who stutter but also have other communication problems. ree approaches are described for planning and carrying out treatment that consider the interactions between stuttering and other issues such as pho nological and language problems. Other concomitant problems, such as attention de cit hyperactivity disorder, will be discussed in Chapter 15 on Treatment of School-Age Children. ■ Beginning stuttering arises from an interaction between children’s constitutional predispositions and developmental and environmental in uences to pro duce primarily repetitive dis uencies with increased tension. ese stutters may commonly become more severe, evolving into prolongations and blocks with tension. Escape and avoidance behaviors may sometimes appear as a component of the disorder, as children experience increasing frustration with their inability to complete a word. ■ A key element of treatment for children of this age is to prevent them from having negative emotions associated with their stuttering, including experi ences they may have as part of their therapy, such as learning that speaking can be fun and rewarding. When children have negative experiences, the danger is that they will react to stuttering (and anticipated stuttering) with tension and struggle that will begin a cycle of increasingly negative feelings and increasingly tense stuttering, coupled with escape and avoidance behaviors. Focusing treatment on increasing uency and building the child’s con dence in their uency can help prevent this cycle. ■ Children with beginning stuttering usually have a large amount of uency that can be reinforced and general ized to situations that previously elicited stuttering. ■ e Lidcombe Program is a parent-delivered, operant conditioning program for preschoolers in which the parent is guided to conduct daily treatment conversa SUMMARY

tions and apply verbal contingencies to uency and stuttering. Treatment begins in practice sessions and moves to natural conversations throughout the day, so that treatment is conducted in the child’s natural speaking environment, promoting generalization to all aspects of the child’s world. Once the child is uent in all situations, the clinician manages a phased with drawal of clinic contact with careful monitoring of progress so that the family can respond to any relapses by reinstating needed features of treatment and then return to the fading process. Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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