Practical Treatment Strategies for Preschool and SchoolAge Children Who Stutter

1
Practical Treatment Strategies for Preschool and
School-Age Children Who Stutter

• J. Scott Yaruss, Ph.D., CCC-SLPBoard-Recognized
  Specialist and Mentor in Fluency
  DisordersAssociate Professor, University of
  PittsburghClinical Research Consultant,
  Childrens Hospital of PittsburghDirector,
  Stuttering Center of Western PennsylvaniaProfessi
  onal Relations Chair, Board of Directors,
  National Stuttering AssociationSteering
  Committee, ASHA Special Interest Division for
  Fluency Disorders

PATTAN TeleconferenceJanuary 31, 2004
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Surveys show that manyspeech-language
pathologistsare uncomfortable treatingchildren
who stutter

• Stuttering rates lowestin rankings of
  disordersclinicians prefer to treat!

3
How Do YOU Feelabout Stutteringand People Who
Stutter?

• What was your first thoughtwhen I started
  speaking?
• What was your first thoughtwhen I stopped
  stuttering?

4
WhydontSLPslike Stuttering?
5
Childhood stuttering can be a difficult problem
to treat.
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What Causes Stuttering?
LanguageAbilities
Speech Motor Abilities
Genetics
EmotionalDevelopment
PhonologicalEncodingDifficulty
Environmental Demands
Sensitivity/Temperament
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What Is the Goal of Treatment?
AcceptingStuttering
EliminatingStuttering
ImprovingSpeechAttitudes
Normal Fluency
SmoothSpeech
EasierStuttering
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Which Technique Is Best?
Relaxation
Turtle Speech
StutteringModification
PauseTime
VoluntaryDisfluency
Cancellation
Pull-out
EasierOnsets
FluencyShaping
Post-blockCorrection
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Purpose

• To demystify stuttering so you will feel more
  confident working with children who stutter
• To reduce your own discomfort with stutteringso
  you will be better able to help your clients
• To discuss current strategies for helping
  preschool and school-age children who stutter
• Increase their fluency
• Change their stuttering
• Improve their communication attitudes

10
Intl Classification of Functioning,Disability
and Health(World Health Organization, ICF 2001)

• Body Function and Structure describes the major
  physiological and psychological functions of the
  body
• Functioning and Disability describes the major
  areas of peoples daily lives
• Impairments in Body Function and Structure can
  lead to limitations in a persons ability to
  perform activities or restrictions in the
  persons ability to participate in life

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The Role of Reactions

• In stuttering, the link between impairment and
  the resulting negative consequences is largely
  mediated by the speakers reactions to stuttering
• Affective Feelings, attitudes, emotions
• Behavioral Actions (Avoidance, tension,
  struggle)
• Cognitive Thought-processes, self-evaluation
• The reactions of those in the speakers
  environment also play an important role for many
  speakers

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Considering the EntireStuttering Disorder
Model for representing stuttering based on the
ICF(adapted from Yaruss, 1998 Yaruss Quesal,
in press)
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Evaluating the Entire Disorder

• Since stuttering is so broad-based, we must
  assess several levels during an evaluation
• Etiology Childs speech/language
  development,oral-motor development, and
  temperament
• Impairment Observable characteristics of speech
• Childs Reactions Affective, Behavioral,
  Cognitive
• Environmental Reactions Communication model /
  Reactions of those in the childs environment
• Activity Limitation / Participation Restriction
  Impact of stuttering on childs life

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Looking at Etiology What Causes Stuttering?

• Most clinical researchers now believe that
  stuttering arisesdue to multiple risk factors
• multifactorial models
• complex interaction betweenchilds abilities
  and environment
• interaction between motoricand linguistic
  factors
• different etiological risk factorsfor different
  speakers

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What Causes Stuttering?
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What Causes Stuttering?

• Stuttering arises due to an interaction among
  several factors that are affected by both the
  childs genes and the childs environment
• Motor Skills for producing rapid and precise
  speech
• Language Skills for formulating messages
• Temperament for reacting to disruptions in speech
• An interaction among factors contributes to the
  likelihood that the child will produce speech
  disfluencies and react to them

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Speech, Language, Oral-Motor Development and
Temperament

• Multiple risk factors contribute to the initial
  onset and early development of stuttering
• For younger children, we examine these factors to
  estimate the childs risk for continuing to
  stutter
• These factors may also contribute to the
  maintenance of stuttering
• For older children, we need to determine whether
  there are concomitant problems that contribute to
  overall communication difficulties

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Observable Characteristics

• Common measures include frequency of
  disfluencies, type of disfluency, and severity
• Stuttering behaviors are highly variable
• Children may not stutter at all in some
  situations
• Collect speech samples in multiple situations
• As children grow older and as stuttering
  progresses, the observable characteristicstell
  less and less about the disorder

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Different Types ofDisfluencies
From Yaruss Reardon (2001), Preschool Children
Who Stutter Information and Support for Parents.
Published by the National Stuttering Association.
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Childrens Reactions / Impact of Stuttering

• Documenting the childs reactions is difficult
• For preschool children, there are no standard
  instruments
• For school-age children, you can use Childrens
  Attitudes about Talking-Revised (CAT-R) (DeNil
  Brutten, 1991)
• There are also no instruments for documenting the
  negative consequences of stuttering however,
  these are apparent from observation and interview
• This means we need to carefully document our
  observations to establish the need for treatment

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Documenting ReactionsPortfolio Assessment

• According to IDEA 97, we can establish a childs
  need for treatment through interviews with people
  important to the childs life
• Parents, teachers, andthe child!
• Portfolio-based assessment is one way to document
  the childs reactions to stuttering
• As soon as a child is aware of stuttering, we can
  help them express their feelings about stuttering
  through drawing, interview, and role-play

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Environmental Factors

• For younger children, the speech/language model
  contributes to the demands placed on the child to
  communicate
• We evaluate these demands to see if changes can
  be made that may facilitate the childs fluency
• For older children we are also interested in the
  demands for perfection, or perfect fluency
• We may need to help parents adjust expectations
  and the messages they give to their children

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Making Diagnostic Decisions

• Determining who needs treatment (who is likely to
  continue stuttering) is a matter of probability,
  not certainty
• Some children are clearly at-risk
• Other children are clearly not at-risk
• The majority are somewhere in the middle
• The best we can do is weigh the risks and
  tolerate the uncertainty

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What are the at-risk factors?

• Family history of stuttering
• Preponderance of stuttered disfluencies
• Time since onset gt 6 months
• Child is aware of or concerned about disfluencies
• Child is particularly sensitive to making
  mistakes
• Environmental reactions are negative or fearful
• Child has concomitant speech/language disorders
• Other Factors?

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To Treat or Not To Treat

• There is a significant debate about when to
  recommend therapy for preschool children
• Many children recover on their own, so some
  prefer to wait and seeI am not comfortable
  with this
• Because there is no simple way to determine who
  will outgrow stuttering
• I prefer to help families that want help, even if
  it seems that the stuttering might ultimately
  resolve
• Of course, this does not mean that all children
  receive full, formal therapy

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Summary of Diagnostic Goals

• For preschool children, the primary diagnostic
  goalis to determine whether the child needs
  treatment
• This is mostly based on an estimation of the
  likelihood that the child will recover naturally
  without intervention
• For school-age children, the primary goal changes
  somewhat we already know the child is
  stuttering
• Now, we also need to evaluate the impact of
  stuttering on the childs life, so we can
  determine whether now is the time for treatment
  and document our broader treatment goals
• Aspects to be assessed include functional
  communication, ability to participate in
  academic/social activities, andimpact of
  environmental reactions to childs stuttering

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What Is the Goal of Treatment?

• The goal of treatment differs(in part) due to
  the childs age
• For most young children (younger than age 7 or
  so), it may be possible to eliminate stuttering
• For older children (older than age7 or so), it
  may no longer be possible to completely eliminate
  stuttering so different goals are appropriate

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Stuttering Treatment Overview Preschool Children

• For preschool children, the primary goal of
  treatment is to improve their fluency
• Help parents and teachers provide
  afluency-facilitating environment
• Help the child develop normal speech fluencyby
  changing the childs communication patterns
• Help the child (and family) maintain healthy,
  appropriate attitudes toward communication

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A Fluency-Facilitating Environment

• Parents and teachers can change theirown speech
  to help the child change his
• Slower speaking rate (b u t n o t t o o s l o
  w)
• Less hurried pace, easier interaction style
• Increased pause time between utterances
• Less hectic scheduling of daily life activities
• One-on-one time with child (for playing and
  interacting, not just for talking)
• Most important principle SHOW, not tell...

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Bucket Analogy

• Cannot distinguish influence of individual
  factors once they are in the bucket

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Improving Fluency

• Concern Child may be attempting to use faster
  speaking rate, express more advanced concepts, or
  produce more complex utterances than he is able
  while still maintaining fluent speech
• Solution Identify specific factors (demands)
  that stress childs fluency, then work with
  parents to provide a model that minimizes those
  stressors
• Guidelines This reduced-demand model can be
  incorporated into treatment and used at home

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Maintaining Healthy Attitudes

• Concern Children who stutter are at risk for
  developing negative communication attitudes
• Solution Help parents learn to...
• Model appropriate attitudes and reactions
• Listen to childrens concerns about speaking
• Talk to children about stuttering
• The goal is for the child to accept disfluencies
  as a normal part of learning to speakp

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Talking about Stuttering

• Concern Child and parents do nothave a way to
  discuss stuttering
• Solution Introduce a vocabulary accessible to
  child and adult for discussing stuttering
• Use analogies for talking about disfluencies
• Repetition going over railroad
• Prolongation going over a bridge
• Block hitting a brick wall
• Goal Child and parents will be able to discuss
  stuttering in a matter-of-fact, accepting way

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Is It REALLY Okay To Talk About Stuttering ?!?

• YES! Talking about stuttering (in a supportive
  way) will not make stuttering worse
• One approach to treatment even encourage parents
  to point out a childs disfluencies and ask them
  to say the words again without bumps
• Its even okay to say the S word
• Always use the proper name for things. Fear of a
  name increases fear of the thing itself.

Albus Dumbledore
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When Do We Talk About Stuttering with Preschoolers
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Summary of Preschool Treatment

• The goal of speech therapy with preschoolers who
  stutter is to eliminate the stuttering
• Create a fluency facilitating environment
• Help the child learn fluent speech patterns
• Develop/maintain healthy communication attitudes
• Efficacy studies are limited, but they indicate
  very high success rates (85 to 90)
• BUT, it is difficult to differentiate from
  recovery rates for children without therapy

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Is This the ONLY WAY to Treat Preschoolers Who
Stutter?

• Absolutely not! The Lidcombe program has been
  gaining popularity around the world
• This approach teaches parents to verbally
  reinforce fluent speech and verbally correct
  (punish) stuttering
• The punishments are gentle and appropriate
• A growing body of evidence demonstrates the
  efficacy of this approach
• For me, the jury is out about whether this is
  better
• Perhaps we could talk about it over lunch

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Stuttering can bevery stubborn
Sometimes children dont get better
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Why Dont SomeChildren Get Better?

• Changing speech is very difficult...some children
  simply cannot make the changes needed to improve
  their speech
• Childrens motoric and linguistic abilities are
  constantly changing, resulting in an unstable
  system that may be more prone to disruption
• Changing speech requires a lot of practice some
  children cannot make the commitment

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Turn and Face the Changes

• As children grow older, it is less likely that
  they will completely recover from stuttering
• Between the ages of 5 and 8, many children (and
  their families) are coming to the realization
  that the child will not simply outgrow
  stuttering
• This realization may be accompanied by increases
  in stuttering severity or negative speech
  attitudes
• Our treatment must take into account this
  critical transition if we are to increase the
  chances of the childs long-term success

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If we keep trying to force children to be
fluentwhen they cant,we give them the message
that stuttering is badand so are they
We may actually increasethe shame and guilt that
make stuttering so problematic!
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Treating Older ChildrenSpecific Objectives

• Help child improve fluency as much as possible
• This is still an important goal, but it is no
  longer the only important goal
• Help child develop healthy attitudes toward
  speaking, stuttering, and speech therapy
• Help parents and teachers develop asupportive
  and accepting environment

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Some Consequences ofthese Treatment Goals

• For older children who stutter,treatment is not
  solely devotedto trying to eliminate stuttering
• Treatment must also focus on
• helping the child become more acceptingof his
  stuttering and speaking abilities
• helping the child learn to cope with
  stutteringin an appropriate manner

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More Consequences

• Parents and teachers need to understand that
  progress is not measured only in terms of the
  frequency or type of disfluencies
• IEP goals should also reflect the fact that
  progress is not measured only in terms ofthe
  frequency or type of disfluencies
• To do this, we need to write treatment goals that
  focus on the entire stuttering disorder

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Treating the Entire Disorder

• Addressing Impairment
• Change speech production to improve fluency
• Addressing the Childs ABC Reactions
• Improve speech attitudes, acceptance of
  stuttering
• Reduce avoidance, tension, struggle, etc.
• Addressing the Negative Consequences(Activity
  Limitation / Participation Restriction)
• Focus on communication skills, not just fluency
• Addressing Environmental Reactions
• Educate others about stuttering to foster
  acceptance
• Help child learn how to handle teasing

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In Other Words...

• Goals such as stuttering easily and feeling good
  about yourself are just as important as not
  stuttering and using easier beginnings
• Children are often relieved to hear this, though
  parents may have more difficulty accepting the
  fact that their child is (and will be) a
  stutterer
• To achieve these goals, clinicians must also
  become more comfortable with stuttering and with
  children who stutter

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You want me to do WHAT?!?

• The best way to teach acceptance of achilds
  stuttering is to model acceptance
• If the clinician seems uncomfortable when a child
  stutters, the child gets the message that he
  should be uncomfortable too
• How can we convince him that he should accept his
  stuttering if we cannot?
• How can we convince him that other people can
  accept his stuttering if he can see contrary
  evidence in our own faces?

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Some Exercises to Help You Become More
Comfortablewith Stuttering

• Stuttering on purpose in real-world situations
• Stuttering and talking in different ways
• Talking about stuttering with other people
• (These also make excellent therapy activities to
  desensitize the child to stuttering, too)

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Overall Goals of Treatment

• The overall goal is improved Communication
• Children should be able say what they want, when
  they want, how they want, to whom they want
• Simple fluency criteria are less relevant
• In addition to fluency, we address factors that
  interfere with the child ability to communicate
• Tension and struggle during stuttering
• Negative communication attitudes
• Negative consequences of stuttering
• Teasing, other environmental stressors

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Addressing ImpairmentImproving Fluency /
Reducing Stuttering

• Most techniques for improving fluency focus on
  changing timing or tension

Timing
Tension
Reducing Speaking RateIncreasing Pause Time
Easier Beginnings
Easier Beginnings,Easing InCancellation,
Pull-out
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Changing Timing Speaking Rate

• One of the most common techniques for improving
  fluency is reducing speaking rate
• For preschoolers, turtle speech canhelp
  children and parents slow theirrate and
  facilitate childrens fluency
• For school-age children, I transition toa more
  natural type of slowed speech

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Changing Timing Speaking Rate

• Guidelines for Reducing Speaking Rate
• Practice using slow rate before you attempt it
  get a feel for too slow and not slow enough
• Use natural intonation and rhythm
• Do not use choppy or
  robot speech or s t r e t c h out
  all the words
• Slower (but still natural) speaking rates canbe
  incorporated into all activities as a positive
  communication model for the child

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Changing Timing Pausing

• Another helpful way to change timing is to
  increase pause time -- the length of time between
  words and phrases
• Pauses should occur at natural locations,e.g.,
  between sentences and phrases
• Phrases should not be so long that the child
  feels uncomfortable with the silence (1 sec)
• It may take some practice for the child(and you)
  to develop comfort with silence

54
An Exercise Changing Timing

• 1) Read the practice passage at your normal rate
• 2) Re-read the passage using a slower rate
• First try stretching out all the sounds, thentry
  slightly stretching some sounds and pausing
• Which one sounds more natural?
• 3) Re-read the passage going VERY slowly(so
  slowly you cant stand it!)
• 4) Return to the rate you used in 2.
• How does it sound now? Better, by comparison

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Practice Passage

• Once upon a time, there was a young boy whose
  name was Joe. Joe liked to play with his friends
  in the sandbox. One day, Joe lost his shoes in
  the sandbox. He looked and he looked and he
  looked, but he could not find them. Later that
  day, Joe found out that one of his friends had
  hidden his shoes as a joke. Joe was relieved to
  find his shoes, and he had a good laugh about the
  practical joke. Joe was a good sport.

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Changing Timing AND Tension

• Easier Beginnings Reduce speaking rate and
  physical tension at the beginning of phrases
• Use phrasing and pausing to give multiple
  opportunities to reduce the physical tension
• Focus on naturalness throughout the phrase only
  the beginning of the phrase is modified
• Requires lots of practice (for you and the child)
• Can also be used when the child knows he isabout
  to stutter (easing in)

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Exercise Easier Beginnings

• 1) Notice that the practice passage can easily be
  divided into phrases.
• 2) Read the passage again, using easier
  beginnings at the start of each phrase
• Be sure to change both the timing and tension of
  your speech at the beginning of phrases
• Make sure the rest of the phrase sounds natural
• What else changed about your speech when you used
  the easier beginnings?

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Practice Passage

• Once upon a time // there was a young boy //
  whose name was Joe // Joe liked to play // with
  his friends // in the sandbox. One day // Joe
  lost his shoes // in the sandbox. He looked //
  and he looked // and he looked // but he could
  not find them // Later that day // Joe found out
  // that one of his friends // had hidden his
  shoes // as a joke // Joe was relieved // to find
  his shoes // and he had a good laugh // about the
  practical joke // Joe was a good sport.

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Techniques forModifying Stuttering

• With fluency techniques, children do become more
  fluent (particularly in the therapy room).
• However, no fluency technique is perfecteven
  successful students will still stutter sometimes
• To improve communication further, we also need to
  help children stutter more easily
• Modifying tension during stuttering
• Reducing childs discomfort with stuttering

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Exploring Stuttering

• To help children change stuttering, we help them
  learn what they are doing when they stutter by
  staying in and exploring stuttering
• What are their speech actors or speech
  helpers (articulators) doing during stuttering?
• How can they move their speech actors differently
  to change the stuttering?
• This also helps desensitize children to
  stuttering
• They probably spend a lot of time trying not to
  stutter, leading to increased tension and struggle

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Dont just tell

• ...EXPLORE

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Exercise Exploring Stuttering

• 1) Pretend to stutter (pseudostutter)
• Try to imitate the type of stuttering one ofyour
  young students might exhibit
• If you cant do it, have your students teach you
• What kind of affective, behavioral, or cognitive
  reactions do you have during this exercise?
• This exercise helps your student (and you)
  overcome these negative reactions and reduces
  struggle
• 2) Consider what your muscles are doing and how
  this contributes to the physical tension

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Reducing Physical Tension

• Physical tension during stuttering is a learned
  reaction (part of the attempt to not stutter)
• Over time, it becomes an automatic part of
  stuttering, then tension and struggle increase
• Children require PRACTICE to learn how to reduce
  this tension and stutter more easily
• Practice reducing tension so the child can learn
  to control and modify tension
• Exercise Pseudostutter with physical tension,
  then repeat the stuttering with less tension

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Easy Stuttering

• Children can use easy stuttering to help them
  learn they can change the way they stutter
• Bouncing and gliding or stretching are
  forms of pseudostuttering without tension
• Also reduces tendency to hide stuttering
• The more children try to hide stuttering,
  themore likely they are to stutter more
• If children are comfortable with stuttering, they
  can use voluntary stuttering to release tension
  in their muscles and prevent bigger blocks

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Exercise Easy Stuttering

• 1) Read a passage using easy (pseudo)stuttering
• Try to use both repetitions (bounces) and
  prolongations (stretches or slides)
• 2) Evaluate your ABC reactions and your ability
  to modify and control physical tension
• You and your students should be able to useeasy
  stuttering without any negative reactions
• If your students still feel negative reactions or
  cant modify tension, they need more practice
  (and so do you)

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Techniques for AddressingFluency AND Stuttering

• Cancellation Replace stuttered speech with more
  fluent (controlled) speech
• After stuttering, repeat the stuttered phrase
  using less physically tense speech
• The repeated speech should not simply be repeated
  -- the point is to change the tension
• Pull-out Reduce tension during stuttering to be
  able to continue speaking more fluently

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Exercise Cancellation

• To practice cancellation, you will need to use
  some pseudostuttering (so you have some tension
  to modify)
• 1) Pretend to stutter in conversation or reading
• 2) Repeat the stuttered phrase using modified
  physical tension (not completely fluent)
• Dont rush through it
• Cancellation helps with tension and
  desensitization

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Planning Therapy

• Many times, I begin with techniques designed to
  modify stuttering
• If we work on fluency first, children are likely
  to become too fluent in the treatment room
• Then, there is little stuttering left to practice
  with and we have trouble with transfer
• I also start with techniques for modifying
  stuttering so we dont over-emphasize fluency
• After the child can modify stuttering events,I
  move to the fluency techniques

69
Techniques forImproving Attitudes

• Techniques for changing stuttering also help
  improve the childs reactions to stuttering
• Talking about stuttering helps children
  understand stuttering and reduces anxiety about
  stuttering
• Easy stuttering helps children learn they can
  control their speech musculature
• Exploring stuttering and cancellation help to
  desensitize children to stuttering and
  reducestheir tendency to struggle and avoid
  stuttering

70
Addressing Reactions Directly

• Concern The childs reactions to stuttering
  increase the severity of the disorder and reduce
  the likelihood of successful treatment
• Affective Child experiences embarrassment,
  shame, isolation, fear, anxiety about speaking
• Behavioral Child exhibits significant physical
  tension and struggle when speaking or stuttering
  Child avoids speaking situations
• Cognitive Child evaluates himself negatively as
  a communicator does not understand stuttering

71
Addressing Reactions

• Goal Child will develop healthy attitudes toward
  himself and his communicationabilities so he
  will not...
• Feel as bad about his stuttering (affective)
• Struggle with speech or avoid talking
  (behavioral)
• View himself as a poor communicator (cognitive)
• Helping the child develop healthy reactions to
  stuttering paves the way for greater success in
  treating the stuttering itself

72
Addressing Affective Reactions feelings about
stuttering...

• Child experiences many difficultemotions
  connected with stuttering
• Stuttering is confusing, frightening
• Child feels uncertain about himself
• Child may feel embarrassed, ashamed
• Child needs to be able to express emotions
• SLPs can help, and very few other people can
  (particularly people who understand stuttering
  and can talk with the child)

73
Addressing Affective Reactions expressing
emotions...

• When child is teased, he probablyfeels
  frustrated and angry
• Instead of lashing out, he can expresshis
  feelings in therapy, then work withyou to find
  an appropriate response
• When a child stutters, he probablyfeels
  embarrassed or ashamed
• Instead of berating himself for not beingfluent,
  the child can talk about his feelings

74
Addressing Affective Reactions reducing shame...

• Shame is a feeling of failure in who we
  aretheres something wrong with us
• The way to reduce shame is to facethe thing
  were ashamed of

• Teach others about it
• Own it
• Become more comfortable with it
• Accept it

• Talk about it
• Think about it
• Express our feelings about it
• Learn about it

75
Addressing Affective Reactions reducing shame...

• I dont know why this is happening to me
• Nobody likes me because I stutter
• I stutter because I did something bad
• There is something wrong with me

• I know what I do when I stutter I am the
  expert
• I can stutter and still have lots of friends
• Stuttering is notmy fault!!!
• I stutter andI AM OKAY!!!

76
Addressing Behavioral Reactions

• Reducing Tension
• Allow production of easy disfluencies,without
  excess physical tension
• Help child reduce tension during stutteringusing
  techniques such as cancellation, pull-out
• Reducing Avoidance
• Help child accept stuttering (affective/cognitive
  reaction) so he will not feel the need to hide
  his stuttering (thereby reducing behavioral
  reactions)

77
Addressing Cognitive Reactions

• Understanding Help child learn what stuttering
  is, and that he has some control over it
• Help child learn about speaking What parts of
  the body are involved and how they work together
• Help child learn about stuttering What happens
  to his speech actors when he is fluent, when he
  stutters, and when he changes stuttering
• Perceptions Help child understand that some
  disfluencies are a normal part of speaking

78
Addressing Cognitive Reactions

• Tolerance Normalize stutteringit is just
  something some people do when talking
• Many people stutter and still achieve their goals
  at school and in life
• Help child learn...IT IS OKAY TO STUTTER
• Support Help child meet otherswho stutter
  through supportgroupsJoin Friends or
  theNational Stuttering Association

79
Activity/Participation

• By addressing the childs impairment and ABC
  reactions, we can reduce the likelihood that he
  will experience negative consequences
• To reduce activity limitations directly, we also
  need to focus on generalization of
  treatmentgains into real-world settings
• Also, we need to directly address aspects of the
  environment that may contribute to the childs
  negative experiences

80
The Childs Environmentteasing...

• People tease because they dontunderstand
  stuttering
• Help child educate classmates aboutstuttering
  through class presentations
• Demystifies the disorder and the child
• Child becomes the expert about stuttering
• He can help others learn about stuttering
• Gives him power, value, strength, importance

81
Modifying the Environmentparents and teachers

• Just as the child needs to accept stuttering,
  parents and teachers need to accept it
• Child is OKAY, stuttering is just one aspect of
  childs abilities and development
• Recognition of broader goals of treatment
• Not just reducing stuttering... accepting
  stuttering
• Not just using techniques to change
  fluencyusing techniques to change stuttering
• Not just being fluentparticipating in life
  activities

82
Techniques forWorking with Parents

• Parents have no problem understanding and
  supporting techniques for improving fluency
• In fact, some parents encourage children to use
  fluency techniques all the time
• This can be helpful, but it can turn into nagging
• We can reduce nagging by helping the children
  teach their parents how to modify their speech
• When parents see how hard this is, they become
  more supportive/understanding of inconsistency

83
You want my child to WHAT?!?

• Some parents have difficulty accepting techniques
  for working on stuttering
• Parents may still be hoping for complete
  elimination of stuttering (a cure)
• Pseudostuttering and easy stuttering may not make
  sense to parents at first
• Parents must understand the purpose of these
  techniques We practice stuttering to change
  stuttering and reduce the impact of stuttering on
  communication

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Complete Acceptance

• Parents acceptance of stuttering is just as
  important as the childs acceptance
• Many children benefit from a safe place where
  they dont have to worry about their speech
• Parents can only provide this safe place if they
  completely accept the childs stuttering
• Parents can only help children deal withemotions
  about stuttering if they havealready dealt with
  those emotions themselves

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Summary

• For preschoolers, our goal is to eliminate
  stuttering
• Modifying the childs environment to reduce
  stressors
• Modifying the childs speech to improve fluency
• Helping the child develop and maintain healthy
  attitudes
• When it seems that a child may continue
  stuttering, our treatment goals must be broader
• Improve fluency (through changes to timing and
  tension)
• Change stuttering (by changing tension and
  accepting stuttering)
• Improve attitudes (through understanding and
  acceptance)
• These strategies can help children cope with
  stuttering and become effective communicators

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Questions? Comments?Please contact me!

• J. Scott Yaruss, Ph.D., CCC-SLP
• Stuttering Center of Western PA
• University of Pittsburgh
• 4033 Forbes Tower
• Pittsburgh, PA 15260
• Phone [phone]
• Fax [phone]
• Email jsyaruss_at_csd.pitt.edu
• Website www.stutteringcenter.org

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Mission of the Stuttering Center

• Provide effective client-centered treatment for
  individuals who stutter
• Conduct meaningful research on the nature and
  treatment of stuttering
• Provide on-going education for student clinicians
  as well as practicing SLPs
• Provide support for individuals who stutter,
  their families, and their clinicians

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Stuttering Organization

• National Stuttering Association
• www.WeStutter.org (800) We Stutter
• Friends The Association for Young People Who
  Stutter www.friendswhostutter.org
• Stuttering Foundation of America (SFA)
• www.stutteringhelp.org [phone]