Treatment section of the Fluency (Children) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Treatment for fluency disorders is highly individualized and based on thorough assessment of speech fluency, language factors, emotional/attitudinal components, and life impact. In creating a treatment plan and setting goals for fluency, the SLP uses linguistically and culturally appropriate stimuli and is sensitive to the unique values and preferences of each individual/family. The clinician considers the degree to which the child's disfluent behaviors and overall communication are influenced by a co-existing disorder (e.g., other speech or language disorders, Down syndrome, ASD, ADHD) and determines how treatment might be adjusted accordingly.
Ideally, a team approach is used in treatment planning, where child and family priorities and desired outcomes drive treatment goals and methods. Clinicians engage in ongoing assessment to ensure that the treatment is appropriate for the changing experiences of the child and family as the child progresses through life and the treatment process.
Most children with fluency disorders demonstrate both observable disfluency and negative life impact (Beilby, Byrnes, & Yaruss, 2012; Ribbler, 2006; Yaruss, Coleman, & Quesal, 2012). When developing treatment goals, the clinician considers the extent to which stuttering affects a child's life. For example, negative reactions (on the part of the speaker or the listener) and difficulties communicating in various speaking situations may impact a child's quality of life.
Goals that focus on minimizing these difficulties may aid children in reducing the effort used to hide or avoid disfluencies and help them begin to communicate with more ease. Such goals may result in increased observable disfluent behaviors, because children may start communicating more freely.
The individual profile is an important factor in the selection of treatment options. For a discussion of a process for selecting evidence-based approaches based on individual needs, see Yaruss and Pelczarski (2007).
When cluttering and stuttering occur together, clinicians need to understand the interaction of symptoms and the strategies that are most effective for dealing with each disorder. The ultimate goal is for the child to understand these interactions and the best ways he or she can manage the disorders.
Treatment approaches are individualized based on the child's needs and family communication patterns. A comprehensive treatment approach for preschoolers includes both parent-focused and child-focused strategies; goals of treatment may be to eliminate, greatly reduce, or help children manage their stuttering and not develop negative emotional reactions related to their stuttering (Yaruss, Coleman, & Hammer, 2006). For preschool children who stutter, parent involvement in the treatment process is essential, as is a home component (Mewherter, 2012).
Young children may or may not verbalize their reactions to stuttering. Clinicians and parents also look for reactions, such as avoidance of words or speaking situations, increased physical tension or secondary behaviors, reduced utterance length, or slight changes in pitch or loudness during stuttering episodes. It is important that parents and clinicians acknowledge and respond to a child's verbal and nonverbal reactions in a supportive manner that helps to minimize the likelihood that the child will develop negative reactions to stuttering.
Treatment Approaches: Preschool Children Who Stutter
Treatment approaches for preschool children who stutter include
Indirect treatment focuses on counseling families about how to make changes in their own speech and how to make changes in their child's environment. These modifications are used to facilitate speech fluency and may include reducing communication rate, using indirect prompts rather than direct questions, and recasting/rephrasing to model fluent speech (Millard, Nicholas, & Cook, 2008; Yaruss et al., 2006).
Direct treatment focuses on changing the child's speech in order to facilitate fluency. Direct treatment approaches may include speech modification and stuttering modification strategies to reduce disfluency rate, physical tension, and secondary behaviors (Hill, 2003). Direct treatment also can target children's communication attitudes (Yaruss et al., 2006).
Operant treatment incorporates principles of operant conditioning and uses a response contingency to reinforce the child for fluent speech and redirect disfluent speech (the child is periodically asked for correction). With this approach, parents are trained to provide verbal contingencies based on whether a child's speech is fluent or stuttered (Jones et al., 2005; Onslow, Packman, & Harrison, 2003). In this way, positive reinforcement is used to increase or strengthen the response of fluency (the desired behavior). Operant approaches operate within a framework of stuttering as learned behavior (for discussion, see Conture, 2001, p. 334; Onslow & Yaruss, 2007).
Franken, Kielstra-Van der Schalk, and Boelens (2005) compared an operant approach with a demands-and-capacities model (i.e., treatment that focuses on decreasing demand and increasing a child's capacity for fluency in the motor, emotional, linguistic, and cognitive domains). There were no differences in these measures, regardless of the treatment approach used. The researchers found that stuttering frequency and severity ratings for both groups studied (one treated with the operant approach and the other with the demands-and-capacities model) showed a significant decrease.
The following 'Evidence Highlights' meet ASHA's guidelines for inclusion and are based solely on existing systematic reviews.
Stuttering treatment should target not only surface level impairment (disfluency), but the entire communicative experience of the person who stutters, including personal and environmental context, and activities of daily living. Clinicians who treat stuttering should be educated and trained appropriately in the treatment approach selected. While published evidence is typically derived from group data, matching treatment procedures to the needs of the individual client, within the context of the family and community, is paramount.
A comprehensive treatment approach for school-age children and adolescents includes multiple goals based on individual needs, focused on increasing fluency as well as other goals, such as "increasing acceptance of stuttering and of being a person who stutters, reducing secondary behaviors, minimizing avoidance, improving communication skills, increasing self-confidence, managing bullying effectively, and ultimately, minimizing the adverse impact of stuttering on the child's life" (Yaruss, Coleman, & Quesal, 2012, p. 537).
Disfluent behavior becomes more complex as fear of speaking, anxiety, and resulting avoidance increases. Similarly, communication apprehension and shame may develop as the child experiences greater difficulty with communication. Treatment may include reduction in the child's and others' negative reactions to stuttering (Yaruss et al., 2012). For example, clinicians may use treatment strategies to reduce bullying through desensitization exercises and by educating the child's peers about stuttering (Murphy, Yaruss, & Quesal, 2007a, b).
Many of the treatment options listed below are used in combination for optimal outcomes. For example, counseling a student to accept or tolerate embarrassment can facilitate the desensitization needed to reduce the use of word avoidance. As word avoidance decreases, the teen is better able to communicate effectively, and, as fear reduces, the resultant reduction in physical tension and struggle enhances observable fluency.
Treatment Approaches: School-Age Children and Adolescents Who Stutter
Below is a list of approaches most commonly used with school-age children and adolescents who have stutter. Approaches may vary for children and adolescents. Many clinicians use an integration of approaches in order to achieve optimal outcomes. All approaches should include a plan for generalization and maintenance of skills involved in activities of daily living.
When a family first seeks advice from an SLP, often the main reason for initiating services is to eliminate or greatly reduce the frequency of disfluent speech. It is the responsibility of the clinician to consider the entire impact of disfluency on the child's communication and life as a whole (and to help the family understand this aspect of the child's experience of stuttering) in order to develop a comprehensive plan of treatment.
In choosing a treatment, the clinician is sensitive to cultural and linguistic factors and addresses goals within the World Health Organization's (WHO) International Classification of Functioning (ICF) Framework (ASHA, 2007; Coleman & Yaruss, 2014; Yaruss, 2007; Yaruss & Quesal, 2004; 2006). The approaches listed below are organized based on the ICF framework. See
treatment goals for fluency disorders in the context of the WHO ICF framework.
Not all of these approaches are appropriate for the treatment of cluttering (see Cluttering Treatment below).
Strategies For Reducing Impairment In Body Function
Strategies for reducing impairment in body function historically have been separated into two categories-speech modification (fluency shaping) and stuttering modification, both of which are described below. A clinician does not have to choose to use one approach or the other. A treatment plan that involves both speech and stuttering modification techniques may be necessary to achieve optimal outcomes. Other treatment approaches described below may also be incorporated as part of a comprehensive treatment approach.
Speech Modification Strategies
Speech modification (including fluency shaping) strategies (Bothe, 2002; Guitar, 1982, 2013) include a variety of techniques that aim to make changes to the timing and tension of speech production or that alter the timing of pauses between syllables and words. These modifications are used regardless of whether a particular word is expected to be produced fluently. Strategies associated with speech modification include
- rate control,
- continuous phonation,
- prolonged syllables,
- easy onset,
- light articulatory contact.
Other speech modification strategies, including appropriate use of pausing, are used not only to increase the likelihood of fluent speech production but also to improve overall communication skills (e.g., intelligibility, message clarity, etc.). In addition to being used for improving communication skills, pausing is also an effective method of rate control.
Just as a child may experience feelings of shame or fear associated with showing stuttering, a child may also experience negative feelings associated with using speech modification strategies, which often sound different from "natural" speech production (Ingham & Onslow, 1985; Martin, Haroldson & Triden, 1984).
Stuttering Modification Strategies (Reducing Physical Tension/Struggle)
Stuttering modification strategies, originated by Van Riper (1973), aim to reduce associated physical tension and struggle by helping children to identify core stuttering behaviors, recognize physical concomitant behaviors, locate the point of physical tension and struggle during moments of disfluency, and ultimately reduce that physical tension. These strategies help a child learn about the speech mechanism and how it operates during both fluent and disfluent speech so he or she can modify it. Increasing awareness and self-monitoring skills helps to reduce unproductive behaviors that interfere with fluency and may allow children to further alter moments of stuttering to be less tense and disruptive to communication.
Traditional stuttering modification strategies include preparatory set, pull-out, and cancellation and require a child to identify a moment of disfluency before, during, or after it occurs, making adjustments to reduce tension and struggle. The specific strategy that is selected will depend on when the client "catches" the disfluency, whether it be following a moment, in the moment, or in anticipation of the moment of disfluency (Van Riper, 1973).
These strategies, like speech modification strategies, are introduced along a hierarchy of speaking situations that varies both with linguistic demands and with the stressors of the environment.
Increasing Speech Efficiency (Reducing Word Avoidance)
Some children develop speech habits to escape or avoid moments of overt stuttering, such as changing words or using interjections (e.g., "um," "uh") and may become so skilled at hiding stuttering that their speech appears to be fluent (Murphy et al., 2007). The cost of such avoidance can be great because of the resulting impact on children's ability to say what they want to say, when they want to say it.
Such children may benefit from treatment strategies that focus on improving speech efficiency and increasing spontaneity in communication. When being spontaneous and saying "all they want to say," children may exhibit more surface-level stuttering; however, as children learn to reduce reactivity (see below), they develop greater comfort while speaking, assume more positive attitudes about their ability to communicate, and are better able to accept and manage moments of disfluency as they occur.
Strategies For Reducing Negative Reactions (Personal And Environmental Context)
Numerous treatment approaches and strategies have been developed in an attempt to help speakers reduce the negative reactions associated with stuttering (e.g., Murphy et al, 2007b). These may include stuttering modification in addition to the approaches described below: desensitization, cognitive restructuring, self-disclosure, and support.
Desensitization strategies help speakers systematically desensitize themselves to their fears about speaking and stuttering by facing those fears in structured, supportive environments. One example of a desensitization activity is the use of voluntary stuttering (sometimes called "pseudostuttering," if the initiation of the activity involves fake stuttering behaviors) in different (and increasingly more difficult) situations where the client might fear the occurrence of real moments of stuttering (e.g., Reardon-Reeves & Yaruss, 2013; Sheehan, 1970).
Cognitive restructuring is designed to help speakers change the way they think about themselves and their speaking situations; they learn to identify the thoughts underlying their negative attitudes and emotional reactions and examine the link between their thoughts, attitudes, and emotional reactions and their speech. Through a process of identifying the assumptions underlying their thoughts, they can evaluate whether those thoughts are helpful (or valid) and ultimately adopt different assumptions or thoughts. Cognitive restructuring can be combined with the desensitization strategies described above (Murphy et al., 2007a).
Self-disclosure involves communicating to others information that reveals one's identity as a person who stutters. Often referred to as "advertising" in the stuttering community, it can involve revealing that identity directly, talking about stuttering or treatment of stuttering, explaining or interpreting symptoms of stuttering, providing advice on how to respond to someone who stutters, or, in the case of school-age children, advertising through a classroom presentation with the guidance of the SLP or classroom teacher (Murphy et al., 2007b).
Support (both giving and receiving) can be valuable for improving attitudes, boosting self-confidence, and reducing feelings of isolation (Yaruss, Quesal, & Reeves, 2007). Treatment approaches that incorporate support activities also can provide venues to practice learned strategies in a safe environment, promoting generalization. Support activities can be incorporated into group treatment and through participation in self-help groups-for example, those run by nonprofit organizations, such as FRIENDS-The National Association of Young People Who Stutter, the National Stuttering Association (NSA), and SAY: The Stuttering Association for the Young; online groups (e.g., online chats); and social media (e.g., blogs). It is important for clinicians to verify online sites and virtual support groups recommended to clients and their families.
Strategies For Reducing Activity Limitations And Participation Restrictions
The child's ability to use speech strategies, to make choices to speak and participate regardless of the level of fluency, and to take risks are greatly reduced outside of the treatment setting when time pressure and conditioned negative feelings may trigger fear and old behaviors. In order to facilitate generalization of skills, the clinician can help the child use a variety of therapeutic activities outside of the treatment room (e.g., bringing peers into the treatment setting; planning strategies to use in the classroom, cafeteria, and playground; taking outings to stores and other businesses; making telephone calls). The SLP can use phone or video conferencing to augment this type of treatment.
The SLP needs to consider the individual's profile prior to developing generalization activities. To foster generalization, assignments adhere to a hierarchy of linguistic skills and environmental stressors. The assignments begin in supportive, low-fear situations and slowly evolve to more challenging situations and settings as the child demonstrates the ability to accept or tolerate potential negative reactions.
Accommodations At School and In the Community
Children with fluency disorders may qualify for accommodations whether or not they have an active Individualized Education Program (IEP).
Section 504 of the Rehabilitation Act of 1973 (United States Department of Labor, n.d.) protects qualified individuals from discrimination based on their disability and outlines reasonable accommodations via a 504 plan for speaking or reading activities to help ensure a child's academic success and access to the learning environment in school. This law also applies to organizations that receive financial assistance from any federal department or agency. Reasonable accommodations include
- using audio/video recording,
- increasing the time provided for an oral reading or presentation,
- providing an alternative assignment to oral reading,
- altering the size of the group or audience.
Because the theory behind cluttering is that speakers are talking at a rate that is too fast for their systems to handle, techniques that help regulate speech rate, such as increased pausing, often are helpful. In fact, increased pausing alone may increase speech fluency and intelligibility for those who clutter (Scaler Scott & Ward, 2013). However, fluency shaping approaches, such as easy onset or continuous phonation, may not be appropriate for the treatment of cluttering.
There has been some documentation of the use of stuttering modification strategies to help those who clutter (Ward, 2006). Such strategies include simulating a fast rate of speech and applying pausing and/or simulating over-articulated speech and applying increased emphasis to increase intelligibility. These simulations and applications of strategies might be most likened to cancellation and pull-out techniques used in stuttering.
Other strategies for treating cluttering include over-emphasizing multisyllabic words and word endings, increasing awareness of when a communication breakdown occurs (e.g., through observation of listener reactions), and increasing self-regulation of rate and clarity of speech. Some people who clutter tend to decrease volume at the ends of sentences or phrases and, therefore, can benefit from learning to keep a steady volume throughout their utterances.
Families may demonstrate a wide range of beliefs regarding the best way to treat fluency disorders, ranging from medical and therapeutic intervention to prayer, sending children to live with relatives, or asking children not to speak in public (Shenker, 2013). Clinicians need to be mindful of family beliefs and the stress imposed on the child and family during treatment. See
Behavioral treatments that address improved speech fluency appear to be effective across a range of cultures and languages (Finn & Cordes, 1997). It appears that bilingual children do not have treatment outcomes that differ from those of monolingual children (Shenker, 2011).
Improvements in fluency may generalize spontaneously from a treated language to an untreated language in bilingual children (Roberts & Shenker, 2007; Shenker, 2011). Engaging parents in treatment helps to achieve carryover in the home environment and helps with treatment across languages (Shenker, 2013).
Treatment considerations for bilingual children include (Shenker, 2011)
- determining which language to use for intervention,
- identifying how that language will be targeted (e.g., one-on-one with the clinician, parent training for home carryover).
Treatment for all communication disorders, including fluency disorders, may necessitate adjustments to protocols, processes, and approaches for bilingual children, such as
- modifying instructions to accommodate the parent's language,
- using exemplars in audio or video format in the home language of the child,
- providing opportunities to practice fluency in linguistically and culturally relevant contexts and activities.
Parents can be taught specific therapeutic techniques and approaches to support early language development (Wing et al., 2007). This may be a beneficial approach for addressing fluency issues in a bilingual child and in young children for whom strong family involvement is essential. See the
collaborating with an interpreter.
Counseling is an integral part of assessment and treatment of children who stutter or clutter. SLPs' counseling skills should be used specifically to help speakers improve their quality of life by minimizing the burden of their communication disorder. The use of such skills in other areas of the speaker's life (that is, those not directly related to communication) is outside the scope of practice for SLPs (ASHA, 2007). An outside referral to another helping professional should be made if a condition or situation falls outside of the SLP's scope of practice.
Effective counseling involves the skills needed to help a client, family member, or caregiver move from a current scenario to a preferred scenario through an agreed-upon action plan (Egan, 2013). Potential roadblocks may be identified through an effective client-clinician relationship (Plexico, Manning, & DiLollo, 2010). A focus on the therapeutic relationship is common across different counseling models, as recognized by the common factors theory in counseling (Wampold, 2001).
Clinicians need to be familiar with various counseling principles and approaches (Luterman, 2006; Zebrowski & Schrum, 1993). Counseling begins with active listening and continues with microskills (Egan, 2013) that emphasize attending behavior, empathy, demonstrated shared interest in the client/family, and work to build trust. Counseling is an interpersonal relationship between the clinician and the client or family. Counseling allows the clinician who works with children who stutter or clutter to practice within the ICF framework by targeting all aspects of the disorder, not just the surface behaviors. Effective counseling and strong client-clinician relationships are important for encouraging children to share information in the affective and cognitive domains.
cultural competence for information related to counseling.
Service Delivery section of the Fluency (Children) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Service delivery for childhood disfluency disorders encompasses, among other factors, treatment format, provider(s), dosage, timing, and setting. Fluency treatment is a dynamic process; service delivery may change over time as the client's needs change.
Format refers to the manner in which a client receives treatment: one-on-one (i.e., individually, the client and the clinician) or as a member of a group of people receiving services at the same time. In most settings, fluency treatment typically takes place one-on-one to allow focused teaching of new skills and ensure privacy for the discussion of personal issues. However, sometimes group treatment may be advantageous. As a member of a group, children may experience less stigma, particularly as they discover that some of their peers also have communication problems. Members of treatment groups often experience a sense of belonging (Rollin, 1987), which aids in the implementation of many phases of treatment. For example, clients can practice treatment targets with more listeners (Ramig, 2003) and monitor each other's speech and secondary behaviors (Williams & Dugan, 2002). Once a child feels comfortable performing speaking tasks within a treatment group, he or she may find it easier to do so in other settings. Groups are sometimes formed with members at different stages of treatment. This situation can allow children to gain insights from group members who are either older or further along in the treatment process. At the same time, those who have progressed further can build self-confidence by taking on a mentoring role.
Provider refers to the person providing treatment (e.g., SLP, trained volunteer, caregiver). The primary provider of fluency treatment is the SLP. Approximately 67% of SLPs working in schools reported serving students with fluency disorders (ASHA, 2012). SLPs providing pediatric services in various health care settings (e.g., hospital, outpatient clinic, home health) reported spending 3% of their time serving children with fluency disorders (ASHA, 2013).
Parental involvement is an integral part of any treatment plan for children who stutter. Parents can be instructed about how to modify the environment to enhance fluency and reduce communication pressure. Parents can also be educated about how to assist their child in generalizing skills from the treatment room to use in different settings and with different people. SLPs can include teachers in the treatment process by educating them about fluency disorders, involving them in treatment sessions, and having them assist with assignments outside of treatment sessions.
Dosage refers to the frequency, intensity, and duration of treatment. Dosage depends largely on the nature of the treatment (direct or indirect) and the task level (e.g., learning basic skills requires more clinic room training than does generalization). Scheduling concerns, cost, and insurance reimbursement also are likely to be factors affecting dosage. Given these potential issues, determining dosage often comes down to the professional opinion of the SLP and the needs of the child and family.
Timing refers to the initiation of treatment relative to the diagnosis. Fluency treatment can occur at any point after the diagnosis. In general, the earlier preschool stuttering is addressed (relative to its onset), the easier it is to manage (Onslow & O'Brian, 2012). For older children, initiation of treatment depends in large part on the child's motivation which, in turn, is dependent on such factors as the speaker's perceived needs, degree of adverse impact experienced, and previous treatment experiences.
Setting refers to the location of treatment (e.g., home, community-based, school environments). Children with disfluencies are seen in all of the typical speech-language pathology service settings, including private practices, university clinics, hospitals, and schools.
Telepractice is possible as well.