This section contains three parts. First, a list of goals, appropriate to the treatment of fluency disorders, is described. The criterion for including goals is that they be acceptable and desirable for speech-language pathologists to try to reach with clients with fluency disorders. These goals follow from the nature of fluency disorders, and it is expected that few will disagree with the choice of goals. Indeed, peer review of the guidelines revealed a broad consensus on the goals.
The philosophy of treatment that a clinician believes in will, of course, strongly determine which goals are considered most important. This list is intended to include all goals that are considered appropriate by all philosophies of treatment currently held by speech-language pathologists who treat people who stutter. The order of goals presented in this document does not reflect their order of importance.
It is recognized that certain goals may be desirable for (some) clients to reach but are nevertheless outside the scope of practice for most speech-language pathologists, e.g., psychotherapeutic goals unrelated to fluency, or parenting issues unrelated to a child's fluency.
The second part lists processes that are useful for achieving specific goals. The inclusion of processes in this list in no way mandates their use by clinicians. Some clinicians will rely exclusively on a few processes; others will combine many different processes. The list is an attempt to set down processes that are in widespread use by speech-language pathologists who treat stuttering.
The criteria for selecting processes combine empirical knowledge, theory, and common practice. For example, one goal is a reduction in the frequency of stuttering behaviors. Processes that have been shown empirically to reduce stuttering behaviors in a lasting way, for example, slowed parental speech rate for young stuttering children, have consequently been included. Another process, for example, instrumental extinction, might be included for more theoretical reasons. In some cases, either the empirical or the theoretical support is weak, and this weakness is pointed out in the document.
The third part identifies competencies—skills and knowledge—that clinicians can use to engage in the processes identified in part two. The criteria for inclusion in this list of competencies are simply logical. If the modification of cognitive structures that make it difficult for clients to think about their speech in a productive manner is a desirable goal, then cognitive restructuring is a useful process, and a competency in that technique is useful for clinicians to have. It is understood that not all clinicians will have all competencies, although it is expected that clinicians will continue to augment their current competencies through continuing education.
Desirable goals in the assessment of fluency disorders:
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Obtain a speech sample that is as representative as possible of the client's speech in everyday use.
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Obtain a sample of the client's speech under circumstances that are constant from one client to the next.
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Generate, from obtained speech samples and incidental observations, quantitative and qualitative descriptions of the client's fluent and disfluent speech behaviors that can be related where applicable to vocal tract physiology, and that are communicable to other interested professionals.
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Obtain information about variables that affect the client's fluency level and apply this to treatment planning.
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Obtain information about a client's early social, physical, behavioral, and speech development, including information about variables that might be related to the origin of the disorder or its course of development, and apply this information to treatment planning.
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Obtain information about variables that might influence clinical outcome and/or the prognosis for treatment and apply this to treatment planning.
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Obtain information about other communicative problems or disorders that may or may not be related to fluency.
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Generate descriptions of the results of assessment that are communicable to other professional and lay persons.
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Observation and recording of the client's speech during an interview with the clinician about the client's stuttering disorder.
Observation and recording of the client talking to a relative or friend prior to meeting with the clinician.
Observation and recording of a child playing with parents after instructions to the parents to play with the child as they normally would at home (Family Play Session).
Tape recordings made by the client of conversations during daily activities at work, home, or anywhere.
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Observation and recording of the client's speech in response to being asked to describe a standard stimulus picture.
Observation and recording of the client's speech while reading a standard passage aloud.
Observation and recording of the client's speech while the client plays a “barrier game” [1] with the clinician, or, preferably, with a third party.
Observation and recording of the client's speech during a structured interview, in which the clinician asks the same question of each client by referring to an interview form.
Observation and recording of the client's speech while performing a specific speech task, such as describing a job or a favorite activity or a school subject.
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Administering any of a variety of published tests of fluency, stuttering severity, attitudes toward stuttering and speech, self-efficacy as a speaker, situational fears, and avoidance behavior.
Administering any of a variety of systematic protocols for coding speech sample(s) so as to reflect the categories of disfluency, and the extent of fluency or nonfluency, and the presence and type of secondary behaviors.
Transcribing a speech sample verbatim in such a way as to accurately reflect all fluent and nonfluent speech behavior.
Identifying and counting the frequency of primary and secondary stuttering behaviors.
Measuring the duration of discontinuous and continuous speech elements.
Measuring speech rate (syllables per second with pauses included) and articulatory rate (syllables per second with pauses excluded).
Observing and recording behavioral and/or physiological measurements of oral, laryngeal, and respiratory behavior so as to relate specifically identified stuttering behaviors to possible vocal tract events and to assess the capacity for fluent speech production.
Describing qualitatively any of the nonmeasurable aspects of fluency, such as apparent level of muscular tension, emotional reactivity to speech or stuttering behaviors, coping behaviors, nonverbal aspects of stuttering behavior, or anomalies of social interaction such as poor eye contact, generalized low muscle tonus, poor body posture.
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Developing and systematically testing hypotheses about variables that might affect fluency level, for example, talking slowly to a stuttering child to see if a measurable improvement in fluency can be obtained.
Interviewing the client or the client's family about social circumstances, words, listeners, sentence types, speech sounds, that improve or exacerbate fluency.
Playing videotapes or audiotapes of parentchild interactions to the parents of a child who presents with a potential or actual fluency disorder.
Conducting a variety of brief trial treatment procedures, such as delayed auditory feedback, whispering, rate modification.
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Developing questionnaires or other written materials (e.g., fluency autobiography) designed to obtain potentially relevant background information.
Interviewing the client, the client's family, or others about developmental milestones of motor control, social-emotional behavior, speech and language, and cognitive level.
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Administering tests or reading reports of others who have administered formal tests of intelligence, attitudes, motivation, comprehension, ability to take direction, or other prognostic indicators.
Making informal tests and observations related to intelligence, attitudes, motivation, comprehension, ability to take direction, or other prognostic indicators.
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Administering tests or reading reports of others who have administered formal tests of language, voice, articulation, psychoemotional function, learning disability, cognitive level, or auditory or visual deficits and using this information to plan for treatment and to provide prognostic information.
Making informal observations of language, voice, articulation, psychoemotional function, learning disability, cognitive level, or auditory or visual deficits, and using this information to plan for treatment and to provide prognostic information.
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Writing reports of assessment processes designed to be read by physicians, psychologists, and other nonspeech-language pathology professionals.
Writing comprehensive reports of assessment processes designed to be read by the current or subsequent clinicians.
Reporting the results of assessment processes, formally or informally, to the client and/or the client's family/significant others.
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Can differentiate between a child's normally disfluent speech, language-based disfluency, the speech of a child at risk for stuttering, and the speech of a child who has already begun to stutter.
Can distinguish cluttered from stuttered speech and understands the potential relationship between these two disorders.
Can relate the findings of language, articulation, voice, and hearing tests to the development of stuttering.
Can obtain a thorough case history from an adult client or the family of a child client.
Can obtain a useful speech sample and evaluate it for stuttering severity both informally by subjective impression and formally by calculating relevant measures such as the frequency of disfluency, duration of disfluency, speaking rate.
Is familiar with the available diagnostic tests for stuttering that serve to objectify aspects of the client's communication pattern (secondary features, avoidance patterns, attitudes, etc.) that may not be readily observed.
Is able to identify, and measure where feasible, environmental variables (i.e., aspects, such as time pressure, emotional reactions, interruptions, nonverbal behavior, demand speech, or the speech of significant others) that may be related to the onset, development, and maintenance of stuttering and to fluctuations in the severity of stuttering.
Can identify disfluencies by type (prolongation, repetition, etc.) and, in addition, can describe qualitatively the fluency of a person's speech.
Can relate, to the extent possible, what stuttered speech sounds like to the vocal tract behavior that is producing it (for example, recognizing the subtle acoustic cues that signal vocal straining).
Can, in appropriate consultation with the client or parents, construct a treatment program, based on the results of comprehensive testing, on the client's personal emotional and attitudinal development, and on past treatment history, that fits the unique needs of each client's disorder(s).
Can administer predetermined programs in a diagnostic way so that decisions with regard to branching and repeating of parts of the program reflect the unique needs of each client's disorder(s).
Can explain clearly to clients or their families/significant others what treatment options, including the various types of speech treatment, medication, devices, self-help groups, and other forms of treatment are available, why they may or may not be appropriate to a specific case, and what outcomes can be expected from each, based on knowledge of the available literature.
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Desirable goals in the management of fluency disorders:
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Reduce the frequency with which stuttering behaviors occur without increasing the use of other behaviors that are not a part of normal speech production.
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Reduce the severity, duration, and abnormality of stuttering behaviors until they are or resemble normal speech discontinuities.
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Reduce the use of defensive behaviors. [3]
Note that when clients use avoidance behaviors that are successful (in that they avoid stuttering behavior) they will appear to have made progress toward Management Goal 1, but in fact will have done so by including some additional, and abnormal, behavior. For example, clients who are able to change words so as to avoid saying a word that they will stutter on will have a reduced frequency of stuttering behavior, but they will also have an increased frequency of cognitive behaviors involved in the search for and retrieval of substitute words.
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Remove or reduce processes serving to create, exacerbate, or maintain stuttering behaviors.
In children, this might entail modification of the child's parents' behavior so as to reduce maladaptive reactions to the child's stuttering behavior. In adults it might include teaching the client how to change his or her listeners' behavior. In some cases, there may be reinforcement for stuttering, such as excuses for failure, or getting attention that is otherwise not forthcoming. In other cases, denial may prevent an adult from perceiving the extent to which stuttering affects his or her life.
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Help the person who stutters make treatment (e.g., adaptive) decisions about how to handle speech and social situations in everyday living.
This includes such things as helping the client learn how to respond to people who try to talk for him or her, or helping the client learn not to use behaviors that avoid, rather than confront, specific social situations such as using the telephone, ordering in a restaurant, or helping the client learn that changing words costs something in personal self-esteem. This also includes teaching the client how to politely influence listeners' behavior so that the client's fluency can be improved.
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Increase the frequency of social activity and speaking.
Clients who have adopted reticence as a strategy to deal with stuttering will need help in regaining a normal amount of social speech.
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Reduce attitudes, beliefs, and thought processes that interfere with fluent speech production or that hinder the achievement of other treatment goals.
In some adults this might involve modifying their attitude toward very brief stuttering behaviors so as to prevent stuttering from returning at a later date. Similarly, certain attitudes toward fluency and disfluency, or beliefs about these attitudes, can maintain stuttering behaviors, for example, perfectionist fluency, abhorrence of normal disfluency, rigidity in speech behavior. Some clients may have attitudes toward themselves that serve to exacerbate or maintain stuttering behaviors, for example, low self-esteem, lack of confidence, or feelings of worthlessness.
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Reduce emotional reactions to specific stimuli when these have a negative impact on stuttering behavior or on attempts to modify stuttering behavior.
For example, fear of specific social situations, word fears, a sense of intimidation by specific categories of listeners, a sense of helplessness or fear of specific speech tasks, such as answering the telephone or asking questions in class, or a fear of the embarrassment of stuttering in public. This should not be confused with the reduction of defensive behavior, which is one kind of reaction to these fears. Both fear reduction and defensive behavior reduction can be appropriate.
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Where necessary, seek helpful combinations and sequences of treatments, including referral, for problems other than stuttering that may accompany the fluency disorder, such as, cluttering, learning disability, language/phonological disorder, voice disorder, psychoemotional disturbance.
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Provide information and guidance to clients, families, and other significant persons about the nature of stuttering, normal fluency and disfluency, and the course of treatment and prognosis for recovery.
In addition, help clients and families/significant others understand the nature of past treatment and the availability and possible utility of other options, including other forms of treatment, devices, and self-help groups.
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It is not the intention of this document to assert that all processes should be used with all clients. A process for reducing excitement is useful only with a client whose fluency is adversely influenced by excitement. For each client, clinicians choose a set of appropriate goals, based on a careful evaluation of the client. Having established what are appropriate goals for a client, a selection of processes to achieve these goals is made. At times during treatment, both goals and processes should be re-evaluated, and after treatment, it is likewise appropriate to review the selection of goals and processes and evaluate them with regard to the outcome of treatment.
Note that processes are not exactly the same as techniques. There might be several techniques for engaging in a particular process. For example, one process mentioned below is “Identify reinforcers for stuttering.” A clinician could engage in this process by interviewing clients and asking what happens after they stutter, or spend some time with clients, observing them in real speaking situations, or interview people who know the clients well, such as parents, siblings, or partners. Each of these techniques would or could result in the identification of reinforcers that are contingent on stuttering behavior.
Note that referral and consultation are processes that may be used to achieve goals.
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Fluency-shaping approach:
Slowed rate of speech movements.
Easy onset of voicing.
Blending, or continuous voicing.
Light articulatory contacts.
Smooth, slow speech movements.
Use of computer-assisted feedback to train clients in fluency — producing coordinated speech production movements.
Vocal control treatment approach.
Better vocal tone, breath support, full resonance, efficient and relaxed voice, adequate loudness.
Typically accompanied by systematic desensitization.
Contingency management:
Combined reinforcement for fluent speech and mild, nonaversive punishment for stuttering behaviors.
Successive approximation (shaping) toward fluent speech.
Practice in a systematically sequenced series of steps from where fluent speech is easiest to achieve toward where fluency is more difficult to achieve, for example, through gradually increasing the length and complexity of an utterance, or through a hierarchy of feared social situations.
Use of fluency-enhancement, in the clinic, or via a wearable device, may be a useful way to establish the behavior in the first place.
Use of computer-assisted devices to ensure rapid and consistent feedback.
Systematically administered reinforcement for more natural-sounding speech.
Reduction of speech-associated anxiety:
Systematic desensitization to social situations.
Desensitization to the experience of stuttering (confrontation).
Pseudostuttering (voluntary stuttering, or faking).
With children, through counseling parents, reduction or removal of as many anxietyproducing events as possible.
Reduction of speech-associated excitement:
With children, through counseling parents, reduction of as many exciting events as practical and reasonable.
In prevention, training parents to speak more slowly but with normal intonation, timing, and stress patterns.
In prevention, training parents to talk less often, and with simpler language, to interrupt less often, and to ask fewer questions requiring long complex answers.
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Disfluency shaping:
Help the client learn ways to be disfluent in a more normal way.
Remove, through modeling and practice, one behavior at a time until disfluencies are normal in type.
Muscle tension reduction:
Reduction of oral and vocal muscular tension during speech.
slowed rate and rate control
direct suggestion to reduce muscle tension in specific parts of the vocal tract
referrals for the possible use of medication to achieve muscle relaxation
attitude modification via techniques described below
Repair treatment:
Teach client the various types of speech sounds and how they are fluently produced.
Teach client the types of stuttering behaviors used by client.
Teach client types of repairs — ways of changing from the stuttered to the nonstuttered type of production.
Practice repairs in different environments.
Work on one or two specific sounds or sound category at a time.
Stuttering modification sequence:
Post-block modification, or cancellation.
In-block modification, or pull-out.
Pre-block modification, or preparatory set.
Counterconditioning techniques:
Associating stuttering with pleasant events, for example, “reinforcement” for stuttering, or tag game.
Voluntary stuttering.
Confrontational (nonavoidance) techniques:
Discussion with the client of specific behaviors, the circumstances under which they occurred, and the variables that may have influenced them.
Listening to clients or watching audio or videotapes of themselves with them while speaking and discussing specific behaviors and reactions with them.
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Extinction of defensive behavior:
For secondary (avoidance) behavior:
direct instructions to stop performing the secondary behavior, accompanied by an alternative to stuttering behavior, for example, in-block modification (pull-outs), or slowed speech, or monitored vocalization
punishment (time-out, response cost or other nonaversive punishment only) accompanied by an alternative to stuttering behavior
For primary (escape) behavior, that is, struggled disfluency:
stuttering modification sequence of post-block, in-block, pre-block modification
modeling stuttering that is easy and free of struggle, then reinforcing the client for disfluency that is less struggled
direct suggestions, accompanied by cuing and reminders
discussions about the client's stuttering pattern, approaching feared situations, to toughen attitudes toward stuttering
In prevention, training parents in the relaxed production of occasional disfluencies that are normal for their child's age.
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Instrumental (operant) conditioning:
Identify reinforcers for stuttering.
Remove conditions in the environment, including in the client's “internal environment” that are reinforcing stuttering or defensive behavior.
Defensive counterconditioning:
Identify aversive consequences for stuttering.
Identify stimuli, or constellations of stimuli (situations) associated with or predictive of aversive consequences, as in a hierarchy of speech situations.
Identify behaviors that terminate or avoid the aversive consequences.
Provide experiences for the client in which the conditioned stimuli occur, but the avoidance behaviors are NOT performed and no aversive consequences follow.
Help client learn how to handle pressure situations while still using newly learned fluency skills.
Vicarious conditioning:
Identify speech models who are reinforced for stuttering, or who avoid stuttering or try to avoid stuttering (i.e., use defensive behavior), or who demonstrate negative emotional reactions to disfluency.
Counsel, train, or modify the behavior of these models so as to remove or reduce the occurrence of vicarious conditioning.
Environmental manipulation:
Alter the client's environment, external or internal, so as to remove any conditioning process that is exacerbating or maintaining stuttering behavior:
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Identification of specific decisions about social behavior that may affect fluency, for example, deciding to let a colleague answer the phone even though the client is closer to it.
Counseling, including sensitive explanations about how decisions based on defensive reactions serve to increase fear and decrease selfconfidence.
Identify, with the client's help, attainable behavioral goals for more effective decisionmaking.
Plan activities that will provide opportunities for the client to make better decisions.
Reinforce client for making decisions that are more conducive to speaking fluently and with confidence.
Help clients foresee the natural consequences of their decisions to use or not use learned treatment techniques in day-to-day activities.
Attendance in a support group with other people who stutter.
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Provide reinforcement for entering speech situations previously feared.
Encouragement and reinforcement for talking more often and in a wider variety of situations, structured hierarchically from least to most stressful or intimidating.
Encourage client to participate in a self-help group.
Use of a fluency-enhancing device to make possible social activity that would otherwise be too intimidating for the client.
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Counsel the client so as to provide for successful experiences of any kind.
Counsel the client so as to provide for successful speech experiences.
Validation of the client as a person and speaker:
Listen to the client and demonstrate appreciation of the client as a person.
Listen to the client and validate aspects of speech that are unrelated to fluency, through expressed appreciation for aspects of the client's speech that are normal or superior, e.g., voice quality, expressiveness, word choice, articulation.
Listen to the client and validate fluency, where appropriate, by expressed appreciation for stuttering behaviors that are less struggled or less abnormal.
Transfer similar listening skills to client (self-listening).
Provide for increased attention from significant others.
Help client attain better identification of self through support group or other activities.
Provide for increased tolerance of failings through counseling, modeling.
Positive self-talk and affirmation training.
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Confrontational desensitization to stuttering events:
Talk about stuttering with the client in an objective way.
Have clients learn, through self-demonstration, that speech improves when they “give permission to stutter” or stutter on purpose.
Stuttering on purpose in the clinical setting.
Stuttering on purpose in real situations.
Keep a record of situations in which clients have stuttered on purpose or allowed themselves to stutter.
Desensitization to anxiety-provoking speech situations:
Traditional systematic desensitization:
constructing a hierarchy of feared words, listeners, and situations
inducing a physically and emotionally relaxed state
imagining feared situations while in a relaxed state
imagining oneself talking to feared listeners while in a relaxed state
imagining oneself producing feared words while in a relaxed state
imagining oneself stuttering while in a relaxed state
testing the effects of these experiences in real situations
in vivo systematic desensitization:
…feared words, listeners, and situations
systematically talking in real life situations, starting with the easiest elements in the hierarchy, and gradually increasing the level of difficulty. A fluencyenhancing device may provide a place to begin this process, although it will be important to wean the client from the device so as not to create a dependency on it.
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Referral to other professionals with regard to psychoemotional or learning disability problems.
Team treatment with other speech-language pathologists so as to work simultaneously on language, phonological, or voice problems.
Sequencing treatment so as to deal with one problem at a time. Usually this means postponing work on language, voice, or articulation until fluency is under control, but sometimes it means postponing work on fluency until some progress is made on the other disorder, for example, improved intelligibility.
Designing treatment plans that deal simultaneously with stuttering and coexisting problems.
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Direct counseling of parents, spouses, siblings, and others.
Bibliotherapy for parents, spouses, physicians, psychologists, and others.
Use of audio and videotape to present to clients and the parents of clients examples of specific behaviors and reactions.
Provide information about other treatment approaches, treatment devices, self-help and consumer advocate groups.
Provide information about third-party payment options.
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Is familiar with the appropriate goals of treatment and the processes for achieving them and can engage these processes, choosing techniques that are best for the client, and administer them with an attitude that balances the goal of normal speech with a tolerance for abnormal speech.
Has flexibility in choosing and changing the level of difficulty of tasks based on fluency level of the client.
Can teach clients to produce vocal tract behaviors that result in normal sounding speech production.
Has sufficient counseling skills so as to interact with clients of all ages and develop a reasonable set of expectations in the client.
Has a thorough understanding of, and knows how to put into practice, the principles of conditioning and learning so as to achieve a successful and appropriate modification of speech behavior.
Understands the relations between stuttering and other related disorders of fluency, such as cluttering, neurogenic and psychogenic stuttering, as well as disorders of language, articulation, learning, and so on, and can with flexibility identify sequences and combinations of treatment options that are helpful to the client.
Understands the dimensions of normal fluency and the relation of normal fluency to speech situations and is able to work toward normal speech, with an awareness of the compromises among effort, fluency, and natural-sounding communication.
Understands that some stuttering behaviors may be reactions to other stuttering behaviors and knows how to plan treatment to account for this.
Can evaluate available treatment programs with regard to treatment application for a wide variety of clients.
Is able to decide, based on objective progress, motivational level, and cost in time and money when it is appropriate to terminate treatment.
Is aware of the continuous nature of fluency and can identify subtle changes in speech or other behaviors related to treatment change and explain their importance to the client.
Can explain stuttering and treatment for stuttering to lay persons, such as day care workers, teachers, baby sitters, grandparents, and others who may influence the life of children who stutter.
Knows how to develop a plan for assessing objectively the efficacy of treatment in an ongoing way.
Can recognize problems that are treated by professionals other than speech-language pathologists and can guide a client to acceptance of an appropriate referral.
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