This is the final post for this blog as I close my speech therapy business. It's been interesting to watch the field of stuttering treatment change over the decades. I appreciate that ASHA (1) has added a few new resources, and I appreciate the hard work of researchers and clinicians. Thank goodness treatment has emerged from the darkness of blaming the client for failure. Fluency used to be the goal. Now the goal of therapy is a combination of cognitive, affective and behavioral changes. It's been refreshing, though I'm disappointed there is no cure.
In the book Show Your Work!, Author Austin Kleon quotes C.S. Lewis: "The fellow-pupil can help more than the master because he knows less. The difficulty we want him to explain is one he has recently met. The expert met it so long ago he has forgotten." All my credentials are red flags that I've been doing this work long enough.
It's time to become an amateur at something new. I’m going to develop my interest in literacy. An excellent, comprehensive, week-long summer course by The Grimes Reading Institute (2) is complementing my training in Reading with TLC (3) and Orton-Gillingham (4). But, alas, I collect more credentials!
I'm also gradually developing an online store at Teachers Pay Teachers Books Too. (5)
Thank you for reading.
Find your voice,
In March, I watched a new DVD from the Stuttering Foundation: Williams’ Normal Talking Approach to Help Children Make Speech Changes  In this video, Dr. Zebrowski seemed to repackage some old concepts in new language. One old concept retrieved from the past which seems to be trending now is Dean William’s approach to treatment. I took a look at The Genius of Dean Williams to prepare for a student's session.
Dr. Dean Williams said that what a child believes will influence the choices he makes. So it's helpful to ask children "what they believe is wrong and what they do that they believe helps them talk better. Dr. Williams wrote that it was important to remember the difference between 1.) the stuttered moment and 2.) the behavior to cope with that moment. This is a concept we could take a look at again.
I’ve observed a lot of disagreement over # 1, what the stuttered word is all about. Since research of the past few decades indicates stuttering is a neurological difference with genetic roots, I'm surprised to see Dr. Williams' old ideas about this resurface in 2014. So I very respectfully disagree with Dr. Zebrowksi when she says to tell children that stuttering is something they do and not something that happens to them. Dr. Williams said to tell children that stuttering is something they do, I believe, in order to empower them, to imply that they can do something different. But, it seems to me that we risk blaming the child with this philosophy.
Nevertheless, there is little disagreement over #2, how children cope with the stutter. They may push at the stutter in order to keep up with the pace of conversation. This can become a physically difficult “fight” that results in negative listener feedback. They may move on to strategies that increase fluency, such as switching out words and talking less. I think that children are not always aware of their coping behavior. I also think children deny coping behaviors. Children who stutter are doing the best they can. Some more progressive thinking is that children should be allowed to stutter. For more such ideas, listen to Vivian Sisskin in StutterTalk podcast episodes 503-507, March 23-27, www.stuttertalk.com.
The take-home concept here is that there is a difference between the stutter and the coping behavior. Dr. Williams said that we can help children discover this distinction. We can talk with them about what they believe helps, their motivation for choosing certain coping strategies. This conversation will involve talking about feelings. The physical act of speaking becomes tangled up with emotion for people who stutter. This is my understanding of chapter 1.
If we can repeatedly help the child see the difference between the stutter and his choices for coping, then we can be clear about the behaviors he may have the power to change. We can help children "learn that attending to and changing one's behavior is dependent on what the child does and is not dependent on reducing or eliminating one's emotions."  Children say they want to stop stuttering; this may be a clue that the distinction between the stutter and the coping strategy is blurred. In response, we repeat the message that we don't have a cure for the stutter (#1). We do have options for coping. (#2) We want children to keep talking. We want them to develop good communication skills all through childhood. And we want them to experiment with coping strategies to make the speaking easier.
In The Child and Adolescent Stuttering Treatment and Activity Resource Guide  there is a drawing of a coping strategy called a “pullout.” It has the moment of the stutter as a jagged line that changes into a gently rolling line. It illustrates a tense disfluency that becomes less tense. The stuttered moment is the tense disfluency. The rolling hills represent a copy strategy, loosening tension. I wasn’t skilled enough to recreate it here using Word®. I thought we could take this drawing and turn it into a way to brainstorm other coping strategies. Remember, a brainstorm is not judgmental. All kinds of ideas are acceptable. After brainstorming, we can talk about why a child might believe a particular coping strategy is most effective. (Note: Doing nothing is a coping strategy associated with acceptance. A speaker may believe that stuttering is the best way to communicate quickly and completely in some situations. )
In conversation, we can talk about the pros and cons of various coping strategies to help the child discover and own his communication skills.
When I attended a master’s degree program decades ago, I was trained that thoughtful lesson planning guided treatment. The speech-language pathologist (SLP) wrote specific goals and designed activities to achieve them. The activities carefully blended fun and reward to help children enjoy the hard work of therapy. The university I attended required that graduate students create their own therapy materials based on current research. I was the expert.
After graduation, I discovered beautifully made picture cards and thick ring-bound workbooks were easy to buy, saving me hours of prep time. Glossy catalogs marketing expensive therapy materials arrived in my mail every fall. Children cooperated more easily with these commercial products. I bought items on clearance. My colleagues encouraged me to purchase formal tests, though quite expensive. Thus, my lesson plans were supported by official diagnostic testing and my therapy activities super charged with specialized teaching materials. Therapy was fun.
Then along came “Evidence Based Practice” (EBP). I attended conferences at which professors challenged earlier research and proclaimed a new (and nearly impossible) standard as the only valid treatment. Data was paramount. Suddenly, the most important thing to do in speech therapy was collect data. I spent perhaps the last 10 years reacting to this pronouncement. I audio recorded activities, filled data grids, photographed children’s drawings, and filled out questionnaires during sessions. I documented diagnostics, individual lessons and long term progress… it was downright distracting. Therapy was about the numbers.
I imagined a backlash to this kind of clinical process was at work when I read a recent e-newsletter from attachment parenting international (1). The January 28th blog post was titled Parents need to be the compass point. By example it reported the following: “A mother recently told me that she met with her son’s teacher, guidance counselor and school psychologist. She wanted to explain that it was important that her son’s teachers develop a caring relationship with him. When she explained to them what her son needed, their response was, ‘You’re only the mother.’ In other words, ‘We are the professionals who know best what students need.’” The blog article encouraged parents to defend themselves against this attitude. Attachment parenting recognizes that parents are their “child’s compass point, guide, comforter and safe home base.” How can therapy welcome collaboration with families?
This change in clinical process has taken place in Early Invention services. In 2004, “the intervention focus moved from engaging children in planned educational therapy activities to supporting caregivers to embed interventions within their typical activities/routines.” (2) This was a “major shift in service delivery.” SLPs put down their traditional lesson plans and materials. They adapted knowledge and skill to the individual needs of a family’s living situation. This paradigm shift meant the SLP’s new job description included “...(a) seeking out and respecting caregivers’ views; (b) ensuring equal participation of family members in the decision-making process; (c) recognizing caregivers’ rights to make decisions even when decisions are contrary to the professionals’ views; and (d) affirming the role of culture, values, and family beliefs in their community.” (3) This was not easy. A study in 2007 found “...that 51% of home visit time was spent in direct instruction with the child, and less than 1% of the time was used to coach the caregiver.” (4) Speech therapy had to move forward by training SLPs to coach adult learners. The article has a detailed description of 11 strategies for coaching caregivers. Speech therapy is now all about collaboration.
A recent continuing education course invited me to re-evaluate once again what goes on in therapy. (5) The title of the course is Balancing Certainty and Uncertainty in Clinical Practice. Children are unique human beings who can’t be defined by the certainty of data points. Every new day is a creative process filled with uncertainty. Given this reality, how might we move forward in speech therapy? The seven articles in this course debated rational thinking as a guiding principal. “Rational, team-based thinking uses a balance of certainty and uncertainty to arrive at decisions that are likely to have a positive impact on student performance. Collective thinking helps to frame problems as uncertainties for which appropriate solutions can be found." (6) Rational thinking depends upon conversation. It’s not a solitary activity. It’s not about an SLP sitting alone in an office carefully crafting lesson plans. This conversation is referred to as generative dialogue. “In generative dialogue, student-centered problems (e.g., behavior, learning difficulties) are reframed as uncertainties that are explored to reveal underlying principles of teaching that apply to all learners.” (7) Decision making becomes a process involving teachers, students, and parents defining mutual goals. (8)
I required that a parent participate in speech therapy with their child for several years now. This reduced my caseload but ensured that caregivers were educated about stuttering. They learned about teaching methods and the process of change. They tailored goals to suit their children’s lives. I was letting go of the lesson plan and beginning to view each therapy session with greater uncertainty. My job description was evolving from lesson planner to listener. Because I was in this transition, The StutterTalk podcast Serious Concerns about Speech Therapy for People Who Stutter in the Public Schools (9) raised the hair on the back of my neck. Taro Alexander recounted a presentation by a self-described expert who felt he had the perfect lesson plan. Mr. Alexander and Peter Reitzes wondered aloud about what was going on in speech therapy and why.
I attended many conferences and workshops over the years searching for answers to this question. Outside of formal presentations, I heard experts comment that a specific treatment protocol didn’t matter, it was the relationship between the client and the clinician that determined success. I don’t recall seeing this point of view on a PowerPoint slide. It simply floated in and out of conversations. This was confusing. I spent much of my career writing lesson plans, buying specialized therapy materials, collecting data, and accumulating continuing education credits. What’s all this about how it doesn’t matter?
At every conference, I asked for references. At the 2014 National Stuttering Conference, one speaker told me to buy the Heart and Soul of Change. (10) I’d heard about the role of counseling in speech therapy and listened Dr. Luterman (11) say to put down the lesson plan. This book explained WHY. This book proposes that something beyond therapy technique is more important to progress. There are four common factors that seem to account for successful change. The authors write, “In all, we found that the effectiveness of therapies resides not in the many variables that ostensibly distinguish one approach from another. Instead, it is principally found in the factors that all therapies share in common.” (12)
This book is about counseling, not stuttering. Yet experience taught me that stuttering is not like learning to play the piano or golf or baseball or math or science or social studies or writing. Speech therapy for stuttering is not only about learning a motor skill or a thought process. It’s about personal transformation. It’s about becoming a different speaker, a new identity with a new voice. When I heard an adult stutterer and her SLP describe this as a part of her increased fluency, I felt they had it right. (13) To paraphrase: my speech language pathologist and I decided what my new voice would be. This is not fluency. This is a new voice, a new speaker, a new identity.
Back to the Heart and Soul of Change. The authors of this book were amazed by “the wide range of theories, therapies, models, and approaches being promoted” at a Family Therapy Network Symposium. So, they “decided to turn to the clinical and research literature for answers on what matters for effective treatment.” (14) They discovered four “common factors.” Only two – only two – of these factors accounted for 70% of success.
1. Client/extratherapeutic factors: This category consists “of the client’s strengths, supportive elements in the environment, and even chance events. In short, they are what clients bring to the therapy room and what influences their lives outside it…. This category accounts for 40% of outcome variance.” (15)
2. Relationship factors: “These represent a wide range of relationship-mediated variables found among therapies no matter the therapist’s theoretical persuasion. Caring, empathy, warmth, acceptance, mutual affirmation, and encouragement of risk taking and mastery are but a few.” This category accounts for “30% of the successful outcome variance.” (16)
3. Placebo, hope, and expectancy: “These curative effects therefore are not thought to derive specifically from a given treatment procedure; they come from the positive and hopeful expectations that accompany the use and implementation of the method.” p. 10 “...their contribution to psychotherapy outcome at 15%.” (17)
4. Model/technique factors: “They include a rationale, offer an explanation for the client’s difficulties, and establish strategies or procedures to follow for resolving them….most therapeutic methods or tactics share the common quality of preparing clients to take some action to help themselves...they account for 15% of improvement in therapy.” (18)
One reason for gathering client input is to establish where he is in the process of change. The book describes nine clinical processes that coincide with different stages of change. I can talk about the stages of change in another article.
I’m learning to welcome more collaboration. Family preference guides therapy. SLPs with little experience in stuttering can read about what it’s like to live with in the archived newsletters of the National Stuttering Association and the Stuttering Foundation. There are personal stories posted in years of International Stuttering Awareness Day online conferences. In StutterTalk podcast (19) What I Wish My SLP Knew About Stuttering, Elana Kahan shares what it was like to attend years of stuttering therapy as a child.
Therapy is not about the SLP dictating a therapy program and manipulating client compliance. It’s about how the “Clients’ own generative, self-healing capacities allow them to take what different therapies have to offer and use them to self-heal.” (20) Therapy is about partnership balanced by certainty and uncertainty. It's about discovering the benefits of change.
(2) J. J. Woods et. al. (2011) Collaborative Consultation in Natural Environments: Strategies to Enhance Family-Centered supports and Services. Lang, Speech, Hear Serv Sch, 42: p. 381
(5) ASHA Professional Development Self Study 8726 © 2011
(6) MK Clark and P Flynn (2011) Rational Thinking in School -Based Practice, Language Speech Hearing Services in Schools, 42, p. 74.
(8) Nickola Wolf Nelson (2011) Questions About Certainty and Uncertainty in Clinical Practice, Lang Speech, Hearing Services in Schools, 42: see Figure 1, page 84
(9) Serious Concerns about Speech Therapy for People Who Stutter in the Public Schools, episode 484, www.stuttertalk.com
(10) Mark A. Hubble, Barry L. Duncan, Scott D. Miller (Eds.) (1999) The Heart & Soul of Change: what Works in Therapy, Washington, DC: the American Psychological Association
(11) David Luterman, Ph. D., Sharpening Your Counseling Skills, July 3, 2014, National Stuttering Association Annual Conference in Washington DC.
(12) Ibid p. (xxii)
(13) K. Sabourin and E. Alpern, Why Stutter More? July 4, 2014 National Stuttering Association Annual Conference in Washington DC.
(14) M.A. Hubble et. al., (1999) p. xxi
(15) Ibid. p. 9
(16) Ibid. p. 9
(17) Ibid. p. 9
(18) Ibid. p. 10
(19) www.stuttertalk.com February 24, Episode 497,
(20) M.A. Hubble et. al., (1999) p. 14
I’m watching a video of one of my students. I’m typing what he says and marking each stuttered word, listening to some of his sentences over and over again to accurately label blocks, prolongations, repetitions and secondary behaviors. I can think about a child’s speech more sensitively this way than if I try to take a frequency count in real time.
It takes several hours to transcribe and score a speech sample this way. I’ve been doing it for more than 20 years. In 1992, I learned a detailed protocol called Systematic Dysfluency Analysis (SDA) . It introduced me to careful listening. Eventually, I had to admit that SDA took too much time. In 2010, I bought the Test Of Childhood Stuttering (TOCS) which provided a simpler method. I knew that most speech language pathologists (SLPs) used the Stuttering Severity Instrument (SSI). However, as a specialist, I felt obliged to offer an alternative. The Stuttering Foundation has a continuing education video called Scoring Disfluencies, an excellent resource for anyone interested.
In this blog post, I'd like to reflect on what speech analysis means. For starters, certain types of disfluency are considered stuttering and others are not. The distinction is especially relevant when considering whether or not a young child might be at risk for developing a chronic stuttering problem. Disfluency types can differentiate between stuttering and cluttering. And, sometimes, I see children show progress by gradually changing the type of disfluency they produce, even if frequency stays the same. The American Speech Language Hearing Association (ASHA) website has a thorough review of this information for SLPs in Clinical Topics: Childhood Fluency Disorders. There is quite a lot of information for the public at the ASHA site as well.
Any presence of physical tension is usually labeled stuttering. One form of tension is a laryngeal block. This is when the vocal cords (located in the larynx) stop vibrating. Speech seems to be stuck in the throat. This may take a fraction of a second or up to several seconds. Tension may also appear in the face and/or neck. It can spread through the torso. A change in timing, a prolongation, is another form of stuttering. It is a sound that lasts too long and fails to transition quickly into the sound that follows. These two types of stuttering are called “disrupted phonation.” , 
Parents may not realize disrupted phonation in their child's speech could be stuttering. It's the repetitions that usually trigger concern. Friends, family and even pediatricians say ‘ wait and see’, maybe the toddler will pass through a common phase called developmental disfluency. Most young children do “outgrow” this. But the mystery remains; which children will develop normal speech and which children will stutter?
Research conducted in the 1990's identified disrupted phonation (blocks and prolongations) as associated with chronic stuttering. Disrupted phonation, whether it has a sudden or gradual onset is probably not normal. It turns out that some kinds of repetition are probably not normal either. Atypical repetitions along with disrupted phonation are called Stuttering Like Dysfluency (SLD). A careful speech analysis will determine precisely what kinds of disfluency is occurring.
A special calculation called the "weighted stuttering like disfluency" has been found to discriminate between young children who do and do not stutter. It combines repetitions and disrupted phonation in a mathematical formula . In fact, a weighted SLD measure of 4 identified 97% of children (35/36 children ages 3 & 4 years) in one study. It is important for parents to know that blocks and prolongations could be warning signs of chronic stuttering.
A careful speech analysis will count three types of repetition. Two types are associated with stuttering in young children: repeating parts of words (I w-w-w-want; I want pop-pop-popcorn.), and repeating single-syllable whole words (I want-want-want popcorn.) In addition, the number of iterations is relevant. This is because the presence of a single repetition (I w-want) versus multiple iterations (I w-w-w-want) also distinguish between children who stutter (CWS) and children who do not stutter. These guidelines have been revered for decades due to extensive research support.
For some children, stuttering apparently worsens with time. One research team proposed that these children “may be encouraged, by a more positive listener reaction, to use increased physical tension to stabilize (or make less obvious) part word repetitions." This didn't make sense to me. Rather, my intuition is that the older children's speech contain more SLDs because it always did. By this I mean, children arriving at a clinic for evaluation at age four would be those who always had more disrupted phonation. But then I read The Genius of Dean Williams.  In chapter 9, he recalls the following: "One second grade boy reported that when he was in kindergarten and first grade he had repeated sounds a great deal. People called it 'stuttering.' Now, he tensed and 'pushed' to get the words out so he wouldn't 'repeat,' or 'stutter,' as he understood the meaning of the word." I was in awe that Dr. Williams could elicit such insights from a youngster.
Recording single-syllable whole word repetitions as stuttering is not universally accepted. "There is evidence...that children who recovered from stuttering showed a greater proportion of WWR than those who did not [and] ...Riley (1994) as creator of the SSI-3 asserts that WWRs should not be counted as moments of stuttering, as long as they are not disrhythmic." Why all the fuss over counting single syllable whole words? Well, we’re talking about accurately diagnosing children at risk for persistent stuttering and recommending who should receive treatment. If we dismiss all childhood disfluency as something children outgrow, parents may not seek appropriate help. Or maybe the opposite. Maybe parents will be unnecessarily concerned.
It turns out that "...as a group, bilingual children produce higher levels of typical speech disfluency than their monolingual peers."  Repetitions ranged from 3-22% and number of iterations 4-8 in a recent study of Spanish-English speaking children. It may be that the guidelines for diagnosis revered for decades actually applies only to monolingual children. Here is a danger of incorrectly labeling children at risk for stuttering. “…at present, researchers do not have a sufficient understanding of the disfluent speech of bilingual children who do not stutter. Thus, it is difficult to determine whether a bilingual child is in fact at risk for stuttering or if, perhaps, as a group, bilingual children produce higher levels of typical speech disfluency than their monolingual peers.”
I began this blog because I was working with a middle schooler. I didn’t find anything new in the ASHA journals for this age group. I did come across an article that validated a common phenomenon. A group of children who stuttered ages 6 years old to 10 years and 5 months old, stuttered more in narrative than in conversation. What’s the difference between having a conversation with someone versus recalling a story?
A conversation is a shared experience. Speakers pay attention to one another. They interpret facial expressions, body language, tone and loudness of voice and changes in topic. There is time pressure to access language and speech/motor skills in socially acceptable ways. It matters who’s talking and the speaking situation. Conversation can be challenging! CWS in this study used shorter utterances in conversation than in narrative. Any surprise here? I’ve certainly seen this.
Okay, let's take a look at narrative. The speaker is completely responsible for all of the information, language, non-verbal messages, and listener reaction. It’s the speaker's job to keep a listener’s interest and ensure that he understands the message. Here’s two reasons a story telling activity would have been more difficult in this particular study. Reason number 1: "...children [need] to hold a series of sequential intentions in memory while simultaneously planning and executing the motor movements required...” Reason number 2: “…the utterances the CWS produced during narration were longer than the utterances they produced during conversation, thus creating the context for motor system instability…” Narrative is also quite challenging! This research suggests that narrative may be an efficient tool for gathering a speech sample.
The results of a speech analysis are combined with other information to help in the accurate diagnosis and the selection of treatment for CWS. For the older child, I refer to lessons found in Easy Talker, my own workbook, and the Stuttering Treatment Guide.  I’m also taking another look at the workshop booklet from Dr. Dean Williams’ presentation I attended in 1993. School-Age Stuttering Therapy is another superb resource. The Stuttering Foundation has many videos about treatment taught by highly respected experts.
This is just a personal reflection. I can only speak from my personal experience. I’ve had 20+ years to form opinions and a clinician bias. I’m looking forward to retiring soon and hope to contribute to the field in ways other than studying speech samples. I’m looking forward to future generations of SLPs bravely taking on the challenge of stuttering therapy.
Thank you for reading,
 Systematic Disfluency Analysis Campbell, J. H. & Hill, D.G. (1987) Systematic Disfluency Analysis, Stuttering Therapy: A Workshop for Specialists, IL: Northwestern University
 R.B. Gillam, K.J. Logan, N.A. Pearson (2009) Test of Childhood Stuttering Austin TX: pro-ed.
 G. D. Riley (2009) Stuttering Severity Instrument, Austin TX: pro-ed, inc.
 E. Yairi and N. G. Ambrose (2005) Early Childhood Stuttering: For Clinicians By Clinicians, Austin, TX: pro-ed, p. 97.
 Let’s remember, too, that some speakers say they stutter when no dysfluency is evident to the listener. This phenomenon is called covert stuttering.
 The weighted SLD is "calculated by multiplying the number of part word (PW) and single syllable (SS) repetitions (PW + SS) per 100 words spoken by the mean number of repetition units (RU) and adding the result to two times the frequency of disrhythmic phonation (DP), thus yielding the following formula: ([PW + SS] x RU) + (2 x DP), as described by Ambrose & Yairi (1999, p. 899). 2002 p. 23." M. W. Pellowski & E. G. Conture (2002) Characteristics of Speech Disfluency and Stuttering Behaviors in 3- and 4- Year Old Children, Journal of Speech, Language, and Hearing Research, vol. 45, 20-34.
 Ibid p. 26
 E. Yairi and N.G. Ambrose (2005) p. 96.
 M. W. Pellowski & E. G. Conture p. 26. “In general, findings indicated that the percentage of total disfluencies, percentage of stuttering-like disfluencies, weighted SLD measure, and mean number of repetition units significantly differed between CWS and CWNS, whereas the percentage of other disfluencies did not significantly differ between the two talker groups.”
 Ibid. p. 26 “…that increases in time since stuttering onset were associated with increases in the percentage of stuttering-like disfluencies for all CWS.”
 Ibid, p. 31.
 Stuttering Foundation Publication No. 0425, p. 96.
 David Ward (2013) Risk Factors and stuttering: Evaluating the evidence for clinicians. Journal of Fluency Disorders, 38, p. 138.
 C.T. Byrd, L.M. Bedore & D.Ramos (2014) The Disfluency Speech of Bilingual Spanish-English Children: Considerations for Differential Diagnosis of Stuttering, Language, Speech, and Hearing Services in Schools, Dec. 10, p. 10.
 Ibid. p. 10
 C.T. Byrd, K.J. Logan, R.B. Gillam (2012) Speech Disfluency in School-Age Children’s Conversational and Narrative Discourse. Language, Speech, and Hearing Services in Schools, 43, p. 160.
 Ibid. p. 160.
 B. Guitar & J. Reville (1997) Easy Talker: A Fluency Workbook for School Age Children, Austin, TX: pro-ed pro-ed, 1997
 J. Butler (2014) Respecting the Communication Needs of Children Who Stutter, a free download at https://sites.google.com/site/judithvbutlermaccc/home/free
 The Child and Adolescent Stuttering Treatment and Activity Resource Guide, Second Edition, Delmar Cengage Learning, 2010
 D. Williams (1993) Stuttering Therapy for Children: Learning to Learn, University of Wisconsin-Milwaukee, School of Allied Health Professions, Office of Continuing Education