Preschool Treatment for Stuttering
Preschool Treatment
Brainstorming Activity
Activity targeting resilience, self-regulation, or emotions for 2.5-5 year olds should be brainstormed.
Consider:
Specific target for the session. What skill or behavior are you trying to improve?
Materials needed. Be specific about what you'll need for the activity.
Caregiver involvement. How will the caregiver participate and support the child?
Link to Canva board provided. Utilize this resource for inspiration and materials: [Canva Board Link]
Disfluency Analysis
A component of a comprehensive stuttering evaluation. It's crucial for understanding the nature of the child's disfluencies.
Helps differentiate between normal disfluency and developmental stuttering. This distinction is key for determining the appropriate intervention strategy.
Cluster Examples of Stuttering-Like Disfluencies (SLD)
Examples of SLDs with notations:
I- I -I like to go uh uh I like to go to the movies with mmmmmy [tension] friends. (2/11)
Last last last last time I saw a movie with my fffffriends uh Mike and Eric. (2/14)
We saw the new J- J -J- James Bond movie. (1/8)
It was it was it was pretty good. (0/5) (1 normal disfluency)
My ffffffffriends and I also like to go down-down downhill skiing at B-B-Bolton. (3/16)
There was was was was really good powder lllllllast week. (2/9)
We mmmmmade a big jump. (1/5)
My friend Mmmmike fell pretty b-b-b-b-ad though and hurt his uh uh um knee. (2/11)
I-I-I think he’ll be okay though. (1/7)
Quantification:
14 stuttering-like disfluencies. Accurately counting SLDs is essential for assessment.
86 syllables. Knowing the total number of syllables helps calculate the %SS.
Calculation: . This calculation provides the percentage of stuttered syllables, a key metric.
Treatment Options for Preschoolers
Monitor (collect Severity Ratings). Useful for children early after onset.
Parent-Child Interaction (PCI) therapy. Focuses on modifying family interaction patterns.
Demands & Capacities Model. Aims to balance environmental demands with the child's capacities.
Lidcombe Program (Onslow, Packman, & Harrison, 2003). A direct treatment approach using operant conditioning.
The ABC(D)s of Stuttering
Affective: Feelings. Understanding the child's emotional responses to stuttering.
Behavioral: Stuttering behavior. Identifying specific stuttering patterns.
Cognitive: Thoughts and attitudes. Addressing negative thoughts and beliefs about stuttering.
Social: Impact. Assessing how stuttering affects the child's social interactions.
Stuttering Approaches
Fluency Shaping:
Learning to talk in ways that prevent or eliminate stuttering. Focuses on techniques to produce fluent speech.
Stuttering Modification:
Modifying stuttering behaviors. Aims to make stuttering easier and less tense.
Acceptance-Based or Stuttering-Affirming:
Focuses on the acceptance of stuttering and reducing escape/avoidance behaviors. Encourages openness and acceptance of stuttering.
Indirect Approaches to Preschool Treatment
Therapy: Monitoring
When to use:
Typically early after onset (age 2-4). Best suited for young children recently diagnosed.
Have not stuttered for more than 6 months-1 year. Appropriate if stuttering has been present for a limited time.
Tools:
Severity Ratings. Used to track the severity of stuttering over time.
Parent-child interaction (show video of their interaction). Helps identify interaction patterns that may impact fluency.
Techniques:
Model slower rate of speech (Mr. Roger’s). Slow and relaxed speech can be a helpful model for the child.
Patient listening. Giving the child ample time to speak without interruption.
Minimize interruptions. Reducing conversational pressure.
Comments instead of questions. Open-ended comments can encourage communication without pressure.
Child-directed play. Following the child's lead in play to create a relaxed environment.
Things to avoid:
Don’t say “slow down” or “take a breath”. These comments can increase anxiety.
Instead, say “I’m listening” and make eye contact. Showing attentiveness and support.
Palin Parent Child Interaction (PCI)
Reference: Millard, Nicholas & Cook, 2008. Provides a structured approach to parent-child interaction therapy.
Studying Family Interaction Patterns
Conversational Stresses:
High rates of speech. Fast-paced conversation can increase disfluencies.
Rapid fire (lack of pauses). Not allowing enough time for the child to process and respond.
Interruptions. Cutting the child off while speaking.
Frequent open-ended questions. Can place pressure on the child to formulate complex responses.
Frequent criticisms or corrections. Negative feedback about speech.
Inadequate or inconsistent listening. Lack of attention to the child's communication attempts.
Vocabulary far above child’s level. Using words the child doesn't understand.
Advanced levels of syntax. Complex sentence structures that are difficult for the child to process.
Family Interaction Patterns That May Facilitate Fluency
Parents should arrange daily one-on-one time with the child. Consistent, dedicated time can improve fluency.
Best done at the same time each day. Establishing a routine can create a sense of security.
Major characteristic is parent attending to child, good listening, child-directed. This approach fosters a supportive environment.
Table 13.1 highlights these patterns:
Listening time for at least 5-10 minutes daily. Dedicated listening time improves communication.
Slow rate of speech with comfortable pauses. Modeling relaxed speech.
Pauses of 1-2 seconds before starting to talk. Allows the child time to process.
Positive comments to encourage the child. Reinforces communication attempts.
Fewer questions to reduce pressure. Reduces the demand on the child's expressive language.
Taking turns in family conversations using a “talking stick”. Helps regulate conversation flow.
Slower Speech Rate With Pauses
Clinician teaches parents/family to use a slower speech rate with appropriate pauses. Essential for modeling fluent speech.
Mr. Rogers videos on YouTube are helpful models. Demonstrates a calm and relaxed speaking style.
Parents/family benefit from practice with clinician to achieve a relaxed and smooth slower speech style. Provides guided practice for effective implementation.
If child asks why parent is speaking slowly, parent can say that they (the parents) talk too fast and need to learn to slow down. Avoids placing blame on the child.
Never ask a child to slow their own speech. Can increase anxiety and self-consciousness.
Commenting on the Child’s Speech
Many children who are starting to stutter are worried about what’s happening to their talking. Addressing the child's anxiety is important.
Signs that children are worried include saying “I can’t talk!” or putting their hand over their mouth when they stutter. Recognizing these signs helps tailor intervention.
If a child is aware, a parent can say, “That’s ok. Lots of times words get stuck. Just take as much time as you need.” Validates the child's experience.
This removes the “conspiracy of silence”. Open communication about stuttering is beneficial.
Comment occasionally, especially if the child seems upset. Provides reassurance and support.
Vary comments and use a relaxed and accepting manner. Maintains a positive and non-judgmental environment.
If the child doesn't like the comments, maintain a relaxed and accepting appearance and eye contact. Empathetic and supportive response.
PCI Clinic Sessions
6 weeks of clinic sessions followed by maintenance. Provides initial intensive therapy followed by ongoing support.
Home video review:
Explore ways to build on and enhance a low-pressure environment. Identify strategies for creating a supportive home environment.
Reviewed by clinician in between sessions. Ensures ongoing assessment and guidance.
Parents watch at the beginning of the next session. Enhances self-awareness and reflection.
Comment on what the parent is pleased with after watching themself. "What’s happening there? How does that help?" Encourages positive self-evaluation.
“Special Time” contracts:
5 minutes of home practice, 3-5 times per week. Regular, focused practice.
Relaxed 1:1 time. Enhances parent-child connection.
Video Review - PCI Goal Progress
Rating scale:
0: No attempt
1: Tried it
2: Still working on it
3: Met goal
Goals:
Child-directed. Letting the child lead the interaction.
Limited questions. Reducing pressure on the child.
Slow speech rate. Modeling a relaxed pace.
Course of Treatment
Clinician’s role:
Be deeply supportive and accepting. Creating a safe and encouraging environment.
Listen well. Paying attention to the parents' and child's concerns.
Praise accurately. Providing specific and genuine praise.
Help parents appreciate their good work. Reinforcing positive parenting behaviors.
Important to:
Measure changes in the child’s stuttering. Tracking progress over time.
Accept ups and downs. Recognizing that progress may not be linear.
Brainstorm with parents how to make effective changes. Collaborative problem-solving.
Maintenance
Continue to support the family so their anxiety decreases. Ongoing support is essential.
Fade contact gradually after fluency is achieved. Weaning off therapy while ensuring continued progress.
Prepare parents for the possible return of stuttering under stress. Equipping parents to manage potential relapses.
Help the family gain confidence in their problem-solving skills. Empowering the family to handle future challenges.
RESTART-DCM (Demands and Capacities Model)
Primary tenet is to reduce demands/stressors:
Motoric. Reducing physical demands related to speech.
Linguistic. Simplifying language complexity.
Cognitive. Reducing cognitive load during communication.
Emotional. Addressing emotional stressors.
Structure:
Starts with weekly parent-only coaching sessions. Provides education and support for parents.
Transitions to parent-child sessions with SLP observing to provide feedback. Allows for observation and guidance in real-time interactions.
Direct stuttering modification therapy with SLP if warranted. Addresses stuttering directly when necessary.
Desensitization and stuttering modification (easier stuttering). Helps the child become more comfortable with stuttering.
Brief, daily practice at home:
15 minutes, 5 days a week, “special time”. Consistent practice reinforces therapy gains.
Handbook available for free online. Provides a readily accessible resource for parents.
Supporting Data
Evidence that when mothers slow their speech rate, the child becomes more fluent (Stephanson-Opsal & Bernstein Ratner, 1988). Highlights the impact of parental speech rate.
Evidence that “demands and capacities” therapy is effective (Starkweather et al., 1990). Supports the use of the Demands and Capacities Model.
Evidence that when parents change interactions, the child becomes fluent (Gottwald, 2010; Guitar et al., 1992). Emphasizes the role of family interaction.
Evidence from a large study that RESTART-DCM is an effective treatment (de Sonneville et al., 2015). Provides strong support for RESTART-DCM.
Think, Pair, Share
How do the Palin Parent Child Interaction and RESTART-DCM approaches align with your understanding of demands and capacities theory? Encourages critical thinking and comparison.
Direct Approaches to Preschool Treatment
Common Factors in Direct Behavioral Approaches
Teach a slow, smooth, relaxed pattern of speech by modeling (parents and/or child).
Progress from one- or two-word utterances to complex sentences and conversational speech. Gradually increasing complexity.
Reducing communicative stressors. Minimizing environmental pressures.
Parent counseling.
Clinician assisted problem-solving. Collaborative approach to addressing challenges.
Some direct fluency work depending on the child and approach. Tailoring the approach to the individual child.
Therapy: Lidcombe Program
Ages: Preschool and School-age (ideally age 4-10). Effective for a range of ages.
Delivery: Parent-delivered. Parents play a central role in treatment.
Based on operant conditioning principles. Uses positive reinforcement to shape behavior.
Ratio of praises:correction (5:1). Emphasis on positive feedback.
Phases:
Begin with structured sessions (10–15 minutes/day at first). Start with short, focused sessions.
Reduce language level (word). Simplifying linguistic demands.
Feedback specific to speech: “smooth talking,” “oops a little bumpy”. Clear and direct feedback.
Parental Behaviors During Lidcombe Treatment
Fluent Speech: Praise, Acknowledge, Request the child's evaluation
Stuttering (SLDS): Acknowledge, Request self-correction
Lidcombe (cont.)
Move quickly to unstructured feedback throughout the day.
Helps generalize fluency gains across situations. Promotes generalization of skills.
Feedback is less predictable. Keeps the child engaged.
Data collection:
SR = Severity Ratings (daily from home, weekly in clinic). Tracks progress over time.
Scale:
1 = no stuttering
10 = most severe stuttering can imagine
Newest scale goes from 0-9 (Packman et al., 2011; Onslow, Packman, & Harrison, 2003).
Lidcombe Stages
Two Stages:
Stage 1: Achieve consistent near-zero stuttering
Weekly or biweekly 1-hour sessions
Median number of sessions at UVM = 17 sessions (Miller & Guitar, 2009)
Median number of sessions in Sydney clinic = 16 sessions (Rousseau et al., 2007)
Stage 2: Maintenance (~1 year)
½-hour sessions at 2, 2, 4, 4, 8, 8, 16 week intervals
Wean off parent-delivered feedback
Parents flexibly deliver contingencies in the event of a spike
Return to Stage 1 if not meeting criteria in two consecutive sessions
Lidcombe Feedback Examples
Stutter-Free Speech:
Acknowledge: "That was smooth."
Praise: "Great smooth speaking!"
Request Evaluation: "Was that smooth?"
Stuttered Speech:
Acknowledge: "That was bumpy."
Request Correction: "Can you say that again with no bumps?"
Resources/Info
Training: www.lidcombeprogram.org
UVM Coaching: Lidcombe listserv
Meet weekly or every other week
Maintain email contact over breaks
Parent support group at UVM
Facebook: www/facebook.com/lidcombe.program/
Lidcombe Program Evidence Base
(Jones et al., 2006)- randomized controlled trial.
(Miller and Guitar, 2009).
(Guitar et al., 2015).
LP works best with children older than 3.5 years.
Dr. Guitar suggests that LP not be used with children who have a very sensitive temperament Use a more indirect approach with these children.
Cheryl Gottwald’s Approach
A “multidimensional” approach:
Based on demands and capacities model.
Parent counseling and education to change home environment.
Helps the child change feelings and attitudes.
Modifying the Child’s Speech
Teaches the child to talk in a slow, relaxed way (“turtle talk”) in a fluency-enhancing setting.
For those children who continue to stutter, SLP teaches “bouncy” and “stretchy” speech.
Child plays games that reward stuttering and stuttering on purpose to change feelings and attitudes about speech.
May help stutters become easier and looser.
Stuttering Therapy Resources (STR)
Nina Reardon and Scott Yaruss
Uses a mixture of parent and child education, manipulating demands and environments, and direct stuttering modification.
Summary Sheet 5J: Limiting Verbal Competition
What is it? Reducing time pressure due to interruptions, competition for talking time, and feeling a need to rush into conversations.
When to use it? As much as reasonable, but sometimes impossible.
How to do it?
Establish family rules like "We don't interrupt when someone else is talking."
Highlight interruptions: "Oops, I am talking right now. Your turn will come up in just a moment."
Use reminder charts.
Use a token like a "talking stick".
What's in it for my child? Reduces desire to rush communication.
Examples:
"Oops, my turn for talking."
"Sorry Jenny, it's Michael's talking time. Your turn is next."
Hold up an index finger.
What else do I need to know? Everyone in the family should follow the same rules.
Resilience and Self-Regulation
The Curtin Early Childhood Stuttering Resilience Program (Druker et al., 2019; 2020).
Based on DCM.
Parent-led resilience training.
Weekly consult with SLPs.
Delivered with direct fluency training (1 hour a week, similar to Lidcombe).
May be particularly helpful for children with co-occurring ADHD and/or other self-regulation challenges.
Example Activity for Each Area Targeted in the Resilience Program.
| Area |
Example Activity |
| :------------------------------------------------------------------------------------------------------------------------------- |
:------------------------------------------------------------------------------------------------------------------------------- |
|
|
| 1 Independence |
Child to dress him/herself every morning |
| 2 Problem Solving |
If a favourite toy gets stuck underneath a table, encourage the child to brainstorm how to retrieve it |
| 3 Responsibility |
Set daily chores e.g. make own bed and help set the dinner table |
| 4 Problem Ownership |
Acknowledge behaviour is problematic and apologise to parent/sibling/friend e.g. shouting at parent |
| 5 Firm limits and boundaries |
Consistent parent response to child's behaviour, time out for unacceptable behaviours such as physical violence |
| 6 Social Graces |
Child is encouraged to wait until parent is finished talking or say "excuse me" (online fluency benefit) |
| 7 Parent encouragement |
If a child is making a puzzle, provide encouragement: "you seem so proud of what you have made" vs. praise: "you're so clever" |
| 8 Parent self-nurturing |
Parent given "permission" to take 30 minutes of time out during the day e.g. listen to music while children play in another room |
Choosing a Treatment Approach
Palin Parent Child Interaction:
Reduces frequency and the impact of stuttering for both parent and child (Matthew et al., 1998; Millard et al., 2009; another in press).
Head-to-head comparisons of LP versus RESTART DCM:
Both considered efficacious.
nearly identical before and after treatment for both programs.
At 18 months post-treatment, approximately equal proportion of children had recovered (LP: 76\%, DCM: 70\%) (de Sonneville et al., 2015).
Keep in mind 75\%-80\% spontaneous recovery!
Consider the importance of clinician-guided, daily parent–child play sessions ((Bloodstein et al., 2021).
Goals of a Family-Focused Treatment Approach
Effective Communication
Improved Fluency
Healthy Communication Attitudes
Easy Talking Model
Increased Pause Time
Reduced Demands
Reflecting/Rephrasing
Components:
Parent Focus:
Understanding Stuttering
Identifying Stressors
Healthy Communication
Accepting Stuttering
Child Focus:
Understanding Speaking
Understanding Stuttering
Desensitization (as necessary)
Speech Modification
Stuttering Modification
Communication Skills
Treatment of any co-existing disorders
General Tips for All Parents
Low pressure
Reduce interruptions and cross-talk at home (siblings)
Speech rate
Pause time
Avoid “slow down” or “take a deep breath”
Listen to what they are saying rather than how
Make eye contact - “I’m listening”
Monitor avoidance behavior
Stuttering is ok
Parent support group
Spero Video
NURTURING and EMPOWERING your CHILD WHO STUTTERS.
Strategies for Teachers
Control pace of classroom
Severity Ratings
Watch for avoidance behavior
Teasing
Oral presentations
Good listening (not interrupting, let finish)
Acceptance and speaking openly about stuttering
Free Resources for Teachers: Stuttering Foundation
Treating Atypical Stuttering
Often co-diagnosis of autism or ADHD
Examples:
What – at – at
Dog – g – g
Bath_room (intake of breath)
Word final or medial stutters
Noticing Games (Sisskin & Wasilus, 2014)
Tics / Tourette Syndrome
UVM Tic clinic:
80\% natural recovery
Don’t draw attention to it – monitor
Tourette Syndrome
Both motor tics and vocal tics are present, although not necessarily at the same time
Tics occur several times a day, nearly every day or intermittently, for more than a year
Tics begin before age 18
Tics aren't caused by medications, other substances or another medical condition
Tics must change over time in location, frequency, type, complexity or severity
Treatment
child learns to recognize ‘urge’
competing response (replace tic with a voluntary behavior)
Assignment 3 & 4
Prebrief
Let’s practice!
Try:
Prolongations: IIIIIIII need to go home.
Rep