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Managing Stuttering Beyond the Preschool


Years
Article in Language Speech and Hearing Services in Schools July 2012
DOI: 10.1044/0161-1461(2012/12-0035) Source: PubMed

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2 authors:
Marilyn A Nippold

Ann Packman

University of Oregon

University of Sydney

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LSHSS

Research Forum
Prologue

Managing Stuttering Beyond


the Preschool Years
Marilyn A. Nippold a and Ann Packman b

Purpose: This prologue serves to introduce a research forum


composed of studies that address the topic of stuttering in
school-age children and adolescents. Researchers are encouraged to continue to build the knowledge base that sustains
evidence-based practice in this area.
Method: The nature of stuttering as it evolves from early childhood into the school years is briefly described. Beyond the
preschool years, children are unlikely to spontaneously recover
from stuttering, and they often go on to suffer negative consequences, academically and socially, because of their disorder.
If they are to overcome or manage their stuttering successfully,
school-age children and adolescents require high-quality
treatment. Three data-based studies that address the topic of

stuttering in school-age children or adolescents are described,


the ongoing need for empirical evidence regarding the management of stuttering is emphasized, and several issues relevant
to future studies in this area are discussed.
Conclusion: Progress has occurred in the management of stuttering in school-age children and adolescents. Nevertheless,
important questions remain unanswered concerning the most
effective techniques and strategies to use in helping students
who stutter achieve more fluent and natural-sounding speech in
their quest to become more confident and effective communicators.

tuttering typically begins during the preschool years


and is often first noticed when children begin producing 2- and 3-word utterances (e.g., kitty go, kitty
run away) (Bloodstein, 1995; Reilly et al., 2009; Yairi,
Ambrose, & Niermann, 1993). Because of the overlap in
timing between the emergence of syntax and the onset of
stuttering, it is often assumed that stuttering reflects a childs
difficulties with language development (Bloodstein, 2006).
However, a far more likely explanation is that the child is
experiencing difficulty with speech production (Nippold,
2012). According to syllable initiation (SI) theory, a child
who is stuttering is having difficulty moving forward in
speech because of a compromised speech motor control
system (Packman, Code, & Onslow, 2007). Consistent
with this theory, in a study of children who stutter (CWS),

Olander, Smith, and Zelaznik (2010) argued that during the


disfluencies that characterize stuttering, the speech motor
system fails to generate and /or send the motor commands
to muscles that are necessary for fluent speech to continue
(p. 876).
Nevertheless, many young CWS spontaneously recover
from the disorder without formal treatment (Yairi, 2004).
Reports have indicated that 80% of preschool CWS eventually recover by age 5 years, but that the remaining 20%
continue to stutter beyond the preschool years (Mnsson,
2000; Yairi & Ambrose, 2005). Thus, as children move
into the school years, their stuttering is likely to persist and
to become a chronic problem (Yairi, 1999, 2004; Yairi &
Ambrose, 1999), a pattern that may be genetically determined
(Ambrose, Cox, & Yairi, 1997; Kraft & Yairi, 2012). These
research findings suggest that if school-age children and
adolescents who stutter are to overcome or successfully manage their stuttering, quality treatment from well-trained professionals is required.
In this prologue, we introduce a research forum composed
of studies that address the topic of stuttering in school-age
children and adolescents. Unfortunately, many students who
stutter do not receive treatment for their speech disorder
(Kelly et al., 1997; Nippold, 2004) and therefore struggle
on their own in their efforts to communicate effectively. This

University of Oregon, Eugene


The University of Sydney, Australia
Correspondence to Marilyn A. Nippold: nippold@uoregon.edu
Editor: Carol Scheffner Hammer
Associate Editor: Patrick Finn
Received April 15, 2012
Accepted June 6, 2012
DOI: 10.1044/0161-1461(2012/12-0035)
b

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Key Words: stuttering, school-age children, adolescents,


treatment

SCHOOLS Vol. 43 338343 July 2012 * American Speech-Language-Hearing Association

situation stems from a combination of factors, including


overly large caseloads in public schools (Kelly et al., 1997;
Nippold, 2004) and the fact that many speech-language pathologists (SLPs) lack confidence, experience, and clinical
training in stuttering (Kelly et al., 1997). Additionally, there
is a dearth of evidence-based interventions for stuttering in
school-age children and adolescents (Nippold, 2011).
Thus, the purpose of this forum is to provide clinically
relevant information for SLPs who are practicing in public
schools today. We take the position that stuttering in schoolage children and adolescents should be treated directly by
the SLP, and that the SLP needs to know how to assist the
child or adolescent to speak more fluently (for discussion,
see Allen, 2012). In addition to the fact that school-age
children and adolescents are not likely to spontaneously
recover from stuttering, another justification for providing
direct treatment is the personal cost of the disorder to the
individual. Charles Van Riperan influential scholar and
clinician in our profession and a person who stuttered his
entire lifeargued eloquently that the ability to speak
freely without the fear of stuttering is a fundamental human
right (Van Riper, 1972).
We concur with this perspective, which is also consistent
with the position of the American Speech-Language-Hearing
Association (ASHA). According to ASHA (2010), the treatment of stuttering in school-age children and adolescents
is the responsibility of the school-based SLP, who is also
required to assist students to achieve their educational goals.
In schools today, there are many situations where stuttering
can seriously interfere with students academic success, as
when they are expected to give oral reports or formal speeches,
answer questions in class, read aloud, contribute to group
discussions, or participate on debate teams. Students who
are unable to manage their stuttering during these common
activities are at a major disadvantage. They also pay a substantial price socially, with research indicating that school-age
children and adolescents who stutter, compared to their normally fluent peers, are more likely to be rejected, bullied, and
viewed as less popular by their classmates (Davis, Howell,
& Cooke, 2002). Hence, it is also within the SLPs purview
to attempt to reduce the likelihood of these social penalties.

The Research Forum


The three articles in this research forum are empirical
investigations. In the first article, Langevin and Narasimha
Prasad (2012) examine the feasibility of a stuttering education and bullying awareness and prevention program for
school-age children in Grades 3 through 6. As the authors
explain, teasing and bullying in the schools today is a pervasive problem, and CWS are often the victims of it because
of their difficulties with communication. Unfortunately,
teasing and bullying can have serious consequences for
CWS, including loss of self-confidence, social withdrawal,
embarrassment, frustration, depression, and increased

stuttering. Thus, Langevin and Narasimha Prasads program, which is delivered by the classroom teacher, was
designed to increase students knowledge of the nature
of stuttering; the communicative, social, and emotional
difficulties experienced by CWS; and ways to minimize
teasing and bullying of classmates who stutter. The results
of the study indicate that the program was successful in
improving students knowledge and attitudes about CWS
and about teasing and bullying in general. Thus, the article provides helpful information on how the school-based
SLP can collaborate with classroom teachers to improve the
school environment for CWS. The article also makes an
important contribution by attending to some of the broader
implications of stuttering. To expand the findings, future
studies of this program are needed and should involve large
numbers of participants randomly assigned to treatment
versus control groups.
The next article, by Andrews et al. (2012), describes a
Phase I clinical trial of a syllable-timed speech (STS) treatment for school-age CWS. A Phase I trial is a preliminary
study of a treatment approach that involves a small number
of participants (Onslow, Jones, OBrian, Menzies, & Packman,
2008). As the authors emphasize, it is critical that school-age
children learn techniques to manage their stuttering because
of the many social penalties they face, including teasing and
bullying. With STS, the child is taught to speak in a manner that
places approximately equal stress on each syllable in a sentence
(e.g., My-dogs-name-is-Bar-ney. Hes-thir-teen-years-old.),
using near normal speech rates and intonation. Described as
a simple technique that is easy to teach and learn, STS is
taught to the child and parent in the clinic and is practiced
by the child during daily conversations with the parent. Although it has been known for centuries that stuttering decreases markedly with rhythmic speech, SI theory suggests
that the mechanism underpinning this effect is a decrease
in the variability of syllabic stress. According to SI theory,
this variability triggers stuttering (Packman et al., 2007).
Revisiting the use of STS with school-age children was
prompted by this theoretical explanation of the rhythm
effect.
Results of the Andrews et al. (2012) study indicate that
STS is potentially a promising treatment method for schoolage CWS, but future research is necessary to determine ways
to enhance its effectiveness through modifications. For example, Andrews et al. suggest that STS may be improved
by incorporating a more systematic reward system for using
the technique and by providing greater feedback to the child
for producing stuttered versus stutter-free speech. Practicing and using the technique in difficult speaking situations
such as oral reports (with the support of the SLP) may help
CWS participate more fully in the classroom.
The third and final article in the research forum is by
Carey, OBrian, Onslow, Packman, and Menzies (2012),
who conducted a Phase I trial of the Camperdown Program
for adolescents who stutter. In the Camperdown Program, the
Nippold & Packman: Prologue

339

client learns to produce stutter-free speech by using a speech


restructuring technique called prolonged speech. This involves speaking slowly, stretching out the words by lengthening the vowels, and gradually learning to use the technique
with a faster speech rate and more natural-sounding intonation. The Camperdown Program has traditionally been
taught in a clinic setting. However, a unique aspect of the
study in this forum is that the treatment was delivered via
Internet technology, with the adolescent working at home
using a webcam with Skype to allow the SLP and adolescent to see and hear each other. Considered an adolescentfriendly approach, this setup was designed to improve
motivation and compliance, increase accessibility and
efficiency, and reduce economic barriers such as travel
expenses and lost income when parents must take time off
from work to transport their adolescent to a clinic. The
results of the study were positive in terms of reducing the
amount and severity of stuttering. Additionally, adolescents commented that the treatment was helpful, they were
comfortable using Internet technology, and they preferred
webcam delivery over clinic visits. Future studies that
attempt to replicate the findings with large numbers of
participants are necessary.

The Need for Empirical Evidence Continues


Although the treatment of stuttering in preschool children
is frequently addressed in the research literature, the same
cannot be said for school-age children and adolescents. For
example, there have been no Phase III trials of either direct or
associated treatments for stuttering in these age groups, a
Phase III trial being one where efficacy is determined by
comparing a treatment to a no-treatment control group or
to another treatment (see Onslow et al., 2008). By direct
treatments, we are referring to treatments that aim to decrease
the severity/frequency of stuttering behaviors; by associated
treatments, we are referring to treatments that address the
negative effects of stuttering on a childs everyday functioning,
including reactions such as shame, anxiety, and avoidance.
Unfortunately, these negative reactions can be heightened
by bullying, teasing, and mocking by peers (Blood, Boyle,
Blood, & Nalesnik, 2010).
In this era of evidence-based practice, school-based SLPs
are searching for objective guidance from research indicating what techniques are most beneficial in helping students
to overcome or effectively manage their stuttering. For example, in working with a school-age child who stutters, an
SLP may seek to assist the student to achieve more fluent and
natural-sounding speech in a variety of daily situations by
reducing the frequency of core behaviors, including repetitions, prolongations, and blocks. Techniques that are often
recommended to achieve greater fluency in school-age children include the use of easy onset, slowed rate, light articulatory contacts, and general relaxation, as well as the insertion
of brief pauses between phrases (e.g., Gregory, 1991; Guitar,

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2006; Justice, 2010; Ramig & Dodge, 2005). Although these


techniques may help individual children, especially when
they are taught by experienced SLPs, it is important that
our scientific journals continue to publish data-based
studies to support and guide the clinical decision-making
process.
Relevant to this discussion is the concept of levels of
evidence. These range from observational studies that do not
employ control groups, the lowest level, to meta-analyses
of high-quality studies that have employed randomized
controlled trials (RCTs), the highest level (Robey, 2004).
Systematic reviews of RCTs are also an excellent source
of best evidence (Ingham, 2003). Thus, to reach the highest levels of evidence, it is necessary that a series of welldesigned RCTs be conducted. Upon searching the scientific
journals, however, SLPs find there is a shortage of empirical studies examining the effectiveness of these and other
techniques to treat stuttering in school-age children (Ingham,
2003; Nippold, 2011; Onslow et al., 2008). Unfortunately,
this shortage was also identified in a detailed systematic
review that encompassed 35 years (19702005) of published studies in the treatment of stuttering (Bothe, Davidow,
Bramlett, & Ingham, 2006). Consequently, without a solid
knowledge base grounded in empirical research, the schoolbased SLP will make decisions about stuttering management
based on the opinion of experts in the field rather than on
the results of well-designed studies. Therefore, with respect
to the management of stuttering in school-age children and
adolescents, it is essential that clinical researchers undertake
high-quality studies that involve RCTs in order to evaluate the
efficacy of various approaches that are frequently recommended for the treatment of stuttering. Information that can
be helpful in designing treatment efficacy research is available
in Dollaghan (2007) and in Schiavetti, Metz, and Orlikoff
(2011). Moreover, when these studies are in the design phase,
several additional issues should be considered.

Issues for Future Research


A primary goal of managing stuttering in school-age
children and adolescents is to assist these clients to speak
more fluently in a wide range of settings, with confidence,
independence, and self-reliance. Under optimal learning
conditions, children and adolescents should be able to adopt
effective and durable strategies in an efficient manner that
does not require an excessive number of treatment sessions
or prolonged dependence on the SLP.
Thus, in relation to the fluency-enhancing techniques
mentioned above, one issue to consider is the nature and
frequency of feedback. When a client is learning a new
technique such as easy onset or slowed rate, it is important
that the type and amount of feedback required to promote
optimal learning be determined. This includes the question
of how often praise or other types of positive reinforcement
should follow fluent responses as well as the question of how

SCHOOLS Vol. 43 338343 July 2012

often other types of contingencies should follow stuttered


responses. Although common sense may suggest that more
is better, there is little evidence to support this or any other
feedback formula.
A second issue to consider concerns the difficulty in
achieving transfer or generalization of fluency-enhancing
techniques to situations beyond the treatment room and the
long-term maintenance of fluency (Finn, 2003). Relevant
to this issue is the question of intensity. An SLP might reasonably ask if a large amount of daily practice using a technique to speak fluently in real-world situations (e.g., talking
in the classroom or on the telephone with different listeners)
is a necessary ingredient and, if it is, how much practice is
sufficient, and how one determines when a client is ready for
a certain amount of practice. It would also be reasonable to
ask if the level of intensity should differ for speakers with
different degrees of stuttering severity. In other words, if
one clients stuttering is more severe than anothers, should
treatment for that individual be more intense? Once again,
common sense suggests that it should be, but there is little
evidence from research to support such a recommendation, at
least for school-age children and adolescents.
A third issuealso related to transfer, generalization, and
maintenanceconcerns the role of self-monitoring, selfevaluation, and self-correction of stuttered versus fluent
speech (for discussion, see Ingham, Ingham, & Bothe, 2012).
It has been suggested that school-age children may be
more successful in building fluency if they are trained to
monitor, evaluate, and correct their own speech (Bothe,
Ingham, & Ingham, 2010). Notably, self-evaluation of
stuttering and speech naturalness is a critical component of
the Camperdown Program. Hence, we encourage clinical
researchers to conduct studies to measure the extent to
which teaching these behaviors can assist children to
establish and maintain fluency in diverse speaking situations, with the studies using matched participants randomly
assigned to experimental and control groups.
A fourth issue concerns the role of the school-age child
or adolescent as an active participant in the treatment process. That is, once the SLP has worked with the client to
reduce the severity of stuttering using one or more fluencyenhancing techniques, the child or adolescent must actively
implement the techniques in the classroom and in other
daily speaking situations. It can be argued that adolescents
are in a position to decide for themselves whether to use
their fluency skills in this way; however, the same cannot
be said of elementary school-age children. Using fluencyenhancing techniques requires constant attention to speech
production and can result in speech that sounds unnatural.
Hence, expecting younger students to use fluency-enhancing
techniques all the time, away from the clinic, may be viewed
as unrealistic. A qualitative study of adults who used prolonged speech (Cream, Onslow, Packman & Llewellyn,
2003) indicated that they remained apprehensive that their
stuttering would return. Although this result cannot be

extrapolated to children, it is a possibility. Further, if a child


is unable or unwilling to use a learned fluency-enhancing
technique away from the clinic, all day every day, this is
likely to lead to feelings of failure.
So what can be done to enhance the use of fluency techniques away from the clinic, at least in the classroom? Finn
(2003) suggested that transfer is enhanced by self-efficacy
and by developing self-regulation and self-responsibility.
Finn also suggested incorporating elements of the clients
real-life into the childs therapy sessions (p. 158). The latter
idea suggests that it could be helpful to limit the use of a
fluency-enhancing technique to certain situations only. For
example, children could identify those situations in which
they would like to be more fluent, and these situations could
become the target of intervention. Rather than expecting a
child to use a fluency-enhancing technique in all speaking
situations, treatment could aim to have the child use it effectively in just a few, such as reading aloud or answering
questions in class, as determined by the child. The SLP could
practice the technique with the child in the clinic and then
implement self-monitoring and problem-solving procedures
with the child to establish the efficacy of the intervention. We
suggest that the STS procedure trialed by Andrews et al.
(2012) may be a suitable fluency-enhancing technique for
achieving this. It is thought that STS reduces stuttering and
makes talking easier for CWS by reducing the variability of
word stress (Packman et al., 2007). Moreover, children learn
STS very quickly, and it does not involve attention to
segmental aspects of spoken language. Treatment efficacy
studies are necessary to evaluate the overall success and
practicality of this approach.
Finally, the role of counseling in conjunction with the
direct teaching of fluency-enhancing techniques must be
examined closely. When clients suffer teasing, mocking,
bullying, and other forms of peer rejection because of their
stuttering, it is critical that teachers, parents, and SLPs work
together to prevent this type of destructive behavior, and that
qualified adults be available to counsel children and adolescents regarding the negative emotions they can experience
related to their stuttering. It has also been suggested that
school-age CWS may benefit from counseling sessions where
they learn how to respond to negative peer behaviors and
gain insight into their own attitudes about speaking and
stuttering (Murphy, Yaruss, & Quesal, 2007a, 2007b). Given
the seriousness of these issues, well-designed treatment studies that involve large numbers of participants should be
conducted to measure the impact of counseling techniques
on clients success in speaking fluently during social interactions, their attitudes about communication, and their
progress in building fluency in their daily lives.
It is clear that our field has come a long way since the
early days of the profession when little was known about
the nature and management of stuttering in children and
adolescents. But it is also clear that we must continue to
make progress in this important area by working together to
Nippold & Packman: Prologue

341

build the knowledge base that sustains evidence-based practice. Our clients are counting on us.

Ingham, J. C. (2003). Evidence-based treatment of stuttering:


I. Definition and application. Journal of Fluency Disorders,
28, 197207.

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Nippold & Packman: Prologue

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Managing Stuttering Beyond the Preschool Years


Marilyn A. Nippold, and Ann Packman
Lang Speech Hear Serv Sch 2012;43;338-343
DOI: 10.1044/0161-1461(2012/12-0035)

This information is current as of July 30, 2012


This article, along with updated information and services, is
located on the World Wide Web at:
http://lshss.asha.org/cgi/content/full/43/3/338

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