1. family and parenting
2. children

Strategies for Treating Elementary
School-Age Children Who Stutter:
An Integrative Approach
E. Charles Healey
Lisa A. Scott
University of Nebraska-Lincoln, Lincoln
clinician working in the public schools can
play a significant role in helping children
manage their fluency problems, particularly
in the early stages of the disorder. Yet, research by
Mallard, Gardner, and Downey (1988) showed that only
24% of the school-based speech-language pathologists with
a master's degree have confidence in their ability to treat
this disorder. Approximately 60% of school-based clinicians
with a master's degree reported that they "need direction"
in developing and implementing treatment programs for
children who stutter.
Even though this survey was conducted 5 years ago, we
would speculate that many clinicians continue to lack
confidence in treating this disorder and seek additional
guidance in planning and implementing programs for
children who stutter. This is in light of the new requirements by the American Speech-Language-Hearing Association, which do not dictate a specific number of clinical
ABSTRACT: The speech-language pathologist plays a
critical role in the treatment of the elementary schoolage child who stutters. The purpose of this article is to
describe a model of service delivery for these children
that emphasizes the integration of fluency-shaping and
stuttering modification approaches. Procedures and
techniques of previously published programs are supplemented with suggestions by the present authors. The
treatment program is divided into three phases. Phase I is
a description of procedures used to have the child
understand and identify fluency and stuttering. Phase II
involves a discussion of techniques for the instruction
and integration of fluency-shaping and stuttering modification procedures. In Phase Ill, transfer and maintenance
of speech improvement procedures are described briefly.
KEY WORDS: stuttering, children, treatment, elementary
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS * VOI.
26
clock hours in the area of fluency disorders. It is possible
that a professional entering the field in the next few years
will have minimal training in treating children who stutter.
In addition to the limited training or lack of confidence
clinicians have in treating stuttering in children, it is
possible that they have limited access to a variety of
clinical methods and materials. Thus, the seemingly best
alternative is to resort to using one approach, strategy, or
program for all children who stutter. Although one program
or approach may be appropriate for some children who
stutter, it is sure to fail with others. When these children
fail to improve in treatment, clinicians begin to question
their methods, the program, and/or the child's motivation
for making improvements in the way he or she talks.
The purpose of this article is to provide the school
clinician with suggested strategies and procedures that
could facilitate the treatment of elementary school-age
children who stutter. For this article, we will focus on
children who are between the ages of 6:0 and 12:0
(years:months) (i.e., grades K-6). An attempt has been
made to show the similarities among treatment programs in
terms of techniques that facilitate improvement in the
child's speech behavior. It is recognized that each child's
fluency disorder is unique and may require a different
approach to the problem. The strategies and procedures
discussed in this article represent an integration of ideas
and approaches.
Changes in a treatment approach may be necessary
depending on the age and circumstances surrounding the
disorder. For example, the nature, focus, and pace of
therapy for a child in first grade will be distinctively
different from that for a child in the fifth grade. A first
grader usually will not display a great deal of fear,
embarrassment, or avoidance behavior about stuttering. By
contrast, the fifth- or sixth-grade child usually has developed fears and avoidance behaviors as well as a negative
attitude toward therapy. Therefore, efforts directed toward
0161-1461/95/2602-0151
American Speech-Language-Hearing Association
151
improving or enhancing the fluency skills of upper elementary-grade children may prove unproductive unless time is
spent in exploring and modifying the child's feelings,
beliefs, and attitudes about stuttering.
With the older elementary child, any treatment session
can represent an opportunity for the child to feel accepted
and understood. The school clinician may be the only
person, or certainly one of a very few, in the child's life
who takes the time to listen to his or her message rather
than the quality of the fluency. In that sense, the school
clinician represents the sympathetic ear the child may not
find elsewhere. In no sense should a clinician view this
form of therapy as a "waste of time." Providing a place
where children can confront their stuttering and communicate freely is beneficial in the long term. Clinicians
should be active and compassionate listeners when the
need arises.
* It is logical to assume that a plan for therapy }will
evolve from data collected during the evaluation.
However, if the evaluation is conducted to assess solely
whether the child qualifies for services, then the data
available for planning treatment may be incomplete.
When this is the case, an assessment and in-depth
analysis of certain aspects of the fluency problem may
need to be explored in the initial stages of therapy.
Ham (1990) lists a number of factors that need to be
considered when developing a treatment plan that could
evolve from a thorough assessment. Examples of these
factors include an assessment of the form of stuttering,
the quantitative and qualitative descriptions of the
child's fluent and disfluent speech behavior, the child's
response to stress, the parent's reaction to the stuttering, and the presence of articulation and/or language
disorders that coexist with the stuttering.
* Therapy is planned according to the constraints on a
clinician's caseload size, scheduling of therapy, and the
amount of parent involvement. It should be recognized
PRINCIPLES UNDERLYING THERAPY FOR
SCHOOL-AGE STUTTERERS
that the best therapy plan may have limited effectiveness if too many constraints are placed on the delivery
of services or there is a lack of support from the
parents. In a companion article in this issue, Ramig
and Bennett address these issues as they relate to
treatment programs for school-age children.
There are several principles that form the foundation of
treatment with school-age children who stutter. Below is a
description of eight principles that we believe are important
for clinicians to consider when treating this age group:
* Once scheduling and service delivery concerns have
been minimized, changes in fluency cannot occur
unless there is direct management of the problem.
* Clinicians need to be flexible in the design and
implementation of a treatment program. This suggests
that the clinician needs to have a broad knowledge of
the different approaches to treatment. Not all stutterers
will "fit" into one approach or benefit from one
program. The clinician needs to fit the program to the
child rather than the child to the program.
This principle necessitates that the clinician has the
knowledge to make decisions about treatment based
on data generated from an assessment of factors that
contribute to the stuttering behavior. Those factors
should be reevaluated periodically during the course
of treatment so that changes in the program can be
made in a timely manner.
* A good working relationship needs to be established
between the child and clinician. This implies that the
clinician must take the time to know the child and his
or her interests. Strong relationships are built on trust
and respect that evolve over time. The sharing of
feelings, attitudes, and experiences will assist in
building a strong client-clinician relationship.
* It is necessary and reasonable to expect that the
elementary-age child can assume most of the responsibility of changing and managing the stuttering. Each
child should learn and display self-corrective behaviors rather than relying on the clinician for all
monitoring. In other words, each child in treatment
should be an active participant in therapy.
* The clinician also should take time to gain a better
understanding about how the child cognitively
perceives or represents events and experiences in his
or her world. The cognitive component of stuttering
therapy (i.e., conceptual knowledge and understanding
of "slow talking" and "gentle onset of voicing") is
critical to success.
* Long-term change in speaking more fluently emerges
once a feeling of control over the speech process has
been developed, positive reactions to the stuttering
have occurred, fear associated ith speech or
stuttering has been reduced, and appropriate changes
in the way one speaks have been chosen. Moreover,
"successful therapy" does not mean that the child will
exhibit 1% or less disfluency in all speaking situations. Rather, treatment has been effective if the child
communicates easily whenever and to whomever he or
she chooses (Conture & Guitar. 1993).
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LANGUAGE,
SPEECH, AND HEARING SERVICES IN SCHOOLS
APPROACHES TO TREATMENT
Treatment for school-age children who stutter has
focused on "fluency-shaping," "stuttering modification," or
an integration of the two treatment approaches. The
application of either a fluency-shaping (i.e., establishment
and operant shaping of fluency under controlled stimulus
conditions) or stuttering modification (i.e., reduction in the
severity of stuttered moments and negative emotions)
treatment approach with children who stutter is discussed at
length by Gregory (1979) and Peters and Guitar (1991).
The reader will find an excellent discussion and explanation of each treatment philosophy in both texts.
Vol. 26
April 1995
An integration of the fluency-shaping and stuttering
modification therapies relates most specifically to the
procedures suggested in this article. This is not to suggest
that the exclusive use of either fluency-shaping or stuttering modification therapies is not effective with children.
Our preference is to use whatever seems best for a child at
any given time as it relates to factors that contribute to the
fluency disorder. For example, it may be appropriate to
apply specific fluency-shaping procedures to help the child
manage the timing and coordination of respiratory,
phonatory, and articulatory movements for a fluent response. The child may lack the physiological capacity to
produce consistent fluency on command, as reflected in the
presence of abrupt onsets of phonation and jaw tremors
during a stuttering moment. The treatment program for this
child would focus on helping him or her overcome the
mistiming and temporal control of the speech mechanism
(Kent, 1984; Van Riper. 1982).
However, attending only to the physical changes necessary
for fluency and ignoring the effects of negative attitudes and
emotional responses does not seem wise. Fluency training
cannot be done without considering the child's confidence as
a speaker. The effects negative listener reactions or feelings
of anxiety have on a child's ability to maintain learned
fluency skills should be included in any treatment program.
Likewise, physiological and emotional factors are influenced
by how well the child believes he or she can manage
fluency in a given speaking situation. The confidence and
positive self-image he or she brings to a speaking situation
usually will dictate how well a child's fluency is maintained.
Some children we have treated can exhibit fluency that
sounds normal in the therapy room when emotionally-neutral
topics are discussed with the clinician. But, as soon as the
emotionality or propositionality of the message increases,
there is an immediate reduction in the child's ability to use
the fluency skills that facilitate the proper coordination of
the speech mechanism.
It also should be recognized that no treatment program
will be effective unless it takes into account the child's
cognitive skills. This refers to how a child solves problems,
conceptualizes, and assigns meaning to objects and events
(Meyers & Woodford, 1992). Children between the ages of
7 to 11 are oriented toward events in the immediate past
rather than events that happened long ago. Moreover, the
event needs to be presented in concrete rather than abstract
terms in order for comprehension to occur. Thus, children
in this age group need considerable structure and multiple
repetitions of events in order to comprehend their meaning
(Gregory, 1991). A child's failure to comprehend concepts
or techniques may be due to an insufficient number of
repetitions of an event or the clinician's failure to explain
concepts that match a child's cognitive understanding.
Finally, it is important to note that the extent to which
any treatment program is effective depends on a number of
factors such as the length of treatment, responsiveness of
the child to the program, support of the parents, and
responsibility a child shows in changing and managing the
stuttering. Most would agree that any stuttering management program involves a large investment of time because
behavioral and attitudinal changes cannot occur quickly.
Children in the school setting usually are enrolled in
treatment for at least a year, maybe longer, considering the
length of time they are treated each week. It is reasonable
to expect that the child's acquisition of new behavioral
strategies associated with talking as well as improvements
in feelings and attitudes will take a considerable length of
time. Therefore, the child, the child's parents, and the
clinician should not expect or accept short-term improvements as a valid measure of treatment effectiveness.
Due to the extended period of time children typically are
enrolled in treatment, it is tempting to define "successful"
therapy as that point in time when the child produces little,
if any, overt stuttering and/or secondary behaviors. Indeed,
a few published programs such as those by Runyan and
Runyan (1993) and Goebel (1989) have reported that a high
percentage of the children who had completed their
treatment programs showed reductions in posttreatment
stuttering and overall ratings of stuttering severity. These
results support the effectiveness of these programs in
reducing stuttering behavior and improving fluency, which
is why the components of these programs are included in
the integrative program described in this article.
Many children treated in our program have achieved
increased levels of fluency when pre- and posttreatment
stuttering frequency data are used as the criterion for
success. However. we are reluctant to base treatment
effectiveness exclusively on pre- and posttreatment fluency
data. This seems to us to be a rather narrow definition of
"success." Some children in our program have demonstrated
increased levels of fluency but were unable to achieve a
positive attitude about themselves as fluent speakers.
Approximately 20% of the children who had completed the
second phase of our treatment program showed steady
reductions in the frequency and duration of their stuttering
as well as secondary behaviors. But, despite the increased
levels of fluency, many of these children maintained fears
and negative attitudes about speaking to particular people
or in certain situations. As a result, we shifted the treatment program from fluency training to building self-esteem
and improving attitudes and perceptions about themselves
as effective communicators.
Conversely, another small number (i.e., 20%) of children
at the end of the second phase of treatment exhibited
relatively high levels of frequency of stuttering ranging
from 6 to 12%. But, they could modify their stuttering
behavior and possessed positive attitudes about themselves
and their stuttering. As a result, these children were not
hesitant to talk with anyone at anytime. Attempts to
instruct and encourage these children to achieve increased
levels of fluency were met with strong resistance and a loss
of motivation to attend treatment.
As stated earlier in this article, we support Conture and
Guitar's (1993) conclusion that treatment is successful
when the child communicates easily whenever and to
whomever he or she chooses. The small group of children
who possessed high levels of fluency but negative attitudes
about their speech might be viewed as "successfully
treated" if we used stuttering frequency data as our
criterion for success. Using Conture and Guitar's criterion
for success, these children fall short of that goal. However,
Healey & Scott
153
the small group of children who exhibited high levels of
stuttering but were willing to speak to anyone at anytime
without fear also might be considered "successful" because
of their willingness to converse with anyone under any
circumstance. We believe this positive attitude toward
talking evolved from an understanding of how and why
certain behavioral and emotional changes improved their
communication ability. For these children, fluency was not
the ultimate goal of treatment.
Regardless of which criteria are used to determine
treatment effectiveness, the assessment of therapy effects
should be done several times during the course of treatment
as well as several months following the child's termination
from therapy. A treatment program would be considered
ineffective if the child only used its procedures and
methods within the clinical setting or showed no willingness to change his or her attitudes and perceptions about
the stuttering. Thus, each child's fluency status should be
evaluated periodically from speech samples from within and
external to the clinic environment. Speech samples should
be obtained from a variety of speaking conditions with a
variety of listeners (Conture & Guitar, 1993). We should
remember, too, that the child's attitudes and perceptions of
his or her speech during and following treatment also
should be measured because these aspects of speaking are
as important as evaluating the level of fluency.
AN INTEGRATIVE TREATMENT APPROACH
From what has been said above, it should be clear that
our approach to treatment emphasizes an integration of
fluency-shaping and stuttering modification treatment
philosophies. This integrative treatment approach incorporates data-based techniques and suggestions from previously
published programs. We have supplemented the suggestions
offered by others with those we have discovered helpful in
implementing an integrative treatment approach.
The service delivery model we use is divided into three
phases. Phase I involves the identification and understanding of fluency and stuttering. Phase II focuses on the
instruction and integration of fluency-shaping and stuttering
modification procedures. Phase III is concerned with the
transfer and maintenance of speech improvement to
speaking situations outside of the clinic environment.
TREATMENT PHASE I
The goal of the first phase of the program is to have the
clinician become familiar with the child who stutters and
understand the nature of the stuttering problem. In order to
do this successfully, we first focus on establishing a good
working relationship and rapport with the child. Our intent
is to understand all we can about the child as a person.
Discussions about the stuttering will come in later sessions.
One way to establish rapport is through a discussion of
interests such as the child's favorite sports, games, movies,
and television programs. Information derived from discus-
154
sions of these topics can serve as a basis for informal
conversations with the child, fluency training activities, and
transfer activities later in the therapy program.
The next step is for the clinician to explore the degree of
the child's awareness of the fluency disorder. We support
Conture's (1990) suggestion of determining a child's
emotional and intellectual "awareness." Emotional awareness is concerned with the extent to which the child copes
with the stuttering problem on a daily basis. Intellectual
awareness deals with the degree to which the child realizes
when a stuttered moment occurs and what is experienced
during that moment. It is unusual to find an elementaryschool-age child who is not aware that he or she talked
differently from other children and who has some degree of
emotional reaction that takes place when the stuttering
occurs. The child's reactions and attitudes about stuttering
can be evaluated using the Children's Attitudes About
Talking-Revised (De Nil & Brutten, 1991).
Exploring the child's awareness of the frequency of the
stuttering is based on the notion that the child cannot
address a problem area unless it is recognized or acknowledged openly. We also want to gain an understanding of the
child's perspective on the fears and reactions that are
associated with the stuttering, For those children who are
unaware or fail to openly discuss their stuttering, it is
beneficial to establish a level of awareness and some
degree of openness regarding the stuttering before discussing the processes involved in fluent and stuttered speech.
When discussing the child's awareness of stuttering, it
may be helpful to determine how well the child perceives
moments of stuttering as imitated by the clinician. Initially,
we spend time having the children identify imitated
stuttered moments from our speech. We also have the child
recognize our imitations of secondary behaviors the child
exhibits in order to avoid or conceal the stuttering. Van
Riper (1982) advocates the use of this method as a way to
reduce the negative emotions associated with the stuttering.
Dell (1979) points out that increasing a child's awareness
of stuttering is an important stage of cognitive understanding of the differences between stuttering and fluency. It
also helps develop a common "language of stuttering"
between the clinician and child.
For some children who stutter, this activity will increase
a child's awareness of stuttering in other speakers as well
as in his or her own speech. However, during this awareness training, we have had the child say to us, "I hear you
stutter, but I don't do that when I talk." For this child. we
use audio- and videotaped segments of the child's stuttering
within a spontaneous speech segment. After a brief segment
has been recorded, we replay the segment of stuttering that
the child may have missed several times. As the child
begins to recognize the stuttered moments. we establish a
signal, such as raising the hand, when we both agree on
when a stuttered moment occurred.
The next step involves a matter-of-fact discussion and
analysis of speech behaviors associated with stuttering and
fluency. Our intent is neither to increase the child's
sensitivity to the stuttering nor engage in a detailed account
of the stuttering. Rather, we are interested in knowing how
the child feels about him or herself and the stuttering. Are
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS * Vol. 26
April 1995
there feelings of shame, embarrassment, anger, or helplessness? We also want to help the child understand the
relationship between speech fears and changes that occur in
the speech mechanism during a moment of fear or negative
self-perception. We like to emphasize that a common
normal reaction to feared situations is an increase in
muscle tension throughout the whole body. Much of that
tension is felt in the throat, tongue, and jaw musculature.
The tension felt during a feared speaking situation then is
contrasted with the reduced tension levels and calm
feelings that occur during a fluent moment.
At this point, the clinician could develop a common
language of fluency (Cooper & Cooper, 1991). The
language of fluency refers to a variety of skills such as a
slow rate, control of outward airflow during speech, easy
onset of phonation, and proper loudness that are necessary
to produce a fluent word. It is important to point out the
coordinated movements of the speech mechanism that occur
when these fluency skills are used.
In order to increase the child's cognitive awareness of
this concept, we need to take into account the age of the
child. For children in the primary grades (i.e., K-3) we use
pictures and line drawings of the speech mechanism and
describe in very simple terms the respiratory, phonatory,
and articulatory systems. For example, we have the child
feel the chest rise during inhalation and the gradual fall
that occurs as a steady flow of air is exhaled. We also have
them feel the vibrations from their own larynx while
counting or saying the days of the week with continuous
phonation. For children in the intermediate grade levels
(i.e., 4-6), we use similar drawings and pictures of the
speech mechanism as with the younger children but
supplement this discussion with videotaped segments of the
clinician imitating stuttered moments. The child then could
talk about the parts of the speech system that were
disrupted in the clinician's speech. Clinicians should not
underestimate a child's ability to analyze, observe, and
understand stuttering behaviors.
For older elementary children, we also include a description of Williams' (1979) normal talking model as a basis
for helping the child understand the processes required for
normal fluency. Children need to learn about the normal
talking process and how stuttering fits into that model.
Williams emphasized that normal talking involves the use
of the airstream and levels of tension in the speech
musculature, timing, and voicing, as well as movements
and placements of the articulators. These speech parameters
can be related to any disrupted speech process a stutterer
might exhibit. These behaviors include the use of an abrupt
onset of phonation and/or the presence of tense posturing
of the articulators during a sound prolongation.
It is important for the clinician to demonstrate and model
behaviors rather than simply talk about the relationship
between the disrupted process and changes that occur in the
normal function of the speech mechanism. Conture (1990)
described in detail some effective ways to convey meaning
about disruptions in the speech mechanism and how the
child interferes with the normal talking process. For
example, his "garden hose" analogy is useful in explaining
how the faucet resembles the function of the larynx
whereas the hose and nozzle connected to the hose represent activity of the tongue and lips. The child learns how
airflow, like water, can be turned off by the faucet (larynx),
by kinking the hose (tongue), or by closing the nozzle
(closing the lips). This and other similar analogies described in his book assist in helping the child focus on
what happens in the vocal tract during talking. Through
these analogies, the child can focus on "those things he is
doing to interfere with talking and those things he is doing
to facilitate it" (Williams, 1979, p. 254).
Once the child can describe the basic concepts taught at
this stage in a meaningful and reliable way, the clinician
can elect to go to Phase II of the treatment program. It is
important, however, to ensure that the child understands
and adequately conceptualizes the changes that need to
occur in the speech system. From this framework, the child
will have an understanding of the rationale underlying a
variety of techniques and methods designed to facilitate
fluency and/or modify stuttering.
TREATMENT PHASE II
The goal of the second phase of our treatment approach
involves instruction in the use of specific fluency-enhancing and stuttering modification procedures. We use a
variety of techniques that seem appropriate for the type of
fluency disorder each child exhibits. As mentioned above,
when teaching fluency-enhancing and stuttering modification procedures, particular attention needs to be paid to the
child's cognitive understanding of how and why certain
techniques or methods help in managing his or her fluency
disorder. However, even if the child understands how and
why a particular method helps, there is no guarantee it will
always work for the child in all speaking situations. It
does, however, provide a reason why it can work for the
child who chooses to try.
Fluency-Enhancing Techniques
The clinician has an array of methods from which to
choose to assist the child in achieving increased fluency.
There is general agreement among experts that considerable
time should be spent in building fluency skills for children
who stutter though the use of techniques that enhance
fluency (Gregory, 1991). Some of the most common
fluency-enhancing techniques include manipulation of
linguistic length and complexity, speech rate reduction,
airflow control, gentle onsets of phonation, and light
articulatory contacts. These fluency procedures form the
foundation from which other fluency management techniques are based, such as smooth transitions between
sounds, proper phrasing, and pitch/loudness control. These
procedures also allow for increased motor and linguistic
planning time needed to coordinate respiratory, phonatory,
and articulatory behaviors (Riley & Riley, 1983; Wall &
Myers, 1984). The following is a description of each
fluency-enhancing procedure along with a discussion of
ways it can be integrated into therapy.
Healey & Scott
155
Reduced linguistic length and complexity. Reductions in
utterance length and syntactic complexity have a positive
impact on the degree of fluent behavior that is exhibited
(Gaines, Runyan, & Meyers, 1991; Ratner & Sih, 1987). It
also has been shown that a short utterance can be made
more linguistically complex by increasing syntactic
complexity (Ratner & Sih, 1987). For these reasons, the
control of utterance length and complexity reflects one of
the fundamental procedures of almost any program for
children who stutter. The gradual increase in the length and
complexity of an utterance (e.g., Ryan's GILCU program,
1974) can be used exclusively to establish fluency or used
in conjunction with the training of other fluency-enhancing
techniques (Costello, 1983). Thus, linguistic length and
complexity increase as the child becomes proficient in
producing a fluent response or acquires skills needed for a
new technique.
Clinicians also can exercise control indirectly over the
length and complexity of a response by modeling a slowerthan-normal speech rate. Ratner (1992) has shown that
when mothers of young children were instructed to speak
slowly, they automatically reduced the length and syntactic
complexity of the spoken message. This effect is the same
as speaking to a person from a foreign country who is not
a proficient speaker of the English language. The message
is short, simple, and to the point. Clinicians should adopt
this type of speaking style throughout all interactions with
school-age children who stutter.
In order to facilitate fluent responses, clinicians could
begin training at the single-word level or carrier-phrase
level. For primary grade school-age children who stutter, the
use of nursery rhymes could be used to elicit fluent
responses as suggested in the Easy Does It-I (Heinze &
Johnson, 1985) treatment program. For children who have
been in treatment for an extended period of time or who are
in the upper elementary grades, we would recommend that
training begin at a linguistic level, where the child can
experience fluency or mild stuttered moments. The clinician
needs to manage the linguistic complexity of responses
during a session so that the child can maintain the length
and complexity of utterance that is expected. The child
should know what level of response is expected during the
training activity. Once reliable fluency is achieved at the
word or carrier-phrase level, the clinician can gradually shift
to short sentences, phrases, and structured conversation.
When the structured conversation level is reached, the
clinician can ask open-ended questions as in the Stocker
Probe Technique (Stocker. 1980) about common objects
(e.g., crayons, baseball, stamps). For example, the child can
be asked to tell everything he or she knows about the
object and to make up his or her own story about the
object. At the sentence and phrase response level, have the
child convey one central message about the sentence or
phrase, then add another thought.
The same procedure can be used when reading paragraph
length or short-story material. Instead of asking the child to
tell us the whole story, we break the story into small
descriptive units, then have the child retell the story with
all the units combined. Changes in the story units should
be encouraged because they may reveal increased flexibility
156
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS
of language skills. Compared to conversation, story
retelling may enhance fluency because of the reduced
length and complexity of the narrative utterances (Weiss &
Zebrowski, 1992). Narratives appear to be a useful way to
simulate the organization of thoughts and control of fluency
skills that occur with conversations outside of therapy.
Reductions in speech rate. Slowing speech rate is one of
the most common techniques used in stuttering therapy.
Because it is used so frequently as an aid to producing
fluent responses, Runyan and Runyan (1993) consider rate
control a universal (i.e., fundamental) treatment procedure
in their Fluency Rules Program. The rationale for implementing a reduced speech rate is the powerful effect it has
on facilitating the coordination of complex movements and
timing associated with respiratory, phonatory, and
articulatory activity (Perkins. 1973; Wall & Myers, 1984).
An indirect benefit associated with reduced speech rate is
a slow, relaxed conversational pace (Runyan & Runyan,
1993). We too have observed that a slower-than-normal
conversational pace tends to have a physical and emotional
calming effect. With elementary school-age children, we
have found that this calming effect is facilitated through
speech and nonspeech behaviors. Thus, the clinician needs
to use a slower-than-normal interaction style as well as a
slower-than-normal pace during the presentation of materials and activities within a treatment session. We believe it
is essential for the clinician to control the pace of the
conversation and session.
Teaching someone who stutters to reduce his or her
speech rate is not an easy task because most people, even
children, are reluctant to speak slowly. Therefore, we like
to emphasize that the use of a slowed rate of speech will
provide the child with an increased "feeling of control"
(Cooper & Cooper, 1991) over the stuttering. It is easier to
have children engage in a deliberate change in speech rate
initially, in order to understand the physical and emotional
feelings associated with talking slower than they normally
do. Once the child speaks more fluently or easily with the
slower rate, the rate should be increased gradually to
approximate normal levels.
A speech rate that is slower than normal can be taught
either by means of a programmed approach using the
delayed auditory feedback (DAF) unit (Ryan, 1974) or by
direct instruction and modeling. The DAF unit will force
the speaker to prolong all syllabic units of a word spoken
in the utterance. Other ways to reduce speech rate include
increasing pause time between words or using a combination of increased pausing and prolonged speech (Healey &
Adams, 1981). Research has shown that rate control through
prolonged speech is an effective way to control stuttering if
the resulting fluency is shaped to normal speech (Andrews,
Guitar, & Howie, 1980; Ingham. 1984). Regardless of
whether a pausing or prolonging rate control method is
taught, it is important that school-age children have a clear
understanding of how it feels to speak in this way and why
it helps them manage their stuttering problem.
When introducing, referring to, and/or modeling a rate
control method to primary grade children who stutter, it is
best to attach some meaningful term such as "turtle or
stretched speech." With older children, one could use terms
Vol. 26
April 1995
like "slow, easy speech," "slow-motion speech," or
"stretched speech." One also could couple slow talking
with slow walking (Meyers & Woodford, 1992; Runyan &
Runyan, 1993) or say the names of objects slowly as the
child slowly places objects or pictures in a container. In
addition, we have found it beneficial to discuss the
concepts underlying slow talking through the use of
semantic mapping. The semantic map helps children
organize and conceptualize how, when, where, and why rate
control is effective in increasing fluency.
Figure I is an example of a semantic map that would be
used to teach the concept of rate control. The map guides a
child through an understanding of how slow rates are
produced, what speech changes occur when a slow rate is
used, and why this manner of talking helps them gain
control over the stuttering. The child is asked to describe in
his or her own words the information under each main
category. In this way, the perception of stuttering and
fluency control emerges from the child's perspective, not
the clinician's.
Once the map is completed, it can be used as the basis
for the instruction of a slower-than-normal speech rate.
Using a single-subject design, we tested the notion that
cues from a semantic map would be as effective in
reducing speech rate as a sound-prolongation procedure. A
7-year-old male with moderate stuttering was taught two
forms of rate reduction-sound-prolongation procedures and
cues from semantic mapping. Baseline rate of speech before
sound prolongation instruction was 4.4 syllables per second.
The child's speech rate during the sound prolongation
treatment phase was 2.5 syllables per second. Following the
second baseline period, in which he spoke at a rate of 4.1
syllables per second, the child was instructed to use cues
from a semantic map to slow his rate. The child's speech
rate during this treatment phase was 2.8 syllables per
second. During a third baseline period, after all rate control
Figure 1. Semantic map for teaching concepts related to the
use of a slow speech rate.
__--A F--,
When
do you use your slow speech?
* when I start to stutter
* when I'm nervous
* when I'm excited
methods were withdrawn, the child spoke at 4.9 syllables
per second (Ellis, Healey, Dombrovskis, & Antonius, 1992).
These data show that cues from a semantic map are as
effective in teaching a slower rate of speech as the
traditional sound prolongation method.
One of the biggest problems related to using any form of
reduced speech rate is the artificial fluency that is created.
Because of this, not many children who stutter choose to
use a slow speech rate on a consistent basis. Perhaps that
is why we discovered that children do not necessarily use
or maintain the rate control method they are taught
throughout an utterance unless reminded to do so (Healey
& Scott, 1991). For example, a child who is instructed to
use prolonged speech may not exhibit that method when
attempting to reduce rate without prompting from the
clinician. For this reason, some treatment programs such as
Easy Does It-2 (Heinze & Johnson, 1987) and Shine's
(1980) approach incorporate a continuous phonation pattern
to reduce rate. Cooper and Cooper (1991) use a cartoon
character called the "Slow FIG" (slow, fluency-initiating
gesture) to represent this form of rate control. Likewise,
the computer-aided fluency establishment trainer for
children, Cafet-for-Kids (Goebel, 1989), teaches a continuous phonation pattern by creating a solid green bar in a
box on the computer screen. When the child learns to
consistently "paint" a continuous green bar on the screen, a
game can be introduced to reinforce this concept. For
example, an animated skier is shown skiing downhill in a
slow continuous fashion as long as the child does not
produce any breaks in phonation.
Another method for teaching rate control is to prolong
only the initial segments of an utterance because the initial
segment is the location of most stuttered moments. The
easy, relaxed approach with smooth movements (ERA-SM)
method, advocated by Gregory and Campbell (1988),
teaches a child to produce a slow, soft speech initiation by
stretching the first sound of the first word in an utterance.
After the first sound is stretched, the remaining words of
the phrase are produced with continuous phonation while
approximating normal rate and prosody. Pindzola's (1987)
Stuttering Intervention Program (SIP) also emphasizes
stretching the initial segment followed by a return to a
normal rate on the remaining words in the phrase. One
should note that this method of rate control incorporates a
normalization of pitch and loudness variation after the
initial segment of the utterance. Normalization of pitch and
loudness allows the child to retain the melodic aspect of
speech while controlling rate.
Regulation of airflow. This technique is useful for those
children who exhibit frequent breath holding behaviors,
audible airflow release without accompanying phonation at
the beginning of the phrase, speaking on inhalation, and/or
shallow breathing (Ham, 1990). Goebel (1989) begins her
Cafet-for-Kids fluency management program with this
procedure. Emphasis is placed on taking a full inspiratory
breath coupled with a slow exhalation of air. The program
uses a color monitor and the children are reinforced visually
for successful slow exhalation by "drawing" a green bar on
the screen. Runyan and Runyan (1993) borrow heavily from
the Cafet-for-Kids program in teaching "speech breathing."
Healey & Scott
157
Both of these programs focus on having the child breathe
in, let air out slowly, speak on the outward flow of air, and
keep air moving throughout the phrase. Cooper and
Cooper's (1991) Deep FIG character symbolizes a deep
inhalation of air before the onset of phonation.
If the child needs practice controlling the airstream, we
have found that a simple line drawing of mountains or a
playground slide provides a visual representation of a
typical inhalation/exhalation curve for speech. We like to
emphasize that children make a smooth inhalation as they
go up the mountain or slide. This is followed by an
immediate, slow, constant release of airflow as they go
down the mountain or slide. Having the child trace the
mountain or slide with his or her finger while inhaling and
exhaling provides some tactile feedback for the motor
pattern being taught. Runyan and Runyan (1993) also
suggest that the child trace a breath curve with one hand
and place the other hand on the abdominal area. At the top
of the inhalation and just before exhalation begins, the
clinician provides a gentle squeeze on the child's arm as a
signal to begin speaking. Tactile feedback of this type can
assist the child in achieving the proper timing associated
with the release of the airflow and the onset of phonation.
Repeated practice with this technique will prepare the child
for the use of a gentle onset of phonation.
Gentle onset of phonation. Many children who stutter
have difficulty initiating phonation on command. Difficulty
in initiating voicing is reflected in the presence of abrupt
onsets of phonation, glottal fry, tense pauses, and/or the
perception of audible vocal tension during fluent and
stuttered moments (Costello, 1983; Ham, 1990). Children
who exhibit any of these difficulties in phonation can
create substantial control over their fluency from this
technique alone.
There are two ways of teaching an easy onset of
phonation. The first and most common way involves a
deliberate use of the exhaled air throughout the initial onset
of phonation. We have used this method successfully with
kindergarten-age children by focusing on audible exhalation
of air like "putting an /h/ sound in front of your words."
Instructing the child to contrast between words like "hat/at"
helps the child feel and hear the difference between an
easy and normal onset of phonation. Older school-age
children have little difficulty producing easy onsets if there
is appropriate modeling of the behavior. Once the child
exhibits reliable use of this technique, the clinician should
work on normalizing phonation onsets. Elimination of the
audible use of airflow associated with the easy onset
should be done gradually so the child can learn how to use
the technique without any abnormal-sounding fluency.
The second way to teach easy onsets is to use a gradual
rise in vocal intensity at the beginning segment of a word.
This method is used in Runyan and Runyan's (1993)
program under the rule of "Start Mr. Voice Box Running
Smoothly." The Runyans point out that they shifted to this
form of easy onset instruction from the teaching of a
breathy onset because of the difficulty in eliminating the
breathy onset from the child's vocalizations. They have not
observed this difficulty with the use of the increased rise in
vocal intensity. However, in the Cafet-for-Kids program,
158
Goebel (1989) did not include the easy onset target because
of the difficulty young children had learning the technique.
Instead, Goebel focused on stretching the first syllable of
the word at normal vocal intensity. Note how similar this
method is to the ERA-SM and SIP programs described in
the reductions in speech rate section above.
Regardless of which method is used to teach an easy
onset, the clinician also should be aware that children also
will tend to reduce loudness in place of an easy onset.
Others have observed this phenomenon and have included
it as part of teaching the easy onset "rule" (Runyan &
Runyan, 1993) or developed a specific fluency gesture for
training such as Cooper and Cooper's (1991) Loud FIG.
This FIG highlights the importance of how loudness control
and variation in spontaneous speech facilitate a "feeling of
control."
Light articulatory contacts. This technique is used
frequently as a means of reducing articulatory tension that
occurs during a stuttered moment (Van Riper, 1982). It
allows the child to minimize the muscle tension needed for
articulatory contacts during an utterance. Maintaining loose
contacts reduces blockage of the airstream, which renders
proper control over phonation, lowers intra-oral pressure
during stop consonant production, and allows for smooth
transitions between sounds.
It is important to teach this concept by having the child
think of things that touch "lightly" and "softly," such as
leaves falling to the ground, a butterfly landing on a
flower, or clapping the hands lightly. Again, a semantic
map might help a child grasp this concept. Things that
touch lightly are contrasted with things that make hard
contacts such as hail, hard rain, or making a loud sound by
clapping the hands forcefully. Once this concept is understood, we shift to making light and hard contacts associated
with speech sounds. We start training with bilabial sounds,
then move to alveolar sound placements within single
words. We have the child focus on the feeling of a soft
bilabial contact for a sound like the /p/ in "paper." After
several repetitions and modeling of light contacts, a
forceful closure of the lips is demonstrated on the same
sound. We want the child to discover the difference in
feeling between a light contact and forceful tongue or lip
contact. During the forceful contact, the child is encouraged
to relax the tension of the articulatory contact gradually
and continue with the word. The use of negative practice,
which requires the child to alternate between light and hard
contacts, increases the child's awareness of the physical
difference between light and soft contacts.
Stuttering Modification Techniques
With many older elementary school-age children, it may
be necessary to couple fluency-enhancing techniques with
methods that teach the child how to modify a moment of
stuttering. Peters and Guitar (1991) suggest that school-age
children who stutter need to learn to modify residual, tense
stutterings. We too, have found that some children who
have stuttered for several years and exhibit excessive
avoidance behaviors fail to achieve success in managing
fluency exclusively through the use of fluency-enhancing
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS * Vol. 26
April 1995
procedures. Therefore, in addition to the use of fluencyenhancing skills, some children should learn how to turn a
tense stuttering moment into "easy" stuttering and cancel
the stuttering as it occurs.
Learning to stutter easily. This stuttering modification
method could be taught by following Dell's (1979) suggestion that the child learn three ways to say a word. A word
can be produced fluently, in an easy stuttered way, and
with tension and struggle. The clinician could select a
simple word like "ball" and then model a fluent production
of the word. Next, the child would be asked to listen to the
clinician's production of an easy, effortless prolongation or
repetition of the /b/sound or syllable. Finally, the clinician
says "ball" with tense blocking on the /b/ sound or
blockage of airflow and voicing during multiple-unit, part
word repetition of the /ba/ syllable. Following these
examples, the clinician and child can play a game in which
the child identifies the way the clinician produced the
word. Van Riper (1982) refers to this as the "catch me"
game in which the child points out disfluent moments from
the clinician's speech.
Once the child is comfortable with this level of monitoring, the clinician can ask the child to practice the three
ways of saying a word. We focus on helping the child learn
how to change from a tense stuttering to an easy stuttering
by producing a slow, slightly stretched articulatory movement on the remaining segments of the word. After the
child is skilled in stuttering more easily with words and
phrases, the clinician can spend time rewarding modified
stuttering during reading and spontaneous speech.
Cancellations. This is one of the key techniques of the
stuttering modification treatment approach and is an
extension of the easy stuttering technique (Peters & Guitar,
1991). It involves a cancellation or interruption of a
disfluent word followed by a second attempt at the word
using an easy stuttering. The cancellation requires the use
of a slight pause, during which time the child releases the
tension in the speech mechanism and then attempts the
word a second time. We also have suggested to some
children that after the cancellation and before the second
production of the word, they use a gentle onset of phonation or a slow stretched movement into the remaining
syllables of the word. Clinicians should make sure the child
understands that the second attempt at the word involves
changing some aspect of talking (i.e., from a tense
articulatory posture to a more relaxed posture) rather than
simply saying the word again. Returning to a discussion of
Williams' (1979) normal talking model might be appropriate when teaching this technique.
Voluntary stuttering. Another technique that is used often
as a way to reduce the embarrassment or fear of stuttering
is to have the child engage in a voluntary stutter that
involves a relaxed, easy repetition or prolongation of the
sound or syllable. This technique is used purposely during
the child's conversational speech. Peters and Guitar (1991)
suggest that this technique be used during some type of
enjoyable speaking activity such as playing a game. Dell
(1979) recommends underlining some words in a reading
passage and having the child voluntarily stutter on those
words. The child also could take the turn as teacher and
instruct the clinician how to stutter voluntarily on certain
words in a passage or while telling a story.
Each time the child shows evidence he or she has
attempted to produce an easy, relaxed repetition or prolongation, the clinician should provide verbal praise and
encouragement. This will help develop the child's confidence in using voluntary stuttering. Remind the child that
the emphasis is on feeling comfortable with using a
purposely stuttered word rather than on struggling through
a stuttered moment.
TREATMENT PHASE III
This phase of treatment involves the transfer and maintenance of skills learned in the first two phases of the
program. Ingham and Onslow (1987) indicate that "generalization and maintenance strategies should be mandatory
features of therapy" (p. 320). They also point out that most
treatment programs for children require maintenance of
performance as long as 2 years after termination from
treatment. In order for this long-term transfer and maintenance phase to be successful, the child should have made
substantial improvements in controlling stuttering and/or
effectively using certain fluency-enhancing procedures. This
phase of treatment focuses on helping the child maintain the
skills that have been learned, encouraging generalization of
speech changes from the treatment setting to realistic
speaking situations, and increasing the self-monitoring and
self-recording of performance. The clinician also should
consider training the parents to recognize changes in the
child's speech behavior that signal a return of the stuttering
(e.g., avoidance of speaking situations, developing negative
attitudes, and subtle signs of struggle behavior).
In terms of transfer, it is the clinician's responsibility to
provide opportunities for the extension of fluency skills to
settings outside of the clinic room during the establishment
of those skills. Training should involve the use of fluency
skills in settings that represent routine speaking situations
within the school (i.e., the classroom, lunch room, gym, or
playground) and home environment. We want the child to
use fluency-shaping and stuttering modification techniques
outside of the therapy room with the clinician as well as
with other communication partners. This also is a good
time to request that the child bring a friend to therapy.
Interacting with a friend in the treatment setting may help
the child feel at ease using newly acquired fluency skills
and modified stuttering strategies. The peer also can serve
as a "clinical assistant" by helping the child who stutters
monitor the use of skills necessary for effective communication outside of the therapy room.
The transfer phase also provides an opportunity for the
clinician to include speaking situations that disrupt fluency.
These situations might involve speaking with a teacher or
parent, answering questions, speaking under time pressure,
or making a telephone call. The clinician should strive to
make these situations as realistic as possible. We agree
with Conture's (1990) recommendation that there should be
considerable advance planning before the child's exposure
Healey & Scott
159
Figure 2. Semantic map related to speaking behavior in the
classroom.
to a real speaking situation. For example, the clinician
could work with the child and his or her teacher on a
subject area assignment (i.e.. social studies) for class. The
child could bring the assignment to therapy and use it as a
basis for discussion with the clinician during therapy.
Before leaving the therapy room, the child and clinician
could summarize the material and agree on the type and
amount of information that will be shared with the classroom teacher. In this way, the child has a structured
context from which to draw information but is free to
choose how the information will be conveyed. The
teacher's role is to confirm that the information is accurate
and to be an attentive listener.
Having children think through all aspects of this and other
similar speaking situations should assist them in reducing the
fear and uncertainty associated with those situations. Using
visual imagery (i.e., mentally visualizing all portions of a
speaking situation) and role-playing social interactions also
are effective at this stage of therapy. Additionally, it is
effective to use behavioral contracts that specify a fluency/
stuttering modification goal for a new speaking situation that
can be practiced outside of therapy. The contract should be
written with the child's input and contain specific tasks that
will be performed. The child is responsible for returning
these contracts and discussing the success or failure that
occurred in a particular speaking situation.
As shown previously in the second phase of the program,
semantic maps can be used at this stage to help the child
conceptualize a situation and develop strategies for dealing
with fluency disrupters. Figure 2 shows a semantic map
developed with two fifth-grade children who stutter about a
classroom speaking situation. The map was completed by
the children with direction from the clinician. Questions to
the children focused on the connections between the
internal feelings they have about the speaking situation and
how their stuttering might be managed in that situation.
Having children think through speaking situations should
assist them in being mentally prepared for that situation.
As the child maintains improved speaking skills in a
variety of situations, we also are concerned about the
maintenance of positive attitudes about talking. We have
found that some children have a good attitude about
themselves and their stuttering but continue to exhibit a
high frequency of stuttering behavior. We continue to see
the child in treatment but gradually decrease the amount of
therapy time to once per week for a month to once every 2
weeks for 2 to 3 months. These children may not be
motivated to continue with treatment because they do not
express concern about their stuttering. Yet, the less intensive schedule allows the clinician to maintain contact with
the child in order to monitor progress.
A child's relapse of fluency skills or the ability to
modify stuttered moments will usually require re-enrollment
in therapy. When this happens, we like to get input from
the parents and classroom teacher on the child's speech
performance at home and in the classroom. We explore
avoidance behaviors, factors related to the mismanagement
of the speech system, and changes in the child's life such
as death of a family member, separation or divorce of the
parents, or other social and emotional factors. Analysis of
160
LANGUAGE,
SPEECH, AND HEARING
SERVICES IN SCHOOLS
these circumstances might reveal the source of the relapse
and provide direction for subsequent treatment sessions.
CONCLUDING REMARKS
We have attempted to illustrate an integrative approach to
the treatment of stuttering in elementary school-age
children. This approach emphasizes that before a child can
learn to mentally and physically change the manner of the
stuttering, there must be an increased understanding and
knowledge of both stuttering and fluency. From this
understanding evolves an increased awareness and recognition that emotional reactions and perceptions play a major
role in how well the speech system can be controlled. Once
the child is aware of the physical and emotional factors
that perpetuate the stuttering, he or she is ready to learn a
variety of fluency-enhancing and stuttering modification
techniques. We believe that an integration of these procedures will help the child develop an improved self-concept
and acquire the ability to use an improved manner of
talking outside of the clinic environment.
Finally, the clinician needs to foster a strong working
relationship with the child so that feelings and emotions
can be shared in an atmosphere of trust and understanding.
All children should be given the opportunity to feel
accepted by the adults important to their lives, and the
school clinician has the unique opportunity to provide such
acceptance to the child who stutters.
Vol
26
April 1995
Seminars in Speech and Language, 8. 303-325.
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Received June 2, 1993
Accepted October 28, 1993
Contact author: E. Charles Healey, Department of Special
Education and Communication Disorders, University of NebraskaLincoln, 253 Barkley Memorial Center, Lincoln, NE 68583-0731.
Healey & Scott
161
Strategies for Treating Elementary School-Age Children Who Stutter: An
Integrative Approach
E. Charles Healey, and Lisa A. Scott
Lang Speech Hear Serv Sch 1995;26;151-161
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