News: Pro Bono Therapy Block at Dalhousie University
Each year as part of the 3rd year Fluency Disorders course in the SLP program at Dalhousie, a pro bono block of therapy is offered to an adult or child who stutters. We are currently accepting referrals or expressions of interest for the fall 2023 spot.
The course takes place during the fall term. Sessions would be in person at the Sir Charles Tupper Medical Building at least once a week but ideally twice a week. Sessions with adolescents and adults can also be held virtually using Zoom Healthcare. SLP students in the third year of their graduate studies observe therapy and occasionally participate in the sessions. The time and day of sessions is worked out based on the schedules of those involved. Interested clients are assessed to determine candidacy.
If you are interested or aware of a person who would be interested in this opportunity, please contact Pamela Coulter at email@example.com for more information.
Stuttering in Early Childhood
Many preschoolers go through periods with stuttering and/or speech disfluencies. Stuttering is different than "normal disfluency". Normal disfluencies include behaviours such as repeating a whole word ("many, many"), using "fillers" such as "um", or restarting a sentence ("I'm gonna...Watch me run!"). These types of disfluencies are a normal part of language development and still occur occasionally in adulthood.
Stuttering involves difficulty starting or a repetition of motor movements. Stuttering can be repetitions of whole words or parts of words ("D-D-D-Danny" or "my-my-my-my"). It could also involve prolonged sounds ("mmmmm-mom"), or blocks where a word won't come out ("gimme.........that"). Stuttering can also involve muscle tension and frustration.
Stuttering most often starts between the ages of 2 and 4 years and is experienced by about 5% of children. When stuttering begins at age 2-3 years, about 80% of children will naturally recover without intervention and 20% will persist (Yairi & Ambrose, 2005). The most predictive factors to help us estimate risk of persistence at this age are a family history of stuttering, and stuttering that does not improve during the first year after onset (Yairi & Ambrose, 1999).
When onset and/or diagnosis doesn't occur until 4-5 years, about 60% will naturally recover and 40% persist (Walsh et al., 2020). While we cannot predict at onset which children will naturally recover and which will not, speech-language pathologists (SLPs) are able to determine relative risk based on a number of factors.
During the initial assessment, an SLP measures and analyzes aspects of a child's speech and stuttering behaviours, classifies the types of disfluencies exhibited, makes visual observations during the child's speech production, takes a detailed case history, and identifies the presence of risk factors. Based on this information, the SLP can make recommendations about whether a child is likely to be exhibiting normal disfluencies, whether they should be monitored and reassessed within a few months, or if treatment should be started.
It is never too early to speak with an SLP about your concerns. Below is a checklist of factors that may mean a child is more likely to experience persistent stuttering. If you check 'yes' to any of the items below, it is recommended that you consult with an SLP.
Risk factors for persistent stuttering:
there is a family history of stuttering***
the child is male
the stuttering has not improved or has gotten worse within a year after onset***
more severe stuttering at onset (if starts at age 4-5y; severity is not predictive when it starts at age 2-3y)
age: if 2-3y at onset and when identified, more likely to naturally resolve (~80%) ; if 4-5y when diagnosed, less likely to naturally resolve (~60%)
There are two overarching methods to treating early stuttering in the preschool years. The indirect method (aka 'parent training') aims to increase a child's capacity for fluent speech and reduce the demands placed on their speech system. This is achieved through the adults in the child's life and may include things like reducing time pressure, eliminating interrupting, and pausing before speaking. It's important to understand that guardians do not cause stuttering if they don't happen to already be doing these things. Rather, we leverage the role of the child's guardian(s) to create the type of environment that we've learned helps children who stutter. There are various approaches and programs within the indirect method such as the Family-Focused Approach (Dr. J. Scott Yaruss and his colleagues), RESTART-DCM, and Palin Parent-Child Interaction Therapy.
Treatment typically starts with the indirect method. If a child continues to stutter, then direct treatment may be layered on. Even if a child requires direct treatment, the environmental changes made by their guardian(s) during the initial indirect phase are still very important. With the direct method, the child's SLP helps them to change their speech so that they can learn to speak fluently and develop positive attitudes about their skills as a competent communicator. If the child has started to develop secondary behaviours (e.g., looking away or physical tension when stuttering) or negative emotional reactions to stuttering, this will also be addressed during treatment. There are a number of approaches and programs within the direct method, including the Lidcombe Program, fluency shaping techniques, and stuttering modification techniques.
Parents often ask how long treatment will take. As with many types of communication intervention, young children who stutter are quite variable in how much treatment they will require. Parent training usually requires 6-8 sessions but may take less time for some families. For 2/3 of young children, stuttering will be eliminated after this phase of treatment. If a child then requires direct treatment, the length of treatment can vary from a few sessions to up to a year (Yaruss, 2006). When using the Lidcombe Program behavioural approach, Phase 1 may take up to 28 sessions (typically weekly), although the median number of sessions required is 15 (Packman et al., 2014). Phase 2 takes one year (frequency of sessions is reduced).
School-age children who stutter may have been stuttering for many years or just begun. Stuttering at this age is very unlikely to naturally resolve - treatment will be required if the goal of the child and their guardian(s) is to achieve fluent speech.
Stuttering episodes may not just be repetitions of sounds (e.g., "P-p-p-pokemon"). Children may also experience blocks in which they cannot initiate speech movements or they become stuck in a fixed position (e.g., "-----Pokemon"). They may also have prolongations in which they cannot end a sound (e.g., "Pooookemon").
School-age children may also experience unpleasant emotional reactions to stuttering (e.g., frustration, embarrassment, shame),and negative thoughts about their speaking (e.g., "I can't say my name," or "I'm a bad talker," or "People will make fun of me."). They may have started avoiding speaking situations (e.g., avoiding introducing themselves, raising their hand in class), specific words, or not saying what they actually want (e.g., "I want the pi-pi-pi-pi....the green book."). It's important to note that not all children have these reactions to stuttering. For those who do, it's essential to address them and help the child develop positive attitudes about themselves as competent communicators.
School-age children who stutter may also have 'secondary behaviours/characteristics' that emerge as their bodies attempt to get speech moving forward again. These behaviours may include physical muscle tension in the facial muscles and voice box, trouble coordinating their breath with their voice, closing their eyes or looking away, grimacing, repeating part of their sentence before the stuttered word or using filler words ("um, um, um"). All of these behaviours actually make it more likely for the child to stutter, unfortunately. Elimination of these behaviours are a part of treatment.
During assessment, the SLP will gather information about these behaviours, reactions to stuttering, the conditions that make the child more or less fluent, and what their goals for therapy are.
Treatment is completely individualized to the client. Depending on the needs of the child and their family, treatment may include:
modification of the environment (e.g., eliminating interrupting during family conversation, addressing bullying at school)
eliminating secondary behaviours
addressing feelings and thoughts about stuttering
eliminating avoidance behaviours
achieving optimal speech fluency
There are numerous treatment approaches and protocols. Depending on the client these may include one or a combination of the following:
fluency shaping techniques
stuttering modification techniques
other direct approaches such as Extended Length of Utterance (ELU) or Gradual Increase in Length and Complexity of Utterance (GILCU)
Resources and Links
"Stuttering: For Kids, By Kids"
from The Stuttering Foundation
"The Age Factor in Stuttering"
by E. Yairi
Canadian Stuttering Association
"Top 3 Things When Meeting Someone who Stutters"
"When I Stutter" Documentary
References on this Page
Packman, A., Onslow, M., Webber, M., Harrison, E., Arnott, S., Bridgman, K., . . . Lloyd, W. (2014). The Lidcombe Program treatment guide. Retrieved from http://www.lidcombeprogram.org/wp-content/uploads/2015/04/Lidcombe-Program-Treatment-Guide-March-2014.pdf
Walsh, B., Bostian, A., Tichenor, S. E., Brown, B., & Weber, C. (2020). Characteristics of 4- and 5-year-old children who stutter and their relationship to stuttering persistence and recovery. Journal of Speech, Language, and Hearing Research, 63, 2555-2566. https://doi.org/10.1044/2020_JSLHR-19-00395
Yairi, E., & Ambrose, N. (1999). Early childhood stuttering I: Persistency and recovery rates. Journal of Speech, Language, and Hearing Research, 42, 1097-1112. doi: 10.1044/jslhr.4205.1097
Yairi, E., & Ambrose, N. (2005). Early childhood stuttering. Austin: Pro-Ed, Inc.
Yaruss, J. S., Coleman, C., & Hammer, D. (2006). Treating preschool children who stutter: Description and preliminary evaluation of a family-focused treatment approach. Language, Speech, and Hearing Services in Schools, 37, 118-36. https://doi.org/10.1044/0161-1461(2006/014)