17/08/2021

Week 5
SPHY304 Fluency
Disorders Across
the Lifespan

Dr Michelle Donaghy

5a
Stuttering at School

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What do you need to know?

• The ‘in-between’ years: variability in
cognitive, social and physical
development
• Stuttering impact in the school years
• What teachers know about stuttering
• The therapeutic relationship:
considerations
• Treatment research for school age
children who stutter
• Problem solving and clinical decision
making

Variability: physical, cognitive, social and emotional growth

Around 6 years SCHOOL AGE Around 18 years

• Concrete thought • Abstract thought

• Dependant • Independent
• Mastery goals • Performance goals
• Conform to adults • Conform to peers
• Physical Self-Concept • Psychological
• Physical Immaturity Self- Concept
• Physical Maturity

(Sigelman & Rider, 2018) 4

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Impact of stuttering
• Negative evaluation and awareness starts in
preschool (Langevin et al, 2009; Ezrati-Vinacour et al, ) and
continues to increase at school (Daniels et al, 2012;
Flynn & Louis, 2011)
• Increased risk social phobia, fear of negative
evaluation and anxiety disorder (Iverach, et al., 2016)
• Reduced opportunities in education and vocation
(Daniels et al, 2012; Davis et al, 2002; O’Brian et al, 2011)
• Vulnerability increases from school entry and
continues to increase (Smith et al., 2015; Gunn et al., 2014,
Mulcahy et al, 2008)
• Treatment outcomes more variable

Considerations:
The Therapeutic Relationship
 Child – Therapist – (Parent) relationship
(Bordin, 1979)
 Shared goals
 Agreement on methods
 Agreement on means
 Agreement on tasks for treatment
 An emotional bond

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Considerations:
Education & Treatment expectations
• Education
✓Cause
✓Epidemiology
✓Intervention
• Treatment is not a cure
✓What is a reasonable outcome?
✓How long to treat?
✓What are the goals for treatment?
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Considerations: Measurement
 Measurement of treatment effects in a variety of linguistic,
environmental and social contexts
 Measure Severity (SR0-9/SEV0-8), level of naturalness/fluency
technique used (NAT/FT) (%SS?)
 Measure for QoL outcomes in academic and social contexts
 Monitor for progress
 Monitor to determine effectiveness of Tx
 Use evidence-based practice to support reasoning

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Considerations: Generalisation

• Use conversation tasks within clinic

• When the child is ‘ready’ and is displaying low SRs,
create short term goals that generalise strategies into
everyday contexts (as chosen by the child)

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5b
What happens at
School?

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Are teachers prepared to teach SCWS??

• Student teachers, and experienced teachers make assumptions,
with little or no knowledge about stuttering (Matheson, Arnott & Donaghy,
2018; Panico et al., 2018)

• Sensitive to CWS, hold stereotyped views, are misinformed (Abdalla &

St Louis, 2012)

• Strategies for teachers have been explored, but not empirically

tested (Davidow, Zaroogian & Garcia-Barrerab, 2016)
• 4 hours teacher training increased knowledge, but unhelpful
attitudes remained (Silva et al., 2016)

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Are teachers prepared to teach SCWS??

• Reduced access to speech pathologists (varies by state)

• No formal training about stuttering in education courses
• Teachers would like to know more (Jenkins, 2010)
• Personal experiences
• Second-hand advice/knowledge

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Are our teachers prepared to teach SCWS??

Primary School (6 – 12 years)
• Class teacher may be the only advocate
• Learning Support teacher/Teacher’s assistant may
help
• Transition to High School

High School (11 – 18 years)

• Many teachers, many students = less opportunity
to know students
• Year Advisor/Counsellor/Welfare team - key
contacts

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Are our teachers prepared to teach SCWS??

Ensure learning outcomes are assessed
and reported
• Teachers assess ‘Speaking’
“the development of skills and techniques
to demonstrate understanding through
fluent, coherent, cohesive speech” (ACARA, 2018)
• How do teachers describe what they see
without a diagnosis?
Duty of Care
• Protect child from harm
• Build resilience, minimise avoidance

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School Age and Adolescent Stuttering

Teacher = learning expert

SLP = speech expert
Parent = home expert
Child = self expert
Discuss with the child and parent for consent to contact
his/her teacher (primary) or the Year Advisor (secondary)

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Speech Pathologists: Working with Teachers

In consultation with the child & family:
✓ Provide a summary/report following assessment that
includes needs as identified by the child
✓ Work with individual teachers
✓ Provide Professional Development
✓ Purpose: to increase teacher knowledge about
stuttering

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What is important for Teachers to Know?

✓ What stuttering is – and what it isn’t! SO they can identify

‘comfortably’
✓ Prognosis once a child reaches school age
✓ Child is vulnerable to bullying (Daniels et al, 2012)
✓ Can affect education and vocational choices (O’Brian et al., 2011)
✓ Educating other students can change attitudes (Flynn & St. Louis,
2011)

✓ BUT – Disclosure is the choice of the CWS

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Stuttering and Curriculum Requirements

NSW DET Bullying Prevention

Bullying is repeated verbal, physical, social or psychological behaviour that
is harmful and involves the misuse of power by an individual or group
towards one or more persons.
….Preventing and responding to bullying behaviour in learning and working
environments is a shared responsibility of all departmental staff, students,
parents, caregivers and members of the wider school community.
https://www.det.nsw.edu.au/policies/student_serv/discipline/bullying/PD20100415.shtml

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Bullying Prevention
Year 4 – English The Australian Curriculum

“They fluently read texts that include varied sentence structures, unfamiliar
vocabulary including multisyllabic words…..
….They make presentations and contribute actively to class and group discussions,
varying language according to context…..
…Use interaction skills….. and a range of vocal effects such as tone, pace, pitch
and volume to speak clearly and coherently…..”

http://www.australiancurriculum.edu.au/english/curriculum/f-10?layout=1

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Duty of Care
Victorian DET
• Classroom programs that clearly establish the educational purpose ……and
additional support that is available for students who may need assistance.
• Whole-school programs that support quality relationships between people, for
example bystander training, ……….school-wide positive behaviour support.
• Professional learning programs for teachers to develop and refresh skills to
collaboratively create and maintain safe, respectful, caring and supportive
school cultures.
https://www2.education.vic.gov.au/pal/bullying-prevention-response/policy

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What can Teachers Do?

✓Identify the child who avoids or has difficulty
responding verbally
✓Talk to the child
✓Talk to the parent

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What can Teachers Do?

✓Monitor peer reactions and bullying

https://education.nsw.gov.au/student-wellbeing/attendance-behaviour-and-engagement/anti-bullying

✓Contact a Speech Pathologist for further advice

✓Educate other teachers

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The lived experience: School Years and Supports

• SAY: Australia supports young people who stutter (8-18 years) using the arts and
creative expression (University of Melbourne) www.sayaustralia.org.au

Movie ‘My Beautiful Stutter’ American CWS, ages 9 to 18, meet other children who stutter at an
interactive arts-based program, The Stuttering Association for the Young, (SAY) New York City.
Michelle Donaghy PhD 2019

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School Aged Stuttering

Treatment:
The Evidence Part I
Lidcombe, Westmead
and Oakville Programs
for School Aged Children
who stutter

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Treatment efficacy for SCWS in Australia

6 Years 18 Years

Speech Restructuring
Lidcombe Program Time Out/SITO (Camperdown Program)

Syllable Timed Speech

(Westmead & Oakville Programs)

Other: Comprehensive Speech Program, GILCU/ELU, Palin Centre

NOTE: No randomised control trials

(read Brignell et al., 2021; Donaghy & Smith, 2016; Nippold & Packman, 2012)
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Treatment efficacy for SCWS in Australia

Lidcombe Program for School Age Children

PROSPECTIVE: 11 children; 7-12 yrs, 80% reduction in %SS pre/post

Lincoln, Onslow, Lewis, and Wilson, 1996

RETROSPECTIVE: 12 children; 6-10 yrs, 81% reduction in %SS pre/post

Koushik, Shenker, and Onslow, 2009

SINGLE CASE STUDY: 1 child; 8;11, 12 clinic visits, no stuttering at end Stage 2
Bakhtiar and Packman, 2009

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LP – School Age

• Many preschool studies

• LP can be done by Telehealth (Bridgman et al, 2016; Lewis et al,
2008) but not specifically tested for school age population
What is it?
• It’s not for preschoolers!!
• Teach the child and the parent
• Age appropriate verbal contingencies (possibly negotiated with
child)

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LP– School Age

• What is it?
• Parent or Child to do severity ratings
• Treatment may take longer than preschool
children (tractability)
• Consider benchmarks
• Class teachers should never be expected to treat!

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LP – School Age

When to use for school age clients…..

• Either no prior treatment history OR positive
outcomes from previous treatment with LP
• If increase in stutter-free speech after a trial
period

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LP – School Age

PROS
• Simple
• School Age Child has an awareness
• Easily adapted
• Able to be done by webcam/telehealth

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LP – School Age
CONS
• Relies on parent/other
• Parents may have difficulty attending visits if
during school time
• Child may not like it
• Tractability issues may influence outcomes

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Treatment efficacy for SCWS in Australia

Syllable Timed Speech - School Age
• Variants/AKA: Westmead Program, Oakville Program, “Robot
Talk”, "Clock Talking”
• Direct
• Many small studies from the 60s, 70s & 80s – ages 11 – 44
years

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Syllable Timed Speech - School Age

What is it?
• Children and parents trained to use STS in
conversation
• Natural sounding STS
• Parents also used verbal contingencies in response to
stutter-free and stuttered speech, and praise for STS
(Andrews et al, 2016)
• Child is prompted to use
• 5-10 mins, 4-6 times per day
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Treatment efficacy for SCWS in Australia

Syllable Timed Speech – School Age
Phase I (Westmead): 10 children, 6-11 yrs, 7/10 responded to Tx, mean
54% reduction in stuttering, variability notable
Andrews, O’Brian, Harrison, Onslow, Packman, & Menzies, 2012

Phase II (STS with contingencies): 22 children, 6-11 yrs, 19 completed Stage 1, 77%
reduction in %SS at 12months post Tx (82% with 2 outliers removed)
Quality of life measure = change from moderate to mild-moderate
• 11 children showed reduced avoidance (but some still avoided situations rather than
control stuttering)
• 18 were more satisfied with fluency
• Indication that inclusion of verbal contingencies was helpful (=Oakville Program)
Andrews, O’Brian, Onslow, Packman, & Menzies, Lowe, 2016

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Syllable Timed Speech - School Age

What is it?
Let’s hear a clinician explain it to a school age child!
• https://www.youtube.com/watch?v=V6KCupih4rI&feature=youtu.be

With many thanks to Dr Simone Arnott and friend

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STS – School Age

PROS
• Simple, straightforward
• Stutter-free speech occurs if done properly
• No resources required
• There is a guide and resources for both
Westmead AND Oakville Programs (2021!)
• Can be useful as a strategy

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STS – School Age

CONS
• Requires a lot of daily practice
• Child may not like talking rhythmically
• Still requires parent/other
• Advice is to find a mentor/extra professional
development
*Articles also provide short descriptions of treatment
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STS – School Age:

What does it look like in practice?

https://youtu.be/4jgXerHQfmg

Can you think of other activities you might use in an STS Clinic session?
Think about this for your exam!

With many thanks to Dr Simone Arnott and friend

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STS – Westmead and Oakville Programs

• Andrews et al. (2016) found that older children benefited from the
use of verbal contingencies for stuttering (once severity had reduced)
• Oakville Program is Westmead Program + verbal contingencies
• The ASRC website at UTS contains the following resources for both Tx:
✓Westmead and Oakville Program treatment guides
✓STS exemplars/training model
✓Stuttering Treatment Activity guide
✓SR chart

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School Aged Stuttering

Treatment:
The Evidence Part II
Time Out/SITO,
Camperdown Program,
GILCU, Other...

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Treatment efficacy for SCWS in Australia

Self-Imposed Time Out (SITO)
• Direct
• Non-programmed
• Measurement using Severity Ratings
• Clinician can signal Time Out;
OR
• Client can monitor - Self Imposed Time Out (SITO)
Let’s hear how clinician explains it to a client!
https://youtu.be/zrR1OAkIoyw
With many thanks to Dr Simone Arnott and friend

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Treatment efficacy for SCWS in Australia

Self-Imposed Time Out (SITO)
PHASE I, n = 4: 2 completed, 9 & 14 year old, 3%SS or below post
treatment
Ryan & Van Kirk Ryan, 1983

PHASE I, n = 3: 8 – 13 year olds, 2/3 clinically significant reduction in

stuttering using TO
Onslow et al., 1997

PHASE II, n = 4 adolescents: 2 completed, aged 14 and 17, 68.5% and

27.6% reduction in %SS respectively
Hewat, Onslow, Packman and O'Brian, 2006

Adult literature eg Hewat et al (2001); James et al (1989); Franklin et al (2008)

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Time Out/ SITO How do you do it?

• Start with easier tasks
• Trouble shoot/goal directions discussed for
beyond clinic use
• Can use verbal or non-verbal signals in TO
• Pause/break can vary in duration depending
on need

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Time Out

When to use?
• Older child or adolescent not responding to other
treatment
• When the child prefers feedback from parent on own
terms
• Relapse from previous treatment
• Not appropriate for children with a more severe stutter
Watch a bit of SITO!
https://youtu.be/FWYjvSNolok

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Time Out
PROS
◦ Simple to use for a response contingent
treatment
◦ Child can use treatment independently
◦ Can be used in general conversation
◦ Can be used strategically

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Time Out
CONS
◦ Child may not like being told when they
stutter, by SP or parent, if so - stop
◦ May not work if stuttering severity high
◦ Child needs to be able to self-monitor

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Treatment efficacy for SCWS in Australia

Camperdown Program (More next week)

PHASE I, n = 3; 13 years (50% reduction),14 years (increase in stuttering),

16 years old (1%SS reduction)
Hearne, Packman, Onslow and O’Brian, 2008

TELEPRACTICE, Phase I, n= 3, 13, 15 & 16 years, 12 months follow up –

significant reductions in %SS and SRs
Carey, O’Brian, Onslow, Packman & Menzies, 2012

TELEPRACTICE, Phase II, n = 16, 12-17 years, group mean 68% reduction
in %SS (range 0% - 96.6%), significant increase in speech satisfaction
Carey, O’Brian, Lowe and Onslow, 2014

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OTHER strategies?
Fluency Skills see Guitar (2019)for detailed descriptions:
‘easy onsets’;
‘light contacts’
‘flexible rate’ ?using STS as a strategy
‘pausing’ ?using TO as a strategy

Think about how & when these strategies might be useful for
children at school?
Read Chapter 13, Guitar (2019) and complete the task in the
LEO Book Chapter this week..

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GILCU/ELU
Gradual Increase in Length and Complexity of Utterance –
GILCU (Ryan & Ryan, 1983,1995)

Extended Length of Utterance - ELU (Costello, 1983, 2004)

• School age, therapy used in schools in USA
• Highly programmed – 54 steps
• Establishment, transfer, maintenance
• Enhancements = parent management, sibling participation, Rx
in different settings

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GILCU/ELU
• Step 1 – Speak one word fluently ten times
consecutively etc
• Operant method/RCS
• Fluent speech response “Good”
• Stuttered speech “Stop, speak fluently”
• Response contingent feedback – one mistake
prevents leveling-up

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GILCU Establishment Steps

Step Stimulus Response
1 Instruct to read 1 word fluently 1 word
2 Instruction to read 2 words 2 words
fluently
3-6 Instructions to read 3-6 words 3-6 words
fluently
7-10 Instructions to read 1-4 1-4 sentences
sentences fluently
11-18 Instructions to read 30 seconds 30 seconds to 5
to 5 minutes fluently minutes of reading
19-54 Re-cycle in monologue and Monologue or
conversation conversation

(Ryan, 1974)
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ELU (Extended Length of Utterance)

PROs
 Very structured
 Progress is measured and gradual
 Can be practiced at home
CONS
 Frustrating for child if they ‘get stuck’ on a level
 Generalisation difficult
 What happens if there’s regression/++fluctuation?
 Needs parent/other

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Other Treatments for School Age

•Little/no training available in Australia = little
support/mentoring
•Evidence is mostly for Adults WS
•Treatment mechanism unknown. Is it the use of
group Tx? CBT?
•Most address social phobia/anxiety/FNE

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5d Problem Solving – School Age

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Treatment efficacy for school age stuttering

Challenges
• Parent delivered – child is at school
• Parent delivered – child may be averse to parent direction
• Treatment delivered outside child’s everyday context (school)
• Classroom teachers can’t deliver treatment
• Small n participants = ?transferable to greater population

For these (health behaviour change) complex interventions, effects are not only
produced by the intervention, but are strongly linked to context.
Tarquinio, Kivits, Minary, Coste & Alla, 2014, p44

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Treatment efficacy for school age stuttering

Challenges
• No ‘guide’ for LP, STS, SITO (LP guide is for preschool children)
• Some professional development available in Australia for Lidcombe
Program, STS and Camperdown Program
• Therapeutic treatment elements often unknown (Intensives? Follow
up?)
• ++ Variability in smaller studies ... will larger studies tell us anything
different?
“In real life, all events are produced in highly complex contexts…the outcome of a
mechanism is…dependent on the context in which it is active”
Danermark, 2003, p.116.

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Treatment efficacy for school age stuttering

Challenges
• Treatments do not allow for focus to shift to address social phobia,
anxiety, wellbeing

“Often client and service delivery factors in the real-world differ from those in
efficacy studies…”
Swift, Langevin & Clark, 2018, (p335)

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Problem Solving
Problem 1:

It has been 5 weeks post treatment, but there has been no reduction
in stuttering.
What could be wrong? What do you need to check?

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Problem Solving
Investigate…..

✓Is practice happening daily?

✓If not, why? Brainstorm possible solutions
✓Check consistency and validity of SRs, ‘calibrate’ within the session
✓How does the child feel about therapy?

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Problem Solving
Investigate…..
✓How does the child react to the parent administering therapy?
✓Is treatment being administered correctly? Always observe……!

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Problem Solving
Investigate….
✓Is this treatment inappropriate because..
-The child thinks it’s ‘babyish’
-The child is not mature enough to employ tasks
-The child is not aware of his/her stuttering enough to do independent tasks
-The child doesn’t like the sound of the fluency technique
-The child’s stuttering severity is too high for the therapy chosen

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Problem Solving
Problem 2:

Over the last few weeks, there has been little progress and the child
has become quiet and reticent to contribute in therapy.
What should I do?

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Problem Solving
Investigate:
Are issues of anxiety evident?
✓Ask the child if there is anything they want to talk about that is
bothering them
✓Ask the parent if they have any concerns
✓Consider disclosure responsibilities if you are working without a
parent

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Problem Solving
Investigate:
✓Ask the child how they really feel about treatment
✓Ask the child how they feel about school. Are they being bullied?
✓Determine whether or not the child is at risk – if in doubt – discuss
referral to a psychologist/counsellor

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Problem Solving
Problem 3:

Therapy has worked well for the child within and beyond clinic,
however the child has revealed that they continue to stutter in
problematic contexts and conversations.
Why won’t fluency effects generalise?

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Problem Solving
Investigate:

✓Check that the child is completely stutter-free in practice tasks

✓Do therapy tasks lack spontaneity? Are conversation tasks used in
therapy?
✓Is the treatment chosen preventing further progress to
generalisation?

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Problem Solving
Investigate:
✓Brainstorm ways that the child might be able to ‘try out’ therapy
strategies in targeted contexts
✓Create achievable generalisation goals that have a high chance of
success
✓Has the child lost motivation?

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Beneficence and Non-Maleficence*

Do good – do No Harm
• Sometimes guides and manuals don’t have all the answers
• Be aware of potential harm
• Direct Treatments can be abused by clinicians and parents
alike.
• Beware of the inherent ‘PUNISHER’
• Emphasise enjoyment
• Promote engagement
• If you use a strategy – MEASURE! To see if it is working!
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Beneficence and Non-Maleficence

• Check for functional progress
• Check for social and emotional responses to stuttering –
MEASURE this, ask the child, ask others
• Use CLINICAL REASONING – Rationales are important!
• How else is the child going to get Tx? Are you the only
option?
• Are you trained enough to treat?

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Considerations:
Treatment Choice Rationale E3BP
 Treatment efficacy
 Treatment expectations
 FUNCTIONAL & Collaborative Goals (school!)
 Individual variables of the child and family
important
External Evidence
Weighing up Evidence from
peer reviewed
Treatment evidence, research

Clinical presentation, Internal

Patient
Evidence
Client/family need The practice
context, clinical
Preference
Needs,
profile, motivation,
developmental supports,
profile measures carers
of progress
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School Age Years: What Next?

• Are clinical trials of rigid treatment appropriate research methodology for SCWS?

“Too many people view EBP as a destination rather than a process or way of
doing the work we do”
Bernstein-Ratner, 2011, p.78

• Could frameworks for clinical decision-making address the challenges faced by

all stakeholders?

“In critical realism, the world is viewed as an open system, with outside influences
interacting with the individual and the target behaviour or intervention”
Swift, Langevin & Clark, 2017, p.337

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School Age Years: What Next?

All forms of evidence are important
All scientific evidence, the stutter, the clients individual needs

Input from all stakeholders

SCWS, Carers, teachers, clinicians, researchers, lecturers

Acknowledge the diversity and variability SCWS

Treatment can never be ‘one size fits all’
We are all their advocates

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Good Treatment
Needs to be
THERAPEUTIC, ENJOYABLE, MEASURABLE,

and a SHARED EXPERIENCE

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Next week
• Prolonged speech programs: Camperdown Program, Smooth
Speech
• Goal setting for adolescents and adults
• WEEK 8 Zoom EXTRAVANGANZA is MANDATORY
attendance – we will be noting all attendees….because WE
WILL HAVE AMAZING GUESTS!! And a SPECIAL
DOCUMENTARY VIEWING!!
• If you are unable to make it owing to placement attendance,
please let your LIC know well beforehand.

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References
• Andrews, C., O’Brian, S., Harrison, E., Onslow, M., Packman, A., & Menzies, R. (2012) Syllable-Timed Speech Treatment for
School-Age Children Who Stutter: A Phase I Trial. Language, Speech and Hearing Services in Schools, 43(359-369)
• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory,
Research & Practice, 16(3), 252-260.
• Bray, M. and Kehle, T. (1996) Self-Modelling as an Intervention for Stuttering. School Psychology Review. Vol. 25 pp. 358-369
• Carey, B., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2011). Webcam delivery of the Camperdown Program for
adolescents who stutter: A Phase I trial. Manuscript submitted for publication.
• Costello Ingham, J. (1999). Behavioural Treatment of young children who stutter: An extended Length of Utterance Method. In
Curlee, R. (Ed.), Stuttering and Related Disorders of Fluency (2 nd ed.). New York: Thieme Medical Publishers Inc.
• Cream, A., O'Brian, S., Jones, M., Block, S., Harrison, E., Lincoln, M., Hewat, S., Packman, A., Menzies, R., and Onslow, M.
(2010). Randomized controlled trial of video self-modeling following speech restructuring treatment for stuttering. Journal of
Speech, Language, and Hearing Research, 53, 887–897.
• Cream, A., O'Brian, S., Onslow, M., Packman,A. and Menzies, R. (2009) Self-modelling as a relapse intervention following
speech-restructuring treatment for stuttering, International Journal of Language & Communication Disorders, 44, 587 — 599.

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References
• Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic relationships between children who stutter and their non-
stuttering classmates. Journal of Child Psychology and Psychiatry, 43, 939-947.
• Davidow, J.H., Crowe, B.T., & Bothe, A.K. (2006) “Gradual increase in Length and Complexity of Utterance” and
“Extended Length of Utterance” treatment programs for stuttering: Assessing the implications of strong but
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