Ch. 11: Stuttering and Other Fluency Disorders

What are the secondary behaviors of stuttering? Give an example of each.

1) Circumlocutions (I want a piece of that red sweet stuff) 2) Physical/motor actions (Excessive eye blinks, extra movements of face and arms, muscle tension) 3) Other speech behaviors (Changes in voice or articulation)

Discuss Guitar's (2014) model of staging the developmental stuttering experience for PWS.

1) Normal disfluency is observed in many typically-developing children early in their language development years. The speech characteristics include observed disfluencies occurring on less than 10% of the words produced; mild easy disfluencies; typical disfluencies. Children at this stage do not show any of the secondary behaviors seen in more advanced stuttering. It is rare for a child at this stage to notice his/her disfluencies. 2) Borderline stuttering also occurs in younger children. It is difficult to differentiate from the normal disfluency at this stage, but the distinguishing characteristics are that occurrence of disfluency is greater than 10% of words produced; the child may begin to use some of the more atypical (stuttering-like) speech disfluencies, but no struggle behaviors are observed; there may be more than two units of repetition; these children show little awareness or concern with stuttering. 3) Beginning stuttering occurs when the child's disfluencies become more stuttering-like and he or she begins to show more secondary behaviors (tension and struggle) in speech. Escape devices and starters become obvious at this stage, as do the initial signs of frustration with difficulty talking. Children at this stage show the first signs of feeling surprised or threatened (indicating awareness). 4) Intermediate stuttering is evident when the child (usually in elementary or middle school) is frankly afraid of his or her stuttering and beginning to use various methods of avoidance. It has been hypothesized that this avoidance is the result of reactions from the environment and the child's repeated negative experiences with speaking and stuttering. Children at this stage begin to show blocks in addition to repetitions and prolongations. The child can also show anticipation of stuttering and so tension before a block becomes evident. Because of experience with embarrassment or other reactions from listeners, the child may develop more complex forms of avoidance (avoiding situations completely). Fear is more prominent at this stage. 5) Advanced stuttering refers to older adolescents and adults who stutter. In some ways, this is an age difference more than a type difference, based on the other features described. Blocks continue to be obvious and the individual may show signs of tremors, as an attempt to control moments of stuttering. Repetitions and prolongations are present as well. Some individuals at this advanced stage have developed sophisticated forms of avoidance and have no obvious blocks. These individuals (sometimes called covert stutterers) may experience the same attitudes and feelings as other PWS. At this stage, emotions of fear, shame and embarrassment are strong. The PWS who has developed to this stage has very strong feelings of helplessness when he or she stutters.

What are the core behaviors of stuttering? Give an example of each.

1) Sound or syllable repetitions of greater than three iterations (I want a piece of c-c-c-candy) 2) Word repetitions of greater than three iterations (I want-want-want a piece of candy). 3) Sound/phoneme prolongations longer than 1 second ( I wwwwwwwwwwant a piece o candy) 4) Blocks lasting longer than 1 second (I want a p.........iece of candy)

How does the World Health Organization define a disability? A handicap?

A disability as defined by the World Health Organization includes the limitations on communication and struggles with speech/language/swallowing as experienced by the person. When the disability interferes with important life issues such as education, employment, interpersonal relationships, or participation in the community, it is considered a handicap.

What are the predominant traits associated with psychogenic stuttering?

A fluency disorder that is seen in patients later in development, usually in the late teens or as an adult. It is reported to emerge after a prolonged period of stress or emotional trauma. Mahr & Leith (1992) and others have described psychogenic stuttering as a form of conversion symptom. Conversion disorders are different from malingering (faking), a symptom for some secondary gain. Rather the patient's symptoms are not volitional. Additional characteristics that can help to confirm psychogenic stuttering include an absence of neurologic factors associated with onset, rapid improvement with trial therapy, resistance to change during fluency enhancing situations, and bizarre secondary behaviors

Describe the Langevin, Kully, & Ross-Harold (2009) approach to stuttering treatment for school-age children who stutter.

Addresses both attitudinal and behavioral aspects of stuttering. Uses fluency-enhancing skills, involvement of parents and family, and home practice. Deals specifically with helping the child learn to cope with teasing and bullying with specific conflict resolution approaches.

What are the feelings (emotional reactions) of stuttering?

Affective responses to stuttering by the PWS include shame, embarrassment, guilt, anger

The decision about the appropriate range of approaches for treatment of stuttering is guided by what two client characteristics?

Age and stuttering stage

Define stuttering.

An abnormally high frequency and/or duration of stoppages in the forward flow of speech. When stuttering is considered further, there are several additional defining considerations, including core stuttering behaviors and secondary behaviors.

What are some general considerations for evaluation of stuttering?

Are significant history and background information (including family history of fluency disorder) available? How does the parent or client describe the problem? Is there a fluency disorder present? If there is a fluency disorder, is it developmental stuttering or another fluency disorder (cluttering, psychogenic, neurogenic)? If it is typical stuttering, what is the developmental level? Are there any specific cultural, health, language, or psychological factors that that are of particular concern? What are the core behaviors present? Frequency of occurrence? Severity? Are there secondary behaviors present? Frequency of occurrence? Severity? What are the individuals' attitudes and feelings about communication? About stuttering? What environmental features contribute to the problem? Excessive demands on communication? Reduced capacity to support communication?

What are the core behaviors associated with stuttering?

Atypical speech disfluencies occurring at a higher frequency than typical disfluencies.

List risk factors for persisting in stuttering.

Being male, positive family history for stuttering, weak phonological abilities

Describe in detail the treatment options for school-age children who stutter (intermediate stuttering).

By the time that children who stutter are enrolled in elementary school, they are likely experiencing symptoms of struggle, including blocks, along with their repetitions and prolongations. They are also likely to be experiencing some of the attitudes and feelings that have been described. Negative experiences with communication, bullying at school and failed attempts at correcting the problem are all unfortunate, but common features of the experience of stuttering in this age group. Approaches to treatment may be focused on developing fluent speech, modifying stuttering and equipping the child for success in a variety of social and academic situations. Stuttering modification focus are traditional approaches to stuttering treatment that include a focus on reducing tension at the moment of stuttering, developing healthy communication attitudes and equipping the child who stutters for a variety of speaking situations. Approaches to tension reduction frequently include learning to describe what is happening during stuttering, relaxing the speech musculature and differentiating degrees of muscular effort/tension. Another aspect of this approach includes exploring feelings associated with stuttering, and this can be done in a number of ways. For some children, it is not easy to do this verbally, and they may benefit from drawings or other creative activities to assist with expression of these emotions. Cancellation of stuttering involves repeating a stuttered word in a more fluent way. Voluntary stuttering involves practicing one's stuttering as a method to decrease fear. These two techniques are common in speech modification approaches. As the child learns to use these modifications more reliably, practice is extended to more meaningful communication situations. Environmental focus addresses important work with teachers, parents, classmates, and other people who are important to the child. The fluency-shaping focus. In fluency-shaping approaches, the goal of the client is to replace stuttered speech with fluent speech. Many different techniques have been developed to achieve fluent speech in people who stutter. Of these, a few approaches are most often described. Rate modification, especially at the initiation of speech. Easy onset of phonation as a method of reducing hard glottal attack at speech onset. Light contact of the articulators. Continuous phonation. These techniques are often delivered through modeling in an exaggerated manner and then shaping the behavior toward a more standard production. Operant conditioning techniques are often used to help establish and generalize the speaking behavior. Once the behaviors are established in structured settings, then the "new" speaking skills are transferred to real world contexts.

Describe the client/patient/family variables, clinical variables, and environmental variables that should inform stuttering treatment decision-making.

Client/patient/family variables include age, culture, linguistic background, educational level, developmental stage of stuttering, motivation for treatment at this time. Clinical variables include developmental stuttering stage, severity, other speech-language or developmental concerns, and client/family preferences and expectations. Environmental variables include family issues or availability and setting for service delivery (school, clinic, other).

What are the predominant traits associated with cluttering?

Cluttering is a low-incidence fluency disorder that is characterized by several distinct features, including 1) Abnormally rapid and irregular rate of speech, and one or more of the following features -Excessive accompanying disfluencies that are not typical of developmental stuttering -Abnormal prosody and pausing -Excessive errors of coarticulation with more difficulty observed on multisyllabic words. Cluttering typically occurs with other disorders (e.g., articulation, language, ADHD, other learning problems). Another feature commonly describe in the literature is reduced self-awareness of the speech error in the person who clutters. This is in contrast to the particular sensitivity and self-consciousness seen in most PWS.

What are the attitudes (beliefs about oneself) of stuttering?

Cognitive response to stuttering by the PWS. Examples include "I can't talk on the telephone." "My parents are sad because I stutter." "I stutter because I am a shy, anxious person."

What are some speaking conditions (the effects) that appear to explain some of the variability observed among PWS and that can also be leveraged to improve fluency and overall communication?

Consistency effect: PWS are likely to stutter on the same words in successive speaking attempts of the same material; Anticipation effect: PWS able to predict words they are most likely to stutter. Adaptation effect: overall amount of disfluency decreases with repeated successive readings (this is also observed in rehearsed practices of a script or common conversation. PWS produce different rates of stuttering in different social environments, among different conversational partners, and in differing linguistic contexts.

What are the three characteristics that can be used to describe therapy approaches for PWS?

Degree of focus on the client or the environment (parent, teacher, etc.) This is related to the directness of the approach being taken. Degree of focus on achieving natural effortless speech and whether the method utilized is targeted at fluency shaping or stuttering modification. Degree of focus on counseling and interpersonal issues.

Describe the diagnostic approach for determining the presence of stuttering.

Determine if stuttering is present or not. Differentiate the type of fluency disorder. Obtain a careful history. If stuttering is present, describe the core and secondary behaviors, determine their severity, and understand the individual's feelings and attitudes about their stuttering and communication.

What is the most common type of fluency disorder?

Developmental stuttering

Compare and contrast developmental stuttering, cluttering, neurogenic stuttering, and psychogenic stuttering with respect to speech traits.

Developmental stuttering is associated with prolongations, repetitions, and blocks. Secondary behaviors are present. Variable fluency under different conditions. Cluttering is associated with a high frequency of disfluency, rapid and irregular speech rate. Neurogenic stuttering has few or no secondary behaviors, attempts to modify speech are less successful. Psychogenic stuttering is associated with atypical and unusual stuttering behaviors. Short-term therapy may produce a dramatic improvement.

Compare and contrast developmental stuttering, cluttering, neurogenic stuttering, and psychogenic stuttering with respect to key causal factors.

Developmental stuttering is attributed to neurophysiologic factors plus environmental conditions. Cluttering is attributed to neurologic causes. Neurogenic stuttering is attribute to stroke, TBI, tumors, and other neurologic conditions. Psychogenic stuttering disfluency develops in reaction to stressful or emotional situations or a traumatic event.

What are the four major types of fluency disorders?

Developmental stuttering, cluttering, neurogenic stuttering, psychogenic stuttering

Compare and contrast developmental stuttering, cluttering, neurogenic stuttering, and psychogenic stuttering with respect to age of onset.

Developmental stuttering: Age 2-6 years, occasionally later. Cluttering: Similar to developmental stuttering, around ages 2-6 years, that gets more notable as language and speech skills develop in school years. Neurogenic stuttering: Usually after early childhood and associated with a neurologic event or condition. Psychogenic stuttering: Usually after early childhood and more common in adolescents and adults

Compare and contrast developmental stuttering, cluttering, neurogenic stuttering, and psychogenic stuttering with respect to self-awareness.

Developmental stuttering: very aware, especially 1-2 years after onset; fear and embarrassment. Cluttering: Often (not always) unaware or not concerned. Neurogenic stuttering: Varies, less likely to be embarrassed. Psychogenic stuttering: Variable, may show exaggerated concern

What does ERA-SM stand for?

Easy relaxed approach with smooth movement

Compare and contrast escape and avoidance behaviors as secondary behaviors associated with stuttering.

Escape behaviors are attempts to stop the movement of stuttering and finish a word or sentence. Examples include eye blinks, head nods, or other motor adjustments made to 'get out' of the moment of stuttering. Avoidance behaviors are learned behaviors that are associated with the anticipation of a moment of stuttering. Thus, when an individual fears that they will stutter on a sound or a word, they may choose to substitute a different sound or word. There are many different types of avoidance.

Describe the specific attitudes and feelings that are often common to PWS.

Feelings are emotional reactions that an individual experiences in reaction to his/her stuttering. Common feelings that individuals who stutter report include shame, embarrassment, and guilt. Attitudes are beliefs that are formed over time. This cognitive component of stuttering is especially evident in older children and adults as they have more negative experience with stuttering. Negative beliefs about oneself can be acquired through a variety of experiences and are sometimes reflections of the beliefs of others in the environment.

Describe the assessment process for suspected fluency disorders for adolescents and adults.

Focused on determining the effect of stuttering on the individual's daily activities, communication, and quality of life. Additionally, degree of severity, frequency, and type of stuttering and secondary behaviors are all assessed. A number of self-assessment tools are commercially-available to assess the attitudes, avoidances, speaking goals, and other important areas for the client who stutters. In adolescents and adults, it is critical to bring in the patient's own perspective on their stuttering problem.

Describe the assessment process for suspected fluency disorders for school-age children.

Focused on the level of stuttering present, the type and severity of disfluencies (core), and secondary behaviors. By the time a child is in elementary schools, stuttering, if it exists, has been identified. Thus, careful description of the features that are most predictive of treatment needs and type is the focus of the evaluation. Identification of early risk factors and family history of stuttering should be elicited, although a child who is stuttering into the elementary school years is a candidate for treatment. In addition to the assessment of the child, it is critical to obtain a complete parent interview and also an interview with the child's teacher. In addition to appreciating the impact of the child's speech problem on his social interactions, it is essential to determine any effect on school performance. Of course, if the assessment is being completed in the school setting, the requirements are established through regulations specified by public law.

Define 'fluency' with respect to stuttering.

Forward, continuous flow of speech. A speaker who is fluent typically speaks with minimal physical or mental effort.

What are the typical types of disfluencies, seen in most speakers?

Give an example of each. Simple phrase repetitions (I want - I want a piece of candy), simple phrase revisions (I want - I need a drink of water), grammatical interjections of one iteration (I am, you know, feeling pretty tired), and non-grammatical repetitions (I am umm feeling pretty tired)

Describe the Guitar (2006) approach to stuttering treatment for school-age children who stutter.

Help the child explore his/her stuttering in terms of beliefs, core behaviors, secondary behaviors, and feelings. Build fluency skills and then master them. Desensitize to fluency disruptions. Reduce fear. Deal with bullying and teasing. Work with parents and teachers.

What does research suggest about the connection between emotion and stuttering?

In some cases, individuals who stutter may have heightened sensitivity to the environment. This observation justifies some treatment approaches that focus on reducing this sensitivity by "unlearning" feared conditions.

Describe the Gregory (2003) approach to stuttering treatment for young children who stutter.

Individual and group therapy. Program is parent and child focused. Clinician models relaxed, slow speech and gradually increases language complexity. Parent focus is on education. Therapy program lasts 8-12 months. Up to 5% of children persist with problems that require additional treatment.

Describe the assessment process for suspected fluency disorders for young/preschool children.

Initially directed at determining whether or not the child has a speech disorder (stuttering) or is exhibiting normal disfluencies. Using the developmental model, it is most likely that the child at this stage, if stuttering, will be at either the borderline or beginning level of stuttering. This is accomplished through obtaining a history, eliciting (and recording) speech samples that allow for determination of the types of disfluencies present and their frequency (per 100 words), units of repetition and prolongation, and any secondary behaviors or word avoidances. Elicitation of the speech sample by observing the parent in interaction with the child can improve reliability. With a preschool child, assessment (or at least a thorough screening) should be completed for other aspects of speech and language development.

Define 'disfluency' with respect to stuttering.

Interruptions in the forward movement, and these can be either typical (seen in all speakers) or atypical (seen primarily in people with speech disturbances). Typical disfluencies include phrase repetitions, multisyllabic word repetitions, phrase revisions, nongrammatical interjections. Atypical disfluencies are more common in people who stutter.

What are the predominant traits associated with neurogenic stuttering?

It is a form of acquired stuttering (as opposed to developmental stuttering) that is seen most commonly in adults with brain injury or neurologic diseases. Key characteristics of people with neurogenic stuttering include patient awareness (but not anxiety) about the disfluency. Disfluencies occur throughout the utterance (not just on initiation). Secondary behaviors do not occur in conjunction with moments of stuttering. Adaptation does not occur. Neurogenic stuttering is reported to be quite variable. It may develop abruptly or slowly, may resolve over time, and there are a number of reports of successful treatments with therapies similar to those used in developmental stuttering treatment.

What is the purpose of Guitar's (2014) model of developmental stuttering?

It is a guide for considering where to begin treatment. Some individuals, regardless of age, may never advance to the most serious levels. Conversely, some children with severe stuttering problems can quickly advance to the intermediate level of stuttering.

Describe in detail the treatment options available for a young child (2-5 years) with normal disfluency or beginning stuttering.

It is common for parents of young children to take note of disfluency in the speech of their children and to seek assistance. As noted earlier, most children who show disfluency at this stage will emerge as fluent speakers. Having said that, factors that increase the risk for advancing to more significant difficulties include increased stress around speech for the child or the parents. Any negative feedback to the child about speech or stuttering. Additionally, children who exhibit concomitant speech and language disorders, or a higher frequency of disfluencies (even those that are not stuttering-like) will likely benefit from assistance. Indirect treatment approaches for young children are frequently used as an approach to managing concerns about disfluencies. The primary goal of intervention at this stage is to reduce the likelihood that the child will advance to beginning or intermediate stuttering. Indirect treatment approaches include features of parent education and counseling, modeling (with the parent) and reinforcing relaxed speech, slower rates, and less linguistic complexity. The desired outcome is a reduction in the number of stuttering-like disfluencies (if present) and reduction of overall percentage of disfluent speech. Variations on this basic approach are seen in a number of established treatment approaches that have been published in the literature. Direct treatment approaches for young children are also frequently described in the literature on treatment. These more direct approaches include skills in teaching the child how to respond to disfluencies, developing the ability to demonstrate fluency skills and/or using operant methods or other feedback to reinforce fluent productions. Even in the direct approaches, it should be noted that parents are a focus of treatment along with the child who stutters. The most frequent approaches to attaining fluency in these methods are achieved through modeling natural, relaxed speech and providing adequate time for children to respond or initiate. One program in particular, the Lidcombe Program (Onslow, et al., 2003) used a RCT to demonstrate effectiveness. However, there are numerous single-subject and small-group studies that support positive outcomes when working with preschool children who stutter.

Who are covert stutterers?

PWS who have sophisticated forms of avoidance and no obvious blocks.

What does PWS stand for?

Person Who Stutters

Although there is no single theory that definitively captures the origins of stuttering, what is generally agreed-upon in the field?

Physiological and developmental predispositions (many times genetic) along with important environmental interactions appear to account for most developmental stuttering.

Describe the Kully & Langevin (1999) approach to stuttering treatment for adolescents and adults who stutter.

Program is delivered over 3-week period. Program uses fluency-shaping techniques to build initial skill. Once clients move to a normal speech rate, they learn speech modifications. Cognitive behavioral therapy is used to develop comfort in challenging situations and to reduce avoidance. Collaboration with support groups is encouraged, and follow-up with clients is maintained after the intensive program concludes.

Describe the Guitar (2006) approach to stuttering treatment for young children who stutter.

Program uses indirect treatment, family centered. Goal is to achieve spontaneous fluency. Focus is on modifying child-parent communication interaction. If child's speech worsens or there are signs of anxiety in the child, then Guitar moves to a more direct approach. No results are reported.

What are the 3 prototypical speech behaviors associated with stuttering?

Prolongations, repetitions, and blocks

Describe Guitar's (2014) theoretical model of stuttering.

Proposed that stuttering development has two main stages. The first part of the model, primary stuttering, includes the earliest developmental symptoms of stuttering (speech disfluencies). The second part of this model (secondary stuttering) includes those features (tension, struggle, escape, avoidance) that are reactions to the primary features. In this model, primary stuttering is associated with those constitutional factors that have led to the disruptions in the speech and language process. Secondary stuttering, as proposed, is associated with the individual's reactive temperament.

Where is stuttering most likely to occur during an utterance? Be specific.

Stuttering is more likely to occur upon initiation of words, phrases, and sentences. It is more likely to be found in longer, more grammatically complex utterances than in shorter ones. Stuttering occurs more on stressed syllables than unstressed.

Describe the onset, occurrence and comorbidities of developmental stuttering.

Stuttering typically emerges between the ages and 2-5 years old, with more males than females. At onset, the male to female ratio is 2:1, and by adulthood the ratio is about 5:1. About 80% of children who exhibit stuttering at an early age will recover from stuttering. As children mature, the likelihood of spontaneous recovery diminishes. Stuttering can co-occur with a variety of other communication problems (e.g., phonological disorders, language impairment) and is often seen in a number of developmental conditions (e.g., Tourette's Syndrome, Down Syndrome)

What is known about the underlying causes of developmental stuttering (e.g., biological and physical considerations)?

There is no definitive cause of stuttering. But, there are several findings that contribute to the understanding of stuttering. It is well-established that stuttering has been observed in some families. This has led to research describing these trends and specific genetic mutations have been identified to explain some familiar stuttering, but not all. Studies of twins, children who were adopted at a very early age, siblings, and family lines have all contributed to the understanding of stuttering as having some hereditary component. It is important to note that heredity is not a single likely cause in all cases of stuttering. Neurophysiology has also been studied extensively in PWS. There is evidence of increased R hemisphere activation in PWS over typical speakers. Studies using blood flow measures have demonstrated this pattern of activation and also shown tendency for increased activation of the left hemisphere when PWS become more fluent. Imaging studies have also demonstrated some physical differences between the right and left hemisphere between PWS and typical speakers. Other indicators of underlying processing differences between stutterers and nonstutterers can be seen in central auditory processing functions, reaction times to speech and nonspeech stimuli and a variety of auditory feedback measures. The development of stuttering is aligned with the development of language in young children. Given the evidence for left hemisphere differences in PWS, it is likely more than coincidental that a variety of semantic and syntactic variables can be associated with manipulation of stuttering frequency. It has also been observed that when language complexity is reduced, stuttering occurrence is also reduced.

What are the secondary behaviors associated with stuttering?

These are understood as attempts to control the core stuttering movements. They include a variety of adjustments in word choice and changes in speech and motoric behaviors. They can be classified as either escape or avoidance behaviors.

Describe in detail the treatment options for adolescents and adults who stutter (advanced stuttering).

They frequently come to the treatment experience having had previous therapy. Building a trusting relationship and allowing open discussion of thoughts and feelings about these experiences (as well as stuttering) becomes an important part of the treatment paradigm. When individuals have experienced stuttering throughout development as it has persisted to adulthood, unique treatment challenges are presented for both the client and clinician. In general, the same approaches as in intermediate stuttering are appropriate for use with the older client. The major difference is the necessity to approach the more mature individual as an adult, allowing for open discussion and reflection and developing an expectation for independent use of treatment skills outside of therapy. Regardless of which major approach is used (fluency shaping or stuttering modification or combination), there are a few unique features that are often discussed as important features of therapy with adults. These include assuring that the individual's beliefs and attitudes about stuttering are addressed as a method for reducing speaking fears and avoidance. Development of client competence in self-management of therapy, including self-measurement of change. Development of highly specific strategies for generalizing desired speech changes to situations, especially those that are self-identified as most challenging.

Describe the O'Brian, Onslow, Cream, & Packman (2003) approach to stuttering treatment for adolescents and adults who stutter.

This is the Camperdown Program. Unique program that uses a videotaped speech sample to provide a model for prolonged speech without additional fluency-shaping instruction. Clients are taught to use a 9-point self-rating scale of stuttering severity as a method for monitoring and self-management. Clients are seen in a group for 1 full day of practice and then followed individually. Results are reported as a mean pretreatment 7.9% SS to 0.4% at 12 months posttreatment.

Describe the Onslow, Packman, & Harrison (2003) approach to stuttering treatment for young children who stutter.

This is the Lidcombe Approach. The goal is to provide extensive, repeated, positive fluent speaking experiences. SLP trains the parent to reinforce fluent speech and then respond to stuttering when it occurs. Operant conditioning is used in weekly sessions, and parent learns to do daily sessions at home. Numerous outcome studies have been reported. All indicate positive results in eliminating stuttering in young children at early stages of stuttering.

Describe the Richels & Conture (2009) approach to indirect treatment for young children who stutter.

Uses family-centered, indirect treatment with separate parent and child groups. Focuses on the documented effect of increased linguistic/communicative complexity and time demands on stuttering in young children. Focuses on emotional regulation and adaptability. Measures change in stuttering-like disfluencies and overall percentage of disfluency. Models easy, simple, stress-free speech in group activities. Reports a 17% decrease overall in disfluencies and a 31% decrease in stuttering-like disfluencies.

Describe the Gregory (2003) approach to stuttering treatment for adolescents and adults who stutter.

Uses integrated approach. Includes use of relaxation plus stuttering modification and fluency shaping. Addresses attitudes and beliefs and education about stuttering. Implements a specific speaking style referred to as ERA-SM (easy relaxed approach with smooth movement) as a transition to more fluent production.

Describe the Guitar (2014) approach to stuttering treatment for adolescents and adults who stutter.

Uses many of his same principles from intermediate stuttering. Particular attention paid to fear reduction, self-understanding of stuttering by the client, and discussing stuttering openly. Replaces avoidance behaviors with approach behaviors.

Describe the Ramig & Dodge (2005) approach to stuttering treatment for school-age children who stutter.

Uses very focused resources for school-age children and teens. Supplies resources to support individual education plan development. Supplies therapy materials that can augment various approaches. Uses child-friendly materials/handouts. Resources in Spanish and English.

What types of situations worsen stuttering? What types of situations facilitate fluent speech for PWS?

Worsen stuttering: pressure around time, speaking in situations the PWS perceives as threatening or stressful, speaking on the telephone. Facilitates fluency: Singing, speaking or reading in unison, delayed auditory feedback, speaking in less stressful situations (e.g., speaking with young children or with animals)

How does the trajectory of developmental stuttering differ for young girls compared to young boys?

Young girls who stutter are more likely to demonstrate more typical fluency within 2 years, and these ratios then change to about 3:1 in early elementary school.

What is the worldwide prevalence of stuttering? What is the lifetime prevalence of stuttering?

~55 million people worldwide, about 5% during lifetime at some point