Preschool Stuttering Case Management

Overview

This lecture follows a case study of “John,” a male who stutters, from preschool through later stages, focusing on assessment, risk factors, and early clinical management, with emphasis on indirect and direct therapy for preschool children.

Preschool Case Profile: John

• John is 2 years 9 months old, in preschool, typically developing with normal speech, language, and motor milestones.
• No concerns with eating or sleeping; attends daycare some days, with maternal grandparents on others.
• Lives with parents and two older sisters; Spanish is spoken at home, English at school; he is bilingual.
• Personality: very social, easygoing; enjoys trains and playing outside.
• Parents report signs of early stuttering beginning about 7 months ago.
• Strong maternal family history: grandfather, two uncles, and one female cousin all stutter.
• Pediatrician advised “wait and see,” predicting he would likely grow out of it.

Risk Factors and Need for Assessment

• An assessment is strongly recommended for this profile; “wait and see” is not appropriate.
• Key risk factors present in John:
  • Family history of stuttering on maternal side.
  • Male gender (higher risk than female).
  • Time since onset ≥ 6 months (John = 7 months).
  • Parental concern about stuttering.
  • Early signs of stuttering vs typical disfluency.
• At this age, decisions are based on risk factors, not only on how disfluent the child is.
• Goal of assessment: differentiate early stuttering from normal disfluency and decide on need for therapy.

Major Preschool Risk Factors for Persistent Stuttering

Differential Diagnosis: Stuttering vs Typical Disfluency

• Assessment must consider more than disfluency frequency.
• Features to examine:
  • Family history of stuttering.
  • Gender and time since onset.
  • Presence or absence of other speech/language concerns.
  • Type of disfluencies:
    • Easy, whole-word repetitions vs part-word repetitions, prolongations, and blocks.
  • Presence of:
    • Physical tension (face, neck, chest).
    • Pitch or loudness changes during disfluencies.
    • Secondary behaviors (eye blinks, head nods, hand tapping).
  • Reactions:
    • Child’s awareness, frustration, negative emotions.
    • Reactions of parents, siblings, and others in the environment.
• Parent concern is especially important in very young children.
• Cannot base decisions solely on “how disfluent” the child is on a single sample.

Assessment Protocol for a Preschool Child Who Stutters

• Case history with parents (child is too young for formal interview):
  • Development and course of stuttering over time (onset, changes, plateau).
  • Health and medical history.
  • Types of stuttering behaviors observed at home.
  • Internal impact: child’s reactions, frustration, thoughts (as inferred by parents).
  • External impact: how others respond to the child’s stuttering.
• Observation and interaction:
  • First observe child interacting with parents to see typical style and comfort.
  • Then clinician interacts:
    • Start calm, relaxed, low-demand interaction to assess fluency in “ideal” conditions.
    • Gradually increase speech demands:
      • Talk faster, ask more questions, increase excitement and time pressure.
  • If child is highly disfluent even in ideal conditions, additional pressure may not be needed.
  • If interaction in clinic is not typical (quiet, shy), ask parents to video interactions at home.
• Measurement and tools:
  • Disfluency counts (e.g., percentage of words stuttered), but used as only one piece of the puzzle.
  • Note physical tension and secondary behaviors during stuttering.
  • Standardized instrument option: SSI-4 to quantify:
    • Frequency of stuttering.
    • Duration.
    • Physical concomitants (tension, secondary behaviors).
• Risk factor analysis:
  • Integrate behavioral observations, case history, and risk factors to judge severity and prognosis.
  • Evaluate how stuttering affects both child and environment for treatment planning.

Initial Assessment Results for John

• Disfluency rate (percent words stuttered, approximate):
  • 4% with clinician.
  • 8% with parents.
  • 16% with sisters.
• Types of stuttering:
  • Primarily whole-word repetitions.
  • Some prolongations.
  • Occasional slight increases in pitch and loudness.
• Physical and emotional aspects:
  • Mild physical tension, but no secondary behaviors observed.
  • Minimal awareness; stuttering not currently restricting communication.
  • Parents observe increased stuttering when:
    • John is tired.
    • He is telling a story or trying to talk over his sisters.
  • Severity has not changed over the 7 months since onset (plateau).

Interpretation of John’s Assessment Profile

• Increase in disfluency from clinician → parents → sisters:
  • Suggests more stuttering in more natural, competitive, high-demand environments.
  • With clinician (new person, low time pressure), speech appears relatively fluent.
  • With siblings, there is more competition for talking time and excitement, resulting in 16% stuttering.
• Prolongations plus pitch/loudness increases:
  • Indicate emerging tension in the speech system and attempts to push words out.
  • Suggest some level of internal awareness even if not verbally expressed.
• Mild tension but no secondary behaviors:
  • Early stage of stuttering behaviors, not yet heavily conditioned.
• Stable severity over 7 months:
  • Lack of improvement is concerning and argues against spontaneous recovery at this stage.
• Overall judgment:
  • John is considered an excellent candidate for therapy given age, risk factors, and profile.

Is John Too Young for Therapy?

• Age alone is not a barrier; therapy can be appropriate even for 2–3-year-olds.
• Decision is based on:
  • Number and strength of risk factors.
  • Pattern and stability of stuttering.
  • Impact on child and family.
• Early therapy aims to maximize the chance of a good outcome and reduce risk of persistence.

Choosing Indirect vs Direct Treatment (Preschool)

Approaches Discussed

• Indirect treatment:
  • Focuses on modifying the environment and parental behaviors.
  • Does not explicitly require the child to change speech patterns at first.
• Direct treatment:
  • Directly addresses stuttering with the child.
  • Teaches specific speech strategies and openly discusses stuttering.
• Operant / response-contingent approaches:
  • Mentioned as existing in the literature.
  • Not recommended for preschool children:
    • Do not address underlying nature of stuttering.
    • Rely on contingencies that can be problematic in this age group.

Initial Treatment Choice for John

• Start with an indirect approach for John:
  • Reasons:
    • Minimal awareness and frustration initially.
    • No urgent need to directly confront stuttering at the beginning.
    • Allows building a strong parent-education foundation.
  • Plan:
    • Use indirect therapy for a short period (about 4–6 sessions).
    • Do not stay in indirect-only therapy for extended periods (e.g., a full year) if insufficient change.
    • Be prepared to move to more direct therapy if needed.

Indirect Therapy: Goals and Strategies

• Main objectives:
  • Reduce speaking demands and time pressure on the child.
  • Modify aspects of the environment that are under parental control.
  • Educate parents about stuttering, risk factors, and realistic expectations.

Environmental and Interaction Changes

• Reduce overall speaking demand:
  • Provide more turn-taking time and space for the child to talk.
  • Avoid rapid-fire questioning and constant demands for verbal responses.
• Reduce time pressure:
  • Slow the pace of family conversations.
  • Allow the child sufficient time to respond without interruptions.
• Modify question types:
  • Change from direct, demanding questions to softer, invitational prompts:
    • From: “Tell me what you did at school today. What did you have for breakfast?”
    • To: “I wonder what you did at school today. Maybe you can tell grandma what we did on vacation.”
  • Presents opportunities rather than demands for immediate speech.

Parent Modeling Strategies

• Phrased speech with pauses:
  • Parents model slower rate by inserting brief pauses between phrases.
  • Example: short phrase, then pause, then next phrase, rather than a continuous rapid stream.
• Recasting and rephrasing:
  • Parent repeats child’s utterance using fluent, clear language and smooth speech.
  • Provides strong language and fluency models.
  • Most importantly: shows the child that their message was understood despite stuttering.
• Education about risk factors:
  • Clarify which factors can be changed (environment, interaction style) vs those that cannot (family history, gender).
  • Emphasize that family history is important but not modifiable.

Progress After Initial Indirect Therapy

• After about five sessions of indirect therapy:
  • Disfluency rates:
    • 8% with clinician (increased from 4%).
    • 6% with parents (approximately same as before).
    • 9% with sisters (decreased from 16%).
  • Changes in awareness and behavior:
    • Awareness and frustration increasing.
    • Parents report statements such as “I can’t say it.”
    • John sometimes walks away when he gets stuck, stopping communication attempts.
  • Changes in stuttering pattern:
    • Shift from mostly easy, whole-word repetitions to:
      • More part-word repetitions.
      • More frequent prolongations.
      • Occasional blocks emerging.

Interpreting These Changes

• Possible explanations for increased disfluency with clinician:
  • Child becoming more comfortable with the clinician and talking more during sessions.
  • More talking can naturally reveal more stuttering; can actually be a positive sign of comfort.
• Language development:
  • Expanding language abilities increase demands on the speech motor system.
  • A child already prone to disfluency may show more stuttering during language “bursts.”
• Concerning signs:
  • Giving up (“I can’t say it”), walking away from communication:
    • Indicate negative reactions and avoidance beginning.
  • Emergence of more prolongations and blocks:
    • Suggest more advanced stuttering behavior and increased tension.

Treatment Implication

• Indirect therapy alone is no longer sufficient.
• This is the point to:
  • Keep indirect strategies as a foundation.
  • Add a more direct therapy approach to address emerging awareness and tension.

Transition to Direct Therapy

• Rationale:
  • Child is now more aware, occasionally frustrated, and showing more advanced stuttering behaviors.
  • Indirect-only therapy is not achieving desired goals.
• Important clinical stance:
  • Do not be afraid to talk about stuttering directly, even with very young children.
  • However, match language to child’s cognitive-developmental level.

Talking About Stuttering with Young Children

• Use developmentally appropriate terms:
  • Older preschoolers (5–6 years):
    • Can usually understand and use “stuttering” as a label.
  • Younger children (2–3 years):
    • May not grasp abstract term “stuttering”; use more concrete terms such as “bumpy speech.”
• Goals of discussion:
  • Normalize stuttering as something that can happen; “It is okay to have bumpy speech.”
  • Increase child’s awareness in a non-threatening, playful way.
  • Build vocabulary so the child can recognize when speech is bumpy vs smooth.
  • Provide a base for later strategy teaching; strategies depend on knowing what stuttering is and when it occurs.

Examples of Direct Therapy Content for John

Fast vs Slow Speech (Turtle vs Rabbit)

• Teach rate control through concrete metaphors:
  • “Turtle talk”:
    • Slow, with pauses between phrases.
    • Calm and steady.
  • “Rabbit talk”:
    • Very fast, continuous speech with few pauses.
• Activities:
  • Playfully contrast turtle and rabbit speech in therapy tasks.
  • Help the child experience and hear the difference between slow and fast speech.
• Key point:
  • Instead of just telling the child “slow down,” clinician teaches what “slow” actually sounds and feels like.

Easy Starts

• Concept:
  • “Easy starts” mean beginning sentences or phrases gently, with low tension.
• Implementation:
  • Model starting phrases softly, then continuing in the child’s usual speech.
  • Practice easy, gentle onsets in play and conversation.
• Benefit:
  • Provides a concrete, positive behavior (“start easy”) instead of an abstract instruction.

Hard Bumps vs Easy Bumps

• Distinguish two types of “bumpy speech”:
  • Hard bumps:
    • Have a lot of tension, struggle, and possible secondary behaviors.
  • Easy bumps:
    • Disfluencies without strong tension or visible struggle.
• In session:
  • When child produces a tense stutter, clinician might say:
    • “That was a really hard bump. Let’s try that again and make the bumps nice and easy.”
  • The goal is not “try again without stuttering,” but “try again with easier bumps.”
• Clinical message:
  • Stuttering is not “bad” or a failure.
  • Reducing struggle and tension makes speaking easier and more rewarding.
  • Child still may stutter, but with more control and less internal effort.

Addressing Bilingualism in John’s Case

• Bilingual profile:
  • Spanish at home; English at school.
  • Family may worry that bilingualism causes or worsens stuttering.

Bilingualism and Stuttering

• Bilingualism is not a cause of stuttering:
  • Does not make a child start stuttering.
  • Genetic and other factors play a much larger role.
• Typical pattern for bilingual children who stutter:
  • Early stage of second-language learning:
    • Child may be surprisingly fluent in second language:
      • Uses mostly single words.
      • Limited sentence length and complexity.
  • As second language develops:
    • Longer, more complex utterances increase linguistic load.
    • Stuttering may increase in the second language.
    • Eventually, disfluency levels can match or exceed those in the first language.

Clinical Advice About Bilingualism

• Do not recommend limiting the child to one language:
  • Doing so may:
    • Distance child from family culture and community.
    • Hinder development of second-language skills.
  • There is no evidence that this improves fluency in the first language.
• If a child is going to stutter, they are likely to stutter across both languages.
• Demand and capacities perspective:
  • Bilingualism adds cognitive and linguistic load.
  • This can contribute to increased disfluency in already susceptible children.
  • It does not cause the underlying disorder.

Language Mixing Consideration

• Caution about frequent code-switching mid-sentence:
  • Avoid habitually starting a sentence in one language and finishing in another.
  • Different languages have different syntactic structures; mixing in the middle:
    • Increases cognitive-linguistic load.
    • Creates a hybrid structure that matches neither language.
  • Better to model complete sentences in one language at a time when possible.

Addressing Concern About “Imitating” Stuttering

• Family context:
  • John spends time with maternal grandparents; grandfather stutters.
  • Cousin who stutters is sometimes present.
  • Family may fear John is copying their stuttering.
• Clinical response:
  • Emphasize role of genetics:
    • Genetic influence is far stronger than any imitation effect.
  • Children are exposed to many speakers:
    • They hear hundreds of fluent speakers.
    • It is unlikely they uniquely imitate the one person who stutters.
  • Stuttering is not typically acquired by copying; it reflects underlying predisposition.
• Communication strategy:
  • Gently shift family away from imitation-based explanations.
  • Focus on hereditary contributions and individual speech system differences.

Explaining Fluctuation in Stuttering Severity

• Parents may observe that:
  • Stuttering seems worse after therapy.
  • Severity differs across listeners and days.
• Key explanations for fluctuation:
  • Variation is a hallmark of stuttering, especially at early ages.
  • Developmental change:
    • Motor, language, and cognitive systems change rapidly in young children.
    • These changes naturally produce variability in fluency.
  • Speaking comfort and talking amount:
    • As children become more comfortable with a clinician, they talk more.
    • More speech provides more opportunities for stuttering to appear.
  • Non-linear progress:
    • Therapy progress rarely shows a smooth, linear decrease in disfluency.
    • Expect ups and downs (peaks and valleys) even with effective treatment.

Clinical Caution About Using Disfluency Counts

• Disfluency counts alone are not reliable as sole indicators of:
  • Need for therapy.
  • Progress in therapy.
• Example:
  • A child could stutter 5% on Monday, 10% on Wednesday, 2% on Friday.
  • Variation may reflect normal fluctuations, not genuine regression or improvement.
• Counts must be interpreted in context of:
  • Speaking demands.
  • Child’s comfort and participation.
  • Risk factors and emotional impact.

Therapy Format and Activities for Preschoolers

• Treatment with very young children is primarily play-based:
  • Avoid rigid, table-top drill approaches.
  • Integrate goals into games and play that the child enjoys.
• Typical therapy structure:
  • At session start, ask child what game or activity they want to do.
  • Follow their lead in choosing toys or games.
  • Embed speech and fluency goals into chosen activities.

Using Games in Therapy

• Example games mentioned:
  • Cranium Cariboo:
    • Often used by speech-language pathologists with young clients.
  • What’s in Ned’s Head:
    • Another fun, engaging game for preschoolers.
• Practical tips:
  • Use commercially available toys and games instead of always creating new materials.
  • Focus clinician effort on:
    • Adapting goals and strategies to fit the chosen activity.
    • Supporting natural, enjoyable interaction.
  • Play-based format increases engagement and more natural speech samples.

Long-Term Course and Discharge from Preschool Therapy

• After approximately one year of therapy (indirect and direct) John’s profile:
  • Stuttering now mild:
    • Still present but significantly reduced in frequency.
    • Fairly consistent across different speaking situations.
  • Tension-free:
    • Disfluencies occur with minimal or no physical struggle.
  • Positive emotional impact:
    • John has positive reactions; parents also respond positively.
    • No noticeable negative effect on:
      • Social interactions.
      • Emotional well-being.
      • Classroom participation or functioning.
• Service reduction plan:
  • Decrease therapy frequency to once monthly for about six months.
  • Use this period to:
    • Monitor stability of gains.
    • Support family as needed during transition.

Discharge Planning Considerations

• Do not immediately stop therapy once progress is evident:
  • Gradual reduction allows observation over time and in varied circumstances.
• Clarify ongoing access:
  • Discharge does not mean child can never return to therapy.
  • Build in understanding that:
    • If concerns re-emerge, there should be an easy path to re-enter services.
    • Needing therapy again is not a failure; it can be part of a normal course.
• Parent communication:
  • Explain:
    • Rationale for phased reduction.
    • Possibility of future variability or increased demands (e.g., new school stage).
    • That many children will not need to return, but some may.

Key Terms & Definitions

• Stuttering:
  • A fluency disorder involving disruptions in the forward flow of speech (e.g., repetitions, prolongations, blocks), often associated with tension and emotional reactions.
• Typical disfluency:
  • Common, non-pathological disruptions in young children’s speech (e.g., occasional whole-word repetitions) without tension or significant concern.
• Risk factors:
  • Features that increase likelihood stuttering will persist (e.g., family history, male gender, long time since onset).
• Indirect therapy:
  • Treatment focusing on modifying the child’s environment and caregiver interactions rather than directly modifying the child’s speech.
• Direct therapy:
  • Treatment that explicitly teaches the child about stuttering and speech strategies; involves directly practicing changes in speech.
• Easy starts:
  • A speech strategy in which the child begins phrases gently, with low tension, then continues in typical speech.
• Hard bumps:
  • Stuttering moments characterized by high tension, struggle, and possibly secondary behaviors.
• Easy bumps:
  • Stuttering moments without strong tension or struggle; more controlled, less effortful.
• Bilingualism:
  • Use and development of two languages; in this case, Spanish at home and English at school.
• Response-contingency/operant approach:
  • Therapy method based on reinforcing fluent speech and/or responding to stuttering with specific contingencies; not recommended as primary approach for preschool stuttering.
• Disfluency counts:
  • Quantitative measures of how often a child stutters, often expressed as a percentage of words or syllables stuttered.
• SSI-4 (Stuttering Severity Instrument – Fourth Edition):
  • Standardized tool measuring severity based on frequency, duration, and physical concomitants of stuttering.

Action Items / Next Steps (Preschool Phase)

• For clinicians:

  • Use a thorough case history and multiple speaking contexts to assess preschool stuttering.
  • Consider all major risk factors when deciding on therapy, not just disfluency counts.
  • Begin with indirect therapy for low-awareness preschoolers; be prepared to move to direct work when needed.
  • Educate parents about:
    • Risk factors.
    • Normal variability in stuttering.
    • How to reduce speaking demands and model supportive communication.
  • Use developmentally appropriate language (e.g., “bumpy speech,” “turtle talk,” “rabbit talk”) when introducing stuttering concepts.
  • Plan for gradual discharge and clear pathways for re-entry if concerns arise later.

• For families:

  • Implement recommended indirect strategies at home:
    • Slower, phrased speech.
    • Reduced time pressure.
    • Recasting without focusing on errors.
  • Avoid restricting languages; continue natural use of both home and school languages.
  • Reframe expectations to understand stuttering variability and non-linear progress.
  • Stay in communication with clinicians about any new avoidance behaviors or changes in stuttering.