#015: Tackling Stuttering Treatment with Special Populations

Marisha: Hey, there. Welcome to the SLP Now podcast. I am so excited to be introducing our guest. Today. We are going to be diving into fluency strategies for some special populations. Our guest is Stephen Groner. He is a practicing speech language pathologist and person who stutters. He now speaks very fluently. I can't wait for him to share a little bit of his story with us.

Marisha: But he is on a mission to make stuttering therapy easy for everyone. He does that by sharing practical strategies. He has such an amazing way of breaking down stuttering and fluency therapy in a way that makes so much sense. I can't wait to hear all of the tips. Without further ado, let's chat with Stephen Groner.

Stephen: Hey, there. It's so good to be with you.

Marisha: Before we dive into all of the amazing tips and resources that I know you've got [crosstalk 00:01:04]-

Stephen: You would be right about that.

Marisha: What got you into the field of speech pathology, and how did you come to learn so much about stuttering? Can you tell us just a little bit about your story and your journey there?

Stephen: Yeah. Well, if you jump back with me, when I was six years old, I had to give a speech. It was a speech on my favorite animal horses. I got this book. I researched all kinds of facts. I wrote my speech down, and I decided to run through it with my mom. I stand up in front of her and my brother. I went to start. I couldn't say the word horses at that age. It just wouldn't come out of my mouth.

Stephen: I don't know how my mom kept a straight face as I tried to get through that word, but that was the first time when I knew that something was wrong, something was up. It continued from there. It was hard to say my name when I would meet new friends, hard for me to raise my hand and talk in class, hard for me to read out loud in front of class even though in like the fourth grade, I could read at a college level. Somehow, I got out of school-based speech therapy, I think, because I had really strong language skills.

Stephen: My stuttering was not impacting my academics, but it's because I would switch words. I had to work so hard to get any thoughts out. By the time I was 17 years old, I had had it. I was done. Talking was just too hard. I was just tired of not feeling like I was known being scared that I would never get a job, tired of like every single conversation being a hard one. I did what we all do.

Stephen: I hopped on Google. I found a two-week long intensive fluency shaping program in Virginia. Two and a half months later, I was there. For two weeks, I sat in a small room with a little box and a lot of workbooks. I was taught how to remake speech sounds in a more fluent way using fluency shaping techniques. It completely changed my whole life.

Stephen: I can still think to when I walked off of Main Street and walked into this little deli. I walked straight up to the counter and ordered lunch for the first time without stuttering like I ordered the exact sandwich that I wanted. I asked for exactly what I wanted on it. It came out. I got it. It was just so freeing. That changed my whole life. I wrestled for a few years wondering if I would ever make a good speech pathologist if I myself sometimes stuttered, but in the end, I decided and was shown that I actually might make a pretty good one because I'd been there in their shoes.

Stephen: It's been over 10 years now since I first went to that fluency shaping program. Every day since and all the years through graduate school and out of it, I have just been learning more and more and more about what we can do to help people like me to speak more fluently. I was pretty down cast when I got to graduate school though and found that fluency wasn't always taught very well or that a lot of students didn't feel like that they got what they needed from their grad school classes. Then, they were kind of thrown out into the field. It had no clue how to help these little kids who couldn't get their thoughts and words out.

Stephen: I felt bad because I knew so much and knew how much good that great therapy could give. I thought, "Well, you know what? I'm just going to make it nice and sweet and simple and easy for speech pathologists to learn how to do this well." That's why I'm here. That's how I got to be here.

Marisha: Oh my god. So many amazing nuggets and nuts for you. I wish you, guys, could see me because I was like, [inaudible 00:06:18].

Stephen: Thank you, Marisha.

Marisha: crosstalk see me. I hope you were [crosstalk 00:06:29].

Stephen: I was, yup, silently inside. crosstalk

Marisha: All the people who are listening because, oh my gosh, [crosstalk 00:06:38].

Stephen: Thank you.

Marisha: Now, let's just get-

Stephen: Let's begin.

Marisha: ... into all of the crosstalk good stuff. We're talking about two special populations today. I've gotten a lot of ... because listeners can submit questions to the podcast. This is one that I've gotten a lot about because like you've talked so much about stuttering and fluency, and we had a focus inside of the SLP Now membership on it too. They're like, "This is amazing like I've got the foundation." But what about this kid or this kid? A lot patterns that were coming up were like children with concurrent intellectual disabilities and bilingual children, and well, you've got lots of great things to share-

Stephen: I do.

Marisha: ... crosstalk on both of those. How about we start with some ... like can we treat stuttering in children with concurrent intellectual disabilities? If so, what does that look like?

Stephen: The answer there is maybe. The research is very ... Well, it's pretty sparse when it comes to fluency treatment, in general. But it is very desolate when it comes to fluency therapy in special populations. There's no agreement on whether or not direct fluency therapy is a good idea in children with ID. There are thoughts on both sides.

Stephen: What we do know and there have been a couple of papers really only three that I found, that I use, that I've drawn from for my own practice that talk about if we can and should do it and how. In the end, I would say,

Stephen: "Yes, we should try. If it doesn't work then, it doesn't work." But we can't not try.

Stephen: What I found, there's a really great paper by [Healy Reed 00:09:04] and [Donna Herr 00:09:08]. The copy that I have has no date, but they say that in a child with ID who has multiple disorders, the disorder that most negatively impacts communication should be treated first or should be given preference.

Stephen: If that is a language disorder, then then that should come first. If it's stuttering, then then that should be treated first, but they also say actually you can sort of blend the two. They say, "Maybe, don't stop all the other kinds of therapy just to give fluency therapy." You can sort of blend all of your goals into the same task. But we should definitely try.

Stephen: What's been found is that children with more mild ID do better when it comes to direct fluency treatment. There really isn't any research that I have found on children with more moderate to severe ID and fluency therapy with them, but Healy Reed and Donna Herr give a lot of tips for how we could and maybe should go about doing fluency therapy for children with ID.

Stephen: They say that you can still try. You can still use the same techniques that you would use with children who stutter, who don't have ID, but you're going to have to adapt them, of course, to your child. First, they say, "Of course, greatly simplify the language that you use to explain tasks and techniques and use of course multiple modalities to get it into them whether that's visuals." I mean use all of the things at your disposal, but make it very, very simple.

Stephen: The next thing, I think, is huge. That is it's been found that modeling a technique or a behavior instead of telling children with ID how to do it works far better. Show them what you want them to do. Don't tell them or talk at them. They also say, "Really, you want to train all of the adults and caregivers who that child spends time with." You want to train them on the techniques as well so they can sort of use it in their speech when they talk to this child so that the child gets that modeling of how we want them to speak or how they could speak to get their thoughts and words out better.

Stephen: That is huge. If you want there to be good carryover, you have to model and show it. The people who the child spends a lot of time with each day also need to model and show it. I know that's hard because we all have so much going on, but it's just been found to work in this population. They also say to reduce your own rate of speech which kind of goes along with that one.

Stephen: This one might be hard too, but they say that in children who have ID, generalization into everyday speech has not been found if they've only been treated in a clinical context, just like it's very hard even for a child or person who does not have ID to generalize fluency techniques outside of the therapy room. It is pretty much impossible for children with ID to do so.

Stephen: Therapy needs to take place in natural environments. You're pretty much going to waste your time if you're not doing therapy where they live and where they are. I know that can be hard, but really, that's just what has been found. Those are some general treatment considerations you can still try and use all of the same techniques that you would use for a child who does not have ID, but they have to be greatly simplified. They have to be shown and modeled not only by you but by other caregivers in that child's environment. Therapy has to take place in naturalistic environment. That's generally what has been found.

Stephen: There are two case studies of a young girl with Down's syndrome and a 21-year-old man with autism who have both been successfully treated for stuttering. You can pick which one I start with if you want to hear about them. Okay. Cool.

Marisha: [crosstalk 00:14:50].

Stephen: All right. Let's start with Sarah. She is or was an 8-year-old girl with Down's syndrome and a profound stutter. She stuttered on 54.7% of her syllables in conversation which is like off-the-charts. There's not even a chart for that, 29.8% of syllables in reading. She had an IQ of 69. That was mild intellectual impairment. Treatment lasted for 17 months. There was a total of 41 sessions in that month. Treatment consisted of teaching, fluency shaping techniques like stretchy speech, diaphragmatic breathing, gentle onsets, continuous phonation and light articulatory contacts.

Stephen: They also trained her in taking extra time so she could formulate her language. They trained her parents and adults at school to model a slower rate of speech as well as some of the techniques. Even though she was eight years old, they also trained the parents in giving verbal contingencies or responses like one would give in the Lidcombe Program, so praise for fluent speech and request for correction at between a 5 to 10 to 1 ratio, so 5 to 10 praises for fluent speech to everyone, request for correction.

Stephen: Last but not least, they included some training on how to respond to teasing and bullying. I don't believe that I mentioned their names at the start, but this is Harrison and Langevin 2012. The results at the end are pretty sweet if you ask me. She went from 54.7% syllable stuttered in conversation to 6.35% syllable stuttered. Then, get this. Four months' post-treatment, that had improved to just 0.8% syllable stuttered, less than 1% syllable stuttered down from 54.7%.

Stephen: It definitely can work that you can treat stuttering in clients who have ID, but this took a long time. It took a lot of buy-in from a lot of people. She had only mild ID, but I still think that that's pretty stinking sweet if you ask me. Isn't that awesome?

Marisha: Yes, that is amazing. I love that.

Stephen: That's Sarah. Do you want to hear about how stuttering was treated in a young man with autism? All right.

Marisha: Yes.

Stephen: They don't give his name. I guess we'll just call him Dude. Brundage, Whelan, and Burgess also in 2012 ... 2012 was a great year for research in fluency and special populations. It seems like it's like the only year where it was done, but there was a 21-year-old young man who had autism and a severe stutter. He had an IQ of 82 and deficits, of course, in receptive and pragmatic language. He stuttered on about 14-1/2% of his words in conversation.

Stephen: What is cool about this case is that he had very poor self-awareness of his stuttering which is something that I hear a lot when I get asked about how on earth do we treat stuttering in children with ID. It's like they're not aware of their disfluencies. How on earth can we help them to change them?

Stephen: They carried out a single subject [AB/AB 00:19:57] experiment. They blended it where they did it at the same time as the social pragmatic treatment that he was getting before they started treatment for fluency. Each session half of the time would be given to stuttering treatment. Then half of the time would be for pragmatic language.

Stephen: They did 43 sessions and condensed some fluency shaping rules to just three. They trained him on speaking slowly saying each word only once and saying each word short. Those were his fluency rules. Those were adapted from, I believe, Runyan and Runyan's 1986 fluency rules program. They had him write those rules down until he could state them by heart. Then, they were used in utterances of increasing length from single words all the way up to conversation. They would advance to the next level when less than 5% of his words were stuttered at the current length.

Stephen: At the end of that treatment which was 43 sessions long, of course, only half of the time in those sessions was dedicated to stuttering therapy. He had reduced his stuttering from 14-1/2% of his words stuttered to just 3% of his words stuttered. That two shows that ... Yes, he was 21 years old, but he still had very poor self-awareness of his stuttering and yet training him in these fluency rules still worked. That was really great to see that it can, in fact, be done.

Marisha: Yeah. That's pretty amazing given that he's a 21 year old plus the concomitant issues that [crosstalk 00:22:28]-

Stephen: Yeah. It's huge.

Marisha: ... made that amount of progress.

Stephen: It can be done.

Marisha: crosstalk encouraging.

Stephen: We just don't know a lot about how it gets done because there's not a lot of science that has been done on it, but what I would say ... Some folks say that we shouldn't do it because it'll be too hard for children with ID to learn these techniques or if they can't do them, then they'll only feel more shame about their speech.

Stephen: Basically, it's just too hard or it's going to harm them more if we try. While I think there are valid reasons for that thinking, I just don't think it plays out at least in the science that I have read. If things are adapted in the way that they have to be and there's a lot of buy-in from other stake holders, it can for sure be done at least for children with more mild ID. Definitely for them, you should do treatment. We don't know all that much about how well it works if you more moderate to severe stuttering, but I think that means that we have to try.

Stephen: Then, if it doesn't work then at least we know that it doesn't work for that child, but to not try I think we'll be doing them one of the greatest disservices in their lives. That's my thought on it from what I know. I'm sure that there's still a lot left that I have to learn. But that's all I had to say about that.

Marisha: inaudible That's so incredibly helpful. That gives us a little bit of license too to just start taking that action because there's not any resource telling us how it has to be done. We get to create or we just-

Stephen: Exactly.

Marisha: [crosstalk 00:24:32].

Stephen: We have brains. We have brains and we know good things and like when have we ever not tried something? I mean any child or client or patient who we have, we throw the book at them like we try every single thing out there that we know to try to help that and so like why would that be any different in stuttering?

Stephen: It's actually cool that we get to go where science has not gone yet. That means that we get to use our brains that we paid a lot of money to have filled with a lot of knowledge to try to help these kids. I think it's pretty sweet.

Marisha: Yes. [crosstalk 00:25:14].

Stephen: I love it. I love that.

Marisha: We get to fill in the science until crosstalk because crosstalk arriving eventually.

Stephen: Oh my gosh, yeah.

Marisha: [crosstalk 00:25:32].

Stephen: It will, but science is slow, right? Just like you said like we have to hold the beach until it gets there. Then, we can follow its lead. We can also help to make it too, but just to kind of surrender the fields because we don't know or it's too hard. That's not us. I mean that's not me. That's not you. Why would we do that?

Marisha: So good. What about crosstalk you have any moment [crosstalk 00:26:08]?

Stephen: Even though I hail from South Texas, Corpus Christi, just a few hours north of the border, I am not bi-lingual. It's one of the greatest regrets of my life that I am not. I know that there are a lot of other people who know more about this than I do, but here's what I know. That is that children who are known to be fluently speaking bilingual children, they produce mazes that sound like sound syllable or word repetitions at a far greater rate than their monolingual peers. They'll have more repetitions in their speech that is just typical as they navigate the formulation of language.

Stephen: 78% of them have greater than 3% of stuttered words in their speech mainly these repetitions that are seen as they formulate language. 78% of them who are known to be typical or fluently speaking, 78% of them run the risk of being diagnosed as stuttering if we use the monolingual standard of 3% word stuttered or more than 2% syllable stuttered.

Stephen: Courtney Byrd down at UT Austin has done a lot of really, really cool work with this population. She's who I go to. Byrd spelled B-Y-R-D, not bird like the flying creature. But she says this that we need to look for three things to know if a bilingual child who is exhibiting disfluencies is truly stuttering.

Stephen: The first is we need to look for if they have audible or inaudible sound prolongations in their speech. Fluently speaking bilingual children will not prolong sounds as they formulate language. If you hear those, then you have one check mark that this is probably actually real stuttering and not just mazes.

Stephen: Number two, we need to look if there is parental concern for stuttering. Usually, when parents come up and say, "Hey, I think that my child might be stuttering," it's usually warranted because they have seen it and heard it so much. They're not even experts, but they think that there's something wrong. You'll see that the parents of fluently speaking bilingual children are not concerned at all, that their children are stuttering. If you do see or hear about parent concern, then that's a second check that this actually might be real stuttering.

Stephen: Then number three, looking for any type of atypical tension. Fluently speaking bilingual children don't seem to exhibit tension in their repetitions. They're light. They're easy. They get through them quickly. If you see tension, then you know that there's struggle and that might be a third checkmark that this actually might be stuttering.

Stephen: That's the best way that we know how. That's from Byrd 2015 and Byrd 2018. I'm sorry. It was Byrd, et al 2015 and then just Byrd 2018. That's the best that we know that I currently know about how to sort of differentiate if they're just typically developing or if they actually stutter.

Marisha: Awesome. I'll also be sharing because you're throwing out lots of really good articles and resources there. I'll share the citations for those at slpnow.com/15 as well as some other resources if you're [crosstalk 00:31:18].

Stephen: Good.

Marisha: I'm taking notes for you guys. No worries. Just to recap, so we're looking for audible or inaudible sound prolongations, parent concern-

Stephen: Correct. Yeah. Nailed it.

Marisha: ... or atypical tension. The three red flags. Awesome. Then, any other tips for us? Is there anything that we would do differently if we like what would we do if we identified one, the red flags versus the three of the red flag crosstalk treatment.

Stephen: That was tough is that, again, we come to a place where there's not a whole lot of science at least not that I have found. If you know of one, please send it to me, but there's not a whole lot about, well, should we treat just their weaker language or should we treat in both languages or should we wait to treat until later or whatnot.

Stephen: Here, we sort of have to use our best judgment and say, "Basically, does their stuttering now, does it adversely impact their communication?" If it does, then we should treat it. if it doesn't or if it's new, then like maybe you could wait or if they're super young or they haven't been stuttering for very long then, of course, I would say, "Wait the six months to one year to see if it resolves on its own."

Stephen: But if you truly think that a bilingual child stutters then you should treat them, and, of course, you can only treat them in the language that you're fluent in. I think it would be great to treat it in both languages because, of course, there are different phonemes in each language. There are different syllable structures, different types of grammatical complexity.

Stephen: It would be great to get to treat all of that in both languages. But, of course, if you're only fluent in English, then ... If there is not a bilingual SLP who is well versed in stuttering treatment who you can refer them to, then it's going to fall on you. That, then, is the best that we can do, and that is to treat them in the language that we are fluent in.

Stephen: I think one thing to keep in mind as you ... I think we should just treat them normally from that point on except to know that their language formulation time might be longer than for one of their monolingual peers and just to give time for that. But besides that like, again, we're sort of on our own. We learn more about how we can best serve them.

Stephen: I think the best thing to do is to just treat them instead of not. Anything that you do will likely be better than doing nothing at all. Don't be scared of it. Just, of course, do the very best that you can just like we do every day.

Marisha: If we're taking our data, we're doing our best. We're being our own scientist until the research catches up. We're just testing different things inaudible one strategy. We have to. We definitely want to give it a fair try, but if we collect data for maybe a couple of weeks. I don't know. Do you have any feedback on how long you typically try something before crosstalk work?

Stephen: Yeah. I like to see them doing it in sentences before I say yay or nay because if they can use a technique in sentences without my help, then I know that they can do it if they choose to. If it still doesn't help, then we can move on.

Stephen: Sometimes, rarely, I've had somebody try something, I like hate this. This makes me feel stressed or tensed and tight. It's so hard. I don't like it. Then, I'll say, "All right. All right. Well, then, we don't have to do it." But if they're learning it, if they're trying to absorb it, I usually don't pull the plug on it until I see them at least try to do it in sentences and then make a decision from there.

Marisha: Just with the nature of stuttering, it sounds like because I feel like we've talked about this before, but I think you said in your own experience like crosstalk go through different strategies yourself crosstalk come out [crosstalk 00:36:33].

Stephen: I know like the back of my hand, I know easily 12 to 15 techniques that I could use at any given time to speak fluently or get through a moment of stuttering. I've definitely used different ones more at different times of my life. I couldn't tell you why that is. Perhaps, it's just me, but I find that, sometimes, some of them seem to come just a bit faster to me or they just seem to be working a little bit better.

Stephen: I'll lean on them. Then maybe, I'll remember one that I used to use more. I'll try it out. Then, it works for me. I'm always trying to find the easiest way to speak. Whatever that is, I'm going to do. Yeah. I sort of cycle through so like, currently, I am using the continuous phonation technique which is very hard for me to say still to this day, but I'm just trying to think to keep my voice turned on as I speak and trying to blend my voice through the borders of syllables.

Stephen: In that way, my voice won't have to turn off and then turn back on and put me at risk of stuttering. I mean, of course, there are some speech sounds that are voiceless. My voice will turn off, but the whole point of that technique is to try to keep your voice on as much as you can, but then as I as I come up to a difficult sound, I'm trying to use the light articulatory contacts technique where I just say it with a lot less force to help myself get through it.

Stephen: Then, I also currently love the attention shift technique. I think that this is going to be like the new wave of stuttering research. Harley 2018 wrote a really good article about the role of attention in stuttering and stuttering treatment. It's been known for a long time that children who stutter have poorer attentional functioning than their fluent peers. She wrote a lot about how instead of doing physical things to change our speech, what if we change what our attention is focusing on.

Stephen: Of course, we don't know what the cause of stuttering is in black and white, plain and dry. But there are some hypotheses that we who stutter relied too strongly on certain types of feedback in our speech and that maybe if we took our attention off of that and on to something else that we would be kind of freed up to speak more fluently.

Stephen: Anyhow, how that plays out for me in my own life and in my own practice is I like to ... As I'm speaking ... Well, before I start a sentence, I like to think in my mind or focus my attention on the single word of rewording because, for most of my life, speaking has not been rewording. I think that really, really strongly before I start to talk and taking my mind off of my physical speech actually lets it to come out more fluently which is kind of nuts especially because in my own story, it was really intense physical techniques where the first thing that allowed me to speak fluently.

Stephen: Then as I speak through my sentence, I flipped my mind back to that word I just try to think it in my head the single word of rewording. For some reason, the act of taking my mind off of what my physical articulator are doing actually helps them to work better. There's not a whole lot of research out on this yet, but I think it's going to boom here in the next few years or so.

Stephen: That's like one of my new phase that I use a ton. I think actually like it might be one of my favorite of all time, but back to what you asked me, yeah it. I love that. I know a ton of different techniques that I can pick and choose from. If I choose to put the work in to use them because they are work, but they're far less work than struggling through constant moments of stuttering.

Stephen: It's nice to have choice. We all like choice, right? It feels great to be armed with all these techniques so teach as many as you can. Then, let them pick. I don't think that you'll be sorry.

Marisha: Yeah. That's so helpful. I think that's important to keep in mind as we're trying these new techniques with these special populations crosstalk know what the data is supposed to look like. Stephen just gave us the okay to try a different strategy, some of them just won't work or they won't work right now, but you never know what it's going to be. We can give it a try.

Marisha: Then, also just with the nature of stuttering, it sounds like some days are much better than others, and so we're just naturally going-

Stephen: Oh my goodness.

Marisha: [crosstalk 00:42:53].

Stephen: I mean there are so many things that go into will it be a good speech day or a bad speech day. It's sort of like when you wake up, is it going to be a good hair day or a bad hair day. If I'm off of work and I'm really relaxed, then my speech is going to be more fluent than if I'm slammed at work have my huge caseload. My wife is sick. She needs my help. I have guests that are going to fly in and we have to get the house ready.

Stephen: With all that stress and movement, it's just going to naturally be more difficult for me to talk. It definitely fluctuates. The amount of reserve that I have to give towards my speech will change as well. Giving me and you giving your clients the most latitude and choice to try to face the fierceness of life. It is fierce. Trying to give them the most tools as you can is the best thing that you can do.

Stephen: It's fun because it means that you get to try a lot of things and then see which one works best. If you only try one thing and it doesn't work and you stop, then you've missed out on all the stuff that could work. Yeah. Never stop trying.

Marisha: I love that. Such good tips in there.

Stephen: I just talked and talked, yeah, and made you forget it. I tend to do that.

Marisha: We had another question. [crosstalk 00:44:44].

Stephen: [inaudible 00:44:44].

Marisha: crosstalk to it, but we'll come back because we've got a lot crosstalk to talk about. That was a super helpful overview of just, generally, how we're going to tackle students with concomitant disorders or intellectual disability, bilingual children. We've got some really great kind of suggestions and a little bit of help [crosstalk 00:45:07].

Stephen: [crosstalk 00:45:07].

Marisha: crosstalk perfect roadmap for us, but it was really cool to be able to hear it, the techniques that you're using for yourself. I thought we could take a couple of minutes to just go through kind of round-robin through a couple different techniques like what is your favorite technique for preschool children who stutter? If you have any ideas for how to modify it for those children with intellectually disabilities, bilingual [crosstalk 00:45:37].

Stephen: Oh my goodness. If you treat crosstalk with preschool children who stutter and you don't know about and don't use syllable timed speech yet, then you're not wrong. You're just, man, you're going to be so pumped when you hear this. The syllable time speech technique which is can be called the robot speech technique. It's also called the Westmead Program in Australia where it was developed is pretty simple, but daily practice with it for five minutes about five times per day for nine to 12 months can reduce stuttering by 96% in children who are already more than a year out from time of onset.

Stephen: For children who are past the horizon where most of them recover naturally, syllable time speech, practice daily for nine to 12 months can reduce their stuttering by 96%. How does that work? Well, you simply break up each of your words that you say into syllables and add a definite boundary around each one. If you hear me, I'm trying to still keep a natural kind of prosody and intonation as I do this. I'm not going very slowly like this. This is too slow.

Stephen: You try to stay at as fast of a speed as you can. Try to keep some natural intonation, but you do that for five minutes five times a day which means, yes, parents have to be involved, but they should be because their kids are in preschool. It's been found that doing that whether you look at pictures, whether you read a book, whether you're talking, while you drive in the car, it's been found that children who are past their best window to recover naturally doing that for five minutes about five times a day can reduce their stuttering by 95% after nine to 12 months.

Stephen: I start with that one always. Always, always, always, I start with that one. There was a phase two clinical trial. It's Trajkovski and Colleagues 2011, I believe. Yeah. That's my fave for those kiddos.

Marisha: Awesome. So helpful. It seems like-

Stephen: Definitely.

Marisha: [crosstalk 00:49:01].

Stephen: Exactly, but you just do it yourself crosstalk and try to get children with ID to copy you. You can even teach this, of course, to parents and teachers and have them try it as well. What it does is it facilitates the forward movement of speech. Even though you break each word up into syllables and add a slight pause as if you listen to me, my speech was plotting forward at a nice speed. It was more fluent than a child who stutters. Giving young children's brains basically access to fluency to what fluency feels like helps, I think.

Stephen: We're not quite sure, of course, because it's so hard to do research on young, young kids, but the thought is that it then helps to rewire their neuro speech circuitry to be more fluent. Definitely, definitely can be modeled well for sure. I like it.

Marisha: Pretty snazzy.

Stephen: Well, first, I'm just going to say crosstalk that syllable time speech can also be used for school-aged children up through their 11th year until they turn 12, at least that's what the research has found. The phase one, phase two trial, it was done by Andrews and Colleagues 2012 did the exact same thing with school-age children aged six through 11. They practiced syllable time speech for five minutes about five times a day for nine to 12 months. Their stuttering was reduced by 87%, so not quite as good as if they were in preschool, but still pretty darn good.

Stephen: What's great about syllable time speech is that it is not meant to be a technique that you use all the time whenever you speak whereas with fluency shaping techniques and with stuttering modification techniques, you're meant to employ those whenever you talk, whenever you choose to, but the thought is whenever you talk for the rest of your life, you may have to choose to use a technique to help you to speak more fluently.

Stephen: Syllable time speech is never meant to be a this is how you're going to talk for the rest of your life. It's a this is what we practice daily just like if we were working out so that our speech then in normal conversation will be more fluent. I love that. Definitely add that into your school-age repertoire as well. It can be as easy as a warm-up that you do at the start of your session.

Stephen: Then, of course, encourage them to do it at home as much as they can. That's probably the newest one that like I hadn't heard of until recently. I think until ... I didn't find it until last year. That's one that's not taught a whole lot for the school-age population, but if I had to pick like my next favorite one, it would be … Well, they sort of come as a bundle, but the cancellation pullout and preparatory set techniques that Van Riper talks about.

Stephen: Those would be my next favorite kind of my go-tos, but I think a lot more research is coming out that school-aged children can actually do a lot of fluency shaping techniques. It used to be said, "Well, fluency shaping techniques can't be used until you're 12." Then it was well maybe some children who were nine who have really good self-awareness and are really committed to therapy.

Stephen: Maybe, they can use it too and more and more research is coming out saying that actually even younger school-age kids can use the whole slew of fluency shaping techniques that can be taught to adults. Never think that you're kind of pigeon-holed to just one kind of therapy. That's what I would say about school-age kiddos. They're super fun.

Marisha: That does sound super fun. I inaudible because we have a variety of techniques that we can be teaching our students. I'm just curious how you use [crosstalk 00:54:26]. Do you target multiple like how many ... I know it really depends on the student, but what's the most techniques you would introduce in one session [crosstalk 00:54:41]?

Stephen: Yeah. I tend to only like to-

Marisha: ... to have any kind of default or [crosstalk 00:54:46]-

Stephen: ... train or to teach one technique per session until they're well versed in multiple techniques. If they have mastered multiple techniques at the sentence or conversational level, then we'll do tasks where they can switch back and forth if they can try to use them both at the same time, but whenever they're just learning techniques, I only teach one per session. Even, I'll spend a few sessions three or five or even eight sessions on just one technique until they've mastered it usually in sentences without my help before I'll move on to the next one.

Stephen: Then, as they learn more and master more at the sentence level, then we can start to do tasks that are more complex. They can choose to switch back and forth or use more than one. For preschool age kids, I teach syllable times speech straightaway. I also teach parents to slow down their rate of speech and to reduce their demands on their child's communication.

Stephen: Then lastly, after those three, I'll teach the verbal contingency technique where those responses that are taught in the Lidcombe Program for school-age kids. I also teach syllable time speech. First, teach them about the speech mechanism, teach them to identify their stuttering, go through the three cancellation pullout and prep set techniques, and also do some light [Bubba Bounces 00:56:47] where I have very light repetitions not ones that are super tense and tight.

Stephen: Then, I'll try out voluntary stuttering and self-advertising which if you had led with those when I was six years old say that you had me in therapy and you had the led with those two, I probably would never have come back to speech at all. I only teach those after I've given them actual physical ways to get through moments of stuttering. Then, I teach them how they can volunteer or share that they stutter which then, of course, does take a lot of the stress off of any conversation.

Stephen: But I don't ever start with that. For adults … Then, I'll even try out some of the techniques that I use more with adults because I think that they can actually work with school-age children who stutter. For adults, I start with the stretched syllable technique. Then, I pair that with me with the diaphragmatic breathing technique. Then, those kind of ... I wean off of the stretched syllable technique and teach gentle onsets, continuous phonation, light articulatory contacts.

Stephen: Then, I teach what I call what I've dubbed the attention shift technique which is the one that I talked about where I actually take my attention off of what I'm doing physically in my speech and put it on to something else. I like the word rewording. I teach them basically how they could have fluency without having to do any of the physical work that I just taught them how to do.

Stephen: That's normally what I what I do with those three age groups. Of course, it can be changed. It can be modified. If I think that a younger child could benefit from some of the techniques that I use more for adults, then I'll go ahead and try them. It's not going to hurt to try them. If they work, you've just discovered gold, so like why not dig and just see if it's down there. But I hope that helps when it comes to my mind when it comes to treatments planning. I'm sorry.

Marisha: Yeah. Super helpful. You just mentioned a lot of different techniques and unfortunately crosstalk time.

Stephen: Wow. I actually made exactly crosstalk what I would have wanted. When I was first learning about all these fluency techniques, I created a package called the Ultimate How to Treat Stuttering Package where I said, "You know what? I hear from a lot of people that they didn't get taught how to do all these techniques and how to teach them. I'll just make it super simple because we have no more time in our lives."

Stephen: I basically made videos of me doing every single one of the techniques that I knew. I wrote a handout for each one that you could give to clients or parents that breaks it down like step-by-step so that you just have to follow the steps, look at me as I model it. Then, you can teach it. You can actually give those to your clients to take home that they can have whenever they do their home practice.

Stephen: I would say, honestly, go there. It's going to give you the most knowledge in the fastest time in the simplest way then, if you tried to go out and search and find how to do all these techniques. That is up at slpstephen, S-T-E-P-H-E-N.com. Honestly, that's where I would go because I made it because it wasn't out there at least not that I had found. I just poured all of what I know into those modules. You get to hear me talk more which I hope has been nice for you. Really?

Marisha: Yeah. That's amazing and I actually got feedback from like someone else was telling me about how she was using these materials with the teenage boy. They were in a really rural area. I don't know if it was intended this way, but she ... Like you got to be the speech therapist for a part of this. It was really helpful for that teenage boy to see because he noticed like he noticed you using some of this [crosstalk 01:02:15]-

Stephen: That is so cool.

Marisha: ... and that was just really powerful.

Stephen: Oh my god. I love that. crosstalk Well-

Marisha: ... just like, "Oh," [crosstalk 01:02:23].

Stephen: Then, here's what I'm going to do. crosstalk I want to give you a promo code for 25% off. I'm just going to make it up in my head right now. I'll go put it in whenever we hang up, but let's make it SLP Now podcast rocks. If you use that, then you can get 25% off just because that story actually almost made me cry. I'm so glad to hear that.

Marisha: Awesome. Well, thank you so much for your time. I know-

Stephen: You are most, most welcome. crosstalk Thank you for all that you do. You know that we all love you too. To all of you who are going to go out and fight the good fight and treat stuttering even though it can be hard and scary like know that you have the power to change lives because I know how much it hurts to not be able to say my name or order the food that I want or say the town where I'm from or the school where I go to.

Stephen: I know that there need to be more of us who know what we're doing. The really cool thing is that we can. It just takes a little bit of courage and maybe a bit of a guide. I'm so glad that I could try to even be that for you tonight. Yeah. Glad to be on. Thank you so much. Bye, Marisha.

Marisha: Yeah. Thank you. Bye.