Journal of Fluency Disorders 32 (2007) 121138

Clinical report

Enhancing treatment for school-age children who stutter I. Reducing negative reactions through desensitization and cognitive restructuring
William P. Murphy a, , J. Scott Yaruss b , Robert W. Quesal c
a b

Purdue University, Department of Speech, Language, and Hearing Sciences, Heavilon Hall, West Lafayette, IN 47907, United States University of Pittsburgh and Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States c Western Illinois University, Macomb, IL, United States

Received 31 March 2006; received in revised form 6 February 2007; accepted 11 February 2007

Abstract This paper describes several treatment strategies that clinicians can use to address negative affective, behavioral, and cognitive reactions that school-age children who stutter may experience as part of their disorder. Specic strategies include desensitization to stuttering, cognitive restructuring, self-acceptance, purposeful self-disclosure, and a combination of both uency enhancing and stuttering modication approaches. To facilitate clinicians application of these techniques, the strategies are presented in the context of a case study involving a 9-year-old boy who participated in a comprehensive treatment program for stuttering. Following treatment, the child exhibited improved communication attitudes and a reduced frequency and severity of stuttering, combined with reduced concern about stuttering, as indicated through formal and informal assessments. Findings suggest that clinicians can help children overcome the negative reactions associated with stuttering through a number of treatment strategies that can be applied in a variety of clinical settings. Educational objectives: After reading this article, participants will be able to: (1) dene desensitization and cognitive restructuring and provide two arguments in favor of using these strategies in treatment for school-age children who stutter; (2) describe two treatment strategies for helping school-age children achieve desensitization through stuttering therapy; (3) describe two treatment strategies for helping school-age children engage in cognitive restructuring in the context of therapy. 2007 Elsevier Inc. All rights reserved.
Keywords: Desensitization; Cognitive restructuring; Stuttering; Treatment

Corresponding author. Tel.: +1 765 494 3810. E-mail address: wpmurphy@purdue.edu (W.P. Murphy).

0094-730X/$ see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.judis.2007.02.002

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Many children who stutter experience negative emotional and cognitive self-reactions as a result of their communication difculties (DeNil & Brutten, 1991; Logan & Yaruss, 1999; Vanryckeghem & Brutten, 1996, 1997). Specically, stuttering may be accompanied by low selfesteem and reduced self-condence (e.g., Manning, 1994), feelings of shame or embarrassment (Murphy, 1989, 1999), and other adverse effects (Coleman, Yaruss, & Quesal, 2004); and these factors can have a negative impact on a childs overall communicative competence (see review in Blood & Blood, 2004). As the disorder develops, negative reactions can become a signicant concern, at least for some children who stutter (Vanryckeghem, Hylebos, Brutten, & Peleman, 2001). Furthermore, the negative reactions of other people in the childs environment can also play a signicant role in the childs experience of stuttering (Blood & Blood, 2004; Davis, Howell, & Cook, 2002; Langevin, 1997, 2000; Murphy, Yaruss, & Quesal, 2007). These negative experiences cannot only have an adverse impact on the childs ability to communicate; they can also interfere with their progress in therapy (Healey, Scott Trautman, & Susca, 2004). Therefore, speech-language pathologists (SLPs) may need to address these issues in treatment to ensure the effectiveness of treatment. Fortunately, there is a sizable literature, both in the eld of speech-language pathology and in the eld of psychology, that demonstrates a number of techniques that clinicians can employ to help people overcome affective and cognitive reactions to a wide variety of disorders (see reviews in J. S. Beck, 1995; Rapee, Wignall, Psych, Hudson, & Schniering, 2000). Unfortunately, many clinicians report that they are not comfortable working with aspects of the stuttering disorder other than uency, even though they acknowledge the importance of these other aspects of the disorder in treatment (e.g., Cooper & Cooper, 1985, 1996; Kelly et al., 1997). Thus, although most clinicians are familiar with techniques for enhancing uency, signicantly fewer clinicians report that they are comfortable with strategies that help children overcome their negative reactions to stuttering. Examples of such strategies include cognitive restructuring, talking about thoughts and feelings about stuttering, and reducing fears about stuttering through desensitization. One purpose of this manuscript is to provide clinicians with a detailed explanation of techniques they can use to help children address these aspects of the disorder. In addition, given the importance of gathering and presenting evidence to support the selection of treatment strategies (i.e., using evidence-based practice), a second purpose of this paper is to provide preliminary databased on a case reportsupporting the use of these treatment strategies with school-age children who stutter who are reacting negatively to their stuttering. Of course, this tutorial cannot address all questions related to the efcacy of the treatment, and additional research will certainly be necessary. Still, results can provide some preliminary information to help clinicians determine whether it is appropriate to explore the use of these strategies with selected children who stutter. Throughout the paper, we have attempted to include information about the procedures and outcomes of treatment (e.g., strategies for implementing treatment activities, methods for ensuring that treatment is administered in the intended fashion, and relevant measures for judging successful outcomes; see Yin, 1994) so clinicians will be able to judge the value of this case report and determine for themselves whether they should implement similar strategies in their own treatment of children who stutter. 1. Desensitization and cognitive restructuring with children who stutter During the past 25 years, the rst author and colleagues have developed and evaluated strategies for helping children handle negative emotional and cognitive reactions to stuttering (Murphy &

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Quesal, 2002; Reardon & Yaruss, 2004; see also Logan & Yaruss, 1999; Yaruss, Murphy, Quesal, & Reardon, 2004; Yaruss & Quesal, 2001, 2003; Yaruss & Reardon, 2002). These strategies, which are designed to minimize childrens negative reactions to stuttering through desensitization and cognitive restructuring tasks, have been selected based on a comprehensive analysis of the literature from cognitive psychology as being effective for helping people change their reactions to difculties they face in their lives (see reviews in J. S. Beck, 1995; Rapee et al., 2000). Desensitization has long been used in stuttering treatment (e.g., Van Riper, 1973), though less has been written about applying desensitization procedures to the treatment of children who stutter. Thus, this paper seeks to describe a number of proven techniques that clinicians can implement to help children overcome the broader challenges associated with stuttering and achieve greater overall success in therapy. Cognitive restructuring and desensitization strategies can be combined with commonly applied techniques for helping children modify speech uency and other aspects of the stuttering disorder (e.g., Healey & Scott, 1995; Ramig & Bennett, 1995, 1997; Ramig & Dodge, 2005; Reardon & Yaruss, 2004). Examples of these types of strategies include changes to speech timing (e.g., slower speech or increased use of pauses) and physical tension (e.g., light contact or easy start). Because the focus of this paper is to address negative self-reactions, these speech-related strategies are not further detailed in this paper. To demonstrate the ways in which desensitization and cognitive restructuring strategies can be implemented in real world clinical settings, including the public schools, and to provide preliminary data supporting the use of these strategies, the treatment approach will be presented in the context of a detailed case study involving a school-age boy we will call Noah. (Note that aspects of treatment for addressing the bullying and inappropriate teasing that Noah was experiencing at school and in other settings are described in a companion paper; see Murphy et al., 2007). 2. Background information 2.1. Prior history of stuttering treatment Noah rst started stuttering when he was 3-year-old and he was initially enrolled in treatment when he was in kindergarten. Early treatment focused on modeling of slow speech patterns. Following a change in clinicians, Noahs treatment was discontinued when he was in rst grade because the clinician reportedly wanted to see if Noahs stuttering would resolve on its own. When Noahs stuttering did not diminish, he was again enrolled in treatment in second grade. According to his parents and his second-grade individualized education plan (IEP), Noahs treatment at that time was devoted largely to uency-shaping activities (e.g., Turtle Speech), with 100% uency as the stated goal of treatment. Noahs stuttering did not diminish, and beginning in the third grade, when Noah was 7-years-old, he expressed a desire to discontinue therapy because he felt uncomfortable leaving the classroom for his treatment sessions. As a result, he was dismissed from therapy at the request of his mother. At the beginning of fourth grade, Noah reported to his mother and teacher that he was concerned about his speech and ready to learn how to cope more effectively with his stuttering. He maintained that he still did not want to be taken out of class to work with the school clinician, in part because other children were already drawing attention to his speaking difculties. As a result, Noahs parents brought him to the Purdue Speech and Hearing Clinic to assess the need for additional treatment.

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Table 1 Noahs pre- and post-therapy scores on measures of behavioral and affective components of stuttering Measure Stuttering severity instrument (3rd ed.) (SSI-3, Riley, 1994) Communication attitude test-revised (CAT-R; DeNil & Brutten, 1991) Stutter-like disuencies Pre-therapy 28 (Severe) 21 11% Post-therapy 8 (Very mild) 10 2%

2.2. Evaluation at the Purdue Clinic At the time of his evaluation at the Purdue Clinic, Noah was 8-year-old. His speech uency, stuttering, and communication attitudes were evaluated through observation, interview, and both formal and informal testing procedures. The evaluation and treatment described below were conducted by the rst author, working with a team of graduate-level students in speech-language pathology. Results of the formal testing (as well as post-treatment results discussed below) are summarized in Table 1. 2.2.1. Speech uency and stuttering Noah exhibited a moderate-to-severe stuttering problem, characterized by numerous bilabial and laryngeal blocks with considerable muscular tension and eye-blinking. During a conversational speaking task, Noah exhibited an average frequency of 11 stutter-like disuencies per 100 words. The average duration of his disuencies was estimated to be approximately 1 s. Combined with the notable physical tension, these observable characteristics resulted in a total overall score on the Stuttering Severity Instrument-3 (SSI-3; Riley, 1994) of 28 (severe). In addition, informal observation indicated that Noah was using numerous avoidance behaviors, including word substitution, starters, and postponements in reaction to his stuttering. These behaviors were directly conrmed by Noahs self-report during an interview conducted as part of the detailed evaluation conducted at Purdue University. 2.2.2. Communication attitudes Standardized and non-standardized tests, including self-report, revealed that Noah was very concerned about his stuttering. On the Childrens Attitude Test-Revised (CAT-R; DeNil & Brutten, 1991), Noah provided 21 negative responses out of 32 items, indicating that he exhibited strongly negative communication attitudes. Other stuttering children Noahs age provide an average of 17.6 negative responses on the CAT-R. During the interview, Noah reported that stuttering bothered him and that other childrens comments about stuttering made him feel angry. He stated that he sometimes wanted to cry, and that he was afraid that other children thought he was dumb or a retard. He said that his speech therapy technique of using stretchy speech to improve uency was for babies and made him sound funny. Finally, he reported that other children were bullying him about his speech at school and in other settings and this made it even more difcult for him to communicate (see Murphy et al., 2007). 2.3. Treatment recommendations Based on these ndings, it was recommended that Noah receive speech therapy designed to help him reduce his negative reactions to stuttering and to learn various speech tools to enhance his uency and reduce physical tension during moments of stuttering. Noah responded by saying

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that he was interested in learning more tools to help him deal with stuttering, though he stated quite clearly that he did not want to use baby turtle speech or stretchy speech. Following consultation with Noah and his parents, he was enrolled in a comprehensive therapy program at the Purdue University Speech and Hearing Clinic. 3. Overall treatment strategies and rationale Noah was enrolled in a broad-based therapy approach that combined strategies for improving uency and modifying stuttering with strategies for helping Noah become desensitized to stuttering so he could cope with his speaking difculties in a more effective manner (e.g., Ramig & Dodge, 2005; Reardon & Yaruss, 2004; Yaruss & Quesal, 2001, 2003). Stuttering modication strategies, such as preparatory sets and pull-outs (Guitar, 2005; Van Riper, 1973; Williams & Dugan, 2002), and uency enhancing techniques, such as easy onsets (Ramig & Bennett, 1997; Runyan & Runyan, 1999), were introduced to facilitate Noahs production of more uent speech. It is important to note, however, that uency was not the primary goal of Noahs treatment. Indeed, Noah was taught that total uency was not necessary in order for him to be a good communicator. Instead, he learned that even though children may, at times, use techniques to manage their stuttering, it is possible that they will still stutter sometimes. In addition to treatment aimed at improving speech uency, Noah also participated in treatment activities designed to reduce his sensitivity to stuttering and to help him become more accepting of his speaking difculties. The rationale for including these other aspects of treatment was the fact that the results of the evaluation demonstrated that Noahs concerns about his stuttering were affecting his ability to successfully use speech management tools. More specically, the evaluation revealed that Noah had already developed a number of negative affective, behavioral, and cognitive reactions to his stuttering that had become part of his overall communication problem (Yaruss & Quesal, 2004). For example, because he was embarrassed about his speech, he was unwilling to use techniques like slower speech that could have led to improved uency, but which might have resulted in less natural-sounding speech. Noah was even reluctant to practice modifying his speech at home and in other safe situations because of his own concerns about stuttering. In order to enhance Noahs willingness to use speech modication techniques, and to help him reduce his negative reactions to stuttering, treatment was designed to address his sensitivity to stuttering and his beliefs and feelings about his speech. A considerable body of research (see reviews in Kaufman, 1985; Rapee et al., 2000) has shown that people can successfully overcome their fears, as well as negative emotions such as shame or guilt, if they gradually experience feared situations in a supportive environment following a systematic, controlled hierarchy. This process, known as desensitization, has been widely used in the treatment of stuttering (Sheehan, 1958; Van Riper, 1973), as well as many other conditions. Still, the application of desensitization techniques to the treatment of school-age children who stutter has not been as widely discussed (see Reardon & Yaruss, 2004; Williams & Dugan, 2002). Therefore, a series of desensitization activities (Murphy, 1989, 1999; see also Dell, 1993) was initiated to reduce Noahs fear of stuttering (or, as the rst author has often called it, to deawfulize stuttering, see Murphy, 1989). As DeNil and Brutten (1991) and others have noted, many children who stutter have negative perceptions about their ability to communicate. These can easily turn into persistent negative thoughts and attitudes that often affect older children, adolescents, and adults who stutter. Noah was no exception, as the diagnostic testing and interview had revealed that he experienced anxiety, fear, and discomfort about what other people were likely to think about his stuttering. Thus, a

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signicant part of the therapy described in this paper was designed to address these thoughts. Incorporating strategies described by Cooper (2000), Kaufman, Raphael, and Espeland (1999), Rapee et al. (2000), and others, various tasks were used to elicit Noahs negative thoughts and feelings about stuttering, and therapy activities were designed to help him learn how to minimize and change these negative reactions. This process, called Cognitive Restructuring (A. Beck, 1976) has been shown to be effective for helping people change negative thoughts and feelings (see reviews in J. S. Beck, 1995; Rapee et al., 2000). In general, cognitive restructuring activities are designed to help people change unrealistic thoughts and beliefs by examining the evidence for these thoughts and beliefs and then modifying them. Modication employs a systematic reanalysis that (a) allows for more realistic thinking and (b) supports behavior management skills. The literature demonstrates that cognitive restructuring can be particularly helpful for individuals who exhibit disorders such as stuttering, for which anxiety is a key component (e.g., Barrett, Dadds, & Rapee, 1996). Indeed, several authors have described the application of cognitive restructuring strategies in the treatment of adults who stutter (e.g., Starkweather & Givens-Ackerman, 1997). Based on this literature, several specic desensitization and cognitive restructuring activities were selected to help Noah overcome his concerns about stuttering. While there are any number of ways that clinicians can help children who stutter increase their awareness and acceptance of stuttering, these specic exercises were selected from among other possible alternatives because they were concrete, relatively easy to implement in typical clinical settings, supported by literature on similar activities used with individuals experiencing a variety of disorders, and appropriate for school-age children. 4. Specic treatment strategies Several different treatment activities designed to enhance Noahs acceptance and desensitization to stuttering were employed throughout therapy. These activities are described in the following sections. In each case, the clinician carefully monitored Noahs progress in achieving the therapy goals by observing changes in his speech behavior, his attitudes, and his ability to communicate effectively. Specic documentation of treatment gains was maintained through the clinicians treatment notes and progress reports, ongoing evaluation of Noahs participation in and response to treatment activities, and portfolio-based assessment of therapy materials. More formal information about the outcomes of therapy (as indicated by changes in communication attitudes inventories and speech uency) are presented later in the paper. In the sections that follow, general guidelines about how clinicians can judge a childs success with these activities are included, so clinicians will be able to determine approximately how long they should address each of the activities. Occasionally, information is provided about how many sessions were required for a given activity, though clinicians should be aware that different children would require different lengths of time to achieve their treatment goals. 4.1. Learning about stuttering A key aspect of all treatment aimed at changing attitudes and reactions is a strong understanding of the nature of the problem one faces (Egan, 2002). Unfortunately, Noahs responses during the diagnostic interview demonstrated that he did not possess basic knowledge about the nature and treatment of stuttering. Therefore, using information obtained from his clinician, as well as from the Stuttering Home Page (http://www.stutteringhomepage.com) and other

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resources, Noah was taught key facts about the disorder. Examples include basic data such as the sex ratio, normal intelligence of people who stutter, various approaches to therapy, and ideas about the cause of the disorder. In addition, Noah learned about the many ways that stuttering may affect peoples lives. This exercise was designed to reduce Noahs uncertainty about the disorder and to help him understand the active role he would need to play in therapy. It also helped him learn that there were specic things he could do to change his speech in positive and proactive ways. These educational activities provided the foundation for Noah to learn more specic details about how to manage his stuttering and how to minimize the negative impact of stuttering on his life. These activities, which were implemented in conjunction with other strategies described below, were addressed during the rst 1215 sessions of treatment. Educational activities were continued until Noah was able to demonstrate his increased understanding of stuttering by reporting what he had learned to the clinician and to others. 4.2. Learning about other people who stutter During the interview, Noah asked why he was the only one who stuttered and he expressed discomfort with the idea that other people did not have the same problems that he did. To minimize these concerns, Noah and his clinician discussed factors such as the prevalence and incidence of stuttering during part of several sessions that were focused on educational activities as described above. For example, he learned that approximately 1% of the population stutters and that more boys stutter than girls. To help him realize that even successful people had dealt with the same problems he was experiencing, he was shown posters of famous people who stutter, using materials available from the Stuttering Foundation of America (SFA), the National Stuttering Association (NSA), and Friends: The National Association for Young People who Stutter. In one exercise, Noah was given the opportunity to explore his feelings about stuttering by writing a letter to one of the famous people. When he received a supportive letter in response, he demonstrated his excitement by sharing the letter with his teachers, clinician, and parents. This helped to emphasize to Noah that he, too, could overcome the challenges associated with his stuttering. (Note that this experience also gave Noah the opportunity to educate others about stuttering, as discussed in more detail below.) 4.3. Stuttering Pen Pal Noahs opportunity to learn more about other people who stutter was enhanced when he developed a correspondence with another boy who stuttered through the NSAs Stutter Buddies newsletter. This helped to conrm for Noah that he was not the only one who stuttered and that there were many other children who were learning to deal effectively with stuttering. It also gave him the opportunity to share his experiences with stuttering and to learn from the experiences of others. This correspondence was maintained throughout his therapy program. Noah reported to his clinician that writing to his pen pal helped him feel less negatively about his stuttering. In other words, it helped to further his desensitization to his concerns about stuttering. Noah conrmed that these aspects of treatment were helping him overcome his fears when he explained that he was less worried about being identied as a child who stutters now that he had a friend who also stuttered and who could understand what he was experiencing. Noah was so enthusiastic about this activity that he encouraged his clinician to help other children who stutter identify pen pals through the Stutter Buddies newsletter.

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4.4. Group interactions To reinforce the lessons Noah was learning about stuttering, he was occasionally grouped with other children in treatment for stuttering at the Purdue Clinic. (These groups occurred approximately twice per academic semester, or approximately two times per 15 sessions.) Together, the children repeated many of the desensitization and cognitive restructuring experiences described throughout this paper. The group setting gave Noah the opportunity to become more comfortable with his speech by expanding his awareness of stuttering and by increasing his willingness to stutter openly when talking with other people. In addition, college-age students who were enrolled in stuttering treatment were also introduced to this group of younger children so they could trade information about how they felt when they stuttered, how people who do not stutter treated them, what happened to their speech when they tried to keep stuttering a secret, and why it might be important to talk to other people about stuttering. In addition to showing Noah that he was not alone in dealing with stuttering, these interactions gave Noah the opportunity to explore other ways of thinking about stuttering, and to see that other children had already learned the lessons he was working on in therapy. Specic examples of these lessons, identied through direct observation and interviews with Noah throughout treatment, included: discovering that he did not have to fear stuttering, learning that stuttering can be discussed openly, and nding that developing a deeper understanding of stuttering was valuable in helping him manage his stuttering and his reactions to stuttering. 4.5. Exploring the moment of stuttering As noted above, experiencing a feared behavior in a supportive environment helps people become desensitized to their discomfort (Rapee et al., 2000). This principle of experience and exploration was applied in Noahs therapy through activities designed to help Noah learn more about his speech while developing a tolerance for the moment of stuttering. One way in which this exploration was accomplished was by helping Noah learn to freeze during a moment of stuttering. In other words, while Noah was in the middle of a repetition, prolongation, or block, he was encouraged to maintain the tense posture of his articulators so he could examine what he was doing with his speech mechanism during the moment of stuttering. Working together with the clinician, he then learned to describe that moment of stuttering so he would develop a detailed understanding of how he stuttered. Later, he imitated his own stuttering as well as (pretend) stuttering behaviors modeled by the clinician, and this gave him an additional opportunity to explore the physical tension and other characteristics of his stuttering (e.g., Van Riper, 1973). Because of the importance of reduced physical tension and diminished sensitivity for a variety of the strategies utilized in Noahs treatment, particular attention was paid to these activities to ensure that he understood what he was doing during the moment of stuttering (e.g., Guitar, 2005; Williams, 1971, 1983). Thus, these activities, which were introduced in the early stages of therapy, were revisited throughout the rst 1520 sessions of therapy. Noahs enhanced understanding of his stuttering moments was conrmed through his increased ability to explain to the clinician his perception of muscle tension and the movement of his speech structures during stuttering. This increased understanding of the moment of stuttering also helped Noah feel a greater sense of empowerment that he could make changes in his speech. To make the activity even more enjoyable, Noah was given the opportunity to teach his parents, siblings, and teacher what he did with his speech mechanism during the moment of stuttering. Noah invited them to try to recreate his stuttering behaviors on their own. Noah then demonstrated his increased knowledge about stuttering by assigning a letter grade to their performance and by explaining

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how their stuttering differed from his own. This helped to place Noah in the position of expert about his speech (e.g., Murphy, 1989, 1998), so he could feel more secure about his knowledge and less concerned about his speaking abilities. In addition to helping to reduce Noahs sensitivity about stuttering, this activity also helped to reinforce the specic lessons Noah was learning in therapy and fostered generalization of Noahs desensitization and improved communication attitudes to other real-world settings. 4.6. Pseudostuttering Another activity employed various pseudostuttering games to help Noah further explore and learn about his stuttering, while becoming desensitized to the discomfort he previously associated with stuttering. Following Dell (1993), Noah was encouraged to create pseudostutters that were longer, louder, harder, or sillier than those produced by the clinician. This again gave Noah the opportunity to explore moments of stuttering in a safe, supportive, and even fun environment. This activity was also used as a foundation for exercises that taught Noah how to modify his stuttering moments (e.g., Van Riper, 1973) so he would understand that he could gain control of the physical tension in his speech. Pseudostuttering activities were employed throughout therapy to ensure that Noah maintained his desensitization to stuttering and to help remind him that he could learn to manage the physical tension in his speech muscles. 4.7. Concrete representations of stuttering Because school-age children are still in the stage of concrete operations (Piaget, 1973), the use of tangible representations or models can help them focus on complex behaviors such as stuttering in a more distinct fashion. This not only helps them learn about the behaviors; it also helps them learn that they can change those behaviors. To help Noah gain a better understanding of stuttering, therefore, he created representations of his stuttering using modeling clay and water balloons. For example, a particularly tense block might be represented by a large water balloon. Noah then used pseudostuttering to imitate the stuttering represented by the balloon. This gave Noah the opportunity to experience and explore the moment of stuttering using a variety of different representations. Finally, he was given the opportunity to burst the water balloon. This represented Noahs ability to break out of stuttering moments and not be held back by his speaking difculties. The goal of this activity was to give him the opportunity to explore and, ultimately, reduce the negative emotional reactions he had associated with his stuttering. In addition to helping Noah reduce his negative feelings about stuttering, this activity also helped him practice various stuttering modications that were introduced in therapy. These concrete representations of stuttering were introduced early in therapy, in conjunction with other activities for helping to increase Noahs awareness and understanding of stuttering. These activities were continued until Noah was able to clearly express to the clinician that he was feeling more condent about his ability to change his stuttering. Indeed, Noah was particularly enthusiastic in his participation during these activities. He repeatedly indicated to the clinician that thinking about stuttering in this way helped him see that stuttering was nothing to fear, for he knew that he could learn to manage his speech. 4.8. Exploring negative reactions To help Noah further understand how his negative reactions to stuttering could affect his ability to communicate, and to help him set goals for changes related to his reactions to stuttering,

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he was invited to draw pictures of how stuttering made him feel (e.g., Reardon & Yaruss, 2004). Noah was also encouraged to draw pictures about how he would like to feel so he could highlight the contrast between what he was experiencing and what he wanted to experience. Later, he was helped to explore various ways he could work toward achieving those desired feelings. For example, when asked to draw a picture of what Noah described as hard stutters, he drew a scary picture of a creature with jagged teeth and a t-shirt that said Big Stutters Smack You Down. In contrast, he also described and drew little stutters that just bounce against your hand. He explained that he did not mind those little types of stutters. He further explained that he was not afraid of them like he was of the big stutters. He expressed his willingness to work in therapy to be able to produce little stutters rather than big, hard stutters. This helped him to conceptualize in a more concrete fashion the specic goals he had developed for himself in therapy. Along the way, he imitated what big and easy stutters would sound like and this, too, helped him to (a) learn about stuttering, (b) become desensitized to different types of stuttering moments, and (c) explain and understand his reactions to stuttering. Again, these activities were used throughout the therapy process to enhance Noahs understanding of the moment of stuttering and they were continued until Noah was able to clearly express to the clinician that he had developed an enhanced understanding of and control over his stuttering. 4.9. Purposeful self-disclosure During the evaluation, Noah stated that he did not want people to know that he stuttered. He reported that he felt embarrassed about stuttering and that his stuttering made him feel different from everybody else. To help Noah overcome these feelings, the clinician and Noah engaged in purposeful self-disclosure activities designed to help Noah acknowledge, in a socially appropriate manner, the fact that he was a child who stutters (Sheehan, 1970). This activity was approached gradually, beginning in the second academic semester of therapy, after Noah had already demonstrated his ability to speak openly about stuttering in the clinic as well as in other safe situations, and after he had learned how to exhibit pseudostuttering. First, Noah and his clinician took turns using pseudostuttering, both inside and outside of the clinic, while watching listeners reactions. This provided Noah with the opportunity to see that listeners reactions were not as negative as he had expected (Van Riper, 1973). Later in therapy, when Noah was able to pseudostutter more freely, he and his clinician went outside of the clinic to conduct surveys of listeners knowledge of basic facts about stuttering (e.g., Breitenfeldt & Lorenz, 2000). The specic situations for practicing self-disclosure were jointly selected by Noah and clinician. Noah rst identied situations where he thought it would be easier to acknowledge his stuttering (e.g., talking to his teacher and to a best friend) and then, later, moving toward situations where Noah thought it would be harder to acknowledge his stuttering (e.g., talking to a clerk in a store or to a server in a restaurant). By moving gradually through this hierarchy, Noah was able to expand the number of situations where he experienced decreased discomfort in acknowledging stuttering. There were three primary purposes of these activities: rst, they served as another means of desensitizing Noah to stuttering; second, they gave Noah the opportunity to practice his speech management tools in real-world situations; and, third, they allowed Noah to practice acknowledging his stuttering in an open, matter-of-fact matter so he could demonstrate the benecial changes in his communication attitudes. Thus, purposeful self-disclosure provided yet another means of helping Noah deal with stuttering more effectively by reducing the negative stigma of stuttering and by minimizing his negative reactions to his speaking difculties. As a result of these activities, Noah also learned that, although most people know someone who

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stutters, they do not typically know factual information about stuttering, and this often contributes to misconceptions about the disorder. Noah learned that he could play a positive role in educating other people about stuttering to reduce those misconceptions and to help people understand and accept him and his stuttering. After some initial trepidation, Noah found that this activity became easier for him. In fact, later in therapy, Noah was joined by two other children who stutter from the larger therapy group for self-disclosure activities, and they reported that purposeful self-disclosure had become a helpful way for them to overcome their fear. 4.10. Positive self-talk Positive self-talk is a strategy that individuals can use to reinforce changes they are making in the way they think about the challenges they face (A. Beck, 1976). With Noah, positive self-talk was introduced in the second academic semester and used repeatedly throughout the remainder of his time in the clinic. Specically, the clinician taught Noah that all people have good, helpful voices inside them, as well as mean, hurtful ones. For example, Noah was told, over several therapy sessions during the third and forth semesters of therapy, When your voice talks about stuttering and is mean to you, talk back! Dont listen to the mean voice, its not nice and will hurt you. If you are upset or frustrated about stuttering, learn how to talk back in order to ght or disprove the voice or think about other things you are proud of. To help Noah develop this skill, the clinician taught him how to identify hurtful self-talk (e.g., people will think I am stupid when I stutter) and to reformulate or reframe such statements into more positive self-talk (e.g., I know I am not stupid . . . stuttering is just something I do when I talk). On a weekly basis over the course of approximately 2530 therapy sessions, Noah practiced writing out both his negative and positive comments and evaluating the effect that these comments had on his feelings about stuttering (e.g., Reardon & Yaruss, 2004). Such activities helped Noah learn that he could change his negative thoughts into positive thoughts that would facilitate better communication. 4.11. Summary of treatment activities Together, these desensitization and cognitive restructuring activities helped Noah to: (a) learn more about stuttering, (b) reduce his sensitivity to stuttering, and (c) be more open about his speaking difculties. Transfer and maintenance of all of these therapy gains were fostered through ongoing discussions between Noah and the clinician about specic situations where he had more or less difculty implementing treatment strategies. Noah was taught that he could help himself continue to make progress outside of the therapy room by beginning with the easier situations and then gradually moving up the hierarchy toward harder situations (e.g., Reardon & Yaruss, 2004). Each session, Noah reported his progress in moving up his hierarchies to the clinician. Combined with the clinicians own observations of Noahs progress in addressing increasingly difcult situations, this information was used to help Noah adjust his practice routine to encourage ongoing success. Ultimately, Noahs success with all of these therapy activities was evidenced through numerous concrete changes in the way he talked about stuttering, as well as by an increased willingness to participate in therapy and classroom activities, as judged by the clinician, the teachers, and the parents. 5. Results of desensitization and cognitive restructuring activities Throughout therapy, Noahs reactions to stuttering were monitored and assessed by the clinician to ensure that he was making adequate progress toward the goals of reducing sensitivity

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to stuttering and enhancing his communication in different speaking situations. The following sections include more detailed information about Noahs treatment outcomes, specically as they are related to communication attitudes. Of course, different clients will have different experiences in therapy, and it is important to note that the Noahs overall treatment involved more that the strategies described above. As noted in the introduction, strategies for cognitive restructuring and desensitization were combined with strategies for minimizing bullying (see Murphy et al., 2007) as well as changes in speech uency and stuttering. Still, this information can provide clinicians with a preliminary indication about whether the treatment procedures described in this paper may be useful components of a comprehensive treatment approach for children who stutter, particularly those who are experiencing sensitivity and concern about their speaking difculties. 5.1. Ongoing assessment After approximately 9 months of one-time-per-week therapy consisting of the activities described above, Noahs parents and clinicians observed that he was exhibiting fewer negative reactions to stuttering. For example, Noahs mother reported that he no longer cried at home about his speech or stuttering, and she reported that he routinely stated and afrmed that stuttering was not his fault. She also reported that Noah and his family could recognize and acknowledge stuttering, with relatively little fear or discomfort. This stood in stark contrast to his reaction to stuttering at the onset of therapy, when Noah expressed extreme discomfort at the mention of this stuttering, as well as a strong reluctance to talk about his speaking difculties. Thus, it is apparent that activities aimed at helping Noah talk about his stuttering in an open, matter-of-fact manner do appear to have helped him achieve the goal of reducing his concerns about stuttering. Noah also demonstrated greater willingness to learn about how to change his speech in order to enhance his uency, as evidenced through more frequent use of speech modications. This was observed by the clinician, the teacher, the parents, and even Noahs peers. For example, at Noahs insistence, he brought several of his classmates to therapy so he could help them learn about stuttering and about what he was doing to improve his speech. This demonstrated Noahs growing tolerance of stuttering and his willingness to participate in a variety of treatment activities. Overall, as Noahs discomfort with stuttering was diminished, he gained improved condence in making changes in both his stuttered and nonstuttered speech, and this helped him to enhance his ability to communicate effectively in a variety of situations. Together, these factors highlight the positive changes that Noah was making in his speech and in his communication as a whole. After the fourth semester of therapy, Noah wrote in his speech journal that he considered himself to be a lucky, special person. He stated that he was able to teach his friends about stuttering and, as a result, they no longer thought he was weird. He also wrote that he was getting better at smoothing out his speech using the modications he had learned in therapy and that he was more willing to use such techniques in different speaking situations. Ultimately, he reported that he felt better about talking even when he did stutter. Throughout his speech journal, he utilized terms and concepts that were consistent with those taught in therapy, thereby providing additional support for the value of the strategies that were employed by the clinician to help Noah overcome his concerns about stuttering. Noahs nal term in therapy at the Purdue clinic was during a 7-week summer session. At that time, Noah was re-evaluated using the same assessment procedures that were employed at the beginning of therapy. As shown in Table 1, Noah demonstrated changes in several aspects of his stuttering disorder, including greatly reduced negative responses on the CAT-R (DeNil & Brutten, 1991), minimal severity of stuttering on the SSI-3 (Riley, 1994), and a much lower

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overall frequency of stutter-like disuencies. Specically, Noah exhibited a stuttering severity rating in the mild range on the SSI-3 and a frequency of stutter-like disuencies in the range that is generally considered to be within normal limits (i.e., 2% syllables stuttered, see Conture, 2001). Furthermore, Noahs score on the CAT-R revealed that his communication attitudes had improved to the point where he exhibited a score that was close to that exhibited by children who do not stutter (Noahs score was 10; children Noahs age who do not stutter score an average of 6.3 with a standard deviation of 5.1; see DeNil & Brutten, 1991). In addition, based on the clinicians report, Noah also demonstrated a dramatically improved ability to use speech management skills in a number of situations that had previously been challenging for him. For example, he was able to successfully modify the majority of his remaining stuttering moments using techniques he learned in therapy. This helped to reduce tension in his speech muscles and allowed him to keep speaking smoothly and freely, even in speaking situations he had previously judged to be more difcult. At several points during therapy, Noah was asked to informally rate his satisfaction with his speech on a 10-point scale, with 10 indicating the greatest satisfaction. Toward the end of the summer session, Noahs self-rating was eight out of 10. He explained that he knew he could do even better with more practice, but overall he stated that he was quite happy with the results. He also indicated that he was glad that he no longer needed to rely upon avoidance behaviors he had used prior to coming to therapy. It is worth noting that this score of eight compares quite favorably with Noahs earlier self-ratings of one and three. These lower ratings were provided soon after he entered therapy at the Purdue clinic and prior to the implementation of any of the treatment strategies described above. Specic assessment of Noahs performance outside of the therapy room revealed that he was able to achieve a high degree of communication success even in difcult situations (e.g., when asking a stranger for directions). For example, Noahs teacher reported that Noah was talking much more in class, even if he did not always appear to use tools to manage his stuttering. She also conrmed that Noah was no longer using avoidance activities (word substitution, starters, and postponements) to hide his stuttering, but that he was speaking freely in class. One specic example of Noahs success following therapy was seen in a science fair project, where Noah reported on his speech therapy experiences in the Purdue clinic. As part of this project, he gave a 5-min presentation that was observed by two certied SLPs. These clinicians reported that Noah exhibited only two instances of unmodied stuttering at the beginning of the presentation. During the remainder of the presentation, Noahs frequency of disuencies was judged to be less than 2%, and all of these disuencies were successfully modied using the specic strategies Noah had learned in therapy. (Noah later explained to his mother that he had used these two moments of unmodied stuttering as a cue to help him remember to use his modication techniques.) Noah also indicated that he helped himself to reduce the tension during his stuttering by acknowledging his stuttering to the judges using purposeful self-disclosure as he had practiced in therapy. This demonstrated Noahs ability to communicate freely and successfully manage his speech uency even in stressful situations. Taken together, these results demonstrate improvements not only in Noahs feelings about himself and ability to communicate freely, but also in his ability to speak more uently, based directly on the techniques and activities utilized in the therapy process. At the conclusion of therapy, Noah, as well as his parents, teacher, and SLP all agreed that he had made signicant progress across all areas addressed in treatment. Because of these successes, Noah stated that he was ready to try managing his speech by himself the following year, when he would be in sixth grade. The childs ability to take responsibility for his own speech has been judged by parents to be a very important factor for determining success after therapy (Mallard,

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1998). At the same time, he also stated that would contact his SLP if he became concerned about his speech or if he started to have negative thoughts or feelings about stuttering. 5.2. One-year follow-up Noahs progress was informally monitored for 1 year after dismissal from treatment. Based on the reports provided by Noah, his teachers, and his parents, his sixth grade experience was successful, both in terms of his academics and his overall communication and speech uency. Although no formal measures of Noahs speech uency or communication attitudes were made during this extended follow-up period, interviews with Noah and his mother indicated that he continued to be satised with his speech and his speech management abilities. Conversations with two of his teachers suggested that Noah consistently volunteered to verbally contribute in class, and that he spoke freely, even if he did not always exhibit perfectly uent speech. When questioned by his SLP about additional therapy, Noah indicated that he was still comfortable managing his speech, as well as his thoughts and feelings about stuttering, on his own. Still, he stated that he might want to reinitiate speech therapy when he started seventh grade for, at that time, he would attend a new school with many different students and teachers. Noah stated that he thought he might get a little scared about his stuttering again and that he might feel funny using his management techniques in the new situations. Still, he also reported that he was condent, based on his past experiences, that he would be able to make changes in his speech and that he would be able to successfully manage his speech even in tough situations. 6. Conclusions The primary purpose of this paper has been to describe a specic set of treatment strategies that can be used in a variety of clinical settings to help children who stutter who are experiencing negative affective and cognitive reactions to their speaking difculties. The strategies described in this paper are based on the application of desensitization and cognitive restructuring principles, drawn from a much broader literature on counseling and cognitive psychology. The strategies are designed to help children overcome their negative reactions so they will be better able to communicate freely, while at the same time working to minimize stuttering behaviors in their speech. They are designed to be used in conjunction with other treatment strategies as needed, such as those used to help children learn to manage their speech uency or stuttering (Guitar, 2005; Healey & Scott, 1995; Ramig & Bennett, 1995, 1997; Ramig & Dodge, 2005; Reardon & Yaruss, 2004), as well as strategies designed to minimize the effect of experiences such as bullying and inappropriate teasing, as described in the companion manuscript (see Murphy et al., 2007). To facilitate clinicians use of these techniques, the strategies were presented in the context of a case study, using the experiences of a child who received treatment at the Purdue University Clinic between third and fth grade. Although the treatment described in this paper was administered in a clinical setting, all of the strategies described above could be used in school or other settings with minimal modication. A second purpose of the manuscript has been to provide preliminary data supporting the use of this type of treatment with children, like Noah, who are experiencing negative affective and cognitive reactions to their stuttering that may interfere with their progress in therapy. Throughout the paper, conrmation of treatment outcomes has been presented in the form of clinical observations, formal measures of Noahs speech uency and communication attitudes, portfolio-based assessment, and numerous self-reports by Noah, his parents, and his teachers. These ndings

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conrm that Noah did experience a number of positive changes during the course of therapy. Of course, additional outcomes research will be needed to demonstrate the overall efcacy of the therapy approach and to build the evidence-base for these strategies. Still, it seems clear that further exploration of these types of techniques with children who stutter is warranted. While aspects of therapy aimed at desensitizing the child to stuttering and cognitive restructuring to reduce negative affective and cognitive reactions may not be necessary for all children who stutter, the results of this paper demonstrate that children like Noah, who clearly exhibit concern and reactions to stuttering, can benet from this type of multifaceted approach. By understanding the nature of the cognitive and emotional aspects of stuttering, their role in impeding therapy progress, and the ways in which they can be addressed, SLPs will be in a better position to help their school-age students who stutter overcome the less observable, yet no less important, consequences of the stuttering disorder. Acknowledgments The authors are grateful to Noah and his family, and to the graduate student clinicians who worked with them. Although this paper is presented as a case study, the techniques were developed over many years in treatment with many different children. We wish to express our gratitude to all the children and families who have participated in this process, as well as to all of the professionals in many disciplines who have worked diligently to develop ways of addressing the cognitive and affective components of communication and other disorders that can have such a negative effect childrens lives. Preparation of this manuscript was supported, in part, by an NIH Grant (R01 03810) awarded to the University of Pittsburgh. CONTINUING EDUCATION Enhancing treatment for school-age children who stutter I. Reducing negative reactions through desensitization and cognitive restructuring QUESTIONS 1. Many school-age children who stutter: a. experience negative emotional and cognitive reactions as a result of their communication difculties b. have positive thoughts or feelings toward communication difculties c. only have negative thoughts and feelings toward communication difculties after the school SLP brings them to their attention d. have less negative thoughts and feelings toward their communication difculties than their uent classmates e. are motivated in therapy by their negative thoughts and feelings 2. Progress in stuttering therapy: a. is usually not limited if a child has negative thoughts and feelings toward stuttering b. can be best achieved by only focusing on changing speech behaviors c. can be limited if a child has negative thoughts and feelings toward stuttering d. is best achieved if the school SLP does not raise issues pertaining to negative thoughts and feelings about stuttering e. all of the above

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3. Desensitization to fear and other negative emotions should be done: a. as rapidly as possible b. only with adults who stutter c. in a supportive environment following a systematic, controlled hierarchy d. only in the childs therapy sessions in order to avoid failure e. only in group therapy to maximize carryover 4. Cognitive restructuring is used to: a. help parents discipline their children b. help children modify their environment c. allow teachers and SLPs to eliminate teasing and bullying in the classroom d. help children modify their negative thoughts and feelings e. allow children to speak more uently 5. Which of the following is not a treatment strategy for desensitization and cognitive restructuring activities? a. negative self-reinforcement b. learning about stuttering c. exploring the moment of stuttering d. positive self-talk e. learning about other people who stutter References
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