evidence based practices: working with young children who

EvidenceBasedPractices:WorkingwithYoungChildren

WhoStutter

KristinA.ChmelaM.A.CCC-SLPBCS-FBuffaloGrove,Illinois

Chmela2018/AllRightsReserved1

“Itisnowwidelyacceptedthatstutteringisamultidimensionaldisorder.Itisalsowidelyacceptedthatstutteringisaneurodevelopmentaldisorder,whichmeansthatitarisesduringdevelopmentinchildhood.”

Chmela2018/AllRightsReserved 2

ChildhoodStuttering–WhereareweandWherearewegoing?

AnneSmith,Ph.D.andChristineWeber,Ph.D.,CCC-SLPSeminarsSpeechLang.2016November;

37(4):291–297

Agenda

•  ApplyaRiskFactorAnalysis•  DevelopDifferentialTreatmentPlans•  Demonstrate5EssentialClinicalSkills


RiskFactors

•  Knowledgeof3types

•  Researchbased

•  GuideChmela2018/AllRightsReserved 4

StutteringPersistencevs.Recovery

Preschool-1stgrade

2nd-4thgrade

5th-8thgrade

1yearpostonset: 63%recover2yearspostonset:47%recover3yearspostonset:16%recover4yearspostonset:5%recover


PrimaryRiskFactors(rankordered)

1.Familyhistoryofpersistedstuttering2.MaleGender3.Trendsoffluencypatternflatorincreasedinfrequency4.Persistence6-12monthspostonset5.Ageatonsetafter3½6.Repetitionsof2-3ormoreunits;quickertempo7.Prolongations/Blocks

6

(Yairi&Ambrose,2005,IllinoisPredictionCriteria;Yairi&Seery,2015;Kraft&Yairi,2011)

Chmela2018/AllRightsReserved

SecondaryRiskFactors

Ø  Quantityofstutteringremainssevereafter1yearØ  Head&neckmovementremainsfrequent&severeafter1

yearØ  Phonologicalskillsbelownormalinearlyphaseof

stutteringØ  Expressivelanguageskillsremainadvancedovertimeor

presentasweak

7

(Yairi&Ambrose,2005,IllinoisPredictionCriteria;Yairi&Seery,2015;Kraft&Yairi,2011)


OtherConsiderations

Ø  Childshowsfrustration/withdrawal/avoidanceØ  Child’stemperamentpresentswithlowersensory

threshold,adaptability,&attention;higherreactivity&distractibility

Ø  OtherdevelopmentalissuespresentØ  Caregiversdisplaysignificantanxiety/negativemanner

ofreactingØ  Familyhistoryofspeech/language,learning,anxiety,

mood,ADHD,ticorcompulsivedisorders;autismspectrumdisorder

8

Jones,Conture,&Walden,2014;Ntourou,Conture,&Walden,2013Choi,Conture,Walden,Lambert,&Tumanova,2013;

Ntourou,Oyler,&Conture,2013;Eggersetal.,2010;Schwenketal.,2007;Karassetal.,2006;Andersonetal.,2003;Embrechtsetal.,2000


RiskFactorAnalysis

VeryHigh

High

Medium

Low

VeryLow

9Chmela2018/AllRightsReserved

InitialContactKeyQuestionsIsthereafamilyhistoryofpersistedstuttering?Whatgenderisyourchild?Whendidtheproblemstart?Howlonghasitbeengoingon?Canyoudescribethetrend?Whatisyourchilddoingwhenhe/shestutters?Doyouhaveanyotherconcernsforyourchild?Canyoudescribehis/hertemperament?Howareyou-othersfeelingandreactingtothis?


Case Example #1•  27monthsoldboy;“extremelyverbal”•  Startedtoexhibitsomenormaltypesofdisfluencyaboutonemonthago

•  “Thelasttwodayshecan’tgetasentenceoutatall…he’llstartcryingandsayhecan’tremember.”

•  Mothercalledverydistressed•  Sheandherhusband“constantlytalktohim”andfeelhislanguageskillsareveryadvanced

•  Nohistoryofstutteringinthefamily•  Nootherconcernswithdevelopment;verysensitive•  Itis“sosadandsuddenandwedon’tknowwhattodo.”


’

InitialContactRiskFactorAnalysisCase#1Primaryfactors?Secondaryfactors?Otherconsiderations?LevelofRisk:


Case Example #2•  6years,0monthsold;male•  Startedtostutteratabout4yearsofage•  Beganwithpartwordrepetitions;prolongationshavenowemergedinlast2months;hekeepsontalking

•  Motherfeelsheisawareofit;Peershaveaskedhimwhyhetalksthewayhedoes

•  Concernsregardingattention;levelofintensity•  Historyofstutteringinthefamily-motherisnotsureifhestillstuttersornot;paternaluncle

•  Verybrightchild;1stgradeteachernotesheseemstobelesstalkativeinclassoverthepastmonthorso

•  Didhavespeechtherapyforphonologicaldelaywhenhewas3-4yearsofage;nospeechsincehis5thbirthday 13Chmela2018/AllRightsReserved

Case Example #3•  Age3years,9months;female•  Startedtostutteraround2½•  Trendhasbeenconsistent(abouta“4”acrossa1-10scaleforfrequency);Asofonemonthago,tensionaroundsomepartwordrepetitionshasemerged

•  Fatherstutters;persisted(mothersayssherarelyseesit)•  Veryeasygoing,happychild;nodifficultywithtransitions•  Seemstohavetroubleexplainingthings;usesmultiplewordandpartwordrepetitions;“uhmandlike”are“everywhere”

•  Fatherhighlyconcerned-feelsitishisfault•  Historyofearinfections,allergies;nomedications 15Chmela2018/AllRightsReserved

Environment&Family

Ø Essentialtoinvolveothers(Boeyetal.,2009;Langevinetal.,2010;Bothe&Richardson,2011;Mewherter,M.,&CincinnatiChildren'sHospitalMedicalCenter.(2012).Cincinnati(OH):CincinnatiChildren'sHospitalMedicalCenter,(BESt137),1-7.)

Ø Environmentalimpactsmayimpactexacerbateproblem((Anderson,Pellowski,Conture,&Kelly,2003)

Ø Siblingimpacts(Beilbyetal.,2012) Chmela2018/AllRightsReserved 17

Ø Communicativecompetenceandlimitedverbalparticipation;increasegestureuse,abortattemptstoconveyamessage,maywithdrawfromplay

(Langevinetal.,2009)Ø Morethanhalfofpreschoolchildrenareawareoftheirstutteringanddevelopnegativeperceptionsabouttheirabilitytocommunicate,whichbecomesincreasinglyapparentasageincreases

(Boeyetal.,2009;Vanryckeghem,Brutten,&Hernandez,2005)


ClinicalActions

VeryHigh

High

Medium

Low

VeryLow


ClinicalActionsVeryLowtoLowRiskatinitialcontact

-Childusuallyveryyoung(underorearly3’s)-Decisionoftenmadebycarefulexplorationofriskfactorsbyphonecontactoraconsultationsession(screening);videosamplessentinbyparent-RTIoption


RTIRedFlag

•  DrivenbyRiskFactors(LowtoVeryLow)

•  Allottedforashortperiodoftime

•  Accompaniedbydocumentation

RTI


ClinicalActionsVeryLowtoLowRiskFactors

1. Provide educational resources & create follow-up plan

ü Resources:stutteringhelp.orgwestutter.orgü Follow-upwithcaregivershouldoccurnolongerthan3monthspostinitiationofplan,unlesssomethingshiftsdramaticallyandanewplaniscreatedsooner



2. Completion by Caregiver-Other: Perceptions of quantity of stuttering & potential contributing factors

ü UsingaRatingScaleof(0-9;0=nostuttering,2=verylittle,9=constantstuttering),anumberisassignedeachdaybaseduponthequantityofstutteringobserved

ü NoteanyChild-Environmentalfactorsthatmayhaveimpactedtheday

ü RatingsareprovidedtoSLPatendofeachweek



3. Daily Modification of select fluency enhancing behaviors

ü  deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)

ü  Millard,Edwards,&Cook(2009)ü  Franken&Putker-deBrujin(2007)ü  Chmela(2005)ü  Hill(2003)ü  Starkweather&Gotwald(1990)Chmela2018/AllRightsReserved 24

ClinicalActions

VeryHigh

High

Medium

Low

VeryLow


ClinicalActionsMedium,High,toVeryHighRisk

atinitialcontactProceedtoacompleteevaluationDetermineneed-developtreatmentandplan


MultifactorialDynamicPathwaysTheorySmith,A.,&Weber,C.(2017)

Duringthepreschoolyears,rapid“changesinneurobehavioralsystemsareongoing,andcriticalinteractionsamongthesesystemslikelyplayamajorroleindeterminingpersistenceoforrecoveryfromstuttering.”


Thistheorymotivatestheclinicalpractitionerto“determinethespecificfactorsthatcontributetoeachchild’spathwaytothediagnosisofstutteringandthosemostlikelytopromoterecovery.”


FamilyEnvironment

Executive Functioning

MotorSocial Emotional

SensoryLanguageCognitive

Child

TheBigPicture


StandardizedFluencyMeasure

InformalSLPFluencyRatings

InformalParent-OtherFluency

Ratings

DetailedHistory Attitudes&Feelings

LanguageMeasures

OtherMeasures ClinicalObservations

TheCritical8EvaluationComponents

Chmela2018/AllRightsReserved30

TreatmentGoal•  Establishpatternofnormalfluency(presenceofOtherDisfluencywithinnormalrange;Ratingsofstutter-likedisfluencywithinthe1-2rangeforconsecutiveperiodof8weeks)

•  Treatmentinvolvescaregiver•  Itispositive,andnaturallyreinforcingtothedevelopmentofpositiveattitudesandfeelingsaboutcommunication;carefulattentionispaidtothechild’sresponseandproblemsaresolvedastheyarise


FollowUp

•  Treatmentgraduallyfadesaway

•  Follow-upoccursforapproximately1year


BriefOverviewofClinicalActionsChildEnrolledinStutteringTreatment

SLP provides education about therapy & resources to caregiver-other

ü Onesessionperweek(unlessotherwarrantedspeech-languagegoals)

ü Overviewofwhattherapyentails

ü Resourcesaboutearlystuttering



SLP teaches CORE Therapy Element #1: 1) Daily Ratings of stuttering-observations of contributing factors

ü UsingaRatingScaleof(1-10;1=nostuttering,2=verylittle,10=constantstuttering),anumberisassignedeachdaybaseduponthequantityofstutteringobserved;noteanyChild-Environmentalfactorsthatmayhaveimpactedtheday

ü RatingsprovidedtoSLPatendofeachweek;SLPmakesownratingforeachsession;DataChartkept



SLP teaches caregiver-other CORE Therapy Element #2 Providing 3 kinds of Daily Feedback

ü FeedbackA:VerbalPraiseorRecognitionofSmoothtalking

ü FeedbackB:RequestforSelf-Evaluation

ü FeedbackC:RequestforSelf-Correction



SLP teaches caregiver-other CORE Therapy Element #3 Problem Solving & Parent Modeling deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)

ü Eachsessionplottingofratingsfromallparties,discussionofchild’sresponsetofeedback;contributingfactorsfortheweek

ü GradualintroductionofInteractiveCommunicativeBehaviorsasnatural,warranted,andappropriatelytimed

ü Ongoingsupportofoveralldevelopment 36Chmela2018/AllRightsReserved

EvaluationandCaseReview#1


•  FemaleM,age5-1;biological2parentfamily,onebrotherage7-6;fatherstuttersandhaspersisted-butonlyoccasionallyaccordingtomother’sreports;onemalecousinonmaternalsidehasADHD;familialenvironmentreportedsomewhathectic,fastpacedcommunicators,frequentrelativesvisitingovernight;frequentsiblingcompetitionfortalking;

•  Pediatriciantoldparentsitwouldresolveoverpastyears;parentschosetogethelpatthispoint;moretroublenoticedwhenstorytelling-morecomplexideas

•  Medicalhistorynegative;seasonalallergieswithnomedication;cognitiveanddevelopmentalmilestone’swithinnormallimits;easy,gentletemperament

•  Stutteringonset2years,11months;cyclicalbutnevercompletelyabated;frequencyandseverityhavemarkedlyincreasedoverpast6months;prolongationsof6-10secondswithpitchandloudnessrise;multiplepartword,rapidrepetitions;Mhasverbalizedabout“notbeingabletotalk;”sometimeswhenMis“caughtupshejustwalksaway”

•  Pre-Kteacherconcerned-reducedverbaloutputcomparedtoherpeers;nootherconcerns

•  TOCS:ModeratetoSevereRangeofStuttering;PPVT-4:125StandardScore;EVT-2:103StandardScore;CELF-Pscoreswithinaveragetohighaverage,nosignificantdiscrepancies;TNL:86NarrativeLanguageIndex



39

•  Male,age4-2;biological2parentfamily;3malesiblings,ages6,8,10);nohistoryofstutteringinfamily;maternalnephew(age20)dxAutismSpectrumDisorder;structuredandconsistentroutines;highcompetitionfortalking;parentsveryfacepacedcommunicators

•  Medicalhistoryrevealedlatetalker;motormilestonesWNL;frequentearinfectionsreporteduntilabout3½yearsofage

•  Stutteringonset3-10;severeblockswithincreasesinloudness;facialtensionandarmmovementsusedtogetwordsout;


•  frequentOtherDisfluencies(“uhmuhmuhmuhm”)upto20repetitionsatstartofsomephrases;patternconsistentsinceonset,withratingsof4-7infrequencyoverpastfewweeks)

•  Parentsfeltnoawarenessorconcernfromchild;hekeepsontalking;increaseswhenroutinechanges;lackofsleep

•  Difficultyfallingasleep;motherreportsheoftenhas“trickydayswithbigmeltdowns”

•  Schoolscreeningindicatednostutteringandrecommendedfollowupin3months;followupatschool-nostutteringobserved;pediatrician(4yearoldcheck-up)recommendedspeechevaluation;


•  Preschoolteachernotestroubletransitioningbetweenactivities&highverbaloutputwithintheclasssetting

•  PPVT-4:105StandardScore;EVT-2:100StandardScore;CELF-P:CoreLanguage98;nodiscrepanciesacrosssubtests;developarticerrors

•  Temperamentnotedaslessrhythmic,lowerthresholdwithintensereactivity;slightlymorenegativeinmood,distractible;approachesquickly(“seemsfearless”)



42

•  Femaleage2-9;biological2parentfamily;sisterage2months;onsetofstutteringat2-5;Unremarkablebirth,medical,developmentalhistory;Daycareprogram3fulldaysperweek;napsatprogram

•  Nohistoryofstuttering;mother(anxietyanddepression;fatherdepression&ADHD);familyrecentlyrelocatedpriortobirthofsecondchild;routinestructuredandconsistent;transitionshurriedandstressful;dadreports“givingintoher”whensheisupset;momsays“painfultowatchandhearthestuttering,butItryandhidemyemotionsfromher”

•  SLDatonsetmultiplerepetitions(partwordandwholeword);sinceonsetincreasedtomoreeffort


•  Someprolongations2-5secondswithpitchrise;frequencycontinuestobevariable;atpresentSLDmoderatetosevere;increasedstutteringwithexcitementor“fightingforthefloor;”shekeepsontalkingnomatterwhat

•  Atonset,childverbalizedfrustrationatnotbeingableto“getwordsout”buthasnotsaidanythingsince;veryverbal;daycareteacherseesstutteringduringtransitions(dropoff)andwhenfrustrated(ex:notwantingtosharewithapeer)

•  DevelopmentalIndicatorsfortheAssessmentofLearning(DIAL-4):WNL;otherS/LareasWNL

•  Moderatelevelofwithdrawal;lowerthreshold;mildintensityofreactions;moreadaptable


5EssentialClinicalSkillsfor

earlystutteringtreatment


5EssentialClinicalSkills


1.MakingDailyRatings2.TeachingVerbalFeedbackA:Praiseor NoticeSmoothTalking

3.TeachingVerbalFeedbackB:Request forSelf-EvaluationofSmooth Talking

4.TeachingVerbalFeedbackC:Request forRetryofStuttering

5.ProblemSolving&ParentModeling

ClinicalSkill1:MakingDailyRatings


q DiscussOtherDisfluencies(OD)vs.Stutter-LikeDisfluencies(SLD)

q DiscussRatingScale(1-10)usedforvariousaspectsofcommunicativebehavior:1=noobservation,2=verylittleobservation,and10=constantobservation

q ClinicianandcaregivereachmakeratingofSLDatendofsessionandcompareresults

q Caregiverisassignedtomakearatingattheendofeachdayusingthe(1-10)scale.“Attheendoftheday,howmuchSLDdidyouhear?”

q Ratingsarecollectedeveryweek&plottedondatachart

MakingDailyRatings


Troubleshootingv Feeling bad rating higher

v Not doing it

v Not bringing it

v Differentiating between OD and SLD

v Rating severity of “moment” verses daily quantity Chmela2018/AllRightsReserved 48

ClinicalSkill#2:TeachingVerbalFeedbackAPRAISEorNOTICESmoothTalking

q ExplainVerbalFeedbackAtocaregiverq DemonstratehowtoadministerFeedbackAduringshortactivitywithnaturalinteraction;reducelanguagedemandifneededinordertofacilitatesmoothspeechtoprovidethiscontingency

q AllowthecaregivertoaskquestionsaboutFeedbackA


q Havecaregivertryandadminister5-10ofFeedbackAonhisorherowninsession

q AssignDailySpecialTimefor10minuteswithadministrationofabout(ahandful,5-6orso)ofFeedbackA(Praise/Notice)onlyduringthespecialtime.


Troubleshootingv What to say

v How to say it

v When to have special time

v What to do during special time

v Dealing with the child’s response Chmela2018/AllRightsReserved 51

q ExplainVerbalFeedbackBtocaregiverq DemonstratehowtoadministerfeedbackA+Btogether,orA(fourtimes),followedbyB(onetime) A+A+A+A+B=OnesetofFeedback

q AllowthecaregivertoaskquestionsaboutprovidingAandBFeedbacktogether


ClinicalSkill#3:TeachingVerbalFeedbackBREQUESTaSELF-EVALUATIONofSmooth

Talking

q Havecaregivertryandadminister1stand2ndtypesonhisorherowninsession

q Observechild’sresponseandproblemsolveifwarranted

q AssigncombinationofbothtypesduringDailySpecialTime



v How to get child’s attention

v What to do when you get no response

v What to do if the response is not correct


q ExplainVerbalFeedbackCtocaregiverq DemonstratehowtoadministerFeedbackC

q ReviewhowFeedbackCiscombinedwithA+B:4(Praise-Notice)+1(RequestforSelf-Evaluation)+1(RequestforRetry)=1SETofFeedbackorContingencies


ClinicalSkill#4:TeachingVerbalFeedbackCREQUESTaReTry

q Allowthecaregivertoaskquestionsabout3rdtype

q Havecaregivertryandadminister1-2fullsets

duringsessionq ContinueDailySpecialTime;havecaregiver

administer2FullSetsduringthattime,andanothersetanyothertimeofday.


VerbalFeedbackC:REQUESTaRETRY


v How to get child’s attention

v When to administer it v Dealing with the child’s response


RESTART-DCMApplicationsØ  Reducingdemands&enhancingcapacitiesØ  ParentModelingoftypicalfluencyenhancingbehaviorsØ  ReinforcementforchildØ  ClinicalModeling


ParentProblemSolving&Modeling

deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)DirectversusIndirectTreatmentforPreschoolChildrenwhoStutter:TheRESTARTRandomizedTrial.PLoSONE10(7):e0133758.doi:10.1371/journal.pone.0133758

GradualDismissalTransitionØ 13-16sessionsapproximately(somechildrentakemuchlonger;somecontinuetopersist)

Ø Criteria:-Caregiverdailyratingsfor6-8weeksof1sand2s,(severalperiodsof1sinarow)-Similarclinicalobservations;nootherspeech- languagegoalsorconcerns

Ø  Graduallyreducetherapysessions(overthecourseof1year)

DuringtheTransitionPeriod,caregiverscontinueengaginginbehaviorsconducivetohealthycommunicationdevelopment,providingverbalcontingencies,andmakingdailyratings.Administrationofcontingenciesgraduallyfadesawayasthecaregiveriscomfortable.


Troubleshootingv When to introduce

v How to highlight it

v How to integrate it into work with feedback


Manner Space Position Routine Support


KeyElements:workingwithyoungchildrenwhostutter

62

RecommendedBooks:HowtoTalkSoLittleKidsWillListen:ASurvivalGuidetoLifewithChildrenAges2-7(Faber&King,2017)

TheWholeBrainChild(DanielSiegel)


63

•  HowdoIknowthat?• Whatdoesthatlooklike?•  AmI/arewemakinganassumption?•  Isthatanobservationorajudgment?Chmela2018/AllRightsReserved

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SelectedReferencesandResources


deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)DirectversusIndirectTreatmentforPreschoolChildrenwhoStutter:TheRESTARTRandomizedTrial.PLoSONE10(7):e0133758.doi:10.1371/journal.pone.0133758

Einarsdόttir,J.,&Ingham,R.(2009).Accuracyofparentidentificationofstutteringoccurrence.InternationalJournalofLanguage&CommunicationDisorders,44,847–863.

Ezrati-Vincour,R.,Platzky,R.,&Yairi,E.(2001).Theyoungchild'sawarenessofstuttering-likedisfluency.JournalofSpeech,Language,andHearingResearch,44,368-380.

Foote,G.(2013,March).Stuttering,bilingualism,andworkingconfidentlyoutsideyourcomfortzone.TheASHALeader.Retrievedfromhttp://leader.pubs.asha.org/Article.aspx?articleid=1784842.

Franken,M.,Kielstra-VanderSchalk,C.,&Boelens,H.(2005).Experimentaltreatmentofearlystuttering:Apreliminarystudy.JournalofFluencyDisorders,30(3),189-199.)

Franken,M.C.&Putker-deBruijn,D.(2007).Restart-DCMMethod.TreatmentprotocoldevelopedwithinthescopeoftheZonMWprojectCost-effectivenessoftheDemandsandCapacitiesModelbasedtreatmentcomparedtotheLidcombeprogrammeofearlystutteringintervention:Randomisedtria.l

Gregory,H.H.(1973b).Stuttering:Differentialevaluationandtherapy.Indianapolis:Bobbs-Merrill.Gregory,H.H.(2003).Stutteringtherapy:rationaleandprocedures,(pp.217-262).Boston:Allyn&Bacon.Hill,D.(2003).Differentialtreatmentofstutteringintheearlystages.InH.H.Gregory(Eds.),StutteringTherapy:rationaleandprocedures(pp.

142-184).Boston,M.A.:Allyn&Bacon.Jones,R.M.,Conture,E.G.,&Walden,T.A.(2014).Emotionalreactivityandregulationassociatedwithfluentandstutteredutterancesof

preschool-agechildrenwhostutter.JournalofCommunicationDisorders,48,38-51.Jones,R.,Choi,D.,Conture,E.,&Walden,T.(2014,May).Temperament,emotion,andchildhoodstuttering.SeminarsinSpeechandLanguage,

35(2),114-131).Thieme.Jones,M.,Onslow,M.,Packman,A.,Williams,S.,Ormond,T.,Schwarz,I.,&Gebski,V.(2005).RandomisedcontrolledtrialoftheLidcombe

programmeofearlystutteringintervention.BritishMedicalJournal,331(7518),659-661.Jones,M.,Hearne,A.,Onslow,M.,Ormond,T.,Williams,S.,Schwarz,I.,&O'Brian,S.(2007)Extendedfollowupofarandomisedcontrolledtrial

oftheLidcombeProgramofEarlyStutteringIntervention.Manuscriptinpreparation.Karrass,J.,Walden,T.A.,Conture,E.G.,Graham,C.G.,Arnold,H.S.,Hartfield,K.N.,&Schwenk,K.A.(2006).Relationofemotionalreactivityand

regulationtochildhoodstuttering.JournalofCommunicationDisorders,39,pp.402-423.Langevin,M.,Packman,A.,&Onslow,M.(2009).Peerresponsestostutteringinthepreschoolsetting.AmericanJournalofSpeech-Language

Pathology,18,264–276.Langevin,M.,Packman,A.,etal.(2010).ParentPerceptionsoftheImpactofStutteringonTheirPreschoolersandThemselves.JournalofCommunicationDisorders,43(5),407-423.

� 


Millard,S.K.,Edwards,S.,&Cook,F.M.(2009).Parent-childinteractiontherapy:Addingtotheevidence.InternationalJournalofSpeech-LanguagePathology,Vol.11,No.1.,pp.61-76.Millard,S.K.,&Davis,S.(2016).ThePalinParentRatingScales:Parents’PerspectivesofChildhoodStutteringandItsImpact.JournalofSpeech,Language,andHearingResearch,Vol.59,950-963.Ntourou,K.,Conture,E.G.,&Lipsey,M.W.(2011).Languageabilitiesofchildrenwhostutter:Ameta-analyticalreview.AmericanJournalof

Speech-LanguagePathology,20(3),163-179.Ntourou,K.,Conture,E.G.,&Walden,T.A.(2013).Emotionalreactivityandregulationinpreschool-agechildrenwhostutter.JournalofFluency

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Ø  StutteringFoundation:stutteringhelp.org;1-800-992-9392Ø  AmericanBoardofFluencyandFluencyDisorders:stutteringspecialists.orgØ  TheStutteringHomePage:www.stutteringhomepage.comØ  TheNationalStutteringAssociation(nsa.org);FriendsWhoStutter:(friendswhostutter.org);SAY:StutteringAssociationfortheYoung

(say.org)


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