CWe are very pleased to welcome Craig E. Coleman, MA, CCC-SLP,
as our guest host for the SLP chat tonight, Monday, April 18, 2005.
He will be addressing the topic of Stuttering in the School-Age Population.

Craig E. Coleman is a Clinical Coordinator at Children's Hospital of
Pittsburgh and Co-Director of the Stuttering Center of Western
Pennsylvania. He received his Bachelor's and Master's degrees at the
University of Pittsburgh. Craig is a member of the National Insurance
Advocacy Initiative and Chair of the National Stuttering Association's
Insurance Advocacy Committee. Craig also is an elected member of the
ASHA Legislative Council (PA).  In addition, Craig provides clinical
service to preschool, school-age, and adolescent children who stutter
and is involved in clinical research activities.

<Robin> Welcome!  We are chatting tonight about Stuttering in the School-Age Population with guest host,
          Craig E. Coleman, MA, CCC-SLP.
<Robin> Glad you could all be here tonight.
<Robin> Craig, please give us some background information on this population.
<Craig Coleman> For preschool children, the goal of treatment is to eliminate stuttering. For school-age
          children (age 7-8 and older) the goals shift to management of stuttering.
<Craig Coleman> For these children, I like to use a lot of analagies as you'll see...
<Craig Coleman> Treatment is like treating asthma, allergies, diabetes...you can't "Cure" those disorders,
          but you can manage them.
<Robin> What is the incidence of stuttering in this population?
<Craig Coleman> The incidence is about 1%--as you get into the school-age population, the incidence
          approaches that of adult stuttering.
<Craig Coleman> The 1% figure is pretty consistent across all cultures.
<Robin> Is there a higher incidence in males?
<Craig Coleman> Robin, to answer your question, there is about a 4:1 ratio male:female.
<Robin> Thank you Craig.
<Craig Coleman> If it is ok with you all, I thought I would take you through a typical evaluation and then
<AdrienneFSU> Sounds like a good plan, Craig, thanks.
<Craig Coleman> When evaluating school-age children, it is important to evaluate the whole disorder,
          not just the number of disfluencies.
<Craig Coleman> To evaluate the entire disorder, you'll want to examine the behavioral (disfluencies)
          component of stuttering along with the affective and cognitive (reactions) components.
<Craig Coleman> Affective refers to feelings and cognitive refers to thoughts.
<Craig Coleman> I typically start out evaluations with parent interviews. While I am talking to the parents,
          I have the child in the waiting room completing an ACES form.
<Robin> What is an ACES form?
<Craig Coleman> ACES stands for Assessment of the Child's Experience of Stuttering.
<Craig Coleman> This tool was developed by Scott Yaruss, Bob Quesal, and I.
<Craig Coleman> We are still in the early stages of developing this tool and collecting data, but the early
          results are promising that this can be a useful way to assess attitudes and emotions related to stuttering.
<Robin> Does someone help the child fill out the form?
<Craig Coleman> We made the form specifically for children so they can usually do it on their own.
<AdrienneFSU> Do the kids need to be a certain age to complete the form?
<Craig Coleman> We use it for kids 8 and up.
<Craig Coleman> If they need help, we'll help them (if they are having difficulty reading).
<Craig Coleman> The ACES is available on our website at www.stutteringcenter.org
<Stephanie> Great, thanks!
<Stephanie> What types of questions are asked on the form?
<Craig Coleman> The Aces has 4 parts.
<Craig Coleman> One part asks specifically about attitudes and emotions relating to stuttering.
<Craig Coleman> Another part asks about communication situations that might be more difficult.
<Craig Coleman> Another section helps understand the child's knowledge of stuttering.
<Craig Coleman> And a last section helps get a sense of how a child views his future as a person who stutters.
<Craig Coleman> From using the form, I have found that children answer these questions on paper much more
          honestly than they do when asked verbally.
<Craig Coleman> For example, the may report verbally that their stuttering doesn't bother them,  but they may
          indicate on the ACES that they are frustrated, anxious, and mad about their stuttering.
<Craig Coleman> It is also really useful in quantifying progress in these areas, which is an important part
          of the treatment process.
<Craig Coleman> While conducting the parent interview, I try to get a sense of how the parents view their child's
          stuttering and find out about family history of stuttering, general health of the child, general strengths
          or weaknesses in other areas of speech and language, and any past treatment for stuttering.
<Craig Coleman> As children get older, parents may have a much different view of stuttering than the child who
<Robin> Can you elaborate on that point, ie, the parents' view of stuttering vs the child's?
<Craig Coleman> Robin, In some cases, the child is much less bothered by his stuttering than the parent is,
          or vice versa.
<Craig Coleman> Parents and children may have very different views on stuttering, as they do with pretty much
          everything else during the school-age and adolescent years!
<Robin> I see, thanks. Which is more common, the parents more bothered or the child?
<Craig Coleman> It definitely works both ways, but you'll see that sometimes parents need treatment for their
          child's stuttering when the child might not. It happens more often that way...
<AdrienneFSU> What about if the parent is contributing to disfluency?
<Craig Coleman> Good question Adrienne--at this stage (school age and older) it is very important for parents
          to understand what can be done with stuttering and what is unrealistic.
<Stephanie> How often is it the school-aged child who seeks the help, rather than the parents?
<Craig Coleman> Stephanie--that's a good question...I would say that the school-age child initiates the process
          much more as they get older.
<Robin> Craig, tell us what you do in your evaluation with the child.
<Craig Coleman> After talking with the parents, I typically bring the child back and have the parents go to the
          waiting room.
<Craig Coleman> When the child is with me, I will typically have them do a 200-word conversational speech sample,
          a 100-word reading sample, and a 100-word picture description sample.
<Craig Coleman> This way, I get a sense of their disfluency rate in a variety of communication contexts.
<Craig Coleman> Remember, when you are talking about school-age kids, ALL of the prognoses includes stuttering
          to a certain degree...
<Craig Coleman> You also might need to assess other areas of speech and language to see if these other areas
          also need to be addressed.
<phatmom2001> During the evaluation, can the child's language ability be the cause of the stuttering, especially
          in the area of language planning?
<Craig Coleman> Yes, language is key to examine and understand. Stuttering has language and motor components.
<linda> Do you observe the child in natural environment as well?
<Craig Coleman> Linda, I try to get a videotape from the parents if I feel I need it--but most times the child
          is able to open up with me to the point where that might not be needed.
<Stephanie> For the school-age kids, what is most important to tabulate in the transcriptions?
<Craig Coleman> Stephanie, the simple answer is everything...disfluencies (number and type), physical tension,
          secondary behaviors, and attitudes and emotions toward stuttering.
<Craig Coleman> A thorough eval should include all of those.
<SandySLP> After you take the samples, exactly what do you measure for the disfluency rate that you mentioned?
<Craig Coleman> Sandy, I typically do an "online" sample when the child is talking--charting types and number
          as we go.
<Stephanie> I suppose the secondary behaviours may play a larger role at this age? Especially since peers can
          be so mean?
<Craig Coleman> Stephanie, you are 100% correct.
<SandySLP> Thanks, so it is a stuttered word/minute count?
<Craig Coleman> I do disfluent words per 100 words.
<Craig Coleman> Word/minute doesn't tell you much because the child could be using 10 words per minute or 200.
<phatmom2001> Words per hundred, it does seem to make more sense than words per minute.
<Robin> What is considered WNL for those hundred words?
<Craig Coleman> 3% or less per 100 words.
<Robin> Thank you
<Craig Coleman> Again, that depends on the type though.
<Craig Coleman>  One disfluency with severe tension and secondary behaviors is not WNL even if it is only 1.
<Stephanie> Ok, that makes sense.
<SandySLP> Gee, now if we could just convince the State Department of Education that!
<Craig Coleman> I'm working on it!
<Craig Coleman> I make it very clear that our long-term objective in treatment is NOT going to be to eliminate
          stuttering but to reduce stuttering, reduce physical tension and other secondary behaviors associated
          with stuttering, decrease negative reactions to stuttering.
<Craig Coleman> If either the parents or the child want only a "cure" for their stuttering, then our goals
          will not match theirs and they may need to seek treatment elsewhere.
<Stephanie> If the child presents with a comorbid problem, say articulation or language...would you focus on
          these in therapy as well, or specialize in fluency?
<Craig Coleman> It would depend on severity of each--I tend to like to treat both at the same time.
<Craig Coleman> The therapy approach just has to be slightly different.
<Craig Coleman> It is important to know that there is a distinct difference between needing treatment and being
          an appropriate candidate for treatment.
<Stephanie> Can you elaborate?
<Craig Coleman> If an older child does not want treatment, he is NOT an appropriate candidate for therapy.
<Craig Coleman> He may want treatment in the future, and if we force him into it when he is not ready, he will
          only have negative experiences to look back on.
<phatmom2001> If you see a child stuttering with secondary features during your evaluation is that a sign that
          this child needs help?
<Craig Coleman> Secondary behaviors are a sign of increased tension and frustration and would indicate a need
          for treatment.
<Craig Coleman> As we look toward treatment, we lay out specific goals.
<Stephanie> What about group sessions with peers? Has that proven to be effective at this age?
<Craig Coleman> I use group treatment to target generalization after some individual therapy has been established.
<Craig Coleman> If used correctly group therapy is great--IF THEY ARE WITH OTHER CHILDREN WHO STUTTER.
<Robin> Craig, please share some of your typical goals with us.
<Craig Coleman> Goals for Targeting Increased Knowledge of Stuttering
<Craig Coleman> Johnny will increase his knowledge about stuttering by passing 3 quizzes on basic stuttering facts.
<Craig Coleman> Johnny will educate 2 friends about his stuttering treatment techniques.
<Craig Coleman> Johnny will give a presentation to his family members, peers, or teachers on stuttering.
<Stephanie> Wow-- that's a hard one (presentations!)
<Craig Coleman> Presentation are hard...I make them a requirement for kids to give to me, their parents,
          and other SLPs before they are discharged.
<SandySLP> I would add that even if the child doesn't do the presentation, preparing for one goes a long
          way to improving understanding of key concepts.
<Craig Coleman> Right Sandy--knowledge is POWER.
<Craig Coleman> Johnny will participate in periodic stuttering trivia contests that are held with other children.
<Craig Coleman> Johnny will be able to identify and explain the process of producing speech and the anatomical
          structures involved in this process through use of drawings and other illustrations.
<Craig Coleman> Goals for Targeting "Quality" of Stuttering:
<Craig Coleman> Johnny will demonstrate the ability to reduce physical tension during stuttering using the
          "easing out" technique, for 50% of disfluencies during various tasks.
<Craig Coleman> Johnny will use cancellation and pull-out techniques for 75% of disfluencies in a structured
          conversational task.
<Stephanie> Do you consult with the teacher or is it up to the child to approach them on their own?
<Craig Coleman> I'll help consult with the teachers if the child wants me to.
<Craig Coleman> If the child is not ready, I would not force them into a classroom presentation.
<Craig Coleman> More goals...Johnny will be able to correctly identify location of physical tension during 80%
          of stuttering episodes in a structured task.
<Craig Coleman> Johnny will decrease the use of any secondary behaviors associated with his stuttering to
          less than 10% of disfluencies.
<Craig Coleman> Goals for Targeting the "Quantity" of Stuttering:
<Craig Coleman> Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by using
          easy starts 85% of the time in a structured conversation.
<Craig Coleman> Johnny will decrease the number of disfluencies in a structured conversational task by 15%.
<phatmom2001> Do you find that if a child inserts a schwae it indicates they will not outgrow their stuttering?
<Craig Coleman> Inserting a schwa is no indicator for prognosis....
<phatmom2001> Hmm, I was taught it was.
<linda> I think I read that someplace as well phatmom2001.
<Stephanie> I'm also interested in knowing about adjunctive therapies that you might propose to the child...
          I've heard of juggling and yoga... are these off the wall? Or are they known to work?
<Craig Coleman> I personally don't use those. Some find it effective to a degree but I think it is a little
          unrealistic to expect a child to go around juggling all the time.
<Stephanie> True. But I've heard of the effectiveness more in terms of a metaphor for helping the child realize
          how hard fluency techniques can be, and as they progress in juggling (or yoga)...that perhaps transfers
          to therapy?!
<Craig Coleman> Yoga is more for anxiety and breath support...and I think in many cases it is the parents who
          need to understand how hard techniques can be...the child already knows this.
<Stephanie> Ah. Now THAT's a good point!
<Robin> Craig, your examples of all these goals are wonderful!  Are there more you can share with us?
<Craig Coleman> When I write a goal to decrease stuttering, I write it to decrease stuttering and NOT
          "Johnny will speak fluently 80% of the time".
<Craig Coleman> Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by
          reducing rate of communication by 20%.
<phatmom2001> If you are getting at least 80% or better fluency in the speech therapy room, when do you start
          to transfer the fluent speech in other environments and what are some of the goals for this?
<Craig Coleman> 80% fluency is NOT a good goal--this means that a child is still stuttering 20% of the time.
<Craig Coleman> Generalization should start from the minute you start treatment.
<Craig Coleman> Having the child keep a journal of when and where they are using strategies and targeting
          knowledge of stuttering is a good way to generalize.
<Sandy> Craig.. school systems require a % to measure when goal is reached.
<SandySLP> This is measureable...if you reduce stuttering from 25% to 20% (based on a speech sample).
<Craig Coleman> Sandy, that's why I use a percent reduction--not based on fluency.
<phatmom2001> Do you ever council parents on making sure their child gets enough sleep, has predictable
          routines and gets to make choices?
<Craig Coleman> phatmom2001, the changes you suggest are not going to be too effective with older kids who
          are going to continue to stutter. They could get 12 hours of sleep, do the same thing every day,
          and when they wake-up they're still going to stutter.
<Craig Coleman> Those strategies are more useful for preschool children. As children get older, changing
          environment is not going to eliminate their stuttering, so you are working more toward helping
          the child rather than changing environment.
<Craig Coleman> More goals: Goals for Targeting Overall Communication:
<Craig Coleman> Johnny will decrease avoidance behaviors associated with his stuttering by entering
          3 specific situations where he previously avoided stuttering.
<Craig Coleman> Johnny will demonstrate desensitization to stuttering by using 5 pseudostutters during
          a conversation in the classroom.
<Craig Coleman> Johnny will increase participation in educational and social situations, as noted on a weekly
          basis by his parents and teachers.
<Stephanie> These are great...thanks!
<Craig Coleman> Johnny will use correct posture and eye contact 85% of the time in conversational speech
          with the clinician.
<Craig Coleman> There are two basic techniques that every child must learn: Speech modification strategies
          and stuttering modification strategies.
<Craig Coleman> Speech modification means that you are modifying speech to reduce stuttering.
<Craig Coleman> This would include using a phrased speech approach (I need to go/ to the store/ to buy some milk),
          using easy onsets, breath support.
<Stephanie> And what must the parents learn?
<Stephanie> How do you council them?
<Craig Coleman> Stephanie, the biggest thing for the parents is to learn how to accept their child's stuttering.
<Craig Coleman> They need to understand that they can work with their child without expecting fluency all
          the time or strategy use all the time. Both are unrealistic.
          <phatmom2001> What do you find helps older kids the most in reducing their stuttering?
<Craig Coleman> Successful treatment for older children means that you have reduced their stuttering, physical
          tension and secondary behaviors.
<phatmom2001> Could you give an example of how you teach using an easy onset?  What do you say to the child?
<Craig Coleman> Easy onset: glide into the word, almost like you are using a very silent "h" to start the word.
<Craig Coleman> Stuttering modification means that you are changing the stuttering. Strategies might include
          pull-outs, cancellations, easing out.
<Craig Coleman> Pull-out (C-c-c-c stop, breath, easy onset Can I go outside), Cancellation (C-c-can stop, breath,
          easy onset Can I go outside).
<AdrienneFSU> Is this different from shaping?
<Craig Coleman> Adrienne, speech modofication and fluency shaping are basically the same.
<AdrienneFSU> Thanks
<phatmom2001> Do you ever use cancellation techniques to cancel secondary behaviors? Could you give an example?
<Craig Coleman> Cancellations do target secondaries by reducing tension--you would use it the same way as above
          when you were tense during a stuttering episode.
<SandySLP> Would you describe the difference between pulling out and easing out?
<Craig Coleman> Pull out involves a stop then restart.
<Craig Coleman> Easing out involves a slight prolongation to end the word.
<SandySLP> Hmm, I'm not sure what that would sound like and how that would help?  Could you elaborate?
<Craig Coleman> Easing out th----iiiis is over.  --- equals a block and then you can use the slight
          prolongation to ease out.
<SandySLP> I see, thanks.
<phatmom2001> Basically, we are teaching ways the child who stutters can gain control over their speech.
<Craig Coleman> phatmom2001, that's only one thing we are teaching...this is where we need to be very careful.
<Craig Coleman> We are also teaching them how to accept their stuttering --this is just as important.
<SandySLP> Craig, if a child is denying that he/she stutters; maybe I should say denies the effects his speech
          has on himself and others, do we push that?
<Craig Coleman> Sandy, try the ACES--I'll bet he is more honest on there!
<Craig Coleman> If you know stuttering IS bothering them, I would try to help them work through it.
<SandySLP> This was very interesting.  I will definitely check out the site--and the ACES
<Craig Coleman> You can check out our website and newsletters (free) if you want...www.stutteringcenter.org.
<AdrienneFSU> great website!
<Robin> Craig..thank you so much for being here tonight and sharing your expertise!  This was an EXCELLENT chat!
<SandySLP> I hope you will be able to come again and share more treatment ideas.
<Robin> Thank you all for being here tonight...excellent questions.
<Abra> The information exchange is wonderful. I'll check back for future topics. Thanks.
<phatmom2001> Thank you
<Stephanie> Thanks for all your insight!
<mitra> Thanks
<AdrienneFSU> Thanks for all the info and suggestions Craig!
<jkasliner> Thank you
<Robin> Craig, thanks again!  Good night!!!
<SandySLP> Craig, thanks again.
<Stacyslp> Great chat, thanks.