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Assessment and Treatment of

Fluency Disorders in Bilingual


Children
Kerry Danahy, M.A., CCC-SLP
University of Minnesota
dana0007@umn.edu

Introduction
There

is very little research examining fluency


disorders in bilingual speakers.
BUT that doesnt mean we are lost in assessing and
treating this population:
We can use what we know about fluency and about
bilingualism, as well as cultural influence, to work
with bilingual children with fluency disorders.

Why do children stutter?


Most

current models of stuttering are


multifactorial.
Factors that interact to cause stuttering include:
genetics, environment, language skills, motor
skills, and temperament.
This information gives us some insight into
bilingual speakers who stutter.

Factors for bilingual children


In

bilingual children, genetics, motor skills, and


temperament will be constant across languages.
It is extremely unlikely that a bilingual child will
stutter in one language and not the other (e.g., Van
Borsel, Maes, & Foulon, 2001).

Factors for bilingual children


Language

skills and environment (including home


vs. school environments, cultural beliefs associated
with one language, etc.) may differ significantly
between languages.
It is common for children to stutter more
frequently in one language than the other (e.g.,
Nwokah, 1988).

Stuttering Prevalence in Bilingual


Speakers
It

has been estimated that about 1% of the worlds


population stutters (Bloodstein, 1995).
Many authors have claimed that stuttering is more
prevalent among bilinguals than among
monolinguals (e.g., Karniol, 1992; Nwokah, 1988).
However, the evidence for this conclusion is
questionable (Van Borsel et al., 2001).

Stuttering Prevalence in Bilingual


Speakers
Evidence that eliminating bilingual input to preschool
children improves fluency is very limited and has been
disputed (see Bernstein Ratner, 2004; and Van Borsel et
al., 2001, for reviews).
No support exists for reducing bilingual input to disfluent
speakers older than preschool.
As in other disorders, the childs need for bilingual
proficiency to meet environmental needs is paramount.

Assessment
Bilingual children may present additional assessment
challenges, because difficulty formulating utterances due
to limited proficiency in either a first or second language
can look like disfluent speech.
However, we can rely on key features of true stuttering to
distinguish children with fluency disorders (Watson and
Kayser, 1994):

Stuttering will be present in both languages.


Stuttering is usually accompanied by self-awareness.
Secondary behaviors often accompany stuttering.

Assessment
Core

areas to assess are the same for bilingual and


monolingual children:
Disfluencies
Secondaries
Childs beliefs

and emotions about stuttering


Other speech and language skills
Parents beliefs about stuttering
Developmental history

Assessing Disfluencies

Measurement of disfluencies is similar for monolingual and


bilingual children:
collect language samples from conversation and oral reading
calculate frequency and duration of disfluencies.

English behavioral stuttering assessment tools (e.g., SSI-3;


Riley, 1994) may be adapted as criterion-referenced
measures for other languages (Bernstein Ratner, 2004).
Word-based (rather than syllable-based) counts of
stuttering frequency may be more accurate across
languages.

Assessing Disfluencies
Specific types of atypical and typical disfluencies
may vary in frequency across languages.
Atypical disfluencies include blocks,
prolongations, sound and syllable repetitions, and
broken words.

Typological features of the language may affect where


these occur, and how often.

Typical disfluencies include hesitations, filler


words, revisions, word and phrase repetitions.

Cultural factors may affect how often and where


speakers use these (Bernstein Ratner, 2004).

Assessing Disfluencies

However, atypical disfluencies have similar


characteristics across languages:
Struggle
Loss of eye contact
Avoidance behavior
Disruption in the typical forward flow of speech

These features have been shown to be prominent


enough for people to identify disfluencies in a
language they do not speak.

Assessing Secondary Behaviors


Types of secondary behaviors look the same in
different languages, and are distinct signs of
fluency disorders.
May involve:

Eyes
Lips
Cheeks/other facial muscles
Arms or legs

A child could have different secondary behaviors


in different languages.

Assessing Behaviors: Things to


Remember
When

assessing frequency and severity of


disfluencies and secondaries, remember that
stuttering is highly variable across environments.
Variability is even more pronounced in bilingual
children because stuttering can also vary across
languages.
Important to get a representative picture of childs
speech across environments.

Assessing Behaviors: Things to


Remember
Word

and situation avoidances can be difficult to


catch in monolingual children.
Bilingual children can also use code-switching to
avoid stuttering.
This makes identifying avoidances even more
difficult, because there are many other reasons to
code-switch, and appropriate code-switching may
be difficult to identify.

Assessing Beliefs and Emotions


Cognitive

and affective factors are central


to stuttering and important to assess.
Cultural factors will impact the childs
beliefs and emotions (e.g., Nwokah, 1988).
Bilingual children may show greater
situational variation in their reactions to
stuttering due to differences in culture
between home and school environments.

Assessing Beliefs and Emotions


Questionnaires

are available to assess this


area for school-aged children (e.g., ACES,
available through
http://www.stutteringcenter.org).
May need to modify questionnaires to
account for:
Limited

English proficiency.
Differences in cultural beliefs across
environments.

Assessing Other Speech and


Language Skills
Language

and/or articulation proficiency may


affect stuttering frequency and severity (also
reviewed in Van Borsel et al., 2001) :
Stuttering

may be more prevalent in weaker language:

Increased

stress in weaker language may increase stuttering.


More difficult motor demands (e.g., unfamiliar sounds) may
increase stuttering.
Stuttering
Slower

may be more prevalent in stronger language:

speech rate and simpler utterances in weaker language


may increase fluency.
Experiences in stronger language may increase disfluencies.

Assessing Other Speech and


Language Skills
It

is also important to remember that children who


stutter are much more likely to have another speech
or language disorder (or even another fluency
disorder, such as cluttering) than children who do
not stutter.

Assessing Parent Beliefs &


Developmental History
Interviews

with parents and other family members


can give valuable insights into cultural beliefs
about stuttering that affect the child.
Asking broad, open-ended questions that allow the
parent to describe his/her views often give the most
information.
Parents descriptions of how the fluency problem
began often reflect views of why children stutter.

Treatment
Central goal of therapy for school-aged children is to
manage stuttering (e.g., Reardon-Reeves & Yaruss, 2004).
We do not currently have a cure past the preschool
years.
Several sub-goals may be important components of
stuttering management for the child:

Reduced frequency and severity of disfluencies


Knowledge of techniques to manage moments of stuttering
Acceptance of self, including stuttering

Treatment: Fluency Shaping


Fluency

shaping techniques are designed to reduce


the frequency of disfluencies.
All of them modify speech in some manner.
It is important to remember that there is a tradeoff
between naturalness and fluency benefits: the more
the child modifies her speech, the less likely she is
to be disfluent, BUT the more unnatural she will
sound.

Treatment: Fluency Shaping


It

is also important to remember that it is


HARD to use fluency shaping techniques in
conversational speech.
It is not reasonable to expect children to use
fluency shaping all the time, because of
difficulty and unnaturalness.
Goal should be for children to learn effective
techniques so that they can choose when to
use them.

Treatment: Fluency Shaping


Fluency

shaping techniques include:

Slowed

rate (typically through prolonged speech with


continuous phonation)
Easy onsets
Light articulatory contacts
Easy prolongations or repetitions to begin utterances
Fluency

shaping techniques can be used in any


language.

Treatment: Fluency Shaping


The

application of fluency shaping techniques will


be different in different languages due to different
typologies.
Children may not be able to apply techniques to
their other language without explicit instruction
and practice.
Cultural impact of using fluency shaping
techniques may vary.

Treatment: Stuttering
Modification
Stuttering

modification techniques are


typically used to reduce the severity of
disfluencies and to give the child increased
control in stuttering moments.
Stuttering modification has been
traditionally been used with children who
stutter more severely.
BUT these techniques can be useful for all
children who stutter, particularly if they
demonstrate shame or avoidance.

Treatment: Stuttering
Modification
Stuttering

modification includes techniques for:

Recognizing

a stuttering moment
Cancelling or pulling out of it
Continuing to speak (perhaps with the help of fluency
shaping techniques)

Treatment: Stuttering
Modification
Stuttering

modification also usually includes


desensitization.
Desensitization work overlaps with cognitive and
emotional treatment.
Basic goal of desensitization is to make the child
less afraid of stuttering.

Treatment: Desensitization

Activities to achieve desensitization include:


Freezing in a stuttering moment
Describing the stuttering moment
Pseudo-stuttering, in increasingly difficult situations
Manipulating length and severity of pseudo-stutters

Desensitization effects are likely to be situationspecific.


It may be particularly difficult for bilingual
children to become more comfortable with
stuttering in their home/community environments.

Treatment: Attitudes and


Emotions

Most children who stutter benefit from a basic


understanding of stuttering, including:
The normal speech production process.
Changes to the process that produce stuttering.
Potential causes of stuttering.
The existence of other people who stutter, including successful
adults.

This education will be similar for monolingual and


bilingual children, except that adult role models may be
different.

Treatment: Attitudes and


Emotions
Identifying

core beliefs about stuttering is an


important goal for most children who stutter.
Negative beliefs often lead children to avoid
stuttering at all costs.
Negative beliefs can be restructured to be more
reasonable.

Treatment: Attitudes and


Emotions
For

example:

If the child believes, No one will want to listen to me if I stutter,


It is more accurate to say that some people may not want to listen,
but others will still want to hear what you have to say.
Rewriting this belief with the child may help him become more
accepting of stuttering.

Bilingual

children may have language-specific


beliefs, such as believing they will not stutter in a
new language.

Treatment: Attitudes and


Emotions
Many

children benefit from making connections


with other children who stutter.
Online groups include the National Association of
Young People Who Stutter
http://www.friendswhostutter.org, and postings on
Judith Kuster's Stuttering Homepage:
http://www.mnsu.edu/comdis/kuster/stutter.html
International Stuttering Association spans countries
but uses English (http://www.stutterisa.org)

Treatment: Generalization
Generalization

is always an important
consideration in fluency therapy.
Bilingual children need to generalize skills to
multiple languages and cultural environments.
Limited evidence exists to show that therapy can
be successful in one language and not generalize to
another (Humphrey, 1999, as cited in Bernstein
Ratner, 2001).

Treatment: Generalization
Setting

up specific plans for the child to use skills


such as fluency shaping, stuttering modification,
and desensitization in both languages and different
environments is essential.
Generalization of cognitive and emotional changes
may be easier, if beliefs associated with both
cultures are addressed in therapy.

Summary
Bilingual

children who stutter present us with


several challenges.
But we have the tools to meet them.
Remember basic principles:
Bilingual

children who stutter will stutter in both


languages.
We need to consider behaviors across languages and
environments during assessment.
We need to address both languages in treatment.

Summary
There

is a critical need for additional research on


bilinguals who stutter to support clinical practice
in this area.
Current additional information is available online
at http://www.stutteringhelp.org/Default.aspx?tabid=55

Additional Language-Specific
Resources
Stuttering

Foundation of America has pamphlets


and videos translated into Spanish and French.
Online

store can be accessed through


http://www.stutteringhelp.org

Stuttering

Foundation of America has also created


a website in Spanish (http://www.tartamudez.org)

References

Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual


children. In B. Goldstein (ed.). Language Development: a focus on
the Spanish-English speaker. Baltimore, MD: Brookes. (287-310).
Bloodstein, O. A handbook on stuttering. London: Chapman & Hall.
Humphrey, B. (1999, November). Bilingual Stuttering: Can treating
one language improve fluency in both? Paper presented at the
American Speech-Language-Hearing Association Annual
Convention, San Francisco, CA.
Karniol, R. (1992). Stuttering out of bilingualism. First Language,
12, 255-283.

References

Reardon-Reeves, N.A., & Yaruss, J.S. (2004). The source for


stuttering. East Moline, IL: LinguiSystems.
Riley, G. (1994). Stuttering Severity Instrument for Children and
Adults (3rd ed.). Austin, TX: PRO-ED.
Nwokah, E. (1988). The imbalance of stuttering behavior in
bilingual speakers. Journal of Fluency Disorders, 13, 357-373.
Van Borsel, J., Maes, E., & Foulon, S. (2001). Stuttering and
bilingualism: A review. Journal of Fluency Disorders, 26, 179-206.
Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural
adults who stutter. Seminars in Speech and Language, 15, 149-163.

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