Early Childhood Stuttering
About 80% of stutterers are children. Almost all stutterers started stuttering as young children.
However, until recently little was known about childhood stuttering. A 1986 survey found that 80% of research studies focused on adult stuttering, and only 20% about childhood stuttering. [1] Recent research has exploded many long-believed myths about early childhood stuttering, and helps us better understand school-age and adult stuttering.
Prevalence and Comparison to Normal Disfluencies
Approximately 5% of preschool children stutter. [2] The average age of stuttering onset is 34 months (two years, ten months old). [3] Approximately 90% of stuttering cases start before the age of four. [4]
At the ages of two and three, children are rapidly developing speech and language skills. All children make speech and language mistakes or normal disfluencies at this age. However, early childhood stuttering is different from normal disfluencies. [5]
Normal disfluencies are mostly interjections of "um," "uh," and similar fillers; and, to a lesser extent, revisions and word repetitions. [6]
Early stuttering is primarily sound, syllable, and word repetitions; and, to a lesser extent, prolonged sounds and blocks; and also revisions and interjections. [7]
The Stuttering Foundation of America has a brochure and a video to help parents and clinicians to make a differential diagnosis between early childhood stuttering and normal disfluencies. [8] However, according to Ehud Yairi and Nicoline Grinager Ambrose,
parents usually are reliable in diagnosing stuttering in their child....the identification of early stuttering in clinical settings is seldom difficult. We wonder why several authors...have expressed a different opinion, emphasizing the great overlap and possible confusion between early stuttering and normal disfluency, and cautioning clinicians of the difficult task. [9]
Onset
Stuttering typically begins suddenly. Unlike other communication disorders, stuttering begins after the development of normal speech. Other communication disorders occur because normal speech fails to develop, for various reasons. [10] But stuttering children first developed normal speech, or, typically, better than normal speech and language skills. Then one day, one week, or over a few weeks, the child starts to stutter.
Approximately 30% of stuttering children started stuttering in one day, 40% started in three days or less, almost 50% in on week or less, and almost 75% in two weeks or less. [11]
85% of parents reported that at the onset of stuttering, their child repeated syllables and words three to five times per instance of stuttering. In addition, 36% reported sound prolongations, and 23% reported conspicuous silent intervals during speech, 14% reported blocks, 18% reported facial contortions, and 18% reported respiratory irregularities. 36% reported moderate to severe tension or force during speech. In contrast, only 32% of parents reported that their child started stuttering with only easy, effortless repetitions. [12]
Within one year of onset, most parents (53%) reported secondary physical symptoms, including tension or strain in the face, eyes, lips, tongue, jaw, and neck; respiratory irregularities, and tense movements (jerks) of the head or limbs. [13]
At the onset of stuttering, boys outnumber girls by about 2:1. [15]
A study of 3,404 preschoolers in Illinois found no differences in prevalence between African-American, European-American, and other racial groups. [16]
Triggering Events for Stuttering Onset
That the onset of stuttering is usually sudden was only recently discovered. Since the 1930s speech-language pathologists believed that stuttering developed gradually, through well-defined stages starting with simple, easy, effortless repetitions and increasing in complexity and severity.
The sudden onset of stuttering is difficult to explain. It suggests that something triggers stuttering in susceptible children. Only about 50% of parents associated a triggering event with the onset of stuttering in their child. In 14% of cases, the onset of stuttering was associated with illnesses or excessive fatigue. 40% of cases were associated with emotionally upsetting events, and 36% of cases were associated with "development stress," e.g., toilet training. [14]
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a triggering event for sudden onset of Tourette syndrome and obsessive compulsive disorder (OCD). A child develops a streptococcal infection and then his autoimmune system attacks an area of his brain. In children who suddenly developed Tourette's the autoimmune system attacked the brain's putamen motor control area. [38]
Tourette's, OCD, and stuttering are disorders associated with the neurotransmitter dopamine. They are all associated with the genes that control dopamine in the brain. Tourette's, OCD, and stuttering are similar in many ways. Both stuttering and Tourette's involve repetitive, semi-voluntary movements; in Tourette's the movements may include eye blinking, throat clearing, touching walls, etc. All three disorders are exacerbated in stressful situations, and trying to control the behaviors exacerbates the behaviors (e.g., trying not to stutter leads to more severe stuttering).
A case of sudden onset childhood stuttering has been associated with PANDAS. [39] It's possible that the child's autoimmune system attacked his left caudate nucleus speech motor control area, making this brain area abnormally sensitive to dopamine, instead of attacking the putamen motor control area associated with Tourette's.
Recovery
In the Illinois Longitudinal Study of 89 stuttering children, most children recovered from stuttering, without treatment or therapy, within three years of the onset of stuttering (around age six).
The greatest period of recover was 31 to 36 months after onset (five to six years old). Four years (48 months) after onset, approximately 75% of children recovered; and five years (60 months) after onset 80% had recovered. None of the 19 children (20%) who stuttered more than five years (i.e., were still stuttering after around age eight) recovered, even though 17 of these 19 children received speech therapy. [17]
The Illinois study found that the 89 children could be divided into two groups. Some children recovered rapidly (the black circles in Figure 5.3), while other children recovered slowly (the black diamonds in Figure 5.3; the white triangles are children who didn't stutter).
The rapid recovery group recovered half their fluency within one year, and almost all their fluency within two years.
The "persistent" group gradually improved fluency over five years. [18] Some of these children recovered fluency, some continued to stutter after five years.
No differences were found between the two groups, i.e., initially severe stutterers were not more likely than initially mild stutterers to recover quickly or slowly. [19] Girls were more likely to recover than boys, and more likely to recover quickly, but the sample size of girls was too small to be statistically significant. [20]
Phonological Development
Phonological development is the ability to perceive and produce speech sounds (phonemes), many of which are subtly different. It encompasses articulation disorders, which are an inability to produce specific speech sounds. Either way the result is a child producing unintelligible speech. [21]
The Illinois study found that soon after onset, children who stutter are behind their peers in phonological development. Within two years, the stuttering children catch up to their peers in phonological development. The children who rapidly recovered from stuttering also rapidly caught up with their peers in phonological development. The children who persisted in stuttering were slower to catch up in their phonological development. [22]
Abnormal auditory processing is linked to phonological disorders. It's possible that the abnormal auditory processing found in adult stutterers could be the cause of phonological delays seen in children who stutter.
Language Development
The language abilities of young children who stutter has been the subject of many studies. The "longstanding view" in the field has been that young children who stutter have language learning difficulties or language impairment, although the deficiencies are small and within normal ranges. [23] Different studies used different tests, and examined different age groups.
A series of studies used a variety of language tests with children within three months of the onset of stuttering, with a control group matched for age, gender (girls develop language skills faster than boys), and socio-economic status. No statistically significant differences were found that. The stuttering children "performed more poorly" than the control group, but "most stuttering children scored well above average for age." [24] This seems impossible, unless the controls were all baby Einsteins, or the tests were standardized poorly.
The Illinois study took a different approach, by analyzing children's spontaneous speech (as opposed to their responses to tests). In this study, the stuttering children were above average in language development, for both comprehension (listening) and expression (speaking). [25]
The children who went on to rapid recoveries (the black diamonds and squares in Figure 7.1) scored especially high. The children whose stuttering persisted (the black circles and triangles in Figure 7.1) had lower language scores, but still better than normal. Over two years the stuttering children lost most of their high scores compared to their peers, i.e., their peers caught up to them in language development.
Language is complex, integrating many areas of the brain, and generalizations about language abilities may be inappropriate. For example, I enjoy slowly composing and rewriting e-mails (and books), but I dislike fast-paced online chatting or text messaging. I can read and write Spanish, but I can't understand spoken Spanish. I was good at a job writing computer manuals, but I can't write poetry. My puns are infamous among my friends. Rap artists make millions of dollars solely on their language skills, but rap songs all sound the same to me.
Making the issue more complex, the ages between two and four are when children rapidly expand their abilities to hear and speak language. [26] Some children develop some language skills faster than other language skills, and this has some relationship to stuttering, but the exact relationship is unclear.
Motor, Psychosocial, and Cognitive Abilities
The fluent speech of preschool children who stutter differs from that of peers who don't stutter. The stutterers appear to have poorer than normal vocal fold function, reflecting difficulty integrating respiratory, laryngeal, and cortical control; [27] and speak slower. [28] Children who later persisted in stuttering had restricted articulatory movements, as measured by F2 formant transitions, although children who later rapidly recovered were as good as or better than their non-stuttering peers in this measure. [29]
Psychologically, no differences were found between children who stuttered, or their parents, when tested close to the onset of stuttering, and non-stuttering children and their parents, for behavior problems, energy levels, and maturity levels; [30] stress levels for the parents; [31] anxiety levels for the children; [32] and non-verbal cognitive skills (e.g., matching blocks with various colors). [33] No link was found between awareness of stuttering and anxiety. [34]
The overactive speech motor control associated with adult stuttering and the genetic abnormalities related to dopamine could precede childhood stuttering and cause the children's' poor vocal fold control and difficulty integrating speech motor activity.
Indirect Therapy
The Iowa treatment for early childhood stuttering is indirect therapy. The aim is reduce a child's fears and anxieties about stuttering by altering the parents' behavior.
The fluency shaping era treatment for early childhood stuttering is direct therapy. The aim is to train the child to speak fluently.
The neurological era of stuttering treatment hasn't developed an early childhood stuttering treatment. Anti-stuttering devices and anti-stuttering medications aren't used with preschool children. Maybe phonological therapy will help young stutterers, but no one has tried this.
The Diagnosogenic Theory
All children have normal disfluencies. Examples include repeating words or phrases, hesitations, or using filler words such as "uh" and "um." [41] The diagnosogenic theory, developed by Wendell Johnson between 1934 and 1939 and published in 1942, proposed that stuttering begins with unusually anxious or perfectionistic parents. These parents react negatively to normal childhood disfluencies. The child then may develop anticipatory avoidance reactions, i.e., try to anticipate normal disfluencies and physically struggle to avoid them. [42] These struggles and avoidances, together with learned fears and anxieties develop in stages into stuttering. Johnson wrote that stuttering begins "not in the child's mouth but in the parent's ear." [43]
Johnson and his researchers were unable to prove that parents of stuttering children were substantially different from parents of non-stuttering children. [44] Then they compared the speech of stuttering children, at the onset of stuttering in one study [45] and after a period of one month to three years in a second study, [46] to the normal disfluencies of non-stuttering children, finding stuttering to be very different from normal disfluencies.
But Johnson didn't let the facts get in the way of his theory. He believed that speech therapy made stuttering worse, and advocated not treating young children's stuttering. Instead, Johnson and others developed indirect therapy. Practitioners of indirect therapy modify the parents' behavior, without altering the child's speech.
Johnson's Popularity Today
Today Johnson's indirect therapy is widely practiced. For example, the Stuttering Foundation of America advises parents to
Try to model slow and relaxed speech when talking with your child, and encourage other family members to do the same. When your child talks to you or asks you a question, try to pause a second or so before you answer. Reduce the number of questions you ask your child. [47]
The National Institute of Deafness and Other Communication Disorders advises parents to "speak slowly and in a relaxed manner. If a parent speaks this way, the child will often speak in the same slow, relaxed manner." [48]
KidsHealth.org advises parents to "Provide a calm atmosphere in the home. Try to slow down the pace of family life. Speak slowly and clearly when talking to your child or others in his or her presence." [49]
Efficacy of Indirect Therapy
A literature review found
little convincing evidence that parents of children who stutter differ from parents of children who do not stutter in the way they talk with their children. Similarly, there is little objective support that parents' speech behaviors contribute to children's stuttering or that modifying parents' speech behaviors facilitates children's fluency. [50]
More than a dozen studies found no evidence that altering parental behavior changed children's speech. These studies found no differences for:
- The language of mothers of preschool children who stutter vs. controls; and no difference between the parents of children who recovered from stuttering vs. parents of children whose stuttering persisted. [51]
- Positive statements (praise, encouragement, agreement).
- Negative statements (criticism, reprimands).
- Questions.
- Topic initiations and terminations. [52]
- Conversational assertiveness and responsiveness. [53]
- "Response time latency," or the time between one person finishing speaking and the other person beginning speaking. [54]
- "Formal" style vs. a "casual" style. [55]
- Illocution (the communicative effect of an utterance). [56]
Some studies found that indirect therapy produced results opposite to the researchers' expectations:
- A study found that mothers interrupt their child after disfluencies, not before. [57] This suggests that not interrupting causes children to stutter!
- A study found that when mothers spoke faster their children spoke slower. [58] Another study trained parents to slow their speaking rates. The children's speaking rate increased. [59] This suggests that parents talking slowly causes their children to stutter!
- Parents of children who stutter produced more positive statements (e.g., praise, encouragement) and fewer negative statements (criticisms, disparaging remarks) than parents of children who didn't stutter. [60] This suggests that parents' praise and encouragement causes children to stutter!
- A multiyear study followed 93 preschool children. At the start, none of the children stuttered. One year later, 26 of the children stuttered. The researchers compared the speech behaviors of the two groups of mothers, before their children started stuttering. No differences were found, except that mothers of children who would stutter had shorter, less complex sentences. [61] That suggests that short, simple language causes children to stutter.
More generally, some psychologists now discount the role of parents in the development of children's character and personality. About 50% of the personality differences are attributable to our genes, and the rest due to the child's peers: " what parents do seems to be nearly irrelevant." [62]
Could Indirect Therapy Harm Children?
Practitioners of indirect therapy advise parents to use simpler language with their stuttering children. But
the complexity of input language is a very potent predictor of children's later language profiles greater sophistication in parental input language is positively associated with children's language proficiency. [63]
In other words, exposure to language in early childhood relates to the child's later language abilities and IQ scores. "Dumbing down" how you talk to your child might achieve nothing but dumbing down your child.
Direct Therapy
In contrast, direct therapy changes the child's speech and behaviors. Typically these speech-language pathologists advocate treating all stuttering children, as soon as possible after the onset of stuttering. They believe that early treatment is more effective with less time and cost than later therapy. [64]
However, little or no research supports these beliefs. One program claimed 100% effectiveness for all the children who completed the program but only about half the children who started the program completed it. [65] Other programs make effectiveness claims without presenting data. [66] Still other programs have good research but failed to use a control group.
Different studies use different methods to measure stuttering. Different studies have different time frames (e.g., measuring fluency one year post-therapy vs. three years post-therapy). Recovery rates might be higher or lower depending on how stuttering is measured, or what the time frame is. A measurement method might find that 90% of children in a therapy program are fluent three years later and find that 90% of children who received no therapy were also fluent three years later.
The Lidcombe Program
The most popular direct therapy, and the only direct therapy that has been proven effective, is the Lidcombe Program. The therapy appears to be more effective than other therapies because it is simple enough for parents to do at home, yet is a direct therapy.
Developed in Australia, the therapy begins with a clinician verbally rewarding the child's fluent speech, e.g., saying "good talking."
Originally the therapy also included negative reinforcement for disfluent speech, e.g., "that was bumpy speech." Clinicians were told to make one negative reinforcement for each five positive reinforcements. The negative reinforcement has been dropped from the current program.
Children are sometimes asked for self-evaluation, e.g., "Was that smooth speech?" The clinician also actively corrects the child's disfluencies by repeating the child's words fluently, and the child is asked to repeat the words fluently, sometimes several times.
Next, a parent is trained to practice this therapy with his or her child at home. Home therapy begins with brief structured sessions and progresses to everyday conversations.
The therapy also encourages children to spontaneously self-evaluate and self-correct, e.g., to recognize when they are disfluent, state this ("that word was bumpy"), and then repeat the word fluently. Eleven clinical visits is typical. [67]
The Lidcombe Program is one of the few stuttering therapy programs that emphasizes documentation of the child's speech progress. [68] Several studies have shown the Lidcombe Program to be effective, including two studies with control groups. [69] In one study, 43 preschool children were found to have near-zero stuttering two to seven years post-treatment. [70]
The Lidcombe Program is ineffective for school-age children.
Other Direct Therapies
Other direct therapies include:
- An adaptation of adult prolonged speech stuttering therapy (fluency shaping therapy) to children, including slow speech with stretched vowels; reducing vocal volume, especially on the first syllable; and blending words (continuous phonation); while progressing from single-syllable words to longer conversations. [71] A study found that a fluency shaping program was effective for 30 out of 33 preschoolers, or 91%. This study is questionable because data was presented for only on child, and the study lacked a control group. [72]
- Gradual Increase of Length and Complexity of Utterances (GILCU) therapy uses verbal positive reinforcement (e.g., "good") for fluent speech, beginning with single-syllable words and progressing to 5-minute conversations. [73] A study of five children who received 20 hours of treatment found that stuttering decreased more than 60%. [74]
- The Stocker Probe rewards the child for fluent speech while increasing linguistic demands, from forced-choice answers (e.g., "Is it round or square?"), to single word responses (e.g., "What is it?"), to open-ended questions (e.g., "What can you use it for?"), to detailed description (e.g., "Tell me about it."), to formulation of novel content ("Make up your own story about it."). [75]
- Speech Motor Training trains the child to produce all of the sounds of speech by saying sequences of nonsense syllables with as fast a speaking rate as the child can achieve while maintaining accuracy. [76] A study of six children found that after 24 sessions stuttering was reduced on average about 49%. [77]
- Psychotherapeutic play therapy analyzes stress in a child's life and his reactions to stress, improve maternal bonding, play and interact with different personalities, etc. [78] A study of a play therapy program in Japan claimed 90% success, but no control group was included.
I'm unaware of any studies or cases of preschool stutterers who received therapy to improve their auditory processing, or other treatments that included use of computers or other electronic devices.
Direct Therapy Games
Speech-language pathologists use games to encourage speaking, to train specific speech skills, or to reinforce fluent speech.
The game "Solo Play" encourages speaking. The speech-language pathologist has two boxes of toys, one for the child, and the other for herself. At first, they silently play with their toys. Gradually, the speech-language pathologist starts making car or animal noises as she plays. Then she adds single words. Then her toys start bumping into the child's toys, and they interact for short periods. Eventually she uses short phrases and sentences. This places no speaking demands on the child. The goal is to let the child verbalize little by little, as he or she feels like talking.
In the game "Turtle Talk," the speech-language pathologist makes a turtle hand puppet walk slowly when the child uses slow, relaxed speech. When the child uses fast, tense speech, the turtle stops and crawls into his shell. The child has to use slow, relaxed speech to ask the turtle to come out of his shell. If you don't have a turtle hand puppet, you can have a car slowly drive along a table, avoiding obstacles.
In the game "Say The Magic Word," the clinician or parent says that he or she is thinking of a word, and if the child guesses the word, he will be rewarded with a peanut or will be allowed to ring a bell. They then look through a picture book or look out a window. This game is easy for a parent to play while driving with the child. When the child says a word fluently, the parent says that that was the magic word, and rewards the child. If the child stutters, he isn't rewarded. The parent doesn't think of any word, but rather listens for the child to say fluent words.
In the game "Can't Catch Me," one person gets a peanut when the other person asks a question. You then quietly eat your peanut before answering the question. If you answer the question before eating your peanut, you must put your peanut back. The parent should lose more peanuts than the child, by answering too quickly. This reduces the time pressure the child feels about quickly answering questions.
Modeling
Caitlyn, a four-year-old female who began to stutter in the midst of her parents' divorce, was exhibiting significant struggle and tension behavior as well as secondary behaviors. Of most concern was her head-banging behavior during difficult moments of stuttering. After many sessions in which I attempted to eliminate this behavior through fluency-shaping principles, I saw no change. One day, shortly after Caitlyn banged her forehead on the table to interrupt a block, I modeled the same behavior. Caitlyn was shocked and ignored me. After I did this several times she asked me, "Why did you do that? Didn't that hurt?" I responded, "I don't know why I did it. But it sure didn't help me get my word out!" Caitlyn never again banged her head to help her talk. She has been out of therapy for six years and remains fluent. [79]
This speech-language pathologist's modeling of Caitlyn's behavior was radically different from conventional stuttering therapy practices. Most clinicians would have pretended not to notice Caitlyn's head-banging behavior. They believe that modeling is the same as mocking, teasing, or bullying and will cause emotional trauma.
But let's try a Gedankenexperiment (thought experiment). Imagine that a teenage brother and sister use profanity at the family dinner table. Should the parents act horrified and tell their children never to use such language?
You know that won't work. The teenagers will use profanity at the next opportunity, just for the amusement of horrifying their parents. Instead, picture the parents immediately using twice the profanity of the teenagers. Dad could say, "#$%^, this is best *&^% meatloaf in the whole @#$% world!" Mom could respond, "Oh, you big !@#$, you're so #$%^ sexy and when you talk ^%$#!"
I guaranty that the teenagers will turn red with embarrassment, and never use profanity again in front of their parents.
In a psychology class about traumatized children we saw a video of a ten-year-old boy destroying a psychologist's office. The boy threw every object he could throw, and smashed everything else. The psychologist sat there calmly telling the boy not to destroy the office. He finally grabbed the boy and hugged him. To me it looked like a full body restraint but the instructor said it was a hug, and that was what the boy really needed.
I asked what would have happened if the psychologist had modeled the boy's behavior, i.e., the psychologist could have thrown and smashed stuff. The instructor said that was the worst idea she'd ever heard. But I think the boy would have stopped, watched in amazement as the psychologist destroyed his own office, and then asked, "Why did you do that?" The boy and the psychologist could then have started talking about their feelings, which is what I think the boy needed.
The purpose of modeling is to improve the subject's awareness of his or her behaviors. Stutterers are largely unaware of their stuttering, or at least what they do when they stutter. Everyone else can see the stuttering but the stutterer can't. Combining video and modeling can help a stutterer improve self-awareness.
Modeling also dispels a person's mistaken view that a behavior is invisible, or it's acceptable, or everyone does it. If everyone ignores undesirable behavior then the person may think it's OK.
Modeling only works when the clinician and/or the client know how to replace the undesirable behavior with a target (good) behavior. For example, it's OK for your speech-language pathologist to model your stuttering because she can then show you how to speak fluently. It was OK for my Romantic Disaster of 1996 to make me aware that I was stuttering, because I knew what to do to talk fluently. It's not OK to point out a problem to someone if they have no idea what to do about it.
References
[1] Yairi, E., & Ambrose, N.G. (2005). Early Childhood Stuttering for Clinicians by Clinicians. ISBN 0-89079-985-7, page 5; citing M. R. Adams, 1986.
[2] Yairi, E., & Ambrose, N.G. (2005). Early Childhood Stuttering for Clinicians by Clinicians. ISBN 89079-985-7, page 5.
[3] Yairi, E., & Ambrose, N.G. (2005). Early Childhood Stuttering for Clinicians by Clinicians. ISBN 89079-985-7, page 6.
[4] Yairi, E., & Ambrose, N.G. (2005). Early Childhood Stuttering for Clinicians by Clinicians. ISBN 89079-985-7, page 6.
[5] Natke, U., Sandrieser, P., Pietrowsky, R., & Kalveram, K.T. (2006). Disfluency data of German preschool children who stutter and comparison children. Journal of Fluency Disorders, 31, 165-176.
[6] Bloodstein, O., & Bernstein Ratner, N. (2007). A Handbook on Stuttering, Sixth Edition.. Clifton Park, NY: Thomson. ISBN 978-1-4180-4203-5, page 313.
[7] Yairi, E., Ambrose, N.G. Early Childhood Stuttering. (2005, ISBN 89079-985-7), page 97.
[8] Guitar, B., & Conture, E. If You Think Your Child Is Stuttering Stuttering Foundation of America, accessed 2008 April 25 http://www.stutteringhelp.org/Default.aspx?tabid=6; Stuttering and Your Child: Help for Parents, http://www.stutteringhelp.org/Default.aspx?tabid=492
[9] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), pages 314-315.
[10] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 46.
[11] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 58.
[12] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 67.
[13] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 69.
[14] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 62-63.
[15] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 53.
[16] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 76.
[17] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 167. Chart on page 177 follows this paragraph.
[18] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 177.
[19] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 192.
[20] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 192.
[21] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 199.
[22] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 229.
[23] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 238.
[24] Bloodstein, O., & Bernstein Ratner, N. (2007). A Handbook on Stuttering, Sixth Edition.. Clifton Park, NY: Thomson. ISBN 978-1-4180-4203-5, page 213.
[25] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 239. Chart on page 240 follows this paragraph.
[26] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 237.
[27] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 256-257.
[28] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 258-259.
[29] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 260.
[30] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 263.
[31] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 263.
[32] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 266-267.
[33] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 266-269.
[34] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 283.
[35] Yairi, E., & Ambrose, N.G. Early Childhood Stuttering for Clinicians by Clinicians. (2005, ISBN 89079-985-7), page 309.
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