About the presenter: Anthony J. Caruso, Ph.D., professor, School of Speech Pathology & Audiology , Kent State University, has been actively involved in the clinical management of adults and children who stutter for over 17 years.. He has published several journal articles and book chapters on the physiological events associated with fluent and stuttered speech. Caruso (with E. Strand) co-edited a recent book entitled "Clinical Management of Motor Speech Disorders in Children" (Thieme).

You can post Questions/comments about the following paper to Anthony Caruso before October 22, 2000.

Virtual clients and real clinicians: Increasing Opportunities for Clinical Training in Fluency

by Anthony J. Caruso
from Ohio, USA

Recent changes in ASHA training requirements at the pre-service level have effectively eliminated problem-solving opportunities for some students in fluency disorders. Students are not required to accrue clinical clock hours in fluency. This is unfortunate in view of recent findings indicating that the current generation of working professionals believes they are not well trained to treat people who stutter (PWS). Moreover, these same professionals and their supervisors ranked fluency disorders as the most needed area (along with voice) for in-service training. Note that although stuttering comprised the smallest proportion of their total caseload it was the top area of demand for further training (Sommers & Caruso, 1995). Recent findings document that many of the currently working professional clinicians view fluency disorders as an area of concern and lack confidence in their clinical skills (Kelly et al., 1997; Sommers & Caruso, 1995; St. Louis & Durrenberger, 1993). One way to "fill the void" of clinical training in stuttering is through the use of interactive, multimedia training modules. Such training modules have been utilized in professions (e.g., aviation and medicine). Two of the major advantages of interactive software training programs that are applicable to communication disorders are: a) facilitating untrained individuals to learn new skills without compromising well being of themselves or consumers; and b) providing training opportunities with patients with low incidence disorders. In light of these advantages the application of this technology in fluency disorders is compelling.

Software that focuses on "anchored instruction" (that is, active learning) through the use of interactive multimedia holds much promise for pre-service and in-service education and training. Anchored learning is a process by which learners generate their own solutions to problems rather than being instructed as to what the solutions are (Vanderbilt, 1992). Patient simulation technology (PST) is a valuable tool which displays clinical scenarios in which learners must self-generate an appropriate solution. Because of its reliance on a problem-solving approach to learning, learners who interact with PST are much more likely to be able to apply learned information to other similar situations than individuals acquiring knowledge through lecture/readings (Clancey, 1991).

The development of instructional software, and, more specifically, PST in fluency disorders is timely as recent findings suggest that the use of interactive, multimedia programs has several positive effects on the learner’s understanding of new and complex concepts. A non-expository format which includes video, sound and graphics can help a learner construct a mental model more readily than the either the written word or lectures by instructor/supervisor (Bloch, 1991; Gagne, 1987; Jonassen, 1995). Moreover, the use of interactive technology often results in students learning more, faster and with greater retention as compared to traditional avenues of learning (cf., Iran-Nejad, Marsh, & Clements, 1992; Johnson; 1994; Shuell, 1990; Steele, 1989).

It is emphasized here that PST can be used to augment rather than replace traditional methods of teaching/learning theoretical constructs and clinical procedures. One major advantage of PST is that it encourages active learning during which the learner experiences direct awareness of developing constructions through self- regulation (Marsh & Iran-Nejad, 1992).

Benefits to Fluency Evaluation and Treatment

Interactive educational software and PST can be used to train some of the following skills necessary in fluency disorders: 1) stuttering identification; 2) administration of (in)formal/(non)standardized tests; 3) various techniques (e.g., slow speech rate) to facilitate fluency (see Max & Caruso, 1997). A sample of such applications was present at a recent ASHA computer lab by Caruso, McClowry & Kuster (1999). Additionally, the present writer is developing software designed to train clinicians to interact with family members of PWS. Specific topics include: a) modifying parents' communication to facilitate their children's fluency; and b) emotional support by parents for their children who stutter. For example, participants will be presented with interactive multimedia segments that are designed to teach parents of children who stutter how to slow down their rate of speech. Participants will work at their own workstations and will be required to answer questions presented by the program. Many of the strategies included in this section have been previously discussed (Logan & Caruso, 1997). The unique advantage of PST is that, although, all participants will view the same training program, it is likely that participants' experiences will differ from each other. The path of this interactional software will depend on how each participant answers questions. Different responses by the participants will take them along different paths such that each participant may see different "versions" of the training program based on his/her responses. Participants will have an opportunity to rate both the lesson as well as self-assess their learning as a result of the these programs.

Classroom Applications

Other uses of software such as those described above include incorporating laboratory activities as a part of a undergraduate or graduate course on stuttering. At Kent State University, the graduate course on stuttering includes several labs designed for use on the Internet. These labs are used to increase students' abilities to consistently identify stuttering types, calculate stuttering and other speech related measure (e.g., speech rate) and learn how to score and interpret tests. Student complete the lab, answer questions pertaining to the lab experience and submit it to the instructor via e-mail. An immediate confirmation showing the student's answers is provided. If readers of this paper would like to see one of these labs, you can find an example HERE


Interactive multimedia and PST may provide cost effective pre-/in-service training in fluency. The present writer wishes to emphasize that while the potential contributions of PST may be considerable, it does not fully replace the face-to-face supervised practica that were formally required by ASHA. Unfortunately, however, given the current requirement for clinical training, virtual patients may be the only reality for many students who are attempting to develop and refine their clinical acumen in fluency disorders.


Caruso,AJ, McClowry, MT, & Kuster J (1999). Computerized PST to Increase Competence in Stuttering Treatment. A computer workshop presented at the American Speech Language Hearing Association, November, San Francisco, CA

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Gagne, R. (1987). Instructional Technology Foundations. Hillsdale, NJ: Lawrence Erlbaum Association. Iran-Nejad, A., Marsh, G.E., & Clements A.D. (1992). The figure and the ground of constructive brain functioning: Beyond explicit memory processes. Educational Psychologist, 27, 473-492.

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Kelly, E.M., et al. (1997). Academic and clinical preparation and practices of school speech-language pathologists with people who stutter, Language, Speech and Hearing Services in Schools, 28, 195-212.

Logan, KJ & Caruso, AJ (1997) Parents as partners in the treatment of childhood stuttering. Seminars in Speech Language, 18(4):309-26

Marsh G.E., & Iran-Nejad, A. (1992). Intelligence: Beyond a monolithic concept. Bulletin of the Psychonomic Society. 30(4), 329-332.

Max, L. & Caruso, A.J. (1997). Contemporary techniques for establishing fluency in the treatment of adults who stutter. Contemporary Issues in Communication Sciences and Disorders, 24, 45-52.

Shuell, T.J. (1990). Phases of meaningful learning. Review of Educational Research, 60, 23-25.

Sommers, R.K., & Caruso, A.J. (1995). Inservice training in speech-language pathology: are we meeting the needs for fluency training?, American Journal of Speech-Language Pathology, 4, 22-28.

St. Louis, K.O. & Durrenberger, C.H. (1993). What communication disorders do experienced clinicians prefer to manage?, Asha, 35, 23-31.

Steele, D.B. (1989). The effects of nonprogrammed, nonremediated, and interactive videotape instruction on the achievement of ninth-grade students. Doctoral dissertation, The University of Alabama, 1989. Ann Arbor, MI: University Microfilms International.

You can post Questions/comments about the above paper to Anthony Caruso before October 22, 2000.

September 22, 2000