Welcome From: Nan Bernstein Ratner Date: 9/24/99 Time: 3:32:41 PM Remote Name: 129.2.24.18 Comments I really appreciate any thoughts you have about our current research direction. I am happy to send copies of papers or more recent conference posters. best regards, Nan Advice for Parents From: Shirley Bowen Date: 10/4/99 Time: 10:24:26 PM Remote Name: 206.96.234.91 Comments What do you advise parents to do as a method of increased fluency? Re: Advice for Parents From: Nan Ratner Date: 10/6/99 Time: 3:42:23 PM Remote Name: 129.2.24.18 Comments The advice we give currently looks like this: Speak more slowly (our research confirms other research suggesting that it helps reduce (not cure) stuttering events. Try to reduce talk time competition (reduce interruption behavior in the household, encourage turn taking, find protected time to share language, such as bed time joint bookreading, etc. Don't IGNORE the problem: if the child has obvious difficulty, reassure him/her that sometimes everyone has trouble talking, and you understand, it's OK. We think this reduces fear. When parents IGNORE something that concerns the child, it can send a bad message. Otherwise, we don't feel we have data to recommend particular parental strategies. We suggest that some strategies out there are not real helpful: telling the child to take a deep breath and start over probably sets up later behaviors that are problematic. Nan question From: Jennifer Harris Date: 10/5/99 Time: 9:33:14 AM Remote Name: 205.188.198.156 Comments Your findings include that the stuttering children's performance on the language development tasks was below that of non-stuttering children. It was concluded that the children may have a language weakness that could affect their ability to fluently produce speech. Have there been any studies which have shown a correlation between language disorders and stuttering in older children or adults who stutter? Re: question From: NanÊ Ratner Date: 10/6/99 Time: 3:47:41 PM Remote Name: 129.2.24.18 Comments There are little data to suggest that people who stutter have overt, clinical language problems. However, research by Wingate (see his book, 1988: The structure of stuttering: a psycholinguistic analysis) has data suggesting weaknesses on some linguistic tasks by stuttering adults; similar information is available in Watson, et al, (1991), Journal of Fluency Disorders. I have a fairly deep study of these issues in a chapter in a chapter in R. Curlee and G. Siegel's recent text: Nature and Treatment of Stuttering: New directions (second edition) 1997, Allyn & Bacon. For a critique of the literature suggesting that children who stutter are linguistically impaired, see Nippold, 1990, Journal of Speech and Hearing Disorders, 51-60. Nan question From: Karen Nix Date: 10/6/99 Time: 7:34:15 AM Remote Name: 152.163.195.199 Comments I enjoyed reading your essay and wonder if you could answer a few questions. In the study that you wrote about, did any of the 15 children grow out of their stutter in the three years that you studied them? If any did, how did that affect your results? I am also curious about whether or not you have looked at or found any difference between the language of children who grow out of stuttering versus children who do not. I would appreciate any insights you have on these questions. Thank you. Re: question From: Nan Ratner Date: 10/6/99 Time: 3:50:12 PM Remote Name: 129.2.24.18 Comments We were not funded to do our research and did not pay subjects. For this reason, many parents did not keep in touch. We suspect that the ones who didn't had children outgrow the problem, since parents who kept in touch had children who were still experiencing difficulty. Using this criteria, 3/15 children were still stuttering throughout the 3-year time frame, or 20%, a number that agrees strongly with data posted by Dick Curlee elsewhere in this conference. The numbers are unfortunately much too small to perform an analysis of whether language skills affected outcome. I wouldn't even speculate given such a small sample size. You need many more children to do that well. Nan Parents of Children Who Stutter From: Amanda Marshall Date: 10/6/99 Time: 9:21:42 AM Remote Name: 150.216.50.130 Comments Hello, I am a first year graduate student at East Carolina University. I was just have one question. Why do you think parents of children who stutter are a better judge of their children's language abilities than other parents? Re: Parents of Children Who Stutter From: Nan Ratner Date: 10/6/99 Time: 3:54:19 PM Remote Name: 129.2.24.18 Comments Well, remember that the parents of the kids who stutter are really paying attention to their kids' speech because of the stuttering. So it may be that the stuttering makes parents more aware in general. However, we interpret our findings a little more loosely. We think that the differences between the groups are not great, and are not significant. We think that they only tell us that parents of children who stutter are not LESS tuned in than parents of kids who are fluent, and therefore the notion that stuttering children live in environments that might stress their language capacities because parents are not tuned into their abilities is not supported by our data. Pardon me if this last sentence was garbled. It's been a long day. Nan question From: Pamela L. Godfrey Date: 10/6/99 Time: 10:42:09 AM Remote Name: 208.25.245.117 Comments Dear Dr. Ratner, I am a graduate student in the CSDI department at East Carolina University. I am also interested in the effects of language and fluency. I have always wondered if fluency has any effect on language learning or language comprehension. For example, if a child stutters while reading a passage outloud, does that effect his comprehension of the passage he has just read-- wondering if he is concentrating more on being fluent and word production instead of word content and meaning. This question also applies to language learning. Is there research that could answer my question? Have you ever considered it in this way, which is totally reversed from your article's statements? Thank you, Pamela L. Godfrey Graduate Student, CSDI East Carolina University Greenville, NC Re: question From: Nan Ratner Date: 10/6/99 Time: 3:55:25 PM Remote Name: 129.2.24.18 Comments I don't know of data to answer your questions, which are very good ones. I think you might have possible thesis topics there. Nan Parental Assessment From: Kathy Perry Date: 10/6/99 Time: 11:11:30 AM Remote Name: 150.216.146.139 Comments What do you think accounts for the difference in how accurately parents of children who stutter assess their child's language skills versus the way parents of nonstuttering children assess these skills? Does this suggest that parents are more in tune when their child exhibits patterns that stray from the norm? Re: Parental Assessment From: Nan Ratner Date: 10/6/99 Time: 3:57:56 PM Remote Name: 129.2.24.18 Comments I answered some of this question in an earlier post (I apologize for being slow today, but I was out of town for a funeral). To answer your second question, I think it is important to note that none of our children were outside the norms for anything other than their fluency. Their speech and language skills were somewhat lower, but perfectly normal. None of the kids could be considered clinically disordered for language, and only one appeared to have a relevant articulation problem. So, I don't think that's it. I think that the advantage we saw for the parents of stuttering children was not statistically significant, and only argues against the opposite view, that parents of stuttering children might have unreasonable expectations of their children. best regards, Nan Effects on Approaching Therapy From: Heather Herrman Date: 10/8/99 Time: 10:55:59 AM Remote Name: 205.188.199.179 Comments I found your results very interesting. I'm wondering if you wuld be able to answer this question though. For the children who had language difficulties along with stuttering, what was addressed first in therapy, the language impairment or the stuttering? Hope you can help. Thank you, Heather Herrman Graduate student, MSU, Mankato Re: Effects on Approaching Therapy: need to clarify your interpretation of my data From: Nan Ratner Date: 10/8/99 Time: 2:33:11 PM Remote Name: 205.188.198.26 Comments Hi, thanks for the question. I need to reiterate (and I apologize if my original presentation was unclear) that NONE of the stuttering children had language PROBLEMS. They simply scored less well on language tests than did the non-stuttering children of the same gender, age and socio-economic background they were matched to. To give some examples, on the articulation test, the stuttering children scored slightly above the 50th percentile, while the fluent children scored about 13 percentile points higher. On receptive vocabulary, the stuttering kids were about 13 points above average (the 50th percentile), while the fluent children were about 8 points higher. For NONE of the language and speech measures we took did the stuttering children score appreciably lower than the normative average score. It's just that the nonstuttering children consistently outscored them by between 8-15 percentile points. Now, this is what we would expect if we try to use clinical speech and language tests to see if stuttering children have somewhat weaker language than nonstuttering children. These tests are not designed to detect SUBTLE language differences between groups. They are designed to "catch" kids who are seriously behind and need therapy. We used them only as a first step in developing hypotheses about the areas in which stuttering children may be developing a little more slowly than nonstuttering children. So, the long answer to your question is that none of the children needed therapy, so the question of whether we addressed fluency or language first is not relevant here. IF we did have such a child, we would address both, not wait until one problem is fixed to solve the other one. However, our work, and clinical experience suggest that children who stutter who have concomitant language problems have more difficulty gaining fluency because language formulation stress is known to seriously compromise a child's ability to generate fluent utterances (my own work, and that of many others, including Scott Yaruss and Peter Howell (also contributing to this conference), among others. best regards, Nan Question From: Marian McGruder Date: 10/10/99 Time: 7:16:36 PM Remote Name: 205.188.192.53 Comments In your article, you stated that parents of stuttering children were "better" at predicting how their children would preform on language tests than parents of children who do not stutter. Could this ability to predict language performance be related to information the parents may have acquired regarding their children from previous or other evaluations? What were the expections of the parents of the stuttering children with regards to language performance levels as oppossed to the parents with children who did not stutter? Were their expections higher, lower, or about the same? Re: Question From: Nan Ratner Date: 10/11/99 Time: 9:20:14 AM Remote Name: 129.2.24.18 Comments Your questions are good ones. I don't believe that the parents of the children who stutter got information about their child from other evaluations because all 15 children whose data we report in this study (under review in a major journal) were seeing us as their first evaluation. No parent reported taking their child elsewhere, and we believe them because we saw the children so close to onset of symptoms (that was the design of the study). The parents of children who stutter ranked them slightly lower on two separate assessments. One (the MacArthur Communcative Development Inventory) looks at vocabulary the adult thinks the child uses and sentence structures characteristic of their conversation; the other (the Speech and Language Assessment Scale) looks at more global impressions (such as "my child understands language as well as other children." The second device examines comprehension as well as production. In all cases, mothers and fathers rated the children who stutter slightly lower. HOWEVER, their children SCORED SLIGHTLY LOWER than did non-stuttering children. In the end, there was stronger correlation between the judgements of parents of stuttering children and actual test and conversational language performance by the children than we observed in the parental judgements and performance of children who did not stutter. Regards, Nan apraxia and dysfluency From: mary harding-smith Date: 10/17/99 Time: 7:45:04 AM Remote Name: 152.163.197.74 Comments You mentioned that other language issues can compromise the improvement rate of stuttering. What information is available regarding apraxia of speech, word retrieval issues and stuttering? Re: apraxia and dysfluency From: Nan Bernstein Ratner Date: 10/18/99 Time: 8:52:16 AM Remote Name: 129.2.24.18 Comments Thanks for writing. There is no structured information available to answer your question. We can infer from many studies that stuttering is exacerbated whenever language load is high, thus a word-finding problem should compromise fluency significantly. In some cases of language impairment, clinicians diagnose stuttering when the fluency problem they see does not have classical signs of stuttering (lack of struggle, tension, awareness), and the child clearly has a word-finding problem. This problem would best be addressed by strengthening language skills. The case of a child with true clinical stuttering and significant word retrieval problems as well would seem to be more difficult to work with, since language skills must be strengthened in addition to fluency skills/stuttering modification strategies for the problem to be adequately addressed. In older children and adults with clinical stuttering, one must also distinguish between what appears to be a word-finding problem and avoidance strategies (and resulting circumlocutions), which can lead to similar language output patterns. I don't know of any real "data" on apraxia concomitant with clinical stuttering, although others on this list may wish to comment. best regards, Nan Parent Assessment of Child's Language From: Christine Showman Date: 10/17/99 Time: 12:42:55 PM Remote Name: 150.135.70.251 Comments You stated that parents of children who stutter were better able to predict how their children would perform on language testing than parents of children who did not stutter. What were your criteria for determining this? How accurate were the parents of children who stutter in predicting their children's language performance? Re: Parent Assessment of Child's Language From: Nan Bernstein Ratner Date: 10/18/99 Time: 9:06:20 AM Remote Name: 129.2.24.18 Comments Parents of all children in our study filled out two different parental report forms. Mothers and fathers filled out forms separately, to allow us to compare their judgements. The two forms were: The MacArthur CDI (Communication Development Inventory; Fenson et al, 1993)), a well-recognized research tool for assessing parental judgements of very young children's language. See Thal, et al, Journal of Speech,Language and Hearing Research, 1999, 42, 482-496 for a recent critique of this device. It asks parents to check off vocabulary items that they believe their children knows and uses, and asks them to select utterances from multiple-choice options that best characterize how their child might say a particular type of sentence. The second device was the SLAS (Speech and Language Assessment Scale; Hadley & Rice, 1993). This tool asks parents to rate their children on a 7-point scale on global measures of language production, understanding and articulation. For example, items might say, "My child's ability to use proper words when talking to others is..." or "My child understands as much as other children his/her age..." What we did was to correlate mothers' and fathers' scores on these two devices with their children's actual performance on standardized tests of: articulation, word naming and comprehension, sentence understanding and grammatical completion, as well as some other measures taken from the children's expressive language samples in our clinic. Correlations were much higher between judgements of parents of children who stutter for both the SLAS and CDI with all of their children's actual scores, and many reached significance. Correlations between parental judgements for parents of children who don't stutter and their children's scores were much much lower, and in some cases, we actually got negative values. We don't want to make a big deal of this. Our interpretation of this particular finding, now in review at a journal, is that parents of stuttering children do reasonably well at understanding their children's linguistic abilities. Thus, we believe that they are unlikely to be creating an environment for them that unduly places linguistic stressors on them. In past research, there is good agreement between parental perception and parental behavior in language to children. Obviously, we need to examine the parents' speech to the stuttering and non-stuttering children. We have just finished doing this, and Stephanie Miles will be presenting her thesis data at the November ASHA convention. Parents of children who stutter accomodate their speech to their children's level of language development just as well as do parents of non-stuttering kids. They do not appear to be "overstimulating" them, or providing them with overly ambitious language models to keep up with. We believe that these data weaken some types of advisement to the parents of stuttering children that suggests simplification of the home language environment as an aid to increased fluency. Hope this helps! best regards, Nan Struggle reactions From: Angelique Budaya Date: 10/21/99 Time: 12:39:40 AM Remote Name: 150.135.118.106 Comments You mentioned a finding that suggested a precocious self-monitoring system that could be characteristic of children who stutter. I understand how this could possibly relate to children whose onset may have been gradual but what of children who have a sudden onset? If I recall, there have been instances in which a child has suddenly found him- or herself stuttering with signs of struggle with no apparent cause. How would the proposition of a precocious self-monitoring system explain such a case? Thanks for your time. Re: Struggle reactions From: Nan Ratner Date: 10/21/99 Time: 1:52:52 PM Remote Name: 129.2.24.18 Comments Sorry for the delay, it's been a busy day. The model we are developing suggests that the disfluencies in early stuttering arise from subtle problems in language encoding. At the typical age at which stuttering emerges, most children do not appear to monitor their speech output very much. We propose that children who begin to display the more characteristic struggled events we see as stutters develop an ability to attend to their output just at this time when their output is not fluent. In a model such as this, one would actually expect a rather sudden onset of symptoms, because when the child begins to hear something he or she doesn't like, it could very quickly sensitize them so that they increasingly monitor, and increasingly react when they hear themselves "failing." Hope this helps explain our reasoning. best regards, Nan Struggle reactions continued From: Angelique Budaya Date: 10/21/99 Time: 12:43:49 AM Remote Name: 150.135.118.106 Comments I just realized in my previous question that your suggested self-monitoring system really pertained to response to DAF. Yet I still have another question. How would it be possible to test language formulation difficulty and its possilbe relation to stuttering with children of such a young age? Re: Struggle reactions continued From: Nan Bernstein Ratner Date: 10/21/99 Time: 2:00:41 PM Remote Name: 129.2.24.18 Comments I really like your questions! There are a number of ways to explore the possibility that language demands affect fluency, even in children this young. I discuss some of them in my chapter for Curlee & Siegel's 1997 textbook, Nature and treatment of stuttering. Briefly, what we have done typically is to see if stuttering increases are linked to increases in length of utterance in morphemes (MLU, a conventional measure of early language complexity), to Developmental Sentence Score, or whether stuttering increases when children are asked to imitate sentences that have been chosen to represent varying levels of linguistic difficulty for children (my own work in the mid-eighties). This time around, we extended our definition. Because children at the onset of stuttering are still rather young and still learning aspects of language, their conversational language contains age-appropriate errors in grammatical usage. Three year old children often leave off plural and tense endings, or leave out articles/helping verbs, or mismatch noun-verb number, or mis-assign case for pronouns ("him going"). What we did was to compare stuttering rates in sentences that kids produced WITHOUT such errors and WITH such errors. We found a HIGHLY significant relationship between stuttering and the presence of these errors in all of our kids. We take this to suggest that stuttering is more likely to occur when a child has not yet mastered the linguistic rules for what he is trying to say (this happens to people trying out second languages as well, they stumble quite a bit!). I hope this answers your question - keep 'em coming! best regards, Nan Question From: Lynn K. Bender Date: 10/21/99 Time: 3:53:01 PM Remote Name: 136.234.50.67 Comments In the article you stated that parents of stuttering children were better at predicting their child's outcome on a language test versus parents of non stutterers. Do you have an idea as to why these parents seemed to be more in tune with their children? Re: Question From: Nan Ratner Date: 10/22/99 Time: 2:29:33 PM Remote Name: 205.188.197.153 Comments As I comment on in an earlier thread, I don't like to make a big deal out of the fact that the parents were better at predicting their kid's language because I do not believe that the parents were significantly better (we did not run tests of significance on the multiple sets of correlations; rather we noted higher correlations between parent ratings and tests in the parents-of-kids-who-stutter group than in the comparison group, but we did not submit these differences in correlations to statistical analysis.) What we prefer to take from this finding, as we note in our article to appear in JSLHR, is that parents of kids who stutter are tuned in WELL, and thus do not need counseling about modifying language demands placed on the children. It is always possible, as we also note in an earlier thread, that once parents note a problem such as fluency, it tunes them in to other aspects of the child's behavior. best regards, Nan