Hierarchies provide a systematic structure for achieving cognitive, behavioral, social and affective goals for the school-aged child who stutters. Challenges that are set up by the child are more likely to create ownership for the child. When goals reflect the child's priorities, there is increased likelihood that the child will practice learned skills, therefore increasing transfer and maintenance (Sisskin, 2002). Utilization of hierarchies in the clinical practice of stuttering aim to explore the nature and variability of speaking fears, promote generalization of learned techniques, increase self-monitoring, and provide data for establishing task sequences for objectives and assignments (Sisskin, 2002).

Goal-setting worksheets acknowledge the child's current accomplishments and provide benchmarks for attainable and relevant future goals (Sisskin, 2002). It is appropriate for clinicians to guide the child in selecting a set of speaking situations, both in and out of the therapy setting and with a variety of speaking partners, and supplement them with situations that are appropriate for the client (Yaruss, J.S.,1997; Costello & Ingham, 1984). Speaking Outside the Box is a visual representation of child-constructed hierarchies in which speaking partners (Who), settings or locations (Where), speaking tasks or activities (What), and speaking situations (When) are listed and entered around the expanding layers of a box. The center box represents Who, What, When and Where the child feels most comfortable with his stuttering. Many times the center of the box represents the therapy setting with the clinician. We ask the child to list another person that the child is willing to complete the agreed upon goal with. Then we ask/guide the child in choosing the other three components: where will he complete the task, what the speaking situation will entail, and when this will happen. Each of the four sides of the first layer will then have a Who, What, When and Where component written in, in two or three words.

At this first level, the child should be very likely to achieve the task. A sample objective for this first task might be: In the therapy room (Where), Sarah will produce 20 easy stretches with Mrs. Cahalan (Who) while reading a list of 25 words (What), during two consecutive group therapy sessions (When). Upon achievement, the child will color in the first layer around the box. As you move out to the next layer, the challenge of the task increases in at least one of the four components. The clinician guides the child and determines if certain components need to stay the same and/or which components will change to allow for gradual increases in variety and complexity of situations. In summary, the clinician guides the child in creating challenges in and out of the therapy room, and the clinician has an effective means of measuring, controlling and manipulating cognitive, behavioral, social/environmental and affective variables. As the child completes the tasks moving from the inner to outer layers of the box, the child colors in the layers until the box is completely filled in. The child can collect boxes in a binder with his other information/projects on stuttering, display the boxes at home, or transfer each completed box to a larger master box with all levels represented.

The following are examples of the four components for a school-aged child:

• Who: SLP, parents, sibling, friend, classmates, teacher
• What: words, sentences, reading out loud, oral report, conversation
• Where: home, classroom, playground, friendıs house, lunchroom
• When: during speech therapy, participating in small group, participating in classroom, during dinner, on telephone

References:

Costelo, J.M., & Ingham, R.J. (1984). Assessment strategies for stuttering. In R. F. Curlee, a & W.H. Perkins (Eds.), Nature and treatment of stuttering: New directions. (pp. 103-323). San Diego,

Sisskin, V., (2002). Therapy Planning for School-Age Children Who Stutter. Seminars in Speech and Language; 23, 173-179.

Yaruss, J.S., (1997). Clinical Measurement of Stuttering Behaviors. Contemporary Issues in Communication Science and Disorders, 24, 33-43

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