As a clinical mentor and workshop provider for stuttering treatment, the feedback that I consistently receive is that clinicians are most reluctant to treat children between the ages of 8-12, who they perceive as the group likely to make the least progress. In light of current interests in evidence-based treatment it is clinically relevant at this time to consider which treatments are the best fit for school aged children. Evidence based treatment is the use of current best evidence in developing treatment programs for individual clients (Sackett, 1996). In evaluation of current treatments for this age group some questions that clinicians might ask that could be answered in the literature include a) what are the characteristics of effective treatments for stuttering in this age range, and b) are these treatments effective across clients in the short and long term?

We also need to evaluate existing resources to identify those treatments that are meeting the objectives of parents and children, are immediately functional to children in their daily life, that easily generalize to beyond clinic settings, that are fun and interesting, time limited from start to finish and result in natural sounding speech. Additionally, the people in the child's environment must be responsive to providing immediate feedback so that the child knows the consequences of his/her performance and can have a role in determining the rate at which treatment occurs in daily life. In order to meet these goals both clinician, child and parent must participate on problem solving strategies to modify behaviors. Therefore treatment must include simple, consistent in clinic and beyond clinic measurements of effectiveness, and must be shown to be efficacious for both the short and long term.

In assessment of stuttering it is understood that evaluation of stuttering in a school age population will include a combination of affective, behavioral and cognitive factors that may affect both the choice of treatment and its' potential outcome. This paper concentrates on the behavioral aspects of assessment and treatment. Our assessments include history of stuttering, its' severity across a variety of situations, treatment history, as well as any negative social consequences of stuttering that may affect treatment choices or outcome. We also identify any time constraints imposed by other activities, determination of who is available to assist with treatment and the expectations of therapy by the child, parent and others involved. Baseline measurements include speech measures such as a) percentage of stuttered syllables (%SS) for a variety of speaking situations both in and beyond the clinic, b) child's self ratings of stuttering severity (SR), naturalness and representativeness of each sample, c) parent rating of severity and typicality of the speech sample. Our assessment of school age children always involves an evaluation of the child's response to a treatment trial and discussion of parent/child expectations of treatment.

Although it is understood that some children may benefit from a multidimensional approach to stuttering treatment, the focus of this paper is on direct behavioral treatments for school age children that are evidence-based.

Several meta-analyses of treatments producing beneficial results have been published (Andrews et al, 1980; 1983; Cordes, 1998; Thomas & Howell, 2001). The results of these studies have noted that treatments are most effective when they a) provide negative contingencies for overt stuttering, b) begin treatment with a reduced length of utterance, c) begin treatment with prolonged speech that is gradually shaped into natural sounding stutter free speech, d) utilize a systematic transfer of fluency across settings and e) provide long term follow up data, although this last point is sadly deficient in the literature on long term outcomes of stuttering treatments.

Stuttering treatments for school aged children include those simple treatments that are based on response contingent stimulation such as the Lidcombe Program, ELU and GILCU. Although the Lidcombe Program was designed for use with a preschool population, data is emerging on the use of the program with school aged children (Lincoln, Onslow, Lewis & Wilson, 1996; Rousseau, Packman & Onslow, 2005). In Lincoln, et al, 11 children aged 7-11 responded to treatment based on the Lidcombe Program although the long term outcomes found that stutter free speech was not as stable as has been noted with preschool children. Rousseau et al evaluated the effectiveness of the Lidcombe Program with 8 school age children finding that it took longer to achieve stutter free speech and that there were more variations during Stage 2, which is the maintenance stage. This underlines the need for increased emphasis on long term support for maintenance of fluency with any program that is selected for a school age population. Our own clinical experience (Koushik & Shenker, 2005) with 14 children between 6; 0 and 10; 8 suggest that the Lidcombe Program can be an effective treatment in the establishment of stutter-free speech. In this group of children the pre-treatment percentage of stuttered syllables (%SS) was 2.4-8.7 (mean 6%SS) and the post treatment %SS ranged from 0.0-1.8%SS (mean 0.6%SS). The number of weeks to Stage 2 (maintenance) was 4-14 (mean 7.5). These children have been followed for up to 57 weeks post treatment (mean 20 weeks) and the range of stuttering at follow up is 0-2.8%SS (mean 0.9%SS) suggesting that while some variability has been noted in follow-up visits, stutter free speech is meeting the established criteria for most children for periods of up to 57 weeks post treatment. Although the Lidcombe Program appears to be a promising treatment for some school aged children, it may take longer to achieve the criterion for stutter free speech than with a preschool population, and lack of availability of parents in the schools has been described as a potential barrier to treatment. The observation that school aged children may present with more stuttering variability during Stage 2 of the Lidcombe Program, highlights the importance of criterion-based maintenance and follow up for any treatment of children in this age range.

Two simple treatments that have also been shown to be effective for school aged children are based in a gradual increase of length and complexity of utterance format. GILCU (Ryan, 1995) is a programmed, criterion-based direct treatment that has 54 programmed steps in the treatment phase. The target responses progress from 1 word, 2 words, 3 words to 1 sentence, 2 sentences, 4 sentences and to timed talking in 30 second increments up to 5 minutes in a clinical setting. The criterion for progression through the program is stutter-free speech (.5SW/M). This model is based on delivering positive feedback in the form of verbal, social, and tangible tokens for stutter free speech, with clinicians modeling in branching steps as needed to demonstrate fluency. Once stutter free speech is established, the transfer phase requires 10-15 hours and maintenance goals are to reduce the frequency of treatment sessions gradually over a two year period. Treatment outcome indicates a mean .6 SWPM, 15 months after maintenance (Ryan, 1995). Another criterion-based, programmed behavioral treatment is the ELU ( Riley & Ingham, 2000). The goal is facilitating spontaneous natural sounding, stutter-free speech in all situations. Treatment is based on control of the length and complexity of the child's utterances by reinforcing stutter-free speech and occasionally stopping the child for a moment of stuttering. A pass/fail criterion for each step of the program determines progression through the treatment format. Maintenance includes monthly beyond clinic %SS measures and longer visit intervals. In order to promote generalization in older children, some self management goals, parent feedback, addition of siblings in treatment, and possibility of adding some fluency shaping targets have been described. Riley and Ingham reported on 6 children aged 3;8 to 8;4. The reported a mean treatment time of 24 hours for therapy administered in twice-weekly, 1-hour clinic sessions. Pretreatment the children had a median 4.3%SS with 1.9% posttreatment.

Examples of complex treatments for school age stutterers are characterized by those which rely on speech restructuring using some form of prolonged speech. Druce, Debney & Byrt (1997) conducted an intensive program with 15 children, aged 6-8 years, for 61/2 hour per day for 5 days. The program utilized a combination of 'slow speech' modeled by the clinician plus token reinforcement for fluency and stuttering. Although a 76% decrease in stuttering was noted posttreatment the authors noted signs of relapse over the following 24 months.

An excellent example of evidence-based treatment of adolescent stutterers in a clinical setting has been described by Langevin & Kully (2003). Prolonged speech as a treatment target has also been used by O'Brian and colleagues ( 2003). This program which utilizes a non-programmed intensive, clinician-modeled speech prolongation may be an option for older children when taught by clinician modeling and shaped through systematic verbal feedback. At this point, although a promising treatment approach, no long term follow up has been published.

The treatments described above are all designed to be implemented within an academic school year. In choosing a treatment for school aged children some issues to be considered are a) number of clinical hours available for treatment, b) ease of generalization of treatment, c) treatment format, e.g., group/individual, weekly/intensive, d) the child's response to a treatment trial and e) amount of parent involvement required. A initial goal would be to aim for a treatment that can result in easy/relaxed stutter free speech in structured conversations in both within and beyond clinic settings. The child should be involved in all phases of treatment including setting all short term goals and activities, deciding the frequency and type of contingencies for stutter free and stuttered speech. Rewards, if used should be structured so that the child can earn them in many speaking situations, and any changes to treatment should be discussed between the clinician, child and others who may be involved. Basic speech measurement should be implemented to inform treatment progress or detect signs of lack of progress, or progress plateau so that these potential barriers to treatment can be identified, discussed and changes implemented within the treatment period. If treatment must be stalled for school holidays parents should agree to help maintain the level of stutter-free speech that has been achieved until the child resumes treatment.

An example of school aged treatment of a 9 year old child with stuttering and no other speech/language concerns follows. Tom was 9; 6 when treatment was initiated. A child in Grade 4, learning French as a second language, Tom had 16-19% SS in pre-treatment probes of stuttering rate and 24%SS at the first treatment session. His stutters were predominately characterized by long audible sound prolongations. He had a history of brief indirect treatment at age 5 that was aimed at environmental modifications, with no other treatment until initiation of the Lidcombe Program. Tom's mother attended and participated in all treatment and conducted therapy at home although it took one hour each way by public transport to attend the therapy. All goals were set by the client, parent and clinician, and in the later stages of treatment Tom collected Severity Ratings (SR) at school to inform treatment progress and to help set the goals for maintenance. All treatment materials were adapted to the child's interests so that the goal of Œhaving fun' could be met. No tangible rewards were required until the end of treatment since Tom was highly motivated by decreasing SRs, positive (however inconsistent) feedback from teachers and an increased ability to communicate with his best friend. Any change in rate or type of verbal/nonverbal feedback, which forms the basis for the Lidcombe Program, was negotiated with Tom and his mother. At a treatment plateau a period of clinician modeled speech prolongation was introduced in order to further reduce stuttering severity. Tom did not accept this step and preferred a short period of increased verbal feedback that resulted in a further increase in stutter free speech after 3 weeks. Some problems that were identified were in helping Tom's mother adapt to giving feedback in more unstructured speaking conversations at home, and a treatment plateau that was solved by increasing the amount of feedback, making the feedback more specific and adding a reward that was highly meaningful to Tom. Treatment time for Stage 1 of the Lidcombe Program was 23 sessions over 40 weeks, due to an interruption of therapy. Tom achieved a Stage 2 criterion that was adjusted to < 2%SS and SR < 2 at his request. A table showing Tom's progress in treatment is presented below. The left axis indicates perceptual rating of stuttering severity on a scale of 1-10 where 1 = no stuttering and 10= extremely severe stuttering. Severity ratings shown are the average for each week. Percent Stuttered Syllables (%SS) is indicated on the right axis.

This paper has been written with the school-based clinician in mind, hoping to stimulate some treatment ideas that can be incorporated into current best practices. It is hoped that these suggestions will help clinicians to implement treatment that can meet the needs of the clinic setting, while incorporating some of the principals of evidence-based therapy for demonstrating the effectiveness of any treatment, as well as planning for the collection of sufficient follow up data to assess the durability of the chosen treatment.

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Koushik, S. & Shenker, R. (2005). Treatment outcomes for a group of school-aged Children treated with the Lidcombe Program. Unpublished clinical audit.

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