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EvidenceBasedPractices:WorkingwithYoungChildren
WhoStutter
KristinA.ChmelaM.A.CCC-SLPBCS-FBuffaloGrove,Illinois
Chmela2018/AllRightsReserved1
“Itisnowwidelyacceptedthatstutteringisamultidimensionaldisorder.Itisalsowidelyacceptedthatstutteringisaneurodevelopmentaldisorder,whichmeansthatitarisesduringdevelopmentinchildhood.”
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ChildhoodStuttering–WhereareweandWherearewegoing?
AnneSmith,Ph.D.andChristineWeber,Ph.D.,CCC-SLPSeminarsSpeechLang.2016November;
37(4):291–297
Agenda
• ApplyaRiskFactorAnalysis• DevelopDifferentialTreatmentPlans• Demonstrate5EssentialClinicalSkills
Chmela2018/AllRightsReserved 3
StutteringPersistencevs.Recovery
Preschool-1stgrade
2nd-4thgrade
5th-8thgrade
1yearpostonset: 63%recover2yearspostonset:47%recover3yearspostonset:16%recover4yearspostonset:5%recover
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PrimaryRiskFactors(rankordered)
1.Familyhistoryofpersistedstuttering2.MaleGender3.Trendsoffluencypatternflatorincreasedinfrequency4.Persistence6-12monthspostonset5.Ageatonsetafter3½6.Repetitionsof2-3ormoreunits;quickertempo7.Prolongations/Blocks
6
(Yairi&Ambrose,2005,IllinoisPredictionCriteria;Yairi&Seery,2015;Kraft&Yairi,2011)
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SecondaryRiskFactors
Ø Quantityofstutteringremainssevereafter1yearØ Head&neckmovementremainsfrequent&severeafter1
yearØ Phonologicalskillsbelownormalinearlyphaseof
stutteringØ Expressivelanguageskillsremainadvancedovertimeor
presentasweak
7
(Yairi&Ambrose,2005,IllinoisPredictionCriteria;Yairi&Seery,2015;Kraft&Yairi,2011)
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OtherConsiderations
Ø Childshowsfrustration/withdrawal/avoidanceØ Child’stemperamentpresentswithlowersensory
threshold,adaptability,&attention;higherreactivity&distractibility
Ø OtherdevelopmentalissuespresentØ Caregiversdisplaysignificantanxiety/negativemanner
ofreactingØ Familyhistoryofspeech/language,learning,anxiety,
mood,ADHD,ticorcompulsivedisorders;autismspectrumdisorder
8
Jones,Conture,&Walden,2014;Ntourou,Conture,&Walden,2013Choi,Conture,Walden,Lambert,&Tumanova,2013;
Ntourou,Oyler,&Conture,2013;Eggersetal.,2010;Schwenketal.,2007;Karassetal.,2006;Andersonetal.,2003;Embrechtsetal.,2000
Chmela2018/AllRightsReserved
InitialContactKeyQuestionsIsthereafamilyhistoryofpersistedstuttering?Whatgenderisyourchild?Whendidtheproblemstart?Howlonghasitbeengoingon?Canyoudescribethetrend?Whatisyourchilddoingwhenhe/shestutters?Doyouhaveanyotherconcernsforyourchild?Canyoudescribehis/hertemperament?Howareyou-othersfeelingandreactingtothis?
10Chmela2018/AllRightsReserved
Case Example #1• 27monthsoldboy;“extremelyverbal”• Startedtoexhibitsomenormaltypesofdisfluencyaboutonemonthago
• “Thelasttwodayshecan’tgetasentenceoutatall…he’llstartcryingandsayhecan’tremember.”
• Mothercalledverydistressed• Sheandherhusband“constantlytalktohim”andfeelhislanguageskillsareveryadvanced
• Nohistoryofstutteringinthefamily• Nootherconcernswithdevelopment;verysensitive• Itis“sosadandsuddenandwedon’tknowwhattodo.”
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’
InitialContactRiskFactorAnalysisCase#1Primaryfactors?Secondaryfactors?Otherconsiderations?LevelofRisk:
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Case Example #2• 6years,0monthsold;male• Startedtostutteratabout4yearsofage• Beganwithpartwordrepetitions;prolongationshavenowemergedinlast2months;hekeepsontalking
• Motherfeelsheisawareofit;Peershaveaskedhimwhyhetalksthewayhedoes
• Concernsregardingattention;levelofintensity• Historyofstutteringinthefamily-motherisnotsureifhestillstuttersornot;paternaluncle
• Verybrightchild;1stgradeteachernotesheseemstobelesstalkativeinclassoverthepastmonthorso
• Didhavespeechtherapyforphonologicaldelaywhenhewas3-4yearsofage;nospeechsincehis5thbirthday 13Chmela2018/AllRightsReserved
InitialContactRiskFactorAnalysisCase#2Primaryfactors?Secondaryfactors?Otherconsiderations?LevelofRisk:
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Case Example #3• Age3years,9months;female• Startedtostutteraround2½• Trendhasbeenconsistent(abouta“4”acrossa1-10scaleforfrequency);Asofonemonthago,tensionaroundsomepartwordrepetitionshasemerged
• Fatherstutters;persisted(mothersayssherarelyseesit)• Veryeasygoing,happychild;nodifficultywithtransitions• Seemstohavetroubleexplainingthings;usesmultiplewordandpartwordrepetitions;“uhmandlike”are“everywhere”
• Fatherhighlyconcerned-feelsitishisfault• Historyofearinfections,allergies;nomedications 15Chmela2018/AllRightsReserved
InitialContactRiskFactorAnalysisCase#3Primaryfactors?Secondaryfactors?Otherconsiderations?LevelofRisk:
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Environment&Family
Ø Essentialtoinvolveothers(Boeyetal.,2009;Langevinetal.,2010;Bothe&Richardson,2011;Mewherter,M.,&CincinnatiChildren'sHospitalMedicalCenter.(2012).Cincinnati(OH):CincinnatiChildren'sHospitalMedicalCenter,(BESt137),1-7.)
Ø Environmentalimpactsmayimpactexacerbateproblem((Anderson,Pellowski,Conture,&Kelly,2003)
Ø Siblingimpacts(Beilbyetal.,2012) Chmela2018/AllRightsReserved 17
Ø Communicativecompetenceandlimitedverbalparticipation;increasegestureuse,abortattemptstoconveyamessage,maywithdrawfromplay
(Langevinetal.,2009)Ø Morethanhalfofpreschoolchildrenareawareoftheirstutteringanddevelopnegativeperceptionsabouttheirabilitytocommunicate,whichbecomesincreasinglyapparentasageincreases
(Boeyetal.,2009;Vanryckeghem,Brutten,&Hernandez,2005)
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ClinicalActionsVeryLowtoLowRiskatinitialcontact
-Childusuallyveryyoung(underorearly3’s)-Decisionoftenmadebycarefulexplorationofriskfactorsbyphonecontactoraconsultationsession(screening);videosamplessentinbyparent-RTIoption
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RTIRedFlag
• DrivenbyRiskFactors(LowtoVeryLow)
• Allottedforashortperiodoftime
• Accompaniedbydocumentation
RTI
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ClinicalActionsVeryLowtoLowRiskFactors
1. Provide educational resources & create follow-up plan
ü Resources:stutteringhelp.orgwestutter.orgü Follow-upwithcaregivershouldoccurnolongerthan3monthspostinitiationofplan,unlesssomethingshiftsdramaticallyandanewplaniscreatedsooner
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ClinicalActionsVeryLowtoLowRiskFactors
2. Completion by Caregiver-Other: Perceptions of quantity of stuttering & potential contributing factors
ü UsingaRatingScaleof(0-9;0=nostuttering,2=verylittle,9=constantstuttering),anumberisassignedeachdaybaseduponthequantityofstutteringobserved
ü NoteanyChild-Environmentalfactorsthatmayhaveimpactedtheday
ü RatingsareprovidedtoSLPatendofeachweek
23Chmela2018/AllRightsReserved
ClinicalActionsVeryLowtoLowRiskFactors
3. Daily Modification of select fluency enhancing behaviors
ü deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)
ü Millard,Edwards,&Cook(2009)ü Franken&Putker-deBrujin(2007)ü Chmela(2005)ü Hill(2003)ü Starkweather&Gotwald(1990)Chmela2018/AllRightsReserved 24
ClinicalActionsMedium,High,toVeryHighRisk
atinitialcontactProceedtoacompleteevaluationDetermineneed-developtreatmentandplan
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MultifactorialDynamicPathwaysTheorySmith,A.,&Weber,C.(2017)
Duringthepreschoolyears,rapid“changesinneurobehavioralsystemsareongoing,andcriticalinteractionsamongthesesystemslikelyplayamajorroleindeterminingpersistenceoforrecoveryfromstuttering.”
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Thistheorymotivatestheclinicalpractitionerto“determinethespecificfactorsthatcontributetoeachchild’spathwaytothediagnosisofstutteringandthosemostlikelytopromoterecovery.”
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FamilyEnvironment
Executive Functioning
MotorSocial Emotional
SensoryLanguageCognitive
Child
TheBigPicture
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StandardizedFluencyMeasure
InformalSLPFluencyRatings
InformalParent-OtherFluency
Ratings
DetailedHistory Attitudes&Feelings
LanguageMeasures
OtherMeasures ClinicalObservations
TheCritical8EvaluationComponents
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TreatmentGoal• Establishpatternofnormalfluency(presenceofOtherDisfluencywithinnormalrange;Ratingsofstutter-likedisfluencywithinthe1-2rangeforconsecutiveperiodof8weeks)
• Treatmentinvolvescaregiver• Itispositive,andnaturallyreinforcingtothedevelopmentofpositiveattitudesandfeelingsaboutcommunication;carefulattentionispaidtothechild’sresponseandproblemsaresolvedastheyarise
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FollowUp
• Treatmentgraduallyfadesaway
• Follow-upoccursforapproximately1year
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BriefOverviewofClinicalActionsChildEnrolledinStutteringTreatment
SLP provides education about therapy & resources to caregiver-other
ü Onesessionperweek(unlessotherwarrantedspeech-languagegoals)
ü Overviewofwhattherapyentails
ü Resourcesaboutearlystuttering
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BriefOverviewofClinicalActionsChildEnrolledinStutteringTreatment
SLP teaches CORE Therapy Element #1: 1) Daily Ratings of stuttering-observations of contributing factors
ü UsingaRatingScaleof(1-10;1=nostuttering,2=verylittle,10=constantstuttering),anumberisassignedeachdaybaseduponthequantityofstutteringobserved;noteanyChild-Environmentalfactorsthatmayhaveimpactedtheday
ü RatingsprovidedtoSLPatendofeachweek;SLPmakesownratingforeachsession;DataChartkept
34Chmela2018/AllRightsReserved
BriefOverviewofClinicalActionsChildEnrolledinStutteringTreatment
SLP teaches caregiver-other CORE Therapy Element #2 Providing 3 kinds of Daily Feedback
ü FeedbackA:VerbalPraiseorRecognitionofSmoothtalking
ü FeedbackB:RequestforSelf-Evaluation
ü FeedbackC:RequestforSelf-Correction
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BriefOverviewofClinicalActionsChildEnrolledinStutteringTreatment
SLP teaches caregiver-other CORE Therapy Element #3 Problem Solving & Parent Modeling deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)
ü Eachsessionplottingofratingsfromallparties,discussionofchild’sresponsetofeedback;contributingfactorsfortheweek
ü GradualintroductionofInteractiveCommunicativeBehaviorsasnatural,warranted,andappropriatelytimed
ü Ongoingsupportofoveralldevelopment 36Chmela2018/AllRightsReserved
EvaluationandCaseReview#1
Chmela2018/AllRightsReserved 37
• FemaleM,age5-1;biological2parentfamily,onebrotherage7-6;fatherstuttersandhaspersisted-butonlyoccasionallyaccordingtomother’sreports;onemalecousinonmaternalsidehasADHD;familialenvironmentreportedsomewhathectic,fastpacedcommunicators,frequentrelativesvisitingovernight;frequentsiblingcompetitionfortalking;
• Pediatriciantoldparentsitwouldresolveoverpastyears;parentschosetogethelpatthispoint;moretroublenoticedwhenstorytelling-morecomplexideas
• Medicalhistorynegative;seasonalallergieswithnomedication;cognitiveanddevelopmentalmilestone’swithinnormallimits;easy,gentletemperament
• Stutteringonset2years,11months;cyclicalbutnevercompletelyabated;frequencyandseverityhavemarkedlyincreasedoverpast6months;prolongationsof6-10secondswithpitchandloudnessrise;multiplepartword,rapidrepetitions;Mhasverbalizedabout“notbeingabletotalk;”sometimeswhenMis“caughtupshejustwalksaway”
• Pre-Kteacherconcerned-reducedverbaloutputcomparedtoherpeers;nootherconcerns
• TOCS:ModeratetoSevereRangeofStuttering;PPVT-4:125StandardScore;EVT-2:103StandardScore;CELF-Pscoreswithinaveragetohighaverage,nosignificantdiscrepancies;TNL:86NarrativeLanguageIndex
38Chmela2018/AllRightsReserved
EvaluationandCaseReview#2
39
• Male,age4-2;biological2parentfamily;3malesiblings,ages6,8,10);nohistoryofstutteringinfamily;maternalnephew(age20)dxAutismSpectrumDisorder;structuredandconsistentroutines;highcompetitionfortalking;parentsveryfacepacedcommunicators
• Medicalhistoryrevealedlatetalker;motormilestonesWNL;frequentearinfectionsreporteduntilabout3½yearsofage
• Stutteringonset3-10;severeblockswithincreasesinloudness;facialtensionandarmmovementsusedtogetwordsout;
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• frequentOtherDisfluencies(“uhmuhmuhmuhm”)upto20repetitionsatstartofsomephrases;patternconsistentsinceonset,withratingsof4-7infrequencyoverpastfewweeks)
• Parentsfeltnoawarenessorconcernfromchild;hekeepsontalking;increaseswhenroutinechanges;lackofsleep
• Difficultyfallingasleep;motherreportsheoftenhas“trickydayswithbigmeltdowns”
• Schoolscreeningindicatednostutteringandrecommendedfollowupin3months;followupatschool-nostutteringobserved;pediatrician(4yearoldcheck-up)recommendedspeechevaluation;
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• Preschoolteachernotestroubletransitioningbetweenactivities&highverbaloutputwithintheclasssetting
• PPVT-4:105StandardScore;EVT-2:100StandardScore;CELF-P:CoreLanguage98;nodiscrepanciesacrosssubtests;developarticerrors
• Temperamentnotedaslessrhythmic,lowerthresholdwithintensereactivity;slightlymorenegativeinmood,distractible;approachesquickly(“seemsfearless”)
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EvaluationandCaseReview#3
42
• Femaleage2-9;biological2parentfamily;sisterage2months;onsetofstutteringat2-5;Unremarkablebirth,medical,developmentalhistory;Daycareprogram3fulldaysperweek;napsatprogram
• Nohistoryofstuttering;mother(anxietyanddepression;fatherdepression&ADHD);familyrecentlyrelocatedpriortobirthofsecondchild;routinestructuredandconsistent;transitionshurriedandstressful;dadreports“givingintoher”whensheisupset;momsays“painfultowatchandhearthestuttering,butItryandhidemyemotionsfromher”
• SLDatonsetmultiplerepetitions(partwordandwholeword);sinceonsetincreasedtomoreeffort
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• Someprolongations2-5secondswithpitchrise;frequencycontinuestobevariable;atpresentSLDmoderatetosevere;increasedstutteringwithexcitementor“fightingforthefloor;”shekeepsontalkingnomatterwhat
• Atonset,childverbalizedfrustrationatnotbeingableto“getwordsout”buthasnotsaidanythingsince;veryverbal;daycareteacherseesstutteringduringtransitions(dropoff)andwhenfrustrated(ex:notwantingtosharewithapeer)
• DevelopmentalIndicatorsfortheAssessmentofLearning(DIAL-4):WNL;otherS/LareasWNL
• Moderatelevelofwithdrawal;lowerthreshold;mildintensityofreactions;moreadaptable
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5EssentialClinicalSkills
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1.MakingDailyRatings2.TeachingVerbalFeedbackA:Praiseor NoticeSmoothTalking
3.TeachingVerbalFeedbackB:Request forSelf-EvaluationofSmooth Talking
4.TeachingVerbalFeedbackC:Request forRetryofStuttering
5.ProblemSolving&ParentModeling
ClinicalSkill1:MakingDailyRatings
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q DiscussOtherDisfluencies(OD)vs.Stutter-LikeDisfluencies(SLD)
q DiscussRatingScale(1-10)usedforvariousaspectsofcommunicativebehavior:1=noobservation,2=verylittleobservation,and10=constantobservation
q ClinicianandcaregivereachmakeratingofSLDatendofsessionandcompareresults
q Caregiverisassignedtomakearatingattheendofeachdayusingthe(1-10)scale.“Attheendoftheday,howmuchSLDdidyouhear?”
q Ratingsarecollectedeveryweek&plottedondatachart
MakingDailyRatings
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Troubleshootingv Feeling bad rating higher
v Not doing it
v Not bringing it
v Differentiating between OD and SLD
v Rating severity of “moment” verses daily quantity Chmela2018/AllRightsReserved 48
ClinicalSkill#2:TeachingVerbalFeedbackAPRAISEorNOTICESmoothTalking
q ExplainVerbalFeedbackAtocaregiverq DemonstratehowtoadministerFeedbackAduringshortactivitywithnaturalinteraction;reducelanguagedemandifneededinordertofacilitatesmoothspeechtoprovidethiscontingency
q AllowthecaregivertoaskquestionsaboutFeedbackA
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q Havecaregivertryandadminister5-10ofFeedbackAonhisorherowninsession
q AssignDailySpecialTimefor10minuteswithadministrationofabout(ahandful,5-6orso)ofFeedbackA(Praise/Notice)onlyduringthespecialtime.
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Troubleshootingv What to say
v How to say it
v When to have special time
v What to do during special time
v Dealing with the child’s response Chmela2018/AllRightsReserved 51
q ExplainVerbalFeedbackBtocaregiverq DemonstratehowtoadministerfeedbackA+Btogether,orA(fourtimes),followedbyB(onetime) A+A+A+A+B=OnesetofFeedback
q AllowthecaregivertoaskquestionsaboutprovidingAandBFeedbacktogether
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ClinicalSkill#3:TeachingVerbalFeedbackBREQUESTaSELF-EVALUATIONofSmooth
Talking
q Havecaregivertryandadminister1stand2ndtypesonhisorherowninsession
q Observechild’sresponseandproblemsolveifwarranted
q AssigncombinationofbothtypesduringDailySpecialTime
Chmela2018/AllRightsReserved 53
Troubleshootingv What to say
v How to get child’s attention
v What to do when you get no response
v What to do if the response is not correct
Chmela2018/AllRightsReserved 54
q ExplainVerbalFeedbackCtocaregiverq DemonstratehowtoadministerFeedbackC
q ReviewhowFeedbackCiscombinedwithA+B:4(Praise-Notice)+1(RequestforSelf-Evaluation)+1(RequestforRetry)=1SETofFeedbackorContingencies
Chmela2018/AllRightsReserved 55
ClinicalSkill#4:TeachingVerbalFeedbackCREQUESTaReTry
q Allowthecaregivertoaskquestionsabout3rdtype
q Havecaregivertryandadminister1-2fullsets
duringsessionq ContinueDailySpecialTime;havecaregiver
administer2FullSetsduringthattime,andanothersetanyothertimeofday.
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VerbalFeedbackC:REQUESTaRETRY
Troubleshootingv What to say
v How to get child’s attention
v When to administer it v Dealing with the child’s response
Chmela2018/AllRightsReserved 57
RESTART-DCMApplicationsØ Reducingdemands&enhancingcapacitiesØ ParentModelingoftypicalfluencyenhancingbehaviorsØ ReinforcementforchildØ ClinicalModeling
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ParentProblemSolving&Modeling
deSonneville-KoedootC,StolkE,RietveldT,FrankenM-C(2015)DirectversusIndirectTreatmentforPreschoolChildrenwhoStutter:TheRESTARTRandomizedTrial.PLoSONE10(7):e0133758.doi:10.1371/journal.pone.0133758
GradualDismissalTransitionØ 13-16sessionsapproximately(somechildrentakemuchlonger;somecontinuetopersist)
Ø Criteria:-Caregiverdailyratingsfor6-8weeksof1sand2s,(severalperiodsof1sinarow)-Similarclinicalobservations;nootherspeech- languagegoalsorconcerns
Ø Graduallyreducetherapysessions(overthecourseof1year)
DuringtheTransitionPeriod,caregiverscontinueengaginginbehaviorsconducivetohealthycommunicationdevelopment,providingverbalcontingencies,andmakingdailyratings.Administrationofcontingenciesgraduallyfadesawayasthecaregiveriscomfortable.
59Chmela2018/AllRightsReserved
Troubleshootingv When to introduce
v How to highlight it
v How to integrate it into work with feedback
Chmela2018/AllRightsReserved 60
Manner Space Position Routine Support
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KeyElements:workingwithyoungchildrenwhostutter
62
RecommendedBooks:HowtoTalkSoLittleKidsWillListen:ASurvivalGuidetoLifewithChildrenAges2-7(Faber&King,2017)
TheWholeBrainChild(DanielSiegel)
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• HowdoIknowthat?• Whatdoesthatlooklike?• AmI/arewemakinganassumption?• Isthatanobservationorajudgment?Chmela2018/AllRightsReserved
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programmeofearlystutteringintervention.BritishMedicalJournal,331(7518),659-661.Jones,M.,Hearne,A.,Onslow,M.,Ormond,T.,Williams,S.,Schwarz,I.,&O'Brian,S.(2007)Extendedfollowupofarandomisedcontrolledtrial
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Pathology,18,264–276.Langevin,M.,Packman,A.,etal.(2010).ParentPerceptionsoftheImpactofStutteringonTheirPreschoolersandThemselves.JournalofCommunicationDisorders,43(5),407-423.
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