Assessment and Treatment of
Fluency Disorders in Bilingual
Kerry Danahy, M.A., CCC-SLP
University of Minnesota
[email protected]
 There
is very little research examining fluency
disorders in bilingual speakers.
 BUT that doesn’t mean we are lost in assessing
and treating this population:
 We can use what we know about fluency and about
bilingualism, as well as cultural influence, to work
with bilingual children with fluency disorders.
Why do children stutter?
 Most
current models of stuttering are
 Factors that interact to cause stuttering include:
genetics, environment, language skills, motor
skills, and temperament.
 This information gives us some insight into
bilingual speakers who stutter.
Factors for bilingual children
 In
bilingual children, genetics, motor skills, and
temperament will be constant across languages.
 It is extremely unlikely that a bilingual child will
stutter in one language and not the other (e.g., Van
Borsel, Maes, & Foulon, 2001).
Factors for bilingual children
 Language
skills and environment (including home
vs. school environments, cultural beliefs associated
with one language, etc.) may differ significantly
between languages.
 It is common for children to stutter more
frequently in one language than the other (e.g.,
Nwokah, 1988).
Stuttering Prevalence in Bilingual
 It
has been estimated that about 1% of the world’s
population stutters (Bloodstein, 1995).
 Many authors have claimed that stuttering is more
prevalent among bilinguals than among
monolinguals (e.g., Karniol, 1992; Nwokah, 1988).
 However, the evidence for this conclusion is
questionable (Van Borsel et al., 2001).
Stuttering Prevalence in Bilingual
Evidence that eliminating bilingual input to preschool
children improves fluency is very limited and has been
disputed (see Bernstein Ratner, 2004; and Van Borsel et
al., 2001, for reviews).
 No support exists for reducing bilingual input to disfluent
speakers older than preschool.
 As in other disorders, the child’s need for bilingual
proficiency to meet environmental needs is paramount.
Bilingual children may present additional assessment
challenges, because difficulty formulating utterances due
to limited proficiency in either a first or second language
can look like disfluent speech.
 However, we can rely on key features of true stuttering to
distinguish children with fluency disorders (Watson and
Kayser, 1994):
Stuttering will be present in both languages.
Stuttering is usually accompanied by self-awareness.
Secondary behaviors often accompany stuttering.
 Core
areas to assess are the same for bilingual and
monolingual children:
 Disfluencies
 Secondaries
 Child’s
beliefs and emotions about stuttering
 Other speech and language skills
 Parents’ beliefs about stuttering
 Developmental history
Assessing Disfluencies
Measurement of disfluencies is similar for monolingual
and bilingual children:
collect language samples from conversation and oral reading
 calculate frequency and duration of disfluencies.
English behavioral stuttering assessment tools (e.g., SSI-3;
Riley, 1994) may be adapted as criterion-referenced
measures for other languages (Bernstein Ratner, 2004).
 Word-based (rather than syllable-based) counts of
stuttering frequency may be more accurate across
Assessing Disfluencies
Specific types of atypical and typical disfluencies
may vary in frequency across languages.
 Atypical disfluencies include blocks,
prolongations, sound and syllable repetitions, and
broken words.
Typological features of the language may affect where
these occur, and how often.
Typical disfluencies include hesitations, filler
words, revisions, word and phrase repetitions.
Cultural factors may affect how often and where
speakers use these (Bernstein Ratner, 2004).
Assessing Disfluencies
However, atypical disfluencies have similar
characteristics across languages:
 Loss of eye contact
 Avoidance behavior
 Disruption in the typical forward flow of speech
These features have been shown to be prominent
enough for people to identify disfluencies in a
language they do not speak.
Assessing Secondary Behaviors
Types of secondary behaviors look the same in
different languages, and are distinct signs of
fluency disorders.
 May involve:
 Lips
 Cheeks/other facial muscles
 Arms or legs
A child could have different secondary behaviors
in different languages.
Assessing Behaviors: Things to
 When
assessing frequency and severity of
disfluencies and secondaries, remember that
stuttering is highly variable across environments.
 Variability is even more pronounced in bilingual
children because stuttering can also vary across
 Important to get a representative picture of child’s
speech across environments.
Assessing Behaviors: Things to
 Word
and situation avoidances can be difficult to
catch in monolingual children.
 Bilingual children can also use code-switching to
avoid stuttering.
 This makes identifying avoidances even more
difficult, because there are many other reasons to
code-switch, and appropriate code-switching may
be difficult to identify.
Assessing Beliefs and Emotions
 Cognitive
and affective factors are central to
stuttering and important to assess.
 Cultural factors will impact the child’s
beliefs and emotions (e.g., Nwokah, 1988).
 Bilingual children may show greater
situational variation in their reactions to
stuttering due to differences in culture
between home and school environments.
Assessing Beliefs and Emotions
 Questionnaires
are available to assess this
area for school-aged children (e.g., ACES,
available through
 May need to modify questionnaires to
account for:
 Limited
English proficiency.
 Differences in cultural beliefs across
Assessing Other Speech and
Language Skills
 Language
and/or articulation proficiency may
affect stuttering frequency and severity (also
reviewed in Van Borsel et al., 2001) :
 Stuttering
may be more prevalent in weaker language:
 Increased
stress in weaker language may increase stuttering.
 More difficult motor demands (e.g., unfamiliar sounds) may
increase stuttering.
 Stuttering
 Slower
may be more prevalent in stronger language:
speech rate and simpler utterances in weaker language
may increase fluency.
 Experiences in stronger language may increase disfluencies.
Assessing Other Speech and
Language Skills
 It
is also important to remember that children who
stutter are much more likely to have another speech
or language disorder (or even another fluency
disorder, such as cluttering) than children who do
not stutter.
Assessing Parent Beliefs &
Developmental History
 Interviews
with parents and other family members
can give valuable insights into cultural beliefs
about stuttering that affect the child.
 Asking broad, open-ended questions that allow the
parent to describe his/her views often give the
most information.
 Parents’ descriptions of how the fluency problem
began often reflect views of why children stutter.
Central goal of therapy for school-aged children is to
manage stuttering (e.g., Reardon-Reeves & Yaruss, 2004).
 We do not currently have a “cure” past the preschool
 Several sub-goals may be important components of
stuttering management for the child:
Reduced frequency and severity of disfluencies
 Knowledge of techniques to manage moments of stuttering
 Acceptance of self, including stuttering
Treatment: Fluency Shaping
 Fluency
shaping techniques are designed to reduce
the frequency of disfluencies.
 All of them modify speech in some manner.
 It is important to remember that there is a tradeoff
between naturalness and fluency benefits: the more
the child modifies her speech, the less likely she is
to be disfluent, BUT the more unnatural she will
Treatment: Fluency Shaping
 It
is also important to remember that it is
HARD to use fluency shaping techniques in
conversational speech.
 It is not reasonable to expect children to use
fluency shaping all the time, because of
difficulty and unnaturalness.
 Goal should be for children to learn effective
techniques so that they can choose when to
use them.
Treatment: Fluency Shaping
 Fluency
shaping techniques include:
 Slowed
rate (typically through prolonged speech with
continuous phonation)
 Easy onsets
 Light articulatory contacts
 Easy prolongations or repetitions to begin utterances
 Fluency
shaping techniques can be used in any
Treatment: Fluency Shaping
 The
application of fluency shaping techniques will
be different in different languages due to different
 Children may not be able to apply techniques to
their other language without explicit instruction
and practice.
 Cultural impact of using fluency shaping
techniques may vary.
Treatment: Stuttering
 Stuttering
modification techniques are
typically used to reduce the severity of
disfluencies and to give the child increased
control in stuttering moments.
 Stuttering modification has been
traditionally been used with children who
stutter more severely.
 BUT these techniques can be useful for all
children who stutter, particularly if they
demonstrate shame or avoidance.
Treatment: Stuttering
 Stuttering
modification includes techniques for:
 Recognizing
a stuttering moment
 “Cancelling” or “pulling out” of it
 Continuing to speak (perhaps with the help of fluency
shaping techniques)
Treatment: Stuttering
 Stuttering
modification also usually includes
 Desensitization work overlaps with cognitive and
emotional treatment.
 Basic goal of desensitization is to make the child
less afraid of stuttering.
Treatment: Desensitization
Activities to achieve desensitization include:
“Freezing” in a stuttering moment
 Describing the stuttering moment
 Pseudo-stuttering, in increasingly difficult situations
 Manipulating length and severity of pseudo-stutters
Desensitization effects are likely to be situationspecific.
 It may be particularly difficult for bilingual
children to become more comfortable with
stuttering in their home/community environments.
Treatment: Attitudes and
Most children who stutter benefit from a basic
understanding of stuttering, including:
The normal speech production process.
 Changes to the process that produce stuttering.
 Potential causes of stuttering.
 The existence of other people who stutter, including successful
This education will be similar for monolingual and
bilingual children, except that adult role models may be
Treatment: Attitudes and
 Identifying
core beliefs about stuttering is an
important goal for most children who stutter.
 Negative beliefs often lead children to avoid
stuttering at all costs.
 Negative beliefs can be restructured to be more
Treatment: Attitudes and
 For
If the child believes, “No one will want to listen to me if I stutter,”
 It is more accurate to say that some people may not want to listen,
but others will still want to hear what you have to say.
 Rewriting this belief with the child may help him become more
accepting of stuttering.
 Bilingual
children may have language-specific
beliefs, such as believing they will not stutter in a
new language.
Treatment: Attitudes and
 Many
children benefit from making connections
with other children who stutter.
 Online groups include the National Association of
Young People Who Stutter, and postings on
Judith Kuster's Stuttering Homepage:
 International Stuttering Association spans countries
but uses English (
Treatment: Generalization
 Generalization
is always an important
consideration in fluency therapy.
 Bilingual children need to generalize skills to
multiple languages and cultural environments.
 Limited evidence exists to show that therapy can
be successful in one language and not generalize to
another (Humphrey, 1999, as cited in Bernstein
Ratner, 2001).
Treatment: Generalization
 Setting
up specific plans for the child to use skills
such as fluency shaping, stuttering modification,
and desensitization in both languages and different
environments is essential.
 Generalization of cognitive and emotional changes
may be easier, if beliefs associated with both
cultures are addressed in therapy.
 Bilingual
children who stutter present us with
several challenges.
 But we have the tools to meet them.
 Remember basic principles:
 Bilingual
children who stutter will stutter in both
 We need to consider behaviors across languages and
environments during assessment.
 We need to address both languages in treatment.
 There
is a critical need for additional research on
bilinguals who stutter to support clinical practice in
this area.
 Current additional information is available online
Additional Language-Specific
 Stuttering
Foundation of America has pamphlets
and videos translated into Spanish and French.
 Online
store can be accessed through
 Stuttering
Foundation of America has also created
a website in Spanish (
Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual
children. In B. Goldstein (ed.). Language Development: a focus on
the Spanish-English speaker. Baltimore, MD: Brookes. (287-310).
Bloodstein, O. A handbook on stuttering. London: Chapman & Hall.
Humphrey, B. (1999, November). Bilingual Stuttering: Can treating
one language improve fluency in both? Paper presented at the
American Speech-Language-Hearing Association Annual
Convention, San Francisco, CA.
Karniol, R. (1992). Stuttering out of bilingualism. First Language,
12, 255-283.
Reardon-Reeves, N.A., & Yaruss, J.S. (2004). The source for
stuttering. East Moline, IL: LinguiSystems.
Riley, G. (1994). Stuttering Severity Instrument for Children and
Adults (3rd ed.). Austin, TX: PRO-ED.
Nwokah, E. (1988). The imbalance of stuttering behavior in
bilingual speakers. Journal of Fluency Disorders, 13, 357-373.
Van Borsel, J., Maes, E., & Foulon, S. (2001). Stuttering and
bilingualism: A review. Journal of Fluency Disorders, 26, 179-206.
Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural
adults who stutter. Seminars in Speech and Language, 15, 149-163.

Assessment and Treatment of Fluency Disorders in …