Is it possible for speech therapy to improve upon

INT. J. LANG. COMM. DIS., JULY–SEPTEMBER VOL.

40,

NO.

2005,

3, 349–358

Short Report

Is it possible for speech therapy to improve upon natural recovery rates in children who stutter? Joseph Kalinowski{, Tim Saltuklaroglu{, Vikram N. Dayalu§ and Vijaya Guntupalli{ {

Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA { Department of Audiology and Speech Pathology, University of Tennessee, Knoxville, TN, USA § Department of Speech Language Pathology and Audiology, Seton Hall University, South Orange, NJ, USA (Received 27 April 2004; accepted 3 November 2004)

Abstract Background: Speech and language therapists treating children who stutter appear to be assigned a difficult task. Natural spontaneous remission accounts for approximately 60–80% of all children recovering from stuttering. Despite our best efforts, no protocol has ever shown its effectiveness separate from natural recovery rates (i.e. 60–80%). Although speech and language therapists have used a vast array of therapeutic protocols, the incidence and prevalence of childhood stuttering appears to have remained unchanged. Therefore, although in possession of multiple treatment tools, speech and language therapists might be ill-equipped to treat stuttering children effectively and efficiently to the point of recovery. Aim: To assess speech and language therapists’ self-reported perceptions of their success in helping children ‘completely recover from stuttering’ (i.e. no longer exhibiting any overt or covert stuttering symptoms or using therapeutic strategies to modify speech and no longer being viewed by themselves or anyone else as a ‘stutterer’). Methods & Procedures: A questionnaire was sent to 290 speech and language therapists providing stuttering therapy to children attending school in North Carolina, USA, in a system similar to what can be found in many other US states. It addressed therapeutic efficacy in the management of stuttering: the numbers of stuttering children treated and those perceived to be recovered, the therapeutic methods, the time spent in practice, therapy durations and schedules. Address correspondence to: Joseph Kalinowski, East Carolina University, Belk Annex, Oglesby Drive, Greenville, NC 27858, USA; e-mail: [email protected]

International Journal of Language & Communication Disorders ISSN 1368-2822 print/ISSN 1460-6984 online # 2005 Royal College of Speech & Language Therapists http://www.tandf.co.uk/journals DOI: 10.1080/13693780400027779

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Joseph Kalinowski et al. Outcomes & Results: Usable questionnaires were returned by 101 respondents who reported treating a total of 2036 children who stutter. They reported using a full array of techniques known to reduce stuttering. The median reported recovery rate among respondents was 13.9%. Twenty-eight respondents reported no recoveries whatsoever, and 81 reported five recoveries or fewer. The median time spent on a caseload was 3 years. In addition, longer practising therapists reported significantly higher recover rates than those with less time practising. Conclusions: Remission from stuttering in children being treated in the schools of North Carolina appears to be the exception rather than the rule. The reported recovery rates suggest that not much is being done therapeutically to help children recover from stuttering. The chance of recovery decreases with age, and speech therapy for children who stutter appears to do little to improve their odds of recovery. Speech and language therapists treating these children either do not possess the tools or the tools do not yet exist to change ‘nature’s recovery agendum’ and put children who stutter on the path towards natural sounding, fluent and spontaneous in all situations. As such, the provision of therapy, in North Carolina at least, does not yet allow for stuttering children to shed the label of ‘stutterer’, in their own eyes and in the eyes of all others for the rest of their lives. In light of these data, the authors suggest re-examining the tools, policies and procedures used in the treatment of stuttering children. Keywords: MeSH Terms; child/preschool, speech therapy/methods, stuttering/ therapy, fluency, inhibition.

Introduction The signature events of incipient stuttering are speech disruptions in the form of syllabic repetitions (Van Riper 1973, Yairi et al. 1993, Bloodstein 1995, Zebrowski 1995, Silverman 1996). These defining behaviours, which usually begin to surface between the ages of 2 and 6, are a ‘red flag’, clearly indicative of normal speech development gone awry. According to Bloodstein (1995), incipient syllabic repetitions are characterized by being easily produced, relatively tension-free, neutralized forms of initial syllables in the intended utterance. Each repetition generally has a vocalic nucleus and the periods of silence separating consecutive repetitions are relatively evenly spaced (Zebrowski 1995, Throneburg and Yairi 2001). Not surprisingly, their highly conspicuous and disruptive nature has made their removal the consistent target of therapies intended to alleviate stuttering. Speech and language therapists are the professionals charged with the task of removing stuttering events and providing those afflicted with the ability to produce fluent speech (Olson and Bolhman 2004). Given the age of onset, preschool- or school-based therapists often present the first line of attack against this debilitating communicative pathology. Over the years, these skilled professionals have faithfully implemented all the tools placed in their hands by the numerous ‘experts’ in the field of stuttering. However, measuring the efficacy of their work is hindered by the knowledge that at least 60–80% of incipient stutterers recover, regardless of the presence or absence of intervention (Yairi and Ambrose 1992, 1999, Yairi et al. 1993, Kalinowski et al. 2002, Kalinowski and Saltuklaroglu 2004). The obvious question that arises is whether any ‘total recovery’ reported during the intervention period can be attributed to the intervention itself or if it is simply another example of natural spontaneous recovery.

Speech therapy for children who stutter

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Total recovery should be differentiated from the simple reduction of overt stuttering symptoms for short periods (e.g. 1–12 months in the same testing environment), which essentially only skims the surface of healing the stuttering syndrome. Here, total recovery is defined by the complete removal of the signature overt (e.g. syllabic repetitions, part-word prolongations of speech sounds) and covert (e.g. avoidances, substitutions and circumlocutions) stuttering events. Thus, total recovery also entails producing speech that is indistinguishable from the speech of those who do not stutter, as perceived by both the child and other listeners (Finn et al. 1997). Finally the ‘truly fluent’ (Dayalu and Kalinowski 2002) speech of the recovered child must extend across all speaking situations over time, and not be restricted to contrived, repeated test environments with the same examiners (e.g. parents or therapists). The emphasis on total recovery may seem overstated, but the present authors’ research team has witnessed dozens of supposedly ‘recovered stutterers’ lining up to purchase electronic fluency aids, suggesting the ongoing need for help reducing stuttering symptoms even after years of childhood therapy. We throw down Bloodstein’s (1995: 439) caution that was made after reviewing 195 studies of ‘apparently’ successful therapies for stuttering. He stated, ‘the assessment of results of therapy is a process fraught with opportunities for error and selfdelusion’. It is for this reason that long-term retrospective or post-hoc analysis of stuttering intervention is so powerful: it allows clinicians the benefit of added objectivity, garnered by allowing a suitable time interval between therapy administration and the determination of treatment efficacy or lack thereof. Typically, when therapists begin to administer treatment, they carry with them high levels of emotional or psychological investment in their protocols of choice (Kerr 2002) that can influence their perception of therapeutic outcomes. Generally, these protocols are time consuming and carry with them years of great personal commitment in their attendant thought and deliberation. Only after a period of time, following careful observation and re-assessment that leads to a wider understanding of the pathology and treatment methods, can typical therapists release themselves from their emotional and psychological ties to particular therapies and more objectively assess the results that they have achieved. The question of therapeutic efficacy in treatment of childhood stuttering has inspired substantial debate as the possibility of spontaneous recovery continues to confound therapeutic claims of remission. It has been vehemently questioned how diametrically opposed methods of intervention can yield similar levels of efficacy (Kalinowski et al. 2002). For example, the Johnsonian approach, which advocated completely ignoring all childhood stuttering behaviours managed to achieve similar high (about 80%) recovery rates (Johnson 1955) as the direct operant intervention methods of speech retraining that remain in vogue today (Ingham 1984, Shine 1984, Boberg and Kully 1994, Onslow et al. 1994, Wagaman et al. 1995, Craig et al. 1996, Elliott 1998). What we have yet to observe is any change in the general incidence (5%) and prevalence (1%) rates of stuttering (Mansson 2000), suggesting that existing claims of therapeutic success in the recovery from childhood stuttering may best be attributed to the natural spontaneous recovery that occurs in up to 80% of children. To make claims of therapeutic success in the remediation of stuttering children, speech and language therapists must always weigh their effectiveness and efficiency in light of the possibility for spontaneous recovery. Thus, the next salient question is whether therapy can improve upon rates of spontaneous recovery. Though the odds

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of recovery from incipient stuttering are initially high, they decrease with age. Otherwise stated, the window of opportunity for natural recovery closes over time. Andrews et al. (1983) reported that 75% of 4-years-olds, 50% of 6-year-olds and only 25% of 10-year-olds would recover from stuttering by age 16. Furthermore, Yairi et al. (1999) reported recovery schedules of children who began stuttering between the ages of 2 and 5 years. They found that the peak recovery periods were between 1 and 3 years post-onset. Given these figures, and the fact that incipient stuttering begins between the ages of 2 and 6 years (Bloodstein 1995), a significant proportion of stuttering children entering school should still be within an age range that may exploit both spontaneous recovery processes and any ameliorative benefits found in the therapeutic interventions that are usually immediately offered. Therefore, if speech therapy for children who stutter is helpful, therapists should be expected to report significantly high levels of recovery among those that they have treated. However, Cooper and Cooper (1996) asked 1111 public school speech and language therapists if they felt ‘public school therapy was ineffective for stutterers’, more that half agreed or were undecided. In addition, they noted that over 70% of these therapists were undecided or disagreed with the statement that ‘operant therapy is effective’, with reference to the treatment of stuttering in the public schools. The ambivalence of these respondents, though often ignored, may be an indication of the true state of stuttering therapy for children. With natural recovery rates of 60–80% and a variety of treatment options being implemented an assessment of the effectiveness and efficiency of speech therapy for stuttering is warranted. Thus, the purpose of this study was to examine a relatively large sample of school-based speech and language therapists in North Carolina and gather selfreported information pertaining to the number of children they have been able to help recover from stuttering over the duration of their time practising in the school system. Around the USA, professional speech and language therapists provide services free of charge to students enrolled in state school systems. North Carolina is no exception to this rule, and as such, the present authors’ suspect that such an examination may provide a window into the general status of stuttering therapy for children in the USA and in other countries that employ similar service models (e.g. community centres) for delivering therapy to stuttering children. Methods Participants The questionnaire (see the appendix) was mailed to 290 speech and language therapists practising in the North Carolina public school system. Their names were randomly selected from the 2002 North Carolina Directory of Licenced Speech and Language Pathologists and Audiologists (North Carolina Board of Examiners 2002). One hundred and one (35%) usable questionnaires were returned. Procedure The questionnaires were sent via mail to the business addresses of therapists working in the North Carolina public school system. Participants were instructed to be ‘rigorously’ honest while completing the questionnaire. The questionnaire was

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mailed along with a self-addressed stamped envelope and participants were asked to return the questionnaire in the envelope. One telephone call was made by the research assistant to the potential participants who did not respond to the questionnaire approximately 1 month after mailing, simply asking them to return the questionnaire if they had the time. Test instrument (questionnaire) The questionnaire collected information from each respondent regarding their experience (i.e. total number of years practising) and their experiences with stuttering children (i.e. the number of stuttering children they had treated, the age range of the stuttering children they had treated, and the number of children they had treated who they felt had recovered). The criteria for recovery was that children should have normal sounding, fluent, spontaneous speech in all situations (Finn et al. 1997), without using any type of imposed controls and, should not be viewed as a ‘stutterer’ by themselves or anyone else. The questionnaire also collected information regarding the duration of therapy (i.e. average number of years on caseload, number of weekly therapy sessions and, the duration of each therapy session), as well as the types of therapy methods used. Results Table 1 summarizes the descriptive data collected from the 101 questionnaires that were returned completed, with respect to the medians and ranges for each set of responses. Among those sampled, 76% reported administering therapy twice weekly to children who stutter, with the others reporting implementing therapy once or thrice weekly. Reports of therapy durations ranged from 20 to 60 min per session, although 87% of therapists reported conducting 30 min therapy sessions. The questionnaire provided a checklist of contemporary techniques used to remediate stuttering. The percentages of the 101 speech and language therapists sampled who reported employing a particular approach were as follows: easy onsets (97%), slowed speech (93%), breathing techniques (58%), light articulatory contacts (57%), relaxation (53%), prolongation (49%), attitudinal changes (40%) and eclectic approaches (25%). According to the data provided by the participants, the total number of children treated was 2036, while the total number of children who were considered to be recovered was 480, making the overall recovery rate among the group 23.5%. Table 1.

Descriptive summary of therapists’ experience, caseloads, recovery statistics and therapy durations

Statistic Years practising speech and language therapy Number of stuttering children treated Youngest child who stutters (years) Eldest child who stutters (years) Number of stuttering children who recovered Percentage of stuttering children who recovered (%) Average time for child on a caseload (years)

Median

Range

17 15 5 11 2 13.9 3

11.5–39 2–100 3–12 4–18 0–42 0–100 1–6

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Figures 1 and 2, respectively, show the distribution of the raw number of recoveries and the percentage of recovered children among the participants. Twenty-eight of 101 therapists sampled reported no recoveries, 81 of the 101 had five recoveries or fewer and, 72 of the 101 reported a recovery rate of 25% or less. However, it is interesting to note that eight of the 101 claimed 249 of the 480, or 52% of the recoveries. A box plot of the raw recovery reports is shown in figure 3, where it can be seen that data submitted by these eight therapists are clearly outliers from the remainder of the group. Furthermore, those respondents who had been practising for more than the 17 years median reported a higher percentage of recoveries (26.7%) than those

Figure 1. Distribution of therapists’ claims of the numbers of stuttering children on their caseloads who recovered.

Figure 2. Distribution of therapists’ claims of the percentages of stuttering children on their caseload who recovered.


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Figure 3. Box plot showing the distribution and outlying cases in therapists’ claims of the numbers of stuttering children on their caseloads who recovered. The box length represents the interquartile range. *Extreme cases (more than three box lengths from the upper edge of the box). The markers ‘O’ represent outlying values (between 1.5 and three box lengths from the upper edge of the box). Markers A and B each represent two extreme cases.

practising fewer than 17 years (16.2%). Thus, longer practising therapists reported recovery rates that were 1.7 times greater than those with less experience. This difference was statistically significant (t(99)522.15, p50.03). Discussion The results indicated that as a group, the 101 public school speech and language therapists sampled retrospectively reported very little therapeutic efficacy for treating children who stutter and implementing therapeutic protocols that allow these children to gain the ability to produce speech that is indistinguishable from the speech of those who do not stutter. This finding is the linchpin of all stuttering therapy, especially since it is evident in the incipient stage and young children who stutter. The lack of therapeutic efficacy is clearly evident in these data on a number of levels. First, the median recovery rate of 13.9% found among the sampled participants seems to show poor treatment efficacy, especially in light of the numerous studies that show evidence of much higher efficacy rates using the methods employed (e.g. Culp 1984, Shine 1984, Craig et al. 1996) and the fact that spontaneous recovery should still play a role in helping some of the children recover. Granted, some respondents treated small numbers of older children for whom natural recovery was no longer a realistic possibility. However, given the median ages of the youngest (5 years) and eldest (11 years) children on caseloads, nearly all therapists worked with a large population of younger children, for whom one might expect higher recovery rates if the therapies used were effective over the long-term. Second, the overall recovery rate (23.5%) is considerably higher than the median recovery (13.9%), suggesting that the recovery data were positively skewed by a small group of respondents. As the median recovery rate is relatively unaffected by outliers as compared with the mean, it is probably a better representation of the overall performance by school-based speech and language therapists in the treatment of stuttering. Simply put, the data suggest that the recovery rate in this study is only 13.9%. The recovery data were most notably skewed by the eight therapists who claimed responsibility for 52% of all the recoveries and, in the

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present authors’ opinion, demonstrate a shortcoming in the reliability of retrospective self-reported subjective data collection. Examples of individuals within this group include one respondent who claimed recovery in 42/84 (50%) children s/he had treated, two respondents who claimed recovery in 40/50 (80%) children they had treated, and one therapist who claimed recovery in all ten stuttering children who had received his/her services. Exclusion of such clear outliers may be justified (figure 3), but even with their inclusion these data demonstrate clear problems in the remediation of stuttering in children. The trend that seems to be highly representative in these data is the large number of respondents who reported five or fewer recoveries (81/101), or those who reported recovery rates of less than 25% (72/101). This group also includes a significant number of respondents (28/101) who reported no recoveries whatsoever. Based on our previous experiences administering stuttering therapy and the large number of desperate parents and clinicians who have recently contacted us for help in treating stuttering children, this group appears to reflect most accurately the state of stuttering therapy in the US school system and their data bespeak of a need to implement changes in service orientation and delivery. Fourth, the median time spent on caseloads for children who stutter (3 years) suggests that little or no progress is being made towards stuttering remediation in the school systems. Three years of therapy with no remittance is a definitive sign of true inefficiency and ineffectiveness. Furthermore, considering that children rarely spend more than 5 years in elementary school, it seems highly probable that children who stutter simply spend as many years as possible occupying space on the caseload of one therapist before transferring schools and being added to the caseload of another. Lastly, the significantly higher recovery rates reported by more experienced therapists (1.7 times greater) compared with those with less experience are suggestive of overly optimistic perceptions of recovery. Surely, those with more experience in the field do not possess any different tools than the newer members of the profession. In fact, one may suspect that more recent graduates from accredited speech pathology programmes, though lacking in experience, should be in possession of the latest and supposedly most effective tools and methods of implementation. Though some may argue that more experienced therapists can achieve better results, the present authors suspect that the higher proportion of reported recoveries by the more experienced therapists is most likely a function of the psychological investment (Kuhn 1962) that is acquired over time by individual dedicated to a particular craft. Though the responses of these 101 participants were taken from therapists working in one US state and are based on the reliability of their own subjective assessments and recollections of the performances of the children they treated, the data reported herein suggest that speech therapy is doing little to help children who stutter completely to recover from stuttering. Despite using an impressive arsenal of well-known tools and the additional support provided by natural recovery rates, remission from stuttering in the state school system appears to be the exception rather than the rule. The results of this study are disconcerting at best. A median recovery rate of 13.9% coupled with a median of 3 years on caseloads is a clear indicator of inefficiency and ineffectiveness in the treatment of childhood stuttering. These figures call for a re-examination of the past policies and procedures used in the treatment of children who stutter and perhaps more importantly, a need to reassess notions regarding the nature and treatment of stuttering. Finally, it should be noted that when discussing ‘recovery from stuttering’ in children, it should be


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operationally defined so as to differentiate it from simple overt symptom reduction, which is much more easily accomplished in all stuttering populations, especially during the extremely dynamic developmental stages of stuttering found in children (Bloodstein, 1995). As such, the criteria for recovery must include producing speech that is natural sounding, fluent and spontaneous in all situations, without the use of any imposed controls, thus allowing children to shed completely the label of ‘stutterer’ in their own eyes and in the eyes of all others for the rest of their lives. References ANDREWS, G., CRAIG, A., FEYER, A. M., HODDINOTT, S., HOWIE, P. and NEILSON, M., 1983, Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 48, 226–246. BLOODSTEIN, O., 1995, A Handbook on Stuttering, 5th edn (San Diego: Singular). BOBERG, E. and KULLY, D., 1994, Long-term results of an intensive treatment program for adults and adolescents who stutter. Journal of Speech and Hearing Research, 37, 1050–1059. COOPER, E. B. and COOPER, C. S., 1996, Clinician attitudes towards stuttering: two decades of change. Journal of Fluency Disorders, 21, 119–135. CRAIG, A., HANCOCK, K., CHANG, E., MCREADY, C., SHEPLEY, A., MCCAUL, A., COSTELLO, D., HARDING, S., KEHREN, R., MASEL, C. and REILLY, K., 1996, A controlled clinical trial for stuttering in persons aged 9 to 14 years. Journal of Speech and Hearing Research, 39, 808–826. CULP, D., 1984, The preschool fluency development program: Assessment and treatment. In M. Peins (ed.) Contemporary approaches to stuttering therapy (Boston: Little Brown and Company), pp. 39–71. DAYALU, V. N. and KALINOWSKI, J., 2002, Pseudofluency in adults who stutter: the illusory outcome of therapy. Perceptual and Motor Skills, 94, 87–96. ELLIOTT, A. J., MILTENBERGER, R. G., RAPP, J., LONG, E. S. and MCDONALD, R., 1998, Brief application of simplified habit reversal to treat stuttering in children. Journal of Behavioural Therapy and Experimental Psychiatry, 29, 289–302. FINN, P., INGHAM, R. J., AMBROSE, N. and YAIRI, E., 1997, Children recovered from stuttering without formal treatment: perceptual assessment of speech normalcy. Journal of Speech Language and Hearing Research, 40, 867–876. INGHAM, R. J., 1984, Stuttering and Behaviour Therapy (San Diego: College-Hill Press). JOHNSON, W., 1955, A study of the onset and development of stuttering. In W. Johnson and R. R. Leutenegger (eds), Stuttering in Children and Adults (Minneapolis: University of Minnesota Press). KALINOWSKI, J., DAYALU, V. N. and SALTUKLAROGLU, T., 2002, Cautionary notes on interpreting the efficacy of treatment programs for children who stutter. International Journal of Language and Communication Disorders, 37, 359–361. KALINOWSKI, J. and SALTUKLAROGLU, T., 2004, The road to efficient and effective management of stuttering: information for physicians. Current Medical Research and Opinion, 20, 509–515. KERR, A. G., 2002, Emotional investment in surgical decision making. Journal of Laryngology and Otolaryngology, 116, 575–579. KUHN, T., 1962, The Structure of Scientific Revolutions (Chicago: University of Chicago Press). MANSSON, H., 2000, Childhood stuttering: incidence and development. Journal of Fluency Disorders, 25, 47–57. NORTH CAROLINA BOARD OF EXAMINERS, 2002, Directory of Licenced Speech and Language Pathologists and Audiologists (Greensboro: NCBE). OLSON, E. D. and BOHLMAN, P., 2002, IDEA ’97 and children who stutter: evaluation and intervention that lead to successful, productive lives. Seminars in Speech and Language, 23, 159–164. ONSLOW, M., ANDREWS, C. and LINCOLN, M., 1994, A control/experimental trial of an operant treatment for early stuttering. Journal of Speech and Hearing Research, 37, 1244–1259. SHINE, R. E., 1984, Assessment and fluency training and the young stutterer. In M. Peins (ed.), Contemporary Approaches in Stuttering Therapy (Boston: Little, Brown). SILVERMAN, F. H., 1996, Stuttering and Other Fluency Disorders. 2nd edn (Englewood Cliffs: Prentice-Hall). THRONEBURG, R. N. and YAIRI, E., 2001, Durational, proportionate, and absolute frequency characteristic of disfluencies: a longitudinal study regarding persistence and recovery. Journal of Speech Language and Hearing Research, 44, 38–51. VAN RIPER, C., 1973, The Nature of Stuttering (Englewood Cliffs: Prentice-Hall).

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WAGAMAN, J. R., MILTENBERGER, R. G. and WOODS, D., 1995, Long-term follow-up of a behavioral treatment for stuttering in children. Journal of Applied Behavior Analysis, 28, 233–234. YAIRI, E. and AMBROSE, N. G., 1992, A longitudinal study of stuttering in children: A preliminary report. Journal of Speech and Hearing Research, 35, 755–760. YAIRI, E. and AMBROSE, N. G., 1999, Early childhood stuttering I: persistency and recovery rates. Journal of Speech Language and Hearing Research, 42, 1097–1112. YAIRI, E., AMBROSE, N. G. and NIERMANN, R., 1993, The early months of stuttering: a developmental study. Journal of Speech and Hearing Research, 36, 521–528. ZEBROWSKI, P. M., 1995, The topography of beginning stuttering. Journal of Communication Disorders, 28, 75–91.

Appendix Questionnaire distributed to 290 therapists working in the North Carolina public school system. Your Experience With Early Stuttering Intervention 1. How long have you been practising as a speech and language therapist? _____ (in years) 2. How long you been working as speech and language therapist in the school system? _____ (in years) 3. Approximately how many children who stutter have you seen since you began working in the school system? _____ 4. What is the approximate age range of the children who stutter on your case load? _____ 5. Approximately how many of these children have completely recovered? By complete recovery, we mean that the child no longer considers himself/ herself as a person who stutters (the parents concur with the child’s opinion), uses none of the speech techniques to control his speech, does not avoid certain words or speaking situations, and produces normal sounding spontaneous speech in all speaking situations. _____ 6. Approximately for how long does a typical child who stutters stay on your caseload? _____ (in years) 7. What therapy techniques do you typically use for children who stutter? >< _____ Slow speech _____ Breathing exercises >< _____ Prolongation _____ Attitudinal retraining >< _____ Easy vocal onset _____ Relaxation >< _____ Light articulatory contacts _____ Eclectic approach >< _____ Others (please describe): >< ___________________________________________________________ >< ___________________________________________________________ >< ___________________________________________________________ 8. What is the typical duration of a therapy session for children who stutter in your school? _____ (in minutes) 9. What is the typical number of sessions provided per week for children who stutter in your school? _____