Word of Mouth 30:4 March/April 2019
A Multidimensional Approach to Stuttering
Shields, L. W. (2018). What constitutes a multidimensional treatment approach for school-age children
who stutter? Seminars in Speech and Language, 39, 333–341.
Summarized by Carol Westby
Stuttering is a complex disorder. Its development and
maintenance result from several interacting factors that
must be taken into account in planning for assessment
and treatment of school-age children who stutter. Schields
describes the multidimensional CALMS model (Cogni-
tive, Affective, Linguistic, Motor, and Social; Healey,
2012; Healey, Scott Trautman, & Susca, 2004) as a
framework for understanding how to assess school-age
children who stutter and develop a comprehensive treat-
ment plan that best supports children who stutter (the
CALMS scale can be downloaded from: http://csd.
wp.uncg.edu/wp-content/uploads/sites/6/2012/12/2.D.._
CALMS_rating_form1.pdf). The CALMS model has
five components:
•• Cognitive: The child’s thoughts about, understand-
ing, and perceptions of stuttering; their level of
awareness of their stuttering. For this dimension, one
rates children’s abilities to identify instances of stut-
tering in the clinician’s and their own speech, their
general knowledge about stuttering, and their under-
standing of specific stuttering management tech-
niques if they have had previous therapy.
•• Affective: The child’s feelings, emotions, and atti-
tudes associated with their stuttering.
•• Linguistic: The child’s language skills and the
impact of language formulation and discourse com-
plexity on their stuttering. In addition to rating
speech and language skills, the CALMS includes a
section where the clinician determines the level of
linguistic complexity at which the child begins to
stutter.
•• Motor: Sensorimotor control of speech movements;
the overt aspects of the child’s stuttering. This
dimension involves rating the types of stuttering,
along with the frequency and duration of disfluen-
cies, and the extent to which the child displays ten-
sion and struggle behaviors.
•• Social: The effects of listener type and speaking situ-
ation on the child’s stuttering. This includes rating
the frequency with which the child avoids words or
a variety of situations, the frequency with which the
child stutters across a variety of situations, how
often stuttering affects the level of social engage-
ment, and the impact of stuttering or fears of engag-
ing in typical school activities (e.g., how often a
child is afraid to answer questions in class when he
or she knows the answer and how often the child
talks at recess, lunch, or on field trips).
The five dimensions are seen as interacting with one
another such that any one component cannot be viewed
as functioning independently. Shields explains,
. . . the motor aspects of stuttering (repetitions,
blocks, and prolongations) are influenced by how
a child thinks and feels about stuttering. These
thoughts and feelings, in turn, will likely influ-
ence whether or not a child who stutters will elect
to be silent or talk in a given situation, and, should
they decide to talk, whether or not they will limit
how much they are willing to say. These choices
on the child’s part may have a negative impact on
his or her social engagement. (p. 334)
CALMS in Assessment
The CALMS Assessment for School-Age Children
Who Stutter provides an assessment framework for
evaluating all five components of the CALMS model.
The purpose is to provide a means of comparison of a
child’s performance over time. In each domain, a series
of items are rated on a 1 to 5 scale, and scores for each
dimension are calculated based on the average of the
item scores. The assessment provides a profile of the
child’s strengths and weaknesses. Scores are evaluated
in the following hierarchy:
•• 1 = normal clinical findings: function is within nor-
mal limits and there are no concerns in terms of
communicative behaviors, attitudes, or perceptions.
The child demonstrates high performance and ability
as well as positive attitudes and/or perceptions.
•• 2 = borderline clinical findings: low, inconsistent, or
variable functioning in communicative behaviors,
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 Word of Mouth 30:4 March/April 2019
attitudes, or perceptions. The child demonstrates
adequate or barely passable performance and ability.
This category also includes any test data with stan-
dard scores of 0.5 to 1.4 SD below normal level.
•• 3 = mildly abnormal clinical findings: a mild degree
of difficulty or deficit in certain functions. There are
some concerns about communicative behaviors, atti-
tudes, or perceptions, and the child demonstrates
variable performance and abilities. This category
also included any test data with standard scores of
1.5 to 1.9 SD below normal level.
•• 4 = moderately abnormal clinical findings: a moderate
degree of difficulty. There are significant concerns
about communicative behaviors, attitudes, or percep-
tions, and the child demonstrates poor performance
and abilities. This category includes any test data with
standard scores of 2.0 to 2.4 SD below normal level.
•• 5 = severely abnormal clinical findings: extreme
concerns about behaviors, attitudes, or perceptions,
and the child demonstrates very poor performances
and abilities. This category also includes any test
data with standard scores of >2.5 SD below normal.
Schields suggests an additional factor that warrants
assessment, beyond the five components of the
CALMS—ascertaining the child’s readiness for change.
Is the client ready for change or perhaps interested, but
not yet ready to work for change? Knowing a child’s
readiness for change is helpful in determining which
goals to target and the types of activities that will be
most beneficial in moving a child toward taking action.
For example, asking the child about what he or she does
to manage stuttering now may indicate whether or not
the child is actively using skills previously learned in
therapy. If a child avoids talking in class, asking the
child about his or her interest in participating in class
may get at readiness to engage in a participation goal.
Finally, what goals are important to the child. Children
must be motivated to acquire the targeted skills and
generalize them outside of therapy.
Shields suggests asking the “miracle question” to
understand the changes that are important to the child.
The child is asked to imagine waking up in the morning
and discovering a miracle has happened relative to the
child’s speech. The clinician uses prompts to elicit a
detailed description of what will be different about the
child, asking what the child or others might notice as a
result of the change. These behaviors tend to correspond
to changes the child would ideally like to make, their
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preferred long-term goals. Finally, the child is asked to
describe what might be different about his or her speech
after a few months of therapy. Children’s responses to
the miracle question inform the development of short-
term goals for which the child is motivated.
CALMS in Intervention
Therapy goals for school-age children who stutter can
be grouped by the CALMS model components. Clini-
cians should recognize that there will be overlap across
the goal areas, as addressing one aspect of stuttering often
impacts other aspects of stuttering that are being targeted.
Treating the Cognitive Component
Treating the cognitive component involves educat-
ing the child about stuttering and guiding the child to an
understanding of thoughts and attitudes about stuttering
and talking. It is important that the child gains an
understanding about what it takes to make changes in
thoughts and behaviors. Understanding this will sup-
port the child developing a sense of agency and knowl-
edge that he or she has the strengths and skills needed
to make the desired change. Goals for this component
could include the following:
•• Increase the client’s understanding of stuttering.
•• Education about normal anatomy and physiology of
speech production and mechanism.
•• Inform peers, family members, and so on about stut-
tering and its treatment (also Social).
•• Develop consistent “language of fluency,” defining
terminology of the communication system, of stut-
tering, of perceptions so that client and clinician are
“on the same page.”
•• Identify stuttering behaviors.
Clinicians can model noticing change by commenting on
what they see the child doing, saying, for example, “I
notice that you looked at me when you talked just now.”
The end goal is for the child to be able to identify
changes in his or her own speech and communication.
Treating the Affective Component
When students who stutter have negative emotions
around their stuttering; it is important to address these in
therapy. As the child becomes more educated about
stuttering, some reduction in negative thoughts and
­
emotions may occur. However, it is important to focus
 Word of Mouth 30:4 March/April 2019
directly on negative thoughts, attitudes, and feelings
over time in therapy because they are often an entrenched
part of how the child views himself or herself. Goals for
this component can include the following:
•• Decrease negative emotions and sensitivity to stut-
tering.
•• Decrease feelings of fear, anxiety, and/or tension
related to stuttering.
•• Increase ability to cope with negative responses by
others, including teasing.
•• Improve areas of self-esteem and self-confidence.
•• Change negative thinking.
•• Observe, reflect, probe, and validate feelings.
•• Increase ability to discuss stuttering with others (also
Social).
Engaging the child in voluntary stuttering both in and
outside of therapy is one way to begin to dissociate
negative emotions from stuttering. A variation on this
activity is to stutter voluntarily with varying degrees of
tension. This may also help children realize that they
can stutter in an easier manner. Engaging children in
talking about their thoughts and feelings fosters their
ability to notice when they are feeling quite anxious
about an upcoming speaking situation, and be ready to
develop ways to self-manage their negative thoughts
and emotions.
Treating the Linguistic Component
Goals for the linguistic component include the fol-
lowing:
•• Increase linguistic complexity from concrete to
abstract.
•• Increase length of utterance from single words to
conversation, as level of smooth speech is defined.
•• Decrease word avoidance.
Controlling the length and complexity of utterances is
a well-known strategy when teaching children to
modify their speech to increase fluency. New skills are
practiced first in single words, then phrases, until the
child is able to speak more fluently in conversation and
narratives. Another aspect of language to consider
when structuring therapy is pragmatics. Some aspects
of pragmatics are known to increase stuttering, that is,
children are more likely to stutter when asking a ques-
tion as opposed to answering a question. They are also
more likely to tell shorter stories, possibly to reduce
the likelihood of stuttering. Clinicians should incorpo-
rate a pragmatic focus in the treatment. Children are
more likely to maintain fluency when the topic and
vocabulary are familiar. As discourse becomes less
structured and children must speak with more partners,
they typically have more difficulty monitoring fluency
and being part of the conversation.
Treating the Motor Component
Fluency-shaping skills are a part of this component.
Examples include slowing the overall rate of speaking
through prolonged speech, providing more time for
motor planning and execution through pausing and
phrasing, and beginning the first word of a phrase in an
easier and more relaxed manner. Stuttering modification
skills, such as cancelations and pullouts, are intended to
help the child manage stuttering when it occurs. Motor
component goals may include the following:
•• Identify speech modification and/or fluency shaping
techniques.
•• Increase practice and use of techniques.
•• Define individual strategies for each client.
•• Increase awareness of self-monitoring skills (in all
domains).
The child’s fluency goals may change over time. The
clinician should allow the child to choose whether to
use fluency skills and if so, when and where. It is help-
ful for parents and teachers to learn the skills the child
is practicing so they can be better practice partners.
Treating the Social Component
Stuttering often results in a negative social impact on
the school-age child who stutters.
When children avoid talking because of their stutter-
ing, they are allowing stuttering to curtail communica-
tion which can feed the children’s the negative emotions
and thoughts around stuttering. Targeting avoidance
behaviors in therapy is critical to help children who
stutter become children who are comfortable making
decisions about when, where, and how much to talk
based on their personal preference or goals, rather than
on the need to prevent people from hearing them stut-
ter. Social component goals include the following:
•• Increase social/pragmatic skills.
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 Word of Mouth 30:4 March/April 2019
•• Increase verbal interactions in familiar and unfamil-
iar situations.
•• Increase number of opportunities for the client to use
new skills in realistic speaking activities.
•• Develop strategies for dealing with bullying.
•• Develop self-advocacy strategies.
Because bullying and teasing are both frequently
reported by children who stutter, teaching the children
strategies to manage bullying is an important social
target of therapy. Children can be assisted in identifying
teasing/bullying behaviors and working out ways to
handle various forms of bullying. These may range
from ways to respond to specific individuals who are
bullying them to educating their class about stuttering,
which may reduce the likelihood of bullying by class-
mates and enlist them as allies when children outside of
Evaluating Digital Media
RESOURCE
Barr, R., McClure, E., & Parkakian, R. (2018). Screen sense. Washington, DC:
REVIEW Zero to Three. Retrieved from www.zerotothree.org/screensense
Reviewed By Carol Westby Common Sense Media www.commonsensemedia.org
In an earlier issue of Word of Mouth, I discussed
research that showed the risks of high levels of screen
time and that persons with autism were particularly at
risk for the negative effects of screen time. Susan
Cooper, author of the award winning children’s fan-
tasy series, The Dark is Rising, has said, “The Age of
the Screen isn’t going to go away; indeed it offers all
kinds of wonderful possibilities, if it could just
acquire a little more quality control” (Cooper, 1996).
The Zero to Three organization has recently released
a set of materials, Screen Sense, that can enable us to
employ quality control in the digital materials we use.
Although the materials are directed toward young
children, the principles described can be used across
ages. Generally most, digital media is not good or bad
in itself.
Selecting Media
The Zero to Three materials suggest we consider 3
Cs when selecting media experiences for children:
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the classroom tease or bully the child. Prepare children
who stutter to proactively deal with negative listener
reactions or false assumptions about people who stutter
by learning to self-advocate. Develop children’s knowl-
edge about stuttering so they can educate others about
stuttering regarding how to talk and interact with them
in ways that are helpful and respectful.
References
Healey, E. C. (2012). The cognitive, affective, linguistic, motor
and social (CALMS) assessment. University of Nebraska.
Retrieved from http://csd.wp.uncg.edu/wp-content/uploads/
sites/6/2012/12/2.D.._CALMS_rating_form1.pdf
Healey, E. C., Scott Trautman, L., & Susca, M. (2004). Clinical
applications of a multidimensional approach for the assess-
ment and treatment of stuttering. Contemporary Issues in
Communication Science and Disorders, 31, 40–48.
•• Child: Consider the specific child—age, interests,
attention span, and current mood. Does the media
seem right for the unique child at this time?
•• Content: Does the media engage the child in meaning-
ful and active ways. Do you support the themes and
topics? Is it relevant to their lives?
•• Context: What is the context in which the child is
learning? Is the child alone or sitting with another
child or an adult? Young children learn more when an
adult interacts with them about the screen content.
Child
Children below age 3 do learn from TV and tablets,
but they do not readily transfer the learning, that is, they
do not apply the knowledge to real world experiences. It
is easier for young children to learn from real-life inter-
actions with people and objects compared with informa-
tion delivered by screens. Young children’s ability to
imitate a multi-step sequence from TV lags behind their
ability to learn from a live demonstration of the same
action. Although 5 year olds are more likely to transfer