Parents as Partners in Young Children's Stuttering Treatment
About the presenter: Anne Cordes Bothe, Ph.D., CCC-SLP, is an Associate Professor in the Department of Communication Sciences and Disorders at The University of Georgia. Her research and clinical interests focus on the measurement of stuttered speech and on the interaction of measurement and treatment variables in determining the efficacy, effectiveness, and efficiency of stuttering treatments.
Parents as Partners in Young Children's Stuttering Treatment
by Anne Cordes Bothe
from Georgia, USA
Mr. and Mrs. Allen arranged for their son Arnie to be evaluated by a speech-language pathologist (SLP) when he was 2 years and 10 months old. He had been stuttering for at least 6 months, maybe more. After the evaluation, the SLP explained to the Allens that they needed to speak more slowly around him and not ask him too many questions, because this would help his stuttering. Mrs. Allen's brother, who was also an SLP, told them on the phone a few weeks later that the advice they had received was outdated and would not help Arnie, and he needed to be taught to use gentle, stretchy speech. After another few weeks, they asked Arnie's SLP about this advice. She told them that there are many views on children's stuttering but that, essentially, Mrs. Allen's brother was wrong. When Arnie was three and a half years old, still stuttering as much as ever, the Allens called a third SLP and were given a third opinion.
Mrs. Baker first called an SLP on the eve of her son Bill's fourth birthday. Bill's pediatrician had told her several times during the past 18 months that Bill would most likely grow out of his stuttering, that they should just ignore it, and that there was no need to do anything at all until he turned four. She had waited as long as she could, watching her son struggle but diligently following the doctor's prescription, until finally on the day before his birthday she found herself in tears again -- and literally unable to wait one more day to pick up the phone.
Mr. and Mrs. Carson had their son Carlos's speech evaluated several times by the SLPs in his elementary school, and Carlos was repeatedly diagnosed with stuttering. For some reasons that they never clearly understood, however, he was always described as too mild to qualify for speech therapy at school. Carlos continued to stutter, and his parents continued to be concerned, especially because Carlos seemed to be refusing to join in activities that he had previously enjoyed. Finally, as Carlos began the third grade, the Carsons sought advice from a family friend who was an SLP. She recommended that they call the university clinic in the next town, because she knew about some of the work being done at the university with children and adults who stutter.
I would guess, unfortunately, that these families' experiences probably sound discouragingly familiar to anyone who has known a young child who stutters. On a more positive note, Arnie, Bill, and Carlos's stories all have a happy ending: They all participated in a study about the treatment of children's stuttering here at The University of Georgia, and they are no longer stuttering. In what follows, I would like to briefly explain this study, as a framework for exploring several questions about how parents and SLPs can work together to assess and treat children's stuttering.
Diagnosing Stuttering in Young Children
Wendell Johnson, one of the pioneers in stuttering theory, proposed that stuttering was the end result of a cycle that began with parental misdiagnosis or overinterpretation of children's normal disfluencies (Johnson & Associates, 1959). It has since been demonstrated convincingly that parents of children who stutter are no stricter than other parents with respect to the speech behaviors that they label stuttering (e.g., Curran & Hood, 1977). Nevertheless, the idea that parents overidentify stuttering in their young children seems to be an oddly persistent notion in our professional and clinical literature. While many other factors are obviously involved, I believe that the advice to wait and allow stuttering to resolve itself, as the Bakers' pediatrician recommended, and the claim that mild stuttering does not need to be treated, as Carlos and his parents were told, are both related to this idea. In other words, in general, it seems that some professionals begin from the assumption that parents are too eager to diagnose stuttering in their children and too eager to force their children into unnecessary treatment.
Such views are very different from the views that control other areas of speech-language pathology. We usually teach our students to listen to parents' concerns and to believe parents' descriptions of the problem. Research about identifying children with specific language impairment, for example, has demonstrated that a young child's parents may be the single best source of information about that child's abilities and problems (Restrepo, 1998). We also work, in general, from the assumption that early identification and early treatment will tend to be the best approach for many disorders.
What does this mean for parents and SLPs working together to diagnosis and assess children's stuttering? First of all, on the whole, I proceed from two assumptions. One, if parents have believed that their child is stuttering long enough to have made and attended an appointment with an SLP, then they are correct that their child is stuttering. And two, parents who believe that their child needs professional help because of his or her stuttering, and needs it sooner rather than later, are also correct. Arnie's first SLP was absolutely correct when she said that there are many different views of children's stuttering, but I don't think that any of these families were well-served by the advice to change their own speech (Arnie's parents), to assume that the child's stuttering would cure itself (Bill's parents), or not to treat persistent but mild stuttering (Carlos). In a sense, stuttering is no different from any other problem that your child might have: If someone is trying to tell you that your child is fine when you know she's not, or trying to tell you that your child does not need help when you know he does, trust yourself, and seek help somewhere else.
Treating Stuttering in Young Children
Many authors have written in different ways about the roles that parents can play not only in the diagnosis but also in the management or treatment of children's stuttering. Some of these approaches are based, at least in part, on the belief that children's stuttering is caused or maintained by something in the child's environment. The focus of treatments emerging from this framework, therefore, is to change the child's environment, which often means changing how the parents respond to or talk with the child. Such treatments are often labeled "indirect," because the child's stuttering itself is not the immediate focus of the treatment.
Approaches labeled "direct," in contrast, begin from the assumption that stuttering reflects a problem with a child's speech-motor production. Therefore, these treatments focus directly on teaching the child to speak differently. Parents can be involved in direct treatments, also, but the reasoning has little or nothing to do with parents as causal or maintaining agents. Instead, the view is simply that parents have more access to the child, more often, than SLPs do.
The study that Arnie, Bill, Carlos, and five other children participated in was designed to compare the effects of direct and indirect treatment procedures. Each child participated with his or her mother in a series of different experimental conditions that usually included at least one direct technique and at least one indirect technique, all administered by the child's own mother. We compared the different conditions using single-subject experimental design procedures; that is, each mother-child dyad completed many 5-minute trials of a few conditions, with the sequence of those conditions arranged so that we could begin to draw conclusions about which ones seemed to reduce the children's stuttering. As described below, the results of this study clearly showed that direct treatments were much more effective than indirect treatments for reducing these children's stuttering.
Indirect treatment options. One common indirect treatment approach involves asking parents to speak slowly. To investigate this approach, we had the mothers speak not more than 100 syllables per minute, about half a normal adult speech rate. All eight children in our study were exposed to reduced maternal speech rate, each for at least four 5-minute conversations and some for as much as 90 minutes across two different days. We found one hint that reduced maternal speech rate was associated with reduced stuttering frequency for one child, and one hint that reduced maternal speech rate was associated with increased stuttering frequency for a second child. Neither of these effects was strong, and none of the other children showed any tendency to reduce their stuttering when their mothers spoke more slowly.
A second common indirect treatment approach involves asking parents to wait for a couple seconds after the end of their children's utterances before they respond, to reduce the pace and therefore the demands of the conversation. The first four children in our study were exposed to this "increased response latency" condition, each for at least three 5-minute conversations and three of them for approximately 40 minutes on two different days. One of these children showed slightly increased stuttering during this condition, one showed no change, and two showed complex social and pragmatic changes that also resulted in less stuttering: One spoke to himself and to his toys, in a high-pitched monologue, apparently believing that his mother was not responding to him, and one repeated her utterances multiple times and with increasing loudness until her mother finally answered her. We did not view these changes as positive, and we chose not to use increased response time for any of the other children.
Direct treatment options. The direct treatment option that our study investigated was asking parents to stop their children when they stuttered, by saying "stop" or "uh-oh" or "oops, there was a bumpy word" or something similar (see Onslow, Andrews, & Lincoln, 1994). Seven of the eight children participated in this condition, for up to 12 5-minute conversations. Six of them showed reduced stuttering; the seventh did not.
Of those six families, five chose to continue in a long-term parent-administered treatment program that incorporated these corrections for the children's stuttering. At home in between clinic visits, the parents completed 10-minute treatment sessions every day, during which they corrected their children's stuttering as they had during the first part of our experiment. We also added the feature that the parents were to praise their children's nonstuttered speech at least four separate times during the day (also a variation of the procedures reported by Onslow et al., 1994). Clinic visits were once per week, and they consisted of discussion of the tapes and ratings that the parents had made during the week, any necessary problem-solving or discussion, and then play with the parent, the child, and a clinician, with the parent providing consequences to the child for stuttered and nonstuttered speech.
This portion of our study was not designed as an experiment; we simply demonstrated that this direct treatment approach seemed to be associated with reduced stuttering for these children. All five met a criterion of stuttering on not more than 0.25 percent of their syllables in a sample of at least 5 minutes' duration recorded at home, and in another sample of at least 10 minutes' duration recorded in the clinic, for four consecutive weeks. The shortest time in treatment before meeting this criterion was 15 weeks, for one of the youngest boys (3 years and 6 months at the beginning of the study; he met the criterion during weeks 12-15). The longest time in treatment, 26 weeks, was for another young boy (also 3-6) who also had moderate to severe phonological problems; he met the criterion during his weeks 23-26.
We have followed all five children in a post-treatment maintenance phase. Four of them no longer stutter, and have not stuttered for between several months and over two years. The fifth shows zero stuttering in some recordings, but produces up to approximately one stutter per 1000 syllables (0.1 percent) in other recordings.
Conclusions
The results of this study were relatively consistent with previous research in showing that direct treatment may be more efficient and more effective than indirect treatment at reducing children's stuttering. Three of the five children studied by Zebrowksi, Weiss, Savelkoul, and Hammer (1996), for example, showed less stuttering when their mothers used a slower speech rate, but one child showed a substantial increase and another did not change. It has also been previously demonstrated that parents of children who stutter do not appear to differ from other parents with respect to their habitual response time latency with their children (Kelly, 1993), a result that suggests that there is no need for parents of children who stutter to increase their response time latency. Other indirect procedures that were not included in our study have also been assessed previously: Wilkenfeld and Curlee (1997), for example, showed that whether an adult partner asked many questions or simply made comments had no effect on three children's stuttering. Direct approaches have been subjected to relatively more research, and they have repeatedly been shown to reduce children's stuttering (e.g., Martin, Kuhl, & Haroldson, 1972; Onslow et al., 1994).
Overall, the research and the clinical work that I have done, combined with the things I have read, have led me to two working assumptions about stuttering treatment for young children. First, it should remove the stuttering. And second, it should allow the child to grow up without any of the social or emotional consequences of living with a communication disorder. I also believe that one of the most efficient ways to achieve the second of these two goals is to achieve the first. In this light, I see at least two very positive results from Arnie, Bill, and Carlos's study. First, direct treatments administered by their parents took only 15 to 26 weeks to eliminate stuttering, for all five children who participated. Second, the parents were pleased with the program, and the children were happy and proud of their progress. With respect to the latter, I will let Carlos have the last word: "I wish we had done this before, because I used to have to say a word over and over and over and over, and I didn't like that, and now I don't do that any more."
Acknowledgments
My sincerest thanks to the families that I referred to here as the Allens, the Bakers, and the Carsons, and to all the other families who have been associated with the Stuttering Research Laboratory at The University of Georgia. Data from the study described here have been reported more formally by Weintraub (1997), Weintraub and Cordes (1997), Cordes (2000a, 2000b), and Starnes (2000), and are currently being prepared for submission for publication as one complete final report.
References
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Cordes, A.K. (2000b). Preschool stuttering: Measurement, training, & recovery. Grant proposal submitted to the National Institutes of Health, June 2000.
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Johnson, W., & Associates (1959). The onset of stuttering. Minneapolis: University of Minnesota Press.
Kelly, E. (1993). Speech rates and turn-taking behaviors of children who stutter and their parents. Seminars in Speech and Language, 14, 203-214.
Martin, R.R., Kuhl, P. & Haroldson, S. (1972). An experimental treatment with two preschool stuttering children. Journal of Speech and Hearing Research, 15, 743-752.
Onslow, M., Andrews, C., & Lincoln, M. (1994). A control/experimental trial of an operant treatment for early stuttering. Journal of Speech and Hearing Research, 37, 1244-1259.
Restrepo, M.A. (1998). Identifiers of predominantly Spanish-speaking children with language impairment. Journal of Speech, Language, and Hearing Research, 40, 1398-1411.
Starnes, K. (2000). Parent-administered direct and indirect treatments for young children who stutter. Unpublished master's thesis, The University of Georgia.
Weintraub, H. (1997). Single-subject analyses of direct and indirect treatments for children who stutter. Unpublished master's thesis, The University of Georgia.
Weintraub, H., & Cordes, A.K. (1997). Single-subject analyses: Direct and indirect treatments for children's stuttering. Poster presented at the Annual Convention of the American Speech-Language-Hearing Association, Boston, MA; November 1997.
Wilkenfeld, J.R., & Curlee, R.F. (1997). The relative effects of questions and comments on children's stuttering. American Journal of Speech-Language Pathology, 6(3), 79-89.
Zebrowski, P. M., Weiss, A. L., Savelkoul, E. M., & Hammer, C. S. (1996). The effect of maternal rate reduction on the stuttering, speech rates and linguistic productions of children who stutter: Evidence from individual dyads. Clinical Linguistics & Phonetics, 10, 189-206.
September 1, 2000
