The Death of Fluency Disorders
About the presenter: Bob Quesal is a professor at Western Illinois University, where he serves as program director. He teaches courses in fluency disorders, anatomy, speech and hearing science, and voice disorders. He is recognized as a Fluency Specialist by the Specialty Board on Fluency Disorders. He is the former editor of the Special Interest Division 4 (Fluency and Fluency Disorders) newsletter and will serve on the SID 4 Steering Committee beginning in January 2002.
The Death of Fluency Disorders
by Bob Quesal
from Illinois, USA
"...you better start swimmin',
or you'll sink like a stone.
For the times they are a-changin'."
-- Bob Dylan
Some Background
What follows may be construed by some as overstatement. It may construed by some as unfair. It may be construed by some as overly pessimistic and negative - perhaps hysterical. To some extent, all of those things may be true. For that reason, I'd like to provide a bit of background before I discuss the topic at hand. My title probably is an overstatement. In order to be fair, I will point out that I will use certain "shorthand" as I talk about this topic (in part because of space limitations). For example, when I talk about "ASHA" (the American Speech-Language-Hearing Association), I am not referring to the people who work in the ASHA National Office in Rockville, MD. The individuals I have met who work at ASHA are hard working, caring people. However, their job is largely to carry out the wishes of the ASHA membership. For that reason, when I refer to ASHA, I am referring to my professional organization - its membership and policies - not to any particular individual or individuals. I do not believe that there is any intent on anyone's part to do harm to the area of fluency disorders or people who stutter. We are where we are because of a series of events that could be considered to be reasonable and logical. I am painting a fairly bleak picture, because until the past few years I was among those who felt that the future of fluency disorders as an area of study and practice in speech-language pathology either was not as bad as it seemed, or that things would get better. However, when viewed from a certain perspective, trends that I (and others) have observed more recently lead me to believe that optimism is no longer an appropriate emotion. My hope is that my perspectives are not correct. I'd like nothing better than to read this essay in 5 or 10 years and be amused by how wrong I was. The concerns I talk about in October of 2001, however, are very real and must be addressed.
Some History
The profession of speech-language pathology is a relatively new one. Formal study of communication disorders actually began in the early 20th century, at places such as Cornell University, Valparaiso University, the University of Michigan, the University of Wisconsin and the University of Iowa (Moeller, 1976). Lee Edward Travis was selected in the 1920s to be the first student in the newly formed doctoral program at the University of Iowa designed for the study of speech and hearing disorders. Although Travis did not stutter, much of his research was devoted to the study of stuttering. Many of Travis's students, most notably Wendell Johnson and Charles Van Riper, became pioneers in the emerging profession that was to become speech-language pathology. While other communication disorders were studied and treated, it is safe to say that a cornerstone of the evolution of speech-language pathology was the disorder of stuttering. This was reflected in the role the disorder of stuttering played in the profession. Stuttering was a much-studied disorder during most of the 20th century, and research reports on stuttering were common in journals such as the Journal of Speech Disorders (later the Journal of Speech & Hearing Disorders) and many other professional journals. Many of these studies dealt with treatment of stuttering, and it was considered important for any "Speech Correctionist" to be able to treat individuals who stuttered.
Stuttering was, for many years, one of the "core" communication disorders, along with articulation, voice, and language, as well as hearing disorders. The field of "speech correction" grew considerably in the 1930s and 1940s, with programs of study springing up all over the United States. Many, if not most, of the individuals who began those programs (e.g., Charles Van Riper at Western Michigan University, Robert Milisen at Indiana University, Bryng Bryngelson at the University of Minnesota, and many others) came out of Iowa's program. I would wager that nearly all SLPs today have some "Iowa/Stuttering" pedigree, even if it is "a professor of a professor." The first meeting of what was to become the American Speech-Language-Hearing Association was held in a house in Iowa City. The point of all this is not to elevate the University of Iowa's program to some mythical status, but instead to point out that the roots of our profession (as much as many people would like to deny it) are largely in Iowa and in the area of stuttering. (I will emphasize once again, however, that these are not the sole roots of the profession.) But those who diminish stuttering's role in speech-language pathology display ignorance of history.
Growth
As more programs turned out more "speech correctionists," more services were delivered to more individuals with communication disorders. (Just one example of a "growth spurt" in the scope of practice in speech pathology occurred during and after World War II, when soldiers who had suffered head wounds in the war returned home. As a result of this, there was an increase in research relating to the understanding and treatment of aphasia and other neurologically-based communication disorders.) By the 1960s, it was clear that post-graduate education was needed in order for someone to treat the many communication disorders, and the Master's degree was established as the entry-level degree for practice in 1965 (ASHA, 1964). The basic standards for the Certificate of Clinical Competence (CCC-SLP) remained largely the same for nearly the next three decades, with the "old" standards undergoing their last revision in 1985, even as scope of practice (and ASHA membership) continued to grow. The 1965 standards specified course work (a minimum of 42 hours, of which 30 had to be earned at the graduate level) and clinical experience ("275 clock hours of supervised, direct clinical experience with individuals presenting a variety of disorders of communication"), but there was no specific mention of how the hours were to be distributed. Eventually, the standards specified a minimum of 25 hours each with fluency, voice, and articulation disorders; 75 hours with language disorders; 50 hours of diagnostics; and 35 hours with hearing disorders.
A Critical Decision
Of course, as scope of practice expanded, it became increasingly difficult to educate SLPs in all the disorder areas that they would need to know. The old "articulation - voice - fluency - language - hearing - assessment" breakdown was becoming less useful because those areas, while relatively comprehensive, could be viewed as both overly restrictive and not specific enough. For example, while there are many clients with articulation and language problems, there are considerably fewer with voice and fluency problems. As mentioned, the "old standards" did not specify the age of the clients with whom students gained experience. For those reasons, and others, a decision was made in 1988 to change the standards for the CCC-SLP. The "new standards" would no longer specify practicum experience based on disorder areas, but instead broke down the practicum into "treatment" & "assessment," "children" & "adults," and "speech" & "language." After January 1, 1993, individuals applying for the CCC-SLP would need 20 hours of direct contact with assessment of speech disorders in children, 20 hours of assessment of speech disorders in adults, 20 hours of assessment of language disorders in children, 20 hours of assessment of language disorders in adults, 20 hours of treatment of speech disorders in children, 20 hours of treatment of speech disorders in adults, etc., etc. - I think you can get the picture. "Fluency" or "stuttering" fell under the heading of "speech disorders" (as did voice and articulation disorders). At first blush, this seemed quite fair - an improvement, perhaps - because in the pre-1993 standards, there was a total of 75 hours specified for articulation, voice, and fluency treatment (plus, possibly, some unspecified proportion of the 75 hours of diagnostics). The new standards specified 80 hours in speech (20 each in child speech assessment, adult speech assessment, child speech treatment, and adult speech treatment). Many felt that one of the strengths of the new standards was their flexibility. Academic programs were now able to structure their students' clinical experiences to better take advantage of program resources - faculty, client base, geographic setting, etc. - while still turning out competent SLPs. Some in the area of fluency disorders were quite concerned about the elimination of the specific requirement for practicum in fluency disorders (although I must admit that I was not among them). The most critical saw it as carte blanche for programs to effectively eliminate stuttering as part of the curriculum. More charitable individuals saw it as a simple change in "bean counting" and trusted academic programs to do the right thing; i.e., keep fluency disorders coursework and practicum in the curriculum with little if any change. In retrospect, it is probably fair to say that we have a classic case of the Law Of Unintended Consequences. As we moved into the mid- and late-1990s, we began to get anecdotal reports of changes in the curriculum that resulted from the 1993 standards. (These changes were not only in fluency disorders, but I will focus on fluency disorders in this paper.) Some programs (such as my program at Western Illinois University) reported "minor" changes to the curriculum. For example, WIU used to offer a 2-credit undergraduate class in Stuttering. In 1996, we eliminated that class and introduced a new, 3-credit class covering fluency, voice, and orofacial disorders. Our motives were pure - we did not have a voice or cleft palate class at the undergraduate level, and those topics were not being covered well in the existing curriculum.
However, to accommodate those areas, fluency coverage was reduced. Colleagues at other universities reported similar changes. These typically were not major changes, but were at least a subtle de-emphasis of fluency disorders in the curriculum. At the annual convention of the Illinois Speech-Language-Hearing Association in the mid-1990s, I sat with some colleagues and we talked, over coffee, about stuttering's role in the context of the new CCC standards. At that time, many of the "pioneers" in fluency disorders were retiring or nearing retirement age, and it appeared that many programs either were opting not to replace them with individuals with expertise in fluency disorders, or were at least considering that as an option. This option was now available - and perhaps appealing - because fluency was no longer required as part of the curriculum. I expressed my concern about the lack of "mentors" for students: if no one on the faculty truly felt passionately about working with stutterers, how would students develop that passion? Some colleagues agreed with me, but more, it seemed, felt that I was being overly pessimistic: certainly there would be someone on the faculty - perhaps a supervisor - who would have that passion, even if there was not an academic faculty member to instill it.
Around that time, my colleague Scott Yaruss was conducting a survey of academic programs - in fact, that may have been the impetus for our discussion that day. Yaruss (1999) found that programs in fact were making changes - and more than we wanted to admit - as a result of the 1993 standards. These included such things as changing graduate courses in stuttering from required classes to electives, and reducing or eliminating practicum experiences in assessment and/or treatment of stuttering. Overall, one-half of the 134 responding programs (representing 56% of institutions offering graduate programs in communication disorders) indicated that they reduced or eliminated their academic and clinical requirements following ASHA's elimination of specific standards for fluency disorders in 1993. It is important to point out that no relationships were found between the amount of academic and clinical education provided in the area of fluency disorders and program size (either in terms of the number of students or the number of faculty), suggesting that the lack of education in fluency disorders was not simply due to a lack of resources. One would hope that this would not have been the predicted outcome of the 1993 standards. As mentioned above, this is probably a classic example of the law of unintended consequences. No one set out to cause relatively major changes to one of the cornerstones of our profession within a span of five years or so, but that appears to be what happened. Unfortunately for those wishing to spread the word about the disintegration of fluency disorders training, Yaruss's paper was published in the Journal of Fluency Disorders - a journal read primarily by people interested in fluency disorders. Yaruss was preaching to the choir. In recent years, we have come to find that most people involved in ASHA decision-making were unaware that empirical data existed which documented the negative effects of the 1993 standards changes.
One bad idea follows another
One of my favorite quotes is "The number one cause of problems is solutions." Apparently, the "flexibility" afforded by the 1993 standards was not quite good enough. In 2000, another set of changes to the CCC-SLP standards were proposed. Individuals attending the annual meeting of the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) got a "sneak preview" of the "improved" standards, hereafter referred to as the "2005 standards." This sneak preview draft got quite a reaction since there were basically no minima for anything. No minimum number of hours with adults or children, no minima for speech vs. language, no minima for amount of supervision students were to receive (although I will note that this was later changed back to a 25% minimum supervision, as in both the 1993 and the 1965 standards. The entire text of the approved standards is available online at .)
Two important quotes from those standards are the following: "standards for entry-level practice include the following requirements:
- practicum experiences that encompass the breadth of the current scope of practice with both adults and children without specific clock-hour requirements for given disorders or settings
- a total of 400 clock hours of supervised practicum, of which at least 375 must be in direct client/patient contact and 25 in clinical observation"
A colleague of mine spoke up at the CAPCSD meeting, quite angrily, and said that these new standards would effectively eliminate fluency disorders in the curriculum. My colleague was pooh-poohed by the folks presenting the new standards, being reassured that academic programs could be trusted to "do the right thing." My colleague then mentioned that there were data to show how the 1993 standards had impacted fluency disorders, and was again pooh-poohed. The authors of the new standards were unaware of those data, and their response suggested that they even doubted that such data existed.
Since that time, we have been reassured that fluency is not at risk. Why, look, the word "fluency" appears twice in those standards! Of course, "swallowing" appears seven times, because "swallowing, and upper aerodigestive functions [are] additional recognized and emerging areas of practice" as opposed to the "traditional parameters of communication." The standards state that "Specific knowledge must be demonstrated in...fluency" (as well as a lot of other areas). As far as implementation of the standards is concerned: "The applicant must demonstrate the ability to analyze, synthesize, and evaluate information about communication differences and disorders and swallowing disorders. Specific knowledge may be demonstrated by successful performance on academic course work and examinations, application of information obtained through clinical teaching, and completion of independent projects...."
I believe that one can reasonably conclude that it would be possible for a student to receive minimal education and experience in fluency disorders and still meet the standards for the CCC-SLP. Whether this will happen or not will depend, to a large extent, on what academic programs decide to do.
The death of fluency disorders?
Do the 2005 standards give us cause for concern? A year or two ago, I might have said "not necessarily." Today, I say "most certainly." I say this because we have more empirical evidence of the trends that began with the 1993 standards. Yaruss and Quesal (2001) followed up the Yaruss (1999) survey with another, somewhat more detailed survey. That survey was returned by nearly 2/3 of the programs in the U.S. offering communication disorders programs, and results revealed the following: more programs allowing students to graduate without academic or clinical training in fluency disorders; a further reduction in the assessment and treatment experience obtained by students; a decrease in the number of full-time faculty members teaching courses in fluency disorders (with more part-time or adjunct faculty members teaching those classes); and a decrease in the number of faculty with extensive clinical and research experience in fluency disorders. Absolutely nothing suggests that things will get better. At best, things will remain the same - and that is an extremely optimistic view.
As I see it, we have four or five choices:
- Do nothing and let fluency disorders die on the vine (and I believe it will).
- Members of ASHA who care about stuttering and fluency disorders must do more to be heard. That so many decision-makers in ASHA were unaware of the Yaruss (1999) data suggests that we did not do enough to point out the "unintended" consequences that came about as a result of the 1993 standards. We must be much more proactive regarding the 2005 standards.
- People who stutter ("consumers") - you folks reading this - have to let ASHA (and anyone else you can think of) know that the diminution of fluency disorders in the profession of Speech-Language Pathology is not a good thing. If there is one thing ASHA responds to, it is negative publicity (e.g., the "Monster Study" debacle in the summer of 2001). If the public puts pressure on ASHA, that will be much more effective than if the relatively small proportion of the membership interested in people who stutter (about 700 of us in Special Interest Division 4 for Fluency and Fluency Disorders - out of about 100,000 total members) tries to act alone.
- We can consider the - less desirable - possibility that ASHA in fact does not care about people who stutter. Perhaps it is time for someone else - some other profession or some "splinter group" - to act on behalf of those who stutter and to ensure that someone is qualified to work with, and help, people who stutter. How this will be accomplished, I am not sure (but I think I have an idea for next year's ISAD conference).
- We can do nothing - oh, wait, I already said that. Are things truly this bleak? As I said at the outset, I certainly hope not. But aside from a somewhat cynical perspective, I do not believe that anything I have said is untrue or inaccurate. Others' interpretations may differ, but the facts are there. The times they are a-changin' and things are not looking all that great.
References
American Speech-Language-Hearing Association, Committee on Clinical Standards (1964). Requirements for the Certificate of Clinical Competence. Asha, 6 (5), 162-164.
American Speech-Language-Hearing Association, Council on Professional Standards (2000). Speech-Language Pathology Standards (effective 1/1/05), Approved 10/23/00.
Moeller, D. (1976). Speech Pathology & Audiology: Iowa Origins of a Discipline. Iowa City: The University of Iowa..
Yaruss, J.S. (1999). Current status of academic and clinical education in fluency disorders at ASHA-accredited training programs. Journal of Fluency Disorders, 24, 169-184.
Yaruss, J.S. & Quesal, R.W. (2001). Academic and Clinical Education in Fluency Disorders: An Update. (Submitted).
August 12, 2001
