Preparing Clinicians to Treat Stuttering

	About the presenter: Robert Kroll, Ph.D. is the Director of the Stuttering Centre and the Co-Executive Director of the Speech Foundation of Ontario and an adjunct professor at the University of Toronto. Bob introduced one of the first specialized and intensive programs for stuttering to Canada in the mid 1970's and presently sees clients from all over the country and beyond. His research interests include neuroimaging studies of stuttering, treatment efficacy and educational issues pertaining the training of clinicians. He has presented and published extensively on stuttering.
	About the presenter: Frances Cook MSc Reg MRCSLT (Hons) Reg UKCP (PCT) Cert CT (Oxford) Honorary Research Fellow, Dept of Psychology, University College London. Frances is the Head of Specialty at The Michael Palin Centre (MPC) for Stammering Children in London, UK, the largest training, therapy and research centre for children who stammer in the UK. She has over 30 years of experience in the treatment of stuttering. Frances was awarded the IFA Clinician of Distinction Award in 2003 and the Honours of the Royal College of Speech and Language Therapists in 2005.
	About the presenter: Luc De Nil is Associate Professor and Chair of the Department of Speech-Language Pathology at the University of Toronto. He is a Senior Scientist at the Toronto Western Research Institute, an Adjunct Scientist at the Hospital for Sick Children in Toronto and a Visiting Professor at the University of Leuven (Belgium). His research interests include using behavioural testing and neuroimaging to study the neural mechanism underlying speech fluency, specifically developmental stuttering, acquired adult-onset stuttering, and Tourette's syndrome. He currently is Editor-in-Chief of the Journal of Communication Disorders.
	About the presenter: Nan Bernstein Ratner, Ed.D., C.C.C. is Professor and Chair, Department of Hearing and Speech Sciences, University of Maryland at College Park. She is the editor of numerous volumes, and author of numerous chapters and articles addressing language acquisition and fluency in children. Dr. Ratner currently serves as Co-editor of Seminars in Speech and Language.She is a frequently-invited presenter at state, national and international speech, language and hearing association meetings. Dr. Ratner is an ASHA fellow, aBoard Recognized Fluency Specialist and received the 2006 IFA Distinguished Research Award.

Preparing Clinicians to Treat Stuttering

by Robert Kroll, Frances Cook, Luc De Nil and Nan Ratner
from Canada, England and U.S.A.

This paper presents a summary of a panel discussion held at the Fifth World Congress on Fluency Disorders in Dublin, Ireland in July, 2006. The panel was convened at the request of the first author of this paper, who, along with his colleague Tom Klassen had just reported on a series of studies examining the academic and clinical training of Canadian SLP's pertaining to treating individuals who stutter. As part of their research, Kroll and Klassen set out to investigate whether confidence levels and feelings of preparedness amongst SLP's have changed since 1990 when the first author conducted a similar survey. A second purpose of the study was to survey English-language Canadian University training programs in speech-language pathology and to specifically obtain responses from instructors and clinical educators pertaining to their opinions regarding the amount and quality of training in fluency disorders at their respective institutions. Kroll and Klassen reported on information obtained from 511 practicing speech-language pathologists and from 12 academic staff (fluency instructors and clinical placement coordinators). Results of the SLP surveys revealed no discernible positive shifts over a fifteen year period. Less than one-quarter of the SLP's rated the amount of their student clinical experience as either very good or excellent. Additionally, only one third of the respondents rated the quality of these experiences positively. Similar results were obtained from the SLP's rating of academic preparation with only about one third of the respondents offering positive ratings. Results of the survey responses from academic staff indicated that, in general, the feeling was that "they were doing the best with what they have". viz. restricted classroom time and few high quality placements. Kroll and Klassen reported that classroom time in fluency disorders did not exceed 10 percent of the total class curriculum, and in one case, totaled only about 2 percent. Almost all of the instructors added comments pertaining to insufficient time to fully address clinical issues in stuttering. The authors speculate on a number of reasons for this restricted number of clock hours for instruction in fluency disorders. One possible reason is that Canadian training programs in speech-language pathology are typically two to three years long and must deal with basic and fundamental courses as well as all of the disorder areas in this expanding field in a relatively compressed period of time. Moreover, most undergraduate programs in Canadian universities offer very few, if any, courses in speech language pathology that might prepare students for their graduate studies. Another explanation is that because fluency disorders typically are viewed as "low incidence", classroom instruction time may have to be limited in order to cover the other higher incidence conditions such as language and phonological disorders.

The authors of this study conclude by stating that their data should serve to alert educators to some of the major issues regarding the preparation of Canadian clinicians working with individuals who stutter. They go on to suggest a number of potential modifications to academic and clinical training, including a reexamination of course content, perhaps incorporating additional laboratory and clinical experiences. They also suggest considering advanced level post graduate courses, continuing education via specialized workshops and more creative clinical practicum experiences.

Given the above issues pertaining to the preparations of Canadian clinicians, the first author of this paper convened a small panel of experts from the United States, the United Kingdom and Canada to further shed light on this topic. The questions posed to these panelists included, among others, "Are we preparing clinicians adequately to treat stuttering clients?".

The answer to this question was first offered by Frances Cook, Head of Specialism, Michael Palin Centre for Stammering Children, London. Cook's answer was a resounding "No". As part of her presentation, Cook offers some of the history of the Michael Palin Centre and states that the Centre currently delivers the syllabus in Disorders of Fluency, both theory and practice, within one university in the UK. It should be noted that in the UK, there are two possible routes to become professionally qualified as a SLT (speech and language therapist). The first is to complete a four year undergraduate Honours Degree, and the second is to complete a two year post graduate Master's Degree. Academic staff of the Michael Palin Centre teach both the undergraduate and the graduates students in Fluency Disorders. According to Frances Cook, in 2002, up to 60 hours of classroom time were allocated to the teaching of fluency disorders for the two groups of students. By 2006, the number of allocated hours had dropped to 18, despite the fact that there has been a rapid growth in both research findings and evidence based practice. Moreover, the undergraduate and graduate classes in fluency disorders have now been combined. The 18 clock hours of classroom instruction are divided into 12 hours for childhood stammering and 6 hours for adults. Furthermore, the courses is now not really a course in its own right, but rather embedded in the "Vocal Tract Structure and Function" Unit.

Cook surveyed several of her colleagues to find out whether other academic institutions in the UK were experiencing similar changes with regard to teaching in fluency disorders. Cook reported that many universities have reduced their class contact hours for theory and practice in stuttering because of the additional syllabus requirements for other disorders (eg. Swallowing). In her survey of 6 colleagues, Cook reported other British training programs as offering between 4 and 20 hours of theory and practice in stuttering. In terms of clinical experience with stammering clients during clinical placements, Cook reported that generally, the common thread was that these were a mater of "pot luck". Additionally, many practicing clinicians expressed a lack of confidence or were even quite negative about working with stammering clients. Cook summarizes the situation in the UK by stating that "too many students do not meet a single client who stammers throughout their training".

In order to provide upgrading to the therapists in the UK, and elsewhere, Cook and her Centre staff deliver intensive three day workshops designed to teach clinical skills. Her workshops are geared for stuttering therapists working with children, adolescents and adults. Cook has been tracking the impact of her training workshops and reports that 90 percent of the workshop attendees report increased confidence and significant changes to their clinical practice with stammering clients.

Cook concludes by reiterating that because of the reduction in the number of teaching hours allocated to stammering, compounded by the lack of opportunity to observe clinical practice in the UK, newly qualified practitioners are not, generally speaking, ready to work with children who stammer without additional training and close supervision.

As we travel west across the Atlantic once again, Nan Bernstein Ratner, of the University of Maryland in the United States has been attempting to shed some light on these issues by surveying American training programs in SLP. Ratner conducted an informal e mail survey of American programs in an attempt to gauge the status of academic and clinical preparation for MA level SLP students to work with fluency disordered clients. Ratner presents data from 71 respondents, representing 23 percent of all graduate programs in the United States. Ratner wisely cautions the reader that these respondents most likely represented those programs and individuals MOST interested in fluency disorders, and, as such, may not provide a full picture of the total American situation regarding these issues.

As part of her survey, Ratner inquired as to whether the surveyed program required a graduate level course in fluency disorders. Most responding programs (86%) required a course but the nature of "a course" varied. Ratner reports that there were troubling trends in what seemed to constitute a course, and includes a number of statements from instructors describing the reduction in numbers of classroom hours allocated to their courses in fluency disorders. One instructor was most concerned with the knowledge and experience base of newly graduated students, while another another commented that classroom instruction puts too much emphasis on theory and not enough emphasis on practical diagnostic and therapeutic techniques and materials. This same instructor further pointed out that most of the students graduating from his/her program will do so without ever having direct therapy experience with a person who stutters. Ratner goes on to report that 70 percent of the surveyed programs indicated that there were no clock hour requirements specifically for fluency disorders at their home institutions, although a few noted that there were some lesser requirements to show competency. Additionally, only three of the surveyed programs required at least 20 or more hours of clinical contact with the vast majority not specifying any mandatory numbers of clinical hours with fluency disorders.

Ratner goes on to point out the extreme shortages of clinical placement opportunities in many environments, whether they are "in-house" placements or externship opportunities. She does point out, however, that some programs have addressed these needs by having students attend and participate in self-help organizations, such as the National Stuttering Association. Another program incorporates a sort of "buddy" system where students who had experience with fluency disordered clients mentor other classmates by demonstrating specific clinical skills. Ratner further reports that over 70 percent of her respondents felt that some sort of specialization in fluency would be desirable, but not necessarily made mandatory.

In her conclusions to the survey, Ratner states that it does appear that many students will graduate from MA level SLP programs without substantial classroom or clinical experience devoted specifically to fluency disorders. Most of the respondents tended to place this problem within the expanding scope of practice for SLP's, the relatively lower incidence of fluency disorders compared to other communication disorders and problems in identifying people to teach or supervise the fluency caseload.

Adding to the Canadian information, Luc De Nil of the University of Toronto reported that most programs in that country have a comparable course offering in the area of stuttering, typically consisting of one course (approximately 3 hours per week for one semester) often, but not always, including a hands-on lab experience of one or more sessions. Most instructors surveyed were of the opinion that the emphasis placed on stuttering was about right, given that each program aims at graduating generalists who have sufficient knowledge and clinical skills in the increasingly broad and complex practice of speech-language pathology, of which stuttering is only one. Most programs felt that they were able to give their students the education needed to work as a beginning clinician with people who stutter, but all programs emphasized that students who are serious about becoming expert clinicians need to pursue advanced post-graduate training specifically focused on stuttering. Nobody who responded to the survey agreed that post-doctoral or specialty training should be a requirement for fluency treatment

With respect to clinician-scientist training, De Nil argued that no, we are not successful in graduating clinician-scientists at the Masters level, but neither can that be an expectation of our training programs. In order to contribute meaningfully as a clinician scientist, practitioners in addition to their clinical skills, also need to gain in-depth research skills which is something that typically cannot be incorporated in a 2-year masters program, but requires advanced research training at the doctoral level.

De Nil feels that academic and research centres serve a very important function in advocating for high quality clinical services for stuttering. These initiatives ideally would demonstrate the real need and efficacy of our interventions. Unfortunately, in many cases data that prove the efficacy of our interventions is not available or insufficiently scientifically grounded to support our arguments for increased services. Therefore, as centres of research we also have a real responsibility to generate such badly needed outcome data in order to be able to show those who control the purse strings that our treatments are effective and benefit not only individuals who stutter but also society as a whole.

In sum, this panel has probably unearthed more issues and questions than providing answers regarding the preparation of clinicians to treat stuttering. One of the major conclusions that can be reached is that issues regarding academic training and clinical placements in fluency disorders are surprisingly similar in Canada, the US and the UK. Most programs are limited in both the numbers of clinical hours and classroom hours that students receive in fluency disorders. Moreover, there is a dirth of treatment efficacy research in this area with which we can lobby for increased training and services. Perhaps the most encouraging aspect of this discussion is the identification of common issues in three intellectually and technically sophisticated countries. It is anticipated that discussions such as these will result in collaborative problem solving such that future generations of beginning practitioners and consumers of our services will ultimately be better served.

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September 20, 2006