What Clinicians Should Know
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About the presenter: Susan Block, PhD, teaches at La Trobe University in Victoria, Australia and is a member of the Stuttering Research Consortium at the Royal Children's Hospital in Melbourne. Her PhD study focused on student-delivered stuttering treatment. She has also investigated prognostic indicators for adults who stutter and collaborated on research involving multi-site trials. Dr. Block has has conducted clinical programs for adults and children who stutter. She is one of the recipients of a $4 million NHMRC program grant, and a Fellow of the Speech Pathology Association of Australia. For the past 25 years she has taught at the university educating undergraduate and graduate students in the area of stuttering. |
What Clinicians Should Know
by Susan Block
from Australia
For some people who stutter, the experience of having treatment for the stuttering can be an exciting and liberating experience. For others it can be a very difficult and confronting process. As a result not everyone is able to make the same amount of change in the same period of time. Consequently it is vital that speech pathologists treat each person as an individual and find out exactly what it is that each person is aiming for when they come for treatment.
People seek treatment for a variety of reasons. Parents bring their children so they will learn how to stop stuttering -- to ease their path through life. They frequently express concern about the potential for teasing and bullying at school. Recent research confirms that this concern may be warranted as the negative reactions to stuttering can be evident in very young children (Langevin et al, 2008). Most adults and adolescents presenting to the La Trobe Communication Clinic report that they are aiming to stop stuttering -- or certainly, wanting increased fluency. This means that they specifically want to work on changing their speech. Some people also want to decrease the anxiety they feel about speaking (because of their stuttering). There are also other things that motivate people to seek treatment. They may have important speaking requirements at school (e.g. oral presentations), the desire to decrease teasing and bullying, presentations at work, job interviews, possibilities for promotion at work, important social events where they need to speak (e.g. weddings) etc. Each of these may need a different focus in treatment. Indeed, there may need to be several aspects to the treatment process to ensure that if someone has several goals for treatment, each goal becomes a focus at the appropriate time. Thus, clinicians need to be very clear about exactly what it is that the people coming to them are expecting from them. Similarly, it is important that those who are seeking treatment are very clear with their clinicians about exactly why they are there. Otherwise, each may not be striving for the same outcome.
With increased access to information through the WorldWideWeb consumers can learn about stuttering and treatment from a huge range of sources. Unfortunately, not all of the sources are accurate. Thus, it is important that clinicians know what information people presenting to them may already have. They need to be able to discuss the variety of evidence in terms of its accuracy and its evidence base. Also, its relevance to the specific situation of each individual who stutters. Speech-Language-Pathologists need to be advocates for those who stutter (and their families). They also need to have a very good awareness of what is the current information available about stuttering. More importantly however, they need to know what the current thinking is about what is evidence-based best practice for the treatment and management of stuttering across the lifespan. They need to be flexible in their approaches to each person and to the different aspects of the treatment they offer.
Current research indicates that the Lidcombe Program should be the treatment of choice for young children who stutter (Jones et al, 2005; Lincoln & Onslow, 1997). Similarly, there is evidence to suggest that Prolonged (or Smooth Speech) should be the treatment of choice for adults who stutter. Evidence also indicates that a variety of formats in which to teach prolonged Speech can produce impressive fluency outcomes (Block et al, 2005; O'Brian et al, 2003). However, there are issues relating to service delivery that can make it difficult to deliver some of these treatments in the format in which they have often been researched -- e.g. weekly treatment, intensive treatment or a combination of both. The problems can be, from the clinician's point of view, in terms of managing the logistics and caseload, or from the perspective of the person who stutters, in terms of being able to be consistently available in the clinic. Work and family commitments often mean that regular treatment can be disrupted.
Relapse is an issue for adults and adolescents who stutter. Indeed, the predictors of outcome have included locus of control, normal attitudes to communication and skill mastery (Andrews & Craig, 1988). More recent research confirms the importance of stuttering severity (mastery of techniques) as the predominant issue in prognosis for adults who stutter (Block et al, 2006). In effect, what this means is that clinicians may need to provide more treatment for people who present with more severe levels of stuttering. This is not only to prevent relapse, but also to enhance the likelihood of maximising fluency and effectively controlling speech production. For those who stutter severely, this may mean they need access to ongoing treatment - in acknowledgement of the fact that they are battling a chronic condition across their lifespan. Additionally, not only should more treatment be available in cases of increased severity, but it may be the case that a variety of treatment approaches may be appropriate, with differing emphases at different stages in treatment.
One of the issues that clinicians also need to acknowledge is the fact that not everyone wants to sound 'different'. While they may not want to stutter, the person seeking treatment may be very self-conscious about how they sound. Speech naturalness can be a huge issue for someone trying to become comfortable with themselves as they endeavour to maintain fluency -- that feels very different and they often assume it therefore sounds odd or unnatural. The development of the Camperdown Program (O'Brian et al, 2003) has naturalness training and awareness and clinicians should be aware of the advantages that this can bring someone trying to self-evaluate accurately. Clinicians should keep a focus on ensuring that they target natural-sounding fluent speech as early as possible in the treatment process. It is certainly the case that for school-aged children and adolescents, they may well reject treatments that make them sound "odd", no matter how fluent they become. It is vital that their fluency does not make them targets for teasing.
As an added complexity, there is increasing evidence that anxiety plays a role in stuttering. While it is not seen as a causal role, people who stutter often comment on the distraction of speech-related anxiety. There is increasing information about the complex relationship between anxiety and stuttering (Messenger et al, 2004; Onslow et al, 2000). This relationship necessitates careful consideration of how to manage anxiety during the treatment process and beyond. The complex interaction means that clinicians need to study ways of managing anxiety during the speech restructuring process. It is a relatively simple task to show someone how to be fluent. It is more challenging to help them use their fluency in situations outside a clinical setting. Even more of a challenge is the maintenance of fluency over time as habituated responses to stress and social situations often result in anxiety and anticipation of stuttering. Bloodstein (2005) was wise in proposing that one of the methods of evaluating the success of a methods of treatment was whether the method removed "not only stuttering, but also the fears, the anticipations, and the person's self-concept as a stutterer" (p.443). It is vital that we consider the range of aspects of the problem of stuttering and the reactions of those who stutter to the speech behaviours they experience. Otherwise, we fall short of helping those grappling with this debilitating problem truly manage and change their speech. Thus, we need to determine how each individual who stutters feels about the problem and importantly, what the impact is for them.
While Speech-Language-Pathologists need to ensure they focus on the issues mentioned above, it is also vital that those who stutter are very clear about their desires when they present for either an assessment or for treatment. While they may feel that it should be abundantly clear that they want to stop stuttering, they may find it helpful to consider some of the other aspects mentioned above. For example, it may be that they cannot focus on treatment techniques for fluency if they cannot manage the anxiety that may occur in specific situations. It may also be the case, that if previous treatment has been unsuccessful, they may be reticent to try further treatment. Thus, it is vital that those who stutter are honest about what they think about their previous treatments; what they felt was useful and what was not. Consideration of the latter may help ensure that the next attempt at treatment might be more satisfactory - in terms of outcome. It should also be useful in tackling the issues collaboratively to ensure the best possible outcome.
Sometimes it may be the case that Speech-Language-Pathologists use very similar strategies to each other with very different outcomes. People seeking treatment should feel that it is appropriate to ask the person whose advice they are seeking exactly how they do their treatment (or treatment focus) that might ensure they will have a better outcome. This may be a different or greater focus on transfer and generalisation; it may be a different sequence of strategies, it may be different amounts of treatment; it may be greater structured practice - or any number of variations. It is also worth considering that you need to feel confident in the abilities of anyone whom you consult for help and advice with any issue. If your clinician cannot answer your questions you should feel confident to seek further advice from another clinician. If you do not make change, it may not be that the treatment per se was the problem, but perhaps the way it was taught. Thus, someone else may suit you better.
However, it is often the case that treatment access is severely limited and alternative professional input may not be available. This may be the case in isolated communities as well as in densely populated communities. Indeed, in many parts of the world, there is no access to any treatment or support for those who stutter (and their families). It should be heartening to read that we are in the process of developing and investigating treatments for stuttering that may be able to be self-managed, or even web-based and self-directed. There are increasingly available sophisticated telehealth options for service delivery in a variety of areas for a variety of 'conditions'. These should see huge opportunities for change in the treatment options for those who stutter. These opportunities should offer flexibility and increased choice for those who stutter. Thus, it is with optimism and excitement that we should view the next couple of years as emerging treatments are trialled and tested.
References
Andrews, G. & Craig, A. (1988). Prediction of outcome following treatment for stuttering. British Journal of Psychiatry, 153, 236-240.
Block, S. Onslow, M. Packman, A. & Dacakis, G. (2006). Connecting stuttering measurement and management: IV. Predictors of outcome for a behavioural treatment for stuttering. International Journal of Language and Communication Disorders, 41, pp. 395-406.
Block, S., Onslow, M., Packman, A., Gray, B., & Dacakis, G. (2005). Treatment of chronic stuttering: outcomes from a student training model. International Journal of Language and Communication Disorders, 40, 455-466.
Bloodstein, O. (1995). A Handbook in Stuttering. (5th edition). Chicago, IL: National Easter Seal Society.
Jones, M., Onslow, M., Packman, A., Williams, S., Ormond, T., Schwarz, T., & Gebski, V. (2005). A randomised controlled trial of the Lidcombe Program for early stuttering interventon. British Medical Journal, 331, 659-661.
Langevin, M., Packman, A., Thompson, R., & Onslow, M. 2008. Peer responses to stuttered utterances. Manuscript in preparation.
Lincoln, M., & Onslow, M. (1997). Long-term outcome of an early intervention for stuttering. American Journal of Speech-Language Pathology, 6, 51-58.
Messenger, M., Onslow, M., Packman, A., & Menzies, R. (2004). Social anxiety in stuttering: measuring negative social expectancies. Journal of Fluency Disorders, 29, 201-212.
O'Brian, S., Onslow, M., Cream, A., & Packman, A. (2003).The Camperdown Program: Outcomes of a new prolonged-speech treatment model. Journal of Speech, Language, and Hearing Research, 46, 933-946.
Onslow, M., Menzies, R., & Packman, A. (2000). Anxiety and the treatment of stuttering. American Journal of Speech-Language Pathology, 9, 91-92.
SUBMITTED: September 28, 2008
