Stuttering in Children and Adolescents, Part III: Therapy

By Karin B. Wexler, Ph.D.
Emergency and Office Pediatrics, Volume 10, Number 1, 1997 p. 14-19.

Introduction

Early intervention is a critical factor in terms of prognosis for a child or adolescent who stutters. It is the only safe alternative. If at all possible, treatment should start before the dysfluency pattern becomes habituated and before reactions to it develop. If not, behavioral, emotional, and thought pattern reactions tend to compound the problem and exacerbate it.(1)

When there is a concern that a child or adolescent might be stuttering, it is important not to assume that he or she does not have a stuttering problem just because

• There are no repetitions in his or her speech (only other disfluencies).
• No dysfluencies of any kind are perceived by listeners in his or her speech (although he or she claims to stutter or have difficulty "getting words out", or shows unusual behaviors, thoughts, or affect in connection with speaking).
• The symptoms come and go, either over time or depending on the situation (e.g., may not be picked up in a short interaction).(1,2)

As fluency disorders are becoming an officially recognized specialty in the field of speech-language pathology, speech-language pathologists in general practice increasingly refer clients who stutter to colleagues specializing in fluency disorders.(1) Fred Bomback, M.D., editor of this journal, stated in the Editorial of the June issue: "I cannot recommend too strongly that, when referring a child with a fluency disorder for diagnosis and therapy, a specialist in the area of childhood fluency disorders be chosen. This is a formidable task as fluency disorders specialists are few and far between. But it is worth the effort ...."(3) How a fluency disorders specialist can be located was discussed in Part I.(1)

This part of the short course is about therapy for children and adolescents who stutter, as usually done by this clinician. Current information on stuttering in children and adolescents was provided in Part I.(1) Therapy is designed based on a comprehensive evaluation and differential diagnosis, for example, between normal dysfluency, stuttering, acquired neurogenic dysfluency, cluttering, spastic dysphonia, other speech or language disorders, and Tourette's syndrome. Core physiologic symptoms and reactions to these are noted.(1-2) The core physiologic symptoms may be oral (articulatory), laryngeal (phonatory), respiratory, or a combination of these. Reactive symptoms or associated features may be behavioral, affective, or cognitive (thought patterns). These are, in my opinion, more diagnostically and therapeutically significant than the speech breakdown itself. Reactions of listeners are also diagnostically relevant.

This Clinician's Philosophy Regarding Therapy for Children and Adolescents who Stutter

My therapy for stuttering is highly client centered, multifaceted/holistic, intrinsically designed for gains in the real world, including long-term, and eclectic.

The extent to which the client is at the center is the most defining characteristic of my approach with individuals who stutter. The client is viewed as a unique individual, with a complexity (especially by adolescece) and blend of strenghts uniquely his or her own. The problems need to be dealt with and the strenghts tapped into in the best ways for the client to maximize gains. The therapy is designed (in terms of approach and process) with him or her and/or his or her parents or significant others specifically for him or her. Decisions emanate from information and insights about the client. The latter include how he or she responds to various methods and techniques and to specific factors of any kind in the real world, as observed by the client, parents, or others, as well as by the clinician.

The second most important characteristic of my therapy for stuttering is that it is multifaceted/holistic. It attempts to deal with the full complexity of the client's stuttering problem (in agreement with new American Speech-Language-Hearing Association guidelines).(4) In a case where the only presenting problems are physiological core symptoms (seen most often in young children), therapy is aimed simply at improved speech mechanics and, importantly, prevention of reactive symptoms. In the majority of cases, however, a multifaceted approach addressing both speech-motor skills and reactions to dysfluency or to stuttering in a broader sense is necessary. If negative feelings and thoughts about stuttering remain unchanged, the best established of fluency skills tend to go out the window in high stress situations.

I seek to base all decisions on the principle of doing what seems best and safest for the child or adolescent as a whole, long-term as well as immediately. The client is viewed in the context of his or her family and all other environments over time. Nothing is to be done which potentially might create or increase reactions to dysfluency or to stuttering in a broader sense. Such reactions tend to become the most handicapping part of the problem for the one who does not outgrow the stuttering and has at least occasional lapses in control of it. The impact of such reactions can be seen, for example, in adult stutterers in self-help organizations and in stuttering listservs on the Internet. Anything that might increase feelings of shame, guilt, performance anxiety, social anxiety, drops in self-esteem, or avoidance behaviors (very likely resulting in increased dysfluency), in a worst case scenario is not be done. As no treatment can guarantee normal or controlled fluency in all situations for life for everyone, I take measures to safe-guard against such risks. One safe-guard measure is to have easy speech (i.e., easy-flowing, relaxed, natural sounding speech that does not affect the flow of communication) be the explicit fluency goal rather than perfect fluency. (This is despite the fact that the most powerful fluency-facilitating and/or dysfluency management skills available are used, maximizing the client's fluency potential). For someone who has lived with fluency failure and maybe therapy failure (possibly failing the clinician's expectations of perfect fluency as well as his or her own), removing the pressure of having to be 100% fluent is thought to be critical to his or her reaching and maintaining full potential as a speaker and communicator. Another safe-guard measure is use of only positive reinforcement (no punishment for dysfluency).

Thirdly, in this therapy, focus on progress outside of the interaction with the clinician is strong throughout. At the same time, there is a strong here-and-now focus.

Fourthly, my approach to stuttering therapy is highly eclectic and constantly evolving. With each new client, an attempt is made to have no preconceived ideas how to approach the problem before seeing the full picture of the person and all that he or she presents. With as clear a view of the client as possible, I draw on empirical evidence, established theories, established methods, clinical experience, and the experience of individuals who stutter and their families to remediate the problem. Literature from which I draw includes that of speech and language pathology, physiology, psychology, and psychiatry. A debt of gratitude is owed to numerous individuals in these fields, including but not limited to, O. Bloodstein, E. Conture, C. and E. Cooper, F. Freeman, H. Gregory, B. Guitar, F. Myers, E. Mysak, W. Perkins, T. Peters, J. Sheehan, C. Van Riper, M. Wall, R. Webster, J. Westbrook, D. Williams, and G. Woolf.(5); W. Starkweather (5, 6); M. Leibowitz(7); C. Rogers(8); F. Schneier(7); and M. Seligman.(9)

The format of therapy is typically individual sessions, an hour (or 1/2 an hour) one or more times per week, with or without group therapy with peers or therapeutic parent support group sessions. Duration of therapy varies greatly. For some children and adolescents (especially the youngest), therapy is a matter of a few sessions or weeks; for others, months; and for some, a year or occasionally longer, with maintenance and follow-up for 6 months. At times, clients are seen more intensively, e.g., daily for 1 hour or more. With this format, maintenance and follow-up programs are especially critical. Self-help support groups and conferences may help meet both the parents' and the child's or adolescent's needs.

Objectives of Therapy

Unifying the objectives is the hope that through this speech therapy, doors will be opened or remain open for the client to develop his or her full potential socially, emotionally, academically, and professionally.

Therapy objectives and goals are both established based on the client's specific and overall problems, needs, and personal preferences (or those of the parents), keeping the child or adolescent as a whole in mind. Since therapy is designed and revised with the client and/or the parents for the client, at the heart of the process is the clinician actively and continuously listening to them.

Typical general objectives for the client, in all speaking situations short-term and long-term, are to

• Speak easily in a relaxed and natural way, without dysfluency interfering with the communication process
• Act, think, and feel positively and constructively in connection with speaking, communicative interaction, and any dysfluency/stuttering.

If a client has additional speech and/or language problems, additional objectives (with corresponding goals) may be added, whether the remediation of these will occur concurrently, before, or after fluency therapy. A management plan for any other coexisting problems, for example referrals to other professionals, is developed with the pediatrician.

Specific Goals

If a child (no matter how young) or adolescent shows any of the signs of struggle or other reactions when speaking exemplified below, the time has come for a consultation with a fluency disorders specialist. This is true even if the stuttering comes and goes. This is also true if frequency of dysfluency is excessive at times; if mild dysfluency has not been resolved in 6-8 weeks; or if the parents are really concerned.(1,2) Early speech-motor dysfluency is typically quickly and easily remedied, in contrast to habituated reactions. Goals may differ greatly from client to client. The following are examples.

In all types of speaking situations (from the least to the most stressful) short-term and long-term, the client will

• Have increased spontaneous fluency, along with increased easily flowing (natural sounding) speech through use of techniques. He or she will thereby have decreased core physiologic oral, vocal and/or respiratory stuttering symptoms. These may include repetitions, oral or laryngeal blocks (complete or partial) with inappropriate pauses or vocal noises, rushes of unvoiced air, running out of or forcing out of air, excessively explosive sounds, or sound prolongations. The extent (or even existence) of speech-motor dysfluency problems is often underestimated as a person can hide them by being quiet or by using other avoidance tricks, often at great personal cost.
• Be physically relaxed while speaking. The client will then have decreased struggle behaviors (counterproductive coping mechanisms to get out of stuttering). These include tension in the speech system or in speech, for example pitch or loudness rises or muscle tension even to the point of tremors; facial grimacing, contortions, or eye squinting, generalized body tension, bulging muscles or veins; a knot in the stomach; autonomic nervous system reactions; or inability to get a word out.
• Have increased frequency and amount of speaking and social activity and decreased stuttering avoidance symptoms (counterproductive coping mechanisms to avoid stuttering). More specifically, there will be decreases in avoidance of eye contact, of speaking and social situations, certain listener or audience types, words or speech sounds. For example, there will be a decrease in the use of incomplete phrases, revisions, abandonment of speech attempts, word substitutions, or unintended topic shifts; and decreases also in avoidance of class participation, presentations, phone calls, reading aloud, talking to peers or teachers, asking for a date, or applying for a job.
• Speak freely without expectation of fluency failure; that is, have decreased stuttering expectancy symptoms (e.g., counterproductive coping mechanisms to prevent stuttering). These mechanisms include rushing or repeating a phrase to get past feared words and anticipated stuttering; use of an extra and unnecessary sound, word, or phrase to get started or maintain momentum; use of an artificial voice or adoption of a foreign accent or dialect; and use of associated movements, throat clearing, coughing, gesturing, or other body activity.
• Act positively, constructively, and effectively in connection with speaking, communicative interaction, and any dysfluency/stuttering, for example by using improved communicative interaction skills; dealing effectively and assertively with negative listener reactions, including teasing or mockery; asserting himself or herself verbally (e.g., with someone speaking for him or her or finishing words or sentences).
• Have attitudes, beliefs, and thought processes that are positive and constructive in connection with speaking, communicative interaction, and dysfluency/stuttering, e.g.,
  • Believing that speech can be easy, fun, and rewarding.
  • Decreased perfectionism.
  • Seeing fluency, stuttering, and communication skills in perspective.
  • Having a more positive self-concept as a speaker and communicator, more independent of reactions of others; and increased general self-esteem.
  • Increased internal locus of control, seeing dealing with stuttering as a challenge within his capacity.
  • Not blaming stuttering on anyone.
  • Acceptance of dysfluency and all aspects of the stuttering problem.
  • Being open about stuttering, and/or being comfortable stuttering openly or at will.
  • Focusing more on life rather than excessively on stuttering.
  • Having a constructive explanatory style for fluency. lapses/relapses, listener reactions, and own successes in speaking and handling speaking challenges (e.g., not generalizing negative thoughts: "I can't talk.").(9)
  • Aspiration levels in life (social, academic, and professional) being unaffected by stuttering.
• Feel good in connection with speech, interpersonal communication, and dysfluency/stuttering. In in other words, the client will have reduced affective reactions to stuttering and to feared speaking situations, listeners, words, or sounds. Affective reactions may include frustration, helplessness, anxiety, fear, panic, embarrassment, humiliation, shame, guilt, bitterness, anger, self-hate, self-reproach, discouragement, resignation, self-consciousness, social anxiety, loneliness, isolation, a sense of lack of control, incompetence, inferiority, stupidity, or worthlessness.
• The parents and others, and as appropriate, the child or adolescent will be well-informed about the nature of stuttering, normal fluency and disfluency, the course of treatment, prognosis for recovery, and self-help organizations and support groups. They will be skilled and self-reliant in self-monitoring/monitoring of speech behaviors and in making adaptive decisions about handling speaking and social situations, in facilitating the child's or adolescent's development and maintenance of speech behaviors, communication skills, and attitudes, and in identifying any return of symptoms and need for occasional additional help after treatment.

The first priority in therapy is to serve the client as fully as possible. The second is documentation. Parameters used for assessing progress should be as relevant as possible to the person's problem as a whole in real life, validity being "the crucial test of a measurement procedure".(10) The most meaningful measures of progress concern the impact of stuttering on the person's life. Concrete behavioral observations and behaviorally defined outcome goals facilitate documentation of progress. Self-ratings (as appropriate), ratings by parents and/or the clinician, and frequency counts are also used to document performance in relation to goals established. Dysfluency counts must be interpreted with caution and must be seen only in relation to the client's functioning in all speaking situations in the real world and to his or her complete problem, objectives, and goals.

Therapy Methods

With information in mind from continuous listening to the client and the parents and observing the client, I draw on my knowledge and experience as broadly as possible to determine the best ways of proceeding in therapy.

Steps are taken to minimize processes which may be maintaining stuttering behaviors. For a preschooler, for example, with the parents' or the teacher's help, speech associated excitement or anxiety or overload of communicative stress may be reduced.

In direct therapy with a young child, the child generally experiences the sessions as play dates or an enrichment activity (developmentally and educationally oriented free play), not as treatment for a pathology. The tone of the sessions is warm, friendly, accepting, nurturing, nonjudgemental, nonpunitive, usually low key, often humorous and spirited. Parents and often others in the child's life participate in the sessions. With school-aged children, the degree of specificity in techniques increases with readiness. The process becomes more structured, for example using games of the child's choice, meaningful communicative interaction, and role playing. With an adolescent, most of each session is usually private, although parents may participate to an extent comfortable for the client. Gradually longer units and greater complexity in terms of language demands, interactional demands, and increased listener/audience demands and communicative stress are used for different ages. Therapeutic conditions facilitating behavior change and personal growth are used with all clients and parents. Sessions are highly interactive.

I take a physiologic approach to fluency or dysfluency management. The principle behind it is working with nature rather than fighting it. The client learns to use his or her speech mechanism in the ways it most easily produces speech that flows, sounds natural, and allows the communication to go on unimpeded. He or she learns to produce and self-monitor the desired motor behaviors or adjustments by feel (through tactile-kinesthetic sensations), by sound, and by sight.

A very young child who appears unaware of any fluency issue learns a pattern of fluency enhancing speech as a whole, often without any mention of speech. If more aware, he or she may learn to call it "stretching our words to speak more easily". I may in turn point to my mouth, throat, and midriff and say "Easy here, easy here, and easy here." The child experiences and learns to appreciate easy options that work in terms sways of speaking. These tend to become in part self-reinforcing, especially for a preschooler. An intent is for her to make the goals and techniques his or her own. The client picks up fluency skills in joyful and rewarding interactions, including in as many natural environments and with as many people as possible, for improved transfer to everyday living. The child learns that it is important to speak easily, but that it is not necessary for the words to be absolutely smooth. Focus on communication and engagement has to be even stronger than the focus on fluency parameters. Enhanced modeling is done by the clinician for the child, the parents, and others, with feedback to all, if working on speech is openly talked about. The parents in turn model the pattern in the child's everyday environments in order to reinforce skills and help transfer them to the rest of the child's life.

An older child or adolescent learns about the effects of different kinds voicing (and rate of speech movements, muscle tone, and breath support) on speech flow for him or her (and millions of others), for example that some ways of using your voice make it easy to speak, whereas other ways make it harder and even can make you get stuck on your words. He or she learns how speech is made physiologically, from the processes of breathing to voicing for some sounds to articulation (making speech sounds by moving your mouth certain ways). On the road to easily flowing, natural sounding speech, the client typically learns gentle slow motion speech, involving several skills, through learning theory based shaping processes. Other processes for increasing fluency or decreasing dysfluency may also be flexibly used, allowing the client as many tools as possible in the tool box.

Interwoven into work on fluency skills is work toward any of the other goals that the client is ready for. I look as much as possible for naturally occurring opportunities to facilitate progress toward each. The image of a sun, with the client as the center, gradually shining more brightly as the sunrays representing progress toward each goal gradually emerge, makes this concept more concrete. Progress ratings can be made for each goal/ray. In her mind, I have a list of sample processes and techniques toward meeting each goal and subgoal. Progress and processes are reassessed continuously, periodically more formally.

Effectiveness of Stuttering Therapy

"Virtually all children speak normally after therapy that typically lasts only a few months" in prevention programs for children at risk and those who already have the disorder in the Temple University clinic and from other clinics in the United States and Europe who use the same principles and methods."(6) This agrees with my experience. A major study "showed clearly that the sooner children are treated, the less time it takes to treat them. Waiting is the worst thing to do."(6) This is also supported by my experience. Through the window of opportunity for intervening before dysfluency behaviors and reactions have been habituated and the problem compounded, the pediatrician can help give a child freedom of speech for life, with full opportunity to become all he or she can be socially, academically, and professionally.

References

1. Wexler KB. Stuttering in children and adolescents, Part I. Emergency & Office Pediatrics 9:73-76, 1996.

2. Wexler KB. Stuttering in children and adolescents, Part II. Emergency & Office Pediatrics 9: 147-150, 1996.

3. Bomback F. Editorial, treating children who stutter. Emergency & Office Pediatrics 9:63, 1996.

4. American Speech-Language-Hearing Association. Guidelines for practice in stuttering treatment. ASHA 37, Suppl 14:26-35, 1995.

5. Bloodstein O. A handbook on stuttering. San Diego, Singular Publishing Group, 1995.

6. Starkweather CW, Gottwald SR, Halfond MM. Stuttering Prevention: A clinical method. Engelwood Cliffs, Prentice Hall, 1990, pp.vii-x.

7. Heinberg RG, Leibowitz MR, Hope DA, Schneier FR. New York, Guilford Press, 1995.

8. Rogers CR. Client centered therapy. Boston, Houghton-Mifflin, 1951. 10. Thorndike RL, Hagen E. Measurement and evaluation in psychology and education. New York, John Wiley & Sons, 1969, p. 189.

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added with permission, September 23, 1997