The Powered-Up Parent Research tells us that parents are key to successful treatment with preschoolers who stutter. But current school practices and ingrained attitudes can make this participation challenging. Here’s what you can do. Features
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Features  |   July 01, 2014
The Powered-Up Parent
Author Notes
  • Peter Reitzes, MA, CCC-SLP, president and host of the StutterTalk podcast, works in an elementary school in Durham, N.C., and in private practice in Chapel Hill, N.C. He is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. preitzes@yahoo.com
    Peter Reitzes, MA, CCC-SLP, president and host of the StutterTalk podcast, works in an elementary school in Durham, N.C., and in private practice in Chapel Hill, N.C. He is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. preitzes@yahoo.com×
Article Information
Speech, Voice & Prosodic Disorders / Fluency Disorders / School-Based Settings / Features
Features   |   July 01, 2014
The Powered-Up Parent
The ASHA Leader, July 2014, Vol. 19, 50-56. doi:10.1044/leader.FTR3.19072014.50
The ASHA Leader, July 2014, Vol. 19, 50-56. doi:10.1044/leader.FTR3.19072014.50
When I take my son, 4, to his occupational therapist and my daughter, 2, to her pediatrician, I naturally expect these professionals to offer treatments consistent with best practices. In the case of preschool stuttering, research suggests the most highly effective treatments are those administered by parents daily (see sources).
In my full-time work in the North Carolina public schools and my part-time work in private practice, I follow preferred practice by training parents of preschoolers who stutter to administer treatment. In my school district, school-based speech-language pathologists regularly serve 3- to 5-year-old preschoolers in the schools. When a new preschooler who stutters joins my school caseload, I call the parents to schedule sessions so that a parent attends and participates.
Parents’ busy schedules and SLPs’ large caseloads can make scheduling weekly sessions highly challenging. Although some parents can and do attend sessions easily, others are exempted from attending before treatment even begins because of work or other time demands. Others want to participate but have such changeable schedules that coordinating times with the SLP is difficult.
Busy school administrators may not be aware of the importance of including parents in treatment sessions. An administrator may, for example, ask an SLP with a full schedule and large caseload to provide treatment to a preschooler who stutters in an articulation or language group. Under such circumstances, it would be very challenging—if not impossible—to train and counsel that child’s parent. Unfortunately, administrators may prioritize making sure all students are served over hiring a second SLP so that all students are served adequately. Even a seasoned SLP may not be comfortable or confident enough to explain this to a supervisor.
In addition, it has been my experience that many school-based SLPs are not aware that parent-administered, SLP-guided treatment is preferred practice for preschoolers who stutter. This is understandable considering that research has found that many school-based SLPs do not feel adequately trained to work with people who stutter: Many report having very few, if any, children who stutter on their caseloads and having very little experience with this population in their training (see sources).
The problem is that under-involvement of parents limits the effectiveness of treatment, and it does so at a critical developmental stage in which recovery from stuttering is most likely to occur. And when an SLP does try to bring in parents, they often resist because parent participation isn’t a common practice in schools. It doesn’t have to be this way. If all of us stakeholders—school administrators included—take steps to involve parents more, we can collectively reset parents’ expectations and make a much bigger impact on assisting children who stutter.
Parent confusion
As a school-based SLP, I am the second or third SLP a preschooler’s parents meet because of the family’s typical route to access services—but I am often the first SLP to explain that parents are a vital part of treatment. Parents concerned about their preschooler’s stuttering typically start with Child Find or take their child to a university or private clinic, where an SLP evaluates and diagnoses stuttering. To receive no-cost services through the schools, the parents then take the evaluation to the preschool assessment team in the local school district. The team, which includes an SLP and parents, uses the information from the previous evaluation or conducts its own. The team writes an IEP and, in North Carolina and other states, the child is assigned to a school-based SLP for treatment.
As part of this process, parents are often not informed that they will be trained by the SLP to administer treatment and record daily data. So when I attempt to schedule sessions with at least one parent present, parents may be confused and even angry because they weren’t expecting to spend time at the session. When treatment begins with anger and frustration, we are creating unnecessary obstacles.
Working with children who stutter is challenging enough, and often involves parental fears, pain, and feelings of helplessness and guilt. Unlike articulation and language delays, a child who stutters begins speaking “normally” and usually begins to stutter between 2 and 4 years old. Parents often think they have done something wrong to cause the stuttering. They are frightened and may feel powerless and desperate to help their child.
But they can help—in large amounts— with an SLP guiding and monitoring treatment (see sources). In fact, many chronic conditions such as asthma and diabetes respond best when parents are involved as part of the treatment process. Several parent-administered preschool stuttering treatments, including the Demands and Capacities approach, the Lidcombe Program of Early Stuttering Intervention, and Parent-Child Interaction Therapy, are supported by many peer-reviewed, published studies.
For example, a study by Marie-Christine J. Franken and her colleagues, published in the Journal of Fluency Disorders in 2005, compared Demands and Capacities treatment to the Lidcombe treatment. They found that stuttering frequencies and severity ratings significantly decreased for both treatment groups, with no differences between them. They also found that parents were equally satisfied with both treatments. Preliminary data presented at the National Stuttering Association’s 2013 annual conference (and using a much larger sample size) compared Lidcombe and DCM treatments. After 18 months of treatment, participants showed no significant differences in percentage of syllables stuttered or percentage of recovery.
A 2010 evidence-based review of preschool stuttering treatment by ASHA explains, “The current state of the evidence does not provide meaningful information for clinicians attempting to decide between the use of direct [Lidcombe] or indirect [DCM] treatments for stuttering in young children.” One way to consider the large evidence base on preschool stuttering treatment is that no one treatment works for all and SLPs should have a solid knowledge of the different approaches for preschoolers who stutter. This consideration is consistent with the evidence base that documents a variety of stuttering treatments that benefit or “work” for older children and adults who stutter.
Despite the differences among evidence-based approaches for preschoolers who stutter, they have much in common, including parent-administered treatment, parent education, parent confidence-building and parent participation in normalizing stuttering:
  • The SLP trains the parent.

  • The parent and SLP make treatment choices together.

  • The parent keeps a daily rating chart of fluency and stuttering.

  • The SLP and parent review the data during clinical visits, assess progress, and attempt to problem-solve and modify treatment.

Changing the school culture
My school district’s speech-language supervisor recently arranged a staff-development presentation on preschool stuttering treatment to underscore the research evidence for including parents in treatment. As a result, the preschool assessment team and school providers better understand how and why to prepare parents to participate in stuttering treatment.
As a school-based SLP, I also regularly explain these issues to my colleagues and administrators, helping them embrace best practice for preschoolers. I share my speech treatment room with other providers who understand that parental tears of fear and joy are common in this work, so they grant us privacy during sessions.
Encouraging involvement
In my experience, parents who seek treatment from private practitioners are very open to participating in treatment sessions, especially if the SLP explains to a parent of a preschooler who stutters, “I only do this work with full parent participation.” However, some parents of 3- to 5-year-olds receiving school-based treatment may not expect that method—and the school-based SLP may not deny services if the parents decline to participate.
SLPs can take several actions to involve parents and to maintain their participation in treatment.
Assign parents daily “special talking time” with their child after each session. During this special talking time, parents implement the strategies they learned in treatment. I find that parents, who often juggle very busy home and work lives, look forward to spending 10 or 15 minutes a day alone with their child, reading books and playing games. Many parents have thanked me for this assignment, saying they feel I am giving them permission to spend quality time with their child. For parents with several children, this special talking time may be the only time alone they have with their child who stutters. Some parents have commented that this special talking time has become the best part of their day.
Ask parents to complete a daily rating chart. Once a day, typically after the child goes to bed, parents take a minute or two to fill out a daily stuttering rating chart. Using a 10-point scale, they rate the child’s daily stuttering levels during structured time (the special talking time with treatment strategies) and unstructured times (the child’s overall level of stuttering throughout the day). I also encourage parents to keep additional notes—for example, if stuttering increases or decreases during certain activities or times—that we can discuss at the next appointment.
Have parents begin to implement the treatment throughout the child’s day. Parents use the strategies at the dinner table, driving to school and in other everyday environments. The parent and SLP work together to decide when and how often to use the strategies outside of special talking time. Ideally, the parent is not being intrusive and or “nagging” the child. For example, a parent may use positive verbal contingencies (“That was nice smooth talking”) too often. Sometimes a parent may use the same phrase repeatedly and need help expanding their praise repertoire. The SLP might ask the parent to identify five or six new phrases (“Great talking”) and to use them—although less frequently—throughout the day.
Give parents stuttering resources—but don’t overload them. The Stuttering Foundation of America offers a number of informative and inexpensive materials. I typically give or loan one to parents at the beginning of treatment, often Edward Conture’s book, “Stuttering and Your Child: Questions and Answers.” Most parents read or watch the materials and come in with questions and thoughts that help us in treatment. One parent recently said that she was reluctant to keep daily stuttering logs but was encouraged to do so after reading about the method. The mother explained that the first two SLPs she met with did not prepare her for the need to keep data and that the book helped her understand that data-keeping was important and not just “busy work.”
During a typical and recent treatment session, the mother and I agreed that her son came into the session stuttering at a level 5, which is a significant amount of stuttering. I began an activity using Demands and Capacities and Lidcombe strategies. After watching for about five minutes, the mother took over. Within minutes her son’s stuttering dropped quite dramatically to level 2 and then level 1. The parents’ daily data began showing that consistently, week after week, their child’s stuttering was reduced and remained at levels 1 to 2.
Some considerations
As indicated as preferred practice in preschool stuttering research, service delivery generally begins with one session each week (see sources). I begin service delivery for most preschoolers who stutter at once-weekly for 45 minutes. This gives the SLP time to review the data and notes recorded by the parent from the previous week, to administer and modify treatment with the parent, and to answer parent questions.
Often—and ideally—parents will notice that the child’s stuttering level decreases when treatment is administered at home and during sessions, increasing parents’ confidence in the treatment and their ability to help their child. It also motivates the parent to complete home assignments, including special talking time, and to continue to participate in treatment sessions.
If parents can’t participate in treatment, the SLP can offer some options. Delivering services through telepractice may be possible: Christine Lewis and her colleagues found telepractice delivery of the Lidcombe treatment to be efficacious, but less effective than standard or in-person treatment, according to a 2008 article in the American Journal of Speech-Language Pathology.
SLPs could also share treatment videos using online file sharing services. The SLP and parents discuss the videos and specific strategies over the phone. Or the SLP may send home additional materials that describe the strategies used in the videos. Just be sure that these options conform to state laws and local regulations. For example, a school district may have policies against telepractice sessions, videotaping students, or using online services to share therapy videos.
Also keep in mind that sometimes a child’s stuttering “spikes” higher in frequency and severity. These times may be emotionally challenging, but may also motivate a parent. The parent who may have felt helpless in the past now has the support and empathy of the clinician for analyzing the treatment and working through difficult days. A parent who may have felt alone now has the SLP as a partner.
One mother shared with me that her son’s stuttering spiked to a level 5 after several months of staying at a level 1 to 2. She explained that a death in the family, followed by a quickly planned family trip and her son’s illness on the journey, were likely associated with the brief increase in stuttering. Rather than feel helpless, she understood this variability in stuttering and shared some thoughtful ways she problem-solved, such as remembering to have the family use good turn-taking and making sure her son got enough sleep during this challenging time. She was proud of herself for responding and thankful that our work prepared her to do so.
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July 2014
Volume 19, Issue 7