The Many Faces of Stuttering Identifying Appropriate Treatment Goals Features
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Features  |   November 01, 2001
The Many Faces of Stuttering
Author Notes
  • J. Scott Yaruss, is an assistant professor at the University of Pittsburgh. He is currently conducting a five-year, NIH-funded research project examining factors involved in the development of stuttering. He also serves on the National Stuttering Association’s Board of Directors, is chair of its research committee, and will be the chair of the Fluency track for the 2002 ASHA Convention. Contact him by email at jsyaruss@csd.pitt.edu.
    J. Scott Yaruss, is an assistant professor at the University of Pittsburgh. He is currently conducting a five-year, NIH-funded research project examining factors involved in the development of stuttering. He also serves on the National Stuttering Association’s Board of Directors, is chair of its research committee, and will be the chair of the Fluency track for the 2002 ASHA Convention. Contact him by email at jsyaruss@csd.pitt.edu.×
  • Robert W. Quesal, is a professor and program director at Western Illinois University in Macomb. He served as newsletter editor for Division 4 from 1997–2000, and will begin a three-year term on the Division 4 Steering Committee in January 2002. Contact him by email at r-quesal@wiu.edu
    Robert W. Quesal, is a professor and program director at Western Illinois University in Macomb. He served as newsletter editor for Division 4 from 1997–2000, and will begin a three-year term on the Division 4 Steering Committee in January 2002. Contact him by email at r-quesal@wiu.edu×
Article Information
Speech, Voice & Prosodic Disorders / Fluency Disorders / Features
Features   |   November 01, 2001
The Many Faces of Stuttering
The ASHA Leader, November 2001, Vol. 6, 4-14. doi:10.1044/leader.FTR1.06212001.4
The ASHA Leader, November 2001, Vol. 6, 4-14. doi:10.1044/leader.FTR1.06212001.4
Working with people who stutter can be challenging for many speech-language pathologists. In fact, numerous surveys have demonstrated that many SLPs rank stuttering at the bottom when asked which disorders they prefer to treat.
There are a number of possible explanations for clinicians’ discomfort in treating people who stutter. One frequently cited factor is the belief, apparently held by many clinicians, that their training in fluency disorders did not adequately prepare them to deal with the complexity of the disorder. Another issue may be the fact that many people who stutter experience significant negative reactions to their stuttering, and some clinicians may feel unprepared to deal with these emotional and cognitive consequences.
One additional factor that appears to frustrate both clinicians and people who stutter is the fact that stuttering is a highly variable disorder—the occurrence of speech disfluencies can vary significantly from day to day, from situation to situation, and even from moment to moment, depending upon many different factors. This variability is a normal part of stuttering, yet it means that clients’ progress in treatment can be difficult to track, and some clinicians may work with their clients for long periods of time without seeing any obvious or lasting changes in fluency. Nevertheless, treatment for stuttering can be successful, and many SLPs are confident in their ability to help people who stutter.
One of the most important—and overlooked—factors affecting the success of stuttering treatment is the selection of proper treatment goals. On the surface, this might seem like an obvious issue: The goal of treatment for people who stutter is the reduction or elimination of stuttering. Unfortunately, the issue is not that simple, and we believe that one of the primary reasons some SLPs feel frustrated with their skills for treating people who stutter is that they are focusing their treatment on the wrong goals.
Treatment Goals for Preschoolers
It is widely recognized that stuttering typically begins in the preschool years, when children are developing the language and motor skills necessary for speaking. The majority of preschoolers who exhibit stuttering “outgrow” their early speaking difficulties and go on to develop normally fluent speech. Unfortunately, it is not entirely clear what percentage of children who recover do so as the result of intervention or “on their own.” Nevertheless, there appears to be consensus that the goal of treatment for preschoolers who stutter is the elimination of stuttering.
Of course, there is disagreement about the best way to achieve this goal. Some practitioners advocate an indirect approach, in which parents are taught to facilitate children’s fluency through modifications to the environment and modeling of a slower, smoother speaking style. Other clinicians, meanwhile, advocate a more direct approach, where parents are taught to provide specific feedback about children’s speech that discourages stuttering and encourages fluent speech. Regardless of the technique that is selected, however, the goal of intervention with preschoolers who stutter is the same: to help children develop normal fluency.
Treatment Goals for Older Children and Adults
While many young children do recover from early stuttering, either with or without treatment, research has shown that many school-age children and adults are much less likely to fully overcome their stuttering and develop completely normal speaking patterns—particularly after they have been stuttering for several years. This is not to say that people who stutter cannot improve their fluency; many do. This improved fluency, however, generally requires the use of various speech modifications that may result in less natural-sounding speech. Such speech modifications are also very difficult to use consistently, and many people who rely solely on such techniques may experience a relapse of stuttering.
The fact that many school-age children and adults are likely to continue stuttering to some extent throughout their lives raises an important question: Should the focus of treatment be primarily on helping clients to develop and maintain fluent speech, or should it be on helping clients to learn how to live with their stuttering and to improve communication even if they continue to stutter?
Aspects of treatment that are focused primarily on improving fluency include speech modification techniques such as easier beginnings, reduced speaking rate and pausing, prolonged speech, and fluency shaping. Aspects of treatment that are focused primarily on changing moments of stuttering so they are less disruptive to communication include stuttering modifications such as cancellation, pull-out, and voluntary stuttering, as well as various desensitization activities that reduce speakers’ frustration, embarrassment, and shame.
A Balanced Set of Goals
The fundamental disagreement about the most appropriate goals of treatment for people who stutter has been with us for many years. Many stuttering specialists have addressed the problem—at least, when treating adults who stutter—by adopting treatment goals that combine fluency enhancing strategies with techniques for minimizing the impact of stuttering on the speaker’s life.
Importantly, the specific balance between fluency and acceptance of a modified form of stuttering is different for each individual who stutters—one size does not fit all—and clinicians should encourage their clients to play an active role in determining the appropriate balance for them.
Furthermore, although these differing approaches to stuttering treatment are often presented as a dichotomy, neither one of these approaches to stuttering treatment functions solely to improve fluency or improve stuttering. Indeed, improvements in fluency often serve to increase a speaker’s sense of confidence and ability to communicate freely. Likewise, reductions in the speaker’s anxiety and fears about communicating result in notable gains in speech fluency. The point to keep in mind is that it is the combination or balance between these approaches to treatment that results in lasting improvements in speakers’ fluency, reductions in the impact ofstuttering, and increases in overall communication ability.
Balanced Goals for School-Age Children
Although these integrated or eclectic approaches have been gaining in popularity for treating adults who stutter, it seems that there is still some reluctance to adopt a similar set of broad-based goals for school-age children. Evidence for this statement comes from clinicians’ complaints that their young students who stutter remain on their caseloads for an extended period of time and that they don’t “use their techniques” consistently, as well as observations that children seem to be able to be fluent in the treatment room, but not in the classroom or other real-world settings.
In addition, children who stutter often report that their treatment sessions at school tend to consist primarily of reading (fluently) or completing worksheets aimed at increasing their fluency while they are in the treatment session. Strategies such as voluntary stuttering and other desensitizing strategies—often applied with great success in treatment for adults who stutter—do not appear to be common in treatment for school-age children.
Some SLPs may be reluctant to adopt treatment goals that involve any acceptance of stuttering at all, for fear that they may be seen as “giving up” on the child’s fluency. Similarly, there may be the perception that “speech” clinicians are supposed to fix children’s speech disorders, not teach children to cope with them. Parents, too, may feel that the SLP is supposed to “make their child fluent” and may, therefore, resist attempts to reach a more balanced outcome for their children’s treatment. The fact that stuttering is so highly variable across different situations likely contributes to this problem since children are able to produce fluent speech in some situations, so clinicians—and parents—may wonder why the children don’t simply speak fluently all the time.
An important point to keep in mind, however, is this: For whatever reason, children who stutter have difficulty maintaining fluent speech in all situations. If the parents and SLP continually stress the necessity of speaking fluently in all situations—either through the use of techniques or other strategies designed solely to eliminate stuttering —this sends children the message that stuttering is unacceptable, and the only time they can feel good about their speech is when they are fluent. By demanding that children continually strive to achieve a goal they may not be capable of achieving consistently, we may actually end up contributing to their shame, embarrassment, and anxiety.
For this reason, we believe it is imperative for clinicians to take a more balanced approach to their treatment goals for school-age children who stutter. In addition to teaching children about their speech and helping them learn strategies for improving fluency, clinicians should also counsel children about stuttering and help them learn to become less concerned about their speech—help them learn to live with the disorder while at the same time helping them learn to manage it. In other words, the goal of treatment for school-age children who stutter should be to help them achieve a balance between using techniques to improve speech fluency—both those that involve changes to speech and those that involve changes to stuttering—while remembering that it is okay to stutter.
In addition, recognizing that stuttering varies significantly from one situation to the next, we feel that it is not realistic for clinicians to expect that children will be able to use techniques in all situations just because they have learned them in the treatment setting. This is especially true if a child has not had the opportunity to practice strategies for improving fluency, modifying stuttering, and accepting stuttering in settings outside the clinic room. Clinicians must help children move out of the treatment room and into the real world if they are to achieve any lasting success in their stuttering treatment. Finally, we believe that clinicians should recognize the fact that a child may be able to successfully use strategies to achieve fluent speech in some situations, but accept modified stuttering in other situations.
Educationally Relevant Objectives
It is interesting to note that treatment goals that focus on helping children accept stuttering are directly relevant to their educational objectives—perhaps even more than goals that focus exclusively on fluency. For example, if a child is embarrassed about stuttering and, as a result, refuses to read aloud in class or give class presentations, that child is missing out on the important opportunities for educational growth that accompany those assignments. Helping children to accept stuttering will directly affect their education because it allows them to fully participate in the experiences that are part of the curriculum.
In addition, addressing these goals will also have a strong impact on the child’s social development and ability to interact with and learn from other children. The important thing to recognize is that goals that focus on children’s feelings and improve their social interaction ultimately have a positive effect on their ability to achieve educational objectives.
Improving Clinical Skills
Some clinicians may be concerned that treatment goals that focus on children’s feelings about speech or treatment strategies that involve counseling techniques may be outside our scope of practice. This is not true, provided that SLPs have received appropriate training in these approaches. Of course, as noted above, many clinicians have expressed concerns about their training in the area of fluency disorders, and there appears to be an alarming trend toward even fewer requirements for academic and clinical education in stuttering in graduate programs across the country. In addition, existing courses in fluency disorders are increasingly taught by individuals whose primary area of interest is not fluency disorders.
Nevertheless, there are many ways SLPs can improve their clinical skills for working with people who stutter. In addition to the many continuing education programs that are offered around the country and at ASHA conventions, there is also ASHA’s Special Interest Division for Fluency and Fluency Disorders, Division 4. Membership in Division 4 provides a newsletter highlighting important developments in the field of fluency disorders. Division members have the opportunity to participate in the annual leadership conferences, and Division 4 has also recently initiated a series of “boot camp” intensive training workshops that are open to all SLPs interested in improving their skills for helping people who stutter.
Clinicians who wish to become even more knowledgeable about stuttering can participate in the newly developed fluency specialty recognition program, which involves an extended program of mentored education and experiences in both the evaluation and treatment of fluency disorders (see story on right).
Information about stuttering is also available from the Stuttering Foundation of America, which offers numerous books, brochures, videotapes, pamphlets, and training workshops. This information, which is available to clinicians at a low cost, is continually updated, thereby giving clinicians the opportunity to expand their knowledge about stuttering, keep their knowledge current, and improve their ability to help people who stutter.
Finally, clinicians can gain important insights about stuttering by participating in stuttering self-help groups, such as the National Stuttering Association and Friends: Association of Young People Who Stutter. These groups provide invaluable support for people who stutter, their families, and the clinicians who work with them. Plus, they invite and encourage SLPs to join them for their local chapter meetings and national conventions. Through these groups, clinicians have the opportunity to meet people who stutter and see how they have learned to cope with their stuttering in order to get the most out of their lives. Clinicians who partner with support groups will also gain a unique perspective about the importance of balance in the treatment for children and adults who stutter.
In sum, although many clinicians have found stuttering to be a frustrating disorder to work with, we have found that success depends largely upon the clinician’s ability to focus treatment on the right goals. When clinicians learn to accept the fact that stuttering treatment involves more than just the use of speaking techniques designed to improve fluency, they begin to recognize that working with people who stutter can be a successful and rewarding part of their professional lives.
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November 2001
Volume 6, Issue 21