A 6-year-old boy skips into school because today he gets to display his new Legos to the class in "show and tell." As he describes all the cool buildings and ships he can make with his new building blocks, he begins to stutter. In some classes, the students might tease, laugh or interrupt. This class is different. His teachers and peers participate in his community-centered treatment, so they know how to react: They let him work through the stutter and continue talking. The boy happily finishes his story.
Community-centered treatment is an approach that builds on the premise of family-focused treatment: Children who receive treatment for stuttering have better outcomes when their parents are active in their treatment. And if the entire family is involved in learning about stuttering and strategies that facilitate children's fluency, the child may achieve even better results.
In 2006, I explored this approach with Scott Yaruss and David Hammer in a study published in Language, Speech, and Hearing Services in Schools. The approach includes parent education sessions, parent-child modeling sessions and more direct treatment, if indicated.
But what if we expanded treatment involvement to include not just family members, but others in the child's life as well? Would a community-centered treatment program help a child even more? In my work with young children who stutter, my goal is to do exactly that, with a community-centered program that:
- Provides education on stuttering to parents, family members and others in the community.
- Targets increased fluency, improved communication and positive reactions for the child who stutters.
- Incorporates siblings and peers into the treatment process.
- Targets generalization and maintenance through home-based activities, follow-up sessions and telepractice.
Each of the community-centered treatment program's four phases targets one of these goals.
Phase I: Education
Educating family members begins immediately, at the diagnostic session. This allows parents to implement changes at home right away, rather than waiting until the treatment phase formally begins.
We talk about risk factors associated with stuttering (genetics, neurophysiology, other speech-language characteristics, temperament, environment, etc.), create an individual treatment plan based on the results of the child's assessment (disfluency rate, secondary behaviors, physical tension, reactions to stuttering, other speech and language areas, and overall impact on communication), and explore with parents and caregivers issues related to the communication environment and the child's overall temperament.
We ground our discussion of environmental factors and temperament in parent-identified communicative and noncommunicative stressors, as described in the family-focused treatment approach. For example, we explore whether there are frequent interruptions or competition for talking time, or if the family talks rapidly at home. We try to identify if—because of his or her temperament—a child who stutters reacts strongly to his or her disfluency. Typically, these children might have perfectionistic tendencies, be less likely to take risks and try new things, or have intense reactions to other situations.
I give parents handouts from various sources, including the National Stuttering Association and Stuttering Foundation of America, and information that I have developed with my colleagues, especially Scott Yaruss at the University of Pittsburgh. In addition, we identify others with whom the child interacts frequently, including siblings, friends, grandparents, teachers and other family members. For example, if the child spends most of his time during the week with a babysitter or grandparents, it is critical to involve them—as well as the parents—in the treatment process.
We also give parents information on communication changes they can implement at home. These changes—including slower communication rate, modified questioning, delayed response and recasting/rephrasing—are part of the family-focused treatment approach.
Although the education phase begins at the diagnostic session, it is an ongoing component throughout treatment. It's important to note that the education process is mutual: We educate parents about stuttering, and they educate us about their child and communication environment.
We don't limit education to parents. We provide information on stuttering to teachers, coaches, physicians and others to help educate all members of the child's community.
Phase II: Intervention
Next, we begin formal, direct treatment with the child, while continuing to educate the child's community and modify the communication environment. We design highly individualized treatment plans to reduce disfluencies, physical tension and secondary behaviors. We also target improved reactions to stuttering and increased communication.
Many children enter the treatment process with significant negative reactions to stuttering. Some exhibit outward frustration ("I can't talk"), while others demonstrate more subtle signs (pitch and loudness changes during stuttering episodes, physical tension and secondary behaviors). Stuttering may have a profound impact on these children's overall communication.
We begin treatment with these children by having age-appropriate discussions on individual differences, using "Tarby Comes Out of His Shell," a children's story I wrote with my colleague Mary Weidner about a character who stutters. Children, parents and the clinician occasionally use pseudostuttering to point out disfluencies and follow up with responses such as, "See, it's OK to have bumpy speech. I have bumpy speech sometimes, too!"
To target decreased physical tension and secondary behaviors, we teach the child the difference between "hard" and "easy" stuttering. "Easy" stuttering may include short repetitions or prolongations without physical tension or secondary behaviors. "Hard" stuttering is tension-filled, has frequent blocks and includes secondary behaviors. The child first identifies the difference between the two, then uses them in single words and structured sentences, and finally in conversational speech.
To decrease disfluencies, we use more traditional fluency-shaping methods, such as reduced rate of speech through pausing, phrasing and easy onsets. We often let the child choose the terms for these methods. Most children use terms such as "turtle talk" or "easy starts," but others are more creative ("supersonic talk" for fast speech). As long as the terms have specific meaning for the child and are used consistently, we give the child the flexibility to make some decisions about his or her treatment.
It cannot be overstated that the primary goal is improved communication. Therefore, we target specific objectives to increase the child's participation: eye contact, turn-taking, topic maintenance, initiating conversations with new partners, discussing the consequences of poor communication, and identifying the consequences of avoidance.
Phase III: Including siblings and peers
To make the greatest impact in treatment, we need to capture the child in everyday situations. Unfortunately, clinic visits do not always do that very well, because one-on-one time with an adult is not representative of a child's typical communication environment. To address this hurdle, we include siblings and peers in the treatment process—for at least a portion of the session—as soon as possible. Including them allows us to provide treatment in a more realistic context and also to gauge the child's fluency, reactions and overall communication in situations that matter the most—peer interactions. School-based intervention offers easier access to peers and sometimes even siblings than do other settings.
In addition, siblings and peers can be powerful allies for the child who stutters. Involving them allows them to become familiar with the treatment process and desensitizes them to the "mysteries" of stuttering. In fact, many peers and siblings are jealous when it is not their turn to be in the treatment room, because they begin to view treatment as a fun—not stigmatizing—process.
Involving siblings conveys another benefit: Clinicians also can demonstrate to parents how to handle potential communication conflicts between their children.
Phase IV: Generalization and maintenance
By involving siblings, peers, teachers, babysitters, other family members and, in the school setting, perhaps the school counselor and nurse, we target generalization from the beginning of treatment. When we achieve our treatment objectives (typically defined as less than five percent disfluent, no physical tension or secondary behaviors, no negative reactions, and no communication avoidance), we reduce treatment intensity—but continue to monitor the child's progress. We also continue the processes of generalization and community-centered care by, for example, communicating with teachers and using parent reports.
We may reduce treatment sessions to once every other week, then to once a month to ensure continued progress. This four- to six-session maintenance phase typically lasts for no more than three months.
Central to community-centered therapy for children at least 8 years old is their participation in a support group—online or in person—for children who stutter. I have been working with the National Stuttering Association to build more online support groups for teens and school-age children who stutter.
Telepractice also offers many advantages to the community-centered treatment program. We are using remote service delivery for long-distance cases and as part of the general program for local clients as well. Through telepractice, clinicians can:
- Bring in the expertise of stuttering specialists to assess, treat and consult on stuttering cases.
- Access clients' home environments.
- Involve more family members in the education process.
The success of a family-focused treatment approach can be expanded even further to benefit children who stutter. Through four distinct yet overlapping phases, the program provides more reimbursement flexibility by allowing lower-cost teletherapy as an option. A family-focused approach also takes advantage of our ability to bring in other communication partners and community members. Though stuttering treatment must be highly individualized, it also must exist in the context of a larger community, not just in the treatment room.