FEATURE

Stuttering Research and Treatment Around the World

see also: References

Professionals from Brazil, India, Israel, Japan, Sweden, Taiwan, and the United Kingdom share their unique perspectives on current work and attitudes toward stuttering in their respective countries.

Brazil

by Fernanda Papaterra Limongi

cite as:
Limongi, F. P. (2005, Oct. 18). Stuttering research and treatment around the world: Brazil. The ASHA Leader, p. 6.

The research and treatment of stuttering in Brazil began in the 1960s in universities in São Paulo, and was greatly influenced by American authors like Van Riper and Johnson. Nowadays, the treatment of stuttering is performed mainly in private speech clinics and in some public hospitals and universities in big cities. In small cities no free treatment is available for those who stutter.

As in other countries, in Brazil the approaches available for the treatment of stuttering differ not only in terms of the goals they seek, but also in the specific strategies used to achieve them. Clinicians who dedicate themselves to the study of stuttering in Brazil, although well aware of the different ways of thinking about the problems and knowledgeable about controversies in the field of fluency disorders, have emphasized the need for a better understanding of the causes and treatment of stuttering.

National Committee

With the idea of deepening the studies on stuttering research in Brazil and gathering together professionals in this area for reflective work on fluency disorders, a group of SLPs decided to create the National Committee of Speech Fluency in São Paulo in 1997. Since then, this group has worked to bring together SLPs and other related professionals who are interested in the study of fluency and its disturbances; to encourage and improve the study and knowledge of fluency; to maintain cultural and scientific relations with similar entities in other countries; to promote national meetings and international courses-like the ones conducted by Janis Costello Ingham and Roger Ingham in 1998 and June Campbell in 2000; and to participate in national and international conventions.

Books and Authors

Several books on stuttering have been published in Brazil in the past three decades. One of them, Tratando Gagueira-Diferentes Abordagens (Treating Stuttering-Different Approaches; Org. Isis Meira, Cortez Editora) was published by the National Committee in 2002.

Some of the Brazilian authors represented in this text see stuttering as a behavioral disturbance (Alvarez et al.); others as a language problem (Bohnen & Chaves). Brito Pereira refers to various causes of stuttering and believes three factors determine its occurrence: predisposition, emotional factors, and social factors. Some (Ferrioli et al.) see stuttering as a symptom; Gargantini sees stuttering as a complex disturbance associated with excessively high muscle tension. Jakubovicz follows a behavioral approach, seeing stuttering as a behavior resulting from a response of the central nervous system, which changes its motor pattern each time it suffers negative influence from the environment. Meira analyzes the person who stutters, his feelings and attitudes related to it, as well as the stuttering created by the person who stutters in his body through atypical action of certain muscle groups. Papaterra-Limongi emphasizes the fact that SLPs do not treat communication disorders, but people who present these disorders. She uses a behaviorist approach, applying biofeedback techniques and behavioral changes proposed by Ryan and Moss. 

ABRA GAGUEIRA: A Self-Help Group

In the past few years, a support group was created to promote interaction among people who stutter and to spread information about it. ABRA GAGUEIRA, founded in São Paulo in 2001, is the largest support organization in Brazil for people who stutter. It provides information about stuttering to the general public and supports local self-help groups as well as lines of communication among people who stutter.

The goals of ABRA GAGUEIRA also are to promote research in stuttering treatment; to produce informative material on aspects of stuttering; to provide a social network to bring people who stutter together; to sponsor seminars and conferences in stuttering treatment; to represent the affiliates in questions related to stuttering in political, therapeutic, educational, legal, and labor matters; to provide orientation about types of treatment available and credential clinicians; and to establish partnerships with similar entities, both national and international.

The group's main projects are: monthly support groups (only for people who stutter); participation in discussion groups; creation and maintenance of a Web site where one can find information on stuttering; and legal orientation for people who stutter and find themselves discriminated against in their work. For the past years, the organization has defended, enhanced, and maintained the quality of life of people who stutter.

 The organization is maintained financially by annual contributions of members and by volunteer contributions.

Although Brazil has made great progress in helping those who stutter, much still needs to be done. What is needed most is to accomplish access to cheaper treatment for a wider population range.

Fernanda Papaterra Limongi is a speech-language pathologist and a member of the National Committee of Speech Fluency Disorders. Contact her at fplfono@osite.com.br.

India

by Uma Subramanian and Bharathi Prabhu

Stuttering as a speech disorder has been documented and treated in India since Vedic times (5000 BC-200 BC). Texts of Ayurveda (the ancient system of Indian medicine) contain references to medicines and yogic practices that help persons who stutter. The first known speech treatment clinic for stuttering, started in India in 1937 by Japan-trained M. S. Rami, still functions in Mumbai.

Speech treatment facilities are currently available at training institutions that offer programs in speech-language pathology and audiology, hospitals, and private speech and hearing clinics. Clinics are available where persons who stutter (who are not formally trained) themselves provide counseling and treatment for stuttering. Apart from speech-language pathologists, psychologists, and psychiatrists, practitioners of alternate systems of medicine also treat stuttering in India.

No studies are documented on the incidence and prevalence of stuttering in India. However, the All India Institute of Speech and Hearing (AIISH), a premier training institute, reports that 10% of those with communication disorders stutter. Systematic study, research, and treatment of stuttering in India began with the establishment of the AIISH in 1965. This institute and several other training institutes subsequently established by the government and private organizations contribute to the bulk of research in the field. Students are required to carry out research projects in their graduate programs and some of them choose stuttering as their area of research. Doctoral projects also have been done on stuttering.

Data Gathering

To gather information for this article, we sent out questionnaires-eight to teaching institutes and seven to private practitioners across the country. The 14 responses revealed that research in stuttering covers a wide spectrum of topics ranging from development of fluency in children to the effect of treatment on various aspects of stuttering.

The aspects under research in India also reflect prevalent research interests elsewhere in the world. For instance, in the 1980s, researchers in India focused on acoustical, laryngeal, and aerodynamic features while the current research focus is on motor programming in persons who stutter.

Other topics being researched include neural networking and its application in differential diagnosis of stuttering and normal non-fluency, sub-grouping of stuttering, variables that affect treatment outcome, and naturalness of speech after treatment. Respondents indicated that status of research in the country needs improvement.

The number of research projects are insufficient, both in the area of stuttering and in the entire field of speech and hearing. The reasons are lack of funds, brain drain, and the overwhelming demand for clinical services, which take up time and energy. Even in teaching institutions, the amount of research is less than required because of the multiple demands (teaching, clinical supervision, administration) placed on staff already small in number.

The research done also does not get published because few Indian journals exist and many Indian SLPs need to hone their writing skills for international publication.

The questionnaire also asked clinicians about the treatment procedures they follow. Responses revealed the generally used treatment procedures are prolongation, air-flow modification, slow-rate of speech, soft contacts, and DAF and different combinations of the above based on age, severity, and type of dysfluency. Clinicians also find group treatment effective with adult persons who stutter.

Among 2- to 5-year-olds, the chief method of management used to be counseling parents. Now clinicians use direct treatment depending on the severity and the need for management indicated by the parents.

Our Own Clinical Observations

We believe that demand for speech treatment in urban India is on the rise due to:

• growing awareness about speech treatment services for stuttering. This awareness is due to the country's media revolution. Articles and programs related to health appear frequently in the media and stuttering has received its share of attention. SLPs also have played a significant role in raising the awareness levels among the general public, doctors, and teachers through interactions, which range from lectures at schools and service organizations to conducting awareness seminars.
• rapid increases in jobs in the BPO (Business Process Outsourcing) sector and call centers where young employees need excellent communication skills. Even those with mild stuttering now seek professional help.
• a burgeoning educated middle-class that wants the very best for its children in all spheres of development, including communication.

In order to extend health and other rehabilitation services to rural and remote areas of the country, service organizations such as the Lions and Rotary Clubs conduct camps. In speech and hearing camps, large numbers of people are screened for various speech and hearing disabilities and some services (e.g., further referrals, counseling, audiometry) are provided.

An interesting observation based on our participation in these camps is that the rural population of India has a greater tolerance for stuttering than do urban people. The reasons could be that demands on communication in those social settings are less as most people are known to each other and livelihood is mostly through manual labor. In the light of many other pressing health and economic problems, stuttering is not considered a disability and there is a philosophical acceptance of any disabling condition.

Current and Future Needs

The majority of SLPs in India are engaged primarily in provision of clinical services, yet the country's clinical needs are not being met. Clinical work is documented but the drive to research and publish is not strong. India, with its large multilingual and multicultural population, offers enormous opportunities for research in stuttering. Severity across languages and perception of stuttering across different socioeconomic groups are some of the issues for study.

Our ancient Yoga practices as they apply to stuttering should be investigated too. Yoga has been practiced in India for thousands of years for better control of mind and body. Yoga aims to improve people's inner tranquility and free them from fears and anxieties. Since it is known that stuttering includes an element of anxiety and fear, Yoga can help reduce this. Pranayama, one of the Yoga techniques, focuses on regulating breathing. Whether fluency can be improved with slow and controlled breathing, as Pranayama teaches, should be scientifically tested.

Finally, because of the dearth of SLPs and the paucity of available funds, the amount of research produced in India is far less than desired. More training programs and foreign collaborations may address these issues.

Uma Subramanian is currently principal of Samvaad Institute of Speech and Hearing, Bangalore, and also a visiting professor to several speech and hearing colleges. She has 33 years of experience in the field. Her areas of interest are child language and its disorders. Contact her at uma_s1@yahoo.com.

Bharathi Prabhu is a consultant speech-language pathologist at Spandana Nursing Home, Bangalore. Her areas of interest include language and stuttering. She has a keen interest in writing and has written several articles for newspapers, many on speech and hearing topics. Contact her at bprabhu@vsnl.net.

Israel

by Ruth Ezrati-Vinacour and Ofer Amir

cite as:
Ezrati-Vinacour, & Amir, O. (2005, Oct. 18). Stuttering research and treatment around the world: Israel. The ASHA Leader, pp. 8-9.

Research into the phenomenon of stuttering and its treatment in Israel, similar to other parts of the world, is very challenging since stuttering still is regarded as an enigma by many researchers and clinicians.

Stuttering research still is taking its preliminary steps, and the number of local researchers in the field is limited. Over the past years, stuttering research in Israel focused on issues such as awareness of stuttering-dysfluency, anxiety, and social phobia in people who stutter. It examined various theories, measuring emotional arousal through event-related brain potentials, and evaluating cognitive processing in people who stutter through different modalities like time estimation, attention in dual task, learning a miniature "artificial" language, meta-linguistic aspects in school-age children, and gestures of people who stutter as a part of non-verbal communication.

The Department of Communication Disorders at Tel-Aviv University and the Stuttering Research Project at the University of Illinois, under the direction of Ehud Yairi (who is also a guest professor at Tel-Aviv University) has collaborated to promote stuttering research in Israel. Yairi has taken a supportive and involved position in the research at Tel-Aviv University in the master's and doctoral programs. Consequently, Tel-Aviv University now is one of the cooperating institutions in this international study, and our team has recruited families for this ongoing study of chromosomal signals for genes underlying stuttering.

Treatment

In contrast to research, stuttering treatment is well developed in Israel. Six highly experienced public clinics have a caseload of hundreds of patients each year and several private clinics specialize in stuttering treatment.

An important problem in stuttering treatment in Israel is the referral process for treatment. Within the public medical service, children who stutter are referred for speech evaluation by the family physician and/or pediatrician. Unfortunately, despite our recommendations, many of these physicians still advise parents to delay professional evaluation of the stuttering child until the age of six.

The different public medical care programs typically cover most of the expenses of the stuttering treatment until the child is 18 years old. However, the total number of treatment sessions the child can receive over this period is limited.

In general, there is no one special stuttering treatment program or treatment approach for stuttering children or adults, which is preferred by most speech-language clinicians in Israel. We feel that when we treat a person who stutters we interact with an individual as well as with the situation of his or her environment (including family, school, work, language, and culture), accepting the person who stutters as a whole person.

In light of that, the approaches toward stuttering treatment in Israel vary and represent different trends in the field. Different centers offer various treatment programs. For example, two local centers conduct an intensive three-week program; one is located in Jerusalem and is basically a public center, and the other is situated in central Israel and is a private clinic. Another unique computerized program is called "Dr. Fluency." This program is based on self-practice fluency treatment, and is performed at home in front of the computer by the person who stutters.

In contrast to these two approaches, most treatment programs for stuttering in Israel have no fixed duration. The speech clinic in the Sheba Medical Center in Tel-Hashomer, (in the vicinity of Tel Aviv) is considered the largest and most acclaimed speech-language pathology and audiology center in Israel. It offers several different approaches to stuttering treatment, conducted in individual or group settings. Some clients are admitted for treatment programs that focus on fluency-shaping techniques and stuttering modification. Other clients are admitted to treatment programs that emphasize the emotional aspects as well as communication skills and attitudes toward stuttering. Additional approaches that are practiced in Israel focus on cognitive and emotional aspects of stuttering, like Rational-Emotional Therapy for adults who stutter.

A leading group of Israeli clinicians who specialize in stuttering have, since 1994, been in professional and supervisory contact with several internationally recognized colleagues. Among these is Nitza Katz from the University of Dortmund, Germany; and Frances Cook, Willie Botterill, and the late Lena Rustin, from the Michael Palin Center, London. These professional contacts and clinical exchanges have enriched our work in the emotional and cognitive aspects of treatment with children who stutter and their families. Thus, we give direct and indirect treatment (family interaction) to children who stutter.

Stuttering treatment is a challenging task, and more so in a multicultural society such as Israel. Communication, in general, is language-and culture-dependent and treating communication disorders needs to address this diversity. As clinicians and researchers, we feel the need to further deepen our professional and clinical knowledge in order to take an active part in advancing the field, and to more effectively treat our clients. We are looking forward to future mutual professional, academic, and research collaborations.

Ruth Ezrati-Vinacour, senior-teacher in the Department of Communication Disorders at Tel-Aviv University, is a speech-language pathologist who specializes in stuttering and fluency disorders. She has a special interest in family therapy and rationale-emotive therapy. Contact her at ruthez@post.tau.ac.il.

Ofer Amir, a lecturer at the Department of Communication Disorders at Tel-Aviv University, is a speech-language pathologist who specializes in stuttering and fluency disorders as well as in voice pathology. Contact him at oferamir@post.tau.ac.il.

Japan

by Masamutsu Kenjo

cite as:
Masamutsu, K. (2005, Oct. 18). Stuttering research and treatment around the world: Japan. The ASHA Leader, pp. 9, 36.

In Japan, the history of speech and language treatment dates only from the 1950s. National licensure for "speech-language-hearing therapists" (SLHTs) began only recently. The first National License Examination for Speech-Language-Hearing Therapists was administered by the Ministry of Health, Labour and Welfare in March 1999. The area of stuttering is a requirement in the SLHTs' curriculum. Therefore, the number of clinicians specializing in stuttering is increasing. Before national licensure was required, stuttering was treated by clinical psychologists as well as clinicians. After licensure was in place, SLHTs became the group that primarily treats stuttering.

Stuttering Treatment in Japan

In Japan, the primary treatments for younger children, including those with severe stuttering, have for a long time been play therapy and modification of environment. These treatments are prevalent for several reasons: 1) the clinicians' belief that increasing self-awareness of stuttering would trigger emotional reactions that might lead to even more severe stuttering; 2) although many clinicians have a background in psychology and/or psychotherapy, many are not skillful in methods of direct speech treatment for stuttering; 3) and in Japan, the diagnosogenic theory of stuttering and its psychological problem have been accepted as important theories until recent years. For these reasons, indirect treatment has mainly been used not only with preschool children but with school-age children as well.

However, since about the end of the 1990s Japanese researchers have reported on a few young children who have improved with direct speech treatment. For example, Hayasaka & Kobayashi ([2000]. Treatment of severe stuttering in a child through integration of direct and indirect treatments. The Japan Journal of Logopedics, 41, 233-242) reported on a school-age child with severe stuttering who was treated combining stuttering modification techniques, play therapy, and environmental modification. Kenjo ([2002]. Speech therapy for a child with severe stuttering: A case report. Japanese Journal of Communication Disorders, 19, 18-26) reported on a school-age child with severe stuttering who was treated with an approach combining fluency facilitation treatment, play therapy, and environmental modification.

Treatment in the Schools

Since 1958, elementary-school children who stutter mainly have been treated in the schools for speech and language disorders in a special room set aside for treatment. Students, who are removed from their regular classrooms, visit the room once or twice a week (for approximately 90 minutes per session) and are treated mostly by a teacher with expertise in speech and language disorders. But until the 1990s, the treatment was carried out as an "educational service" rather than as a regular part of the standard educational curriculum.

The number of treatment rooms gradually increased and became a regular part of the educational curriculum beginning in 1993. Most of these treatment rooms are in the elementary schools, with a few in the junior high schools. Even so, the teacher with expertise in speech and language disorders may not have specialty training in stuttering. On the other hand, school-age children who stutter often visit SLHTs for treatment.

Self-Help Groups

Self-help groups for stuttering play an important role in solving the problem of stuttering in Japan. The "Japan Stuttering Association" (Genyu-kai) was founded in 1966 in Tokyo. Afterward, local Genyu-kai were established in various regions. Currently, 29 regions in Japan are represented by Genyu-kai.

Genyu-kai and the "Japan Stuttering Project" (established in 1994) are the two biggest stuttering self-help groups in Japan now. Some SLHTs as well as teachers of speech and language disorders and stuttering researchers attend meetings on a regular basis and sometimes offer participants their own special knowledge about stuttering.

Interaction with the members is not only face-to-face but also occurs through e-mail. The main purpose of the groups is to help members live as well as possible with their stuttering rather than offer promises of complete recovery. The groups are making efforts to support junior high school students and high school students who stutter. This is especially important because many are not receiving regular treatment.

Research

In the past, Japanese researchers of stuttering have studied under researchers in the United States such as Wendell Johnson, Charles Van Riper, and, more recently, Ehud Yairi (who allowed me to attend his stuttering research program at the University of Illinois from Oct. 2003 to March 2004). After they returned to Japan, they passed on their knowledge of research methods through their teaching in their home universities.

There has not been a great deal of stuttering research performed in Japan. However, the number of researchers has increased little by little and participation and presentation of Japanese researchers at International Fluency Association meetings has increased remarkably in recent years. Japanese researchers are working on various topics such as treatment approaches for children, brain imaging, and psychological issues.

Masamutsu Kenjo is an associate professor and speech-language-hearing therapist at the Fukuoka University of Education. Contact him at mkenjo@fukuoka-edu.ac.jp.

Sweden

by Cecilia Lundström and Marie Garsten

cite as:
Lundstrom, C., & Garsten, M. (2005, Oct. 18). Stuttering research and treatment around the world: Sweden. The ASHA Leader, pp. 36-37.

The seven-member speech-language pathology and treatment team to which we belong is located at the Department of Otolaryngology, Helsingborg Hospital, Helsingborg, Sweden. Our beautiful city lies along the shore of the three-mile strait between the North Sea and the Baltic Sea, just across the Hamlet Castle in Denmark.

Health care in Sweden is generally funded by public resources through each county's Health Care Council. Health services for children are free while adults are charged modest fees. Speech, language, and hearing services typically are provided at the county council's hospital by professionals in the field; children and adults usually are seen for treatment once a week. For the treatment of disorders such as cleft palate, dysphagia, and aphasia, the SLP often works in teams that include other health specialists.

There are also private clinics, especially in larger cities such as Stockholm and Gothenburg. The private sector, however, is very small. Currently, we estimate that the country's population of nine million is served by approximately 900 SLPs. Similar to the United States, many speech-language clinicians in Sweden are generalists, working with individuals who exhibit a wide range of communication disorders. Although opportunities to specialize in a particular disorder have increased in Sweden, a focus on stuttering is still rare.

Registered professionals in communication disorders are trained in speech and language and hold a Master of Medical Science degree in Speech Pathology and Therapy. Education programs are available at five universities. Audiologists are a specialized group with a different education.

The Swedish Association of Logopedists (SLOF) is the national body with which most of the country`s professionals in communication disorders are affiliated. The association is a member of the European organization, Comité Permanent de Liaison des Orthophonistes-Logopèdes de l´Union Européenne (CPLOL), and is also an affiliated member of the International Association of Logopedics and Phoniatrics (IALP). The Swedish association holds a biennial national congress for its members.

Treatment

During the past 50 years, stuttering treatment in Sweden has been influenced greatly by the knowledge and scientific literature in the United States and other English-speaking countries. For example, the writings of Wendell Johnson, Charles Van Riper, Joseph Sheehan, and Carl Dell had great impact on our approaches to treatment.

Currently, the theoretical groundwork of Swedish stuttering treatment is a multifactorial view of the disorder. The treatment integrates elements of the traditional Van Riper modification of stuttering and modification of emotional reactions techniques and the more recent fluency-shaping techniques. The Van Riper influence was important during the early 1970s when a national intensive treatment program, administered by the University Hospital in Gothenburg, was developed by psychologist Anders Lundberg, phoniatrician Rune Stenborg, SLP Lennart Larsson and others.

This intensive treatment program offers a good supplement to the treatment available at local hospitals. The intensive treatment is divided into three sections of approximately one week each spread over a year. Started as a program for adults, it has expanded to include children and their parents. Additionally, the Swedish Stutterers Organisation offers an intensive, one-week summer camp treatment program for teenagers. The organization also sponsors self-help groups for adults, mostly with a focus on fluency shaping with breathing exercises and slow speech. The participants are also trained to apply the techniques in daily life.

Parents with children who stutter are encouraged to contact a speech and language clinician as early as possible. They can often choose between several alternatives depending on their individual problems and needs. The options could be consultation for parents, direct treatment for the child, group treatment for children and possibilities for the parents to join parent support groups. Fluency-shaping programs for children are not common in Sweden but some clinicians have been trained in the Lidcombe program while others work with fluency shaping as part of an integrated approach.

Research

Swedish scientists (e.g., Gunnar Fant, Johan Sundberg, Ulrika Nettelbladt, Britta Hammarberg, Lena Hartelius) have made internationally recognized research contributions to speech, voice, and language science. The field of stuttering has seen modest, though growing, research activities. For example, during the past five years the authors of this article, within the division of Logopedics at the Helsingborg Hospital, have been active participants in a biological genetic study of stuttering funded by the United States National Institutes of Health. We have had a formal subcontract, through the University of Illinois, collecting blood samples from selected families for genotyping purposes. These findings should be published in the near future. Also Per Alm of Lund University has been conducting an extensive research program on the neurobiology of stuttering. In 2003 and 2004 Lund and Umeå Universities had three master's theses about stuttering covering the following topics: prediction of chronic stuttering, teachers' attitudes to stuttering, and cognitive treatment and stuttering.

Still, contacts with clinics and researchers in other countries are of great importance to us. We continue to cross the Atlantic Ocean to update and maintain our professional knowledge as well as to receive inspiration, and during the last two decades our interaction with Ehud Yairi, Ed Conture, Ellen Kelly, Barry Guitar, Karin Wexler, and others has been extremely rewarding.

Cecilia Lundström and Marie Garsten attended the University of Lund, Sweden, in the 1970s and hold MSc degrees in speech pathology and therapy. They have had a deep interest in stuttering for 30 years and daily see children and adults with a stuttering problem in their work at the Department of Otolaryngology, Helsingborg Hospital, Sweden. They also supervise students in the speech-language pathology program at the University of Lund. Contact them at cecilia.lundstrom@helsingborgslasarett.se and marie.garsten@helsingborgslasarett.se, respectively.

Taiwan

by Shu-lan Yang

cite as:
Yang, S. (2005, Oct. 18). Stuttering research and treatment around the world: Taiwan. The ASHA Leader, pp. 37-38.

Before I obtained my doctoral degree in speech-language pathology at the University of Illinois at Urbana-Champaign (UI) in 2000, well-designed research on stuttering in Taiwan was quite scant. We do, however, have an experienced clinician, Hsi-Che Ho, who began treating people who stutter 48 years ago, and published his book, The Modification of Stuttering, in 1957. He is now 83 years old and continues his therapeutic work every week in Taipei, Taiwan's capital. He is viewed in Taiwan as the "Father of Stuttering." He is the highly spirited gentleman in the middle of the first row in the photo accompanying this article on page 38.

Before studying in the U.S., I was a school counselor for many years and already had obtained my first PhD in counseling psychology. I aimed to investigate stuttering at UI because at that point, no researcher in Taiwan was specifically interested in the area. Under Ehud Yairi's supervision, I acquired a second PhD and subsequently began to teach courses in language-speech disorders in the Department of Special Education at the National Ping-tung University of Education in southern Taiwan. I also teach "the Seminar on Stuttering" at two graduate schools and advise a number of graduates who are enthusiastic about engaging in stuttering research.

Research

Several master's theses have been completed during these years: Fang-Chi, Chou (2004): Revised, The Stuttering Severity Instrument-3 for Mandarin Speaking Children; Feng-Chu, Tseng (2004): Study on Treatment Effects of the Integrated Approach for Stuttering Adults Who Speak Mandarin; Zey-Yi, Wu (2005): The Comparisons of Communication Attitude, Communication Anxiety, and School Adjustment between Stuttering and Non-Stuttering Children; Tan-Chiung, Hsu (2005): The Comparisons of Attitudes Towards Stuttering Between Speech-Language Therapists and the General Population; and Hsin-Yi, Lin (2005): The Relationship Between Anxiety and Stuttering: Anxiety Levels of People Who Stutter in Various Speech Conditions.

Certainly, all the participants in the above studies speak Mandarin, which is very different from English in terms of linguistic structures. Unfortunately, the researchers have not yet published their results in English. Nevertheless, I have been working on a study entitled: The Epidemiology of Stuttering in Preschool Children in Taiwan, wherein 1,800 preschool children were randomly selected and their speech samples collected. I will calculate the prevalence, recovery rate, and the sexual ratio, and then compare the communication attitudes of the stuttering children with those of the non-stuttering children. Their speech samples also will be recollected at the follow-ups, after six and twelve months, from the initial evaluation.

An assessment tool for stuttering children who speak Mandarin from preschool to school age was published in 2004, The Severity of Stuttering Instrument for Children and Adults-3, that Chou and I modified with the permission of Pro-Ed, Inc.

More than 70% of speech clinicians work in Taiwan's hospitals, where they offer stuttering treatment. However, few speech clinicians have obtained their master's degrees in speech-language pathology because the first graduate school was just established in Taiwan in 2000. Until now, we have had only three graduate programs in communication disorders. Most of the speech clinicians do not have training at the master's level on stuttering.

Attitudes

Based on the prevalence of stuttering estimated abroad-about 1%-there should be 230,000 people with the condition in Taiwan. Therapists' lack of solid training may be one of the reasons why people with stuttering do not often seek help in hospitals.

Many people who stutter prefer to discuss their experiences on the Web sites in Taiwan. Why? There may be several reasons: 1) Speech clinicians cannot offer good quality services for clients who stutter; 2) Clients who stutter do not have confidence in speech clinicians and stuttering treatments; and 3) They worry they'll be labeled as stutterers if they seek treatment in hospitals.

According to Mr. Ho, at least two adult clients  have committed suicide because they stuttered. I also have heard from some clients who stutter that they would "prefer no arms rather than to suffer from stuttering." One female client told me that she felt very abashed because of her troublesome stuttering.

I wonder whether people who stutter in Taiwan's eastern culture have more negative feelings and beliefs than those in western cultures. I never read about people who stutter committing suicide in the books on stuttering in English. The results of Tseng's (2004) study showed that clients' dysfluencies significantly decreased but that their attitudes and beliefs concerning their communication did not improve after a two-day workshop and 10-week group treatment. Therefore, I intend to add more counseling concepts and skills in my stuttering training programs for speech clinicians.

Two stuttering groups have been actively participating in the Taipei area. One is based on self-help, and is run by a former client of Mr. Ho, who was cured of his stuttering. The other is managed by the speech clinician Tseng whose work is based on the experimental group she ran for her master's thesis. Both of them have been operating in the north of Taiwan. Someone is urgently needed to lead another group in the south of Taiwan.

My Web site, "The Stuttering Institute in Taiwan," was established in 2004. The English version has not been set up yet.  A few articles I have written on the subject have been posted. Information regarding stuttering treatments around Taiwan also is offered. Questions can be sent to a discussion area and I or someone else with expertise will respond.

In the near future we plan to invite foreign specialists in stuttering to give speeches and workshops to improve our research and treatment. I hope that I can do as much as possible for the people with stuttering in my country.

Shu-lan Yang is an associate professor in the Department of Special Education at the National Ping-tung University of Education in southern Taiwan. Contact her at shuyang@mail.npttc.edu.tw.

United Kingdom

by Willie Botterill and Jane Fry

cite as:
Botterill, W., & Fry, J. (2005, Oct. 18). Stuttering research and treatment around the world: United Kingdom. The ASHA Leader, pp. 39, 41.

Reflecting on the recent meeting of Special Interest Division 4, Fluency and Fluency Disorders, it is comforting to know that the issues we face in the UK are very similar to those discussed at Division 4, despite our services being organized in very different ways.

Historically, treatment for stuttering in the UK has been notable for its diversity. Clinicians have drawn on and integrated a variety of approaches across the age range with clients who stutter. Specialist clinicians in the UK may use indirect or direct therapy with young children or a combination of the two. With older children, teenagers and adults, clinicians may integrate fluency management (using aspects of fluency shaping and block modification), communication skills, and cognitive restructuring, with the particular configuration of treatment led by individual client needs.

Interest in and emphasis on the role of psychological change in stuttering has led many clinicians in the UK to develop skills in psychological therapies such as Personal Construct Psychology, Cognitive Therapy, Brief Solution Focused Therapy, and Narrative Therapy and to use these approaches to help clients achieve their goals. This diversity is highly valued as it may be argued that it encourages flexibility and creativity, and the development of clinicians who are able to engage in the process of therapy by understanding and responding to individual needs, goals, and preferences.

Evidence-Based Practice

However, there also is a drive within the National Health Service, led by central government policy, to develop and provide health care that is both evidence-based and cost-effective. A key principle in evidence-based health care is that only interventions that have been objectively evaluated should be included in clinical practice [see Sackett et al. (1996) Evidence-based practice: What it is and what it isn't. British Medical Journal, 312, 71-72]. The challenge for all health services in the UK at this time, speech and language therapy included, is to reach consensus about what, based on the evidence, constitutes best practice, and to develop clinical guidelines that reflect this.

Despite the apparent advantages of restricting treatment interventions to those that have been objectively evaluated, concerns are voiced in the UK, as elsewhere, about the potential constraints that such a principle may impose on individual clinical decision making and innovation. For example, the complexity of psychological change, fundamental to the process of therapy for many people who stutter, may not be revealed when quantitative research methods, which may be favored in evidence-based practice, are relied on.

Furthermore, limiting "outcome" to elements that can be easily measured may ultimately be too reductionist to be either useful to clinicians or meaningful to clients. In addition, in the field of stuttering, as in many others, the definition of "success" in therapy is highly individual and may best be defined by individual clients rather than either clinicians or researchers. Finally, problems are inherent in generalizing research findings in a disorder such as stuttering that is heterogeneous in nature. The situation is further complicated by the relative scarcity of available research evidence with respect to treatment for stuttering.

While the UK community has made valuable contributions to stuttering research it is imperative that more is undertaken, although here as elsewhere the financial resources to support research initiatives are scarce. Clinicians frequently lack sufficient time, knowledge, and support, and are inhibited by demands of client throughout and are thus less able to systematically evaluate their work. For many clinicians, interest also may be eroded by a perception that evidence-based practice necessarily involves "gold standard" research.

The way that clinical skills development in the field of stuttering is approached in the UK may offer a useful way forward. Emphasis is being placed on developing clinical skills and confidence from a grass-roots level upwards and on demystifying therapy for stuttering through extensive training opportunities from a variety of leading clinicians throughout the country. In this way less experienced clinicians are encouraged to feel more confident in their skills while also being able to seek the support of specialists when required, rather than viewing stuttering therapy as the domain of specialists alone.

In the same way, all clinicians may be encouraged to develop strategies for gathering evidence as part of their practice, using standard activities such as careful recordkeeping, assessment, seeking client feedback, and conducting clinical audits. This "real world" approach has the potential to provide evidence that is practice-based as well as practice that is evidence-based, the bi-directionality of which is intuitively appealing. Within the UK, a significant initiative in this respect is the development of national clinical care pathways, which will chart each client's progress through therapy and identify points at which clinicians are encouraged to reflect on their practice as part of their clinical decision making.

Ultimately, what emerges in discussions both in this country and elsewhere is that while the process of developing an evidence base and applying it to clinical practice is far from straightforward, it is fundamental to the future development of our profession. This approach offers us challenges as well as opportunities to meet the needs of our clients more effectively.

Willie Botterill is a consultant speech and language therapist and clinical manager at the Michael Palin Centre. She has worked as a specialist in the field of stuttering for 25 years and has a special interest in the use of Personal Construct Psychology and Solution Focused Brief Therapy in stuttering, and in group work with parents. Contact her at willie.botterill@nhs.net.

Jane Fry is a developing consultant speech and language therapist at the Michael Palin Centre where she has worked for 13 years. She has additional training in Cognitive Therapy and a special interest in working with teenagers. Contact her at jane.fry@nhs.net.