March 1, 2013 Departments

Overheard: Bilingual and Disfluent: A Unique Treatment Challenge

In November 2012, bilingual fluency expert Garth Foote chatted with participants during an ASHA online conference on fluency. The Leader was listening.

Bahaa Sudqui Moh'd Abdeljawad: In your lecture, I understood that we treat the language that bothers the client. What if the client says, "I want stuttering to fade out of my speech," or we have a child who cannot be asked to choose? Which language do we start with? And what is the "taboo" of stuttering?
Garth Foote:
If the client wants stuttering to fade from their speech entirely, that's far enough. However, for many, the problem is primarily in one language. Remember, languages are often specifically associated to certain social settings. My talk was more for teens and adults than children. But I would begin similarly, by at least asking the child where they are experiencing the most trouble. For many—maybe most—stuttering can be considered a taboo, something that is not okay to talk about openly, but rather to be hidden.

Diane Paul: I've always heard that one way to diagnose stuttering versus difficulty learning a language is that stuttering occurs in both languages. But you indicated that some bilingual speakers stutter only in one language. Can you comment on this, please?
In my experience, I've only rarely seen stuttering occur only in one language, if ever. Stuttering typically may be more or less severe in one language than another—and again, remember the social connection to any given language spoken. But it is usually, in my experience, present in all languages, although the speaker is not always aware of this initially. I have seen that stuttering may vary across languages for many reasons, as may the problem of stuttering—that is, stuttering may be more severe in one language, say, the mother tongue, but yet pose fewer problems, because of the social contexts in which that language is used.

Bahaa Sudqui Moh'd Abdeljawad: Bilingualism is speaking two languages perfectly, even if the second language was learned after age 32?
Bilingualism is not speaking two languages perfectly. Not at all. I began learning French at around 32, and came to work in French after several years. Bilingualism is better defined more loosely, as having any degree of proficiency—not perfect mastery.

Miriam Buysse: Please explain who set, suggested or defined the implementation intentions for your clients who stutter.
Typically, I helped the client construct early implementation intentions: namely, helping frame realistic, manageable and well-defined intentions. Still, these were done as collaboratively as possible. Later, the client suggested or created his or her own intentions, often fading the use of these as a target skill became better mastered.

Sheila Garrison: I currently work in an ELL [English-language learner] school with elementary-age children. Our ELL staff encourages parents to use and develop L1 [the first language] for their children, saying L2 [second language] development is better if there is a solid L1 basis. I know there is some controversy here, but can you expand on if you feel L2 actually impacts stuttering or not? And how I should deal with this as an SLP? Also ideas on presenting implementation intentions to younger children?
There is much controversy here, as you note. In my experience, learning a second language often does affect stuttering, though not in predictable ways. The question is, of course, much more nuanced with younger children. For younger children, increased demands and changed social settings may increase stuttering. The best, and perhaps only, suggestion I will make there is that stuttering is not a reason to deny a child bilingualism. I would suggest focusing primarily on where stuttering is creating the greatest challenge for the student at that time, as determined by speaking with the client. I've not used implementation intentions with children. However, I feel the idea could be adapted to work.

Beth Holloway: Since implementation intentions are so difficult for the bilingual patient, are there any special techniques they can "file" in their working memory to use when unexpected situations occur?
I did not find implementation intentions particularly difficult for bilinguals, more that bilinguals often faced particularly difficult situations. Implementation intentions are, originally at least, less set up for unexpected situations and more for typical situations. In that way, the intention would set an environmental cue—"when I talk to John tonight at dinner, then..."—that will serve as a reminder for the behavior in the environment. After some progress is made in this way, it seems to me that it would become easier for the client to decide how to act when the unexpected happens. For example, "If I'm not sure what to do in a tense speaking situation, then I'll…" But it would depend on the client.

Diane Paul: Assessing reading fluency is a challenge for students who stutter. There's an added challenge for bilingual speakers who may have more literacy problems in one language than another. What do you recommend for evaluating reading fluency?
Tricky one. In some cases, say a client who speaks six or even seven languages, I don't attempt to assess in all languages, for many—often simply practical—reasons. It may be helpful to consider what you are looking for, specifically, when you assess reading fluency. I'm thinking of a man whose L1 was Bengali, and it was his strongest language as well. Still, he seemed to have little proficiency in the written language. For him, I was interested in whether reading shone a light on avoided sounds. After we'd established a good rapport, and could talk openly about this, I relied on his report rather than a reading assessment. It is also difficult to impossible to determine the complexity of the reading passage in a language with which you have no familiarity. When it was a goal, I worked with the client to identify passages, say, online through Google news. Beware of religious texts that may be well-learned and rehearsed if they are all you otherwise have access to, and use the passages found only to work toward your specific goal—that is, avoidance of a non-English sound. Others may not, but I wasn't afraid to leave reading tasks in certain situations, depending.

Diane Scoffone: If a client has negative associations with a particular language, would you describe strategies you have found to be successful in reducing that?
This happens a lot, and certainly happened with me and French, which made learning very difficult. For clients who stutter, and were forced to learn French—which many [people] were in Quebec—they learned to hate the language itself, then yet again because of their exaggerated stuttering. I'll try to limit my response, but first, one must understand what the associations with the given language are—is it work? Required for some specific reason? Social? Fun? Family? Then try to examine what might alter those associations in some way. As one general rule, I find personally and have found with clients that comfort with and pleasure in a language increase when expectations for perfection and "correct speech" are removed. I only started to like French, as an example, when I dropped my concern over verb forms and gender and used whatever I felt like—even the infinitive. In this sense, "fluency"—proficiency—could be practiced. Just keep the conversation moving, no matter how much violence is committed to the grammar. It helps a lot. Practicing a language in an imperfect way helps internalize the language much more quickly. I learned German by the book, but couldn't speak it, but my French is better from caring less.

Jessica Sanford: What if a client started to stutter in a second language, but had not stuttered prior to this, and then shortly after, started to stutter in their first language as well. Have you seen this before?
I'd have many questions about this. How old is the client, please?
Sanford: Ninth grade.
My first feeling would be to suspect that there probably was some early stuttering, or even current but very subtle stuttering. I have seen clients only slightly older who did not realize they stuttered in L1 until after they'd come to me for help with their stutter in English. I wonder if that's what happened in this case. It seems unlikely that the stutter started in L1 after L2 in this situation, but rather a case of accurate identification.
Sanford: I was thinking the same thing.
Unless some other event had happened to exaggerate stuttering in all languages.

Risa Radeke: When working with a bilingual or multilingual client, how do you distinguish lack of vocabulary or word-finding versus dysfluency for a client with limited language proficiency in his or her second or third language?
Very tricky business. After we've established sufficient rapport, and the client is clear about their own avoidance patterns, I ask them directly whether this is an avoidance strategy—"How do you say...?" I've seen that a lot. When it is ambiguous—Is this a stutter? Is it word-finding?—somewhere in between, I try to cut to the chase. Namely, in an open discussion: "This is what I'm noticing in our conversations. Would you say that's right?" If the client can't tell and I'm unsure, I always, always, default to the pragmatic. "In what way is this a problem, if it is?" From there, fluency/stuttering skills could be brought in, or even conversational strategies, such as, "I don't know all the words to talk about this." It's very subtle. Focus on the practical, I would say. From there, see if the details begin to sort themselves out, or need to be sorted out.

Judd Emery: I have noticed that sometimes my students with articulation and phonological disorders begin to stutter at the moment they begin to apply skills to connected speech. Likewise, at certain stages in my learning Spanish, I began stuttering much more than usual, even in English—though I never considered myself a "stutterer." Do you think, or have you witnessed that the metalinguistic, articulatory and phonological gymnastics involved in becoming fluent in a second language can tip the scale and bring about a persistent stutter in the mother tongue?
I don't think so. I have certainly observed that all these skills and problems can make a mild stutter into a severe one, at least within a given social context. Sometimes, in learning a second language, the speaker can develop habits, patterns of interacting and speaking that may be transferred back to the L1, at least for a time. For example, speaking with phrases one would not otherwise use with such frequency comes to mind, but I don't see it bringing about a persistent stutter.

Liz Ehrstein: And with that, I think we've reached the end of this chat session!

Garth Foote, MScA, SLP, has focused his clinical practice on stuttering since 2007. He is a clinician with Northern Health, which provides health services to 300,000 people in British Columbia.


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