The journal Language, Speech, and Hearing Services in the Schools (LSHSS) recently published a letter authored by 113 stuttering experts.[ref]Yaruss et al. (2012) Stuttering in School-Age Children: A Comprehensive Approach to Treatment. Lang Speech Hear Serv Sch.2012; 43: 536-548[/ref] The co-authors were mostly Ph.D. speech-language pathologists, but also included leaders of organizations such as the Stuttering Foundation, the National Stuttering Association, and Friends. Almost “everyone who is anyone” in the field of fluency disorders signed the letter. In 5,900 words (about the same length as my e-book What Stuttering Treatments Are Effective?) the experts present the near-consensus view of how school-age children who stutter should be treated.
You can download “Stuttering in School-Age Children: A Comprehensive Approach to Treatment” from LSHSS for free if you’re an ASHA member, or $10 for non-members.
Nippold’s Editorial
The letter was written in response to an editorial by Marilyn Nippold, “Stuttering in School-Age Children: A Call for Treatment Research.”[ref]Nippold, M.A.(2011) Stuttering in School-Age Children: A Call for Treatment Research. Language, Speech, and Hearing Services in Schools Vol.42 99-101 April 2011. doi:10.1044/0161-1461(2011/ed-02), page 99.[/ref]
Dr. Nippold noted that most published stuttering treatment research has been done with pre-school children, not school-age children; that most research with school-age children was published in the 1980s and 1990s; and that in the past ten years no studies of stuttering treatments for school-age children have been published in American Speech-Language Hearing Association (ASHA) journals. Dr. Nippold then observed
a trend in the literature toward counseling children to accept their stuttering and to learn to cope with its negative side effects instead of working directly on the stuttered speech, as if to say that we are throwing in the towel on the effort to acheive fluency in school-age children.
The Experts Respond
In October, 2012, LSHSS published the stuttering experts’ response to Dr. Nippold’s editorial. The experts’ begin,[ref]page 537[/ref]
Dr. Nippold presents a dichotomy between treatments that focus on increasing fluency and treatments that focus on helping people reduce negative attitudes.
The experts counter that “people who stutter are a heterogenous group” (i.e., different stutterers are different) and so “treatment plans should include multiple goals that can be selected for each individual’s unique needs.” [ref]page 537[/ref] The experts say that “comprehensive treatment approaches” are available that include both goals.
The experts then recommend teaching “acceptance” to school-age children who stutter. This is defined as treatment to[ref]page 539[/ref]
minimize physical tension, struggle behaviors, avoidance, and other negative experiences, that may result from their attempts to “not stutter.” Acceptance is rooted in an awareness of what the speaker is doing during moments of stuttering
Are “Comprehensive” Treatments Possible?
There are three ideas in that definition:
minimize physical tension, struggle behaviors, avoidance, and other negative experiences
Those are secondary behaviors. Fluency-based stuttering treatments instead focus on the core behaviors such as repetitions, prolongations, and blocks. The presumption in fluency-based stuttering treatment is that when a person no longer has core behaviors then his or her secondary behaviors will disappear.
that may result from their attempts to “not stutter.”
In other words, the experts recommend telling children not to try not to stutter. In contrast, fluency-based stuttering treatments train children to not stutter.
Acceptance is rooted in an awareness of what the speaker is doing during moments of stuttering
The experts recommend training children to develop awareness of what they do when they stutter. In contrast, fluency-based stuttering treatments train children to develop awareness of what they do when they speak fluently, e.g., integrate respiration with phonation, reduce vocal fold tension, relax their lips, jaws, and tongues, etc.
No “comprehensive” (also called “integrated”) stuttering treatments have been proven effective in a published study. Here’s why:
- You can’t treat core behaviors and secondary behaviors at the same time. If your treatment of core behaviors is effective, then the stutterer doesn’t have secondary behaviors. I once did a Van Riper-style stuttering modification therapy program, which focused on secondary behaviors. But I was fluent in the speech-language pathologist’s office. I didn’t have secondary behaviors to “cancel” or “pull out” of.
- Telling children to not try not to stutter is possible while training them not to stutter?
- Children should be trained to develop awareness of what they do when they stutter and develop awareness of what they do when they’re fluent? I suppose it’s possible, but given the limitations of the speech-language pathologist’s time and the child’s patience, let’s just focus on one of those.
Is “Acceptance” the Same as Stuttering Modification Therapy?
The experts’ letter never mentions stuttering modification therapy. To me, “acceptance” looks like stuttering modification therapy. I’d like one of the 113 experts to explain the difference between “acceptance” and stuttering modification therapy.
Is “Acceptance” Effective?
The experts state that “acceptance” reduces
the adverse impact of stuttering and increase the child’s willingness to speak; it can also lead to reduced stuttering severity, increased fluency, and improved communication…and minimize relapse.
Six references are then given to support these claims:
- A 2007 case study of a 9-year-old boy.
- 2005 interviews with seven adults about how they manage their stuttering.
- A 2010 article written by an adult stutterer in a newsletter.
- A 2010 textbook written by one of the letter’s authors.
- A 1973 textbook.
- A 2002 tutorial explaining how to use personal construct psychology in stuttering therapy.
Those aren’t scientific references. The only published scientific study of stuttering modification therapy was of 19 adults. Post-treatment the stutterers’ speech improved 10%. Six months later this modest gain had all but disappeared. Several measures of anxiety found a 10-15% psychological improvement. The researchers cautioned that six months isn’t a long follow-up, and that this psychological improvement might not last, given the absence of improved speech. The researchers concluded that the program “appears to be ineffective in producing durable improvements in stuttering behaviors.”[ref]Blomgren, M., Roy, N., Callister, T., Merrill, R. “Intensive Stuttering Modification Therapy: A Multidimensional Assessment of Treatment Outcomes,” Journal Speech Hearing Research, 48:509-523, June 2005.[/ref]
A 2007 literature review observed that stuttering modification therapy[ref]Bloodstein, O. & Bernstein Ratner, N. 2007. A Handbook on Stuttering: Sixth Edition, pages 386-387.[/ref]
tended to make relatively heavy demands on the time, skill, patience, and insight of both the stutterer and the clinician. In the hands of poorly trained therapist, it could degenerate into little more than an attempt to teach people who stutter to live with their speech difficulty. At best, it almost never resulted in normal fluency.
The experts admit
the efficacy of treatment that address acceptance has not yet been fully explored through empirical research, so further study is needed.
Stuttering modification therapy was developed between 1927 and 1958. If, over 75 years, no one proved the treatment to be effective, and one high-quality study found the treatment to be ineffective, IMHO no further study is needed.
Children’s Speech-Related Fears and Anxieties
Much of the experts’ letter is about treating children’s speech-related fears and anxieties, e.g., not answering questions in class, fear of making a 5-minute speech, teasing and bullying, avoiding using the telephone, and avoiding making new friends.
Is it the job of speech-language pathologists to treat children’s speech-related fears and anxieties? Or should speech-language pathologists train children to speak fluently? In my opinion, speech-language pathologists should train children to speak fluently. If a child learns to speak fluently and continues to have speech-related fears and anxieties, the speech-language pathologist should refer the child to a psychologist, as the child might have other issues besides stuttering.
Several recent studies[ref]Ross G. Menzies, Sue O’Brian, Mark Onslow, Ann Packman, Tamsen St Clare, and Susan Block. (2008) An Experimental Clinical Trial of a Cognitive-Behavior Therapy Package for Chronic Stuttering. J Speech Lang Hear Res 2008 51: 1451-1464. doi:10.1044/1092-4388(2008/07-0070). Lisa Iverach, Mark Jones, Sue O’Brian, Susan Block, Michelle Lincoln, Elisabeth Harrison, Sally Hewat, Angela Cream, Ross G. Menzies, Ann Packman, Mark Onslow. (2009) The relationship between mental health disorders and treatment outcomes among adults who stutter. Journal of Fluency Disorders, 34, 1, March 2009, 29–43. http://dx.doi.org/10.1016/j.jfludis.2009.02.002 Lisa Iverach, Mark Jones, Sue O’Brian, Susan Block, Michelle Lincoln, Elisabeth Harrison, Sally Hewat, Ross G. Menzies, Ann Packman, Mark Onslow. (2009) Screening for personality disorders among adults seeking speech treatment for stuttering. Journal of Fluency Disorders, Volume 34, Issue 3, September 2009, Pages 173–186. http://dx.doi.org/10.1016/j.jfludis.2009.09.001[/ref] have suggested that about half of adult stutterers have social phobia, and many have personality disorders. But that doesn’t mean that children who stutter also have social phobia. Social phobia is an adult disorder among non-stutterers, with a prevalence ten times higher in adults than in children. No studies have investigated whether children who stutter have social phobia. Why should speech-language pathologists, who aren’t qualified to treat psychological disorders, treat children for a psychological disorder they likely don’t have?
What Stuttering Experts Don’t Recommend
Nowhere in the experts’ “comprehensive” letter do they mention the evidence-based stuttering treatments that have been proven effective for school-age children: DAF, prolonged speech, fluency shaping, GILCU, and EMG.
In my opinion, parents should do the opposite of what stuttering experts say. Parents should avoid ineffective treatments and instead seek effective, evidence-based treatments for their children.
What do you think? Should speech-language pathologists train children to talk fluently or to accept their stuttering?
You are proposing that there has to be a choice between treating children’s speech-related fears and anxieties versus teaching them speech techniques. It is clear that we have to treat both. We now know that 25% of children who stutter suffer from social anxiety. By the time they are adults, this number increases to 60%. Studies have shown that social anxiety in children who stutter is not linked to their temperament, it is not a character trait, it is directly linked and caused by negative social experiences connected to their stutter. The logical conclusion is that treating their stuttering behavious is not enough and that treating their social anxiety alongside teaching them speech techniques will improve their struggle behavious and avoidance and thus improve their stutter. CBT is the most effective treatment approach for anxiety and does not have to lead to cognitive overload. I very effectively treat children with a combination of the Lidcombe Program and CBT techniques. This treatment combination reduces both their stutter and their anxiety. My little patients regain their confidence and ability to speak smoothly in any type of social situation while at the same time not worrying if they do have a little bump.
Finally, I am not one of the 113 experts but I can explain the difference between “acceptance” and stuttering modification therapy. In a nutshell, acceptance is one part of stuttering modification therapy but it is not the entire treatment approach, in the same way as the legs are not the entire body. The Van Riper appoach incorporates BOTH physical (freeze, hold, pull out) and psychological (desensitization, reduction of avoidance, acceptance) elements. He was the first to show that acceptance and learning speech techniques are not mutually exclusive and that a combination of both benefit the patient and bring better and longer lasting results.