About the presenter: Rosemarie Hayhow, PhD, is a UK Speech & Language Therapist (SLT) who has worked with field of stuttering for over 30 years in clinical, educational and research settings. She currently works at the SLT Research Unit in Bristol in the South West of England. One of her research interests is people's experiences of therapy and how these can help us understand more about the therapy process and what makes it work as well as we hope for or, more frustratingly, fail to work as well as we'd like.

You can post Questions/comments about the following paper to the author before October 22, 2010.


Parents and children who stutter: The pleasures and pains of working together

by Rosemarie Hayhow
from England

There is a long history of parent involvement in treatments for early childhood stuttering. Some approaches advocate helping children indirectly, changing things in the children's environment and subtly altering the way that parents communicate with their children in the expectation that this will reduce the stuttering (Millard et al. 2008; Yaruss et al. 2006). With younger children it may be more appropriate to work indirectly as parents are often the children's primary communicative partners. Additionally, the younger the child the greater their chances of natural recovery from stuttering so we would not wish to intervene too much in case we interfere with the natural developmental process. However, once children have been stuttering for over a year to 18 months their chances of natural recovery reduce, and as they get older - from about four years old - they will increasingly be talking to people outside their home. We are not able to control the way that other adults talk to our children nor are we able to control the way children talk with each other. So as children get a little older, if they are still stuttering, then increasingly parents will want to do something more direct in order to help their child's speech. Clinicians may also want parents to be more actively involved if indirect methods have not helped sufficiently. If we think about stuttering as a motor pattern then we know that the longer a child continues to stutter the more they are practicing that stuttering pattern. As Professor Anne Smith said during a keynote presentation at the International Fluency Association conference in Dublin (2006) 'if you fire it you wire it'. If at all possible we want to stop the stuttering pattern becoming hardwired as this makes it much more difficult to change - as many adults who have tried to change their stuttering will tell you.

Thinking about stuttering in more general terms raises the question of whether or not it matters, in any other ways, if children continue to stutter during their childhood. The clinical and research evidence we have suggests that stuttering can affect quality of life (e.g. Menzies et al. 2008). Many adults who stutter remember problems in school, in their social lives, and in their employment (Hayhow et al. 2002). There is a negative stuttering stereotype which can add to the difficulties facing adults who stutter. While it is important to support any endeavour that helps reduce the negative impact of stuttering we know we will never change everybody's attitudes and behaviours towards those with communication impairment. I believe we need to help young children develop their own strategies for managing their stuttering in as relaxed a way as possible. Children who are open in their attitude towards their bumpy words, and who have experienced many instances of smoothing these words, are well-equipped to deal with the hurly-burly of everyday communication. Some children seem to learn how to do this all on their own- these are the ones who recovery naturally- but many become increasingly embarrassed by their speaking and so increase effort and tension when they stutter. It is possible that the experience of embarrassment or shame when stuttering accelerates the establishment of the motor patterns. As children get a little older they begin to anticipate difficulties with speaking and this can lead to anxiety, which in turn makes it much harder for them to smooth their speaking. There is plenty of evidence that stuttering becomes more than just a speech problem when it persists and this provides a good enough reason for wanting to eliminate or reduce it when children are young and their brains still highly receptive to new learning.

If we accept that there are good reasons for helping young children who are at risk for persistent stuttering we must then consider how best to help them. Parents are ideally placed to help their children as they spend more time talking with them than any other adults and also because loving their children, they care very much about their health and happiness. When however parents do not know how to help with their child's stuttering then their feelings of helplessness and anxiety (Langevin et al. 2010) can add to the burden that the child carries when they stutter. Parents also know that there is a fine line between helping and nagging. Adults who stutter talk about their parents attempts to help them, how they found this embarrassing or how they resented their parents' interference. They may feel that their parents were well intentioned but misguided. It is worth remembering however that the adults who are still stuttering and report these reactions were, as children, the ones who did not benefit from their parents' help or who had parents who did not know how to help them. We don't know how many adults there are who used to stutter and who attribute their increased fluency to the help their parents gave them.

Some parents worry that asking a child to smooth their bumpy words is giving them the message that stuttering is wrong or bad. Similarly they are concerned that praising their child's smooth talking is telling them that smooth talking is good thereby implying that stuttering is bad. I am not convinced that children see it this way. Children know that most people don't stutter and they also know that when they themselves stutter they often feel uncomfortable because they cannot achieve what they are trying to do. In the majority of cases it is patronising to assume that when children stutter they don't realise that something is going wrong with their talking (Langevin et al. 2010). In clinical interviews parents report a variety of negative responses to stuttering in their children and these have also been documented in the literature (Boey et al. 2009; Bloodstein & Ratner 2008). To some extent this is an inevitable consequence of the process by which we learn to speak, that is, by listening and constantly comparing our own speech with that of those speaking around us. By 3 to 4 years of age children know that other people don't get stuck in the way that they do when they are stuttering.

Are there ways that parents can directly help their young children who stutter? For over a decade I have been using the Lidcombe Program (LP) for Early Stuttering Intervention (Jones et al. 2005; Onslow et al. 2003; ASRC website). This is a direct treatment that teaches parents how to respond to their children's stutter-free and stuttered speech in order to reduce their stuttering. Initially the parents' respond to their children's talking in short home treatment sessions where talking is structured so that children only stutter a little. This has the effect of reducing stuttering in the child's everyday speech so that parents can then begin to respond to their talking in natural conversations.

Parents must always identify smooth talking more frequently than stuttering and when they invite their child to self-correct they can do it in a way that best suits their particular child. If a child doesn't want to self-correct their stuttering then the parent will accept this but most children are happy to do so and many even seem relieved that they can have a little space in a conversation to sort out their stuttering. From clinical observation it seems that the more children self-correct the easier and more natural it becomes for them. As treatment progresses we often notice that the children with more severe stuttering take a little more care on those words where they feel they might stutter and are therefore learning how to manage the glitches in their talking. Gradually they correct themselves more and more easily and they experience increased natural fluency. These children may talk about smoothing or fixing their bumpy words and take great pleasure in gradually learning how to control those moments when they feel stuck with their speaking. Even children with severe stuttering can achieve stutter-free or almost stutter-free talking with this treatment.

Some children with milder stuttering or who seem to have a weaker predisposition to stuttering can respond very quickly to the LP and appear largely unaware that their speaking has been 'worked on' by their parents. Some parents may at first be very anxious about asking their child to say a word again or asking them if they would like to smooth a bumpy word but then find that their child's willingness to work on their talking gives them confidence to help them in this direct way.

When treatment goes well children's stuttering reduces consistently over a few weeks and after 3-4 months many children are no longer stuttering. If they do stutter again their parents have learned how to help them and so they quickly regain their fluency. When the treatment works in this way both parents and children seem to enjoy the process and it can make them feel closer, and more relaxed and open about speaking.

Sadly the treatment is not always straightforward, there are times when children dislike their parents commenting on their speech, and there are some parents who find it difficult to give their children feedback in a way that is encouraging (Hayhow, 2009). In some cases the child may respond very well to the treatment initially but then reach a plateau where, although they are much more fluent, stuttering is still present in their spontaneous talking. It can then be hard for parents to continue with the therapy and children may get bored or begin to resent their parents' commenting on their speaking. When progress is slower parents may also begin to feel guilty about not doing enough home treatment (Goodhue et al. 2010) or not doing it in the right way.

Clinicians who are experienced in using the LP can often help parents find ways of working with their children so that they remain motivated and continue to find the feedback helpful. Clinicians with less experience may struggle with these more difficult cases. Their lack of confidence may interfere with the problem solving abilities of both parent and themselves and the child's talking may suffer as a result. We know that commenting on children's talking is potentially stressful and could be harmful and so the successful implementation of the treatment strategies is very important.

So what ideas do parents, children and adults who stutter, and clinicians have about how best to harness parental love and commitment when helping young children overcome or learn to manage their stuttering? What strategies or processes have people found helpful? What prevents well intentioned 'help' being experienced as helpful by the recipient? Are parents in a no win situation? If they do nothing they can later be accused of not caring enough, yet if they do try, but it doesn't work out as they had hoped, they may be accused of lacking sensitivity. How can parents balance the desire for their children to do well and grow up without major problems with an acceptance of who their children are - 'warts and all'? I hope that young people and adults who have benefited from parental help and those who have found such attempted help a hindrance will share their experiences. I hope too that parents will share their perspectives on helping children who stutter. Hopefully there will be things for us all to learn.

Acknowledgements: I wish to thank the many parents and children who have taught me so much about early stuttering and its resolution and my colleague and friend Mary Kingston for her constructive comments on an earlier draft of this paper.

References:

Australian Stuttering Research Centre http://sydney.edu.au/health_sciences/asrc/

Bloodstein, O., & Bernstein Ratner, N. (2008). A handbook on stuttering (6th ed.). Clifton Park, NY: Delmar.

Boey, R. A., Van de Heyning, P. H., Wuyts, F. L., Heylen, L., Stoop, R., & De Bodt, M. S. (2009). Awareness and reactions of young stuttering children aged 27 years old towards their speech disfluency. Journal of Communication Disorders, 42, 334346.

Goodhue, R., Onslow, M., Quine, S., O'Brian, S. & Hearne, A. (2010). The Lidcombe Program of early stuttering intervention: mothers' experiences. Journal of Fluency Disorders, 35, 70-84.

Hayhow, R. (2009). Parents' experiences of the Lidcombe Program of early stuttering intervention. International Journal of Speech-Language Pathology, 11. 20-25.

Hayhow, R., Cray A.M. & Enderby, P. (2002). Stammering and therapy: views of people who stammer. Journal of Fluency Disorders, 27, 1-17.

Jones, M., Onslow, M., Packman, A., Williams, S., Ormand, T., Schwarz, I. and Gebski, V. (2005). Randomised controlled trial of the Lidcombe Program of early stuttering intervention. British Medical Journal, 331, 659-661.

Langevin M., Packman, A. & Onslow, M. (2010). Parent perceptions of the impact of stuttering on their preschoolers and themselves. Journal of Communication Disorders 43, 407423.

Menzies, R.G., O'Brian, S., Onslow, M., Packman, A., St Clare, T. & Block, S. (2008). An Experimental Clinical Trial of a Cognitive-Behavior Therapy Package for Chronic Stuttering. Journal of Speech, Language, and Hearing Research, 51, 14511464.

Millard, S., Nicholas, A. & Cook, F. (2008). 'Is Parent-Child Interaction Therapy Effective in Reducing Stuttering?' Journal of Speech, Language and Hearing Research, 51, 636-650.

Onslow, M., Packman, A. and Harrison, E., (eds.) (2003). The Lidcombe Program of Early Stuttering Intervention: A Clinician's Guide. (Austin, Texas: pro-ed).

Yaruss, J. S., Coleman, C., & Hammer, D. (2006). Treating preschool children who stutter: Description and preliminary evaluation of a family-focused treatment approach. Language, Speech and Hearing Services in Schools, 37, 118-136.


You can post Questions/comments about the above paper to the author before October 22, 2010.


SUBMITTED: September 2, 2010
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