Stuttering as a Burden?

"School-age stuttering is a difficult problem to treat."

This is a sentiment that we hear expressed over and over again, in one form or another, by speech-language pathologists in the schools and in private practice, university faculty in communication disorders programs, classroom teachers, and school administrators.

Certainly, there is some truth to the statement -- stuttering can be difficult to treat. Still, the message that is most often conveyed by this statement is the inherent belief that stuttering is too difficult to treat -- that many people simply don't think that it can be treated successfully. As a result, there is a sense of hopelessness imbued this statement -- the implicit assumption that a child is somehow 'doomed' if he cannot completely eliminate his stuttering. According to this line of thinking, because there is no universal cure for stuttering, the child is obviously doomed!

Such an attitude is pervasive throughout the field of speech-language pathology. Ample research has demonstrated that many speech-language pathologists do not prefer to work with individuals who stutter (Brisk, Healey, & Hux, 1997; St. Louis & Durrenberger, 1993). Many feel that their training was inadequate and that they are not well-prepared to meet the challenges of working with children who stutter (Kelly et al., 1997; Mallard, Gardner, & Downey, 1988). We often hear stories of speech-language pathologists who try to refer all of their children who stutter to the one clinician in their setting who is willing to work with stuttering. Or, we hear of clinicians who, one way or the other, find reasons that a child who stutters is not eligible for treatment. Put simply, too many clinicians find the treatment of stuttering to be a burden -- something to be avoided if possible; something to be ignored if all else fails.

The consequence of this situation, of course, is the unfortunate fact that many school-age children who stutter are underserved. Although some are certainly getting good treatment, too many are not getting the treatment they need -- or, if they are getting treatment, it is not the treatment that they could most benefit from. For example, too often, clinicians have been trained to focus their treatment solely on speech fluency rather than considering the communication, personal, and other needs of the child as a whole. Too often, our field blithely places blame on the child or the family rather than recognizing the inherent difficulty of modifying one's speech, especially for children. Too often, adults (including clinicians, parents, and teachers) assume that a child "could do better if he only tried hard enough." Too often, our field has misunderstood stuttering, and the result has been inadequate or inappropriate treatment. Thus, the burden that some speech-language pathologists feel surrounding the treatment of stuttering has translated to an increased burden on the shoulders of the children we seek to serve

As clinicians who specialize in the treatment of stuttering, and as presenters who have given workshops on stuttering to many thousands of speech-language pathologists, we cannot accept the notion that stuttering is "too hard to treat." We have known too many clinicians who have learned to work skillfully and empathetically with children who stutter and their families -- even when they weren't sure of themselves or their clinical skills when they first started out. We have seen them grow in their understanding of stuttering and in their interest in learning even more about stuttering so they can better help the children and families they serve. And, more importantly, we have seen countless children (and adults) who stutter overcome the burden of their stuttering disorder, learning to speak more easily and communicate more effectively, and ensuring that stuttering does not limit their ability to do what they want to do in their lives. Because of the successes we have seen -- not just in our own clinical practice, but in the practice of the many clinicians with whom we have collaborated -- we feel firmly that treatment for stuttering should not be seen as a burden for speech-language pathologists. Instead, the challenges inherent in treating stuttering should be viewed realistically yet optimistically. And, ultimately, the opportunity for clinicians to improve their clinical skills -- and for children who stutter to improve their lives -- should be emphasized and celebrated.

Stuttering as a Challenge.

As noted in the opening paragraphs of this essay, stuttering can indeed be a difficult problem to treat. The disorder can be associated with a wide range of negative consequences for children who stutter, beyond the rather obvious fact that their speech fluency is sometimes disrupted. Fortunately, these negative consequences have been well-documented in our research and clinical literature (Bloodstein & Bernstein Ratner, 2008; Yaruss & Quesal, 2004), and this knowledge can help clinicians better understand the disorder. For example, children who stutter have been shown to experience: negative emotional reactions, such as embarrassment, shame, and anxiety; physical tension and struggle in their speech muscles and elsewhere, during both fluent and stuttered speech; negative thoughts about themselves and their ability to communicate; difficulty communicating in key situations, such as at school or when talking to friends; negative reactions on the part of others, including bullying and inappropriate teasing; and an overall adverse impact on their quality of life.

All of these negative consequences can make communication (and life in general) difficult for children who stutter and their families. And, these negative consequences can complicate treatment, for clinicians cannot (or, at least, should not) expect to address all of these varied issues by simply focusing on speech fluency strategies. That is just too simplistic a view for a disorder as complex as stuttering. Thus, clinicians must also be prepared to address the negative consequences of stuttering, through treatment methods such as: educating the child about stuttering; helping to reduce his negative reactions to speech disruptions and listener reactions; minimizing physical tension and struggle behaviors through desensitization and acceptance activities; teaching other people in the child's environment about stuttering so they can become part of the solution rather than part of the problem -- this includes peers, family members, teachers, and other people, such as school bus drivers and cafeteria staff; helping the child learn to say what he wants to say, regardless of whether or not stuttering might occur; and more. Of course, this is all in addition to commonly used strategies for enhancing speech fluency and reducing physical tension. Thus, it is true that treating stuttering in school-age children can be a challenge, for it encompasses many different facets and requires a wide range of skills on the part of both the clinician and the child.

Still, treating stuttering is not a challenge that should be viewed as insurmountable. Instead, clinicians (and children who stutter) can view stuttering as a condition to be addressed in an honest and straightforward fashion that acknowledges the real difficulties that children face, yet still offers hope that such difficulties can be overcome. As noted above, we have seen countless examples of clinicians who have learned to provide meaningful treatment and just as many examples of children who have learned to minimize the burden of their stuttering.

Hope is an important commodity in treatment. Children need to hear -- from their clinicians, their parents, and, ultimately, from themselves -- that there is hope for their future. It is critical for readers to understand what we mean by offering hope. Offering hope that the burden of stuttering can be overcome does not mean that clinicians should promise children that they will become fluent someday or that the adequate use of techniques will ultimately make their stuttering go away completely. This is false hope, and the costs will be paid by children when they are unable to consistently maintain the fluent speech pattern that they understandably desire.

The fact that children need hope also means that clinicians should not present an unnecessarily stark or bleak picture of the child's future. Simply explaining to children that "there is no cure" for stuttering does not help them see a path toward a better life. Also problematic are seemingly well-intentioned statements that children "will always stutter" -- or, worse, that they will always stutter unless they practice in therapy. Certainly, the appeal of these types of admonitions is understandable, at least for some clinicians. If a speech-language pathologist does not feel confident in her skills for helping children who stutter, or if she sees that children do tend to become more fluent when they use speaking strategies, then it might seem entirely reasonable to encourage children toward fluency through such words of warning. Such warnings do not reflect the reality of the stuttering disorder, however. They simply reflect the clinician's lack of confidence and misunderstandings about the real possibilities to be found in effective stuttering treatment. To us, then, instilling hope means helping children gain an absolute knowledge and conviction that stuttering does not have to stand in their way. Sure, they may continue to stutter in some fashion, but that stuttering does not have to prevent them from doing anything they want to do in their lives. They will, over time, learn to use strategies that can improve their fluency, but such strategies are far from perfect and there is far more to good communication than just fluent speech. Thus, even if stuttering may continue to be a factor in their speech, but it does not always have to be a negative factor in their communication or in their lives as whole. Thus, offering children hope involves helping them see the "big picture" -- helping them come to terms with and move toward acceptance stuttering, even as we are working on helping them change their speech.

In our experience, the key to these successes lies in the selection of appropriate treatment goals (Murphy, Yaruss, & Quesal, 2007a; Murphy, Yaruss, & Quesal, 2007b; Reeves & Yaruss, in prep; Yaruss, Coleman, & Quesal, in press). Such goals should address not only improvements in the surface characteristics of stuttering, but also the broader consequences of stuttering -- the negative reactions, the communication difficulties, and the adverse impact. When children see that there is hope for their future, then they can begin to look at their speaking difficulties as a challenge to be overcome, not as a burden that will ruin their lives. And, as clinicians observe these positive changes in their young clients, then they, too, can see the benefits of viewing stuttering as a challenge -- one that they can learn to treat effectively, as their clinical skills develop and their confidence grows.

Stuttering as an Opportunity!

It can be seen from this essay that we do not view children who stutter as "doomed." Instead, we believe that, with appropriate treatment, children who stutter have the opportunity to develop a critical set of life skills that will help them overcome the potential challenges of stuttering and live their lives to the fullest. Our opinions about stuttering should not be misinterpreted as diminishing or denying the difficult experiences that children who stutter will probably face. Instead, it is our desire to present stuttering as a complicated, multi-faceted condition that can be managed successfully through the careful application of broad-based, individual treatment approaches that draw upon a variety of clinical skills and strategies. In this way, clinicians can help children minimize the burden of their disorder, overcome the challenges they face in communication, and realize the opportunities that await them.

And, just as the process of learning to cope effectively with stuttering can present valuable opportunities for children, we also believe that developing the skills needed to be effective stuttering clinicians can present valuable opportunities for speech-language pathologists. Clinicians who learn to help children who stutter will acquire new abilities for listening to and establishing rapport with their young clients, helping their clients come to terms with and accept the difficulties they face in their lives, maintaining their focus on the "big picture" (i.e., the child as a whole, not just speech), and accomplishing the ultimate treatment outcome established by our scope of practice, improving quality of life (ASHA, 2007). None of this can be achieved by focusing too narrowly on speech fluency; it is only by recognizing the broad nature of the stuttering disorder that clinicians can achieve these benefits.

Thus, we would like to end this essay by encouraging clinicians to view stuttering as more than just stuttering -- that is, to recognize that the experience of stuttering involves more than just disfluent speech behavior. Once a clinician takes this view, treatment can begin to address more than just disfluent speech behavior. This immediately opens up a world of new opportunities for intervention. Rather than feeling restricted to a set of speech modifications that focus just on fluency, clinicians and their clients can work together to actively pursue individualized goals that ensure that the child will be able to communicate effectively, regardless of whether, or how much, he stutters. These are the opportunities that we see in treating school-age children who stutter, and we look forward to the opportunity to discussing these opportunities with our colleagues through the ISAD forum.

References

ASHA (2007) "Scope of practice in speech-language pathology." Available from www.asha.org/policy.

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

Brisk, D., Healey, E. C., & Hux, K. (1997). Clinicians' training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in the Schools, 28, 164-176.

Kelly, E. M., Martin, J. S., Baker, K. I., Rivera, N. J., Bishop, J. E., Kriziske, C. B., Stettler, D. S., & Stealy, J. M. (1997). Academic and clinical preparation and practices of school speech-language pathologists with people who stutter. Language, Speech and Hearing Services in Schools, 28, 195-212.

Mallard, A. R., Gardner, L., & Downey, C. (1988). Clinical training in stuttering for school clinicians. Journal of Fluency Disorders, 13, 253-259.

Murphy, W. P., Yaruss, J. S., & Quesal, R. W. (2007a). Enhancing treatment for school-age children who stutter I. Reducing negative reactions through desensitization and cognitive restructuring. Journal of Fluency Disorders, 32(2), 121-138.

Murphy, W. P., Yaruss, J. S., & Quesal, R. W. (2007b). Enhancing treatment for school-age children who stutter II. Reducing bullying through role-playing and self-disclosure. Journal of Fluency Disorders, 32(2), 139-162.

Reeves, N. A., & Yaruss, J. S. (in prep). School-Age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering Therapy Resources, Inc.

St. Louis, K. O., & Durrenberger, C. H. (1993). What communication disorders do experienced clinicians prefer to manage? ASHA, 35, 23-31.

Yaruss, J. S., Coleman, C., & Quesal, R. W. (in press). Stuttering in School-Age Children: A Comprehensive Approach to Treatment. Language, Speech, and Hearing Services in Schools.

Yaruss, J. S., & Quesal, R. W. (2004). Stuttering and the International Classification of Functioning, Disability, and Health: An update. Journal of Communication Disorders, 37(1), 35-52.

You can post Questions/comments about the above paper to the authors before October 22, 2012.