Early Intervention With Childhood Stuttering Revisited -- by Richard 
F. Curlee (USA)

Thank you for your interest and participation in the Second 
International Stuttering Awareness Online Conference. The 
conference officially ended October 22, 1999.The papers and what is 
on the threaded discussions will remain at this address and you are 
welcome to read and/or copy them. The papers will be permanently 
archived on the Stuttering Home Page. However, the presenters have 
concluded their responsibilities for checking and answering any 
questions posted, so will not be responding here anymore. 

early intervention with childhood stuttering
From: Susan Short Castleberry
Date: 10/1/99
Time: 8:41:00 PM
Remote Name:
Comments:  Dr. Curlee, you state that most clinicians feel that every 
child should "receive treatment as soon as possible after stuttering 
begins". As a speech pathologist and parent of a teenager who 
stutterers, I have to question how you define beginning stuttering. I 
work in early intervention. It is not uncommon for me to be a first 
contact for parents who have concerns about stuttering in a 
preschool age child. When I interview the parent and the child and I 
notice no at-risk behavior, and if I can reassure the parent and give 
information so that they better understand normal, developmental 
non-fluency; then I feel satisfied that the child may not require 
immediate intervention. I always make sure the parent knows how 
to contact me should concerns arise. However, what if the 
presentation is not so benign? What if the parent shows concern that 
is not easily reassured or seeks counselling or intervention, or if I 
observe at-risk, struggle, behavior in the child? Is it ok for me to 
ignore these behaviors and assume the risk that chronic stuttering 
will develop? What would you do, Dr. Curlee, with a child I saw for 
the first time this week- a three year old who presents with rising 
pitch during multiple repetitions, loss of eye contact, occasional 
gasping for air. Is he at risk of developing a chronic stutter? Is he 
stuttering now? I suspect he is beginning to stutter, and I am 
wrestling with the issue of how to deal with parents who seem to 
resist involvement in his treatment. Perhaps there is not empirical 
support for treatment efficacy, but can I as a clinician ignore 
behaviors that signal risk? Sure, let's do what we can to determine 
effectiveness of interventions and to better understand normal, 
developmental patterns. But let's not put children and families at 
risk by adopting a "wait and see" approach.  

Re: early intervention with childhood stuttering
From: Dick Curlee
Date: 10/21/99
Time: 6:30:40 PM
Remote Name:
Comments:  I prefer a watch and see approach and have found, at 
least in my experience, that the severity of stuttering early after 
onset doesn't mean a child isn't going to stop without treatment. The 
recent JSLHR, for example, reported that the children in the Illinois 
longitudinal project who stopped without receiving therapy stuttered 
more severely when first seen than did those who did not stop. In 
addition, I am not familiar with any evidence that shows waiting to 
start therapy for 12-24 months post-onset adversely affects therapy. 
Perhaps you can provide me some references.

bottom line
From: Susan Short etc.
Date: 10/22/99
Time: 7:22:42 AM
Remote Name:
Comments: Others in this forum have responded convincingly to 
advocate for appropriate intervention and support for children and 
their families. For me the argument to "wait and see" is moot. I 
would hope that clinicians who are inexperienced or uneasy with 
stuttering in young children will refer families on to others who are 
comfortable weighing risk factors and offering supportive services. 

Early Intervention
From: Mike Hughes, Ex. Dir., Speak Easy Inc.
Date: 10/3/99
Time: 12:34:09 PM
Remote Name:
Dr. Curlee: 
Aha! The emperor wears no clothes! 
Based on the prevalent feeling, Speak Easy has "strongly" 
recommended immediate assessment by qualified SLP's whenever a 
parent feels that his child has begun to stutter. We frequently state 
that "early intervention has been proven to prevent or lessen the 
probability of childhood stuttering becoming an adult disability." 
While we will still present this statement, we've been somewhat 
concerned about the lack of empirical evidance for such a statement. 
In our monthly magazine, "Speaking Out," we attempt to present ALL 
reasonable approaches to stuttering. Would you be willing to write a 
short paper (500 - 2,000 words) to describe your thoughts on "early 
intervention"? We'd love to publish a thoughtful article that appears 
to resist the flow of current thought. You can contact us at 

Re: Early Intervention
From: Dick Curlee
Date: 10/21/99
Time: 6:42:54 PM
Remote Name:
I'm flattered by your invitation. If you're still interested after the 
first of the year, check with me at curleer@u.arizona.edu

Early Intervention for Stuttering
From: Gail Lind, Educ.SLP
Date: 10/4/99
Time: 9:19:07 AM
Remote Name:
In discussing early intervention for preschoolers and early elemtary 
children, what is a rough estimate for how long the 
dysfluency/stuttering should be apparent before a formal 
therapeutic approach is considered?

Re: Early Intervention for Stuttering
From: Dick Curlee
Date: 10/21/99
Time: 6:40:03 PM
Remote Name:
Ms. Lind -- I apologize for not responding sooner. I just realized I 
hadn't addressed your question. As long as the parents feel 
comfortable delaying therapy, the child seldom if ever seems 
concerned or upset, and there are no other co-occurring speech-
language problems, I feel comfortable monitoring the child's 
disfluencies for at least 12 months post-onset. During that period I 
believe I should see a substantial improvement in the child's fluency 
to continue monitoring. If I don't, I think nature may need some help 
and I should discuss therapy alternatives with the parents.  

From: Samantha DeLuca
Date: 10/5/99
Time: 4:24:01 PM
Remote Name:
I have a question really, not a comment. I worked with a 3 1/2 year 
old boy over the summer addressing his deletion of initial 
consonants. After the 2 week vacation period, therapy resumed. He is 
now having difficulty speaking in fluently. He has a numerous 
amount of sound and word repetitions. I interviewed the parent and 
she stated, it just started out of the blue. Nothing at home seems to 
have precipitated it. I wanted to monitior his dysfluencies for a short 
period of time and then maybe address it in the future. Does this 
seem like the ethical/right thing to do? Just curious on your opinion. 
I might refer to another therapist that has more experience in 
fluency problems. Thank you for your time. Samantha DeLuca CCC-

Re: Treatment
From: Dick Curlee
Date: 10/7/99
Time: 3:54:31 PM
Remote Name:
Most children being seen in therapy for phonological or other 
language difficulties don't begin to stutter but it is not a rare 
occurrence, either. As you may know, there is an unusually high co-
occurrence (e.g, 30-40%) of stuttering and other speech, language, or 
learning difficulties among school-age children. So, it's likely that 
some of these school-age children were showing signs of more than 
just one problem when they were preschoolers. Because I haven't 
seen a 30-40% co-morbidity of stuttering and these other problems 
in the preschoolers I've evaluated or seen in therapy, I have 
wondered if the co-occurrence of stuttering and other speech-
language difficulties may indicate that a child is less likely to stop 
stuttering without treatment that a similar child who only stutters. 
Consequently, I usually see children who have co-occurring speech-
language problems in therapy w/o delay and work on their fluency 
and other problem in therapy at the same time. My strategy is have 
the "other problem" determine what speech-language 
skills/behaviors we work on and the child's stuttering to determine 
the types of activities we use. For example, while looking at a book or 
pictures or playing some "game," we may work on the use of "is 
verbing" or "locative state" in which the child repeats the correct 
form after it is modeled by the clinician, using exagerated pitch 
changes to highlight the language target(s)and somewhat slower 
speech. What is said is relevant to what we're looking at or doing and 
includes the speech-language target. How the target is produced by 
the child is intended to eliminate or reduce stuttering to nearly zero. 
Most of the children I've seen can repeat these sorts of models w/o 
stuttering. Subsequent tasks, which gradually become more difficult, 
might be to display two pictures and, using the same type of speech, 
say "In this picture, the boy is swimming, but in this picture the 
girl_______," with the child completing the utterance while imitating 
how the clinician is talking. Other tasks may involve having the child 
say speech-language targets while whispering (quiet time), in unison 
with the clinician, etc., all of which are activities likely to be free of 
stuttering. I usually avoid working on phonemes in word- and 
utterance-initial positions, especially stops, because that's where 
most stutters occur. So, I usually use fluency-enhancing speech tasks 
in which the target phoneme occurs in medial or final positions of 
words or nonse syllabic chains. As the target form is produced 
correctly in highly structured activities, I gradually reduce the 
structure and move to increasingly more naturalistic speaking 
activities as the child's fluency and other speech-language skills 
permit. If you feel uncomfortable with the child you describe, I think 
you should consider helping the parents find someone who has 
worked with young preschool-age children a lot. I think is very 
important for children to have fun and enjoy what they do in 
therapy, because play is a young child's "learning activity" or "work". 
I believe also that children learn what they do, so if we can help a 
child do a lot of talking w/o stuttering while "playing and having 
fun," we're likely to have a successful outcome. And the best way I 
know to make sure that a child is having fun is by playing and 
having fun with the child in therapy. Hope you find some of this of 

Early Intervention with childhood stuttering
From: Katie D'Amore
Date: 10/6/99
Time: 9:36:54 AM
Remote Name:
I find it interesting that "the necessity of early childhood 
intervention" remains to lack accurate research and data. I 
personally believe it is better to treat than to not treat. However, this 
could overburden Speech Pathologists in the school system. How do 
you think future research finding on this matter might affect 
qualifications for therapy, especially in the public school system? 
Could the answer we find hurt us rather than help?

Re: Early Intervention with childhood stuttering
From: Dick Curlee
Date: 10/7/99
Time: 5:55:44 PM
Remote Name:
I'm not sure if you are concerned that waiting 6-12 months to 
initiate therapy for 2-4 year-olds will increase the number of 
children who stutter in the schools or not. Such delays should not 
prevent such children from receiving therapy long before they begin 
school, so I doubt that the prevalence of stuttering in schools would 
change if careful, responsible monitoring of the child's speech is done 
during the delat to ensure he or she is improving and stuttering isn't 
getting worse. It is a shame that we do not have reliable data on the 
prevalence of stuttering in each grade, K-3, for the last 40 years or 
so, then we might be able to see if early intervention may have had 
an effect on the prevalence of stuttering in 5-9 year olds. I think the 
liklihood of untreated remissions drops over time, but I don't think 
this should be studied empirically. If I've missed the point of your 
question, ask it another way and I'll try to do a better job. 

types of verification
From: Woody Starkweather
Date: 10/7/99
Time: 3:30:24 PM
Remote Name:
Hi Dick: 

I don't think anyone can argue against your basic idea -- that we 
lack controlled studies of early intervention efficacy. But I would 
argue that we are never going to get them because (a) parents will 
be unwilling to have their children forego treatment, even 
temporarily, and (b) there is no way to construct a convincing 
placebo condition.   But there are other kinds of verification. Skinner 
-- actually I think it was Sidman -- proposed another type. When a 
scientist sees a change that occurs immediately following the 
introduction of a condi- tion, he or she is legitimately impressed. And 
then, if the same change is seen repeatedly, to the point that the 
scientist feels the outcome can be predicted, the conclusion can be 
reached that the effect is real, even though control conditions, other 
than the preceding and following nontreat- ment periods, were not 
used.   We see such things in early intervention. Once parents have 
been trained in how to modify the environment, and have 
implemented those changes, the child's stuttering behavior typically 
either disappears altogether or is dramatically reduced within a day 
or two. It happens to concomitantly to be a coincidence, and it 
happens often, although unfortunately it does not happen all the 
time. There is enough of this kind of effect that, when combined with 
the effects that are a little slower or a little less dramatic in extent, it 
is quite appropriately scientific to conclude that the treatment is 
efficacious, particularly when the same effects are reported in 
different clinics by different clinicians.   I should comment too about 
your description of that emotional ASHA miniseminar, in which you 
and Dr. Yairi presented these views. I don't know why others were 
upset, but my reactions were not be- cause I felt that early 
intervention was sacrosanct. I was upset because Dr. Yairi made a 
number of mistatements of fact. I remember only one of them, 
however. It was that there was no credible evi- dence for the critical 
period of stuttering de- velopment. But Andrews and Harris' data 
show very clearly that there is such a critical period, and Dr. Yairi 
obviously considers their study credible because he cites it himself. 
It was that that raised my emotional level. 

Woody Starkweather

Re: types of verification
From: Dick Curlee
Date: 10/7/99
Time: 6:34:34 PM
Remote Name:
Woody, thanks for commenting. I agree that it is highly unlikely that 
we can get an adequately controlled study of early intervention, not 
because enough parents wouldn't agree to delay therapy for some 
period but because they would not be from the same population of 
parents who would not be willing to delay. I base this on the high 
percentage of parents I have seen who have chosen that option over 
the past 5-10 years. I always give them the SFA Questions & 
Answers booklet, which you may consider as treatment, but the only 
thing I've done with the child is supervise assessing his stuttering. 
Another problem with studying those who agreed to delay would be 
allowing them to withdraw the child from the study, which they 
should do, if their child's stuttering worsened or continued at a 
severe level, which would make the group even less representative. 
At the same time, the findings obtained from this admittedly tainted 
group would be better than not having that data at all. I am also 
bothered, perhaps unnecessarily so, by recommending therapy for 
children who may not need it. It doesn't bother me to provide it if 
that is what parents wish as long as I don't recommend it. For me, 
providing unnecessary treatment is just as unethical as refusing to 
provide needed or necessary treatment, even though the former is 
likely to be more harmful than the latter. Both are wrong to me, the 
latter is just more wrong. Thanks, again, for your thoughful comment. 

Ethical Question
From: Rebecca Hubbling and Kelly Birken
Date: 10/7/99
Time: 4:42:23 PM
Remote Name:
We are two students currently enrolled in a graduate seminar 
stuttering course. We found your paper to be very informative. 
However, one issue came to mind upon reading your paper. We were 
wondering how you would deal with a parent who demanded 
treatment be started on their child, even though you believed it 
would be in the child's best interest to wait? This is an ethical issue 
and we were wondering how it would be handled.

Re: Ethical Question
From: Dick Curlee
Date: 10/7/99
Time: 6:42:56 PM
Remote Name:
I always see children who are stuttering if their parents want them 
to be seen. I try not to discourage parents from early intervention, 
only inform them that there is another alternative available if they 
want to try it. I don't want to recommend therapy for anyone unless 
I believe they need it, and I believe that most of the children 
described in my article will stop stuttering w/o treatment. I just 
don't know which ones will and won't, so that's why I insist on 
monitoring if parents choose to delay. As I mentioned in my 
response to Woody Starkweather, I feel that recommending 
unnecessary treatment is wrong just as I believe refusing to treat 
someone who may need it is wrong. The latter is worse because it 
could result in harm to the patient, but both are wrong and unethical 
for me to do.   

Aspirin, anyone?
From: Nan Ratner
Date: 10/8/99
Time: 3:07:12 PM
Remote Name:
Dick, I agree that we don't have a good notion of how well stuttering 
therapy works in this young population, but do you think it does 
some good for some children? I ask this because if it does, I see no 
ethical dilemma in providing therapy when a problem may resolve 
itself at a later point. If therapy helps resolve it earlier, then it is 
beneficial. As I noted in another forum, headaches go away by 
themselves, too, but there is quite a legitimate market for aspirin.   
What are your thoughts on this? 
my very best regards, 
Re: Aspirin, anyone?
From: Dick Curlee
Date: 10/8/99
Time: 5:44:16 PM
Remote Name:
Nan, I believe (but do not know) that therapy appears to help most 
young children. I believe and know that most young children who 
stutter stop within a year of onset. I believe and know that I can 
only guess which ones will stop and which ones wont. My problem is 
how I feel about recommending that a child receive therapy when I 
believe and know that, statistically, the child's odds are higher for 
not needing therapy than for needing it. Although there is no 
personal, financial conflict of interest in my making such 
recommendations at present, there is a personal conflict of interest 
related to having children come weekly and being used for 
observation, demonstration, training, and/or research. There is also 
the issue of recommending therapy that may not be needed and that 
may put unnecessary financial burdens on families and the effects 
such burdens may have on the family. It appears that I'm the lone 
ranger on this issue, but I feel that it is unethical for me (not you or 
the others who choose to refer) a child for treatment when the 
liklihood of the child not needing it is higher than his/her needing it. 
The aspirin for headaches analogy misses the mark, I think. How 
about weekly high colonics for locked bowels?  

Re: Aspirin, anyone?
From: Woody
Date: 10/17/99
Time: 11:28:32 AM
Remote Name:
But Dick, yes of course it would be better not to recommend therapy 
that is not needed, and in that sense, such a recommendation might 
be unethical. But in reality, as you said, you don't really know 
whether it is needed or not, because you can't know who will and 
who will not recover spontaneously. Therefore, when you 
recommend no therapy, because the odds are that the child will 
recover, you are at the same time incurring a risk that the person 
may go for a while without treat- ment, and the evidence is pretty 
clear that delay- ing treatment makes treatment more difficult, or at 
least take longer. So there is a possibly bad consequence to BOTH 
recommending therapy and to recommending no therapy. One has to 
balance the possibly unnecessary expense and effort of unnecessary 
treatment against the possibility that the child will become a chronic 
stutterer. It has always seemed to me that the latter possibility is so 
serious that it justified the other, milder risk. 


Re: Aspirin, anyone?
From: Dick Curlee
Date: 10/21/99
Time: 3:10:03 PM
Remote Name:
Woody: I'm not familiar with any evidence showing that selective 
delays of 6-12 months post-onset has any effects on treatment.  

Re: Aspirin, anyone?
From: Woody
Date: 10/17/99
Time: 11:29:26 AM
Remote Name:
But Dick, yes of course it would be better not to recommend therapy 
that is not needed, and in that sense, such a recommendation might 
be unethical. But in reality, as you said, you don't really know 
whether it is needed or not, because you can't know who will and 
who will not recover spontaneously. Therefore, when you 
recommend no therapy, because the odds are that the child will 
recover, you are at the same time incurring a risk that the person 
may go for a while without treat- ment, and the evidence is pretty 
clear that delay- ing treatment makes treatment more difficult, or at 
least take longer. So there is a possibly bad consequence to BOTH 
recommending therapy and to recommending no therapy. One has to 
balance the possibly unnecessary expense and effort of unnecessary 
treatment against the possibility that the child will become a chronic 
stutterer. It has always seemed to me that the latter possibility is so 
serious that it justified the other, milder risk. 


Early Intervention Comment/Question
From: Elizabeth Ritchie
Date: 10/9/99
Time: 11:01:56 AM
Remote Name:
Mr. Curlee - I enjoyed reading your article about early intervention. 
I do understand the importance of early intervention, however, I am 
currently working in the public schools as a speech therapist and 
often times, these children are not referred to us until kindergarten. 
Frequently, if the parents had some concern about thier child's 
stuttering in the preschool age, they were simply told the child 
would "grow out of it". (As we all have heard before.) Yes, some of 
the children may overcome the developmental disfluencies, but there 
are those that are true stutterers. How can we prevent these children 
from not being referred? As a school therapist, I am responsible for 
providing services to children as young as 3 years old. It is ashame 
that many parents and other professionals do not know this. Also, 
how do we make certain that a young child absolutely needs 
intervention? Are you looking for more severe disfluency patterns 
and secondary behaviors? Thank you for your time.   

Re: Early Intervention Comment/Question
From: Dick Curlee
Date: 10/9/99
Time: 8:51:03 PM
Remote Name:
I understand your concern; I've seen some "children" who have been 
stuttering since three or four years of age and whose parents are still 
waiting for them to "grow out of it." I think the single most important 
"danger sign" that stuttering is likely to continue unless therapy is 
begun is how long a child has been stuttering. Findings from the 
Univ. of Illinois study indicate that most untreated remissions occur 
within the first two years of onset and that almost all of those who 
do stop within two years w/o receiving therapy can be identified 
within 12 months of onset. Identifying them is based on careful 
assessments of their stutters every 2-3 months, because those who 
stop begin to show decreases in their stuttering during the first year 
after onset. I think the best way to prevent children from showing 
up at school after having stuttered more than a year is for parents to 
take any child who has stuttered longer than 2-3 months to a 
certfified speech-language pathologist who has extensive experience 
in working with children who stutter. As you may know, a large 
percentage of certified SLPs have reported in surveys that working 
with people who stutter is an area that they feel least capable or 
competent to handle. That's one of the reasons that ASHA's Special 
Interest Group on Fluency Disoders established a Specialty 
Commission on Fluency Disorders that is responsible for awarding 
Specialty Recognition in this area to applicants whose knowledge and 
experience in working with people who stutter qualify them for 
recognition. This is the first year that the Commission has been 
processing applications, but in time, it should become much easier for 
parents, less experienced SLPs, and other professionals to identify 
recognized specialists in fluency disorders in their community. 
Having children who stutter see specialists within a few months of 
onset is probably the best way to make sure that each child is 
handled in terms of his or her specific risks. For example, children 
with histories of chronic stuttering in their family trees, evidence 
lags in phonological development, and are male are at higher risk for 
continuing to suttter than girls with no phonological lags or family 
history of chronic stuttering. A chapter I wrote for the 2nd edition of 
Stuttering & Related Disorders of Fluency describes how I evaluate 
children who stutter and the guidelines I use in assessing a child's 
risk for continuing to stutter. I hope that you may find some of this 
of help.  

A nagging worry
From: Michelle Lincoln
Date: 10/10/99
Time: 9:13:43 AM
Remote Name:
Hi Dick 
While I agree with you that in some cases it is a good idea to 
postpone treatment for stuttering in preschool children because they 
have a reasonable chance of recovery I have a nagging worry. We 
don't know what impact stuttering for 12-24 months has on the 
child's socio-emotional development, language development, self 
esteem, confidence etc and whether these are short or long-term 
effects. If treatments are available that can avoid the development of 
these types of problems why not emplot them. Arguably this is done 
with other disorder groups e.g. artic or phonology when it is likely 
also that they might recover. If research showed that spending your 
preschool years stuttering had no effect on any of the things 
mentioned above I would feel alot more comfortable about with 
holding treatment. What do you think about this? Do you lose sleep 
over this one? 

Michelle Lincoln

Re: A nagging worry
From: Dick Curlee
Date: 10/14/99
Time: 6:02:28 PM
Remote Name:
No, I don't lose sleep over the worries you apparently have. I worry 
more about my having encouraged parents to spend time and money 
doing something that is more likely to be unnecessary than 
necessary. There is also no evidence that children seen in successful 
therapy don't have their self-image as a normal child undermined 
and that children whose therapy is unsuccessful usually have their 
self-esteem irreparably damaged. I don't worry or lose sleep about 
either of these. In the absense of credible evidence the harm of 12-
24 month delays and psychological side-effects of therapy are 
similarly plausible. I don't think you should worry about either until 
there is reason (i.e., some evidence) to worry, but I appreciate your 

And on the other side of the garden wall...
From: lheite@astro.temple.edu
Date: 10/14/99
Time: 1:22:31 PM
Remote Name:
Interesting discussion. It's an old argument, and one driven by a 
kind of intellectual prissiness that really doesn't have much 
application beyond academe. The proposal that therapy should not 
be offered to all at-risk kids because of the chance of involving a lot 
of kids who don't need it has a tone of "Don't just do something, stand 
there!" to it. 

If speech therapy in the absence of true need were something that 
had genuinely deleterious effects, that would be one thing. It is not 
chemotherapy, though. An overdose won't kill you, render you 
infertile, or make your hair fall out. If a kid spends a few months in 
therapy and then stops stuttering for whatever reason, no harm is 
done. If he doesn't spend a few months in thearpy, and continues to 
stutter to the point that it becomes deeply habituated, then real 
harm is done. 

The quibbles about whether to wait for two or three months or or to 
take the child right into therapy are also an empty intellectual 
exercise. What are the estimates of how long before a child begins to 
stutter and the parents' decision to seek help? Probably two or three 
months have already elapsed before the parent decides to seek help, 
so in reality most kids who are asked to wait two or three months 
have in fact been made to wait four to six months at least. But of 
course we really don't know, do we.  

Analogy is weak argument, but it is often good illustration. Imagine a 
waterfall, and a high cliff that overlooks the waterfall. The place is a 
minor tourist attraction, and a thousand people a year go stand on 
the cliff to admire the tumbling water. Five percent of those people, 
fifty souls, are foolhardy enough to lean too far over the edge, lose 
their balance, and tumble into the whirlpool at the base of the 
waterfall. Of those fifty, thirty-five manage to struggle to the surface 
and scramble back up on the bank, shaken, wet, cold, scared silly, 
maybe with a broken bone or two, but alive. The other fifteen drown 
and their corpses are washed out to sea. 

Now shift scenes. The township tourism committee is considering 
putting a rail along the cliff far enough back to keep the fifty 
expected causalties from falling over the edge. However, a committee 
of concerned scientists augmented by a few civil libertarians (who 
bathed for the occasion) says that the railing is too expensive. Since 
people sometimes climb over railings, its efficacy is doubtful. Besides, 
in the committee's considered and honest judgment it is unethical to 
put up such a railing because there is no way to predict in advance 
who is likely to fall and so the ability of the others to view the 
waterfall unhindered should not be curtailed. 

I'd love to see the media coverage of such a debate. 

I just can't buy the proposal that providing a noninvasive and 
relatively harmless intervention to kids who might not need it is a 
worse ethical decision than withholding that same intervention from 
the unidentifiable minority who do need it. That is not the same 
thing as suggesting that efficacy assessment should not be an ongoing 
project, or that therapy should be dispensed willy-nilly. But given 
the current state of our knowledge about the etiology of stuttering, 
who among us is going to take seriously a proposal that our best 
preventative measures, crude though they be, should be withheld 
until we have uncontrovertable proof of their success and a way to 
separate kids according to their need? That person truly has a heart 
of stone. 

Lou Heite

Re: And on the other side of the garden wall...
From: Dick Curlee
Date: 10/14/99
Time: 6:12:58 PM
Remote Name:
Thanks for taking the time to express the opinions of a true believer. 
I suppose it's prissy to say it, but I think disagreement is healthy 
until there is conclusive evidence. 

Re: And on the other side of the garden wall...
From: lheite@astro.temple.edu
Date: 10/15/99
Time: 10:51:25 AM
Remote Name:
Dr Curlee: 
Yes, disagreement is the rich soil that might some day produce 
results, if it doesn't rot the roots of the ideas that are planted in it. 
However, mixing metaphors, "true belief" is a glass apartment house 
with many chambers, and one had best be careful when tossing 
pebbles. In the absence of proof, all belief is "true belief." 

You have stated yourself that it is unlikely that we will ever be able 
to assemble incontrovertable proof of the efficacy, or lack thereof, of 
early intervention. From your reply to Woody Starkweather 
somewhere up above in this discussion, I quote: " I agree that it is 
highly unlikely that we can get an adequately controlled study of 
early intervention, not because enough parents wouldn't agree to 
delay therapy for some period but because they would not be from 
the same population of parents who would not be willing to delay." 

It really doesn't matter what the reason is for the lack of proof, the 
proof isn't there. Assemble the proof, and I shall be happy to 
embrace your position or something like it. But in the meantime, 
there are some kids who will grow up and become stutterers while 
academicians are sitting around lamenting the lack of a proper 
controlled study. Those kids are not abstractions. They are the people 
who will have to live with the results of a decision not to intervene 
for a year or two, because some beancounting school administrator 
has read somewhere that some experts are not sure of the efficacy of 
early intervention and recommend waiting a couple of years. Those 
children will pay the cost of your belief, not you. 

Each child at risk has a window of time in which therapy will be 
most effective. Their lives march forward under the unbendable 
cadence of time, whether they are among the minority who become 
chronic stutterers or not. The ones who may become stutterers 
cannot wait until those for whom their very human problem is 
primarily a scientific puzzle decide that the solution has been found. 
Dressing inaction up in a lab coat and calling it science does nothing 
for these children. It also does nothing for science. 

My true belief is probably dismissible by some as smarmy 
liberalism, though I prefer to think of it as humanistic activism. Your 
true belief is equally dismissible as icy scientificism, though I am 
guessing that you prefer to think of it as intellectual rigor or 
something along those lines. Both courses are valid, but I don't think 
that they are equally defensible. So far all you have raised is a 
sensible caution against crowing in triumph over the defeat of early 
stuttering. You have not provided a sufficiently rigorous reason to 
withhold therapy from those who show signs of needing it. Moreover, 
by your own admission, you probably never will. 

Maybe early intervention doesn't work. Maybe it does. Neither 
outcome has been proven. Certainly neither late intervention nor no 
intervention works very well, because if they did this conference 
wouldn't be happening. So, weighing the _certainty_ that some kids 
will become chronic adult stutterers without intervention or with 
late intervention, against the _possibility_ that most if not all of 
those kids will not become stutters with early intervention, I would 
prefer to err on the side of the children - even while hoping for proof 
one way or the other. 


Early Intervention
From: Mary Ahlers SLP
Date: 10/15/99
Time: 10:59:18 AM
Remote Name:
It has been my experience that it is often beneficial to delay 
enrolling a preschool aged child in speech therapy for stuttering. 
Many times when parents are given simple directives for helping the 
child at home, and these techniques are carried out throughout the 
child's environment (grandparents, child care people, etc.), direct 
speech therapy services are not always required. Sometimes focusing 
in on the family's hectic schedules and/or things going on at home, 
can help in alleviating speech problems. I feel it is our professional 
responsibility to look at all areas before automatically placing 
children in services. 

Re: Early Intervention
From: Woody Starkweather
Date: 10/17/99
Time: 11:42:09 AM
Remote Name:
This is a very good point. A small delay does very little, if any, harm, 
and it is possible while waiting a month or two, to inform the parents 
about ways they make the environment more conduc- ive to the 
development of normal fluency. 

One of the fascinating byways of our data on early intervention at 
Temple was that about ten per cent of the parents who called us 
were SLP's. We routinely listen during the first phone call to the 
parents' complaint/description, give them some hasty advice, and 
send them a pamphlet on how to change the environ- ment. It isn't 
therapy, but it is something. What we found was that in the case of 
the parents who were SLP's, nearly all of the children stopped 
stuttering even before their first appointment. Of course, the training 
in speech pathology made a difference, and there may have been 
other factors. But I believe that in many cases, particularly when 
parents are well educated, it doesn't take very much inter- vention 
to produce change.  

Woody Starkweather

Re: Early Intervention
From: Dick Curlee
Date: 10/19/99
Time: 5:50:26 PM
Remote Name:
Believe it or not, Woody, I agree with you!

Re: Early Intervention
From: Dick Curlee
Date: 10/19/99
Time: 5:47:58 PM
Remote Name:
I have had many similar experiences, although I'm seldom sure what 
changes parents actually make. The important thing is the child stops 
stuttering for whatever reason. Thanks for your comments.  

Dr. Curlee
From: Jerry Johnson
Date: 10/17/99
Time: 8:39:30 PM
Remote Name:
Lets duke this out on the playing field of the frustrated, emotional, 
tearful, and cries of help from the parents of children who "stutter." I 
dont give a damn how an SLP, much less a "researcher" who cant see 
the trees for the forest, DEFINES beginning stuttering. Parents are a 
pretty good judge of their children and to be turned away into the 
darkness of night is unconscionable. Information on a continuing 
basis for parents is a must, and "therapy" for these children can take 
many many forms. Lets buy some time for these people through 
direct contact on a continuing basis. And for the cost factor: whats 
wrong with FREE? Try it some time it is very liberating. Anyway, a 
person who works withing the university setting, whose salary is 
paid by the taxpayer, should be providing some free service anyway. 
So be it. Take the advice of Lou Heite and the world will be a better 

Re: Dr. Curlee
From: Dick Curlee
Date: 10/19/99
Time: 5:56:55 PM
Remote Name:
I was surprised that you feel so knowledgeable about me; I was not 
aware we had met. 

Re: Dr. Curlee
From: Jerry Johnson
Date: 10/20/99
Time: 2:45:02 PM
Remote Name:
Doggone it anyway. I tried to get a rise, but you are too fast for me. A 
chuckle is worth a thousand words. Seriously, your studies have done 
much to understand the underlying facets of stuttering. Keep up the 
good work. 

A middle ground?
From: J. Scott Yaruss
Date: 10/18/99
Time: 11:19:01 AM
Remote Name:

Hi all...An interesting discussion -- this forum is a nice way of 
exchanging ideas without getting TOO hot and bothered about it 
(though it seems that the discussion has approached that threshold in 
some posts). 

In any case, I'm wondering if there's a middle ground to this debate. 
I understand and agree with the concerns raised by Dr. Curlee 
regarding providing unnecessary treatment. My clinic is run through 
a traditional health-care setting (Children's Hospital) where payment 
issues are real and faced by parents and clinicians alike every day. 
Nearly every time we recommend therapy, the insurance company 
denies payment and the parents are forced with a difficult decision. 
(For some reason, when I worked through a University clinic, there 
was never any question...insurance wasn't going to pay so the 
parents did pay...now that I'm in a hospital, they expect insurance to 
pay, which it doesn't, so the kids end up not getting the treatment...I 
don't understand this, but it is a point for another thread.) The 
bottom line is, even though our treatment at the hospital costs no 
more than most University Clinic treatments, we need to be VERY 
sure that we don't recommend unnecessary treatment because of the 
real expenses involved. Many families can't afford treatment, and I 
can't feel comfortable recommending that they waste their money. 

ON THE OTHER HAND...I don't know for sure if they would be wasting 
their money. We don't have the data indicating which children will 
recover. (And, I maintain that it is essentially impossible to collect 
such data since. Aside from the arguments raised by Drs. Curlee and 
Starkweather about the difficulties of this type of research, we have 
additional problems. Put simply, we can't easily assess the child's 
fluency without also making some sort of impact on the ultimate 
outcome. Furthermore, I believe that the ultimate outcome is 
affected by factors that occur throughout the child's development, 
not just his initial status at the time of evaluation...therefore, no 
matter how detailed our original analysis is, I don't think we can use 
that information to extrapolate the child's ultimate outcome without 
additional information collected at multiple points throughout the 
child's early development.)   Therefore, once I have collected all the 
data, I must go with something that amounts to a data-driven, 
theory-driven, but ultimately gut-level decision about whether 
treatment seems indicated. I make the presentation to the parents 
about what their options are, and then I make a recommendation 
about what I would do if it were my child (and my older daughter 
has had significant fluency concerns, so I think I can understand a 
little bit where the parents are coming from). It's still their decision 
of course, and I make that clear. Also, I explain to them the "risk" 
that the child will get better on his/her own at that all of this will be 
for naught -- Still, I feel an obligation to make a recommendation, 
knowing full well that I might be wrong. 

So...where's the middle ground? Simply this. I don't see the issue as 
one of recommending therapy or not recommending therapy. I see it 
as one of DEGREE of intervention. Regardless of the outcome of the 
evaluation, I am going to recommend some sort of intervention. 
Sometimes, if the child appears to be on the right track toward 
natural recovery from stuttering, the intervention takes the form of 
nothing more than informal counseling with the parents about what 
danger signs to watch for and when to contact me if the child's 
stuttering appears to be persisting (this is probably akin to the 
traditional "no treatment" option, though I provide detailed input to 
parents, and I FOLLOW-UP about 4 weeks later and then again after 
that to make sure the child is recovering.) 

One the other extreme, if the child is clearly at risk (due to factors 
such as family history of persistent stuttering, presence of co-
occurring disorder, or something else, such as extreme concern on the 
part of the parents or child), then I will recomment a more direct 
form of intervention, including both the parent counseling mentioned 
above and treatment with the child. This is akin to the traditional 
"yes treatment" recommendation. 

But what about in the middle -- of course, that is where most of the 
kids tend to fall. A child who has some risk factors, perhaps, some 
apparent stuttering, perhaps, but no clear signs either way of which 
way things are going to go. Now, I have a problem -- I don't want to 
recommend no therapy, because I saw something there that 
concerned me and I don't just want to "wait and see." Plus, and even 
more importantly, the parents themselves were concerned, and this 
is enough reason to spend more time on the problem and recommend 
some type of intervention. BUT, is it really the CHILD who needs the 
invervention? Not always, and many times no. If I'm not sure which 
way the child is going to go, I use a third recommendation category 
that involves, primarily, parent training and counseling, but also 
some work with the child. 

Like the first option mentioned above, talking about danger signs to 
look for, etc, including ample opportunities for parents to discuss 
their concerns about the child's fluency and to begin to process some 
of their fears. Also, we spend a lot of time on training parents to 
make modifications to their own communication (if warranted) that 
can stack the deck in the child's favor...help him be as fluent and 
successful a communicator as possible. Help him maintain or develop 
healthy attitudes toward his developing speaking abilities (a la Logan 
& Yaruss, 1999 in CICSD), and the like. A lot of this also involves 
working with the child, but not for the sake of directly treating the 
child -- more for the sake of training the parents. We use a wireless 
microphone receiver system with which the parents can interact 
with the child while we observe from behind a mirror and provide 
suggestions and training about how they can facilitate the child's 
fluency, just like we train student clinicians to do. 

Together, this "parent training" package is a form of intervention that 
is not direct therapy with the child (which, as we said, might not be 
necessary). What it does is it gives the parents a way to help, while 
keeping us in the loop, and begins the process of treatment in a less 
direct way than the traditional "yes treatment" recommendation. 

The trick to using all of this as a middle ground is that it is FINITE in 
duration. Four to six sessions -- a two to three-hundred dollar 
investment, to shift to the bottom line. Not pocket change, to be sure, 
but not open-ended, long-term treatment that might not ultimately 
be necessary. 

The parents get trained and we observe the child for longer (now 
we've seen him for several sessions, not just the initial evaluation). 
Now, if the child gets better, the parents know what to look for and 
what to do if he flares up again. Some money may have been wasted, 
but then again, the parent involvement in treatment might have 
contributed to the child's recovery (and I think this is likely -- if not 
the fact of the recovery, at least the timing of the recovery). Plus, 
we've helped the parents feel better along the way -- an 
accomplishment that is far from trivial. 

If the child doesn't get better, then we've already begun the 
treatment process and no money or time is wasted. We didn't do a 
"wait and see" -- we did more of a "watch and see" -- a critical 
difference, IMHO. 

Whew! This was longer than I expected...I'll be talking about this 
approach at ASHA in at least 2 presentations. First, the SID Short 
Course with Bill Murphy and Ken Logan (we'll focus on techniques for 
improving fluency and attitudes in young children who stutter) and 
also in a talk with Dave Hammer, my co-director at the Stuttering 
Center who formalized the parent training program. We'll talk a bit 
about the diagnostic issues but then spend more time on the actual 
training of the parents. 

As always, the usual caveats apply...I didn't make this stuff up on my 
own (I stole it from lots of other people). There are many clinicians 
who view the issue this way, and have made valuable contributions 
to the development of my thinking (including Drs. Curlee & 
Starkweather)...I just felt moved to write about it this time... 

Thanks for listening, and sorry about the length. S 

(Note: this diagnostic approach is different from that described in a 
paper my colleagues and I published in AJSLP last year, which used 
more traditional "no treatment, re-evaluation, and treatment" 
categories...Opinions change, no?) 

Re: A middle ground?
From: Dick Curlee
Date: 10/21/99
Time: 6:22:47 PM
Remote Name:
Gee, Scott, I thought that's where I am! I enjoyed reading your 
comments regardless of where we stand.

Re: A middle ground?
From: Scott Yaruss
Date: 10/22/99
Time: 8:59:36 AM
Remote Name:
Hi Dick 

Hmmm...told you I stole most of my stuff from you folks. 

Still, I hadn't seen any explicit recommendation for a set course of 
parent counseling in your comments. Yes, I know you give parents 
information about stuttering prior to allowing them to make the 
decision about treatment. BUT, are you training them to make 
changes at home that are BELIEVED (not necessarily proven) to 
facilitate fluency? Are you providing an extended period of time for 
them to explore their concerns in the presence of a clinician? 

I had not gotten this impression from your writings. I guess I was 
hearing more of a "treat / no-treat" dichotomy, left in the parent's 
hands. Can you elaborate on your middle ground? 


PS: If we all say we're recommending the same thing, then where's 
the controversy?

Feelings and Attitudes
From: Erin Davis
Date: 10/18/99
Time: 12:43:26 PM
Remote Name:
Dr. Curlee, from my perspective as a graduate student of speech-
language pathology, your paper presents an alternate viewpoint. 
Much of the information I have encountered advocates the need for 
early intervention due in part to the feelings and attitudes of the 
young stutterer. I am interested in your opinion on the impact early 
intervention would have on eliminating the anxiety that contributes 
to the secondary characteristics oftentimes associated with 

Re: Feelings and Attitudes
From: Dick Curlee
Date: 10/19/99
Time: 6:46:20 PM
Remote Name:
Ms. Davis: Most of the children from 2 to 4 years of age who stutter I 
have seen do not appear to be bothered about their stuttering and 
those who are seem to be upset only at the time they're having a lot 
of trouble talking because of their stuttering. In addition, I usually 
see the appearance of tension, effortful speech and other accessory 
behaviors before the child appears anxious or expresses ideas or 
attitudes about being unable to say things. If a child is evidencing 
such attitudes or feelings about talking, I wouldn't tell the parents it 
would be OK to delay therapy, because I think those ideas and 
feelings are likely to make the child's stuttering worse and perhaps 
even lead to other problems. I can understand your concern even 
though most of the children I've seen in this age group who have not 
been stuttering long seem to be relatively oblivious to their stutters.    

Suggested Protocol?  
From: Judy Butler 
Date: 10/18/99 
Time: 8:13:24 PM 
Remote Name:  
Dr. Curlee, Thank you for this paper because it generated a discussion 
in which I was interested. I am an SLP in private practice. I have 
been using recommendations by Zebrowski in her 1997 article in 
AJSLP Vol 6 pp 19-27 "Assisting Young Children Who Stutter and 
Their Families: Defining the Role of the Speech Language Pathologist" 
when determining if and how often to "treat" a preschooler with 
disfluent speech. I take a monthly audiotaped speech sample of these 
children to monitor their fluency over time. In the last paragraph of 
your article, you recommended collecting scientific data. I am up to 
the challenge of collecting data long term on my young clients. Can 
you recommend a protocol for doing so?    

Re: Suggested Protocol?  
From: Dick Curlee 
Date: 10/21/99 
Time: 3:47:20 PM 
Remote Name:  
Ms. Butler-- If you'll give me your address, I'll be glad to mail you a 
handout I use for class.     

Early Intervention  
From: Shari Seal 
Date: 10/19/99 
Time: 7:06:44 PM 
Remote Name:  
For a child who is 4 years old, it is continually recommended to 
provide parental suggestions and re-evaluate in 6 months. When the 
child returns, pre and post data reveals improvements. The data 
denotes that the child still demonstrates atypical characteristics, 
which are indicative of an individual who stutters, but an increase in 
fluency is evident.   What should be recommended at the time? Are 
there any definite flags to suggest when therapy should be initiated?    

Re: Early Intervention  
From: Dick Curlee 
Date: 10/21/99 
Time: 3:58:46 PM 
Remote Name:  
I try to monitor changes in children's disfluencies over shorter 
intervals [e.g., 2-3 months] and as long as the child's fluency is 
increasing, I feel that watchful waiting is "working." I always make 
sure, however, that the parent believes what I'm recording is typical 
of the child's speech most of the time. It's been my experience that 
when stuttering stops, it usually decreases somewhat irregularly 
over an extended period of time, but 12-24 months after onset, 
stutters occur VERY infrequently, if at all, according to parents. 
Assuming your description is a real child, I would feel comfortable 
watching another three months anyhow.     

Appropriate interventions  
From: Brenda Harguth 
Date: 10/20/99 
Time: 4:34:48 PM 
Remote Name:  
I have been working with a 6 year old stuttering client for two years. 
She is unaware of her stuttering. We have been using the indirect 
therapy approach. She can be very fluent during therapy, but is 
much more disfluent in other environments. Would it be appropriate 
to make her aware of her stuttering for therapy purposes or continue 
with a more indirect approach? I would hate to make her anxious 
about her speech.     

Re: Appropriate interventions  
From: Dick Curlee 
Date: 10/21/99 
Time: 6:19:41 PM 
Remote Name:  
Comments  Although most children appear to generalize fluency 
gains spontaneously from therapy to outside settings, some don't. If a 
child isn't generalizing spontaneously, I have parents, over family 
members living in the home, and "best" friends participate in 
therapy activities with the child. Sometimes this stimulates 
generalization. Next, I might ask parents to engage in the same sorts 
of activities at home for 10-15 minutes and bring me a recording so I 
can evaluate what was done and its success. I have even scheduled 
therapy at children's homes for a few weeks to see if that seems to 
make a difference. In general, the more similar the setting, the 
activities, and the speaking tasks in therapy are to those the child 
engages in normally, the more likely generalization will occur. In 
terms of calling attention to stuttering, I think that it's important for 
positive comments and praise of stutter-free segments to greatly 
outnumber comments on stutters. As a result you need to be engaged 
in a talking activity in which the child stutters very infrequently. 
The Lidcombe Program, for example, recommends a 10-11 to 1 ratio 
of fluency to stutter feedback. Even then some children may react 
negatively to stuttering feedback, which means it needs to decrease 
or stop, at least for awhile. If you think you would like to try 
something like that, you can download descriptions of how to do it 
from a website liked to their home page. Hope some of these ideas 
may help.      

Early Intervention...  
From: Pamela L. Brophy 
Date: 10/21/99 
Time: 11:31:36 AM 
Remote Name:  
Comments  I have never felt it was essential to work with pre-school 
age stutterers. To me, you look at severity, parental concern, the 
child's awareness level, etc.     

Re: Early Intervention...  
From: Dick Curlee 
Date: 10/21/99 
Time: 4:02:30 PM 
Remote Name:  
Comments  I also like to look at how long a child has stuttered and if 
his/her stuttering is decreasing. If it hasn't changed noticeably for 
the better after 12-15 months post-onset, I begin to believe that 
something should be done to help nature.    

To treat or not?  
From: Amy Ogburn 
Date: 10/21/99 
Time: 10:15:22 PM 
Remote Name:  
Comments  Dr. Curlee, I found your article to be very informative. 
Currently, I am in graduate school and I have a 3 1/2 year old client 
who stutters. His disfluency has significantly reduced since treatment 
began, however his family is extremely motivated. I believe early 
intervention can be a positive experience, however in some cases it 
might not be cost effective.     Re: To treat or not?  From: Dick Curlee 
Date: 10/22/99 Time: 1:05:13 PM Remote Name:  
Comments  Ms. Ogburn -- I agree that early treatment may be a very 
positive experience and I suspect that it is seldom harmful. My 
concern is that we do not have yet to gather the kind of support 
needed to know if or how much more effective it is to intervene as 
soon as possible after onset. This failure undermines efforts to obtain 
insurance coverage for families who cannot afford therapy and the 
credibility of our work as a profession. It's as if we don't recognize 
that our good intentions and personal experiences as clinicians are 
not enough to support our beliefs.