A Brief Review of Treatment Techniques for Early Intervention
There are many programs available for the direct treatment of young children who stutter. These early intervention programs have a common thread in that they introduce the child to one or more known fluency facilitation techniques. Before we describe the approach that we favor, we would like to look at some of the early intervention programs that have influenced our thinking.
Wall and Myers (1995) identify the reduction of rate of speaking and reduction of linguistic complexity as activities that can facilitate fluency. Most of the approaches combine one or both of these direct treatment strategies with elements of parent and family counseling. As early as 1971, Ryan (Ryan, 1971; Ryan & Van Kirk, 1978) has treated stuttering children with behavioral techniques designed to diminish and eventually eliminate the stuttering. Ryan and his associates use a combination of controlling the length and complexity of utterances (GILCU) and carefully scheduled social and token reinforcement through the establishment, transfer and maintenance stages of treatment. They continue to report high levels of fluency in children who have been treated with this program.
Like the Ryans, Shine (1980) controls the length and complexity of utterances and uses token reinforcement to establish and maintain fluent speech in 3 to 9 year old stuttering children. Shine believes that children's dysfluent speech reflects overly forceful use of the muscles of respiration, articulation, and phonation. His program targets the diminishing of this excessive force, encouraging the child to use an easy voice or prolonged speech in order to establish initial fluency. He introduces a hierarchy of structured speaking activities beginning with picture identification, a task that carries a low level of linguistic demand, and concluding with spontaneous language elicited by a "surprise box" activity (requiring a much higher level of linguistic demand).
Stocker (1980) devised yet another behaviorally based program that employs a hierarchy of linguistic demands, to assess and treat young children. The Stocker Probe is based upon the notion that young children (preschool and early elementary school age) become more dysfluent as the linguistic demands of their communicative interactions increase. Stocker presents questions at five different levels of linguistic demand, practicing each of these levels with the child until fluency is achieved, before moving to the next level.
Starkweather and his associates (Starkweather, Gottwald & Halfond, 1990; Starkweather & Gottwald, 1990; Starkweather, 1997; Starkweather & Givens-Ackerman, 1997) have described a model of treatment based upon the idea that a child's fluency is at risk when that child's capacity for fluency does not equal the cognitive, motoric, emotional, and environmental demands for fluency which may be placed upon him. They maintain that children have a certain capacity for fluency that is related to their speech motor control abilities, language formulation abilities, social-emotional maturity and cognitive skills. This varies from child to child and from one age to another. When demands exceed the child's capacity for fluency, stuttering occurs.
This Demands and Capacities program combines direct intervention with a strong parent-counseling component. Starkweather suggests that after careful assessment, the focus of therapy becomes increasing the child's capacities for fluency (cognitive, motor, linguistic and emotional) while decreasing the parallel demands. He recommends that parent counseling include education about stuttering as well as answering parent questions and helping them to bring stuttering out in the open with their child. He focuses, as well, on exploring, identifying, and confronting parents' attitudes in a supportive way. Finally, through a process of self-discovery with family members, he addresses the issue of changing the way parents and other family members behave in relation to their participation in the communicative environment.
In working with the child, Starkweather targets the removal of struggle, reducing speech rate and controlling the linguistic level during speaking events. When necessary, he recommends introduction of such fluency shaping activities as gentle onsets, light articulatory contacts, and improved resonance. This may be accomplished through modeling of desired behaviors including the modeling of easy whole word and phrase repetitions, and by highlighting slowed conversation and "polite" turntaking behavior.
Meyers and Woodford (1992) also developed a program that combines parent-counseling techniques with decreasing the child's speaking rate, using smooth and easy speech, and practicing appropriate pragmatic skills (i.e. turntaking). Their approach relies heavily upon a systematic analysis of interaction between stuttering children and their conversational partners. The direct intervention is described as a behavior modification approach in which children are taught to contrast fast and slow speech, use smooth and relaxed speech rather than bumpy speech, and understand and practice certain pragmatic strategies (turn taking, sequencing, acknowledging disagreement and retrieving thoughts). The parent training/counseling component is quite similar to the Starkweather approach described above. Portions of this treatment program have been adapted and are widely used by many clinicians, especially the device known as "talking like a turtle" as opposed to "talking like a racehorse", or using "turtle speech" as opposed to "racehorse speech".
The work of Walton and Wallace (1997) was reported at the Second World Congress of the International Fluency Association. This interesting approach, one which endorses both fluency shaping (without the use of punishment and negative reinforcement) and stuttering modification principles, is the most direct of the treatment strategies suggested for young children. They endorse moving from a direct focus on techniques which facilitate fluency (i.e. easy speech, stretchy talk, bouncy speech) to a direct focus on the differences between fluent and dysfluent speech (i.e. speech villains-- hard speech and pushing).
This therapy approach incorporates Ryan' GILCU strategy as well as what they call desensitization and empowerment therapy (Walton & Wallace, 1997, personal correspondence). The desensitization principles include voluntary stuttering which they call "bouncy talk" or "Tigger talk" and games in which the child is asked to catch the therapist who is not using easy speech. Later the child is taught to speak fluently in the presence of speech fluency disrupters. The empowerment program helps the child to identify "speech villains" which s/he can capture by drawing pictures of them and then engaging in such activities as tying them up, locking them up, and/or sending them away.
The parent-training component includes education and training with the use of available written materials from the Stuttering Foundation of America and the National Stuttering Project, as well as a thorough explanation of Walton and Wallace's philosophy of treatment. Parents are then assisted in developing conversational and listening strategies that will facilitate fluency. Parent participation is enlisted in practicing carryover activities at home. Parents are taught the therapy techniques and asked to practice them during specified and time limited periods each day.
Schneider (1998) describes a program which he calls Self-Adjusting Fluency Therapy (SAFT), an approach that he has found to be successful with preschool and school age children who are overtly dysfluent but who do not tend to avoid speaking situations. This treatment paradigm involves teaching..."children [to] integrate fluency enhancing speech adjustments by repeatedly experiencing the effects of volitional increases and decreases in loudness and pausing" (Schneider, 1998, personal correspondence). The clinician first models variations in loudness and rate (i.e. pausing), demonstrating that 'choice' is possible. These choices are offered as different options for speaking as the therapist uses self-talk to demonstrate which speaking style s/he chooses to use at any given time.
The child is encouraged, next, to choose how s/he wants the therapist to speak. This can be presented in a game format in which the child has the therapist shift from one speech style to another (fast rate to pauses between words; loud voice to gentle or quiet voice). Once the child understands the concept of self-adjustment, s/he is encouraged to try this technique, shifting at will from one speech style to another, and being positively reinforced for making the choices. Ultimately the child is asked to make these adjustments before beginning to speak and/or during, what Schneider calls, periods of fluency interruption.
Parents are involved in this treatment program from the outset. In fact, parent counseling begins with the initial telephone contact, during which Schneider attempts to enlist the parent's partnership in the treatment process by engaging immediately in shared decision making about the need for face to face consultation. Before a child is scheduled for therapy the parents are invited for a consultation. An environment is created in which the parents feel comfortable enough to discuss their fears, concerns, perceptions of the child's communication effectiveness, and notions about why their child is dysfluent.
Schneider attends particularly to the family's communication dynamics, its process for setting limits, and the parent's pattern of asserting the role of 'person-in-charge'. He also pays particular attention to the child's desire to communicate and to how the family members respond to this. During the child's treatment period, parent counseling takes the form of shared problem solving about ways in which fluency can be facilitated, and ways in which family members may respond to periods of fluency and dysfluency. Parents are cautioned not to expect the child to be able to use self-adjustments to control dysfluency consistently. They are taught the process of self-adjustment, and learn that successful use of this technique takes time and patience. The therapist's observations of family communication patterns and parental concerns and issues form the basis for ongoing counseling sessions. Parents are encouraged to problem solve with the therapist, ways to facilitate less demanding communication experiences at home.