AS I NEARED the end of a long career in speech pa-thology it became evident to me, if not to others, that my professional life had been misdirected. I had con-centrated my efforts on relieving stuttering in the adult rather than in children. Although I had worked intensively with many stuttering children, and for the most part rather successfully, the suffering and challenges presented by the older confirmed stutterer were my major concern and interest. This I regret for I was wrong--dead wrong. While I had helped many adults to become reasonably fluent and to live satisfy-ing lives, I had done little to stem the yearly ap-pearance over the horizon of hordes of new stutterers. I had been the ant trying to remove the seashore one grain of sand at a time. Even when I took into account the profession I had helped pioneer, the students I had trained, and the books I had written, what had I really accomplished in finding a solution to the ancient problem of stuttering? The answer was appallingly clear. I had been shooting at the wrong target.
The worst of it was that I had been forewarned. Long ago, in the early 1950s, Philip Glasner had reproached me for working so hard with adult stutterers. "Forget them!" he said. "Stuttering is a public health problem requiring an emphasis upon prophylaxis. You should be working exclusively with young stutterers, seeking to prevent or to reverse the morbid growth of the disorder rather than trying to treat it after it has become full-blown. What we really need is a nation-wide program focused directly on the very young stutterer."
Although it seemed folly to try to take his advice so belatedly, I surveyed the situation to see what I might do. Obviously most of these young stutterers would be found in the elementary grades of the public schools and could be reached through the public school clinicians. That prospect, however, seemed dis-couraging. Wingate (1971) had shown clearly that many of these workers were fearful of working direct-ly with young stutterers, and even those who were not afraid seemed to lack confidence in their ability to help them. His conclusions agreed closely with my own impressions. Many adult stutterers in recent years had told me of the years of superficial treatment they had received in the schools and of the years they had spent on waiting lists as the reason for their lack of motivation, a lack that had not been evident during the early years of my practice. Many of these adults had lost all hope that our profession could help them and were more or less resigned to having to endure their stuttering for the rest of their lives.
A similar tale was told by many of the public-school clinicians. They were fearful of working with young stutterers lest they make the stuttering worse. They knew all the theories about stuttering but did not know what to do with them. Most of the clinicians at-tributed their feelings of inadequacy to their training. Their contacts with young stutterers had been very sparse or nonexistent. That this indeed might be true was shown by Leith (1971) who surveyed the prac-ticum experiences in stuttering of 50 training programs. He showed that in the average graduate train-ing program there were eight student clinicians for each stuttering child, a situation that can hardly be expected to produce much expertise, confidence, or competence. Even in our own training center (which has always had a strong program in stuttering) our students were not getting nearly enough supervised experience with stutterers of any age. To satisfy ASHA requirements for practicum experiences with clients showing a wide variety of disorders, of dif-ferent ages, and in different settings, it is difficult for any student to feel that he can cope with the many problems of young stutterers. Our policy has always been to train general practitioners. We do not train specialists. Perhaps we should do both.
As I scanned the situation it seemed that any hope that we could soon upgrade the training of student clinicians with respect to stuttering seemed dim to say the least. Nevertheless, perhaps if I could train a few very competent specialists in stuttering and plant them in a few schools, and if they could indeed demonstrate the value of their services in reducing the number of stutterers or at least reversing the growth of their disorder, we might, just might have the beginning of a solution to the old problem. A lot of ifs, and I had little time, but I decided to try.
At first I vainly tried to interest certain experienced public-school clinicians to invest a year of their lives in getting this specialized training. They had very good reasons for refusing. Why should they spend a year of their lives preparing for a job that didn't exist? Their colleagues would probably resent having a specialist in their schools. They doubted that, even after special training, they could be very successful because of the complexity of the disorder and the many environmental forces that maintained it and that they could not control. They already had their CCCs and could see little personal advantage in further education. There were other reasons, all very good ones.
So I looked over our own current crop of graduate students and finally persuaded one of then, Carl Dell, to take an extra year on his M.A. and to prepare himself under my direct tutelage for a public-school posi-tion as a stuttering specialist. Dell was a veteran and had the G.I. Bill to help finance that extra year. Moreover he knew personally the plight of the stuttering child and the kind of inadequate treatment he had been given throughout his school years. Due to the intensive treatment he had received in our university clinic he was finally very fluent and had worked suc-cessfully with a number of adult and child stutterers during his practicum experience.
Space limitations forbid more than a general account of the training I gave him for the job that didn't exist. During the first semester he read and discussed with me most of the literature on the treatment of the young stutterer. We critically reviewed and dis-cussed videotapes of other clinicians working with stuttering children or their parents, identifying the possible objectives of each clinical interaction, recog-nizing the ineffective or successful procedures, and inventing alternative or better ways of achieving the same goals. He also worked intensively with one young stutterer in sessions that were videotaped, and these were viewed together critically. Calling on my long experience I was able to offer information about how other young stutterers had responded to the ac-tivities Dell had designed or to those I felt might be preferable. This tutorial training was focused on prob-lem solving--the problems involving motivation. con-frontation, and modification--and also on defining and seeking to develop the characteristics of a skilled and competent clinician (Van Riper, 1975). The training was very intensive, occasionally traumatic, always very practical.
During the second semester, Dell worked with a small group of young stutterers, again videotaped and critically analysed, but I also arranged for him to visit a large number of school systems and to observe and do trial therapy with the young stutterers being served by public-school clinicians, an experience that he said later was very valuable. It provided an oppor-tunity to know, not only the setting, but also the at-titudes toward such a specialist of public-school clini-cians, classroom teachers, administrators, and parents.
Toward the end of the second semester we confronted the task of placement, and immediately a new obstacle presented itself. Dell did not have a teacher's certificate and several school systems that had previ-ously indicated a willingness to employ him as a specialist in stuttering now refused to hire him for this reason. After some difficulty I persuaded the Speech Foundation of America, a charitable institu-tion dedicated to the cause of the stutterer, to provide the funds for a two-year demonstration project on the condition that I agree to supervise it closely. Accord-ingly a grant was given for this purpose to the Kent County Intermediate District just outside Grand Rapids, Michigan.
The setting was hardly ideal. There were 20 school systems in the district, each served by a public-school clinician, and some of these were an hour in traveling time from the others. The scheduling problems were horrendous. The young stutterers were referred to the specialist by the public-school clinicians, and from an initially screened pool of 60, 38 children judged as most needing treatment were chosen for his case load. Several recycling block scheduling systems were de-vised and revised during that first year, and only di-rect individual treatment was administered, though there were frequent conferences with parents, teach-ers, and the public-school clinicians. Demands for speeches, diagnoses, and demonstrations created addi-tional burdens for the specialist but by spring the program had gained widespread acceptance and ap-preciation by all concerned.
The results seemed substantial. Of the 3S children in the specialist's case load, nine became so fluent, not only in the therapy room but in the classroom, play-ground, and at home, that they were dismissed as no longer needing the specialist's services. Four (mostly high school students) dropped out of the program for various reasons. Of the remainder (25) all but one showed improvement, often marked, as revealed in changes in their charted profiles of frequency, dura-tion, tension, and avoidance. Reports from teachers and parents indicated that the children were talking more and stuttering less frequently and severely. Our criteria for dismissal and improvement were stringent and Dell continued to work with children I would have dismissed. The stuttering children below the fourth grade made greater gains than those in the upper elementary grades. None of them became more severe during this period, not even the one who showed no improvement. Initially reluctant, they were now enjoying the sessions with the specialist. Their concerns and poor attitudes about their stuttering had decreased, and this at a time when they often are exacerbated. All in all, the results seemed better than I had expected but I kept my fingers crossed. Would they relapse over summer vacation? Would they reverse their improvement and be stuttering more sev-erely the following fall?
In September all the children, including those dis-missed, were rechecked. None of those discharged from treatment had relapsed; they simply were not stuttering. Of those in the improved category, only three of the 25 were stuttering more frequently or more severely than they had done at the end of the school year. Most of them maintained their gains. Some were better, more fluent. Most were about the same. Hesitantly I concluded that the stuttering spe-cialist could not only free a substantial number of child stutterers from their fluency difficulties but could also stem and reverse the growth of the disorder. Ad-mittedly these impressions had only face validity, for the project was an exploration, not an experiment. Perhaps the same results might have been found in a comparable control group of young stutterers that had not had the specialist's services though that seemed doubtful. Certainly they had only shown change for the worse in the preceding school years. In any event it seemed worthwhile to try the program another year.
During the second year of the project financed by the Speech Foundation of America, the specialist in stuttering concentrated his efforts on fewer and younger children, since it was this group that had shown the most remission or improvement. Early in the fall semester his case load consisted of only 17 children, seven of whom were from the improved group of the preceding year while 10 were new clients. All were enrolled in the first four grades. Again the block scheduling was used and direct therapy given but the children were seen more frequently. More time was also spent by the specialist in the role of a consultant to other public-school clinicians, some of whom were working with his former clients. He also became involved in more parent and teacher con-ferences and public relations. I personally interviewed some of the public-school clinicians and found that they not only considered the specialist program valu-able but were interested in learning how to help the young stutterers in their own case loads. According to Dell, they had been very cooperative and helpful, and he found their support and assistance crucial to his success. He felt that if any specialists were to be trained in the future that more emphasis should be placed on the problems and methods for achieving this liaison.
During this second year, as children were dis-charged from treatment new ones were substituted in their place. Altogether, 23 young stutterers received the specialist's services. At year's end, 13 had been dis-missed, eight showed substantial improvement, and two made no gain whatsoever. Two days were spent in checking these children, and it was evident that Dell had been conservative in his evaluations of suc-cess or improvement. It seemed apparent that this pilot project had demonstrated the usefulness of em-ploying a specialist in stuttering in these public schools.
But the proof is once again in the pudding. What would happen when the specialist's services were no longer completely funded by the Speech Foundation of America? The answer is that Dell was rehired and is currently serving in that role today.
In retrospect, I have the feeling that much of the training I gave this person was unnecessary and that any major training center could prepare such special-ists in a shorter time. Very young stutterers respond readily to intensive treatment by a skilled clinician who understands their problems and knows how to work with them directly. Most school systems have one or more certified clinicians who are interested in and show some special skill in helping them. Were they to be able to get training in their specialty we are certain that many public school administrators would be able to adjust case loads to permit them to play such a role. Two former presidents of our as-sociation ( Moll, 1974; Ainsworth, 1974) have spoken of the urgent need for continuing education for our professionals. Must that training be confined solely to preparing general practitioners, or can it also be used to train specialists in stuttering as well as other disorders? Perhaps this is an idea whose time has come.
AINSWORTH, S.. The specialist in the treatment of stuttering. J. fluency Dis., 1, 52-57 (1974).
LEITH, W. R., Clinical Training in stuttering therapy: A survey. Asha, 13, 6-8 (1971).
MOLL, K. L., Issues facing us--Continuing education. Asha, 16, 306-307 (1974).
VAN RIPER, C., The stutterer's clinician. In Jon Eisenson (Ed.), Stuttering: A Second Symposium. New York: Harper and Row (1975).
WINGATE, M. E., The fear of stuttering. Asha, 13, 3-5 (1971).
added with permission
December 28, 2007