The purpose of this paper is to describe the procedures that I use in a public school system to manage stuttering in pre-school and school-age children who have either developed or who appear to be on their way to developing secondary stuttering.

I was employed as a consultant by a local school district in Texas following my retirement from Texas State University in 2006. I completed three years in my public school role at the end of the past school year. My schedule is two full days a week but I am available to attend meetings and work via the Internet as needed. My duties include seeing all the children who stutter and developing parent-based home programs for any child regardless of problem who might not need to be enrolled full-time in a speech and language program.

It may not be realistic to assume that a traditional school-based therapy schedule for stuttering will be successful (Mallard and Westbrook, 1988). Given the local, state and federal regulations that must be followed with assessments, reports, schedules, etc., it seems as if "the system" is designed to prevent us from providing competent clinical services. We must work within the law and find creative ways to assist as many children as possible. I believe the child's communication environment is critical to the child using newly acquired speech skills. The question that must be answered, as I see it, is: "How can we teach the child's communication environment (teachers, parents, peers if appropriate) to provide daily reinforcement for controlled speech using simple, easy to monitor techniques?" What follows in how I answer the above question using a stuttering modification approach (Dell, 1980).

Procedures

Initial Meeting: The first step in the evaluation process is to schedule a conference, hopefully with both parents and the teacher. The purpose of this meeting is to determine exactly what concerns they have. Information about speech and language development and fluency issues are presented. I explain my philosophy of management and generally how we will proceed. Parents are normally encouraged that they will play the key role in the process. The focus of treatment will be what they and the classroom teacher can do to facilitate speech control. Almost without fail the parents and teacher want to know "what to do" and they are usually willing to be the key players in the process.

Talk Time Home Assignment: A three-week home assignment is given at the conclusion of this meeting. Each parent is asked to spend five minutes, two times a week talking with the child in the child's room. This is not to be done in the automobile, while watching television, or where distractions are present. Attempts to help the child talk are not allowed. The parent is to have a conversation and that is all. The session ends after five minutes.

The parent then describes the session on a short form that I provide. They indicate the child's name, which parent is reporting, what happened during the session, and their comments, observations, and/or feelings during the Talk Time. This form is provided via an email attachment (If a computer is not available in the home, then a hard copy of the form is used.). The parent is instructed to complete the form each week (two entries for each parent) and then forward it back to me. Thus, I have three separate reports at the conclusion. I acknowledge receiving each form but provide no feedback at this point. I do not want to influence what they might say or observe.

This three-week assignment provides four important pieces of information. First, it tells me if the parents either will or can follow instructions. There is no reason to assume the parents will be able to complete additional steps if they do not complete this first assignment. As a result, a home program may have to be abandoned in favor of an in-school model.

Second, this assignment establishes a routine for the parent and child to set aside time to communicate. This time together will provide the basis for speech assignments to be conducted at home.

Third, this assignment allows the parent to inform me about what they see, feel, or observe about the fact that their child stutters. This is often critical information that may have a direct impact on all future goal development.

Fourth, information gained during the three weeks makes it possible to determine if the child needs to be enrolled formally for speech services. It is not uncommon that monitoring the child through the Talk Time procedure is all that is required.

I try to schedule another meeting with the parents after this assignment to discuss what they reported. If this is not possible, then we can visit at the time of the required Admission, Review, Dismissal (ARD) meeting provided the required evaluation has taken place. The purpose of this meeting is to approve goals and initiate speech and language services.

Philosophy of Management: I believe that stuttering is a problem that needs to be solved, not necessarily a disorder that needs to be treated. Therefore, I use a problem solving procedure initially to determine what specific problems need to be addressed. After twenty plus years of approaching stuttering therapy from this perspective I have been amazed at how many times the problems identified by the child and/or parents involve coping with stuttering rather than direct speech therapy for stuttering. Speech-language pathologists have a greater chance of being successful working with children in a school setting if they step back from being the primary decision maker regarding management. The major stakeholders (parents and child) should play the leading role in identifying specific problem(s) and what should be done about them. Then, the child and the communication environment can learn the relevant variables to solve the problem(s) and work with the speech-language pathologist on if or how to proceed.

The details of the problem solving procedure can be found at Mallard (1998b). Basically, when the child is faced with a communication situation that may be difficult such as giving an oral report in class, the following steps are followed:

1. The specific problem is identified. This may be more involved than it first appears. Consider the following interaction:
   Child: I have to give a report in class and I don't want to.
   Clinician: What is the problem?
   Child: I stutter.
   Clinician: We both know that but what is the problem?
   Child: I will be teased. The class might laugh at me.
   Clinician: Is stuttering or dealing with the teasing the problem?
   Child: Dealing with the teasing.
   

   Thus, the focus of attention should be directed to dealing with teasing, not teaching techniques to control or avoid stuttering.

2. List all options for dealing with teasing that can be imagined without discussion. Think creatively.
3. Eliminate the options that are not possible or that are not acceptable. For example, one option might be for the child to give the presentation to the teacher only. This option would not be in the child's best long-term interest. Reinforcing avoidance of meeting a speech-related activity is not teaching the child to accept responsibility for facing and managing his problem in the real world.
4. Prioritize the remaining options from most likely to implement to least likely to implement.
5. Discuss the positive and negative consequence of implementing each option.
6. Reprioritize the list if necessary.
7. Implement the option that is most likely to be implemented with success.
8. Evaluate the results of the implementation after a reasonable time.

Goal 1: The first goal is to keep eye contact during talking, especially during moments of stuttering. The IEP goal would be stated something like, "David will keep eye contact during conversations." The initial performance criteria will be akin to 60 to 70% of a designated time during one or two days a week. The child, teacher, and I negotiate the specific times for practice. The Talk Times will probably be the times decided by the parents. The teacher and student can discuss a time for school. We normally develop an indiscreet signal for the teacher to use to remind the student to keep eye contact. This is decided by asking the child, "What do you want your teacher to do to remind you to keep eye contact when talking with her?" Such things as touching her eye, nodding, or something that does not attract attention is encouraged.

Reinforcement signals are also developed for the teacher and child. The question for the child to accomplish this procedure is, "What would you like for your teacher to do to signal "Good job.'" A wink, smile, or some other positive gesture is chosen normally.

Please note that all questions of management are directed to the child to decide or to negotiate. It is important to establish that it is the child's responsibility to determine how speech is to be managed. It is when the child takes responsibility for speech change that independent improvement can take place. If the child decides that treatment is not wanted or warranted, then that decision can be negotiated and perhaps honored.

Goal 2: The second goal involves stuttering in a relaxed manner. This involves desensitization through voluntary stuttering with control. It is explained to all concerned that teaching behaviors to not stutter can be an avoidance that can lead to increased tension and struggle, thus compounding the problem. The child begins by learning to stutter voluntarily using easy repetitions while keeping eye contact. I always begin with the child and a parent or teacher present. It is best, of course, when both a parent and teacher can be present at the same time. We begin with easy repetitions at the beginning of individual words and then incorporate those words into sentences. We then move into structured conversation in which the child is encouraged to feel how easy stuttering can be when it is controlled on purpose. It is explained that keeping eye contact maintains communication contact between the child and the person(s) being addressed. In addition, stuttering on purpose serves to decrease the fear of stuttering "happening to me" and gives the child confidence that the stuttering moment can be controlled by not getting tense and trying to avoid.

The identification and reinforcement procedures described above for eye contact are used for easy stuttering with eye contact. The times when the child is monitoring speech involve private conversations between the child and teacher, usually at the teacher's desk. Liberal reinforcement of the child's success is encouraged on a daily basis.

The five-minute Talk Times are used several times a week with the parents and child to transfer skills used at school to the home environment. The parents communicate with me via emails or telephone conversations when questions or problems arise.

These are the main goals that I use when working within the constraints of a school setting. Accomplishing these two skills not only provides a strong foundation for further speech work as needed, but they address the important issues of reducing secondary struggle and desensitization.

When using the procedures described above, the role of the speech-language pathologist changes from that of the primary service provider to that of a monitor of how the teacher, parents, and child are progressing. "Therapy time" is taking place in the normal classroom environment and at home. As a result, the child is not removed from the classroom and stigmatized as having to go to speech. Furthermore, success is being achieved on a regular basis with easy to monitor goals, giving the child confidence in the ability to communicate with control. The schedule of services on the IEP is described as a "Home Program." The times of treatment in the school environment are flexible and can be described as "no less than" a minimal contact time per evaluation period.

The following statement from the parents of a fourth grade son summarizes the potential effect a program such as described in this article can have. Notice the parents focused on problem solving procedures as the key to success, not specific speech change or fluency enhancing procedures. Other clinical reports support the same finding (Mallard, 1998a, b).

Dell, C. W. (1980). Treating the School Age Stutterer: A Guide for Clinicians. Memphis, TN: Speech Foundation of America.

Mallard, A. R. and Westbrook, J. B. "Variables Affecting Stuttering Therapy in School Settings," Language Speech Hearing Services in Schools, 19, 1988 (362-370).

Mallard, A.R., "Encouraging A Broader Perspective in Judging the Effectiveness of Stuttering Therapy." Journal of Fluency Disorders, 23, 1998a (123-126).

Mallard, A.R., "Using Problem Solving Procedures in Family Management of Stuttering." Journal of Fluency Disorders, 23, 1998b (127-135).

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