STUTTERING PREVENTION: A MANUAL FOR PARENTS

C. Woodruff Starkweather, Ph.D.

Sheryl Ridener Gottwald, Ph.D.

Murray Halfond, Ph.D.

Temple University Stuttering Prevention Clinic

INTRODUCTION

This manual is for parents who are concerned that their child might be stuttering. When very young children -- two to six years of age -- begin to repeat sounds, syllables, or words in their speech, parents often worry that the child is going to become a stutterer. They will worry even more if the child repeats these parts of speech often, if the repetitions last a long time, or if they are accompanied by other behaviors. Fortunately there are a number of specific things that parents can do, at home or with a speech pathologist (speech therapist), that can prevent the child's speech pattern from developing into a chronic stuttering problem. If you cannot see a speech pathologist, you may be able to improve your child's speech effectively on your own, but there is no question that you will be more successful in removing or preventing stuttering if you work under the guidance of a speech pathologist who has been trained in stuttering prevention.

Make no mistake about it, when stuttering has fully developed, it is a severe disorder that places a heavy burden on the child. A child who is afraid to ask questions or talk to other adults or children may not develop as quickly, academically or socially, as a child who likes to talk. Once established in an older child or adult, stuttering is difficult, often impossible, to control. But in children under five, or when the disorder has been present for only a year or so, parents and speech pathologists, working together, can usually prevent this from happening.

The material presented in this manual is based on experience gained over the years at the Temple University Stuttering Prevention Clinic. The method used in this clinic, developed after years of research, has been highly successful in preventing the development of stuttering in children. We have seen many young children, from two to six, who are beginning to stutter. In almost all cases, the disorder has been stopped from developing and the child has become a normal speaker. If there is one lesson we have learned, it is this: The cooperation of the parents in carrying out the suggestions made by the speech/language pathologist is vital. Without the parents' efforts at home, the program is not likely to succeed. Parents do not cause stuttering, but there is much that they can do to prevent it from becoming a chronic problem.

WHAT IS STUTTERING?

Every parent wants to know the answer to this question. But the answer is complicated and requires some understanding of how speech develops in the normal child. When children are about a year old, they typically say their first words. These are single words, which the child uses for a variety of purposes. By two years, the child has usually begun to put two or three words together, and is producing primitive sentences like "Mommy go?" "Want truck," or "See doggy." Usually, at this stage, the child's pronunciation of sounds is imperfect, the tempo of speech is slow, and each syllable is given equal stress. The sentences given above would be pronounced "Mama go," "Want twuck," "tee dawdaw," or something like that. Between two and three years of age, these primitive sentences become longer and more elaborate, pronunciation improves somewhat, and the children begin to talk more quickly and with a more grownup rhythm. Instead of saying "dawdaw" for doggy," a three year old would be more likely to say dawdy," still mispronouncing the "g" but producing the correct rhythm of the word, with the accent on the first syllable. It is during this stage of development, that children learn to produce unaccented syllables. This development, which goes unnoticed by most parents, enables the child to talk faster, and that is important because it is just at this same time that the child is beginning to use longer and more complex sentences, and it is also just at this time that the child is beginning to notice many complicated things about the world, which the child wants to talk about in those longer sentences. The drive to communicate at this age is very powerful, and the child will be frustrated by anything that gets in the way of the communication of ideas.

Quite a few children, at this stage of development, begin to repeat words or syllables, usually at the beginning of a clause or sentence. They say things like "I, I, I, I, I, saw a big, a big truck in the, in the street. And, and, and it, and it, it -- Mommy do trucks do wee wee?" In this sentence, you can see some of the things that make children hesitate -- a confusing thought, uncertainty about some event in the world, a complicated sentence to produce, perhaps a doubt about the politeness of the question. When children hesitate in their speech, they tend to repeat phrases, words, and syllables. Later, when they are older they have more sophisticated ways of hesitating -- saying "well," "like" and "um" for example. But at this age, they just repeat elements. Sometimes, if they are very unsure of themselves or of how to say something, or if they are very excited or nervous, they will continue to repeat for a very long time --- "Mommy Mommy, Mommy, Mommy, Mommy, Mommy I saw a birdy and he, and he, and he, he, he, he, he, he, he wash his bottom in the dirt." These repetitions of whole words or syllables, even the long ones, produced easily and without evident concern, are probably not very abnormal, unless they occur often. They are just the way the child talks who has more to say, or who wants to say more, of who wants to say it more quickly, than his speech mechanism or language skills can accommodate. But even though they are not too abnormal, these repeated elements, particularly when they are a common feature of the child's speech, mean that there is a risk that stuttering can develop. We believe that any child at risk should be dealt with. If the risk is small, it is easier to deal with, but stuttering is too awful a problem to just "wait and see."

The word fluency is used to refer to the ease with which speech is produced. The three year old who is highly fluent will say "But, but Daddy, if I, if I can have the candy now, I'll still eat my dinner." The less fluent child, less sure of which words to use, less sure of the grammar, and not so quick at moving his tongue, lips, jaw, and voice might say "But, but, but, but Da-daddy, if, if,, I have the ca-candy now, I, I, I, I'll still, still eat my dinner."

We like to think of two aspects of speech development that affect the child's fluency -- the demands for fluency, and the child's capacity for fluency. By capacities, we mean the skills and abilities that are required to talk -- the ability to move the speech mechanism to make sounds, the ability to choose the right words, the ability to compose the sentences so that others will understand, and the ability to know what is an appropriate thing to say under the circumstances. Naturally as children grow, these capacities for talking fluently are also maturing, and the child finds it easier and easier to say what he wants to say. We can tell that children find it easier to talk because they take less time to produce sounds, to find words, and to construct sentences. As a result they talk faster and with fewer hesitations and repetitions.

Demands for fluency come from the people the child talks to -- parents, brothers and sisters, friends -- and from the child too. As children grow, more is expected of them, and a child who is smart enough to think of the argument that he or she will eat dinner even if some candy is eaten now, is expected to be able to speak easily enough to utter the argument without too much hesitation and at a rate of speech that is age-appropriate. Not all of the demands for fluency come from the people the child is talking to. Some of them come from within the child. Just as parents expect a child to produce speech that is appropriately fluent for the child's age, intelligence, and linguistic sophistication, so too does the child have some sense of how easy it should be to talk. Some children have a lot to say but lack the capacity to say it easily, and they may become very frustrated because they expect more, demand more, of their speech mechanisms than it has the capacity to produce. As long as children's capacities for fluent speech are developing fast enough to meet the increasing demands that are made on them, including those they make on themselves, they will not hesitate, repeat sounds, stutter, or stumble in speaking very often. But when too much is asked of the mechanism, children will try to make it do what it lacks the capacity to do. And as a result, their speech will contain more than the usual amount of repetition of words, syllables, and phrases.

If, in addition, they find the presence of those repeated elements too time-consuming, or if they come to believe that these repetitions are bad, that they shouldn't talk that way, they will try to force the repeated words out, they will try to repeat the words and syllables faster so as to get to the rest of the sentence, and they will start to struggle when they talk. This struggle to talk, manifested by an unusual amount of repetition, by the repetition of smaller elements of speech such as syllables and sounds, by the presence of vocal strain and tension, and by the presence of muscular tension in the speech mechanisms, is stuttering

Unfortunately, we don't know very much about why stuttering develops in some children but not in others. There is clearly a tendency for stuttering to run in families, and some of this tendency seems to result from inheritance. Genes do make a difference, but it is also clear that they do not make the entire difference, since there are many children whose parents stutter but who develop normal speech, and there are many children who stutter despite having no one in the family who stutters. Besides, the way in which stuttering develops is clearly a result of the child's interaction with his or her immediate environment.

We do know that stuttering is not caused by tickling the child, nor is it acquired by imitation of some other child who stutters. We also know that the child who stutters is not retarded or mentally ill, and that he or she does not have a personality disorder. Sometimes children who stutter are socially withdrawn, shy, or nervous, but these are probably reactions to the disorder. Nevertheless, these reactions probably do make the problem worse.

Some children do not follow the gradual path of development described above. Instead, they begin to stutter suddenly, usually under circumstances that involve emotional distress, either sudden or prolonged -- absence of one or both parents, moving to a new location, starting a new school, death or serious illness in the family, hospitalization of the child or of a sibling. Typically also, the emotional distress is somehow related to speaking, and there is sometimes a period of not talking at all (mutism) before the child begins to stutter. Stuttering can also develop suddenly following a head injury, but this is quite rare in children.

NORMAL FLUENCY DEVELOPMENT

The ability to speak fluently is a skill that develops as children grow. All children, especially between the ages of two and six, occasionally stumble or hesitate as they begin to put sounds, words, and sentences together. These normal disfluencies are different from stuttered speech, both in the number of times they occur and in the way in which they are produced. The following are examples of normal disfluencies:

1. Whole word and phrase repetitions -- "My, my ball is on the roof." I want, I want to get up."

2. Revising sentences -- It went, My ball went on the roof."

3. Pauses filled with um, ah, uh -- "I want my, um, ball."

4. Silent pauses such as hesitations -- Daddy, I want (pause) my ball."

5. Infrequent, easy, single, part-word repetitions -- Y-you said you'd get it."

Children vary widely in the number and types of normal disfluencies they produce. Some children will remain quite fluent except for an occasional hesitation or pause. Others are obviously disfluent, showing the entire range of normal disfluencies described above. In general, the most common normal disfluencies are whole-word repetitions, and these occur most frequently at the beginnings of sentences. Boys seem to show more word repetitions than girls, but both boys and girls show fewer repetitions as they grow.

You may notice that these normal disfluencies occur more frequently in your child's speech at certain times. Normal disfluencies seem to increase under some conditions. When your child is excessively tired, excited or in more formal speaking situations such as speaking with and adult, disfluencies will typically increase. Talking with a partner who speaks much faster than the child or who is non-attentive may make it more difficult for the child to remain fluent. Likewise, when the child interrupts, tries less familiar vocabulary words or attempts more form language, the number of normal disfluencies can be expected to rise.

SYMPTOMS OF RISK

There are three general areas of risk -- the amount of repetition in the child's speech, the amount of struggle in the child's speech, and the parents' attitudes toward and reactions to the child's behavior.

Children who have more repetition and hesitation in their speech are more at risk than children who have less. The more hesitant and repetitive the child is, the more likelihood that he or she will begin to be frustrated by these barriers to rapid and easy communication and the more likely that speech will begin to be struggled, forced, and tense.

Children who are already beginning to struggle in their speech are of course more at risk than those who are not showing any signs of muscular tension. However, the development of this struggle and tension is usually (there are exceptions -- see below) quite slow, and the earliest signs are quite subtle. One of the early signs is a rising pitch of the voice during the repetition of a word or syllable. As the word or syllable is repeated, the vocal pitch rises almost like a siren. This rise in pitch is a sign that the vocal cords themselves are becoming increasingly tense, like tightening a guitar string while playing a note.

Another early sign is shortening of the repeated element. If a child who has been repeating whole words, like "But, but, but, but...." starts to begin sentences with "bu-, bu-, bu-,..." cutting each word off before it is completed, or even b-, b-, b-,b,, trying to push through the repetition, to get it over with, to get to the rest of the sentence. Similar to this sign, is an increase in the tempo with which the repeated element is produced. Many children start out saying "Can, can, can, can I..." progress to "Ca-, ca-, ca-, can I ..." then to "C-,c-,c-,c-, can, I" and finally to "cccccan I."

Another early sign is a change in the vowel itself. The child who says "Mom, mom, mom, mommy" is less at risk than the child who says "muh, muh, muh, mommy."

Once a child has begun to show evident signs of struggle, tension in the facial muscles, body movements, gasping for breath, hard blinking of the eyes, or using a very loud voice, he is not simply at risk but really is stuttering, perhaps severely. Similarly, the child who shows, by his attitude toward speaking and toward social situations that he is afraid or embarrassed to talk, or who abandons sentences that he has begun is also well along in the development of stuttering.

A third category of risk is the parent's attitude. Unlike many programs, the Temple University Stuttering Prevention Clinic accepts for treatment any child whose parents are concerned that the child is beginning to stutter. We do this for two reasons. One reason is that the parents are almost always right. We have only seen two cases where the parents were worried and the child was actually not at risk. But our second reason is that parents who are worried about their child's speech react differently to it. They almost always feel badly when the child stutters, although exactly how they feel varies. The disfluency may make them upset, nervous, angry, or depressed. It may be almost feel painful to watch a child struggling to talk. These reactions are perfectly normal, in most cases, and usually stem from the parents' love and concern. But often, in spite of their good intentions, the way the parents react to disfluent speech communicates inadvertently to the child that disfluent speech is to be avoided at all costs. The child reacts to this by struggling more and struggling harder, which actually makes the stuttering worse. So the concern of the parents may end up contributing to the problem, and we treat it as a risk factor.

HOW PARENTS CAN HELP -- ENHANCING FLUENCY AT HOME

When parents come to us for help, it is interesting to note that they are already doing many helpful things for their child, although they may be unaware of them. Reviewing the following list of suggestions will help you identify those things you are currently doing that make it easer for your child to speak fluently. By identifying these things, it will then be easy for you to increase the frequency with which you do them. Also, you may wish to implement some of the other suggestions, until you are no longer concerned about a risk of stuttering developing. Rather than attempting to master all of the suggestions at once, choose one or two new strategies each week. This gives you and your child enough time to gradually adjust to the changes you'll be making. On final word of caution. Each family is unique and not all of the suggestions to follow will be appropriate for all families. Apply only those that seem useful to your particular situation.

Listening Differently

Most likely, your child is at a stage of development where there is significant growth in the ability to use language. There may even be times when the child is talking so incessantly that you wonder if it will ever stop. When children are in this stage of growth, parents necessarily listen selectively. The purpose of this section is to help you examine how you listen and provide some suggestions for selective listening that convey to the child your interest in and respect for his or her communications.

You can begin this process by playing a bit of the detective role. In order to begin adjusting your listening style, you will need to know what that present listening style is. Over the period of a week, step back as an objective third party might and observe the ways in which you listen. Jotting down some notes in a log book as the thoughts occur may help you to focus in on the larger picture at the end of the week.

Since you cannot listen with all ears every time your child talks, mentally note the topics that interest you as well as the topics that your child chatters on about that are not as interesting to you. Do you tend to listen to every word when your child tells you about something dangerous he's just done, but with only half an ear when he's chattering on about a TV rerun you've seen three times? Identify times of the day that your child seems more interested in conversing, as well as times of the day when you have energy to listen more intensively. Do you have difficulty doing anything before your first cup of coffee in the morning, but that's when your child comes bouncing into your bedroom full of stories: When you are listening to your child, examine your body position and eye contact. Are you likely to be engaged in another activity such as washing the dishes or reading the paper during these conversations?

Once you have a feeling for how you listen, you may want to begin making some changes. If there are times of the day that seem to occur consistently where things are just too hectic or when you are just too tired to listen well, set up a quiet time activity. When you are frazzled and worn out, you can't listen as effectively. Your child may interpret this as a message that he or she is not interesting or not worth listening to, when that's not the case at all. Everyone can benefit from quiet time during the day; it is generally a time to relax and unwind, without the pressures of interacting with others. Children and adults should engage in some nondemanding activity by themselves such as reading or looking at books, quiet play with puzzles or even watching TV. Little or no talking should be allowed during this time. This quiet time should be a consistently scheduled time, so that each day, family members will expect it to occur and accept it as part of the family routine.

You can also try adjusting somewhat to your child's schedule to provide more intensive listening. Families we have worked with have come up with some creative solutions that seemed to make a big difference in their lives. One family got up half an hour earlier in the morning, to provide more time for quality listening at a time when the children were very interested in talking. Another family postponed doing the dinner dishes until after the children went to bed in order to spend that half hour listening more carefully. The important thing to learn is that the changes you make can be minimal, maybe only affecting as much as a half hour of your day. Yet that one half hour that you have allotted for more selective listening may make a world of difference to your child.

When you are listening to your child more intensively, try increasing the amount of eye contact you make. Looking at someone when they're speaking communicates interest. And open posture with arms unfolded and legs uncrossed also indicates a willingness to participate in your child's conversation. You will want to follow your child's lead, rather than introducing new topics yourself.

When your child speaks, practice listening for the ideas expressed rather than focusing on the way he or she is speaking. This will take discipline, especially if your child speaks very slowly or struggles through the words. By responding to how your child talks (i.e., "You're talking too fast" or "Take a breath.") you are giving the message that what the child is saying is not worth listening to AND that he or she is a failure at producing the message as well. By responding to the content of the message, you are telling your child that you are listening and that you are interested in what your child has to say.

Speaking Differently

Slowing Down. Most adults speak almost as quickly as is physically possible. Young children speak much more slowly, since they are just learning how to coordinate the speech mechanism. When children speak with adults, they attempt to match the speaking rates of the adults they are conversing with. They are consequently under some time pressure whenever they speak to an adult who is speaking at a typical adult rate. Fluency can be compromised whenever there is time pressure; it is one of the most common demands on fluency. One thing parents can do in this regard is to slow down while speaking to or in front of the child. "Try talking as slowly as your child talks. Some parents have found it helpful to tape record their child and then listen to the tape focusing on how fast the child produces words. Replay the tape and this time, try saying the same words as your child along with the tape it is this speed that you should try to maintain. Rather than chopping up the words in a sentence to slow down, draw out the sounds and let one word flow into the next. Slowing down is not easy, and you will need to consciously work at it when you are with your child. As you learn to slow your speech rate down, you will feel a sense of relaxation. This is another sign that you are slowing enough to reduce time pressure on the child. It is worth reminding parents that they do not cause stuttering by talking too fast, but they can help the child become more fluent by talking more slowly.

Increasing Pause Time. Pause frequently while you talk. Wherever commas or periods would appear if you were writing your speech, stop and take a breath. This provides a model for your child that reduces time pressure and places value on carefully presented, well thought out speech.

Increasing Silence. Allow more time for silence in general. In this way, your child will learn that every second does not need to be filled with talking. This will help to reduce the pressure he may experience trying to keep a conversation going. In addition, a great deal of talking by parents stimulates the child's language development. Some children are stimulated so much that their linguistic skills develop way ahead of their motor skills to produce the sounds of speech, and stuttering seems often to result from this imbalance of skills.

Eliminating Interruptions. Let family members completely finish their ideas before someone else is allowed to speak. There are two things we know about normally developing children and interruptions. If children are allowed to interrupt others, they are more likely to stumble over their words during the interruption. Also, if a child who does not stutter is interrupted by another speaker, the child will most likely be disfluent if he or she tries to continue speaking. For the child at risk for developing a stuttering problem, interrupting or being interrupted can seriously interfere with fluency.

Reducing Certain Kinds of Questions. There are many things children must do in order to answer a question. First, they must figure out what the question means. Then they need to organize their thoughts to answer the question appropriately, and find the right words and grammar to respond with. Finally, they need to execute the message orally. All of this must be accomplished immediately, since that's what the question-and-answer format demands. Many questions, of course, are simple to answer, requiring only a brief response, but questions requiring long, thoughtful or narrative answers can be difficult for a child still developing language competence skills, and can contribute to fluency breakdown. It is advisable to refrain from asking your child questions that require a length oral response, such as "What did you do in school today?" or "Tell Aunt Corrine what you saw at the zoo." But parents need to find out what happened at school. We suggest that you make a few comments about your own activities. This will usually stimulate your child to begin talking about his or her activities as well. Tell your child what you had for lunch, or what you heard on the radio, or who you saw on the bus. If something pops into your child's mind at this time about the school day, he or she will spontaneously share it with you. Spontaneously shared information is much more likely to be fluent.

Modeling Normal Disfluencies. Parents are advised to provide a model of normal speech for their children. Since normal speech is not completely fluent, you will want to demonstrate for your child acceptable ways to be disfluent. Young children with normally developing speech frequently repeat the first word in a phrase or sentence one or two times. Young children will also pause and say um or uh as they are searching for words. Therefore, it is important that you occasionally model these acceptable forms of disfluency in a nonchalant, easy way. For example, when telling a child to go get his shoes you could " Go, go get your shoes: or "Go get your, um, shoes." The repetitions or pauses should be produced slowly and smoothly.

Conversing Differently

Talking with Your Child. Since a parent's role encompasses many responsibilities, you may find that the majority of time you spend conversing with your child is as disciplinarian or caretaker. Typically, during these times, the parent must talk "at" the child in order to give the necessary instructions or rules. It will be helpful to your child if you gradually increase the amount of time you spend talking "with" your child -- actually engaged in a conversation which is shared by both of you. In this way, talking becomes more of a pleasurable experience, something to anticipate. Engaging in activities with your child that the child enjoys doing sets the tone for quality talking. For example, as your child helps you make chocolate chip cookies, he or she is certain to begin commenting about the task. This is your cue to respond to the content of his message. Allow your child to introduce the speech topics and then follow his or her conversational lead.

Being Nonjudgmental. During this shared conversation time, be sure that your comments are nonjudgmental. Evaluation or the fear of being criticized inhibits most people, even adults. For a child who is at risk for stuttering, the fear of saying something wrong can lead to speech that is produced in a halting, stumbled way. This does NOT mean that you should not discipline your child for misdeeds. Children need the direction that discipline provides. But it is best not to make the child at risk for stuttering speak as a form of punishment. In other words, asking the child to explain why they did something wrong, or asking them to apologize or confess may not be the best form of punishment for a child at risk for stuttering.

Eliminating Nonspontaneous Speech. When speech is demanded from a child, the time and performance pressure experienced by the child can precipitate a fluency breakdown. Demand speech can take many forms, including asking the child to recite the alphabet, retell a story, or explain how Snoopy got stuck in the toilet. Even asking the child to say "please" and "thank you" can increase pressure enough to cause the child to be disfluent. For the time being, it is wise to eliminate these requests for speech performance. Modeling the appropriate social amenity for the child is just as effective in establishing manners as is having the child repeat the phrase on demand.

Dealing Differently with Daily Living

Increasing Routine. Many parents report that their children have more difficulty speaking during exciting times such as at birthday parties or on vacations. It might seem though, that because these are happy, fun times, it should be easier for your child to speak fluently. That is not the case at all. Birthday parties and vacations are examples of events that do not follow the daily routine. They are full of surprises and anticipation. It is this lack of structure and uncertainty that contributes to an increase in stuttering. It is suggested that a daily routine be adhered to as consistently as possible, even on the weekends. If the child knows that after breakfast, he gets dressed, then watches TV and then plays, the uncertainty he might feel is significantly reduced.

Preparing the child in advance for special events, such as a birthday party or a visit from grandparents, also helps to reduce the uncertainty that comes from anticipation. The child should be familiar with the exact sequence of events, and an effort should be made to keep the events as relaxed and predictable as possible. For example, rather than having a birthday party with a lot of friends in the middle of the day, plan a smaller family celebration at the regularly scheduled dinner time. If the family is going on vacation, allow the child an opportunity to help plan some of the activities and pack some of his clothes and toys. Again, the important idea to keep in mind is that the child should know what to expect and that as much of the daily routine as possible should be preserved.

Family Communication Rules. It is helpful if all members of the family develop more effective speaking skills. Developing family communication rules is a way to accomplish this task. The rules can be as simple as:

1. Only one person speaks at a time.

2. Everyone gets an opportunity to speak.

3. No one evaluates the contribution of another speaker.

These rules provide for orderly, fair, and safe family communication. Present them when the family is together along with methods for enforcing the rules. One family developed this strategy for monitoring the family's use of communication rules: Each family member began the week with 25 pennies in a cup. Each time someone violated a rule, they had to remove one penny from their cup. At the end of the week, the family members were able to keep the remaining pennies. Not only do rules such as these facilitate fluency for the at risk child, they teach the rest of the family patterns of interaction that will be helpful in any environment.

Daily Talking Time. It is advisable to set aside a small amount of time each day in which one parent can devote full attention to the child at risk for stuttering. It is important that your attention not be divided at this time. Leave the dishes or the lawn to be done at another time. Exclude siblings for a while and arrange for someone else to answer the phone. This special talking time does not have to be very long. Fifteen minutes seems to be enough, but it is best if it can be done every day at about the same time. During this time, engage you child in quiet play -- doing puzzles, reading stories or playing with play dough are all nondemanding activities appropriate for the special talking time. The goal of this time is to provide a regularly scheduled, nondemanding opportunity for your child to be with you, without having to compete with all the distractions of the outside world. It is likely that during this time you will be more relaxed. Thus you may be able to adjust your speech more easily. This will consequently facilitate easy speech from your child.

ATTITUDES AND REACTIONS TO STUTTERING

The Problem

Watching and listening as your child struggles his or her way through speech can be a worrisome experience. Parents report feeling helpless, frustrated and very alone. They are mostly worried that their child's hesitant speech will develop into a life-long stuttering problem, carrying with it social, emotional, and even educational or occupational limitations.

Stuttering Behaviors Make Parents Nervous. When a parent or other listener engages in a conversation with a child who stutter, feelings of anxiety, fear, embarrassment, impatience, and pity may be expressed outwardly through facial expressions or body movements. Some parents have freeze, even stop breathing, and then visibly relax when the stuttering moment ends. Others have said that the stuttering behavior is so painful to watch, that they turn away until the child finishes stuttering. Some parents try very hard not to react al all, but the underlying feelings and attitudes often show through anyway. These negative feelings and attitudes will affect the child who is at risk for developing a stuttering problem. The child senses that the way he or she is talking is wrong and consequently may try very hard not to stutter. The increased effort that is required to avoid stuttering also increases the muscle tension in the mouth, face and neck. If you have tried to play a sport when you were very tense, you will understand why speech fluency is more likely to break down under these tense circumstances.

A vicious cycle is created. The child has some disfluent speech which triggers negative feelings in the parents. These negative feelings are received by the child who then tries very hard tp speak in what he or she thinks is a better way. The increased muscle effort may cause the child to struggle and force through words, only renewing the anxious feelings in the parents.

Negative Listener Reactions Lead to Talking Fears. The child who receives frequent messages that the way he or she is talking is "bad" or "not right" may begin to lose confidence in his or her ability to communicate at all. For a young child, difficulty talking is easily generalized to difficulty doing ANYTHING successfully. As a child becomes more aware of difficulty speaking or experiences negative listener reactions, he or she is more likely to experience frustration, shame, poor self-esteem, or come to expect social disapproval. This lack of confidence can develop into a fear of talking or a deep sense of shame, that is, a feeling that you are not enough, or even defective. Fear of talking can easily develop into fear of specific words, speaking situations, and people. This reaction may vary from mild uneasiness to panic and can lead to the child avoiding speaking.

The Solutions

In order to break the vicious cycle that develops when disfluencies are reacted to in a negative way, parents can learn to react to the child's problem more positively. But this is not an easy thing to do.

Get the Facts. First, you will want to learn all you can about normal fluency development and stuttering. Getting the facts will help you to evaluate more objectively feelings and attitudes you may have acquired years ago. All speakers are occasionally disfluent, some more than others. Listen to the hesitations and repetitions that occur in the speech of your friends and relatives. Speech disfluencies are not always faulty speech attempts. They are ways for competent speakers to gain time to think while still maintaining control of the conversation. Normal speech is not without hesitations, pauses, ums and ahs, and other breaks in the flow.

From the ages of four to seven, a number of preschool children (25-50%) will experience a period of more than usual disfluency. About 50 percent of these children will outgrow the problem, even without speech therapy. For those enrolled in an early intervention or prevention program, the success rate is 95 per cent or better, and this seems to be true regardless of the approach that is used.

Deal with Stuttering More Effectively. When children stutters, it is best to let them finish the thought on their own. A general rule of thumb is not to interrupt your child during stuttering or at any time. There may be some exceptions to this rule. If your child is stuck on a word and is forcing very hard but still not able to say the word, you may ask if help is wanted. With permission, you may then say the word. By asking permission, you are still allowing the child to be in control his or her speech. This does set a bad example to the child, but distress and frustration at not being able to force the word out can also lead to further development of stuttering, so it is a difficult choice. Once a child has learned better ways to deal with stuttering than struggle, your help should no longer be needed.

It may seem to you that if your child would just slow down or take a breath, stuttering would not be a problem. . In fact suggestions such as these will probably only complicate the problem in a number of ways. First, it is likely that the stuttering is causing the breathing problems, rather than the other way around. As for slowing down, it is true that slower speech is more fluent, but it is very hard , even for an adult, to slow down all the time. For children, who tend to be more spontaneous anyway, slowing is even more difficult. But when you tell your child to talk in a different way, it tells him or her very clearly that what they are doing is wrong. You imply that if he or she would only do things differently, this problem could be solved. The child begins to feel hat he is not very good at talking. His self-esteem as a speaker, and as a person, begins to suffer You can compare this experience to the feelings you might have while attempting to play a sport you're not very good at. You feel defeated before you begin. Also, if the child continually hears suggestions that he can't implement, he may beginning to feel guilty and try harder to change his speech. In trying harder, the child may begin to struggle, developing tricks to help force out the words. This would be a worse stuttering problem, not a better one. Getting over stuttering is not simply a matter of will power. In fact, the attempt to talk fluently through as an exercise of will, typically backfires and creates more stuttering behavior.

Increase Your Tolerance for Disfluencies. While speaking with your child, you may become distracted by the repeated words or syllables or blocks. Through practice and discipline, you can learn to focus on what the child is saying and not on how the child is saying it. Many adult stutterers say that they never felt that anyone heard them as a child. Everyone was always listening to the stuttering. Being heard is an essential ingredient in any relationship, and it is particularly important for children talking to their parents. It is important that you work on gradually developing a tolerance for disfluent speech. By responding to children's content rather than the disfluencies, you show them that you value them and the time you spend talking to them. Despite the disfluencies, the children feel that they are worthwhile as communicative partners. Their self-confidence as speakers will remain intact.

Feel Free to Talk about Stuttering. Stuttering should not be ignored. It is easy to understand, though, why families might avoid talking about stuttering. Stuttering does seem like a nervous kind of problem and talking about it might even make the child more nervous. However, that is not the case at all. When the child is struggling and disfluencies are obvious but no one talks about them, a problem may develop which has been called "the conspiracy of silence." Even the very young child who stutters knows that he is talking differently or that speech is a difficult thing to do. He or she will begin looking to the parents for help and support. When no one talks about the difficulty, the child may begin to think that his or her speech is so bad that it must remain hidden. Many stutterers develop a deep sense of personal shame over their stuttering as a result of this pattern of parental reaction. Other children may come to believe that stuttering is somehow inaudible. These are not healthy reactions. A stumble in speaking is not much different from a stumble in walking. You need to pick yourself up and go on. If a child falls down, the parents help the child get up, make sure he or she is not hurt, and go on. The child who is stuttering also needs some brief reassurance and emotional support.

It is suggested that if the stuttering is obvious, parents feel free to talk about it with their child in words that the child will understand. The object of this suggestion is two-fold. First, in talking about the problem, you are acknowledging that it exists and that you are there to help and support the child. Second, by acknowledging the problem in a matter-of-fact way you are reassuring the child that the problem is not catastrophic. It is important to use words that the child can understand. If your child's speech behavior contains repetitions, the word "bumpy" may be appropriate. If the child prolongs sounds or blocks, "sticky" or "hard" may be appropriate words. Frequently, the children will come up with their own words to describe the problem, if given the opportunity. For example, one two and a half year old child talked about the words "getting stuck inside my mouth" so her stuttering was referred to as "sticky speech." Another prolonged vowels and this reminded him of pulling bubble gum apart, so he called it "bubble gum speech." If the child has learned to call his problem stuttering then that word should be used to talk about the disfluencies. The only caution here is that have a stuttering problem and being a stutterer are two very different things. Your child may have a stuttering problem, but he or she is also fluent many times during the day. And the child is probably going to become a normal speaker. It's too soon to put a label on the child, particularly one that describes only a small portion, and an undesirable portion, of speech behavior. If we can separate children from the behavior they perform, they can learn that they are good and valuable people even though their behavior is not always perfect -- a good lesson for all of us.

It is appropriate to comment in a neutral way from time to time on the child's stuttering after the child has finished speaking. You can tell the child that yes the speech was a little bumpy just at that moment and that sometimes people have bumpy speech. Make your own speech a little bumpy (but not forced or struggled) every once in a while to show that it is not something to be afraid of. Mentioning the child's bumpy speech and showing some of your own help let the child know that we all have bumpy speech once in a while. It is most important that the child learns that despite the repetitions, he or she is accepted and loved. But this does not mean that every time the child stutters he or she should get a hug or a pat on the head. This would tell the child that he or she is loved because of the stuttering, and that would be wrong too.

Build Self Confidence. Since children's sense of self-esteem and self-confidence as a speaker may be at risk because of speech breakdowns, it is important to counteract this by providing many opportunities for positive experiences. First, a parent can increase verbal praise. Children need to hear periodically that their parents enjoy being with them, enjoy talking to them and are happy with who the child is. To help in this endeavor, you might want to think about what you like about your child and in what areas your child does well. In addition to increasing praise, parents can provide more opportunities for children to engage in the things that they do well, while minimizing opportunities for things they struggle with. If your child is good at sports and vigorous play, frequent trips to the park might be scheduled instead of more activities such as board games or arts and crafts, which usually involve more speech. If you notice that your child is having a particulary easy time speaking, provide more opportunities for conversation. Likewise, minimize speaking time if stuttering seems particularly severe by engaging your child in nonverbal activities such as listening to records or singing. But don't make this obvious or rigid; it could also teach the child not to talk when stuttering is present.

CONTACTING A SPEECH/LANGUAGE PATHOLOGIST

When the Contact is Appropriate.

You may be wondering at what point you should consult with a speech pathologist about your child's disfluencies. When a child exhibits any of the warning signs described earlier in this manual of if anyone expresses any concern about the child's fluency skills, a speech pathologist should be contacted. It is unwise to postpone this appointment, hoping that the problem will solve itself. Although some young children with stuttering problems do get better without help, many do not. Generally, the earlier intervention is begun, the shorter the therapy program will be.

How to Make the Contact. Finding the right professional(s) to work with your child is a process that should be conducted carefully. There are a number of agencies and individuals that provide speech services; you will want to find one that has experience treating preschool children with stuttering problems.

The American Speech-Language-Hearing Association has a help line number that may be called if you are having difficulty locating a speech pathologist. If contacted, they will provide a listing of services available in any geographic area requested. Their toll free number is 800-638-TALK (8255).

The public school system also provides speech services to children, including children who are not yet of school age, who may be at risk educationally as a result of a speech problem. Stuttering can interfere seriously with education because school aged children who stutter are often afraid to ask questions, and will sometimes pretend not to know the answer to a question so as to avoid speaking. The local school principal or counselor will be able to provide you with information about this service.

Many large universities and hospitals have speech and hearing centers. The speech departments in these institutions should be contacted. If the agency called does not have a program for or a staff member who specializes in treating children who stutter, they should be able to refer you to another agency.

Fees for speech therapy services vary widely. If your child is seen through the public school system, you will pay no out-of-pocket expenses. In addition, therapy services may be provided locally. Many universities offer significantly reduced rates because their primary goal is to train student clinicians. Although in this case, the service providers are less experienced, students are typically well supervised by an experienced faculty member. Also university settings frequently offer the most updated, innovative techniques, since they are teaching and research centers as well. Finally, hospital and private practice settings, although typically more costly, many be able to provide you with a carefully individualized program implemented by an experienced clinician or specialist. Administrative staff may be able to assist you in identifying third party payment sources to help with the fee.

It is most important that you feel comfortable with the person and agency you choose to work with your child. If you continue to have concerns about your child that are not addressed, securing a second opinion should be considered.

Often the speech pathologist will want you to see other professionals as well -- a family therapist, a psychotherapist, a physician, an audiologist, or a dentist. Also, the speech pathologist will want to talk to your child's teacher or day care worker, both to get and to give information. In these collaborative endeavors, the speech pathologist will generally be the one coordinating the activities of all members of the team so that the ultimate goal of better speech is attained.

THE GOALS AND PROCESSES OF EARLY INTERVENTION PROGRAMS

When speech pathologists intervene to prevent stuttering from developing, they do so with some sense of urgency. Stuttering is a disorder that begins in a relatively benign form -- usually the child is repeating words or syllables but is not struggling or forcing, and quite a few children talk in this way -- but gradually speech behavior becomes more and more tense, the units that are repeated become shorter, the child may react emotionally to the problem, and the child is talking less and less like his or her peers and more and more abnormally. The speech pathologist, aware of the possibility that the disorder can develop in this way wants to intervene soon and effectively. At Temple, we see parents and children once a week, but we see them for two hours each, with different clinicians working simultaneously, a luxury we can afford because we are a teaching clinic. Other speech pathologists may see the parents and children separately but more often.

The first goal in any treatment program is to assess the child's present state, and to understand from that assessment just what the problem is. In the case of stuttering, that will mean observing and recording the child's and the parents' speech, taking a detailed case history of when the problem was first noticed and what it was like when it was first noticed, and how it has changed since then. Many clinicians will also perform an analysis of the child's language skills at the same time. With all this information about the child's present and past speech behavior, the clinician is in a good position to plan therapy.

The first goal of therapy is to stop the disorder from developing any further. This is usually easy to do. The first line of attack is usually training the parents to slow down the rate of their own speech, which gives the child a more relaxed speech model and removes time pressure. Of all the therapy goals, slowing the rate at which parents talk to their children has proved the most effective and efficient way to decrease the number of disfluencies in the child's speech. That is not to say that it will work equally well with all children. It may not.

A second goal is to teach the parents better way of reacting to the child's disfluency. Most parents are worried and concerned and can't help but let this show. The child sees it and becomes concerned too. If parents show a pained expression, hold their breaths, turn away, tell the child to slow down or take a breath or think about what he or she wants to say, all of these reactions tell the child that he or she is doing something wrong. If they could slow down this would be good advice, but children at this age (and many adults) lack the control to do this. Taking a breath can lead to further struggle. So the clinician will want to help parents learn how to respond to a disfluent child in a way that doesn't increase struggle and tension. In addition, most clinicians will want parents to begin to talk about their own feelings and come to understand more clearly how they feel about the child's disfluency. This increased understanding and awareness leads to a calming of the parents's feelings, which in turn leads to a change in they way they react. It is pretty difficult for parents who are close to panic not to let their feelings show to the child. Children pick up on nonverbal reactions even more readily than adults. It is better if the parents can actually reduce their emotional reactions. Pretending to be calm is nowhere near as effective as actually being calm.

In some cases, it will be important for the clinician to find, with the parents, activities that parent and child can do together that will be mutually satisfying as interactions, but will involve less talking.

There are a number of other instructions that clinicians will give to parents. Interruptions are to be avoided as much as possible, both interruptions of the child and interruptions by the child of others. Sometimes the whole family needs to learn new ways to converse. Many families live under daily time pressure. The whole household is rushed with multiple activities and little time to do anything. This general time pressure can translate into time pressure to speak, which makes it harder for the child to speak fluently. Some families are under a lot of tension for other reasons -- someone is ill or there is a source of emotional tension such as marital discord. All of these things make it harder for the child to be fluent in speech, and the clinician will need to examine each possibility and try to help the parents find ways to improve the setting so that it asks less of the child as a speaker.

Another common problem is the way parents talk, or don't talk, about speech to the child. Many parents believe that they shouldn't talk about stuttering to the child who stutters. This is an old idea, and there are some speech pathologists who still believe it. We hope there aren't many, however, because this practice deprives the child of an important source of emotional support -- his parents -- at a time of crisis. However, we do think it is important for parents to understand how to talk to a child who is disfluent, what words to use, and how to approach such a topic in a way that reassures and helps the child. So an important therapy goal can be training the parents in ways to talk to their child about disfluency and stuttering.

All of the goals mentioned so far are ways to improve the environment around the child to make it less demanding of fluency. There are also many things that the clinician may want to do to change more directly the way the child talks. These more direct efforts are aimed for the most part at slowing the child's speech through modeling and at reducing and eventually removing the struggle and tensions from the child's speech. Sometimes, with an older child, a system of rewards is used, but more often, and particularly with younger children, modeling is the preferred techniques. Since children may need to learn easier and less tension-filled ways of being disfluent, parents may be asked to learn how to model easy, calm disfluencies in front of the child. There is the potential for alarming the child in this technique and it is best not to attempt it without consultation with and training by the speech clinician.

When these techniques are all put together, and when the parents are able to extend the therapy activities into the home by carrying out the instructions of the speech clinician, there is usually rapid progress. If the child has been excessively disfluent for less than a year his or her speech should, in fact, begin to improve almost immediately. The most rapid progress we have seen has been a disappearance of the symptoms in three or four weeks of therapy. On the other hand, some children, particularly those who have been disfluent for a longer period of time -- over a year -- may take much longer, up to a year, before they begin to speak normally But even if it takes two years, the child should eventually speak normally. Even after they have been speaking normally for a while, however, some of the children appear to be vulnerable to a relapse of stuttering in the event that they go through a stressful period such as might be brought on by a move to a new location, a change in school, a separation from parents, a marital separation, or illness or death of a parent or sibling. Relapse in preschool children is much less frequent than it is in adult stutterers.