The pediatrician faced with a parent expressing concern about his or her child's dysfluency or reactions to it runs several risks:
Parents of dysfluent children and adolescents are rightfully worried and have a lot of questions. The outcome, in answer to many questions parents ask, is unfavorable for many children who do not get the help they need at the right time. Are the dysfluencies in my child's speech normal for his or her age? (For many they are; for many they are not.) Will he "outgrow it"? (More than 20% will not. Many of the others will "outgrow it" only after years of stuttering and suffering from it, affecting the remainder of their lives.)(1) Are the ways we deal with it as parents helpful and safe? (Some ways are; some are not.) Will my child be teased for it in school? (Many are and, of these children, many are profoundly affected.) Will she ever start making phone calls, and if she does not, how will that affect her life? Will he be comfortable enough to ask for a date? Will she marry someone as bright and attractive as she is? Will he find rewarding work? Will she reach her full potential in life? Will he be able to become a physician like dad or an lawyer like mom?
This part of the short course presents this clinician's philosophy and way of evaluating children and adolescents for fluency disorders. First and foremost, stuttering evaluation and therapy should be client centered. Stuttering therapy should emanate from that specific child or adolescent, seen within the contexts of his or her specific environments. It should be designed with the client and/or the client's parents for the client. It should be holistic, addressing the problem in its full complexity (3) and should be aimed at long-term gains in the real world. It should be designed to be a positive experience and to have only positive long-term effects. Stuttering evaluation and therapy is an art as well as a science. Part III of this short course will describe this clinician's therapy approach, client centered stuttering therapy.
Purposes of the fluency evaluation are to formulate diagnostic impressions and recommendations, based on objective information, and to develop a therapeutic relationship and working alliance with the client and his or her parents.
Information gathered, on which impressions and recommendations are based, is qualitative and quantitative. It is obtained through direct observation as well as through reported observations. The information sought includes different aspects of dysfluency and reactions to dysfluency or to stuttering in a broader sense. The information also includes the nature of the child's or adolescent's communicative interaction, as well other speech and language functions, peripheral speech mechanism functioning, and hearing. Information is also obtained on environmental factors, other problems, and other etiological and prognostic factors. The effects of different factors are noted, when possible.
Assessment of disfluency behaviors is qualitative and quantitative. It is based on observations (including those made by parents and client, as appropriate) about as many speech situations as possible, whether quantified or not. This assessment includes noting characteristics and severity of dysfluencies, frequency of dysfluency (including of different types), duration of individual dysfluencies, speech rate, and other factors. To this clinician, physiological aspects of dysfluency (which are inferred as necessary) are more diagnostically and therapeutically significant than perceptual ones (e.g., what they sound like). Immediate physiological cause and effect relationships are sought for individual dysfluencies on oral, laryngeal, and respiratory levels. Perceptually, dysfluencies are identified as e.g., various forms of repetitions, prolongations, blocks, interjections, incomplete words or phrases, revisions, dysrhythmic phonation, or tense pause.(1)
Reactions to (or associated features of) dysfluency or stuttering in a broad sense are carefully explored, which are highly significant in terms of prognosis. These include behavioral, affective, and cognitive symptoms (symptomatic thought patterns). Behavioral reactions sought include struggle and tension in speech or in the speech system, tremors, autonomic nervous system responses, facial grimacing, generalized body tension, bulging muscles or veins, counterproductive coping mechanisms to get out of stuttering, crying about speech, loss of eye contact, dysfluency hiding, and speech avoidance. Affective reactions noted are e.g., frustration, helplessness, anxiety, fear, panic, embarrassment, shame, guilt, humiliation, anger, self-hate, bitterness, inferiority, hopelessness, and despair. Cognitive symptoms and factors sought include awareness or degree of awareness of the problem; counterproductive thought patterns, which may affect both behavior and emotions; decision making influenced by stuttering; a distorted self-concept; and decreased self-esteem.
Interaction is assessed in terms of verbal and nonverbal communication processes, e.g., use of, and coping with, interruptions; initiations of speech versus responses or extensions of someone else's topic; verbal turn taking; and use of body language. Information is also obtained about the amount of speech the person uses in different situations in relation to how much he or she wants to talk.
Other speech and language functions are informally screened for possible problems coexisting with a fluency disorder), and if indicated, fully evaluated at another time. Aspects of speech aside from fluency that are observed include articulation/phonology (production and making distinctions among speech sounds, i.e., the various consonant and vowel sounds) and voice (voice quality, pitch, loudness, and resonance).
Both receptive and expressive components of different aspects of language are observed, including vocabulary, syntax, grammar, and how these are used for different purposes.
Each child or adolescent and each set of parents are seen as unique. Flexibility is necessary throughout. The type of interaction used, the attitudes expressed by the clinician, and the types of relationships formed with the child or adolescent and each of the parents are of major importance to get at all aspects of the problem. Only this way can all aspects of the problem be considered and dealt with in therapy, for the best prognosis for the whole child. The atmosphere established is warm, low key, relaxed, and accepting, to set the tone for open, free, and safe communication, including of unspoken thoughts and feelings about the problem. The clinician attempts to give full attention to the client or the parents as people, showing through active listening what she hears them say. anything the child expresses about the problem is acknowledged, calmly, casually, and matter-of-factly, and is shown to be accepted as okay and common among children.
Before the evaluation, telephone communication takes place with the parents. The parents (and the client, if he or she is an adolescent) complete questionnaires providing extensive preliminary information and perceptions about the presenting problem and medical and developmental history. When appropriate, an audio- or videotape of the child speaking is provided by the parents ahead of time.
A parent interview takes place in private, preferably at a different time. The evaluation of the client will be extremely different if he or she is an unaware toddler at one end of the spectrum or an insightful adolescent at the other. For the unaware toddler, the visit is set up as an enjoyable free play situation in a cheerful nursery school type environment, with the parents and/or family, and with the clinician as a new adult friend. No formal testing occurs. An effort is made not to suggest to the child that his or her speech is being observed. An older child may have a conversation with the clinician on topics like pets, school, or favorite activities, and through sensitive probing start talking about the speech problem and any teasing about it. Use of drawings may stimulate talk about concerns and experiences. The child may read a passage aloud and perform other specific verbal tasks. The client is asked to carry out certain nonspeech and speech tasks as a test of his or her peripheral speech mechanism. An adolescent is interviewed in depth about the problem, performs some of the same tasks, and may speak in a variety of situations, e.g., on the telephone. After the evaluation of the client, findings and recommendations are summarized to the parents in private, or in part with the client, if he or she is an adolescent. Questions are answered and general plans jointly developed, considering what is best for that individual child or adolescent. The evaluation is discretely audio-and usually videotaped. At the end of the visit, the clinician might say to one preschooler "We will all play here again soon" and to another one "Do you know why I have so many toys? A lot of kids come here. You told me that it's hard for you to get your words out sometimes. You know how you go to kiddie gym to learn how to tumble more easily? Kids come to me to play and have fun and to learn to speak more easily. Would you like to do that?" A typical answer is a resounding "Yes!"
The results of the evaluation, including impressions and recommendations, are formally or informally communicated to the referring pediatrician and to others, as indicated. Information to the pediatrician may include statements such as the following:
Regarding impressions, a diagnosis may be "normal dysfluency", "stuttering", "acquired neurological dysfluency", or "cluttering".(1) A diagnostic statement might include "This 2-year 2-months old male shows stuttering with reported sudden onset with first use of 2-word combinations at age 2 and a decrease of fluency periods since, to a maximum of half a day a week. The stuttering is characterized by high frequency of generally mild to moderate but on occasion severe, disfluency, and by severe reactions for his age."
Severity statements may include a general description of the impact of stuttering on the child's or adolescent's life, e.g., "Stuttering is affecting every aspect of his life. It is socially isolating him from his peers and making him attempt to resolve conflicts through fights rather than verbally, and academically depriving him of class participation." Separate severity and frequency statements are made regarding dysfluency and reactions to disfluency and/or stuttering. An informal example is "He is severely affected by his stuttering, as shown in his behavior, emotional status, and thought patterns, despite low frequency of mild dysfluency."
In terms of etiology,(1) a statement may include "Suspected etiological factors are primarily physiological and secondarily environmental and emotional, resulting in apparent neurological overload. The predisposing organic factor for the core motor component seems associated with a family history of stuttering, laterality differences (left-handedness), and other sensory and motor problems". A statement on etiology may also include "A precipitating factor in the recent exacerbation of the problem may have been emotional stress with performance in a school play (her stuttering escalating with her stage fright during the rehearsals, and her running off the stage crying during the play, being unable to get a word out)". For a preschooler, an etiologic hypothesis may include "A suspected environmental component is inability to keep up with high the high speech rate and language complexity of others in his environment, with self-imposed or perceived demands to do so."
A recommendation may be for fluency therapy designed with the parents and, to the extent appropriate, the child, toward easy speech (with fluency as normal as possible) and self-confidence as a speaker and communicator, in all situations. Frequency and estimated duration of therapy is stated and referrals may be recommended. Part III of this short course will discuss in greater detail therapy for children and adolescents who stutter.
By referring a dysfluent child or adolescent to a specialist in pediatric fluency disorders, the pediatrician has an opportunity to make a real difference in that person's life and future. A child who eventually would have "outgrown" the stuttering anyway may do so sooner. (We cannot be completely sure who will, and if so, when.) This may shorten the time that his or her life and developing self-concept are affected by stuttering and negative attitudes toward it. It may give another child who would never have "outgrown it" the opportunity to feel good about himself or herself as an effective speaker and communicator, well integrated into the speaking world. The difference may be helping a human being reach full potential socially, academically, and professionally. The effect may even be, as expressed by some who have grown up with stuttering, "to save a life".
1. Wexler KB. Stuttering in children and adolescents, Part I. Emergency & Office Pediatrics 9:73-76, 1996.
2. Bomback F. Editorial: Treating children who stutter. Emergency & Office Pediatrics 9:63, 1996.
3. American Speech-Language-Hearing Association. Guidelines for practice in stuttering treatment. ASHA 37, Suppl 14:26-35, 1995.
added with permission, September 23, 1997