Musings on the Funding of Stuttering Treatment

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Editor’s Note: This post is another viewpoint on Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Volunteer firefighters are not presently supported by government funding; instead they rely on local fundraising and private donations. Everyone values their work, and all agree that firefighters should be compensated.

The professional association for volunteer firefighters proposes to the government that payment be provided for their services. Due to demands on legislators’ time and attention, the association selects one method for putting out fires – water – and suggests that firefighters should be compensated when they use water to put out fires.

Many firefighters ask, “What do we do when water is not the best way to fight a particular fire?” They point out that other methods for fighting fires have been shown to work just as well as water. They are told that water has more data, and they don’t want to confuse the legislators with multiple options.

Some firefighters express concern that their input was not solicited before the proposal was submitted. They further worry that their options will be limited by such legislation. The association says, “You will not be limited in what you do—only in what you get paid for.” The firefighters ask, “Will we get paid if we use another method?” The answer: “You don’t get paid for anything now, so this will definitely be better.”

The firefighters persist, “Why not seek payment for the service of putting out fires, rather than a particular method?” The association says, “When other methods have as much data as water, we can consider approaching the legislators again, telling them that the issue was not as straightforward as we first suggested. We can ask then them to consider other methods…That would be simpler.”

The firefighters collect numerous comments from specialty firefighters and support organizations in opposition to the proposal. Despite the grass-roots opposition, the proposal proceeds as originally written and is accepted. Volunteer firefighters start to receive government payment for one approach to fighting fires. Those who favor that approach are delighted. Others weren’t being paid before anyway, so nothing changes for them, at least not at first.

Soon, homeowners start to call the fire department to ask, “Does your department use water? I heard that you get paid for water. I want you to get paid, but I don’t want to pay myself. Plus, I read on a professional association’s website that water is ‘best!’” Thus, market forces drive firefighters to use water exclusively, although many know that there are other helpful approaches.

One day, a water-using firefighter finds himself working a fire against which water does not appear to help. He wonders if he should use some other approach in conjunction with—or instead of—water. Other firefighters have long used the method of changing the draft pattern in the house, but that method is not approved for payment. If he does it, his services will no longer be covered. He hesitates.

What is better for the homeowner? For the firefighter? Should he do what he knows is right for the house or what he gets paid for?

Ultimately, he decides that he should only respond to fires that can be put out with water. Other firefighters can deal with more complicated fires. It’s up to them if they don’t want to get paid?

Why has the firefighter been put in this ethical dilemma?

It all could have been avoided if only the professional association had pursued coverage for the service of fighting fires, not the specific treatment that they favored.

But that would evidently have been too complicated…

 

J. Scott Yaruss, PhD, CCC-SLP, is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He is also associate professor and director of graduate programs in speech-language pathology at the University of Pittsburgh, coordinator of clinical research in audiology and speech-language pathology at Children’s Hospital of Pittsburgh, and director of the Stuttering Center of Western Pennsylvania. He can be reached at jsyaruss@pitt.edu.

Call for Advocacy to Garner Government Support for Evidence-Based Treatments

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Editor’s Note: This post is another viewpoint on the Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Evidence-based practice encompasses evidence from high-level research, expert opinion, patient needs and values, along with the context within which the treatment is conducted. In the field of stuttering, we are fortunate to have strong evidence that the Lidcombe Program is effective. If we have clear evidence that a treatment approach works, it should be made available to the people who need it.

Speech Pathology Australia has made a submission to our [Australia’s] federal government to fund stuttering treatment. I’m sure it will be the first of many submissions, which aim to bridge the evidence-practice gap. However, there appears to have been a misunderstanding about the announcement, so SPA published a clarification on its website stating that “SPA’s submission relates only to the formation of the 2015-2016 federal budget. SPA is not supporting legislation or a policy change to promote one program, service or form of treatment over any other.”

As a founder of the speechBITE evidence-based practice website, I thought long and hard about the effect EBP has on clinical practice, funding sources and, most importantly, the clinical outcomes of the people we serve. There are three key aspects to making EBP a central component of clinical decision-making:

  • Firstly, clinicians need to know about the latest treatment advances.
  • Secondly, patients and clients need to be informed about current best practice options, and be satisfied with their treatment decision.
  • Thirdly, funding agencies need to be confident that they are funding treatments that are based on strong evidence.

How can funding agencies be aware of current best practice and confident in their funding decisions? As a profession we need to be proactive by giving this information to funding agencies and lobbying the government. This is precisely what SPA is doing with its proposal. I applaud SPA for taking this step and promoting evidence-based speech pathology practice at the highest level.

 

Leanne Togher, PhD, SLP, is a professor of communication disorders following traumatic brain injury at The University of Sydney and is Senior National Health and Medical Research Council Fellow of Australia. Togher is the director of the speechBITE evidence-based practice website. She is also an international affiliate of ASHA and Fellow of Speech Pathology Australia. She can be reached at Leanne.togher@sydney.edu.au.

Another View on Speech Pathology Australia’s Stuttering Treatment Proposal

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Editor’s Note: This post is a follow-up to yesterday’s post from Craig Coleman regarding a controversial proposal on stuttering treatment and reimbursement from Speech Pathology Australia. We reached out for responses from Ann Packman and Mark Onlsow, two of the originators of the Lidcombe approach to stuttering treatment—on which the SPA proposal centers. We also reached out to SPA and include a statement here from SPA President Deborah Theodoros.

Response from Ann Packman and Mark Onslow:

During the past two decades the Australian government has invested millions of dollars in research funding to develop an evidence-based treatment for early stuttering. The Lidcombe Program is a result of this funding and is now supported by strong evidence from randomized controlled trials. Those randomized trials include evidence for face-to-face treatment, for treatment using webcam, and for group treatment. The Speech Pathology Australia proposal is for our government to further invest in the health of Australian children who stutter, but in a more direct way by contributing to the cost of their treatment.

We wish to clarify that the Speech Pathology Australia proposal is not for a mandate—a directive—that Australian speech pathologists must use the Lidcombe Program to treat preschool children who stutter. Nor is it a proposal to overturn customary evidence-based reasoning and standardize how Australian preschoolers who stutter in Australia are managed. Nor is there any suggestion that the Australian government would not in the future fund any other evidence-based intervention that is supported by randomized controlled trials. Indeed, if such evidence emerges for the efficacy of another treatment for early stuttering, we would encourage Speech Pathology Australia to approach the Australian government to consider it also for taxpayer-assisted support.

 

Message from Deborah Theodoros, president, SPA:

Speech Pathology Australia is advocating for public funding (Medicare) rebates for early stuttering intervention at a level which is demonstrated to be highly efficacious and supported by the strongest level of evidence. However, SPA is not suggesting any policy or legislation which would restrict interventions to one program over another or would require a speech pathologist to use a specific treatment, intervention or service. SPA continues to strongly support the principle of practice that speech pathologists remain free, and duty-bound, to exercise their clinical decision-making in relation to the interventions they provide to clients.

 

Ann Packman, PhD, SLP, is associate professor and senior research officer for the Australian Stuttering Research Centre, The University of Sydney. She has more than 30 years’ experience in the area of stuttering as a clinician, teacher and researcher and researches nature and treatment of stuttering. Packman recently served as associate editor for fluency for the American Journal of Speech-Language Pathology and is associate editor for fluency for Language, Speech, and Hearing Services in Schools. Packman is an international affiliate of ASHA. She can be reached at ann.packman@sydney.edu.au.

Mark Onslow, PhD, SLP, is the foundation director of the Australian Stuttering Research Centre, The University of Sydney. He was a principal research fellow of the National Health and Medical Research Council of Australia. Onslow’s research interests are the epidemiology of early stuttering in preschoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering. He is a member of the international Lidcombe Program Trainers Consortium. Onslow is an international affiliate of ASHA. He can be reached at mark.onslow@sydney.edu.au.

Deborah Theodoros, PhD, SLP, national president of Speech Pathology Australia, is also professor and head of the division of speech pathology in the University of Queensland’s School of Health and Rehabilitation Sciences. She is a founder and co-director of the multidisciplinary Telerehabilitation Research Unit in the school and past chair of the Telerehabilitation Special Interest Group of the American Telemedicine Association. She can be reached at president@speechpathologyaustralia.org.au.

 

 

A Controversial Proposal on Stuttering Treatment from Speech Pathology of Australia: What It Means and What Happens Next

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Editor’s note: This blog post was submitted by ASHA member Craig Coleman and does not necessarily reflect the views or position of ASHA. Here is the original release from Speech Pathology Australia that spurred Coleman to submit this post. It was published in the February 2015 issue of SPA’s publication Speak Out:

Speech Pathology Australia recently submitted a proposal to the Australian Government Department of Treasury for the federal budget 2015-2016. Given the difficult political and budgetary climate, and in anticipation of a government response to the recommendations made from the Senate inquiry—the budget proposal focused on a single budget initiative.

We argue that Medicare should be targeted towards health interventions that are evidence-based, effective, safe and minimise future health treatment needs. Our proposal focused on an internationally recognised intervention, developed in Australia and based on the most robust scientific evidence of effectiveness—the Lidcombe Program—to treat stuttering in young Australian children.

Tomorrow, we will run a post on this proposal from two of the originators of the Lidcombe approach, Mark Onslow and Ann Packman, along with a statement from the president of SPA, Deborah Theodoros. We encourage your comments on this issue, which you can post below this post from Coleman.

 

Recently, Speech Pathology Australia (the national speech-language pathology association of Australia) submitted a proposal to the Australian Government Department of Treasury that would require Medicare rebates be made available for children who stutter, but only if they are treated using the Lidcombe Program.

I feel this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective. What happens when a child receives treatment with the Lidcombe program and doesn’t make progress? Does the child have other treatment options? From this proposal, it would appear that is not the case.

How are new (and perhaps more effective) treatment approaches expected to emerge when only treatment with an existing evidence-base is funded? Imagine if all infections were still treated using penicillin because it was an early treatment option. Would the government and medical associations support such a position? Perhaps a clearer question is would pharmaceutical industry lobbyists allow legislators to even remotely consider the idea? Do we think less of ourselves as a profession to allow this to happen?

This proposal also highlights a concerning trend of what constitutes “evidence.” While certain treatments might have more data than others it doesn’t always mean that treatment is more effective. Evidence-based practice includes current scientific evidence, clinician experience and client /family values. What if the clinician is not properly trained in the treatment approach? What if the personality of the client, family or clinician is not a good fit for one particular approach? Surely, the best “evidence” comes not from group data, but the individualized outcome of each client we serve. While group data certainly present scientific evidence, individual outcomes present actual evidence-based practice. That type of data takes into account all aspects of the evidence-based practice triangle.

After this precedent has been established, we would be naïve to think this could not happen with other disorders in all parts of the world. This is not an issue for the stuttering community of Australia to deal with. It is an issue for the speech-language-hearing community of the world to deal with.

So, where do we go from here? Here is a potential plan I would like to suggest:

  1. Advocate for reimbursement for stuttering. The state of reimbursement for stuttering treatment in the United States can best be described as dire. One of our missions as SLPs should be to work with insurance providers and demand that they pay for stuttering treatment. Somewhere along the way, we have allowed insurance companies to dictate that stuttering treatment should not be reimbursed. We must reverse that trend.
  2. Create a consortium of professionals. This would allow a database of treatment outcomes to be collected from clinicians in the field. Not only would this help with reimbursement, but it would also allow publication of data collected from individualized treatment approaches. We are professionals, not technicians. Our clients deserve better than “follow-the-manual” based programs and protocols.
  3. We need to educate our professionals and the public about stuttering. Stuttering is not merely a disruption in the flow of speech. It is much more than that.

As concerning as this proposal is, it can be a positive if we choose to act with reason, courage and passion.

In order to provide both sides of the discussion, I am including a recent statement from Speech Pathology Australia. While this statement seeks to clarify that this is not an endorsement of one approach, advocating for reimbursement for only one approach certainly seems to send the opposite message. Many insurance companies will not pay for stuttering treatment here in the United States. But responding to that by supporting a policy that would cover only one approach would be very dangerous and erroneous.

It is also important to understand that once Medicare programs establish a policy, private payers soon follow suit. It’s very naive to believe this policy won’t have major negative ramifications in the long run. While it may benefit some children in the short term, there is no doubt in my mind it will not benefit people who stutter or our profession in the long term.

You can read Coleman’s original blog post in full here.

 

Craig E. Coleman, MA, CCC-SLP, is an assistant professor at Marshall University and a board-certified specialist in fluency disorders. Coleman is also an adjunct instructor at Indiana University of Pennsylvania and co-director of the Stuttering U. summer program for children who stutter, their families and SLPs. He is coordinator of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He can be reached at craig.coleman@marshall.edu

The Complementary Role of Therapist and Mother

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I was a speech language pathologist for seven years before I became a mother. I love our field and the chances I get to bring positive change to the lives of children and their families. As a parent, being an SLP helps me be more attuned to my children’s developmental milestones.

My professional skills also allow me to provide my children rich language input, particularly because they are growing up in a bilingual home. I consciously employed language strategies such as narration, expansions and recasts in our everyday interactions. So now, when my 6-year-old daughter says, “Mommy, I made an observation about rainbows today,” or when my 4 1/2-year-old son says, “Alvin was being irresponsible” when talking about Alvin the Chipmunk’s many mischievous behaviors, it affirms that, yes, purposeful, engaging play builds language! Yes, consistent book sharing experiences build vocabulary! Yes, attentive caregiving builds confidence in children!

As a mother, I’ve also stopped judging embarrassing tantrums, senseless meltdowns and stubborn non-compliance at the worse times. How easy it is to judge without experience. My recently learned lesson is aptly summarized by a mom whose son has autism. In her witty and honest blog, Carrie Cariello states, “I don’t want to focus so much on the what and when and where and how that I forget about the who.”

This reality is tested in my own life with my son, who began to stutter at around age three. As an SLP, I always try to convey to parents that what children are communicating is far more important than how they communicate it, and that who they are inside is far more valuable than any outward challenges. In other words, we seek to value and see the person, not the disorder. What an easy thing to say when it’s not your child.

A few months ago, I remember approaching our van in a Wal-Mart parking lot one afternoon feeling teary, overwhelmed, and helpless after hearing my son significantly struggle to communicate fluently. I looked at his sweet face with despair and thought, what if he doesn’t outgrow this? And in that moment, I realized the truth of what I’ve “preached” to parents for many years…the who is what matters.

If the stuttering persists, my son is still the same cuddly, sensitive, funny, smart, and active little boy I love. He’s still a gift I am privileged to enjoy every day. He’s still the one who follows me around the house and says for no apparent reason at the most random times, “Mama, I love you so much!” And even if he continues to stutter, he’ll know he’s loved, he’s special and that what he has to say is important to us.

Lastly, I realize more fully now how much effort it actually takes to make needed changes in the home in order to help our children when they struggle with communication. For my son, it forces us to slow down transitions, to give him needed thinking time as well as curb our tendency to interrupt his talking time, especially when his sweet and chatty sister frequently attempts to cut into his sentences. It means coaching my husband on altering his pace, reducing interruptions and valuing the message.

So when we as professionals make recommendations for environmental changes in the home or in communication styles, we must be very patient and really clear on what that actually looks like, because at the end of the day, the who is what matters.

 

Ana Paula G. Mumy, MS, CCC-SLP,  is a trilingual speech-language pathologist who provides school-based and private services.  The author of various continuing education eCourses, leveled storybooks and instructional therapy materials for speech/language intervention, Ana Paula also offers free resources for SLPs, educators, and parents on her website The Speech Stop. You can contact her at apmumy@gmail.com.

 

 

“Use Your Speech Tools!” Why Your Child Who Stutters May Not Be Using His Strategies

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When a child who stutters demonstrates the ability to change his speech during a treatment session, it seems obvious that he’d want to use the same strategies to improve speech outside the session as well.  Children, especially teenagers, rarely want to stand out in a way that stigmatizes them, provokes questions or increases the chances of teasing.   So the question arises, “Why aren’t they using their tools?!”

Speech and stuttering modification techniques are often learned quickly and easily within the treatment setting.  However, SLPs and parents often feel discouraged when these tools seem to disappear as soon as the client gets to his car.  Is it laziness on the part of the child?  Is it the fault of the family for not following through with home assignments?  Is the SLP not teaching the best strategies?

Instead of placing blame, consider the following three reasons a child may have difficulty generalizing his skills:

Reason # 1: These Techniques Are Too Hard! 

Making changes to one’s speech becomes exponentially harder when you introduce factors that often are not present in the session, such as interruptions, time pressure and feelings of embarrassment or shame associated with stuttering. Learned escape/avoidance behaviors and increased language demands may make it very difficult to use these tools.  Suddenly, what felt like an easy decision to use a new technique, becomes complicated by the person’s desire to be heard in a large group of chatty peers or by the need to formulate an excuse about why he doesn’t have his homework.

How Can I Help?

Children will be more likely to use speech/stuttering strategies if they are first introduced in safe and supportive environments (i.e. home, session room).  To help with this, create a hierarchy of speaking situations and use it to guide where the client practices the strategies.  If a child who stutters is not yet using speech tools in certain situations such as the classroom, it is probably because of where that situation is on his hierarchy. Work with your clients to determine where they would like to use their strategies , while also identifying those situations where they would prefer to concentrate on things other than using their tools.

Reason #2: These Techniques Make Me Sound Weird! 

There are several techniques that may be taught to a child who stutters. Some strategies involve prolonging the initial sound to ease into or out of a word with less physical tension or struggle.  Other techniques include inserting more pauses into speech.   All speech tools require a child to alter their speech in a way that is still different from how his friends sound.  Children may report that they have similar negative thoughts and feelings about using these strategies as they do about their stuttering.  This may play a role in why they are choosing not to use speech strategies outside their sessions.

How Can I Help?

Just as you might spend time trying to help reduce negative reactions to stuttering, you might also spend time desensitizing clients to hearing themselves use strategies through voluntary stuttering assignments.  Children can also benefit from improving their ability to handle listener reactions. This can be addressed by participating in role-playing activities that help the child create “scripts” for responding to curiosity/teasing.  For example: “Why do you sound like that?” “Sometimes I stretch my sounds like that to help me get out of a stutter.”  The more comfortable the child feels with his strategies and ability to respond to questions about his speech, the more prepared he will be to use these techniques outside the session.

Reason #3: These Techniques Aren’t Worth it!  

A cost-benefit analysis can be useful when trying to understand why a child may choose not to use speech/stuttering strategies.  At the surface, it may appear that there are many benefits of using strategies which include increased fluency and improved overall communication. However, SLPs and parents must be careful to consider the costs, as well.  Costs may include increased effort, difficulty concentrating on the content of message, the risk of showing more stuttering and the potential that the strategy doesn’t work.

How Can I Help?

Have discussions with clients about what they perceive as potential costs versus benefits of using strategies in a variety of different speaking situations.  As the child becomes more accepting of stuttering and is better able to tolerate both his feelings about stuttering and listener reactions, physical tension and struggles associated with speaking will decrease.  As this happens, tools become easier to use and costs may not feel so high.

The bottom line 

There are several strategies that may help reduce stuttering frequency and severity.  However, you often can’t offer these tools without first considering and incorporating goals that target how the client thinks and feels about his speech both while stuttering and while using tools.

Brooke Leiman, MA, CCC-SLP, is the Director of the Stuttering Clinic at the National Speech/Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.

 

 

A Misleading Account of Research on Stuttering Treatment for Young Children

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A recent ASHA Leader article by Peter Reitzes on treatment for preschoolers who stutter makes claims to the efficacy of some treatments that are both misleading and not evidence based – at least as far as published research is concerned.  Reitzes refers readers to a study by Franken, Kielstra-Van der Schalk and Boelens (2005) that claims to have shown no difference between the results or outcome of the Lidcombe Program and a Demands and Capacities treatment approach.  That study, as Bothe, Davidow, Bramlett and Ingham (2006) reported in their systematic review of research on the treatment of stuttering, is fundamentally flawed, making the results uninterpretable.

A study by Jones et al. (2005) evaluating the Lidcombe Program, did so by comparing children who stutter that were treated by Lidcombe with a control group that did not receive treatment. Another study by Yairi, Ambrose, Paden and Throneburg (1996) made it clear that preschool children (especially those who have been stuttering for less than 15 months) have a very high rate of untreated recovery. Consequently, any treatment evaluation using that age group needs to be compared with an untreated control group so as to show that its beneficial effects exceed those that would occur without treatment.  In the case of the Franken et al. (2005) study there was no untreated control group.  Hence, Bothe, et al. (2006) concluded that “Franken et al.’s data are difficult to interpret without a no-treatment control group to confirm that their application of either treatment was actually effective” (2005, p. 331).  In fact, that is a very charitable comment because the data are not just “difficult to interpret” – they are impossible to interpret! There is nothing in this study that would show that any speech performance improvements (from Lidcombe or Demands and Capacities) exceeded those that might have occurred without treatment.

There is even more to be concerned about in the Reitzes article.  He describes a presentation by Franken at the 2013 NSA conference of another study that also compared Lidcombe Program with a Demands and Capacities treatments. This study (Franken, 2013) used a larger cohort (n =199; 3-6 years) and reported findings similar to those reported by Franken et al. (2005).  It was claimed that after 18 months there was no significant difference between the groups in terms of stuttering frequency and percentage of children recovered.  But this study simply repeats the design error identified by Bothe et al. (2006): yet again there was no untreated control group.  The importance of controlling for a natural rate of recovery is also underscored by the report that many of the study’s children may have been stuttering for between 6 and 15 months when they entered the study. It is now almost indisputable that a high rate of untreated recovery characterizes children in this bracket (Ingham & Cordes, 1999). The argument that some might raise that running an untreated control group would amount to unethically withholding treatment is not an excuse or defense. There are many alternative research designs that can offset this problem (see Kazdin, 1998). And if one is concerned about ethics in research, how can it be argued that it’s ethical to draw unwarranted conclusions about the effects of treatments for preschool children who stutter that are based on research designs that cannot support those conclusions?

The fact that the Bothe et al. (2006) review was not mentioned among the sources or references for this article is puzzling.  Either Reitzes was unaware of this critique of the Franken et al. (2005) study, or for some reason chose to ignore it. Or perhaps he is unaware of the high rate of natural recovery in this population and thus did not understand the threat that that fact posed to the usefulness of the Franken and colleagues’ findings. Nonetheless, readers should not be ignorant of the deceptive message conveyed within his article.

Roger J. Ingham and Janis Costello Ingham are professors in the Department of Speech and Hearing Sciences at the University of California, Santa Barbara. Roger Ingham is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders.

 

References

Bothe, A.K., Davidow, J.H., Bramlett, R.E., & Ingham, R.J. (2006).  Stuttering treatment research, 1970 – 2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and related approaches.  American Journal of Speech-Language Pathology, 15, 321-341.

Franken, M-C. (2013). Comparing a Demands and Capacities Model approach and the Lidcombe Program for preschool stuttering children: The RESTART randomized trial (Abstract). NSA Conference Presentation, Scottsdale, AZ.

Franken, M-C., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30, 189-199.

Ingham, R.J., & Cordes, A.K. (1999). On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. In N. Bernstein Ratner and E.C. Healey (Eds.), Stuttering Research and Practice: Bridging the Gap (pp. 211-230). Mahwah, New Jersey: Lawrence Erlbaum.

Jones, M., Onslow, M., Packman, A.,Williams, S., Ormond, T., Schwartz, I., et al. (2005). Randomized controlled trial of the Lidcombe Programme of early stuttering intervention [Electronic version]. British Medical Journal, 331(7518), 659.

Kazdin, A.E.  (1998). Research design in clinical psychology (3rd ed).  Boston MA: Allyn and Bacon.

Reitzes, P. (2014). The powered-up parent. The ASHA Leader, 19, 50-56.

Yairi, E., Ambrose, N.G., Paden, E.P., & Throneburg, R.N.  (1996). Predictive factors persistence and recovery: Pathways of childhood stuttering.  Journal of Communication Disorders, 29, 51-77.

 

Avoidance Reduction Therapy: A Success Story

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I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein.  Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist.  Ben also happened to be a person who stutters (PWS).    As the interview continued he shared that he was introduced to avoidance reduction therapy by Vivian Sisskin at the College Park campus of UMD.  I had already been applying aspects of avoidance reduction therapy with my clients,  however Ben helped solidify my feelings on this approach.  Ben was kind enough to answer some questions and walk me through his experience with avoidance reduction therapy, which is included below.

Avoidance reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients.  This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering.   The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.).  These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.

Avoidance reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering.   Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech.  Avoidance reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.

How do you incorporate avoidance reduction therapy into your sessions?  Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering.  Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations.  As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before.   Read on to learn about Ben Goldstein’s first-hand experience with avoidance reduction therapy.

Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?

Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.

Can you describe your stuttering pattern prior to beginning avoidance reduction therapy?  Do you feel like stuttering impacted your quality of life?   

Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.

In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter.  If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.

All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.

How were you introduced to avoidance reduction therapy?  

Ben:  After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic.  It was there that I was introduced to avoidance reduction therapy.

How would you define avoidance reduction therapy and the rationale behind this approach?  

Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life.  In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear.  If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process.  If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.

Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?  

Ben:  Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech.  Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”

Can you explain what a typical therapy session would look like?

Ben:  A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.

After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.

Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.

What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group? 

Ben:  I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.

How do you think your stuttering has changed?  Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?

Ben:  A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.

In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.

Do you think that there are individuals who would not benefit from this approach?  

Ben:  I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.

My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change.  The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.

If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.

Brooke Leiman, MA, CCC-SLPis the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency     Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on      fluency disorders and their treatment

 

Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in Speech Pathology in the Fall of 2014.  Ben is a member of the Rockville Chapter of the National Stuttering Association and formerly served as it’s co-chapter leader.  He can be reached at bagoldstein@gmail.com.

When Is Treatment for Stuttering ‘Completed’?

asianboy_89387926Both parents and speech therapists alike find themselves struggling to decide when treatment is complete for someone who stutters. Therapy for a child who has difficulty saying their “r”s has a distinct beginning and end (when a child meets criterion for 90 percent accuracy in conversation), however, stuttering is much more variable, by nature. In fact, once a child reaches the age of 8, it is much more likely that their stuttering is going to persist, in some form.

Does this mean that treatment will continue forever? The idea of treatment continuing indefinitely is daunting to both the therapist who has to continue to think of new and exciting activities and the parent who has to both make room in their schedule and in their budget!

Preschool age children
Many children go through a period of “temporary” disfluency as they begin to place more demands on their language system. Preschool children often have not developed the negative reactions to disfluencies that play a role in persistent stuttering that we see in older children and adults. As a result, for a child this age, it makes sense for a therapist (and parent) to aim to eliminate stuttering. I believe that a period of stutter-free speech is necessary to warrant dismissal from therapy for a young child (minimal “typical” disfluencies such as phrase repetitions or sentence revisions may persist).

Following a month or more of stutter-free speech, therapy should be slowly faded, going from weekly visits to monthly visits and finally entering into a monitoring period. This is a period where parents should keep in touch with their therapist to discuss how their child is doing at home and school. It is important to educate parents that stuttering is highly variable and that if a child does not stutter for weeks or even months, the parents should still continue to follow the program the therapist has set up for them and monitor changes in fluency so that they can quickly address a “reoccurrence,” should it occur.

School-age children/adolescents
As a child enters school and begins to demonstrate a more complex stuttering pattern, total elimination of stuttering may not be a realistic goal. Instead, it is more reasonable for a child this age to have a goal of improving their communication skills to include more forward-moving speech, although maybe not completely stutter-free. In addition a goal should be put in place to reduce the negative impact of stuttering on the child’s academic and social life. With these types of goals, it is much harder for a parent or therapist to assess when a child meets criterion for discharge from therapy.

A child should not be discharged unless a therapist determines that stuttering is no longer having a negative impact on how the child is participating in activities, interacting with others and communicating messages. Benchmarks for success cannot be solely based on frequency of stuttering, as a child who stutters on 50 percent of their syllables may be less impacted by their speech than a child who only stutters on 10 percent of syllables. The amount of impact is largely dependent on the severity of disfluencies (for example, blocks versus whole word repetitions), length of disfluencies (for example, fleeting versus 5 seconds), degree of secondary behaviors (for example, eye blinks, tension in lips, loss of eye contact), and child’s temperament.

Even a child who is not demonstrating any obvious disfluencies may be in great need of intervention. It takes a carefully observant therapist and parent to detect if the child that is seemingly fluent is actually masking disfluencies by avoiding words or situations. I suggest that therapy for school-age children who stutter be ongoing and, at the very least, be on a consult basis.

A child may comfortably get through fifth grade, with stuttering having relatively little impact on them, however, that same child may begin sixth grade, in a new school, and suddenly stuttering may play a very different role in their daily life. Having a speech therapist monitoring your child will allow for you to quickly catch any changes that may warrant more direct and intensive therapy.

Adults
With maturity, adults can decide for themselves if they are going through a period when speech has become a priority (for example, when interviewing for a job, gaining a new responsibility at work that involves speaking, dating, relocating, and so forth).

Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at National Speech Language Therapy Center in Bethesda, Md. Brooke hosts a blog focused on stuttering and stuttering therapy at www.stutteringsource.com. She can be contacted at Brooke@nationalspeech.com.

Distinguishing Cluttering from Stuttering

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Developmental stuttering affects 1 percent of the population and over 3 million people in the United States. However, there are other, lesser known fluency disorders that include neurogenic stuttering and cluttering. Telling the difference between stuttering and cluttering is often a point of confusion, so we take a closer look here at what, exactly, cluttering is—and the process of identifying and treating it.

The International Cluttering Association defines cluttering as “…a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular or both for the speaker. These rate abnormalities further are manifest in one or more of the following symptoms: an excessive number of disfluencies, the majority of which are not typical of people who stutter; the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints; and inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words. ”

So what does cluttering look and sound like?

1. Often people who clutter have what I (and many other speech-language pathologists) refer to as “machine-gun” speech. Their speech comes out in rapid bursts, which is described above as “irregular rate,” and may include pauses where it doesn’t feel appropriate.

2. A person who clutters may also demonstrate disfluencies that are unlike what we see in people who stutter. Some examples of disfluencies that are more typical of a person who clutters is excessive whole word repetitions, unfinished words and interjections (such as um and well). I have also noticed more atypical disfluencies, such as final part word repetitions (chair-air, bike-ike).

3. Coarticulation refers to when a person collapses or omits a syllable of a word (for example, “wuffel” for “wonderful”).

There is quite a bit of symptom variability, as well as co-existing conditions, that make this an even more confusing diagnosis. Below is a list of characteristics and co-morbid conditions that have been seen in people who clutter. (Note: Some people who clutter may have several of the below symptoms/co-existing conditions; some may have only one; and some may have none at all.)

  • Limited or no awareness of their irregular speech pattern unless someone draws their attention to it (very different from what we see in stuttering).
  • Sloppy handwriting.
  • Difficulty organizing thoughts; listeners easily get “lost.”
  • Learning disability.
  • Attention difficulties (i.e., ADHD).
  • Auditory Processing Disorders.
  • Asperger’s Syndrome/Autism Spectrum Disorder.
  • Stuttering (a person can clutter and stutter).

If you feel this diagnosis is hard to grasp, you’re not alone.  As a result, this condition goes largely misdiagnosed (as developmental stuttering) or undiagnosed (“I just speak too fast! I don’t have a “real” speech problem!”). For a helpful chart that breaks down the similarities and differences between stuttering and cluttering, see this brochure created by Kathleen Scaler Scott for the National Stuttering Association.

So what do you do if you think your child is cluttering?

Since this a relatively lesser known diagnosis, your best bet would be to find a speech- language pathologist who has experience working with fluency disorders. As you have learned, cluttering is a highly variable disorder. We cannot prescribe a “one size fits all” plan of treatment. There must be careful and continuous observation in order to create a treatment plan that is specific to the symptoms your child is displaying. Here are some common treatment objectives:

    • Self-Monitoring. One common characteristic among people who clutter is limited awareness of their own speech. It is important to heighten the client’s ability to monitor his or her disfluencies, rate, and/or mis-articulations. For a person who stutters, calling their attention to stuttering, although sometimes necessary, may initially cause an increase in disfluencies. However, for people who clutter, calling attention to their speech often helps them improve their rate and overall clarity (at least for a short bit).
    • Over-articulation. Another common characteristic among people who clutter is the collapsing or omitting of syllables. By practicing the over-articulation of sounds, it calls a person’s attention to all the syllables in a word, both stressed and unstressed. The speech of people who clutter may be monotone or “robotic.” Practicing over-articulation can be worked on in conjunction with exaggerating stressed syllables and inflection. Here is a useful video of an SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables:http://youtu.be/2AFygz-bxwQ
    • Pausing and Phrasing. Using this technique,  a person practices inserting more pauses into their speech, with attention to the proper placement of these pauses. For younger children, I will have them place pauses every one to three words, but as they get older, more attention will be paid to inserting pauses based on proper phrasing. I often will transcribe a client’s language sample, to include both the words they say and the placement of their pauses. I will then have them mark up the paper with where the pauses should have gone. Having a visual representation of speech is a helpful way to identify when there are way too many words being said between pauses (machine gun speech). Pausing is another too used in teaching a people to slow their rate, which is much more effective and constructive when compared with saying “slow down.
    • Provide strategies for “typical” disfluencies. As noted above, some people will demonstrate stutter-like disfluencies in addition to their cluttering characteristics. In this case, standard stuttering techniques should be addressed. These include cancellations, pull-outs and the like. SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables.

Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.