Lessons Learned

Abstract

You have accessThe ASHA LeaderFeature1 Feb 2012Lessons Learned Mark AllenPhD, CCC-SLP Mark Allen Google Scholar More articles by this author , PhD, CCC-SLP https://doi.org/10.1044/leader.FTR2.17022012.14 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In I was on the playground, at recess after lunch, and a fifth-grader was amusing himself by mimicking my stuttering. “Wh-wh-wwwhat’s the mm-m-m-matter? C-c-can’t yyyyou t-t-t-talk?” It was September 1972, the beginning of third grade at McArthur Elementary school. I had just moved to Albuquerque, New Mexico, from a small town in Connecticut. Evidently, being a new white kid from New England in a predominantly Hispanic, urban, unruly public school wasn’t going to be easy—and being a person who stutters would make it even less so. I tried to tell this kid to stop, but in fact—it was true, I couldn’t talk. I would have loved to retaliate verbally, but my speech was totally stuck. So, when he finally stopped and turned around, I went to Plan B. That is: I jumped on his back and did my best to strangle him. Needless to say, this was not a good plan. The kid was eight inches taller and 50 pounds heavier than I. Within seconds, I was flipped over and pinned to the ground, with my face shoved into the dirt. I didn’t know it at the time, but this would be my first lesson in “when not to retaliate.” Thankfully, we can learn from difficult life experiences. As a speech-language pathologist who stutters, I’ve found that doing so can lead to personal and professional growth. My own struggles with fluency have affected my overarching approach to stuttering treatment, as well as the way I work with school-age children who stutter. Although many of the strategies in the following description of my treatment method could be drawn from literature and clinical expertise, my personal experience has provided an additional tool to guide practice decisions. Geared for clinicians who have limited experience with stuttering, this article includes personal anecdotes highlighting essential elements of the treatment process. As with any approach, it can and should be modified based on the needs of individual students. Nevertheless, one central tenant remains: Stuttering treatment for school-age students needs to be rooted in a multidimensional perspective that considers cognitive, affective, linguistic, motor, and social aspects of stuttering (Healey, 2004). Indeed, treatment is not just about physical speech behaviors. It’s about feelings, beliefs, attitudes, and emotions. It’s about helping kids to communicate effectively and live their lives as freely and fully as they would if they did not stutter. Although this goal is quite challenging, that challenge is precisely what makes working with children who stutter engaging and gratifying. Fundamentally Flawed As we walked toward the pool, my brother John—at 9 years old, two years my senior—was telling me how he could hold his breath for a full three minutes. Listening to him talk, I thought to myself, “He just says whatever he wants to say. How does he do that?” John paused for a moment to see if I was listening, but I was still lost in thought. “Why does my speech get stuck and his doesn’t? Why is it so difficult for me to talk? What’s wrong with me?” From the beginning, stuttering was a complete mystery to me—a mystery that left me feeling confused and fundamentally flawed. Many children who stutter have little understanding of what stuttering is or why they do it. Therefore, during early treatment sessions, we help students learn about stuttering in general and their own stuttering in particular. We talk about the physical parts and processes involved in speaking. Students explore how their speech system works and how different sounds are made. They identify and analyze both fluent and non-fluent speech. These activities, along with conversations about feelings and beliefs, desensitize children to their stuttering and reduce the mystery surrounding it. They set the stage for treatment by giving students an understanding of stuttering and by promoting an attitude of openness and acceptance toward it. (For examples of these types of activities, see “Resources and References Related to School-Age Stuttering Therapy.”) Positive Intentions My SLP was sitting across from me, perched on a child-size chair. We were in a repurposed storage room: fluorescent bulbs, no windows, the door propped open with a rubber wedge. The lights overhead were buzzing and I could hear students in the hallway. She was reading words and I was repeating them. Not a bad way to spend half of my language arts class—I just couldn’t figure out why we were doing it. It seemed that she was uncertain about how to treat my stuttering, but that didn’t matter too much. Her intentions were entirely positive, and I liked her. It was a relief to have someone who was invested in helping me and a place where it was okay to stutter. This anecdote captures the essence of what my treatment was like throughout primary school. Although I appreciated my SLPs’ efforts, ultimately what they taught me never quite seemed to add up. I felt I was being exposed to a patchwork of practices that fell short of giving me what I really needed. Students need to feel confident in our ability to help them learn and integrate practical, concrete skills that make sense. Therefore, after helping students to understand their stuttering and how their speech system works, we give them explicit, age-appropriate instruction on specific fluency-enhancing and stuttering modification strategies. We also provide clear rationales to ensure that students understand why we’re teaching these particular skills (e.g., Allen, 2007; Guitar, 2005; Ramig & Dodge, 2005; Reardon-Reeves & Yaruss, 2004). These skills are not unique or new, but many SLPs have not had the opportunity to learn or use them to a significant degree. The Pursuit of Fluency During high school and the first two years of college, I didn’t seek stuttering treatment. Instead, I pretended I was a fluent speaker. I avoided speaking situations, changed words, talked around words, added extra words, made excuses, feigned ignorance, lied, and more. All this hiding and pretending inevitably made my stuttering worse. By my sophomore year at Amherst College, speaking was an absolute nightmare. I found it extremely difficult to introduce myself, use the telephone, talk to new people, and answer questions in class. These difficulties motivated me to learn about and attend an intensive fluency-shaping program. Unlike my previous speech treatment, this program taught clearly defined strategies in an organized, systematic manner. The skills I learned dramatically increased my fluency and gave me a profound sense of empowerment. Less than two weeks after finishing this program, I traveled to Scotland to spend my junior year at the University of Edinburgh. When I boarded the bus for the last leg of the trip, I scanned the rows for an open seat. Just a few weeks earlier, I would have searched for a spot next to the most introverted and uncommunicative-looking passenger I could find (thereby avoiding the possibility of having to talk during the 10-hour ride). Feeling confident about my newfound fluency, however, I sat next to a pleasant-looking woman and spoke with ease throughout the entire trip. I was absolutely amazed. I then decided I would adopt a whole new speaking persona: I would be a careful, deliberate, and confident speaker. This event marked the beginning of the most fluent year of my life. But the story does not end there. The fluency skills that I learned included techniques that change breath flow, speech rate, voice production, and articulation in ways that promote more fluent speech (see box [PDF]). When we effectively teach these strategies to school-age students, the resulting fluency frequently engenders (as it did for me) more confidence about speaking, decreasing negative reactions, and perhaps leading to even greater freedom of speech. (Descriptions and rationales [PDF] for specific fluency-enhancing strategies are available at Center for Stuttering Therapy’s website.) The Reality of Relapse When I returned to Amherst senior year, I unconsciously reverted to my pre-treatment speech patterns. It was as if old habits and feelings were quietly reasserting themselves. My fluency skills began to break down and my stuttering got worse. As this disintegration continued, I was filled with dread—because as a senior, I was required to take comprehensive oral final exams to graduate. These speech difficulties continued for months and reached a climax on the day of my oral examination. I entered the exam room, sat down across from my professors, and tried to relax. When the questions began, I was mortified to find that every time I tried to answer, my speech totally froze. No words, no sounds...nothing. I simply could not talk. I was absolutely stunned… and more ashamed than at any other time in my life. My professors were very understanding. Ultimately, they assessed my written work and I graduated with my classmates. I only wish that I had possessed the acceptance and compassion for myself that these professors demonstrated toward me. This experience with relapse was a wake-up call, and made me realize that I had a lot to learn. Fluency strategies are most certainly an essential element of school-age stuttering treatment. However, focusing only on fluency—as did the treatment program I attended—can leave clients without the necessary means to address speech breakdown. Its failure to teach stuttering modification strategies and address attitudes and emotions left me unprepared to manage times when my fluency skills did not work. Exploring and Engaging Stuttering Most stuttering specialists agree that both fluency-enhancing and stuttering modification skills should be incorporated into school-age treatment (e.g., Gregory, 2003.) Stuttering modification strategies help children increase awareness of disfluent speech, explore and decrease physical tension, and change moments of stuttering (see box [PDF]). They help students to reduce struggling and speak in a more relaxed way and also can decrease sensitivity about stuttering, reduce negative reactions, and increase feelings of control, openness, and acceptance (e.g., Van Riper, 1973). Teaching these skills sends a clear message to students: You can directly address, work with, and change your stuttering. Indeed, these skills encourage students to accept and work with their stuttering rather than try to eliminate it. (Descriptions and rationales [PDF] for specific stuttering modification strategies are available at The Center for Stuttering Therapy’s website.) Openness and Acceptance Soon after graduating from Amherst, I decided to become a speech-language pathologist. I spent two years taking prerequisite classes and worked part-time at the speech-language clinic where I attended the fluency-shaping program. In time, I regrouped and got my fluency back on track. Nevertheless, my relapse and my observation of fluency clients at the clinic made it clear that stuttering treatment must include much more than just fluency strategies. My subsequent study with Hugo Gregory at Northwestern University had a major effect on my understanding of stuttering. It emphasized the importance of using a multi-dimensional treatment approach that includes both fluency-enhancing and stuttering modification strategies. When I arrived at Northwestern, I tried to use my fluency-shaping skills as much as possible. I was particularly careful about modifying whenever I spoke to Gregory. I didn’t stutter with him at all during the first several weeks of school—and I talked with him a lot. But he never said a word about it. Then one day, he overheard me stuttering with a staffer in the clinic and appeared out of nowhere. He gave me a broad smile and said he was pleased that I was “sharing my stuttering” and that he had worried that I’d “forgotten how to stutter.” Of course this incident was humorous to Gregory, but it also led to discussions that helped me see the danger of trying to present myself as a normally fluent speaker, and that doing so probably contributed to my relapse. For years, I tried to present myself as a normally fluent speaker, pointedly using my fluency techniques to maintain this pretense. Although it was fine for me to redefine myself as a careful, deliberate, and confident speaker, I needed to balance this definition with being a speaker who stutters at times, and does his best to manage it. Of course, if I was going to adhere to the second part of this definition, I needed to be open about my stuttering and accept myself as a person who stutters. In treating stuttering, we must early on engage students in activities and conversations that promote attitudes of openness and acceptance. Realistic Expectations, Ultimate Goals After integrating their fluency-enhancing and stuttering modification strategies, students use the skills in activities that require gradually increasing length of utterance and linguistic complexity. When they have success with these strategies in conversation, we start to transfer skills to outside settings at home, school, and in the community. Children should have a variety of effective skills from which to choose. Teachers, parents, other family members, and the children themselves need to have realistic expectations about how and when to use these strategies. We need to remind students that their skills won’t always work—even the strongest strategies will break down sometimes. Therefore, the issue is not whether the skills always work; it’s how students can best manage the times when they don’t. Finally, students should understand that the goal is not perfect fluency. The goal is to practice the skills enough to keep them fresh and accessible, so students can use them when needed, and to become effective communicators with a variety of strong, reliable, and flexible strategies that help them to speak freely. Sources Allen M. (2007). Speak freely: Essential speech skills for school-age children who stutter. Evanston, IL: Speak Freely Publications. Google Scholar Gregory H. H. (2003). Stuttering therapy: Rationale and procedures. Boston, MA: Allyn & Bacon. Google Scholar Guitar B. (2005). Stuttering: An integrated approach to its nature and treatment. (3rd ed.). Baltimore, MD: Lippincott, Williams & Wilkins. Google Scholar Healey E. C. (2004). A multidimensional approach to assessment and treatment of stuttering in school-age children who stutter.Presented at the Stuttering Foundation workshop on stuttering therapy: Practical ideas for the school clinician: Cincinnati, OH. Google Scholar Ramig P. R., & Dodge D. M. (2005). The child and adolescent stuttering treatment and activity resource guide. Clifton Park, NY: Thomson Delmar Learning. Google Scholar Reardon-Reeves N. A., & Yaruss J. S. (2004). The source for stuttering: Ages 7–18. East Moline, IL: LinguiSystems, Inc. Google Scholar Van Riper C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice Hall. Google Scholar Author Notes Mark Allen, PhD, CCC-SLP, directs the Center for Stuttering Therapy and Speak Freely Publications in Evanston, Illinois. He has more than 25 years’ experience working with children, adolescents, and adults who stutter, and was one of the first SLPs to be recognized as a fluency specialist by ASHA’s Special Commission on Fluency Disorders. He is a member of ASHA Special Interest Group 4, Fluency and Fluency Disorders, and presents local and national professional workshops on stuttering treatment. Contact him at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetailsCited byLanguage, Speech, and Hearing Services in Schools43:3 (338-343)1 Jul 2012Managing Stuttering Beyond the Preschool YearsMarilyn A. Nippold and Ann Packman Volume 17Issue 2February 2012 Get Permissions Add to your Mendeley library History Published in print: Feb 1, 2012 Metrics Current downloads: 481 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...