About the author: Robert L. Dellinger, M.S., CCC-SLP, is an elementary school speech-language pathologist in the Wake County (N.C.) Public School System. Mr. Dellinger serves as fluency consultant for his district, helping colleagues to navigate through ongoing challenges within the evaluation and treatment process for children who stutter. Mr. Dellinger is active in the local National Stuttering Association chapter and presents workshops on stuttering evaluation and treatment.  Mr. Dellinger, a person who stutters, lives in Raleigh, N.C., with his wife and two daughters.

Aiden* is a 5th grader whose stuttering increased dramatically toward the end of his 4th-grade year.  In response, Aiden’s school speech-language pathologist has started off the new school year by doubling down on fluency practice. It appears to be working – at least in the therapy room. During speech therapy, Aiden is using his fluency techniques with “100% accuracy” and is speaking stutter-free. Despite the positive outcome, Aiden’s treatment success is undermined by an uncomfortable realization: He is unable to use his fluency skills outside of therapy. In the classroom, he is stuttering as much as ever.

Aiden’s speech-language pathologist (SLP) is unsure about how to respond. She is wondering about his treatment plan. Should it include explicit goals for transferring speech skills to the classroom? Should it target goals other than fluency?

In her uncertainty, Aiden’s school SLP is hardly alone. Stuttering is a highly complex condition that can be frustrating and confusing not only for children who stutter, their parents, and their teachers, but also their clinicians. The variability and persistence of school-age stuttering – and the way in which stuttering can affect almost every aspect of a child’s life – may also be sources of frustration and confusion for everyone involved (Yaruss, 2014).

Personal factors among SLPs may also play a significant role. The majority of SLPs report a lack of comfort when working with people who stutter. Stuttering ranks lowest among disorders that SLPs prefer to treat. Many SLPs report inadequate training in fluency disorders at the university level. SLPs may feel they do not see enough children who stutter to maintain clinical competence (e.g., Brisk, Healey, & Hux, 1997; Cooper & Cooper, 1988, 1996; Kelly et al., 1997; Mallard & Westbrook; Mallard, Gardner, & Downey, 1988; St. Louis & Durrenberger, 1993; St. Louis & Lass, 1981; Tellis, Bressler, & Emerick, 2008). Such challenges may be multiplied in school-based practice, where clinicians must be generalists and cannot choose which clients, or disorders, to treat. When SLPs feel unprepared to treat children who stutter, but have to treat them anyway, we may wonder: Are children who stutter receiving adequate services from SLPs in schools?

In our metropolitan school district, the speech-language department is responding to the many challenges of working with school-age children who stutter. It began by resourcing me, a full-time elementary school SLP (and a person who stutters) with a special interest in fluency disorders, into the part-time role of “fluency consultant.” The primary goal was to assist school SLPs in coordinating effective services for students who stutter. Starting officially in January 2017, the position so far has primarily involved responding to frequent email inquiries, fielding phone calls, analyzing speech samples, assisting in the development of treatment goals, participating in meetings, and making on-site visits.

Our consultation model is a work in progress. At first, colleagues mostly asked questions about their challenging fluency cases, and I answered them. Quickly, I learned that questions about specific cases are difficult to answer definitively because I do not know the students or all the details of their case histories. Instead of ready answers, what I now offer is a “way of thinking,” a framework to facilitate critical thinking and navigate ongoing challenges within the evaluation and treatment process (Chmela & Campbell, 2014).

The framework – and our evolving consultation model in our district – is Basic Principle Problem Solving (Chmela & Campbell, 2014). Basic Principle Problem Solving incorporates treatment evidence, desires of all relevant parties, clinical knowledge and expertise, and work-setting rules and regulations into an ongoing clinical problem-solving model. The focus on ongoing challenges is essential due to the complexity, variability, and chronic nature of school-age stuttering.

The framework is based on a core set of 11 basic principles developed by Hugo Gregory (Gregory, 1968), refined through decades of collaboration (e.g., Gregory, Campbell, & Hill, 2003), and redefined by Kristin Chmela and June Campbell in their manual, Working with School-Age Children Who Stutter: Basic Principle Problem Solving (Chmela & Campbell, 2014). The basic principles are as follows:

1. Differential Evaluation-Differential Treatment (comprehensive and ongoing for each child);
2. Relationship (positive relationships cultivated among all parties – the child, parents, siblings, teachers, SLPs, and relevant others);
3. Counterconditioning, Deconditioning, & Desensitization (of tense speech responses and maladaptive attitudes and behaviors to more adaptive ones);
4. Modeling (of exemplary communicative skills, including actions of assertiveness, confidence, and effectiveness, and ease of communication);
5. Guided Practice (by manipulating child and environmental variables during treatment activities and home assignments);
6. Reinforcement (of desired behaviors, attitudes, and communication skills;
7. Self-Monitoring, Self-Reinforcement (of desired  behaviors, attitudes, and communication skills);
8. Transfer (of more adaptive behaviors, attitudes and communication patterns through systematically planned and conducted treatment activities);
9. Generalization (of more adaptive behaviors, attitudes, and communication patterns);
10. Gradual Dismissal, Follow-Through, & Maintenance (of positive treatment gains); and
11. Integration of Child-Related & Environment-Related Factors (throughout evaluation, treatment, dismissal, and maintenance processes) (Chmela & Campbell, 2014).

While referencing the Basic Principles, SLPs apply ongoing “actions of thinking” (Chmela & Campbell, 2014) to solve clinical challenges. SLPs learn to 1) Recognize a Challenge (Is there a fluency problem? What is it? Is it stuttering or something else?); 2) Define Further (Who has challenges? What are they? When, where, and why do they occur?); 3) Represent & Rank Order Problem(s) (Is this one big problem? Or a series of smaller ones? What is the best order in which to solve them?); 4) Construct a Plan (What do all parties desire? What is the evidence? What do clinical knowledge & expertise suggest?); 5) Develop a Monitoring System & Execute the Plan (Are we going in the right direction? How will we know?); and 5) Evaluate the Results (What are the outcomes? What adjustments must be made?) (Chmela & Campbell, 2104).

In our interpretation of Basic Principle Problem Solving, problems are viewed as challenges, and challenges are seen as opportunities (Chmela & Campbell, 2014) to help students become the best overall communicators they can be, whether fluent, disfluent, or stuttering at any given time. Overall communication skills are developed across five domains of communication competence: Assertive (moving toward communication, saying what you want, resisting time pressure, not avoiding); Attentive (being “in” the conversation, responding and connecting); Confident (self-assurance portrayed by eye contact, posture, body language, volume of voice); Effective (getting one’s message across, greater ease of communication, efficient rate of information flow); and Proactive (making plans, setting goals, and following through; and honesty about communication) (Chmela and Campbell, 2014; Johnson, 2015).

Our next step will be to offer continuing education in stuttering and other fluency disorders to our district’s SLPs through three-hour workshops scheduled for Fall 2017 and Spring 2018. The fall workshops will cover comprehensive, differential evaluation and goal setting. Differential treatment (incorporating all of the core principles) will be covered in the spring. Participants will learn to plan and conduct a differential evaluation that assesses not only the motor aspects of a child’s speech and the breakdowns in fluency, but also reactions (the child’s and the environment’s) to those breakdowns, and other contributing factors that affect the problem in some way, such as development of negative feelings and attitudes about stuttering and communicating. Participants will learn to identify the communication discrepancies and performance gaps that manifest in schools as adverse educational effects. They will learn to conduct therapy that targets more than just the development of speech skills, addressing social and emotional needs and improving overall communication competence inside and outside of the therapy room. Finally, participants will learn to start generating their own solutions to the many challenges of stuttering by engaging in the ongoing, differential problem-solving process.

In Aiden’s case, based on our collaboration, the school SLP has already begun to apply Basic Principle Problem Solving. Aiden’s new goals address transfer of skills, and therapy is moving beyond the confines of the speech room. Child-teacher contract cards assist in transferring treatment gains into to the classroom, where they matter most. Goals no longer focus solely on speech, but also on overall communication skills necessary for school success, such as assertively answering questions that the teacher asks and retelling stories.

As I reflect on the basic principles, I am reminded of how a singular focus on fluency may lead to frustration for everyone, difficulty with transfer and generalization, and poor treatment outcomes. In the worst case scenario, by focusing on fluency alone, we may send children the unintended message that stuttering is bad, and so are they when they stutter (Yaruss, 2014). In my district, I am profoundly grateful that we are developing the knowledge and expertise to take a comprehensive, differential approach that sends the opposite message: Children who stutter can become exceptional communicators.

*The student’s name and identifying information
have been changed to protect confidentiality.

References

Brisk, D., Healey, E. C., & Hux, K. (1997). Clinicians’ training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in the Schools, 28, 164-176.

Chmela, K. A., & Campbell, J. H. (2014). Working with school-age children who stutter: Basic principle problem solving. Greenville, SC: Super Duper Publications.

Cooper, E. B., & Cooper, C. S. (1985). Clinician attitudes toward stuttering: A decade of change (1973-1983). Journal of Fluency Disorders, 10, 19-33.

Cooper, E. B., & Cooper, C. S. (1996). Clinician attitudes toward stuttering: Two decades of change. Journal of Fluency Disorders, 21, 119-135.

Gregory, H. H. (1968). Learning theory and stuttering therapy. Evanston, IL: Northwestern University Press.

Gregory, H. H., Campbell, J. H., & Hill, D. G. (2003). Differential evaluation of stuttering problems. In H. H. Gregory (Ed.), Stuttering therapy: Rationale and procedures (pp. 80-141).Boston, MA: Allyn & Bacon.

Johnson, L. (2015). Effective Service Delivery for Fluency in the Schools – Handout [workshop handout]. Retrieved from http://c.ymcdn.com/sites/www.wisha.org/resource/resmgr/2015_Convention/Blk_4_Schls_Johnson.pdf

Kelly, E. M., Martin, J. S., Baker, K. I., Rivera, N. J., Bishop, J. E., Kriziske, C. B., Stettler, D. S., & Stealey, J. M. (1997). Academic and clinical preparation and practices of school speech-language pathologists with people who stutter. Language, Speech and Hearing Services in the Schools, 28, 195-212.

Mallard, A. R., & Westbrook, J. B. (1988). Variables affecting stuttering therapy in school settings. Language, Speech and Hearing Services in the Schools, 19, 362-370.

Mallard, A. R., Gardner, L., & Downey, C. (1988). Clinical training in stuttering for school clinicians. Journal of Fluency Disorders, 13, 253-259.

St. Louis, K. O., & Durrenberger, C. H. (1993). What communication disorders do experienced clinicians prefer to manage? ASHA, 35, 23-31.

St. Louis, K. O., & Lass, N. J. (1981). A survey of communicative disorders students’ attitudes toward stuttering. Journal of Fluency Disorders, 6(1), 49-79.

Tellis, G., Bressler, L., & Emerick, K. (2008). An exploration of clinician views about assessment and treatment of stuttering. Perspectives on Fluency and Fluency Disorders, 18(1), 16-23.

Yaruss, S. (2014, March 6-7). Effective treatment for school-age children who stutter: An advanced course. [Course handout]. Course presented at Speech and Hearing Association of Alabama convention. Retrieved from https://www.alabamashaa.org/files/Handouts%202014/Yaruss-School-AgeChildrenStutter.pdf