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Practical Thoughts Blog

“I want to dismiss him, but the parents are worried!”

“I want to dismiss him, but the parents are worried!”

A recent Facebook post raised an important question: what if you think a school-age child who stutters is doing well and is ready to be done with therapy, but the parents still want him to stay? What about the child who has learned how to use strategies, feels good about himself, and communicates freely? Can you justify dismissal if the child is still stuttering? What if the parents want you to keep treating him anyway?

This is a really tough set of questions, describing a situation that is relatively common. It can be hard for parents to let go of the support that they feel has been helpful for their children, even when the children no longer appear to need it.

Parents may also not recognize the chronic nature of stuttering in school-age children. The fact is, school-age children will, in all likelihood, continue to stutter in some fashion throughout their lives. Parents may feel that they're not ready for dismissal if the child is stuttering at all because they’re still hoping for a cure. This is understandable, but that's not how therapy for stuttering works. For school-age children, we focus on reducing adverse impact, and if we can document that there is no adverse impact for a child, then dismissal is appropriate.

The key factor in my mind is the bit about *documenting* that lack of adverse impact. The SSI and other stuttering-frequency based measures will not help with this. That's simply not what they are designed for. And, they can tend to reinforce the parents' concerns about the fact that the child is still stuttering and therefore in need of treatment. ("He scored an X on the SSI and that still puts him in the category of stuttering!").

Instead, the measures that I would make in order to support dismissal are related to adverse impact and communication. For example, I would talk to the classroom teachers about the child’s participation in class, and I’d talk to the child about his own perceptions about his stuttering. (One way to do that is to use the “Checking In” forms from School-Age Stuttering Therapy: A Practical Guide.)

Still, it can be hard to convince parents who aren't ready to let go that the child is really, truly "okay." Parents often say, "I just want to make sure I'm doing everything I can for my child." Of course they do, and they're right. One of my favorite things to do in therapy is to be able to tell them, "You have! You got your child into therapy; you supported him through that process; and now, here he is, thriving in his educational and social environments."

It can help to show them all of the ways in which the child is communicating freely and how stuttering is not standing in the way of his success. I also highlight the fact that the child is still stuttering (and will likely always stutter), but that it’s not getting in his way. This is the outcome we look for in stuttering therapy.

I also support this through documentation of a standardized assessment that is specifically designed to measure adverse impact. That would be something like the Overall Assessment of the Speaker's Experience of Stuttering (OASES; Yaruss & Quesal, 2016), which is specifically designed to show how the child is functioning in his life.

What I typically do is this: I administer the OASES to the child then go through the responses with him afterwards to ensure that I have a good understanding of how stuttering is affecting his communication and his life. THEN, I review those same OASES results with the parent so the parent can see all of the ways in which the child is communicating effectively.

If I discover through this process that there are remaining areas where the child is having difficulty, then I refocus my therapy on those areas. The parent can then see that I am being responsive to the child's specific areas of need. The parent is happy; the child is happy; and I am happy because I have a good set of therapy goals that are directly relevant to the child.

If I discover that the child is truly experiencing minimal adverse impact, then I can feel comfortable with dismissal (or, at least, a shift to monitoring or consult status). The parents will then feel more comfortable too, because they have been involved in the process.

Note that all of this assumes that we have engaged in a comprehensive approach to therapy that addresses more than just the observable characteristics of the child's stuttering behavior. Stuttering involves more than just speech behavior, so our therapy should involve more than just speech behavior, too. We'll know that we have achieved our goals in therapy when a child has learned to use strategies to enhance fluency and modify stuttering when he chooses; when he can speak freely in situations that are relevant for his life; and when he is experiencing minimal adverse impact due to stuttering. Those are our ultimate goals for therapyand with your help, parents can come to recognize that these are their goals, too!