In prior blog posts, I have talked about the information that I consider when recommending treatment for a young child who stutters. I have also highlighted the fact that we have choices when it comes to selecting a specific therapy approach and that we want to be sure to individualize our treatment for the needs of each child and family we see.
This time, I will discuss some of the factors that help me determine which approach might be most appropriate for a specific child who stutters. To do this, we need to think about the different options that are available for early childhood stuttering therapy. These can be broadly conceptualized as:
- Less-direct therapy (therapy that focuses primarily on helping parents reduce demands on the child’s speech that may exacerbate stuttering)
- More-direct therapy (therapy that focuses on helping the child make changes in his own speech in order to enhance fluency
- Operant conditioning therapy (therapy that involves providing differential contingencies for the child’s fluent vs. stuttered speech to reinforce fluency)
Different practitioners have different preferences and philosophies about these approaches, and in prior posts, I have discussed the differing amount of research data supporting the various programs. One important point that I want to highlight is the fact that the available data suggests very similar success rates across the different approaches.
No treatment works for everyone, of course, but all of the commonly described treatments do appear to work for some. What’s interesting is that the different approaches also seem to have roughly similar efficacy. Although there is some question about the precise figures, maybe as many as 90% or 95% of young children who stutter will recover: either on their own, through natural recovery (maybe 75% to 80%), or with the help of treatment.
Finally, then, it comes to this question: when faced with a particular child who stutters, which therapy do you implement? As I have foreshadowed, the answer depends upon the child.
If the child is quite young and the time since onset if low, I typically start with some less-direct treatment strategies. These often involve helping the parents identify factors that make it more difficult for the child to maintain fluency, then brainstorming with the parents about how to reduce the impact of those factors. Such activities are common in the RESTART DCM therapy, the Palin PCI therapy, and in what we often call a “comprehensive approach” described in Early Childhood Stuttering Therapy: A Practical Guide. (We call it this because it contains both less-direct and more-direct elements, combined together based on a decision tree presented at the beginning of the book.)
Preliminary evidence suggests that this less-direct aspect treatment is sufficient for many children—some children simply need to have the excess stressors removed from their communication environment, and they are able to go on to develop typically fluent speech. These are also children who I think can be well-served by the Lidcombe program—simple contingencies that encourage fluent speech production and discourage stuttered speech. How do I decide between less-direct therapy and Lidcombe in these situations? This depends upon the family’s preferences. If the parents are comfortable offering contingencies, and if it appears that they will be able to implement the tracking and practice times that are required, then this is just fine. Likewise, if it appears that the parents are going to be able to identify and reduce environmental stressors (such as competition for talking time, perhaps), then I will feel comfortable recommending the less-direct therapies.
In other words, for these children, we have choices, and the decision can safely be based on parental and clinician preferences. I can begin with either less-direct or operant therapy, while monitoring to see if more-direct might ultimately needed. Research shows that it is not for most children, though some may benefit from it if they do not recover quickly following the initial therapy recommendations.
If, on the other hand, the child is particularly sensitive to his stuttering—if he exhibits a lot of physical tension and struggle behaviors or is upset about his communication difficulties—then I am less likely to select less-direct therapy. I may start with some recommendations to the parents about identifying and reducing conversational stressors, but ultimately, I am going to want to work more specifically with the child to reduce his negative reactions: I am going to want to help him learn that it is okay for him to go through this time of stuttering, so he is less likely to develop the fear and tension and struggle that characterize older children who stutter. I may also want to implement some specific speech changes to help the child change either the timing of his language formulation and speech production or the tension involved in speaking and stuttering. Obviously, there is much, much more to say about these therapy—they are all described in detail in Early Childhood Stuttering Therapy: A Practical Guide, Chapter 6.
I should note that these children are not ones for whom I would favor a recommendation for the Lidcombe program. I have seen many children who react negatively to the corrections of stuttering, and I do not want to exacerbate that or increase the likelihood that they might come to believe that stuttering is a bad thing for them to do. Some clinicians might stick with only the praise components of Lidcombe therapy in this situation, but even then, I have reservations. If we praise the child for fluent utterances only, we may inadvertently give him the message that his speech is only valuable when it is fluent. I have literally had young children tell me that they change words or avoid talking when they sense that they are about to stutter. I don’t want to do anything to compound that. Instead, I want them to learn that what they say is valuable and worthy of being said, regardless of whether it comes out fluently or with some stuttering. What they say matters more than how they say it. This is a fundamental, philosophical difference between the therapy I advocate for and operant conditioning therapy.
Note, though, that I do not think it is an issue in all cases. For those children who are less worried about their speech, experiencing minimal tension or struggle, then I think it’s fine to choose from the available range (including Lidcombe). If that is not the case, however, then I think that the child and family may be better served by other approaches that focus more on successful communication, like RESTART DCM, Palin PCI, or the comprehensive approach.
Is this the only way to approach decision-making early childhood stuttering? No, but with luck, this will provide a bit more of the rationale for why I recommend therapy the way I do—and why I’m constantly asking people on facebook for MORE INFORMATION about the young children they evaluate.
