I have been getting a lot of questions from SLPs and parents that all seem to center around the question "Is this stuttering" or "Does this warrant speech services?"  


Question:  
I am a school based SLP. I just screened a 7 year old girl. Her teacher was concerned that she might be stuttering. She is repeating whole words and phrases quite often. She also used some interjections such as "um". Her teacher has never heard her repeat or prolong sounds. Is this really considered stuttering if a child is only repeating words and phrases? I have been looking on the internet, but most children either repeat syllables or sounds as well as words or else they don't repeat whole words as often as this student. 

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 in order to apply for graduate school to become a speech 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 towards reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works towards 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.  

Much like, cancellations and pull-outs, a prep set is a speech tool I use with clients as they gain the ability to monitor their speech.  Prep sets help a person who stutters (PWS) make changes to their speech so that their speech can be more forward-moving and so that they can stutter more comfortably.   Once a client demonstrates the ability to use cancellations and pullouts, I will introduce the idea of prep sets.  

In my time working in a private practice, I have had parent after parent come to me utterly frustrated with the lack of speech services being provided by their school district.  Too often these concerned parents are being told that their child does not qualify for services as stuttering does not have an "academic impact."  Unfortunately, this explanation is often being provided not because the child does not warrant services but rather because the therapist does not feel comfortable or competent in providing stuttering therapy.  Even worse, some children are being denied services as a direct result of therapists receiving pressure from their district to limit the students being added to the caseload.    Despite the challenges involved in providing stuttering therapy within the school setting, there are many dedicated therapists that demonstrate that it can be done! I want to take this time to spotlight the Kenosha Unified School District, of Kenosha, Wisconsin.  Thanks to a small group of devoted speech pathologists working in this district, KUSD has created a monthly therapy and support group, the Friends Stuttering Group (FSG).  I hope FSD can act as a model for how school districts around the country choose to serve their students who stutter. 

In order to see progress, you must know know what you're looking for.  Seems like a pretty obvious statement, but having a skewed vision of progress or success is the reason why so many people who stutter (PWS) report either jumping from therapist to therapist or quitting therapy altogether.  It is the job of the speech pathologist to teach strategies, but even more importantly to help clients set realistic and obtainable goals so that they will ultimately recognize the progress they're making when it happens! 

Both parents and speech therapists alike find themselves struggling to decide when therapy is complete for someone who stutters.  Therapy for a child who has difficulty saying their "r"s  has a distinct beginning and end (i.e. when a child meets criterion for 90% 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 therapy will continue forever?? The idea of therapy 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! 

Above is a video created by Pamela Mertz, a person who stutters and the host of the website, www.stutterrockstar.com/.   In this video, she articulately describes and provides examples of voluntary stuttering (stuttering on purpose).  Voluntary stuttering is one of the speech tools I encourage my clients to experiment with.  I often begin using this tool with my school aged clients, depending on their level of awareness.  

There are three main reasons for voluntary stuttering.  

1.  To desensitize, or get used to, a moment of disfluency.  
When a person stutters, they often have an immediate and negative reaction to the moment of disfluency.   This reaction results in increased tension and may manifest itself as eye blinks, head nods or tension in the lips, tongue or cheeks.  However, voluntary stuttering can help a person work towards reducing that reaction and tension, leaving a more comfortable form of stuttering.  

In the past several years, speech pathologists have decided to leave the "wait and see" era of fluency treatment behind us.  With this change in perspective we have begun to usher in a more proactive approach, complete with suggestions on how to alter the child's environment to enhance fluency, encouragement to track changes, and most importantly the acknowledgment and acceptance of stuttering.  Unlike past generations, you'll be hard pressed to find a fluency specialist who tells parents to "ignore" the child's stuttering as we no longer prescribe to the idea that speaking about stuttering around a child will cause them to stutter.  

Thank goodness parents no longer are being told to sit by and watch their child struggle for 6-12 months without providing them ways to help!  The Stuttering Foundation of America recently produced a video that discusses the things parents can do to assist their child who stutters and this video is posted above.  As you watch, do not beat yourself up if you have been handling things differently than the therapists suggest.  There are a number of different variables that are thought to interact in order to cause the onset of stuttering.  By not initially following these suggestions you did not cause your child to stutter, however these environmental changes will help reduce time pressure and language demands so that your child can speak more freely!  

Do you find this video helpful?  Comment below!  

I recently came across an article written in the NY Times about a student, Philip Garber Jr., and his experience with a particular college professor at the County College of Morris.  The article, Professor's Response to a Stutterer-Dont Speak, highlights how Garber was asked to hold questions for the beginning and end of class so he "does not infringe on other students' time."   He was also asked to respond to questions on paper, rather than raise his hand like the rest of the students.  He advocated for himself to the dean and was transferred to another class, where he is now able to speak freely. 

Although this is quite an extreme situation and there are many wonderful teachers that are very sensitive to the needs of students who stutter, this article still brings up the importance of educating teachers on stuttering.  Like parents, teachers are often trying their very best, but quite simply may not be aware that some things they are saying or doing are, in fact, not helping at all. 

Here are some tips for teachers: 

A few months back one of my fabulous students, Spencer, wrote a letter to Vice President Joe Biden and shared with him his experiences with stuttering.  As many of you may know, VP Biden, whose very job it is to speak publicly, identifies as a person who stutters (PWS).  He is a spokesperson for the American Institute of Stuttering and has spoken publicly about stuttering on such talk shows as The View (posted above).  Because I am so very proud of Spencer and all of my students for their willingness to advertise and educate others on stuttering, I have attached the letter Spencer received from Biden (upon Spencer's permission of course!)