By Alex Whelan 
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Back to school season fills children with a mixture of excitement and anxiety. They may feel eager to reunite with friends, participate in clubs, sports or other extracurricular activities, and to continue learning (even if they refuse to admit it!) On the flip side, they might be nervous about making new friends, getting accepted socially by peers, and if new teachers will be nice or mean. As children get a bit older, they might also worry about achieving good grades.

Inevitably, the first day of school arrives. Take a minute and try to put yourself in the shoes of a 4th grader on the morning of that first day:

In an effort to help everyone get to know each another, your teacher decides to go around the room for everybody to introduce themselves and share a fun summer break story. The anxiety builds as your turn approaches. “Hi, I’m…”, but to your dismay, your name doesn’t readily come out. You try starting with a different phrase, “My name is…”, again, nothing. You want so badly to say your name, a seemingly rudimentary task, but you are a child who stutters and your name happens to be one of the most difficult things for you to say. Finally, your name comes out after what seems like an eternity. How will your friends react to what they just heard? Will this set the tone for how you choose to participate for the rest of the year?

As speech-language pathologists, we can offer a child who stutters and their family several tools to help them minimize the negative impact of stuttering and develop healthy communication attitudes. This often starts with education and advocacy. For young children, the parents might take on much of the educating and advocating, while also exposing their child to useful approaches to help school staff “get it.” However, as they get older, parents can gradually relinquish this role to their child.

The following examples offer our students or clients who stutter ways to take an active role in creating a safe and nurturing environment within their school. I always share or remind students or their parents of these tips around this time of year:

In 1988 Ronald Reagan declared the 2nd week of May as National Stuttering Awareness Week (NSAW)- a week dedicated to educating our communities about stuttering and its impact on peoples' lives.  Members of the National Stuttering Association (NSA) played a huge role in establishing this week so what better way to celebrate it than to hear from current NSA members? The following excerpts come from the social media accounts of 4 NSA members (with permission).  

If you had a chance to go back in time, would you do things differently?  Is there advice you might give your younger self, knowing what you know now? Why not put it in writing?  Simon Walsh, a person who stutters and the host of the blog "Diary of a Stutterer", did just that. After reading his post, I immediately knew I wanted to use this idea in my own therapy room.  The purpose of this assignment is not to dwell on "mistakes" of the past, but rather to help identify all the positive changes that have been made.  This is a fun way to get students talking about the consequences of previous unhelpful thoughts or habits so that if they were to reappear, which habits so often do, the student might be better equipped to identify and extinguish them.  For younger students and students that are new to therapy, this assignment can be adapted by having them write a letter to their future self. Instead of focusing on how things have changed and what they have learned, instead this assignment allows students to ask questions they may have about stuttering and identify things that they want to change. 

This is one of my favorite therapy activities!  With permission from the student, I have posted an example of one of these letters.  Do you have any similar activities you have done with your student, your child or something you did for yourself?  Post below!  

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.  

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). 

There are three main rationales for using voluntary stuttering.  

1.  To desensitize, or get used to, a moment of disfluency.  
When a person stutters, they often have an immediate and sometimes negative reaction to the moment of disfluency.   This reaction may manifest as eye blinks, head nods, tension in the lips, tongue or cheeks, lip smacking, irregular breathing etc.   Voluntary stuttering can help a person work towards reducing that reaction and tension, leaving a more comfortable form of stuttering.  A person may also choose to purposefully use “hard” stuttering to reduce their reaction to moments of tense disfluency.   

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!)   

In the 1930's, Dr. Wendell Johnson decided to create an experiment to test out his theory that stuttering is a learned behavior and occurs as a result of a child being told that they stutter.
Johnson was quoted to have said that stuttering ''begins not in the child's mouth but in the parent's ear.''  His research assistant, Mary Tudor, went on to take a group of children who stutter and a group of children that were fluent and separate them into groups to determine if children who were fluent would begin stuttering if they were told they stuttered and if children who stuttered would stop stuttering if they were treated as a fluent child.  Some of the children (both fluent and disfluent children) received praise in regards to their speech and some were provided harsh criticism to include statements such as "Don't ever speak unless you can do it right."  The results of the study indicated that the children (both fluent and nonfluent) receiving harsh criticism demonstrated reduced speech, shorter utterances and negative feelings about speaking.  However, in my opinion, this did nothing to prove that stuttering is caused by telling a child that they stutter, rather demonstrated how verbal abuse can result in social anxiety! The study was never published and later dubbed "The Monster Study" due to how unethical it was. (Reynolds, 2003)  Unfortunately, remnants of Johnson's theory still remain and many parents worry about the possible negative effects of drawing attention to their child's stuttering.  

Not only do I disagree with Johnson's premise that labeling a child's speech as disfluent could induce stuttering, I venture to say that NOT labeling it and ignoring a child's disfluencies can potentially be harmful.  

After spending the entirety of this week telling clients and colleagues about Katherine Preston's book, "Out With It: How Stuttering Helped Me Find My Voice", I figured it only made sense to shamelessly plug it on my website!  Besides being beautifully written, I found this book to be a wonderful resource in informing people who stutter (PWS) and parents of PWS on the trials and tribulations often experienced in a person's search for fluency.  

"Trick" is defined by the Merriam-Webster Dictionary as "a crafty procedure or practice meant to deceive or defraud."  So it makes sense why speech pathologists have used the word "tricks"  (AKA secondary behaviors) to describe the behaviors a person who stutters (PWS) uses to avoid, hide or get out of a moment of stuttering.  The clip above is an interview with the actor, Samuel L. Jackson, as he discusses one of his "tricks" as a child to hide his stuttering.  Some common tricks I see amongst my clients are eye blinks, tensing up the face or mouth, pretending to think, yawning, and using a silly voice. It is very important not to confuse "tricks" with strategies (i.e. easy speech, cancellations, etc.)  Strategies are voluntary and intentional changes made to one's speech that work to assist a PWS in creating more forward-moving speech and reducing the frequency and severity of disfluencies.  "Tricks" may initially disguise themselves as helpful strategies, but with time, PWS learn that the very behavior that initially helped them, may actually be causing more harm then good!  Let's walk you through how "tricks" begin and where they go wrong! 

For the sake of example, let's use the behavior of eye blinks.  

Although researchers are gradually learning more about stuttering and its cause/s, there is still a lot that remains a mystery.  With "the unknown" comes room for parents to try and fill in the gaps with their own guesses as to what caused their child to begin stuttering.  One of the questions I most often hear from parents is "Is it something I did?"  The answer is a resounding "NO!"  



What We Know:

According to the Stuttering Foundation, there are four factors that most likely play a role in the development of stuttering.  It is hypothesized that a combination of these factors may result in a child with a predisposition for stuttering.  

1.  Genetics- approximately 60% of people who stutter have a close family member that stutters as well. In addition, recent research by Dr. Dennis Drayna has identified three genes as a source of stuttering in families studied.    

2.  Neurophysiology- brain imaging studies have indicated that people who stutter may process language in different areas of the brain than people who do not stutter.  

3.  Child development- children with developmental delays or other speech/language disorders are more likely to stutter.   (Note:  By no means, is this implying that all people who stutter have delays in other areas.  There is simply an increased likelihood of stuttering in children with developmental delays and language disorders.)  

4.  Family dynamics- high expectations and fast-paced lifestyles may play a role in stuttering 

Family Dynamics?? I Thought I Wasn't the Cause??

You're not!  There are plenty of "fast-paced" families out there that do not have children that stutter.  However, there are certain environments that may exacerbate disfluencies in a child who already has the increased propensity to stutter.