By Brooke Leiman, Katie Gore & Rita Thurman
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Dealing with fluency issues can be confusing and frustrating for the client and family. Navigating health insurance reimbursement for stuttering treatment can also present challenges for them. In our extensive work with clients who stutter, we’ve learned several tips for getting treatment covered—either initially or through an appeal if the insurance company denies coverage.
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Ease your clients’ and your own anxiety by learning how to navigate through (or around) these four common insurance roadblocks.

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).  

Very excited to be helping to facilitate a FRIENDS workshop on March 28, 2015 in Washington, D.C.  There will be sessions for children, teens, siblings, parents and speech-language pathologists .  You can learn more about this wonderful organization by visiting their website at http://www.friendswhostutter.org/.  

When a child who stutters is demonstrating the ability to make changes to their speech in the therapy room, it seems obvious that they’d want to use the same strategies to improve their speech outside of the therapy room as well.  Children, especially teenagers, rarely want to stand out in a way that can stigmatize them, provoke questions or increase the chances of teasing.   The question then arises, “Why aren’t they using their tools?!”

Speech and stuttering modification techniques are often learned quickly and easily within the therapy setting.  However, speech/language pathologists and parents often feel discouraged when knowledge of these techniques seem to disappear as fast as it takes for the child to get to their car in the clinic’s parking lot.  Is it laziness on the part of the child?  Is it the fault of the family for not following through with home assignments?  Is the speech/language pathologist not teaching the correct strategies?  Instead of pointing fingers at each other, let’s uncover why speech/stuttering strategies can be difficult and determine how we can best navigate these challenges. 

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.  

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.  

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). 

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.