From the Editor...
Ben is a 9-year-old boy who attends the fourth grade at an elementary school in Oregon where he enjoys learning about science, math, and music. A good student, Ben says that he would like to become a veterinarian someday. However, his teacher reports that because of his stuttering, Ben refuses to answer questions in class and is terrified by an upcoming assignment to deliver a 5-min expository speech. Moreover, although Ben was once a popular playmate, he no longer spends time with his peers after school, preferring instead to go home and care for his family's cats and dogs. Ben's mother reports that this change in behavior is related to an increase in the amount of teasing and bullying that he has experienced at school because of his stuttering.
In consultation with the school's speech-language pathologist (SLP), Ben's mother also reports that during the past year, Ben's stuttering has increased in frequency and severity, resulting in numerous emotional outbursts at home and a growing tendency to avoid speaking situations that involve using the telephone, making new friends, or interacting with individuals he does not know well (e.g., store clerks, bus drivers, waitresses). Understandably, Ben's mother is concerned that if the stuttering continues, Ben's future will be filled with anxiety and uncertainty, along with many unforeseeable obstacles that may limit his social, academic, and vocational success.1
Ben's SLP, Ms. Blake, shares these concerns and is willing to work hard to design and implement an individualized intervention program to help Ben establish and maintain fluency in natural speaking situations. However, upon looking to the research literature for the latest information on the treatment of childhood stuttering, Ms. Blake finds that most of the published studies were conducted with preschool children (ages 3–5 years) rather than school-age children (ages 6–12 years). She was dismayed also to learn that most of the treatment studies of school-age children were published during the 1980s and 1990s, and that during the past 10 years, NO data-based studies that focused on building fluent speech in school-age children have been published in American Speech-Language-Hearing Association journals—including Language, Speech, and Hearing Services in Schools (LSHSS), the American Journal of Speech-Language Pathology (AJSLP), and the Journal of Speech, Language, and Hearing Research (JSLHR)—and that only one such study (Koushik, Shenker, & Onslow, 2009) was published in the Journal of Fluency Disorders (JFD). Rather, Ms. Blake detected a trend in the literature toward counseling children to accept their stuttering and to learn to cope with its negative side effects instead of working directly on the stuttered speech, as if to say that we are throwing in the towel on the effort to achieve fluency in school-age children.
Given the scarcity of recent research on methods used to establish and maintain fluency in school-age children who stutter, Ms. Blake was surprised to find numerous advertisements in recent issues of The ASHA Leader—a publication that is sent to more than 140,000 professionals and students—for books, workbooks, pamphlets, and DVDs available for purchase that claim to be effective in the treatment of stuttering in school-age children. Confused by this apparent inconsistency, Ms. Blake contacted her former university professor for advice and guidance. In response to this disturbing situation in an era that emphasizes evidence-based practice, Ms. Blake's professor stated that one thing is certain: "There is an urgent need to conduct and publish studies that examine the effectiveness of methods used to treat stuttering in school-age children."
In this editorial, I offer suggestions for how this might be accomplished, focusing on what I believe to be two worthy candidates for treatment research with school-age children, the Lidcombe Program (LP; Koushik et al., 2009) and Gradual Increase in Length and Complexity of Utterance (GILCU; Ryan & Ryan, 1995). Representing contrasting approaches, both are often discussed at research conferences and in the literature and deserve careful consideration.
With LP, a "nonprogrammed" approach to the treatment of stuttering, the SLP trains the child's parent to identify fluent utterances in the child's conversational speech and to reinforce those utterances with frequent praise (e.g., "That was smooth talking!"). During the beginning stages of treatment, the child and parent engage in structured one-on-one sessions of approximately 15 min each day where they talk about a book, game, or other shared activity at home. During those sessions, all stuttering is ignored initially and only fluent utterances are commented on by the parent. Gradually, as a result of this positive reinforcement, the percentage of fluent utterances increases as the percentage of stuttered utterances declines. Then, the parent begins to point out the occasional stutter (e.g., "I heard a stutter that time.") and may ask the child to repeat the word fluently (e.g., "Let's try that word again: baseball."). After achieving success with the structured sessions, the parent moves to "online" therapy and begins to reinforce fluency only during unstructured daily conversations. As with the structured sessions, praise for fluency occurs far more often than does the occasional correction for stuttering. Throughout the treatment period, the parent and child meet with the SLP on a weekly basis to discuss the child's progress, address any problems that might arise (e.g., the child decides he does not like to hear praise, the parent has limited time to work with the child), and ensure that the treatment remains positive for both the child and the parent. After the child consistently demonstrates a high rate of fluency and a low rate of stuttering (<1%) at home and in the clinic each week, a maintenance stage begins at which time the weekly clinic visits occur less often or are discontinued (see Australian Stuttering Research Centre, 2011; Harrison, Bruce, Shenker, & Koushik, 2010; and Koushik et al., 2009, for more details).
Some strengths of LP include the fact that the child is not asked to learn to use a different speaking pattern, such as an exaggerated airflow or slowed rate with prolonged vowels (aka "turtle speech"). Although fluent, this type of speaking pattern calls attention to itself when used in the "real world," and may invite teasing and ridicule from a child's peers or even from misinformed adults. In contrast, LP reinforces what the child is already doing well (speaking fluently) and occasionally corrects the undesirable behavior (stuttering). It thereby capitalizes on the fact that even if a child stutters severely (e.g., more than 10% of his spoken syllables are stuttered), the majority of the child's speech (e.g., 90% of his spoken syllables) is produced fluently. Thus, by praising the desirable behavior frequently, and correcting the undesirable behavior occasionally, the parent helps to ensure that the child's fluent speech gradually increases as his stuttering decreases.
Although LP reportedly has had a high success rate with preschool children (e.g., Jones et al., 2005), only one known published study (Koushik et al., 2009) has employed it with school-age children (n = 11), who ranged in age from 6 to 10 years old (Mage = 9 years). The results of that study were promising, but the researchers identified several challenges in using LP with older children. These included difficulty that some parents reported in finding time to have a structured conversation with the child each day to work on speech; difficulty that some parents encountered in learning and carrying out the procedures correctly; and difficulty that some children experienced in maintaining low levels of stuttering in natural speaking situations after treatment had ended.
Given these challenges, it may be useful to explore the possibility of using GILCU as a supplement to LP or, in some cases, as a substitute for it when parents (or other caring and responsible adults) are unable to participate as the child's primary interventionist.
Unlike LP, GILCU is a "programmed" approach to the treatment of stuttering that involves a highly structured hierarchy that is administered directly by the SLP rather than by the child's parent (Ryan, 1974). With GILCU, the SLP follows a carefully sequenced set of small steps in which the child produces a large number of fluent utterances. Treatment is carried out over a large number of sessions that gradually move the child from the production of single words to the production of short phrases, short sentences, longer sentences, and multiple connected sentences. Eventually, the child is expected to speak fluently for longer periods of time, gradually moving from 30 sec to 5 min. Throughout these sessions, fluent utterances are reinforced with praise (e.g., "Good!") or tokens, and stuttered utterances are corrected with verbal feedback (e.g., "Try that again."). For most clients, treatment begins with reading, then shifts to monologue, and finally to conversation. As with LP, GILCU does not attempt to teach the child to use a different speaking pattern, but simply reinforces the child's fluent utterances. However, it differs from LP because of its drill-like nature and its emphasis on gradually building the length and complexity of fluent utterances, moving from smaller to larger linguistic units (words, phrases, sentences) that are produced largely in nonnatural speaking contexts during the initial phase of treatment, which is called "establishment." Following success with the establishment phase, the client moves to the next phase, "transfer," and is expected to speak fluently in all situations beyond the clinic setting. To ensure success, a hierarchy of "easy" to "difficult" speaking situations is identified and followed. Finally, the "maintenance" phase of treatment begins, where the client is expected to speak fluently in all situations beyond the clinic for an extended period of time (e.g., 22 months).
Ryan and Ryan (1995) conducted a study that included a group of school-age children (n = 9, Mage = 12 years) who received GILCU treatment for their stuttering. Treatment was delivered by a trained SLP at school, twice a week for 30-min sessions, over a 9-month school year. The results indicated that GILCU was effective in establishing fluency for most of the children, but some of the children did not complete the transfer and maintenance activities. Nevertheless, the findings, although preliminary, are promising and support the case for conducting additional, larger studies using GILCU with school-age children who stutter.
Some strengths of GILCU include the fact that the program is straightforward, is fairly easy to administer, and does not require the child to adopt an unnatural speaking pattern (e.g., prolonged speech) that may set him up for peer teasing and bullying in real communication settings (e.g., on the playground, school bus). However, the data supporting its effectiveness were collected many years ago and involved a small number of school-age children who stuttered. Moreover, no updated versions of the program have been designed—variations that might involve the use of technology to enhance its accuracy, effectiveness, efficiency, and motivational properties.
Thus, it is recommended that studies be designed and carried out to compare the effectiveness of different approaches to the treatment of stuttering in school-age children: LP, GILCU, and a combination of LP + GILCU. Of course, it will be essential to ensure that (a) large numbers of children participate in this research in order to control for individual variability; (b) participants are assigned randomly to their groups (rather than on the basis of convenience or preference); and (c) groups do not differ with respect to potentially confounding factors such as age, gender, socioeconomic status, severity of stuttering, nonverbal cognition, or language development. Then, when evaluating the effectiveness of the different approaches, it will be necessary to measure the percentage of stuttered syllables produced in natural speaking situations. This should occur immediately following formal treatment and at future points in time (e.g., 3, 6, 12, and 24 months after treatment) to determine the effectiveness and durability of treatment. Moreover, in order to have a comprehensive evaluation of treatment effectiveness, it will be important to question the participants about their perceptions of themselves as communicators who are able to speak fluently and confidently in a variety of situations without the fear of teasing or bullying.
In conclusion, it is worth mentioning that new investigators, including doctoral students, with an interest in stuttering would be well advised to ponder the many possibilities and rewards that a career that focuses on the treatment of stuttering in school-age children can offer. Given that stuttering is a neurodevelopmental disorder that is best remediated when children are young, it is critical that school-age children receive effective treatment before the disorder becomes an entrenched and lifelong pattern. Investigators who can break new ground in this arena will be making a significant contribution to the field of speech-language pathology and to society.