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STUTTERING PREVENTION: A MANUAL FOR
PARENTS
C. Woodruff Starkweather, Ph.D.
Sheryl Ridener Gottwald, Ph.D.
Murray Halfond, Ph.D.
Temple University Stuttering Prevention Clinic
INTRODUCTION
This manual is for parents who are concerned that their child might be stuttering.
When very young children -- two to six years of age -- begin to repeat sounds,
syllables, or words in their speech, parents often worry that the child is going to
become a stutterer. They will worry even more if the child repeats these parts of
speech often, if the repetitions last a long time, or if they are accompanied by other
behaviors. Fortunately there are a number of specific things that parents can do, at
home or with a speech pathologist (speech therapist), that can prevent the child's
speech pattern from developing into a chronic stuttering problem. If you cannot see
a speech pathologist, you may be able to improve your child's speech effectively
on your own, but there is no question that you will be more successful in removing
or preventing stuttering if you work under the guidance of a speech pathologist
who has been trained in stuttering prevention.
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Make no mistake about it, when stuttering has fully developed, it is a severe
disorder that places a heavy burden on the child. A child who is afraid to ask
questions or talk to other adults or children may not develop as quickly,
academically or socially, as a child who likes to talk. Once established in an older
child or adult, stuttering is difficult, often impossible, to control. But in children
under five, or when the disorder has been present for only a year or so, parents and
speech pathologists, working together, can usually prevent this from happening.
The material presented in this manual is based on experience gained over the years
at the Temple University Stuttering Prevention Clinic. The method used in this
clinic, developed after years of research, has been highly successful in preventing
the development of stuttering in children. We have seen many young children,
from two to six, who are beginning to stutter. In almost all cases, the disorder has
been stopped from developing and the child has become a normal speaker. If there
is one lesson we have learned, it is this: The cooperation of the parents in carrying
out the suggestions made by the speech/language pathologist is vital. Without the
parents' efforts at home, the program is not likely to succeed. Parents do not cause
stuttering, but there is much that they can do to prevent it from becoming a chronic
problem.
WHAT I S STUTTERING?
Every parent wants to know the answer to this question. But the answer is
complicated and requires some understanding of how speech develops in the
normal child. When children are about a year old, they typically say their first
words. These are single words, which the child uses for a variety of purposes. By
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two years, the child has usually begun to put two or three words together, and is
producing primitive sentences like "Mommy go?" "Want truck," or "See doggy."
Usually, at this stage, the child's pronunciation of sounds is imperfect, the tempo of
speech is slow, and each syllable is given equal stress. The sentences given above
would be pronounced "Mama go," "Want twuck," "tee dawdaw," or something like
that. Between two and three years of age, these primitive sentences become longer
and more elaborate, pronunciation improves somewhat, and the children begin to
talk more quickly and with a more grownup rhythm. Instead of saying "dawdaw"
for doggy," a three year old would be more likely to say dawdy," still
mispronouncing the "g" but producing the correct rhythm of the word, with the
accent on the first syllable. It is during this stage of development that children
learn to produce unaccented syllables. This development, which goes unnoticed by
most parents, enables the child to talk faster, and that is important because it is just
at this same time that the child is beginning to use longer and more complex
sentences, and it is also just at this time that the child is beginning to notice many
complicated things about the world, which the child wants to talk about in those
longer sentences. The drive to communicate at this age is very powerful, and the
child will be frustrated by anything that gets in the way of the communication of
ideas.
Quite a few children, at this stage of development, begin to repeat words or
syllables, usually at the beginning of a clause or sentence. They say things like "I,
I, I, I, I, saw a big, a big truck in the, in the street. And, and, and it, and it, it --
Mommy do trucks do wee wee?" In this sentence, you can see some of the things
that make children hesitate -- a confusing thought, uncertainty about some event in
the world, a complicated sentence to produce, perhaps a doubt about the politeness
of the question. When children hesitate in their speech, they tend to repeat phrases,
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words, and syllables. Later, when they are older they have more sophisticated ways
of hesitating -- saying "well," "like" and "um" for example. But at this age, they
just repeat elements. Sometimes, if they are very unsure of themselves or of how to
say something, or if they are very excited or nervous, they will continue to repeat
for a very long time --- "Mommy Mommy, Mommy, Mommy, Mommy, Mommy I
saw a birdy and he, and he, and he, he, he, he, he, he, he wash his bottom in the
dirt." These repetitions of whole words or syllables, even the long ones, produced
easily and without evident concern, are probably not very abnormal, unless they
occur often. They are just the way the child talks who has more to say, or who
wants to say more, of who wants to say it more quickly, than his speech
mechanism or language skills can accommodate. But even though they are not too
abnormal, these repeated elements, particularly when they are a common feature of
the child's speech, mean that there is a risk that stuttering can develop. We believe
that any child at risk should be dealt with. If the risk is small, it is easier to deal
with, but stuttering is too awful a problem to just "wait and see."
The word fluency is used to refer to the ease with which speech is produced. The
three year old who is highly fluent will say "But, but Daddy, if I, if I can have the
candy now, I'll still eat my dinner." The less fluent child, less sure of which words
to use, less sure of the grammar, and not so quick at moving his tongue, lips, jaw,
and voice might say "But, but, but, but Da-daddy, if, if,, I have the ca-candy now,
I, I, I, I'll still, still eat my dinner."
We like to think of two aspects of speech development that affect the child's
fluency -- the demands for fluency, and the child's capacity for fluency. By
capacities, we mean the skills and abilities that are required to talk -- the ability to
move the speech mechanism to make sounds, the ability to choose the right words,
the ability to compose the sentences so that others will understand, and the ability
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to know what is an appropriate thing to say under the circumstances. Naturally as
children grow, these capacities for talking fluently are also maturing, and the child
finds it easier and easier to say what he wants to say. We can tell that children find
it easier to talk because they take less time to produce sounds, to find words, and to
construct sentences. As a result they talk faster and with fewer hesitations and
repetitions.
Demands for fluency come from the people the child talks to -- parents, brothers
and sisters, friends -- and from the child too. As children grow, more is expected of
them, and a child who is smart enough to think of the argument that he or she will
eat dinner even if some candy is eaten now, is expected to be able to speak easily
enough to utter the argument without too much hesitation and at a rate of speech
that is age-appropriate. Not all of the demands for fluency come from the people
the child is talking to. Some of them come from within the child. Just as parents
expect a child to produce speech that is appropriately fluent for the child's age,
intelligence, and linguistic sophistication, so too does the child have some sense of
how easy it should be to talk. Some children have a lot to say but lack the capacity
to say it easily, and they may become very frustrated because they expect more,
demand more, of their speech mechanisms than it has the capacity to produce. As
long as children's capacities for fluent speech are developing fast enough to meet
the increasing demands that are made on them, including those they make on
themselves, they will not hesitate, repeat sounds, stutter, or stumble in speaking
very often. But when too much is asked of the mechanism, children will try to
make it do what it lacks the capacity to do. And as a result, their speech will
contain more than the usual amount of repetition of words, syllables, and phrases.
If, in addition, they find the presence of those repeated elements too time-
consuming, or if they come to believe that these repetitions are bad, that they
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shouldn't talk that way, they will try to force the repeated words out, they will try
to repeat the words and syllables faster so as to get to the rest of the sentence, and
they will start to struggle when they talk. This struggle to talk, manifested by an
unusual amount of repetition, by the repetition of smaller elements of speech such
as syllables and sounds, by the presence of vocal strain and tension, and by the
presence of muscular tension in the speech mechanisms, is stuttering
Unfortunately, we don't know very much about why stuttering develops in some
children but not in others. There is clearly a tendency for stuttering to run in
families, and some of this tendency seems to result from inheritance. Genes do
make a difference, but it is also clear that they do not make the entire difference,
since there are many children whose parents stutter but who develop normal
speech, and there are many children who stutter despite having no one in the
family who stutters. Besides, the way in which stuttering develops is clearly a
result of the child's interaction with his or her immediate environment.
We do know that stuttering is not caused by tickling the child, nor is it acquired by
imitation of some other child who stutters. We also know that the child who
stutters is not retarded or mentally ill, and that he or she does not have a
personality disorder. Sometimes children who stutter are socially withdrawn, shy,
or nervous, but these are probably reactions to the disorder. Nevertheless, these
reactions probably do make the problem worse.
Some children do not follow the gradual path of development described above.Instead, they begin to stutter suddenly, usually under circumstances that involve
emotional distress, either sudden or prolonged -- absence of one or both parents,
moving to a new location, starting a new school, death or serious illness in the
family, hospitalization of the child or of a sibling. Typically also, the emotional
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distress is somehow related to speaking, and there is sometimes a period of not
talking at all (mutism) before the child begins to stutter. Stuttering can also
develop suddenly following a head injury, but this is quite rare in children.
NORMAL FLUENCY DEVELOPMENT
The ability to speak fluently is a skill that develops as children grow. All children,
especially between the ages of two and six, occasionally stumble or hesitate as they
begin to put sounds, words, and sentences together. These normal dis-fluencies are
different from stuttered speech, both in the number of times they occur and in theway in which they are produced. The following are examples of normal dis-
fluencies:
1. Whole word and phrase repetitions -- "My, my ball is on the roof." I want, I
want to get up."
2. Revising sentences -- It went, My ball went on the roof."
3. Pauses filled with um, ah, uh -- "I want my, um, ball."
4. Silent pauses such as hesitations -- Daddy, I want (pause) my ball."
5. Infrequent, easy, single, part-word repetitions -- Y-you said you'd get it."
Children vary widely in the number and types of normal dis-fluencies they
produce. Some children will remain quite fluent except for an occasional hesitation
or pause. Others are obviously dis-fluent, showing the entire range of normal dis-
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fluncies described above. In general, the most common normal dis-fluencies are
whole-word repetitions, and these occur most frequently at the beginnings of
sentences. Boys seem to show more word repetitions than girls, but both boys and
girls show fewer repetitions as they grow.
You may notice that these normal dis-fluencies occur more frequently in your
child's speech at certain times. Normal dis-fluencies seem to increase under some
conditions. When your child is excessively tired, excited or in more formal
speaking situations such as speaking with and adult, dis-fluencies will typically
increase. Talking with a partner who speaks much faster than the child or who is
non-attentive may make it more difficult for the child to remain fluent. Likewise,
when the child interrupts, tries less familiar vocabulary words or attempts more
form language, the number of normal dis-fluencies can be expected to rise.
SYMPTOMS OF RISK
There are three general areas of risk -- the amount of repetition in the child's
speech, the amount of struggle in the child's speech, and the parents' attitudes
toward and reactions to the child's behavior.
Children who have more repetition and hesitation in their speech are more at risk
than children who have less. The more hesitant and repetitive the child is, the more
likelihood that he or she will begin to be frustrated by these barriers to rapid and
easy communication and the more likely that speech will begin to be struggled,
forced, and tense.
Children who are already beginning to struggle in their speech are of course more
at risk than those who are not showing any signs of muscular tension. However,
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the development of this struggle and tension is usually (there are exceptions -- see
below) quite slow, and the earliest signs are quite subtle. One of the early signs is a
rising pitch of the voice during the repetition of a word or syllable. As the word or
syllable is repeated, the vocal pitch rises almost like a siren. This rise in pitch is a
sign that the vocal cords themselves are becoming increasingly tense, like
tightening a guitar string while playing a note.
Another early sign is shortening of the repeated element. If a child who has been
repeating whole words, like "But, but, but, but...." starts to begin sentences with
"bu-, bu-, bu-,..." cutting each word off before it is completed, or even b-, b-, b-,b,,
trying to push through the repetition, to get it over with, to get to the rest of the
sentence. Similar to this sign, is an increase in the tempo with which the repeated
element is produced. Many children start out saying "Can, can, can, can I..."
progress to "Ca-, ca-, ca-, can I ..." then to "C-,c-,c-,c-, can, I" and finally to
"cccccan I."
Another early sign is a change in the vowel itself. The child who says "Mom,
mom, mom, mommy" is less at risk than the child who says "muh, muh, muh,
mommy."
Once a child has begun to show evident signs of struggle, tension in the facial
muscles, body movements, gasping for breath, hard blinking of the eyes, or using a
very loud voice, he is not simply at risk but really is stuttering, perhaps severely.
Similarly, the child who shows, by his attitude toward speaking and toward socialsituations that he is afraid or embarrassed to talk, or who abandons sentences that
he has begun is also well along in the development of stuttering.
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A third category of risk is the parent's attitude. Unlike many programs, the Temple
University Stuttering Prevention Clinic accepts for treatment any child whose
parents are concerned that the child is beginning to stutter. We do this for two
reasons. One reason is that the parents are almost always right. We have only seen
two cases where the parents were worried and the child was actually not at risk.
But our second reason is that parents who are worried about their child's speech
react differently to it. They almost always feel badly when the child stutters,
although exactly how they feel varies. The disfluency may make them upset,
nervous, angry, or depressed. It may be almost feel painful to watch a child
struggling to talk. These reactions are perfectly normal, in most cases, and usually
stem from the parents' love and concern. But often, in spite of their good
intentions, the way the parents react to disfluent speech communicates
inadvertently to the child that disfluent speech is to be avoided at all costs. The
child reacts to this by struggling more and struggling harder, which actually makes
the stuttering worse. So the concern of the parents may end up contributing to the
problem, and we treat it as a risk factor.
HOW PARENTS CAN HELP -- ENHANCING FLUENCY AT HOME
When parents come to us for help, it is interesting to note that they are already
doing many helpful things for their child, although they may be unaware of them.
Reviewing the following list of suggestions will help you identify those things youare currently doing that make it easier for your child to speak fluently. By
identifying these things, it will then be easy for you to increase the frequency with
which you do them. Also, you may wish to implement some of the other
suggestions, until you are no longer concerned about a risk of stuttering
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developing. Rather than attempting to master all of the suggestions at once, choose
one or two new strategies each week. This gives you and your child enough time to
gradually adjust to the changes you'll be making. On final word of caution, Each
family is unique and not all of the suggestions to follow will be appropriate for all
families. Apply only those that seem useful to your particular situation.
L istening Dif ferently
Most likely, your child is at a stage of development where there is significant
growth in the ability to use language. There may even be times when the child istalking so incessantly that you wonder if it will ever stop. When children are in this
stage of growth, parents necessarily listen selectively. The purpose of this section
is to help you examine how you listen and provide some suggestions for selective
listening that convey to the child your interest in and respect for his or her
communications.
You can begin this process by playing a bit of the detective role. In order to begin
adjusting your listening style, you will need to know what that present listening
style is. Over the period of a week, step back as an objective third party might and
observe the ways in which you listen. Jotting down some notes in a log book as the
thoughts occur may help you to focus in on the larger picture at the end of the
week.
Since you cannot listen with all ears every time your child talks, mentally note the
topics that interest you as well as the topics that your child chatters on about that
are not as interesting to you. Do you tend to listen to every word when your child
tells you about something dangerous he's just done, but with only half an ear when
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he's chattering on about a TV rerun you've seen three times? Identify times of the
day that your child seems more interested in conversing, as well as times of the day
when you have energy to listen more intensively. Do you have difficulty doing
anything before your first cup of coffee in the morning, but that's when your child
comes bouncing into your bedroom full of stories: When you are listening to your
child, examine your body position and eye contact. Are you likely to be engaged in
another activity such as washing the dishes or reading the paper during these
conversations?
Once you have a feeling for how you listen, you may want to begin making some
changes. If there are times of the day that seem to occur consistently where things
are just too hectic or when you are just too tired to listen well, set up a quiet time
activity. When you are frazzled and worn out, you can't listen as effectively. Your
child may interpret this as a message that he or she is not interesting or not worth
listening to, when that's not the case at all. Everyone can benefit from quiet time
during the day; it is generally a time to relax and unwind, without the pressures of
interacting with others. Children and adults should engage in some non-demanding
activity by themselves such as reading or looking at books, quiet play with puzzles
or even watching TV. Little or no talking should be allowed during this time. This
quiet time should be a consistently scheduled time, so that each day, family
members will expect it to occur and accept it as part of the family routine.
You can also try adjusting somewhat to your child's schedule to provide more
intensive listening. Families we have worked with have come up with some
creative solutions that seemed to make a big difference in their lives. One family
got up half an hour earlier in the morning, to provide more time for quality
listening at a time when the children were very interested in talking. Another
family postponed doing the dinner dishes until after the children went to bed in
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order to spend that half hour listening more carefully. The important thing to learn
is that the changes you make can be minimal, maybe only affecting as much as a
half hour of your day. Yet that one half hour that you have allotted for more
selective listening may make a world of difference to your child.
When you are listening to your child more intensively, try increasing the amount of
eye contact you make. Looking at someone when they're speaking communicates
interest. And open posture with arms unfolded and legs uncrossed also indicates a
willingness to participate in your child's conversation. You will want to follow
your child's lead, rather than introducing new topics yourself.
When your child speaks, practice listening for the ideas expressed rather than
focusing on the way he or she is speaking. This will take discipline, especially if
your child speaks very slowly or struggles through the words. By responding to
how your child talks (i.e., "You're talking too fast" or "Take a breath.") you are
giving the message that what the child is saying is not worth listening to AND that
he or she is a failure at producing the message as well. By responding to the
content of the message, you are telling your child that you are listening and that
you are interested in what your child has to say.
Speaking Di f ferently
Slowing Down. Most adults speak almost as quickly as is physically possible.
Young children speak much more slowly, since they are just learning how to
coordinate the speech mechanism. When children speak with adults, they attempt
to match the speaking rates of the adults they are conversing with. They are
consequently under some time pressure whenever they speak to an adult who is
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speaking at a typical adult rate. Fluency can be compromised whenever there is
time pressure; it is one of the most common demands on fluency. One thing
parents can do in this regard is to slow down while speaking to or in front of the
child. "Try talking as slowly as your child talks. Some parents have found it
helpful to tape record their child and then listen to the tape focusing on how fast
the child produces words. Replay the tape and this time, try saying the same words
as your child along with the tape it is this speed that you should try to maintain.
Rather than chopping up the words in a sentence to slow down, draw out the
sounds and let one word flow into the next. Slowing down is not easy, and you will
need to consciously work at it when you are with your child. As you learn to slow
your speech rate down, you will feel a sense of relaxation. This is another sign that
you are slowing enough to reduce time pressure on the child. It is worth reminding
parents that they do not cause stuttering by talking too fast, but they can help the
child become more fluent by talking more slowly.
Increasing Pause Time. Pause frequently while you talk. Wherever commas or
periods would appear if you were writing your speech, stop and take a breath. This
provides a model for your child that reduces time pressure and places value on
carefully presented, well thought out speech.
Increasing Silence. Allow more time for silence in general. In this way, your child
will learn that every second does not need to be filled with talking. This will help
to reduce the pressure he may experience trying to keep a conversation going. In
addition, a great deal of talking by parents stimulates the child's language
development. Some children are stimulated so much that their linguistic skills
develop way ahead of their motor skills to produce the sounds of speech, and
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stuttering seems often to result from this imbalance of skills.
Eliminating Interruptions. Let family members completely finish their ideas
before someone else is allowed to speak. There are two things we know about
normally developing children and interruptions. If children are allowed to interrupt
others, they are more likely to stumble over their words during the interruption.
Also, if a child who does not stutter is interrupted by another speaker, the child will
most likely be disfluent if he or she tries to continue speaking. For the child at risk
for developing a stuttering problem, interrupting or being interrupted can seriously
interfere with fluency.
Reducing Certain Kinds of Questions. There are many things children must do in
order to answer a question. First, they must figure out what the question means.
Then they need to organize their thoughts to answer the question appropriately, and
find the right words and grammar to respond with. Finally, they need to execute
the message orally. All of this must be accomplished immediately, since that's
what the question-and-answer format demands. Many questions, of course, are
simple to answer, requiring only a brief response, but questions requiring long,
thoughtful or narrative answers can be difficult for a child still developing
language competence skills, and can contribute to fluency breakdown. It is
advisable to refrain from asking your child questions that require a length oral
response, such as "What did you do in school today?" or "Tell Aunt Corrine what
you saw at the zoo." But parents need to find out what happened at school. We
suggest that you make a few comments about your own activities. This will usually
stimulate your child to begin talking about his or her activities as well. Tell your
child what you had for lunch, or what you heard on the radio, or who you saw on
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the bus. If something pops into your child's mind at this time about the school day,
he or she will spontaneously share it with you. Spontaneously shared information
is much more likely to be fluent.
Modeling Normal Dis-fluencies. Parents are advised to provide a model of
normal speech for their children. Since normal speech is not completely fluent, you
will want to demonstrate for your child acceptable ways to be disfluent. Young
children with normally developing speech frequently repeat the first word in a
phrase or sentence one or two times. Young children will also pause and say um or
uh as they are searching for words. Therefore, it is important that you occasionally
model these acceptable forms of disfluency in a nonchalant, easy way. For
example, when telling a child to go get his shoes you could " Go, go get your
shoes: or "Go get your, um, shoes." The repetitions or pauses should be produced
slowly and smoothly.
Conversing Di ff erentl y
Talking withYour Child. Since a parent's role encompasses many
responsibilities, you may find that the majority of time you spend conversing with
your child is as disciplinarian or caretaker. Typically, during these times, the parent
must talk "at" the child in order to give the necessary instructions or rules. It will
be helpful to your child if you gradually increase the amount of time you spendtalking "with" your child -- actually engaged in a conversation which is shared by
both of you. In this way, talking becomes more of a pleasurable experience,
something to anticipate. Engaging in activities with your child that the child enjoys
doing sets the tone for quality talking. For example, as your child helps you make
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chocolate chip cookies, he or she is certain to begin commenting about the task.
This is your cue to respond to the content of his message. Allow your child to
introduce the speech topics and then follow his or her conversational lead.
Being Non-judgmental. During this shared conversation time, be sure that your
comments are nonjudgmental. Evaluation or the fear of being criticized inhibits
most people, even adults. For a child who is at risk for stuttering, the fear of saying
something wrong can lead to speech that is produced in a halting, stumbled way.
This does NOT mean that you should not discipline your child for misdeeds.
Children need the direction that discipline provides. But it is best not to make the
child at risk for stuttering speak as a form of punishment. In other words, asking
the child to explain why they did something wrong, or asking them to apologize or
confess may not be the best form of punishment for a child at risk for stuttering.
Eliminating Non-spontaneous Speech. When speech is demanded from a child,
the time and performance pressure experienced by the child can precipitate a
fluency breakdown. Demand speech can take many forms, including asking the
child to recite the alphabet, retell a story, or explain how Snoopy got stuck in the
toilet. Even asking the child to say "please" and "thank you" can increase pressure
enough to cause the child to be dis-fluent. For the time being, it is wise to eliminate
these requests for speech performance. Modeling the appropriate social amenity for
the child is just as effective in establishing manners as is having the child repeat
the phrase on demand.
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Dealing Di ff erently with Dail y L iving
Increasing Routine. Many parents report that their children have more difficulty
speaking during exciting times such as at birthday parties or on vacations. It might
seem though, that because these are happy, fun times, it should be easier for your
child to speak fluently. That is not the case at all. Birthday parties and vacations
are examples of events that do not follow the daily routine. They are full of
surprises and anticipation. It is this lack of structure and uncertainty that
contributes to an increase in stuttering. It is suggested that a daily routine be
adhered to as consistently as possible, even on the weekends. If the child knows
that after breakfast, he gets dressed, then watches TV and then plays, the
uncertainty he might feel is significantly reduced.
Preparing the child in advance for special events, such as a birthday party or a visit
from grandparents, also helps to reduce the uncertainty that comes from
anticipation. The child should be familiar with the exact sequence of events, and an
effort should be made to keep the events as relaxed and predictable as possible. For
example, rather than having a birthday party with a lot of friends in the middle of
the day, plan a smaller family celebration at the regularly scheduled dinner time. If
the family is going on vacation, allow the child an opportunity to help plan some of
the activities and pack some of his clothes and toys. Again, the important idea to
keep in mind is that the child should know what to expect and that as much of the
daily routine as possible should be preserved.
Family Communication Rules.It is helpful if all members of the family develop
more effective speaking skills. Developing family communication rules is a way to
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accomplish this task. The rules can be as simple as:
1. Only one person speaks at a time.
2. Everyone gets an opportunity to speak.
3. No one evaluates the contribution of another speaker.
These rules provide for orderly, fair, and safe family communication. Present them
when the family is together along with methods for enforcing the rules. One family
developed this strategy for monitoring the family's use of communication rules:
Each family member began the week with 25 pennies in a cup. Each time someone
violated a rule, they had to remove one penny from their cup. At the end of the
week, the family members were able to keep the remaining pennies. Not only do
rules such as these facilitate fluency for the at risk child, they teach the rest of the
family patterns of interaction that will be helpful in any environment.
Daily Talking Time. It is advisable to set aside a small amount of time each day in
which one parent can devote full attention to the child at risk for stuttering. It is
important that your attention not be divided at this time. Leave the dishes or the
lawn to be done at another time. Exclude siblings for a while and arrange for
someone else to answer the phone. This special talking time does not have to be
very long. Fifteen minutes seems to be enough, but it is best if it can be done every
day at about the same time. During this time, engage you child in quiet play --
doing puzzles, reading stories or playing with play dough are all non-demanding
activities appropriate for the special talking time. The goal of this time is to
provide a regularly scheduled, non-demanding opportunity for your child to be
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with you, without having to compete with all the distractions of the outside world.
It is likely that during this time you will be more relaxed. Thus you may be able to
adjust your speech more easily. This will consequently facilitate easy speech from
your child.
ATTI TUDES AND REACTIONS TO STUTTERING
The Problem
Watching and listening as your child struggles his or her way through speech can
be a worrisome experience. Parents report feeling helpless, frustrated and very
alone. They are mostly worried that their child's hesitant speech will develop into a
life-long stuttering problem, carrying with it social, emotional, and even
educational or occupational limitations.
Stuttering Behaviors Make Parents Nervous. When a parent or other listener
engages in a conversation with a child who stutter, feelings of anxiety, fear,
embarrassment, impatience, and pity may be expressed outwardly through facial
expressions or body movements. Some parents have freeze, even stop breathing,
and then visibly relax when the stuttering moment ends. Others have said that the
stuttering behavior is so painful to watch, that they turn away until the child
finishes stuttering. Some parents try very hard not to react al all, but the underlying
feelings and attitudes often show through anyway. These negative feelings and
attitudes will affect the child who is at risk for developing a stuttering problem.
The child senses that the way he or she is talking is wrong and consequently may
try very hard not to stutter. The increased effort that is required to avoid stuttering
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also increases the muscle tension in the mouth, face and neck. If you have tried to
play a sport when you were very tense, you will understand why speech fluency is
more likely to break down under these tense circumstances.
A vicious cycle is created. The child has some dis-fluent speech which triggers
negative feelings in the parents. These negative feelings are received by the child
who then tries very hard tp speak in what he or she thinks is a better way. The
increased muscle effort may cause the child to struggle and force through words,
only renewing the anxious feelings in the parents.
Negative Listener Reactions Lead to Talking Fears. The child who receives
frequent messages that the way he or she is talking is "bad" or "not right" may
begin to lose confidence in his or her ability to communicate at all. For a young
child, difficulty talking is easily generalized to difficulty doing ANYTHING
successfully. As a child becomes more aware of difficulty speaking or experiences
negative listener reactions, he or she is more likely to experience frustration,
shame, poor self-esteem, or come to expect social disapproval. This lack of
confidence can develop into a fear of talking or a deep sense of shame, that is, a
feeling that you are not enough, or even defective. Fear of talking can easily
develop into fear of specific words, speaking situations, and people. This reaction
may vary from mild uneasiness to panic and can lead to the child avoiding
speaking.
The Solutions
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In order to break the vicious cycle that develops when dis-fluencies are reacted to
in a negative way, parents can learn to react to the child's problem more positively.
But this is not an easy thing to do.
Get the Facts. First, you will want to learn all you can about normal fluency
development and stuttering. Getting the facts will help you to evaluate more
objectively feelings and attitudes you may have acquired years ago. All speakers
are occasionally dis-fluent, some more than others. Listen to the hesitations and
repetitions that occur in the speech of your friends and relatives. Speech dis-
fluencies are not always faulty speech attempts. They are ways for competent
speakers to gain time to think while still maintaining control of the conversation.
Normal speech is not without hesitations, pauses, ums and ahs, and other breaks in
the flow.
From the ages of four to seven, a number of preschool children (25-50%) will
experience a period of more than usual dis-fluency. About 50 percent of these
children will outgrow the problem, even without speech therapy. For those enrolled
in an early intervention or prevention program, the success rate is 95 per cent or
better, and this seems to be true regardless of the approach that is used.
Deal with Stuttering More Effectively. When children stutters, it is best to let
them finish the thought on their own. A general rule of thumb is not to interruptyour child during stuttering or at any time. There may be some exceptions to this
rule. If your child is stuck on a word and is forcing very hard but still not able to
say the word, you may ask if help is wanted. With permission, you may then say
the word. By asking permission, you are still allowing the child to be in control his
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or her speech. This does set a bad example to the child, but distress and frustration
at not being able to force the word out can also lead to further development of
stuttering, so it is a difficult choice. Once a child has learned better ways to deal
with stuttering than struggle, your help should no longer be needed.
It may seem to you that if your child would just slow down or take a breath,
stuttering would not be a problem. . In fact suggestions such as these will probably
only complicate the problem in a number of ways. First, it is likely that the
stuttering is causing the breathing problems, rather than the other way around. As
for slowing down, it is true that slower speech is more fluent, but it is very hard ,
even for an adult, to slow down all the time. For children, who tend to be more
spontaneous anyway, slowing is even more difficult. But when you tell your child
to talk in a different way, it tells him or her very clearly that what they are doing is
wrong. You imply that if he or she would only do things differently, this problem
could be solved. The child begins to feel that he is not very good at talking. His
self-esteem as a speaker, and as a person, begins to suffer You can compare this
experience to the feelings you might have while attempting to play a sport you're
not very good at. You feel defeated before you begin. Also, if the child continually
hears suggestions that he can't implement, he may beginning to feel guilty and try
harder to change his speech. In trying harder, the child may begin to struggle,
developing tricks to help force out the words. This would be a worse stuttering
problem, not a better one. Getting over stuttering is not simply a matter of will
power. In fact, the attempt to talk fluently through as an exercise of will, typically
backfires and creates more stuttering behavior.
Increase Your Tolerance for Dis-fluencies. While speaking with your child, you
may become distracted by the repeated words or syllables or blocks. Through
practice and discipline, you can learn to focus on what the child is saying and not
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on how the child is saying it. Many adult stutterers say that they never felt that
anyone heard them as a child. Everyone was always listening to the stuttering.
Being heard is an essential ingredient in any relationship, and it is particularly
important for children talking to their parents. It is important that you work on
gradually developing a tolerance for dis-fluent speech. By responding to children's
content rather than the dis-fluencies, you show them that you value them and the
time you spend talking to them. Despite the dis-fluencies, the children feel that
they are worthwhile as communicative partners. Their self-confidence as speakers
will remain intact.
Feel Free to Talk about Stuttering. Stuttering should not be ignored. It is easy to
understand, though, why families might avoid talking about stuttering. Stuttering
does seem like a nervous kind of problem and talking about it might even make the
child more nervous. However, that is not the case at all. When the child is
struggling and dis-fluencies are obvious but no one talks about them, a problem
may develop which has been called "the conspiracy of silence." Even the very
young child who stutters knows that he is talking differently or that speech is a
difficult thing to do. He or she will begin looking to the parents for help and
support. When no one talks about the difficulty, the child may begin to think that
his or her speech is so bad that it must remain hidden. Many stutterers develop a
deep sense of personal shame over their stuttering as a result of this pattern of
parental reaction. Other children may come to believe that stuttering is somehow
inaudible. These are not healthy reactions. A stumble in speaking is not much
different from a stumble in walking. You need to pick yourself up and go on. If a
child falls down, the parents help the child get up, make sure he or she is not hurt,
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and go on. The child who is stuttering also needs some brief reassurance and
emotional support.
It is suggested that if the stuttering is obvious, parents feel free to talk about it with
their child in words that the child will understand. The object of this suggestion is
two-fold. First, in talking about the problem, you are acknowledging that it exists
and that you are there to help and support the child. Second, by acknowledging the
problem in a matter-of-fact way you are reassuring the child that the problem is not
catastrophic. It is important to use words that the child can understand. If your
child's speech behavior contains repetitions, the word "bumpy" may be
appropriate. If the child prolongs sounds or blocks, "sticky" or "hard" may be
appropriate words. Frequently, the children will come up with their own words to
describe the problem, if given the opportunity. For example, one two and a half
year old child talked about the words "getting stuck inside my mouth" so her
stuttering was referred to as "sticky speech." Another prolonged vowels and this
reminded him of pulling bubble gum apart, so he called it "bubble gum speech." If
the child has learned to call his problem stuttering then that word should be used to
talk about the dis-fluencies. The only caution here is that have a stuttering problem
and being a stutterer are two very different things. Your child may have a stuttering
problem, but he or she is also fluent many times during the day. And the child is
probably going to become a normal speaker. It's too soon to put a label on the
child, particularly one that describes only a small portion, and an undesirable
portion, of speech behavior. If we can separate children from the behavior they
perform, they can learn that they are good and valuable people even though their
behavior is not always perfect -- a good lesson for all of us.
It is appropriate to comment in a neutral way from time to time on the child's
stuttering after the child has finished speaking. You can tell the child that yes the
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speech was a little bumpy just at that moment and that sometimes people have
bumpy speech. Make your own speech a little bumpy (but not forced or struggled)
every once in a while to show that it is not something to be afraid of. Mentioning
the child's bumpy speech and showing some of your own help let the child know
that we all have bumpy speech once in a while. It is most important that the child
learns that despite the repetitions, he or she is accepted and loved. But this does not
mean that every time the child stutters he or she should get a hug or a pat on the
head. This would tell the child that he or she is loved because of the stuttering, and
that would be wrong too.
Build Self Confidence.Since children's sense of self-esteem and self-confidence
as a speaker may be at risk because of speech breakdowns, it is important to
counteract this by providing many opportunities for positive experiences. First, a
parent can increase verbal praise. Children need to hear periodically that their
parents enjoy being with them, enjoy talking to them and are happy with who the
child is. To help in this endeavor, you might want to think about what you like
about your child and in what areas your child does well. In addition to increasing
praise, parents can provide more opportunities for children to engage in the things
that they do well, while minimizing opportunities for things they struggle with. If
your child is good at sports and vigorous play, frequent trips to the park might be
scheduled instead of more activities such as board games or arts and crafts, which
usually involve more speech. If you notice that your child is having a particularly
easy time speaking, provide more opportunities for conversation. Likewise,
minimize speaking time if stuttering seems particularly severe by engaging your
child in nonverbal activities such as listening to records or singing. But don't make
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this obvious or rigid; it could also teach the child not to talk when stuttering is
present.
CONTACTING A SPEECH/LANGUAGE PATHOLOGIST
When the Contact is Appropriate
You may be wondering at what point you should consult with a speech pathologist
about your child's dis-fluencies. When a child exhibits any of the warning signs
described earlier in this manual of if anyone expresses any concern about the
child's fluency skills, a speech pathologist should be contacted. It is unwise to
postpone this appointment, hoping that the problem will solve itself. Although
some young children with stuttering problems do get better without help, many do
not. Generally, the earlier intervention is begun, the shorter the therapy program
will be.
How to Make the Contact. Finding the right professional(s) to work with your
child is a process that should be conducted carefully. There are a number of
agencies and individuals that provide speech services; you will want to find one
that has experience treating preschool children with stuttering problems.
The American Speech-Language-Hearing Association has a help line number that
may be called if you are having difficulty locating a speech pathologist. If
contacted, they will provide a listing of services available in any geographic area
requested. Their toll free number is 800-638-TALK (8255).
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The public school system also provides speech services to children, including
children who are not yet of school age, who may be at risk educationally as a result
of a speech problem. Stuttering can interfere seriously with education because
school aged children who stutter are often afraid to ask questions, and will
sometimes pretend not to know the answer to a question so as to avoid speaking.
The local school principal or counselor will be able to provide you with
information about this service.
Many large universities and hospitals have speech and hearing centers. The speech
departments in these institutions should be contacted. If the agency called does not
have a program for or a staff member who specializes in treating children who
stutter, they should be able to refer you to another agency.
Fees for speech therapy services vary widely. If your child is seen through the
public school system, you will pay no out-of-pocket expenses. In addition, therapy
services may be provided locally. Many universities offer significantly reduced
rates because their primary goal is to train student clinicians. Although in this case,
the service providers are less experienced, students are typically well supervised by
an experienced faculty member. Also university settings frequently offer the most
updated, innovative techniques, since they are teaching and research centers as
well. Finally, hospital and private practice settings, although typically more costly,
many be able to provide you with a carefully individualized program implemented
by an experienced clinician or specialist. Administrative staff may be able to assist
you in identifying third party payment sources to help with the fee.
It is most important that you feel comfortable with the person and agency you
choose to work with your child. If you continue to have concerns about your child
that are not addressed, securing a second opinion should be considered.
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Often the speech pathologist will want you to see other professionals as well -- a
family therapist, a psychotherapist, a physician, an audiologist, or a dentist. Also,
the speech pathologist will want to talk to your child's teacher or day care worker,
both to get and to give information. In these collaborative endeavors, the speech
pathologist will generally be the one coordinating the activities of all members of
the team so that the ultimate goal of better speech is attained.
THE GOALS AND PROCESSES OF EARLY I NTERVENTION PROGRAMS
When speech pathologists intervene to prevent stuttering from developing, they do
so with some sense of urgency. Stuttering is a disorder that begins in a relatively
benign form -- usually the child is repeating words or syllables but is not struggling
or forcing, and quite a few children talk in this way -- but gradually speech
behavior becomes more and more tense, the units that are repeated become shorter,
the child may react emotionally to the problem, and the child is talking less and
less like his or her peers and more and more abnormally. The speech pathologist,
aware of the possibility that the disorder can develop in this way wants to intervene
soon and effectively. At Temple, we see parents and children once a week, but we
see them for two hours each, with different clinicians working simultaneously, a
luxury we can afford because we are a teaching clinic. Other speech pathologists
may see the parents and children separately but more often.
The first goal in any treatment program is to assess the child's present state, and to
understand from that assessment just what the problem is. In the case of stuttering,
that will mean observing and recording the child's and the parents' speech, taking a
detailed case history of when the problem was first noticed and what it was like
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when it was first noticed, and how it has changed since then. Many clinicians will
also perform an analysis of the child's language skills at the same time. With all
this information about the child's present and past speech behavior, the clinician is
in a good position to plan therapy.
The first goal of therapy is to stop the disorder from developing any further. This is
usually easy to do. The first line of attack is usually training the parents to slow
down the rate of their own speech, which gives the child a more relaxed speech
model and removes time pressure. Of all the therapy goals, slowing the rate at
which parents talk to their children has proved the most effective and efficient way
to decrease the number of dis-fluencies in the child's speech. That is not to say that
it will work equally well with all children. It may not.
A second goal is to teach the parents better way of reacting to the child's
disfluency. Most parents are worried and concerned and can't help but let this
show. The child sees it and becomes concerned too. If parents show a pained
expression, hold their breaths, turn away, tell the child to slow down or take a
breath or think about what he or she wants to say, all of these reactions tell the
child that he or she is doing something wrong. If they couldslow down this would
be good advice, but children at this age (and many adults) lack the control to do
this. Taking a breath can lead to further struggle. So the clinician will want to help
parents learn how to respond to a dis-fluent child in a way that doesn't increase
struggle and tension. In addition, most clinicians will want parents to begin to talk
about their own feelings and come to understand more clearly how they feel about
the child's dis-fluency. This increased understanding and awareness leads to a
calming of the parents' feelings, which in turn leads to a change in the way they
react. It is pretty difficult for parents who are close to panic not to let their feelings
show to the child. Children pick up on nonverbal reactions even more readily than
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adults. It is better if the parents can actually reduce their emotional reactions.
Pretending to be calm is nowhere near as effective as actually being calm.
In some cases, it will be important for the clinician to find, with the parents,
activities that parent and child can do together that will be mutually satisfying as
interactions, but will involve less talking.
There are a number of other instructions that clinicians will give to parents.
Interruptions are to be avoided as much as possible, both interruptions of the child
and interruptions by the child of others. Sometimes the whole family needs to learn
new ways to converse. Many families live under daily time pressure. The wholehousehold is rushed with multiple activities and little time to do anything. This
general time pressure can translate into time pressure to speak, which makes it
harder for the child to speak fluently. Some families are under a lot of tension for
other reasons -- someone is ill or there is a source of emotional tension such as
marital discord. All of these things make it harder for the child to be fluent in
speech, and the clinician will need to examine each possibility and try to help the
parents find ways to improve the setting so that it asks less of the child as a
speaker.
Another common problem is the way parents talk, or don't talk, about speech to the
child. Many parents believe that they shouldn't talk about stuttering to the child
who stutters. This is an old idea, and there are some speech pathologists who still
believe it. We hope there aren't many, however, because this practice deprives thechild of an important source of emotional support -- his parents -- at a time of
crisis. However, we do think it is important for parents to understand how to talk to
a child who is dis-fluent, what words to use, and how to approach such a topic in a
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way that reassures and helps the child. So an important therapy goal can be training
the parents in ways to talk to their child about disfluency and stuttering.
All of the goals mentioned so far are ways to improve the environment around the
child to make it less demanding of fluency. There are also many things that the
clinician may want to do to change more directly the way the child talks. These
more direct efforts are aimed for the most part at slowing the child's speech
through modeling and at reducing and eventually removing the struggle and
tensions from the child's speech. Sometimes, with an older child, a system of
rewards is used, but more often, and particularly with younger children, modeling
is the preferred techniques. Since children may need to learn easier and less
tension-filled ways of being dis-fluent, parents may be asked to learn how to model
easy, calm dis-fluencies in front of the child. There is the potential for alarming the
child in this technique and it is best not to attempt it without consultation with and
training by the speech clinician.
When these techniques are all put together, and when the parents are able to extend
the therapy activities into the home by carrying out the instructions of the speech
clinician, there is usually rapid progress. If the child has been excessively dis-
fluent for less than a year his or her speech should, in fact, begin to improve almost
immediately. The most rapid progress we have seen has been a disappearance of
the symptoms in three or four weeks of therapy. On the other hand, some children,
particularly those who have been dis-fluent for a longer period of time -- over a
year -- may take much longer, up to a year, before they begin to speak normally
But even if it takes two years, the child should eventually speak normally. Even
after they have been speaking normally for a while, however, some of the children
appear to be vulnerable to a relapse of stuttering in the event that they go through a
stressful period such as might be brought on by a move to a new location, a change
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in school, a separation from parents, a marital separation, or illness or death of a
parent or sibling. Relapse in preschool children is much less frequent than it is in
adult stutterers.
copyright C. Woodruff Starkweather
added with permission, June 11, 1997