Putting treatment to practice: General Considerations

There are three general treatments for fluency disorders:

 Behavioral interventions (through the use of behavioral techniques)

 Assistive interventions (through the use devices like DAF)
 Pharmacological interventions (through the use of medications, but till now there are no
pharmacological treatments for fluency disorders, they are still experimenting)

Sometimes the treatment of stuttering doesn't go as planned. In such a case the use of two
approaches is implemented (ex. behavioral+ assistive) to maximize treatment outcomes.

Data from neuro-imaging studies showed that behavioral interventions used to treat stuttering
were more beneficial. This data found that the activation of neurons during such interventions
was similar to the neuron activations in normal fluency. So, we can understand that the
behavioral treatments we teach to our patients are not only external, but they tend to change the
way neurons are activated in the brain.

Treatment approaches that emphasize environmental context:

These are the treatment approaches that will be targeting in the environment of the child. Here,
they are typically used for children who stutter (2-5 years old).
These types of treatments have two purposes:
- to prevent the stuttering
- to prevent the child from developing a stutterer personality or disability.
That's why it’s very important to use treatment approaches that target the environment. Usually
these types of approaches are very natural and target how the child is behaving at home while
primarily focusing on the parents.

 Parent-training focus:

Here the focus is on the parents more than the child. Sometimes we only invite the
parents to therapy or we tell them to bring their children to the session. This way we can
video tape how they interact with their child to be able to show them the right techniques
to use instead. Here the intervention is indirect because we are not intervening directly
with the child, instead we are teaching the parents how to create an environment that will
help the child communicate better and stutter less. Of course, we don’t teach them to
become therapists! The goal is to let them put their child in an environment that will help
him/her reduce what aggravates the stuttering and maximize what helps the child
communicate fluently. We minimize time pressure, shouting, hitting or any negative
comment that will put the child in a situation of stuttering. We maximize organizing,
planning and provide a sense of anticipation for the child by not surprising him/her with
anything new. We advise them to speak slowly, give enough time to their child, give their
 child importance, and be active listeners. It always depends on the situation at home (if
the parents work and how the family dynamic is...). Essentially, we want to try to create
the best possible environment for the child.

Communication behaviors that parents strive for:

What are the conversation variables that affect stuttering frequency?

- The speech rate:

If parents are speaking fast, the conversation will be fast paced. The parent speech rate is a
variable that affects the speaking rate. How many times/instances are there for the child to
speak? Do the parents speak more than the child? Do they ignore their child’s speaking turn?
Parents, sometimes, tend to speak more than the child. We should know what is the duration of
the pause from when the child finished speaking to when the parents start again? As SLPs we
must use these strategies properly as well when working with the child.

- The conversational complexity:

It is not good to be too complex with the child. When a child stutters, complex conversations
create stress. So, by reducing this complexity, the stuttering will be reduced. Children tend to
stutter more when there is a fast conversation, and when concepts or words used are difficult and
complex. This is why when we completely cut these events, the stuttering will reduce.

Of course factors like bullying, teasing, mocking or any negative sentences or words are
environmental stressors too. So by reducing and eliminating these situations, the stuttering will
disappear.
We have to be strict with these comments as well by explaining to the parents that such words or
actions are not acceptable because they hinder the child’s progress and make stuttering worse!

As SLPs we must be advocates for the patient who stutters.

Addressing social, emotional and cognitive factors:

As you may know, stuttering is not a psychological disorder but it has psychological
consequences which is why the treatment plan should target all these factors.

We can compare stuttering behaviors to the ice-berg analogy:

- If we only treat what we see and hear (the visible part of the ice-berg), it doesn’t mean
that we are treating the stuttering as a whole. Under this visible part of the ice-berg, there
are all the hidden components (ex: feelings of shame, guilt, anxiety, fear of expressing
oneself due to accumulating negative experiences, and so on...). Along with that, there
are all the tricks and behaviors the stutterer use to hide their stuttering. All these factors
 highlight the wholeness of the stuttering we are dealing with. So, if I hear the speaker
speak normally, that doesn’t always mean that they are doing well with their speech.
Also, if the speaker stutters less or not at all, this doesn’t rule out the presence of anxiety
and stress for them.

This is why it is important to work with the child when they are young to prevent this
“handicap” personality from developing. If we work properly with that child he/she will
not grow up with that personality and with feelings of guilt and shame. This is why
addressing parents and parental behaviors is essential in order to put the child in the right
environment.

As SLPs we have to target the social-emotional aspect too to reduce these negative feelings.
- We use these three primary ways of reducing the patient’s sensitivity towards their
stuttering:

 First one is providing techniques that teach them how they should react in order not
to stutter.
 Second one is helping the patient interpret his/her own stuttering in the correct way
by understanding it and why it happened. We teach the patient how to evaluate
his/her own stuttering accurately.
 Third one is providing techniques to make the patient accept the stuttering and to
make others accept them. This is to help disclose the stuttering to allow the patient to
become confident with who they are and stop making stuttering as a secret.

Some considerations:

 Learning about stuttering can be applied to all ages. This will make the person know that
they are not alone in their stuttering, and that there are a lot of people who stutter too
(even famous people/celebrities).
 Interacting with other people who stutter can also help shift how the patient feels about
their stuttering, and allows them to be more confident with it.

Assistive devices on the treatment of stuttering:

There are two types of assistive devices: DAF and FAF

 Delayed auditory feedback (DAF): the patient hears his/her voice but in a delayed and
slowed manner
 Frequency-altered auditory feedback (FAF): the patient hears his/her voice in a different
frequency
Further stuttering therapy programs to look in to:

Examples and overview:

- Lidcombe Program:

Link to treatment guide: https://www.lidcombeprogram.org/download/1609/

- Camperdown Program:

Link to treatment guide: https://www.uts.edu.au/sites/default/files/2018-10/Camperdown

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