It's an honor and a pleasure to be part of this panel discussion and to be asked to provide my thoughts on forecasting the future of stuttering therapy. I have devoted the last 25 years of my professional career to understanding, evaluating, and treating children and adults who stutter and it might be safe to say that the more I learn, the harder it is to put all the pieces together about my understanding of stuttering.
There are times when I think we've been on the right track but on the wrong train when it comes to understanding and treating this complex disorder. I also think it is safe to say that the number of research studies published in the area of stuttering every year is a little overwhelming and I can't imagine how anyone who doesn't specialize in this area can keep up with the expanding knowledge base in our field. Also, the importance of course work and clinical training in stuttering is beginning to disappear off the professional radar. That's one reason our Special Interest Division #4 has worked hard over the last few years to create and implement a fluency specialist program and has fought to maintain academic standards.
I must admit that much of what I SUSPECT will change in the future is based on what I HOPE will change in the future. I'm well aware that some of the things I propose will probably take at least the next 10 years to accomplish. But, I'm optimistic that the movement toward improved clinical practice in stuttering will pick up substantial momentum in the next decade.
It goes without saying that during the last half of the 20th century, our field has seen the development of many published and commercially available treatment programs for children and adults who stutter. In many respects, the 20th century could be called the Era of Intervention?"if you stutter, we have an intervention" And, although the intervention may not have much data supporting it, clinicians tend to use the approach that matches their views about stuttering and what seems to work. Unfortunately, If one carefully looks at the majority of treatment programs that have been developed over the past 50 years, one could be concerned about how simplistically many of the programs approach the management of this complex disorder.
For the most part, I believe that very few of the current treatments for stuttering account for the complex, multidimensional aspects of the disorder. In my opinion, the vast majority of treatments are based on rather narrow perspectives of stuttering, such that stuttering events (i.e., repetitions and prolongations) emerge from one or a few factors such as abnormal genetic, environmental, linguistic, physiological, emotional, attitudinal, or cognitive processes. In other words, certain factors "cause" stuttering to occur so a therapy is developed to address the "cause" of the problem. Given this, I find it interesting that practically every treatment for stuttering can be placed into one of three categories: 1) Fluency Shaping, 2) Stuttering Modification, and 3) an integration of Fluency Shaping and Stuttering Modification. As most of you know, those who advocate a "fluency shaping" approach argue that the most effective way to treat stuttering is to rebuild the speech system as well as systematically replace stuttering with fluent speech using a variety of techniques such as reduced speech rates, controlled voicing and reduced tension in the speech mechanism. The assumption is that the contributing "cause" of stuttering is a disrupted speech system that simply needs to be normalized.
On the other hand, a stuttering modification or "stutter more fluently" approach focuses on modifying the tension, struggle, and severity of the moments of stuttering. Proponents of this approach contend that the modification of stuttering can be accomplished only when the person who stutters accepts the stuttering, understands it, learns to stutter in an easier fashion, and confronts fears. In this approach, emotional and cognitive factors are two major "causal" factors that disrupt fluency. Because it is believed that normal fluency isn't necessary, the approach only seeks to modify moments of stuttering.
Of course too, there are clinicians that believe the best approach is to use a combination or an integration of fluency shaping and stuttering modification approaches. An integrated approach might be appear to have some face validity because it blends the components of fluency shaping and stuttering modification. However, even integrated approaches vary in terms of how components related to stuttering are blended together and how clinicians implement those programs.
Since the 1980's, a number of multidimensional perspectives about stuttering have been proposed by Zimmermann, Smith, and Hanley (1981), Conture (1990) Wall and Myers (1995) and Starkweather (1987). However, in my opinion, Smith and Kelly (1997), Smith (1999), and DeNil (1999) have done the best job of articulating a multifactorial, dynamic, perspective about stuttering. Their premise is that multiple factors interact in a complex way to influence stuttering across time frames that range from seconds to years. If stuttering emerges from an interaction of cognitive, affective, linguistic, motor, social factors, then the relative influence or impact any one factor on the disorder varies from one individual to the next. The differential contributions of each factor produce a unique multifactorial profile that characterizes each person's stuttering pattern. Depending on life events, each component will either be strongly or weakly connected to the stuttering. Our treatments need to account for those individual component strengths and weaknesses.
The notion that stuttering might relate to a dynamic, multidimensional interaction of factors has important implications for our future understanding, assessment, and treatment of preschool children who stutter. In the last decade, the field has made giant leaps forward in understanding the factors that contribute to the onset and persistence of stuttering in very young children. The field owes a great deal of gratitude to Dr. Ehud Yairi and his colleagues at the University of Illinois for expanding and refining our collective knowledge about the onset of stuttering. From a number of studies published by this group of researchers, we have a clearer understanding of which children are at risk for persisting or recovering from stuttering. We should also applaud the efforts of Dr. Nan Ratner, Dr. Ruth Watkins, and Dr. Nancy Hall for their research on helping us understand the linguistic basis of the early stages of stuttering. I believe their future research and that of others, will continue to provide us with a much clearer picture of how stuttering is influenced by linguistic factors.
I predict that within the next 10 years, we will make much better clinical decisions about whether a preschool child will persist or recover from stuttering. Our future research will continue to delineate specific criteria related to the many components that allow clincians to decide if a child is at risk for developing persistent stuttering. We will also have advances in genetic research that will identify specific genes that will be responsible for the transmission of the disorder from one generation to the next. I believe there be specific etiologies, behaviors, and profiles that are more likely to be associated with children who will recover from stuttering. In 1999, Paden, Yairi, and Ambrose reported that preschool children who show persistent stuttering are slower and have poorer phonological development than children who recover from stuttering. Whether children who have persistent stuttering have delayed language development is unclear at this time given the results of Watkins, Yairi, and Ambrose (1999). Future studies on preschoolers who stutter will continue to refine the unique characteristics of these subgroups of children and with this information, we will make better treatment decisions about who will or will not require therapy.
I also believe our future research and clinical efforts will be focused on improving the identification of subgroups within school-age children who stutter. For many years, researchers in our field have suggested that stuttering is NOT a homogeneous disorder. There is little doubt that this is true given the growing body of evidence that many children who stutter exhibit a variety of concomitant speech and langauge disorders in addition to stuttering. A recent study that I completed with one of my former graduate students (Arndt & Healey, in press) showed that approximately 45% of school-age children who stutter have a verified phonological and/or language disorder. Another study by Scott, Healey and Norris (1995) found subtle language deficits in 33% of a group of children who stuttered but none of these children were identified as "language disordered" according to state eligibility criteria. This subgroup was discovered from the poor quality of their story retellings compared to the other children who stuttered. In the future, I think we will discover a connection between subtle langauge differences and stuttering.
The field is making steady progress in delineating some important distinctions among children who stutter. However, we need to do a better job of identifying these subgroups. I predict that clinicians and researchers will eventually have better information from which to differentially diagnose children who stutter who also have a concomitant disorder. From these assessments, it will be clear that the goals and objectives of treatments as well as the outcome of those treatments will have to be different from children who do not exhibit a concomitant disorder. We can't expect effective treatment outcomes if we continue to apply the same general treatment approaches to different subtypes of stuttering. Additionally, in the next decade, our society will become more culturally diverse. Given this, it will become increasingly important to understand how multicultural issues will impact service delivery.
For too long, the field has been concerned about WHICH treatment works. As we enter the 21st century, the field should be more concerned about HOW and WHY certain treatments work. Therefore, we are moving away from the "Era of Intervention" to an "Era of Clinical Decision Making" which is to say, "if you stutter, we will provide an intervention because we know how and why it is effective for persons with your type of stuttering profile." In order to make this transition and change how the field conceptualizes stuttering we must:
Have a large number of fluency specialists treating the disorder.
Develop better collaborative efforts among researchers, fluency specialists, and the National Stuttering Association so data can be collected on a variety of approaches for treating stuttering.
Develop treatment outcome studies that will be based on a dynamic, multidimensional theoretical framework so that successes and failures in treatment can be explained.
Ensure that the characteristics of the participants included in these treatment studies are clearly specified and based on objective, reliable measures.
Have researchers and fluency specialists reach some consensus about a) which outcome measures should be used for different diagnostic profiles, b) how often the measures should be obtained, c) the number of sessions needed to establish that a treatment is effective, and d) the frequency of post-treatment measures to ensure the effects of therapy are maintained.
Ensure that the treatment programs under study will be implemented by fluency specialists who are not directly associated with or invested in the treatment program under study.
Recognize that the treatment programs selected for study will need to be tested for their effectiveness in different clinical environments such as school settings, university clinics, and private practices.
Recognize that we will learn as much from people who fail to improve their fluency as we do from those who are successful in significantly reducing their stuttering as a result of a particular treatment.
Finally, I believe ASHA, with the help of NIH, will fund a clinical trials research program in stuttering. Many of the things I just mentioned would be included in a clinical trials research program. I believe that clinical trial research and other rigorous tests of our treatment will increase our credibility with parents of children who stutter, adults who seek stuttering therapy services, third party payers, and society.
What I have proposed will be no small undertaking. It will take consistent, deliberate efforts by a large number of researchers and clinicians to accomplish these goals. I am confident that our field is up to the task and in that respect, I think our future looks very bright.
References
Arndt, J. and Healey, E. C. (in press). Concomitant disorders in school-age children who stutter. LSHSS.
Conture, E. (2001). Stuttering: It's nature, diagnosis, and treatment. Needham Heights, MA: Allyn and Bacon.
DeNil, L. (1999). Stuttering: A neurophysiological perspective. In N. Ratner and E.C. Healey (Eds). Stuttering Research and Practice: Bridging the Gap. Mahwah, NJ: Lawrence Earlbaum Publishers.
Paden, E., Yairi, E., and Ambrose, N. (1999). Early childhood stuttering II: Initial status of phonological abilities. JSLHR, 42, 1113-1124.
Scott, L.A. ,Healey, E.C., & Norris, J.A. (1995). A comparison between children who stutter and their normally-fluent peers on a story retelling task. Journal of Fluency Disorders,20, 279-292.
Smith, A. (1999). Stuttering: A unified approach to a multifactorial, dynamic disorder. In N. Ratner and E.C. Healey (Eds). Stuttering Research and Practice: Bridging the Gap. Mahwah, NJ: Lawrence Earlbaum Publishers.
Smith, A. and Kelly, E. (1997). Stuttering: A dynamic, multifactorial model. In R. Curlee and G. Siegel (Eds.) Nature and treatment of stuttering: New directions. Boston. MA: Allyn and Bacon.
