An Overview of An Integrated Approach to Treating Children Who Stutter

The purpose of this handout is to give parents and family members an understanding of how stuttering can be treated from an integrated point of view.  This overview is not intended to cover all aspects of therapy that a clinician may provide a child who stutters.  Rather, it is intended to provide a general guide to understanding why certain goals and objectives might be addressed in a therapy program for children who stutter.  There are many approaches used to treat stuttering but the approach described here integrates, or blends, the best aspects of several treatment methods.

What are some common characteristics of school-age children who stutter?

Children between the ages of 7 and 12 who stutter show individual differences in terms of how they stutter, how they think and feel about their stuttering, how well they use language to communicate their ideas, and how comfortable they are talking to adults and other children.  Many children of this age are reacting to their stuttering with struggle and tension which might prompt them to use some type of behavior to cope, escape, or eliminate the stuttering.  These behaviors might include closing the eyes or looking away, stopping the air during speech, abruptly starting the voice at the beginning of words, and moving the head or body during a stuttered moment.  Your child also might develop negative feelings, attitudes, and reactions to the stuttering.

We believe that the above characteristics are a by-product of many years of faulty learning.  This suggests that with proper instruction, we can change, modify or eliminate the behaviors that prompt your child to stutter.  Also, since the behaviors have not been well established, there is a good chance that stuttering can be reduced significantly.

What's the main goal of an integrated therapy approach?

Although there are many goals and objectives that could be developed for treating stuttering, the main goal is to help your child talk in an easier way as well as understand and accept his/her current level of stuttering.  Our philosophy is that the goal of therapy is NOT to have your child speaking normally in all situations.  Eventually, that may happen but to set a goal for your child to achieve high levels of fluency puts a lot of pressure on your child and might create frustration for you and your child.  A more realistic goal is to help your child learn strategies about how to talk in an easier way and developing a feeling of success when talking in a variety of situations.

What's involved in an integrated treatment approach?

The process of changing stuttering takes considerable time and effort. It is not something that is easily "fixed" and changes don't occur after a few therapy sessions.  Because therapy can last many months or even years, children who stutter may get discouraged or be concerned that they are not talking better after being in therapy.

Our integrated approach is designed to make therapy a positive experience.  We want your child to develop a positive perspective about stuttering and understand what is taking place when they stutter.  Specifically, our approach addresses five major behaviors that we believe contribute to stuttering.  We refer to these as "CALMS" behaviors. The acronym CALMS refers to Cognitive (thinking), Affective (feeling), Linguistic (forming the message), Motor (producing speech) and Social (normal communication) behaviors. For example, we work with your child in helping him/her understanding what happens during stuttering, suggest changes in how talking can be made easier, and how it feels to talk in a new way.  We also use a controlled conversational dialogue during therapy so the speech practice involves a realistic way to talk.

Now, let's take a closer look at what we try to address with each CALMS behavior:

Cognitive Behaviors: Before children can work on changing the way they talk, we need to know what they understand about their stuttering and talking in general.  In other words, what does your child know about his/her stuttering?  We also need to know if they are aware of what they do when they stutter and what they think about other peoples' reactions to their stuttering.  We also want your child to understand that stuttering is under his/her control and is not something that happens but something he/she does that's a little different from how most people talk.

Affective Behaviors: These behaviors involve the feelings, emotions, and attitudes related to stuttering.  If your child has some negative feelings about stuttering, then these need to be addressed.  Included in this aspect of therapy is some discussion of being teased about stuttering and what your child can do in response to being teased about stuttering.  We can do this in a non-threatening manner.  We also know that children who stutter try to avoid stuttering.  However, we don't want your child to run away or hide from stuttering.  Rather, we want to work on reducing or eliminating the feeling of wanting to avoid stuttering.  Through the course of therapy, we want children to know that it's OK to stutter, it's OK to fail, and it's OK to feel bad about stuttering.  However, it's not OK to avoid stuttering and hide it.  Providing positive talking experiences and talking openly about stuttering are just a couple of ways that affective behaviors can be changed.

Linguistic Behaviors:One of the things we know about stuttering is that the more the child has to say, the more the child will stutter.  So, we need to help the child experience success speaking in short sentences and giving simple responses to questions.  After some success at these simple linguistic levels, we increase the difficulty of what needs to be said to see if the child can continue to manage his/her speech when there are increased demands to say a lot about a topic.

Motor Behaviors: Speaking is a very complex motor act so it takes a lot of skill and coordination to be fluent. Children who stutter are thought to have a fragile motor control system for speech.  Sometimes it works fine (child is fluent) and sometimes it gets locked up or goes into a repetitive pattern (child stutters).  There are many "techniques" for talking smoothly and easily.  We try to find the techniques which seem to help your child talk as easily as possible.  At first, we might ask your child to talk in a slightly artificial way in order to practice a new technique.  We don't want the child to talk in this artificial way all the time.  Eventually, we hope the child will develop enough skill in using the technique so that it can sound somewhat natural.  We might also teach your child how to modify a stuttering when it occurs.  In all, we will try to give your child lots of  "tools" for talking easier and the child can choose the speech "tools" that are the most helpful.

Social Behaviors: The speaking situation usually will dictate how well your child manages his/her stuttering. Some speaking situations will be quite difficult for your child and others will be easy.  We will talk with your child and come up with a list of easy and difficult speaking situations.  Our hope is to have him/her understand that the ease or difficultly of the speaking situation will influence how well they can talk.  Another goal in this area is to help your child become a good communicator.  This involves being a good listener, providing some eye contact between speaker and listener, not interrupting others, and feeling in control of most social speaking situations.  We will address how to communicate with others by role playing various speaking situations and talking about what others do that make them good or poor communicators.

How long will this therapy program take?

It is difficult to know how long it will take to address all of these issues so the length of therapy will differ for each child.  Certainly, we don't want to rush through the program but on the other hand, we don't want to spend an excessively long time on training one behavior.

As a parent, how can I help?

The best thing you can do as a parent is be a supportive of your child's hard work on trying to talk with less stuttering.  Provide encouragment to your child by seeing the positive side in everything he/she does.  Try to avoid giving your child specific instructions about what to do when he/she talks, such as saying "slow down, remember to use your techniques, try again, or if you try harder, you can be fluent."  Comments like these might seem helpful but your child might develop a sense of shame and embarrassment about stuttering.

Also, be a supportive listener and look at the positive things your child does or can do.  Your role is to be a parent, not a secondary speech therapist.  At appropriate times in the course of therapy, your clinician might ask that you to participate in therapy and/or do some home practice.  However, specific tasks and guidelines for this practice will be given ahead of time.

We encourage you to talk with your child about stuttering and discuss what is happening in therapy.  See if your child understands what is happening in therapy.  For example, ask your child to explain why he/she is being taught a certain technique in therapy.  Have the child show you how to talk in the new way.  Use the new technique yourself and ask your child if you are doing it correctly.  Emphasize that you can see how that might help them talk easier and gain some control over the stuttering.