stuttering prevention-a manual for parents

8/22/2019 Stuttering Prevention-A Manual for Parents

1/33

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.


2/33

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


3/33

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,


4/33

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


5/33

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


6/33

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


7/33

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-


8/33

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,


9/33

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.


10/33

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


11/33

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


12/33

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


13/33

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


14/33

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


15/33

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


16/33

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


17/33

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.


18/33

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


19/33

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


20/33

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


21/33

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


22/33

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


23/33

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


24/33

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,


25/33

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


26/33

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


27/33

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).


28/33

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.


29/33

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


30/33

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


31/33

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


32/33

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


33/33

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

stuttering prevention-a manual for parents

Documents