# Speech-Language Pathology/Stuttering/Childhood Stuttering/Pre-School Stuttering
## Indirect Therapy

Indirect therapy is a "gentle nudge." Indirect therapy changes the parents' speech and behaviors. The speech-language pathologist trains the parents to slow down and use simple vocabulary, and not criticize the child, to not put pressure on the child (e.g., don't demand that the child confess guilt), to wait two seconds after the child finishes speaking before answering the child, and to give the child lots of hugs.
Indirect therapy is ineffective. A literature review found
   &#133;little convincing evidence&#133;that parents of children who stutter differ from parents of children who do not stutter in the way they talk with their children. Similarly, there is little objective support&#133;that parents' speech behaviors contribute to children's stuttering or that modifying parents' speech behaviors facilitates children's fluency.
More than a dozen studies found no evidence that altering parental behavior changed children's speech. These studies found no differences for positive statements (praise, encouragement, agreement), negative statements (criticism, reprimands), questions, topic initiations and terminations; conversational assertiveness and responsiveness; response time latency or the time between one person finishing speaking, and the other person beginning speaking; "formal" style vs. a "casual" style; or illocution.
The studies I really liked found the opposite of what the "experts" have been telling parents for 75 years:
* A study found that mothers interrupt their child after dysfluencies, not before. This suggests that not interrupting causes children to stutter!
* A study found that when mothers spoke faster their children spoke slower. Another study trained parents to slow their speaking rates. The children's speaking rate increased. This suggests that parents talking slowly causes their children to stutter!
* Parents of children who stutter produced more positive statements (e.g., praise, encouragement) and fewer negative statements (e.g. criticisms, disparaging remarks) than parents of children who didn't stutter. This suggests that parents' praise and encouragement causes children to stutter!
* A multiyear study followed 93 preschool children. At the start, none of the children stuttered. One year later, 26 of the children stuttered. The researchers compared the speech behaviors of the two groups of mothers, before their children started stuttering. No differences were found, except that mothers of children who would stutter had shorter, less complex utterances. This contradicts the "capacities and demands model" of childhood stuttering.
More generally, some psychologists now discount the role of parents in the development of children's character and personality. About 50% of the personality differences are attributable to our genes, and the rest due to the child's peers: "&#133;what parents do seems to be nearly irrelevant."

## Direct Therapy

In contrast, direct therapy changes the child's speech and behaviors. Direct therapy can be more of a big shove, rather than a gentle nudge. It may include:
* Games to encourage speaking.
* Games to train specific speech skills, similar to adult fluency shaping therapy.
* Modeling the child's speech and/or behaviors.
A child's first therapy session may just be playing a game to encourage the child to talk. E.g., the speech-language pathologist and child silently play with separate boxes of trucks, on opposite sides of the room. The speech-language pathologist begins making engine sounds. She then gradually moves to the center of the room, and her trucks interact with the child's trucks.
"Say the Magic Word" is another game to encourage talking. You can play this while looking through a picture book, or while driving. The parent says she sees something. The child guesses what the parent sees. When the child says the "magic word," the parent rings a bell or gives the child a peanut. No particular word is magic&#151;the child is rewarded for fluent words.
A frequency-shifted auditory feedback (FAF) device makes shy children want to talk. They're fascinated to hear their voices sounding like a "little kid" (frequency upshift) or a "monster" (frequency downshift).
Some games teach speech skills. In "Can't Catch Me," one person gets a peanut when the other person asks a question. You then quietly eat your peanut before answering the question. If you answer the question before eating your peanut, you must put your peanut back. The parent should lose more peanuts than the child, by answering too quickly. This reduces the time pressure the child feels about quickly answering questions.
A turtle hand puppet can teach slow speech with stretched vowels. When the child uses the target speech skills, the turtle slowly walks. When the child speaks fast, the turtle retreats into her shell.
Super Duper has other games for stuttering therapy.

## Modeling

   Caitlyn, a four-year-old female who began to stutter in the midst of her parents' divorce, was exhibiting significant struggle and tension behavior as well as secondary behaviors. Of most concern was her head-banging behavior during difficult moments of stuttering. After many sessions in which I attempted to eliminate this behavior through fluency-shaping principles, I saw no change. One day, shortly after Caitlyn banged her forehead on the table to interrupt a block, I modeled the same behavior. Caitlyn was shocked and ignored me. After I did this several times she asked me, "Why did you do that? Didn't that hurt?" I responded, "I don't know why I did it. But it sure didn't help me get my word out!" Caitlyn never again banged her head to help her talk. She has been out of therapy for six years and remains fluent.
This speech-language pathologist's modeling of Caitlyn's behavior was radically different from conventional stuttering therapy practices. The speech-language pathologist improved the child's awareness of her stuttering. In contrast, most "experts" would have pretended not to notice Caitlyn's head-banging behavior. They would have predicted that making Caitlyn aware of her head-banging would have caused emotional trauma and made her stuttering worse.
Imagine that a teenage brother and sister use profanity at the family dinner table. Should the parents act horrified and tell their children never to use such language? Should they refuse to allow dessert or television for the teenagers?
You know that won't work. The teenagers will use profanity at the next opportunity, just for the amusement of horrifying their parents. Instead, the parents should immediately use twice as much profanity. Dad should say, "#$%^, this is best *&^% meatloaf in the whole @#$% world!"
Mom should then respond, "Oh, you big !@#$, you're so &^%$ cool and #$%^ sexy and when you talk ^%$#!"
The teenagers will turn red with embarrassment, and never use profanity again in front of their parents!
In a psychology class about traumatized children we saw a video of a ten-year-old boy destroying a psychologist's office. The boy threw every object he could throw, and smashed everything else. The psychologist sat there calmly telling the boy not to destroy the office. He finally grabbed the boy and hugged him. To me it looked like a full body restraint but the instructor said it was a hug, and that was what the boy really needed. I asked what would have happened if the psychologist had modeled the boy's behavior. E.g., the psychologist could have thrown and smashed stuff. The instructor said that was the worst idea she'd ever heard. But I think the boy would have stopped, watched in amazement as the psychologist destroyed his own office, and then asked, "Why did you do that?" The boy and the psychologist could then have started talking, with understanding of what the boy was feeling, which is what I think the boy needed.--Thomas David Kehoe 02:06, 28 March 2006 (UTC)
The purpose of modeling is to improve the subject's awareness of his or her behaviors. Stutterers are largely unaware of their stuttering, or at least what they do when they stutter. Everyone else can see the stuttering but the stutterer can't. Combining video and modeling can help a stutterer improve self-awareness.
Modeling also dispels a person's mistaken view that a behavior is invisible, or it's acceptable, or everyone does it. If everyone ignores undesirable behavior then the person may think it's OK.
Modeling only works when the modeler or the modelee knows how to replace the undesirable behavior with a target behavior. E.g., it's OK for your speech-language pathologist to model your stuttering because she can show you how to speak fluently. It was OK for my Romantic Disaster of 1996 to make me aware that I was stuttering, because I knew what to do to talk fluently. It's not OK to point out a problem to someone who has no idea what to do about it.

## References

* ^ Nippold, M., Rudzinski, M. "Parents' Speech and Children's Stuttering: A Critique of the Literature," Journal of Speech and Hearing Research, 38:5, October 1995.
* ^ Meyers, S.C., & Freeman, F.J. (1985a) "Are mothers of stutterers different? An investigation of social-communicative interaction." Journal of Fluency Disorders, 10, 193-209.
* ^ Weiss, A.L., & Zebrowski, P.M. (1992) "Disfluencies in the conversations of young children who stutter: Some answers about questions." Journal of Speech and Hearing Research, 35, 1230-1238.
* ^ Kelly, E.M. & Conture, E.G. (1992) "Speaking rates, response time latencies, and interrupting behaviors of young stutterers, non-stutterers, and their mothers." Journal of Speech and Hearing Research, 37, 1256-1267; Kelly, E.M. (1994) "Speech rates and turn-taking behaviors of children who stutter and their fathers." Journal of Speech and Hearing Research, 37, 1284-1294; Yaruss, J.S., Conture, E.G. (1995) "Mother and Child Speaking Rates and Utterance Lengths in Adjacent Fluent Utterances: Preliminary Observations," Journal of Fluency Disorders, 20, 257-278; Yaruss, J.S. (1997) "Utterance Timing and Childhood Stuttering," Journal of Fluency Disorders, 22, 263-286.
* ^ Howell, P., Kapoor, A, Rustin, L. "The Effects of Formal and Casual Interview Styles on Stuttering Incidence," in Speech Production: Motor Control, Brain Research and Fluency Disorders, edited by W. Hulstijn, H.F.M. Peters, and P.H.H.M. Van Lieshout, Amsterdam: Elsevier, 1997.
* ^ Rommel, D., Häge, A., Johannsen, H., Schulze, H. "Linguistic Aspects of Stuttering In Childhood," in Speech Production: Motor Control, Brain Research and Fluency Disorders, edited by W. Hulstijn, H.F.M. Peters, and P.H.H.M. Van Lieshout, Amsterdam: Elsevier, 1997.
* ^ Meyers, S.C., & Freeman, F.J. (1985b) "Interruptions as a variable in stuttering and disfluency." Journal of Speech and Hearing Research, 28, 428-435.
* ^ Meyers, S.C., & Freeman, F.J. (1985c) "Mother and child speech rates as a variable in stuttering and disfluency." Journal of Speech and Hearing Research, 28, 436-444.
* ^ Stephenson-Opsal, D., & Bernstein Ratner, N. (1988) "Maternal speech rate modification and childhood stuttering." Journal of Fluency Disorders, 13, 49-56.
* ^ Meyers, S.C. (1990) "Verbal behaviors of preschool stutterers and conversational partners: Observing reciprocal relationships." Journal of Speech and Hearing Disorders, 54, 706-712.
* ^ MKloth, S.A.M., Jannsen, P., Kraaimaat, F.W., Brutten, G.J. (1995) "Communicative Behavior of Mothers of Stuttering and Nonstuttering High-Risk Children Prior to the Onset of Stuttering," Journal of Fluency Disorders, 20, 365-377.
* ^ Gladwell, Malcolm. "Do Parents Matter?" The New Yorker, August, 17, 1998, reviewing The Nurture Assumption: Why Children Turn Out the Way They Do, by Judith Rich Harris, 1998, ISBN 0684857073.
* ^ Mary Wallace and Patty Walton, Fun With Fluency: Direct Therapy With The Young Child (Imaginart, 1998).