Is there a treatment sequence??

Question: Do you have a sequence in which you like to introduce techniques to students who stutter?

I do not believe there is a “right” sequence. Each child and family experiences stuttering in a different way due to their temperament, home environment, communities, etc. and their treatment plan has to reflect that. However for new clinicians or clinicians who have little experience with treating a child who stutters, it is understandable that you may want a blueprint of what therapy should look like.

Let’s consider a child who is over the age of 7 and therefore the likelihood that they will “outgrow” or eliminate stuttering has dropped significantly. I often do not start with techniques but rather I begin by educating the child and their family on stuttering and work towards building their awareness and acceptance of stuttering. Our job is to reduce the burden of the fluency disorder and quite often the burden can not be measured by the frequency of stuttering but rather by how the child is thinking, feeling and reacting to the stuttering moments. For a child that is avoiding speaking situations or trying to escape or hide stuttering moments, this is what we need to address first before even considering which techniques might be helpful to teach them. Activities should be developed to help the child becomes experts on their own speech by learning which parts of the speech machine are involved in speaking, understanding their stuttering pattern and identifying where they have tension. Not only will this empower a child who stutters but it will also ensure that they are equipped to answer questions they may get from peers or people in the community. Many children will also benefit from activities that are designed to help build their tolerance for hearing themselves stutter and allowing others to hear them stutter as well. As with all aspects of stuttering treatment, building acceptance of stuttering should be addressed along a hierarchy, beginning in more comfortable, supportive settings and progressing to higher feared speaking situations.

This is not to say that you should not teach techniques. However, it is important to understand that introducing techniques is not the only thing to consider when developing a treatment plan, just as the observable stuttering is not the only thing to measure when assessing a child who stutters. Many clinicians introduce stuttering modification techniques (cancelations, pullouts, preparatory sets) before fluency shaping techniques (easy onset, light contact, etc.). When beginning with fluency shaping strategies, the child might become very fluent in the session. This is especially true considering the supportive nature of the therapy room. The child is left with less opportunities to practice strategies that might be more meaningful to them in the “real-world” where they may not be as fluent. With that being said, for younger children or children who have co-occurring speech/language or cognitive disorders, I often start with fluency shaping techniques. These strategies can act as a precursor to the mechanics necessary for stuttering modification strategies at a time where their awareness of stuttering moments may be low.

There are a number of different factors that contribute to why a child begins to stutter and why they persist. The child will make much more progress when you let go of your worries about the order of “techniques” and instead focus on developing a treatment plan that considers that individual’s experience with stuttering.