decision making in the treatment of school-age children who stutter

ELSEVIER

DECISION MAKING IN THE TREATMENT OF SCHOOL-AGE CHILDI N WHO STUTTER E. C H A R L E S H E A L E Y , L I S A A. SCOTT, and G A Y L E E L L I S Department of Special Education and Communication Disorders, Teachers College University of Nebraska-Lincoln, Lincoln, Nebraska

The purpose of this article is to provide clinicians information on some of the key issues in making decisions about the treatment process for children who stutter. Ten decisions that should be considered prior to, during, and at the time of dismissal are discussed. These decisions relate to a number of issues regarding treatment such as: increasing clinicians' confidence in treating stuttering in children, setting long- and short-term goals, selecting an approach to treatment, documenting progress, involving parents and teachers in the treatment process, and determining when the child is ready to be dismissed from treatment. Additionally, questions clinicians should ask themselves are presented with each of the ten decisions. The intent of this article is to show how an analysis of clinical information systematically collected over a period of time will help a clinician make accurate decisions about the treatment of children who stutter.

I N T R O D U C T I O N

A speech-language pathologist (SLP) must make a number of decisions that will have impact on the treatment of a child who stutters. The decisions that clinicians need to make about children who have a fluency disorder are not always clear because of the nature or complexity of the problem. Moreover, because of their lack of experience or training with fluency disorders, clinicians may have difficulty making informed decisions about the structure of treatment. Indeed, research has shown that SLPs report that they are not adequately trained to treat children who stutter (Mallard, Gardner, and Downey, 1988) and consider stuttering one of the least preferred disorders to treat (St. Louis and Durrenberger, 1993).

Address correspondence to E. Charles Healey, Ph.D., 253 Barkley Memorial Center, Department of Special Education and Communication Disorders, University of Nebraska-Lincoln, Lincoln, NE 68583-0731.

J. COMMUN. DISORD. 28 (1995), 107-124 © 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

0021-9924/95/$9.50 SSDi 0021-9924(95)00005-X

108 HEALEY ET AL.

The purpose of this article is to assist SLPs in identifying some of the key issues in making decisions about the treatment process for children who stutter. We will focus on a variety of clinical issues that we believe should be considered when treating elementary school-aged children who stutter. Specifically, we will discuss the decisions that need to be made and questions that need to be asked prior to, during, and after treatment. From this information, clinicians might obtain a better understanding of how to plan for the initiation of treatment, how to manage a child's slow progress in therapy or when improvement plateaus, and how to decide when to dismiss the child from treatment.

We will assume that the person reading this article has had at least some academic and clinical experience treating school-aged children who stutter. We also assume that the reader is knowledgeable of various approaches to the treatment of stuttering. We realize that the small number of fluency- disordered clients seen in the elementary schools prevents the average clinician from honing their "stuttering treatment" skills. Thus, the limited ex- periences that clinicians have with this population could mean that they attend only to the speech disfluencies and ignore the psychodynamic aspects of the disorder. Leith (1984) pointed out that paying close attention to a child's feelings, attitudes, perceptions, and beliefs contributes as much to the fluency disorder as does the disfluent speech. Because of this, we believe that an integrative approach which includes both shaping of the fluency as well as managing feelings, emotions, and perceptions of the problem seems warranted with most children who stutter.

Although we attempt to tailor the treatment approach to the needs of a child, it is not uncommon to find that the child fails to achieve increased levels of fluency regardless of the approach used. The child may not be motivated and/or finds it difficult to change his/her speech patterns. How- ever, even when this occurs, we find that clinicians begin to question their methods, the program, and/or their competence in treating the fluency disorder. In order to know which factors contribute to success or failure in treatment, clinicians should ask themselves a number of questions about key treatment decisions they have made.

The following is a description of some of the key decisions that school clinicians need to make at various points in the treatment process. Within each decision, we have posed questions that may help clinicians in the decision making process. When needed, we have provided a brief description of clinical procedures that could be followed when changes in clinical decisions appear necessary. For additional information on treatment techniques, we recommend that the reader consult the list of references and suggested readings at the end of this article.

The reader should note that the ten decisions discussed are sequential but should be revisited when changes in the treatment program are con-

DECISION MAKING IN TREATMENT 109

templated. In the Appendix, we have included a summary of the decisions made and questions asked about treatment. We will begin our discussion with four decisions that need to be considered prior to the beginning of treatment.

P R E - T R E A T M E N T D E C I S I O N M A K I N G

Decision 1

One of the first decisions that clinicians need to make concerns the confidence they have in treating this disorder. A lack of confidence will have an obvious negative impact on the child's treatment program. Does the clinician need to seek additional information about stuttering? Many publications are available to the professional community that offer a number of suggestions for treating stuttering. The articles in this clinical series and the books by Peters and Guitar (1991), Ham (1990) and Conture (1990) are examples of resources for the professional. It might also be helpful to seek the advice of someone who is an "expert" in the area of fluency disorders. The Stuttering Foundation of America maintains a list of individuals who have completed workshops in becoming a "fluency specialist." Perhaps too, a clinician could call upon an expert in his/her geographical area for as- sistance or consult with other SLPs who work in area or regional school districts.

Decision 2

A second pretreatment decision is concerned with the long-term goal of treatment. Establishing long-term goals may require considerable thought because of the multifaceted nature of the fluency problem. Consideration also should be given to the parent's and teacher's expectations of the treatment program. The challenge for a clinician is meeting the needs of "several players" at one time, knowing that in order to meet the needs of the student, the clinician has to address the expectations of the parents and classroom teacher. For example, long-term goals of therapy might include: l) having the child obtain a criterion level of fluency (i.e., 98°/o fluency) at the end of therapy; 2) reducing the severity of the stuttering as well as the fear, embarrassment, and shame felt as a result of stuttering; or 3) reducing the frequency of stuttering but also focusing on communicating and stuttering easily with an increased level of confidence or self-esteem.

Typically, we find that the last goal is more realistic for children than the first two. It seems unrealistic to expect that the child will be able to achieve 100o7o fluency in every setting with every conversational partner. Many clinicians have observed that children who stutter are capable of

ll0 HEALEY ET AL.

producing high levels of fluency during treatment but then relapse into their old speech patterns once they leave the clinic environment. We believe that one reason this might occur is because the focus of therapy and the expectations for "success" have not been clarified or discussed with others involved in the child's programming. Clarification of participant's roles in the treatment program needs to be determined.

Once the long-term goal of the program is established, the following questions need to be asked: 1) Is the goal a result of a collective decision among clinician, child, parent and teacher? 2) Is the long-term goal realistic? and 3) Does the long-term goal meet the needs of the parents and teachers as well as the student's?

Another related issue to the long-term goal of treatment is for clinicians to determine how they can be an advocate for the child who stutters. This could take the form of educating other teachers and children in the child's classroom or school about stuttering. This would include a discussion of facts about stuttering, popular misconceptions about why some children stutter (i.e., people stutter because they are nervous), and why certain conditions induce fluency (e.g., singing, whispering, talking to pets, etc.). We believe that it is beneficial for a clinician to take a leadership role in demystifying the problem of stuttering to children of all ages as well as individuals within a child's immediate communicative environment.

Decision 3

Another decision that follows directly from the selection of the long-term goal involves the philosophical approach that will be used to treat the fluency disorder. There are three basic approaches to treating stuttering: 1) fluency shaping which focuses on the establishment and operant shaping of fluency under controlled stimulus conditions; 2) stuttering modification which emphasizes monitoring and modifying the stuttering behavior as well as reducing the negative emotions associated with the fluency disorder; and 3) a combination of fluency shaping and stuttering modification techniques. The reader can find excellent discussions and explanations of each treatment approach in the publications by Gregory (1979) and Peters and Gui- tar (1991).

The decision about which treatment philosophy to adopt with each client should be based primarily on diagnostic information and what the clinician, child, and parents agree on as the desired outcome. The following questions should facilitate the decision making process.

When should a fluency shaping approach be used? The decision to focus on shaping a fluent response seems warranted when the children who


stutter have a relatively good attitude about themselves and their stuttering. This approach also seems appropriate if the goal of a high level of fluency appears attainable. In general, fluency shaping is indicated if the child is not embarrassed by the stuttering and does not display any avoid- ance behaviors that indicate that they are trying not to stutter. Speech skills emphasized in a fluency shaping approach facilitate increased breath and phonatory control as well as a reduced rate of speech. It is expected that when control over the stuttering is achieved in structured speaking situations through various fluency enhancing techniques, a child will feel successful and have an enhanced self-esteem.

The decision to use a fluency shaping approach is supported by the sug- gestion offered by Gregory and Campbell (1988). They suggest that analyz- ing and modifying stuttered moments may be difficult for school-aged children. Therefore, they recommend that a clinician start treatment teaching a child easy, relaxed speech movements with words and short phrases.

When is a stuttering modification approach recommended? We would recommend this approach for children who seem overly sensitive about the stuttering to the point that they are avoiding talking with anyone and show considerable embarrassment and shame when they stutter. The child perceives that stuttering is not acceptable to his/her parents, family, or friends. Because of this, the child has developed a number of feared sounds or words and will attempt to avoid most speaking situations. Confronting fears and finding ways not to avoid talking are some of the key elements of this approach. A clinician will have to deal with a child's resistance or fear of change in speech, self-critical behaviors, low self-esteem or a variety of negative emotions associated with the fluency problem. Klevans (1988) suggested that the counseling portion of treatment must be built on trust and mutual respect. Even very young disfluent children will need emotional support and encouragement from the clinician. Moreover, good listening skills and awareness of the child's nonverbal communication play an important role in establishing a collaborative relationship which facilitates change in speech behavior.

It is possible that some of a child's fears, avoidances, and negative perceptions of stuttering came from being teased about the stuttering. Most children will report that they have been teased about their stuttering. Some are affected by it while others are not. Therefore, a clinician needs to decide how to help the child confront the teasing and manage it in an effective way. Peters and Guitar (1991) and Murphy (1994) suggest ways this can be accomplished.

Having a child become less sensitive about the stuttering is one of the major components of the stuttering modification treatment approach. It

112 HEALEY ET AL.

also is designed to desensitize children to the fear, mystery, and shame that might result from stuttering. Once a child develops an improved attitude about him/herself and the stuttering, then modification of the stuttering in the form of "easy" stuttering can be taught. Dell (1979) described in de- tail how to teach a child to progress from a tense, struggled disfluent moment to an easy stutter to an eventual fluent production of the word. A clinician could supplement the different ways to stutter with having the child teach the clinician and parents how to stutter. Teaching the child to work through the disfluency at that moment and then change to a mild, easy stuttering would be another major focus of treatment.

When would an integrative approach be used? We believe that many children who stutter would benefit most from an integrative approach. We have found that it is beneficial to use an approach where the child learns how to achieve increased control over the speech mechanism as well as cope with negative feelings, attitudes, and perceptions about stuttering. This approach demands that a clinician be flexible in planning treatment since the needs of the child may change from one session to the next. This approach is designed to provide a child with new speech skills as well as new ways to cope with the stuttering. Healey and Scott (1995) provide a detailed description of an integrative approach to treating school-age children who stutter.

Decision 4

A decision about the long-term goal and approach of treatment would not be complete without the clinician deciding on how the goals and outcome of therapy will be documented prior to treatment. The system of documentation that is chosen should allow a clinician to make judgments about the effectiveness of the treatment techniques as they relate to the long- and short-term goals of therapy. The documentation system also should assist the clinician in making decisions about when to decrease the amount of intervention that comes from the achievement of stated goals or a child's failure to progress in therapy. Consideration should be given to both the frequency of charting (i.e., weekly or bi-weekly). From those data, a plan for charting progress at predetermined intervals, such as once a month, should yield the long-term view of progress that may be obscured when plotting many discrete points over several months.

How will the clinician document the long-term goal o f the program? We recommend documenting the frequency of certain behaviors in the tradi- tional way and through the development of a "portfolio" of information.


The portfolio might include an accumulation of a child's written and/or tape-recorded explanations of how and why certain fluency techniques improve fluency. If the goal of therapy is to document that a child has developed a more positive emotional reaction to stuttering, the portfolio might include copies of statements from the child about attitudes and feelings that are made across several weeks/months. Comments made about how the child perceives him/herself and the stuttering could be supplemented with responses obtained from a standardized attitude scale such as the Chil- dren's Attitudes About Talking-Revised [CAT-R] (DeNil and Brutten, 1991). Additionally, written notes from the classroom teacher or direct observa- tion of the child in class which indicate that the child is talking moreand showing less reluctance to volunteer information in class should be included in the portfolio.

Now that some decisions have been made about the overall goals and approach to treatment as well as the documentation system that will be used, the clinician needs to make different types of decisions once treatment is initiated. The following decisions and related questions are relevant to this stage of therapy.

D E C I S I O N M A K I N G D U R I N G T R E A T M E N T

Decision 5

One of the first decisions that needs to be made during treatment concerns scheduling, parent involvement, and how to establish a good relationship with the child. These factors have a major impact on treatment, yet are issues over which the clinician has minimal control.

When grouping and scheduling children for therapy, clinicians are often constrained by the schedules of the classroom teachers and having large numbers of other children with communication disorders other than stuttering on their caseload. Clinicians should ask themselves if it is possible to schedule the child who stutters for individual therapy. We have found that grouping children who stutter with articulation and language disordered students can interfere with effective management of the fluency problem.

Another factor over which clinicians have limited control is parental involvement. In order to maximize success, clinicians should ask themselves, "How supportive and involved are the parents and family members?" We all realize that parents need to be involved and participate in therapy. How- ever, many parents are unavailable for conferences while others have unrealistic expectations about their child's rate of progress or levels of fluency that can be achieved through therapy. Direct contact with the parents at

114 HEALEY ET AL.

school or in the home, frequent telephone contacts, and/or occasional written notes to parents would be ways to keep parents involved. Parents need to be informed and involved in establishing the long- and short-term goals of therapy. They also need frequent feedback from the clinician about the child's progress in therapy. Zebrowski and Schum (1993) provide some helpful hints on how to counsel parents about stuttering and their role in the treatment process.

A final factor over which clinicians may have limited control is the client- clinician relationship. Asking, "How will I establish a good relationship with this student?" is important because the answer determines the foundation for how trust and mutual respect for each other will be developed. This implies that the clinician should take the time to know the child and his/her interests. It also suggests that the clinician should take the time to examine the negative impressions that may exist about children who stutter. Several studies have shown that SLPs possess negative perceptions of persons who stutter (Cooper and Cooper, 1985; Lass, Ruscello, Pannbacker, Schmitt and Everly-Meyers, 1989; Silverman, 1982; Woods and Williams, 1976). Therefore, the clinician needs to be cognizant that the perception they have of a child who stutters may impact the relationship that is established with the child.

Decision 6

Once some of the logistical concerns about treatment have been resolved, a clinician's attention should focus on setting realistic short-term goals for therapy. This means that the objectives listed on the Individual Education Plan (I.E.P.) must also be realistic and attainable. Documentation and evalu- ation of a child's progress toward achieving these I.E.P. objectives usually involves measuring the behaviors at least every other treatment session. As stated above, the frequency with which the I.E.P. objectives are measured and charted should be done prior to treatment.

Many clinicians might not consider the child's perspective in setting the short-term goals of therapy. As the SLP, we believe that we know what is best for the child. However, it should be recognized that children who stutter possess a wide variety of opinions and beliefs about their speech (Williams, 1985). This suggests that the child needs to be included in the decision about the short-term goals of therapy. As with the long-term treatment goals, the parents and the classroom teacher need to be included in setting the short-term goals for treatment. Again, clinicians need to ask themselves if the child, clinician, parents, and teacher agree on what is expected in the early stages of therapy.

If there are differences in opinion on the short-term goals, a clinician


needs to decide how to get everyone focused on the same goals and objectives. Clinicians might need to counsel parents and teachers about how much fluency can be expected from the child in the classroom and at home. Moreover, a clinician needs to discuss how negative emotions and feelings directly impact the amount of fluency the child will exhibit. Once these issues are discussed, an agreement should be reached on how much fluency shaping and stuttering modification the treatment sessions will involve.

If fluency-enhancing procedures are selected, the I.E.P. objectives might focus on having the child achieve improved fluency through a variety of procedures such as a reduction in speech rate or a gentle onset of phonation. However, the clinician needs to make a decision about how these techniques will be introduced into treatment. The selection of fluency techniques cannot be haphazard. A fluency procedure should be chosen because it will have a direct impact on the fluency problem. In other words, a child should not be taught to use a particular technique that has no relevance to the fluency problem (i.e., using an easy onset of phonation in the absence of any laryngeal involvement in the stuttering problem). When fluency enhancing procedures are used, the clinician needs to be sure that all children know how and why a technique assists them in acquiring increased levels of fluency.

In contrast to focusing on a fluency shaping objective, the clinician may have discovered that the child believes or has learned that stuttering is something bad or shameful. This being the case, modifying stuttered moments and reducing the negative attitudes about stuttering would be the targets of therapy. The clinician needs to determine the child's willingness to discuss feelings and attitudes about stuttering as well as understand why it its important to stutter in an easier manner. Decisions about how to educate the child's parents about the impact that negative emotions and perceptions have on the fluency disorder also need to be considered. Parents may not realize that too much emphasis in therapy on fluency and fluency enhancing skills will inadvertently convey to the child that stuttering is not acceptable. The clinician should indicate to the parents that too much emphasis on fluency implies that treatment is designed to "fix" or eliminate the stuttering.

Thus, clinicians who decide to explore the child's willingness and ability to modify a stuttered moment do so with the understanding that this activ- ity prepares the child to cope with the fact that 100% fluency will not always occur and that it is acceptable to stutter. Once the child shows some willingness to stutter openly without shame or guilt, the clinician should provide verbal praise and encouragement. As the child's attitude about stuttering improves, the clinician could then introduce specific speech patterns that facilitate improvements in fluency.

116 HEALEY ET AL.

Decision 7

At some predetermined time after treatment has begun, a clinician may discover that a child has failed to achieve fluency or has failed to modify his/her attitudes about the stuttering. In other words, the child's progress is slow or has plateaued. This can occur with any treatment approach and with any child.

Several factors may account for the child's failure to increase fluency if that was the focus of therapy. First, the child may not have internalized the desired treatment goals. For instance, a child may not know how and why certain fluency enhancing procedures facilitate fluency. Explore answers to the questions, "Am I certain the child understands the procedures that I am teaching and how they will change the speech behavior? .... How can I document that the child understands the procedures that have been taught?" Perhaps a discussion of Williams' (1979) "normal talking" model or something concrete like Conture's (1990) "garden hose" analogy and Cooper and Cooper's (1991) fluency initiating gesture cartoon characters would be helpful in enhancing the child's understanding of the normal phys- iological processes of speech and their relationship to stuttering.

Second, failure in using a specific fluency enhancing procedure might relate to the complexity of the speech task or the environment in which the procedure was taught. For example, abrupt shifts in linguistic complexity of the response during therapy or failure to conduct therapy in settings other than a familiar room might contribute to the lack of improved fluency. In turn, the child becomes discouraged or unmotivated to speak more fluently. Clinicians need to ask themselves if they have developed an appropriate and logical hierarchy of speech tasks in a variety of settings which lead to the accomplishment of steady improvements in fluency.

A third factor that might relate to slow progress in treatment is the clinician's failure to provide meaningful and functional opportunities for speech change. The clinician could ask, "Have I provided choices for the student and allowed him/her to generate self-selected speech tasks and activities?" We have found that structuring the speech tasks around the child's interests is more meaningful than simply using general sentence, phrase, and para- graph-length materials.

If the focus of treatment has been on modifying emotions and attitudes about stuttering, it is possible that a child shows minimal progress because he/she is reluctant to confront or talk about the stuttering. Perhaps the child has difficulty expressing feelings and attitudes verbally. The clinician could select other methods of expression such as drawings or mapping feelings and emotions about stuttering (Healey and Scott, 1995).

Another reason might be related to a child's reluctance to stutter openly in front of the clinician. Theclinician may be uncomfortable imitating or


asking the child to teach him/her how to stutter. In other words, slow progress could have emerged because the child has not been given the opportu- nity to stutter in different ways. Peters and Guitar (1991) and Dell (1979) are excellent references for additional suggestions on how to facilitate the child's ability to modify stuttered moments.

Once the child has achieved the long- and short-term treatment goals, the decision of when to terminate treatment is relatively easy to make. How- ever, if a child exhibits a plateau in progress, the decision about dismissal becomes more difficult. We find that many clinicians lack confidence in deciding to dismiss children who are not showing change as a result of treatment. Usually, clinicians question their skills and the treatment program that has been used rather than other factors. Although considering dismissal of any child with a chronic communication disorder needs to be weighed carefully, we believe it is possible to make informed and data-based decisions. The following decisions are relevant to the dismissal of children who show minimal progress in treatment.

DECISION MAKING FROM DISMISSAL FOR TREATMENT

Decision 8

The first decision clinicians should make when considering termination of treatment is determining the role they played in the success or failure of intervention. Simply, the decisions made before and during treatment should be revisited.

First, clinicians should ask themselves, "Have I provided a variety of ways for the student to be a successful communicator as a result of the therapy process?" If clinicians seek additional information and guidance from others when needed, include the child, parents, and teacher in the establishment of realistic goals, and have modified treatment approaches/techniques when appropriate, then they have likely provided the necessary opportunities for the child to improve his/her communication ability. Given these data, the clinician, child, parents, and teacher should realize that additional therapy probably is not warranted.

Second, the clinician might ask, "Have I advocated for this child and educated others about the chronicity and variability of this disorder?" If the clinician has considered the needs of the child first, and has made an effort to educate others about stuttering, about the treatment process, and helped advocate for the child by setting realistic goals, then the clinician has contributed to a successful outcome.

Answers to these questions should indicate that the clinician has done all that is possible for a successful treatment outcome. However, what hap- pens when the child continues to exhibit a high frequency of stuttering out-

118 HEALEY ET AL.

side of the clinic environment, maintains a negative attitude towards stuttering, and/or has shown little change in speech over an extended period, the clinician is faced with a difficult decision. How will this clinical decision for dismissal be made while at the same time maintain the clinician's accountability? In part, the answer to this question is considered in the discussion of Decisions 9 and 10.

Decision 9

When confronted with the question above, the clinician needs to make decisions about how the child's communication behavior has stabilized. In- formation used to make this decision should include both objective and subjective data that is drawn from the documentation established and im- plemented in the pretreatment and treatment phases of the program. Ob- jective information regarding speech behaviors should be taken from the charting and compilation of data accumulated over the period of intervention. Subjective information taken from the child's portfolio will yield in- sight into the child's emotions and attitudes towards stuttering.

The importance of systematic documentation cannot be overlooked in these circumstances. Documentation should not only reflect a child's lack of progress, but also provide a clear picture of the course of intervention. It should be clear to anyone how decisions were made regarding the design of treatment and what information was used that resulted in program changes.

Decision 10

When both speech behavior and attitudes/emotions have remained un- changed and a clinician has sufficient documentation to support consideration of termination, a clinician finally needs to make a decision about whose needs are being met if intervention is continued. The clinician needs to ask, "Have I prepared for the possibility that the child will not improve further or that the stuttering may actually get worse?" Clinicians should realize that despite the planning, preparation, modifications in the therapy schedule, etc., a child who stutters might not wish to continue working on speech. Talking with the child about the lack of progress and noting the child's reaction when told that a gradual dismissal from treatment is being considered will help the clinician decide if dismissal is the appropriate ac- tion. The clinician also needs to prepare the parents, teachers and others for the plans and rationale to dismiss the child from therapy.

Often, clinicians may avoid making a decision about dismissal or to place the child on a "speech vacation" because it is easier to keep the child in


treatment. Consequently, the child remains in treatment beyond a point which is both functional and necessary. The clinician then needs to ask, "Am I confident that I have made good decisions throughout the interven- t ion process?" If a clinician does not have confidence in the decisions they have made, keeping a child in treatment is likely meeting the clinician's needs rather than those of the child. Additionally, the fear of having others (e.g. parents and teachers) confront the clinician about the decision to dismiss the child from therapy may make it easy to rationalize that continued treatment for the child is necessary.

SUMMARY

Keeping in mind the chronicity and variability of the disorder, it is unrealistic to expect that a// children who stutter will eventually become highly fluent and feel positive about themselves and their speech. Clinicians who treat these children should develop an intervention program that is tailored to each child's individual needs, and that sets realistic goals for the outcome of intervention in order to maximize both speech behaviors and attitudes. Involvement of the parents, teachers, and child in setting long- and short- term goals is important to the success of the program. In developing a treatment program, accountability regarding what and how decisions for intervention were made also becomes critically important.

Clinicians should not view treatment as having to "fix" every child who stutters. Rather, therapy should increase the child's communicative competence and achievement of realistic, functional speech goals. Viewing the disorder as chronic, much like a language disorder, may decrease the pres- sure clinicians feel in changing the speech behavior of the child who stutters. Generating decisions from clinical data that have been collected systematically over a pre-determined period of time will increase the clinician's confidence that they have made accurate, data-based decisions about treating children who stutter.

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le t

o sc

hedu

le t

his

chil

d fo

r in

divi

dual

th

erap

y?

• If

ind

ivid

ual

trea

tmen

t is

n't

real

isti

c, h

ave

I m

axim

ized

my

sch

edul

ing

op

tio

ns?

• D

o I

hav

e ad

equ

ate

par

enta

l in

vo

lvem

ent

and

su

pp

ort

?

rn

t"

• H

ave

I d

on

e as

mu

ch a

s po

ssib

le t

o in

volv

e th

e pa

rent

s?

• H

ave

I d

on

e m

y be

st t

o es

tabl

ish

a go

od r

elat

ions

hip

wit

h th

is s

tud

ent?

D

ecis

ion

6: E

stab

lish

rea

list

ic s

hort

-ter

m g

oals

.

• A

re t

he I

.E.P

. ob

ject

ives

rea

list

ic a

nd

ob

tain

able

? •

Am

I i

nclu

ding

a s

ched

ule

for

do

cum

enta

tio

n i

n th

e th

erap

y p

lan

? •

Hav

e I

cons

ider

ed t

he c

hild

's p

ersp

ecti

ve w

hile

set

ting

goa

ls?

• H

ave

I in

clud

ed t

he p

aren

ts a

nd

tea

cher

in

sett

ing

goal

s?

• D

oes

ever

yone

agr

ee o

n w

hat

is e

xpec

ted

from

ear

ly s

tage

s o

f th

erap

y?

• If

usi

ng a

flu

ency

sh

ap

ing

app

roac

h:

Do

I ha

ve a

sys

tem

atic

pla

n f

or i

ntr

od

uct

ion

of

tech

niqu

es?

Do

the

sele

cted

tec

hniq

ues

dire

ctly

rel

ate

to e

xhib

ited

stu

tter

ing

beha

vior

s?

• If

usi

ng a

stu

tter

ing

mod

ific

atio

n ap

proa

ch:

Do

I ha

ve a

pla

n f

or c

han

gin

g a

ttit

ud

es/e

mo

tio

ns?

H

ave

I se

lect

ed t

echn

ique

s fo

r m

od

ify

ing

stu

tter

ed m

om

ents

?

Hav

e I

educ

ated

oth

ers

rega

rdin

g ac

cept

able

out

com

es o

ther

th

an i

ncre

ased

flu

ency

? D

ecis

ion

7: E

xam

ine

reas

ons

for

slow

pro

gres

s of

fai

lure

to

achi

eve

goal

s.

• A

m I

cer

tain

the

chi

ld u

nd

erst

and

s th

e pr

oced

ures

I'm

tea

chin

g an

d h

ow t

hey

chan

ge

spee

ch b

ehav

ior?

•

Hav

e I

used

an

ap

pro

pri

ate

and

log

ical

hie

rarc

hy i

n pr

esen

ting

spe

ech

task

s an

d s

itua

tion

s to

the

chi

ld?

• H

ave

I pr

ovid

ed c

hoic

es f

or t

he s

tude

nt,

and

all

owed

for

gen

erat

ion

of

self

-sel

ecte

d ta

sks

and

act

ivit

ies?

•

Is t

he c

hild

rel

ucta

nt t

o co

nfr

on

t/ta

lk a

bo

ut

stut

teri

ng?

• H

ave

I gi

ven

the

chil

d o

pp

ort

un

ity

to

stut

ter

in d

iffe

rent

way

s?

Z

>

0 m

Z

(con

tinue

d)

Ap

pen

dix

(co

ntin

ued)

Dec

isio

ns f

or D

ism

issa

l/T

reat

men

t T

erm

inat

ion

Y

es

No

Unc

erta

in

F.,

to

Dec

isio

n 8:

Exa

min

e th

e cl

inic

ian'

s ro

le i

n su

cces

s of

int

erve

ntio

n.

• H

ave

I pr

ovid

ed a

var

iety

of

way

s fo

r th

is s

tude

nt t

o be

com

e a

mo

re s

ucce

ssfu

l co

mm

unic

ator

? •

Hav

e I

advo

cate

d fo

r th

is c

hild

, ed

ucat

ing

othe

rs a

bout

the

chr

onic

ity

and

vari

abil

ity

of

stut

teri

ng?

Dec

isio

n 9:

Det

erm

ine

whe

ther

sta

bili

zati

on o

f pr

ogre

ss h

as o

ccur

red.

•

Do

I ha

ve o

bjec

tive

inf

orm

atio

n fr

om

cha

rtin

g,

etc.

, to

ill

ustr

ate

stab

iliz

atio

n in

spe

ech

beha

vior

s?

• D

o I

have

sub

ject

ive

info

rmat

ion,

su

ch a

s co

mm

ents

and

not

es f

rom

dis

cuss

ions

, to

il

lust

rate

sta

bili

zati

on?

• D

oes

my

docu

men

tati

on

mak

e cl

ear

to o

ther

s th

e de

sign

and

pro

gres

sion

of

inte

rven

tion

?

Dec

isio

n 10

: E

xam

ine

mot

ivat

ion

s fo

r te

rmin

atio

n o

f tr

eatm

ent

wh

en p

rogr

ess

has

plat

eaue

fl.

• H

ave

l pr

epar

ed

mys

elf

for

the

poss

ibil

ity

that

the

chi

ld m

ay n

ot i

mpr

ove

furt

her,

or

may

ac

tual

ly s

tutt

er m

ore?

• H

ave

I pr

epar

ed

the

chil

d fo

r th

is p

ossi

bili

ty?

• H

ave

I pr

epar

ed

othe

rs f

or t

his

poss

ibil

ity?

•

Hav

e I

talk

ed t

o th

e ch

ild

abou

t te

rmin

atin

g tr

eatm

ent

beca

use

of

lack

of

prog

ress

?

• H

ave

I ta

lked

to

othe

rs a

bout

the

pla

ns a

nd r

atio

nale

for

ter

min

atio

n o

f th

erap

y?

• A

re t

he c

hild

's n

eeds

bei

ng m

et b

y co

ntin

uing

or

term

inat

ing

trea

tmen

t?

t-

,q


REFERENCES

Conture, E. (1990). Stuttering (2nd ed.). Englewood Cliffs, New Jersey: Pren- tice Hall.

Cooper, E.B., and Cooper, C.S. (1991). A fluency disorders prevention program for preschoolers and children in the primary grades. American Jour- nal o f Speech-Language Pathology." A Journal o f Clinical Practice 1, 28-31.

Cooper, E.B., and Cooper, C.S. (1985). Clinician attitudes toward stuttering: A decade of change (1973-1983). Journal o f Fluency Disorders 10, 19-33.

Dell, C.W. (1979). Theating the school age stutterer: a guide for clinicians. Memphis: Speech Foundation of America.

De Nil, L.E, and Brutten, G.J. (1991). Speech-associated attitudes of stuttering and nonstuttering children. Journal o f Speech and Hearing Re- search 34, 60-66.

Gregory, H. (1979). Controversies about stuttering therapy. Baltimore: University Park Press.

Gregory, H., and Campbell, J. (1988). Stuttering in the school-age child. In D. Yoder and R. Kent (Eds). Decision making in speech-language pathology (pp 162-163). Toronto: B.C. Decker.

Ham, R.E. (1990). Therapy o f stuttering: preschool through adolescence. Englewood Cliffs, New Jersey: Prentice-Hall, Inc.

Healey, E.C., and Scott, L.A. (1995). Strategies for treating elementary school-age children who stutter: an integrative approach. Language, Speech, Hearing Services in Schools 26, 151-161.

Klevans, D.R. (1988). Counseling strategies for communication disorders. Seminars in Speech and Language 9, 185-208.

Lass, N., Ruscello, D., Pannbacker, M., Schmitt, J., and Everly-Myers, D. (1989). Speech-language pathologists' perceptions of child and adult fe- male and male stutterers. Journal o f Fluency Disorders 14, 127-134.

Leith, W. (1984). Handbook of Stuttering Therapy for the School Clini- cian. San Diego: College-Hill Press.

Mallard, A.R., Gardner, L.S., and Downey, C.S. (1988). Clinical training in stuttering for school clinicians. Journal o f Fluency Disorders 13, 253-259.

124 HEALEY ET AL.

Murphy, W. (1984). Helping children who stutter: A potpourri of clinical ideas. Paper presented at the Stuttering Foundation of America and University of Colorado Boulder Conference, Boulder, Colorado.

Peters, T.J., and Guitar, B. (1991). Stuttering." An integrated approach to its nature and treatment. Baltimore: Williams and Wilkins.

St. Louis, K.O., and Durrenberger, C. (1993). What communication disorders do experienced clinicians prefer to manage? American Speech- Language-Hearing Association 35, 23-31.

Silverman, D. (1992). Speech-language clinician's and university student's impressions of women and girls who stutter. Journal of Fluency Dis- orders 7, 469-478.

Williams, D.E. (1979). A perspective on approaches to stuttering therapy. In H. Gregory (Ed). Controversies about stuttering therapy (pp 241-268) Baltimore, MD: University Park Press.

Woods, C., and Williams, D. (1976). Traits attributed to stuttering and nor- mally fluent males. Journal of Speech and Hearing Research 36, 267-278.

Zebrowski, P., and Schum, R. (1993). Counseling parents of children who stutter. American Journal of Speech-Language Pathology 2, 52-64.

C O N T I N U I N G EDUCATION S U G G E S T E D R E A D I N G S

Bernstein Ratner, N. (1995). Treating the child who stutters with concomi- tant grammatical or phonological impairment. Language, Speech, and Hearing Services in Schools 26, 180-186.

Conture, E., and Guitar, B.E. (1993). Evaluating efficacy of treatment of stuttering: School-age children. Journal of Fluency Disorders 18, 253-287.

Gregory, H. (1991). Therapy for elementary school-age children. Seminars in Speech and Language 12, 323-335.

Kelly, E., and Conture, E. (1991). Intervention with school-age stutterers. Seminars in Speech and Language 12, 309-322.

Ramig, P., and Bennett, E. (1995). Working with 7- to 12-year-old children who stutter: Ideas for intervention in the public schools. Language, Speech, and Hearing Services in Schools 26, 138-150.

decision making in the treatment of school-age children who stutter

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