Fluency Consulting in a Metropolitan School District: Helping School SLPs Understand Stuttering (Robert Dellinger)

About the author: Robert L. Dellinger, M.S., CCC-SLP, is an elementary school speech-language pathologist in the Wake County (N.C.) Public School System. Mr. Dellinger serves as fluency consultant for his district, helping colleagues to navigate through ongoing challenges within the evaluation and treatment process for children who stutter. Mr. Dellinger is active in the local National Stuttering Association chapter and presents workshops on stuttering evaluation and treatment.  Mr. Dellinger, a person who stutters, lives in Raleigh, N.C., with his wife and two daughters.

Aiden* is a 5th grader whose stuttering increased dramatically toward the end of his 4th-grade year.  In response, Aiden’s school speech-language pathologist has started off the new school year by doubling down on fluency practice. It appears to be working – at least in the therapy room. During speech therapy, Aiden is using his fluency techniques with “100% accuracy” and is speaking stutter-free. Despite the positive outcome, Aiden’s treatment success is undermined by an uncomfortable realization: He is unable to use his fluency skills outside of therapy. In the classroom, he is stuttering as much as ever.

Aiden’s speech-language pathologist (SLP) is unsure about how to respond. She is wondering about his treatment plan. Should it include explicit goals for transferring speech skills to the classroom? Should it target goals other than fluency?

In her uncertainty, Aiden’s school SLP is hardly alone. Stuttering is a highly complex condition that can be frustrating and confusing not only for children who stutter, their parents, and their teachers, but also their clinicians. The variability and persistence of school-age stuttering – and the way in which stuttering can affect almost every aspect of a child’s life – may also be sources of frustration and confusion for everyone involved (Yaruss, 2014).

Personal factors among SLPs may also play a significant role. The majority of SLPs report a lack of comfort when working with people who stutter. Stuttering ranks lowest among disorders that SLPs prefer to treat. Many SLPs report inadequate training in fluency disorders at the university level. SLPs may feel they do not see enough children who stutter to maintain clinical competence (e.g., Brisk, Healey, & Hux, 1997; Cooper & Cooper, 1988, 1996; Kelly et al., 1997; Mallard & Westbrook; Mallard, Gardner, & Downey, 1988; St. Louis & Durrenberger, 1993; St. Louis & Lass, 1981; Tellis, Bressler, & Emerick, 2008). Such challenges may be multiplied in school-based practice, where clinicians must be generalists and cannot choose which clients, or disorders, to treat. When SLPs feel unprepared to treat children who stutter, but have to treat them anyway, we may wonder: Are children who stutter receiving adequate services from SLPs in schools?

In our metropolitan school district, the speech-language department is responding to the many challenges of working with school-age children who stutter. It began by resourcing me, a full-time elementary school SLP (and a person who stutters) with a special interest in fluency disorders, into the part-time role of “fluency consultant.” The primary goal was to assist school SLPs in coordinating effective services for students who stutter. Starting officially in January 2017, the position so far has primarily involved responding to frequent email inquiries, fielding phone calls, analyzing speech samples, assisting in the development of treatment goals, participating in meetings, and making on-site visits.

Our consultation model is a work in progress. At first, colleagues mostly asked questions about their challenging fluency cases, and I answered them. Quickly, I learned that questions about specific cases are difficult to answer definitively because I do not know the students or all the details of their case histories. Instead of ready answers, what I now offer is a “way of thinking,” a framework to facilitate critical thinking and navigate ongoing challenges within the evaluation and treatment process (Chmela & Campbell, 2014).

The framework – and our evolving consultation model in our district – is Basic Principle Problem Solving (Chmela & Campbell, 2014). Basic Principle Problem Solving incorporates treatment evidence, desires of all relevant parties, clinical knowledge and expertise, and work-setting rules and regulations into an ongoing clinical problem-solving model. The focus on ongoing challenges is essential due to the complexity, variability, and chronic nature of school-age stuttering.

The framework is based on a core set of 11 basic principles developed by Hugo Gregory (Gregory, 1968), refined through decades of collaboration (e.g., Gregory, Campbell, & Hill, 2003), and redefined by Kristin Chmela and June Campbell in their manual, Working with School-Age Children Who Stutter: Basic Principle Problem Solving (Chmela & Campbell, 2014). The basic principles are as follows:

  1. Differential Evaluation-Differential Treatment (comprehensive and ongoing for each child);
  2. Relationship (positive relationships cultivated among all parties – the child, parents, siblings, teachers, SLPs, and relevant others);
  3. Counterconditioning, Deconditioning, & Desensitization (of tense speech responses and maladaptive attitudes and behaviors to more adaptive ones);
  4. Modeling (of exemplary communicative skills, including actions of assertiveness, confidence, and effectiveness, and ease of communication);
  5. Guided Practice (by manipulating child and environmental variables during treatment activities and home assignments);
  6. Reinforcement (of desired behaviors, attitudes, and communication skills;
  7. Self-Monitoring, Self-Reinforcement (of desired  behaviors, attitudes, and communication skills);
  8. Transfer (of more adaptive behaviors, attitudes and communication patterns through systematically planned and conducted treatment activities);
  9. Generalization (of more adaptive behaviors, attitudes, and communication patterns);
  10. Gradual Dismissal, Follow-Through, & Maintenance (of positive treatment gains); and
  11. Integration of Child-Related & Environment-Related Factors (throughout evaluation, treatment, dismissal, and maintenance processes) (Chmela & Campbell, 2014).

While referencing the Basic Principles, SLPs apply ongoing “actions of thinking” (Chmela & Campbell, 2014) to solve clinical challenges. SLPs learn to 1) Recognize a Challenge (Is there a fluency problem? What is it? Is it stuttering or something else?); 2) Define Further (Who has challenges? What are they? When, where, and why do they occur?); 3) Represent & Rank Order Problem(s) (Is this one big problem? Or a series of smaller ones? What is the best order in which to solve them?); 4) Construct a Plan (What do all parties desire? What is the evidence? What do clinical knowledge & expertise suggest?); 5) Develop a Monitoring System & Execute the Plan (Are we going in the right direction? How will we know?); and 5) Evaluate the Results (What are the outcomes? What adjustments must be made?) (Chmela & Campbell, 2104).

In our interpretation of Basic Principle Problem Solving, problems are viewed as challenges, and challenges are seen as opportunities (Chmela & Campbell, 2014) to help students become the best overall communicators they can be, whether fluent, disfluent, or stuttering at any given time. Overall communication skills are developed across five domains of communication competence: Assertive (moving toward communication, saying what you want, resisting time pressure, not avoiding); Attentive (being “in” the conversation, responding and connecting); Confident (self-assurance portrayed by eye contact, posture, body language, volume of voice); Effective (getting one’s message across, greater ease of communication, efficient rate of information flow); and Proactive (making plans, setting goals, and following through; and honesty about communication) (Chmela and Campbell, 2014; Johnson, 2015).

Our next step will be to offer continuing education in stuttering and other fluency disorders to our district’s SLPs through three-hour workshops scheduled for Fall 2017 and Spring 2018. The fall workshops will cover comprehensive, differential evaluation and goal setting. Differential treatment (incorporating all of the core principles) will be covered in the spring. Participants will learn to plan and conduct a differential evaluation that assesses not only the motor aspects of a child’s speech and the breakdowns in fluency, but also reactions (the child’s and the environment’s) to those breakdowns, and other contributing factors that affect the problem in some way, such as development of negative feelings and attitudes about stuttering and communicating. Participants will learn to identify the communication discrepancies and performance gaps that manifest in schools as adverse educational effects. They will learn to conduct therapy that targets more than just the development of speech skills, addressing social and emotional needs and improving overall communication competence inside and outside of the therapy room. Finally, participants will learn to start generating their own solutions to the many challenges of stuttering by engaging in the ongoing, differential problem-solving process.

In Aiden’s case, based on our collaboration, the school SLP has already begun to apply Basic Principle Problem Solving. Aiden’s new goals address transfer of skills, and therapy is moving beyond the confines of the speech room. Child-teacher contract cards assist in transferring treatment gains into to the classroom, where they matter most. Goals no longer focus solely on speech, but also on overall communication skills necessary for school success, such as assertively answering questions that the teacher asks and retelling stories.

As I reflect on the basic principles, I am reminded of how a singular focus on fluency may lead to frustration for everyone, difficulty with transfer and generalization, and poor treatment outcomes. In the worst case scenario, by focusing on fluency alone, we may send children the unintended message that stuttering is bad, and so are they when they stutter (Yaruss, 2014). In my district, I am profoundly grateful that we are developing the knowledge and expertise to take a comprehensive, differential approach that sends the opposite message: Children who stutter can become exceptional communicators.

*The student’s name and identifying information
have been changed to protect confidentiality.

References

Brisk, D., Healey, E. C., & Hux, K. (1997). Clinicians’ training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in the Schools, 28, 164-176.

Chmela, K. A., & Campbell, J. H. (2014). Working with school-age children who stutter: Basic principle problem solving. Greenville, SC: Super Duper Publications.

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

Cooper, E. B., & Cooper, C. S. (1996). Clinician attitudes toward stuttering: Two decades of change. Journal of Fluency Disorders, 21, 119-135.

Gregory, H. H. (1968). Learning theory and stuttering therapy. Evanston, IL: Northwestern University Press.

Gregory, H. H., Campbell, J. H., & Hill, D. G. (2003). Differential evaluation of stuttering problems. In H. H. Gregory (Ed.), Stuttering therapy: Rationale and procedures (pp. 80-141).Boston, MA: Allyn & Bacon.

Johnson, L. (2015). Effective Service Delivery for Fluency in the Schools – Handout [workshop handout]. Retrieved from http://c.ymcdn.com/sites/www.wisha.org/resource/resmgr/2015_Convention/Blk_4_Schls_Johnson.pdf

Kelly, E. M., Martin, J. S., Baker, K. I., Rivera, N. J., Bishop, J. E., Kriziske, C. B., Stettler, D. S., & Stealey, J. M. (1997). Academic and clinical preparation and practices of school speech-language pathologists with people who stutter. Language, Speech and Hearing Services in the Schools, 28, 195-212.

Mallard, A. R., & Westbrook, J. B. (1988). Variables affecting stuttering therapy in school settings. Language, Speech and Hearing Services in the Schools, 19, 362-370.

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

St. Louis, K. O., & Durrenberger, C. H. (1993). What communication disorders do experienced clinicians prefer to manage? ASHA, 35, 23-31.

St. Louis, K. O., & Lass, N. J. (1981). A survey of communicative disorders students’ attitudes toward stuttering. Journal of Fluency Disorders, 6(1), 49-79.

Tellis, G., Bressler, L., & Emerick, K. (2008). An exploration of clinician views about assessment and treatment of stuttering. Perspectives on Fluency and Fluency Disorders, 18(1), 16-23.

Yaruss, S. (2014, March 6-7). Effective treatment for school-age children who stutter: An advanced course. [Course handout]. Course presented at Speech and Hearing Association of Alabama convention. Retrieved from https://www.alabamashaa.org/files/Handouts%202014/Yaruss-School-AgeChildrenStutter.pdf

592 total views, 6 views today


Comments

Fluency Consulting in a Metropolitan School District: Helping School SLPs Understand Stuttering (Robert Dellinger) — 14 Comments

  1. Rob,
    HI! What a great submission! I’m so glad you wrote something and shared it with the world. You did a wonderful job explaining the principles and how it can so relevant to children in a school. You would really like Camp Shout Out. It is based on those principles for as one of the theoretical foundations for the camp. Kristen, Julie, June, and Lynn have done a nice job weaving them into the camp.
    Let me ask, what are some challenges you have had in your school district regarding colleagues treating kids who stutter?

    I hope you are well!!!
    With compassion and kindness,
    Scott

    • Scott, thanks so much for your kind comments! I’ve really wanted to apply for Camp Shout Out … it’s on my bucket list. But since I work at a year-round school and don’t track out, and since I always seem to have conflicting family obligations, the timing has never been right. One of these days, for sure! Before I answer your question, allow me to give a “shout out” to my supervisor, who recognized the need for a stuttering consultant and resourced me into the role, and to my colleagues, who have embraced the position and allow me to fulfill a longtime professional dream. Regarding our challenges. … At the Multi-Tiered Systems of Support level, one challenge is helping SLPs understand that stuttering interventions that change talking are (in my opinion) not appropriate for children with an obvious stuttering problem, because we cannot know how to intervene until a comprehensive, differential evaluation is conducted. At the evaluation level, another challenge is helping SLPs assess the whole condition of stuttering – not only the breakdowns in fluency, but reactions to those breakdowns and anticipated breakdowns, avoidance behaviors, emotions and attitudes, and other contributing factors. At the eligibility level, a challenge is helping SLPs identify adverse educational effects when students who stutter are doing well in school. At the treatment level, challenges include targeting skills other than just use of “Speech tools,” such as analyzing reactions to stuttering; increasing assertiveness, confidence, and verbal output in challenging speaking situations; and addressing transfer and generalization of skills. Finally, an ongoing challenge is learning how to write goals for all of this stuff! I am so encouraged by the progress we are making. Wishing you all the best!
      Rob

  2. Great paper Rob! Every school district should have an expert like you to consult with other SLPs on staff. You raise an excellent point when you say: “a singular focus on fluency may lead to frustration for everyone”– I know that you have worked hard to bring this benefit to your county–thanks for being such a great resource to families, SLPs and children who stutter!

    • Thank you, Rita! I wholeheartedly agree that every school district needs a stuttering consultant, since so many school SLPs lack comfort in working with children who stutter. I’m grateful for the support I’ve received in my district. I’m also grateful for your support! In being a resource to families, SLPs, and children who stutter, you are my role model.

  3. Great paper! I like how you are bringing awareness to the variability and individuality of people who stutter and the attitudes toward treatment. I think it is important for parents, teachers, clinicians, and relevant others to realize how multidimensional stuttering is and how it is easily affected in various situations. There may be a lot of frustration and confusion for anyone who is not the person experiencing the stuttering directly, but the models you provided give hope to finding methods appropriate to meet their wants and needs.

    From the perspective of a student, it is helpful to learn these models of thinking that can be applied to future intervention processes. It is also reassuring to read experiences of uncertainty from other clinicians, and to learn these methods prior to practice to aid in becoming a more competent clinician. This paper encourages clinicians to make their own best judgment based on what they do know about stuttering and how it affects everyone differently. It also builds the confidence of speech-language pathologists working in potentially stressful situations, and provides a guide to solving any issues related to feeling inexperienced with a specific client population.

    Thanks for sharing!
    MacKenna

    • MacKenna, thank you for your kind feedback. I am happy to hear that as a student, you found the paper helpful. I’m glad you see our consulting model as a “model of thinking.” I agree that Basic Principle Problem Solving allows us to think critically and work to solve problems in an ongoing manner. I am always happy to see a young professional interested in stuttering and working with people who stutter. Best to you,
      Rob

  4. Rob, Thank you for bringing up the role of Fluency-Stuttering Consultant in the public schools. There is definitely a need! I am a PWS and SLP working in the schools. This 2017-2018 school year, I was given title of Fluency-Stuttering Consultant in Rutherford. Co. Schools in North Carolina. My role thus far has been to assist SLPs within our schools with evaluations, writing IEP goals, student – family counseling, and student-family-teacher education, and treatment. My goal is individualize and help SLPs individualize plans of care for our children who stutter. Yes, there is too much focus on fluency! My goal for students is communication freedom that facilitates academic-social success achieved by controlled stuttering. Lets talk more about the role of SLP Fluency – Stuttering Consultants in the NC public schools.

    Derek Taylor

    • Derek, thanks for your comments, and congratulations on the consultant position! I agree that the overarching goal is communicative freedom. I’m looking forward to connecting with you!
      Rob

  5. Thank you for this informative presentation! I am a graduate student in speech language pathology and am currently taking a class on fluency disorders. We have talked a lot about how the treatment of stuttering is not just about how to manage fluency, but also about how to empower the person who stutters to re-frame how they see themselves with regard to their communication. I am very interested in learning more about how to approach treatment and hope to be able to advocate for students in the school system in the future.

  6. Hello!
    My name is Katelyn Bauman and I am currently a 2nd year graduate student at the University of MN Duluth. I am take a course titled Advanced Fluency Disorders. Your paper was extremely informative and provided a lot of insight into setting up treatment. As I was reading, I came up with 2 questions.

    1. What are some strategies you have used to help generalize skills from inside the therapy room to everyday situations?

    2. In the paper you mention that part of Aiden’s goals include assertively answering questions, how does this look like? What are some other ways that you incorporate the other 4 domains of communication competence?

  7. Hello! My name is Annie Zlotowitz. I am a 2nd year graduate student at Touro College’s Speech and Language Pathology Program, and have become very interested in treating fluency disorders. Your paper was very enlightening and provided me with a whole different outlook and point of view on treating fluency disorders.
    I do have one question, why is it that children (and adults) have such a hard time generalizing their fluency skills they learn in therapy to outside of the therapy room?
    Thanks for your time!
    Kind regards,
    Annie

  8. Hi Rob,
    As a second year SLP grad student in North Carolina, I loved reading the progress being made within the NC school system pertaining to stuttering. It sounds like your district is very in tune with the needs of the SLPs and what an awesome position you have of being able to assist them in providing the best therapy to the students!

    I have two questions for you pertaining to working in the school system and stuttering. For children who stutter, background information from the parents is important for having a whole picture of the child across all settings (within therapy, in the classroom, at home). How do you handle a hole in the case history of children who stutter whose parents are not involved? And how do you know if their progress at school is being generalized to the home without communication from the parents? Obviously we hope this is not the case, but know that some parents may not be involved.

    My second question pertains to the set up of therapy. Many states have high case load caps and one-on-one therapy seems impossible even though it may be most beneficial. Have you personally seen a difference in stuttering therapy one-on-one vs. group therapy?

    Thank you,
    Juliana

  9. Hi Rob!

    What a small world! I was born in raised in Raleigh and went the Leesville for years! I appreciate you working in this area and improving the education of SLP’s in the area that I plan on living in one day! I had a question about why you think so many SLP’s are coming out of school feeling unprepared to treat a PWS? I am currently a graduate student at WCU (a little far away but the same state!) and was reading our book, Stuttering Intervention by David Shapiro, for our fluency class and came across that ASHA got rid of certification requirements for specific academic and clinical experiences in the area of fluency disorders in 1993 (Shapiro, 306). Do you think these certifications should be implemented again?

    Thank you,
    Natalie Williams

  10. Hello Rob,

    This sounds like a brilliant and comprehensive program! I would like to see a similar approach in all school districts throughout the country, but I understand that the logistics of that can be tricky. I am a graduate student at ISU and I feel lucky that our fluency professor is also a PWS, so I feel that we’re at least getting more information and perspectives about fluency. It is still disheartening that most SLPs report inadequate training at the university level.

    I’m curious as to how exactly to go about transferring skills outside of the SLP’s therapy room. I know that as children get into the pre-teen and teen years anything that calls attention to the fact that they’re receiving special therapy might cause more resistance in communicative situations outside the therapy room. Has your district attempted any strategies to help raise awareness of stuttering within the general student population in order to facilitate a friendlier communicative environment, and if so, have the outcomes been positive?

    Thank you,

    Kimberly Miller

Leave a Reply