Stuttering Therapy for Children: What Makes Therapy Work?

Stuttering Therapy for Children: What Makes Therapy

Work?

Patricia M. Zebrowski, Ph.D., CCC-SLP

University of Iowa

The Great Therapy Debate: Different Fields, Same Questions.

• What therapy approach “works best?”

• What is the evidence?

• Are there different kinds of evidence?

• If so, do they receive equal weight in treatment planning?

• How does evidence translate into clinical practice?

Evidence-Based Practice

Evidence-based practice is the integration of the best research evidence with clinical expertise and client values.

1. ‘best research’ = ‘outcomes research’ or clinically relevant research into the accuracy, precision, and efficacy of diagnostic tests and treatments

The Technique


2. ‘clinical expertise’ = the ability to use our best clinical skills and past experience to identify delay or disorder, appropriate intervention, and the client’s personal values and expectations

The Clinician


3. ‘client-values’ = the unique preferences, concerns and expectations each client brings to the clinical experience

The Client

What Can We Learn from Psychotherapy Research?

• Numerous studies have compared the effectiveness of different therapeutic approaches for depression, anxiety, schizophrenia, etc.

• Many of these investigations consisted of meta-analyses of the efficacy of various types of therapy (e.g. Wampold, Mondin, Moody, Stich, Benson & Ahn, 1997).

What Can We Learn from Psychotherapy Research?

• With rare exception, research has uncovered little significant difference among different psychotherapeutic approaches.

• This observation has been described as “the dodo effect” (e.g. Tallman & Bohart, 2004).

“Everybody has won and all must have prizes”

- Lewis Carroll

Explaining the “Dodo Effect”

• Different therapy approaches use dissimilar strategies or processes to achieve the same outcome

• Research methods may not be sensitive enough to detect differences in therapeutic effectiveness among approaches OR differences are so subtle that they cannot be observed using conventional between-group designs


Studies of treatment efficacy do not provide objective descriptions or operational definitions of therapy protocol (i.e., client-centered).

Studies of treatment efficacy do not provide the quantitative information to allow for inclusion in meta-analysis

There are common factors throughout all therapies that facilitate change or progress.


It is the similarities, rather than the differences, between approaches that account for the observation that all psychotherapeutic approaches are, in general, effective.


These similarities can be collapsed into four factors or elements that are common to all forms of psychotherapy:

• Technique• Extratherapeutic Change• Therapeutic Relationship• Hope or Expectancy

The Common Factors

• Techniques – factors or ‘strategies’ unique to different therapy approaches (e.g. “easy onset”, “voluntary stuttering”)

• Extratherapeutic Change – characteristics of the client and his/her environment (e.g. temperament, social support)

The Common Factors• Therapeutic Relationship – characteristics of the

clinician and client (and family) that facilitate change and are present regardless of clinician’s therapy orientation (i.e. ‘technique’). Components include shared goals, agreement on methods, means and tasks for treatment, and an emotional bond (Bordin, 1979).

• Expectancy – Hope; sometimes thought of as “placebo”. Improvement that results from client (and clinician’s?) belief that treatment will help.


Further….

Lambert (1992) and Asay and Lambert (1999) reviewed the extant literature and concluded that these factors (separate and combined) account for most of the change observed in therapy.

The “Common Factors” in Treatment Responsiveness

TherapeuticRelationship30%

ExtratherapeuticChange40%

Technique15%

Expectancy (Placebo)15%

Lambert & Bergin (1994)Asay & Lambert (1999)Bernstein Ratner (2005)Franken, Kielstra-Van der Schalk & Boelens (2005)

The “Dodo” Effect in Speech and Language Treatment Research?

Robey, R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. JSLHR, 41, 172-187.

Law, J., Garrett, Z., Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disorder: A meta-analysis. JSLHR, 47, 924-943.


Gillam, R., Loeb, D., Friel-Patti, S., Hoffman, L., Brandel, J., Champlin, C., Thibodeau, L., Widen, J., Bohmah, T., Clarke, W. (2005). Randomized comparison of language intervention programs. ASHA.


• Treatment better than no treatment• On average, treatment is effective• Different effect sizes most likely due to

client characteristics, “age” or severity of problem, clinician skill-level, differences in social validity for individual clients, and so forth.


• Further research to support the conclusion that in general, “therapy works” would waste resources.

• Future work should aim toward testing focused hypotheses (i.e., client characteristics + clinician skill + treatment approach).

Robey, 1998

The “Dodo” Effect in Stuttering Treatment Research?

• Limited data available on efficacy of stuttering therapy for either children or adults.

• Studies have shown that in general, treatment is better than no treatment.

• Primary dependent variable is % stuttered words or syllables.


Emerging evidence that between-treatment comparisons yield nonsignificant findings (Lidcombe compared to Demands-Capacities)

- Franken, Kielstra-Van Der Schalk & Boelens (2005)

AND…..


Recent meta-analysis of the results from 12 studies of behavioral stuttering treatment revealed that intervention for stuttering results in an overall positive effect. Additionally, the data show that no one treatment approach for stuttering demonstrates significantly greater effects over another treatment approach.

- Herder, Howard, Nye & Vanryckehgem (2006).

The “Common Factors” in Treatment Responsiveness

TherapeuticRelationship30%

ExtratherapeuticChange40%

Technique15%

Expectancy (Placebo)15%

Lambert & Bergin (1994)Asay & Lambert (1999)Bernstein Ratner (2005)Franken, Kielstra-Van der Schalk & Boelens (2005)

Treatment for School-Aged Children Who Stutter

TECHNIQUE

Making Speech Change

• Exploring Talking and Stuttering

• Changing Talking

• Changing Stuttering

• Choosing Tools: What and When

Exploring Talking

• In order to understand and feel what s/he does during stuttering, the child must know how we talk

– Establishes common terminology between child and clinician

– Develops understanding of how we coordinate respiration, phonation & articulation for speech (i.e. “speech helpers”)

– Reinforces that his/her speech system is “normal”; i.e. NOTHING NEEDS TO BE ‘FIXED’

• Rationale for this step

– Starting treatment in a way that is removed from emotion: neutral and objective

– Encouraging child to approach something that he/she fears and is used to avoiding

Exploring Talking

Purpose of exploring talking and stuttering is to experiment with choices for:

– Changing speech• Tools for changing airflow, tension, voicing,

movement, rate

WHICH LEADS TO…

– New ideas about speaking, for example:• I don’t have to keep using the same patterns of

speaking• I have options for speaking and for stuttering

Exploring Stuttering• Identify aspects of stuttering

– In order to change behavior, need to know when and what to change

• Exploring stuttering ties information from exploring talking to child’s own behavior/speech patterns

• Desensitizing

Exploring Stuttering: How do you stutter?

• Disfluency and stuttering represent difficulty in connecting sounds, syllables and words. Given that,

• Attend to where you are “disconnecting” and what you are doing. What needs to be done to “move forward” and smoothly connect sounds, syllables and words while speaking?

• The same principles are used to both initiate and maintain ‘easy’ speech, and to produce ‘easier’ stuttering

Tools For Change

Changing Talking• Soft starts/easy onsets/light contacts• Changing rate

Changing Stuttering• Voluntary stuttering • Holding & tolerating a moment of stuttering• In-block corrections/pullouts• Post-block corrections/cancellations

Changing TalkingSoft Starts/Easy Onset and

Light Contacts• What are they?

– Slower, physically relaxed speech initiation– Decreased muscle tension and less tense articulatory

constriction (e.g. bilabial closure, tongue-alveolar contact)

• Why use them?– Help initiate smooth airflow, voicing, and physically

relaxed, smooth articulator movement

• When to use them?- Beginning of phrases or utterances

- Phrase boundaries

Changing Talking: Changing Rate

• What is it? – Slower speech overall: fewer syllables or words per minute– Should sound smooth and connected, not choppy

• Why use it?– It’s fluency enhancing because it…

• Helps child attend to what he/she is doing• Gives more time to process• Gives child time to make changes in complex motor coordination• Helps child feel changes in muscle tension

• How can rate be changed?– Stretching sounds or syllables– Phrasing and pausing – Combining stretches with phrasing/pausing

Changing Stuttering:Deliberate (or Voluntary) Stuttering

• What is it?– The child stutters “on purpose”, choosing when and how

• Why use it?– Can be used to teach any aspect of changing and varying stuttering– Assists in building awareness of stuttering moments– Decreases fear and avoidance of stuttering – Desensitizes to listener reactions– Creates a feeling of confidence in the ability to say feared words– Confront what might otherwise be avoided

• When and how to use it?– Prelude to using “pullouts”– Begin teaching at the single word level with unfeared sounds or words– Begin using it in unfeared situations– Build to use on feared words or in feared situations

Changing Stuttering:Holding & Tolerating A Moment of Stuttering

• What is it?– Staying in a moment of stuttering– Child continues speech “movement” rather than stopping,

“backing up”, or otherwise using “reactive” speech strategies• Why use it?

– Increases child’s awareness of what he/she is doing during the stuttering moment

– Helps reduce avoidances– Is desensitizing

• When and how to use it?– After child can identify when and how he/she is stuttering– Clinician HAS to be supportive and encouraging as the child is

holding the stuttering moment

Changing Stuttering: Pullout

• What is it?– “Holding on” to the stuttering moment and “staying with it”

– Helps to focus in on site of physical tension and cessation of movement so as to

- Change the stuttering moment through reducing or “easing off” tension and slowly moving ahead into the next sound or word

• Why use it?– Confront the stuttering moment and “take charge”

(desensitization)– Release tension and keep speech moving forward– Reinforce a looser or “easier” way of stuttering

• When and how to use it?

– When the child experiences a high degree of emotionality or feels “stuck” in a moment of stuttering

– After the child has learned to “hold onto” a moment of stuttering and tolerate it

– Start with deliberate or “fake” stuttering at the single word level

Changing Stuttering:Cancellation

• What is it?– Finishing a stuttered word then– Pausing for a moment to plan (e.g. pantomime or silently

revisit the word) then– Stuttering on the word again in an easier way

• Why use it?– The child learns to “cancel out” or replace hard stuttering

with a looser, more controlled form of stuttering – Cancellation discourages avoidance behaviors such as

recoiling, changing words, stopping in a block and backing up

– Cancellation reinforces easier stuttering and build confidence

– When and how to use it?• Child MUST complete the hard stutter before

pausing and making it easier

• If the child is unable to pullout or missed the opportunity to use a pullout, this will provide another opportunity to learn to stutter more easily and build confidence

• Typically used in the therapy room only as a way of learning a strategy, not in the outside world

Disclosure • What is it?

– Child chooses to openly acknowledges own stuttering to listeners

• Why use it?– Allows the child to take control of the situation– It promotes openness about using techniques– Helps listeners know what to expect– Informs listeners what the client wants them to do

• When to use it?– Like other tools, it should occur in a hierarchy (e.g., family,

friends, group therapy, teachers/co-workers, strangers)– At the beginning of a conversation or presentation

Treatment for Pre-School Children Who Stutter

TECHNIQUE

Patterns of Unassisted Recovery

• Probability of recovery highest from 6-36 months post onset

• Majority of children recover within 12-24 months post onset

• Period of recovery marked by steady decrease in sound/syllable and word repetitions and prolonged sounds over time, beginning shortly after onset

• Relatively brief beginning and ascending phase, and a relatively long declining phase

• Subgroup of children presenting with “severe” stuttering at onset, with frequency of behaviors peaking at 2-3 months post onset and full recovery seen by 6-12 months

• Described by Yairi and associates (1992,1999, 2005), and others (Conture, 2004; Pellowski & Conture, 2002; Zebrowski, 1991)

• Onset before age 3

• Female

• Measurable decrease in sound/syllable and word repetitions, and sound prolongations, overtime, observed relatively soon post-onset

Recovery Predictors

• No family history of stuttering or a family history of recovery

• No coexisting phonological problems (and possibly language and cognitive problems?)

****ALL ARE PROBABILITY INDICATORS****

We suspect that a child is either stuttering or at risk for developing a stuttering problem if (s)he meets BOTH of the following criteria:

• Produces THREE (3) or more WITHIN-WORD speech disfluencies per 100 words of conversational speech (i.e., sound/syllable repetitions and/or sound prolongations)

• Parents and/or other people in the child’s environment express concern that the child either stutters or is a stutterer.

• After Johnson, Williams, Conture and others

Parent-Child Interaction Therapy (PCIT)(Millard, Nicholas & Cook, 2008)

• Rooted in “multifactorial” model of early stuttering

•Collaborative, flexible approach tailored to individual family

•Stuttering is openly discussed and acknowledged with child

• Tools based on (a) child assessment, (b) parent interview, and (c) guided observation of videotaped parent-child playto determine physiological, linguistic, environmental orpsychological factors


Session 1

- Clinician feedback from evaluation and ‘discovery’ while watching videotape.

- Management and Interaction tools are chosen.

- “Special Time” is negotiated.

Parent-Child Interaction Therapy (PCIT)(Millard, Nicholas & Cook, 200

Session 1

Management Tools:

managing child and parent anxiety about stuttering

coping with sensitive children

confidence building

behavior management (e.g. sleeping, eating,turn-taking, tantrums, etc.)


Session 1

Interaction Tools:

Reduce speech rate;

Increase duration of turn-taking pauses;

Reduce amount of talking and length/complexityof utterances;

Decrease language demands (i.e. vocabulary, grammar,amount of talking, “performance” requests)

Parent reduces “time pressure” in daily routine, and “communicative time pressure” in verbal interaction with child

Decrease time pressure in daily life


Session 1

Interaction Tools During Play:

Follow child’s lead during play and verbalinteraction (less physically active role);

Reduce instructions and questions (use commentsinstead);

Maintain attention with eye contact, showing interest,encouragement and praise

Reduce language demands (i.e. vocabulary, grammar,amount of talking, “performance” requests)


Session 2

Videotape parent-child play and observe use of selected interaction tools and their effectiveness;

Parent taught to observe relationship between child “stressors” (internal and external) and fluency, and modifies/manipulates when possible

Provide feedback sheets and schedule weekly parentvisits

Parent provides treatment following training by clinician

Spontaneous fluency is reinforced, instances of stuttering are highlighted through parent request to “say it easy.” (Similar to ‘cancellation?’) Ratio of praise to request for “do-over” @ 5:1

Lidcombe(Onslow, Packman & Harrison, 2003)

www.fhs.usyd.edu.au/asrc

http://www.fhs.usyd.edu.au/asrc

Lidcombe (cont’d)

Parent provides treatment in daily intervals of increasing length and communicative complexity.

Parents taught to rate stuttering frequency and severity, and keep daily ratings of each for self and clinician.

EXTRATHERAPEUTIC CHANGE

CHILD STRENGTHS

• “Signature Strengths”

• Temperament and Resilience

• Self-Perception of Control and Competence

• Phonological Abilities

Positive Psychology

www.ppc.sas.upenn.edu

What’s RIGHT with you?

http://www.ppc.sas.upenn.edu/

“Signature Strengths” - Seligman, 2002

• An important construct in “Positive Psychology”

• (www.authentichappiness.org)

• Are seen across cultures

• Are psychological traits seen across different situations over time

http://www.authentichappiness.org/


• Are valued in their own rite

• Can be acquired and measured

• Contribute to adaptive coping

- Curiosity, interest in the world- Love of learning- Judgment, critical thinking, open- mindedness- Ingenuity, practical intelligence- Emotional intelligence


- Perspective- Bravery- Perseverance- Integrity, honesty - Kindness, generosity- Loving, and allowing oneself to be

loved- Citizenship- Fairness- Leadership


- Self-control- Discretion- Humility- Appreciation of Beauty- Gratitude- Optimism- Sense of Purpose- Forgiveness- Humor- Enthusiasm

Temperament• A largely inherited, multi-faceted construct

that characterizes a child’s general disposition and range of moods (Goldsmith, 1987)

• Reactivity – excitability of the nervous system to behavioral responses or external stimuli

• Self-regulation – the processes that inhibit or facilitate reactivity (for example, attention, approach-avoidance strategies, etc.)

• Activity – lethargic to hyperactive

• Emotionality – emotional response to new or novel stimuli

• Sociability – comfort in being alone as opposed to being with other

Temperament mediates the influence of the environment on the child.

The “Behaviorally Inhibited” (BI) Child

• Described by Kagan (1984; 1994) as one type of normal temperamental profile

• Relatively timid, sensitive to environment and own behaviors, higher levels of reactivity and lower thresholds for excitability than other children

• Based on results from administration of the Temperament Characteristic Scale (TCS) and the Parent Perception Scale, Oyler (1996a, 1996b) and Oyler and Ramig (1995) determined that young children who stutter were significantly more behaviorally inhibited and less likely to take risks than children who do not stutter.

• Further, Anderson, Pellowski, Conture & Kelly (2003) used similar measures and observed that children who stutter are less adaptable, less rhythmic in physiological functioning, and less distractible than their nonstuttering peers.

Resilience

• Children who are successful at regulating excitability and emotional reactivity exhibit resilience.

• Children are described as resilient when their temperament and related adaptive skills (or personality traits) facilitate the ability to “bounce back”, or take negative experiences (e.g. stuttering) in stride.

Resilience• Resilient children may exhibit a more dominant (i.e. less

timid), extraverted and sociable personality, and are inclined to readily and positively approach social situations, including therapy.

• May display a relatively high degree of attentional focusing and risk-taking in therapy and in social (communication) situations.

• Temporal substrate of rhythmicity may benefit from practice effects in therapy.

• All may contribute to progress in therapy OR unassisted recovery.

Teaching Resilience

Penn Resiliency Project curriculum (http://www.ppc.sas.upenn.edu/prpsum.htm)

Fishful Thinking

(www.fishfulthinking.com)

The Optimistic Child (Seligman, 1995)

http://www.ppc.sas.upenn.edu/prpsum.htm

http://www.fishfulthinking.com/

Teaching ResilienceSeven ingredients to teach children:

• Emotion awareness and control

• Impulse control

• Realistic optimism (i.e. explanatory style)

• Flexible thinking

• Self-efficacy

• Empathy

• Reaching out (i.e. risk taking)

Teaching Resilience

Emotion Awareness and Control

- Coping – listen and value; relaxation; guided imagery.

- Link between thoughts and feelingsWhat I think How I feel What I feel in my body What I do(Cook & Botterill, 2009)

Teaching Resilience

- “Two sides” of the coin can be true.

- My thinking side and my feeling side.

- What does my “wise brain” know?

(Scott, 2009)

Teaching Resilience

- Desensitization through:

Talking about talking and stuttering

Identification and “holding on” to the moment of stuttering (i.e. changing stuttering)

“Stutter buddy”

Class presentation

Teaching Resilience

Impulse Control

- Notice, breathe and pause

Realistic Optimism

- Explanatory Style (optimistic/pessimistic)- Learned Optimism (Seligman, 1998)- ABCDEs (Adversity, Belief, Consequence, Disputation/Distraction, Evidence)

Teaching Resilience

A: “I stuttered when I said my name.”

B: “She’ll think I’m stupid”; “I can’t do anything right”; “I shouldn’t talk when I meet someone.”

C: “I felt embarrassed and frustrated”;

D: “She’s really nice”; “People don’t really care when I stutter”; “She still wanted to talk to me even though I stuttered”

E: “I have a lot of friends”; “I can talk in class, and have good things to say.”

Teaching Resilience

“Learned optimism works not through an unjustifiable positivity about the world, but through

the power of “non-negative” thinking.”

(Seligman, 1998)

Teaching Resilience

Flexible Thinking

- Notice, breathe and pause

Realistic Optimism

- Explanatory Style (optimistic/pessimistic)- Learned Optimism (Seligman, 1998)- ABCDEs (Adversity, Belief, Consequence, Disputation/Distraction, Evidence)

Teaching Resilience

Empathy

- Provide opportunities for altruism

- “View from two windows”

- Service/learning projects

Self-Perception of Control and Competence (Self-Efficacy)

• Research in youth sport participation has shown that internal locus of control = higher self-perception of competence, and vice versa (i.e. external locus of control).

• Internal locus of control serves as a protective factor in children who exhibit high levels of trait anxiety or abuse/neglect.

Self-Perception of Control and Competence

• Internal locus of control characterizes children who are motivated to engage in a particular activity or learning task, and maintain a high level of interest across time (e.g. therapy).

• Equivocal evidence that internal locus of control facilitates short-term gains in stuttering therapy.

Phonological Abilities

• Evidence suggests that children who stutter are more likely to exhibit (co-existing) phonological delay or disorder when compared to their nonstuttering peers (Louko, Edwards and Conture, 1990; Paden and Yairi, 1996; Paden, Yairi and Ambrose, 1999; Paden, 2005).

AND…

Phonological Abilities• Comparisons of children who recover

from, and persist in, stuttering show that the persistent group are more likely to achieve poorer scores across a number of tests of phonological proficiency (Paden and Yairi, 1996; Paden, Yairi and Ambrose, 1999; Paden, 2005).

Phonological Abilities

• Some children who stutter may exhibit developmental asynchronies (Watkins, Yairi and Ambrose, 1999; Watkins, 2005), perhaps contributing to a lower threshold for perturbation or disruption.

FURTHER…

Phonological Abilities• Children who stutter who have age-

appropriate phonology and speech articulation are more likely to experience a positive therapy outcome that is attained relatively quickly.

• Young children close to onset with no co-occurring phonological problems are more likely to experience unassisted recovery.

PARENT STRENGTHS

• “Signature Strengths”

• Congruence

• Able to Shift the Parenting Perspective

• There are human strengths that act as buffers against mental illness: courage, future-mindedness, optimism, interpersonal skill, faith, work ethic, hope, honesty, perseverance, the capacity for flow and insight, to name several.

(www.authentichappiness.org)


Emotional Responses

• Parents will often have an emotional response(s) to their child’s stuttering.

• Emotions are important to uncover as they can influence the way parents cope with the child and his stuttering.

Emotional Responses

• Grief• Feelings of inadequacy• Anger• Guilt• Feelings of vulnerability• Feelings of confusion

Coping Strategies

• Fight or Flight• Modification• Reframing• Stress Reduction

Coping: A Wellness Perspective(Holland, 2007)

• Positive Psychology is the study of strength and virtue. Treatment is not just fixing what is broken; it is nurturing what is best.

• Positive Psychology does not rely on wishful

thinking, faith, self-deception, fads, or hand-waving; it tries to adapt what is best in the scientific method to the unique problems that human behavior presents.

• There are human strengths that act as buffers against mental illness: courage, future-mindedness, optimism, interpersonal skill, faith, work ethic, hope, honesty, perseverance, the capacity for flow and insight, to name several.

(www.authentichappiness.org)


Congruence

• Congruence helps parents to respond to a situation with both intellect (rational intelligence) and emotion.

• An idealized situation that is difficult to attain.

• As people, we all need to work continually to attain congruence; as clinicians, we want to help our clients to attain it.

• Different styles of internal organization- high or low in intellect- high or low in affect

• High intellect: focus on facts; deny or repress emotions

• High affect: difficulty in processing information

• We want to help a parent who is intellectually oriented to gain access to and express feelings

• We want to help a parent who is affect oriented to express feelings so he/she can begin to process information

Counseling Microskills (Ivey, 1994)

• Specific communication skills that help clinicians interact more intentionally with clients

• Microskills form the foundation of interviewing and obtaining information in all interactions

Counselor Response: Determining the Course of the Interaction

• Content response

• Counterquestion

• Affect response

• Reframing

Counselor Response: Determining the Course of the Interaction

• Sharing self

• Affirmation

• High affectlisten and value, recognizing

they have options, focus on process, relaxation, stay in the now, give assignments to bind up anxiety

• High intellect microskills to recognize feelings

Able to Shift the Parenting Perspective

• “Fix” or “force” vs. “ally and advocate”

• Refocus comes about through:- planned communication- objective understanding- active acceptance

THERAPEUTIC RELATIONSHIP

• Characteristics of clinician that facilitate change

• Child and Family Education and Preparation

• Attending to the Child’s and Parent’s “Theory of Change”

Attributes and Behaviors of the Counselor That Facilitate Listening and

Valuing

• Client-centered• Accepting• Concerned and empathetic• Relaxed and calm• Does not interfere or impede• Does not judge• Does not suggest or give answers

• Does not deny feelings• Absence of self-focus – paralysis vs. oblivion• No noticeable disinterest• Tolerates silence• Avoids superficial content• Appropriate topic change• Listens and attends• Appropriately reinforcing

• Generates warmth and trust• Tolerates crying• Accepts emotional language

(adopted from Luterman, 2001; Shames, 2000)

Child and Family Education and Preparation

• Limited understanding of clinical process OR mismatch between child and family expectations and realities encountered leads to poor therapeutic relationship

AND

• Puts child and family at greater risk for dropping out of therapy


• Child and family will respond positively to treatment when engaged in an exploration of various topics, including:

- nature of stuttering- contemporary theories of etiology- why children come for therapy- the general structure of therapy- some specifics of behavior change


- what will be taught and why- the importance of active participation- self-expression- trust and confidentiality- child, parent and clinician roles and responsibilities - examples of positive outcomes and how they were achieved


Coleman, D. & Kaplan, M. (1990). Effects of pretherapy video preparation on child therapy outcomes. Professional Psychology: Research and Practice, 21(3), 199-203.

Attending to the Child’s and Parent’s “Theory of Change”

“Within the client is a theory of change waiting for discovery, a frame-work for

intervention to be unfolded and accommodated for a successful outcome”

(Hubble, Duncan & Miller, 1999)


• What ideas do you have about what needs to happen for improvement to occur?

• Often people have a hunch about what is causing a problem, and also how they can resolve it. Do you have a theory of how change is going to happen here?

• In what ways do you see me and this process helpful in attaining your goals?

- Hubble, Duncan & Miller, 1999


• How does change usually happen in your life?

• What do you do to initiate change?

• What have you tried to help with stuttering so far? Did it help? How did it help? Why didn’t it help?

- Hubble, Duncan & Miller, 1999


• Each client and family presents the clinician with a new theory to learn and a new, client-directed intervention to suggest.

• Research in psychotherapy has shown that what the client and family want from treatment, how these goals are accomplished , and their perception of improvement may be the most important factors in therapy.

HOPE or EXPECTANCY

• Pathways Thinking

• Agency Thinking

• “Expectancy Theory”

Hope or Expectancy

The positive emotion that stems from the ability to successfully engage in both pathways and agency thinking is the

essence of hope. Hope is not a purely emotional phenomenon; it is an emotional

response that is rooted in cognition.

- Barnum, Snyder, Rapoff, Mani & Thompson, 1998).

Hope or Expectancy

• “Expectancy Theory” – With hope for change comes expectancy that change can and will take place. An individual’s belief that a certain treatment will yield a certain effect either triggers or correlates to that effect.

• Expectancy Theory has long been used to explain the placebo effect in medicine.

Hope or Expectancy

Stuttering Therapy for Children: What Makes Therapy Work?

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