Childhood stammering therapy has come under less scrutiny than adult stammering therapy from a social model perspective. In this blog, we want to look at how criticisms of the medical model, and the rise of the social model and neurodiversity, may challenge some clinical practices for childhood stammering therapy.
Childhood stammering therapy differs from adult stammering therapy in its approach and outcomes. Research has found that therapy can help children to stammer significantly less or even return to a fluent speech pattern.
“Evidence from randomised trials has shown that treatment before 6 years of age reduces the chance of stuttering becoming intractable.” (Onslow & Brian, 2011).1
Given this, most early childhood therapy, whether seeking to directly modify speech or to address multiple factors by changing the environment, aims to increase fluency as a central goal.2-4
This is, superficially at least, understandable. Society is filled with negative, stereotyped views of stammering, and these are often reflected in the views of the parents of children who stammer. Many parents attend their initial speech and language therapy appointment anxious about their child’s future: how will they manage in school; hold down a job; find a partner? They want the stammering to go away, with the belief that this is the only way that their child can live a successful and full life.
It is natural as a speech and language therapist to want to offer therapy that seeks to ease these concerns and they have evidence-based ways to directly meet them by working on a child’s fluency. But, is this the best thing to do for the child’s development?
It is our belief that before offering ‘fluency-orientated therapy’ we need to expose, discuss, and challenge the stigma that might be at the heart of the decisions made by parents, clinicians and wider society.
We need to question, at a deeper level, why we, as individuals, professionals, parents and society, desire fluency so much? To ask if it is the children who stammer who need therapy to become fluent to succeed, or whether it is us and our society as a whole which needs to become more accepting of human variation and difference?
Attention needs to be brought to the detrimental effects a narrow focus on fluency has on both the resilience of those children who will continue to stammer into adulthood and the societal stigma around stammering.
Why should we be concerned about a focus on fluency?
A traditional medical model approach to assessment and therapy for children who are stammering generally focuses on stammering being a condition that is ‘abnormal’ or ‘disordered’ and which needs remedying or reducing.
Assessment often takes account of the ‘severity’ or ‘struggle’ of a child’s stammering and therapy aims to reduce this. The presumption is that the stammer is the problem, thus if the stammering is eradicated or diminished, the child will be fine again. This, however, is a simplistic and reductive approach to stammering. In our next article, we will discuss how we feel the social model and neurodiversity offer more nuanced and empowering ways to understand stammering.
For us, one of the problems of the medical model approach is that it reinforces stigmatising views and does not foster accepting attitudes to diversity and disability. The problem, we feel, lies with societal attitudes, beliefs and behaviours towards stammering that exist around the child who stammers rather than the stammering itself.
Speech and language therapists may try to challenge negative parental attitudes and beliefs towards stammering before offering therapy. We believe, however, that maintaining ‘it is okay to stammer’, whilst offering children and parents a therapy that has reducing stammering as a central goal, asks child, family and therapist to engage in some significant cognitive dissonance over whether it is, in truth, ‘okay to stammer’.
Effect on the individual
One worrying aspect of this medical model ‘fix it’ approach is the effect on the psychological well-being, behaviour and resilience of children who stammer into adulthood.
It is perhaps easiest to understand the possibility of therapy deepening shame around stammering with direct approaches that look to modify speech. In the Lidcombe programme, for example, fluent speech is praised and stammered speech is gently asked to be tried again. Thus, from an early age therapy is re-enforcing fluency as the preferred way to speak to both the child and family.
Indirect approaches, however, can also affect how a child who stammer grows to feel about their speech. Indirect approaches attempt to control linguistic, environmental and psychological factors that can affect stammering; the child’s world is shaped to avoid and modify a multitude of variables that may lead to more stammering. We wonder if these approaches are inhibiting children’s life experience by parents, unconsciously or consciously, ‘controlling’ who with, where, when and how they want their children to speak? Does this begin to set in motion a path to children and their family looking to avoid environments they might stammer in?
While some children who stammer become more fluent through both of these therapies, others do not. Once the ‘window of opportunity’ for return to fluency has passed, the goal posts are typically changed. Young people and their families, who have previously been given strategies and techniques to reduce stammering, are then encouraged to become more accepting of stammering and learn to ‘manage’ it.
Anecdotes amongst the stammering community suggest that going through therapy that seeks to modify or stop stammering in children may lead to long-term, negative psychological effects on those who stammer into adulthood.5 However, there is a lack of research into the damage that inhibiting stammering in childhood can have on adults who stammer and wider society.
From our point-of-view, the same young people who have traditional therapy informed by the medical model are more likely to be referred for speech and language therapy as adults. Only now their stammer is hidden under a layer shame. Therapy becomes a delicate process (on both sides of the therapeutic relationship) of firstly facilitating and allowing stammering; to encourage the person to stammer naturally and openly when they fear and feel shame to do so.
Not enough consideration is currently given to the negativity associated with stammering and the impact this has on young people, especially regarding the effect it has on individual therapy choices or life choices for them in the future.
Effect on society
There is also an ethical argument to be had against providing a therapy where the primary aim is to reduce or ‘cure’ stammering. A significant proportion of difficulties in life associated with stammering come from the societal stigma attached to it rather than the physical difference in speaking. This societal stigma comes from the ingrained belief that stammering is ‘deviant’ and ‘wrong’; that stammering is undesirable and a marker of individual weakness or anxiety.
If stigma in society is indeed the primary problem for people who stammer, then arguably speech and language therapists offering therapies that aim to ‘cure’ or reduce stammering are complicit in this unhelpful societal narrative. Also, if these therapies do facilitate fluency for children do they not then lead to a loss of potential advocates for stammering in the future?
‘Fluency-orientated therapy’ may indeed enable a few children who stammer to regain fluency, but at what cost to the children who stammer into adulthood? Are we winning the battle with a single child in-front of us, but sacrificing the war to societal stigma?
Recent and compelling research now confirms that stammering has a primary neurological basis.6 Furthermore, research has found differences in ‘severity’ of stammering between children may be due to individual differences at a neurological level – reduced blood flow in Broca’s area, a part of the brain linked to speech processing.7 This new knowledge aligns stammering with other neurological differences, such as autism and dyslexia, which are increasingly being seen as a natural spectrum of human variation rather than ‘defects’.
If we begin to see children who stammer as having unique neurology rather than ‘pathology’, a new form of therapy emerges; one in which understanding and acceptance of stammering by society is the crucial factor. Focussing on reducing what is perceived as ‘severe’ stammering in individuals for whom that way of speaking is ‘natural’ also becomes, dare we argue, unethical.
Patrick Campbell & Kathryn Bond
- O’Brian S. & Onslow M. (2011) Clinical management of stuttering in children and adults. BMJ. 342: d3742. Available: https://www.bmj.com/bmj/section-pdf/187269?path=/bmj/343/7813/Clinical_Review.full.pdf
- Jones M., Onslow M., Packman A., Williams S., Ormond T., Schwarz I. et al. (2005) Randomised controlled trial of the Lidcombe programme of early stuttering intervention. BMJ. British Medical Journal Publishing Group. 331: 659.
- Millard S.K., Zebrowski P., Kelman E. (2018) Palin Parent–Child Interaction Therapy: The Bigger Picture. Am J Speech Lang Pathol. American Speech-Language-Hearing Association. Available: https://ajslp.pubs.asha.org/article.aspx?articleid=2709702
- De Sonneville-Koedoot C., Stolk E., Rietveld T., Franken M-C. (2015) Direct versus Indirect Treatment for Preschool Children who Stutter: The RESTART Randomized Trial. PLoS One. 10: e0133758.
- Holte D.L. (2011) Voice Unearthed: Hope, Help and a Wake-Up Call for the Parents of Children Who Stutter. BookBaby.
- Chang S-E., Zhu D.C., Choo A.L., Angstadt M. (2015) White matter neuroanatomical differences in young children who stutter. Brain. 138: 694–711.
- Desai J., Huo Y., Wang Z., Bansal R., Williams S.C.R., Lythgoe D. et al. (2017) Reduced perfusion in Broca’s area in developmental stuttering. Hum Brain Mapp. 38: 1865–1874.