The deeper my understanding of stuttering grows, the more I understand the crucial role parents and caregivers play in the quality of life of children who stutter. This understanding has also sharpened my focus on the direct role of the speech-language therapist in equipping parents and caregivers. As a result, I’ve begun to question the traditional dichotomy between direct versus indirect treatment in stuttering for young children who stutter.
SLPs are uniquely qualified to promote the well-being of children who stutter by guiding caregivers to cultivate healthy communication environments at home. In a recent conversation with a colleague discussing my implementation of Palin Parent-Child Interaction Therapy (Palin PCI) with young children who stutter, I emphasized its value in helping families explore their inherent strengths and identify what contributes to healthy communication and well-being in their homes. For those unfamiliar with Palin PCI, the approach utilizes video feedback to help caregivers recognize their natural strengths and increase these positive behaviors during interactions with their children. Through this process of self-discovery, caregivers might notice they naturally use more pauses while speaking, naturally leading to a comfortable and unhurried speaking pace. Or they might notice they naturally listen attentively to their child with minimal interruptions. Similarly, though identifying less helpful behaviors are not the focus of this approach, caregivers might also discover less beneficial tendencies, such as frequent interruptions or rushed transitions, that don’t contribute to positive communicative interactions. They may choose to work toward minimizing these tendencies to actively develop new strengths that enhance their communication with their child, whether or not they continue to stutter.
During this discussion, my colleague commented that her families tend to seek a more “direct approach” to treatment, questioning whether they would respond to what she viewed as a more “indirect approach.” I left that conversation puzzled and a bit rattled because family-centered treatment IS direct treatment! I believe a caregiver-directed approach is direct intervention at the most fundamental and powerful level. How could we not consider it a direct approach when we're fostering positive changes in caregiver behaviors that positively impact the child - especially given that caregivers are the most influential and constant adult presence in a child’s life?
The Oxford dictionary defines indirect as “not directly caused by or resulting from something,” however, the intentionality evidenced by caregivers engaging in active environmental and/or interaction strategies (focused on themselves and the communication environment, not on the child stuttering less) absolutely results in positive communication changes in the home, so can we stop calling family-centered, family-directed treatment indirect treatment? ASHA defines direct care as “evaluation, treatment, or counseling completed in the presence of an individual and/or their caregivers.” Bottom line: The face-to-face, personal, and firsthand engagement of caregivers in the therapeutic process, where they focus on their growth and improving the environment, is direct treatment. Furthermore, reduced parental anxiety and worry are often the first observable signs of progress (Miller, 2018), so caregiver education, support, and empowerment are critical components of effective treatment.
Allow me to offer a few examples of intentional environmental and interaction strategies that promote healthy communication environments at home and the classroom for children who stutter. For therapists, parents and caregivers, and teachers, these might be:
Making Space for Children Who Stutter - This might be using a talking stick to give the floor to a child who may not easily achieve entrance into a conversation or discussion. It could also be a verbal cue such as, “I think Johnny has something to say…” or “Go ahead Johnny, I’m listening…” or “It’s Johnny’s turn to share…”
Holding Space for Children Who Stutter - Holding space goes hand-in-hand with making space for children to speak, and it may involve physical or verbal cues to allow time for a child to finish. It could be a simple hand gesture signaling “wait” or “hold on” or a verbal cue such as, “Johnny is not finished…” or “It’s still Johnny’s talking turn…” or “Please wait for your turn…” or “I’m listening to Johnny’s voice right now…”
Modeling Unhurried Transitions - Whether it be transitioning from one topic to another, from one conversational partner to another, or from one activity to another, rushed transitions generally create time pressure. Time pressure may contribute to competition for talking time and/or pressure to speak quickly (i.e., “spit it out”), which may exacerbate stuttering.
Open-Ended Prompting - Open-ended prompting or non-question starters in conversational turns, such as “I wonder..., I bet..., I noticed…, Tell me more…,” lend themselves to a more relaxed and inviting communicative exchange, where there’s less pressure to generate answers quickly, precisely, or on the spot.
Taking Time to Respond - Modeling “thinking” and non-immediate responses provides the child an example of taking time to respond without impulsivity or rushing.
Listening Attentively - Children know when the adults in their lives are physically present while cognitively or emotionally absent. Remove or lessen distractions when engaging with your child and demonstrate attentive listening through your words, actions, and body language.
Valuing the Message - We can demonstrate valuing the message rather than the form (i.e., way of talking) by actively listening to children, whether or not they’re stuttering. We can fill in the gaps of time with patience and simply listen without rushing or interrupting. This may also mean verbally acknowledging to the child who struggled to get their words out, “That seemed hard but I'm so glad you told me anyway…” or validating the child who might be likely to give up and stop talking, “I'm so glad you finished and told me that story…”
Across all these strategies, the resounding message for children who stutter is KEEP TALKING!
Millard, S. K., Zebrowski, P., & Kelman, E. (2018). Palin parent-child interaction therapy: The bigger picture. American Journal of Speech-Language Pathology, 27(3S), 1211–1223. https://doi.org/10.1044/2018_AJSLP-ODC11-17-0199
Spero Stuttering, Inc. (2024, May 18). Nurturing and empowering your child who stutters [Video]. Youtube. https://youtu.be/GPjKPYUB9qw
