When we turn to indirect models for the treatment of preschool stuttering (Palin PCI, Demands-and-Capacities, RESTART), we often imagine the child in question in passive terms. We think of him as a victim of a high-stress speech environment, right? Grown-ups are peppering him with too many questions. Siblings are interrupting him. He’s got no time to respond. No one’s following his lead in play. In fact, when we list the environmental factors we tend to target first in indirect treatment protocols—a too-fast rate of speech, say, or a dinner-table culture of cross-talk and competition—it seems like a bunch of stuff that can happen to a child. A list of speech no-no’s, perpetrated by others in the family. The CWS is just a bystander.
We correctly view the conversational space as a first-site of intervention. But it's usually only the parents we ask to alter their interaction style. We don't ask the child to change anything about his speech. That's what makes it indirect, right?
Well, what if it's the child himself who is creating the stressful conversational vibe?
In my years specializing in pre-school stuttering—which requires a distinctively different approach from older kids and adults—I’d say that, for every one timid kid I meet who’s getting bulldozed by a too-hectic speech environment, I see three other kids who….well, who are doing the bulldozing.
It's the quintessential gift of gab. And as stuttering specialists, we love it, right? Look at this kid's communication confidence! Just think of all the adult clients we’ve steered toward improv classes, or Toastmasters, trying to generate the same charisma.
But this gift of gab often comes with a very practical downside: It creates an internal time-pressure, an urgency to win that stage time, to grab the microphone before anyone else does, and—above all—to hold the floor so no one else can take the spotlight. I call these the “Hold the Floor” kids. Each of their excited utterances is a mini filibuster, a verbal control tactic to win and keep attention, one that relies on keeping that voice going—and going and going and going. Their overt stuttering behaviors manifest as rapid first-sound repetitions, often at the very beginning of an utterance. These increase in frequency and in duration as the child’s MLU (length of utterance) expands from 5 to 10...from 10 to 20...from 20 to 30. Rate of speech tends to grow as the sentences do. Maybe irregular breathing patterns emerge, as the child struggles to finish his performance. The parents—well coached by their SLP and hyper aware of stuttering etiquette—hold eye contact and practice full listening. They keep quiet and wait. And wait. And wait.
The parents, as communication partners, have absorbed the lessons of indirect therapy. They've altered their pragmatics, dialing down the demands they are placing on their child. But it takes two to tango. And what indirect approaches to therapy so often miss is the child's role in contributing to the family's conversational space.
For these kids, we want to go after that potent combo of pausing and turn-taking. But we also don’t want to dampen the child’s enthusiasm for speaking and expressing. So how do we effectively break up these conversational sprints and work some resting space into their speech? Well, we can directly target the child's social communication skills as a means of indirectly improving fluency.
Here’s what we do:
It's Bingo with a Zing! But it's also a game that has polite, patient conversational etiquette baked right into the play.
The CWS gets to be the caller. Parents and siblings take Zingo cards but make a BIG DEAL out of the fact that they are going to remain quiet and really listen to the Zingo caller, so as to be sure they don't miss out on collecting a token. The CWS retains center-of-attention status while being required, by the game, to practice pausing—it takes about two seconds to click the Zingo machine—and explicit turn-taking
(Perfect for Zoom)
SLP and child both set out to draw the same robot on a pad of paper. But it's the CWS who gets to decide what it looks like. The SLP makes a BIG DEAL out of the fact that he is going to listen carefully to the instructions, so he can get the drawing just right. The child gives simple, one-step directions for the design: “Make a big square for the body,” “The head is an upside-down triangle.” The SLP might coach the CWS to "wait until we both look up from our paper" before giving the following instruction. Both the SLP and CWS each create a robot. After the drawings are complete, SLP and child hold up their drawings, amazed at how different they are.
The SLP and CWS play Guess Who?, but with one important modification: Instead of burdening the child with the job of coming up with strategic questions—which may be linguistically too taxing—the SLP introduces cards that each list one attribute of a Guess Who face (hat, facial hair, hair color, glasses, etc.) On each turn, the player draws a card and uses that as the basis for his question.
Eventually, the CWS will settle into a rhythm of pausing and turn-taking, one based on the very specific pace of gameplay. The child now has a context and a model for a set of social rules governing speaking—one that might differ from the spontaneous or rushed speech environment that has developed in the home. And so the seeds have been sown for a type of pragmatic code-switching: When we want to be very careful about having our messages heard, we need to use lots of pausing and observe turn-taking, checking in with our eyeballs to see if the other person is ready to continue. But when we're at home having fun...we can let loose! Both are totally great ways of talking! And you get to choose which style you want to use.
By injecting just a little bit of direct, social communication-coaching into our stuttering intervention, we can give kids something pro-active that they can do to make talking a little bit easier.
The American Institute for Stuttering is a leading non-profit organization whose primary mission is to provide universally affordable, state-of-the-art speech therapy to people of all ages who stutter, guidance to their families, and much-needed clinical training to speech professionals wishing to gain expertise in stuttering. Offices are located in New York, NY, Atlanta, GA, and Minneapolis, MN, and services are also available online. Our mission extends to advancing public and scholarly understanding of this often misunderstood disorder.
Photo by Moses Vega on Unsplash