2003 IFA Congress: Montreal, Canada

Group Therapy for School-Aged Children Who Stutter and Their Parents

Suzana Jelcic Jaksic1 and Mirjana Lasan2
1Croatian Association for People Who Stutter “Hinko F rennd ” and Zagreb Children’s Hospital, Klaiceva 16, 10000 Zagreb, Croatia
2Croatian Association for People Who Stutter “Hinko Freund” Klaiceva 16, 10000 Zagreb, Croatia

SUMMARY

This academic. year for the first time, The Croatian Association for People Who Stutter “Hinko Freund,” organized group therapy for school-aged children and their parents. The intervention employed an integral therapy approach to stuttering. Eight boys and girls, ranging in age from 7-11 years, participated. The children met once a week for an hour at a time. Once monthly, at the same time as the children met, parents and/or other family members attended an organized education and group counselling program. Attendance at group therapy included identical pre- and post-therapy evaluations. The results of therapy and directions for the future are discussed.

  1. Introduction
In this paper we would like to introduce a new program from the Croatian Association for People Who Stutter “Hinko Freund”. The Association was established in 2000 as the first and only non-governmental and non-profit organization in this country for helping people who stutter, aiming to provide them with a better quality of life and communication. During the past two years the Association has organised self-help groups for people who stutter of all ages, including children from first to fourth grade of elementary school. Due to the need for a better realisation of the purpose of the Association and also because of the need to compensate for the limited opportunities for conducting stuttering therapy within the health and educational system in our country, we decided, from this academic year, to organise group therapy for a number of children. Because only a few professionals are employed in the health services and elementary schools. they are not able to provide a methodical therapy for most children who stutter or, especially, counselling for their parents. In addition, some professionals are not motivated or knowledgeable enough to deal with stuttering.

We consider that it is possible and necessary to work with children in the first grades of elementary school so that we can help prevent stuttering developing into a life-long handicap. The question which we have asked ourselves, as professionals and volunteers of the Association, was: could we, within the Association, help the children at elementary school who show signs of stuttering to prevent it becoming a bigger problem?

According to the above, our goals were: 1) to enable the children through group therapy to use techniques which will facilitate their speech; 2) to prevent development of negative attitudes toward their speech and their generalisation; 3) to educate parents about stuttering in order to make them feel more competent in everyday communication with their child, and 4) to help them accept their own feelings about the child’s dysfluency.

  1. Methods
2.1 Group Organisation

Whilst being aware of the advantages and disadvantages of group therapy as a method which enables the clinician to treat dysfluencies more effectively with some children (Stewart & Tumbull, 1995), we decided to inform parents of all reachable children from seven to eleven years old who stutter about the new program. Some of the children were on the waiting list for therapy in the Children’s hospital in Zagreb for more than a year. The other children attended a pre-school group of the Association last year which provided education and counselling for parents. So, the children we are discussing are those who for more than a year had not had the opportunity to attend individual therapy, which is a typical approach in our country for children who show symptoms of stuttering.

From 15 invitation letters which were sent to parents, seven of them responded - one eight years old girl and six boys, seven, eight and ten years old. Although we were acquainted with the importance of the aims, composition and size in organising groups, in order to ensure commonality of needs, compatibility and stability as well as group vitality (Stewart & Turnbull, 1995), the group finally consisted of all the children whose parents were interested in therapy.

The reason why we consciously avoided known roles and accepted all children was the length of the waiting list for therapy and the very limited number of volunteers within the Association. In a different situation, we would have children organised in two groups, taking more care of the compatibility of the attendants - their age, gender and personal characteristics.

2.2 Meetings and Accommodation

The group therapy for the children took place once a week for one hour and was led by one speech therapist who is a volunteer at the Association. At the same time, once a month there were organised education and counselling sessions for parents, also led by one of the speech therapist volunteers. Meetings with children and their parents were organised in the Children’s hospital in Zagreb, which is also the seat of the Association.

2.3 Description of the children

The_initial examination of the children was made by the speech therapist who would carry out the therapy. The examination included assessment of speech fluency: frequency of dysfluencies during conversation (Fl), average duration of the longest dysfluencies (D1) and concomitants (C1). To assess the attitudes of children toward their speech (CAT-Cl), we applied the Croatian version of the Communication Attitude Test (Brutten, 1985). One of the parents completed the Iowa scale of attitudes toward stuttering (IOWA 1). The initial data are shown in Table 1.

The boy I.K was seven years old and was included in group therapy after attending the pre- school group of the Association and previous individual therapy in which articulation problems and dysfluency were treated. He started to stutter when he was three years old. By speech assessment, a small number of dysfluencies, mostly the vowel prolongations that are short and transient, were identified. During dysfluencies he mostly blinked and helped himself by stopping and taking a loud breath in before a difficult word. There were no negative attitudes toward speech, in fact, the test results were below the average for boys who do not stutter (Jelcic Jaksic & Brestovci, 2000). The parents’ attitudes toward stuttering were moderate.

The girl M.P was eight years old. Last academic year she was included in the self-help group for younger elementary school children. The stuttering severity assessment showed severe stuttering. Duration of dysfluencies was up to three seconds and difficulties were mostly evident as repetitive prolongations of the first syllable. During those repetitions tension of extremities and the face, and avoiding eye contact were evident. Assessment showed very negative attitudes toward speech. Parents’ attitudes toward stuttering were positive.

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Table 1. Results of the initial examination of the speech fluency and attitudes toward speech

The boy P.Z. was eight years old. Stuttering first occurred when he was five years old. Speech therapy included enclosed stuttering and articulation therapy. Last year he also attended a self- help group for younger elementary school children. In the stuttering severity assessment moderate frequency of repetitions and prolongation was observed. Attitude testing showed mild negative attitudes toward speech.

The boy F.R., 10 years old, was included in group therapy after last year when he attended a self-help group for younger elementary school children. Also, for a shorter period of time he attended individual stuttering therapy in private practice. During stuttering severity assessment, dysfluencies such as repetitions and prolongations of severe frequency were identified. Duration of dysfluencies was about two seconds. Attitudes toward speech were mildly negative.

The boy A.M was 10 years old. He had not attended any kind of speech therapy earlier. With regard to stuttering severity, he showed frequent dysfluencies of one to two seconds duration. Attitudes toward speech were mildly negative. Parents’ attitudes were moderate.

The boy D.G was seven years old. The assessment of stuttering severity showed moderate stuttering, mostly sound prolongation and repetitions. Attitudes toward speech were very negative. Last year he also attended the pre-school group of the Association. Parents’ attitudes were positive.

The boy K.S. was ten years old. Until this time he had not been involved in speech therapy. Speech fluency assessment showed a moderate frequency of dysfluencies with duration of about one second. Attitudes toward speech were moderately negative. Parents’ attitudes were between positive and moderate.

  1. Therapy process
Every therapy session with children was divided into three parts. The first part of the session lasted about ten minutes, especially in the beginning, and it consisted of games which develop and strengthen confidence and acquaintance between group members. During a certain period of time that part of the session primarily consisted of a conversation about the news or about any interesting situation that had happened since the last meeting. The second part of the therapy session lasted about thirty minutes. During the first two months, the second part of the therapy consisted of learning breathing regulation and control techniques, smooth starts, practising light articulatory contacts and the difference between tensed and relaxed vowel articulation. After that we practised smooth articulation of words and phrases to extended and more complex utterances.

Even though through that part we concentrated on decreasing and eliminating fears and avoiding speech situations, in the last part of the session the emphasis was on conversation, and accepting and changing feelings and attitudes toward speech. That part of the therapy session was the most interesting to the children because they had an opportunity to talk about their thoughts, to share their experiences and to learn and accept similarities and differences. As one of the most interesting activities it is worth mentioning the creation of nursery songs about stuttering. The idea has been taken from the book “Sometimes I just stutter” by de Geus (1999). The conversation about what they read helped them to understand other children’s thoughts toward their speech and stuttering, what to do when somebody is teasing them etc. By the end of the academic year the group invented the name “Turtles” with the motto “ slow walk - you’1l achieve smooth talk “ and after that they painted the same slogan on their T-shirts.

During counselling sessions parents were encouraged first to express their observations of their child’s speech and reactions to speech difficulties. We had to get familiar with terms used in order to better understand their comments. Following their descriptions and questions, they were asked to demonstrate described behaviours and to express the sensations and feelings they themselves had in such situations. Some of them felt really uncomfortable during this task and some even refused to do it. Through the following sessions parents were taught to better notice and differentiate various kinds of dysfluent behaviours in their child’s speech, to notice fluent phases, positive and negative influences of certain events on the child’s fluency, and the effect speech disruptions have on their child. We tried to encourage them to talk with their child about their speech difficulties and their feelings related to them and also to make them see how important it is for the child to keep expressing their feelings and opinions, to communicate irrespective of his fluency level. An emphasis was also placed on the value of pointing out and encouraging the development of the child’s other talents in order to feel good about themselves in general (Turnbull & Stewart, 1996).

  1. Results
At the end of the academic year a final examination was carried out by the speech-therapist who led a group of parents. The examination of each child included assessment of speech fluency: frequency of dysfluencies during conversation (F2), average duration of the longest dysfluencies (D2) and concomitants (C2). To assess attitudes of children toward their speech (CAT-C2) and attitudes of parents toward stuttering (IOWA 2) the same tests that had been applied in the initial examination were used.

Final data for each child who attended group therapy are shown in Table 2. There it shows that we do not have final data for three children. Girl M.P. did not attend the final examination even after two invitations. In fact, she attended therapy very irregularly. The data from the initial examination shows that she had a poor image of herself and her speech compared to the other children in the group. The girl was unmotivated so maybe an individual approach might have worked better in her case. D.G. had dropped out of therapy after two months although other children elected him as leader of the group. Even though he initially showed negative attitudes toward speech, the reason why he dropped out could be explained by his father’s denial of stuttering and/or his fear that the boy would start to stutter more severely if he was in a group with other children who stutter. Boy K.S. also does not have final examination data. Although initial examination data showed a need for therapy, in agreement with his parents they dropped out because of the long distance between their home residence and the hospital where meetings were organised.

Table 2 also shows the data of final examination for girl A.R. who was seven years old. She was included in therapy two months after the group started. The speech-language pathologist who leads the group of pre-school children and their parents at the Association referred her to us. Last year the girl was a member of that group. Final data show a small number of dysfluencies which are transient, and mildly negative attitudes toward speech. As the youngest in the group she was often under big pressure, did not participate a lot and attended therapy very irregularly. Although we do not have her data when she joined this group, data from an examination when she was six years old shows that she was very timid, less sociable and more restrained, whereas she is now more willing to communicate and to openly share her experience.

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Table 2. Results offinal examination of speech fluency and attitudes toward speech

There were only four children that we did manage to collect data for from both assessments:

I.K. in the final examination did not show dysfluencies and secondary behaviours at all and as in the initial examination his attitudes toward speech were under the expected average for children who do not stutter. A reason for these results could be explained by his and his parent’s regularity in attending therapy process, but also as a result of interventions that he had had previously.

P.Z. in the final assessment showed a smaller number of dysfluencies and more positive attitudes in relation to the initial examination data.

According to initial data, F.R. showed improvement regarding speech fluency. His attitudes toward speech are still moderately negative. Those data could be explained by his higher ability and need to control his speech.

A.M. showed similar data to the previous boy and the explanation could also be very similar except this boy often showed anger during dysfluencies to which other children reacted with disapproval.

Although we are aware of the fact that the two speech therapists who did the assessments might have had different criteria in assessing speech dysfluencies, those children whose results between initial and final examination were compared showed an improvement in speech fluency.

Data concerning ‘attitudes toward speech vary from normal to moderately negative. Looking at overall scores, they do not seem to be significantly different or changed during the therapy process compared to the initial examination data. Only one boy (IK) showed normal attitudes in the final as well as in the initial examination. One boy (PZ) changed his attitudes in a positive direction and, according to overall scores, two boys changed their attitudes, becoming slightly more negative, whilst still staying in the same category. However, analysing children’s responses to specific test items more interesting changes can be noticed. 94 Theory, research and therapy in fluency disorders

The results of parents’ attitudes toward stuttering testing are insufficient. Parents of only two children had taken both, pre- and post-counselling tests. One of them showed positive and the other negative shift.

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Table 3. Number of visits

It is very likely that irregular attendance for therapy influenced the test results as well (Table 3). Even though parents were informed in writing as well as several times verbally about the importance of full attendance, only twenty-five of thirty-four planned therapy sessions were realised. Because of it, the therapy plan and program could not be accomplished completely. The child who gained the best test results in both assessments was also the most regular attendee of a group, but even his visits are not above twenty.

  1. Discussion
By the end of this academic year, we believe that we have succeeded in accomplishing most of our set goals. Although we could gather data for only a small number of children and their parents, we feel we have helped them to better cope with the problem of stuttering.

Even though children’s therapy attendance was not too regular, they all showed certain improvement in their fluency skills. We did manage partly to prevent the tendency for negative attitudes toward speech development in most of the group participants. Maybe some children would benefit more from individual therapy, or from a combination of individual and group therapy, or from more frequent sessions. We noticed that children care very much about the room in which therapy takes place. They want to arrange it their way, which was not possible this time.

T In our work with parents we feel we have changed a little. What is not mentioned above, and we consider it worth mentioning, is the attendance regularity of parents. They were asked to come in couples -- mothers and fathers together. They did not stick to this rule - as a matter of fact, some of the parents we had not seen even once. In fact, there were sessions with only two parents present and we could hold only four out of six sessions set because of their absence, so the education could not been provided systematically.

We could explain it with reference to the problem of parents’ attitudes towards stuttering, towards therapy within a non-government organisation and towards group therapy in general. No matter how many times during the sessions it was emphasised, we felt as if most of them were not aware of their role and the importance of their behaviour in the success of changes in their child’s communicative abilities. They were interested the most in the possible cause of stuttering, particularly in the case of their own child. They were rather surprised by the fact that their children showed signs of belonging and responsibility to the group and that they had given priority to attending therapy sessions when choosing between some other activities they could have participated in. Even close to the end of the therapy, when asked about their children, parents would talk about their child’s dysfluency rather then noticing other positive but subtle changes in behaviour.

We know there is a more time and effort needed to change someone’s attitudes, so we did not expect to make it during a few sessions. This only tells us that the work on parent education should be continued, so that their knowledge and attitudes become better and they feel more confident and comfortable in communication with their children.

In the future we will have to think of training and including more professionals in order to take more Care about group organisation with regard to the compatibility of members, frequency of therapy sessions as well as the accommodation in which the group will take place. We are aware that having a control group of children would have enabled us to better present our data and to evaluate the results of our work.

However, by starting group therapy for school-aged children within our Association we believe we have started a worthwhile action which will improve every year. Despite the above-mentioned disadvantages, according to our experience the continuation of group therapy is recommended. Working in groups can decrease anxiety and feelings of isolation, and also increase feelings of understanding and support for the same problem. Indeed, non-participation and avoidance of speaking situations and being put under pressure from friends in the group can give the child experience and practice in more realistic life situations.

References
De Geus, Eelco (1999). Sometimes I just stutter. Memphis: The Stuttering Foundation of America.

Jelcic Jaksic, S. & Brestovci, B. (2000). Speech-associated attitudes in children who stutter and in children who do not stutter. In H.-G. Bosshardt, J .S. Yaruss, &  Peters (Eds.), Fluency Disorders: Theory, Research, Treatment and Self-Help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark (pp. 598-604). Nijmegen: Nijmegen University Press. ,

Stewart, T. & Turnbull, J . (1995). Working with dysfluent children, Oxon: Winslow Press Limited.

Turnbull, J . & Stewart, T. (1996). Helping children cope with stamrnering. London: Sheldon Press.

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