2003 IFA Congress: Montreal, Canada

Stuttering Therapy in The Schools: Focus Groups With School Clinicians

John A. Tetnowski, Jack S. Damico, & Jennifer T. Tetnowski
University Of Louisiana at Lafayette, P.O. Box 431 70, Lafayette, LA 70504-3170 USA

SUMMARY

Past research has shown that speech-language pathologists lack confidence when working with people who stutter (Brisk, Healey, & Hux, 1997; St. Louis, & Lass, 1981). These data comes primarily from survey, or anecdotal evidence, without in-depth analysis of the causes for this attitude. This study presents results from a series of focus groups with public school clinicians that treat PWS. Results show that clinicians perceive barriers to successful therapy. These barriers include stuttering-specific reasons, such as small incidence of PWS on their caseloads or poor training, as well as organizational-specific reasons, such as lack of flexibility in scheduling and uncooperative teachers.

  1. Introduction
It has been documented in the literature that speech-language pathologists do not feel confident when working with people who stutter (Brisk et a1., 1997; St. Louis, & Lass, 1981). Despite the lack of confidence, speech-language pathologists continue to treat people who stutter in the schools. A recent publication summarized the problems that must be dealt with when managing fluency problems in the public schools (Ryan & Ryan, 2002). Among these problems are the need for large group sessions to satisfy caseload requirements, lack of sufficient time in therapy due to extensive paperwork requirements, and lack of continuity in therapy due to the limited school year. Despite this anecdotal evidence that accentuates the problems of efficacious treatment in the schools for people who stutter, little systematic research has been completed that examines what factors actually add to these difficulties.

As stated previously, much of the previous research cites a lack of confidence by speech- language pathologists when treating people who stutter. This evidence comes from either surveys or anecdotal evidence. These strategies are certainly sufficient for collecting a description of the problem. However, a more in-depth analysis is required to get to the heart of the problem. For this reason, a focus group strategy was chosen as the appropriate methodology for gaining greater insight into this issue (Fontana & Frey,1994; Morgan, 1988).

  1. Methods
In order to gather in-depth interview information related to the problems with treating stuttering in the public schools, several focus groups were conducted. The groups consisted of public school clinicians in the Lafayette, Louisiana area. A brief survey of the public school clinicians revealed that the clinicians had received their education from several different university training institutions, and had been practicing speech-language pathology for between 2 and 25 years. All speech-language pathologists held ASHA’s Certificate of Clinical Competence and held a current state license. None of the clinicians held specialist status based upon ASHA’s specialty recognition program. In addition, each clinician had at least one “ï uency” client on their caseload that has been enrolled in therapy for stuttering (and has not been dismissed from therapy for meeting their therapy goals) for at least two years.

The focus groups were held in a seminar room on a university campus. All of the participants were volunteers. The list of names was generated by a questionnaire sent to all of the speech- language pathologists in the district by their supervisor. This brief questionnaire simply asked clinicians if they had any fluency cases on their caseload, and if they were interested in a follow-up group meeting. The volunteers were contacted by telephone by the first author, and asked to take part in a focus group. The volunteers received no pay for their time, but did receive meal as compensation for their time. In addition, all clinicians in the district received an opportunity to receive free tuition for a stuttering workshop in exchange for their time. A total of 11 clinicians attended a series of two focus groups (16 clinicians were invited, therefore this group was 68.7% of the total number of clinicians invited) . The focus groups lasted between 55 and 90 minutes. Both focus groups were audio recorded on a Marantz tape recorder using a Shure multi-directional microphone. The audiotape was then cyclically reviewed by the authors and transcribed as needed.

  1. Results
During the first focus group, the clinicians were asked whether they felt comfortable with treating clients that stutter. Responses were similar to those obtained by Brisk et al., 1997, with approximately 50% of the focus group members stating that they felt comfortable when treating school-age children who stutter. Reasons given for why clinicians felt comfortable in treating fluency clients included:
  • I received good training in this area
  • I really like working with stutterer_s
  • I read the journals and attend workshops in this area
Reasons given for why clinicians did not feel comfortable working with fluency cases (in general) included:
  • I don’t really like working with people who stutter
  • I don’t know enough to be successful
  • They make up such a small part of my caseload, I don’t have time to learn more
  • Someone else in the district likes to work with stutterers, so I send them all to her 0 There are so many variables to be considered (emotional, as well as physical)
  • Conflicting reports and unclear information from parents
  • Conflicting reports from journals versus “popular suggestions”
  • Inadequate training as graduate students
In addition, results from the first focus group also indicated that there were some barriers to treating fluency, specifically in the schools (rather than treating fluency disorders in general). These specific included:
  • A lack of time to see clients individually
  • A lack of flexibility in scheduling clients as needed
  • Lack of support from teachers
  • Lack of support from parents
  • Lack of funding
It should be noted that lack of flexibility (due to times when clinicians could not get clients for therapy was considered to be a much larger barrier than purely caseload size). The restrictions placed on clinicians included the inability to schedule fluency clients on specific days (due to school or teacher policy), and the inability to schedule clients at specific times (due to school district policy that forbids taking students out of specific courses, like reading, math, or physical education). These restrictions were complicated by matching available “time slots” with client availability. That is, the clinicians could schedule a client at the time that they needed, but the constraints were complicated by the remainder of the caseload needing those same times.

Following completion of the first focus group, it was decided that the goals of the second focus group should focus on potential solutions for the barriers to successful treatment that were outlined by the clinicians during the initial focus group. Clinicians at the first focus group noted that “prioritizing of clients” or “prioritizing of clinician interest” can be barriers to successful treatment of stuttering in the public schools. One clinician noted, “. . .with all the clients I need to see, I can’t be an expert at everything. Therefore, I treat best what I like doing best. . ..and it’s not stuttering.” Another clinician noted, “. . .there are so few of them (people who stutter) on my caseload, that I just can’t spend my time learning about stuttering.” Based upon these initial findings, the mediator also attempted to get the clinicians to talk about some potential strategies that could help them become more successful in treating their fluency-disordered clients in the schools.

The second focus group brought about discussion indicating that clinicians have some good ideas to help them become more successful in treating fluency cases. Some of the possible strategies to generate higher success levels included:
  • Formation of a monthly “support” group in a school with mixed age groups
  • Better grouping of cases
  • Working in tandem with other speech-language pathologists (this step would include
  • finding “experts”, and getting district permission for these experts to assist other clinicians during work hours)
  • Getting assistance from support staff (counselors, etc.)
  • Increased education opportunities
A second discussion centered on finding out what skills would help the school-based speech language pathologist become more successful in treating fluency-disordered cases. These suggestions were grouped into what we refer to as “disorder group” suggestions, and “general” suggestions. That is, the “disorder group” suggestions would help the clinicians specifically with fluency-disordered children, while the “genera” suggestions would help with school-based and administrative issues that apply to their entire caseload. The “disorder group” suggestions included:
  • Learning and implementing multi-modality treatment schemes (i.e., treating the entire person, building self-esteem, controlling emotions, and implementing counseling strategies)
  • Setting up groups for children who stutter (so that older students could help younger students cope with stuttering)
  • Beginning parent support groups that offer information to parents
  • Beginning area wide focus groups to share ideas with other clinicians
  • Generating a handbook (and other tools) that would help “tell teachers what to do” with their fluency cases in the classroom
  • Getting more training from experts that includes demonstrations of actual therapy techniques with real students
Finally, the second focus group generated “general” ideas that could help alleviate administrative and school-based problems while working with fluency-disordered children in the schools. Among the possible solutions discussed were:
  • Getting the trust of the faculty at your site
  • Getting the trust of the parents _
  • Getting more “hands-on” training (specifically training that included more group therapy strategies and more training that included viewing examples of real therapy
  • Starting a “mentoring program” for beginning clinicians (from more senior clinicians; this could help with scheduling issues and learning how to work successfully within district policy)
  • Learning to manage time
  • Eliminating scheduling restrictions (reading block, math block, etc)
  • Gaining access to more equipment (video equipment for feedback, computers for ease in paper work, and fluency enhancing tools like DAF)
It is interesting to note that many of the strategies to generate higher success levels correspond with the “disorder group” suggestions, and “general” suggestions outlined above._

  1. Summary and Conclusions
The results of these focus group meetings indicated that many speech-language pathologists still feel uncomfortable with treating school-age people who stutter. Focus group discussion indicated that there are indeed many barriers to successful treatment for children who stutter; some of these barriers appear to administrative and logistical, creating general problems that are not necessarily related to treating fluency disorders. However, some barriers are related specifically to just fluency-disordered cases.

It also appears that at least some of these barriers are by choice. That is, clinicians place less emphasis on improving skills in stuttering therapy because of their relatively low numbers on their caseloads, or limited interest in this area. This small percentage of fluency cases on their caseload can lead to apathy when trying to improve skills for treating schoo1s-age people who stutter. Discussion by the clinicians also revealed that there were limited opportunities to learn more about stuttering treatment in their geographic area, and that past stuttering workshops did not always meet their needs (too much focus on diagnosis rather than treatment; theory rather than practice; and individual versus group therapy strategies).

Discussion of possible solutions included some very specific recommendations. Pinpointing experts to “consult with” was a definite theme. ASHA’s Specialty Board on Fluency Disorders (SBFD) appears to be moving in the right direction, however, not a single clinician in the district holds specialty recognition in fluency disorders. As a matter of fact, a review of the SBFD database revealed only five clinicians in the entire state of Louisiana hold specialist recognition (SBDF, 2003). In addition, it is apparent that a different model that allows for sharing of resources would have to be implemented in order to make maximum use of recognized specialists.

Finally, we should all take notice of the shortfalls that are highlighted by clinicians with current in-service training sessions. Strategies like focus groups can outline the needs of the clinicians that are actually serving the fluency-disordered population.

References
Brisk, D.J., Healey, E.C., & Hux, K.A. (1997). Clinicians’ training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in Schools, 28, 164-176.

Fontana, A. & Frey, J.H. (1994). Interviewing: The art of science. In N.K. Denzin & Y.S. Lincoln (Eds.) Handbook of Qualitative Research (pp. 361-377) Newbury Park, CA: Sage Publications. _

Morgan, D.L. (1988). Focus groups as Qualitative Research. Newbury Park, CA; Sage Publications.

Ryan, B.P., & Ryan, B.V. (2002). Can effective treatment for stuttering be accomplished in the public schools? Perspectives on Fluency and Fluency Disorders, 12, 14-17.

Specialty Board on Fluency Disorders (2003, July 21). Initial Cadre of Fluency Specialists. Retrieved August 11, 2003 from http://www.ausp.memphis.edu/sbfd/materials/specialists.pdf

St. Louis, K.O., & Lass, NJ. (1981). A survey of communicative disorders students’ attitudes toward stuttering. Journal of Fluency Disorders, 7, 49-79.

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