2003 IFA Congress: Montreal, Canada

Facilitating Treatment of Stuttering in Children and Adolescents

Hermann Christmann
The Association for Stutterers In Denmark, Kloverprisvej I 0 B, 2650 Hvidovre, Denmark


Treatment of stuttering in children in Denmark is carried out in municipally based treatment sites within the school administrations, where Speech Language Pathologists are working with all kinds of speech and language impediments; none are working exclusively with stuttering. This paper reports the preliminary results of a project with the aim of developing models to enable small treatment sites to render a standing, consistent service of adequate quality to children who stutter. An important aspect of the project is to work on speech language therapists becoming familiar working with organizational matters in order to get the services explicitly embedded within the organization.

  1. Introduction
The present project is a spring off of the project presented at the IFA-Congress in 2000, where Christmann (1999, 2001a, 2001b) and Niclasen (2001) reported that treatment of stuttering in the municipally administered school system in Denmark is characterized by a volatile service that furthermore varies greatly from one municipality to another. Though organized and financed very differently from the Danish sites, the same kind of problems seem to exist in the National Health Service in the UK (Humphreys, 2002a). In both countries the service rendered Varies Very much dependent upon whether the Speech Language Therapists (SLT) in a given site are devoted to working with stuttering or not and of their level of competency in the treatment of stuttering. The managements of these settings seemingly have not accomplished setting up adequate frames for the professional staff enabling it to secure a consistent service characterized by an adequate level of quality. Based on these findings from two very different organizational set-ups one might assume that a considerable part of the problem is due to the small-sized and scattered treatment units with small staff numbers, the skills of which do not necessarily encompass all kinds of speech, language, and hearing impediments that, due to legislation, are mandatory topics of treatment for the sites.

In Denmark, each municipality has the authority to tax its citizens and has to a certain degree the authority to decide on its own service level dependent upon its political aims, priorities, and legislation. In other words, the municipalities have a high degree of political autonomy, which means, for example, that economic problems in a given municipality can hamper the carrying into effect of national legislation despite the fact that according to legislation it is mandatory to provide services for speech disorders, including stuttering. This kind of conflict is very difficult to handle because there are not really any sanctions against the municipalities for infringing the law.

  1. Stuttering as a low incidence phenomenon
The flaws reported by Christmann (1999, 2001a, 2001b) are: Non-sufficient basic training of therapists; A decentralized treatment system combined with a low-incidence (see Humphreys, 2002a) disorder tends to result in a non-sufficient on-the-job training; Problems recruiting specialists; No amassing, but rather a decrease of skills as compared to more centralized and bigger treatment sites; Sites are vulnerable to loss of knowledge and skills when qualified staff members are leaving for other jobs or going into retirement; The services rendered are based mainly on enthusiastic individuals, hence “system-embedded” rendering of service is virtually non-existing, which results in a volatile service. We cannot do without enthusiastic individuals, but they need systematical support and incentives from their managers and their workplace, their services thus being embedded in the system. Hence the idea arose of initiating a project based on the interaction of organizational, managerial, and educational conditions for rendering a qualified service for stuttering children and their parents.

Treatment services are provided by the school administrations run by the local municipalities, many of which are too small to recruit staff with the wide range of skills required to secure a sufficient amassing of personal competencies in all the areas within the field of speech, language, reading, and hearing that are covered by the treatment sites. Although mandatory according to legislation, “small” areas like stuttering in reality only get a treatment that is professionally adequate in a small minority of the sites. Furthermore there usually are too few clients, especially school children, resulting in a insufficient on the job training. Insufficient continuing education budgets mean further erosion of treatment skills. Many of the initiatives for treating stuttering that have been taken, have not been completed as the result of a managerial (or political) decision on the basis of a discussion of ways and means, but have simply been started by enthusiastic SLTs who did not pay much attention to management and red tape.

The Association for Stutterers of Denmark is managing the project as a co-operation between the Association and the participating treatment sites.

  1. Objective
The objective of the project is to develop models that will secure any stuttering child a professional qualified service at any time. In other words the aim of the project is to establish a consistent service based on explicitly expressed rules that are confirmed at administrative and political levels and integrated in administrative procedures, such as budgeting and formal reporting of plans and activities. Thus the project addresses organizational development issues, including items such as knowledge management, knowledge creation, and learning, as much as it addresses pure stuttering treatment issues. One of the efforts of the project is to embed the treatment of stuttering within the organization, thus not solely relying on enthusiastic individuals. The process and the results of the project are to be published giving other treatment sites the opportunity to find inspiration for enhancing their own provision of service toward stuttering.

  1. Project phases
The project is divided into four phases:
Phase I : Establishing contact with participants, each participating site formulating its objectives;
Phase 2: Identification, looking for good practices, planning the activities;
Phase 3: Concrete measures undertaken for enabling the settings rendering the services;
Phase 4: Embedding of the gathered knowledge on how to obtain the services aimed at. The project started July 2001 and it terminates June 2005.


  1. Introduction of the participating treatment sites
Seven treatment sites are participating in the project. Overall the participating treatment sites are working in communities somewhat larger than the average for the country. The seven 528 Theory, research and therapy in fluency disorders municipalities nevertheless vary greatly in population and in size of staff. The population varies from 7,000 in the smallest to 280,000 in the biggest, average is 81,000 inhabitants, and median is 29,000 inhabitants. The substantially smaller median than average is due to two of the participating municipalities being much bigger than the remaining five. If we exclude these two municipalities, the average population of the remaining five is 24,000 inhabitants, which is more in line with the average population of all Danish municipalities of 19,000 inhabitants.

The SLT staff in the seven sites vary from 1 to 32 full time positions. In most of the sites some sort of specializing has emerged, as a couple of SLTs are doing most of the work with stuttering, while the other SLTS working “out in the districts” predominantly are referring to the more specialized therapists, but most of them are also doing counseling work and some treatment of the moderate cases. None of the specialized therapists are "exclusively working with stuttering, they have other job assignments as well. The number of the specialized therapists varies from 2 to 4 in most sites, though in one site there is only one SLT covering all impediments including stuttering, and in another site there are as many as 12 SLTs who are working with group therapy for stuttering - on a regular basis.

It was striking to the project manager, that even though working with stuttering is not a negligible part of their time, very few of the SLTs felt, that they were specialists in the sense that they had much to offer, as for instance writing articles; neither did they feel comfortable devoting their time to study much stuttering literature. Thus they expressed the need for textbooks and other material that were directly applicable to their everyday working situation.

  1. Method - and Results so far
In a project like this it often is difficult clearly to distinguish between process and outcome as in fact the process itself is part of the outcome. During the first project phase, responding to advertisements in professional magazines, the treatment sites approached the project wanting to participate. The reasons given by the SLTS in the sites for participating crystallize into an overall wish of rendering a good service. Some of the explicit reasons quoted were: To obtain a more “streamlined” (i.e. system-embedded and systematized) service; To enhance our professional qualifications; To participate in a network; To be able to extend our services; To avoid stuttering becoming a life-long handicap; To maintain our competency.

Regardless of the size of the site, all SLTs are busy doing their work. This represents a certain problem for the project manager, who cannot rely on the participating persons devoting their full attention to working with the project, which off course is quite natural, the project being an additional assignment to their normal chores.

A two day start-up seminar arranged by the project manager addressed some of the key issues in strategic planning, such as setting up a vision, objectives, and goals, as well following-up on goals and evaluation of objectives. Further the participants addressed their own strengths and weaknesses, their actual situation, and how to get closer to the objective from where they were at that time.

Each of the treatment sites was asked to set up its objectives and goals for their participation in the project. This obviously is a new way of thinking for SLTs, who traditionally only have been thinking in terms of speech therapy. Now they had to extend their work to encompass organizational matters in order to be able to strive to secure therapy and to get the provision of it embedded within the organization i.e. the SLTs also need to think in terms of organizational theory and organizational development, although in a very straightforward and practical “down-to-earth” manner. Specifically they have to think of how to act in the given context to obtain their goals of providing good services, e.g. influencing managers, having the services explicitly entered into the plans and budgets of the treatment sites, working on getting the administrative as well as the political system familiar with stuttering and treatment of stuttering. They and their work with stuttering need to be visible among colleagues not working with stuttering and among managers within the treatment site as well as in the community in general.

During the time following the seminar all the participating sites set up their objectives and goals regarding their participation in the project and regarding embedding their provision of service in the organization. The objectives are defined as the state of affairs in five years’ time from now. The objectives set up by the SLTs were overall reflecting their desire to render a service that is consistent, permanent, visible (to the public as well as to colleagues and management), of a good professional quality, and based on politically approved plans and budgets.

The objectives and goals have crystallized into the following activities to carry the sites closer to the states envisioned. The activities can be classified into six categories: (1) Dissemination of information, (2) Involving a psychologist in the work with stuttering, (3) Embedding the work into the administrative and political level in the municipality, (4) Continuing education, (5) Planning specific measures for stuttering treatment, and (6) Co-operation with adjacent municipalities as well as with more specialized centers. to enter into activities that do not pose any problem for other sites. The following more elaborated list reflects this broad range of activities. Each category heading is italicized, and the corresponding activities are listed under the caption.

Dissemination of information - visibility and raising the awareness of stuttering
  • Informing school teachers making it clear that treatment involves the associates of the child, including school teachers. Some of the participants have found it extremely difficult to reach teachers, arising, at least partly, from the Very strict regulations of the work conditions of the teachers. These participants are trying to find ways to overcome this problem.
  • Informing colleagues within the treatment sites, raising awareness among staff members who do not work with stuttering.
  • Rendering information to parents, kindergarten personnel, and nurseries through local media and addressing the different groups in person.
  • Introducing the work the SLTs are doing with stuttering on the web site of the municipality and/or the treatment site.
  • Conveying information prepared by The Stuttering Information Center of Denmark on stuttering in school children to all schools in the municipality.
  • Raising public awareness through participation in The International Stuttering Day and writing articles in the local newspapers and advertising in weekly papers.
Involving a psychologist in the Work with stuttering
  • Carrying out a pilot project and evaluate the outcome.
  • Filing an application to management for obtaining 200 hours of psychological assistance during the next school year.
Embedding the work into the administrative and political level in the municipality
  • Describing the planned activities for the coming school year regarding stuttering and enter it into the activity plan for the whole site. In that way the work with stuttering is explicitly expressed as thus will gain more attention among administrative managers and political leaders
  • Establishing plans and outlines of the stuttering work for the coming school year, e. g. number of groups for each age bracket and duration of each group.
  • Preparing a “binder” for all colleagues not working with stuttering. The binder includes information on the service, such as legal requirements, diagnostic procedures, treatment procedures, etc.
  • Providing a standard, though flexible, service.
  • Establishing statistics on the work in order to enhance the service, to share knowledge
  • and skills among the speech therapists working with stuttering, and to describe the children in the groups.
Continuing education
  • Visiting colleagues in the other sites.
  • Participating in networks provided by the Stuttering Information Center (these are networks for working with young children, working with schoolchildren and adolescents, working with adults, and a network of psychologists working with stuttering).
  • On the job training, where less experienced therapists learn from more experienced ones
  • during group therapy. - Participating in formal courses in stuttering.
  • Specific measures for stuttering treatment
  • Establishing groups of stuttering school children in different age brackets.
  • Establishing a “cafe” for adolescents who temporarily do not feel like going into therapy.
  • Developing models to evaluate treatment outcome.

Many feel a need to co-operate with other therapists. The networks have been mentioned above. Another type of co-operation is referring children with a severe stutter to more specialized treatment sites. As mentioned many municipalities have a quite small population and thus have too few stuttering school age children to form a group in a given age bracket. In these cases a co- operation across the municipal boundaries with the SLTs in the adjacent municipalities could be warranted.

  1. Discussion
The initiation of the project reported was due to the results of a previous project which pointed out that the services provided for stuttering children have serious flaws. Especially direct treatment of pre school children and treatment of school children is insufficient in the vast majority of the municipally based treatment sites. The services are decentralized to a high degree and there are political endeavors to drive this decentralization even further. This situation results in a gap between the needs of children who stutter and the stuttering therapists’ abilities to meet these needs.

Three elements are crucial for ameliorating the situation:
  • SLTS’ poor basic training in working with stuttering.
  • The organizational set-up of the treatment sites, which do not give any incentives to
  • secure the rendering of a consistent service.
  • The overall small treatment units, which do not give space for sufficient amassing of
  • professional competencies in working with stuttering, and the number of stuttering school children is often too small to form a stuttering group within a given age bracket.
The SLTS are very much aware that their basis for rendering a consistent service is fragile, and that they themselves have to work on enhancing it by being visible within the organization and to their management and thus pursue their aim of getting better work conditions.

The activities suggested by the SLTs encompass aspects such as being visible, conveying information, and enhancing their professional skills. The suggested activities are generally rather small and restricted in scope. Some of these activities are already familiar to them, others are not. In particular, working with within the organization to obtain one’s goals seems strange to people who are used to working solely with speech and language pathology.

All of the participants are participating in the project with enthusiasm and all are learning from each other and from external sources, and all are working on the project with all their excess capacity. At present all the participants in the project are in an organizational learning process, and time and outcome of the activities will show whether the organizations eventually will succeed in transforming the small sites into being systematically working stuttering treatment sites.

Christrnann, H. (1999). Indsats over for stammen hos barn (Eng.: Treatment of Stuttering in Children). FSD Forlag. ISB

Christmann, H. (200la) Intervention toward stuttering in children. In H-G Bosshardt. , J. S Yaruss, H.F.M Peters,. Eds.), Fluency disorders: theory, research, treatment, and self-help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark.Nijn1egen, The Netherlands: Nijmegen University Press.

Christmann, H. (200lb) Professionals and consumers cooperating in intervention for school age children. In H-G Bosshardt. , J. S Yaruss, H.F.M Peters,. (Eds. ), Fluency disorders: theory, research, treatment, and self-help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark.NijInegen, The Netherlands: Nijmegen University Press.

Humphreys, S. (2002a) Designing an evidence-based model of service-delivery: The process. Paper given at the sixth Oxford Dysfluency Conference, Oxford, UK, June 2002.

Humphreys, S. (2002b) Developing a model of service delivery. Paper given at the sixth Oxford - Dysfluency Conference, Oxford, UK, June 2002.

Niclasen, T.K. H. (2001). Professionals and consumers cooperating in intervention for school age children. . In H-G Bosshardt. , J. S Yaruss, H.F.M Peters,. (Eds.), Fluency disorders: theory, research, treatment, and self-help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark.Nijmegen, The Netherlands: Nijmegen University Press. 532
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