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.
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.
- Stuttering as a low incidence phenomenon
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.
- Project phases
- Introduction of the participating treatment sites
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.
- Method - and Results so far
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.
- 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.
- 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.
- 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.
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 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