Vol. 16 •Issue 19 • Page 6
Benchmarks in Therapy
Writing appropriate goals is one of the biggest challenges in stuttering therapy," said Nina Reardon-Reeves, MS, CCC-SLP, BRS-FD, a private practitioner who also provides fluency therapy in the public schools.
Clinicians who work with children who stutter should look at goals in terms of their appropriateness in order to best address a child's needs, Reardon-Reeves suggested. "When we're talking about stuttering therapy, the word 'appropriate' comes to mind because we want to make certain we are writing goals that meet the needs of a child's communication system in school."
Goals in stuttering therapy should be observable, measurable, and meet the constraints of the child's education system, she told ADVANCE. "Speech pathologists can feel less than comfortable in writing goals for stuttering therapy and may feel that measurable only means countable."
Many aspects of stuttering need to be assessed and then addressed in the goals and objectives of the individualized education plan (IEP).
One of the most important tools for a clinician is a full case history that includes the child's perceptions of stuttering, the parent's perceptions, and the input of the classroom teacher.
Stuttering case histories are available in textbooks and on Web sites like the Stuttering Homepage (www.thestutteringhomepage.com). Relying on general health records and forms is not sufficient.
"When we do an evaluation in the schools, we have a speech health history that goes home to the parents," she explained. "You get a nice look at the child' speech development, but you don't get a thorough look at what's been happening with the child's stuttering. You find out if they've had any developmental speech errors, diseases or medical conditions; but the forms we fill out just for the district are not complete stuttering or fluency histories."
It is also important not to overlook the role and input of the child when setting treatment goals.
"If they have received therapy in the past, find out if they know what they've been doing and why they've been doing it," she advised. "That will help you write more appropriate goals going forward."
With a stuttering history in hand, the clinician can begin to write goals and develop a treatment plan using a whole child approach. Because goals sometimes focus on the stutter more than the child, clinicians need to keep the child at the forefront of treatment.
"Clinicians must make certain they are writing goals based on their knowledge of the child from the history and assessment," she said.
That includes considering the following:
• the child's beliefs and feelings about his or her communication;
• the frequency and severity of the child's stuttering behaviors;
• the child's knowledge, if any, of how the speech mechanism works; and
• the child's (age-appropriate) factual knowledge of the disorder of stuttering as a whole.
Documenting progress in therapy can be challenging, but doable. Clinicians can choose their rubrics or rating scales and may ask the child to use a self-rating scale to chart progress on goals such as "Child will increase ability to communicate in the classroom as measured by ______."
A teacher checklist also may be a helpful tool to determine if children are communicating at the level they are capable of in the classroom setting.
Using speech journals is an excellent way to document change, she noted. Both the clinician and child record everything they've done in therapy and everything they are working toward in a simple spiral notebook. Not only does the journal help the child see their progress in therapy, it benefits the therapist's overall treatment plan.
"There's a lot of portfolio documentation when we utilize journaling. This documentation will be very important when you get to the annual review and someone says, 'What has this child been doing all year?'" she said.
It is imperative to consider how stuttering affects children in all aspects of their life: in the home, at school, and in social settings.
"We're not looking at grades," she said. "The child does not have to be failing a class to have their stuttering show up as affecting their communication. The most effective treatment strategy for children who stutter is to get a big picture of the disorder and how it's impacting the child's life."
For instance, if a child who stutters gets teased at school, the speech-language pathologist can work to address the situation by incorporating it into their therapy.
"We are 'good communication' specialists, and learning to deal with teasing is a communication strategy," she said. "If children are getting teased about their stuttering, it's our job to deal with that. If they're having trouble raising their hand in class because they feel nervous about their speech, it's our job to deal with their fear and anxiety toward communication."
Using elements from whatever is going on in a child's life can make therapy instantly relatable. Reardon-Reeves suggested incorporating social studies terms or spelling words into therapy, as well as incorporating social language skills that can be used outside the classroom, such as starting or ending a conversation.
"I believe in having stuttering materials [for therapy], but I don't believe that we are limited to this," she said. "We're talking about communication, so anything that stimulates communication is a material for stuttering therapy."
The cornerstones of Reardon-Reeves' stuttering therapy are the benchmarks she sets for each step of therapy, measuring progress through interim goals rather than focusing only on the final, yearly goal.
"I will always have benchmarks for children," she said. "It makes no sense to have that broad goal and not know how I'm going to get there."
Writing benchmarks in stuttering therapy can be particularly helpful for clinicians who may not deal with stuttering on a daily basis, she said. "I have had children with autism on my caseload, but it's not something I treat everyday, which is what stuttering falls into for many speech-language pathologists. I would want to set a clear path for myself and the child through benchmarks. It raises the confidence level of the clinician to have a written plan."
Benchmarks are stepping stones in therapy-a chartable way for clinicians to see how to meet yearly goals in feasible increments. Benchmarks are not rigid, and clinicians should be flexible in dealing with the often abstract goals in stuttering therapy.
"Kids' attitudes and feelings change, and stuttering changes; yet I need to have some plan in my head for going from the 'present level of performance' to what I'm trying to achieve in a one-year time frame," she said.
Rather than attempting to explain to parents the meaning of a general, yearly goal, such as the child demonstrating the use of stuttering management techniques, clinicians should can tell parents, "Here are the techniques and issues we're going to be working on for the next bit of time, and I want your child to understand why they're doing this and how it is going to help."
Explain how any tool or therapy technique used will help their child's speech, she urged. "The parents will want a list. The benchmarks are written not only for me but for the parents and child as well."
Clinicians should ensure the parents have a clear understanding of stuttering. Reardon-Reeves recalls "many heads nodding" at presentations she gives on stuttering therapy when she talks about the need for all to understand the true nature of the disorder.
"Everyone thinks they know what stuttering is; but when you ask them, you find out that they really have the myths, not the factual information about stuttering," she said.
An example of the myths that surround stuttering is the fact that many parents believe stuttering is an emotional disorder and their children just need to "slow down and relax." Not only are these types of beliefs wrong, but they and similar misconceptions can end up having a detrimental effect on therapy.
"Your therapy isn't going to be as effective as you want it to be if you're writing goals and working with a child but have a parent sitting at home believing it's an emotional disorder they caused because they moved or had a second child," Reardon-Reeves stated.
Clinicians must ensure parents and classroom teachers have a basic working knowledge of the disorder, she said.
In addition, "it is our job to help parents get involved in therapy." Ideally, they could attend some therapy sessions. If they are unavailable to attend sessions, she suggests videotaping a few sessions for them to view so they can remain involved in their child's progress. Involved and knowledgeable parents help to ensure a child continues to progress in home practice.
"I don't want the parent to be the speech therapist; I just want them to listen," she said. "But they have to know what they're listening for."
Throughout their work with children who have fluency problems, clinicians should keep in mind a universal goal in stuttering therapy.
"We want to help children communicate more effectively," Reardon-Reeves stated. "Even though there is currently no cure for stuttering, speech therapy can help children improve their fluency and increase their communicative confidence."
It is important to note, she said, that children who stutter may not stop stuttering completely, no matter how effective a clinician's therapy may be. The speech-language pathologist can emphasize a balance of speech management skills and improved confidence and comfort in communication.
For More Information
• National Stuttering Association, online: www.WeStutter.org.
• Nina Reardon-Reeves, online: www.ninareardon-reeves.com.
• The Stuttering Foundation, online: www.stutteringhelp.org.
Alyssa Banotai is an Assistant Editor at ADVANCE. She can be reached at firstname.lastname@example.org.