Fluency specialists meet in Denmark
Doreen Faisca, then BSA Parental Awareness Campaign co-ordinator, focusses particularly on early intervention in this account of the 3rd World Congress on Fluency Disorders.

BSA's Doreen Faisca (right) with Liz Hoey (Glasgow) and Hugo Gregory

The 3rd World Congress on Fluency Disorders is organised every three years by the International Fluency Association (IFA). This year it was held in Nyborg, Denmark, from the 7th to the 11th August 2000 and it brought together over 350 people including researchers, clinicians as well as people who stammer from all over the globe. There were approximately 160 papers presented and 25 posters on display over the five days. Unfortunately, one absentee was Professor Ehud Yaïri, from Illinois University, who has been carrying out pioneering work in the area of spontaneous recovery and predictive factors of persistent stuttering in young children. Dr Yaïri suffered a heart attack on his way to Denmark and we wish him a speedy recovery.

The Congress opened on Tuesday morning with keynote addresses by Edward Conture, from Vanderbilt University in Nashville and Thomas Krall, president of the International Stuttering Association (ISA).

Conture's address entitled "Dreams of our theoretical nights meet the realities of our empirical days: Stuttering Theory and Research", consisted of a review of the research and developments in theory over the past 20 years. He described the shift in thinking: from "nurture" accounts in the '70s (which suggested that environmental and behavioural factors were at the origin of stuttering) to "nature" explanations in the early 90s (whereby organic or motoric factors were implicated). In the last ten years however, Conture stressed that researchers and clinicians had begun to speculate that stuttering could not be solely explained from a motoric point-of-view. He emphasised that it was not clear from research findings what elements of the stutter resulted from "primary" motor control difficulties and which elements were "learnt" adjustments, compensatory or reactions to the symptom of stuttering. It was this difficulty in differentiating between inherent difficulties versus learned compensation that led Conture to look at other "lines of evidence".

Professor Ed Conture and Nan Ratner

He went on to discuss recent studies in the area of brain imaging and the emerging differences in hemispheric involvement and cortical activity between people who stutter and fluent speakers. He also emphasised the need for researchers to create testable hypotheses rather than simply provide descriptive analyses of brain functioning and stressed that, methodology permitting, it would also be important to study brain activity in stammering children. In terms of linguistic functioning, research was suggesting that both planning and production of speech and language were problematic for stammerers. For instance, length and complexity of utterances had been directly associated with instances of stuttering. Another line of evidence related to studies of temperamental characteristics of people who stammer. Conture conjectured that they have a sensitive temperament that leads to "over reaction" to typical speaking "mistakes". Hence, inherent difficulties may cause frequent "mistakes" that a child with a sensitive temperament may attempt to frequently correct leading to stuttering-like speech.

Conture felt that it was necessary to combine these lines of research to develop theories of "creation of stuttering", which were likely to be an interaction between linguistic difficulties and motoric co-ordination. In terms of maintenance or exacerbation of stuttering, Conture suggested that there is evidence that temperamental sensitivity may exacerbate underlying difficulties. He ended the speech by stressing the need to link theory to practice and for clinicians and researchers to work closely together.

On a lighter note, Thomas Krall in his presentation described the origins of the ISA and gave an overview of its work and objectives. He emphasised in particular the need to foster closer links with other organisations such as the European League of Stuttering Associations (ELSA), IFA and the World Health Organisation (WHO). He ended his talk poignantly with ISA's dreams for self-help and therapy and his vision of the "Dream House" which would have lots of rooms for all sorts of departments.

Over the coming days, papers were presented in 5 parallel sessions and were loosely organised into topics covering various aspects of therapy programmes; research into the genetic and neurological basis of stuttering; new and innovative professional services to stammerers and their families; outcome measures and efficacy of therapy programmes; and self-help initiatives, to name but a few. The choice was difficult, to say the least. Most of the papers reported here focussed on early intervention because my special interest in this area.

Nan Bernstein-Ratner, from the University of Maryland College Park, focussed her presentation on reviewing the appropriateness/effectiveness of common advice given to parents of stammering children by speech and language therapists. Examples given were: "parents should adjust their rate of speech to the child's", "parents should simplify their language" and "should adjust their conversational style by asking fewer questions and not interrupting their child". The underlying premise for these recommendations was that if parents used longer and more complex language then this provoked stuttering in their child when they attempted to match the adult model. Ratner and her colleagues set out to study the language used by children and their parents. Her subjects included 15 pairs of children and their parents split into two groups: a stuttering versus a fluent group. Ratner found that on the whole the language skills of children who stuttered were not as good as those of fluent children but still above the 50th percentile; consequently, she described them as having "fragile" language skills. She also found that the parents of stammering children where good at "fine-tuning" their own language to their child's and did not place more language demands upon the children. They were also good at estimating the level of their child's language development. On the basis of her findings Ratner raised some interesting questions: are speech and language therapists perhaps inhibiting or slowing down the language development of stammering children when advising parents to simplify and slow their own speech. She emphasized that stammering children already have vulnerable or fragile language skills therefore suggesting that what they hear should be made simpler may do more harm than good! She concluded that it was important to acknowledge openly the difficulties that stammering children may be experiencing to remove the shame and fear of stuttering. She highlighted how some stress was likely to be induced by what parents "don't say", when they don't talk about the stuttering.

"Why therapy for young stuttering children (2-5 years)" was presented by Ronny Boey, who described the work he carried out in his private practice specialising in stuttering in Antwerp, Belgium. Boey felt that providing therapy as close as possible to onset was a preventative measure. He reported that early intervention could prevent the development of emotional symptoms, such as "avoidance" and "struggle" behaviours. He found from clinical observations that avoidance behaviours were present in 30% of children under five but increased to about 80% if children were referred between the ages of 6 to 12 years. More struggle behaviours were also observed in older children referred. In terms of intervention he calculated that intervention for 2 to 5 year olds took approximately 42 hours whereas this number doubled for older children, leading to the conclusion that intervention provided in the early years was certainly more cost-effective.

Anthony Wray, a speech and language therapist in private practice in Canada also described activities, which he has developed to raise awareness amongst parents and physicians about the need for early intervention/prevention of stuttering. What prompted him was firstly reports from parents of school-aged children who were saying they knew "there was a problem when their child was 3 or 4 but nobody did anything about it", and secondly, limited therapy success with school-aged children. Wray began his awareness raising campaign by investigating the knowledge base of physicians in his area. He sent out questionnaires to physicians and paediatricians and found that most had "inadequate" training in preschool fluency and had no written material on the subject for parents to access. Wray followed up these findings by supplying all physicians with copies of the NSA stuttering booklets and organising parent information sessions in the public library. He found that the most effective way of marketing these information sessions was through advertising in local newspapers and advising physicians on a quarterly basis of the sessions. The sessions consisted of showing a 30 minute video, followed by a 60 minute lecture on what constitutes normal dysfluency; overview of demands & capacity model; phases of stuttering development; warning signs of a child at risk of developing a persistent problem; tips on how to reduce the demands placed on a child's speech and an overview of different treatment options available.

An evening's relaxation in the bar

Another interesting programme, which also focussed on raising community awareness about the importance of early intervention for stuttering was reported by Lucia Barbosa, a Brazilian psychologist. She presented an account of the work being undertaken by a group of psychology and speech and language therapy students in poor neighbourhoods of Sao Paulo. The primary aim was first to increase professional training in the area of stuttering. Barbosa stated that in Brazil there was very little specialization and few speech and language therapists gained any expertise in this area. There was a limited number of books translated into Portuguese and only five written by Brazilian authors. She reported that the most prevalent practice was for stammerers, including stammering children, to be referred to a psychologist because stuttering was viewed as a psychological disorder. The second aim was to disseminate updated knowledge on stuttering and dispel prejudices in students and professionals as well as in the community about stuttering.

Twelve undergraduate students were offered an elective course in stuttering and early intervention. The students attended lectures and were required to develop information materials which could be used in the community to raise awareness, e.g. posters, leaflets and interactive games. From March 2000 the students began visiting local schools and talking to teachers about stuttering and early intervention. The third phase of this project will involve the foundation of a Centre of Studies in Stuttering, scheduled for 2001.

Bruce Ryan from California State University presented two papers, which generated some lively debate. The first, called "Prediction of spontaneous recovery in preschool children who stutter", described a 10 year retrospective analysis of 22 preschool children who had not received any intervention in the first year of their observations. Ryan found three trends in the development of their stutter, which could be used to predict or differentiate between those children who would recover from their stutter and those who would not. He concluded that further research was required but felt that prediction of spontaneous recovery could eventually be made on initial trends.

Ashley Craig from University of Sydney reported on research conducted on the prevalence of stuttering across all ages in New South Wales. Overall, Craig and colleagues found a slightly lower prevalence figure of 0.72% in the overall population but a higher prevalence in children of approximately 1% to 1.5%. The gender ratio in children under five was found to be slightly lower than usually reported, e.g. 2.3 males to 1 female. He surmised that with a population of 18 million at any one time there will be approximately 100,000 people who stammer.

Yaruss from Pittsburgh reported on an instrument to measure stuttering treatment outcomes. The instrument consisted of rating scales based on an adaptation of the International Classification of Impairments, Disability and Handicaps (ICDIH). The three part classification assessed the impact of the stutter as an "impairment" including affective, behavioural, cognitive and attitudinal aspects of speakers' reactions to stuttering, as a "disability" relating to the functional limitations associated with stuttering, and a "handicap" reflecting the impact of stuttering on the speaker's quality of life.

Ann Packman from Sydney, Australia provided an overview of the Lidcombe Programme. Based on parent-conducted operant conditioning the aim of this approach was to eliminate stuttering from the child's speech, through "highlighting" stutter-free speech and stuttering. Packman reported that it was most effective for children under 7 years and most successful before the end of the pre-school years. She stressed that on the whole clinicians would not try to intervene before a child was 3 or 4 years of age and not within 6 months of reported onset to allow for spontaneous recovery. On average a median of 11 clinic visits were required for a child to complete the programme.

Sheryl Gottwald and Susan Dietrich, speech and language therapists from the USA, described their treatment approach for young school-aged children. Gottwald advocated a model of intervention which involved looking at the child's speech patterns at the same time as modifying the communicative environment. This approach was premised on Starkweather's "demands-capacity" model of stuttering. Within this approach parents were often advised to do some of the following: adjust their rate of speech, pause between conversation turns, eliminate interruptions or reduce their language complexity. In addition therapy time was also devoted to making family routines more predictable and addressing the child's affective needs.

Daniel Costa, a psychiatrist from Canada, reported on the latest developments in the treatment of stuttering using anti-depressant drugs. Earlier studies using "haloperidol", a dopamine antagonist, had significant secondary or side effects, such as weight gain, which overshadowed improvements made in fluency for people who stammer. However, Costa stated that in newer drugs such as "ziprasidone" these side-effects had been reduced. Costa planned to initiate randomised controlled trials using this drug.

In terms of organisation the event was faultless, thanks to the time and effort invested by everyone from the Danish Stuttering Information Centre.

Finally, the 10th Anniversary of IFA was celebrated in style with fine food and wine followed by dancing. During the evening the Nominations and Awards committee of the IFA presented awards in recognition of outstanding contributions to stuttering and fluency in the categories of clinician, consumer and researcher. The awards went to Bill Murphy, from Purdue University, in the clinician category; Michael Sugarman from the National Stuttering Association, USA, in the consumer category; and in the research category, Ehud Yaïri, from Illinois-Champaign, USA and University of Tel Aviv, Israel.

The 3rd World Congress has left me with a lot to take home to BSA to discuss with colleagues and think about, as well as a taste for Danish smoked salmon and pickled eel!

From the Summer 2000 issue of 'Speaking Out'

See also:
4th World Congress on Fluency Disorders, 2003 - reports