The fourth bi-annual Symposium, organised by the European Clinical Specialisation in Fluency Disorders (ECSF), was held in Antwerp. Two Speech and Language Therapists (SLTs) in attendance report back.
Rosemarie Hayhow, Bristol Speech and Language Research Unit: Many people ask how a person who stammers can speak easily and fluently in one situation then find talking so hard in another. When parents bring their children to my clinic, the child often becomes more fluent yet stammers lots when talking to the parent in the car park. Adults often have the same experience - life outside the treatment setting is much tougher. Two presentations shed some light on this variability.
Ann Packman from the University of Sydney opened the event and talked about the three-factor model of moments of stammering, developed with colleague Joe Attanasio (known as the ‘P&A’ model). The essential factor is a neurologically-based weakness in the speech processing system. This might be a genetically transmitted difference but not necessarily so. A child with this weakness will not usually stammer when first learning to talk but as their language becomes more complex as they need to stress and de-stress syllables and articulate more quickly to keep pace with the flow of ideas, so their vulnerable speaking system gets stressed. This still may not be enough to trigger stammering - they may also need some other ‘modulating’ factors to tip the balance from smooth and easy talking to stammering. These modulating factors might be excitement, tiredness, having a lot to say, etc. We have to remember that young children are novice talkers and talking is one of the most complex things we do, so speaking fluently is a vulnerable skill and if there is even a mild immaturity or difference, it can have a big effect. As time goes on, childrens’ neurological systems mature and many stop stammering, but those who don’t learn that talking is more difficult and feelings of anxiety or unease may interact with the other factors. We can get a better understanding of moments of stammering by thinking about the interaction of these three factors.
Tom Weidig’s presentation also sought, in part, to explain stammering variability and he also thinks there is sufficient research evidence to put reduced neurological capacity at the centre of his framework, ‘NDC-4’. NDC stands for Neurological Demands and Capacities and 4 refers to the four biopsychosocial domains: body, environment and two sorts of memory (those that can be communicated and those that are experiential, like motor and sensory memories and associations). He said that it is the demands in the environment and within the individual’s body and mind that challenge the system and lead to speech production errors. He added, “People who stammer might vary in causes and symptoms, but all say, ‘I have moments where I can say exactly what I want at the moment I want to say it,’ ‘I have moments where I know exactly what I want to say but cannot actually say it,’ and ‘Those moments are abnormally frequent and the duration of the jam is abnormally long.’”
What is meant by ‘abnormally’ is subjective and what is acceptable to one person may feel abnormal to another, so this description works for both those who observe stammering and those who produce the stammered words.
In both models, different treatment approaches can be viewed as targeting one factor or aspect of the system and so offer a tentative explanation for partial ‘success’ with particular treatments or individual differences in responsiveness.
Plea for research participants
Finally, I would like to make a plea! My own presentation at the Symposium was on ‘outcomes’ and after over 40 years of working in stammering, I am deeply disappointed at the lack of evidence to support different treatment approaches. Mark Pertijs talked about his work on developing ‘Evidence-based clinical guidelines in stuttering therapy’, Rosalee Shenker referred to the evidence base for Lidcombe and Jonathon Linklater described his study examining the ‘Effectiveness of avoidance reduction therapy for adults who stutter’.
I welcome these studies but they are not enough. We need much stronger evidence that stammering treatment can be effective if services are to continue within the NHS. There are all sorts of problems when attempting clinical research. However, examining how different treatments target aspects of stammering, as outlined in Ann’s and Tom’s frameworks, might help us move forward with identifying the appropriate treatment options for individuals. To do this SLTs need to be more research-active but also, it would be wonderful if everyone who stammers, or who has a child who stammers, were to engage in research. We need you - your contributions can make a real difference to our collective knowledge base to the benefit of future people who stammer.
Webmaster note: you can link here to Requests for research participants.
Gemma Clarke from the Michael Palin Centre for Stammering Children gives her take on Ann Packman’s talk: During her presentation ‘Exploring the relationship between treatment and causal theory in stuttering', Ann Packman used an analogy of a wildfire. She defined ‘cause’ as ‘necessary and sufficient conditions for an event to happen’. She went on to explain that for a fire to occur you need to have the source (heat) and then adequate materials and conditions (material to burn and oxygen). This is the same for all fires. However, each individual fire can have a different trigger, e.g., a cigarette or an electrical spark. She paralleled this with what causes somebody to be vulnerable to stammering and then what triggers individual moments of stammering. In her three-factor causal model, there is firstly a physiological basis for stammering (genetics and neurology), i.e., the cause. The trigger for each moment of stammering would be different for each person; for example, maybe saying a particularly complex sentence. Then, the emotional and physiological responses to speech in specific situations are the ‘modulating’ factors, the things that ‘fan the flames’, if you like.
So, while we cannot change the cause, we can recognise, and work with, the triggers and the modulating factors in therapy. I used this analogy with a family recently and found it helpful to explain why we would work on their daughter’s language difficulties and also on helping her manage her emotions more easily in order to help her increase her fluency.
Margaret Leahy, Mary O’Dwyer and Fiona Ryan led a workshop on ‘Narrative Therapy’ that was touching and inspiring. Narrative Therapy helps people to explore and change their story about their stammer and therefore the impact that it has on them. The therapist’s aim is to develop a ‘preferred story’ with their client by using ‘double listening’. They described listening to the ‘problem’ story in order to identify ‘sparkling moments’ and to draw out the clients’ intrinsic strengths from a narrative that they have built around their fluency. For example, a story that somebody tells about what they perceive as a failure in a given situation may also be about their personal resilience and bravery when the spotlight is shone on different elements of the story. Once the client’s strengths are identified the process continues by ‘thickening’ the preferred story, i.e., finding and investigating other moments where the client has shown the same strengths, thereby strengthening their newly discovered narrative. As they say, there are two sides to every story and carefully asked questions and listening can help us see the side that hasn’t been clear to us.
This approach helped one of my clients to re-experience his story of ‘failure’ as a class rep (because he hadn’t managed to give a speech in the Easter assembly), as a story of perseverance. In his new story he acknowledged the fact that he had faced his fears by talking in small groups and in front of the class and he just hadn’t spoken in assembly yet. He commented that uncovering this side of the story made him feel braver and more hopeful and he was almost looking forward to another opportunity to give assembly a go!
Writing this has given me the chance to reflect on what I have taken away from the event, and reminded me of what I can bring to my practice with children who stammer and their families. The process of reflecting has ‘thickened’ my preferred story of continuous learning and development. So I would urge you, if you have been on a training course, had a block of therapy or been to a conference - recap and refresh the key points - you may be surprised how much you have learned!
Read pdfs of all the presentations from the Symposium at www.ecsf.eu/news-and-events/european-symposium-on-fluency-disorders-2014...
From Speaking Out Summer/Autumn 2015, pp,18-19