Preschoolers who stutter: What and how? - Part 2: A talk with Norwegian SLT, Therese Espegard

Therese Espegard

Our series about working with preschoolers who stutter continues today with speech and language therapist Therese Espegard. In this ongoing series we will be talking to healthcare professionals, speech and language therapists and parents about managing preschool children who stutter. Therese Espegard is a SLT working in her own private practice in Drammen. She has been working with preschool children who stutters for six years, lately in her private clinic, Drammenslogopeden. Here she shares some of her thoughts about treating preschool children who stutters:

What is a common question you get asked about stuttering by parents and/or kindergarten teachers?

In my experience, many parents have heard myths about stuttering. They are often worried stuttering is caused by something they did. A typical example is questions about whether the stuttering can be caused by them tickling their child. Many parents meet at the clinic expecting the stuttering to disappear. This also reflects on the questions that I am asked. I often start the collaboration with the parents by presenting them with information about stuttering, research and prognosis.

Does your service have a waitlist for services? If so, does your service have a protocol for determining who receives access to intervention? 

I do have a waitlist, but I normally prioritize children who stutter. That means I often have the possibility to start early in those cases, proving parents with information, assessing the child, and when its appropriate, start treatment at an early stage.

What factors do you consider when deciding when to start treatment with a preschool child who stutters?

I normally consider how long the child has been stuttering for, whether there is a genetic factor, whether the child is aware its own stuttering and if the child has started to show negative reactions or secondary behavior towards its stuttering.

What is the earliest age you provide stuttering treatment for preschool children?

I consider this differently from case to case, but I have worked with several kids from they are about three years of age, and I have positive experiences with early intervention.

How do you decide which treatment to use with preschool children who stutter?

Again, I consider this from case to case. It depends on how long the child has stuttered, stuttering severity, and awareness. Sometimes I change approach after a while. It is normally a continuous consideration. I do this in close collaboration with the parents. 

What stuttering managing approaches do you use the most with preschool children and why?

Working on Lidcombe with a fun game of explaining.

I work both directly and indirectly. I try to stay in close contact with parents and preschool teachers. I have positive experiences from using the Lidcombe program. Although in my experience, not all parents want to start doing Lidcombe because of the time consume.

Other management approaches I use with children and parents consists of desensitization, giving the child good strategies and experiences with coping. Research show that many children who stutter, can have negative thoughts about their own speech from a very young age. That means getting help early is important. My hope is early intervention will prevent the child from getting into a vicious circle of avoidance and problematic relationship with communication situations, etc.

The green and red piece works as positive reinforcement
together with the verbal contingencies. Published with permission from parents.

I also work closely with the parents as to how they react to the child's stuttering, mention the stuttering and so on. I find that many parents are afraid to talk about stuttering with their child, making the stuttering the pink elephant in the room. In my experience, children are often relieved when they can talk about it and neutralize stuttering. 

I do not always use the word stuttering with the children. Sometimes I will rather use hand puppets and role-play, explaining how words can jump or get stuck. In my experience, children respond well to this. I also work with desensitization by using voluntary easy stuttering and by letting effortless disfluencies into my own speech.

I also introduce fluency shaping techniques and contrasting using concretes like a turtle and a hare, a rock and a piece of cotton. With the older children I draw on elements from CBT. I find using CBT “roadmaps” to be a useful tool when talking about anxiety and stuttering with the older kids.

This turtle exemplifies slow rate, and the preschool child
Therese was working with here wanted the kitten to symbolize smooth stalking. 

On a scale from 1 to 10, 1 being not confident at all and 10 being extremely confident, how confident do you feel about working with preschool children who stutter and their families?

I’d say I feel about a 5 or a 6. I feel confident, but there is a lot still to learn and I wish to still develope as a clinician.  This is a field continuously in change, and I think there will be a lot of interesting research coming on the field, that will be of great importance for me as a clinician.  As far as possible, I try to sign up for all courses on stuttering I can find, so I make sure I stay professionally updated.

Do you have any formal training working with preschool children who stutter? If so, what type of training have you received?

In addition to my formal training as a SLP I have Lidcombe training. I also do my best to attend courses, networks and seminars to keep up to date. Lately, courses I have attended have covered topics from indirect treatment to fluency shaping and CBT. This fall I look forward to learning more about stuttering management doing a MiniKIDS training. It is also my wish and a personal goal to attend the European Clinical Specialization in Fluency Disorders one-year program at some point.

Describe one thing you find rewarding and one thing you find challenging about working with preschool children who stutter?

I find meeting children and the people around them rewarding, as well as the possibility to make a difference and to make the child more confident and less anxious in communication situations.

Some of the biggest challenges might be when a parent stutters and have a hard time coping with their own stuttering. In that case I spend a lot of my time talking to that parent. I believe that parents with a negative view on their on stuttering might reflect that in how they cope with their child’s stuttering.  

In your country, are there national guidelines for treating stuttering in preschool children? If so, what are the key recommendations for working with preschool children who stutter?

I follow the ethical rules made by the Norwegian association for Speech and Language therapists.  Beyond that there is, to my knowledge, no special recommendations for using a special method in treating preschool children who stutter. I consider treatment approaches according to the needs and challenges the child has. Further, I inform parents about the methods that exist and finding the right treatment approach to pursue together with them. I assess the effect of the treatment on a continuous basis. Working with preschool children who stutter, I think it’s important to clarify expectations and not promise anything for results etc.

In your opinion what’s the most important outcome of intervention when working with preschool children who stutter?

Not everyone will be fluent, so the goal is often less fear of their own speech, more coping with the communication situation, reducing the frequency of stuttering, and limiting negative strategies and negative feelings related to their own speech.

Thank you, Therese!

Public Health Nurses – a resource for detecting stuttering

Public health nurses are one group of early childhood professionals that have regular contact with young children and also expertise in childhood development. This makes public health nurses important for the EST-project of several reasons. First, combing different competencies in early childhood development makes the team better positioned to carry out this project. Secondly, since the majority of Norwegian children are regularly in contact with public health nurses, they play a important role in enhancing parents’ knowledge about stuttering and distributing information about the project. Given this, this blog post is dedicated to the work that public health nurses do and their competence as early childhood health professionals.

Picture from pexel.com

Norwegian public health nurses are authorized nurses with post bachelor or a master education with specialist qualification in public health nursing. The health care service is a part of the municipal health services that cover the need for nursing services in health promotion and preventive work. Public Health nurses has informative, guiding and advisory tasks within national health programs.

The tasks are mainly linked to the health center for children 0-5 years, school health service in primary and secondary school and health center for youth. The public health nurses follow national healthcare program with 14 consultations, including a home visit to the newborn. The health service also includes environmental protection and refugee health services. Public Health nurses provides services to all children and adolescents with a systematic health offer from "cradle to adult", and with this effort public health nurses is a key player in the municipalities' public health work.

Public health nurses are usually assigned a geographical area where they carry out immunizing and national screening and health programs. Public health nurses give advice and counsel both individuals and groups. Almost 100% of the Norwegian families avail themselves of the services at child health centers-

The aim of the healthcare program is:

• That parents experience coping in parenting

• To contribute to good interaction between parents and children

• To promote physical, mental and social development among infant and toddlers

• Prevent, ward off and uncover violence, abuse and neglect

• Uncovering developmental physical and mental disabilities

• To ensure that children receive follow-up and referring to specialist if necessary

At both 2 years and 4 years consultation, speech and language has a special focus in the health program. Special developed language and speech tests for the children are performed to detect needs for follow-up. Language and speech problems in children are also an important part of the public health nurse education. Public health nurses work in multidisciplinary teams like schools teachers, pedagogic-psycologic services, doctors and other health personnel. Small children regularly attend primary health nurse consultations, thus the public health nurses are an important resource for detecting and providing help for children in language and speech problems, such as stuttering.

 Picture from pexel.com

Written by EST-member Elisabeth Holm Hansen

References:

Norwegian Nurses Association, (2008) Professional interest group of public health nurses: “Mer enn et sprøytestikk”  Available at: https://www.nsf.no/Content/396553/cache=20162106125759/Helses%C3%B8ster_web1.pdf

Clancy, A., Leahy-Warren, P., Day, MR., Mulcahy, H. (2013).Primary health care: comparing public health nursing models in Ireland and Norway. Nurs Res Pract.2013:426107. doi: 10.1155/2013/426107.  

Dahl, BM. (2018) Challenges and demands in the population-based work of public health nurses. Scand J Public Health. 46:53-58. doi:10.1177/1403494817743897.

Preschoolers who stutter: What and how? A talk with Norwegian SLT Gry Line Tokerud Bakke

While our EST-project team is busy working on systematic reviews, collecting literature, reading articles and preparing for our intervention study, we thought it would be fun to use our blog to learn about how other speech and language therapists, healthcare professionals and parents manage stuttering in preschool children here in Norway and around the world.

Our first guest was Norwegian speech and language therapist Gry Line Tokerud Bakke who works in public schools and preschools in south-east Norway.

Gry Line has been working with preschool children who stutter since 2013. She receives five new referrals for preschool children who stutter every year, from either kindergartens or parents. 

Here she shares some of her experiences.

What is a common question you get asked about stuttering by parents and/or kindergarten teachers?

«Do you think my child stutters a lot?» «Do you think this will pass?» «Is this normal?” and «Should I be worried?»

Does your service have a waitlist for services? If so, does your service have a protocol for determining who receives access to intervention?

No, I am the only SLT in our municipality and the child will be added to my caseload immediately. I always contact parents quickly (within two weeks of receiving a referral). In this initial contact, the parents and I plan a meeting to talk and assess the child.

What factors do you consider when deciding when to start treatment with a preschool child who stutters? 

I take into consideration how worried the parents are, if they want direct treatment for their child, and how motivated they are to work with the child. However, when it comes to assessment and counseling towards the preschool and parents - that is something I always do, if a child is referred because of stuttering.

What is the earliest age you provide stuttering treatment for preschool children?

Management approaches that could be labeled as indirect treatment, like changing the surroundings and language environment, and counseling parents and professionals around the child, are given to all children regardless of age. I start giving more structured and direct treatment from the child is 3 years of age.

How do you decide which treatment to use with preschool children who stutter?

It often depends on the parents. Some parents do not want their child to know they stutter, and want advice from me as an SLT on how to approach the stuttering in the right way. Others want their child to work with strategies like breathing, rate, soft and easy stuttering with a SLT, and follows up at home for a while, before they wait and see. Others wants to do something immediately. In that case I would provide more structural treatment that will demand a lot from the parents, like Lidcombe.  

Pixabay

What stuttering managing approaches do you use the most with preschool children and why? Do you use any other management approaches and if so why? What is the main goal of each approach?

In addition to consulting parents and the preschool, I try to visualize some principles for the child. I usually start with raising the child’s awareness around breathing. I play with the child with different toys to blow through and we talk about the breath we use to shout and the one we use to talk. The shouting breath is powerful and is similar to the one we use when blowing a ball high up in the air with a toy. Talking breath is the smooth breath, which allows the ball to be almost kept calm in the air for a long time when we blow. Parents often say that the children can correct themselves after they have seen me and "forget to use talking-breath" and that they then manage to change to a slower speech by using the smooth breath.

In addition, I also work with rate reduction. I often use a car and make a racetrack on the floor. My goal is to show the child how the car will not crash or drive out of the way if we keep a slower pace. Then we try to transfer these "discoveries" to the speech and find that the slower speech makes it easier for others to understand us.

I have used the Lidcombe program with one child before and have just started treatment with a second child. Unlike the other approaches, I like that the program has a specific structure for the progress and the content of every session.

In all approaches, the goal is for the child to achieve better speech flow.

On a scale from 1 to 10, 1 being not confident at all and 10 being extremely confident, how confident do you feel about working with preschool children who stutter and their families?

7. Stuttering is generally one of the fields where I don’t feel so confident. This might be related to the fact that I like fixing things. Stuttering is challenging for myself as a therapist, because I have to find other goals than stutter free speech. With preschool children who stutter I often feel that my work is depending on that of the parents. I find it challenging when they are not following up what I do in therapy, or do not want to talk to their child about stuttering.

Do you have any formal training working with preschool children who stutter? If so, what type of training have you received?

In my formal training as a speech and language therapist, fluency disorders is included as a part of the education. I have attended different courses at Statped over the last years. I was recently counseled on how to use Lidcombe with a child, but do not have training in Lidcombe or any other stuttering management approaches.

Describe one thing you find rewarding and one thing you find challenging about working with preschool children who stutter?

After providing them with information, new knowledge and some advice, I can often see how parents experience their child’s stuttering to be less scary and overwhelming, and they feel in control of the situation. Seeing how parents meet their child with a new sense of confidence and calm when the child is stuttering in very rewarding and gratifying.  At the same time, I find it frustrating in cases where the parents are reluctant to get help because they don’t want their child to “know it stutters”.

In your country, are there national guidelines for treating stuttering in preschool children? If so, what are the key recommendations for working with preschool children who stutter?

On their homepage, The Norwegian Fluency Association describe the legal rights that people who stutter have on treatment, as well as facilitation of the workplace and at school. When it comes to preschoolers, I don’t know about any given recommendations for treatment.

In your opinion what’s the most important outcome of intervention when working with preschool children who stutter?

To provide the child with tools they are able to use if they feel they are stuck. In addition to giving parents tools to reduce their worry and anxiety around stuttering. 

Pixabay

Thank you, Gry Line!