Book Preview: Transfer and Maintenance
Working with children in the school environment
The purpose of this chapter is to discuss ways to accomplish and some problems involved in "transfer" and "maintenance" in stuttering therapy for elementary school aged children. Ordinarily the clinician works to "establish" a desired response pattern in the therapy room and then to transfer it to outside situations. Problems can and do arise when clinicians consider that they are generalizing a speech pattern that has already been learned. This "has learned" viewpoint too often reflects the faulty assumption that the child has learned a speech production skill in the therapy room and that the transfer phase involves only habitually "using" the learned behavior in outside situations. Instead, when a child leaves the therapy room and talks to a friend or to his teacher is not solely transferring a response pattern, he also is establishing a new reaction pattern. The communicative interaction changed from the one that existed in the therapy room.
Stuttering develops as a communication problem every bit as much, if not more so, as it does a speech production problem. The essence of therapy is to help the child cope constructively with his speech production abilities in the presence of the feelings involved in his ever-changing communicative interactions. From this perspective, the concepts of "transfer and maintenance," if considered to encompass solely speech production skills, can be misleading to the beginning clinician. We hope to clarify this point in the following discussion.
As stuttering develops in children, their feelings become a fundamental part of their stuttering, and by so doing, stuttering becomes part of them. This is one reason that for many children, their stuttering is so personal and so private. To them, their feelings represent the internal part of their stutter. The speaking behavior that the listener observes, is the part that the child could not hide. Various terms have been used to discuss these "stuttering feelings," for example, anxiety, anticipation, stress, negative emotion, fear, etc., etc. Regardless of the terms used, most theorists agree that a person's "feelings" become paired with the overt struggle behaviors. Hence, a change in a person's feelings may trigger an instance of stuttering. These "feelings of stuttering" result from a combination of emotional and motoric feelings. They combine to serve as internal cues that the child comes to monitor before or as he speaks in order, he hopes, to be better able to cope with the way he talks.
We are well aware that our emotional feelings change constantly as we talk to different people, in different places, in different roles, about different topics, with different language structures, etc. As a result, the internal cues that the child experiences are changing constantly. Therefore, to rephrase what I stated earlier: a clinician's task, fundamentally, is to help the child learn how to learn to cope constructively with changing communicative interactions and the internal cues that are such a vital part of them.
In the discussion that follows, the term "transfer" refers not to a response that has been learned but rather to the transferring establishing process involved in learning to cope with differing communicative environments. Furthermore, my comments will focus on those issues commonly found in the elementary school environment.
The therapy program that the clinician develops in a school system should take into account the unique aspects of each school in which she works. She will need to explain to the principal, teacher, etc., the structure of the stuttering therapy program so that she, with the help of these school personnel, can work together to adapt, where possible, school policies and regulations to fit her therapy program. The three main aspects of structuring a program are (1) the frequency and length of therapy sessions per week, (2) the support by and cooperation of the school personnel for the child and for the therapy program, and (3) the clinical procedures used during the therapy sessions that will promote their use in the school environment.
Scheduling Therapy Sessions
The clinician should schedule therapy sessions frequently enough per week and of sufficient duration to meet the needs of the child who stutters. To attempt to force a stutterer into an established school schedule, for example, of two 15 minute individual sessions per week is being professionally irresponsible. A school clinician must adapt her schedule to fit the needs of the client. If this cannot be done, the child should be referred to someone who can. Ordinarily, two to three individual sessions per week, each for 30-40 minutes, is a minimal requirement. In addition, however, the clinician should plan on time to be spent with school personnel and, if possible, the child's parents. This may appear to be a great deal of time to spend with one client in the schools but (1) the nature of the stuttering problem requires more clinician time than some of the other speech problems do, and (2) most clinicians who spend less time than this report very little success with the stuttering child.
Preparing the Environment for Transfer
In order for a child to transfer improved speech into his school environment, he is required to begin behaving in ways that are different from the ways he has behaved in the past. For many children, this can be rather frightening. They are unsure of what they will do and how other people will react. For them, when they act in ways in which they are not used to acting they feel conspicuous. They feel strange or "kind of funny." They are afraid that people will notice and say something! As a result, it is not uncommon for stuttering children to prefer to act "like themselves" and to just hope that they do not stutter. In my experience, it often has been difficult for clinicians to realize that for many children, it is more important at times to communicate their thoughts and their feelings "honestly" than it is to say the words fluently.
Obviously, it is easier for a child to change certain ways of acting and to observe the consequences if the people in his environment are supportive and reinforcing to the ways he is communicating both verbally and nonverbally. These people, teachers, principals, etc., can be important contributors to a child's successful "transfer and maintenance" of improved fluency.
When a clinician accepts a child who stutters for therapy in a school, it is important for her to open lines of communication with the principal and the child's classroom teacher. In discussions with them, the clinician can find out how they "see" the child. What do they like about the ways he acts, both verbally and nonverbally, and what things do they dislike and wish he could change? Is it for example, when he tenses so much, or when he holds his breath, or when he keeps looking at the floor? The information obtained can be used at a later date in discussion with teachers and principals. The clinician may want to work with the child to change certain ways he acts (verbally or nonverbally) that his teacher, for example, did not like. Then, the clinician can alert her to notice the change and to comment upon it. This can help the child learn to feel free to change the ways he acts.
The nature of stuttering should be discussed with the principal and the teacher. They need to understand the relation of communicative interaction to the problem and the need to modify these interactions as a part of therapy. In this way they can obtain a perspective about what therapy involves and ways that they can be helpful. For example, several years ago, we had a conference with a group of principals and teachers who had stutterers in their schools. We asked them if they talked to the stutterers informally in the halls or between classes as much as they did to children who do not stutter. Their answer was "no." When we discussed the reasons for this, several of them verbalized, and others agreed, that it honestly was not because they were embarrassed when the child stuttered. After all, they were used to working with children with problems. Rather, it was because if they talked to the child and the child stuttered in answering, they felt responsible for making the child stutter. It was their fault if he stuttered. They believed they were being kind by not placing the child in the turmoil of having to talk and to stutter. This example is used to point out the kinds of misconceptions that exist. Principals and teachers want to help children. It is the clinician's responsibility to help them learn ways to do it.
The principal needs to be provided with information about the structure of the clinician's therapy program. Then he will understand the logic behind requests to take the child into the halls during class time even though it is ordinarily against school policy. He is more likely to permit this so that the clinician and the child can talk to the janitor, the cook, the secretary, and even to him.
The classroom teacher needs to understand the therapy program so that she can understand her place in it. It is especially important that the clinician work for open lines of communication with the teacher based on mutual sensitivity and understanding. In talking to groups of school clinicians, the most common complaint I hear is that the classroom teacher is "not cooperative." This is unfortunate. It is difficult for me to believe that a teacher who is devoting her professional life to helping children will refuse to help children. After discussions with many classroom teachers, a different picture emerges from that reported by the clinicians. Some report that they do not understand what they can do to be helpful, and why it will help, as opposed to doing something else. Also, they resent, at times, the way they are told what to do. The clinician comes to her room, tells her that she is doing this and this wrong, and that she should be doing this, then leaves. Other complaints involve the problem of time. When a teacher has 30 and even 40 children in a class, it is unreasonable to expect her to spend undue time with one child at the expense of the others. Other problems of time occur that reflect a lack of understanding or sensitivity on the part of the clinician. For example, the clinician bursts in on the teacher to have a conference when the teacher has ten minutes to make final preparations for the remainder of the day.
The other major complaint involves requests by clinicians that are unreasonable. Several examples will illustrate the point. One clinician informed the teacher that Johnny was learning to "stutter smoothly." She requested the teacher to stop Johnny anytime he did not "stutter smoothly" and make him do it again until it was "smooth." One might argue about the advisability of using such procedures; however, a more critical issue is the fact that the teacher was not trained, and had no way of knowing how "smooth stuttering" has to be before it is "smooth" enough. The other example concerns a clinician who was attempting to transfer to the classroom the fluency the child had learned in the therapy room. She requested that for the first week the teacher ask the child questions that could be answered with only three words. The next week the questions were to be answered with only five words. Teacher cannot be expected to serve as surrogate clinicians. The clinician should assume the responsibility for blending the therapy activities into the daily classroom routine.
The clinician can discuss with the teacher the daily activities that occur with the children. She should learn about the various opportunities that the children have to speak each day. Do they have a chance to answer questions, to ask them, to tell a story, to read aloud, etc.? How does "Chester" perform these activities? Which appear to give him the most and the least difficulty? The clinician should determine also the types of materials and books used with each subject taught and then utilize them where possible in therapy. In preparing the child to transfer improved speech into the classroom, the clinician can incorporate a reality into the therapy room activities that the child can understand.
The teacher can be asked about the ways that it would be most convenient for her to communicate with the clinician about the child's needs. This may be done, for example, by any combination of the following: write short notes; establish a specific time during a day, e.g., recess or gym time, when the teacher is "more likely" to have free time; eat lunch together on days when you have information to share; or make phone calls at home. Obviously, there are many other ways it can be done. The point is that mutual sharing of decisions enhances the opportunities for cooperation.
The clinician can discuss with the teacher ways that she would feel comfortable participating in the therapy program. Her role will vary from situation to situation. Generally, the teacher can be extremely helpful by being supportive of the changes the child is making. She can provide the opportunities for the child to speak and she can observe his performance. She should not be expected to directly "correct" or "modify" the child's speech. In fact, she should refrain from doing so, as one clinician is enough.
In my opinion, one of the most important ways that the teacher can assist in the transfer aspect of therapy for a child is through her supportive role as "his teacher." Prior to asking the child to practice improved ways of talking in the classroom, it should be demonstrated to the teacher. Some teachers are able to visit the therapy room and observe just what it is the child is practicing. Others will meet with the child and the clinician in the classroom after school. In this way, the teacher will know what to expect. More importantly, now the child knows that the teacher knows, and that she approves. Furthermore, now the clinician and the teacher stand side by side in what they expect the child to do and this makes it easier for the child to be successful. Also, it opens up communication between the teacher and the child about his therapy program.
The clinician's interactions with the parents of the child can be similar to those with the teacher. There needs to be a discussion in order for them to understand the therapy program and their place in it. Also, prior to the time when the child is to transfer improved ways of talking to the home environment, one or both of the parents should, if at all possible, join the clinician and the child so that they can demonstrate for the parent(s) the changes he is making. Again, as with his teacher, he now knows that they know what to expect and that his mother and/or father approve. During the course of the therapy program, much of the communication between the clinician and the parents can be done by phone.
Preparing the Child for the Transfer of Improved Speech
The clinician cannot take the responsibility for "ensuring success" outside of the clinic room. The child must do it. The clinician does have the obligation, however, to maximize the chances that the child will be able to cope constructively with his communicative interactions involving increased emotion.
One must realize that it takes courage as well as motivation for a person to change his behavior. Furthermore, it takes courage, and for some, a great deal of courage to change speaking behavior in prescribed ways when he is scared of what might occur and fearful that he might fail. A child is no different from anyone else.
A clinician can talk with the child. She can find out his beliefs about stuttering. What does he think is wrong with him? Why does he stutter? What does he do to help himself talk "better?" What would he do or what would it sound like if he did not do that to "help himself?" How does he feel when he stutters? What does he think other people think of him when he stutters? These, as well as other questions, can be discussed with the child using language and examples that can be understood and shared. This can serve as the foundation from which to discuss with him what is "going on" when he stutters, the things he can do that will make it harder to talk, and the things he can do to help. From this, the clinician can discuss the therapy program. This should include what he will be asked to do, why he will do it, and what he will accomplish. The child should be made to feel that he is a participant in his own therapy program. Also, she can discuss with him his confusions and his fears about stuttering. He should be helped to understand that his "bad" feelings are normal, and that he is normal and OK, that he can learn to talk acceptably, that he will goof at times but that he can do it, and that the clinician, teacher, and parents are there to help in any way he wants them to help. When a child knows what is wrong, when he understands what he can do to help, when he feels relatively good about himself, and when he realizes people are supportive, it is much easier to have courage than it is when his talking world is mysterious, confusing and lonely.
In the therapy room, the clinician ordinarily works with the child in order to establish a desired speech response pattern. The "desired" behavior will vary from clinician to clinician depending upon her approach to therapy. Regardless of the approach used, however, the difficulty of establishing a desired response pattern usually will increase with increased complexity of the speaking interactions. These include the social complexity, the language-propositionality complexity, and the reaction complexity.
The social complexity involves those speaking situations usually thought of as the "transfer stage." They include, for example, talking to the clinician alone in the therapy room, talking to another child or an adult in the hall, talking to the teacher, and talking in the classroom.
The language-propositionality complexity refers to the nature of the speaking task. It involves, for example, the following: a one word response, a short comment, asking a question, answering a question, reading a word, sentence or a paragraph, telling a story or a joke, describing an event, and discussing opinions. Each of the above represents a different speaking task. There are, of course, many more.
The reaction complexity refers either to the way the listener reacts to the speaker or the way the speaker reacts to the speaking task. The listener may, for example, be attentive, be distracted and be paying little attention to what is said, be irritated and hurried, be smiling or chuckling, or be disgusted and shake his head and frown. On the other hand, the speaker may react and speak rapidly, slowly, hurriedly, deliberately, excitedly, calmly, etc. As each of the reactions of the speaker and listener change, the communicative interaction changes. The clinician can help the child learn to cope constructively with these changing listener reactions.
The child can practice the desired manner of speaking in the therapy room with the clinician. This first will be done at one level of language-propositionality complexity, with the clinician reacting with a constant level of complexity, usually attentively and calmly. Then, the child can vary the language-propositionality complexity. Also, the clinician can vary the listener's reaction pattern by role playing different reactions. Together, they can note the ways the child's feelings and speaking behavior change. This can help the child prepare for speaking outside of the therapy room. It can serve to emphasize the need to practice in "easy situations" in order to know what to do at those times when increased emotion is involved.
The clinician can then vary systematically the complexity of the speaking situation. The child first practices with the clinician. Then, prior to entering an outside situation, for example, asking the teacher a question, the clinician and child can role play the situation. The clinician is "the teacher" and the child asks the desired question. This is practiced until the child feels that he knows what to do. Then, he can go and ask his teacher the question. This type of therapy structure can be followed for increasingly complex speaking situations.
Children differ in the ease with which they transfer the improved manner of speaking. Some are able to transfer easily and consistently into increasingly difficult situations following a period of role playing with the clinician. Others have more difficulty. They are those with relatively strong emotional reactions associated with talking and stuttering. For these, it is helpful for the clinician to accompany the child during the early stages of transfer. For some, this is all that is needed. For others, more is needed. For these children, the clinician can help the child verbalize and accept his feelings of fear. For example, just before entering the situation, the clinician can say "are you scared now? Do you feel real funny right in your stomach? It's okay to be scared. Feel it. It doesn't hurt you. You can still talk even though you are scared. Let's practice again saying what you plan to say while you are scared. Good. Good. I'm with you. Let's go in and you begin to talk the way you want to even though you are scared. Once a child learns that he can cope constructively with his feelings and the way he talks, transfer progresses rapidly. School personnel can be very helpful. For example, the teacher can talk with the child about ways she can help. The school secretary, the janitor, and the cook can help by encouraging him to keep up the good work. Successful transfer into the school environment provides a firm foundation for maintenance of his improved speech.
Maintaining Improved Fluency
Early in this paper the point was made that the child is continually "establishing" improved fluency as he enters new situations. A therapy program should prepare him for such a challenge. This same concept exists for what is commonly called the "maintenance program." Maintenance involves no more than continuing the transfer phase, which in turn, involves no more than expanding the "establishing phase." We are dealing with a continuing process. We separate, at times, the learning process into three "phases" or "categories" for convenience of discussion and not because they reflect the reality of behavior change and stabilization.
In my opinion, if the child understands what he is doing to talk the ways he wants to talk, if he understands that he is continually learning to improve his speech, and if he understands that in learning we all "goof" at times, then he will be able to cope constructively with times when he occasionally stutters. If he does not understand these things, then, following an instance of stuttering, he will be prepared for little more than to "hope" that he will not do it again. This can rekindle feelings of fear and of helplessness. These feelings can be one of the first steps leading to regression.
As the child is transferring improved fluency into more and more types of verbal interactions, the clinician can be laying the foundation for maintaining this improvement. The child can participate in the planning of speaking tasks. This can lead to a period of time when he will make and carry out the assignments. The clinician's task is to help him learn meaningful ways to do it and to assess with him his progress. As a child becomes competent at planning, carrying out, and assessing his own daily speaking activities, then the clinician can begin stretching out times between clinical sessions. She may begin to meet with the child every two or three weeks. Then, if successful, the time period can be extended. If the child begins to experience difficulties in coping, they can meet more often until he gets back "on track." Then, the time periods can be extended again.
There are advantages to continuing to meet with the child for a year every two to three weeks even for 15 minutes each time. This helps him learn that therapy is not "ended." It emphasizes the fact that he is "expected" to continue improving. Furthermore, it provides for him the opportunity of having someone to "answer to" and having someone who can share his speaking experiences. In addition to this type of program, the school environment offers the opportunity to obtain the evaluations of other persons. The clinician can check with the teacher, secretary, principal, etc., who talk with the child. She can go out of her way to meet the child in the hall to ask, "How is it going?" If he says "okay," a smile, a wink, a pat on the back can keep things active and rewarding.
Embodied in the short talks with the child over time can be the philosophy that he is a pretty "normal kid" who may get tangled up at times when he talks, but that if he does, he can change what he is doing and talk the way he wants to talk.
This excerpt by Dean E. Williams, Ph.D., is from Stuttering Therapy: Transfer and Maintenance.