ASSESSING SPEECH-LANGUAGE PATHOLOGISTS’ COMFORT WITH STUTTERING By Corinne Smyk A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Communicative Sciences and Disorders – Master of Arts 2019 ABSTRACT ASSESSING SPEECH-LANGUAGE PATHOLOGISTS’ COMFORT WITH STUTTERING By Corinne Smyk There are approximately 3 million individuals in the United States who stutter; however, according to previous research, speech-language pathologists generally have lower levels of comfort and more negative attitudes regarding working with individuals who stutter. Although it is generally known that this population is not favored by speech-language pathologists, there has been a lack of research aimed at understanding why speech-language pathologists have these lower comfort levels and more negative attitudes. In the current study, the researchers interviewed speech-language pathologists across Michigan and gathered their input regarding working with students who stutter. The results indicate that there is a wide range in comfort levels and attitudes working with this population, based on a variety of correlating factors. ACKNOWLEDGMENTS I would like to thank my thesis advisor, Dr. J. Scott Yaruss, for being an excellent mentor, encouraging me each step along the way, and working with me throughout the past two years on this project. I would also like to thank the other members of my thesis committee, Dr. Peter LaPine and Dr. Morgan Ellithorpe, for their guidance, knowledge, and feedback throughout this process. iii TABLE OF CONTENTS LIST OF TABLES ............................................................................................................................................................ v INTRODUCTION ...........................................................................................................................1 CHAPTER 1 ....................................................................................................................................4 LITERATURE REVIEW ..........................................................................................................4 Clinician Attitudes Towards Stuttering ...............................................................................4 SLP Fluency Disorders Coursework ....................................................................................6 Interventions to Improve Attitudes Towards Stuttering ......................................................7 Purpose .................................................................................................................................9 CHAPTER 2 ..................................................................................................................................10 METHOD ................................................................................................................................10 Participants .........................................................................................................................10 Data Collection and Data Analysis ....................................................................................11 Credibility and Reliability..................................................................................................12 CHAPTER 3 ..................................................................................................................................14 RESULTS ................................................................................................................................14 Identified Themes ..............................................................................................................14 Comfort Level and Attitude .........................................................................................14 Knowledge and Experiences ........................................................................................15 Progress ........................................................................................................................16 Variability ....................................................................................................................17 Implications of Intervention .........................................................................................17 Inadequacy ...................................................................................................................18 Prevalence ....................................................................................................................18 When and How to Intervene ........................................................................................19 Complexity of Stuttering..............................................................................................19 Goal Setting .................................................................................................................20 Miscellaneous ..............................................................................................................20 Next Steps ....................................................................................................................21 CHAPTER 4 ..................................................................................................................................23 DISCUSSION ..........................................................................................................................23 Limitations .........................................................................................................................25 Future Directions and Implications ....................................................................................25 APPENDICES ...............................................................................................................................28 APPENDIX A: Demographic Questionnaire...........................................................................29 APPENDIX B: Interview Transcriptions.................................................................................31 REFERENCES ..............................................................................................................................55 iv LIST OF TABLES Table 1: Participant characteristics………………………………………………………………11 Table 2: Identified themes and subthemes……………………………………………………….14 v According to the National Institute on Deafness and Other Communication Disorders INTRODUCTION (NIDCD), approximately 3 million individuals in the United States stutter (2017). While therapy can help individuals who stutter to reduce their disfluencies, improve their communication abilities, and enhance their quality of life (Yaruss, 2010), stuttering in school-age children, adolescents, and adults is generally considered to be a chronic condition. Research shows that members of the general public have misconceptions regarding the etiology of stuttering and how to respond to those who stutter. In part due to these misconceptions, many people hold negative attitudes about stuttering (Boyle, 2017; St. Louis, 2011; St. Louis, et al., 2014). Even some professionals, including speech-language pathologists (SLPs) and teachers, harbor misconceptions and negative attitudes towards individuals who stutter (Boyle, 2014; Cooper & Cooper, 1996; Li & Arnold, 2015). These negative public attitudes can impact how people who stutter are treated (Arnold & Li, 2016), and this, in turn, can lead to discrimination and other challenges. Research has shown that negative attitudes can impact how the general public and even health professionals treat individuals with mental illness (Corrigan & Watson, 2002), cognitive impairments (Lewis & Stenfert-Kroese, 2010), and obesity (Phelan, et al., 2015). For example, people may avoid those with mental illness, withhold help from them, and coerce them into treatment (Corrigan & Watson, 2002). Nurses are more likely to hold negative feelings and attitudes towards patients with cognitive impairments and to provide reduced quality of care for these patients (Lewis & Stenfert-Kroese, 2010). Health care professionals hold negative stereotypes towards patients who are obese, correlating with reduced quality of care (Phelan, et al., 2015). This same situation may also exist with stuttering: people may avoid interacting with 1 those who stutter, and SLPs may allow their misconceptions about stuttering to affect their recommendations for treatment, even if this occurs unintentionally. Such attitudes towards people who stutter should be addressed in order to assure that SLPs have more positive perceptions of clients who stutter and can provide more beneficial treatment. According to the American Speech-Language-Hearing Association (ASHA) School Survey Report, 68% of clinicians work with people who stutter (ASHA, 2014). Despite this number, converging and long-standing evidence leads to the fact that many SLPs harbor negative feelings and a negative stigma towards this population (Boyle, 2014; Cooper & Cooper, 1985; Cooper & Cooper, 1996). Few, if any, studies have examined why these attitudes remain despite attempts to improve public perceptions about stuttering. It is important to understand what this negative stigma stems from in order to better know how to change it. One possibility is that clinicians have not had sufficient education about stuttering, for studies have shown that it is possible to graduate from SLP master’s degree programs without having taken a course on fluency disorders or gaining any clinical experience with people who stutter (Yaruss, 1999; Yaruss & Quesal, 2002; Yaruss et al., 2017). Even practicing SLPs who have had a graduate course in fluency disorders expressed discomfort with stuttering, as clinicians self-reported that they do not feel fully competent working with clients who stutter (Kelly, et al., 2007). Therefore, further research is needed in order to understand why clinicians harbor such discomfort and stigma towards stuttering. The Expectancy Violations Theory (EVT) has been applied in many disciplines (e.g. business, law, medicine, psychology) regarding human behavior and expectations (Clor-Proell, 2009; Sears & Stanton, 2001; Sleath & Woodhams, 2014). The premise of the theory is that when expectations are not met, they violate beliefs. These violations can be seen as positive or as 2 negative depending on the initial expectation (Burgoon, 2015). For example, if the expectation is that a coworker is lazy and he violates those expectations by being productive, the violation would be seen as positive—and more positive than if the co-worker had initially been viewed neutrally. In contrast, if a coworker is expected to be productive but is actually lazy, they would be viewed negatively, even if the production output of the two individuals is the same. Again, the view would likely be even more negative than if the co-worker had initially been viewed neutrally. As applied to the challenge of negative perceptions about stuttering and people who stutter, it may be that SLPs have inaccurate expectations regarding their clients who stutter. This could impact how they view their clients. For example, if an SLP expects that an elementary- aged child who stutters will “grow out” of the stutter instead of understanding that it is a lifelong diagnosis, they may have a negative view of that child when they are on caseload for the duration of their elementary years. This negative view may, in turn, lead to anger and unwillingness to help their clients who stutter (Boyle, 2014). Understanding the basis of misconceptions about stuttering and identifying the underlying causes of those misperceptions can help clinicians and researchers develop programs to reduce stigma about people who stutter. This can potentially increase the quality of care that SLPs offer their clients who stutter. The purpose of the present study, therefore, is to gain more knowledge about the factors that may contribute towards negative stigma towards clients who stutter held by SLPs. This information can then be used in the development of effective methods for changing and improving attitudes about stuttering held by SLPs – and, ultimately, for improving treatment of children who stutter. 3 CHAPTER 1: LITERATURE REVIEW Clinician Attitudes Towards Stuttering Many studies have demonstrated that SLPs have negative attitudes and misconceptions towards working with clients who stutter and that these attitudes are present in SLPs around the world (Boyle, 2014; Cooper & Cooper, 1996; Crichton-Smith, Wright, & Stackhouse, 2003; Lee, 2014; Wesierska, Wesierska, St. Louis, & Beste-Guldborg, 2015). An early study by Cooper and Copper (1996) analyzed the attitudes that practicing clinicians held towards their clients who stutter over two decades. Using the Clinician Attitudes Towards Stuttering (CATS) scale, they found that SLPs had incorrect knowledge regarding stuttering etiology. Many respondents held the belief that stuttering is associated with psychological problems. The researchers also found that a majority of SLPs believed that generally, clinicians were not adept at treating clients who stutter, and 93% felt they were less comfortable working with clients who stutter compared to clients with an articulation disorder. Another study used the CATS scale and showed that 95% of clinicians in the United Kingdom also felt uncomfortable working with clients who stutter (Crichton-Smith, Wright, & Stackhouse, 2003). Using the CATS scale, Lee (2014) found that many SLPs in Korea believed that parents contribute to their child’s stutter. Respondents also indicated that they felt unprepared to work with clients who stutter. These findings show that negative views and misconceptions about stuttering are held in countries around the world. Wesierska, Wesierska, St. Louis, and Beste-Guldborg (2015) used the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S) to compare Polish SLPs and Polish SLP students. They looked at attitudes and knowledge that participants held regarding people who stutter. The study showed that SLPs and SLP students believed people who stutter to be more shy, nervous, and fearful. Both groups had low scores for whether or not individuals who stutter 4 can succeed in any job. They also found that both groups scored low on comfort level for working with clients who stutter, experience working with clients who stutter, and knowledge regarding stuttering and stuttering treatment. The researchers found that SLPs and SLP students scored higher (more positively) on the POSHA-S compared to members of the general public; however, the low scores for knowledge, comfort level, and personality traits for people who stutter are still of significant concern, given that SLPs are the professionals who are responsible for evaluating and treating individuals who stutter. Swartz, Gabel, and Irani (2009) analyzed SLPs’ attitudes towards people who stutter compared to individuals who do not stutter. The researchers used a semantic differential rating scale with 26 traits, and instructed clinicians to rate how they perceived the two populations. The researchers found that there seems to be an overall improvement in SLPs’ attitudes towards people who stutter compared to Cooper and Cooper (1985); however, a different scale was used, making it difficult to directly compare the results. Additionally, Swartz et al. (2009) commented that the improvement in clinician attitudes may be due to SLPs providing more socially desirable and acceptable responses, which they identified as a weakness of the semantic differential scale. Boyle (2014) used rating scales to assess how practicing SLPs viewed three different client populations with respect to four characteristics: (a) perceived onset and offset controllability (i.e., how much control they believe the person has over their disorder), (b) willingness to help the individual, (c) sympathy, and (d) anger about working with clients from each population. Boyle compared SLPs’ attitudes toward middle school students diagnosed with either stuttering, cerebral palsy, or a functional articulation disorder. He found that SLPs held more negative attitudes, even anger, towards working with clients who stutter compared to clients with cerebral palsy or functional articulation disorder. Boyle hypothesized that this may 5 stem from the SLPs’ beliefs about the onset and offset controllability of stuttering, meaning that clinicians were more inclined to believe that stuttering could be controlled by the individual compared to the other two disorders. Viewed in the framework of EVT, SLPs may have increased negative attitudes towards children who stutter because they believe that their clients should be able to control their stuttering; the SLPs may become upset when their clients do not conform to this expectation. SLP Fluency Disorders Coursework Many studies have indicated that SLPs do not receive sufficient education about fluency disorders, including stuttering (Kelly et al., 1997; Tellis, Bressler, & Emerick, 2008; Yaruss, 1999; Yaruss & Quesal, 2002; Yaruss et al., 2017). Yaruss and Quesal (2002) reported that one quarter of ASHA-accredited programs do not require their graduate students to take a course in fluency disorders. They also found that there was a decrease over time in the number of full-time faculty teaching at the graduate level who reported having clinical expertise in fluency disorders. Overall, it appears that approximately 65% of graduate students can graduate without any clinical experience in fluency disorders, though it is not clear exactly what percentage actually does so. Yaruss et al. (2017) surveyed ASHA-certified graduate programs in an update to the literature and found that in one-third of graduate programs that require coursework in fluency disorders, it is possible for students to graduate without having any direct clinical experience with clients who stutter. This means that there are many SLPs entering the field without any coursework or hands-on clinical experience with people who stutter. This lack of direct experience may contribute to the negative feelings towards clients who stutter. Still, there is a 6 lack of a compelling explanation for why clinicians who do have coursework or clinical experience also report discomfort and a lack of knowledge about working with those who stutter. Tellis et al. (2008) studied SLPs’ views about assessment and treatment for people who stutter. They found that even with graduate coursework in fluency disorders and stuttering, as well as continuing education in stuttering and other fluency disorders, clinicians continued to lack knowledge and skills regarding how to assess and treat clients who stutter. Almost half of the participants (46.5%) indicated that they felt uncomfortable working with clients who stutter, and many lacked knowledge regarding treatment techniques for stuttering. For example, over half of respondents indicated that they did not know about how to teach clients to freeze during blocks (74.6%), or to use pull-outs (51.2%), cancellations (60.0%), or preparatory sets (68.5%). Half indicated that they could not differentiate between fluency shaping and stuttering modification (50.8%), and more than three-quarters were unfamiliar with commonly used treatment approaches such as the Lidcombe Program (78.2%). These quantitative results indicate that many clinicians lack the knowledge necessary to provide appropriate treatment for their clients who stutter. Interventions to Improve Attitudes Towards Stuttering A few studies have analyzed the impact of interventions on changing and improving practicing SLPs’ attitudes towards working with clients who stutter, though some studies have examined the impact of interventions on other populations (Leahy, 1994; McGee et al., 1996; Snyder, 2001; Flynn & St. Louis, 2011; Langevin & Prasad, 2012; Abdalla & St. Louis, 2014; Abdalla, 2015). Abdalla (2015) overviewed the literature available regarding studies that have attempted to improve perceptions towards people who stutter. The author found that some studies have shown inconsistent results with few statistically significant improvements in 7 attitudes towards people who stutter, and other studies found that interventions are ineffective at changing attitudes. For example, Abdalla and St. Louis (2014) attempted to improve views of teachers and student teachers in Kuwait towards people who stutter. They used an educational video and personal testimonies of people who stutter to try to improve attitudes. The results showed minimal improvements in the student teachers but no improvements in the teacher population. Studies by Leahy (1994) and Snyder (2001) analyzed intervention method for future SLPs (SLP students). Leahy (1994) included participants who simulated stuttering. The author reported that there were positive changes in attitude from pre- to post-survey; however, these changes were not statistically significant. Snyder (2001) used two types of videos with SLP students. One video was intended to be emotional and informative; it included a personal account from a person who stutters. The other video was more informative, detailing a research study involving people who stutter. In both groups, the change from pre- to post-video was minimal and not statistically significant. Boyle, Dioguardi, and Pate (2016) detailed three potentially effective methods for improving attitudes towards people who stutter. The three methods include: education, protest, and contact. Education involves dispelling myths about stuttering and informing individuals about actual facts. Education campaigns have been used to reduce negative attitudes towards other stigmatized topics, such as mental illness (Evans, 2005). Protest includes responding to the negative treatment and injustices that people who stutter experience. Contact involves individuals interacting with a person who stutters and learning about their experiences as a first- person account. The authors found that all three methods were effective in improving attitudes towards people who stutter based on pre- to post-surveys. The authors found that all methods 8 reduced “negative emotions, stereotypes, and discriminatory intentions” (Boyle, Dioguardi, & Pate, 2016, p. 51) and that the education and contact methods were most effective in improving participants’ positive attitudes towards people who stutter. As of this writing, these methods have not yet been directed towards practicing SLPs. Purpose The literature has shown that SLPs have long held negative attitudes and feelings of discomfort with people who stutter, and that these attitudes are present in clinicians around the world. Research has shown that there is a lack of appropriate education and/or clinical experiences in graduate school with fluency disorders prior to entering the workforce. Additionally, studies have shown that there have not been any intervention studies targeting practicing SLPs to modify attitudes. Furthermore, the studies that have been conducted with other populations have been minimally effective. Research has shown that SLPs feel uncomfortable, unprepared, and generally negative towards their clients who stutter. The reasons that SLPs feel like this are not fully understood, however. If the field hopes to change this situation and help clinicians respond in a more neutral or even accepting fashion toward people who stutter, then it is critical to understand the specific underlying reasons that clinicians feel uncomfortable and/or hold negative attitudes about stuttering. The purpose of this study is to address this gap in the literature by examining the underlying issues that clinicians have about working with people who stutter. This information will inform the development of effective interventions design to improve clinician attitudes towards people who stutter and, ultimately, the treatment they provide for this population. 9 To gain the perspectives of SLPs about working with people who stutter, this study CHAPTER 2: METHOD employed a qualitative method. The first author interviewed SLPs about their thoughts, beliefs, and experiences in stuttering intervention. After transcribing the interviews, the first author analyzed common themes or patterns in their responses which were identified for further study. The study was conducted using semi-structured interviews, completed with each participant individually. This design was chosen in order to gain a greater understanding of SLPs’ attitudes regarding their clients who stutter, and the reasoning behind attitudes and perceptions of these clients. All information regarding the participants was kept confidential, in accordance with IRB regulations and to increase the likelihood that participants would provide honest answers. The current study was judged to be IRB exempt (category 2), under 45 CFR 46.101(b) 2. Participants The participants in this present study included 11 school-based SLPs who currently work with school-age children. Participants were required to possess the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) and have at least 5 years of clinical experience. Participants for this study were recruited using convenience sampling through email, social media advertising on multiple platforms, and personal contacts of the authors and affiliated university. Exclusion criteria included having less than five years of experience or working in a medical setting where clinicians are less likely to interact with children who stutter. Board- certified specialists in fluency disorders and individuals who stutter themselves were also 10 excluded in order to reduce potential bias associated with having greater knowledge of and experience with stuttering. Demographic information for the participants was collected through an online questionnaire. This questionnaire requested information from the participants about topics such as years of experience, amount of experience with clients who stutter, and type of graduate training in fluency disorders. The questions which were asked in this demographic questionnaire are presented in Appendix A. The 11 participants in this study were all school-based SLPs currently employed in the state of Michigan. All participants held the Certificate of Clinical Competence, and as a group had a collective average of 15 years of experience in the field. For specific demographic information regarding each participant, please see Table 1. Participant Years with CCCs Setting/Caseload Age Fluency Disorders Table 1: Participant Characteristics Coursework 1 2 3 4 5 6 7 8 9 10 11 14 24 6 27 20 19 5 25 5 12 10 ASD and ECSE rooms Elementary School Preschool and ECSE Elementary School 30-39 No graduate course 40-49 One graduate course 30-39 One graduate course 50-59 One graduate course K-12th grade and EI room 40-49 One graduate course 40-49 One graduate course 30-39 One graduate course 60+ One graduate course 20-29 One graduate course 40-49 One graduate course 30-39 One graduate course Lower Elementary Preschool-12th grade ASD and Preschool Preschool Elementary School Preschool-12th grade Data Collection and Data Analysis The demographic questionnaire was used in order to determine if the participants met the inclusion and exclusion criteria to participate in the present study. A total of 16 individuals completed the demographic questionnaire in its entirety. Of these 16 individuals, 14 met the inclusion and exclusion criteria for the current study. If a potential participant met the 11 inclusion/exclusion criteria described above, they were then contacted by the first author with an invitation to participate in an online video/audio semi-structured interview. The interviewer asked open ended-questions regarding participants’ attitudes and experiences about working with clients who stutter (e.g., “Can you describe an experience working with a client who stutters?” “What type of training have you had regarding fluency disorders?”). Based upon the participants’ response, the interviewer proceeded to ask follow-up questions for clarification (e.g., “Can you talk more about your feelings when working with this client?” “Why do you think you feel this way when working with clients who stutter?”). No suggestions about whether or how respondents should think or feel about stuttering therapy were introduced by the examiner; all ideas were introduced by the respondents, and the examiner only used follow-up questions to explore previously introduced ideas. Once the interviews were completed, the author transcribed the responses. The complete transcript of responses can be found in Appendix B. The responses were analyzed by coding themes, and then calculating frequency of occurrence through NVivo analysis software. Coding was completed by multiple investigators in order to promote high inter-rater reliability with themes and frequency of the themes (meaning units) present in interviews. Subgroups of responses were explored to determine if there were relationships between respondent characteristics and the presence or absence of identified themes. Credibility and Reliability Credibility was established, in part, though a saturation analysis. The first author interviewed participants from the initial 10 participant to identify relevant themes. Then, data from an additional (11th) participant were analyzed to see if any new themes were identified. 12 This analysis revealed no additional themes, suggesting that saturation was reached and that no additional interviews were necessary. In order to promote inter-rater reliability, a second investigator analyzed the themes identified by the first author. The second investigator identified themes that could be adjusted and collaborated with the first author in order to reach a consensus regarding the identified themes. 13 CHAPTER 3: RESULTS Identified Themes During the interviews, participants talked about their experiences with stuttering and about how these experiences affected their attitudes and comfort level when working with people who stutter. Overall, a total of 12 themes were identified in the participants’ responses, along with 12 subthemes that further described their experiences. The 12 identified themes are presented in Table 2 and discussed below. Supporting data for each theme is presented via representative quotes from the participants’ interviews. Table 2: Identified Themes and Subthemes Theme Comfort Level/Attitudes Knowledge and Experiences Progress Variability Inadequacy Prevalence When and How to Intervene Complexity of Stuttering Implications of Intervention Goal Setting Miscellaneous Next Steps Comfort Level and Attitudes Subthemes • Comfortable/Positive • Uncomfortable/Negative • Helpful • Not Helpful N/A • Variability Between Individuals • Variability Within Individuals N/A N/A • When to Qualify • How to Qualify N/A N/A N/A • Motivation • Preparing Therapy Materials • Seeking Information • Not Taking Action Frequency 13 22 15 10 15 5 5 9 8 6 2 6 5 4 1 1 12 4 Based on the interviews from the participants, the overarching theme was related to comfort and attitudes regarding stuttering. Some participants self-identified as being comfortable 14 with stuttering. They expressed that they enjoyed working with children who stutter, as shown in the following participant quotes: Participant 3 (P3): I do really enjoy working with stuttering. I know that’s kind of not the norm. P5: I feel pretty comfortable just because I'm not the type of person who thinks I know it all. P7: I mean I'm definitely interested in fluency… and I feel like I really connect with those students. Other participants self-identified as being uncomfortable with stuttering. They expressed that they did not prefer to work with children who stutter, as exemplified by the following comments from participants: P4: I would have to say fluency [is my least favorite]. I don’t feel confident. P8: I think that everybody kind of rolls their eyes at [stuttering].” P10: I feel frustrations, not with the kids themselves, but with myself. The following themes were discussed by participants as factors that contribute to their comfort levels and attitudes towards stuttering. Knowledge and Experiences Multiple individuals discussed their knowledge and experiences with stuttering. Many of these comments included thoughts about how graduate school and additional experiences all impacted their overall knowledge and experiences. Although individuals may have talked about similar topics (such as graduate school), these shared experiences were sometimes interpreted differently, as being both positive and negative. Therefore, this theme was divided into two subthemes: helpful experiences and unhelpful experiences. 15 Helpful Experiences P3: When I was in grad school, my first student internship was with a supervisor who worked at a fluency clinic where students came. I just really liked [stuttering]. P6: I had a fantastic stuttering class in grad school that was just stuttering for an entire semester. My professor did a lot to shape my view and perception and comfort. I remember my first student who stuttered, and I went back to my professor… and I said “I just want to let you know that it’s only because of you that I felt comfortable and confident.” P5: I have had preschoolers, lower elementary, upper elementary, and even high schoolers and middle schoolers who have all stuttered. I also have a family friend who stutters… so I feel pretty comfortable. P11: I went to a camp for kids who stutter… it was an interesting experience for me. Unhelpful Experiences P1: It would have been nice if I had more coursework on this or that [strategy]. P4: I don’t feel like I had a good background [in stuttering] in grad school. P10: I don’t always know how to answer the parents’ questions… I don’t feel like I know enough to have a great handle on it. Progress In response to a query about disorder areas that they preferred to work with, participations indicated that a number of areas other than stuttering were preferred. In fact, only a few indicated that stuttering was an area that they preferred. A theme arose regarding the reasons that they preferred some areas over others (and especially over stuttering): specifically, the progress that is observed through therapy. P1: I’m just happier with other things because… it works well and we’re making good progress. P9: [My favorite are] the little ones, like ages two to three. Most like the ones with delayed expressive language, because they usually have pretty good progress and parents are happy, so it’s nice to see that. 16 P6: There are some students that you try strategies with that you don’t find success, and they tell you that they don’t find success with those strategies… In my dream world, I’d like to find a strategy that works right away. P10: I think maybe I’m instant gratification, but like I said with the phonological errors, I can see a ton of progress. And I feel like with kids that have fluency issues on my caseload, I see progress and then I see about 10 steps backwards. So, I feel like my continuum of progress is different. And maybe it’s because I like seeing success after success after success. I mean, stuttering is a lifelong disorder or issue, so the progress is going to be different than anything else. Variability Stuttering itself is known to be variable in its presentation, from person-to-person and over time within a specific person. The variable nature of stuttering (between individuals and within individuals) was frequently cited as a factor affecting clinicians’ understanding of and comfort with stuttering. Variability Between Individuals P5: I think with stuttering it’s not cut and dry. You know, fluency is so specific to each individual. P6: You try different strategies and see what works for each student. So, I think it’s trial and error. Variability Within Individuals P8: I began to realize that there were weeks at a time where they [students] didn’t need me, but then they might again. P5: And it just depends on the day whether or not you see a lot of disfluencies with him or not. Implications of Intervention Participants discussed their concerns about the implications of their intervention. For example, some expressed fears about what might happen if they choose to intervene or not to 17 intervene at a particular moment in a child’s life. Participants also mentioned the potential impact of therapy, specifically, the fear of doing more harm than good for students. P8: I think underlying stuttering is always the fear: am I going to make it worse? I think out of all of the speech problems, I think that fluency is just one of the most horrible for the person themselves. And you really want to come through for them… P11: It seems like there’s such grave consequences for a preschooler that I work with to persist with stuttering and be a person who stutters. P10: Communication is such an intimate thing. With fluency, if you’re really treating it well, you have to get into those emotions. And sometimes, I just don’t know how far to probe. I’ve made kids cry in therapy before, not on purpose, but it’s not a good feeling. I just don’t want people to feel uncomfortable around me, and I hope I’m not doing anything to make them feel uncomfortable… I don’t want to cause more harm to the student. Inadequacy Multiple participants discussed feeling a sense of inadequacy and other co-occurring emotions regarding their ability to effectively provided treatment for children who stutter. P4: I would have to say fluency [is my least favorite]. I don’t feel confident. I wish I was more confident. I don’t have anything against the students themselves. I feel nervous I think because I don’t feel like I’m giving them everything they need. P8: There’s the initial anxiety of “Oh golly, here we go again. I hope I can do a good job for this kid.” … And if there’s some bullying going on, that can make you feel inadequate. P7: There’s … just this feeling of you don’t know what you don’t know. P10: I feel like I just have such a lack of knowledge… I just feel like I don’t know enough about fluency. I don’t always know how to answer the parents’ questions. I just don’t feel like I have a great handle on it. I feel frustrations, not with the kids themselves, but with myself. I don’t know if it’s just that personality of an SLP, where we are all often type A and are anxious about wanting to be perfect. Prevalence Research shows a relatively high incidence for preschool stuttering: 5% in some studies (e.g., Yairi & Ambrose, 2005) and as much as 11% in others (Reilly et al., 2013). The overall 18 prevalence of stuttering is roughly 1% (Yairi & Ambrose, 2005). Nevertheless, respondents routinely suggested that stuttering is not common. They highlighted the difficulties with not seeing children who stutter frequently enough due to the perceived low prevalence of stuttering. P2: It’s a more challenging diagnosis when you don’t have many students [who stutter]. P8: I think the problem is that they don’t come along often enough to keep your feeling of confidence up. If they were regular… I don’t think it would be as much of a problem. When and How to Intervene Participants talked about their uncertainties and concerns regarding qualification for students who stutter for possible intervention. This theme was divided into two subthemes: when to qualify students, and how to qualify students. When to Qualify P1: And [the questions have] been more about “When do we pick up?” “When do we treat?” “When do we back off?”… I’m still in the process of teasing it out and watching [this student]. P11: Like if I don’t pick them up when I should, or if I can’t resolve the issue by the time they’re 7 or 8, that it will be a lifelong impairment for them… Again, working at the preschool level just made me feel a little bit more uneasy that I’m missing out on picking all of these kids up when I should be. How to Qualify P6: Another part that is a struggle sometimes in the schools is we have to relate how it impacts them educationally. If they are doing really well academically, it is really hard to justify some of those services… I hate doing fluency evaluations because they are so time consuming. So that is probably my least favorite part about working with students who are disfluent. Complexity of Stuttering Some participants discussed the multi-faceted nature of stuttering, and how its added complexities impact their comfort levels and attitudes towards working with children who stutter. 19 P2: I think the best-case scenario when working with students who have disfluencies is when that is the only area that is academically challenging. So, it's more of a pure disorder, so not co-occurring with other things. P9: But you have to really consider the emotional aspect with stuttering as well. And then also, how parents feel about it. I just feel like it's very different from a lot of the other disorders that we work with. Goal Setting Some individuals talked about their uncertainties about how to set treatment goals for children who stutter, along with how they measure the outcomes for these goals for students who stutter. P4: I would just feel confident if I could make a difference in their speech. I try to write goals that are specific to using certain strategies. And, then track progress on how well they put that strategy into use. P9: I am kind of in the middle but I enjoy it… when I write goals obviously being able to control their fluency would be ideal, but I think that the confidence is the main thing for me. P11: Probably fluency [is my least favorite]…I mean usually I write goals that students will identify different strategies and then that they'll implement them. And then maybe that they'll use it to demonstrate whatever percentage of fluent speech. Miscellaneous In addition to the main themes discussed above, two miscellaneous subthemes were mentioned across all of the interviews that also related to feelings of comfort. Although they were not reported by multiple participants, they were still judged to be relevant to the experiences of clinicians who work with children who stutter: 20 Motivation One participant discussed student motivation, and how that impacts comfort levels when working with students who stutter. Some students with fluency disorders are motivated, and others are not as motivated to participate in therapy. P2: I enjoy kids who are engaged and willing to work… and just want to do better with their speech… I think I feel more comfortable because I’ve got students who are motivated. Preparing Therapy Materials One individual discussed the longer amount of preparation time it takes to prepare materials for treating students with fluency disorders, especially when compared to preparing for treating other students on caseload. P1: I would say I’m happier doing other things. [With language and AAC] I feel like I have a good flow and it works well… [with stuttering] I would say that it takes more prep. Next Steps The previous examples from participants all illustrate different reasons that impact why individuals feel a certain way in regards to working with children who stutter. In addition to these factors, another theme arose during thematic analysis: what do individuals do about these feeling? This theme was divided into two subthemes. Some individuals described taking action and seeking out information in order to increase their confidence and/or comfort with stuttering. Other individuals indicated that they just don’t know what to do. Seeking Information P5: So I’m not afraid to ask for help. So when I was really struggling I ended up talking with my fluency professor. It was a really good idea. P2: I think I feel more comfortable because… I did a lot of continuing education DVDs. 21 P11: I’ve sought out quite a bit of professional development about it. I went to an early childhood stuttering course, and it really kind of shook my core beliefs. P7: I would say that I'm definitely in a phase of actively trying to learn more about [stuttering]. Some individuals who identified themselves as having more experience with stuttering talked about being a resource for other speech-language pathologists to reach out to them, as well. P3: Yeah [other colleagues] have definitely reached out to me multiple times… if they have stuttering questions, they do come to me because they don’t have a lot of experience. Not Taking Action P4: [Stuttering] is not something I’ve focused on as far as continuing ed. P9: I haven’t taken a lot of CEUs about [stuttering]. 22 CHAPTER 4: DISCUSSION Although previous research has demonstrated that SLPs generally hold negative attitudes and are uncomfortable working with stuttering, analysis from the present study suggests that there is a wider range of attitudes that SLPs have towards working with stuttering. Some individuals expressed enjoyment, comfort, and overall positive attitudes towards this clinical population. Other participants identified stuttering as an area associated with discomfort and more negative attitudes. Individuals who tended to enjoy stuttering and rated themselves as being comfortable working with stuttering commented on similar themes during their interviews. These individuals had positive graduate school experiences with supportive faculty members, were more likely to take advantage of continuing education opportunities that focus on stuttering, had volunteered to participate in outside experiences related to stuttering, and were more likely to take action and seek out help when confronted with a difficult student or situation. Individuals who tended to dislike stuttering and indicated they were more uncomfortable working with stuttering commented on several themes during their interviews as well. These participants did not have as helpful of a graduate school experience, did not feel that they saw enough students who stutter, believed that they were inadequate to deal with the counseling and emotional aspect of stuttering, were concerned with feeling inadequate and about the implications of intervention, had difficulty knowing when to qualify individuals for therapy, wanted to see more progress with their students who stutter, and were less likely to seek out continuing education with a focus on stuttering. Additionally, the analysis showed that SLPs are more likely to favor working with individuals who have clear progress and better treatment outcomes. This was illustrated 23 repeatedly in the responses to the following question posed by the researchers: “What type of student is the most enjoyable for you to work with, and why?” Consequentially, stuttering was less favored by SLPs as these students do not make as much progress, due to its chronic nature. The Expectancy Violations Theory (EVT; citation) may play a role in these situations related to how clinicians perceive student progress. Clinicians may be expecting that students who stutter will make the same amount of progress as other types of students that are on caseload, such as students with articulation, language, or phonological disorders. However, school-age students who stutter will likely continue to stutter throughout their lives (Yairi & Ambrose, 1999). The expectation that these students who stutter will make as much progress as other students is violated in a negative manner, therefore leading to more negative attitudes towards stuttering. Researchers also found that individuals who identified as feeling more uncomfortable with stuttering may be targeting inappropriate/ineffective goals for individuals who stutter. Some of these inappropriate goals included targeting a percentage of fluent speech for older students. Based on research, students at this age would benefit more from goals focused on “increasing acceptance of stuttering and of being a person who stutters, reducing secondary behaviors, minimizing avoidance, improving communication skills, increasing self-confidence, managing bullying effectively, and ultimately, minimizing the adverse impact of stuttering on the child's life" (Yaruss, Coleman, & Quesal, 2012, p. 537) versus focusing solely on reducing the frequency of disfluencies in conversation. Additionally, the ASHA Practice Portal for Childhood Fluency Disorders states: When developing treatment goals, the clinician considers the extent to which stuttering affects a child's life…Goals that focus on minimizing these difficulties may aid children in reducing the effort used to hide or avoid disfluencies and help them begin to 24 communicate with more ease. Such goals may result in increased observable disfluent behaviors, because children may start communicating more freely (ASHA, 2019). The EVT may impact the comfort levels and attitudes of these clinicians as well. Their expectations for student progress towards these goals may be violated, in part due to the fact that the goals are not the most appropriate for the student. As the EVT has shown, when expectations are violated in a negative manner (such as not meeting the goal, or not making progress), this can lead to more negative attitudes towards the object violating expectations (the students who stutter). Limitations Results from this study revealed multiple factors that impact comfort levels and attitudes of SLPs towards stuttering. However, there were also limitations to the present study. It was difficult to recruit participants who were willing to be interviewed about their experiences with stuttering. The researchers speculate that this may be due to not wanting to discuss an area of perceived weakness or difficulty, or being less willing to talking about topics that create a sense of discomfort. Additionally, the researchers utilized a convenience sampling method, versus a random sampling method (which would promote higher levels of external validity). Furthermore, the participants may have been impacted by the Hawthorne Effect (Landsberger, 1958). Individuals could have changed their responses or views, due to knowing that they were participating in a study with a focus on stuttering. Future Directions and Implications The purpose of the present study was to gain more knowledge about factors influencing SLPs’ comfort levels and attitudes towards stuttering, in order to help improve these attitudes. Therefore, future directions include the utilization of these results in creating an effective 25 intervention that targets factors correlated with discomfort and negative attitudes towards stuttering. By gaining more knowledge regarding underlying reasons why these feelings of discomfort and negative attitudes occur, an intervention is more likely to be effective with improving these feelings. Based on these results, there are many methods that can be utilized in order to improve both comfort levels as well as attitudes that SLPs have regarding stuttering. One approach is to improve graduate-level coursework in fluency disorders for future SLPs and specifically target themes that were mentioned by those who are uncomfortable with stuttering. This might include focusing more on appropriate goal writing, when and how to qualify students who stutter, the importance of seeking out information, participating in continuing education focused on stuttering, and implications of intervention. In order to improve the attitudes of currently practicing SLPs, it is important to start with encouraging continuing education focused on stuttering. This may need to be campaigned for by the state organization or employer, in order to ensure that individuals are seeking out that information and taking action. If this first step is not completed, then it will be difficult to reach these individuals who feel uncomfortable. Continuing education should focus on areas of identified concern, such as addressing feelings of inadequacy, lack of knowledge, wariness of the implications of intervention, and inappropriate goal writing. These themes were consistently mentioned by individuals who felt uncomfortable with stuttering. The results indicate that an overall lack of knowledge regarding stuttering is involved with each of the themes mentioned above. Discomfort and negative attitudes are related to the stigma towards stuttering, which is long-standing among SLPs. Therefore, it will take time and effort in order to improve these attitudes and reduce this stigma. By improving graduate-level 26 fluency coursework for future SLPs, encouraging practicing SLPs to participate in continuing education and seek out information about fluency disorders, and modifying information provided in these continuing education courses or lectures, these steps can all aid to improve SLPs’ comfort levels and attitudes towards stuttering. 27 APPENDICES 28 APPENDIX A Demographic Questionnaire 29 1. Do you currently hold the CCC-SLP? ___No ___Yes ___In the past; currently expired 2. Years in the Field post-CCC: _________ 3. Gender: _______ 4. Are you a member of ASHA SIG4 (for Fluency Disorders), the International Fluency Association, or any other professional organization related to fluency disorders? If so, please list the stuttering-related professional organizations you are affiliated with. ___Yes ___No 5. Do you hold any specialty certifications? If so, please indicate below. 6. Graduate Coursework in Fluency Disorders ___No graduate-level courses specifically on fluency disorders ___Part of a course ___One full course ___More than one course 7. Do you now participate or have you participated in support or self-help groups for people who stutter (e.g., the National Stuttering Association, Friends: The National Association for Young People Who Stutter; SAY: The Stuttering Association for the Young, or any stuttering camp program)? If yes, please elaborate. ___Yes ___No 8. Have you ever participated in continuing education for fluency disorders? If so, please elaborate. 9. Do you now, or have you ever considered yourself to be a person who stutters? ___Yes ___No 10. Do you now, or have you ever known someone who stutters, who is not a client/previous client (e.g. family member, spouse)? If yes, please elaborate. ___Yes ___No 11. On average, approximately how many people who stutter do you work with in a given year? ___0 ___1-2 ___3-5 ___6-10 ___10+ 12. On a scale from 1-10 (1=very uncomfortable, 10=very comfortable), how comfortable are you working with clients who stutter? ______ 13. Age: ___20-29 ___30-39 ___40-49 ___50-59 ___60+ 30 APPENDIX B Interview Transcriptions 31 *Key: Normal Text: Interviewer; Bolded Text: Participant Participant 1 Can you just briefly tell me about what type of setting you work in? I work in four school districts and I’m on our preschool evaluation team. We only get the more severe cases or multidisciplinary cases, so kids that need a speech therapist and a psychologist or something like that. So, we don’t get many that are straight speech kids. And then I cover two self-contained preschool rooms that are all early childhood self- contained special education rooms. And then I cover another preschool that’s about half and half with general ed and special education. You sound busy! That sounds like fun. It is. CS: So out of all the students that you work with, which are the most fulfilling for you, or which do you enjoy working with the most? I like all my preschoolers and I like the variety. Like for a while some of our classrooms were like this is a classroom for Autism. So, I prefer kind of intermingled and mixed. Alright so of course we love all of our students and we like working with all of them, but is there a population that you don’t enjoy working with as much? I don’t like the straight articulation kids. If it’s complex phonology then I’m more interested, but I think that’s what I would struggle with more for the more school-age kids. Do you work with any students who stutter, or have you ever worked with any students who stutter? I do, or well I have. I don’t have any with fluency goals right now, but we’re noticing a couple of kids on caseload have started having more disfluencies so we’re kind of watching to see if it’s more of normal disfluency phase or if it’s something more. I know that one is already on my caseload and one is in the gen ed portion of one room. And I’ve kind of noticed it enough that I’m more concerned. We’re in that period of watching and it’s been… one of them I’ve noticed more last week like “wow that’s quite a block there.” And the other one, it kind of ebbs and flows. It was a couple weeks before Christmas break that I started becoming aware of his speech that way. So, it’s been a little less than 8 weeks. And they’ve both had big jumps in their language skills and they’re more on the active side and they have these big ideas that they’re quickly trying to get out before they zoom off so I’m still in the process of teasing it out and watching. And actually, trying to get more information from the parents. Nothing direct but more indirect stuff here and there. So, you mentioned that you enjoy working with the mix of students and kind of more of those complex cases, and then the other side that straight artic type student… where does stuttering fall into this mix of ones that are the most enjoyable and then ones that aren’t your favorite as much? I would say probably in the middle probably leans more on the “like” side. Okay. At this preschool-age… I’ve enjoyed my older kids with it more than the younger ones, when we’re getting more into the… expose them to more and overcome some of their fears and we can have real conversations like that. That’s different than what we’re doing with the little ones who aren’t that aware of themselves. And so, I guess more when we get into the counseling part of it. 32 So, I want to make sure I’m understanding this correctly, you enjoy more of the counseling aspect than the fluency driven goals? No… I guess I mean you get to the point where you start to generalize and more where we generalize to real world things like calling the pizza place and ordering and why is that difficult? And what can we do to make it easier? And talking through that with them. I guess what it is, is that I’m kind of a “mess with your world” type of person, and so I like to do the things that are hard for you, and help you overcome it. Got it, that’s great! And so, going off of that, do you know of any other SLPs or any colleagues who feel similarly as you about working with kids who stutter? Or anyone who maybe feels differently about working with this population? In our district we haven’t had any big discussions lately, I mean it’s been a few years since we’ve watched a couple of PDs and that. And they’ve been more about when do we pick up? When do we treat? When do we back off? And I don’t remember strong opinions either way as much on fluency as much as some other things that we come across. I guess I have had a couple of “oh gosh I don’t know what to do with that” type of responses. From other colleagues? Yeah. And I know that some of the graduate interns I’ve had don’t feel as confident with that. But it’s been a couple years since that’s come up. But I had one of them that was working on that while I had them. Okay. So then did you feel like you were able to help the graduate interns learn to be more confident? Or did you feel similarly or on the same level as them? Yeah, we talked through and processed a lot of it. We had a lot of discussions about “gosh it would have been nice if I had more coursework on this or on that.” And we talked about resources and where to go to find information and that type of stuff. Alright, and then my last question for you would be, what would make it more rewarding or more fulfilling to work with these young kids who stutter or students who stutter in general, since it’s kind of more towards your “middle?” I’m not sure that there’s a good answer for that. I don’t think it’s that I dislike or don’t like working with it… I think I just like it when it’s more complicated and I don’t want to wish more complicated speech disorders on anybody. Because I have had some younger kids who are really fun to work with and we’ve made good progress and that’s all quite fulfilling. But it might just be that it’s not something that I run into as often as other things too. Yeah definitely not as common as artic! But I wouldn’t say that it’s boring therapy or repetitive, and it changes enough that it doesn’t get old. And I guess I don’t know! I don’t know that there’s anything that would make it more fulfilling. I think I’m just happier with the other things because I do it a lot more all the time. And I feel like I have a good flow and it works well and we’re making good progress. Like with your other students or with your kids who stutter? Like with language or AAC and those kinds of things. So since you have more of a flow for your language and AAC sessions, how much prep do you have to put into your stuttering therapy, or is it about the same? I would say there’s probably more prep because I have all my language themes, like this is one monthly them and another monthly theme and I pull it out quickly. When I ran into 33 more kids with dysfluencies, I had more stuff together and prepped, and I’ve moved too many times to know where that is so I have to recreate it every time. So, it takes more prep. Participant 2 So, to start off can you just briefly describe the type of setting that you work in? I work as a public school SLP and my primary public school is a preschool through 5th grade building. And I only work with the students who are transitional kindergarten so like the year before kindergarten. And I also have 3 other schools which incorporate the grade levels from 3rd grade through 12th grade. Perfect you've got a wide range! Yes, I do! So out of all of these types of students that you work with, which type of student would you say is the most enjoyable? That is a mixed bag because I've found that I enjoy kids who are engaged and willing to work. So, when you say "enjoy" that's what I think of. But I also like working with the kids who just want to do better with their speech. So, I have a student who is in high school who had a health crisis and now he is apraxic. And he is so cooperative and so smart and he's probably one of my most challenging kids but I thoroughly enjoy working with him because of his motivation. So, the ones you enjoy working with most is more behavior related rather than diagnosis like artic or language or something like that. Agreed. That's a good summary. And of course, I'm sure you love working with all of your students but is there a type of student or a diagnosis that you don't enjoy working with quite so much? Off the top of my head, it goes again to a child's cooperation. So, a student who is a behavior challenge for me... so I do have a little guy with Fragile X who is diagnosed with ASD so I enjoy working with him but I also have to be completely on my game. Because if I'm not... I mean he's never been aggressive physically, but I know that he has hit other students. So, I obviously don't enjoy working with students who might be physically harming; let's just say that. Okay, got it. Yeah, I guess it really is not diagnosis driven. In regards to diagnoses, if you had to rank these students that you enjoy working with so much and then these ones that are not so much, where does stuttering fall into this mix, on that scale? So typically, maybe even just a couple years ago, I would have put fluency and stuttering towards the bottom because it is a more challenging diagnosis when you don't have many students with that. But in the past year and a half, I've started a new therapy approach, and I have 4 kids currently on my caseload who stutter. And 2 of them have been highly motivated and therefore I have really dug through the information. And so, they are probably near the top of my list, but not the top. So, I'd say they're probably second. So, it goes back to motivation for you then. Yes. So, I wanted to back track to something that you said before, like how a couple of years ago fluency was a little more challenging or a little lower, because you didn't have a lot of students on your caseload who had fluency diagnoses. Can you tell me more about that? Maybe more why it may have been challenging? 34 So, I think back to a student who was probably maybe 3-4 years ago someone that I worked with. And he was just a reluctant talker. So, it really didn't seem to be a skill that I could get him engaged with any stuttering shaping or modification, because he was just so reserved in what he would say. So, that was his strategy, "I just won't talk so therefore I won't stutter." And he actually just wanted to be done with speech. He didn't want to work on it or talk about it. He felt like he could manage it. So that was kind of frustrating; versus I have 2 students who pretty much reached out to their teacher to reach out me to go into speech therapy, because they wanted to work on their stutter. So, kind of the opposite ends of the spectrum there. Yeah, so then it's kind of like "Alright I'm going to dig through this, and let's see what we can do." So, they're excited and ready to learn and they ask me leading questions and they really want to practice. Alright well I guess if someone is not quite so motivated it might be more difficult to engage them, especially if they are ready to be done with speech. Exactly. Yeah, it's very different and difficult. Now since you have more students that you work with who stutter, are there any other experiences that led you to feel... would you say you feel more comfortable working with them or you just enjoy it more? I think I feel more comfortable because I've got kids who are motivated. So about 11 years ago I was a speech therapist who went to a camp for stuttering and that was the first year that they ran the program. And so, I did a lot of continuing education program through DVDs, and then I attended that camp. This camp started with 2- or 3-days training prior to kids starting at the camp. So, you get a very intense education before you are even working directly with the students. So, I had done all that training and then had gone back to my position... but I didn't have any kids who needed those skills. So, I feel like I have the tools, and I just had to believe that I knew what I was doing; it was just okay let's do this. I guess that's where I feel like I've become more confident because I see it working, versus before "this is not working" like with the particular student I talked about earlier, it wasn't working for him. But it doesn't mean I wasn't doing my job, it just means it wasn't working for him. That sounds good, I've never done that camp but I've heard it's an awesome experience. It's phenomenal and I highly recommend it if you have the opportunity. Do you know of any colleagues or any other SLPs who feel similarly to you with working with kids who stutter? And I guess on the opposite end of that, any individuals who feel differently about working with them? I can think of probably 2 who'd say they are very comfortable with stuttering therapy. And we have the opportunity to have a presentation this upcoming Friday with someone coming to our county school district. And there's a couple people who aren't going, so I addressed it with one of the SLPs and she really works with kids who are 6 and under and didn't know if it would be practical therapeutic strategies for her. Which I tried to say that she would glean something from it. So, I think those who don't work with it that often, they have more of a neutral view. And then another person who isn't going, maybe she just feels really prepared, "like I don't need that." And I'm just thinking, "Who can't learn more from this person!?" But that's just my own personal opinion. So, it's hard to gauge it. We actually have 8-9 SLPs in our district, so we have quite a range. 35 So, I guess based on everything that you've told me, is there any way to make working with kids who stutter become more rewarding in your eyes? Or do you feel like it's kind of at the max amount of rewarding that it could be, or is there anything that could make it better? I think the best-case scenario when working with students who have disfluencies is when that is the only area that is academically challenging. So, it's more of a pure disorder, so not co-occurring with other things. For those kids, I feel like I'm kind of getting to the point where I want to do more community-based instruction with these kids because they can get more experience. But until they get practical application, we can't get to that next stage. So, that's kind of pieces of it. So, I feel like that's a nice component. And another component which I winged this past week, was I had the twin sister of my student come to therapy and we gave her a rundown of what stuttering is. And we planned ahead what we'd present to the sister, but then I did most of the talking. So, I was able to present the student's concerns with interrupting or finishing statements. I felt like I was pulling out some of my counseling background from way-back-when. And I was using materials from other sources I had about classroom conversation. And I don't know if there's anything else that would have been a helpful resource... and I don't know if there is a resource out there; but that's something that I think we could really do more to help the student if we could educate the family. Participant 3 Can you just briefly describe what type of setting you work in? I am in a self-contained ASD classroom and in a special ed preschool. An elementary ASD. Okay, so more of the younger students. Yeah. So out of all of these students that you work with, which types of students do you enjoy working with the most? I like the higher-level social skills, more of like the Asperger-type students I guess you could say. And then I do really enjoy working with stuttering. I know that's not kind of the norm. So I guess along those lines, I'll skip around on my questions, why do you enjoy working with stuttering so much? I don't know, I guess. When I was in grad school, my first student internship was with a supervisor who worked at a fluency clinic where students came. They also came to the university clinic. And that was my first exposure other than a few classes at ___. I just really liked it! You know I don't know how to explain it but some people like working in CI rooms, some people love Autism, and I was just like "This is my thing. I love this." So, you had those few classes in grad school and then also the off-campus experience at a place that specialized in fluency, is that correct? Yes, so my first experience in grad-school at the university clinic there were a couple students who stuttered and I worked with them there. And then for my whole semester externship I worked in a fluency clinic. So, would you say compared to other colleagues that you know of or other SLPs, that you have more experience? Or less or about the same? More experience. And so do you think those colleagues feel differently about working with this population? 36 Yeah, they definitely have reached out to me multiple times. You know, "I don't know what to do with this student, can you give me some pointers?" And it's interesting, even colleagues of mine who have been therapists for 30+ years, but don't come across students who stutter that often. So just because I did a whole externship at a fluency clinic and then I did one summer at Camp Shout Out. So just some more experience there. I did a little in- service with my speech cohort. So definitely, if they have stuttering questions, they do come to me because they don't have a lot of experience. That's awesome that you're a resource for them. It sounds like in grad school and after that, you continued to seek out those experiences. Yeah! So those clinicians that reach out to you, you mentioned that sometimes they don't know what to do because they don't have a lot of students who stutter on their caseload or they haven't seen that as much, are there any other reasons why they reach out to you? I think just that I've had some hands-on experience. Sometimes it's easier to explain something to someone "this is what I did in this case" versus reading about it in a textbook or during an in-service. Yeah, I definitely know what you mean. So, in general can you just briefly describe how you feel about working with clients who stutter? I feel pretty good, I mean! Currently I don't have any kids who stutter, but a few years ago I had a few kids before I switched schools. I felt pretty good, I think. One thing that I would have liked to do, because in the elementary school setting you might only have one student, I would have liked to do some more of the emotional piece with having another peer. You don't really have other people to relate to in your school. So that's something I wish I` could have done more then, that emotional piece. Overall, I felt pretty good about it. I definitely get how that would be helpful. So, you sound like you felt already fairly prepared to work with students who stutter. But just looking back, is there anything that could have helped you feel more prepared or make it more rewarding to work with this population? I guess just more experiences. Like the more you practice the skill and the more exposed, the better you're going to become. In my externship, I mostly worked with as young as 3 or 4 years old up to high school and then we did have a support group for adults. But I don't feel as comfortable I guess in the adult realm, versus with the elementary school-aged kid. You know you can talk about whatever fluency shaping techniques you want to. But I don't know if I was working with an adult who had stuttered for 30 years, you know. Or I guess I don't have any experience too with stuttering post-stroke or more like a brain injury you know? Like the neurogenic stuttering? Yeah. I also have had a couple of times when I inherited the school and classroom that I'm in now, that I'd get referrals for kids with higher functioning ASD to be evaluated for stuttering. And I guess could see how maybe a clinician who didn't have as much experience with stuttering would think that they stuttered. But to me, it seemed more of maybe higher-level language planning, versus a stutter. Participant 4 37 So, to start off can you just briefly describe what type of setting you work in? I work in an elementary school. Okay, and do you work with all age groups there? Kindergarten through 4th grade, yes. In your setting, out of all of these diagnoses and types of students that you work with, which one is the most enjoyable for you to work with? I like to work with kids who are struggling with reading. Okay, so more of the literacy aspect? Yes. And why do you think that's most enjoyable for you? That's a good question, let me think. I think because it's easy to see success. Okay, so more success and progress... so easier for that to be seen for you? Yeah, and it's just very important, too. Not that it isn't all important, it all is. I didn't learn a lot about it and then my daughter really struggled learning to read, so I had to learn in the streets! Now you're an expert! I guess on the flip side of that, which is a type of student or diagnosis that you do not find as enjoyable to work with? I would have to say fluency. Okay. Yeah. And why would you say that? Because I don't feel confident, and write that down. Why don't you feel confident with this population? Well it's not a frequently diagnosis or eligibility in the schools. You only have maybe one a year. And so, it's not something I've focused on as far as continuing ed. And I don't feel like I had a good background in that in grad school. So, I've gone through periods where I started to feel more comfortable when I started to go to more PD, and when I was maybe working with a student and found some success. But overall, I would say I don't feel that comfortable and confident with it. Okay. So just one little thing you mentioned there, you mentioned you felt more confident when you saw success... Could you expand on that? Yeah, let me think for a minute. I don't even know now if I have had success... maybe yeah, sometimes. I guess I don't have much to add to that. Okay, that's alright. So, you've mentioned that you don't feel as confident with fluency in general, more specifically with the students, how do you feel about working with the students themselves in the session? I mean I feel like I wish I was more confident. I mean I don't have anything against the students themselves. I feel nervous I think because I don't feel like I'm doing the best. I don't feel like I'm giving them everything they need. Okay, so it's more your feelings, versus anything that they are doing; am I understanding that correctly? Yeah. Okay. No, it's not them at all. I just want to make sure I'm not misinterpreting anything! 38 Okay. Do you know of any colleagues or any other SLPs that feel similarly as you do? Yeah, I think they do. I work in a district that has 9 SLPs. And there's one who feels really confident about fluency. She's kind of focused her PD in that. But I don't know, she has come to help me some. But I didn't feel like it was super helpful. Okay. But the one who feels differently, she's focused more of her continuing education on fluency, is that correct? Correct. Is there anything that would make working with this population more rewarding for you? Hmm... yeah, if I just felt really confident that I could make a different in their speech and therefore in their lives. And when you do work with fluency clients, what types of goals have you been working on? Or how are you tracking their progress? I try to write goals that are specific to using certain strategies. And, then track progress on how well they put that strategy into use. Got it, okay. Participant 5 Just to start off, can you briefly describe what type of setting you work in? I work for an ISD, and my current assignment... I have a wide range of ages. I have one kid who I see with home visits, so as young as 3. And I have a couple preschools that I service. And then I also service a K-12 district and also a self-contained emotionally impaired classroom. So, 4 classrooms of kids with emotional impairments. You sound very busy, but like a lot of variety! Yes! So out of all of these students that you work with, is there a type of student or diagnosis that you enjoy working with the most? I mean I love language kids, those are definitely my interest. I do team teach with 4 classroom teachers. 2 first grade classrooms, our CI classroom, and our young 5's classroom. So, I go into pretty intense language lessons each week. That sounds great! Yeah, gets them out of the typical pull-out sessions. So why is that the most enjoyable for you? I think it's because there's so much of a variety. You know, articulation is just a lot of drill and repetitive work where the kids might get bored. So, I try to keep them motivated. I did recently switch to a quick artic program to keep them interested. But language is just so wide in our range. You know where you could work on anything from vocabulary to syntax or social skills with students with autism. Okay, so more of the variety with that. I also run a special education camp for students who are non-verbal who use augmentative alternative communication devices to communicate. That's amazing. That sounds great. So, you mentioned with the language kids, the variety is something you enjoy. Is there a type of student or diagnosis that maybe isn't so enjoyable or as rewarding for you? 39 No, I wouldn't say that at all actually. I love what I do. Even the artic kids, now that I've switched to the quick artic program it's nice to see them one-on-one and build that relationship with them. So, I would say I haven't really run into a specific disability that I've found not interesting. I mean I love it all. That's great. Thank you. Alright, so do you have any kids who stutter on your caseload? Or have you ever worked with kids who stutter or have fluency disorders? Yeah. I actually have had preschoolers, lower elementary, upper elementary, and even high schoolers and middle schoolers who have all stuttered. I also have a family friend who stutters. I don't currently have anyone technically diagnosed as been a stutterer. However, I do have a first grader that I'm watching and kind of treating. He's a language kid of mine who shows signs of disfluencies but no secondary behavior. So, during language therapy we do some fluency shaping techniques. And I've also talked with the parents about things they can do at home. And it just depends on the day whether or not you see a lot of disfluencies with him or not. So how do you feel about working with these students who stutter? I feel pretty comfortable just because I'm not the type of person who thinks I know it all. So, like I had a student who I saw in middle school, and he was put on an anxiety medication and it actually decreased his disfluencies to the point where I ended up dismissing him. And then his junior year at his IEP, his mom had expressed concerns about his disfluencies again. So, I went to the meeting and they had removed the anxiety medication and so his fluency was really really bad. So, I ended up picking him back up. Typically, you don't, but I felt like I wouldn't do him justice if I let him leave school without him having an idea. So, I let him know that it is a life-long disability. It's not something that can just be cured. And so really trying to find the fluency shaping techniques that work for him. So, I was really struggling so I ended up talking with my fluency professor. I mean I graduated over 20 years ago, but I have stayed in touch with my professors. And so, she had given me the new idea of having him do voluntary stuttering and then have him be able to pull out of that. It was very helpful for him, because he had so much anxiety due to his speech and disfluencies. So, it was a really good idea, so I've put that in my bag of tricks and do that with kids if they're not as successful with other fluency techniques. It's kind of a practice tool, and that wasn't a tool that I learned in school. So have the student stutter and have them use one of the shaping techniques to pull themselves out of it so they feel like they're in control. And I really liked how empowering that was for them. I can see that. So, you mentioned that you feel pretty comfortable working with these students who stutter and that you contact your old fluency professor if you need suggestions or anything. Have there been any other instances where you've felt like you've needed to reach out? In regards to stuttering? Yes. Yeah. So, when my oldest was close to 3, he ended up getting the flu and went to the hospital and they gave him a medication to stop the coughing. And I didn't notice a lot of disfluencies then, but a couple months later, he had to go again and they gave him the medication again. And he became a severe stutterer, to the point where he was using his hands to try to push the word "mom" out of his mouth. As a mom I don't think I was able to really process what was happening or what to do. Then as a speech therapist, I thought "wait a minute let me think!" So, I reached out to my professor again and asked what 40 should I do? So, I just did a lot of what I teach parents. You know be patient, don't finish their sentences, don't rush them, don't talk for them. And after 8-10 months, his disfluencies were completely gone. Then 2 years later I had a student with the same situation! He was in the hospital with the flu and got this medication in his IV. So, I was talking with his mom and asking about a case history and she told me the same thing happened. So, I gave her all of the techniques and told her that I would contact her in about 6 months. I guess that's not a drug of choice anymore but I don't know what happened with that, I don't know if too many kids were having a reaction to it. Wow, that's interesting! Yeah, but that was probably the only other time I've reached out. But we have 30 people on staff at the ISD and we all help each other out if we need to or if we have a sticky situation. So, I'm not afraid to ask for help. That's great, it sounds like you have a lot of resources. Yeah. I think the updated webinars though are pretty crucial for therapists, especially now that new techniques are coming out. I think that the people out there that are doing the research and studies need to keep us all informed with new techniques. So, would you say that you keep up with evidence and recommendations with professional development opportunities? Yes. We get to pick topics for professional development talks. And we have some therapists on staff that aren't as confident or comfortable with stutterers, so that's a topic that we usually pick is fluency. Well that works right into my next question! I was going to ask if you knew of any colleagues who feel differently and are more uncomfortable with stuttering? Yeah there are. A few will admit it, like at staff meetings they might say they're not all that comfortable and if we can get more webinars or in services to go over it. We try to share within ourselves so we can break into groups, and have a language, artic, fluency, pragmatics groups so that people are able to share ideas that they're using that are successful. I know you can't speak for everyone, but do you know maybe why some feel less comfortable working with kids who stutter? I think it has to do with your exposure. You know, you learn things in college and if you don't apply it... it's one of those if you don't use it, you lose it. I think with stuttering it's not as cut and dry. It's not, "place your tongue here and blow out air here and that's good." Or it's not cut and dry of "here's categories" or "doing questions". You know, fluency is so specific to each individual, so it's one of those... if you're not practicing it you may lose some of that knowledge you have on how to help people get through life with stuttering. I have my neighbor who would call me on any given day that would ask "what are those fluency shaping techniques you showed me that help me?" And she's been a stutterer since elementary school, and she's like, "gosh I wish you were around when I was in elementary, because I struggled!" For her, the light contact and easy airflow worked best for her. For me to remember that these are the ones that work for her is a lot. It's one of those things that you have to stay up on. That sounds great, and great to hear too. One more question I have, is although you feel comfortable with this population, is there anything that you could think of that would make it more rewarding or enjoyable? 41 I think we've had one therapist go to a camp for kids who stutter and go and be a counselor there. I wish now with social media that there were support groups for teens and young adults, that could get on there. I know when I had my middle school and upper elementary student, I would take the stuttering newsletter from a magazine and I would show them kids in there and their story. So, I wish for older kids there was something on social media where they could actually have a support group where they could talk to people about how they feel, or what works for them, or what they're struggling with. Because not everyone can afford to go to a camp or the transportation to get there. Yeah, that's a great idea. Participant 6 Can you just briefly describe what type of setting you work in? I'm in an elementary school, and I primarily service the Kindergarten and 1st graders. Okay, so more of the lower elementary then. Lower elementary, yes. Okay, sounds good. So out of all of the types of students and different diagnoses that you work with, is there one that's the most enjoyable to work with for you? Yes. I really enjoy the truly language impaired students. Okay. And why is that? Or why do you think that is? So, I think it's because you can set specific goals and you can see the progress. And you can also trial different accommodations and see what language accommodations work for them, and you can see them progress. And also, a lot of teachers help with advocacy. And especially for expressive students, those are the kids that you can really see the light in their eyes with that empowerment that they can advocate for themselves. So, being able to see them progress towards those goals? Yes. Exactly. And, of course we love working with all of our different types of students and diagnoses, but is there one that maybe is not so enjoyable for you to work with? Yes, the cognitively impaired is not my favorite. Okay. Do you have a reason why? I think just because it takes so many more repetitions and so much longer to see progress. So much longer for some of our students. Yes, I understand that. I was in a center-based school for one of my internships so I can see that. Yes! Those with multiple impairments and who are severely cognitively impaired are the most difficult for me. Got it. Do you work with any students who stutter, or have you ever worked with any students who stutter? Yes. So, I guess on that continuum of most enjoyable to not as much, where would you say that stuttering falls for you? Right in the middle. Okay, and why is that for you? I think there's the challenge of some of the stuttering to determine if it's stuttering or cluttering, which is the puzzle piece I absolutely love. I also love the fact that you can try different strategies and see what works with the students because typically they are cognitively intact and are aware that they do stutter. At least a good chunk of them are 42 aware that they do stutter. So, I think it's the trial and error, and putting those pieces together is what I enjoy about it. Okay, and then so what is maybe the part that brings it from the enjoyable side and back towards the middle for you. Because there's some students that you try strategies with that you don't find success. And they tell you that they don't find success with those strategies. And then what? What do you do in those types of situations? Research and support groups for students who stutter. And the family too as far as giving them some research and also some support groups that they can get information for and learn about. Well that's good that you don't just stop when they're not working! No, of course not! We keep looking and we keep trying until something sticks. Do you usually find that those steps that you take helps? No, not always. Not as far as the percentage of disfluencies. Not as far as their actual clinical representation, if that makes sense? More along the anecdotal information. More that they talked on the phone with their grandmother or something like that. So the quality, not quantity. So, the percentage of words or syllables stutters does not change, but maybe how it impacts them changes? Yes, their perception. And would you say the impact changes for the better? Yes, I would! Alright, so you mentioned that stuttering is more in the middle for you. But how do you feel working with clients or students who stutter? Alright so I have to tell you I hate doing fluency evaluation. I just loathe them because they are so time consuming. And if you get in a conversation, you know or you don't know especially if those secondary characteristics are present. But again, that quantitative portion. So that is probably my least favorite part about working with students who are disfluent. Another part that is a struggle sometimes in the schools is we have to relate how it impacts them educationally. If they are doing really well academically, it is really hard to justify some of those services. Not impossible, just more challenging and you have to be creative with how the wording is. So, relating it to the adverse impact that it actually has on academics? Yes. And then if you loosely interpret academics to mean "educational," then you have the social implications, which you can do. It's a little bit of finessing. Especially when you are looking at students who are trying a strategy out and you don't need to see them 2 times a week or every day, putting that in an IEP versus a response to intervention mode. So those are all big questions to ask as you're going through. So that last part that you just mentioned, then deciding if it's going to be more RTI versus doing a full evaluation and putting them on your caseload, is that correct? Yes. Okay. Yes, from what I've learned in class there are a lot of pieces to a fluency evaluation! And then do you know of any colleagues who feel similarly as you do about working with kids who stutter? Or any who feel differently? 43 I have a colleague and we share an office, and I think he feels similarly as me. And then I have one that tells us that we need to fix them in our building so she doesn't have to deal with them in her building. She's not so comfortable! Are there any experiences you had that shaped how you feel about working with this population or any that you wish you had? I had a fantastic stuttering class in grad school that was just stuttering for an entire semester. And my professor did a lot to shape my view and perception and comfortability. And I remember my first student who stuttered and I went back to my professor, and we were colleagues at this time, and I said I just want to let you know that it's only because of you that I felt comfortable and confident. And I said, "here's where I am, and here's what I'm thinking" and she said I was right on. And I will never forget that, like phew! Alright! But it was about how it was presented during that class. So that kind of shaped your thinking? Yes. It wasn't so fearful or scary. It just was. Now what, you know? Got it. So, do you feel like this experience helped build the foundation with this population? Yes, definitely. I just have one more major question. What would make it more rewarding to work with students who stutter? In my dream world, I'd like to find a strategy that works right away and that is implemented with fidelity and consistency. But it's also how... I'm trying to put this into words... something about the ability of others to also know what to do, and not do the wrong thing if that makes sense? So, if a kid who stutters... some of the teachers say that it takes forever for the student to get their words out so they don't call on them. Call on them, it's okay. I don't know how else to describe it. No, I understand that! And for the younger kids I think they just own it and it's more accepted. I find it's that the adults like the parents or the adults at schools who work with those students that have the hardest time. Well it sounds like you advocate for those students! Yes, I do! Participant 7 To start, can you briefly describe what type of setting you work in? I am a school-based SLP. I've worked with the same populations my whole time here so I have a lower elementary building which is preschool through second grade, and I have a K- 12 grade building. So, I have both ends of the K-12 population. Got it. So, the younger ones and older ones. So, what did you do before this, you mentioned that you worked somewhere else prior to the schools. I just worked in short-term rehab with adults for about a year. Okay, I was just wondering if you did more things with kids like outpatient peds or something. Nope, just adults, which is what I originally thought I would stay in actually, but life works out funny sometimes and I really enjoy kids more than I thought! Alright, so out of all the students that you work with, which type of diagnosis is most enjoyable for you to work with? 44 Wow, that's a tough question, because it's so individual depending on who I connect with. I mean I'm definitely interested in fluency, which is part of the reason that I responded to this survey. That's definitely something that's of high interest and I feel like I really connect with those students. And at the high school level, I would say more of the social communication and pragmatics aspects with those students. Okay. On the opposite end, is there a type of diagnosis or student that maybe is not so much your favorite or is not as enjoyable for you to work with? Yes, articulation for sure. That is definitely not my favorite. It's just too repetitive for me at times. Okay, going back to something you said before with your interest in fluency... why do you think that you are interested in fluency? Well I would say that I'm definitely in a phase of actively trying to learn more about it. Why that is, I guess just because the cause is so multifactorial and a little bit mysterious. That makes it interesting. And also, I think that a part of it too, is that I've connected really solidly with several students of various ages that I've seen for that reason. So just that desire to help. Okay, got it. I know it is kind of a mysterious diagnosis. So, are there any experiences that lead you to feel this way with these students? Like anything before you started as an SLP or anything since then? Like a specific event, or anything I went to? It doesn't have to be an event, just anything that influenced your comfortability or attitudes towards fluency in general. Well I can say that before I went back to school to be a speech pathologist, I was not aware of anyone that I knew of being someone who stuttered. So really my graduate school experience would have been my first exposure to working with stuttering and learning about it, besides being a lay person. I guess as far as specifics... I guess it's hard to point to something. I was a teaching assistant in grad school and I did that for 3 years since I didn't have my Bachelor's in communication disorders. I worked under a professor whose main interest was fluency, so I'm guessing that maybe influence for me? And would you say your experience in the clinic helped prepare you for working with this population? Yes, definitely. And did you have a fluency course in graduate school as well? Yes, I did. And then do you know of any colleagues who feel similarly as you do about working with fluency? In terms of it being higher interest and that sort of thing? Yes. Yeah, I would say so! And are there others who feel differently and maybe it's not as high of an interest for them? Yes, definitely. I work for a fairly decent size public school district. And we have an 8- person team, actually last year it was 9 people, so you know a decently sized team. And I would say it's probably split down the middle with people who are highly interested and pretty comfortable working with stuttering and those kinds of case studies and talking it out. And maybe half that are not as interested and maybe have someone else take that kid or are just not as comfortable in their own capacities. 45 And have you ever had any conversations with these colleagues where they mentioned a reason why they are uncomfortable? Or is it just that they say they are uncomfortable and don't really expand upon that? I think yeah, it's just more of my impression that it's just lack of their forced experience. Since we do have a decently sized department, there are many times where multiple people are in and out of a building and split caseloads that way. So, I guess maybe lack of experience maybe because they've chose to take other types of students. Okay. And then I think my last major question would be, is there anything that would make working with students who stutter more enjoyable or more rewarding? Well, let's see. I guess one thing that I think about sometimes, especially with my high school students but regardless of age, is just that sometimes I wonder... it's hard for me to truly walk their shoes I'd say because I've never been a person who stutters, so I guess I just wonder about that aspect of it, and whether I can bring everything to the table in that sense. Having said that, I mean I try to meet that need through other channels. So, making sure that I get kids together within the high school and talk about different things we could do outside of our own campus. And I actually brought a speaker from a university to our school in the spring to talk. So, I guess I don't know if that really dampens my enjoyment, but in the sense that I want to be as efficacious as possible. I guess it's just, as a practicing clinician you strive to meet the needs of all of your kids, but there's limited time to make sure that you're doing everything you can, and just this of feeling of you don't know what you don't know. So, I guess the more confident I get, probably the more enjoyable it will be. Participant 8 Just to start off, can you briefly describe the type of setting that you work in? I'm in the school system. I work for an ISD. I have changed through the years to a lot of settings within that system. Right now, I'm mainly working in self-contained autism classes and preschool. But in the past, I've done all kinds of things. So, I have been K-12, and I've done inclusion and I've done all kinds of things. Most of the stuttering would come from those years rather than right now. But through the year you end up with developmental stutterers, of course. Okay, so not too many on your classroom right now with the self-contained ASD room and the preschool, but in the past, you've had experience. Right. So out of all of the types of students that you work with or that you have worked with, which is the most fulfilling for you or most enjoyable for you? I guess the ones who make progress! Probably autism is my niche. Although I've enjoyed the little kiddies too. Oh yeah in the preschool? Yeah even before preschool too. Okay, and why do you think the students with autism are the most enjoyable for you? Is it that progress? Or is it something else? I think I've just spent so many years trying to help those kids break through that I think it's just an exciting time to be in the field. I mean my first autistic kid was a long time ago, and with everything happening now with the pragmatics and everything, it's things we never dreamed of. 46 Of course, we love working with all of our students, but is there a type of student or a diagnosis that you don't enjoy working with quite as much? Well that's always been probably the fluency kids. Or I guess what tops that is ADHD kids. I have good patience for autism, but ADHD and emotionally impaired kids are really a challenge for me. I have to bite my lip a lot. I think that fluency would be the next one. Okay, and why do you kind of put them in that spot? Or why aren't they as enjoyable for you? Well they're all sweet kids, but I think the problem is that they don't come along often enough to keep your feeling of confidence up. If they were regular and I knew every year that I had 2 or 3 fluency cases and I kept myself primed, I don't think it would be as much of a problem. And what I tend to do is I find out I have a child... or one year I had 3 of them and that was cool... what I usually do is head into a course really quick and get back on my reading and look at some materials. As soon as I do that, I feel okay again. Okay, so once you brush up on things again. Yeah. I think out of all of the speech problems, I think that fluency is just one of the most horrible for the person themselves. And see you really want to come through for them. Yeah, I can see that. So how do you feel personally about working with students who stutter, or how did you feel in the past? Did you have any emotions that go along with that? I don't think so more than other kids who you watch struggle. Sometimes you might get protective, especially if there's some bullying going on. Something that can make you feel inadequate. Usually then I'd reach out to extra resources to make sure that someone at that school could help and know what's going on. But you know I don't really think it was different than for any other kid. Other than the initial anxiety of “Oh golly, here we go again" or "I hope I can do a good job for this kid." I think that's the main thing. Okay, got it. Thank you. And did you have any experiences with stuttering or fluency or kids who stutter that shaped the way you feel about working with these students? Or anything that sticks out to you? I think my favorite year was when I had three students: two in middle school and one in high school. Just because the way their schedules ran, I couldn't group them together, so I worked with them individually. But I really enjoyed working with them just because we made so much progress. And I got to the point where our goals were a very broad range of time, because I began to realize there were weeks at a time that they didn't need me, but then they might, you know? So, I kind of reached that place where I would just stand out in the hall on therapy day and they'd see me and give me a wave if they were okay and come into my room if they weren't. I remember one boy would say "I'm doing great" and then another day would say "I need to see you, I block this week and I couldn't get out of it and now I'm afraid to read in class." So, we talked about it and read and practiced and such. And then he was good to go again. And so, I felt really good about that, you know. So, I think that was one of my favorite years. But I haven't had most of the kids long enough like that, probably just a year. But I saw those three for 2 years and really got a chance to know them. The most challenging kids I've had really were clutterers. So, it wasn't true stuttering. I had this teacher consultant come to me and say "we can't understand this kid!" And I thought, okay probably a really bad "R". That's usually what you see in middle school. So, I made an appointment with the kid to meet me in the library. So, from the time he said "hi" to the end, I couldn't get a word in. I didn't understand a word out of his mouth. I knew he was saying words, and there were not any articulation errors. But it was just crazy. And then there was just really poor, jumbled up syntax. And I taped him a 47 couple of times so that I could listen to it myself afterwards. Then I played it to him after I got to know him and thought he could handle it. I said, "Okay, this is what people hear, I want you do listen to yourself." It had been a few weeks so he'd forgotten what he was talking to me about. And he said, "I didn't understand one word of that!" I said, "Okay, now you understand why people are complaining." So anyway, I only got to work with him one year and I passed him to a good friend of mine who took over that school. She said he improved a little at a time. He was just so happy-go-lucky so he couldn't remember very long to keep monitoring. So that was my most outstanding cluttering experience. I didn't know it could be that intense, that you absolutely couldn't understand a person from it. In fact, I took a tape of him for training for our staff since none of them had really seen that either. Yeah, that's a great resource then! Yeah. So, you mentioned that more than stuttering, your students who cluttered were the most challenging, so why were they so challenging? There's an awful lot of good stuff out there for stuttering. I mean if you can't do it one way, there's another way, you know? I love the fact that we've added things into the pragmatics of stuttering as well. It's really helped and made more sense to me. I've found one good slideshow on cluttering. It gave me a lot of guidance, but that was it. I felt like I didn't have a lot of direction on where to guide this kid into, you know? Yeah, got it. Okay. So, regarding fluency in general, are there any colleagues of yours who feel similarly as you do about working with this population? Oh, yeah I think that's pretty prevalent. Although I have a couple of colleagues who got sick of feeling that way jumped into it. I have a couple who went and became part of a stuttering camp because they wanted to learn more about it. And they'd come back and share really good stuff with us. So, I think there's some people that take it on. I think that everybody kind of rolls their eyes at it. One other thing we tend to do though, every 2-3 years we all sit down as an ISD and watch a video about it. So, it's a given that everybody agrees and yeah let's do another stuttering thing. And they may not even have anybody on their caseload, but you can just see that everybody wants to stay up-to-date. Okay, yeah. The last question I have for you... is there anything that would make working with these fluency students more rewarding? Or would have made it more rewarding when you worked with these students? I think just the fact that there's more information now. I wish I'd known back with some of the older fluency students what is being taught now. But other than that, no the kids are great. I did have a preschooler a few years ago, and she was probably one of the worst stutterers I've ever encountered. And there could have been some developmental, but it was not that. She had secondary characteristics like crazy. And really hard blocks and just... but I felt like trying to explain it to her on her level was very challenging, and that would be very helpful. I modeled, but she was in her own world of tension and you know, I could relax her a little by just pacing myself and modeling and stuff. But it wasn't nearly enough. And trying to explain it to the little ones can be really challenging. We did have a training maybe 2 years ago with a bunch of things where one girl was being a proponent of taking on developmental stutterers into therapy. We all had kind of mixed feelings about that. I think underlying stuttering, is always the fear: am I going to make it worse? Like what if she was a developmental kid? Like okay I can get in here and do this, but what if 48 I'm bringing attention to something they're not even attending to. So, I know that when I have a developmental stutterer, the first play I usually look is their syntax. It seems like that's usually where the breakdown is. But I just tell the parents that "hey, I really feel that this kid is just really in a time where he's getting new ideas and stuff, so I'll see him again in 6 months" and give them some strategies. But I don't usually jump in on the disfluency, other that to speak in a calm and listening type way and a little modeling, but that's about as direct as I get. Okay, thanks for sharing that. Participant 9 Can you just briefly describe what type of setting you work in? Yes, so I'm in between jobs right now. I'm going to be working in a pediatric outpatient facility at a hospital. I am currently working with preschoolers ages 3-5. And then I previously worked in a private practice with kids who were 18 months to 14 years. Alright, so you have a lot of experience with the little ones! Yes, I do! Got it. Of all of the types of students or clients that you've worked with, which type is the most enjoyable or most fulfilling for you to work with? I think probably the little ones, like 2-3. Most like the ones with delayed expressive language because they usually have pretty good progress and parents are pretty happy so it's nice to see that. I did have one stuttering kid I had for a few sessions, but I feel like the connection that I had with mom was really great and made me feel really happy with what I was doing and the difference I could make. He was only 4, but he had a pretty severe stutter. Of course, we love working with all of the kids, but is there a type of diagnosis or student that you don't enjoy working with quite so much? Or that maybe isn't your favorite? I feel like... I don't want to say that autism is my least favorite because I've had some that are great and it's so broad. But they can be very challenging. But I don't think I have a least favorite. How is that challenging for you? I'd say maybe more of the behavior piece. Trying to figure out what makes them tick and what will help them learn. And also, this might be included with their behaviors, but trying to figure out what will help them get to the next step can be challenging. Okay. And then you mentioned that you worked with that one 4-year-old child who stuttered, did you work with any other students with fluency disorders or developmental stuttering? Yes, I've had one of two who were developmental, and then I worked with another one who also had autism. He was 10. And then I don't know if you want me to include grad school, but I had a group of 3 siblings who all had fluency disorders in grad school. So since you have some experience working with fluency disorders, where does stuttering fall along that continuum of really enjoyable for you and then not so much you favorite? Where does that fall for you? I think kind of in the middle. I mean I enjoy it, but I also think it's because I don't see it that much and I need to brush up what I'm going to do. And I mean for all disorders, all children are different. But you have to really consider the emotional aspect with stuttering 49 as well. And then also how parents feel about it. I just feel like it's very different from a lot of the other disorders that we work with. Okay. Can you expand upon those differences? Yeah, I think that emotional piece. Where I feel like a lot of other disorders, you don't see that as much where kids don't want to talk or shut down or are embarrassed. I think because they're usually typically developing kids, this makes them different from their peers and they really notice the difference. Versus a kid with autism or another difference who maybe don't really know or don't really care. So how do you feel in general about working with students who stutter? I feel like overall I like it. I feel like if I were in a private practice where I had the opportunity to give the client to another SLP, I wouldn't. But like I said it's something I need to research more and prep for more, rather than just have them come in and me do my thing. And then were there any experiences that you had, I know you mentioned grad school, that shaped how you felt about working with this population? I think my grad school experiences really helped a lot. I had a great grad school professor, and she would put on a stuttering panel. And people would come in with different fluency disorders and they would just tell their story. And then answer questions from the audience. And just seeing how stuttering impacted them and their life was really touching. And I was able to observe some sessions of a client who had therapy for the first time, and just to hear her talk about it and open up about it was really touching. Okay, got it. So, a lot of your grad school experiences, then? Yes, I think my grad school experience really shaped my thinking of it. I haven't taken a lot of CEUs about it, so yeah probably grad school more than anything. Okay. And just so I'm not assuming, was a positive experience in grad school or more of a negative or other type of experience? It was definitely positive. Alright, I just wanted to make sure. Do you know of any colleagues who feel similarly as you do about working with fluency disorders, or anyone who feels differently? So, when I was at that private practice, there was one SLP who was very comfortable and the rest did not feel very comfortable at all. I think a lot of it is your experience in grad school, it seems like to me at least. And then so that was at your private practice, correct? What would it make it more rewarding or more fulfilling for you with working with fluency disorders? I think it depends on the setting... I think making sure that parents are on board always makes the experience more rewarding. So, getting that input? Yeah. And then what type of progress would you like to see with your students who have fluency disorders? I would like them to be more confident. I think that would be the biggest thing. I mean, obviously being able to control their fluency would be ideal, but I think that the confidence is the main thing for me. 50 Participant 10 Can you just briefly describe the type of setting that you work in? Yes. I work in a public school. I'm in two different buildings in a large district, so the caseload is growing like crazy. So, I work in elementary schools, pre-K through 5th grade. Got it, so you have a lot of kids on your caseload then! Yes, and I have a lot more with the response to intervention kids! So I have closer to 60 kids then with all of that. It can be hard to manage all of these things, but yeah. Sounds busy! Okay. So out of all of the students that you work with, which type of student, or which type of diagnosis is the most fulfilling or enjoyable for you to work with? I actually love working with kids with phonological impairments. I see huge gain and huge growth. I had one little boy that eliminated the medial consonant in pre-k out of every word. I did the cycles approach with him and now we're at basically an expressive language impairment. He's making the sounds he's supposed to and the syllable structure that he's supposed to. So, I think in terms of most enjoyable for me it's definitely the phonological impairments because you see so much growth and progress with them. Whereas, the other areas I love working with too because you can do language with anything but the progress is a lot slower and it takes longer to see success. Okay, so more based on the growth and progress for you? Yes, yes. And I guess on the opposite end of that, is there a type of student or diagnosis that is maybe not so enjoyable for you do work with? Well there are a couple. The "r" for articulation is so challenging. I've had some kids on my caseload for years and we can't take over that stubborn "r". And also, those kids with fluency issues. I get so nervous and freak out about it. I just had a kid that moved into the district but he has the diagnosis of cluttering. And I've been practicing in the field for a while, but I just called up some of my friends and asked "what the heck do I do with a clutterer?!" I mean I haven't talked about this since grad school! So, we're all like, I don't know! So, it's just really challenging. It's really challenging for me. I feel like I can do the other diagnoses, but that cluttering and fluency is always very tricky for me. Got it, thanks for sharing. So, I guess going back to the fluency aspect, you said that it makes you feel nervous when you get someone with a fluency diagnosis...why do you think you feel that way? Well my husband and I were talking about this, and I said, "well she's doing her thesis on fluency" and I said it's not my favorite type of challenge to work with. You'll definitely see this as you practice, that communication is such an intimate thing. So, you really get to know kids. So, I have kids tell me things about their families that they don't even tell their teachers because I see them in a smaller setting, maybe 3 kids at the most. But I feel like communication is so intimate, that it is really tricky. With fluency, if you're really treating it well you have to get into those emotions. And sometimes I just don't know how far do I probe this kid? I've made kids cry in therapy before, not on purpose, but it's not a good feeling. I struggle with the balance where you want to call it to their attention so that they can have that desensitization. But then, how much do you call it to their attention? Where they're like, "I know, I hear this!" So, it's just a balance with how far do you push, and just the steps moving on. Does that make sense? Yes. Thank you for sharing all of that, I appreciate that. You mentioned that you feel nervous again, are there any other feelings that go along with working with fluency disorders? 51 I feel frustrations, not with the kids themselves, obviously, but with myself. I feel like I just have such a lack of knowledge. And I mean I had great professors too, and I loved learning from them. One of them came recently and did a talk for my ISD. And I've attended a couple of seminars about it. And then in grad school I had a professor who was very knowledgeable about fluency. But I just feel like I just don't know enough about fluency. I don't know if it's just that personality of a SLP, where we are all often type A and are anxious about wanting to do the right thing and be perfect... I don't know if it's just that or if I just don't have enough information... I don't want to cause more harm to the student. I don't always know how to answer the parents' questions. I mean, I do my very best and I let them know that if I don't know the answer that I'll get back to them, but I guess that is what makes it challenging for me. I just don't feel like I have a great handle on it. Because, not that it's rare, but I don't see a lot of kids with fluency issues. Okay, got it. So, you mentioned that you had some good professors and that you've attended some talks for continuing education. Are there any other experiences that you've had related to fluency that either positively or negatively shaped how you feel about working with these students? Well I had a student that I worked with, well 2 students who were siblings, and their mom was pretty much nonverbal and I am positive that it was because of a fluency issue. When she would speak, she hardly spoke. And when she did speak, there was so much blocking that she could hardly get any words out and there would just be these characteristics. And I didn't feel uncomfortable with it, but she seemed uncomfortable around me because she knows what I do. That's hard too. There are people that know what you do and when they go to communicate, they think I'm analyzing them. And I mean I am, but I would never tell them that. But I just felt that was challenging. I didn't want her to feel nervous, and I wanted her to be able to talk. And it was just really hard because she didn't necessarily communicate in person with the kids or with the teachers. And then almost had selective mutism and then there were just a lot of issues. So that definitely shaped my viewpoint with fluency. And I just don't want people to feel uncomfortable around me. And I hope I'm not doing anything to make them feel uncomfortable. I hope that answers your question. Yes, it does. Do you know of any colleagues or other SLPs who feel similarly as you do about working with individuals with fluency disorders, or differently? I would say that one of my colleagues that I share an office with, she's like "I got this, this is a piece of cake!" I'm always like ____ what did you do for this? So, she is my person and I talk it through with her. She has such great ideas so she doesn't seem as bothered by it, which is fantastic. But otherwise I would say that my other colleagues feel similar as to what I do. But she does not. I mean she feels pretty confident with fluency, so that's good. I'm thankful that we share an office! Yes, I'm sure that's helpful to have someone close by. What would make it more rewarding or more enjoyable to work with students with fluency disorders? I've thought about that before, and I've thought about why I don't find it as enjoyable. I think, maybe I'm instant gratification, but like I said with the phonological errors, I can see a ton of progress. And I feel like with kids that have fluency issues on my caseload, I see progress and then I see about 10 steps backwards. And then I see them progress and then I see some steps backwards. So, I feel like that continuum of progress is different. And maybe it's because I like seeing success after success after success. It's not anybody's fault, 52 it's just the way it is. I mean, fluency is a lifelong disorder or issue so the progress is going to be different than anything else. I guess what types of goals have you been working towards or what progress would you like to see with them? Well I have one little guy in 3rd grade and I've been working with him since Kindergarten, and I just love this kid to pieces. He's made some progress, but I see that every year, it's always the same. He can hear himself and he's doing better with recognizing it, but then he just gets busy and doesn't pay attention to his speech. I would like to see him make progress. I worked with some things with his classroom teacher like "hey if you notice this, then can you do this?" But I know that classroom teachers are really busy. But I'd like to see more of that follow through with the classroom teacher. And I'd like to see him on his way to being more successful, although he is a successful kid. I think he can do better. He even tells me that he doesn't think about his speech... the honesty of kids, I love it. Participant 11 Can you just describe what type of setting you work in? Yeah, I work in a school setting. Okay, so what types of students do you see, what is your age range? I work with preschool through high school. Okay, so quite a large range then. Yes! Okay, so out of all of the students that you work with, which type of diagnosis or student is most enjoyable for you? Probably preschool, and I guess language impaired. And why is that most enjoyable for you? I feel like I have a huge impact when I help, especially younger students communicate because it makes such a vast difference for them and their families. I also like working with preschool students because I like to be the first point of contact for parents when they enter the school setting. Alright, that makes a lot of sense. And then is there a type of student or diagnosis that maybe isn't so much your favorite, or that you don't enjoy working with as much? I mean, I probably would say fluency. Okay, and why would you say that? Because it seems like there's such grave consequences for a preschooler that I work with to persist with stuttering and be a person who stutters. And can you elaborate on the consequences that you mentioned? Like if I don't pick them up when I should, or if I can't resolve the issue by the time they're 7 or 8 that it will be a lifelong impairment for them. For more when to intervene and the importance of intervening? Yes. So, I guess, how do you feel about working with students with fluency disorders just more in general? I mean I have sought out quite a bit of professional development about it. I went to an early childhood stuttering course, and it really kind of shook my core beliefs. Because this is my 11th year, so I spent 10 years of telling parents that this is developmental and here's the 53 handout of developmental versus non developmental... if it crosses over to this then it's not developmental. And then I went to this and it was just like, no if they are exhibiting stuttering then talking to the parents and intervening is really important. Again, working at the preschool level that just made me feel a little bit more uneasy that I'm missing out on picking all of these kids up when I should be. So, I just want to make sure I'm understanding this correctly, did going to the talk make you re- think some things? Yes, it made me re-evaluate a lot of things, like who I should evaluate and things like that. So, would you say that was more beneficial? Or not so much? I mean I think it's probably beneficial, but kind of negative on my caseload. But I don't know I think it's probably beneficial. I mean it was last year, but I haven't seen any different outcomes yet from that. Okay. Got it. So how do you feel when you find out that you have a new kid on your caseload that may have a fluency disorder. I mean, fine. Not nervous or anything. And you mentioned that you attended some professional development things and especially that talk, are there any other experiences that you've had with fluency disorders that shaped how you feel about working with them? I went to a camp for kids who stutter about 8 years ago, and I think that's probably it for now. Okay, and was that a helpful experience for you? I mean it was an interesting experience for me. Most of it was counseling high schoolers who are probably going to be persistent people who stutter, so like how to do that and how to function. So, at that point I worked with 4th-12th graders so it was helpful because one of the students was on my caseload. But it didn't really give me like, here's how you treat fluency disorders, as much as I thought it might. So more of the counseling and emotional aspect versus fluency shaping and modification strategies? Yes exactly. And then do you have any colleagues or other SLPs you know who feel similarly as you do about working with students with fluency disorders? I'd say all of them. I'm the most senior SLP at my school. Okay. And do they ever talk about maybe why it's not their favorite? Well I think it's because it's so rare! I have 2 kids on my caseload, another person has 2 kids on my caseload. I've been in the district for 5 years, and I think total there have never been more than 4 kids at a time. So, it's just not very prevalent. Is there anything that would make it more rewarding or enjoyable to work with students with fluency disorders? Um, no I don't think so. And then what type of progress would you like to see with these students? Or what types of goals are you working towards? 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