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Early intervention - A view from Ireland

Patrick Kelly | 01.12.2011

Patrick Kelly carried out an 11-year audit into the outcomes of stammering intervention. Here he explains his findings.

Patrick KellyI qualified as a speech and language therapist (SLT), as a mature student, in Manchester in 1986 and have stammered for as long as I can remember. I was appointed to the NHS as a generalist therapist, became a specialist in stammering and worked with people of all ages who stammered. I was also actively involved with BSA until my family and I moved to Ireland where we now live. I recently retired from the Irish Health Service where I worked for 18 years. I am enjoying retirement but still run adult residential intensive courses on a non-profit basis. I decided to continue running these courses due to the successful and very rewarding 'Patmar' courses, which we ran for the Health Service in Ireland.

Because I have worked for many years with people of all ages, I could see clearly how a stammer can develop from the very early stages, through adolescence and into adulthood. To be honest my college training taught me very little on how to treat stammering in early childhood but it soon became apparent that the problem could be resolved if the appropriate therapy was provided as soon as possible after the onset of dysfluency. I have read many of the world's 'experts' in childhood stammering and have presented with some of them at world conferences; but there still appears to be little agreement on how to treat young children who stammer. Do we use direct intervention or try to change the child's environment and hope the stammer resolves itself? Are these children's brains 'different' from other children's? It is very difficult to decide the best way forward to help these children, and there is still the fear among many people that intervention might even make the stammer worse!

I have always felt that stammering in very early stages can be resolved if treated by a specialist experienced in childhood stammering who believes that the treatment will be successful. Where did I reach this conclusion? When I worked in the UK from 1986-1993, it became apparent that practically all of the children under 5 that I treated no longer stammered. A basic questionnaire was sent to all of the parents of those children who were then either discharged or failed to attend the clinic. The results of this showed that nearly all the children treated no longer stammered. Although this was by no means an accurate measure of therapy outcomes, it showed me that I was on the right path to helping these children becoming fluent. Another aim of the questionnaire was to assess the parents' attitudes to my therapy techniques and asked if and how it could be improved. At this stage in my professional career these results gave me the confidence to tell the parents that if we all worked together, their children could overcome the stammer.

When I moved to Ireland in 1993 my catchment area covered a large but sparsely populated rural area in the west of Ireland with a population of around 19,000 people. I worked in Community Care, which meant I liaised closely with all the other health professionals as well as the schools in that area. Significantly, I lived in that same community and would see many clients socially within the area. I also worked very closely with teachers in the schools, many of whom referred pupils for therapy. This was important because I would have been informed if a child was stammering, not only by the teachers but also the school nurse who covered the same catchment area. I worked with stammering people of all age groups and was the sole therapist in the community for 18 years, which allowed me to follow up most of my clients.

The Audit

I decided to send out a questionnaire to the parents of all the children under 5 years old who were referred and treated because they were dysfluent (I use the term 'dysfluent' because some young children were 'normally non-fluent', which can be a phase of normal speech development). All of these children were seen over an 11 year period from 1993-2003 inclusive and had since been discharged from therapy either because they gained fluency or failed to attend the clinic.

The aim of the audit initially was to prove to myself that stammering can be significantly reduced if detected and treated early.

Therapy was based on a client-centred eclectic approach, which combines elements of direct therapy focused on the child's speech, and a number of indirect approaches to treatment which focus on the child's environment. Each child was given an individual programme which involved the parents and any other significant adults involved with the child. Follow-up of the children in the audit was conducted by means of a short questionnaire to the parents. Non-responders were assessed informally by a school nurse with responsibility for the same catchment area over the 11 year period of the audit. Questionnaires were returned by 46 of the 64 children in the audit, of whom 43 were reported as not stammering, 2 with persistent stammers and 1 child with missing data on the fluency status. No stammering was detected by the school nurse, who spoke with all 18 non-respondents. Thus 61 of the 63 children with documented fluency status were reported free of stammering at the follow-up. The mean age of onset of dysfluency was 3.2 years, and the children received an average of 5.2 sessions. The outcome measures exceeded expected natural recovery rates.

Methods

The study was carried out in Leitrim, where 1,900 of the 19,000 population are under 5 years old. The speech and language therapy clinic has a high profile and there are high rates of referrals from school nurses, GPs, consultants, teachers and other health professionals. Parents can also refer directly to the clinic. The service is free in Ireland. Children referred as dysfluent were seen within 2–4 weeks. The initial assessment lasted for one hour and a full history was provided by the parents (both parents were asked to attend). All aspects of both speech and language were assessed: the type of stammer (normal non-fluency, repetitions, blocking), any associated tension, and both the child's and parent's attitude to the stammer were noted. Each child was given an individual programme involving the parents and each programme involved either indirect or direct therapy, or a combination of both. They were seen for one hour each week for 6 weeks and a further block of 6 weeks a month later where necessary. Children who were aware of the stammer were given direct therapy and were encouraged to talk openly about it to the therapist and the parents. Others who were unaware of the dysfluency were given a programme to change the child's environment, especially to reduce any parental anxiety, which is common with this client group.

Discussion

I have always worked as a 'hands-on' therapist and am not a researcher. As a person who suffered in childhood due to stammering, I always wanted to help others from going through life with a stammer. The aim of the audit initially was to prove to myself that stammering can be significantly reduced if detected and treated early. Treating stammering as we all know can be difficult - regardless of the age of the client.

I sincerely believe that practically all stammering can be eliminated if treated in the very early stages by an experienced therapist who specialises in stammering. I also feel that treating young children is a speciality in itself, differing markedly from adolescent and adult stammering. Even with all the advances in our understanding and treatment of stammering, the prevalence of the disorder does not appear to reducing. I have been at odds with colleagues over the years by telling parents that their child can be fluent if the therapist and family work together. I feel that parents must have complete confidence in the therapist, especially when they ask if their child will be fluent. The therapeutic programme can easily fall apart if parents do not have confidence and will quickly revert back to reacting negatively to the child. This anxiety shown by the parents can easily transfer to the child, resulting in more stammering behaviour. I also feel that one reason why the 'Lidcombe Programme' has been relatively successful in treating young children is because the therapist is confident it will work - this helps reduce parental anxiety and thus they will stick with the programme.

In conclusion, I again stress that I am a therapist, not a researcher, and base my opinions on many years working with people who stammer. I must thank my professor, Ivan Perry from Cork University, himself a person who stammers, who published the audit with me. Ivan has had a number of papers published over the years and I could not have done it without his help.

The full paper can be found in the May 2011 edition of the Irish Medical Journal: see www.imj.ie

www.patrickkellystammering.com

From the Winter 2011/12 issue of 'Speaking Out', pages 22-23