A well-known parable depicts six blind men investigating the nature of an elephant through touch.[1] Each observer, interfacing with the elephant from a single vantage point (i.e., side, trunk, tusk, leg, ear, tail), reaches an independent conclusion (i.e., wall, snake, spear, large cow, carpet, or rope), seemingly incompatible with those of his peers. In the field of stuttering, and many others, this tale serves to remind us that a single or narrow view of the complexities of human nature falls short, as the whole is greater than any one perspective or even than the sum of its parts.[2] [3] Given this understanding, in recent decades, speech-language pathologists (SLPs) have become increasingly well-versed in applying theories, models, and evidence from research to clinical service provision across client populations, including those who stutter.[4] [5] [6]

The inherent challenges associated with understanding and integrating the multifaceted development of distinct individuals in unique contexts into methods for the assessment, diagnosis, and treatment of children who stutter are evident in a proliferation of frameworks and clinical approaches.[7] [8] [9] [10] Increased attention also has been directed to understanding and addressing the relations between and among nature and nurture, or, more explicitly, the interplay between genetics and the environment through the process of epigenesis.[11] These endeavors provide speech-language clinicians with a window into the expected and unexpected processes and changes that occur over the course of development.[12] [13] Furthermore, the likelihood of stuttering cooccurring with other conditions, disorders, and communication challenges (e.g., autism spectrum disorder [ASD], language, articulation and/or phonological delays or disorders, and attention deficit hyperactive disorder) has broadened our understanding of relations between a wide range of characteristics and the need to address them integratively.[14] [15] This process presents challenges as we endeavor to interweave knowledge and methods from our own and other disciplines to maximize our clients' participation in and enjoyment of communication and its many qualities in the contexts of their everyday lives.

In this issue of Seminars in Speech and Language, authors summarize available research evidence, present pertinent models, and utilize case-based examples to guide clinicians in the assessment and treatment of children who stutter, clutter, and/or have other challenges concomitant to stuttering. Multidimensional approaches incorporating affective, behavioral, and cognitive elements, with an eye to clients' and families' strengths and challenges, are provided to guide treatment. Incorporation of available research and implementable strategies are offered for immediate application by clinicians to positively impact the communication abilities of children who stutter.

In the first part of the volume, we tap the expertise of two specialized clinical centers in Europe to explicate the intricacies of multidimensional treatment of school-age children who stutter. First, Sarah Caughter, Elaine Kelman, and Sarah Delpeche of the Michael Palin Centre for Stammering Children outline their conceptual model of developmental stuttering and the supporting evidence that guides their holistic approach to assessment and treatment. Utilizing data from two clients (ages 8 and 15), they demonstrate a client- and family-focused approach that elicits hopes, strengths, and resources, and incorporates approaches from psychology (i.e., solution-focused brief therapy [SFBT], cognitive behavior therapy [CBT], acceptance and commitment therapy, and compassion-focused therapy) to help children become confident, effective, competent communicators, and their families to understand and support them. Next, a Greek trio, George Fourlas, Katerina Ntourou, and Dimitris Marousos, explicate the Lexipontix therapy program for school-age children who stutter. The authors draw from the International Classification of Functioning, Disability, and Health Model (ICF) to incorporate elements of CBT, Palin Parent–Child Interaction (PCI) therapy, SFBT, fluency shaping, and stuttering modification approaches in a creative, child- and family-friendly, holistic approach to therapy tailored to the individual needs of children who stutter. A comprehensive presentation of one client and family's journey with Lexipontix is provided to illustrate the approach and guide clinicians in relevant decision-making based on quantitative and qualitative data gathered throughout the therapy process. Additional insights about outcomes and mechanisms for achieving effectiveness and the role of the therapeutic relationship add to the richness and utility of Lexipontix for comprehensively assisting children who stutter.

In the second section, the frequently encountered challenge of treating children who both stutter and have other communication (e.g., language, articulation, phonology) and/or pragmatic (e.g., ASD) challenges, or present with less frequently encountered speech fluency challenges such as cluttering, are illustrated. First, Nancy Hall, Cara Singer, and Jean Sawyer consider sequential, concurrent, and cyclical approaches to helping children who stutter and also have language and/or phonological impairments. Utilizing the ICF Model and data from assessment and therapy with a 7-year-old client presenting with speech fluency, language, phonological, and oral motor challenges, the authors outline the models, processes, and rationales guiding therapeutic decision-making. Then, John Tetnowski and Joe Donaher embrace the challenge of serving children who stutter with ASD. After summarizing the limited, largely case-based evidence specific to stuttering in children with ASD, they draw from more general knowledge of speech nonfluencies (typical stuttering, typical disfluencies, atypical disfluencies, cluttering) and ASD (speech, language, social, cognitive, and communication aspects) to propose practical assessment and treatment methods. Focusing on the course of treatment of a 15-year-old with ASD and nonfluencies, the authors describe and provide rationale for the selection of assessment tools, present related findings and treatment goals, illustrate selected therapy procedures, and highlight the outcomes achieved by the client. While acknowledging the need for additional study of this population, the authors emphasize the application of a multifaceted, individually tailored approach to addressing the speech fluency of children with ASD. Next is Kathleen Scaler Scott's step-by-step presentation of the hypothetical journey of a school SLP presented with a child with decreased intelligibility who the SLP suspects clutters. We are guided through the initial referral, evaluation, differential diagnosis, and treatment processes with the assistance of relevant research findings, answers to common questions about cluttering, and strategies to address therapeutic motivation, enhance client awareness, address relevant communication goals, and educate the family and school personnel. Scaler Scott's piece is a comprehensive tutorial guiding any SLP in confidently helping children who clutter, whether exclusively or in combination with other challenges.

The third and final section provides additional tools for working with school-age children who stutter that have evolved in recent years. Vivian Sisskin, widely known for her development of Avoidance Reduction Therapy for Stuttering (ARTS) to address the physical and socioemotional components of struggle that become central to stuttering, teams up with her colleague, Benjamin Goldstein, to motivate, describe, and clinically exemplify the utility of ARTS with school-age children. Child-friendly therapy concepts, rationales, and clinical activities are provided with reference to an 11-year-old boy who stutters. Sisskin and Goldstein also challenge the reader to consider the impacts of stigma, and the role of self-identity and a view of stuttering as a difference versus disorder, on stuttering treatment philosophies and treatment methods. Wrapping up the volume, Naomi Rodgers presents numerous ideas for meeting adolescents “where they're at” by exploring motivation or readiness to change as related to stuttering. A relevant model, explication of the stages of change, assessment tools, and motivational interviewing strategies are provided and applied to working with a 14-year-old who stutters. Rodgers clearly illustrates how the approach can lead to readiness for change, meaningful engagement, and positive outcomes by adolescents who stutter—a welcome counterpoint to their oft-assumed lack of motivation.

At times, it can be daunting for those of us who practice clinically to apply complex and sometimes disparate theories and models, ever-accumulating research findings, and evolving assessment and treatment approaches to our work with those who stutter.[12] [13] We have chosen a field that is becoming increasingly divergent and where the complexities of the epigenesis of neurodevelopmental disorders, including stuttering, increasingly inform our practice.[4] [15] We further recognize the need to look beyond traditional medical or pathology-based approaches to embrace social disability or strengths-based ability models that highlight the real-life contexts, hopes, goals, and preferences of our clients and their families.[10] [15] The authors of the manuscripts in this volume have clearly risen to the challenge of multidimensionally and holistically assessing and treating those who stutter, clutter, and/or have concomitant challenges. Their integration of available research and implementable strategies, through case-based examples, provide the background, rationale, and clear guidance for immediate clinical application to positively impact the communication abilities of our clients. Like the six blind men and the elephant, they help us to “put all the parts together,” and walk “shoulder to shoulder” with those we serve.[1]

Article published online:
13 June 2022

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