Initial Counseling With Parents of Preschoolers who Stutter: Enhancing Graduate Students’ Skills Using Simulated Caregivers No other therapeutic approach to stuttering in general has achieved the consensus of support given to parental involvement in the clinical management of early childhood stuttering. In most cases, this involvement begins with and is based on information received during the initial evaluation. This extremely important initial step in the ... Article
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Article  |   May 2013
Initial Counseling With Parents of Preschoolers who Stutter: Enhancing Graduate Students’ Skills Using Simulated Caregivers
Author Affiliations & Notes
  • Gregg Gregg
    Department of Communication Sciences and Disorders, University of Central Arkansas, Conway, Arkansas
  • Disclosure: Brent Andrew Gregg has no financial or nonfinancial relationships related to the content of this article.
    Disclosure: Brent Andrew Gregg has no financial or nonfinancial relationships related to the content of this article.×
Article Information
Speech, Voice & Prosodic Disorders / Fluency Disorders / Articles
Article   |   May 2013
Initial Counseling With Parents of Preschoolers who Stutter: Enhancing Graduate Students’ Skills Using Simulated Caregivers
SIG 4 Perspectives on Fluency and Fluency Disorders, May 2013, Vol. 23, 21-29. doi:10.1044/ffd23.1.21
SIG 4 Perspectives on Fluency and Fluency Disorders, May 2013, Vol. 23, 21-29. doi:10.1044/ffd23.1.21

No other therapeutic approach to stuttering in general has achieved the consensus of support given to parental involvement in the clinical management of early childhood stuttering. In most cases, this involvement begins with and is based on information received during the initial evaluation. This extremely important initial step in the therapeutic process often can prove difficult for beginning clinicians, especially because of the current landscape of graduate clinical training opportunities. In this manuscript, I will provide a framework for the use of simulated caregivers in the process of enhancing the parent counseling skills during an initial evaluation of graduate students in communication sciences and disorders. Though the field of communication disorders has come late to the idea of using simulated patients, there is a rich and varied literature on this teaching tool in other healthcare fields (e.g., nursing, medicine, psychology). What follows is a review of: (a) the factors affecting graduate training in fluency, (b) the need for better training in parent counseling during the preliminary stages of working with preschool CWS, and (c) a possible framework for this incorporating this training in a tightly-controlled clinical opportunity.

Factors Affecting Graduate Training in Fluency Disorders
Researchers previously have documented the various factors that have contributed to the shortfall in the preparation of speech-language pathologists (SLPs) to prevent, assess, and treat pediatric stuttering (Yaruss, 1997). Some of these factors may be related to the inherent complexities involved with this disability or university training programs’ challenges with changing accreditation standards. For most SLPs, training in the area of fluency begins with graduate school. Yet, as a result of changes in the standards for the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) made in 2005, many academic programs reduced or eliminated required course work in fluency disorders and the minimum clinical practicum hours in stuttering (Yaruss, 1997). Because of these changes, an unknown, but significant, number of graduates of professional programs are entering the profession with little or no clinical experience in the assessment or treatment of fluency disorders in children.
The fact that stuttering is a low-incidence disorder also contributes to the breakdown of best practice services for children who stutter because it often creates a small number of available clients who stutter in many academic training programs. Many universities, particularly (but not only) those in less populated areas, may be unable to find a sufficient client base to allow all students to gain face-to-face clinical experience with children who stutter. Consequently, there are few university programs that have specialty clinics in the area of stuttering to train graduate students in practicum. It is, therefore, incumbent on university training programs to develop unique educational and clinical training opportunities for students in order to meet minimum knowledge and skills competencies in the area of stuttering. Because of the complexity of stuttering and the repeated finding that many practicing clinicians already lack sufficient comfort and competence with fluency disorders (Cooper & Cooper, 1996; Manning, 2010; Tellis, Bressler, & Emerick, 2008), it would seem that clinicians need more training and experience, not less, in order to help people who stutter. Training programs, and indeed, the profession as a whole, must work to identify unique and alternative ways of preparing student clinicians to appropriately and effectively evaluate and treat fluency disorders. If this does not happen, and if the apparent trends identified in the area of pediatric fluency disorders continue, then it is likely that the number of clinicians who are qualified to help children who stutter will decrease even further. With the current landscape of academic training in the area of pediatric stuttering, how do we address this critical therapeutic component, especially when the training framework may not always allow the opportunity? More specifically, how can graduate training programs work to build confidence and competence in beginning clinicians during the preliminary stage of the client-clinician relationship, the initial evaluation. This extremely important initial step in the therapeutic process often can be difficult for beginning clinicians, especially given the current landscape of graduate clinical training opportunities. Therefore, how can we prepare our future clinicians to adequately counsel the parents of young children who stutter during the initial evaluation? What information should we include, and how can we as academic institutions assist in ensuring our students feel competent and confident in carrying out this task?
Brief Review of Initial Parent Counseling Trends
The focus on parent counseling following the initial evaluation of young children who stutter is not a new direction. Johnson’s (1948, 1961) initial advice to parents consisted of sharing information on speech development, the normalcy of disfluencies, and the causes of stuttering according to Johnson’s own theory. Other early practitioners focused the initial evaluation session on altering the parents’ perceptions and attitudes so as to promote a strong feeling of acceptance in the child (Schuell, 1949), and recommended creating a favorable and consistent environment for fluency so that the child’s communication system could mature and stabilize (Zwitman, 1978). Numerous researchers have written and developed programs for advising parents of preschool age children who stutter, sometimes as components in more comprehensive treatment programs, with some variations in orientation, general structure, and step-by-step details (Gregory & Gregory, 1999; Rustin, Botterill, & Kelman, 1996; Starkweather, 1990; Zebrowski & Schum, 1993). These programs appear to reflect both past thinking and significant portions of current practices in advising parents throughout the therapeutic process.
Because of the breadth and depth of the past literature in this area, it is important to understand that the therapeutic relationship with the family of a preschooler who stutters begins at the initial evaluation. Therefore, we must make a distinction between the immediate advising in conjunction with the initial evaluation and the in-depth counseling provided as part of comprehensive intervention. The focus here is on the former.
Use of Standardized/Simulated Patients in Communication Disorders
To date, no researchers have conducted preliminary studies using standardized/simulated participants (SPs) in the context of counseling individuals who stutter and/or their families. However, the use of SPs as an educational and clinical tool has a rich and respected history in medical, nursing, and allied health training (Bradley & Humphris, 1999). More recently, this method has made its way into the field of speech-language pathology (Hill, Davidson, & Theodoros, 2010), specifically in such areas as aphasia and Alzheimer’s disease (Zraick, 2002).
In an effort to enhance clinical skills in speech and language, Snyder (1996), developed a bank of simulated clients for the teaching of generic clinical skills to two groups of speech-language pathology students. Snyder trained actors to portray “patients” with communication impairment, and these SPs interacted with graduate students at various levels of clinical training. Students interacted with the SPs for 1 hour, both individually and as part of a group consisting of their peers. During their interaction with the SP, students took turns exhibiting skills such as interviewing, giving information, responding to confrontation, and developing a therapy plan. Students generally responded favorably to the use of SPs, and Snyder suggested that professors incorporate SPs into introductory courses on clinical management.
The design of the study, however, did not allow for objective analysis of the SP teaching method. For example, although there were expected and stated clinical competencies, he did not report data regarding whether students ultimately demonstrated clinical competency in part or whole.
Zraick, Allen, and Johnson (2003)  studied the use of SPs to teach and test interpersonal and communication skills with students in speech-language pathology. In particular, they investigated the use of SPs with aphasia to teach those skills and to test using Objective Structured Clinical Examinations (OSCEs). This study included three phases: (1) clinical teaching using SPs, (2) mid-term evaluation via a single case OSCE, and (3) end-of-term evaluation via multicase OSCE. Researchers integrated these phases with classroom teaching and testing components over a 16-week academic semester. Eighteen students participated while concurrently enrolled in a course on diagnosis and management of aphasia taught by the first author. Half of the class received initial instruction through a combination of didactic lecture and standardized patient interaction, while the other half of the class learned initially through didactic lecture only. On OSCE I, there was no statistically significant difference between the two groups in their interpersonal and communication skills, with the class as a whole demonstrating less than acceptable competency. After targeting these skills in all students through additional class lectures, there was a statistically and clinically significant improvement in their competency in this area on OSCE II. Student feedback regarding the experience was positive (Zraick, et al., 2003).
In a similar study, Zraick (2004)  investigated the use of SPs with Alzheimer’s disease (AD) and standardized AD family members to teach new graduate student-clinicians in speech-language pathology how to assess speech, language, and swallowing and share results of those assessments, and also to test their assessment and information-sharing skills through serial Objective Structured Clinical Examinations (OSCEs). Twenty students participated while concurrently enrolled in a two-semester course sequence on the diagnosis and management of neurogenic speech, language, and swallowing disorders taught by the author. Half of the class received instruction through a combination of didactic lecture and SP and SP family member interaction, while the other half of the class learned through didactic lecture only. On each of four serial OSCEs, there was a statistically significant difference (p. <.05) between the two groups in their interpersonal and communication skills, domain-specific assessment skills, and information-sharing skills. Again, student feedback was positive.
Necessary Knowledge and Skills Prior to the Evaluation
Based on the aforementioned information, the use of standardized patients provides students with a rich and unique training experience. Again, no one has developed this training technique/method, to this point, in the area of fluency disorders. The development of such a clinical teaching module would help to provide graduate students with a unique opportunity to hone clinical/counseling skills within an area that is often considered “low incidence.” In order for a practitioner to address stuttering in a young child, he/she first must be able to understand the variable nature of stuttering, the effect it can have on the life and family of the child, and how the caregivers can help best. This information is an essential component of the initial evaluation session.
Sharing information with patients regarding any disorder has become increasingly common for various purposes, such as deciding upon treatment choice. In early childhood stuttering, we have assumed that knowledge about the disorder reduces parents’ apprehension. So, what information has been deemed most important to share with parents of preschoolers who stutter at the initial evaluation? What information does a clinician need to own as he or she enters into a fluency evaluation? Much of this information centers around three overarching questions most asked by parents of children who have just begun to stutter: (1) what caused the stuttering, (2) how long will it last/when will it go away, and (3) what can we do to help? Yairi and Ambrose (2005)  summarized some major areas to share with parents of young children who stutter during this initial evaluation. This includes, but is not limited to:
  • Information about stuttering: Epidemiology, onset and development, myths and inaccuracies about causes

  • Information about normal and stuttered speech: Development, disfluency norms, warning signs for persistent stuttering, changing symptomatology of disfluencies

  • Environmental pressures: Speech-related pressures, behavioral or social/family pressures

  • Multifactorial nature: How stuttering onset overlaps with a period of rapid development in other capacities, including language, phonological, and motor skills, and the concomitant problems a child may experience as a result.

Armed with this information, and with opportunities to practice conveying it, a graduate clinician can confidently address concerns a caregiver might have following the initial evaluation. This may, of course, characterize just a surface representation of the specific case at hand. Many times, we are confronted with situations where parents have received erroneous or misleading information from a variety of sources, such as friends, a pediatrician, or the internet. It is, therefore, the responsibility of the clinician (student or otherwise) to dispel any myths or inaccuracies held by the child’s parents/caregivers. To be confident in the manner in which one delivers this information takes time and practice. A training experience using SPs certainly would provide a graduate clinician with that opportunity.
Counseling During the Initial Evaluation
There is a distinction between the immediate advising in conjunction with the initial evaluation and in-depth counseling provided as part of comprehensive intervention. In the SP framework I describe here I focus on the first. Although this kind of “counseling” often ends up largely as the clinician’s monologue, after completing a lengthy evaluation lasting several hours over two or three sessions, sharing information with parents about findings, impressions, and reasons for recommendations and allowing them special time for questions is a must. At this point, it is important to share the knowledge regarding the variable nature of stuttering and its characteristics. Many times, the clinician should consider the possibility that this may be the last contact with the family and, therefore, select the essential information and advice she or he would like to leave with the parents. We know from experience that graduate clinicians, as well as experienced clinicians, can be a bit overwhelmed with the task of summarizing and presenting basic feedback and information for parents. Yairi and Ambrose (2005) provide an outline and a sample narrative for the initial parent advising session, which, of course, one could imbed into the SP training experience. At the center of this narrative are the following components:
  • Results of the evaluation : Findings concerning stuttering, disfluency types, associated physical tension, and comparison of findings to disfluency norms

  • Information and prognosis: Incidence and prevalence data, recovery and chronicity information, and possible predictive factors

  • Intervention: Discuss therapy options and the effectiveness of treatment, validating the feelings and wishes of the caregivers in this respect

  • Parental involvement: Information regarding handling moments of stuttering/facilitating fluency, decreasing speech, language, and environmental pressures, and maintaining/improving the child’s self-confidence.

Again, too lengthy to include and describe here, Yairi and Ambrose (2005)  also provide a detailed example narrative that could prove useful for both graduate and experienced clinicians who may be anxious about this information sharing session (pg. 382–392).
Possible Framework for Implementation
Again, the purpose of this essay is to shed light on the need for a clinical training experience such as this and to provide a possible outline where simulated/standardized parents of young CWS can be developed for use in a brief postdiagnostic counseling and information sharing session. With the backdrop of the previously-described knowledge needed for parent counseling during the initial evaluation by a graduate clinician, how can we better prepare our future clinicians to accomplish this task? One such framework could include imbedding this training opportunity into a graduate course on fluency disorders (Zraick et al., 2003), given that such a course typically targets epidemiology, treatment and management, and counseling of fluency disorders. In this environment, the instructor would give specific didactic lectures on these topics and would test students on their content knowledge through traditional pen-and-paper examinations. Six pairs of standardized patients (SPs) could be trained to act as parents/caregivers of a preschool child who stutters (descriptions provided in Appendix A). Although the pairs described in Appendix A certainly cannot represent the myriad possible family dynamics a student could encounter in clinical practice, and that this would, in turn influence the counseling process, they can serve as a starting point for graduate clinicians and these roles certainly can be modified accordingly. Three of these sets of parents/caregivers could be portrayed as “accepting” of the fluency disorder and could consist of: (1) a traditional married couple, (2) a divorced couple, and (3) a parent/step-parent couple. The three other sets of parents/caregivers could have the same three marital statuses but could be portrayed as “not accepting.” These six sets of parents/caregivers represent a variety of the same environments inhabited by preschool children who stutter. Certainly, other factors could be included in the parent/caregiver profiles that could challenge the students’ counseling skills (i.e., a father who stutters and who feels guilty because his child now stutters; a child who stutters and who is in an environment with multiple siblings, etc.). Of course, for those who have conducted many parent counseling sessions, the situations we encounter seem limitless.
Following the outline of Zraick and colleagues (2003), the structure of this training opportunity could include three phases: (1) clinical teaching using SPs, (2) mid-term evaluation via a single case OSCE, and (3) end-of-term evaluation through multicase OSCE. These phases could be integrated with classroom teaching and testing components over an academic semester. Half of the students could receive initial instruction through a combination of didactic lecture and standardized patient interaction, while the other half of the students would be taught initially via didactic lecture only. Researchers would hypothesize that on the first administration of the OSCE, there would be no statistically significant difference between the two groups in their knowledge of material and counseling skills. After targeting these skills in all students through additional class lectures, however, we would expect a statistically and clinically significant improvement in their competency in this area on the second administration of the OSCE. In order to assist the SPs (actors) in understanding the nature of fluency disorders and the effect it can have on a young child and on his/her family, researchers could provide written case notes and scripts for SPs to review, model desired reactions, and provide feedback as they rehearse their presentation of the case (Appendix B). Additionally, during training, each SP pair could have, for their review, checklists of the specific skills and competencies expected from each student (Appendix C). These checklists would serve to further educate the SP pairs about the nature of the teaching interaction. It also would be beneficial in a deeper exploration of this adult learning process to examine Berliner (1994), whose work provides a discussion of how learning progresses from novice to expert.
Summary and Conclusion
The sheer number of publications over several decades addressing the issue of parent counseling during the initial evaluation of preschoolers who stutter indicates a widespread, long-sustained belief in the importance of this clinical feature. However, at present, there are less than adequate opportunities for our future clinicians to hone this important clinical skill. As stated earlier, it is necessary for university training programs to develop educational and clinical training for students in order to meet minimum knowledge and skills competencies in the area of stuttering. We should include the various aspects of parent/caregiver counseling and information sharing during the preliminary stages of the therapeutic process. It is incumbent on academic training programs, and indeed, the profession as a whole, to identify alternative ways of preparing student clinicians to appropriately and effectively work with young children who stutter and their families. If we do not undertake such efforts, and if the apparent trends identified in the area of pediatric fluency disorders continue, then it is likely that the number of clinicians who are qualified to help children who stutter will decrease even further.
The use of SPs in graduate training represents a unique way to integrate clinical skills with classroom teaching. Zraick and colleagues (2003) suggested that incorporating SPs and checklists like the OSCE into a graduate course on disordered communication is possible and acceptable to students. As described above, imbedding the opportunity for practice in initial parental counseling with SPs into a course on fluency disorders would provide our future clinicians with an experience to hone clinical and interpersonal skills, while also desensitizing them to this information sharing process. Additional class lectures, combined with guided practice with SPs, undoubtedly would play a key role in helping students become more competent and confident in this area. On a broader scale, if results of future studies indicate that SPs could be infused successfully into all disorder-based classes across a curriculum (or perhaps integrated with traditional clinical practicum), then it may represent a robust opportunity for training and measuring competency.
Appendices
Appendix A: Sample Simulated Patient Profiles (Can Be Modified Accordingly by Changing Age, Gender, etc.)
  1. Married couple. Family is supportive and understanding. They have a 4 year-old son who has been brought to the clinic because he stutters. When told the news, they are saddened, but understanding.

  2. Married couple. Mom and Dad both work all the time and are attending marital counseling. They have a 4 year-old son who has been brought to the clinic because his teacher thinks he stutters. The parents have noticed it, but are not concerned. When told the news, they are not accepting and are leery of receiving services.

  3. Divorced couple. Mom and Dad are still speaking and are at the evaluation. They have a 4 year-old son who has been brought to the clinic because he stutters. When told the news, they become angry with each other. Mom blames the Dad for leaving and for not being involved in the child’s life. Dad blames the Mom for being over-protective.

  4. Divorced couple. Mom and Dad are angry at one another, but they are still speaking at the evaluation. They have a 4 year-old son who has been brought to the clinic because he stutters. They are accepting of the diagnosis, but they have joint custody and may not be able to attend therapy regularly.

  5. Biological Parent and Step-Parent. They have a 4 year-old son who has been brought to the clinic because he stutters. They are concerned with the diagnosis but now have a blended family of 5 children. Parent focus on this child will be minimal, but they want to know all they can do to help.

  6. Grandparents. They have a 4 year-old grandson who stutters, and they are his primary caregivers. The parents are not involved/concerned. The grandparents are very confused about stuttering and its terminology.

Appendix B: Parent Dynamic for Actors
This is an example of a summary of a standardized/simulated parent dynamic that could be presented to actors portraying the child’s caregivers.

John and Jane Doe are happily married couple. They are coming to the Stuttering Center because their 3 and a half year-old son, Jack, has been stuttering. They have noticed part-word repetitions and prolongations. They are very supportive and understanding and want their child to have a normal life. The kids at school are beginning to ask why he talks funny and the parents are very concerned. There is no history of stuttering in the family. Your challenges as the standardized parents are as follows:

  1. To appropriately and accurately respond to the diagnosis given by the clinician.

  2. To observe the students behavior.

  3. To ask specific questions regarding the diagnosis.

  4. To accurately recall the student’s behavior and complete the performance checklist.

Your emotional tone for the session: John and Jane are saddened by the diagnosis, but want help and the best care for Jack.
Appendix C: Student Skills and Competence Checklist
Interpersonal/Professional
  1. Student introduced themselves appropriately

  2. Student touched patient or shook hands with family member

  3. Student was dressed appropriately for the encounter

  4. Student maintained eye contact with the family member

  5. Student “told” before “doing”

  6. Student treated family members with respect

Pre-Evaluation Session
  1. Student explains and appropriately responds to questions regarding epidemiological factors such as incidence, prevalence, and “causes.”

  2. Student explains and appropriately responds to questions regarding changing symptomatology of disfluencies.

  3. Student explains and appropriately responds to questions regarding age and gender factors consistent with indicators for persistence and recovery.

  4. Student reacts appropriately to parents/caregivers’ emotions.

Post-Evaluation Session
  1. Student states accurate diagnosis including severity and a description of qualitative and quantitative data.

  2. Student restates epidemiological information related to incidence and prevalence data, recovery and chronicity, and possible predictive factors.

  3. Student explains and appropriately responds to questions regarding speech-related pressures and behavioral or social/family pressures.

  4. Student describes at least two management strategies for diagnosis.

  5. Student explains and appropriately responds to questions regarding handling moments of stuttering/facilitating fluency, decreasing speech, language, and environmental pressures, and maintaining/improving the child’s self-confidence.

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