An exploration of the mechanisms of change following an integrated group intervention for stuttering, as perceived by school-aged children who stutter (CWS)
Introduction
Stuttering is a complex problem which is heterogeneous, in terms of causation and presentation, and can impact on individuals and their families in different ways. Within the population of children who stutter (CWS), the overt features of stuttering vary widely and there can be a strong emotional component. Therapy outcomes can vary and the perception of the process of change is unique (Manning, 2010).
Studies have shown that CWS can develop negative attitudes towards their speech from a young age, which has important implications for their emotional wellbeing (Vanryckeghem, Brutten & Hernandez, 2005). School-aged CWS commonly experience teasing and bullying by their peers (Blood, Boyle & Blood, 2010; Langevin, Packman & Onslow, 2009) and by adolescence and adulthood, there is a high co-occurrence of stuttering and anxiety disorders (Blood, Blood, Maloney, Meyer & Qualls, 2007; Kraaimaat, Vanryckeghem & Van Dam-Baggen, 2002). Consequently, stuttering can have a negative impact on children’s communicative confidence and quality of life (Yaruss & Quesal, 2006), which may contribute to parents’ level of worry and impact on the wider family context (Biggart, Cook & Fry, 2007). Given the increasingly negative reactions from others that CWS may experience as they get older, it is important that they are supported to manage these challenges in school (Healey, 2010), to minimise the impact of stuttering and to increase children’s and families’ coping and resilience.
Therapy programmes need to be multi-faceted, so that aspects of the client’s real-world and overall communication are incorporated into the intervention (Cook and Botterill, 2005, Blomgren, 2013). This may include developing and maintaining social communication skills in a range of increasingly challenging speaking situations, identifying and challenging negative thoughts, assumptions and emotions that may have developed around speaking e.g. using Cognitive Behavioural Therapy (CBT) and building coping skills and confidence, alongside the development of behavioural strategies to manage moments of stuttering with more control. All of these components are incorporated in Cook and Botterill’s (2005) therapy model and are framed within the context of the child’s environment (see Fig. 1).
There has been little research carried out to determine which of the above core components of Cook and Botterill’s (2005) therapy model may be most instrumental in the mechanism of change, for individual CWS. Each component of this model will be explored below and the rationale for the current study presented.
CBT is a therapeutic and educational approach commonly used with adults, and increasingly used with children and young people, to address psychological problems (Fuggle, Dunsmuir & Curry, 2013). People who stutter may develop negative patterns of thinking and experience increased levels of anxiety in speaking situations (Blood, Blood, Bennett, Simpson & Susman, 1994; Blumgart, Tran & Craig, 2010; Ezrati-Vinacour and Levin, 2004) and heightened fear of negative evaluation by others (Iverach & Rapee, 2014). This can often lead to the use of safety behaviours (such as avoidance), consistent with Clark and Wells’ (1995) model of social anxiety, applied within CBT. This model postulates that CWS need to identify their negative automatic thoughts before, during, and after speaking situations in order to challenge their negative assumptions and predictions. There is evidence from a developmental perspective that children are able to engage in CBT (Grave & Blissett, 2004) and that it can be effective in bringing about cognitive change in a range of disorders (Bailey, 2001). Growing evidence in the literature supports the innovative and successful use of CBT as part of an integrated intervention for adolescents and adults who stutter (Murphy, Yaruss, & Quesal, 2007; Menzies et al., 2008; Fry, Millard, & Botterill, 2014). The use of CBT is an emergent approach in the field of stuttering in school-aged children, and is not typically a standard component of interventions offered. Cognitive restructuring may be supported through methods such as: reviewing the evidence; considering alternative explanations and considering the helpfulness or the accuracy of cognitions, for example using behavioural experiments, to gather empirical and meaningful evidence in the child’s everyday environment, to support more adaptive thoughts and beliefs (Kelman & Wheeler, 2015). By developing emotional regulation, flexible thinking, helpful self-talk and problem-solving skills, using a CBT approach, protective factors associated with emotional resilience can be enhanced during therapy. This more holistic focus may then lead to better resilience, improved regulation of emotions and cognitive reactions, better overall mental health and improved quality of life (Plexico, Manning, & Levitt, 2009). Research into resilience in children and adolescents has been a focus of investigation in psychological research over many years. Resilience is a complex, multifaceted construct which can be described as a “dynamic process encompassing positive adaptation within the context of significant adversity” (Luthar, Cicchetti & Becker, 2000, p.543) and the ability “to bounce back from a negative experience” (Prince-Embury, 2006; p.1). Factors that predict resilience in adolescents include: having one or more supportive parents, cognitive and problem-solving skills, positive self-efficacy and worth, hopefulness, prosocial friends and effective school and community environments (Masten, 2004). Masten (2004) also describes the regulatory processes implicated in the neurodevelopment of resilience, which include executive functioning, emotional regulation, relationships with adults and peers and opportunities for capacity building. Risk factors associated with low resilience include low socio-economic status, parental mental health difficulties, low birth weight, parental divorce, maltreatment or violence, or a combination of risks which are cumulative (Masten, 2001). However, a common critique of resilience research relates to the challenge faced by researchers in measuring and comparing the level of adversity or ‘risk’ experienced by individuals (Luthar et al., 2000). In addition, given the heterogeneous nature of resilience, factors which may present as ‘risks’ for one child, may not have the same detrimental impact on another. The factors which predict resilience may be relatively stable (e.g. a person’s personality) whilst other factors are likely to vary as life events change and a person’s internal resources and coping skills change (Bonanno & Diminich, 2013). Resilience may therefore fluctuate over time and across domains.
As previously described, CWS are at increased risk of developing social anxiety in adolescence and adulthood and report high levels of teasing and bullying as a result of stuttering. However, their capacity to cope or ‘bounce back’ is not routinely measured or explored. Some CWS may have built resilience to adversity over time, in response to their experiences of stuttering, as described by Rutter (2013): “Resilience may stem from the effects of repeated brief exposure to negative experiences in circumstances that allow the individual to cope successfully with the experience” (p. 477). However, others may not have the necessary coping skills or environmental protective factors that build resilience in the face of potential adversity. An important aspect of research with this client group therefore is to try to determine the factors associated with positive outcomes following therapy and to explore the process by which CWS experience positive change. Whilst there are generic programmes available for children, focusing on building self-esteem, resilience and well-being, using CBT (Stallard & Buck, 2013), to date there has been no research exploring the construct of resilience, or its use in therapy, in school-aged CWS.
Developing increased control over moments of stuttering and increased overall fluency are often the main goals for CWS, and their parents (Berquez, Hertsberg, Hollister, Zebrowski, & Millard, 2015). Children and adolescents frequently report feeling helpless or frustrated by the lack of predictability of their stuttering and limited knowledge of what can support fluency. Strategies typically used in therapy are fluency shaping techniques (Hearne, Packman, Onslow & O’Brien, 2008) to achieve complete control and eliminate stuttering, and speech modification (Van Riper, 1973) where the focus is on reducing sensitivity towards stuttering, reducing negative thoughts, feelings and reactions to stuttering and increasing feelings of control, openness and acceptance. The integration of these two approaches (Guitar, 2013), offers a viable option for CWS, which empowers them to make choices about preferred ways to manage their stuttering in different environments.
Stuttering can be variable and unpredictable, and social communication skills and communicative confidence can be affected by stuttering to varying degrees. For example, stuttering can interfere with the speaker’s ability to demonstrate effective use of verbal and non-verbal communication skills, due to the effect of increased anxiety or reduced confidence during some social situations (Rustin & Kuhr, 1999). Some adolescents who stutter have higher levels of communication apprehension and poorer self-perception of communicative competence, compared to those who do not stutter; and higher levels of speaking-related anxiety, correlated with stuttering severity (Blood, Blood, Tellis, & Gabel, 2001). It is therefore important that communication skills are developed and enhanced, in a series of graded steps (i.e. graded exposure of least to most anxiety provoking) in increasingly difficult social situations (Spence, Donovan, & Brechman-Toussaint, 2000), to enable CWS to communicate successfully, regardless of speech fluency.
Children’s support networks are a fundamental component to building resilience. A key component of therapy, to ensure that therapeutic gains are supported and maintained in the child’s real world, is the consideration and involvement of the ‘system’ in the intervention process i.e. the child’s family and school environments (Fuggle et al., 2013). Parental involvement in therapy for CWS is fundamental (Jones et al., 2005, Kelman and Nicholas, 2008). As parents’ own cognitions, emotions and behaviour are closely interwoven with their child’s, their own beliefs and assumptions will influence how they respond and consequently inform how the child construes a situation, which may impact on their own behaviour (Biggart et al., 2007). Teachers also play a vital role in supporting children to develop their skills and learning in school. Studies exploring the reactions of teachers towards stuttering highlight some negative emotions (such as discomfort) around stuttering and teachers’ lack of confidence in how to manage it (Plexico, Plumb & Beacham, 2013). The impact of teachers’ emotional and behavioural response to stuttering, alongside the anxiety commonly experienced by CWS during speaking tasks in class, may lead to teachers inadvertently reinforcing children’s avoidance by reducing their expectations of the child. It is therefore important that teachers play a positive role in supporting CWS in class (Berquez, Cook, Millard, & Jarvis, 2011). A further crucial social support for children in schools is the development of a positive peer group and close friendships. Donald (2010) describe the role of self-disclosure within adolescent friendships, which can strengthen the closeness of the relationship and further develop the social-emotional bond between friends. The effects of peer support are also important in ‘protecting’ adolescents against emotional vulnerability and in providing a positive support network in the school environment (Naylor & Cowie, 1999).
Finally, the therapeutic environment and the relationship that CWS develop with the clinician during the therapy process is also a key dynamic which requires exploration and consideration. The therapeutic relationship is an area of extensive investigation, with a research base stemming from psychotherapy and counselling psychology research (Duncan, Miller, Wampold, & Hubble, 2010). The ‘common factors model’ (Imel & Wampold, 2008) seeks to identify the elements that contribute to treatment effectiveness and the relative weighting of each, including the therapeutic alliance: 30%; extra-therapeutic factors: 40%; therapy technique: 15%; and expectancy: 15%. This suggests that the therapeutic relationship accounts for more than the therapy intervention itself, and that client’s and therapists’ hope (i.e. a belief that change is possible), also play an important role in client responsiveness to change. Factors that contribute to a successful alliance with clients who stutter (from the clients’ perspective) have been reported to include: therapists’ competence and understanding of the clients’ experience of stuttering; showing a passion for supporting them; the willingness of clinicians to listen; and the focus on client’s goals and strengths (Plexico, Manning, & DiLollo, 2010). The development of an effective and trusting relationship is particularly important in anxiety-focused interventions due to the challenging nature of some therapy tasks (e.g. exploring difficult emotions and tolerating anxiety during exposure tasks). It is therefore key that the client experiences the relationship with the therapist as meaningful and supportive (Duncan et al., 2010).
The ‘common factors model’ (Imel & Wampold, 2008) highlights the importance of the therapy relationship in promoting change, alongside extra-therapeutic change (i.e. client and family factors, including their skills, resources, beliefs and attitudes, social support and potential for change). The change process in therapy may be gradual and influenced by a number of factors. The clients’ ‘stage of change’ may be one of these influential factors i.e. the clients’ readiness to contemplate, prepare for and commit to action, in order to make a change. This process was originally presented by Prochaska & DiClemente (1986) in their seminal model of the process of change using a transtheoretical approach. This model has been applied to people who stutter, to consider the varying stages of change that clients may experience, in relation to seeking and pursuing support to manage their speech (Floyd, Zebrowski, & Flamme, 2007).
Manning (2010) proposes that the clients’ stage of change, their support system and their potential for use of more effective cognitive, emotional and behavioural coping styles, may all influence the process of change in therapy for stuttering. Clients’ sense of increased control and coping alongside positive shifts in mood are likely to have a beneficial impact on their fluency. Therefore, small changes in one area can influence important changes in other domains and are likely to be closely inter-linked.
There is emerging quantitative evidence for the effectiveness of the integrated therapy approach presented in Fig. 1, particularly in intensive group therapy with children and adolescents who stutter (Millard, 2011, Fry et al., 2014). Whilst some studies have used a phenomenological approach to explore clients’ perspectives (Plexico, Manning & DiLollo, 2005; Plexico et al., 2010), the use of CBT and the role of resilience in the process of change have not been previously evaluated and both quantitative and qualitative research in this area is scarce.
The aims of this study were to explore the perceptions of seven CWS regarding the changes they made following intensive group therapy for stuttering; to identify their most significant change as a result of therapy; and to explore the mechanism of change in relation to the key components of the therapy model (i.e. communication skills; fluency management; cognitive and emotional change; systemic support and therapeutic alliance).
This study places importance on user involvement and listening to the client’s voice (Tait and Lester, 2005, Stewart and Richardson, 2004), in order to explore individual experiences of therapy and its effectiveness. These ‘missing voices’ in research are important in reflecting clients’ own life experiences and generalising findings to real-life settings (Kovarsky, 2008). This level of detailed outcome analysis of combined therapy has not previously been carried out and therefore provides a unique and distinctive contribution to this field.
Section snippets
Participants
Children who attended an intensive group therapy programme at the Michael Palin Centre (MPC), were invited to participate in the study. Seven children opted into the study (4 boys, 3 girls, M = 12.4 years, range = 10.4-14.11 years), with parental consent (see Table 1 for summary of participants).
The entry criteria for the children’s intensive course includes: the child’s age (10.0-14.11 years), a diagnosis of stuttering (assessed by a specialist speech and language therapist) and adequate cognitive
Quantitative Data
Using the RCI (Jacobson & Truax, 1991) to measure statistically reliable change between baseline and final follow-up (12 months post intervention) scores on the Resiliency Scales questionnaire, four participants (A, B, C and G; 57%) demonstrated a reliable improvement in their resourcefulness over time and six participants (all except case E; 85.7%) showed a reliable reduction in their vulnerability scores i.e. a positive change in their resilience profile (see Table 2 for results).
Cases D and
Discussion
Transcripts of semi-structured interviews were explored using TA, enabling a rich and enlightening interpretation of the data. In addressing the research questions regarding therapeutic change and the nature and mechanisms of change, participants identified changes across a range of domains. The results reported are consistent with Cook & Botterill’s (2005) theoretical model and both the qualitative and quantitative data support the existing literature regarding the effectiveness of this
Conclusion
This study offers a unique insight into the perceptions of a group of CWS regarding their experiences of therapy and their process of change. Cognitive and emotional change was a fundamental component reported by participants in their process of change, alongside access to a positive support network, which linked to a change in behaviour (e.g. communicating more and being more fluent) and to participants’ ability to recover from difficulties (i.e. the capacity to be more resilient). The
Acknowledgements
This research was supported by Whittington Health NHS Trust, University College London, and Action for Stammering Children. Thank you to the families who participated in this study, for their time and fascinating insights.
Sarah Caughter qualified from Newcastle University in 2004. Sarah works at the Michael Palin Centre for stammering, a national tertiary centre for children, adolescents and adults who stammer. Her role at the centre involves clinical work with children and adults who stammer; carrying out research; delivering a range of specialist training programmes and supervising SLTs. In 2015 Sarah completed a 3 year part-time University College London (UCL) Masters course (in collaboration with the Anna
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Sarah Caughter qualified from Newcastle University in 2004. Sarah works at the Michael Palin Centre for stammering, a national tertiary centre for children, adolescents and adults who stammer. Her role at the centre involves clinical work with children and adults who stammer; carrying out research; delivering a range of specialist training programmes and supervising SLTs. In 2015 Sarah completed a 3 year part-time University College London (UCL) Masters course (in collaboration with the Anna Freud Centre, London), in using Cognitive Behavioural Therapy with Children and Young People (CBTCYP). 2015–2016 she worked as a practice tutor on the CBTCYP post-graduate course at UCL.
Sandra Dunsmuir is Director of the Educational Psychology Group at University College London (UCL) where she leads the professional doctorate programme. She is also joint Course Director on the UCL postgraduate courses in CBT for Children and Young People. An experienced registered and chartered educational psychologist, she continues to practice on a regular basis with children, their families and teachers in school and community settings. Her research integrates empirical research and psychological theory with a particular focus on relationships and communication, interventions to support children's learning and mental health, and cross-professional collaborative working.