Survey for the Development of the Contents of the Adolescent Stuttering Treatment Program

Ⅰ. Introduction

It is important to speak fluently in modern society. In the adolescent period of teenagers, in particular, speech fluency such as self-assertion, presentation, and conversation is more important for maintaining academic or peer relationships. In the adolescent period, a complex maturation of physical, neurological, and social development remarkably occurs. Many factors influence the fluent speaker to maintain fluency. Stuttering begins with repetition or prolongation, which progresses to severe blockage, struggle, or avoidance. A child who stutters has little or no awareness of his own speech initially, so no negative emotions or negative self-images are formed until he progresses into adolescence and stuttering becomes more complex and internalized (Guitar, 1998; Shin et al., 2020). Therefore, involuntary stuttering in adolescence can lead to anxiety, frustration, and hostility compared to childhood and adulthood, and it becomes impossible for him to express his own opinion more in a communication situation (Manning, 2013). A type of stuttering begins with repetition in the early stages, followed by prolongation or blockage as the stuttering deepens. Commonly, the main type of adolescent stuttering is blockage (Guitar, 1998); therefore, it is necessary to grasp the extrinsic characteristics of stuttering and the emotional and cognitive characteristics caused by stuttering in order to understand the essential characteristics of adolescents who stutter and to treat them accordingly.

On-site SLP (speech language pathologist) are burdened with the treatment of fluency disorders among the areas of communication disorders, and the reason was perceived as a lack of applicable treatment programs and a lack of experience in cases compared to other communication disorders. Also, applying stuttering treatment to actual subjects is difficult, and the lack of tools to be used in treatment activities creates a high demand for the development of treatment programs for fluency disorders (Chang et al., 2011). Although there are few studies on the effect of the stuttering treatment program published in Korea, the contents and information of the treatment program are mostly provided in text, making them difficult to apply to clinical practice (Kwon et al., 2012), and they are done mainly for children and adults, so there are limitations in applying them to adolescent who stutter (Chang et al., 2019).

The adolescent who stutter has different characteristics from that of a child whose stuttering period is relatively short after stuttering occurrence and whose language environment has a significant effect and that of an adult whose stuttering is advanced and fixed (Shin et al., 2019a, 2019b). This adolescent who stutters is also in the last step where stuttering can be treated before it becomes chronic when it enters adulthood. Adolescents with higher severity and anxiety of stuttering are predicted to have a more negative consequent experience of stuttering. In a study of adolescent stuttering, peer adolescents and teachers or parents lack awareness of stuttering, and they consider that stuttering itself is not sufficient reason to receive treatment. The stuttering adolescents perceive their own communication skills to be lower than the average, their communication apprehension is higher, and the adolescents who stutter are more likely to be teased or bullied than their fluent peers. Also, they say they do not want to talk to others about stuttering. In addition, the stuttering adolescent's family is reported to have difficulty managing high levels of emotional tension, family conflict, and children's frustration. Proper evaluation and treatment for the adolescent who stutter will prevent them from progressing to adults who stutter. However, the existing stuttering evaluation tools and treatment are mainly divided into children and adults. It is general to consider middle school students and older students as one group (adults) and evaluate or treat them (Riley, 2009; Sim et al., 2010). However, middle and high school students who are adolescents have a school environment, culture, and sensitivity to peer responses different from that of adults, and they are in the period of various psychological changes in the process of their self-identity being established, so the treatment activities and materials should be composed of contents that consider the interests and cultures of adolescents.

While the application of fluency enhancement techniques is also effective for children and adults, it can be difficult for adolescents to treat or participate due to lack of awareness of the motivation and necessity of stuttering treatment, negative prediction of the effectiveness of treatment, and lack of continuous practice time for new speaking techniques because of a burden on academic time. In addition to fluency enhancement techniques and stuttering modification approaches for stuttering, various treatment techniques have been introduced, but many difficulties have been reported in practice (Chang et al., 2019, Shin et al., 2019b). For example, even if the technique of slow speech is highly effective, it can be confusing how much speed needs to be adjusted, or whether all syllables, the beginning of a clause, or the utterances after breathing should be slowed down.

An adolescent who stutters can harbor shame, fear, and anger beyond simple stuttering and anxiety about listeners. It is a normal sentiment for those who have stuttered for several years and have been agitated, rejected, teased and harassed by listeners (Shin et al., 2019a). Recently, studies on social anxiety and social anxiety treatment of stuttering adolescents have been published (Gunn et al., 2019; Nnanani et al., 2019; Mulcahy et al., 2009). Therefore, activities that help them express their feelings about speech, stuttering, and control emotions are needed. Organizing target-oriented treatment activities with emphasis on their own initiatives and responsibilities of adolescent who stutter will increase treatment participation and treatment effectiveness.

Therefore, SLPs should not only improve the speech fluency of adolescents who stutter, but also understand the adolescents' self-identity, attitudes toward stuttering, and variability in emotions, providing balanced treatment that is not biased. In addition, adolescents have a great deal of time to interact with their peers at school, so teachers' perceptions of stuttering and information on fluency enhancement can affect adolescent stuttering. Therefore, adolescent stuttering treatment should take a comprehensive approach, considering not only extrinsic and intrinsic symptoms, but also various developmental and environmental characteristics from a life-cycle perspective.

As a result, this study aims to investigate the current status and perception of adolescent stuttering treatment and the necessity of factors related to adolescent stuttering treatment for SLP. It likewise intends to prepare a clinical basis for the development of a fluency enhancement program and an emotional cognitive support program considering the characteristics of adolescents.

Ⅱ. Methods

Ⅲ. Results

1. Current Status of Adolescent Stuttering Treatment for SLP

For the questions about the experience of adolescent stuttering treatment, 72 respondents (44.44%) answer that they have treatment experience, and 90 respondents (55.56%) answer that they have no treatment experience. Among those who have had experience with adolescent stuttering treatment, 27.78% answered that they are treated 1 to 3 times, which is the highest, 11.11% answer that they are treated more than 11 times, and 5.56% answer that they are treated 4 to 6 times. In the case where they answer that they have no experience in adolescent stuttering treatment, most (93%) answer that adolescent stuttering is not requested when asked why.

It is examined whether there is a difference between a stuttering treatment experience and an adolescent stuttering treatment experience according to the gender of an SLP (male: 92.9%, female: 72.5%, p<.001). It is found that there is a difference in adolescent stuttering treatment experience according to the gender of an SLP (male: 71.4%, female: 35.0%, p<.001).

Table 1.

Stuttering treatment experience and an adolescent stuttering treatment experience according to the gender of an SLP

It is investigated whether there is a difference between the experience of stuttering treatment and the experience of adolescent stuttering treatment according to the qualification level of an SLP (Qualification level 1: 92.3%, Qualification level 2: 64.3%, p<.001). There is a difference in the experience of stuttering among adolescents according to the level of qualifications of an SLP (Qualification level 1: 65.4%, Qualification level 2: 25.0%, p<.001).

Table 2.

Stuttering treatment experience and an adolescent stuttering treatment experience according to the qualification level of an SLP

2. Perception of SLP on Adolescent Stuttering Treatment

For the questions on whether adolescent stuttering treatment should be approached differently compared to adult stuttering treatment, 141 (87.04%) respondents answer yes, but only 21 (12.96%) respondents say otherwise.

Of the 72 SLPs with adolescent stuttering treatment, 69 (95.8%) answer that adolescent stuttering treatment should be approached differently compared to adult stuttering treatment. Of the 90 SLPs with no adolescent stuttering treatment, 72 (80%) answered so.

There was a statistically significant difference in the idea that the treatment of adolescent stuttering should be different from that of adult stuttering depending on the experience of adolescent stuttering. It was found that SLPs with experience of adolescent stuttering treatment agreed at a higher rate that adolescent stuttering treatment should be different from adult stuttering treatment than SLPs with no experience.

Table 3.

Awareness of the need for different interventions of adolescent stuttering according to the experience of adolescent stuttering treatment

For the reason why adolescent stuttering treatment should be different from adult stuttering treatment, “because the proportion of negative emotions is large” registers 68.09%, “because they are sensitive to the reaction of friends” takes up 65.96%, and “because the intrinsic characteristics of the adolescents are different from adults” occupies 59.57%. In addition, there are responses such as “because of lack of motivation to cure,” “because it is difficult to induce utterance,” and “because the adolescent has insufficient time.”

Table 4.

The reasons why adolescent stuttering treatment should be different from adult stuttering treatment

For the question about whether the adolescent stuttering treatment program is needed, 100% of respondents answer that it is needed. For the reasons, 66.67% say “because it is difficult to deal with psychological characteristics” and “because it is difficult to induce active participation in treatment activities,” with both responses being in the highest rate. The response of around 10% is as follows: “because it is difficult to motivate,” “because the language is different from that of a child or adult,” “because it is difficult to share empathy,” “because treatment activities are not diverse,” “because it is difficult to induce utterance,” and “because it is difficult to apply treatment techniques.”

Table 5.

Reasons to develop an adolescent stuttering therapy program

For the question about the types of treatment required for the adolescent stuttering treatment program, the “adolescent's cognitive and emotional search and treatment program” is the highest with 77.78%, the “fluency enhancement program” is 35.19%, the “counseling program for parents of adolescents who stutter” is 29.63 %, “stuttering modification program” is 27.78%, and “counseling program for teacher of adolescent who stutter” is 20.37%.

Table 6.

The types of treatment required for the adolescent stuttering treatment program

For the abilities that a pathologist must have to perform adolescent stuttering treatment, 74.07% is for “skills to deal with negative emotions such as anxiety and fear,” 68.52% for “adolescent counseling techniques,” and 51.85% for “listening and communication skills” and “clinical beliefs about counseling and treatment techniques,” respectively. Furthermore, 48.15% is for “fluency enhancement program implementation ability,” and 37.04% for “parent counseling ability” and “the ability to conduct stuttering correction procedures,” respectively. In addition, there are responses such as “evidence-based treatment decision ability,” “the ability to provide teacher information and request cooperation,” “the ability to access teams,” and “the ability to conduct group therapy.”

Table 7.

Statistics of the language ability of normal children

3. Importance of Adolescent Stuttering Treatment Factors

Based on the prior research on adolescent stuttering treatment, the responses to the importance of the extracted elements are as follows. The average response is given on a 7-point scale. The importance scales for mental treatment elements are 6.15 to 6.69, indicating that all elements are important for adolescent stuttering treatment. In particular, listening and empathy are rated as significantly important elements.

Table 8.

The importance scales for mind treatment elements in adolescent stuttering treatment

The importance scales for intrinsic treatment elements are 5.35 to 6.43. The high importance scale element is negative emotion reduction for stuttering (6.43), positive self-concept formation for speech (6.37), and anxiety reduction due to stuttering (6.35), and the lowest importance scale element is stuttering disclosure (4.70).

Table 9.

The importance scales for intrinsic treatment elements in adolescent stuttering treatment

The result of importance evaluation for extrinsic treatment elements is 5.35 to 6.37, gentle onset technique 6.37, practice applied to various listeners and environments 6.35, self-checking ability to maintain fluency 6.31, speed control technique 6.26, with cancellation, pull-out, and preparatory set 6.24 evaluated as the most important elements. The elements rated as low importance are intentional stuttering (5.35), DAF technique (5.52), proprioception (5.76), and online treatment (5.76).

Table 10.

The importance scales for extrinsic treatment elements in adolescent stuttering treatment

The importance scales for parent treatment elements are 6.20 to 6.59. Treatment element with high importance is to explain positive communication methods between parents and children (6.59), and the question with low importance is to listen to the grievance as parents of stuttering children (6.20).

Table 11.

The importance scales for parent treatment elements in adolescent stuttering treatment

The importance scales for teacher treatment elements are 5.91 to 6.26. The treatment element with high importance is how to cope with stuttering in class activities (6.26), and the question with low importance is to give other students a positive perception of stuttering (5.91).

Table 12.

The importance scales for teacher treatment elements in adolescent stuttering treatment

Ⅳ. Discussion and Conclusion

This study conducted a questionnaire survey on the current status of domestic adolescent stuttering treatment, recognition of speech language pathologists, and importance of adolescent stuttering treatment program elements for the purpose of developing the contents of the adolescent stuttering treatment program.

First, only 44.44% of respondents said that they had experience with domestic adolescent stuttering treatment. 77.78% of the speech therapists who answered the questionnaire had experience with stuttering treatment, while 44.44% of them said that their adolescent stuttering treatment experience was not high. 93% of the respondents said that the reason why they had no adolescent stuttering treatment experience was because adolescent stuttering treatment was not requested. For the question about the number of cases of adolescent stuttering treatment, 27.78% had 1 to 3 cases, 5.56% had 4 to 6 cases, 7.41% had 7 to 10 cases, and 18.52% had more than 11 cases. According to a study by Chang et al. (2011), domestic speech therapists were burdened with treatment of fluency disorders among speech disorder types, and there was a lack of applicable treatment programs. In addition, it was similar to what was reported as lack of case experience, and in the area of fluency disorders, adolescent stuttering treatment showed such characteristics more.

There was a difference in the adolescent stuttering treatment experience according to the gender and qualifications of speech therapists. Male therapists rather than females and speech therapists, who were qualified as first-level speech language pathologists instead of second-level, had more experience in adolescent stuttering. It was found that the adolescent stuttering treatment was assigned to a specific speech therapist rather than it being evenly assigned. The rate of a male speech therapist's stuttering treatment experience (92.9%) was higher than that of female speech therapist's (72.5%), and the rate of a male speech therapist's adolescent stuttering treatment experience (71.4%) was higher than that of a female speech therapist's (35.0%). The gender element can be considered in relation to the reason why the gender rate of the stuttering subjects is high in males. Compared to other disorders such as speech development and articulation disorders, the age distribution of subjects varied from adolescents to adults, so it could be assumed that they were assigned to male speech therapists more than female ones.

For the speech language pathologist qualification level, the rate of stuttering treatment experience of the first-level speech language pathologist (92.3%) was higher than that of the second-level speech language pathologist (65.4%), and the rate of adolescent stuttering treatment experience of the first-level speech language pathologist (65.4%) was higher than that of the second-level speech language pathologist (25.0%). According to a previous study by Chang et al. (2011), adolescent stuttering treatment was more likely to be assigned to the first-level speech language pathologist with more experience as the treatment of fluency disorders was burdensome and difficult for the second-level speech language pathologist with less experience.

The speech language pathologist's perception of adolescent stuttering treatment indicated that 87.04% of respondents said they should approach the case differently compared to an adult stuttering treatment, and for the necessity of the adolescent stuttering treatment program, 95.8% of them answered that it was needed. For the question that an adolescent stuttering treatment should be approached differently compared to that of an adult stuttering treatment, pathologists with adolescent stuttering treatment experience responded positively higher than those with no experience. For the differentiation of adolescent stuttering treatment, the majority of speech therapists responded positively. Particularly, the therapists with actual experience of adolescent stuttering treatment responded that it was more necessary to distinguish adolescent stuttering treatment from that of adults. Many domestic books and studies about fluency disorders suggested the evaluation and diagnosis of adolescent and adult stuttering by the same approach, but in reality, adolescents and adults required different approaches because the characteristics of the subjects were different, and experts in the field recognized the need.

The following responses were given to the reasons for the need for an adolescent stuttering treatment program: because it is difficult to deal with the psychological characteristics of adolescents (66.67%), because it is difficult to induce active participation in treatment activities (66.67%), and because it is difficult to give motivation (31.48%). Through this study, the necessity of a treatment program considering the psychological and environmental characteristics of the stuttering youth age group was confirmed.

Specifically, when asked about the importance among the elements of the adolescent stuttering treatment program, the mental treatment element received the highest rate (6.40), followed by the parent treatment element (6.38), teacher treatment element (6.13), intrinsic treatment element (6.04), and extrinsic treatment element (6.00). As before, the need for a mental treatment element in the case of adolescent stuttering was emphasized from the psychological point-of-view, and in adult stuttering treatment, the importance of parent treatment or teacher treatment, which was relatively less emphasized, was higher (Gunn et al., 2019; Mulcahy et al., 2009; Nnanani et al.. 2019). In addition, it was found that the importance of intrinsic and extrinsic treatments, corresponding to the existing stuttering treatment, was still important. In the categories measured with relatively low importance, the stuttering disclosure (4.70), the intentional stuttering application (5.35), and the maintenance program through online treatment (5.76) were found to be low. It was confirmed that stuttering disclosure and intentional stuttering were techniques that were frequently used for the treatment of internal characteristics in adult stuttering, but it was difficult to apply to adolescent stuttering treatment due to higher psychological resistance. In addition, online treatment or remote treatment was frequently seen in foreign studies, but it could be seen that it still needed a process for verification in the field of speech therapy in Korea.

This study investigated the current status and perception of adolescent stuttering treatment among Korean speech therapists and the importance of its program elements. Based on the results of this study, it can be said that a treatment program that meets the characteristics of domestic adolescent stuttering and meets the needs of the field should be developed and widely used for adolescent stuttering treatment.

Acknowledgments

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (No. NRF-2019S1A5A2A03054105).

이 논문은 2019년 대한민국 교육부와 한국연구재단의 지원을 받아 수행된 연구임(No. NRF-2019S1A5A2A03054105).

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