Our observation as professionals interacting with teens who stutter is that many have had therapy experiences which have placed a major emphasis on the practice, development and use of speech techniques as a means to stop or control stuttering. Many of these teens report that they are very reluctant - and have great difficulty - using the speech techniques emphasized in their therapy experiences during "real life" interaction with others. Teens often report a fear of stuttering and a fear of talking.

Our observation as professionals interacting with parents of teens who stutter is that many have had the belief that therapy emphasizing the practice, development and use of speech techniques will lead to the elimination or controlling of stuttering by their teen who stutters. Many of these parents report that their teen is reluctant -- and has great difficulty -- using the speech techniques emphasized in their teen's therapy experiences during "real life" interaction with others. Parents often report their teen who stutters does not talk as much as other teens and believe their teen is afraid to stutter. Parents often report very little involvement in their own teen's therapy process.

Our professional and personal journeys with stuttering have led us to believe anxiety associated with the fear of stuttering is at the core of most stuttering and can be paralyzing, especially for teens who stutter. We believe this leads to less talking, more tension in stuttering and less interacting with others. In addition, we believe most parents do not have an adequate understanding of stuttering to be effectively involved in their teen's therapeutic process.

These observations suggest to us that a reasonable approach for teens who stutter should emphasize the goals of increased talking, reduction of communication apprehension, increased interaction and active parent participation in the therapeutic process.

In this paper, we are proposing a new model of intensive group treatment for teens who stutter and their parents that focuses on reducing the fear of stuttering and the fear of talking. One of the advantages of an intensive group treatment program (for any disorder) is that the individuals involved realize that others face similar challenges to their own, which helps them to acknowledge their own difficulties. Acceptance of one's problem is a necessary first step if change is to occur. Another advantage of an intensive treatment program is that an individual can seek the expertise of clinicians outside of their geographical area. Given that there are currently only 179 Board Recognized Fluency Specialists in the United States, it is quite likely that most teens who stutter will not have access to a local SLP with an expertise in treating teens who stutter and their families. One disadvantage of many intensive programs however, is that the teenager is seen for 2-3 weeks in a novel setting and the parents stay at home. This model ignores the fact that 1) parents need to be just as involved in the therapeutic process as the teen who stutters, and 2) treatment is most effective when it occurs in an individual's natural environment.

Because parent involvement is crucial to treatment success, we argue that any intensive treatment model must include significant parent involvement. We also argue that both parents (or guardians) need to be actively involved in the therapeutic process. Given the economic realities of life in the United States, and that most families are allowed only 2 weeks of vacation/leave each year, developing an effective treatment model for teens and their parents has been challenging. With the advent of telecommunications software such as Skype however, new treatment models are possible. A short (3-4 day) intensive group program for teens and their parents could be combined with longer-term (3-6 month) individual follow-up using teletherapy. In addition to the individual follow-up by the SLP with both parents and teens, parents and teens would be able to continue to problem solve with other participants from the group using the same telecommunication methods they use with the SLP. Thus a network of support from individuals with a shared experience could be developed.

Teletherapy is the application of telecommunications service to deliver professional services at a distance. In other words, teletherapy is when an SLP in one location treats a person who stutters and their family at another location. The SLP and client can be in different cities, different states, or even different countries. Teletherapy allows you to receive therapy in the comfort of your home or school; even at your local coffee shop.

Not too long ago, this required expensive equipment, which limited its use to hospitals and schools. Now, most laptops and desktops come with built in video cameras and microphones that can capture very good quality audio and video. If your computer doesn't have a video camera, you can purchase one for under $50.00. Using free telecommunications software such as Skype, a SLP and person who stutters can have a video chat anywhere that you can connect to high speed internet.

When this technology first became available, research was carried out to see if teletherapy was comparable to face-to-face treatment. The assumption was that face-to-face treatment would be better, but that teletherapy might get similar treatment results. It turned out that in some instances teletherapy was actually better. This initial research was carried out with adults who had suffered a stroke or some other brain injury. It was suggested that the patients may have done better because they were less fatigued since they didn't have to travel to therapy, may have been more comfortable at home, and were being treated in the environment that they lived in. While there has been little research so far in the effectiveness of teletherapy for treating stuttering, the anecdotal evidence is encouraging.

While there are many exciting advantages to the use of teletherapy, its use is not without challenges. The biggest challenge professionals currently face is that the specialist must hold a license in the state that the client is in, not the state the specialist is in. This means, that while specialists can legally work with a person who stutters outside of the Unites States, they cannot work with someone who lives outside of the state they are licensed in. Some states are talking about reciprocal coverage, but this is not yet a reality. This has significant ramifications for a model such as the one we propose. Some clinicians are applying for a license in the states that surround their residence in the event that they would draw a client from another state. But what about a client who lives across the country but is willing to travel for the 3- to 4-day workshop? Some SLPs have suggested that treatment (which would require a license) is only provided during the intensive treatment component of a model such as the one presented. It has been argued by these individuals that the follow-up (even if for 6 months) is not technically treatment, and therefore does not need to be provided by an SLP licensed in the state that the client resides in. Until the licensing laws quickly catch up with technology, this may end up being decided by the courts.

Another obstacle to teletherapy in general, and its use in the model discussed above in particular, is the issue of reimbursement for services. Many insurance products limit the amount that they will reimburse for treatment each day or each week. Reimbursement of teletherapy is currently an evolving process. The vast majority of insurance plans have different levels of reimbursement for providers that are in network versus out of network. It would seem quite likely that a provider in another city or state would be considered out of network. We are hopeful however, that once a program such as the one described in this article is able to demonstrate success, that insurance would find it cost effective to sign limited treatment agreements with out of state providers to pay for treatment. Reimbursement rates may be lower than the provider receives from their own insurance provider, but it may be sufficient to allow an out of network client to take part in a treatment models such as the one we describe.

A third obstacle relates to marketing an intensive program to a target audience that is not in a SLPs immediate geographic area. Most SLPs have had little need to explore marketing very far beyond their own city, town, or region. They may lack an understanding of how best to market to a large audience. The fact that consumers tend to search for information on stuttering and stuttering treatment via the World Wide Web, suggests that search engine optimization would be a significant marketing goal.

Hopefully during the 2012 ISAD online conference we will be able to present data from our own 3-day intensive treatment program that will be combined with 6 months of follow-up using Skype. At this time however, we look forward to your feedback regarding this proposed treatment model.

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