When treating young children who stutter, speech-language pathologists may choose to provide direct therapy, indirect therapy, or a combination of these two approaches. The notion of direct early intervention for children with fluency disorders is relatively new. Although our colleagues and we have provided indirect therapy for young children who stutter since the early days of the profession, many of us have only recently begun to think in terms of providing direct service to these children.

According to Bloodstein (1987), in the 1980s we began to treat young children more directly with a combination of parent counseling, increasing the child's feelings of success as a speaker through simple exercises which guaranteed success (reciting nursery rhymes, choral speaking etc) and simple behavior modification techniques (easy, slow speech, controlling length and complexity of utterances etc). The decade of the nineties saw an increase in research related to stuttering treatment for children. Yairi and his colleagues (1997, 1996, 1992) have investigated a variety of variables related to stuttering in young children, including speech and voice characteristics, and the genetic basis of recovery. The works of Starkweather (1997), Starkweather and Givens-Ackerman (1997), Starkweather, Gottwald and Halfond (1990) and Perkins (1992) have emphasized that stuttering can be prevented when treated early enough, and Starkweather further suggests it be treated directly if necessary.

Whether we believe that this disorder can be prevented or just successfully treated at a very early age, for us the course of action remains the same. We are committed to the concept of early intervention and endorse the combination of direct and indirect treatment procedures for young, sometimes very young children. We agree with many of our colleagues (Adams, 1980; Costello, 1984; Peters & Guitar, 1991; Ryan, 1979; Shine, 1980; Starkweather, 1997; Starkweather & Givens-Ackerman, 1997; Starkweather & Gottwald, 1990) who have suggested that early intervention has a far more positive prognosis than later treatment. Starkweather (1997) tells us that..."most young children who successfully completed early intervention or prevention programs have natural sounding speech, no need to be vigilant, and only a remote possibility of relapse" (p.257).

Our view of stuttering treatment for young children is synergistic, or holistic, in that it combines fluency shaping strategies with environmental modification and attention to attitudinal or affective factors. Stuttering is not merely a speech disorder; it is a communication disorder. Because we see stuttering as a multidimensional, multi-causality communication disorder, we are committed to treating the whole child, rather than only the vocal stuttering symptoms.

The treatment program that we recommend for young children combines features of many early intervention programs which have influenced our thinking. The synergistic approach to early intervention considers the dimensions of normal speech production as well as the child's attitudes and feelings and the home and communicative environment. We endorse the combined fluency shaping and stuttering modification philosophies seen in so many of the child-oriented treatment programs available today (Cooper & Cooper, 1985 ; Healy & Scott, 1995; Meyers & Woodford, 1992), and all therapy sessions are conducted in the context of play.

We begin with a careful assessment of the child, paying special attention to his/her linguistic maturity. It has been our experience that young children who stutter often have difficulty with the organizational (categorization and sequencing) and pragmatic (conversational rules) aspects of language, as well as difficulty with such higher level language functions as expressing abstract concepts, verbal problem solving, verbal reasoning, and expressing relationships among words and ideas.

Various investigators (Bloodstein, 1993; Peters & Guitar, 1991; Ratner, 1995; Wall & Meyers, 1995; Wingate, 1988; Yovetich, 1984) have noted this linguistic fragility in some young children who stutter. Although there remains much controversy regarding the language abilities of young stuttering children (Bernstein-Ratner & Sih, 1987; Nippold, 1990; Ryan, 1992), the role of language should not be overlooked in the treatment of this age group, since the period of greatest language development (2.5 to 5 years) frequently coincides with the period of greatest risk for the development of stuttering.

Our assessment entails the administration of a variety of formal tests including the Preschool Language Assessment Instrument (PLAI) by Blank, Rose and Berlin (1978). We chose this tool, despite the fact that it has not been standardized, because it reveals the child's ability to handle four different levels of abstraction: matching perception, selective analysis of perception, reordering perception, and reasoning about perception. If fluency breaks down at a particular level, we have an increased understanding of the role of linguistic complexity on the child's fluency. For example, if stuttering occurs or increases markedly when the child is asked to predict, explain or find a logical solution to a problem (level 4), then we may predict that this child would benefit from treatment that targets higher level language tasks, and that the lower levels of abstraction (i.e., identifying or labeling; describing; defining by concept) do not present a problem to the child.

Finally, assessment also includes interviews with parents, teachers and significant others in the child’s life. We attempt to gather as much information as possible from as many sources as we can. We observe the child in a wide variety of speaking environments in order to understand more completely, the fluctuations in fluency that s/he experiences.

In treating the young stuttering child, we take the perspective that a language-based approach is most efficient and effective. We therefore begin with a focus on communication, teaching the child as Yovetich (1984) recommends, that communication is the sending of good messages. We explain that a "good message" means that the other person understands what we said. We spend several sessions establishing the concept of good messages, exploring various ways of deciding if the conversational partner understands our messages (facial expressions, nods, sounds like ah-ha, etc.), practicing sending messages to each other, practicing sending messages to mom and dad, brother and sister, and friends. Once the idea of a good message has been established, we introduce the idea of smooth or easy messages as opposed to rough, bumpy, or hard messages. Whenever possible we use the child's language to describe the stuttering. If the child does not have a word for his stuttering we may suggest the terms rough, bumpy, or hard. Then good messages that are hard or bumpy can be made easy or smooth. We continue to reinforce good messages, and encourage the child to problem solve how to make a hard message easy. Children are remarkably skillful at figuring out their own ways of converting stuttered utterances into fluent ones. The words "easy speech", "smooth talk" and "turtle speech", are frequently introduced to facilitate fluency.

Many clinical investigators suggest that simplifying the linguistic demands will increase the child's fluency (Ryan, 1980; Shine, 1980; Costello, 1983; Meyers, 1992). We often begin our treatment by requiring only single word responses and gradually increasing the length and complexity of required responses while practicing the fluency facilitation techniques described above. We also introduce a set of "family speech rules" that are good conversational practice for any communication partners. These rules include waiting until it's your turn to talk, listening to what the other person is saying, and making sure to talk about the same thing that the other person is talking about. Again, even very young children respond positively to these pragmatic language requirements, quickly learning the conversational rules and, in so doing, giving themselves more time to organize their language responses to conversational demands.

When the results of language testing suggest that there are more significant language concerns, our treatment plan includes goals and objectives that address those concerns. Language goals are easily incorporated into fluency practice. After all, language is the context in which we present all of our teaching of fluency skills. What difference whether we practice smooth and easy speech or turtle talk in picture naming tasks, verbal problem solving activities, or narrative construction? The important issue here is to engage in a careful task analysis before teaching a new language concept, so that the level of difficulty of the linguistic demand is compatible with the child's capacity for the use of the fluency facilitation techniques we have previously taught.

Like Starkweather and his associates (1990) we sometimes introduce easier ways to stutter, helping the child move back down through the stages of stuttering severity. We use easy voluntary stuttering ourselves, sometimes pointing it out to the child, sometimes not. We assure the children we treat that there are times it is hard for all of us to say things, but that we always listen because what they have to say is important to us.

Feelings and attitudes are as important to us in treating children as they are in treating adults. The negative impact of unsuccessful speech attempts and failed communicative interactions, we believe, must be counteracted through strong positive reinforcement of successful communication. In keeping with the synergistic model, our focus is placed upon building self-esteem and assertiveness and increasing an internal locus of control. Our young clients are taught to realistically evaluate the success of their communicative attempts on an ongoing basis. They are constantly assessing whether their messages are "good messages",(i.e. understood by the other person). Unrealistic beliefs about what other people think are directly confronted as we teach our clients to read such nonverbal responses as body language, facial expression and eye contact. They come to feel more successful because they are viewing the total communication event, rather than just the role of their fluency in their social and communicative interactions. We believe they are empowered by the knowledge that they are in charge of their messages, thereby helping to internalize their locus of control, even at the very youngest ages.

In addition, this sense of empowerment makes our young clients more confident, and assertive. Success in therapy is transferred to success in real life situations over the course of treatment, and the children come to believe that they are as special as we, their parents, and others who know them think they are. Please note that success in therapy is not necessarily defined as "fluency"; rather it is defined as effective communication, making certain that the people we talk to understand the meaning of our messages. Children learn that others and we value what they have to say more than we value how they say things.

All treatment programs for children who stutter must concern themselves with the social and communicative environments within which the children function. The Synergistic Approach seeks to specifically address those issues which were identified during the comprehensive assessment, in addition to the more typical concerns which are a part of the picture of most, if not all stuttering children. It is here that we address parental concerns, sibling issues, family and school or teacher questions, and cultural factors related to such ideas as shame, fear, pride or custom.

Issues are addressed through parent/family counseling and systematic parent training. Both counseling and training are tailored to the individual needs of the families of our clients. For example, if discipline is a problem for parents, we might discuss various standard approaches to this issue during a counseling session, and facilitate the exploration of the parents' comfort level with each approach. If a family's cultural background has negatively influenced the way in which family members view the child's stuttering, we seek to understand this and find ways to mitigate against their acting upon these negative attitudes. Some issues are more sensitive than others are. Our job is to uncover issues, whether sensitive or not, and bring them to the open forum of family problem solving.

Counseling occurs in various ways. For children who are enrolled in our clinic-based program, counseling sessions are held during the child's regular therapy time, or during additional sessions which are scheduled as necessary. While the child is seen by a graduate student, the family member or members who accompany the child to the clinic are viewing the session with a clinical supervisor who specializes in the treatment of fluency disorders in children.

The supervisor explains the techniques that are being used and encourages the family member(s) to ask questions or comment on the child's participation. The supervisor models techniques and gives the family member(s) an opportunity to practice using some of these techniques under his/her guidance. Later in the course of treatment, parents and other family members (siblings, grandparents, caregivers) are introduced into the actual treatment sessions, and begin to interact with the child and therapist using the techniques which have been modeled for them.

Parents are given a variety of home-based observation tasks to complete, and these are discussed during this clinical period. These tasks include analyses of fluent periods, with emphasis on such variables as the conversational partners, topics of conversation, who initiated the interaction, what the environmental conditions were at the time, and how the fluency was reinforced by the conversational partner. These tasks highlight for the family those environmental variables that serve to facilitate fluency. Parents are asked to heighten their awareness of the role that specific events might play in their child's fluency successes and breakdowns.

As family related issues surface that require more discussion time, parents are invited to return to the center without the child for in- depth exploration of these issues. Often parents are confused about how to handle well-meaning grandparents or other significant family members who offer advice which is counter to what they are learning in the clinic sessions; sometimes other siblings begin to "act out" in negative ways during the treatment period; in other cases parents need to talk about their fears for the future. These and other topics are addressed during the "special sessions".

The second form of counseling takes place in a group with other parents of children who are, or were, at risk for stuttering. Although an experienced fluency therapist facilitates the group, we have found that families learn important strategies from each other that they might not be able to learn from us. There is a built in credibility that exists when parents who have lived through an experience share it with those who have not. No amount of 'telling' on our part can compare to the impact of the words of a parent who has "been there".

These counseling sessions take place two evenings a month for as many weeks as the group members choose to participate. The format of the session generally includes brief introductions, an open forum for discussion of any issues that come from the group, and the presentation of a planned topic by the therapist. This last part is flexible, and may not be introduced if group members wish to continue discussing the issues that surfaced during the forum.

Often our adult clients are invited to attend some of these parent-counseling sessions to answer questions and to demonstrate their effectiveness as communicators to parents who may feel that stuttering means their children will never be able to speak in public or make a favorable communicative impression. We have found this to be a most effective teaching tool for parents, as well as a powerful transfer activity for the adult clients who choose to participate.

As we have seen, stuttering therapy for young children can include direct intervention, using both fluency shaping and stuttering modification techniques. However, these techniques, alone, are insufficient. Children need to learn to deal with the feelings and attitudes that develop as they face difficult communication situations. They also need to learn ways of dealing with their communication environments. Parents and other significant adults must be included in the treatment process. A holistic approach to treatment encourages the clinician to consider and address all possible factors that may have some impact on the child as s/he moves toward effective communication.

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