Monday, October 28, 2013

Giving Out Stickers Like There's No Tomorrow...

After reading my ISAD submission, The Right Time to Break Out the Stickers, (see previous blog posting) many graduate students in speech therapy acknowledged that it might not be such a good idea to give rewards to a child for successfully using speech tools, but they asked about rewards for “paying attention, doing something correct, positive speech behaviors, doing their best job, confidence, good talking, etc… As one student put it “speech therapists give out stickers like there’s no tomorrow!”  Everyone, just step back and take a deep breath. .. and enough already! 
I did asked myself … if I felt speech therapists were trained to provide treatment focused on keeping them talking rather than reducing speech errors, would I be so bothered by the inclusion of stickers (or applause, or praise, or candy)?   My conclusion?  Yes I would. 
So at the risk of getting a bit sidetracked, I will focus again on rewards.  I was inspired by the writings of Australian psychologist and author, Robin Grille*.  Grille’s primary audience is parents, but he helps us all to understand the shortcomings of the ever-so-popular practice of giving out rewards to children.  I will be using excerpts from his article, Rewards and Praise: The Poisoned Carrot that I feel are most relevant to speech therapists and parents of children who stutter.  (You can view the full article at 
Grille states that
  “Rewards and praise condition children to seek approval; they end up doing things to impress, instead of doing things for themselves. This can hold back the development of self-motivation and makes them dependent on outside opinion. When children get used to getting goodies for ‘performing,’ they become pleasers, over-reliant on positive strokes. Rewards and praise can create a kind of addictive behavior: children can get addicted to recognition, and thus lose touch with the simple joy of doing what they love.”  
  One of the worst things we can do is to praise a child's potential. Acclamations like "I just know you can do it", "You're getting better!", "I know you've got it in you!", "You'll get there!" sound supportive on the surface. Underneath the praise is the silent implication: "you're not good enough yet".
The last impression you want a child who stutters to walk away with is “you’re not good enough.”  I do believe there can be a healthy balance between doing everything for themselves and doing things to impress.  The extreme ends of either of these motivators lead to obvious problems, depending on the circumstances.  But let’s face it…we want kids who are comfortable enough in their own skins to express their feelings, not kids who are overly-motivated to impress others.  We want kids who are self-motivated, with their sense of self and well-being not reliant on external praise and rewards.  Grille goes on to say:
  When children are bribed with rewards for "good" behavior, they soon learn how to manipulate us by acting the part that is expected of them. They become superficially compliant, doing whatever it takes to flatter or impress us, and honesty suffers. After all, who wants to be honest or real with a person who is evaluating them?
Children are under constant evaluation and being judged all day in school.  Therapists are trained to do the same.  This does not inspire honesty or being in touch with your true feelings. 
Eli hated practicing his speech tools at home, or doing anything that focused on his speech struggles.  No matter what game I adapted to the process, which book I pulled out, or how hard I clapped my hands and assured him it was going to be fun, he still hated it.  Oh, and he did express his true feelings -- “This is sta sta sta stupid!, why does the fa fa fa fa fa fa focus of eeeeeeeeeeeeverything have to be on my speech?”  I didn’t listen.  I forged on, assuming that even though it felt stupid to him, at some point he would find it useful.  I did nothing to acknowledge or appreciate his honesty.  Grille is so right when he states:
  Rewarding children's compliance is the flip-side of punishing their disobedience. It is seduction in the place of tyranny
Until now I have never considered rewards to be equivalent to tyranny.  But I think Grille is right on the money.  It’s too easy for kids to lose touch with what they are really thinking and feeling when they are being seduced with stickers and praise.  Eli never told a speech therapist that he thought speech tools were too hard or stupid.  He did exactly what they told him to do.  He was compliant and well-mannered and got lots of stickers for “paying attention, doing something correct, positive speech behaviors, doing his best job, confidence, good talking, etc…”  We all rewarded him over and over again –  I was always so proud .
So instead of “giving out stickers like there’s no tomorrow,” let’s focus instead on creating a space where these kids can safely build their courage and capacity for honesty and self-expression.  It’s time to set our egos aside.  We need to keep them talking!    
Dori Lenz Holte

*Printed with permission.  Robin Grille is the author of Parenting for a Peaceful World and Heart-to-Heart Parenting.

Wednesday, October 23, 2013

The Right Time to Break out the Stickers

The Right Time to Break Out the Stickers
By Doreen (Dori) Lenz Holte
When our son Eli was around 12, I asked him if he remembered being told that it was okay to stutter.  It had been three years since we stopped traditional speech therapy and I was curious as to how he would respond.  He thought for a moment and replied “Once I stopped stuttering they would give me stickers or let me play with the toys in the room.  They’d tell me it was okay, then they’d tell me not to do it… I stopped talking as much because they said it was wrong.”

When Eli was between five and nine years of age he saw a number of speech therapists for treatment for his stuttering.  These therapists had varying degrees of experience with children who stuttered – ranging from none to having an ASHA Board Recognized Fluency Specialist certification.  Each therapist enlisted fluency shaping and stuttering modification speech tools, the approach considered to be “evidence-based best practice” by ASHA and leading universities.  Each therapist enthusiastically rewarded Eli with an array of colorful stickers when he used his speech tools.  At the same time I witnessed each of them kindly and continually assuring Eli that it really was okay to stutter.   They never told him it was wrong…I am certain of that.  

At home during special time (time set aside each day to practice using speech tools)  I would clap for and praise Eli when he successfully used his Tigger talk and turtle talk to deliver non-stuttered speech.  I would also assure him that it really was okay to stutter.  I also never told him it was wrong to stutter, but that was unfortunately the message he came away with.

We were confused and confounded when, even with all the positive reinforcement, Eli did not transfer the use of speech tools outside the clinic setting or our special time at home.  After four years of therapy we resigned ourselves to believing that at least we had given him a tool box full of speech tools...he would hopefully use them when he was ready.  (This is a common lament I've heard from both parents and speech therapists throughout the years.  “If he would just use his tools.  He can use them in therapy, so why not in other places?  He just needs more practice...”)

When Eli was nine, we stopped traditional speech therapy.  He had gone from mild to moderate to severe and was now twisting his chin to his shoulder and growling in order to talk...if we were lucky.  Most of the time he just didn't talk.  We noticed the silence when he was sitting around the table at Easter with aunts, uncles and cousins.  We noticed the silence at 4H meetings and during home school co-op days with friends.  Even at home with us he became increasingly withdrawn.  We felt like we were literally watching our Eli fade away.   We would vacillate between gently reminding him to use his speech tools and ignoring the behavior. We felt increasingly fearful and lost when it came to Eli’s struggles with speaking.  It seemed that the silence and disconnection was proving to be a far greater handicap than the stuttering itself.      

In retrospect, there is no doubt that the silence was a result of the shame Eli felt when he stuttered.  He also felt that shame when he didn’t meet up to the expectations implied in the ongoing praises and reward of stickers for non-stuttered speech.  Dr. BrenĂ© Brown has researched the subject of shame extensively and states that “nothing silences us more effectively than shame.”  Brown, Ph.D.,  licensed social worker, and renowned author and speaker goes on to say:

            shame unravels our connection to others...In fact, I often refer to shame as the fear of
            disconnection - the fear of being perceived as flawed and unworthy of acceptance or belonging. 
            Shame keeps us from telling our own stories and prevents us from listening to others tell their
            stories.  We silence our voices and keep our secrets   out of the fear of disconnection. ¹

The role that shame plays in stuttering behavior is no surprise to parents or speech therapists.  It is the absolute last feeling we want them to experience around talking but are our efforts backfiring? Was it really developmentally appropriate to expect a child of this age to manage the complex and conflicting messages of “It’s okay to stutter but here’s a reward if you don’t.”?  Research into the cognitive traits shared by children, ages 6-10, helps to shed some light on our discomfort.  In general, child development experts ² agree that this age group: 

§  Has a strong desire to perform well and do things right.
§  Finds criticism or failure difficult to handle.
§  Views things as black and white, right or wrong, wonderful or terrible, with very little middle ground.
§  Naturally seeks praise and wants to conform. 

Using speech tools requires a level of energy and concentration that is hard to fathom even for adults.  When you consider the development traits of children you begin to understand how shame can result from the unrealistic expectations and conflicting messages.  In addition, many experts (and parents) report that children who stutter are often more sensitive than others their age.   Mary Elizabeth Oyler,  a speech-language pathologist who also stutters has done extensive research around the issue of children who stuttering and sensitivity.  She found that: 

            children who stutter were significantly more sensitive and vulnerable than nonstuttering    children.  In addition, 84% of the children who stutter fell in the highly sensitive range as          compared to 36% of the children who do not stutter.  4

When we step away from a focus on eliminating the moment of stuttering behavior and look at the whole child, we truly begin to understand why a child might choose silence over risking continued failure in front of those they most want to impress and please.    

In 2011, I  published Voice Unearthed: Hope, Help, and a Wake-Up Call for the Parents of Children Who Stutter.   During my six years of research and reflection for this book I discovered a plethora of  disagreement, confusion, and uncertainty around treatment for children who stutter.   Extensive research around shame and stuttering has been done by Dr. Bill Murphy, speech-language pathologist and a clinical faculty member at Purdue.  Murphy warns:   

            The emotions of shame are self-perpetuating, regenerated repeatedly by the child, even if the        external stimulus (a parent inappropriately reminding a child to “use your techniques,” or a classmate laughing) is no longer present... the self acquires the identity of failure, at least in relationship to speaking skills. ³

Professional organizations and academia have an ethical obligation to abide by treatment approaches that are deemed to be best practice stemming from evidence-based research.  The problem in this particular area is that the vast majority of research has been done on adults.  The research done with children is extremely limited and often labeled as “emerging” or “promising.”   The goals of the research are to make fewer speech errors.  The goal for a child is to avoid feeling shame and the most realistic way to accomplish this is to stop talking. 

I am encouraged when I increasingly hear about a greater focus on desensitization and creating positive feelings around communicating.  But the use of stuttering modification and fluency shaping speech tools remain as a significant component of therapy for children as conveyed in ASHA’s  Specialty Board on Fluency Disorders Manual.5  The Stuttering Foundation of America even acknowledges that “many children and teens who stutter do not have the maturity or skill to monitor their speech in all situations. Therefore, it may be unrealistic to expect your child to use her tools in other environments at all times.”  What happens when you throw in a few stickers as a reward for using those tools?  What message does a child really walk away with?   Eli says “I stopped talking as much because they said it was wrong.”

From the time Eli was nine to this day, Dr. Jerry Halvorson, retired Communicative Disorders professor at the University of Wisconsin, River Falls has helped us provide support focused on keeping Eli talking and engaged in the world around him.  Within three months of changing our focus from reducing speech errors to keeping Eli talking we saw significantly less twisting, gurgling, and far more talking.  It was a long process that is far from over.  But today Eli is 17 years old, a full-time college student, a part-time employee, and a supportive and positive role model to his group of friends.   He still stutters, sometimes severely.  But he puts himself out there each and every day.  He can be wickedly funny… I figured it was a good sign when his co-workers affectionately nick-named him “Snarky.”  Now there is a good reason to break out the stickers.        

1.        Brown, Brene (2007) I Thought It Was Just Me (but it isn’t): Telling the Truth About
           Perfectionism, Inadequacy, and Power Penguin/Gotham
2.        The National Network for Childcare, Great, Human Development and Family
           Studies at Iowa State University
3.                  Murphy, B. (1999). The School-Age Child Who Stutters: Dealing Effectively with Guilt and
            Shame, VHS Publication NO. 86, Memphis, TN, Stuttering Foundation of America
4.                  Oyler, M. E. (1996b). Vulnerability in stuttering children. (No. 9602431). Ann Arbor, MI: UMI  
            Dissertation Services.

Biography:  Doreen (Dori) Lenz Holte is a professional writer and author of Voice Unearthed:  Hope, Help, and a Wake-Up Call for the Parents of Children Who Stutter.  She is also the proud mom to Abe, Adam, and Eli.
From Dori Lenz Holte at Voice Unearthed...

Hello all!  I see I promised back in September of 2012 that I was back to blogging...I lied.  I've been having health issues over the past year, so please forgive me for my inconsistent communication.  I'm doing much much better (I struggle with Lupus/autoimmune stuff), and I am back!  Seriously...

I hope you are all doing well!  Those of you parents with kids exhibiting stuttering behavior, I would love to hear  how you are doing!  Speech therapists -- hope you're hanging in there and keeping them talking!!  Would love the hear from you too!

Over the past month I was honored to participate in the International Stuttering Day Online Conference (ISAD) which actually runs from October 1 through October 22.  I will be posting my submission here on my blog and you can also go to

to read the paper and responses.  Most responses and questions come from graduate students in Communicative Disorder programs, and they are inspiring!   We've got a very passionate and dedicated group of future therapists getting ready to tackle this complex issue.  

I would like to publicly thank the ISAD Conference Committee - Keith Boss, Bruce Imhof, Anita Blom, Dan Hudock, and David Resnick for their tremendous efforts.  The site was visited over 14,000 times by people all over the world!    And of course, thank you to Judith Kuster!  Judith started this conference back in 1999 and kept it going until she retired last year.   Absolutely amazing!!  She also started the Stuttering Home Page (through University of Minnesota, Mankato State) which is a wonderful resource for anyone interested in this issue.  Her contribution to this field is legendary... Thank you all for your support and KEEP THEM TALKING!    Best,Dori Lenz Holte