Recent advances in our understanding of developmental stuttering have yielded support for several theories, including the recently updated Multifactorial Dynamic Pathways theory (MDP; e.g., Smith & Kelly, 1997; Smith & Weber, 2017), and the Demands and Capacities Model (DCM; Adams, 1990; Starkweather & Gottwald, 1990) that is often applied in parent-based treatments of children who stutter (e.g., de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015; Franken, Kielstra-Van der Schalk, & Boelens, 2005; Kelman & Nicholas, 2008). In both cases, however, while the importance of the “environment” is mentioned (e.g., in the MDP theory), and even addressed with regard to motoric, linguistic, cognitive, and social/emotional “demands” (e.g., in the DCM), both approaches appear to be uninformed by the rich theoretical, observational, and experimental history of psychological research in examining critical environmental influences (e.g., parent-child interactions). Thus, the addition of “attachment theory” (e.g., Ainsworth, 1989; Bowlby, 1988; Bretherton, 1992; Moncher, 2006) broadens our understanding of the dynamic, bidirectional relationship between children and caregivers that begins in infancy, develops over time (e.g., through the process of co-regulation), and influences a wide variety of short- and long-term behavioral, emotional, and social outcomes (e.g., Benoit, 2004; Oldfield, Stevenson, Ortiz, & Haley, 2018).
Even by combining facets of the MDP theory, DCM, and attachment theory, however, treatment methods designed to help parents whose children stutter would benefit from a more comprehensive model of human flourishing. Such a model would provide “a richer and truer understanding of the person,” discerned from a comprehensive understanding of “the distinct qualities of complex human nature and the dynamic human person” (p. 1), informed by Catholic-Christian faith and reason, “in dialogue with the sciences and other forms of knowledge” (p. 4) – and is exemplified by The Catholic-Christian Meta-Model of the Person (CCMMP; The Institute for the Psychological Sciences [IPS] Group, 2016).
Brief reviews of each of the above-named models/theories and their contributions to our understanding of stuttering (MDP and DCM) will be provided, building towards an integrated view of the child who stutters in the context of parent-child relationships (attachment theory), and finally envisioned in light of a fuller view of the human person (CCMMP). Taken together, these models/theories will be used to inform the design and implementation of a program (two, half-day workshops) for parents of 8- to -16-year-old children who stutter and attend Camp T.A.L.K.S. (Talking And Learning with Kids who Stutter), that includes parent education (about stuttering, communication, child development, parenting, and attachment), support (from other parents and by speech-language pathologists), and training (including development of individualized plans for extra-clinic parent-child interactions related to communication and stuttering).
Multifactorial Dynamic Pathways (MDP) Theory of Stuttering Development
Consistent with the identification of “childhood onset fluency disorder” as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), the MDP asserts that stuttering arises “during early childhood due to atypical development of the central nervous system (CNS)” (p. 3). It is called the MDP because “a primary feature is an emphasis on the multilevel events ongoing in the time window in childhood when stuttering emerges and recovery or persistence occurs, (with) …each child (having) …a dynamic pathway to the diagnosis of stuttering” (p. 1). Genetic, epigenetic, and neural growth patterns are all shown to contribute to stuttering’s development and course, with particular influences of speech motor, linguistic, cognitive, and emotional/temperament systems and processes, all during a time of rapid growth and development within and across domains (Smith & Weber, 2017). While the MDP focuses primarily on genetic and neural development and related systems (speech, language, motor, and emotional), and acknowledges epigenetic processes (i.e., “the timing and intensity of gene expression over development,” p. 5), it does include reference to “responses of the child’s internal and external milieu at both behavioral and physiological levels” (p. 13) as part of the multifaceted, dynamism of stuttering development, impacting both recovery and persistence. The confluence of multiple factors, internal and external to the child, impacts the course of stuttering development, and the behavioral, affective, cognitive, and social consequences experienced, particularly for those for whom stuttering is chronic. Based, in part, on the MDP, attention to multiple factors, including speech, language, motor, emotional/temperamental, and social variables, are incorporated into pre-, post-, and longer-range (6- and 12-months post-camp) assessments as well as therapy targets for each child enrolled in Camp T.A.L.K.S. (Talking And Learning with Kids who Stutter). Parent education will include a summary of our present understanding of developmental stuttering, informed by the MDP and the growing body of evidence that supports it. The MDP theory lacks specificity, however, in exploring or relating stuttering development, or development in general, to specific “psychosocial” influences, such as those present in the developmental “environments” (e.g., family, and specifically, parent-child interactions) of children who stutter.
Demands and Capacities Model of Stuttering Development
The DCM is based on the premise that “Fluency breaks down when environmental and/or self-imposed demands exceed the speaker’s cognitive, linguistic, motoric, and/or emotional capacities for responding” (pp. 136-137). Capacities refer to the development and interplay between children’s cognitive, linguistic, motoric, emotional, and/or social resources or skills (Adams, 1990). As long as they are within the normal or typical range in comparison to a child’s age and developmental level, typically fluent speech production occurs (Adams, 1990). However, when one or more of these capacities is delayed, or even advanced relative to other capacities, excessive “demands” are placed on the developing child, interfering with speech fluency, often temporarily as children’s capacities increase (Adams, 1990; Starkweather & Gottwald, 1990). Similarly, environmental demands specific to speech and language production and pragmatics (e.g., parental expectations of rapid, correct, and/or advanced – for the child – cognitive, linguistic, motoric, emotional, and/or social skills, negative evaluations of communication or stuttering) may exceed the child’s capacities for typically fluent speech production (Adams, 1990; Starkweather & Gottwald, 1990). As a result, recommended assessment protocols focus on identifying capacities and demands on the part of the child and environment as observed during parent-child communicative interactions, with subsequent therapy designed to modify demands with parental involvement, and, if necessary, enhance the child’s capacities (e.g., through speech and/or language therapy) (Starkweather & Gottwald, 1990). Children who stutter chronically often need a combination of speech “retraining,” environmental modification, and individualized attention to stuttering impact (behaviorally, cognitively, socially, and emotionally), ideally within the context of family and beyond (e.g., school, e.g., with peers). For this project, identification of “demands” and “capacities” will be accomplished through quantitative and qualitative assessments of children and parents prior to Camp T.A.L.K.S., as part of comprehensive evaluations, and reassessed immediately following, and 6- and 12-months post camp. Results will be used to help tailor individualized treatment plans that include suggestions to parents about how best to support their children who stutter by attending to communication-related demands and capacities within their children and in the environmental context (Starkweather & Gottwald, 1990). While the DCM addresses variables specific to speech, language, and social pragmatics, it lacks consideration of parent-child relationships and interactions, in general. A more comprehensive view of each camper and his parent(s) will be gained by exploring the influences of parenting and, specifically, attachment (e.g., co-regulation), to the child’s overall development and quality of life (e.g., parent-child interactions – communicative and otherwise).
Attachment Theory
At the most basic level, attachment begins as an “inborn” system that “motivates an infant to seek proximity to parents and to establish communication with them” (Bowlby, 1969, cited in Moncher, 2006). The child, in essence, “uses the primary caregiver as a secure base from which to explore and, when necessary, as a haven of safety and a source of comfort” to access when faced with uncertainty (Benoit, 2004, p. 541; Hoffman, Cooper, & Powell, 2017). Attachment theory has been used to develop the “Circle of Security” (COS) framework – a clear and accessible guide that may be provided to parents to support their children’s development of self-regulation, with demonstrated effectiveness across cultures (Hamoudi, Murray, Sorensen, & Fontaine, 2015; Hoffman et al., 2017; Powell, Cooper, & Hoffman, 2014). On the COS, children are either “going out” to explore or “coming in” to fill their “emotional cups” in the face of challenges (Hoffman et al., 2017; Powell et al., 2014). The ways in which caregivers respond to their children on the COS – from infancy through young adulthood – impact the types and qualities of attachments, as well as children’s long-range behavioral, emotional, social, and vocational outcomes (Benoit, 2004; Hoffman et al., 2017; Hoffman, Marvin, Cooper, & Powell, 2006). Responsive, contingent parenting contributes to secure attachment, thus promoting healthy, adaptive development of self-regulation, a key skill for life-long adaptation to change (e.g., Hoffman et al., 2017).
Self-regulation, or “the ability to control behaviors or emotions when challenged,” influences children’s developmental outcomes across cultural and socio-economic strata, even in the presence of adversity (Hamoudi, Murray, Sorensen, & Fontaine, 2015; Song, Miller, Leung, Lumeng, & Rosenblum, 2018). Abilities to concentrate (cognitive self-regulation), manage feelings (emotional self-regulation), and control impulses (behavioral self-regulation) improve with age, brain development, and practice (Institute for Learning and Brain Science [ILBS], 2016; Murray, Rosanbalm, Christopoulos, & Hamoudi, 2015). Self-regulation develops through a process of co-regulation that, in infancy, is almost entirely directed (i.e., regulated) by parents, but, over time, fosters the gradual acquisition of children’s own self-regulation abilities (e.g., Hoffman et al., 2017; ILBS, 2016; Rosanbalm & Murray, 2017). It is “influenced by stress and adversity in the environment as well as caregiving supports and children’s own biology, skills, and motivation” (Murray & Rosanbalm, 2017a,b,c). Optimal parental co-regulation, from infancy through young adulthood, includes building warm, responsive relationships, structuring the environment, and “coaching” self-regulation skills consistent with children’s developmental stages, environmental experiences, and individual differences (e.g., ILBS, 2016; Murray & Rosanbalm, 2017a,b,c; Rosanbalm & Murray, 2017). Implementation of this project will include presentation of attachment theory using the Circle of Security (COS) (with a focus on optimal development of self-regulation via parent-child co-regulation), as a framework for parenting the child who stutters, with particular attention to the challenges stuttering poses for the child within the family context and beyond (e.g., with parents, siblings, extended family, peers, teachers, coaches, and/or mentors). Specific recommendations for promoting self-regulation for school-aged, middle-school aged, and high-school aged youth will be shared, discussed among parents in a group format, and incorporated into individualized planning sessions with parents for application post-camp. Results will be assessed, through qualitative interviews with parents, and additional recommendations offered, at 6- and 12-month post-camp intervals.
The Catholic-Christian Meta-Model of the Person (CCMMP)
Frameworks such as the MDP, DCM, and attachment theory, are useful in understanding and assisting children who stutter and their parents/families within the broader contexts of daily living. Attachment theory, in particular, provides a positive approach to helping parents examine their own parenting skills (and the ways they were parented) in relation to their interactions with their children who stutter. What are lacking are more holistic views and motivation for endeavoring to help children who stutter within the family (and other contexts). The CCMMP takes us beyond the child’s “multiple capacities,” including the “organic (vegetative and motoric), cognitive (sensation-perception and reason or rational intellect), and affective (emotion and will or volitional intellect)” (as are essential to the MDP and DCM perspectives), as well as beyond familial (as evident in the DCM and attachment theory), community and cultural contexts (IPS, 2016, p. 5). It provides a framework from which “capacities” are considered not only as “neurodevelopmental,” but emerging as a result of natural “inclinations toward existence (being), truth (knowledge), goodness (love), relationship (family, friends, and society), and beauty (integrity, ordering, and clarity),” and fulfilled in virtue (IPS, 2016, p. 6). The CCMMP informs the therapeutic approach utilized within Camp T.A.L.K.S., acknowledging the family as “the basic unit of society,” instrumental in developing and nurturing the unique capacities, vocations, and calls to flourishing of children and, ultimately, their communion with God in this life and beyond (IPS, 2016; John Paul II, 1981; Moncher, 2006). As viewed through the lens of the CCMMP, clinicians will model and support parents in helping their children “with special needs” who allow the family “together with the Christian community, (to discover) …new approaches, new ways of acting, (and) a different way of understanding and identifying with others, by welcoming and caring for the mystery of the frailty of human life” (Francis, 2016, n. 276). The planned workshops will provide parents with the knowledge and tools they need, to not only understand stuttering, responding in positive, supportive, and helpful ways, but to strengthen the bonds of communication between themselves and their children who stutter, contributing to the flourishing of all within the interpersonal and relational contexts of the family and society.