TREATMENT MANAGEMENT OF STUTTERING

Edited by: Kunnampallil Gejo John (SLP)

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CONTENTS

Introduction

Need For Early Identification And Treatment Of Stuttering

Decisions Regarding Treatment Of Stuttering

Direct and Indirect therapy

Basic Principles Underlying Therapy

Steps in the treatment of stuttering

Counseling and Guidance

Treatment Approaches In The Management Of Stuttering In Preschoolers

Treatment Approaches In The Management Of Stuttering In Children

Treatment Approaches In The Management Of Stuttering In Adults

Conclusion

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Introduction

The term fluency is derived from the Latin root fluere. It refers to many things but seems

to in communication, to the smooth and easy flow of utterance (Stein, 1967). Stuttering is

a disorder of fluency.

Stuttering occurs when the forward flow of speech is interrupted abnormally by

repetitions of a sound, syllable, or articulatory posture or by avoidance and struggle

behaviors. (Van Riper, 1978).

Stuttering is a disorder of fluency with high inter and intra individual variability and is

described as a mystery surrounded by enigma wrapped in a puzzle. There are various

questions about stuttering, which are unanswered even after decades of research by

people from various disciplines or are answered inadequately. Some of these are:

Is stuttering physical, psychological, both or neither? Can parents cause it, exacerbate it, cure it, or neither? Is it a relatively straightforward speech disorder or is it an impairment/ a

disability/ a handicap, all of which represent complex interactions of neurological,

physiological, anatomical, linguistic, emotional, social and other characteristics?

Can it be treated? Should it be treated? By whom, when, how, and why? What treatment results should be demanded? What constitutes acceptable evidence that a reported result has truly been

obtained?

What constitutes acceptable evidence that a certain treatment was directly responsible for the obtained results?

One is overwhelmed by the complexity and perplexity of the disorder, challenged or even

excited by the difficulties that surround our attempts at understanding the management

aspects of the problem.

The theorists aiming to look for the causative factors for stuttering have come back and

forth to physiological to psychological and to more recent nature-nurture dynamic

models. Van Riper (1990), a pioneer in the field and himself a stutterer, in his final

thoughts about stuttering (at the age of 85 years) confesses his inability to fulfill a

promise he made to a Birch sapling when he was 16 years old to find a cause and a cure

for stuttering.

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Since the time of Aristotle (4th

century BC), various remedies ranging from

psychotherapeutic, learning theory-based approaches to more medical, surgical

approaches have failed to find a permanent solution to the problem.

The need for early identification and treatment of stuttering

Stuttering is a disorder of childhood, onset of which in more than 90% of the individuals

is before the age of 6 years. Clinicians are often apprehensive in counseling the parents

regarding the need for intervention for young children with stuttering in terms of duration

of treatment required, outcome expected, the techniques which facilitate recovery, etc.

this is more so with those who adhere to the Johnsons Diagnosogenic theory. This is a serious problem when the current emphasis is more on early identification and

intervention.

However, early identification and treating children close to onset of stuttering is

increasingly emphasized by many authors for the following reasons:

1. It is easy, less time consuming and more long lasting [i.e., approximately 1-3 months or 20 hours for children (Starkweather and Gottwald, 1986) and one to several

months / years or 140 hours for adults (Van Riper, 1973; Webster, 1974)] and is

reported to be dependant on the chronicity of the problem.

2. Reported rates of success is higher (>90%) compared to that for adults (50-75%) (Franken, 1988; Starkweather, Gottwald and Halfond, 1990; Webser 1974).

3. Relapse rate for treated adults is reported to be around 50% (Franken, 1988); whereas for children it is close to zero (Starkweather, Gottwald and Halfond 1990).

4. Adults who are treated are reported to have carefully monitored speech (Boberg and Kuly, 1994) and diminished quality of speech (Franken, 1988) or may have residual

stuttering behaviors (Prins, 1984) while the treated children are reported to be no

different from their non stuttering peers (Starkweather, Gottwald and Halfond 1990;

Gottwald and Starkweather, 1984 and others)

5. Although it is reported that many children with stuttering spontaneously recover (the recovery rates range from 20-80% according to various estimates), nearly 20% would

continue to stutter if not treated and it is not a small number when 1% of the total

adult population who continue to stutter if not treated is considered. Further, although

some predicting factors are there to guide us regarding who will and who will not

recover spontaneously as given above, they are not fool proof.

6. The impact of stuttering problem on the young minds to live with it could be quite handicapping emotionally, socially, educationally and vocationally as reported by

many PWS.

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Decisions regarding treatment of stuttering

The clinicians have to make decisions regarding whether treatment is required or not;

should it be direct or indirect (in case of CWS) or both; intensive or extensive or both;

approximate duration of treatment needed; what are the prognostic indicators in a given

client and so on. These aspects have to be communicated to the clients or the givers.

Gregory and Hill (1980) recommend preventive parent counseling, prescriptive parent

counseling and or comprehensive treatment program for children based on their

differential evaluation procedure.

Packman and Lincoln (1996) recommend a set of criteria to decide early intervention as

given in the diagram below:

Yaruss La Sale, and Conture (1998) have provided a number of guidelines for deciding

whether treatment is warranted.

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Conture (2001) has provided a diagnostic decision flow chart and flowchart depicting

the threefold diagnostic decision- Yes, no, or uncertainty.

DOES THE CHILD HAVE PROBLEM

NO

YES UNCERTAIN PARENT COUNSELING/DISMISS

F OLLOW UP

EVALUATION

REFERRAL/DISMISS

INITIATE THERAPY

PARENT COUNSELING

INDIRECT PROCEDURES

DIRECT PROCEDURES

Presumed

likelihood

that child

will require

treatment

Total

frequency

of

disfluencies

Sound

prolongation

index

IOWA

scale

SSI SPI

Most likely

to require

treatment

More than

10%

More than

30%

More than 3 More than

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More than

16

May

require re

evaluation

6% to 10% 12 to 30% 2 to 3 12 to 18 10 to 16

Least likely

to require

treatment

Less than

6%

Less than

12%

Less than 2 Less than 2 Less than 10

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This flowchart shows 3 possible discussions and their resulting consequences:

1) Yes, the child has a problem (i.e. client most likely to require treatment) 2) Uncertain of the problem ( so the client may require re- evaluation) 3) No, the client does not have a problem (i.e. client least likely to require

treatment).

If the child meets three/more of the criteria, its described that the child would most likely

require treatment.

INDIRECT THERAPY

Indirect therapy is any therapy where we do not talk with the child about his or her

speech problem and do not attempt to teach the child to make changes in his or her

speech. Indirect therapy most typically involves working with parents and care givers in

an effort to modify communicative demands and to facilitate fluent speech within the

childs environment.

The children best suited for indirect therapy will meet the following criteria:

Children who have been stuttering for less than a year Their stuttering and associated behaviors have not changed significantly since the

onset of their stuttering.

Children who have not developed strong emotional reactions to their speech problems

They do not appear to be behaviorally or cognitively aware that a problem exists. One key factor for determining the candidacy is the age of onset of stuttering. The child who is closest to stuttering onset will be best suited for indirect therapy.

Modifying Parental communication:

Indirect therapy involves helping parents to identify and modify those aspects of their

communication and daily activities and routines that may have a negative impact on their

childs developing speech fluency. It involves modifying the normal routine activities that may have a negative impact on those children at risk for continued stuttering.

This basically involves:

Parents modifying their speaking rate Modification of turn switching pauses Rewarding fluent speech Modifying situations and schedules within the family Demonstrating speech and environmental modifications

DIRECT THERAPY

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Direct therapy involves a program where we work directly with the child to teach him or

her number of speech skills that will result in fluent speech production.

The child best suited for therapy:

The best candidate is the child who has begun to demonstrate an awareness of his or her

stuttering. In addition, parental reports may include mention of a childs avoidance of certain sounds, words or situations.

Providing direct therapy:

It focuses on the anatomy associated with speech production and activities that focus on

increasing the childs awareness of both, his or her speech production and stuttering. The child is exposed to various treatment techniques and packages proposed by various

individuals with ultimate aim of any treatment being to teach the fluency tasks.

Basic principles underlying therapy:

Irrespective whether the client is an adult or a child there are some basic principles

underlying the therapy procedures:

Treatment is based upon a developmental continuum, as stuttering is a progressive disorder.

The client-clinician relationship is an important variable built upon trust, confidence and understanding.

Children and adolescents typically do not have intrinsic motivation to change their speech; therefore, it is important to make therapy enjoyable and rewarding.

Building self-confidence of the client is important.

Treatment plans should be highly flexible and are designed to meet each client's changing needs.

It is important to help the clients to express and understand their feelings about stuttering.

Steps in the treatment of stuttering:

The management of fluency disorders involves three stages:

1. Establishment of fluency: Establishment of fluency is easy and can be achieved using a variety of fluency

shaping or stuttering modification approaches. Many PWS do not exhibit

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stuttering or exhibit less severe problem in the clinical set up because they do not

try to suppress the problem. Many novel ways of speaking reduce disfluencies.

Venkatagiri (2005) suggests that these novel speaking conditions involve speech

construction (voluntarily coding speech production) as against speech

concatenation (automatic retrieval of stored units).

The method and mode of therapy varies with children and adults who stutter, as

the demands and capacities vary in children and adults. For young children

various analogies are adopted to make it enjoyable and fun. For older children and

adults different approaches are combined to provide a comprehensive treatment

plan, which include:

a. Traditional approaches: Following are a few of the traditional techniques being used for decades with varied success: Voluntary

stuttering/ stutter fluently techniques, prolongation or many of its variants,

cancellation, pull out, soft/loose contacts, relaxation, airflow therapies,

and shadowing.

b. Cognitive approach/Cognitive restructuring: Developing an understanding about the production of speech in general and fluent speech

in particular is essential part of any therapy. Even young children are

encouraged to understand the same using various analogies (Garden

hose/Blown up balloon analogies). PWS are made to realize how and why

the stuttering problem varies and how can they get a control over it. This

would reduce their dependency on the clinician and gradually make them

more confident in getting control over their problem. Maintenance of a

diary would facilitate this. Rational Emotive Behavior Therapy (REBT)

and Personal Construct Therapy (PCT) are some procedures incorporating

cognitive reconstructive principles.

c. Behavior therapy approach: Although the cause of stuttering is not very well understood, recent theorists emphasize nurture or environmental

factors to contribute as maintaining factors in stuttering. Appropriate

reinforcement procedures to facilitate fluency and punishment strategies

like the Time out and Response cost to reduce dysfluencies could aid in

achieving fluent speech. Other techniques using behavior therapy

principles include Modeling, shaping, role play, over correction (negative

practice), extinction (reinforcement that previously followed an operant

conditioning) and the like. Further, in clients with anxiety traits,

progressive relaxation combined with systematic desensitization

procedures could be very effective.

d. Emotional or effective approaches: Using varieties of psychotherapy and counseling, positive changes in emotional or affective

states of the individual need to be brought about. Stuttering is a disorder

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which evokes unusual reactions from the peers parents and public. These

negative reactions are unpleasant and speaking situations may be

traumatic to PWS, who will start avoiding them. Hegde (1990) opines that

if the attitudinal changes are not brought about during the therapeutic

management, the unchanged maladaptive attitudes will soon wipe out the

temporary and shaky fluency generated by the treatment procedure.

e. Instrumental approach: Mechanical and electronic devices and various equipments are available for establishing fluent speech in the

clinical set up such as, metronome, EMG Biofeedback, Masking, DAF,

FAF, Dr. Fluency. Some portable bone conduction hearing aids are also

available which provide noise to mask auditory feedback, delayed or

frequency shifted feedback. School DAF, Telephone fluency system,

pocket fluency, desktop fluency system, and voice changer are some of the

other devices used in the management of PWS.

f. Supportive approach: Periodic counseling and guidance to the parents, relatives, friends, teachers, employers or significant others in the

social environment of PWS is very important for bringing about long

lasting maintenance of the fluency that is achieved. It is necessary for

PWS to get support and encouragement from these people to overcome

their negative feelings and attitudes and proper motivation to control the

fluency achieved.

2. Transfer/ Generalization of fluency: Once the fluency is established in the clinical set up the clinician should start

activities to transfer these skills to outside situations in a gradually graded

manner. Situational hierarchy ratings obtained during pre-therapy assessment

would help in this exercise. Maintenance of log books or diary is necessary to

monitor progress achieved in day-to-day practice. PWS should be encouraged to

self monitor and self- correct to reduce dependency on the clinician. A close

friend or a family member could be assigned to assist the client in this process

initially.

3. Maintenance of fluency: PWS have to be prepared for any relapses that could occur during the treatment or

later so that it does not come as a shock if he suddenly encounters situation where

he is not able to maintain the fluency achieved. After intensive and extensive

practice sessions, the frequency of treatment sessions should be gradually reduced

to make follow up or booster sessions to monitor the maintenance of fluency.

Counseling and guidance

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Periodic counseling is very essential to bring about positive attitude changes. This would

include the following:

Having less desire to avoid stuttering. Being more willing to bring the stuttering problem into the open. Judging performance in speaking situation more on the basis of success in

communication rather than fluency.

Developing better self concept by recognizing other talents one possesses. Developing stronger belief in coping with stuttering. Anticipating more fluency than dysfluency. Becoming less embarrassed and ashamed about stuttering. Gaining realization that one can succeed in life in spite of stuttering problem. Not to assume that people will underestimate them because of stuttering.

COUNSELING THE CHILDS PARENTS:

The childs parents should be counseled regarding the following: Nature of the childs problem. How it hampers the childs communication skills. Treatment options. Possible course of the treatment. Meeting realistic expectations. Avoidance of putting unnecessary stress on the child. Home management. Transfer. Maintenance.

TREATMENT APPROACHES FOR STUTTERING

IN PRESCHOOLERS

Till 1960s it was considered that young stutterers should not be directly but instead parent

counseling is the only way (Johnson, 1955). It was opined that treating young stutters was

potentially harmful. In the early 70s methods for modifying the interactions between

parents and children evolved. However, the emphasis was still on parents. By early 80s

the belief changed and programs advocating therapy for children were started. In the

recent programs the emphasis has been on both, counseling the parent regarding the

childs problem and their coping up strategies at home and other environments & involving the child directly in the therapy program.

Treatment options for preschoolers include various packaged programs that exist for

treating stuttering in preschoolers. But, most of them are not tested. Evidence based

techniques include the following:

Fluency reinforcement Fluency reinforcement plus corrective feedback

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Response cost

FLUENCY REINFORCEMENT (2002, M.N HEGDE):

That stuttering may be eliminated in children by positively reinforcing fluency has been known since the 1970s (e.g., a study by Shaw & Shrum)

The idea has not been vigorously pursed mostly because of a lack of professional validity

Almost all current treatment procedures offered to preschoolers use positive reinforcement for fluency as their main component (e.g., the Lidcombe program

of Onslow and colleagues)

The sequential hierarchy for treatment is as follows:

1. Set the stage for fluency reinforcement

Collect toys, picture and story books, puzzles, activities (e.g., coloring or drawing), and other stimulus materials.

Hold sessions for 30 to 40 minutes; if longer, give breaks to the preschooler. Seat the child across a small table or, if found necessary, sit along with the child

(side-by-side seating).

2. Select effective reinforcers

Prompt and enthusiastic verbal praise is effective with young children. If there is no decrease in measured stuttering rate, add additional reinforcers. High probability behaviors and tokens are effective additional procedures. Add them to verbal praise, which is a constant factor.

3. Have the parents observe the sessions

Ask parents to observe the sessions from the beginning. Let them observe through one-way mirrors (not in the treatment room). Later on, bring parents into the treatment room to eventually train them in fluency

reinforcement procedure.

4. Introduce the treatment procedure

Describe stuttering and smooth speech for the child. Model the childs dysfluent productions. Reassure the child that he or she can talk smoothly and that you can help.

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5. Begin at the sentence level

Sit with the child, show story book pictures or engage the child in planned activities, and talk with the child.

Reinforce all fluent productions while evoking conversational speech from the child.

Initial session or two may involve some practice at the word level, while still evoking phrases or sentences.

With very young children (e.g., 2.6 to 4 year olds), several initial sessions may involve phrases or incomplete sentences.

6. Systematically reinforce fluency

Children (and adults) who stutter have plenty of fluent speech that may be positively reinforced.

Preschoolers and younger school-age children react positively to fluency reinforcement.

All fluent utterances, whether a word, a phrase, or a sentence are positively reinforced with verbal praise.

7. Use a variety of verbal praise

Enthusiastically and promptly praise the child with a variety of statements: Excellent! I like your smooth speech! Very good! That was smooth speech! Your speech is so smooth! You are working hard! Your speech is nice! That was smooth speech! That was wonderful! You said it smoothly! You said it nicely!

8. Ignore stuttering

Do not react to stuttering in any manner. Do not stop the child, do not give corrective feedback. Stuttering is technically on an extinction course. When the child stutters, model the same production fluently. Reinforce the fluent production that typically follows.

9. Progression of treatment

Move from phrases/sentences to continuous speech Move from sentences to continuous speech.

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Move from continuous speech to narrative speech. Move from narrative speech to more spontaneous conversational speech.

10. Reinforce fluency in continuous speech

Evoke continuous speech with the selected stimulus materials (e.g., story books with large pictures).

Prompt the child to produce more continuous speech (e.g., Say it in longer sentences, tell me more about this picture, Tell me everything happening in this picture, Tell what you are doing now etc.).

Model continuous productions. Instruct the child to talk in longer sentences. Model longer productions. Reinforce imitated productions. Withdraw modeling, evoke productions. Reinforce spontaneous, longer productions.

11. Reinforce fluency in narrative speech Tell or read aloud a short story that is appropriate to the child. Ask the child to retell the story in smooth speech. Reinforce smooth speech on a variable schedule. Prompt the story elements when the child is unsure.

12. Reinforce fluency in conversational speech Note that you may reinforce fluency in conversational speech before you

reinforce in narrative speech.

Engage the child in typical conversations. Ask questions about the childs family, friends, school, teachers, hobbies,

activities, sports, or games of interest.

Reinforce fluent productions on a variable schedule.

13. Use objective criteria to move from one level to the other At each level of training (e.g., sentences, continuous speech, narrative speech, and

conversational speech) use an objective performance criterion.

We use 2% or less dysfluency rate at a given level, sustained over three sessions, to move to the next level.

Most preschoolers attain less than 1% dysfluency rate in treatment sessions.

14. Record the frequency of stuttering

Use a prepared recording sheet.

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Minimally, record the frequency of stuttering and percent dysfluency rate for each session.

Optionally, record the frequency of specific types of dysfluencies and then calculate the percent of dysfluency, and rate of speech.

15. Periodically probe the stuttering rate

A probe is a measure of target skills without the treatment procedures. Engage the child in conversational speech; tape record the speech sample. Do not model, prompt, or reinforce fluent speech; keep the conversational natural

and typical.

Record the rate of stuttering or dysfluencies.

16. Before dismissal, make sure the parents can reinforce fluency at

home

Train parents in fluency reinforcement. Have hem conduct sessions in front of you. Fine-tune their skills in evoking, modeling, and reinforcing fluent productions. Train them in ignoring stuttering (a task that is difficult for many).

17. Use an objective dismissal criterion

We use a criterion of less than 2% dysfluency rate (preferably less than 1%) in conversational speech sustained across 3 sessions to dismiss the child (or an adult)

from therapy.

Adopt your own criterion and adhere to it. We prefer the less-than-2% criterion because it allows a cushion for eventual

increase in the natural environment.

We want them to sustain less than 5% dysfluency rate over time and across situations.

18. Follow-up the child

A two-year-follow-up is essential for most children (longer in the case of adults). A follow-up is essentially a probe. Record a naturalistic conversational speech sample to measure the stuttering rate. If the rate is close to 5% or exceeds it, offer booster treatment. Give the same treatment or a new treatment that is known to be effective;

schedule another follow-up.

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FLUENCY REINFORCEMENT PLUS CORRECTIVE FEEDBACK

The second option for preschoolers (M.N HEGDE, 2002):

The second option is to add corrective feedback for stuttering while maintaining positive

reinforcement for fluent productions. Addition of corrective feedback for stuttering may

enhance the treatment effects. In this procedure, the clinician reacts to both fluent and

dysfluent productions.

The role of corrective feedback:

Although fluency reinforcement may be used exclusively, corrective feedback should not be used exclusively.

There is no strong evidence that mere corrective feedback will eliminate stuttering.

Corrective feedback should always be combined with fluency reinforcement. The child should receive more positive reinforcement than corrective feedback.

There are several steps in fluency reinforcement plus corrective feedback as follows:

1. Maintain fluency reinforcement

Use all the suggestions and guidelines offered under fluency reinforcement.

Introduce the treatment.

Use toys, activities, story books and other materials to evoke speech.

Select effective reinforcers.

Begin treatment at the phrase/ sentence level.

2. Reinforce fluent productions

Enthusiastically and promptly praise the child with a variety of statements:

Excellent! I like your smooth speech!

Very good! That was smooth speech!

Your speech is so smooth!

You are working hard! Your speech is nice!

That was smooth speech!

That was wonderful! You said it smoothly!

You said it nicely!

3. Offer corrective feedback for stuttering

Offer corrective feedback at the earliest sign of a stutter (e.g., twitching of the lips, tension in the face, shoulder, or chest, irregular breathing, any facial feature

associated with stuttering).

Do not let the stuttering run its course; stop it by immediate corrective feedback.

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4. Vary corrective feedback

Promptly offer one of several forms of corrective feedback at the earliest sign of

stuttering. Say:

Stop! That was bumpy!

Oh no! You didnt say it smoothly!

That was bumpy!

Stop! You are having trouble saying it

No, that was not smooth!

5. Progression of treatment

Move from phrases/ sentences to continuous speech.

Move from continuous speech to narrative speech.

Move from narrative speech to more spontaneous conversational speech.

6. Use objective criteria to move from one level to the other

At each level of training (e.g., sentences, continuous speech, narrative speech, and conversational speech) use an objective performance criterion.

To move to the next level, the dysfluency rate at a given level must be 5% or less sustained over three sessions.

(Most preschoolers attain less than 1% dysfluency rate in treatment sessions.)

7. Record the frequency of stuttering in each session

Use a prepared recording sheet.

Minimally, record the frequency of stuttering and percent dysfluency rate for each session.

Optionally, record the frequency of specific types of dysfluencies and then calculate the percent dysfluency, and speech rate.

8. Periodically probe the stuttering rate

A probe is a measure of target skills without the treatment procedures.

Engage the child in conversational speech; tape record the speech sample.

Do not model, prompt, or reinforce fluent speech; keep the conversational nature and typical.

Record the rate of stuttering or dysfluencies.

9. Before dismissal, make sure the parents can reinforce fluency at home

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Train parents in fluency reinforcement.

Have them conduct sessions in front of you.

Fine-tune their skills in evoking, modeling, and reinforcing fluent productions.

Train them in ignoring stuttering (a task difficult for many).

10. Use an objective dismissal criterion

A criterion of dysfluency rate less than 5% (preferably >1%) in conversational speech sustained across 3 sessions can be used to dismiss the child (or an adult)

from therapy.

Adopt your own criterion and adhere to it.

11. Follow-up the child

A 6-month follow up is essential. According to Hegde (2007) two-year-follow-up is essential for most children (longer in the case of adults).

A follow-up is essentially a probe.

Record a naturalistic conversational speech sample to measure the stuttering rate.

If the rate is close to 5% or exceeds it, offer booster treatment.

Give the same treatment or a new treatment that is known to be effective.

Schedule another follow-up.

RESPONSE COST FOR PRESCHOOLERS (2003, M.N HEGDE):

Response cost is an attractive alternative to fluency shaping. It is effective with young

children for whom fluency shaping is not a good option. It does not affect the speech rate

and speech naturalness. It is easily administered; clinicians are readily trained in its use.

Parents accept it and therefore it has high social validity.

The response cost treatment

During the first individual session, introduce the treatment procedure to the child.

Show a box of goodies (a collection of small gift items) to the child and ask the child to select a gift he or she will buy at the end of the session.

Have the child describe the procedure to make sure the child understands the procedure.

Administration of response cost: Token award

During the individual response cost therapy:

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The clinician uses toys, story books, puzzles, selected games, activities, and so forth to evoke speech from the child.

For every fluent production (a word, a phrase, or a sentence), the clinician places a token in the childs container.

The clinician also praises the child for smooth speech as she places the token in the childs cup (e.g., Says, That was smooth speech! Here is a token for you)

Administration of response cost: Token withdrawal

When the child stutters, the clinician says something like Oh no! That was bumpy! I am taking a token back! and removes a token from the childs cup and places the removed token in his/ her own cup.

The clinician fluently models the childs stuttered production for the child to imitate and awards a token to the child if the imitated production is fluent.

Variation and progression

Initially, withdraw a token with announcement (That was bumpy, I am taking a token back)

Later, take a token back without announcement.

While showing pictures and evoking controlled responses, interject brief conversational episodes

Progression across response complexity

As with other procedures, advance the child from isolated sentence level to more continuous speech.

From continuous speech, advance the child to narrative speech.

From narrative speech, advance the child to conversational speech.

Remember, continuous and narrative modes can be trained in any sequence.

Trouble shooting

Occasionally a child may react emotionally to the first token withdrawal and refuse cooperation.

The child may stop talking, fight tears, leave the seat, or ask for Mommy.

Showing signs of disappointment is natural and the clinician needs to do nothing

Serious emotional reactions need to be handled promptly and sensitively.

Reverse the Roles

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Role reversal is invariably effective in completely eliminating the childrens unfavorable reactions to the initial token withdrawal.

The clinician plays the childs role, and asks the child to give and take tokens for smooth and bumpy speech (and produces many bumps).

Children gleefully withdraw tokens from the clinician!

When the treatment is resumed, children have no problem with token withdrawal.

Token bankruptcy

Another potential problem to be handled is token bankruptcythe child who is left with no tokens, which means no gift at the end of the session.

That, of course, cant happen; the clinician should avoid token bankruptcy at all cost.

Token bankruptcy means no reinforcement for fluency.

The child will react explosively if there is token bankruptcy.

Handling token bankruptcy

Clinicians monitor the number of tokens the child has at any moment

When the childs token collection is precariously low, the clinician can

award two tokens for fluent and longer productions.

more frequently model fluent productions.

extend the session by a minute or two so the session ends with surplus tokens for the child.

Parent training

Parents must be trained in the administration of response cost at home.

Parent training must not be monitored in any systematic manner.

p.t.o.

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TREATMENT APPROACHES FOR STUTTERING

IN CHILDREN

THE MONTEREY FLUENCY PROGRAM (MPF, 1970s):

The MPF was developed in the late 1960s and early1970s. It was based on learning

principles, in particular operant conditioning. The major target for people of all ages, who

stutter, is normally fluent speech. The MPF involves speech only, because it was

observed that changes in attitude and anxiety often occurred after changes in fluency

(Craig et al., 1996). The MPF is based on 3 major components of programmed instruction

and operant conditioning: (a) overt responses (stuttering and fluent speech), (b) small

steps or successive approximation (e.g., one fluent word, two fluent words, etc.) and (c)

immediate consequences (positive feedback for fluent utterances and corrective feedback

for stuttering moments). Tokens with backup reinforcers (e.g., toys) are also used with

children. Additional components are the requirements of some reasonable duration of

performance (eg a criterion of 10 consecutive correct or fluent words) and continuous on-

line (real time) collection of data to achieve the target of normally fluent speech. These

procedures make the MPF amenable to clinical trials of efficacy (Ingham & Riley, 1988).

There are 3 phases of treatment: establishment (within-clinic fluency), transfer (out of

clinic), and maintenance (fluency within and out of the clinic over time) (Ryan, 1974).

The MFP is a performance driven clinical treatment with a built in data collection system.

Two tests are built into the program, because we adhered to the instructional

programming principle of test-teach-test (Pipe, 1966). First, the fluency interview, which

is composed of 10 speaking tasks ranging from automatic (e.g., counting) to

conversational speech with strangers, and strangers, and second, a criterion test (5

minutes each of reading, monologue, and conversation) are administered. These two tests

serve to determine the level of pre treatment stuttering and as post tests to determine

improvement and effectiveness of the treatment program at various stages. Following the

administration of these two tests, the client progresses through as speech fluency, which

contains steps in three phases: establishment, transfer and maintenance.

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THE LIDCOMBE PROGRAM (1980s):

The Lidcombe Program is a behavioural treatment for young children who stutter. It was

developed by a research team led by Professor Mark Onslow, consisting of researchers at

the Faculty of Health Sciences, The University of Sydney, and clinicians at the Stuttering

Unit, Bankstown Health Service. The program takes its name from the suburb of Sydney

where the Faculty of Health Sciences is located. The program is administered by a parent

(or care giver) in the child's everyday environment. Parents learn how to do the treatment

during weekly visits to the speech pathologist. At these visits, the speech pathologist

trains the parent by demonstrating various features of the treatment, observing the parent

do the treatment, and giving the parent feedback about how they are going with the

treatment. This parent training is essential, because it is the speech pathologist's

responsibility to ensure that the treatment is done appropriately and is a positive

experience for the child and the family. The treatment modality is direct. This means that

it involves the parent commenting directly about the child's speech. This parental

feedback is overwhelmingly positive, because the parent comments primarily when the

child speaks fluently and only occasionally when the child stutters. The parent does not

comment on the child's speech all the time, but chooses specific times during the day in

which to give the child feedback. As well as learning how to give feedback effectively,

the parent also learns to measure the child's stuttering by scoring it each day out of 10,

where 10 is "very severe stuttering" and 0 is "no stuttering." At each clinic visit, the

speech pathologist and the parent examine these scores for the previous week to see what

effect the treatment is having outside the clinic. These parental measures are essential

because it is well known that stuttering may improve in a clinic without necessarily

improving where it really matters-outside in the real world. The Lidcombe Program is

conducted in two stages. In Stage 1, the parent conducts the treatment each day and the

parent and child attend the speech clinic once a week. This continues until stuttering

either disappears or reaches a very low level. Stage 2 of the program commences at this

point. The aim of Stage 2 is to maintain the absence, or low level, of stuttering for at least

one year. The frequency of parental feedback during Stage 2 is reduced, as is the

frequency of clinic visits, providing that stuttering remains at the low level at entry to

Stage 2. This maintenance part of the program is essential because it is well known that

stuttering may reappear after the conclusion of an apparently successful treatment. All

children and families are different, and the speech pathologist takes this into account

when supervising the treatment. While the essential features of the program as set out in

the Lidcombe Program Manual are always included, the way they are implemented is

adjusted to suit each child and family.

In essence- the whole treatment is about?

The treatment is that parents give feedback about stuttering and stutter-free speech

during conversations with their children.

What are the feedbacks the parents would give in the case of stutter-free speech, there are

three types of feedback ?:

Parents may acknowledge or praise (eg, "no bumps there", "that was lovely smooth

23

talking").

Parents may request self-evaluation from the child (eg, "was that smooth?").

In the case of stuttered speech:

Parents may acknowledge the stuttering (eg, "that was a stuck word").

Parents may request self-correction from the child (eg, "try it again without the stuck

word").

It is critical to the success of the treatment that parents are positive and supportive of the

children, who must enjoy the treatment. As is the case with any treatment for a childhood

speech and language disorder, it will not work if the child does not enjoy it and feel it is a

positive experience. Most important of all in the Lidcombe Program, care is taken that

parental feedback is not constant, intensive or invasive.

Also, parents need to take care that the treatment does not interfere with the child's

communication. It is essential that the treatment occurs as a background to a child's

everyday life - it must fit in with, not be imposed on, daily childhood activities.

The speech pathologist needs to ensure parents are presenting feedback safely and

correctly. Therefore, at the start of the Lidcombe Program, when the parent is first

learning to give feedback, it is done in carefully structured conversations only.

This structured application of feedback facilitates the initial teaching of the parent by the

clinician. Further, consistent with standard speech pathology practices, it enables the

parent to ensure the task is organized flexibly so that the child's responses are mostly

correct.

Finally, structured parental feedback at the start enables the child to get used to the

treatment and enables the parent to convey positive and helpful messages to the child

about what is occurring. When the parent has mastered the requisite skills and the child is

happy with the procedure, parental feedback is introduced into everyday, unstructured

situations. This is when the treatment is fully operational and when its effects become

apparent.

The administration of the Lidcombe Program relies heavily on measurement of stuttering.

In fact, the treatment cannot be done without it.

Speech measures used are:

To check that the child's stuttering is improving and so that adjustments can be made in

the event that there are no signs of improvement.

To precisely identify when the child has met speech criteria for recovery.

To check that the child's speech continues to meet those criteria in the long term.

Speech measures enable the clinician and the parent to communicate effectively about the

severity of the child's stuttering throughout the treatment process. The clinical measures

24

used in the Lidcombe Program are a 10-point severity scale which is used by the parent

and a "percent syllables stuttered" (%SS) measure which is used by clinician.

Improvement in stuttering in the Lidcombe Program is specified with the severity rating

scale and the percent syllables stuttered measure. There are 2 stages involved in this

program, to successfully complete Stage 1 and enter Stage 2, the child must have severity

ratings for the previous week of 1 or 2, with most ratings being 1, and less than 1.0 %SS

during speech within the clinic.

During Stage 2, the parent gradually withdraws the feedback. During this period visits to

the clinic decrease in frequency.

A report of 250 cases has shown the median time for the completion of Stage 1 - the

elimination of stuttered speech - is 11 weekly clinic visits. The recovery plot for the

Lidcombe Program is shown in the figure below.

Recovery plot for the Lidcombe Program. (Adapted from Jones, et al. [2000].)

The studies present long-term outcome data for a total of 42 children and show that after

the treatment they have near-zero stuttering in everyday speaking situations. The outcome

studies of the Lidcombe Program are summarized in the figure below, which shows long-

term near-zero stuttering in preschool children in everyday speaking situations after the

treatment.

25

Summary of outcome data for the Lidcombe Program of early stuttering intervention. Data are presented for %SS scores of the children talking at

home and outside their homes, and also for covert assessments when the children were not aware that their speech was being tape recorded.

At present, outcome data allow only a confident statement that children are not stuttering

when assessed after the treatment. Those data do not permit conclusions about whether

the treatment provides effects beyond those of natural recovery.

Nonetheless, confidence in the treatment is justified for two reasons. First, there are

outcome data to show that stuttering is at near-zero levels in school-age children after the

treatment. This age group has little chance of natural recovery, which suggests it was the

treatment that was responsible for their stuttering reductions.

Second, the known predictors of the rate of recovery with the Lidcombe Program are

different from those known to predict whether natural recovery will occur. As stated

previously, age and gender are powerful predictors of whether natural recovery will

occur, but they have been shown not to predict anything about treatment recovery with

the Lidcombe Program. Hence, there is reason to believe that treatment recovery and

natural recovery are two different processes.

Another type of outcome research that supports the Lidcombe Program deals with the

social validity of the treatment. It has been shown that children's speech after treatment is

perceptually indistinguishable from that of control children. These data are consistent

with our clinical experiences that, long after the treatment has been completed, the

children have forgotten all about their stuttering.

A preliminary outcome report has been published of a "tele-health" version of the

Lidcombe Program for the roughly one-third of Australian children who live rurally and

are isolated from speech pathology treatment services. At the time of writing, a

randomised controlled trial of this treatment model is in progress, funded by the

NHMRC.

Who uses it? The Lidcombe Program was developed in Australia and is now used by more than 80%

26

of speech pathologists in Australia who treat children who stutter. The specialist

clinicians at the Stuttering Unit in Sydney use it with all preschool children who stutter.

The first report of the treatment was published in 1990 and this was followed by regular

reports in scientific and professional journals, books, and at speech-language pathology

conferences. The Lidcombe Program is now widely used in Canada, the United Kingdom

and New Zealand. There is also considerable interest in South Africa, the United States,

and several non-English speaking countries. The manual has been translated into five

languages, and these translations can be downloaded from this website. There is an

international Lidcombe Program Trainers Consortium, with members in the United

Kingdom, the United States, Canada, and Australia.

Is it effective?

A considerable amount of research has been conducted into the Lidcombe Program, and

development of the Lidcombe Program continues to be an important focus of ASRC

research. Research to date has shown that for preschool children participating in the

program, stuttering is no longer present, or is present to only a very mild degree, after

treatment, and that this outcome has been maintained in those children who have been

monitored for a number of years. Preliminary research is also showing that the program is

safe: It does not appear to interfere with parent-child relationships and has no apparent

effect on other aspects of communication. Indeed, parents report that their children are

more outgoing and talk more after treatment because they are no longer stuttering. At

present, there are two major, international clinical trials of the Lidcombe Program being

conducted: One in New Zealand and one in Germany.

Some children recover naturally from stuttering. Because of this, the question is often

asked: Is treatment for stuttering in young children more effective that natural recovery?

More specifically, do the reductions in stuttering that occur after treatment with the

Lidcombe Program reflect anything other than natural recovery? Randomised, controlled

trials of the Lidcombe Program, currently under way, will explore the efficacy of this

treatment and provide the "gold standard" of scientific evidence. In the meantime, there is

enough evidence to suggest that the program has a powerful therapeutic effect that is

above and beyond the effects of natural recovery. First, factors that predict how quickly

children respond to the treatment are different from factors that predict natural recovery

and, second, the program also reduces stuttering in older children for whom natural

recovery is unlikely.

How long does it take? Children differ in the time they take to complete the Lidcombe Program. However,

research has shown that the average number of weekly clinic visits needed for preschool

children to reach Stage 2 of the program is around 11. Children whose stuttering is more

severe tend to take more than 11 visits, while children whose stuttering is less severe tend

to take fewer than 11 visits. It also seems thatfor preschool children onlydelaying treatment with the Lidcombe Program for a year or so after onset does not make the

child's stuttering less responsive to the treatment.

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The study done by Jones et al in 2000 reports the data pertinent to this issue for 261

preschool-age children who received the Lidcombe Program of early stuttering

intervention. Of these children, 250 completed the program and were considered by their

clinicians to have been treated successfully. For the children who were treated

successfully, logistical regression analyses were used to determine whether age, gender,

period from onset to treatment, and stuttering severity related systematically to the time

required for treatment. The present data confirmed previous reports that a median of 11

clinic visits was required to achieve zero or near-zero stuttering with the Lidcombe

Program. Results were also consistent with a preliminary report of 14 children (C. W.

Starkweather & S. R. Gottwald, 1993) showing a significant relation between stuttering

severity and the time needed for treatment, with children with more severe stuttering

requiring longer treatment times than children with less severe stuttering. However,

results did not associate either increasing age or increased onset-to-treatment intervals

with longer treatment times. This finding is not consistent with the Starkweather and

Gottwald report, which linked advancing age with longer treatment time. In fact, the

present data suggest that, for a short period after stuttering onset in the preschool years, a

short delay in treatment does not appear to increase treatment time. An important caveat

to these data is that they cannot be generalized to late childhood or early adolescence.

The present findings are discussed in relation to natural recovery from stuttering.

Another randomised controlled trial of the Lidcombe Program is being conducted in

Germany and is in its final stages.

New evidence for treating young children with the Lidcombe Program

A major study published August 2005 in the British Medical Journal showed that

preschool children who stammer will have significantly less stammering and a higher

recovery rate if they are treated with the Lidcombe Programme, compared to those who

receive none, or minimal therapy.

As a randomised controlled trial, it studied two similar groups of children, one who

received Lidcombe treatment, the other receiving little or no treatment. After nine months

of treatment, children receiving Lidcombe had reduced their stammering by 77%,

compared to 43% who did not receive it.

The study was run by the Australian Stuttering Research Centre and conducted at two

sites in New Zealand. It involved 54 children between three and six years (with frequency

of stammering of at least 2% syllables stuttered). The children had been stammering for

at least six months before the study, and had not received treatment for stammering

during the previous year. There were 29 in the Lidcombe group, and 25 in the other

group. 12 of the participants were girls.

In recent years therapy for pre-school children has become more widely accepted. BSA

has campaigned for more therapy provision for young children because stammering is

most effectively treated before a child starts school.

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The significance of this study is that it has produced very clear evidence that therapy, in

this case the Lidcombe Programme in the preschool years, can significantly reduce

stammering. With therapy services needing to show clear evidence to justify their work,

this study provides important data to show that treating stammering in young children is

much more effective than relying on natural recovery.

THE FLUENCY RULES PROGRAM (Late 1980s):

The fluency rules program (FRP) was conceived and designed to provide therapeutic

direction to help preschool and early grade stutterers acquire fluent speech. In the initial

stages of this program attempts were made to teach the children the association between

physiology and fluency and they were reasonably successful, they were labeled rules of good speech. By 1981, these clinical techniques were known as Fluency Rules.

Originally there were ten rules designed to teach children to speak fluently and to sound

natural. However with continued clinical effort the number of rules was reduced to seven

and the instructions for them was simplified. The FRP was revised and FRP-R was

published in1995 (Runyan & Runyan, 1993).The revised FRP procedure provided a

structure and order for the presentation of the rules. The rules that had consistently been

presented first to every child became the Universal Rules. The next rules, the Primary

Rules, were physiologically based rules, which were used with children who exhibited

breathing and laryngeal problems associated with instances of stuttering. Finally,

Secondary Rules were used only when secondary behaviors were a component of the

stuttering blocks.

THE PROGRAM:

This section describes the individual fluency rules and how they are applied with respect

to preschool stutterers, early grade stutterers and special population stutterers.

UNIVERSAL RULES:

There are two Universal Rules: Speak Slowly and Say a word One Time. These two rules are usually the only rules necessary to treat very young stutterers. However, for

young stutterers who also demonstrate prolongations, the Secondary Rule, Say it Short, is included as a Universal Rule. The intent of Universal Rules is to provide basic

instructions to assist the child in producing fluent speech.

Rule 1: Speak Slowly (Turtle Speech)

This rule is presented first to encourage a reduced rate of speech production. Reduction in

rate may provide additional time for the development of self monitoring skills, which the

29

child can use to acquire and develop physiologic skills necessary for fluent speech

production. Although this rule has always been labeled speak slowly or turtle speech, the intent was never to encourage children to produce abnormally slow speech or to say

words one at a time in a rhythmic pattern. But as this Speak Slowly Rule continued to be

used in all the clinics, an unexpected benefit associated with this rule became apparent.

Therapy data revealed the frequency of stuttering decreasing while speech rate remained

virtually unchanged. After repeated observations, it was concluded that the reduction in

the frequency of stuttering may be due to a general calming effect. This calming effect

appeared to be a by- product of the modeled slow rate of speech encouraged by this

Universal Rule in the therapy sessions and home environment.

Rule 2: Say a Word One Time:

This rule is the foundation of FRP when treating very young children. Obviously part

word and whole word repetitions are the speech characteristics typically exhibited by

young disfluent children. A technique to control these repetitions must be a vital

component of any treatment program designed for this population. To use this rule

effectively, children must understand the concept of one, once, or one time. TO teach this

concept, sequential materials such as days of the week or months of the year, letters of

the alphabet have been useful. An explanation is provided that each word is unique and

does not need to be said more than one time. Then the child and the therapist repeat one

of the repeat one of the series of words in unison. To demonstrate the concept further in

an animated fashion, the therapist selects one word from the series and repeats this word

20 times (e.g One, two, two, two [20*1]) while bouncing up and down with the

production of each number. This redundancy and animated physical activity captures the

childs attention and allows the therapist to ask, Did I need to say the word more than one time for you to understand it? The response has always been no. This dialog helps the child understand the importance of being careful about what we say and listening to make sure we say each word only one time.

To ensure the success of this rule, the child is encouraged to identify repeated words

produced by the therapist. During this phase of therapy, the clinician intentionally and

frequently repeats words and part words and the child is encouraged to signal when these

repetitions occur. When clinician generated repetitions are identified correctly every time,

the child is asked if the clinican can help identify repeated words in his or her speech.

This procedure takes the format of a game with each participant trying to catch the other

repeating a word. As the child becomes more fluent and there are fewer opportunities for

repetitions, to keep the awareness high, the clinician should produce increasingly more

repetitions so at the intent of therapy is not lost.

Secondary Rule (Third Rule)

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The intent of this rule is to assist the stutterer therapeutically to eliminate prolongations.

For maximum results this rule must be applied immediately following every instance of a

prolongation.

Rule Three: Say it Short

This rule becomes an Universal Rule for very young stutterers who exhibit prolongations.

When needed, the most effective therapy technique is another hand signal. The hand

signal is the well known signal for short, which is placing the thumb and forefinger close

together. Because this nonverbal hand signal is so well known, therapy time needed to

teach this concept has been minimal.

Primary Rules

The primary rules are used to treat aspects of stuttering that appear to be physiologically

based. Children treated using the Primary Rules have demonstrated abnormal breathing

patterns or laryngeal activity (during their stuttering blocks). These physiological

behaviors usually are not manifested in the speech of preschoolers. However, the Primary

Rules have been used with children as young as second grade. When use of the Primary

Rules is necessary, based on the diagnosis or clinical observation, they are taught as a

package. In other words, if a child experiences difficulty with speech breathing or

laryngeal tension, then an explanation of speech production incorporating both primary

rules is undertaken.

Rule Four: Use Speech Breathing

To explain speech breathing, a breath curve is drawn on paper or a chalk board, using a

steep slope upward to indicate rapid inspiration and a gradual downward slope for slow

exhalation. Then this drawing is related to what occurs physiologically when the child

breathes. To relate this drawing in a tactile manner to breathing, the childs hand is placed just below the sternum with the clinicians hand on top, so the rise and fall of the chest wall can be felt. After the child comprehends the relationship of chest wall

movements and breathing, this breathing pattern is related to speech production. To do

so, an X is placed on the down slope just after the peak on the breathing curve where inhalation ends and exhalation begins. The child is told that this X is the point during exhalation begins. The child is told that this X is the point during exhalation at which to start speech. With hands properly positioned and the breath curve drawing set up easy

viewing, the child is instructed the trace the breath curve with a finger while feeling the

corresponding movements of the chest wall. Once this procedure has been practiced and

understood, speech is introduced using the designated X. The first speaking tasks include the sequential material used during practice of the Universal Rules. Following

this activity short simple phrases are repeated, none of which begins with a sound

associated with stuttering. During these drill activities, the children are explained that and

demonstrated that we speak on exhalation, and that air carries the words out. To teach this concept, again in a humorous fashion, it is demonstrated with exaggerated effort that

speech cannot be produced when we hold our breath.

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Rule Five: Start Mr. Voice Box Running Smoothly/Gently

For the young stutterer this rule is infrequently used. If needed, we incorporate gentle

onset of voicing with speech breathing by instructing the child to exhale slowly, feeling

the air as it comes up the throat, and at the designated X to start to hum gently. This activity is followed by having the child repeat phrases with the initial word beginning

with /m/. On occasion, depending on the childs age and comprehension ability, an awareness technique is needed to explain that Mr. Voice Box lives in the neck. To demonstrate this point, we phonate or hum while shaking our neck vigorously with our

hand and hear the funny sound this activity causes, thus proving that Mr. Voice Box lives

in our neck.

Program Implementation:

The FRP is implemented in the following manner:

1. Determine the Rules That Are Broken. 2. Teach The Necessary Concepts. 3. Develop the Childs Self Monitoring Skills. 4. Therapeutic Practice Using the Rules. 5. Carryover to the Home and/or Classroom.

SPEECH MOTOR TRAINING (Early 1990s):

A speech motor training motor training program to treat stuttering was developed over 20

years based on empirical, theoretical and research evidence. The possibility of a reduced

speech motor system underlying stuttering was hypothesized. If a reduced speech motor

system existed in a child who stuttered, the questions emerged, how to test it, how to train

it? If speech motor function improved through training, would it have a positive impact

on decreasing stuttering and /or providing a more effective speech motor to support

fluency? That is, when fluency was achieved, would a better speech motor system reduce

the tenuousness of maintaining fluency? Also, would such a system eliminate the need

for maintenance after treatment? It was from these questions that the speech motor

program was developed.

THE PROGRAM:

The purpose of SMT is to improve speech motor production, thus reducing stuttering

frequency and severity. Improvement in speech motor control can be inferred from

changes in VRT and durations of brief acoustic speech segments following treatment.

These changes in speech motor production are reported from controlled experimental

studies but cannot be measured in most clinical applications. The behavioral goal of SMT

is that the child with correct sequencing, and at an age- appropriate rate.

32

Clinicians who are planning to use the SMT program need to (a) develop he required

clinical skills, (b) learn the general principles of training (including handling special

problems) so that they are readily applied during the training sessions, and (c) follow

specific training procedures that implement the principles on which therapy is based.

The equipment required includes a good tape recorder, a high quality external

microphone and a stop watch.

GENERAL PRINCIPLES OF TRAINING:

1. Motor training should be done at 3 rates; very slow (1 sps), slow (2 sps) and normal (3 sps).

2. After a given set at the same level of difficulty has been accurately trained, probing for generalization is done at an age appropriate of approximately 3 sps.

3. Training is done by modeling the desired behaviors. 4. Varying syllable stress is modeled during SMT to improve the flow of

nonlinguistic syllables.

5. Vowels, /i/, /ae/, /ei/, /ou/, /u/, /a/, /ai/ were selected for inclusion in the training sets because they seemed natural and easy to produce.

SPECIFIC TRAINING PROCEDURES:

1. The levels of difficulty of SMT are indicated in the outline of Speech Motor Training. There are 14 levels of difficulty.

2. For each indicated, the number of times the syllable set is modeled by the clinician and then produced by the clinician and then produced by the child in one

breath is varied systematically: first one set is produced in a breath group (eg

/bavi/, then 2 sets in a breath group (eg /bavibavi/), then 3 sets, then 5 sets, then 8

sets and then 10 sets. For long strings of sets with 3 and 4 syllables, the child may

take an extra breath.

3. The rate is varied systematically. At first one syllable per second is used. For example, a 3 syllable set will require 3 seconds to model and 3 seconds for the

child to perform. This rate is not comfortable, but it requires practice to model at

this rate and assist the child to maintain it. Rate is increased to 2 sps then 3 sps as

the child progresses through training on the selected syllable set.

4. Accurate voicing (Unvoiced or voiced) and smooth flow are maintained. A child can usually produce voiced consonants more easily than the unvoiced cognates. .

Therefore, when voiceless consonants are used in a training set, it is important to

monitor correct voicing.

5. Contingency management such as tokens can be used. The level is passed when a child can perform the trained set and two untrained sets; 80% accuracy is required

to pass.

6. The pass criterion at each step for a training set is 3 consecutive successes. The level is passed when a child can perform the trained set and two untrained sets;

80% accuracy is required to pass.

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7. If a child fails to perform correctly on 6 consecutive tries, he or she should branch to an easier level.

8. The clinician and child establish a pattern of training during level 1 that will influence all other levels. The clinician should not move to the next level until the

childs production is automatic and overlearned.

VOLUNTARY STUTTERING (1994):

Bryngelson et al (1994) found that the stutterers reported that their speech was out of

control during stuttering and claimed that a sound or word got struck and would not come out i.e., it was involuntary and beyond control. He evolved the method of voluntary stuttering in 1994. He maintained that stutterers should confront their speech

disruptions by consciously and willingly practicing voluntary stuttering. In this way

stutterers would reduce their fears of the unkown and be better able to control stuttering

when it did occur.

In accord with a proposed innate link between speech perception and production (e.g.,

motor theory), the study done by Saltuklaroglu et al (Percept psychophysics.2004

feb:66{2}) provides compelling evidence for the inhibition of stuttering events in people

who stutter prior to the initiation of the intended speech act, via both the perception and

the production of speech gestures. Stuttering frequency during reading was reduced in 10

adults who stutter by approximately 40% in three of four experimental conditions: (1)

following passive audiovisual presentation (i.e., viewing and hearing) of another person

producing pseudostuttering (stutter-like syllabic repetitions) and following active

shadowing of both (2) pseudostuttered and (3) fluent speech. Stuttering was not inhibited

during reading following passive audiovisual presentation of fluent speech. Syllabic

repetitions can inhibit stuttering both when produced and when perceived, and we

suggest that these elementary stuttering forms may serve as compensatory speech

gestures for releasing involuntary stuttering blocks by engaging mirror neuronal systems

that are predisposed for fluent gestural imitation.

ANALOGIES (Conture, 1990):

Conture (1990) has provided several analogies which could be used to teach the child

stutterer regarding normal & disrupted flow of speech.

The Garden Hose Analogy

Author: Contour (1990)

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Rationale: Analogies are used to help the child understand what the child must do to

increase speech fluency. This helps the child to understand their speech system and

visualize it.

Before understanding the analogy, the working of garden hose should be explained to the

child:

1. Permit water to flow out of the hose 2. Minimize the amount of water that flows 3. Completely stop the water from flowing out of the hose. 4. After the child is familiar with this concept similarities between the garden hose

and our speech production mechanism should be taught.

Blown up Balloon Analogy:

Author: Contour (1990)

Rationale: analogies are used to help the child understand what the child must do to

increase speech fluency. It is an excellent way to help the child understand tightness

resulting from aerodynamic backpressure.

One excellent way to help the child understand tightness resulting from aerodynamic

back pressure is by using a blown up balloon with the thumb and index finger of one

hand on the balloons neck to stop the flow of air out of the balloon. Blow up the balloon and have the child feel the taut or tense sides of the balloon and explain this is a bit like

the tension created by air pressure in the lungs and the vocal tract. Have the child gently

squeeze the sides of the balloon and feel the changes in the pressure on the sides of the

balloon. The child can hold the neck of the balloon and feel the pressure as the clinician

squeezes the sides of the balloon. Have the child figure out the best way to let the

pressure out of the balloon, for eg by 1. Pushing hands on the sides of the balloon,

2.Squeezing the thumb and index finger together and 3. Slowly releasing the air through

slightly separated finger thumb.

Lily pad/ Barrel bridge analogy:

Author: Contour (1990)

Rationale: Analogies are used to help the child understand what the child must do to

increase speech fluency. This indicates that speech involves a smooth continuous

movement from one sound to another.

35

This analogy involves pretending as a Frog or the childs jumping from one lily pad to the next to cross a stream. The therapist has to pretend that each pad is a letter of a short

word like baby and that they have to hop from the bank to the first pad, then to the next

pad and so on until they reach the other bank. Easy speech, repetition and stoppage could

be demonstrated using this analogy. The same idea can also be conveyed by the analogy

of a floating bridge made of barrels tied to each other with rope.

Thumb and opposing finger analogy:

Author: Contour (1990)

Rationale: Analogies are used to help the child understand what the child must do to

increase speech fluency. This indicates that speech involves a smooth continuous

movement from one sound to another.

Each finger can be considered as a letter or sound of a short word and our opposing

thumb, the tongue, or speech system, is used to produce each letter or sound. Fluent

speech is like having the thumb move smoothly, sequentially and easy from one finger to

the next. Conversely, stuttering is like pressing for too long with too much of force

between the thumb and any one of its opposing fingers or repeatedly the thumb and one

of the fingers.

PARENT CHILD FLUENCY GROUPS:

The parent child fluency group serves a number of functions. The clinician is able to

work directly with the children who are stuttering while their parents can receive

instruction regarding the nature of their childs problem, share similar concerns with parents of other children who stutter, and learn techniques and strategies for facilitating

fluency outside the clinic.

The child best suited for a PC fluency group:

The child who is recommended for the PC fluency group has typically been stuttering for

more than a year and has begun exhibiting some awareness of his or her stuttering. The

age of the client typically ranges from2 to 6 years. Because of the many developmental

differences eg physiological size, emotional maturity that occurs within this age range,

the children will be divided based on age and emotional maturity.

Structure of the program:

The parents meet in one room, while the children meet in another. Near the end of the

session, the parents are brought together with the children for a planned parent-child

activity. The general objectives of the childs group are modification: a) Communicative interactions b) Speech production behaviors, and

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c) Attitudes about speech in general, the childrens speech in particular, and themselves as speakers.

The objectives for the parent group, to help and change their own and their childrens communicative interactions and behaviors are brought about through

Counseling and information sharing Guided observations of the children interacting with the clinician, and Guided participation in therapy with the children and clinicians.

P.T.O.

TREATMENT APPROACHES IN MANAGEMENT

OF STUTTERING IN ADULTS

Management of adult stutterers is a far more difficult task than managing child stutteres

as the adults are completely of their problem and tend to have a low morale which would

itself act as a hindrance to the process of therapy. So counseling is an important

component in the management of adult stutterers in order to drive the negative thoughts

and emotions which pre dominates in an adult stutterer.

Factors to be considered for therapy for adults:

Psychological make up of the client Motivation Family support Socio-economic background Self confidence Cognitive factors Clinician- client interaction Environmental factors

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COUNSELING

An important point to be remembered for adult therapy is the process of counseling:

Counseling the patient regarding the:

Nature of the problem.

How it hampers the communication skills of the client.

Probable treatment options.

Probable duration of the therapy.

Meeting the realistic expectations of the prognosis.

Transfer

Maintenance.

VARIOUS THERAPY PACKAGES FOR ADULTS IN HIERARCHIAL

SEQUENCE:

SHADOWING (1956,83):

Cherry and Sayers (1956) popularized shadowing as a technique and reported good

results with clients with stuttering. In shadowing, the client listens to model and attempt

to repeat the model utterances lagging one or more syllables behind the model.

Feider and Standop (1983) applied shadowing by having the clinician begin with a list of

short sentences spoken at a slow rate. The client follows the model production, lagging

behind. Once the client is able to perform adequately, sentences are lengthened and rate is

increased. Progressively longer and varied material is used. Deliberate changes in tempo,

inflection, pronunciation and so forth can be used.

The effects of shadowing are attributed to sheer novelty, distraction, induced rhythm,

intonation, prosody, timing alterations, and changes in auditory feedback.

ARTICULATORY LEVEL THERAPY (1950, 1987):

LIGHT CONSONANT CONTACT (LCC):

Froeschels (1950) described LCC. Every speaker develops habituated sets of articulator

performance in terms of shaping (modulations in the vocal tract), force and deviation.

Any distortion in any of these parameters would result in stuttering. Tension leads to be

tensed, prolonged, interrupted articulatory movements.

Teaching LCC:

Have the client utter a phrase Repeat the phrase with his / her mouth open as wide as possible. Production

should be relaxed, not too loud and the speech should be melodic with least effort.

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The clinician can use different practice material (word lists, phrases and sentences)

CONTINUOUS PHONATION AND BLENDING:

It was described by Pindzola (1987)

Prolongation is mostly used therapy procedure for clients with stuttering.

Prolongation always involves an element of continuous phonation. Continuous

phonation results in blending of words. Continuous phonation can be used along with

LCC.

PROCEDURE:

Ask the client to read the word (count the number or days of week) normally. Extend the phonation on the last sound of each word to the first sound of the

next word.

Move onto sentences, close end questions, paragraphs and so on. Finally, have the client speak for at a stretch using continuous phonation and

blending at various contexts.

DELAYED AUDITORY FEED BACK (1956)

Gold Diamond was the first to use DAF in the context of stuttering.

It is a method where an individual hears his own voice delayed by a few msecs through

an instrument. Its a good treatment for the reduction of stuttering.

Rationale: It is based on classical behavioral approach.

Curlee and Perkins (1969) described a therapy program in which slow, fluent speech was

established by DAF of 250 msecs.

In a study done by sparks et al in 2002 (J Fluency Disorders. 2002 Fall;27(3):187-200)

Delayed auditory feedback (DAF) has been documented to improve fluency in those who

stutter. The increased fluency has been attributed to the slowed speech rate induced by

DAF. This investigation described the effect of combining a fast speech rate and DAF on

the fluency of four people who stutter. Fluency of the two mildly dysfluent subjects was

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the same for both no DAF and DAF conditions at normal and at fast oral reading rates. In

contrast, the two severely dysfluent subjects improved in fluency from the no DAF to the

DAF conditions. They were found to be dysfluent at both normal and fast oral reading

rates without DAF. The results of the study point to the need for further research on the

relationship between speech rate and stuttering frequency under conditions of DAF and

no DAF.

METRONOME TIMED SPEECH (1965):

Rationale: Most AWS become more fluent, at least temporarily, when they speak using

an artificial rhythm.

Procedure: Demonstrate the use of it to the client.

Set the metronome at 40 beats/ min and ask the client to carry out the following:

Tap fingers on table.

Nod head left and right.

Open and close jaw.

Non sense syllables.

Move to word level utterance each syllable to a beat.

Sentence level: One word per beat.

UNISON SPEECH (Gregory, 1968):

Simplest method of achieving slower rate of speech is choral speaking or unison speech,

where one person (clinician) provides a vocal model to another speaker (AWS).

Unison speech is generally used with reading aloud performance or common speaking

material to both the clinician and the client. Pre-recorded material at various speeds can

be played to the client through head phones and asked to match the rate of speech. The

clinician overwhelm the clients own auditory feedback with his/her loud speech. The

clinician and the client read together, moving from words to phrases to sentences and

then to paragraphs. This recorded and played back to the client.

A novel phenomenon of fluency enhancement via visual gestures of speech in the

absence of traditional auditory feedback was reported Stuart et al in 2000. The effect on

visual choral speech on stuttering frequency was investigated. Ten participants who

stuttered recited memorized text aloud under two conditions. In a visual choral speech

(VCS) condition participants were instructed to focus their gaze on the face, lips and jaw

of a research assistant who 'silently mouthed' the text in unison. In a control condition,

participants recited memorized text to the research assistant who sat motionless. A

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statistically significant (P=0.0025) reduction of approximately 80% in stuttering

frequency was observed in the VCS condition. As visual linguistic cues are sufficient to

activate the auditory cortex, one may speculate that VCS induces fluency in a similar yet

undetermined manner as altered auditory feedback does

INTENSIVE TOKEN ECONOMY THERAPY (1972):

Author: Andrews & Ingham (1970,1973)

Rationale: A behavior punished decreases & a behavior rewarded is reinforced.

In this technique initially slow rate is induced using DAF. Speech is then gradually

shaped to normal rates in structured group conversation. Stutterers have to speak at

specific rates at each step of therapy. No DAF is used during this stage. Penality are

provided for the stuttering and reward for achieving target speech rate and fluency.

Transfer and maintenance are carried out in real life situation.

The value of token reinforcement in the instatement and shaping of fluency was examined in an intensive treatment program for adult stutterers done by Howie &Woods

in1982. Experiment 1 examined the effect of removing the tangible back-up reinforcers

for the token system and found that clients' performance in the program was equally good

with or without these back-up reinforcers, suggesting that a strict token economy may not

be crucial to rapid progress through treatment. Experiment 2 compared contingent and

noncontingent token reinforcement, while controlling for some variables that may have

confounded the results of earlier research, and found no difference in clients'

performance. Experiment 3 examined the effect of the entire removal of token

reinforcement. Performance was found to be no worse under a "no tokens" system than

under a system of tokens with back-up reinforcers. It is argued that in a highly structured

treatment program where many other reinforcers are operating, token reinforcement may

be largely redundant.

A stuttering therapy program (Ingham & Andrews, 1973) in which adult stutterers were

hospitalized and treated in small groups (n = 4) under token economy conditions is

described. The Token System reinforced reductions and penalized increases in stuttering

during conversation. The therapy program was divided into three stages. Initially,

subjects were treated by the token system, which was then integrated with a delayed

auditory feedback schedule designed to instate and shape a prolonged speech pattern into

normal fluent speech. Finally, subjects passed through a speech situation hierarchy while

under token control conditions. Experiments conducted in the first two stages of

treatment are described. The first-stage experiments examined the design of the token

system; the second-stage experiment assessed the effect of a contingent punishment

schedule integrated with the delayed auditory feedback procedure in order to shape rate

of speaking as well as fluency.

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PRECISION FLUENCY SHAPING THERAPY-PFP (1974):

Author: Webster (1974)