MANAGEMENT OF STUTTERING

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

 Group therapy
  Drug therapy

 Psychotherapy
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.

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.

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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
Johnson’s 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.

Decisions regarding treatment of stuttering

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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.

Presumed Total Sound IOWA SSI SPI

likelihood that child frequency of prolongation scale
will require disfluencies index
treatment

Most likely to More than More than 30% More More than More than
require treatment 10% than 3 18 16
May require re 6% to 10% 12 to 30% 2 to 3 12 to 18 10 to 16
evaluation
Least likely to Less than 6% Less than 12% Less Less than Less than
require treatment than 2 2 10

Conture (2001) has provided a diagnostic decision flow chart and flowchart depicting the threefold
diagnostic decision- Yes, no, or uncertainty.

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 DOES THE CHILD HAVE PROBLEM

NO
YES UNCERTAIN PARENT COUNSELING/DISMISS

FOLLOW UP
EVALUATION

REFERRAL/DISMISS

INITIATE THERAPY

PARENT COUNSELING

INDIRECT PROCEDURES

DIRECT PROCEDURES

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

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 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 child’s 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 child’s 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
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 child’s 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
child’s 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:

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 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 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.

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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 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.

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Counseling and guidance

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 CHILD’S PARENTS:

The child’s parents should be counseled regarding the following:

 Nature of the child’s problem.
 How it hampers the child’s 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 child’s 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
 Response cost

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 (M.N.Hegde,2002)

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 child’s dysfluent productions.

• Reassure the child that he or she can talk smoothly and that you can help.
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.

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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.
• 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.

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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 child’s 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.
• 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).

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• 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.

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

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• 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.

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 didn’t 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:

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

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• For every fluent production (a word, a phrase, or a sentence), the clinician places a token in the child’s
container.
• The clinician also praises the child for smooth speech as she places the token in the child’s 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 child’s cup and places the removed token in his/ her own
cup.
• The clinician fluently models the child’s 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

•Role reversal is invariably effective in completely eliminating the children’s unfavorable reactions to
the initial token withdrawal.
•The clinician plays the child’s 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

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 •Another potential problem to be handled is token bankruptcy—the child who is left with no tokens,
which means no gift at the end of the session.
•That, of course, can’t 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 child’s 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.

TREATMENT APPROACHES FOR STUTTERING IN CHILDREN

THE MONTEREY FLUENCY PROGRAM (MPF, 1970’s):

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

17
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.

THE LIDCOMBE PROGRAM (1980’s):

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?

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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 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.

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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 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.

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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.

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Who uses it?
The Lidcombe Program was developed in Australia and is now used by more than 80% 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 that—for
preschool children only—delaying treatment with the Lidcombe Program for a year or so after onset
does not make the child's stuttering less responsive to the treatment.

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

22
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.

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 1980’s):

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

23
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 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

24
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 child’s 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)

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.

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 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 child’s hand is placed just below the sternum with the clinician’s 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.

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 child’s 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 Child’s Self Monitoring Skills.
4. Therapeutic Practice Using the Rules.
5. Carryover to the Home and/or Classroom.

SPEECH MOTOR TRAINING (Early 1990’s):

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

26
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.

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

27
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.
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 child’s 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
duri ng 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.

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The Garden Hose Analogy

Author: Contour (1990)

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 balloon’s 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.

This analogy involves pretending as a Frog or the child’s 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

29
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
child’s 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 child’s group are modification:
a) Communicative interactions
b) Speech production behaviors, and
c) Attitudes about speech in general, the children’s speech in particular, and themselves as
speakers.
The objectives for the parent group, to help and change their own and their children’s 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.

TREATMENT APPROACHES IN MANAGEMENT OF STUTTERING IN ADULTS

30
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

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.

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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.
 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.
It’s 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.

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

33
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.

PRECISION FLUENCY SHAPING THERAPY-PFP (1974):

34
Author: Webster (1974)

Rationale: Stutterers articulatory and phonatory gestures are distorted and require reconstruction
through intensive over learning of appropriate speech targets.

Theories describing stuttering as an emotionally-based problem have been abundant for nearly half a
century, despite a lack of scientific evidence supporting those theories. In addition, therapy programs
developed from such theories have been unreliable in providing treatment for stuttering.

More recently, research devoted to the physical aspects of stuttered speech has evolved into an effective,
as well as efficient, means of treating the problem. Through the use of computer analysis, speech
spectography, additional techniques, a succession of essential - though minute - elements of speech
movement has been observed which, without difficulty, can take the place of the distorted speech
gestures of stuttering.

At the Precision Fluency Shaping Program, stuttering is treated as a behavioral problem, and not
perceived as the consequence of a complex emotional disorder. The accurate redevelopment of the
physical properties of speech compromises a valuable approach to a perplexing, long-standing affliction.

The term "fluency shaping" is descriptive of the process by which the speech of stutterers is
reconstructed. Through an exacting gradation of activity stuttered speech is progressively "shaped" into
speech which is essentially fluent not only in the clinical setting, but in everyday life as well.

The Precision Fluency Shaping Program employs laboratory-derived principles of learning in the
development of new speech skills. In the therapy program, the physical mechanisms used in the
production of speech are precisely and systematically retrained. Initially, participants in the Precision
Fluency Shaping Program relearn the proper means of producing the elementary sounds of speech. The
stutterers then rebuild their ability to correctly produce syllables, words, and ultimately, complete
sentences.

HOW DID THE PROGRAM GET STARTED?

The Precision Fluency Shaping Program was developed by Ronald L. Webster, Ph.D., at the Hollins
Communications Research Institute in Roanoke, VA and is administered at the Eastern Virginia Medical
School under the direction of Ross S. Barrett, M.A., CCC/SLP. Mr. Barrett helped conduct the Precision
Fluency Shaping Program at Hollins from 1976 to 1983 after having gone through the program as a
patient in 1972.

As a stutterer himself, Ross has dedicated his professional life to helping other stutterers achieve the
same level of fluency that he reached. He was also Instructor in the Psychology Department at Hollins
College where he taught Speech Pathology and Audiology courses where the HCRI clinic is located. In
1983 Mr. Barrett started his own PFSP clinic at the Eastern Virginia Medical School where he has
successfully treated over 500 stutterers.

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WHAT DOES THE PROGRAM INVOLVE?

The Precision Fluency Shaping Program involves approximately 100-110 hours of therapy at the
Eastern Virginia Medical School in Norfolk, Virginia. Each individual receives personal supervision as
they progress through the program at their own pace. In the therapy program, the physical mechanisms
used in the productions of speech are precisely and systematically retrained. A small personal computer
is also used to monitor the participants’ speech to assure correct development of new speech skills.
Initially, participants in this program relearn the proper means of producing the elementary sounds of
speech. The stutterers then rebuild their ability to correctly produce syllables, words, and ultimately,
complete sentences.

After the completion of the Precision Fluency Shaping Program a follow-up program assists the
individual in transferring the use of proper speech responses into the home environment. In addition,
periodic data obtained from those who have completed the therapy program is used to anticipate
difficulties.

The PFP is designed for adolescent and adult secondary stutterers. It may be used in schools, university
programs, speech and hearing clinics, hospitals, and by the private practitioner. The clinician
implementing the program should be an ASHA certified Speech-Language Pathologist. Any student
clinician should work directly under the supervision of the certified clinician. Many well-motivated,
sophisticated stutterers can implement this program on their own. After all, in the final analysis, the
stutterer is the only one who can learn how to manage his stuttering successfully. The clinician can only
guide, direct and encourage.

The program is designed for either individual or group therapy; however, it is written for a group (any
more than one is considered a group). The group approach is strongly encouraged both for interest and
for mutual support which will grow during the program and, in all probability, will carry over to the
post-therapy period of the stutterers' lives.

The PFP provides a practical, hands-on approach to stuttering therapy. It is a program of doing, not one
of philosophizing about, theorizing about, nor debating about, stuttering. There is a myriad of
information in those areas, and it was not our intent to add to that.

The underlying rationale for this program is that stuttering is a unique communication disorder of
presently unknown origin or origins, and it cannot be cured--not unlike many other human ills. The
stutterer can, however, learn to manage his stuttering and his speech so that he can communicate as a
stutterer in any situation without undue stress and strain to himself or his listener. The clinician will
guide and execute this therapy program, but it is the responsibility of the stutterer to accept not only the
fact that he is a stutterer, but also the responsibility for changing his way of communicating to one that
is much more socially acceptable.

AIR FLOW THERAPIES (1974 & 76):

1. Regulated breaking method

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2. Flow and slow technique

1. Regulated breathing method:

Author: Azrin and Nunn (1974)

Rationale: Stuttering is a habitual disorder of the initiation and maintenance of airflow and should be
eliminated if the stutterer emits speech behaviors that are incompatible with these airflow anomalies.

This method is based on the belief that stuttering is a habitual disorder of initiation and maintenance of
air flow and hence should be eliminated if the stutterer emits speech behavior that are incompatible with
these air flow anomalies. Stutterers are trained to control a wide range of aspects of air flow. These
aspects involve

a) Smooth breathing.

b) Exhalation prior to speech,

c) Blending words into exhalation patterns

d) Continued exhalation after the last sound of utterance

e) Pausing at natural juncturing points

f) Smooth inhalation during the prespeech pause and

g) Formulation of general speech content

A brief treatment of one or two sessions each of two to three hours involves breath mananagement
practice. This is done initially in reading followed by spontaneous speech gradually decreasing the
frequency of pauses. Generalization is minimal and is restricted to the clinic and its environment

2) Flow and Slow Method / Modified Airflow:

Author: Martin Schwartz (1976)

Rationale: Stuttering is the result of excessive tensing of vocal folds before speech producing feedback
that triggers conditional struggle. To eliminate this malfunctioning, stutterers are made to relax the vocal
folds by maintaining passive airflow.

This method is based on the assumption that stuttering is the result of excessive tensing of the vocal
folds before speech, producing feedback that triggers conditional struggle. To eliminate this
malfunction, stutterers are made to relax the vocal folds by maintaining passive airflow.

37
Initially, the stutterer has to initiate passive airflow prior to speech and to slow the first of each
utterance. These skills are to be practiced in increasingly long and complex utterances and finally in
generalization tasks. For a year after intensive treatment, daily home assignments are carried out and
audio taped sample are mailed to the clinic.

It is found that the manipulation of air flow can reduce stuttering dramatically in the short term.
However, data on the outcome of airflow therapies indicate that nothing could be concluded about the
lasting effect of these techniques. The outcome also indicates that this technique is distinctly inferior to
the prolonged speech therapies. In summary it requires a better quantitative backup.

STUTTER FREE SPEECH (1980):

Shames and Florence (1980) devised stutter free speech in which the stutterer is encouraged to explore
and clarify feelings of anxiety, inadequacy and other aspects. The stutterer is trained with DAF to speak
fluently at a slower rate with continuous phonation and airflow. The stutterer is to prolong only the
stressed words and aim at normal inflection.

Once stutterer learns to monitor his/her speech to the degree that they can produce slow, fluent
utterances without the aid of DAF, they are taught to self reinforce these fluent responses. Fluency is
transferred to the stutterer’s daily life by means of written contracts that specify the times, places and
situation in which speech will be monitored. Contracts increase gradually until perfect self-monitoring is
attained, following which maintenance phase wherein clinical contacts occur at progressively less
frequent intervals.

PRINCE HENRY PROGRAM (1983):

Authors: Andrews, Craig & Feyer (1983)

This represents the cumulative developments of treating 50 adult stutterers each year since 1971 and
grew out of the orginal Andrew Ingham program.

The speech pattern taught is labeled smooth motion speech. The characteristics of this pattern are gentle
onset of phonation, continuous air flow, continuous movement of articulators throughout each utterance,
soft contacts and extension of vowel and consonant duration.

During the first week, smooth motion speech is trained at a speech rate of 50 SPM (1/4 th of normal
speech rate). Speech rate is then increased to the normal rate over the course of the week in gradual
increments of 5 SPM. Each step is considered to be achieved when the patient exhibits ‘zero’ stuttering
and correct speech rate in a 45 minute session.

A 1- minute monologue is video recorded for each patient who then evaluates his speech for acceptable
continuity, gentle onsets (less than 3 errors) and a speech rate within 20 SPM of target. Later three other

38
characteristics are also evaluated ; intonation, presentation (Overall acceptability) and appropriate pause
(less than 3 appropriate pauses).

During the second and third week patients transfer these skills to the real world. They have to complete
a graded hierarchy of 25 speech assignments, each recorded on cassette tapes (phone calls, shopping
etc). There are 15 standard assignments which must be completed by all patients and 15 personal
assignments which patients plan to cover many aspects many aspects of their speaking life. Each
assignment must contain atleast 1400 consecutive syllables of stutter free speaking at 200+40 SPM,
otherwise it must be reported. Patients must evaluate their speech quality and rate in each assignment
before submitting it for the therapist evaluation. Each day of the transfer phase begins and ends with a 2
hour session of smooth speech practice at 100, 150, 200 and 220 SPM.

A 3, 6, 9 weeks and at 6 months after intensive treatment, patients have to attend a follow up clinic
which involves participation in rating lessons and planning of maintenance activities. If they are not
satisfied with their progress they have to continue to attend the follow up clinic until they are fluent.
Patients should be encouraged to perform formal practice and generalization assignments daily for
atleast 9 weeks after the completion of intensive treatment. They should attend weekly self help meeting
of former patients. Booster treatment program are also available.

Research on the effectiveness of prolonged speech treatment suggests that they are effective both in
short and long term. The major value of prolonged speech techniques is that they force a patient to slow
his speech sufficiently to allow him to pay attention to what he does when he is fluent and to reprogram
his articulators accordingly.

Dr. FLUENCY (Dr.Trudy stewart & Monia Bray) (1990’s):

It is a computerized fluency shaping program. Dr. Fluency instructs, monitors, provides feedback to the
client regarding:

• Prolonged syllables.
• Breathing pattern.
• Gentle onset.
• Reducing air pressure
• Control of volume

PROLONGATION:

Rationale: Conversational rate control and breathstream management.

Prolongation involves stretching of words by lengthening the amount of time required to produce each
syllable (Goldberg, S.A., Carlotta, R., 1995).

39
Procedure:

Extensive Prolongation: The stutterer is asked to engage in a number of activities using an extensive
amount of prolongation. It may approximate 60 syllables/min.

Reduced Prolongation: As the stutterer successfully masters extensive prolongation, either producing
fluent speech or reduced stuttering, the rate of speech is gradually increased.

Slow fluent speech: Eventually the client’s speech is brought upto a speed that is slower than the orginal
rate, but not slow enough to call attention to it.

Fluency-modification strategies:

Bloodstein (1949, 1950) researched a variety of conditions where stuttering was reduced or absent. He
found that there were as many as 115 conditions that decreased stuttering markedly. Such circumstances
included activities such as speaking alone or during a relaxed state; speaking in unison with others;
talking to an animal or an infant or in time to a rhythmic stimulus; singing; using a dialect; talking and
simultaneously writing; speaking during auditory masking, in a slow, prolonged manner under delayed
auditory feedback; and shadowing another speaker. Many of these fluency-producing activities involve
combinations of altered vocalization (Wingate, 1969) or enhancement of the speaking rhythm (Van
Riper, 1973). These treatments often results in more assertive attitudes and a reduction of avoidance
behavior as the speaker’s fluency increases.

Stuttering modification approaches, tend to be the treatment of choice by clinicians who themselves
have experienced stuttering. This strategy is, by nature, more cognitive in nature in that the treatment
requires the client not only to evaluate and change behavioral characteristics, but to self-monitor and
self-manage cognitive and attitudinal features of the syndrome as well/ Informal counseling is some
form is typically an integral part of this approach.

This is also referred to as the traditional, VanRiperian, or nonavoidance approach. It’s

based on the concept that a large part of the problem is the speaker’s struggle, fear,
tension and avoidance of the core moment of stuttering. The primary goal involves the
reduction and management of fear and avoidance, typically via desensitization and
assertiveness training. This approach is more eclectic and counseling-based and requires
greater adjustment of the treatment to the individual clients.

Van Riper (1982) describe by taking the clients through the stages of
 Identification,
 Desensitization,

40
  Variation,
 Modification, and
 Stabilization.

Identification- Identify both surface and intrinsic features of stuttering. With the
assistance of the clinician, client making a list of “things I do when I stutter” to identify
surface features of stuttering. These are the behaviors that can be observed in a mirror,
recorded, and identified on video and audiotapes. Another list, “things I do because I
stutter,” can include the less obvious, intrinsic features of the syndrome such as
avoidances, anxieties, feelings of fear and helplessness, and the decisions and choices the
speaker makes because of the possibility of stuttering. Thus identify the feature that
occurs frequently during treatment. (Ex- writing autobiography)

Desensitization- For both overt (surface) and covert (intrinsic) features of his stuttering.
This includes voluntary, intentional, or pseudostuttering. The clinician can often begin by
asking the client to follow her in producing easy one or two unit repetitions and brief 1-2
sec prolongations. In severe case one can include struggle behaviors and blocking of
airflow and voicing. Voluntary stuttering provides a way to break the link between the
experience of stuttering and being out of control.

Variation- Here the client is not asked to stop performing surface or secondary behavior
but rather to vary them in some preplanned manner. That is the client may select the
feature of producing a series of “ahs” prior to a feared word. Rather than attempting to
cease production of the ‘ah” as a postponement or timing device as he anticipates a feared
word, he could choose to systematically vary the rate, intensity, number, or vowel
segment.

Modification- Here the client is asked to begin varying some of his behaviors in even
more specific and appropriate ways. Here the goal is to replace the old, out of control
fluency breaks with a new, smoother utterance which he can completely control. But it’s
not an easy process.

41
First step in this is often termed cancellation and has client approach the moment of
stuttering after the event. That is, the client is shown how to perform a post-event
of his stuttering. Immediately following a stuttered word, the speaker is asked to stop
and pause for approximately three seconds which serve as a mild form of punishment for
the speaker, since he can do longer continue communicating with the listener. The client
will be able to recognize the stuttering moment and consistently pause following the
event, he can now perform an analysis of his stuttered behavior. Cancellation is usually
done during reading, monologue, and conversation, both inside and outside the treatment
setting. The main purpose here is not to be fluent, but to replace the old, automatic
stuttering with a new form of fluent stuttering. This is usually difficult to perform,
particularly during the expectations and time pressure of real-life speaking situations.
Second step, Para event modification, often called the pullout. Rather than waiting until
he makes it all the way through a stuttered word, the speaker will grab the word and
begin to “slide out of it” by enhancing his airflow, altering his vocal tract with
articulatory postures, and generally stuttering smoothly through the word. Clients find
that this technique is a natural progression from the cancellation technique and can begin
doing this spontaneously. This is less obvious than cancellation, and listener reactions
tend to be more favorable.
Final step, pre-event modification or preparatory set. This is intended to produce a
smooth form of easy stuttering. The speaker is preplanning, rather than reacting to, his
stuttering. The purpose is not to avoid stuttering and produce completely fluent speech.
Fluency-initiating gestures incorporated in fluency-shaping techniques like full breath, air
flow, gradual onset of constant phonation, and light articulatory contacts are helpful in
achieving a smooth preparatory set.

Stabilization- Newly learned modification skills are practiced under more stressful
conditions both within and outside of the treatment setting, with the goal of having the
speaker become resilient in response to stress and communicative pressure. Use of
delayed auditory feedback (DAF) or frequency altered feedback (FAF) can be used to
stabilize the behavior. Telephone calls, public speaking, and social introductions are
examples of particularly difficult speaking situations, which often need to be

42
systematically confronted. Most stabilization activities take place away from clinician
and treatment facility and will continue long after formal treatment is concluded.

3). Cognitive restructuring, here the intrinsic features of the syndrome become the major
focus of treatment. With this approach, relatively little effort is directed toward the direct
modification of surface behaviors and the speaking mechanism. The primary goal is to
change the way in which the client considers himself and his stuttering and how he
interprets the events of stuttering. By decreasing avoidance behavior and becoming more
assertive, the speaker is often able to make significant changes in the handicapping nature
of his stuttering. Rather than fighting his speech blocks, he may be asked to stutter more
openly. Although the frequency of stuttering moments will stay the same or even
increase, the quality of the fluency will improve. In addition, and most important, the
quality of the client’s communication, as well as his lifestyle, will often change for the
better. Rational emotive behavioral therapy (REBT) (Ellis, 1977) may be the best known
of the cognitive psychotherapies (Emerick, 1988).
Each strategy dictates that the speaker systematically learns and practice techniques, first
within the treatment setting and then gradually outside the security of the clinic, in real-
world speaking situations.
St. Louis and Westbrook reports the results of a survey of 30 treatment intervention
studies that is published from 1980 through 1986. These authors found that the reported
treatment of choice for the majority of adults who stutter was a form of prolonged speech
or rate control procedure, both forms of fluency modification. Furthermore, same authors
pointed out that few of the authors of the studies listed activities such as the modification
of stuttering moments, client counseling, or desensitization (any systematic analysis and
subsequent self management of attitudes and speech behaviors) as a significant part of
treatment.
According to Emerick, the cognitive aspects of treatment involve at least four main
phases.
Phase 1 educating the client about the overall approach of the treatment.
Phase 2 involves having the client identify his self-defeating patterns of thinking
analyzing his thoughts before, during, and after speaking situations in general and

43
stuttering events in particular. The client can categorize his responses in terms of
dependency/helplessness (“I know I will relapse when therapy is over”), irresponsibility
(“I just cannot control my feelings”), dichotomizing (“There are good listeners and bad
listeners”), catastrophizing (“I know I will fall apart if I am asked to introduce myself”)
and fantasy (“Most of my problems would be solved if I didn’t stutter”).
Phase 3 is one of reality testing. The clients’ task is to evaluate his metal constructs by
asking:
-Does the construct deal with the reality of the situation?
-Does this construct make unreasonable demands on me?
-Does the construct help me accomplish the treatment goals?
Example-
“It is difficult to think of failing in a speaking situation while at the same time
concentrating on positive thoughts”.
Negative cognitions must become cues for the client tells himself, “Stop”. At this point,
the clinician can role-play for the client, alternating between the negative and positive
self-statements. This can be an ideal activity during group treatment sessions.
Phase 4 involves having the client substitute self-enhancing language for the traditional
negative thoughts.
Example-
“This may be a difficult situation, but I can deal with it”
One of the best examples of cognitive restructuring approach along with stuttering
modification approach is described by Maxwell (1982). He summarizes the program in
the following steps:
1. Information giving- client receives verbal preparation and instructions of the
treatment plan.
2. Cognitive appraisal- client summarizes in his own words the objectives and
methods of treatment plan.
3. Thought reversal- client begin to reduce and eliminate negative cognition. Here
client will be taught to tell himself “stop” when there is negative thinking of
speech in his mind. Initially say “stop” loudly later say silently.

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 4. Vicarious observation- once the client is able to experience some success at
disengaging negative cognitions, the clinician begins to model positive
cognitions.
5. Speech modification- the client begins to improve his information-processing,
decision-making, and problem-solving abilities. This comes as a initial stage of
behavioral change.
6. Identification- the client becomes proficient at identifying specific moments of
stuttering, beginning with ten-minute segments using short words and progressing
to reading and conversation.
7. Termination- this accomplish first following (as in a cancellation), then during (as
in a pullout), and finally before (as in a preparatory set) the stuttering moment.
8. Cognitive restructuring- the client is asked to restructure his thought in more
stressful extra-treatment speaking situations.
9. Coping skill
10. Self management- during this final stage of treatment, client becomes able to self-
manage without the assistance of the clinician.

As the field of fluency disorders continues to mature, there is the possibility that clinicians are more
likely to prefer a treatment approach that is eclectic, one that incorporates elements from each of these
three generic strategies according to the capacities and needs of the clients.

CONCLUSION:

The treatment methods for stuttering has improved drastically over the years, nowadays there are lot of
treatment packages available for children as well as for adults. A SLP can not just try out a therapy
technique on the clients as per his/her wish, the clinician must choose the correct therapy technique
which is tailor made for the client and which will benefit the client in the process of fluency
modification ultimately. The management of stuttering for adults as well as for children is a challenging
task for a SLP, but if the clients are guided in the right direction good prognosis can definitely be seen
clinically.

GROUP THERAPY FOR MANAGEMENT OF STUTTERING

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 {Group therapy sessions are important because the client sometimes feels that as the therapist doesn’t
stutter, he/she does not understand that it is tough to go through an instant of stuttered speech and still
communicate.}

• Luterman (1991) suggested 2 types of groups: therapy groups and counseling groups.
• Usually group meetings serve functions of both counseling n therapy session where client can get
desensitized to stuttering in general and also to his own stuttering behavior.
• Conture in 1990 stated that group meetings also provide clients with opportunities to communicate
understand the nature of the problem and monitor self progress in social settings.
• According to Levy, 1983 group activities are a natural extension of individual treatment.

1/ Group introduction:

• The initial one to one interaction helps to desensitize the clients when speaking to a stranger but have
a common reason for being in the situation.
• Kelly (1970) and Levy1989 viewed behavior as a principle instrument of inquiry. In the group
setting clients can give each other support in attempting interaction that is usually avoided in extra
clinical situations.
• The role of the therapist is to facilitate discussion and decision making and record the rules. Some
issues such as punctuality, interruption, listening, and verbosity etc are also to be addressed by the
therapist.
• Negotiation should be encouraged during group tasks. Here entering a win situation is assertive
behavior and helps to raise self esteem, which is another goal of therapy.
• Feeling of the individual expectation is also important for the group facilitator. There should be a
sufficient flexibility to incorporate particular group needs.

2/ The block modification process:

• First stage is the identification; here one has to identify stuttering behavior.
• A common vocabulary within the group is made by observing the blocks, repetitions and secondary
behaviors.
• Then each member of the group is asked to pair up with a different partner, in order to identify each
others stuttering behavior and report what they observed, to each other.
• Then those behaviors of the stutterer are discussed to know how much he is aware about it.

3/ Focusing on the communication

• Here topics are placed infront of the group and group members are invited to contribute their ideas.
• After the discussion each item is considered interms of whether it is speech or non speech factor of
the communication.

4/ Changing perspectives:

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• According to Kelly1955, cited in Hayhow and Levy, 1989, that invalidation occurs in a sensitive and
supporting setting, and in an active experimental way, it may be reduce anxiety, guilt and hostility
and increase aggressiveness in kellyan sense.
• Here the client is encouraged to “go for it” rather than holding back

5/ Studying speech:

• In this stage, the group is encouraged to look carefully at fluent speech and how it produced. By the
use of diagram, the members are shown the process of the articulation and phonation.
• They are encouraged to experiment to produce the voiced and voiceless sounds and to have control
over their blocks, gradually removing the mystery of the sound production.
• Then diaphragmatic breathing is included as a relaxation tool that helps to increase the awareness of
the mechanics of breathing and the control over respiration for speech.
• This stage can be followed by small group work where the students can practice with difficult sounds
with an easy and smooth release of phonation.

6/ Structuring activity

• It is very much important for each session to have a structured beginning and more importantly an
end.
• The session should start with some active group name. The groups are asked to choose a topic and
each member of the group selects one from of that category and speaks about it.
• This is a good desensitization exercise where the student is put on the spot and has to think.
• This involves the whole group and reduces the fear of participating in group interaction.

7/ Assignments

• It is very much important that the course should have continuity and that each day should end with a
set of the assignments.
• Assignments like, watch the TV and note down the 3 good communicators and 3 bad communicator
and note down that why they are termed as bad communicator.
• They are also asked to listen out for any dysfluency in so called fluent or normal speaker.

8/ Dealing with feelings and changing perceptive

• In this stage the feelings or the covert aspects of stuttering that the student experiences of which the
listener is often not aware of are identified.
• In this stage self disclosure in a group of relative strangers happens.
• Here the student is initially asked to brain storm the covert feeling and the facilitator can write them
in the mind.
• The facilitator writes down the student’s words exactly as they are given.
• Students are encouraged to relate the experiences when they felt the listed emotions.
• The facilitator has to then offer alternative possibilities for the student’s construction of the particular
perspective on the event.

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 9/ Dealing with avoidance

• The motto is to develop a common language as well as to challenges negative constructs.

• No student is allowed to avoid a word if it is the one they really want to use.
• There is strong correlation between anxiety and self-esteem (Benjina1992) and a factor that may
contribute to this association is the tendency for the people with low esteem to present a false front to
the world.
• The student is asked to write down 10 to12 situations which cause the student anxiety.
• The main aim of this stage is to reduce fear through experience and experiment; it is very much
useful to introduce role play of these fears and often avoided situations.

10/ Encouraging more objective approach:

• Here one student is the observer and other is the actor.

• The actor is asked to stand and speak in a particular way and the observer is asked to note the
dysfluency, the facial expressions and the body posture.
• The observer then turns his back and has to detect the changes that the actor has been asked to do.
Roles are then reversed.

11/ Dealing with negative feelings within the group

• Here the therapist should be aware about the mood of the group.
• He should be able to pick up the discomfort or the things unsaid as they can produce a negative
atmosphere and should be dealt with as soon as possible.
• Any therapist working with adults who stutter should at least have basic counseling skills and
knowledge of group dynamics and facilitation.

12/Experimentation and desensitization

• Here video recording is done to observe their stuttering behavior and how they appear to their
listener.
• Each student is asked to speak three minute on a topic which is particularly of interest to them. At the
end of the day a discussion about the achievement and failure of the speaker is done.
• The facilitator must make it clear that the first observation have to be reported by the student who has
been filmed, after which other members may make constructive observation.
• The student is encouraged to make as many positive observations as negative one.

13/Encouraging the awareness of nonverbal aspect of speech:

• To move the focus from speech one can employ a task called “in the manner of the word”.
• Each student is given an adverb or an emotive word such as “angrily” or “surreptitiously”, written on
a piece of paper so that the rest of the group can’t see it.
• The group gives the student an action such a digging or driving and student does this in the manner of
his word.
• Here students are made aware of the non verbal behavior and their contribution to speech.

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 14/Trying out speech and prediction in the group:

• Lawson, 1992 describe the use of the Obstacle courses. Here one of the facilitator is blindfolded and
guided through an obstacle course of tables and chairs set up by the student.
• The students are told that the blindfolded person is a robot and needs small, specific directions, e.g.
move your left foot two inches to the right.
• The robot will not respond to any massage if there is any avoidance, back tracking or the use of
fillers. Students are not allowed to avoid and have to go for the exact word.
• They are told that robot will respond to a word that has been released after a block as long as the
student has attempted it. Here the student is asked to think and speak in a group situation where their
massage is important and has consequences.
• And also this provides an opportunity to carry out a mock interview with a stranger. This makes their
confidence high and makes them ready to face the stranger.

15/ Educating the public

• During this therapy session considerable prejudices and assumptions are made about on the part of
the person who stutters and members of the public.
• One of the final activities on the course is the creation of a survey by the group to check out some of
their assumptions about what the public thinks.
• The students go out as pairs and intercept members of the public. Feedback after this experiment is
usually extremely positive the students.

16/Negotiation and confrontation

• The final task is to make negotiation, confrontation and good communication in a group setting.
• Mock group discussions are encouraged and students are asked to try to reach a conclusion at the
end.
• At the end of the debate there is a vote as to who should be staying based on the quality of their
argument.
• This exercise involves all the social and communication skills learnt over the course of the debate.
• Student have to initiate conversation, turn-taking and express their opinions. Group role may have to
be reiterated if discussion gets heated.

17/The final session

• Lawson, 1992 has also commented about the final moment of a group, which are often full of an
intense mixture of feeling and it is important that there is some attempt to debrief the session.
• It is useful for the student to look at their original expectation and to see how far these have been
achieved.
• It is important for the therapist to have feedback on how successful the group was for each student
because an honest feedback can give benefit to their group therapy management.

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 PSYCHOTHERAPY FOR MANAGEMENT OF STUTTERING
• In the early twentieth century a new method of treating stutterers was tried for the first time based
upon studies by Freud, who considered stuttering as a neurotic symptom rooted in unconscious
conflicts.
• As stated by Freud, psychoanalysis would warrant a substantial amount of satisfaction in eliminating
stuttering but Brill in 1923 dispelled this hope. He said that the difficulty stutterers faced was not
because they were not able to improve themselves with therapy but because they had a tendency to
relapse.
• Travis (1957) & Glauber (1958) successfully treated clients with stuttering using Freudian
psychoanalytic method.
• Hence, not only classical Freudian psychoanalysis but also neo-Freudian forms of psychoanalysis
like group psychotherapy, by nondirective therapy, psychodrama, gestalt therapy, rational emotive
therapy and other types of psychotherapeutic procedures.

Suggestion

• This method was used to eliminate stuttering temporarily since the phenomenon of hypnotism was
being used.
• These days for treating stuttering, posthypnotic suggestion of fluency, hypnotic suggestion repeated
regularly over long period and autosuggestion techniques are used.
• Those clients who can be hypnotized talk to themselves and convince themselves that their stuttering
can be overcome; most clients relapse after such sessions but those whose conviction is strong they
tend to get over with the failure to speak fluently.

Relaxation

• Anxiety and tension lead to increase in frequency and duration of stuttering, hence, relaxation
techniques have been satisfactorily used by researchers to minimize the occurrence of stuttering
behavior.
• Relaxation in isolation or in conjunction with other forms of treatment has been effective in reducing
both core and secondary behaviors associated with stuttering.
• Zaliouk and Zaliouk in 1965 used relaxation and speech therapy on 58 subjects with ages ranging
from 6-15yrs for 6 months; results showed 81% of the subjects had full recovery from stuttering.

Psychoanalysis

• It deals with analyzing the past and present of the stutterers through free association, dream
interpretation and the analysis of their behaviors and resistances both covert and overt.
• The stutterer has to undergo catharsis, transference, aberection, and many other unnerving
experiences.
• This will help them to understand why they feel and behave as they do in terms of their past and will
also enable them to adapt to their present.

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• In traditional Freudian psychoanalysis, the therapist doesn’t reveal himself and just acts as a mirror in
which the patient can perceive him as his own parent or significant figure and by doing so, discover
and relieve the early traumatic experiences which are the sources of his present difficulties.
• In early Freudian days hypnosis was the most widely used technique of psychoanalysis.
• Gradually the use of these techniques was discontinued due to the associated demerits of the
procedure.
• One of the earliest studies done by Donath in 1928 used hypnosis for treatment of stuttering on 48
clients; reported improvement in speech of 71% of the clients under treatment.
• Lockhart and Robertson in 1977 did a study on 7 subjects from age of 18-62 yrs using hypnosis
techniques for a period of 4-6 wks; reported improvements in fluency for all the subjects after end of
the period of hypnosis.
• In another study they reported 10 out of 18 subjects (15-43yrs) to show marked improvements in
speech after undergoing hypnosis for 12-54wks.

Psychodrama

• Various hypothetical situations were arranged on stage by Moreno 1956 and cast was selected to play
various roles while inventing actins and verbal exchange on the spot.
• The client plays his own role and by such activities it was seen that there was reduction in fear and
tension associated with that particular situation and gradually there was lessening of stuttering
behavior.

Ventilation

• This is used when there is a lot of an emotional problem with the client that relates to stress.
• These emotional problems could be external pressures, internal pressures or faulty learning.
• This technique involves a lot of personal aspect of the client’s life as he will be asked to talk about
his suppressed experiences and bring down his distress.

Persuasion

• In persuasive approach the first step is to convince the client that due to disappointing experiences
he/she has come to over emphasize the speech function.
• Because of this more attention is paid to the manner of speech than to the content of speech.
• Persons overcome from the symptoms of stuttering when they acknowledge this fact by themselves.

Supportive adjuncts

• Certain evasions and defenses are taught to the client to tide over stuttering situations.
• Drawing, speaking in a rhythmic manner or in a sing-song tone, utilizing distracting sounds like ‘ah’
or a sigh prior to articulation, employing gesture or engaging in some motto act like pacing or
rubbing a watch chain purposefully, pauses and a variety of other tricks are told to the client.
• These are entirely palliative and are escapes rather than therapeutic devices

Reinforcements

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• These are potent methods to enhance the desired behavior by verbal or material reward and helps
reducing stuttering behavior.
• Onslow, Cosla and Rue (1990) did a study on 4 subjects between 3-5yrs for a period of 4-10wks;
• Technique used was verbal reward and punishment; at the end of the defined period all children
showed significant reduction on stuttering, a follow up study after 9 months showed improvements in
fluency skills of the children.
• Various studies have been done using psychotherapeutic intervention strategies to reduce stuttering,
some of them exhibited improvements while others didn’t reveal any significant benefits of the
treatment strategy.
• Etsenck in 1952 published a review of efficacy of treatment techniques in which he concluded that
results of psychoanalysis were not much better than those of reassurance, suggestion or persuasion.
• While Kurth and Schmidt in 1964 combined speech therapy with psychotherapeutic techniques and
reported significant improvements in fluency in 67% of the 32 subjects (6-13yrs)
• Dalai and Sheehan in the year 1974 used different techniques of psychotherapy to treat stuttering.
They used assertion training, feeling clarification and avoidance reduction on 8 adults respectively
for a period of 6 hrs and noted no change in severity of stuttering.
• Moleski and Tosi (1976) compared psychotherapy and behavior therapy (rational emotive therapy
and systemic desensitization) on 20 adults for a period of 8 sessions and noted that former was more
fruitful in reducing stuttering.
• In opposition to the use of psychotherapy, Forestless (1951) stated that speech therapy should be tried
first and then psychotherapy in rare cases, it should always be in adjunct with fluency therapy or
follow it.

DRUG THERAPY FOR MANAGEMENT OF STUTTERING

• Neurobiological researches (Fox et al. 1996; Wu et al. 1997; Braun et al. 1997; De Nil et al. 2000)
state that an excessive level of the neurotransmitter “dopamine” (dopamine D-2 receptor) in the
caudate tail of basal ganglia might be responsible for dysfluency producing symptoms.
• A wide variety of pharmaceutical agents have been used for treatment of stuttering.
• Prins et al. in 1980 suggested dopamine receptor antagonists as it directly affects the motor pathways
involved in producing the stuttering behavior.
• Tranquilizers have also been known to be effective as they control anxiety and tension which are
primarily related to the disorder. The effects of such drugs are more on the complexity and severity
of blocks rather than on their frequency of occurrence.

Haloperidol

• In the nervous control of the motor speech system of the brain, two particular neurotransmitters are
involved – acetycholine and dopamine.
• In general, dopamine is stored in presynaptic neurons and has an inhibitory effect on motor speech
system, while acetycholine has an excitatory effect.
• Haloperidol, a dopamine antagonist receptor, is thought to block dopamine receptors and increase the
turnover rate of acetycholine.
• The dosage is usually 0.5-4.5mg daily; 3mg is the most frequently prescribed dose.

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• However, there are side effects due to the usage of this drug; the most reported being lethargy,
drowsiness, weakness and pain in legs, blurred vision, nausea, nervousness, restlessness, dizziness,
increases urination frequency and dry mouth.
• A study on 48 individuals with stuttering from 4-41 years in age under medication of haloperidol and
triperidol was done by Lozzo and Gabrielli in 1965, which showed improvement in 33% of the
subjects.
• Studies by Andrews and Dozsa (1977) on administration of haloperidol on 15 individuals with
stuttering between age ranges of 19-29 have shown that 40% of their subjects reported a reduction of
stuttering behavior by atleast 50% within 20 days of medication.
• In another study by Burns, Brady and Kuruvilla 9 out of 12 subjects reported to be more fluent after a
single injection of haloperidol.
• Murray and Kelly at al. 1977 reported 61% improvement in fluency after the usage of the drug for a
period of 3 months amongst 18 individuals ranging from adolescents-adults.
• While there was a small benefit from the prescription of this drug, for 8 weeks, to 14 individuals
ranging from 7-41 years as studied by Prins, Mandelkorn and Cerf in 1980.

Chlorpromazine

• This is a tranquillizing drug which has been used with stutterers but sufficient data doesn’t exist for
its confident applicability and role in reducing stuttering.
• Lang in 1954 reported the use of this drug on a 15yr old mentally retarded boy who stuttered.
• Hackett, Hoffman, Macwood and Surtees (1958) studied the effect of this drug alongwith speech
therapy on a group of children.
• All children were given placebo for 6 weeks and then Chlorpromazine for next 6 wks after which
they were put into groups of 2 based on the drug administered and drugs were continued for 24
weeks.
• At the end of this period improvement in speech was noted in 80% of the active drug users’ group
while only 30% of the placebo group showed a similar improvement.
• Kent in 1963 quoted an experiment by Heaver, Franklin and Arnold who gave 4 groups of 10
stutterers Reserpine, Reserpine-placebo, Chlorpromazine and Chlorpromazine-placebo over a period
of 9 weeks.
• They reported that on assessment of fluency skills the effects of the drugs couldn’t be differentiated
from the placebo groups.
• They reported that Chlorpromazine has a similar effect as that of Reserpine and its effect is more
pronounced when used in conjunction with speech therapy.

Reserpine

• Reserpine is a useful drug for reduction of anxiety but its role on effect of stuttering is still unclear.
• Hollister in 1955 used an objective assessment to determine the effect of this drug on 6 subjects;
results were variable, i.e. two of them improved, two of them didn’t shown any improvement while
others showed similar improvement with the drug and placebo.
• Mitchell in 1955 in a study of 16 stutterers being treated with Reserpine found no improvements in
severity or frequency of blocks but there was a tendency towards easier and more overt blocks with a
subjective reporting of more control over the blocks.

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• Meffert in 1956 in a single case study found that the stutterer’s speech showed improvements due to
administration of Reserpine.

Meprobamate

• This is another group of tranquilizing drug, even its effect on speech is uncertain. But many studies
have been done to evaluate its efficacy for stuttering reduction.
• Studies done by Katz show a substantial reduction in the mean number of stuttered words in children
being treated for stuttering with Meprobamate, placebo and under no medication.
• In another study by Dicarlo et al., similar to the work of Katz, results showed a reduction in mean no.
of stuttered words in 30 patients under medication of Meprobamate.
• Maxwell and Paterson concluded that this drug helped in restoring fluency skills after studying its
effect on 18 patients. They stated that administration of the drug shortens the period for speech
therapy and enhances fluency skills.

Pentobarbitone

• This belongs to the barbitutae group of drugs and its effect on stuttering has been investigated
intensively.
• Love attempted to determine its influence on stuttering along with another drug (Benzedrine, a
stimulant) and compare them. 24 stutterers were asked to read 200 word paragraphs on each day for 4
consecutive days (different paragraphs for each day).
• During these 4 days they were given they were given Pentobarbitone, Benzedrine, placebo and no
capsule on each day respectively.
• Results showed a negative influence of all the drugs on stuttering. Benzedrine and Pentobarbitone
both failed to show any significant improvement in fluency, Pentobarbitone led to decrease in no. of
words stuttered but that was not significant, while the other drug showed no effects.
• The results of placebo and no capsule condition couldn’t be distinguished on basis of effect on
stuttering.
• Some other studies have been carried out to assess the efficacy of Thiamine (Hale, 1951) and
Glutamic acid (Hale, 1954).
• In a survey by Kent in 1961, use of carbon dioxide inhalation therapy with stutterers indicated varied
and equivocal results.
• Bioch, Dalby and Johanneses (1977), used Propanolol and it was found to b effective against
essential tremor but had no significant effect upon stuttering, but a few subjects seemed to show
improvements.
• Oxprenolol, a drug used to improve performance under stress, as studied by Rustin, Kuhr, Cook and
James (1981) didn’t show any reduction in stuttering behavior.
• Also similar result was found by Brumfitt and Peake (1988) that used Verapamil on 14 subjects with
stuttering.
• As reported Hays in 1987 in his study of effect of Benthanecol Chloride found improvements in his 2
subjects.

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