Efficacy of Stuttering therapeutic techniques

• Introduction
• Criteria for Treatment Effectiveness
• Treatment Efficacy of Various Therapeutic Approaches
• Perceptual Measures
o Frequency Measures
o Speech Naturalness
o Assessment Conditions
• Frequency Measures
• Acoustic Measures
• Cognitive, Pharmacological, Behavioral and other related approaches

• Indicators of Therapy Progress

• Increasing the clients self monitoring ability
• Increasing the clients ability to produce ‘open speech’
• Decreasing the frequency and duration of motoric fluency breaks
• Increasing the naturalness of fluent speech
• Metalinguistic changes
• Decreased avoidance
• Increased (speech) assertiveness
• Improved self concept, self esteem and role changes
Introduction
Efficacy is the extent to which a specific intervention procedure, regimen or service produces a
beneficial result under ideally controlled conditions when administered or monitored by experts
(Last, 1983).

In contrast treatment effectiveness is the extent to which an intervention or treatment employed in the
fields does what it is intended to do for a specific population.
Otswang (1990) observed that treatment efficacy is a broad term that can address several questions
related to:
 Treatment effectiveness (does treatment work)
 Treatment efficiency (does one treatment work better than other) and
 Treatment effects (in what way does the treatment alter the behavior)

Criteria for Treatment Effectiveness

Van Riper (1973), Andrews and Ingham (1972) and Sheehan (1984) summarized ten tests, which as
method of treating stuttering must meet before it can be considered successful.

1. The method must be shown effective with an ample and representative group of stutterers.
2. Results must be demonstrated by objective measures of speech behavior such as frequency of
stuttering or rate of speech and by judges rating of severity. Such measurements should be made
before, during and after treatment by observers.
3. Reports of therapeutic success must be based on repeated evaluation and adequate samples of
speech.
4. Improvement must be shown to carryover to speaking situation outside the clinical setting.
The best known but frequently ignored fact about stuttering is that is the special environment of
clinic stutterer are likely to become normal
5. The stability of result must be demonstrated by long-term follow-up investigation. The
follow-up evaluation is likely to be biased if it is done in the same clinical environment in which
treatment was administered.
6. Suitable control groups or control conditions must be used to show that reductions in
stuttering are the result of treatment. There are other variables besides adaptation to the clinical
 setting that may create a false impression of successful therapy. For eg. Spontaneous recovery
especially in children
7. Subject must sound natural and spontaneous to lustiness. Residual element of slowness,
monotony or stereotype in the subject’s speech may seen more peculiar to listeners that the stuttering
itself.
8. Subjects must be free from necessity to monitor their speech though fluency can hardly be
considered normal as long as continued attention on part of speakers is required to maintain it.
9. Treatment must remove not only stuttering but also fear, anticipation and person’s self
concept as a stutterer.
10. Success of a therapy program should not be conflated by ignoring drop out. The problems
presented by stutterers who dropout of treatment has been pointed out by Martin (1931). Estimates of
the improvement during therapy are often based exclusively on those who complete clinical program.

Treatment Efficacy of Various Therapeutic Approaches

I. Perceptual Measures

a. Frequency Measures

Frequency measures are calculated in terms of percentage of syllables / words (%SS or %WS) usually.
In order to obtain %SS or %WS scores, the number of syllables / words is counted along with the
number of words / syllables that are stuttered. For outcome research frequency measure is most
acceptable because large differences are of interest. The following table shoes the results of various
studies that used percent of dysfluency as a measure to depict the outcome of prolonged speech
procedure, gentle phonatory onset, and smooth flow of speech. The Results of all these studies
indicate that the post-treatment mean percent dysfluency reduced significantly to less than 5%, which
is considered as normal.
Prolonged Speech
Author No. Of Age of Duration Results
Subjects Subject of
s Treatment
Spencer (1976) 5 Adults 4 months Stuttering was reduced to less
and than 1% of syllables
children
 Boberg (1976) 21 17 – 44 3 weeks Stuttering decreased from mean
of 21% of syllables to 1.3%
Franck (1980) 68 Mean of 1 year 95% of subjects increased fluency
20.2 by 60% or more
years
Boberg (1980) 6 16 - 46 3 weeks Mean percent syllables stuttered
years decreased from 16.55 or more
Howie, Tanner & 36 Adults 3 weeks Stuttering was virtually
Andrews (1981) eliminated
Eveshen and 47 Adults 3 weeks 91% stuttered on less than 1% of
Huddles (1983) syllables
Boberg (1984) 12 18 -47 2 weeks Mean percent of stuttered
years syllables decreased from 18.9 to
0.9

Gentle Phonatory Onset

Author No. Of Age of Duration Results

Subjects Subject of
s Treatment
Webster (1975) 56 8-59 3 months Significant difference in pre-post
years treatment
Schwartz and 29 9-50 3 weeks 97% improved, 72% stuttered on 6%
Webster (1977) years or less of words
Webster (1980) 200 3 weeks Mean percent of words decreased
from 15.1 to 1.3
Mallard and 50 14-50 6 weeks Mean percent of words fell from
Kelly (1982) years 20.05 to 2.92
Schulman (1983) 85 6-65 4 weeks 84% achieved normal or near-
years normal fluency in conversation
Franken, Bover, 32 15-46 3 weeks Mean % of stuttered syllables
Peters and years declined from 25.7 to 5.8
Webster (1992)
Onslow, Costa, 12 10.7- 3 weeks Within clinic and beyond clinic % SS
Andrews (1996) 41.6 reduced generally to near zero
years

b. Speech Naturalness

The adjective natural is derived from the Latin word naturalis, meaning ‘of nature’. The impetus for
studying speech naturalness of individuals treated for stuttering came from observations that though
the frequency of stuttering decreased, listeners found that many speakers continued to sound
unnatural. Their speech was effortful, uncomfortable to listen to, and contained auditory or visual
features that prevented listeners from fully attending to the content of message

Author No. Of Subjects Age of Results

Subjects
Ingham and Packman 9 adolescents and 13-24 Listener’s ratings of
(1978) adults compared with naturalness of clients recived
9 age matched significantly fewer normal
normals speaker judgments
Martin et al, 1984 10 adults without • 20-53 Both group of stutterers
DAF sounded less natural than the
10 adults with DAF • 20-51 normals
10 normals

• 21-45
Ingham and Onslow 5 Adolescent Predicatble trends in speech
(1985) 9 – point rating s naturalness
scale for speech Stutterers speech naturalness
naturalness could be modified to targeted
levels
Ingham, Gow & Costello !5 stutterers and 15 Mean naturalness rating if
(1985), 9 – point rating normals matched for 4.26 for stutterers and mean
scale of martin age and gender value of 2.39 for non-
stutterers
Metz, Sxhiavetti, Sacco 15 males, 15 females Mean 14.5 Strategies like gentle voicing
(1990) 9- point rating years onset and prolonged speech
scale may slow the post therapy
speech patterns and the may
influence listeners to judge
speech of stutterers to be
more unnatural
Onslow, Hayer and 36 9-50 years Most severe clients’ speech
Newman (1992) prior to treatment and
Considered the effect of naturalness scores more than
 severity on pre and post 2 values higher (less natural)
treatment naturalness than least severe clients.
ratings
Onslow, Adam and 7 male stutterers and 14-36 No significant differences in
Ingham, 1992 compared 7 normals years the naturalness scores of
the influence of conversation / monologue for
monologue and either stutterers or normals
conversation speech. 9 –
point rating scale
Martin and Horoldson, 6 males and 4 20-62 Naturalness judgments of
1992 studied visual females (stutterers) years fluent speakers were not
components of stuttering 6 males and 6 significantly different for
related to speech females (normals) 21-64 audio and audio-visual
naturalness judgements years samples on rating scale (2.3-
used 9-point rating scale 2.7 respectively) but
audiovisual samples were
judged to be more unnatural
than audio only
Finn and Ingham, 1994 11 males and 1 Adults (19- Stutterers gave valid self
(Stutterers self rating of female 71 years) ratings of speech quality and
naturalness) were consistently able to
differentiate how natural
their speech were

Other naturalness rating scales were developed by Subramaniam (1997) and Kanchan (1997).
Subramaniam scale included confidence, command over language, clarity, speed of stuttering and
overall rating. It was a binary scale for both natural and unnatural items. Kanachn’s scale was also a
binary one which included rate, continuity, effort, stress, intonation, rhythm, articulation, breathing
pattern and overall rating. Currently the 9 – point scale developed by Martin et.al 1984, has been
widely used and reliable for either oral reading or spontaneous speech.

c. Assessment Conditions:
Ideally the speech samples should be obtained under multiple conditions and on multiple occasions
(Conture, 1996). Speech measures should be collected without client’s knowledge that their speech is
being evaluated so that they do not react to being assessed and try to create a favorable outcome and
speech outcome measures should reflect everyday speech performance free from stimulus controls.
The following table summarizes assessment conditions used in prolonged speech therapy technique.
Author N Stutterin Spe Speech Freq of Situation Nature
g Severity ech task Assessme
rate nt

Andrew 23 %SS SP Monologue 4 times in Within Overt

and M 18 months and and
Ingham, beyond covert
1972 clinic
Howie, 36 %SS SP Phone Twice in 9 Within Overt in
Tanner and 43 %SS M conversatio weeks and both
Andrews, SP n in both beyond conditio
1981 M groups clinic ns

Webster, 200 % of - Reading, Twice in Within -

1980 dysfluenci conversatio 10 months and
es n on phone beyond
clinic
Boberg, 16 %SS - Reading, 3 times in Within -
1981 conversatio 12 months and
n on phone beyond
clinic
Andrews 37 %SS SP Phone Twice in Within -
and Feyer, M 12 months clinic
1985
 Andrews 84 %SS SP Phone Twice in Within Overt
and Craig, M 18months clinic
1988
Boberg and 42 %SS SP Phone 4 times in Within Overt
Kully, 1994 M 24 months clinic

Many of the Speech outcome data are based on single within clinic situations / telephone calls from
staff in clinic, where the clients may be able to control their stuttering with a pronounced speech
pattern that cannot be used in everyday speaking situations.

Long term Efficacy of Prolonged Speech Measure

In a literature review of current clinical status of fluency following treatment for stuttering, Boberz
and Kully 1985 concluded that though the treatment procedures such as prolonged speech may
reduce / eliminate stuttering, the long term effects were not satisfactory.

Author Method N Age Duration Results Follow-up Results

of interval
treatmen
t
Webster Prolonged 200 - 3 weeks Mean % of Mean of 10 Mean % of stuttered
(1980) speech stuttered months words was 3.2
words
reduced
from 15.1 to
1.3
Boberg Prolonged 6 16-46 3 weeks Decreased 12 months Mean % of stuttered
(1981) speech years from 16.55 syllables of 8
or more subjects was 1.53 at
end of 12 months
maintenance period
Honie, Prolonged 36 Adult 3 weeks Stuttering 2 months Little significant
Turner and speech s virtually deterioration
Andrews, eliminated
1981 in 5
subjects
Mallard Gentle 50 14-50 3 weeks Mean % of At least 6 Mean % of stuttered
and Kelly, phonatory stuttered months words for 28 subjects
1982 onsets words fell was 9.74
from 20.05
to 2
Heller, Gentle 85 6-65 6 weeks 84% 6 months to 80% maintained
Schulman, phonatory achieved 5 years their post treatment
Teryak, onsets normal to fluency levels
1983 near
normal
fluency in
conversatio
n
Craiz and Smooth 17 Adult 3 weeks Mean % 10 months Mean % stuttered
Andrews, flow s declined syllables was 1.9%
1988 speech from 12.9-
0.9
Andrews Smooth 37 21-60 3 weeks Mean % 10-15 Mean % stuttered
and Feyer, flow declined months syllables was 1.1%
1985 speech from 14.1-
0.1
Frank et al, Gentle 32 15-46 4 weeks Declined 6 months Mean % stuttered
1922 phonatory from 25.7 to syllables was 16.3%
onsets 5.8
Boberg and Prolonged 16 3 weeks 12-16 Mean % was 6.38
colleagues, speech months outside clinic, 1.86
1987 in reading, 2.54
conversing with
strangers
II. Acoustic Measures

The use of a novel speech pattern to eliminate stuttering is a speech motor adjustment, and temporal
aspects of motor activity are reflected in temporal pattern of acoustic activity (Bover 1987, Cent
1999). Discovery of functional acoustic components of speech patterns could lead to development of
more cost and time effective treatments for advanced stuttering (Onslow and Ingham, 1989). Ingham
in 1983 highlighted that stuttering could be reduced with the use of acoustic data feedback. Many
other problems and issues could be resolved with the discovery of functional acoustic components of
treatments based on prolonged speech. But it is unclear which acoustic feature of speech patterns in
these treatments has a functional relationship to stuttering frequency. Additionally these patterns may
be similar / different across subjects.

Almost all the studies on acoustic analysis of speech of stutterers are in adults. Results of the studies
can be summarized as:
Authors Treatment No. Of Acoustic Results
Procedure subjetcs analysis
Metz et.al, Instructed to “slowly 9 Increased Indication that stuttering
1979 initiate phonation duration for therapy could alter certain
and maintain a both vowels and acoustic properties of
forward flow of air stop consonants stutters’ fluent speech
and reduce increased
articulation rate”
Metz et.al, Examined 12 males, 5 Analysed CVC Decrease in stuttering
1983 relationships females duration, VOT, frequency,
between acoustic absolute time of Increase in voiced and
variables and fluency frication, voiceless VOT duration,
within a group of voicing and Increase in frication
mild to severe silence duration,
stutterers associated with Voicing duration and no
intervocalic significant change in
intervals of both silence associated with
 voiced and intervocalic intervals
voiceless stop
consonants
Mallard Precision Fluency 26 Analysed vowel • On an average persons
and Shaping Program duration with stuttering increased
Westbrook (PFSP) changes and vowel duration.
, 1985 also phrase • Vowel duration
duration decreased as stuttering
moved from initial to final
part of phrase
Mohan Investigated acoustic One, 17 • Presence of atypical
Murthy and aerodynamic year old transitions
(1987) measures of /g/ subject • Inappropriate voicing
before and after and duration of segments
modified airflow inspiratory frications
techniques and soft • Articulatory fixations
contacts • Abnormal articulatory
constrictions
• Longer closing phases
on Lx- excessive vocal
adduction
Franken, Precision Fluency Men of 32.4 Prosodic Decrease in expressiveness
Bover, Shaping Program years features
Peters and (PFSP)
Webster,
1991
Onslow, Prolonged speech School VOT, Voice Decreased variablility in
Van aged duration, and vowel duration
Doom, children interphonation
Newman, interval
1992
Madhavila Instruction to initiate 1 normal Analysis of Reduced Fo range and
 tha, 1997 intonation patterns (model), 10 different longer sentence duration in
depicting emotions stutterers intonation stutterers, also other
such as anger, patterns frequency and amplitude
surprise, sarcasm, perceptually parameter
command, question and acoustically
and statement
Ananthi, Prolongation therapy 1 normal Analysed word No significant difference in
2002 (model), 10 stress, word stress and word duration
stutterers duration, peak
Fo, Lowest Fo
and Fo range

III. Cognitive, Pharmacological, Behavioral and other related approaches

1. Electromyographic Feedback (EMG)

The subjects were provided with visual feedback about selected muscle activity.
Authors Age Stuttering Frquency < 5% Social, eotional or cognitive
variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Craiz & 10-14 Yes Yes - -
Cleary, 1982 years
Graiz et.al , 9-14 Yes Yes Yes Yes
1996 years

2. Gradual increase in length and complexity of utterance

A program which progressed from 1 word response to oral reading, monologue and concersational
tasks mainly worked out with children.
Authors Age Stuttering Frquency < 5% Social, eotional or cognitive
variables improved
 Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Ryan and 7-18 Yes Yes - -
Ryan, 1983 years
Ryan and 7-17 Yes Yes - -
Ryan, 1995 years

3. Metronome conditioned speech retraining:

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Ost et.al, 14-46 No No No No
1976 years

4. Prolonged Speech

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Craiz et.al, 1996 9-14 Yes Yes Yes Yes

Howie et al, 21+ Yes - Yes -

1961
Ingham, 1982 18 Yes - - -
-20
Ingham and 18- Yes - - -
Andrews, 1973 56
Ingham, 2001 18- Yes - - -
28
Ingham and 42 Yes Yes - -
Packman, 1977
 James et. Al, 34 Yes Yes Yes Yes
1989
O’Brian et. Al, 1759 Yes - - -
2003
Onslow, 1996 10- Yes Yes - -
41
Perkins et.al, 12- Yes No - -
1974 52
Ryan and Ryan, 7-18 Yes - - -
1963
Ryan and Ryan, 7-17 Yes Yes - -
1995
Tanbaugh and 12 Yes Yes - -
Guitar, 1961

Conclusion: Most of the above studies showed 50% reduction in stuttering frequency

5. Regulated Breathing and airflow

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Andrews and 26 No - Yes -
Tanner, 1982a
Andrews and Adult Yes No Yes Yes
Tanner, 1982b s
 Landoucer, 1981 15-47 Yes - - -

Landoucer, 1982 17-74 No - - -

Landoucer and 5-16 Yes - - -
Martin, 1962
Landoucer and 18-36 Yes Yes No No
Saint Laurent, 1986
Mittemberger et.al, 19-27 Yes Yes - -
1996
Landoucer and 18-50 Yes No - -
Saint Laurent, 1987
Franken, 2005 6 Yes - - -
Harrison, 1999 5 Yes Yes - -

Ingham, 1980 9-23 Yes Yes - -

James et.al, 2005 3-6 Yes - - -

Lattermann, 2005 4-5 Yes - - -

6. Response Contingencies:

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Wilson et.al, 3-5 Yes Yes - -
2004
Franken, 2005 6 Yes - - -
Harrison, 5 Yes Yes - -
1999
Ingham, 1980 9- Yes Yes - -
 23
James et.al, 3-6 Yes - - -
2005
Lattermann, 4-5 Yes - - -
2005

7. Self Modeling of Fluent Speech

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Bray and 13- No - - -
Kehle, 1996 17

8. Shadowing

Otz et.al included 4 steps: Chronic reading, with clinician, changing text, immediate shadowing,
delayed shadowing and whispering

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Otz et.al, 14- No No No No
1976 46

9. Token Economy
 Authors Age Stuttering Frquency < 5% Social, eotional or cognitive
variables improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Ingham and 18- No - - -
Andrews, 1973 56

Indicators of Therapy Progress

Main indicators of therapy progress include:

1. Increasing the clients self monitoring ability

2. Increasing the clients ability to produce ‘open speech’
3. Decreasing the frequency and duration of motoric fluency breaks
4. Increasing the naturalness of fluent speech
5. Metalinguistic changes
6. Decreased avoidance
7. Increased (speech) assertiveness
8. Improved self concept, self esteem and role changes

Increasing the clients self monitoring ability

A basic indicator of progress is the speaker’s ability to tuning tuning into what he is doing when he
stutters and what he is capable of doing in order to enable himself to speak fluently. Even if he is not
able to modify his production he may be able to accurately monitor what he is doing to make
speaking so difficult. Accurate self monitoring of any behavior or thought process is a preparatory
step toward taking responsibility and transforming the event.

Self monitoring will continue to be a critical element of long term success. During the initial stages of
treatment, the clients monitoring is focused on the overt stuttering behavior. Although the focus early
in treatment is on monitoring rather than the modification of stuttering events, as speaker improves
his ability to catch his behavior nearer to the initiation of the stuttering event, some instinctive and
positive changes in the stuttering often take place. That is the speaker will not only recognize what he
is doing to make speaking difficult, he will begin to make some changes in the behavior. He may
 provide himself with some airflow, or he may slightly decrease a constriction in his vocal tract that
will assist him in smoothening his speech. These changes are small and transient victories to be sure,
but the clinician should look for them and reward these subtle changes in the form of stuttering. As
Conture (1990) indicates, the client’s consistent identification at the beginning or the middle of
stuttering events sometimes becomes associated with his ability to change his stuttering behavior.

As treatment progresses, such self monitoring activities continue to be pivotal for long term progress
outside the treatment environment. In addition, self evaluation also comes to mean the monitoring of
the cognitive aspects of change, such as the self talk the client provides to himself prior to and
following successful, as well as less than successful, speaking situations.

Increasing the clients ability to produce ‘open speech’

Improvement can be observed during every treatment session by the clinician and the client if close
attention is paid to the form of fluency breaks. Early in treatment the fluency breaks are typically
characterized by a greater degree of vocal tract constriction and effort. As the speaker begins to
understand the nature of his speech production system and becomes able to modify moments of
stuttering, progress can be observed in the form of airflow, increased smoothness and blending of
sounds and words. Perhaps most importantly he begins to produce speech with less vocal and
articulatory effort. As he becomes able to monitor his production, especially via proprioceptive
feedback, he will be able to appreciate the difference between the tension and constriction of old way
of speaking and the new flowing and effortless production using an open vocal tract. The speaker as
well as listener can hear the increased openness and ease of such speech movements. At each such
occurrence of enhanced airflow and smoothness of articulatory of movement, there is the opportunity
for the clinician to reward the progress. The client’s speech may not be completely fluent, but the
changes are obvious and satisfying. The result is a much easier form of stuttering. As Conture (1990)
suggests, a shortening in the duration of stuttering is a sign of progress. The client is stuttering, to be
sure, but it is the speech that is produced with less effort and is much easier to listen to.

Decreasing the frequency and duration of motoric fluency breaks

Decreasing the frequency of motoric fluency breaks is an obvious goal of treatment and a commonly
used indicator of progress. As the speech becomes more open and flowing, both the frequency and
 especially the duration of stuttering movements should show some obvious changes. It may be that
the frequency of brief stuttering events may even increase somewhat if the speaker is successful in
changing in his patterns of avoidance and word substitution. However, if the duration and associated
tension in terms of both the degree and the sides of physical tension decreases, real progress is being
accomplished. Again, this progress will be likely to be recognized by the speaker if self monitoring is
maintained.

Increasing the naturalness of fluent speech

The impetus for studying the speech naturalness of individuals treated for stuttering came from
observations that many people who had undergone successful treatment using fluency modification
strategies continue to sound less than satisfactory. That is although, the frequency of stuttering had
decreased dramatically, and listeners found that many speakers continue to sound unnatural. Their
speech was effortful, uncomfortable to listen to and contained auditory or visual features that
prevented the listener from fully attending to the content of the message. Despite an otherwise
successful treatment experience, many speakers found that they were still regarded by themselves
and others as having the problem.

Naturalness Rating Scale

In 1984, Martin, Haroldson and Triden began the development of a reliable scale for rating speech
naturalness. The scale consisted of a 9-point rating scale with 1 equivalent to highly natural sounding
speech and 9 equivalents to highly unnatural speech. This scale has been used in virtually all
subsequent investigations of speech naturalness.

Martin had 30 listeners use the scale to assess the speech naturalness of 10 adults who stuttered
speaking without DAF, 10 adults who stuttered speaking under DAF, and a group of 10 normal
speaking adults. They found that both groups of speakers who stuttered sounded significantly less
natural than the non stuttered sample. The mean naturalness rating of stutterers was 6.5, stuttering
group under DAF received an mean of 5.8 and non-stuttering group had a mean of 2.1. Based on inter
rater agreement and rater consistency, Martin concluded that observers are able to quantify speech
naturalness.
 VOT and sentence duration were found to be significantly related to and predictive of speech
naturalness, with the VOT values being most predictive of naturalness during spontaneous speech
and duration was the primary predictor of naturalness during reading.

Metalinguistic Changes

The way a person depicts his situation or problem often indicates important signs of progress during
treatment. As people progress through effective treatment, they begin to think and talk differently
about themselves and their speech. The intrinsic features of affective and cognitive change are
reflected in the words the client uses to describe himself, his speech, and his interaction with others.
How the client talks about himself and his speech provides a window for viewing these intrinsic
features.

Early in treatment the client typically feels helpless. He believes he is unable to do much to change
his speech or himself. There is a high degree of mystery associated with stuttering. AS treatment
progresses, client slowly begins to develop the language of fluency. As well as use more appropriate
self talk. As the client begins to successfully change his previously uncontrollable behavior, he will
begin to change the way he observes himself and his speech moreover, he will begin to describe his
behaviors and actions in more specific and realistic ways. The client will begin to interpret stuttering
as something that he is doing rather than happening to him.

These metalinguistic changes provide the clinician with important evidence of change and indicate
that the client is beginning to take charge of the problem. Such utterances may be used as a way to
monitor cognitive changes or in some cases; the clinician can take a more active role and point out to
the client how he is describing himself and his problem. The client’s language will reflect some
degree of liberation from the problem. That is coinciding with the fact that the speaker shows a great
degree of fluency, they are more liberated in terms of their choices and have a greater involvement in
life.

Decreased Avoidance

As avoidance decreases, the frequency of fluency breaks may increase. Early in treatment less
avoidance and greater participation in speaking activities may yield a slight increase in the frequency
 of stuttering. There may even be an increase in the duration and tension of stuttering events.
Although these changes may not be pleasant to the client, if stuttering modification strategies are
being used, they can be viewed as progress within the context of the overall treatment process.
Taking part in activities and making better choices may not be the first step for each client, but it is
always a critical step. Furthermore, a decrease in the avoidance behavior permits the client to go
directly at the problem and the associated fear.

Increased (Speech) Assertiveness

With a decrease in avoidance behavior, there is likely to be a corresponding increase in overall

assertiveness. In reality being more assertive about once speaking behavior is likely to translate into
increased assertiveness in general. There may be changes in roles and a relationship as the persons no
longer plays the primary role of a stutterer. It is a distinctive indicator of progress when the speaker
begins to decrease his reflexive self censorship and begins to consider many speaking situations h
once considered unimaginable. This is not to say that he will now take part nonetheless and to
consider new opportunities is a significant measure of progress.

Improved Self-Concept, Self-Esteem and role changes

Self-Concept and Self-Esteem have been referred to many times in the literature on fluency disorders.
According to Peck (1978), self esteem is the corner stone of psychological change. Although persons
who stutter have not been found to have a unique self esteem or to be lacking in self esteem, this
concept has frequently been mentioned as an aspect of treatment programs. When the client
experiences success in the self management of surface and intrinsic aspects of his fluency disorder,
self esteem and the self concept begins to shift in positive direction. This is certainly the case with
children who are still in the process of developing their self concept. Of-course this is a major reason
why intervention for fluency problems is much more likely to result in long term success in these
groups of clients. Adults are also able to make big changes that are reflected in a changed view of
themselves during and following treatment. They are able to redefine themselves and create an
altered paradigm of their lives. Such changes can be quantified by self reports during individual and
group treatment sessions as well as by measures such as the locus of control.