APPROACHES TO MANAGEMENT OF FLUENCY DISORDERS - PDF / KUNNAMPALLIL GEJO

APPROACHES TO MANAGEMENT OF FLUENCY DISORDERS KUNNAMPALLIL GEJO JOHN,MASLP
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BEHAVIORAL COGNITIVE INSTRUMENTAL
AND
ALTERNATIVE METHODS
The need for early identification and treatment of stuttering
2 schools of thoughts:
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KUNNAMPALLIL GEJO JOHN
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) to one to several months/years or 140 hours for adults (Van Riper, 1973; Webster, 1974) and is reported to be dependent on the chronicity of the problem;
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(2) Reported rates of success is higher (>90%) compared to that for adults (50-75%) (Franken, 1988; Starkweather, Gottwald and Halfond 1990; Webster, 1974);
(3) Relapse rates 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 Kully, 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);
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(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 will not recover spontaneously as given above, they are not fool proof;
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(6) The impact of stuttering problem on the young minds to live with it could be quite handicapping emotionally, socially, educationally and vocationally as reported by many PWS.
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Decisions regarding treatment of stuttering:

The clinicians have to make decisions regarding whether treatment is required or not; should it be direct or indirect (in case of CWS) or both; intensive or extensive or both; approximate duration of treatment needed; what are the prognostic indicators in a given client and so on. These aspects have to be communicated to the clients or the caregivers. 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:
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Steps in the treatment of stuttering:

Establishment of fluency
Traditional approaches Cognitive approach / cognitive restructuring Behavior therapy approach Emotional or affective approaches Instrumental approach Supportive approach
Transfer/ generalization of fluency Maintenance 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.
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Many novel ways of speaking reduce disfluencies. 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:
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a. Traditional approaches:
Voluntary stuttering/stutter fluently techniques, prolongation or many of its variants, cancellation, pullout, preparatory sets, soft/loose contacts, relaxation, airflow therapies, Shadowing are to name a few of the traditional techniques being used for decades with varied success.
b. Cognitive approach/Cognitive restructuring:

PWS are made to realize how and why the stuttering problem varies and how they can 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 restructuring principles.
c. Behavior therapy approach:

Although the cause of stuttering is not very well understood, recent theorists emphasize nurture or environmental factors to contribute as maintaining factors in stuttering. Appropriate reinforcement procedures to facilitate fluency and punishment strategies like the Time out, Response Cost to reduce disfluencies 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 behavior is discontinued). Further, in clients with anxiety traits, progressive relaxation combined with systematic desensitization procedures could be very effective.
d. Emotional or affective 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.
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e. Instrumental approach:
Mechanical or electronic devices and various equipments are available for establishing fluent speech in the clinical set up. Metronome, EMG Biofeedback, Masking, DAF, FAF, Dr. Fluency are some of the devices, which will help PWS to gain confidence in speaking fluently. Some portable wearable devices like 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 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 pretherapy assessment would help in this exercise. Maintenance of logbooks or diary is necessary to monitor progress achieved in day-to-day practice. PWS should be encouraged to self-monitor and selfcorrect 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 that is achieved. After intensive and extensive practice sessions, the frequency of treatment sessions should be gradually reduced to make follow up or booster sessions to monitor the maintenance of fluency.
Counseling and guidance:

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 he possesses.
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Developing stronger belief in coping with stuttering. Anticipating more fluency than disfluency. Becoming less embarrassed or 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.
Group counseling and group therapy procedures are very useful in the management of PWS in addition to individual therapy approach.
Some of the advantages of group therapy include instillation of hope, promotion of universality, imparting of information, possibility of catharsis, development of existential issues.
Adjuncts to speech therapy:

The concept of stuttering being treated or alleviated by resort to 'outside agencies' has been popular with stutterers.
These outside agencies have taken many forms, from swallowing of various substances to using many types of mechanical or electronic devices.
The stutterer himself often shows considerable faith in these aids, and the therapist, while recognizing the importance of the interpersonal aspects of this disorder, may employ such aids as adjuncts to a more comprehensive treatment program.
If the aim of therapy is initially the achievement of fluency then the use of these adjuncts can be very beneficial.
Many such adjuncts have been described for the treatment of stuttering but only a few of those are currently in use. These are considered to be representative of the machines, swallowing of substances etc used.
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Edinburgh masker - has created interest in the use of auditory masking machines. Biofeedback machines - interest in the use of relaxation-based treatment approaches. Use of hypnosis and drugs - has continued to intrigue stutterers and clinicians.
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Auditory Masking
One effect of high intensity white noise for stutterers is that the frequency of disfluency is reduced.
Van Riper (1973) discusses accounts of 'therapeutic deafening' written half a century ago, although at that time its use was not confined solely to stuttering.
Interest in the relationship of hearing and stuttering was aroused in 1912 by a report of Guzzmann (referred to in Wingate 1976) stating that the congenitally deaf never stutter.
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The presence of stuttering has been noted among the-deaf and hard of hearing population but the incidence is much lower than amongst the normal hearing population (Harms and Malone 1939). Following this finding the next step would involve the experimental reduction of hearing level in stutterers.
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Noise characteristics:
When a very loud masking noise was used, it was sufficient to over come bone conducted self-hearing; there was a very substantial reduction in stuttering. They eliminated first the high frequency components of the noise and then the low frequency components and concluded that the latter was more effective. (Cherry and Sayers, 1956)
Ham and Steer (1967) masked frequencies of below 800 Hz and found increased fluency.
While, Stromsta(1958) noted that disflueney was decreased when frequencies of below 500 Hz were masked.
Dewar, Dewar and Barnes (1976) described the Edinburgh masker, which has a frequency range of 100-140 Hz (the frequency of vibration of the vocal cords).
Low frequency masking is necessary but there is no evidence that any specific frequency range is the most effective for stutterers.
Most reports on the intensity of masking noise conclude that the noise level must be sufficient to overcome bone-conducted hearing. Maraist and Hutton (1957) using masking level of 30,50, 70 and 90dB found a progressive decrease in stuttering as intensity of masking noise increased with considerable decreases above 50 dB.
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Ham and Steer (1967) returned the stutterers speech signal at intensities of 30, 45, 60 and 75 dB above the individual speech reception thresholds and found that only the 60 and 75 dB increases were associated with a significant reduction in stuttering. Adams and Hutchinson (1974) have confirmed the general finding that stuttering decreased as noise level increased.
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Continuous Vs Contingent Masking:

Masking noise presented to stutters has been continuous and triggered by a manual switch, which was under the conscious control of the subject.
Sutton and Chase (1961) used the stutterer's phonation to activate the masking noise. They created two conditions of masking,
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Viz., masking was presented only when the stutterer was phonating and masking was presented only during intervals of silence.
They compared the results with those of the continuous masking and found that fluency was improved in all conditions and that masking during silence was just as effective as even continuous masking or masking only during phonation.
Dewar, Dewar and Barnes (1976) produced the Edinburgh Masker, which incorporates a device for triggering the masking sound by means of a laryngeal microphone switch.
It is activated only when the subject initiates phonation and claims have been made that stutterers have obtained considerable benefit from this.
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Effect of Masking:
Garber and Martin (1974) Aim: To determine the effect of slightly longer period of exposure to masking noise.
They asked 3 stutterers to speak for 50 minutes, during which time they received while noise presented binaurally in alternate 5minute periods. All subjects experienced a decrease in stuttering frequency during the first 5-minute period, in which 100 dB noise was presented.
Over longer periods of time while using a tone with an intensity of 100 dB,
one subject increased and one subject decreased stuttering slightly. the frequency of
Third subject showed a significant decrease in stuttering frequency.
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Ingham, Southwood and Horsburgh (1981)

Aim: Evaluate the effects of masking noise over a longer period of time and they required 4 stutterers to read and speak spontaneously during eight 30 minute sessions, 2 hours with the Edinburgh masker and 2 hours without.
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Result:
Stuttering was absent during masking for only one subject. While, another subject showed some improvement during spontaneous speech only. The remaining 2 subjects displayed only marginal reductions in stuttering during spontaneous speech or oral reading. The fact that some stutterers can maintain some increase in fluency with masking noise has led to the development of portable masking machines to assist transfer of noise-induced fluency.
Portable Maskers:
Parker and Christopherson (1963) designed the unit originally to assist stutters to speak more freely during psychiatric examination, but later considered that this device could be useful for the treatment of the stutter itself. This machine was considered only as an adjunct to other types of therapy, e.g. sleep therapy, psychotherapy, etc.
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Gruber (1971) also found the masker to be useful when considered as an adjunct to therapy. She combined the use of the masker with a treatment technique described by Van Riper (1963) and trained her subjects to activate the masker when learning to pull out of a block.
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Aim was to shift the stutterers self-monitoring from auditory to tactile and proprioceptive channels. While using the masker none of the stutterers obtained stutter free speech and although the frequency of stuttering remained approximately the same, there was a significant reduction in the severity of the block.
There have been variations on the type of masker used.
Perkins and Curlee (1969) experimented with a masking device, which generated a pulsing signal with variable rate and intensity and compared this with an unfiltered white noise unit.
Their subjects were 3 stutterers who were in the final phases of conversational rate control therapy and used these devices to assist transfer of fluency to situations outside the clinic.
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All subjects reported that stuttering was decreased with both units, though 2 subjects preferred the pulsed noise to the white noise. A pulsed signal was also used by Donovan (1971), who developed a device, which combines a pacemaker and masking sound.
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Difficulties:
Like so many devices, difficulties have been reported in the use of masking for treatment of stuttering. Wingate (1976) has commented that stutterers do not adapt to the use of this device even on an intermittent "as needed" basis, or sometime, inappropriate reactions are elicited from others who may erroneously believed that the stutterer is deaf and shout to him.
Van Riper (1973) has also noted that some patients tended to press the switch to activate the masker either too soon or too late and even when the therapist turned on the noise, his reaction time delayed the contingent sound.
Voice activated masking devices would seem to be useful here. But concern here is longterm effect on the stutterers hearing.
Dewar et al., (1979) have found no evidence of temporary threshold shift.

The role of masking noise in therapy:

Despite the difficulties, masking devices could be regarded as useful adjuncts to therapy specifically:
To shift the stutterers attention from auditory to tactile/proprioceptive monitoring of speech (Gruber, 1971). To encourage the stutterer to monitor speech without recourse to the auditory channel or to give him confidence or the feeling of fluency in difficult speaking situations.
Dewar et al (1976) have noted that masking noise may also help to reduce concomitant movement of stutterers. Effective with children the effect being maintained after the device was removed (Mac Culloch, Eaton and Long 1970)
However, there is a paucity of information on the long-term effects on auditory masking on child stutterers.
DAF therapy:
The program consists of several steps to teach the patient
to read, engage in monologue, and converse in slow, prolonged fluent pattern with the aid of delayed auditory feedback apparatus.
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The first 6 steps are to teach the patient to correctly identify stuttered words in reading and monologue. Criteria of 1min and 90% accuracy of identification are used in these stages.
The next 7 steps involve reading and use DAF starting with 250msec of delay, which is gradually reduced in 50msec steps until the patients can read in the prolonged fluent pattern without the DAF equipment.
The next 7 steps are to use these in monologue and then the final 7 steps are the same except that these are in conversation. The patient has to reach to a criterion of 5 min of fluency in each of the 21 steps to pass. Verbal reinforcement such as "good" is administered for the completion of the steps. The program also includes transfer of the technique.
The four main types of auditory feedback are:

Delayed auditory feedback (DAF) delays the voice to your headphones a small fraction of a second (typically 50 milliseconds). Frequency-altered auditory feedback (FAF) shifts the pitch of your voice in your headphones, typically one-half octave.
Laryngeal auditory feedback (LAF) provides the sound of your vocal fold vibration to the ears. Synthesized auditory feedback (SAF) provides a synthesized tone which sounds like your vocal fold vibration. The popular Edinburgh Masker device provided SAF.
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All four types of auditory feedback reduce stuttering about 80%.

The devices require no training or mental effort. The client's speech sounds normal and can talk as fast as he/she wants.
But without the headphones the fluency right back to stuttering. But with few exceptions, stutterers don't prefer to wear a prosthetic device all the time. They want to overcome stuttering.
Hence, auditory feedback devices should be used in conjunction with stuttering therapy. The stutterer should switch off the device for short periods and continue to use fluency techniques. The stutterer then switches off the device for longer periods, until he no longer needs the device.
Establishment and Trainer (CAFET)

This monitors the breathing and voice. The computer trains the client to inhale gently, let out a little air, begin voicing quietly, and gently increase the vocal volume (gentle onset). The computer provides instant, accurate information on what the client's doing whether right or wrong always with a continuous feedback.
The Computer-Aided Fluency
Metronome:
A metronome is any device that produces a regulated audible and/or visual pulse, usually used to establish a steady beat, or tempo, measured in beats-per-minute (BPM) for the performance of musical compositions.
Stutterers can speak fluently when they time their speech to the rhythmic beat of a metronome. Although metronomes have been widely used for the treatment of stuttering, their effect is reportedly difficult to transfer to daily life.
Pocket fluency system:

It is used 1 hour each day in most stressful conversations. DAF and FAF help to slow down and stay in control of the voice, so that the client can maintain the fluency. Then carryover fluency is maintained without the device in easier conversations later in the day, Overtime, need for use of the device will be reduced, until he doesn't need to wear it at all.
Desktop fluency system:

Vocal tension biofeedback displays green light when the client's speaks with relaxed breathing, vocal folds and lips, jaw & tongue. A red light alerts when the client tenses the speech production muscles. DAF and FAF help to slow down and stay in control of the voice. Professional who is on the telephone at least one-hour per day and whose most stressful conversations are telephone calls, experience carryover fluency the rest of the day and don't need to wear a device.
School DAF: Used to slow down and improve control of speech. It is pocket sized and easy to use.
Telephone fluency system: for adults who only need fluency on the telephone, and don't want the advanced therapy features of the desktop fluency system, this provides delayed auditory feedback and frequency-shifting auditory feedback.
Voice changer: provides frequency-shifting auditory feedback in 3 playful voices: robot, alien and ghost.
Immediately makes stuttering children fluent and makes shy children talk, helpful for diagnosing language disorders. The child hears his voice in headphones the clinician hears only the child's natural voice.
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Bio feedback training:

As struggle behavior plays an important role in stuttering, the use of relaxation techniques in the treatment of this disorder has been known to produce fluency.
It not only aims to inform the patient of the degree of tension present in the muscle groups, but also of the effectiveness of his strategies for reducing this tension.
The most widely used biofeedback machine for the treatment of stuttering EMG.
Electrodes are placed over the muscles being studied to pick up their electrical signals and these signals are then electronically amplified processed and finally displayed, by either auditory or visual means to the patient. Alternatively some biofeedback machines are dependent on psycho galvanic skin response and thus give a measure of generalized tension than that of specific muscle groups.
Other methods assessing degree of tension would include measurement of heart rate, laryngography etc. Monitors utilizing EMG feedback have been most widely used; recourse to other types of monitoring may reveal additional information on physiological changes occurring before and during the stuttering instance.
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Stuttering and Increased Muscle Activity

Biofeedback machines have been used to demonstrate that increased muscular activity exists either before or during the audible or obvious moment of stuttering.
Shurum (1967) measured surface electrical activity of facial, neck and chest muscles in stutterers and found that stuttering was preceded by an early and sustained rise in signal amplitude in almost all muscles studied.
Knox (1974) using spectrographic analysis found increased fundamental frequency, inappropriate transition and slow rate of articulation in the seemingly fluent syllables preceding the obvious moments of stuttering. The results were interpreted as evidence of excessive laryngeal muscle activity.
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Biofeedback in Treatment
Electrode placement: One of the major problems in the use of biofeedback techniques is the site of electrode placement, as no single site has yet been delineated as optimal for all stutterers. Many muscles have been used, mainly in the facial and throat regions. Stromer (1979) suggested that choices for relaxation site specification would thus involve:
Choosing the site showing the highest EMG level during blocks, or
Noting the voice quality breakdowns or airflow deviations during observed blocks. This may also involve an analysis of those sounds that seem to be most often blocked, e.g. if the patient showed most difficulty with /p/, /b/, /m/ and /w/, electrodes would be placed on the lips.
Guitar (1975) found that the effective sites did not necessarily correlate with sound production, e.g. he found that by placing electrodes on the lips, stuttering was reduced on lingual consonants. Each stutterer there is an optimal site for electrode placement, but a means for ascertaining this has not yet been systematically developed and it thus seems likely that this decision will be based on trial and error for some time.
Type of feedback display:

The stutterer is given feedback of his degree of tension either through the auditory or visual channel. Auditory feedback may involve a series of audible clicks, which are increased or decreased according to a rise/fall in tension, or tension may be represented by a constant sound, rising in pitch. Visual feedback often takes the form of a modified voltmeter. There is little evidence to suggest that one form of feedback is more effective for some/all stutterers.
Possible technique:
Patient is given an initial period of training in reducing tension levels of these muscles by attending to the biofeedback machine. When the patient has learned to relax these muscle groups he is given a criterion level to reach, often 4-5 v (Laynyon et al 1976) or the criterion level is determined by averaging the integrated EMG activity during base line segments (Moore 1978).
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If the patients tension levels rose beyond the criterion level they received a blast of white noise with an intensity of 65 dB, but if the patients remained below the criterion level 85 % of the time over at least two 5 minute segments, then the criterion voltage was decreased in either 2.5 or 5 v Steps.
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Patients are then instructed to look at the
first word of speaking task and by utilizing the biofeedback machine, ensure that the criterion level has been reached. If it has, they can proceed to say the first word of the task. The same procedure is used for every other word until gradually the length of the task in increased.
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Transfer:
In order to assist in transfer a period of indirect feedback may be given. Lanyon (1977) utilized visual feedback, which involves turning the feedback monitor to face the therapist who requests that the stutterer does not begin to speak until he has reached the criterion level already practiced with direct feedback.
If the patient speaks too soon or too late after criterion level has reached, the therapist then indicates to the client that he should initiate speech. Thus the client is trained to attend to somaesthetic cues without relying solely on biofeedback instrumentation. The results of most studies employing this technique have shown that stutterers were able to achieved increased fluency when using the material given to them in the laboratory or clinic conditions.
Rationale
The concept of distraction has been used, i.e. if the stutterer's attention is almost entirely towards achieving and maintaining a certain criterion level of relaxation, he does not think solely of his speech. The fluency effects of these techniques may also result from the biofeedback equipment acting as a vigilance device ensuring that the stutterers pay more attention to the planning and execution of his utterances (Cross 1977).
If stuttering is regarded as an anticipatory disorder, biofeedback training may be effective, as it trains the stutterer to lower or eliminate covert pre-utterance activity (Guitar 1975). The stutterer may have some form of discrete awareness of types of physiological behavior involved in his disfluencies and therefore learn strategies, which help to reduce these.
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Value of Biofeedback training

One of the main advantages of this technique is that it is unobtrusive as the stutterer does not noticeably modify or alter his speech, but rather provides for himself the pre utterances reduction of tension and/or pre utterances strategies, which assist fluency. Laynyon (1977) lists the advantages of instrumentation as:
A greater degree of experimental precision is possible Objective criteria for relaxation are continually available and Immediate and continuous feedback is present.
Biofeedback training could be helpful particularly in the initial stages of a fluency instatement program but would be most effective if regarded not as a single treatment technique, but as part of a wider therapeutic program designed to meet the requirements of each individual stutterer.
Guitar (1975) found that subjects showing great amounts of laryngeal tension were less successful when using biofeedback techniques. Future use of biofeedback techniques will be limited to the early stages of therapy with the stutterer i.e. diagnostic and fluency instatement phases.
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Hypnosis:
It is the state of 'heightened sensibility'. Under hypnosis the person is not truly asleep, as EEG studies have shown that his cortical brain waves are undistinguishable from those recorded in his waking states when his eyes are closed. Van Riper (1958) found that fluency could be attained when the patient was deeply hypnotized, but there was only a momentary transfer of this fluency, when the post hypnotic suggestion was used, that the stutterer would be able to speak without stuttering.
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Increase in fluency was noted when hypnotic training was used to induce relaxation while speaking and then the post hypnotic suggestion was given that the stutterer could speak in the same relaxed suggestion was given that stutterer could speak in the same relaxed way upon coming-out of the trance.
Unfortunately these fluency effects wore off and patients required more and more hypnotic session boosters to maintain the relaxed way of speaking.
Hypnosis and speech therapy

Van Riper found the inhibition and unlearning of instrumental behaviors more rapidly by means of hypnosis. Use of hypnosis either to assist the patient in achieving success with a speech symptom treatment or to desensitize him to various feared situations and the attendant anxiety.
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Ritcher (1928) gave one of the early reports on the use of hypnosis to aid speech symptoms. He hypnotized stutterers and told them while in a hypnotic trance, to repeat simple words and sentences speaking slowly and carefully. Moore (1946) also used hypnosis as a supplementary method to other systems of therapy and found that the relaxation obtained by stutterers under hypnosis persisted during subsequent performances in complex speech situations.
Lockhart & Robertson (1977) hypnotherapy and block control.
combined
Under hypnosis, patients were given suggestions to improve awareness of tactile feedback and to associate block control with calmness, confidence and relaxation.
23 patients were given this form of treatment and 10 were discharged as fluent with some evidence of maintenance of fluency.
Elicitation of Etiology: Hypnosis would help to elicit the cause or causes of this disorder; the researchers assumed that the etiology was related to some emotional trauma. Hypnosis and psychotherapy: Morley (1957) mentions the use of hypnosis during psychotherapy with the severe stutterer who is unable to speak the sufficient fluency to explain his thoughts and feelings to the psychiatrist. However, hypnosis does not seem to have been widely used, or at least no great claims have been made of its use in this connection with stutterers.
Treatment of children:
Silber (1973) used hypnosis with children who present with various speech disorders including stuttering. He sees the goals of hypnosis with children as
(a) the restoration of damaged self-esteem and boosting of self-confidence and (b) the vulnerable area, which has given way, must be healed and strengthened. Importance of rapport being established almost completely on terms comparable with the child's understanding imagination and needs.
Value of hypnosis:
The use of hypnosis with stutterer's value lies in the treatment of non-speech symptoms or in providing the patient with a feeling deep relaxation and enhanced fluency, through the patient should be cautioned that this is not a 'cure'. It is also likely that only a limited number of stutterers will respond positively to hypnosis and interestingly, much, of the reported successes of hypnosis has been with patients who began to stutter relatively late in childhood or in adulthood.
Drugs:
Wolloch(1977) suggested dietary techniques to control stuttering recommending aromatic salty & sharp food , while advising abstinence from pastries ,nuts & fish .
Sir Francis Bacons belief that the stutter tongue was cold & dry & noted that more difficulty was experienced at the beginning of sentences, hence suggested that the stutterer should drink hot wine to heat the tongue
Van Riper (1973) gives examples of Bantu stutterers chewing garlic while those in Japan were forced to swallow raw eggs or to ear charred shirkers or frogs tongues.
Thus stutterers have been treated to dietary control, swallowing of unpleasant substances and the use of drugs, which seem to have had varying effects, including purgatives, tonics and analgesics.
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The effects of various drugs and place placebos on the stutter have been investigated, the tranquillizing drugs have been popular, as these have a calming effect do not appear to alter the state of consciousness.
Reserpine: A useful drug for anxiety reduction but its effect on stuttering is still unclear. Meffert (1956) in a single case study found that the stutterers speech showed a reduction in disfluency during administration of reserpine. But the results are variable in different cases.
Some of the other tranquilizers used for the treatment of stuttering include:
Chlorpromazine Meprobamate Pentobarbitone (Barbiturate)
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Haloperidol :
which is thought to block dopamine receptors and so increase the turn over rate of acetylcholine. Use of haloperidol arose because of the resemblance of the stuttering to the tics, habit spasm, and movement disorders of Gilles de la Tourette syndrome. They consider that the tremor in the Parkinsons is superficially similar to the slowness and tense pauses in stuttering.
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Although results with this drug so far very
variable further studies with the other agents affecting the dopaminergic system would be useful to assist understanding of a possible ethological factor in stuttering.
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Stuttering : Behavior therapy

Behavioral approaches to the treatment of stuttering have always been popular, in part because stuttering severity has long been known to diminish under a variety of specific conditions such as reading in chorus, rhythmic speech, singing, speaking when alone, talking to animals or infants, use of masking noise, use of delayed auditory feedback, and speech shadowing.
Some of these conditions have been utilized as the basis for therapeutic programs. In the field of speech Pathology, behavior therapy has been vastly applied Perkins (1971).
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It has been shown that stuttering response is an operant that occurs in the context of another operant i.e. verbal behavior (Flagan et al).
It is a learnt maladaptive behavior that is maintained through habit strength and or reinforcement, and that it is reinforced by the subjects own feedback on an a periodical schedule which is highly resistant for extinction.
There are a number of principles involved in behavioral therapy that helps to bring about rapid and effective learning. This includes:
The first principle is that knowledge or behavior to be learned should be arranged in small structured steps.
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Attention should only be given to the next step in the sequence, which should always be sufficiently small so that the patient is almost certain to perform it correctly.
Failure to master a step within a short space of time usually means that the step was too big, and the therapist should break it down into two or more smaller steps.
Advantages:
The patient experiences virtually no failures, and is successful at almost every step. The patient develops a sense of continuous progress. Each step requires a relatively small amount of practice, so new steps appear soon, and patient motivation is continually maintained.
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Accurate rehearsal and repetitive practice are the second principle.

about the patient's performance, whenever possible, is the third principle. Learning will be more efficient if feedback is given immediately en the extent to which the patient's performance was accurate. Eventually the patient will learn to observe himself and provides his own feedback on the adequacy of his behavior. The fourth basic principle in rapid effective learning is the importance of setting highly explicit goals.
Immediate
feedback
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The various techniques that fall under the umbrella of behavioral approach are:
Extinction Differential reinforcement of other behavior Punishment Negative reinforcement Reinforcement Response cost Time-out Over correction Modeling
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Guided participation Shaping Systematic desensitization GILCU Role-playing Cancellation Pull-outs Covert sensitization Cognitive restructuring Self-control
Extinction :
The term extinction is applied to a procedure in which reinforcement that previously followed an operant behavior is discontinued. No punishment is involved; instead a formerly available reinforcer is no longer provided when the target response occurs. Compared with other procedures, extinction less rapidly produces behavior cessation, and may even cause a brief increase in the emission of the previously reinforced behavior (extinction burst).
It is an easy principle but difficult in practice to identify and consistently withhold reinforcement for the particular target behavior. Moreover, to be most effective extinction should be used with behaviors that have continuously rather than intermittently reinforced.
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Differential Reinforcement of Other Behaviors (DRO):

DRO consists of differentially reinforcing the patient's behaviors except one specific target behavior. Thus, the target behavior is placed on an extinction schedule while behavioral alternatives are reinforced.
Omission Training: Similar to DRO, involves reinforcing the child for failing to emit the objectionable behavior during a specified time period.
Differential
Reinforcement of Incompatible Responding (DRI): Here,
one reinforces behaviors that are physically incompatible with the undesirable response. This is a variant of DRO. Differential Reinforcement of Low rates of Behavior (DRL): Here, the target behavior may be tolerable, or even appropriate at a low rate, but troublesome when very frequent. Lower rates of responding are reinforced in such situations.
Punishment:
Review of literature in the treatment of stuttering will show the predominance of punishment. From a blow to the head to the contingent blast of white noise, punishments of all sorts have been applied to stutterers. Numerous experiments have shown that punishment has produced remarkable changes in the frequency of stuttering.
Some of the various forms of punishment that have been administered across the centuries include:
Corporal punishment (i.e., flogging, Whipping). Slitting of the tongue . Burning of the tongue . Placement of leeches on lips. Pouring ice-cold water on themselves outdoors at midnight in winter in a biting wind. Acupuncture (sharp long needles inserted body) Moxacauterization (burning grass fibers on the skin)
Drinking decoctions of persimmon stones. Swallowing raw eggs. Swallowing a variety of vile substances Purging after being forced to swallow catharic croton oil Chewing of garlic by Bantu stutterers. Impletol blocking (subcutaneous injections a injections at speech organs, which cause Anaesthetization of the cutaneous zones of speech organs, which reflexively spreads to the cerebral centers of speech). Electrical shock, warm baths and music. Eating charred frogs tongue Loud blasts of noise or tones.
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Punishment consists of decreasing rate of a particular response by applying an aversive stimulus or event contingent upon the emission of that response.
Punishment can consist of an aversive stimulus or of the contingent withholding of positive reinforcement (as in time-out procedures).
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Punishment should be used as a last resort after positive reinforcement; extinction and DRO programs have failed to alter the undesired behavior. Great care must be taken to protect the client's rights and welfare when utilizing punishment. New alternatives to harsh physical punishment (i.e. electric shock)
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Paced instructions and commands at regular intervals. Ignoring client Undiluted lemon juice Hot pepper sauce Facial screening with a bib Immobilization
Reprimands:
Reprimands, criticism, and just plain screaming are the ones most commonly used. Reprimands are used to suppress children's undesirable behavior following the failure of positive reinforcement contingences to increase the rate of alternative responses; reprimands are not physically painful, so are less objectionable than most other forms of punishment.
Reinforcement:
The reinforcement most easily utilized in treatment programs possess the following characteristics:
They are resistant to satiation: if a child becomes rapidly satiated with a reinforcer the number potential of learning trials is reduced as his rate of behavior changes. To prevent satiation, a variety of reinforcers need to be used, & the training sessions need to be kept brief if the child's task is repetitive.
Reinforcers should be administered immediately after occurrence of the desired behavior.

Reinforcers should be administered in small units and frequently. Offering copious amounts of reinforcer, but infrequently and for large amounts of work can result in a ratio strain and consequent disruption or collapse of performance. By being stingy the program will prosper as long as the child is not underpaid for his efforts.
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Reinforcer used should be solely under the treatment agent's control. If the reinforcer used (i.e. a candy) is given to the child by an aunt, then the effectiveness of the usage of candy is lost as a reinforcer.
Rein forcers should be compatible with the overall treatment program. Reinforcers must be practical. Chose reinforcers which are readily available, inexpensive, easily administered and should have no obvious side effects.
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Praise and Tokens: Whenever possible generalized reinforcers, such as praise or points that are exchangeable for back-up reinforcers should be used, rather than primary reinforcers such as food.
Praise a particularly useful reinforcer because it is used frequently in everyday life, and thus is natural to the child and. adult. Whenever possible use praise statements that describe the desired performance as these statements aid the client in identifying and responding to response contingency. 10/24/2013 KUNNAMPALLIL GEJO JOHN 124
Negative Reinforcement:
The great bulk of the stutterer's abnormality consists of avoidance and escape. Therefore, negative reinforcement, which by definition consists of the escape from punishment, should prove to be a powerful therapeutic tool if used wisely.
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For example, if an attempt is made to extinguish a tongue protrusion, the stutterer could be asked to read aloud to some listener for an unpleasantly long time-say 60 minutesbut for each time he stutters without protruding his tongue he can deduct 5 minutes from that long hour.
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Response cost:
In a response cost (RC) contingency, engaging in a specified prohibited behavior produces a loss of reinforcing stimuli and events. Most often, point, tokens or money are removed contingent upon the client's making an incorrect response. Responses cost penalties are employed most often in situations where the client is earning points or money for desirable performances. Responses cost contingencies are often included in token economy programs.
Deprivation of privileges is another common response cost procedure.

There are a variety of response cost procedures in current use, they include:
Deprivation of privileges Fines of tokens/ money/ points Fine of allowed free time.
Time-out from positive reinforcement:

Is a mild form of punishment in which an undesired response is followed by a short period during which customary, ongoing reinforcement is withheld.
As the name implies, time out from positive reinforcement (TO) derives its effects from a contrast with rich positive reinforcement schedule for the child's desirable actions.
Hall and Hall (1980), claim that if TO is used correctly, it always results in a decrease in the target behavior's rate. However, if used incorrectly, TO procedure can cause problem behavior rates to increase.
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Over correction
Foxx and Azrin (1972, 1973) developed over correction (OC). OC consists of a reprimand ("Don't shake your leg"), a description of the undesired behavior ("you are tensing up your shoulders again") or a rule statement ("we don't drum our fingers"). The client is then administered restitution or positive practice OC, or both.
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Restitution Over correction: Requires the child to make amends for any damage he has done and to overcorrect or improve on the original state of affairs. The client is required to compensate for whatever harm he\she has done. Treatment effects seem to be more enduring with children than with adults, perhaps because adults have engaged in the disordered behavior for longer periods (Marholin, et al., 1980).
Modeling:
The therapist attempts to facilitate behavior change, by having the client witness the performance of another person the model. In some cases, the client learns how to perform new responses; in others, to refrain from making old, unwanted responses; and in others, to make certain responses more frequently.
Modeling procedures are non-coercive and effective providers of information, and are highly effective, especially in the alleviation of specific fears or phobias. If the modeling program fails, then the therapist can always turn to the more cumbersome shaping procedures to build desirable behavior or can use response suppression techniques to reduce inappropriate responding.
Guided Participation:
Guided participation in fear-provoking situations has been particularly effective (Blanchard, 1970; Rosenthal & Bandura, 1978).
Here, the client first watches a model engage in approach behavior and then gradually imitates the models performances. The client is gently induced to participate with the assistance of whatever performance aids are necessary.
For example, the client with fear of public speaking situations might first watch models fearlessly speaking in front of large groups of people.
The use of several different models is more effective than restricting to just the one model. After witnessing the demonstration, the client is asked to be on stage with the models while they speak.
Next the client may be asked to contribute a few words or sentences to the models speech.
In successive and gradual phases the client is asked to behave increasingly boldly, until he finally speaks to the group just as the models did.
Bandura (1977) believes that such successful experiences are helpful in building self-efficacy expectations, or feeling that one can successfully complete a task. Self-efficacy expectations, in turn, promote further performance gains.
SHAPING:
Shaping consists of the therapist's requesting and reinforcing successive approximations to the final behavior. The client's behavior might initially be too infrequent or overly brief, or the behavior may be too delayed, of too low intensity, or the performance form may be inappropriate and require change. Each stutterer has his own unique set of progressive approximations through which he can sequentially work.
SYSTEMATIC DESENSITIZATION:
Wolpe and Eyesenk first popularized this technique. When using systematic desensitization (or reciprocal inhibition therapy), a therapist usually describes a set of threatening situations, sometimes called an anxiety hierarchy. With the help of the client, the potential situations are ranked from least threatening to most threatening.
According to Van Riper, the aim is to reduce the client's negative feelings about stuttering. Desensitization aims to response from the stimuli. dissociate the
If the client can become toughened to his stuttering and if he can learn that he does not need to panic when he anticipates stuttering, the eventual modification of the problem becomes easier.
There are a number of desensitizing techniques (Van Riper):
Calming the client down Eye contact Self disclosure Voluntary stuttering Freezing
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Gradual Increase In Length and Complexity of Utterance (GILCU):

This is a 54-step program that starts with reading a single word and works up to 5 minutes of fluent conversation.
The words are constantly changed and the client is reinforced for each fluent novel response.
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The GILCU program is concerned with the development of fluent speech through the control of the evoking stimuli.
These procedures have concentrated on starting with simple verbal tasks such as uttering one word. These programs are characterized by very low rate of stuttering throughout the procedure. This program is recommended for preschoolers.
Role Playing:
In effecting change, one of the therapist's important tools is role-playing. Janis and King (1954) et al have shown that role-playing can significantly alter the attitude of the person assuming the role, and since attitudes tend to influence behavior, roleplaying should be a useful aid.
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The client and therapist role-play various scenes which pose speaking problems for the patient expressing disagreement with a friend's social arrangements, asking a favor, talking to a superior at work, talking to parents, talking to a group of people, talking to persons of the opposite sex, etc.
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Commencing with the less demanding situations first, each scene was systematically rehearsed until troublesome encounters have been enacted with satisfaction of the client and therapist.
The client's role is shaped by means of constructive criticism as well as modeling procedures in which therapist assumed the client's role and demonstrated desirable responses.
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Training role enactment docs seem to free stutterer to a remarkable degree. Moreover, it has its own inbuilt reinforcement, since stutterer often speak much more fluently when playing some other part. And they become more spontaneous, less constrained.
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Self control:
The use of self control procedures often involves the manipulation of cognitive elements, such as the client's awareness of the rate at which he emits a certain response.
The client is instructed to determine how often the target behavior occurs and under what condition. Some efforts are usually made to alter those conditions that, it is hypothesized, are helping to maintain the behavior.
Finally, the client, with the help of the therapist, will attempt to program his environment so that the unwanted behavior will be punished or its absence rewarded. Alternatively, some behavior that interferes with the undesirable response might be systematically rewarded. Usually, little reliance is placed on the attempt to control the unwanted response by the use of "will power".
These were the number of the behavioral therapy techniques in behavioral approach to therapeutics that can be utilized in the habilitation of a stutterer. Over the past years the developments of behavioral approaches to stuttering have rapidly increased in popularity and now constitute the majority of therapeutic endeavors.
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APPROACHES TO MANAGEMENT OF FLUENCY DISORDERS KUNNAMPALLIL GEJO JOHN,MASLP

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BEHAVIORAL COGNITIVE INSTRUMENTAL

The need for early identification and treatment of stuttering

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Decisions regarding treatment of stuttering:

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Steps in the treatment of stuttering:

Transfer/ generalization of fluency Maintenance of fluency

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b. Cognitive approach/Cognitive restructuring:

c. Behavior therapy approach:

d. Emotional or affective approaches:

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(2) Transfer/generalization of fluency:

(3) Maintenance of fluency:

Counseling and guidance:

Adjuncts to speech therapy:

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Continuous Vs Contingent Masking:

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Third subject showed a significant decrease in stuttering frequency.

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Ingham, Southwood and Horsburgh (1981)

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Dewar et al., (1979) have found no evidence of temporary threshold shift.

The role of masking noise in therapy:

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The four main types of auditory feedback are:

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All four types of auditory feedback reduce stuttering about 80%.

Establishment and Trainer (CAFET)

The Computer-Aided Fluency

Pocket fluency system:

Desktop fluency system:

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Bio feedback training:

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Stuttering and Increased Muscle Activity

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Type of feedback display:

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Patients are then instructed to look at the

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Value of Biofeedback training

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