Enhancing treatment for school-age children who stutter I. Reducing negative reactions through desensitization and cognitive restructuring

This paper describes several treatment strategies that clinicians can use to address negative affective, behavioral, and cognitive reactions that school-age children who stutter may experience as part of their disorder. Specific strategies include desensitization to stuttering, cognitive restructuring, self-acceptance, purposeful self-disclosure, and a combination of both fluency enhancing and stuttering modification approaches. To facilitate clinicians' application of these techniques, the strategies are presented in the context of a case study involving a 9-year-old boy who participated in a comprehensive treatment program for stuttering. Following treatment, the child exhibited improved communication attitudes and a reduced frequency and severity of stuttering, combined with reduced concern about stuttering, as indicated through formal and informal assessments. Findings suggest that clinicians can help children overcome the negative reactions associated with stuttering through a number of treatment strategies that can be applied in a variety of clinical settings. Educational objectives: After reading this article, participants will be able to: (1) define desensitization and cognitive restructuring and provide two arguments in favor of using these strategies in treatment for school-age children who stutter; (2) describe two treatment strategies for helping school-age children achieve desensitization through stuttering therapy; (3) describe two treatment strategies for helping school-age children engage in cognitive restructuring in the context of therapy.     

Systematic desensitization: a technique worth trying

Systematic desensitization is a limited form of behavior therapy used in the treatment of anxiety attached to specific objects or situations. The principles underlying the technique as developed by Wolpe and others are described briefly in this article. The author also relates his experiences in using a modified form of systematic desensitization in a public school setting with counselees whose success and development are hampered by test anxiety and fear of public speaking.     

Dealing with Fear and Anxiety in the School Setting: Behavioral Approaches to Treatment

This review focuses on behavioral intervention strategies for the reduction of school-related fears and anxieties. Four major behavior therapy procedures are reviewed: systematic desensitization and the variations of this procedure, modeling approaches, and self-control and cognitive behavioral approaches. General trends in school-related fears and anxiety reduction research are also discussed.     

The efficacy of progressive relaxation in systematic desensitization and a proposal for an alternative competitive response--the relaxation response.

The theoretical basis of systematic desensitization is reciprocal inhibition in which an alternative, competitive response to anxiety is conditioned to arousal-producing, phobic stimuli. Abbreviated training in progressive relaxation is believed to serve as a competitive response to anxiety by decreasing autonomic nervous system activity. However, physiologic studies of progressive relaxation have not substantiated that its practice is associated with such decreased autonomic activity. Consequently, the use of progressive relaxation has been a confounding factor in the determination of the function of reciprocal inhibition in systematic desensitization. To confirm and refine the theoretical constructs of reciprocal inhibition, it is necessary to test the effects of a response which is competitive to the anxiety response. Such a response may be the relaxation response which is characterized by physiologic changes consistent with decreased autonomic nervous system activity. Derived from meditational practices, techniques which ehcit the relaxation response incorporate the element of focused attention which has been implicated as a critical factor in systematic desensitization. Thus, the use of the relaxation response should be a more appropriate method than progressive relaxation if the therapeutic usefulness of systematic desensitization is indeed due to reciprocal inhibition.     

Real and virtual classrooms can trigger the same levels of stuttering severity ratings and anxiety in school-age children and adolescents who stutter

PurposeMany school-age children and adolescents who stutter experience the fear of public speaking. Treatment implications include the need to address this problem. However, it is not always possible to train repeatedly in front of a real audience. The present study aimed to assess the relevance of using a virtual classroom in clinical practice with school-age children and adolescents who stutter.MethodsTen children and adolescents who stutter (aged 9–17 years old) had to speak in three different situations: in front of a real audience, in front of a virtual class and in an empty virtual apartment using a head-mounted display. We aimed to assess whether the self-rated levels of anxiety while speaking in front of a virtual audience reflect the levels of anxiety reported while speaking in front of a live audience, and if the stuttering level while speaking to a virtual class reflects the stuttering level while speaking in real conditions.ResultsResults show that the real audience creates higher anticipatory anxiety than the virtual class. However, both the self-reported anxiety levels and the stuttering severity ratings when talking in front of a virtual class did not differ from those observed when talking to a real audience, and were significantly higher than when talking in an empty virtual apartment.ConclusionOur results support the feasibility and relevance of using a virtual classroom to expose school-age children and adolescents who stutter to a feared situation during cognitive behavioral therapy targeting the fear of public speaking.     

A case report on the use of flooding in stuttering therapy

The last several years have seen the development and use of anxiety-reduction procedures in stuttering therapy. Among these types of methods, systematic desensitization and reciprocal inhibition have been employed almost exclusively. Emotional de-conditioning by means of flooding or implosive techniques has been attempted far less often. This article presents a case report on the utilization of the flooding tactic. Results are offered and discussed relative to the question of whether the elimination of anxiety is a realistic goal in therapy. The suggestion is offered that what many stutterers may really need to develop is the ability to generate fluency-enhancing behaviors in spite of the presence of heightened emotionality.     

Social skills training and systematic desensitization in reducing dating anxiety.

Cooper et al. (1969) have criticized the types of target behavior chosen for therapy analogue studies for being irrelevant to clinical practice. A potential target behavior which appears to be pervasive, complex and directly relevant to clinical practice is interpersonal anxiety. Of special concern to college students is the interpersonal anxiety elicited by members of the opposite sex. especially in dating situations (Martinson and Zerface, 1970).An individual may experience interpersonal anxiety because of a deficit in social skills (reactive anxiety) or because of prior conditioning (conditioned anxiety) or because of some combination of both reactive and conditioned components. While it is possible that a treatment program aimed at a reduction of either of these anxiety components may be instrumental in ameliorating the other component, it would appear that a comprehensive treatment program would attempt to teach social skills as well as reduce conditioned anxiety.Desensitization procedures have demonstrated success in alleviating conditioned anxiety for a wide variety of clinical problems (Paul, 1969a. 1969b) and appears to be a logical choice for the conditioned component of dating anxiety. A number of outcome studies have reported some success in the use of in vivo desensitization (Rehm and Marston, 1968; Martinson and Zerface, 1970) and systematic desensitization (Stark, 1970) in reducing anxiety in date anxious subjects.The literature on treatment programs aimed at social skills training for date anxious subjects is meager. Melnick (1973) reported success in improving the appropriateness of the social behavior of subjects who had experienced a minimal dating history by the use of modeling, behavioral rehearsal and self-observation techniques.The present study was designed to test the relative effectiveness of two different types of treatment programs in alleviating interpersonal dating anxiety. The two experimental groups consisted of a systematic densensitization program which focused on the condition anxiety component and a social skills training program which focused on the reactive anxiety component.     

RECREATING THE SCENE: AN EFFECTIVE WAY TO PROVIDE DELAYED PUNISHMENT FOR INAPPROPRIATE MOTOR BEHAVIOR

A mediated punishment procedure that involved recreating a behavioral sequence by guiding the subject through the behavior in the situation in which it occurred was used to suppress several severe problem behaviors in two developmentally delayed children. The mediational procedure was first used with a 4-year-old autistic boy for biting and then for foot stomping. Next the procedure was used for stealing and hoarding behavior with a multiply handicapped 17-year-old girl. Results indicated that the procedure was effective and produced relatively rapid results. One advantage of the procedure is that it provides an opportunity for trained personnel to apply restrictive procedures to low frequency behavior that occurs in their absence rather than relying on less qualified staff to implement the procedure immediately after the behavior occurs.     

A comparison of systematic desensitization and reinforced practice procedures in fear reduction

At least two strategies of behavior modification seem possible in the treatment of neurotic disorders. In the first, systematic desensitization is used to reduce the anxiety associated with the avoidance behavior, thus reducing avoidance of the feared stimulus. In the second, anxiety is ignored and approach behavior is shaped by direct reinforcement according to operant conditioning principles. Each procedure enjoys a literature of successful application in both laboratory and clinical settings. Systematic desensitization has been effective in treating fears of small animals (Lang and Lazovik, 1963) interpersonal anxieties (Paul, 1966), and classic phobias (Lazarus, 1961). Operant approaches involving reinforced practice have proved successful in treating agoraphobia (Agras et al., 1968), anorexia nervosa (Bachrach et al., 1965), and various types of behavior of psychotic patients (Risley and Wolf, 1967; Ayllon and Azrin, 1968).The present study was designed to examine the relative therapeutic effectiveness of systematic desenzitization and reinforced practice in the treatment of snake phobia. Although Barlow et al. (1970) have suggested that “shaping” is more effective than systematic desensitization in the reduction of avoidance behavior, Ss in their “shaping” condition were given more experience with the aversive stimulus than desensitization Ss. The present study avoids such confounding.     

A rapid method of eliminating stuttering by a regulated breathing approach

The Habit Reversal Procedure for eliminating nervous habits was applied to the problem of stuttering. In the new procedure the speaker interrupted his speech at moments of actual or anticipated stuttering and at natural pause points, and resumed speaking immediately after breathing deeply during the pause. In addition to this regularized pausing and breathing, the program included other factors such as formulation of one's thoughts prior to speaking, identification of stutter-prone situations, identification of mannerisms associated with stuttering, speaking for short durations when tense or nervous, daily breathing exercises, relaxation procedures for anxiety, immediate display of improved speaking, and enlisting family support for progress. Fourteen stutterers were given training in the program during a single counseling session of about two hours duration. The next day, the average number of stuttering episodes decreased by 94 per cent, by 97 per cent at the end of one month, and by 99 per cent during the extended follow-up. Each of the clients was improved by at least 93 per cent. The new procedure appears to be more rapid and effective than alternative procedures.     

Drive level, incentive conditions and systematic densensitization

The role of drive level was investigated as it bears upon the process mechanism(s) involved in systematic desensitization. Drive was defined by subjects' performance on a pre-BAT. High and Low Drive subjects were randomly assigned to a systematic desensitization, a reward. an extinction, and a control condition. The results indicated that systematic desensitization was the most effective condition for both high and low drive subjects. However, there were indications that both the extinction and reward conditions may be effective with further trials. The suggestion was that systematic desensitization might be the more efficient, but not the sole effective treatment. If so, the process mechanism involved is likely to be extinction rather than reciprocal inhibition. The role of relaxation, then, would be one of an incentive that permits the subject to maintain exposure to the feared stimuli, thus facilitating extinction.     

Effects of delayed auditory feedback on acquired stuttering following head injury

This study examined the effects of Delayed Auditory Feedback (DAF) with three cases of acquired stuttering following head injury. To determine the effects of DAF on stuttering behavior a multiple baseline design across three speaking tasks was employed. All subjects reduced stuttering with application of DAF. Stuttering behavior on untreated tasks continuing in baseline was not affected by DAF. When treatment was applied to the untreated tasks, stuttering events decreased for all three subjects. Results indicate DAF has potential as a treatment procedure with cases of acquired stuttering in a way similar to cases of developmental stuttering.     

Message therapy: Language approach to stuttering therapy with children

Message therapy is a clinical procedure designed to be used as a carry-over technique with school-age stutterers or as a sole technique with the preschooler. The focus of therapy is on a unit of communication rather than on the moment or place of stuttering. One of the basic assumptions of the procedure is that the child is beginning to monitor how he/she is speaking rather than what is being communicated (i.e., the “message”)—each task requiring a different cognitive process. The emphasis of the therapy is to redirect the child's attention to “what he/she is saying.” The clinical procedures are discussed as they relate to the specific population.     

Reciprocal inhibition or extinction?

Since reciprocal inhibition therapy techniques involve the procedure for classical extinction, it is reasonable to consider the possibility that it is extinction, rather than counterconditioning, that is responsible for their efficacy. Certain experiments increase the plausibility of this possibility by suggesting that a certain feature of the extinction procedure involved in the reciprocal inhibition techniques makes it more effective than free response avoidance extinction. This feature is the fact that the subject's escape from the anxiety stimuli is delayed by the therapist's instructions. Only one experiment clearly indicates any feature of any reciprocal inhibition technique which could not be attributed to extinction, this characteristic being a superiority of a reciprocal inhibition procedure to extinction in eliminating fear in rats. Thus for explaining reciprocal inhibition therapy, it is still essentially an open question as to whether the concept of reciprocal inhibition is better than extinction.     

Group play therapy for Japanese children who stutter

Twenty-one sessions of group play therapy were conducted with children who stutter in order to improve their stuttering and to promote their development in social adaptation. Follow-up surveys were made 6 mo and 5 yr after therapy.As therapy progressed, a definite process of change was observed in each child, from periods of anxiety, appearance of aggressive behavior, frequent occurence of aggressive behavior, to a decrease in aggressive behavior. After the appearance of aggressive behavior, a fluctuation in stuttering occured as cooperative play with other children was established. This was followed by a decrease in stuttering. The appearance of aggressive behavior during therapy is thought to be of major significance for the disappearance of stuttering and for interpersonal relationships.A follow-up survey showed that both stuttering and social adjustment had improved, indicating the effectiveness of therapy.     

Psychotherapy by reciprocal inhibition

Reciprocal inhibition is a process of relearning whereby in the presence of a stimulus a non-anxiety-producing response is continually repeated until it extinguishes the old, undesirable response. A variety of the techniques based on reciprocal inhibition, such as systematic desensitization, avoidance conditioning, and the use of assertion, are described in detail. Behavior therapy techniques evaluated on the basis of their clinical efficacy are found to have striking success over traditional psychoanalytic methods. Currently, more comparative studies are required which will validate the merit of behavior therapy in the psychotherapeutic field while experimental research should continue to refine the techniques.     

Stottern

Stuttering is a fluency disorder with a point prevalence of approximately 1%. Stuttering begins in childhood and is characterized by frequently occurring breaks in the flow of speaking. These fluency breaks are repetitions of words and syllables, prolongations of sounds and pauses. Many people who stutter show avoidance behaviors, social anxiety, shame and social withdrawal. Empirical studies point to genetic origins of the disorder; however, distinct physical deficits causing stuttering are not yet known. While most children outgrow stuttering before adolescence those who do not typically continue to stutter throughout their life. The severity of stuttering as well as its impact on the quality of life can be reduced by a combination of cognitive-behavioral therapy and speech-language therapy.     

Electrophysiological measurement during a time-out procedure in stuttering and normal speakers

Eight stuttering and eight normal speaking subjects were given a time-out (TO) procedure during reading. Simultaneous measures of heart rate and galvanic skin response were obtained in order to infer anxiety level during the TO period. Multivariate and univariate analysis of variance procedures indicated that stutterers, when compared to normals, initially relax during a TO period compared to base rate levels. Near the latter part of the TO period stutterers anticipate the onset of speech and become relatively more anxious. This anxiety level increases even more during the actual speech intervals. Normal speakers resent the intrusion of the TO interval and become more anxious during this period.     

Vicarious desensitization of test anxiety

students fail in the university environment due to an inability to perform in testing situations because of anxiety associated with tests (Suinn, 1968). Systematic desensitization has been found to be effective in the treatment of test anxiety, and attempts are being made to improve both the efficiency and effectiveness of this procedure (Mann and Rosenthal, 1969; Suinn and Hall, 1970). This study evaluates the relative effectiveness of four methods of systematic desensitization in the treatment of test anxiety. Specifically, two changes were investigated which may lead to: (a) more rapid forms of treatment (massed treatment versus distributed treatment); (b) more easily administered forms of treatment (vicarious desensitization versus active desensitization).