Case descriptions of nonfluency and loci Initial and follow-up conversations with three preschool children

It has been hypothesized that fluency development may be influenced by linguistic uncertainty, slow speech milestones, and language delay. The purpose of this study was to describe the nonfluent speech characteristics of a stuttering child, a language-impaired child, and a nonstuttering child. Initial assessment results revealed that the stutterer produced more stuttering, the language-impaired child emitted more normal disfluency, and the nonstutterer had only a few normal disfluencies. Six months after therapy, the stutterer had decreased stuttering behavior but increased in normal disfluency. Six months after the initial evaluation and without fluency intervention, the language-impaired child showed an overall decrease in nonfluent behaviors, especially in part-word, whole-word, and phrase repetitions. Both the stutterer and the language-impaired children revised. Minimal nonfluency was observed in the nonstutterer during the initial and postobservation periods. All children produced more nonfluencies on conjunctions and pronouns. Implications for language therapy will be presented.     

Speech—Language clinicians'' and university students'' impressions of women and girls who stutter

To identify impressions speech—language clinicians and university students have of females who stutter, a 47-scale semantic differential form was administered to members of each group to obtain their responses to eight hypothetical constructs, i.e., “A Girl,” “A Girl Who Stutters,” “A Boy,” “A Boy Who Stutters,” “A Woman,” “A Woman Who Stutters,” “A Man,” and “A Man Who Stutters.” Both groups were found to possess negative stereotypes for all four categories of stutterers. The nature of the stereotypes appeared to be influenced by a stutterer's gender and relative age. Clinicians considered stuttering to exert a stronger negative impact on females and on children. Their strongest stereotype was of “A Girl Who Stutters.” University students considered stuttering to exert a stronger negative impact on males. Their stereotypes of stutterers seemed unaffected by the relative age of the stutterer. Their strongest stereotype was of “A Man Who Stutters.” Several theoretical and clinical implications of these findings are discussed.     

Issues to consider in the differential diagnosis of normal childhood nonfluencies and stuttering

Historically more attention has been focused on the adult stutterer than on the young stutterer. This article discusses three key issues in the differential diagnosis of normal childhood nonfluencies and childhood stuttering. The three issues are (1) whether early childhood disfluencies are heterogeneous or homogeneous phenomena, (2) whether the relationship between normal childhood nonfluencies and early stuttering is continuous or dichotomous, and (3) whether normal nonfluencies and stuttering differ quantitatively or qualitatively. Theoretical research as well as clinical implications of these issues are discussed.     

Ten commandments for long-term maintenance of acceptable self-help skills for persons who are hard-core stutterers

Hard-core stutterers require long-term self-help maintenance skills. In spite of how successful the laboratory achievement of fluency skills is, it is inevitable that some stuttering either remains or returns after termination of therapy. Most successful programs develop self-help skills so that the severe stutterer can continue to generate acceptable speech. This maintenance program is intended to complement any therapy and integrates the stutterers self-help skills into his or her life-style.     

Evaluation and elimination of an avoidance response in a child who stutters: A case study

In this case study, efforts to treat stuttering in a 6-year-old male with cerebral palsy were complicated by frequent replies of “I don't know” that allowed the child to avoid more extensive answers to conversational questions. Following a program of extinction plus differential reinforcement of alternative behavior (DRA), the response “I don't know” was decreased while both speech rate and stuttering increased. Simplified habit reversal (SHR) techniques (controlled breathing) were then applied and resulted in a reduction of stuttering and maintenance of low rates of avoidance. A reversal to baseline resulted in initially high levels of avoidance and low levels of stuttering, with these trends reversing as baseline continued. The SHR treatment for stuttering was then reimplemented and stuttering rates again decreased while avoidance rates remained low, Implications are discussed.     

Design of randomized controlled trials: Principles and methods applied to a treatment for early stuttering

The “gold standard” methodology for treatment efficacy research is the randomized controlled trial (RCT), which is used extensively in medical research and in other areas such as psychology. Results from a well designed and conducted RCT, which show a new treatment to be clinically and statistically superior to current standard practice, can lead to a change in clinical practice. This paper presents a tutorial on RCTs, presenting and discussing the following principles and methods: the trial protocol, choice of control treatment, eligibility criteria, random allocation, outcomes and hypotheses, sample size, subject recruitment, analysis by intention to treat, interim analysis, stopping rules, safety data monitoring/trial management, and study documentation. RCTs are a complicated and logistically involved methodology. Hence, prior to the commitment of resources to such a trial in the development of a new treatment, the safety and clinical promise of the new treatment needs to be demonstrated with preliminary studies. Such preliminary studies have been completed for the Lidcombe Program (LP) of early stuttering intervention, and an RCT of that treatment is being conducted at the time of writing. The principles and methods of RCTs are illustrated with reference to that study.

Educational objectives: The reader will understand the design principles and methods of RCTs. The reader will understand the logistics of conducting a RCT of a treatment for early stuttering.     

Controversies about stuttering therapy

Current controversies with respect to (1) the need to attend to the feelings and attitudes of stutterers; (2) the teaching of controlled stuttering as opposed to shaping fluency; (3) criteria for determining successful therapy; (4) the problem of relapse; and (5) therapy for the young stutterer are briefly discussed. It is noted that while there may be many controversies in the area of stuttering therapy, the author presently believes that the issue of whether or not to attent to the feelings and attitudes of stutterers is the most important and that the proliferation on the market of exclusively behavior-oriented therapy programs may be fostering the training of technicians without the skills necessary to assist others in identifying and handling feelings and attitudes.     

Stuttering and the valsalva mechanism: A hypothesis in need of investigation

This note presents the hypothesis than the excessively forceful closure of the mouth of larynx associated with certain types of stuttering may involve a neurological confusion between speech and the human body's Valsalva mechanism, which is designed to increase pulmonary pressure by forceful closure of the upper airway to assist in many types of physical effort. It is suggested that such behavior may result from excessive neuromotor tuning of the Valsalva mechanism prior to speech, especially in situations where the stutterer anticipates the need to “try hard” to speak properly. Such tuning may both interfere with phonation and render the Valsalva mechanism overexcitable to triggering stimuli, such as the increase in subglottal pressure that accompanies the start of articulation.     

Clinician attitudes toward stuttering in the United States and Great Britain: A cross-cultural study

The attitudes toward stutterers and stuttering of 702 speech-language clinicians in the United States and Great Britain were studied. Three hundred seventy-one clinicians from six states in the U.S. and 331 clinicians from England and Wales completed the Clinician Attitudes Toward Stuttering (CATS) Inventory. Results of the study were analyzed in terms of differences and similarities in attitudes between the two groups with respect to the etiology of stuttering, early intervention, the effectiveness of stuttering therapies, various therapy techniques, stutterers and their personality, parents of stutterers, clinicians, and reactions of others to stutterers.     

Evaluation of the efficacy of a stutter modification program with particular reference to two new measures of secondary behaviors and control of stuttering

This study aimed to assess the changes in speech behaviors and attitudes of a group of stutterers who attended an intensive stutter modification program, using measures specifically designed to reflect the aims of the program. These included a measure of “clean” stuttering to quantify overt secondary behaviors and a quantitative measure of speech control to assess changes in control over stuttering moments using the taught handling techniques. High interjudge and intrajudge agreement was obtained on the two new speech measures. In addition, the program’s own Attitude Scale was used to assess changes in attitudes toward communication. The five subjects were assessed immediately after and 2 years after the program. Each subject was analyzed as a single case study, and there was great individual variation in response to therapy. The general trend was a decline in the maintenance of speech behaviors, with good maintenance of attitude gains 2 years postworkshop. The poorest maintenance was linked to lack of attendance at refresher therapy and initial severity of stuttering. The two new measures used to evaluate change in clean stuttering and control may be useful tools in the assessment protocol of other Stutter Modification programs.     

Toward an integrated approach to early childhood stuttering

This article proposes a model that integrates various factors influencing early childhood stuttering. The factors interact in a synergistic manner and can be subsumed under three macrofactors: physiological, psycholinguistic, and psychosocial. Such a model can be clinically applied toward an integrated approach to the assessment and treatment of the young stutterer.     

Perceptions of speakers with minimal eye contact: Implications for stutterers

One hundred and thirty-three college students responded to percentage definitions of “good,” “minimal,” and “no” eye contact. They also judged their perceptions of a speaker with “little or no eye contact” on a semantic differential scale containing 60 polarized adjective pairs regarding personality traits. The majority of the student respondents defined an individual with “good” eye contact as looking at his/her audience/listener 90–100% of the time. This is a more stringent definition than other literature has indicated. Furthermore, speakers with little or no eye contact were judged less favorably on 70% of the items, which indicates that low eye contact adversely affects perceptions of a speaker's personality. Therefore, stutterers need to be made aware of the importance of and determinants of effective eye contact in communication. Also, the development of effective eye contact needs to be incorporated as a major goal in stuttering therapy.     

Contemporary issues with stuttering: The Fourth Croatia Stuttering Symposium

PurposeDuring the 2019 Fourth Croatia Clinical Symposium, speech-language pathologists (SLPs), scholars, and researchers from 29 countries discussed speech-language pathology and psychological practices for the management of early and persistent stuttering. This paper documents what those at the Symposium considered to be the key contemporary clinical issues for early and persistent stuttering.MethodsThe authors prepared a written record of the discussion of Symposium topics, taking care to ensure that the content of the Symposium was faithfully reproduced in written form.ResultsSeven contemporary issues for our field emerged from the Symposium.ConclusionEffective early intervention is fundamental to proper health care for the disorder. However, as yet, there is no consensus about the timing of early intervention and how it should be managed. Currently, clinical translation is a barrier to evidence-based practice with early stuttering, and proactive strategies were suggested for junior SLPs. Apprehension emerged among some discussants that treatment of early stuttering may cause anxiety. For persistent stuttering, assessment procedures were recommended, as were strategies for dealing with childhood bullying. There was agreement that SLPs are the ideal professionals to provide basic cognitive-behavior therapy for clients with persistent stuttering. Questions were raised about our discipline standards for basic professional preparation programs for stuttering management.     

Oral motor discoordination among children who stutter

A large body of literature describes subtle oral motor differences among people who stutter, which are not typical of other speakers. The purpose of this report was to propose that oral motor discoordination (OMD) can be assessed and treated, and that such treatment may be useful prior to targeting perceived stuttering behaviors.

Oral motor coordination (correct voicing, smooth coarticulation, proper sequencing, and age appropriate rate of production of syllables) was assessed using an Oral Motor Assessment Scale. An oral motor training program was described that improved OMD 78% after 14 hours of training in nine children. Stuttering was improved 62% by the training, although it was not specifically targeted. This report proposes that improvement in OMD and reduction of stuttering may be reciprocal (i.e., treatment of one may produce improvement in the other as a byproduct). It may be that OMD is among the physiologic features that can cause post-treatment fluency to be “tenuous.” Its inclusion in treatment programs may improve maintenance and naturalness of fluency.     

Tokens for stuttering

Four young stutterers were observed during 10 weekly sessions. Each session was divided into pretreatment, treatment, and posttreatment segments. Redeemable tokens were administered contingent upon stuttering behaviors in the treatment segment of the Experimental condition. In a Parallel Control condition, no tokens were administered during the entire session. The differences between the pretreatment and treatment segments were compared for the two conditions. Three subjects had dramatically fewer stuttering behaviors when tokens were being administered, while the fourth had more stuttering under the same condition. The subject whose stuttering increased had a history of therapy in which voluntary, “faked” stuttering had been called for, and the behaviors that increased were judged to be of this type. The decreases were interpreted as suggesting that the contingent tokens acted to countercondition the aversiveness of the stuttering experience, which reduced the anticipation of stuttering and hence the stuttering itself. The increase was felt to be simple reinforcement. The counterconditioning interpretation was borne out in two clinical applications in which money was presented contingent on stuttering behaviors judged to be aversive to the stutterer, and in which dramatically sudden, but long-lasting, improvement was seen.     

Learning from negative outcomes in stuttering therapy: II. An epiphany of failures

Proceeding on the premise that learning advances on the feet of failure, a litany of therapeutic failures with stutterers across 3 decades is recounted. The basis for these failures included the assumptions that stuttering is a neurotic symptom; that “lucky fluency” can be maintained permanently; that a fluent drone is preferable to stuttering; that controlled fluency, once established, can be maintained permanently; that a proper task for clinicians is to motivate clients to achieve and preserve fluency; that the clinician has the responsibility for marching clients through their therapeutic paces; and that stuttering is punishing to the stutterer, so it is not preserved by reinforcement. Unfortunately, more has probably been learned about what does not work than what does.     

Horn stuttering

This is a case report on an adult male stutterer who also exhibited stuttering-like behavior while playing the French horn. The effects of speech fluency targets on the playing and the physiological and psychological correlates between the stutter in speech and the “stuttering-like” behaviors when playing an instrument are discussed. Etiological implications are considered.     

Modifying Exposure-Based CBT for Cambodian Refugees with Posttraumatic Stress Disorder

Cambodian refugees represent a severely traumatized population living in the United States. In this paper, we describe the modification of a cognitive-behavior therapy program to facilitate delivery of an exposure-based treatment for posttraumatic stress disorder while addressing some of the challenges brought by differences in language and culture between providers and patients. Our treatment modifications include the use of metaphors and culturally relevant examples to aid the communication of core concepts by interpreters, an emphasis on teaching the “process” of exposure therapy rather than relying on specific exposure practice in the group setting, a focus on interoceptive exposure to allow more effective group practice and to address culturally specific symptom interpretations, attention to the way in which treatment procedures interacted with culturally specific beliefs, and efforts to integrate treatment services within the community. Although data are limited, results to date suggest that this modified treatment was acceptable to patients and offered benefits on the order of large effect sizes.     

Demands and capacities or demands and performance?

The Demands and Capacities Model of stuttering purportedly provides a framework for obtaining information concerning a child's capacities for fluency and the demands placed on the child by the environment and for integrating that information in devising individual therapy plans. The current paper analyzes the model, with specific attention to the status of the “capacities” component. It is suggested that the model is more accurately characterized as a Demands and Performance rather than a Demands and Capacity Model because capacities are not actually addressed.