approaches to management of fluency disorders.pdf / kunnampallil gejo

8/22/2019 APPROACHES TO MANAGEMENT OF FLUENCY DISORDERS.pdf / KUNNAMPALLIL GEJO

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APPROACHES TO MANAGEMENT

OF FLUENCY DISORDERS

KUNNAMPALLIL GEJOJOHN,MASLP

KUNNAMPALLIL GEJO JOHN


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BEHAVIORAL

COGNITIVE

INSTRUMENTAL

AND

ALTERNATIVE METHODS



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The need for early identification and

treatment of stuttering

2 schools of thoughts:



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Early identification and treating children close toonset of stuttering is increasingly emphasized bymany authors for the following reasons:

(1) It is easy, less time consuming and morelong lasting

[i.e., approximately 1-3 months or 20 hours forchildren (Starkweather and Gottwald, 1986) toone to several months/years or 140 hours foradults (Van Riper, 1973; Webster, 1974) and is

reported to be dependent on the chronicity ofthe 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 Halfond1990; Webster, 1974);

(3) Relapse rates for treated adults is reported tobe around 50% (Franken, 1988); whereas for

children it is close to zero (Starkweather,Gottwald and Halfond 1990);



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(4) Adults who are treated are reported to have

carefully monitored speech (Boberg andKully, 1994) and diminished quality of speech(Franken, 1988) or may have residualstuttering behaviors (Prins, 1984) while the

treated children are reported to be nodifferent from their non stuttering peers(Starkweather, Gottwald and Halfond 1990;Gottwald and Starkweather, 1984 andothers);



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(5) Although it is reported that many children with

stuttering spontaneously recover (the recovery ratesrange from 20-80% according to various estimates),nearly 20% would continue to stutter if not treatedand it is not a small number when 1% of the totaladult population who continue to stutter if not

treated is considered.

Further, although some predicting factors are there toguide us regarding who will and will not recoverspontaneously as given above, they are not fool

proof;



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(6) The impact of stuttering problem onthe young minds to live with it could bequite handicapping emotionally,socially, educationally and vocationallyas reported by many PWS.



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Decisions regarding treatment of stuttering:

The clinicians have to make decisions regardingwhether treatment is required or not; should it bedirect or indirect (in case of CWS) or both;intensive or extensive or both; approximateduration of treatment needed; what are the

prognostic indicators in a given client and so on.

These aspects have to be communicated to the clientsor the caregivers. Gregory and Hill (1980)recommend preventive parent counseling,

prescriptive parent counseling and or comprehensivetreatment program for children based on theirdifferential evaluation procedure.



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Packman and Lincoln (1996) recommend a set ofcriteria to decide early intervention as given in thediagram below:



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Steps in the treatment of stuttering:

Establishment of fluency Traditional approaches

Cognitive approach / cognitiverestructuring

Behavior therapy approach

Emotional or affective approaches

Instrumental approach

Supportive approach Transfer/ generalization of fluency

Maintenance of fluencyKUNNAMPALLIL GEJO JOHN


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Establishment of fluency

Is easy and can be achieved using avariety of fluency shaping or stutteringmodification approaches.

Many PWS do not exhibit stuttering orexhibit less severe problem in theclinical set up because they do not try

to suppress the problem.



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Many novel ways of speaking reducedisfluencies.

For young children various analogies areadopted to make it enjoyable and fun.For older children and adults differentapproaches are combined to provide acomprehensive treatment plan, which

include:



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a. Traditional approaches:

Voluntary stuttering/stutter fluentlytechniques, prolongation or many ofits variants, cancellation, pullout,preparatory sets, soft/loose contacts,relaxation, airflow therapies,Shadowing are to name a few of the

traditional techniques being used fordecades with varied success.



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b. Cognitive approach/Cognitive restructuring:

PWS are made to realize how and why thestuttering problem varies and how they can get acontrol over it.

This would reduce their dependency on theclinician and gradually make them more confident in

getting control over their problem. Maintenance of adiary would facilitate this.

Rational Emotive Behavior Therapy (REBT) and

Personal Construct Therapy (PCT) are someprocedures incorporating cognitive restructuringprinciples.



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c. Behavior therapy approach:

Although the cause of stuttering is notvery well understood, recent theoristsemphasize nurture or environmental factorsto contribute as maintaining factors in

stuttering.Appropriate reinforcement procedures to

facilitate fluency and punishment strategieslike the Time out, Response Cost to reducedisfluencies could aid in achieving fluentspeech.



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Other techniques using behavior therapy

principles include Modeling, shaping,role-play, over correction (negativepractice), extinction (reinforcement

that previously followed an operantbehavior is discontinued).

Further, in clients with anxiety traits,

progressive relaxation combined withsystematic desensitization procedurescould be very effective.



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d. Emotional or affective approaches:

Using varieties of psychotherapy andcounseling, positive changes inemotional or affective states of theindividual need to be brought about.

Stuttering is a disorder, which evokesunusual reactions from the peers,parents and public. These negative

reactions are unpleasant and speakingsituations may be traumatic to PWS,who will start avoiding them.



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Hegde (1990) opines that if theattitudinal changes are not broughtabout during the therapeutic

management, the unchangedmaladaptive attitudes will soon wipe outthe temporary and shaky fluencygenerated by the treatment procedure.



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e. Instrumental approach:

Mechanical or electronic devices and variousequipments are available for establishing fluentspeech 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 tomask auditory feedback, delayed or frequency shiftedfeedback. School DAF, Telephone fluency system,pocket fluency, desktop fluency system, and voicechanger are some of the other devices used in themanagement of PWS.



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f. Supportive approach:

Periodic counseling and guidance to theparents, relatives, friends, teachers,employers or significant others in the socialenvironment of PWS is very important for

bringing about long lasting maintenance ofthe fluency that is achieved.

It is necessary to get support andencouragement from these people to

overcome their negative feelings andattitudes and proper motivation to control thefluency achieved.



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(2) Transfer/generalization of fluency:

Once the fluency is established in the clinical set upthe clinician should start activities to transfer theseskills to outside situations in a gradually gradedmanner.

Situational hierarchy ratings obtained during pre-

therapy 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 self-correct to reduce dependency on the clinician. Aclose friend or a family member could be assigned toassist the client in this process initially.



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(3) Maintenance of fluency:

PWS have to be prepared for any relapsesthat could occur during the treatment or laterso that it does not come as a shock if hesuddenly encounters situation where he is not

able to maintain the fluency that is achieved. After intensive and extensive practice

sessions, the frequency of treatment sessionsshould be gradually reduced to make followup or booster sessions to monitor themaintenance of fluency.



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Counseling and guidance:

Periodic counseling is very essential to bringabout positive attitude changes. This wouldinclude the following:

Having less desire to avoid stuttering.

Being more willing to bring the stutteringproblem into the open.

Judging performance in speaking situation moreon 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 withstuttering.

Anticipating more fluency than disfluency.

Becoming less embarrassed or ashamedabout stuttering.

Gaining realization that one can succeed inlife in spite of stuttering problem.

Not to assume that people willunderestimate them because of stuttering.



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Group counseling and group therapyprocedures are very useful in themanagement of PWS in addition toindividual therapy approach.

Some of the advantages of grouptherapy include instillation of hope,promotion of universality, imparting of

information, possibility of catharsis,development of existential issues.



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Adjuncts to speech therapy:

The concept of stuttering being treated oralleviated by resort to 'outside agencies' hasbeen popular with stutterers.

These outside agencies have taken manyforms, from swallowing of various

substances to using many types ofmechanical or electronic devices.



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The stutterer himself often shows

considerable faith in these aids, and thetherapist, while recognizing the importance ofthe interpersonal aspects of this disorder,may employ such aids as adjuncts to a more

comprehensive treatment program.

If the aim of therapy is initially theachievement of fluency then the use of theseadjuncts can be very beneficial.



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Many such adjuncts have beendescribed for the treatment ofstuttering but only a few of those are

currently in use. These are consideredto be representative of the machines,swallowing of substances etc used.



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Edinburgh masker - has created interest inthe 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 whitenoise for stutterers is that the frequency ofdisfluency is reduced.

Van Riper (1973) discusses accounts of'therapeutic deafening' written half a century

ago, although at that time its use was notconfined solely to stuttering.



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Interest in the relationship of hearingand stuttering was aroused in 1912 bya report of Guzzmann (referred to inWingate 1976) stating that thecongenitally deaf never stutter.



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The presence of stuttering has been noted

among the-deaf and hard of hearingpopulation but the incidence is much lowerthan amongst the normal hearing population(Harms and Malone 1939).

Following this finding the next step wouldinvolve the experimental reduction of hearing

level in stutterers.



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Noise characteristics:

When a very loud masking noise was used, itwas sufficient to over come boneconducted self-hearing; there was a verysubstantial reduction in stuttering.

They eliminated first the high frequencycomponents of the noise and then the low

frequency components and concluded thatthe latter was more effective. (Cherry andSayers, 1956)



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Ham and Steer (1967) maskedfrequencies of below 800 Hz and foundincreased fluency.

While, Stromsta(1958) noted thatdisflueney was decreased when

frequencies of below 500 Hz weremasked.



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Dewar, Dewar and Barnes (1976) describedthe Edinburgh masker, which has a frequencyrange of 100-140 Hz (the frequency ofvibration of the vocal cords).

Low frequency masking is necessary butthere is no evidence that any specific

frequency range is the most effective forstutterers.



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Most reports on the intensity of masking

noise conclude that the noise level must besufficient to overcome bone-conductedhearing.

Maraist and Hutton (1957) using maskinglevel of 30,50, 70 and 90dB found aprogressive decrease in stuttering as intensity

of masking noise increased with considerabledecreases above 50 dB.



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Ham and Steer (1967) returned the stutterers

speech signal at intensities of 30, 45, 60 and75 dB above the individual speech receptionthresholds and found that only the 60 and 75dB increases were associated with a

significant reduction in stuttering.

Adams and Hutchinson (1974) have

confirmed the general finding that stutteringdecreased as noise level increased.



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Continuous Vs Contingent Masking:

Masking noise presented to stutters has beencontinuous and triggered by a manual switch,which was under the conscious control of thesubject.

Sutton and Chase (1961) used the stutterer'sphonation 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 thecontinuous masking and found that fluencywas improved in all conditions and thatmasking during silence was just as effectiveas even continuous masking or maskingonly during phonation.



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Dewar, Dewar and Barnes (1976) producedthe Edinburgh Masker, which incorporates adevice for triggering the masking sound bymeans of a laryngeal microphone switch.

It is activated only when the subject initiatesphonation and claims have been made thatstutterers have obtained considerable benefitfrom 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 noisepresented binaurally in alternate 5minute periods.

All subjects experienced a decrease in stutteringfrequency during the first 5-minute period, inwhich 100 dB noise was presented.



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Over longer periods of time while using a

tone with an intensity of 100 dB,

one subject increased and

one subject decreased the frequency ofstuttering slightly.

Third subject showed a significant decrease instuttering frequency.



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Ingham, Southwood and Horsburgh (1981)

Aim: Evaluate the effects of masking noiseover a longer period of time and

they required 4 stutterers to read andspeak spontaneously during eight 30minute sessions, 2 hours with theEdinburgh masker and 2 hours without.



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Result:

Stuttering was absent during masking for only onesubject.

While, another subject showed some improvementduring spontaneous speech only.

The remaining 2 subjects displayed only marginalreductions in stuttering during spontaneous speechor oral reading.

The fact that some stutterers can maintain some

increase in fluency with masking noise has led tothe development of portable masking machines toassist transfer of noise-induced fluency.



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Portable Maskers:

Parker and Christopherson (1963) designedthe unit originally to assist stutters to speakmore freely during psychiatric examination,but later considered that this device could beuseful for the treatment of the stutter itself.

This machine was considered only as anadjunct 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 totherapy. She combined the use of the maskerwith a treatment technique described by VanRiper (1963) and trained her subjects to

activate the masker when learning to pull outof a block.



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Aim was to shift the stutterers self-monitoringfrom auditory to tactile and proprioceptivechannels.

While using the masker none of the stutterersobtained stutter free speech and although thefrequency of stuttering remained

approximately the same, there was asignificant reduction in the severity of theblock.

There have been variations on the type ofmasker used.



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Perkins and Curlee (1969) experimented witha masking device, which generated a pulsing

signal with variable rate and intensity andcompared this with an unfiltered white noiseunit.

Their subjects were 3 stutterers who were inthe final phases of conversational rate controltherapy and used these devices to assisttransfer of fluency to situations outside the

clinic.



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All subjects reported that stuttering was

decreased with both units, though 2 subjectspreferred the pulsed noise to the white noise.

A pulsed signal was also used by Donovan(1971), who developed a device, whichcombines a pacemaker and masking sound.



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Difficulties:

Like so many devices, difficulties have been

reported in the use of masking for treatmentof stuttering.

Wingate (1976) has commented thatstutterers do not adapt to the use of thisdevice even on an intermittent "as needed"basis, or sometime, inappropriate reactionsare elicited from others who may erroneously

believed that the stutterer is deaf and shoutto him.



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Van Riper (1973) has also noted that somepatients tended to press the switch to activatethe masker either too soon or too late andeven when the therapist turned on the noise,his reaction time delayed the contingentsound.

Voice activated masking devices would seemto be useful here. But concern here is long-term effect on the stutterershearing.

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



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The role of masking noise in therapy:

Despite the difficulties, masking devices couldbe regarded as useful adjuncts to therapyspecifically:

To shift the stutterers attention from auditory totactile/proprioceptive monitoring of speech(Gruber, 1971).

To encourage the stutterer to monitor speechwithout recourse to the auditory channel or togive him confidence or the feeling of fluency indifficult speaking situations.



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Dewar et al (1976) have noted thatmasking noise may also help to reduce

concomitant movement of stutterers.

Effective with children the effect beingmaintained after the device was removed(Mac Culloch, Eaton and Long 1970)

However, there is a paucity of

information on the long-term effects onauditory masking on child stutterers.



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DAF therapy:

The program consists of several stepsto teach the patient

to read, engage in monologue, and

converse in slow, prolonged fluent patternwith the aid of delayed auditory feedbackapparatus.



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The first 6 steps are to teach the patient tocorrectly identify stuttered words in

reading and monologue. Criteria of 1minand 90% accuracy of identification areused in these stages.

The next 7 steps involve reading and useDAF starting with 250msec of delay, whichis gradually reduced in 50msec steps until

the patients can read in the prolongedfluent pattern without the DAF equipment.



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The next 7 steps are to use these in

monologue and then the final 7 steps arethe same except that these are inconversation.

The patient has to reach to a criterion of 5min of fluency in each of the 21 steps topass. Verbal reinforcement such as "good" isadministered for the completion of the steps.The program also includes transfer of thetechnique.



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The four main types of auditoryfeedback are:

Delayed auditory feedback (DAF) delays thevoice to your headphones a small fraction of

a second (typically 50 milliseconds).

Frequency-altered auditory feedback (FAF)

shifts the pitch of your voice in yourheadphones, typically one-half octave.



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Laryngeal auditory feedback (LAF) providesthe sound of your vocal fold vibration tothe ears.

Synthesized auditory feedback (SAF)provides a synthesized tone which soundslike your vocal fold vibration. The popularEdinburgh Masker device provided SAF.



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All four types of auditory feedback reducestuttering about 80%.

The devices require no training or mentaleffort. The client's speech sounds normal andcan talk as fast as he/she wants.

But without the headphones the fluency rightback to stuttering.

But with few exceptions, stutterers don'tprefer to wear a prosthetic device all thetime. They want to overcome stuttering.



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Hence, auditory feedback devices should be

used in conjunction with stuttering therapy.

The stutterer should switch off the device forshort periods and continue to use fluencytechniques.

The stutterer then switches off the device for

longer periods, until he no longer needs thedevice.


h C id d l


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The Computer-Aided FluencyEstablishment and Trainer (CAFET)

This monitors the breathing and voice.

The computer trains the client to inhalegently, 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 doingwhether right or wrong always with acontinuous feedback.


Metronome:


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Metronome:

A metronome is any device that produces a

regulated audible and/or visual pulse, usuallyused to establish a steady beat, or tempo,measured in beats-per-minute (BPM) for theperformance of musical compositions.

Stutterers can speak fluently when they timetheir speech to the rhythmic beat of ametronome.

Although metronomes have been widely usedfor the treatment of stuttering, their effect isreportedly difficult to transfer to daily life.



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Pocket fluency system:

It is used 1 hour each day in most stressfulconversations.

DAF and FAF help to slow down and stay incontrol of the voice, so that the client can

maintain the fluency.

Then carryover fluency is maintained withoutthe device in easier conversations later in the

day, Overtime, need for use of the device willbe reduced, until he doesn't need to wear itat all.


k fl


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Desktop fluency system:

Vocal tension biofeedback displays green lightwhen the client's speaks with relaxedbreathing, vocal folds and lips, jaw & tongue.

A red light alerts when the client tenses the

speech production muscles. DAF and FAF helpto slow down and stay in control of the voice.

Professional who is on the telephone at least

one-hour per day and whose most stressfulconversations are telephone calls, experiencecarryover fluency the rest of the day and don'tneed to wear a device.



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School DAF: Used to slow down andimprove control of speech. It is pocket sized

and easy to use.

Telephone fluency system: for adults whoonly need fluency on the telephone, and don'twant the advanced therapy features of thedesktop fluency system, this provides delayed

auditory feedback and frequency-shiftingauditory feedback.



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Voice changer: provides frequency-shiftingauditory feedback in 3 playful voices: robot,

alien and ghost.

Immediately makes stuttering children fluentand makes shy children talk, helpful fordiagnosing language disorders.

The child hears his voice in headphones the

clinician hears only the child's natural voice.


Bi f db k t i i


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Bio feedback training:

As struggle behavior plays an important rolein stuttering, the use of relaxation techniquesin the treatment of this disorder has beenknown to produce fluency.

It not only aims to inform the patient of thedegree of tension present in the musclegroups, but also of the effectiveness of hisstrategies for reducing this tension.


Th t id l d bi f db k hi


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The most widely used biofeedback machinefor the treatment of stuttering EMG.

Electrodes are placed over the muscles beingstudied to pick up their electrical signals andthese signals are then electronically amplified

processed and finally displayed, by eitherauditory or visual means to the patient.

Alternatively some biofeedback machines are

dependent on psycho galvanic skin responseand thus give a measure of generalizedtension than that of specific muscle groups.



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Other methods assessing degree of tensionwould include measurement of heart rate,laryngography etc.

Monitors utilizing EMG feedback have beenmost widely used; recourse to other types ofmonitoring may reveal additional informationon physiological changes occurring before

and during the stuttering instance.


St tt i d I d M l


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Stuttering and Increased MuscleActivity

Biofeedback machines have been used todemonstrate that increased muscular activityexists either before or during the audible orobvious moment of stuttering.

Shurum (1967) measured surface electricalactivity of facial, neck and chest muscles instutterers and found that stuttering waspreceded by an early and sustained rise in

signal amplitude in almost all musclesstudied.



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Knox (1974) using spectrographic analysis

found increased fundamental frequency,inappropriate transition and slow rate ofarticulation in the seemingly fluent syllablespreceding the obvious moments of stuttering.

The results were interpreted as evidence ofexcessive laryngeal muscle activity.


Bi f db k i T t t


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Biofeedback in Treatment

Electrode placement: One of the majorproblems in the use of biofeedbacktechniques 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 sitespecification would thus involve:



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Choosing the site showing the highest EMGlevel during blocks, or

Noting the voice quality breakdowns orairflow deviations during observed blocks.

This may also involve an analysis of thosesounds that seem to be most oftenblocked, e.g. if the patient showed mostdifficulty with /p/, /b/, /m/ and /w/,electrodes would be placed on the lips.



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Guitar (1975) found that the effective sites didnot necessarily correlate with sound

production, e.g. he found that by placingelectrodes on the lips, stuttering was reducedon lingual consonants.

Each stutterer there is an optimal site forelectrode placement, but a means forascertaining this has not yet beensystematically developed and it thus seems

likely that this decision will be based on trialand error for some time.


Type of feedback display:


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Type of feedback display:

The stutterer is given feedback of his degree oftension either through the auditory or visualchannel.

Auditory feedback may involve a series ofaudible clicks, which are increased or decreasedaccording to a rise/fall in tension, or tensionmay be represented by a constant sound, risingin pitch.

Visual feedback often takes the form of amodified voltmeter. There is little evidence tosuggest that one form of feedback is moreeffective for some/all stutterers.


Possible technique:


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Possible technique:

Patient is given an initial period of training inreducing tension levels of these muscles byattending to the biofeedback machine.

When the patient has learned to relax thesemuscle groups he is given a criterion level toreach, often 4-5 v (Laynyon et al 1976) orthe criterion level is determined by averagingthe integrated EMG activity during base linesegments (Moore 1978).



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If the patients tension levels rose beyond thecriterion level they received a blast of white noisewith an intensity of 65 dB, but if the patientsremained below the criterion level 85 % of the

time over at least two 5 minute segments, thenthe criterion voltage was decreased in either 2.5or 5 v Steps.



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Patients are then instructed to look at thefirst word of speaking task and by utilizingthe biofeedback machine, ensure that thecriterion level has been reached. If it has,

they can proceed to say the first word of thetask. The same procedure is used for everyother word until gradually the length of thetask in increased.


Transfer:


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Transfer:

In order to assist in transfer a period ofindirect feedback may be given.

Lanyon (1977) utilized visual feedback, which

involves turning the feedback monitor to facethe therapist who requests that the stuttererdoes not begin to speak until he has reachedthe criterion level already practiced withdirect feedback.



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If the patient speaks too soon or too lateafter criterion level has reached, the therapist

then indicates to the client that he shouldinitiate speech. Thus the client is trained toattend to somaesthetic cues without relyingsolely on biofeedback instrumentation.

The results of most studies employing thistechnique have shown that stutterers wereable to achieved increased fluency when

using the material given to them in thelaboratory or clinic conditions.


Rationale


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Rationale

The concept of distraction has been used, i.e.if the stutterer's attention is almost entirelytowards achieving and maintaining a certaincriterion level of relaxation, he does not thinksolely of his speech.

The fluency effects of these techniques mayalso result from the biofeedback equipmentacting as a vigilance device ensuring that thestutterers pay more attention to the planningand execution of his utterances (Cross 1977).



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If stuttering is regarded as an anticipatory

disorder, biofeedback training may beeffective, as it trains the stutterer to lower oreliminate covert pre-utterance activity (Guitar1975). The stutterer may have some form ofdiscrete awareness of types of physiologicalbehavior involved in his disfluencies andtherefore learn strategies, which help to

reduce these.


V l e of Biofeedb k t i i


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Value of Biofeedback training

One of the main advantages of thistechnique is that it is unobtrusive as thestutterer does not noticeably modify or

alter his speech, but rather provides forhimself the pre utterances reduction oftension and/or pre utterances strategies,which assist fluency. Laynyon (1977)

lists the advantages of instrumentationas:


A greater degree of experimental precision is


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A greater degree of experimental precision ispossible

Objective criteria for relaxation arecontinually available and

Immediate and continuous feedback ispresent.

Biofeedback training could be helpful particularlyin the initial stages of a fluency instatementprogram but would be most effective if regardednot as a single treatment technique, but as part of

a wider therapeutic program designed to meet therequirements of each individual stutterer.



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Guitar (1975) found that subjects showinggreat amounts of laryngeal tension were lesssuccessful when using biofeedbacktechniques. Future use of biofeedback

techniques will be limited to the early stagesof therapy with the stutterer i.e. diagnosticand fluency instatement phases.


Hypnosis:


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Hypnosis:

It is the state of 'heightened sensibility'. Under

hypnosis the person is not truly asleep, as EEGstudies have shown that his cortical brainwaves are undistinguishable from thoserecorded in his waking states when his eyes

are closed.

Van Riper (1958) found that fluency couldbe attained when the patient was deeplyhypnotized, but there was only a momentarytransfer of this fluency, when the post hypnoticsuggestion was used, that the stutterer wouldbe able to speak without stuttering.


I i fl t d h h ti


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Increase in fluency was noted when hypnotictraining was used to induce relaxation while

speaking and then the post hypnoticsuggestion was given that the stutterer couldspeak in the same relaxed suggestion wasgiven that stutterer could speak in the samerelaxed way upon coming-out of the trance.

Unfortunately these fluency effects wore offand patients required more and more

hypnotic session boosters to maintain therelaxed way of speaking.


Hypnosis and speech therapy


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Hypnosis and speech therapy

Van Riper found the inhibition and unlearningof instrumental behaviors more rapidly bymeans of hypnosis.

Use of hypnosis either to assist the patient inachieving success with a speech symptomtreatment or to desensitize him to variousfeared situations and the attendant anxiety.



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Ritcher (1928) gave one of the early reportson the use of hypnosis to aid speech

symptoms. He hypnotized stutterers and toldthem while in a hypnotic trance, to repeatsimple words and sentences speaking slowlyand carefully.

Moore (1946) also used hypnosis as asupplementary method to other systems oftherapy and found that the relaxationobtained by stutterers under hypnosis

persisted during subsequent performances incomplex speech situations.



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Lockhart & Robertson (1977) combinedhypnotherapy and block control.

Under hypnosis, patients were givensuggestions to improve awareness of tactile

feedback and to associate block control withcalmness, confidence and relaxation.

23 patients were given this form of treatmentand 10 were discharged as fluent with someevidence of maintenance of fluency.


Eli it ti f Eti l


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Elicitation of Etiology: Hypnosis would help to elicit the cause or

causes of this disorder; the researchersassumed that the etiology was related tosome emotional trauma.

Hypnosis and psychotherapy: Morley (1957) mentions the use of hypnosis

during psychotherapy with the severestutterer who is unable to speak the sufficientfluency to explain his thoughts and feelings to

the psychiatrist. However, hypnosis does notseem to have been widely used, or at leastno great claims have been made of its use inthis connection with stutterers.


Treatment of children:


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Treatment of children:

Silber (1973) used hypnosis with children whopresent with various speech disordersincluding stuttering. He sees the goals ofhypnosis 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 almostcompletely on terms comparable with the child'sunderstanding imagination and needs.


Value of hypnosis:


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Value of hypnosis:

The use of hypnosis with stutterer's value lies

in the treatment of non-speech symptoms orin providing the patient with a feeling deeprelaxation and enhanced fluency, through thepatient should be cautioned that this is not a'cure'.

It is also likely that only a limited number ofstutterers will respond positively to hypnosisand interestingly, much, of the reportedsuccesses of hypnosis has been with patients

who began to stutter relatively late inchildhood or in adulthood.


Drugs:


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Drugs:

Wolloch(1977) suggested dietary techniquesto control stuttering recommending aromaticsalty & sharp food , while advising abstinencefrom pastries ,nuts & fish .

Sir Francis Bacons belief that the stuttertongue was cold & dry & noted that moredifficulty was experienced at the beginning ofsentences, hence suggested that the stutterershould drink hot wine to heat the tongue


Van Riper (1973) gives examples of Bantu


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Van Riper (1973) gives examples of Bantustutterers chewing garlic while those in Japan

were forced to swallow raw eggs or to earcharred shirkers or frogs tongues.

Thus stutterers have been treated to dietary

control, swallowing of unpleasant substancesand the use of drugs, which seem to have hadvarying effects, including purgatives, tonics and

analgesics.


The effects of various drugs and place


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The effects of various drugs and placeplacebos on the stutter have been

investigated, the tranquillizing drugs havebeen popular, as these have a calming effectdo not appear to alter the state ofconsciousness.

Reserpine: A useful drug for anxiety reductionbut its effect on stuttering is still unclear.

Meffert (1956) in a single case study found thatthe stutterers speech showed a reduction in

disfluency during administration of reserpine. Butthe results are variable in different cases.



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Some of the other tranquilizers used forthe treatment of stuttering include:

Chlorpromazine

Meprobamate

Pentobarbitone (Barbiturate)


Haloperidol :


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Haloperidol :

which is thought to block dopamine

receptors and so increase the turn overrate of acetylcholine.

Use of haloperidol arose because of theresemblance of the stuttering to the tics,

habit spasm, and movement disorders ofGilles de la Tourette syndrome.

They consider that the tremor in the

Parkinsons is superficially similar to theslowness and tense pauses in stuttering.



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Although results with this drug so far veryvariable further studies with the other agentsaffecting the dopaminergic system would be

useful to assist understanding of a possibleethological factor in stuttering.


Stuttering : Behavior therapy


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Stuttering : Behavior therapy

Behavioral approaches to the treatment ofstuttering have always been popular, in partbecause stuttering severity has long beenknown to diminish under a variety of specific

conditions such as reading in chorus,rhythmic speech, singing, speakingwhen alone, talking to animals orinfants, use of masking noise, use of

delayed auditory feedback, and speechshadowing.



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Some of these conditions have been utilizedas the basis for therapeutic programs. In thefield of speech Pathology, behavior therapy

has been vastly applied Perkins (1971).



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It has been shown that stuttering response isan operant that occurs in the context of

another operant i.e. verbal behavior (Flagan etal).

It is a learnt maladaptive behavior that ismaintained through habit strength and orreinforcement, and that it is reinforced by thesubjects own feedback on an a periodicalschedule which is highly resistant forextinction.


Th b f i i l


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There are a number of principlesinvolved in behavioral therapy that

helps to bring about rapid and effectivelearning. This includes:

The first principle is that knowledge orbehavior to be learned should be arrangedin small structured steps.



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Attention should only be given to the nextstep in the sequence, which should alwaysbe sufficiently small so that the patient isalmost certain to perform it correctly.

Failure to master a step within a shortspace of time usually means that the stepwas too big, and the therapist should break

it down into two or more smaller steps.


Advantages:


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g

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, andpatient motivation is continually maintained.


Accurate rehearsaland repetitivepracticeare thed i i l


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second principle.

Immediate feedback about the patient'sperformance, whenever possible, is the thirdprinciple. Learning will be more efficient if feedbackis given immediately en the extent to which the

patient's performance was accurate. Eventually thepatient will learn to observe himself and provides hisown feedback on the adequacy of his behavior.

The fourth basic principle in rapid effective learningis the importance of setting highly explicit goals.


The various techniques that fall under the


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qumbrella of behavioral approach are:

Extinction

Differential reinforcement of other behavior

Punishment

Negative reinforcement Reinforcement

Response cost

Time-out

Over correction

Modeling


G id d ti i ti


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Guided participation

Shaping

Systematic desensitization

GILCU

Role-playing

Cancellation

Pull-outs

Covert sensitization

Cognitive restructuring

Self-control


Extinction :


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The term extinction is applied to a

procedure in which reinforcement thatpreviously followed an operant behavior isdiscontinued. No punishment is involved;instead a formerly available reinforcer is nolonger provided when the target response

occurs.

Compared with other procedures, extinctionless rapidly produces behavior cessation, and

may even cause a brief increase in theemission of the previously reinforced behavior(extinction burst).



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It is an easy principle but difficult in practiceto identify and consistently withholdreinforcement for the particular targetbehavior. Moreover, to be most effective

extinction should be used with behaviors thathave continuously rather than intermittentlyreinforced.


Differential Reinforcement of Other


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Behaviors (DRO):

DRO consists of differentially reinforcing thepatient's behaviors exceptone specific targetbehavior. Thus, the target behavior is placedon an extinction schedule while behavioralalternatives are reinforced.

Omission Training:Similar to DRO, involvesreinforcing the child for failing to emit the

objectionable behavior during a specified timeperiod.


Differential Reinforcement of


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Differential Reinforcement ofIncompatible Responding (DRI): Here,

one reinforces behaviors that are physicallyincompatible with the undesirable response.This is a variant of DRO.

Differential Reinforcement of Low ratesof Behavior (DRL): Here, the targetbehavior may be tolerable, or evenappropriate at a low rate, but troublesome

when very frequent. Lower rates ofresponding are reinforced in such situations.


Punishment:


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Review of literature in the treatment of

stuttering will show the predominance ofpunishment.

From a blow to the head to the contingent

blast of white noise, punishments of all sortshave been applied to stutterers.

Numerous experiments have shown that

punishment has produced remarkable changesin the frequency of stuttering.


Some of the various forms of punishment that have


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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 theskin)


Drinking decoctions of persimmon stones.


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Swallowing raw eggs.

Swallowing a variety of vile substances

Purging after being forced to swallow catharic crotonoil

Chewing of garlic by Bantu stutterers.

Impletol blocking (subcutaneous injections a

injections at speech organs, which causeAnaesthetization of the cutaneous zones of speechorgans, which reflexively spreads to the cerebralcenters of speech).

Electrical shock, warm baths and music.

Eating charred frogs tongue

Loud blasts of noise or tones.


Punishment consists of decreasing rate of a


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Punishment consists of decreasing rate of aparticular response by applying an aversive

stimulus or event contingent upon the emissionof that response.

Punishment can consist of an aversive stimulusor of the contingent withholding of positivereinforcement (as in time-out procedures).



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Punishment should be used as a last resortafter positive reinforcement; extinction andDRO programs have failed to alter theundesired behavior. Great care must be taken

to protect the client's rights and welfare whenutilizing punishment. New alternatives toharsh physical punishment (i.e. electricshock)



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Paced instructions and commands atregular intervals.

Ignoring client

Undiluted lemon juice Hot pepper sauce

Facial screening with a bib

Immobilization


Reprimands:


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Reprimands, criticism, and just plainscreaming are the ones most commonly used.

Reprimands are used to suppress children's

undesirable behavior following the failure ofpositive reinforcement contingences toincrease the rate of alternative responses;reprimands are not physically painful, so are

less objectionable than most other forms ofpunishment.


Reinforcement:


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The reinforcement most easily utilized intreatment programs possess the followingcharacteristics:

They are resistant to satiation: if a child becomesrapidly satiated with a reinforcer the numberpotential of learning trials is reduced as his rate ofbehavior changes. To prevent satiation, a variety

of reinforcers need to be used, & the trainingsessions need to be kept brief if the child's task isrepetitive.


Reinforcers should be administered


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immediately after occurrence of the desired

behavior.

Reinforcers should be administered in smallunits and frequently. Offering copious

amounts of reinforcer, but infrequently andfor large amounts of work can result in aratio strain and consequent disruption orcollapse of performance. By being stingythe program will prosper as long as thechild is not underpaid for his efforts.


Reinforcer used should be solely under the


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treatment agent's control. If the reinforcerused (i.e. a candy) is given to the child byan aunt, then the effectiveness of the usageof candy is lost as a reinforcer.

Rein forcers should be compatible with theoverall treatment program.

Reinforcers must be practical. Chose

reinforcers which are readily available,inexpensive, easily administered and shouldhave no obvious side effects.


Praise and Tokens: Whenever possible


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generalized reinforcers, such as praise or

points that are exchangeable for back-upreinforcers should be used, rather thanprimary reinforcers such as food.

Praise a particularly useful reinforcer becauseit is used frequently in everyday life, and thusis natural to the child and. adult. Wheneverpossible use praise statements that describethe desired performance as these statementsaid the client in identifying and responding toresponse contingency.


Negative Reinforcement:


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g

The great bulk of the stutterer's abnormalityconsists of avoidance and escape. Therefore,negative reinforcement, which by definitionconsists of the escape from punishment,should prove to be a powerful therapeutictool if used wisely.



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For example, if an attempt is made toextinguish a tongue protrusion, the stutterercould be asked to read aloud to some listenerfor an unpleasantly long time-say 60 minutes-

but for each time he stutters withoutprotruding his tongue he can deduct 5 minutesfrom that long hour.


Response cost:


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In a response cost (RC) contingency,

engaging in a specified prohibited behaviorproduces a loss of reinforcing stimuli andevents.

Most often, point, tokens or money are

removed contingent upon the client's makingan incorrect response. Responses cost penalties are employed most

often in situations where the client is earningpoints or money for desirable performances.

Responses cost contingencies are oftenincluded in token economy programs.


Deprivation of privileges is another


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p p gcommon response cost procedure.

There are a variety of response costprocedures in current use, they include:

Deprivation of privileges

Fines of tokens/ money/ points

Fine of allowed free time.


Time-out from positive reinforcement:


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Is a mild form of punishment in which an

undesired response is followed by a shortperiod during which customary, ongoingreinforcement is withheld.

As the name implies, time out from positivereinforcement (TO) derives its effects from acontrast with rich positive reinforcement

schedule for the child's desirable actions.



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Hall and Hall (1980), claim that if TO isused correctly, it always results in adecrease in the target behavior's rate.However, if used incorrectly, TO

procedure can cause problem behaviorrates to increase.


Over correction


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Foxx and Azrin (1972, 1973) developed overcorrection (OC).

OC consists of a reprimand ("Don't shake your

leg"), a description of the undesired behavior("you are tensing up your shoulders again") ora rule statement ("we don't drum ourfingers"). The client is then administered

restitution or positive practice OC, or both.


Restitution Over correction: Requires the


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qchild to make amends for any damage he has

done and to overcorrect or improve on theoriginal state of affairs. The client is requiredto compensate for whatever harm he\she hasdone.

Treatment effects seem to be more enduringwith children than with adults, perhaps

because adults have engaged in thedisordered behavior for longer periods(Marholin, et al., 1980).


Modeling:


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The therapist attempts to facilitate behaviorchange, by having the client witness theperformance of another person themodel.

In some cases, the client learns how toperform new responses; in others, to refrainfrom making old, unwanted responses; and inothers, to make certain responses morefrequently.


M d li d i d


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Modeling procedures are non-coercive andeffective providers of information, and arehighly effective, especially in the alleviation ofspecific fears or phobias.

If the modeling program fails, then thetherapist can always turn to the morecumbersome shaping procedures to builddesirable behavior or can use responsesuppression techniques to reduceinappropriate responding.


Guided Participation:


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Guided participation in fear-provokingsituations has been particularly effective(Blanchard, 1970; Rosenthal & Bandura,1978).

Here, the client first watches a model engagein approach behavior and then graduallyimitates the models performances. The clientis gently induced to participate with theassistance of whatever performance aidsarenecessary.


For example, the client with fear of publicspeaking situations might first watch models


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speaking situations might first watch modelsfearlessly speaking in front of large groups of

people.

The use of several different models is moreeffective than restricting to just the onemodel.

After witnessing the demonstration, the client

is asked to be on stage with the models whilethey speak.


Next the client may be asked to contribute afew words or sentences to the models speech.


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few words or sentences to the models speech.

In successive and gradual phases the client isasked to behave increasingly boldly, until hefinally speaks to the group just as the modelsdid.

Bandura (1977) believes that such successfulexperiences are helpful in building self-efficacyexpectations, or feeling that one cansuccessfully complete a task. Self-efficacyexpectations, in turn, promote furtherperformance gains.


SHAPING:


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Shaping consists of the therapist's requesting

and reinforcing successive approximations tothe final behavior.

The client's behavior might initially be tooinfrequent or overly brief, or the behavior

may be too delayed, of too low intensity, orthe performance form may be inappropriateand require change.

Each stutterer has his own unique set of

progressive approximations through which hecan sequentially work.


SYSTEMATIC DESENSITIZATION:


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Wolpe and Eyesenk first popularized this

technique.

When using systematic desensitization (or

reciprocal inhibition therapy), a therapistusually describes a set of threateningsituations, sometimes called an anxietyhierarchy. With the help of the client, the

potential situations are ranked from leastthreatening to most threatening.


According to Van Riper the aim is to reduce


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According to Van Riper, the aim is to reducethe client's negative feelings about stuttering.

Desensitization aims to dissociate theresponse from the stimuli.

If the client can become toughened to hisstuttering and if he can learn that he doesnot need to panic when he anticipates

stuttering, the eventual modification of theproblem becomes easier.


There are a number of desensitizing techniques

(Van Riper):


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(Van Riper):

Calming the client down

Eye contact

Self disclosure

Voluntary stuttering

Freezing


Gradual Increase In Length andComplexity of Utterance (GILCU):


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Complexity of Utterance (GILCU):

This is a 54-step program that starts withreading a single word and works up to 5minutes of fluent conversation.

The words are constantly changed and theclient is reinforced for each fluent novelresponse.


The GILCU program is concerned with thedevelopment of fluent speech through the


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development of fluent speech through thecontrol of the evoking stimuli.

These procedures have concentrated onstarting with simple verbal tasks such asuttering one word.

These programs are characterized by verylow rate of stuttering throughout the

procedure. This program is recommended forpreschoolers.


Role Playing:


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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 attitudeof the person assuming the role, and sinceattitudes tend to influence behavior, role-playing should be a useful aid.



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The client and therapist role-play various

scenes which pose speaking problems for thepatient expressing disagreement with afriend's social arrangements, asking a favor,talking to a superior at work, talking toparents, talking to a group of people, talkingto persons of the opposite sex, etc.


Commencing with the less demandingsituations first each scene was systematically


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situations first, each scene was systematicallyrehearsed until troublesome encounters have

been enacted with satisfaction of the clientand therapist.

The client's role is shaped by means ofconstructive criticism as well as modelingprocedures in which therapist assumed theclient's role and demonstrated desirableresponses.



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Training role enactment docs seem tofree stutterer to a remarkable degree.Moreover, it has its own inbuiltreinforcement, since stutterer often

speak much more fluently when playingsome other part. And they becomemore spontaneous, less constrained.


Self control:


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The use of self control procedures often

involves the manipulation of cognitiveelements, such as the client's awareness ofthe rate at which he emits a certain response.

The client is instructed to determine howoften the target behavior occurs and underwhat condition. Some efforts are usuallymade to alter those conditions that, it is

hypothesized, are helping to maintain thebehavior.



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Finally, the client, with the help of the

therapist, will attempt to program hisenvironment so that the unwanted behaviorwill be punished or its absence rewarded.

Alternatively, some behavior that interfereswith the undesirable response might besystematically rewarded. Usually, littlereliance is placed on the attempt to control

the unwanted response by the use of "willpower".



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These were the number of the behavioral

therapy techniques in behavioral approach totherapeutics that can be utilized in the

habilitation of a stutterer. Over the past yearsthe developments of behavioral approaches

to stuttering have rapidly increased inpopularity and now constitute the majority of

therapeutic endeavors.

approaches to management of fluency disorders.pdf / kunnampallil gejo

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