Identify two potential treatment techniques that would be suitable for use with an adult. Your answer should name the treatment and include a summary of evidence from the literature which supports the use of the treatment with adults (20 marks)
With respect to stuttering treatment in adults, the type of positive feedback system suggested earlier involving the interplay between the hemispheres and between emotions and speech implies that successful therapy or management of stuttering must have at least two components. The first is to counteract the fragility of the left hemisphere system. This is done when speech is modified through the use of fluency shaping skills, or through the use of stuttering modification skills. The deliberate use of gentle onsets, linking phonation or respiration control, for example, focuses attention on motor skills and brings speech within the capability of an inefficient and fragile speech motor system. The second component of successful treatment or management of stuttering is to remove sources of interference with speech. A major source of interference is right-hemisphere activity. One implication is that, therapy include dealing with avoidance, withdrawal, and apprehension. As these tendencies are overcome, the right-hemisphere activation associated with them decreases and then the interference with the left-hemisphere SMA decreases.
Currently, the influence of theory on treatment for adults who stutter appears to be minimal. However, the literature suggests that the management of stuttering in young children is still predominantly theory driven. Specifically, the theoretical perspective that drives much current treatment for young children is that stuttering is a multifactorial disorder.
The real context within which stuttering treatment decisions are made is actually often a small room containing a clinician, a worried parent, and a preschooler who has unquestionably been stuttering for some number of months or even years. Alternatively, the room might contain a clinician and a slightly diffident teen who would rather not stutter but who is not entirely comfortable seeking help, or even a clinician and a cautiously hopeful adult who has decided to try stuttering treatment again. In these and most other clinical situations, the theoretical and academic arguments discussed here become much less relevant, and the practicalities of clinical decision-making take precedence. Given this context, many authors writing about stuttering treatment seem to agree that restricting oneself or one’s clients to only one approach may be artificially limiting, recommending combined or eclectic treatments as an alternative.
Outline a potential management plan for Catherine. Include in your plan goals and techniques relating to:
Multifactorial models describe stuttering as the result of a combination of a number of innate and environmental factors. In their strongest form, multifactorial models maintain that any combination of a range of innate and environmental factors may cause stuttering and that the combination of causal factors is different in each person. Further, according to these models, it is not necessary for any of the factors, of themselves, to be pathological or abnormal. The factors simply interact in unique ways to cause stuttering. In short, proponents of this type of multifactorial model maintain that the innate and environmental factors are together necessary but neither is sufficient for a child to begin stuttering, and no one factor in either domain is either necessary or sufficient for the condition to occur.
Multifactorial models of stuttering have risen to prominence over the past decade or more, to the extent that there is even a view among some current writers that this view of stuttering is indisputable. It has been argued that dissatisfaction with previous theories and models of stuttering was instrumental in this rise to prominence because they looked for purely physical or purely environmental factors to account for stuttering and failed to account for the variability and unpredictability of stuttering. However, we have argued elsewhere that all this does not necessarily mean that stuttering has many causes and that these causes must be different in each person (Onslow, & Packman, 1998).
- Transfer of fluent speech to her work environment (10 marks)
Social praise (and tokens, in some applications) is provided contingent on fluent speech, and “stop, speak fluently” is used contingent upon stuttering. The transfer phase addresses the goal of fluent utterances in multiple speaking conditions and situations, and with multiple people; verbal reinforcement and punishment are used in the transfer phase. The maintenance program consists of reading, monologue, and conversation measurements (less than 0.5 stuttered words per minute; SW/M, is required to pass each step), along with reports of the client’s speech from the client and from persons in his/her environment, which are gradually faded.
Progression through the establishment, transfer, and maintenance phases requires the client to produce no more than 0.5 SW/M during 5 minutes of reading, 5 minutes of monologue, and 5 minutes of conversation in a “Criterion Test” before progressing to the next phase of the program. If any one of these three situations is failed, the client repeats the steps of the program congruent with the failure (e.g., repeats the reading steps if more than 0.5 SW/M was produced on the reading portion of the criterion test). Criterion tests are given before establishment, after establishment, and after transfer. Clients, parents, or spouses are also taught to identify stutters so that home practice can be conducted.
- Maintenance of fluency (10 marks)
Many of the methodological details that may have contributed to the poor maintenance of fluency shown in investigation continue to be seen in some subsequent treatment investigations, as is discussed in further detail later. These include pass criteria within and between steps that allow some stuttering, unclear criteria for progression between steps, no data from the natural environment, questionable definitions of stuttering, and no maintenance program.
Lastly, the studies reported by Ryan and his colleagues (Ryan & Ryan, 1995) are marked by subject attrition, with some participants moving or failing to complete parts of the program in time to be included with the reported results. Their discussion of reasons for attrition is exemplary and a necessary part of proper experimental protocol, but the resulting differences in group sizes do complicate interpretation of data from transfer and maintenance phases.
Imagine that Catherine had significant difficulty transferring her fluent speech to her work environment. Name factors that you would investigate that may be contributing to her difficulty (10 marks)
Ingham (1990) stressed the need to identify “‘pivotal’ situations; that is, situations which act as ‘barometers’ for all or most speech performance” (p. 92). However, it seems that we have not progressed very far in identifying such “pivotal” situations, if in fact there are such situations. Despite the fact that a number of recent treatment studies have measured stuttering outcomes outside the clinic, there seems little consistency in the making of those measures.
The real context within which stuttering treatment decisions are made is actually often a small room containing a clinician, a worried parent, and a preschooler who has unquestionably been stuttering for some number of months or even years. Alternatively, the room might contain a clinician and a slightly diffident teen who would rather not stutter but who is not entirely comfortable seeking help, or even a clinician and a cautiously hopeful adult who has decided to try stuttering treatment again. In these and most other clinical situations, the theoretical and academic arguments discussed here become much less relevant, and the practicalities of clinical decision-making take precedence. Given this context, many authors writing about stuttering treatment seem to agree that restricting oneself or one’s clients to only one approach may be artificially limiting, recommending combined or eclectic treatments as an alternative. This approach seems reasonable at first, but it raises a problem similar to the problem raised for the multiplicity of theories about stuttering: If none is correct, what argument could possibly be made to support the notion that all are correct? Theanswer, for the individual client in my clinic this morning as well as for our discipline as a whole, cannot come from accepting all common or proposed treatments as reasonable. It might come, however, from an evidence-based focus on effective and efficient treatments that are known to result in well-defined intermediate, instrumental, and ultimate goals. Individual client–clinician pairs need to identify their desired outcomes and then use evidence-based treatments that have been shown to result in those outcomes; our discipline as a whole needs to focus on developing the information base necessary to make such evidence-based, outcomes-focused treatment possible.
Evidence-based clinicians and researchers suggest using treatment approaches that have been well-supported in the literature and that seem to the client and the clinician in question to be a reasonable way of effectively and efficiently approaching their mutually agreed upon goals. Evidence-based thinkers, in addition, share with scientist practitioners and other empirically based clinicians and researchers the assumption that data must be gathered during treatment, used as the basis for decisions in that treatment, and then publicized to become the source of improved future treatments. Stuttering treatment and stuttering treatment research can only move forward, for individual clients and as a professional discipline, with a commitment to increasing the quantity and the quality of the evidence that selected approaches can effectively and efficiently reach a series of well-defined intermediate, instrumental, and ultimate goals and outcomes.
Part B – Compare and contrast
- Two treatments for early childhood stuttering
It is also widely believed that early childhood stuttering is highly responsive to professional intervention. Numerous studies have reported on the benefits of treatment for early childhood stuttering, although few are actually supported by scientific evidence (Cordes, 1998). Still, a high percentage of school speech-language pathologists (70%) agree that they are successful in treating preschool children who stutter and treatment research shows that management of early childhood stuttering often requires minimal treatment time and usually results in satisfactory, long-term outcomes (Onslow & Packman, 1999).
But what happens to those children who continue to stutter into their elementary school age years and beyond? It is widely believed that the longer they live with the disorder, the more persistent, complex, and chronic it will become. Unassisted recovery becomes less and less likely and the need for treatment becomes more and more likely. In fact, by the time stuttering has persisted into adolescence, the disorder is typically viewed as highly resistant to change and difficult to manage.
Clinician surveys and treatment studies appear to support this view. School speech-language pathologists agree that stuttering treatment is less and less successful as the age level of their stuttering clients advances from elementary to high school levels. Treatment research findings documenting long-term stuttering treatment outcome based on adolescents and adults are consistent with this picture. Evidence shows that treatment of persistent stuttering requires considerable professional and economic resources, substantial treatment time, and outcomes that for almost one third will include relapse within 6 to 12 months post-treatment or an improvement that is considered unsatisfactory (Onslow & Packman, 1996).
But in the midst of this rather negative portrayal, there is an often overlooked body of research suggesting that persistent stuttering is not always as intractable as widely believed. There is evidence suggesting that stuttering is sufficiently changeable that adolescent and adult aged speakers who stutter are capable of improving to a degree that they no longer consider themselves handicapped by stuttering and some even recover to the extent that they are essentially perceived as normally fluent speakers. This improvement in many cases occurs without the benefit of professional help and it appears that most learned to self-manage their disorder. The evidence that supports these statements and focuses on the following questions: Why has the phenomenon been ignored, what are rates of recovery after childhood, what are subjects’ perceived reasons for recovery, and what are the implications of these findings for understanding recovery from stuttering?
A high rate of recovery without treatment occurs during adolescence and adulthood. It also appears that females who stutter are more likely to recover than males, a trend also evident during early childhood. Second, at least two thirds of speakers who recover after childhood believe it was because of self-change, their own efforts to reduce or eliminate stuttering without professional help. Furthermore, these self-regulated efforts resulted in speech fluency that was reportedly functional and usually perceived as normal by everyday contacts as well as the investigators who studied them. Occasional stuttering was more likely to occur with late recovery, but this tendency was highly situational and easily managed. Fear of stuttering may still linger for some; but for most it now appears to be absent.
The conventional view of stuttering after childhood is that the disorder becomes resistant to change and difficult to manage. Although treatment outcome research based on adolescents and adults who stutter supports this view to some extent, it is not based on a complete account of all adolescents and adults who have ever stuttered. Contrary to popular perception some adolescents and adults recover from persistent stuttering and, more significantly, this recovery often occurs on the basis of their own self-help efforts and without professional help. Their resulting speech fluency may not always be perceived as completely normal or natural but it is still functional for everyday purposes and although there may be occasional stutters, these are easily self-managed.
References
- Ingham, R. J. (1990). Research on stuttering treatment for adults and adolescents: A perspective on how to overcome a malaise. In J. A. Cooper (Ed. ), Research needs in stuttering: Roadblocks and future directions (pp. 91–94). Rockville, MD: American Speech-Language-Hearing Association
- Ingham, R. J., & Packman, A. (1977). Treatment and generalization effects in an experimental treatment for a stutterer using contingency management and speech rate control. Journal of Speech and Hearing Disorders, XLII, 394–407
- Ryan, B. P., & Ryan, B. V. K. (1995). Programmed stuttering treatment for children: Comparison of two establishment programs through transfer, maintenance, and follow-up. Journal of Speech and Hearing Research, 38, 61–75.
- Onslow, M., & Packman, A. (1997). Designing and implementing a strategy to control stuttered speech in adults. In R.F Curlee & G.M. Siegel. Nature and treatment of stuttering: New directions. Allyn and Bacon: Boston.
- Menzies, R., Onslow.M., & Packman, A. (1999). Anxiety and stuttering: Exploring a complex relationship. American Journal of Speech-Language Pathology, 8, 3-10.