Efficacy of Stuttering therapies

Introduction Efficacy is the extent to which a specific intervention procedure, regimen or service produces a beneficial result under ideally controlled conditions when administered or monitored by experts (Last, 1983). In contrast treatment effectiveness is the extent to which an intervention or treatment employed in the fields does what it is intended to do for a specific population. Otswang (1990) observed that treatment efficacy is a broad term that can address several questions related to:  Treatment effectiveness (does treatment work)  Treatment efficiency (does one treatment work better than other) and  Treatment effects (in what way does the treatment alter the behavior)

Criteria for Treatment Effectiveness Van Riper (1973), Andrews and Ingham (1972) and Sheehan (1984) summarized ten tests, which as method of treating stuttering must meet before it can be considered successful. 1. The method must be shown effective with an ample and representative group of stutterers. 2. Results must be demonstrated by objective measures of speech behavior such as frequency of stuttering or rate of speech and by judges rating of severity. Such measurements should be made before, during and after treatment by observers. 3. Reports of therapeutic success must be based on repeated evaluation and adequate samples of speech. 4. Improvement must be shown to carryover to speaking situation outside the clinical setting. The best known but frequently ignored fact about stuttering is that is the special environment of clinic stutterer are likely to become normal

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5. The stability of result must be demonstrated by long-term follow-up investigation. The follow-up evaluation is likely to be biased if it is done in the same clinical environment in which treatment was administered. 6. Suitable control groups or control conditions must be used to show that reductions in stuttering are the result of treatment. There are other variables besides adaptation to the clinical setting that may create a false impression of successful therapy. For eg. Spontaneous recovery especially in children 7. Subject must sound natural and spontaneous to lustiness. Residual element of slowness, monotony or stereotype in the subject‟s speech may seen more peculiar to listeners that the stuttering itself. 8. Subjects must be free from necessity to monitor their speech though fluency can hardly be considered normal as long as continued attention on part of speakers is required to maintain it. 9. Treatment must remove not only stuttering but also fear, anticipation and person‟s self concept as a stutterer. 10. Success of a therapy program should not be conflated by ignoring drop out. The problems presented by stutterers who dropout of treatment has been pointed out by Martin (1931). Estimates of the improvement during therapy are often based exclusively on those who complete clinical program.

Treatment Efficacy of Various Therapeutic Approaches I. Perceptual Measures a. Frequency Measures Frequency measures are calculated in terms of percentage of syllables / words (%SS or %WS) usually. In order to obtain %SS or %WS scores, the number of syllables / words is counted along with the number of words / syllables that are stuttered. For outcome research frequency measure is most acceptable because large differences are of interest. The following table shoes the results of various studies that used percent of dysfluency as a measure to depict the outcome of prolonged speech procedure, gentle phonatory onset, and smooth flow of speech. The Results of all KUNNAMPALLIL GEJO JOHN, MASLP

these studies indicate that the post-treatment mean percent dysfluency reduced significantly to less than 5%, which is considered as normal. Prolonged Speech Author No. of Subjects Spencer (1976) 5 Age of Subjects Adults and children Boberg (1976) 21 17 – 44 3 weeks Duration of Treatment 4 months Stuttering was reduced to less than 1% of syllables Stuttering decreased from mean of 21% of syllables to 1.3% Franck (1980) 68 Mean of 20.2 years 1 year 95% of subjects increased fluency by 60% or more Boberg (1980) 6 16 - 46 years 3 weeks Mean percent syllables stuttered decreased from 16.55 or more Howie, Tanner & Andrews (1981) Eveshen and Huddles (1983) Boberg (1984) 12 18 -47 years 2 weeks 47 Adults 3 weeks 91% stuttered on less than 1% of syllables Mean percent of stuttered syllables decreased from 18.9 to 0.9 Gentle Phonatory Onset Author No. of Subjects Webster (1975) 56 Age of Subjects 8-59 years Duration of Treatment 3 months Significant difference in pre-post treatment Schwartz and 29 9-50 years 3 weeks 97% improved, 72% Results 36 Adults 3 weeks Stuttering was virtually eliminated Results

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Webster (1977)

stuttered on 6% or less of words

Webster (1980)

200

3 weeks

Mean percent of words decreased from 15.1 to 1.3

Mallard and Kelly (1982) Schulman (1983)

50

14-50 years

6 weeks

Mean percent of words fell from 20.05 to 2.92

85

6-65 years

4 weeks

84% achieved normal or near-normal fluency in conversation

Franken, Bover, Peters and Webster (1992) Onslow, Costa, Andrews (1996)

32

15-46 years

3 weeks

Mean % of stuttered syllables declined from 25.7 to 5.8

12

10.7-41.6 years

3 weeks

Within clinic and beyond clinic % SS reduced generally to near zero

b. Speech Naturalness The adjective natural is derived from the Latin word naturalis, meaning „of nature‟. The impetus for studying speech naturalness of individuals treated for stuttering came from observations that though the frequency of stuttering decreased, listeners found that many speakers continued to sound unnatural. Their speech was effortful, uncomfortable to listen to, and contained auditory or visual features that prevented listeners from fully attending to the content of message Author No. of Subjects Age of Subjects Ingham and Packman (1978) 9 adolescents and adults compared with 9 age 13-24 Listener‟s ratings of naturalness of clients recived significantly fewer normal Results

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matched normals Martin et al, 1984 10 adults without DAF 10 adults with DAF 10 normals Ingham and Onslow (1985) 9 – point rating scale for speech naturalness Ingham, Gow & Costello (1985), 9 – point rating scale of martin Metz, Sxhiavetti, Sacco (1990) 9point rating scale !5 stutterers and 15 normals matched for age and gender 15 males, 15 females Mean 14.5 years 5  21-45  20-51  20-53

speaker judgments Both group of stutterers sounded less natural than the normals

adolescents

Predicatble trends in speech naturalness Stutterers speech naturalness could be modified to targeted levels Mean naturalness rating if 4.26 for stutterers and mean value of 2.39 for non-stutterers

Strategies like gentle voicing onset and prolonged speech may slow the post therapy speech patterns and the may influence listeners to judge speech of stutterers to be more unnatural Most severe clients‟ speech prior to treatment and naturalness scores more than 2 values higher (less natural) than least severe clients.

Onslow, Hayer and Newman (1992) Considered the effect of severity on pre and post treatment naturalness ratings

36

9-50 years

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Onslow, Adam and Ingham, 1992 compared the influence of monologue and conversation speech. 9 – point rating scale Martin and Horoldson, 1992 studied visual components of stuttering related to speech naturalness judgements used 9-point rating scale Finn and Ingham, 1994 (Stutterers self rating of naturalness)

7 male stutterers and 7 normals

14-36 years

No significant differences in the naturalness scores of conversation / monologue for either stutterers or normals

6 males and 4 females (stutterers) 6 males and 6 females (normals)

20-62 years

Naturalness judgments of fluent speakers were not

21-64 years

significantly different for audio and audio-visual samples on rating scale (2.3-2.7 respectively) but audiovisual samples were judged to be more unnatural than audio only

11 males and 1 female

Adults (19-71 years)

Stutterers gave valid self ratings of speech quality and were consistently able to differentiate how natural their speech were

Other naturalness rating scales were developed by Subramaniam (1997) and Kanchan (1997). Subramaniam scale included confidence, command over language, clarity, speed of stuttering and overall rating. It was a binary scale for both natural and unnatural items. Kanachn‟s scale was also a binary one which included rate, continuity, effort, stress, intonation, rhythm, articulation, breathing pattern and overall rating. Currently the 9 – point scale developed by Martin et.al 1984, has been widely used and reliable for either oral reading or spontaneous speech. KUNNAMPALLIL GEJO JOHN, MASLP

c. Assessment Conditions: Ideally the speech samples should be obtained under multiple conditions and on multiple occasions (Conture, 1996). Speech measures should be collected without client‟s knowledge that their speech is being evaluated so that they do not react to being assessed and try to create a favorable outcome and speech outcome measures should reflect everyday speech performance free from stimulus controls. The following table summarizes assessment conditions used in prolonged speech therapy technique. Author N Stuttering Severity Speec h rate Speech task Frequency of Assessmen t Andrew and Ingham, 1972 Howie, Tanner and Andrews , 1981 Webster, 1980 20 0 % of dysfluencie s Reading, conversatio n on phone Twice in 10 months Within and beyond clinic Boberg, 1981 16 %SS Reading, conversatio n on phone 3 times in 12 months Within and beyond clinic Andrews 37 %SS SPM Phone Twice in Within 36 43 %SS %SS SPM SPM Phone conversatio n in both groups Twice in 9 weeks 23 %SS SPM Monologue 4 times in 18 months Within and beyond clinic Within and beyond clinic Overt in both condition s Overt and covert Situatio n Nature

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and Feyer, 1985 Andrews and Craig, 1988 Boberg and Kully, 1994 42 %SS SPM Phone 84 %SS SPM Phone

12 months

clinic

Twice in 18months

Within clinic

Overt

4 times in 24 months

Within clinic

Overt

Many of the Speech outcome data are based on single within clinic situations / telephone calls from staff in clinic, where the clients may be able to control their stuttering with a pronounced speech pattern that cannot be used in everyday speaking situations. Long term Efficacy of Prolonged Speech Measure In a literature review of current clinical status of fluency following treatment for stuttering, Boberz and Kully 1985 concluded that though the treatment procedures such as prolonged speech may reduce / eliminate stuttering, the long term effects were not satisfactory.

Author

Method

N

Age

Duration of treatmen t

Results

Follow -up interval

Results

Webster (1980)

Prolonge d speech

20 0

-

3 weeks

Mean % of stuttered words reduced from 15.1 to

Mean of 10 months

Mean % of stuttered words was 3.2

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1.3 Boberg (1981) Prolonge d speech 6 16-46 years 3 weeks Decreased from 16.55 or more 12 months Mean % of stuttered syllables of 8 subjects was 1.53 at end of 12 months maintenance period Honie, Prolonge 36 Adult s 3 weeks Stuttering virtually eliminated in 5 subjects Gentle phonatory onsets 50 14-50 3 weeks Mean % of stuttered words fell from 20.05 to 2 Heller, Schulman, Teryak, 1983 Gentle phonatory onsets 85 6-65 6 weeks 84% achieved normal to near normal fluency in conversatio n Craiz and Andrews, 1988 Smooth flow speech 17 Adult s 3 weeks Mean % declined from 12.90.9 Andrews Smooth 37 21-60 3 weeks Mean % 10-15 10 months Mean % stuttered syllables was 1.9% Mean % 6 months to 5 years 2 months Little significant deterioratio n At least Mean % of 6 months stuttered words for 28 subjects was 9.74 80% maintained their post treatment fluency levels

Turner and d speech Andrews, 1981 Mallard and Kelly, 1982

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and Feyer, 1985

flow speech

declined from 14.10.1

months

stuttered syllables was 1.1%

Frank et al, 1922

Gentle phonatory onsets

32

15-46

4 weeks

Declined from 25.7 to 5.8

6 months

Mean % stuttered syllables was 16.3%

Boberg and colleagues , 1987

Prolonge d speech

16

3 weeks

12-16 months

Mean % was 6.38 outside clinic, 1.86 in reading, 2.54 conversing with strangers

II. Acoustic Measures The use of a novel speech pattern to eliminate stuttering is a speech motor adjustment, and temporal aspects of motor activity are reflected in temporal pattern of acoustic activity (Bover 1987, Cent 1999). Discovery of functional acoustic components of speech patterns could lead to development of more cost and time effective treatments for advanced stuttering (Onslow and Ingham, 1989). Ingham in 1983 highlighted that stuttering could be reduced with the use of acoustic data feedback. Many other problems and issues could be resolved with the discovery of functional acoustic components of treatments based on prolonged speech. But it is unclear which acoustic feature of speech patterns in these treatments has a functional relationship to stuttering frequency. Additionally these patterns may be similar / different across subjects.

Almost all the studies on acoustic analysis of speech of stutterers are in adults. Results of the studies can be summarized as: KUNNAMPALLIL GEJO JOHN, MASLP

Authors

Treatment Procedure

No. of subjetcs 9

Acoustic analysis

Results

Metz et.al, 1979

Instructed to “slowly initiate phonation and maintain a forward flow of air and reduce articulation rate”

Increased duration for both vowels and stop consonants increased

Indication that stuttering therapy could alter certain acoustic properties of stutters‟ fluent speech

Metz et.al, 1983

Examined relationships between acoustic variables and fluency within a group of mild to severe stutterers

12 males,

Analysed CVC

Decrease in stuttering frequency, increase in voiced and voiceless VOT duration, increase in frication duration, voicing duration and no significant change in silence associated with intervocalic intervals 

5 females duration, VOT, absolute time of frication, voicing and silence associated with intervocalic intervals of both voiced and voiceless stop consonants

Mallard and Westbrook, 1985

Precision Fluency Shaping Program (PFSP)

26

Analysed vowel duration changes and also phrase duration

On an average persons with stuttering increased vowel duration.

Vowel duration decreased as

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stuttering moved from initial to final part of phrase Mohan Murthy Investigated (1987) acoustic and aerodynamic measures of /g/ before and after modified airflow techniques and soft contacts   One, 17 year old subject   Presence of atypical transitions Inappropriate voicing and duration of segments inspiratory frications Articulatory fixations Abnormal articulatory constrictions  Longer closing phases on Lxexcessive vocal adduction Franken, Bover, Peters and Webster, 1991 Onslow, Van Doom, Newman, 1992 Precision Fluency Shaping Program (PFSP) Prolonged speech School aged children VOT, Voice duration, and interphonation interval Decreased variablility in vowel duration Men of 32.4 years Prosodic features Decrease in expressiveness

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Madhavilatha, 1997

Instruction to initiate intonation patterns depicting emotions such as anger, surprise, sarcasm, command, quesyion and statement

1 normal (model), 10 stutterers

Analysis of different intonation patterns perceptually and acoustically

Reduced Fo range and longer sentence duration in stutterers, also other frequency and amplitude parameter

Ananthi, 2002

Prolongation therapy

1 normal (model), 10 stutterers

Analysed word stress, word duration, peak Fo, Lowest Fo and Fo range

No significant difference in stress and word duration

III. Cognitive, Pharmacological, Behavioral and other related approaches 1. Electromyographic Feedback (EMG) The subjects were provided with visual feedback about selected muscle activity.

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Authors

Age

Stuttering Frquency < 5%

Social, eotional or cognitive variables improved

Post Treatment Craiz & Cleary, 1982 Graiz et.al , 1996 10-14 years 9-14 years Yes Yes

At 6 months Follow-up Yes

Post Treatment -

At 6 months Follow-up -

Yes

Yes

Yes

2. Gradual increase in length and complexity of utterance A program which progressed from 1 word response to oral reading, monologue and concersational tasks mainly worked out with children. Authors Age Stuttering Frquency < 5% Social, eotional or cognitive variables improved Post Treatment Ryan and Ryan, 1983 Ryan and Ryan, 1995 7-18 years 7-17 years Yes Yes Yes At 6 months Follow-up Yes Post Treatment At 6 months Follow-up -

3. Metronome conditioned speech retraining: Authors Age Stuttering Frquency < 5% Social, eotional or cognitive variables improved Post Treatment At 6 months Follow-up Post Treatment At 6 months Follow-up

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Ost et.al, 1976

14-46 years

No

No

No

No

4. Prolonged Speech Authors Age Stuttering Frquency < 5% Social, eotional or cognitive variables improved Post Treatment Craiz et.al, 1996 Howie et al, 1961 Ingham, 1982 18 20 Ingham and Andrews, 1973 Ingham, 2001 1856 1828 Ingham and Packman, 1977 James et. al, 1989 O‟Brian et. al, 2003 Onslow, 1996 1041 Perkins et.al, 1974 Ryan and Ryan, 1963 KUNNAMPALLIL GEJO JOHN, MASLP 1252 7-18 Yes Yes No Yes Yes 1759 Yes 34 Yes Yes Yes Yes 42 Yes Yes Yes Yes Yes 9-14 21+ Yes Yes At 6 months Follow-up Yes Post Treatment Yes Yes At 6 months Follow-up Yes -

Ryan and Ryan, 1995 Tanbaugh and Guitar, 1961

7-17

Yes

Yes

-

-

12

Yes

Yes

-

-

Conclusion: Most of the above studies showed 50% reduction in stuttering frequency 5. Regulated Breathing and AIrflow Authors Age Stuttering Frquency < 5% Social, eotional or cognitive variables improved Post Treatment Andrews and Tanner, 1982a Andrews and Tanner, 1982b Landoucer, 1981 Landoucer, 1982 Landoucer and Martin, 1962 Landoucer and Saint 18-36 Laurent, 1986 Mittemberger et.al, 1996 Landoucer and Saint 18-50 Laurent, 1987 Franken, 2005 Harrison, 1999 Ingham, 1980 6 5 9-23 Yes Yes Yes Yes Yes Yes No 19-27 Yes Yes Yes Yes No No 15-47 17-74 5-16 Yes No Yes Adults Yes No Yes Yes 26 No At 6 months Follow-up Post Treatment Yes At 6 months Follow-up -

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James et.al, 2005 Lattermann, 2005

3-6 4-5

Yes Yes

-

-

-

6. Response Contingencies: Authors Age Stuttering Frquency < 5% Social, eotional or cognitive variables improved Post Treatment Wilson et.al, 2004 Franken, 2005 6 Yes Yes Yes Yes Yes 3-5 Yes At 6 months Follow-up Yes Post Treatment At 6 months Follow-up -

Harrison, 1999 5 Ingham, 1980 923 James et.al, 2005 Lattermann, 2005 4-5 3-6

Yes

-

-

-

Yes

-

-

-

7. Self Modeling of Fluent Speech

Authors

Age

Stuttering Frquency < 5%

Social, eotional or cognitive variables improved

KUNNAMPALLIL GEJO JOHN, MASLP

Post Treatment Bray and Kehle, 1996 1317 No

At 6 months Follow-up -

Post Treatment -

At 6 months Follow-up -

8. Shadowing

Otz et.al included 4 steps: Chronic reading, with clinician, changing text, immediate shadowing, delayed shadowing and whispering

Authors

Age

Stuttering Frquency < 5%

Social, eotional or cognitive variables improved

Post Treatment Otz et.al, 1976 1446 No

At 6 months Follow-up No

Post Treatment No

At 6 months Follow-up No

9. Token Economy

Authors

Age

Stuttering Frquency < 5%

Social, eotional or cognitive variables improved

Post Treatment Ingham and Andrews, 1973 1856 No

At 6 months Follow-up -

Post Treatment -

At 6 months Follow-up -

Indicators of Therapy Progress
Main indicators of therapy progress include: 1. Increasing the clients self monitoring ability

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2. Increasing the clients ability to produce „open speech‟ 3. Decreasing the frequency and duration of motoric fluency breaks 4. Increasing the naturalness of fluent speech 5. Metalinguistic changes 6. Decreased avoidance 7. Increased (speech) assertiveness 8. Improved self concept, self esteem and role changes

Increasing the clients self monitoring ability A basic indicator of progress is the speaker‟s ability to tuning tuning into what he is doing when he stutters and what he is capable of doing in order to enable himself to speak fluently. Even if he is not able to modify his production he may be able to accurately monitor what he is doing to make speaking so difficult. Accurate self monitoring of any behavior or thought process is a preparatory step toward taking responsibility and transforming the event. Self monitoring will continue to be a critical element of long term success. During the initial stages of treatment, the clients monitoring is focused on the overt stuttering behavior. Although the focus early in treatment is on monitoring rather than the modification of stuttering events, as speaker improves his ability to catch his behavior nearer to the initiation of the stuttering event, some instinctive and positive changes in the stuttering often take place. That is the speaker will not only recognize what he is doing to make speaking difficult, he will begin to make some changes in the behavior. He may provide himself with some airflow, or he may slightly decrease a constriction in his vocal tract that will assist him in smoothening his speech. These changes are small and transient victories to be sure, but the clinician should look for them and reward these subtle changes in the form of stuttering. As Conture (1990) indicates, the client‟s consistent identification at the beginning or the middle of stuttering events sometimes becomes associated with his ability to change his stuttering behavior.

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As treatment progresses, such self monitoring activities continue to be pivotal for long term progress outside the treatment environment. In addition, self evaluation also comes to mean the monitoring of the cognitive aspects of change, such as the self talk the client provides to himself prior to and following successful, as well as less than successful, speaking situations. Increasing the clients ability to produce ‘open speech’ Improvement can be observed during every treatment session by the clinician and the client if close attention is paid to the form of fluency breaks. Early in treatment the fluency breaks are typically characterized by a greater degree of vocal tract constriction and effort. As the speaker begins to understand the nature of his speech production system and becomes able to modify moments of stuttering, progress can be observed in the form of airflow, increased smoothness and blending of sounds and words. Perhaps most importantly he begins to produce speech with less vocal and articulatory effort. As he becomes able to monitor his production, especially via proprioceptive feedback, he will be able to appreciate the difference between the tension and constriction of old way of speaking and the new flowing and effortless production using an open vocal tract. The speaker as well as listener can hear the increased openness and ease of such speech movements. At each such occurrence of enhanced airflow and smoothness of articulatory of movement, there is the opportunity for the clinician to reward the progress. The client‟s speech may not be completely fluent, but the changes are obvious and satisfying. The result is a much easier form of stuttering. As Conture (1990) suggests, a shortening in the duration of stuttering is a sign of progress. The client is stuttering, to be sure, but it is the speech that is produced with less effort and is much easier to listen to. Decreasing the frequency and duration of motoric fluency breaks Decreasing the frequency of motoric fluency breaks is an obvious goal of treatment and a commonly used indicator of progress. As the speech becomes more open and flowing, both the frequency and especially the duration of stuttering movements should show some obvious changes. It may be that the frequency of brief stuttering events may even increase somewhat if the speaker is successful in changing in his KUNNAMPALLIL GEJO JOHN, MASLP

patterns of avoidance and word substitution. However, if the duration and associated tension in terms of both the degree and the sides of physical tension decreases, real progress is being accomplished. Again, this progress will be likely to be recognized by the speaker if self monitoring is maintained. Increasing the naturalness of fluent speech The impetus for studying the speech naturalness of individuals treated for stuttering came from observations that many people who had undergone successful treatment using fluency modification strategies continue to sound less than satisfactory. That is although, the frequency of stuttering had decreased dramatically, and listeners found that many speakers continue to sound unnatural. Their speech was effortful, uncomfortable to listen to and contained auditory or visual features that prevented the listener from fully attending to the content of the message. Despite an otherwise successful treatment experience, many speakers found that they were still regarded by themselves and others as having the problem. Naturalness Rating Scale In 1984, Martin, Haroldson and Triden began the development of a reliable scale for rating speech naturalness. The scale consisted of a 9-point rating scale with 1 equivalent to highly natural sounding speech and 9 equivalents to highly unnatural speech. This scale has been used in virtually all subsequent investigations of speech naturalness. Martin had 30 listeners use the scale to assess the speech naturalness of 10 adults who stuttered speaking without DAF, 10 adults who stuttered speaking under DAF, and a group of 10 normal speaking adults. They found that both groups of speakers who stuttered sounded significantly less natural than the non stuttered sample. The mean naturalness rating of stutterers was 6.5, stuttering group under DAF received an mean of 5.8 and non-stuttering group had a mean of 2.1. Based on inter rater agreement and rater consistency, Martin concluded that observers are able to quantify speech naturalness. VOT and sentence duration were found to be significantly related to and predictive of speech naturalness, with the VOT values being most predictive of

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naturalness during spontaneous speech and duration was the primary predictor of naturalness during reading. Metalinguistic Changes The way a person depicts his situation or problem often indicates important signs of progress during treatment. As people progress through effective treatment, they begin to think and talk differently about themselves and their speech. The intrinsic features of affective and cognitive change are reflected in the words the client uses to describe himself, his speech, and his interaction with others. How the client talks about himself and his speech provides a window for viewing these intrinsic features. Early in treatment the client typically feels helpless. He believes he is unable to do much to change his speech or himself. There is a high degree of mystery associated with stuttering. AS treatment progresses, client slowly begins to develop the language of fluency. As well as use more appropriate self talk. As the client begins to successfully change his previously uncontrollable behavior, he will begin to change the way he observes himself and his speech moreover, he will begin to describe his behaviors and actions in more specific and realistic ways. The client will begin to interpret stuttering as something that he is doing rather than happening to him. These metalinguistic changes provide the clinician with important evidence of change and indicate that the client is beginning to take charge of the problem. Such utterances may be used as a way to monitor cognitive changes or in some cases; the clinician can take a more active role and point out to the client how he is describing himself and his problem. The client‟s language will reflect some degree of liberation from the problem. That is coinciding with the fact that the speaker shows a great degree of fluency, they are more liberated in terms of their choices and have a greater involvement in life. Decreased Avoidance As avoidance decreases, the frequency of fluency breaks may increase. Early in treatment less avoidance and greater participation in speaking activities may yield a slight KUNNAMPALLIL GEJO JOHN, MASLP

increase in the frequency of stuttering. There may even be an increase in the duration and tension of stuttering events. Although these changes may not be pleasant to the client, if stuttering modification strategies are being used, they can be viewed as progress within the context of the overall treatment process. Taking part in activities and making better choices may not be the first step for each client, but it is always a critical step. Furthermore, a decrease in the avoidance behavior permits the client to go directly at the problem and the associated fear. Increased (Speech) Assertiveness With a decrease in avoidance behavior, there is likely to be a corresponding increase in overall assertiveness. In reality being more assertive about once speaking behavior is likely to translate into increased assertiveness in general. There may be changes in roles and a relationship as the persons no longer plays the primary role of a stutterer. It is a distinctive indicator of progress when the speaker begins to decrease his reflexive self censorship and begins to consider many speaking situations h once considered unimaginable. This is not to say that he will now take part nonetheless and to consider new opportunities is a significant measure of progress. Improved Self-Concept, Self-Esteem and role changes Self-Concept and Self-Esteem have been referred to many times in the literature on fluency disorders. According to Peck (1978), self esteem is the corner stone of psychological change. Although persons who stutter have not been found to have a unique self esteem or to be lacking in self esteem, this concept has frequently been mentioned as an aspect of treatment programs. When the client experiences success in the self management of surface and intrinsic aspects of his fluency disorder, self esteem and the self concept begins to shift in positive direction. This is certainly the case with children who are still in the process of developing their self concept. Of-course this is a major reason why intervention for fluency problems is much more likely to result in long term success in these groups of clients. Adults are also able to make big changes that are reflected in a changed view of themselves during and following treatment. They are able to redefine themselves and create an altered paradigm of their lives. Such changes can be KUNNAMPALLIL GEJO JOHN, MASLP

quantified by self reports during individual and group treatment sessions as well as by measures such as the locus of control.

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