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Treatment efficacy: Stuttering

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 Journalof Speech and HearingResearch, Volume 39, S18-S26, October 1996

Treatment Efficacy: Stuttering

Edward G. Conture
Syracuse University
Syracuse, NY

The purpose of this article is to review the state of the art regarding treatment efficacy for
stuttering in children, teenagers, and adults. Available evidence makes it apparent that indi-
viduals who stutter benefit from the services of speech-language pathologists, but it is also
apparent that determining the outcome of stuttering treatment isneither easy nor simple. Whereas
considerable research has documented the positive influence of tratment on stuttering fre-
quency and behavior, far less attention has been paid to the effects of treatment on the daily life
activities of people who stutter and their families. Although itseems reasonable to assume that
ameliorating the disability of stuttering lessens the handicap of stuttering, considerably more
evidence is needed to confirm this assumption. Despite such concerns, it also seems reason-
able to suggest that the outcomes of treatment for many people who stutter are positive and
should become increasingly so with advances in applied as well as basic research.

KEY WORDS: stuttering, treatment, efficacy, fluency disorders

There is both scientific and clinical evi-
dence that individuals who stutter ben-
efit from the services of speech-language
pathologists. This evidence is docu-
mented by experimental research, pro-
gram evaluation data, and case studies.
Olswang (1990) has observed that
treatment efficacy is a broad term that
can address several questions related
to treatment effectiveness (Does treat-
ment work?), treatment efficiency (Does
one treatment work better than an-
other?), and treatment effects (In what
ways does treatment alter behavior?).
Treatment efficacy studies have used
either group or single-subject experi-
mental designs to answer these ques-
tions; findings from both methodologies
are included in this paper. Information
will be used from other sources, such
as case studies, to supplement experi-
mental findings of treatment efficacy
with more individualized and client-ori-
ented accounts of treatment benefits.
Thus, the specific purpose of this ar-
ticle is to review the efficacy of state-
of-the-art treatment of stuttering in chil-
dren, teenagers, and adults. Stuttering
can, and often does, have significant
negative effects on the academic, so-
cial, and vocational achievements and
status of individuals who stutter. How-
ever, as will be shown, when treated
properly and in a timely fashion, much
can be done to improve the communi-
cation abilities of people who stutter.
Such improvements meaningfully con-
tribute to all facets of the person's per-
sonal and professional life.
Incidence/Prevalence of
Stuttering
To provide some context for the scale
of the disorder within the general popula-
tion and, thus, the relative need for treat-
ment, a brief review of the incidence and
prevalence of stuttering is appropriate.
Incidence
Incidence of stuttering is typically as-
sessed by estimating "the percentage
of adults who say they have stuttered
at some point in their lifetime" (Conture
& Guitar, 1993, p. 258). Estimates of
about 5% lifetime incidence (Andrews
et al., 1983) must be tempered by esti-
mates of a 50% recovery rate by age 6
(Andrews, 1984). In other words, only

C 1996, American Speech-Language-Hearing Association S18 0022-4685/96/3905-O 18

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about half of the 5% (i.e., 2.5%) will still
be stuttering after age 6. More recent
findings (Yairi & Ambrose, 1992; Yairi,
Ambrose, & Nierman, 1993), however,
indicate that within the first 2 years of
the onset of stuttering, recovery rates
for children range between 65% and
75%, with as many as 85% of children
recovering within the next several years
(i.e., about 4 of 5 [85%] children who
begin to stutter eventually recover).
Thus, the percentage of individuals who
stutter after 6 years of age is most likely
closer to 1% (i.e., about 4 out of 5 will
recover from a lifetime incidence rate of
5%), a figure consistent with the approxi-
mately 1%prevalence discussed imme-
diately below. The precise influence of
spontaneous recovery on treatment out-
come, particularly for preschoolchildren
who stutter, is unknown. However, it is
believed to be an important consider-
ation when evaluating treatment efficacy
for stuttering.
Prevalence
Prevalence of stuttering is typically
assessed by determining the number of
cases present in a population (e.g., a
school) during a given period of time,
divided by the number of people in the
population (Beitchman, Nair, Clegg, &
Patel, 1986). Seventeen studies of U.S.
schoolchildren cited by Bloodstein
(1995) report an average prevalence of
stuttering of 0.97%, with a range from
0.3% (grades 1-12: Rocky Mountain
area, Hull, 1969) to 2.12% (grades 7-
12: Tuscaloosa, AL, Gillespie & Cooper,
1973). Bloodstein's review of these stud-
ies suggests that the prevalence of stut-
tering remains relatively steady through
grades 1-9 and then declines each year
in grades 10, 11, and 12. Estimates of
incidence and prevalence of stuttering
are undoubtedly influenced by many of
the same issues that affect the assess-
ment of treatment efficacy-for ex-
ample, differences in definition of stut-
tering, measures of stuttering, and
sample sizes. Although advances in the
area of measurement of stuttering are
being made (e.g., time-interval judg-
ments of stuttering: Cordes, Ingham,
Frank, & Ingham, 1992; Ingham,
Cordes, & Finn, 1993), Ingham (1990)
correctly notes that there is still consid-
erable need for research that will im-
prove the reliability as well as the valid-
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ity of clinician- as well as researcher-
judgments of stuttering.
Definition of Stuttering
To provide further context for an over-
view of treatment efficacy for stuttering,
it also seems appropriate to consider
what researchers and/or clinicians typi-
cally refer to when describing stuttering
or stuttered speech behavior. Although
no universally acccepted definition of
stuttering exists at present (operational
or otherwise), certain observations can
reasonably be made.
Speech, like many other human behaviors,
is occasionally produced by speakers with
hesitations, interruptions, prolongations and
repetitions. These disruptions in...ongoing
speech behavior are termed disfluency and
the frequency, duration, type, severity and so
forth of these speech disfluencies vary greatly
from person to person and from speaking situ-
ation to speaking situation. Some of these
speech disfluencies, particularly those which
involve within-word disruptions (such as sound
or syllable repetitions), are most apt to be clas-
sified or judged by listeners as stuttering.
[Conture, 1990a, p. 2]
Thus, stuttering or stuttered speech
typically involves part-word repetition,
sound prolongation, monosyllabic whole-
word repetition, or within-word pause. It
has been shown, however, that stutter-
ing events can also be perceived as oc-
curring in the intervals between words
(e.g., Cordes & Ingham, 1995; Curlee,
1981; MacDonald & Martin, 1973)-for
example, on effortful-sounding or appear-
ing disfluency perceived between words,
such as a tense pause, hesitation, or
block. It is safe to say that methodologi-
cal advances such as the time-interval
measurements reported by Ingham and
colleagues (e.g., Cordes et al., 1992) will
undoubtedly refine both our description
as well as the measurement of those
behaviors perceived as "stuttered."
In brief, stuttering or stuttered speech
behaviors typically involve within-word
disfluencies (e.g., Boehmler, 1958;
Schiavetti, 1975; Williams & Kent, 1958;
Zebrowski & Conture, 1989) but some-
times can also include effortful-sounding
or appearing disfluency perceived be-
tween words, such as tense pauses or
hesitations (e.g., Curlee, 1981). How-
ever, it should be noted that not all within-
word disfluencies are consistently per-
ceived or judged as stuttered. For
example, mothers of children who do and
Conture: Treatment Efficacy in Stuttering S19
children who do not stutter infrequently
(15% to 30% of the time) judge as stut-
tered sound prolongations of relatively
brief duration (less than 300 ms) but very
frequently (83% or more of the time)
judge as stuttered sound/syllable repeti-
tions of any duration (Zebrowski &
Conture, 1989). Whatever the case, none
of the above discussion of the disability
(i.e., behavioral manifestations) features
of stuttering address the handicapping
(i.e., social, psychological, etc. disadvan-
tages) aspects of stuttering. Indeed, it is
fair to say that we need to know much
more about the influence of treatment on
the handicapping aspects of stuttering-
something to be discussed in this article.
As Purser (1987) notes, the evaluation
of treatment efficacy involves treatment
process research (e.g., study of the meth-
ods of conducting treatment) and treat-
ment outcome research (e.g., study of the
effects of treatment), the latter being the
focus of the present review. A basic chal-
lenge of treatment outcome research is
determining the most relevant aspects of
a stuttering disability to measure (see
Curlee, 1993), because many different
aspects of stuttering can be measured
(e.g., frequency of occurrence, duration,
severity, type of stuttering, associated
behaviors). For this, as well as other rea-
sons, St. Louis and Westbrook (1987)
note that "Determining the outcome of
stuttering therapy is not a simple task" (p.
235). Perhaps, as Baer (1990) suggests,
treatment research would be improved if
researchers were better able to discern
what clients' main complaints or concerns
actually are. To date, most published stud-
ies of the efficacy of stuttering treatment
have relied on measures of stuttering or
stuttered speech (e.g., frequency of stut-
tering). Thus, unless otherwise indicated,
this review of treatment efficacy will rely
on these kinds of objective measures of
stuttering or stuttered speech. We fully
realize that, as St. Louis and Westbrook
suggest, "achieving healthy client attitudes
or feelings, or a reduction of avoidance
or anxiety, are viewed as essential ingre-
dients inmany therapies" (p.236). Indeed,
treatment outcome measures, although
currently focused on changes in disability
features (e.g., frequency of stuttering),
should, in an ideal world, also assess
changes in the degree of handicap (e.g.,
extent to which an individual, after treat-
ment, enters and engages in previously
avoided speaking situations).
 S20 Journalof Speech and Hearing Research
Definition of Effectiveness
As Bloodstein (1995) notes, "The as-
sessment of results of therapy is a pro-
cess fraught with opportunities for error
and self-delusion" (p. 439). Although this
topic has been extensively reviewed
(e.g., Curlee, 1993; Ingham, 1984, 1993;
St Louis & Westbrook, 1987; Van Riper,
1973), we are still challenged to clearly,
objectively, and succinctly state what we
mean when we describe treatment as "ef-
fective." In other words, if we want to
describe the "effectiveness" of treatment
for stuttering, we need to define what we
mean by "effective." Perhaps we could
start by noting that effectiveness has
been defined as the "ability to produce a
specific result or to exert a specific mea-
surable influence" (Dorland, 1988). This
definition is not sufficient, however, be-
cause discussions of effectiveness fre-
quently involve descriptions of whether
a treatment was successful; and judg-
ments of success, it would seem, are
highly dependent on who is making the
judgment.
With regard to judging effectiveness
or success of treatment of stuttering, we
could discuss subject-independent mea-
sures of stuttering (e.g., frequency and
duration of instances of stuttering) as well
as subject-dependent measures of effec-
tiveness (e.g., the client's belief that he
or she can talk to anyone at any time;
Conture & Wolk, 1990). And, as Conture
and Wolk have stated, it simply is unclear
which of these measures is more impor-
tant in judging the effectiveness of stut-
tering treatment.
Beyond the use of inferential
(non)parametric statistics to assess
whether pre- versus posttreatment events
significantly differ, at present there are no
known, one-size-fits-all objective criteria
for judging effectiveness of stuttering treat-
ment-at least none that would receive
wide agreement among experienced
workers in this area. Ingeneral, treatment
for stuttering might be considered effec-
tive if it resulted in the individual's being
able to speak with disfluencies within
normal limits whenever and to whomever
he or she chose, without undue concern
or worry about speaking. More specifi-
cally, to quote Conture and Guitar (1993),
"treatment efficacy or effectiveness [may
be] maximum when [the person who stut-
ters] as a result of treatment exhibits the
ability to communicate readily and/or
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easily whenever, wherever, and to whom-
ever, whatever he or she wants" (p.254).
Thus, whatever the eventual consensus
definition of effectiveness of stuttering
treatment, it most likely will involve some
complex mix of subject-independent and
subject-dependent measures of change
in (a) stuttering or stuttered speech, (b)
related attitudes and feelings, and (c) will-
ingness to enter into and engage in vari-
ous communication situations with vari-
ous people. (For a thorough overview of
representative, contemporary treatment
regimens for stuttering see Peters &
Guitar, 1991, pp. 189-354.)
Effects of Stuttering on Daily
Life Activities
One model for understanding the ef-
fects of stuttering on daily life activities
is that of the World Health Organization.
This model has been applied to stutter-
ing by both Prins (1991) and Curlee
(1993). As described by Curlee (p. 320),
this model could be used to conceptual-
ize the disorder of stuttering as follows:
1. An impairment, including all the
neurophysiological and neuropsycho-
logical events that immediately precede
and accompany the audible and visible
events of stuttering
2. A disability, comprising all audible
and visible events that are the behavioral
manifestations of stuttering
3. A handicap, comprising the disad-
vantages that result from reactions to the
audible and visible events of a person's
stuttering, including those of the person
who stutters
Applying this conceptualization to the
possible effects of stuttering on "daily life
activities," one would appear to be de-
scribing the handicap of stuttering or the
handicapping conditions produced by
stuttering. Numerous informal observa-
tions suggest that stuttering, particularly
when it is not treated properly and/or in
a timely fashion, is a handicap in terms
of daily life activities (e.g., children refuse
to orally communicate in class, adults
select professions that require little or no
oral communication, individuals withdraw
from social contact because of fear of
speaking). Likewise, as the brief review
in the following section shows, more for-
mal observations indicate that stuttering
can be a handicap, to greater or lesser
39 S18-S26 October 1996
degrees, within three main "venues" of
daily life activities: work, school, and so-
cial interactions.
Work
Hurst and Cooper (1983) suggested
that stuttering was a vocationally handi-
capping condition after they found that
employers thought stuttering decreases
"employability" and interferes with pro-
motion opportunities. (For similar findings
regarding negative stereotypes about
people who stutter held by many groups,
e.g., school administrators, see also
Collins &Blood, 1990; Lass et al., 1994;
Ruscello, Lass, Schmitt, & Pannbacker,
1994; Silverman & Paynter, 1990.) Craig
and Calvert (1991) found that employ-
ers' perceptions of adult employees who
stuttered were enhanced for those who
sought treatment versus those who did
not. That is, employers seemed to have
less than positive perceptions of individu-
als who stutter; but when individuals ob-
tained treatment for stuttering, employ-
ers' perceptions of their speech was
considerably enhanced. Craig and
Calvert also found that 43% of these who
had maintained, on average, an 88% re-
duction in stuttering 10 months posttreat-
ment reported being promoted in their
jobs after treatment.
Hence, assessment of treatment effi-
cacy should not only take account of the
disability aspects of stuttering but the
handicap aspect of stuttering-for ex-
ample, how did treatment affect "job his-
tory, employer reactions, and communi-
cation efficiency in the work place" (Craig
& Calvert, p. 283). As these authors indi-
cate, it is "very important that clinicians
understand the relationship between
treatment and vocation outcome" (p.
281). Indeed, Howie and Andrews (1984)
suggest that a minimal requirement for
stuttering treatment outcome evaluations
should be the "extent of handicap" (e.g.,
avoidance of speaking, negative self-
concept, etc.).
School
Bloodstein (1995) states that there is
"fairly consistent evidence that stutterers,
on the whole, are poorer in educational
adjustment than normal speakers" (p.
253). For example, schoolchildren who
stutter are older than classmates who do
not stutter in the same grade, suggest-

ing that children who stutter are more
likely to be held back (e.g., Darley, 1955);
and schoolchildren who stutter have
lower achievement test scores than do
those who do not stutter (Williams,
Melrose, & Woods, 1969). Such findings
may result from the stuttering and/or from
those factors influencing the child's pre-
disposition to stutter, the onset of stut-
tering, or its persistence. To the extent
that stuttering affects educational adjust-
ment, appropriate and timely treatment
could be expected to improve the aca-
demic achievement and performance of
children who stutter.
Social
Bloch and Goodstein (1971), in a re-
view of a decade's research on person-
ality and adjustment of stuttering chil-
dren, concluded that there is no evidence
of severe maladjustment in children who
stutter. Bloodstein (1995) agrees that
seldom, if ever, has research found stut-
terers, as a group, to exhibit "recognized
patterns of psychoneurotic disturbance
[although] signs of mild social maladjust-
ment have been found frequently" (p.
213). What is clearly needed, however,
as Bloch and Goodstein suggest, is a
better understanding of how personal-
ity and social-emotional variables may
influence the type, length, and outcome
of treatment of stuttering and/or whether
such treatment changes or leads to im-
provements in psychosocial adjustment
and more satisfying lifestyles. (See
Blood & Conture, in press, for further
discussion of these issues.) As Lyon
(1992) points out, with regard to apha-
sia, there is less than complete under-
standing of how disabilities, in this case
stuttering, influence the mental health
of "normal" personalities. Thus, the effi-
cacy of current treatments for the handi-
cap of stuttering will remain unclear un-
til there are studies of how (and if)
psychological well-being ("mental
health") changes during and after treat-
ment of stuttering. Although informal
clinical observations suggest that
people who stutter-particularly adults
who have improved as a result of treat-
ment-report varying degrees of im-
provement in their social interactions,
the number, nature, duration, and sig-
nificance of these changes in social be-
havior and interactions are not very well
documented.
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Role of the Speech-Language
Pathologist in Treating
Stuttering
Speech-language pathologists, be-
cause of their academic and clinical train-
ing, national certification examination,
and state licensure (where applicable),
are the professionals who usually assess
and treat stuttering in children, teenag-
ers, and adults inthe United States. Aca-
demic coursework and practicum oppor-
tunities (diagnostic and treatment) in the
area of stuttering are available as a part
of all educational/training programs ac-
credited by the Council on Academic Ac-
creditation of the American Speech-Lan-
guage-Hearing Association (ASHA). A
Special Interest Division (SID) for fluency
disorders, organized under the auspices
of ASHA, is also available for speech-
language pathologists who specialize in
the study and treatment of stuttering. Fur-
ther testimony to the expertise of speech-
language pathologists inthe area of stut-
tering is demonstrated by the fact that
the editor and most associate editors and
editorial consultants of one of the major
journals in the area of stuttering (Journal
of Fluency Disorders) are speech-lan-
guage pathologists.
Speech-language pathololgists, who
work invarious employment venues-for
example, public and private schools,
public and private hospitals and clinics,
university and college clinics, and private
practice-routinely diagnose and treat
people who stutter. Although some man-
age a variety of communication disor-
ders, a number of speech-language pa-
thologists-with appropriate graduate-
level degrees (master's and/or doctor-
ates), certification, and state licensure-
have specialized experience, interest,
and training in stuttering. For stuttering,
as for all communication disorders, di-
agnosis is the gateway to treatment and
may consist of initial screenings, full-
scale evaluations, and subsequent re-
evaluations, when needed. Treatment for
stuttering can be intensive (i.e., many
hours every day for relatively few weeks)
or extensive (i.e., one or two hours per
week for several months to over a year)
and can involve both individual as well
as group treatment sessions. (See St.
Louis & Westbrook, 1987, p. 250, for fur-
ther discussion of the pros and cons of
"intensive" versus "nonintensive" treat-
ment for stuttering.)
Conture: Treatmment Efficacy in Stuttering S21
With children, particularly preschool-
children, treatment often includes consid-
erable parental involvement-for instance,
information-sharing and counseling regard-
ing parent-child communicative and related
psychosocial interactions (Zebrowski &
Schum, 1993) as well as training to
change parental communication and re-
lated behaviors (e.g., Kelly & Conture,
1991; Rustin & Cook, 1995; Stark-
weather, Gottwald, & Halfond, 1990).
Treatment can also involve response-
contingent procedures (e.g., Ingham,
1982; Onslow, Andrews, & Lincoln, 1994)
as well as various fluency-shaping and/
or stuttering modification approaches
(e.g., Kully & Boberg, 1991). Treatment
approaches used may be determined by
such factors as available resources at the
speech-language pathologist's place of
employment, age of the person who stut-
ters, possible exacerbation of stuttering
because of inappropriate parent-child
communicative interactions, nature and/
or severity of the person's stuttering, as
well as the clinician's training and expe-
rience in treating stuttering.
On following pages is a case study of
the speech-language treatment of a typi-
cal child who stutters. This case study is
not representative of all treatments for
school-age children who stutter but
merely one of the more typical treatments
such children receive.
Evidence of the Benefits of
Treatment
Bloodstein (1995), inhis review of ap-
proximately 150 studies of treatment for
stuttering, suggests several criteria for
assessing whether a method of treating
stuttering may be considered success-
ful (e.g., "Have results of the treatment
method been demonstrated by long-term
follow-up study?"; see a similar discus-
sion by Starkweather, 1993, pp. 151-
155). However, an exhaustive review of
such criteria is beyond the scope of this
paper. One might also evaluate or mea-
sure the effectiveness of various treat-
ments by using a single means of defin-
ing "stutter events." For example, one
might define stutter events as involving
(a) covertly perceived disruptions in
speech (e.g., a sense of loss of control)
and (b)overt, defensive, or coping reac-
tions to these perceptions (e.g., muscle
tensing) (Prins, 1991). Applying such a
definition in evaluating the efficacy of
 S22 Journal of Speech and HearingResearch 39 S18-26 October 1996

treatment of adults would lead to (a) "ex-
ternal" validation of the "defensive" re-
actions by people other than the stut-
terer-for example, the speech-language
pathologist or observers in the adult
stutterer's environment-and (b) "inter-
nal" validation of the covert perceptions
by the stutterer-that is, validation by the
stutterer him- or herself (Conture & Wolk,
1990; also see Prins, 1993). However,
using such definitions with children who
stutter would be problematic because of
the difficulties one would have in reliably
and/or validly assessing the presence of
and/or changes in "internal" or "covert"
perceptions of preschool and early el-
ementary school-age children. There-
fore, because both stuttering as well as
its diagnosis and treatment are likely to
differ across the life span in terms of fre-
quency, length, nature, type, and rates
of recovery, review of treatment efficacy
is probably best considered relative to
four age-groups: preschoolers, school-
age children, teenagers, and adults.
Preschool
Yairi (1993) and Yairi and Ambrose
(1992), in their review of the efficacy of
stuttering treatment in preschoolchildren,
report that there is a 65% or more spon-
taneous recovery or natural remission
rate (i.e., positive change with little or no
therapeutic intervention) inthe stuttering
of preschool children in the first 2 years
post-onset. Such remissions, however,
more than likely decrease as stuttering
persists. For example, Andrews (1984)
estimates a spontaneous recovery of
only 18% for those individuals who stut-
ter for 5 years or more.
Increasingly, clinicians appear to ad-
vocate early diagnosis and treatment of
stuttering (e.g., Conture, 1990b; Onslow,
1992; Peters & Guitar, 1991; Ryan &
Van Kirk Ryan, 1983); however, until the
recent, relatively large-scale study of
Fosnot (1993), Yairi (1993) noted that
only six studies on treatment efficacy,
involving a total of 14 preschool children
who stutter, had been published.
Fosnot's study involved 33 preschool
children who stuttered and who were fol-
lowed, at 6 month intervals, for a 5-year
period after their initial evaluation.
Fosnot reported that "of the 33 children
who graduated, 30 (90.91%) have re-
mained fluent" (p. 237). She did not in-
clude a no-treatment control group, be-
cause withholding or delaying services
for stuttering in preschoolers (as Fosnot
discusses, p. 246) may be fraught with
various ethical and therapeutic con-
cerns. Her findings do seem to support
the efficacy of treating stuttering in
preschoolers, because these children
were followed for a 5-year period after
their initial evaluation. However, it
should be recalled that recovery rates
for children who stutter (and who have
received no direct treatment) may range
as high as 85% (e.g., Yairi & Ambrose,
1992; Yairi et al., 1993). Therefore, it is
quite possible that some ameliorative
changes reported to result from treat-
ment of preschool children who stutter
are compounded by the fact that vary-
ing degrees of recovery apparently oc-
cur in the absence of direct intervention.
Recently, however, Gottwald and
Starkweather (1995) reported, on the
basis of 2-year posttreatment telephone
calls to parents, that "fluency had been
maintained" for 45 of 45 preschoolers
who were treated for stuttering. Likewise,
following encouraging preliminary find-
ings (Onslow, Andrews, & Lincoln, 1994),
Lincoln and Onslow (in press) recently
reported results of a relatively large-scale
treatment study of preschoolers who stut-
ter that employed a parent-conducted
program of verbal response-contingent
stimulation. Providing considerable sup-
porting data, Lincoln and Onslow con-
clude that significant in-clinic as well as
posttreatment reductions occurred in the
preschoolers' stutterings (e.g., 7 chil-
dren, who were studied 4 years post-
treatment, reportedly maintained fluent
speech). Thus, despite appropriate con-
cerns for the influence of spontaneous
recovery on treatment effects with pre-
school children who stutter, recent find-
ings are consistent with Fosnot and are
strongly suggestive of the benefits to be
gained by treating the early stages of
the disorder.

Background Information Treatment History

In February 1992, 9-year-old Michael was initially evalu-
ated at a university-based speech and hearing clinic, where
he was diagnosed as a moderately severe stutterer. At that
time, Michael averaged 11 speech disfluencies per 100
words of conversational speech, with his most commonly
occurring disfluencies being sound/syllable repetition (e.g.,
"wha-wha-when") and interjections (e.g., "and [uh] she
thinks"), with an average duration of 1100 ms per sound/
syllable repetitions. Michael's parents noticed that speech
was becoming "effortful" for their son and expressed concern
that his speech difficulties might not be resolved unless he
received intervention.
Because of caseload restrictions and scheduling difficul-
ties, treatment onset was delayed until September 1992,
when Michael was initially assigned to weekly parent-child
group treatment to address his speech fluency concerns.
Although Michael's parents demonstrated improvement in
terms of a number of communicative behaviors thought to
exacerbate childhood stuttering (e.g., they spoke at a slower,
more appropriate rate; and they lengthened pause time
intervals), Michael made minimal progress. Consequently, in
April 1993, a combination of group and individual treatment
was initiated. Individual treatment targeted two main goals:
(a) helping Michael learn to speak in a way that prevented or
minimized the instances of stuttering, and (b) helping
Michael learn to effectively and appropriately change or
modify instances of stuttering when they occurred.

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 Conture: Treatment Efficacy in Stuttering S23

School-Age Children
Conture and Guitar (1993), intheir re-
view of the efficacy of treating stuttering
in school-age children, focused on the
nine most recent studies (published
within the past 15 years), chiefly because
these nine studies (involving over 160
children) presented results that were
objectified in considerable detail. These
studies reported an average of 61% de-
crease (range: 33% to over 90%) in stut-
tering frequency and/or severity in
school-age children. One such study
(Ryan & Van Kirk Ryan, 1983), which re-
ported a 60% average improvement dur-
ing transfer (i.e., posttreatment) across
four different treatment procedures, is
particularly noteworthy interms of its com-
prehensive study of different treatment
approaches (serving as a model for how
such research should be conducted) and
the fact that it assessed treatment results
not only in clinical settings but in the
children's classrooms as well (the latter,
of course, being one of the salient ven-
ues inthese children's daily life activities).
More recent study of treatment outcome
with school-age children who stutter
(Runyan & Runyan, 1993), based on a
clearly explicated and seemingly reason-
ably motivated treatment program (i.e., the
"fluency rules program"), reports signifi-
cant improvement in 9 of 12 (75%)
school-age children. Likewise, in a care-
fully conducted comparison study of two
intervention programs with school-age
children, Ryan and Van Kirk Ryan (1995)
recently reported significant in-clinic im-
provement instuttering for nearly all chil-
dren studied (96%), improvement that
was reportedly maintained 14-months
posttreatment. Thus, although consider-
ably more study of treatment outcome
with school-age children who stutter is
warranted, present findings suggest cau-
tious optimism that many of these chil-
dren have been, are being, and will con-
tinue to be helped.
Teenagers
Schwartz (1993), in his review of treat-
ment efficacy studies of stuttering among
teenagers, notes that the "literature avail-
able regarding specific therapy programs
for adolescents is sparse" (p. 299). He
says further that, unlike when dealing
with preschoolers and younger school-
age children who stutter, "when dealing
with adolescents we are confronted with
a population who have experienced stut-
tering for a number of years" (p. 291).
Thus, length of time stuttering or experi-
ence with the problem suggests that treat-
ment islikely to take longer, to need modi-
fications from those used with younger
children, and to have less success than
with preschool or school-age children.
Daly, Simon, and Burnett-Stolnack (1995),
as well as Van Riper (1971), appear to
agree that the emotional, personal, and
social aspects of teenagers' fluency prob-
lems makes them among the '"toughest
clinical cases" a speech-language pa-
thologist must manage.
There is, however, some seemingly
positive news in this area. Recently,
Blood (1995) reported quite encourag-
ing preliminary findings regarding a cog-
nitive-behavioral treatment regimen de-
signed for relapse management in
teenagers who stutter. Besides minimiz-
ing relapse after treatment, inteenagers
as well as adults, we may be developing
some ability to make earlier predictions
of the likelihood of relapse (Craig &
Andrews, 1985; Craig, Franklin, &
Andrews, 1984). Craig and his col-
leagues provide some evidence that
measures of locus of control (i.e., an
individual's perceived control over him-
or herself and the environment) are use-
ful in predicting which individuals who
stutter will relapse 10 months after
completion of treatment-information
that may help clinicians make appropri-
ate adjustments inthe quantity and qual-
ity of treatment for some of their teen-
age and adult clients who stutter.
Furthermore, although outcome data
were not reported, Daly et al. (1995) re-
cently provided seemingly reasonable
suggestions for the treatment of attitudes,
beliefs, and perceptions of teenagers
who stutter-cognitive and emotional
changes that further research may show
to be crucial if the teenager who stutters

Treatment Progress ued to show decreases in frequency (average: 2 to 3

Group treatment was gradually discontinued, and
individual treatment was reduced once Michael began to
consistently demonstrate easier, more relaxed speech
production in a variety of speaking situations in the clinic, at
home, and at school. Michael's frequency of disfluency was
reduced to an average of 5 per 100 words of conversational
speech, and considerable improvements were noted (by
clinicians, parents, and teachers) in Michael's attitude toward
speaking and speaking situations and in his abilities as a
speaker. By January 1994, approximately 16 months after
treatment initiation, Michael's speech-language posttreat-
ment or "maintenance treatment" consisted of 8 sessions
(approximately one session every 40-45 days throughout
1994) to monitor and maintain his speech fluency skills.
Observations during this time indicated that Michael contin-
disfluencies per 100 words) and duration of disfluencies
(average: 400 ms or less) as well as increased willingness
and ability to speak in greater numbers and varieties of
speaking situations outside the clinic-for example, in the
classroom, answering the phone at home, and so forth.
Cost of Treatment
Given that the university-based clinic is a training as well
as service facility, costs are somewhat modest in comparison
to other service venues. Total cost of Michael's speech
treatment services was $885, which included the cost of the
initial speech-language diagnostic plus 12 group and 16
individual treatment sessions (but not including 8 mainte-
nance treatment sessions).

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 S24 Journal of Speech and Hearing Research
is to maintain improvements in fluency,
particularly after completion of treatment.
Adults
Blood (1993), in his review of the effi-
cacy of stuttering treatment in adults,
cites Bloodstein's (1987) review of over
100 studies with adults, in which Blood-
stein concluded that "substantial im-
provement, as defined in these studies,
typically occurs as a result of almost any
kind of therapy in about 60 to 80% of
cases" (p. 399). The literature inthis area
is voluminous, ranging from earlier very
promising results based on response-
contingent, operant behavioral models
(e.g., Ingham, 1982; Martin & Haroldson,
1982) through the use of various phar-
maceutical agents to ameliorate stutter-
ing (e.g., Andrews & Dozsa, 1977). Al-
though the long-term effectiveness of
certain behavioral approaches (e.g., R.
Ingham, 1982; J. C. Ingham, 1993) seem
supported by findings in carefully con-
ducted clinical investigations, the long-
term effectiveness of treating stuttering,
in whole or in part, with pharmaceutical
agents remains far less certain (see
Brady, 1991, for a thorough overview of
pharmacological approaches to stutter-
ing). When taken as a whole, however,
certain procedures (i.e., "prolonged
speech" and "gentle onsets") appear to
yield the greatest effectiveness for
remediating stuttering in adults, accord-
ing to a meta-analytical review of 42 stud-
ies of treatment of stuttering in756 adults
(Andrews, Guitar, & Howie, 1980). It is
also possible, particularly for adults who
stutter, that some treatments may lead to
increases in speech fluency at the cost of
decreases in the "naturalness of speech"
(e.g., inappropriately slow speech and
monoprosodic intonation). Indeed, some
changes in the "naturalness" of speech
do occur during and/or after certain treat-
ments for adults (Franken, 1987; Ingham,
Ingham, Onslow, & Finn, 1989); however,
it is unclear what impact, if any, such
changes have on long-term therapeutic
effectiveness for stuttering. Clearly, how-
ever, as suggested by recent reviews of
treatment efficacy research with adults
who stutter (Blood, 1993; Prins, 1993),
we need to expand our measurement of
treatment outcome beyond basic mea-
sures of disability and at least consider
such events as client attitudinal change,
locus of control, the cognitive nature of
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cues leading to coping or defensive re-
actions, and so forth. Such consideration
seems warranted given the possibility
that these nonspeech-but-related-to-stut-
tering events, at least with adults, may
have as much influence on long-term
treatment efficacy as modification of stut-
tering itself.
Returning to the apparent efficacy of
"prolonged speech" approaches, Ingham's
(1993) review of behavior modification
approaches to stuttering strongly sug-
gests that treatments involving "pro-
longed speech" result in short- as well
as long-term reductions instuttering fre-
quency. Although prolonged speech and/
or gentle onset appear to be effective
procedures for treatment of the disabil-
ity of stuttering in adults, there is contin-
ued need for objective, peer-reviewed
studies of these approaches (as well as
many other approaches) regarding long-
term (e.g., 5 years posttreatment) effec-
tiveness for treating stuttering. Indeed,
as Ingham's (1993) review points out,
more than a few programs involve, to
greater or lesser degrees, prolonged
speech procedures (much the same
could be said about gentle onsets). How-
ever, professionals and consumers alike
can adequately and objectively evaluate
the effectiveness of a treatment regi-
men--especially its long-term effective-
ness-only iftreatment outcome data are
published in appropriate scholarly or pro-
fessional literature. Thus, no matter what
treatment regimen is employed (e.g.,
Webster's [1979] precision fluency shap-
ing program, Schwartz's [1976] airflow
method, and so forth) treatment outcome
data published in peer-reviewed schol-
arly or professional journals is needed
for the most complete, objective, and
thorough assessment of short-, medium-,
and long-term treatment outcome.
Summary
Across the life span, treatment for
stuttering appears to result in improve-
ment, on the average, for about 70% of
all cases, ranging from a low of 33% to a
high of over 90%. Although most current
treatments for stuttering focus on ame-
liorating the disability of stuttering, it ap-
pears reasonable to assume, as the re-
ports of people who stutter would
suggest, that as the disability of stutter-
ing decreases, the handicap of stutter-
ing also becomes less problematic. Re-
39 S18-S26 October 1996
covery without treatment, particularly in
the preschool and school-age years,
plays a role in the remission of stutter-
ing, but much more needs to be known
about the identification, at the time of ini-
tial evaluation, of those children who
have "no," "low," "moderate," or "high" risk
for continuing to stutter without treatment.
It should be noted, however, that impor-
tant strides have been made with regard
to the diagnosis and evaluation of child-
hood stuttering (Curlee & Bahill, 1993;
Riley, 1980; Riley & Riley, 1981), and en-
couraging treatment outcome data rela-
tive to preschoolers who stutter have
been reported (e.g., Gottwald & Stark-
weather, 1995; Fosnot, 1993; Onslow,
Costa, & Rue, 1990; Onslow, Andrews,
& Lincoln, 1994; Lincoln & Onslow, in
press). Likewise, studies like those of
DeNil and Brutten (1991) and Miller and
Watson (1992) provide us with objective
insights into the self-perception of handi-
cap by people who stutter as well as high-
light the need to further our understand-
ing of these self-perceptions. When
routinely employed, these procedures
and information may increase the
chances that fewer treatment services
will be allocated to individuals who may
need them less, whereas more treatment
services will be allocated to individuals
who need them more.
The average number of people esti-
mated to stutter who benefit from treat-
ment (7 of 10) undoubtedly varies with
age (younger clients appear to improve
somewhat more quickly and more easily
than older clients), severity, type, and/or
length of stuttering (longer history of stut-
tering appears to increase the duration
of treatment and decrease likelihood of
a complete recovery). Although much
more needs to be known about the im-
pairment, disability, and handicap of stut-
tering and how to most appropriately and
effectively diagnose and treat stuttering
(particularly in the preschool population),
it is clear that present and future treat-
ment outcomes for people who stutter
and their families is bright and becoming
more so with advances in applied as well
as basic research. Current information
suggests that effective treatment of stut-
tering is increasingly able to improve the
daily life of people who stutter by increas-
ing their ability to communicate when-
ever, wherever, about whatever, and to
whomever they want, without undue con-
cern and worry about speaking.

-vrnnwInnlfmenQ
Preparation of this paper was made pos-
sible in part by a research grant from NIH/
NIDCD (DC000523) to Syracuse University.
The author would like to thank Collette Fay
and Colleen Halstead for their assistance with
manuscript preparation and case study devel-
opment.
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Contact author: Edward G. Conture, PhD,
Communication Sciences & Disorders, Syra-
cuse University, 805 South Crouse Avenue,
Syracuse, NY 13244-2280. Email:
econture@sued.syr.edu