Efficacy of Stuttering therapeutic techniques

• • • Introduction Criteria for Treatment Effectiveness Treatment Efficacy of Various Therapeutic Approaches
• o o o • • • Perceptual Measures Frequency Measures Speech Naturalness Assessment Conditions Frequency Measures Acoustic Measures Cognitive, Pharmacological, Behavioral and other related approaches

Indicators of Therapy Progress
• • • • • • • • Increasing the clients self monitoring ability Increasing the clients ability to produce ‘open speech’ Decreasing the frequency and duration of motoric fluency breaks Increasing the naturalness of fluent speech Metalinguistic changes Decreased avoidance Increased (speech) assertiveness Improved self concept, self esteem and role changes

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. 2. The method must be shown effective with an ample and representative group of stutterers. 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. 4. Reports of therapeutic success must be based on repeated evaluation and adequate samples of Improvement must be shown to carryover to speaking situation outside the clinical setting. speech. The best known but frequently ignored fact about stuttering is that is the special environment of clinic stutterer are likely to become normal 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. itself. 8. 9. Subjects must be free from necessity to monitor their speech though fluency can hardly be Treatment must remove not only stuttering but also fear, anticipation and person’s self considered normal as long as continued attention on part of speakers is required to maintain it. 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. 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

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 these studies indicate that the post-treatment mean percent dysfluency reduced significantly to less than 5%, which is considered as normal. Prolonged Speech Author Spencer (1976) No. Of Subjects 5 Age of Subject s Adults and children Duration of Treatment 4 months Results Stuttering was reduced to less than 1% of syllables

Boberg (1976) Franck (1980) Boberg (1980) Howie, Tanner & Andrews (1981) Eveshen and Huddles (1983) Boberg (1984)

21 68 6 36 47 12

17 – 44 Mean of 20.2 years 16 - 46 years Adults Adults 18 -47 years

3 weeks 1 year 3 weeks 3 weeks 3 weeks 2 weeks

Stuttering decreased from mean of 21% of syllables to 1.3% 95% of subjects increased fluency by 60% or more Mean percent syllables stuttered decreased from 16.55 or more Stuttering was virtually eliminated 91% stuttered on less than 1% of syllables Mean percent of stuttered syllables decreased from 18.9 to 0.9

Gentle Phonatory Onset Author Webster (1975) Schwartz and Webster (1977) Webster (1980) Mallard and Kelly (1982) Schulman (1983) Franken, Bover, Peters and Webster (1992) Onslow, Costa, Andrews (1996) No. Of Subjects 56 29 200 50 85 32 12 14-50 years 6-65 years 15-46 years 10.741.6 years Age of Subject s 8-59 years 9-50 years Duration of Treatment 3 months 3 weeks 3 weeks 6 weeks 4 weeks 3 weeks 3 weeks Results Significant difference in pre-post treatment 97% improved, 72% stuttered on 6% or less of words Mean percent of words decreased from 15.1 to 1.3 Mean percent of words fell from 20.05 to 2.92 84% achieved normal or nearnormal fluency in conversation Mean % of stuttered syllables declined from 25.7 to 5.8 Within clinic and beyond clinic % SS reduced generally to near zero


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 Ingham (1978) and No. Of Subjects Packman 9 9 Martin et al, 1984 adolescents age Age Subjects and 13-24 of Results Listener’s ratings of normal

adults compared with matched without • • 20-53 20-51 normals 10 adults DAF 10 adults with DAF 10 normals

naturalness of clients recived significantly fewer speaker judgments Both group of stutterers sounded less natural than the normals

Ingham scale

and for

Onslow 5 speech

• 21-45 Adolescent s

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-

(1985) 9 – point rating naturalness Ingham, Gow & Costello !5 stutterers and 15 (1985), 9 – point rating normals matched for scale of martin age and gender

Metz, Sxhiavetti, Sacco 15 males, 15 females (1990) 9- point rating scale

stutterers Mean 14.5 Strategies like gentle voicing years 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

Onslow, Newman


and 36 (1992)

9-50 years

Considered the effect of

severity on pre and post treatment ratings Onslow, the naturalness Adam influence and 7 male stutterers and 14-36 years of and

2 values higher (less natural) than least severe clients. No significant differences in the naturalness scores of conversation / monologue for either stutterers or normals

Ingham, 1992 compared 7 normals monologue

conversation speech. 9 – point rating scale Martin and Horoldson, 6 1992 related naturalness studied to components of stuttering 6 judgements males males and and 4 20-62 years 6 21-64 years Naturalness fluent audio 2.7 significantly and judgments were different of not for

visual females (stutterers) speech females (normals)


audio-visual but were

samples on rating scale (2.3respectively) samples audiovisual

used 9-point rating scale

judged to be more unnatural Finn and Ingham, 1994 11 naturalness) males and than audio only 1 Adults (19- Stutterers gave valid self 71 years) 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. c. Assessment Conditions:

(Stutterers self rating of female

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 Stutterin g Severity Spe ech rate Andrew and Ingham, 1972 Howie, Andrews, 1981 Webster, 1980 200 % es Boberg, 1981 16 %SS of 36 %SS %SS SP M SP M Phone conversatio n in both groups Reading, conversatio n on phone Reading, conversatio n on phone Andrews and Feyer, 1985 37 %SS SP M Phone Twice in 3 times in 12 months Twice in Twice in 9 weeks Tanner and 43 23 %SS SP M Monologue Speech task Freq nt 4 times in 18 months Within and beyond clinic Within and beyond clinic Within and beyond clinic Within and beyond clinic Within clinic 12 months Overt in both conditio ns Overt and covert of Situation Nature Assessme


10 months

Andrews and Craig, 1988







Within clinic Within clinic


18months Phone 4 times in 24 months

Boberg and 42 Kully, 1994




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 Webster (1980) Prolonged speech 200 t 3 weeks Mean % of Mean of 10 Mean % of stuttered stuttered words reduced from 15.1 to Boberg (1981) Prolonged speech 6 16-46 3 weeks years 1.3 Decreased from 16.55 or more 12 months Mean % of stuttered syllables of 8 subjects was 1.53 at end of 12 months Honie, Prolonged 36 Adult 3 weeks Stuttering 2 months maintenance period Little significant months words was 3.2 Results Follow-up interval Results

Turner and speech Andrews, 1981 Mallard and 1982 Gentle onsets 50


virtually eliminated in 5


14-50 3 weeks

subjects Mean % of At least 6 Mean % of stuttered stuttered words to 2 84% achieved normal near normal fluency n Mean declined from 12.90.9 Mean declined from 14.10.1 Declined from 25.7 to 5.8 in conversatio to fell from 20.05 months words for 28 subjects was 9.74

Kelly, phonatory

Heller, Schulman, Teryak, 1983

Gentle phonatory onsets



6 weeks

6 months to 80% 5 years


their post treatment fluency levels

Craiz 1988

and Smooth flow speech Smooth speech Gentle phonatory


Adult 3 weeks s

% 10 months





syllables was 1.9%

Andrews 1985 Frank et al, 1922


21-60 3 weeks

% 10-15 months




and Feyer, flow

syllables was 1.1%


15-46 4 weeks

6 months




syllables was 16.3% 12-16 months Mean % was 6.38 outside clinic, 1.86 in reading, 2.54 with conversing strangers

onsets Boberg and Prolonged colleagues, 1987 speech


3 weeks

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: Authors Treatment No. Of Acoustic analysis Increased duration Results Indication that stuttering for therapy could alter certain properties of Procedure subjetcs Metz et.al, Instructed to “slowly 9 1979 initiate and and phonation maintain a

both vowels and acoustic increased 12 males, 5 females Analysed CVC Decrease

forward flow of air reduce articulation rate” Metz et.al, Examined 1983 relationships between acoustic variables and fluency within a group of mild to severe stutterers

stop consonants stutters’ fluent speech


stuttering voiced and

duration, VOT, frequency, absolute time of Increase in frication, voicing silence intervocalic and Increase duration, significant change in with in voiceless VOT duration, frication

associated with Voicing duration and no intervals of both silence associated

voiced voiceless Mallard and Westbrook , 1985 Precision Shaping (PFSP) Fluency Program 26

and intervocalic intervals stop On an average persons

consonants Analysed vowel • duration changes also duration

with stuttering increased and vowel duration. phrase • Vowel as duration stuttering decreased

moved from initial to final Mohan Murthy (1987) Investigated acoustic and before modified contacts measures of and One, 17 old part of phrase • Presence of transitions • Inappropriate voicing and duration of segments inspiratory frications • • • on Franken, Bover, Webster, 1991 Onslow, Van Doom, Newman, 1992 Madhavila Instruction to initiate 1 normal Prolonged speech School aged children VOT, duration, interval Analysis of Reduced Fo range and Voice Decreased variablility in Precision Shaping Fluency Program Men of 32.4 years Prosodic features Articulatory fixations Abnormal articulatory atypical

aerodynamic year /g/ subject after airflow

techniques and soft

constrictions Longer closing phases Lxexcessive vocal

adduction Decrease in expressiveness

Peters and (PFSP)

and vowel duration


tha, 1997

intonation depicting such surprise, command, as

patterns emotions anger, sarcasm, question

(model), 10 stutterers

different intonation patterns perceptually and acoustically

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

Ananthi, 2002

and statement Prolongation therapy



Analysed word No significant difference in stress, duration, word stress and word duration peak

(model), 10 stutterers

Fo, Lowest Fo and Fo range

III. Cognitive, Pharmacological, Behavioral and other related approaches
1. Electromyographic Feedback (EMG)

The subjects were provided with visual feedback about selected muscle activity. 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 Yes Post Treatment Yes At 6 months Follow-up 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

At 6 months Follow-up Yes Yes

Post Treatment -

At 6 months Follow-up -

3. Metronome conditioned speech retraining: Authors Age Stuttering Frquency < 5% Post Treatment Ost et.al, 1976 4. 14-46 years No At 6 months Follow-up No Social, eotional or cognitive variables improved Post Treatment No At 6 months Follow-up No

Prolonged Speech Authors Age Stuttering Frquency < 5% Post Treatment Craiz et.al, 1996 Howie et al, 1961 Ingham, 1982 Ingham and Andrews, 1973 Ingham, 2001 Ingham and Packman, 1977 9-14 21+ 18 -20 1856 1828 42 Yes Yes Yes Yes Yes Yes At 6 months Follow-up Yes Yes Social, eotional or cognitive variables improved Post Treatment Yes Yes At 6 months Follow-up Yes -

James et. Al, 1989 O’Brian et. Al, 2003 Onslow, 1996 Perkins et.al, 1974 Ryan and Ryan, 1963 Ryan and Ryan, 1995 Tanbaugh and Guitar, 1961

34 1759 1041 1252 7-18 7-17 12

Yes Yes Yes Yes Yes Yes Yes

Yes Yes No Yes Yes

Yes -

Yes -

Conclusion: Most of the above studies showed 50% reduction in stuttering frequency

5. Regulated Breathing and airflow Authors Age Stuttering Frquency < 5% Post Treatment Andrews and Tanner, 1982a Andrews and Tanner, 1982b 26 Adult s No Yes At 6 months Follow-up No Social, eotional or cognitive variables improved Post Treatment Yes Yes At 6 months Follow-up Yes

Landoucer, 1981 Landoucer, 1982 Landoucer and Martin, 1962 Landoucer and Saint Laurent, 1986 Mittemberger et.al, 1996 Landoucer and Saint Laurent, 1987 Franken, 2005 Harrison, 1999 Ingham, 1980 James et.al, 2005 Lattermann, 2005

15-47 17-74 5-16 18-36 19-27 18-50 6 5 9-23 3-6 4-5

Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes No Yes Yes -

No -

No -

6. Response Contingencies: Authors Age Stuttering Frquency < 5% Post Treatment Wilson et.al, 2004 Franken, 2005 Harrison, 1999 Ingham, 1980 3-5 6 5 9Yes Yes Yes Yes At 6 months Follow-up Yes Yes Yes Social, eotional or cognitive variables improved Post Treatment At 6 months Follow-up -

23 James et.al, 2005 Lattermann, 2005 7. Self Modeling of Fluent Speech Authors Age Stuttering Frquency < 5% Post Treatment Bray and Kehle, 1996 1317 No At 6 months Follow-up Social, eotional or cognitive variables improved Post Treatment At 6 months Follow-up 3-6 4-5 Yes Yes -


Shadowing Otz et.al included 4 steps: Chronic reading, with clinician, changing text, immediate shadowing, delayed shadowing and whispering Authors Age Stuttering Frquency < 5% Post Treatment Otz et.al, 1976 9. Token Economy 1446 No At 6 months Follow-up No Social, eotional or cognitive variables improved Post Treatment No At 6 months Follow-up No



Stuttering Frquency < 5% Post Treatment At 6 months Follow-up -

Social, eotional or cognitive variables improved Post Treatment At 6 months Follow-up -

Ingham and Andrews, 1973



Indicators of Therapy Progress
Main indicators of therapy progress include: 1. 2. 3. 4. 5. 6. 7. 8. Increasing the clients self monitoring ability Increasing the clients ability to produce ‘open speech’ Decreasing the frequency and duration of motoric fluency breaks Increasing the naturalness of fluent speech Metalinguistic changes Decreased avoidance Increased (speech) assertiveness 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. 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 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 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 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 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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