TREATMENT MANAGEMENT OF STUTTERING

Edited by: Kunnampallil Gejo John (SLP)

CONTENTS

Introduction
Need For Early Identification And Treatment Of Stuttering
Decisions Regarding Treatment Of Stuttering
Direct and Indirect therapy
Basic Principles Underlying Therapy
Steps in the treatment of stuttering
Counseling and Guidance
Treatment Approaches In The Management Of Stuttering In
Preschoolers
Treatment Approaches In The Management Of Stuttering In
Children
Treatment Approaches In The Management Of Stuttering In
Adults
Conclusion

Introduction
The term fluency is derived from the Latin root fluere. It refers to many things but seems
to in communication, to the smooth and easy flow of utterance (Stein, 1967). Stuttering is
a disorder of fluency.
Stuttering occurs when the forward flow of speech is interrupted abnormally by
repetitions of a sound, syllable, or articulatory posture or by avoidance and struggle
behaviors. (Van Riper, 1978).
Stuttering is a disorder of fluency with high inter and intra individual variability and is
described as a mystery surrounded by enigma wrapped in a puzzle. There are various
questions about stuttering, which are unanswered even after decades of research by
people from various disciplines or are answered inadequately. Some of these are:

Is stuttering physical, psychological, both or neither?

Can parents cause it, exacerbate it, cure it, or neither?
Is it a relatively straightforward speech disorder or is it an impairment/ a
disability/ a handicap, all of which represent complex interactions of neurological,
physiological, anatomical, linguistic, emotional, social and other characteristics?
Can it be treated?
Should it be treated? By whom, when, how, and why?
What treatment results should be demanded?
What constitutes acceptable evidence that a reported result has truly been
obtained?
What constitutes acceptable evidence that a certain treatment was directly
responsible for the obtained results?

One is overwhelmed by the complexity and perplexity of the disorder, challenged or even
excited by the difficulties that surround our attempts at understanding the management
aspects of the problem.
The theorists aiming to look for the causative factors for stuttering have come back and
forth to physiological to psychological and to more recent nature-nurture dynamic
models. Van Riper (1990), a pioneer in the field and himself a stutterer, in his final
thoughts about stuttering (at the age of 85 years) confesses his inability to fulfill a
promise he made to a Birch sapling when he was 16 years old to find a cause and a cure
for stuttering.

Since the time of Aristotle (4th century BC), various remedies ranging from
psychotherapeutic, learning theory-based approaches to more medical, surgical
approaches have failed to find a permanent solution to the problem.

The need for early identification and treatment of stuttering

Stuttering is a disorder of childhood, onset of which in more than 90% of the individuals
is before the age of 6 years. Clinicians are often apprehensive in counseling the parents
regarding the need for intervention for young children with stuttering in terms of duration
of treatment required, outcome expected, the techniques which facilitate recovery, etc.
this is more so with those who adhere to the Johnsons Diagnosogenic theory. This is a
serious problem when the current emphasis is more on early identification and
intervention.
However, early identification and treating children close to onset of stuttering is
increasingly emphasized by many authors for the following reasons:
1. It is easy, less time consuming and more long lasting [i.e., approximately 1-3 months
or 20 hours for children (Starkweather and Gottwald, 1986) and one to several
months / years or 140 hours for adults (Van Riper, 1973; Webster, 1974)] and is
reported to be dependant on the chronicity of the problem.
2. Reported rates of success is higher (>90%) compared to that for adults (50-75%)
(Franken, 1988; Starkweather, Gottwald and Halfond, 1990; Webser 1974).
3. Relapse rate for treated adults is reported to be around 50% (Franken, 1988); whereas
for children it is close to zero (Starkweather, Gottwald and Halfond 1990).
4. Adults who are treated are reported to have carefully monitored speech (Boberg and
Kuly, 1994) and diminished quality of speech (Franken, 1988) or may have residual
stuttering behaviors (Prins, 1984) while the treated children are reported to be no
different from their non stuttering peers (Starkweather, Gottwald and Halfond 1990;
Gottwald and Starkweather, 1984 and others)
5. Although it is reported that many children with stuttering spontaneously recover (the
recovery rates range from 20-80% according to various estimates), nearly 20% would
continue to stutter if not treated and it is not a small number when 1% of the total
adult population who continue to stutter if not treated is considered. Further, although
some predicting factors are there to guide us regarding who will and who will not
recover spontaneously as given above, they are not fool proof.
6. The impact of stuttering problem on the young minds to live with it could be quite
handicapping emotionally, socially, educationally and vocationally as reported by
many PWS.
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Decisions regarding treatment of stuttering

The clinicians have to make decisions regarding whether treatment is required or not;
should it be direct or indirect (in case of CWS) or both; intensive or extensive or both;
approximate duration of treatment needed; what are the prognostic indicators in a given
client and so on. These aspects have to be communicated to the clients or the givers.
Gregory and Hill (1980) recommend preventive parent counseling, prescriptive parent
counseling and or comprehensive treatment program for children based on their
differential evaluation procedure.
Packman and Lincoln (1996) recommend a set of criteria to decide early intervention as
given in the diagram below:

Yaruss La Sale, and Conture (1998) have provided a number of guidelines for deciding
whether treatment is warranted.

Presumed
Total
Sound
IOWA
SSI
SPI
likelihood
frequency
prolongation scale
that child
of
index
will require disfluencies
treatment
More than
More than 3 More than
More than
Most likely More than
10%
30%
18
16
to require
treatment
6% to 10%
12 to 30%
2 to 3
12 to 18
10 to 16
May
require re
evaluation
Less than
Less than 2
Less than 2
Less than 10
Least likely Less than
6%
12%
to require
treatment
Conture (2001) has provided a diagnostic decision flow chart and flowchart depicting
the threefold diagnostic decision- Yes, no, or uncertainty.

DOES THE CHILD HAVE PROBLEM

YES

NO
PARENT COUNSELING/DISMISS

UNCERTAIN

F OLLOW UP
EVALUATION
REFERRAL/DISMISS

INITIATE THERAPY

PARENT COUNSELING

INDIRECT PROCEDURES

DIRECT PROCEDURES

This flowchart shows 3 possible discussions and their resulting consequences:

1) Yes, the child has a problem (i.e. client most likely to require treatment)
2) Uncertain of the problem ( so the client may require re- evaluation)
3) No, the client does not have a problem (i.e. client least likely to require
treatment).
If the child meets three/more of the criteria, its described that the child would most likely
require treatment.

INDIRECT THERAPY
Indirect therapy is any therapy where we do not talk with the child about his or her
speech problem and do not attempt to teach the child to make changes in his or her
speech. Indirect therapy most typically involves working with parents and care givers in
an effort to modify communicative demands and to facilitate fluent speech within the
childs environment.
The children best suited for indirect therapy will meet the following criteria:
Children who have been stuttering for less than a year
Their stuttering and associated behaviors have not changed significantly since the
onset of their stuttering.
Children who have not developed strong emotional reactions to their speech
problems
They do not appear to be behaviorally or cognitively aware that a problem exists.
One key factor for determining the candidacy is the age of onset of stuttering.
The child who is closest to stuttering onset will be best suited for indirect therapy.
Modifying Parental communication:
Indirect therapy involves helping parents to identify and modify those aspects of their
communication and daily activities and routines that may have a negative impact on their
childs developing speech fluency. It involves modifying the normal routine activities
that may have a negative impact on those children at risk for continued stuttering.
This basically involves:
Parents modifying their speaking rate
Modification of turn switching pauses
Rewarding fluent speech
Modifying situations and schedules within the family
Demonstrating speech and environmental modifications

DIRECT THERAPY
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Direct therapy involves a program where we work directly with the child to teach him or
her number of speech skills that will result in fluent speech production.
The child best suited for therapy:
The best candidate is the child who has begun to demonstrate an awareness of his or her
stuttering. In addition, parental reports may include mention of a childs avoidance of
certain sounds, words or situations.
Providing direct therapy:
It focuses on the anatomy associated with speech production and activities that focus on
increasing the childs awareness of both, his or her speech production and stuttering. The
child is exposed to various treatment techniques and packages proposed by various
individuals with ultimate aim of any treatment being to teach the fluency tasks.

Basic principles underlying therapy:

Irrespective whether the client is an adult or a child there are some basic principles
underlying the therapy procedures:

Treatment is based upon a developmental continuum, as stuttering is a

progressive disorder.

The client-clinician relationship is an important variable built upon trust,

confidence and understanding.

Children and adolescents typically do not have intrinsic motivation to change

their speech; therefore, it is important to make therapy enjoyable and rewarding.

Building self-confidence of the client is important.

Treatment plans should be highly flexible and are designed to meet each client's
changing needs.

It is important to help the clients to express and understand their feelings about
stuttering.

Steps in the treatment of stuttering:

The management of fluency disorders involves three stages:

1. Establishment of fluency:
Establishment of fluency is easy and can be achieved using a variety of fluency
shaping or stuttering modification approaches. Many PWS do not exhibit

stuttering or exhibit less severe problem in the clinical set up because they do not
try to suppress the problem. Many novel ways of speaking reduce disfluencies.
Venkatagiri (2005) suggests that these novel speaking conditions involve speech
construction (voluntarily coding speech production) as against speech
concatenation (automatic retrieval of stored units).
The method and mode of therapy varies with children and adults who stutter, as
the demands and capacities vary in children and adults. For young children
various analogies are adopted to make it enjoyable and fun. For older children and
adults different approaches are combined to provide a comprehensive treatment
plan, which include:

a. Traditional approaches: Following are a few of the traditional

techniques being used for decades with varied success: Voluntary
stuttering/ stutter fluently techniques, prolongation or many of its variants,
cancellation, pull out, soft/loose contacts, relaxation, airflow therapies,
and shadowing.

b. Cognitive approach/Cognitive restructuring: Developing an

understanding about the production of speech in general and fluent speech
in particular is essential part of any therapy. Even young children are
encouraged to understand the same using various analogies (Garden
hose/Blown up balloon analogies). PWS are made to realize how and why
the stuttering problem varies and how can they get a control over it. This
would reduce their dependency on the clinician and gradually make them
more confident in getting control over their problem. Maintenance of a
diary would facilitate this. Rational Emotive Behavior Therapy (REBT)
and Personal Construct Therapy (PCT) are some procedures incorporating
cognitive reconstructive principles.

c. Behavior therapy approach: Although the cause of stuttering is not

very well understood, recent theorists emphasize nurture or environmental
factors to contribute as maintaining factors in stuttering. Appropriate
reinforcement procedures to facilitate fluency and punishment strategies
like the Time out and Response cost to reduce dysfluencies could aid in
achieving fluent speech. Other techniques using behavior therapy
principles include Modeling, shaping, role play, over correction (negative
practice), extinction (reinforcement that previously followed an operant
conditioning) and the like. Further, in clients with anxiety traits,
progressive relaxation combined with systematic desensitization
procedures could be very effective.

d. Emotional or effective approaches: Using varieties of

psychotherapy and counseling, positive changes in emotional or affective
states of the individual need to be brought about. Stuttering is a disorder

which evokes unusual reactions from the peers parents and public. These
negative reactions are unpleasant and speaking situations may be
traumatic to PWS, who will start avoiding them. Hegde (1990) opines that
if the attitudinal changes are not brought about during the therapeutic
management, the unchanged maladaptive attitudes will soon wipe out the
temporary and shaky fluency generated by the treatment procedure.
e. Instrumental approach: Mechanical and electronic devices and
various equipments are available for establishing fluent speech in the
clinical set up such as, metronome, EMG Biofeedback, Masking, DAF,
FAF, Dr. Fluency. Some portable bone conduction hearing aids are also
available which provide noise to mask auditory feedback, delayed or
frequency shifted feedback. School DAF, Telephone fluency system,
pocket fluency, desktop fluency system, and voice changer are some of the
other devices used in the management of PWS.
f. Supportive approach: Periodic counseling and guidance to the
parents, relatives, friends, teachers, employers or significant others in the
social environment of PWS is very important for bringing about long
lasting maintenance of the fluency that is achieved. It is necessary for
PWS to get support and encouragement from these people to overcome
their negative feelings and attitudes and proper motivation to control the
fluency achieved.
2.

Transfer/ Generalization of fluency:

Once the fluency is established in the clinical set up the clinician should start
activities to transfer these skills to outside situations in a gradually graded
manner. Situational hierarchy ratings obtained during pre-therapy assessment
would help in this exercise. Maintenance of log books or diary is necessary to
monitor progress achieved in day-to-day practice. PWS should be encouraged to
self monitor and self- correct to reduce dependency on the clinician. A close
friend or a family member could be assigned to assist the client in this process
initially.

3.

Maintenance of fluency:
PWS have to be prepared for any relapses that could occur during the treatment or
later so that it does not come as a shock if he suddenly encounters situation where
he is not able to maintain the fluency achieved. After intensive and extensive
practice sessions, the frequency of treatment sessions should be gradually reduced
to make follow up or booster sessions to monitor the maintenance of fluency.

Counseling and guidance

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Periodic counseling is very essential to bring about positive attitude changes. This would
include the following:
Having less desire to avoid stuttering.
Being more willing to bring the stuttering problem into the open.
Judging performance in speaking situation more on the basis of success in
communication rather than fluency.
Developing better self concept by recognizing other talents one possesses.
Developing stronger belief in coping with stuttering.
Anticipating more fluency than dysfluency.
Becoming less embarrassed and ashamed about stuttering.
Gaining realization that one can succeed in life in spite of stuttering problem.
Not to assume that people will underestimate them because of stuttering.
COUNSELING THE CHILDS PARENTS:
The childs parents should be counseled regarding the following:
Nature of the childs problem.
How it hampers the childs communication skills.
Treatment options.
Possible course of the treatment.
Meeting realistic expectations.
Avoidance of putting unnecessary stress on the child.
Home management.
Transfer.
Maintenance.

TREATMENT APPROACHES FOR STUTTERING

IN PRESCHOOLERS
Till 1960s it was considered that young stutterers should not be directly but instead parent
counseling is the only way (Johnson, 1955). It was opined that treating young stutters was
potentially harmful. In the early 70s methods for modifying the interactions between
parents and children evolved. However, the emphasis was still on parents. By early 80s
the belief changed and programs advocating therapy for children were started. In the
recent programs the emphasis has been on both, counseling the parent regarding the
childs problem and their coping up strategies at home and other environments &
involving the child directly in the therapy program.
Treatment options for preschoolers include various packaged programs that exist for
treating stuttering in preschoolers. But, most of them are not tested. Evidence based
techniques include the following:
Fluency reinforcement
Fluency reinforcement plus corrective feedback

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 Response cost

FLUENCY REINFORCEMENT (2002, M.N HEGDE):

That stuttering may be eliminated in children by positively reinforcing fluency

has been known since the 1970s (e.g., a study by Shaw & Shrum)
The idea has not been vigorously pursed mostly because of a lack of professional
validity
Almost all current treatment procedures offered to preschoolers use positive
reinforcement for fluency as their main component (e.g., the Lidcombe program
of Onslow and colleagues)

The sequential hierarchy for treatment is as follows:

1.

Set the stage for fluency reinforcement

2.

Select effective reinforcers

3.

Prompt and enthusiastic verbal praise is effective with young children.

If there is no decrease in measured stuttering rate, add additional reinforcers.
High probability behaviors and tokens are effective additional procedures.
Add them to verbal praise, which is a constant factor.

Have the parents observe the sessions

4.

Collect toys, picture and story books, puzzles, activities (e.g., coloring or
drawing), and other stimulus materials.
Hold sessions for 30 to 40 minutes; if longer, give breaks to the preschooler.
Seat the child across a small table or, if found necessary, sit along with the child
(side-by-side seating).

Ask parents to observe the sessions from the beginning.

Let them observe through one-way mirrors (not in the treatment room).
Later on, bring parents into the treatment room to eventually train them in fluency
reinforcement procedure.

Introduce the treatment procedure

Describe stuttering and smooth speech for the child.

Model the childs dysfluent productions.
Reassure the child that he or she can talk smoothly and that you can help.

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5.

Begin at the sentence level

6.

Systematically reinforce fluency

7.

Enthusiastically and promptly praise the child with a variety of statements:

Excellent! I like your smooth speech!
Very good! That was smooth speech!
Your speech is so smooth!
You are working hard! Your speech is nice!
That was smooth speech!
That was wonderful! You said it smoothly!
You said it nicely!

Ignore stuttering

9.

Children (and adults) who stutter have plenty of fluent speech that may be
positively reinforced.
Preschoolers and younger school-age children react positively to fluency
reinforcement.
All fluent utterances, whether a word, a phrase, or a sentence are positively
reinforced with verbal praise.

Use a variety of verbal praise

8.

Sit with the child, show story book pictures or engage the child in planned
activities, and talk with the child.
Reinforce all fluent productions while evoking conversational speech from the
child.
Initial session or two may involve some practice at the word level, while still
evoking phrases or sentences.
With very young children (e.g., 2.6 to 4 year olds), several initial sessions may
involve phrases or incomplete sentences.

Do not react to stuttering in any manner.

Do not stop the child, do not give corrective feedback.
Stuttering is technically on an extinction course.
When the child stutters, model the same production fluently.
Reinforce the fluent production that typically follows.

Progression of treatment

Move from phrases/sentences to continuous speech

Move from sentences to continuous speech.

13

Move from continuous speech to narrative speech.

Move from narrative speech to more spontaneous conversational speech.

10. Reinforce fluency in continuous speech

Evoke continuous speech with the selected stimulus materials (e.g., story books
with large pictures).
Prompt the child to produce more continuous speech (e.g., Say it in longer
sentences, tell me more about this picture, Tell me everything happening in
this picture, Tell what you are doing now etc.).
Model continuous productions.
Instruct the child to talk in longer sentences.
Model longer productions.
Reinforce imitated productions.
Withdraw modeling, evoke productions.
Reinforce spontaneous, longer productions.

11. Reinforce fluency in narrative speech

Tell or read aloud a short story that is appropriate to the child.
Ask the child to retell the story in smooth speech.
Reinforce smooth speech on a variable schedule.
Prompt the story elements when the child is unsure.

12. Reinforce fluency in conversational speech

Note that you may reinforce fluency in conversational speech before you
reinforce in narrative speech.
Engage the child in typical conversations.
Ask questions about the childs family, friends, school, teachers, hobbies,
activities, sports, or games of interest.
Reinforce fluent productions on a variable schedule.

13. Use objective criteria to move from one level to the other

At each level of training (e.g., sentences, continuous speech, narrative speech, and
conversational speech) use an objective performance criterion.
We use 2% or less dysfluency rate at a given level, sustained over three sessions,
to move to the next level.
Most preschoolers attain less than 1% dysfluency rate in treatment sessions.

14. Record the frequency of stuttering

Use a prepared recording sheet.

14

Minimally, record the frequency of stuttering and percent dysfluency rate for each
session.
Optionally, record the frequency of specific types of dysfluencies and then
calculate the percent of dysfluency, and rate of speech.

15. Periodically probe the stuttering rate

A probe is a measure of target skills without the treatment procedures.

Engage the child in conversational speech; tape record the speech sample.
Do not model, prompt, or reinforce fluent speech; keep the conversational natural
and typical.
Record the rate of stuttering or dysfluencies.

16. Before dismissal, make sure the parents can reinforce fluency at
home

Train parents in fluency reinforcement.

Have hem conduct sessions in front of you.
Fine-tune their skills in evoking, modeling, and reinforcing fluent productions.
Train them in ignoring stuttering (a task that is difficult for many).

17. Use an objective dismissal criterion

We use a criterion of less than 2% dysfluency rate (preferably less than 1%) in
conversational speech sustained across 3 sessions to dismiss the child (or an adult)
from therapy.
Adopt your own criterion and adhere to it.
We prefer the less-than-2% criterion because it allows a cushion for eventual
increase in the natural environment.
We want them to sustain less than 5% dysfluency rate over time and across
situations.

18. Follow-up the child

A two-year-follow-up is essential for most children (longer in the case of adults).

A follow-up is essentially a probe.
Record a naturalistic conversational speech sample to measure the stuttering rate.
If the rate is close to 5% or exceeds it, offer booster treatment.
Give the same treatment or a new treatment that is known to be effective;
schedule another follow-up.

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FLUENCY REINFORCEMENT PLUS CORRECTIVE FEEDBACK

The second option for preschoolers (M.N HEGDE, 2002):
The second option is to add corrective feedback for stuttering while maintaining positive
reinforcement for fluent productions. Addition of corrective feedback for stuttering may
enhance the treatment effects. In this procedure, the clinician reacts to both fluent and
dysfluent productions.

The role of corrective feedback:

Although fluency reinforcement may be used exclusively, corrective feedback

should not be used exclusively.
There is no strong evidence that mere corrective feedback will eliminate
stuttering.
Corrective feedback should always be combined with fluency reinforcement.
The child should receive more positive reinforcement than corrective feedback.

There are several steps in fluency reinforcement plus corrective feedback as follows:
1.

Maintain fluency reinforcement

2.

Use all the suggestions and guidelines offered under fluency reinforcement.
Introduce the treatment.
Use toys, activities, story books and other materials to evoke speech.
Select effective reinforcers.
Begin treatment at the phrase/ sentence level.

Reinforce fluent productions

Enthusiastically and promptly praise the child with a variety of statements:
Excellent! I like your smooth speech!
Very good! That was smooth speech!
Your speech is so smooth!
You are working hard! Your speech is nice!
That was smooth speech!
That was wonderful! You said it smoothly!
You said it nicely!

3.

Offer corrective feedback for stuttering

Offer corrective feedback at the earliest sign of a stutter (e.g., twitching of the
lips, tension in the face, shoulder, or chest, irregular breathing, any facial feature
associated with stuttering).
Do not let the stuttering run its course; stop it by immediate corrective feedback.

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4.

Vary corrective feedback

Promptly offer one of several forms of corrective feedback at the earliest sign of
stuttering. Say:
Stop! That was bumpy!
Oh no! You didnt say it smoothly!
That was bumpy!
Stop! You are having trouble saying it
No, that was not smooth!

5.

Progression of treatment

6.

Move from phrases/ sentences to continuous speech.

Move from continuous speech to narrative speech.
Move from narrative speech to more spontaneous conversational speech.

Use objective criteria to move from one level to the other

At each level of training (e.g., sentences, continuous speech, narrative speech, and
conversational speech) use an objective performance criterion.
To move to the next level, the dysfluency rate at a given level must be 5% or less
sustained over three sessions.

(Most preschoolers attain less than 1% dysfluency rate in treatment sessions.)

7.

Record the frequency of stuttering in each session

8.

Use a prepared recording sheet.

Minimally, record the frequency of stuttering and percent dysfluency rate for each
session.
Optionally, record the frequency of specific types of dysfluencies and then
calculate the percent dysfluency, and speech rate.

Periodically probe the stuttering rate

A probe is a measure of target skills without the treatment procedures.

Engage the child in conversational speech; tape record the speech sample.
Do not model, prompt, or reinforce fluent speech; keep the conversational nature
and typical.
Record the rate of stuttering or dysfluencies.

9. Before dismissal, make sure the parents can reinforce fluency at home

17

Train parents in fluency reinforcement.

Have them conduct sessions in front of you.
Fine-tune their skills in evoking, modeling, and reinforcing fluent productions.
Train them in ignoring stuttering (a task difficult for many).

10. Use an objective dismissal criterion

A criterion of dysfluency rate less than 5% (preferably >1%) in conversational

speech sustained across 3 sessions can be used to dismiss the child (or an adult)
from therapy.
Adopt your own criterion and adhere to it.

11. Follow-up the child

A 6-month follow up is essential. According to Hegde (2007) two-year-follow-up is

essential for most children (longer in the case of adults).
A follow-up is essentially a probe.
Record a naturalistic conversational speech sample to measure the stuttering rate.
If the rate is close to 5% or exceeds it, offer booster treatment.
Give the same treatment or a new treatment that is known to be effective.
Schedule another follow-up.

RESPONSE COST FOR PRESCHOOLERS (2003, M.N HEGDE):

Response cost is an attractive alternative to fluency shaping. It is effective with young
children for whom fluency shaping is not a good option. It does not affect the speech rate
and speech naturalness. It is easily administered; clinicians are readily trained in its use.
Parents accept it and therefore it has high social validity.

The response cost treatment

During the first individual session, introduce the treatment procedure to the child.
Show a box of goodies (a collection of small gift items) to the child and ask the
child to select a gift he or she will buy at the end of the session.
Have the child describe the procedure to make sure the child understands the
procedure.

Administration of response cost: Token award

During the individual response cost therapy:

18

The clinician uses toys, story books, puzzles, selected games, activities, and so
forth to evoke speech from the child.
For every fluent production (a word, a phrase, or a sentence), the clinician places
a token in the childs container.
The clinician also praises the child for smooth speech as she places the token in
the childs cup (e.g., Says, That was smooth speech! Here is a token for you)

Administration of response cost: Token withdrawal

When the child stutters, the clinician says something like Oh no! That was
bumpy! I am taking a token back! and removes a token from the childs cup and
places the removed token in his/ her own cup.
The clinician fluently models the childs stuttered production for the child to
imitate and awards a token to the child if the imitated production is fluent.

Variation and progression

Initially, withdraw a token with announcement (That was bumpy, I am taking a

token back)
Later, take a token back without announcement.
While showing pictures and evoking controlled responses, interject brief
conversational episodes

Progression across response complexity

As with other procedures, advance the child from isolated sentence level to more
continuous speech.
From continuous speech, advance the child to narrative speech.
From narrative speech, advance the child to conversational speech.
Remember, continuous and narrative modes can be trained in any sequence.

Trouble shooting

Occasionally a child may react emotionally to the first token withdrawal and
refuse cooperation.
The child may stop talking, fight tears, leave the seat, or ask for Mommy.
Showing signs of disappointment is natural and the clinician needs to do nothing
Serious emotional reactions need to be handled promptly and sensitively.

Reverse the Roles

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Role reversal is invariably effective in completely eliminating the childrens

unfavorable reactions to the initial token withdrawal.
The clinician plays the childs role, and asks the child to give and take tokens for
smooth and bumpy speech (and produces many bumps).
Children gleefully withdraw tokens from the clinician!
When the treatment is resumed, children have no problem with token withdrawal.

Token bankruptcy

Another potential problem to be handled is token bankruptcythe child who is

left with no tokens, which means no gift at the end of the session.
That, of course, cant happen; the clinician should avoid token bankruptcy at all
cost.
Token bankruptcy means no reinforcement for fluency.
The child will react explosively if there is token bankruptcy.

Handling token bankruptcy

Clinicians monitor the number of tokens the child has at any moment
When the childs token collection is precariously low, the clinician can
award two tokens for fluent and longer productions.
more frequently model fluent productions.
extend the session by a minute or two so the session ends with surplus
tokens for the child.

Parent training

Parents must be trained in the administration of response cost at home.

Parent training must not be monitored in any systematic manner.

p.t.o.

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TREATMENT APPROACHES FOR STUTTERING

IN CHILDREN
THE MONTEREY FLUENCY PROGRAM (MPF, 1970s):
The MPF was developed in the late 1960s and early1970s. It was based on learning
principles, in particular operant conditioning. The major target for people of all ages, who
stutter, is normally fluent speech. The MPF involves speech only, because it was
observed that changes in attitude and anxiety often occurred after changes in fluency
(Craig et al., 1996). The MPF is based on 3 major components of programmed instruction
and operant conditioning: (a) overt responses (stuttering and fluent speech), (b) small
steps or successive approximation (e.g., one fluent word, two fluent words, etc.) and (c)
immediate consequences (positive feedback for fluent utterances and corrective feedback
for stuttering moments). Tokens with backup reinforcers (e.g., toys) are also used with
children. Additional components are the requirements of some reasonable duration of
performance (eg a criterion of 10 consecutive correct or fluent words) and continuous online (real time) collection of data to achieve the target of normally fluent speech. These
procedures make the MPF amenable to clinical trials of efficacy (Ingham & Riley, 1988).
There are 3 phases of treatment: establishment (within-clinic fluency), transfer (out of
clinic), and maintenance (fluency within and out of the clinic over time) (Ryan, 1974).
The MFP is a performance driven clinical treatment with a built in data collection system.
Two tests are built into the program, because we adhered to the instructional
programming principle of test-teach-test (Pipe, 1966). First, the fluency interview, which
is composed of 10 speaking tasks ranging from automatic (e.g., counting) to
conversational speech with strangers, and strangers, and second, a criterion test (5
minutes each of reading, monologue, and conversation) are administered. These two tests
serve to determine the level of pre treatment stuttering and as post tests to determine
improvement and effectiveness of the treatment program at various stages. Following the
administration of these two tests, the client progresses through as speech fluency, which
contains steps in three phases: establishment, transfer and maintenance.

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THE LIDCOMBE PROGRAM (1980s):

The Lidcombe Program is a behavioural treatment for young children who stutter. It was
developed by a research team led by Professor Mark Onslow, consisting of researchers at
the Faculty of Health Sciences, The University of Sydney, and clinicians at the Stuttering
Unit, Bankstown Health Service. The program takes its name from the suburb of Sydney
where the Faculty of Health Sciences is located. The program is administered by a parent
(or care giver) in the child's everyday environment. Parents learn how to do the treatment
during weekly visits to the speech pathologist. At these visits, the speech pathologist
trains the parent by demonstrating various features of the treatment, observing the parent
do the treatment, and giving the parent feedback about how they are going with the
treatment. This parent training is essential, because it is the speech pathologist's
responsibility to ensure that the treatment is done appropriately and is a positive
experience for the child and the family. The treatment modality is direct. This means that
it involves the parent commenting directly about the child's speech. This parental
feedback is overwhelmingly positive, because the parent comments primarily when the
child speaks fluently and only occasionally when the child stutters. The parent does not
comment on the child's speech all the time, but chooses specific times during the day in
which to give the child feedback. As well as learning how to give feedback effectively,
the parent also learns to measure the child's stuttering by scoring it each day out of 10,
where 10 is "very severe stuttering" and 0 is "no stuttering." At each clinic visit, the
speech pathologist and the parent examine these scores for the previous week to see what
effect the treatment is having outside the clinic. These parental measures are essential
because it is well known that stuttering may improve in a clinic without necessarily
improving where it really matters-outside in the real world. The Lidcombe Program is
conducted in two stages. In Stage 1, the parent conducts the treatment each day and the
parent and child attend the speech clinic once a week. This continues until stuttering
either disappears or reaches a very low level. Stage 2 of the program commences at this
point. The aim of Stage 2 is to maintain the absence, or low level, of stuttering for at least
one year. The frequency of parental feedback during Stage 2 is reduced, as is the
frequency of clinic visits, providing that stuttering remains at the low level at entry to
Stage 2. This maintenance part of the program is essential because it is well known that
stuttering may reappear after the conclusion of an apparently successful treatment. All
children and families are different, and the speech pathologist takes this into account
when supervising the treatment. While the essential features of the program as set out in
the Lidcombe Program Manual are always included, the way they are implemented is
adjusted to suit each child and family.
In essence- the whole treatment is about?
The treatment is that parents give feedback about stuttering and stutter-free speech
during conversations with their children.
What are the feedbacks the parents would give in the case of stutter-free speech, there are
three types of feedback ?:
Parents may acknowledge or praise (eg, "no bumps there", "that was lovely smooth

22

talking").
Parents may request self-evaluation from the child (eg, "was that smooth?").
In the case of stuttered speech:
Parents may acknowledge the stuttering (eg, "that was a stuck word").
Parents may request self-correction from the child (eg, "try it again without the stuck
word").
It is critical to the success of the treatment that parents are positive and supportive of the
children, who must enjoy the treatment. As is the case with any treatment for a childhood
speech and language disorder, it will not work if the child does not enjoy it and feel it is a
positive experience. Most important of all in the Lidcombe Program, care is taken that
parental feedback is not constant, intensive or invasive.
Also, parents need to take care that the treatment does not interfere with the child's
communication. It is essential that the treatment occurs as a background to a child's
everyday life - it must fit in with, not be imposed on, daily childhood activities.
The speech pathologist needs to ensure parents are presenting feedback safely and
correctly. Therefore, at the start of the Lidcombe Program, when the parent is first
learning to give feedback, it is done in carefully structured conversations only.
This structured application of feedback facilitates the initial teaching of the parent by the
clinician. Further, consistent with standard speech pathology practices, it enables the
parent to ensure the task is organized flexibly so that the child's responses are mostly
correct.
Finally, structured parental feedback at the start enables the child to get used to the
treatment and enables the parent to convey positive and helpful messages to the child
about what is occurring. When the parent has mastered the requisite skills and the child is
happy with the procedure, parental feedback is introduced into everyday, unstructured
situations. This is when the treatment is fully operational and when its effects become
apparent.
The administration of the Lidcombe Program relies heavily on measurement of stuttering.
In fact, the treatment cannot be done without it.
Speech measures used are:
To check that the child's stuttering is improving and so that adjustments can be made in
the event that there are no signs of improvement.
To precisely identify when the child has met speech criteria for recovery.
To check that the child's speech continues to meet those criteria in the long term.
Speech measures enable the clinician and the parent to communicate effectively about the
severity of the child's stuttering throughout the treatment process. The clinical measures

23

used in the Lidcombe Program are a 10-point severity scale which is used by the parent
and a "percent syllables stuttered" (%SS) measure which is used by clinician.
Improvement in stuttering in the Lidcombe Program is specified with the severity rating
scale and the percent syllables stuttered measure. There are 2 stages involved in this
program, to successfully complete Stage 1 and enter Stage 2, the child must have severity
ratings for the previous week of 1 or 2, with most ratings being 1, and less than 1.0 %SS
during speech within the clinic.
During Stage 2, the parent gradually withdraws the feedback. During this period visits to
the clinic decrease in frequency.
A report of 250 cases has shown the median time for the completion of Stage 1 - the
elimination of stuttered speech - is 11 weekly clinic visits. The recovery plot for the
Lidcombe Program is shown in the figure below.

Recovery plot for the Lidcombe Program. (Adapted from Jones, et al. [2000].)
The studies present long-term outcome data for a total of 42 children and show that after
the treatment they have near-zero stuttering in everyday speaking situations. The outcome
studies of the Lidcombe Program are summarized in the figure below, which shows longterm near-zero stuttering in preschool children in everyday speaking situations after the
treatment.

24

Summary of outcome data for the Lidcombe Program of early stuttering intervention. Data are presented for %SS scores of the children talking at
home and outside their homes, and also for covert assessments when the children were not aware that their speech was being tape recorded.

At present, outcome data allow only a confident statement that children are not stuttering
when assessed after the treatment. Those data do not permit conclusions about whether
the treatment provides effects beyond those of natural recovery.
Nonetheless, confidence in the treatment is justified for two reasons. First, there are
outcome data to show that stuttering is at near-zero levels in school-age children after the
treatment. This age group has little chance of natural recovery, which suggests it was the
treatment that was responsible for their stuttering reductions.
Second, the known predictors of the rate of recovery with the Lidcombe Program are
different from those known to predict whether natural recovery will occur. As stated
previously, age and gender are powerful predictors of whether natural recovery will
occur, but they have been shown not to predict anything about treatment recovery with
the Lidcombe Program. Hence, there is reason to believe that treatment recovery and
natural recovery are two different processes.
Another type of outcome research that supports the Lidcombe Program deals with the
social validity of the treatment. It has been shown that children's speech after treatment is
perceptually indistinguishable from that of control children. These data are consistent
with our clinical experiences that, long after the treatment has been completed, the
children have forgotten all about their stuttering.
A preliminary outcome report has been published of a "tele-health" version of the
Lidcombe Program for the roughly one-third of Australian children who live rurally and
are isolated from speech pathology treatment services. At the time of writing, a
randomised controlled trial of this treatment model is in progress, funded by the
NHMRC.
Who uses it?
The Lidcombe Program was developed in Australia and is now used by more than 80%

25

of speech pathologists in Australia who treat children who stutter. The specialist
clinicians at the Stuttering Unit in Sydney use it with all preschool children who stutter.
The first report of the treatment was published in 1990 and this was followed by regular
reports in scientific and professional journals, books, and at speech-language pathology
conferences. The Lidcombe Program is now widely used in Canada, the United Kingdom
and New Zealand. There is also considerable interest in South Africa, the United States,
and several non-English speaking countries. The manual has been translated into five
languages, and these translations can be downloaded from this website. There is an
international Lidcombe Program Trainers Consortium, with members in the United
Kingdom, the United States, Canada, and Australia.
Is it effective?
A considerable amount of research has been conducted into the Lidcombe Program, and
development of the Lidcombe Program continues to be an important focus of ASRC
research. Research to date has shown that for preschool children participating in the
program, stuttering is no longer present, or is present to only a very mild degree, after
treatment, and that this outcome has been maintained in those children who have been
monitored for a number of years. Preliminary research is also showing that the program is
safe: It does not appear to interfere with parent-child relationships and has no apparent
effect on other aspects of communication. Indeed, parents report that their children are
more outgoing and talk more after treatment because they are no longer stuttering. At
present, there are two major, international clinical trials of the Lidcombe Program being
conducted: One in New Zealand and one in Germany.
Some children recover naturally from stuttering. Because of this, the question is often
asked: Is treatment for stuttering in young children more effective that natural recovery?
More specifically, do the reductions in stuttering that occur after treatment with the
Lidcombe Program reflect anything other than natural recovery? Randomised, controlled
trials of the Lidcombe Program, currently under way, will explore the efficacy of this
treatment and provide the "gold standard" of scientific evidence. In the meantime, there is
enough evidence to suggest that the program has a powerful therapeutic effect that is
above and beyond the effects of natural recovery. First, factors that predict how quickly
children respond to the treatment are different from factors that predict natural recovery
and, second, the program also reduces stuttering in older children for whom natural
recovery is unlikely.
How long does it take?
Children differ in the time they take to complete the Lidcombe Program. However,
research has shown that the average number of weekly clinic visits needed for preschool
children to reach Stage 2 of the program is around 11. Children whose stuttering is more
severe tend to take more than 11 visits, while children whose stuttering is less severe tend
to take fewer than 11 visits. It also seems thatfor preschool children onlydelaying
treatment with the Lidcombe Program for a year or so after onset does not make the
child's stuttering less responsive to the treatment.

26

The study done by Jones et al in 2000 reports the data pertinent to this issue for 261
preschool-age children who received the Lidcombe Program of early stuttering
intervention. Of these children, 250 completed the program and were considered by their
clinicians to have been treated successfully. For the children who were treated
successfully, logistical regression analyses were used to determine whether age, gender,
period from onset to treatment, and stuttering severity related systematically to the time
required for treatment. The present data confirmed previous reports that a median of 11
clinic visits was required to achieve zero or near-zero stuttering with the Lidcombe
Program. Results were also consistent with a preliminary report of 14 children (C. W.
Starkweather & S. R. Gottwald, 1993) showing a significant relation between stuttering
severity and the time needed for treatment, with children with more severe stuttering
requiring longer treatment times than children with less severe stuttering. However,
results did not associate either increasing age or increased onset-to-treatment intervals
with longer treatment times. This finding is not consistent with the Starkweather and
Gottwald report, which linked advancing age with longer treatment time. In fact, the
present data suggest that, for a short period after stuttering onset in the preschool years, a
short delay in treatment does not appear to increase treatment time. An important caveat
to these data is that they cannot be generalized to late childhood or early adolescence.
The present findings are discussed in relation to natural recovery from stuttering.
Another randomised controlled trial of the Lidcombe Program is being conducted in
Germany and is in its final stages.
New evidence for treating young children with the Lidcombe Program
A major study published August 2005 in the British Medical Journal showed that
preschool children who stammer will have significantly less stammering and a higher
recovery rate if they are treated with the Lidcombe Programme, compared to those who
receive none, or minimal therapy.
As a randomised controlled trial, it studied two similar groups of children, one who
received Lidcombe treatment, the other receiving little or no treatment. After nine months
of treatment, children receiving Lidcombe had reduced their stammering by 77%,
compared to 43% who did not receive it.
The study was run by the Australian Stuttering Research Centre and conducted at two
sites in New Zealand. It involved 54 children between three and six years (with frequency
of stammering of at least 2% syllables stuttered). The children had been stammering for
at least six months before the study, and had not received treatment for stammering
during the previous year. There were 29 in the Lidcombe group, and 25 in the other
group. 12 of the participants were girls.
In recent years therapy for pre-school children has become more widely accepted. BSA
has campaigned for more therapy provision for young children because stammering is
most effectively treated before a child starts school.

27

The significance of this study is that it has produced very clear evidence that therapy, in
this case the Lidcombe Programme in the preschool years, can significantly reduce
stammering. With therapy services needing to show clear evidence to justify their work,
this study provides important data to show that treating stammering in young children is
much more effective than relying on natural recovery.

THE FLUENCY RULES PROGRAM (Late 1980s):

The fluency rules program (FRP) was conceived and designed to provide therapeutic
direction to help preschool and early grade stutterers acquire fluent speech. In the initial
stages of this program attempts were made to teach the children the association between
physiology and fluency and they were reasonably successful, they were labeled rules of
good speech. By 1981, these clinical techniques were known as Fluency Rules.
Originally there were ten rules designed to teach children to speak fluently and to sound
natural. However with continued clinical effort the number of rules was reduced to seven
and the instructions for them was simplified. The FRP was revised and FRP-R was
published in1995 (Runyan & Runyan, 1993).The revised FRP procedure provided a
structure and order for the presentation of the rules. The rules that had consistently been
presented first to every child became the Universal Rules. The next rules, the Primary
Rules, were physiologically based rules, which were used with children who exhibited
breathing and laryngeal problems associated with instances of stuttering. Finally,
Secondary Rules were used only when secondary behaviors were a component of the
stuttering blocks.
THE PROGRAM:
This section describes the individual fluency rules and how they are applied with respect
to preschool stutterers, early grade stutterers and special population stutterers.
UNIVERSAL RULES:
There are two Universal Rules: Speak Slowly and Say a word One Time. These two
rules are usually the only rules necessary to treat very young stutterers. However, for
young stutterers who also demonstrate prolongations, the Secondary Rule, Say it Short,
is included as a Universal Rule. The intent of Universal Rules is to provide basic
instructions to assist the child in producing fluent speech.

Rule 1: Speak Slowly (Turtle Speech)

This rule is presented first to encourage a reduced rate of speech production. Reduction in
rate may provide additional time for the development of self monitoring skills, which the

28

child can use to acquire and develop physiologic skills necessary for fluent speech
production. Although this rule has always been labeled speak slowly or turtle speech,
the intent was never to encourage children to produce abnormally slow speech or to say
words one at a time in a rhythmic pattern. But as this Speak Slowly Rule continued to be
used in all the clinics, an unexpected benefit associated with this rule became apparent.
Therapy data revealed the frequency of stuttering decreasing while speech rate remained
virtually unchanged. After repeated observations, it was concluded that the reduction in
the frequency of stuttering may be due to a general calming effect. This calming effect
appeared to be a by- product of the modeled slow rate of speech encouraged by this
Universal Rule in the therapy sessions and home environment.
Rule 2: Say a Word One Time:
This rule is the foundation of FRP when treating very young children. Obviously part
word and whole word repetitions are the speech characteristics typically exhibited by
young disfluent children. A technique to control these repetitions must be a vital
component of any treatment program designed for this population. To use this rule
effectively, children must understand the concept of one, once, or one time. TO teach this
concept, sequential materials such as days of the week or months of the year, letters of
the alphabet have been useful. An explanation is provided that each word is unique and
does not need to be said more than one time. Then the child and the therapist repeat one
of the repeat one of the series of words in unison. To demonstrate the concept further in
an animated fashion, the therapist selects one word from the series and repeats this word
20 times (e.g One, two, two, two [20*1]) while bouncing up and down with the
production of each number. This redundancy and animated physical activity captures the
childs attention and allows the therapist to ask, Did I need to say the word more than
one time for you to understand it? The response has always been no. This dialog helps
the child understand the importance of being careful about what we say and listening to
make sure we say each word only one time.
To ensure the success of this rule, the child is encouraged to identify repeated words
produced by the therapist. During this phase of therapy, the clinician intentionally and
frequently repeats words and part words and the child is encouraged to signal when these
repetitions occur. When clinician generated repetitions are identified correctly every time,
the child is asked if the clinican can help identify repeated words in his or her speech.
This procedure takes the format of a game with each participant trying to catch the other
repeating a word. As the child becomes more fluent and there are fewer opportunities for
repetitions, to keep the awareness high, the clinician should produce increasingly more
repetitions so at the intent of therapy is not lost.

Secondary Rule (Third Rule)

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The intent of this rule is to assist the stutterer therapeutically to eliminate prolongations.
For maximum results this rule must be applied immediately following every instance of a
prolongation.
Rule Three: Say it Short
This rule becomes an Universal Rule for very young stutterers who exhibit prolongations.
When needed, the most effective therapy technique is another hand signal. The hand
signal is the well known signal for short, which is placing the thumb and forefinger close
together. Because this nonverbal hand signal is so well known, therapy time needed to
teach this concept has been minimal.
Primary Rules
The primary rules are used to treat aspects of stuttering that appear to be physiologically
based. Children treated using the Primary Rules have demonstrated abnormal breathing
patterns or laryngeal activity (during their stuttering blocks). These physiological
behaviors usually are not manifested in the speech of preschoolers. However, the Primary
Rules have been used with children as young as second grade. When use of the Primary
Rules is necessary, based on the diagnosis or clinical observation, they are taught as a
package. In other words, if a child experiences difficulty with speech breathing or
laryngeal tension, then an explanation of speech production incorporating both primary
rules is undertaken.
Rule Four: Use Speech Breathing
To explain speech breathing, a breath curve is drawn on paper or a chalk board, using a
steep slope upward to indicate rapid inspiration and a gradual downward slope for slow
exhalation. Then this drawing is related to what occurs physiologically when the child
breathes. To relate this drawing in a tactile manner to breathing, the childs hand is
placed just below the sternum with the clinicians hand on top, so the rise and fall of
the chest wall can be felt. After the child comprehends the relationship of chest wall
movements and breathing, this breathing pattern is related to speech production. To do
so, an X is placed on the down slope just after the peak on the breathing curve where
inhalation ends and exhalation begins. The child is told that this X is the point during
exhalation begins. The child is told that this X is the point during exhalation at which
to start speech. With hands properly positioned and the breath curve drawing set up easy
viewing, the child is instructed the trace the breath curve with a finger while feeling the
corresponding movements of the chest wall. Once this procedure has been practiced and
understood, speech is introduced using the designated X. The first speaking tasks
include the sequential material used during practice of the Universal Rules. Following
this activity short simple phrases are repeated, none of which begins with a sound
associated with stuttering. During these drill activities, the children are explained that and
demonstrated that we speak on exhalation, and that air carries the words out. To teach
this concept, again in a humorous fashion, it is demonstrated with exaggerated effort that
speech cannot be produced when we hold our breath.

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Rule Five: Start Mr. Voice Box Running Smoothly/Gently

For the young stutterer this rule is infrequently used. If needed, we incorporate gentle
onset of voicing with speech breathing by instructing the child to exhale slowly, feeling
the air as it comes up the throat, and at the designated X to start to hum gently. This
activity is followed by having the child repeat phrases with the initial word beginning
with /m/. On occasion, depending on the childs age and comprehension ability, an
awareness technique is needed to explain that Mr. Voice Box lives in the neck. To
demonstrate this point, we phonate or hum while shaking our neck vigorously with our
hand and hear the funny sound this activity causes, thus proving that Mr. Voice Box lives
in our neck.
Program Implementation:
The FRP is implemented in the following manner:
1.
2.
3.
4.
5.

Determine the Rules That Are Broken.

Teach The Necessary Concepts.
Develop the Childs Self Monitoring Skills.
Therapeutic Practice Using the Rules.
Carryover to the Home and/or Classroom.

SPEECH MOTOR TRAINING (Early 1990s):

A speech motor training motor training program to treat stuttering was developed over 20
years based on empirical, theoretical and research evidence. The possibility of a reduced
speech motor system underlying stuttering was hypothesized. If a reduced speech motor
system existed in a child who stuttered, the questions emerged, how to test it, how to train
it? If speech motor function improved through training, would it have a positive impact
on decreasing stuttering and /or providing a more effective speech motor to support
fluency? That is, when fluency was achieved, would a better speech motor system reduce
the tenuousness of maintaining fluency? Also, would such a system eliminate the need
for maintenance after treatment? It was from these questions that the speech motor
program was developed.
THE PROGRAM:
The purpose of SMT is to improve speech motor production, thus reducing stuttering
frequency and severity. Improvement in speech motor control can be inferred from
changes in VRT and durations of brief acoustic speech segments following treatment.
These changes in speech motor production are reported from controlled experimental
studies but cannot be measured in most clinical applications. The behavioral goal of SMT
is that the child with correct sequencing, and at an age- appropriate rate.

31

Clinicians who are planning to use the SMT program need to (a) develop he required
clinical skills, (b) learn the general principles of training (including handling special
problems) so that they are readily applied during the training sessions, and (c) follow
specific training procedures that implement the principles on which therapy is based.
The equipment required includes a good tape recorder, a high quality external
microphone and a stop watch.
GENERAL PRINCIPLES OF TRAINING:
1. Motor training should be done at 3 rates; very slow (1 sps), slow (2 sps) and
normal (3 sps).
2. After a given set at the same level of difficulty has been accurately trained,
probing for generalization is done at an age appropriate of approximately 3 sps.
3. Training is done by modeling the desired behaviors.
4. Varying syllable stress is modeled during SMT to improve the flow of
nonlinguistic syllables.
5. Vowels, /i/, /ae/, /ei/, /ou/, /u/, /a/, /ai/ were selected for inclusion in the training
sets because they seemed natural and easy to produce.
SPECIFIC TRAINING PROCEDURES:
1. The levels of difficulty of SMT are indicated in the outline of Speech Motor
Training. There are 14 levels of difficulty.
2. For each indicated, the number of times the syllable set is modeled by the
clinician and then produced by the clinician and then produced by the child in one
breath is varied systematically: first one set is produced in a breath group (eg
/bavi/, then 2 sets in a breath group (eg /bavibavi/), then 3 sets, then 5 sets, then 8
sets and then 10 sets. For long strings of sets with 3 and 4 syllables, the child may
take an extra breath.
3. The rate is varied systematically. At first one syllable per second is used. For
example, a 3 syllable set will require 3 seconds to model and 3 seconds for the
child to perform. This rate is not comfortable, but it requires practice to model at
this rate and assist the child to maintain it. Rate is increased to 2 sps then 3 sps as
the child progresses through training on the selected syllable set.
4. Accurate voicing (Unvoiced or voiced) and smooth flow are maintained. A child
can usually produce voiced consonants more easily than the unvoiced cognates. .
Therefore, when voiceless consonants are used in a training set, it is important to
monitor correct voicing.
5. Contingency management such as tokens can be used. The level is passed when a
child can perform the trained set and two untrained sets; 80% accuracy is required
to pass.
6. The pass criterion at each step for a training set is 3 consecutive successes. The
level is passed when a child can perform the trained set and two untrained sets;
80% accuracy is required to pass.

32

7. If a child fails to perform correctly on 6 consecutive tries, he or she should branch

to an easier level.
8. The clinician and child establish a pattern of training during level 1 that will
influence all other levels. The clinician should not move to the next level until the
childs production is automatic and overlearned.

VOLUNTARY STUTTERING (1994):

Bryngelson et al (1994) found that the stutterers reported that their speech was out of
control during stuttering and claimed that a sound or word got struck and would not
come out i.e., it was involuntary and beyond control. He evolved the method of
voluntary stuttering in 1994. He maintained that stutterers should confront their speech
disruptions by consciously and willingly practicing voluntary stuttering. In this way
stutterers would reduce their fears of the unkown and be better able to control stuttering
when it did occur.
In accord with a proposed innate link between speech perception and production (e.g.,
motor theory), the study done by Saltuklaroglu et al (Percept psychophysics.2004
feb:66{2}) provides compelling evidence for the inhibition of stuttering events in people
who stutter prior to the initiation of the intended speech act, via both the perception and
the production of speech gestures. Stuttering frequency during reading was reduced in 10
adults who stutter by approximately 40% in three of four experimental conditions: (1)
following passive audiovisual presentation (i.e., viewing and hearing) of another person
producing pseudostuttering (stutter-like syllabic repetitions) and following active
shadowing of both (2) pseudostuttered and (3) fluent speech. Stuttering was not inhibited
during reading following passive audiovisual presentation of fluent speech. Syllabic
repetitions can inhibit stuttering both when produced and when perceived, and we
suggest that these elementary stuttering forms may serve as compensatory speech
gestures for releasing involuntary stuttering blocks by engaging mirror neuronal systems
that are predisposed for fluent gestural imitation.

ANALOGIES (Conture, 1990):

Conture (1990) has provided several analogies which could be used to teach the child
stutterer regarding normal & disrupted flow of speech.
The Garden Hose Analogy
Author: Contour (1990)

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Rationale: Analogies are used to help the child understand what the child must do to
increase speech fluency. This helps the child to understand their speech system and
visualize it.
Before understanding the analogy, the working of garden hose should be explained to the
child:
1. Permit water to flow out of the hose
2. Minimize the amount of water that flows
3. Completely stop the water from flowing out of the hose.
4. After the child is familiar with this concept similarities between the garden hose
and our speech production mechanism should be taught.

Blown up Balloon Analogy:

Author: Contour (1990)
Rationale: analogies are used to help the child understand what the child must do to
increase speech fluency. It is an excellent way to help the child understand tightness
resulting from aerodynamic backpressure.
One excellent way to help the child understand tightness resulting from aerodynamic
back pressure is by using a blown up balloon with the thumb and index finger of one
hand on the balloons neck to stop the flow of air out of the balloon. Blow up the balloon
and have the child feel the taut or tense sides of the balloon and explain this is a bit like
the tension created by air pressure in the lungs and the vocal tract. Have the child gently
squeeze the sides of the balloon and feel the changes in the pressure on the sides of the
balloon. The child can hold the neck of the balloon and feel the pressure as the clinician
squeezes the sides of the balloon. Have the child figure out the best way to let the
pressure out of the balloon, for eg by 1. Pushing hands on the sides of the balloon,
2.Squeezing the thumb and index finger together and 3. Slowly releasing the air through
slightly separated finger thumb.

Lily pad/ Barrel bridge analogy:

Author: Contour (1990)
Rationale: Analogies are used to help the child understand what the child must do to
increase speech fluency. This indicates that speech involves a smooth continuous
movement from one sound to another.

34

This analogy involves pretending as a Frog or the childs jumping from one lily pad to
the next to cross a stream. The therapist has to pretend that each pad is a letter of a short
word like baby and that they have to hop from the bank to the first pad, then to the next
pad and so on until they reach the other bank. Easy speech, repetition and stoppage could
be demonstrated using this analogy. The same idea can also be conveyed by the analogy
of a floating bridge made of barrels tied to each other with rope.

Thumb and opposing finger analogy:

Author: Contour (1990)
Rationale: Analogies are used to help the child understand what the child must do to
increase speech fluency. This indicates that speech involves a smooth continuous
movement from one sound to another.
Each finger can be considered as a letter or sound of a short word and our opposing
thumb, the tongue, or speech system, is used to produce each letter or sound. Fluent
speech is like having the thumb move smoothly, sequentially and easy from one finger to
the next. Conversely, stuttering is like pressing for too long with too much of force
between the thumb and any one of its opposing fingers or repeatedly the thumb and one
of the fingers.

PARENT CHILD FLUENCY GROUPS:

The parent child fluency group serves a number of functions. The clinician is able to
work directly with the children who are stuttering while their parents can receive
instruction regarding the nature of their childs problem, share similar concerns with
parents of other children who stutter, and learn techniques and strategies for facilitating
fluency outside the clinic.
The child best suited for a PC fluency group:
The child who is recommended for the PC fluency group has typically been stuttering for
more than a year and has begun exhibiting some awareness of his or her stuttering. The
age of the client typically ranges from2 to 6 years. Because of the many developmental
differences eg physiological size, emotional maturity that occurs within this age range,
the children will be divided based on age and emotional maturity.
Structure of the program:
The parents meet in one room, while the children meet in another. Near the end of the
session, the parents are brought together with the children for a planned parent-child
activity. The general objectives of the childs group are modification:
a) Communicative interactions
b) Speech production behaviors, and

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c) Attitudes about speech in general, the childrens speech in particular, and

themselves as speakers.
The objectives for the parent group, to help and change their own and their childrens
communicative interactions and behaviors are brought about through
Counseling and information sharing
Guided observations of the children interacting with the clinician, and
Guided participation in therapy with the children and clinicians.

P.T.O.

TREATMENT APPROACHES IN MANAGEMENT

OF STUTTERING IN ADULTS
Management of adult stutterers is a far more difficult task than managing child stutteres
as the adults are completely of their problem and tend to have a low morale which would
itself act as a hindrance to the process of therapy. So counseling is an important
component in the management of adult stutterers in order to drive the negative thoughts
and emotions which pre dominates in an adult stutterer.
Factors to be considered for therapy for adults:
Psychological make up of the client
Motivation
Family support
Socio-economic background
Self confidence
Cognitive factors
Clinician- client interaction
Environmental factors

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COUNSELING
An important point to be remembered for adult therapy is the process of counseling:
Counseling the patient regarding the:
Nature of the problem.
How it hampers the communication skills of the client.
Probable treatment options.
Probable duration of the therapy.
Meeting the realistic expectations of the prognosis.
Transfer
Maintenance.
VARIOUS THERAPY PACKAGES FOR ADULTS IN HIERARCHIAL
SEQUENCE:
SHADOWING (1956,83):
Cherry and Sayers (1956) popularized shadowing as a technique and reported good
results with clients with stuttering. In shadowing, the client listens to model and attempt
to repeat the model utterances lagging one or more syllables behind the model.
Feider and Standop (1983) applied shadowing by having the clinician begin with a list of
short sentences spoken at a slow rate. The client follows the model production, lagging
behind. Once the client is able to perform adequately, sentences are lengthened and rate is
increased. Progressively longer and varied material is used. Deliberate changes in tempo,
inflection, pronunciation and so forth can be used.
The effects of shadowing are attributed to sheer novelty, distraction, induced rhythm,
intonation, prosody, timing alterations, and changes in auditory feedback.
ARTICULATORY LEVEL THERAPY (1950, 1987):
LIGHT CONSONANT CONTACT (LCC):
Froeschels (1950) described LCC. Every speaker develops habituated sets of articulator
performance in terms of shaping (modulations in the vocal tract), force and deviation.
Any distortion in any of these parameters would result in stuttering. Tension leads to be
tensed, prolonged, interrupted articulatory movements.

Teaching LCC:
Have the client utter a phrase
Repeat the phrase with his / her mouth open as wide as possible. Production
should be relaxed, not too loud and the speech should be melodic with least effort.

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 The clinician can use different practice material (word lists, phrases and
sentences)

CONTINUOUS PHONATION AND BLENDING:

It was described by Pindzola (1987)
Prolongation is mostly used therapy procedure for clients with stuttering.
Prolongation always involves an element of continuous phonation. Continuous
phonation results in blending of words. Continuous phonation can be used along with
LCC.
PROCEDURE:
Ask the client to read the word (count the number or days of week) normally.
Extend the phonation on the last sound of each word to the first sound of the
next word.
Move onto sentences, close end questions, paragraphs and so on.
Finally, have the client speak for at a stretch using continuous phonation and
blending at various contexts.

DELAYED AUDITORY FEED BACK (1956)

Gold Diamond was the first to use DAF in the context of stuttering.
It is a method where an individual hears his own voice delayed by a few msecs through
an instrument. Its a good treatment for the reduction of stuttering.
Rationale: It is based on classical behavioral approach.
Curlee and Perkins (1969) described a therapy program in which slow, fluent speech was
established by DAF of 250 msecs.
In a study done by sparks et al in 2002 (J Fluency Disorders. 2002 Fall;27(3):187-200)
Delayed auditory feedback (DAF) has been documented to improve fluency in those who
stutter. The increased fluency has been attributed to the slowed speech rate induced by
DAF. This investigation described the effect of combining a fast speech rate and DAF on
the fluency of four people who stutter. Fluency of the two mildly dysfluent subjects was

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the same for both no DAF and DAF conditions at normal and at fast oral reading rates. In
contrast, the two severely dysfluent subjects improved in fluency from the no DAF to the
DAF conditions. They were found to be dysfluent at both normal and fast oral reading
rates without DAF. The results of the study point to the need for further research on the
relationship between speech rate and stuttering frequency under conditions of DAF and
no DAF.

METRONOME TIMED SPEECH (1965):

Rationale: Most AWS become more fluent, at least temporarily, when they speak using
an artificial rhythm.
Procedure: Demonstrate the use of it to the client.
Set the metronome at 40 beats/ min and ask the client to carry out the following:

Tap fingers on table.

Nod head left and right.
Open and close jaw.
Non sense syllables.
Move to word level utterance each syllable to a beat.
Sentence level: One word per beat.

UNISON SPEECH (Gregory, 1968):

Simplest method of achieving slower rate of speech is choral speaking or unison speech,
where one person (clinician) provides a vocal model to another speaker (AWS).
Unison speech is generally used with reading aloud performance or common speaking
material to both the clinician and the client. Pre-recorded material at various speeds can
be played to the client through head phones and asked to match the rate of speech. The
clinician overwhelm the clients own auditory feedback with his/her loud speech. The
clinician and the client read together, moving from words to phrases to sentences and
then to paragraphs. This recorded and played back to the client.
A novel phenomenon of fluency enhancement via visual gestures of speech in the
absence of traditional auditory feedback was reported Stuart et al in 2000. The effect on
visual choral speech on stuttering frequency was investigated. Ten participants who
stuttered recited memorized text aloud under two conditions. In a visual choral speech
(VCS) condition participants were instructed to focus their gaze on the face, lips and jaw
of a research assistant who 'silently mouthed' the text in unison. In a control condition,
participants recited memorized text to the research assistant who sat motionless. A

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statistically significant (P=0.0025) reduction of approximately 80% in stuttering

frequency was observed in the VCS condition. As visual linguistic cues are sufficient to
activate the auditory cortex, one may speculate that VCS induces fluency in a similar yet
undetermined manner as altered auditory feedback does

INTENSIVE TOKEN ECONOMY THERAPY (1972):

Author: Andrews & Ingham (1970,1973)
Rationale: A behavior punished decreases & a behavior rewarded is reinforced.
In this technique initially slow rate is induced using DAF. Speech is then gradually
shaped to normal rates in structured group conversation. Stutterers have to speak at
specific rates at each step of therapy. No DAF is used during this stage. Penality are
provided for the stuttering and reward for achieving target speech rate and fluency.
Transfer and maintenance are carried out in real life situation.
The value of token reinforcement in the instatement and shaping of fluency was
examined in an intensive treatment program for adult stutterers done by Howie &Woods
in1982. Experiment 1 examined the effect of removing the tangible back-up reinforcers
for the token system and found that clients' performance in the program was equally good
with or without these back-up reinforcers, suggesting that a strict token economy may not
be crucial to rapid progress through treatment. Experiment 2 compared contingent and
noncontingent token reinforcement, while controlling for some variables that may have
confounded the results of earlier research, and found no difference in clients'
performance. Experiment 3 examined the effect of the entire removal of token
reinforcement. Performance was found to be no worse under a "no tokens" system than
under a system of tokens with back-up reinforcers. It is argued that in a highly structured
treatment program where many other reinforcers are operating, token reinforcement may
be largely redundant.
A stuttering therapy program (Ingham & Andrews, 1973) in which adult stutterers were
hospitalized and treated in small groups (n = 4) under token economy conditions is
described. The Token System reinforced reductions and penalized increases in stuttering
during conversation. The therapy program was divided into three stages. Initially,
subjects were treated by the token system, which was then integrated with a delayed
auditory feedback schedule designed to instate and shape a prolonged speech pattern into
normal fluent speech. Finally, subjects passed through a speech situation hierarchy while
under token control conditions. Experiments conducted in the first two stages of
treatment are described. The first-stage experiments examined the design of the token
system; the second-stage experiment assessed the effect of a contingent punishment
schedule integrated with the delayed auditory feedback procedure in order to shape rate
of speaking as well as fluency.

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PRECISION FLUENCY SHAPING THERAPY-PFP (1974):

Author: Webster (1974)
Rationale: Stutterers articulatory and phonatory gestures are distorted and require
reconstruction through intensive over learning of appropriate speech targets.
Theories describing stuttering as an emotionally-based problem have been abundant for
nearly half a century, despite a lack of scientific evidence supporting those theories. In
addition, therapy programs developed from such theories have been unreliable in
providing treatment for stuttering.
More recently, research devoted to the physical aspects of stuttered speech has evolved
into an effective, as well as efficient, means of treating the problem. Through the use of
computer analysis, speech spectography, additional techniques, a succession of essential though minute - elements of speech movement has been observed which, without
difficulty, can take the place of the distorted speech gestures of stuttering.
At the Precision Fluency Shaping Program, stuttering is treated as a behavioral problem,
and not perceived as the consequence of a complex emotional disorder. The accurate
redevelopment of the physical properties of speech compromises a valuable approach to a
perplexing, long-standing affliction.
The term "fluency shaping" is descriptive of the process by which the speech of stutterers
is reconstructed. Through an exacting gradation of activity stuttered speech is
progressively "shaped" into speech which is essentially fluent not only in the clinical
setting, but in everyday life as well.
The Precision Fluency Shaping Program employs laboratory-derived principles of
learning in the development of new speech skills. In the therapy program, the physical
mechanisms used in the production of speech are precisely and systematically retrained.
Initially, participants in the Precision Fluency Shaping Program relearn the proper means
of producing the elementary sounds of speech. The stutterers then rebuild their ability to
correctly produce syllables, words, and ultimately, complete sentences.

HOW DID THE PROGRAM GET STARTED?

he Precision Fluency Shaping Program was developed by Ronald L. Webster, Ph.D., at
the Hollins Communications Research Institute in Roanoke, VA and is administered at
the Eastern Virginia Medical School under the direction of Ross S. Barrett, M.A.,

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CCC/SLP. Mr. Barrett helped conduct the Precision Fluency Shaping Program at Hollins
from 1976 to 1983 after having gone through the program as a patient in 1972.
As a stutterer himself, Ross has dedicated his professional life to helping other stutterers
achieve the same level of fluency that he reached. He was also Instructor in the
Psychology Department at Hollins College where he taught Speech Pathology and
Audiology courses where the HCRI clinic is located. In 1983 Mr. Barrett started his own
PFSP clinic at the Eastern Virginia Medical School where he has successfully treated
over 500 stutterers.

WHAT DOES THE PROGRAM INVOLVE?

The Precision Fluency Shaping Program involves approximately 100-110 hours of
therapy at the Eastern Virginia Medical School in Norfolk, Virginia. Each individual
receives personal supervision as they progress through the program at their own pace. In
the therapy program, the physical mechanisms used in the productions of speech are
precisely and systematically retrained. A small personal computer is also used to monitor
the participants speech to assure correct development of new speech skills. Initially,
participants in this program relearn the proper means of producing the elementary sounds
of speech. The stutterers then rebuild their ability to correctly produce syllables, words,
and ultimately, complete sentences.
After the completion of the Precision Fluency Shaping Program a follow-up program
assists the individual in transferring the use of proper speech responses into the home
environment. In addition, periodic data obtained from those who have completed the
therapy program is used to anticipate difficulties.
The PFP is designed for adolescent and adult secondary stutterers. It may be used in
schools, university programs, speech and hearing clinics, hospitals, and by the private
practitioner. The clinician implementing the program should be an ASHA certified
Speech-Language Pathologist. Any student clinician should work directly under the
supervision of the certified clinician. Many well-motivated, sophisticated stutterers can
implement this program on their own. After all, in the final analysis, the stutterer is the
only one who can learn how to manage his stuttering successfully. The clinician can only
guide, direct and encourage.
The program is designed for either individual or group therapy; however, it is written for
a group (any more than one is considered a group). The group approach is strongly
encouraged both for interest and for mutual support which will grow during the program
and, in all probability, will carry over to the post-therapy period of the stutterers' lives.
The PFP provides a practical, hands-on approach to stuttering therapy. It is a program of
doing, not one of philosophizing about, theorizing about, nor debating about, stuttering.
There is a myriad of information in those areas, and it was not our intent to add to that.

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The underlying rationale for this program is that stuttering is a unique communication
disorder of presently unknown origin or origins, and it cannot be cured--not unlike many
other human ills. The stutterer can, however, learn to manage his stuttering and his
speech so that he can communicate as a stutterer in any situation without undue stress and
strain to himself or his listener. The clinician will guide and execute this therapy
program, but it is the responsibility of the stutterer to accept not only the fact that he is a
stutterer, but also the responsibility for changing his way of communicating to one that is
much more socially acceptable.

AIR FLOW THERAPIES (1974 & 76):

1. Regulated breaking method
2. Flow and slow technique
1. Regulated breathing method:
Author: Azrin and Nunn (1974)
Rationale: Stuttering is a habitual disorder of the initiation and maintenance of airflow
and should be eliminated if the stutterer emits speech behaviors that are incompatible
with these airflow anomalies.
This method is based on the belief that stuttering is a habitual disorder of initiation and
maintenance of air flow and hence should be eliminated if the stutterer emits speech
behavior that are incompatible with these air flow anomalies. Stutterers are trained to
control a wide range of aspects of air flow. These aspects involve
a) Smooth breathing.
b) Exhalation prior to speech,
c) Blending words into exhalation patterns
d) Continued exhalation after the last sound of utterance
e) Pausing at natural juncturing points
f) Smooth inhalation during the prespeech pause and
g) Formulation of general speech content
A brief treatment of one or two sessions each of two to three hours involves breath
mananagement practice. This is done initially in reading followed by spontaneous speech

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gradually decreasing the frequency of pauses. Generalization is minimal and is restricted

to the clinic and its environment

2) Flow and Slow Method / Modified Airflow:

Author: Martin Schwartz (1976)
Rationale: Stuttering is the result of excessive tensing of vocal folds before speech
producing feedback that triggers conditional struggle. To eliminate this malfunctioning,
stutterers are made to relax the vocal folds by maintaining passive airflow.
This method is based on the assumption that stuttering is the result of excessive tensing
of the vocal folds before speech, producing feedback that triggers conditional struggle.
To eliminate this malfunction, stutterers are made to relax the vocal folds by maintaining
passive airflow.
Initially, the stutterer has to initiate passive airflow prior to speech and to slow the first of
each utterance. These skills are to be practiced in increasingly long and complex
utterances and finally in generalization tasks. For a year after intensive treatment, daily
home assignments are carried out and audio taped sample are mailed to the clinic.
It is found that the manipulation of air flow can reduce stuttering dramatically in the short
term. However, data on the outcome of airflow therapies indicate that nothing could be
concluded about the lasting effect of these techniques. The outcome also indicates that
this technique is distinctly inferior to the prolonged speech therapies. In summary it
requires a better quantitative backup.

STUTTER FREE SPEECH (1980):

Shames and Florence (1980) devised stutter free speech in which the stutterer is
encouraged to explore and clarify feelings of anxiety, inadequacy and other aspects. The
stutterer is trained with DAF to speak fluently at a slower rate with continuous phonation
and airflow. The stutterer is to prolong only the stressed words and aim at normal
inflection.
Once stutterer learns to monitor his/her speech to the degree that they can produce slow,
fluent utterances without the aid of DAF, they are taught to self reinforce these fluent
responses. Fluency is transferred to the stutterers daily life by means of written contracts
that specify the times, places and situation in which speech will be monitored. Contracts

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increase gradually until perfect self-monitoring is attained, following which maintenance

phase wherein clinical contacts occur at progressively less frequent intervals.

PRINCE HENRY PROGRAM (1983):

Authors: Andrews, Craig & Feyer (1983)
This represents the cumulative developments of treating 50 adult stutterers each year
since 1971 and grew out of the orginal Andrew Ingham program.
The speech pattern taught is labeled smooth motion speech. The characteristics of this
pattern are gentle onset of phonation, continuous air flow, continuous movement of
articulators throughout each utterance, soft contacts and extension of vowel and
consonant duration.
During the first week, smooth motion speech is trained at a speech rate of 50 SPM (1/4th
of normal speech rate). Speech rate is then increased to the normal rate over the course of
the week in gradual increments of 5 SPM. Each step is considered to be achieved when
the patient exhibits zero stuttering and correct speech rate in a 45 minute session.
A 1- minute monologue is video recorded for each patient who then evaluates his speech
for acceptable continuity, gentle onsets (less than 3 errors) and a speech rate within 20
SPM of target. Later three other characteristics are also evaluated ; intonation,
presentation (Overall acceptability) and appropriate pause (less than 3 appropriate
pauses).
During the second and third week patients transfer these skills to the real world. They
have to complete a graded hierarchy of 25 speech assignments, each recorded on cassette
tapes (phone calls, shopping etc). There are 15 standard assignments which must be
completed by all patients and 15 personal assignments which patients plan to cover many
aspects many aspects of their speaking life. Each assignment must contain atleast 1400
consecutive syllables of stutter free speaking at 200+40 SPM, otherwise it must be
reported. Patients must evaluate their speech quality and rate in each assignment before
submitting it for the therapist evaluation. Each day of the transfer phase begins and ends
with a 2 hour session of smooth speech practice at 100, 150, 200 and 220 SPM.
A 3, 6, 9 weeks and at 6 months after intensive treatment, patients have to attend a follow
up clinic which involves participation in rating lessons and planning of maintenance
activities. If they are not satisfied with their progress they have to continue to attend the
follow up clinic until they are fluent. Patients should be encouraged to perform formal
practice and generalization assignments daily for atleast 9 weeks after the completion of
intensive treatment. They should attend weekly self help meeting of former patients.
Booster treatment program are also available.

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Research on the effectiveness of prolonged speech treatment suggests that they are
effective both in short and long term. The major value of prolonged speech techniques is
that they force a patient to slow his speech sufficiently to allow him to pay attention to
what he does when he is fluent and to reprogram his articulators accordingly.

Dr. FLUENCY (Dr.Trudy stewart & Monia Bray) (1990s):

It is a computerized fluency shaping program. Dr. Fluency instructs, monitors, provides
feedback to the client regarding:

Prolonged syllables.
Breathing pattern.
Gentle onset.
Reducing air pressure
Control of volume

PROLONGATION:
Rationale: Conversational rate control and breathstream management.
Prolongation involves stretching of words by lengthening the amount of time required to
produce each syllable (Goldberg, S.A., Carlotta, R., 1995).
Procedure:
Extensive Prolongation: The stutterer is asked to engage in a number of activities using
an extensive amount of prolongation. It may approximate 60 syllables/min.
Reduced Prolongation: As the stutterer successfully masters extensive prolongation,
either producing fluent speech or reduced stuttering, the rate of speech is gradually
increased.
Slow fluent speech: Eventually the clients speech is brought upto a speed that is slower
than the orginal rate, but not slow enough to call attention to it.

CONCLUSION:

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The treatment methods for stuttering has improved drastically over the years, nowadays
there are lot of treatment packages available for children as well as for adults. A SLP can
not just try out a therapy technique on the clients as per his/her wish, the clinician must
choose the correct therapy technique which is tailor made for the client and which will
benefit the client in the process of fluency modification ultimately. The management of
stuttering for adults as well as for children is a challenging task for a SLP, but if the
clients are guided in the right direction good prognosis can definitely be seen clinically.
***

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