chapter 2 review of literature -...
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CHAPTER 2
REVIEW OF LITERATURE
“There are of course, observable aspects of this disorder, but do we want to say that
efficacious therapies are those that deal only with the observable aspects? If
anything, it should be the other way around. The unobservable events seem more
important than the observable ones”.
(Starkweather, 1999)
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CHAPTER 2
REVIEW OF LITERATURE
From a period of ancient Indian Vedic literature, Speech has been given an
immense importance and considered as a messenger of knowledge which is capable of
expressing one’s inner abstract thoughts, invisible emotions, hidden feelings, and
unseen ideas. Thus, any disruption in this powerful mode can bring about
dissatisfaction and a sense of inferiority in any individual. Stuttering is one such
condition of disruption in forward flow of speech.
2.1. What is stuttering?
In spite of decades of research by professionals from varied disciplines like
speech-language pathologists, neurologists, psychiatrists, psychologists, the fluency
disorder called stuttering remains perplexing and challenging. It is still evading the
professionals dealing with it in terms of defining, describing or understanding the
etiological features, its nature, assessment, treatment outcome as recovery and relapse,
which in turn influence on its management options. Many researchers have tried to
define stuttering from different perspectives. In most of the definitions stuttering has
been defined mainly with a focus on its visible characteristic features associated with
stuttering (such as repetitions, prolongations and blocks that generally characterize the
stuttered speech) whereas, the focus of other definitions has been more on the
speaker’s perspective and reaction of PWS on his or her own stuttering problem.
Some definitions have focused more precisely on the causes assumed to be underlying
in the individual who stutters.
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2.1.1 Definitions
Johnson (1955) said, “…stuttering consists of the reactions made by the
stutterer in an effort not to stutter…” According to him, “Stuttering is a disorder of
the social presentation of the self. Basically, stuttering is not a speech disorder but a
conflict revolving around self and role, an identity problem”.
A standard definition of stuttering which is considered as one of the most
comprehensive definitions was proposed by Wingate (1964). He defined “Stuttering
as 1.(a) Disruption in the fluency of verbal expression, which is (b) characterized by
involuntary, audible or silent, repetitions or prolongations, namely: sounds, syllables,
and words of one syllable. (c) Usually these disruptions occur frequently or are
marked in character and (d) are not readily controllable. 2. The disruptions are
sometimes (e) accompanied by accessory activities involving the speech apparatus,
related or unrelated body structures, or stereotyped speech utterances. 3. Also, there
are no infrequent (f) indications or report of the presence of an emotional state,
ranging from a general condition of ‘excitement’ or ‘tension’ to more specific
emotions of a negative nature such as fear, embarrassment, irritation, or the like. (g)
Some incoordination expressed in the peripheral speech mechanism is the immediate
source causing stuttering”.
World Health Organization (WHO) in 1977 defined stuttering (also known as
stammering) as “the disorder in the rhythm of speech in which the individual knows
precisely what he wishes to say, but at the same time is unable to say it because of an
involuntary, repetitive prolongation or cessation of a sound”. This definition attempts
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to explain the behaviors observed in those who stutter along with the disfluencies they
experience.
Van Riper (1982) stated that “stuttering occurs when the forward flow of
speech is interrupted by a motorically disrupted sound, syllable, or word, or by the
speaker’s reactions thereto”. According to him, stuttering is a condition in which
speech is produced inappropriately in time which also includes reaction of an
individual towards his or her stuttering. Thus, stuttering refers to a problem in speech
planning, patterning, coordination, and reaction of the person who stutters toward his
or her speech impediment.
Tanner, Belliveau and Siebert (1995) tried to put together the primary and
secondary features of stuttering and defined stuttering, as “any condition where an
individual improperly patterns phonemes, syllables, words and/or phrases in time,
experiences classically-conditioned negative emotional reactions to disfluent speech
and associated stimuli, and who may engage in visible avoidance or escape behaviors
when confronted with disfluent speech or associated stimuli”.
According to Guitar (2006), any unusual frequent disruption which may
include repetitions (phoneme, syllable, or word), prolongations and blocks is called as
stuttering.
Stuttering can also be well understood by taking an example of a volcano. The
surface units of stuttering are akin to the smoke of the volcano. Volcanologists need
to deeply understand the formation and various events which gave rise to that
volcano. Similarly, there are many psychological processes already built up in the
mind of PWS which comes out in form of disfluencies.
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2.1.2. Onset and nature of stuttering
The age of onset refers to the age at which an informant reported the speech
behaviours were noticed as abnormal. Stuttering is a heterogeneous disorder with high
intra and inter individual variability in terms of its symptomatology, onset,
development, etiology and variability characteristics. Its onset in majority of
individuals is reported as before the age of 6 years.
Although stuttering is found at all ages and can begin at any age, most persons
begin to stutter before adolescence. However, in most cases it is reported to be
between the ages of two to five years (Bloodstein, 1987). The mean ages of onset of
stuttering is reported to range from 28 months to 46 months (Darley, 1955; Johnson &
Associates, 1959; Yairi, 1983) and the nature of stuttering is reported to be gradual in
most of the studies with a wide range as 69% (Berlin, 1954), 92% (Morley, 1957),
76% (Preus, 1981), 90% (Van Riper, 1982). The nature of stuttering as reported either
is sudden or gradual (Yairi, 1983). Almost after a decade, Bloodstein (1995) reported
an onset of stuttering between 3 and 6 years in more than 75%, with no reported onset
after the age of 12 years.
2.1.3 Incidence and prevalence of stuttering
According to Craig (2002), the prevalence of stuttering i.e., number of people
who stutter at a particular time has been reported to be somewhat lower than 1%
(about 0.73%), while the actual incidence i.e., number of people who ever faced
stuttering in life, is reported as around 5%. This implies that 5% of the world
population experienced stuttering at some time in life, whereas only 1% of individual
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may experience stuttering at a given time. It has also been reported that nearly 4% of
those who experienced stuttering may recover spontaneously.
2.2. Multidimensional characteristics of stuttering
Over the past several years, researchers have opined that stuttering can be best
understood from a multidimensional perspective. As stuttering is considered as one of
the most inconsistent and highly variable speech disorders, stuttering behaviours are
known to be varying according to their communication partner, task and type of
speaking situation and typically it varies with respect to person’s linguistic situation.
A person who stutters may feel more fluent in the clinical situation than
outside. Conversation with a friend or family member may be easier and more fluent
for an individual than talking with a higher authority. Ordering a meal in a restaurant
may be an extreme difficult situation as compared to speaking in home situations.
Talking on the telephone or giving a speech in front of an audience may be a
significant difficult situation for most PWS.
The stuttering frequency varies in its occurrence, and occurs mostly on the
initial sound or syllable of a word (Andrews, Howie, Dozsa, & Guitar, 1982;
Bernstein Ratner, 1997; Bloodstein, 1995). According to Bernstein Ratner (1997),
Hubbard and Prins (1994), the content words are reported to be the most interrupted
in fluency occurrence than that of function words. Increase in language and demand
of correct speech production usually result into a more disfluent speech showing its
related behaviours (Wingate, 1988).
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Stuttering is a dynamic fluency disorder where different processes that lead to
visible stuttering behaviours, are hidden. These processes occur at multiple levels.
These visual stuttering behaviours are usually called as overt symptoms, such as
repetitions of sounds, syllables and words, blocked sound or word. Other behaviours
such as fear, anxiety, increased tension as well as struggle behaviour to speak out the
stuttered sound are associated covert symptoms. The speaker’s reactions, feelings and
thoughts developed over time are the most non observable characteristics. This, along
with some very specific speech characteristics makes stuttering a complex
multidimensional speech disorder.
2.2.1. Speech characteristics in stuttering
The stuttering problem has been considered as a symptom of speech behaviour
and these speech behaviours are typically being used to distinguish stuttering
behaviour from normal disfluent speech. These include repetitions such as sound
repetition, syllable repetition, whole words repetitions, and phrase repetitions,
prolongations which involve stretching of a sound or syllable and blocks or Tense
pauses implies of a long gap between words in order to produce the stuck utterance.
Johnson and Associates (1959) suggested that the type of disfluency in
stuttering has received significant consideration for research and therefore, another
aspect i.e., types of disfluencies needs to be the focus of stuttering analysis. Further,
through the language sample analysis, Johnson (1959) developed a classification
system consisting of eight characteristic behaviours for classifying different types of
disfluencies. These are explained with examples as:
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1) Interjections (I..umm..i mean…ahh..I am going to market);
2) Repetition of sounds or syllables (I..I…I...I am..g-g-go..going..to market)
3) Part word repetition (I am going to mar-mar-mark-market);
4) Phrases repetition (I am..I am going..I am going..I am going to market);
5) Revisions (I am going to shop…ahh..no actually…to market);
6) Incomplete phrases (I am …I am going..I..am..going..);
7) Broken words (I am g - (pause) - oing to market);
8) Prolonged sounds i.e., stretching of sounds (I am goooing to mmmmarket).
The Johnson’s classification system has been adapted by many researchers
(Hubbard, 1998; Natke, Sandrieser, Van Ark, Pietrowsky, & Kalveram, 2004;
Throneburg & Yairi, 2001). These studies were conducted to determine the types of
disfluencies present mainly in children with stuttering.
Yairi and Ambrose (1992) reorganized Johnson’s eight disfluency types and
proposed a composite classification system where the different types of disfluencies
were subdivided into two categories as:
1. Stuttering-like disfluencies (SLD) consisting of single-syllable, part-word
repetition, prolongations and tense pauses or blocks (disrhythmic
phonation)
2. Other disfluencies (OD) consisting of multisyllabic word or phrase
repetition, interjections, revisions, hesitations or incomplete phrase
According to Yairi and Ambrose (1992) this classification had a principle that
SLDs are stuttering related disfluencies and ODs are those disfluencies which are
observed in normal speakers as well. Although, this classification system has been
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considered as perhaps the most frequently used system to categorize different types of
disfluencies, this system had been criticized too. Since, Yairi and Ambrose (1992)
classified the whole-word repetitions (WWR) as SLD; Wingate (2001) stated that the
WWR are usually observed as normal speech feature and argued for not including
WWR as a SLD. Graham, Conture and Camarata (2004) conducted a study and
analysed the stuttering speech using the categorization system which consisted of with
and without repetitions of whole word, the authors found that on excluding the WWR
within SLDs, no change was observed in results obtained.
Einarsdottir and Ingham (2005) raised the issue of considering the types of
disfluency in the assessment of stuttering and argued that even within the SLD and
OD categories of disfluency types, there has been variation to be included within. The
authors reported a lack of consistency in the categorization system and poor reliability
score was reported by them for measuring the disfluency types.
According to Colburn (1985), phrase repetition, word repetition and phrase
revisions are the most frequently occurring disfluency types in the speech of children
with stuttering (CWS). Similar results were reported by Anderson, Pellowski and
Conture (2005) who elicited conversational speech samples of CWS during an
interaction with adult and measured their disfluencies in speech. Throneburg and
Yairi (2001) found no significantly different patterns between the two groups of
preschool CWS and children with no stuttering while comparing the disfluency type
proportions.
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This is to note that literature review has good number of studies measuring
types of disfluencies in CWS but not many studies have been conducted to measure
the types of disfluencies present in the speech of adult PWS.
Santosh (2006) made an attempt to compare the pre and post therapy
difluencies types in individuals with stuttering. The author conducted a study on total
30 adolescents and adult persons with stuttering (age range 15 to 38 years) and
reported that the particular types of disfluencies included in the pre therapy reading
and speech samples of the participants were syllable, part-word and word repetition,
filled and unfilled pauses, interjections, omissions, and prolongations. In post therapy
and six month post therapy reading and speech samples, the types of disfluencies
observed were syllable, part word and word repetition along with filled and unfilled
pauses. As reported the prolongations were eliminated in post therapy condition, but
were found to be present in 6 month post therapy reading and speech samples. Also, it
was reported that, out of the different types of disfluencies, most commonly the
syllable repetitions were observed and prolongations were observed as least common
in the participants.
The speech fluency was defined by Starkweather (1980) in terms of rate,
continuity, effort, and articulation. Continuity in speech was described as the extent
to which sounds, syllables and words are smoothly arranged in a speech. According
to him, “the speech is interpreted as fluent if the semantic units follow one another in
a continual and logical flow of information”. There can be various behaviours that
may disrupt the smooth flow of a message in speech such as repetition, pauses (filled
and unfilled), incomplete sentences and revisions called as disfluencies in speech. The
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speech fluency is disrupted by any of these behaviors, as a result of which
interruptions in the flow of message occur. Thus, an interrupted message may be
perceived as disfluent to the listener when the speaker is unable to speak at an
estimated rate.
The second dimension of fluency is rate. In a continuous flow of speech,
usually the length of words varies as there are words which are longer than others
having more sounds and, a normal speaker can maintain the rate of speaking at
constant rate of information flow. It is quite uncertain as to the appropriate unit for
computing the rate of speech. The rate of speech is usually measured in syllables per
minute (SPM) or words per minute (WPM). For a normal speaker, the preferred rate
by which the information flows is considered to be between 115-165 WPM and 162-
230 SPM, on an average (Guitar, 2006). The measure of rate in SPM appears to be
generally favoured over WPM as “length of syllables, whether measured in phonemes
or in units of time tends to be less variable than the length of words” (Ingham, 1984;
Costello & Ingham, 1984). However, a very little supporting evidence available to
state those measures of SPM are more reliable than WPM to find rate of speech in the
clinical situations particularly.
Johnson (1961) reported that the rate of speech and reading was generally
higher for adult females compared to males. Contrary to this, Lutz and Mallard (1986)
reported that the rate of reading and talking was faster in adult males compared to
females. However, the differences reported in the latter study was not analysed
statistically.
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Speech rate is considered as a measure to determine the treatment outcome in
stuttering (Ingham & Cordes, 1997). A reduction in the rate of speech of adult PWS
results in an increase in fluency as reported by many authors (Adams, Lewis, &
Besozzi, 1973; Onslow & Ingham, 1987; Van Riper, 1973; Zebrowski & Kelly,
2002). Different researchers (Kalinowski, Armson, & Stuart, 1995; Ramig, 1984;
Sparks et. al., 2002) have studied the effects of changed speaking rate on the
disfluencies of PWS. No difference was found between adult PWS and without
stuttering in their rate of articulation when compared for speech and oral reading. The
author reported that it is not necessary that the rate of speaking analysis requires a
natural speaking context (Gronhovd, 1977).
Many clinicians using rate control therapies frequently use 200 SPM or 150
WPM to set goals for rate of speech (Boberg & Kully, 1985), but due to variability in
rate of different individuals, the goal set for one client may prove inappropriate for
another (Kelly & Steer, 1949; Miller, Grosjean, & Lomato, 1984). Thus, this “one
size fits all” approach to management of rate control is not desirable to an extent.
For a normal speaker, the preferred rate by which information flows, is
considered to be between 115-165 WPM and 162-230 SPM, on an average (Block &
Killen, 1996). A normal fluent speaker speaks at a rate of 167 WPM, whereas, for a
PWS 123 WPM is the average speaking rate (Darley, 1955). According to Venkatagiri
(1999), a spontaneous speech rate reported in the literature is somewhat similar to the
one found in his study. He reported a mean speaking rate as143 WPM and 195 SPM;
and describing rate as 147 WPM and 187 SPM. A mean rate of conversation was
reported as 158.6 WPM (216.6 SPM) and a mean rate of reading was reported as 198
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WPM (254 SPM) by Lutz and Mallard (1986). A mean rate of 159.06 WPM for
speech was reported by Kelly and Steer (1949). In a study, Duchin and Mysak (1987)
reported that mean rate of conversation in young adults as 182.7 WPM (236.4 SPM).
Yorkston and Beukelman (1981) reported a mean rate of reading as 188 WPM (262
SPM).
A study was conducted by Savithri, Jayaram, Kedarnath, and Goswami (2006)
to determine the rate of speech and reading in four Dravidian languages (Dravidian
languages are Indian languages, spoken mostly in southern states of India). The
authors reported the rate of speech in adult speakers (age range of 16 to 50 years) as
383 to 448 SPM and 115 to 135 WPM (Kannada language); 346 to 388 SPM and 120
to 135 WPM (Tamil language); 476 to 535 SPM and 116 to 130 WPM (Malyalam
language); 367 to 422 SPM and 105 to 132 WPM (Telugu language) respectively.
The third aspect of fluency is the effort while speaking. An easy, effortless or
relatively less effortful sounding speech is one of the prominent features of a fluent
speaker. There are mainly two ways to describe this; first, a very little muscular or
physical effort is present while speaking by a fluent speaker. Second, a very little
mental effort is put by a fluent speaker while speaking. However, PWS are observed
putting more physical and mental effort while talking. The two primary indicators of
excess physical effort could be tension and struggle while speaking. It is reported that
PWS often exhibits excessive tension in tongue, lip, jaw, and throat which
subsequently reach to the head and neck region, and other parts of the face. Also,
some struggling signs are visible in PWS when they try (sometimes pushing their
tongues with pressure) to get what they want to say. These overt symptoms in
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stuttering usually disrupt the airflow by putting excessive effort while producing a
speech sound (Denny & Smith, 1997; Peters, Hietkamp, & Boves, 1994; Van Riper,
1982). As a result, their voice pitch might rise when they struggle to speak out a stuck
word. Therefore, the rhythm of their speech might sound irregular, rough and
disrhythmic instead of regular, even and rhythmic.
All these speech parameters are considered as good contributors for
determining a “perceptually natural” speech. The adjective ‘natural’, is derived from
the Latin word naturalis, meaning “of nature”. The speech naturalness is one of the
important measures in comparing the speech of those who stutter with those who do
not. According to Parrish (1951), the notion of naturalness as a desirable speech
behaviour suggests the significance of distinguishing between natural speech
production and a perceptually natural sounding speech as a speaker and listener
judgment. There is no specific definition as such to define the term ‘speech
naturalness’ has not been provided. However, Schiavetti and Metz (1997) stated that
the observers can use their own internal standards on an individual to define the
concept of speech naturalness.
Martin, Haroldson, and Triden (1984) developed a reliable scale for rating
speech naturalness consisting of nine points where, ‘1’ was considered as “highly
natural sounding speech” and ‘9’ as “highly unnatural sounding speech”. The
researchers did not provide the listeners with a definition of naturalness and asked the
listeners to “make their rating on how natural or unnatural the speech sounds to
them”. The authors studied the speech naturalness eliciting one minute speech sample
of 10 adult PWS (ages 20-53) speaking without delayed auditory feedback (DAF), 10
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adult PWS (ages 20-51) speaking under DAF, and a group of 10 normal speaking
adults (ages 21-45). 30 listeners used the scale to assess speech naturalness. They
found that both groups of speakers who stuttered (those with and without DAF)
sounded significantly less natural than the normal speaking group. The mean
naturalness ratings for the speakers who stuttered (without DAF) was higher than
those who spoke under DAF. The authors concluded that they were able to quantify
speech naturalness. This finding led Ingham, Martin, Haroldson, Onslow and Leney
(1985) to investigate whether such highly reliable listener ratings on this 9-point scale
might also mean that these ratings could be used to modify speech naturalness. In
experiments with 6 adolescent and adult PWS, they demonstrated that, when a
listener’s rating on the scale was fed back to the subject after each 20 seconds of
spontaneous speech, 5 subjects improved their speech naturalness. This finding raised
the obvious possibilities that a listener rating procedure might be profitably blended
with therapy strategies, particularly those that utilize prolonged speech, in order to
improve speech quality.
Nearly all investigators of speech naturalness have used monologue speech or
some combination of monologue and oral reading. Some were not specific concerning
the speech tasks. Onslow, Adams, and Ingham (1992) were the first to investigate the
effect of speaking task by comparing the influence of monologue and conversational
speech. The subjects were seven males ranging in age from 14 to 36 years (average
age of 21) who had received prolonged speech treatment. The subjects were matched
in age (within six months) with seven non-stuttering male speakers. All the subjects
were recorded during conversation and monologue on three different occasions. The
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listeners selected 96 speech samples for analysis. A group of 29 undergraduate
university students assigned naturalness scores using the nine-point naturalness rating
(Martin, Haroldson & Triden, 1984). The results showed no significant differences in
the naturalness scores of conversation or monologue for either the speakers who
stuttered or those who did not.
A multidimensional speech naturalness scale was developed by Kanchan and
Savithri (1997), Subramanian and Savithri (1997), to rate the naturalness in speech of
persons with stuttering and the ratings were compared from a group of
unsophisticated listeners with those from a group of sophisticated listeners. The
authors conducted a study using prolongation technique, where 29 speech samples,
including pre and post therapy speech samples of PWS and normal speakers were
rated by three sophisticated (Subramanian & Savithri, 1997) and three unsophisticated
(Kanchan & Savithri, 1997) listeners on a nine-point scale (ratings from “highly
natural” to “highly unnatural” sounding speech). The results indicated a correlation
between mean naturalness scores, percent disfluency and rate of speech. However,
using a 9-point scale, it was not possible to differentiate between pre-therapy speech,
post-therapy speech and speech of normals. Therefore, it was decided to use a binary
scale to rate naturalness. Subramanian and Savithri (1997) listed the parameters
contributing to speech naturalness. The number of times (in percentage) a parameter
contributed to speech naturalness was calculated. Based on the percent weightage of
each parameter, naturalness scale was constructed. This scale included confidence,
command over language, clarity, speed, continuity, stuttering, and overall rating.
Using a binary scale (natural, unnatural), six judges (3 unsophisticated and 3 PWS)
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rated 68 samples of spontaneous speech and reading which included seven normal
speech samples, 32 pre-therapy samples of PWS and 29 post-therapy speech samples
of PWS. Six of the samples were repeated to check intra judge reliability. A score of
“1” was given when the parameter was judged “natural”. The naturalness score, the
percent disfluency and the rate of speaking (WPM) were calculated. The results
indicated that unsophisticated listeners and persons with stuttering rated the pre-
therapy samples, post-therapy samples (4.97 and 4.66, respectively) and speech of
normals (3.55) differently. No significant difference between the ratings of persons
with stuttering and unsophisticated judges was observed. Low naturalness was
correlated with slow rate of speaking and increase in percent disfluencies. Factor
analysis indicated that confidence, continuity, speed, clarity, stuttering and overall
rating were some of the important factors determining naturalness. However,
command over language did not influence naturalness. A high inter-and intra judge
correlation (0.99) was observed.
Kanchan and Savithri (1997) followed the same method using prolongation
technique. However, the binary naturalness scale included rate, continuity, effort,
stress, intonation, rhythm, articulation, breathing pattern and overall rating. Five
sophisticated listeners (all postgraduate students) rated samples for naturalness on a 2-
point scale (natural-unnatural). The judges rated the speech of PWS, both pre- and
post-therapy as, unnatural. There was a significant difference between the naturalness
score of the speech of normals and PWS. Naturalness score increased from pre-therapy
sample (5.52) to post-therapy sample (4.64) to normal speech (3.08). A better mean
naturalness score was obtained on post therapy speech sample of participants and
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normal speech. The mean naturalness score were reported to be well correlated with
naturalness rating of other parameters. Low naturalness score for pre-therapy speech
samples was attributed to slow rate of speech, disrupted intonation pattern and
increased effort. The naturalness score reportedly increased with an improved rate of
speaking and reduced disfluencies. Factor analysis indicated parameters such as rate,
continuity, effort and stress as important factors in perceptually judging the
naturalness. The results of these two studies indicated that there were some common
parameters like continuity and rate, which both unsophisticated and sophisticated
listeners employed in judging naturalness of speech. Though termination from therapy
is based on the judgment of sophisticated listener (speech pathologist), the PWS have
to face the unsophisticated listeners after therapy. Therefore, the parameters identified
by the unsophisticated listeners as contributing to naturalness should also be the
deciding factor for termination from therapy.
2.2.2. Non-speech characteristics in stuttering:
The abnormal speech behaviours constitute one part of the definition of
stuttering, while the other refers to the individual’s reaction to his/her disruption in
fluency. Stuttering is often accompanied by non-speech phenomena. The non-speech
characteristics are generally those related behaviours observed in PWS, secondary to
speech characteristics. Some behaviours such as frequent blinking of eyes, tapping a
finger or foot, neck jerks, hand or fist clinching, head turning away during the
moments of stuttering are some of the secondary behaviours observed in those who
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stutter. In some cases, PWS try to cover up their mouth in order to be less noticeable
to the listeners.
Wingate (1964) classified the non speech behaviours under the headings of:
(a) Speech related movements: This category embraces those exaggerated or
inappropriate movements of the peripheral speech mechanism associated with the
difficulty in uttering speech. Examples would include, pursing the lips, protruding the
tongue, clenching the teeth and the movements which may or may not be consistent
with the sound being attempted. While it seems to be widely accepted that such
characteristics are learned, it is by no means certain that they are. It remains
conceivable that they are essentially spasms, which the PWS can learn to control.
(b) Ancillary body movements: This category includes all other kinds of body action
occurring in association with difficulty in uttering speech, such as eye blink, snorting,
jerking the head, clenching fists, etc. Often these features give the appearance of
intentional struggle and thus are assumed to be learned reactions. It may be that some
are learned, but again the possibility remains that some of them may well represent
"overflow" expression of a spasm.
(c) Verbal features: These consist of verbal expressions of one to several words in
length, which are notable in the sense that they either appear at relatively inappropriate
points in the context of a message, are unduly repetitive, associated with signs of
struggle, or followed by a repetition or prolongation. Sometimes they appear to occur
voluntarily, and some PWS report their use to avoid or "get through'' a word. As
mentioned earlier, certain kinds of interjections, repetitions of phrases and words of
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more than one syllable, and even some single-unit word repetitions are classifiable as
verbal accessories. They are not basically the integral parts of stuttering.
Certain characteristics beyond those of the speech abnormalities can be
observed frequently in stuttering called as secondary behaviors. These secondary
behaviors are commonly assumed to be learned behaviors. However, to consider that
"secondary" does not mean that these features necessarily occur secondly, but that
they stand second in significance because they are not universal in the observable
symptoms of stuttering (Spiller, 2001). These features vary in some individuals than
in others. Lanyon (1978) viewed these behaviors as a result of fine motor control
system deficit or increased tension in muscles related to speech.
Johnson (1959) stated that stuttering is a reaction of PWS to their speech
interruption. Increased tensions in vocal muscles, lip or tongue are some of those
reactions that accompany stuttering and these additional related behaviours may vary
from individual to individual. Tension and tremor are the two non-speech behaviours
which generally begin to increase with the feeling of being non-accepted by others
due to the presence of core stuttering symptoms. In an attempt to regain control over
articulators and the speech flow, the muscular tension increases, first from lips,
tongue, and jaw, and may reach to face, head and neck. The reason for tremors of
muscles could be an excessive tension while speaking. An involuntary muscle
movement when tremor occurs can cause a person to feel unable to speak. In order to
control a tremor, the individual may use some struggling behaviours such as use of
sudden jerks, pushing the muscles harder or escape from stuttering moment, in order
to get a flowing and smooth speech.
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Some behaviour, often called avoidance behaviours exhibited by PWS
develops in a response to fear of speaking abnormally. In order to avoid a moment of
stuttering, PWS may substitute the feared word with the word they feel is easier to
say. Many a times a PWS might just talk around a word but not able to say it at all,
giving a pause in between and pretend as if thinking to speak, and sometimes not
talking at all or avoid talking. These are some of the examples of an avoidance
behaviour. Sometimes a postponement of feared word is shown by PWS when they
are not able to avoid a word or situation altogether until they can speak it without
stuttering.
Johnson (1937) stated that the reactions produced as a result of false
assumptions and avoidance is the root cause of the stuttering problem. There is a
belief that stuttering is elicited by avoidance reactions, a feeling of being blocked on a
word and anticipation of stuttering to occur ,which further invokes a neuromuscular
adjustment that elicits an overt stuttering (Van Riper, 1937). According to Hubbard
(1998), stuttering is a consequence of avoidance of the problem; the avoidance may
be restricted only to the language or may extend to different speaking situations. They
avoid many speaking situations such as calling on phone, ordering a meal in
restaurant or answering a question during lecture. There can be voluntary avoidance
of specific sounds, words, people or situations. Almost all adult PWS exhibit
avoidance behaviours. However, in what circumstances such avoidance behaviours
occurs may vary.
According to Wingate (1964), there are some associated features
accompanying stuttering which include indication of excitement, tension, personal
39
reactions, feelings, or attitudes. Attitude, being a hypothetical construct, refers to
something that cannot be directly observed but inferred from their effects on
behavioural actions, which are directly observable. The attitude of PWS about
themselves, others and about their communication problems may vary depending on
the personality characteristics and their levels of emotional upsets from any real or
perceived communication failure, frustration and anxiety.
Anxiety has been considered as a negative emotion consisting of mainly two
components i.e., state and trait anxieties. As explained by Ezrati-Vinacour and Levin
(2004), an anxiety to a specific situation which may elicit by certain factors related to
social interface is called as state anxiety. In contrast, trait anxiety is not related to
situational factors and is considered as persons’ basic level of anxiety which develops
gradually over a period of time (Menzies, Onslow & Packman, 1999). An increased
level of state anxiety exhibited mainly in social situations have been reported in those
who stutter as compared to those who do not (Messenger et al, 2004). When an
individual is exposed to threatening or demanding stimuli, stuttering becomes more
severe and when the stimulus is less threatening stuttering is reported to be reduced.
Some anxiety-provoking situations such as speaking in front of audience or speaking
with higher authority, or to a listener who seems to be impatient or critical, are
associated with increased stuttering (Bloodstein, 1995). In contrast, the frequency of
stuttering is generally reduced in PWS while talking to a familiar person or someone
not in authority which are not anxiety-provoking situations.
Coping behaviour is yet another characteristic in PWS, which further related
to two forms i.e. physiological behaviours in the speech mechanism and the non-
40
speech physiological such as speeding up the speech rate, disrupting the natural
sequence of speech movements and extraneous movements of body parts.
The literature on attitudes, anxiety and coping strategies seen in PWS shows
the existence of negative attitudes and anxiety in PWS. Though the attitudes are
universal, they differ to some extent with cultures. Jasmine and Geetha (2010)
conducted a study on 30 adult PWS, to compare the attitude, anxiety and coping
strategies in new, post therapy and relapsed PWS as three groups of participants. The
results showed that the PWS who relapsed and new PWS obtained higher scores as
compared to PWS who recovered after therapy with respect to attitude and anxiety
level. A higher score was observed on coping strategies for PWS after therapy as
compared to new PWS and relapsed PWS group. Much higher mean scores were
obtained by new and relapsed PWS than the post therapy group for coping strategies.
The authors reported that this may be due to the decreased confidence level in
speaking situations due to relapse, leading to the reuse of the same. Significant
changes were reported in PWS group after therapy and in relapsed PWS with respect
to change in their attitude towards stuttering. Further, authors concluded that PWS do
have negative attitude, anxiety problems and adopt various coping strategies as well.
Breathing abnormality is one of the observed behaviours which tend to occur
often with stuttering. Exhibiting a feature of shallow breath or involuntarily holding
of breath during a moment of stuttering are few of the abnormal behaviours observed
in PWS. Some PWS may experience a rapid heart rate and high or low blood
pressure during moments of stuttering.
41
Brown and Hull (1942) noted that adult individuals who stutter lack
confidence and speaking enthusiasm. They may speak relatively less in social
situations, experience embarrassment and a sense of shame while speaking as a result
of loss of control of behaviours, compared to those who do not stutter. The authors
also stated that, PWS believe themselves to be less efficient to communicate properly
and thus sometimes withdrawal is often seen in addition to speaking less frequently.
According to Sheehan (1975), any facial grimacing, fixed articulatory postures
and fear during speech or anticipation of speech failure prior to speech attempts are
some of the additional non-speech behaviours, resulting in the analogy of stuttering as
an iceberg. These visible signs of stuttering are likened to tip of an iceberg that rises
above the water level and its submerged portion is more destructive, which when
linked to stuttering, comprises feeling of fear, shame, guilt, anxiety, hopelessness,
denial and isolation.
The emotional reaction may take the form of anger, guilt, embarrassment, and/
or frustration. After prolonged stuttering, the individual may develop shame-based
reactions to stuttering and negative cognitive thought processes that hinder the ability
to cope effectively. These associated behaviours vary from individual to individual
and change over time (Ambrose, Cox, & Yairi, 1997; Poulos & Webster, 1991; Smith
& Kelly, 1997; Van Riper, 1982).
The notion of “locus of control” was first introduced by Rotter (1966) and
according to him, locus of control is “the extent to which a person perceives a causal
relationship between his or her behaviour and the reinforcement that follows it”. The
author stated that an individual may be considered as having an “internal locus of
42
control” when he or she feels that his or her outcome behaviours are being under
personal control. On contrary, an individual may be considered as having an “external
locus of control” when he or she feels the outcome behaviour are resulting in
consequence of his or her fate, destiny or luck being more powerful. Usually PWS
develop an external locus of control as, for them every day events seem to be more
controlled by others than by themselves (Madison, Budd & Itzkowitz, 1986).
Craig, Franklin and Andrews (1984) developed a scale consisting of 17-items
in the form of statements. The scale was termed as the “Locus of Control of
Behaviour (LCB) scale”. The LCB scale measures the extent or a range to which an
individual show concern to their personal behaviours problem. The authors conducted
an investigation on a group of total 45 adult PWS who were evaluated using the LCB
scale, after attending a three-week fluency treatment programme. The participants
were re-assessed during follow-up after 10-months, when 32 of the 45 participants
reportedly maintained their post treatment fluency, while other 13 participants showed
a significant relapse (more than 2% of the syllables stuttered were considered as
relapse). The majority (28 out of 32) of the recovered participants were reported to
have a higher internality score on LCB scale and an association between internalized
LCB scores and maintained recovery. An externalized LCB was associated with those
who relapsed. The authors reported that the 11 of the 13 participants who relapsed had
either shown no change or showed the higher scores toward externality. The LCB
scale reportedly shown to have a satisfactory internal reliability and it was reported
that its usage is not to be related to sex, age or social desirability (Craig, Franklin &
Andrews, 1984).
43
In an another study, Craig and Andrews (1985) measured LCB in 17 clients
during their treatment course, and a similar results were reported. That is, an
externalized LCB score was associated more with relapse at 10 months post-
treatment, and none of the participants who experienced relapse obtained an
internalized LCB score. However, a less convinced result was reported by De Nil and
Kroll (1995) who conducted a study on 13 individuals who attended prolonged speech
treatment and re-analysed after 2 years. The authors reported that the LCB failed as a
predictor of treatment outcome.
Some researchers (Foon, 1987; Lefcourt, 1976; Oberle, 1991) conducted
studies with an objective to measure the extent of LCB to predict the treatment
outcome for a different variety of problems. In general, mixed results were obtained
from these studies. However, these studies suggested that an individual’s LCB
orientation can be considered while looking for a short or long term change in his or
her behaviour. The predictive value of LCB may be affected by other factors such as
the nature of the behavioural problem, the presence of other environmental
circumstances, and previous learning experiences. The reports indicated that both
behavioural and non-behavioural variables may predict long-term success in
prolonged speech based treatments. These studies have looked for variables both
before treatment and immediately after treatment.
It would undoubtedly be advantageous to know in advance which client is
likely to benefit more from the treatment and which client would not respond so well
for the treatment. This may further help in modifying the therapy goals to the client’s
need ensuring a better treatment outcome. Thus, the application of locus of control
44
measure is reportedly worth applying to those who are working with PWS. It is seen
most often, that those who stutter express a feeling that there is something that has
happened to their speech on which they have very little control (Van Riper, 1971).
Also, in therapy programs individuals are asked to learn self-control their own speech
that they have to become "their own clinician" (Adams, 1983; Kuhr & Rustin, 1985).
Those individuals who show behaviours such as over-dependant on their clinician,
depend more to their therapy techniques as a source of reinforcement of fluent speech
rather than self-capability, were reported to be more likely to relapse after their
discharge from therapy (Boberg, Howie & Woods, 1979). Such individuals may
generalized for an external LCB orientation which, according to Rotter (1966), will
have negative affect to their ability to accurately acquire new and appropriate
behavioural skills.
In a study by Rotter and Mulry (1965), results indicated higher level of
motivation among those participants having higher internal score. The PWS having
good internal locus of control, search for some relevant information to their problem
solving (Seeman, 1963). However, Shriberg (1974) suggested that locus of control
may prove to be a useful factor in predicting treatment outcome. The possibility for
those who show more internality control may be more in showing improvement and
therapy benefits than in those who are more externally controlled. Lefcourt (1976)
reported that those individuals who are less motivated are more likely to have external
control and are less likely to confront challenges.
In a preliminary study, Craig and Howie (1982) studied 30 PWS who were
treated in an intensive behaviour therapy program. The effect of therapy on their long
45
term perceptions of self control was investigated. The treatment was shown to be
effective in eliminating stuttering behaviours in the long term. The authors reported
that those clients who maintained their improvement acquired during therapy
attributed the positive effects to their own efforts.
Dharitri (1985) attempted to investigate the therapeutic progress made by
individuals with stuttering (age range 18 to 24 years) in relation to their locus of
control. All the participants had been diagnosed with moderate to severe degree of
stuttering and underwent stuttering treatment using prolongation and shadowing
techniques (45 minutes in each session, twice a week). Rotter’s I-E scale was
administered to the 28 participants at pre and post therapy level (after 16 therapy
sessions). A significant difference was reported by the author between high and low
internals in response to therapy. The results indicated that 17 out of total 28
participants showed higher internality after therapy whereas 11 participants showed
lower internality scores on Rotter’s scale. The result revealed a direct relationship
between internality and therapeutic progress made by the participants in the study
since participants who had scored high internality scores showed more benefit from
therapy. The authors concluded that a higher rate of progress in therapy can be
expected among PWS having high internal locus of control. Also, it has been reported
that a low motivation level may relate to an external locus of control in individuals
with stuttering. Dharitri, in review of her study, mentioned report on Rajmohan and
Rajarathnam (1979), who also found a significant and positive correlation between
internality and achievement motivation and stated that a good motivation level is an
important aspect in therapeutic progress, especially in individuals with stuttering.
46
A prediction of maintenance or relapse of therapeutic gains can be measure by
changes in locus of control (Craig & Andews, 1985). Ginsberg (2000) conducted a
study on 119 adults with stuttering to investigate the three psychological factors such
as “shame”, “self-consciousness” and “locus of control” for predicting three
behaviours such as “struggle”, “avoidance” and “expectancy”, which are considered
to be self reported behavioural dimensions of the stuttering. The results revealed that
the factors of shame and self-consciousness were found to be significant
psychological predictors of stuttering dimensions whereas locus of control was not
found to be a predictor.
There is a range of secondary behaviours which develop as a result of increase
in reactions to the fear of stuttering behavior. Van Riper, (1982; p. 122-123) said, "the
variety of these accessory or secondary behaviours is almost incredible". Bloodstein
(1987, p. 17) added that "...the concomitant features of stuttering are many and
extremely varied". Thus, despite considerable interest in the non-speech behaviours
associated with stuttering and recognition of their importance to thorough descriptions
of stuttering (Bloodstein, 1987; Egolf & Chester, 1973; Van Riper, 1982; Wingate,
1964), there have been relatively few attempts to objectify the number and nature of
these behaviours (Barr, 1940; Krause, 1982; Prins & Lohr, 1972; Schwartz &
Conture, 1988). An attempt was made by Janssen and Kraaimaat (1986) who explored
the speech of normally disfluent, stuttered and a fluent speech to determine the
functions of various accessory facial movements. The authors reported that the
speech-related movements may exhibit primarily due to an excessive muscle tension
and avoidance behaviour may primarily have an ancillary body movement.
47
To summarize, a distinction is made between the speech characteristics and
non-speech characteristics in stuttering. The speech characteristics features in
stuttering, may include repetitions, prolongations and audible/silent blocks. Though
the nature of non-speech accessory features is not that clear, they are generally viewed
as learned behaviours. These include avoidance, escape or coping behaviours, anxiety,
attitude, confidence, motivation, and self monitoring. The non-speech behaviours
associated with stuttering are variously referred to as accessory, associated, or
secondary behaviours, as well as physical concomitants (Bloodstein, 1987; Van Riper,
1982; Wingate, 1964).
2.3. Measures of stuttering
There have been various studies where the researchers have suggested of
essential components to measure during the assessment of stuttering. The importance
of inclusion of different measures to assess speech and non-speech behaviours in
stuttering evaluation has been recommended in many of the below mentioned studies.
Curlee (1993) suggested that the components essential for a detailed
assessment of stuttering should include:
1. Measure of stuttering frequency (percentage of syllables or words stuttered)
2. Rate of speech in syllables or words per minute
3. Speech naturalness ratings
4. Severity of stuttering by administering a standardized scale such as the
Stuttering Severity Index-SSI given by Riley (1994)
48
5. Non-speech aspects of stuttering by administering behavioural scales such as
S-24 Scale (Andrews & Cutler, 1974), and scale of Locus of control of
Behaviour (Craig, Franklin & Andrews, 1984).
Guitar (1998) suggested that for an assessment to be called ideal, it should
include aspects of treatment related to primarily three components of stuttering i.e.,
Core behaviours (frequency, duration, rate and type of stuttering), Secondary
behaviours (avoidance, coping strategies and physical concomitants), and Affective
aspect of stuttering (self perception, attitude, feeling and anxiety level).
The speech rate, frequency of stuttering and naturalness in speech are the three
important and well established measures considered in the literature for describing
behaviours in PWS as these behaviours reportedly change over time or under different
speaking conditions (Ingham, 1975). As suggested by Ingham and Costello (1985),
these three measures should be a part of any data collected for those researches aimed
to describe relevant and fundamental aspects of speech behaviours in individual with
stuttering. However, there may be additional aspects of behaviours of PWS in which a
clinician may be interested.
Length of a speech sample for disfluency count has been an important point
to consider while collecting data. For differentiating between stuttering and non-
stuttering populations and to identify the stuttering behaviours based on the
disfluencies, a 300-word sample has been suggested as sufficient by many researchers
(Hubbard & Yairi, 1988; Kelly & Conture, 1992; LaSalle & Conture, 1995; Logan &
LaSalle, 1999; Ryan, 2001; Throneburg & Yairi, 2001; Zebrowski, 1991; Zebrowski,
1994).
49
The assessments of stuttering have focused majorly on the visible
manifestations of stuttering, and relatively very little importance is given to the
hidden or non-observable features experienced by a speaker (Andrews, Guitar &
Howie, 1980). The emphasis is usually put on reducing disfluencies which can be
reasoned out well based on many factors. Some of these are that these observable
behaviours are core characteristic of the problem, and individuals attending therapy
definitely want reduction in the problem. Treating these surface characteristics is most
salient for the listeners and also the easiest aspect to measure and it also makes the
rating of improvement due to intervention easy. However, when PWS are asked about
their own “complaints”, the negative consequences of stuttering faced by these
individuals is a key aspect present and hence should be given equal importance in
assessment and as well as therapy.
O’Brian, Packman and Onslow (2004) compared the two measures i.e.,
disfluencies in terms of “percentage of syllables stuttered” and on “nine point
severity rating scale” to assess disfluencies in stuttering. The authors reported that
these two measures provided similar results and can be interchangeable. However,
exceptions are possible with a significantly small number of articulatory fixed
postures or when repeated movements are relatively large in number in the speech
samples. In such cases the authors recommend using both the percentage score and
the severity rating scale.
Block, Onslow, Packman and Dacakis (2006) conducted a study to predict the
treatment outcome using different measures such as %SS, LCB, an attitude scale, and
a scale for measuring speech naturalness. A surprise telephone call was made during a
50
3.5–5 years post-therapy follow up. The authors reported that pre treatment %SS was
found to be the only predictor at immediate post treatment, which proved valuable in
prediction of long term outcome. The authors suggested developing procedures to
prevent relapse by investigating the underlying factors at soon after completion of
treatment that may predict long-term outcome better.
2.4. Prolonged speech treatment for stuttering
There are different approaches available for the treatment of stuttering.
However, fluency shaping and stuttering modification approaches are the two most
renowned treatment approaches in stuttering management.
Fluency shaping approaches are thought to be more a form of physical therapy
for the speech production system where fluency is enhanced by altering the manner in
which the speaker uses his or her respiratory, phonatory, and articulatory system. On
the other hand, stuttering modification therapy focuses on bringing the stuttering
under voluntary control of the person. The main presumption here is the involuntary
nature of the problem.
Ann Meltzer (1998) observed that majority of the clinicians accept that a
behaviour modification approach to treatment aims for (a) normal-sounding speech;
(b) controlling speech behaviours and to choose the way of speaking; (c) enhancing
confidence to use fluency skills; (d) well-organized communicative skills, (e)
improving problem solving ability to act as their own therapist. The main objective of
the approach is to make the client experience a feeling of pleasure or satisfaction from
speaking.
51
Goldiamond (1965) introduced a type of speech produced by DAF, called as
‘prolonged speech’, in a single case study. He reported that with the reduction in the
DAF intervals, an increase in the speech rate of PWS could be achievable, with a
normal sounding speech. He further concluded that to control stuttering, the stutter-
free prolonged speech patterns can be used. This procedure was later adopted by
many clinicians in combination with other systematic stuttering treatments such as
behaviour modification. It was reported that by providing a model and without the use
of DAF, a prolonged speech can be taught (Ingham, 1984).
Numerous variations on the speech pattern emerged from the Goldiamond’s
procedure. As a result, “prolonged speech” became a standard term and variants of
prolonged speech were considered by clinicians such as “precision fluency shaping”,
“smooth motion speech”, “breath stream management”, and “regulated breathing”.
The speech skill in the prolonged speech originally referred to the slowing of
speech by prolonging vowels. This is the pattern which usually occurs artificially
during DAF at about a quarter of a second delay. A comparative research (Ingham &
Andrews, 1973) suggested that, although both the therapy techniques i.e.. a syllable
timed speech and prolonged speech proved helpful in reducing stuttering, prolonged
speech was found to be a better procedure for obtaining stutter free speech. Those
who attended prolonged speech were found to be able to speak at a fast rate following
treatment, and repetitions of sounds were found in their residual stuttering rather than
blocks.
Curlee and Perkins (1969, 1973) adopted Goldiamond’s findings and
developed the approach further in their conversational rate control therapy. The
52
rationale of their therapy approach was that the duration of DAF determines the rate
of speech, which can be controlled in PWS. The steps of the therapy were:
(a) establishment of the baseline, (b) use of DAF to elicit prolonged speech,
(c) decreasing delay when client shows zero stuttering, (d) eliminating delay, and
(e) extending the new fluent speech in increasingly demanding situations. A less
fluent and unnatural sounding speech was observed in unrecorded than the recorded
samples. To overcome this, the authors used the approach along with breath stream
management, phrasing and prosody which resulted in improved long-term results,
both in terms of greater reduction in stuttering frequency and more normal speech
rates (Perkins, Rudas, Johnson, Michael & Curlee, 1974). According to Perkins
(1981), the treatment approach involves a consecutive acquisition of seven skills
(slow rate, phrasing, easy voice onset, soft contacts, breathy voice, blended words,
and normal stress) with mastery of each required before progress on to the next. The
mastery of these skills is mainly based on subjective judgments by the clinician.
Over the years, the term “prolonged speech” has comprised of various
combinations of gentle onset of words, soft articulatory contacts, smooth transition
between sounds, and exaggerated continuity of speech. O’Brian, Onslow, Cream, and
Packman (2003), introduced a “non-programmed, instrument free approach of
prolonged speech” consisting of four components in the program such as: (a)
teaching in individual sessions, (b) a group practical day, (c) sessions for improving
individual problem solving skills and (d) a maintenance phase. During individual
teaching sessions, clients learn the prolonged speech pattern in a slow and
exaggerated fashion, imitating a video exemplar. No reference is made to specific
53
target behaviours such as soft contacts or continuous vocalization. At this stage, the
clients also learn to evaluate their stuttering severity according to a nine-point severity
rating scale having points from 1 to 9; where 1 indicated no stuttering and 9 indicated
extremely severe stuttering. The purpose of this component is to determine whether
the clients can learn the basic behaviours required during the treatment. During the
group practice day, the clients complete a number of trails. Each trial consists of a
sequence of three tasks: (a) practicing prolonged speech in an exaggerated manner,
(b) speaking with instructions to use characteristics of the prolonged speech treatment,
in order to control stuttering while attempting to sound naturally, and (c) using nine-
point scale to evaluate their stuttering severity and speech naturalness. The clients are
taken through any systematic speech shaping procedure. The trials occur in one to one
and then group settings. The purpose of this component is for clients to obtain a
control on their stuttering. Subsequently, during the problem solving stage in
individual sessions, the clients visit the clinician regularly in order to obtain stutter-
free speech by developing strategies for generalization. And finally, on reduction of
stuttering to minimal levels for number of weeks, across various situations beyond the
clinic, clients move into a performance-contingent phase.
To summarize, in prolonged speech techniques, the participants’ control their
stuttering with slower rate of speech and then towards more normal sounding speech
obtained systematically. This stutter free speech is then used outside the clinic.
Despite the similarity of some aspects of these programs to the stuttering schools,
most treatment programs now incorporate procedures designed to assist clients to
generalize and maintain the benefits of the clinic-based stage of treatment.
54
2.5 Studies on treatment outcome following prolonged speech
An extent to which a treatment does what it is intended to do for a specific
population is termed as treatment effectiveness (Last, 1983). There are studies
focusing on treatment efficacy of one treatment approach over the other in providing
better treatment outcome, long term maintenance of fluency and reducing relapse. In a
review of global stuttering treatment practices, Andrews, Guitar and Howie (1980)
concluded that the prolonged speech treatment is the most effective treatments for
stuttering. There are numerous studies on treatment outcome which indicate that the
recent prolonged speech treatment programs are capable of eliminating or reducing
stuttering in order to gain an immediate improved fluency skill for a brief period and
to a lesser degree in the long term.
On reviewing about 42 studies, Andrews, Guitar and Howie (1980) examined
the symptom reduction treatments in adults who stuttered. Their results revealed that
the six most common principal treatments such as prolonged speech, gentle onset,
attitude change, airflow rhythm, and desensitization proved effective in symptom
reduction. The prolonged speech and the gentle onset therapy yielded the highest
treatment effectiveness and considered to be the most effective treatments in both
long and short-term analysis. According to Bothe et al (2006), the most powerful
treatment for AWS with respect to both speech, socio-emotional or cognitive
outcomes include variants of prolonged speech, self management, response
contingency and other variables.
There are numerous studies (Dayalu & Kalinowski, 2001; Franken, Boves,
Peters & Webster, 1995; Ingham, Gow, & Costello, 1985; Ingham, Martin,
Haroldson, Onslow & Leney, 1985; Kalinowski, Noble, Armson, & Stuart, 1994)
55
which reported that using the fluency enhancing techniques for treatment of stuttering
may not always be effective and tends to result in unnatural speech. The impetus for
studying the speech naturalness of individuals treated for stuttering came from
observations that many people who had undergone successful treatment using
prolonged speech strategies continued to sound less than satisfactory. That is,
although the frequency of stuttering had decreased dramatically, the listeners found
that many speakers continued to sound unnatural. Their speech was effortful,
uncomfortable to listen to, and contained auditory or visual features that prevented the
listener from fully attending to the content of the message. Despite an otherwise
successful treatment experience, many speakers found that they were still regarded by
themselves and others as having problems (Schiavetti & Metz, 1997).
A much research interest has been generated considering perceptual speech
naturalness of the speech of those PWS who completed treatment successfully. A
number of studies (Ingham & Packman, 1978; Ingham, Gow, & Costello, 1985;
Kalinowski, Noble, Armson, & Stuart, 1994) have been conducted to investigate the
naturalness perceived following fluency shaping therapies. The listeners rated an
unnatural sounding speech at post treatment. The result arises a question as to whether
the disfluencies itself are the cause for lacking speech naturalness, or the perceptually
unnatural sounding speech the result of reduction in the disfluencies using fluency
shaping techniques. However, Conture (1996) supported the fluency shaping
treatment and suggested that a more fluent speech may be obtained following fluency
shaping treatment. There are studies comparing pre- and post-therapy speech of PWS
using prolongation technique with respect to speech naturalness.
56
Santosh and Savithri (2007) compared the speech naturalness in three
conditions of pre, post and 6 months post treatment using spontaneous speech in 30
PWS. The authors reported a significantly higher score in mean naturalness for the
spontaneous speech at post therapy condition and in post 6 months following therapy
in comparison to their pre therapy condition when 10 naive listeners rated the samples
using multidimensional speech naturalness scale
Some previous studies (Ingham & Packman, 1978; Jones & Azrin, 1969;
Runyan & Adams, 1978; Runyan, Hames, & Prosek, 1982) on perceptual judgment
have discussed the methods to differentiate between the speech of those who stutter
and those who do not. A perceptual analysis technique was used by Frayne, Coates
and Marriner (1977) to analyse the quality of speech of PWS who received treatment
using prolonged speech technique. They reported that the listeners in the study
generally could not distinguish between the samples from PWS and PWNS.
The speech that is free from perceptually overt stuttering has been described
as a fluent speech in PWS. (Franken, 1980). In other studies (Franken, 1987;
Franken, Boves, Peters, & Webster, 1992), naturalness is reported as a “multifaceted
variable” as it relates to other perceptual characteristics in speech. There is a
probability that because of the multiple dimensions in nature of speech, and various
perceptual characteristics in speech, one may fail to sound natural even after
treatment. Thus, if a clinician can find the features that are most deviant in the
individual seeking treatment, a clinician can help the individual in improving an
overall speech quality.
57
Sheehan (1984) suggested that majority of the studies of successful prolonged
speech treatment are based on the frequency of stuttering measures. The
representation of the speech measures reported is less than satisfactory and further
suggested a need for the inclusion of speech rate and naturalness evaluation.
Many studies (Conture, 1996; Craig, 2002; Craig et al., 1996; Langevin &
Boberg, 1993) have shown that prolonged speech treatment proved to be effective for
many individuals in terms of reducing or eliminating stuttering moments. However,
not all individuals showed satisfactory long term effects in maintaining fluency. Thus,
as reported by Boberg and Kully (1985) the maintenance of fluency following
stuttering treatment is essential for stabilizing of improved fluency gains in order to
prevent relapse.
In the Indian context, there are only a handful of studies conducted to
determine the treatment outcome in PWS, with respect to efficacy of the particular
treatment.
Madhavilatha (1997) investigated the intonation pattern in the speech of PWS
before and after therapy. One normal 47 year old female (model) and 10 PWS in the
age range of 15-30 years participated in the study. The material consisted of 10 audio-
recorded sentences uttered by the model with different intonation patterns depicting
emotions such as anger, sarcasm, surprise, command, question and statement. The
subjects were instructed to imitate the intonation patterns before and soon after
prolongation therapy. Three judges perceptually evaluated the sentences uttered by
the model and the imitations indicated whether the intonation patterns in PWS was the
same or different from the model. The results indicated a significantly reduced
58
intensity range and longer sentence duration in the speech of persons with stuttering.
Pre and post therapy speech of persons with stuttering differed significantly in
intonation pattern. The sentence duration was reported to be shorter in the post-
therapy speech. The results indicated that the prolongation therapy brought changes in
intensity related parameters in the post therapy speech of PWS.
Savithri (2002) evaluated the efficacy of prolongation therapy by measuring
some acoustic parameters in the pre-and post-therapy samples of PWS. Five adult
PWS in the age range of 12 to 25 years participated in the study. The participants read
a standard passage before and after prolongation therapy. Wide band spectrograms of
the words in the pre-therapy sample and same words in the post-therapy samples were
obtained. The results indicated no significant difference between pre-post-therapy
samples of terminal frequencies. In the pre-therapy samples, the participants showed
various types of mis-coordinations that included frication before trill, error in place
and or manner of articulation, dental clicks before trill, non-nasal for nasal and vice
versa. The other errors noted were omissions, half voiced murmur for voiced
phonemes, absence of voicing, voicing for unvoiced phonemes, audible inspiratory
frication, aspiration for unaspirated phoneme and vice-versa. Not all types of mis-
coordinations were noticed in all PWS. No articulatory mis-coordinations were
observed in the post-therapy samples of any PWS. It appeared that prolongation
therapy was successful in eliminating only the articulatory mis-coordination and not
the other two. No generalizations were drawn as the study included only 5
participants.
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Ananthi (2002) investigated the production of word-stress in adult PWS before
and after prolongation therapy. Ten Kannada adjective noun phrases as spoken by a
35 year-old Kannada speaker with stress on the adjective was audio-recorded
(model). Ten PWS and ten normal individuals in the age rage 12-30 years participated
in the study. All of them were Kannada speakers. The first sample was recorded
before therapy and the second sample was recorded immediately after therapy. All the
participants underwent prolongation therapy. The experimenter listened to the
recorded samples and identified those phrases in which the words were stressed.
These words were acoustically analyzed to measure word duration, peak F0, Lowest
F0 and F0 range. All the parameters obtained before and after therapy were compared
with those of normal controls. The result indicated no significant difference in word
duration. No significant difference in F0 range between post therapy samples of PWS
and normal subjects was found. However, F0 range in 60% of PWS at post therapy
was narrower than that in normals.
Santosh (2006) investigated the efficacy of non-programmed speech technique
in 30 PWS in the age range 15-38 years and the effect of age at the time of treatment
on the efficacy of such technique. The participants were stratified into two groups
based on their age at the time of treatment. Group I consisted of 20 participants in the
age range of 15-24 years and group II consisted of 10 participants in the age range of
25-38 years. All the participants attended three week non-programmed prolongation
speech therapy. The perceptual measures included percent disfluencies, types of
disfluencies, rate of reading in SPM and speech naturalness. The results revealed that
1). Mean percent disfluency decreased significantly from pre to post therapy condition
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and increased form immediate post to 6 month post therapy condition in reading and
speech tasks in both the groups. This suggested no effect of task and group on percent
disfluency. The reason for increase in percent disfluency in 6 months post treatment
condition was attributed to lack of maintenance. 2.) The number, but not the type of
disfluencies significantly reduced in post-therapy condition compared to pre-therapy
condition. 3.) The SPM reduced and MNS increased significantly from pre-to post
therapy condition in both groups. The perceptual data indicated no effect of age on
treatment measures except MNS which was maintained better in group II than group
I. The author concluded that percent and types of disfluencies, rate of reading, and
speech naturalness can be used as efficacy measures of prolonged speech technique.
Ananthi (2007) examined the effects of prolonged speech technique and
modified airflow therapy on intonation in PWS. The two groups of participants
consisted of twenty six in the age range 15-26 years (Group I); 18 age and gender
matched normal control subjects (Group II). The subjects were randomly assigned to
either prolonged speech technique or modified airflow therapy. 13 subjects underwent
3 week prolonged speech technique or modified airflow therapy accordingly. All the
subjects read a 209 word passage in Kannada and their speech and reading was audio
recorded. The perceptual and intonation analysis was compared with normals. The
results revealed a significant difference between the groups on mean percent
disfluency, which decreased from pre to post therapy condition in PWS using
prolonged speech technique and modified airflow therapy. However, no significant
difference was noted within the group of PWS. Of the different types of disfluencies,
syllable repetitions and unfilled pauses were the most common and interjections were
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the least common. A significant difference was reported between pre and post therapy
SPM of PWS who underwent prolonged speech technique. Also, the SPM in pre- and
post-therapy conditions were significantly reduced compared to normal subjects.
Further, the author reported an increase in the mean naturalness score (MNS) from pre
therapy to post therapy condition for reading in modified airflow therapy and
prolonged speech technique group, though not significantly. The pre and post therapy
MNS were significantly lower in PWS as compared to normal speakers. It was
reported that intonation improved in the fluent pre therapy and post therapy
conditions. The intonation was found to be absent only in disfluent utterances. She
concluded that the percent disfluency and SPM significantly reduced in post therapy
conditions as compared to pre-therapy condition. Also, SPM was significantly lesser
in post therapy condition compared to normal subjects. The MNS was reported to be
significantly less in PWS as compared to normal participants.
Geetha, Sangeetha, and Sachin (2011) analysed 57 individuals with stuttering
(age range of 18 to 35 years) to determine the efficacy of the stuttering treatment and
the variable contributed to the treatment efficacy. A ‘treatment efficacy scale’ was
developed by the authors which consisted of a checklist to gather demographical
details of the participants and twelve parameters viz. (1) Frequency of stuttering, (2)
Duration of stuttering, (3) Secondary behaviors, (4) Confidence in speaking, (5)
Avoidance behaviors, (6) Anxiety features, (7) Attitudinal changes, (8) Naturalness
of speaking, (9) Listeners’ reaction to speech, (10) Satisfaction with treatment, (11)
Self-monitoring skills and (12) Feeling about maintenance and generalization of
fluency. A 5 point rating scale was used for each of the parameters which varied for
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different parameters. The parameters (1) to (3) were the common characteristics
considered for evaluating stuttering severity like in SSI, which were subjectively rated
by the clients themselves. The parameters (10) to (12) mainly concerned with the post
therapy ratings. The authors concluded that majority of the PWS showed
improvement in their fluency (severity of their stuttering) although to various extents
on the different parameters. The ratings improved on all the 12 parameters on the
treatment efficacy scale, more so on confidence level, naturalness, listeners’ reaction
and reduced anxiety during post therapy.
Finn (1997) conducted a study to determine if listeners could differentiate the
speech naturalness of unassisted recovered and treated recovered PWS from normally
fluent speakers. The results showed a perceptually different and more unnatural
sounding speech of treated recovered PWS. The recovered PWS were reported to be
as natural sounding as normal speakers. Also, it has been reported that all the
unassisted recovered individuals showed more natural sounding speech than that of
treated recovered adult individuals. The authors conclude that the speech outcomes
from unassisted recovery are more functional than speech from treated recovery.
There are evidences which reported that some individuals maintain their
improved fluency in long term but for some it is extremely difficult to maintain
speech improvement achieved during therapy (Boberg, 1981; Bray, Kehle, Lawless,
& Theodore, 2003; Eichstaedt, Watt, & Girson, 1998; Finn, 2003b; Hasbrouck &
Lowry, 1989; Ryan & Ryan, 1995; Craig, 1998; Wagaman, Miltenberger, &
Arndorfer, 1993). However, it is not clear that how some people who stutter benefits
more than others following the same therapy and how those who successfully
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completed therapy are able to maintain the benefits achieved in short and long term
whereas others fail to do so.
One way to address this issue is by exploring the factors in clients with
different pre-treatment stuttering profiles which may be related to the maintenance of
recovery in them or responsible for their relapse. A number of researchers reported
various aspects of stuttering such as etiology (Blood, 1985; Poulos & Webster, 1991),
recovery (Seider, Gladstein, & Kidd, 1983), and stuttering features (Andrew & Harris,
1964; Watson, 1987; Borden, 1990; Schwartz & Conture, 1988; Van Riper, 1982;
Yairi, 1990) as important aspects to characterize recovery.
Ann Meltzer (1998) observed that exclusive elimination of stuttering was
considered as a focus of treatment outcome in many studies (Andrews, Guitar, &
Howie, 1980; Prins, 1997). That is, they ignored the multidimensional nature of the
disorder and defined success narrowly in terms of stuttering frequency. However, a
limitations of using such single focus measure was noted when multidimensional
problem in adults with stuttering were highlighted (Boberg & Kully, 1985; Curlee &
Perkins, 1984; Gregory, 1979; Peters & Guitar, 1991; Smith & Kelly, 1997).
It is widely believed that motor speech production disrupted by negative
emotions may further interfere in using different speech improving fluency enhancing
techniques (Bloodstein. 1987; Boberg et al., 1979; Owen, 1981; Peters & Guitar,
1991; Prins. 1997; Van Riper, 1973). Thus, a treatment strategy is warranted that
promotes change in speech production, avoidance behaviour, and attitude towards
communication (Boberg & Kully 1985; Peters & Guitar, 1991; Prins, 1997) for
successful therapy and to maintain fluent speech. Also, the use of speech naturalness
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measure has been emphasized (Boberg & Kully, 1994; Gregory, 1994; Meltzer, 1995;
Onslow & Packman, 1997).
Kully and Boberg (1991) followed up eight CWS who underwent a combined
treatment programme of stuttering modification and fluency shaping after 8 to 18
months of termination from therapy. The results showed that the improvement
achieved during treatment was reportedly maintained at follow up. In another study
by Hancock et. al (1998), 46 PWS including children and adolescents were treated
using smooth speech and EMG feedback as treatment techniques. They were followed
up for a period of 2 to 6 years and 13% were found to experience relapse to pre
therapy level and a majority of participants, i.e., 53% experienced partial relapse
whereas for 29% of the subjects treatment was found to be effective and no relapse
was observed.
Neaves (1970) conducted a study on 165 PWS, aged 8 to 17 years, of which
84 were treated as “successful” and 81 as “unsuccessful” after therapy. Significant
differences were found in measures of motor ability, intelligence, speech
development, age of stuttering onset, family history and social class. The four factors
seemed to stand out were motor impairment, speech development, age of stuttering
onset and family history of stuttering. If any subject presented only one of the factors
listed, the success rate of therapy was 80%, dropping to 50% if any two of the factor
operated. The therapy success rates dropped to 55% if three or all four factors
occurred in some subjects.
Rustin (1978) used behaviour modification technique along with syllable
timed speech, while conducting a study in a group of adolescents with stuttering
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(mean age of 14 years). A reduced stuttering was reported immediately following
treatment. However, a high relapse rate was observed at the three months follow up.
Relaxation, role reversals, time out, parental involvement along with video recording
was done. All the participants were self motivated and were assessed on a personal
questionnaire at pre, during and post therapy conditions. The author concluded and
suggested few important features to determine success following therapy such as: (a)
subjects’ view to perceive their defect should be changed so that they understand the
major responsibilities of progress, (b) organizing treatment in such a way that an
individual can generalize newly acquired skills to other people outside situations as
well, and (c) giving knowledge to the client regarding appropriate use of fluency.
Bloosdstein (1995) surveyed numerous studies and found to be varied widely
from each other. He reported that the terms used to indicate significant improvement
have different meanings for different clinicians. The details on speech measures,
trainers who rated the speech measures, the conditions in which speech performance
was measured were not specified in many of the studies. An increase in percentage of
disfluency after the follow up for almost 50% of the cases was reported.
2.6. Recovery in stuttering
In general terms, any restoration to an improved and better condition can be
termed as recovery. In stuttering, some PWS show improvement by reducing overt
disfluencies and recover as a result of therapy, although a constant monitoring of
improved speech is required in order to remain fluent and maintain the recovery.
Others stop stuttering spontaneously with no treatment. Some view recovery as an
immediate and complete cessation wherein they never stutter, never think about
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stuttering, and know they will never stutter again. From the research, one can say that
changes in speech and desire to improve can lead someone to declare himself
recovered.
2.6.1 Spontaneous recovery
Spontaneous recovery is that recovery which occurs without any intervention
and is more common in young children. The recovery rate was reported as 71.6% after
2 years of onset and 85% after 5–6 years in children (Mannson, 2000). Ryan
(2001) conducted a follow up study on 22 (2-3 years old) children for 2 years
and reported a recovery rate of about 68%.
According to Yairi and Ambrose (2005), the highest rate of spontaneous
recovery in children who stuttered was reported to be between 65% and 80% after 3–5
years of onset and stated the follow ups are essential in children for
an average of 40
months to ensure that recovery has occurred. There are other longitudinal studies
which enabled a closer monitoring of recovery in children. The investigators of these
studies found recovery of 80% (Panelli, McFarlane, & Shipley, 1978), 65% (Ryan,
1990). There are no reliable estimates of how many adults experience spontaneous
recovery, but all indications are that it is a rare occurrence. Therefore, spontaneous
recovery in adults remains a mystery.
In a longitudinal study, Andrews and Harris (1964) reported that the
percentage of individuals who recovered from stuttering by 16 years of age was
reported to be 79.1%. This includes early episodes of brief duration of stuttering.
Yairi and Ambrose (2005) reported that a high rate of recovery without treatment
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occurs during adolescence and adulthood where female PWS were more likely to
recover than males. As reported, two thirds of PWS who recovered believed it was
because of self-change and their own efforts to reduce or eliminate stuttering
without professional help. The male to female ratio for very early stuttering,
including 70-80% recovered PWS, has been reported as approximately 2:1 (Yairi &
Ambrose, 1992). For adults who persisted in stuttering, the male-to-female ratio was
estimated to range from 4-6 males to 1 female.
2.6.2 Recovery following treatment
Yairi and Ambrose (1992) conducted a pilot study on 27 preschool aged CWS.
A few speech treatment sessions were provided to 18 of the 27 CWS,
whereas no direct
treatment was provided to 9 children. Results indicated that there was a significant
decrease in mean frequency of stuttering-like disfluency (SLD) for the two subgroups. It
was indicated that by about 20 months post onset, the group differences become
discriminating between the recovering and chronic CWS.
In an investigation by Finn (1996), 11 of 15 adult PWS self reported as
recovered when continued to practice speaking with a modified speech pattern. In a
separate study by Finn (1997), using many of the same subjects, 9 of 15 recovered
subjects stated that they still had the tendency to stutter. So, while a spontaneous and
total cessation of stuttering can happen, it is atypical by any definition and requires
thorough observance to speech modifications.
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2.7 Relapse in stuttering
Relapse, in general term, is a condition of partial or complete reoccurrence of
former symptoms that were either had taken under control, replaced or diminished
after therapy. The problem of relapse is considered as foremost concern in stuttering
following a successful treatment outcome (Boberg, 1981; Cooper, 1990). The
difficulty in maintaining the fluency gained during therapy for some clients is not
unique to stuttering treatment.
Relapse is the enemy of every therapy and of every clinician. To find that a
discharged client from therapy has regressed back after few months, to a point where
therapy again is required, is the ultimate defence for a clinician. Just as one factor
cannot predict or result in relapse, there is no single measure that can determine
relapse.
Any individual who suffers from stuttering desires to speak in a stutter-free
manner. But unfortunately, not all can maintain their fluency well and as a
consequence, almost one-third of the individuals relapse (Boberg, Howie, & Woods,
1979; Craig & Calver 1991; Martin, 1981; Starkweather, 1993).
Kuhr and Rustin, (1985) called relapse as “Achilles Heel” of stuttering
intervention. It is a Greek idiom which implies a weakness, where “one can actually
or potentially lead to downfall in spite of overall strength”. The stuttering disorder
differs from most other communication disorders in terms of relapse as a regression
form which may occur in PWS where a reoccurrence of speaking patterns to pre-
therapy patterns.
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Different researchers used different criteria for defining relapse in their study.
Craig (1998) in his study, considered relapse as perceived by the PWS and defined
relapse as ‘the recurrence of stuttering symptoms that were perceived as personally
unacceptable after a time of improvement’. Craig and Calver (1991) described relapse
as stuttering to a degree which is not acceptable to oneself for at least a period of one
week”. Few researchers considered %SS as the measure to define relapse. A
description as “…all persons whose frequency of stuttering was over 2% syllables
stuttered (%SS) were regarded as having relapsed” according to Craig, Feyer, and
Andrews (1987). They evaluated PWS on telephonic conversations after 10 month for
a long term follow-up. They reported a relapse in the treated persons found to be in
range of about 30%.
A number of different approaches in stuttering management have consistently
achieved success and proved helpful for PWS in acquiring fluent speech (Guitar,
1998; Onslow, 1999). However, improvement occurs in the form of short term
recovery in PWS which may not always remain to long term maintenance. Thus
relapse after treatment remains to be a “major concern” for both the client and the
clinician involved in stuttering treatment.
As noted by Prins (1970), a significant relapse occurs in the majority of the
clients within six months after the cessation of a formal treatment. Other researchers
suggested follow-up after two to five years following discharge from treatment
(Young, 1975). The relapse rates for adults and older children appeared to be
significantly higher than that for younger children. This may be due to a little
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awareness of the problem in children, lack of social concern or neural plasticity of the
brain (Starkweather, Gottwald & Halfond, 1990).
Regardless of the specifics of treatment, on average, as long as a year after
treatment, PWS can be expected to demonstrate fluency at less than 2% syllables
stuttered (SS) with normal speech rate (between 160 and 240 SPM). Any new
therapies would need to equal or better this outcome.
According to Craig (1986), the prevalence of relapse one year following
treatment using fluency shaping approach reported to be 30%. However, Boberg and
Kully (1994) found 69% of subjects to have maintained a satisfactory post treatment
fluency in a follow up study conducted after 12 to 24 months on total 17 adult and 25
adolescent with stuttering. A year later, Craig and Hancock (1995) reported that 70%
of total 152 subjects who received fluency shaping therapy considered themselves as
relapsed in self report and on objective measures as well, while 28% were found to be
maintaining recovery with no self report of relapse. Therefore, it was believed that
fluency shaping approaches may not be very helpful in maintaining fluency in the
long term.
2.7.1 The possibilities of relapse
According to Van Riper (1973), “The old habits are always the strongest” and
he further stated that “Relapses and remissions are the rule, not the exception, for the
adult persons with stuttering if long term follow up investigations are conducted”. St.
Louis and Westbrook (1987) reported that “relapse is a ubiquitous and familiar
problem in stuttering therapy”.
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Silverman (1981) reported that relapse is likely to occur with a 40 to 90%
probability and the relapse rates of over 50% have been reported for adults with
stuttering (Boberg, 1981). Many authors (Bloodstein, 1987; Craig, 1998) have
recognized relapse as a common event following treatment for adult PWS and found
that about 40% of clients taking part in an intensive residential program experienced
some regression following treatment. Martin (1981) reviewed the literature and
estimated relapse at approximately 30%. Craig and Hancock (1995) found that 71.7%
of 152 adults surveyed experienced relapse but that the majority found that they
subsequently regained fluency. They also found that relapse tended to be cyclical,
occur up to three times in a year. The literature indicates that for adult clients, the
possibility of relapse is more.
To understand the problem of relapse from a psychological point of view,
Personal Construct Theory (PCT) proposed by Kelly (1955), is meaningful. PCT is a
psychotherapeutic approach for individuals with stuttering and is based on the notion
of “people as scientists”. It relates the problem of stuttering to self-concept of the one
who stutters. Personal construct has been defined as “a way in which some things are
construed as being alike and yet different from others” (Kelly, 1955, p.105). Landfield
and Leithner (1980) described this process in terms of how a person relates his life
events to the experiences gained by him. Also, the authors defined PCT in terms of
threat (an awareness of comprehensive change in core structure), fear (awareness of
changes related to one’s basic structure), anxiety (an awareness of event that is
experienced by a person stays out of range of ease), and guilt (occurs on act
contradictory to core role structure). Thus, the PCT view of stuttering relates to the
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resistance of the stuttering problem to have effective long term treatment outcomes
and its maintenance. The knowledge and implication of PCT to stuttering treatment in
combination with behavioural approaches may be effective in establishing fluent
speech. If so, PCT may prove helpful in enhancing long term outcomes of stuttering
therapy.
In a study done by Evesham and Fransella (1985), 47 adults who stuttered
were randomly grouped into two; those receiving fluency enhancing approach using
prolongation in one group and, other group provided with PCT. Both the groups
showed a reduction in stuttering (less than 2% SS) at the end of treatment suggesting
that both the techniques were helpful in reducing disfluencies. However, the group
receiving PCT was found to maintain the recovery after 24 months follow up and
showed less relapse rates compared to the group receiving prolonged speech
technique.
Craig, Feyer, and Andrews (1987), presented a cognitive behaviour therapy
approach (targeted to bring change in inappropriate thought patterns and attitude with
successful therapy process) as a stuttering treatment on 191 adult PWS treated over a
period of six years. Generalization of the skills was encouraged following treatment in
an out-patient situation such as home and outside clinic environment. The concept of
self control and therapy practice schedule was taught for the long term maintenance of
treatment outcome. The results showed that the programme proved successful and
effective in reducing the relapse rate.
Blood (1995) conducted a research employing single case experimental design
in adults with stuttering using computer assisted feedback along with cognitive
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behavioural therapy as stuttering management procedure. The results showed a
reduction to 3% SS in all four subjects during 12 months post therapy follow up.
2.8 Recovery and relapse from stuttering: cyclic variation
Kuhr and Rustin (1985) have observed that relapse is cyclical as those who
treated for stuttering tend to show fluctuations in their speech from a fluent to
disfluent period. Relapse following successful stuttering treatment is an ever-present
concern for the client and for those who treat them. Some people grasp recovery
quickly and have smooth sailing, while others require much more determination to
pull out of lapses and not let themselves relapse completely. The criterion for success
is following a ‘strong plan of recovery’ free from relapse. However, for many PWS
there are small successes along the way with four steps forward and three steps back.
It is uncertain to predict who will make it in recovery and who will not, but it is
important that professionals work creatively with individuals and tailor-make each
person's progress plan as each one’s recovery and relapse probability is unique.
2.9. Factors related to recovery and relapse in stuttering
There are some overlapping factors related to recovery and relapse in treated
PWS reported by different authors such as:
2.9.1 Gender and Age
A higher occurrence of stuttering in males than in females is generally
reported with around 4:1 ratio. Yairi and Ambrose (2005) reported a predominance of
males over females having stuttering showing a slight increase in the sex ratio with
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age. Also, the onset of stuttering is often reported to be between the ages of 3 to 5
years with a period of normal fluency before the onset. Gender and age are the two
important variables and risk factors reported in the onset, development and recovery
or relapse of stuttering. Seider, Kidd and Gladstien (1983), conducted a study in CWS
and reported gender to be one of the major variables in the recovery and persistence
of stuttering distributions. A significantly earlier age of onset of stuttering was
reported in the recovered females than the other groups (recovered male PWS and
persistent male and female PWS). Also, the recovered females recovered earlier than
male PWS. It appears from all available findings that some degree of recovery may
occur at any age. A study on recovered adult PWS by Martyn and Sheehan (1968)
showed that the age varied within a very broad range, although there was a
considerable tendency for recovery between the ages 13 and 20 years. Seider, Kidd
and Gladstien (1983) showed a decreasing probability of recovery with age.
2.9.2 Family history
Seider, Kidd and Gladstien (1983) conducted a study on a large group of adults
with stuttering to investigate if recovery and persistence of stuttering is related to their
first-degree relatives. The study reported that recovered and persistent stuttering are not
independent disorders. An attempt was made by Ambrose, Cox and Yairi (1997) to
describe the relationship between genetic component to persistence and recovery in
stuttering. To examine whether a recovered and persistent form of stuttering is based on
genetic transmission, an investigation on 66 CWS and their immediate and extended
families was carried out. The results of their study indicated that recovery or persistence
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of stuttering are transmitted and possess a common genetic etiology in CWS. They
found that individuals with a family history of persistency in stuttering also inclined to
persist the problem, whereas those having a family history of recovery from
stuttering also inclined toward recovery. Boberg, Howie, and Woods (1979) mentioned
that PWS with heavy genetic and/or neurophysiological fluency factors may create an
inevitable relapse situation.
Quarrington, (1977) and Finn (1996, 1997) reported modifications in speech
pattern, along with good motivation to speak correctly and slowly, acquiring new
attitudes towards self and evaluating self speech are some of the major factors
associated with recovery as a positive treatment outcome.
2.9.3 Severity of the stuttering problem
The one factor that seemed to make a difference between persistence and
recovery in many studies is the severity of stuttering. Dickson (1971), in a study
reported that the more severe cases inclined towards persistence of stuttering, and
recovered individuals were found to have less severe problem and hence had received
formal speech therapy less often. Anderson and Felsenfeld (2003), identified some
overlapping behaviors, which included increased confidence and motivation for better
change in stuttering severity. However, severity has not been found to be a marker of
persistent stuttering (Yairi & Ambrose, 2005).
Pre-treatment severity and chronicity of the stuttering problem are the
strongest factors reported in literature which relates to outcome. A high correlation
between a pretreatment measure and outcome was found by Gregory (1969), who
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reported that pretreatment severity rating is positively correlated with change in
severity rating from pre to immediately after treatment. He concluded that individuals
with higher stuttering severity have to travel greater range during treatment. Many
authors (Guitar, 1976; Craig 1998) have reported that pre-treatment severity is one of
the major concerns which contributed to treatment outcome. They reported that PWS
showing more severity in pre-treatment stage show higher level of regression one to
two years of post discharge from therapy. The stuttering severity was assessed based
on many behavioral and cognitive factors. Higher the severity of pretreatment
stuttering larger was the margin of behavioral progress, reported to be associated with
higher rates of relapse. Individuals with more stuttering and slower speech rate prior
to treatment were reported as more likely to stutter at follow up (Craig, 1998).
Landouceur, Caron and Caron (1989) carried out a single case multiple baseline
design research on 9 PWS (age range 19-37 years) having less than 15% SS in 6 PWS
and more than 15% SS in 3 PWS out of total 9 PWS. The authors reported that greater
the %SS in pre-treatment, higher is the risk factor for relapse. All mild and moderate
PWS showed clinical improvement at the end of treatment and at the six months
follow up, whereas individuals with severe stuttering failed to maintain clinical
improvement in follow up.
2.9.4. Genetic factors
Not much research is done to determine whether relapse or recovery has any
genetic basis with or without treatment in adult PWS. However, genetic factors have
been suggested as one of the factors contributing to relapse by few researchers.
Cooper (1972) stated that few individuals with stuttering are genetically predisposed
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to relapse. Boberg (1986) reported that those clients having positive family history of
stuttering problem containing genetic loading may possess an underlying
physiological or neuro-physiological condition. Felsenfeld (1998) put forward the
difficulty in conducting research to determine genetic factors related to stuttering and
its outcome. The author reported that stuttering is familial and there is a familial
tendency for recovery but sufficient empirical justification to use a family history
profile to predict outcome for any individual is not possible.
2.9.5 Pre-treatment factors
Guitar (1976) conducted a study to determine the factors associated with
stuttering management and its treatment outcome at pre-treatment level. Different
measures such as stuttering behaviors, attitude about speaking and personality
behaviors were obtained from total 20 adult PWS (age range from 21 to 64 years) at
the beginning of treatment. The participants underwent prolonged speech training for
3 weeks to a criteria of 0%SS. The results obtained using multiple regression analysis
indicated that these measures were correlated a year after treatment and those
measures reported to be highly related to outcome were the pretreatment attitudes,
personality measures followed by behaviors present in pre-treatment stuttering.
2.9.6. Therapy related factors
The therapy techniques or approach used, and duration of therapy taken by the
individual is an important factor while investigating the maintenance of fluency
achieved after treatment.
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The different therapy approaches like fluency shaping and stuttering
modification therapy and their maintenance has been a crucial factor for treatment
outcome in person seeking treatment. Also, it has been reported that stuttering
modification approaches are generally preferred by many clinicians in spite of its
difficulty and longer time it takes to bring fluent speech.
A survey was conducted by Yarrus, Quesal, and Murphy (2002), using
questionnaire on 71 PWS who attended speech therapy in the past. The questionnaire
consisted of questions related to speech treatment taken, their experiences and
satisfaction after completing treatment course. The results reported indicated a
statistically higher probability of self reported relapse for the members of a self help
group who followed the fluency shaping techniques, in contrast to those who received
stuttering modification or avoidance reduction therapies. This is in contrast with the
study done by Bloodstein (1995), where relapse rates were more for treatment based
majorly on behavioral approaches using prolongation of syllables and speaking slow
in manner to speak fluent.
2.9.7 Clinician related factors
As stated by Murphy and Fitzsimons (1960, p.27) “the most important single
variable affecting the success in the treatment of person with stuttering is the
clinician”. A clinician’s role is crucial in making wise clinical decisions during
assessment and treatment regarding appropriate therapy approach for individual client
for a good treatment outcome. Many researchers (Cooper & Cooper, 1985c; Emerick,
1974; Hood, 1974) provide convincing support that an experienced clinician is the
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critical part of treatment process, perhaps more apparent in a counseling based
treatment. However, there is no exclusive set of features that defines the ‘ideal
clinician’ (Manning, 2010). A clinician has significant role in providing the services
to the client using his/her expertise knowledge of therapy approaches to be used,
problem solving abilities, establishing therapeutic alliance for a change to occur and
to maintain it following treatment. One of the reasons of relapse after therapy is the
setting of very large edges for fluency breaks by the clinician (Silverman, 1981). The
relapse following treatment was seen as a setback of the clinician by Crichton-Smith
(2002) who argued that clinicians and many therapeutic techniques do over emphasize
the fluency production and unintentionally promoting the concealment of stuttering
possibly increasing the chances of relapse.
2.9.8 Client related factors
The one who is undergoing treatment is the most important aspect when
determining the factors associated with treatment outcome. During the treatment
process, a good client-clinician alliance is important as the client gets constant
guidelines from the clinician to obtain significant improvement after therapy.
However, it is the client’s responsibility to maintain the achieved improvement after
dismissal from therapy.
Some of the specific client related factors highlighted in literature are:
Motivation: A constant motivation and willingness to improve and bring a positive
change in one’s behavior have critical impact on outcomes following treatment. A
number of authors (Blood, 1993; Manning, 2001, 2006) reported that it is wise to
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begin therapy when a client is most ready for changes in his/her speech leading to
more positive treatment outcome and its maintenance. Thus, willingness of a client to
have change in his/her speech before therapy enrolment is an important factor towards
success.
Practicing: Each individual is different in abilities to perform during treatment
sessions and his/her abilities play a great part in development of expertise. All clients
should be counseled to self monitor and practice the techniques regularly, as a
constant practice is required to maintain the improvement. Training, preparations and
regular practice are necessary prerequisites for improvement in performance (Ericsson
& Smith, 1991).
According to Andrews (1981) and, Silverman (1981) the nature of stuttering
management is tedious which requires a significant amount of effort and many PWS
fail to do so and abort the task. Usually, a client notices improvement in his/her
speech and tends to be confident about using his/her speech skills after treatment but
lack of constant practicing the technique in the long term may lead to relapse. The
failure to practice is one of the main reasons that PWS experience relapse (Geetha,
Sangeetha, & Sachin, 2011). In a study done by Ingham (1982), 2 PWS were assessed
to examine the effectiveness of self evaluation (self scoring and evaluating
performances) on maintaining fluency using single case multiple baseline
experimental research. A reduction in frequency of stuttering on self evaluation along
with intensive speech therapy was reported. Both the subjects maintained
improvement up to 6 months of follow up. Kamhi (1982) mentioned that some PWS
must pay considerably more effort than others to achieve and maintain fluency due to
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natural variability of their speech production system and this variability is more
common and perhaps more severe in those who experience relapses. Craig and
Andrews (1985) suggested that using self monitoring skills can be more beneficial in
maintain improvement and reducing a risk of relapse in a long term. Craig (1998)
suggested factors crucial for a successful treatment such as practice of treatment
techniques, positive self reinforcements, use of self monitoring skills, scheduling
regular follow up sessions and emphasizing on self corrections and self responsibility
to the client.
Entropy is the tendency of things to break down or fall apart described by Egan
(2007). That is, it is the tendency to give up on a course of action that has been
initiated. The author mentioned this as one of the factors which may lead to relapse.
Embarrassment to use the techniques: In a study done by Craig and Calver (1991),
embarrassment about the change in speech pattern using prolongation technique was
self reported by 40% of adult PWS who experienced relapse following treatment. The
PWS may find the change in their speech or fluency using techniques taught during
treatment to be very noticeable to others and leading to embarrassment. Therefore
they may avoid using the techniques outside the clinical situations which further
becomes a strong reason for the relapse of the problem.
Loss of confidence in the technique: Silverman (1981) reported that one of the reasons
for relapse to occur is losing confidence in the treatment technique due to prior
relapse experienced. The PWS not using the techniques due to negative thinking that
this technique would not help them in the long term as the previous one and their
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lacking confidence in using the technique may lead to relapse. Thus, a belief in the
technique taught by clinician is an essential element in increasing the probability of
success in treatment and in maintaining that improvement.
Attitude towards the problem: Post treatment attitude has been reported as one of the
factors valuable in predicting fluency maintenance in adults who stutter up to one year
post treatment (Guitar & Bass, 1978). The pervasive nature of relapse is an indicator
that good therapy is something more about changing the features of the problem
(DiLollo, Neimeyer & Manning, 2002) and the client’s attitude and belief towards
his/her problem has crucial role in treatment outcome. Helps and Dalton (1979) stated
that those individuals with stuttering having negative attitudes are less likely to obtain
long term gains from a behavioral treatment using rate control techniques. A number
of researchers (Craig & Andrews, 1985, Madison, Budd & Itskowitz, 1986) observed
that those individuals who had a positive thinking attained better outcomes and
showed long term resistance from relapse than those who failed to make cognitive
changes. Many studies (Blood, 1993; Craig, 1998; Guitar, 1976, 1998) reportedly
mentioned different variables such as negative attitude about speech along with
avoidance, learned compensatory behavior, higher trait anxiety and an external locus
of control to be associated with relapse due to poor maintenance of long term gains
after therapy. Some studies (Andrews & Craig, 1988; Guitar, 1976) implicated that a
change in attitude towards speech in individuals with stuttering resulting from
treatment may be correlated with weak maintenance of fluency in the long term. In a
retrospective analysis by Plexico, Manning and DiLollo (2005) done on seven adult
PWS, it was found that self acceptance and fear reduction are among those factors
associated with treatment outcome. To assess client’s attitude towards their own
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speech problem using psychological tests have been emphasized by many researchers,
which will be helpful in investigating the relapse and its relation to attitude of the
client. In a study Guitar (1976) reported that those individuals who had presence of
avoidance behaviors and with higher negative reactions to the problem of stuttering
reportedly showed more probability of relapse. However, no significant relationship
was found between neuroticism, and extroversion and their long term outcome
measured on a measure of personality inventory. The changes in attitude and
cognitive aspects of the problem often in the form of negative self talk may take the
lead in the progression of relapse. Seigel (1999) stated that the cognitive factors have
been recognized as factors for decades, which holds the stuttering problem, mainly
when they relate with behavioral factors.
In a study by Guitar (1976), a significant relationship was found on long term
outcomes, between stuttering and abnormal pre-treatment speech attitudes measured
on S24, a shortened version of Erickson scale (by Andrews & Cutler, 1974). A
relationship between normalizing the attitude on S24 and long term treatment
outcome was strongly supported by Andrews and Craig (1988). They also reported
that the two measures of attitude in combination with measures of stuttering behavior
are useful in predicting relapse after using fluency shaping technique as treatment.
In a retrospective research survey done by Craig and Hancock (1995), 152
individuals who underwent fluency therapy and trying to maintain the benefits
received after a successful treatment were considered as subjects. As reported, 109
(72%) out of 152 subjects experienced relapse in the long term and associated their
relapse with stress, negative emotions and feeling of helplessness.
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2.9.9 Environmental factors
According to De Nil (1999), the environmental variables influence the central
neurophysiological processing that may have an indirect impact on communication.
The central processing would be different for each individual due to continuous
filtering of environmental information. This explains how a reaction to particular
treatment program varies considerably for individual with stuttering.
A habitual manner of the speech of PWS is altered to improve his/her fluency
and goal for a new, improved and better pattern of speaking is planned and achieved
during the treatment process. However, studies (Boberg, 1981; Perkins, 1979)
reported that this change may bring discomfort to some PWS and a new manner of
speaking by the client himself is difficult to be accepted outside clinical situations.
According to Boberg (1981), in addition to the findings showing an improvement in
speech, a client finds his/her new manner of speaking to be non-habitual and
punishing when facing outside clinical environment. The demands from both internal
and external environment also make it difficult for a client to maintain the
improvement. The expectations and fluent speaking demands become high in the
outside environment for a client after successful cessation from treatment. The PWS
somehow are expected to display stutter free speech. This may not be very evident,
being subtle most of the time. In this manner the individual comes under enormous
internal and external pressure or stress to speak fluently. Craig and Calver (1991)
found that the majority of those who experienced relapse related their condition to the
feeling of speaking under pressure in order to speak faster with fluency. The demands
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from the environment to speak faster were reported by majority of subjects. In
addition to the physiological basis of the disorder, other factors which may contribute
to relapse could be lack of rewards to the PWS after successful treatment and change
in post treatment environment (Boberg, 1986).
2.9.10. Other factors related to relapse
i. The severity of the problem: Higher the pretreatment stuttering severity levels,
greater is the difficulty in achieving fluent speech and maintaining it for long. Many
previous researches (Guitar, 1976; Andrews et al., 1983; Ladouceur, Caron, & Caron,
1989; Block, Onslow, Packman, & Dacakis, 2006) have shown that pre- treatment
severity of stuttering is a consistent factor to determine treatment outcome. That is,
more severe stuttering prior to treatment is typically associated with poorer treatment
outcomes, smaller reductions in stuttering predicted higher rates of vulnerability to
relapse on long term follow-up (Andrews & Craig, 1988; Craig, 1998; Block et al.,
2006).
ii. Practice makes perfect, a famous saying which means doing something over and
over again is the way to learn fast and remember it well. This saying goes for
individuals who have taken therapy as well. The more they practice, chances of
avoiding relapse becomes more. It is also reported that there will be
neurophysiological changes that happen with every learning and it requires intensive
practice to move away from unstable patterns to achieve more stable patterns.
iii. Client’s motivation and attitude: According to an idiom “Impossible word itself
says that i-m-possible”, which implies that if a client has positive attitude and good
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motivation before therapy, success rate in therapy and the maintenance of long term
improvement is good for the client.
According to Boberg, Howie, and Woods (1979), the persistence of small
disfluencies that diminishes during therapy but later grow in the form of relapse. They
also mentioned that lack of monitoring of the achieved fluency may allow relapse.
Although there are many variables associated in therapeutic relapse, the most
common is the client’s mental attitude in a clinical experience (Guitar & Bass, 1978).
There may be some deeply imbedded negative behaviors and self-defeating mental
images that persist even after the improved speech affects a client’s problem.
Sometimes the PWS unknowingly sets himself in irrational automatic thoughts,
particularly when a difficult speaking situation is encountered. In other words, one
still thinks like a “stutterer” even when showing relatively fluent speech.
iv. Clinician’s attitude: The role of clinician’s attitude in making good rapport with
the client and in bringing the positive change in his/her client is as important as the
client’s himself. The clinician plays the critical part of the whole therapy process
(Cooper & Cooper, 1985c; Shaprio, 1999; Conture, 1996; Guitar, 2006, Manning,
2010) and any setback or falls on part of clinician and client can lead to relapse. The
clinician’s knowledge, manner and approach of providing therapy to the client can
substantially help in maintaining fluency and avoiding relapse. An open attitude of the
clinician, his/her capability and readiness to bring a positive change in fluency by
proper counseling, teaching self monitoring and self correction strategies can help a
client to avoid relapse.
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v. Speaker’s frame of reference: Perkins (1990) introduced another factor to be
considered in stuttering and that is the speaker’s frame of reference, where how a
speaker perceives his stuttering is also important. In a study Howell, Rosen, Hannigan
and Rustin, (2000), reported that adaptation occurs in the central nervous system
(CNS) due to prolonged stuttering because of such adaptations, the chances of
recovery reduce either naturally or as a result of therapy outcome.
Sheehan and Matyn (1966) discussed some of the common factors which were
supported by other authors (Boberg, 1979; Kamhi, 1982) as causing relapse:
a. Weak establishment and transfer of new speaking modes
b. Failure to develop or more likely to use, self-monitoring adequately: Also,
neglecting to self monitor the problem may allow relapse in some individuals with
stuttering.
c. Dissatisfaction of the client with the new speech mode
d. Failure to eradicate social avoidance behavior: The negative emotions and
avoidance behaviors learned for many years tend to become a habit for PWS,
and are also more resistant to change, leading to another factor causing relapse
after success in therapy.
e. False fluency: the client is not fluent but in response to suggestion and
pressure is persuaded into a false fluency
f. Doubts on self-efficiency: when a client over-depend on his or her clinician
and on the therapy program rather than on his own capacities and self
confidence, probability of relapse increases.
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g. Boredom: using the same technique in order to maintain fluent speech
becomes boring for a client and hence stop using and practicing it. As a
consequence, chances of getting relapse become high.
h. Jost’s law: when two approximately equal responses compete, the older
response will, over time, tend to displace the new one. The less sure, firm,
acceptable the new response is, the sooner relapse will occur.
i. Penalty for fluency: Many PWS obtain gains from disfluency. Some find the
responsibility and penalties of fluency just not rewarding enough to maintain.
j. Residual disfluency: The PWS could be unprepared for any fluency
breakdown subsequent to success in therapy.
k. The influence of the post-treatment environment resulting in difficulty for a
PWS to adjust to new role as fluent speaker after successful treatment could be
one of the factors responsible for relapse.
l. Any variability in the speech production mechanisms could lead to relapse.
The review of literature indicated that the researchers have taken interest in
comparing the measures of speech on pre and post therapy conditions having
relatively more studies on short-term follow-ups. Studies concerning the treatment
outcome and recovery and relapse as treatment outcome are less. The rate of relapse is
reported to be more as compared to maintaining the recovery. The information
available for the possible factors responsible for a treatment outcome is scanty. Also,
how the recovered and relapsed individuals vary in terms of their speech and non-
speech characteristics is unknown. Thus, the review of literature supports the need for
the present study.
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The present study is an attempt to investigate such factors responsible for
discriminating those who maintain their recovery from those who relapse. Thus, with
an objective of evaluating speech and non speech characteristics to compare
recovered and relapsed PWS following treatment, the present study was planned. The
results of the present study would add information to the literature on stuttering. Such
information would help in understanding the stuttering disorder and its characteristics
in recovered and relapsed PWS following treatment. This would aid in predicting the
treatment outcome and formulating the treatment goals. This would facilitate recovery
by reducing the probabilities of relapses.