the establishment, transfer, and maintenance of … · the establishment, transfer, and maintenance...

T H E E S T A B L I S H M E N T , T R A N S F E R , A N D M A I N T E N A N C E O F F L U E N T S P E E C H IN 5 0 S T U T T E R E R S U S I N G D E L A Y E D A U D I T O R Y F E E D B A C K A N D O P E R A N T P R O C E D U R E S

Bruce P. Ryan Behavioral Sciences Institute, Monterey, California

Barbara Van Kirk Easter Seal Rehabilitation Center, Bridgeport, Connecticut

operant speech fluency techniques are being used in a clinical program in a rehabilitation center to treat people who stutter. Establishment, transfer, and maintenance programs are used. Delayed auditory feedback is commonly employed to produce the initial fluent speech. From more than 200 clients seen over the past four years, 50 recent dients were selected for a detailed analysis. The results indicate that the programs are effective in helping people of varying ages and stuttering severity to speak fluently. This was accomplished in relatively short periods (approximately 20 hours of therapy). The fluent speech of the clients has transferred to their environment and checks indicate that it has been maintained.

Dur ing the past decade a number of operant procedures applied to the problem of stuttering have been reported (Goldiamond, 1965; Curlee and Perkins, 1969; Webster, 1970; Haroldson, Martin, and Starr, 1968; Shames, Egolf, and Rhodes, 1969; Andrews and Ingham, 1972; Ryan, 1971). T h e accumulated information suggests that a systematic use of operant procedures may prove to be of great therapeutic value. Procedures using delayed auditory feedback to produce a slow, prolonged, fluent speech pat tern which is then shaped toward normal fluency have been shown to be part icularly effective.

Operant programs (step-by-step procedures which include prescribed reinforcement schedules and criterion levels) with establishment, transfer, and maintenance phases are valuable (Ryan, 1970, 1971, in press). Establishment re- fers to obtaining fluent conversational speech in the presence of the clinician in the clinical t reatment room. Transfer procedures promote the use of the speech fluency in a variety of settings. Maintenance provides for the cont inued use of the fluent speech over long time periods. This is accomplished by systematic clinic rechecks which are gradually el iminated if the client continues to be fluent.

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4 JOURNAL OF SPEECH A N D HEARING DISORDERS - - XXXlX, 1

A clinical program for treating stuttering in a rehabilitation center was started by one of the authors (Van Kirk) in 1969. The program has grown during the past four years, and over 200 stutterers have .received fluency training (Van Kirk, 1972). The major treatment procedure uses delayed auditory feedback in an operant program which provides for establishment, transfer, and maintenance. The purposes of this program are to help clients obtain normal, fluent speech and to develop, test, and refine the programs to help them do so.

PROCEDURES

Clients. The only criterion for admitting a client to the program was the overt stuttering behavior observed during the initial evaluation. For this report, the performance of 50 recent clients (the first 50 admitted to the program from September 1971 through February 1972) was selected for detailed analysis. The clients ranged in age from nine to 66 years with a mean of 27.2 years and an SD of 13.2 years. There were six females and 44 males. On a nine-point scale of stuttering severity (Ryan, in press) which was based on speaking rate, stuttering rate, and topography of stuttering, the 50 clients demonstrated an average 6.3 severity rating with an SD of 1.9. These clients repre- sented a wide cross section of socioeconomic, educational, and occupational levels. Most of them had received speech therapy in the past but continued to demonstrate stuttering. The clients paid for their therapy, although the amount was prorated on the basis of income.

Definition of Stuttering. Stuttering was defined as whole word repetitions, part word repetitions, prolongations of words, and struggle accompanying the utterance of words (Ryan, 1971, in press). Each stuttered word was counted only once.

Measurement. Throughout all phases of the program, stuttered words were counted and the speaking of the clients was timed. These data permitted the computation of stuttered words per minute (SW/M). This measurement was used in all testing and in the treatment programs. In certain tests (criterion tests), the total number of words spoken or read aloud was also counted. This permitted the computation of words read or spoken per minute (WR/M or WS/M). The two measures SW/M and WS/M provided a two-dimensional description of the clients' fluency. The number of therapy hours, client talk hours, and calendar weeks and months of therapy were also collected.

Testing. Before being admitted to the program, the clients were administered a standard interview (Ryan a n d V a n Kirk, 1971; Ryan, in press). This interview consisted of 13 different speaking tasks, such as counting, reading, and talking on the telephone, and required about 30 minutes to complete, includ- ing scoring. The clients had to demonstrate a rate of at least 3 SW/M to be admitted to the program.

The clients were next given criterion tests composed of five minutes each


RYAN, VAN KIRK: FLUENT SPEECH IN 50 STUTTERERS

of reading, monologue, and conversation. These required approximately 30 minutes to administer. A criterion test was given before the establishment program (Criterion Test 1), after the establishment program (Criterion Test 2), and after the transfer program (Criterion Test 3). The results of the criterion tests were used for measurement before and after treatment and to make the decision whether or not to move the clients to the next phase of treatment. All criterion tests were tape-recorded to provide auditory records of the clients' progress and to permit a word count.

Description of Programs. The establishment program consisted of 27 steps to teach the clients to read, engage in monologue, and converse in a slow, prolonged, fluent pattern with the aid of delayed auditory feedback apparatus. The first six steps were to teach the clients to correctly identify stuttered words in reading and monologue. Criteria of one minute and 90% accuracy of iden- tification were used in these steps. The next seven steps were in reading and used delayed auditory feedback starting with 250 msec of delay, which was gradually reduced in 50-msec steps until the client could read in the prolonged, fluent pattern without the delayed auditory feedback equipment. The next seven steps were the same except that these were in monologue. The final seven steps were the same except that these were in conversation. Clients had to reach a criterion of five minutes of fluency in each of the 21 steps to pass. Verbal reinforcement, such as "Good," was administered for the completion of steps. This program was similar to those described by Curlee and Perkins (1969), Goldiamond (1965), and Andrews and Ingham (1972). There were two major differences. The clients were instructed to keep their speaking rates down and their speech prolonged and fluent until the transfer program. They also engaged in varying amounts of practice at home (four times a week for five to 10 minute periods over three to six weeks). The clients attended two one-hour or half-hour sessions a week. The goal of the establishment program was a prolonged, fluent speech pattern in the clinic room with the clinician. When the program was completed, the clients took Criterion Test 2. If they passed, they continued on to the transfer program. If they failed (more than 0.5 SW/M in any five-minute period of reading, monologue, or conversation), they recycled through a part of the establishment program. They then repeated Criterion Test 2.

The transfer program consisted of nine different types of speaking situations: different physical settings with the clinician, gradual increase in the size of the audience, classroom activities, home activities, telephone, speaking to strangers, work activities, residual (additional training on specific speaking tasks that were difficult for individual clients), and all day. The criterion was five minutes of fluent conversation in each step. Depending on the client's age and activities, such as going to school o r working, the clients completed 20 to 60 steps in the transfer program. They continued to receive the verbal reinforcer, "Good," for the completion of steps. The clients also continued home practice throughout the transfer program. The clients were encouraged to


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JOURNAL OF SPEECH AND HEARING DISORDERS - - XXXlX, 1

increase their rate of speech during the transfer program steps provided they could hold their fluent speech pattern. Upon completion of the transfer program, the clients took Criterion Test 3. If they passed it, they proceeded to the maintenance program. If they failed (more than 0.5 SW/M in any mode: reading, monologue, or conversation), they recycled through parts of the transfer program or received additional establishment program training.

The maintenance program consisted of three-minute samples of reading, monologue, and conversation in the clinic training room. There were four steps distributed over a 22-month period. The criterion was 0.5 SW/M or less for all three modes to pass a step. The clients continued to receive the verbal reinforcer, "Good," for the completion of steps. As long as the clients continued to demonstrate fluent speech (less than 0.5 SW/M for all modes) and reported no problems in speaking in the environment, the maintenance checks were gradually, systematically eliminated. If a client demonstrated or reported difficulty during the maintenance program, he was given additional training appropriate to the difficult situation. For example, if the client reported difficulty with the telephone, and this difficulty was verified by observation or tape recording, more practice on the telephone was given. If the client demonstrated that he had "lost" the fluent speech pattern, additional fluent speech pattern training was instituted. The complete operational esablishment, transfer, and maintenance programs may be found in Ryan and Van Kirk (1971).

Clinicians. There were nine different clinicians working with the 50 clients. One of the authors (Van Kirk) trained the other eight clinicians and supervised their therapy. The clinicians were trained to count stuttered words, time the reading and talking of the clients, administer program steps, and collect the necessary written data.

Reliability. To determine the reliability of judgments of the occurrence of stuttered words and to train the clinicians to count stuttered words correctly, an interobserver agreement procedure was used. The clinician responsible for the client and another observer (another clinician) either listened to the tape recording of Criterion Test 1 or observed it live. Both observers independent- ly counted stuttered words. Their two counts were compared and a percentage of agreement computed. A criterion of 90% agreement was used. If the computed agreement was 90% or above, the clinician proceeded to run the program. If it was below 90%, the clinician and observer listened to the tape recording and discussed what each had been counting. They then independent- ly counted randomly selected one-minute samples until they achieved 90% agreement. In addition to this procedure, the supervisor did numerous informal probes of the counting accuracy of the clinicians throughout the establishment, transfer, and maintenance programs.

RESULTS AND DISCUSSION

Testing. The results of the standard interview and criterion tests are shown


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TABLE 1. Means and standard deviations of the number of stuttered words per minute (SW/M) and words read or spoken per minute (WR/M or WS/M) in reading, monologue, and conversation demonstrated by clients on the standard interview and Criterion Tests 1, 2, and 3. Words read per minute and words spoken per minute were not counted during the standard interview.

SW/M WR/M SW/M WS/M Test N Mean SD Mean SD Mean SD Mean SD

Total Monologue Standard

Interview 50 g.2 5.8 - - 9.8 6.8 - - Criterion

Test I 50 8.4 6.8 - - 8.3 6.0 108.2 36.9 Criterion

Test 2 49 0.3 0.4 - - 0.3 0.6 67.5 36.3 Criterion

Test 3 30 0.1 0.1 - - 0.1 0.1 124.3 24.5 Reading Conversation

Standard Interview 50 8.9 7.6 - - 9.3 6.5 - -

Criterion Test I 50 8.9 6.9 110.6 38.3 8.0 5.7 128.0 42.4

Criterion Test 2 49 0.2 0.3 63.9 55.2 0.5 1.2 8S.7 43.7

Criterion Test 3 30 0.1 0.2 126.4 21.0 0.2 0.3 135.3 24.1

in T a b l e 1. T h e in i t i a l S W / M rate was 9.2 in the s tandard in terview and 8.4 in Cr i te r ion Tes t 1. T h e r e was a s ignif icant posit ive corre la t ion (r = 0.72, d[48, p > 0.01) of S W / M between the two tests. Both the s tandard in terview a n d Cr i te r ion Tes t 1 ind ica ted less t han one S W / M difference among the m e a n n u m b e r of S W / M for reading, monologue, a n d conversation. However, a more de ta i led analysis revealed i n d i v i d u a l var ia t ion. Twenty- four clients demonstrated their highest rate of s tu t ter ing in reading, 12 in mono logue a n d 14 in conversation. T h e word rate in Cr i te r ion Tes t 1 ind ica ted that the clients spoke at a h ighe r ra te (128.0 W S / M ) d u r i n g conversat ion than d u r i n g e i ther r ead ing or monologue. T h i s observat ion he ld consistent for al l three cr i ter ion tests.

Before discussion, the percentage of agreement of the c l in ic ians in coun t ing s tu t te r ing words averaged 82. It was necessary to l is ten to, discuss, and recount the tape recordings of 24 clients before 90% or better agreement was achieved.

T h e most marked change in s tu t ter ing rate occurred d u r i n g Cr i te r ion Tes t 2. T h e total S W / M rate for all three modes was only 0.3 (one s tut tered word in three minutes of t a lk ing) . T h e word rate was depressed d u r i n g Cr i te r ion Tes t 2, reflecting the emphas is d u r i n g the es tab l i shment p rogram on slow, prolonged, f luent speech. Conversa t ion y ie lded the highest ra te of s tu t te r ing (0.5 SW/M) . T h i r t e e n clients demons t ra ted 0 S W / M for al l three modes in Cr i te r ion Tes t 2, and 14 had to recycle in one or more modes (commonly conversation),


JOURNAL OF SPEECH AND HEARING DISORDERS - - XXXIX, 1

There was a significant positive correlation (r = 0.43, d[47, p>O.O1) of SW/M between Criterion Tests 1 and 2.

Criterion Test 3 revealed further decrease in stuttering rate (0.1 SW/M, or one stuttered word for every 10 minutes of talking). Reading, monologue, and conversation word rates increased to levels higher than those of Criterion Test 1. The speech of the clients in Criterion Test 3 sounded normal. The stuttering that did occur was usually whole or part word repetitions. The rates of 135 WS/M in conversation and 0.2 SW/M (one stuttered word for every five minutes of talking) are comparable to those reported by Johnson (1961) and discussed by Andrews and Ingham (1971) for normal speakers. The clients had increased their speaking rates during the transfer program. Ten clients demonstrated 0 SW/M for all three modes and two clients failed and had to recycle through parts of the transfer program.

Program Performance. The results of the clients' performance in the establishment, transfer, and maintenance programs are shown in Table 2. There

TAaLv 2. Means and standard deviations of the number of stuttered words per minu te (SW/M), therapy hours with criterion testing (CT) time included, talking hours, and calendar days and months for clients in establishment, transfer, and maintenance programs.

Program N Mean SD Mean SD Mean SD

Therapy Hours Talking Hours SW/M (With CTt) (Without CT)

Establishment 49 0.2 02, 6.2 2.8 2.6 1.1 Transfer $0 0.2 0.1 13.5 5.4 5.9 1.7 Maintenance 30 0.1 0.2 1.1 0.4 0.3 0.1

Calendar Calendar Days Months

Establishment 24.5 16.2 - - Transfer 116.9 42.7 - - Maintenance - - 5.1 2.9

t CT 1 and 2 in establishment and C T 3 in transfer.

were 49 clients who completed the establishment program. One client dropped out during this program; his data were comparable to those of the other clients. The clients demonstrated a mean of 0.2 SW/M (one stuttered word for every five minutes of talking) during a mean of 6.2 hours of total therapy time. This time included Criterion Tests 1 and 2, which required 30 minutes each to administer. Therefore, the actual time in program therapy was 5.2 hours. Of these 5.2 hours an average 2.6 hours were spent by the client talking. The clients also engaged in home practice five to l0 minutes a day four times a week, which provided additional practice time. The clients completed the establishment program in three weeks (two hours of therapy each week). There was a significant positive correlation (r = 0.41, df47, p > 0.01) between talking hours in the establishment program and SW/M in Criterion Test I and another positive correlation (r = 0.38, df 47, p > 0.01) between severity



and SW/M during the establishment program. The implication is that those clients who demonstrated more stuttering initially during the preprogram tests tended to stutter more during the establishment program and thus to take longer to complete it.

As of the time of this report, 30 clients had completed the transfer program. They demonstrated a mean of 0.2 SW/M (one stuttered word for every five minutes of talking) during a mean of 13.5 hours of therapy time. This time included Criterion Test 3, which required 30 minutes to administer; therefore, the actual time in program therapy was 13 hours. Of these 13 hours the clients spent an average 3.9 hours talking. Part of the therapy time in the transfer program was spent in setting the stage for each step and the participation of the individual people involved in the step; hence the amount of time avail- able for client talking was reduced. The clients stuttered most during steps involving strangers or the telephone. Casual observation revealed that the clients' speaking rate gradually increased during the first few transfer program steps as they performed in more natural settings. The transfer program was spread out over an average of four months, which permitted the clients to complete their transfer assignments at home, school, or work.

Three clients are still in transfer and 16 clients dropped out during the transfer program. An analysis of the dropouts indicated that they were doing well in the program and that work schedule conflicts, transportation problems, or the achievement of fluency satisfactory to them were the common reasons for their departure. Some clients said they would return to the program when their circumstances permitted.

Thirty clients have been on maintenance. During maintenance checks they have demonstrated 0.1 SW/M (one stuttered word per 10 minutes of talking). These stuttered words have been primarily whole or part word repetitions. Their speech sounds normal. The maintenance checks have required a mean of 1.1 hours of therapy distributed over a mean of 5.1 months. Only one client had to be recycled through parts of the transfer program. Additional casual observations of clients in their environments and reports of their friends or relatives indicate that they are continuing to speak fluently in a wide variety of settings.

This clinical program has been in operation for four years. More than 200 people who stutter have been treated, although this report concerns only a recent 50. The program demonstrates the effectiveness of large-scale fluency training programs based on behavioral and learning principles. The DAF process or "prolonged speech" results parallel those found by others (Andrews and Ingham, 1972; Curlee and Perkins, 1969; Goldiamond, 1965; Ryan, 1971). This program meets the evaluation standards proposed by Andrews and Ingham (1972) of continued measurement of stuttering and speaking rate, transfer of fluency to extraclinical settings, and measurement of the permanence of the fluency. These standards are, in fact, embodied in the procedures of establishment, transfer, and maintenance.

The most encouraging points are that the clients were able to achieve and


10 JOURNAL OF: SPEECH AND HEARING DISORDERS -- XXXIX, 1

maintain normal fluent speech in a reasonable amount os therapy time; the program worked for people of widely varying ages, of both sexes, and with varying degrees of stuttering severity; the results were obtained by nine different clinicians, suggesting that the procedures are not clinician-bound; and the procedures and the results are similar to those of other clinician-re- searchers in other settings, suggesting that the procedures are not clinic- bound.

A C K N O W L E D G M E N T At the time of this research, Barbara Van Kirk was alfiliated with the Dean S. Edmonds

Institute of Operant Conditioning in Stuttering Therapy, of the Easter Seal Rehabilitation Center of Eastern Fairfield County, Bridgeport, Connecticut. She is now affiliated with the Behavior Sciences Institute, Monterey, California. The authors wish to acknowledge the help of the late Dean S. Edmonds, who provided financial support for the Stuttering Institute at the Easter Seal Rehabilitation Center; of Edmund McLaughlin, who provided administrative guidance; and of the clinicians: Joan Goldstein, Gary Stotsky, Shonna Stanfill, Judy Boren- stein, Bruce Wigder, Arlene Zerbo, Mark Harlor, and Ted Culler, who did the clinical work. Van Kirk presented part of this report at the Annual Convention of the American Speech and Hearing Association in San Francisco in November 1972. Requests for reprints should be addressed to the Behavioral Sciences Institute, 969 Pacific, Monterey, California 9S940.

R E F E R E N C E S ANDREWS, G., and INGHAM, R., An approach to the evaluation of stuttering therapy. ]. Speech

Hearing Res., 15, 296-S02 (1972). ANDREWS, G., and INGHAM, R., Stuttering: Considerations in the evaluation of treatment.

Brit. ]. Dis. Commun., 6, 129-1S8 (1971). CURL~, R., and P ~ N S , W., Conversational rate control therapy for stuttering. ]. Speech

Hearing Dis., $4, 245-250 (1969). GOLO~MONO, I., Stuttering and fluency as manipulable operant response classes. In L. Kramer

and L. Ullman (Eds.), Research in Behavior Modification. New York: Holt, Rinehart (1965).

HAROLDSON, S., MARTIN, 1~., and STA]~, C,, Time-out as a punishment for stuttering. ]. Speech Hearing Res., 11, 560-566 (1968).

JOHNSON, W., Measurements of oral reading and speaking rate and disfluency of adult male and female stutterers and nonstutterers. ]. Speech Hearing Dis., Monogr. Suppl. 7, 1.20 (19~1).

RYAN, B., An illustration of operant conditioning therapy for stuttering. In M. Fraser (Ed.), Conditioning in Stuttering Therapy. Memphis, Tenn.: Speech Foundation of America (1970).

RXAN, B., Operant procedures applied to stuttering therapy for children. ]. Speech Hearing Dis., S6, 264-280 (1971).

RYAN, B., Programmed Therapy for Stuttering in Children and Adults. Springfield, Ill.: Charles C Thomas (in press).

RYAN, B., and VAN Kin , B., Programmed Conditioning lot Fluency. Monterey, Calif.: Be- havioral Sdences Institute (1971).

SHAMES, G., ECOLF, D., and RHODe, R., Experimental programs in stuttering therapy. ]. Speech Hearing Dis., ~,, S0-47 (1969).

VAN KL.~, B., Operant therapy programs for stuttering conducted in a rehabilitation center. Rehab. Lit., $8, 107-108 (1972).

W~STEg, R., Stuttering: A way to eliminate it and a way to explain it. In lt. Ulrich, T. Stachnik, and J. Mabry (Eds.), Control ol Human Behavior. Vol. 2. Chicago: Scott, Fores- man (1970).

Received May 17, 1973. Accepted August Sl, 1975.


the establishment, transfer, and maintenance of … · the establishment, transfer, and maintenance...

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