Recent Advances In Stuttering Treatment

EDITED BY : KUNNAMPALLIL GEJO JOHN (SLP)

Introduction:

Behavioral approaches to treatment have always been popular.

Because stuttering severity diminishes under a variety of conditions (reading in
chorus etc.).
In the field of speech pathology behavior therapy has been vastly applied (Perkins,
1971).
Stuttering response is an operant that occurs in the context of another operant i.e.,
verbal behavior.
It is a learnt maladaptive behavior that is maintained through habit strength and/or
reinforcement and,
It is possible that it may be reinforced by a subjects own feedback on an aperiodical
schedule which is highly resistant for extinction.

Integrated Approaches:

Stuttering is related to a number of factors (i.e., physiological, genetic, psychosocial,

environmental, and linguistic).
Recognizing the need to address these multiple factors in treating stuttering, several
integrated treatment programs have been described in the literature (Guitar, 1998).
Cooper and Cooper (1985) developed an integrated approach that addresses,

Affective (feelings),

Behavioral (speech changes) and

Cognitive (thoughts) components of the disorder (i.e., the ABC's of stuttering).

Guitars (1998) approach focus on creating speech changes along with a reduction in
or elimination of negative feelings, emotions and avoidance behaviors.
First phase increasing awareness and desensitizing stuttering.
Second phase teaching to stutter easily and speak more fluently through the use
of progressively longer and more complex linguistic units (i.e., single words,
sentences, phrases, paragraph reading and conversation).
Following this training - reducing negative emotions and attitudes as well as
reducing avoidance behaviors.

Final phase maintenance, generalization and increasing self-monitoring of

performance.

Enhancements To Integrated Approaches:

1) Utilizing speech tasks during therapy that involve thematic, topic-centered contexts of
interest to the client
2) Having client-clinician interactions follow a continuum of high- to low-structured
interactions within a session and throughout the program.
Using Thematic, Topic-Centered Speech Contexts

Creates realistic client-clinician interactions.

Makes interactions more socially appropriate and meaningful.
Finding a topic relevant to clients' interests will increase their motivation.
Various communicative partners could be involved.
Allows the client to devote greater attention to specific cognitive, linguistic, motor,
and emotional responses because of his/her familiarity with the topic.

Structuring Communicative Interactions Through Scaffolding

Scaffolds are cues, prompts, or any type of physical, visual, auditory support which
assists the client in becoming an active participant in an interaction.
Scaffolds may be,

Real objects.

Replicas.

Pictures.

Reading materials.

The clinician may paraphrase or summarize information that is about to be read by the
client so the linguistic processing demands are minimized.
Scaffolding should be minimized as the patient improves.
The clinician might also expect the client to increase the number of speaking turns,
produce more complex discourse and speak to other listeners.

DAF/FAF Assistant:

This is a software application that implements Delayed Auditory Feedback (DAF) and
Frequency Altered Feedback (FAF) techniques on Windows computers.
40 220 milliseconds (10 ms step).
FAF shifts the pitch of the patients voice.
Provides pitch shift in the range from one-half octave down to one-half octave up.

Pocket DAF/FAF Assistant:

Small Talk
Casa Futura Technologies

DAF range: 30 to 200 ms.

FAF range: +0.8, +0.6, +0.4, 0, -0.4, -0.8, -1.2 octaves.
Binaural sound is 25% more effective than monaural sound and is recommended for
severe stutterers.
Mild stutterers may be able to use monaural sound.
35-7500 Hz frequency range.

Speech Easy:

Worn similar to BTE and ITC hearing aids.

This device uses Altered Auditory Feedback (AAF) and produces choral effect.

The speech is fed in to the patients ear with a slight delay along with frequency
modification.

This induces perception of speaking in unison which creates the choral effect.

13 adult stutterers were tested using the Speech Easy anti-stuttering device for reading,
monologue, and conversation.

On average stuttering was reduced 36%, however, the effectiveness "varied greatly
across participants."

The subjects were then given speech therapy (training vowel prolongation) and the
combination of therapy and the device reduced stuttering 53%.

[Armson, J., Keifte, M., Mason, J., De Croos, D. "The effect of SpeechEasy on stuttering
frequency in laboratory condition," Journal of Fluency Disorders 31 (2006) 137-152].

9 stutterers used a DAF/FAF device about seven hours per day. Their fluency was
measured after 4 months and after 12 months.

Delay - 60 ms and FAF at 500 Hz up.

The subjects received brief speech therapy, specifically to prolong vowels and use
"starter sounds" such as "um" and "ah."

The device reduced stuttered syllables about 80%.

[Stuart, A., Kalinowski, J., Rastatter, M., Saltuklaroglu, T., Dayalu, V. "Investigations of
the impact of altered auditory feedback in-the-ear devices on the speech of people who stutter:
initial fitting and 4-month follow-up," International Journal of Language and Communication
Disorders, 2004, 39:1, 93-113].
[ Stuart, A., Kalinowski, J., Saltuklaroglu, T., Guntupalli, V. "Investigations of the impact
of altered auditory feedback in-the-ear devices on the speech of people who stutter: One-year
follow-up," Disability and Rehabilitation, 2006. 1-9].

Pacemaster (electronic metronome) - resembles a BTE hearing aid.

Fluency Master - provides aural enhancement of the vocal tone. A miniature microphone
amplifies the "buss" of phonation and returns it to an earpiece that resembles a BTE hearing
aid.

Edinburgh Masker - provides a low buzzing to both ears that masks his own voice when
speaking.

Valsalva Stuttering:
The stutterer instinctively activates the body's Valsalva mechanism in an attempt to force
out words, particularly during anticipation.

Symptoms:

Excessively forceful closures of the mouth or larynx, either of a sustained or repetitive

nature, accompanied by tightness in the abdominal muscles and increased air pressure
in the lungs;

Delays in phonation.

The ordinary Valsalva maneuver involves effort closure of VF for the purpose of sealing
off the respiratory tract, accompanied by contraction of muscles of the abdomen and
chest.
The Valsalva Hypothesis postulates that the symptoms may involve a neurological
confusion between speech and the human body's Valsalva mechanism.
Stutter may have learned to activate the Valsalva mechanism in an effort to produce
words.

The Fluency Cycle

Develop a positive attitude toward speech.

Resist the urge to "try hard" in speaking.

Relax the Valsalva mechanism - don't force!

Focus on phonation and vowels.

Speak slowly and deliberately, without avoidance (Voluntary Valsalva).

View your speech objectively.

Computer Aided Fluency Establishment Training:

Core program with 54 modular steps teaches a new phonatory and respiratory skill,
including

Diaphragmatic breathing.

Continuous airflow

Pre-voice exhalation.

Gentle voice onset.

Continuous phonation.

Adequate breath support.

The targets are manipulable by the clinician.

The second stage of the program emphasizes using the skills in the real world.

Cafet-for-Kids:

A program designed for treating children aged 5 to 12.

Hardware consists of a plug-in circuit board, respiratory sensor, and tie-clip microphone.

Offers continuous real-time visual biofeedback that integrates airflow characteristics

with voicing time and amplitude simultaneously.

Video game graphics for teaching a new phonatory and respiratory skill, including

Diaphragmatic breathing

Continuous airflow

Pre-voice exhalation

Syllable stretch

Continuous phonation.

The targets are manipulable by the clinician to meet individual client needs.

References:
www.valsalva.org
http://www.mnsu.edu/comids/kuster/TherapyWWW.html.
http://www.mnsu.edu/comdis/kuster/TherapyWWW/intensive/cafet.html
http://www.mnsu.edu/comdis/kuster/TherapyWWW/intensive/cafetkids.html