Approaches to Management of Fluency Disorders: The management of fluency disorders involves three stages.

1. Establishment of Fluency
2. Generalization of Fluency
3. Maintenance of Fluency

Establishment of Fluency

Establishment of fluency is easy and can be achieved using a variety of fluency shaping or stuttering modification approaches. Establishment of fluency involves many approaches.

Behavioral Approach/Traditional Approaches

Following are a few of the traditional techniques being used for decades with varied success: Voluntary stuttering/ stutter fluently techniques, prolongation or many of its variants, cancellation, pull out, soft/loose contacts, relaxation, airflow therapies, and shadowing. Behavioral approach divided into two techniques:

1. Fluency Modification Techniques: In modification techniques clinician may work on, Modify moments of stuttering; Reduce tension and rapidity; Learn to stutter in a more relaxed, easy, and open manner.
   • Voluntary Stuttering – Bryngelson et al (1944)
   • Stutter Fluency Technique (modified voluntary stuttering) – Van Raiper (1954)
   • Bounce Technique (modified voluntary stuttering) – Johnson (1955)
   • Shadowing – Cherry and Sayers (1956)
   • MIDVAS – Van Raiper (1972)
   • Anticipatory Struggle – Oliver Bloodstein (1982)

[Note – For Detailed Information about these techniques please go through this article ⇒ Different Techniques and Strategies used in Management of Stuttering ]

1. Fluency Shaping Techniques: Fluency shaping or fluency enhancement involves techniques like Deep breathing, Slowed speech rate, light articulatory contact, Easy onset of speech, and Gentle voice onset.
   • Air Flow Therapies (Regulated breaking method) – Azrin and Nunn (1974)
   • Flow and Slow Method (Modified Airflow) – Martin Schwartz (1976)
   • Articulatory Level Therapy – Froeschels (1950)
   • Continuous Phonation and Blending – Pindzola (1987)

[Note – For Detailed Information about these techniques please go through this article ⇒ Different Techniques and Strategies used in Management of Stuttering ]

Instrumental Approach

Mechanical and electronic devices and various equipments are available for establishing fluent speech in the clinical set up such as, Metronome, EMG Biofeedback, Masking, DAF, FAF, Dr. Fluency. School DAF, Telephone Fluency System, Pocket fluency, Desktop Fluency System, and Voice Changer are some of the other devices used in the management of person who stutter.

• Delayed Auditory Feedback – Gold Diamond (1956)
• Metronome Timed Speech (1965)
• Unison Speech – Gregory (1968)
• Intensive Token Economy Therapy – Andrews and Ingham (1970, 1973)
• Pacing – Helm (1979)
• Dr. Fluency – Dr. Trudy Stewart and Monia Bray (1990’s)

[Note – For Detailed Information about these techniques please go through this article ⇒ Different Techniques and Strategies used in Management of Stuttering ]

Cognitive Approach/Cognitive restructuring

Developing an understanding about the production of speech in general and fluent speech in particular is essential part of any therapy. Even young children are encouraged to understand the same using various analogies (Garden hose/Blown up balloon analogies).

Analogies (Conture, 1990)

Conture (1990) has provided several analogies which could be used to teach the child stutterer regarding normal & disrupted flow of speech.

• The Garden Hose Analogy
• Blown up Balloon Analogy
• Lily pad/ Barrel Bridge Analogy
• Thumb and Opposing finger Analogy

[Note – For Detailed Information about these Analogies please go through this article ⇒ Different Techniques and Strategies used in Management of Stuttering ]

Behavior Therapy Approach

Although the cause of stuttering is not very well understood, recent theorists emphasize nurture or environmental factors to contribute as maintaining factors in stuttering. Appropriate reinforcement procedures to facilitate fluency and punishment strategies like the Time out and Response cost to reduce dysfluencies could aid in achieving fluent speech. Other techniques using behavior therapy principles include Modeling, shaping, role play, over correction (negative practice), extinction (reinforcement that previously followed an operant conditioning) and the like. Further, in clients with anxiety traits, progressive relaxation combined with systematic desensitization procedures could be very effective.

• Fluency Reinforcement (2002, M.N Hegde)
• Response Cost for Preschoolers (2003, M.N Hegde)

[Note – For Detailed Information about these techniques please go through this article ⇒ Different Techniques and Strategies used in Management of Stuttering ]

Emotional or Effective Approaches

Using varieties of psychotherapy and counseling, positive changes in emotional or affective states of the individual need to be brought about. Stuttering is a disorder which evokes unusual reactions from the peers parents and public. These negative reactions are unpleasant and speaking situations may be
traumatic to PWS, who will start avoiding them. Hegde (1990) opines that if the attitudinal changes are not brought about during the therapeutic management, the unchanged maladaptive attitudes will soon wipe out the temporary and shaky fluency generated by the treatment procedure.

Supportive Approach

Periodic counseling and guidance to the parents, relatives, friends, teachers, employers or significant others in the social environment of PWS is very important for bringing about long lasting maintenance of the fluency that is achieved. It is necessary for PWS to get support and encouragement from these people to overcome their negative feelings and attitudes and proper motivation to control the fluency achieved.

Other Approaches

The Monterey Fluency Program (MPF, 1970’s)

• It was based on learning principles, in particular operant conditioning.
• The major target for people of all ages, who stutter, is normally fluent speech.
• The MPF involves speech only, because it was observed that changes in attitude and anxiety often occurred after changes in fluency (Craig et al., 1996).
• The MPF is based on 3 major components of programmed instruction and operant conditioning:

1. 1. Overt responses (stuttering and fluent speech),
   2. Small steps or successive approximation (e.g., one fluent word, two fluent words, etc.) and
   3. Immediate consequences (positive feedback for fluent utterances and corrective feedback for stuttering moments).

• There are 3 phases of treatment:

1. 1. Establishment (within-clinic fluency),
   2. Transfer (out of clinic), and
   3. Maintenance (fluency within and out of the clinic over time) (Ryan, 1974).

• Two tests are built into the program:
  1. Fluency interview, which is composed of 10 speaking tasks ranging from automatic (e.g., counting) to conversational speech with strangers, and strangers.
  2. Criterion test (5 minutes each of reading, monologue, and conversation) are administered.
• These two tests serve to determine the level of pre treatment stuttering and as post tests to determine improvement and effectiveness of the treatment program at various stages

The Lidcombe Program – Mark Onslow (1980’s)

• The program is administered by a parent (or care giver) in the child’s everyday environment. Parents learn how to do the treatment during weekly visits to the speech pathologist.
• The speech pathologist trains the parent by demonstrating various features of the treatment, observing the parent do the treatment, and giving the parent feedback about how they are going with the treatment.
• The treatment modality is direct. This means that it involves the parent commenting directly about the child’s speech. This parental feedback is overwhelmingly positive, because the parent comments primarily when the child speaks fluently and only occasionally when the child stutters.
• The parent does not comment on the child’s speech all the time, but chooses specific times during the day in which to give the child feedback.
• The parent also learns to measure the child’s stuttering by scoring it each day out of 10, where 10 is “very severe stuttering” and 0 is “no stuttering.”
• The Lidcombe Program is conducted in two stages:
  • Stage 1, the parent conducts the treatment each day and the parent and child attend the speech clinic once a week. This continues until stuttering either disappears or reaches a very low level.
  • Stage 2 of the program commences at this point. The aim of Stage 2 is to maintain the absence, or low level, of stuttering for at least one year.

GILCU Approach – Bruce Ryan (1974, 1984)

• GILCU) approach works on the premise that speech is an operant, and that fluent responses can be elicited when appropriate rewards and punishments are administered.
• Note that the GILCU program is aimed predominantly at school aged children, but its significance as a precursor to the Lidcombe Program and its similarities warrant its inclusion here.
• As is the case with all operant programs, therapy is very carefully controlled and highly structured as the child progresses through three phases: establishment, transfer and maintenance.
• This approach requires the child to work through a series of 54 steps. Step one of the establishment phase requires the child to speak one word fluently, ten times consecutively. When he is able to do this, he moves to step two (two words consecutively), step three (three words), and so on up to stage six. Stage seven comprises one sentence; stage eight, two sentences. At stage 11, 30 seconds of fluency speech is required. By stage 18 the child will be able to produce 5 minutes of fluent speech.
• The establishment phase, the child responds to specific instructions, initially using single word utterances as in each of three modes, reading, monologue and conversation.
• Stuttered responses are negatively reinforced, for example, “stop, speak fluently”, and the child is required to repeat fluently before continuing.
• Fluent speech is rewarded with praise “good”, and tokens which can later be exchanged for a tangible award are given.

Treatment of Advanced Stuttering (Guitar Approach) – Guitar (1982)

• Targets: learn new behaviour (controlled fluency), reduce old behaviour.
• Goals: Spontaneous fluency, all situations
• Options:
  • Apply fluency skills
  • Easy mild forms of stuttering
  • Comfortable with mild stuttering; stay relaxed
• Feelings & attitudes :

• • Negative feelings
  • Avoidance: not reduce
  • Controlled fluency, mild easy stuttering: Reduce fear
  • Fear: muscle tension, alter speech production
  • Counter conditioning: confront problem, clinician supports
  • Clinician’s +ve regard reduces fear
  • Deconditioning: Hierarchy
• Clinical procedure:
  • Beginning therapy
    • Understanding Rx goals: options of controlled fluency etc
  • Exploring
    • Objective about behavior
    • Optimistic: change, control
  • Understanding:
    • Rationale: exploration, partnership
    • New behavior, decreases fear
  • Approaching Stuttering:
    • Face it than backing away
    • Core & escape behaviors, desensitize
    • Examine: moments of stuttering in clinic
  • Analyzing:
    • Accurate analysis: moments of stuttering & avoidance
    • Decrease negative emotions, fear toward listeners
    • Transfer changes outside clinics
  • Learning and generalizing controlled fluency
  • Flexible Rate
  • Easy onset of Voice
  • Articulatory Light Contacts
  • Combination of all controlled fluency
  • Transfer of controlled fluency to fluent speech
  • Hierarchy of speaking context: syllable to sentence
  • Generalize controlled fluency to outside clinics, telephonic counselling, everyday conditions reporting.
  • Maintenance

Group Therapy

Group therapy sessions are important because the client sometimes feels that as the therapist doesn’t stutter, he/she does not understand that it is tough to go through an instant of stuttered speech and still communicate. Luterman (1991) suggested 2 types of groups: therapy groups and counseling groups. Usually group meetings serve functions of both counseling n therapy session where client can get desensitized to stuttering in general and also to his own stuttering behavior. Conture in 1990 stated that group meetings also provide clients with opportunities to communicate understand the nature of the problem and monitor self progress in social settings. According to Levy, 1983 group activities are a natural extension of individual treatment. Group therapy includes:

• Group introduction
• The block modification process
• Focusing on the communication
• Studying speech
• Structuring activity
• Assignments
• Dealing with Feelings and Changing perceptive
• Dealing with avoidance
• Encouraging more objective approach
• Dealing with negative feelings within the group
• Experimentation and desensitization
• Encouraging the awareness of nonverbal aspect of speech
• Trying out speech and prediction in the group
• Educating the public
• Negotiation and confrontation
• The final session

Drug Therapy

Neurobiological researches (Fox et al. 1996; Wu et al. 1997; Braun et al. 1997; De Nil et al. 2000) state that an excessive level of the neurotransmitter “dopamine” (dopamine D-2 receptor) in the caudate tail of basal gangliaBasal ganglia is several nuclei in the diencephalon, near the thalamus. They are responsible for regulation of major muscle groups that make postural adjustments and compensate for inertial forces during movement. Depending on who is writing about them, the basal ganglia include the caudate nucleus, putamen, globus pallidus, subthalamic nucleus, and substantia nigra. Reference: Introduction to Neurogenic Communication Disorders (Eighth... More might be responsible for dysfluency producing symptoms. Prins et al. in 1980 suggested dopamine receptor antagonists as it directly affects the motor pathways involved in producing the stuttering behavior. Tranquilizers have also been known to be effective as they control anxiety and tension which are primarily related to the disorder. The effects of such drugs are more on the complexity and severity of blocks rather than on their frequency of occurrence.

A wide variety of pharmaceutical agents have been used for treatment of stuttering. These drugs are used in drug therapy:

• Haloperidol
• Chlorpromazine
• Reserpine
• Meprobamate
• Pentobarbitone

Psychotherapy

Travis (1957) & Glauber (1958) successfully treated clients with stuttering using Freudian psychoanalytic method. Psychotherapy for fluency disorder includes:

Suggestion: This method was used to eliminate stuttering temporarily since the phenomenon of hypnotism was being used.

Relaxation: Anxiety and tension lead to increase in frequency and duration of stuttering, hence, relaxation techniques have been satisfactorily used by researchers to minimize the occurrence of stuttering behavior.

Psychoanalysis: It deals with analyzing the past and present of the stutterers through free association, dream interpretation and the analysis of their behaviors and resistances both covert and overt. In traditional Freudian psychoanalysis, the therapist doesn’t reveal himself and just acts as a mirror in
which the patient can perceive him as his own parent or significant figure and by doing so, discover and relieve the early traumatic experiences which are the sources of his present difficulties.

Psychodrama: The client plays his own role and by such activities it was seen that there was reduction in fear and tension associated with that particular situation and gradually there was lessening of stuttering behavior.

Ventilation: This is used when there is a lot of an emotional problem with the client that relates to stress.

Persuasion: In persuasive approach the first step is to convince the client that due to disappointing experiences he/she has come to over emphasize the speech function.

Supportive adjuncts: Drawing, speaking in a rhythmic manner or in a sing-song tone, utilizing distracting sounds like ‘ah’ or a sigh prior to articulation, employing gesture or engaging in some motto act like pacing or rubbing a watch chain purposefully, pauses and a variety of other tricks are told to the client.

Reinforcements: Onslow, Cosla and Rue (1990) did a study on 4 subjects between 3-5yrs for a period of 4-10wks. Technique used was verbal reward and punishment; at the end of the defined period all children showed significant reduction on stuttering, a follow up study after 9 months showed improvements in fluency skills of the children.

Generalization of Fluency

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

Maintenance of Fluency

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

References:

⇒ STUTTERING An Integrated Approach to Its Nature and Treatment – BARRY GUITAR, PH.D. (Book)
⇒ A Handbook on Stuttering – Bloodstein (book)
⇒ Treatment Protocols for Stuttering – M. N. Hegde (Book)
⇒ Stuttering and Cluttering – David Ward (Book)
⇒ Speech Correction An Introduction to Speech Pathology and Audiology – Charles Van Riper, Robert L. Erikckson (Book)

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Approaches to Management of Fluency Disorders