An operant intervention for early stuttering. The development of the Lidcombe program.

Stuttering is a common speech disorder that causes significant distress and may cause social maladjustment and hinder occupational potential. Treatments for chronic stuttering in adults can control stuttering by teaching the speaker to use a new speech pattern. However, these treatments are resource intensive and relapse prone, and they produce speech that sounds unnatural to the listener and feels unnatural to the speaker. This article describes the development and evaluation of an operant treatment for early stuttering. Parents are trained to present verbal contingencies for stuttered and stutter-free speech during everyday speaking situations with their children. The authors overview outcome data from several studies that suggest that this program produces relapse-free control of stuttered speech in preschool children in the medium and long term in a cost-effective manner.

Novel speech patterns and the treatment of stuttering.

Variants of rhythmic speech and legato speech have been used for centuries to treat stuttering. Despite considerable empirical and theoretical inquiry, the reason for the effectiveness of these novel speech patterns in suppressing stuttering is unknown. Recent acoustic research conducted at the University of Sydney suggests that a reduction in the variability of syllabic stress is a critical feature of these two speech patterns, and that this reduction suppresses stuttering by stabilizing the speech motor system. This paper reviews what is known about rhythmic speech and legato speech from this perspective, and the theoretical and clinical implications of reconceptualizing them in this way are discussed.

Treating stuttering in young children: predicting treatment time in the Lidcombe Program.

It is known that children may recover from stuttering without formal treatment during the first years after onset. Consequently, the timing of professional, early stuttering intervention is a pressing issue in speech-language pathology. This report presents data pertinent to this issue for 261 preschool-age children who received the Lidcombe Program of early stuttering intervention. Of these children, 250 completed the program and were considered by their clinicians to have been treated successfully. For the children who were treated successfully, logistical regression analyses were used to determine whether age, gender, period from onset to treatment, and stuttering severity related systematically to the time required for treatment. The present data confirmed previous reports that a median of 11 clinic visits was required to achieve zero or near-zero stuttering with the Lidcombe Program. Results were also consistent with a preliminary report of 14 children (C. W. Starkweather & S. R. Gottwald, 1993) showing a significant relation between stuttering severity and the time needed for treatment, with children with more severe stuttering requiring longer treatment times than children with less severe stuttering. However, results did not associate either increasing age or increased onset-to-treatment intervals with longer treatment times. This finding is not consistent with the Starkweather and Gottwald report, which linked advancing age with longer treatment time. In fact, the present data suggest that, for a short period after stuttering onset in the preschool years, a short delay in treatment does not appear to increase treatment time. An important caveat to these data is that they cannot be generalized to late childhood or early adolescence. The present findings are discussed in relation to natural recovery from stuttering.

Reliability of clinicians' judgments about prolonged-speech targets.

Treatments for stuttering based on variants of Goldiamond's prolonged-speech procedure involve teaching clients to speak with novel speech patterns. Those speech patterns consist of specific skills, described with such terms as soft contacts, gentle onsets, and continuous vocalization. It might be expected that effective client learning of such speech skills would be dependent on clinicians' ability to reliably identify any departures from the correct production of such speech targets. The present study investigated clinicians' reliability in detecting such errors during a prolonged-speech treatment program. Results showed questionable intraclinician agreement and poor interclinician agreement. Nonetheless, the prolonged-speech program in question is known to be effective in controlling stuttered speech. The clinical and theoretical implications of these findings are discussed.

Control of children's stuttering with response-contingent time-out: behavioral, perceptual, and acoustic data.

Many stuttering treatments incorporate contingencies for stuttering that are thought to contribute to treatment effectiveness. One contingency used in a number of treatment programs for children is time-out (TO) from speaking. However, although TO has been shown to control stuttering in adults there are no clear demonstrations of this effect in children. One aim of the present study was to demonstrate in the laboratory that TO reduces stuttering in children. Three school-age children spoke in a single-subject ABA experiment. In the B phase, a red light was illuminated for 5 seconds when the subject stuttered, during which time the subject stopped talking. Two of the three children showed clear reductions in stuttering in response to TO. The second aim of the study was to detect whether the children who responded to To adopted an unusual speech pattern in order to control their stuttering. Listeners did not detect any differences between the perceptually stutter-free speech of baseline conditions and that of TO conditions, and a subsequent acoustic analysis revealed a reduction in the variability of vowel duration during TO in one subject and no changes in the other. The theoretical and clinical implications of the findings are discussed.

The Lidcombe Programme of early stuttering intervention: methods and issues.

The Lidcombe Programme is an operant intervention for early stuttering that parents administer to children in their everyday speaking environments. The treatment was developed at the Suttering Unit, Bankstown Health Service, Sydney, and The University of Sydney. Recently, staff from the Australian Stuttering Research Centre. The University of Sydney, toured universities and clinics in the UK to present lectures about this treatment. We were encouraged to write this paper because an independent survey showed that most speech and language therapists who attended the presentations were open to this treatment. Prior to and following that lecture tour, publications in the press and professional journals in the UK alluded to many positive features of the Lidcombe Programme, but also raised several issues about it. The purpose of this paper is to summarise the Lidcombe Programme and address the following criticisms of the treatment that were raised in the UK: (1) Stuttering is complex but the Lidcombe Programme is simple; (2) the Lidcombe Programme is not an operant treatment, but invokes positive changes in children's environments; (3) the Lidcombe Programme is harmful to children; and (4) the scientific evidence in support of the Lidcombe Programme is flawed. Each of these issues is addressed from logical, theoretical and empirical viewpoints.

Speech outcomes of a prolonged-speech treatment for stuttering.

It has been shown that people who stutter can speak with greatly reduced stuttering after treatments that use variations of Goldiamond's (1965) prolonged-speech (PS). However, outcome research to date has not taken account of several important issues. In particular, speech outcome measures in that research have been insufficient to show that lasting relief from stuttering has been achieved by clients outside the clinic for meaningful periods. The present study used extensive speech outcome measures across a variety of situations in evaluating the outcome of an intensive PS treatment (Ingham, 1987). The speech of 12 clients in this treatment was assessed on three occasions prior to treatment and frequently-on eight occasions-after discharge from the residential setting. For 7 clients, a further assessment occurred at 3 years posttreatment. Concurrent dependent measures were percent syllables stuttered, syllables per minute, and speech naturalness. The dependent measures were collected in many speaking situations within and beyond the clinic. Dependent measures were based on speech samples of substantive duration, and covert assessments were included in the study. Detailed data were presented for individual subjects. Results showed that 12 subjects who remained with the entire 2-3-year program achieved zero or near-zero stuttering. The majority of subjects did not show a regression trend in %SS or speech naturalness scores during the posttreatment period, either within or beyond the clinic. Some subjects showed higher posttreatment %SS scores during covert assessment than during overt assessment. Results also showed that stuttering was eliminated without using unusually slow and unnatural speech patterns. This treatment program does not specify a target speech rate range, and many clients maintained stutter-free speech using speech rates that were higher than the range typically specified in intensive PS programs. A significant correlation was found between speech rate and perceived posttreatment speech naturalness.

A control/experimental trial of an operant treatment for early stuttering.

A preliminary study (Onslow, Costa, & Rue, 1990) suggested that a parent-conducted program of verbal response-contingent stimulation would be an effective treatment for stuttering children younger than 5 years. The present study was designed to expand those preliminary findings by using a larger group of children and by comparing them to a control group of children. Twelve children in the experimental group achieved median percent syllables stuttered (%SS) scores below 1.0 for a 12-month posttreatment period. The children's treatments were completed in a median of 10.5 1-hour clinic sessions and a median of 84.5 days from the start of treatment. The majority of parents of the control children withdrew from the study and elected to have treatment begin for their child. These results suggest that the program may be a cost-effective method for managing a clinical caseload of stuttering children younger than 5 years. It is suggested that controlled clinical trials cannot be used validly or ethically to determine the number of cases of early stuttering who recover without formal intervention.

Prolonged speech and modification of stuttering: perceptual, acoustic, and electroglottographic data.

Prolonged speech and its variants are a group of novel speech patterns that form the basis of a popular treatment for stuttering (Ingham, 1984). It is difficult to determine which features of prolonged speech are necessary for the elimination of stuttered speech because the speech pattern produces simultaneous changes in respiratory, laryngeal, and articulatory activity. Experimental studies have shown that the modification of phonation and of speech rate contributes to stuttering reduction, and increased duration of speech segments and reduced variability of vowel duration are known to occur as a result of prolonged-speech treatment programs. However, previous studies of prolonged speech have all instructed subjects to modify their customary speech patterns in a particular way. The aim of the present study was to investigate changes in the speech pattern of individual subjects when stuttering was modified with prolonged speech without specific instruction in how this should be done. In one experimental phase, 3 subjects showed clinically significant stuttering reductions when instructed to use whichever features of prolonged speech they needed to reduce their stuttering. The resulting perceptually stutter-free speech was judged to be natural sounding. Stuttering in a fourth subject reduced without experimental intervention. Recordings of acoustic and electroglottographic signals from the 4 subjects were analyzed. Changes in the variability of vowel duration occurred in all subjects. Theoretical and clinical implications of the results are discussed.

Choosing a treatment procedure for early stuttering: issues and future directions.

The new responsibility of speech-language pathologists to provide direct, early intervention for stuttering creates a further responsibility for them to choose justifiable treatment procedures for that intervention. This paper has two purposes. The first is to encourage clinicians to evaluate the conceptual and practical aspects of the treatments they use for early stuttering. The second purpose of the paper is to overview available early intervention procedures and consider the advantages, disadvantages, and prominent issues associated with each. The procedures considered are environment manipulation, prolonged speech, and response-contingent stimulation. It is concluded that clinicians have no cause to be satisfied with any currently available early intervention procedure. Further, it is concluded that (a) although anticipatory struggle theories have made a useful contribution to scholarship, their line of theoretical reasoning is questionable for clinical practice; (b) although theoretically sound for the purpose, variants of prolonged speech pose prohibitive conceptual and practical shortcomings if they are used to treat very young stuttering children; (c) despite its disadvantages, response contingent stimulation is the most conceptually and practically justifiable method for early intervention with stuttering.

Reliability of speech naturalness ratings of stuttered speech during treatment.

This study evaluated the reliability with which relatively sophisticated and unsophisticated judges used a 9-point scale to rate the speech naturalness of speech samples from 10 clients in a treatment program for stuttering that employed prolonged speech. Judges rated repeated speech samples from different speakers during various phases of the program. Different groups of sophisticated and unsophisticated judges made ratings at either 15 sec, 30 sec, or 60 sec intervals while listening to the samples. Of the reliability indices, intraclass correlations were significantly higher for sophisticated judges although the consistency and agreement of unsophisticated judges were generally equivalent to that of sophisticated judges. Both agreement scores and intraclass correlations were higher when ratings were made at 60 sec rather than 30 sec intervals. The predominant variable that influenced judgement reliability appeared to be differences among the subjects. The methodology partially replicated Martin, Haroldson, and Triden's (1984) initial investigation on the use of this scale. However, the levels of intra- or interjudge reliability in this study were lower than the levels achieved by Martin et al.'s judges. There were important differences between the Martin et al. study and this one that may account for the findings, and these are discussed.

Variability of acoustic segment durations after prolonged-speech treatment for stuttering.

Existing literature suggests that one of the effects of treatment based on prolonged speech is increased durations of acoustic segments. However, the external validity of the data concerned may be questioned because the data were not based on spontaneous speech samples and were gathered from subjects with unknown treatment histories. With this in mind, the present investigation used young clients with no history of treatment based on prolonged speech and obtained pretreatment and posttreatment acoustic measures from spontaneous speech samples. Acoustic measures showed no significant posttreatment increases in durations of acoustic segments. However, for the acoustic measure of vowel duration and a measure of articulation rate, posttreatment speech samples showed significantly reduced variability. The potential theoretical and practical relevance of these findings is discussed.

Speech naturalness and prolonged-speech treatments for stuttering: further variables and data.

It is well known that unusual speech quality may result from stuttering treatments that are based on prolonged speech. However, empirical information concerning the speech quality associated with those treatments is lacking. The present study was designed to contribute such empirical information. Results indicated that speech quality assessments of posttreatment clients, using Martin, Haroldson, and Triden's (1984) speech naturalness scale, gave similar results regardless of whether they were based on monologues or conversations. The speech quality of those clients remained stable at the conclusion of their treatment program. Further, there was a significant, positive correlation between pretreatment speech measures and measures of speech naturalness made after the establishment of stutter-free speech. The subjects whose pretreatment stuttering was the most severe had posttreatment speech naturalness scores that were more than two scale values worse than the subjects whose pretreatment stuttering was the least severe. Speech naturalness scale scores are presented for nonstutterers and posttreatment stutterers and these data are compared with existing findings.

Stuttered and normal speech events in early childhood: the validity of a behavioral data language.

A set of 200 utterances from stuttering and normally speaking children aged 2-4 years was obtained. Each utterance contained a disfluency. A group of 5 sophisticated listeners assigned one of Johnson's eight disfluency categories to each of the 200 utterances. These clinicians showed poor agreement in the categories they assigned. Subsequently, the 200 disfluencies were presented to a group of generalist clinician listeners and a group of unsophisticated listeners, who were asked to judge whether each disfluency was "stuttering" or "normal." The disfluencies judged with high agreement to be "stuttering" and the disfluencies judged with high agreement to be "normal" were not categorically distinguished by the disfluency categories assigned previously by the sophisticated listeners. Further, judged presence of various disfluency categories accounted for only a small portion of the variance in numbers of "stuttering" judgments assigned to disfluencies. It is concluded that it is justifiable to question the validity of the data language used by researchers to describe stuttered and normal speech in early childhood. Several implications of this conclusion are discussed.

Direct early intervention with stuttering: some preliminary data.

Many clinicians recognize a need for direct intervention with cases of early stuttering. However, this recognition is not supported by adequate empirical information about how such cases should be managed. One possibility is that early stuttering might be controllable by parent-administered, operant, verbal stimulation procedures. The purpose of this paper is to present preliminary data that depict the results of such an intervention procedure with four cases of early stuttering. Speech measures were gathered in a variety of speaking situations, within and beyond the clinic, over a 2-month pretreatment period and a 9-month posttreatment period. Results showed that the 4 subjects achieved reductions in stuttering comparable to those reported for adult treatment programs. However, the present results were obtained in far fewer clinical hours than normally needed in the treatment for older subjects. The treatment times in the present study also compare favorably to those published in other reports of operant intervention procedures with children. These findings suggest that cases of early stuttering might be managed effectively by parents, with limited expenditure of clinical time. Findings are discussed in terms of their implications for the development of early intervention programs that are more efficient and effective than existing intervention procedures for older clients.