FLUENCY AND ITS DISORDER

TRANSFER, MAINTANENCE, RECOVERY & RELAPSE OF STUTTERING

KUNNAMPALLIL GEJO JOHN, MASLP

KUNNAMPALLIL GEJO JOHN MASLP

Transfer/ Generalization of fluency:

Transfer refers to generalization of modified communication styles and speech techniques from within the clinic to settings and situations outside the clinic. Transfer activities occur as an integral part of the therapy process, under the guidance of clinician. This process lays the foundation for subsequent long term maintenance of modified communication behaviors. The difficulty of transfer activities is usually hierarchically structured to build the childs confidence in his ability to employ techniques across various settings, while benefiting from the clinicians leadership and support.
KUNNAMPALLIL GEJO JOHN MASLP

Transfer during therapy:

Although transfer of new speech behaviors to the childs speaking environment is important, it is not necessary to begin this process immediately in therapy, before the new techniques have been properly learned.

Parents often expect homework after one or two sessions. To satisfy this desire, the clinician may assign some stuttering identification task instead. Indeed, homework assignments should reflect as closely as possible the clinical activities taking place at that point in the therapy process.
KUNNAMPALLIL GEJO JOHN MASLP

 The transfer process is sequential and hierarchical, but also iterative, as it builds momentum during the treatment phases of identification, desensitization, modification and stabilization. The clinician can usually identify an environment or situation in which the child is comfortable discussing stuttering. Such an activity would provide a more appropriate starting point for the process of transfer.

KUNNAMPALLIL GEJO JOHN MASLP

 In addition to the conscious transfer of behaviors, automatic transfer during the treatment process is also possible.

This is particularly the case with very young , pre school children .

This automatic transfer appears to follow from the childs observation of clinician modeling and practice with easier and less effortful speech in the clinic.
KUNNAMPALLIL GEJO JOHN MASLP

Transfer of identification:
Consciously identifying stuttering behaviors and environmental factors begins an important aspect of the behavioral change involved in the transfer of stuttering therapy; changing stuttering from something that is hidden, unconscious and automatic to something that is examined and modified in a conscious and deliberate way. This transformation is an essential aspect of any therapeutic or change process, and it can actually undermine or mitigate the development of habitual fears of sounds, situations and communication partners. This change in perspective is actually the foundation for the transfer process.
KUNNAMPALLIL GEJO JOHN MASLP

Transfer of desensitization: Although the identification of stuttering behaviors is desensitizing to some degree, it does not directly confront those aspects of stuttering to which children are more sensitive, the reactions, comments and judgments of listeners.

Transfer of modifications:

Generally, transfer of actual speech modification techniques (e.g. prolongations, easy onsets) is how most people decline transfer.
KUNNAMPALLIL GEJO JOHN MASLP

 Without adequate attention to identification and desensitization, however, it is unlikely that meaningful generalization of modification skills will ever be adequately achieved. To ensure that the treatment process is one in which the child experiences success, it is important to develop a hierarchy of speech situations in which to use modifications.

It is also important to document those situations in which the child is actually making or using modification.
KUNNAMPALLIL GEJO JOHN MASLP

Maintenance of fluency: Maintenance refers to a variety of after- therapy activities that are applied to help clients keep intact the gains of a treatment program. It is the long term continuation of fluency in a wide variety of settings. Before the maintenance phase begins, the child has experienced success in transferring techniques across settings and has gradually learned to become his own therapist.

KUNNAMPALLIL GEJO JOHN MASLP

 For maintenance to succeed, transfer must have become a natural part of the childs experience.

Maintenance is seen as an integral part of therapy and the client experiencing the maintenance aspect of a therapy is still in therapy. - Ryan 1979. Andrews and colleagues (1980) found that a planned maintenance program is necessary for any stuttering treatment to be successful
KUNNAMPALLIL GEJO JOHN MASLP

 Follow up is a post therapy evaluation of a clients long term performance after a period of non clinical intervention. - Boberg et al (1979)
Many clinicians believe that therapeutic gains are not likely to be maintained without changes in some of the stutters feelings and attitudes. An increasing number of behavior therapy programs in recent years have incorporated the so called maintenance procedure in an effort to cope with the possibilities for the relapse following therapy.
E.g. of such procedures are periodic clinical contacts after the termination of therapy, self- therapy assignments and work on speech attitudes. KUNNAMPALLIL GEJO JOHN
MASLP

 Perkins (1979) suggested that for some stutters, the problem of maintaining fluency is largely one of identity, when fluent, they feel like unwelcome strangers to themselves. They wish to feel like themselves, and stuttering is a part of that self image

KUNNAMPALLIL GEJO JOHN MASLP

Goals of generalization and maintenance programs with four main objectives by Ingham (1993)
To have the client use therapy practices that reduce or eliminate stuttering in the absence of formal therapy. To have the client demonstrate that the factors associated with therapy (people or situations) are not necessary for the client to evidence therapy benefits. To have others regard the client as a normally fluent speaker. To have the client no longer do things with his or her speech to sound fluent. KUNNAMPALLIL GEJO JOHN
MASLP

Procedures to maintain gains:

By enhancing activities like Daily self - monitoring activities: dismissal from intensive therapy does not excuse a client from the need to purposefully engage in self monitoring activities of all types, ranging from monitored fluency to visualization.

Regular clinic contacts: scheduling of periodic contacts on a decreasing frequency ranging from monthly to semi annually to yearly serve as maintenance ,markers for many clients (Ryan et al 1971). Each visit allows clients to review immediately past behavior and to analyze their fluency status.

KUNNAMPALLIL GEJO JOHN MASLP

 Refresher programes: if a client begins to show evidence of loss of gains made in therapy it may be necessary to recycle appropriate segments of the previously completed therapy program. (Ryan and Van Cirk 1974, Webster 1980, Boberg 1981).

Self help groups: form a self help group or make him join an existing one, often these groups are valuable for ventilation, practicing therapy techniques or even socialization. (Howie et al 1981).

KUNNAMPALLIL GEJO JOHN MASLP

Factors for poor maintenance:

Boberg (1981) - if client does not spend considerable time and energy in house activity and clinic visits.

Dalton (1979) - if regular follow up therapy is not carried out.

Ryan (1981) - extend of stuttering prior to therapy (for adults) maintenance is better in children. Florence, Shanes (1980) - if not self monitorred . Guitar and bass (1978) - negative attitudes. Webster (1979) - inadequate initial learning fluency- producing skills. Fransella (1985) - self characterization of individual as a stutter
KUNNAMPALLIL GEJO JOHN MASLP

Recovery from stuttering:

There has been considerable debate about the nature of recovery from stuttering, especially from its chronic form. (Coregory, 1979). Much of this debate appears to have been fueled by the long held belief that complete recovery is unlikely, if, not impossible, when stuttering persist beyond childhood. There are views that elimination of stuttering, even if it was possible, is a baseless outcome because reactions to stuttering, such as fear and avoidance are the most weakening features of disorder and thus a full recovery is possible only if these problems are alleviated. (Manning 2001).
KUNNAMPALLIL GEJO JOHN MASLP

Assisted and unassisted recovery from stuttering:

A complete understanding of individuals who recover from stuttering because of treatment and those who recover without treatment is critical to be complete understanding of the nature and treatment of stuttering. The patterns of recovery have important implications for stuttering treatment because they would provide clinicians and clients with empirically based treatment goals and realistic expectations for treatment outcome.

KUNNAMPALLIL GEJO JOHN MASLP

 Finn (1997) found speech quality differences in adults who have recovered relatively late in life as compared to controls who had never stuttered. However these differences are not found among children who had apparently recovered without assistance.

These findings indicate that there seem to be a higher likelihood that speech performance will differ from normal for those who recover in adulthood, as opposed to those who recovered in childhood. Such a finding suggests that stuttering recovery may have interaction with neural plasticity and from a number of other problems.
KUNNAMPALLIL GEJO JOHN MASLP

 There are well documented evidence of reorganization of the neural system in response to developmental and environmental demands, known as neural plasticity. Even the adult cortex is thought to undergo plastic changes during the acquisition of new motor skills. Recovery from stuttering at different ages could be controlled by or could result in different neuro-anatomic and neurophysiologic markers. i.e. children showing early, complete and lasting recovery from stuttering could be neurologically identical to those who have never stuttered whereas those recovered as adolescents or adults are predicted to continue to differ neurologically .
KUNNAMPALLIL GEJO JOHN MASLP

 Neural changes after treatment with adults has also been reported for stuttering. CBF imaging studies have been used to study the effects of treatment. Kroll and Heule (2003) studied 13 adult stuttering speakers (20-25 years) and 10 controls. The stuttering speakers received an intensive version of an established prolonged speech program. They reported that the initial lateralized bias (to the right hemisphere) for some areas shifted as subjects first completed intensive therapy and subsequently the maintenance phase.
KUNNAMPALLIL GEJO JOHN MASLP

 Neumann et al (2003) similarly studied 5 adult male stuttering speakers treated by prolonged speech. Using fMRI, they found that the over activations immediately after therapy were more wide spread and more bilaterally distributed than before. And At follow up, the majority of the over activations had shifted back to the right hemisphere, but remained still more wide spread than before therapy.

Thus, Ingham, Finn and Bothe (2005) suggest that those who have recovered could constitute a behavioral, cognitive and neurophysiologic benchmark for evaluating stuttering treatment for adolescents and adults, while helping to identify the limits of recovery from a persistent disorder
KUNNAMPALLIL GEJO JOHN MASLP

Based on the research findings on the hemispheric studies and neuro linguistic explanations on stuttering and brain models, Webster (1998) made the following observations:

Modern concepts of brain organization indicate clearly that , not only is brain activity the origin of the behavior, thought and feelings, but behavior , thought and feelings are themselves in part the origin of brain activity. When speech motor control processes are brought under voluntary control through the deliberate and systemic use of stuttering modification and fluency shaping techniques, inevitably brain activation is being focused more in the left hemisphere motor systems and probably the supplementary motor area in particular.

KUNNAMPALLIL GEJO JOHN MASLP

 When cognitive or behavioral technique are used to bring fears under control and counter tendencies to avoid social and speaking situations, inevitably right hemisphere activation is being kept under control. As clients practice their skills and become more proficient in an ever broadening range of social and speaking situations, the skills become more automatic and require less concentration. With the maintenance of this skill, altered state of brain activation will also become more automatic.

KUNNAMPALLIL GEJO JOHN MASLP

Predictive factors of persistence and Recovery in children:

Differentiating between beginning stutters who are at risk of developing a chronic disorder and those who are likely to recover has been a central objective of investigators. According to Van Ripers (1971) differentiation system, early symptomatology dominated by repetitions has a favorable prognosis for recovery but if blocks and prolongations dominate, chronic stuttering is likely.

Yairi et al (1996) indicates that language indexes, non verbal performances, phonological skills, genetics and disfluency characteristics may all contribute to the prediction of persistent stuttering
KUNNAMPALLIL GEJO JOHN MASLP

Age: one predictive factor is the effect of age of onset. A later age of onset inturn may be related to slower language / phonologic development.

Disfluencies: Disfluencies become more reliable predictors after 7 to 12 months post onset. Considering the high rate of recovery during the early months of stuttering, which continues until at least 15 months post onset, this time period is an important indicator of chronicity or recovery.

KUNNAMPALLIL GEJO JOHN MASLP

 Durational characteristics: the time interval between single unit repetitions could emerge as a reliable predictive factor around 13 to 18 months post onset of stuttering.

Phonology, language and Non Verbal skills: it has been reported that chronic stutters perform poorer than do recovered stutteres on phonology, language and non verbal skills. Phonological skills may be below age norms at very early stages of stuttering in children with the potential of becoming chronic. Thus , this parameter may be especially useful for children who are being evaluated soon after onset

KUNNAMPALLIL GEJO JOHN MASLP

Relapse and its prevention:

The term relapse is not well defined because it covers all forms of client regression from occasionally stuttered words to the resumption of speaking patterns to pre-therapy patterns . Silverman (1992) reports fewer than 50% of older children and adults who acquire normal sounding fluency during treatment are able to maintain fluency permanently. Martin (1981) - roughly one third of PWS appeared to achieve lasting fluency, about a third relapsed significantly after treatment and the remaining third either dropped out of therapy before completion or were not available for follow up evaluation.
KUNNAMPALLIL GEJO JOHN MASLP

However, it is reported that relapse rate in whatever way being measured, appears to be much lower for preschool aged children (Starkweather, 1990).

Craig and Calver (1991) found that the majority of those who had suffered relapse related it to feeling under pressure to talk faster while others reported it due to embarrassment to use the new speech patterns. It is suggested that maximum regression occurred with in the 6 months post treatment and there is a need to follow up clients for 2-5 years period following treatment .

KUNNAMPALLIL GEJO JOHN MASLP

Some of the factors related to relapse include:

slow decay due to similar stimuli encountered outside clinical set up which are not taken care of during therapy failure to practice . genetic factors. chronicity and severity of the problem. neuro physiological loading in terms of demands (internal and self imposed) exceeding the capacities of the individual.

KUNNAMPALLIL GEJO JOHN MASLP

inadequate assumptions of responsibilities by the client. attitude change. lack of motivation and interest
inadequate or insufficient guidance and treatment with regard to establishment, transfer and maintenence. achievement of false fluency. self efficacy doubts. poor self monitoring and self correction strategies. Dissatisfaction with the new methods of speaking introduced in therapy. Boredom
KUNNAMPALLIL GEJO JOHN MASLP

Possible causes of relapse:

Egan (1998) briefly discusses the idea of entropy i.e. the tendency of things to break down or fall apart. Applied to humans who are attempting to change, this may be thought of as the tendency to give up actions that have been initiated. The stutters may grow tired of talking with the intense concentration that the new way requires. Normal speech is free and spontaneous, as nearly all stutters know from their own periods of normal speech. Sometimes the targets that are so easy to achieve in the clinical environment are completely inaccessible when the situation is difficult

KUNNAMPALLIL GEJO JOHN MASLP

Silverman (1981) suggested a number of possible reasons for relapse.

Clients who are especially likely to relapse are those who, following treatment, believe themselves to be cured believing they have experienced a cure, they are less likely to continue the rigorous process of self management. Other clients may regress as they come to lose confidence in the treatment program. This is more apt to occur if they have experienced relapse following previous treatment experiences.

KUNNAMPALLIL GEJO JOHN MASLP

 Neurophysiological Loading:
Several authors have suggested that some of the individuals with stuttering possess an underlying physiological or neurophysiological condition. Clients with genetic loading who have a family history of stuttering may have a greater chance of relapse (Sheehan and Martyn, 1996, Cooper et al, 1972). Starkweather (1990) suggested, the demand placed on the persons capacities to produce speech, fluency break will be apt to occur. Treatment techniques must focus on enabling the clients to maintain appropriate self management abilities to compensate for the demands placed on the speaker and the persons capacities to produce speech.
KUNNAMPALLIL GEJO JOHN MASLP

Client Adjustment to a new role:

As proposed by theories such as Personal Construct Theory, in many important ways , the speaker must evolve as a person beyond an individual who stutters, and form a new paradigm, a new view of himself and his possibilities.

As Dalton (1987) explains, the speaker makes a choice to stutter, not because he prefers to do so, but because it is what is familiar and consistent with how he understands his world.

KUNNAMPALLIL GEJO JOHN MASLP

 Kuhr and Rustin (1985) found evidences of minor depression in several fluent speakers during maintenance following formal treatment. Clients may state that they are not as comfortable as they thought they would be with their fluency. From the perspective of PCT, even when fluent, the speaker is attempting to gain evidence of support for their new construct of themselves and their world.

KUNNAMPALLIL GEJO JOHN MASLP

 Speaking in a non-habitual manner:

It has been argued by several clinicians that treatment programs that bring about increased fluency by encouraging the person to speak in a nonhabitual manner tend o have only a temporary impact on a speakers fluency. (Bloodstein 1949, Boberg 1986 and Van Riper 1990). Changes in habitual speech production are difficult to change in the long term. It takes concentration and a great deal of effort to maintain what are clearly nonhabitual, respiratory, phonatory and articulatory patterns. Some speakers are found to maintain their altered ways of producing speech. For others, use of their altered patterns eventually wears off.

KUNNAMPALLIL GEJO JOHN MASLP

 Combinations of variables hold more promise of predicting long term fluency.

Relapse was shown to be related to a combination of variables such as pre treatment severity, speech attitudes, personality variables, locus of controls and self help factors. The other factors that needs to be explored are clinician-client relationship, the influence of marital stability, the influence in the possible differences in the stuttering subtypes, the influence of extremes in the socio-demographic factors such as age, education and unemployment.

KUNNAMPALLIL GEJO JOHN MASLP

 All these factors have to be taken care of in achieving better outcome and maintenance of fluency in PWS. Achieving good, natural sounding speech and motivating the individual and his parents the need for good practice, maintaining diary or daily log of goal related activities and bringing out the necessary attitude change in the PWS and significant others in his environment is very crucial.

KUNNAMPALLIL GEJO JOHN MASLP

Journal articles

KUNNAMPALLIL GEJO JOHN MASLP

Adults recovered from stuttering without formal treatment: perceptual assessment of speech normalcy. JSLHR vol 40, 1997 Author: Patrick Finn

Purpose of this study was to determine if the speech of adults who self-judged that they were recovered from stuttering without the assistance of treatment is perceptually different from that of adults who never stuttered. (in terms of speech naturalness and speech variables as rate and fluency)
KUNNAMPALLIL GEJO JOHN MASLP

 Method:

2 groups of adults participated in the study; 15 adults recovered from stuttering (URS) without assistance and 15 normally fluent adults.
All speakers were video taped performing a five 10 minute monologue on a self generated task.

URS speakers underwent a 2 step procedure independent verification and self report evaluation.
KUNNAMPALLIL GEJO JOHN MASLP

As reported by the URS speakers, the factors that led to recovery were: Speech formulation Speaking slowly Speech breathing.
Judges viewed video taped speech samples of all speakers and were instructed to decide whether a speaker used to stutter or never stuttered.

KUNNAMPALLIL GEJO JOHN MASLP

Results: It revealed that the speech of speakers who used to stutter was perceptually different from that of speakers who never stuttered. This difference was correlated with un natural sounding speech and a high frequency of part word repetitions. Speech rate was also found to have contributed to un- naturalness.

KUNNAMPALLIL GEJO JOHN MASLP

Relapse following treatment of stuttering: a critical review and correlative data. JFD 2(3) 1998
Author: Ashley Craig Aim: to provide a critical review of data based research in which relapse after treatment for stuttering. Method: stuttering was investigated in either children or adults and also to provide correlative data involving long term predictors of relapse in 4 adult groups treated for stuttering.

KUNNAMPALLIL GEJO JOHN MASLP

 Conclusions: a critical review of research into relapse suggests that, there is no single major course for failure to maintain treatment gains. Pre treatment severity has been shown to be a consistent but weak predictor of fluency outcome. Generally, greater the severity, higher the vulnerability to relapse.

KUNNAMPALLIL GEJO JOHN MASLP

Predictors of stuttering relapse one year following treatment for children aged 9-14 years: the relation between attitude change and long term outcome. JFD, vol23, 1998 Author: Hancock K; Craig. A. In order to enhance our understanding of the relapse process, the present studys process was to investigate predictors of relapse in older children

KUNNAMPALLIL GEJO JOHN MASLP

 Method: subjects were 77 children and adolescents aged 9-14 years who were diagnosed as having stuttered for at least one year. All successfully participated in treatment and were assessed 12 months later. Possible determinants investigated consisted of pre and post treatment factors, including demographic variables, severity of stuttering and anxiety levels. A standard regression analysis isolated factors that predicted the likelihood of relapse.

KUNNAMPALLIL GEJO JOHN MASLP

 Results: Only pre treatment stuttering frequency measured by percentage syllables stuttered and trait anxiety post treatment significantly predicted stuttering frequency one year post treatment. Those having severe stuttering before treatment and who were less anxious immediately post therapy were those susceptible to higher levels of stuttering in the long term. Although frequency of stuttering is not an exhaustive measure of relapse, the present study offers an elementary ability to predict those children at risk of relapse following successful treatment.

KUNNAMPALLIL GEJO JOHN MASLP

THANK YOU

KUNNAMPALLIL GEJO JOHN MASLP