ACQ Vol 12 no 1 2010

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ACQ Volume 12, Number 1 2010 23
C3 waited 3 months for treatment. At his first
appointment, he was able to reduce stuttering severity
from 2.5%SS (SR 3) to 1.7%SS with an instruction to “try
not to stutter”. When prompted to “slow down” severity
decreased further to 1%SS. Additional prompting to “slow
down” resulted in a further reduction in severity (0.3%SS).
Initially, C3 was advised to use this strategy of thinking about
slowing down in one situation per day. He collected daily
SRs which were used to monitor progress. For the next three
weeks he practised 10–15 minutes daily with his girlfriend.
After that he applied the strategy to actual conversations.
Severity reduced by the second clinic visit and gradually
improved over four weeks within-clinic (see figure 1) and
beyond-clinic (see figure 4). Speech rate reduced initially
but was not assessed regularly so it is unclear whether C3
actually slowed down to control his stutter. Despite this, the
instruction for him to “slow down” was sufficient for him to
become more fluent.
C3 attended 5 clinic visits over seven weeks. At the final
therapy visit, measures were 0.5%SS and SR 2. Beyond-
clinic SRs were 2s, representing occasional single part-
word repeated movements that were difficult to detect.
C3’s speech fluency was stable and he stated that he
was pleased with his treatment outcome. C3 completed
performance-contingent maintenance over 10 months. At
the final maintenance visit measures were 0.5%SS and SR
2. Reported severity ratings beyond clinic were 2s with no
fixed postures. As shown by this case study, a prompt to
“slow down” was an effective treatment for this adult.
Discussion
Behavioural treatments are a clinical option worthwhile
considering. All clients achieved their goals with efficient use
of clinician and client resources. Clients were not required to
use an unnatural speech pattern. Speech naturalness is
usually measured with complex treatments and resulting
speech can sound unnatural (Onslow, 1993). Anecdotally,
treating clinicians have reported that the clients in this paper
did not have unnatural-sounding speech although this was
not formally assessed.
Clients completed the weekly phase of treatment in 6,
6 and 5 visits respectively. This is less than the minimum
number of hours required to complete the instatement phase
in any of the documented intensive programs which is 20.1
hours for the Camperdown Program (O’Brian, Onslow,
Cream, & Packman, 2003) and 24 hours for Harrison et al.’s
(1998) one-day intensive. All clients successfully completed
a lengthy maintenance program (12, 15 and 10 months
respectively).
These case studies highlight that it is possible and
appropriate to treat some adults with simple behavioural
treatments. Although it is not known how many adolescent
or adult clients will respond, such treatments can be effective
and efficient. Using the evidence both in the literature and
from case history, treatment for each client was selected
using the simplest treatment that was effective and suitable.
A simple prompt not to stutter was trialled, followed by either
prompts to “slow down” or SITO depending on case history.
With measurements used to monitor progress speech
pathologists implemented simple behavioural treatment and
monitored its impact on the stuttering of clients.
Simple behavioural treatment is not suitable for clients
who are unable to gain control of their stutter without
direct speech restructuring. However, further research
is warranted as there are clients who respond to simple
behavioural treatments. Although these case studies had
C2’s stuttering severity reduced within the first week
of treatment and gradually improved over several weeks
within-clinic (see figure 1) and beyond-clinic (see figure 3).
C2 was taught soft contacts and gentle onsets (components
of PS treatment) for certain sounds in visit 4 as he reported
difficulties restarting on particular sounds. He was advised
to use these if needed to control his stutter, but PS elements
were not prompted for again during his treatment.
C2 attended 6 clinic visits over eight weeks. At his final
therapy visit, measures were 0.1%SS and SR 1. Beyond
the clinic SRs were all 1s for the week preceding the visit.
Performance-contingent maintenance was completed over
15 months. At his final maintenance visit, measures were
0%SS and SR 1. C2 reported severity ratings beyond the
clinic of 1–2, but mainly 1s.
As shown by these two cases studies, SITO was an effective
treatment. However, C1 used elements of self-control after
having been prompted to “try not to stutter” and C2 was
exposed to some elements of prolonged speech in one clinic
visit. It is not clear how much these additional strategies
contributed to the outcomes.
Treatment 2. Prompting to “slow down”
The following clinical example is a client who was treated
with a prompt to “slow down”.
Client 3 (C3)
C3’s stuttering severity had varied since onset and was at its
worst when he was a teenager. At the time of his initial clinic
visit, C3 stated that stuttering severity increased when he felt
anxious. He also reported avoiding interacting in some social
situations due to his stutter. He reported controlling his
stutter by breathing slowly, avoiding words, and “taking his
time”.
Client C3
Figure 4. C3’s severity rating chart (Key: o = % within-clinic SS,
• = beyond-clinic SR)
At assessment, baseline measures were 1.8%SS and SR
3. This was apparently typical, but his severity could increase
to SR 4–5. C3 stated that he had 2–3 second fixed postures
without audible air emission about once per fortnight. His
goals were to reduce his stuttering severity and to reduce
his rate, as C3 was concerned that he was sometimes
unintelligible as a result of talking quickly.