ACQ Vol 12 no 1 2010

It is imperative to identify those clients who are likely to respond to simple behavioural treatments. Onslow (1993) stated that adults typically have advanced stuttering which is less responsive to intervention, less variable without remission, and does not recover without treatment. However, certain client characteristics may indicate the use of simple behavioural treatments. These include that a trial results in a reduction of stuttering, the client has mild stuttering and/ or occasions when speech is stutter-free, or as Hewat et al. (2006) conclude, the client has had previous speech restructuring treatment. Treatment choices are based on evidence in the literature as described. However, clinical skill is required to select the best treatment option for each client. This is done on a case-by-case basis in consultation with the client. Case studies Three retrospective adult/adolescent clients were treated with simple behavioural treatments at the Stuttering Unit, Bankstown Health Service. The treatments were self- imposed time-out, prompts to reduce rate and training to access existing fluency techniques. Treatment was conducted as part of a routine clinical caseload in a one-hour weekly format. Characteristics of clients Client characteristics are summarised in table 1. For all clients, case history factors were identified at assessment which indicated that the stutter might respond to simple behavioural therapy. Outcome measures Treatment outcomes are described using clinician and client speech measures, collected within-clinic and beyond-clinic. These measures are percentage of syllables stuttered (%SS) and severity ratings (SR). The SRs are based on a scale 1–10 (1 = no stuttering, 10 = extremely severe stuttering). SRs have been shown to be a reliable measure of stuttering (O’Brian, Packman & Onslow, 2004).Clinicians collected %SS at most clinic visits and during some beyond-clinic telephone calls. Clients rated their stuttering severity daily beyond-clinic using the severity rating scale. The reliability of these measures was monitored in the weekly clinic visits by comparing them with the clinician’s ratings. The goal of treatment for the three clients was to reduce stuttering to a sustainable level. Goals were negotiated with each client and regularly reviewed to ensure they were optimal and achievable. As is common clinical practice, clinicians problem-solved any treatment issues that arose. When they had attained consistent speech measures that met their specified speech targets and had showed stability,

clients completed performance-contingent maintenance based on that described by Harrison, Onslow, Andrews, Packman, and Webber (1998). That is, they attended clinic visits with increasing time intervals between them when they met the speech criteria. If they did not meet speech targets at any visit, progress through maintenance was halted until they did. The treatments Treatment 1. Self-imposed time out (SITO) Two cases using SITO as the primary treatment technique are outlined. SITO was implemented in a non-programmed format. The first client (C1) also incorporated the strategy of accessing his own existing fluency techniques as he was prompted to “try not to stutter”. The second client (C2) was exposed to elements of PS to elicit further progress when he had plateaued.

5 4 3 2 1 0

C1

C2

C3

% syllables stuttered

Final mtn

1 2 3 4 5 6

Clinic visit

Figure 1. Within-clinic measures for C1, C2 and C3

Client 1 (C1) C1 was frustrated with his stutter. He had stuttered since he was young but had not had therapy as an adult. He stuttered most on the telephone, when talking to business people, and when speaking with his father. At assessment, a severe stutter was evident (see table 1). He presented with SR 8, but this was reported as his most severe stuttering. Typically his SRs were reported to be 2–3 although he had periods most days when stuttering severity increased. During therapy trials at assessment when C1 was instructed to “try not to stutter” his SRs reduced from 8–9 to 3. When SITO was trialled in conversation by instructing C1 to stop talking for several seconds when or before he stuttered, he stopped stuttering. During those trails C1 reported that he was “speaking properly” and talking with “slow and pronounced speech” to control his stutter. C1’s initial therapy visit was one month later. His speech was rated at SR 7 and 3.9%SS within the clinic. Stutters consisted of audible inspirations and multiple repetitions.

Table 1: Client characteristics

Client

Age at initial Language/s

Severity at assessment

Types of stutters

Previous therapy?

therapy visit

C1

39

English

SR 8. Reported representative of

Multiple repeated movements with During primary school;

worst rating; typically much lower tension and deep breaths with

no therapy as an adult

raised shoulders

C2

15

English, Serbian 3.8%SS, SR 4. Typical SR 3

Repeated movements, fixed postures No with and without audible air emission and verbal superfluous behaviors

reported

C3

29

English, Chinese, 1.8%SS, SR 3. Reported SR 4–5 Initial syllable repeated movements No Vietnamese at worst and some fixed postures without audible air emission

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ACQ Volume 12, Number 1 2010

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