ACQ Vol 12 no 1 2010

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.

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ACQ Volume 12, Number 1 2010

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