Efficacy of Stuttering Therapies

8/7/2019 Efficacy of Stuttering Therapies

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Efficacy Of Stuttering

TherapeuticTechniques


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Efficacy is the extent to which a specific

intervention procedure, regimen or serviceproduces a beneficial result under ideallycontrolled conditions when administered ormonitored by experts (Last, 1983).

Otswang (1990)

Treatment effectiveness (does treatment work)

Treatment efficiency (does one treatment work

better than other) and Treatment effects (in what way does the

treatment alter the behavior)


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Van Riper (1973), Andrews and Ingham (1972)and Sheehan (1984)

1. The method must be shown effective with anample and representative group of stutterers.

2. Results must be demonstrated by objectivemeasures of speech behavior such as frequency

of stuttering or rate of speech and by judgesrating of severity. Such measurements shouldbe made before, during and after treatment byobservers.


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3. Reports of therapeutic success must be basedon repeated evaluation and adequate samplesof speech.

4. Improvement must be shown to carryover tospeaking situation outside the clinical setting.The best known but frequently ignored fact

about stuttering is that is the specialenvironment of clinic stutterer are likely tobecome normal.

5. The stability of result must be demonstrated by

long-term follow-up investigation. The follow-up evaluation is likely to be biased if it is donein the same clinical environment in whichtreatment was administered.


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6. Suitable control groups or control conditionsmust be used to show that reductions in

stuttering are the result of treatment. There areother variables besides adaptation to theclinical setting that may create a falseimpression of successful therapy.

7. Subject must sound natural and spontaneous tolustiness. Residual element of slowness,monotony or stereotype in the subjects speechmay seen more peculiar to listeners that thestuttering itself.


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8. Subjects must be free from necessity to monitortheir speech though fluency can hardly be

considered normal as long as continued attentionon part of speakers is required to maintain it.

9. Treatment must remove not only stuttering butalso fear, anticipation and persons self concept as

a stutterer.10.Success of a therapy program should not be

conflated by ignoring drop out. The problemspresented by stutterers who dropout of treatment

has been pointed out by Martin (1931). Estimatesof the improvement during therapy are oftenbased exclusively on those who complete clinicalprogram.


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1. Perceptual Measures

2. Acoustic Measures

3. Cognitive, Pharmacological, Behavioral andother related approaches


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a. Frequency Measures

Frequency measures are calculated in terms of percentage of

syllables / words (%SS or %WS) usually. In order to obtain%SS or %WS scores, the number of syllables / words iscounted along with the number of words / syllables that arestuttered. For outcome research frequency measure is mostacceptable because large differences are of interest. Thefollowing table shoes the results of various studies that used

percent of dysfluency as a measure to depict the outcome ofprolonged speech procedure, gentle phonatory onset, andsmooth flow of speech. The Results of all these studiesindicate that the post-treatment mean percent dysfluencyreduced significantly to less than 5%, which is considered asnormal.


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Author No. Of

Subjects

Age of

Subjects

Duration of

Treatment

Results

Spencer (1976) 5 Adults

and

children

4 months Stuttering was reduced to less

than 1% of syllables

Boberg (1976) 21 17 44 3 weeks Stuttering decreased from mean

of 21% of syllables to 1.3%

Franck (1980) 68 Mean of

20.2

years

1 year 95% of subjects increased

fluency by 60% or more

Prolonged Speech


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Boberg (1980) 6 16 - 46

years

3 weeks Mean percent syllables stuttered

decreased from 16.55 or more

Howie, Tanner &

Andrews (1981)

36 Adults 3 weeks Stuttering was virtually

eliminated

Eveshen and

Huddles (1983)

47 Adults 3 weeks 91% stuttered on less than 1% of

syllables

Boberg (1984) 12 18 -47

years

2 weeks Mean percent of stuttered

syllables decreased from 18.9 to0.9


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Author No. Of

Subjects

Age of

Subject

s

Duration

of

Treatment

Results

Webster (1975) 56 8-59

years

3 months Significant difference in pre-post

treatment

Schwartz and

Webster (1977)

29 9-50

years

3 weeks 97% improved, 72% stuttered on

6% or less of words

Webster (1980) 200 3 weeks Mean percent of words

decreased from 15.1 to 1.3

Mallard and

Kelly (1982)

50 14-50

years

6 weeks Mean percent of words fell from

20.05 to 2.92


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Schulman

(1983)

85 6-65

years

4 weeks 84% achieved normal or near-

normal fluency in

conversation

Franken,

Bover, Peters

and Webster

(1992)

32 15-46

years

3 weeks Mean % of stuttered syllables

declined from 25.7 to 5.8

Onslow, Costa,

Andrews(1996)

12 10.7-

41.6years

3 weeks Within clinic and beyond clinic

% SS reduced generally tonear zero


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The adjective natural is derived from the Latinword naturalis, meaning of nature.

The needs for studying speech naturalness of

individuals treated for stuttering came fromobservations that though the frequency ofstuttering decreased, listeners found that manyspeakers continued to sound unnatural.

Their speech was effortful, uncomfortable tolisten to, and contained auditory or visualfeatures that prevented listeners from fullyattending to the content of message


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Author No. Of Subjects Age of

Subjects

Results

Ingham and Packman

(1978)

9 adolescents and

adults compared with

9 age matched

normals

13-24 Listeners ratings of naturalness

of clients recived significantly

fewer normal speaker judgments

Martin et al, 1984 10 adults withoutDAF

10 adults with DAF

10 normals

20-5320-51

21-45

Both group of stutterers soundedless natural than the normals

Ingham and Onslow

(1985) 9 point rating

scale for speech

naturalness

5 Adolescen

ts

Predicatble trends in speech

naturalness

Stutterers speech naturalness

could be modified to targeted

levels


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Ingham, Gow & Costello

(1985), 9 point rating

scale of martin

!5 stutterers and 15

normals matched

for age and gender

Mean naturalness rating if 4.26

for stutterers and mean value of

2.39 for non-stutterers

Metz, Sxhiavetti, Sacco

(1990) 9- point rating

scale

15 males, 15

females

Mean

14.5

years

Strategies like gentle voicing

onset and prolonged speech may

slow the post therapy speech

patterns and the may influencelisteners to judge speech of

stutterers to be more unnatural

Onslow, Hayer and

Newman (1992)

Considered the effect of

severity on pre and post

treatment naturalness

ratings

36 9-50

years

Most severe clients speech prior

to treatment and naturalness

scores more than 2 values higher

(less natural) than least severe

clients.


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Onslow, Adam and Ingham,

1992 compared the influence

of monologue and

conversation speech. 9

point rating scale

7 male stutterers and 7

normals

14-36 years No significant differences in the

naturalness scores of conversation

/ monologue for either stutterers

or normals

Martin and Horoldson, 1992

studied visual components of

stuttering related to speech

naturalness judgements used

9-point rating scale

6 males and 4 females

(stutterers)

6 males and 6 females

(normals)

20-62 years

21-64 years

Naturalness judgments of fluent

speakers were not significantly

different for audio and audio-

visual samples on rating scale

(2.3-2.7 respectively) but

audiovisual samples were judged

to be more unnatural than audio

only

Finn and Ingham, 1994

(Stutterers self rating of

naturalness)

11 males and 1 female Adults (19-

71 years)

Stutterers gave valid self ratings of

speech quality and were

consistently able to differentiate

how natural their speech were


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Other naturalness rating scales were developed bySubramaniam (1997) and Kanchan (1997).

Subramaniam scale included confidence,command over language, clarity, speed ofstuttering and overall rating.

It was a binary scale for both natural and

unnatural items. Kanachns scale was also a binary one which

included rate, continuity, effort, stress, intonation,rhythm, articulation, breathing pattern and overall

rating. Currently the 9 point scale developed by Martin

et.al 1984, has been widely used and reliable foreither oral reading or spontaneous speech


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Ideally the speech samples should be obtainedunder multiple conditions and on multipleoccasions (Conture, 1996).

Speech measures should be collected without

clients knowledge that their speech is beingevaluated so that they do not react to beingassessed and try to create a favorable outcomeand speech outcome measures should reflect

everyday speech performance free from stimuluscontrols.

The following table summarizes assessmentconditions used in prolonged speech therapy

technique


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Author N Stuttering

Severity

Speech

rate

Speech task Freq of

Assessment

Situation Nature

Andrew and

Ingham,

1972

23 %SS SPM Monologue 4 times in 18

months

Within

and

beyond

clinic

Overt

and

covert

Howie,

Tanner and

Andrews,

1981

36

43

%SS

%SS

SPM

SPM

Phone

conversation

in both

groups

Twice in 9

weeks

Within

and

beyond

clinic

Overt in

both

conditio

ns


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Webster,

1980

200 % of

dysfluenci

es

- Reading,

conversation

on phone

Twice in 10

months

Within

and

beyond

clinic

-

Boberg,

1981

16 %SS - Reading,

conversation

on phone

3 times in 12

months

Within

and

beyond

clinic

-

Andrews

and Feyer,

1985

37 %SS SPM Phone Twice in 12

months

Within

clinic

-


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Andrews

and Craig,

1988

84 %SS SPM Phone Twice in

18months

Within

clinic

Overt

Boberg

and Kully,

1994

42 %SS SPM Phone 4 times in

24 months

Within

clinic

Overt

Many of the Speech outcome data are based on person withinclinic situations / telephone calls from staff in clinic, where

the clients may be able to control their stuttering with apronounced speech pattern that cannot be used in everyday

speaking situations


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In a literature review of current clinical statusof fluency following treatment for stuttering,Boberz and Kully 1985 concluded that though

the treatment procedures such as prolongedspeech may reduce / eliminate stuttering, thelong term effects were not satisfactory.


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Author Method N Age Duration

of

treatment

Results Follow-up

interval

Results

Webster

(1980)

Prolonged

speech

200 - 3 weeks Mean % of

stuttered

words

reduced

from 15.1 to

1.3

Mean of

10 months

Mean % of stuttered

words was 3.2

Boberg

(1981)

Prolonged

speech

6 16-46

years

3 weeks Decreased

from 16.55

or more

12 months Mean % of stuttered

syllables of 8 subjects

was 1.53 at end of 12

months maintenance

period


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Honie, Turner and Andrews,

1981with

Prolonge

d speech

36 Adul

ts

3 weeks Stuttering

virtually

eliminated

in 5subjects

2 months Little significant

deterioration

Mallard and Kelly, 1982 Gentle

phonator

y onsets

50 14-

50

3 weeks Mean % of

stuttered

words fell

from 20.05

to 2

At least 6

months

Mean % of

stuttered words for

28 subjects was

9.74

Heller, Schulman, Teryak,

1983

Gentle

phonator

y onsets

85 6-65 6 weeks 84%

achieved

normal to

near

normal

fluency in

conversati

on

6 months

to 5 years

80% maintained

their post treatment

fluency levels


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Craiz and Andrews, 1988 Smooth

flow

speech

17 Adul

ts

3 weeks Mean %

declined

from 12.9-

0.9

10

months

Mean % stuttered

syllables was 1.9%

Andrews and Feyer, 1985 Smooth

flow

speech

37 21-

60

3 weeks Mean %

declined

from 14.1-

0.1

10-15

months

Mean % stuttered

syllables was 1.1%

Frank et al, 1922 Gentle

phonator

y onsets

32 15-

46

4 weeks Declined

from 25.7

to 5.8

6 months Mean % stuttered

syllables was 16.3%

Boberg and colleagues, 1987 Prolonge

d speech

16 3 weeks 12-16

months

Mean % was 6.38

outside clinic, 1.86

in reading, 2.54

conversing

strangers


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The use of a novel speech pattern to eliminate stuttering isa speech motor adjustment, and temporal aspects ofmotor activity are reflected in temporal pattern of acousticactivity (Bover 1987, Cent 1999).

Discovery of functional acoustic components of speech

patterns could lead to development of more cost and timeeffective treatments for advanced stuttering (Onslow andIngham, 1989). Ingham in 1983 highlighted that stutteringcould be reduced with the use of acoustic data feedback.

Many other problems and issues could be resolved withthe discovery of functional acoustic components of

treatments based on prolonged speech. But it is unclear which acoustic feature of speech patterns

in these treatments has a functional relationship tostuttering frequency. Additionally these patterns may besimilar / different across subjects.


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Authors Treatment Procedure No. Of

subjetcs

Acoustic analysis Results

Metz et.al,

1979

Instructed to slowly

initiate phonation and

maintain a forward flow

of air and reduce

articulation rate

9 Increased duration

for both vowels and

stop consonants

increased

Indication that stuttering

therapy could alter certain

acoustic properties of stutters

fluent speech

Metz et.al,1983

Examined relationshipsbetween acoustic

variables and fluency

within a group of mild to

severe stutterers

12 males, 5females

Analysed CVCduration, VOT,

absolute time of

frication, voicing

and silence

associated with

intervocalic

intervals of both

voiced and voiceless

stop consonants

Decrease in stutteringfrequency,

Increase in voiced and

voiceless VOT duration,

Increase in frication duration,

Voicing duration and no

significant change in silence

associated with intervocalic

intervals


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Mallard and

Westbrook,

1985

Precision Fluency

Shaping Program (PFSP)

26 Analysed vowel

duration changes

and also phrase

duration

y On an average persons with

stuttering increased vowel

duration.

y Vowel duration decreased

as stuttering moved from

initial to final part of phrase

Mohan

Murthy

(1987)

Investigated acoustic and

aerodynamic measures of

/g/ before and after

modified airflow

techniques and soft

contacts

One, 17 year

old subject

y Presence of atypical

transitions

y Inappropriate voicing and

duration of segments

inspiratory frications

y Articulatory fixations

y Abnormal articulatory

constrictions

y Longer closing phases on

Lx- excessive vocal

adduction


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Franken,

Bover, Peters

and Webster,

1991

Precision Fluency

Shaping Program (PFSP)

Men of 32.4

years

Prosodic features Decrease in expressiveness

Onslow, Van

Doom,

Newman,

1992

Prolonged speech School aged

children

VOT, Voice

duration, and

interphonation

interval

Decreased variablility in vowel

duration

Madhavilath

a, 1997

Instruction to initiate

intonation patterns

depicting emotions such

as anger, surprise,

sarcasm, command,

question and statement

1 normal

(model), 10

stutterers

Analysis of

different intonation

patterns

perceptually and

acoustically

Reduced Fo range and longer

sentence duration in stutterers,

also other frequency and

amplitude parameter

Ananthi,

2002

Prolongation therapy 1 normal

(model), 10

stutterers

Analysed word

stress, word

duration, peak Fo,

Lowest Fo and Fo

range

No significant difference in

stress and word duration


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Electromyographic Feedback (EMG)

The subjects were provided with visualfeedback about selected muscle activity.


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Authors Age Stuttering Frquency

< 5%

Social, eotional or

cognitive variables

improved

Post

Treatment

At 6

months

Follow-up

Post

Treatment

At 6

months

Follow-up

Craiz &

Cleary,1982

10-14

years

Yes Yes - -

Graiz et.al

, 1996

9-14 years Yes Yes Yes Yes


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A program which progressed from 1 wordresponse to oral reading, monologue and

concersational tasks mainly worked out withchildren.


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< 5%

Social, eotional or

cognitive variables

improved

Post

Treatment

At 6

months

Follow-up

Post

Treatment

At 6

months

Follow-up

Ryan and

Ryan,

1983

7-18 years Yes Yes - -

Ryan and

Ryan,

1995

7-17 years Yes Yes - -


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< 5%

Social, eotional or

cognitive variables

improved

Post

Treatmen

t

At 6

months

Follow-up

Post

Treatmen

t

At 6

months

Follow-up

Ost et.al,

1976

14-46

years

No No No No

Metronome conditioned speech retraining:


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Prolonged Speech

Authors Age Stuttering Frquency < 5% Social, eotional or cognitive

variables improved

Post

Treatment

At 6 months

Follow-up

Post

Treatment

At 6 months

Follow-up

Craiz

et.al,

1996

9-14 Yes Yes Yes Yes

Howie et

al, 1961

21+ Yes - Yes -

Ingham,

1982

18 -20 Yes - - -


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Ingham

and

Andrew

s, 1973

18-56 Yes - - -

Ingham, 2001

18-28 Yes - - -

Ingham

andPackma

n, 1977

42 Yes Yes - -


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James et.

Al, 1989

34 Yes Yes Yes Yes

OBrian et.

Al, 2003

1759 Yes - - -

Onslow,

1996

10-41 Yes Yes - -

Perkins

et.al, 1974

12-52 Yes No - -


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Ryan and

Ryan, 1963

7-18 Yes - - -

Ryan and

Ryan, 1995

7-17 Yes Yes - -

Tanbaugh

and Guitar,

1961

12 Yes Yes - -


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Authors Age Stuttering Frquency < 5% Social, emotional or

cognitive variables

improved

Post

Treatment

At 6 months

Follow-up

Post

Treatment

At 6 months

Follow-up

Andrewsand Tanner,

1982a

26 No - Yes -

Andrews

and Tanner,

1982b

Adults Yes No Yes Yes

Landoucer,

1981

15-47 Yes - - -


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Landoucer

, 1982

17-74 No - - -

Landoucer

and

Martin,

1962

5-16 Yes - - -

Landoucer

and Saint

Laurent,

1986

18-36 Yes Yes No No


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Mittemberger et.al, 1996 19-27 Yes Yes - -

Landoucer and Saint

Laurent, 1987

18-50 Yes No - -

Franken, 2005 6 Yes - - -

Harrison, 1999 5 Yes Yes - -

Ingham, 1980 9-23 Yes Yes - -

James et.al, 2005 3-6 Yes - - -

Lattermann, 2005 4-5 Yes - - -


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Main indicators of therapy progress include: Increasing the clients self monitoring ability Increasing the clients ability to produce open

speech Decreasing the frequency and duration of motoric

fluency breaks Increasing the naturalness of fluent speech Metalinguistic changes

Decreased avoidance Increased (speech) assertiveness Improved self concept, self esteem and role

changes


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A basic indicator of progress is the speakers abilityto tuning tuning into what he is doing when hestutters and what he is capable of doing in order toenable himself to speak fluently.

Even if he is not able to modify his production hemay be able to accurately monitor what he is doing tomake speaking so difficult.

Accurate self monitoring of any behavior or thoughtprocess is a preparatory step toward taking

responsibility and transforming the event. Self monitoring will continue to be a critical element

of long term success. During the initial stages of treatment, the clients

monitoring is focused on the overt stuttering

behavior


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Although the focus early in treatment is on monitoringrather than the modification of stuttering events, asspeaker improves his ability to catch his behavior nearer tothe initiation of the stuttering event, some instinctive andpositive changes in the stuttering often take place.

That is the speaker will not only recognize what he isdoing to make speaking difficult, he will begin to makesome changes in the behavior.

He may provide himself with some airflow, or he may

slightly decrease a constriction in his vocal tract that willassist him in smoothening his speech. These changes are small and transient victories to be sure,

but the clinician should look for them and reward thesesubtle changes in the form of stuttering.

As Conture (1990) indicates, the clients consistentidentification at the beginning or the middle of stutteringevents sometimes becomes associated with his ability tochange his stuttering behavior.


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As treatment progresses, such self monitoringactivities continue to be pivotal for long term

progress outside the treatment environment. In addition, self evaluation also comes to mean

the monitoring of the cognitive aspects ofchange, such as the self talk the client provides

to himself prior to and following successful, aswell as less than successful, speakingsituations.


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Improvement can be observed during everytreatment session by the clinician and the client ifclose attention is paid to the form of fluency breaks.

Early in treatment the fluency breaks are typicallycharacterized by a greater degree of vocal tractconstriction and effort.

As the speaker begins to understand the nature of his

speech production system and becomes able tomodify moments of stuttering, progress can beobserved in the form of airflow, increasedsmoothness and blending of sounds and words.

Perhaps most importantly he begins to produces eech with less vocal and articulator effort.


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As he becomes able to monitor his production, especiallyvia proprioceptive feedback, he will be able to appreciatethe difference between the tension and constriction of oldway of speaking and the new flowing and effortlessproduction using an open vocal tract

The speaker as well as listener can hear the increasedopenness and ease of such speech movements.

At each such occurrence of enhanced airflow andsmoothness of articulatory of movement, there is theopportunity for the clinician to reward the progress.

The clients speech may not be completely fluent, but thechanges are obvious and satisfying. The result is a much

easier form of stuttering. As Conture (1990) suggests, a shortening in the duration

of stuttering is a sign of progress. The client is stuttering, to be sure, but it is the speech that

is produced with less effort and is much easier to listen

to.


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Decreasing the frequency of motoric fluency breaks is anobvious goal of treatment and a commonly used indicator ofprogress.

As the speech becomes more open and flowing, both the

frequency and especially the duration of stutteringmovements should show some obvious changes. It may be that the frequency of brief stuttering events may

even increase somewhat if the speaker is successful inchanging in his patterns of avoidance and wordsubstitution.

However, if the duration and associated tension in terms ofboth the degree and the sides of physical tension decreases,real progress is being accomplished.

Again, this progress will be likely to be recognized by thespeaker if self monitoring is maintained.


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The impetus for studying the speech naturalness ofindividuals treated for stuttering came from observationsthat many people who had undergone successfultreatment using fluency modification strategies continue

to sound less than satisfactory. That is although, the frequency of stuttering had

decreased dramatically, and listeners found that manyspeakers continue to sound unnatural

Their speech was effortful, uncomfortable to listen to and

contained auditory or visual features that prevented thelistener from fully attending to the content of themessage.

Despite an otherwise successful treatment experience,many speakers found that they were still regarded by

themselves and others as having the problem.


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In 1984, Martin, Haroldson and Triden began the development of areliable scale for rating speech naturalness.

The scale consisted of a 9-point rating scale with 1 equivalent tohighly natural sounding speech and 9 equivalents to highlyunnatural speech.

This scale has been used in virtually all subsequent investigations ofspeech naturalness.

Martin had 30 listeners use the scale to assess the speechnaturalness of 10 adults who stuttered speaking without DAF, 10adults who stuttered speaking under DAF, and a group of 10normal speaking adults.

They found that both groups of speakers who stuttered soundedsignificantly less natural than the non stuttered sample.

The mean naturalness rating of stutterers was 6.5, stuttering groupunder DAF received an mean of 5.8 and non-stuttering group had amean of 2.1.

Based on inter rater agreement and rater consistency, Martinconcluded that observers are able to uantif s eech naturalness.


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The way a person depicts his situation or problem oftenindicates important signs of progress during treatment.As people progress through effective treatment, theybegin to think and talk differently about themselves and

their speech. The intrinsic features of affective and cognitive change

are reflected in the words the client uses to describehimself, his speech, and his interaction with others.

How the client talks about himself and his speechprovides a window for viewing these intrinsic features.

Early in treatment the client typically feels helpless. Hebelieves he is unable to do much to change his speech orhimself.

Th i hi h d f t i t d ith


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There is a high degree of mystery associated withstuttering. AS treatment progresses, client slowlybegins to develop the language of fluency

As well as use more appropriate self talk.

As the client begins to successfully change hispreviously uncontrollable behavior, he will begin

to change the way he observes himself and hisspeech moreover, he will begin to describe hisbehaviors and actions in more specific andrealistic ways.

The client will begin to interpret stuttering assomething that he is doing rather than happeningto him.


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These metalinguistic changes provide the clinicianwith important evidence of change and indicate thatthe client is beginning to take charge of the problem.

Such utterances may be used as a way to monitorcognitive changes or in some cases; the clinician cantake a more active role and point out to the client howhe is describing himself and his problem.

The clients language will reflect some degree of

liberation from the problem. That is coinciding with the fact that the speaker shows

a great degree of fluency, they are more liberated interms of their choices and have a greater involvementin life.


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As avoidance decreases, the frequency of fluency breaks mayincrease.

Early in treatment less avoidance and greater participation inspeaking activities may yield a slight increase in thefrequency of stuttering.

There may even be an increase in the duration and tension ofstuttering events.

Although these changes may not be pleasant to the client, ifstuttering modification strategies are being used, they can beviewed as progress within the context of the overall treatment

process. Taking part in activities and making better choices may not be

the first step for each client, but it is always a critical step.

Furthermore, a decrease in the avoidance behavior permits

the client to go directly at the problem and the associated fear.


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With a decrease in avoidance behavior, there is likely to bea corresponding increase in overall assertiveness.

In reality being more assertive about once speakingbehavior is likely to translate into increased assertiveness

in general. There may be changes in roles and a relationship as the

persons no longer plays the primary role of a stutterer.

It is a distinctive indicator of progress when the speakerbegins to decrease his reflexive self censorship and beginsto consider many speaking situations h once consideredunimaginable.

This is not to say that he will now take part nonethelessand to consider new opportunities is a significant measureof progress.


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Self-Concept and Self-Esteem have been referred tomany times in the literature on fluency disorders.

Peck (1978), self esteem is the corner stone ofpsychological change. Although persons whostutter have not been found to have a unique selfesteem or to be lacking in self esteem, this concepthas frequently been mentioned as an aspect oftreatment programs.

When the client experiences success in the selfmanagement of surface and intrinsic aspects of hisfluency disorder, self esteem and the self conceptbegins to shift in positive direction.

Efficacy of Stuttering Therapies

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