Programmed Stuttering Treatment for Children: Comparison ... · senior high school students. These children were selected for subjects from a pool of 44 children who were referred

Journal of Speech and Hearing Research, Volume 38, 61-75, February 1995

Programmed Stuttering Treatmentfor Children: Comparison of TwoEstablishment Programs ThroughTransfer, Maintenance, andFollow-Up

Bruce P. RyanBarbara Van Kirk Ryan

Behavioral Sciences InstituteMonterey, CA

Two different Establishment programs, Delayed Auditory Feedback (DAF) and GradualIncrease in Length and Complexity of Utterance (GILCU), for improving the fluency ofschool-age children who stutter, were compared. The programs were carried out by 12 cliniciansunder supervision with 24 clients (12 elementary and 12 junior/senior high school) in the schools.Both programs produced important improvement in fluency in 23/24 (96%) of the children in areasonable time period (7.9 hours). Generally, the two programs were similar in performance.The only difference (between GILCU and DAF) was that the GILCU program provided initially forbetter generalization of fluency. Transfer and Maintenance programs (10.4 hours) demonstratedthat the children from the two Establishment programs performed in a similar manner and thatthe Transfer and Maintenance Programs were helpful. In a total of 18.3 hours of establishment,transfer, and maintenance treatment, 11 subjects, who completed the programs, reduced theirstuttering from 7.9 SW/M to .8 SW/M at a 14-month follow-up showing that the children hadmaintained their fluency. Clinicians' performances contributed to the effectiveness and efficiencyof the programs.

KEY WORDS: stuttering, treatment, DAF, GILCU, prolongation

In the past 20 years two operant speech treatment programs for establishing fluentspeech, Delayed Auditory Feedback (DAF), and Gradual Increase in Length andComplexity of Utterance (GILCU), have received considerable attention and researchattesting to their efficacy (Andrews, Craig, Feyer, Hoddinot, Howie, & Nielson, 1983;Bloodstein, 1987; Boberg & Kully, 1985; Brutten, 1993b; Ham, 1990; J. Ingham, 1993;R. Ingham, 1984, 1993a, 1993b; Ryan, 1979).

The essence of the DAF program is prolongation; therefore, it is understood thatprolongation and DAF refer to very similar procedures in general, differentiated onlyby the use of DAF equipment. Research on DAF (and/or prolongation) is exemplifiedby Boberg (1980), Curlee and Perkins (1969), Ingham and Andrews (1973a, 1973b),Ryan and Van Kirk (1974a), and Webster (1980). The research concerning GILCU isexemplified by Costello (1980, 1983), Mowrer (1975), Rustin, Ryan, and Ryan (1987),Ryan (1971), and Shine (1980a, 1980b, 1984a, 1984b). All of these researchersfound that DAF and GILCU were effective and efficient.

Ingham (1984), in a very extensive review, cited a number of programs thatemployed either or both DAF and prolongation, but the subjects commonly were alladults, or there was a child or two embedded within the group data set (e.g., Curlee& Perkins, 1969; Ryan & Van Kirk, 1974b; Webster, 1980). An exception is the Ryan

© 1995, American Speech-Language-Hearing Association 61 0022-4685/95/3801-0061

62 Journal of Speech and Hearing Research

and Ryan (1983) study that compared four programs. One,DAF, ran the fastest (mean = 6.0 hours) and was effective inreducing stuttering from 6.4 to 0.1 stuttered words per minute(SW/M). Two subjects completed transfer in a mean of 9.9hours, but none could pass the last test to go on to mainte-nance. Budd, Madison, Itzkowitz, George, and Price (1986),using the DAF procedure described by Shames and Florence(1980), reported the results for treatment with 18 children(age range 5-18, mean age = 10.5 years). After 25-30 hoursof group and individual treatment, the children received anadditional, indefinite amount of treatment at school and athome with their parents. Percentages of disfluency in con-versation for pre, post, 2-, and 6-month follow-up periodswere presented. With the mothers, these percentages were9.02, 4.98, 5.17, and 5.86, respectively. With the clinicians,they were 16.21, 6.44, 8.17, and 8.17, respectively. Theseresults indicated relatively high post-treatment rates of stut-tering. Rustin, Ryan, and Ryan (1987) reported 17 subjects(mean age = 17.1, range 9-29) who demonstrated a changefrom 13.8 to .2. SW/M in 6.2 hours of treatment. Finally, Kullyand Boberg (1991) reported the results of a prolongation-based procedure with 10 subjects, aged 4 to 11 years of age.Complete data were presented on 6 subjects (mean 7.2years). Those 6 improved from means of 16.7% to .5%stuttered syllables after treatment. At follow-up, from 8-18months afterward, they demonstrated a mean of .5% stut-tered syllables and in a home sample they demonstrated amean of 2.5% stuttered syllables. One outright failure wasreported. The authors reported that there were at least 16-48in-clinic extended or intensive treatment hours with an indef-inite number of hours in school and at home after the in-clinicexperience.

Johnson, Coleman, and Rasmussen (1978) reported that ittook 21 hours to go from single syllables to eight-wordsentences using a GILCU-like procedure. Costello (1980)presented the effectiveness and efficiency of the ExtendedLength of Utterance (ELU) program. A description of the ELUprogram, a fine-grained variation (e.g., syllables instead ofwords) of GILCU, with 20 steps from monologue to conver-sation, can be found in Costello (1983). For an 11-year-oldchild there was a reduction in stuttering from 12 to 20%syllables stuttered to .7 to 1.2% syllables stuttered in clinicconversation in 33 hours of treatment. Shine (1980a, 1980b,1984b) reported a study of 14 young children (mean age =4.9 years) in which "Easy speaking voice" (prolongation) wasused as part of a GILCU-like procedure. Stuttering wasreduced from 13.9 to 1.7 SW/M in 56.7 sessions. Follow-upindicated 3.2 SW/M. Ryan and Ryan (1983) observed thatfour GILCU subjects (mean age = 11.3 years) went from 5.9to .3 SW/M in 9.6 hours of treatment. Three of the 4 passedthe transfer program (6.4 hours) and went into maintenance(2.0 hours). Follow-up at 9 months indicated that the 3subjects had maintained their fluency at .8 SW/M in bothclinic and extra clinic contexts.

Mallard and Westbrook (1988) used a Van Riperian ap-proach (year 1) and a GILCU approach (year 2). The authorsreported that the groups averaged 44, 30-45-minute ses-sions (22 to 33 hours of treatment) to achieve a reduction forthe GILCU group from 12.0% syllables stuttered pretreat-ment to 7.0% at follow-up. This study had several design

problems. Year 1 subjects were mixed with year 2. It is notclear if transfer or maintenance programs were run. Anexcellent review of stuttering treatment for children thatincludes the studies above and others is presented byConture and Guitar (1993).

In the study by Ryan and Ryan (1983) it was found thatGILCU and DAF performed best (most efficient, most effec-tive, most transfer, and maintenance) out of four differentestablishment programs, but there were some design prob-lems (somewhat few subjects in each group, incomplete setof collection of home and school samples, and possibleineffective training of clinicians to teach slow, prolongedspeech). They recommended additional research with thetwo most efficient and effective programs, DAF and GILCU.

Ryan (1974) discussed the value of viewing treatment inthe three phases of establishment, transfer, and mainte-nance. Not only do data from these phases describe theimportant effects of the establishment phase of treatment, butthey demonstrate whether such effects were evidenced,fluency was transferred, and maintained.

There is a paucity of comparative behavioral data on thewidely used GILCU and DAF treatment establishment pro-grams (Curlee, 1985). This is especially true for their transfer(generalization) and maintenance phases. These phases arethe most important variables according to Bloodstein (1987)and Ingham (1993a, 1993b). Also, previous researchershave presented almost no information on efficiency (a sadlyneglected, yet so important variable). We need to be able toidentify the most effective and efficient treatment proceduresso that we may disseminate them and make them evenbetter. We also, of course, need to eliminate those proce-dures that are not effective and efficient.

The goal of this research was to compare DAF and GILCUestablishment programs for both effectiveness and efficiencythrough the phases of establishment, transfer, and main-tenance. The specific purposes of this study were to:(a) compare two different programs for establishing fluency,(b) determine if these procedures could be applied effectivelyand efficiently to children, (c) determine if these procedurescould be carried out in the public school setting by publicschool speech clinicians, (d) determine the transfer, mainte-nance, and follow-up effects of these two programs, and(e) describe the clinicians' contributions to these programs.

Method

Subjects

The subjects were 24 school-age children who stuttered,ranging in age from 7 to 17 (mean age = 11.8 years). Therewere 20 boys and 4 girls, 12 elementary and 12 junior orsenior high school students. These children were selected forsubjects from a pool of 44 children who were referred by localpublic school speech clinicians in the three sites of the study.The project supervisor (second author) interviewed each ofthese children, taking a sample of their reading, monologue,and conversation. The final 24 children were selected by thesupervisor because they met the following criteria: a stutter-ing rate of three SW/M or more (Ryan, 1974; Ryan & Ryan,

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Ryan & Ryan: Programmed Stuttering Treatment 63

1983), identification as a person who stutters by their parentsand referring clinician, English spoken as their native lan-guage, normal intelligence and ability to read at, or neargrade level. The last criterion was determined by having thesubjects read aloud graded reading material and observingtheir performance.

Sites, Clinicians, and Program Assignment

Three school districts or sites and 12 public school speechclinicians (4 clinicians per site) were used. The clinicianswere chosen on the basis of their interest in the project andavailability of subjects. In most situations, each clinician hadat least one child who stuttered already in the school theclinician was serving. Each clinician was assigned two chil-dren in varying combinations of elementary-elementary, jun-ior/senior high-elementary, and junior/senior high-junior/se-nior high. Seven of the 12 clinicians had to serve schools thatwere not part of their regular assignment.

One of the two Establishment programs, DAF or GILCU,was randomly assigned to each pair of the two pairs ofclinicians in each of the three sites; the other pair receivedthe other program. Therefore, in each of the three sites, fourelementary school children and four junior/senior high schoolchildren received either DAF or GILCU treatment (four chil-dren per program, two clinicians per program). All 12 clini-cians ran the same Transfer and Maintenance programs.Each of the two groups (DAF and GILCU) was composed ofsix elementary and six junior or senior high school students(i.e., 12 each, 24 total).

Groups

Overall, for data analysis, the subjects from the three siteswere put into two groups (DAF or GILCU) of an equal numberof 12 children (2 females and 10 males in each group, 4subjects from each site) with similar stuttering severity(means 7.0, 6.4 SW/M, respectively, on the Stuttering inter-view) and age (11.4, 12.2 years of age, respectively). Theprograms were run twice a week for 30-minute periods inregular public school speech treatment settings while theclinicians carried a normal caseload of other clients.

Clinicians, Training, and Supervision

The clinicians were trained by the authors to conduct oneof the two Establishment programs, the one Transfer and theone Maintenance program. This training required 15 hours ina 3-day workshop (Ryan, 1985). The training included count-ing stuttered words: whole-word repetitions, part-word repe-titions, prolongation, and struggle (Ryan, 1974), and theadministration of the programs. Occasional retraining andcorrection of clinician error took place throughout the year.The project supervisor (the second author) observed each ofthe 12 clinicians once every 3 weeks during the fall and oncea month during the winter and spring for the 9 months of thestudy. During these observations the clinicians were formallymonitored and aided in program operation and reliability

measures were taken. A major constraint in this project wasthat it had to be confined to the 9-month school year tosimulate the conditions normally found in the public schoolsetting.

The Two Establishment Programs

Delayed Auditory Feedback (DAF). This program wasdeveloped from research done by Goldiamond (1965) andwas similar to that described by Curlee and Perkins (1969).Its original name was taken from the use of the DAFequipment, but the essential core of this program is pro-longed speech. Therefore, it may also be described as aprolongation procedure using DAF (Phonic Mirror, HC DAF).Prolongation as a treatment technique can be used withoutany delayed auditory feedback equipment (Ingham, 1984).With this said, the program will be referred to as the DAFprogram (prolongation with DAF equipment) throughout therest of this article. The program differed from that of Inghamand Andrews (1973a, 1973b) and Ingham (1980a, 1980b) inthat only minimal control over increasing speech rate wasemployed; that is, no effort was made, after the pattern ofslow, prolonged speech was installed, to systematicallyincrease speaking rate. Speaking rate was allowed to comeback to normal as the subject continued to practice in theprogram. The program was essentially the one found in Ryan(1971, 1974, 1984) and Ryan and Van Kirk (1974a, 1978).An exact copy may be found in Ryan (1973). This programstarted with a four-step series (pattern training) during whichthe clinician taught the subject a slow, prolonged, fluentspeaking pattern at 40 words spoken per minute or less. Thisinitial series was followed by three, 7-step series, one each inreading, monologue, and conversation. The seven 5-minutesteps consisted of gradually decreasing the amount of de-layed feedback in 50 millisecond steps from 250 millisecondsto no delayed auditory feedback. Delayed auditory feedbackequipment was used to aid in the production of the slow,prolonged, fluent pattern. Each series ended with the subjectspeaking fluently for 5 consecutive minutes with no machinesupport. There was a total of 25 steps. The subjects weretold, "Good," by the clinician after each correct response andreceived redeemable tokens for passing steps. The programhad a minimal run time of 110 minutes. Minimal run time wasthe least amount of time required for a subject to completethe program, if the subject operated error-free (completelyfluent).

Gradual Increase in Length and Complexity of Utter-ance (GILCU). This program was based on work by Ricardand Mundy (1965) and Ryan (1971). The program wasessentially the same one found in Ryan (1971, 1974, 1984),and in Ryan and Van Kirk (1978). An exact copy of theprogram may be found in Ryan (1973). The program con-sisted of 54 steps in three series starting with one-wordutterances that were gradually increased to 5 minutes offluent speaking first in reading, then in monologue, andfinally, in conversation. The subjects were told, "Good," bythe clinician after each correct response and received re-deemable tokens for each correct response. The minimal runtime was 105 minutes.


Equating the Two Establishment Programs

Both programs had fluent speech as their goal. In DAF, thegoal was prolonged, fluent speech that was gradually shapedinto 5 minutes of fluent speech, commonly at less thannormal speaking rates. In GILCU, the goal was starting withone-word fluent utterances and eventually ending with 5minutes of fluent speech, usually at normal speaking rates.

Effort was made to equate the two programs along thedimensions of minimal run time, number of tokens earned,and modes of reading, monologue, and conversation. Eachprogram had special branching procedures. Special branch-ing is done if the subject fails a step. In DAF, branchingreferred to increasing the volume setting on the DAF ma-chine and in GILCU, branching included modeling by theclinician and smaller inter-step time increments (See Ryan,1973, 1984; Ryan & Van Kirk, 1978). Both programs wereprepared in written scripts (12 pages for GILCU and 11pages for DAF) for the clinicians to follow (Ryan, 1973). Eachprogram varied only by its special feature, such as delayedauditory feedback (prolonged speech) for DAF and a se-quence of short (one word) to long (5 minutes of conversa-tion) utterances for GILCU. Both programs had a conse-quence for stuttering behavior ("Stop, speak fluently" forGILCU, and "Stop, speak in your slow, fluent pattern" forDAF) and positive reinforcement for fluency (the cliniciansaid, "Good," paired with a token). Tokens were exchangedfor a variety of backup reinforcers that ranged from small toysfor the younger subjects to records and gift coupons for theolder subjects. The token system was equated so that thesubjects earned a similar number of tokens in each program.All sessions of both program runs were audiotape-recorded.

Transfer and Maintenance Programs

All subjects went through the same Transfer and Mainte-nance programs after they completed and passed one of thetwo Establishment programs. The Transfer program wasbased on previous work by Ryan (1971, 1974), but wasshortened for research purposes. This program was similarto that found in Ryan and Van Kirk (1978) and described inRyan (1984). An exact copy (six pages of script) may befound in Ryan (1973). The Transfer program consisted of sixseries (different physical settings, increased audience size,home, school, telephone, and strangers) with different num-bers of steps in each series. The verbal reinforcer, "Good,"was used for completion of steps during the Transfer pro-gram. When a subject gave the desired response (e.g., readfor 1 minute fluently and conversed for 3 minutes fluently),the clinician told the subject, "Good." For the first four series,subjects had to read for 1 minute and converse for 4 minutesto pass each step. In the last two series, 5 consecutiveminutes of fluent conversation were required in each step.There was a total of 23 steps. The minimal run time was 115minutes.

The Maintenance program consisted of four steps andrequired 3 minutes each of reading, monologue, and conver-sation in each step. The verbal reinforcer, "Good," was usedfor completing steps fluently. When the subject completed

the desired step (e.g., read for 3 minutes fluently, engaged inmonologue for 3 minutes fluently, and conversed for 3minutes fluently) the subject was told, "Good," by the clini-cian. Minimal run time was 36 minutes distributed over a15-week period. This program was similar to that found inRyan (1974, 1984) and in Ryan and Van Kirk (1978), but wasshortened (from eight to six series) for research purposes. Anexact copy (one page of script) may be found in Ryan (1973).All Transfer and Maintenance program sessions were audio-tape-recorded.

Measurement

The number of stuttered words and words spoken wascounted. Only the actual reading and talking time of thesubjects was timed. Stuttered words per minute (SW/M) andwords spoken per minute (WS/M) were computed by dividingthe number of each by the time period during which theywere emitted. Stuttered words consisted of whole wordrepetitions, part word repetitions, prolongations, and strugglebehaviors ("Any of the preceding stuttered words or normaldisfluencies accompanied by struggle. Any secondary char-acteristic such as tongue protrusion, facial grimaces imme-diately preceding the utterance of a word.") (Ryan, 1974, p.14.). Each word stuttered was counted only once. The rulesused for counting stuttered words and total words spokenand determining SW/M and WS/M are described by Ryan(1971, 1974).

Two types of tests were given. There were: (a) a Criteriontest, and (b) a Stuttering interview. These were administeredthree times: before the Establishment program; after theEstablishment program; and after the Transfer program. Thesecond and third administrations were done only after thesubjects had completed the appropriate program. Addition-ally, samples of speech in the subject's home and schoolwere collected on the same schedule. Three measures(Stuttering interview, home sample, and school sample)served to evaluate generalization.

The Criterion test. This test consisted of three parts: 5minutes each of reading, monologue, and conversation. AllCriterion tests were audiotape-recorded. The Criterion testwas administered and timed by the clinicians. The firstCriterion test was administered and timed by the clinicians.The first Criterion test was administered three times todetermine stability. For Criterion test 2 (after the Establish-ment program had been completed), the DAF programsubjects were instructed to "Use your pattern," and theGILCU subjects were instructed to "Speak fluently." This wasconsonant with the way these programs were run and thefinal steps in each of the programs. The project supervisorattended the first (a) of the three administrations (a, b, c) ofCriterion test 1 and independently counted stuttered wordsand timed the subjects' reading and talking during theseobservations. This live count of the first administration by theproject supervisor was used in the data analysis becausefurther study revealed no significant differences between thesecond and third administrations of Criterion test 1 (b and c)and the first (a). The project supervisor did the same countingand timing for Criterion tests 2 and 3, but from the audiotape

38 61-75 February 995


recordings. The count of stuttered words and time data of theproject supervisor were used in data analysis and decidingwhether a subject had passed Criterion test 2 or 3 (achieveda level of 0.5 SW/M or less in all three modes of reading,monologue, and conversation). The subjects had to achievethis rate on Criterion tests 2 and 3 to pass from the Estab-lishment program to the Transfer program and then, from theTransfer program to the Maintenance program. When asubject did not pass Criterion test 2, the subject was recycledthrough parts of the previous program in the mode (reading,monologue, or conversation) that was failed on the Criteriontest. After the recycle, the subject repeated Criterion test 2.The total number of words spoken on the Criterion tests wascounted from the audiotape recordings of these Criteriontests by the study staff (authors and trained institute volun-teers). The 12 clinicians also counted words for all theCriterion tests as follow-through on their training, but only thecounts of the study staff were used for data analysis.

The Stuttering Interview. This test has 14 speaking tasksthat range in complexity from counting to talking on thetelephone. A copy of this test may be found in Ryan (1974).The Stuttering interview required about 15 minutes to admin-ister and yielded approximately 10 minutes of subject talkingtime. The Stuttering interview was administered before andafter the Establishment program and after the Transferprogram. The second and third administrations were givenonly to those who had passed the Establishment and theTransfer programs, respectively. The Stuttering interviewwas administered and scored only by the project supervisor.It was both audio and videotape-recorded. Stuttered wordswere counted live by the project supervisor, and the numberof words spoken during the Stuttering interview was countedfrom the audiotapes later by the study staff.

Home and school speech samples. Samples of thesubjects' speech in the home (Home) and in the school(School) were taken before and after the Establishmentprogram was completed, after the Transfer program wascompleted, and in some cases, a fourth time before the studywas concluded. The Home sample was audiotape-recordedby the parent (mother or father) in the home with the subjectand one other person (sister, or brother, or friend, or otherrelative) in attendance. The School sample was audiotape-recorded by the teacher in an empty classroom with thesubject and one other person in attendance (another stu-dent). The samples consisted of conversation for 15 minuteswith the first 5 minutes of talk time selected for analysis. Thenumber of stuttered words for each Home and Schoolsample was counted by the project supervisor. The numberof total words spoken was counted from the audiotaperecordings by the project staff.

Interviews. Interviews, composed of a standard set ofquestions about the programs, were conducted with thesubjects, their parents, and teachers before the Establish-ment program, after the Establishment program, and afterthe Transfer and Maintenance programs for those subjectswho completed these latter programs. The clinicians wereinterviewed at the end of the study. The interview protocolsmay be found in Ryan and Van Kirk (1974a).

Measures of efficiency. Efficiency is the amount of timetaken to complete a task, in this case, a program. Three

measures of efficiency were made. The first measured hoursof treatment time and is referred to as session hours. Thismeasure provided information about how many traininghours each program required for completion. The secondwas percentage of talking time. Talking time was the timeduring which the subject was actually reading, engaging inmonologue, or conversing. This time included only the sub-jects' actual talking. For example, during the conversationalmode only the talking time of the subject was recorded. If thesubject stopped talking, the timing was stopped. The totaltime of each treatment session was 30 minutes. The talkingtime of the subject was divided by the total session time. Thisyielded a percentage of talking time. For example, if a subjectactually talked for only 15 minutes out of a 30-minutesession, this would yield 50% (15 divided by 30) talking time.This measure provided information about both clinician andprogram efficiency by assuming that talk time representedactual working or performing time (on-task behavior) by thesubject. Talking time percentage was affected by the config-uration of program steps (conversation yielded less talkingtime per session than either reading or monologue) andclinician efficiency (clinicians who spent a portion of theirsession time in nonprogram tasks such as setting up theirequipment or chatting demonstrated less subject talkingtime). Whereas total session time represented how muchtime the subject and clinician spent together, talking timemore accurately represented actual working time during thesession.

The third measure was of calendar days required tocomplete the program. This measure is, of course, related tosession time, but it provides additional measurement ofprogram and clinician efficiency. Other factors, such asclinician and client attendance, and vacations, or otherbreaks in training are reflected in the number of calendardays required to complete a program.

Follow-up

It was possible to do follow-up of both DAF and GILCUgroups of subjects after the project was officially over. Thefirst was done at 7.0 months for 18 subjects. The second wasdone at 14.1 months for 11 subjects. Various clinicianscollected audiotape-recorded conversation samples. Stut-tered words per minute and words spoken per minute werecounted from the tape recordings by the project supervisor.

Reliability

Counting stuttered words. The project supervisor whodid most of the counting of stuttered words was calibrated byan independent observer (first author). The two observersindependently counted stuttered words from eight randomlyselected videotaped Stuttering interviews from 66 pre- andpost-program Stuttering interviews. The percentage ofagreement between these two observers averaged 93.5%.This compared favorably with the percentage of agreementof 95.4% achieved in a previous study between the twoobservers (Ryan & Ryan, 1983). In any rare instance of lessthan 90% agreement, the observers discussed the subject's


stuttering behavior and what behavior to count and then didanother independent count. This continued until the twoobservers achieved 90% or better agreement. The stutteredword count of the project supervisor was employed in allstuttered word count data used in analysis except for thatobtained by the clinicians during program operation (treat-ment program steps). The clinician's stuttered word countduring Criterion tests was only used to determine their ability(and reliability) to do so.

The project supervisor independently counted stutteredwords live with the clinicians on the first Criterion tests. Amean of 84.8% (S.D. = 10.0) was achieved. In instances ofless than 90% agreement, the two observers discussed thesubject's behavior and did another independent count on thenext Criterion test until 90% or better agreement was at-tained. For the Criterion tests 2 and 3, the means of the initialpercentages of agreement were 59.7 (S.D. = 29.2) and 53.8(S.D. = 24.4), respectively. These latter two relatively lowpercentages of agreement were due to the low rate ofstuttering (less than I SW/M), exhibited by the subjects duringCriterion tests 2 and 3. Therefore, one or two missedstuttered words by the clinicians, if the overall rate was low,resulted in a low percentage of agreement for a very slightdifference between the two counts. For example, if theclinician counted one stuttered word and the project super-visor counted two, this would result in a percentage ofagreement of a low 50% that was only one stuttered worddifferent in a 15-minute sample.

A third measure of reliability consisted of the supervisorcounting stuttered words live during monitoring visits. Theaverage percentage of agreement during such monitoringwas 78.0%. A serendipitous finding was that the clinicianscounted more accurately when the supervisor was presentand covertly counting stuttered words. All sessions wereaudiotape-recorded; therefore it was possible to compareclinician counts with and without the supervisor present. Acomparison of a set of six randomly chosen sessions for sixclinicians from immediately before the supervised sessionwith the following supervised session revealed mean per-centages of 47.8% agreement unsupervised with 98.3%supervised, which were significantly different [t(1,5) = 3.94,p < .05]. This suggests a strong supervisor factor thatimproved clinician accuracy. Other researchers have noted a"supervision effect" (Skinrud, 1973). Though this difference(50.5%) appears to be extremely large, in actuality, thenumber of stuttered words could have been extremely low(one vs. two = 50% agreement, but only one stuttered worddifferent), similar to the situation discussed above for theCriterion tests 2 and 3. During program operation subjectsoperated at less than 1 SW/M, which meant that missing oneor two stuttered words could result in a low percentage ofagreement. The clinicians' most common error was under-counting.

Counting total words spoken. Seven different study staffmembers (not clinicians), including both authors, listened toaudiotape recordings and counted total word output in one ormore of the various tests or samples used. The results of 15different reliability measures of their counting accuracy of thetotal number of words spoken revealed an average 91.7%agreement.

Timing. The project supervisor randomly selected 10Criterion tests, including some from each of the three Crite-rion test periods, retimed them, and compared the results tothose obtained by the clinicians. The average percentageagreement was 96.1% (S.D. = 2.3). Timing errors wereequally divided between over- and undercounting and aver-aged 48 seconds per 15-minute talking sample. In theaverage worst possible situation of undercounting stutteredwords and overtiming, this yielded a .3 SW/M variation.Commonly, the clinicians undercounted stuttered words andeither over- or undertimed. This would yield an averagediscrepancy of .2 SW/M per 15 minutes of talking time. Thisamount of error was minimal. Measures of timing for sixsupervised and six unsupervised sessions, the procedures ofwhich are described above, revealed an average percentageof agreement of 89.6% unsupervised with 94.8% supervisedor only a 5.2% difference.

Recording data. A certain portion of the data (programrun) was recorded on data sheets and calculated by theclinicians and used in analysis of program operation. Studystaff recalculated these data on 19 randomly selected sam-ples of the first set of program data completed by theclinicians. The percentage agreement for the calculation ofSW/M was .97 whereas that for timing was .99.

Results

Establishment Programs

Overall, 24 subjects started one of the two Establishmentprograms, DAF or GILCU. Twenty of these 24 finished one ofthe two Establishment programs, passed Criterion test 2(<.5 SW/M), and started the Transfer program. Of these 20,11 passed Criterion test 3 (<.5 SW/M) within the 9-monthschool year. These 11 subjects then went into and finishedthe Maintenance program and were followed up later.

The means and standard deviations for age, and sixefficiency and effectiveness variables are shown in Table 1for 20 subjects (11 DAF and 9 GILCU subjects) who com-pleted the Establishment program and passed Criterion test2. The data for stuttered words per minute (SW/M) are alsoshown in Figure 1. The three effectiveness variables werestuttered words per minute (SW/M), words spoken perminute (WS/M), and percentage of stuttered words. Thethree efficiency variables were treatment hours, talking timepercentage, and calendar days. The twelfth DAF subject wasunable to hold the prolonged speech pattern, probably due toclinician error in pattern training (see Ryan & Ryan, 1983, onthis point), and continued to fail Criterion test 2. Two of the 3GILCU subjects were doing well and probably would havepassed Criterion test 2, had they not moved. The third, a verysevere subject (Criterion test 1 = 19.2 SW/M, 101.2 WS/M,19.1% stuttering, mostly struggle), was unable to completethe program and was considered a failure on the GILCUprogram after an extensive run (51, 30-minute sessions, 25.5hours).

It can be seen in Table 1 that the only variable thatdiscriminated between the two Establishment programs wasspeaking rate on Criterion test 2, (means = 77.9 and 127.9

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TABLE 1. Results for two establishment programs: delayed auditory feedback (DAF) andgradual increase In length and complexity of utterance (GILCU).

DAF (n 11) GILCU (n 9) Difference

Variables Mean S.D. Mean S.D. Mean

Age 11.4 2.7 12.2 3.9 .8Criterion test 1

Stuttered words/min 7.5 4.1 6.0 4.9 1.5Words spoken/min 112.6 21.4 119.3 28.7 6.7Stuttered % 6.7 3.5 5.5 5.3 1.2

Criterion test 2Stuttered words/min .3 .2 .4 .1 .1Words spoken/min 77.9 38.5 127.9 27.0 50.0**Stuttered % .4 .2 .4 .1 0

Session hours 8.0 3.2 7.9 1.8 .1

Talking time % 45.8 10.7 47.6 8.3 1.8

Calendar days 86.7 50.8 75.2 25.8 11.5

**"t" = 2.89, 18 df, p < .01.

WS/M, respectively, for DAF and GILCU) [(18) = 2.89, p <.01]. This was a direct result of the pattern training at slowrates. Subjects were encouraged to use their pattern duringCriterion test 2. The logic was that it was more important tobe fluent than to speak at a normal rate. Normal rate wouldbe one of the results of the Transfer program (Ryan & VanKirk, 1974b). There were 2 subjects with recycles in the DAFprogram and 7 of 9 in the GILCU program, the latter probablydue to undercounting in the program causing the subjects topass steps in the program with stuttered words and then failon the Criterion test when stuttered words were countedaccurately. Overall, both programs, DAF and GILCU, re-duced stuttering from 7.5 to .3 SW/M, and 6.0 to .4 SW/M,respectively. These latter SW/M rates were well within nor-mal disfluency rates (Craven & Ryan, 1985) in 8.0 and 7.9hours, respectively. There was a nonsignificant correlation of.25 between Criterion test 1 SW/M and hours of treatment forboth programs combined.

7

6

S 5w 4

M 3

2

1

0

Table 2 shows the results of measurement of stutteringand speaking rate to determine generalization. A three-factorANOVA (group x test x pre/post) was run for each of thevariables, SW/M, WS/M, and percentage of stuttering. Thisanalysis for SW/M revealed that there was a main effect forpre (mean = 6.6) versus post (mean = 3.1), [F(1,18) = 70.9,p < .01]. There was significant interaction between groupand pre/post, [F(1,18) = 5.91, p < .05]. A Scheffe testrevealed that there was a significant difference (p < .01)between the pre means of DAF and GILCU (means = 7.0,6.4, respectively) and the GILCU post mean = 1.5. The postresults revealed better generalization for GILCU although thetwo groups had similar pretreatment SW/M, and this differ-ence was shown across all three tests.

For WS/M, the only significant finding was a main effect forpre versus post [F(1,18) = 12.0, p < .05]. There was a higherspeaking rate for both groups combined for the post-test thanthe pretest (for DAF and GILCU combined, and Stuttering

CT1 Sl 1 HS1 SS1 CT2 SI2 HS2 SS2 CT3 Sl3 HS3 SS3Tests and Times

- DAF O GILCU

FIGURE 1. Stuttered words per minute (SW/M) for three Criterion Tests (CT), Stutteringinterviews (Si), Home samples (HS), and School samples (SS).


TABLE 2. Generalization for two establishment programs (DAF and GILCU) as measured by theStuttering Interview, home speech sample (Home), school speech sample (School).

DAF (n 11) GILCU (n 9) Difference

Measure Mean S.D. Mean S.D. Mean

Stuttering interview 1Stuttered words/min 7.0 3.6 6.4 5.0 .6Words spoken/min 112.2 10.5 113.9 19.1 2.7Stuttered % 6.3 3.1 6.0 5.2 .3

Home 1Stuttered words/min 6.8 3.2 5.3 2.6 1.5Words spoken/min 105.8 25.4 108.4 17.7 2.5Stuttered % 6.6 3.3 5.3 3.3 1.3

School 1Stuttered words/min 7.1 4.5 7.1 4.6 0Words spoken/min 114.6 20.0 103.7 20.5 10.9Stuttered % 6.4 4.4 7.3 5.1 .9

Stuttering interview 2Stuttered words/min 4.7 4.7 1.5 2.7 3.2Words spoken/min 122.3 22.0 131.4 29.4 9.1Stuttered % 4.1 4.1 1.4 2.9 2.7

Home 2Stuttered words/min 4.1 3.6 1.3 .7 2.8Words spoken/min 120.7 19.8 118.6 23.3 2.1Stuttered % 3.8 3.6 1.1 .5 2.7

School 2Stuttered words/min 4.5 5.1 2.2 3.2 2.3Words spoken/min 128.5 17.2 116.1 21.1 12.4Stuttered % 3.8 4.6 2.0 2.8 1.8

Interview, Home sample, and School samples combined,means = post 123.0, pre 109.6, respectively). This observa-tion of increased speaking rate supports the observation ofreduced stuttering.

For percentage of stuttering, there was a similar finding asfor SW/M, that is, more pre than post [F(1,18) = 51.8,p < .01], (means = 6.3, 2.8, respectively). There was also asignificant interaction [F(1,18) = 4.5, p < .05] between groupand pre/post. A Scheffe test revealed that the DAF andGILCU pre stuttering percentages (means = 6.4, 6.2, re-spectively) were significantly greater than the post GILCUstuttering percentage (mean = 1.5). This result is similar tothat found for SW/M. It also should be noted that there wereno significant differences in SW/M, WS/M, nor percentage ofstuttering in any of the three tests, pretreatment, confirmingthat there was no difference in stuttering between the DAFand GILCU groups pretreatment. These data suggest GILCUhad a better generalization effect. The DAF group did notspontaneously use their slow prolonged pattern in othersettings, although there was a noticeable reduction in stut-tering (See Figure 1) in Stuttering interview 2, and Home andSchool samples 2.

Although not a specific goal of this study, it was possible todetermine the interrelationships among the numerous testsgiven in this study. Pearson r correlations were done forSW/M between pairs of scores of Criterion tests, Stutteringinterviews, Home samples, and School samples. Most of thecorrelations were positive. The first Criterion tests, Stuttering

interviews, and Home and School samples correlated wellwith each other (mean = .83, see Figure 1, also). The secondHome and School samples correlated well with each other(.80), but not with the Criterion tests and Stuttering interviews(mean = -. 42). The third Home and School samples did notcorrelate well with the other samples (mean = .20), but didcorrelate with each other (.88). Something was being mea-sured in these samples that was not in the other samples,although the differences were not significant as judged by theprevious ANOVA analyses. The average correlation, for bothgroups combined, in all six tests, between SW/M and per-centage of stuttering, was 91.6. Because of this finding ofsimilarity, only SW/M will be used in the rest of this article.

Transfer Program

Twenty subjects started the Transfer program, but only 11finished the program within the school year. Four of the 11initial DAF subjects completed the Transfer program, butcould not pass Criterion test 3 at less than .5 SW/M. TheirCriterion test 3 after the program was a mean 2.1 SW/M(S.D. = .3), an improvement over their Criterion test 1performance of a mean 7.2 SW/M. These 4 DAF subjectshad to recycle and there was not time for them to completethe recycle. One other DAF subject did not complete theTransfer program in time and one more DAF subject moved.

38 61-75 Febrary 995


TABLE 3. Transfer program and generalization results for 11 subjects (DAF 5, GILCU 6) whocompleted.

DAF GILCU Difference

Variables Mean SD Mean SD Mean

Age 11.2 2.4 11.5 3.9.3

Session hours 10.8 3.8 8.0 2.3 2.8Talking time % 30.3 4.5 34.2 7.6 3.9Calendar days 107.4 43.8 80.3 36.0 26.7

Criterion test 2Stuttered words/min .2 .1 .4 .1 .2*Words spoken/min 65.6 37.0 125.7 30.3 60.1*

Stutter Interview 2Stuttered words/min 6.4 5.4 .5 .2 5.9Words spoken/min 117.0 22.8 142.3 21.3 25.3

Home 2Stuttered words/min 3.4 3.6 .9 .5 2.5Words spoken/min 121.2 21.5 110.1 22.8 10.9

School 2Stuttered words/min 3.6 3.5 .9 .7 2.7Words spoken/min 138.5 2.6a 118.7 26.8 19.8

Criterion test 3Stuttered words/min .4 .2 .3 .1 .1Words spoken/min 127.6 24.9 138.9 34.0 11.3

Stutter Interview 3Stuttered words/min .8 .7 .4 .2 .4Words spoken/min 141.8 15.3 136.0 29.0 5.7

Home 3Stuttered words/min 1.1 .8 .7 .8 .4Words spoken/min 119.6 18.8 136.3 33.7 16.7

School 3Stuttered words/min 1.3 1.1 1.1 1.0 .2Words spoken/min 132.6 14.2 129.5 28.4 3.1

aSmall SD partly due to missing data and the use of the average of the available scores in place of themissing data." t" test significant, p < .05.

Three of the 9 GILCU subjects did not complete theTransfer program within the school year. When given Crite-rion test 3, anyway, in order to end the project year, they didnot pass Criterion test 3 at .5 SW/M. They did demonstrateimprovement (means = Criterion test 1, 8.6 SW/M, andCriterion test 3, 1.7 SW/M). The Transfer program requiredextensive organization, and it was not always possible tocarry out all the steps.

Means and standard deviations for age, and programeffectiveness and efficiency variables for the Transfer pro-gram are shown in Table 3 for the 11 (5 DAF, 6 GILCU)subjects who completed the Transfer program and passedCriterion test 3. These data for SW/M are also shown inFigure 1. A series of t tests revealed there were two signifi-cant differences. The first was for SW/M on Criterion test 2[t(9) = 3.00, p < .05], with the DAF group showing a mean of.2 SW/M, whereas GILCU demonstrated a larger mean of .4SW/M. Although statistically significant, probably because ofthe low standard deviation, this .2 difference was clinically

negligible (a difference of one stuttered word in 5 minutes oftalking time). The second significant difference [(9) = 2.96, p< .05] was for WS/M. This difference (60.1) was great, andreflected the use of slow prolonged pattern during Criteriontest 2 by the DAF group as noted before. The WS/M of theDAF group did increase, as predicted, during the Transferprogram (65.6 WS/M on Criterion test 2 to 127.6 WS/M onCriterion test 3, an increase of 62 WS/M). There were nosignificant differences between the two groups on the threeefficiency variables.

Three-factor ANOVAs (group x test x pre/post) were run forSW/M and WS/M for the 3 samples, Stuttering interview,Home sample, and School sample, pre and post (2 & 3,respectively) the Transfer program. There was a main effectfor group [F(1,9) = 8.31, p < .05], (means = DAF, 2.8 SW/M;GILCU, .8 SW/M). There was a significant interaction be-tween group and test [F(2,18) = 4.34, p < .05]. A Scheffe testrevealed that the combined mean of 3.6 SW/M on the DAFgroup's two Stuttering interviews (2 & 3) was significantly


TABLE 4. Maintenance program results for 11 subjects (DAF n 5, GILCU n 6) who completed.

DAF GILCU Difference

Variables n Mean S.D. n Mean S.D. Mean

Session hours 5 1.2 .7 6 1.0 .4 .2Talking time % 5 50.0 10.3 6 50.0 5.9 0Calendar months 5 1.6 .7 6 1.8 1.3 .2

Home 4 SW/Ma 4 .7 .9 3 .5 .3 .2School 4 SW/M 4 1.0 .6 3 .8 .3 .2

aStuttered words per minute.

greater than those of the GILCU group on the two Stutteringinterviews, 2 Home and 2 School samples (means = .4, .8,and 1.0 SW/M, respectively). A significant interaction effectwas demonstrated for group, test, and pre/post [F(2,18) =3.55, p < .05]. A Scheffe test revealed that the DAF group'smean 6.4 SW/M on Stuttering interview 2 was significantlygreater (p < .5) than 9 of the 11 other SW/M means.

The six GILCU subjects continued to show less stutteringin transfer measurements that held true in six out of sixcomparisons, although there were greater differences in thesecond measures (Stuttering interview 2, Home sample 2,School sample 2 combined mean = 3.7 SW/M) than therewere for the third, post-transfer measures (Stuttering inter-view 3, Home sample 3, and School sample 3 combinedmean = .3 SW/M). The Transfer program had a greaterimpact on the DAF subjects than it did on the GILCUsubjects. The Transfer program ended for both groups withthe "worst" measure of 1.2 SW/M in the School sample 3,which actually was within the limits of normal fluency (Craven& Ryan, 1985). All three measures, Stuttering interview,Home sample, and School sample, revealed improvement(i.e., reduction in SW/M) between tests 2 and 3. This may beattributed to the Transfer program and was more pronouncedfor the DAF group.

For WS/M, there was a significant main effect for test[F(2,18) = 4.28 p < .05]. A Scheffe test revealed that WS/Mwas significantly higher on the Stuttering interview (mean =134.7) than on the Home sample (mean = 121.9). There wasa main effect for pre/post [F(1,9) = 8.56, p < .05], means =118.4, 132.7, respectively. There was an increase in speak-ing rate between the pre and post measures, concurrent withand related to the decrease in stuttering. There was asignificant interaction effect among group, test, and pre/post,[F(2,18) = 5.19, p < .05]. Scheffe tests were used tocompare the 12 means. Of primary interest was the changefrom test period 2 to test period 3. The DAF group didsignificantly increase their WS/M on Stuttering interview 2 to3 (means = 117.0, 141.8, respectively, p < .01). However,they did not demonstrate a significant increase in ratebetween Home and School samples 2 and 3. The onlysignificant change for the GILCU group was between Homesamples 2 and 3 (means = 110.1 to 136.3 WS/M). Ofsecondary interest were the differences between the DAFsubjects and the GILCU subjects. The only two significantdifferences were between Stuttering interview 2 (means =117.0, 142.3 WS/M, respectively, p < .01) and betweenSchool 2 samples (means = 138.5, 118.7 WS/M, respec-

tively, p < .01). Of interest was the difference between theStuttering interview and the Home and School samplesthemselves. The lowest mean stuttering rate (.6 SW/M) andhighest mean speaking rate (138.6) were shown in theStuttering interview 3. The lowest combined (2 & 3) meanSW/M was shown on the Home sample (1.5 SW/M), whereasthe highest combined (2 & 3) mean WS/M was shown for theStuttering interview (134.7). Of final interest is the observa-tion that for all eight of the third measures, the DAF groupS.D.s for speaking rate were consistently smaller than thoseof the GILCU group (e.g., Home 3, DAF S.D. = 18.8, GILCUS.D. = 33.7). This may be an artifact or may have been dueto more older children in the DAF group, or, of more interest,due to their recent history of slow, prolonged speech thatproduced a more regular, less variable speaking rate.

Maintenance

The results for the Maintenance program are shown inTable 4. A series of ttests indicated no significant differencesbetween the two groups on any of these measures. Due tocircumstance, it was not possible to collect Home and Schoolsamples 4 on all 11 subjects.

Follow-Up

Table 5 shows the results of the first follow-up that wasconducted at a mean of 7.0 months after the project wasover. There had been some change of schools by bothsubjects and clinicians. The clinicians attempted to find thechildren and to continue to work with 18 of them, 10 of the 11who had been on the Maintenance program and 8 who hadnot. The subjects were divided into those who participated ina Maintenance program and those who did not. Those whostayed in Maintenance did better (.3 SW/M) than those whodid not (2.8 SW/M). These data suggest the value andcontribution to continued reduced stuttering by the Mainte-nance program. A second follow-up was conducted of 11(DAF [n 5] and GILCU [n 6]) subjects at a mean of 14.1months later, after the Maintenance program concluded andthe project was officially over. The results are shown in Table6. A series of t tests again revealed that there were nostatistically significant differences between the two groups onany of the measures. With one exception (a female aged 16,at 4.0 SW/M, from the DAF group, who had interruptedtraining), the other 10 children (91%) who had completed all

38 61-75 February 995


TABLE 5. Maintenance program follow-up.

Criterion tests#1 #4

UnderAge SW/Ma SW/M Monthsb 1 SW/M DAF GILCU

Group f Mean Mean Mean Mean f f f

Maintenance 8 12.9 7.4 .3 8.7 8 4 4No maintenance 10 13.3 7.2 2.8 5.7 4 3 1

aStuttered words per minute.bMonths from last program step.

phases of the program continued to show low rates ofstuttering (mean = .8 SW/M). These were, commonly, singlewhole-word, or part-word repetitions, well within the limits ofnormal fluency (Craven & Ryan, 1985).

use these programs next year?," 12 (100%) answered,"Yes." Follow-up revealed they did indeed use the programsthe following year.

DiscussionInterviewsInterview data for children, parents, and teachers (before

and after establishment and after transfer, three times) maybe found in Ryan and Van Kirk (1974a). Because of thevaried outcomes of the individual subjects involved, theindirect nature of interviews, and missing data, no effort wasmade to do extensive inferential statistical analysis. Someinteresting findings are worth noting here, however. Seven ofthe 19 children (37%) at time 3, after being on the Transferprogram, reported that they no longer viewed themselves ashaving a problem (stuttering) after treatment. There was alsoa major reduction in reported avoidance by the children from74% in time one to 47% in time three, after treatment.

Of most interest were the answers of parents and teachersto the question on avoidance that revealed that neither theparents (54%) nor the teachers (8%) thought the childrenavoided as much as the children reported they avoided(74%). Both parents (93%) and Teachers (75%) reported attime 3, after treatment, that they believed the children hadimproved.

The clinicians rated the project activities on a 5-point scale(1 poor-5 excellent). Training was rated 4.7, supervision4.6, the children's responses to the programs 4.1, Transferprogram 4.0, change in child's speech 3.9, and Establish-ment program 3.7 (this relatively low rating of the establish-ment program was probably due to the comparatively poorperformance of a few children as discussed earlier). To, "Didthey work?," 11 (91%) answered, "Yes." To, "Do you plan to

DAF Versus GILCU Establishment Programs

One purpose of this study was to compare two differentprograms for establishing fluency, Delayed Auditory Feed-back (DAF), or prolongation, and Gradual Increase in Lengthand Complexity of Utterance (GILCU). They were similar ineffectiveness (reduction to .3 and .4 SW/M, respectively) andin efficiency (8.0, 7.9 hours, respectively). Both were effectiveand efficient in reducing stuttering behavior. These perfor-mances are similar to those of the two programs in a previousstudy of DAF and GILCU (Ryan & Ryan, 1983) for stutteringreduction (.1, .3), but very different for efficiency (6.0 and 9.6hours, respectively). This was probably due to some refine-ments made in both the programs themselves and thetraining and supervision of the clinicians. GILCU was re-ported and observed to be easier to run for the clinicians, butfailed on one severe subject. However, 23/24 (96%) of thesubjects improved from a mean of 7.5 SW/M to 1.3 SW/M.There was a low, nonsignificant correlation (.25) betweenCriterion test 1 SW/M and hours of treatment.

The major differences between the two approaches camefrom measures, before the Transfer phase was run, where itappeared that the GILCU program produced better general-ization of fluency. Subjects from both programs maintainedtheir fluency for at least a mean of 14.1 months after a meanof 18.2 hours in establishment, transfer, and maintenance.This project also provided systematic replication (Hersen &

TABLE 6. Follow-up results for 11 subjects. (DAF n 5, GILCU n 6.)

Criterion test #1 Last maintenance Follow-up

SW/M WS/M SW/M WS/M Months 1 Months 2b SW/MAge

Program M M SD M SD M SD M SD M SD M SD M SD

DAF 11.2 10.3 5.8 117.8 15.0 .5 .5 133.4 17.4 9.0 7.8 12.8 4.6 1.1 1.7GILCU 11.5 5.9 2.4 125.2 21.8 .7 .7 137.5 35.3 8.5 5.1 15.2 3.1 .6 .3

Total 11.4 7.9 4.7 121.2 18.5 .6 .6 135.6 27.4 8.0 6.1 14.1 3.9 .8 1.1aMonths in Maintenance program.bMonths from last Maintenance program step.

-


Barlow, 1976) of these two operant speech treatment Estab-lishment programs in that they worked across a variety ofchildren of differing ages and stuttering severity with differentclinicians. These are important criteria for program evalua-tion according to Bloodstein (1987).

The paucity of similar research data on other programsmakes it difficult to compare these results. The study of Budd,Madison, Itzkowitz, George, and Price (1986), using the DAFprocedure described by Shames and Florence (1980) with 18children of similar age, is somewhat comparable. Percentageof disfluency in conversation with the mothers for pretreat-ment and at 6-month follow-up times were 9.02 and 5.86,respectively. These values were 16.21 and 8.17, respec-tively, with the clinicians. The results of Budd et al. do notcompare favorably with those of this study. After more hours(exactly how much more is not known) of treatment there wasless reduction in stuttering.

The results from Rustin, Ryan, and Ryan (1987) for DAF,on the other hand, were quite comparable, if not better, for 17subjects (mean age = 17.1, range 9-29), to those reported inthis study (a change from 13.8 SW/M to .2. SW/M in 6.2hours of treatment). The British clinicians had been trainedby Rustin and the Ryans to use the same DAF and GILCUprograms. Kully and Boberg (1991) reported the results of aprolongation-based procedure (Boberg & Kully, 1985) with10 subjects, aged 4 to 11 years. Complete data werepresented for six children (mean age 7.2 years). These siximproved from means of 16.7% to .5% stuttered syllablesafter treatment. At follow-up, from 8-18 months afterward,they demonstrated a mean of .5% stuttered syllables and ina home sample they demonstrated a mean of 2.5% stutteredsyllables. These are comparable results to those of thepresent study except for the hours of treatment that appear tobe much longer.

Johnson, Coleman, and Rasmussen (1978) reported that ittook 21 hours to go from single syllables to eight-wordsentences using a GILCU-like procedure. Costello (1980)presented the effectiveness and efficiency of the ExtendedLength of Utterance (ELU) program for an 11 -year-old child.A reduction in stuttering of from 12% to 20% syllablesstuttered to .7% to 1.2% syllables stuttered in clinic conver-sation was obtained after 33 hours of treatment. Shine(1980a, 1980b, 1984b) reported data for 14 young children(mean age = 4.9 years). "Easy speaking voice" (prolonga-tion) was used as part of a GILCU-like procedure. The resultswere a reduction in stuttering from 13.9 SW/M to 1.7 SW/M in56.7 sessions. Follow-up indicated 3.2 SW/M, four timeshigher than the .8 SW/M reported in this study. Theseeffectiveness results are generally similar, but it should benoted that the children in the Shine research were mostlypreschoolers with a high probability of spontaneous recovery(Bloodstein, 1987).

A distinguishing variable between this present study andother studies is treatment hours. Other studies often reportedtwice as many hours of treatment, and less effectiveness instuttering reduction. The results from Rustin, Ryan, and Ryan(1987), however, were quite comparable for 48 6-12 year oldEnglish subjects, to those reported in this study (a changefrom 10.0 to .2 SW/M in 7.8 hours of Establishment programtreatment). Of interest, a scan of the data found in Rustin,

Ryan, and Ryan (1987) revealed that some very severesubjects, including adults, responded well to the GILCUprogram in similar treatment time periods. The clinicians inthe Rustin et al. (1987) study had been trained by Ryan andRyan (Ryan, 1985) on the GILCU program and supervised byRustin.

The public school study of Mallard and Westbrook (1988)used a Van Riperian approach (year 1) and a GILCUapproach (year 2). There were many design problems, butbecause of the similarity of setting and one program(GILCU), it was decided to attempt a comparison. The dataon 40 subjects (actually 33 different subjects) reported byMallard and Westbrook (1988) were reanalyzed with moreappropriate and sensitive statistical procedures. A two-factorANOVA (year x repeated measures; pre, post, and follow-uppercentage disfluency) was done with a first-year outliersubject (JC) removed. Only subjects who had been in eitheryear 1 (Van Riper traditional, n = 19) or year 2 (GILCU, n =13) were compared. There was a significant interactionbetween group and repeated measures [(F(2,60) = 5.03, p <.01]. A Scheffd multiple comparison test revealed that theyear 2 GILCU program provided for a significant change (p <.01) from the pretest disfluency (11.7%) to the follow-up(4.8%) measure (a difference of 6.9%) as compared to theyear 1 traditional group of a pretest (7.9%) to a follow-up(6.1%) for a difference of 1.8%. One may infer from this thatthe second year GILCU had a better result than the first yeartraditional procedures. Actually, this was not a very goodresult for either year considering it was reported that thegroups averaged 44 30-45-minute sessions (22 to 33 hoursof treatment) against 8 hours in an Establishment program inthis study for an improvement to .4% stuttering. It is not clearif Transfer or Maintenance programs were run. It should benoted that Westbrook was indeed trained by the Ryans asreported by Mallard and Westbrook (1988), but did not finishthe training nor was ever supervised by the Ryans.

One may conclude from this discussion that operantspeech fluency treatment programs are both efficient andeffective in reducing stuttering. There are, however, varia-tions in effectiveness and efficiency (especially) among thedifferent operant programs.

Effect on Children

A second goal was to determine if these procedures (e.g.,like those with adults from Ryan & Van Kirk, 1974b) could beapplied effectively and efficiently to children. Children re-sponded very well to the programs as determined by boththe interview and program run data. Neither the childrenthemselves nor the clinicians reported any strong negativeresponses by the children. It is hard to do a statisticalcomparison of the children's performances with adults' per-formances although casual observation of the data mostly ofadults from Ryan and Van Kirk (1974b) and Rustin et al.(1987) suggest they are similar. For example, the averagenumber of treatment hours for establishment was 7.9 in thisstudy and 8.3 hours for adults in Rustin et al. (1987).

38 61-75 February 995


Public School Setting

A third goal was to determine if these procedures could becarried out in the public school setting. All of the data suggestthat this indeed was possible. It was noted that the 9-monthschool year, with two 30-minute sessions weekly, was notenough time to permit some of the subjects to complete theTransfer program. On the other hand, the classroom part ofthe Transfer program was more easily run because thetreatment setting was in the school. The number of sessionsavailable for treatment was commonly around 40-45 ses-sions for the 9-month school year (Mallard & Westbrook,1988; Ryan & Van Kirk, 1974a, 1983). These sessions areusually around 20-30 minutes in length, meaning that pro-grams that run more than 20 hours probably cannot becompleted in the school year and one might predict someloss of skills after a summer hiatus.

Transfer and Maintenance

A fourth goal was to determine the transfer, maintenance,and follow-up effects of the two Establishment programs. TheTransfer program ran in a mean of 9.2 hours (longer whencompared to a mean of 7.9 hours of the Establishmentprogram) with a reduced talking time percentage comparedto the Establishment program (means = 32.4%, 46.6%,respectively). This was partly due to the nature of theTransfer program steps (e.g., the increased audience pro-gram steps involved several other children who talked duringthe session time reducing the subject's talking time) andpartly due to organizational problems (e.g., the class was ona field trip when a classroom program step was due to bescheduled). It seems clear that the predetermined use ofslow, prolonged speech in the DAF program in Criterion test2 did interfere with the generalization of fluent speech.However, this fact permitted examination of the effects of theTransfer program that produced a very pronounced improve-ment in fluency for the DAF subjects. There was very littleeffect of the Transfer program for the GILCU students whowere already fluent in the second Stuttering interview, Home,and School samples (.5, .9, and .9 SW/M, respectively).

Although the specific circumstances for each subject whodid not pass the Transfer program varied, the commonthread was clinician error, commonly undercounting stutter-ing. This permitted the subject to appear to pass a Transferprogram step when in reality the subject had not. Thesubject, then, could not pass Criterion test 3. An analysis ofthe individual performances of the children causes one toquestion the need for an elaborate Transfer program withsome children. However, for individuals who had not gener-alized well, the Transfer program seemed helpful. MaybeTransfer programs should be used selectively for thosechildren who do not generalize spontaneously. After theTransfer program there were no obvious differences in flu-ency between the children from the DAF program and thosefrom the GILCU program.

In a previous study, Ryan and Ryan (1983), the Transferprogram was run in a similar 7.6 treatment hours. Further,there was more stuttering in Home than in School and in

program, but not significantly so. The opposite was observedin this study. This may be due to differences in sample size,or in the method of data collection. In the first study (Ryan &Ryan, 1983) several School samples were collected overtime by the project supervisor, whereas in this study onesample was collected by the teacher in a conversation withthe subject and a classmate. Although the pre-measureswere different, the post were not and both were in the samedirection. There are little comparable transfer or generaliza-tion data on children available in the literature for comparison(an exception is Ryan & Van Kirk, 1974b), and most of theseare for adults.

The transfer or generalization data shown in Table 3demonstrate the complex relationship between stuttering andspeaking rate. Commonly, people who stutter increase theirspeaking rate as their stuttering decreases (Costello, 1980,1983; Ryan, 1974; Ryan & Ryan, 1983; Ryan & Van Kirk,1974b). The exception is the person who initially had highstuttering rates and high speaking rates. That person maydecrease speaking rate, or simply maintain it when stutteringrate decreases. Examination of the generalization of the DAFsubjects revealed reduced stuttering, but not to the extent ofthat exhibited in the treatment setting. This was especiallynoticeable in the comparison between Stuttering interviews 2and 3. The DAF group's speaking rates in the Home andSchool samples were relatively stable probably due to somesubjects slowing down and some subjects increasing theirspeaking rates after their stuttering decreased.

The findings about the low correlations between inclinicand extraclinic samples after treatment suggest that theclinician, to confirm generalization, should obtain a measurein at least the home or the school setting because thestuttering rates were consistently higher than those in eitherthe Criterion test or the Stuttering interview. There was muchsimilarity in the outside measures (e.g., Home sample)between the first and second Ryan and Ryan studies. Thisfinding suggests that the very difficult, elaborate, and time-consuming data collection procedures used in the first study(Ryan & Ryan, 1983) are probably not necessary to get areasonable estimate of the subjects' stuttering in other set-tings.

The data shown in Table 4 permit evaluation of theMaintenance program. Interpretation of these data is that the11 subjects did maintain their low stuttering rates, well under3 SW/M, during the Maintenance program at a relatively lowcost in treatment hours (total mean = 1.1 hours). TheMaintenance program was shown to be effective as mea-sured by Follow-up.

Clinician's Role

A final purpose of this research was to describe theclinicians' contributions to the effectiveness and efficiency ofthese programs. Overall, the clinicians were extremely coop-erative and did very well, earning a mean 77.6% totalperformance rating by the end of the project year (Ryan &Van Kirk, 1974a). This figure, based on 100% as perfect, wasderived from averaging the clinicians' numerical perfor-mances (in percentages) on a counting stuttered word test, a


written test over the program, a monitoring score (programadministration, timing, counting stuttered, talk time percent-age, and accuracy in written data analysis), and subjectperformance (initial severity or SW/M times phase completeddivided by hours of treatment, times eight to convert to apercentage-like score that could be compared to the others).The clinicians produced a large reduction in stuttering. Theirmajor problem, initially, was identifying (therefore not provid-ing a consequence for) stuttered words during unmonitoredprogram treatment sessions. They missed stuttered wordsduring the program, but did count correctly during Criteriontests, indicating they could detect stuttered words, but didnot.

Differences did not exist for the other skills of timing, givinginstructions, offering consequences after correct identifica-tion of stuttering or fluent utterances, and collection ofappropriate talk time. The identification, counting, and provi-sion of appropriate consequences for stuttering turn out to bethe critical skills in the administration of effective pro-grammed instruction. Missing even one stuttered word canmake a difference (e.g., result in unnecessary recycles).Under-identification in the program run meant that the sub-ject inaccurately passed without meeting the criterion of 0SW/M in the program step. The subject then went into afollowing Criterion test where the subject's stuttering wasaccurately counted (by the project supervisor and the clini-cian) and the subject failed, resulting in a recycle. However,in the interest of accuracy, it may be said that the stutteringidentification problem, important as it is, did not prevent theclinicians from producing very good results overall. Also, theydid improve greatly over the project year with continuedmonitoring and training. A secondary, relatively minor prob-lem concerned the clinicians' inability to organize the Trans-fer program.

On the positive side, measures of efficiency, session time(means = 7.9, 9.2 hours in Establishment and Transferprograms, respectively), percentage of talk time (46.6% and32.4% in Establishment and Transfer programs, respective-ly), and calendar days (means = 81.6 and 92.7 in Transferand Maintenance programs, respectively) revealed reason-able times based on our experience (Ryan & Ryan, 1983).However, there was great variance (e.g., calendar daysS.D. = 40.9 days). The efficiency data generated in this studyshould be considered as starting points against which otherresults may be compared. Of course, the severity of thestuttering of the subject plays a role in the efficiency andefficacy equation, also (Ryan & Van Kirk, 1974a, 1974b).

Finally, based on the clinicians' interviews, the cliniciansviewed the programs positively except for minor irritationswith the Transfer program and the DAF equipment. Theclinicians were in good agreement that the programs hadbeen effective in reducing stuttering.

Conclusins__. ._.__._. ._

Programmed stuttering treatment was demonstrated to beeffective and efficient in producing speech fluency in the mostcommon treatment setting, the public schools, with publicschool speech clinicians running the programs. In a total of

18.4 hours of establishment, transfer, and maintenancetreatment therapy, 11 subjects reduced their stuttering from7.9 SW/M to .8 SW/M at a 14-month follow-up. Curlee (1985)related that 65.9% of university training programs reportedteaching prolonged speech, 46.3% taught DAF, and 43.9%taught GILCU. Although minimal difference was shown be-tween the two establishment programs (GILCU and DAF),our experience from this project and others (e.g., Ryan &Ryan, 1983) suggests the two programs be used in se-quence, especially with children. One may start with GILCUbecause it is so much easier to run, provides for speech atmore normal rates, and generalizes better. If GILCU provesto be unsuccessful, then one may switch to DAF or prolon-gation.

There is a need for more clinical evaluation studies like thisstudy, similar to those in medicine (clinical trials) (Brutten,1993a; R. Ingham, 1993b). For stuttering, clear, replicabledescription of procedures, pre- and post-tests of stutteringand speaking rate in both clinic and outside settings, andhours of treatment are needed. Further establishment, trans-fer, maintenance, and follow-up data should be collected.The criterion of hours of treatment has been woefully ne-glected and, as this study demonstrated, is extremely impor-tant because of the limited treatment time in the mostcommon treatment setting, the public school. Interview dataadded another necessary dimension of evaluation. We needto generate more data so that we can evaluate and comparetreatment procedures to make inferences about their relativeeffectiveness and efficiency. We need to identify the bestprograms and then train personnel to run them in ouruniversity training programs.

Acknowledgments

We thank the three California public school districts of Palo Alto:Peggy Tuder, supervisor, and clinicians Jean Sidwell, Jane Stocklin,Gloria McConnell, and Barbara Bean; San Jose: Bernita Gross,coordinator, clinicians Barbara Ellingson, Florence Goehler, AnnetteSobi, and Edna McPherson; and San Luis Obispo: Bill Kent, coor-dinator, clinicians Kathy High, Doreen Smith, Diane Adorno, andJackie Steele. We thank Burl Gray for continued, multifacetedconsultation on the project during its operation. We are indebted toWalter H. Moore for statistical consultation. This project was fundedby the Bureau of Education of the Handicapped, DHEW, Projectnumber 232456, grant number OEG-0-72-4422.

References

Andrews, G., Craig, A., Feyer, A., Hoddinott, S., Howie, P., &Neilson, M. (1983). Stuttering: A review of research findings andtheories circa 1982. Journal of Speech and Hearing Disorders, 48,226-245.

Bloodsteln, 0. (1987). A Handbook on stuttering. Chicago: NationalEaster Seal Society.

Boberg, E. (1980). Intensive adult therapy program. Seminars inSpeech, Language, and Hearing, 1, 365-374.

Boberg, E., & Kully, D. (1985). Comprehensive stuttering program.San Diego, CA: College-Hill Press.

Brutten, E. (Ed.) (1993a). Proceedings of the NIDCD workshop ontreatment efficacy research in stuttering. September 21-22, 1992.Journal of Fluency Disorders, 18, 121-361.

38 61-75 February 995


Brutten, E. (Ed.) (1993b). Richard R. Martin symposium on behaviormodification and stuttering. Journal of Fluency Disorders, 18,1-120.

Budd, K., Madison, L., Itzkowitz, J., George, S., & Price, H.(1986). Parents and therapists as allies in behavioral treatment ofchildren's stuttering. Behavior Therapy, 17, 538-553.

Conture, E., & Guitar, B. (1993). Evaluating efficacy of treatment ofstuttering: School age children. Joumal of Fluency Disorders, 18,253-288.

Costello, J. (1980). Operant conditioning and the treatment ofstuttering. Seminars in Speech, Language, and Hearing, 1, 311-326.

Costello, J. (1983). Current behavioral treatments for children. In D.Prins & R. Ingham (Eds.), Treatment of stuttering in early child-hood (pp. 69-112). San Diego: College Hill Press.

Craven, D., & Ryan, B. (1985, November). Disfluent behavior ofnormal speakers: Three tasks. Paper presented at ASHA, Wash-ington, D.C.

Curlee, R. (1985). Training students to work with stutterers. Semi-nars in Speech, Language, and Hearing, 6, 131-144.

Curlee, R., & Perkins, W. (1969). Conversational rate controltherapy for stuttering. Journal of Speech and Hearing Disorders,34, 245-250.

Goldlamond, I. (1965). Stuttering and fluency as manipulatableoperant response classes. In L. Krasner & L. Ullman (Eds.),Research in behavior modification (pp. 106-156). New York: Holt,Rinehart, & Winston.

Ham, R. (1990). Therapy of stuttering. Englewood Cliffs, NewJersey: Prentice-Hall.

Hersen, M., & Barlow, D. (1976). Single-case experimental designs.New York: Pergamon.

Ingham, J. (1993). Current status of stuttering and behavior modi-fication I: Trends in the application of behavior modification tochildren and adults. Joumal of Fluency Disorders, 18, 27-56.

Ingham, R. (1980a). Modification of maintenance and generalizationduring stuttering treatment. Journal of Speech and Hearing Re-search, 23, 732-745.

Ingham, R. (1980b). Stuttering therapy manual: A clinician's guide.Cumberlin, Australia: College of Health Sciences, School of Com-municative Disorders, Cumberland College.

Ingham, R. (1984). Stuttering and behavior therapy. San Diego:College Hill.

Ingham, R. (1993a). Current status of stuttering and behaviormodification II: Principles, issues, and practices. Journal of Flu-ency Disorders, 18, 57-80.

Ingham, R. (1993b). Stuttering treatment efficacy: Paradigm depen-dent or independent. Journal of Fluency Disorders, 18, 133-150.

Ingham, R., & Andrews, G. (1973a). Behavior therapy and stutter-ing. Journal of Speech and Hearing Disorders, 38, 405-441.

Ingham, R., & Andrews, G. (1973b). Details of a token economystuttering therapy program for adults. Australian Journal of HumanCommunication Disorders, 1, 13-20.

Johnson, G., Coleman, K., & Rasmussen, K. (1978). Multidays:Multidimensional approach for the young stutterer. Language,Speech, and Hearing Services in the Schools, 9, 129-132.

Kully, D., & Boberg, E. (1991). Therapy for school-age stutterers.Seminars in Speech and Language, 12, 291-299.

Mallard, A., & Westbrook, J. (1988). Variables affecting stutteringtherapy in public school settings. Language, Speech, and HearingServices in the Schools, 19, 362-371.

Mowrer, D. (1975). An instructional program to increase fluentspeech of stutterers. Journal of Fluency Disorders, 1, 25-35.

Ricard, H., & Mundy, M. (1965). Direct manipulation of stutteringbehavior, an experimental-clinical approach. In L. Ullman & L.Krasner (Eds.), Case studies in behavior modification (pp. 268-278). New York: Holt, Rinehart, & Winston.

Rustin, L., Ryan, B., & Ryan, B. (1987). Use of the Montereyprogrammed stuttering therapy in Great Britain. British Journal ofDisorders of Communication, 22, 151-162.

Ryan, B. (1971). Operant procedures applied to stuttering therapyfor children. Journal of Speech and Hearing Disorders, 36, 264-280.

Ryan, B. (1973). Programmed stuttering therapy for children. Projectmanual. Unpublished paper. Behavioral Sciences Institute, Mon-terey, California.

Ryan, B. (1974). Programmed stuttering therapy for children andadults. Springfield: CC Thomas.

Ryan, B. (1979). Stuttering therapy in a framework of operantconditioning. In H. Gregory (Ed.), Controversies about stutteringtherapy (pp. 129-144). Baltimore: University Park Press.

Ryan, B. (1984). Treatment of stuttering in school children. In W.Perkins (Ed.), Current therapy of communication disorders: Stut-tering disorders (pp. 95-106). New York: Thieme-Stratton Inc.

Ryan, B. (1985). Training the professional. Seminars in Speech andLanguage, 6, 145-168.

Ryan, B., & Ryan, B. (1983). Programmed therapy for children:Comparison of four programs. Journal of Fluency Disorders, 8,291-321.

Ryan, B., & Van Kirk, B. (1974a). Programmed stuttering therapyfor children. Final report. Office of Education Project 0-72-4422,U.S. Department of Health, Education and Welfare, Washington,D.C.

Ryan, B., & Van Kirk, B. (1974b). The establishment, transfer, andmaintenance of fluent speech in 50 stutterers using delayedauditory feedback and operant procedures. Journal of Speech andHearing Research, 39, 3-10.

Ryan, B., & Van Kirk, B. (1978). Monterey fluency program.Monterey, California: Monterey Learning Systems.

Shames, G., & Florence, C. (1980). Stutter-free speech: A goal fortherapy. Columbus, Ohio: Charles E. Merrill.

Shine, R. (1980a). Direct management of the beginning stutterer.Seminars in Speech, Language, and Hearing, 1, 339-350.

Shine, R. (1980b). Systematic fluency training for young children.Tigard, OR: CC Publications.

Shine, R. (1984a). Assessment and fluency training with the youngstutterer. In M. Peins (Ed.), Contemporary approaches in stutter-ing therapy (pp. 173-216). Boston: Little, Brown.

Shine, R. (1984b). Direct management of the beginning stutterer. InW. Perkins (Ed.), Current therapy of communication disorders:Stuttering disorders (pp. 57-76). New York: Thieme-Stratton.

Skinrud, K. (1973). Field evaluation of observer bias under overtand covert monitoring. In L. Hamerlynck, L. Handy, & E. Mash(Eds.), Behavior change: Methodologies, concepts, and practice(pp. 97-118). Champaign, IL: Research Press.

Webster, R. (1980). Evolution of a target-based behavioral therapyfor stuttering. Journal of Fluency Disorders, 5, 303-320.

Received January 3, 1994Accepted July 22, 1994

Contact author: Bruce P. Ryan, PhD, Communicative DisordersDepartment, 305, California State University, Long Beach, LongBeach, CA 90840. E-mail: [email protected]

1995;38;61-75 J Speech Hear Res Bruce P. Ryan, and Barbara Van Kirk Ryan

Establishment Programs Through Transfer, Maintenance, and Follow-Up

Programmed Stuttering Treatment for Children: Comparison of Two

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