Category: fluency

Maintaining fluency – The Risk of Relapse

After a busy week, with three days at the hospital and two at the fluency clinic, I must admit I’ve missed out on a few posts. However, after a conversation with a Clinical Educator, I felt like investigating the ‘dark side’ of stuttering treatments: Relapse.

I was told that relapse rates were enormously high (>50%), and that the risk factors were contested. Here’s a smattering of the literature

  • Andrews and Craig [1] identified three factors:
    • “Skill mastery as evidenced by no stuttering”
    • “normal attitudes to communication”
    • “internalisation of the locus of control”
    • They found pre-treatment severity to be only a small predictor.
  • A 1996 study [2] claimed “that 12 subjects who remained with the entire 2-3-year program achieved zero or near-zero stuttering”
    • Since I’ve only got the abstract, it’s impossible to say how many subjects were in the trial at its beginning, and therefore how many may have dropped out because it didn’t work.
  • Dayalu and Kalinowski [3] supposed that therapy only provides ‘pseudofluency’, masking rather than removing the stuttering; and suggested that this explains high rates of relapse.
  • A detailed study [4] into the experiences of people after they received prolonged speech treatment found:
    • Risk of stuttering continues, even after therapy.
    • “the maximum benefits of prolonged speech are attained when clients use a strategic approach to control stuttered speech and daily communication.”
  • A few years later, researchers from La Trobe and Sydney Uni found [5] that only stuttering severity predicted short or long-term outcomes for people who stuttered who sought therapy.

Colin-Firth-in-The-Kings--007My experience

I saw a client at a review day on Friday that had been through an intensive Smooth Speech program, and attended many review days. Upon arrival I noted they were quite severe, with many blocks exceeding 5 seconds in duration. However, within an hour of therapy they ‘miraculously’ became fluent — well not miraculously, as I was creating a fluency-inducing environment. Why couldn’t they do this at the beginning of the session.

I thought they needed to be able to self-cue at home and work to create their own fluency-inducements. I asked them to practice in the mirror, before high-stakes interactions and just for the hell of it, to maintain the pattern. I also told them to record themselves during our session being fluent, and to play it back when they were having trouble with fluency: a reminder that they could be fluent. This approach (I later discovered) has preliminary evidence, and is very time/cost effective for both clinician and client [6]. As I explained to them, they needed to develop strategies to maintain their fluency actively, and couldn’t rely on the odd review day to do it for them.

The previous night, another client said they couldn’t wait until the smooth speech became second-nature, and they could talk freely without monitoring what they were doing. Unfortunately, this will probably never happen. They will always need to monitor their speech and actively use the pattern, and this will probably require greater effort than someone who does not stutter. I felt awful delivering this news (in the form of a pep-talk) — if only there were a pill!

This raised interesting questions about whether cognitive constructs like executive-function and attention could be considered prognostic indicators for this type of therapy – a topic for another day.


  1. Andrews, G., & Craig, A. (1988). Prediction of outcome after treatment for stuttering. British Journal of Psychiatry, 153(2), 236-240.
  2. Onslow, M., Costa, L., Andrews, C., Harrison, E., & Packman, A. (1996). Speech outcomes of a prolonged-speech treatment for stuttering. Journal of Speech, Language, and Hearing Research, 39(4), 734-749.
  3. Dayalu, V. N., & Kalinowski, J. (2002). Pseudofluency in adults who stutter: The illusory outcome of therapy. Perceptual and Motor Skills, 94(1), 87-96.
  4. Cream, A., Onslow, M., Packman, A., & Llewellyn, G. (2003). Protection from harm: The experience of adults after therapy with prolonged-speech. International Journal of Language and Communication Disorders, 38(4), 379-395. doi: 10.1080/13682820310001598166
  5. Block, S., Onslow, M., Packman, A., & Dacakis, G. (2006). Connecting stuttering management and measurement: IV. Predictors of outcome for a behavioural treatment for stuttering. International Journal of Language and Communication Disorders, 41(4), 395-406. doi: 10.1080/13682820600623853
  6. Cream, A., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2009). Self-modelling as a relapse intervention following speech-restructuring treatment for stuttering. International Journal of Language and Communication Disorders, 44(5), 587-599. doi: 10.1080/13682820802256973

Stuttering across the seas

I just finished an intensive fluency placement at University. We work in pairs with adult clients who stutter for nine hours a day for five days, teaching them the Smooth Speech technique. It was intense, and at a conservative estimate I think I provided over two thousand verbal corrections to my assigned client (who I’ll anonymize as X and use the gender neutral pronoun ‘they’). Several of the clients spoke multiple languages, and I thought it would be interesting to take a quick look on the state of the literature on bilingual stuttering and then present a quick anecdote regarding a complication of Smooth Speech therapy in multilingual clients.


  • Do bilinguals stutter more? I think it’s safe to say no. An ELVS paper on stuttering (perhaps the best designed/controlled study of its type) found bilingualism or speaking a language other than English not to be a predictor of stuttering (n>1500) [1].
  • Are bilinguals less likely to recover? This is more controversial. One study of 38 children found bilingualism to be an risk factor for persistence of stuttering [2]. This seems suspect to me, if only because it should be easy to see if stuttering is more prevalent in adulthood in linguistically rich countries where many are bilingual (say, Switzerland) as opposed to reasonably resolutely monolingual countries (like Australia).
  • Can monolingual clinicians treat bilingual clients? Here I will defer to my anecdotal experience in the next section of this post.

Client X

It’s difficult to say too much about client X without revealing confidential information. Suffice to say that they had stuttered from early childhood, and spoke five languages: three widely spoken Indo-Aryan languages, Arabic and English.


We began by taking a detailed language history. We asked X which languages they spoke, where they had learned them, when they used them today, whether they understood/spoke/read/wrote better in any, and if their stuttering was better in any of the languages. X reported that they spoke most fluently in English, but thought this was because they spoke English at home and work, and only used their other languages on the phone home. X stuttered in each language, and the loci of the stuttering appeared to be common (word initial glides, stops and fricatives). We did not take an initial rating in X’s other languages, as X believed delivering monologues in these languages was not representative of their usual verbal requirements.


I did a little research into the phonology of X’s languages (Wikipedia normally has great summaries). X’s primary language distinguishes four voicing types for each stop:

  1. tenuis, as /p/, which is like p in English spin
  2. voiced, as /b/, which is like b in English bin
  3. aspirated, as /pʰ/, which is like p in English pin, and
  4. murmured, as /bʱ/. [according to Wikipedia]

English distinguishes two, which are generalised to voiced and unvoiced, although English stop allophones encompass many more possibilities.

X’s stops in English were tense and explosive, and led to the characteristic ‘choppy’ sound of the speech stream associated with Indo-Aryan speakers who speak English. This presented a problem for the smooth speech treatment, which relies on gentle onsets – For my client, using the gentle onsets in Hindi would cause the stops to sound murmured, and would possibly change the meaning of the word. Much of the week involved softening and elongating X’s utterance-initial syllables, something they found quite difficult due to the bilingual interference. Tasks were completed in all of X’s languages, and luckily their were other clients who could converse with them in multiple languages (us clinicians felt fairly linguistically inadequate by comparison).

By the end of the week, X found a happy medium in their native language and English between not saying the right word and being ‘explosive’, and the end result was rewarding for them to see.


  1. Reilly, S., Onslow, M., Packman, A., Cini, E., Conway, L., Ukoumunne, O. C., . . . Wake, M. (2013). Natural history of stuttering to 4 years of age: a prospective community-based study. Pediatrics, 132(3), 460-467. doi: 10.1542/peds.2012-3067
  2. P. Howell, S. Davis, R. Williams. (2009). The effects of bilingualism on speakers who stutter during late childhood. Archives of Disease in Childhood, 94 (2009), 42–46. doi:10.1136/adc.2007.134114

Deconstructing Interventions

A throwaway remark by my Audiology lecturer caught me by surprise. She said that she sits behind children when training them after they receive a cochlear implant in order that they not rely on visual cues when learning to discriminate speech sounds.

Cochlear_implant2Children and adults with hearing loss cannot simply be fitted with an aid or an implant and then walk away ready to hear. They need specific (and in some cases a lot of) training in perceiving speech sounds (as do hearing people, who do this as babies). However, there is a divide between deaf educators/audiologists about the best way to train listening in this population:

  • Auditory-Verbal: No sign language, no visual-cues (i.e. lip-reading) – the child must learn to listen solely through the use of the acoustic signal.
  • Auditory-Oral: Children can use lip-reading and contextual cues as well as listening to crack the speech signal.

Of course there are many shades between these two approaches, and countless other approaches to deaf education. Perhaps I’ll just link to the ASHA Evidence Map

On the other side of the SP range of practice…

I thought it was interesting, because it conflicted with how we do phonological therapy in Speech Pathology, where children who cannot distinguish phonemes are encouraged to perceive both the articulatory and acoustic differences in the sounds. It also is a similar ‘debate’ in Aphasia rehabilitation. One approach is Constraint-Induced Language Therapy (CILT), where clients are restricted to verbal output (no gesture, writing or drawing) through the use of physical screens. A review [1] found large effect sizes, but since the therapy was intense, it remains unknown whether ‘constraint’ is an important aspect of the treatment.

However, there is another school of thought which claims clients should be able to draw on any residual communication in any form. Such an approach is found in Multi-Modal Aphasia Treatment (MMAT), which a pilot study found to be equally efficacious as CILT. A RCT is in the works.

The danger of single-treatment studies

When your study has only one treatment, even if it has a control, it is impossible to say whether it is a treatment that should be used. If clinicians are to choose the best treatments (which we are not presently required to do, all we are required to do is to use evidence-based treatments), we need more studies like [2] and less like [1]. Two other examples spring to mind:

  • Literacy: Is Reading Recovery more efficacious than a Systematic Phonics program?
  • Fluency: Is Demands and Capacities Therapy more efficacious than the Lidcombe Program?

(There is research on the second question [3] finding equal efficacy, but the Lidcombe program was only administered for 12 weeks, in defiance of best-practice and proscribed standards for its implementation).


When we do therapy, we cannot point to research that proves that every component of the intervention (like constraint) is directly related to a result. Perhaps if we removed it, the treatment would still work. This is where a solid theoretical framework helps. If what I’m doing is reasonable given what I know about the body and the brain, I think I’m a lot more comfortable, even if a small aspect of my intervention hasn’t been checked by an RCT.

  1. Cherney, L. R., Patterson, J. P., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282–1299.
  2. Rose, M. L., Attard, M. C., et al. (2013). Multi-Modality Aphasia Therapy Is as Efficacious as a Constraint-Induced Aphasia Therapy for Chronic Aphasia: A Phase 1 Study. Aphasiology, 27(8), 938-971.
  3. Franken, M. C., Kielstra-Van der Schalk, C. J., Boelens H. (2005). Experimental treatment of early stuttering: a preliminary study. Journal of Fluency Disorders, 30(3), 189-99.