Fluency and fluency disorders: Their definition, measurement, and modification

/OURNAL

OF FLUENCY

DISORDERS

3 (1978),

51-71

Fluency and Fluency Disorders: Their Definition, Measurement, M.

N.

and Modification

Hegde of Communicative

Department

Disorders,

College

of Saint

Teresa,

Winona,

Minnesota

55987

Attempts at designing clinical disfluent

procedures

speakers have been increased

basic problems

relating

that would directly enhance

in the recent past. However, measurement,

to the definition,

and

fluency

modification

fluency and fluency disorders have not received much systematic attention. of these problems research

are examined

and clinical

in this article with a view to identify

needs. Published

studies on fluency

therapy

in

some of the of

Some

important

are also re-

viewed.

INTRODUCTION

The traditional

clinical

and research strategies in the field of stuttering

have been directed against various types of disfluencies recent

years,

however,

the emphasis

is being

cedures designed to modify stuttering hance fluency (Ryan, 1971; 1973;

fluency

Culatta, 1971;

1972;

Culatta, 1976),

no systematic

examine some of these questions

1977).

definition

THE

DEFINITION

OF

1977). and

and measurement

It is the purpose of this article to

in an effort to identify significant and fluency

prob-

therapy.

three major areas are reviewed: (I) the

of fluency and its disorders;

and (3) the modification

designed to en-

Culatta and Rubin,

attention has been paid to

lems and research needs in the area of fluency Problems relating to the following

In

the pro-

advocated (Rubin

concerning the definition

(Hegde and Brutten,

from

Hegde and Brutten,

therapy has been vigorously

some of the basic questions of fluency

Culatta, 1976;

themselves.

away

to those directly

Shaw and Shrum,

Manning, et al., 1976;

Although

shifted

(2) the measurement

of fluency;

of fluency disorders. FLUENCY

AND

ITS DISORDERS

At present, fluency cannot be adequately defined in positive terms. This is largely due to the fact that the dimensions Q Elsevier North-Holland,

and the controlling

variables of

Inc., 1978

51 0094-730X/78/0003-001

3501.75

M. N. Hegde

52

fluency

have not been systematically

studies

designed to enhance fluency

analyzed.

In fact, a number

do not contain a definition

of

of it

(Rickard and Mundy, 1966; Bar, 1971; Leach, 1969; Ryan, 1971; Culatta and Rubin, 1973).The lack of operational definitions a theoretical

gap. When clinical

enhance fluency,

intervention

of fluency is not just

strategies are designed to

it should be possible to specify it in measurable terms.

From a descriptive

standpoint, speech behavioral transition

tant factor in fluency.

Smooth

intraunit

transitions

is an impor-

and interunit

succes-

sions are the most outstanding properties of fluency. The units themselves may have phonetic, syllabic, successive

transition

lexical,

of phonetic,

and sentenial

syllabic,

structures.

lexical,

As such,

and sentential

se-

quence of verbal responses can be considered to be the crux of fluency. An unqualified

assumption

of intra- and interunit

transitions

and succes-

sions of speech units, however, would soon run into difficulties there are acceptable forms of repetitive,

because

nontransition

speech behaviors

that are a part of fluent utterances. Phonemic clusters

may repeat them-

selves in certain parts of the same word and/or same sentence. Words may be repeated for emphasis, or because of listener requests; repetitions of some words may be a part of a complex sentence structure. Some kinds of pauses, at a certain level of frequency, may be considered appropriate, and even necessary for meaningful

discourse.

quency of interjections,

and fluency interruptors

considered

hesitations,

to be significant.

may be considered

normal,

All

these nontransition

may not be

speech behaviors

in the sense that their controlling

are other than those that create clinically Efforts at isolating the contorlling able forms of fluency

A certain variety and fre-

significant transition

variables difficulties.

variables of acceptable and nonaccept-

interruptions

would go a long way in limiting

the

parameters of fluency. As long as the parameters of fluency remain unknown,

fluency will

have to be defined in negative terms, that is, it will have to be defined in terms of the absence of behaviors that negate fluency. One obvious solution is to define fluency as the absence of stuttering.

This

solution,

how-

ever, is not as easily achieved as might seem possible because of the fact that there are several different consequence, fluency

one will

kinds

of definitions

have to select a definition

of stuttering. of stuttering

can be defined as the absence of stuttering.

adopted definition

of stuttering

will

As a before

Obviously,

the

play a crucial role in the measure-

Fluency

and Fluency Disorders

ment of fluency.

53

The available definitions

into five differe,nt categories: restrict

the term

to certain

definitions

forms of disfluencies;

can be grouped

(1) perceptual-judgmental

stuttering

experimental-theoretical

of stuttering forms

definitions

(3) definitions

molar moments;

(2)

that also restrict the term to certain that do not consider disfluencies

be crucial, and are based on avoidance behaviors; (4) definitions of unspecified

that

of disfluencies;

and (5) definitions

to

in terms

couched in terms of

hypothetical variables. An example from each of these five categories will be examined in an effort to evaluate the possibility

of defining fluency as

the absence of stutterings. The perceptual-judgmental fact that listeners

differentially

definitions

of stuttering are based on the

react to different forms of disfluencies.

A

number of studies have shown that both trained and untrained listeners tend to classify

syllable

repetitions

and speech sound prolongations

“stuttered”

as against other forms of disfluencies,

repetitions,

and interjections

Sander,

(Williams

notably revisions,

and Kent, 1958; Boehmler,

1963). Young (1961) found that syllable

sound prolongations,

1958;

or sound repetitions,

broken words, and words involving

or tension correlated highly with the ratings of stuttering

apparent stress severity.

Furth-

ermore, analysis fo speech samples of normal speakers and stutterers shown that the latter exhibit a-higher frequency of syllable repetitions

and speech sound

1949; Egland, 1955; Johnson,

prolongations

as

word

(Voelker,

has

or part word

1944; Wyrick,

1959), although a more recent study has

indicated that even children not classified as stutterers may exhibit a high rate of these two forms of disfluencies

(Silverman,

1972). Based on these

and other studies, a number of speech pathologists part word repetitions of stuttering.

Definitions

in their definitions

offered by Van Riper (1971) and Wingate (1964)

are examples. Most of these definitions, disfluency

have included only

and speech sound prolongations

however, do include other non-

behaviors such as tension, avoidance, and other psychological

variables. If fluency is to be defined in relation to definitions

of stuttering that

include only part word repetitions and speech sound prolongations, the occurrence of a number of disfluency whole

word

would still

repetitions,

phrase repetitions,

forms silent

then

such as interjections, pauses, and so on

be considered a part of fluent speech. Although the available

evidence indicates that these disfluencies

are not judged as stutterings,

it

54

M. N. Hegde

is not evident that their presence will

not affect judgments

of fluency.

stands to reason that if a speech sample contained interjections, repetitions,

pauses, and other forms at a high level of frequency, then that

speech may not be judged as being fluent, judged as being stuttered. evoke listener

judgments

Whether

even though it may not be

nonstuttering

of Jack of fluency,

levels are critical for such judgments, empirically fluencies

types of disfluencies

and if so, what frequency

needs to be researched. Until

demonstrated that the presence of nonstuttering fluency

will

not

may not be appropriately

de-

fined as the absence of only the part word repetitions prolongations. From the standpoint of a scientific ses can be established

analysis,

if and when different

isolated for them. If different disfluencies independent variables,

and speech sound

different response clascontrolling

variables

are shown to be controlled

then there would

basis to categorize speech disfluencies. no means unequivocal,

it is

types of dis-

in the speech of speakers at any level of frequency

evoke the judgment of disfluency,

different

It

word

are by

be an experimental

Although the existing data are by

there is some evidence to indicate that operant

punishment

contigency may not have the same effect on all of the speech

disfluencies

(Brutten,

for a review). The suggestion has been that

1975,

part word repetitions and speech sound prolongations by punishment this

kind of evidence,

theoretical

distinction

prolongations, other.

Possibly,

siological

are not suppressed

in the way that other forms of disfluencies Brutten

and Shoemaker

(1967)

between part word repetitions

are. Based on have made a

and speech sound

on the one hand, and all other forms of disfluencies research

mechanisms

demonstrate

on the

that different

neurophy-

control different forms of disfluencies,

providing

yet another experimental

might

basis to make distinctions

viding a basis for a definition

among them. In pro-

of fluency, however, this approach would

also create difficulties

that are similar

perceptual-judgmental

approach to the definition

sence, even if different controlling

to those encountered

the

In es-

variables or different neurophysiologi-

cal mechanisms are isolated for sets of disfluencies, sary to exclude all forms of disfluencies The third approach to the definition

it might still be neces-

from a definition

of fluency.

of stuttering places no particular

emphasis on disfluencies

at all. Johnson’s

stuttering

to a variety of behaviors

refers primarily

with

of sutttering.

(1967)

general position

that

designed to avoid

Fluency

and Fluency

nonfluencies

Disorders

55

is a good example of this approach. Stuttering

terms of an anticipatory

is defined in

avoidance reaction with no critical significance

attached to speech disfluencies.

Surprisingly

enough, Johnson’s

1961) own data on the fluency and disfluency

(1959,

behaviors in children and

adults have demonstrated that when compared to the speech of nonstutterers, stutterers’ speech is characterized by a higher frequency of certain forms

of disfluencies,

sound prolongations.

particularly, Johnson,

part word

however,

repetitions

developed a theory that has remained inconsistent any case, a definition

stuttering,

of fluency.

Defining

stuttering

used within

but is not exhibiting

of

any avoi-

have to be considered fluent. in terms

moments has been a traditional originally

will be of little help in the formu-

For, according to Johnson’s definition

a person who is very disfluent

dance behaviors will

and

with his own data. In

of stuttering that places a primary emphasis on the

behaviors designed to avoid stutterings lation of a definition

and speech

ignored these differences

of behaviorally

nonspecific

molar

practice in speech pathology. Although

the Johnsonian framework,

the moment of stutter-

ing has been one of the popular measures used in clinical

and research

work.

Even some of the better known operant studies (Flanagan et al.,

1958;

Martin

and Siegel,

operant tradition

1966;

of specifying

Martin

employed this concept. Apparently, during which

some nonspecific

ment of stuttering

et al., 1975),

the behaviors

contrary

under investigation,

to the have

the ‘moment’ refers to a time period

behaviors occurred. Actually,

concept hardly constitutes

a definition

does not say what forms of behaviors constitute

the mo-

of stuttering.

stuttering.

It

And for that

reason, it cannot provide a basis for defining fluency, if fluency has to be defined as the absence of measurable behaviors. Finally,

there are some definitions

of stuttering that are couched in

terms of hypothetical variables. Sheehan’s (1970) definition that stuttering is a disorder of the social presentation of the self is a good example of this kind of definition.

Like those based on avoidance behaviors, the defini-

tions based on hypothetical fluencies.

variables make no specific reference to dis-

According to Sheehan (19701, stuttering

is not a speech disor-

der at all. It is only an indication of the presence of an identity problem. Since within

this approach, stuttering,

or whatever the variables

ulated, can hardly be measured, its counterpart, fluency, fined in measurable terms. Definitions

post-

cannot be de-

of stuttering based on hypothetical

M. N. Hegde

56

variables, therefore, are least useful in defining fluency. In sum, it can be stated that the available definitions not provide an adequate basis for defining fluency. definitions

of stuttering

fluency

matter.

of these theoretical

As such, their

is not immediately

the available definitions what irrelevant.

positions

fluencies

on

is itself a con-

relevance to a scientific

analysis

of

evident. In addition to being too theoretical,

of stuttering

They are restrictive

are either too restrictive

or some-

in the sense that the absence of part

word repetitions and speech sound prolongations speech is fluent.

speaking,

are tied down to various theoretical positions

that behavior. The validity troversial

of stuttering do

Generally

Some are irrelevant

may not mean that the

because they do not refer to dis-

or other speech characteristics.

It is therefore

evident that

fluency is better defined as the absence of all the known forms of fluency interruptors

that are also measurable. It is thus suggested that fluency may

be defined as ongoing speech or oral reading behaviors that are devoid of all forms of disfluencies, more, disfluencies

silent prolongations,

and silent pauses. Further-

may be identified in terms of the following:

repetitions

of parts of words, whole words, phrases, and sentences; prolongations speeech sounds; incomplete described

interjections

phrases; and revisions. by Johnson

(1961),

pauses. Descriptively,

of behaviors

Broken words, a form of disfluency

can perhaps be included

under silent word units.

silent pauses and silent prol,ongations are added that interrupt

pauses, there, is no observable whereas in silent

of

words, and phrases;

broken words contain pauses within

Along with disfluencies, to the list

of sounds, syllables,

prolongations

fluency.

In inappropriate

effort to articulate

sounds

silent

or words,

there is an observable motor behavior

pattern associated with the production

of sounds

and syllables.

pauses, although often accepted as a part of stuttering,

Silent

have not been

studied in a systematic manner. It should be clear that from the standpoint of behavioral topography, pauses and silent fluencies.

However,

prolongations

in the way that disfluencies

interrupt fluency. They are also accepted by listeners not exceed as yet empirically

undetermined

are not dis-

do, these behaviors also as long as they do

criteria of frequency, dura-

tions, and loci. THE

MEASUREMENT

OF FLUENCY

A majority of the few published studies have made no systematic effort to measure fluency (Rickard and Mundy,

1966;

Leach, 1969;

Bar, 1971;

Fluency

and Fluency

Ryan, 1971;

Disorders

57

Rubin and Culatta, 1971;

Culatta and Rubin,

the studies reported by Shaw and Shrum (1972),

1973).

Only

Manning et al. (1976),

and Hegde and Brutten (I 977) have included the measurement of both fluency

and disfluencies.

number

of stutterings

The

other studies

have either

or have made some qualitative

reported the

and subjective

statements regarding the improved level of fluency after therapy. In the measurement of stuttering, several procedures have been used (Bloodstein,

1969) and it is possible to use them, or their counterparts,

in

the measurement of fluency. These procedures vary considerably in terms of validity

and practical usefulness.

mean durations,

and individual

Rate of speech, ratings of severity,

and total frequencies

all been used in the measurement of stutterings

of behaviors have

or disfluencies.

Slower or

faster rates of speech might reflect relative levels of fluency, as they have been taken to reflect the different degrees of the’severity Studies

have shown

that in oral reading stutterers

exhibit a mean rate of I23

of stuttering.

(Bloodstein,

1944)

words per minute with a range of 42 to 191,

whereas normal speakers (Darley,

1940) have a mean rate of I67

per minute with a range of 129 to 222 words.

The difficulty

words

with the

speech rate is that it is only an indirect measure of fluency or lack of it. Besides, the wide and overlapping range reported for both the normal and the disfluent

speakers makes it practically worthless.

As many clinicians

have observed, a faster rate does not always guarantee fluency, slower rate does not always indicate the presence of disfluencies cally significant

levels. Sometimes

presence of disfluencies

the slower

at all. Similarly,

and a at clini-

rate may not indicate the

rating

scales

of stutterings

or

fluency also provide only indirect measures. Rating scales are a subjective way of arriving at what appear to be quantitative data. When fluency is rated with such categories as minimal,

moderate, excellent,

and so on,

there are actually no objective and discrete measures of what is being measured. Since rating scales are basically evaluative tools, they do not serve the more exact purpose of measuring individual The measurement

of the mean duration of fluent utterances could

provide yet another procedure. As will measures themselves

behaviors.

be discussed below, the duration

can be very useful, but the mean duration may not

be. To say that a particular person is fluent for IO set (or whatever) on the average is better than saying that he is a moderately fluent person. However, the mean duration

suffers

from the weakness

averaging method does. It masks the properties surement

that any statistical

of the individual

units. The mean duration of fluency is particularly

mea-

unattractive

M. N. Hegde

58

when the chosen intervention

strategy involves

placing a specific con-

tingency on individual durations of fluency. In such a clinical strategy, the clinician

needs specific durations

that occur frequently

enough, not an

abstract mean that may have a very low frequency of occurrence. Measuring the frequency of fluent utterances can be a useful procedure, although the inherent potential problem.

This

extent by specifying syllables

variability

problem,

of the length of utterances is a

however,

can be overcome to some

the length of utterances in terms of the number of

at different levels of measurement.

It would still

some procedure at best because of the difficulty the number of syllables considerable conversational

be a cumber-

involved in monitoring

in successive utterances. This difficulty

when the response mode in which fluency speech. This

measure, however, can be used when the

subject is made to read specially

prepared prose material.

In general, a form of duration measure are practical at the present. procedures are superior

would be

is measured is

measure and a form of utterance It may be argued that these two

to other procedures such as rating scales and

speech rate. Practical forms of these two procedures are described below. Time-based

measures of fluency

The time-based

measures are specified

in terms of a duration for

which fluency is sustained by the subject. Usually, sured

in terms of seconds or minutes,

severity

of the subject’s

selected for measurement However,

disfluent

disfluencies.

the duration is mea-

the critical Therefore,

depends mostly

element

being the

the specific

duration

on the individual

speaker.

speakers exhibit periods of fluency that keep varying

most of the time. This is apparently due to the shifting loci of disfluencies. Nevertheless, will

the clinician

serve as the criterion

program. Procedurally, clinician sustained duration

needs to select a particular duration, measure throughout

an experiment

after having obtained reliable speech samples, the

will have to measure all different durations for which the subject fluency.

Once such a set of durations, is obtained, a single

may then be selected as the criterion

measure. One obvious

method is to select the mean of the observed measures. statistical

which

or clinical

mean suffers from the kinds of weaknesses

although two published studies (Shaw and Shrum,

However,

the

described above,

1972; Manning, et al.,

Fluency

and Fluency

Disorders

59

1976) have used the mean duration of fluency. A better alternative is to select the mode (Hegde and Brutten, 1977). The most frequently occurring duration of fluency

(mode) is superior

to the mean measure because it

represents a discrete behavior. The mode may also be useful in obtaining an optimum effect of the selected clinical intervention

strategy. For exam-

ple, if the clinical strategy involves placing a positive operant contingency on fluency,

the mode measure gives the maximum

number of oppor-

tunities to reinforce in any single session. The mean measure would mostly result in fewer reinforcement length of individual tunities

opportunities.

durations

In fact, if the variability

is considerable,

the reinforcement

of the oppor-

may actually be negligible.

Response-unit-based

measure of fluency

In the response-unit-based

measure of fluency, what is measured is

not a duration for which the client sustained fluency, but a specific unit of response that is devoid of disfluencies, pauses. It is similar

silent

prolongations,

and silent

to the fluent utterance measure, but is not the same.

Utterance measures are obtained usually per utterance, whereas the response-unit

in terms of number of syllables measure may not be restricted to

syllable count. In most cases, the measurement may not necessarily begin at the syllable level. Instead, the first level of measurement may constitute single word utterances that are fluent. Subsequent units of measurement can include two word utterances, phrases, single, and multiple sentences. In addition to these units, paragraph(s) and page(s) can be used when the mode of response is oral reading. When therapeutic contingencies

are

placed on fluent reading of a paragraph or a page, the actual number of words read will

certainly

vary. Such variations,

however,

may not be

crucial as long as the number of words read are also counted. In such a clinical

strategy, subjects

will

actually

varying schedule of reinforcement,

be performing

under a form of

which may be advantageous in terms

of higher resistance to extinction. The time-based and the response-unit-based the criterion frequency.

of reliability

and a criterion

measures should fulfill

that might be referred to as

A stable rate of the measured duration or response unit will

have to be obtained before the intervention

technique can be effected. A

stable rate is one that shows neither a decreasing trend nor an increasing

60

M. N. Hegde

trend over time (Hersen and Barlow, 1976). Although such a stable rate is the ideal preintervention desirable

rate of response, often a decreasing trend in the

behavior to be manipulated

undesirable

fect in such a situation base-line trend. When experimental

(and an increasing

trend in the

behavior in question) may be accepted. The therapeutic efwill

have to be strong enough to reverse the

such a reversal is obtained, the influence of the

contingency will

The criterion

have been demonstrated.

of frequency

that the selected measures must fulfill

refers more to the practical aspects of planned clinical to the actual concerns of measurement.

intervention

than

In essence, the selected duration

or the response unit should not be occurring

100%

of the time; if it did,

there would be no need to modify it. Or should its occurrence be 0%, in which case it cannot be reinforced, although it can be shaped. Since most stutterers

exhibit

some level of fluency,

the slow procedure of shaping

can be avoided. The statistical

mode can easily meet the requirements

when the measurement

procedure adopted is fluent

other procedure, the selection determined

by the severity

of frequency

durations.

of the length of units would

of disfluencies.

initially,

In the

largely be

at least, a very dis-

fluent subject’s fluency may have to be measured only in terms of single word utterances.

By and large, response-unit-based

suitable to subjects who are relatively

are suitable to subjects who are relatively surement

more fluent.

In terms fo mea-

of fluency,

perhaps under 4

procedures, very short durations

set, may be difficult

to measure without the aid of operant conditioning

equipment. Manning, et al. (1976), ing with a stopwatch, durations although most clinicians that and similar

measures are more

less fluent. The duration measures

levels.

however, have succeeded in measur-

of fluency that were as brief as 1% set,

would find it difficult The

to maintain accuracy at

need for programming

case, is greater with the duration-based

equipment,

in any

procedure than it is with the

other. The response-unit-based

measures are relatively

simple as long as

the units themselves

are limited to a few words or sentences. From then

on, the within-session

measurement of fluent responses becomes increas-

ingly more complex and difficult

to accomplish.

However, once the sub-

ject attains a certain level of fluency, the measurement procedure can be switched to that of durations.

As the fluency

increases, the length of the

duration can also be increased in a systematic

and gradual manner.

61

Fluency and Fluency Disorders

THE MODIFICATION

Attempts at directly

OF FLUENCY

modifying

fluency are relatively

new. Traditionally,

increased amount of fluency was achieved as an indirect effect of directly modifying stuttering.

As pointed out by Culatta (1976) more than 95% of

the articles published in the journals of the American Speech and Hearing Association

under the heading “Stuttering”

the measurement, it certainly

discussion,

is surprising

modification

have been concerned with

or manipulations

that fluency,

of disfluencies.

Although

the clear target of any disfluency

program, has been neglected to the point that the basic

parameters of it remain unclear, it is difficult

to agree with Culatta (1976)

who contends that the study of stuttering oriented, and illogical.

Culatta (1976)

is negatively oriented, failure

implies that if research is directed

against a deviant behavior, then somehow becomes the therapeutic the goal of stuttering

goal.

that deviant behavior itself

It is true that fluency has not always been

therapy (Van Riper,

1973).

indeed, the belief that

fluency is an unattainable goal for most stutterers

may have been based

on the fact that speech pathologists have not been successful ing a therapeutic across subjects,

method that resulted settings,

and clinicians.

in reliable

One of these positions stuttering

implies

and lasting fluency

As a result,

positions with regard to stuttering modification

in develop-

two philosophical

have emerged in the past.

that what can be modified is the form of

response, not so much the frequency of it. The form is modified

so that the client, even though he continues to stutter, does so with less tension, struggle, and with less bizarre behaviors. Some reduction in the frequency may also be achieved, but almost as a side effect. The other position implies that what should be modified is not so much the form of disfluency,

but its frequency.

this philosophical disfluencies

Therapeutic

procedures designed within

posture seek to obtain a reduction in the frequencies of

to a level that is judged normal or socially

two sets of procedures

based on these two philosophies,

no means incompatible.

A clinician

acceptable. The however, are by

attempting to obtain an overall re-

duction in the number of disfluencies

might use, in the initial

stages of

therapy, procedures that would modify the form of disfluencies. The belief that perfect fluency is not a realistic goal for most stutterers is not a necessary part of any attempt designed to analyze stutterings and disfluencies.

There

is nothing

illogical

in analyzing

a deviant be-

62

M. N. Hegde

havior that needs to be eliminated. undesirable

Certainly,

one way of eliminating

behavior is to isolate its controlling

achieved only through

an analysis

variables.

of that undesirable

This

an

can be

behavior itself.

Often, this may be the most economical way of enhancing the incompatible, desirable, stuttering

behavior. Unfortunately,

and speech disfluencies.

that has not been the case with

The reason for this failure may lie in

the tendency, on the part of a number of investigators,

to rely heavily on

hypothetical variables in their research on stuttering and disfluencies. a consequence,

the independent

variables

that the investigators

after have rarely proved to be the crucial ones. However, methodological

posture of analyzing

be blamed for this failure. fluency and disfluency of fluency

Moreover,

modification

modification

the ultimate

clinical

cannot

goal of both

remains the same: increased amount

or disfluency

Whether

the adopted

modification

may not be

as long as one can obtain a concomitant

unfocused, behavior. Without

the general

and disfluencies

and decreased amount of disfluencies.

strategy is fluency crucial

stuttering

As were

effect on the other,

such a concomitant effect, no program can

be considered to have been successful.

In fact, the terms fluency therapy

and stuttering therapy are not used to make a distinction respective therapeutic goal or outcome. Particularly are used to refer only to procedural distinctions.

in terms of their

in this article, they

In stuttering therapy, the

selected independent variables are applied to all or certain kinds of disfluencies.

In fluency

therapy the independent variables are applied to

units or durations of fluent speech. Culatta (1976) stuttering

further

implies

that procedures designed to modify

are not compatible with those designed to enhance fluency.

This again ignores the dependency and concomitancy found between the two. Moreover,

purely from a technological

procedures are perfectly compatible. cies on fluency, the clinician fluencies

While

standpoint, the two sets of placing positive contingen-

can place punishing

contingencies

(Martin and Siegel, 1966). The punishment

on dis-

studies have in fact

shown that a more effective way of reducing a behavior is to reinforce an alternative,

desirable,

behavior while

the undesirable

behavior comes

under the influence of punishing contingency (Azrin and Holz, quite

possible

hypothesis

that research

that the best clinical

and the disfluency

modification

in fluency

therapy

might

approach is to utilize

1966). It is

support

the

both the fluency

procedures in a single subject.

Fluency

and Fluency

Published

have mostly

studies in the area of fluency modification

used operant conditioning procedures,

63

Disorders

techniques, particularly positive reinforcement One of the earliest case studies was

to enhance fluency.

reported by Rickard and Mundy (1966) who ignored stuttering and positively reinforced fluency in a 9-year-old boy. The child was asked to utter phrases from given words,

read sentences, and to engage in conversa-

tional speech. Fluent utterances were reinforced well as with

points

leading to extrinsic

with verbal stimuli

rewards.

sessions, the subject was able to attain fluency in conversational although

a 6-month

follow-up

showed

fluency in the natural environment. defined as ‘nonstuttering

errors.”

tion errors”

only a partial maintenance and stuttering

Presumably,

included other forms of disfluencies.

of

itself was de-

reinforced “fluent speech”

In all the sessions, only the “repeti-

were measured; other forms of disfluencies

tered responses were not measured. Finally, propriate control conditions

speech,

In this study, fluency, however, was

verbal behavior,’

fined only as “repetition

as

Over a period of 23

and fluently

ut-

the study did not have ap-

since only pretherapy baselines were estab-

lished in each session. Another

case study was reported by Leach (1969).

The important

aspect of this study involved the presentation of a penny for every 15 set of fluency in conversational of unspecified “blocks”

speech. A significant reduction in the number

was observed in 42 sessions,

held over a period of

1 year. Although the criterion measure was a fluent duration, the frequency of durations themselves was not measured before, during, or after therapy. Besides,

fluency

was not defined. In addition, the reinforcers

delivered immediately

following

were not

the occurrence of fluent durations. They

were withheld until the beginning of the next session, reportedly to ensure prompt attendance. This A study by Nelson

resulted, at the best, in delayed reinforcement. (1968)

has been described as an attempt to

reinforce fluency (Shaw and Shrum,

1972). This

study, however, did not

have fluency as its target behavior at all. Nelson reinforced “easy repetitions and prolongations” significant

and not fluent speech. Not very surprisingly,

increase was evident in the frequency

sponses. This attempt suggests that for some clinicians when the form of stuttering Bar (1971)

of fluent

no

speech re-

fluency is achieved

is modified.

reported a clinical

study in which

children (48) were included. Unfortunately,

a large number of

this study has methodological

M. N. Hegde

64

deficiencies.

The procedure used is simply

make fluency

“fun”

by socially

described as an attempt to

rewarding its occurrence. The outcome

was described in equally vague terms: 44 out of 48 children are said to have become “fluent speakers.”

No specific information was made avail-

able with regard to (1) the behaviors defined as stuttering;

(2) their fre-

quency before and after therapy; (3) the criteria employed in judging a child as having become a “fluent speaker”; (4) operational specification of the therapeutic procedure; and finally (5) the definition and measurement procedures employed in the study. Most of these deficiencies are common to a number of fluency studies,

however.

Ryan’s (1971) study used a variety of techniques to enhance fluency in five children who stuttered. Although stages of increasing task complexity

reinforcing fluency at successive

was a common procedure used with

all subjects, different subjects experienced a variety of different additional procedures tion.”

including

such methods as prolongation

and “desensitiza-

For this reason, no valid statements can be made regarding the

effectiveness include

of any one of those techniques.

control

procedures.

specified for individual

Although

Besides, the study did not

types

of disfluencies

were

subjects, they were measured in terms of a mean

rate per minute. One of the subject’s mean rate of stuttering

per minute

was reported to be 13.3, with a range of 0 to 24. With this kind of range, the mean rate of stuttering of disfluencies.

per minute is one of the least useful measures

Furthermore,

no specific measures of fluency

ported in the study. The combination however, were apparently successful in disfluencies

in all five children.

obtained after 6 to 15 months,

of techniques

were re-

used in the study,

in obtaining a significant

reduction

Ryan also included follow-up

reports

which indicated that fluency was main-

tained, although no quantitative data were offered. An experimental reinforced

study in which

fluent

durations

was reported by Shaw and Shrum

(1972).

were positively Three

stuttering

children aged 9 to 10 years were used as subjects. Fluency was defined as the absence of disfluencies identified

in conversational

according to Johnson’s (1961) criteria.

used in which the selected durations one session

and stutterings

for fluency was reinstated. fluencies

speech. Disfluencies

A reversal design was

of fluency were first reinforced in

in the next. In a final session, Baselines

were obtained in a single,

were

of both fluency initial,

session.

reinforcement

measures and disThe results

showed

Fluency

and Fluency

65

Disorders

that fluency increased when it was reinforced in all three subjects with a concomitant

decrease in disfluency.

Similarly,

disfluencies

increased

when they were reinforced, with a concomitant decrease in fluency, thus demonstrating

the controlling

Shaw and Shrum study

(1972)

in the direct

effect of the experimental

study

perhaps constitutes

manipulation

of fluency.

contingency. The the first

controlled

It did demonstrate

that

fluency could be enhanced with an appropriate contingency while ignoring disfluencies. Culatta and Rubin (1973)

have described a program for the initial

stages of fluency therapy. The program involves subjects are normally

some 11 steps and the

moved through these steps sequentially.

steps are described as the philosophical

The first six

portion of the program whereas

the last five steps are referred to as the performance

portion.

In the

performance portion of the program both the fluent and disfluent ances are evoked at different predict them. The

levels;

utter-

the subjects are also requested to

program ‘is terminated

when the speaker is able to

produce on three occasions at least two fluent sentences containing

at

least two words each. The data presented for six subjects have shown that the program is able to effect a reduction in disfluencies, subjects were still exhibiting of program termination.

a disfluency

although most

rate in excess of 3% at the time

A number of desirable design features, however,

are missing from this report. Although the authors indicated that a ‘h-hour base-line session was held to assess fluency, no operational description of this procedure is provided; no quantitative data on fluency are offered. In view of the variability

and the situational

known to affect the disfluency can be judged to be highly stuttering

Reportedly,

base-line

session

both fluency

fluency

and

was again as-

the completion of the program, but no description of the

procedure is provided. More importantly, of control condition.

the study did not have any kind

These deficiencies are serious enough to raise ques-

tions about the usefulness Certain assumptions

of this program. inherent

gram are also of questionable designed to change stutterers’ philosophical

Yz-hour

inadequate. In addition,

have remained undefined.

sessed following

adaptation factors that are

rate, a single

in the Culatta and Rubin (1973)

validity.

verbal behavior should

and cognitive. The most significant

verbal behavior of stutterers

constitutes

pro-

It is not clear as to why attempts

an explicit

be regarded as

change effected in the acknowledgment

that

66

M. N. Hegde.

they (stutterers) are responsible was originally

for their fluency and disfluency.

expressed by Williams

external force responsible

(1957)

for stuttering.

This

idea

who stated that there is no much discussed statement

that it is the stutterer who is “doing” the stuttering trivial

This

can be true only in a

sense. The statement can be taken to mean only that there is no

mystical

or supernatural

stutterers

still

force that is responsible

believe in the influence

for stuttering.

If some

of such a force, the idea can

perhaps be used to dispel1 such a belief. On the other hand, if the statement is intended to exclude the influence pendent variables, then obviously

that do show that a number of situational, ables

affect the frequency

neurophysiological present similar

of all kinds of external

inde-

it runs against much of the existing data

of stuttering.

audience, and linguistic In addition,

when

variand if

independent variables are isolated, they would also

difficulties

for that philosophical

statement. The stutterer

as a person and the independent variables that control his stutterings not be the same. Therefore,

may

the question as to why a person stutters is not

answered by the statement that it is the stutterer who does the stuttering. This

position

may actually give a false impression

variables of stutterings framework,

that the controlling

have been found. Furthermore,

Culatta and Rubin

strated that the philosophical the kind of improvement

(1973)

within

a clinical

have not unequivocally

demon-

portions of their program were necessary for

observed in their subjects.

They

did run two

subjects through the performance portion only and found that one of the subjects showed a significant

reduction in disfluencies

subject showed no change. Both were subsequently

whereas the other

run through the entire

program. This time, the subject who had not improved with the help of the performance portion showed significant control

procedures,

however,

improvement.

makes it difficult

Lack of any type of

to conclude with

authors that the cognitive portion was necessary. Particularly

the

important is

the lack of data based on the cognitive steps only. In a more recent study, Manning et al (1976) addressed themselves to the question as to whether tangible reinforcers would be more effective than verbal reinforcers

in enhancing fluency in stuttering children.

In their

effort to determinte the relative effects of these two types of reinforcers, the authors also added another independent variable, a mark placed on a piece of paper for every criterion

response. After one base-line session

Fluency and Fluency

Disorders

67

that lasted 15 min during the first week, the subjects were run through one conditioning,

one reversal, and one reinstatement

session during the

second week. About 2 months later, there was also a IS-min session.

The three experimental

segments. In the conditioning mark for every fluent interval

sessions

carryover

were divided into three 10-min

and reversal sessions the subject received a in the first

min, the positive verbal reinforcer

10 min;

during the second 10

was added, but it was not response

contingent. The child was praised at the end of that segment. During the final 10 min-segment,

the tangible reward was added to the marks in the

same manner as the verbal reward. During reinstatement

session,

changed to “marks

the three segments of the

the order of the reinforcement

plus a tangible reward,”

ward,” and “marks only.”

“marks

presentation

was

plus a verbal re-

The results obtained indicated that predicted

changes were taking place within the three segments of each experimental session:

Fluency and disfluency

perimental

contingencies.

and tangible However,

reinforcers

came under the influence of the ex-

The authors concluded that both the verbal were equally

effective

due to some methodological

this study, the conclusions

in enhancing fluency.

deficiencies

that are present in

are guarded. First of all, one 15-min

taken 1 week before the experimental

sessions,

able measure of fluency and disfluencies.

baseline,

may not indicate a reli-

Second, in the manipulation

of

the three independent variables, the authors did not adhere to the rule of changing only one variable when (moving from one phase of the experiment to the next (Hersen

and Barlow,

1976).

The results also show that

marks themselves were effective in increasing fluency. Either the verbal or the tangible reinforcers were never administered alone in conditions separated by control conditions.

As a result, the three independent variables did

not have appropriate control conditions.

The reversal procedure served

only to demonstrate that the combination

of the contingencies

used was

effective; the relative and interactive effects of these variables, however, remain unclear. The research questions

raised by Manning et al. (1976),

however, are quite important and they need to be researched systematically. Unlike

most other studies in the area of fluency manipulation,

Hegde and Brutten

(1977) study had adult stutterers

as subjects.

the

Three

subjects were run through a sequence of two base-line, two experimental,

68

M. N. Hegde

and two extinction

sessions on 6 consecutive days. Each session lasted 45

min. Fluency was defined as ongoing speech behavior in the absence of all forms of disfluencies,

which were further specified. Based on an initial

speech sample, all durations of fluency were measured and the statistical mode was selected for the experimental line, experimental, fluencies

and extinction

manipulation.

sessions,

and the selected modal duration

During the experimental

condition,

of fluency

prose passage in all the sessions.

all three subjects, fluency.

the reinforcing

Near base-line

vered in the extinction is the experimental

contingency

were measured.

contingency

This

The subjects read a

The results indicated that for

measures of fluency sessions.

of dis-

a dime was delivered contingent on

the occurrence of every modal duration of fluency. continuous

During the base-

both the frequency

had a positive effect on

and disfluency

were reco-

study therefore demonstrated that it

that was responsible

changes in the fluency of the disfluent

for the observed

speakers who served as subjects.

There has been an earlier study in which adult stutterers received positive reinforcers

for fluency.

This

also involved a punishment

study (Martin

and Siegel,

contingency for stuttering.

1966),

however,

As a result,

it did

not permit specific statements on the effects of rewarding fluency. As this review indicates, controlled studies in the area of fluency therapy are just beginning to appear. The need to analyze fluency in a systematic manner is twofold. As a normal aspect of speech behavior, it deserves to be studied in its own right. From the clinical standpoint, the need stems more from methodological possibilities than from philosophical considerations. At least within the operant paradigm, being able to place reinforcing contingencies on fluency in stutterers either alone or in combination with punishing contigencies for stuttering would mean that clinicians are better able to exploit the full range of operant procedures. Finally, it should be pointed out that much needs to be done before fluency therapy can be well established. It is quite possible that reinforcement procedures will have to be combined with others, such as controlled breathing, biofeedback, delayed feedback, and many other procedures to obtain durable fluency (Ryan, 1971; Azrin and Nunn, 1974; Hanna et al., 1975). However, it would be prudent to establish the effects of each of those variables separately before combining several of them into therapeutic packages. Combining a conglomerate of techniques without a proper analysis of the individual, interactive, and cumulative effects would lead to the same

Fluency

and Fluency

69

Disorders

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