Multiple baseline analysis of the regulated breathing procedure for the treatment of stuttering

/OURNAL OF FLUENCY DISORDERS

Multiple

6 (1981), 327-339

327

Baseline Analysis of the Regulated

Breathing Procedure for the Treatment of Stuttering Donald A. Williamson Baton Rouge

Lousiana State University,

Leonard H. Epstein and Chris Coburn University

of Pittsburgh

The effects

School of Medicine

of a regulated

breathing

speech of an adult stutterer design.

Speech rate, dysfluency

measured

during

speaking change

in each

listened

samples

The naive observers

to understand and global breathing,

validation

the subject’s

impression

stuttering,

facial

baseline procedure

subjective

made

and while reliable

speech speech

of the

The treatment

in which

naive

effects

observers

in all phases

of the

in terms of the ability

desire to interact

by the subject.

(EMG) were

situation,

implementation

fashion.

of the subject’s

of the

across situations

Results showed

with

rated the subject’s

speech,

social

social

intercom.

consistent

in a multiple

by a social

to tape-recorded

characteristics

baseline

a simulated

an office

measure

treatment

substantiated

experiment.

or over

dependent

breathing

on several

in a multiple

rate, and masseter electromyelogram

an interview,

on the telephone

regulated were

reading,

procedure

were evaluated

with

Descriptors

the subject,

were

regulated

EMG, and social validation.

INTRODUCTION Azrin

and

Nunn

long-lasting

treatment

provided

training

regulated

breathing

in subjects

reversal

as a behavior

stuttering.

Fourteen

subjects

package

that

episodes

is an attempt first

to

A.

with

stuttering.

suggested

was

Williamson,

to

two

were

Changes and

of 1 mo.

issues involving

provide

Department

a systematic

of

Psychology,

Baton Rouge, LA 70803

“Elsevier North Holland, Inc., 1981 52 Vanderbilt Ave., New York 10017

and

included

an immediate

for a minimum

to analyze

purpose

Donald

to be a rapid

treatment

that was maintained

The

correspondence

State University,

breathing

incompatible

of stuttering

study

breathing.

Address

regulated

for self-reported

in stuttering

The present

Louisiana

showed

in a habit

self-report

rapid decline regulated

(1974)

0094-730X/81/04327-13$2.50

Donald A. Williamson

328 laboratory

analysis

of the specificity

of treatment

effects of regulated

breathing in several situations that set the occasion for stuttering.

Second,

the effects of regulated breathing on facial EMG activity were assessed, as numerous

researchers assume that dysfluent

sive facial muscle tension (Williams,

1955,

speech results from exces1957;

Shrum,

1967).

The effects of regulated breathing were evaluated in two ways: (1) a multiple

baseline across settings design provided evidence that changes

in stuttering

behavior observed were related to the regulated breathing

procedure, and (2) social validation procedures were used to ensure that changes in speech were apparent to uninvolved Wolf,

observers (Kazdin,

1977;

1978).

METHOD Subject The subject was a 39-yr-old He had previously therapy,

man with a 31-yr

history of stuttering.

received several types of speech therapy and psycho-

but none of these therapies

had effectively

stuttering for more than 1 mo. Preliminary

assessment

remediated

his

indicated that his

stuttering was worst around strangers or persons he regarded as impatient with his frequent blockages of speech. Also, he noted that he was most fluent while reading aloud and was most dysfluent while speaking on the telephone.

Furthermore,

behavioral observations

indicated that the sub-

ject engaged in numerous facial gestures, e.g., grimacing and clenching teeth while attempting to speak during blocking episodes.

Apparatus Speech during all baseline and training sessions was recorded using a cassette tape recorder.

Masseter

EMG was recorded using

a Grass

Model 7 polygraph. Raw and simple integrated EMG were amplified and integrated

by a 7P3

recorded

using

ver-chloride

preamplifier.

a 7PlO

Cumulative

preamplifier.

Small

integrated

EMC

Beckman

silver-sil-

electrodes were used for recording EMG.

was

Regulated Breathing

329

Procedure All baseline and treatment sessions

were of approximately

45-60-

min duration and occurred once or twice per week. During each session, the patient’s speech was tape recorded during four 5-min periods. During the first period, the patient read aloud from current periodicals.

During

the second

or

5 min,

one of the two

therapists

(either

DW

CC)

interviewed the subject regarding a variety of different topics, e.g., family and interests.

During

the third

period,

one therapist

and the subject

role-played talking in a social situation, e.g., small talk at a party. Finally, during the fourth period, the subject spoke to one of the therapists over the telephone or over an office intercom. With three sessions, During

the exception of the first

masseter EMG was recorded during the entire session.

sessions

laryngeal muscles.

4-6,

EMG

was also

Preliminary

masseter EMC was positively

recorded from

the chin

and

analysis of these data indicated that only related to the rate of dysfluency.

and laryngeal EMGs were not recorded during the remaining

Thus,

chin

sessions.

Masseter EMG electrodes were positioned directly over the left masseter muscle, parallel to the angle of the jaw. An initial baseline record of speech was obtained during the first six sessions. instructions

During

the baseline

condition,

the subject

was

given

no

regarding the treatment procedures.

During sessions

7-11,

the subject was given instructions

regarding

use of the regulated breathing procedure. He then practiced the procedure

first

therapists.

during

reading

Following

this

and later

during

conversations

practice, the subject

utilized

breathing procedure only during the first two assessment during reading and interview instructed

to follow

periods, including The

periods.

During

the procedure during

the social situation

sessions

all four

with

periods,

12-16,

components:

of the assessment

and telephone/intercom

(1) the subject learned to discriminate

stuttered and to anticipate when stuttering subject adopted a relaxed posture (Azrin

i.e.,

he was periods.

regulated breathing procedure used’ in this study consisted

following

the

the regulated

of the

when he

was about to occur; (2) the and Nunn,

1973);

(3) when

stuttering was anticipated, the subject stopped speaking and inhaled, then began speaking again in a slightly

deeper voice as he exhaled; and (4) the

330

Donald

number

of words

spoken

during

A. Williamson

each inhalation-exhalation

cycle

gradually increased. Modeling, feedback, and positive practice was used to train the subject in using each of these behavioral components. Following

these training

additional eight sessions

sessions,

the patient was seen for

over the next 3 mo to promote generalized

of the regulated breathing procedure in nonclinic the first month following

environments.

an use

During

training, the patient practiced using the breath-

ing technique while reading at home. At the end of this period, the patient audiorecorded suggested

30

min

by Azrin

of speech while

and Nunn

(1974),

reading aloud at home. family

members

were

As

then

incorporated into the treatment team. The subject’s wife learned to use the regulated breathing procedure in the clinic. this skill,

Once she had mastered

she modeled speaking using the procedure for about 5 min, and

the subject

imitated

her exact words.

This

method was similar

procedure called copying (Ost, Gotestam, and Melin,

to a

1976) in that the

subject repeated his wife’s words after about three to six words were spoken. It differed from copying in that the wife modeled appropriate use of regulated breathing rather than simply Following

this

modeling

procedure,

engaged in natural conversation the control

of stuttering.

speaking in her usual manner.

both the subject

while he utilized

and his

wife

regulated breathing for

In order to assess the effectiveness

of this

procedure and the frequency of its use at home, the wife recorded the frequency session.

of the subject’s These

records

technique approximately times/wk.

blocking

indicated

and the length of each averaged practicing

the

five times/wk with a range from three to seven

Also, in order to formally

conversations

episodes that they

at home, two 30-min

evaluate the subject’s speech during audiorecordings

were obtained at the

end of the second and third months after the original training had ended. Dependent

Variables

Speech data were obtained by counting the number of words and the number of dysfluent words during each minute of the audiorecordings of the subject’s speech. A word was defined as any unit of speech that could be written as a single English word. If a word was repeated, it was not counted. Sounds such as uh and ah were not regarded as words. A dysfluent

word was defined as any repetition or prolongation

of a sound

Regulated Breathing

331

or word. If a dysfluent once. Also,

word was repeated, it was not scored more than

each segment of audiorecording

was timed using a stop-

watch. From these data, the dependent variables of rate of speech and dysfluencies dividing

per word were derived. Rate of speech was determined by

the

number

Dysfluencies dysfluent

of words

spoken

by the

number

of minutes.

per word were determined by dividing the total number of

words by the total number of words. The primary speech data

were counted by one student observer. For six of the 16 sessions-three baseline and three treatment sessions-a words

and dysfluent

second observer also counted

words to determine

the reliability

of the scoring

procedures. Percentage of agreement was computed for both words and dysfluent

words by dividing the smallest

number of the two recorders by

the largest number for each minute of audiorecording.

Average agree-

ment was then obtained by averaging the percentage of agreement within each 5-min

period, e.g., reading aloud and interview.

ment was found to be less than 80%,

If average agree-

the two recorders again indepen-

dently scored that speech recording until 80% agreement was achieved. Following validation

treatment,

purposes.

The

nine audiorecordings nine recordings

were rated for social

were obtained by randomly

selecting three recordings from each of the three experimental when

baseline

conditions

treatment was implemented

were in effect for all situations, during two situations,

ment was used in all four situations.

phases: (1) (2) when

and (3) when treat-

The order of presentation

of the

recordings was randomized and then rated by three persons who had no involvement

in the study. Each rater listened to each 5-min segment of the

nine recordings and rated the subject’s speech on three subjective rating scales.

All

three

rating scales

ranged from

anchored with written descriptions first

rating was labeled: Ability

one to seven and were

for ratings of one, four, and seven. The to understand the subject. This

rating

ranged from one (could understand every word spoken) to four (could understand

about one-half

the words

spoken)

to seven

(could

not

understand any words spoken). The second rating was called: Desire to interact with the subject. Ratings ranged from one (very desirable) to four (moderately desirable) to seven (very undesirable). labeled: Global

social

impression

The third rating was

made by subject.

This

rating scale

ranged from one (excellent) to four (moderate) to seven (very poor). The three subjective

raters were told that they were to rate each segment of

Donald

332

A. Williamson

recordings that contained samples of speech by a person with a stuttering problem. They were not informed of the purpose of the study or of any aspect of treatment.

All three raters scored the recordings

random order, which

controlled

for biases resulting

in the same

from the natural

ordering of baseline and treatment sessions. The master EMG data were scored by computing the cumulative integrated EMG in microvolt-seconds

(PV-see)

from the polygraph rec-

ords. All numbers were rounded to the nearest one-tenth of a PV-sec. data presentation,

these EMG

scores

For

were averaged for each 5-min

segment of speech. RESULTS Reliability

checks indicated a high percentage of agreement between the

two raters for both words and dysfluent

words. The mean percentage of

agreement for words was 90% with a range from 80 to 98%.

For dysfluent

words, the mean percentage of agreement was 88% with a range from 80 to 100%.

Mean agreement for words

interview,

87% for social situation,

for reading, 87%

for

and 89% for intercom/telephone.

was 96%

For

dysfluent words, the mean percentage of agreement was 94% for reading, 87%

for interview,

telephone. was 89%

During

87%

for social

baseline,

and for dysfluent

situation,

and 85%

for intercom/

mean percentage of agreement for words words was 86%.

During

treatment,

percentage of agreement was 93% for both words and dysfluent Figure 1 presents the stuttering across all situations. ranged from 0.16

During

data in terms of dysfluencies/word

baseline,

the subject’s

to 0.46 in the four situations.

reduced to below 0.10

dysfluencies/word

As the regulated breathing

procedure was applied in each of the situations, immediately

mean

words.

rate of dysfluency

with a mean of 0.036

was

across the four

situations. Changes in rate of speech are presented in Figure 2. At baseline, words/minute situations,

ranged from 13.2 to 41.8, with a mean of 24.62.

rate of speech increased considerably

applied. By the final session, 35%

in all four conditions

In all four

as the treatment was

rate of speech was increased by more than

with the largest behavioral changes occurring

during the reading and telephone/intercom

periods.

Table 1 presents the social validation data in terms of median ratings

333

Regulated Breathing TREATMENT

BASELINE

READING ALOUD

.lO 0

j+4 1

,

,

,

,

5

,

,

,

I

1

,,I

I

10

,

I

I

15

SESSIONS Figure 1: situations.

Rate of dysfluency during each session, as observed during four

for each situation

across three groups of sessions.

that sessions

were baseline for all situations.

l-6

applied in the reading and interview During

sessions

12-16,

situations

the table.

Treatment

was then

during sessions

7-11.

treatment was applied in all four situations.

Table 1, baseline and treatment conditions dividing

It should be recalled

In

are indicated by the solid line

For each of the ratings,

the introduction

regulated breathing procedure resulted in improvement,

of the

as judged by the

raters. The masseter EMG data are presented in Figure 3. The bottom frame shows EMG while the subject was counting aloud. While

counting, the

334

A. !A’il/iamson TREATMENT

BASELINE 80

1.“:

/JJG

f=$y

I 20 -vl I o-

,,,,

*,I

,,,,,,,,,, I

60 -

INTERVIEW z:&IQw

I So- ,,,,,,I ‘;r 260 -

Figure 2:

,,,,,,,,,, 1 I _____,

SOCIAL

Rate of speech during each session, as observed during four situations.

subject was perfectly fluent. Masseter EMG during this fluent speech was always

below 25pV-sec.

Figure 3 shows that during baseline, EMG was

always

well

level.

above this

With

the introduction

procedures, masseter EMG was consistently

of the treatment

reduced to below 25pV-set

level. Thus, the regulated breathing procedure had the effect of producing a level of masseter muscle

tension that was within the EMG range found

during fluent speech. Follow-up

data were collected at l-, 2-, and 3-mo intervals.

During

the first month, the subject practiced the regulated breathing technique while reading aloud at home. Audiorecordings that his mean rate of speech was 48.25

of this speech

words/min,

indicated

and that the mean

335

Regulated Breathing

TABLE 1 Social Validation Data A. Ability to Understand Speech Situation

Sessions Treatment

Baseline 1-6

7-11

Reading aloud Interview

4 3

1 2

1 2

Social situation Intercom/telephone

4 4

3 3

2 2

12-16

B. Desire to Interact with Subject Sessions

Situation

Treatment

Baseline l-6

7-11

12-16

Reading aloud Interview

6 5

3 4

2 3

Social situation Intercom/telephone

5 6

5 5

3 4

C. Global Social Impression Made by Subject Situation

Sessions

Treatment

Baseline l-6

7-11

Reading aloud Interview

6 6

3 3

Social situation Intercom/telephone

5 5

5 5

dysfluencies/word

was 0.01.

months

speech during

reflected

second-month

follow-up

Audiorecordings conversations

dysfluency

words/min,

3 3 3 3

at the end of 1 and 2 with

data indicated some problems

that the rate was reduced, i.e.,18.40

12- 16 -

his

family.

The

with speech in

and the percentage of

had increased, i.e., 0.12 dysfluencies/word.

However,

by the

end of the third month, the subject’s speech had again improved. Mean rate of speech was found dysfluencies/word.

Thus,

to be 33.20

words/min,

with

only

0.02

3 mo after treatment, the subject was success-

fully using the regulated breathing procedure outside the clinic setting.

336

Donald

TREATMENT

MSELINE loo-

, I

IS: 50

A. Williamson

?j

READING ALOUD

INTERVIEW

I I

25-

^y o-, I, I, I,,++y , , , ul L____, 5 7s *M 2 2s f

SOCIAL SITUATION ROLE PLAY

%.fi

INTERCOM/ TELEPHONE

1

25-

iv o-, , , , , , , , , , ,,, , , , , 75 -

COUNTING

50-

(NO DYSFLUENCIES)

2

4

6

8

10

12

14

16

SESSIONS

Figure 3:

EMG activity during each session,

as recorded during four situations.

DISCUSSION The results

of this single-subject

experiment

suggest that the regulated

breathing procedure was an effective method for reducing stuttering improving Furthermore, speech

the quality

of speech as judged

by unbiased

this procedure was found to systematically

and reduce facial

muscle

tension.

These

and

observers.

increase rate of treatment

affects

generalized to several laboratory and nonlaboratory settings and persisted for a 3-mo period.

RegulatedBreathing These findings and Nunn (1974),

337 replicated the results reported by the clients of Azrin

with a few minor exceptions.

more than one 2-hr session,

train the subject adequately to utilize with skill.

Careful examination

five sessions,

First, this case required

as reported by Azrin

and Nunn (1974),

to

the regulated breathing procedure

of Figure 1 shows that even after four or

the subject sometimes stuttered on almost 10% of his words.

As modeling, practice, and feedback continued, his performance showed consistent

improvement.

involving

training

generalized

his

Also, for this case, additional therapy sessions wife

as a therapist

use of the technique

were

at home.

required

Azrin

to improve

and Nunn

(1974)

suggested to their clients that they involve family members and friends as supportive

agents, but they did not provide

them with

a structured

program to follow. The modeling procedure used in this study appears to have some promise as a systematic

means of promoting generalized

use

of the procedure. It seems likely that the regression of the subject’s speech observed at 2-mo follow-up

would

have continued,

had the modeling

procedure not been utilized. These results also extended the findings of Azrin and Nunn (1974) in several respects. First, the regulated breathing procedure had the effect of increasing

rate of speech.

However,

the final

rate of speech never

approached the normal rate of 1OO- 130 words/min, speech researchers (Webster,

commonly

used by

1970; Ost et al., 1976). Itappears that this

technique produces speech that is slower than the normal rate of speech, but is not characterized as unnatural by unbiased observers. The second new finding was that this procedure improved the quality of the subject’s speech, as indicated derstandable, improvements Nunn (1974) ment. The

by subjective

ratings

and by the social impression

that his

speech was un-

he made on others. These

probably account for the anecdotal reports by Azrin that their clients

third

new finding

procedure systematically

increased social contact following

and treat-

was that use of the regulated breathing

produced levels of masseter

EMG that were

within the range of muscle tension recorded during periods of completely fluent

speech. This

finding

has implications

for both the theoretical

explanations of stuttering and the treatment of stuttering. As noted earlier, several theorists (Williams, 1955, 1957; Shrum, 1967) suggested that stuttering

is caused by excessive facial muscle tension.

explanation

This

theoretical

has led several behavioral researchers to treat stuttering

by

Donald A. Williamson

338 reducing facial EMG Barrington,

using

EMG biofeedback (Guitar,

1975;

Lanyon,

and Newman, 1976). The results of this study showed that by

treating the speech problem, masseter EMG was reduced without intervention. stutterers

This

finding

suggests

that the elevated facial

is a result of the dysfluent

stuttering.

The

subject

of this

direct

EMC

of

speech rather than a cause of the

study

had learned a variety

of facial

gestures, e.g., grimacing and clenching his teeth, as part of his attempt to interrupt

episodes of speech blockages. Casual behavioral observations

indicated that there was a significant decrease in this type of behavior. As these behaviors increase masseter EMG, the reductions in muscle tension produced by the treatment grimacing.

Thus,

probably

the regulated

reflect

breathing

a lowered

procedure

frequency

of

had therapeutic

effects on speech, excessive facial EMG, and associated facial gestures. Webster

described similar

(1970)

interventions.

These

findings,

muscle tension and stuttering

improvements

using other behavioral

taken together,

suggest that excessive

are highly correlated and that both can be

changed without directly modifying facial EMG. In summary,

using a multiple

baseline across situations

design,

it

was found that the regulated breathing procedure decreased stuttering, increased rate of speech, and decreased facial EMG. Furthermore, improvements

in the subject’s speech were perceived as socially

the

signifi-

cant by independent observers.

REFERENCES Azrin,

N.H.,

and Nunn,

R.G. Habit

habits and tics. Behavior Azrin,

N.H.,

regulated

and

Nunn,

breathing

reversal:

A method

Research and Therapy,

R.G.

A rapid

approach.

method

Behavior

of eliminating

1973,

of eliminating

Research

nervous

11, 619-628. stuttering

and Therapy,

by a

1974,

12,

279-286. Guitar,

B. Reduction

feedback. Journal Kazdin,

of stuttering

A.E: Assessing the clinical

through social validation. Lanyon,

R.I.,

Barrington,

Ost,

using analog

or applied

importance

Behavior Modification,

C.C.,

through EMG biofeedback: 96-

frequency

electromyographic

of Speech and Hearing Research, 1975, 18, 672-685.

and

Newman,

A preliminary

A.C.

of behavior

1977,

Modification

study. Behavior

change

1, 427-452. of stuttering

Therapy,

1976,

7,

103.

L., Gotestam,

K.G.,

and Melin,

L. A controlled

study of two

methods in the treatment of stuttering. Behavior Therapy,

behavioral

1976, 7, 587-592.

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W.F.

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electromyography.

and nonstutterers

Dissertation

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by 26

(2-A), 825. Webster,

R.L. Stuttering:

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D.E. Masseter

Ulrich,

it and a way to explain it. In Control J. Stachnik,

1957,

muscle action potentials

eds.).

in stuttered and noristuttered 1955,20,242-261. of Speech and Hearing

22, 390-397.

M.M. Social validity: 11,203-214.

and J. Mabry,

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D.E. A point of view about “stuttering.“lournal

Disorders, Wolf,

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