Paralinguistic intonation-rhythm intervention with a developmental stutterer

.I. FLUENCY DISORD. 14 (1989), 185-208

PARALINGUISTIC INTONATIONRHYTHM INTERVENTION WITH A DEVELOPMENTAL STUTTERER

Researchers

have been alerted to a possible link between

and cognitive-linguistic quire and maintain purposes.

linguistic stuttering

inguistic rules. which fluent fluency

speech.

Therefore.

extralinguistic

properties reported

is disrupted.

coded and habitualired. movement

in reducing

limited

knowledge

features

and the motor

The intervention

Further

of stuttering

research

of paral-

necessary

for

planning

for

focuses on the rules of

to teach them. The results indicate

disfluencies.

link in the development

A child must ac-

in this article is based on the theory

of the suprasegmental

of speech

and its breakdown

of language for communication

in the young child’s

planning

the timing

and uses motoric

is effective

intervention is founded

incapacitates

is inappropriately

intonation vention

and extralinguistic

The intonation-rhythm

that developmental

speech fluency

loading during the period of language acquisition.

that this inter-

in the possible

linguistic-

is warranted.

A competent communicator exhibits internal knowledge of underlying processes and rules of speech and language by the communicative behavior he or she exhibits. This internal knowledge must be acquired and maintained for both linguistic (phonology. morphology, semantics, syntax, and pragmatics) and extralinguistic tparalinguistic and metalinguistic) properties of language and its communication. Current research of various developmental communicative disorders, including disfluency, focuses on these underlying processes and rules. Primarily, there has been a focus on the linguistic properties of language communication. This focus has alerted researchers to the possibility of a link between speech fluency and its breakdown and cognitive-linguistic loading during the period of language acquisition. Starkweather (1987) reported that increased syntactic, semantic, phonologic, and pragmatic knowledge during a child’s language development contribute to demands for tluency. He pointed out Address correspondence IO: M. Mnr\hall Grube. Ph.D.. East Tennessee State University. Department of Communicative Disorders. P.O. Box 2179OA. .lohnson City. TN 37614-0002.

M. M. GRUBE and D. S. SMITH

that disfluency and stuttering occur where language is being formulated and suggests “that the production of fluent speech and the use of language put simultaneous demands on the same system” (p. 255). Andrews and Harris (1964) suggested that the onset of stuttering corresponds to later stages of language acquisition, when speech and language production are becoming habituated and automatized. St. Louis (1979) emphasized that extensive exploration of relationships between stuttering and language development is required, since research suggests that language abilities of beginning stutterers are related to stuttering. Despite the acknowledgement that linguistic and speech fluency demands are concurrent during a crucial phase of the acquisitional period, little is known about why the stress of these demands yields disfluency in some children, yet fluency in others. It is the proposition of this article’s authors that a key to the resolution of this issue lies in the examination of the extralinguistic properties of language, in particular, paralinguistics. According to convention, paralinguistic competence incorporates the suprasegmentals (intonation, stress, rate, and pause) as they augment the segmental features of language. The suprasegmental and segmental features are inextricably connected for communication purposes. The sum effect of suprasegmental and segmental interaction yields the rhythm of language or what Perkins (1977) and Martin ( 1972) refer to as language rhythm. Perkins (1977) described language rhythm as the timing pattern of phonetic elements of words and phrases. Martin (1972) suggested the rhythm of language to be a temporal structure representing a conventional system held jointly by the speakers of a language. It is logical to surmise that the competent communicator employs rule-governed combinations of suprasegmental features that reflect internal knowledge of paralinguistic rules.This internal knowledge serves as the foundation for cognitive planning of suprasegmental combinations that facilitate the timing of speech and fluency. Thus, motor planning for fluency is appropriately coded and habitualized. Based on this theory, the young stutterer’s limited internal knowledge of paralinguistic rules of intonation. stress, rate, and pause features of language is reflected in a breakdown of ability to produce suprasegmental features that govern the sequencing and timing of speech flow. Moreover, a delay in the acquisition of the paralinguistic rules of speech tlow disrupts the learning of plans for motoric movement necessary for fluent speech. In sum, (I) the young stutterer has limited knowledge of the paralinguistic rules of language, (2) this limited knowledge incapacitates planning of the suprasegmental features necessary to produce fluent speech, (3) this inability disrupts the timing of speech, (4) the young stutterer exhibits disfluency, and (5) the individual automatizes and habitualizes inappropriate motoric patterns that perpetuate the disorder. The intonationrhythm intervention reported in this study is based on this theoretical

PARALINGUISTIC

INTERVENTION

progression. Assuming that this theoretical progression is so, the question arises on how to teach the young stutterer paralinguistic rules in order for fluent speech to be the end result. The answer is believed to lie in the rhythm-induced fluency research that addresses the concept that stuttering is a timing disorder. Bergmann (1986), in his discussion of stuttering as a prosodic disturbance, cautions that the evidence of incorrect timing does not infer that stuttering is caused by a motoric or sensorimotor defect. Again, this article purports the timing disfunction to be a direct result of limited paralinguistic knowledge. Van Riper (1982) reported that fluency is enhanced if the stutterer times his or her utterance to the beat of a regular rhythm and supports the use of rhythmic timers with disfluent children (1973). He suggested that the young stutterer’s internal timing mechanism might be faulty. Reviews by Andrews et al. (1983) and Kent (1983) support the view that stuttering represents a constitutional weakness in the planning, timing, and/or control of speech. St. Louis (1979) stated that the most successful interventions for stuttering have as their common denominator linguistic and motor awareness and that such awareness is enhanced by rhythm during speech. Furthermore, Van Riper (1982) regards abnormal behaviors such as jerking the head or jaw as timing devices. This bodily movement is used in the stutterer’s attempt to time his or her speech in order to obtain fluency. Informal observations of nonstutterers reveal that during moments of “normal disfluency,” they tend to move a part of the body. The authors believe that stutterers are telling us that such motoric movement is a key element in directing clinicians to successful treatment strategies. The intonation-rhythm intervention reported here uses the natural instinct for body involvement to an advantage, therefore using motoric movement in a positive manner, instead of rejecting it as unimportant and extraneous to disfluency. The use of induced rhythm on stuttering has been acknowledged to be the most effective and rapid method for inducing fluency (Ham, l986), and its use has been traced to ancient Greece (Wingate, 1976). Observation, report and experimental studies, mainly with adolescents and adults, demonstrate fluency gained when using measured or cadence techniques (Andrews, Harris, Garside, and Kay, 1964; Azrin, Jones, and Flye, 1968; Barber, 1939; Bloodstein, 1949, 1950; Brady, 1971; Johnson and Rosen, 1937; Van Dantzig, 1940; Wingate, 1969). Barber (1940) included motor movements such as walking, tapping a foot, and/or swinging an arm or hand on each syllable or word as various types of rhythmic devices. Why rhythm is effective has yet to be determined. Bloodstein (1972) suggested that it facilitated simplification of motor planning. Kent (1983) and Watts (1973) purported that rhythm therapy reduces temporal or timing uncertainty on the part of the stutterer. The present authors believe that

188

M. M. GKUHE

and D. S. SMITH

rhythm therapy with the developmental stutterer facilititates learning of paralinguistic rules. The literature regarding the use of rhythm in stuttering therapy is controversial (Azrin. Jones, and Flye, 1968: Barber, 1940: Bloodstein. 1949: Brady, 1971; Brady and Brady. 1972: Johnson and Rosen. 1937: Van Riper. 1973: Wingate. 1969). The controversy centers around the use of measured rhythm or cadence techniques, such as the use of the metronome. Speech, although it has characteristics of melody, movement, and change, is not rhythmical in the sense of a measured pattern of regularity (Wingate, 1969). A composite of reasons for nonacceptance of the therapeutic use of rhythm are: (I 1 lack of understanding of how it works. (2) the effect is short-term. (3) professional belief that it is associated with quackery, (4) the resultant atypical speech patterns represent another form of “abnormal” rhythm, and (15) generalization to normal speech is difficult (Adler, 1966: Andrews, Guitar. and Howie. 1980; Barber. 1940: Bloodstein, 1972; Boome and Richardson. I93 I : Bruce and Adams, 1978; Ham, 1986, Sheehan, 1975). Although the use of rhythm techniques in therapy are generally opposed, its potential value cannot be ignored. Recommendations for its use do recur in the literature (Andrews, Howie. Dosza, and Guitar, 1982; Beech, 1967: Bloodstein, 1969: Brady, 1971; Curlee and Perkins. 1969; Ham, 1986; Hutchinson and Norris, 1977; lngham and Andrews. 1971: Ingham and Winkler. 1972; Martin and Haroldson, 1979; Ost, Gotestan, and Lennert, 1976; Silverman, 1976: Trotter and Silverman. 1974: Van Riper, 1973). Noteworthy is the fact that these techniques are predominately used in treatment studies with older stutterers, not with developmental stutterers. Such techniques quickly result in what has been termed “artifical fluency” with little or no generalization to reduce stuttering behaviors in natural speech. The authors of this article believe there to be a viable reason for this lack of generalization in the older stutterer. A part of the theoretical progression (step 5) presented earlier in this article suggests that the developmental stutterer automatizes and habitualizes inappropriate motoric patterns that perpetuate the disorder. Thus, “disfluency” is coded during the period of language acquisition. When rhythm therapy decreases disfluency in the older stutterer, the internal coding mechanism is temporarily suppressed. Generalization does not occur, since the primary code, established during the acquisition period, predominates. Therefore, the authors suggest that rhythm therapy would be more appropriately used with the developmental stutterer who is in the stages of language, linguistic and extralinguistic, acquisition. The authors suggest that there is a readiness period in which paralinguistic rules are to be learned. Thus, rhythm therapy during the developmental stages will assist the child in acquiring the necessary pairing of segmental and suprasegmental features of communication.

PARALINGUISTIC INTERVENTION

189

This article purports that an individual acquires rules of language rhythm. paralinguistics. just as he or she acquires the better-known rules of language. Therefore, distluent speech may result from the child’s limited knowledge of paralinguistic rules. Since therapy follows theory. the intervention. in this case. would be to teach the disfluent child the rules. Based on the theoretical assumptions that distluent speech represents a lack of knowledge of paralinguistic rules and that motoric enhancement of the rhythm of language facilitates the learning of paralinguistic rules, an intonation-rhythm intervention strategy was developed and used with a j-year old stutterer. Of the elements of paralinguistics-intonation, stress, rate and pause-intonation was selected to be taught. Intonation contours encompass stress structures of utterances. which are essential for the linguistic functions of intonation (Ladd. 1983). Two clinical study questions were asked: (I) Can teaching the young stutterer the paralinguistic rules of intonation patterns utilizing physical movement by the child reduce stuttering behaviors, and, if so, (2) was the decrease in stuttering behaviors better facilitated by the use of upper body movement or the use of lower body movement in the teaching of the paralinguistic rules of intonation?

METHOD Subject The subject was a 5-year old white male diagnosed as having a fluency disorder. His disfluencies were predominately repetitions. These repetitions were described and distinguished in terms of monosyllabic and multisyllabic productions, representing 97% of his disfluent behavior. The remaining 3% of disfluent behavior was characterized by prolongations. The monosyllabic repetitions were single syllable words such as “that.” “and, ” “how,” and “well.” Ninety-three percent of the multisyllabic repetitions was in units of two to three words such as “how about,” “well you know.” and “can you,” and the remaining 7% was composed of multisyllabic words such as “because” and “maybe.” An analysis of the subject’s spontaneous speech revealed that 78% of his disfluencies occurred on the initial syllable or word(s) of an utterance. Other studies have reported a higher incidence of disfluency on initial words (Brown, 1938; Gemelli, 1982; Jayaram, 1984; Quarrington, 1965; Quarrington, Conway, and Siegel, 1962: Taylor, 1966). Their findings report that the initial words of a sentence generate more stuttering than subsequent words, regardless of sentence length. The remaining 22% of the subject’s disfluent behavior occurred on connector words. Pauses and uncertainty on the subject’s part as what to say next during his moments of disfluency were observed. In a study on pause loci in

190

M. M. GRUBE and D. S. SMITH

stuttered and normal speech, Wingate (1984a) reported that pauses are more typical in stuttered speech with more hesitancy exhibited than in nonstuttered speech. He reported three roles of individual pauses, namely that they reflect (a) delays resulting from choice of words, (b) delays related to planning longer speech units, and (c) as markers of clause endings. The subject for this study evidenced the first of these roles and the researchers tallied word-finding difficulties. An analysis of the subject’s intonation patterns revealed that 82% of his utterances were monotone with slight pitch variations and appropriate syllabic stress. The faster he spoke, the less appropriate his intonation patterns were. Statements, questions, and exclamations all had the same intonation pattern, making it difficult to follow the content of his message. Wingate (1969, 1976, 1984b) and Bergmann (1986) support the assertation that stuttering is a prosodic disturbance, but the issue of monotony as a significant component of stuttering has not been verified through research. Clinical observations of stutterer’s speech as montonous have been reported by Van Riper (1982). Observation of the subject revealed that he had exaggerated inhalation and exhalation patterns during disfluent speech. This was characterized by the subject taking in excessive amounts of air before speaking and then expelling a large amount of air on the first two to three syllabic productions, making the rest of his sentence sound as though he had run out of breath. Ventilatory discoordination has been described as part of the stuttering complex. Baken, McManus, and Cavallo (1983) reported that peculiar ventilatory activity often occurs immediately before or during stuttering moments. When the subject’s disfluent behavior was characterized by four or more repetitions, tension was visible in his neck muscles and facial expressions. The extrinsic muscles surrounding his laryngeal region bulged, revealing tension and stress. Further tension was observed around his mouth, especially on the left side, A number of studies have shown, either directly or by inference, that abnormal behavior of the larynx, including inappropriate abductions and contraction of opposing muscles, characterizes many disfluent episodes (Adams and Hayden, 1976; Conture, McCall, and Brewer, 1977; Freeman and Ushijima, 1978; Ladouceur, Cote, Leblond, and Bouchard, 1982; Wingate, 1969).

Procedure The intonation-rhythm therapy program utilized in this intervention was derived from a program designed by Grube, Spiegel, Buchhop. and Lloyd (1986). The original intervention strategy was incorporated in the treatment for unintelligible children. Results indicated greater perceived in-

PARALINGUISTIC

INTERVENTION

191

telligibility on the part of listeners after the intonation training. Nonsense syllables, instead of words, were used in that study. The intonation-rhythm therapy developed for stuttering intervention targeted the declarative, interrogative, and exclamatory intonation patterns, and utilized physical movements to augment their teaching. By using sentences as a vehicle of prosody, the sessions were monopolized by kinesthetic integration. Initially, the intonation patterns were taught with one word and expanded to more words when the subject met a 100% accuracy criterion for each length of utterance. The presentation of each intonation pattern was accompanied with upper- or lower-extremity movement specific to the pattern. Upper-extremity movement included arms up for interrogative patterns, arms down for declarative patterns, and hands brought together as if crashing cymbals for exclamatory patterns. Lower-extremity movements incorporated the use of stairs. The subject started on one step representing a monopitch and then went up or down the steps to represent a change in intonation. The design of the intonation-rhythm training included six steps progressing from modeled imitation plus motor movement in step 1 to spontaneous production without motor prompt or imitation in step 6. For the first three steps of the procedure, the clinician had physical contact with the subject. Specifically, the intonation-rhythm training procedure followed these steps: (I) The clinician modeled the targeted intonation pattern and paired motor movement while moving the subject’s hands (upper body) or walking up and/or down stairs (lower body) with the subject: (2) the clinician and the subject produced the intonation pattern and the motor movement together; (3) the subject produced the targeted intonation pattern without clinician model, performing the motor movement with the clinician; (4) the subject produced the targeted intonation pattern and the motor movement alone, while the clinician parallelled the motor movement; (5) the subject produced the targeted intonation pattern and the motor movement alone, without clinician participation; and (6) the subject produced the targeted intonation pattern without any accompanying motor movement. At no time was the concept of “stuttering” ever addressed with the subject. The length of the project was 2 months. which included I4 I-hr sessions. The experimental program (12 sessions) was implemented in two cycles with each cycle having three sessions each of upper- and lower-body movement. The final two sessions did not include the established procedure. Only one intonation pattern was targeted per session. Thus, session I was upper-body movement with declarative intonation, session 2 was upper-body movement with interrogative intonation, and session 3 was upper-body movement with exclamatory intonation. Sessions 4-6 were lower-body movement with the same intonation patterns. Sessions 7-9 were upper-body movement, and IO-12 were lower-body movement.

192

and D. S. SMITH

M. M. GRUBE

MONOSYLLABIC REPETITIONS

161 . 1412loNUMBER OF 6 42 -’ ;y

cmLRRBX;ES

.:\,

0, PRE-INTERVENTION

.

POST-INTERVENTION

1 MONTH POSTINTERVENTION COMPARISON OF DATA OVER TIME

Figure 1. Comparison of number of monosyllabic to postintervention

Auditory

I month

to

stimulation

(1983) reported, stimulation

was also part ofthe

in their work

produced

Furthermore, ditory

stimuli.

in the establishment

higher levels of intensity

Van Riper.

ulation. With this in mind. two auditory were incorporated Phonic Mirror

the importance

of articulation cues through

it is logical that the distlucnt

or emphasized

stimulation

auditory

stim-

segments. 7 min each.

into each session, once before and once after the intraining.

The

subject

set at a low amplification

such as coloring

that young normal hear-

than adults to process au-

stimuli are the natural and primary

child might also profit from concentrated

regular

of new sound patterns.

to be a component

which children acquire the spoken language.

tonation-rhythm

that auditory

through

as early as 1939. underscored

which is still considered

Since auditory

Hodson and Paden

children,

that was not achieved

they cited research that concludes require

of ear training. therapy.

procedure.

with unintelligible

awareness

listening and was productive ing children

repetitions from preintervention

postintervention,

or doing a puzzle.

sentences containing

wore

earphones

connected

to a

level and engaged in quiet activity During

the target intonation

this time. pattern

the clinician

read

for the session. Sen-

tences were those that the sub.ject could relate to and cognitively

undcr-

(I) auditory

stimu-

stand.

lation.

In

summary,

(2) motoric

stimulation.

the

intervention

pairing

with

procedure

intonation

was

patterns.

and (3) auditory

PARALINGUISTIC

193

INTERVENTION

MULTISYLlABIC

REPETITIONS

NUMBER OF -Es

PRE-INTERVENTION

POST-INTERVENTION

1 MONTH POSTINTERVENTION

COMPARISION OF DATA OVER TIME

Figure 2. Comparison of number of multisyllabic to postintervention to I month postintervention.

repetitions

from preintervention

Measures and Data Analysis speech samples were taken for IO min before and after each intonation-rhythm training session. All sessions were audio- and videotaped for data analysis. Frequency of occurrence of prolongations, monosyllabic repetitions, multisyllabic repetitions, and word finding difficulties were tallied. Review of both audio and video tapes by the researchers verified the frequencies of occurrence. Intrasession data and intersession data were compared by frequency of occurrence and percentage of decrease or increase of disfluent behavior. Preintervention. postintervention, and l-month postintervention frequencies of occurrence and percentages of decrease were noted. Percentage of monotone utterances and loci of disfluency were calculated and analyzed before and after intervention. Data was graphed and tabled after each session for visual inspection to allow observation of trends. Spontaneous

RESULTS The data representing changes in distluent and associated behaviors from preintervention to postintervention to l-month postintervention are presented in Figures l-4 and in Tables l-3. lntrasession and intersession data are presented in Figures 5-8 and in Tables 4 and 5. Summary in-

194

M. M. GRUBE Postintervention, and I Month of Disfluent Behaviors

Table 1. Preintervention, Number of Occurrences

and D. S. SMITH

Postintervention

1 Month Preintervention number Disfluent Monosyllabic Multisyllabic

behavior

Postintervention

of

number

occurrences

repetitions repetitions

Prolongations Word finding difficulties

postintervention

of

number

occurrences

of

occurrences

1

15

6

IO

3

I

5

0

0

38

I3

5

PFCLCNGATKWS

5* 4.5 4 3.5 3

NUMBER OF

2 1.5 1 0.5 -

0

.

POST-INTERVENTION

1 MONTH POSTINTERVENTION

2.50 il PRE-INTERVENTION

COMPARISCNOF DATAOVER TIME

Figure 3. Comparison of number of prolongations tintervention to I month postintervention.

Table 2. Preintervention, Postintervention, Percentages of Occurrence of Monotone

from preintervention

and I-Month Pitch

to pos-

Postintervention I Month

Associated Monotone

pitch

behavior

Preintervention

Postintervention

postintervention

percentage

percentage

percentage

82

41

46

PARALINGUISTIC

195

INTERVENTION

WORD FINDING DIFFICULTIES

40 35 30 25 NUMBER OF

20 15 10 5 I

OJ PRE-INTERVENTION

POST-INTERVENTION

I MONTH POSTINTERVENTION

COMPARISCN OF DATA OVER TIME

Figure 4. Comparison

to postintervention

of number of word-finding to 1 month postintervention.

difficulties from preintervention

formation representing percentages of decrease in disfluent behaviors are in Tables 6 and 7. The following report is based on that information.

Preintervention and Postintervention

Data

Preintervention, postintervention, and l-month postintervention data reflect decreases in frequency of occurrence for all measures. Prior to intervention, the subject evidenced 15 monosyllabic repetitions in the lomin spontaneous speech sample. Frequency of occurrence of this measure decreased to 6 repetitions during postintervention analysis and further decreased, without intervention, to 1 repetition 1 month postintervention (see Table 1 and Figure 1). Multisyllabic repetitions decreased from 10 occurrences preintervention to three occurrences postintervention to one

Table 3. Preintervention,

Number of Occurrences

Postintervention, and 1 Month Postintervention of Loci of Disfluency I Month

Loci of disfluency Initial syllable/word(s) Connector

words

Preintervention number of

Postintervention number of

postintervention

occurrences

occurrences

occurrences

number

23

6

1

7

3

I

of

M. M. GKUBE

MONOSYLLABIC

N C E s

o.oJ,

,

I

I

1u

2u

1 I

3u

and D. S. SMITH

REPETITIONS

,

,

,

, I

I

,

,

,

,

,

, I

I

4L

5L

6L

7u

BU

9u

IOL

11L

i2L

13x

14x

I

I

&UPPER

I

I

I

I

I

,

BODY L=LOWER BODY X=NOTFWlNlNG

q POST-INTERVENTION

o PRE-INTERVENTION

Figure 5. Intrasession

data comparison of number of monosyllabic repetitions before and after intonation-rhythm intervention using upper-body movement or lower-body movement.

N U M B E R

MULTISYLLABIC

REPETITIONS

40 36 32 20 24 20 16 12 8 4

id

C E S

I O,,,,,,,,,l

I

I

I

I

I

I

I

I

tu

2u

3u

4L

5L

6L

7u

&UPPER o PRE-INTERVENTKIN

Figure 6. lntrasession

I

BU

I

I

9u

IOL

I

11L

I

I

I

11 13x

12L

I

14x

BODY L=LOWER BODY X=NO TRAINING

q POST-INTERVENTION

data comparison of number of multisyllabic repetitions before and after intonation-rhythm intervention using upper-body movement or lower-body movement.

PARALINGUISTIC

N U

197

INTERVENTION

PROLONGATIONS 5 “+ 4.5 4.0 3.5 30 25 20 1.5 1.0

R E N C E S

05 0.0

, , , IIIIITY--TTTT~v 1u

2u

.L

3u

4L &UPPER

N U M B E R

7u

8U

9u

1OL

*

*

11L

12L

L. 13x

* 14x

BODY L=LOWER BODY X=NO TRAINING

q POST-INTERVENTION

o PAE-INTERVENTK)N

Figure 7. Intrasession after intonation-rhythm movement.

6L

5L

data comparison of number of prolongations before and intervention using upper-body movement or lower-body

WORD

FINDING

DIFFICULTIES

40 35

0 F

30

0 C C U R R E N C E s

20

25

15 10 5 I

01, I

iu

,

,

,

,

I

I

I

I

II

5L

6L

7u

2u

3u

4L &UPPER

o PRE-INTERVENTiON

Figure 8. Intrasession

,

, I

,

,

8U

9u

,

11

, 1

1OL

11L

I

,

” 12L

13x

I

1 14x

BODY L=LOWER BODY X&JO TRAINING

a POST-INTERVENTION

data comparison of number of word-finding fore and after intonation-rhythm intervention using upper-body lower-body movement.

difficulties bemovement or

M. M. GRUBE and D. S. SMITH

198

Percentage of Intrasession Decrease (Increase) of Disfluent Behaviors by Upper- and Lower-body Intonation-Rhythm Training

Table 4.

Sessionupper/lower

Monosyllabic repetitions

Multisyllabic repetitions

Word-finding difficulties

Prolongations

AB’SABBABBAB

r/r

I Upper 2 Upper 3 Upper

I5 I5 21

II 10 09

27 33 57

IO 09 I5

09 05 09

IO 44 40

05 03 02

05 02 02

00 33 100

38 36 40

33 34 35

I3 05 13

4 Lower 5 Lower 6 Lower

19 21 20

II I4 I3

42 33 35

13 I3 I4

08 IO II

38 23 21

00 02 00

01 00 00

(100) 100 00

31 33 31

36 29 29

(16) I2 06

7 Upper 8 Upper 9 Upper

I9 23 24

I4 20 20

26 13 I7

II 32 35

09 25 25

18 22 29

00 00 04

00 00 00

00 00 100

26 36 40

24 30 32

07 17 20

IO Lower II Lower I2 Lower

15 II 09

09 IO 07

40 09 22

19 I7 09

II IO 07

42 41 22

00 00 00

00 00 00

00 00 00

32 28 24

26 26 23

I9 07 04

I3 None I4 None

09 06

09 06

00 00

07 03

07 03

00 00

00 00

00 00

00 00

21 I4

20 13

05 07

Note:

A

=

pretraininp. B = posttraining.

occurrence 1 month postintervention (see Table 1 and Figure 2). Prolongations decreased from five occurrences preintervention to no occurrences for both postintervention and 1 month postintervention (Table 1 and Figure 3). Word finding difficulty decreased from 38 occurrences preintervention to 13 occurrences postintervention to five occurrences 1 month postintervention (see Table 1 and Figure 4). Percentage of monotone utterances decreased from 82% preintervention to 41% postintervention to 49% I month postintervention (see Table 2). Loci of disfluency are presented in Table 3. During the preintervention spontaneous speech sample, with 30 disfluencies, the subject exhibited 23 occurrences of disfluent behavior on initial syllable/word(s) and seven occurrences on connector words. Of the nine postintervention number of occurrences, six were on initial syllable/word(s), and three were on connector words. During the IO-min spontaneous speech sample I month postintervention, disfluent behavior occurred once each on initial syllable/word(s) and connector words.

Intrasession Data Intrasession data are presented in Table 4 and in Figures 5-8. Sessions 1-3 and 7-9 utilized upper-body movement to teach intonation patterns, whereas 4-6 and lo-12 utilized lower-body movement. No intonation-

PARALINGUISTIC

Table 5. Percentage of Intersession By Pretraining, Posttraining, and

Multisyllabic repetitions

00

I0

09

09

09

05 OS

IO 44 50

05 05 OS

03 02 02

40 60 60

38 33 38

36 34 24

53 (03) 37

(40) (44) 00

03 02 03

02 02 02

33 00 33

36 34 36

40 35 3s

(I I) (03) I7

13 II 47

02 02 02

00 01 01

100 50 50

40 35 40

31 36 36

23 (03) IO

00 (25) 23

00 01 00

02 00 00

(100) 100 00

31 36 31

33 29 29

(06) I9 IO

02 00 02

00 00 00

100 00 100

33 29 33

31 29 29

06 00 I2

15

I5

II

IO

Pre-post

I5

IO

33

IO

Pre

I5

21

(40)

09

IS

Post

IO

09

IO

05

09

Pre-post

IS

09

40

09

09

Pre

21

I9

IO

I5

I3

Post

09

IO

09

08

Pre-post

21

IO

52

I5

08

Pre

I9

21

(II)

I3

I3

Post

IO

I4

(40)

08

IO IO

I9

I4

26

I3

Pre

21

20

OS

I3

I4

Post

I4

I3

07

IO

II

Pre-post

21

I3

38

I3

II

(08) (IO) IS

Pre

20 I3 20

19 I4 I4

05 (08) 30

I4 I I I4

II 09 09

71 I8 36

00 00 00

00 00 00

00 00 00

31 29 31

26 24 24

I6 21 23

I9 I4 I9

23 20 20

(21) (43) (05)

II 09 II

32 25 25

(191) (177) (127)

00 00 00

00 00 00

00 00 00

26 24 26

36 30 30

(38) (25) (IS)

23 20 23

24 20 20

(04) 00 I3

32 25 32

35 25 25

09 00 22

00 00 00

04 00 00

(400) 00 00

36 30 36

40 32 32

(I I) (07) II

24 20 24

I5 09 09

38 55 63

35 25 35

I9 II II

46 56 69

04 00 04

00 00 00

100 00 100

40 32 40

32 26 26

20 I9 85

I5 09 IS

II IO IO

27 (II) 33

I9 II I9

I7 IO IO

II 09 47

00 00 00

00 00 00

00 00 00

32 26 32

28 26 26

I3 00 19

II IO II

08 07 07

27 30 36

I7 IO 17

09 07 07

47 30 59

00 00 00

00 00 00

00 00 00

28 26 28

24 23 23

I4 I2 I8

Pre-post

08 07 08

09 09 09

(13) (29) (13)

09 07 09

07 07 07

22 00 22

00 00 00

00 00 00

00 00 00

24 23 24

21 20 20

I4 13 I7

Pre Post Pre-post

09 09 09

06 06 06

33 33 33

07 07 07

03 03 03

57 57 57

00 00 00

00 00 00

00 00 00

21 20 21

14 I3 I3

33 35 38

Pre-post Pre Post Pre-post 8-9

Pre Post Pre-post

9-10

Pre Post Pre-post

IO-11

Pre Post Pre-post

I I-I?

Pre Post Pre-post

12-13

Pre Post

13-14

Note:

(II)

Pre-post

Post

7-8

difficulties

AB%ABB

Pre

6-7

Word-finding Prolongations c/c

Post

S-6

Behaviors

B

%

4-S

of Disfluent

A

B

3-4

(Increase)

to Posttraining

repetitions A

2-3

Decrease Pre-

Monosyllabic

Sessions I-2

199

INTERVENTION

A = measure from first indicated se&x:

B = measure from second indicated \es\iw

200

M. M. GRUBE

Table 6. Number of Occurrences of Disfluent Behaviors Percentages of Decrease from Session I to Session 14 Session number Disfluent Monosyllabic

behavior

Session

14

number

of

occurrences

occurrences

and

Percentage decrease

IS

06

60

IO

03

70

Prolongations

OS

00

100

Word finding difficulties

38

I3

66

Multisyllabic

repetitions

I of

and D. S. SMITH

repetitions

rhythm training was incorporated in sessions I3 and 14. Reported in Table 5 are the number of occurrences of each behavior during the IO-min spontaneous speech sample before intonation-rhythm training (A) and during the IO-min spontaneous speech sample after the intonation-rhythm training (B), as well as the percentage of decrease or increase in the measured behaviors. Monosyllabic and multisyllabic repetitions were consistently decreased during the intervention sessions (I-12). No decrease in these behaviors occurred between the two measures when the intervention was not included in the sessions; therefore, frequency of occurrence remained the same in sessions 13 and 14. For monosyllabic repetitions. the range of percentage decrease was 13%-57% for upper-body movement and 9% 42% for lower-body movement. The average percentage of decrease for the first set of upper body movement was 39%, and 18.7% for the second set. The average percentage of decrease for the first set of lower body movement was 36.7%. and 23.7% for the second set. For multisyllabic repetitions, the range of percentage decrease was 10%44% for upperbody movement and 215%.42% for lower-body movement. The average percentage of decrease for the first set of upper-body movement was 31.3%, and 23% for the second set. The average percentage of decrease

Table 7. Number of Occurrences of Disfluent Percentages of Decrease from Preintervention Postintervention

Behaviors and To I Month

I-Month Preintervention number Disfluent

behavior

Monosyllabic

repetitions

Multisyllabic

repetitions

of

occurrences IS

I0

Prolongations

05

Word finding difficulties

38

postintervention number

of

occurrence\

Percentage decrease

PARALINGUISTIC

INTERVENTION

201

for the first set of lower body movement was 27.3%, and 35% for the second set. Prolongations decreased in all but one session. During session 4, the first lower body movement, the subject had no occurrences during the pretraining sample and one occurrence during the posttraining sample, which represents a 100% increase. Prolongations did not occur for 6/12 intervention sessions nor during the two postintervention sessions. The range of decrease for upper body movement was 0%-100%, with an average of 44.3% for the first set. The subject only exhibited prolongations during one session of the second set of upper-body movement with a 100% decrease. For the first set of lower-body movement, the subject had a 100% increase in the first session, 100% decrease in the second session, and no occurrence of prolongations in the third session. No prolongations occurred during the second set of lower-body movement. After the first nine sessions of the intonation-rhythm intervention, prolongations no longer occurred. Word-finding difficulties decreased in all but one session. As with prolongations, this occurred in session 4. The range of percentage of decrease for upper-body movement was 5%-20% with an average percentage of decrease of 10.3% for the first set of upper-body movement and 14.7% for the second set. The range of percentage for decrease for lower-body movement was 4%-19%, with a 16% increase in session 4. For the first set of lower-body movement, which included the increase in one of the sessions, the average percent of decrease was 0.7%. The average percentage of decrease for the second set of lower-body movement was 10%. The average decrease in word-finding difficulties for sessions 13 and 14 (no intervention) was 6%.

Intersession Data Intersession data are presented in Table S and in Figures 5-8. Table 5 contains three measures comparing intersession data. The first two measures represent pretraining and posttraining data from one session to the next. The third measure represents a comparison of pretraining data of one session to the posttraining data of the next session. Actual number of occurrences in the first-noted session is given under “A,” and in the second-noted session under “B.” The percentages of decrease(increase) for the 13 intersession comparisons are also given. The first 12 comparisons contain sessions that incorporated the intonation-rhythm training. The thirteenth comparison, between sessions I3 and 14, represents no intonation-rhythm training. The information that follows presents intersession datga for sessions I and 2 inclusive to sessions I2 and 13. All data for pretraining, posttraining, and pre- to posttraining for all behaviors, monosyllabic repetitions, multisyllable repetitions, prolongations. and

202

M.M.GRUBE

and D.S.SMITH

word-finding difficulties for sessions 13 and 14 represent decreases in frequencies of occurrence. In intersession analysis of data for session to session for monosyllabic repetitions, decreases occurred for 7 of the I2 pretraining session comparisons, 6 of the 12 posttraining comparisons, and IO of the pretraining to posttraining comparisons. The decreases of frequency of occurrence for multisyllabic repetitions for both pretraining and posttraining measures was evident in 8 intersessions. Decreases from pretraining to posttraining occurred for 10 intersession comparisons. For prolongations, decreases in intersession comparisons occurred 10 times in pretraining comparisons, I2 times in posttraining comparisons. and I2 times in preto posttraining comparisons. Word-finding difficulties decreased for 8 of the pretraining comparisons, 7 of the posttraining sessions, and 11 of the pre- to posttraining sessions.

Summary The percentages of decrease from session 1 to session I4 are presented in Table 6. There was a 60% decrease in monosyllabic repetitions, a 70% decrease in multisyllabic repetitions, a 100% decrease in prolongations, and a 66% percent decrease in word-finding difficulties. The decrease in percentage of monotone utterances from session I to session 14 was 50%. The overall percentages of decrease from preintervention to 1 month postintervention are presented in Table 7. There was a 93% decrease in monosyllabic repetitions, a 90% decrease in multisyllabic repetitions, a 1007~ decrease in prolongations, and an 87% decrease in word-finding difficulties. The overall decrease in percentage of monotone utterances was 44%. Increasing appropriate use of intonation patterns resulted in an increase in the subject’s intelligibility. Additionally. clinical observations showed a decrease in the subject’s exaggerated inhalation and exhalation patterns.

DISCUSSION The two clinical study questions asked were: (I) Can teaching the young stutterer the paralinguistic rules of intonation patterns utilizing physical movement by the child reduce stuttering behaviors, and, if so, (2) was the decrease in stuttering behaviors better facilitated by the use of upperbody movement or the use of lower-body movement in the teaching of the paralinguistic rules of intonation? Results indicated an affirmative answer to the first clinical study question and a negative answer to the second clinical study question. Preintervention data compared with both postintervention data and 1 month postintervention data indicatkd that the teaching of intonation patterns utilizing physical movement facilitated

PARALINGUISTIC INTERVENTION

x3

fluent speech. Interestingly, decreases in disfluent behaviors continued after the intonation-rhythm intervention was discontinued. There was no clinically significant difference in reduction of disfluencies in relation to upper- or lower-body movement. Both appeared to have similar results. The subject, however, stated a preference for the lower-body movement segments of the intonation-rhythm training. He would inquire at the beginning of the sessions as to whether he would be working on the stairs that day. Visual inspection of Figures 5-8 indicate increases on all measured behaviors for sessions 8 and 9, with marked decreases for session IO. Prior to these sessions, the subject was very cooperative and approached the intonation-rhythm training in a positive manner. When he arrived for session 8, he appeared tired, and his mother confirmed this observation. He also displayed some apprehension toward therapy and appeared unsure as to whether he wanted to participate on this day, but he did. When he arrived for session 9, his previous reluctant behavior was intensified. He was hesitant on going to the therapy room and clung to his mother. After entering the therapy room and playing with toys. he relaxed somewhat until the “work session” (as he called it) began. He was extremely fidgety and reluctant to model the clinician’s movement. The senior researcher interrupted the session and asked the subject if he would like to see himself on videotape. He agreed and went into the monitoring room and sat on the researcher’s lap. She spoke to him about Halloween, which was in a couple of days. The subject began talking about his perception of Halloween and was disfluent on nearly every word. Tension was observable on his face, around his mouth and neck muscles. He made minimal eye contact and clasped and unclasped his hands while he spoke. He relayed that there was a lot of hard work in walking and collecting candy on Halloween. He expressed concern that his mother would not be accompanying him and his siblings because she was going to be home passing out candy. The subject mentioned that he had fallen last year while “trick or treating,” and that the children had been warned by their teacher at school to be careful or he (the children) could be hit by a car. He appeared extremely frightened of Halloween. The senior researcher comforted him and explained that these fears were okay to have; that we all are frightened some times; and that he was not alone in having fears. Following this talk, the subject watched himself on videotape and responded with excitement and laughter. He then reentered the therapy room and continued with the “work session” in his usual positive manner. By the end of session 9, the disfluent behaviors decreased to near or below those tallied prior to Halloween. The most encouraging result of this study was the fact that further reductions in all disfluent behaviors were evident 1 month postintervention, which occurred over the Christmas holidays. The intonation-rhythm

M. M. GKUBE and

204

D. S. SMITH

intervention facilitated additional fluency. This study, however. represents only a beginning in the attempt to understand the contribution of paralinguistic knowledge to fluency. The treatment approach was effective, but it provides little treatment data. Research is needed to ferret out the importance or lack of importance of the intonation-rhythm intervention components. Developmental data in fluency acquisition and the possible link between the linguistic and extralinguistic properties of language communication is indicated. As with many studies, this study generated more questions than answers. Theoretical questions are: (I) What are the stages of paralinguistic acquisition‘? (2) What are the suprasegmental combinations of intonation, stress, rate, and pause that underlie tluency? (3) Why do the demands for linguistic and speech fluency acquisition yield disfluency in some children, yet fluency in others’? (4) Is developmental stuttering a languagebased disorder reflected in limited cognitive knowledge of paralinguistics? (5) Is there a readiness time, neurologically, that paralinguistic rule learning must occur? (6) Does habituation and automatization of distluent behavior preclude the natural learning of paralinguistic rules? Questions regarding the intonation-rhythm intervention reported in this article are: (I) Will this intervention strategy facilitate more fluent speech for other young children? It is certainly unwise to generalize from a singlesubject study; however, the senior author has used this intervention strategy with another Syear-old male stutterer and had similar results in decreasing his disfluency. (2) Can intonation patterns be taught to the young child without motoric rhythm as a timing device’? (3) Is the use of motoric movement reflective of an underlying inclination for body involvement during disfluent moments‘? (4) Which of the components of this intervention-teaching of intonation patterns, motor movement of the rhythm of the sentence, or auditory stimulation-are most germane in reducing disfluent speech? (5) What effect, if any, did the auditory stimulation part of the intervention have on the decrease in disfluent behavior? (6) Does the young stutterer need auditory amplification to enhance the learning of paralinguistic rules? (7) Up to what age level will an intonation-rhythm intervention be productive in reducing disfluency? (8) Does the coding of inappropriate motor patterns of disfluency during the habitualization stages of speech production preclude the adolescent or adult stutterer from learning paralinguistic rules and benefiting from an intonationrhythm therapy approach? These authors suggest a research focus on the gestalt of linguistic and extralinguistic interactions in language communication. Normal paralinguistic acquisition data may hold the illusive key to developmental disfluency disorders. The data for this paper

was collected

at The University

of Toledo

(Ohio). The manuscript