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Stuttering treatment within an operant framework

Background. In most behavioral treatments, positive reinforcement (reward) is the most commonly identified operant contingency.However, stuttering has most often been examined in relationship to punishment.The most common punishment principle that has been used is time-out from reinforcement (TO),

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Stuttering treatment within an operant framework

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    1. Stuttering treatment within an operant framework HESP 612

    2. Background In most behavioral treatments, positive reinforcement (reward) is the most commonly identified operant contingency. However, stuttering has most often been examined in relationship to punishment. The most common punishment principle that has been used is time-out from reinforcement (TO), also called response-contingent time-out (RCTO).

    3. Contingent responses and behavior

    4. Efficacy of TO Most classic laboratory studies are somewhat old: Haroldson, Martin & Starr (1968): 4 adults, stuttering was reduced by 88%. Early replications and extensions: Martin & Berndt (1970): 1 boy Martin, Kuhl & Haroldson (1972) (the “Puppet study): 2 preschoolers talked with a puppet and received RCTO, stuttering dropped to near zero and gains were maintained at one-year follow-up. Martin & Haroldson (1979): for 20 adult PWS, TO was more effective than RC noise, “wrong” (neg verbal feedback, RC DAF, or paced speech. Average reduction in stuttering was 76%.

    5. Early variations on the theme: Can PWS in group environments administer the tx? Martin & Haroldson (1971) suggested the system did not work well when PWS monitored and reinforced each other. Egolf, Shames & Selzer (1971): rotating speaking turns in a group as a form of RCTO can reduce stuttering. Improving generalization: self-administration of TO may lead to greater gains than clinician-administered TO (Martin & Haroldson, 1972).

    6. Fine-tuning TO Length of the TO does NOT seem to affect its efficacy, although 30 sec. appears marginally most efficacious (James & Ingham, 1974) Contingency of TO is necessary; non-contingent TO doesn’t work, suggesting the TO is not merely a distractor (James, 1981).

    7. Effects of other forms of punishment on fluency Shock – variable effects, although group trends suggest reduction of stuttering (see Costello, 1984) DAF – a classic reducer of stutter events (Goldiamond, 1962,1965) Verbal contingencies – all work, suggesting that they “highlight” moments of stuttering and punish regardless of content. The classic examples are Cooper, Cady & Robbins (1970) and Daly & Kimbarow (1978); CC & R found that right, wrong and tree ALL reduced stuttering in adults and children.

    8. Can stuttering be operantly INCREASED? The test of a behavior truly responsive to operant techniques is to see if it can be increased through positive reinforcement. Virtually no studies of adults have managed to increase stutter events via token or monetary award systems. An unpublished paper by Costello & Felsenfeld (1979) suggested that the stuttering of a six-year old child could be manipulated through reward consisting of praise and tokens.

    9. Examples of current operant programs for stuttering: ELU Costello (Ingham) (1984) and elsewhere: Extended Length of Utterance (ELU) program Contingencies for fluency: verbal praise and tokens used in token economy Steps and criteria samples: Single fluent word 12 trials 92% 2 consecutive words 10 100% 3-6 consecutive words 10 each 100% 5 sec – 90 sec fluent monologue variable 2 min – 5 min fluent monologue variable

    10. The Monterey Program (Ryan and van Kirk Ryan, 1995 and elsewhere) Combines DAF and GILCU DAF shapes speech from 40 wpm in seven step series in reading, monologue, conversation GILCU shapes from single word utterances in 54 steps to five minutes of fluent reading, monologue and conversation. Both programs highly operant, with verbal and token reinforcement for fluency and negative consequation for stuttering (e.g., “stop, speak fluently/in your fluent pattern”).

    11. The Lidcombe Programme Onslow et al. - parent-administered program for treatment of early childhood stuttering Original contingencies: praise on fixed schedule for fluency, request for retrial on fixed schedule for stutters. Revised contingencies: praise only. Fully documented program with impressive efficacy data: See manual and forms: I:\COURSES\LidcombeProgramManual.pdf I:\COURSES\lidspeech_measures_form.pdf

    12. How do operant programs work? Some disagreement about establishing the negative and positive “values” of contingencies Some contingencies viewed as negative by clinicians are viewed positively (and conceptually) by clients Some evidence that RCTO/punishment is most effective when client has prior therapy techniques to utilize following TO (James, et al., 1974)

    13. New data on Lidcombe (Bonelli, et al., 2000) Some evidence that fluency gains may be indirect result of reinforcement/punishment schedule that shapes shorter responses by children. Read the article:I:\COURSES\Bonellietal.pdf Read more about the Lidcombe programme at http://www.cchs.usyd.edu.au/asrc//treatment/lidcombe.htm

    14. How to get children to simplify language without simplifying parental models: one possible notion Bonelli, Dixon, Onslow & Ratner (CLP, 2000) analyzed the operant-based Lidcombe program for behaviors that distinguished pre- and post-therapy language use by parents and children. This program has parents praise fluent utterances (which are statistically likely to be shorter and less ambitious than stuttered utterances) The primary finding was that study children began treatment with relatively high expressive language scores that plateaued (did not meet growth expectations) post-therapy. The children seemed to intuit that parents were happy with shorter, simpler speech turns; these turns were less likely to stress the developing fluency system.

    15. Intake/outcome language measures for Lidcombe children

    16. Summary: operant procedures Strengths of operant approaches: Strongly data-based, with individual baseline, treatment and follow-up data – some of the best data out there. Good short-term and now, evolving long-term efficacy data, particularly for very young children Can be parent-administered, under guidance (Lidcombe) Limitations of operant approaches: Not widely used for large-scale clinical evaluation; programs are confined to small numbers of historical working groups Follow-up data sometimes lacking Assessment and outcomes of the As and Cs not usually available. Somewhat of a theoretical “black box” in terms of links to stuttering etiology and functional source of efficacy (i.e., WHY/HOW DOES IT WORK?) AND IF STUTTERING ISN’T LEARNED, WHY/HOW should it respond to behavioral therapy?

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