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8/11/2019 R. G. Wahler Et Al. - The Modification of Childhood Sttuttering
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JOURNAL OF EXPERIA MEN’TAL CHILD PSYCHOLOGY 9, 411-428 (1970)
The Modification of Childhood Stuttering:
Some Response-Response Relationships1
R. G. WAHLER, K. A. SPERLING,M.R. THOMAS,N.C.TEXTER
Psychology Departmenf., University oj Tennessee
AND
H. L. LUPER
Department oj Audiolo gy & Speech Pathology, Universify of Teunes.yee
The present study was an attempt to examine experimentally funct ional
relationships between stuttering and nonspee ch deviant be haviors. Tw o chil-
dren, both of who m presented stuttering problem s, were observed in clinic
and home se ttings. Init ial observa tions revealed tha t both children also pre-
sented secondary, m ildly deviant behavior problems. When cont ingency
managem ent procedures were applied to t .he secondary problems, both the
second ary problem s and the stuttering were reduced.
In recent years, learning theory explanations of stuttering and ap-
proaches to its modification have become increasingly popular (e.g.,
Gregory, 1968; Brutten & Shoemaker, 1967). A number of investigators,
f,orne working within a respondent learning framework (e.g,, Brutten &
Gray, 1961) and others following a rcinforccment model (e.g., Flanagan,
Goldiamond, & Azrin, 1958), have explored various therapeutic poss ibil-
ities. At this point, most of the empirical evidence has been gathered by
proponents of reinforcement theory. Investigators such as Goldiamond
(1965) and Sheehan (1951 j have shown repeatedly that stuttering bc-
havior can be modified by manipulating its stimulus consequences.
The majority of studies like those menti,oned above have involved one
or more of the following conditions which limit their application to the
treatment of stuttering: (1’) focus has been on the patient’s behavior in
laboratory settings; (2) unnatural stimuli such as delayed auditory feed-
back, shock, or loud masking noises which are not readily utilized in non-
laboratory settings have been employed to manipulate stuttering fre-
quencies; and (3) accurate records of the speech of subjects outside the
laboratory setting have not been maintained or reported.
1 This study w as supported in part by Research Grant MHl3914-01 from the
Nat ional Inst i tute of Mental He alth.
411
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412
WAHLER ET -4L.
Unfortunately, those few studies which have examined the practical
value of reinforcement-oriented treatment have produced equivocal W-
suits. Rickard and Mundy (1965), operating in laboratory and home sct-
tings, successfully reduced the frequency of stuttering in a g-year-old
boy. However, follow-up observations in the boy’s home and school rc-
vealed a recurrence of the problem. Browning (,1967) obtained somewhat
more stable generalization in his treatment of a @year-old schizophrenic
child-but these results were observed within a cont’rolled institutional
setting, and a low frequency of st’utt,ering was yet evident in his inter-
actions wit’h ward personnel. Finally, while Kondas (1967) reported long-
term success in his treatment of stammering in chilclren, his dat.a were
largely anecdotal and thus difficult to evaluate. All in all, little evic lencc
is available to support the therapeutic effectiveness of reinforcement
techniques in the t’reatment of stuttering.
Upon closer examination of stut’tering as a problem behavior, it is not
surprising to find such a paucity of data relating to general and long-term
effects of treatment. Most reinforcement theorists assume that, improvc-
ments in any problem behavior are maintained ,or lost through contingen-
cies provided by the patient’s natural environment. In the case of the
child, his parents, his teachers, etc., must provide their social attention
differentially, focusing on his “normal” behavior and ignoring or punish-
ing his problem behavior. Thus) in large measure, the patient’s prognosis
for change is dependent on the extent to which these soc ial agents can
provicle such contingencies.
Providing natural t,herapeut,ic cont.ingencies for stuttered versus fluent
speech is by no means a simple problem. For example, because of the often
rapicl and frequent interplay between a child ’s stuttered and fluent
speech, it would be difficult for a parent, to provide correct contingencies
on a continual basis. Although effective contingency management, pro-
cedures have been devised for parents (e.g., Patterson, Ray, & Shaw, 1969)
and for teachers (e.g., Harris, Wolf, & Baer, 1965), the deviant child be-
haviors involvecl did not present the temporal problems inherent in
stuttered versus fluent speech. Thus, in the treatment of stuttering, it
would seem desirable to explore other more practical contingency manage-
ment procedures.
One such alternate approach to contingency management with child
stutterers might capitalize on the often demonstrated relationship bc-
tween a child’s verbal behavior and other aspects of his behavior. Several
laboratory investigators (I,ovaas, 1961; Sherman, 1964) have shown that
contingency operations performed on classes of verbal behavi,or can pro-
duce predictable effects on nonverbal behavior; and, partly exploring the
other side of the coin, Wahler and Pollio (1968) demonstrated that a(lult
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contingency shifts for several classes of a child’s deviant behavior pro-
duced fairly reliable changes in the child’s verbal description of that be-
havior. In light of these findings, a hopeful poss ibility arises: a child’5
stuttered speech may bear functional relationships to other classes of his
behavior. If these other classes are practically manageable in terms of
long-term control of their natural environmental contingencies, thera-
peutic modification of the child’s stuttering could be affected.
The present study was initiated with the following goals in mind: (1)
to examine the possible presence of
secondary deviant, nonspeech be-
haviors in two young stutterers-behaviors which may be related t’o the
children’s disfluencies; (2) to manipulate the nonspclecb behavior through
appropriate changes in the children’s natural environment ; (3) to assess
the effect of these manipulations on the stuttering.
M E T H O D
Subjects were two boys (ages 9 and 4 yearsj , referred to the University
of Tennessee Hearing and Speech Cent’er because of stuttering problems.
Both children were class ified as “beginning stutterers” (after Bloodstein.
1960) ; that is, neither child displayed much concern over his disfluencies
and neither displayed struggle or avoidance speech behaviors. In both
cases, treatment, was carried out in a clinic playroom and in the sub,i(~ct~’
homes. The subjects’ parents were includecl in both settings.
Recording of subject ancl parent behaviors were obtained via audio
tape recorders ancl via a behavior checklist, formulated after observing
the family at home and in the playroom. The formulation and use of the
checklist wil l be described in a later section of this paper.
All observers used in this study were sophisticated in the use of operant
techniques and natural science princip les of observation. At regular in-
tervals, reliability checks on both the audio tapes and the behavioral
checklist were made by procedurally naive observers.
Prior to beginning the observational procedures, the parents were inter-
viewed for purposes of obtaining information on general classes of the
subjects’ behavior. Essential ly, the parents were asked to provide cx-
amples of any behavior other than stuttering which they considered to
create problems. While bot’h sets of parents were able to provide
such
examples, they also pointed out that their concern over such secondary
problem behaviors was only mild; that is, they would not, have sought
professional help for the secondary problems alone.
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414
WAHLEFt ET AL.
Observations were scheduled in the clinic playroom and in the subjmb’
homes on a once weekly basis. In most sessions the subject and his
parents were the focus of attention; however, for one of the subjects a
professional behavior therapist was involved because of parental difficulty
in following instruct’ions. Playroom observations were always made from
a concealed observation booth.
Behavior classifkattin sessions. Several of the initia l home and play-
room sessions were used to adapt the subject and his parents to the ob-
server’s presence and to obtain written records of the parent-child inter-
actions. These records were analyzed in the f,ollowing way: The subjects’
responses were grouped into classes on the basis of similarit ies among the
separate responses. These classes were then labeled as deviant or normal,
depending on their similarity to behavior which the parents reported to
create problems at, home. All responses provided by the parents following
these classes were considered as a single stimulus class, namely parent
social attention.
Observer relia.biZity and baseline obsewation. When the secondary bc-
havior classes were established by the face valid ity groupings described
above, efforts were then made to obtain frequency counts of selected
classes.
Frequency counts were made through a procedure similar to one
described by Hawkins, Peterson, Schweid, and Bijou (19686). The method
essentially required an observer to make coded checks for the occurrence
of a behavior class and its stimulus contingencies within successive lo-set
intervals; any occurrence of a class, regardless of its duration during an
interval, was scored as a single unit’.
Four classes of child behavior were recorded in this study. Pilot work
revealed that two of these classes (verba behavior and stuttered verbal
beh,avior) required little formal definition for reliable scoring. Verbal
hehavior simply referred to any verbal output recognized by the observers
as conversational speech-although the speech need not be directed to
anyone in part icular. Singing and nonlanguage utterances (e.g., coughing
and crying) were not, included in this definition. According to the checklist
definit#ion of a response unit, any conversational speech during a lo-set
interval was scored as a single unit. Stuttered verbal behavior referred to
word repetition and word prolongation or stammering. Since this behavios
class was considered as a subclass of the verbal behavior class all in-
stances of stuttered verbal behavior were also scored into the former
category. The category was scored in the unit checklist if any of the above
“stuttering” behaviors occurred during the lo-set interval.
Two classes of secondary deviant behaviors were formulated, one class
for each subject. For subject No.
1,
oppositional
behmjior was defined in
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MODIFICATION OF CHILDHOOD STVTTE RIRG
415
a functional sense as specific responses following parental requests or
commands. When a parental request or command was presented to the
subject, observers scored his future behavior as either oppositional or
cooperative depending on whether or not the instrucGon was followed. In
order for one unit of cooperative behavior to be scored, the subject had
to comply with the instruction for a full 10 sec. Thus, any period of non-
compliance during a lo-set interval resulted in that interval being scored
as oppositional. Observers continued to score the chi ld’s behavior into
these two categories until he completed the parental requirement or until
a new parent request or command was presented; opposiCona1 or coopera-
tive scoring was then considered in light of the new parental instruction.
Activ ity &iffs was the label describing subject No. 2’s secondary
deviant behavior. This response class was defined in terms of interactions
with objects or people; whenever the subject’s interactions changed from
one object or person to another object or person, an activ ity shift occurred.
It was also possible to score this behavior when the subject’s verbal be-
havior changed, either from person to person or from topic to topic. Fol-
lowing our checklist definition of a response unit, any of the above
interaction changes during a lo-set interval were scored as a single unit.
Two classes of adult behavior were recorded, and both were considered
as stimulus classes for the subjects’ behavior. L3o&L attention was con-
sidered as a single stimulus cla.ss composed of the behavior of one or more
adults. Any verbal or physical behavior that clearly involved the subject
was scored into this category as long as it closely followed a category of
his behavior (within the same or the following lo-set interval). The
principal adult behaviors composing this category included talking to the
subject, physical contact with him, and nonverbal play.
Instructions constituted the second stimulus class of adult behavior,
scored only for the parents of subject No. 1. This cat,egory was scored
merely because of its function in defining the subject’s oppositional be-
havior. Any requests or commands were scored into this stimulus category.
Before all observation sessions, the parents were told to provide instruc-
tions for this subject. The instructions presented were taken from a list
of household chores that the parents considered aversive to their child
(e.g., picking up t,oys). The parents were also told to feel free to use
instructions to terminate undesirable behavior. During the baseline ses-
sions, these were the only directions given to t’he parents.
After the reliability check sessions, an agreement or disagreement was
t,allied for each lo-set interval, and the percentage of agreements for the
observers was computed for each response and stimulus class. For all be-
havior and stimulus classes, these checks were provided for all of the
playroom sessions bnt unfortunately for only a small porCon of the home
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416
WAHLER ET AL .
sessions. In evaluating the results of t’his st’udy, one must remember that
only the fOlloW-up sessions Were evaluated for observer W]iabilii,y, For-
tunately) the experimental analyses were conducted only in the playroom,
Reliability checks for the playroom and follow-up data were as follows:
For subject No. 1, agreement percentages for stuttering and its adult con-
tingencies ranged from 80 to 92$% (Stuttering x = 89..3yG Contingencies
x 1 87.9%) ; for subject No. 2) the agreement ranged from 86 to 90yc
(Stuttering x = 88%, ; Contingencies x = 89.2% ) Agreement percentages
for the subjects’ secondary deviant behaviors and their stimulus con-
tingencies were appreciably higher. For subject No. 1, the agreement was
never below 95%; for subject No. 2, agreement percentages ranged from
90 to 96% (Secondary Class X = 94.5% ; Contingencies LX = 95%).
Baseline observations were cont,inued until unit counts of all behavior
and stimulus classes appeared stable across sessions. At, that point the
treatment program was initiated.
IkfmZifi~ati~n
of a.dtdt xh.uz~ior. After the baseline sessions, all adults
involved in this study were instructed in the use of behavior modification
t’echniques based on reinforcement theory. In line with the hypothesis dis-
cussed in the introductory s&ion of t,his article, the modification pro-
cedures were aimed at the subjects’ secondary problem behavior. The
specific nature of the procedures varied for the two subjects beca.use of
dJferences in their secondary problems (see Wahler, 1969). The parents
of subject No. 1 were instructed in the use of a combination time-out and
differential program. They were told to isolate t’he subject (at home, in
his bedroom; at the Clin ic, in an empty roan?) following the occurrence
of oppositional behavior. The subject was
to remain isolated for approxi-
mately 5 min unless he exhibited undesirable behaviors such as scream-
ing or crying; if these behaviors occurred he was t,o relnain in isolation
until the behavior terminated. The parents were told also to be especially
sensitive to their child’s cooperative behavior, regardless of when it’
OC-
curred. Any occurrence of cooperative behavior was to be immediately
followed by parental approval, administered in any manner the parents
desired.
The parents of subject No. 2 were instructed in the use of a shaping
procedure to increase his time spent interacting with objects, people, or
verbal topics. Essentia.lly, they were told to provide their social attention
as usual, except when the subject, produced activ ity shifts. Upon the oc-
currence of this behavior the parents were to ignore the subject mltil he
returned to the discontinued activity. Because of parental difficulties in
mastering this procedure, a professional behavior therapist imr)lemented
the program initia lly, and the parents observed his performance. Follows-
ing experimental demonstrations of t,he professional’s reinforcement’
COn-
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MODIFICATIOX OF C HILDHOOD STCTTERIXG
417
trol of t’he subject’s secondary behaviors, the parents began the procedures
themselves.
The above instructions were provided after the parents were given a
brief explanation of reinforcement theory. Marked emphasis was placed
on the importance of rigid adherence to the treatment procedures.
In
fact,
the parents were told to think of themselves of mechanical rcinforccment,
and/or punishment dispensers, operable by specific actions of their
children.
Assessment of Teinforcement control and functional relationships be-
tween. response classes. As later data wi ll show, the parents and the pro-
fessional therapist were able to implement the contingency change pro-
gram, and changes in their social attention contingencies for the subjects’
behavior were followed by predictable changes in the subjects’ secondary
behavior and stuttering. At this point, experimental sessions were sched-
uled to assess the role of contingency changes in producing thcsc effects
and to further examine reationships between secondary deviant behavior
and the stuttering.
Experimental test’s were conducted by instructing the parents and the
therapist to resume their baseline contingencies for the subjects’ secondary
behavior. After several of these sessions, all adults were instructed to rc-
sume their therapeutic contingencies, thus, again focusing their attention
on those secondary behaviors which were incompatible with the deviant
behavior. These instructions were in effect for the duration of the study.
FolLo~~up. 14fter completing the above experimental analysis, the
parents were told to continue their differential attention to the sub.jects’
secondary behavior. The playroom sessions were cliscontinued, and home
observations were schecluled on a twice monthly hasis for 2 months; at
t,he end of that time the home observations were scheduled on a once-a-
month basis. Presently, the two cases are in the ninth and sixth month of
follow-up.
RESULTS
Case No. 1
-Johnny (age 4) was referred to the Clin ic because of a combination of
stuttering and articulation problems. While the articulation problem had
improved with speech training, his stuttering showed little rhange.
According to the parents, Johnny’s stuttering was particu larly notice-
able when he was about 2 years ,old-at about the time one of his three
sisters was born; from that point until he was referred to the Clin ic, his
stuttering displayed little variability in rate.
Johnny’s parents also pointed out their mild concern over another as-
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418
WAHLER ET AL .
pect of his behavior. Both agreed that he tended to be “headstrong” and
“stubborn,” particularly when either parent and Johnny’s older sister
(age 8) was present. The parents felt that these ,oppositional tendencies
were due to the two children’s competition for parental attention. N&her
parent believed that, this problem behavior was related to the stuttering.
Clin ic playroom sessions included ,Johnny, his mother, and older sister.
Although Johnny’s father was unable to attend the playroom sessions, he
was included in the home observations.
Behavior classification sessions
revealed that both children tended to oppose parental demands, but, as
the parents had reported, *Johnny’s oppositional episodes were not neces-
sarily accompanied by stuttering. Both parents tended to be quite respon-
sive to Johnny’s oppositional behavior, primarily in the form of reasoning
or arguing with him. No other class of ,Johnny’s behavior was considered
deviant, either by the parents or the professional Clin ic staff.
Figure 1 presents unit counts of Johnny’s opposit’ional behavior, total
verbal behavior, and stuttered verbal behavior over all playroom sessions.
An examination of the baseline sessions reveals that much of Johnny’s
verbal behavior was stuttered; however, as the behavior classification
sessions indicated, no relationship is evident between unit counts of stut-
tering and oppositional behavior. Furthermore, a unit by unit (l@sec
intervals) comparison of stuttering and oppositional behavior revealed
that only 26.3% (mean) of the stuttered units were concordant with the
oppositional units. Thus, the baseline sessions provide no support for the
50
- Oppo si¶ional Behavior
- Tot01 Verbal
45 -
u--e Stuttered Verbal
Sessions I 2 3 I 2 3 I 2 I 2
Basel ine
~Reinforce Coopp ’ ~ZZ%op.
Punish Opp.
FIG. 1. Unit counts of Johnny’s oppositio nal behavior, total verbal behavior, and
stuttered behavio r over al l pla,yroo m sessions.
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assumption that Johnny’s ,&uttering and oppositional behavior were cor-
related in time.
Figure 1 also describes t’he results of parental contingency operations
on Johnny’s oppositional behavior. Following the baseline sessions,
*Johnny’s parents were instructed in the use of a time-out and a differen-
tial attention program, applicable to both Johnny and his older sister.
Essential ly, they were instructed to isolat’e either child following oppo-
sitional behavior, (at home, in a bedroom; at the Clinic , in an empty
room next to the playroom). In addition, the parents were instructed to
make their approval contingent upon the children’s cooperative behavior.
As Figure 1 shows, this contingency management, program had predictable
effects on Johnny’s oppositional behavior; over three sessions, marked
drops in oppositional behavior are evident. More interest’ing, however, is
the equally dramatic drop in Johnny’s stuttering while his verbal output
remains comparable to baseline assessments.
Further tests for parental reinforcement control of Johnny’s opposi-
tional behavior are also presented in Fig,ure 1. L4s expected, increases and
decreases in Johnny’s oppositional behavior were perfectly correlated
with the systematic presence and absence of appropriate parental con-
tingencies. In addition, contrary to baseline expectations, *Johnny’s stut-
tering continued t’o show its positive relationship to oppositional behavior;
as oppositional behavior displayed increases and decreases in strength, so
did the percentage of stuttered speech.
The data presented in Figure 1 lead to two conclusions: (1) social at-
tention contingencies provided by Johnny’s mother were at least partially
responsible for changes in his oppositional behavior; (21 Johnny’s stutter-
ing was clearly affected by operations performed on t,hc oppositional be-
havior. Further data analyses were performed to examine likely sources
of stimulus control of the stuttering. For example, i f stuttering and op-
positional behavior shared a unit by unit relationship during the experi-
mental manipulation sessions, parental contingency operations on the
oppositional behavior would have also been performed on the stuttering.
Table 1 presents data relevant to the above possibility. As this table
shows, stuttering and oppositional behavior showed little evidence of a
point for point relationship over the playrooom sessions. Furthermore,
measures of maternal at’tention to Johnny’s fluent and stutt,ered speech
also fail to support the possibili ty that stuttering was directly affected by
maternal stimulus operations.z That’ is, although Johnny’s mother was
‘Johnny’s mothe r wa s required to utiI ize the time-out operation only three time s
during the playroom sessions and once during the home sessions,. These operat ions
were never contiguous with stuttered speech units, nor did they imme diately follow
stuttered units. In order to ma ke all sess ions of comparab le length, the t, ime-ou t
periods were added to total session time .
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420
WAHLER ET AL .
TABLE 1
PERCENT ok JOHNNY 'S STUTTERN ~TNITS CONCORD ANT WITH OPPOSIT ION.~L
ENITS IN PL~~YROOM
a),
‘WD PER CENT OF M,+TERKAL SOCUL ATTENT ION
DURING UNITS
O F
JOHNNY'S
STUTTZRED
AND FLUENT
SPEECH (b)
Punish
Punish
oppos.,
oPPosY
reinforce
Baseline
reinforce
Baseline c0op. 2
coop.
I
2 .3 1 2 3 12 12
(a) Percent concordant
(b) Speech
42 31 36
24 16 14 31 37
22 ‘3
,
Fhlent
64 52 49 42 54 67 64 58 79 86
Stxtt,ered
36 48 51 58 46 33 36 42 21 14
differentiaIly responsive to these two speech categories, no differences in
her attention pattern are evident between baseline sessions and the first
set of treatment sessions. In all likelihood t,he very high percentage of
maternal attention to fluent speech during the last set of treatment’ ses-
sions was due to marked frequency differences between .Johtmy’s fluent
and stuttered speech (see Figure 11.
Thus, Table 1 indicates that changes in Johnny’s stuttering were not a
direct function of the contingency management program. Of course, it
could be argued that a relationship between stuttering and maternal be-
havior might be evident if successive rather than simultaneous time units
were compared. From a reinforcement theory viewpoint it would be rea-
sonable to assume that Johnny’s fluent speech was strengthened by ma-
ternal attention closely following time units containing fluent speech. To
evaluate this possibility, maternal att’ention occurring in units following
,Johnny’s stuttered and fluent units was compared. As Table 2 shows, the
results again fail to support direct maternal control of *Johnny’s fluent
and stuttered speech: maternal attention following units of fluent and
TABLE 3
PERCENT OF ~IATERN~IL SOCIAL ATTENTION FOLLOWING UNITS OF JOHNN~'S
STKJTTF,REDIND FLUENT SPEECH IN PLAYROOM
Fluent speech
Stuttered speech
Ptmish
Punish
oppw.,
0PPOS.I
reinforce Baseline
reinforre
Baseline coop.
2 coop.
1 2 3 123 12 12
66 47 61 78 49 39 52 49 88 93
;<4 53 39 22 51 61 48 51 12 7
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MODIFICAT IOX OF CHILDHOOD STUTTERING
421
stuttered speech was clearly nondifferential over baseline and treatment’
sessions.
Table 3 presents a final analysis of the playroom data. Although the
data presented in Figure 1 indicate dramatic changes in *Johnny’s stutter-
ing, such changes could be due to reduced verbal output. This possibili ty
seems unlikely when one examine s the consistently high rate of total
verbal behavior in Figure 1. However, these data indicate time spent
talking; they do not reflect the number of words per sentence or phrase.
Conceivably, <Johnny could have altered his speech pattern from baseline
to treatment sessions. That is, his speech could have shifted from multiple
to single word communications. To assess this possibility, all audio tapes
were time sampled for number of words per phrase or sentence. As Table
3 indicates, systematic changes in mean sentence or phrase length were
not evident over the various sets of sessions.
Plmish
Punish
oppos.,
oPPo&
reinforce Baseline reinforce
Baseline
coop. 2 coop.
1 *2 3 I 2 s 1 2 1 2
Mean nllrnber of words S.1 4.0 ‘2.6 S.9 4.1 L2.9 ‘2 8 2.9 s.3 4.5
Standard deviation 1.2 1.0 0 8 1.9 0.9 1.2 10 1.2 1.9 2.0
‘* Data based on 10 randomly select,ed sentences or phmsey taken from earh session.
Figure 2 describes oppositional behavior and stuttering during the
home ObscrvaLions. These data are quiLe similar to the playroom obser-
vations in showing Johnny’s stuttering and oppositional behavior de-
clining rapidly over the treatment sessions. Also, notice that these changes
remain evident over the 6 month follow-up.
Case No. 2
Carl (age 9) was referred to the Clin ic 1 year prior to the beginning of
this study. During that year he was exposed to a variety of behavioral
t’echniques, all of which involved efforts to treat his stuttering directly .
Essentia lly, attempts were made to train both of Carl’s parents to respond
differentially to his fluent and stuttered speech. As Figure 3 indicates,
some of the procedures appeared to affect Carl’s stuttering in the Clinic
playroom; however, no systematic changes in stuttering were apparent
over
10
months of home observations.
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422
WAHLER ET AL .
1
40 -
04 Oppos~tionol 6ehovior
35 -
5-
.j ’
--
Oe
--A,
Sessions I 2 3 4 5 I 2 3 4 I 2 3 4 5 6 7 6 3 IO I
Baseline Punish Oppositional
Follow-up
Reinforce Coopemtive
FIG. 2. Unit counts of Johnny’s opposition al behavior, total verbal behavior, and
stuttered behavio r over al l hom e sessions.
According to the parents) Carl’s stuttering began when he was about
7 years of age and remained relatively unchanged until the beginning of
this study. Upon inquiry Car l’s parents also pointed out their mild con-
cern over another aspect of his behavior. Both agreed that Carl appeared
to be overly active to t’he point that he seldom maint#ained any specific
interactions for more than a few minutes at a time. Neither of the parents
were greatly concerned about’ this tendency, and neither felt, that it was
related to Carl’s stuttering.
Before the beginning of this study it was evident that Car l’s parents,
IO0
o- -0 Home
- Clinic
so -
30 1
20
t
oL
2 4 6 6
IO I2 I4 I6
Two-week Intervals
IO
t
FIG. 3. Percent of Carl’s speech classified as stuttered durin g hom e and clinic sessions.
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particularly his mother, found it quite difficult to follow instructions. Be-
cause of this problem, it was decided t’o study interactions between Carl
and a professional behavior therapist during the playroom sessions. The
parents observed the playroom sessions from a concealed observation
booth and discussed Car l’s playroom interactions with the therapist after
each session. It was decided to incorporate the parents into these sessions
only when and if t’herapeutic success wa,s obtained.
Behavior classification sessions revealed that Carl’s interactions with
the therapist and with toys were of rather brief durations. That is, he was
easily distracted by the playroom st’imuli and frequently shifted his ac-
tivi ty from object to object. A s the parents had reported, Carl’s activity
shifts were not necessarily accompanied by stuttered speech.
Figure 4 presents frequency counts of Car l’s act’ivity shifts, total verbal
behavior, and stuttered verbal behavior over all playroom sessions. L4n
examination of the baseline sessions reveals that much of Carl’s verbal
behavior was stuttered; between 59 and 91% (Mean = 67%) of his speech
was classified as stuttered. Contrary to Case No. 1, a roughly consistent
relationship was apparent between total frequency counts of stuttering
and activ ity shifts. However a unit by unit comparison of stuttering and
activ ity shifts revealed that only 29% (Mean) of the stuttered units were
concordant with the activity shift units. Thus, the baseline sessions pro-
- Activity Shifts
M Tota l Verba l
.- -. Stuttered Verba l
I60 -
60 -
40 -
20 -
0 1 1 1 1 1 1 8 1 T L G 0 L , 1 1
Session l 2 3 4 I 2 3 4 5 6 I 2 I 2 3
Baaet ine Oi f ferent ia l Attent ion
Basl ine
I i
Oifferential
2 Attent ion
FIG. 4. Unit counts of Carl’s activity shifts, t,ota l verbal behavio r, and stuttered
verbal hehavior over al l playroo m sessions.
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424
WAHLER ET AL
vide little support for the assumption that C’arl ’s stuttering and activ ity
shifts shared a close temporal relationship.
Figure 4 also describes the results of therapist contingency operations
on Carl’s activ ity shifts. Following the baseline sessions the therapist was
instructed to direct Car l’s activ ities and to attend to him only when he
followed directions. Essentia lly, t#he therapist attempted to “shape” in-
creasingly longer periods of specific activ ity and thus reduce the number
of Carl’s activity shifts. As Figure 4 shows, this contingency management
program had predictable effects on Carl’s behavior; over six sessions,
marked drops in activ ity shifts were evident. In addition, an appreciable
drop in stuttered speech i3 evident; bet,ween 22 and ,507~ (Mean = 359’ 1
of his speech was class ified as stuttered. Unfortunately, since Carl’s total
verbal behavior also dropped considerably, t)he reduced stuttering could
have been a simple artifact of reduced verbal output.
Further tests for therapist reinforcement control of Carl’s activ ity
shifts are also presented in Figure 4. As expected, increases and decreases
in Carl’s activ ity shifts were perfectly correlated with the systematic
presence and absence of appropriate therapist contingencies. Also, Car l’s
stuttering continued to show its positive relationship to activ ity shifts;
as activ ity shifts displa,yed increases and decreases in strength, so did
the proportion of stuttered speech.
A final feature of Figure 4 is important to notice. During the last con-
tingency operation, Carl’s stuttering was exceptionally infrequent, and
his total verbal output remained almost comparable to baseline measure-
ments. Thus, while the initial reductions in his stuttering could have been
an artifact of reduced verbal output, the later reductions were not.
The data presented in Figure 4 are consistent with Case No. I in demon-
strating adult reinforcement control of a mild ly deviant class of child be-
havior (activity shifts). In addition, it is clear that CarlJs stuttering was
affected by contingency operations performed
on
this response class. As
in Case No. 1) further data analyses were performed to examine likely
sources of stimulus control of the stuttering.
Table 4 presents data relevant’ to the above topic. As this ta,ble shows,
stuttering and activ ity shifts showed little evidence of a point for point
relationship over the playroom sessions. Furthermore, measures of thera-
pist social attention to Carl’s fluent and stuttered speech also failed to
support the possibility that stuttering was directly influenced by therapist
stimulus operations. That is, although the therapist was differentialIy
responsive to these two speech categories, no differences in his attention
pattern are evident, between baseline sessions and the first set of treat-
ment sessions. As was true in Case No. 1, the high proportion of therapist
at,tention to fluent speech during t#he last set of treatment sessions was
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MODIFICATION OF CHILDHOOD STVTTE RING
425
TABLE 4
PMWENT ok CARL ’S STUTTERED UNITS CONCORD.LNT WITH ACTIVITY SHIFT UNITS
IN PLAYROOM (a), -&ND PKR~ENT OF THERA PISTS Soc1.4~ ATTENW~N
DURING UNITS OF C.~RL’S STUTTERED .~ND FLUENT SPE ECH
IN PLAYROO M (b)
1)iRerential Baseline l)ifferent,ial
Baseline
attention
*2 attention
1 2 3 4 1 2 3 4 t5 6 1 2 I 2
3
-~-
(a ) Percent 32 26 18 40 19 31 20 -* 21 30 12 19 13 23 9
concordant
(b) Speech
Fluent
58 49 74 38 42 51 38 -’ 66 29 70 46 48 66 82
Stuttered 42 51 26 @2 58 49 62 -* 34 71 30 54 52 34 18
* Dat,a lost.
probably due to marked frequency differences between Carl’s fluent and
stuttered speech (see Figure 4).
A further analysis of temporal relationships between Carl’s verbal be-
havior and therapist social attention involved an assessment of therapist
attention occurring in units following time units containing fluent and
stuttered speech. Reference to Table 5 shows that the results again fail
to support direct therapist control of Car l’s stuttering; therapist’ attention
following units of Car l’s fluent and stuttered speech was clearly nondiffer-
ential over baseline and treatment sessions.
Table 6 presents the final analysis of the playroom data. As in Case
No. 1, it is possible that Carl altered his speech pattern from baseline to
treatment sessions. That is, his speech could have shifted from multiple
to single word communications-and such a shift would be likely to affect
his stuttering. To assess this possibil ity, all audio t’apes were time sampled
for number of words per phrase or sentence. As Ta’ble 6 indicates, sys-
tematic changes in mean sentence or phrase length were not evident over
the various sets of sessions.
TABLE 5
PER~EN~IY OF THERAPIST Soc1.4~ INTENTION FOLLOWING UNITS OF C.~RL’s
ST~TTTERED .~ND FLTXNT SPE ECH IN PL~LYROOM
Differen& Baseline Differential
Baseline attention 2 attention
1 2 3 4
1 2 3 4 .-I 6 1 2 I 2 3
-
Fluent speech 40 56 61 47 5Zd 41 38 -* 72 52 61 36 42 71 39
St)ut,tered speech 60 44 39 53 47 59 C2 -* 28 48 39 64 58 29 61
* L)at,a lost,.
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childhood stuttering-changes which remained evident for the better part
of 1 yrar. The procedures employed to product these changes were rela-
tively simple, requiring
~xople
in the children’s natural environments to
respond differentially to rather gross aspects of their behavior. As such,
it was not necessary to deal directly with the children’s stuttering; when
the adults involved were suc~:~-ful in controlling the children’s secondary
problem behaviors, they also reduced the stuttering. The control tech-
niques were based
on
reinforcement theory and, as prior research has
S~IOWII,
arc readily taught to parents and t(>achers (e.g., Hawkins et al.,
1966; Harris et al., 1964).
The findings are clear in showing functional relationships between the
children’s stuttering and secondary problem behaviors. However, the na-
ture of these relationships is puzzling. Eviclently the two classes were not
related on the basis of sharing
COIIIUIOII
stimulus control variables. That
is, little evidence was obtained in support of a close temporal relationship
between the classes nor was there proof of appropriately differential aclult
attention to fluent and stutt’ercd speech. Certainly it could be argued that
tlies(> response and stimulus classes were related on a more remote tem-
\)oral basis, but, such an argument for stimulus control is contrary to a
large body of lit’erature pointing to the importance of brief rcsponse-
stimulus intervals for optimal instrumental control. Thus, it is unlikely
[ha:. dirtdc: stimulus
control was involvetl in reducing the children’s
stuttering.
In summary, the children’s secondary problem behaviors and/or thei
environmental contingencies were apparently determining (in some
WI-
IUIOWII
way I frequencies of their stuttering. Although external reinforce-
ment control was obtained over the secondary problems, control of the
.+tuttering was most, clearly related to specific aspects of the children’s
own behavior-namely, changes in t’heir Fecondary problems. How these
funct’ional relationships occurred cannot, be cvaluat’ed hy the present
Aucly.
RENFERENCES
BLOODSTEIN. 0. N. The developmen t of stuttering. II. Dcvelopment~l ph:ws. ~ownc/~
oj Speech and Hearing D&orders, 1960, 25, 366-376.
BROWNING,
R. N. Beha vior therapy for stuttering in a schizophrenic child. ~e/~wk
Research and Thempy, 1967, 5, 2G35.
BRKJTTEN. Em. J., & S H O E M A K E R , D. J. The modificuttin oj sktkkng. Englew ood Cliffs,
N. J.: Prentice-Hall, lQ67.
BRUTTEN, E. J., & GRAY, B. B. Effect of word cue removal on adapta tion and ad-
jacency: a clinical paradigm. Journal oj Speech mad Hewing Disordem. 1961. 26,
385-389.
FLANAMN, B., GIADIAMOND, I., & AZRIN, N. opera nt stuttering: the control of stutter-
ing behavior through response-contingency consequences. In L. P. Pull man and
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