2003 IFA Congress: Montreal, Canada

Maintenance of Fluency in Extra-Clinical Settings: Lack of Empirical Data

Glen Tellis1, Michelle Henning1, and Cari Tellis2
1Indiana University of Pennsylvania, Dept. of Special Education, 259 Davis Hall, Indiana, PA I 5 705
2University of Pittsburgh, Dept. of Communication Disorders


The long-term maintenance of fluency is the goal of many stuttering therapy programs. Thirty-two years of articles were reviewed to determine how many maintenance studies were conducted. Studies were reviewed for: gender, age, therapy techniques, study duration, and design. Results indicate that there is an acute shortage of published maintenance studies. The review yielded only 25 treatment studies that mentioned maintenance procedures. In the studies that included the maintenance stage of therapy, however, the authors did not agree about the amount, type, and duration of the maintenance programs. More research is needed to address issues in maintenance and relapse.

  1. Introduction
The American Speech-Language and Hearing Association (ASHA) (1995) defines the goals of maintenance as (1) generalization of the behavioral changes learned in the treatment setting to speech situations in the client’s everyday life, (2) a sense of committed interest and self-reliance on the part of clients in managing their speech behaviors, balanced against an awareness of the need for occasional help as needed, (3) an ability on the client’s part at recognizing the earliest signs of returning emotional reactions and/or recognizing stuttering behaviors and recognizing knowledge and skills for dealing with these occurrences, (4) and the knowledge and skills that parents need to facilitate their child’s further development of fluency.

Experts acknowledge that maintenance of fluency in extra-clinical situations and long-term follow-up are very important for success in any therapy program (Conture, 2001; Hanna & Owen, 1977; Ingham, 1980; Shapiro, 1999). Maintenance has also been defined as a continuation of fluency gained during the establishment and transfer phases of therapy (Hegde & Davis, 1995). For maintenance to occur, communicative behaviors that are achieved in the clinic must be produced in the natural environment in conversational speech. These behaviors also must be sustained over time.

Although there are some variations in maintenance programs, most researchers agree that regular clinical contact, positive speech attitudes, regular self-monitoring, and refresher sessions are important elements of a successful maintenance program (Boberg, 1981). Common maintenance strategies include making the client become his or her own clinician, decreasing the frequency of scheduled treatment, and periodic maintenance checks for at least two years (Shapiro, 1999; Silverrnan, 1996).

Many clinicians believe that when treating people who stutter, the -maintenance phase of therapy is most difficult (Martin, 1981). This phase is also challenging for people who stutter (Stewart, 1996). A high rate of relapse has been reported as well as a decrease in fluency in the months following dismissal from therapy (Craig & Keams, 1995). It is estimated that the greatest amount of fluency regression occurs within the first three months and stabilizes by six months post therapy (Perkins et al., 1974).

Different views about the nature and cause of relapse have been proposed. Webster (1979) suggested that the deterioration of fluency may be related to the competence of the clinician in teaching new fluency techniques and the client’s ability to acquire these new skills and generalize them to everyday situations. Howie, Tanner, and Andrews (1981) suggested that relapse may be due to differential reinforcement contingencies between the clinic and non-clinic setting. A few researchers also believe that relapse may occur as a result of poor attitudes toward communication (Guitar, 1976; Guitar & Bass, 1978; Kamhi, 1982).

Numerous authors have recommended that there is a need for maintenance studies. A review of the literature, however, indicates that there is a paucity of stuttering maintenance studies. A review of the past 32 years yielded only 25 treatment studies that mentioned maintenance procedures. In the studies that included the maintenance stage of therapy, however, the authors did not agree about the amount, type, and duration of the maintenance programs.

The purpose of this study, therefore, was to review articles from 1970 to 2002 to determine the number of published maintenance studies. Articles were reviewed for gender, age, type of therapy techniques, study duration, and design. The authors also looked at whether children, adolescents, or adults were treated.

  1. Method
The authors conducted a thorough literature review in various databases including Psychlnfo and Medline. Search words included, stuttering, stammering, fluency, treatment, maintenance, generalization, and relapse. Fluency maintenance studies were found in the Journal of Speech- Language Hearing Research, European Journal of Communication Disorders, Behavior Modification, Journal of Speech and Hearing Disorders, British Journal of Disorders of Communication, British Journal of Clinical Psychology, Journal of Fluency Disorders, School Psychology Review, Behavior Therapy, Language Speech and Hearing Services in Schools, Biofeedback and Self Regulation, British Medical Journal of Clinical Research, and Behavior Research and Therapy. Only studies that specifically addressed maintenance procedures were included.

  1. Results
It was interesting to note that within a 32-year period there were only 25 treatment studies that discussed maintenance. A majority of the studies (13) (52%) were published in the Journal of Speech-Language and Hearing Research, Journal of Fluency Disorders, and Journal of Speech and Hearing Disorders. A few of these studies addressed the maintenance of fluency after dismissal from therapy. These studies rarely mentioned the maintenance procedures that were followed - making replication of the studies difficult.

A total of 414 subjects participated in the 25 studies. Samples sizes ranged from two to 50 participants. Every study mentioned the age and gender of the subjects. From the 25 studies, fluency shaping therapy was used in 14 (56%) studies, stuttering modification was used in 1 (4%) study, acupuncture was used in 1 (4%) study, biofeedback was used in 2 (8%) studies, a combination of fluency shaping and biofeedback was used in 1 (4%) study, self modeling was used in 1 (4%) study, personal construct psychology was used in 1 (4%) study, a combination of fluency shaping and medication was used in 1 (4%) study, delayed auditory feedback was used in 1 (4%) study, and a combination of fluency shaping and psychological reconstruction was used in 2 (8%) studies (Figure1). Fluency shaping was used with children in 4 studies and with adults in 7 Studies. Stuttering modification was used with adults in 1 study.

Follow-up was conducted from two months to 61 months post-therapy. The average duration of follow-up for the 25 studies was 15.41 months. Two studies did not mention the maintenance period.

Surprisingly, 72% of the studies did not mention the design. Only 28% of the studies discussed the design. From the 25 studies, 6 (24%) were conducted with children, 14 (56%) targeted adults, 1 (4%) studied adolescents, 2 (8%) targeted adolescents and adults, and l (4%) was conducted with children and adolescents. One study did not mention the target group (Figure 2).


Figure 1.  Number of Maintenance Studies – 1970-2002


Figure 2. Populations Treated in the Studies

  1. Discussion
Most experts agree that maintenance of fluency in extra-clinical settings is one of the most important aspects of successful therapy. It is apparent from this review, however, that there are very few fluency maintenance studies. It is alarming that within the past 32 years, there are only 25 studies that specifically mention maintenance of fluency in extra-clinical settings and long-term follow-up. The results indicate that there is a paucity of research on long-term maintenance of fluency in extra- clinical situations with children and adolescents who stutter. More maintenance research, therefore, is needed with these populations.

If researchers are interested in follow-up data, they should outline the research design, specify the maintenance procedures used, and describe subject characteristics in detail. Systematic replication would then be possible. More maintenance studies should be conducted with stuttering modification and fluency shaping procedures with all population groups. Once these suggestions are incorporated, clinicians who are concerned with treatment efficacy and maintenance will be able to make rational judgments about the usefulness or effectiveness of procedures described in the literature.

Many stuttering treatment studies also fail to mention follow-up measures in their data. According to Boberg (1981), there is a lack of research in the area of maintenance because of the considerable amount of time and money required to conduct studies. It is also difficult to find subjects at the post-treatment level of therapy who are willing to participate in such long studies. Attrition also occurs from the time subjects begin treatment to follow-up sessions. Another problem with maintenance studies is that some subjects find it difficult to keep in Contact with their clinicians due to time constraints or the physical distance between the client and clinician.

A possible method of overcoming the problem of distance between the client and the clinician and keeping in Contact with the clinician is to explore the use of audio-capture technology. Clients can audiotape speech samples in their homes and offices, immediately save the samples as WAV and MP3 files with special recording devices, and email them as attachments to their clinicians for analysis and feedback.

The results of this study indicate that there is a critical need for maintenance studies. It is essential that maintenance studies target all age groups as well as address issues related design. Clinicians should not only devise strategies for conducting maintenance procedures but also develop methods for dealing with relapse. Since many persons who stutter have problems with relapse and maintaining learned behaviors in extra-clinical situations, researchers must focus on conducting more maintenance studies. We will improve our clinical practice as well as provide our clients a much needed service by addressing maintenance and relapse issues.

ASHA. (1995) Guidelines for practice in stuttering treatment. ASHA, 36, 26-36.
Boberg, E. (1981). Maintenance of fluency, E. Boberg (ed.). New York: Elsevier, North Holland.
Conture, E. (2001). Stuttering: Its nature, diagnosis, and treatment. Needham Heights: MA Allyn & Bacon.
Craig, A. R., & Kearns M. (1995). Results of a traditional acupuncture intervention for stuttering. Journal of Speech and Hearing Research, 38, 572-8.
Guitar, B. (1976). Pretreatment factors associated with the outcome of stuttering therapy. Journal of Speech and Hearing Disorders, 19, 590-600.
Guitar, B., & Bass, C. (1978). Stuttering therapy: The relationship between attitude change and long term outcome. Journal of Speech and Hearing Disorders, 43, 392-400.
Hanna, R., & Owen, N. (1977). Facilitating transfer and maintenance of fluency in stuttering therapy. Journal of Speech and Hearing Disorders, 42, 65-76. 236 Theory, research and therapy in fluency disorders
Hegde, M. N., & Davis, D. (1995). Clinical methods and practicum in speech-language pathology (2”d ed. ). San Diego, CA: Singular Publishing Group, Inc. Howie, P. M., Tanner, S., & Andrews, G. (1981). Short- and long-term outcome in an intensive treatment program for adult stutterers. Journal of Speech and Hearing Disorders, 46, 104- 109.
lngham, R. J. (1980). Modification of maintenance and generalization during stuttering treatment. Journal of Speech and Hearing Research, 23, 732-45.
Kamhi, A. G. (1982). The problem of relapse in stuttering: Thoughts on what might cause it and how to deal with it. Journal of Fluency Disorders, 7, 459-467.
Martin, R.R., (1981). Introduction and perspective: Review of published research. In: Maintenance of Fluency, E. Boberg (ed.). New York: Elsevier North Holland.
Perkins, W., Rudas, J ., Johnson, L., Michael, W., & Curlee, L. (1974). Replacement of stuttering with normal speech. IH. Clinical Effectiveness. Journal of Speech and Hearing Disorders, 39, 416-428.
Shapiro, D. A. (1999). Stuttering intervention: A collaborative journey to fluency freedom. Austin, TX: PRO-ED.
Silverman, “F. H. (1996). Stuttering and other fluency disorders (2nd ed.). Needham Heights, MA: Simon & Schuster Co.
Stewart, T. (1996). A further application of the Fishbein and Ajzen model to therapy for adult stammerers. European Journal of Disorders of Communication, 31 (4), 445-64.
Webster, R. L. (1979). Empirical considerations regarding stuttering therapy. In: Controversies about stuttering therapy, H. Gregory (ed.). Baltimore: University Park Press.
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