Efficacy Of Stuttering

Therapeutic
Techniques
• Efficacy is the extent to which a specific
intervention procedure, regimen or service
produces a beneficial result under ideally
controlled conditions when administered or
monitored by experts (Last, 1983).

Otswang (1990)
• Treatment effectiveness (does treatment work)

• Treatment efficiency (does one treatment work

better than other) and

• Treatment effects (in what way does the

treatment alter the behavior)

 Criteria for Treatment Effectiveness
• Van Riper (1973), Andrews and Ingham (1972)
and Sheehan (1984)

1. The method must be shown effective with an

ample and representative group of stutterers.
2. Results must be demonstrated by objective
measures of speech behavior such as frequency of
stuttering or rate of speech and by judges rating
of severity. Such measurements should be made
before, during and after treatment by observers.
3. Reports of therapeutic success must be based on
repeated evaluation and adequate samples of
speech.
4. Improvement must be shown to carryover to
speaking situation outside the clinical setting.
The best known but frequently ignored fact
about stuttering is that is the special environment
of clinic stutterer are likely to become normal.
5. The stability of result must be demonstrated by
long-term follow-up investigation. The follow-up
evaluation is likely to be biased if it is done in the
same clinical environment in which treatment
was administered.
6. Suitable control groups or control conditions
must be used to show that reductions in
stuttering are the result of treatment. There are
other variables besides adaptation to the
clinical setting that may create a false
impression of successful therapy.
7. Subject must sound natural and spontaneous to
lustiness. Residual element of slowness,
monotony or stereotype in the subject’s speech
may seen more peculiar to listeners that the
stuttering itself.
8. Subjects must be free from necessity to monitor
their speech though fluency can hardly be
considered normal as long as continued attention
on part of speakers is required to maintain it.
9. Treatment must remove not only stuttering but
also fear, anticipation and person’s self concept as
a stutterer.
10.Success of a therapy program should not be
conflated by ignoring drop out. The problems
presented by stutterers who dropout of treatment
has been pointed out by Martin (1931). Estimates
of the improvement during therapy are often
based exclusively on those who complete clinical
program.
Treatment Efficacy of Various Therapeutic
Approaches
1. Perceptual Measures
2. Acoustic Measures
3. Cognitive, Pharmacological, Behavioral and
other related approaches
 Perceptual Measures
a. Frequency Measures

• Frequency measures are calculated in terms of percentage of

syllables / words (%SS or %WS) usually. In order to obtain %SS or
%WS scores, the number of syllables / words is counted along with
the number of words / syllables that are stuttered. For outcome
research frequency measure is most acceptable because large
differences are of interest. The following table shoes the results of
various studies that used percent of dysfluency as a measure to
depict the outcome of prolonged speech procedure, gentle
phonatory onset, and smooth flow of speech. The Results of all these
studies indicate that the post-treatment mean percent dysfluency
reduced significantly to less than 5%, which is considered as normal.
 Prolonged Speech
Author No. Of Age of Duration of Results
Subjects Subjects Treatment
Spencer (1976) 5 Adults 4 months Stuttering was reduced to less
and than 1% of syllables
children

Boberg (1976) 21 17 – 44 3 weeks Stuttering decreased from mean

of 21% of syllables to 1.3%

Franck (1980) 68 Mean of 1 year 95% of subjects increased

20.2 fluency by 60% or more
years
Boberg (1980) 6 16 - 46 3 weeks Mean percent syllables stuttered
years decreased from 16.55 or more

Howie, Tanner & 36 Adults 3 weeks Stuttering was virtually

Andrews (1981) eliminated

Eveshen and 47 Adults 3 weeks 91% stuttered on less than 1% of

Huddles (1983) syllables

Boberg (1984) 12 18 -47 2 weeks Mean percent of stuttered

years syllables decreased from 18.9 to
0.9
 Gentle Phonatory Onset
Author No. Of Age of Duration Results
Subjects Subject of
s Treatment

Webster (1975) 56 8-59 3 months Significant difference in pre-post

years treatment

Schwartz and 29 9-50 3 weeks 97% improved, 72% stuttered on

Webster (1977) years 6% or less of words

Webster (1980) 200 3 weeks Mean percent of words

decreased from 15.1 to 1.3

Mallard and 50 14-50 6 weeks Mean percent of words fell from

Kelly (1982) years 20.05 to 2.92
Schulman 85 6-65 4 weeks 84% achieved normal or near-
(1983) years normal fluency in
conversation

Franken, 32 15-46 3 weeks Mean % of stuttered syllables

Bover, Peters years declined from 25.7 to 5.8
and Webster
(1992)

Onslow, Costa, 12 10.7- 3 weeks Within clinic and beyond

Andrews 41.6 clinic % SS reduced generally
(1996) years to near zero
 b. Speech Naturalness
• The adjective natural is derived from the Latin
word naturalis, meaning ‘of nature’.
• The needs for studying speech naturalness of
individuals treated for stuttering came from
observations that though the frequency of
stuttering decreased, listeners found that many
speakers continued to sound unnatural.
• Their speech was effortful, uncomfortable to listen
to, and contained auditory or visual features that
prevented listeners from fully attending to the
content of message
Author No. Of Subjects Age of Results
Subjects
Ingham and Packman 9 adolescents and 13-24 Listener’s ratings of naturalness
(1978) adults compared with of clients recived significantly
9 age matched fewer normal speaker judgments
normals
Martin et al, 1984 10 adults without 20-53 Both group of stutterers sounded
DAF 20-51 less natural than the normals
10 adults with DAF 21-45
10 normals

Ingham and Onslow 5 Adolescen Predicatble trends in speech

(1985) 9 – point rating ts naturalness
scale for speech Stutterers speech naturalness
naturalness could be modified to targeted
levels
Ingham, Gow & Costello !5 stutterers and 15 Mean naturalness rating if 4.26
(1985), 9 – point rating normals matched for stutterers and mean value of
scale of martin for age and gender 2.39 for non-stutterers

Metz, Sxhiavetti, Sacco 15 males, 15 Mean Strategies like gentle voicing

(1990) 9- point rating females 14.5 onset and prolonged speech may
scale years slow the post therapy speech
patterns and the may influence
listeners to judge speech of
stutterers to be more unnatural

Onslow, Hayer and 36 9-50 Most severe clients’ speech prior

Newman (1992) years to treatment and naturalness
Considered the effect of scores more than 2 values higher
severity on pre and post (less natural) than least severe
treatment naturalness clients.
ratings
Onslow, Adam and Ingham, 7 male stutterers and 7 14-36 years No significant differences in the
1992 compared the influence normals naturalness scores of conversation
of monologue and / monologue for either stutterers
conversation speech. 9 – or normals
point rating scale

Martin and Horoldson, 1992 6 males and 4 females 20-62 years Naturalness judgments of fluent
studied visual components of (stutterers) 21-64 years speakers were not significantly
stuttering related to speech 6 males and 6 females different for audio and audio-
naturalness judgements used (normals) visual samples on rating scale
9-point rating scale (2.3-2.7 respectively) but
audiovisual samples were judged
to be more unnatural than audio
only
Finn and Ingham, 1994 11 males and 1 female Adults (19- Stutterers gave valid self ratings of
(Stutterers self rating of 71 years) speech quality and were
naturalness) consistently able to differentiate
how natural their speech were
• Other naturalness rating scales were developed by
Subramaniam (1997) and Kanchan (1997).
• Subramaniam scale included confidence, command
over language, clarity, speed of stuttering and
overall rating.
• It was a binary scale for both natural and unnatural
items.
• Kanachn’s scale was also a binary one which
included rate, continuity, effort, stress, intonation,
rhythm, articulation, breathing pattern and overall
rating.
• Currently the 9 – point scale developed by Martin
et.al 1984, has been widely used and reliable for
either oral reading or spontaneous speech
 c. Assessment Conditions
• Ideally the speech samples should be obtained
under multiple conditions and on multiple
occasions (Conture, 1996).
• Speech measures should be collected without
client’s knowledge that their speech is being
evaluated so that they do not react to being
assessed and try to create a favorable outcome and
speech outcome measures should reflect everyday
speech performance free from stimulus controls.
• The following table summarizes assessment
conditions used in prolonged speech therapy
technique
Author N Stuttering Speech Speech task Freq of Situation Nature
Severity rate Assessment

Andrew and 23 %SS SPM Monologue 4 times in 18 Within Overt

Ingham, months and and
1972 beyond covert
clinic

Howie, 36 %SS SPM Phone Twice in 9 Within Overt in

Tanner and 43 %SS SPM conversation weeks and both
Andrews, in both beyond conditio
1981 groups clinic ns
Webster, 200 % of - Reading, Twice in 10 Within -
1980 dysfluenci conversation months and
es on phone beyond
clinic

Boberg, 16 %SS - Reading, 3 times in 12 Within -

1981 conversation months and
on phone beyond
clinic

Andrews 37 %SS SPM Phone Twice in 12 Within -

and Feyer, months clinic
1985
Andrews 84 %SS SPM Phone Twice in Within Overt
and Craig, 18months clinic
1988

Boberg 42 %SS SPM Phone 4 times in Within Overt

and Kully, 24 months clinic
1994

Many of the Speech outcome data are based on person within

clinic situations / telephone calls from staff in clinic, where
the clients may be able to control their stuttering with a
pronounced speech pattern that cannot be used in everyday
speaking situations
 Long term Efficacy of Prolonged Speech
Measure
 In a literature review of current clinical status
of fluency following treatment for stuttering,
Boberz and Kully 1985 concluded that though
the treatment procedures such as prolonged
speech may reduce / eliminate stuttering, the
long term effects were not satisfactory.
Author Method N Age Duration Results Follow-up Results
of interval
treatment

Webster Prolonged 200 - 3 weeks Mean % of Mean of Mean % of stuttered

(1980) speech stuttered 10 months words was 3.2
words
reduced
from 15.1 to
1.3

Boberg Prolonged 6 16-46 3 weeks Decreased 12 months Mean % of stuttered

(1981) speech years from 16.55 syllables of 8 subjects
or more was 1.53 at end of 12
months maintenance
period
Honie, Turner and Andrews, Prolonge 36 Adul 3 weeks Stuttering 2 months Little significant
1981with d speech ts virtually deterioration
eliminated
in 5
subjects
Mallard and Kelly, 1982 Gentle 50 14- 3 weeks Mean % of At least 6 Mean % of
phonator 50 stuttered months stuttered words for
y onsets words fell 28 subjects was
from 20.05 9.74
to 2

Heller, Schulman, Teryak, Gentle 85 6-65 6 weeks 84% 6 months 80% maintained
1983 phonator achieved to 5 years their post treatment
y onsets normal to fluency levels
near
normal
fluency in
conversati
on
Craiz and Andrews, 1988 Smooth 17 Adul 3 weeks Mean % 10 Mean % stuttered
flow ts declined months syllables was 1.9%
speech from 12.9-
0.9

Andrews and Feyer, 1985 Smooth 37 21- 3 weeks Mean % 10-15 Mean % stuttered
flow 60 declined months syllables was 1.1%
speech from 14.1-
0.1

Frank et al, 1922 Gentle 32 15- 4 weeks Declined 6 months Mean % stuttered
phonator 46 from 25.7 syllables was 16.3%
y onsets to 5.8

Boberg and colleagues, 1987 Prolonge 16 3 weeks 12-16 Mean % was 6.38
d speech months outside clinic, 1.86
in reading, 2.54
conversing
strangers
 Acoustic Measures
• The use of a novel speech pattern to eliminate stuttering is a
speech motor adjustment, and temporal aspects of motor activity
are reflected in temporal pattern of acoustic activity (Bover 1987,
Cent 1999).
• Discovery of functional acoustic components of speech patterns
could lead to development of more cost and time effective
treatments for advanced stuttering (Onslow and Ingham, 1989).
Ingham in 1983 highlighted that stuttering could be reduced with
the use of acoustic data feedback.
• Many other problems and issues could be resolved with the
discovery of functional acoustic components of treatments based
on prolonged speech.
• But it is unclear which acoustic feature of speech patterns in these
treatments has a functional relationship to stuttering frequency.
Additionally these patterns may be similar / different across
subjects.
Authors Treatment Procedure No. Of Acoustic analysis Results
subjetcs

Metz et.al, Instructed to “slowly 9 Increased duration Indication that stuttering

1979 initiate phonation and for both vowels and therapy could alter certain
maintain a forward flow stop consonants acoustic properties of stutters’
of air and reduce increased fluent speech
articulation rate”

Metz et.al, Examined relationships 12 males, 5 Analysed CVC Decrease in stuttering

1983 between acoustic females duration, VOT, frequency,
variables and fluency absolute time of Increase in voiced and
within a group of mild to frication, voicing voiceless VOT duration,
severe stutterers and silence Increase in frication duration,
associated with Voicing duration and no
intervocalic significant change in silence
intervals of both associated with intervocalic
voiced and voiceless intervals
stop consonants
Mallard and Precision Fluency 26 Analysed vowel  On an average persons with
Westbrook, Shaping Program (PFSP) duration changes stuttering increased vowel
1985 and also phrase duration.
duration  Vowel duration decreased
as stuttering moved from
initial to final part of
phrase

Mohan Investigated acoustic and One, 17 year  Presence of atypical

Murthy aerodynamic measures old subject transitions
(1987) of /g/ before and after  Inappropriate voicing and
modified airflow duration of segments
techniques and soft inspiratory frications
contacts  Articulatory fixations
 Abnormal articulatory
constrictions
 Longer closing phases on
Lx- excessive vocal
adduction
Franken, Precision Fluency Men of 32.4 Prosodic features Decrease in expressiveness
Bover, Peters Shaping Program (PFSP) years
and Webster,
1991
Onslow, Van Prolonged speech School aged VOT, Voice Decreased variablility in vowel
Doom, children duration, and duration
Newman, interphonation
1992 interval
Madhavilath Instruction to initiate 1 normal Analysis of Reduced Fo range and longer
a, 1997 intonation patterns (model), 10 different intonation sentence duration in stutterers,
depicting emotions such stutterers patterns also other frequency and
as anger, surprise, perceptually and amplitude parameter
sarcasm, command, acoustically
question and statement
Ananthi, Prolongation therapy 1 normal Analysed word No significant difference in
2002 (model), 10 stress, word stress and word duration
stutterers duration, peak Fo,
Lowest Fo and Fo
range
Cognitive, Pharmacological, Behavioral
and other related approaches
 Electromyographic Feedback (EMG)

 The subjects were provided with visual

feedback about selected muscle activity.
Authors Age Stuttering Frquency Social, eotional or
< 5% cognitive variables
improved

Post At 6 Post At 6
Treatment months Treatment months
Follow-up Follow-up
Craiz & 10-14 Yes Yes - -
Cleary, years
1982
Graiz et.al 9-14 years Yes Yes Yes Yes
, 1996
 Gradual increase in length and
complexity of utterance

 A program which progressed from 1 word

response to oral reading, monologue and
concersational tasks mainly worked out with
children.
Authors Age Stuttering Frquency Social, eotional or
< 5% cognitive variables
improved
Post At 6 Post At 6
Treatmen months Treatmen months
t Follow-up t Follow-up
Ryan and 7-18 years Yes Yes - -
Ryan,
1983
Ryan and 7-17 years Yes Yes - -
Ryan,
1995
 Metronome conditioned speech retraining:

Authors Age Stuttering Frquency Social, eotional or

< 5% cognitive variables
improved
Post At 6 Post At 6
Treatmen months Treatmen months
t Follow-up t Follow-up
No No No
Ost et.al, 14-46 No
1976 years
 Prolonged Speech
Authors Age Stuttering Frquency < 5% Social, eotional or cognitive
variables improved

Post At 6 months Post At 6 months

Treatment Follow-up Treatment Follow-up

Craiz 9-14 Yes Yes Yes Yes

et.al,
1996

Howie et 21+ Yes - Yes -

al, 1961

Ingham, 18 -20 Yes - - -

1982
Ingham 18-56 Yes - - -
and
Andrew
s, 1973
Ingham 18-28 Yes - - -
, 2001
Ingham 42 Yes Yes - -
and
Packma
n, 1977
James et. 34 Yes Yes Yes Yes
Al, 1989
O’Brian et. 1759 Yes - - -
Al, 2003
Onslow, 10-41 Yes Yes - -
1996
Perkins 12-52 Yes No - -
et.al, 1974
Ryan and 7-18 Yes - - -
Ryan, 1963
Ryan and 7-17 Yes Yes - -
Ryan, 1995
Tanbaugh 12 Yes Yes - -
and Guitar,
1961
Authors Age Stuttering Frquency < 5% Social, emotional or
cognitive variables
improved
Post At 6 months Post At 6 months
Treatment Follow-up Treatment Follow-up
Andrews 26 No - Yes -
and Tanner,
1982a
Andrews Adults Yes No Yes Yes
and Tanner,
1982b
Landoucer, 15-47 Yes - - -
1981
Landoucer 17-74 No - - -
, 1982
Landoucer 5-16 Yes - - -
and
Martin,
1962
Landoucer 18-36 Yes Yes No No
and Saint
Laurent,
1986
Mittemberger et.al, 1996 19-27 Yes Yes - -

Landoucer and Saint 18-50 Yes No - -

Laurent, 1987

Franken, 2005 6 Yes - - -

Harrison, 1999 5 Yes Yes - -

Ingham, 1980 9-23 Yes Yes - -

James et.al, 2005 3-6 Yes - - -

Lattermann, 2005 4-5 Yes - - -

 Indicators of Therapy Progress
Main indicators of therapy progress include:
• Increasing the clients self monitoring ability

• Increasing the clients ability to produce ‘open speech’

• Decreasing the frequency and duration of motoric

fluency breaks
• Increasing the naturalness of fluent speech

• Metalinguistic changes

• Decreased avoidance

• Increased (speech) assertiveness

• Improved self concept, self esteem and role changes

 Increasing the clients self monitoring
ability
• A basic indicator of progress is the speaker’s ability to tuning
tuning into what he is doing when he stutters and what he is
capable of doing in order to enable himself to speak fluently.
• Even if he is not able to modify his production he may be
able to accurately monitor what he is doing to make
speaking so difficult.
• Accurate self monitoring of any behavior or thought process
is a preparatory step toward taking responsibility and
transforming the event.
• Self monitoring will continue to be a critical element of long
term success.
• During the initial stages of treatment, the clients monitoring
is focused on the overt stuttering behavior
• Although the focus early in treatment is on monitoring rather than
the modification of stuttering events, as speaker improves his ability
to catch his behavior nearer to the initiation of the stuttering event,
some instinctive and positive changes in the stuttering often take
place.
• That is the speaker will not only recognize what he is doing to make
speaking difficult, he will begin to make some changes in the
behavior.
• He may provide himself with some airflow, or he may slightly
decrease a constriction in his vocal tract that will assist him in
smoothening his speech.
• These changes are small and transient victories to be sure, but the
clinician should look for them and reward these subtle changes in
the form of stuttering.
• As Conture (1990) indicates, the client’s consistent identification at
the beginning or the middle of stuttering events sometimes becomes
associated with his ability to change his stuttering behavior.
 As treatment progresses, such self monitoring
activities continue to be pivotal for long term
progress outside the treatment environment.
 In addition, self evaluation also comes to mean
the monitoring of the cognitive aspects of
change, such as the self talk the client provides
to himself prior to and following successful, as
well as less than successful, speaking
situations.
 Increasing the clients ability to produce
‘open speech’
• Improvement can be observed during every treatment
session by the clinician and the client if close attention
is paid to the form of fluency breaks.
• Early in treatment the fluency breaks are typically
characterized by a greater degree of vocal tract
constriction and effort.
• As the speaker begins to understand the nature of his
speech production system and becomes able to modify
moments of stuttering, progress can be observed in the
form of airflow, increased smoothness and blending of
sounds and words.
• Perhaps most importantly he begins to produce speech
• As he becomes able to monitor his production, especially via
proprioceptive feedback, he will be able to appreciate the
difference between the tension and constriction of old way of
speaking and the new flowing and effortless production using an
open vocal tract
• The speaker as well as listener can hear the increased openness
and ease of such speech movements.
• At each such occurrence of enhanced airflow and smoothness of
articulatory of movement, there is the opportunity for the
clinician to reward the progress.
• The client’s speech may not be completely fluent, but the changes
are obvious and satisfying. The result is a much easier form of
stuttering.
• As Conture (1990) suggests, a shortening in the duration of
stuttering is a sign of progress.
• The client is stuttering, to be sure, but it is the speech that is
produced with less effort and is much easier to listen to.
 Decreasing the frequency and duration of
motoric fluency breaks
• Decreasing the frequency of motoric fluency breaks is an
obvious goal of treatment and a commonly used indicator of
progress.
• As the speech becomes more open and flowing, both the
frequency and especially the duration of stuttering movements
should show some obvious changes.
• It may be that the frequency of brief stuttering events may even
increase somewhat if the speaker is successful in changing in his
patterns of avoidance and word substitution.
• However, if the duration and associated tension in terms of
both the degree and the sides of physical tension decreases, real
progress is being accomplished.
• Again, this progress will be likely to be recognized by the
speaker if self monitoring is maintained.
 Increasing the naturalness of fluent speech
• The impetus for studying the speech naturalness of individuals
treated for stuttering came from observations that many people
who had undergone successful treatment using fluency
modification strategies continue to sound less than satisfactory.
• That is although, the frequency of stuttering had decreased
dramatically, and listeners found that many speakers continue
to sound unnatural
• Their speech was effortful, uncomfortable to listen to and
contained auditory or visual features that prevented the
listener from fully attending to the content of the message.
• Despite an otherwise successful treatment experience, many
speakers found that they were still regarded by themselves and
others as having the problem.
 Naturalness Rating Scale
• In 1984, Martin, Haroldson and Triden began the development of a
reliable scale for rating speech naturalness.
• The scale consisted of a 9-point rating scale with 1 equivalent to highly
natural sounding speech and 9 equivalents to highly unnatural speech.
• This scale has been used in virtually all subsequent investigations of
speech naturalness.
• Martin had 30 listeners use the scale to assess the speech naturalness of 10
adults who stuttered speaking without DAF, 10 adults who stuttered
speaking under DAF, and a group of 10 normal speaking adults.
• They found that both groups of speakers who stuttered sounded
significantly less natural than the non stuttered sample.
• The mean naturalness rating of stutterers was 6.5, stuttering group under
DAF received an mean of 5.8 and non-stuttering group had a mean of 2.1.
• Based on inter rater agreement and rater consistency, Martin concluded
that observers are able to quantify speech naturalness.
  Metalinguistic Changes
• The way a person depicts his situation or problem often
indicates important signs of progress during treatment. As
people progress through effective treatment, they begin to
think and talk differently about themselves and their
speech.
• The intrinsic features of affective and cognitive change are
reflected in the words the client uses to describe himself, his
speech, and his interaction with others.
• How the client talks about himself and his speech provides a
window for viewing these intrinsic features.
• Early in treatment the client typically feels helpless. He
believes he is unable to do much to change his speech or
himself.
• There is a high degree of mystery associated with
stuttering. AS treatment progresses, client slowly
begins to develop the language of fluency
• As well as use more appropriate self talk.
• As the client begins to successfully change his
previously uncontrollable behavior, he will begin
to change the way he observes himself and his
speech moreover, he will begin to describe his
behaviors and actions in more specific and
realistic ways.
• The client will begin to interpret stuttering as
something that he is doing rather than happening
to him.
• These metalinguistic changes provide the clinician with
important evidence of change and indicate that the client is
beginning to take charge of the problem.
• Such utterances may be used as a way to monitor cognitive
changes or in some cases; the clinician can take a more active
role and point out to the client how he is describing himself
and his problem.
• The client’s language will reflect some degree of liberation
from the problem.
• That is coinciding with the fact that the speaker shows a great
degree of fluency, they are more liberated in terms of their
choices and have a greater involvement in life.
 Decreased Avoidance
• As avoidance decreases, the frequency of fluency breaks may
increase.
• Early in treatment less avoidance and greater participation in
speaking activities may yield a slight increase in the frequency of
stuttering.
• There may even be an increase in the duration and tension of
stuttering events.
• Although these changes may not be pleasant to the client, if
stuttering modification strategies are being used, they can be
viewed as progress within the context of the overall treatment
process.
• Taking part in activities and making better choices may not be the
first step for each client, but it is always a critical step.
• Furthermore, a decrease in the avoidance behavior permits the
client to go directly at the problem and the associated fear.
 Increased (Speech) Assertiveness
• With a decrease in avoidance behavior, there is likely to be a
corresponding increase in overall assertiveness.
• In reality being more assertive about once speaking behavior
is likely to translate into increased assertiveness in general.
• There may be changes in roles and a relationship as the
persons no longer plays the primary role of a stutterer.
• It is a distinctive indicator of progress when the speaker
begins to decrease his reflexive self censorship and begins to
consider many speaking situations h once considered
unimaginable.
• This is not to say that he will now take part nonetheless and
to consider new opportunities is a significant measure of
progress.
 Improved Self-Concept, Self-Esteem and
role changes
• Self-Concept and Self-Esteem have been referred to
many times in the literature on fluency disorders.
• Peck (1978), self esteem is the corner stone of
psychological change. Although persons who stutter
have not been found to have a unique self esteem or to
be lacking in self esteem, this concept has frequently
been mentioned as an aspect of treatment programs.
• When the client experiences success in the self
management of surface and intrinsic aspects of his
fluency disorder, self esteem and the self concept
begins to shift in positive direction.