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



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



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.



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



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



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-



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-



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.



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 .



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



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.



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.



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.



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



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,.



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

r. g. wahler et al. - the modification of childhood sttuttering

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