Stuttering therapy

Stuttering therapy is any of the various treatment methods that attempt to reduce stuttering to some degree in an individual. Stuttering can be seen as a challenge to treat because there is a lack of consensus about therapy.

Before beginning therapy treatment, an assessment is needed, as diagnosing stuttering requires the skills of a certified speech–language pathologist (SLP). Some of the available treatments focus on learning strategies to minimize stuttering through speed reduction, breathing regulation, and gradual progression from single-syllable responses to longer words, and eventually more complex sentences. Furthermore, some stuttering therapies help to address the anxiety that is often caused by stuttering, and consequently worsens stuttering symptoms. This method of treatment is referred to as a comprehensive approach, in which the main emphasis of treatment is directed toward improving the speaker's attitudes toward communication and minimizing the negative impact stuttering can have on the speaker's life. Treatment from a qualified S-LP can benefit stutterers of any age.

In addition, people may learn to start saying words in a slightly slower and less physically tense manner. They may also learn to control or monitor their breathing. When learning to control speech rate, people often begin by practising smooth, fluent speech at rates that are much slower than typical speech, using short phrases and sentences. Over time, people learn to produce smooth speech at faster rates, in longer sentences, and in more challenging situations until speech sounds both fluent and natural. When treating stuttering in children, some researchers recommend that an evaluation be conducted every three months in order to determine whether or not the selected treatment option is working effectively. "Follow-up" or "maintenance" sessions are often necessary after completion of formal intervention to prevent relapse.

Approaches
There are different approaches to stuttering therapy. There is no cure for the condition.

Depending the child or adult, therapy is generally a management of speech comfort, and/or teaching techniques to speak in a controlled way.

Therapy for children
Treatment of stuttering in children younger than six years of age focuses on the prevention or elimination of stuttering. Families play an important role in the management of stuttering in children: therapy is usually characterized providing an environment that encourages slow speech, affording the child time to talk, and modeling slowed and relaxed speech.

The Lidcombe Program
Lidcombe therapy has involves a parent or some significant person in the child's life being trained and delivering treatment in the child's everyday environment. In the program, family members are to provide an environment in which the child receives praise for fluent speech in the child's daily speaking and negative correction of stuttering. Some of the most effective preschool intervention programs call for direct acknowledgment of stuttering in the form of contingencies such as "that was bumpy" or "that was smooth".

Fluency shaping
Fluency shaping therapy focuses on changing all of the speech of the person who stutters. This type of therapy involves teaching the stutterer to use a speaking style that requires careful and prominent self-monitoring; examples of such therapy include one in which the stutterer slows his speech down or speaks in a controlled tone. This type of approach can reduce stuttering, although in children its effectiveness decreases if stuttering persists after eight years of age.

People who stutter are trained to reduce their speaking rate by stretching vowels and consonants, and using other disfluency-reducing techniques such as continuous airflow and soft speech contacts. The result is very slow, monotonic, but fluent speech, used only in the speech clinic. After the person who stutters masters these skills, the speaking rate and intonation are increased gradually. This more normal-sounding, fluent speech is then transferred to daily life outside the speech clinic, though lack of speech naturalness at the end of treatment remains a frequent criticism. Fluency shaping approaches are often taught in intensive group therapy programs, which may take two to three weeks to complete.

Modifying Phonation Intervals (MPI)
The Modifying Phonation Intervals (MPI) Stuttering Treatment Program is designed to be a computer-aided, bio-feedback program that requires appropriate software (MPI smartphone app) and hardware (a throat microphone headset) which records the phonation intervals, or PIs, from the surface of the speaker's throat.

The app records all PIs as well as speaker-rated speech performance measures.

The MPI Stuttering Treatment Program is based on a series of experimental studies by Roger Ingham and colleagues (Gow & Ingham, 1992; Ingham, Kilgo, Ingham, Moglia, Belknap, & Sanchez, 2001; Ingham, Montgomery, & Ulliana, 1983 ).

The MPI Stuttering Treatment Schedule is divided into four phases: Pre-Treatment, Establishment, Transfer, and Maintenance. Each phase is designed to be managed jointly by the speaker (person who stutters) and the clinician. The Pre-Treatment phase is directed by the clinician, but the other phases are largely self-managed while also requiring regular validation by a clinician.

Stuttering modification
Stuttering modification therapy, also known as traditional stuttering therapy, was developed by Charles Van Riper between 1936 and 1958. It focuses on reducing the severity of stuttering by changing only the portions of speech in which a person stutters, to make them smoother, shorter, less tense and hard, and less penalizing. This approach attempts to reduce the severity and fear of stuttering, and strives to teach stutterers to stutter with control, and not to make the stutterer fluent. Therapy using this approach tends to recognize the fear and avoidance of stuttering.

Contemporary devices
Contemporary devices used to reduce stuttering alters the frequency of the speaker's voice to mimic the "choral effect", a phenomenon in which person's stutter decreases or ceases completely when she is speaking with a group of others, or slows the rate of speech through delayed auditory feedback.

Delayed auditory feedback devices, such as Speech Easy encourage the slowing down of speech by replaying the speaker's words into their ears. The stutterer is then forced to slow their rate of speech to prevent distortions in the speech that is heard through the device. This is not effective for all people who stutter, and is shown to wear off over time. In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups.

There are specialized mobile applications and PC programs for stutter treatment. The goal pursued by the applications of this kind is speech cycle restoration: I say, I hear, I build a phrase, I say, and so on, using various methods of stutter correction.

The user interacts with the application through altered auditory feedback: they say something into the headset's microphone and listen to their own voice in the headphones processed by a certain method.

The following stutter correction methods are typically used in applications:


 * MAF (masking auditory feedback). It is basically masking by white noise or sinus noises of the user's own speech. Scientists believe that people who stutter can speak more smoothly when they do not hear their own speech. This method is considered old-fashioned and ineffective.
 * DAF (delayed auditory feedback). This method involves sending the user's voice from a microphone to headphones with a delay of fractions of a second. The goal of this method is to teach people who stutter to prolong vowels and reduce their speech rate. After speech correction with long delays, the application is adjusted at shorter delays which increase the speech rate until it becomes normal.
 * FAF (frequency-shifted auditory feedback). This method involves shifting the user's voice tone frequency that they are listening to compared to their own voice. The shift range can be different: from several semitones to half an octave.
 * Using metronomes and tempo correctors. Rhythmic metronome strikes are used in this method. The effectiveness of the method is related to the fact that rhythm has positive effect on someone who stutters, especially when pronouncing slowly.
 * Using visual feedback. This method determines the user's speech parameters (for instance, speech tempo) and their representation on screen as visual information. The principal goal of the method is allowing the user to effectively manage their voice through achieving the defined targeted parameters. It is supposed that the user sees visual representation of both current and targeted parameters (such as speech tempo) on the screen while pronouncing.

Medications
No medication is FDA-approved for stuttering.

The best studied medication in stuttering is olanzapine, whose effectiveness as of 2004 had been established in replicated trials. Olanzapine acts as a dopamine antagonist to D2 receptors in the mesolimbic pathway, and works similarly on serotonin 5HT2A receptors in the frontal cortex. At doses between 2.5 and 5 mg, olanzapine has been shown to be more effective than placebo at reducing stuttering symptoms, and may serve as a first-line pharmacological treatment for stuttering based on the preponderance of its efficacy data. However, other medications are generally better tolerated with less weight gain and less risk of metabolic effects than olanzapine.

The investigational compound, ecopipam, is unique from other dopamine antagonists in that it acts on D1 receptors instead of D2, owing little, if any risk, of movement disorders. A 2019 open label study of ecopipam in adults demonstrated significantly improved stuttering symptoms with no reports of parkinsonian-like movement disorders or tardive dyskinesia which can be seen with D2 antagonists. In addition, ecopipam had no reported weight gain, but instead has been reported to lead to weight loss. In a preliminary study, it was well tolerated in subjects, effectively reduced stuttering severity, and was even associated in a short-term study with improved quality of life in persons who stutter. Further research is still warranted, but this novel mechanism is showing promise in the pharmacologic treatment of stuttering.

Diaphragmatic breathing
Several treatment initiatives use diaphragmatic breathing (or costal breathing) as a means by which stuttering can be controlled.

Psychological approach
Cognitive behavior therapy has been used to treat stuttering. Also sociological approaches has been explored regarding how social groups maintain stuttering through social norms.

Community groups
Stuttering support/community groups have gained prominence and visibility and can be an important part of the process for stutterers, A growing number of speech–language pathologists encourage their clients to participate in support groups.

Research shows that participating in support groups and self-help sessions with others who stutter may reduce the negative attitudes associated with stuttering. Becoming part of stuttering groups may help reduce the feelings of loneliness, fear, shame and embarrassment that comes with years of stuttering. Participants of group sessions show lower internalization of stigma regarding stuttering. They have lower levels of negative feelings about themselves. Moreover, the goal of helping others who stutter in the group has been linked to better psychological well-being.

Studies in the United States involving members of support groups of the National Stuttering Association have found that 57.1% of survey respondents said that the support group had affected their self-image "very positively", with no respondents indicating that it had a negative impact.

McGuire Programme
The McGuire Programme is a stammering or stuttering treatment programme/course run for people who stammer or stutter (ages 14+) by people who stammer. There are no licensed speech therapists involved. It was founded in 1994 by American Dave McGuire in Holland.

Scottish international rugby union captain, Kelly Brown, is a graduate of the course. Singer Gareth Gates attended the programme's workshops and subsequently qualified as a speech instructor himself. Stammering awareness activist Adam Black, also a graduate of the course, received a British Empire Medal in the 2019 New Year Honours list where his work raising awareness of stammering was recognised.

Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) may be used to help people who stutter. CBT may be partially effective in helping clients reduce their secondary behaviors, anxiety, and cognitive distortion. Cognitive behavioral therapy is a collaborative process that requires the client and the therapist working together to explore the buried feelings of frustration, avoidance, anger, and self-doubt. Younger children who stutter are more benefited by CBT as compared to adults who stutter. Research at the Michael Palin Center has shown that CBT is a powerful tool for children who stutter.

Pharmacologic therapy
Several pharmacologic, i.e. drug-based, methods to control or alleviate stuttering events have been studied, but each has either proved ineffective or have had adverse effects. A comprehensive review of pharmacologic interventions for stuttering showed that no agent leads to valid improvement in stuttering or in secondary social and emotional consequences.