Contingency Management and Stuttering in Children

This is a review of the contingency management literature and current related treatment programs for stuttering in childhood: the Lidcombe Program, Gradual Increase in Length and Complexity of Utterance (GILCU), and Prolongation (PS). Treatment efficacy research has shown these treatments to be effective and efficient for children, but there should be control for the estimated 80% spontaneous recovery in children under eight. Unfortunately, these procedures are not generally well accepted or used by the profession of speech-language pathology. It is hoped that the recent interest in evidence-based practice will motivate speech-language pathologists to use these validated procedures. Key words: stuttering; operant conditioning; GILCU; Lidcombe Program; Prolongation treatment ********** Since the seminal work by Skinner (e.g., 1953) in operant conditioning and others (Flanagin, Goldiamond, & Azrin, 1959; Goldiamond, 1965, Ryan, 1971) in operant conditioning and stuttering, much has been accomplished with contingency management and stuttering in children. Early studies indicated that stuttering was indeed operant behavior controlled by its consequences (e.g., Costello, 1975; Martin, 1968; Ryan, 1971, 1974, pp. 123-127, 142-149; Shaw & Shrum, 1972). The frequency of stuttering, when followed by aversive events or stimuli, decreased and stuttering, and when followed by positive events or stimuli, increased. Then followed more than a decade of a wide variety of studies as reviewed in Brutten (1993) and Siegel (1993). Most of which demonstrated the effects of different contingencies of positive and/or aversive stimulation on stuttering. One of the most interesting is reported in Ryan (1974, pp. 142-149). In this study the 12 year old male participant was first reinforced for five sessions with a "penny" for each stuttering with the goal to gain positive reinforcement control of the stuttering and then eliminate the stuttering when postive reinforcement was withdrawn during the subsequent extinction period. Stuttering did increase but also increased during the following extinction phase which was attributed to the increase in response rate commonly seen during the withdrawal of a positive reinforcer. Perhaps if this extinction phase had been continued, the effect might have occurred. In the fourth phase, positive reinforcement was reintroduced with effort made by the experimenter to reinforce gradually smaller and smaller stutterings in the hope of "shaping out" the stuttering. That did indeed happened as measured both during the process itself and later in a reliability recount, which indicated an even more dramatic reduction. Unfortunately, circumstances and the design of a preset limited number of sessions per phase may have failed to allow enough time for the effects to occur , that is, let the various contingencies have time to work. There were also efforts made to develop "programs" of treatment (small, sequential steps with consequences delivered on predetermined schedules leading to the end goal of fluent speech) which included an acquisition phase (later known as establishment to provide fluency in the presence of the clinician), a generalization phase (later known as transfer to provide extraclinic fluency), and a maintenance phase (long-term, life time production of fluency in a wide variety of natural situations). Most of these programs included small easy to hard steps with aversive consequences for stuttering (e.g., "Stop") and positive consequences for fluency (e.g., "Good" and/or tokens). Establishment Programs Three different operant-based, contingency management establishment treatment programs for children have emerged and been supported by extensive treatment efficacy research (TER): the Lidcombe, Gradual increase in Length and Complexity of Utterance (GILCU), and Prolonged Speech (PS) (Bothe, 2002; Conture, 1996, Cordes, 1998; Onslow, 1996; Ryan, 1974, 2001d): They constitute a major part of the present evidence-based practice (EBP) or treatment (Ingham, 2003) with people who stutter. …