PRETREATMENT FACTORS ASSOCIATED WITH THE OUTCOME OF STUTTERING THERAPY BARRY GUITAR
University of New South Wales Teaching Hospitals, Sydney, Australia Measures of stuttering behavior, personality, and attitudes about speaking were obtained from 20 stutterers at the beginning of treatment. These measures were correlated with three measures of stuttering behavior a year after treatment. Pretreatment attitudes were most highly related to outcome, followed by pretreatment stuttering behavior, and then personality measures. Multiple regression analyses of the pretreatment measures demonstrated that combinations of these variables correlated moderately high (r = 0.79, 0.66, 0.73) with outcome. Prediction equations derived from the multiple regression analyses were used to predict outcomes for an independent group of 18 stutterers. Predicted and actual outcomes were shown to be correlated moderately high (r = 0.75, 0.73, 0.51). Suggestions for clinical use of predictive factors are given. Implications for the design of treatment and understanding the nature of stuttering are discussed. Prediction of treatment outcome can be useful for several reasons. Most obviously, clinicians may wish to give treatment priority to those patients who will benefit most from treatment. Moreover, those variables which are predictors of outcome may highlight areas in which treatment can be altered to help patients who would do poorly on current treatment programs. Finally, the important predictor variables may give some insight into the nature of the disorder. Unfortunately, several decades of stuttering research have failed to produce any useful predictors of treatment outcome (Van Riper, 1973). The results of several recent studies are representative of research in this area. Lanyon (1965) and Prins (1968) found that pretreatment measures of stuttering adaptation were not clinically useful in predicting amount of change in stuttering during treatment. Lanyon (1965) also reiected pretreatment stuttering consistency as a possible predictor of outcome. Turning from pretreatment stuttering to personality, investigators still have had little success in finding predictors. Lanyon (1966) found no clinically useful correlation between MMPI scores and change in stuttering during therapy. Gregory (1969) failed to find a significant correlation between MMPI, Holtzman Inkblot, or Edwards Personal Preference Schedule scores and change in treatment. Perkins (1973) also found no clinically meaningful relationships between three personality measures (16 PF Test, Rorschach, and the Guilford590
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Zimmerman Temperament Survey) and treatment outcome measured in percent reduction in stuttering six months after discharge from therapy. In all the recent studies, the only high correlation between a pretreatment measure and outcome is the finding by Gregory (1969) that pretreatment severity rating was positively correlated (r = 0.78) with change in severity rating from before to immediately after treatment. This result is not surprising, however, since severe stutterers enter therapy with higher levels on the severity scale and thus have a greater range to travel during treatment. Moreover, this correlation is dependent on when outcome is measured. When the ninemonth posttreatment changes in severity were correlated with pretreatment severity, the correlation dropped from 0.78 to 0.48. Changes in stuttering severity from immediately after to many months after treatment, such as shown by Gregory's subiects , are not unusual. Data are now available to support the long-standing clinical impression that many stutterers regress considerably after treatment (Ingham and Andrews, 1973; Perkins, 1973). In fact, those who improve most in treatment may show the greatest regression later (Prins, 1970). Thus, studies which measure stuttering immediately after treatment, such as those of Lanyon (1965, 1966), Prins (1968), and Gregory (1969), may not have assessed the most clinically important outcome of treatment. Long-term outcome is a more accurate assessment of how treatment has affected a stutterer. Of the studies cited here, only Perkins (1973) used longer term outcome in attempting to find predictors of treatment effects. The lack of useful predictors of long-term outcome of stuttering treatment suggests a need for further investigation. Although personality measures by themselves have not been effective predictors, they might well be combined with overt measures of pretreatment stuttering for prognosis. Besides measures of personality and level of stuttering, some assessment of attitudes might also be helpful in forecasting outcome. This seems particularly possible in light of recent evidence that cognitive variables are important in determining overt behaviors ( Kimble, 1973). The present study was designed to evaluate a combination of pretreatment measures of stuttering, attitudes toward stuttering, and personality factors, as predictors of long-term outcome of treatment. METHOD Subiects
Two groups of subiects were used in this study. The first group (Group 1) consisted of 20 stutterers treated at the Prince Henry Hospital between October 1973 and June 1974. Of the 54 stutterers treated during this period, 25 were living in Sydney at the time of a follow-up evaluation. However, four could not be contacted and one refused to be interviewed. The remaining 20 (16 males and 4 females) became Group 1. Their ages ranged from 21 to 64 with a mean age of 30.4 years. GUITAR: Pretreatment Factors 591
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The second group (Group 2) consisted of 18 stutterers treated between June and December 1974. Of the stutterers treated in this period, 19 lived in Sydney and one could not be contacted. Group 2 consisted of 17 male and one female stutterers with an age range of 17 to 30 years and a mean age of 24.6 years. Treatment Program
All subjects received treatment for stuttering on the Prince Henry Hospital Stuttering Treatment Program described by Ingham and Andrews (1973). This is a group treatment, token economy program in which subjects live in the treatment environment while they undergo training in prolonged speech to a criterion of zero percent syllables stuttered (%SS) at 200-----20 syllables per minute (SPM). After subjects achieve the fluency criterion in the hospital, they then transfer their fluent speech into a variety of everyday situations. Treatment is completed in three weeks, although subjects often return periodically for advice on maintenance of their fluency. Procedures
The basic design of the study was to obtain pretreatment measures from subjects in Group 1 and then evaluate their fluency a year after treatment. Following this, multiple regression analyses were carried out to determine the degree to which pretreatment measures predicted the subjects' outcomes. Equations derived from the regressions were then used to predict the outcomes for subjects in Group 2 on the basis of their pretreatment measures. Correlations between the predicted and actual outcomes for subjects in Group 2 provided cross-validation of the findings for subjects in Group 1. Pretreatment Measures. The pretreatment data, which included measures of personality, attitudes about stuttering, and amount of stuttering, were obtained when subjects entered the hospital. Personality was assessed by the extroversion and neuroticism scales of the Eysenck Personality Inventory (Eysenck and Eysenck, 1963). Neuroticism and extroversion have been shown previously to be associated with success and failure on stuttering therapy programs (Brandon and Harris, 1967). Attitudes toward stuttering were measured by the short form of the Erickson Scale of Communication Attitudes (Erickson, 1969; Andrews and Cutler, 1974) and by an abbreviated version of the Stutterer's Self-Rating of Reactions to Speech Situations (Johnson, Darley, and Spriestersbach, 1963; Cutler, 1973). Only the avoidance and reaction responses of the Stutterer's Self-Rating form were used because these appeared to be most related to attitudes. Clinical experience suggested that those stutterers who scored high on the avoidance and reaction parts of this assessment were more likely to be emotionally affected by their stuttering, regardless of their actual level of stuttering. In addition to the above assessments, amount of stuttering was measured when the subjects entered treatment. Stuttering was measured during conver592 Journal of Speech and Hearing Research
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sational speech in percentage syllables stuttered (pre%SS) and syllables per minute (preSPM). These measures have been shown to correlate highly with listener iudgments of severity and to be reliable (Young, 1961; Andrews and Ingham, 1971 ). Stuttering scores used for the multiple regression analyses were %SS and "alpha" score, 1 a measure which combines frequency of stuttering and speech rate. The alpha score was developed because speech rate has been considered an important adjunct in the assessment of fluency (Ingham, 1972; Perkins, 1975). Posttreatment Measures. Twelve to 18 months after the subiects completed the three-week treatment program, they were contacted by a management consultant who was unknown to them, and a meeting was arranged in his office in a different part of the city from the place of treatment. A five-minute sample of conversational speech was recorded and later scored by the experimenter. Measures of outcome were percentage of syllables stuttered (post%SS), alpha score (postalpha), and percent change in frequency of stuttering (%change). This last score, %change, was calculated by the following formula: pre%SS - post~;SS pre~SS
Reliability of Measurements of Stuttering A random sample of one-third of the tape recordings of stutterers was rescored by the experimenter and by another rater. Correlations between the original scores and the remeasured scores were computed by the Pearson product-moment formula. Intrarater reliability for total syllables stuttered and syllables per minute were 0.99 and 0.95, respectively. Interrater reliability for syllables stuttered and syllables per minute were 0.99 and 0.92, respectively. RESULTS This study sought to measure a variety of pretreatment variables and assess their usefulness in predicting outcome of treatment. This section will present (1) pretreatment and outcome measures collected from subiects in Group 1, (2) correlations between the pretreatment and outcome measures for Group 1, and (3) correlations between predicted and actual outcomes for subiects in Group 2. XA formula to transform frequency and rate into a single score was developed by Megan Neilson and Gavin Andrews, Human Communication Laboratory, University of New South ~SS SPM - ~ + 47.96, is based on a pre1.23 4.17 dicted relationship between frequency and rate in a large group of stutterers (Andrews and Ingham, 1971). When a subiect had 0~SS, his alpha score was deemed to be 0, because alpha was intended to measure stuttered speech. Wales Teaching Hospitals. The formula, alpha -
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Pretreatment and Outcome Measures
The means and standard deviations for pretreatment variables and measures of outcome for Group 1 are given in Table 1. TAttLE 1. Means and standard deviations for pretreatment variables and measures of outcome for Group 1.
Variable
Mean
SD
Pre~SS Prealpha Avoidance Reaction Erickson Extroversion Neurotic*sin Post~SS ~change Postalpha
7.50 24.30 2.46 2.71 20.50 11.90 11.90 2.40 68.00 8.10
6.9 15.1 0.7 0.6 3.0 3.9 6.3 3.7 48.0 10.5
Correlations Between Pretreatment Variables and Measures o[ Outcome Simple Correlations. Correlations between pretreatment variables (pregSS, prealpha, avoidance, reaction, Erickson, extroversion, and neuroticism) and measures of outcome (postgSS, gchange, and postalpha) are given in Table 2. TABLE 2. Spearman correlations between pretreatment variables and measures of outcome of treatment.
Pretreatment Variable
Postf~SS
~chang e
Postalpha
Pre~SS Prealpha Avoidance Reaction Erickson Extroversion Neuroticism
0.39" 0.45" 0.56 * * 0.48* 0.45* 0.17 0.37
- 0.24 - 0.25 - 0.45 * - 0.49* - 0.51* - 0.17 -- 0.23
0.44" 0.42 * 0.48" 0.55"* 0.61" * 0.10 0.39*
*Level of significance is 0.05. **Level of significance is 0.01. Because m a n y of the scores w e r e in percentages, n o r m a l i t y of the distributions c o u l d not b e assumed. N o n p a r a m e t r i c ( S p e a r m a n ) correlations were therefore
used. T h e correlations in T a b l e 2 i n d i c a t e that post~SS was most h i g h l y correlated w i t h the three m e a s u r e s of attitude, p a r t i c u l a r l y avoidance, f o l l o w e d b y the m e a s u r e s of stuttering, a n d t h e r e a f t e r b y m e a s u r e s of personality. Correlations w i t h ~ c h a n g e f o l l o w e d the p a t t e r n set b y post~SS, a l t h o u g h in this case measures of stuttering s h o w e d a m u c h lower correlation w i t h the o u t c o m e m e a sure. Correlations w i t h p o s t a l p h a were g e n e r a l l y similar to those w i t h post~SS. Intercorrelations. T a b l e 3 shows the intercorrelations a m o n g the pretreat-
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TABLE 3. Intercorrelations among pretreatment variables. Pretreatment Variables
Avoidance Reaction
Avoidance Reaction Erickson Extroversion Neuroticism Pre~SS Prealpha
-
0.87** -
Erickson 0.77** 0.79"* -
Extroversion
Neuroticism
-0.22 -- 0.06 0.08 -
0.56** 0.44"* 0.65* * 0.08 -
PregSS
PreaIpha
0.13 0.20 0.42* 0.14 0.38 -
0.13 0.06 0.32 0.07 0.27 0.89"*
*Level of significance is 0.05. **Level of significance is 0.01. m e n t variables. T h e s e d a t a indicate the extent to w h i c h each of the pretreatm e n t variables is r e l a t e d to each of the others. T h e d e g r e e of relationship suggests w h e t h e r these variables are m e a s u r i n g the same or different aspects of the subiect a n d his stuttering. T h e three m e a s u r e s of a t t i t u d e ( a v o i d a n c e , reaction, a n d E r i c k s o n ) are highly intercorrelated. T h e y are, h o w e v e r , not at all highly c o r r e l a t e d with extroversion or p r e t r e a t m e n t s t u t t e r i n g measures. To some extent the three attitude m e a s u r e s are c o r r e l a t e d w i t h neuroticism. T h e two m e a s u r e s of stuttering, pre~SS a n d p r e a l p h a , are also h i g h l y intercorrelated. T h e two personality measures, extroversion a n d neuroticism, h o w e v e r , are not i n t e r c o r r e l a t e d to any real extent. M u l t i p l e Correlations. The results of m u l t i p l e regression analyses ( M c N e m a r , 1969) are s u m m a r i z e d in T a b l e s 4, 5, a n d 6. T h e s e analyses e m p l o y the simple correlations in T a b l e 2, as well as the intercorrelations in T a b l e 3, to d e t e r m i n e the best c o m b i n a t i o n of p r e t r e a t m e n t variables to p r e d i c t outcome. TABLE 4. Cumulative multiple correlations between pretreatment variables and post~SS. Pretreatment Variable Avoidance Prealpha Extroversion Pre~SS Reaction Neuroticism
Multiple r
Simple r
Signi]~cance Level
0.56 0.68 0.75 0.78 0.78 0.79
0.56 0.45 0.17 0.39 0.48 0.37
0.01 0.01 0.01 0.01 0.01 0.05
TABLE 5. Cumulative multiple correlations between pretreatment variables and ~change. Pretreatment Variable Erickson Extroversion Neuroticism Avoidance PreaIpha Pre~SS Reaction
Multiple r
Simple r
Signi]icance Level
0.51 0.55 0.58 0.61 0.63 0.66 0.66
-- 0.51 - 0.17 -- 0.23 - 0.45 - 0.25 - 0.24 -- 0.49
0.05 0.05 NS NS NS NS NS
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TABLE 6. Cumulative multiple correlations between pretreatment variables and postalpha scores.
Pretreatment Variable
Erickson Prealpha Reaction Extroversion PregSS Avoidance Neuroticism
Multiple r
Simple r
Significance Level
0.61 0.65 0.69 0.70 0.72 0.73 0.73
0.61 0.42 0.55 0.10 0.44 0.48 0.39
0.01 0.01 0.05 0.05 0.05 NS NS
For each measure of outcome, the pretreatment variable with the highest F value for its correlation is shown first. Thereafter, other variables are combined and the cumulative correlation of the combination is shown. The amount of correlation added to the combination by a new variable is determined by the amount of variance (r 2) accounted for by that variable independently by the previously entered variable(s). Thus, in Table 5, which shows the multiple correlations for postgSS, avoidance is entered initially. Prealpha is the first variable to be added to it because prealpha is also highly correlated with postgSS and yet shows a low intercorrelation with avoidance. The data in Table 4 indicate that six of the seven pretreatment variables together correlate 0.79 with postgSS. Avoidance, prealpha, and extroversion account for most of this correlation (0.75). The Erickson score added too little to this correlation to be included. Table 5 indicates that the combination of all seven pretreatment variables is correlated 0.66 with gchange. Attitude and personality variables account for almost all of the variance. Erickson and extroversion together correlate 0.55 with gchange. Table 6 shows that all seven variables correlate 0.73 with postalpha. Erickson and prealpha account for the greatest part of the correlation (0.65). The entire multiple correlation for post~SS is significant at the 0.05 level, but those for gchange and postalpha are not. Tables 4, 5, and 6 give the details of which variables in the combination are significant. Predictions of Outcome
The multiple regression analyses summarized in Tables 4, 5, and 6 provided equations for the best possible prediction of each measure of outcome. These equations, based on the pretreatment variables and outcomes for Group 1, are given below: post~SS = (2.77) avoidance + (0.25) prealpha + (0.42) extroversion + (1.67) reaction - (0.33) pre~SS - (0.22) Erickson - (13.11). ~change = (4.60) pre~;SS + (1.63)neuroticism - (7.18) Erickson - (4.93) extroversion - (6.62) avoidance - (2.39) prealpha - (21.6) reaction + (353.69). 596 Journal of Speech and Hearing Research
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postalpha = (9.17) Erickson + (6.22) prealpha + (1.34) reaction + (5.97) extroversion + (1.56) neuroticism -- (9.70) pre%SS - (55.9) avoidance (496.26). Outcomes from Group 2 were calculated with the above equations, using Group 2's pretreatment data. The Spearman correlations between the predicted outcomes for Group 2 and their actual outcomes, measured a year after treatment, are as follows: post%SS = 0.75"* %change -- 0.71"* postalpha = 0.51" DISCUSSION The results of this study suggest that a combination of factors which can be measured before treatment are fairly highly correlated with outcome. Moreover, these factors have been shown to predict outcome, with moderate accuracy, for an independent group of subjects. The implications are, first, that it may be possible to predict outcome for other stutterers who present themselves for treatment, and second, that those factors which are highly correlated with outcome should be considered in the design of treatment. Prediction of Outcome
The moderately high rank correlations obtained for predicted vs actual outcomes of Group 2 suggest that the equations presented, based on Group 1, may be useful for predicting rank outcomes for other groups. Prediction of an individual's exact outcome is another matter, however. The numerical values of the predicted outcomes for Group 2 were, except for post%SS, somewhat different from the actual outcomes. 2 Equations based on a larger group of subjects would obviously result in more accurate predictions, particularly if an exact prediction of an individual's outcome is needed. The equations developed in this study may be too tedious for some clinicians to bother computing for each subject in practice. Some simple and informal procedures may be more useful for making a rough estimate of prognosis. Table 4 indicates attitudes and pretreatment stuttering behavior account for much of the correlation with post%SS. A simple measure of each, avoidance and pre%SS, appears to distinguish between the 10 best and 10 worst outcomes (post%SS) of Groups 1 and 2 combined. All of the 10 best have both an *Level of significance is 0.05. **Level of significance is 0.01. 2pearson product-moment correlations, which may not be justified with nonnormal distributions, were obtained for predicted vs actual outcomes. These correlations were 0.76, 0.50, and 0.58, for post%SS, %change, and postalpha, respectively. GvxwAm Pretreatment Factors 597
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avoidance score below 2.56 and a pre~SS score below 13. All but three of the 10 worst have avoidance scores above 2.56 and all but one have a pre~SS above 13. All of the 10 worst have either an avoidance score above 2.56 or a pre~SS above 13. Thus, an informal prognosis for post~SS could be made as follows: If a stutterer has an avoidance score above 2.56 or a pre~SS above 13, he is likely to have an appreciable level of stuttering (for subjects in this stud),, above 3~SS) a year after treatment. If both scores are above the suggested levels, he is much more likely to have such an outcome.
Factors Correlated with Outcome Attitudes. The results of the present study indicate that the best predictor of treatment outcome is pretreatment attitude. For each measure of outcome, post%SS, ~change, and postalpha, a measure of attitude was the most highly correlated pretreatment variable. Moreover, pretreatment attitude factors are independent from pretreatment stuttering measures, as indicated by the intercorrelation in Table 3. This independence suggests that attitude measures tap an entirely different dimension of stuttering than do counts of stutters and syllables. The fact that attitudes appear to be good predictors of outcome and to be independent of the level of stuttering may have special implications for the design of treatment. Specifically, treatment may need to deal differently with those subjects who have unfavorable pretreatment attitude scores. In this study, it appears that although every subject left treatment stutter free, those with high avoidance, Erickson, or reaction scores regressed far more than others. The reason for this is not entirely clear, but the following explanation seems likely. Most of the questions on the three attitude questionnaires refer to specific environmental situations requiring speech. It is likely, then, that unfavorable attitude scores reflect strongly conditioned responses between the subject's stuttered speech and his environment. When these attitudes are strong, treatment may fail to decondition this link between the environment and stuttering. If this is so, subjects with high pretreatment attitude scores may have been more vulnerable to relapse, simply because the environment continued to elicit stuttering, the oldest and strongest habit, even after fluency had been established in the laboratory and in a small number of environmental situations. The implication for treatment is that subjects with high avoidance, reaction, or Erickson scores may need longer and more detailed transfer procedures similar to those already used in this treatment program. In group treatment programs, these special procedures may be more easily carried out if these subjects are grouped together. The other alternative is that subjects with high attitude scores be given other kinds of treatment not used by fluency-shaping programs, such as the desensitization or respondent deconditioning techniques used by programs which focus more on attitudes than on overt symptoms. Stuttering. The fact that pretreatment stuttering is moderately correlated 598 Journal of Speech and Hearing Research
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with outcome is not particularly surprising. More severe stutterers would seem to have a greater degree of handicap, and perhaps require more time to overcome it. The intensive group program studied here ~eas perhaps not suited to those needing individual treatment. Moreover, there are suggestions in the literature that more severe stutterers on even relatively individualized programs may not do as well in treatment (Prins, 1970; Van Riper, 1973). Personality. Neuroticism and extroversion appear to be largely independent of each other, and, of the two, only neuroticism is strongly related to outcome. Neuroticism, however, is also strongly related to attitude measures. This intercorrelation weakens the position of neuroticism in the multiple correlations. That is, since neuroticism is so highly intercorrelated with attitudes, it adds little to the multiple correlation once an attitude variable has been entered. Extroversion adds a great deal more to the multiple correlations because it accounts for variance (r 2) not accounted for by the attitude and stuttering variables. It is of interest that neuroticism is moderately intercorrelated with attitudes. This suggests that those subjects who show unfavorable stuttering attitudes are also likely to show high neuroticism scores. It may be, then, that neuroticism and stuttering attitudes are reflections of a single characteristic in stutterers, or at least that these two factors have an influence on each other.
Implications about the Nature of Stuttering As previously noted, the results of this study suggest that pretreatment attitudes are a separate dimension of stuttering, different from the overt symptomatology. The fact that pretreatment attitudes are independent of stuttering severity, as well as important predictors of outcome, suggests that in these adult subjects, stuttering is multidimensional, and that for at least some stutterers, relieving the overt symptoms does not deal with the entire problem. The fact that the pretreatment avoidance score was the most highly correlated pretreatment variable with post%SS suggests that avoidance behaviors in particular may be an important dimension of stuttering. Avoidance has been portrayed in some models of stuttering (Sander, 1975) as a crucial maintaining factor. It seems possible that a tendency to avoid expected punishment associated with stuttering may be as important a component of the stuttering problem as frequency and severity of symptoms. ACKNOWLEDGMENT The author wishes to thank Gavin Andrews, Colin Bass, and Megan Neilson for their advice and assistance in collecting and analyzing these data, and Lee Woods for his constructive criticisms of this paper. The support and encouragement of the staff of the Human Communication Laboratory, University of New South Wales Teaching Hospitals, is also gratefully acknowledged. Requests for reprints should be directed to Barry Guitar, Department of Communication and Theater, University of Vermont, Burlington, Vermont 05401.
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REFERENCES
ANDREWS, G., and INCHAM, R., Stuttering: Considerations in the evaluation of treatment. Brit. 1. Dis. Commun., 6, 129-138 (1971). ANDREWS, G., and CvTLER, J., Stuttering therapy: The relationship between changes in symptom level and attitudes. J. Speech Hearing Dis., 39, 312-319 (1974). BRANDON, S., and HARRIS, M., Stammering--An experimental treatment programme using syllable-timed speech. Brit. J. Dis. Commun., 2, 64-86 (1967). CtrTL~.r~, J., Assessing changes in communication attitudes following the behavior modification of stuttering. Bachelor's thesis, Univ. of New South Wales (1973). ERICKSON, R. L., Assessing communication attitudes among stutterers. 1. Speech Hearing Res., 12, 711-724 (1969). EYSENCK, H. J., and ErCSENCK,S., Eysenck Personality Inventory. London: Univ. of London Press (1963). Gm~coav, H., An assessment of the results of stuttering therapy. Final Report, Research and Demonstration Project 1725-S HEW (1969). INCHA~f, R., The development, application, and analysis of a token system for the treatment of adult stutterers. Doctoral dissertation, Univ. of New South Wales (1972). INCHAXl, R., and ANDREWS, G., Details of a token economy stuttering therapy programme for adults. Aust. I. Hum. Commun. Dis., 1, 13-20 (1973). JOHNSON, W., DARL~.Y, F. L., and SPRIESTERSBACH, D. C.,'Diagnostic Methods in Speech Pathology. New York: Harper (1963). KIMBLE, G. A., Scientific psychology in transition. In F. McGuigan and D. Lumsden (Eds.), Contemporary Approaches to Conditioning and Learning. Washington, D.C.: V. H. Winston and Sons (1973). LANYON, R., The relationship of adaptation and consistency to improvement in stuttering therapy. J. Speech Hearing Res., 8, 263-269 (1965). LANYON, R., The MMPI and prognosis in stuttering therapy. J. Speech Hearing Dis., 31, 186-191 (1966). MCNEMAR, Q., Psychological Statistics. (4th ed.) Sydney, Aust.: John Wiley and Sons ( 1969 ). PERKINS, W., Behavioral management of stuttering. Final Report, Social and Rehabilitation Service Research Grant No. 14-P-55281 (1973). PERKXNS, W., Articulatory rate in the evaluation of stuttering treatment. 1. Speech Hearing Dis., 40, 277-278 (1975). PAINS, D., Pretherapy adaptation of stuttering and its relation to speech measures of therapy progress. I. Speech Hearing Res., 11. 740-746 (1968). PAINS, D., Improvement and regression in stutterers following short-term intensive therapy. 1. Speech Hearing Dis., 35, 123-135 (1970). SANDER, E., Untangling stuttering: A tour through the theory thicket. Asha, 17, 256-262 ( 1975 ). VAN Rn'En, C., The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice-Hall (1973). YOUNC, M. A., Predicted ratings of severity of stuttering. In Studies of Speech Disfluency
and Rate of Stutterers and Nonstutterers: J. Speech Hearing Dis. Monogr. Suppl. 7. Washington, D.C.: American Speech and Hearing Association, 31-'54 (1961). Received January 14, 1976. Accepted April 30, 1976.
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University of New South Wales Teaching Hospitals, Sydney, Australia Measures of stuttering behavior, personality, and attitudes about speaking were obtained from 20 stutterers at the beginning of treatment. These measures were correlated with three measures of stuttering behavior a year after treatment. Pretreatment attitudes were most highly related to outcome, followed by pretreatment stuttering behavior, and then personality measures. Multiple regression analyses of the pretreatment measures demonstrated that combinations of these variables correlated moderately high (r = 0.79, 0.66, 0.73) with outcome. Prediction equations derived from the multiple regression analyses were used to predict outcomes for an independent group of 18 stutterers. Predicted and actual outcomes were shown to be correlated moderately high (r = 0.75, 0.73, 0.51). Suggestions for clinical use of predictive factors are given. Implications for the design of treatment and understanding the nature of stuttering are discussed. Prediction of treatment outcome can be useful for several reasons. Most obviously, clinicians may wish to give treatment priority to those patients who will benefit most from treatment. Moreover, those variables which are predictors of outcome may highlight areas in which treatment can be altered to help patients who would do poorly on current treatment programs. Finally, the important predictor variables may give some insight into the nature of the disorder. Unfortunately, several decades of stuttering research have failed to produce any useful predictors of treatment outcome (Van Riper, 1973). The results of several recent studies are representative of research in this area. Lanyon (1965) and Prins (1968) found that pretreatment measures of stuttering adaptation were not clinically useful in predicting amount of change in stuttering during treatment. Lanyon (1965) also reiected pretreatment stuttering consistency as a possible predictor of outcome. Turning from pretreatment stuttering to personality, investigators still have had little success in finding predictors. Lanyon (1966) found no clinically useful correlation between MMPI scores and change in stuttering during therapy. Gregory (1969) failed to find a significant correlation between MMPI, Holtzman Inkblot, or Edwards Personal Preference Schedule scores and change in treatment. Perkins (1973) also found no clinically meaningful relationships between three personality measures (16 PF Test, Rorschach, and the Guilford590
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Zimmerman Temperament Survey) and treatment outcome measured in percent reduction in stuttering six months after discharge from therapy. In all the recent studies, the only high correlation between a pretreatment measure and outcome is the finding by Gregory (1969) that pretreatment severity rating was positively correlated (r = 0.78) with change in severity rating from before to immediately after treatment. This result is not surprising, however, since severe stutterers enter therapy with higher levels on the severity scale and thus have a greater range to travel during treatment. Moreover, this correlation is dependent on when outcome is measured. When the ninemonth posttreatment changes in severity were correlated with pretreatment severity, the correlation dropped from 0.78 to 0.48. Changes in stuttering severity from immediately after to many months after treatment, such as shown by Gregory's subiects , are not unusual. Data are now available to support the long-standing clinical impression that many stutterers regress considerably after treatment (Ingham and Andrews, 1973; Perkins, 1973). In fact, those who improve most in treatment may show the greatest regression later (Prins, 1970). Thus, studies which measure stuttering immediately after treatment, such as those of Lanyon (1965, 1966), Prins (1968), and Gregory (1969), may not have assessed the most clinically important outcome of treatment. Long-term outcome is a more accurate assessment of how treatment has affected a stutterer. Of the studies cited here, only Perkins (1973) used longer term outcome in attempting to find predictors of treatment effects. The lack of useful predictors of long-term outcome of stuttering treatment suggests a need for further investigation. Although personality measures by themselves have not been effective predictors, they might well be combined with overt measures of pretreatment stuttering for prognosis. Besides measures of personality and level of stuttering, some assessment of attitudes might also be helpful in forecasting outcome. This seems particularly possible in light of recent evidence that cognitive variables are important in determining overt behaviors ( Kimble, 1973). The present study was designed to evaluate a combination of pretreatment measures of stuttering, attitudes toward stuttering, and personality factors, as predictors of long-term outcome of treatment. METHOD Subiects
Two groups of subiects were used in this study. The first group (Group 1) consisted of 20 stutterers treated at the Prince Henry Hospital between October 1973 and June 1974. Of the 54 stutterers treated during this period, 25 were living in Sydney at the time of a follow-up evaluation. However, four could not be contacted and one refused to be interviewed. The remaining 20 (16 males and 4 females) became Group 1. Their ages ranged from 21 to 64 with a mean age of 30.4 years. GUITAR: Pretreatment Factors 591
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The second group (Group 2) consisted of 18 stutterers treated between June and December 1974. Of the stutterers treated in this period, 19 lived in Sydney and one could not be contacted. Group 2 consisted of 17 male and one female stutterers with an age range of 17 to 30 years and a mean age of 24.6 years. Treatment Program
All subjects received treatment for stuttering on the Prince Henry Hospital Stuttering Treatment Program described by Ingham and Andrews (1973). This is a group treatment, token economy program in which subjects live in the treatment environment while they undergo training in prolonged speech to a criterion of zero percent syllables stuttered (%SS) at 200-----20 syllables per minute (SPM). After subjects achieve the fluency criterion in the hospital, they then transfer their fluent speech into a variety of everyday situations. Treatment is completed in three weeks, although subjects often return periodically for advice on maintenance of their fluency. Procedures
The basic design of the study was to obtain pretreatment measures from subjects in Group 1 and then evaluate their fluency a year after treatment. Following this, multiple regression analyses were carried out to determine the degree to which pretreatment measures predicted the subjects' outcomes. Equations derived from the regressions were then used to predict the outcomes for subjects in Group 2 on the basis of their pretreatment measures. Correlations between the predicted and actual outcomes for subjects in Group 2 provided cross-validation of the findings for subjects in Group 1. Pretreatment Measures. The pretreatment data, which included measures of personality, attitudes about stuttering, and amount of stuttering, were obtained when subjects entered the hospital. Personality was assessed by the extroversion and neuroticism scales of the Eysenck Personality Inventory (Eysenck and Eysenck, 1963). Neuroticism and extroversion have been shown previously to be associated with success and failure on stuttering therapy programs (Brandon and Harris, 1967). Attitudes toward stuttering were measured by the short form of the Erickson Scale of Communication Attitudes (Erickson, 1969; Andrews and Cutler, 1974) and by an abbreviated version of the Stutterer's Self-Rating of Reactions to Speech Situations (Johnson, Darley, and Spriestersbach, 1963; Cutler, 1973). Only the avoidance and reaction responses of the Stutterer's Self-Rating form were used because these appeared to be most related to attitudes. Clinical experience suggested that those stutterers who scored high on the avoidance and reaction parts of this assessment were more likely to be emotionally affected by their stuttering, regardless of their actual level of stuttering. In addition to the above assessments, amount of stuttering was measured when the subjects entered treatment. Stuttering was measured during conver592 Journal of Speech and Hearing Research
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sational speech in percentage syllables stuttered (pre%SS) and syllables per minute (preSPM). These measures have been shown to correlate highly with listener iudgments of severity and to be reliable (Young, 1961; Andrews and Ingham, 1971 ). Stuttering scores used for the multiple regression analyses were %SS and "alpha" score, 1 a measure which combines frequency of stuttering and speech rate. The alpha score was developed because speech rate has been considered an important adjunct in the assessment of fluency (Ingham, 1972; Perkins, 1975). Posttreatment Measures. Twelve to 18 months after the subiects completed the three-week treatment program, they were contacted by a management consultant who was unknown to them, and a meeting was arranged in his office in a different part of the city from the place of treatment. A five-minute sample of conversational speech was recorded and later scored by the experimenter. Measures of outcome were percentage of syllables stuttered (post%SS), alpha score (postalpha), and percent change in frequency of stuttering (%change). This last score, %change, was calculated by the following formula: pre%SS - post~;SS pre~SS
Reliability of Measurements of Stuttering A random sample of one-third of the tape recordings of stutterers was rescored by the experimenter and by another rater. Correlations between the original scores and the remeasured scores were computed by the Pearson product-moment formula. Intrarater reliability for total syllables stuttered and syllables per minute were 0.99 and 0.95, respectively. Interrater reliability for syllables stuttered and syllables per minute were 0.99 and 0.92, respectively. RESULTS This study sought to measure a variety of pretreatment variables and assess their usefulness in predicting outcome of treatment. This section will present (1) pretreatment and outcome measures collected from subiects in Group 1, (2) correlations between the pretreatment and outcome measures for Group 1, and (3) correlations between predicted and actual outcomes for subiects in Group 2. XA formula to transform frequency and rate into a single score was developed by Megan Neilson and Gavin Andrews, Human Communication Laboratory, University of New South ~SS SPM - ~ + 47.96, is based on a pre1.23 4.17 dicted relationship between frequency and rate in a large group of stutterers (Andrews and Ingham, 1971). When a subiect had 0~SS, his alpha score was deemed to be 0, because alpha was intended to measure stuttered speech. Wales Teaching Hospitals. The formula, alpha -
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Pretreatment and Outcome Measures
The means and standard deviations for pretreatment variables and measures of outcome for Group 1 are given in Table 1. TAttLE 1. Means and standard deviations for pretreatment variables and measures of outcome for Group 1.
Variable
Mean
SD
Pre~SS Prealpha Avoidance Reaction Erickson Extroversion Neurotic*sin Post~SS ~change Postalpha
7.50 24.30 2.46 2.71 20.50 11.90 11.90 2.40 68.00 8.10
6.9 15.1 0.7 0.6 3.0 3.9 6.3 3.7 48.0 10.5
Correlations Between Pretreatment Variables and Measures o[ Outcome Simple Correlations. Correlations between pretreatment variables (pregSS, prealpha, avoidance, reaction, Erickson, extroversion, and neuroticism) and measures of outcome (postgSS, gchange, and postalpha) are given in Table 2. TABLE 2. Spearman correlations between pretreatment variables and measures of outcome of treatment.
Pretreatment Variable
Postf~SS
~chang e
Postalpha
Pre~SS Prealpha Avoidance Reaction Erickson Extroversion Neuroticism
0.39" 0.45" 0.56 * * 0.48* 0.45* 0.17 0.37
- 0.24 - 0.25 - 0.45 * - 0.49* - 0.51* - 0.17 -- 0.23
0.44" 0.42 * 0.48" 0.55"* 0.61" * 0.10 0.39*
*Level of significance is 0.05. **Level of significance is 0.01. Because m a n y of the scores w e r e in percentages, n o r m a l i t y of the distributions c o u l d not b e assumed. N o n p a r a m e t r i c ( S p e a r m a n ) correlations were therefore
used. T h e correlations in T a b l e 2 i n d i c a t e that post~SS was most h i g h l y correlated w i t h the three m e a s u r e s of attitude, p a r t i c u l a r l y avoidance, f o l l o w e d b y the m e a s u r e s of stuttering, a n d t h e r e a f t e r b y m e a s u r e s of personality. Correlations w i t h ~ c h a n g e f o l l o w e d the p a t t e r n set b y post~SS, a l t h o u g h in this case measures of stuttering s h o w e d a m u c h lower correlation w i t h the o u t c o m e m e a sure. Correlations w i t h p o s t a l p h a were g e n e r a l l y similar to those w i t h post~SS. Intercorrelations. T a b l e 3 shows the intercorrelations a m o n g the pretreat-
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TABLE 3. Intercorrelations among pretreatment variables. Pretreatment Variables
Avoidance Reaction
Avoidance Reaction Erickson Extroversion Neuroticism Pre~SS Prealpha
-
0.87** -
Erickson 0.77** 0.79"* -
Extroversion
Neuroticism
-0.22 -- 0.06 0.08 -
0.56** 0.44"* 0.65* * 0.08 -
PregSS
PreaIpha
0.13 0.20 0.42* 0.14 0.38 -
0.13 0.06 0.32 0.07 0.27 0.89"*
*Level of significance is 0.05. **Level of significance is 0.01. m e n t variables. T h e s e d a t a indicate the extent to w h i c h each of the pretreatm e n t variables is r e l a t e d to each of the others. T h e d e g r e e of relationship suggests w h e t h e r these variables are m e a s u r i n g the same or different aspects of the subiect a n d his stuttering. T h e three m e a s u r e s of a t t i t u d e ( a v o i d a n c e , reaction, a n d E r i c k s o n ) are highly intercorrelated. T h e y are, h o w e v e r , not at all highly c o r r e l a t e d with extroversion or p r e t r e a t m e n t s t u t t e r i n g measures. To some extent the three attitude m e a s u r e s are c o r r e l a t e d w i t h neuroticism. T h e two m e a s u r e s of stuttering, pre~SS a n d p r e a l p h a , are also h i g h l y intercorrelated. T h e two personality measures, extroversion a n d neuroticism, h o w e v e r , are not i n t e r c o r r e l a t e d to any real extent. M u l t i p l e Correlations. The results of m u l t i p l e regression analyses ( M c N e m a r , 1969) are s u m m a r i z e d in T a b l e s 4, 5, a n d 6. T h e s e analyses e m p l o y the simple correlations in T a b l e 2, as well as the intercorrelations in T a b l e 3, to d e t e r m i n e the best c o m b i n a t i o n of p r e t r e a t m e n t variables to p r e d i c t outcome. TABLE 4. Cumulative multiple correlations between pretreatment variables and post~SS. Pretreatment Variable Avoidance Prealpha Extroversion Pre~SS Reaction Neuroticism
Multiple r
Simple r
Signi]~cance Level
0.56 0.68 0.75 0.78 0.78 0.79
0.56 0.45 0.17 0.39 0.48 0.37
0.01 0.01 0.01 0.01 0.01 0.05
TABLE 5. Cumulative multiple correlations between pretreatment variables and ~change. Pretreatment Variable Erickson Extroversion Neuroticism Avoidance PreaIpha Pre~SS Reaction
Multiple r
Simple r
Signi]icance Level
0.51 0.55 0.58 0.61 0.63 0.66 0.66
-- 0.51 - 0.17 -- 0.23 - 0.45 - 0.25 - 0.24 -- 0.49
0.05 0.05 NS NS NS NS NS
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TABLE 6. Cumulative multiple correlations between pretreatment variables and postalpha scores.
Pretreatment Variable
Erickson Prealpha Reaction Extroversion PregSS Avoidance Neuroticism
Multiple r
Simple r
Significance Level
0.61 0.65 0.69 0.70 0.72 0.73 0.73
0.61 0.42 0.55 0.10 0.44 0.48 0.39
0.01 0.01 0.05 0.05 0.05 NS NS
For each measure of outcome, the pretreatment variable with the highest F value for its correlation is shown first. Thereafter, other variables are combined and the cumulative correlation of the combination is shown. The amount of correlation added to the combination by a new variable is determined by the amount of variance (r 2) accounted for by that variable independently by the previously entered variable(s). Thus, in Table 5, which shows the multiple correlations for postgSS, avoidance is entered initially. Prealpha is the first variable to be added to it because prealpha is also highly correlated with postgSS and yet shows a low intercorrelation with avoidance. The data in Table 4 indicate that six of the seven pretreatment variables together correlate 0.79 with postgSS. Avoidance, prealpha, and extroversion account for most of this correlation (0.75). The Erickson score added too little to this correlation to be included. Table 5 indicates that the combination of all seven pretreatment variables is correlated 0.66 with gchange. Attitude and personality variables account for almost all of the variance. Erickson and extroversion together correlate 0.55 with gchange. Table 6 shows that all seven variables correlate 0.73 with postalpha. Erickson and prealpha account for the greatest part of the correlation (0.65). The entire multiple correlation for post~SS is significant at the 0.05 level, but those for gchange and postalpha are not. Tables 4, 5, and 6 give the details of which variables in the combination are significant. Predictions of Outcome
The multiple regression analyses summarized in Tables 4, 5, and 6 provided equations for the best possible prediction of each measure of outcome. These equations, based on the pretreatment variables and outcomes for Group 1, are given below: post~SS = (2.77) avoidance + (0.25) prealpha + (0.42) extroversion + (1.67) reaction - (0.33) pre~SS - (0.22) Erickson - (13.11). ~change = (4.60) pre~;SS + (1.63)neuroticism - (7.18) Erickson - (4.93) extroversion - (6.62) avoidance - (2.39) prealpha - (21.6) reaction + (353.69). 596 Journal of Speech and Hearing Research
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postalpha = (9.17) Erickson + (6.22) prealpha + (1.34) reaction + (5.97) extroversion + (1.56) neuroticism -- (9.70) pre%SS - (55.9) avoidance (496.26). Outcomes from Group 2 were calculated with the above equations, using Group 2's pretreatment data. The Spearman correlations between the predicted outcomes for Group 2 and their actual outcomes, measured a year after treatment, are as follows: post%SS = 0.75"* %change -- 0.71"* postalpha = 0.51" DISCUSSION The results of this study suggest that a combination of factors which can be measured before treatment are fairly highly correlated with outcome. Moreover, these factors have been shown to predict outcome, with moderate accuracy, for an independent group of subjects. The implications are, first, that it may be possible to predict outcome for other stutterers who present themselves for treatment, and second, that those factors which are highly correlated with outcome should be considered in the design of treatment. Prediction of Outcome
The moderately high rank correlations obtained for predicted vs actual outcomes of Group 2 suggest that the equations presented, based on Group 1, may be useful for predicting rank outcomes for other groups. Prediction of an individual's exact outcome is another matter, however. The numerical values of the predicted outcomes for Group 2 were, except for post%SS, somewhat different from the actual outcomes. 2 Equations based on a larger group of subjects would obviously result in more accurate predictions, particularly if an exact prediction of an individual's outcome is needed. The equations developed in this study may be too tedious for some clinicians to bother computing for each subject in practice. Some simple and informal procedures may be more useful for making a rough estimate of prognosis. Table 4 indicates attitudes and pretreatment stuttering behavior account for much of the correlation with post%SS. A simple measure of each, avoidance and pre%SS, appears to distinguish between the 10 best and 10 worst outcomes (post%SS) of Groups 1 and 2 combined. All of the 10 best have both an *Level of significance is 0.05. **Level of significance is 0.01. 2pearson product-moment correlations, which may not be justified with nonnormal distributions, were obtained for predicted vs actual outcomes. These correlations were 0.76, 0.50, and 0.58, for post%SS, %change, and postalpha, respectively. GvxwAm Pretreatment Factors 597
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avoidance score below 2.56 and a pre~SS score below 13. All but three of the 10 worst have avoidance scores above 2.56 and all but one have a pre~SS above 13. All of the 10 worst have either an avoidance score above 2.56 or a pre~SS above 13. Thus, an informal prognosis for post~SS could be made as follows: If a stutterer has an avoidance score above 2.56 or a pre~SS above 13, he is likely to have an appreciable level of stuttering (for subjects in this stud),, above 3~SS) a year after treatment. If both scores are above the suggested levels, he is much more likely to have such an outcome.
Factors Correlated with Outcome Attitudes. The results of the present study indicate that the best predictor of treatment outcome is pretreatment attitude. For each measure of outcome, post%SS, ~change, and postalpha, a measure of attitude was the most highly correlated pretreatment variable. Moreover, pretreatment attitude factors are independent from pretreatment stuttering measures, as indicated by the intercorrelation in Table 3. This independence suggests that attitude measures tap an entirely different dimension of stuttering than do counts of stutters and syllables. The fact that attitudes appear to be good predictors of outcome and to be independent of the level of stuttering may have special implications for the design of treatment. Specifically, treatment may need to deal differently with those subjects who have unfavorable pretreatment attitude scores. In this study, it appears that although every subject left treatment stutter free, those with high avoidance, Erickson, or reaction scores regressed far more than others. The reason for this is not entirely clear, but the following explanation seems likely. Most of the questions on the three attitude questionnaires refer to specific environmental situations requiring speech. It is likely, then, that unfavorable attitude scores reflect strongly conditioned responses between the subject's stuttered speech and his environment. When these attitudes are strong, treatment may fail to decondition this link between the environment and stuttering. If this is so, subjects with high pretreatment attitude scores may have been more vulnerable to relapse, simply because the environment continued to elicit stuttering, the oldest and strongest habit, even after fluency had been established in the laboratory and in a small number of environmental situations. The implication for treatment is that subjects with high avoidance, reaction, or Erickson scores may need longer and more detailed transfer procedures similar to those already used in this treatment program. In group treatment programs, these special procedures may be more easily carried out if these subjects are grouped together. The other alternative is that subjects with high attitude scores be given other kinds of treatment not used by fluency-shaping programs, such as the desensitization or respondent deconditioning techniques used by programs which focus more on attitudes than on overt symptoms. Stuttering. The fact that pretreatment stuttering is moderately correlated 598 Journal of Speech and Hearing Research
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with outcome is not particularly surprising. More severe stutterers would seem to have a greater degree of handicap, and perhaps require more time to overcome it. The intensive group program studied here ~eas perhaps not suited to those needing individual treatment. Moreover, there are suggestions in the literature that more severe stutterers on even relatively individualized programs may not do as well in treatment (Prins, 1970; Van Riper, 1973). Personality. Neuroticism and extroversion appear to be largely independent of each other, and, of the two, only neuroticism is strongly related to outcome. Neuroticism, however, is also strongly related to attitude measures. This intercorrelation weakens the position of neuroticism in the multiple correlations. That is, since neuroticism is so highly intercorrelated with attitudes, it adds little to the multiple correlation once an attitude variable has been entered. Extroversion adds a great deal more to the multiple correlations because it accounts for variance (r 2) not accounted for by the attitude and stuttering variables. It is of interest that neuroticism is moderately intercorrelated with attitudes. This suggests that those subjects who show unfavorable stuttering attitudes are also likely to show high neuroticism scores. It may be, then, that neuroticism and stuttering attitudes are reflections of a single characteristic in stutterers, or at least that these two factors have an influence on each other.
Implications about the Nature of Stuttering As previously noted, the results of this study suggest that pretreatment attitudes are a separate dimension of stuttering, different from the overt symptomatology. The fact that pretreatment attitudes are independent of stuttering severity, as well as important predictors of outcome, suggests that in these adult subjects, stuttering is multidimensional, and that for at least some stutterers, relieving the overt symptoms does not deal with the entire problem. The fact that the pretreatment avoidance score was the most highly correlated pretreatment variable with post%SS suggests that avoidance behaviors in particular may be an important dimension of stuttering. Avoidance has been portrayed in some models of stuttering (Sander, 1975) as a crucial maintaining factor. It seems possible that a tendency to avoid expected punishment associated with stuttering may be as important a component of the stuttering problem as frequency and severity of symptoms. ACKNOWLEDGMENT The author wishes to thank Gavin Andrews, Colin Bass, and Megan Neilson for their advice and assistance in collecting and analyzing these data, and Lee Woods for his constructive criticisms of this paper. The support and encouragement of the staff of the Human Communication Laboratory, University of New South Wales Teaching Hospitals, is also gratefully acknowledged. Requests for reprints should be directed to Barry Guitar, Department of Communication and Theater, University of Vermont, Burlington, Vermont 05401.
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REFERENCES
ANDREWS, G., and INCHAM, R., Stuttering: Considerations in the evaluation of treatment. Brit. 1. Dis. Commun., 6, 129-138 (1971). ANDREWS, G., and CvTLER, J., Stuttering therapy: The relationship between changes in symptom level and attitudes. J. Speech Hearing Dis., 39, 312-319 (1974). BRANDON, S., and HARRIS, M., Stammering--An experimental treatment programme using syllable-timed speech. Brit. J. Dis. Commun., 2, 64-86 (1967). CtrTL~.r~, J., Assessing changes in communication attitudes following the behavior modification of stuttering. Bachelor's thesis, Univ. of New South Wales (1973). ERICKSON, R. L., Assessing communication attitudes among stutterers. 1. Speech Hearing Res., 12, 711-724 (1969). EYSENCK, H. J., and ErCSENCK,S., Eysenck Personality Inventory. London: Univ. of London Press (1963). Gm~coav, H., An assessment of the results of stuttering therapy. Final Report, Research and Demonstration Project 1725-S HEW (1969). INCHA~f, R., The development, application, and analysis of a token system for the treatment of adult stutterers. Doctoral dissertation, Univ. of New South Wales (1972). INCHAXl, R., and ANDREWS, G., Details of a token economy stuttering therapy programme for adults. Aust. I. Hum. Commun. Dis., 1, 13-20 (1973). JOHNSON, W., DARL~.Y, F. L., and SPRIESTERSBACH, D. C.,'Diagnostic Methods in Speech Pathology. New York: Harper (1963). KIMBLE, G. A., Scientific psychology in transition. In F. McGuigan and D. Lumsden (Eds.), Contemporary Approaches to Conditioning and Learning. Washington, D.C.: V. H. Winston and Sons (1973). LANYON, R., The relationship of adaptation and consistency to improvement in stuttering therapy. J. Speech Hearing Res., 8, 263-269 (1965). LANYON, R., The MMPI and prognosis in stuttering therapy. J. Speech Hearing Dis., 31, 186-191 (1966). MCNEMAR, Q., Psychological Statistics. (4th ed.) Sydney, Aust.: John Wiley and Sons ( 1969 ). PERKINS, W., Behavioral management of stuttering. Final Report, Social and Rehabilitation Service Research Grant No. 14-P-55281 (1973). PERKXNS, W., Articulatory rate in the evaluation of stuttering treatment. 1. Speech Hearing Dis., 40, 277-278 (1975). PAINS, D., Pretherapy adaptation of stuttering and its relation to speech measures of therapy progress. I. Speech Hearing Res., 11. 740-746 (1968). PAINS, D., Improvement and regression in stutterers following short-term intensive therapy. 1. Speech Hearing Dis., 35, 123-135 (1970). SANDER, E., Untangling stuttering: A tour through the theory thicket. Asha, 17, 256-262 ( 1975 ). VAN Rn'En, C., The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice-Hall (1973). YOUNC, M. A., Predicted ratings of severity of stuttering. In Studies of Speech Disfluency
and Rate of Stutterers and Nonstutterers: J. Speech Hearing Dis. Monogr. Suppl. 7. Washington, D.C.: American Speech and Hearing Association, 31-'54 (1961). Received January 14, 1976. Accepted April 30, 1976.
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