Outcome of stuttering therapy on Egyptian school-aged children using the speak freely program

Background The training program presented depends on improving the physical dimension for stutters by teaching both stuttering modification and fluency-shaping techniques based on the Speak Freely Program. Aim of the work This study is designed to adapt and apply the ′Speak Freely Program′ of stuttering intervention for Arabic-speaking school-aged stuttering children and to explore its effectiveness as a therapeutic tool. Subjects and methods The present work was carried out on 25 stuttering children of both sexes in the age range of 7-18 years. The participants were divided into two age groups: group I (7-12 years) and group II (12.1-18 years). Each participant was subjected to the protocol of stuttering evaluation as follows: (a) assessment of history and analysis of complaints; (b) observation of features of stuttered speech (core behavior, secondary reactions, devices to cancel stuttering, escape, antiexpectancy) and overt behaviors; (c) Stuttering Severity Instrument (SSI-3) was used to assess moments of stuttering in a speech sample and reading aloud; (d) psychometric battery was used to compare between pretherapeutic and post-therapeutic anxiety and depression scale; (d) two objective evaluations were used: first, spectral analysis to measure the voice onset time, formant transition, and vowel duration for all participants′ fluent productions of monosyllabic words with initial /t/ and /d/, and second, Visipitch to measure fundamental frequency, relative average perturbation, amplitude, shimmer, voiced percent (voiced%), voiceless%, and pause% in an automatic, reading, and spontaneous. Results The study showed that the younger stutterers achieved better outcome with the therapeutic program. The results of the SSI-3 and the anxiety and the depressive state of the studied children, respectively, showed a highly significant difference between the pretherapeutic and the post-therapeutic values of the two groups studied. Formant transition of the (voiced and voiceless) and the vowel duration of (voiceless) monosyllabic words showed a difference after therapy. Both groups showed higher post-therapeutic values for the voiced%, voiceless%, and the amplitude measurements. Conclusion To conclude, stuttering therapy alters the acoustic properties of stutterers′ fluent speech concomitant with reducing stuttering frequency speech samples.


Introduction
Stuttering is a diagnostic label referring to a clinical syndrome characterized most frequently by abnormal and persistent dysfl uency in speech accompanied by characteristic aff ective, behavioral, and cognitive patterns [1]. Stuttering aff ects 4-5% of the preschool children. Th e natural course of developmental stuttering is spontaneous resolution by age 16 in 80% of children. However, some children continue to stutter and the prevalence of developmental stuttering in the adult population is 1% [2]. Although stuttering often resolves before adulthood, it can cause signifi cant anxiety for children and their families [3]. Methods for working with the physical dimension of stuttering have typically been divided into two categories: stuttering modifi cation and fl uency shaping. Stuttering modifi cation strategies reduce physical tension during stuttering and enable individuals to stutter more easily. Fluency-shaping strategies directly improve the fl uency of speech. Th ese approaches have their unique, complementary benefi ts and should be incorporated into school-age therapy [4]. Th e Speak Freely Program is a comprehensive direct intervention for stuttering that incorporates both stuttering modifi cation and fl uency-shaping strategies, off ering the benefi ts of both approaches. It provides detailed instructions and materials that facilitate the development of specifi c stuttering Outcome of stuttering therapy on Egyptian school-aged children using the speak freely program Abo Ras YA, El-Maghraby RM, Madkour WM

Background
The training program presented depends on improving the physical dimension for stutters by teaching both stuttering modi cation and uency-shaping techniques based on the Speak Freely Program.

Aim of the work
This study is designed to adapt and apply the 'Speak Freely Program' of stuttering intervention for Arabic-speaking school-aged stuttering children and to explore its effectiveness as a therapeutic tool. modifi cation and fl uency-enhancing strategies. It aims to help clinicians develop practical and eff ective clinical tools for working with school-age stutterers aged 7-18 years [4]. Th e lack of a stuttering training program addressing Arabic-speaking stutterers that off ers a well-integrated progression of therapeutic procedures led to the present research.

Aim
Th e aim of this study is to provide a stuttering training program based on integrating stuttering modifi cation techniques and fl uency-shaping techniques for schoolage children who stutter.

Participants and methods
Th e present study was carried out on 25 stuttering children of both sexes in the age range of 7-18 years, recruited from among cases attending the Unit of Phoniatrics, Faculty of Medicine, Alexandria University. Th e selection criteria were as follows: children diagnosed to have stuttering on the basis of the following: (i) Clinical criteria: patient or parent complaint; (ii) Defi nitive diagnostic criteria: on the basis of the Stuttering Severity Instrument (SSI-3).
Th e exclusion criteria were as follows: (i) Children with mental subnormality; (ii) Children with psychiatric problems; and (iii) Children with hearing or visual impairments.
Th e participants were divided according to their age range into two groups: group I: age range from 7 to 12 years, and group II: age range from 12.1 to 18 years. An informed consent was obtained from all participants of the study.

Methods
Th e present study proceeded according to the following steps.

Formulation of the remediation program
Th e remediation program aims to improve the physical dimension for stutters by teaching both stuttering modifi cation and fl uency-shaping techniques based on the Speak Freely Program [4].
Th e program was translated into Arabic and a number of modifi cations were made to the words, phrases, sentence levels, and reading paragraphs on the basis of diff erences between Arabic and English sounds. (

Initial assessment
Each participant was subjected to the following protocol of assessment: (1) Elementary diagnostic procedure: this included complete assessment of history. Auditory perceptual assessment to determine the severity of stuttering; overt behaviors including eye contact, associated movements, breathing, and skin reactions were noted. (2) Clinical diagnostic procedures: this included SSI-3 [5] to assess stuttering moments in a speech sample and while reading aloud. (3) Language assessment: the Comprehensive Arabic Language Test ( CALT) [6] was used for formal assessment of the language. (4) Psychometric evaluation: this was carried out using the Stanford Binet test [7], Children's Anxiety Scale ( CAS) [8], Children's Depression Scale ( CDS) [9], the Children Behavior Rating Scale ( CBRS) [10], and the Taylor Manifest Anxiety Scale ( TMAS) [11]. Th e program is divided into three phases: Phase I: learning about speech and stuttering: It includes teaching children about the body parts involved in producing speech as well as understanding and identifi cation of fl uency and stuttering moments.
(1) Anatomy of speech system: in language appropriate to the child's conceptual level, the child is introduced to the anatomy and physiology involved in voice production and what 'happens' during stuttering. (2) Types of dysfl uencies: these were described to the child. Th e child was asked to identify the type of stuttering that he/she has. (3) Catching the stutter: child identifi es the moment of stuttering and signals it by closing their hand. Th ey are instructed to attempt to match the tension level of the hand to the tension level of the dysfl uency. (4) Relaxing the stutter: it involves having the child purposefully stutter on a word with 100% tension, observe the dysfl uency, and then repeat the word with decreased tension.

Phase II: integration of stuttering modifi cation and fl uency-shaping strategies
(1) Stuttering modifi cation strategies: these strategies aim to reduce physical tension during stuttering and enable individuals to stutter more easily.
(a) Slide: children catch themselves during a moment of stuttering and then 'slide out' of the dysfl uency gradually. (b) Easy stuttering: the child intentionally produces relaxed, controlled repetitions of sounds, syllables, or words. (c) Cancellation: the child pauses for a couple of seconds after a moment of stuttering (to acknowledge and analyze the dysfl uency), and then say the stuttered word again with less tension. (2) Fluency-shaping strategies: these aim to improve the production of a more fl uent, controlled, and less eff ortful output.
(a) Relaxed breath: the child learns to use relaxed diaphragmatic breathing as he/she speaks. (b) Slow stretched speech: the child prolongs individual syllables to 10 times their normal duration. Stretchable consonants are m, n, l, r, w, j, ð, z, ð , , .
(c) Smooth movement: it is achieved by slowing, exaggerating, and blending transitional articulatory movements at the syllable level and then the word level. (d) Easy voice: children initiate the production of vowel sounds in a relaxed and gentle manner. (e) Light contact: children touch their speech articulators together gently when producing stops (b, d, t, g, k, t , q, d ) and voiceless fricatives (f, , s, s , , h, , x). (f ) Stretched speech: stretched speech requires prolonging syllables by increasing the rate of the slow stretched speech (increases the rate to approximately one second per syllable). (g) Linked relaxation rhythm: this is a rhythmic speech pattern in which relaxed, continuous phonation is maintained. Oscillation of loudness is produced on each syllable, infusing periodic cycles of relaxation within the connected speech. (h) Extra intonation: the child exaggerates rising and falling infl ections, and adds variation and fl exibility to the rhythm of their speech. Extraintonation enables the child to speak in a more spontaneous and free-fl owing manner while integrating previously learned fl uency skills. (i) Nearly natural speech: this is a usage of a more normal intonation increasing speech rate, reducing the exaggerated quality of extraintonation. (j) Natural speech: it is a controlled production speech modifi cation that children use when they choose to do so.
Phase III: carry-over with appropriate expectations: (1) Children use these stuttering modifi cation and fl uency-enhancing skills during structured activities, which gradually increase the length of utterance and linguistic complexity. (2) Children should continue to practice their skills to keep them accessible.

Re-evaluation
Participants were re-evaluated after the application of the remediation program using the same protocol of initial assessment.

Results
In the present study, 92% of the participants in group I were males and 75% of the participants in group II were males. Th is is in agreement with several studies reporting a predominance of males. Nearly 24% of stuttering children in both groups had a positive family history for older relatives who were stutterers. In addition, a signifi cant relation was observed between family history and the percent of change in the severity of stuttering. Stutterers with a negative family history showed better results post-therapeutically.
Th e current study showed a pattern of improvement across all items of SSI-3, showing a highly signifi cant diff erence between the pretherapeutic and the posttherapeutic values of the two groups studied. In addition, group I showed a higher percentage of change posttherapeutically in all items of SSI-3 compared with group II, with a signifi cant diff erence in the duration of the stuttering moment item in favor of group I. Th e signifi cant negative correlation between the age of the child and the percentage of change in the total score of stuttering severity indicated that better improvement is to be expected in the younger age group (Tables 1 and 2).
In group I, the younger age group, the psychometric evaluation tools used were the CAS and CDS to evaluate the anxiety and the depressive state, respectively, of the children studied. Th e results showed a signifi cant diff erence between the pretherapeutic and the posttherapeutic scores (Table 3). Moreover, there was a   signifi cant positive correlation between percentage of change in CAS and CDS and the percentage of change in SSI-3 scores. Th is indicates that a decrease in anxiety and depressive state is associated with an improvement in stuttering severity. Children learned to improve their ability to manage stuttering and the accompanying fear, anticipatory stress, and self-concept.
In group II, anxiety was evaluated using the TMAS and the results obtained showed a signifi cant improvement in the post-therapeutic TMAS scores compared with the pretherapeutic TMAS scores (Table 4). It is clear that eff ective treatment that reduces stuttering symptoms with a consequential decrease in avoidance and escape behavior will also result in a reduction in anxiety as a result of the decreased stuttering.
Treatment of stuttering frequently aff ects changes in the overall speech pattern, resulting in a situation in which successfully treated individuals who stutter are relatively fl uent, but their phonemes are slow, paced, or monotonous and can be discriminated from normal speech [103].
Spectrographic analysis showed that stuttering therapy alters the acoustic properties of stutterers' fl uent speech concomitantly with reducing stuttering frequency.
Th ere are highe r post-therapeutic spectrographic values. In group I, a signifi cant diff erence was found between pretherapeutic and post-therapeutic values in the FT of the (voiced and voiceless) and the VD of (voiceless) of monosyllabic words (Tables 5 and 6). In group II, a signifi cant diff erence was found between pretherapeutic and post-therapeutic values in the VD and FT of both (voiced and voiceless) of monosyllabic words (Tables 7 and 8). Furthermore, a signifi cant negative correlation was found between the percentage of change in VD (voiced) and percentage of change in the total SSI-3 in both groups (Table 9). Th e therapeutic program taught children to cognitively produce easy onset of phonation, prolong syllables, gentle transition between sounds, and to reduce the articulatory tension.
VOT has been one of the most extensively studied areas of motor control in stuttering. Th e increased duration   of VOT reported in the present study can be attributed to the practice of smooth articulatory movement between sounds and the light contacts of articulators during stops and the production of fricative sounds.
Diff erence in FTs is a fairly consistent fi nding among younger children who stutter. Th e increased duration of FT reported could be related to the slow stretched speech and the smooth articulatory movement techniques that stutterers acquired during the training program.
With reference to the Visipitch analysis, both groups showed increased post-therapeutic values of the voiced%, voiceless%, and amplitude. However, decreased post-therapeutic values of the silence%, RAP%, and shimmer were found. Th is can be attributed to instruction to stuttering children to prolong voiced sounds and produce easy onset of phonation.

Discussion
Group I showed a higher percentage of change posttherapeutically in all items of SSI-3 compared with group II, with a signifi cant diff erence in the duration of the stuttering moment item in favor of group I. Th is would indicate that better improvement is to be expected in the younger age group. Healy and Scott [12], who used an integrative approach for treating school-age children who stutter, reported that many children treated in their program achieved increased levels of fl uency on the basis of pretherapeutic and post-therapeutic stuttering frequency data as the criteria for success. Th ey found that 20% of the children who had completed the treatment program showed steady reductions in the frequency and duration of their stuttering as well as secondary behaviors [12].
Using the CAS and CDS to evaluate the anxiety and the depressive state of the studied children, respectively, the results showed a signifi cant diff erence between the pretherapeutic and the post-therapeutic scores. Th is is in agreement with the study of Davis et al. [13], who reported a signifi cant diff erence in state anxiety in the persistent stuttering group than controls and the recovered from stuttering group, but no signifi cant  diff erences were found between the three groups studied with respect to trait anxiety [13]. Moreover, the present study showed a signifi cant positive correlation between percentage of change in CAS, CDS, and the percentage of change in the severity of stuttering. Th is indicates that a decrease in anxiety and depressive state is associated with an improvement in stuttering severity. Th is may be attributed to the improved ability to manage stuttering and the diffi culties that accompany stuttering, such as fear, anticipatory stress, and self-concept [14]. Evaluation of anxiety in group II was carried out using the TMAS and the results obtained were in consistency with previous researches showing a signifi cant improvement in the post-therapeutic TMAS scores compared with the pretherapeutic TMAS scores. It is clear that eff ective treatment that reduces stuttering symptoms, with a consequential decrease in avoidance and escape behavior, will also, to some degree, result in a reduction in anxiety as a result of the decreased stuttering. Th is is in agreement with the work of Yaruss JS, (2010), who reported that the group means showed a decrease in psychic anxiety and somatic anxiety immediate ly after treatment and further decreased to a statistically signifi cant level 6 months after treatment [14]. Treatment of stuttering frequently aff ects changes in the overall speech pattern, resulting in a situation where successfully treated individuals who stutter are relatively fl uent, but their phonemes are slow, paced, or monotonous and can be discriminated from the speech of non-stutterers [15]. Th e results of this study were consistent with previous research indicating that stuttering therapy alters the acoustic properties of stutterers' fl uent speech concomitant with a reduction in stuttering frequency [16]. Th e present study showed a higher post-therapeutic spectrographic value in all the items tested. In group I, a signifi cant diff erence was found between pretherapeutic and post-therapeutic values in the FT of the (voiced and voiceless) and the VD of (voiceless) of monosyllabic words. In group II, a signifi cant diff erence was found between pretherapeutic and post-therapeutic values in the VD and FT of both (voiced and voiceless) monosyllabic words. Furthermore, a signifi cant negative correlation was found between the percentage of change VD (voiced) and percentage of change in the total SSI-3 in both group I and II. Th is may be attributed to the fact that the children participating in the therapeutic program were required to cognitively produce easy onset of phonation, prolong syllables, make a gentle transition between sounds, and to reduce the articulatory tension. Th e signifi cant increase in VD post-therapeutically was in agreement with the result of Riley and Ingham [17], who found a signifi cant increase in VD after therapy. Th ey speculated that the increased VD s allow more time for speech motor planning and that stuttering is reduced moderately as a byproduct of longer VDs [17]. However, this was in contrast to the results of Lisa Brown et al. (2008), who reported that the acoustic signal of all participants was altered following treatment. However, no consistent pattern of change was observed [18]. Moreover, Onslow et al. [19] found no signifi cant increase in the VD post-therapeutically. VOT has been one of the most extensively studied areas of motor control in stuttering. Th e increased duration of VOT reported in the present study may be attributed to the practice of smooth articulatory movement between sounds and the light contacts of articulators during stops and production of fricative sounds. , who did not fi nd any statistical signifi cance. With reference to the Visipitch analysis, in the present study, both groups showed higher posttherapeutic values of the voiced%, voiceless%, and the amplitude. However, lower post-therapeutic values of the silence%, RAP%, and shimmer were found. Th is can be attributed to instructing stuttering children to prolong voiced sounds and producing easy onset of phonation. Th e majority of results of the previous studies suggested th at post-treatment fl uency of stutterers can be characterized by a general pattern of increased duration of voiced speech segments and decrease in the duration of silent intervals. Dehqan et al. [23] showed that therapy resulted in decreasing irregularity in the shimmer. In other words, the therapy increases t he steady state of the laryngeal system. Th is steady state involves an even maintenance of such forces as vocal fold tension, mass, length, and subglottic pressures, and it also maintains the supralaryngeal articulatory adjustments required for the production of sounds. Th is parameter can be used as an index for the eff ectiveness of therapy [23]. In addition, the results obtained were in agreement with the results obtained by Salihovic et al. [24], who reported that shimmer values were signifi cantly higher in stuttering individuals than in normally fl uent speakers. It was determined that stuttering individuals have variable, sometimes even chaotic subglottal pressure. It is believed that this is caused by muscle incoordination of respiratory tract. Stuttering children were considered to have weaker laryngeal neuromuscular control and greater disturbances in integrating respiratory and laryngeal control, which justifi es measurements of voice disturbances [24].

Conclusion
Th e presented program provides participants with strategies that signifi cantly improve their speech behavior. Th e participants in this study showed signifi cant clinically measurable gains on all objective clinical measures of stuttering severity and attitude change. Th e younger age group showed better outcome with the therapy program. Improvement in stuttering is associated with increasing values of spectral parameters and improvement in Visipitch value s.