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Feedback of stutterers’ electromyographic activity Hanna, Richmond 1975

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FEEDBACK OF STUTTERERS  1  ELECTROMYOGRAPHIC ACTIVITY  RICHMOND CHARLES HANNA M.A., U n i v e r s i t y of A l b e r t a , 1971  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE  REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  i n the Department o f Psychology  We accept t h i s t h e s i s ad coj/f Qr'jnin-g' t o t h e r e q u i r e d  THE UNIVJ&SlTY- OF BRITISH ^COLUI^fJIA September 1975  standard  In presenting this thesis  in partial fulfilment of the requirements for  an advanced degree at the University of B r i t i s h Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this  thesis  for scholarly purposes may be granted by the Head of my Department or by his representatives.  It  is understood that copying or publication  of this thesis for financial gain shall not be allowed without my written permission.  Department of  Psychology  The University of B r i t i s h Columbia Vancouver 8. Canada  D  a  t  e  September  ?S  J  ii  P r o f e s s o r P.O. Davidson, Research S u p e r v i s o r  Abstract F i v e s t u d i e s were performed to e x p l o r e t h e f e a s i b i l i t y c h r o n i c s t u t t e r i n g w i t h EMG feedback.  o f t r e a t i n g severe  EMG s p i k i n g from the t h r o a t was  found t o c o r r e l a t e w i t h s t u t t e r i n g , and t o d i f f e r e n t i a t e between s t u t t e r i n g and f l u e n t  speech.  EMG s p i k i n g tended t o d i s a p p e a r when s t u t t e r i n g was  reduced by metronome-paced speech and by speech therapy.  L i k e w i s e , when  EMG s p i k i n g was reduced by feedback t r a i n i n g , s t u t t e r i n g was c o n c u r r e n t l y reduced.  P r e s e n t a t i o n o f the feedback tone without i n s t r u c t i o n s o r i n f o r -  mation produced no r e d u c t i o n i n s t u t t e r i n g o r EMG s p i k i n g . was a l s o g e n e r a l l y i n e f f e c t i v e . i s a p p a r e n t l y n o t an a r t i f a c t  Pseudofeedback  I t was concluded t h a t the feedback  effect  o f i n s t r u c t i o n s , masking, d i s t r a c t i o n , adap-  t a t i o n , s l o w i n g o f speech, or o f a s t u t t e r - c o n t i n g e n t a v e r s i v e tone, n o r i s i t a Hawthorne o r placebo e f f e c t .  I m p l i c a t i o n s of t h e r e s u l t s a r e d i s c u s s e d .  TABLE OF CONTENTS  Page ABSTRACT  li  LIST OF TABLES  V  LIST OF FIGURES  yl  ACKNOWLEDGEMENTS  vii  Chapter I.  INTRODUCTION  1  Stuttering BiofeedbackII.  1 10  GENERAL METHODOLOGY  17-  Subjects Dependent V a r i a b l e s Stuttering EMG S p i k i n g Speech Rate Observer Agreement Design III.  IV.  17 18 18 20 20 21 23  STUTTERING AND LARYNGEAL HYPERTENSION  29  L a r y n g e a l Involvement i n S t u t t e r i n g Study 1 Method Results Study 2 Method Results D i s c u s s i o n o f S t u d i e s 1 and 2  29 31 33 35 35 35 37 37  FEEDBACK OF ELECTROMYOGRAPHIC P i l o t f o r Study 3 Method R e s u l t s and D i s c u s s i o n Study 3 Method Results Discussion  ACTIVITY  42 42 ' 42 44 47 47 48 53  iv  Chapter V.  Page FEEDBACK WITHOUT INSTRUCTIONS Study 4 Method Results Discussion  VI.  55 56 56 60  FALSE FEEDBACK  62  P i l o t t o Study 5 Method R e s u l t s and D i s c u s s i o n Study 5 Method Results Discussion VII.  55  63 63 63 66 66 67 71  CONCLUSION  74  ADDENDUM  81  REFERENCE NOTES  84  REFERENCES  85  APPENDICES  93  VIHli  A.  Assignment of S u b j e c t s  to S t u d i e s  B.  Inter-Rater  C.  Minimum Pen D e f l e c t i o n s D e f i n i n g an  R e l i a b i l i t y Check  93 94  95  EMG Spike 3 and 5  D.  I n s t r u c t i o n s f o r Studies  E.  Questions Used t o I n v e s t i g a t e Awareness of Feedback C o n d i t i o n  96 9.7  LIST OF TABLES  Table 1.  Designs Used i n the P r e s e n t S e r i e s  2.  Reduction i n S t u t t e r i n g C o n t r o l Therapy"  3.  Reduction i n EMG C o n t r o l Therapy  4.  C o r r e l a t i o n Between P e r c e n t S y l l a b l e s S t u t t e r e d and EMG S p i k e s p e r 100 S y l l a b l e s i n Study 1 And C o r r e l a t i o n Between P e r c e n t S y l l a b l e s S t u t t e r e d and EMG Spikes p e r 100 S y l l a b l e s i n Study 2  5.  of S t u d i e s  as a F u n c t i o n of Rate  Spiking  as a F u n c t i o n of Rate  6.  S u p p r e s s i o n of S t u t t e r i n g Metronome Treatment  and EMG  7.  E f f e c t s o f EMG  Pilot  8.  E f f e c t of EMG Spiking  Feedback on S t u t t e r i n g  9.  E f f e c t o f EMG  Feedback on Speech Rate  Feedback:  Spiking  by  Study and  10.  E f f e c t of Feedback Without I n s t r u c t i o n s S t u t t e r i n g and EMG S p i k i n g  on  11.  E f f e c t o f Feedback Without I n s t r u c t i o n s Rate  dn Speech-  12.  E f f e c t s of Genuine and F a l s e Study  Pilot  13.  E f f e c t o f Genuine and F a l s e Feedback S t u t t e r i n g and EMG S p i k i n g  14.  E f f e c t o f Genuine and F a l s e Speech Rate 1  15.  Feedback:  on  Feedback on  ^Changes i n Muscle A c t i o n P o t e n t i a l and S t u t t e r i n g Frequency  (MAP)  Levels  vi  LIST OF FIGURES  Figure  Page  1.  Sample EMG  2.  E f f e c t of Metronome on S t u t t e r i n g ;  3.  E f f e c t of Metronome on EMG  4.  EMG  5.  E f f e c t of EMG  Feedback on S t u t t e r i n g :  John  45  6.  E f f e c t of EMG  Feedback on S t u t t e r i n g :  Don  49  7.  E f f e c t o f Feedback on EMG  8.  E f f e c t o f EMG  9.  E f f e c t of Feedback Without I n s t r u c t i o n s Stuttering: Rick  on  E f f e c t o f Feedback Without I n s t r u c t i o n s EMG S p i k i n g : Rick  on  10.  11.  Recordings  32 David  Spiking:  David  Feedback System  38 39. 43  Spiking:  Don  Feedback on S t u t t e r i n g :  50 Ruth  52  57  58  E f f e c t of Genuine and F a l s e Feedback on Stuttering:  John  12.  Sample EMG  Recordings From Study 5  13.  E f f e c t of Genuine and F a l s e Feedback on Stuttering: Doug  65 68  69  yii  ACKNOWLEDGEMENTS  The author wishes t o thank Robert D. Hare, Ph.D. f o r t h e use o f h i s l a b o r a t o r y , B r e n t M c N e i l l f o r c o n s t r u c t i n g t h e b i o feedback equipment, in  and N e v i l l e Owen, Ph.D. f o r hi,s p a r t i c i p a t i o n  the i n t e r - r a t e r r e l i a b i l i t y  check.  S p e c i a l thanks a r e due; to  the G.F. S t r o n g R e h a b i l i t a t i o n C e n t r e f o r p r o v i d i n g t h e s u b j e c t s for  this  research.  1  CHAPTER 1 INTRODUCTION Stuttering S t u t t e r i n g i s one of the most thoroughly r e s e a r c h e d t o p i c s i n psycho^ p a t h o l o g y , w i t h over 2000 r e f e r e n c e s i n the p s y c h o l o g i c a l , m e d i c a l l i t e r a t u r e s i n c e 1900.  D e s p i t e t h i s v a s t amount of research-and  and  ?  the  speech-  apparent  s i m p l i c i t y of the d i s o r d e r , t h e r e i s as y e t no g e n e r a l l y accepted t h e o r y or treatment  f o r s t u t t e r i n g , nor even a s t a n d a r d S t u t t e r i n g appears  definition.  to be an u n i v e r s a l phenomenon, u n r e l a t e d t o i n -  t e l l i g e n c e and socio-economic  status.  Slight differences i n incidence figures  w i t h i n and a c r o s s c u l t u r e s p r o b a b l y r e f l e c t the l a c k of a s t a n d a r d  definition  of s t u t t e r i n g , p l u s the p o s s i b i l i t y t h a t i t i s continuous w i t h normal d i s fluency.  Whether i t a r i s e s out of normal c h i l d h o o d d i s f l u e n c y i s not known.  At any r a t e , n e a r l y a l l s t u t t e r i n g has i t s onset between the ages of two seven one,  (Van R i p e r , 1971).  Male s t u t t e r e r s outnumber females by about t h r e e t o  f o r unknown reasons.  80% r e m i t spontaneously  and  The p r o g n o s i s f o r c h i l d s t u t t e r e r s i s good:  (Sheehan & Martyn, .1966)..  about  The p r o g n o s i s f o r a d u l t  s t u t t e r e r s i s r e l a t i v e l y poor (Beech. & F r a n s e l l a , 1968)_. I t i s common to speak of a g e n e t i c p r e d i s p o s i t i o n to s t u t t e r i n g , but t h i s h y p o t h e t i c a l mechanism has not been i d e n t i f i e d and value.  thus has no  explanatory  G e n e t i c r e s e a r c h on s t u t t e r i n g i s s c a n t y , but i t has been e s t a b l i s h e d  t h a t a c h i l d w i l l have a d i s p r o p o r t i o n a t e l y h i g h r i s k of becoming a s t u t t e r e r i f he has  r e l a t i v e s who  stutter  (Andrews & H a r r i s , 1964).  The p o s s i b l e model-  l i n g e f f e c t of c o n t a c t w i t h such r e l a t i v e s has u s u a l l y not been Adequate modern s t u d i e s of concordance are l a c k i n g .  controlled.  2  S t u t t e r i n g usually- c o n s i s t s mainly t a t i o n s , p l u s obvious head j e r k i n g , f i s t operants.  o f s y l l a b l e r e p e t i t i o n s and k e s i ^  t e n s i o n and d i v e r s e m o t o r behaviors- (e.g., b l i n k i n g ,  c l e n c h i n g ) which-are o f t e n c o n s i d e r e d to be s u p e r s t i t i o u s ,  S t u t t e r i n g can take -many forms- a c r o s s i n d i v i d u a l s - , and w i t h i n i n ^  d i v i d u a l s over time. d i s o r d e r and concluded  Van R i p e r  Q971). reviewed  63 n o s o l o g i c a l s t u d i e s o f t h i s  t h a t d e f i n i t e subgroups have n o t y e t Keen d e f i n e d .  Nevertheless,, the p o s s i b i l i t y t h a t t h e r e a r e d i s t i n c t  types o f s t u t t e r e r s re-r-  mains an e n t i c i n g one, f o r i t would h e l p account  f o r the many-inconclusive  and  literature.  c o n t r a d i c t o r y r e s u l t s - i n the huge s t u t t e r i n g  S t u t t e r e r s can p r e d i c t with: c o n s i d e r a b l e accuracy they w i l l s t u t t e r  ( B l o o d s t e i n , 1972).  p o i n t s where a normal speaker phrases.  the words on w h i c h  S t u t t e r i n g o c c u r s most" f r e q u e n t l y a t  i s l i k e l y t o h e s i t a t e o r pause, e.g., between  I t i s n o t r e l a t e d t o word l e n g t h , grammatical form, o r i n i t i a l  sound,  but i t i s p o s i t i v e l y r e l a t e d t o the p r o p o s i t i o n a l i t y (meaningfulness): o f t h e message b e i n g communicated and t o the p e r c e i v e d s t a t u s of t h e l i s t e n e r . S t u t t e r i n g tends  to occur d u r i n g manding, a s t a t e i n w h i c h t h e speaker i s  e x p e r i e n c i n g d e p r i v a t i o n o r o t h e r a v e r s i v e s t i m u l a t i o n ( S k i n n e r , J957)_. It  Is- w e l l - e s t a b l i s h e d t h a t s t u t t e r i n g  tends  over time i n a r e l a t i v e l y constant s t i m u l u s s i t u a t i o n  t o decrease  (Beech & F r a n s e l l a , 1968).  This-phenomenon i s commonly c a l l e d the a d a p t a t i o n e f f e c t . buted  "spontaneously"  It has been  attri^  t o e x t i n c t i o n due to a n x i e t y r e d u c t i o n (Johnson, .1959), although, t h e r e  are some d i f f e r e n c e s between e x t i n c t i o n and a d a p t a t i o n curves Gray and B r u t t e n sweating,  (1965) found  adaptation occurred without  an index of a n x i e t y , and concluded  accumulation  of r e a c t i v e i n h i b i t i o n .  (Wingate, 1966)_.  a d e c l i n e I n palmar  that adaptation is-due to the  This- i n t e r p r e t a t i o n i s : c o n s i s t e n t w i t H  3  the f a c t t h a t a f t e r a d a p t a t i o n and a s h o r t r e s t - p e r i o d , d u r i n g w h i c h time r e a c t i v e i n h i b i t i o n c o u l d d i s s i p a t e , . s t u t t e r i n g tends: to r e t u r n to i t s base-r line level.  Another p o s s i b i l i t y is* t h a t a d a p t a t i o n i s s i m p l y a s p e c i a l  of s t i m u l u s h a b i t u a t i o n (Van R i p e r , 19.71)..  case  The a d a p t a t i o n phenomenon is-.not ••  u t i l i z e d i n therapy, s i n c e i t i s very- t r a n s i e n t and does n o t : t r a n s f e r to extra-clinical situations.  I n s t e a d , i t is- c o n s i d e r e d a n u i s a n c e v a r i a b l e  w h i c h must be c o n t r o l l e d , l e s t i t r a i s e f a l s e hopes i n t h e n a i v e r e s e a r c h e r . A d a p t a t i o n and spontaneous, recovery- can l a r g e l y - be e l i m i n a t e d ..by-- t h e s i m p l e expedient of changing speech s t i m u l i r a t h e r than exposing t h e ' s u b j e c t r e p e a t e d l y to the same m a t e r i a l , and b y - u s i n g continuous speech, r a t h e r than a l l o w i n g breaks.. A m i n o r i t y of a d u l t stutterers-<over,come t h e i r handicap without, speechtherapy.  For those who  do n o t - r e m i t spontaneously-, t h e c l i n i c a l p i c t u r e re-r  mains r e l a t i v e l y - b l e a k i n s p i t e of a v a s t amount of r e s e a r c h ;  S t u t t e r e r s , haye  been t r e a t e d w i t h almost every- c o n c e i v a b l e v a r i e t y - of' psychotherapy- and he-rh a v i o r therapy, medicated w i t h almost e v e r y t h i n g from ataractics.- to ampKetamines, and even t r e a t e d w i t h surgery-, ECT and acupuncture.  A number of  speech,  t h e r a p i e s w h i c h have no c o u n t e r p a r t s i n psychology-or-medicine haye a l s o been developed s p e c i f i c a l l y f o r s t u t t e r e r s .  The v a r i o u s t h e r a p i e s : have been t h o r o u g h l y  reviewed by Van R i p e r Q 9 7 3 ) , the u n d i s p u t e d dean of s t u t t e r i n g research, and therapy, who  a f t e r 40 y e a r s i n the f i e l d remains  R i p e r is. p e s s i m i s t i c about  a stutterer himself.  the l i k e l i h o o d of a " c u r e " f o r ' s t u t t e r i n g ,  r i n g i n s t e a d to d e s e n s i t i z e the s t u t t e r e r to h i s problem to l i v e with i t .  Van prefer-  so that, he may  learn  F o r Van R i p e r and h i s numerous f o l l o w e r s , s u c c e s s f u l therapy  i n v o l v e s t u r n i n g a tense, anxious s t u t t e r e r i n t o a more r e l a x e d , " f l u e n t "  4  s t u t t e r e r who  no  l o n g e r avoids  the., s i t u a t i o n a l and phonemic cues w h i c h p r e -  cede s t u t t e r i n g . Three of f o u r r e c e n t l y developed p o t e n t i a l , however.  One  of these i s r a t e - c o n t r o l therapy  1) i n which b e h a v i o r a l techniques at a slow r a t e .  t h e r a p i e s appear to have c o n s i d e r a b l e  are used to t r a i n the s t u t t e r e r  to.speak  N e a r l y a l l s t u t t e r e r s can be made f l u e n t t h i s way,  tenance of f l u e n c y i n v o l v e s c o n t i n u i n g ,to speak abnormally In a six-month f o l l o w - u p  study, P e r k i n s found  r e t a i n e d some improvement and  53% m a i n t a i n e d  remain to be  but main-  s l o w l y at  times.  t h a t 92% of h i s s t u t t e r e r s had "normal" f l u e n c y , although  r a t e data were not g i v e n . . Adequate independent follow-up c o n t r o l therapy  (e.g., P e r k i n s , Note .  s t u d i e s of r a t e  done.  I t has been known f o r c e n t u r i e s t h a t s t u t t e r i n g i s reduced  dramati-  c a l l y when the s t u t t e r e r paces h i s words o r s y l l a b l e s w i t h an i t e r a t e d e.g.,  a metronome.  T h i s e e f f e c t i s not due  ( R o t t e r , 1955).  se i s not an e s s e n t i a l p r o p e r t y of the stimulus.:  rhythmic  and  therapy,  Nor  arhythmic  Van  Riper  to be independent of speech r a t e (Hanna  Q.97.1) suggested  t h a t t h e metronome a c t s as a  t i m i n g d e v i c e to i n t e g r a t e the motor p a t t e r n i n g of speech, but t h i s occurs.  stuttering  i s . t h e metronome e f f e c t merely a v a r i a n t of r a t e c o n t r o l  f o r i t s e f f e c t has been found  & M o r r i s , Note 2 ) .  how  Rhythm per  of e q u a l p r e d i c t a b i l i t y are e q u a l l y e f f e c t i v e i n s u p p r e s s i n g  CBrady, 1969).  stimulus,  to a d e f i c i e n c y i n the p e r c e p t i o n  or p r o d u c t i o n of rhythm on the s t u t t e r e r ' s p a r t  beats  speech  i t i s not known  U n f o r t u n a t e l y , the metronome e f f e c t i s apparatus-rbound:  wears o f f i n a matter of minutes.  Still,  i t . may  A g r e a t d e a l of s t u t t e r i n g r e s e a r c h and  it  have t h e r a p e u t i c p o t e n t i a l . t h e r a p y has been based  the assumption t h a t s t u t t e r i n g i s symptomatic of n e u r o s i s .  The  on  extreme s t a t e -  5  ment o f this, p o s i t i o n i s : the orthodox p s y c h o a n a l y t i c view  ( J e n i e h e l , 19.45)_,  wherein s t u t t e r i n g i s a symptom of a p r e g e n i t a l c o n v e r s i o n n e u r o s i s which.: i n v o l v e s a symbolic upward displacement of the a n a l s p h i n c t e r .  Stuttering .  thus a l l o w s the.speaker t o smear h i s l i s t e n e r w i t h ! s y m b o l i c f e c e s .  Other  psychodynamic i n t e r p r e t a t i o n s a r e l e s s e n t e r t a i n i n g but e q u a l l y u n c o n s t r a i n e d by d a t a .  Although psychotherapy  remains  one of the most' common treatments  f o r s t u t t e r i n g , i t s v a l u e r-afiiis§ to be demonstrated 1973).  ( P e r k i n s , .1973; Van R i p e r ,  Moreover, r e v i e w e r s of the p e r s o n a l i t y l i t e r a t u r e have c o n s i s t e n t l y  concluded, sometimes to t h e i r own a n e u r o s i s has not been made. t e r e r s as a group & Fransella,  s u r p r i s e , t h a t the case f o r s t u t t e r i n g  There i s l i t t l e u n e q u i v o c a l e v i d e n c e t h a t  as stut-  are more n e u r o t i c . o r m a l a d j u s t e d than n o n s t u t t e r e r s (Beech  1968;  Sheehan, 1970).  t e r e r s have been p r e t t y normal something" .(1971, p. 2721.  A c c o r d i n g to,Van R i p e r , "most of our  individuals —  stut-  except when they- had to say  In the r e l a t i v e l y few. cases w h e r e - n e u r o t i c  symp-  toms are p r e s e n t , they p r o b a b l y r e p r e s e n t the outcome o f y e a r s of communicat i v e f r u s t r a t i o n and s o c i a l p e n a l t i e s .  The p o p u l a r s t e r e o t y p e p o r t r a y s the  s t u t t e r e r s a s a e n e u r o t i c n l n t r o y e r t , as e x e m p l i f i e d by P-P-Porky P - P i g . some s t u t t e r e r s undoubtedly  f i t t h i s d e s c r i p t i o n , as a whole they do n o t .  There i s no evidence to suggest t h a t the s t u t t e r e r has a p a r t i c u l a r p r o f i l e o r group  While  personality  of t r a i t s t h a t d i f f e r e n t i a t e s him o r h e r from the n o n s t u t t e r e r .  The b u l k of a huge body of r e s e a r c h has f a i l e d  to demonstrate, that  as a group have b a s i c a l l y d i f f e r e n t p e r s o n a l i t i e s from normal a f t e r y e a r s of s t u t t e r i n g  (Beech & F r a n s e l l a , 1968;  Van  stutterers  s p e a k e r s , even  R i p e r , 19711.  Much of the r e c e n t p s y c h o l o g i c a l r e s e a r c h on s t u t t e r i n g has been concerned w i t h the p o s s i b i l i t y t h a t i t i s e s s e n t i a l l y a l e a r n e d b e h a v i o r .  6  B r u t t e n and Shoemaker (1967) have proposed stuttering.  an e l e g a n t two-rfactor t h e o r y of  S t r e s s is- known to cause f l u e n c y f a i l u r e i n normal  speakers.  Through repeated exposure to s t r e s s , n e g a t i v e emotion may" become c l a s s i c a l l y c o n d i t i o n e d to c e r t a i n s t i m u l i , e.g.,  speaking to an a u t h o r i t y f i g u r e .  p a t t e r n of autonomic a c t i v i t y which- d e f i n e s n e g a t i v e emotion causes  The  disinter  g r a t i o n of the p r e c i s e l y - t i m e d motor b e h a v i o r of speech. > Thus the h e s i t a t i o n s , r e p e t i t i o n s , b r e a t h i n g a b n o r m a l i t i e s e t c . which, c o n s t i t u t e t h e core b e h a v i o r s of s t u t t e r i n g are thought  to be respondents.  velopment of s t u t t e r i n g , secondary through escape and avoidance d u r i n g s t u t t e r i n g may  In the second  stage of the  de^  symptoms a r e a c q u i r e d by some i n d i v i d u a l s  c o n d i t i o n i n g , e.g., h e a d - j e r k i n g t h a t occurs  be r e i n f o r c e d by e v e n t u a l f l u e n t u t t e r a n c e and by: the  t e r m i n a t i o n of s e l f - g e n e r a t e d and l i s t e n e r - g e n e r a t e d a v e r s i y e s t a t e s . course, the f a c t t h a t such-operants h i g h l y r e s i s t a n t to e x t i n c t i o n .  Van  Of  are r e i n f o r c e d i n t e r m i t t e n t l y - m a k e s them Riper  j e r k i n g b e h a v i o r t h a t h i s s t u t t e r i n g was  (1973). developed  once mistaken  s u c h gross head-  f o r an e p i l e p t i c  As t h e r a p y , B r u t t e n and Shoemaker p r e s c r i b e r e c i p r o c a l  seizure.  inhibition  t h e r a p y t o weaken the c o r e of c l a s s i c a l l y c o n d i t i o n e d n e g a t i v e emotion, p l u s the o p t i o n a l treatment formance.  of secondary  symptoms through, u n r e i n f o r c e d massed p e r -  Although some e a r l y r e p o r t s of r e c i p r o c a l i n h i b i t i o n t h e r a p y f o r  s t u t t e r e r s were not encouraging  (e.g., Lazarus,-1963;'Wblpe,'.19.61)1, t h e r e have  been some p o s i t i v e r e s u l t s r e c e n t l y (Adams, 1971;  Webster, 19-70)1.  Lanyon  (1969) and T y r e , M a i s t o , and Companik .'(19.73)1 r e p o r t e d a d e c r e a s e i n both., s t u t t e r i n g and s t a t e a n x i e t y a f t e r r e c i p r o c a l i n h i b i t i o n therapy, but' Gray England  (1972) found t h a t these o c c u r r e d a t d i f f e r e n t times.  reduced  e a r l y i n treatment when a n x i e t y , measured i n terms of s k i n  and  Stuttering  was  conductance  7  s c o r e s , was h i g h .  A n x i e t y seems t o have been a l l e v i a t e d a few. s e s s i o n s a f t e r  s t u t t e r i n g had decreased. The  T h i s i s ; i n c o n s i s t e n t with, the t w o - f a c t o r  theory.  t w o - f a c t o r t h e o r y p r e d i c t s : t h a t the core b e h a v i o r s o f s t u t t e r i n g  would be i n c r e a s e d by punishment, .through t h e p r o d u c t i o n o f d i s r u p t i v e a u t o n o ^ mic a c t i v i t y . stuttering  There a r e r e p o r t s t h a t random punishment does indeed i n c r e a s e  1965 ;  (Siegel & Martin,  Brookshire & Eveslage,  e f f e c t was n o t found by Biggs and Sheehan  (19691.  Contingent  however, has u s u a l l y been found t o i n c r e a s e s t u t t e r i n g . s i v e s t i m u l i have i n c l u d e d v e r b a l reprimand  .19691, although, punishment,  Such contingent  CQuist & M a r t i n ,  this  19671,  aver^  very loud  n o i s e (Flanagan, Goldiamond & Az.rin, 1958; S i e g e l & M a r t i n , 1965) , e l e c t r i c shock (Daly & Cooper,  19671,  100-candihepower gun (Brady,  and even t h e b l i n d i n g f l a s h , of a  1968),.  photographer's  On b a l a n c e , t h e bulk, o f r e c e n t r e s e a r c h  on punishment supports a p u r e l y operant view o f s t u t t e r i n g , as opposed t o the t w o - f a c t o r theory. S t u t t e r i n g has o t h e r operant p r o p e r t i e s as. w e l l . p o r a r i l y i n s t a t e d i n normal speakers ment (Van R i p e r ,  1973;  of f l u e n c y reduces  through- p o s i t i v e and n e g a t i v e reinforce-^-  Flanagan, Goldiamond, & A z r i n ,  stuttering  I t has been tem-  19581.  (Van R i p e r , 1973; P e r k i n s , Note J)., as do r e s -  ponse c o s t (Halvorson, 1971) and s t u t t e r s - c o n t i n g e n t time-out (Haroldson, M a r t i n & S t a r r , speech  can be brought  Reinforcement  1968).  from  speaking  Once e s t a b l i s h e d , a s t u t t e r e r ' s  under s t i m u l u s c o n t r o l  (Martin & S i e g e l ,  fluent  .19661.  I f s t u t t e r i n g i s an o p e r a n t , i t s a c q u i s i t i o n and maintenance are n o t f u l l y understood  (Sander,  1975).  Many operant r e s e a r c h e r s assume t h a t  normal speech i n c l u d e s s t u t t e r s , b u t a t such a low frequency i s apparent  schedules  t h a t no problem  (Goldiamond, 1965).,In some c h i l d r e n , r e p e t i t i o n s and o t h e r d i s -  8  f l u e n c i e s t h a t occur d u r i n g mandingmay- he - u n i n t e n t i o n a l l y ^ r e i n f o r c e d by. p a r e n t s and  other  l i s t e n e r s : through, a t t e n t i o n a n d - n o n i n t e r r u p t i o n .  r e p e t i t i o n s , and h e s i t a t i o n s may  serve  to postpone the a v e r s i v e  of s t u t t e r i n g (Shames & S h e r r i c k , 1963)_.  consequences  However, s e l f - g e n e r a t e d  t e n e r - g e n e r a t e d punishment p r o b a b l y occur p r i o r to r e i n f o r c e m e n t utterance), tained. may  be  and  thus i t i s d i f f i c u l t  H a l v o r s o n Q973) has  to understand how  At any  and  lis-  (i.e.,  fluent  s t u t t e r i n g i s main-r  suggested t h a t s t u t t e r i n g and  I t s punishment  the i n i t i a l components of a b e h a v i o r c h a i n t e r m i n a t i n g  ment f o r f l u e n c y .  Furthermore,  with r e i n f o r c e -  r a t e , the v a l u e of the operant a p p r o a c h Is  ted by t h e r a p i e s which have s u c c e s s f u l l y u t i l i z e d shaping  illus.tra^  ( P e r k i n s , Note 1),  stimulus  c o n t r o l ( A z r i n , Jones, & F l y e , 19681, s e l f - r e c o r d i n g _ ( L a C r o i x , J.9.73V.,  time out  (James' & Ingham, 1974)., s o c i a l reinforcement  ment f o r s t u t t e r i n g (Ryan, 1971;  Quist  & Martin,  f o r f l u e n c y and  1967), and  punish.-^  even token econo?  mi-€s (Ingham & Andrews, J973b)_. A l t h o u g h most r e s e a r c h e r s ptoms of s t u t t e r i n g are l e a r n e d , disorder i s a disturbance  p r o b a b l y would agree t h a t many of the  some suspect  of a u d i t o r y  sym-^  t h a t the e s s e n t i a l cause of  feedback.  "Artificial  the  s t u t t e r i n g " may  be induced i n a l a r g e p r o p o r t i o n of normal speakers be f e e d i n g back t h e i r t a p e - r e c o r d e d speech at a d e l a y of about .20 t h i s delayed a u d i t o r y for  feedback (DAF)  the simultaneous and  successive  muscles i n v o l v e d i n speech. stutterers:  d i s r u p t s the p r e c i s e t i m i n g contractions  However, DAF  i t makes them " a r t i f i c i a l l y  ment at t h i s time because t h e r e i s l i t t l e l i f e , but  i t has  seconds (Lee, 1951).  has  of the dozens of  a paradoxical  fluent".  DAF  carry-over  Apparently required antagonistic  e f f e c t on many  i s not  a viable treats  of fluency- from l a b to  spawned s e v e r a l i n t r i g u i n g models-of s t u t t e r i n g as a feedback  9  disturbance  (e.g.,  G r u b e r , 1965; Mysak,  1960; S k l a r , 19691.  Speech, i s a f i n e l y -  i n t e g r a t e d motor a c t i v i t y which presumably I n v o l v e s at l e a s t t h r e e k i n d s of feedback: 1. )  airborne auditory  2. )  bone-conducted and t i s s u e ^ o n d u c t e d  3.1 somesthetic  feedback  (1.e., t a c t i l e ,  a u d i t o r y f e e d b a c k , and  kinesthetic,  and p r o p r i o c e p t i v e ) ,  feedback from the speech, m u s c u l a t u r e . Left-Bright feedback a s y n c h r o n y , found i n some s t u t t e r e r s  a p o s s i b l e source of i n s t a b i l i t y * has b e e n  (Stromsta,  Note 3 ) .  Another s o u r c e o f feedback dis-r  t o r t i o n might be temporal d i f f e r e n c e s between competing channels., and indeed t h i s has been demonstrated words,  f o r channels I  and 2 ( S t r o m s t a , -1962)1..  some s t u t t e r e r s may have an o r g a n i c DAF system.  causes t h i s u n s t a b l e feedback system t o f a i l ,  In other  S t r e s s presumably  e . g . , Timmons and-Boudreau  0.9.721 h y p o t h e s i z e d t h a t anxiety- produces changes  i n t h e contour of t h e o r a l  cavity-, w h i c h l e a d to f u r t h e r feedback, d i s t o r t i o n , g r e a t e r anxiety-, The s t u t t e r e r c a r r i e s  h i s own s t r e s s e r s w i t h , h i m , i n t h e form o f  emotion c o n d i t i o n e d to s i t u a t i o n a l and phonemic c u e s . f l u e n t presumably adds to f u t u r e  and SQ o n .  negative  Each, f a i l u r e to b e  stress;'  DAF must u s u a l l y be at l e a s t as l o u d as t h e s p e a k e r ' s . o w n speech to be e f f e c t i v e ,  and i t i s most d i s r u p t i v e when l o u d enough to mask bone conduc-  tion,  i . e . , g r e a t e r than 50 dB above t h r e s h o l d ( B u t l e r - & G a l l o w a y , 19.57).  Yates  (1963) h y p o t h e s i z e d t h a t n o n s t u t t e r e r s  whose s p e e c h i s - n o t d i s r u p t e d  by DAF a c t u a l l y monitor t h e i r speech, v i a channel 2 a n d / o r 3. mond, A t k i n s o n and B i l g e r 1(1962)1 found t h a t n o n s t u t t e r e r s resistant  to DAF when i n s t r u c t e d not to l i s t e n t o i t .  Indeed,  can become  Goldia-^ relatively  10  The  d e f e c t i v e feedback theory  i s . supported by another phenomenon as  w e l l : , many- s t u t t e r e r s become a r t i f i c i a l l y - f l u e n t when l i s t e n i n g at  a loudness of a p p r o x i m a t e l y 90 dB above t h r e s h o l d  (Cherry  to white  & Sayers,  noise  1956L.  Speech t h e r a p i s t s c a l l ; t h i s treatment "masking n o i s e " because i t minimizes; or e l i m i n a t e s the s t u t t e r e r ' s , h e a r i n g DAF,  o f h i s speech, v i a channels 1 and 2 .  masking n o i s e g e n e r a l l y has no l o n g - l a s t i n g t h e r a p e u t i c  of considerable  Like  1  t h e o r e t i c a l i n t e r e s t because.it  e f f e c t but i t i s  apparently- f o r c e s t h e s t u t t e r e r  to m o n i t o r h i s speech through, channel 3 . The are c l e a r : teaching  t h e r a p e u t i c i m p l i c a t i o n s o f t h e feedback,model of . s t u t t e r i n g I f channels 1 and 2 a r e somehow d e f e c t i v e , therapy s h o u l d  :  involve  the s t u t t e r e r t o r e l y on channel 3 (Mysak, 1 9 6 0 ; Gruber, 1 9 6 5 ) .  T h i s c o u l d be achieved  through masking chanrieilsifi oand'.^2"cb'.yjhap"plying 'loud  wha-lre-bnoWse^ie^• CSklar, 1 9 6 9 ) .  _  An a l t e r n a t i v e s t r a t e g y , which i s the essence  of t h i s d i s s e r t a t i o n , i n v o l v e s enhancing p r o p r i o c e p t i v e i n f o r m a t i o n by f e e d i n g it  through t h e a i r b o r n e a u d i t o r y feedback  channel.  Biofeedback B i o f e e d b a c k t r a i n i n g i s based on the fundamental l e a r n i n g p r i n c i p l e t h a t we can l e a r n t o make a g i v e n  response when we r e c e i v e < i i n f o r m a t i o n  that  1975).  Im-  we have made t h a t response, o r an a p p r o x i m a t i o n t o i t ( L a z a r u s ,  mediate feedback i s the most e f f e c t i v e , e.g., feedback from the eyes  facili-  t a t e s c o n t r o l of the s t r i a t e muscles i n v o l v e d i n w r i t i n g a sentence.  Under  ordinary cal in  c o n d i t i o n s , we do n o t r e c e i v e much feedback about c e r t a i n p h y s i o l o g i -  processes,  e.g., the f i n e a c t i v i t y o f the p o s t e r i o r c r i c o a r y t e n o i d muscle  the l a r y n x , b u t b i o f e e d b a c k can make t h i s i n f o r m a t i o n more s a l i e n t .  11  In  the p a s t decade, b i p f e e d b a c k has been shown to• have important  t h e o r e t i c a l r a m i f i c a t i o n s as w e l l as p o t e n t i a l f o r t h e treatment of a h o s t of  disorders.  A c c o r d i n g t o Budzynski . Q-973) :  "An accumulating body of c l i n i c a l and r e s e a r c h , evidence suggests t h a t b i o f e e d b a c k r e p r e s e n t s a r e l a t i v e l y e f f e c t i v e technique f o r t h e shaping o f s e l f - c o n t r o l over c e r t a i n p h y s i o l o g i c a l e v e n t s . These events a r e u s u a l l y autonomous I n t h a t they tend t o occur a u t o m a t i c a l l y and below the l e v e l of awareness. When these, i n t e r n a l events f a l l o u t s i d e the normalrrange o f f u n c t i o n i n g , they cons t i t u t e m a l a d a p t i v e b e h a v i o r s t h a t can l e a d t o f e e l i n g s of anxiety,, o r the - appearance o f such, s t r e s s — r e l a t e d ' d i s o r d e r s as m i g r a i n e and t e n s i o n headaches, c e r t a i n c a r d i o v a s c u l a r problems, and s l e e p - o n s e t insomnia, to name a few. Through feedback t r a i n i n g , p a t i e n t s l e a r n to m a i n t a i n t h e i r p h y s i o l o g y w i t h i n a normal range o f functioning." (p. 546).. In view of t h e p o s s i b i l i t y  that s t u t t e r i n g i s the r e s u l t of d e f e c t i v e f e e d -  back, an i n v e s t i g a t i o n o f t h e e f f e c t s of feedback  t r a i n i n g on s t u t t e r i n g seems  warranted. Some of t h e e a r l i e s t  and most important b i o f e e d b a c k r e s e a r c h , from  a t h e o r e t i c a l p o i n t of view, i n v o l v e d operant c o n d i t i o n i n g o f autonomic r e s ponses.  These i n c l u d e d reward and avoidance c o n d i t i o n i n g of smooth..muscle  responses such as h e a r t r a t e (Snyder & Noble,  1968);  ( M i l l e r & D i C a r a , 1967), and vasomotor b e h a v i o r '  and o f g l a n d u l a r responses such, as s a l i v a t i o n  & Carmona, 1967) and GSR (Snyder & Noble, .1968)..  (Miller  M i l l e r , D i C a r a and c o l l e a g u e s  c u r a r i z e d and a r t i f i c i a l l y r e s p i r a t e d t h e i r animal s u b j e c t s i n o r d e r t o c o n t r o l for  the p o s s i b i l i t y  s k e l e t a l muscles  that t h e autonomic responses were a c t u a l l y mediated by  under v o l u n t a r y c o n t r o l .  Under these c o n d i t i o n s t h e i r  sub-  j e c t s were a b l e t o i n c r e a s e and decrease t h e i r h e a r t rate' and b l o o d p r e s s u r e , produce  l o c a l i z e d B l o o d f l o w i n one e a r w i t h o u t p r o d u c i n g such, a change I n  the o t h e r e a r , modify  t h e i r stomach and i n t e s t i n a l c o n t r a c t i o n s , and v a r y  12  their rate of urine secretions.  Results l i k e these,if  they can be r e p l i c a t e d ,  p r o v i d e the b a s i s f o r a r e i n t e r p r e t a t i o n o f psychosomatic v  symptoms.in humans,  i . . , operant c o n d i t i o n i n g o f autonomic responses. z  Another e a r l y l i n e o f b i o f e e d b a c k research, has i n v o l v e d attempts t o t e a c h human s u b j e c t s t o produce  o r suppress a l p h a waves (Kamlya, J.9.69.).. '  F a c i l i t a t i o n o f a l p h a was i n i t i a l l y t o u t e d as a r o y a l road t o a l t e r e d of c o n s c i o u s n e s s and o t h e r i l l - d e f i n e d  experiences.  a l p h a a c t i v i t y i s e x p e r i e n c e d o n l y as normal  I t now appears  relaxation.  as o r i g i n a l l y c l a i m e d .  that  Moreover, i t appears  that f a c i l i t a t i o n and b l o c k i n g o f a l p h a d i d not i n v o l v e operant at a l l ,  states  conditioning  A l p h a can be r e a d i l y b l o c k e d b y eye movement  and f a c i l i t a t e d by l a c k . o f eye movement.  Thus what was f i r s t  e v i d e n c e o f operant c o n d i t i o n i n g o f EEG a c t i v i t y now. appears  thought  t o be  t o b e an a r t i - ^  f a c t o f responses which were a l r e a d y i n the r e p e r t o i r e , v i z . ^ o c u l o m o t o r ac-r tivity.  Moreover, the magnitude o f EEG changes d i d not exceed the l i m i t s o f  baseline fluctuations  (Peper & M u l h o l l a n d , 1970),.  In s p i t e o f the f a c t t h a t some e a r l y r e s u l t s have not,been t i a t e d , b i o f e e d b a c k does appear  t o have c o n s i d e r a b l e c l i n i c a l  substan-  potential.  A u d i t o r y feedback o f GSR has been used i n the treatment o f agoraphobia (Lader & Wing,  1966) and g e n e r a l i z e d p h o b i a (Lader & Mathews, JL968)_,  Green and W a l t e r s  Sargent  ?  (1973) taught t h e i r s u b j e c t s t o c o n t r o l the d i f f e r e n c e i n  s k i n temperature between the f o r e h e a d and the r i g h t i n d e x f i n g e r .  T h i s study  has i m p l i c a t i o n s f o r the treatment o f m i g r a i n e headaches, s i n c e s k i n temperat u r e i s d i r e c t l y r e l a t e d t o b l o o d flow.  E l d e r , R u i z , Deabler and D i l l e n k o f f e r  (1973) taught e s s e n t i a l h y p e r t e n s i o n p a t i e n t s how t o reduce t h e i r d i a s t o l i c b l o o d p r e s s u r e by a t t e n d i n g t o a v i s u a l s i g n a l .  Rosen Q.9.73J. used a s i m i l a r  .13  s i g n a l , v i z . , a r e d l i g h t t o i n f o r m h i s s u b j e c t s when they had e x c e s s i v e p e n i l e tumescence.  T h i s s t u d y has p o t e n t i a l f o r the treatment o f p s y c h o g e n i c  impotence, f e t i s h i s m and other used feedback o f b l o o d becoming p r o f o u n d l y  sexual  disorders.  a l c o h o l l e v e l to teach  intoxicated.  (1971)  L o v i b o n d and Caddy  a l c o h o l i c s to drink without  Other d i s o r d e r s  c u r r e n t l y being  treated  with: b i o f e e d b a c k i n c l u d e e p i l e p s y , premature v e n t r i c u l a r c o n t r a c t i o n s , d i a c arhythmias, stomach a c i d i t y , and e x c e s s i v e D i C a r a , Kamiya, Shapiro & S t o y v a ,  p e r s p i r a t i o n ( M i l l e r , Barber,  1974).  Feedback of e l e c t r o m y o g r a p h i c a c t i v i t y S e l f - c o n t r o l of EMG responses can be achieved Green & W a l t e r s , tions.  1971),  car-  (EMG). i s p a r t i c u l a r l y  relatively easily  presumably because i t i n v o l v e s  U s i n g i n d w e l l i n g e l e c t r o d e s , Basamajian  (1963)  promising.  (Green,  s t r i a t e muscle  func-  has demonstrated  that  humans can make f i n e adjustments o f s i n g l e motor u n i t s i n t h e thumb muscles. Surface  EMG has been used t o t r e a t s e v e r a l d i s o r d e r s w h i c h i n v o l v e  muscle t e n s i o n .  excessive  Hardyck, P e t r i n o v i t c h and Ellsworth..'0-9.66). e l i m i n a t e d sub-^  v o c a l i z a t i o n i n students with reading  problems by p r o v i d i n g  feedback of l a r y n g e a l muscle a c t i v i t y .  Jacobs and F e l t o n  EMG feedback t o induce r e l a x a t i o n i n n e c k - i n j u r e d  them w i t h  0969).  patients.  auditory  used v i s u a l  Auditory  feed-  back of f r o n t a l i s muscle a c t i v i t y has been used t o t r e a t t e n s i o n headaches (Budzynski, S t o y v a , A d l e r  & M u l l a n e y , 1973) and c h r o n i c a n x i e t y  (Raskin, Johnson & Rondestvedt, l i p hypertonia  (1973)  N e t s e l l and C l e e l a n d  O9.73).  review o f the c u r r e n t  reduced  p a t i e n t by means o f EMG feedback and C l e e l a n d  a l s o a p p l i e d t h i s paradigm to t h e m o d i f i c a t i o n o f spasmodic  A general  0972).  i n a Parkinsonian  1973).  and insomnia  s t a t e of EMG feedback: i s p r o v i d e d  torticollis. by Basmajian  •14 Biofeedback  i s a remarkable form of b e h a v i o r  therapy  i n that subjects  o f t e n a c h i e v e s t r o n g p o s i t i v e r e s u l t s i n a s i n g l e s e s s i o n , e s p e c i a l l y when the s t r i a t e d musculature reinforcement  i s involved.  T h i s l e a r n i n g can be a c h i e v e d  without  o t h e r than knowledge of the r e s u l t s , i.e.", the feedback  C u r i o u s l y , s u b j e c t s u s u a l l y are unable over a g i v e n p h y s i o l o g i c a l response,  to v e r b a l i z e how  any more than one  itself.  they e x e r t e d  control  c o u l d d e s c r i b e how  to  move a f i n g e r . In o r d e r to apply the p r o m i s i n g b i o f e e d b a c k i t was  necessary  paradigm t o s t u t t e r i n g ,  to s e l e c t a p s y c h o p h y s i o l o g i c a l c o r r e l a t e of t h i s d i s o r d e r .  S e v e r a l such c o r r e l a t e s have been i n v e s t i g a t e d , a l t h o u g h the amount of r e s e a r c h i n t h i s a r e a i s perhaps l e s s than one might expect of the s t u t t e r i n g l i t e r a t u r e i n g e n e r a l .  from the immense volume  Severe s t u t t e r i n g i s o f t e n accom-  p a n i e d by a host of obvious b o d i l y movements, e.g.,  e y e b l i n k s , gasping,  lowing, head nodding, l i p tremors and gross movements of the l i m b s . may  a l s o be i n c r e a s e s i n palmar sweating  (Kline,  1959),  pupil dilation s e t e r EMG  abnormal EEG  activity  (Luchsinger & Arnold,  and found  swal-  There  (Brutten,--19-63)1, i n c r e a s e s i n  (Knott, C o r r e l l & Shepherd,  19651.  Williams  GSR  -19591,  Q955)_ monitored  and mas-  t h a t a c t i o n p o t e n t i a l s from t h i s s i t e were s i g n i f i c a n t l y  h i g h e r d u r i n g s t u t t e r i n g than d u r i n g f l u e n c y . r e c o r d d u r i n g s t u t t e r i n g , but  EMG  d i s a p p e a r e d when s t u t t e r e r s d e l i b e r a t e l y made  r e l a t i v e l y r e l a x e d r e p e t i t i o n s of s y l l a b l e s . faked s t u t t e r i n g , s p i k i n g was  Spikes appeared on the  produced.  Moreover, when normal  W i l l i a m s concluded  i s accompanied by e x c e s s i v e t e n s i o n i n the jaw muscles.  speakers  that s t u t t e r i n g  Sheehan and Voas  (1954)  found  failed  to r e p l i c a t e t h i s f i n d i n g but d i d f i n d more t e n s i o n i n the neck, chest  t h a t masseter t e n s i o n peaked b e f o r e s t u t t e r i n g .  Shrum (Note  4)_  15  Land jaw d u r i n g s t u t t e r i n g than /.during ...fluency. EMG appeared t o b e t h e most r e a c t i v e p h y s i o l o g i c a l parameter s t u t t e r i n g and thus was a p r o m i s i n g assumed t h a t EMG would p r o b a b l y  modality  f o r feedback, t r a i n i n g .  during I t was  d i s c r i m i n a t e s t u t t e r i n g from f l u e n c y i n a  l a r g e p r o p o r t i o n o f s u b j e c t s , although, i t was a l s o r e a l i z e d t h a t each, s t u t ^ t e r e r has h i s own p r o f i l e o f responses. A f t e r some p i l o t  r e s e a r c h , t h e masseter s i t e was r e j e c t e d i n f a v o u r  of e l e c t r o d e placement near t h e l a r y n x , f o r s e v e r a l reasons:  First,  the m a j o r i t y of s t u t t e r e r s a r e male, t h e masseter s i t e i s o f t e n with sideburn h a i r .  More s p i k i n g was r e c o r d e d  l a y r n g e a l s i t e than from t h e masseters i n p i l o t  (Schwartz, 1974).  covered  Second, movement a r t i f a c t s a r e common a t t h e masseter  s i t e but l e s s common near t h e l a r y n x .  t h e r e i s evidence  since  research.  from the  And f i n a l l y ,  t h a t t h e l a r y n x may be a l o c u s o f t h e s t u t t e r i n g Thus I decided  block  t o i n v e s t i g a t e t h e e f f e c t of f e e d i n g back  s t u t t e r e r ' s EMG a c t i v i t y from a s i t e near t h e l a r y n x . S t u t t e r i n g r e s e a r c h and b i o f e e d b a c k  research are both notable f o r  i n i t i a l l y p o s i t i v e r e s u l t s t h a t tend n o t t o be s u b s t a n t i a t e d l a t e r (Van R i p e r , 1973; B l a n c h a r d  & Young, 1973).  Green, Green and W a l t e r s  t o u t e d feedback t r a i n i n g as a cure f o r e v e r y t h i n g  from warts t o cancer.  Budzynski (1973) warned a g a i n s t such high, e x p e c t a t i o n s f u l l y c o n t r o l l e d l a b o r a t o r y s t u d i e s b e done b e f o r e tempted.  I n stepwise  and urged t h a t  care-  c l i n i c a l studies are a t ^  r e s e a r c h , demonstration o f a treatment e f f e c t  the e v a l u a t i o n o f t h a t treatment. not  (1971)  The i n t e n t o f t h e p r e s e n t  precedes  research, was  to d e v i s e a new s p e e c h t h e r a p y a t t h i s time, b u t r a t h e r t o o b s e r v e t h e  e f f e c t o f EMG feedback i n a c o n t r o l l e d l a b o r a t o r y s i t u a t i o n .  I f i t were  16  shown that biofeedback did suppress stuttering, then biofeedback would have potential as speech, therapy.  However, the development of an effective  therapeutic program was- not within the scope of the present research.  17  CHAPTER I T GENERAL METHODOLOGY Sub j ectsSevere c h r o n i c s t u t t e r i n g Is r e l a t i v e l y r a r e i n a d u l t s . dence of s t u t t e r i n g i n the g e n e r a l p o p u l a t i o n i s l e s s - than 1% F r a n s e l l a , 1968), but  even t h i s f i g u r e may  l e a d one  f i c u l t y of p r o c u r i n g s u b j e c t s f o r r e s e a r c h .  The  inci>  (Beech- &  to u n d e r e s t i m a t e the d i f T -  The p r e v a l e n c e  of s t u t t e r i n g i s  undoubtedly much lower than the i n c i d e n c e , because 1)1. the r a t e of spontaneous r e m i s s i o n In young s t u t t e r e r s i s about 80%  CSheehan & Martyn, 1970)1,  and  2) even i n a d u l t s , s t u t t e r i n g i s . o f t e n an I n t e r m i t t e n t d i s o r d e r which disappear severe  f o r days or weeks and  then r e c u r .  Probably  the p r e v a l e n c e  always been hampered by  s m a l l sample s i z e s .  The median sample s i z e i n 70 a r t i c l e s on s t u t t e r i n g p u b l i s h e d of Speech and Hearing from 1970  through 1974  Disorders was  14.  f l u e n t subjects simulate  U s h i j i m a , Note 5 ) . is  of  c h r o n i c s t u t t e r i n g i n a d u l t s i s a s m a l l f r a c t i o n of .1%', S t u t t e r i n g r e s e a r c h has  having  may  and  the J o u r n a l of Speech and Hearing  Some r e s e a r c h e r s stuttering  A more v a l i d  i n the J o u r n a l  cope w i t h  t h i s problem by  (e.g., W i l l i a m s , 1955;  Freeman &  s o l u t i o n to the problemtuof s u b j e c t  the use of s i n g l e - s u b j e c t designs  t h r e e females,  approximates the u s u a l sex r a t i o ) , p a r t i c i p a t e d i n v a r i o u s phases of s e r i e s of s t u d i e s .  T h i s sample was  very  to socio-economic s t a t u s , e t h n i c i t y , e d u c a t i o n mean age  27.3).  A l l had  s t u t t e r i n g , without  whicfu the  heterogeneous-with.regard  and  r e c e i v e d speech, therapy-or  much s u c c e s s ,  scarcity  (e.g., M a r t i n , 1968).  A t o t a l of 14 a d u l t s t u t t e r e r s (11 males and  present  Research  age  (range 17^-49-years-;,  psy-chotherapy f o r t h e i r  and were on a w a i t i n g l i s t  for rate-control  .18  therapy.  Most r e p o r t e d  c u p a t i o n a l handicap.  that t h e i r s t u t t e r i n g was  In g e n e r a l ,  these s u b j e c t s  a s e v e r e s o c i a l and seemed to be  underachievers  r e l a t i v e to t h e i r l e v e l of e d u c a t i o n  (e.g., a 3 6 - y e a r ^ o l d PhD  was  Most seemed d e f i c i e n t i n s o c i a l  employed as a sawmill l a b o r e r ) .  i n physics  F i v e s u b j e c t s p a r t i c i p a t e d i n a s i n g l e s t u d y , e i g h t i n two and  two  i n three s t u d i e s .  The  exact  assignment o f s u b j e c t s  oc-  skills.  studies,  to s t u d i e s i s  g i v e n i n Appendix A.  There were :3Q s i n g l e - s u b j e c t s t u d i e s of s t u t t e r i n g ,  fit'studies  .23 s t u d i e s of speech r a t e i n the p r e s e n t  of EMG  and  S t a t i s t i c a l a n a l y s i s was  based on the number of o b s e r v a t i o n s  r a t h e r than on the number of Dependent  research.  per  subject  subjects.  Variables  Stuttering.  Is s t u t t e r i n g i n the ear of the b e h o l d e r , o r i s i t s u f -  f i c i e n t l y d i s t i n c t from f l u e n c y t h a t i t can be d e f i n e d and measured r e l i a b l y ? In a lengthy  review of t h i s i s s u e , Van  Riper  (1971) argued:  J u s t because s t u t t e r i n g i s o c c a s i o n a l l y d i f f i c u l t to d i s t i n g u i s h from normal d i s f l u e n c y i n i t s e a r l y or minor forms (and we must remember t h a t s t u t t e r e r s a l s o have normal d i s f l u e n c i e s ) we need not deny t h a t s t u t t e r i n g e x i s t s as an ; e n t i t y . (p. 15) Van  Riper  concluded by d e f i n i n g s t u t t e r i n g as "a word improperly  i n time and  the speaker's r e a c t i o n s t h e r e t o "  While Van ently s p e c i f i c .  Riper's  (p.  patterned  15).  d e f i n i t i o n i s c e r t a i n l y c o r r e c t , i t i s not  For the purpose of the p r e s e n t  research,  stuttering  sufficiwas  d e f i n e d as i n c l u d i n g : 1. ,:t  Sound or s y l l a b l e r e p e t i t i o n s .  These comprise the l a r g e s t  r p f .^stutters foremost j sub jieets^ r-"Kuhl-kun^Kuh^^ -• o n e . s t u t t e r .  proportion counted  as  ,19  2.  Abnormal p r o l o n g a t i o n s of sounds. about one the  3.  ''Abnormal" would Se. i n the  o r d e r of  second at the b e g i n n i n g of a word, o r l e s s than one  prolongation occurred within  Abnormal h e s i t a t i o n s . noises c a l l e d "vocal  a word.  These are  accompanied by- the  f r y " (Moser, 1942), or By  e x c e s s i v e t e n s i o n and  second i f  respiratory  strange h i s s i n g  o t h e r i n d i c a t i o n s ' of  a b n o r m a l i t i e s , and  g u i s h a b l e from normal h e s i t a t i o n s  a r e thus- d i s t i n -  t h a t r e s u l t from not  knowing what to  say. Thompson (1971) used a s i m i l a r d e f i n i t i o n of s t u t t e r i n g p r o l o n g a t i o n s , part-word r e p e t i t i o n s , undue pauses") and ability  c o e f f i c i e n t of _r = .87  when two  r a t e r s who  t h i s d e f i n i t i o n s c o r e d tapes f o r s t u t t e r i n g . t a p e s , r e p o r t e d an  Martin  i n t e r - r a t e r r e l i a b i l i t y of _r =.98.  (1973) used u n t r a i n e d s t u d e n t s to count s t u t t e r s videotapes, without g i v i n g ponse c a t e g o r i e s . reliability,  them any  (1968), a l s o  Flye  relito  Martin  other d i s f l u e n c i e s  concluded t h a t  res-  stuttering judges. percent  T h i s measure i s s a t i s f a c t o r y i f a l l s u b j e c t s use i t i s c l e a r that  from  inter^rater  (1968) measured s t u t t e r i n g i n terms of  same words (e.g. , i n a r e a d i n g t a s k ) but  use  scoring  MacDonald and  r e l i a b l e response c l a s s even to u n t r a i n e d  A z r i n , Jones and  i f two  the  subjects  same p e r c e n t a g e sco<re tTth\eTS;ub#ect<^  words w i l l  ?  a c t u a l l y be  more f l u e n t .  advocate p e r c e n t s y l l a b l e s s t u t t e r e d . of the  been t r a i n e d  N e v e r t h e l e s s , t h e y found h i g h i n t r a - and  i s an unambiguous and  have the  and  achieved a  a p r i o r i d e f i n i t i o n s of. t h e s e two  i n terms of p e r c e n t agreement, and  of words s t u t t e r e d .  had  ("hesitations,  For  t h i s r e a s o n James and  A l t h o u g h t h i s i s not  d u r a t i o n of e a c h s t u t t e r , judgements of  the  Ingham (1974)  a d i r e c t measure  s e v e r i t y of  stuttering  20  are h i g h l y c o r r e l a t e d with: f r e q u e n c y - o f s t u t t e r i n g and with, speech, r a t e (Young, 1961;  Sander, 1961),  frequency, and  P e r c e n t s y l l a b l e s s t u t t e r e d i s a measure of  c o n t r o l s f o r d i f f e r e n c e s i n speech r a t e , e.g,,  j a c e n t one-minute segments of speech.  between  ad-  A c c o r d i n g t o Ingham and Andrews (1973a).:  ... changes i n the s e v e r i t y of the d i s o r d e r may be s u i t a b l y a s s e s s e d from frequency counts of moments of s t u t t e r i n g and p o s s i b l y from measures of the r a t e of speaking. These two i n d i c e s can a l s o Be measured "on l i n e " w i t h h i g h r e l i a b i l i t y - (Ingham and Andrews, 1971b), thereby p r o v i d i n g u s e f u l i n d i c e s of a subject's: speech b e h a v i o r . (p. 407). EMG  spiking.  S i n c e the a u d i t o r y  was  a c t i v a t e d By  pen  d e f l e c t i o n s i n the EMG  appropriate  feedback- tone used i n t h i s  the same e l e c t r i c a l a c t i v i t y - w h i c h produced s p i k e s  measure of  record,  the  a count of EMG  s p i k e s was  during  was  a c t i v a t e d was  on  panied by  Depending on  the s u b j e c t ' s  deflections representing  representing  up  (but not  to .50 mV,  the  subject  the s e n s i t i v i t y l e v e l at w h i c h the  thee o t h e r hand, were o f t e n  conspicuous s p i k e s  at which  determined i n d i v i d u a l l y f o r each  (Appendix C).  a c t i v i t y and  S t u t t e r s , on  an  r  s e t , f l u e n t speech produced pen  .20 mV.  other  ef fec't'f of c f eedbaekd'trainlng''on E M G ' a c t i v i t y .  the b a s e l i n e p e r i o d  p a t t e r n of EMG  and  chosen as  Because of d i f f e r e n c e s i n b a s a l l e v e l s , the t h r e s h o l d feedback tone was  research-  own  polygraph  not more than  i n e v i t a b l y ) accom-  Signals  attributable  to yawning, swallowing and movement a r t i f a c t s were r e a d i l y d i s t i n g u i s h a b l e from s t u t t e r s p i k e s  and were hofctcounted,  S p i k e s , l i k e s t u t t e r s , were expressed r e l a t i v e to speech, r a t e . the degree of s p i k i n g was for  each minute of  expressed as the number of s p i k e s  per 100  Thus  syllables  speech.  Speech r a t e .  When normal speakers are r e q u i r e d  to speak abnormally  21  f a s t , ' they become d i s f l u e n t .  Stutterers  and  s l o w i n g down (Van  can become more f l u e n t by  t r a d e - o f f between r a t e and and may  be  involved  Riper,  1 9 7 1 , 19.73).  as w e l l .  In o r d e r to determine t h a t  independent of r a t e c o n t r o l , i t was  necessary  monitor speech r a t e , which i s u s u a l l y expressed i n s y l l a b l e s per CSPM).  a retarded  speech r a t e , this, would not  minute  necessarily  from i t s e f f e c t i v e n e s s . I t i s important to note t h a t SPM  l a t o r y r a t e , s i n c e i t does not speech.  to  I t s h o u l d be noted t h a t even i f a b i o f e e d b a c k e f f e c t were accompanied  by or even produced by detract  This  f l u e n c y is- the essence of r a t e - c o n t r o l therapy  i n other therapies  a b i o f e e d b a c k e f f e c t was  tend to speak, f a s t e r than normals,  It i s a conceivable  c r e a s e i n SPM  i s only  an e s t i m a t e of t r u e  articu-  take i n t o account pauses between moments of  paradox, a l t h o u g h not  c o u l d be produced by  a retarded  a l i k e l y one,  t h a t an i n -  a r t i c u l a t o r y r a t e i f slower  speech were accompanied by a decrease i n time—consuming pauses, h e s i t a t i o n s and  repetitions.  than o f f s e t by  That i s , s y l l a b l e p r o l o n g a t i o n  a decrease i n the  c o u l d o c c a s i o n a l l y be more  time o c c u p i e d by s t u t t e r s - .  of a r t i c u l a t o r y r a t e would i n c l u d e s p e e c h o n l y , and In p r a c t i c e , i t would be t h a t SPM  so d i f f i c u l t  A t r u e measure  e l i m i n a t e a l l pauses.  to c a l c u l a t e a t r u e a r t i c u l a t o r y r a t e  i s v i r t u a l l y always used i n s t e a d .  SPM  i s an adequate e s t i m a t e of  a r t i c u l a t o r y r a t e f o r our purposes, and  the p o s s i b i l i t y - : t h a t i t c o u l d  occa-  s i o n a l l y be m i s l e a d i n g  the p r o b a b i l i t y - t h a t i t would  not  be m i s l e a d i n g  i s outweighed by  i n several replications:.  Observer Agreement on the Dependent One  s u b j e c t was  t h i s d i s s e r t a t i o n , and  Variables  s e l e c t e d a t random from eacIL of t h e f i y e s t u d i e s  a lO^minute sample of speech.was- randomly s e l e c t e d '  in  22  from each_.of these s u b j e c t s .  S t u t t e r i n g and  from tape r e c o r d i n g s ,  s p i k e s were counted from the  polygraph, r e c o r d s .  and  EMG  These d a t a were t a l l i e d  p r a c t i c i n g speech t h e r a p i s t who S t u t t e r i n g was chapter. pen  defined  An EMG  was  corresponding  on hand c o u n t e r s by m y s e l f and  a c c o r d i n g to the d e f i n i t i o n d e s c r i b e d :  s p i k e was  defined  a  unaware of the e x p e r i m e n t a l hypotheses. earlier in this  as a sharp downward d e f l e c t i o n ' of the  t r a c e , w h i c h exceeded a c e r t a i n c u t o f f  S y l l a b l e s t h a t were repeated during Before scoring  s p e e c h r a t e d a t a were c a l c u l a t e d  ( v i z . , the feedback  EMG  threshold)..  s t u t t e r i n g were o n l y counted once.  the d a t a , both; r a t e r s p r a c t i c e d on an a d d i t i o n a l speech, sample,  i n o r d e r to ensure t h a t the d e f i n i t i o n s of the dependent v a r i a b l e s were  fully  understood. I n t e r - r a t e r r e l i a b i l i t y d a t a are rater r e l i a b i l i t i e s and  of  .89,  .93,  and  Fisher's  l i t y c o e f f i c i e n t s were s i g n i f i c a n t at the However, a h i g h degree of r e l i a b i l i t y  between r a t e r s was  does not  c a l c u l a t e d a c c o r d i n g to the  U s i n g t h i s more c o n s e r v a t i v e  reliabi-  r_C8)_= , 77)_.  ( c r i t i c a l v a l u e of  n e c e s s a r i l y imply agreement performed,  Agreement  formula  ——-—  measure, mean agreements of 80%,  A l e s s e r degree of agreement was than f o r s p e e c h r a t e .  All  x  , 100 n n  of agreements & disagreements  were found f o r s t u t t e r i n g , s p i k i n g , and  spiking  level  no. of agreements • •—•=-• ——: ;— no.  Bl.  .01  Z-^transformation.  so an a d d i t i o n a l a n a l y s i s was  ^ % agreement = a,  Mean i n t e r -  ,9.5 were a c h i e v e d f o r s t u t t e r i n g , s p i k i n g ,  speech r a t e , r e s p e c t i v e l y , u s i n g  on s p e c i f i c i n s t a n c e s ,  g i v e n i n Appendix B.,  This  9.2%  speech rate, r e s p e c t i v e l y  and  97%  (Appendix  c o n s i s t e n t l y found f o r s t u t t e r i n g  Is i n p a r t due  to the f a c t t h a t  and  the  former v a r i a b l e s were expressed r e l a t i v e to a denominator of 100. s y l l a b l e s ,  23  and thus i n c l u d e d the e r r o r v a r i a n c e of the speech r a t e measure. agreement was  Less  found f o r s t u t t e r i n g than f o r s p i k i n g , p r o b a b l y because t h e .  low base r a t e of the former o b s e r v e r agreement due s t u t t e r i n g and  (e.g., 2%-20% s y l l a b l e s s t u t t e r e d ) minimized  t o chance a l o n e .  Moreover, the d i s t i n c t i o n between  f l u e n c y i s sometimes a s u b t l e one..  The h i g h degree of agreement between the.two r a t e r s t h a t the d a t a are not s e r i o u s l y contaminated  by random e r r o r and e x p e r i -  menter b i a s , i . e . , nonrandom e r r o r which i s confounded w i t h the effect.  T h i s tends  indicates,  treatment  to i n s p i r e c o n f i d e n c e i n the r e s u l t s of the .studies  that follow. Design  Design Time s e r i e s methodology has been used  mental a n a l y s i s of b e h a v i o r , and r e c e n t l y has  f o r decades i n the e x p e r i -  gained i n c r e a s i n g  i n o t h e r areas of b e h a v i o r a l r e s e a r c h CSidman, 1960; 1973).  acceptance  Chassan,.1967; L e i t e n b e r g ,  Campbell and S t a n l e y (1970) d e f i n e a t i m e - s e r i e s d e s i g n as 0  .  0  0  1  0.  0  0 .  where each 0 r e p r e s e n t s a r e g u l a r o b s e r v a t i o n of the dependent v a r i a b l e I r e p r e s e n t s the e x p e r i m e n t a l i n t e r v e n t i o n .  A c t u a l l y the b a s i c d e s i g n  and used  i n the p r e s e n t s e r i e s of s t u d i e s i s b e t t e r i l l u s t r a t e d as0  0  0  10  because the i n t e r v e n t i o n continues-throughout  10 the treatment ;  LO period.  A sum-  mary of designs used i n .the p r e s e n t r e s e a r c h i s g i v e n i n T a b l e I . T i m e - s e r i e s designs appear to-be p a r t i c u l a r l y a p p r o p r i a t e i n psychophysiology  (Johnson  & L u b i n , 1972)  and s t u t t e r i n g r e s e a r c h ( M a r t i n , 1968)..  24  Table 1 Designs Used i n t h e P r e s e n t S e r i e s o f S t u d i e s  Study 1  2  Schematic  °1  Ca). Cb)  °i 2 - - - ° i 5 2°ie i o I O ...I O 0  1  2  0  Ca)  5 (pilot)  °20  16  o ..o ir  30  , , , 0  2 7 3°28 3°29**' 3°36 °37 1  I  1  Wn  —  h^o  °1 • 2 " ' - 1 5 . - 4 i 6 . 4 1 7 . v 4 3 0 0  V l  0  I  0  O  r  0  r  I , = feedback w i t h o u t 4 . instructions  .  0  I  0  0  I  4 2 - - - 4 ° 1 5 °16 ° 1 7 - " ° 3 0  °1 2 " - ° 9  I  /  , , , 0  b  T  e  a  k  h 10 3 ll''' 3 18  /  0  T  0  1  0  2 7 5°28 5°29"'" 5°36 3°37 I  I  I  r  3°38'* 3°'45 ,,I  °1 2 - - - ° 1 5 3 16 0  T  0  I  3°17--- 3 30 I  0  / b r e a k /  °31 ° 3 2 - - ° 4 5 5 4 6 5 ° 4 7 ' ' ' 5 ° 6 0 E  Cb).  1^ = feedback  38--'°45  °19 2 0  Ca)  o  1 5  °i °2---°i5 V i e  Cb).  5  2  . . . Og /break/ I^O^Q ^ ^ l l ' ' ' ^3°18 8l9  4  2  T.2 = me t r onome paced speech  h°ir"h°3o-  T  3 (pilot)  3  T ^ = r a t e control; therapy  l °2  T  2  Intervention  Q  °1 2 " - ° 1 5 5 ° 1 6 0  °31 ° 3 2 "  X  , 0  I  r  Vn-'-VsO  / b r e a k /  4 5 3°46 3°47*' " ^ ^ O I  I  I ^ = feedback 1,. = f a l s e feedback  25  A t i m e ^ s e r i e s a n a l y s i s i s an.economical and e f f i c i e n t way t o b e g i n ching a new a r e a , s u c h as i n the p r e s e n t with_ a s i n g l e s u b j e c t . evitable.  resear-  i n s t a n c e , because i t can be used  Where s u b j e c t s a r e r a r e , t h i s method i s almost i n -  The power of a t i m e — s e r i e s a n a l y s i s i s a f u n c t i o n of the number  of data p o i n t s r a t h e r than the number of s u b j e c t s . t h i s approach i s i t s f l e x i b i l i t y . be used t o determine the course  T n stepwise  Another advantage of  research., e a r l y r e s u l t s can  of subsequent s t u d i e s without  seriously  d e p l e t i n g a s m a l l sample of r a r e s u b j e c t s . ' ( T h i s i s i l l u s t r a t e d b y the way i n which S t u d i e s 3 and 5 d i f f e r from t h e i r p i l o t  studies.1  A r e l a t e d advantage o f s i n g l e ^ s u b j e c t designs r e p l i c a t i o n w i t h a minimum of s u b j e c t s .  i s t h a t they  permit  I n t e r - s u b j e c t r e p l i c a t i o n may be  more v a l u a b l e than i n t e r - g r o u p r e p l i c a t i o n where t h e r e l i a b i l i t y and general i t y o f a treatment e f f e c t a r e o f i n t e r e s t .  I n group d e s i g n s , . r e p l i c a t i o n •  of changes i n c e n t r a l tendency r e q u i r e s r e l a t i v e l y l a r g e samples, and may obscure w i t h i n - g r o u p  d i f f e r e n c e s - (Sidman, I 9 6 0 ) .  Within^group d i f f e r e n c e s a r e p a r t i c u l a r l y common i n d s t u t t e r i n g (yan.Riper, 1971) and p s y c h o p h y s i o l o g y who s t u t t e r e d on 77% o f h i s s y l l a b l e s .  (Lacey, 1967). Consider  I once.had a c l i e n t  t h e e f f e c t of grouping  t h i s s u b j e c t w i t h f i v e o t h e r s who each s t u t t e r e d s e v e r e l y on 5% o f t h e i r syllables:  a strong biofeedback  e f f e c t on the l a t t e r f i v e s u b j e c t s  be obscured p a r t i a l l y or completely and v i c e - v e r s a .  could  by a weak e f f e c t on t h e former s u b j e c t ,  In exploratory i n v e s t i g a t i o n s l i k e the present  research,  i n d i v i d u a l d i f f e r e n c e s need t o be s c r u t i n i z e d c l o s e l y r a t h e r than a s c r i b e d to e r r o r v a r i a n c e . h i s own c o n t r o l .  I t makes; a g r e a t d e a l o f sense to u s e e a c L s u b j e c t as An u n t r e a t e d  c o n t r o l group i s an u n a t t a i n a b l e l u x u r y where  26  s u b j e c t s are s c a r c e , and  seems p a r t i c u l a r l y I n a p p r o p r i a t e i n the  present  r e s e a r c h where a l l s u b j e c t s have been s t u t t e r i n g severely-, f o r 15-^45 years.. (However, i n Study 5 each, s u b j e c t p a r t i c i p a t e d i n a pseudotreatment c o n t r o l c o n d i t i o n as. w e l l as s e r v i n g as-hisr. own  control.)_  Another unique advantage of the time-^series d e s i g n i s i t s longitu-r dinal perspective.  Tlme^serles  research, i n v o l v e s continuous  r a t h e r than o n l y p r e - and post-^treatment as .well as outcome r e s e a r c h .  The  measurement  measures, thus, p e r m i t t i n g  process  time s e r i e s i l l u s t r a t e s the immediacy-and  d u r a t i o n of treatment effects:, p l u s changes i n treatment e f f e c t s oyer time. T h i s k i n d of i n f o r m a t i o n i s c l e a r l y of g r e a t i n t e r e s t i n b i o f e e d b a c k therapy  research. Of course,  as w e l l .  and  the t i m e - s e r i e s d e s i g n has  c e r t a i n p o t e n t i a l disadvantages')  One.of these i s h i s t o r i c a l i n v a l i d i t y , where a v a r i a b l e , o t h e r  the treatment may  account f o r any  effect  Cor  l a c k of e f f e c t ) ! t h a t  a f t e r the p o i n t of i n t e r v e n t i o n (Campbell & S t a n l e y , .19.70.)..  than  occurs  H i s t o r i c a l inT-  v a l i d i t y i s a major problem i n ex p o s t f a c t o a n a l y s e s , e.g. , i n v e s t i g a t i o n s of a r c h i v a l data.  In the p r e s e n t  planned time s e r i e s a n a l y s e s  relevant.problem,  because the i n t e r v a l between pretreatment  ment o b s e r v a t i o n s  i s o n l y 60 seconds.  against h i s t o r i c a l  i t i s not  a  and p o s t t r e a t r -  R e p l i c a t i o n i s a recognized  defense  invalidity.  Another p o t e n t i a l problem i s ; r e g r e s s i o n to the mean.(Glass, K i l l s o n , & Gottman, 1972).  T h i s i s . of major concern i n t r u e c l i n i c a l  s u b j e c t s come f o r - t r e a t m e n t  during a personal crisis..  Any-spontaneous change  back toward b a s e l i n e would appear to be an e f f e c t .of therapy-. research a regression a r t i f a c t  research.wh.ere  In  stuttering  c o u l d occur i f the treatment c o i n c i d e d w i t h .  27  a l a r g e spontaneous  f l u c t u a t i o n In s t u t t e r i n g  i n either  direction.  A subset-  quent decrease i n v a r i a n c e would tend t o : l o o k s i g n i f i c a n t , . e y e n i n the ah-?sence of a change i n l e v e l o r s l o p e of tlie time series;.trolled statistically-  This; c o u l d be c o n ^  through the use of an i n t e g r a t e d moying a y e r a g e ,  that no extreme v a l u e o c c u r r e d  so  at the end of the b a s e l i n e p e r i o d . - Replica-r-  t i o n would be an a d d i t i o n a l p r e c a u t i o n ; Where two o r more t r e a t m e n t s a r e a p p l i e d d u r i n g a s i n g l e experiment, Stanley,  1970).  appropriate (e.g.,  t h e r e i s a r i s k of m u l t i p l e treatment i n t e r f e r e n c e  time-series  (Campbell &  T h i s p o s s i b i l i t y can be c o n t r o l l e d by c o u n t e r b a l a n c i n g , by  statistical  analysis,  and b y a r e s t p e r i o d between  treatments  Study 5 ) . i  U n t i l recently, of s t a t i s t i c a l  the t i m e - s e r i e s  analysis.  d e s i g n has been used w i t h o u t  Few would argue t h a t the e x p e r i m e n t a l  benefit  a n a l y s i s of  b e h a v i o r has been h e l d back because of a d i s r e g a r d o f s t a t i s t i c s ; neverthe-r less,  mere v i s u a l i n s p e c t i o n of the d a t a can markedly- i n c r e a s e  inappropriate inferences  (Gottman,  Chassan (1967) suggested p r e - and p o s t - i n t e r v e n t i o n I t i s not d i f f i c u l t leading,  adaptation  that errors  that a standard  t - t e s t c o u l d be a p p l i e d to  Others have used a n a l y s i s  of v a r i a n c e .  where such a n a l y s e s  effect  might be misp-  would tend to produce a s p u r i o u s l y  d i f f e r e n c e i n p r e - and p o s t - i n t e r v e n t i o n means. . Moreover,  t e r i n g d a t a (and most t i m e - s e r i e s thus, v i o l a t e  1973).  t o imagine i n s t a n c e s  e . g . , a strong  significant  data.  the r i s k of  a basic  data,  f o r that m a t t e r l  assumption of._t_-tests a n d . a n a l y s i s  associated  w i t h observations  time s e r i e s i s - b a s i c a l l y an e x t e n s i o n  stut-  a r e dependent and of v a r i a n c e , v i z . ,  must be i n d e p e n d e n t .  of the p r e t e s t - r - p o s t t e s t  A l t h o u g h the design,  it  28  r a i s e s unique s t a t i s t i c a l Fortunately, valid  statistical  problems.  t e c h n i q u e s - h a v e r e c e n t l y been developed which p e r m i t  i n f e r e n c e from the time-^series- data  Gottman, 1972). . The  analysis-used  program developed by Maguire and average model w i t h  i n the p r e s e n t  G l a s s . Q.967)_.  i n the b a s e l i n e data.  mate of the l e v e l of the time s e r i e s has of freedom when d i v i d e d by observations at  its* standard  i n the,time s e r i e s .  An  the pre^- and p o s t — i n - r  The  T h i s model  a t d i s t r i b u t i o n w i t h N^3  abrupt s h i f t  degrees  i n the l e v e l of the s e r i e s A delayed  treat-  r e l a t i v e l y u n l i k e l y to r e a c h s t a t i s t i c a l s i g n i f i c a n c e .  changes i n the d r a f t and v a r i a n c e  not  f o r t u n a t e l y they are of l i t t l e i n t e r e s t h e r e .  but  esti-  e r r o r , where N e q u a l s the number of  Abrupt o r delayed analyzed,  can  least^squares  the p o i n t of i n t e r v e n t i o n i m p l i e s a treatment e f f e c t .  ment e f f e c t would be  a  I t uses an i n t e g r a t e d moving  t e s t f o r s i g n i f i c a n c e between them.  accomodate some i n s t a b i l i t y  &  r e s e a r c h ^ i s Eased on  d e t e r m i n i s t i c d r i f t to t r a n s f o r m  t e r v e n t i o n data and  (Glass, Willson  multivariate statistics  of the time s e r i e s are  f o r time s e r i e s a n a l y s i s have not  each dependent v a r i a b l e must be  analyzed  separately.  Since  y e t been p e r f e c t e d ,  29  CHAPTER I I I STUTTERING AND LARYNGEAL HYPERTENSION L a r y n g e a l Involvement i n S t u t t e r i n g As mentioned p r e v i o u s l y ,  a p h y s i o l o g i c a l c o r r e l a t e of s t u t t e r i n g i s  a n e c e s s a r y p r e r e q u i s i t e to a b i o f e e d b a c k treatment.  L a r y n g e a l EMG was  s e l e c t e d because o f accumulating evidence of. l a r y n g e a l  involvement i n the  stuttering block. I t has long been known t h a t s t u t t e r i n g i s accompanied by i n r e s p i r a t i o n (VantiRiper, necessary condition opinion  197.1).  Since a i r - f l o w (usually exhalation) i s a  f o r p h o n a t i o n , some>speech p a t h o l o g i s t s  (1971), such a b l o c k c o u l d  the airway.  A c c o r d i n g t o Van R i p e r  occur a t one o r more o f f o u r l o c i :  a t . t h e f r o n t o r r e a r o f the tongue, o r a t the l a r y n x .  at the l i p s ,  Van R i p e r suggested  the s i t e o f the s t u t t e r i n g b l o c k need not be the same f o r a l l s t u t t e r e r s . S u r p r i s i n g l y , the r o l e o f the l a r y n x  scrutiny u n t i l recently.  i n s t u t t e r i n g has l a r g e l y escaped  L a r y n g e a l involvement i n airway b l o c k a g e i s c e r -  t a i n l y p l a u s i b l e , f o r the g l o t t i s i s the s m a l l e s t - a p e r t u r e Freeman and U s h i j i m a (Note/S) used depth e l e c t r o d e s from f o u r i n t r i n s i c l a r y n g e a l muscles d u r i n g and  a r e of the  t h a t what the . s t u t t e r e r c a l l s a " b l o c k " i s indeed a p h y s i o l o g i c a l  b l o c k , i . e . , a temporary occlusionviof  that  abnormalities  a normal speaker who faked s t u t t e r i n g .  along the airway.  t o take EMG  recordings  the speech, o f a s i n g l e s t u t t e r e r I t was found t h a t  f l u e n t speech,  was accompanied by a p r e c i s e r e c i p r o c a l i n t e g r a t i o n of adductor and abductor muscles, but t h a t t h i s r e c i p r o c i t y was n o t p r e s e n t d u r i n g  stuttered  In o t h e r words, s t u t t e r i n g i s l i t e r a l l y - a d i s i n t e g r a t i o n o f speech." r e s e a r c h e r s a l s o found g e n e r a l l y Higher l e v e l s o f l a r y n g e a l - m u s c l e  speech. These activity  30  during  s t u t t e r i n g than d u r i n g  f l u e n c y , presumably because s t u t t e r i n g i n v o l v e s  simultaneous a n t a g o n s i t i c a d d u c t o r - a b d u c t o r Schwartz (1974) p r o v i d e d  activity.  the d e f i n i t i v e statement of  t h a t s t u t t e r i n g i s a d i s o r d e r of l a r y n g e a l h y p e r t e n s i o n .  the.position  During normal  r e s p i r a t i o n the v o c a l f o l d s abduct s l i g h t l y w i t h i n h a l a t i o n and with  exhalation.  This abduction  and  adduction  adduct  i s ~ presumably due  to  the  c o n t r a c t i o n o r i n h i b i t i o n of the p o s t e r i o r c r i c o a r y t e n o i d (PCA)_, one strongest PCA  i n t r i n s i c muscles of the l a r y n x .  would p r o b a b l y  Uninhibited  p r e v e n t p h o n a t i o n by b l o c k i n g  or c o n s t r i c t i n g the  d u r i n g p s y c h o l o g i c a l s t r e s s . ' S t r e s s produces a b n o r m a l i t i e s  p i r a t i o n and  the PCA  d u c t i y e response.  tongue and  the the.  airway.  i s dis-r of r e s r  inappropriate  ab-  An i n d i v i d u a l c o u l d attempt to overcome t h i s response i n  s e v e r a l ways, e.g., lips,  responds to these with, a v i g o r o u s ,  of  c o n t r a c t i o n of  Schwartz argued t h a t the normal s u p r a m e d u l l a r y c o n t r o l of the PCA rupted  slightly  forceful  jaw.  contraction'of other  Unfortunately,  t h e s e responses produce a i r  which o n l y p e r p e t u a t e the e x c i t a t i o n . o f the PCA. i n d i v i d u a l does manage to speak.  The  to r e i n f o r c e the m a l a d a p t i v e s t r u g g l e  l a r y n g e a l muscles o r of  the  pressures  E v e n t u a l l y , however,  the  consequent r e d u c t i o n i n s t r e s s i s thought Fehaviors.  W h i l e the above hypotheses about l a r y n g e a l involvement i n s t u t t e r i n g are p l a u s i b l e , they are based on i n s u f f i c i e t n t d a t a at t h i s research  time.  i s r e q u i r e d to demonstrate t h a t l a r y n g e a l h y p e r t e n s i o n  i n t i m a t e l y r e l a t e d to the s t u t t e r i n g b l o c k . that s t u t t e r s were o f t e n accompanied by EMG f l u e n c y was  During p i l o t  found by W i l l i a m s  (1955), who  placed  e l e c t r o d e s on  is  research  s p i k i n g from the  accompanied by an absence of s p i k i n g .  Further indeed I noted  l a r y n x , whereas  S i m i l a r r e s u l t s were the m a s s e t e r s .  I  origi-  31  nally. attempted to investigate the temporal relationship between spikes and stutters by recording laryngeal EMG on one polygraph channel, and using the adjacent channel to record speech.  Any noise at the approximate frequency  of human speech caused pen deflection away from a silent baseline.  Unfor-  tunately, sounds other than human speech caused artifacts' which were not readily distinguishable from speech. Moreover, stuttering was often characterized by silent hesitations and thus was not always accompanied by deflections.  pen  In short, the speech, channel did not permit discrimination  between fluency and stuttering, or even between speech and silence.  As an  alternative a tape recorder was- synchronised with, the EMG record so that the temporal relationship between stuttering and spiking could.be investigated with an accuracy of a fraction of a second. The results were striking. T found that often hesitations, repetitions, and prolongations which, were counted as stutters were not accompanied by spiking, but most pen deflections not attributable to artifacts (e.g., yawning, swallowing) did occur during moments of stuttering.  Depending on  i t s severity, a single stutter may be accompanied by no spiking, by a single spike, or by more than 100 spikes.  Some i l l u s t r a t i o n s of the stutter-spiking  relationship are given i n Figure 1. These p i l o t data were highly encouraging.  Subsequently, 'two related  studies were performed to explore the relationship between stuttering and spiking.  Study 1 Stuttering can be reduced dramatically by rate control therapy, at  EMG  32Figure 1. Sample EMG recordings, a) Don  ;  , : .' j i  Baseline, Study 3  ;  i  .5 SEG. !  i  i  1  •  rr A ... !  ! \ \  1  • • ' \i  "G-G-GOAL"  l  ' \  ^SILENCE ^  L  '1i \ i•  ;  T'" o"Vv~^~~T' '^-y  i  •  \ ^ ' . > ' .  '. * .  1  1  y \  V" SWALLOW 6  '• :  ;  \ " 1" |  • \ \ \  A .\  ' ,. \ 1  \  !  \  b) Don Biofeedback condition. Studyj3  ^  FEEDBACK THRESHOLD !.Q5 mV  ' • - \ \ \\\  SWALLOW"'.  FLUENT SPEECH  c) Ruth, I FeedbackTwi,thout-ihstru ctiLons (condition; Study'4 :  i ii •• •-i • 1  i!  FEEDBACK THRESHOLD . .025 mV  :  ,1; •  "M4M0THER"  SILENCE  i \\ "F-FUTILE"  d) Rufh ,' . . ' ; ; ; ; ; • •' ,  : J  /•  Metronome condition, Study 2  I  1 FLUENT SPEECH ,  v  33  l e a s t t e m p o r a r i l y .(Perkins, Note i>l. I t was and  s p i k i n g are' indeed  be accompanied by  predicted that i f s t u t t e r i n g  i n t i m a t e l y r e l a t e d , suppression  of s t u t t e r i n g would  a similar reduction i n spiking.  Method Three s u b j e c t s p a r t i c i p a t e d i n t h i s study. course  of s p e e c h therapy  hour therapy The  from myself and  four other.therapists.  Five  two-  s e s s i o n s were h e l d d a i l y f o r t h r e e weeks ( e x c l u d i n g week-ends).  therapy.emphasized r a t e c o n t r o l , which was  r a t e and p e r c e n t  s y l l a b l e s t u t t e r e d and  s u b j e c t at the end of every  e.g.,  one  and  speech  Increases  d o l l a r f o r every 10%  the  in  reduction  S t u t t e r s were punished by means of  T r a n s f e r and maintenance of f l u e n c y were emphasized  d u r i n g the t h i r d week of treatment, e.g., out of the c l i n i c  by c a l c u l a t i n g  f e e d i n g t h i s i n f o r m a t i o n back to  i n t t h e percentage of s y l l a b l e s s t u t t e r e d . a l o u d , a v e r s i v e tone.  achieved  f i v e minute p e r i o d of speech.  f l u e n c y were rewarded m o n e t a r i l y ,  own  Each r e c e i v e d an i n t e n s i v e  the s u b j e c t s were r e q u i r e d to move  engage s t r a n g e r s i n c o n v e r s a t i o n w h i l e r e c o r d i n g  d i s f l u e n c i e s c o v e r t l y on g o l f c o u n t e r s .  No  attempt was  made to  their  induce  the s u b j e c t s to r e l a x t h e i r speech muscles or any o t h e r muscles. Measures of d i s f l u e n c y and l a r y n g e a l t e n s i o n were taken at the g i n n i n g and attached  end of the three-week treatment.  s u r f a c e EMG  2 cm b i l a t e r a l to the body ^ejafcey-jL^e^ approximately  the t h y r o i d prominence. The  Two  A ground e l e c t r o d e was  attached  e l e c t r o d e s were 1 cm  data on a Beckman R411  movement d i d not  appear to produce EMG  polygraph  above  to the l e f t w r i s t .  s u b j e c t s s a t i n a padded armchair i n a sound-proof room, w h i l e I  i n t e g r a t e d EMG  be-  i n an a d j a c e n t  room.  recorded Head  artifacts.  Cards from the Thematic A p p e r c e p t i o n  Test  (TAT) were used as  stimuli  34  Table 2 R e d u c t i o n i n S t u t t e r i n g as a F u n c t i o n o f Rate C o n t r o l Therapy-  Subject  Percent s y l l a b l e s s t u t t e r e d Pre  Post  i-ramc Frank  12.04  0  Rick  14.65  3.12  John  17.91  2.80  Table 3 R e d u c t i o n i n EMS S p i k i n g as a F u n c t i o n o f Rate C o n t r o l Therapy  Subject  EMG s p i k e s p e r 100 s y l l a b l e s Pre  Post  Frank  50.07  3.56  Rick  71.18  5.19  John  131.54 .  0.97  35  f o r speech..  The subject's, t a s k was: to speak f o r t h r e e minutes about  s i t u a t i o n p o r t r a y e d on each c a r d . s e l e c t e d cards.  E a c h s u b j e c t was- exposed to f i v e randomly-^  The same procedure was  week treatment , except t h a t d i f f e r e n t to i n t e r p r e t the TAT normal speakers  the  r e p e a t e d a t t h e end of the t h r e e -  cards were used.  No  attempt was  made  responses, as- these&do not d i f f e r e n t i a t e s t u t t e r e r s  from  CSheehan, 197.0.).',  Results S t u t t e r i n g and s p i k i n g d a t a are p r e s e n t e d i n T a b l e s 2 and 3 r e s p e c tively.  T i m e - s e r i e s a n a l y s i s was  not used i n t h i s study because the t h r e e -  week i n t e r v a l between the p r e - and post^-treatment measures a l l o w e d f o r h i s t o r i c a l confounding. used, y i e l d i n g £(2). for spiking. subjects  I n s t e a d , a o n e ^ t a i l e d _ t - t e s t f o r r e l a t e d measures = 11. 52 , p_ <. 005 , f o r s t u t t e r i n g  and t_C2L = 3.19,  was  p_, <. 05,  S t u t t e r i n g and s p i k i n g were p o s i t i v e l y c o r r e l a t e d f o r a l l t h r e e  (Table 4 ) .  was _r(28) = .72, p_  The mean c o r r e l a t i o n , u s i n g F i s h e r ' s . Z-rtransformation, <.01.  Study  2  S t u t t e r i n g can be almost t o t a l l y suppressed by the simple of i n s t r u c t i n g the s u b j e c t to speak i n time w i t h a metronome beat 1969.; Hanna and M o r r i s , Note 2 ) . to the p r e v i o u s one:  expedient (Brady,  The r a t i o n a l e behind t h i s study was  i f s t u t t e r i n g and EMG  similar  s p i k i n g a r e r e l a t e d , they s h o u l d  covary. Method The s u b j e c t (David), performed g e a l EMG  was  r e c o r d e d as i n Study 1,  the TAT  t a s k f o r 30 minutes w h i l e  During the l a s t  laryn-  15 minutes- the s u b j e c t  Table 4 C o r r e l a t i o n Between P e r c e n t S y l l a b l e s  Stuttered  and EMG S p i k e s - p e r 100 S y l l a b l e s I n Study! J.  Subject  " r_  Frank  .79*.  Rick  .78*  John  .52*  * p_ ,<;.0.1 •  Table 5 C o r r e l a t i o n Between P e r c e n t and EMG S p i k e s - p e r 100  S y l l a b i es  Stuttered  S y l l a b l e s i n Study- 2  Subj e c t  • r  David  .15  Ruth-  ,37*  Don  .85**  Ray  .33  *p_  <,05  p_ <,01  37  spoke i n time with: a metronome s e t at 120:jieats: per -minute. . T h i s study r e p l i c a t e d w i t h another s u b j e c t Ray) was  (Ruth) ; then two  o t h e r s t u t t e r e r s : (Don  performed the s p e e c h tasks- i n r e v e r s e o r d e r . used to o f f s e t  the a d a p t a t i o n  This balancing  was and  strategy  effect.  Results S t u t t e r s and polygraph  records  EMG  s p i k e s were c a l c u l a t e d from t a p e r e c o r d i n g s  f o r each minute of speech.  g r a p h i c a l l y i n F i g u r e s 2 and i n T a b l e 6.  3,  David's d a t a are  and  presented  Data f o r a l l f o u r s u b j e c t s a r e summarized  Speech r a t e data were not  analyzed  i n t h e i r own: r i g h t , because  the metronome s e t t i n g of .120 b e a t s per minute c l e a r l y produced a slowing  of  speech.  the  S t u t t e r i n g and  s u b j e c t s .'([Table 5 ) . was  £(28)  s p i k i n g were s i g n i f i c a n t l y c o r r e l a t e d f o r two  of  The mean c o r r e l a t i o n , u s i n g F i s h e r ^ s Z - r t r ans format i o n ,  = .49, p_<.01.  D i s c u s s i o n of S t u d i e s Two  1 and  2  major c o n c l u s i o n s  can be  drawn from these  data.  First,  the  r a t e c o n t r o l and metronome treatments were d r a m a t i c a l l y - e f f e c t i v e i n t h e s h o r t run.  (An i n f o r m a l threes-month f o l l o w - u p  s u b j e c t s r e v e a l e d t h a t one had some improvement, and  of the  r e l a p s e d completely,  three r a t e c o n t r o l  another  hadrretained  the t h i r d r e t a i n e d s u b s t a n t i a l improvement.  nome e f f e c t , which hadbbeen even more s t r i k i n g , wore o f f w i t h i n Second, and more t o the p o i n t , s t u t t e r i n g and EMG be p o s i t i v e l y c o r r e l a t e d .  The  metro-  minutes.).  s p i k i n g appear t o  r e l a t i o n s h i p i s c l o s e f o r some s u b j e c t s ,  moderate f o r o t h e r s , and n e g l i g i b l e f o r two significant.  The  s u b j e c t s , but on the whole i t i s  P o s s i b l y the c o r r e l a t i o n would have been h i g h e r except f o r the  f a c t t h a t the number of s p i k e s i s r e l a t e d to the d u r a t i o n of a s t u t t e r , which  38  BASELINE  METRONOME  25  20  w  H H !=> H co  15  CO  w IJ  OO EH  TO  W U  w CH  5  10  15  rv~\ 25  20  MINUTES F i g u r e 2.  E f f e c t of metronome on  stuttering:  David  (p_<s.005),  30  39  BASELINE  5  METRONOME  10  15  20  25  MINUTES F i g u r e 3.  E f f e c t of metronome on EMG  spiking:  David  (p_< .005)..  30  Table & S u p p r e s s i o n o f S t u t t e r i n g and EMG S p i k i n g By- Metronome Treatment  t(27)_ f o r change i n l e v e l Subject  Percent syllables stuttered  David  5.93  Ruth  2.85  Don  .88  Ray  2.59  A A  p_ <.005  2.86 2.18 .79  *  p_<.05 A A  A A  EMG spikesp e r 100 s y l l a b l e s  1.17  A A  A A  41  is highly variable within s t u t t e r i n g and  EMG  subjects.  At any  r a t e , the., correlation,b.etween  s p i k i n g i s c o n s i s t e n t with_ the l a r y n g e a l  hypertension  model. L a r y n g e a l h y p e r t e n s i o n i s not  n e c e s s a r i l y a cause of s t u t t e r i n g ,  a l t h o u g h t h i s would make t h e o r e t i c a l sense. e f f e c t of ficient  the s t r e s s of Being a s t u t t e r e r .  to demonstrate  The  next step was  sufficient  an attempt  concurrently  reduced.  to j u s t i f y  the degree of  an suf-  concomitant  f u r t h e r research, i n t h i s  to demonstrate the converse of what  Been a c h i e v e d h e r e , v i z . , to reduce EMG would be  j u s t as w e l l be  C o r r e l a t i o n a l d a t a i s not  causality; nevertheless,  v a r i a t i o n I have found was vein.  I t could  spiking  i n the hope t h a t  had  stuttering  42  CHAPTER IV  .  FEEDBACK OF ELECTROMYOGRAPHIC ACTIVITY At l e a s t t h r e e independent l i n e s o f r e s e a r c h suggest t h a t i t may p o s s i b l e to reduce s t u t t e r i n g w i t h b i o f e e d b a c k . was  the most i n f l u e n t i a l i n i n i t i a t i n g  s i m p l y t h a t EMG  The f i r s t  be  o f t h e s e , which  the p r e s e n t s e r i e s o f s t u d i e s , i s  feedback has a l r e a d y been a p p l i e d s u c c e s s f u l l y t o a h o s t of  stress-related disorders  ( e . g . , R a s k i n , Johnson  A d d i t i o n a l impetus and d i r e c t i o n was model (Schwartz, .1974). d e f e c t i v e feedback  & Rondestvedt,  1973).  p r o v i d e d by the l a r y n g e a l h y p e r t e n s i o n  F i n a l l y , the p o s s i b i l i t y  that s t u t t e r i n g  (Mysak, .1960) i m p l i e s t h a t enhanced  involves  proprioceptive feed-  back might suppress s t u t t e r i n g . - ;Tt waS anticipate*-- a i a t i f b i o f e e d b a c k were e f x  a greater  (more d i r e c t ) e t t e c t on  s p i k i n g than on  • ;  s r u c i -  P i l o t f o r Study 3 Method A single subject  (John) p a r t i c i p a t e d i n t h i s s t u d y .  EMG  was  recorded  from the t h r o a t as d e s c r i b e d i n Study 1, w h i l e the s u b j e c t performed the TAT  task.  back was  A f t e r a b a s e l i n e p e r i o d of n i n e minutes o f speech, a u d i t o r y p r e s e n t e d t h r o u g h a speaker a t the s u b j e c t ' s s i d e .  The  feed-  feedback  c o n s i s t e d of a tone whose f r e q u e n c y v a r i e d i n p r o p o r t i o n to the amplitude of the EMG  signal.  The feedback apparatus i s i l l u s t r a t e d i n F i g u r e  The s u b j e c t was speech muscles: H i s t a s k was  4.  t o l d t h a t the feedback tone r e f l e c t e d t e n s i o n i n h i s  the g r e a t e r the t e n s i o n , the h i g h e r the p i t c h . o f the tone.  t o produce a low f r e q u e n c y tone as o f t e n as p o s s i b l e , j u s t  as  43  A C PREAMPLIFIER  LOW PASS  HIGH PASS  FILTER  FILTER  5 Hz  10 Hz  EMG PRINTOUT  AMPLIFIER  <J.  L  BECKMAN R411 POLYGRAPH AUDIO . FREQUENCY MODULATOR  Experimenter  INTERCOM  Subject  SPEAKER  TAT  TAPE RECORDER  F i g u r e 4.  EMG feedback system.  SOUNDPROOF CHAMBER  j  44  one  l e a r n s to c o n t r o l the amount of p r e s s u r e e x e r t e d .on an automobile  c e l e r a t o r by l i s t e n i n g t o the sound of the motor. how  s u b j e c t was  not  told  to r e l a x his- speech, muscles; he was-merely i n s t r u c t e d to t r y to do  S t u t t e r i n g /was  not mentioned  The b i o f e e d b a c k s e v e r a l times. for  The  ac-  so.  explicitly.  e f f e c t was  demonstrated by h a v i n g  the s u b j e c t swallow  He p r a c t i c e d t e n s i n g a n d . r e l a x i n g h i s throat, w i t h o u t  about a minute and: a half,, u n t i l he was  .speaking  a b l e to v a r y the p i t c h of the'. ..  tone at w i l l . , Then the .subject p r a c t i c e d s a y i n g h i s . name, a d d r e s s , e t c , s e v e r a l t i m e s , .noting changes i n the p i t c h , of ;the tone as he b l o c k e d on words..  Within, two  and a h a l f minutes, he was  s e v e r e l y . a n d without  a b l e to chat w i t h o u t  g r e a t l y i n c r e a s i n g the frequency  t h i s b r i e f p r a c t i c e p e r i o d the ^subject resumed the TAT the -tone on.  He was  these  stuttering  of the tone.  After,  t a s k as b e f o r e , with.,  t o l d t h a t the feedback .would-be turned on and  off,.inter-,.  m i t t e n t l y w h i l e he .spoke.  A complete ,on--off c y c l e comprised :six- cards . (18  minutes) ., .The  c o n c l u d e d \ a f t e r the s u b j e c t had. completed  s e s s i o n was  about .the f i f t e e n t h  speaking  card.  R e s u l t s and D i s c u s s i o n . S t u t t e r i n g data are i l l u s t r a t e d t i i n F i g u r e 5, and for  a l l t h r e e dependent v a r i a b l e s are summarized i n T a b l e 7.  p a r i s o n , v i z . , the f i r s t b a s e l i n e v s . the f i r s t in  analyses  The f i r s t com-z  feedback p e r i o d , i s a t y p i c a l  t h a t a f o u r minute i n t e r v a l o c c u r r e d between t h e s e c o n d i t i o n s .  the r i s k of h i s t o r i c i l confounding The  statistical  Fortunately,  d u r i n g such. a . b r i e f i n t e r v a l is. s l i g h t , .  second comparison must also, be i n t e r p r e t e d . c a u t i o u s l y because of  p o s s i b i l i t y of c a r r y o v e r of the biofeedback, e f f e c t from t h e f i r s t p e r i o d i n t o the .second b a s e l i n e p e r i o d .  the  feedback.  I f t h i s o c c u r r e d i t would tend to  .  45  BASELINE 1  PRACTICE  5  10  FEEDBACK 1  15  20  MINUTES  FEEDBACK 2  BASELINE 2  -i  25  1  30  1  1  35  BASELINE 3  r-  40  MINUTES F i g u r e 5.  E f f e c t of EMG feedback on s t u t t e r i n g : (From Hanna e t a l . , 1975).  John  46  Table 7 E f f e c t s , of EMG Feedback.;  Comparison  Pilot  Study  t_Q5). f o r change i n l e v e l Percent EMG spikes. syllables stuttered p e r J.00 s y l l a b l e s  Speech, r a t e . (SPM)_.  B a s e l i n e .1 v s .  Feedback!  4.66**  2.31*  1.80* .  1.14  1.86*  Baseline 2 vs. Feedback 2  * p_<; .05 **£P_< .0005  .43  47  obs cure the r e v e r s a l e f f e c t , and thus t h e time s e r i e s s t a t i s t i c may be conservative.  I n s p i t e of t h e s e q u a l i f i c a t i o n s , i t appears t h a t t h e feedback  treatment was accompanied b y a s i g n i f i c a n t decrease i n s t u t t e r i n g both, t i m e s . EMG s p i k i n g was s i g n i f i c a n t l y reduced t h e f i r s t  time, b u t n o t t h e second..  The s u b j e c t ' s speech, r a t e appeared to increasev^the f i r s t i n c r e a s e d u r i n g the second a p p l i c a t i o n o f feedback.  time, b u t d i d n o t  I t can be concluded  t e n t a t i v e l y t h a t the feedback e f f e c t was n o t dependent on s l o w i n g of speech. Other time s e r i e s comparisons- of l e s s e r i n t e r e s t , e.g,, the second feedback p e r i o d v s . the t h i r d b a s e l i n e , were n o t a n a l y z e d s t a t i s t i c a l l y b e cause o f the problems i n h e r e n t I n u s i n g the t_ d i s t r i b u t i o n to make m u l t i p l e comp a r i s ons.  among/me ans;  Study 3 The r e s u l t s of the p i l o t  s t u d y were s u f f i c i e n t l y - encouraging t h a t an  attempt was made to r e p l i c a t e these f i n d i n g s s e v e r a l times.  The r e v e r s a l  d e s i g n used i n the p i l o t study was abandoned because of t h e d i f f i c u l t y o f i n t e r p r e t i n g carryover e f f e c t s .  The p r a c t i c e I n t e r v a l between the b a s e l i n e  and feedback p e r i o d s was a l s o e l i m i n a t e d .  E a c h - p e r i o d was lengthened to 15  minutes i n o r d e r t o i n c r e a s e the power of> t h e time s e r i e s , , s t a t i s t i c . Method The g e n e r a l p r o c e d u r e was s i m i l a r to t h a t used i n t h e p i l o t The s u b j e c t  (Don) was  ito&d  study.  t h a t a f t e r a b a s e l i n e p e r i o d o f 15 minutes, of  speech, an a u d i t o r y feedback tone would b e p r e s e n t e d through, a speaker a t his  side.  A g a i n , the feedback tone i n c r e a s e d I n f r e q u e n c y - T n p r o p o r t i o n t o  the  amplitude of the EMG s i g n a l .  T h i s was accomplished by> u s i n g t h e ampll^-  48  f i e d EMG  s i g n a l to power a tone g e n e r a t o r .  tone shut  off entirely.  I t was  explained  l e c t e d t e n s i o n In h i s speech muscles: the p i t c h of the tone.  The  Below a c e r t a i n a m p l i t u d e ,  subject's  to the s u b j e c t  the g r e a t e r t a s k was  the  t h a t the  t e n s i o n , the  at the end  i n s t r u c t i o n s are g i v e n i n Appendix D.)_ previous  studies while  30 minutes:  of the experiment, r a t h e r  of the b a s e l i n e p e r i o d , because the t i m e — s e r i e s  permit an I n t e r r u p t i o n between b a s e l i n e and  EMG  the s u b j e c t performed the TAT  15 minutes of b a s e l i n e speech, f o l l o w e d  T h i s s t u d y was* r e p l i c a t e d w i t h  design  treatment p e r i o d s .  Laryngeal  minute p e r i o d d u r i n g w h i c h the feedback was  higher  These i n -  s  to be g i v e n a t the b e g i n n i n g  ref-  to t r y to t u r n the tone o f f ,  o r a t l e a s t to produce a low-r-pitched t o n e a s o f t e n as p o s s i b l e . s t r u c t i o n s had  tone  the  was task.  than  d i d not (Verbatim  recorded The  as i n  the  study took  immediately by  a J.5  i n operation.  four other  subjects.  Results Data f o r the f i r s t gures 6 and but not and  7.  i n EMG  subject  (Don), are i l l u s t r a t e d g r a p h i c a l l y i n F i -  Biofeedback r e s u l t e d i n a s i g n i f i c a n t spiking, f o r this subject.  s p i k i n g i s noteworthy n e v e r t h e l e s s .  terlng  and  s p i k i n g data  Ruth's s t u t t e r i n g data  (Figure-8).  no  covariation in stuttering  Statistical  for a l l f i v e subjects  n i f i c a n c e of time s e r i e s d a t a . cant because t h e r e was  The  analyses  i l l u s t r a t e the v a l u e  The  of the stut^-  are summarized i n T a b l e  treatment e f f e c t  of t e s t i n g the  appears h i g h l y  8. sigs-  signifi-  s t u t t e r i n g at a l l i n the b i o f e e d b a c k p e r i o d .  However, c l o s e r i n s p e c t i o n r e v e a l s t h a t t h e r e was f l u c t u a t i o n i n the b a s e l i n e d a t a , t i o n s were zero.  reduction i n s t u t t e r i n g ,  and  a h i g h degree of  t h a t seven of the 15 b a s e l i n e  In s h o r t , b i o f e e d b a c k d i d not  spontaneous observa-  reduce RuttL's s t u t t e r i n g  49  BASELINE  5  FEEDBACK  10  15  20  25  MINUTES  F i g u r e 6.  Effect  o f EMG feedback on s t u t t e r i n g :  Don  (p_•<, .05)..  30  50  BASELINE  FEEDBACK  MINUTES  F i g u r e 7.  Effect  of feedback  on EMG s p i k i n g :  Don CNot s i g n i f i c a n t ) .  51  Table 8 Effect  of EMG  Feedback on S t u t t e r i n g and S p i k i n g  tp.1)  f o r change i n l e v e l  Percent syllables stuttered  Subj e c t  *  Don  2.24  David  2.61  A  EMG s p i k e s p e r .100 s y l l a b l e s  .91 2.97  Ray  .86  .30  Ruth  .63  3.37  1.27  6.32  Larry  £  <-05  p <.005  **  ** **  52  F i g u r e 8.  E f f e c t of EMG feedback on s t u t t e r i n g : significant).  Ruth (Not  53  significantly. Nevertheless-, i n two  s t u t t e r i n g was- s i g n i f i c a n t l y - reduced b.y- B i o f e e d b a c k  out of f i v e cases-.  S p i k i n g was  reduced i n t h r e e  Speech r a t e data a r e g i v e n i n T a b l e 9..  One  cases.  of the f i y e  subjects  showed a s i g n i f i c a n t r e d u c t i o n i n speech, rate* d u r i n g the. feedback, c o n d i t i o n . Discussion • The s i x subjects  biofeedback  e f f e c t appears to Be  ( i n c l u d i n g the p i l o t  i n a s i n g l e s e s s i o n and  a promising  s u b j e c t ! achieved  t h r e e achieved  one:  f o u r out  of  reductions i n spiking  r e d u c t i o n s In stuttering..- ' This?- e f f e c t  i s p a r t i c u l a r l y s u r p r i s i n g i n view'of the f a c t t h a t a l l s i x s u E j e c t s w e r e c h r o n i c s t u t t e r e r s who  haddheen t r e a t e d - u n s u c c e s s f u l l y i n - t h e p a s t .  Moreover,  the l a s t f i v e s u b j e c t s d i d not have the advantage of a p r a c t i c e i n t e r v a l between the b a s e l i n e and treatment e f f e c t .  feedback p e r i o d s , y e t t h r e e of them .showed an  T h i s l e a r n i n g e f f e c t was  o t h e r ithaft knowledge of the Only one treatment. task.  achieved w i t h o u t  reinforcement  results.  s u b j e c t appeared to slow h i s . s p e e c h  T h i s may  d u r i n g -the feedback  have been a response to the n o v e l t y . o f t h e  I t can be c o n c l u d e d  abrupt  feedback  t e n t a t i v e l y that, the feedback, e f f e c t was, not  an  a r t i f a c t of r a t e c o n t r o l . , F u r t h e r . r e p l i c a t i o n s of the feedback e f f e c t may- be found i n S t u d y 5 .  Table 9 E f f e c t of EMG  Feedback on Speech Rate  tC27). f o r change i n l e v e l Subject  Speech r a t e  Don  .1.09  David  1.80  Ray-  .39  Ruth.  .73  Larry  .66  p_ <.05  *  (SPM)  •55  CHAPTER V FEEDBACK WITHOUT INSTRUCTIONS  Study 4 It  appears t h a t feedback t r a i n i n g  can be used e f f e c t i v e l y  t o modify  a g i v e n p h y s i o l o g i c a l response, even when the s u b j e c t has not been w h i c h response he  i s supposed to m o d i f y .  Beatty  Q972) reported  i n s t r u c t i n g h i s s u b j e c t s t o i n c r e a s e the loudness of a tone lated  to EEC  activity) resulted i n significant  a l p h a and b e t a  activity,  Ascough, and  o t h e r s have r e p o r t e d s i m i l a r r e s u l t s w i t h h e a r t be of r e l a t i v e l y formation"  effect  (which was  informed  that  I t would  However, a r e l a t e d and  u n e x p l o r e d problem concerns the e f f e c t of i n s t r u c t i o n s (to reduce the  cle tension).  w i t h o u t i n s t r u c t i o n s s h o u l d not he and  EMG  spiking.  back" e f f e c t was than b e i n g  due  I f i t were, we an a r t i f a c t  i f i t i s indeed  component of  authentic,  the  feedback  accompanied by a r e d u c t i o n i n s t u t t e r i n g  s h o u l d have to c o n c l u d e t h a t the  "hiofeed-s-  of the p r e s e n t a t i o n of the tone I t s e l f ,  to enhanced i n f o r m a t i o n about l a r y n g e a l muscle  I t has been r e p o r t e d  pitch  ( t h a t the.tone i s r e l a t e d to mus-  I n s t r u c t i o n s are presumably a n e c e s s a r y  feedback e f f e c t r e p o r t e d i n Study 3,  EEC  "feedback w i t h o u t i n s -  s e r i e s of s t u d i e s .  of the tone) as d i s t i n c t from i n f o r m a t i o n  re-  0 - 9 6 8 ! and  Sipprelle  rate conditioning.  l i t t l e i n t e r e s t to r e p l i c a t e t h i s i n the p r e s e n t  t h a t merely  c h a n g e s - i n the p r o p o r t i o n of  a l t h o u g h the subjects- were not  was- the dependent v a r i a b l e of i n t e r e s t .  informed  t h a t s t u t t e r i n g can be  reduced by  rather  activity. presentation'  of a l o u d a v e r s l v e tone ( B a r r & C a n n e l , 1969;  Biggs & Sheehah, .1969; F l a n a g a n ,  Goldiamond & A z r i n , 19581.  t h a t t h i s e f f e c t o c c u r s whether  However, the f a c t  56  the tone i s p r e s e n t e d i t may  at random or c o n t i n g e n t  be an a r t i f a c t o f masking.  the p r e s e n t b i o f e e d b a c k p i t c h e d and  upon s t u t t e r i n g suggests t h a t  Masking i s not a f e a s i b l e e x p l a n a t i o n  e f f e c t , because the EMG  of  feedback tone i s too• .high-  i n s u f f i c i e n t l y l o u d to mask the f r e q u e n c i e s  of speech.  Method The  subject  (Rick) performed the TAT  and s t u t t e r i n g d a t a were recorded b a s e l i n e p e r i o d , I announced: high-pitched  was  questionedd  Appendix E ) .  as u s u a l .  "From now  At the end  of the 15 minute T  Continue t a l k i n g about the  When 30 minutes of s p e e c h had been r e c o r d e d ,  the  to see i f he had p e r c e i v e d the f u n c t i o n of the tone  F i n a l l y the s u b j e c t was  EMG  on you w i l l hear an I n t e r m i t t e n t  tone w h i l e you are speaking.  t u r e s as b e f o r e . "  t a s k f o r 30 minutes, w h i l e  pic-  subject (see  d e b r i e f e d about the t r u e purpose of  the experiment. T h i s procedure was  repeated  s u b j e c t s were Frank and Ruth. 3).  Three o t h e r s u b j e c t s  (The  week l a t e r , Ruth p a r t i c i p a t e d i n Study  ( T e r e s a , Doug, Ron)  i n s t r u c t i o n s treatment f i r s t , back.  .One  i n two more s i n g l e - s u b j e c t s t u d i e s .  r e c e i v e d the feedback-without-  f o l l o w e d by a .15 minute p e r i o d without  feed-  ( T h i s p r e c a u t i o n a g a i n s t the a d a p t a t i o n e f f e c t may- have' been unneces-  s a r y , i n view o f the f a c t t h a t the.ttime-series s t a t i s t i c does attempt t o accomodate trends i n the  data.  Results S t u t t e r i n g and F i g u r e s 9 and 10 T a b l e 10.  s p i k i n g data f o r t h e f i r s t  respectively-.  s u b j e c t . ( R i c k ) : are g i y e n i n  Data f o r a l l s i x s u b j e c t s - a r e summarized i n  R e s u l t s were s i g r i i f l e a n t f o r two  subjects:  Frank showed an i n -  crease i n s t u t t e r i n g and s p i k i n g d u r i n g the feedback c o n d i t i o n and  Teresa  57  15  10  20  25  MINUTES  F i g u r e 9.  E f f e c t of feedback w i t h o u t i n s t r u c t i o n s R i c k CNot s i g n i f i c a n t ) . .  on  stuttering:  30  58  F i g u r e 10.  E f f e c t of feedback w i t h o u t i n s t r u c t i o n s on EMG R i c k CNot s i g n i f i c a n t ) .  spiking:  T a b l e 10 E f f e c t of Feedback Without I n s t r u c t i o n s on S t u t t e r i n g and EMG  Spiking  _tC27) f o r change i n l e v e l Percent s y l l a b l e s y , stuttered •  Subject  Rick Frank Ruth Teresa  EMG p e r 100  spikes syllables  .83  .45  1.78 .  2.01 .  .06  .52  1.23  1.83  *  *  Doug  .66  .19.. .  Ron  .66  .88  p  <.05  60  showed an i n c r e a s e i n spiking;.. The  i n s i g n i f i c a n t r e s u l t s f o r the  f i v e , s u b j e c t s " were, i n B o t h d i r e c t i o n s : decreases i n s t u t t e r i n g d u r i n g  t h e r e were two  other  i n c r e a s e s :and  the feedback c o n d i t i o n , , and  three  three increases . ,  and, one .decrease i n s p i k i n g . , Speech r a t e data are g i v e n i n T a b l e ,11,. t i o n s , produced no  significant  Feedback without  instruc-  change- In speech, r a t e for" any of the. s i x  sub-  j ects'. None of the s u b j e c t s - w e r e aware that, the t o n e . r e f l e c t e d l a r y n g e a l muscle t e n s i o n .  One  subject  (Ru'th). commented, " I t squeaks when.I swallow.".  None.of the s u b j e c t s r e p o r t e d t h a t the tone made any d i f f e r e n c e to  their,'  speech. Discussion . I n s t r u c t i o n s , appear to be a n e c e s s a r y e f f e c t r e p o r t e d i n Study 3. a reduction.in spiking,and c r e a s e them.  T h i s may  se ,'. or to the f a c t -  Feedback without  component of the feedback, i n s t r u c t i o n s d i d hot. produce  stuttering, i n fact, i t  apparently-tended;to.in-  have been due.to the alarming  that i t s f u n c t i o n was, not  nature  of the  and more e f f e c t i v e than a u d i t o r y feedback.  e f f e c t appears not  to be an a r t i f a c t  tone.per  e x p l a i n e d , , I f t h e former  p o t h e s i s i s c o r r e c t , feedback by means, of a v i s u a l s i g n a l might be alarming  .  hy-r  less,  At any:.rate, the  feedback  of masking or of t h e p r e s e n t a t i o n of a  loud-, a v e r s i v e tone. The  f i n d i n g s t h a t - feedback, w i t h o u t  i n s t r u c t i o n s . - produced no\ s i g n i f i-?.  cant changes i n speech r a t e , r e g a r d l e s s of i t s e f f e e t , o n s t u t t e r i n g and • s p i k i n g , supports We  -  a s i m i l a r , f i n d i n g i n Study 3.  have concluded  in this series'addresses  t h a t i n s t r u c t i o n s are n e c e s s a r y .  itself  to the q u e s t i o n :  "Are  The  final  study  instructions sufficient?  61  T a b l e 11 Effect  of Feedback Without  Instructions  on, Speech Rate  t_G27l Subject  Rick Frank  f o r change i n l e v e l  Speech r a t e  .47 1.19  Ruth  .25  Teresa  .59-  Doug  .64  Ron  .52  (SPM)  62  CHAPTER VI FALSE FEEDBACK The  r e l a t i v e ease w i t h which, s t u t t e r i n g can be manipulated i n t h e  l a b o r a t o r y has g i v e n r i s e to numerous f a l s e l e a d s i n t h e search.: f o r ' an e f f e c t i v e treatment  (Van R i p e r , 19731.  M a r t i n and S i e g e l (1966) demonstrated ;  t h a t merely i n s t r u c t i n g t h e i r s u b j e c t s -to• MRead;.more c a r e f u l l y " and-.to "saye a c h word f l u e n t l y " r e s u l t e d . i n a r e d u c t i o n i n s t u t t e r i n g . calling  a s t u t t e r e r ' s a t t e n t i o n to h i s d i s f l u e n c y w i l l  temporarily  sometimes decrease i t  s  Likewise,  s e r i e s o f experiments.  t h e placebo  e f f e c t - h a d t o be c o n t r o l l e d .  several questionable  The i n i t i a l  treatments used i n the p a s t : s u g g e s t s  the a t t e n t i o n g i v e n and hope aroused d u r i n g any n o v e l : t r e a t m e n t t e r i n g may w e l l haVe an e f f e c t on f l u e n c y . Hawthorne e f f e c t , i . e . , t h e p o s s i b i l i t y  than t o the s p e c i f i c n a t u r e . o f  that  for stut- ,  A r e l a t e d problem -concerns the  t h a t changes I n s t u t t e r i n g  and/or  spiking.may be due to the s u b j e c t ' s awareness: of t h e e x p e r i m e n t a t i o n the,treatment.  than a t r a n s i e n t , p u r e l y p s y c h o l o g i c a l - e f f e c t .  rather  The aim o f t h e p r e s e n t  was, to e s t a b l i s h a p o t e n t i a l l y permanent p s y c h o p h y s i o l o g i c a l e f f e c t  is  simply•  (Wingate, 1959).. .Thus t h e e f f e c t o f i n s t r u c t l o n s r . n e e d e d t o be  i n v e s t i g a t e d i n the p r e s e n t  "success"-of  Likewise,  The s t u t t e r e r ' s fund  research,  rather of'hope  too s m a l l t o be wasted. I n s t r u c t i o n , placebo  and Hawthorne e f f e c t s c o u l d a l l be "ruled out  i f pseudofeedback were found to be i n e f f e c t i v e ' .  63  Pilot  f o r Study 5 .  Method. The  s u b j e c t i n - t h i s . s t u d y (John), had  feedback-training, week e a r l i e r .  i . e . , he had  S t u t t e r i n g and  s u b j e c t performed the TAT  had  previous  p a r t i c i p a t e d i n the p i l o t  s p i k i n g . d a t a were r e c o r d e d  experience  in  f o r Study 3 a as u s u a l w h i l e  t a s k . • A f t e r a n i n e minute b a s e l i n e and  a  the  briefs  p r a c t i c e p e r i o d , genuine feedback was-given f o r n i n e minutes, s T h i s was  fol4-  :  lowed by a second n i n e minute b a s e l i n e , then n i n e minutes of f a l s e and  f i n a l l y n i n e more minutes of genuine feedback.  complished simply by  r e c o r d i n g EMG  F a l s e feedback was  f rom'-another s u b j e c t  and  in  own.  Discussion .  Statistical i n Table  ac^r  i n an.adjacent room  and p r e s e n t i n g . t h i s person's feedback to John, o s t e n s i b l y - a s . h i s Results  feedback  analyses  f o r a l l t h r e e dependent v a r i a b l e s are  12. .Changes i n the f r e q u e n c y of J o h n s s t u t t e r i n g are ?  F i g u r e 11.  l i n e during  . I t appears t h a t s t u t t e r i n g was  the f i r s t  feedback period.'  r e d u c t i o n may  have been due  to the f a c t  of b a s e -  c o n c u r r e n t l y reduced. ..  F a l s e feedback reduced s t u t t e r i n g and - s p i k i n g ' s l i g h t l y , but,not This s l i g h t  illustrated  reduced to about 50%  "Spiking was  summarized  significantly.  t h a t the s u b j e c t j who  had  a l r e a d y had  was  e s s e n t i a l l y r e c e i v i n g random s i g n a l s to r e l a x h i s t h r o a t muscles  some exposure to feedback t r a i n i n g i n the p i l o t .for Study: 3,  the f a l s e feedback c o n d i t i o n .  Moreover, he kept complaining  during  the  p e r i o d t h a t " t h i s t h i n g i s n ' t ;adjusted •right .', which suggests t h a t  had  indeed  1  acquired subject  some degree of awareness of h i s . l a r y n g e a l muscle appeared to i n c r e a s e h i s s p e e c h r a t e d u r i n g  genuine f e e d b a c k p e r i o d , but n o t / d u r i n g  the  the f a l s e feedback, p e r i o d . ,  <  during  ter  The  •  lathe  activity. first This i s  T a b l e 12 E f f e c t s of Genuine"and F a l s e Feedback:  P i l o t Study-;  £p-5)„ f o r change i n l e v e l Comparison  Percent syllables stuttered,  EMG. spikes.. p e r 100 s y l l a b l e s  Speech, r a t e (S?M)_.  B a s e l i n e .1 v s , Feedback!  .  2.86**  1.91*  1.30  1.59.  3.96*  BaBaseMne. .2svs. F a l s e Feedback  * _p_,^ .05 ** p_ < .01  .'1.04  65  BASELINE 1  T  5  PRACTICE  GENUINE FEEDBACK 1  I  1  10  15  '  I  20,  25  MINUTES  Figure 1 1 .  E f f e c t of genuine and f a l s e feedh.ack. on John CFrom Hanna e t a l . , 1975)_.  stuttering:  66  c o n s i s t e n t w i t h e a r l i e r f i n d i n g s t h a t feedback-induced f l u e n c y i s not accompanied by a reduction i n speech r a t e . These conclusions- a r e s u b j e c t to the q u a l i f i c a t i o n s , d i s c u s s e d i n the p i l o t f o r Study 3.  Study- 5 The r e s u l t s o f the p i l o t  study were encouraging but i n c o n c l u s i v e ,  . so I attemptedtto r e p l i c a t e these f i n d i n g s s e v e r a l t i m e s , w i t h m e t h o d o l o g i c a l refinements. Method' EMG  and s t u t t e r i n g were r e c o r d e d as u s u a l w h i l e t h e s u b j e c t  performed the TAT t a s k .  A 15 minute b a s e l i n e was  15 minutes o f genuine feedback.  f o l l o w e d immediately by  (No p r a c t i c e i n t e r v a l o c c u r r e d between  these p e r i o d s , as i n the p i l o t study-. 1 was  (Eric),  'Following a J-0>minute_bTreak, t h e r e  a. second b a s e l i n e p e r i o d f o l l o w e d b y J.5 minutes of f a l s e feedback.  -10 minute break was  The  g i v e n i n o r d e r to reduce the p o s s i b i l i t y o f m u l t i p l e  treatment i n t e r f e r e n c e , 1.e.,  c a r r y o v e r of f l u e n c y from the genuine feedback  s e s s i o n i n t o the f a l s e feedback s e s s i o n .  vThe subjectTreeemved e x a c t l y the  same i n s t r u c t i o n s f o r f a l s e feedback as f o r genuine feedback (Appendix D i , 'False feedback was  of  h i s own  EMG  a c h i e v e d By. p r e s e n t i n g each- s u b j e c t with, feedback  a c t i v i t y , but with, a delay of 30 seconds..  accomplished manually:  T h i s was  I s i m p l y c o p i e d e a c h s u b j e c t ' s EMG  readily  r e c o r d on a second  channel of the p o l y g r a p h , a t a l a g o f 30 seconds, By m a n i p u l a t i n g t h e " c e n t r e " control.  D e f l e c t i o n s of t h e pen on this- a r t i f i c i a l EMG  tone g e n e r a t o r .  The f i d e l i t y with-which- the f a l s e EMG  channel powered t h e r e c o r d resembled t h e  67  genuine r e c o r d i s . i l l u s t r a t e d i n F i g u r e 12. even more s t r i k i n g . it  difficult  The auditory, s i m i l a r i t y  was  While l i s t e n i n g to':tapes of t h i s ; e x p e r i m e n t I found  to d i f f e r e n t i a t e Between genuine and f a l s e f e e d b a c k . c o n d i t i o n s  on the .Basis ,of sound a l o n e . , This: type of f a l s e feedBack was  s u p e r i o r to  t h a t u s e d . i n the p i l o t s t u d y i n t h a t , i t .resembled genuine feedBack jnore closely, and d i d not r e q u i r e a c o n f e d e r a t e suBj.ect. The s u B j e c t was his  degree of awareness of the e x p e r i m e n t a l m a n i p u l a t i o n (Appendix E ) , and  then was, d e B r i e f e d aBout was  q u e s t i o n e d a f t e r t h i s s t u d y i n o r d e r to a s c e r t a i n  the t r u e n a t u r e . o f the experiment.  r e p e a t e d i n the .same o r d e r f o r two o t h e r s u B j e c t s  and .then r e p l i c a t e d  The p r o c e d u r e .  ( T e r e s a and Doug).,  t h r e e more times ( J e f f , Ron and S u s a n ! i n c o u n t e r B a l a n c e d .  o r d e r , i . e . , f a l s e feedBack preceded genuine feedBack. Results The e f f e c t s  o f genuine and f a l s e feedBack were t e s t e d f o r signi-r  f i c a n c e a g a i n s t t h e i r r e s p e c t i v e B a s e l i n e s r a t h e r than a g a i n s t each, o t h e r , , Because of the p o s s i B i l i t y of h i s t o r i c a l i n v a l i d i t y - and multiple-rtreatment interference. cient  The 10 minute Break a t h a l f . t i m e appears ,to have Been  to a l l o w t s t u t e t e r i n g n a n d ^ s p i ^ ^  (e.g., F i g u r e 13).  genuine feedBack f e l l feedBack was  and s p i k i n g with.,  The r e d u c t i o n i n o E r i c ' s. EMG  s h o r t of s i g n i f i c a n c e :  spiking  t_(28)l ^T.64, p_ <.06. =  x  during Genuine  sometimes e f f e c t i v e when i t preceded f a l s e feedBack, But never  when i t f o l l o w e d f a l s e feedBack. it  Baseline  Doug reduced Both, t h i s s t u t t e r i n g  genuine feedBack (TaBle J.3)..  suffi-  F a l s e feedBack was  remarkaBly  ineffective:  reduced .spiking o n l y - o n c e In s i x c a s e s , and d i d not r e d u c e . s t u t t e r i n g  at a l l .  .  -6.8  Figure  12.  Sample EMG r e c o r d i n g s from Study 5.  a) J e f f  /  /e 5 ;  Baseline  SEC.  •,'.'!•''  '  b) J e f f :  ;  '  '•  FLUENT SPEECH.  i •'!'!'  r  ........  ..  c) J e f f  '  ''".'.!•'  !  .  True EMG r e c o r d .during f a l s e ' feedback; c o n d i t i o n  ! I  !  I  ,  i  I  f  /.....•/..  ;  - /  j  I  Manually pperateci f a l s e ; feedback  FEEDBACK THRESHOLD  d l Jeff,:  •';'//•/•  Genuine  .05 mV  / I  feedback condition^  FEEDBACK. THRESHOLD  •j  .05 mV;  1 . I n t h i s i T l u s t r a t i o n the •feedback tone was a c t i v a t e d o n l y i . e . , when the pen d e f l e c t i o n . e x c e e d e d the t h r e s h o l d .  once,  69  BASELINE 1  t— 5  GENUINE FEEDBACK  i .10  r 15  1  1  1  20  25  r30  MINUTES  BASELINE 2  3  w  FALSE FEEDBACK  20-  H H 1= H cn  co W iJ  sa  10-  >> CO  H  W u  w  40  —i— 45  —r  50  55  60  65  MINUTES  F i g u r e 13.  E f f e c t of genuine and f a l s e feedback on s t u t t e r i n g : Doug (p_^.005 f o r genuine feedback; f a l s e feedback not s i g n i f i c a n t ) .  70  70  T a b l e 13 E f f e c t of Genuine and E a l s e Feedback on S t u t t e r i n g and EMG S p i k i n g  _t(27) f o r change i n l e v e l  Subject  Eric  Teresa  Order of treatments  Jeff  Ron  J .21  f.'aMee •  1.05  .77  genuine  .04  .45  false  .06  .04  1.64  ** 3.32  1.75  false  .70  1.35  false  1.26  !  2.27'  genuine  .95  .88  false genuine genuine  .39  .20.  .93  .77  1.31  .39  .70  .32  false Susan  EMG s p i k e s per 100 s y l l a b l e s  genuine  genuine Doug  Percent s y l l a b l e s stuttered  genuine  71  Speech  r a t e d a t a a r e g i v e n i n T a b l e 14.  p a r i s o n s were s i g n i f i c a n t :  Only two of the 12 com- . .  E r i c ' s speech, r a t e decreased under f a l s e feedr-,  back, w h i l e Ron's i n c r e a s e d under genuine feedback.  Generally, neither  type of :feedback had a c o n s i s t e n t e f f e c t on speech.,rate. Two  subjects  and f a l s e feedback. that thing s t i l l  CDoug and E r i c ) , d e t e c t e d a d i f f e r e n c e between genuine Doug s t a t e d , "Even w h e n T was  squeaked  E r i c c l a i m e d t h a t i t was feedback tones.  r e l a x e d the second time,  ... I c o u l d n ' t c o n t r o l i t as w e l l the second t i m e . " equally d i f f i c u l t  to c o n t r o l the genuine and  The o t h e r f o u r s u b j e c t s r e p o r t e d t h a t the tones made no  d i f f e r e n c e to t h e i r speech, which-was g e n e r a l l y t r u e . she was  false  a b l e to c o n t r o l the tone, which, was  .  Susan c l a i m e d that,  not t r u e . , The s u b j e c t who  a b l e .to . c o n t r o l the genuine feedback tone s u c c e s s f u l l y was, unable to  was arti-  c u l a t e how he d i d s o , except i n vague terms, e.g., " L j u s t c o n c e n t r a t e d on it  and t r i e d to r e l a x " T@ou'gl;.'  Discussion T h i s study (and i t s p i l o t ) , demonstrated feedback t r a i n i n g was spiking.  sometimes e f f e c t i v e i n r e d u c i n g s t u t t e r i n g and  And i f any more e v i d e n c e were needed, the f e e d b a c k e f f e c t  independent of speech, r a t e . Study  t h a t a b r i e f p e r i o d of genuine EMG appeared  These c o n c l u s i o n s a r e c o n s i s t e n t w i t h , t h o s e of .  3. F a l s e feedback was  back was feedback.  generally ineffective.  Moreover,  i n e f f e c t i v e i n the t h r e e cases i n which, i t was T h i s suggests t h a t f a l s e feedback may  genuine  preceded by  feed^  false  have i n t e r f e r e d w i t h subse-  quent genuine feedback t r a i n i n g , because of n e g a t i v e t r a n s f e r . Unfortunately-, the d a t a are not s u f f i c i e n t l y s t r o n g to support t h i s l i n e o f s p e c u l a t i o n .  72  T a b l e 14E f f e c t o f Genuine and F a l s e Feedback on Speech. Rate  _tC27) f o r change i n l e v e l Subject  Speech r a t e ($ml under genuine feedback  Speech, r a t e (STM). under f a l s e f e e d b a c k  **  .29  2.87  1.29  .55  Doug  .35  1.53  Jeff  .30  Eric Teresa  .63 ,  *  Ron  1.83  Susan  ' _p_<.05 £ <.005  .04  . 1.19L .03  73  The sibility  f a l s e feedback- c o n t r o l  that  condition  allows, us to d i s c o u n t the pos-  any changes i n s t u t t e r i n g o r s p i k i n g were due t o c o n c e n t r a -  t i o n on the t a s k o f c o n t r o l l i n g the tone, o r t o d i s t r a c t i o n o f the s u b j e c t ' s attention  away from h i s speech.  Although d i s t r a c t i o n has o f t e n . b e e n i n -  voked as an " e x p l a n a t i o n " of treatment e f f e c t s i n the s t u t t e r i n g t u r e , i t has r a r e l y been d e f i n e d . o p e r a t i o n a l l y .  Moreover, Thompson (1971)  demonstrated i n a s e r i e s o f u n p u b l i s h e d studies':that not  litera-  d i s t r a c t i n g tasks do  reeuce s t u t t e r i n g s i g n i f i c a n t l y . In summary, the f a l s e feedback c o n t r o l  clude that  condition  t h e b i o f e e d b a c k e f f e c t was. not a t t r i b u t a b l e  a l l o w s us t o conto a placebo dr  Hawthorne e f f e c t , n o r was i t an a r t i f a c t of i n s t r u c t i o n s , masking d i s t r a c t i o n or rate  control.  74  CHAPTER V I I CONCLUSION In r e t r o s p e c t , i t may Be seen t h a t t h e r e were s e v e r a l i n d i c a t i o n s that feedBack o f EMG a c t i v i t y ; s h o u l d  have worked as w e l l as i t d i d .  EMG  feedBack has a l r e a d y Been a p p l i e d e f f e c t i v e l y t o s e v e r a l o t h e r s t r e s s - r e l a ted d i s o r d e r s , e.g. , insomnia, t e n s i o n headaches and c h r o n i c a n x i e t y ,  More-  over, one o f the l e a d i n g t h e o r i e s o f s t u t t e r i n g suggests t h a t s t u t t e r e r s s u f f e r from d e f e c t i v e feedBack about t h e i r own speech-, and thus enhanced feedBack o f l a r y n g e a l muscle a c t i v i t y would seem t o Be an a p p r o p r i a t e F i n a l l y , the f l e d g i n g model of s t u t t e r i n g as a d i s o r d e r o f e x c e s s i v e g e a l muscle t e n s i o n c e r t a i n l y I m p l i e s Be  remedy. laryn-  t h a t feedBack-induced r e l a x a t i o n might  therapeutic. The  r e s u l t s of t h i s s e r i e s of s t u d i e s support t h e l a r y n g e a l hyper-  t e n s i o n model i n t p l p r t i c u l a r .  EMG s p i k i n g from t h e t h r o a t , which- d i f f e r e n -  t i a t e d Between s t u t t e r i n g and f l u e n c y , was found t o c o r r e l a t e p o s i t i v e l y w i t h s t u t t e r i n g ( S t u d i e s ! and 2)_,  S u p p r e s s i o n o f s t u t t e r i n g as a r e s u l t of  r a t e - c o n t r o l t h e r a p y and metronome-paced s p e e c h r e s u l t e d i n a p a r a l l e l p r e s s i o n o f EMG s p i k i n g  (Studies  1 and 2)_.  The d i f f e r e n c e i n s t u t t e r e r s '  EMG a c t i v i t y B e f o r e and a f t e r these treatments was- s t r i k i n g ; treatment EMG r e c o r d s of f l u e n t speakers. i n concurrent  sup-  the post-  (e.g.. F i g u r e l ( d ) X a r e i n d i s t i n g u i s h a B l e from those S u p p r e s s i o n of EMG s p i k i n g witb_BiofeedB.ack- r e s u l t e d  reductions  i n s t u t t e r i n g (Studies  3 and 5 ) . These d a t a c e r t a i n l y -  i m p l i c a t e d the l a r y n x as a l o c u s o f the s t u t t e r i n g B l o c k , a l t h o u g h n o t n e c e s s a r i l y the o n l y l o c u s : . a i r f l o w B l o c k a g e c o u l d a l s o o c c u r . a t .the f r o n t o r Back o f t h e tongue (Van R i p e r , 1971)-.  the l i p s or at  75  The  present  r e s u l t s are a l s o c o n s i s t e n t w i t h  the feedback model of  s t u t t e r i n g : s e v e r a l s u b j e c t s d i d become more f l u e n t when t h e i r feedback was  enhanced.  Moreover, t h i s e f f e c t  operant framework, e.g.,  auditory stimulus.  The  doubt t h a t the tone was  can be i n t e r p r e t e d w i t h i n  the p r o p o r t i o n of low amplitude EMG  increased through negative reinforcement,  somesthetic  signals  v i z . , t e r m i n a t i o n of an  an  was  aversive  spontaneous: comments of some subjects: l e a v e  little  a v e r s i v e f o r them.  A t o t a l of twelve s u b j e c t s r e c e i v e d feedback t r a i n i n g i n S t u d i e s and,5.  Four s u b j e c t s achieved  reduced t h e i r EMG  s i g n i f i c a n t r e d u c t i o n s i n s t u t t e r i n g , and  spiking significantly.  c a t e d twice w i t h i n one  3  The  feedback e f f e c t was  subject, with p o s i t i v e results.  also  five  repli-  These r e s u l t s may  be  c o n s e r v a t i v e , because the timer-series s t a t i s t i c i s s e n s i t i v e to immediate changes o n l y , i . e . , changes o c c u r i n g i n the f i r s t minutes of feedback t r a i n i n g . Indeed, the s t r o n g e s t e f f e c t was lowed to p r a c t i c e m a n i p u l a t i n g b a s e l i n e and  feedback p e r i o d s .  r e s u l t s r a p i d l y without  this  achieved by the p i l o t  Nevertheless,  some s u b j e c t s a t t a i n e d p o s i t i v e  advantage.  t h i n g , the l e n g t h of each EMG  these r e s u l t s , may  s p i k e was  be  conservative.  not taken i n t o account.  t h e o r y , a s u b j e c t c o u l d have reduced.the amplitude of h i s EMG during  was al^-  the feedback:tone f o r a few minutes between  There are a d d i t i o n a l reasons why For one  s u b j e c t , who  In  s p i k e s by  50%  the feedback treatment, y e t t h i s would not n e c e s s a r i l y b e r e f l e c t e d i n  the frequency a tedious hypothesis  of s p i k e s which exceeded the feedback t h r e s h o l d .  I t would  t a s k to measure the l e n g t h s of about ten thousand s p i k e s , so has not been t e s t e d .  cords of some s u b j e c t s - d o e s  not  However, v i s u a l i n s p e c t i o n of the EMG discourage  t h i s l i n e of s p e c u l a t i o n .  be  this re-r '<..  76  The s t r e n g t h o f the feedback e f f e c t may a l s o have been l i m i t e d by the f a c t t h a t the s u b j e c t s were drawn from a w a i t i n g l i s t about which they.had h i g h e x p e c t a t i o n s . '  f o r a therapy  T h i s might have.tended  t h e i r enthusiasm f o r the b i o f e e d b a c k treatment.  Moreover\  to l i m i t  the subjects,  were a l l c h r o n i c and s e v e r e s t u t t e r e r s who had h i s t o r i e s o f u n s u c c e s s f u l speech therapy. minute  L a r y n g e a l h y p e r t e n s i o n d u r i n g s t u t t e r i n g must be a v e r y  and g r o s s l y o v e r l e a r n e d response, y e t n e a r l y h a l f o f t h e s u b j e c t s  were a p p a r e n t l y . a b l e to make f i n e adjustments o f t h e i r speech, musculature on t h e b a s i s o f a mere 15 minutes o f a u d i t o r y feedback.  T h i s i s indeed a  p r o m i s i n g trestment e f f e c t . I t i s n o t immediately apparent why some s u b j e c t s were a b l e t o master the b i o f e e d b a c k t a s k w h i l e o t h e r s were n o t .  There a r e no w e l l - e s t a b -  l i s h e d p r o g n o s t i c i n d i c a t o r s i n the b i o f e e d b a c k l i t e r a t u r e .  Perhaps  the most  l i k e l y e x p l a n a t i o n i s that the 15 minute feedback p e r i o d was s i m p l y too brief  f o r some s u b j e c t s . The EMG f e S d b a e k h e f f e e t appears t o be an a u t h e n t i c . o n e , r a t h e r than  an a r t i f a c t  of some o t h e r c o n d i t i o n t h a t reduced s t u t t e r i n g .  The importance  of m o n i t o r i n g speech r a t e d u r i n g any treatment f o r s t u t t e r i n g has been s t r e s s e d by P e r k i n s (1975).  i n S t u d i e s 3 through.4, 27 t e s t s o f s i g n i f i c a n c e f o r  change i n speech r a t e were.performed.  Two s u b j e c t s were found t o i n c r e a s e  t h e i r speech r a t e , w h i l e two o t h e r s decreased t h e i r s . . I t can be concluded t h a t feedback e f f e c t i s n o t g e n e r a l l y accompanied  by, much l e s s a r e s u l t o f ,  s l o w i n g of speech. I n f o r m a t i o n t h a t the feedback tone i s r e l a t e d t o l a r y n g e a l  muscle  t e n s i o n , p l u s i n s t r u c t i o n s to reduce the p i t c h of t h e tone, appear to be necessary  (Study 4 ) , but not s u f f i c i e n t  (Study 5 ) .  Thus the feedback e f f e c t  77  i s not a t t r i b u t a b l e to i n s t r u c t i o n s a l o n e , nor i s i t m e r e l y a case of r e d u c t i o n o f s t u t t e r i n g by means of a c o n t i n g e n t a v e r s i v e tone.  F a l s e feedback  did  received i t ,  not reduce s t u t t e r i n g  nor d i d i t reduce EMG  f o r any of the seven s u b j e c t s who  s p i k i n g i n s i x out of seven c a s e s ,  eluded, t h e n , t h a t the feedback e f f e c t nor i s i t an a r t i f a c t  i t can be  i s not a p l a c e b o oriHawthorne  of d i s t r a c t i o n or masking  effect,  (Study 5L.  The r e l a t i v e l y h i g h degree of o b s e r v e r agreement on the measures i n s p i r e s some c o n f i d e n c e i n these r e s u l t s . tical  con-r  Moreover,  dependent  the  statis-  t e s t s which support the above c o n c l u s i o n s were not based on the  sma!ibnumber'.of subjeegsyinoeachastudy^.-but e  r a t h e r ono the 30-60  data p o i n t s  i n - e a c h d t i m e - s e r i e s .reLTihis is;.an, exSmp-leijoif3:the?cWayi on.which a s m a l l number of r e l a t i v e l y r a r e s u b j e c t s can be used e f f i c i e n t l y .  I d i s a g r e e with- the  o p i n i o n o f Johnson and L u b i n 0-9721 t h a t we need not use s i g n i f i c a n c e in  s i n g l e - s u b j e c t p s y c h o p h y s i o l o g i c a l experiments.  tests  The ease with, which,  e r r o r s o f i n f e r e n c e c o u l d a r i s e from v i s u a l i n s p e c t i o n of the d a t a i s i l l u s t r a t e d i n F i g u r e s 7 and At  t h i s p o i n t , b i o f e e d b a c k can be s a i d t o have j o i n e d s e v e r a l o t h e r  treatments which demonstrated feedback 1965).  8.  reduce s t u t t e r i n g .  f o r masking  S i m i l a r l a b o r a t o r y e f f e c t s have been  n o i s e ( C h e r r y & S a y e r s , 1956), delayed a u d i t o r y  (Goldiamond, .1965) and metronome-paced speech. ( F r a n s e l l a &.Beech, U n f o r t u n a t e l y , none of the l a t t e r treatments have much c a r r y o v e r  l a b o r a t o r y to l i f e ,  and thus t h e y have not f u l f i l l e d  from  t h e i r t h e r a p e u t i c pro^-  mise. The p r o s p e c t s f o r b i o f e e d b a c k as s p e e c h therapy appear more encoura-r ging.  P r o b a b l y the feedback e f f e c t  c o u l d be made s t r o n g e r and more d u r a b l e .  78  Shaping  (i.e..',  varying  the EMG  amplitude at which, the feedback, tone i s a c -  t i v a t e d o r becomes h i g h - p i t c h e d ) , c o u l d be used to make f e e d b a c k easy a t f i r s t ,  then p r o g r e s s i v e l y more c h a l l e n g i n g .  o u t , the s t u t t e r e r would t h e t i c cues. tone might  training  As feedback was  faded  presumably be f o r c e d t o r e l y i n c r e a s i n g l y on somes-r  M a n i p u l a t i o n of the volume and f r e q u e n c y range of the feedback  a l s o enhance feedback t r a i n i n g .  Non-auditory-modalities (e.g.,  a v i s u a l d i s p l a y of r e d , green, and amber l i g h t s ) might b e used i n s t e a d o f , or i n c o n j u n c t i o n with., the a u d i t o r y tone. t i o n that  the a v e r s i v e feedback tone i t s e l f may  speech of some s u b j e c t s (Study 4)1. the feedback t a s k more rewarding. meters  Indeed, t h e r e Is a s l i g h t  (e.g. , GSR,  Back-rup  Indica-  have tended to d i s r u p t  the  r e i n f o r c e r s - c o u l d be used to make  And o f c o u r s e , feedback of s e v e r a l p a r a -  r e s p i r a t i o n , h e a r t rate), c o u l d be used to teach, the  s t u t t e r e r t o moderate h i s g e n e r a l a r o u s a l l e v e l .  Biofeedback, t r a i n i n g  a l s o be used i n c o n j u n c t i o n w i t h : o t h e r treatments f o r s t u t t e r i n g ,  could  e.g.,  r a t e c o n t r o l t h e r a p y , o r w i t h f l o o d i n g o r s y s t e m a t i c d e s e n s i t l z a t i o n to f e a r e d s i t u a t i o n a l and phonemic cues-.  The l a b o r a t o r y - s i t u a t i o n c o u l d be.  made more r e a l i s t i c by h a v i n g s u b j e c t s c o n v e r s e spontaneously- w i t h . each, o t h e r , o r w i t h a v i d e o t a p e d speaker. of i n c i p i e n t stuttering  s t u t t e r i n g , i f EMG  EMG  might prove u s e f u l i n t h e d i a g n o s i s  s p i k i n g were found t o d i s c r i m i n a t e  from n o r m a l e c h i l d h o o d d i s f l u e n c y .  Young s t u t t e r e r s  true  c o u l d perhaps,  be g i v e n p r e v e n t i t i v e f e e d b a c k t r a i n i n g . Now  t h a t a treatment e f f e c t has been e s t a b l i s h e d , t h e next s t e p i n  t h i s l i n e of r e s e a r c h might  i n v o l v e a comparison of t h e e f f e c t i v e n e s s of  b i o f e e d b a c k a g a i n s t the b e s t e x i s t i n g  therapy, v i z . , rate^-control therapy.  I f a s u f f i c i e n t number of matched s u b j e c t s c o u l d Fe f o u n d , a group d e s i g n  79  would be a p p r o p r i a t e  f o r t h i s purpose.  Otherwise, t i m e - s e r i e s a n a l y s i s  c o u l d be used p r o f i t a b l y , e.g., each data p o i n t might r e p r e s e n t frequency  the mean  of s t u t t e r i n g d u r i n g a one-hour weekly treatment s e s s i o n .  Subjects  c o u l d be f o l l o w e d up c o v e r t l y a f t e r the therapy had been completed, e.g., they c o u l d be telephoned experimenter.  on some p l a u s i b l e p r e t e x t by an accomplice  The use o f n o n r e a c t i v e measures and n a t u r a l i s t i c  of t h e  observation  i n t h e e v a l u a t i o n o f s t u t t e r i n g therapy has' been advocated by. Andrews and Ingham.(1972). I t might be p o s s i b l e t o c o n s t r u c t a m i n i a t u r e EMG feedback, u n i t ( c o n s i s t i n g of a p o c k e t s - s i z e d  a m p l i f i e r p l u s e l e c t r o d e s and an earplug)_  w h i c h c o u l d be worn as a p r o s t h e t i c . veloped.  Brady (1972) has patented  S i m i l a r d e v i c e s a r e a l r e a d y b e i n g de-r-.  a m i n i a t u r e metronome which, can be worn  l i k e a h e a r i n g a i d , But u n f o r t u n a t e l y i t Imparts a s t a c c a t o q u a l i t y - t o t h e wearer's s p e e c h w h i c h i s as conspicuous as a s e v e r e s t u t t e r , masking n o i s e generator  i s a v a i l a b l e ( T r o t t e r & L e s c h , .1967).but i t produces  f l u e n c y i n the wearer a t the c o s t o f t e m p o r a r i l y deafening difficult  A portable  t o use i n c o n v e r s a t i o n a l s i t u a t i o n s .  him, and thus. i s .  P o r t a b l e delayed  auditory-  feedback u n i t s have been c o n s t r u c t e d but a r e not s u i t a b l e f o r c l i n i c a l use at  t h i s time (Van R i p e r , 1973),. B a i l e y (Note 6),, f o l l o w i n g the l e a d o f Hanna e t a l . (1975), i s  p r e s e n t l y t e s t i n g a take-home.feedback, u n i t f o r s t u t t e r e r s . of a t a k e s - h o m e feedback u n i t a r e obvious-:  ;  The advantage  the s t u t t e r e r c o u l d l e a r n c o n t r o l  of h i s l a r y n g e a l muscles i n l h i s own time and a t h i s own!place, r a t h e r than d u r i n g r e g u l a r - v i s i t s to the c l i n i c i a n ' ' s o f f i c e . a l s o Be u s e f u l i n a c r i s i s s i t u a t i o n when access  A take^hbme d e v i c e  could  t o the c l i n i c would be im-  80  possible.  The  c o s t and q u a l i t y . o f p o r t a b l e EMG  more a t t r a c t i v e  (Paskewitz,. 1975).  the p o s s i b i l i t y  t h a t the b i o f e e d b a c k e f f e c t  t r a n s f e r t o r e a l l i f e speaking  feedback, equipment i s becoming  The success o f s u c l i a d e v i c e r e l i e s i s not apparatus-abound,  will  situations.  B i o f e e d b a c k as a treatment f o r s t u t t e r i n g deserves to be gated i n the c o n t e x t o f an i n t e n s i v e t r e a t m e n t program emphasizing and maintenance o f : f l u e n c y .  but  on  A l t h o u g h t h i s treatment r e q u i r e s  investitransfer  relatively  s o p h i s t i c a t e d i n s t r u m e n t a t i o n i t i s c o n c e i v a b l e that -.after:'.sufficient train-n i n g j a s t u t t e r e r c o u l d l e a r n to a t t e n d to p r o p r i o c e p t i v e . c u e s of l a r y n g e a l t e n s i o n i n the absence demonstrated  I n d e e d , t h i s has been  i n o t h e r b i o f e e d b a c k ^ a p p l i c a t i o n s .'• B i o f e e d b a c k may -be the  technique •motor sequences (Van  of Biofeedback equipment.  t h a t w i l l ' p r e v e n t o r e l i m i n a t e the c o r e d i s r u p t i o n s of the t h a t perhaps  R i p e r , 1973, p. 203)..  comprise the h e a r t of the ' ( s t u t t e r i n g ) , problem" '  81  CHAPTER V I I I ADDENDUM Guitar  (Note 7). has i n d e p e n d e n t l y performed a s e r i e s of experiments  w h i c h resemble Study 3.  G u i t a r t r a i n e d t h r e e s t u t t e r e r s t o reduce  muscle a c t i o n p o t e n t i a l s  (MAPs) at f o u r  their  sites:  1) over the o b i c u l a r i s o r i s s u p e r i o r  (lip1,  2) over the a n t e r i o r b e l l y of the d i g a s t r i c  Cchinl,  3) j u s t above the t h y r o i d c a r t i l e g e ( l a r y n x ) , . 4) over the f r o n t a l i s muscle EMG  (forehead).  feedback c o n s i s t e d o f a tone w h i c h i n c r e a s e d i n f r e q u e n c y i n p r o p o r t i o n  to the v o l t a g e of the EMG  signal.  G u i t a r ' s and Ilanna's EMG  feedback were  a p p a r e n t l y v e r y s i m i l a r , because b o t h were based on the e l e c t r o d e s i t e feedback apparatus-used by Hardyck, P e t r i n o v i c h and E l l s w o r t h  (1966).  F o l l o w i n g a b a s e l i n e p e r i o d , feedback t r a i n i n g f o c u s e d on one muscle at a time.  Shaping was used t o f a c i l i t a t e feedback t r a i n i n g .  p r e s e n t e d i n T a b l e 15.  and  group  R e s u l t s are  A l t h o u g h s i g n i f i c a n c e l e v e l s : a r e not g i v e n , a l l t h r e e  s u b j e c t s appeared t o show s u b s t a n t i a l improvement w i t h feedback from the laryngeal s i t e .  G u i t a r a l s o found t h a t s u b j e c t s 1 and 3 showed improvement  w i t h feedback from the l i p as w e l l , and concluded t h a t t h e s t u t t e r i n g b l o c k may  n o t be l o c a l i z e d at the l a r y n x a l o n e f o r a l l s t u t t e r e r s .  change shown i n T a b l e 15 may  The degree of  be an o v e r e s t i m a t e because of t h e p o s s i b i l i t y  of a s t r o n g a d a p t a t i o n e f f e c t d u r i n g r e p e a t e d r e a d i n g of l i s t s of s t i m u l u s words.  Indeed, t h e decrease i n s t u t t e r i n g d u r i n g feedback from the f r o n t a l i s  s i t e p r o b a b l y r e f l e c t s some degree of a d a p t a t i o n ^ as; w e l l a s - g e n e r a l head relaxation.  -82  Table.15 Changes i n Muscle A c t i o n P o t e n t i a l CMAP) L e v e l s and S t u t t e r i n g Frequency  (From G u i t a r , Note.7)  Percent Site  Subject  1  2  3 •  decrease  i n MAP  level  Percent  decrease  lh stuttering  frontalis  19  18  lip  76 .  89  chin  24  larynx  51 •  frontalis  52  0  lip  39  6  chin  13  2  larynx  56  25  frontalis  41  28  lip  87  57  chin  73  32 .  larynx  37  55  1 44  83  G u i t a r claimed and  of h i s t h r e e s u b j e c t s achieved  "partial"  " c o n s i d e r a b l e " g e n e r a l i z a t i o n of f l u e n c y o u t s i d e the l a b o r a t o r y , but  presented was  t h a t two  no  data to t h i s e f f e c t .  used as therapy  Subsequently, EMG  f o r a fourth, s u b j e c t .  feedback from the  S t u t t e r i n g was  reduced to a  n e g l i g i b l e l e v e l a f t e r o n l y . t h r e e s e s s i o n s of feedback d u r i n g speech.  F i v e weeks l a t e r the s u b j e c t r e p o r t e d t h a t he was  f l u e n t i n a l l s i t u a t i o n s " , and t i o n with a stranger. to be speaking The  d i d not  conversational  "satisfactorily  s t u t t e r during a videotaped  At a nine-^month: f o l l o w - u p ,  chin  the s u b j e c t was  conversareported  f l u e n t l y at a normal r a t e .  s i m i l a r i t y between the r e s u l t s of G u i t a r ' s r e s e a r c h and  i s encouraging, as i s G u i t a r ' s e x p l o r a t o r y treatment  study.  Study 3  84  REFERENCE. NOTES  1.  P e r k i n s , W.H. B e h a v i o r a l management of s t u t t e r i n g . Final report, S o c i a l and R e h a b i l i t a t i o n S e r v i c e r e s e a r c h grant 14-P----55281. Washington, D.C.: Department of H e a l t h , E d u c a t i o n , and W e l f a r e , 1973..  2.  Hanna, R., & M o r r i s , S. Speech, r a t e and s c r i p t submitted f o r p u b l i c a t i o n , 1975.  3.  Stromsta, C. Average evoked responses of s t u t t e r s and n o n s t u t t e r s as a f u n c t i o n of i n t e r n a l time r e l a t i o n s h i p s . T e c h n i c a l r e p o r t . National I n s t i t u t e s of H e a l t h , P r o j e c t NB-03541-03, 1965.  4.  Shrum, W.F. A study of the speaking b e h a v i o r of s t u t t e r e r s and nons t u t t e r e r s by means of m u l t i c h a n n e l electromyography. Paper p r e s e n t e d at the c o n v e n t i o n of the American Speech and H e a r i n g A s s o c i a t i o n , 1967.  5.  Freeman, F . J . , & U s h i j i m a , T. L a r y n g e a l a c t i v i t y accompanying the moment of s t u t t e r i n g : A p r e l i m i n a r y r e p o r t (SR-37/38). H a s k i n s L a b o r a t o r i e s : S t a t u s r e p o r t on speech r e s e a r c h , 1974.  6.  B a i l e y , G.  7.  G u i t a r , B. Reduction of s t u t t e r i n g frequency u s i n g electromyographic feedback of muscle a c t i o n p o t e n t i a l s . 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S i e g e l , G.M., & M a r t i n , R.R. V e r b a l punishment of d i s f l u e n i c e s i n normal speakers. J o u r n a l o f Speech and H e a r i n g Research, 1965, j8, 245-251. S k i n n e r , B.F.  Verbal behavior.  New York:  Appleton,  1957.  Snyder, C.,& Noble, M. Operant c o n d i t i o n i n g of v a s c o n s t r u c t i o n . of E x p e r i m e n t a l P s y c h o l o g y , 1968, 77, 263-268.  -Jourrial ~~~  92  Stromsta, C. E x p e r i m e n t a l b l o c k a g e of p h o n a t i o n of d i s t o r t e d s l d e t o n e . J o u r n a l of Speech and Hearing Research:, 1959, 2_, 280-301. Stromsta, C. Delays a s s o c i a t e d w i t h c e r t a i n s i d e t o n e pathways. of A c o u s t i c a l S o c i e t y of America, 1962, \34_, 392-396.  Journal  Stromsta, C. I n t e r a u r a l phase d i s p a r i t y o f s t u t t e r e r s and n o n s t u t t e r e r s . J o u r n a l o f Speech and H e a r i n g Research, 1972, 15, 771-780. Thompson, A.H. 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Recent e m p i r i c a l and t h e o r e t i c a l approaches to the e x p e r i m e n t a l m a n i p u l a t i o n of speech i n normal s u b j e c t s and stammerers. B e h a v i o r a Research arid Therapy, 1963, 1^, 95-119. Young, M.A. P r e d i c t i n g r a t i n g s of s e v e r i t y of s t u t t e r i n g . J o u r n a l of Speech and H e a r i n g D i s o r d e r s , Monograph supplement 7, 1961, 31-54.  APPENDIX A Assignment o f S u b j e c t s t o S t u d i e s  Subject  1 .  2  3  4  Rick  X  X  Frank  X  X  John  X  X  X  David  X  X  Don  X  X  Ray-  X  X  Ruth  X ..  X  5  X  X  Larry Teresa  X  X  Doug  X  X  Ron  X  X  Eric  X•  Jeff  X  Susan  X  N =14.  3  • 4  6  6  7  94  APPENDIX B  Dependent V a r i a b l e s :  Inter-Rater R e l i a b i l i t y  and Percent  Agreement  Dependent Study  1  Subject  Frank  Percent syllables- stuttered  .87 81%  2 .  David  .84 76%  3  Ray  .89 85%  4  Ruth  .93. 77%  5  Doug  .89. 83%  variable  EMS s p i k e s p e r .100 s y l l a b l e s ;  .90. 92%  .92 . 90%  .94 93%  T95 90%  .92 94%  Speech; r a t e (SPM)  .9,4 9.6%  . .90 94%  .9-7 98%  .96 .,97%  .94 98%  95  APPENDIX C Minimum Pen D e f l e c t i o n s . D e f i n i n g  an EMG  Spike  Subject  Polygraph, s e n s i t i v i t y (mV/cm).  Feedback a c t i v a t i o n t h r e s h o l d (mVl  David  .05  .025  Don  .10  .05  Ray  .05  .05  Ruth  .05  .025  John ( p i l o t s t u d i e s ) .  .10  .10.  (Study 1)  .20  .20:  Rick  .10  .05  Frank  .10  .05  Larry  .10  .05  Teresa  .05  .075  Doug  .05  .075  Ron  .05  .05  Eric  .05  .025  Jeff  .05  .0.5  Susan  .02  .02  , 96  * .  APPENDIX D I n s t r u c t i o n s - f o r S t u d i e s 3 and 5  (Before b a s e l i n e , a f t e r TAT i n s t r u c t i o n s ) When y o u nave spoken about t h e cards f o r 15 minutes, you w i l l hear a h i g h ^ p i t c h e d tone coming  from t h e speaker a t your s i d e .  t e n s i o n i n your s p e e c h muscles. tense you a r e .  The tone i n d i c a t e s , the  The h i g h e r t h e p i t c h o f t h e tone, t h e more  When you a r e speaking i n a r e l a x e d way, t h e tone w i l l  off  completely.  Your j o b i s to t r y to shut i t o f f , o r a t l e a s t  the  p i t c h of the tone as low as p o s s i b l e .  shut  to keep  I can't e x p l a i n how you c o u l d  do t h i s , any more than I c o u l d . t e l l you how t o l i f t  your arm.  Just t r y  anything you can to p r e v e n t t h e tone from coming on, o r b e i n g highr-pitched, w h i l e you speak about t h e c a r d s .  (At  Do you understand?  t h e end of the b a s e l i n e p e r i o d )  The tone w i l l be i n o p e r a t i o n from now on. the  Do a n y t h i n g you can to p r e v e n t  tone from coming on, o r from b e i n g h i g h - p i t c h e d , w h i l e you speak.  a new card and c o n t i n u e s p e a k i n g .  Take  97  APPENDIX E Questions Used  Study 4  to I n v e s t i g a t e Awareness of Feedback  Conditions  CFeedback without- i n s t r u c t i o n s )  1.  What do you t h i n k t h a t tone was f o r ?  2.  Do you t h i n k the tone made any d i f f e r e n c e t o your  speech?  Clf s o , what?)  Study 5  CFalse 1.  feedback)  Do you t h i n k the tone made any d i f f e r e n c e to your speech? . C l f s o , what?)  2.  D i d you do anything  t o t r y to p r e v e n t the tone from coming on?  Clf s o , what?) 3.  Do you t h i n k you d i d any b e t t e r a t c e o h t r o l l i n g t h e tone t h e first  4.  time i t was on, o r the second time?  Do you t h i n k the tone was t h e same each time?  

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