The Immediate and Long-term Effects of Altered Auditory Feedback

226 Pages·2012·1.64 MB·English

by  Julia Prinzing

The Immediate and Long-term Effects of
Altered Auditory Feedback (AAF) on the
Characteristics of Persistent Developmental Stuttering

Technisch unterstützte Reduktion des Stotterns (TURS):
Die sofortige und langfristige Wirkung von
modifiziertem auditivem Feedback (MAF) auf das chronische Stottern

Von der Pädagogischen Hochschule Heidelberg
zur Erlangung des
Grades einer Doktorin der Philosophie (Dr. phil.)
genehmigte Dissertation von

Julia Unger
aus
Bad Neustadt
2012
Erstgutachter: Prof. Dr. Christian Glück
Zweitgutachter: Prof. Dr. Jürgen Cholewa
Fach: Angewandte Sprachwissenschaft/Sprachheilpädagogik
Tag der Mündlichen Prüfung: 26.September 20121  

1 Anmerkung: Zum Zeitpunkt der elektronischen Veröffentlichung des Gesamtwerkes sind bereits
Teilergebnisse der hier vorgelegten Arbeit in Form eines wissenschafltichen Fachartikels erschienen:
Unger, J.P., Glück, C.W., & Cholewa, J. (2012). The immediate effects of AAF devices on the
characteristics of stuttering: a clinical analysis. Journal of Fluency Disorders. 37(2), 122-134. Die
bereits veröffentlichten Teilergebnisse sind in dieser Dissertation in von dem Artikel abweichenden
Grafiken abgebildet. Gleiche Inhalte sind mit Erlaubnis reproduziert.
Meiner Familie in tiefster Dankbarkeit
Danksagung

Mein besonderer Dank gilt meinen Promotionsbetreuern Herrn Prof. Dr. Christian
Glück und Herrn Prof. Dr. Jürgen Cholewa für die Möglichkeit meine
Forschungsvorhaben im Rahmen einer Promotion umsetzen zu können. Für die
aktive Unterstützung durch die Erstellung zahlreicher Gutachten zum Erwerb einer
Forschungsförderung, als auch für den inspirierenden fachlichen Austausch und die
auf persönlicher Ebene stets wohlwollend-herzliche Begleitung bin ich sehr dankbar.

Auch bei dem Forschungsausschuss der Pädagogischen Hochschule Heidelberg
möchte ich mich für die Verleihung eines Landesgraduiertenstipendiums in aller
Form bedanken. Des Weiteren bedanke ich mich bei den Studienprobanden, die
durch ihre Anreise und aufgeschlossene Teilnahme die Durchführung der Studien
ermöglichten.
Abstract: Immediate effect study

Purpose: The immediate effects of altered auditory feedback (AAF) and a placebo
condition on clinical attributes of stuttering during scripted as well as spontaneous
speech are investigated herein. The primary purpose is the extension of the
evidence-base of the impact of AAF on the clinical characteristics of stuttering.

Method: Two commercially available AAF devices were used to create the delayed
auditory feedback (DAF) and frequency altered feedback (FAF) effects. The
participants consisted of thirty German-speaking people who stutter (PWS), aged 18
to 68 (M = 36.5; SD = 15.2). Each subject produced four sets of oral readings, three
sets of monologs and three sets of dialogs. The participants were exposed to
different experimental conditions (No device, Placebo, active AAF using Device A,
and active AAF using Device B) while producing the speech samples. The
recordings were then electronically analyzed to detect changes in select features of
stuttering; frequency, duration, speech rate, articulation rate and core behaviors. The
occurrence of these variables was examined across all speech samples collected
within the four experimental conditions.

Results: A statistically significant difference in the frequency of stuttered syllables
(%SS) was found while using both devices (p = .000). Although individual reactions
varied widely, the most notable reductions in %SS occurred within the reading (M =
2.33, SD = 3.75) and monolog (M = 2.26, SD = 3.32) samples. Thus, active AAF
settings had the least impact on speech fluency during conversational speech (M =
1.49, SD = 2.71). In the analysis of stuttering type, it was found that blocks were the
only core behavior that was reduced to a statistically significant degree (p = .001).
During the placebo condition (no active AAF parameters), the subject group also
experienced a statistically significant decline in %SS (p = .028).

Conclusion: This result indicates that the effects of AAF alone may not be the sole
reason for fluency enhancements experienced when using a portable speech aid.
Abstract: longitudinal trail

Purpose: The effects of a portable altered auditory feedback (AAF) device on the
severity of stuttering over a three-month period were investigated. The main goal
was to examine the usage behavior and fluency-enhancements displayed during
extended device utilization.

Method: Qualitative data on implementation environments, utilization patterns and
user satisfaction were collected weekly from a group of seven adults (M = 45.3; SD =
11.4) who stutter. For the analysis of quantitative changes in stuttering severity,
speech samples were collected in person at the beginning and end of the trial period.
Two phone conversations throughout the study provided additional conversational
samples.

Results: Individual responses were quite diverse within both quantitative and
qualitative measures. Group analysis revealed that conversational speech was
overall significantly more fluent when a device was used. The percentage of
stuttered syllables was significantly lower z = -2.201, p = .028, r = -0.18 upon first
using AAF (with device: Mdn = 1.53; without device: Mdn = 3.53) and during the
personal conversation at the end of three months (with device: Mdn = 1.89; without
device: Mdn = 3.97). However, during the two mid-trial phone conversations utilizing
a device (T2 & T3), stuttering frequency remained largely unaltered T2: z = -.943, p =
.345 (Mdn = 3.87); T3: z = -1.57, p = .116 (Mdn = 3.00). The analysis of weekly
questionnaires and user diaries revealed that the device was most commonly used
in familiar environments (63% at home). On average, the speech aid was utilized
four to five times a week, with an overall satisfaction rate of 42%.

Conclusion: Some meaningful conclusions for clinical work with clients wishing to
use AAF can be drawn from these results. While AAF has its limits in reducing
stuttering, ability to use a device may be optimized if usage is acquired in a guided
clinical process.
PART I: INTRODUCTION .......................................................................................... 1
Chapter 1: The fluency disorder stuttering ............................................................ 2
1.1. Core behaviors ................................................................................................ 9
1.2. Secondary behaviors ..................................................................................... 11
1.3 The holistic presentation of core and secondary behaviors ............................ 13
1.4. Diagnosis ....................................................................................................... 17
1.4.1. Criterion-referenced tools ........................................................................ 17
1.4.1.1. Measurement of core behaviors ....................................................... 17
1.4.1.1.1. Frequency of moments of stuttering/Frequency of specific
dysfluency types ........................................................................................ 17
1.4.1.1.2. Mean duration of moments of stuttering ..................................... 19
1.4.1.1.3. Speech Rate .............................................................................. 20
1.4.1.2. Measurement of secondary behaviors .............................................. 20
1.4.1.2.1. Perceptions of Stuttering Inventory (cid:177) PSI (Woolf, 1967) ............ 21
1.4.1.2.2. Modified Erikson Scale of Communication Attitudes - S-24
(Andrews & Cutler, 1974) ........................................................................... 22
(cid:20)(cid:17)(cid:23)(cid:17)(cid:20)(cid:17)(cid:21)(cid:17)(cid:22)(cid:17)(cid:3)(cid:50)(cid:89)(cid:72)(cid:85)(cid:68)(cid:79)(cid:79)(cid:3)(cid:36)(cid:86)(cid:86)(cid:72)(cid:86)(cid:86)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:82)(cid:73)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:54)(cid:83)(cid:72)(cid:68)(cid:78)(cid:72)(cid:85)(cid:182)(cid:86)(cid:3)(cid:40)(cid:91)(cid:83)(cid:72)(cid:85)(cid:76)(cid:72)(cid:81)(cid:70)(cid:72)(cid:3)(cid:82)(cid:73)(cid:3)(cid:54)(cid:87)(cid:88)(cid:87)(cid:87)(cid:72)(cid:85)(cid:76)(cid:81)(cid:74)(cid:3)(cid:177)
OASES (Yaruss & Quesal, 2008) .............................................................. 23
1.4.2. Norm-referenced tools ............................................................................ 24
1.4.2.1. Stuttering Severity Instrument, 4th Edition - SSI-4 (Riley, 2009) ....... 25
Chapter 2: Etiology of stuttering .......................................................................... 27
2.1. Individualized theories on the nature of stuttering.......................................... 27
2.1.1. Breakdown hypotheses ........................................................................... 28
2.1.1.1. Physiological theories ....................................................................... 28
2.1.1.2. Psycholinguistic theories .................................................................. 31
2.2. Integrated theories on the nature of stuttering ............................................... 37
2.2.1. The communication-emotional model of stuttering (C-E Model) .............. 38
2.2.2. The dynamic multifactorial model of stuttering (DM-Model) .................... 40
Chapter 3: Established speech pathological treatments .................................... 44
3.1. Fluency shaping ............................................................................................. 44
3.2. Stuttering modification ................................................................................... 47
3.3. Evidence-base for the utilization of speech techniques ................................. 50
3.4. The clinical reality of stuttering management in daily life ............................... 59
Chapter 4: Technical treatment components ...................................................... 63
4.1. The development of altered auditory feedback (AAF) .................................... 63
4.2. Hypotheses on the effects of altered auditory feedback (AAF) ...................... 66
4.2.1. Influences on a deficient auditory processing system ............................. 67
4.2.2. Neurophysiological differences ............................................................... 68
4.2.3. Hypotheses on changes in speech production ........................................ 70
4.3. Influence of altered auditory feedback (AAF) on the speech of people who
stutter (PWS) ........................................................................................................ 71
4.3.1. Scripted speech ...................................................................................... 72
4.3.2. Spontaneous speech .............................................................................. 73
4.3.3. Subjective impressions of device usage ................................................. 75
4.4. Portable altered auditory feedback (AAF) devices ......................................... 78
4.5. Need for the present studies .......................................................................... 80
PART II: IMMEDIATE EFFECT STUDY .................................................................. 83
Chapter 5: Materials and methods........................................................................ 84
5.1. Participants .................................................................................................... 84
5.2. Apparatus ...................................................................................................... 84
5.3. Procedure ...................................................................................................... 87
5.4. Research questions ....................................................................................... 88
5.5. Assessment of speech parameters ................................................................ 89
5.6. Statistical design ............................................................................................ 91
Chapter 6: Results (cid:177) immediate effects ............................................................... 93
6.1. Effects on stuttering frequency and duration ................................................. 93
6.1.1. Frequency ............................................................................................... 93
6.1.2. Duration................................................................................................... 93
6.2. Influence on speech and articulatory rate ...................................................... 94
6.2.1. Speech rate ............................................................................................. 94
6.2.2. Articulatory rate ....................................................................................... 95
6.3. Impact on stuttering type ............................................................................... 95
6.3.1. Total Repetitions ..................................................................................... 95
6.3.2. Prolongations .......................................................................................... 95
6.3.3. Total Blocks ............................................................................................. 95
6.4. Effects on speech samples ............................................................................ 96
6.4.1. Reading ................................................................................................... 96
6.4.2. Monolog .................................................................................................. 96
6.4.3. Dialog ...................................................................................................... 96
6.5. Fluency-enhancement across severity ratings ............................................... 97
6.5.1 Reading .................................................................................................... 99
6.5.2. Monolog ................................................................................................ 100
6.5.3. Dialog .................................................................................................... 100
6.6. Changes in speech fluency during the Placebo setting ............................... 101
6.6.1. Stuttering Frequency ............................................................................. 101
6.6.2. Influence on the percentage stuttered syllables (%SS) within low and high
SSI-4 severity ratings ...................................................................................... 102
6.7. Subjective impressions of the device usage ................................................ 104
6.7.1. Subjective improvement ........................................................................ 104
6.7.2. Wearing comfort .................................................................................... 104
6.7.3. Usage in daily life .................................................................................. 104
Chapter 7: Discussion (cid:177) immediate effects ....................................................... 106
7.1. Summary of findings and conclusion ........................................................... 106
7.2. Limitations and future research directions ................................................... 109
PART III: THREE-MONTH LONGITUDINAL TRIAL ............................................. 112
Chapter 8: Materials and methods...................................................................... 112
8.1. Participants .................................................................................................. 112
8.2. Apparatus .................................................................................................... 112
8.3. Procedure .................................................................................................... 114
8.4. Research questions ..................................................................................... 116
8.5. Assessment of speech parameters .............................................................. 118
8.6. Statistical design .......................................................................................... 118
Chapter 9: Results - longitudinal effects ........................................................... 119
9.1. Longitudinal effects of AAF on quantitative features of stuttering severity ... 119
9.1.1. Effects on stuttering frequency .............................................................. 119
9.1.1.1. Stuttering Frequency during Reading ............................................. 119
9.1.1.2. Stuttering Frequency during Monolog ............................................. 120
9.1.1.3. Stuttering Frequency during Conversation ..................................... 120
9.1.2. Effects on duration of moments of stuttering ......................................... 123
9.1.2.1. Average Duration of Moments of Stuttering while Reading ............ 123
9.1.2.2. Average Duration of Moments of Stuttering during Monolog .......... 123
9.1.2.3. Average Duration of Moments of Stuttering during Conversational
Speech ........................................................................................................ 123
9.1.3. Influence on speech and articulatory rate ............................................. 124
9.1.3.1. Effects on Speech Rate .................................................................. 124
9.1.3.2. Effects on Articulatory Rate ............................................................ 124
9.1.4. Impact of device usage on stuttering type ............................................. 125
9.1.4.1. Effects on Repetitions ..................................................................... 125
9.1.4.2. Influence on Prolongations ............................................................. 126
9.1.4.3. Impact on Blocks ............................................................................ 126
9.1.5. Effects on Stuttering Severity ................................................................ 126
9.2. Qualitative analysis of device usage in natural environments ...................... 127
9.2.1. Frequency of device usage ................................................................... 127
9.2.1.2 Relationship between usage frequency and occurrence of stuttering
.................................................................................................................... 131
9.2.2. Utilization patterns ................................................................................. 132
9.2.2.1. Communicative contexts ................................................................. 132
9.2.2.3. Usage environments ....................................................................... 133
9.2.3. Feature utilization .................................................................................. 133
9.2.3.1. Setting preference .......................................................................... 134
9.2.3.2. Headphone preference ................................................................... 135
9.2.4. User perception of device utilization ...................................................... 135
9.2.4.1. Overall user satisfaction ................................................................. 135
9.2.4.2. Prominent concerns during device usage ....................................... 136
Chapter 10: Discussion (cid:177) longitudinal effects ................................................. 137
10.1. Summary of findings and conclusion ......................................................... 137
10.2. Limitations and future research directions ................................................. 141
Chapter 11: The professionalization of speech aid implementation in the
treatment of stuttering: a proposal ..................................................................... 143
References ............................................................................................................ 147
Table Index ........................................................................................................... 176
Figure Index .......................................................................................................... 178
Appendix Index .................................................................................................... 179
Appendix 1: Deutsche Zusammenfassung der Englischen Originalarbeit .......... 180
Appendix 2: Formatvorlage eines diagnostischen Berichtes über individuelle,
gerätespezifische Effekte auf die Sprechflüssigkeit ............................................ 206
Appendix 3: Ananmesebogen zur Identifikation personenspezifischer Daten vor
der Anwendung von modifiziertem auditiven Feedback (MAF) ........................... 210
Appendix 4: Formatvorlage für einen Fragebogen und ein Anwendertagebuch zur
kontinuierlichen Erfassung klientenspezifischer Eindrücke während einer
Gerätenutzung .................................................................................................... 212
Appendix 5: Übersicht der elektronischen Anhänge auf den Begleitmedien ....... 216