Early intervention for preschoolers is thought by many to be desirable, although the known 70% natural recovery rate of this population (Yairi and Ambrose, 2005) must be controlled for in client selection, lest we divert attention from those who will not recover to treat those who will. Therefore, another treatment variation for preschoolers is extended base rate observation for at least three to four times every 3–5 months, for at least 9–15 months, to determine stability of the stuttering response. If the stuttering is naturally decreasing, the child is on the recovery path and therapy should be withheld, with extended base rate continued until the child shows stability of under 3.0 SWM for a second year. If the rate is stable or increasing during that first observation year, then the child should be offered treatment of GILCU or the Lidcombe Program (see Chapter 4). After several more years of follow-up of both groups, this procedure proved to be 95% accurate in selecting persistent stuttering clients for treatment. Figure 17.1 presents some results about this topic from Ryan (2001b), showing two groups of preschool stuttering children aged 2–5 years. One group (N = 7) persisted and one group (N = 15) naturally recovered. This provided a natural recovery rate of 68%, which is broadly consistent with the Yairi and Ambrose (2005) results. Based on these results, we have used the extended base rate procedure to select persisted clients for treatment. In short, we have very little GILCU data with preschoolers because most recovered naturally, and/or we also focused on doing Phase I trials on other independent variables like interruption or experimental programmes like ‘slow’ talk with children who did not recover. In short, I have not used the preschool version of the GILCU programme very much, only reporting on one 4-year-old child in Ryan (2001a).

Advantages and disadvantages

Advantages

The GILCU Establishment programme is easy to administer to clients and to teach to student clinicians. The programme has been conducted successfully by many different trained clinicians (Ryan, 1981, 2001a). It requires only that the clinician be able to accurately and consistently identify stuttered words and/or syllables and provide appropriate consequences and the client to be able to speak fluently for gradually longer and longer utterances or time periods, starting with one word up to sentences, and then 1 minute up to 5 minutes of talking.

This programme has been successful in the schools, partly because in the American school system the students and their parents are easily available, especially for transfer and maintenance. The Individuals with Disabilities Education Act of 1975 is a US federal law2 that mandates individual educational programmes as needed. The Act requires that at least one parent comes to the school to develop and participate in any treatment programme planning and execution for any 3–21-year-old person who has been identified with a special problem, including stuttering. GILCU has been used in the United Kingdom (Rustin et al., 1987). Additionally, GILCU has been used successfully in several countries in a non-English language: Mandarin (Ryan, 1998) and German (Scheppe and Jehle, 1985).

Disadvantages

My clinical experience and research has shown that a weakness of GILCU is that it is less effective with more severe clients, particularly teenagers or adults (Ryan and Ryan, 1983, 1995). In my view, clients must ‘find’ their own way to speak fluently and some with severe stuttering cannot achieve that. For those few failure clients with GILCU, we have then used the DAF-Prolongation Establishment programme (Ryan, 2001a), or we have pre-sorted the severe clients into DAF-prolongation programmes (Rustin et al., 1987). Another potential disadvantage of GILCU is that some clinicians have trouble identifying and consequating stuttering even after training. It is also the case that transfer is difficult for some clinicians to arrange in private practice settings.

It is not a disadvantage of GILCU, but a disadvantage for people who stutter, that GILCU is not used by the speech pathology profession. In my opinion, based on examination of the literature and the American Speech-Language-Hearing website, GILCU is not widely known nor recognised nor practiced in our profession by people who treat stuttering. It is not taught in our university professional preparation programmes nor adequately cited with data in our modern speech-language pathology textbooks.

Conclusions and future directions

Evaluation of the GILCU programme shows that normal, permanent speech fluency is an attainable goal for people who stutter of all ages. After over 40 years of evidence-based practice and clinical research on over 200 clients using GILCU or a variation, to establish fluent speech, I believe GILCU has been shown to be a powerful, effective, easy to use and easy to teach procedure for helping people who stutter of all ages to speak fluently. The new shortened version is designed especially for school-age children for use by public school clinicians (Ryan and Ryan, 2005). This shortened version is still usable for adults with additional transfer procedures drawn from Ryan (2001a). This programme should be taught and practiced in every university training programme and be in the therapy repertoire of every speech-language pathologist who works with people who stutter. Our past research during which we gave students only the self-instructional materials and a week to study them before they went into treatment with a client, revealed that they were able to self-learn the programme in hours and conduct it out well with their clients, with only a few problems (Ryan and McMicken, 2007).

Discussion

Ann Packman
We were wondering what is meant by the statement that the procedures lead to ‘normal fluency’? How do you know that stutter-free speech is normally fluent speech?
Bruce Ryan
We refer to our data gathered from the Fluency Interview given to over 400 normally fluent people, male and female speakers aged 3–63, as judged by themselves and people who knew them (Ryan, 2001a). We considered (1) type of stuttered word, such as whole- and part-word repetition, prolongation and struggle, (2) rate of stuttered words and (3) speaking rate. We assume normal fluency, if, post-treatment, our stuttering clients speak within one SD either above or below each of the means of these three parameters for normally fluent speakers of varying ages with no struggle. Rarely did our normally fluent speakers demonstrate struggle. Finally, our clients must sound normally fluent to us by casual observation or formal naturalness ratings (Ryan, 2001a).
Ann Packman
This all raises the issue that it seems paradoxical that normal speech can contain stuttering. What do you say to that?
Bruce Ryan
No, not at all. One may stutter occasionally and not be a stutterer. For example, the stuttered utterances of ‘c-car’ or ‘car-car’ or ‘caaar’ can and are spoken by almost all normally fluent speakers as well as stutterers. This is not true for struggle. The difference is the rate of occurrence. If the speaker emits above 3% of words spoken, or 1.5 percent syllables stuttered (%SS; Ryan, 2001a), the speaker is considered to be a stutterer by both lay people and most speech professionals. Few normally fluent speakers are 100% fluent, according to our numerous hours of audiotape of normally fluent speakers. These cut-offs have been very functional both to select clients and to decide whether treated clients have reached normal fluency. Basic research was done on this point by Wendell Johnson in the 1940s and many speech-language pathologists have built their classification systems on his work, as have I.
Ann Packman
Can you elaborate on which of your data sets support your statement that the programme has been extremely effective in the American school system.
Bruce Ryan
The best data sets for GILCU in the public schools are to be found in Ryan (2001a) and Ryan and Ryan (1983, 1995). I was motivated to study operant programmes, like GILCU, in the public schools, because of the large number of stuttering children found in the public schools in America. We researched treatment programmes that were developed by us, but conducted by public school clinicians while carrying out their regular duties with their other regular clients in their respective public schools. These clinicians were trained and supervised by us to control for administration validity. Further, Barbara Ryan has worked in the public schools of Southern California for the past 33 years and has collected extensive, but as yet unpublished data, using GILCU with her public school stuttering clients. She has reported to me that she has seldom failed to establish fluent, normal speech. Follow-up, conducted by her, indicated that the children had remained fluent.
Ann Packman
Can you give us more details about how you collected the outcome measures obtained for the studies you overviewed?
Bruce Ryan
The Fluency Interview and Criterion Tests were done with the clinician in the clinic room, pre-establishment, post-establishment, post-transfer, post-maintenance and at follow-up. We also measured clients’ stuttering during all transfer steps, such as speaking in the classroom or at work, and at follow-up. The number of steps varied with the client’s age. Most often, in the first transfer activities, the clinician was there and counted and recorded stuttered words. In some of the latter Transfer programme steps, depending on age and ability, the client self-recorded on a small tape recorder, or simply reported stuttered words. These outside measures served to check the client’s speech in the natural environment. We compared these to our in-clinic measures and found them quite comparable. We also asked for self-reports from the client or client’s parents about the client’s stuttering, which generally reflected the improvement shown in the SWM measures.
Joseph Attanasio
Your programme requires that clinicians can accurately and consistently identify stuttered words and syllables. Is there evidence available for the accuracy and consistency of those clinician judgments? Certainly, other researchers have found this to be a problem.
Bruce Ryan
It is a problem. We all need to accurately identify and count stuttering events, if we are to conduct operant conditioning programmes that require appropriate, immediate consequences for the undesired responses of stuttered syllables and words and the desired responses of fluent syllables and words. We noted the problem in Ryan and Ryan (1983). To develop a classification system, I used basically the Johnson (1961) dual categories of normal disfluencies: interjections, revision, incomplete phrases, phrase repetitions, pauses and stuttered disfluencies, whole- and part-word repetitions, prolongations and struggle disfluencies (Ryan, 1974). Later, I modified this system to break down the categories of whole- and part- word repetition each into single and multiple repetitions after Yairi and Ambrose (2005) for my research with preschool children (Ryan, 2001a). Normal fluency would be defined as the absence or low rate (< 3.0 SWM) of stuttered disfluencies. I have always used and taught a classification system with the belief that such a system aided the identifier in counting accuracy, more of a match-to-sample or sort task rather than a simple identification of behaviours like ‘unambiguous stuttering’. Clinician observers were trained on this system to a high degree of accuracy using audio- and video-recorded samples (e.g. Ryan, 2001a; Ryan and Van Kirk, 1974). In addition, I used numerous inter- and intra-reliability procedures, commonly percentage agreement of simple counts between two or more observer clinicians. In my research with preschoolers, we also made scripts of our conversations with subjects and did point-to-point counts in our determination of reliability. We have striven for and usually achieved better than 90% agreement, or did more training, if we did not. The answer to your question is that there is an abundance of evidence of reliability measures in my research and that of others that clinicians can achieve high accuracy of identifying and counting with or without using the elaborate procedures of a classification system and audio–video training that I did.
Joseph Attanasio
Given that the programme has been in use for 40 years, we were wondering why randomised controlled trials have not been done.
Bruce Ryan
The programme appeared to be running well, in my purview, and according to our research. See the results of eight studies that I reported previously. Also, one could describe our research reported in Ryan and Ryan (1983, 1995) as a stratified random sampling design, advanced for the time of data collection during 1972–1974. Participants in these two studies were children who were 6 years of age or older. Almost all were past the age of spontaneous recovery, were able to read and had a high probability of persistence. My wife, Barbara Ryan has run the programme very successfully in the public schools from 1978 to 2011. She often said that she never failed to help a school-age stuttering child become normally fluent. Unfortunately, she has not been able to share these data because of local school privacy of information policy. We eventually shortened the programme (Ryan and Ryan, 2005) and still she has achieved equal success using it primarily with school-age children. We have run the original GILCU (Ryan, 2001a) in my University clinic since 1978, then have tested the self-instructional form of the programme for 5 years with similar positive results (Ryan and McMicken, 2007).
Joseph Attanasio
Given the evidence in support of the Lidcombe Program for early stuttering and the Camperdown Program for adolescents and adults, both of which are non-programmed treatments, what are the arguments in favour of a highly structured and programmed approach such as GILCU?
Bruce Ryan
The major value of tight structure, as in the GILCU programme, is accuracy of replication, important both for scientific investigation and effectiveness. As I discuss in Ryan (2001a), careful examination of the Lidcombe Program reveals that it may have more structure and be more programmed than the authors realise. As an update, I recently re-read both the current guides for the Camperdown Program and the Lidcombe Program. I noted a great amount of detail in these latest instructional manuals, including score sheets and rating scale data sheets. True, there were few criterion levels (save for %SS levels for passing some treatment phases, but still, in my opinion, these manuals, and the programmes they describe, very closely approximate at least ‘train loosely’ (Stokes and Baer, 1977) programmed instruction. I would speculate that in actual practice, the Lidcombe Program and the Camperdown Program are not that much different in basic structure and operant logic from the GILCU programme; they both use observable behaviour, small, sequential steps towards a goal of reduced or no unambiguous stuttering and appropriate consequences for desired and undesired behaviour.
Joseph Attanasio
There are several components to your very meticulous response, but I would like to follow-up on what seems to be your relevant point. That is, your statement that the only advantage you can see for tight programming is the accuracy of replication or treatment integrity, also called treatment fidelity. Might the case be the opposite of what you suggest? That is, the more tightly programmed the treatment, the more likely it might be that clinicians and researchers would err in following treatment steps in the manner those steps are prescribed and, at the same time, the less likely would treatment take advantage of the individual ways in which clients successfully respond to treatment and of the ways in which clinicians (or parents, in the case of Lidcombe) successfully adapt treatment to fit the needs and responses of clients? In short, might tight programming be unnecessarily rigid and prone to error?
Bruce Ryan
Anything is possible, but I thought we were in the context of science, not speculation. I think structure and clarity of procedures are important assets of programmed instruction, which lead to replication, an important facet of science itself. Our observations have been that clinicians do adapt the GILCU programme regardless of what they have been taught and how clearly the programme is described (Ryan and Ryan, 1983, 1995). Further, we have seen what they do ‘intuitively’ has often been to the detriment of the efficacy of the programme (Ryan, 2001a). While supervising, we have often had to say, ‘Stick to the programme!’ Programmes based on operant conditioning principles use these principles to solve the problems that arise during the construction and testing of the programme, not people’s instinctive or intuitive problem-solving abilities. For example, when we worried about the possibility that teenagers might not want to show up for treatment or do their home practice, we did not leave it to their parents or school clinicians or the teens themselves to intuitively solve the problem; we increased the reinforcement system, which solved the problem. When I worried about accidentally treating preschool children who might spontaneously recover, I did not elect to treat them all, instead we studied preschool stuttering children, giving them no therapy until the extended baseline trend of their stuttering behaviour over a year from the first observation was found to predict natural recovery or persistence (Ryan, 2001b).
Finally, how would one scientifically measure or control for the intuitive contributions made to the success of any treatment programme? If client, clinician and parent intuition are part of the programme, then there would be as many different programmes as there were clients, clinicians, and parents, along with their various intuitive behaviours.

References

Johnson, W. (1961) Measurements of oral reading and speaking rate and disfluency of adult male and female stutterers and nonstutterers. Journal of Speech and Hearing Disorders. Monograph Supplement(No. 7), 1–20.

Moore, W. (1984) Central nervous system characteristics of stutterers. In: R. Curlee & W. Perkins (Eds.), Nature and Treatment of Stuttering: New Directions (pp. 49–72). San Diego, CA: College-Hill.

Moore, W. (1993) Hemispheric processing research: past, present, and future. In: E. Boberg (Ed.), Neuropsychology of Stuttering (pp. 39–72). Edmonton, Alberta, Canada: University of Alberta Press.

Rustin, L., Ryan, B., & Ryan, B. (1987) Use of the Monterey programmed stuttering treatment in Great Britain. British Journal of Disorders of Communication, 22, 151–162.

Ryan, B. (1974) Programmed Stuttering Therapy for Children and Adults. Springfield, IL: CC Thomas.

Ryan, B. (1979) Stuttering treatment in a framework of operant conditioning. In: H. Gregory (Ed.), Controversies About Stuttering Treatment (pp. 129–144). Baltimore, MD: University Park Press.

Ryan, B. (1981) Maintenance programs in progress-II. In: E. Boberg (Ed.), Maintenance of Fluency (pp. 113–146). New York: Elsevier North Holland Inc.

Ryan, B. (1998) The use of the Monterey Fluency Program in Hong Kong (Abstract). Paper presented at the first Asia-Pacific Speech, Language, and Hearing Conference. Hong Kong. Asia Pacific Journal of Speech, Language, and Hearing, 3, 164–165.

Ryan, B. (2001a) Programmed Stuttering Therapy for Children and Adults (2nd ed.). Springfield, IL: Charles C. Thomas.

Ryan, B. (2001b) A longitudinal study of the articulation, language, rate, and fluency of 22 preschool children. Journal of Fluency Disorders, 26, 107–127.

Ryan, B., & McMicken, B. (2007) Evidence-based practice in universities: teaching students an evidence-based treatment. Research, treatment, and self-help in fluency disorders: new horizons. Proceedings of the Fifth World Congress on Fluency Disorders. The International Fluency Association; pp. 298–303.

Ryan, B., & Ryan, B. V. (1983) Programmed stuttering therapy for children: comparison of four establishment programs. Journal of Fluency Disorders, 8, 291–321.

Ryan, B., & Ryan, B. V. (1995) Programmed stuttering therapy for children: comparison of two establishment programs, through transfer, maintenance, and follow-up. Journal of Speech and Hearing Research, 38, 61–75.

Ryan, B., & Van Kirk, B. (1974) The establishment, transfer, and maintenance of fluent speech in 50 stutterers using delayed auditory feedback and operant procedures. Journal of Speech and Hearing Disorders, 39, 3–10.

Ryan, B., & Van Kirk, B. (1978) Monterey Fluency Program. Palo Alto, CA: Monterey Learning Systems.

Ryan, B. V., & Ryan, B. P. (2005) The Ryan fluency program workbook. Long Beach, CA: Authors.

Scheppe, D., & Jehle, P. (1985) Das Monterey-Sprechtraining Program in der praxis. Die Sprachheilarbeit, 30(5), 217–224.

Shames, G., & Sherrick, C. (1963) A discussion of nonfluency and stuttering as operant behavior. Journal of Speech and Hearing Disorders, 28, 3–18.

Skinner, B. F. (1953) Science and Human Behavior. New York: Macmillan.

Stokes, T., & Baer, D. (1977) An implicit technology of generalization. Journal of Applied Behavioral Analysis, 10, 349–367.

Yairi, E., & Ambrose, N. (2005) Early Childhood Stuttering: For Clinicians by Clinicians. Austin, TX: Pro-Ed.

1 Readers can obtain a copy of this author published manuscript by contacting the author at bpryan@csulb.edu.

2 http://en.wikipedia.org/wiki/United_States_federal_law.

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