Not the naughty corner: time-out - a stuttering treatment for children and adults

Lots of stuttering treatments are behavioural therapies. Evidence-based examples include the Lidcombe Program for pre-schoolers who stutter and the Camperdown Program for adults who stutter.

Some behavioural treatments – like the Lidcombe Program – are based on the idea of operant conditioning. In these treatments, rewards are given for the behaviours we want to promote (e.g. fluent speech) and a lack of rewards or ‘light’ or ‘safe’ corrections are given in response to the behaviours we want to discourage (e.g. stuttered speech).

One of the most interesting questions in stuttering research is why treatments that look to change behaviours work when stuttering is thought to be a physical problem caused by a glitch in the way the brain processes speech (rather than a learned behaviour or psychological problem). I’d certainly like this answered in my lifetime!

As we’ve said before, no stuttering treatment to date works for everyone. For example:

in general, school-aged children do not respond as well as pre-schoolers to the Lidcombe Program;
some adult clients have problems learning the Camperdown Program prolonged speech pattern;
some teenagers and adults clients detest prolonged speech patterns like that used in the Camperdown Program, feeling it forces them to speak in an unnatural or even “fraudulent” way;
some adults and children who stutter relapse after initially successful treatment; and
outside of broad populations divisions (e.g. pre-schoolers vs adults), there is not a lot of research about which client factors (e.g. severity, gender) speech pathologists should consider when thinking about treatment options.

So are there other evidence-based treatment options?

Yes: Time-out.

1. What is it?

Time-out is a simple operant procedure. The client pauses (i.e. takes a “time-out”) immediately after he or she stutters. Because these “time-outs” are triggered by stutters, the treatment is sometimes called “response-contingent time-out” (e.g. Franklin et al., 2008).

Time-out treatments come in a variety of flavours; and have been used to treat stuttering since at least the late 1950s (James, 2007). There are two main kinds:

(a) Speech pathologist-led time-outs: The speech pathologist presses a button whenever the client stutters, which illuminates a light or makes a noise, or simply says “stop”. When this happens, the client stops talking.

(b) Self-administered time-outs: Clients monitor their own speech and impose a time-out on themselves whenever they stutter.

One of the more recent versions of time-out uses a combination of these techniques: the speech pathologist initially imposes the time-out, and then trains the client to do it (Hewat et al., 2006).*

2. Who is it for?

Time-out is usually considered a stuttering treatment for teenagers and adults (e.g. Hewat et al., 2006). However, it has been used with:

pre-schoolers (e.g. Martin, Kuhl & Haroldson, 1972); and
school-aged children (e.g. Onslow et al., 1997).

3. What matters most in the treatment?

Time-outs need to happen when the person stutters (and not at other times or for other reasons).
Self-imposed time-outs seem to help clients achieve real world gains more than speech pathologist-imposed time outs (which makes sense – it’s not as if the speech pathologist can follow the client around the clock).
Results seem to be best when combined with rate control and/or prolonged speech treatments.

4. What doesn’t seem to matter?

It doesn’t seem to matter whether the client thinks it will work!
The duration of the time-out seems irrelevant: short (1-5 second) time-outs seem to work as well as longer ones.

5. Does it work?

The clinical evidence-base exists though it’s patchy and sometimes contested. Although there are a number of low quality studies showing good results for some people, it’s not as well-researched as the Camperdown Program. But there’s enough research (including a non-randomised Phase II clinical trial on 22 adults) to give it a go if the Camperdown Program or other treatments don’t suit a particular client or their family’s needs or have been trialled and have not achieved the client’s desired level of fluency.

In the Phase II clinical trial (cited below), there was a wide range of responsiveness. More than half of the participants reduced their stuttering by more than 50%. Interestingly, participants with more severe stuttering tended to do better than others. The drop out rate was very high – 10/22 didn’t finish the treatment – and it’s not clear how much therapy or for how long clients need to do in the real world to maintain results. It’s been alleged that the study has a number of major flaws, e.g. there were no controls for prior treatments (James, 1997). It wasn’t randomised and neither the clinicians nor participants could be blinded as to the treatment of experiment hypothesis, meaning it’s susceptible to bias (like most Phase II trials).

Clinical bottom line

Time-out is an option with some clinical evidence to support it – particularly for teens and adults. It’s not usually my preferred option. But, for the right client, and in the right circumstances, it’s well worth a shot.

Related articles:

Principal sources:

(1) Hewat, S., Onslow, M., Packman, A., & O’Brian, S., (2006). A phase II clinical trial of self-imposed time-out treatment for stuttering in adults and adolescents. Disability and Rehabilitation, 28(1): 33-42.

(2) James, J.E. (2007). Claims of a ‘new’ stuttering treatment using time-out from speaking are exaggerated: A brief review of the literature and commentary on Hewat et al. (2006). Disability and Rehabilitation, 29(13): 1057-1060.

(3) Packman, A., Onslow, M., O’Brian, S., & Hewat, S., (2007). Down memory lane with James and time-out. Disability and Rehabilitation, 29(13): 1061-1065.

* For any speech pathologists able to peek behind journal pay-walls, there was a terrifically entertaining public squabble about the originality of the treatment described in this paper (see James, 2007; and Packman et al., 2007). My favourite quote from Packman et al.,: “The theme running through James’ commentary is that we did not accord him sufficient credit in our report for the development of the [treatment] procedure…”

I would hazard a guess that most clients are more interested in whether the treatment actually works, rather than its inventor.

Image: http://bit.ly/1SbkySx

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.