Generalization and maintenance are a widely recognized challenge for stuttering treatment. There are many reasons why this is the case. First, there is no accepted model of recovery, though self-efficacy may be a helpful construct and, secondly, the client’s age, stuttering severity, and negative attitudes may be complicating factors.
Three strategies for promoting generalization and maintenance in school settings are suggested based on current research evidence. They include probing and training for generalization, incorporating real-life elements into therapy, and training clients to self-regulate their behavior. These strategies appear to be viable and practical, but further research is needed to fully evaluate their effectiveness for school settings.
Learning outcomes: Readers will learn about (1) typical approaches to managing stuttering in the school setting, (2) barriers to generalization and maintenance of stuttering treatment gains, and (3) three strategies for promoting generalization and maintenance.  (Journal Abstract).

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Finn, P. (2003). Evidence-based treatment of stuttering: II. clinical significance of behavioral stuttering treatments. Journal of Fluency Disorders, 28, 209-218.

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature.
Educational objectives: The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.  (Journal Abstract).

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Gilman, M., & Yaruss, J. S. (2000). Stuttering and relaxation: Applications for somatic education in stuttering treatment. Journal of Fluency Disorders, 25, 59-76.

Relaxation techniques have been an integral part of many stuttering treatment approaches since the early part of the 19^th century. The therapeutic use of relaxation has fallen out of favor in recent years, however, due to concerns that the sensation of being relaxed is difficult to generalize and so has limited efficacy outside the treatment environment. This paper reviews the history of relaxation techniques in stuttering therapy and proposes a means for viewing relaxation not as a passive process (e.g., a feeling of calmness), but rather as an active, dynamic process involving coordinated movement of the entire neuromusculoskeletal system. This balance is central to the theories of somatic education, such as those developed by Alexander, Rolf, and Fedenkrais. Accordingly, this paper argues that the use of somatic education in stuttering treatment may promote the perception of relaxation and facilitate the habituation of new behavior patterns, thereby leading to improved generalization of relaxation outside the treatment setting.  (Journal Abstract).

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Nippold, M. A. (2002). Stuttering and phonology: Is there an interaction? American Journal of Speech-Language Pathology, 11, 99-110.

Speech-language pathologists have been interested for many decades in the phonological skills of children who stutter. Many investigators have reported that children who stutter are often more likely to have a phonological disorder than their peers who do not stutter. It is commonly reported that 30%-40% of children who stutter have a co-occurring phonological disorder. Reports of this nature have prompted researchers to examine the possibility that stuttering and phonology may interact in some way. In the intervention literature, it is recommended that treatment for children who stutter and have a phonological disorder take an indirect approach. Many examinations of children were alluded to in the article but in the end the results indicated that children did demonstrate normal phonological development when being classified as a mild to severe stutterer, and that children with phonological disorders did not necessarily stutter more severely than those with normal phonological development.  (Journal Abstract).

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Ratner, N. B. (2004). Caregiver-child interactions and their impact on children's fluency: Implications for treatment. Language, Speech, and Hearing Services in Schools, 35, 46-56.

There is a relatively strong focus in the stuttering literature on the desirability of selected alterations in parental speech and language style in the management of early stuttering. In this article, the existing research support for such recommendations is evaluated, together with relevant research from the normal language acquisition literature that bears on the potential consequences of changing parental interaction style. Recommendations with relatively stronger and weaker support are discussed. Ways in which children's communication styles and fluency may be altered through newer fluency treatment protocols are contrasted with older, more general parent advisements. Finally, directions for future research into the efficacy of recommendations made to the parents of children who stutter (CWS) are offered.  (Journal Abstract).

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Saltuklaroglu, T., & Kalinowski, J. (2005). How effective is therapy for childhood stuttering? Dissecting and reinterpreting the evidence in light of spontaneous recovery rates. International Journal of Language and Communication Disorders, 40, 359-374.

Background: Similar positive results (e.g. immediate decreases in stuttering frequency and a 60-80% recovery rate from stuttering) have been reported for numerous therapeutic protocols for treating childhood stuttering, many of which have been diametrically opposite in their orientations and implementations. For example, Johnson advocated indirect treatments that simply advocated refraining from drawing any negative attention to childhood disfluencies as persistent and chronic stuttering was thought to progress via negative parental reactions to normal disfluencies. In contrast, direct interventionists sought immediately to eliminate stuttered speech patterns by training ‘corrected’ speech models that usually involved some form of prolonged speech. However, reports from speech and language therapists around North Carolina, USA, suggest much lower recovery rates in the children they treat (i.e. 13.9% over a median therapeutic period of 3 years, which to the present authors is an indicator of therapeutic inefficiency and ineffectiveness).
Aims: The discrepancy between these recovery rates calls for a re-examination of the efficacy of stuttering therapy for children, especially in light of recent statements from some therapies suggesting that therapy might be curative in nature.
Main contribution: Spontaneous and complete recovery (removing all overt and covert markers of the pathology) occurs in 60-80% of all children who display incipient stuttering behaviours. As such, it appears that many claims of therapeutic success in children who stutter are confounded by the possibility of spontaneous recovery during the testing and intervention period. Simply put, it is impossible to discriminate between recovery that would occur naturally over time, and what may have been simply accelerated via therapy. Based on stable prevalence rates and the data in the present paper, it is suggested that therapy does little to boost recovery rates from incipient stuttering. Therapy can provide ‘inhibitory’ symptomatic relief with varying degrees of success with respect to decreasing stuttering severity and the need for continued therapy. However, it must be made clear that curing stuttering is not a likely outcome of therapy, although successful management can decrease the severity of the problem. It is argued that all forms of stuttering inhibition, including those at work during spontaneous recovery, are all mediated by the degree of mirror neuron engagement in the brain.
Conclusions: It is proposed that in children who stutter, the best source of relief from stuttering is in the effective and efficient engagement of mirror neurons via methods that best replicate choral speech. In order to induce natural sounding, fluent speech, it is suggested that one uses primarily derivations of choral speech such as altered auditory feedback. Motoric techniques might also be used synergistically to provide supplementary sources of mirror neuron engagement.  (Journal Abstract).  

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Thomas, C., & Howell, P. (2001). Assessing efficacy of stuttering treatments. Journal of Fluency Disorders, 26, 311-333.

Efficacy has been defined as the extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideally controlled conditions when administered or monitored by experts. Studies on efficacy can be divided into those that study methods of conducting treatment (i.e., treatment outcome research) and those that are concerned with the effects of treatments (i.e., treatment outcome research). This review covers both areas, emphasizes the former, and considers such key determinants of efficacy as measurement, treatment integrity, and design issues. A set of criteria is given and a meta-analysis of whether studies published since 1993 meet these criteria is reported (incorporating some pragmatic and ethical considerations). The review ends by considering directions that warrant further investigation in the future.
Educational objectives: The reader will learn about and be able to describe (1) measurements appropriate for evaluating treatment efficacy studies; (2) how to evaluate reports of stuttering treatment programs; and (3) different designs used in treatment efficacy studies.  (Journal Abstract).

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Van Borsel, J., Maes, E., & Foulon, S. (2001). Stuttering and bilingualism: A review. Journal of Fluency Disorders, 26, 179-205.

Although stuttering in bilinguals is an area of interest to both clinicians and researchers, data on bilingualism and stuttering are scanty. This paper reviews the available literature on stuttering and bilingualism. Major findings are that stuttering is probably more prevalent in bilinguals than in monolinguals, that stuttering can affect one or both languages, that the two languages may be equally or differently affected, and that diagnosis and treatment in bilingual stutterers seem to require a particular approach.
Educational objectives: The reader will learn about the prevalence of stuttering in bilinguals. The reader will learn about and be able to describe the different patterns of the manifestation of stuttering in bilinguals. The reader will learn about and know some issues to consider in diagnosing and treating dysfluent bilingual clients.  (Journal Abstract).

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Venkatagiri, H. S. (2005). Recent advances in the treatment of stuttering: A theoretical perspective. Journal of Communication Disorders, 38, 375-393.

Prolonged speech and its variants are widely used in the behavioral treatment of stuttering. Unlike these approaches, which depend on clinician-prescribed speech pattern changes, two behavioral treatment regimens, one for children and another for adults, recently developed at the Australian Stuttering Research Center, promote self-monitoring of speech as a means of controlling stuttering. In these programs, the clients themselves modify their speech in subtle and variable ways to gain control over stuttering and, in that, they appear to be similar to a well-known experimental technique for suppressing stutters known as response contingent stimulation. The present paper provides an integrated explanation for the effectiveness of both clinician-directed as well as client-initiated speech pattern modifications and, in the process, develops a new model of stuttering. It also shows why client-generated speech patterns changes potentially produce faster and more lasting improvement than those changes prescribed by a clinician.
Learning outcomes: The reader will learn about: (1) two hypothesized methods of preparing utterance motor plans--speech concatenation and speech construction; (2) how behavioral treatment programs make use of speech construction to promote fluency in persons who stutter; (3) why therapy procedures based on cognitively driven speech construction produce faster and superior results than those based on motorically driven speech construction; and (4) the empirical evidence that suggests that speech concatenation is the source of stuttering.  (Journal Abstract).

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