J O U R N A L OF T H E SOUTH A F R I C A N L O G O P E D C SOCIETY Speech Therapy at the Pretoria School for Cerebral Palsy * MT7.TC-F.NT SILANSKY, B.A., Diploma Logopedics, Former Speech Therapist, Pretoria School of Cerebral Palsy. In South Africa the last 5 y e a r s h a v e seen a growing interest in the many-sided prob- lems of c e r e b r a l palsy. For the maximum rehabilitation of the child with c e r e b r a l palsy, the services of the paediatrician, orthopaedic surgeon, neurologist, psychologist, physio- therapist, s p e e c h therapist, o c c u p a t i o n a l thera- pist a n d educationist a r e r e q u i r e d ; bui this ideal combination is seldom attained·. The Pretoria School lor Cerebral Palsy, started b y p a r e n t s of children afflicted with this condition, w a s o p e n e d in 1950, with 3 pupils a n d 1 therapist, a n d h a s since i n c r e a s e d to 41 children a n d a staff of 3 t e a c h e r s (one a nursery-school teacher), 3 physiotherapists, 1 occupational therapist, 2 s p e e c h therapists, a matron a n d 4 African " h e l p s . " Unfortunately the female professional staff is constantly changing a n d there is never a full comple- ment. T h e author worked a s s p e e c h therapist at this School for 21 months u p to July 1954. Only children suffering from c e r e b r a l palsy are admitted to the School, but doubtful c a s e s are received a n d kept under observation for 3-6 months until the d i a g n o s i s c a n b e e s t a b - lished." J TYPES O F CEREBRAL PALSY. i " C e r e b r a l | Palsy is a term u s e d to d e s i g n a t e crny paralysis, w e a k n e s s , inco-ordination or functional aberration of the motor system re- sulting from a pathological condition in the motor centres of the brain. The d i s e a s e m a y b e so localized a s to c a u s e only motor symp- toms. More frequently, however, the brain d a m a g e is diffuse a n d m a y a l s o c a u s e c o n - vulsions, mental retardation, s p e e c h defects, behaviour d i s t u r b a n c e s a n d sensory losses of varying d e g r e e s , particularly in h e a r i n g a n d v i s i o n . " 1 During the first 3£ y e a r s of the School the following were the number a n d types of cere- bral palsy in the children handled, a n d the proportion of these with s p e e c h d e f e c t s : 'S.A.M.J. 28:1074 (Dec.) 19S4 Reprinted with permission. Types Spastic Atheioid Flaccid Mixed Ataxic Rigid Aphasic Unclassied Total Total Number 19 . 6 1 3 4 3 S 41 Number with Speech Defects 14 4 1 2 3 3 3 30 ' Thus 11 children (i.e., 2 7 % ) h a v e normal or a d e q u a t e speech a n d do not require s p e e c h therapy. C a s e s h a v e to b e chosen carefully a s there is insufficient time to give s p e e c h therapy to all who a r e in n e e d of it. Sometimes a com- plete lack of co-operation from the home will- render therapy ineffective in spite of the in- telligence of the child. In selection, younger children a r e given preference to older ones a n d the more intelligent to the more dull. It is important to spend not more than 20- minute periods daily on therapy, a s the child- ren tire easily and their span of attention is short. Individual treatment is preferred, but w h e r e 2 c a s e s are similar in respect of a g e , intelligence and therapy they a r e taken to- gether. APPROACHING THE PROBLEM. In a p p r o a c h i n g the problem of s p e e c h therapy, e a c h c a s e is treated individually a n d ά s e p a r a t e programme worked out for e a c h child ; there is no set line of therapy for ail spastics or all athetoids. However, the therapy for spastics will involve g a i n i n g greater mobi- lity of spastic muscles, w h e r e a s that for the athetoid group will involve gaining g r e a t e r control over the affected muscles, while the a t a x i c c a s e , in which the c e r e b e l l a r lesion c a u s e s a loss of b a l a n c e a n d a diminished s e n s e of a w a r e n e s s of muscle feeling a n d placement, will to a l a r g e extent call for a kinaesthetic a p p r o a c h to therapy. Obviously therefore it is n e c e s s a r y to know the physical d i a g n o s i s before starting the speech pro- gramme;· at the School it is supplied b y the • paediatrician, who b a s e s it on a full history a n d physical examination. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) MAY T o c o m p l e t e p s y c h o l o g i s t s report is cdso ° V h . i d intelligence tes is done on ^ ^ g i n t ° a C C < a i I ' c h i l d r e n is noTwholly a p p l i c a b l e to for normal children is r , ^ m a y h a v e c h l l d r e n with h a n d i c a p s — a fair K f * S S £ SSSSuTS Λ ^ *»» over a long period. F o r t h i s r e a s o n , the ^ e ^ y a i u a b ! e source m e e t i n g s the physical, b y progress (or re t r o g r « s i o r i s d ^ the staff, as> well a s the emo t Q of the .child. The p a χ , w h e n discuss a n y problem a n d is given a a n d n e e d , e 1 · · a T c S i a r e n o t e T b y a p a n e l p s y c h o l o g i c a l ° t h e c h i l d . a t regu- o f d o c t o r s w n o r e e x a m i n e h e ^ ^ lar intervals during the y e a r ^ t Q a n d l e e c h h a n d i c a p a r e the child s p , , , s i c - a . e d _ n t h e important fac L oi= to c - s p e e c h treatment. . SPEECH EVALUATION. S p e e c h i e ^ ^ ^ h l ^ r S - p a l s y m a y b e drrecfly due to ^ ^ ^ or they m a y occur, a s m } { a c t o r s . through o.ther o r g a n i c ο I o l l o w . F o r the purposes cf c i a « m c a a o n , ^ \ t r ^ g u s e f f l s c n b m e the s p e e c h S S f S e r w h K the children fall. Τ D e l v e d . S p e e c h c e r e b r a l q a l s y h a v e foued to d e v e ο . ^ delay m a y b e o n e of the following : ' ( a ) S p e e c h is a n a c q u i r e d skill . t h e normal child h e a r s the words, I η frequent to h e a r a mo,ner , a y · W - • ^ don't talk to him much he a o e ? η understand, so v™at r e a l l i y the child with c e r e b r a l J e n ° e x D e r i e n c e , n e e d s more stimulation a n d mo e ^ d i _ The Child m a y h a v e ^ g r o u n d g o * physical a n d mental de^e oprnent. ?„g slow rate of s p e e c h development (g) The child m a y b e mentally retarded. 2. C e r e b r a l - P a l s y ^ ^ ^ * velops s p e e c h it may b e c h a ς - o f jerky, indistinct s o u n d , d u e t o ^ J 'speech moving m a n j a w or t i m e s the M e n t i s severely u v u l a a r e so spastic - a . j a n d Λ d f f l s l o ^ u n S ^ i b i e to the 1 ί 5 Γ O r a a n i c or Structural Defects. S p e e c h 3. u r g a n i c 01 rviUied children c a u s e d defects m a y occur m p a l , ea^cn by a n o m a l i e s of ° r £ U f i s T 0 n o M h e C.N.S. than ' ^ o s e c a u s e d b y o f the athetoid group. I n e t ϊ α η - y γ defect in the sounds such often it involves h e a r or dis- c s s. sh, ch, ne c r ι t h e r e i o r e S g u i S S s ? s o ^ s c ^ r e c i l y f d Produces them incorrectly or not at all. 5 Stuttering. Stuttering m a y o c c u r ^ n g cerebral-palsy children, p e r n a p s a» a re.uLt o^ confused, c e r e b r a l d o m i n a n c e R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) J O U R N A L O F T H E SOUTH A F R I C A N L O G O P E D C SOCIETY . s p e e c h . Due to spasmodic or uncontrolled breathing musculature, the breath is said to \-e "out of p h a s e . " The child may b e unable to direct the flow of air through the mouth dur- . s p e e c h , or movement may b e so inhibited q S to cause' shallow breathing insufficient for normal speech. 8. Aphasia. This defect is a n impairment of linguistic function due to d a m a g e of the speech centre a n d a s s o c i a t e d tracts. E i s e n s o n 5 s t a t e s : "Those patients whose outstanding dif- i i c u l t i e s a r e in the comprehension of l a n g u a g e , c'ooken or written, may b e classified a s belong- ing to the receptive type. Where the predomi- nant difficulties consist of an impairment of ability in speaking, word finding, oral read- ing, spelling, or writing, the patient may b e classified a s a n expressive a p h a s i c . " Very often it a p p e a r s a s if the child's lack of re- sponse to speech is due to deafness, but in an aphasic hearing is usually unaffected. If the child develops a certain amount of speech, sentence structure is distorted, " s m a l l " words are often left out, while writing is characterized by "mirror" formation of letters a n d words. The speech defects found at the School a r e enumerated in the right-hand column of the table on p a g e 13 (one child m a y h a v e more than one defect). Speech Examination. Before speech therapy is begun, a thorough speech examination must be m a d e to determine the possible c a u s e or causes of the delay or defect in the speech. The treatment will depend on these factors. The examination will include : 1. A physical examination of the speech organs to discover a n y structural malforma- tion. j 2. A test' of the ability of the child to move tongue, lips, uvula, j a w s , etc., for a d e q u a t e speech performance. 3. A test of all the speech sounds in initial, medial a n d final positions, using pictures or objects. From this phonetic inventory omis- sions, distortions, a n d substitutions of sound during speech c a n b e detected. 4. A crude hearing test is given and if possible an audiometer test. 5. Force a n d direction of the breath, a s well a s whether it is in co-ordination with the act of speech, a r e noted. 6. Sucking, chewing a n d swallowing a c t s are g a u g e d . 7. Voice factors such a s pitch a n d quality a r e noted. 8. A recording of the child's speech is taken to determine understandability and, after in- tervals, to determine progress if any. Record- ings a r e v a l u a b l e for therapy, a s they provide excellent auditory stimulation. Very often the child h a s no idea what his speech sounds like, and the recordings allow him to hear himself and his defects. THERAPY AND TECHNIQUES. The child who, from the a g e 2 j years onwards h a s little or no speech is treated for delayed speech. At all times the child is e n c o u r a g e d to m a k e sounds, to b a b b l e , to indulge in all manner of vocal play. He must be taught to watch the lips, hear the sounds a n d feel the placement a n d voice vibrations. S p e e c h must b e a p l e a s u r a b l e activity a s well a s a necessary one. For stimulation, toys, pictures, rhymes, songs, g a m e s and drama- tizations a r e used, depending on the a g e a n d amount of speech the child already has. At the school there a r e regular singing periods apart from the speech lessons, in which the nursery group a n d the older groups a r e separately taken. The children sing a n d dramatize English and Afrikaans songs, a n d from their obvious enjoyment of the whole procedure it is clear that they are being stimulated and motivated to vocalize. In this group, too, there is a certain amount of healthy competition, and e a c h one tries to sing well so i'hat he or she will b e chosen to be the "Matrosie," or "Little Miss Muffet." The mother must b e instructed to b a b b l e with the child, to talk, sing a n d read to him. While she is doing his physical exercises with him, she can rhythmically count or sing in time with the actions. Defects in the limited speech at this stage a r e ignored. Any attempt to vocalize or say a n e w word is praised. At the s a m e time it is important to strengthen the speech musculature. The organs of speech h a v e a primary function other than for speech. The act of chewing a n d swallowing employs the s a m e muscles a s those used for speech. Therefore practice in b a s i c functions, such c s chewing, sucking and swallowing form an im- portant part of therapy. The mother is in- structed to encourage the child to eat "hard foods" a n d to swallow all liquids through a straw. This procedure is adopted at school, too. In this manner the muscles of speech a r e strengthened and drooling, so often found in cerebral-palsy children, is diminished. The "chewing-method" is successful in achieving "improvement of the functions of the mouth a n d speech organs, a s well a s of the voice."6· In d e l a y e d speech, all types of cerebral- palsy a r e similarly treated. In an atmosphere R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 1 J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D C SOCIETY MAY of quiet, r e l a x a t i o n is practised, using a r a g doll to illustrate floppy l e g s a n d arms, or de- m o n s t r a t i n g the difference b e t w e e n the ;eel of t e n s e m u s c l e s a n d soft muscles. Later, when the d e v e l o p m e n t of s p e e c h is progressing, dif- ferentiation is m a d e b e t w e e n the types 01 c e r e b r a l - p a l s y , so that a p p r o p r i a t e metnods of e x e r c i s i n g c a n b e given. Strictly s p e a k i n g , though, there is not much difference in the m e t h o d s a d o p t e d for s p a s t i c s a n d athetoids. It h a s b e e n s a i d that " t h e r e a r e 3 w a y s to treat the s p e e c h of the s p a s t i c p a r a l y t i c : first, r e l a x a t i o n ' ; s e c o n d , r e l a x a t i o n ; a n d third, re- l a x a t i o n . " " T h e s a m e m a y b e s a i d to a p p l y to the t r e a t m e n t of athetoids. If the affected m u s c l e s c a n b e r e l a x e d , the s p a s t i c c a n b e t a u g h t to m o v e them in the d e s i r e d direction, a n d the a t h e t o i d c a n learn to control them. Whilst in a r e l a x e d position the child is then given b r e a t h i n g e x e r c i s e s , first on his b a c k , a n d later in a sitting position. T h e child learns the " f e e l " of correct· b r e a t h i n g b y gently push- ing the rib c a g e in a n d out. To promote g r e a t e r b r e a t h force there a r e m a n y g a m e s which the child c a n play, such a s blowing out a c a n d l e , b l o w i n g b u b b l e s , or blowing up a b a l l o o n . Later h e c a n c o m b i n e b r e a t h i n g a n d a r t i c u l a t i o n b y vocalizing a sound, e.g., ' a h , a n d at the s a m e time s e e i n g how far a toy a e r o p l a n e will fly—the flight lasting a s long a s the vocalization. T h e child is a l s o t a u g h t to direct the air through the mouth. Here a g a i n , blowing g a m e s a r e used, a s well a s e x e r c i s e s for im- proving tlie m o v e m e n t s cf the soft p a l a t e . T h e t o n g u e isj s u b j e c t to a g r e a t e r amount of in- volvement c a u s i n g s p e e c h d e f e c t s than a n y other of the articulator}- o r g a n s . T o n g u e exer- cises, therefore, a r e given in the majority οι c a s e s . Ih order to e n c o u r a g e the child to m o v e the Itongue up, out, to the sides, or round the mouth, h e is instructed to lick a lollipop b y p l a c i n g it in a c e r t a i n position on the mouth, or outside the mouth. As a variation, a r u b b e r m a s k with a m o v a b l e t o n g u e is used, a n d the child h a s to imitate its actions. T h e r u b b e r " f u n n y m a n " is u s e d , too, for lip exer- c i s e s to stretch the lips into a smile;_ to pucker them or o p e n them into a n " a h " position. With the u s e of g a m e s , j a w a n d u v u l a exer- c i s e s a r e similarly given. If the child u s e s c e r t a i n s o u n d s incorrectly o w i n g to functional or o r g a n i c c a u s e s , the sounds a r e practised, not in isolation, but in words. F o r "this purpose s c r a p - b o o k s contain- ing l a r g e pictures illustrating the particular words a r e u s e d for e a c h child. For e x a m p l e , if a child subsitutes "f" for " t h " in his s p e e c n , l a r a e illustrations of a thumb a n d a t h i m c i e are" p a s t e d in to a s c r a p - b o o k . Parents h a v e to help find the pictures a n d the child c a n p a r t i c i p a t e b y cutting them out a n d p a s t i n g them in (if his p h y s i c a l h a n d i c a p permits). An- other set of c a r d s roughly d r a w n b y the thera- pist a n d duplicating the pictures provide m a n y a n d v a r i e d g a m e s to stimulate further p r a c t i c e on the sound. T h e " f e e l " of the sound on tne child's h a n d often provides the c u e lor cor- rect imitation a n d motivation, e.g., letting tne child feel the b r e a t h force a s the therapist re- p e a t s a n explosive c o n s o n a n t . All physical e x e r c i s e s to g a i n m u s c l e strength a n d control, a n d s p e e c h sound e x e r c i s e s a r e done m iront of the mirror so that the child c a n m a k e u s e of all sensory stimuli, visual, auditory a n a tactile. T h e treatment of a p h a s i c s is a n interesting c h a l l e n a e to a n y s p e e c h therapist. It is a n a t t e r of stimulating the child through a u d i - tory visual a n d k i n a e s t h e t i c m e a n s until a meaningful response is elicited. O n e oi the children at the S c h o o l , a mixed type of e x - pressive-receptive a p h a s i a , responded d r a m a - tically to t r e a t m e n t : it b e g a n b y the cmld holding a felt ball, noting its size, s h a p e , a n d texture a n d hearing s e v e r a l repetitions of the word " b a l . " At the s a m e time she w a t c h e a the formation of the word in the mirror. Alter s e v e r a l w e e k s of c o n s t a n t repetition, s h e re- speondc-d b y s a y i n g " b a l " when s h e s a w tne ball. From then on, s e n t e n c e s w e r e con- structed around this word, a l w a y s dramatiz- ing the action, e.g., "skop die b a l . " Mew words w e r e then introduced until a n e x t e n s i v e v o c a b u l a r y w a s built up. T h e results w e r e far b e t t e r for the e x p r e s s i v e impairment than fcr the receptive. In treating the h a r d - o f - h e a r i n g child, lip- r e a d i n g is taught and, t o g e t h e r with the visum c u e s , kinaesthetic a n d a g r e a t d e a l of a u a i t o r y stimulation is given. E a r p h o n e s a t t a c h e d t c the recording m a c h i n e a r e a n important a i d to stimulate h e a r i n g . T h e school a s yet d o e s not p o s s e s s a " t r a i n - e a r . " In the one c a s e w h e r e a h e a r i n g a i d h a s b e e n p u r c h a s e d ior a hard-of-hearing child, the results w e r e dis- a p p o i n t i n g ; the p a r e n t s could not afford a r e l i a b l e set, a n d the child, owing to low in- telligence, could not a d j u s t herself to > this a p p a r a t u s . "It is urgent that all d e a f c e r e o r c , - p a l s y children of g o o d ability who h a v e resi- d u a l c a p a c i t y to benefit from the u s e of h e a r - ing a i d should b e given auditory training from ' the b e g i n n i n g of their education.''^. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D I C SOCIETY RESULTS. What is the aim of the s p e e c h therapist in dealing with these children? Evans^ says, "Perfect s p e e c h is usually a n impossibility . . After all p o s s i b l e repair or help to the m e c h a - nism h a s b e e n secured, aim for practicality rcther than normalcy. If the s p e e c h sounds ccceo'able e v e n if not h i g h - g r a d e , it should ™ a c c e p t e d b y the clinician a n d the effort r x c i ^ d " In judging the results of nearly I ν oars' therapy, therefore, the question h a s not b e * n whether the child c a n now s p e a k normally but, rather, whether in the very slow oroce-s of developing or improving his speecn, certain a o a l s h a v e b e e n r e a c h e d a n d main- tained. For instance, c a n A now lift his tongue into a position to s a y t ? C a n Β now blow out a c a n d l e directing the flow οι air through the mouth? Has C s t o p p e d drooling? is D correctly substituting " t h " m words in- stead of " f " ? It is extremely difficult to a s s e s s the results objectively. T h e following is a s u b j e c t i v e at- tempt to a s s e s s the children's progress at speech ; Number Speech improved Delayed Speech 7 Cerebral-Palsy b Organic or Structural Defects Hard-of-hearing. Speech Stuttering Voice Disorders Breathing Disorders A p h c s l c s ί I DIFFICULTIES. The difficulties e n c o u n t e r e d in the s p e e c h therapy of 'children with c e r e b r a l - p a l s y h a v e posed m a n y problems, most important of which a r e i relaxation a n d breathing. t h e therapist m a y spend months trying to r e l a x a spastic or athetoid in supine or prone position only to find that there is no c a r r y - o v e r m a sitting or standing position, a n d certainly no carry-over during the a c t of s p e e c h . Similarly, the child m a y learn a form of correct silent breathing, yet during s p e a k i n g it m a y b e quite "out of p h a s e , " or entirely i n a d e q u a t e for speech. In other words the c a r r y - o v e r is often a b s e n t h e r e too. The therapist must query whether a spastic muscle c a n b e completely r e l a x e d , or whether an athetoid muscle c a n b e controlled. Par- ticularly during speech, when a r t i c u l a t o r a n d breathi ng muscles a r e in action, how n e a r to normal c a n the parts b e conditioned, so that a d e q u a t e s p e e c h c a n b e a c h i e v e d ? A h a n d - m a n i p u l a t e d iron lung, used in the United S t a t e s for t e a c h i n g correct breathing, should b e tried here, a s well a s all the stimu- lating " g a d g e t s " for motivating speech. Ap- p a r a t u s h a s b e e n constructed which lights -up or rings bells when the child s a y s a particular word correctly. Another important problem at the school is that of achieving an a c c u r a t e assessment c i the child's hearing ability. Crude hearing te<=ts a r e not very r e l i a b l e a n d the results a r e subjective. Tests using the pure-tone audio- meter a r e difficult to u s e in a young child, since h e does not know what is required 01 him a n d h e tires easily. It is even more dn- ficult to a s s e s s the a c c u r a c y of such a test when given to children of sub-normal intelli- g e n c e . Varying d e g r e e s of hearing-loss s e e m to b e relatively common a m o n g palsied chila- ι 1 1 - ι 2 2 1 5 3 Total in Group 13 10 1 2 2 7 15 3 ren a n d this aspect h a s b e e n sadly n e g l e c in e x a m i n a t i o n a n d therapy cmd for record purposes. A difficulty peculiar to South African thera- pist is that of l a n g u a g e . Naturally, e a c h child is given therauy in his h o m e l a n g u a g e but sometimes there is a confusion of both lang- u a a e s in the home a n d the child h a s tnis a d d e d difficulty to c o p e with. Also, although there is a wealth of s p e e c h sound material at h a n d in English, the therapist must compile all Afrikaans material from m a g a z i n e s , boons, verse etc. An Afrikaans phonetic s p e e c n b o o k ' w o u l d b e of great h e l p to s p e e c h thera- pists. The present classification of s p e e c h defects h a s not proved very satisfactory. D e l a y e d s p e e c h a n d c e r e b r a l - p a l s y s p e e c h include too w ' d e a variety of defects. Leather's r e c e n h v Dublished classifications should b e of g r e a t e r v a l u e 'or diagnostic a n d therapeutic purposes a n d to gain a more o b j e c t i v e assessment ot results. With c e r e b r a l - p a l s y there is no "full under- standing of the implications of the injury to the total orgctnism."i° To i n c r e a s e the un- derstanding, the g r e a t e s t co-operation is n e c e c s a r v between the s p e e c h therapist a n d the physiotherapist. Indeed, fu.ll c o - o p e r a n o n is n e c e s s a r y among all staff m e m c e r s of a school to co-ordinate p h y s i c a l a n d educational methods. SUMMARY. C e r e b r a l - p a l s y is p r o l o n g e d a n d difficult, a n d in its treatment it is n e c e s s a r y for workers in v a r i o u s fields to pool their observations a n d e x p e r i e n c e . S p e e c h therapy is one of the primary n e e d s communication b e t w e e n individuals for social a n d e c o n o m i c n e e d s b e i n g so essential. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 1 J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D I C SOCIETY MAY Experience of 41 children at the Pretoria School for Cerebral-palsy is described. Types of cerebral-palsy a n d speech defects found in these children a r e detailed. Methods a n d techniques in speech therapy a r e reviewed. Results a n d difficulties a r e discussed. My thanks are due to Dr. B. Epstein, chairman of the Board o! Management of the Pretoria Scnool for Cerebral-palsy, for his encouragement and assist- ance, and for allowing me cccess to files and recoras. REFERENCES. 1 Perlstein Μ A and B a m e ^ Η. E. (1952) : J. Amer. Med. Assoc., 148, 1389. 2 Pohl J. F. (1950) : Cerebral-Palsy. 2nd ed., p. 165- 167.' St. Paul, Minnesota: Bruce Publishing'Co. 3. Rutherford, B. R. (1948) : Give Them a Chance to Talk, 1st ed., p. 3. Minneapolis, Minnesota: Burgess Publishing Co. 4 Kastein, S. (1952) : Notes on Speech Therapy, 1st ed., p. 7. British Council for the V/elfcre of Spastics. 5 Eisenson, J. (1946): Examining ior Aphasia, 1st ed., p. 4. New York: The Psychological Corpora- tion. 6. Sittig, E. (1947) : J. Speech -Dis., 12, 194 (quoting Froeschells). 7. Evans, M. F. (1947): Ibid., 12, 97. 8 Ε wing I. R. and A. W. G. (1954) : Speech and the Deaf Child, 1st ed., p. 127. Manchester: University Press. 9. Leather, D. (1954): Int.-J. Phoniatry, 6, 38 (Separa- tum). 10' Clemons, E. S. (1953): J. S. Afr. Logopedic Soc., Special Congress ed., p. 48 (Johannesburg Univ. Witwatersrand). THE CONQUEST OF STUTTERING C. VAN RIPER Director, Speech Clinic, Western Michigan. College Kalamazoo, Michigan, U.S.A. Western Michigan College of Education. For centuries the treatment of stuttering h a s wrecked itself on the rock of symptom avoid- ance. The various therapeutic methods^ used, relaxation, rate control, unusual modes oi speech, h a v e b e e n focussed on the s a m e goal which h a s b e t r a y e d - e v e r y stutterer's own at- tempts to h e a l himself: the attempt to speaK without stuttering. Such c n effort carries with- in itself, even when successful, the seeds ot its own eventual failure. For a v o i d a n c e c r e e d s fear W h e n we flee from fear, w e magnify it. The situation a n d word fears so long condi- tioned in the adult stutterer c a n haralv ce e r a s e d by; such measures. According to modern Teaming theory, anxiety conditioned responses never extinguish completely. O n e pairing of the shock with the conditioned stimuli restores them to almost full strengtn. And so we find the discouraging frequency of r e l a p s e s in stuttering therapy. Moreover, much of the older methods did little more than to repress the symptoms. The powenul sug- gestion employed b y most therapists can in- d e e d produce such repression temporarily, ^ut stuttering, like murder, will out ! W e may b e a b l e to hold down the coiled spring of tne disorder for a time, but so long a s it is intact a n d a s strona a s ever, it will eventually e s c a p e from our grasp. W e a r e but mortals with no ability to sustain a repression for long. No matter how confident we b e c o m e , existence will sooner or later c a u s e morale to efco. No environment, however favourable, will b e without its moments of trauma. To build fluency upon an attitude a l o n e is to use fiux instead of mortar for the foundation. Ana. so at these i n e s c a p a b l e moments of e g o weakness, the fears invade our minds a g a i n , and the stuttering returns to haunt our lives. Is there no w a y to exorcise this evil ghost whose strength seems almost of the super- natural? The psychoanalysts have tried a n d most of them confess failure since speech, their · healing tool, is itself affected. The myriad de- vices, methods a n d tricks which have b e e n used upon stutterers since the dawn of history give us little hope of s u r c e a s e from that direc- tion. Witchcraft and surgery, vocal training a n d hypnosis, in none of these have we found consistent effectiveness. Our inability to c o p e with the severe stutterer after all these y e a r s still reflects discredit upon our profession. Perhaps we h a v e b e e n working in the wrong direction. The stutterer does not need to b e taught how to talk normally. He already h a s that skill, a s much of his speech attests. Sup- pose, instead of trying to k e e p him from stut- tering with all of its attendant evils, we try to train him to modify his symptoms in the direc- tion of fluency. The immense variety of stut- tering symptoms suggests that among them there might b e a few types which society would not Dunish. Among them there should R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)