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Regulated breathing as a treatment for stuttering: a review of the empirical evidence.


Regulated Breathing (RB) is a behavioral treatment for stuttering designed to address airflow irregularities by teaching breathing patterns that are incompatible with stuttering. The current paper describes the RB procedure and reviews published literature to examine the empirical support for the efficacy of RB. Existing data indicate that RB is an effective treatment for stuttering and could be considered a "probably efficacious" treatment according to the criteria described by Chambless and Ollendick (2001). Limitations of the present literature are discussed, as well as suggestions and possible directions for future research.

Keywords: Regulated Breathing, Stuttering.


Stuttering is characterized by a disturbance in the normal fluency and time patterning of speech (APA, 2000). Speech disturbances include frequent occurrences of sound, syllable, and whole-word repetitions; sound prolongations or hesitations; interjections; broken words; or circumlocutions. The Diagnostic and Statistical Manual of Mental Disorders includes the criterion that stuttering interferes with academic, occupational or social functioning and must not be better accounted for by a speech-motor or sensory deficit (APA, 2000). However, a diagnosis of stuttering in young children is often given even in the absence of functional impairment. When young children are diagnosed, speech patterns are usually evaluated and compared to the normal fluency for their age group (APA, 2000). Clinicians also take into consideration developmental and emotional factors that can disrupt a child's speech (Williams, 1985).

Prevalence rates of stuttering are approximately 1% (Bloodstein, 1995) but can be as high as 5% during childhood (Leung & Robson, 1990). The onset of stuttering usually occurs between the ages of 2 and 6 (Andrews et al., 1983; Homzie & Lindsay, 1984) and is more common in males. The male-to-female gender ratio is 3 to 1 during childhood and increases to 5 to 1 in adulthood (APA, 2000, Bloodstein, 1995). Although a specific cause for stuttering is not known, it is believed to be a heritable disorder (Felsenfeld et al., 2000; Andrews, Morris-Yates, Howie, & Martin, 1991).

Stuttering is associated with various airflow irregularities. Healey (1991) suggested that stuttering is primarily associated with the tightening of the laryngeal muscles in the throat, resulting in a disruption of airflow and speech production, and Bloodstein (1995) noted that in some cases a complete cessation of breathing or an irregularity of the respiratory cycle occurs during stuttering. Also, people who stutter tend to have less airflow during speech difficulties involving the coordination of laryngeal muscles, which results in decreased air volume in the lungs before speech initiation (Stager, Denman, and Ludlow, 1997). To address the issue of airflow irregularities in stuttering, modification of speech-related respiratory behavior is believed to be useful in the treatment of the disorder.

Description of Regulated Breathing

Regulated Breathing (RB) is a multicomponent behavioral treatment that attempts to inhibit stuttering by teaching a speech-related breathing pattern that is incompatible with stuttering (Azrin & Nunn, 1973). RB consists of several different treatment components, including awareness training, relaxation, competing response training, motivation training, and generalization training. It shows significant overlap with habit reversal, a procedure designed to treat nervous habits and motor tics.

Awareness Training. Awareness training is comprised of four techniques. During response description, the client deliberately stutters and provides a detailed verbal description of physical movements, sounds, and sensations (tension) associated with his or her stuttering. The second awareness technique, response detection, requires a client to point out a stutter when it occurs. The clinician either praises the client for correct identification or stops the patient and points out occurrences of a stutter. In situation awareness training, the client identifies words, situations and persons which provoke stuttering. If the client is a child, this report is generally confirmed by a knowledgeable person such as a parent. During the fourth technique, called anticipation awareness or early warning, the client is taught to identify somatic cues that may predict stuttering.

Relaxation Training. During relaxation training, the client learns three relaxation procedures to counter feelings of tension. The client first learns the relaxed posture procedure, which consists of sitting and standing in a comfortable posture conducive to relaxing chest and abdomen muscles. Diaphragmatic breathing is taught as part of the relaxed breathing procedure. Finally, the self-directed relaxation procedure enables the client to facilitate his or her own relaxation.

Competing Response Training. After a client is aware of stuttering and environmental and somatic precursors to stuttering, he or she is trained to engage in behaviors that are incompatible with stuttering. Competing response training focuses on regulating breathing patterns. Upon stuttering or upon anticipation of a stutter, the client is told to stop speaking and engage in diaphragmatic breathing while consciously relaxing chest and throat muscles, to think about what needs to be said, and to start speaking following a small exhale. In addition, clients are taught to do the breathing exercises at the beginnings of sentences and to initially speak for short durations until speech is fluent, at which time speech duration is increased. The competing responses are practiced with the clinician until the client is able to engage in the responses independently.

Motivation Training. Three motivation training techniques are used to reinforce proper use of the competing response. First, a client gives an inconvenience review of the past frustrations with stuttering. Second, family and friends are taught to praise a person for correctly using a competing response and learn to point out when competing responses should be used. This social support technique also helps to enhance client awareness of stuttering. Lastly, clients should be encouraged and praised for putting themselves in situations where they are prone to stuttering and effectively use the competing response; Azrin and Nunn (1974) called this public display.

Generalization Training. Generalization training enhances the likelihood that treatment gains will generalize to non-clinic settings. In an attempt to generalize the treatment, the clinician uses symbolic rehearsal, in which a client is asked to imagine stuttering-prone situations, while demonstrating the correct competing response. Positive practice is also used to generalize treatment effects, and involves the client reading one sentence at a time to the clinician, while doing regulated breaths between each word; later taking such a breath after two words, then three words, and continuing this pattern until fluent speech is formed. A clinician instructs the patient to use this technique in multiple settings, including phone conversations with friends or at home with family. As a client progresses, speech rate is gradually increased until fluent speech is formed without stuttering.

RB and slightly modified versions of the treatment have been examined in several studies (Andrews & Tanner, 1982; Azrin & Nunn, 1974; Azrin, Nunn, & Frantz, 1979; Ladouceur & Saint-Laurent, 1986; Waterloo & Gotestam, 1988; Williamson, Epstein & Coburn, 1981).

In the original evaluation of RB, Azrin and Nunn (1974) examined 14 people who stuttered, 13 of whom had previously received unsuccessful stuttering treatment. Pre and post-treatment self-reports of stuttering frequency were recorded by participants. Self-reports were validated by corroborating friend or family member reports and post-treatment telephone contact between the therapist and client. Treatment was given in a single 2 hour session, and stuttering reductions of 94% were reported the day after treatment. Treatment gains were maintained for at least one month for all clients, regardless of the severity of pre-treatment stuttering. Azrin et al. (1979) then compared RB to an abbreviated Systematic Desensitization control condition. At a 3-month follow-up, average stuttering reductions were approximately 95% for the regulated breathing group compared to the 7% reduction found in control group.

Recognizing the limitations of self-report data, Williamson et al. (1981) incorporated direct observation measures to assess stuttering. Specifically, speech rate, dysfluency rate, and facial masseter EMG activity were assessed in several situations (while reading aloud, being interviewed, role playing a social situation, and speaking over the telephone). Treatment resulted in reductions of stuttering and facial muscle tension and an increase in speech rate. Furthermore, social validation data were collected by independent raters. These data suggested that following treatment, the treated person was easier to understand, more desirable to interact with, and made a better social impression. Treatment gains were maintained through the 3 month follow-up.

Andrews and Tanner (1982) also found treatment gains following RB, but did not reach as favorable conclusions. RB was applied to six participants who received two sessions of group treatment. Each session was 6 hours long and consisted of 2 hours of individual attention per participant. Stuttering frequency and speech rate were assessed using 3-min. recordings of speech obtained 5 times (2 pretreatment, 1 post-treatment, and 2 follow-up). Stuttering frequency decreased 45% from pretreatment levels; however, the authors concluded that the gains were not clinically significant.

Ladouceur and Saint-Laurent (1986) attempted to evaluate the clinical validity of improvement by comparing RB in a group of people who stuttered to a matched non-stuttering criterion group. In addition to collecting subjective improvement measures, behavioral assessment of stuttering was conducted by obtrusively and unobtrusively recording participants' speech during telephone, interview, and public speaking situations. Stuttering was significantly reduced from pre-treatment to post-treatment, and treatment gains were maintained at 1- and 6-month follow-ups. Furthermore, the stuttering group did not significantly differ from the non-stuttering criterion group at the 6-month follow-up, supporting the clinical efficacy of RB.

In another study, Waterloo and Gotestam (1988) randomly assigned 32 participants to either a single, 2-3 hour session of Regulated Breathing or to a waiting-list control group. Stuttering frequency and speech rate were measured 4 and 2 weeks before treatment, and follow-up measures were taken 2, 3, and 8 months after treatment completion. Recorded speech samples were obtained during conditions of phrase reading and spontaneous speech, and the dependent variables were measured by assessing the first 200 words of each sample. Although the two groups did not differ prior to treatment, significant improvements in speech fluency and rate were found only for the RB group at the 8-month follow-up.

Since the development of the original RB procedure, various studies have sought to enhance treatment efficacy. Components of the treatment were expanded by further enhancing awareness of stuttering (Ladouceur, Boudreau, & Theberge, 1981; Ladouceur, Cote, Leblond, & Bouchard, 1982) and increasing social support (Cote & Ladouceur, 1982). Likewise, attempts have been made to improve treatment efficiency by implementing the treatment with trained parents (Ladouceur & Martineau, 1982) and in a massed versus distributed fashion (Saint-Laurent & Ladouceur, 1987). In nearly all studies, RB has proven to be a robust treatment in producing substantial reductions in stuttering regardless of treatment modality or attempts at enhancement.

Researchers have also attempted to simplify RB in various ways (Caron & Lacouceur, 1989; Elliott, Miltenberger, Rapp, Long, & McDonald, 1998; Gagnon & Ladouceur, 1992; Miltenberger, Wagaman, & Arndorfer, 1996; Wagaman, Miltenberger, & Arndorfer, 1993). A RB procedure consisting of awareness training, competing response training, and "gentle contact" was examined by Caron and Lacouceur (1989). The procedure was evaluated with 4 children using a multiple baseline across subjects design. During the "gentle contact" component, participants were taught to voluntarily tense and relax facial muscles. Participants first practiced the competing response and "gentle contact" techniques while using single-syllable words until stuttering reached a criterion of less than 3% of syllables stuttered (% SS). Practice with progressively more complex speech continued until participants were speaking in full sentences, and treatment ended when a 3%SS or fewer criterions was reached. Decreases in %SS and increases in speech rate were maintained by all participants through a 6-month follow-up. Furthermore, measurements of parental attitudes towards stuttering indicated that all parents were more accepting as the treatment progressed.

Gagnon and Ladouceur (1992) conducted a series of three studies examining the effectiveness of a simplified RB procedure for children who stutter. In the first experiment, four children learned the procedure described by Caron and Ladouceur (1989) in a group format. One-hour treatment sessions were conducted twice per week and included parental involvement and structured group practice designed to aid in generalization of skills. Participants showed clinically significant improvements in %SS (less than 3% SS) after an average of 7 sessions, and treatment gains were maintained at 1-month and 6-month follow-up assessments. In addition, audiotape speech samples were assessed by independent raters to measure social validation. Although raters were able to distinguish between participants who stuttered and participants who did not stutter at pretreatment, they were unable to differentiate between the two following treatment.

To examine treatment efficacy in younger children, Experiment 1 was replicated with 4 younger participants. All participants reached the 3% SS or less criterion at post-treatment, although the number of sessions needed to reduce stuttering to that level varied from 5 to 41 sessions. Stuttering reductions were maintained through 1-month follow-up for 3 participants and through 6-month follow-up for 2 participants; however, all participants were still stuttering far below baseline levels and were speaking at an increased rate. Social validation measures at post-test also indicated that the independent observers could not differentiate the participants from people who did not stutter.

Experiment 3 combined the aforementioned procedures with parental participation and booster sessions. Three children and their parents participated in treatment sessions. Parents performed exercises with their children, provided encouragement and reinforcement for correct implementation of the procedures, and supervised daily home practice. After stuttering was reduced to 3% SS or less, parents directed treatment sessions and met with the therapist every 3 weeks for booster sessions. Stuttering was reduced to 3% SS or less for all participants after a mean of four sessions, and SPM was in the normal range. Treatment gains were maintained through a 6-month follow-up for all 3 participants.

In the most simplified version of RB, consisting of awareness training, competing response training, and social support, participants received an initial 2-hour treatment session and approximately 3 sessions per week thereafter until the criterion level of 3% SS or less was consistently reached (Wagaman et al., 1993). Post-treatment booster sessions occurred when the % SS exceeded 3% for two consecutive sessions. Based on speech recordings and generalization probes, the authors observed a stuttering reduction of 89% from baseline to post-treatment. Stuttering continued to remain below the criterion level through 10 to 13 month follow-up. In addition, parents and speech pathologists rated social validity. The post-treatment ratings suggested that the children's speech was unimpaired and that no further stuttering intervention was needed.

Elliott et al. (1998) attained similar results using this protocol with 4 of 5 children who stuttered and by Miltenberger et al. (1996), who examined the procedure in a multiple baseline across participants design with adult participants. This latter study also highlighted the importance of compliance, as one subject appeared to experience a mild relapse after failing to maintain treatment compliance.

de Kinkelder and Boelens (1998) combined a simplified procedure of awareness training, RB and social support with training designed to enhance parents' positive attitudes. Speech samples were recorded in a speech clinic and in the child's home and school. A list of suggestions for increasing positive attitudes was given to parents, and included statements such as "I speak slowly" and "I do not interrupt my child when he talks" (Caron & Ladouceur, 1989). The suggestions were practiced by the parents during the treatment sessions. Parents also reminded their children to complete homework assignments and praised correct homework. Parents also gave tangible reinforcers on four occasions as new skills were acquired. After an average of 21 treatment sessions, stuttering was reduced to 3% SS or less both in the clinic and at home, speech rates increased, and speech was judged to sound more natural by independent raters.

In a recent case study, Freeman and Friman (2004) applied a simplified RB procedure to treat stuttering in an older adolescent living in residential care. To analyze environmental variables affecting stuttering, the participant's stuttering was assessed in three conditions: during reading, neutral conversation, and emotional conversation. Following treatment, stuttering frequency was reduced in all conditions and speech was rated as more socially acceptable. However, treatment gains were not identical in all conditions, highlighting the author's notion that analysis of environmental contingencies may improve treatment gains.


Stuttering can be a socially debilitating condition, and behavior analytically derived treatments appear to be effective in its management. RB appears to have a relatively large amount of data to support its efficacy. In a review of the Regulated Breathing literature, Woods, Twohig, Fuqua, and Hanley (2000) summarized the effectiveness of the simplified and original procedures and available control groups. As a common metric across studies, the mean percent change in stuttering frequency and speech rate from pretest to posttest and follow-up were calculated. Original or enhanced RB resulted in a mean stuttering reduction of 68%, and at an average of 3.5 months follow-up, stuttering was 59.5% below baseline levels. Of the studies that reported speech rate, a mean increase of 29.3% was maintained at a mean of 3.7 months follow-up.

Following the simplified procedure, stuttering was an average of 74% below pretreatment levels, and 78.8% below baseline at an average of 7.8 months follow-up. Mean speech rate increased by 38% at an average of 9.8 months follow-up. In comparison, the mean percent changes for control groups in the four studies that included such groups (Ladouceur & Martineau, 1982; Ladouceur & Saint-Laurent, 1986; Saint-Laurent & Ladouceur, 1987; and Waterloo & Gotestam, 1988) showed that stuttering decreased by a mean of 9.2% and speech rate increased by a mean of 6.1% at post-treatment. Stuttering was reduced by 14.8% at follow-up. Combined, these results suggest that gains seen following RB treatment are not simply due to the passage of time.

RB appears to be an effective treatment for stuttering and fits the criteria described by Chambless and Ollendick (2001) to be considered a "probably efficacious" treatment (Woods et al., 2000). However, to be considered a "well-established" treatment, there are several issues that must be addressed. First, many of the group studies of RB have not included control groups. Of the studies that did include control groups, the groups were wait-list controls. "Well-established" treatment criteria specify that the treatment must demonstrate efficacy by showing its superiority to alternative treatments or to a psychotherapy placebo (Chambless & Ollendick, 2001). Accordingly, Woods et al. (2000) recommend comparing Regulated Breathing to placebo control groups to control for expectancy effects. In addition, simplified, expanded and original versions of the treatment should be compared directly, and the procedure should also be compared to other fluency-enhancing procedures, such as Prolonged Speech (Ingham, 1984) and the Precision Fluency Shaping Program (Webster, 1980).

Second, the workgroup criteria for a "well-established" treatment state that the characteristics of research samples must be specified (Chambless & Ollendick, 2001). Woods et al. (2000) point out that the studies examining Regulated Breathing have not clearly specified participant characteristics. Cognitive ability and the global severity of stuttering, including stuttering frequency, speech rates, functional impairments, and physical movement accompanying stuttering, should be assessed and reported. It would also be beneficial to further examine treatment outcome differences for adults and children who stutter. For example, of the research on the simplified treatment, only one study sample (Miltenberger et al., 1996) was comprised of adults.

Third, a component analysis of the RB treatment package would help to identify effective treatment components and thereby increase treatment efficiency. The original RB package described by Azrin and Nunn (1974) included awareness, relaxation, competing response, motivation and generalization training. Studies examining simplified versions of Azrin and Nunn's (1974) treatment procedure have resulted in stuttering improvements, suggesting that one or more of the original treatment components may not be necessary. However, no direct attempt at isolating effective RB treatment components has been made. For example, it is possible that the contingent corrective feedback given during breathing pattern modification produces awareness of stuttering, thereby rendering a separate awareness training component unnecessary. Future research addressing such issues would help to identify the active RB treatment components.

Fourth, study methodology could be improved upon in several ways. Dependent variables have typically only included stuttering frequency, speech rate, and social validity ratings. Since the targeted change in Regulated Breathing is a person's breathing pattern, physiological measures of breathing patterns could be a more accurate measure of treatment effectiveness (Woods et al., 2000). Stuttering frequency and speech rate assessments could also be improved. Most of the studies summarized in this paper assessed stuttering based on short samples of speech, generally only 1-3 minutes long. Longer, more frequent samples taken in multiple environmental settings might better capture baseline and posttreatment levels of stuttering and speech rate. With methodological improvements such as these, future research might better determine if Regulated Breathing should be considered a "well-established" treatment for stuttering.


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Author contact information:

Christine A. Conelea, B.A.

Department of Psychology

P.O. Box 5075

Milwaukee, WI 53211

Telephone: (414) 229-2830


Kevin A. Rice

Department of Psychology

P.O. Box 5075

Milwaukee, WI 53211

Telephone: (414) 229-2830


Douglas W. Woods, Ph.D.

Department of Psychology

P.O. Box 5075

Milwaukee, WI 53211

Telephone: (414) 229-5335

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Author:Conelea, Christine A.; Rice, Kevin A.; Woods, Douglas W.
Publication:The Journal of Speech-Language Pathology and Applied Behavior Analysis
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Date:Jun 22, 2006
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