I. INTRODUCTION

Since the 1960's, a succession of wearable, electronic devices have been marketed to help those who stutter (Molt, 2005). These devices became smaller and less conspicuous as technology improved, and in 2001 the SpeechEasy was introduced as the state of the art in anti- stuttering devices. In contrast to the somewhat cumbersome nature of earlier electronic fluency aids, the SpeechEasy's appearance resembles a digital hearing aid, making it more cosmetically pleasing and thus more appealing to many consumers. The device garnered considerable press upon its introduction, much of it in the form of sensationalist accounts of dramatic, instantaneous stuttering reduction (e.g., Hudson, 2003; Sloan, 2007). This type of media portrayal casting the device as a "miracle cure" for stuttering understandably upset many stuttering therapists and researchers who, unlike most laypeople, understood the variable nature of the disorder and knew that not all individuals who stutter (IWS) would benefit from the device. As a result, many professionals balked at its use as a potential therapy tool, at least until independent clinical trials assessing its effectiveness became available.

Over the past few years those studies have begun to emerge. Laboratories such as Larry Molt's at the University of Auburn and Joy Armson's at Dalhousie University have published studies on the SpeechEasy in peer-reviewed journals and presented preliminary findings at professional conferences (Armson & Kiefte, 2008; Armson, Kiefte, Mason, & De Croos, 2006; Molt, 2006a, 2006b, 2006c; O'Donnell, Armson, & Kiefte, 2008). Our laboratory at the University of Colorado has also conducted research on the device. We have examined its effectiveness across time during situations of daily living and we have also measured its performance when used in conjunction with traditional stuttering therapy. This paper will highlight some of our more notable findings and discuss some clinical implications of those results. For the interested reader, our clinical trial is published in the Journal of Speech, Language and Hearing Research (Pollard, Ellis, Finan, & Ramig, in press). An additional case study of SpeechEasy use paired with traditional stuttering therapy is currently under review and can be found at http://convention.asha.org/2007/handouts.cfm, and we have written a chapter on the SpeechEasy to appear in the forthcoming book Treatment of Stuttering: Conventional and Emerging Interventions edited by Barry Guitar and Rebecca McCauley (Ramig, Ellis, Pollard, & Finan, in press).

II. FINDINGS FROM OUR CLINICAL TRIAL & CASE STUDY

Clinical trial: Pollard, R., Ellis, J. B., Finan, D., & Ramig P. R. (in press). Effects of the SpeechEasy on objective and perceived aspects of stuttering: a six-month, Phase I clinical trial in naturalistic environments. Journal of Speech, Language and Hearing Research.

Our clinical trial of the SpeechEasy followed a group of 11 IWS as they wore the device during their everyday lives. The research design consisted of a 1-month baseline phase (without device), 4- month treatment phase (with device), and 1-month withdrawal phase (without device). Speech samples were collected roughly every two weeks outside of the laboratory. We also gathered subjects' opinions of the device and recorded their responses on questionnaires designed to assess hidden components of stuttering such as those associated with anxiety.

The group results revealed that the SpeechEasy significantly reduced stuttering immediately after the device was fit. However, we did not find a significant effect for the device across four months of continuous use. On an individual level, our subjects' responses to the SpeechEasy were highly variable in terms of both overt stuttering and subjective impressions of the device. Interestingly, the device's impact on our subjects' speech did not always correspond with their overall impressions of the device. For instance, some who showed no measurable improvement in fluency nevertheless reported very high satisfaction levels with the device, while others whose fluency substantially improved reported negative opinions of the device. Lastly, we found that after using the SpeechEasy for four months, our group had significantly lower (i.e., improved) scores on the Perceptions of Stuttering Inventory (PSI). The PSI is a questionnaire that inventories the maladaptive, compensatory behaviors IWS often use when speaking or anticipating speaking.

Case study: Pollard, R., Ramig, P. R., Ellis, J. B., Finan, D. (in review). Case study of SpeechEasy use combined with traditional stuttering treatment.

Our case study was an offshoot of the larger project mentioned above. Because one of the participants from that project chose to purchase his device and then begin traditional stuttering therapy, we were provided with a unique opportunity to conduct a natural experiment studying the effects of ongoing stuttering treatment coupled with SpeechEasy use. We were motivated to do so primarily because no research of that nature yet existed and because the manufacturer recommends that, for optimal outcomes, device use should be combined with traditional stuttering treatment that continues beyond device fitting (SpeechEasy Professional Information Packet, 2006). Also, anecdotal evidence and our own experiences with fitting the device suggest that some IWS use the SpeechEasy as their sole method of treatment (Ramig et al., in press). These may include clients living in rural areas, those with schedules precluding regular clinical contact, or those with a history of unsuccessful treatment. Although we only followed one individual, we felt any evidence bearing on the manufacturer's recommendation would be useful to those desirous of best practice guidelines for device use.

We found that our participant was able to use traditional, active stuttering management techniques in conjunction with the SpeechEasy to achieve fluency gains beyond what he attained with the device alone. His overt stuttering counts and his PSI scores each showed a pattern of relapse without traditional treatment, followed by rapid improvement when treatment was reinstated. According to his self-reports, easy onsets to initiate voicing were the most helpful therapeutic strategy with the device. Interestingly, he also stated that his use of the device became more restricted over time as traditional stuttering therapy progressed. He reportedly uses his device now in only higher stress situations such as class presentations and study groups, relying at other times on stuttering management techniques learned during treatment.

III. CLINICAL IMPLICATIONS OF OUR RESEARCH

Our examinations of the SpeechEasy over the past two years have yielded some very interesting results. More importantly, we hope that our work and the work of others have gone some way toward replacing the conjecture and extravagant claims surrounding the device at its inception with credible, well-founded outcomes data that can be of use to those wishing to know more about the SpeechEasy.

No doubt our most striking finding was the device's failure to produce lasting fluency enhancement for our sample of IWS. While this is indeed compelling--particularly as our data was gathered outside of the clinic in naturalistic speaking environments--it is not the whole story. Inspection of individual profiles revealed significant stuttering reduction and positive self-reports from some subjects. Similar results have been obtained by other, independent research groups (e.g., Cook & Smith, 2006; O'Donnell et al., 2008; Molt, 2006a, 2006b, 2006c; Runyan, Runyan, & Hibbard, 2006). This indicates that the SpeechEasy may be a viable treatment option for some IWS. But here's the rub: aside from personally testing out the device, there are currently no reliable means for determining which clients may or may not be good candidates. As we state in our forthcoming chapter on the device, by and large, "Clients' personal experience with how the SpeechEasy impacts their stuttering during the initial two to three-hour evaluation is the determining factor as to whether or not they will purchase the device" (Ramig et al., in press). This presents a potential problem for clients deciding whether to try the device and the clinician they may ask for advice. In light of this, we hope that SpeechEasy research will turn to this question of candidate characteristics in the near future. We should note here that at least one lab has conducted investigations along these lines (see Molt 2007b, 2007c). The early results are encouraging insofar as they indicate that reliable, practical means for screening SpeechEasy candidates are within reach.

In a related vein, we and others (O'Donnell et al., 2008) have demonstrated an adaptation effect for some users after prolonged use. This means that, for some, the device's benefits may wane over time. Unfortunately, there is currently no dependable method to predict to whom this may occur. Perhaps Molt's preliminary efforts will help steer future inquiries into the matter. At present, however, a clinician is limited to relaying the available information on this topic to interested clients so that they may make an informed decision.

Another possible issue facing clinicians fitting the SpeechEasy is incongruity between the device's impact on the client's overt stuttering and the client's personal opinion of its effectiveness. We saw this with several of our subjects. Two subjects responded to the device with significantly decreased stuttering, but did not enjoy wearing it at all. Two other subjects showed virtually no improvement in fluency, yet were reportedly very happy with the SpeechEasy. What is a clinician to do if faced with the latter case, for instance? Should the client's own perception of device benefits take precedence over the clinician's often more objective judgment? This is without doubt a difficult area, as some clinicians may, knowingly or unknowingly, wish to impose their own fluency standards on the client. We feel the clinician should give her professional opinion if asked to do so, but understand that the client's impressions are paramount and in the end it will likely be the client's unique perspective that determines his/her final decision. We might mention here that many of our subjects reported a perceived boost in confidence while wearing the SpeechEasy. Also, at the end of the study our group improved significantly on the PSI, a questionnaire with many items referring to stuttering phenomena assumed to be associated with anxiety. These findings and others (e.g., Cook & Smith, 2006) point toward the possibility of a general anxiolytic (i.e., anxiety reducing) effect of the device that may not be apparent, at least initially, in a client's surface speech behaviors.

Our case study was, to our knowledge, the first attempt to examine the interaction of SpeechEasy use with ongoing stuttering therapy. While it was admittedly only a modest attempt to begin to explore that topic, we feel that the results raise important questions and we hope that other, more fully realized work along those lines will soon emerge. One issue raised by that study and others pertains to the overall cost of stuttering treatment. Our subject happened to show an adaptation effect while wearing the device during the prior group study. During the subsequent case study he 1) showed improvement when ongoing, traditional therapy was paired with the device, 2) relapsed during his summer break from school while he wore the device without additional treatment, and then 3) immediately improved once school was back in session and he reenrolled in therapy. Given this response and other reports of adaptation effects in the absence of treatment (e.g., O'Donnell et al., 2008; Pollard et al., in press), it appears that at least some SpeechEasy users will need an additional form of treatment to maintain fluency gains over the long term. Recall also that this is what the manufacturer of the device recommends for optimal outcomes (SpeechEasy Professional Information Packet, 2006). It is easy to understand, then, how the prospect of additional, ongoing stuttering therapy may present a concern for clients already faced with the decision of whether or not to purchase a device that at present sells for $4,100 - $4,900. While it is true that stuttering treatment--regardless of how it is delivered- -is typically a costly investment, adding supplemental therapy to the equation may alter the cost-benefit analysis for clients considering a SpeechEasy. The clinician should be aware of this potentiality and discuss the issue straightforwardly with the client at the initial meeting.

Related to this issue of cost is that of device usage patterns. Our subject reported that he gradually came to use his device only in higher stress settings, feeling less inclined to wear it in most other day-to-day speaking situations. This phenomenon of device use becoming more situation-specific over time is also reported elsewhere (e.g., Ramig et al., in press). For some clients, being able to speak with confidence and increased fluency on the telephone or while giving important presentations, to take two common examples, may be worth the cost of the device. Other clients may feel otherwise. Either way, the clinician fitting the device should be cognizant of and honest about this possibility with prospective buyers.

IV. REFERENCES

Armson, J., & Kiefte, M. (2008). The effect of SpeechEasy on stuttering frequency, speech rate, and speech naturalness. Journal of Fluency Disorders, 33, 120-134.

Armson, J., Kiefte, M., Mason, J., & De Croos, D. (2006). The effect of SpeechEasy on stuttering frequency in laboratory conditions. Journal of Fluency Disorders, 31, 137-152.

Cook, M. J., & Smith, L. M. (2006). Outcomes for adult males using the SpeechEasy fluency device for one year. Presented to the American Speech-Language-Hearing Association, Miami, FL.

Hudson, D. A. (Executive Producer). (2003, February 3). The Oprah Winfrey Show [Television broadcast]. Chicago: Harpo Productions.

Molt, L. (2005). A brief historical review of assistive devices for treating stuttering. 8th International Stuttering Awareness Day Online Conference (ISAD8). Link: www.mnsu.edu/comdis/isad8/isadcon8.html.

Molt, L. (2006a). SpeechEasy AAF device long-term clinical trial: Attitudinal/perceptual measures. Poster presented to the American Speech-Language-Hearing Associating, Miami, FL.

Molt, L. (2006b). SpeechEasy AAF device long-tem clinical trial: Speech fluency and naturalness measures. Poster presented to the American Speech-Language-Hearing Associating, Miami, FL.

Molt, L. (2006c). SpeechEasy AAF device long-tem clinical trial: Usage patterns and satisfaction ratings. Poster presented to the American Speech-Language-Hearing Associating, Miami, FL.

Molt, L. (2007a). Speecheasy AAF device long-term clinical trial: 24-month outcomes. Poster presented to the American Speech- Language-Hearing Association, Boston, MA.

Molt, L. (2007b). Auditory processing measures as predictors for altered auditory feedback success. Poster presented to the American Speech-Language-Hearing Association, Boston, MA.

Molt, L. (2007c). Indicators for long-term successful usage of altered auditory feedback devices. Poster presented to the American Speech-Language-Hearing Association, Boston, MA.

O'Donnell, J. J., Armson, J., & Kiefte, M. (2008). The effectiveness of SpeechEasy during situations of daily living. Journal of Fluency Disorders, 33, 99 - 119.

Pollard, R., Ellis, J. B., Finan, D., & Ramig P. R. (in press). Effects of the SpeechEasy on objective and perceived aspects of stuttering: a six- month, Phase I clinical trial in naturalistic environments. Journal of Speech, Language and Hearing Research.

Pollard, R., Ramig, P. R., Ellis, J. B., Finan, D. (in review). Case study of SpeechEasy use combined with traditional stuttering treatment.

Ramig, P. R., Ellis, J. B., Pollard, R., & Finan, D. (in press). Application of the SpeechEasy to stuttering treatment: Introduction, background, and preliminary observations. In B. Guitar & R. McCauley (Eds.), Treatment of Stuttering: Conventional and Emerging Interventions. Baltimore, MD: Lippincott, Williams & Wilkins.

Runyan, C. M., Runyan, S. E., & Hibbard, S. (2006). The Speech Easy [sic] device: a three year study. Poster presented to the American Speech-Language-Hearing Association, Miami, FL.

Sloan, D. (Executive Producer). (2007, January 10). ABC Primetime: Medical Mysteries. [Television broadcast]. New York: ABC News.

SpeechEasy Professional Information Packet (2006). Available from Janus Development Group, Inc. 112 Staton Road Greenville, NC 27834. Phone: 866-551-9042. Email: customerserv@janusdevelopment.com.

You can post Questions/comments about the above paper to the authors before October 22, 2008.