Tuesday, December 3, 2013

Delayed Auditory Feedback Systems

Delayed Auditory Feedback

Recently, I have had the opportunity to work with a patient that has neurogenic stuttering. We have attempted easy onset and using continuous voicing to improve the dysfluency. We have seen some gains with both of these therapy techniques and I plan to continue to utilize both of them but this patient has a goal to be back to work in a relatively short period of time. So, I decided to try a delayed auditory feedback (DAF) system with my patient. We have seen great results! Now there are several approaches to providing treatment for patients who stutter and this blog post is only discussing one of them, delayed auditory feedback.

1.  What is delayed auditory feedback and how does it work? DAF is a device that takes your voice and delays it by a set time. This set time can be predetermined by the speech-language pathologist or the patient.  DAF systems are thought to best help patients who stutter that have an under activated auditory processing system.
Before I try this system with a patient I explain to them it’s like you have a poor connection with your phone and you keep hearing your voice echo. Instead of turning off the phone for a better connection we are going to be working through the delay, the best way to work through the delay is to slow your rate of speech and prolong syllable sets.
DAF systems have come a long way. I was first introduced to DAF systems with The Facilitator that, I believe, was made by Kay Elemetrics and Dr. Daniel Boone. I don’t think they even make it anymore but if you click on the link below you can find an article on The Facilitator. http://www.kayelemetrics.com/index.php?option=com_publication&Itemid=5&id=16&menu_id=46&subid=194
Now DAF systems are available on the VisiPitch (the system I have), apps, and various other forms. The constant with all of the DAF systems is that there is a microphone for you to speak into, a processor that alters your voice (in our case delays it) and an ear piece for you to hear your own voice at the selected delayed time.

2.     Do we have evidence to support the use? In graduate school I was taught that a DAF system is like a one hit wonder, it only would work while the patient was wearing the device, once the patient removed it that there would be no carry over. I was pleasantly surprised when my colleague Kimberly Herrejon M.S. CCC-SLP provided me with this journal article, Delayed auditory feedback in the treatment of stuttering: clients as consumers. (Borsel, Reunes, and Bergh 2003). http://www.ncbi.nlm.nih.gov/pubmed/12745932. In short, they first assessed patients stuttering occurrences independently and with a DAF system. Over a three month time span they had the participants use the DAF system alone, when they brought them back for testing they found that the stuttering occurrences without a DAF declined significantly!  So yes we do have some evidence out there to support this method!

 I have also read that there is a method of using the DAF system in a weaning manner. Some have started a DAF system at an appropriate delayed setting and once their patient is fluent over several contexts they then reduce the delayed setting and continue to do so until there is no need for the DAF system. I find this so interesting and I can’t wait to find some more research on this!

3.     Is it for everyone? I do not believe that a DAF system is a cure all for people who stutter. I do think the best way to find out though is to give it a try. Your patient will either have a reaction or no reaction. I had a patient in just the other day that had no reaction to the DAF system despite several trials and settings so we are not going to use it. We are going to move on and find what works best for the patient.

4.     Video! This gentleman did a great job presenting his DAF system. And I think it is a true picture of what a basic DAF system looks like. With some of the other systems they have made it much more discrete. 

5.     Vendors. I was so fortunate to already come across a pre-made list by The Stuttering Foundation. It can be found below as well as a note from the foundation. I as well have no financial ties to any of the below organizations.
“Note: The Stuttering Foundation of America does not warrant the efficacy of these devices nor guarantee their treatment in any way. This page is here for your information only. Appearing on this page is NOT an endorsement by the Stuttering Foundation.
Speech Monitor
Rick Arenas
SpeechEasy - $2,500 - $4,500
Janus Development Group, Inc.
112 Staton Road
Greenville, NC 27834
Toll-free (877) 4-Fluency
These devices, worn like traditional hearing aids, use altered auditory feedback in the form of auditory delays & frequency shifts.
Casa Futura Technologies - $1,495 - $3,500
720 31st Street
Boulder, CO 80303
888-FLUENCY or 888-358-3629 or 303-417-9752
303-413-0853 (Fax)
DAF, FAF, MAF, and stuttering bio feed back devices for clinical, home practice, telephone, and pocket use. 15 States (CA, MA, TX, WI and more) provide funding for anti-stuttering telephone devices to qualified consumers. Schools may inquire about special rates.
KayPentax - $4,000
2 Bridgewater Lane
Lincoln Park, NJ 07035
800-289-5297 (toll-free USA & Canada)
The Stuttering Foundation has also provided a list of apps and computer software available for DAF use. Again below is also a note from The Stuttering Foundation.
Note: The Stuttering Foundation does not warrant the efficacy of these apps nor guarantee their treatment in any way. This page is here for your information only. Appearing on this page is NOT an endorsement by the Stuttering Foundation.
Apps for smart phones, tablets and iPad/IPhones etc…
Smarty Ears (Fluency Tracker and Disfluency Index Counter)
The Stammurai, a game created by teens who stutter
Software for Computers
Speech Monitor (free) 
I believe these are all already hyperlinked for further exploring if you are interested! I also just wanted to take a short moment and say a big Thank You to The Stuttering Foundation and other organizations that support people who stutter. I am so impressed with their the time and dedication!
6. Real life Experience. Here is a review from a person who stutters and has used a DAF system. Some of his thoughts are positive and some are negative but I think it is important to see both sides!
7.     Resources

Have you used a DAF system before? What is your experience?

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