A speech and psychological profile of treatment-seeking adolescents who stutter

PURPOSE

The purpose of this study was to evaluate the relationship between stuttering severity, psychological functioning, and overall impact of stuttering, in a large sample of adolescents who stutter.

METHOD

Participants were 102 adolescents (11-17 years) seeking speech treatment for stuttering, including 86 boys and 16 girls, classified into younger (11-14 years, n=57) and older (15-17 years, n=45) adolescents. Linear regression models were used to evaluate the relationship between speech and psychological variables and overall impact of stuttering.

RESULTS

The impact of stuttering during adolescence is influenced by a complex interplay of speech and psychological variables. Anxiety and depression scores fell within normal limits. However, higher self-reported stuttering severity predicted higher anxiety and internalizing problems. Boys reported externalizing problems-aggression, rule-breaking-in the clinical range, and girls reported total problems in the borderline-clinical range. Overall, higher scores on measures of anxiety, stuttering severity, and speech dissatisfaction predicted a more negative overall impact of stuttering.

CONCLUSION

To our knowledge, this is the largest cohort study of adolescents who stutter. Higher stuttering severity, speech dissatisfaction, and anxiety predicted a more negative overall impact of stuttering, indicating the importance of carefully managing the speech and psychological needs of adolescents who stutter. Further research is needed to understand the relationship between stuttering and externalizing problems for adolescent boys who stutter.

An investigation of the effects of a speech-restructuring treatment for stuttering on the distribution of intervals of phonation

PURPOSE

The purpose of this study was to investigate whether stuttering reductions following the instatement phase of a speech-restructuring treatment for adults were accompanied by reductions in the frequency of short intervals of phonation (PIs). The study was prompted by the possibility that reductions in the frequency of short PIs is the mechanism underlying such reductions in stuttering.

METHOD

The distribution of PIs was determined for seven adults who stutter, before and immediately after the intensive phase of a speech-restructuring treatment program. Audiovisual recordings of conversational speech were made on both assessment occasions, with PIs recorded with an accelerometer.

RESULTS

All seven participants had much lower levels of stuttering after treatment but these were associated with reductions in the frequency of short PIs for only four of them. For the other three participants, two showed no change in frequency of short PIs, while for the other participant the frequency of short PIs actually increased.

CONCLUSIONS

Stuttering reduction with speech-restructuring treatment can co-occur with reduction in the frequency of short PIs. However, the latter does not appear necessary for this reduction in stuttering to occur. Thus, speech-restructuring treatment must have other, or additional, treatment agents for stuttering to reduce.

A Brief Version of the Unhelpful Thoughts and Beliefs About Stuttering Scales: The UTBAS-6

PURPOSE

A significant proportion of adults who stutter experience anxiety in social and speaking situations. The Unhelpful Thoughts and Beliefs About Stuttering (UTBAS) scales provide a comprehensive measure of the unhelpful cognitions associated with social anxiety in stuttering. However, reducing the number of UTBAS items would make it ideal as a brief screening instrument. Therefore, the aim of the present study was to develop a brief version of the full UTBAS scales.

METHOD

The 66-item UTBAS scales were completed by 337 adults who stutter. Item reduction was used to determine a smaller set of items that could adequately reproduce the total score for each full UTBAS scale.

RESULTS

Item reduction resulted in the inclusion of six items for the brief UTBAS-6 scales. Decile ranges for scores on the brief UTBAS-6 provide reliable estimates of the full UTBAS scores and valuable clinical information about whether a psychological assessment is warranted.

CONCLUSIONS

The brief UTBAS-6 provides a reliable and efficient means of screening the unhelpful thoughts and beliefs associated with speech-related anxiety among adults who stutter. Referral for a psychological assessment is recommended in cases where the UTBAS total score falls in or above the fifth decile.

Lidcombe Program Webcam Treatment for Early Stuttering: A Randomized Controlled Trial

PURPOSE

Webcam treatment is potentially useful for health care in cases of early stuttering in which clients are isolated from specialized treatment services for geographic and other reasons. The purpose of the present trial was to compare outcomes of clinic and webcam deliveries of the Lidcombe Program treatment (Packman et al., 2015) for early stuttering.

METHOD

The design was a parallel, open plan, noninferiority randomized controlled trial of the standard Lidcombe Program treatment and the experimental webcam Lidcombe Program treatment. Participants were 49 children aged 3 years 0 months to 5 years 11 months at the start of treatment. Primary outcomes were the percentage of syllables stuttered at 9 months postrandomization and the number of consultations to complete Stage 1 of the Lidcombe Program.

RESULTS

There was insufficient evidence of a posttreatment difference of the percentage of syllables stuttered between the standard and webcam Lidcombe Program treatments. There was insufficient evidence of a difference between the groups for typical stuttering severity measured by parents or the reported clinical relationship with the treating speech-language pathologist.

CONCLUSIONS

This trial confirmed the viability of the webcam Lidcombe Program intervention. It appears to be as efficacious and economically viable as the standard, clinic Lidcombe Program treatment.

Prevalence of anxiety disorders among children who stutter

PURPOSE

Stuttering during adulthood is associated with a heightened rate of anxiety disorders, especially social anxiety disorder. Given the early onset of both anxiety and stuttering, this comorbidity could be present among stuttering children.

METHOD

Participants were 75 stuttering children 7-12 years and 150 matched non-stuttering control children. Multinomial and binary logistic regression models were used to estimate odds ratios for anxiety disorders, and two-sample t-tests compared scores on measures of anxiety and psycho-social difficulties.

RESULTS

Compared to non-stuttering controls, the stuttering group had six-fold increased odds for social anxiety disorder, seven-fold increased odds for subclinical generalized anxiety disorder, and four-fold increased odds for any anxiety disorder.

CONCLUSION

These results show that, as is the case during adulthood, stuttering during childhood is associated with a significantly heightened rate of anxiety disorders. Future research is needed to determine the impact of those disorders on speech treatment outcomes.

Standalone Internet speech restructuring treatment for adults who stutter: A phase I study

PURPOSE

This Phase I trial reports the results of a clinician-free Internet speech restructuring treatment for adults who stutter. The program consists of nine phases with concepts loosely based on the Camperdown Program.

METHOD

Twenty adults who stutter were recruited. They were given unlimited access to the program for 6 months. Primary outcome measures were the percentage of syllables stuttered and self-reported severity ratings.

RESULT

Five participants accessed all phases of the program, while another five accessed more than half the phases. The remaining 10 accessed between one and four phases. Four of five participants who accessed all phases reduced their stuttering frequency by more than 50% and an additional two participants who accessed more than half the phases also achieved similar reductions. These results were confirmed by self-reports of stuttering severity. Stuttering reductions were largely commensurate with the amount of the program accessed.

CONCLUSION

As with other clinician-free programs in related health areas, maintaining adherence to the program's procedures was a significant issue. Nonetheless, this novel approach to treating stuttering has the potential to be a viable alternative for some clients and may help to address the significant access and relapse issues that affect treatment provision for adults who stutter.

Phase II trial of a syllable-timed speech treatment for school-age children who stutter

PURPOSE

A recent clinical trial (Andrews et al., 2012) showed Syllable Timed Speech (STS) to be a potentially useful treatment agent for the reduction of stuttering for school-age children. The present trial investigated a modified version of this program that incorporated parent verbal contingencies.

METHODS

Participants were 22 stuttering children aged 6-11 years. Treatment involved training the children and their parents to use STS in conversation. Parents were also taught to use verbal contingencies in response to their child's stuttered and stutter-free speech and to praise their child's use of STS. Outcome assessments were conducted pre-treatment, at the completion of Stage 1 of the program and 6 months and 12 months after Stage 1 completion.

RESULTS

Outcomes are reported for the 19 children who completed Stage 1 of the program. The group mean percent stuttering reduction was 77% from pre-treatment to 12 months post-treatment, and 82% with the two least responsive participants removed. There was considerable variation in response to the treatment. Eleven of the children showed reduced avoidance of speaking situations and 18 were more satisfied with their fluency post-treatment. However, there was some suggestion that stuttering control was not sufficient to fully eliminate situation avoidance for the children.

CONCLUSIONS

The results of this trial are sufficiently encouraging to warrant further clinical trials of the method.

International Phase II clinical trial of CBTPsych: A standalone Internet social anxiety treatment for adults who stutter

PURPOSE

CBTPsych is an individualized, fully automated, standalone Internet treatment program that requires no clinical contact or support. It is designed specifically for those who stutter. Two preliminary trials demonstrated that it may be efficacious for treating the social anxiety commonly associated with stuttering. However, both trials involved pre- and post-treatment assessment at a speech clinic. This contact may have increased compliance, commitment and adherence with the program. The present study sought to establish the effectiveness of CBTPsych in a large international trial with no contact of any kind from researchers or clinicians.

METHOD

Participants were 267 adults with a reported history of stuttering who were given a maximum of 5 months access to CBTPsych. Pre- and post-treatment functioning was assessed within the online program with a range of psychometric measures.

RESULTS

Forty-nine participants (18.4%) completed all seven modules of CBTPsych and completed the post-treatment online assessments. That compliance rate was far superior to similar community trials of self-directed Internet mental health programs. Completion of the program was associated with large, statistically and clinically significant reductions for all measures. The reductions were similar to those obtained in earlier trials of CBTPsych, and those obtained in trials of in-clinic CBT with an expert clinician.

CONCLUSIONS

CBTPsych is a promising individualized treatment for social anxiety for a proportion of adults who stutter, which requires no health care costs in terms of clinician contact or support.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) discuss the reasons for investigating CBTPsych without any clinical contact; (b) describe the main components of the CBTPsych treatment; (c) summarize the results of this clinical trial; (d) describe how the results might affect clinical practice, if at all.

Parent verbal contingencies during the Lidcombe Program: Observations and statistical modeling of the treatment process

PURPOSE

The purpose of this study was to document parent presentation of the Lidcombe Program verbal contingencies and model potential relationships between contingency provision and treatment duration.

METHODS

Forty parent-child pairs undertaking the Lidcombe Program participated, 26 of whom completed Stage 1. All participants were included in the analyses. Parents completed weekly audio-recordings of treatment during practice sessions and a diary of treatment during natural conversations. The number and types of contingencies provided during practice sessions were counted for 520 recordings. Accelerated failure time modeling was used to investigate associations between contingency provision during the first 4 weeks of treatment and duration of time to complete Stage 1.

RESULTS

During practice sessions 91% of contingencies were for stutter-free speech, 6.8% were for stuttering and 2.7% were incorrectly applied. Parents often combined several verbal contingencies into one. During natural conversations, the number of verbal contingencies reportedly provided across the day was low, an average of 8.5 (SD=7.82) contingencies for stutter-free speech and 1.7 (SD=2.43) for unambiguous stuttering. There was a positive, significant relationship between the number of verbal contingencies for stuttering provided during the first 4 weeks of treatment and time taken to complete Stage 1.

CONCLUSION

Parents mostly provided the expected types of contingencies but the number was lower than expected. An unexpected association was found between number of verbal contingencies for stuttering and treatment duration. Further research is required to explore the relation between rates of parent verbal contingencies, treatment process duration, and treatment outcome.

Assessing attentional biases with stuttering

BACKGROUND

Many adults who stutter presenting for speech treatment experience social anxiety disorder. The presence of mental health disorders in adults who stutter has been implicated in a failure to maintain speech treatment benefits. Contemporary theories of social anxiety disorder propose that the condition is maintained by negative cognitions and information processing biases. Consistent with cognitive theories, the probe detection task has shown that social anxiety is associated with an attentional bias to avoid social information. This information processing bias is suggested to be involved in maintaining anxiety. Evidence is emerging for information processing biases being involved with stuttering.

AIMS

This study investigated information processing in adults who stutter using the probe detection task. Information processing biases have been implicated in anxiety maintenance in social anxiety disorder and therefore may have implications for the assessment and treatment of stuttering. It was hypothesized that stuttering participants compared with control participants would display an attentional bias to avoid attending to social information.

METHODS & PROCEDURES

Twenty-three adults who stutter and 23 controls completed a probe detection task in which they were presented with pairs of photographs: a face displaying an emotional expression-positive, negative or neutral-and an everyday household object. All participants were subjected to a mild social threat induction being told they would speak to a small group of people on completion of the task.

OUTCOMES & RESULTS

The stuttering group scored significantly higher than controls for trait anxiety, but did not differ from controls on measures of social anxiety. Non-socially anxious adults who stutter did not display an attentional bias to avoid looking at photographs of faces relative to everyday objects. Higher scores on trait anxiety were positively correlated with attention towards photographs of negative faces.

CONCLUSION & IMPLICATIONS

Attentional biases as assessed by the probe detection task may not be a characteristic of non-socially anxious adults who stutter. A vigilance to attend to threat information with high trait anxiety is consistent with findings of studies using the emotional Stroop task in stuttering and social anxiety disorder. Future research should investigate attentional processing in people who stutter who are socially anxious. It will also be useful for future studies to employ research paradigms that involve speaking. Continued research is warranted to explore information processing and potential biases that could be involved in the maintenance of anxiety and failure to maintain the benefits of speech treatment outcomes.

Children and adolescents who stutter: Further investigation of anxiety

PURPOSE

Despite the greatly increased risk of social anxiety disorder in adults who stutter, there is no clear indication of the time of onset of this disorder in childhood and adolescence. The purpose of this study was to explore this issue further using the Revised Children's Manifest Anxiety Scale (RCMAS), so that appropriate interventions can be developed prior to adulthood. This is the first time the RCMAS has been completed by children younger than 11 years. Using the same test for both school-age children and adolescents can potentially identify when anxiety starts to develop from age 6 years through to adulthood.

METHODS

The RCMAS was administered to 18 school-age boys, five school-age girls, 41 adolescent boys and nine adolescent girls who were seeking treatment for their stuttering. Participants also rated the severity of their own stuttering.

RESULTS

All mean scaled scores on the four RCMAS subscales and Total Anxiety scores were within normal limits. However, for both groups of boys, scores on the Lie Scale were significantly higher than scores on the other three subscales.

CONCLUSIONS

Experts suggest high scores on the RCMAS Lie Scale are indicative of participants attempting to present themselves in a positive light and so cast doubt on the veracity of their other responses on the test. One interpretation, then, is that the boys were concealing true levels of anxiety about their stuttering. The results suggest why findings of anxiety studies in children and adolescents to date are equivocal. Clinical implications are discussed.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) discuss why understanding when anxiety starts in people who stutter is important, (b) describe the function of the RCMAS Lie sub scale and (c) summarize the possible implications of the RCMAS findings in this study.

Comparison of audio and audiovisual measures of adult stuttering: Implications for clinical trials

PURPOSE

This study investigated whether measures of percentage syllables stuttered (%SS) and stuttering severity ratings with a 9-point scale differ when made from audiovisual compared with audio-only recordings.

METHOD

Four experienced speech-language pathologists measured %SS and assigned stuttering severity ratings to 10-minute audiovisual and audio-only recordings of 36 adults.

RESULT

There was a mean 18% increase in %SS scores when samples were presented in audiovisual compared with audio-only mode. This result was consistent across both higher and lower %SS scores and was found to be directly attributable to counts of stuttered syllables rather than the total number of syllables. There was no significant difference between stuttering severity ratings made from the two modes.

CONCLUSION

In clinical trials research, when using %SS as the primary outcome measure, audiovisual samples would be preferred as long as clear, good quality, front-on images can be easily captured. Alternatively, stuttering severity ratings may be a more valid measure to use as they correlate well with %SS and values are not influenced by the presentation mode.

Feasibility of automated speech sample collection with stuttering children using interactive voice response (IVR) technology

PURPOSE

To investigate the feasibility of adopting automated interactive voice response (IVR) technology for remotely capturing standardized speech samples from stuttering children.

METHOD

Participants were 10 6-year-old stuttering children. Their parents called a toll-free number from their homes and were prompted to elicit speech from their children using a standard protocol involving conversation, picture description and games. The automated IVR system was implemented using an off-the-shelf telephony software program and delivered by a standard desktop computer. The software infrastructure utilizes voice over internet protocol. Speech samples were automatically recorded during the calls. Video recordings were simultaneously acquired in the home at the time of the call to evaluate the fidelity of the telephone collected samples. Key outcome measures included syllables spoken, percentage of syllables stuttered and an overall rating of stuttering severity using a 10-point scale.

RESULT

Data revealed a high level of relative reliability in terms of intra-class correlation between the video and telephone acquired samples on all outcome measures during the conversation task. Findings were less consistent for speech samples during picture description and games.

CONCLUSION

Results suggest that IVR technology can be used successfully to automate remote capture of child speech samples.

An investigation of the role of parental request for self-correction of stuttering in the Lidcombe Program

PURPOSE

The Lidcombe Program is a behavioural treatment for stuttering in children younger than 6 years that is supported by evidence of efficacy and effectiveness. The treatment incorporates parent verbal contingencies for stutter-free speech and for stuttering. However, the contribution of those contingencies to reductions in stuttering in the program is unclear.

METHOD

Thirty-four parent-child dyads were randomized to two treatment groups. The control group received standard Lidcombe Program and the experimental group received Lidcombe Program without instruction to parents to use the verbal contingency request for self-correction. Treatment responsiveness was measured as time to 50% stuttering severity reduction.

RESULT

No differences were found between groups on primary outcome measures of the number of weeks and clinic visits to 50% reduction in stuttering severity.

CONCLUSION

This clinical experiment challenges the assumption that the verbal contingency request for self-correction contributes to treatment efficacy. Results suggest the need for further research to explore this issue.

Observer perspective imagery with stuttering

PURPOSE

Adults who stutter are at risk of developing a range of psychological conditions. Social anxiety disorder is the most common anxiety disorder associated with stuttering. Observer perspective imagery is one cognitive process involved in the maintenance of some anxiety disorders. This involves viewing images as if looking at the self from the perspective of another. In contrast, the field perspective involves looking out from the self at the surrounding environment. The purpose of this study was to assess the presence of observer perspective imagery with stuttering.

METHOD

The authors administered the Hackmann, Surawy and Clark (1998) semi-structured interview to 30 adults who stutter and 30 controls. Group images and impressions were compared for frequency, perspective recalled and emotional valence.

RESULT

The stuttering group was significantly more likely than controls to recall images and impressions from an observer rather than a field perspective for anxious situations.

CONCLUSION

It is possible the present results could reflect the same attentional processing bias that occurs with anxiety disorders in the non-stuttering population. These preliminary results provide an explanation for the persistence of conditions such as social anxiety disorder with stuttering. Clinical implications are discussed.

English-only treatment of bilingual speakers who stutter: Generalization of treatment effects from English to Mandarin

PURPOSE

Speech language pathologists often do not speak the dominant language of their clients and so the language of treatment is an important consideration. This research investigated whether stuttering treatment delivered in English resulted in reductions in stuttering in English and Mandarin bilingual Singaporean speakers.

METHOD

Participants were 19 English-Mandarin bilinguals who stuttered. They received a speech re-structuring intensive program (IP) delivered in English only. Three 10-minute conversations in English and Mandarin, sampled at pre-treatment, immediately post IP, 4 weeks post IP and 12 weeks post IP, were analysed by two English-Mandarin bilingual clinicians for percentage of syllables stuttered (%SS).

RESULT

After English-only treatment, stuttering reductions were found to generalize to Mandarin. Stuttering reductions were significantly higher in English compared to Mandarin at 4 weeks post-IP, but there was no significant difference in the stuttering reductions between languages at the end of IP and at 12 weeks post-IP. Mean %SS scores for English and Mandarin were comparable with the outcome data reported for a similar intensive speech-restructuring program for monolingual English-speaking adults.

CONCLUSION

The results of this study show that stuttering reductions can be achieved in two languages following treatment in one language only. Future research in this area is proposed.

Webcam Delivery of the Camperdown Program for Adolescents Who Stutter: A Phase II Trial

Purpose

This Phase II clinical trial examined stuttering adolescents' responsiveness to the Webcam-delivered Camperdown Program.

Method

Sixteen adolescents were treated by Webcam with no clinic attendance. Primary outcome was percentage of syllables stuttered (%SS). Secondary outcomes were number of sessions, weeks and hours to maintenance, self-reported stuttering severity, speech satisfaction, speech naturalness, self-reported anxiety, self-reported situation avoidance, self-reported impact of stuttering, and satisfaction with Webcam treatment delivery. Data were collected before treatment and up to 12 months after entry into maintenance.

Results

Fourteen participants completed the treatment. Group mean stuttering frequency was 6.1 %SS (range, 0.7–14.7) pretreatment and 2.8 %SS (range, 0–12.2) 12 months after entry into maintenance, with half the participants stuttering at 1.2 %SS or lower at this time. Treatment was completed in a mean of 25 sessions (15.5 hr). Self-reported stuttering severity ratings, self-reported stuttering impact, and speech satisfaction scores supported %SS outcomes. Minimal anxiety was evident either pre- or post-treatment. Individual responsiveness to the treatment varied, with half the participants showing little reduction in avoidance of speech situations.

Conclusions

The Webcam service delivery model was appealing to participants, although it was efficacious and efficient for only half. Suggestions for future stuttering treatment development for adolescents are discussed.

Group lidcombe program treatment for early stuttering: a randomized controlled trial

PURPOSE

This study adds to the Lidcombe Program evidence base by comparing individual and group treatment of preschoolers who stutter.

METHOD

A randomized controlled trial of 54 preschoolers was designed to establish whether group delivery outcomes were not inferior to the individual model. The group arm used a rolling group model, in which a new member entered an existing group each time a vacancy became available. Assessments were conducted prerandomization and 9 months and 18 months postrandomization.

RESULTS

There was no evidence of a difference between treatment arms for measures of weeks or clinic visits required, percent syllables stuttered, or parent severity ratings. However, children in the group arm consumed around half the number of speech-language pathologist hours compared with children treated individually. In addition, children in the group progressed more quickly after the treating speech-language pathologist became more practiced with the group model, suggesting the group results are conservative estimates.

CONCLUSIONS

Group delivery of the Lidcombe Program is an efficacious alternative to the individual model. Parents responded favorably to the group model, and the treating speech-language pathologists found group treatment to be more taxing but clinically gratifying.

A standalone Internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych

PURPOSE

Social anxiety is common for those who stutter and efficacious cognitive behavior therapy (CBT) for them appears viable. However, there are difficulties with provision of CBT services for anxiety among those who stutter. Standalone Internet CBT treatment is a potential solution to those problems. CBTpsych is a fully automated, online social anxiety intervention for those who stutter. This report is a Phase I trial of CBTpsych.

METHOD

Fourteen participants were allowed 5 months to complete seven sections of CBTpsych. Pre-treatment and post-treatment assessments tested for social anxiety, common unhelpful thoughts related to stuttering, quality of life and stuttering frequency.

RESULTS

Significant post-treatment improvements in social anxiety, unhelpful thoughts, and quality of life were reported. Five of seven participants diagnosed with social anxiety lost those diagnoses at post-treatment. The two participants who did not lose social anxiety diagnoses did not complete all the CBTpsych modules. CBTpsych did not improve stuttering frequency. Eleven of the fourteen participants who began treatment completed Section 4 or more of the CBTpsych intervention.

CONCLUSIONS

CBTpsych provides a potential means to provide CBT treatment for social anxiety associated with stuttering, to any client without cost, regardless of location. Further clinical trials are warranted.

EDUCATIONAL OBJECTIVES

At the end of this activity the reader will be able to: (a) describe that social anxiety is common in those who stutter; (b) discuss the origin of social anxiety and the associated link with bullying; (c) summarize the problems in provision of effective evidence based cognitive behavior therapy for adults who stutter; (d) describe a scalable computerized treatment designed to tackle the service provision gap; (e) describe the unhelpful thoughts associated with stuttering that this fully automated computer program was able to tackle; (f) list the positive outcomes for individuals who stuttered that participated in this trial such as the reduction of social anxiety symptoms and improvement in the quality of life for individuals who stuttered and participated in this trial.

Stuttering, temperament, and anxiety: data from a community cohort ages 2-4 years

PURPOSE

The purpose of this study was to ascertain whether and when temperament differences, including precursors of anxiety, emerge before onset and during stuttering development.

METHOD

The authors prospectively studied temperament characteristics of a community cohort of children who stutter (N = 183) and children in the control group (N = 1,261).

RESULTS

No significant differences were found at ages 2, 3, or 4 years between children who stutter and control children for approach or at ages 3 or 4 years for easy/difficult temperament. Both of these measures are precursors of anxiety. Significant differences were found for reactivity and persistence at age 3 years. Children who stutter were less reactive to environmental stimuli and had a reduced ability to attend to a task until completion. There was no evidence of this difference for persistence at age 4 years. Reactivity was not measured at age 4 years.

CONCLUSION

On the basis of parents' responses to the Short Temperament Scale, preschoolers who stutter did not have innately different temperaments from control children on those temperament traits measured from ages 2 to 4 years. They showed no signs of temperament precursors of anxiety before stuttering onset or shortly after. Results suggest, at most, that temperament is influenced somehow during the period after stuttering onset but with a waning developmental influence subsequently.

Safety behaviors and speech treatment for adults who stutter

PURPOSE

Those with anxiety use safety behaviors when attempting to prevent negative outcomes. There is evidence that these behaviors contribute to the persistence of anxiety disorders. Safety behaviors have been prominent in the cognitive behavior therapy literature during the last decade, particularly with social phobia management. However, nothing is known of safety behavior use by those who stutter. This is surprising given the high prevalence of social phobia in the stuttering population who seek clinical help.

METHOD

Clinical psychologists and speech-language pathologists (SLPs) created a list of safety behaviors that might be used by adults during treatment for stuttering. Participants were 160 SLPs who were asked whether they advised adults who stutter to use any of these safety behaviors.

RESULTS

SLPs commonly recommend safety behaviors during stuttering management. Factor structures were found for the following 5 safety behavior categories: (a) general safety behaviors, (b) practice and rehearsal, (c) general avoidance, (d) choosing safe and easy people, and (e) control-related safety behaviors.

CONCLUSIONS

There is a need to determine the frequency with which adults who receive stuttering treatment follow these clinician recommendations. In addition, there is a need to experimentally determine whether following such recommendations prevents fear extinction at long-term follow-up.

Absolute and relative reliability of percentage of syllables stuttered and severity rating scales

PURPOSE

Percentage of syllables stuttered (%SS) and severity rating (SR) scales are measures in common use to quantify stuttering severity and its changes during basic and clinical research conditions. However, their reliability has not been assessed with indices measuring both relative and absolute reliability. This study was designed to provide such information. Relative reliability deals with the rank order of participants in a sample, whereas absolute reliability measures the closeness of scores to one other and to a hypothetical true score.

METHOD

Eighty-seven adult participants who stutter received a 10-min unscheduled telephone call. Three experienced judges measured %SS and also used a 9-point SR scale to measure stuttering severity from recordings of the telephone calls.

RESULTS

Relative intrajudge and interjudge reliability were satisfactory for both scales. However, absolute intrajudge and interjudge reliability were not satisfactory. Results showed that paired-judge SR and %SS procedures improved absolute reliability compared with single-judge measures. Additionally, the paired-judge procedure improved relative reliability from high to very high levels.

CONCLUSION

Measurement of group changes of stuttering severity can be done in research contexts using either %SS or SR. However, for detecting changes within individuals using such measures, a paired-judge procedure is a more reliable method.

Webcam delivery of the Lidcombe program for early stuttering: a phase I clinical trial

PURPOSE

The Lidcombe Program is an operant treatment for early stuttering shown with meta-analysis to have a favorable odds ratio. However, many clients are unable to access the treatment because of distance and lifestyle factors. In this Phase I trial, we explored the potential efficacy, practicality, and viability of an Internet webcam Lidcombe Program service delivery model.

METHOD

Participants were 3 preschool children who stuttered and their parents, all of whom received assessment and treatment using webcam in their homes with no clinic attendance.

RESULTS

At 6 months post-Stage 1 completion, all children were stuttering below 1.0% syllables stuttered. The webcam intervention was acceptable to the parents and appeared to be practical and viable, with only occasional audiovisual problems. At present, there is no reason to doubt that a webcam-delivered Lidcombe Program will be shown with clinical trials to have comparable efficacy with the clinic version.

CONCLUSION

Webcam-delivered Lidcombe Program intervention is potentially efficacious, is practical and viable, and requires further exploration with comparative clinical trials and a qualitative study of parent and caregiver experiences.

Axis I anxiety and mental health disorders among stuttering adolescents

PURPOSE

The purpose of this study was to evaluate anxiety and psychological functioning among adolescents seeking speech therapy for stuttering using a structured, diagnostic interview and psychological questionnaires. This study also sought to determine whether any differences in psychological status were evident between younger and older adolescents.

METHOD

Participants were 37 stuttering adolescents seeking stuttering treatment. We administered the Computerized Voice Version of the Diagnostic Interview Schedule for Children, and five psychometric tests. Participants were classified into younger (12-14 years; n=20) and older adolescents (15-17 years; n=17).

RESULTS

Thirty-eight percent of participants attained at least one diagnosis of a mental disorder, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involving anxiety. This figure is double current estimates for general adolescent populations, and is consistent with our finding of moderate and moderate-severe quality of life impairment. Although many of the scores on psychological measures fell within the normal range, older adolescents (15-17 years) reported significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioral problems, than younger adolescents (12-14 years). There was scant evidence that self-reported stuttering severity is correlated with mental health issues. There are good reasons to believe these results are conservative because many participants gave socially desirable responses about their mental health status.

DISCUSSION

These results reveal a need for large-scale, statistically powerful assessments of anxiety and other mental disorders among stuttering adolescents with reference to control populations.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) explain the clinical importance of assessing for mental health with stuttering adolescents, (b) state the superior method for adolescent mental health assessment and (c) state a major issue with determining the genuineness of stuttering adolescent responses to psychological assessment.

Clinician percent syllables stuttered, clinician severity ratings and speaker severity ratings: are they interchangeable?

BACKGROUND

At present, percent syllables stuttered (%SS) is the gold standard outcome measure for behavioural stuttering treatment research. However, ordinal severity rating (SR) procedures have some inherent advantages over that method.

AIMS

To establish the relationship between Clinician %SS, Clinician SR and self-reported Speaker SR. To investigate whether Clinician SRs and Speaker SRs can be used interchangeably.

METHOD & PROCEDURES

Participants were three experienced speech-language pathologist (SLP) judges and 87 adults who stuttered. Adults who stuttered received a 10-min unscheduled telephone call at the conclusion of which they self-reported a SR using a nine-point scale. The SLPs measured the stuttering for these conversations with %SS and also with the SR scale. The mean scores for Clinician %SS and Clinician SR were compared with Speaker SR using appropriate indices of relative and absolute reliability. Relative reliability indices deal with the rank order of participants in a sample and whether they can be distinguished from each other. However, absolute reliability indices are related to the closeness of the measurement scores to each other and to a hypothetical true score.

OUTCOMES & RESULTS

Strong correlations were found between Clinician %SS and Clinician SR, and also between Clinician %SS and Speaker SR, although with higher values in the former case. Additionally, very high correlations showed acceptable relative reliability between Clinician SR and Speaker SR. However, absolute reliability in terms of standard error of measurement and limits of agreement was poor for Clinician SR and Speaker SR.

CONCLUSIONS & IMPLICATIONS

The results suggest that Clinician SR and Speaker SR cannot be used interchangeably to measure temporal stuttering severity changes for an individual client. However, researchers might use these two measures interchangeably in research contexts, such as clinical trials, where changes of the entire group are of interest to determine and compare treatment effect size across trials.

Effectiveness of the Lidcombe Program for early stuttering in Australian community clinics

This study explored the effectiveness of the Lidcombe Program for early stuttering in community clinics. Participants were 31 speech-language pathologists (SLPs) using the Lidcombe Program in clinics across Australia, and 57 of their young stuttering clients. Percentage of syllables stuttered (%SS) was collected 9 months after beginning treatment along with information about variables likely to influence outcomes. The mean %SS for the 57 children 9 months after starting treatment was 1.7. The most significant predictor of outcome was Lidcombe Program Trainers Consortium (LPTC) training. The children of trained SLPs (n = 19), compared to the children of untrained SLPs, took 76% more sessions to complete stage 1, but achieved 54% lower %SS scores, 9 months after starting treatment. Results suggest that outcomes for the Lidcombe Program in the general community may be comparable to those obtained in clinical trials when SLPs receive formal training and support.

Using statistical process control charts to study stuttering frequency variability during a single day

PURPOSE

Stuttering varies between and within speaking situations. In this study, the authors used statistical process control charts with 10 case studies to investigate variability of stuttering frequency.

METHOD

Participants were 10 adults who stutter. The authors counted the percentage of syllables stuttered (%SS) for segments of their speech during different speaking activities over a 12-hr day. Results for each participant were plotted on control charts.

RESULTS

All participants showed marked variation around mean stuttering frequency. However, there was no pattern of that variation consistent across the 10 participants. According to control charts, the %SS scores of half the participants were indicative of unpredictable, out-of-control systems, and the %SS scores of the other half of the participants were not. Self-rated stuttering severity and communication satisfaction correlated significantly and intuitively with the number of times participants exceeded their upper control chart limits.

CONCLUSIONS

Control charts are a useful method to study how %SS scores might be applied to the study of stuttering variability during research and clinical practice. However, the method presents some practical problems, and the authors discuss how those problems can be solved. Solving those problems would enable researchers and clinicians to better plan, conduct, and evaluate stuttering treatments.

Unscheduled telephone calls to measure percent syllables stuttered during clinical trials

PURPOSE

Researchers have used unscheduled telephone calls for many years during clinical trials to measure adult stuttering severity before and after treatment. Because variability is a hallmark of stuttering severity with adults, it is questionable whether an unscheduled telephone call is truly representative of their everyday speech.

METHOD

The authors studied the speech of 9 men and 1 woman for a 12-hr day during different speaking activities. On that day and 1 week prior to that day, participants received an unscheduled 10-min telephone call from a person unknown to them. The authors compared the percent syllables stuttered (%SS) for the unscheduled telephone call on the day to the %SS of the unscheduled telephone call 1 week prior to the day and to the %SS during the entire day.

RESULTS

No significant differences were found, and all confidence intervals with t tests included 0. The concordance correlation test also showed a strong positive correlation between %SS scores for the entire day and for the unscheduled 10-min telephone call.

CONCLUSION

The authors conclude that there is no reason to doubt that 10-min unscheduled telephone calls are a representative speech sample for %SS during clinical trials of stuttering treatments.

Natural history of stuttering to 4 years of age: a prospective community-based study

OBJECTIVES

To document the natural history of stuttering by age 4 years, including (1) cumulative incidence of onset, (2) 12-month recovery status, (3) predictors of stuttering onset and recovery, and (4) potential comorbidities. The study cohort was a prospective community-ascertained cohort (the Early Language in Victoria Study) from Melbourne, Australia, of 4-year-old children (n = 1619; recruited at age 8 months) and their mothers.

METHODS

Outcome was stuttering onset by age 4 years and recovery within 12 months of onset, defined using concurrent monthly parent and speech pathologist ratings. Potential predictors: child gender, birth weight, birth order, prematurity, and twinning; maternal mental health and education; socioeconomic status; and family history of stuttering. Potential comorbidities: preonset and concurrent temperament, language, nonverbal cognition, and health-related quality of life.

RESULTS

By age 4 years, the cumulative incidence of stuttering onset was 11.2% (95% confidence interval [CI]: 9.7% to 12.8%). Higher maternal education (P = .004), male gender (P = .02), and twinning (P = .005) predicted stuttering onset. At outcome, stuttering children had stronger language (mean [SD]: 105.0 [13.0] vs 99.6 [14.6]; mean difference 5.5, 95% CI: 3.1 to 7.8; P < .001) and nonverbal cognition (mean [SD]: 106.5 [11.4] vs 103.9 [13.7], mean difference 2.6, 95% CI: 0.4 to 4.8; P = .02) and better health-related quality of life but were otherwise similar to their nonstuttering peers. Only 9 of 142 children (6.3%; 95% CI: 2.9% to 11.7%) recovered within 12 months of onset.

CONCLUSIONS

Although stuttering onset is common in preschoolers, adverse affects are not the norm in the first year after onset.

Management of childhood stuttering

Stuttering is a speech disorder that begins during the first years of life and is among the most prevalent of developmental disorders. It appears to be a problem with neural processing of speech involving genetics. Onset typically occurs during the first years of life, shortly after language development begins. Clinical presentation during childhood is interrupted and effortful speech production, often with rapid onset. If not corrected during early childhood, it becomes intractable and can cause psychological, social, educational and occupational problems. There is evidence from replicated clinical trials to support early intervention during the pre-school years. Meta-analysis of studies indicates that children who receive early intervention during the pre-school years are 7.7 times more likely to have resolution of their stuttering. Early intervention is recommended with a speech pathologist. Some children who begin to stutter will recover without such intervention. However, the number of such recoveries is currently not known, and it is not possible to predict which children are likely to recover naturally. Consequently, the current best practice is for speech pathologists to monitor children for signs of natural recovery for up to 1 year before beginning treatment.

Avoidance of eye gaze by adults who stutter

PURPOSE

Adults who stutter are at significant risk of developing social phobia. Cognitive theorists argue that a critical factor maintaining social anxiety is avoidance of social information. This avoidance may impair access to positive feedback from social encounters that could disconfirm fears and negative beliefs. Adults who stutter are known to engage in avoidance behaviours, and may neglect positive social information. This study investigated the gaze behaviour of adults who stutter whilst giving a speech.

METHOD

16 adults who stutter and 16 matched controls delivered a 3-min speech to a television display of a pre-recorded lecture theatre audience. Participants were told the audience was watching them live from another room. Audience members were trained to display positive, negative and neutral expressions. Participant eye movement was recorded with an eye-tracker.

RESULTS

There was a significant difference between the stuttering and control participants for fixation duration and fixation count towards an audience display. In particular, the stuttering participants, compared to controls, looked for shorter time at positive audience members than at negative and neutral audience members and the background.

CONCLUSIONS

Adults who stutter may neglect positive social cues within social situations that could serve to disconfirm negative beliefs and fears.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe the nature of anxiety experienced by adults who stutter; (b) identify the most common anxiety condition among adults who stutter; (c) understand how information processing biases and the use of safety behaviours contribute to the maintenance of social anxiety; (d) describe how avoiding social information may contribute to the maintenance of social anxiety in people who stutter; and (e) describe the clinical implications of avoidance of social information in people who stutter.

Investigating optimal intervention intensity with the Lidcombe Program of early stuttering intervention

This paper addresses optimal intervention intensity in stuttering with reference to the Lidcombe Program of early stuttering intervention. This is an operant program in which the parent provides the actual treatment, for proscribed periods each day, in the child's everyday environment. The parent learns how to do this during weekly visits with the child to the speech-language pathologist. This program was chosen because it is supported by considerable research evidence. This evidence includes randomized controlled trials and file audits. Individual children vary in the time taken to reach the program criteria, with children with milder stuttering taking less time than children whose stuttering is more severe. Hence, the dose depends largely on stuttering severity. Other service delivery models for the Lidcombe Program have been investigated, including telehealth (distance delivery) and group delivery. While telehealth delivery was as efficacious as face-to-face delivery, 3-times more clinician hours were needed to achieve this. Group delivery of the program was also as efficacious as face-to-face delivery but required 30% less clinician time. The fact that treatment is delivered by parents but is directed by the speech-language pathologist raises interesting issues about what constitutes dose.

Early stuttering, temperament and anxiety: two hypotheses

PURPOSE

The topic of temperament and early stuttering and the extent to which it involves anxiety is theoretically and clinically relevant. The topic can contribute to theory development and clinical practices with early stuttering.

METHOD

We present a review of the empirical literature for this area with a view to determining which of two hypotheses might be true. The first is that, for the population of those who stutter, unusual temperament is a causal factor for the development of the disorder and its later association with anxiety. The second hypothesis is that for the population of those who stutter the developmental manifestation of anxiety is an effect of stuttering. Both hypotheses attempt to account for the well-known association of anxiety with chronic stuttering.

RESULTS

A firm conclusion about the matter would be premature at present because the literature involved is limited and contains some inconsistencies. We suggest some quantitative and qualitative directions for future research. We argue also that the only way to resolve the matter is with longitudinal studies of cohorts ascertained prior to stuttering onset.

CONCLUSION

Conclusive findings about the matter can only emerge when research extends beyond its modest scope of 10 interpretable publications.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe temperament and the role it plays during anxiety development, (b) explain two alternative hypotheses which implicate temperament in early childhood stuttering; (c) describe current knowledge regarding temperament similarities and differences between stuttering and control children, and (d) discuss the theoretical and clinical implications of understand the relationship between temperament, anxiety and early stuttering.

Webcam Delivery of the Camperdown Program for Adolescents Who Stutter: A Phase I Trial

Purpose

This Phase I clinical trial explored the viability of webcam Internet delivery of the Camperdown Program for adolescents who stutter.

Method and Procedure

Participants were 3 adolescents ages 13, 15, and 16 years, with moderate-severe stuttering. Each was treated with the Camperdown Program delivered by webcam with no clinic attendance. Primary outcome measures were percentage of syllables stuttered and number of treatment sessions to maintenance. Secondary outcome measures were speech naturalness, situation avoidance, self-reported stuttering severity, and parent and adolescent satisfaction. Data were collected pre treatment and at 1 day, 6 months, and 12 months post entry to maintenance.

Results

Participants entered maintenance after means of 18 sessions and 11 clinician hours. Group mean reduction of stuttering from pre treatment to entry to maintenance was 83%, from pre treatment to 6 months post entry to maintenance was 93%, and from pre treatment to 12 months post entry to maintenance was 74%. Self-reported stuttering severity ratings confirmed these results. Post entry to maintenance speech naturalness for participants fell within the range of that of 3 matched controls. However, avoidance of speech situations showed no corresponding improvements for 2 of the participants.

Conclusion

The service delivery model was efficacious and efficient. All of the participants and their parents also found it appealing. Results justify a Phase II trial of the delivery model.

Camperdown Program for adults who stutter: a student training clinic Phase I trial

OBJECTIVES

During speech pathology professional preparation there is a need for adequate student instruction with speech-restructuring treatments for adults. An important part of that clinical educational experience is to participate in a clinical setting that produces outcomes equivalent to those attained during clinical trials. A previous report showed that this is possible with a traditional, intensive speech-restructuring treatment. Considering the treatment process advantages and time efficiency of the Camperdown Program, it is arguably a compelling prospect for clinician education. Therefore, the present study is a Phase I trial of the treatment at a student university clinic, with a similar design to a previous report.

BACKGROUND

During speech pathology professional preparation there is a need for adequate student instruction with speech-restructuring treatments for adults. An important part of that clinical educational experience is to participate in a clinical setting that produces outcomes equivalent to those attained during clinical trials. A previous report showed that this is possible with a traditional, intensive speech-restructuring treatment. Considering the treatment process advantages and time efficiency of the Camperdown Program, it is arguably a compelling prospect for clinician education.

AIMS

The present study is a Phase I trial of the treatment at a student university clinic, with a similar design to a previous report.

METHODS & PROCEDURES

The design was a non-randomized Phase I clinical trial with 12 adult participants. Primary outcomes were per cent syllables stuttered (%SS) within and beyond the clinic, and speech naturalness scores from pre- and post-treatment stutter-free speech samples.

OUTCOMES & RESULTS

Pooled %SS scores pre-treatment were 5.7, at immediate post-treatment were 1.0, and at 12 months post-treatment were 2.4. The group speech naturalness scores post-treatment did not increase to a clinically significant extent.

CONCLUSION & IMPLICATIONS

Results essentially replicate the previous study by producing similar outcomes to those attained with clinical trials. The Camperdown Program is recommended as a clinical environment for speech-restructuring speech pathology student training.

Syllable-timed speech treatment for school-age children who stutter: a phase I trial

PURPOSE

This clinical trial determined the outcomes of a simple syllable-timed speech (STS) treatment for school-age children who stutter.

METHOD

Participants were 10 children, ages 6-11 years, who stutter. Treatment involved training the children and their parents to use STS at near normal speech rates. The technique was practiced in the clinic and at home with the parents during everyday conversations.

RESULTS

Nine months after commencing treatment, stuttering had decreased by >50% for half of the children, with 2 children attaining 81% and 87% reduction. Intention-to-treat analysis showed a clinically and statistically significant reduction in stuttering for the group even when a withdrawn participant was included. These results were mostly confirmed by self-reported stuttering severity ratings and were supported by improved situation avoidance and quality-of-life scores. There was considerable individual variation in response to the treatment.

CONCLUSION

STS shows promise as a treatment for some school-age children who stutter. As a fluency technique, it is simple to learn and simple to teach, and the children in this study appeared to enjoy the treatment. The efficacy of the treatment could likely be improved with modifications.

Palin Parent Child Interaction and the Lidcombe Program: clarifying some issues

PURPOSE

The authors used the "1000-bites" format (Onslow & Yaruss, 2007) to discuss two therapies used with preschool children who stutter: Palin Parent Child Interaction and the Lidcombe Program. The aim is to provide background to the therapies and to explore the differences and similarities between the approaches and research plans for them.

METHOD

The format is designed to give the reader the feeling of contemporaneous observation of conversation between the authors. To that end, the format guidelines are as follows: (1) alternating responses from two authors with no response greater than 100 words, (2) a maximum of 1000 words per author, (3) when one author has used 1000 words the other may complete 1000 words in a final response or opt to not issue a final response, (4) debate may be controversial and vigorous but must be collegial, and (5) a non-contemporaneous edit by an author to a response requires the agreement of the other author.

CONCLUSIONS

The "1000-bites" format achieved a collegial exchange between two discussants with differing opinions by creating a single work of shared authorship. Arguably, this format is more informative to clinicians than independent essays and rebuttals in a sequence of letters to the editor. One of its advantages is that it provides insights into the issue at stake by means of short and contemporaneous segments of spontaneous interaction.

EDUCATIONAL OBJECTIVES

At the end of this activity the reader will be able to (1) outline the different theoretical backgrounds of Palin Parent Child Interaction Therapy and the Lidcombe Program, (2) describe the different goals of the two treatments, (3) contrast the different methods for the two treatments, and (4) explain any commonalities between the two treatments.

Online CBT I: Bridging the Gap Between Eliza and Modern Online CBT Treatment Packages

Reviews have demonstrated large effect sizes when using computerised cognitive behaviour therapy (CBT) protocols for treating anxiety, depression and health related concerns. However, the amount of therapist contact per user seems to be the most significant prognostic indicator. Thus, in some ways current online interventions can be viewed primarily as an extension of one-on-one therapy. The present article provides guidelines for targeting this limitation of online psychological interventions. The goal is to mimic the therapeutic relationship using a computer, without having any therapist involved. Consequently, thousands of users would be able to receive treatment simultaneously, reaching a wider audience, which was the initial goal of the online model. The development of a treatment program using file audit data is suggested as an alternative to having an individual therapist for each user. This is done by allowing the ‘computer psychologist’ to tailor individualised treatments for each user based on their psychological profile. The user is provided with individualised corrective feedback based on a set of prewritten responses to common faulty thoughts. A new paradigm is proposed for online treatment delivery.

Treatment of Stuttering in Preschool Children

Stuttering is a speech motor disorder that begins in the first years of life and if not treated effectively can have catastrophic effects on the individual. This article briefly describes the disorder, and overviews treatment of stuttering in preschool children. Such treatment is considered far preferable to treatment in adolescence and adulthood. Evidence of the effectiveness of early stuttering treatment from clinical trials is overviewed, along with clinical benchmarks for such treatment. Epidemiological data showing considerable natural recovery are reviewed, and the implications of those data for the timing of early stuttering intervention are considered.