Online CBT II: A Phase I Trial of a Standalone, Online CBT Treatment Program for Social Anxiety in Stuttering

This paper introduces a novel approach to internet treatment for social anxiety. The goal of this treatment was to address key limitations of current standalone treatments (Helgadottir, Menzies, Onslow, Packman, & O'Brian, 2009). The ‘computer psychologist’ designed for this study used fully automated, prewritten individualised sample answers in order to simulate a human–human interaction through a human–computer interface. Two males who sought treatment for stuttering and met the diagnosis for social phobia according to the DSM-IV and ICD-10 criteria were selected for this study. After receiving the treatment, both users no longer met criteria for social phobia. Also, significant improvements were observed on other psychometric tests, including measures of unhelpful cognitions, behavioural avoidance, quality of life, and low mood. The quality of the interaction appeared to be similar to face-to-face therapy, indicating that the ‘computer psychologist’ established an effective therapeutic relationship, and the automated techniques used were sufficiently engaging to prompt users to log on regularly and complete the treatment program.

Treating Stuttering in a Preschool Child With Syllable Timed Speech: A Case Report

In this article we report the use of a simple, nonprogrammed, syllable timed speech procedure to treat stuttering in a 3-year-old boy with a 2-year history of stuttering. The treatment involved the boy and his parents visiting the clinic 7 times, and the parents modelling syllable timed speech 2 to 6 times per day for 5- to 10-minute intervals in and around the home. After 7 weeks, clinic measures and objective, blinded measures of speech beyond the clinic showed stuttering frequency below 1.0% syllables stuttered. Along with low severity ratings made by the parent each day, this meets the stuttering criteria of another, proven treatment for early stuttering intervention. However, in this study reduction in stuttering was achieved with a simpler and more cost efficient procedure. With the caveat that this is a nonexperimental case report, we discuss its potential implications.

A phase II trial of the Westmead Program: syllable-timed speech treatment for pre-school children who stutter

This report presents a Phase II clinical trial of a syllable-timed speech treatment for early stuttering known as The Westmead Program. Of 17 children recruited, eight children aged between 3-4.5 years (mean 3 years 8 months) completed the treatment. The primary outcome measure was percentage syllables stuttered (%SS) measured from independent, blinded speech assessments of beyond-clinic audio recordings. Secondary outcomes were measures of treatment time, speech quality, and parent severity ratings. Dropouts occurred, but at a similar rate to other clinical trials of this nature. For the eight children who completed the treatment, mean pre-treatment stuttering was 6.0%SS and at 12-months post-Stage 2 entry stuttering had decreased to 0.2%SS, representing a mean stuttering reduction of 96%. A large effect size was obtained with a mean of 8.0 clinical hours required for these children to reach Stage 2. Independent listeners judged the everyday speech of all children to be not unnatural in any way. Stuttering reductions were attained with clinical efficiency and simplicity compared to other early stuttering interventions. Further clinical trials development of the treatment is warranted.

Anxiety and stuttering: continuing to explore a complex relationship

PURPOSE

The relationship between anxiety and stuttering has been widely studied. However, a review conducted more than 10 years ago (Menzies, Onslow, & Packman, 1999) identified 5 methodological issues thought to preclude consistent research findings regarding the nature of this relationship. The purpose of the present review was to determine whether methodological improvements have occurred since the Menzies et al. (1999) review.

METHOD

Literature published since the Menzies et al. review was evaluated with regard to the 5 methodological issues identified in that review: (a) the construct of anxiety, (b) trait anxiety measures, (c) participant numbers, (d) treatment status of participants, and (e) speaking tasks.

RESULTS

Despite some remaining ambiguous findings, research published since the Menzies et al. review has provided far stronger evidence of a relationship between stuttering and anxiety, and has focused more on social anxiety, expectancies of social harm, and fear of negative evaluation.

CONCLUSION

The aims of future research should be to improve research design, increase statistical power, employ multidimensional measures of anxiety, and further develop anxiolytic treatment options for people who stutter.

North-American Lidcombe Program file audit: replication and meta-analysis

Thousands of North American clinicians have trained for the Lidcombe Program of Early Stuttering Intervention, yet there are no benchmark data for that continent. This retrospective file audit includes logistical regression of variables from files of 134 children younger than 6 years who completed Stage 1 of the Lidcombe Program. Benchmarking data for clinic visits to Stage 2 is available for these files. Meta-analysis supplements worldwide Lidcombe Program benchmark data. The median number of clinic visits to Stage 2 was 11. High pre-treatment stuttering severity predicted more clinic visits than low severity. A trend toward statistical significance was found for the frequency of clinic visits. Frequent attendance of mean less than 11 days was associated with longer treatment times than infrequent attendance of mean 11 days or more. Results for North America were consistent with benchmark data from the UK and Australia. The mean attendance trend is clinically important and requires further investigation because of its potential clinical significance.

Investigating parent delivery of the Lidcombe Program

The Lidcombe Program is an early childhood stuttering treatment delivered by parents in the child's everyday environment, under the guidance of a speech-language pathologist (SLP). Given the parents' central role in the treatment delivery, the way it is implemented away from the clinic and away from the SLP's input is very important. And yet, to date there has been very little investigation into this process. This study investigated to what extent parents deliver contingencies for stuttering and stutter-free speech, in structured and unstructured conversations, as directed in the treatment manual. Participants were three mothers and their children who were receiving the Lidcombe Program. They recorded two treatment sessions each week and completed a daily treatment diary. The recordings were analysed for the use of parent verbal contingencies (PVCs). This method detected differences in PVC delivery by the mothers both across and within cases over time. The results show that valuable information can be gained from analysing home treatment sessions in this way and with a few modifications this methodology would be useful in larger scale studies. The strengths and limitations of this methodology are discussed with future larger studies of this type recommended.

Stuttering severity and educational attainment

PURPOSE

This study investigated the relationship between self-reported stuttering severity ratings and educational attainment.

METHOD

Participants were 147 adults seeking treatment for stuttering. At pretreatment assessment, each participant reported the highest educational level they had attained and rated their typical and worst stuttering severity on a 9-point scale for a range of speaking situations. These included: (1) talking with a family member, (2) talking with a familiar person, not a family member, (3) talking in a group of people, (4) talking with a stranger, (5) talking with an authority figure such as a work manager or teacher, (6) talking on the telephone, (7) ordering food or drink, and (8) giving their name and address.

RESULTS

There was a significant negative relationship between highest educational achievement and mean self-reported stuttering severity rating for the eight situations.

CONCLUSIONS

Future research is needed to investigate how this result should be addressed in educational institutions.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe the negative effects of stuttering through childhood to adulthood; (2) identify some of the negative consequences associated with stuttering on peer and teacher relationships, and academic performance at school; and (3) summarise the relationship between stuttering severity and educational attainment.

Further development and validation of the Unhelpful Thoughts and Beliefs About Stuttering (UTBAS) scales: relationship to anxiety and social phobia among adults who stutter

BACKGROUND

In an initial validation study, the Unhelpful Thoughts and Beliefs About Stuttering (UTBAS I) scale, demonstrated excellent psychometric properties as a self-report measure of the frequency of unhelpful cognitions associated with social anxiety for adults who stutter.

AIMS

The aim was to further validate the original UTBAS I scale, and to develop two additional scales to assess beliefs (UTBAS II) and anxiety (UTBAS III) associated with negative thoughts.

METHODS & PROCEDURES

A total of 140 adults seeking speech-restructuring treatment for stuttering completed the original UTBAS I scale, the newly developed UTBAS II and III scales, and self-report measures of psychological functioning. Participants also completed a first-stage screener for the presence of anxious personality disorder, and a diagnostic assessment to evaluate the presence of social phobia, according to criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Classification of Diseases (ICD-10).

OUTCOMES & RESULTS

The mean UTBAS I score for the present sample did not differ significantly from the mean score reported in the original UTBAS I validation study. Convergent validity was confirmed by significant correlations between the UTBAS Total score and all anxiety-related measures. Discriminant validity was established by the absence of strong correlations between the UTBAS Total score and some of the self-report measures of unrelated constructs, although it was found to tap into the negative cognitions associated with depression and life problems. Approximately one-quarter of participants met criteria for a diagnosis of DSM-IV or ICD-10 social phobia (23.5% and 27.2% respectively), and nearly one-third met first-stage screening criteria for anxious personality disorder (30%). The mean UTBAS scores for participants who met criteria for these disorders were significantly higher than scores for participants who did not, confirming known-groups validity.

CONCLUSIONS & IMPLICATIONS

The present study demonstrates the validity and utility of the UTBAS scales in assessing negative cognitions associated with speech-related anxiety among adults who stutter. Results also confirm previous evidence of a high rate of social phobia among adults who stutter, and reveal that the UTBAS discriminates between adults with and without social phobia. In terms of clinical applications, the UTBAS scales could be used to screen for indicators of social phobia among adults who stutter, and may prove useful in identifying negative cognitions which have the potential to impact treatment outcomes.

An experimental investigation of the effect of altered auditory feedback on the conversational speech of adults who stutter

PURPOSE

To investigate the impact on percentage of syllables stuttered of various durations of delayed auditory feedback (DAF), levels of frequency-altered feedback (FAF), and masking auditory feedback (MAF) during conversational speech.

METHOD

Eleven adults who stuttered produced 10-min conversational speech samples during a control condition and under 4 different combinations of DAF, FAF, and MAF. Participants also read aloud in a control condition with DAF and FAF.

RESULTS

A statistically significant difference was found between the NAF conversation condition and the 4 combined altered auditory feedback (AAF) conditions. No statistically significant differences in percentage of syllables stuttered were found in conversation or reading between the control conditions and the FAF/DAF or MAF conditions. The analysis of individual participants' data showed highly individual responsiveness to different conditions.

CONCLUSIONS

Participants' varying responses to differing AAF settings likely accounted for the failure to find group differences between conditions. These results suggest that studies that use standard DAF and FAF settings for all participants are likely to underestimate any AAF effect. It is not yet possible to predict who will benefit from AAF devices in everyday situations and the extent of those benefits.

Mood and substance use disorders among adults seeking speech treatment for stuttering

OBJECTIVES

Stuttering has been associated with a range of anxiety disorders, including social phobia. In the general community, anxiety disorders are frequently associated with increased rates of mood and substance use disorders. Therefore, in the present study, the authors sought to determine the rate of mood and substance use disorders among adults who stutter.

METHOD

The study employed a matched case-control design. Participants included 92 adults seeking treatment for stuttering and 920 age- and gender-matched controls. Mental health assessments were conducted via a computerized psychiatric diagnostic interview. Conditional logistic regression models were used to estimate odds ratios for the prevalence of mood and substance use disorders in both groups.

RESULTS

When compared with matched controls, adults seeking treatment for stuttering had twofold increased odds of meeting criteria for a 12-month diagnosis of any mood disorder but were not found to report significantly higher lifetime prevalence rates for any substance use disorder.

CONCLUSIONS

Although adults who stutter in the present study were characterized by significantly higher rates of mood disorders than matched controls, they do not appear to self-medicate with substances such as alcohol. Results are discussed in terms of treatment implications and possible reasons why adults who stutter may avoid alcohol.

Parent perceptions of the impact of stuttering on their preschoolers and themselves

Speech-language pathologists (SLPs) are advised to consider the distress of preschoolers and parents along with the social consequences of the child's stuttering when deciding whether to begin or delay treatment. Seventy-seven parents completed a survey that yielded quantitative and qualitative data that reflected their perceptions of the impact of stuttering on their children and themselves. Sixty-nine (89.6%) parents reported between 1 and 13 types of negative impact (modal=2). The most frequently reported reactions of children were frustration associated with their stuttering, withdrawal, reduced or changed verbal output, making comments about their inability to talk, and avoidances. The most frequently reported peer reaction was teasing (27.3%). Seventy parents (90.9%) reported that they were affected by their child's stuttering. Their most frequently reported reactions were worry/anxiety/concern, uncertainty about what to do, frustration, upset (parent term), self-blame (fear that they had caused the stuttering), taking time to listen, waiting for the child to finish talking, modifying their own speech, and asking the child to modify speech. Findings support calls for SLPs to consider the distress of preschool children and their parents and the social consequences of the children's stuttering when making the decision to begin or delay treatment.

LEARNING OUTCOMES

Readers will be able to describe parents' perceptions of the impact of stuttering on their children and themselves. In particular, readers will learn about (1) parents' perceptions of young children's awareness and reactions to their stuttering, (2) parents' perceptions of the social consequences of stuttering for young children; and (2) the emotional effect of stuttering on parents.

Randomized controlled trial of video self-modeling following speech restructuring treatment for stuttering

PURPOSE

In this study, the authors investigated the efficacy of video self-modeling (VSM) following speech restructuring treatment to improve the maintenance of treatment effects.

METHOD

The design was an open-plan, parallel-group, randomized controlled trial. Participants were 89 adults and adolescents who undertook intensive speech restructuring treatment. Post treatment, participants were randomly assigned to 2 trial arms: standard maintenance and standard maintenance plus VSM. Participants in the latter arm viewed stutter-free videos of themselves each day for 1 month.

RESULTS

The addition of VSM did not improve speech outcomes, as measured by percent syllables stuttered, at either 1 or 6 months postrandomization. However, at the latter assessment, self-rating of worst stuttering severity by the VSM group was 10% better than that of the control group, and satisfaction with speech fluency was 20% better. Quality of life was also better for the VSM group, which was mildly to moderately impaired compared with moderate impairment in the control group.

CONCLUSIONS

VSM intervention after treatment was associated with improvements in self-reported outcomes. The clinical implications of this finding are discussed.

A new method to sample stuttering in preschool children

This study reports a new method for sampling the speech of preschool stuttering children outside the clinic environment. Twenty parents engaged their stuttering children in an everyday play activity in the home with a telephone handset nearby. A remotely located researcher telephoned the parent and recorded the play session with a phone-recording jack attached to a digital audio recorder at the remote location. The parent placed an audio recorder near the child for comparison purposes. Children as young as 2 years complied with the remote method of speech sampling. The quality of the remote recordings was superior to that of the in-home recordings. There was no difference in means or reliability of stutter-count measures made from the remote recordings compared with those made in-home. Advantages of the new method include: (1) cost efficiency of real-time measurement of percent syllables stuttered in naturalistic situations, (2) reduction of bias associated with parent-selected timing of home recordings, (3) standardization of speech sampling procedures, (4) improved parent compliance with sampling procedures, (5) clinician or researcher on-line control of the acoustic and linguistic quality of recordings, and (6) elimination of the need to lend equipment to parents for speech sampling.

The five factor model of personality applied to adults who stutter

Previous research has not explored the Five Factor Model of personality among adults who stutter. Therefore, the present study investigated the five personality domains of Neuroticism, Extraversion, Openness, Agreeableness and Conscientiousness, as measured by the NEO Five Factor Inventory (NEO-FFI), in a sample of 93 adults seeking speech treatment for stuttering, and compared these scores with normative data from an Australian and a United States sample. Results revealed that NEO-FFI scores for the stuttering group were within the 'average' range for all five personality domains. However, adults who stutter were characterized by significantly higher Neuroticism, and significantly lower Agreeableness and Conscientiousness, than normative samples. No significant differences were found between groups on the dimensions of Extraversion and Openness. These results are discussed with reference to the relationship between personality factors among adults who stutter, their directionality, and implications for predicting treatment outcome.

LEARNING OUTCOMES

The reader will be able to: (1) describe the Five Factor Model of personality, including the NEO-FFI personality domains of Extraversion, Neuroticism, Openness, Agreeableness, and Conscientiousness, and (2) discuss differences in NEO-FFI domain scores between adults who stutter and normative samples, and (3) understand the clinical implications of personality profiles in terms of treatment process and outcome for adults who stutter.

The Lidcombe program of early stuttering intervention: mothers' experiences

The Lidcombe Program is a behavioral treatment for early stuttering which is implemented by parents, typically the mother. Despite this, there is limited detailed knowledge about mothers' experiences of administering the treatment. This article describes the findings of a qualitative study which explored the experiences of 16 mothers during their implementation of the Lidcombe Program. Information was collected using semi-structured, in-depth, face-to-face and telephone interviews. Participants were interviewed pre-treatment, and then regularly throughout the 6-month treatment period. Data were collected from nine interviews conducted with each participant. All interviews (n=140) were audio recorded and then transcribed verbatim. Thematic analysis was used to identify major issues and topics which emerged from the data. Practicalities of implementing the program are reported, including obstacles that mothers faced and solutions to address these. Positive aspects that mothers experienced through their involvement are discussed. The mothers' perceptions of the treatment are outlined and descriptions of the emotions mothers reported are also presented. Findings from the study will enable clinicians to better deliver the Lidcombe Program and will enable improved course instruction and clinical education about the procedure.

EDUCATIONAL OBJECTIVES

The reader will be able to (1) describe the key components of the Lidcombe Program, (2) describe the rationale and methodology for this study, (3) outline the major findings regarding the mothers' experiences of the Lidcombe Program, (4) describe how the findings can be implemented in a clinical setting and (5) evaluate the strengths and limitations of a qualitative study.

Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: the Camperdown Program

BACKGROUND

Although there are treatments that can alleviate stuttering in adults for clinically significant periods, in Australia there are barriers to the accessibility and availability of best-practice treatment.

AIMS

This parallel group, non-inferiority randomized controlled trial with multiple blinded outcome assessments investigated whether telehealth delivery of the Camperdown Program provides a non-inferior alternative to face-to-face treatment for adults who stutter.

METHODS & PROCEDURES

Forty participants who presented to a university speech clinic were randomized: 20 to the telehealth arm and 20 to the face-to-face arm. Exclusion criteria were age younger than 18 years, frequency of stuttering less than 2% of syllables stuttered and previous speech-restructuring treatment within the past 12 months. The Camperdown Program for adults who stutter was the intervention. Primary outcome measures were frequency of stuttering measured in per cent syllables stuttered (%SS) before treatment and at 9 months post-randomization and efficiency, measured by counting the number of speech pathologist contact hours used by each participant. Intention to treat analysis was conducted using last observation carried forward. Secondary outcome measures were speech naturalness, self-reported stuttering severity, and treatment satisfaction.

OUTCOMES & RESULTS

There was no statistically or clinically significant difference in %SS between the two groups at 9 months post-randomization. Analysis of covariance adjusting for baseline %SS showed telehealth had 0.8% absolute lower per cent syllables stuttered than face-to-face. There were also no differences in %SS between groups immediately post-treatment, or at 6 months and 12 months post-treatment (p = 0.9). In the second primary outcome measure, the telehealth group used statistically less contact time (221 min) on average than the face-to-face group (95% confidence interval = - 387 to - 56 min, p = 0.01).

CONCLUSIONS & IMPLICATIONS

The results provide evidence to support the use of the Camperdown Program delivered by telehealth as an alternate to the face-to-face treatment delivery of this programme for adults who stutter. Such a model will increase accessibility to this evidence-based treatment for adults currently isolated from treatment services.

Follow-up of 6-10-year-old stuttering children after Lidcombe program treatment: a phase I trial

PURPOSE

This Phase I trial sought to establish (1) whether the Lidcombe Program is viable for school-age children, (2) whether there is any indication that it requires modification for school-age children, (3) whether treatment effects are durable, (4) how many treatment sessions appear to be required to significantly reduce stuttering frequency and (5) whether there is an association between follow-up period and relapse tendency.

METHOD

Twelve children were treated, and one required an addition to the Lidcombe Program. The results for this child were excluded from group analysis, leaving a group of 6-10 year-olds. A retrospective method was used using routine pre-treatment clinic recordings. At follow-up, all children were telephoned and audio-recorded three times at random times during the day within a 7-10-day period.

RESULTS

A blinded observer's mean percent syllables stuttered score pre-treatment was 9.2 and 1.9 at follow-up. No association was found between follow-up period and stuttering rates. The mean syllables per minute score pre-treatment was 145.8 and 179.3 at follow-up. These results were attained in a median of eight clinic visits with a range of 6-10 visits.

CONCLUSIONS

Procedurally, the Lidcombe Program is viable for school-age children and parents report enjoyment in administering it. There appears to be a treatment effect that can be attained in a reasonable number of clinical hours. These results compel continued exploration with young school-aged children in subsequent Phase II and III studies.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) summarize the status of clinical trials for stuttering school-age children, (2) describe the phases of clinical trial development, (3) evaluate outcomes the Lidcombe Program for a school-age population in terms of stuttering reduction and treatment time, (4) evaluate the suitability of the Lidcombe Program with population of school-age stuttering children, and (5) provide an interpretation of the finding of no correlation between follow-up and post-treatment stuttering rates.

Prevalence of anxiety disorders among adults seeking speech therapy for stuttering

The present study explored the prevalence of anxiety disorders among adults seeking speech therapy for stuttering. Employing a matched case-control design, participants included 92 adults seeking treatment for stuttering, and 920 age- and gender-matched controls from the Australian National Survey of Mental Health and Well-being. A conditional logistic regression model was used to estimate odds ratios for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases (ICD-10) anxiety disorders. Compared with matched controls, the stuttering group had six- to seven-fold increased odds of meeting a 12-month diagnosis of any DSM-IV or ICD-10 anxiety disorder. In terms of 12-month prevalence, they also had 16- to 34-fold increased odds of meeting criteria for DSM-IV or ICD-10 social phobia, four-fold increased odds of meeting criteria for DSM-IV generalized anxiety disorder, and six-fold increased odds of meeting criteria for ICD-10 panic disorder. Overall, stuttering appears to be associated with a dramatically heightened risk of a range of anxiety disorders.

Cognitive behavior therapy for adults who stutter: a tutorial for speech-language pathologists

This paper explores the relationships between anxiety and stuttering and provides an overview of cognitive-behavior therapy (CBT) strategies that can be applied by speech-language pathologists. There is much support for the idea that adults who stutter (AWS) may need CBT. First, approximately 50% of AWS may be suffering from social anxiety disorder. A difficult developmental history marked by problematic peer relationships and bullying may contribute to this. Stereotypes in the general community lead AWS to have occasional experiences that confirm their fears of negative evaluation. This can leave AWS with significant social and occupational avoidance and can impact on their quality of life. Second, in a recent large study of behavioral treatment for AWS, participants who had a mental health disorder, including social anxiety, failed to maintain the benefits of treatment. Available evidence supports the contention that CBT can effectively decrease anxiety and social avoidance, and increase engagement in everyday speaking situations for AWS. The components of CBT presented here are drawn from a model widely used in clinical psychology, and existing supportive data reviewed. Worksheets for speech-language pathologists undertaking CBT in this population are provided. CBT procedures, in their essentials, are straightforward to implement. Hence, the present authors suggest that speech-language pathologists who have had training in conducting CBT should be able to apply the techniques described in this paper.

EDUCATIONAL OBJECTIVES

The reader will be able to explain: (1) the relation between stuttering and anxiety; (2) the nature of Social Anxiety Disorder; (3) why those who stutter are often diagnosed with Social Anxiety Disorder; (4) the four components of cognitive behavior therapy; (5) how cognitive behavior therapy is adapted for the management of speech-related anxiety in those who stutter.

Self-modelling as a relapse intervention following speech-restructuring treatment for stuttering

BACKGROUND

Speech restructuring is an efficacious method for the alleviation of stuttered speech. However, post-treatment relapse is common.

AIMS

To investigate whether the use of video self-modelling using restructured stutter-free speech reduces stuttering in adults who had learnt a speech-restructuring technique and subsequently relapsed.

METHODS & PROCEDURES

Participants were twelve adults who had previously had speech-restructuring treatment for stuttering and relapsed. They were video recorded for 1 hour within the clinic, practising their speech-restructuring technique. The videos were then edited to remove all observable stuttering. Participants then viewed the resulting video of themselves using restructured stutter-free speech each day for 1 month and were instructed to speak as they did on the video. Beyond-clinic speech samples and self-report severity data were collected before and after the intervention.

OUTCOMES & RESULTS

Very large effect sizes were found. The mean per cent syllables stuttered was 7.7 pre-intervention and 2.3 post-intervention. For all but one participant there was a reduction in stuttering from pre-intervention to post-intervention. These results were verified with self-report data. Speech naturalness was not compromised by the video self-modelling procedure.

CONCLUSION & IMPLICATIONS

Video self-modelling as a relapse management tool does not involve excessive time expenditure by the clinician or the client. The study indicates video self-modelling is potentially useful for managing relapse after speech-restructuring treatment for stuttering, and in some cases may be a stand-alone procedure to manage relapse. Phase II and III trials are warranted to determine the size and duration of the effect. It is suggested video self-modelling could also be included in a relapse management plan.

Screening for personality disorders among adults seeking speech treatment for stuttering

Stuttering is frequently associated with negative consequences which typically begin in early childhood. Despite this, no previous studies have investigated the presence of personality disorders among adults who stutter. Therefore, the aims of the present study were to screen for personality disorders among adults who stutter, and to compare these screening estimates with matched controls from a national population sample. Using a matched case-control design, participants were 94 adults seeking treatment for stuttering, 92 of whom completed the International Personality Disorders Examination Questionnaire (IPDEQ) as a first-stage screener, and 920 age- and gender-matched controls from the Australian National Survey of Mental Health and Well-Being (ANSMHWB). A conditional logistic regression model was used to estimate odds ratios for the primary outcome: first-stage presence of any personality disorder; as well as specific personality disorders. Based on first-stage screening, the presence of any personality disorder was significantly higher for adults in the stuttering group than matched controls, demonstrating almost threefold increased odds. This difference between groups remained significant for all specific personality disorders, with four- to sevenfold increased odds found for Dissocial, Anxious, Borderline, Dependent and Paranoid personality disorders, and two- to threefold increased odds found for Histrionic, Impulsive, Schizoid and Anankastic personality disorders. In conclusion, stuttering appears to be associated with a heightened risk for the development of personality disorders. These results highlight the need for research regarding the assessment and treatment of personality disorders among adults who stutter.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe the nature of personality disorders, including factors thought to contribute to their development; (2) identify some of the negative consequences associated with stuttering which may contribute to the development of personality disorders among adults who stutter; (3) describe the process involved in screening for personality disorders, including various methods of scoring; and (4) summarize findings regarding the first-stage presence of personality disorders among adults seeking speech treatment for stuttering in the present sample in comparison with age- and gender-matched controls from a national population sample.

Peer responses to stuttering in the preschool setting

PURPOSE

This study investigated peer responses to preschoolers' stuttering in preschool and sought to determine whether specific characteristics of participants' stuttering patterns elicited negative peer responses.

METHOD

Four outdoor free-play sessions of 4 preschoolers age 3-4 years who stutter were videotaped. Stutters were identified on transcripts of the play sessions. Peer responses to stuttered utterances were judged to be negative or neutral/positive. Thereafter, participants' stuttering behaviors, durations of stutters, and judgments of the meaningfulness of peer-directed stuttered utterances were analyzed.

RESULTS

Between 71.4% and 100% of peer responses were judged to be neutral/positive. In the negative responses across 3 participants, peers were observed to react with confusion or to interrupt, mock, walk away from, or ignore the stuttered utterances. Utterances that elicited negative responses were typically meaningless and contained stutters that were behaviorally complex and/or of longer duration. Other social interaction difficulties also were observed-for example, difficulty leading peers in play, participating in pretend play, and resolving conflicts.

CONCLUSIONS

Results indicate that the majority of peer responses to stuttered utterances were neutral/positive; however, results also indicate that stuttering has the potential to elicit negative peer responses and affect other social interactions in preschool.

A phase II clinical trial of self-imposed time-out treatment for stuttering in adults and adolescents

PURPOSE

This study reports the development and clinical trial of a new treatment program for persistent developmental stuttering in adolescents and adults. The treatment is based on the operant procedure of self-imposed time-out. This involves the person stopping speaking for a short period after each stutter.

METHOD

Twenty-two participants completed Stage 1 (Instatement and Generalisation) of the program and 18 completed Stage 2 (Maintenance) of the program. Stuttering outcome was measured from independent audio and video recordings made outside and inside the clinic, before and after treatment. Speech naturalness was measured at the end of Stage 1. Secondary analyses were conducted to investigate whether responsiveness to the program was related to stuttering severity or age. Participants completed an extensive self-report inventory at the end of treatment.

RESULTS

There was a range of responsiveness to the treatment, with more than half the participants reducing their stuttering by more than 50%. Participants with more severe types of stuttering appeared to respond better but no other predictors of responsiveness were identified. Speech sounded reasonably natural after treatment. Participants' perceptions of the treatment were for the most part positive with the majority reporting that the treatment was easier to use and more effective than treatment based on prolonged-speech.

CONCLUSIONS

The self-imposed time-out treatment program reported here is clearly effective for a significant number of adolescents and adults who stutter. Given that it does not require speech restructuring and the constant attention to speech that this involves, this could be a treatment of choice for those who are likely to respond. Consequently, further research is needed to determine which clients seeking behavioural treatment for their stuttering will benefit most from this program. Further research is also needed to determine the extent to which the effectiveness of time-out is increased when combined with other behavioural treatments.

The effect of stuttering on communication: a preliminary investigation

This paper describes a study in which Systemic Functional Linguistics was applied to describe how people who stutter use language. The aim of the study was to determine and describe any differences in language use between a group of 10 adults who stutter and 10 matched normally-fluent speakers. In addition to formal linguistic analyses, analyses drawn from Systemic Functional Linguistics were used to further investigate the expression of both syntactic and semantic complexity. The findings from this study replicated previous findings of Packman et al. in which they found that the language used by people who stutter was significantly less complex than the control group. Another major finding was that adults who stuttered used the linguistic resource of modality significantly less than the normally-fluent matched peers. The implications these strategies have on communication and social participation will be discussed.

The Peer Attitudes Toward Children who Stutter (PATCS) scale: an evaluation of validity, reliability and the negativity of attitudes

BACKGROUND

Persistent calls for school-based education about stuttering necessitate a better understanding of peer attitudes toward children who stutter and a means to measure outcomes of such educational interventions. Langevin and Hagler in 2004 developed the Peer Attitudes Toward Children who Stutter scale (PATCS) to address these needs and gave preliminary evidence of reliability and construct validity.

AIMS

To examine further the psychometric properties of PATCS and to examine the negativity of attitudes.

METHODS & PROCEDURES

PATCS was administered to 760 Canadian children in grades 3-6. Measures included reliability, a confirmatory factor analysis (CFA), a known groups analysis, convergent validity with the Pro-Victim Scale of Rigby and Slee, and the negativity of attitudes.

OUTCOMES & RESULTS

PATCS appears to tap a second-order general attitude factor and three first-order factors representing the constructs of Positive Social Distance (PSD), Social Pressure (SP), and Verbal Interaction (VI). In the known groups analysis, participants who had contact with someone who stutters had higher scores (more positive attitudes) than those who had not, and girls had higher scores than boys. PATCS correlated moderately (0.43, p<0.01) with the Pro-Victim scale. Finally, one-fifth (21.7%) of participants had scores that were somewhat to very negative.

CONCLUSIONS & IMPLICATIONS

Results provide evidence of the validity and reliability of PATCS and confirm the need for school-based education about stuttering. The PSD and SP factors suggest that education include discussions about (1) similarities and differences among children who do and do not stutter in order to increase acceptance, and (2) making personal choices and handling peer pressure in thinking about children who stutter. The VI factor suggests that open discussion about stuttering may alleviate frustration experienced by listeners and provide the opportunity to give strategies for responding appropriately. Results also suggest that education involve contact with a person who stutters.

Unhelpful thoughts and beliefs linked to social anxiety in stuttering: development of a measure

BACKGROUND

Those who stutter have a proclivity to social anxiety. Yet, to date, there is no comprehensive measure of thoughts and beliefs about stuttering that represent the cognitions associated with that anxiety.

AIMS

The present paper describes the development of a measure to assess unhelpful thoughts and beliefs about stuttering.

METHODS & PROCEDURES

The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) self-report measure contains 66 items that assess the frequency of unhelpful thoughts and beliefs. Items were constructed from a comprehensive file audit of all stuttering cases seen in a cognitive-behavior therapy based treatment programme over a ten-year period.

OUTCOMES & RESULTS

Preliminary investigations indicate that the UTBAS has high levels of test-retest reliability (r = 0.89) and internal consistency (Chronbach's alpha = 0.98). It has good known-groups validity, being able to discriminate between stuttering and non-stuttering participants on items that contain no reference to stuttering [t(38) = 8.06, p<0.0001], with a large effect size (d = 2.3). It has good convergent validity (r = 0.53-0.72) and discriminant validity (r = 0.24-0.27). The UTBAS sensitivity to change was supported by improvements in thoughts and beliefs related to social anxiety following cognitive-behavioural treatment for anxiety in stuttering [t(25) = 10.13, p<0.0001]. The effect size was large (d = 2.5).

CONCLUSIONS & IMPLICATIONS

Implications for the use of the UTBAS as an outcome measure and a clinical tool are discussed, along with the potential value of the UTBAS to explore the well-documented social anxiety experienced by those who stutter.

The relationship between mental health disorders and treatment outcomes among adults who stutter

The ability to reduce stuttering in everyday speaking situations is the core component of the management plan of many who stutter. However, the ability to maintain the benefits of speech-restructuring treatment is known to be compromised, with only around a third of clients achieving this [Craig, A. R., & Hancock, K. (1995). Self-reported factors related to relapse following treatment for stuttering. Australian Journal of Human Communication Disorders, 23, 48-60; Martin, R. (1981). Introduction and perspective: Review of published research. In E. Boberg (Ed.), Maintenance of fluency. New York: Elsevier]. The aim of this study was to determine whether the presence of mental health disorders contributes to this failure to maintain fluency after treatment. Assessments for mental health disorders were conducted with 64 adults seeking speech-restructuring treatment for their stuttering. Stuttering frequency, self-rated stuttering severity and self-reported avoidance were measured before treatment, immediately after treatment and 6 months after treatment. Stuttering frequency and situation avoidance were significantly worse for those participants who had been identified as having mental health disorders. The only subgroup that maintained the benefits of the treatment for 6 months was the third of the participants without a mental health disorder. These results suggest that prognosis for the ability to maintain fluency after speech restructuring should be guarded for clients with mental health disorders. Further research is needed to determine the benefits of treating such disorders prior to, or in combination with, speech-restructuring.

EDUCATIONAL OBJECTIVES

The reader will (1) evaluate the impact of one or more mental health disorders on medium-term outcomes from speech-restructuring treatment for stuttering, (2) describe how this finding affects prognosis for certain groups of stuttering clients, (3) evaluate how these finding are consistent with estimates of post-treatment relapse after speech-restructuring treatment, (4) describe two test instruments for detecting mental health disorders, and (5) outline the findings about the relation between pre-treatment stuttering severity and mental health disorders.

Using syllable-timed speech to treat preschool children who stutter: a multiple baseline experiment

This report presents the results of an experimental investigation of the effects of a syllable-timed speech treatment on three stuttering preschool children. Syllable-timed speech involves speaking with minimal differentiation in linguistic stress across syllables. Three children were studied in a multiple baseline across participants design, with percent syllables stuttered (%SS) as the dependent variable. In the week following the initial clinic visit, each child decreased their beyond-clinic stuttering by 40%, 49% and 32%, respectively. These reductions are only evident in the time series after the introduction of the syllable-timed speech treatment procedure. Participants required a mean of six clinic visits, of approximately 30-60 min in duration, to reach and sustain a beyond-clinic %SS below 1.0. The results suggest that clinical trials of the treatment are warranted.

EDUCATIONAL OBJECTIVES

The reader will be able to summarize, discuss and evaluate: (1) The nature, impact and treatment options available for early stuttering. (2) The syllable-timed speech treatment protocol administered. (3) The advantages of syllable-timed speech treatment for early stuttering. (4) The questions that further research needs to answer about the syllable-timed speech treatment.

Predicting stuttering onset by the age of 3 years: a prospective, community cohort study

OBJECTIVES

Our goals were to document (1) the onset of stuttering and (2) whether specific child, family, or environmental factors predict stuttering onset in children aged up to 3 years.

METHODS

Participants included a community-ascertained cohort of 1619 2-year-old Australian children recruited at 8 months of age to study the longitudinal development of early language. The main outcome measure was parental telephone report of stuttering onset, verified by face-to-face expert diagnosis. Preonset continuous measures of the child's temperament (approach/withdrawal) and language development were available. Information on a range of predictor measures hypothesized to be associated with stuttering onset was obtained (maternal mental health and education levels, gender, premature birth status, birth weight, birth order, twinning, socioeconomic status, family history of stuttering).

RESULTS

By 3 years of age, the cumulative incidence of stuttering onset was 8.5%. Onset often occurred suddenly over 1 to 3 days (49.6%) and involved the use of word combinations (97.1%). Children who stuttered were not more shy or withdrawn. Male gender, twin birth status, higher vocabulary scores at 2 years of age, and high maternal education were associated with stuttering onset. The multivariable model, however, had low predictive strength; just 3.7% of the total variation in stuttering onset was accounted for.

CONCLUSIONS

The cumulative incidence of stuttering onset was much higher than reported previously. The hypothesized risk factors for stuttering onset together explained little of the variation in stuttering onset up to 3 years of age. Early onset was not associated with language delay, social and environmental factors, or preonset shyness/withdrawal. Health professionals can reassure parents that onset is not unusual up to 3 years of age and seems to be associated with rapid growth in language development.

An experimental clinical trial of a cognitive-behavior therapy package for chronic stuttering

PURPOSE

The aims of the present study were to (a) examine the rate of social phobia among adults who stutter, (b) study the effects of speech restructuring treatment on social anxiety, and (c) study the effects on anxiety and stuttering of a cognitive-behavior therapy (CBT) package for social anxiety.

METHOD

Thirty-two adults with chronic stuttering were randomly allocated to receive either speech restructuring following a CBT package for social anxiety or speech restructuring alone. Data were obtained on a variety of speech and psychological measures at pre-treatment, post-CBT, post-speech restructuring, and 12 months follow-up.

RESULTS

Sixty percent of our cohort were diagnosed with social phobia. Speech restructuring treatment alone had no impact on the social phobia of our cohort at 12 months follow-up. At follow-up, participants who had received CBT showed no social phobia and greater improvements than control participants on a range of psychological measures of anxiety and avoidance. However, the CBT package made no difference to the speech outcomes of those with social phobia.

CONCLUSION

The CBT treatment was associated with significant and sustained improvements in psychological functioning but did not improve fluency.

Stuttering in English-Mandarin bilingual speakers: the influence of language dominance on stuttering severity

PURPOSE

English and Mandarin are the 2 most spoken languages in the world, yet it is not known how stuttering manifests in English-Mandarin bilinguals. In this research, the authors investigated whether the severity and type of stuttering is different in English and Mandarin in English-Mandarin bilinguals, and whether this difference was influenced by language dominance.

METHOD

Thirty English-Mandarin bilinguals who stutter (BWS), ages 12-44 years, were categorized into 3 groups (15 English-dominant, 4 Mandarin-dominant, and 11 balanced bilinguals) using a self-report classification tool. Three 10-min conversations in English and Mandarin were assessed by 2 English-Mandarin bilingual clinicians for percent syllables stuttered (%SS), perceived stuttering severity (SEV), and types of stuttering behaviors using the Lidcombe Behavioral Data Language (LBDL; Packman & Onslow, 1998; Teesson, Packman, & Onslow, 2003).

RESULTS

English-dominant and Mandarin-dominant BWS exhibited higher %SS and SEV scores in their less dominant language, whereas the scores for the balanced bilinguals were similar for both languages. The difference in the percentage of stutters per LBDL category between English and Mandarin was not markedly different for any bilingual group.

CONCLUSIONS

Language dominance appeared to influence the severity but not the types of stuttering behaviors in BWS. Clinicians working with BWS need to assess language dominance when diagnosing stuttering severity in bilingual clients.

Extended follow-up of a randomized controlled trial of the Lidcombe Program of Early Stuttering Intervention

BACKGROUND

In the Lidcombe Program of Early Stuttering Intervention, parents present verbal contingencies for stutter-free and stuttered speech in everyday situations. A previous randomized controlled trial of the programme with preschool-age children from 2005, conducted in two public speech clinics in New Zealand, showed that the odds of attaining clinically minimal levels of stuttering 9 months after randomization were more than seven times greater for the treatment group than for the control group.

AIMS

To follow up the children in the trial to determine extended long-term outcomes of the programme.

METHODS & PROCEDURES

An experienced speech-language therapist who was not involved in the original trial talked with the children on the telephone, audio recording the conversations using a telephone recording jack. Parental reports were gathered in addition to the children's speech samples in order to obtain a balance of objective data and reports from a wide range of situations.

OUTCOMES & RESULTS

At the time of this follow-up, the children were aged 7-12 years, with a mean of 5 years post-randomization in the 2005 trial. Twenty of the 29 children in the treatment arm and eight of the 25 children in the control (no treatment) arm were able to be contacted. Of the children in the treatment group, one (5%) failed to complete treatment and 19 had completed treatment successfully and had zero or near-zero frequency of stuttering. Three of the children (16%) who had completed treatment successfully had relapsed after 2 or more years of speech that was below 1% syllables stuttered. Meaningful comparison with the control group was not possible because an insufficient number of control children were located and some of them received treatment after completing the trial.

CONCLUSIONS & IMPLICATIONS

The majority of preschool children are able to complete the Lidcombe Program successfully and remain below 1% syllables stuttered for a number of years. However, a minority of children do relapse and will require their parents to reinstate the treatment procedures.

Defining, identifying, and evaluating clinical trials of stuttering treatments: a tutorial for clinicians

PURPOSE

To develop a method for clinicians to evaluate stuttering treatment efficacy research with very little burden of work.

METHOD

The clinical trial is the most fundamental, clinically interpretable, and useful output unit of stuttering treatment research. We define a clinical trial of a stuttering treatment and specify 3 levels of clinical trials evidence. We use this taxonomy to identify and evaluate clinical trials of stuttering treatment. Our taxonomy draws on 2 fundamental principles of clinical trials used to evaluate health care: randomization and effect size.

RESULTS

Published clinical trials of stuttering treatments were identified and allocated to 1 of 3 levels of evidence.

CONCLUSIONS

We outline a 3-step, semi-automated, Internet-based method to identify the publication of a report of stuttering treatment efficacy. For a report identified as such, a 10-item checklist is applied to verify its status as a clinical trial and to allocate it to 1 of 3 levels of clinical trials evidence. The present taxonomy reduces the burden of work of a 136-item checklist in an existing taxonomy.

Developing Treatment for Adolescents Who Stutter: A Phase I Trial of the Camperdown Program

Purpose

To investigate in detail how adolescents who stutter perform during treatment, with the aim of informing treatment development for this age group.

Method

The Camperdown Program was conducted with 3 adolescents who stutter. Their performance during treatment was recorded in detail, and outcome measures were collected before treatment and on 5 occasions after treatment.

Results

One participant responded extremely well to treatment, with percentage of syllables stuttered (%SS) scores at 12 months follow-up around 1%. In addition, his speech naturalness was within normal limits. Another participant withdrew from treatment during maintenance, yet he still approximately halved his pretreatment %SS scores and was also sounding natural after treatment. This participant was satisfied with his treatment outcome. A third participant did not reach maintenance and did not benefit from the treatment.

Conclusion

The adolescent who succeeded in treatment presented with a high level of self-confidence and maturity. When examining the factors that seemed to impact on treatment outcome, an underlying theme of decreased parent influence and increased peer influence and self-direction was detected. These are fundamental during the journey through adolescence from childhood to adulthood. Future directions in developing treatments for adolescents are discussed.

Comparisons of audio and audiovisual measures of stuttering frequency and severity in preschool-age children

PURPOSE

To determine whether measures of stuttering frequency and measures of overall stuttering severity in preschoolers differ when made from audio-only recordings compared with audiovisual recordings.

METHOD

Four blinded speech-language pathologists who had extensive experience with preschoolers who stutter measured stuttering frequency and rated overall severity from audio-only and audiovisual recordings of 36 preschool children who were stuttering. Stuttering frequency (percentage of syllables stuttered [%SS]) was based on counts of perceptually unambiguous stutterings, made in real time, and overall severity was measured using a 9-point rating scale.

RESULTS

Stuttering frequency was statistically significantly lower by around 20% when made from audio-only recordings. This was found to be directly attributable to differences in the counts of stuttered syllables, rather than to differences in the total numbers of syllables spoken. No significant differences were found between recording modalities for the ratings of overall severity. Correlations between %SS scores in the 2 modalities and severity rating scores in the 2 modalities were high, indicating that observers agreed on data trends across speech samples.

CONCLUSIONS

Measures of %SS made from audio-only recordings may underestimate stuttering frequency in preschoolers. Although audio-only %SS measures may underestimate stuttering frequency at the start of a clinical trial to a clinically significant extent, posttreatment scores at or below 1.0%SS are likely to underestimate by 0.2%SS or less, which is clinically insignificant.

A phase II trial of telehealth delivery of the Lidcombe Program of Early Stuttering Intervention

PURPOSE

The aims of this study were to evaluate the efficacy of telehealth delivery of the Lidcombe Program of Early Stuttering Intervention, compared with a control group, and to determine the number of children who could be regarded as "responders."

METHOD

A speech-language pathologist provided telehealth delivery of the Lidcombe Program during telephone consultations with parents in their homes, remote from the clinic. The study design was an open plan, parallel group, randomized controlled trial with blinded outcome assessment. Children in the no-treatment control group who were still stuttering after 9 months then received the same treatment. The primary outcome measure was frequency of stuttering, gathered from audiotape recordings of participants' conversational speech in everyday, nontreatment situations, before and after treatment.

RESULTS

Analysis of covariance showed a 73% decrease in frequency of stuttering at 9 months after randomization in the treatment group, as compared with the control group (95% confidence interval = 25%-90%, p = .02). Measures of treatment time showed that telehealth delivery of the Lidcombe Program requires around 3 times more resources than standard presentation.

CONCLUSIONS

Telehealth delivery of the Lidcombe Program is an efficacious treatment for preschool children who cannot receive the standard, clinic-based Lidcombe Program. Avenues for improving efficiency are considered.

Telehealth delivery of the Camperdown Program for adults who stutter: a phase I trial

PURPOSE

This Phase I trial investigated the viability of telehealth delivery of the Camperdown Program with adults who stutter. This program involves speech restructuring.

METHOD

All treatment was conducted remotely with participant-clinician contact occurring by telephone and e-mail.

RESULTS

Ten adults completed the program. The group showed an 82% reduction in stuttering frequency immediately after treatment and a 74% reduction 6 months after treatment. However, there was significant individual variation in response to the program.

CONCLUSION

These preliminary data suggest that telehealth Camperdown has the potential to provide efficacious treatment for clients who do not have access to traditional face-to-face treatment.