Stuttering and its treatment in adolescence: the perceptions of people who stutter

Adolescence is a complicated phase of maturation during which a great deal of physical, neurological and social development occurs. Clinically this phase is thought to be the last chance to arrest the development of the disorder of stuttering before it becomes chronic in adulthood. However, little treatment development for this age group has occurred. Previous research on the impact of stuttering during adolescence presents a complex picture of apprehension about speaking which does not, however, appear to interfere with social life. The purpose of the present study was to investigate further the experiences of adolescents who stutter with respect to: (1) their experience of stuttering during the adolescent years, (2) reasons for seeking or not seeking therapy during the adolescent years, (3) barriers to seeking therapy during the adolescent years, (4) their experience of therapy during the adolescent years, and finally (5) suggested improvements to therapy for adolescents. Two focus groups and seven individual interviews were conducted with 13 adolescents and young adults. The major finding was a perceived lack of awareness about stuttering by teachers and parents, as well as other adolescents. In addition it appeared that having a stutter was, in itself, not enough reason to seek treatment. However when adolescents did seek treatment, for reasons such as joining the workforce, group therapy was well liked.

EDUCATIONAL OBJECTIVES

The reader will summarize key features that characterize: (1) the complex developmental phase of adolescence, (2) evaluate the experience of stuttering during the adolescent years, (3) discuss the experience of stuttering therapy during the adolescent years, (4) list adolescents' reported barriers to seeking therapy during the adolescent years, and (5) suggest possible ways to improve management of stuttering in adolescence.

Eternity and clinical translation of speech-language pathology research (†)

The work we do as clinicians and researchers is forever vulnerable to political trends which can cause dramatic and rapid change in higher education. A current example is the funding of universities according to the value of their research outputs. In comparison to some other domains of health care, the discipline of speech-language pathology is particularly vulnerable to such politics. If we have evolved, we can devolve. The thesis here is that this matter concerns clinicians and clinical researchers, and that both parties need to shore up their relationship to ensure that this discipline has a guaranteed passage into eternity. This can be achieved by sharpening the focus of clinical research and driving its translation into clinical practices. The different and complementary contributions that clinicians and clinical researchers can make to that pursuit are discussed. It is argued that clinicians and clinical researchers can best pursue their necessary relationship with models of spatial cohabitation, and four models are presented for how that might be achieved. The paper concludes with some speculations about alternatives to eternity for the discipline of speech-language pathology.

An investigation of language and phonological development and the responsiveness of preschool age children to the Lidcombe Program

Knowledge of variables that predict treatment time is of benefit in deciding when to start treatment for early stuttering. To date, the only variable clearly related to treatment time with the Lidcombe Program is pre-treatment stuttering frequency. Previous studies have shown that children whose stuttering is more severe take longer to complete Stage 1 of the program. However, studies to date have not investigated phonology and language as predictors of treatment time. In the context of a Phase II clinical trial, the present prospective study showed that phonological development does not predict treatment time but that, together, stuttering severity, MLU and CELF Receptive Score predict 35-45% of the variance for time taken to complete Stage 1.

LEARNING OUTCOMES

The reader should be able to (1) understand guidelines developed for the timing of intervention with the Lidcombe Program based on previous retrospective studies, (2) determine whether pre-treatment language and phonological development play a role in treatment-led recovery with the Lidcombe Program and (3) understand recent empirical evidence on time taken by preschool children to complete Stage 1 of the Lidcombe Program.

Oliver Bloodstein: reflections on a career. Interview by Mark Onslow

Oliver Bloodstein arrived at the University of Iowa in 1941 to study under Wendell Johnson. There he began an influential career that included a seminal documentation of the development of stuttering, the development of the continuity hypothesis and the anticipatory struggle hypothesis, and the writing of five editions of the influential text "A Handbook on Stuttering." In this interview Dr. Bloodstein reflects on his remarkable and inspiring career, which continues today with his involvement in the preparation of a sixth edition of this text.

EDUCATIONAL OBJECTIVES

The reader will: (1) describe the contribution to the field of stuttering made by Dr. Bloodstein; (2) discuss the career influences that led to his achievements; (3) know Dr. Bloodstein's current views on the cause of stuttering; and (4) identify the locations at which he worked during his career.

Differing perspectives on what to do with a stuttering preschooler and why

PURPOSE

In order to produce a compact and readable overview of clinical issues for clinicians, the authors developed a "1,000-bites" format in which they discuss a topic initiated by one of the authors.

METHOD

The format is designed to give the reader the feeling of contemporaneous observation of a conversation between 2 authors. To that end, the format guidelines are as follows: (a) alternating responses from the authors with no response greater than 100 words; (b) a maximum of 1,000 words per author; (c) when one author has used 1,000 words, the other can complete 1,000 words in a final response or opt to not issue a final response; (d) debate may be controversial and vigorous but must be collegial; and (e) a noncontemporaneous edit by an author to a response requires the agreement of the other author.

CONCLUSIONS

The "1,000-bites" format achieved a collegial exchange between 2 discussants with differing opinions by creating a single work of shared authorship by them. 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.

Guidelines for statistical analysis of percentage of syllables stuttered data

PURPOSE

The purpose of this study was to develop guidelines for the statistical analysis of percentage of syllables stuttered (%SS) data in stuttering research.

METHOD

Data on %SS from various independent sources were used to develop a statistical model to describe this type of data. On the basis of this model, %SS data were simulated with varying means, standard deviations, and sample sizes. Four methods for analyzing %SS were compared.

RESULTS

Results suggested that %SS data can be adequately modeled with a gamma distribution. Simulations based on a gamma distribution showed that all 4 analysis techniques performed favorably with respect to Type I error except for F. E. Satterthwaite's (1946) t test, which had increased Type I error on two occasions. Power was generally lower for the Wilcoxon-Mann-Whitney test compared with the other methods. Analysis of variance (ANOVA) performed on square-root-transformed data performed adequately under all scenarios, but ANOVA performed on nontransformed data and Satterthwaite's t test performed poorly when sample sizes were small or when sample sizes and variances of the groups were markedly different.

CONCLUSIONS

Standard techniques such as t test and ANOVA are appropriate for most analysis scenarios with %SS data. Two occasions when this is not the case are when sample size is small, with fewer than 20 in each group, or when sample sizes and variances of the groups are markedly different. Under these circumstances, analyses should be based on standard methods, with a suitable transformation performed prior to analysis.

Connecting stuttering management and measurement: V. Deduction and induction in the development of stuttering treatment outcome measures and stuttering treatments

BACKGROUND

The development of evidence-based practice, which is increasingly popular in stuttering treatment, is closely linked to the development of outcome measures.

AIMS

Two approaches to the development of stuttering treatment outcome measures are outlined. The first is the deductive, top-down approach, where the development of specific outcome measures is guided by a priori general conceptualizations of the nature of the disorder. A competing approach to the development of stuttering treatment outcome measures is outlined. This is the inductive, or bottom up approach. This approach uses Baer's (1988, 1990) notion of specific complaints of clients as the starting point to develop inductive statements for use as general guidance for developing treatment outcome measures.

MAIN CONTRIBUTION

It is argued that the deductive approach to development of outcome measures has limitations. It is overly prescriptive, generating numerous and increasingly complex outcome measures that are potentially confusing for clinicians. Further, it is arbitrary and fragile, being linked to conceptualizations and theories about stuttering, which, by necessity, are limited themselves. Further, the development of numerous outcome measures is not compatible with the conduct of randomized controlled trials, which allow a maximum of two primary outcome measures. In contrast, the inductive approach to the development of outcome measures has in its favour that it is empirically driven rather than arbitrary, and that it facilitates a yoking of the development of clinical outcomes and the clinical methods to attain those outcomes. The approach is unlikely to lead to the development of fruitless treatment methods. Further, the approach is parsimonious to the extent that it is likely to produce few guiding generalities for treatment outcome assessment -- perhaps as few as two in the case of adults and one in the case of preschoolers. This is well suited to the use of the randomized controlled trial as a source of evidence for treatment efficacy.

CONCLUSIONS

One inductive statement that can be used to guide the development of outcome measures is that the ill effects of stuttered speech could be troubling for those who seek clinical help. The other is that those who seek clinical help are likely to experience speech-related anxiety. Together, these sources of information provide sound guidance for the development of outcome measures relating to stuttered speech and speech-related anxiety, and guidance for the development of treatments to offset those ill effects of the condition. Until another outcome measure can be derived from inductive processes, those treatment developments should serve all the needs of those who stutter and the clinicians who provide those needs.

Connecting stuttering management and measurement: IV. Predictors of outcome for a behavioural treatment for stuttering

BACKGROUND

Clinical trials have shown that behavioural treatments based on variants of prolonged-speech (PS) are best practice for reducing the stuttering rate in adults. However, while stuttering is significantly reduced or eliminated for most adults in the short-term with such treatment, relapse in the longer-term is common. Consequently, there has been interest in attempting to establish variables that predict responsiveness to PS-based treatments. Identifying such variables would enable risk prediction and also contribute to the tailoring of treatments to suit individuals who are less likely to benefit in the long-term from the conventional PS-based treatments. Variables that have been investigated to date are the stuttering severity, the attitude to communication and the locus of control.

AIMS

The present study revisited this issue with methodological improvements.

METHODS AND PROCEDURES

Prospective, continuous measures of outcome several years after treatment, and well-powered, least-squares multivariate regression, with backwards elimination, were used to determine the best model to predict short- and long-term outcomes of a PS-based treatment. Other predictor variables were also included. The stuttering rates of 78 participants were measured immediately after the intensive stage of treatment, and during a surprise telephone call 3.5-5 years after treatment.

OUTCOMES AND RESULTS

Attitude to communication and locus of control were separate constructs to stuttering rate. While the stuttering rate predicted outcome, neither of the two non-behavioural variables predicted outcome in either the short- or the long-term.

CONCLUSIONS

The most significant finding is that the non-behavioural variables of attitude to communication and locus of control did not predict treatment outcomes. This is contrary to the findings of most previous studies.

Altered auditory feedback and the treatment of stuttering: a review

Several authors have suggested that devices delivering altered auditory feedback (AAF) may be a viable treatment for adults and children who stutter. This paper reviews published, peer reviewed journal papers from the past 10 years that investigate the effect of AAF during different speaking conditions, tasks and situations. A review of that literature indicates that considerable experimental evidence and limited Phase 1 treatment outcome evidence has been accumulated about the effect of AAF on the speech of people who stutter. However, critical knowledge about the effect of AAF during conversational speech and in everyday speaking situations is missing. Knowledge about how to determine the correct levels of AAF for individuals, and the characteristics of those likely to benefit from AAF, also needs to be established. At present there is no reason to accept a recent suggestion that AAF devices would be a defensible clinical option for children. In general device development and availability has occurred at a faster pace than clinical trials research.

EDUCATIONAL OBJECTIVES

After reading this paper readers should be able to: (1) describe what altered auditory feedback is and common ways the speech signal is altered in stuttering; (2) describe the effects of AAF on the speech of adults who stutter; (3) provide a critical analysis of the literature in the area of AAF and stuttering.

Treatment of chronic stuttering: outcomes from a student training clinic

BACKGROUND

It has been suggested that one way to increase speech pathologists' confidence in working with people who stutter is to provide them with relevant and stimulating clinical experiences during their professional preparation. This paper describes a treatment programme for adults who stutter that is conducted by speech pathology students, under supervision, in an Australian university setting. The aim of the research presented here was to establish speech outcomes for this programme, and to determine whether the programme meets benchmarks set by reports of similar programmes, in addition to providing mentorship for student clinicians.

METHODS & PROCEDURE

Participants were 78 adults who were treated in one of five consecutive treatment programmes during a 3-year period. The treatment was a traditional intensive speech restructuring treatment known as Smooth Speech, conducted over a 5-day period. Speech assessments were conducted 1 week and 1 day before the start of the treatment programme. Post-treatment assessments were conducted immediately following the intensive component of the programme, and 3 months, 12 months and 3.5-5 years post-treatment. The student clinic treatment model in this report produced objective speech data for more subjects in one outcome study than has ever been reported before. Data for 87% (68/78) of participants were available at 3.5-5-year follow-up. Results showed that outcomes for stuttering, speech naturalness, and client self-reports were all comparable with existing reports of similar programmes. The present results were attained with a student/supervisor ratio of around 8:1.

CONCLUSIONS

We conclude that a clinician-supervised student clinic has the potential to supply services for those with chronic stuttering, as well as providing effective clinical education for student clinicians during their professional preparation. The student clinic treatment model produced varied, objective speech data for more subjects than has ever been reported before in one study. The present findings also replicated a previous finding that stuttering was more severe within the clinic than in speech samples collected in everyday speaking environments.

Randomised controlled trial of the Lidcombe programme of early stuttering intervention

OBJECTIVES

To evaluate the efficacy of the Lidcombe programme of early stuttering intervention by comparison to a control group.

DESIGN

A pragmatic, open plan, parallel group, randomised controlled trial with blinded outcome assessment.

SETTING

Two public speech clinics in New Zealand.

PARTICIPANTS

Stuttering preschool children who presented to the speech clinics for treatment. Inclusion criteria were age 3-6 years and frequency of stuttering of at least 2% syllables stuttered. Exclusion criteria were onset of stuttering during the six months before recruitment and treatment for stuttering during the previous 12 months. 54 participants were randomised: 29 to the Lidcombe programme arm and 25 to the control arm. 12 of the participants were girls.

INTERVENTION

Lidcombe programme of early stuttering intervention.

MAIN OUTCOME MEASURES

Frequency of stuttering was measured as the proportion of syllables stuttered, from audiotaped recordings of participants' conversational speech outside the clinic. Parents in both arms of the trial collected speech samples in three different speaking situations before randomisation and at three, six, and nine months after randomisation.

RESULTS

Analysis showed a highly significant difference (P = 0.003) at nine months after randomisation. The mean proportion of syllables stuttered at nine months after randomisation was 1.5% (SD 1.4) for the treatment arm and 3.9% (SD 3.5) for the control arm, giving an effect size of 2.3% of syllables stuttered (95% confidence interval 0.8 to 3.9). This effect size was more than double the minimum clinically worthwhile difference specified in the trial protocol.

CONCLUSIONS

The results provide evidence from a randomised controlled trial to support early intervention for stuttering. The Lidcombe programme is an efficacious treatment for stuttering in children of preschool age.

A Critique of Venkatagiri's Hypothesis (2004) about the Cause of Stuttering

This paper critiques a recent proposed causal hypothesis of stuttering. It is argued that the proposal is a classic example of the misuse of the representativeness heuristic in the search for the cause of the disorder.

A preliminary investigation of the impact of stuttering on language use

This paper reflects on the application of Systemic Functional Linguistics (SFL) to the field of stuttering. It is argued that the SFL theory may offer insight into the impact that stuttering has on language use. Two case studies are presented to illustrate the application of SFL theory. The two SFL analyses found to be of most use in this pilot study were the analysis of how language is modulated in response to interpersonal aspects of communication (modality) and the analysis of how information is foregrounded (theme). The implications of applying the SFL model to consideration of the utilisation of language resources in people who stutter are discussed.

Measurement of stuttering in adults: comparison of stuttering-rate and severity-scaling methods

This study investigated the comparative reliability of 2 stuttering measurement tools when used by experienced judges: percentage of syllables stuttered (%SS) and a 9-point severity scale (SEV). The study also investigated the degree to which scores on 1 tool predict scores on the other and the distributions of stuttering when measured by these tools. Twelve experienced judges watched 3-min videotapes of 90 stuttering and 10 nonstuttering participants. Half the judges rated %SS, and half made severity ratings. Results showed very high intrajudge and interjudge agreement for both measures. There was a strong linear correlation between %SS scores and SEV scores. Based on this finding, it seems that the 2 measures can be regarded as largely interchangeable. The exception to this, however, was in cases where there was either a small number of significant fixed postures (blocks and prolongations) or a large number of innocuous repeated movements (repetitions) in the speech sample. In such cases, it appears that %SS and SEV scores combined would be needed to provide a valid measure of stuttering. SEV scores were more normally distributed than %SS scores, which were clearly skewed. The advantages and limitations of the SEV scale are discussed.

Effects of self-modelling on stuttering

BACKGROUND

The paper reports on a laboratory investigation of the effects of self-modelling on stuttering rate in adolescents and adults. Self-modelling refers to a therapeutic or training method, usually involving videotape, that uses exposure to oneself performing selected error-free behaviours as the conduit for promoting behaviour change.

AIMS

To investigate self-modelling in single-subject experiments to determine whether any reductions in stuttering could be directly attributable to watching self-modelling videotapes and to ascertain whether instruction to focus attention on the target behaviour, namely stutter-free speech, was necessary for experimental effects.

METHODS & PROCEDURES

A single-subject withdrawal design was employed with two adult men and an adolescent boy. Speaking sessions during all phases of the study were of 3-min duration. During the B Phase, subjects watched one of their self-modelling videotapes, which had been edited to remove all stuttered speech, before each speaking session. In the B + C Phases, subjects continued to watch the self-modelling videotapes before each speaking session and, in addition, were instructed to attempt to speak during the session as they had spoken on the videotape.

OUTCOMES & RESULTS

Stuttering reduced under self-modelling conditions for one of the three subjects. This effect was observed during the B + C Phases, which included instruction to attend to the target behaviour.

CONCLUSIONS

The study provides laboratory evidence that self-modelling can ameliorate stuttering. The clinical implications of this finding are that treatments for adults may well benefit from the inclusion of self-modelling procedures, and self-modelling procedures may form a part of relapse prevention and management strategies.

Self-rating of stuttering severity as a clinical tool

Scaling is a convenient and equipment-free means for speech-language pathologists (SLPs) and clients to evaluate stuttering severity in everyday situations. This study investigated the extent to which the severity ratings of 10 adult stuttering speakers, made immediately after speaking and again from recordings 6 months later, agreed with ratings made by an SLP. For 9 of the 10 speakers, there was good agreement between their initial ratings and those of the SLP. For 8 of the 10 speakers, there was also good agreement between their initial ratings and those made from recordings 6 months later, indicating that the severity ratings made at the time of speaking were reliable. These findings support the use of the 9-point scale as a clinical measurement procedure.

Dismantling the Lidcombe Program of early stuttering intervention: verbal contingencies for stuttering and clinical measurement

BACKGROUND

Data have accumulated to show that the Lidcombe Program of early stuttering intervention is a safe treatment with positive outcomes for preschoolers who stutter, and a randomized controlled trial is under way at the time of writing. Program components have not been investigated experimentally so the functionality of each component is unknown.

AIMS

The aim of this preliminary study was to establish the viability of a programme of research that would assess the clinical value of two program components. These components were parental verbal contingencies for stuttering and severity ratings.

METHODS & PROCEDURES

In the present preliminary experiment, 38 preschool children were randomized to an experiment involving a 4-week 'dose' of treatment followed by 4 weeks without treatment. The dependent variable was the percentage of syllables stuttered (%SS) obtained from the mean %SS score from recordings on three recording occasions.

OUTCOMES & RESULTS

Some preliminary indications were found that parental verbal contingencies for stuttering contributed to treatment outcomes. No preliminary evidence was found for the contribution of parent severity ratings to treatment outcomes.

CONCLUSIONS

It was concluded that a robust, statistical demonstration of these result would be desirable, but effect size estimates from the present data show that access to more than 650 families of stuttering preschool children would be required for such a study. Such a project would be beyond the resources of any one research group to complete in a timely manner, and a method to address this problem is proposed.

Telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention: five case studies

This article describes and reports data-based outcomes of a low-tech telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention. Participants were 5 children with early stuttering, ranging in age from 3;5 (years;months) to 5;7, and their families. All children met the speech criteria for completion of Stage 1 of the Lidcombe Program. Data suggested that the treatment method may be viable and that favorable outcomes may be achievable. Mean posttreatment stuttering rates in everyday speaking situations were available 12 months posttreatment for 4 children. Two children scored a mean percent syllables stuttered of less than 1.0 at that time, and 2 children scored a mean of below 2.0. As occurs often in standard delivery of the Lidcombe Progam, 1 child relapsed after Stage 1, apparently because of parental noncompliance, but this relapse was managed successfully. Follow up data were unavailable for 1 child. For 4 of the 5 cases, the number of consultations required exceeded established benchmarks for standard Lidcombe Program delivery, suggesting that telephone-based telehealth may be a less efficient version of the treatment. The implications of these preliminary data are discussed.

Social anxiety in stuttering: measuring negative social expectancies

Much research has suggested that those who stutter are likely to be anxious. However, to date, little research on this topic has addressed the role of expectancies of harm in anxiety, which is a central construct of anxiety in modern clinical psychology. There are good reasons to believe that the anxiety of those who stutter is related to expectancies of social harm. Therefore, in the present study, 34 stuttering and 34 control participants completed the Fear of Negative Evaluation (FNE) Scale and the Endler Multidimensional Anxiety Scales-Trait (EMAS-T). The FNE data showed a significant difference between the stuttering and control participants, with a large effect size. Results suggested that, as a group, a clinical population of people who stutter has anxiety that is restricted to the social domain. For the EMAS-T, significant differences between groups were obtained for the two subtests that refer specifically to people and social interactions in which social evaluation might occur (Social Evaluation and New/Strange Situations) but not for the subtests that contained no specific reference to people and social interactions (Physical Danger and Daily Routines). These results were taken to suggest that those who stutter differ from control subjects in their expectation of negative social evaluation, and that the effect sizes are clinically significant. The findings also suggest that the FNE and the EMAS-T are appropriate psychological tests of anxiety to use with stuttering clients in clinical settings. The clinical and research implications of these findings are discussed, in terms of whether social anxiety mediates stuttering or is a simple by-product of stuttering. Possible laboratory explorations of this issue are suggested, and potential Cognitive Behavior Therapy packages for stuttering clients who might need them are discussed.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) explain why expectancy of social threat or harm may be associated with stuttering; (2) name and describe two psychological tests that are suitable for assessment of the social threat or harm that may be associated with stuttering; and (3) explain how findings for the EMAS-T test in the present results suggest that expectancy of social threat or harm, but not other kinds of negative expectancy, are associated with stuttering.

Protection from harm: the experience of adults after therapy with prolonged-speech

BACKGROUND

It is well documented that adults can control stuttering if they use certain novel speech patterns referred to generically as prolonged-speech (PS). These speech patterns were refined in the 1960s and developed into behavioural treatment programmes. The bulk of available PS treatment research has focused on speech parameters thought to reflect favourable treatment outcome. Considering this, and that post-treatment relapse is known to be common, clinicians and researchers could be usefully informed by knowledge about the experiences of those who receive these treatments. Subsequently, they could use such information in attempts to control stuttering in their clients. Yet, at present, systematic research on this topic is scant.

AIMS

The continued development of PS treatments could be usefully informed by research into the experiences of those who use PS to control stuttering. Hence, that is the topic of the present report.

METHODS & PROCEDURES

The method used was phenomenology. Participants were a purposive sample of 10 people who had received PS treatment. During a 2-year period, a collaborative approach to the study of the topic was developed between the participants and interviewer. Interviews were from 1.5 to 2 hours, and a total of 34 interviews and discussions were undertaken with participants. Transcripts of these were used to generate text from which themes were identified using line-by-line, holistic and selective approaches.

OUTCOMES & RESULTS

The main findings were that even after therapy with PS there is a continued risk of stuttering occurring, and although adults have the novel experience of controlling stuttering, they also continue to experience feeling different from those who do not stutter, which may be exacerbated after therapy. Given the negative consequences associated with stuttering and feeling different, the essence of the experience after therapy with PS is that adults use their own resources to integrate behavioural skills with existing experiences in order to protect themselves from the harm of stuttering as best they can. PS changes speech, but not the dynamic and often unpredictable communication situations of everyday life. Hence, the maximum benefits of PS are attained when clients use a strategic approach to control stuttered speech and daily communication.

CONCLUSIONS

These findings are consistent with the results of existing outcome research as well as with other current research from the present group. Their implications are discussed in relation to the structure of PS treatments as well as in relation to future PS outcome research. The clinical implications of these findings are discussed in terms of informing prospective clients of the experiential consequences of PS, selecting clients who might benefit from PS and in terms of assisting clients to achieve optimal benefits from PS.

The Lidcombe Behavioral Data Language of stuttering

The Lidcombe Behavioral Data Language (LBDL; K. Bryant & A. Packman, 1999; A. Packman & M. Onslow, 1998; A. Packman, M. Onslow, & K. Bryant, 2000) is a recently developed taxonomy of stuttering. It fills a void in stuttering research because most current descriptive systems are taxonomies of disfluencies, not stuttering alone, and are not behaviorally based. This study is an investigation of intrajudge and interjudge agreement for the LBDL. Ten experienced speech-language pathologists and 10 undergraduate students received brief instruction in the LBDL and then applied it to 15 intervals of stuttered speech on 2 occasions. The speakers were children and adults. Intrajudge agreement was high for both groups but only experienced judges achieved satisfactory interjudge agreement. Results suggest that some stuttering behaviors may be easier to categorize than others. Possible applications of the LBDL to research and clinical practice in stuttering are discussed.

The Camperdown Program: outcomes of a new prolonged-speech treatment model

Considerable research has been directed at the outcomes of prolonged-speech (PS) treatment for the control of chronic stuttering, but little research to date has focused on the PS treatment process. This report examines a Stage 2 clinical trial of a reconceptualized PS treatment model known as the Camperdown Program. This program requires fewer clinician hours than traditional programs and has no formal transfer phase. Additionally, it incorporates the following treatment process innovations, which replace treatment process components that are intuitively and empirically problematic: (a) PS is taught without incorporating target behaviors in clinician instruction, (b) participants learn to control stuttering without programmed instruction, and (c) the treatment process does not involve clinician identification of stuttering moments. Thirty participants were initially enrolled in the trial. Final outcome data are presented for the 16 participants who completed all trial requirements, including 12 months posttreatment data collection. These 16 participants showed minimal or no stuttering in everyday speaking situations for up to 12 months after entering the maintenance program, with speech rates in the normal range. Speech naturalness and social validation data were also favorable. Although self-report data generally confirmed the speech data, the results were not as positive. The present outcomes were achieved in a mean of 20 hours of clinic attendance per participant, which is much fewer than the hours required by treatment programs reported recently that run intensively over 2-3 weeks. The promise of this Stage 2 clinical trial has led the authors to initiate a Stage 3 randomized controlled trial of the Camperdown Program.

Generalizability Theory I: Assessing reliability of observational data in the communication sciences

Perceptual rating scales can be valid, reliable, and convenient tools for evaluating speech outcomes in research and clinical practice. However, they depend on the perceptions of observers. Too few raters may compromise accuracy, whereas too many would be inefficient. There is therefore a need to determine the minimum number of raters required for a reliable result. In this context, the ideas of Generalizability Theory have become increasingly popular in the behavioral sciences; suggestions have been made for their application to the assessment of speech-language disorders. Here we review the concepts involved, which are applied in a companion article dealing with speech naturalness data obtained from clients who recently completed treatment for their stuttering. We pay particular attention to the statistical requirements of the theory, including some cautions about possible inappropriate use of these techniques. We also offer a new interpretation of the results of the analysis that aims to be more meaningful to most speech-language pathologists.

Generalizability Theory II: Application to perceptual scaling of speech naturalness in adults who stutter

Generalizability theory has been recommended as the most comprehensive method for assessing the reliability of observational data. It provides a framework for calculating the various sources of measurement error and allows further design of measurements for a particular purpose. This paper gives a practical illustration of how this method may be used in the analysis of observational data. We use the ratings of 15 unsophisticated raters using the 9-point speech naturalness scale of R. R. Martin, S. K. Haroldson, and K. A. Triden (1984) to evaluate the speech of adults before and after treatment for stuttering. We calculate various sources of measurement error and use these to estimate the minimum number of raters and ratings per rater for a reliable result. For posttreatment data, the average of three independent raters, and for pretreatment data, the average of five independent raters should give a result within one scale point of the hypothetical true score for the speaker in at least 80% of samples. The example illustrates the advantages of using this method of analysis.

Is listener comfort a viable construct in stuttering research?

This article reports the development of a tool for measuring how comfortable a person feels when communicating with someone who has undergone treatment for stuttering. The person rates the speaker on a 9-point Listener Comfort Scale (9 = extremely comfortable, 1 = extremely uncomfortable). In a preliminary investigation of the reliability and validity of the scale, 15 unsophisticated listeners rated video recordings of 10 adults before and after a prolonged-speech treatment for stuttering and of 10 matched controls. The results were compared with those of another 15 listeners who rated the same recordings with the widely used 9-point Speech Naturalness Scale (R. R. Martin, S. K. Haroldson, & K. A. Triden, 1984). Results showed that reliability of the Speech Naturalness Scale was superior to the Listener Comfort Scale, although users of both scales were able to distinguish between pretreatment speech, posttreatment speech, and the speech of controls. The results suggest that the Listener Comfort Scale captures information that is somewhat different than the information captured by the Speech Naturalness Scale. The authors concluded that the concept of listener comfort is a potentially useful additional way of investigating the social validity of behavioral treatments for stuttering.

Predicting treatment time with the Lidcombe Program: replication and meta-analysis

BACKGROUND

The benefits of treating stuttering close to onset have become obvious in recent years, and the Lidcombe Program has emerged as an effective and safe treatment method for children in their preschool years. The benefits of implementing the programme with young children, however, need to be weighed against the knowledge that many children recover from stuttering without treatment. In light of this, speech-language therapists need to know how long treatment is likely to take and whether treatment time can be predicted. In particular, they need to know if adopting a 'watchful waiting' approach--to see if natural recovery occurs--jeopardizes responsiveness to treatment. A recent Australian study of 250 preschool-age children found that stuttering rate was the only significant predictor of treatment time with the Lidcombe Program. In other words, children whose stuttering was more severe took longer to pass through the programme. There were other trends in the data but they did not reach significance.

AIMS

The present study, conducted independently in the UK, was designed to replicate the Australian study. Direct replication enabled pooling of the data from the two studies in a meta-analysis.

METHODS & PROCEDURES

The study included 66 children who began treatment before 6 years of age. They were treated with the Lidcombe Program at a specialist stuttering clinic in Norwich. Logistic regression analyses were conducted on the data. The data from both the British and Australian cohorts were pooled in a meta-analysis.

OUTCOMES & RESULTS

Results indicated that Stage 1 of the Lidcombe Program was completed in a median of 11 clinic visits, which is in line with the findings of the Australian study. Stuttering rate at first clinic visit was again found to be a significant predictor of treatment time. The remaining data trends were similar to those in the Australian data. In the meta-analysis, stuttering rate was once more found to be a predictor of treatment time. Of particular interest, however, was that the increased power provided by the meta-analysis identified an additional predictor, namely onset-to-treatment interval. Contrary to what is known about the responsiveness of children to the Starkweather and Gottwald treatment, and contrary to what might be expected given what we know about natural recovery, children who had been stuttering for more than 12 months took less time to progress through the programme than children who had been stuttering for less than 12 months.

CONCLUSIONS

These findings indicate that delaying intervention with the Lidcombe Program for 1 year after onset, within the preschool years, is unlikely to jeopardize responsiveness to treatment. The clinical implications of these findings are discussed.

Evidence-based treatment of stuttering: IV. Empowerment through evidence-based treatment practices

Assertion-based treatments for stuttering have historically been more popular than evidence-based treatments. In this paper it is argued that the use of evidence-based treatments for stuttering is professionally empowering for clinicians, but that the use of assertion-based treatments is a circular process that inhibits professional development. The arguments in favor of evidence-based treatment are elaborated under headings of "professional investment," "professional development and diversity," and "optimizing treatment efficacy."

EDUCATIONAL OBJECTIVES

The reader will understand and be able (1) to describe the distinction between assertion-based and evidence-based treatment practices (2) to present a series of arguments that evidence-based treatment practices are professionally empowering.

Statistical power in stuttering research: a tutorial

The capacity to make reliable inductive statements about populations is critical for the advancement of scientific knowledge. An important contribution to that advancement of knowledge is determining that effects are either present or not present in populations. Statistical power is an important methodological qualification for any research that presents statistical results, and particularly so for research that presents null results. In this paper we describe the statistical concept of power, outline parameters of research that influence it, and demonstrate how it is calculated. With reference to selected published research, attention is drawn to the problems associated with a body of underpowered research, one being that population effects may go undetected. One way to prevent this problem is to calculate power a priori in planning research and include confidence intervals when presenting the results of research. However, it is difficult, if not impossible in many cases, to obtain high participant numbers for communication disorders of low prevalence such as stuttering. With this in mind, the paper concludes with an attempt to open discussion about ways to redress the problems associated with statistical power.

Psychological impact of the Lidcombe Program of early stuttering intervention

The Lidcombe Program is an operant treatment for stuttering in preschool children for which favourable outcome and social validity data have been published. The treatment involves parental praise for stutter-free speech in children's everyday speaking environments, and occasional correction of stuttered speech. Theoretical perspectives on the origins of stuttering have prompted suggestions that the Lidcombe Program may have an adverse psychological impact on children. The present preliminary investigation sought to identify any evidence of such a systematic, pernicious trend, which might justify statistically powerful investigations of the issue with large subject numbers. Subjects were eight preschool children who were successfully treated with the Lidcombe Program. The Child Behavior Checklist (CBCL) detected any post-treatment behavioural markers of changes in children such as anxiety, aggression, withdrawal or depression. The Attachment Q-Set (AQS) measured any changes in the quality of the attachment relationship between child and mother over the course of treatment. These case studies revealed no evidence of a systematic trend in either. In fact, CBCL data suggested improvements in the children after treatment. It is concluded that there is no reason to doubt that the Lidcombe Program is a safe treatment.

An experimental investigation of the impact of the Lidcombe Program on early stuttering

Preliminary Phase I and II trials for the Lidcombe Program of early stuttering intervention have found favorable outcomes and that the treatment is safe. Although speech-language pathologists (SLPs) often need to intervene with pre-schoolers' early stuttering, many of these children will recover at some time in the future without such intervention. Consequently, they need to know whether the Lidcombe Program's effect on stuttering is greater than that of natural recovery. Participants were 23 pre-school children who were randomly assigned to either a control group or a treatment group that received the Lidcombe Program for 12 weeks. A repeated measures ANOVA showed no main effect on stuttering for the group (control/treatment), a significant main effect for the measurement occasion (at the start and at the end of the treatment period), and a significant interaction between group and measurement occasion. Stuttering in the treatment group reduced twice as much as in the control group. These results are interpreted to mean that the introduction of the Lidcombe Program has a positive impact on stuttering rate, which exceeds that attributable to natural recovery.

Speech timing in children after the Lidcombe Program of early stuttering intervention

It is known that operant treatments can control stuttering in children. However, at present it is unknown why such treatments are effective. Changes in the usual way of speaking are frequently observed after behavioural treatments for adults who stutter, and it is possible that operant treatments for children also invoke such changes. To explore this idea, selected acoustic measures of speech timing were made in eight preschool children before and after receiving the Lidcombe Program, which is an operant treatment for stuttering. No systematic changes were detected after treatment. Considering this finding and a previous report, there is no evidence to suggest that the reductions in stuttering that occur with this treatment are related to systematic changes in speech timing or curtailment of language function.

An operant intervention for early stuttering. The development of the Lidcombe program

Stuttering is a common speech disorder that causes significant distress and may cause social maladjustment and hinder occupational potential. Treatments for chronic stuttering in adults can control stuttering by teaching the speaker to use a new speech pattern. However, these treatments are resource intensive and relapse prone, and they produce speech that sounds unnatural to the listener and feels unnatural to the speaker. This article describes the development and evaluation of an operant treatment for early stuttering. Parents are trained to present verbal contingencies for stuttered and stutter-free speech during everyday speaking situations with their children. The authors overview outcome data from several studies that suggest that this program produces relapse-free control of stuttered speech in preschool children in the medium and long term in a cost-effective manner.

Treating stuttering in young children: predicting treatment time in the Lidcombe Program

It is known that children may recover from stuttering without formal treatment during the first years after onset. Consequently, the timing of professional, early stuttering intervention is a pressing issue in speech-language pathology. This report presents data pertinent to this issue for 261 preschool-age children who received the Lidcombe Program of early stuttering intervention. Of these children, 250 completed the program and were considered by their clinicians to have been treated successfully. For the children who were treated successfully, logistical regression analyses were used to determine whether age, gender, period from onset to treatment, and stuttering severity related systematically to the time required for treatment. The present data confirmed previous reports that a median of 11 clinic visits was required to achieve zero or near-zero stuttering with the Lidcombe Program. Results were also consistent with a preliminary report of 14 children (C. W. Starkweather & S. R. Gottwald, 1993) showing a significant relation between stuttering severity and the time needed for treatment, with children with more severe stuttering requiring longer treatment times than children with less severe stuttering. However, results did not associate either increasing age or increased onset-to-treatment intervals with longer treatment times. This finding is not consistent with the Starkweather and Gottwald report, which linked advancing age with longer treatment time. In fact, the present data suggest that, for a short period after stuttering onset in the preschool years, a short delay in treatment does not appear to increase treatment time. An important caveat to these data is that they cannot be generalized to late childhood or early adolescence. The present findings are discussed in relation to natural recovery from stuttering.

Novel speech patterns and the treatment of stuttering

Variants of rhythmic speech and legato speech have been used for centuries to treat stuttering. Despite considerable empirical and theoretical inquiry, the reason for the effectiveness of these novel speech patterns in suppressing stuttering is unknown. Recent acoustic research conducted at the University of Sydney suggests that a reduction in the variability of syllabic stress is a critical feature of these two speech patterns, and that this reduction suppresses stuttering by stabilizing the speech motor system. This paper reviews what is known about rhythmic speech and legato speech from this perspective, and the theoretical and clinical implications of reconceptualizing them in this way are discussed.

Reliability of clinicians' judgments about prolonged-speech targets

Treatments for stuttering based on variants of Goldiamond's prolonged-speech procedure involve teaching clients to speak with novel speech patterns. Those speech patterns consist of specific skills, described with such terms as soft contacts, gentle onsets, and continuous vocalization. It might be expected that effective client learning of such speech skills would be dependent on clinicians' ability to reliably identify any departures from the correct production of such speech targets. The present study investigated clinicians' reliability in detecting such errors during a prolonged-speech treatment program. Results showed questionable intraclinician agreement and poor interclinician agreement. Nonetheless, the prolonged-speech program in question is known to be effective in controlling stuttered speech. The clinical and theoretical implications of these findings are discussed.

Control of children's stuttering with response-contingent time-out: behavioral, perceptual, and acoustic data

Many stuttering treatments incorporate contingencies for stuttering that are thought to contribute to treatment effectiveness. One contingency used in a number of treatment programs for children is time-out (TO) from speaking. However, although TO has been shown to control stuttering in adults there are no clear demonstrations of this effect in children. One aim of the present study was to demonstrate in the laboratory that TO reduces stuttering in children. Three school-age children spoke in a single-subject ABA experiment. In the B phase, a red light was illuminated for 5 seconds when the subject stuttered, during which time the subject stopped talking. Two of the three children showed clear reductions in stuttering in response to TO. The second aim of the study was to detect whether the children who responded to To adopted an unusual speech pattern in order to control their stuttering. Listeners did not detect any differences between the perceptually stutter-free speech of baseline conditions and that of TO conditions, and a subsequent acoustic analysis revealed a reduction in the variability of vowel duration during TO in one subject and no changes in the other. The theoretical and clinical implications of the findings are discussed.

The Lidcombe Programme of early stuttering intervention: methods and issues

The Lidcombe Programme is an operant intervention for early stuttering that parents administer to children in their everyday speaking environments. The treatment was developed at the Suttering Unit, Bankstown Health Service, Sydney, and The University of Sydney. Recently, staff from the Australian Stuttering Research Centre. The University of Sydney, toured universities and clinics in the UK to present lectures about this treatment. We were encouraged to write this paper because an independent survey showed that most speech and language therapists who attended the presentations were open to this treatment. Prior to and following that lecture tour, publications in the press and professional journals in the UK alluded to many positive features of the Lidcombe Programme, but also raised several issues about it. The purpose of this paper is to summarise the Lidcombe Programme and address the following criticisms of the treatment that were raised in the UK: (1) Stuttering is complex but the Lidcombe Programme is simple; (2) the Lidcombe Programme is not an operant treatment, but invokes positive changes in children's environments; (3) the Lidcombe Programme is harmful to children; and (4) the scientific evidence in support of the Lidcombe Programme is flawed. Each of these issues is addressed from logical, theoretical and empirical viewpoints.

Speech outcomes of a prolonged-speech treatment for stuttering

It has been shown that people who stutter can speak with greatly reduced stuttering after treatments that use variations of Goldiamond's (1965) prolonged-speech (PS). However, outcome research to date has not taken account of several important issues. In particular, speech outcome measures in that research have been insufficient to show that lasting relief from stuttering has been achieved by clients outside the clinic for meaningful periods. The present study used extensive speech outcome measures across a variety of situations in evaluating the outcome of an intensive PS treatment (Ingham, 1987). The speech of 12 clients in this treatment was assessed on three occasions prior to treatment and frequently-on eight occasions-after discharge from the residential setting. For 7 clients, a further assessment occurred at 3 years posttreatment. Concurrent dependent measures were percent syllables stuttered, syllables per minute, and speech naturalness. The dependent measures were collected in many speaking situations within and beyond the clinic. Dependent measures were based on speech samples of substantive duration, and covert assessments were included in the study. Detailed data were presented for individual subjects. Results showed that 12 subjects who remained with the entire 2-3-year program achieved zero or near-zero stuttering. The majority of subjects did not show a regression trend in %SS or speech naturalness scores during the posttreatment period, either within or beyond the clinic. Some subjects showed higher posttreatment %SS scores during covert assessment than during overt assessment. Results also showed that stuttering was eliminated without using unusually slow and unnatural speech patterns. This treatment program does not specify a target speech rate range, and many clients maintained stutter-free speech using speech rates that were higher than the range typically specified in intensive PS programs. A significant correlation was found between speech rate and perceived posttreatment speech naturalness.

A control/experimental trial of an operant treatment for early stuttering

A preliminary study (Onslow, Costa, & Rue, 1990) suggested that a parent-conducted program of verbal response-contingent stimulation would be an effective treatment for stuttering children younger than 5 years. The present study was designed to expand those preliminary findings by using a larger group of children and by comparing them to a control group of children. Twelve children in the experimental group achieved median percent syllables stuttered (%SS) scores below 1.0 for a 12-month posttreatment period. The children's treatments were completed in a median of 10.5 1-hour clinic sessions and a median of 84.5 days from the start of treatment. The majority of parents of the control children withdrew from the study and elected to have treatment begin for their child. These results suggest that the program may be a cost-effective method for managing a clinical caseload of stuttering children younger than 5 years. It is suggested that controlled clinical trials cannot be used validly or ethically to determine the number of cases of early stuttering who recover without formal intervention.

Prolonged speech and modification of stuttering: perceptual, acoustic, and electroglottographic data

Prolonged speech and its variants are a group of novel speech patterns that form the basis of a popular treatment for stuttering (Ingham, 1984). It is difficult to determine which features of prolonged speech are necessary for the elimination of stuttered speech because the speech pattern produces simultaneous changes in respiratory, laryngeal, and articulatory activity. Experimental studies have shown that the modification of phonation and of speech rate contributes to stuttering reduction, and increased duration of speech segments and reduced variability of vowel duration are known to occur as a result of prolonged-speech treatment programs. However, previous studies of prolonged speech have all instructed subjects to modify their customary speech patterns in a particular way. The aim of the present study was to investigate changes in the speech pattern of individual subjects when stuttering was modified with prolonged speech without specific instruction in how this should be done. In one experimental phase, 3 subjects showed clinically significant stuttering reductions when instructed to use whichever features of prolonged speech they needed to reduce their stuttering. The resulting perceptually stutter-free speech was judged to be natural sounding. Stuttering in a fourth subject reduced without experimental intervention. Recordings of acoustic and electroglottographic signals from the 4 subjects were analyzed. Changes in the variability of vowel duration occurred in all subjects. Theoretical and clinical implications of the results are discussed.

Direct early intervention with stuttering: some preliminary data

Many clinicians recognize a need for direct intervention with cases of early stuttering. However, this recognition is not supported by adequate empirical information about how such cases should be managed. One possibility is that early stuttering might be controllable by parent-administered, operant, verbal stimulation procedures. The purpose of this paper is to present preliminary data that depict the results of such an intervention procedure with four cases of early stuttering. Speech measures were gathered in a variety of speaking situations, within and beyond the clinic, over a 2-month pretreatment period and a 9-month posttreatment period. Results showed that the 4 subjects achieved reductions in stuttering comparable to those reported for adult treatment programs. However, the present results were obtained in far fewer clinical hours than normally needed in the treatment for older subjects. The treatment times in the present study also compare favorably to those published in other reports of operant intervention procedures with children. These findings suggest that cases of early stuttering might be managed effectively by parents, with limited expenditure of clinical time. Findings are discussed in terms of their implications for the development of early intervention programs that are more efficient and effective than existing intervention procedures for older clients.

Speech quality measurement and the management of stuttering

This paper reviews the various approaches that have been made toward the investigation of speech quality in stuttering treatment. The review takes into account the findings of relevant perceptual and acoustic investigations in the area of normal communication skills and voice disorders. Similar consideration is given to investigations on the stutter-free speech of stutterers where the contribution and relevance of this research to the search for a reliable and viable measure of speech quality is discussed. The review concludes with an overview of some promising findings from recent studies on the use of listener ratings of speech naturalness in the measurement and modification of untreated and treated stutterers. Some avenues for research and issues that have emerged from these studies are also discussed.

Measurement and modification of speech naturalness during stuttering therapy

This paper describes two studies that illustrate the utility of listener ratings of speech naturalness for measuring and modifying speech naturalness during a stuttering therapy program. The program involved 5 adolescent stutterers who were receiving an intensive treatment incorporating a prolonged speech procedure. In Study A, a clinician used a 9-point rating scale to score the speech naturalness of 1-min speaking samples each stutterer made at intervals over the course of the program. The results demonstrated predictable trends in speech naturalness during the program, but they also showed that natural sounding speech is not a predictable outcome of a procedure that removes stuttering, controls speaking rate, and exposes clients to transfer procedures. In Study B, 3 of the 5 stutterers participated in single subject experiments partway through their therapy program. These experiments were designed to assess the effect of regular feedback of speech naturalness ratings on the stutterer's spontaneous speech. The results showed that each subject's speech naturalness ratings could be modified toward a target level of speech naturalness.