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

A theory building critical realist evaluation of an integrated cognitive-behavioural fluency enhancing stuttering treatment for school-age children. Part 1: Development of a preliminary program theory from expert speech-language pathologist data

PURPOSE

This study initiated a program of research that aims to develop a program theory underlying integrated cognitive-behavioural fluency enhancing stuttering treatments for school-age children. This research asks, what in the treatment program works (or does not work), for whom, in what contexts, and why.

METHODS

Using a critical realist evaluation approach, seven speech-language pathologists (SLPs) with extensive experience in treating children who stutter were asked about barriers and facilitators of optimal treatment outcomes within the context of the Comprehensive Stuttering Program - School-aged Children (CSP-SC). From these data discrete resource mechanisms, contexts, within child reasoning mechanisms, and outcomes were derived and a preliminary program theory was proposed.

RESULTS

Facilitating and impeding child physiology, treatment and SLP resource mechanisms, family and school contexts, and within-child mechanisms were identified. Facilitating mechanisms included motivation, personality/psychological characteristics, understanding and trust of the treatment process, experience of speaking with less effort, and self-efficacy. Impeding mechanisms included reduced motivation, impeding personality/psychological characteristics, lack of buy-in, and, for some children, a prohibitive cost of effort in using learned strategies.

CONCLUSION

A preliminary program theory was hypothesized which will be further developed in future analysis of data obtained from children and parents who participated in the CSP-SC at the same centre from which the SLPs came. Subsequent research with new cohorts of SLPs, children, and parents from other treatment programs and centres will be needed to establish the generalizability of the program theory generated in this program of research.

Reduced stuttering for school-age children: A systematic review

BACKGROUND

Treatment of school-age children (6-12 years of age) who stutter is a public health priority. Their clinical needs include a psychosocial focus and stuttering reduction. For the latter clinical need, there is a critical window of opportunity for these children warranting research attention.

PURPOSE

The purpose of the review is to guide future clinical research by establishing (a) what interventions are associated with stuttering reduction for school-age children (b) the reported immediate and longer-term effects of those interventions, and (c) the level of evidence for these interventions in terms of study design.

METHODS

Fourteen databases and three conference proceedings were searched for interventions used to reduce stuttering in school-age children. Primary outcomes were mean stuttering reductions pre-treatment, immediately post-treatment, and any follow-up assessments.

RESULTS

Of the 4305 studies identified from the databases, 67 studies met inclusion criteria. Five different treatment approaches were reported in the literature that might reduce stuttering for a school-age child, but with varying effect sizes. These include (a) operant methods, (b) speech restructuring, (c) combined operant methods and speech restructuring, (d) machine-driven treatments, and (e) treatments with a cognitive behaviour therapy component.

CONCLUSIONS

Operant methods warrant investigation in future clinical trial research, as do variants of speech restructuring. Hybrid approaches showed encouraging results, including speech restructuring variants combined with operant methods or with cognitive behaviour therapy. However, evidence is preliminary only at Phase I and II trials. Several treatments with reported clinical promise have been overlooked for decades and require further investigation.

Effectiveness of Stuttering Modification Treatment in School-Age Children Who Stutter: A Randomized Clinical Trial

PURPOSE

This study investigated the effectiveness of the stuttering modification intervention Kinder Dürfen Stottern (KIDS) in school-age children who stutter.

METHOD

Seventy-three children who stutter were included in this multicenter, two-group parallel, randomized, wait-list controlled trial with a follow-up of 12 months. Children aged 7-11 years were recruited from 34 centers for speech therapy and randomized to either the immediate-treatment group or the 3 months delayed-treatment group. KIDS was provided by 26 clinicians who followed a treatment manual. Although the primary outcome measure was the impact of stuttering (Overall Assessment of the Speaker's Experience of Stuttering-School-Age [OASES-S]), the secondary outcomes included objective and subjective data on stuttering severity.

RESULTS

At 3 months postrandomization, the mean score changes of the OASES-S differed significantly between the experimental (n = 33) and control group (n = 29; p = .026). Furthermore, treatment outcomes up to 12 months were analyzed (n = 59), indicating large effects of time on the OASES-S score (p < .001, partial η2 = .324). This was paralleled by significant improvements in parental ratings and objective ratings (stuttering severity, frequency, and physical concomitants).

CONCLUSIONS

The significant short-term treatment effects in the OASES-S are in line with the (initial) focus of KIDS on cognitive and affective aspects of stuttering. Over 12 months, these changes were maintained and accompanied by behavioral improvements. The results suggest that individual treatment with KIDS is an adequate treatment option for this age group.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24207864.

Australian pre-service primary teachers' knowledge, attitudes, and skills regarding stuttering

Purpose: Exploring Australian pre-service primary teachers' knowledge, attitudes, and classroom strategies regarding stuttering provides speech-language pathologists (SLPs) with information that can facilitate enhanced outcomes for school-aged children who stutter.Method: In this exploratory descriptive cross-sectional study, 51 final-year Bachelor of Education (Primary) students enrolled at an Australian university completed an online survey about stuttering.Result: Responses demonstrated positive and negative beliefs. Seventy-four per cent of pre-service teachers believed that stuttering has a psychological aetiology and that students who stutter are more likely to be shy or anxious. Participants agreed that their reactions and support offered would largely be based on their assumptions rather than knowledge.Conclusion: Pre-service primary teachers share similar misconceptions and unhelpful attitudes towards stuttering with previously evaluated populations. Implications for SLPs are discussed.

Psychosocial features of stuttering for school-age children: A systematic review

BACKGROUND

Contemporary clinical and empirical perspectives indicate that management of the psychosocial features of stuttering is fundamental for effective treatment. Interventions that improve psychosocial outcomes for school-age children who stutter are, therefore, needed.

AIMS

This systematic review identifies what psychosocial outcomes have been explored in existing school-age clinical research, the measures used and the potential treatment effects. This will provide guidance for developing interventions that reflect contemporary perspectives of stuttering management.

METHODS & PROCEDURES

A total of 14 databases and three conference proceedings were searched for clinical reports of psychosocial outcomes of children aged 6-12 years. The review did not include pharmacological interventions. Psychosocial measures and outcomes were analysed in each study based on data recorded pre-treatment, immediately post-treatment and for any follow-up assessments.

MAIN CONTRIBUTIONS

Of the 4051 studies identified from the databases, a total of 22 studies met criteria for inclusion in the review. From these 22 studies, the review identified four prominent psychosocial domains that have been explored in school-age clinical research to date: Impact of stuttering, communication attitude, anxiety and speech satisfaction. These domains vary in measurement and effect sizes. Two behavioural treatments were associated with anxiety reduction, even though they did not contain anxiolytic procedures. No evidence of potential treatment effects emerged for communication attitudes. Quality of life-an important psychosocial domain pertinent to health economics-did not feature in school-age clinical reports.

CONCLUSIONS & IMPLICATIONS

The psychosocial features of stuttering need to be managed during the school years. Three psychosocial domains-impact of stuttering, anxiety and speech satisfaction-show evidence of potential treatment effects. This review provides direction for future clinical research so that speech-language pathologists can effectively and holistically manage school-age children who stutter.

WHAT THIS PAPER ADDS

What is already known on the subject Elevated levels of anxiety are apparent for children and adolescents who stutter. Therefore, the need to assess and manage psychosocial features of stuttering are expertly regarded as clinical priorities. Clinical trials of such psychosocial features of stuttering for children aged 6-12 years are not well advanced and, therefore, do not reflect current best practice management of this disorder. What this study adds to existing knowledge This systematic review identifies four different psychosocial domains measured and reported in the literature for school-age stuttering management. For three psychosocial domains, some evidence of potential treatment effects emerged with participant numbers greater than 10: Impact of stuttering, anxiety and speech satisfaction. Though treatment effect sizes varied, there is a suggestion that cognitive behaviour therapy can improve anxiety of school-age children who stutter. There is also suggestion that two other behavioural treatments can improve anxiety of school-age children who stutter. What are the potential or actual clinical implications of this work? Given the essential need for school-age children who stutter to receive management of any speech-related anxiety they may experience, it would be productive to discover in future clinical research what interventions could contribute to that goal-behavioural or psychosocial, or both. This review reveals that cognitive behaviour therapy, and other behavioural treatments, are associated with anxiety reductions. Such approaches should be considered for future clinical trial research to help advance the evidence base for managing school-age stuttering.

Stuttering management practices in Sri Lanka: A mixed method study

PURPOSE

Speech and language therapy is a growing profession in Sri Lanka, and little is known about how stuttering is currently managed in the country. Therefore, this study aimed to investigate the current stuttering management practices in Sri Lanka and to investigate any barriers to service provision.

METHOD

A convergent mixed methods design was employed across two phases. Sixty-four Sri Lankan speech and language therapists (SALTs) participated in online surveys in phase one and ten participated in semi structured interviews in phase two. Survey data in phase one was analysed using descriptive statistics and data in phase two was analysed using thematic analysis. Results from both phases were triangulated for the overall interpretation of the data.

RESULTS

Sri Lankan SALTs conduct a comprehensive assessment, however some assessment contexts (e.g., stuttering beyond the clinic) were not routinely considered. Speech and language therapists reported using multiple and varied intervention approaches/strategies, which were often adapted and/or combined. It was noted that the delivery of treatment was more challenging. Barriers identified were including limited knowledge of some aspects of stuttering management, limited access to resources, and workplace constraints.

CONCLUSION

Overall, findings revealed that most Sri Lankan SALTs employ a comprehensive and holistic approach in assessment; however, some limited knowledge of the disorder and intervention was identified. Findings highlighted the need for further training for SALTs regarding the management of stuttering, the need for culturally and linguistically validated appropriate assessments as well as the need to consider logistical issues in clinical settings and service delivery.

The effect of manual movements on stuttering in individuals with down syndrome

PURPOSE

Stuttering may disrupt the speech of individuals with Down syndrome (DS), but standard stuttering therapies may be less adapted to these clients' needs. This study examined if their strength in gesture use can lead to the development of a new stuttering therapy.

METHOD

Eighteen individuals with DS who stutter participated in an experimental task. During this task, they produced sentences in three different conditions: once without the ability to use gestures, once while moving the mouth of a hand puppet synchronous with their speech, and once while making beat gestures along their speech. Stuttering frequency was measured and compared between conditions while controlling for the effect of articulation rate.

RESULTS

The experimental hand puppet and beat condition did not affect the stuttering frequency, but the covariate articulation rate did. An exploratory posthoc analysis showed that the articulation rate decreased during the experimental hand puppet and beat condition. Manual movements in the present task might only induce fluency through articulation rate reduction. However, analyses at individual level show significant interindividual variability.

CONCLUSION

Individual analyses show that effect on stuttering frequency cannot be attributed entirely to articulation rate reduction and that beat gestures might still play a role. However, at this point, there is not enough direct evidence to implement beat gestures in current stuttering therapy.

Implementation fidelity in parent-implemented interventions for stuttering

Knowledge of the fidelity with which interventions are delivered in research studies is crucial to meaningful examination of intervention impact. This paper presents a review of fidelity implementation (FOI) measurements in interventions jointly delivered by speech-language pathologists (SLP) and parents in research for preschool-aged children who stutter (CWS). Four key FOI components were examined: dosage, adherence, quality, responsiveness. Thirty-six studies met the inclusion criteria for this study. Articles were published between 1990 and 2020 described nine different interventions and examined CWS aged 2-6 years. No study reported all FOI components in both the clinical and the home setting and five did not report on any FOI component in either setting. The number of FOI components reported ranged from 0 to 4 in both clinical (M = 1.5) and home (M = 1.0) settings. Across studies, dosage was most often reported (n = 27, 75.0%) and responsiveness was least often reported (n = 16, 44.4%). The number of FOI components reported in articles did not increase over time, although a trend towards greater reporting in recent years was observed. Poor reporting of FOI in intervention research presents a serious methodological concern that impacts the ability of clinicians and researchers to interpret the findings of these studies. Rigorous measurement and reporting of FOI in future intervention studies is required in order to better inform evidence-based practices for interventions with CWS.

Conversational speech of school-age children after syllable-timed speech treatment for stuttering

Purpose: The purpose of this laboratory study was to investigate whether rhythmic speech was primarily responsible for stuttering reductions in four school-aged children after the instatement stage of the Westmead Program of syllable-timed speech (STS) intervention. The study was designed to inform further development of the program. Reduction in variability of vowel duration is a marker of STS, and it was predicted that this would be present in the children's conversational speech after Stage 1 of the program if they were using STS. To strengthen such a finding, it was also predicted that there would be no reduction in articulation rate, sentence complexity, and utterance length after treatment, as there is evidence that reductions in these can reduce stuttering. Perceptual judgments of speech quality after treatment were also made by independent listeners.Method: Participants were four children, ages 8-11 years, who completed Stage 1 of an STS program and whose stuttering had reduced significantly. Pre-treatment (PRE) and post-treatment (POST) within-clinic audio-visual recordings of conversational speech were analysed for percentage of syllables stuttered, variability of vowel duration, articulation rate, and length and complexity of utterance. Four blinded listeners made perceptual judgments of speech quality in the POST recordings.Result: Recordings of all children showed that variability of vowel duration clearly reduced from the PRE to POST speech samples. Importantly, articulation rate and language use were not compromised. Some possible indicators of rhythmicity were identified in one child in the perceptual study.Conclusion: The findings suggest that STS was primarily responsible for the clinically significant reductions in stuttering after Stage 1 of the program. There is an urgent need for more evidence-based interventions for stuttering in this age group and further development of STS interventions is warranted.

Measures of Psychological Impacts of Stuttering in Young School-Age Children: A Systematic Review

Purpose Recent research has shown that some school-age children who stutter may have speech-related anxiety. Given this, speech-language pathologists require robust measures to assess the psychological effects of stuttering during the school-age years. Accordingly, this systematic review aimed to explore available measures for assessing the psychological impacts of stuttering in young school-age children and to examine their measurement properties. Method The systematic search protocol was registered with PROSPERO (ID: 163181). Seven online databases, in addition to manual searching and screening of reference lists, were used to identify appropriate measures for the population of children who stutter aged 7-12 years. The first two authors independently assessed the measures using the quality appraisal tool described by Terwee et al. (2007). Results Despite the comprehensive search strategy, only six measures were identified for quality appraisal. No assessment tool was found to possess adequate measurement properties for the eight assessed domains: content validity, internal consistency, construct validity, reproducibility, reliability, responsiveness, floor and ceiling effects, and interpretability. No measure had clear evidence of responsiveness to clinical change. Based on the criterion defined by the Terwee et al. (2007) appraisal tool, the Communication Attitude Test and the Overall Assessment of the Speaker's Experience of Stuttering for School-Age Children received the highest number of ratings in support of their measurement properties. Conclusions The results highlight a lack of available measures in this domain and poor practices in developing and testing measurement instruments. To ensure that clinicians and researchers are equipped with sound measures to meet the mental health needs of this vulnerable population, further research to establish resources is needed.

Speech restructuring group treatment for 6-to-9-year-old children who stutter: A therapeutic trial

For children who stutter (CWS), there is good evidence of the benefits of treatment for pre-school age, but an evidence gap for elementary school age. Here we report on the effectiveness of a fluency shaping treatment for 6- to 9-year-old children. The main treatment component is the reinforcement of soft voice onsets. An intensive in-patient group treatment phase lasts 6 days, followed by a 6-month maintenance phase with 3 in-patient weekend group refresher courses. Child and a parent participate together in various treatment activities. In this controlled intervention study (waitlist control, intention-to-treat design) assessments were performed before treatment (T1), 4 weeks after the intensive phase (T2), at the end of the maintenance phase (T3), and 1 year later (T4). Participants were 119 children (108 boys, 11 girls, age 5.5‑10.4 years). Control conditions included a subgroup with delayed treatment (N=25) as well as the assessment of complexity of utterances, inter-rater reliability, and speech naturalness. From before treatment to 1-year follow-up, percent stuttered syllables and OASES-S (Overall Assessment of the Speaker's Experience with Stuttering - School-age) scores decreased with large effect size. Speech naturalness improved during this period but did not reach the level of non-stuttering children. Complexity of utterances increased during the intensive phase, but only temporarily. Twenty children (16.8 %, including dropouts) showed no demonstrable treatment benefit. Fluency shaping treatment can be effectively applied to young school children. It is assumed that parental support, group therapy, intensive treatment, and regular exercises at home are essential.

Associations between stuttering, comorbid conditions and executive function in children: a population-based study

Background

The aim of this study was to investigate the relationship between executive function (EF), stuttering, and comorbidity by examining children who stutter (CWS) and children who do not stutter (CWNS) with and without comorbid conditions. Data from the National Health Interview Survey were used to examine behavioral manifestations of EF, such as inattention and self-regulation, in CWS and CWNS.

Methods

The sample included 2258 CWS (girls = 638, boys = 1620), and 117,725 CWNS (girls = 57,512; boys = 60,213). EF, and the presence of stuttering and comorbid conditions were based on parent report. Descriptive statistics were used to describe the distribution of stuttering and comorbidity across group and sex. Regression analyses were to determine the effects of stuttering and comorbidity on EF, and the relationship between EF and socioemotional competence.

Results

Results point to weaker EF in CWS compared to CWNS. Also, having comorbid conditions was also associated with weaker EF. CWS with comorbidity showed the weakest EF compared to CWNS with and without comorbidity, and CWS without comorbidity. Children with stronger EF showed higher socioemotional competence. A majority (60.32%) of CWS had at least one other comorbid condition in addition to stuttering. Boys who stutter were more likely to have comorbid conditions compared to girls who stutter.

Conclusion

Present findings suggest that comorbidity is a common feature in CWS. Stuttering and comorbid conditions negatively impact EF.

The Effectiveness of Hybrid Telepractice and In-Person Fluency Treatment for a School-Aged Child: A Case Study

Purpose

This case study assessed the effects of hybrid telepractice and in-person delivery of the Smooth Speech Treatment (Craig, 2010) for a school-aged child who stutters.

Method

The participant was an 8-year-old child who stuttered. Telepractice or in-person delivery were randomly assigned to treatment sessions in a single-subject AB design. The primary outcome measures were the percentage of syllables stuttered in conversation and reading probes taken at the beginning and end of each treatment session. Communication attitudes were measured before treatment began and at a posttreatment maintenance session. The pattern of treatment gains by delivery platform was also evaluated.

Results

Visual inspection of trends for outcome measures supported an association between the overall treatment package and a reduction in syllables stuttered. Pre- to post- treatment measures indicated an improvement in the child's attitudes toward stuttering. Within-session gains for telepractice sessions were more variable than in-person sessions.

Conclusions

These results indicate that fluency treatment delivered using a blend of telepractice and in-person delivery can be effective for a school-aged child who stutters. The findings align with prior studies showing the effectiveness of telepractice-delivered treatment for preschool children and adolescents. Replications of these results are needed with additional school-aged participants. Additional research is also warranted on factors that contribute to the variability of telepractice treatment effects for school-aged children.

Auditory temporal processing assessment in children with developmental stuttering

OBJECTIVE

Stuttering is a developmental disorder of speech production with a dynamic and multifactorial nature. Scientific theories mentioned the role of auditory processing disorder in stuttering. Investigating the auditory processing in stuttering would provide insights into the mechanisms of stuttering. The details of basic auditory processing in children with stuttering (CWS) continue to remain uncertain. This study aimed to investigate the auditory temporal processing (ATP) in CWS and also its relationship with the stuttering severity.

METHODS

The participants of this comparative cross-sectional study were 54 CWS and 63 children without stuttering (CWOS). All children were between 7 and 12 years old. ATP ability of the participants was measured using the Backward Masking (BM), Duration Pattern (DP), and Gap in Noise (GIN) tests. Then, the groups were compared in terms of ATP results. The correlation between the scores of these tests and stuttering severity was assessed.

RESULTS

According to the results, CWS showed poorer performance on DP, BM and GIN tests when compared with CWOS. Moreover, the stuttering severity had a significant negative correlation with the DP scores and percentage of correct identification scores in GIN; whereas it had a significant positive correlation with the BM thresholds.

CONCLUSIONS

The results showed that some CWS have ATP disorder, which could exacerbate their stuttering. These findings highlighted the role of ATP disorder in stuttering.

Bilingual children who stutter: Convergence, gaps and directions for research

PURPOSE

The aim of this systematic review is to examine the early interactions between bilingualism and stuttering to synthesize knowledge that could inform diagnosis and treatment for bilingual children who stutter.

METHOD

Scopus, Science Direct, PubMed, ERIC Ebsco, and Google Scholar were searched with no limits placed on the year of publication. Search terms consisted of: ("stuttering" [MeSH] OR "stutter") AND ("child" [MeSH] OR "children") AND ("multilingualism" [MeSH] OR "bilingualism"). Inclusion criteria were children who stutter, bilinguals who stutter, empirical research articles, and published in peer review journals. Exclusion criteria were studies that reported on only adults, only monolinguals, or were not published in English.

RESULTS

A total of 50 articles met the criteria. There was convergence with monolingual studies reporting sexually dimorphic and familial trends in the prevalence of stuttering and rates of recovery. Findings surrounding language proficiency, cross-linguistic stuttering severity, and development were ambivalent. Results point to the difficulty in identifying stuttering in bilingual children, and the need for culturally competent research and interpretations.

CONCLUSION

Current findings offer a fragmented view of bilingual development and echoes a recurring theme, i.e., the current understanding of bilingualism and stuttering is limited and more research is warranted.

Language development in children who stutter: A review of recent research

Purpose: This article reviews recent studies that examined the controversial claim that children who stutter (CWS), as a group, have weaker language skills than children who do not stutter (CWNS). The article was an effort to address the conflicting conclusions of two previous reviews of the research in this area. Method: Studies published in research journals during the past 7 years (2011-2018) were located through a systematic review of the literature. Each study was analysed to determine how well it supported the claim that CWS, as a group, have weaker language skills than CWNS. Result: The evidence was not convincing to support this controversial claim. Rather, the review indicated that CWS performed as well as or better than CWNS on formal language tasks. Conclusion: The claim that language weaknesses are linked to children's stuttering is not well supported by recently published studies. Alternative interpretations of the literature are offered.

After the RESTART trial: six guidelines for clinical trials of early stuttering intervention

BACKGROUND

The Rotterdam Evaluation Study of Stuttering Therapy randomized trial (RESTART) was seminal, comparing the Lidcombe Program with RESTART Demands and Capacities Model-based treatment (RESTART-DCM) for pre-school age children who stutter.

AIMS

To critique the methods of the RESTART trial to develop guidelines for its systematic replication and extension. Beyond that, to contribute to the refinement of existing methodological guidelines for early stuttering intervention.

METHOD

The discussion is organized around methodological issues of primary outcomes, treatment completion, clinician allegiance, treatment fidelity, age exclusions and no-treatment control reasoning.

MAIN CONTRIBUTION

We recommend six methodological guidelines to guide future clinical trials comparing the Lidcombe Program with RESTART-DCM, which can be applied to clinical trials of other early stuttering intervention methods: (1) incorporate a continuous measure of primary outcome; (2) ensure that all children in clinical trials have completed treatment; (3) eliminate potential bias due to clinician allegiance; (4) establish treatment fidelity within and beyond the clinic; (5) include children younger than 3 years in clinical trials; and (6) establish an estimate of treatment effect size at some stage of treatment development.

CONCLUSION

In addition to guiding future clinical research comparing RESTART-DCM and Lidcombe Program treatment, these recommendations may extend to influence positively other treatment developments for early stuttering.

Rhythmic speech and stuttering reduction in a syllable-timed language

Speaking rhythmically, also known as syllable-timed speech (STS), has been known for centuries to be a fluency-inducing condition for people who stutter. Cantonese is a tonal syllable-timed language and it has been shown that, of all languages, Cantonese is the most rhythmic (Mok, 2009). However, it is not known if STS reduces stuttering in Cantonese as it does in English. This is the first study to investigate the effects of STS on stuttering in a syllable-timed language. Nineteen native Cantonese-speaking adults who stutter were engaged in conversational tasks in Cantonese under two conditions: one in their usual speaking style and one using STS. The speakers' percentage syllables stuttered (%SS) and speech rhythmicity were rated. The rhythmicity ratings were used to estimate the extent to which speakers were using STS in the syllable-timed condition. Results revealed a statistically significant reduction in %SS in the STS condition; however, this reduction was not as large as in previous studies in other languages and the amount of stuttering reduction varied across speakers. The rhythmicity ratings showed that some speakers were perceived to be speaking more rhythmically than others and that the perceived rhythmicity correlated positively with reductions in stuttering. The findings were unexpected, as it was anticipated that speakers of a highly rhythmic language such as Cantonese would find STS easy to use and that the consequent reductions in stuttering would be great, even greater perhaps than in a stress-timed language such as English. The theoretical and clinical implications of the findings are discussed.

Stuttering in Preschool Children: Direct Versus Indirect Treatment

Purpose

The purpose of this article is to discuss the controversial topic of stuttering in preschool children and how to evaluate the options for treatment, emphasizing the role of external research evidence.

Method

A hypothetical but realistic case study of a 3-year-old boy who stutters is described. Two contrasting approaches to treatment are presented, the Lidcombe Program (LP) and the demands and capacities model (DCM). Studies published in peer-reviewed research journals that have examined the effectiveness of each approach are summarized and critiqued.

Results

The review indicates that the LP is the preferred treatment approach for stuttering in preschool children and that it offers the best opportunity for rapid success.

Conclusion

The LP should be carried out by knowledgeable, experienced, and flexible speech-language pathologists who are able to accommodate the individual needs and differences of every child and family.

Clozapine-Induced Microseizures, Orofacial Dyskinesia, and Speech Dysfluency in an Adolescent with Treatment Resistant Early Onset Schizophrenia on Concurrent Lithium Therapy

Clozapine is an atypical antipsychotic used in the treatment of refractory schizophrenia. It has a well-known side effect profile, including agranulocytosis, decreased seizure threshold, and tardive dyskinesia. In addition, numerous case reports have described clozapine-induced stuttering in adults. However, there has been only one previous case report describing it in the adolescent population. In addition, concurrent lithium therapy has been shown to enhance the neurotoxic effects of antipsychotics and lower the seizure threshold. Here, we report on the development of clozapine-induced microseizures, orofacial dyskinesia, and stuttering in a 17-year-old adolescent male with treatment of refractory early onset schizophrenia on clozapine and concurrent lithium therapy. The patient's symptoms of schizophrenia responded well to the clozapine regimen. However, with the escalating dose of clozapine, the patient developed speech dysfluency in the form of stuttering and perioral twitching. An electroencephalogram confirmed seizure activity. Due to similarities with tardive dyskinesia, symptoms of microseizures induced by atypical antipsychotics may not be accurately diagnosed. A multidisciplinary treatment of speech dysfluency is of particular importance in the adolescent schizophrenic patients, who are expected to have longer duration of lifetime exposure to antipsychotics and in whom peer group interaction is crucial for normal personal and social development.