The Satisfaction with Communication in Everyday Speaking Situations (SCESS) scale: An overarching outcome measure of treatment effect

The application of non-invasive neuromodulation in stuttering: Current status and future directions

Non-invasive neuromodulation methods such as transcranial Direct Current Stimulation (tDCS) and Transcranial Magnetic Stimulation (TMS), have been extensively utilized to enhance treatment efficacy for various neurogenic communicative disorders. Recently, these methods have gained attention for their potential to reveal more about the underlying nature of stuttering and serve as adjunct therapeutic approaches for stuttering intervention. In this review, we present existing research and discuss critical factors that might influence the efficacy of these interventions, such as location, polarity, intensity, and duration of stimulation, as well as the impact of combined behavioral training. Additionally, we explore implications for future studies, including the application of different neuromodulation methods to address various aspects of stuttering such as speech fluency and associated psychological and cognitive aspects in people who stutter.

Behind the mask: Stuttering, anxiety, and communication dynamics in the era of COVID-19

BACKGROUND

While wearing masks during the pandemic poses communication and social challenges for people in everyday life, those with social anxiety might find them plausible, aligning with contemporary cognitive theories. Social anxiety involves fearing negative assessments and holding a negative self-image. Concealing anxiety symptoms during mask use may contribute to a more positive self-perception.

AIMS

Given that up to 60% of adults seeking stuttering treatment also meet criteria for social anxiety disorder, this study aims to investigate the complex relationship between communication freedom, self-perceived stuttering and anxiety in adults who stutter (AWS). The unique context of mandatory mask-wearing during the pandemic provides an opportunity to explore these dynamics and understand the conflicting relationships between stuttering, anxiety-related safety behaviours and the need for open communication in AWS.

METHODS AND PROCEDURES

Twenty AWS participated in interviews, responding to open-ended questions to elucidate their affective, cognitive and behavioural experiences while wearing masks during the COVID-19 pandemic. Thematic analysis was used to identify the emerging themes and subthemes based on information-rich quotes, employing a six-phase recursive process. Various speech and anxiety-related measures were used to describe the characteristics of the study participants.

OUTCOMES AND RESULTS

Three main themes and sub-themes emerged. The first theme highlights communication challenges for AWS wearing masks, impacting verbal and nonverbal interactions. The second theme reveals AWS wearing masks to conceal stuttering cues, experiencing reduced stress. The third theme indicates that, despite the comfort in concealment, most AWS prefer speaking freely without a face mask.

CONCLUSIONS AND IMPLICATIONS

The conflict between the desire for authentic, fluent communication and the ease of hiding stuttering symptoms poses a major dilemma for AWS. According to the results of this study, most adults who stutter prioritize open communication. However, there were some individual differences. A major factor influencing their decision was their fear of negative evaluation.

WHAT THIS PAPER ADDS

What is already known on the subject The prevalence of social anxiety is higher among adults who stutter (AWS), possibly stemming from their prior negative experiences with stuttering. In response, AWS may adopt adaptive or maladaptive coping behaviours to manage stuttering and mitigate fears of negative evaluation. Maladaptive strategies, like avoiding certain communication situations, can diminish their satisfaction with everyday speaking situations. What this study adds This study leveraged the mask-wearing mandate during the pandemic to explore the intricate relationship between anxiety-related symptoms and communication. While some participants saw masks as a plausible means to conceal stuttering and anxiety, most preferred open communication without the challenges posed by masks. Our findings offer additional support for the varied emotional, cognitive and behavioural responses that AWS may display in response to changes in daily life, emphasizing the individual differences within this population and highlighting that stuttering goes beyond observable speech dysfluencies. What are the clinical implications of this work? Our study underscores the need for comprehensive therapeutic interventions addressing both the physical and cognitive-emotional aspects of stuttering in AWS. Recognizing the role of safety behaviours and self-focused attention emphasizes the importance of an integrated approach, enhancing communication efficacy and social well-being for AWS. Addressing speech fluency alone, without considering pertinent cognitive-emotional factors, falls short in providing adequate stuttering treatment.

Validated patient reported outcome measures in speech-language pathology: A scoping review of adult practice

PURPOSE

Patient reported outcome measures (PROMs) are increasingly used to inform value-based healthcare. Within speech-language pathology (SLP), there is no synthesis of validated PROMs to guide professional practice. This scoping review systematically identifies and evaluates condition-specific PROMs across adult SLP practice.

METHOD

A literature search was performed to identify studies published until 18th February 2022 from MEDLINE, Embase, CINAHL, PsycInfo, Scopus, Cochrane Collaboration, and Web of Science. Abstracts and full texts were screened in Covidence. Relevant studies that validated PROMs in English were extracted and assessed using the "Checklist to operationalise measurement characteristics of PROMs" by two independent reviewers.

RESULT

Ninety-seven articles provided validation data for 71 PROMS across seven SLP practice areas. These included voice (n = 18), swallowing (n = 14), language (n = 11), fluency (n = 8), speech (n = 4), laryngectomy (n = 3), and cognitive-communication (n = 2). No PROMs were identified for augmentative and alternative communication (AAC) (n = 0). Quality ratings were variable on the Francis et al. checklist.

CONCLUSION

A range of validated PROMs were identified to guide SLP practice in measuring patient perceptions across a range of practice areas in adults. Opportunities for further development in SLP practice areas with limited PROMs, such as speech, cognitive-communication, and AAC are also highlighted.

Treatment for preschool age children who stutter: Protocol of a randomised, non-inferiority parallel group pragmatic trial with Mini-KIDS, social cognitive behaviour treatment and the Lidcombe Program-TreatPaCS

Stuttering is a speech disorder in which the flow of speech is disrupted by involuntary repetitions of sounds, syllables, words or phrases, stretched sounds or silent pauses in which the person is unable to produce sounds and sound transitions. Treatment success is the highest if stuttering is treated before the age of 6 years, before it develops into "persistent" stuttering. Stuttering treatment programs that focus directly on the speech of the child, like the Lidcombe Program, have shown to be effective in this age group. Mini-KIDS is also a treatment that focuses directly on the speech of the child. It is possible that capturing the increased brain plasticity at this age in combination with creating optimal conditions for recovery underlie these treatments' success rate. A treatment focusing on the cognitions, emotions and behaviour of the child, the social cognitive behaviour treatment (SCBT), is also frequently delivered in Belgium. In this study we want to compare, and collect data on the effectiveness, of these three treatment programs: Mini-KIDS, SCBT and the Lidcombe Program (protocol registered under number NCT05185726). 249 children will be allocated to one of three treatment groups. Stuttering specialists will treat the child (and guide the parents) with Mini-KIDS, the SCBT or the Lidcombe Program. They will be trained to deliver the programs meticulously. At 18 months after randomisation, the speech fluency of the child and the attitude of the child and parent(s) towards speech will be measured. It is expected that the three programs will achieve the same (near) zero levels of stuttering in nearly all children and a positive attitude towards speech at 18 months after the start of treatment. The amount of treatment hours to reach the (near) zero levels of stuttering will be compared between the different programmes. For families as well as for the health system this could generate important information.

Further development in measuring communicative participation: identifying items to extend the applicability of the communicative participation item bank

BACKGROUND

The ability to communicate is a prerequisite for participation in today's society. To measure participation in adults with communication disorders, the Communicative Participation Item Bank (CPIB) was developed in 2006. Since then, several new PROMs have been developed to measure communication and the impact of communication disorders on participation. Moreover, the CPIB items do not all appear to be relevant to certain populations with communication problems and context of communicative participation is changing rapidly, given the increased use of digital communication forms. The purpose of this study was to identify new PROMs developed since 2006 that aim to measure (aspects of) communication, in order to select items that are suitable for expanding the Communicative Participation Item Bank to make the item bank more widely applicable (e.g., to the hearing-impaired population) and tailored to the current societal context.

METHODS

Medline and Embase were used to search for PROMs that aim to measure (aspects of) communication. Each new PROM as well as the CPIB, was evaluated to determine to what extent it contains items that measure communicative participation and to what extent these items capture all communicative participation domains by linking each item to the ICF Activities and Participation domains.

RESULTS

This study identified 31 new PROMs, containing 391 items that were labelled as measuring communicative participation. The majority of the 391 items measure aspects of ICF Activities and Participation domain 'communication', followed by the domain 'interpersonal interactions and relationships'. The other ICF Activity and Participation domains were less often addressed. Analysis of the CPIB showed that items do not cover all domains of participation as defined in the ICF, such as the 'major life areas' domain.

CONCLUSIONS

We found a potential pool of 391 items measuring communicative participation that could be considered for extending the CPIB. We found items in domains that are already present in the CPIB, but also items that relate to new domains, such as an item on talking with customers or clients for the 'major life areas' domain. Inclusion of new items in other domains would benefit the comprehensiveness of the item bank.

Sleep Problems, Social Anxiety and Stuttering Severity in Adults Who Do and Adults Who Do Not Stutter

Background: While there is sufficient evidence that children and adolescents who stutter reported more impaired sleep compared to children and adolescents who did not stutter, findings among adults who stutter (AWS) were scarce. Furthermore, stuttering is associated with issues related to verbal communication in a social context. As such, it was conceivable that AWS reported higher scores for social anxiety, compared to adults who do not stutter (AWNS). In the present study, we tested whether AWS reported higher sleep complaints compared to AWNS. We further tested whether scores for social anxiety and stuttering independently predicted sleep disturbances. Methods: A total of 110 AWS (mean age; 28.25 years, 27.30% females) and 162 AWNS (mean age; 29.40 years, 51.20% females) completed a series of self-rating questionnaires covering sociodemographic information, sleep disturbances and social anxiety. Adults with stuttering further completed a questionnaire on stuttering. Results: Compared to AWNS, AWS reported a shorter sleep duration, a lower sleep efficiency, higher scores for drug use in terms of sleep-promoting medications (significant p-values and medium effect sizes), and an overall higher PSQI score (significant p-values and large effect size), when controlling for age and social anxiety. Next, while p-values were always significant for subjective sleep quality, sleep disturbances, and daytime functioning, when controlling for age and social anxiety, their effect sizes were trivial or small. For sleep latency, the p-value was not significant and the effect size was trivial. Among AWS, higher scores for stuttering and older age, but not social anxiety, predicted higher sleep disturbances. The association between higher sleep disturbances and higher stuttering severity was greatest among those AWS with highest scores for social anxiety. Conclusions: When compared to AWNS, AWS self-reported higher sleep disturbances, which were associated with older age, and higher scores for stuttering severity, but not with social anxiety. Adults who stutter might be routinely asked for their sleep quality.

Evaluating Palin Stammering Therapy for School Children (Palin STSC 8–14): protocol for a feasibility randomised controlled trial comparing Palin STSC(8–14) with usual treatment

Background

Having a stammer can have a significant effect on a child’s social, emotional and educational development. With approximately 66,000 children in the UK having a stammer, there is a need to establish an adequate evidence base to inform clinical practice. We describe a feasibility trial to explore the effectiveness of a new therapy programme for children aged 8–14: Palin Stammering Therapy for School Children (Palin STSC(8–14)). Preliminary data from the Michael Palin Centre, where the programme was developed, indicate that Palin STSC(8–14) is effective in reducing stammering frequency and impact for children, with beneficial effects for parents too. We will investigate the feasibility of the methods required for a definitive randomised controlled trial to investigate the application of this therapy by NHS speech and language therapists (SLTs), compared with ‘treatment as usual’ (TAU), beyond the specialist context in which it was developed.

Methods

This is a two-arm feasibility cluster-randomised controlled trial of Palin STSC(8–14) with TAU control arm, and randomisation at the level of the SLT. Quantitative and qualitative data will be collected to examine the following: the recruitment and retention of therapists and families, the acceptability of the research processes and the therapeutic intervention and the appropriateness of the therapy outcome measures. Assessments will be completed by children and parents at baseline and 6 months later, including measures of stammering severity; the impact of child’s stammering on both children and parents; child temperament, behaviour and peer relations, anxiety; quality of life; and economic outcomes. There will also be a qualitative process evaluation, including interviews with parents, children, SLTs and SLT managers to explore the acceptability of both the research and therapy methods. Treatment fidelity will be examined through analysis of therapy session records and recordings.

Discussion

The findings of this feasibility trial will inform the decision as to whether to progress to a full-scale randomised controlled trial to explore the effectiveness of Palin STSC(8–14) when compared to Treatment as Usual in NHS SLT services. There is a strong need for an evidence-based intervention for school age children who stammer.

Trial registration

ISRCTN. ISRCTN17058884. Registered on 18 December 2019.

Stuttering interventions for children, adolescents, and adults: a systematic review as a part of clinical guidelines

INTRODUCTION

Stuttering may have a holistic effect on the quality of life of a person who stutters by limiting participation in social situations, resulting in feelings of isolation and frustration, leading to difficulties in education and employment and increasing the likelihood of mental health problems. Even young children who stutter may have negative experiences of speaking. Therefore, it is important to treat stuttering behavior effectively in both children and adults. The purpose of this paper was to systematically review group and case studies about the effectiveness of behavioral stuttering interventions to provide evidence-based guidelines for clinicians.

METHODS

Systematic data retrieval was conducted in four electronic databases (PsycINFO, CINAHL, PubMed, Cochrane). The assessment of search results was conducted according to predetermined inclusion and exclusion criteria by two independent judges. The methodological quality of each paper was assessed using strict criteria to include only high-quality research.

RESULTS

The search revealed 2293 results, and 38 papers (systematic reviews N=3, group design studies N=21 and case studies N=14) with acceptable methodological quality were included. The data show that there is most evidence about the treatment of early childhood stuttering, very little evidence about school-aged children and some evidence about adults. The most convincing evidence is about the Lidcombe Program in the treatment of young children who stutter, but also other methods have promising evidence. Our data imply that in the treatment of adults who stutter, holistic treatments may influence speech fluency and overall experience of stuttering behavior. Speech restructuring treatments may have a positive effect on overt characteristics of stuttering, but not on covert stuttering behavior.

CONCLUSIONS

The results of this review agree with earlier reviews about the treatment of young children. However, due to different inclusion criteria, this review also shows the benefits of holistic treatment approaches with adults and adolescents.

The good, the bad, and the ugly: Unpacking the pros and cons associated with change for adults who stutter

PURPOSE

The purpose of the current study was to document the pros and cons that adults who stutter may consider when deciding to change how they live with stuttering.

METHODS

Semi-structured interviews were conducted with 11 adults who stutter and 12 speech-language pathologists who specialize in stuttering therapy. Participants were asked to identify and discuss the advantages and disadvantages of making a change to how they live with stuttering. Reflexive thematic analysis was used to generate multilevel themes.

RESULTS

Meaningful units were extracted from interview transcripts to develop 37 discrete pros and 15 discrete cons. The pros of change clustered into five organizing themes: enriching one's social relationships, feeling better in social interactions, developing a healthier sense of self, gaining autonomy, and communicating easier. The cons of change clustered into three organizing themes: experiencing discomfort, expending resources, and recognizing that some things may not change.

CONCLUSION

This study documented why adults who stutter may or may not seek change. Identifying the pros and cons of behavior change is an important step in understanding why some clients who stutter are ambivalent about, or resistant to, the therapeutic process.

"Knowledge Without Action Means Nothing": Stakeholder Insights on the Behaviors That Constitute Positive Change for Adults Who Stutter

PURPOSE

The aim of this study was to document the behaviors that adults who stutter (AWS) may engage in to make positive changes to living with stuttering.

METHOD

We interviewed 23 key stakeholders, including 11 AWS and 12 speech-language pathologists who specialize in stuttering therapy. The semi-structured interviews began with the primary question, "If an adult who stutters was making positive changes to living with stuttering, what would they be doing?" Follow-up probing questions focused the interviews on identifying actionable behaviors that would suggest positive changes. The interviews were transcribed and qualitatively analyzed using applied and reflexive thematic analyses to develop multilevel themes.

RESULTS

Meaningful units extracted from the interviews contributed to three high-order global themes: (a) noticing and adjusting physical behaviors involved in speaking, to the extent that it is personally important to do so; (b) developing neutral or positive thoughts and feelings about stuttering; and (c) participating more fully in social and professional activities, even if the person stutters or thinks they might stutter. We developed 35 low-order basic themes, which we grouped into 11 mid-order organizing themes, to richly illustrate the three global themes.

CONCLUSIONS

These findings extend the ongoing discussion regarding best practices for therapy targets in stuttering intervention. We identified measurable, multidimensional actions that clinicians can integrate in their therapy plans with AWS. While these actions represent a holistic approach to making positive changes, it grants clients and clinicians space to develop individualized intentions and outcomes.

What works for whom? Multidimensional individualized stuttering therapy (MIST)

PURPOSE

This study reports outcomes from a stuttering therapy approach that combines value and awareness-based elements from Acceptance and Commitment Therapy (ACT) with those of stuttering and speech modification interventions. The approach, entitled Multidimensional Individualized Stuttering Therapy (MIST), includes a combined clinician and client selection of factors across five areas: 1) general breathing patterns and body tension, 2) breathing patterns during speech production, 3) vocal features in speech production, 4) value and mindfulness-based strategies, and 5) general communication and/or presentation skills. The aims of this study were to evaluate whether the MIST a) reduces the impact of stuttering and stuttering severity, and b) has a positive impact on speaking ability, confidence in communication, avoidance-behavior, and quality of life.

METHOD

Eighteen adults, age 21-61 years took part in an A-B-A multiple case study design. Participants underwent a pre-clinic assessment phase, followed by 10 h of therapy over four sessions administered by an experienced speech-language therapist. Outcome measures examined both psychosocial and behavioral aspects of therapy three-, six- and twelve-months post-therapy.

RESULTS

Most participants chose elements from at least four of the five areas of focus. There was a significant reduction in the impact of stuttering at both 6- and 12-months post-therapy, with moderate (d = .71) to very large (d = 1.06) effect sizes. A strong association was found between overall satisfaction with MIST and improved speaking abilities. Moderate to strong associations were also found between experienced speaking abilities, confidence in communication, reduction in avoidance behaviors and improved quality of life.

DISCUSSION

Findings indicate that MIST can be effective in managing adult stuttering. The findings highlight the importance of shared decision making and personal considerations using flexible therapy approaches that integrate stuttering and speech modification interventions with value and awareness-based skills. The nature of a multidimensional individualized approach, as shown in this study, highlights the importance of adjusting the relative weighting of different subcomponents according to each individual's needs and goals.

CONCLUSION

MIST was shown to be efficacious in clinical settings and effective in real life settings. Findings were promising, despite a relatively small sample, and replication by other SLPs and with larger samples is warranted.

Clinical Trials of Adult Stuttering Treatment: Comparison of Percentage Syllables Stuttered With Self-Reported Stuttering Severity as Primary Outcomes

Purpose In a companion paper, we found no statistical reason to favor percentage syllables stuttered (%SS) over parent-reported stuttering severity as a primary outcome measure for clinical trials of early stuttering. Hence, considering the logistical advantages of the latter measure, we recommended parent-reported stuttering severity for use as an outcome measure. The present report extends the prior analysis to a comparison of %SS with self-reported stuttering severity (SRSS) for use as an outcome measure in clinical trials of stuttering treatments for adults. Method We analyzed data from four randomized clinical trials for adults that incorporated %SS and SRSS data at prerandomization and at 6 months post randomization. We analyzed the distributions associated with the two measures, their agreement, and their estimates of effect sizes. Results The positively skewed distribution of %SS warrants much reservation about its value as a clinical trial outcome measure. This skew causes inherent instability because of spurious data associated with low scores, which occur commonly at the low end of such a distribution. This inherent instability is compounded by inherent problems with absolute reliability of %SS measures. These problems are reduced with the much more normal distribution of SRSS. Conclusions The logistical arguments in favor of SRSS apply similarly to adults as they do when parents report the stuttering severity of their children. However, there are statistical reasons to favor SRSS over %SS measures as a primary outcome of clinical trials with adult participants: SRSS has acceptable discriminant validity and a normal distribution, and it is less error prone than %SS. We recommend SRSS as a primary outcome for clinical trials of adults with stuttering.

What do people search for in stuttering therapy: Personal goal-setting as a gold standard?

PURPOSE

Stuttering affects people in individual ways, and there are multiple factors which may influence a person's goals when seeking therapy. Even though there is a common consensus that speech-language pathologists should discuss the individual's goals and expectations for stuttering therapy and outcomes, few studies have systematically investigated this issue. The aims of the present study were to investigate individual motivations and goal-setting related factors in stuttering therapy. The associations between self-reported impact of stuttering and the participants' perceptions of stuttering interference in communication, speaking abilities, and relationships with other people were also investigated.

METHOD

This study is part of a wider-ranging treatment study of individualized stuttering management tailored to the participants' personal goals and preferences. A mixed method, multiple single-case design was used to address the research questions. Twenty-one adults, age 21-61 years, took part in a pretherapy interview, which also included two quantitative measures: the Client Preferences for Stuttering Therapy-Extended version (CPST-E) and the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A). Findings from the study sample was compared with a Norwegian reference group, in order to check for the representativeness of the study sample.

RESULTS

Quantitative data showed that most participants wanted to focus on both physical and psychological aspects of therapy, and that 95% considered 'to gain a sense of control over the stuttering' as important. Participants' perspectives on their speaking ability and stuttering interference in communication were identified as central factors, particularly in social and professional settings. These outcomes aligned well with the finding of avoidance behaviors, such as avoiding words and speaking situations. Qualitative data identified four main areas that the participants wanted to improve: speech fluency, emotional functioning, activity and participation, and understanding of their stuttering.

CONCLUSION

The study confirms that multiple and individual factors may influence the person's goals for therapy. Goals were mainly anchored in participants' wish of better coping in real world settings. A high degree of avoidance behavior was reported, suggesting that anxiety, and in particular linguistic-related anxiety needs to be taken into account when addressing social anxiety in fluency disorders.