Stuttering treatment research 1970-2005: II. Systematic review incorporating trial quality assessment of pharmacological approaches

Lidcombe Program telehealth treatment for children 6-12 years of age: A Phase II trial

BACKGROUND

For children older than 6 years who stutter, there is a gap in clinical research. This is an issue for speech-language pathologists because the tractability of stuttering decreases and the risk of long-term psychological consequences increase with age.

PURPOSE

To report a Phase II trial of a telehealth version of the Lidcombe Program with school-age children.

METHODS

Participants were 37 children who stuttered, 6-12 years of age, from Australia, New Zealand, Hong Kong, and Singapore. Parents were trained by video telehealth how to deliver the Lidcombe Program to their child. Primary and secondary outcomes were stuttering severity and psychosocial functioning measured pre-treatment and at 6 months and 12 months after starting treatment. Parents submitted two 10-minute recordings of their child speaking in conversation, and three measures of anxiety, impact of stuttering, and communication attitude.

RESULTS

Six months after starting treatment, seven children (18.9%) attained Lidcombe Program Stage 2 criteria, 25 children (67.6%) showed a partial response to treatment, and five children (13.5%) showed no response. By 12 months, 12 children (32.4%) had reached Stage 2 criteria. Psychosocial improvements were observed 6 and 12 months after starting treatment.

CONCLUSIONS

The Lidcombe Program may eliminate or nearly eliminate stuttering for about one third of children 6-12 years of age. Randomized controlled trials with this age group involving the Lidcombe Program are warranted. In the interim, the Lidcombe Program is a clinical option clinicians can implement with this age group to reduce stuttering and its psychosocial impacts.

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.

Evaluation of an integrated fluency and Acceptance and Commitment Therapy intervention for adolescents and adults who stutter: Participant perspectives

PURPOSE

Childhood-onset stuttering is a neurodevelopmental disorder that may cause pervasive negative consequences for adults who stutter. In addition to significant challenges in personal, social, and emotional domains, stuttering has been shown to impose an economic burden on adults who stutter. Intervention for adults who stutter has historically addressed speech fluency more so than the covert psychosocial aspects of the disorder. There is an identified clinical need for holistic, efficacious, and cost-effective stuttering interventions that meet consumer needs. The purpose of the present study is to evaluate a novel, integrated intervention that combined traditional fluency techniques with Acceptance and Commitment Therapy, from the perspective of the adults who stutter who participated in the intervention.

METHOD

Twenty-eight adults who stutter completed the intervention program. Participants were invited to complete an online post-program written survey (including qualitative comments) and a semi-structured interview to explore their evaluations of the program with respect to its authenticity, acceptability, and social validity.

RESULTS

Participants perceived positive psychosocial changes as a result of the program, and were satisfied with the program overall. Qualitative thematic analyses of the written survey comments and the semi-structured interviews identified two major themes: factors specific to the intervention and factors specific to the therapeutic process. Several important sub-themes were also identified.

CONCLUSION

Findings support the authenticity, acceptability, and social validity of an integrated fluency and psychosocial intervention for stuttering. Findings also highlight the need for consideration of the consumer voice in the management of stuttering disorders, in keeping with person-centred care.

Efficacy of Levetiracetam in Treatment of Childhood Stuttering

Background:

Stuttering is a kind of speech disorder that affects about 1% of total population. As the origin of this disorder is not obviously diagnosed yet, various remedies have been practiced and among them different medicines have been studied, but unfortunately no significant effective drugs have been recognized yet. As stuttering imposes a great social and mental costs to the patients and their families, finding an effective medicine will help significantly. In this study we have focused on the effects of levetiracetam (LEV) treatment on children suffering from stuttering.

Methods:

In this clinical trial study, 30 children aged > 3 years (median 3.8 years) with stuttering and abnormal sleep electroencephalogram (EEG) were treated by LEV and followed-up for a minimum period of 6 weeks. The starting dose of 20 mg/kg/day was increased at an interval of 1 week by 20 mg/kg/day, if necessary, up to maximum dose of 60 mg/kg/day.

Results:

Overall LEV was effective in 70% of patients, decreasing stuttering to at least 50%. Three children (10%) became stuttering-free and only in one (3.3%) child an increase in stuttering was observed. There were statistically significant differences for efficacy in the presence of variables such as age groups, seizure, stuttering family history, and EEG data.

Conclusions:

LEV is an effective drug for treatment of childhood stuttering in those that have abnormal sleep EEG.

Involvement of the Cortico-Basal Ganglia-Thalamocortical Loop in Developmental Stuttering

Stuttering is a complex neurodevelopmental disorder that has to date eluded a clear explication of its pathophysiological bases. In this review, we utilize the Directions Into Velocities of Articulators (DIVA) neurocomputational modeling framework to mechanistically interpret relevant findings from the behavioral and neurological literatures on stuttering. Within this theoretical framework, we propose that the primary impairment underlying stuttering behavior is malfunction in the cortico-basal ganglia-thalamocortical (hereafter, cortico-BG) loop that is responsible for initiating speech motor programs. This theoretical perspective predicts three possible loci of impaired neural processing within the cortico-BG loop that could lead to stuttering behaviors: impairment within the basal ganglia proper; impairment of axonal projections between cerebral cortex, basal ganglia, and thalamus; and impairment in cortical processing. These theoretical perspectives are presented in detail, followed by a review of empirical data that make reference to these three possibilities. We also highlight any differences that are present in the literature based on examining adults versus children, which give important insights into potential core deficits associated with stuttering versus compensatory changes that occur in the brain as a result of having stuttered for many years in the case of adults who stutter. We conclude with outstanding questions in the field and promising areas for future studies that have the potential to further advance mechanistic understanding of neural deficits underlying persistent developmental stuttering.

Stuttering Severity Modulates Effects of Non-invasive Brain Stimulation in Adults Who Stutter

Stuttering is a neurodevelopmental disorder that manifests as frequent disruptions in the flow of speech, affecting 1% of adults. Treatments are limited to behavioral interventions with variable success and high relapse rates, particularly in adults. However, even in severe cases, fluency can be temporarily induced during conditions in which the speaker synchronizes his speech with external rhythmic cues, such as when reading in unison (choral speech) or with a metronome. Non-invasive neuromodulation techniques such as transcranial direct current stimulation (tDCS) have shown promise in augmenting the effects of behavioral treatment during motor and speech/language rehabilitation, but only one study to date has examined behavioral modulatory effects of tDCS in the context of stuttering. Using high-definition (HD)-tDCS electrodes, which improves focality of stimulation relative to conventional tDCS, we investigated the effects of tDCS on speech fluency and brain activation in 14 adults who stutter (AWS). Either anodal or sham stimulation was delivered on separate days over left supplementary motor area (SMA). During stimulation, participants read aloud in sync with a metronome. Measures of speech fluency and brain activity functional magnetic resonance imaging (fMRI) were collected before and after stimulation. No significant differences in brain activity or speech fluency were found when comparing active and sham stimulation. However, stuttering severity significantly modulated the effect of stimulation: active stimulation attenuated the atypically strong association between stuttering severity and right thalamocortical network activity, especially in more severe speakers. These preliminary results warrant additional research into potential application of HD-tDCS to modulate speech motor networks to enhance fluency in stuttering.

We Have a Voice: Exploring Participants' Experiences of Stuttering Modification Therapy

PURPOSE

Qualitative data were obtained from 8 people who stutter about their experiences and changes they perceived following attendance of an intensive group therapy intervention. Measures that related to reductions in stuttering, improved communicative confidence, and impacts on stuttering and quality of life were used to complement the qualitative data.

METHOD

Eight participants attended a group stuttering modification course for adults who stutter. They reported their experiences of therapy and perceived changes in a focus group immediately after therapy and at a semistructured interview 6 months post-therapy. Participants completed 5 additional quantitative standardized outcome measures at 3 data collection points (before and directly after therapy and 6 months post-therapy). These measures provided information about stuttering severity and frequency, use of avoidance strategies, attitude change, communicative confidence, quality of life, and locus of control.

RESULTS

Thematic analysis of the qualitative data identified 4 main areas: thoughts, feelings, and behaviors before therapy and motivation for seeking therapy; direct experience of the course; learning outcomes and challenges and solutions for maintaining change; and ways in which attending therapy had made a difference. These reported changes were supported by the quantitative measures that demonstrated improved communicative confidence; increased self-awareness; affective, behavioral, and cognitive changes; reduced use of avoidance strategies; and lower impact of stuttering on quality of life.

CONCLUSIONS

The qualitative analyses confirmed positive speech and attitude changes consequent on participants' attendance at stuttering modification therapy. These changes, further corroborated by quantitative measures, were linked to reports of improved quality of life. Further research is required to investigate the effectiveness of this form of therapy empirically and from the client's perspective.

Challenges and Strategies for Speech-Language Pathologists Using the Lidcombe Program for Early Stuttering

PURPOSE

The Lidcombe program is a treatment for preschool-age children who stutter. Studies indicate that its implementation is not always straightforward. In this study, challenges that parents and speech-language pathologists (SLPs) encounter when implementing the Lidcombe program were identified, and strategies to address them were sought.

METHOD

In Part 1, Lidcombe program treatment challenges were determined from 4 sources. In Part 2, 7 SLPs with 15 to 23 years of Lidcombe program experience were interviewed to develop strategies to respond to the identified treatment challenges.

RESULT

A template of the themes and a report with possible strategies are the outcomes of this study. A total of 124 themes were identified, mostly related to the implementation of Lidcombe program procedures. Strategies to deal with these challenges were formulated.

CONCLUSIONS

This study provides treatment challenges that parents or SLPs may encounter during the Lidcombe program. It also provides strategies that SLPs can suggest to address them. An added contribution of the findings is that SLPs in the clinic can now anticipate the sort of treatment challenges that parents may face. A summary of the findings will be made available on the Australian Stuttering Research Centre website and through the Lidcombe Program Trainers Consortium.

Beliefs and behavioural intentions towards pharmacotherapy for stuttering: A survey of adults who stutter

PURPOSE

Although considerable efforts have been made to investigate the effectiveness of pharmacological treatments for stuttering, little is known about how the stuttering community perceives these treatments. This study aimed to assess and quantify beliefs regarding pharmacotherapy for adults who stutter and to establish whether behavioural intentions to undertake treatment were related to these beliefs.

METHOD

An adapted version of the Beliefs about Medicine Questionnaire was completed by adults who stutter. Participants also reported perceptions of their stuttering including its overall impact, ratings of previous speech therapy, and behavioural intentions to initiate pharmacotherapy and speech therapy in future.

RESULTS

Necessity and concern beliefs were distributed widely across the sample and in a pattern indicating a relatively balanced perception of the benefits and costs of medication prescribed specifically for stuttering. Of the study's measures, the necessity-concerns differential most strongly predicted the behavioural intention to initiate pharmacotherapy. The overall impact of stuttering predicted intentions to seek both pharmacotherapy and speech therapy. Participants reported the likelihood of pursuing pharmacotherapy and speech therapy in equal measure.

CONCLUSIONS

The theoretical model of medication representations appears to be a useful framework for understanding the beliefs of adults who stutter towards the medical treatment of their disorder. The findings of this study may be of interest to clinicians and researchers working in the field of stuttering treatment and to people who stutter considering pharmacotherapy.

Evidence, Goals, and Outcomes in Stuttering Treatment: Applications With an Adolescent Who Stutters

Purpose

The purpose of this clinical focus article is to summarize 1 possible process that a clinician might follow in designing and conducting a treatment program with John, a 14-year-old male individual who stutters.

Method

The available research evidence, practitioner experience, and consideration of individual preferences are combined to address goals, treatment procedures, and outcomes for John.

Conclusions

The stuttering treatment research literature includes multiple well-designed reviews and individual studies that have shown the effectiveness of prolonged speech (and smooth speech and related variations) for improving stuttered speech and for improving social, emotional, cognitive, and related variables in adolescents who stutter. Based on that evidence, and incorporating the additional elements of practitioner experience and client preferences, this clinical focus article suggests that John would be likely to benefit from a treatment program based on prolonged speech. The basic structure of 1 possible such program is also described, with an emphasis on the goals and outcomes that John could be expected to achieve.

Stuttering generalization self-measure: Preliminary development of a self-measuring tool

INTRODUCTION

Generalization of treatment is considered a difficult task for clinicians and people who stutter (PWS), and can constitute a barrier to long-term treatment success. To our knowledge, there are no standardized tests that collect measurement of the behavioral and cognitive aspects alongside the client's self-perception in real-life speaking situations.

PURPOSE

This paper describes the preliminary development of a Stuttering Generalization Self-Measure (SGSM). The purpose of SGSM is to assess 1) stuttering severity and 2) speech-anxiety level during real-life situations as perceived by PWS. Additionally, this measurement aims to 3) investigate correlations between stuttering severity and speech-anxiety level within the same real-life situation.

METHOD

The SGSM initially reported includes nine speaking situations designed that are developed to cover a variety of frequent speaking scenario situations. However, two of these were less commonly encountered by participants and subsequently not included in the final analyses. Items were created according to five listener categories (family and close friends, acquaintances, strangers, persons of authority, and giving a short speech to small audience). Forty-three participants (22 PWS, and 21 control) aged 18 to 53 years were asked to complete the assessment in real-life situations.

RESULTS

Analyses indicated that test-retest reliability was high for both groups. Discriminant validity was also achieved as the SGSM scores significantly differed between the controls and PWS two groups for stuttering and speech-anxiety. Convergent validity was confirmed by significant correlations between the SGSM and other speech-related anxiety measures.

Euler H, Bosshardt HG, Cook S, Sandrieser P, Sommer M. The Pathogenesis, Assessment and Treatment of Speech Fluency Disorders

BACKGROUND

Approximately 1% of children and adolescents, 0.2% of women, and 0.8% of men suffer from stuttering, and lesser numbers from cluttering. Persistent speech fluency disorders often cause lifelong problems in communication and social participation.

METHODS

In an interdisciplinary, evidence and consensus based clinical practice guideline, the current understanding of the nature, identification, diagnosis, and treatment of stuttering and cluttering was summarized. A systematic review of the literature was carried out to assess the efficacy and effectiveness of treatments for stuttering. Evidence is lacking on the etiology, pathogenesis, evaluation, and treatment of cluttering.

RESULTS

In view of the fact that common (developmental, idiopathic) stuttering is associated with structural and functional changes of the brain, the guideline recommends that it should be called "originary neurogenic non-syndromic stuttering." Heritability estimates for this disorder range from 70% to over 80%. For preschool children, the Lidcombe therapy has the best evidence of efficacy (Cohen's d = 0.72-1.00). There is also strong evidence for an indirect treatment approach. For children aged 6 to 12, there is no solid evidence for the efficacy of any treatment. For adolescents and adults, there is good evidence with high effect sizes (Cohen's d = 0.75-1.63) for speech restructuring methods such as fluency shaping; weak evidence with intermediate effect sizes for stuttering modification (Cohen's d = 0.56-0.65); and weak evidence for combined speech restructuring and stuttering modification. The evidence does not support the efficacy of pharmacotherapy, rhythmic speaking, or breathing regulation as the sole or main form of treatment, or that of hypnosis or eclectic, unspecified stuttering therapies.

CONCLUSION

Stuttering is often treated in Germany with therapies for which there is inadequate evidence, and the initiation of treatment is often unnecessarily delayed. The guideline presents treatment methods whose efficacy is supported by the current evidence.

ACTH has beneficial effects on stuttering in ADHD and ASD patients with ESES: A retrospective study

INTRODUCTION

Etiology of stuttering remains unknown and no pharmacologic intervention has been approved for treatment. We aimed to evaluate EEG parameters and the effect of adrenocorticotropic hormone (ACTH) therapy in stuttering.

METHODS

In this retrospective study, 25 patients with attention deficit and hyperactivity (ADHD) or autism spectrum disorder (ASD), and comorbid stuttering were followed and treated with ACTH for electrical status epilepticus in sleep (ESES). Sleep EEGs were recorded at referral and follow-up visits and short courses of ACTH were administered when spike-wave index (SWI) was ⩾15%. The assessment of treatment effectiveness was based on reduction in SWI, and the clinician-reported improvement in stuttering, and ADHD or ASD. Statistical analyses were conducted in order to investigate the relationship between the clinical and EEG parameters.

RESULTS

Following treatment with ACTH, a reduction in SWI in all the patients was accompanied by a 72% improvement in ADHD or ASD, and 83.8% improvement in stuttering. Twelve of the 25 patients with stuttering showed complete treatment response. Linear regressions established that SWI at final visit significantly predicted improvement in ADHD or ASD, and in stuttering. If symptoms had recurred, improvement was once again achieved with repeated ACTH therapies. Stuttering always improved prior to, and recurred following ADHD or ASD.

CONCLUSION

The underlying etiology leading to ESES may play a significant role in the pathophysiology of stuttering and connect stuttering to other developmental disorders. ACTH therapy has beneficial effects on stuttering and improves EEG parameters.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A preliminary investigation of daily variability of stuttering in adults

PURPOSE

Variability in frequency of stuttering has made the results of treatment outcome studies difficult to interpret. Many factors that affect variability have been investigated; yet the typical range of variability experienced by speakers remains unknown. This study examined the day-to-day variability in the percentage of syllables containing stuttered and nonstuttered disfluencies in the speech of six adult speakers in three spontaneous speaking situations and two reading tasks.

METHODS

The frequency of moments stuttering during the tasks were compared within and between speakers and days to document the degree of variability in stuttering frequency and explore whether there were any consistent patterns. The Stuttering Severity Instrument-Fourth Edition (SSI-4) and Overall Assessment of the Speaker's Experience of Stuttering for Adults (OASES-A) were also tested for day-to-day variability. Correlations between frequency, severity, and life impact were made.

RESULTS

The primary result of this study was the large range over which frequency of stuttering varied from day to day for the same individual. This variability did not correlate with any measures of stuttering severity but did correlate with life impact as measured by the OASES-A. No global pattern was detected in variability from day to day within or between participants. However, there were significantly more nonstuttered disfluencies present during the spontaneous speaking tasks than during the reading tasks. The day-to-day variability in the life impact of the disorder (OASES-A) was less than the day-to-day variability in observable stuttering behavior (percentage of syllables stuttered and SSI-4).

CONCLUSION

Frequency of stuttering varies significantly from situation to situation and day to day, with observed variability exceeding the degree of change often reported in treatment outcomes studies from before to after treatment. This variability must be accounted for in future clinical and scientific work.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness

BACKGROUND

The growing range of available treatment options for people who stutter presents a challenge for clinicians, service managers and commissioners, who need to have access to the best available treatment evidence to guide them in providing the most appropriate interventions. While a number of reviews of interventions for specific populations or a specific type of intervention have been carried out, a broad-based systematic review across all forms of intervention for adults and children was needed to provide evidence to underpin future guidelines, inform the implementation of effective treatments and identify future research priorities.

AIMS

To identify and synthesize the published research evidence on the clinical effectiveness of the broad range of non-pharmacological interventions for the management of developmental stuttering.

METHODS & PROCEDURES

A systematic review of the literature reporting interventions for developmental stuttering was carried out between August 2013 and April 2014. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for the identification of relevant studies included electronic database searching, reference list checking, citation searching and hand searching of key journals. Appraisal of study quality was performed using a tool based on established criteria for considering risk of bias. Due to heterogeneity in intervention content and outcomes, a narrative synthesis was completed.

MAIN CONTRIBUTION

The review included all available types of intervention and found that most may be of benefit to at least some people who stutter. There was evidence, however, of considerable individual variation in response to these interventions. The review indicated that effects could be maintained following all types of interventions (although this was weakest with regard to feedback and technology interventions).

CONCLUSIONS

This review highlights a need for greater consensus with regard to the key outcomes used to evaluate stuttering interventions, and also a need for enhanced understanding of the process whereby interventions effect change. Further analysis of the variation in effectiveness for different individuals or groups is needed in order to identify who may benefit most from which intervention.

Influence of Methylphenidate on the Frequency of Stuttering

Background: Recently, a case report described a decrease in frequency of stuttering after intake of methylphenidate (MPH). Objective: This study was undertaken to investigate if this effect could again be reproduced in a population of young healthy male adult persons with developmental stuttering. Methods: A double-blind randomized crossover trial, with a 2-week washout period, including 15 Dutch-speaking young healthy persons with developmental stuttering, assessed the effects of a single dose of 20 mg MPH compared with placebo on stuttering. Dependent and 1-sample t tests were used to detect significant differences. The end point was the number of stutter moments and self-perceived improvement. Results: MPH yielded a significant decrease in the number of stutter moments when reading and speaking ( P = 0.002), which was not the case with placebo ( P = 0.090). There was a significant improvement from baseline after intake of MPH as compared with placebo ( P = 0.003). Self-perceived improvement with MPH was not significantly better as compared with placebo ( P = 0.28). Conclusions: This study showed that the participants had an objective statistically significant decrease in the frequency of stuttering with MPH, and this was not the case with placebo. This was also the case for a reduction in stutter moments when reading out loud and speaking spontaneously. However, this result was not subjectively perceived by the participants.

The effectiveness of stuttering treatments in Germany

PURPOSE

Persons who stutter (PWS) should be referred to the most effective treatments available, locally or regionally. A prospective comparison of the effects of the most common stuttering treatments in Germany is not available. Therefore, a retrospective evaluation by clients of stuttering treatments was carried out.

METHOD

The five most common German stuttering treatments (231 single treatment cases) were rated as to their perceived effectiveness, using a structured questionnaire, by 88 PWS recruited through various sources. The participants had received between 1 and 7 treatments for stuttering.

RESULTS

Two stuttering treatments (stuttering modification, fluency shaping) showed favorable and three treatments (breathing therapy, hypnosis, unspecified logopedic treatment) showed unsatisfactory effectiveness ratings. The effectiveness ratings of stuttering modification and fluency shaping did not differ significantly. The three other treatments were equally ineffective. The differences between the effective and ineffective treatments were of large effect sizes. The typical therapy biography begins in childhood with an unspecified logopedic treatment administered extensively in single and individual sessions. Available comparisons showed intensive or interval treatments to be superior to extensive treatments, and group treatments to be superior to single client treatments.

CONCLUSION

The stuttering treatment most often prescribed in Germany, namely a weekly session of individual treatment by a speech-language pathologist, usually with an assorted package of mostly unknown components, is of limited effectiveness. Better effectiveness can be expected from fluency shaping or stuttering modification approaches, preferably with an intensive time schedule and with group sessions.

EDUCATIONAL OBJECTIVES

Readers will be able to: (a) discuss the five most prevalent stuttering treatments in Germany; (b) summarize the effectiveness of these treatments; and (c) describe structural treatment components that seem to be preferable across different kinds of treatments.

A Survey on Conceptions of Stuttering

The conceptions about stuttering vary amongst cultures. Culturally specific findings regarding stuttering help in understanding the peoples' views and conceptions about stuttering and devising awareness and counselling strategies. A total of 132 passengers on the Coromandal Express from Chennai to Howrah participated in this study. All of them belonged to the upper middle socio-economic class. Preliminary Stuttering Conception Questionnaire (PSCQ) was used to understand their conceptions of stuttering. 23% had no idea and 12% had myths about the etiology of stuttering. 11% assumed it was a genetic problem and 5—6% a physical-mental problem. 31% had no idea of treatment options. 25% preferred medicine, 23% rehabilitation for treatment of stuttering. For rehabilitation, only 45% precisely knew about the speech language pathologist; the remaining 55% were unaware of this profession. Steps need to be taken towards educating the common man about stuttering.

Análise da produção científica internacional sobre gagueira

OBJETIVO: descrever as características da produção científica internacional sobre gagueira publicada em periódicos no período entre 2005 e 2010. MÉTODOS: pesquisa documental em que se analisaram artigos online, considerando-se: 1) distribuição da frequência por período; 2) temática; 3) vertente epistemológica; 4) procedimento metodológico; 5) faixa etária. RESULTADOS: foram analisados 339 artigos, distribuídos em 76 revistas, estando a maioria no Journal of Fluency Disorders (94;27,73%). As temáticas mais frequentes foram: Características da Gagueira (150;44,25%) e Tratamento da Gagueira (106;31,27%). O método de pesquisa mais utilizado foi Levantamento (157;46,31%). A maioria das pesquisas pertenceu à vertente Positivista (324;95,57%). A faixa etária mais estudada foi Adultos (174;45,31%). CONCLUSÃO: a produção internacional sobre gagueira apresenta crescimento discreto. Prepondera o paradigma Positivista. Dois fatos chamam atenção nos estudos positivistas: a emergência de pesquisas que quantificam aspectos qualitativos para olhar a gagueira como fenômeno multifatorial; os mesmos aspectos sendo tratados ora como característica, ora como causa da gagueira. Conjuntamente, esses fatos apontam para a complexidade do tema e para o desafio que a compreensão da gagueira tem representado aos pesquisadores, o que pode indicar a necessidade de se buscar novos caminhos epistemológicos para decifrá-la. Faltam pesquisas sobre prevenção e promoção de saúde; delineamentos de Estudo de Caso Clínico, e estudos sobre adolescentes.

Behavioral stuttering interventions for children and adolescents: a systematic review and meta-analysis

PURPOSE

To evaluate the effectiveness of behavioral interventions designed to treat stuttering in children.

METHOD

Studies were included for review if (a) the treatment was a behavioral intervention, (b) participants were between 2 and 18 years old, (c) the design was an experimental or quasi-experimental group design, and (d) the reported outcome measure assessed stuttering. An electronic search of 8 databases yielded a total of 9 studies, representing 327 treated participants across 7 different intervention types. Data were extracted for participant, treatment, and outcome characteristics as well as for methodological quality.

RESULTS

An analysis of the treatment effects yielded significant positive effects approaching 1 SD when compared with a nontreatment control group. No significant differences emerged for studies comparing 2 different treatments.

CONCLUSION

Conclusions drawn from the extant research suggest that data to support the efficacy of behavioral intervention in children exists for a limited number of intervention strategies, based on a meager number of methodologically acceptable studies.

Theory and therapy in stuttering: a complex relationship

There are many treatments currently available for stuttering, for both children and adults. These range from direct interventions intended to reduce the severity and/or frequency of the speech behaviors of stuttering, to those intended to alleviate the anxiety and other mental health issues that can accompany the disorder. However, as there are little supporting data for many of these treatments, there is little consensus about which to use. Another way to evaluate stuttering treatments is to explore the extent to which they address the cause of the disorder. However, the cause of stuttering is not yet known. In this theoretical paper, a 3-factor causal model is presented, to which the mechanisms thought to be driving different treatments are then aligned. The model is innovative, in that it attempts to explain moments of stuttering. It is argued that all causal factors must be operating at each moment of stuttering. The model is intended as a new way of looking at cause, and how treatments may address cause. It is hoped this will stimulate discussion and lead to further lines of inquiry.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe the P&A 3-factor causal model of moments of stuttering; (b) state how indirect direct stuttering treatments relate to cause, according to the P&A model; (c) describe how direct stuttering treatments relate to cause, according to the P&A model; (d) state the purpose of cognitive behavior therapy; and (e) describe at least one suggestion for further research arising from the P&A model.

Integrating functional measures with treatment: a tactic for enhancing personally significant change in the treatment of adults and adolescents who stutter

PURPOSE

It is proposed that stuttering treatment, particularly for adults and adolescents who stutter, may benefit from more inventive and extensive use of functional measurement-measures that are also treatment agents. Such measures can be tailored to produce more personally significant and evidence-based treatment benefits. They may be especially useful when employed in conjunction with partial self-management and performance-contingent procedures.

METHOD

Previous approaches to the definition of stuttering treatment goals and the measurement of stuttering treatment outcomes are critically reviewed. Suggestions for improvements are presented within the framework of an evidence-based and relatively standardized stuttering treatment.

RESULTS AND CONCLUSION

Results from a review of existing literature and from 2 case studies show that 2 specific personally significant problems, saying one's name and addressing large audiences, were improved by implementing these strategies in treatment. Functional measures directly connected to treatment, and partially self-managed performance-contingent schedules, merit further research as methodologies that are suitable for conducting personally significant and evidence-based treatments with adults and adolescents who stutter.

Hypnotically assisted diaphragmatic exercises in the treatment of stuttering: a preliminary investigation

This preliminary study investigates the combined effect of intensive hypnotherapy and diaphragmatic exercises in the management of stuttering. Fifty-nine clients with stuttering were trained to practice abdominal weightlifting to strengthen their respiratory muscles and to improve their diaphragmatic movements. The weightlifting exercises involved lifting a dumbbell (2.0-4.0 kg) with the abdomen for 2 hours daily for 8 consecutive days. Hypnotherapy was utilized to alleviate anxiety, to boost self-confidence, and to increase motivation for weightlifting exercise. The pre- and postmeasures were statistically significant (p < .001). Results of the study provide support for the effectiveness of hypnotically assisted diaphragmatic training in the management of stuttering but should be further studied in controlled trials.

Reprint of: technology and the evolution of clinical methods for stuttering

The World Wide Web (WWW) was 20 years old last year. Enormous amounts of information about stuttering are now available to anyone who can access the Internet. Compared to 20 years ago, people who stutter and their families can now make more informed choices about speech-language interventions, from a distance. Blogs and chat rooms provide opportunities for people who stutter to share their experiences from a distance and to support one another. New technologies are also being adopted into speech-language pathology practice and service delivery. Telehealth is an exciting development as it means that treatment can now be made available to many rural and remotely located people who previously did not have access to it. Possible future technological developments for speech-language pathology practice include Internet based treatments and the use of Virtual Reality. Having speech and CBT treatments for stuttering available on the Internet would greatly increase their accessibility. Second Life also has exciting possibilities for people who stutter.

EDUCATIONAL OBJECTIVES

The reader will (1) explain how people who stutter and their families can get information about stuttering from the World Wide Web, (2) discuss how new technologies have been applied in speech-language pathology practice, and (3) summarize the principles and practice of telehealth delivery of services for people who stutter and their families.

Technology and the evolution of clinical methods for stuttering

The World Wide Web (WWW) was 20 years old last year. Enormous amounts of information about stuttering are now available to anyone who can access the Internet. Compared to 20 years ago, people who stutter and their families can now make more informed choices about speech-language interventions, from a distance. Blogs and chat rooms provide opportunities for people who stutter to share their experiences from a distance and to support one another. New technologies are also being adopted into speech-language pathology practice and service delivery. Telehealth is an exciting development as it means that treatment can now be made available to many rural and remotely located people who previously did not have access to it. Possible future technological developments for speech-language pathology practice include Internet based treatments and the use of Virtual Reality. Having speech and CBT treatments for stuttering available on the Internet would greatly increase their accessibility. Second Life also has exciting possibilities for people who stutter.

EDUCATIONAL OBJECTIVES

The reader will (1) explain how people who stutter and their families can get information about stuttering from the World Wide Web, (2) discuss how new technologies have been applied in speech-language pathology practice, and (3) summarize the principles and practice of telehealth delivery of services for people who stutter and their families.

Assessing methodological quality of randomized and quasi-experimental trials: a summary of stuttering treatment research

The purpose of this study is to provide a detailed analysis of the methodological quality of experimental and quasi-experimental group designed studies in the area of stuttering intervention. A total of 23 randomized controlled trials (RCT) and quasi-experimental studies of treatment in the area of stuttering were identified and retrieved from an electronic search of nine databases and 13 individual journals. Using the Downs and Black Checklist each study was coded for reporting, external validity, internal validity, and internal validity confounding. Results of the coding indicated that while overall reporting was reasonably complete, the quality of the external and internal validity scores was found to be substantively incomplete. This lack of clarity and completeness of reporting issues related to the external and internal validity makes the interpretation of the findings of individual study results problematic and seriously effects the replicability of the individual study. Implications of these findings are suggested for both researchers and clinicians.

Exploratory randomized clinical study of pagoclone in persistent developmental stuttering: the EXamining Pagoclone for peRsistent dEvelopmental Stuttering Study

INTRODUCTION

Stuttering is a speech disorder in which the flow of speech is disrupted by repetitions, prolongation, and blocks of sounds, syllables, or words. No pharmacological treatments are approved for use in stuttering, and the most common form of treatment is speech therapy. This study was designed to assess the safety, tolerability, and effectiveness of pagoclone during 8 weeks of double-blind treatment followed by a 1-year open-label extension in patients who stutter.

METHODS

An 8-week, multicenter, parallel-group, 2-arm, randomized (ratio 2:1 pagoclone-placebo), double-blind study with a 1-year open-label extension conducted at 16 US centers, including men and women aged 18 to 65 years who developed stuttering before 8 years of age. Twice-daily dosing with pagoclone (n = 88 patients) or matching placebo (n = 44 patients), with primary and secondary efficacy variables defined a priori, including Stuttering Severity Instrument Version 3 outcomes, clinician global impressions of improvement, and the change in the percentage of syllables stuttered.

RESULTS

Pagoclone produced an average 19.4% reduction in percentage of syllables stuttered compared with 5.1% reduction for placebo. During open-label treatment, a 40% reduction in the percent syllables stuttered was observed after 1 year of treatment with pagoclone. The most commonly reported adverse event during double-blind treatment was headache (12.5% pagoclone patients, 6.8% placebo patients).

DISCUSSION

Pagoclone was effective in reducing symptoms of stuttering and was well tolerated. In light of its favorable tolerability profile, as well as consistency of effects across multiple efficacy variables, pagoclone may have potential as a pharmacological treatment of stuttering.

LIMITATIONS

The main limitation of this study was the adequacy of the number of subjects who participated because this study was conducted as a pilot investigation. Furthermore, as this condition waxes and wanes, the assessment of stuttering within the clinic setting may not be an adequate reflection of the stuttering of the patients within the community.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

EDUCATIONAL OBJECTIVES

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Comments on Bothe, Davidow, Bramlett, Franic, and Ingham (2006)

PURPOSE

To critically assess the quality, methodology, and conclusions in A. K. Bothe, J. H. Davidow, R. E. Bramlett, D. M. Franic, and R. J. Ingham's (2006) systematic review of pharmacological approaches to stuttering.

METHOD

A. D. Oxman and G. H. Guyatt's (1988) guidelines for reading literature reviews and A. D. Oxman and G. H. Guyatt's (1991) criteria for assessing the scientific quality of systematic reviews were adopted to accomplish the purpose.

RESULTS

Bothe et al.'s review was rated on a 7-point scale from extensive flaws on the high end to minimal flaws on the low end of the scale. The ratings varied from poor to good.

CONCLUSIONS

We judged Bothe et al.'s review of the pharmacological literature as it pertains to stuttering as flawed in its methodology and conclusions. However, we agree that the existing evidence for the use of pharmacological agents with persons who stutter is insufficient to recommend them in practice. Directions for improving the quality of clinical trials are suggested. In addition, we advocate for the multimethod measurement in stuttering research, including comparison, subjective evaluation, and social impact measures.

Stuttering treatment research 1970-2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and related approaches

PURPOSE

To complete a systematic review, with trial quality assessment, of published research about behavioral, cognitive, and related treatments for developmental stuttering. Goals included the identification of treatment recommendations and research needs based on the available high-quality evidence about stuttering treatment for preschoolers, school-age children, adolescents, and adults.

METHOD

Multiple readers reviewed 162 articles published between 1970 and 2005, using a written data extraction instrument developed as a synthesis of existing standards and recommendations. Articles were then assessed using 5 methodological criteria and 4 outcomes criteria, also developed from previously published recommendations.

RESULTS

Analyses found 39 articles that met at least 4 of the 5 methodological criteria and were considered to have met a trial quality inclusion criterion for the purposes of this review. Analysis of those articles identified a range of stuttering treatments that met speech-related and/or social, emotional, or cognitive outcomes criteria.

CONCLUSIONS

Review of studies that met the trial quality inclusion criterion established for this review suggested that response-contingent principles are the predominant feature of the most powerful treatment procedures for young children who stutter. The most powerful treatments for adults, with respect to both speech outcomes and social, emotional, or cognitive outcomes, appear to combine variants of prolonged speech, self-management, response contingencies, and other infrastructural variables. Other specific clinical recommendations for each age group are provided, as are suggestions for future research.