Treatment for School-Age Children Who Stutter: A Systematic Review of Japanese Literature

PURPOSE

This systematic review identified and synthesized published research articles, written in Japanese, on the clinical effectiveness of a broad range of nonpharmacological interventions for school-age children who stutter.

METHOD

A systematic review of Japanese literature published between January 1, 1980, and July 7, 2020, reporting interventions for school-age children who stutter, was carried out through a search of two databases (CiNii Article database and Japan Medical Abstract Society database) using the key words "stuttering" and "school-age" or "child" or "primary school students" or "children" or "school child" in Japanese. To be included in the review, the articles must report studies where data were subjectively reported by clinicians, where school-age participants were treated for developmental stuttering, where participants received interventions conducted by clinicians, and where quantitative outcomes (pre- and/or posttreatment) were measured; and they must be published in Japanese.

RESULTS

Forty articles met all the inclusion criteria. Most articles adopted a case series or single-case study design. A total of 179 intervention programs were identified from all the articles and broadly classified into speech therapy, psychological therapy, interventions for modifying the child's environment, and others.

CONCLUSIONS

Our systematic review provided a broad overview of the treatments used for school-age children who stutter in Japan. Future research should focus on gathering more reliable, systematic, and rigorous evidence to establish the effectiveness of stuttering treatments for school-age children and thereby develop evidence-based practices.

Obtaining consensus on core components of stuttering intervention for adults: An e-Delphi Survey with key stakeholders

BACKGROUND

Evidence-based practice involves the synthesis of multiple forms of evidence to inform clinical decision-making and treatment evaluation. Practice- and patient-based evidence are two forms of evidence that are under-represented in the stuttering literature. The collection of such knowledge is essential to support the design and delivery of effective stuttering interventions for adults.

AIMS

To build stakeholder consensus on the core components of intervention for adults who stutter, and to establish a guiding framework for the design and development of evidence-based interventions for adults who stutter.

METHODS & PROCEDURES

Adults who stutter and speech and language therapists (SLTs) with experience in providing stuttering intervention participated in the three-round e-Delphi Survey focused on: (1) identifying key stuttering intervention components, including principles, practices, and structural and contextual elements; and (2) obtaining group consensus on stuttering intervention components. Statements were categorized using the International Classification of Functioning, Disability and Health (ICF) model adapted to the study of stuttering.

OUTCOMES & RESULTS

A total of 48 individuals agreed to participate: 48/48 (100%) completed the Round 1 questionnaire, 40/48 (83%) responded to Round 2 and 36/40 (90%) participated in Round 3. Following content analysis of Round 1, 101 statements were developed, and consensus was achieved on 89 statements perceived as representing the core components of stuttering intervention for adults. Categorization of these statements reflected the key stuttering intervention components relating to personal reactions to stuttering, limitations in life participation and environmental factors.

CONCLUSIONS & IMPLICATIONS

Consensus on the core components of stuttering intervention was reached through engagement with key stakeholders. The evidence-based framework presented highlights the range of key intervention components a clinician should consider when designing interventions for adults who stutter.

WHAT THIS PAPER ADDS

What is already known on the subject Evidence-based practice endorses the synthesis of multiple knowledge forms including research, practice and patient evidence to support clinical decision-making and treatment evaluation. The stuttering literature is characterized by an over-representation of efficacy evidence, with significantly less practice and patient evidence to guide clinical practice. What this paper adds to existing knowledge This study adds valuable practice- and patient-based evidence for effective stuttering intervention components for adults who stutter. These relate to personal reactions to stuttering, limitations in life participation and environmental factors. What are the potential or actual clinical implications of this work? This research presents a stakeholder-informed framework for stuttering intervention to guide SLTs working with adults who stutter in designing evidence-based interventions. The framework supports the adoption of a person-centred approach to intervention to ensure each client's unique needs, preferences, values and desired outcomes are explored and integrated into therapy.

Intervención de la tartamudez en niños: una revisión integrativa de la literatura

RESUMEN Objetivo: describir las metodologías de intervención implementadas durante los últimos años en niños con tartamudez Métodos: se realizó la búsqueda de artículos empíricos de tratamiento en niños con tartamudez entre los 2.5 a 7 años. Se consideraron artículos publicados entre enero del año 2014 a junio del año 2020. La búsqueda se realizó en las bases de datos Embase, WOS, Pubmed y Scopus. Junto a lo anterior se realizó un análisis de las referencias de los artículos seleccionados. Revisión de la Literatura: se seleccionaron 11 artículos de 1.099 revisados. Se observaron distintas propuestas de intervención de las cuales el Programa Lidcombe es el que mayor evidencia presenta. La mayoría de las investigaciones fueron realizadas en hablantes de lengua inglesa. Los participantes son evaluados tanto en aspectos lingüísticos como no lingüísticos. Todos consideraron la participación de los padres en la intervención. No hubo investigaciones con mediciones a más de 24 meses. Predomina la modalidad de intervención individual. Conclusión: se evidencian buenos resultados terapéuticos en todas las intervenciones revisadas. En las investigaciones que compararon dos tipos de tratamiento no se observó la superioridad de uno por sobre otro.

Stuttering intervention in children: an integrative literature review

ABSTRACT Purpose: to describe intervention methodologies implemented in recent years in stuttering children. Methods: a search was performed for empirical articles on interventions in stuttering children aged 2.5 to 7 years. The search was carried out in Embase, WOS, Pubmed, and Scopus, considering articles published between January 2014 and June 2020. Literature Review: 11 articles were selected out of the 1,099 retrieved. Different approaches were observed, of which the Lidcombe program showed the most evidence. Most studies were conducted on English-speaking children and participants were assessed regarding linguistic and non-linguistic aspects. All studies considered parental involvement in the intervention. No investigation took measurements for more than 24 months. Individual interventions predominated. Conclusion: good therapeutic results were found in all reviewed interventions. Research comparing two types of treatments did not find one to be superior to the other.

Interventions for children and adolescents who stutter: A systematic review, meta-analysis, and evidence map

PURPOSE

This systematic review critically appraises and maps the evidence for stuttering interventions in childhood and adolescence. We examine the effectiveness of speech-focused treatments, the efficacy of alternative treatment delivery methods and identify gaps in the research evidence.

METHODS

Nine electronic databases and three clinical trial registries were searched for systematic reviews, randomised controlled trials (RCTs) and studies that applied an intervention with children (2-18 years) who stutter. Pharmacological interventions were excluded. Primary outcomes were a measure of stuttering severity and quality assessments were conducted on all included studies.

RESULTS

Eight RCTs met inclusion criteria and were analysed. Intervention approaches included direct (i.e. Lidcombe Program; LP) and indirect treatments (e.g. Demands and Capacities Model; DCM). All studies had moderate risk of bias. Treatment delivery methods included individual face-to-face, telehealth and group-based therapy. Both LP and DCM approaches were effective in reducing stuttering in preschool aged children. LP had the highest level of evidence (pooled effect size=-3.8, CI -7.3 to -0.3 for LP). There was no high-level evidence for interventions with school-aged children or adolescents. Alternative methods of delivery were as effective as individual face-to-face intervention.

CONCLUSION

The findings of this systematic review and evidence mapping are useful for clinicians, researchers and service providers seeking to understand the existing research to support the advancement of interventions for children and adolescence who stutter. Findings could be used to inform further research and support clinical decision-making.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part I. Scale Development

Purpose This article is the first in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. In this article, we describe the process of developing measures to assess stage of change (SOC) by defining behaviors of stuttering management, as well as the two primary cognitive constructs that underlie one's readiness to make behavioral change: decisional balance (DB) and situational self-efficacy (SSE). This work hinges on the ability to develop an operational definition of what it means to successfully manage or do something positive about one's stuttering. Method We used an iterative process to develop the three scales. Through qualitative analysis of key informant interview and focus group transcripts with 24 adolescents who stutter and 26 clinicians specializing in stuttering, we developed stuttering-specific SOC, DB, and SSE scales. The drafted scales were cognitively tested with nine adolescents who stutter. Results Thematic analysis yielded a three-part definition of successful stuttering management that formed the basis for the SOC scale: (a) learning and using strategies to modify speech or stuttering, (b) changing negative thoughts and attitudes regarding stuttering, and (c) talking without avoiding sounds, words, or situations. Results from this analysis support a broader view of successful stuttering management; that is, it is likely that doing so requires more than just behavior change, which has long been considered the main objective of stuttering treatment. Additional analyses yielded pros and cons of managing stuttering (62 items for the DB scale) and situations in which it is difficult to manage stuttering (39 items for the SSE scale). Conclusions Qualitative analyses provided a three-part definition of "stuttering management" and a comprehensive pool of items that would allow measurement of DB and SSE that underlie readiness to manage stuttering among adolescents. In the companion article in this two-part series, we describe the next step in scale development: exploratory scale validation of the drafted SOC, DB, and SSE scales.

Intensive Stuttering Therapy with Telepractice Follow-Up: Longitudinal Outcomes

PURPOSE

This study estimated the treatment outcomes of a behavioral stuttering therapy program that blended a combination of intensive face-to-face therapy with telepractice-based follow-up therapy.

METHOD

A total of 17 participants (mean age = 22 years) who stutter participated in the program, preceded by an extended baseline period. The participants completed a series of assessments conducted over multiple time points, spanning a total of 42 weeks. Growth curve modeling was used to analyze the changes participants experienced in the frequency of stuttering, stuttering severity, communication attitudes, and quality of life.

RESULTS

The participants demonstrated stability throughout the extended baseline period, and experienced positive outcomes from the intensive program and the gains in communication attitudes and quality of life were largely maintained with weekly follow-up telepractice sessions. However, stuttering frequency and severity increased when the telepractice follow-up session frequency transitioned to a biweekly basis. Neither gender nor age group predicted the treatment outcomes for frequency or severity of stuttering. Gender-based differences were found for the treatment outcomes of specific self-report measures, with male participants having demonstrated a greater proportional decline on their standard scores, relative to female participants. Outcomes were similar for both adolescents and adults.

CONCLUSIONS

Participants attending the intensive stuttering therapy program experienced positive and significant changes in their speech, attitudes toward communication, and overall quality of life, which were maintained over time with structured, weekly telepractice follow-up sessions.

Non-pharmacological interventions for stuttering in children six years and younger

BACKGROUND

Stuttering, or stammering as it is referred to in some countries, affects a child's ability to speak fluently. It is a common communication disorder, affecting 11% of children by four years of age. Stuttering can be characterized by sound, part word or whole word repetitions, sound prolongations, or blocking of sounds or airflow. Moments of stuttering can also be accompanied by non-verbal behaviours, including visible tension in the speaker's face, eye blinks or head nods. Stuttering can also negatively affect behavioural, social and emotional functioning.

OBJECTIVES

Primary objective To assess the immediate and long-term effects of non-pharmacological interventions for stuttering on speech outcomes, communication attitudes, quality of life and potential adverse effects in children aged six years and younger. Secondary objective To describe the relationship between intervention effects and participant characteristics (i.e. child age, IQ, severity, sex and time since stuttering onset) at pretest.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, nine other databases and two trial registers on 16 September 2020, and Open Grey on 20 October 2020. There were no limits in regards to language, year of publication or type of publication. We also searched the reference lists of included studies and requested data on unpublished trials from authors of published studies. We handsearched conference proceedings and programmes from relevant conferences.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that assessed non-pharmacological interventions for stuttering in young children aged six years and younger. Eligible comparators were no intervention, wait list or management as usual.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified four eligible RCTs, all of which compared the Lidcombe Program to a wait-list control group. In total, 151 children aged between two and six years participated in the four included studies. In the Lidcombe Program, the parent and their child visit a speech and language therapist (SLT) in a clinic. One study conducted clinic visits by telephone. In each clinic visit, parents were taught how to conduct treatment at home. Two studies took place in Australia, one in New Zealand and one in Germany. Two studies were conducted for nine months, one for 16 weeks and one for 12 weeks. The frequency of clinic visits and practice sessions at home varied within the programme. One study was partially funded by the Rotary Club, Wiesbaden, Germany; and one was funded by the National Health and Medical Research Council of Australia. One study did not report funding sources and another reported that they did not receive any funding for the trial.  All four studies reported the outcome of stuttering frequency. One study also reported on speech efficiency, defined as articulation rate. No studies reported the other predetermined outcomes of this review, namely stuttering severity; communication attitudes; emotional, cognitive or psychosocial domains; or adverse effects.  The Lidcombe Program resulted in a lower stuttering frequency percentage syllables stuttered (% SS) than a wait-list control group at post-test, 12 weeks, 16 weeks and nine months postrandomization (mean difference (MD) -2.16, 95% confidence interval (CI) -3.48 to -0.84, 4 studies, 151 participants; P = 0.001; very low-certainty evidence).  However, as the Lidcombe Program is designed to take one to two years to complete, none of the participants in these studies had finished the complete intervention programme at any of the data collection points. We assessed stuttering frequency to have a high risk of overall bias due to high risk of bias in at least one domain within three of four included studies, and to have some concern of overall bias in the fourth, due to some concern in at least one domain. We found moderate-certainty evidence from one study showing that the Lidcombe Program may increase speech efficiency in young children. Only one study reported outcomes at long-term follow-up. The long-term effect of intervention could not be summarized, as the results for most of the children in the control group were missing. However, a within-group comparison was performed between the mean % SS at randomization and the mean % SS at the time of extended follow-up, and showed a significant reduction in frequency of stuttering.  AUTHORS' CONCLUSIONS: This systematic review indicates that the Lidcombe Program may result in lower stuttering frequency and higher speech efficiency than a wait-list control group in children aged up to six years at post-test. However, these results should be interpreted with caution due to the very low and moderate certainty of the evidence and the high risk of bias identified in the included studies. Thus, there is a need for further studies from independent researchers, to evaluate the immediate and long-term effects of other non-pharmacological interventions for stuttering compared to no intervention or a wait-list control group.

The Lidcombe Program for Early Stuttering in Non-English-Speaking Countries: A Systematic Review

BACKGROUND

The Lidcombe Program is a stuttering treatment approach for children between the ages of 3 and 6 years. Most papers about the Lidcombe Program, however, are based on studies conducted in native English-speaking countries. The aim of this paper is to systematically review the delivery and implementation of the Lidcombe Program in non-native English-speaking countries.

SUMMARY

A resource search was conducted between October and November 2019. Scopus, PubMed, ASHA, Cochrane Library, ERIC, Google Scholar, and SpeechBITE databases and reference lists of relevant papers were searched for the identification process. Joanna Briggs Institute tools were used for the appraisal of the studies. The search yielded 8 studies conducted in non-native English-speaking countries. The Lidcombe Program is efficacious in non-native English-speaking countries when delivered to both preschool and young school age children who stutter. It is reported to be delivered with minor changes and challenges. The number of weekly clinic visits and the total time needed to reach zero or near-zero stuttering levels with the Lidcombe Program can be up to 3 times greater in non-native English-speaking countries than in native English-speaking countries, mostly due to the increased time needed to introduce the parental verbal contingencies. Key Messages: Speech and language therapists practicing in non-native English-speaking countries are encouraged to use the Lidcombe Program for both preschool and young school age children who stutter, although this can take more time than that reported in native English-speaking countries. Further investigation to explore the therapy process with children and parents in non-native English-speaking countries is needed.

Effectiveness of nonpharmacological stuttering interventions on communication and psychosocial functioning in adults: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis of the research evidence examining the effectiveness of nonpharmacological stuttering therapy on communication and psychosocial functioning for adults who stutter.

METHODS

A systematic search of nine electronic databases for studies published from database inception to December 2018 was completed to identify randomized controlled trials of interventions for adults with developmental stuttering. Two reviewers independently screened articles and assessed methodological quality using the Cochrane risk-of-bias tool. Treatment outcomes were classified using the International Classification of Functioning, Disability and Health (ICF) framework.

RESULTS

The search yielded nine randomized controlled trials, comprising 276 participants, using a diverse range of interventions which were classified into four categories: speech restructuring interventions; speech restructuring plus psychological interventions; interventions with stimulating techniques and interventions targeting anxiety. Meta-analysis showed that interventions did not demonstrate a significant pooled difference when compared to comparison groups in improving speech fluency (standardized mean difference [SMD] = -0.35, 95% confidence interval [CI] -1.14 to 0.45, I²   = 81%, P = .39), overall experience of stuttering (mean difference [MD] = -0.10, 95% CI -0.36 to 0.15, I²   = 0%, P = .43) and quality of life (SMD = -0.32, 95% CI -0.83 to 0.19, I²   = 0%, P = .21).

CONCLUSIONS

This article identified a diverse range of treatments and outcome measures for adults who stutter, with meta-analysis highlighting no significant pooled difference between intervention and comparator groups in improving communication and psychosocial functioning.

International expert perspectives on the principles and components of effective intervention for adults who stutter

BACKGROUND

While evidence-based practice is widely endorsed by researchers, clinicians and professional bodies as a guiding framework for the provision of quality care to clients, the reliance on efficacy evidence may overshadow the benefits of other knowledge forms in supporting intervention design and evaluation. Due consideration needs to be given to varied forms of evidence, including practice and patient evidence. Stuttering intervention for adults is one area in which there is a significant shortage of practice-based research literature.

AIMS

This study aimed to add to practice evidence by exploring the perspectives of international researchers and clinical experts on the components of effective stuttering intervention. This practice-based evidence will be used to inform the multi-stakeholder co-design of an evidence-based stuttering intervention for adults.

METHODS & PROCEDURES

Criteria defining expertise were developed based on a review of the literature. Experts were recruited using purposive sampling and snowballing. Seventeen international experts were approached, of which 10 completed semi-structured interviews. Interview questions were developed and centred on five topics: the nature of stuttering; efficacy evidence base; intervention techniques, principles of effective intervention; and outcome measurement.

OUTCOMES & RESULTS

Inductive thematic analysis identified three overarching themes: 'One size doesn't fit all', 'A really collaborative relationship where we are both bringing our sense of expertise to this' and 'Some of the most frustrating things'.

CONCLUSIONS & IMPLICATIONS

These findings emphasize the complexity of stuttering intervention, the need for individually tailored treatments and the role of multiple factors, beyond therapeutic technique, that influence treatment outcomes. Findings also demonstrate the benefit of collecting practice-based evidence to support clinical decision-making and intervention evaluation. What this paper adds What is already known on the subject Evidence-based practice involves the synthesis of multiple forms of knowledge, including research, practice and patient evidence to support clinical decision-making and intervention evaluation. Research evidence for stuttering intervention effectiveness is the dominant form of knowledge in stuttering literature, while other forms such as practice and patient evidence are less represented. What this paper adds to existing knowledge This study provides valuable practice evidence for effective stuttering intervention components, including individually tailored intervention, person-related factors and therapeutic alliance. It highlights the need to consider multiple forms of knowledge to guide the design and evaluation of intervention. What are the potential or actual clinical implications of this work? Clinicians should adopt a person-centred care approach when designing and evaluating an intervention for adults who stutter. Multiple factors beyond therapeutic technique influence treatment outcomes and should be incorporated into any intervention for adults who stutter.

The working alliance in stuttering treatment: a neglected variable?

BACKGROUND

Multiple factors can influence the working alliance and treatment outcome in speech and language therapy. The 'working alliance' is an important concept in treatment and can be described as the degree to which a treatment dyad is engaged in collaborative, purposive work. To date, relatively little attention has been paid to this concept within speech and language treatment in general, and within stuttering treatment research in particular.

AIMS

To investigate the role of the working alliance within stuttering treatment, and to evaluate whether the quality of the working alliance correlated with clients' concept of motivation and treatment outcomes 6 months post-therapy.

METHODS & PROCEDURES

Eighteen adults (21-61 years) participated in this multiple single-case treatment study, with treatment facilitated by an experienced speech and language therapist. The working alliance was investigated using the Working Alliance Inventory-Short Version Revised (WAI-SR), an Extended version of the Client Preferences for Stuttering Treatment (CPST-E), the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A), the Wright & Ayre Stuttering Self-Rating Profile (WASSP) and the Hospital Anxiety and Depression Scale (HADS).

OUTCOMES & RESULTS

Analyses demonstrated significant associations between the working alliance and client motivation (r = 0.781) and treatment outcomes (r = 0.644) 6 months post-treatment. The association between client-led goals and therapy tasks appeared particularly important.

CONCLUSIONS & IMPLICATIONS

The working alliance between speech and language therapists and persons who stutter matters. Within the alliance, the level of client-clinician agreement on treatment goals and therapy tasks may be of greater importance than the bond between client and clinician. Further research with greater numbers of participants is warranted.

The Influence of Treatment on Children's Recovery From Stuttering: Comments on Kefalianos et al. (2017) and Leech et al. (2017)

Purpose Two studies published recently in this journal sought to expand on previous attempts to explain and predict young children's recovery from stuttering. This letter addresses the influence of treatment on such research. Conclusions Recent publications from Kefalianos et al. (2017) and Leech, Bernstein Ratner, Brown, and Weber (2017) added to previous information that gender and language ability (or language growth) may be related to children's recovery from stuttering. The conclusions from both studies are difficult to interpret, however, because neither incorporated two factors known to influence children's recovery: a family history of recovery and, especially, the type and timing of treatment. Consideration of these two articles therefore raises multiple empirical, theoretical, and clinical issues that deserve to be fully addressed if our discipline is seeking to understand and to maximize recovery for young children who stutter.

A clinical training model for students: intensive treatment of stuttering using prolonged speech

PURPOSE

This study describes a practical model for improving the quality of Speech-Language Pathology (SLP) education on a clinical setting in a Bulgarian University. During this study, adults who stutter (AWS) received intensive treatment (IT) to increase fluent speech. The intensive treatment was delivered by students trained in the SLP Master's degree program "Logopedics Management in Fluency and Voice Disorders".

METHODS

The La Trobe University intensive program of prolonged speech was implemented. SLP students were trained and delivered the IT for AWS, under supervision in all stages. The treatment followed a clinical modeling pattern.

RESULTS

The primary outcomes were measured according to (i) percent of syllables stuttered (%SS) within and outside the stuttering research center of the university; (ii) self-reported inventory scores; and (iii) speech naturalness score evaluations from pre-treatment, immediately following treatment, 11 months post-treatment, and 18 months after the intensive treatment using stutter-free speech samples. The outcomes were reported for the overall IT program delivered by the SLP Master students.

CONCLUSION

The treatment delivered by students can ensure objective speech outcomes. The evidence-based practice model allowed students to develop and master specific clinical skills in establishing fluent speech by applying a prolonged speech technique. During the IT experience, students began to incorporate elements of evidence-based practice (EBP), clinical expertise, and consider values held by AWS. After four outcome-sessions, the AWS developed self-consciousness about the quality of their prolonged speech during controlled fluent patterns. The participants produced objective speech fluency data and statistically significant differences before and immediately after the IT regarding %SS and overall speech naturalness.

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.

Self-Esteem, Self-Efficacy, and Social Support as Predictors of Communicative Participation in Adults Who Stutter

PURPOSE

This study aimed to identify contributors to communicative participation in adults who stutter. Specifically, it was of interest to determine whether psychosocial variables of self-esteem, self-efficacy, and social support were predictive of communicative participation beyond contributions of demographic and speech-related variables.

METHOD

Adults who stutter (N = 339) completed an online survey that included measures of communicative participation, self-esteem, self-efficacy, social support, self-reported speech-related variables (speech usage, number of years stuttering, history of treatment and self-help support group participation for stuttering, and physical speech disruption severity), and demographics (age, sex, living situation, education, and employment status). Hierarchical regression was performed for prediction of communicative participation, in addition to calculating Spearman correlations between social roles variables, communicative participation, and physical speech disruption severity.

RESULTS

After controlling for demographic and speech-related variables, self-esteem, self-efficacy, and social support each significantly predicted communicative participation in adults who stutter. Large correlations were observed between communicative participation and measures of social roles, whereas medium correlations were observed between physical speech disruption severity and measures of social roles.

CONCLUSIONS

Communicative participation in adults who stutter is associated with a variety of demographic, speech-related, and psychosocial variables. Speech-language pathologists should be aware of predictors of communicative participation such as self-esteem, self-efficacy, and social support, in addition to severity of physical speech disruptions. They should consider and evaluate these factors in clients who stutter and target them in treatment if necessary.

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.

Randomized clinical trial: the use of SpeechEasy® in stuttering treatment

BACKGROUND

Numerous studies have demonstrated the benefit of devices delivering altered auditory feedback (AAF) as a therapeutic alternative for those who stutter.

AIMS

The effectiveness of a device delivering AAF (SpeechEasy®) was compared with behavioural techniques in the treatment of stuttering in a randomized clinical trial.

METHODS & PROCEDURES

Two groups of adults who stutter participated: group 1 consisted of 10 men and one woman aged 21-42 years (mean = 30.0). Group 2 consisted of six men and one woman aged 20-50 years (mean = 35.6). Participants in group 1 were fit with a SpeechEasy® device and were not given any additional training (i.e., supplementary fluency enhancing techniques). Participants used the device daily for 6 months. Participants in group 2 received treatment in the form of a 12-week fluency promotion protocol with techniques based on both fluency shaping and stuttering modification.

OUTCOMES & RESULTS

There were no statistically significant differences (p > .05) between groups in participants' stuttered syllables following treatment. That is, both therapeutic protocols achieved approximately 40% reduction in number of stuttered syllables from baseline measures, with no significant relapse after 3 or 6 months post-treatment.

CONCLUSIONS & IMPLICATIONS

The results suggest that the SpeechEasy® device can be a viable option for the treatment of stuttering.

Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes

BACKGROUND

Despite many years of research, there is no certainty regarding the cause of stuttering. Although numerous interventions have been developed, a broad-based systematic review across all forms of intervention for adults and children was needed including views and perceptions of people who stutter.

OBJECTIVE

The aims of the study were to report the clinical effectiveness of interventions for people who stutter (or clutter), to examine evidence regarding the views of people who stutter and the views of professionals regarding interventions.

DATA SOURCES

A systematic review of quantitative and qualitative literature was carried out between August 2013 and April 2014. The following electronic databases were searched: (1) MEDLINE, (2) EMBASE, (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database), (4) PsycINFO, (5) Science Citation Index, (6) Social Science Citation Index, (7) Cumulative Index to Nursing and Allied Health Literature, (8) ASSIA, (9) Linguistics and Language Behavior Abstracts, (10) Sociological Abstracts and (11) the EPPI Centre. Reference lists of included papers and other reviews were screened and also key journals in the subject area were hand-searched.

REVIEW METHODS

The searches aimed to identify (1) evidence of clinical effectiveness in populations of pre-school children, school-aged children, adolescents and adults, and (2) data relating to perceptions of barriers and facilitators to intervention clinical effectiveness among staff and people who stutter. A metasynthesis of the two linked elements via development of a conceptual model was also carried out to provide further interpretation of the review findings.

RESULTS

A systematic search of the literature identified a large number of potentially relevant studies. Of these, 111 studies examining the clinical effectiveness of interventions, 25 qualitative papers and one mixed-methods paper met the criteria for inclusion in this review. Review of the effectiveness literature indicated evidence of positive outcomes across all types of interventions. Virtually all evidence we identified reported at least some positive effect for some participants. However, there was evidence of considerable individual variation in outcome for study participants. The qualitative literature highlighted the need for programmes to be tailored to individual need with variation at the levels of the intervention, the individual and interpersonal/social elements. Metasynthesis of the data highlighted the complexity of elements that need to be considered in evaluation of long-term impacts following stuttering interventions.

LIMITATIONS

Around two-thirds of the studies were considered to be at higher risk of bias. The heterogeneous nature and variability in outcomes meant that we were unable to complete a meta-analysis.

CONCLUSIONS

Although much of the evidence we identified was from studies at risk of bias, it is suggested that most available interventions for stuttering may be of benefit to at least some people who stutter. There is a requirement for greater clarity regarding what the core outcomes following stuttering intervention should be and also enhanced understanding of the process whereby interventions effect change. Further analysis of those for whom interventions have not produced a significant benefit may provide additional insights into the complex intervention-outcomes pathway.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004861.

The impact of causal attribution on stigmatizing attitudes toward a person who stutters

PURPOSE

This study investigated the impact of providing low control (biological) and high control (psychobehavioral) causal explanations for stuttering on a variety of stigma related variables including blame, anger, social distance, stereotypes, dislike, sympathy, willingness to help, and perceptions of potential for recovery for a hypothetical person who stutters.

METHOD

One hundred and sixty-five university students read one of three vignettes describing a person who stutters with different descriptions about the cause of stuttering (low control, high control, and a control group in which no explanation was given) and answered a series of self-report measures assessing stigmatizing attitudes and perceived potential for recovery.

RESULTS

The controllable explanation for stuttering led to more blame compared to the uncontrollable explanation and no explanation. The controllable explanation resulted in higher levels of anger and stereotypes compared to no explanation. There were no significant differences between uncontrollable explanations and no explanation on any of the stigma related variables of interest. Uncontrollable explanations increased prognostic pessimism compared to controllable explanations. Self-reported familiarity and closeness with people who stutter was significantly related to more positive attitudes toward a hypothetical person who stutters.

CONCLUSIONS

Reducing the belief that stuttering is ultimately caused by psychobehavioral factors will reduce blame toward people who stutter. However, providing biological explanations for stuttering is not effective for reducing stigma compared to no explanation at all, and could increase prognostic pessimism. Biological explanations for stuttering should be provided to inform clients and society about current research findings, however this information must be given carefully and be balanced with evidence that people who stutter can make great progress with appropriate, personalized therapy that addresses the multidimensionality of the disorder.

LEARNING OUTCOMES

As a result of reading this paper, readers should be able to: (1) describe how causal attributions impact attitudes toward individuals with disabilities (2) summarize the effects of providing a biological explanation for stuttering on stigmatizing attitudes toward a person who stutters (3) summarize the effects of providing a psychobehavioral explanation for stuttering on stigmatizing attitudes toward a person who stutters, (4) discuss how familiarity and closeness toward people who stutter relates to stigmatizing attitudes toward a person who stutters.

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.

Event- and interval-based measurement of stuttering: a review

BACKGROUND

Event- and interval-based measurements are two different ways of computing frequency of stuttering. Interval-based methodology emerged as an alternative measure to overcome problems associated with reproducibility in the event-based methodology. No review has been made to study the effect of methodological factors in interval-based absolute reliability data or to compute the agreement between the two methodologies in terms of inter-judge, intra-judge and accuracy (i.e., correspondence between raters' scores and an established criterion).

AIMS

To provide a review related to reproducibility of event-based and time-interval measurement, and to verify the effect of methodological factors (training, experience, interval duration, sample presentation order and judgment conditions) on agreement of time-interval measurement; in addition, to determine if it is possible to quantify the agreement between the two methodologies

METHODS & PROCEDURES

The first two authors searched for articles on ERIC, MEDLINE, PubMed, B-on, CENTRAL and Dissertation Abstracts during January-February 2013 and retrieved 495 articles. Forty-eight articles were selected for review. Content tables were constructed with the main findings.

MAIN CONTRIBUTION

Articles related to event-based measurements revealed values of inter- and intra-judge greater than 0.70 and agreement percentages beyond 80%. The articles related to time-interval measures revealed that, in general, judges with more experience with stuttering presented significantly higher levels of intra- and inter-judge agreement. Inter- and intra-judge values were beyond the references for high reproducibility values for both methodologies. Accuracy (regarding the closeness of raters' judgements with an established criterion), intra- and inter-judge agreement were higher for trained groups when compared with non-trained groups. Sample presentation order and audio/video conditions did not result in differences in inter- or intra-judge results. A duration of 5 s for an interval appears to be an acceptable agreement. Explanation for high reproducibility values as well as parameter choice to report those data are discussed.

CONCLUSIONS & IMPLICATIONS

Both interval- and event-based methodologies used trained or experienced judges for inter- and intra-judge determination and data were beyond the references for good reproducibility values. Inter- and intra-judge values were reported in different metric scales among event- and interval-based methods studies, making it unfeasible to quantify the agreement between the two methods.

Self-perception of people who stutter regarding their experiences and results of stuttering treatments

PURPOSE

To investigate the opinion about stuttering treatments in people who stutter, based on their answers to two open questions.

METHODS

The participants were 40 adults of both genders, with self-reported stuttering. During the first phase of the research, we contacted two Brazilian nongovernmental organizations: the Brazilian Stuttering Association (ABRAGAGUEIRA) and the Brazilian Fluency Institute (IBF). These associations agreed to participate and were responsible for sending the research questions to their members via electronic mail. The first contact with the participants elucidated the purpose and method of our research and, after obtaining informed consent from participants, the two questions were sent. The research questions involved their opinion about cure, treatments to which the participants had been submitted, and their outcome.

RESULTS

After analysis, the answers obtained indicated that people who stutter believe in a cure for stuttering; that the ideal therapy would be the one that led to the disappearance of the symptoms; and the most frequently reported professional to treat the disorder is the speech-language pathologist. The results also indicated that although most of the participants had undergone speech-language treatment for stuttering, neither significant improvements were observed nor satisfaction was positive.

CONCLUSION

The results indicate that the answers presented by the participants were not based on scientific knowledge about the disorder but on their wish that "something could happen" to make stuttering "disappear." Although in this study we did not investigate the type of treatment to which the patients were submitted, the results suggest that the factors that contribute to an effective treatment are contentious.

Understanding perceptions of stuttering among school-based speech-language pathologists: an application of attribution theory

INTRODUCTION

The purpose of this study was to investigate whether attribution theory could explain speech-language pathologists (SLPs) perceptions of children with communication disorders such as stuttering. Specifically, it was determined whether perceptions of onset and offset controllability, as well as biological and non-biological attributions for communication disorders were related to willingness to help, sympathy, and anger toward children with these disorders. It was also of interest to determine if blame for stuttering was related to perceived controllability of stuttering and negative attitudes toward people who stutter (PWS).

METHOD

A survey was developed to measure perceived onset and offset controllability, biological and non-biological attributions, willingness to help, sympathy, and anger toward middle school children with developmental stuttering, functional articulation disorders, and cerebral palsy. In addition, a scale was developed to measure blame and negative attitudes toward PWS in general. Surveys were mailed to 1000 school-based SLPs. Data from 330 participants were analyzed.

RESULTS

Supporting the hypotheses of attribution theory, higher perceived onset and offset controllability of the disorder was linked to less willingness to help, lower sympathy, and more anger across conditions. Increased biological attributions were associated with more reported sympathy. Increased blame for stuttering was linked to higher perceived controllability of stuttering, more dislike of PWS, and more agreement with negative stereotypes about PWS.

CONCLUSIONS

Educating SLPs about the variable loss of control inherent in stuttering could improve attitudes and increase understanding of PWS. Reductions in blame may facilitate feelings of sympathy and empathy for PWS and reduce environmental barriers for clients. Learning outcomes Readers should be able to: (1) identify the main principles of Weiner's attribution theory (2) identify common negative perceptions of people who stutter (3) describe how disorders of stuttering, articulation disorders, and cerebral palsy are differentiated in terms of perceived onset and offset controllability, and biological and non-biological attributions (4) describe relationships between perceived onset and offset controllability of disorders and sympathy, anger, and willingness to help.

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.

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.

Stuttering in School-Age Children: A Comprehensive Approach to Treatment

Purpose

This letter, prepared through a close collaboration between the authors and more than 100 colleagues, responds to a paper by the editor of Language, Speech, and Hearing Services in Schools that highlighted the need for research on treatment for stuttering in school-age children.

Method

Our response addresses 3 themes: First, we offer agreement with the editor’s call for research because more evidence about treatment for children who stutter is certainly needed. Second, we provide an overview of recent literature, demonstrating that the majority of current treatments include strategies for helping children improve speech fluency in addition to helping them increase acceptance of their stuttering and diminish the negative consequences of the disorder. Third, we present several strategies designed to help clinicians respond to the individual needs of children who stutter in a data-based, comprehensive manner that focuses on minimizing the adverse impact of stuttering on children’s educational endeavors, and on their lives as a whole.

Conclusion

Much has been learned about the factors that contribute to the successful treatment of stuttering in school-age children, and evidence will continue to accumulate. Meanwhile, speech-language pathologists can help children increase their fluency while simultaneously minimizing the adverse impact of their speaking difficulties and helping them improve their overall communication.

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.

Construct validity of modified time-interval analysis in measuring stuttering and trained speaking patterns

PURPOSE

The aim of the present study was to examine the construct validity of modified time-interval analysis. This measure allows judgments on stuttered and fluent speech as well as trained speaking patterns and might be valuable for outcome studies.

METHOD

Construct validity was investigated in an intervention study with two treatment groups (24 clients received stuttering modification treatment, 30 clients received fluency modification treatment) and a control group (38 stuttering adults). All participants were interviewed during surprise phone calls before and after treatment; the speech samples were analyzed by means of modified time-interval analysis and stuttering frequency counts.

RESULTS

The outcomes confirmed prior hypotheses for the most part. First, the amount of trained speaking patterns after therapy was significantly higher in both treatment groups than in the control group. Secondly, longitudinal changes in the treatment groups met prior expectations based on differing treatment goals and exceeded the changes in the control group. Modified time-interval analysis was sufficiently sensitive to detect changes of speech fluency, but underestimated spontaneous fluent speech when trained speaking patterns were applied.

CONCLUSION

The present study supports construct validity of modified time-interval analysis in measuring stuttering and trained speaking patterns, but also reveals a lack of accuracy.

EDUCATIONAL OBJECTIVES

At the end of this activity the reader will be able to (a) explain different forms of validity in relation to the use of modified time-interval analysis, (b) evaluate whether construct validity of modified time-interval analysis has been supported by the outcomes of an intervention study and (c) describe the usefulness and limitations of modified time-interval analysis for future research.

The "Iowa Way" revisited

This paper attempts to bridge the gap between past and present stuttering therapy approaches. Specifically, the ideas and methods of Wendell Johnson and Dean Williams are compared to current approaches used in treating mental illness and communication disorders in which there is an emphasis on focusing on what is "right" with the individual and spending less time focusing on the "disorder". There is particular emphasis on tying Johnson's and Williams' overall philosophy to modern psychological approaches rooted in "Positive Psychology", to highlight how these early ideas in stuttering therapy may help us to discover the common factors that underlie the success of several different stuttering therapy approaches, independent of the specific techniques employed. It is proposed that future research on clinical efficacy in stuttering should use focused hypotheses techniques to investigate common factors that make therapy effective across individuals and therapy approaches.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) summarize the basic philosophy of the "Iowa" approach to stuttering as laid out by Wendell Johnson and Dean Williams; (2) describe current therapeutic techniques that incorporate "positive psychology"; (3) discuss possible common factors that influence therapy outcome that are independent of the therapeutic technique employed.

Developing the therapeutic relationship: from 'expert' professional to 'expert' person who stutters

This article looks back over the years and identifies some of the most influential thinkers, writers, and researchers who have had a profound effect on the way the therapy at the Michael Palin Centre for Stammering Children in London has evolved. It tracks the changes that have occurred in theoretical perspective, treatments offered, and the delivery of therapy. In particular this author is interested in the changing nature of the therapeutic relationship between professionals and people who stutter (PWS), and describes the way it has developed from the "expert professional" towards a more collaborative relationship that recognises the "expert patient". It was inspired by a book written in 1902 by Mr Beasley, a person who stammered. After several unsuccessful attempts to find a 'cure' he found his own solution to his stuttering and then used what he had learned to help many others. Much of what he wrote was well ahead of his time and reminds us, the professionals, of the importance of listening to and taking account of the views of PWS in therapy and designing treatment that meets the needs of the individual. This article also looks briefly at evidence based practice (EBP) and the issues involved in measuring outcomes that reflect the complex and individual nature of the problem. Finally the importance of the research in developing the knowledge and skill base of clinicians as well as PWS is acknowledged and discussed and the way ahead signposted.

EDUCATIONAL OBJECTIVES

The reader will learn about (1) the early history and development of stuttering therapy, (2) the influence of a variety of psychotherapeutic approaches, (3) the relevance of designing therapy to meet the needs of the PWS, and (4) discuss the role of 'common' factors in EBP.

Past speech therapy experiences of individuals exploring a new stuttering treatment

Perceptions of benefits of speech therapy, success of therapy across clinical settings, reasons for returning to therapy, client-clinician relationships, and clinicians' competency were assessed in 57 participants (47 men, 10 women; M age = 34 yr.) trying a new therapy. A majority of respondents had cumulatively five or more years in therapy and at least two stuttering therapies. Respondents rated university or hospital settings as more successful than services in public schools. 70% of the respondents noted difficulty communicating basic needs; they blamed themselves for inability to maintain posttherapeutic gains while perceiving their clinicians to be competent and attentive--although 47% of the respondents had minimal to no contact with their therapist after therapy.

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.

Client perceptions of effective and ineffective therapeutic alliances during treatment for stuttering

The treatment components that contribute to and account for successful therapeutic outcomes for people who stutter are not well understood and are debated by many. The purpose of this phenomenological study was to describe in detail the underlying factors that contribute to a successful or unsuccessful therapeutic interaction between clients and their clinicians. Twenty-eight participants, 19 men and 9 women, who had received from 6 months to more than 12 years of therapy for stuttering were studied. The participants were asked to consider their experience with one or more speech-language pathologists with whom they had received fluency therapy and to describe the characteristics that made that individual effective or ineffective in promoting successful change in their ability to communicate. Analysis of these data resulted in 15 primary categories. Finally, the essential structure of an effective and ineffective therapeutic interaction was described. Results highlighted the importance for effective therapy of understanding the stuttering experience, forming a positive client-clinician, alliance, and being knowledgeable about stuttering and its treatment.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe, from the perspective of a select group of adults who stutter, the themes associated with an effective therapeutic interaction, (2) describe, from the perspective of a select group of adults who stutter, the themes associated with an ineffective therapeutic interaction, and (3) describe the ways in which an effective or ineffective therapeutic interaction could impact a person who stutters.

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.