Temperament, emotion, and childhood stuttering

Behavioral and cognitive-affective features of stuttering in preschool-age children: Regression and exploratory cluster analyses

PURPOSE

The purpose of this study was to investigate associations among behavioral and cognitive-affective features of stuttering in preschool-age children who stutter, and the extent to which participants may or may not cluster together based on multiple indices of stuttering.

METHODS

Participants were 296 preschool-age children who stutter (mean age 47.9 months). Correlation and regression analyses, as well as k-means cluster analyses were conducted between and among several indices of stuttering: frequency of stuttering- and non-stuttering-like disfluencies (SLDs and NSLDs), ratios of repetitions and prolongations/blocks out of total number of SLDs, associated nonspeech behaviors, duration of stuttering events, KiddyCAT scores (Vanryckeghem & Brutten, 2007), and a TOCS parent-rated scale (Gillam et al., 2009).

RESULTS

For preschool-age children who stutter, most indices of overt stuttering behaviors were intercorrelated (e.g., more SLDs were associated with higher ratio of repetitions). Self-reported KiddyCAT scores (Vanryckeghem & Brutten, 2007) were largely not significantly associated with stuttering. Cluster analyses yielded two participant groupings: a larger group with less prominent stuttering features and a smaller group with more prominent features.

CONCLUSIONS

This study contributes to an increasingly comprehensive and nuanced understanding of the heterogeneous features of stuttering and their development in preschool-age children. Findings show strong intercorrelations between measures of stuttering behaviors, but more tenuous relationships between behaviors and cognitive-affective reactions to stuttering. Exploration of clusters of characteristics within this population revealed potential opportunities for future research.

A study of respiratory sinus arrhythmia and stuttering persistence

INTRODUCTION

The present study investigated potential differences in respiratory sinus arrhythmia between preschool-age children with persisting stuttering, children who recovered from stuttering, and children who do not stutter.

METHODS

Participants were 10 children with persisting stuttering (persisting group), 20 children who recovered from stuttering (recovered group), and 36 children who do not stutter (non-stuttering group). Participants viewed a neutral video clip to establish a pre-arousal baseline and then viewed two emotionally-arousing video clips (positive and negative, counterbalanced). Age-appropriate speaking tasks followed each of the video clips (post-baseline, post-positive, and post-negative). Respiratory sinus arrhythmia (RSA), an index of parasympathetic nervous system activity, was measured during the video clips and subsequent speaking tasks.

RESULTS

First, the persisting group, recovered group, and non-stuttering group did not significantly differ in baseline RSA. Second, during the emotionally-arousing video clips, there was a significant group x condition interaction, with the recovered group exhibiting significantly lower RSA in the positive than negative condition, and the non-stuttering group exhibiting significantly higher RSA in the positive than negative condition. Third, in the narrative tasks, there was a significant group x condition interaction, with a greater difference in RSA between the post-baseline speaking task and the post-positive and post-negative speaking tasks for the persisting compared to the non-stuttering group. Lastly, a follow-up analysis indicated that the recovered and nonstuttering groups, compared to the persisting group, exhibited significantly greater RSA during the baseline (neutral) condition compared to the post-neutral narrative task.

CONCLUSIONS

Findings provide a physiological perspective of emotion within children who stutter and persist and children who stutter and recover. Future investigations with larger sample sizes and diverse methodologies are necessary to provide novel insights on the specific emotion-related processes that are potentially involved with persistence of stuttering in young children.

Complex response inhibition and cognitive flexibility in school-aged Cypriot-Greek-speaking children who stutter

PURPOSE

Over the last few years, research findings have suggested limitations in executive function (EF) of children who stutter (CWS) with the evidence being more consistent in studies with preschoolers (3-6  years old) than in studies with school-aged children (6-12  years old). The purpose of the current study was to assess complex response inhibition and cognitive flexibility in school-aged CWS and their non-stuttering peers.

METHODS

Participants, 19 CWS (mean age = 7.58  years, range 6.08-9.17) and 19 age-and gender-matched children who do not stutter (CWNS; mean age = 7.58  years, range 6.08-9.33), completed a visual task consisting of three task blocks. Analyses were based on response times and error percentages during the different task blocks.

RESULTS

All participants showed expected performance-costs in task block comparisons targeting complex response inhibition and cognitive flexibility. Significant group differences were found in measures of cognitive flexibility with CWS performing slower compared to CWNS (p = 0.02). Additionally, significant block × group interactions demonstrated that CWS, compared to CWNS, slowed down more (i.e., higher performance-cost) under both complex response inhibition (p = 0.049) and cognitive flexibility task conditions (p = 0.04 for no-set-shifting and p = 0.02 for set-shifting).

CONCLUSION

These results are in line with some of the previous findings in school-aged CWS and suggest that CWS present lower performance in complex response inhibition and cognitive flexibility task conditions when compared to their non-stuttering peers.

The disabling nature of hope in discovering a biological explanation of stuttering

Discovering developmental stuttering's biological explanation has been an enduring concern. Novel advances in genomics and neuroscience are making it possible to isolate and pinpoint genetic and brain differences implicated in stuttering. This is giving rise to a hope that, in the future, dysfluency could be better managed if stuttering's biological basis could be better understood. Concurrent to this, there is another hope rising: a hope of a future where differing fluencies would not be viewed through a reductive lens of biology and associated pathologies. The central aim of this paper is to edge out ethical implications of novel research into stuttering's biological explanation. In doing so, the paper proposes to look beyond the bifurcation sketched by the medical and social model of disability. The paper demonstrates how the scientific hope of discovering stuttering's biological explanation acts as an accessory of disablement due to the language of 'lack' and 'deficit' employed in reporting scientific findings and proposes participatory research with people who stutter as an antidote to manage this disablement.

The role of temperament in stuttering frequency and impact in children under 7

INTRODUCTION

Increased emotional reactivity and decreased regulation have been associated with increased stuttering severity and frequency in preschool children who stutter (CWS) and may be predictors for the development of negative reactions to stuttering in young children. Understanding which children are likely to be impacted to a greater or lesser degree has implications for clinical decision making. Associations between temperament and stuttering impact have been explored with older CWS, but not with preschool CWS.

AIM

To investigate the relationship between temperament (specifically emotional reactivity and regulation) and both stuttering frequency and stuttering impact in preschool CWS.

METHODS

Data collected at initial assessment for 119 young CWS (age range= 3;00-6;11 years) at a specialist centre for stuttering in London, UK were analysed. The following measures were completed: The Children's Behaviour Questionnaire-Short Form (Putnam & Rothbart, 2006); Palin Parent Rating Scales (Millard & Davis, 2016); The Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (Vanryckeghem & Brutten, 2007); and a stuttering frequency measure.

RESULTS

Emotional reactivity and regulation were not significantly associated with stuttering frequency. Higher scores on negative reactivity were significantly associated with an increased impact of stuttering on the child (from parents' perspective), but not significantly associated with child-reported communication attitude. Positive reactivity was not significantly associated with parent-reported impact of stuttering or child-reported communication attitude. Additional investigation revealed negative affect as a significant predictor of parent-reported impact of stuttering before and after adjusting for age.

DISCUSSION

The results provide evidence to support the role of temperament on the impact that stuttering has in the early years. While the directionality of the relationship between negative reactivity and impact of stuttering is unknown, the importance of targeting emotional reactions in therapy for young CWS is implicated.

Bidirectional Associations of Childhood Stuttering With Behavior and Temperament

PURPOSE

Behavior and temperament (e.g., emotional reactivity, self-regulation) have been considered relevant to stuttering and its developmental course, but the direction of this relation is still unknown. Knowledge of behavior difficulties and temperament in childhood stuttering can improve screening and intervention. The current study examined both directions of the relationship between stuttering and behavior difficulties and temperament and between persistent stuttering and behavior difficulties and temperament across childhood.

METHOD

This study was embedded in the Generation R Study, a population-based cohort from fetal life onward in the Netherlands. We analyzed data from 145 children (4.2%) with a history of stuttering (118 recovered, 27 persistent) and 3,276 children without such a history. Behavior and temperament were repeatedly assessed using parental questionnaires (Child Behavior Checklist) and Infant/Child Behavior Questionnaire between 0.5 and 9 years of age. Multiple logistic and linear regression analyses were performed.

RESULTS

Six-month-old children who were less able to "recover from distress," indicating poor self-regulation, were more likely to develop persistent stuttering later in childhood (odds ratio = 2.05, 95% confidence interval (CI) [1.03, 4.05], p = .04). In the opposite direction, children with a history of stuttering showed more negative affectivity (β = 0.19, 95% CI [0.02, 0.37], p = .03) at 6 years of age than children without such a history. Stuttering persistence was associated with increased internalizing behaviors (β = 0.38, 95% CI [0.03, 0.74], p = .04) and higher emotional reactivity (β = 0.53, 95% CI [0.09, 0.89], p = .02) at the age of 9 years.

CONCLUSIONS

Behavior and temperament were associated with stuttering persistency-seemingly as both predictor and consequence-but did not predict a history of stuttering. We suggest that children who persist in stuttering should be carefully monitored, and if behavioral or temperamental problems appear, treatment for these problems should be offered. Supplemental Material https://doi.org/10.23641/asha.16869479.

Complex nonverbal response inhibition and stopping impulsivity in childhood stuttering

PURPOSE

The primary purpose of this study was to examine complex nonverbal response inhibition and stopping impulsivity in children who do (CWS) and do not stutter (CWNS).

METHOD

A total of 30 CWS and 30 CWNS between the ages of 3;1 and 6;0 (years; months) performed the Peg-Tapping Task (PTT; Diamond & Taylor, 1996; Luria, 1966), in which children were required to tap a dowel once when an examiner taps twice and vice versa. The main dependent variables were the number of practice trials, response accuracy, response latency for accurate responses, and the number of extra taps (i.e., tapping more than two times).

RESULTS

The CWS were less accurate and slower on the PTT than the CWNS, with no differences in the number of practice trials. Furthermore, the CWS, especially boys, produced more extra taps than the CWNS.

CONCLUSIONS

Findings revealed that preschool CWS have weaknesses in complex response inhibition and stopping impulsivity in the nonverbal domain compared to CWNS. Taken together, these findings along with those of previous studies indicate that CWS may have weaknesses in inhibition and impulsivity in the nonverbal domain as well as the verbal domain, suggesting a domain-general weakness.

Temperament is Linked to Avoidant Responses to Stuttering Anticipation

PURPOSE

The purpose of the present study was to examine the degree to which certain temperament constructs predict individual differences in three types of behavioral responses to anticipation among children and adults who stutter (CWS and AWS, respectively): avoidance, physical change, and approach.

METHODS

Participants included 64 CWS (9- to 17-years-old) and 54 AWS (18- to 50-years-old) who completed an online survey package including a temperament questionnaire (Early Adolescent Temperament Questionnaire-Revised for the CWS; Adult Temperament Questionnaire for the AWS) and the Stuttering Anticipation Scale. The data were analyzed separately for CWS and AWS using multivariate multiple regressions to assess how each temperament construct predicted avoidance, physical change, and approach responses to anticipation.

RESULTS

CWS who reported higher levels of shyness were more likely to engage in avoidant behavioral responses when they anticipate an upcoming moment of stuttering. AWS who reported higher levels of orienting sensitivity were more likely to engage in avoidant behavioral responses when they anticipate an upcoming moment of stuttering. No temperament constructs predicted physical change or approach responses to anticipation among either age group.

CONCLUSION

Specific aspects of temperament appear to be linked to the degree that CWS and AWS engage in avoidant behavioral responses to stuttering anticipation. These findings support the continued study of how individual differences impact the internal experience and outward manifestation of stuttering behaviors.

Identifying developmental stuttering and associated comorbidities in electronic health records and creating a phenome risk classifier

PURPOSE

This study aimed to identify cases of developmental stuttering and associated comorbidities in de-identified electronic health records (EHRs) at Vanderbilt University Medical Center, and, in turn, build and test a stuttering prediction model.

METHODS

A multi-step process including a keyword search of medical notes, a text-mining algorithm, and manual review was employed to identify stuttering cases in the EHR. Confirmed cases were compared to matched controls in a phenotype code (phecode) enrichment analysis to reveal conditions associated with stuttering (i.e., comorbidities). These associated phenotypes were used as proxy variables to phenotypically predict stuttering in subjects within the EHR that were not otherwise identifiable using the multi-step identification process described above.

RESULTS

The multi-step process resulted in the manually reviewed identification of 1,143 stuttering cases in the EHR. Highly enriched phecodes included codes related to childhood onset fluency disorder, adult-onset fluency disorder, hearing loss, sleep disorders, atopy, a multitude of codes for infections, neurological deficits, and body weight. These phecodes were used as variables to create a phenome risk classifier (PheRC) prediction model to identify additional high likelihood stuttering cases. The PheRC prediction model resulted in a positive predictive value of 83 %.

CONCLUSIONS

This study demonstrates the feasibility of using EHRs in the study of stuttering and found phenotypic associations. The creation of the PheRC has the potential to enable future studies of stuttering using existing EHR data, including investigations into the genetic etiology.

Cognitive Flexibility and Effortful Control in School-Age Children With and Without Stuttering Disorders

Purpose This study compared attention control and flexibility in school-age children who stutter (CWS) and children who do not stutter (CWNS) based on their performance on a behavioral task and parent report. We used a classic attention-shifting paradigm that included manipulations of task goals and timing to test effects of varying demands for flexibility on switching accuracy and speed. We also examined associations between task performance, group, and relevant aspects of temperament. Method Participants included 33 children (15 CWS, 18 CWNS) between 8 and 11 years of age. Children sorted stimuli that differed on two dimensions (color and shape) based on sorting rules that varied from block to block or trial to trial. Timing manipulations included intervals of 200-, 600-, or 1,200-ms durations for critical trial components. Temperament data were obtained via the Children's Behavior Questionnaire. Results All children showed expected performance costs in response to block and trial manipulations; however, CWS were more affected by task conditions that increased demands for cognitive flexibility. Effects of interval durations also differed by group. Factor scores on the Children's Behavior Questionnaire indicated differences in effortful control between groups; however, this aspect of temperament did not mediate between-groups differences in switching performance. Conclusions Findings suggest that stuttering continues to be associated with differences in attention control and flexibility beyond the preschool years. Further research is needed to clarify how these cognitive processes shape the development of stuttering throughout childhood.

Emotion processing in children who do and do not stutter: An ERP study of electrocortical reactivity and regulation to peer facial expressions

PURPOSE

Event-related brain potentials (ERPs) were used to investigate the neural correlates of emotion processing in 5- to 8-year-old children who do and do not stutter.

METHODS

Participants were presented with an audio contextual cue followed by images of threatening (angry/fearful) and neutral facial expressions from similarly aged peers. Three conditions differed in audio-image pairing: neutral context-neutral expression (neutral condition), negative context-threatening expression (threat condition), and reappraisal context-threatening expression (reappraisal condition). These conditions reflected social stimuli that are ecologically valid to the everyday life of children.

RESULTS

P100, N170, and late positive potential (LPP) ERP components were elicited over parietal and occipital electrodes. The threat condition elicited an increased LPP mean amplitude compared to the neutral condition across our participants, suggesting increased emotional reactivity to threatening facial expressions. In addition, LPP amplitude decreased during the reappraisal condition- evidence of emotion regulation. No group differences were observed in the mean amplitude of ERP components between children who do and do not stutter. Furthermore, dimensions of childhood temperament and stuttering severity were not strongly correlated with LPP elicitation.

CONCLUSION

These findings are suggestive that, at this young age, children who stutter exhibit typical brain activation underlying emotional reactivity and regulation to social threat from peer facial expressions.

College professors' perceptions of students who stutter and the impact on comfort approaching professors

PURPOSE

Previous literature has documented that college professors view hypothetical students who stutter more negatively than their fluent peers. The purpose of the present study was to investigate whether individuals who stutter report they experience more negative perceptions in the college classroom, and the impact of those perceptions on their comfort approaching professors.

METHODS

Two hundred forty-six adults who do and do not stutter, matched for age, participated in this study. Participants were presented with 16 positive and negative personality traits and asked to rate how strongly they believed their professor viewed them along each trait. All participants were asked whether they felt comfortable approaching their professors to discuss their performance. Adults who stutter were asked additional questions to investigate their college experience more comprehensively.

RESULTS

Adults who stutter reported they experienced significantly more negative perceptions from their professors than adults who do not stutter, and were significantly less likely to feel comfortable approaching their professors. These reported negative perceptions, specifically being perceived as less self-assured, predicted comfort approaching professors to receive performance feedback for adults who stutter. Finally, amongst adults who stutter, perception of how they were evaluated compared to their peers was significantly related to comfort approaching professors.

CONCLUSIONS

Results support that the negative perceptions towards hypothetical students who stutter reported in previous literature are experienced by individuals who stutter, and that these perceptions drive comfort approaching professors for performative feedback. Results suggest professors may increase students' comfort by clearly outlining equality in evaluation procedures.

Temperament and the Impact of Stuttering in Children Aged 8-14 Years

Purpose The goal of this study was to evaluate possible associations between child- and mother-reported temperament, stuttering severity, and child-reported impact of stuttering in school-age children who stutter. Method Participants were 123 children who stutter (94 boys and 29 girls) who were between 9;0 and 14;10 (years;months) and their mothers. Temperament was assessed with the revised child and parent version of the Early Adolescent Temperament Questionnaire-Revised (Ellis & Rothbart, 2001). The Overall Assessment of the Speaker's Experience of Stuttering (Yaruss & Quesal, 2006) was used to evaluate the stuttering impact. Results Child- and mother-reported Early Adolescent Temperament Questionnaire-Revised temperament factors correlated moderately. No statistically significant associations were found between temperament and stuttering severity. The temperament factors of Surgency (both child- and mother-reported) and Negative Affect (only child-reported) correlated moderately with the Overall Impact and several subsections (i.e., Speaker's Reactions, Daily Communication, and/or Quality of Life) of the Overall Assessment of the Speaker's Experience of Stuttering. Conclusions More extraverted and less fearful/shy children experience a lower overall impact of their stuttering. Children with higher levels of irritability and frustration experience a higher overall impact of their stuttering. Since children's ratings of temperament were more sensitive to these associations than mothers, this study supports the inclusion of child-reported temperament questionnaires in future research.

Manual response inhibition and quality of life in adults who stutter

BACKGROUND

A considerable amount of research has identified inhibition differences, including slower inhibition of manual responses, in people who stutter. Recent investigations have failed to link slowed motor inhibition with overt stuttering severity. This study investigated the potential relationship between slowed manual response inhibition and the negative impact of stuttering upon individual lives of adults who stutter (AWS).

METHODS

Thirty-four adults (AWS, n = 17; AWNS, n = 17) matched by nonverbal IQ completed a manual stop-signal task and provided a conversational speech sample. Motor inhibition latency for AWS and AWNS were compared. For AWS, motor inhibition latency was compared to the four subsections of the Overall Assessment of the Speaker's Experience with Stuttering (OASES; Yaruss & Quesal, 2006; General Information, Reactions to Stuttering, Communication in Daily Situations, Quality of Life).

RESULTS

Similar to previous studies, AWS were significantly slower to inhibit inaccurate manual responses than AWNS. Quality of Life subtest of the OASES was found to significantly predict inhibition latency.

CONCLUSION

These data replicate findings that indicate that AWS exhibit slower manual inhibition latency, and suggest that these inhibition differences may be associated with an individual's negative experience with stuttering rather than stuttering severity.

An Evaluation of an Integrated Stuttering and Parent-Administered Self-Regulation Program for Early Developmental Stuttering Disorders

Purpose This study reports findings from a clinical trial that implemented an early stuttering treatment program integrated with evidence-based parenting support (EBPS) to children who stutter (CWS) with concomitant self-regulation challenges manifested in elevated attention-deficit/hyperactivity disorder (eADHD) symptoms and compared those outcomes to CWS receiving stuttering treatment without EBPS. Method Participants were 76 preschool CWS and their parent(s). Thirty-six of these children presented with eADHD and were quasirandomized into two groups: stuttering treatment only (eADHD_standard) or stuttering treatment integrated with EBPS (eADHD_integrated). The remaining children did not meet criteria for eADHD symptoms and received stuttering treatment only (No-eADHD_standard). Pre, post, and 3-month follow-up measures of stuttering treatment outcomes as well as treatment effects on measures of child behavior difficulties and parenting practices were examined. Results Significant reduction in stuttering was found for all groups. However, the eADHD_integrated group showed a greater reduction in stuttering frequency than the eADHD_standard group, and at follow-up, stuttering frequencies in the eADHD_integrated group matched those of children in the No-eADHD_standard group, while stuttering in the eADHD_standard group remained significantly higher. Children with eADHD symptoms who received the integrated program also required significantly less stuttering intervention time than those children with eADHD symptoms who received stuttering treatment only. Families in the eADHD_integrated group reported large and significant improvements in child behavior and parenting practices. Conclusion This study provides support for an early treatment program for CWS. The integrated stuttering and self-regulation management program for CWS with eADHD symptoms proved successful for fluency and behavioral improvements, which were sustained at follow-up.

Temperament and early stuttering intervention: Two perspectives

PURPOSE

To discuss clinical applications of research findings about temperament and early stuttering.

METHOD

A "1000-bytes" format (Onslow & Millard, 2012) was used to provide readers with contemporaneous observation of a "conversation" between the authors. The conversation is proceeded by a prologue and followed by concluding statements from each author.

RESULTS

One author contended that comprehensive, multidimensional assessment of temperament domains is essential during clinical management of early stuttering, and the results of that assessment are best incorporated into a multifactorial treatment approach. The other author contested that view, arguing that such an approach is not empirically justifiable at present.

CONCLUSIONS

The authors agree about the salience of research on temperament and early stuttering but have different perspectives about the topic when applied to providing health care for early stuttering.

The Role of Behavioral Inhibition for Conversational Speech and Language Characteristics of Preschool-Age Children Who Stutter

Purpose The purpose of this study was to investigate whether preschool-age children who stutter (CWS) were more likely to exhibit a temperamental trait of behavioral inhibition (BI), a correlate of shyness, than children who do not stutter (CWNS) and whether this temperamental trait affected preschool-age children's speech fluency and language complexity during a conversation with an unfamiliar adult. Method Sixty-eight preschool-age children (31 CWS, 37 CWNS) participated. The degree of BI was assessed by measuring the latency to their sixth spontaneous comment and the number of all spontaneous comments during a conversation with an unfamiliar examiner (following Kagan et al.'s [1987] methodology). Parent report of shyness from the Children's Behavior Questionnaire served as an indirect measure of BI. Children's language complexity was assessed by measuring their mean length of utterance and the number of words spoken. For CWS, the frequency of stuttering and the negative impact of stuttering were also assessed. Results First, we found no between-group differences in the degree of BI across the behavioral observation measures. However, CWS were rated shyer by parents than CWNS. Second, for CWS only, higher BI was associated with less complex utterances and fewer words spoken. Third, for CWS, higher BI was associated with fewer stuttered disfluencies produced. Conclusions This study provides empirical evidence that BI to the unfamiliar may have salience for childhood stuttering as it affected the quantity and quality of language spoken with an unfamiliar adult. Clinical implications of high BI for the assessment and treatment of preschool-age stuttering are discussed.

Physiological Correlates of Fluent and Stuttered Speech Production in Preschool Children Who Stutter

Purpose The purpose of this study was to compare physiological indices of sympathetic nervous system arousal recorded during fluent and stuttered utterances in a preschool children who stutter (CWS). Method Twenty-two 4- to 5-year-old CWS participated in the experiment. We recorded children's skin conductance response amplitude and frequency, blood pulse volume amplitude, and pulse rate as they completed a picture description task. We then compared indices of phasic sympathetic arousal recorded during stuttered versus fluent utterances. In addition, children's communication attitudes were evaluated with a self-report measure. Results We detected significantly higher sympathetic arousal during stuttered utterances compared to fluent utterances. Specifically, we found larger skin conductance responses occurring at an increased frequency and decreased blood pulse volume amplitudes during stuttered speech. The behavioral measure indicated a negative communication attitude in only one-third of the participants. Conclusion Our findings suggest that preschool CWS may exhibit higher levels of sympathetic arousal during stuttered speech compared to when they are speaking fluently. We discuss the potential impact of increased sympathetic arousal on speech regulatory mechanisms in early childhood stuttering and present questions to guide future research.

Parent perceptions of an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering

PURPOSE

Recent research has identified approximately half of children who stutter present with self-regulation challenges. These manifest in elevated inattentive and/or impulsive behaviours, aligned with attention deficit hyperactivity disorder (ADHD) symptoms. These symptoms have been found to influence the child's responsiveness to their stuttering treatment, and may exacerbate the psychosocial consequences of stuttering for them and their families. Early stuttering intervention identifies parents as key agents of change in the management of their children's stuttering. This study sought feedback from parents regarding their experiences with an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering, addressing the child's self-regulation challenges.

METHOD

Eight parents of children who stutter who had co-occurring self-regulation challenges completed the integrated program. This incorporated the Triple P--Positive Parenting Program adapted for the developmental stuttering population, and the Curtin University Stuttering Program (CUSP). Semi-structured qualitative interviews were conducted to capture parents' reflections on, and experiences with, the integrated program.

RESULTS

Thematic analysis identified several major themes regarding the parents' experiences with the integrated program: emotional impact on parents, child self-regulation, link between stuttering and behaviour, parent self-regulation, impact on family dynamics, and overall positive perceptions of the integrated program. All of the parents indicated they would recommend the program to future parents of children who stutter.

CONCLUSION

This study provides insights into parents' perceptions regarding an integrated intervention approach for early stuttering and behavior management. It also indicates how adopting a holistic approach to stuttering intervention is positive and has social validity.

Sympathetic Nervous System Activity in Preschoolers Who Stutter

BACKGROUND

In our Dynamic Pathways, account, we hypothesized that childhood stuttering reflects an impairment in speech sensorimotor control that is conditioned by cognitive, linguistic, and emotional factors. The purpose of this study was to investigate potential differences in levels of sympathetic arousal during performance of speech and non-speech tasks between children who do and do not stutter.

METHODS

Seventy-two preschool-aged children participated in the study, 47 children who stutter (CWS; 38 boys) and 25 children who do not stutter (CWNS; 18 boys). We recorded skin conductance and blood pulse volume (BPV) signals, indices of sympathetic arousal, during higher/lower load speech tasks (structured sentence production and picture description) and non-speech tasks (jaw wagging and forceful blowing). We included a measure that reflects children's attitudes about their communication skills and a parent-report assessment of temperament.

RESULTS

We found no significant differences between preschool CWS and CWNS in phasic skin conductance response amplitude or frequency, BPV, and pulse rate for any of the experimental tasks. However, compared to CWNS, CWS had, on average, significantly higher skin conductance levels (SCL), indexing slowly changing tonic sympathetic activity, across both speech and non-speech experimental conditions. We found distinctive task-related profiles of sympathetic arousal in both groups of preschool children. Most children produced the highest levels of sympathetic arousal in the physically demanding blowing task rather than in speech, as seen in previous studies of adults. We did not find differences in temperament between the two groups of preschool children nor a relationship among behavioral indices of temperament and communication attitude and physiological measures of sympathetic arousal.

CONCLUSION

We did not find that atypically high, speech-related sympathetic arousal is a significant factor in early childhood stuttering. Rather, CWS had higher, on average, task-related tonic SCLs across speech and non-speech tasks. A relationship among behavioral measures of temperament and physiological measures of sympathetic arousal was not confirmed. Key questions for future experiments are how the typical coupling of sympathetic and speech sensorimotor systems develops over childhood and adolescence and whether task related developmental profiles follow a different course in children who continue to stutter.

Temperament, Executive Functioning, and Anxiety in School-Age Children Who Stutter

The purpose of this study was to examine temperament dimensions, executive functioning ability, and anxiety levels in school-age children who stutter and their non-stuttering peers. Participants were 100 Portuguese children aged 7 to 12 years (M = 9.13; SD = 1.70), including 50 children who stutter and 50 children who do not stutter. Analyses, which were performed separately for younger and older participants, sought to identify correlations between key variables. Temperament was evaluated through a parent questionnaire, executive functioning was evaluated through children’s responses on a performance test, and anxiety level was assessed through a self-perception scale. On the temperament measure, comparisons between children who stutter and their non-stuttering peers revealed that older children who stutter exhibited significantly higher scores on the Anger/Frustration, Impulsivity, and Sadness subscales, and lower averages on the Attention/Focusing, Perceptual sensitivity, and Soothability/Falling Reactivity subscales. On the executive functioning task, comparisons revealed that the group of younger children who stutter exhibited significantly higher average execution times than their non-stuttering peers. There were no statistically significant differences in anxiety between children who stutter and children who do not stutter, and there were no statistically significant correlations between temperament factors and measures of executive functioning. Children who stutter experienced lower ability to orient attention and greater emotional reactivity compared with their non-stuttering peers. Significant correlations were found between executive functioning and age and among the temperament factors themselves. These results, which support the need for a multidimensional view of stuttering, were interpreted in the context of the Dual Diathesis – Stressor model. Findings indicate that temperament and executive functioning abilities may contribute to the development of stuttering.

Differences in the relation between temperament and vocabulary based on children's stuttering trajectories

PURPOSE

The purpose of this study was to assess the relation between temperament and vocabulary development for children who stutter and persist, children who stutter and recover and children who do not stutter.

METHODS

Participants, aged 3;0-4;11 at the start of the study, were followed for two years. They were classified as persisting (n = 10), recovered (n = 26), and non-stuttering (n = 24) based on multiple assessments of stuttering spaced across study participation. Groups were balanced for age and gender ratios. At each visit, participants completed the Peabody Picture Vocabulary Test, 4th edition, and the Expressive Vocabulary Test, 2nd edition; caregivers completed the Children's Behavior Questionnaire.

RESULTS

For both persisting and recovered groups, higher negative emotionality was associated with lower receptive vocabulary. These associations were both significantly more negative than the non-stuttering group's association.

CONCLUSION

These findings suggest that receptive vocabulary development is differentially linked to temperament based on a child's stuttering status. As others have speculated (Conture & Walden, 2012), it appears as though there are salient associations between temperament, speech-language development, and childhood stuttering.

Cognitive flexibility in preschool children with and without stuttering disorders

PURPOSE

Multifactorial explanations of developmental stuttering suggest that difficulties in self-regulation and weak attentional flexibility contribute to persisting stuttering. We tested this prediction by examining whether preschool-age children who stutter (CWS) shift their attention less flexibly than children who do not stutter (CWNS) during a modified version of the Dimension Card Change Sort (DCCS), a reliable measure of attention switching for young children.

METHODS

Sixteen CWS (12 males) and 30 children CWNS (11 males) participated in the study. Groups were matched on age (CWS: M=49.63, SD=10.34, range=38-80months; CWNS: M=50.63, SD=9.82, range=37-74months), cognitive ability, and language skills. All children completed a computer-based variation of the DCCS, in which they matched on-screen bivalent stimuli to response buttons based on rules that switched mid-task.

RESULTS

Results showed increased slowing for CWS compared to controls during the postswitch phase, as well as contrasting patterns of speed-accuracy tradeoff for CWS and CWNS as they moved from the preswitch to postswitch phase of the task.

CONCLUSIONS

Group differences in performance suggest that early stuttering may be associated with difficulty shifting attention efficiently and greater concern about errors. Findings are consistent with a growing literature indicating links between weak attentional control and persisting developmental stuttering.

What Are Predictors for Persistence in Childhood Stuttering?

Over the past 10 years, we (the Purdue Stuttering Project) have implemented longitudinal studies to examine factors related to persistence and recovery in early childhood stuttering. Stuttering develops essentially as an impairment in speech sensorimotor processes that is strongly influenced by dynamic interactions among motor, language, and emotional domains. Our work has assessed physiological, behavioral, and clinical features of stuttering within the motor, linguistic, and emotional domains. We describe the results of studies in which measures collected when the child was 4 to 5 years old are related to eventual stuttering status. We provide supplemental evidence of the role of known predictive factors (e.g., sex and family history of persistent stuttering). In addition, we present new evidence that early delays in basic speech motor processes (especially in boys), poor performance on a nonword repetition test, stuttering severity at the age of 4 to 5 years, and delayed or atypical functioning in central nervous system language processing networks are predictive of persistent stuttering.

The effect of emotion on articulation rate in persistence and recovery of childhood stuttering

PURPOSE

This study investigated the possible association of emotional processes and articulation rate in pre-school age children who stutter and persist (persisting), children who stutter and recover (recovered) and children who do not stutter (nonstuttering).

METHODS

The participants were ten persisting, ten recovered, and ten nonstuttering children between the ages of 3-5 years; who were classified as persisting, recovered, or nonstuttering approximately 2-2.5 years after the experimental testing took place. The children were exposed to three emotionally-arousing video clips (baseline, positive and negative) and produced a narrative based on a text-free storybook following each video clip. From the audio-recordings of these narratives, individual utterances were transcribed and articulation rates were calculated.

RESULTS

Results indicated that persisting children exhibited significantly slower articulation rates following the negative emotion condition, unlike recovered and nonstuttering children whose articulation rates were not affected by either of the two emotion-inducing conditions. Moreover, all stuttering children displayed faster rates during fluent compared to stuttered speech; however, the recovered children were significantly faster than the persisting children during fluent speech.

CONCLUSION

Negative emotion plays a detrimental role on the speech-motor control processes of children who persist, whereas children who eventually recover seem to exhibit a relatively more stable and mature speech-motor system. This suggests that complex interactions between speech-motor and emotional processes are at play in stuttering recovery and persistency; and articulation rates following negative emotion or during stuttered versus fluent speech might be considered as potential factors to prospectively predict persistence and recovery from stuttering.

Executive function and childhood stuttering: Parent ratings and evidence from a behavioral task

PURPOSE

The purpose of this study was to examine the executive function (EF) abilities of preschool children who do (CWS) and do not stutter (CWNS) using a parent-report questionnaire and a behavioral task.

METHOD

Participants were 75 CWS and 75 CWNS between the ages of 3;0 and 5;11 (years; months). Parents rated their children's EF abilities using the Behavioral Rating Inventory of Executive Function-Preschool Version (BRIEF-P; Gioia, Espy, & Isquith, 2003). Children's ability to integrate cognitive flexibility, inhibitory control, and working memory was measured using a behavioral task, the Head-Toes-Knees-Shoulders (HTKS; Cameron Ponitz, McClelland, Matthews, & Morrison, 2009).

RESULTS

The CWS were judged by their parents as being less proficient in working memory, shift/flexibility, and overall EF than the parents of the CWNS. Children in the CWS group were also 2½ to 7 times more likely than children in the CWNS group to exhibit clinically significant difficulties with EF. Behavioral task findings revealed that 3-year old CWS performed more poorly than their peers on the HTKS. Parental ratings of executive function and working memory were significantly and moderately correlated with receptive and expressive vocabulary skills only for the CWNS group.

CONCLUSION

CWS have more difficulty with EF in everyday life and may experience early delays in their ability to integrate aspects of attention and EF compared to CWNS.

Auditory Attentional Set-Shifting and Inhibition in Children Who Stutter

PURPOSE

The purpose of this study was to investigate whether previously reported parental questionnaire-based differences in attentional shifting and inhibitory control (AS and IC; Eggers, De Nil, & Van den Bergh, 2010) would be supported by direct measurement of AS and IC using a computer task.

METHOD

Participants were 16 Finnish children who stutter (CWS; mean age = 7.06 years) and 16 Finnish children who do not stutter (mean age = 7.05 years). Participants were matched on age (±8 months) and gender. AS and IC were assessed by the auditory set-shifting task of the Amsterdam Neuropsychological Tasks (De Sonneville, 2009).

RESULTS

No group differences were found for the speed of auditory AS or IC. However, CWS, as a group, scored significantly lower on the accuracy (error percentage) of auditory AS. In addition, CWS, compared with the children who do not stutter, showed a higher increase in error percentages under AS and IC conditions.

CONCLUSIONS

The findings on error percentages partly corroborate earlier questionnaire-based findings showing difficulties in CWS on AS and IC. Moreover, it also seems to imply that CWS are less able to slow down their responses to achieve higher accuracy rates.

Developmental Stuttering in Children Who Are Hard of Hearing

Purpose

A number of studies with large sample sizes have reported lower prevalence of stuttering in children with significant hearing loss compared to children without hearing loss. This study used a parent questionnaire to investigate the characteristics of stuttering (e.g., incidence, prevalence, and age of onset) in children who are hard of hearing (CHH).

Method

Three hundred three parents of CHH who participated in the Outcomes of Children With Hearing Loss study (Moeller & Tomblin, 2015) were sent questionnaires asking about their child's history of stuttering.

Results

One hundred ninety-four parents of CHH responded to the survey. Thirty-three CHH were reported to have stuttered at one point in time (an incidence of 17.01%), and 10 children were still stuttering at the time of survey submission (a prevalence of 5.15%). Compared to estimates in the general population, this sample displayed a significantly higher incidence and prevalence. The age of onset, recovery rate, and other characteristics were similar to hearing children.

Conclusions

Based on this sample, mild to moderately severe hearing loss does not appear to be a protective factor for stuttering in the preschool years. In fact, the incidence and prevalence of stuttering may be higher in this population compared to the general population. Despite the significant speech and language needs that children with mild to moderately severe hearing loss may have, speech-language pathologists should appropriately prioritize stuttering treatment as they would in the hearing population.

Supplemental Material

https://doi.org/10.23641/asha.5397154.

How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

Purpose

We advanced a multifactorial, dynamic account of the complex, nonlinear interactions of motor, linguistic, and emotional factors contributing to the development of stuttering. Our purpose here is to update our account as the multifactorial dynamic pathways theory.

Method

We review evidence related to how stuttering develops, including genetic/epigenetic factors; motor, linguistic, and emotional features; and advances in neuroimaging studies. We update evidence for our earlier claim: Although stuttering ultimately reflects impairment in speech sensorimotor processes, its course over the life span is strongly conditioned by linguistic and emotional factors.

Results

Our current account places primary emphasis on the dynamic developmental context in which stuttering emerges and follows its course during the preschool years. Rapid changes in many neurobehavioral systems are ongoing, and critical interactions among these systems likely play a major role in determining persistence of or recovery from stuttering.

Conclusion

Stuttering, or childhood onset fluency disorder (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; American Psychiatric Association [APA], 2013), is a neurodevelopmental disorder that begins when neural networks supporting speech, language, and emotional functions are rapidly developing. The multifactorial dynamic pathways theory motivates experimental and clinical work to determine the specific factors that contribute to each child's pathway to the diagnosis of stuttering and those most likely to promote recovery.

Executive Functions Impact the Relation Between Respiratory Sinus Arrhythmia and Frequency of Stuttering in Young Children Who Do and Do Not Stutter

Purpose

This study sought to determine whether respiratory sinus arrhythmia (RSA) and executive functions are associated with stuttered speech disfluencies of young children who do (CWS) and do not stutter (CWNS).

Method

Thirty-six young CWS and 36 CWNS were exposed to neutral, negative, and positive emotion-inducing video clips, followed by their participation in speaking tasks. During the neutral video, we measured baseline RSA, a physiological index of emotion regulation, and during video viewing and speaking, we measured RSA change from baseline, a physiological index of regulatory responses during challenge. Participants' caregivers completed the Children's Behavior Questionnaire from which a composite score of the inhibitory control and attentional focusing subscales served to index executive functioning.

Results

For both CWS and CWNS, greater decrease of RSA during both video viewing and speaking was associated with more stuttering. During speaking, CWS with lower executive functioning exhibited a negative association between RSA change and stuttering; conversely, CWNS with higher executive functioning exhibited a negative association between RSA change and stuttering.

Conclusion

Findings suggest that decreased RSA during video viewing and speaking is associated with increased stuttering and young CWS differ from CWNS in terms of how their executive functions moderate the relation between RSA change and stuttered disfluencies.

Temperament and Early Stuttering Development: Cross-Sectional Findings From a Community Cohort

PURPOSE

The purpose of this study was to ascertain if there is an association between stuttering severity and behaviors and the expression of temperament characteristics, including precursors of anxiety.

METHOD

We studied temperament characteristics of a prospectively recruited community cohort of children who stutter (N = 173) at ages 3, 4, and 6 years using the Short Temperament Scale STS (Prior, Sanson, Smart & Oberklaid, 2000).

RESULTS

Six of 131 statistical tests of association between stuttering severity and behaviors and temperament traits were statistically significant at the 5% level, which was no more than expected by chance alone.

CONCLUSIONS

On the basis of parent responses to the STS, preschoolers who exhibited different levels of stuttering severity and behaviors did not generally express temperament traits differently from one another. Stuttering severity and stuttering behaviors were not associated with the precursors of anxiety. Overall, taking multiple tests into consideration, results show little evidence of association between stuttering severity and temperament up to 4 years of age or between stuttering behaviors and temperament up to 6 years of age.

Evidence-Based Multifactorial Assessment of Preschool-Age Children Who Stutter

This review summarizes extant findings supporting multifactorial models of stuttering within the context of preschool-age stuttering assessment. Evidence is given for a number of speech-language and associated factors/domains to consider when evaluating young children who stutter. Selected factors are presented in two parts: (1) Caregiver Interview and (2) Direct Child Assessment. Factors addressed during caregiver interviews include: gender, time since and age at stuttering onset, family history of stuttering, caregivers' perception/concerns about stuttering, and temperament. Factors addressed during direct child assessments include: stuttering behaviors, speech-associated attitudes/awareness, and speech rate, as well as speech sound and language development. Interactions/relations among factors are noted, showing their combined effects and contributions to childhood stuttering. Additionally, suggested clinical applications are provided wherever appropriate. Such evidence and practical applications bridge the gap between theory and clinical practice, thus advancing the abilities of speech-language pathologists to conduct well-informed, comprehensive stuttering evaluations.

Self-perceived competence and social acceptance of young children who stutter: Initial findings

PURPOSE

The goals of this study were to determine whether young children who stutter (CWS) perceive their own competence and social acceptance differently than young children who do not stutter (CWNS), and to identify the predictors of perceived competence and social acceptance in young speakers.

METHOD

We administered the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (PSPCSA; Harter & Pike, 1984) to 13 CWS and 14 CWNS and examined group differences. We also collected information on the children's genders, temperaments, stuttering frequencies, language abilities, and phonological skills to identify which of these factors predicted PSPCSA scores.

RESULTS

CWS, as a group, did not differ from CWNS in their perceived general competence or social acceptance. Gender predicted scores of perceived general competence, and stuttering frequency predicted perceived social acceptance. Temperament, language abilities, and phonological skills were not significant predictors of perceived competence or social acceptance in our sample.

CONCLUSIONS

While CWS did not significantly differ from CWNS in terms of perceived competence and social acceptance, when both talker groups were considered together, girls self-reported greater perceived competence than boys. Further, lower stuttering frequency was associated with greater perceived social acceptance. These preliminary findings provide motivation for further empirical study of the psychosocial components of childhood stuttering.

LEARNING OUTCOMES

Readers will be able to describe the constructs of perceived competence and social acceptance in young children, and whether early stuttering plays a role in the development of these constructs.

Childhood Stuttering: Where Are We and Where Are We Going?

Remarkable progress has been made over the past two decades in expanding our understanding of the behavioral, peripheral physiologic, and central neurophysiologic bases of stuttering in early childhood. It is clear that stuttering is a neurodevelopmental disorder characterized by atypical development of speech motor planning and execution networks. The speech motor system must interact in complex ways with neural systems mediating language and other cognitive and emotional processes. During the time when stuttering typically appears and follows its path to either recovery or persistence, all of these neurobehavioral systems are undergoing rapid and dramatic developmental changes. We summarize our current understanding of the various developmental trajectories relevant for the understanding of stuttering in early childhood. We also present theoretical and experimental approaches that we believe will be optimal for even more rapid progress toward developing better and more targeted treatment for stuttering in the preschool children who are more likely to persist in stuttering.

Emotional Diathesis, Emotional Stress, and Childhood Stuttering

PURPOSE

The purpose of this study was to determine (a) whether emotional reactivity and emotional stress of children who stutter (CWS) are associated with their stuttering frequency, (b) when the relationship between emotional reactivity and stuttering frequency is more likely to exist, and (c) how these associations are mediated by a 3rd variable (e.g., sympathetic arousal).

METHOD

Participants were 47 young CWS (M age = 50.69 months, SD = 10.34). Measurement of participants' emotional reactivity was based on parental report, and emotional stress was engendered by viewing baseline, positive, and negative emotion-inducing video clips, with stuttered disfluencies and sympathetic arousal (indexed by tonic skin conductance level) measured during a narrative after viewing each of the various video clips.

RESULTS

CWS's positive emotional reactivity was positively associated with percentage of their stuttered disfluencies regardless of emotional stress condition. CWS's negative emotional reactivity was more positively correlated with percentage of stuttered disfluencies during a narrative after a positive, compared with baseline, emotional stress condition. CWS's sympathetic arousal did not appear to mediate the effect of emotional reactivity, emotional stress condition, and their interaction on percentage of stuttered disfluencies, at least during this experimental narrative task following emotion-inducing video clips.

CONCLUSIONS

Results were taken to suggest an association between young CWS's positive emotional reactivity and stuttering, with negative reactivity seemingly more associated with these children's stuttering during positive emotional stress (a stress condition possibly associated with lesser degrees of emotion regulation). Such findings seem to support the notion that emotional processes warrant inclusion in any truly comprehensive account of childhood stuttering.

Autonomic nervous system activity of preschool-age children who stutter

PURPOSE

The purpose of this study was to investigate potential differences in autonomic nervous system (ANS) activity to emotional stimuli between preschool-age children who do (CWS) and do not stutter (CWNS).

METHODS

Participants were 20 preschool-age CWS (15 male) and 21 preschool-age CWNS (11 male). Participants were exposed to two emotion-inducing video clips (negative and positive) with neutral clips used to establish pre-and post-arousal baselines, and followed by age-appropriate speaking tasks. Respiratory sinus arrhythmia (RSA)-often used as an index of parasympathetic activity-and skin conductance level (SCL)-often used as an index of sympathetic activity-were measured while participants listened to/watched the audio-video clip presentation and performed a speaking task.

RESULTS

CWS, compared to CWNS, displayed lower amplitude RSA at baseline and higher SCL during a speaking task following the positive, compared to the negative, condition. During speaking, only CWS had a significant positive relation between RSA and SCL.

CONCLUSION

Present findings suggest that preschool-age CWS, when compared to their normally fluent peers, have a physiological state that is characterized by a greater vulnerability to emotional reactivity (i.e., lower RSA indexing less parasympathetic tone) and a greater mobilization of resources in support of emotional reactivity (i.e., higher SCL indexing more sympathetic activity) during positive conditions. Thus, while reducing stuttering to a pure physiological process is unwarranted, the present findings suggest that the autonomic nervous system is involved.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) summarize current empirical evidence on the role of emotion in childhood stuttering; (b) describe physiological indexes of sympathetic and parasympathetic activity; (c) summarize how preschool-age children who stutter differ from preschool-age children who do not stutter in autonomic activity; (d) discuss possible implications of current findings in relation to the development of childhood stuttering.