Attitudes of Malaysian Speech-Language Pathologists and Speech-Language Pathology Students Toward Stuttering.

INTRODUCTION: Attitudes of speech-language pathologists (SLPs) toward stuttering play an important role in managing stuttering cases. Yet, such studies had not been studied in Malaysia, a country that is still developing the profession of speech-language pathology. This study aimed to explore the attitudes of Malaysian SLPs and speech-language pathology students toward stuttering. METHODS: A total of 50 SLPs and 67 speech-language pathology students completed the Clinician Attitudes Towards Stuttering (CATS) inventory. There were eight domains of attitudes toward stuttering: (a) etiology, (b) early intervention, (c) therapeutic efficacy, (d) personalities of PWS, (e) clinician expertise and roles, (f) teacher/counsellor roles and client/public reactions, (g) therapy strategies, and (h) parent attitudes. Descriptive data were presented and Multivariate Analysis of Variance was conducted to examine the effects of clinical certification on the eight domains of attitudes toward stuttering. RESULTS: Participants who possessed a clinical certification were more accepting toward the personalities of people who stutter (PWS) and therapy strategies. On the other hand, participants without a clinical certification were more accepting toward clinician expertise and roles. CONCLUSIONS: Current curriculum and professional training should be re-evaluated to remediate less accepting stereotypes held by SLPs and students toward PWS and to enhance essential skills such as counselling.

Public attitudes toward stuttering in Malaysia.

PURPOSE: This study aims to: (a) measure public attitudes toward stuttering in Malaysia using the Public Opinion Survey of Human Attitudes-Stuttering [POSHA-S], (b) determine how reported attitudes and knowledge related to stuttering compare to existing data, and (c) determine whether there are differences between groups for identified variables. METHOD: A total of 250 adults (mean age = 29 years; range = 19-60 years) completed the POSHA-S in English. We compared this sample's attitudes toward stuttering to POSHA-S data from other global samples. General linear modeling examined differences in overall stuttering score, beliefs, and self reaction subscores for demographic variables such as age, gender, marital status, parenting, education, employment status, prior exposure to a person who stutters, multilingual, race, and religion. RESULTS: The Malaysian participants' overall stuttering score and the beliefs and self reactions subscores were all considerably lower (i.e., less positive) than the other samples around the world from the POSHA-S database median values. Being male, receiving a higher education, and knowing someone who stutters were linked to having more positive self reactions, but none of those factors was linked to positive or negative beliefs. Those who had previously been exposed to stuttering scored significantly higher than those who had not. CONCLUSION: Malaysians may have less positive attitudes toward stuttering than Westerners. More needs to be done to make society more accepting of people who stutter. Future research should aim to find ways to educate and to raise public awareness about stuttering.

The Complexity of Stuttering Behavior in Adults and Adolescents: Relationship to Age, Severity, Mental Health, Impact of Stuttering, and Behavioral Treatment Outcome.

PURPOSE: This study investigated the complexity of stuttering behavior. It described and classified the complexity of stuttering behavior in relation to age, behavioral treatment outcomes, stuttering severity, anxiety-related mental health, impact of stuttering, and gender. METHOD: For this study, a taxonomy was developed-LBDL-C7-which was based on the Lidcombe Behavioral Data Language of stuttering. It was used by five experienced judges to analyze the complexity of stuttering behavior for 84 adults and adolescents before and after speech restructuring treatment. Data were 3,100 stuttering moments, which were analyzed with nominal logistic regression. RESULTS: The complexity of stuttering behavior appears not to change as a result of treatment, but it does appear to change with advancing age. Complexity of stuttering behavior was found to be independently associated with clinician stuttering severity scores but not with percentage of syllables stuttered or self-reported stuttering severity. Complexity of stuttering behavior was not associated with gender, anxiety, or impact of stuttering. CONCLUSION: Clinical and research applications of these findings are discussed.

The Feasibility of the Functional Listening Index-Paediatric (FLI-P®) for Young Children with Hearing Loss.

(1) Background: There is clear evidence supporting the need for individualized early intervention in children with hearing loss. However, relying on hearing thresholds and speech and language test results to guide intervention alone is problematic, particularly in infants and young children. This study aimed to establish the feasibility of a tool to monitor the development of functional listening skills to inform early and ongoing decisions by parents and professionals. (2) Methods: The FLI-P® is a 64-item checklist completed by parents and/or a child's team. The listening development of 543 children with hearing loss enrolled in an early intervention and cochlear implant program was tracked with the FLI-P over a 6-year period. The scores for individual children were grouped according to hearing loss, device, additional needs, and age at device fitting. (3) Results: Results indicate that the FLI-P is a feasible and viable clinical measure that can be used to identify and track a child's developing listening skills. Its use across a wide range of children supports its broad application. Children's individual scores and aggregated group data were consistent with indicated expected differences and variations. Children's individual scores and aggregated group data indicated expected differences and variations. (4) Conclusions: Information provided by children's listening scores on the FLI-P can guide and support discussions and intervention decisions and bridge the gap between information from audiological assessments and language measures.

Psychological characteristics of early stuttering.

PURPOSE: The purpose of this study was to use psychological measures of pre-schoolers who stutter and their parents to inform causal theory development and influence clinical practices. This was done using data from a substantive clinical cohort of children who received early stuttering treatment. METHOD: The cohort (N = 427) comprised parents and their children who were treated with the Lidcombe Program, the Westmead Program, and the Oakville Program. The study incorporated demographic information, stuttering severity, and child and parent psychological measures prior to treatment. RESULT: The cohort revealed nothing unusual about behavioural and emotional functioning, or the temperaments, of pre-school children that would influence treatment, be targeted during treatment, or influence causal theory development. However, a third of parents were experiencing moderate to high life stressors at the time of seeking treatment, and half the parents failed first-stage screening for Anankastic Personality Disorder. CONCLUSION: The present results are consistent with a number of previous reports that showed that the population of pre-schoolers who stutter have no unusual psychological profiles. Hence, these results suggest that the association between mental health and stuttering later in life is a consequence of the disorder rather than being a part of its cause. The finding of the life stress of parents who seek stuttering treatment for pre-school children has potential clinical importance and warrants further investigation. Further psychological research is required about parents of pre-school children who stutter, because half the parents in the cohort failed the screener for Anankastic Personality Disorder. This is of interest because a previous study associated screening failure for another personality disorder (Impulsive Personality Disorder) with treatment dropout for early childhood stuttering.

Predictors of Lidcombe Program treatment dropout and outcome for early stuttering.

BACKGROUND: Information is available about what predicts Lidcombe Program treatment time, but nothing is known about what predicts treatment prognosis. AIMS: To investigate the predictors of treatment dropout and treatment outcome for children who were treated for early stuttering with the Lidcombe Program (N = 277). METHODS & PROCEDURES: A total of 32 variables were used as predictors in regression analyses of short- and medium-term Lidcombe Program outcome, and of treatment dropout. OUTCOMES & RESULTS: Regression analyses associated children who have better language skills and easy temperament with better treatment outcome, although only a small portion of the variance of treatment outcome was accounted for by these variables. There was an association between treatment dropout and parental scores on a personality screening tool relating to their impulsivity. CONCLUSIONS & IMPLICATIONS: Variables identified as predictors of Lidcombe Program treatment outcome were statistically significant, but not clinically significant. They did not account for a clinically substantive portion of treatment outcomes. Findings about parental impulsivity and their relationship with intervention drop-out require replication with prospective methods and comprehensive assessment of parent psychological status. This is particularly important because parents are involved in conducting all early interventions. What this paper adds What is already known on the subject Information is available about what predicts Lidcombe Program treatment time, but nothing is known about what predicts Lidcombe Program treatment outcome. What this paper adds to existing knowledge There are predictors of Lidcombe Program treatment outcome that are statistically significant, but none are clinically significant. What are the potential or actual clinical implications of this work? Clinicians can tell parents that nothing has been found that can assist with making prognostic indications about treatment outcome for their children.

Comparison of social anxiety between Japanese adults who stutter and non-stuttering controls.

PURPOSE: Adults who stutter (AWS) often develop social anxiety disorder. This study was to provide comparative data on the Liebowitz Social Anxiety Scale-Japanese version (LSAS-J) from AWS and non-stuttering adult controls. METHODS: LSAS-J, a 24-item self-reported survey of social phobia and avoidance across various daily situations, was administered to 130 AWS (Mean Age = 41.5 years, SD = 15.8, 111 males) and 114 non-stuttering adults (Mean Age = 39.5, SD = 14.9, 53 males). The test-retest reliability and internal consistency of the LSAS-J were assessed. A between-subject multivariate analysis of variance (MANOVA) was also conducted to determine whether attitude toward social anxiety differed between AWS and AWNS, or by age (<40 and ≥ 40 years old), or sex (female and male). RESULTS: AWS reported higher scores on both fear subscales of the LSAS-J. Age had no significant influence on the social anxiety levels reported by either participant group. Sex differences were found in the fear subscales, with females scoring higher on both fear subscales, although these were only marginally significant (p = .06). LSAS-J showed good test-retest reliability and high Cronbach's alpha coefficient, indicating that it is an internally consistent measure of attitudes about social anxiety. CONCLUSION: Given the similarly high incidence of social anxiety in adults in Japan who stutter compared with those in other countries, social anxiety should be identified and assessed during clinical decision making and before decisions are made about stuttering treatment. LSAS-J is an easy tool to administer, and showed reliable results of social phobia and avoidance for AWS.

Evidence for the treatment of co-occurring stuttering and speech sound disorder: A clinical case series.

PURPOSE: There is a paucity of evidence to guide treatment for children with co-occurring stuttering and speech sound disorder. Some guidelines suggest treating the two disorders simultaneously using indirect treatment approaches; however, the research supporting these recommendations is over 20 years old. In this clinical case series, we investigate whether these co-occurring disorders could be treated concurrently using direct treatment approaches supported by up-to-date, high-level evidence, and whether this could be done in an efficacious, safe and efficient manner. METHOD: Five pre-school-aged participants received individual concurrent, direct intervention for both stuttering and speech sound disorder. All participants used the Lidcombe Program, as manualised. Direct treatment for speech sound disorder was individualised based on analysis of each child's sound system. RESULT: At 12 months post commencement of treatment, all except one participant had completed the Lidcombe Program, and were less than 1.0% syllables stuttered on samples gathered within and beyond the clinic. These four participants completed Stage 1 of the Lidcombe Program in between 14 and 22 clinic visits, consistent with current benchmark data for this programme. At the same assessment point, all five participants exhibited significant increases in percentage of consonants correct and were in alignment with age-expected estimates of this measure. Further, they were treated in an average number of clinic visits that compares favourably with other research on treatment for speech sound disorder. CONCLUSION: These preliminary results indicate that young children with co-occurring stuttering and speech sound disorder may be treated concurrently using direct treatment approaches. This method of service delivery may have implications for cost and time efficiency and may also address the crucial need for early intervention in both disorders. These positive findings highlight the need for further research in the area and contribute to the limited evidence base.

Grey matter volume differences in the left caudate nucleus of people who stutter.

The cause of stuttering has many theoretical explanations. A number of research groups have suggested changes in the volume and/or function of the striatum as a causal agent. Two recent studies in children and one in adults who stutter (AWS) report differences in striatal volume compared that seen in controls; however, the laterality and nature of this anatomical volume difference is not consistent across studies. The current study investigated whether a reduction in striatal grey matter volume, comparable to that seen in children who stutter (CWS), would be found in AWS. Such a finding would support claims that an anatomical striatal anomaly plays a causal role in stuttering. We used voxel-based morphometry to examine the structure of the striatum in a group of AWS and compared it to that in a group of matched adult control subjects. Results showed a statistically significant group difference for the left caudate nucleus, with smaller mean volume in the group of AWS. The caudate nucleus, one of three main structures within the striatum, is thought to be critical for the planning and modulation of movement sequencing. The difference in striatal volume found here aligns with theoretical accounts of stuttering, which suggest it is a motor control disorder that arises from deficient articulatory movement selection and sequencing. Whilst the current study provides further evidence of a striatal volume difference in stuttering at the group level compared to controls, the significant overlap between AWS and controls suggests this difference is unlikely to be diagnostic of stuttering.

Assessment of Reliable Change Using 95% Credible Intervals for the Differences in Proportions: A Statistical Analysis for Case-Study Methodology.

PURPOSE: Case-study methodology studying change is often used in the field of speech-language pathology, but it can be criticized for not being statistically robust. Yet with the heterogeneous nature of many communication disorders, case studies allow clinicians and researchers to closely observe and report on change. Such information is valuable and can further inform large-scale experimental designs. In this research note, a statistical analysis for case-study data is outlined that employs a modification to the Reliable Change Index (Jacobson & Truax, 1991). The relationship between reliable change and clinical significance is discussed. Example data are used to guide the reader through the use and application of this analysis. METHOD: A method of analysis is detailed that is suitable for assessing change in measures with binary categorical outcomes. The analysis is illustrated using data from one individual, measured before and after treatment for stuttering. CONCLUSIONS: The application of this approach to assess change in categorical, binary data has potential application in speech-language pathology. It enables clinicians and researchers to analyze results from case studies for their statistical and clinical significance. This new method addresses a gap in the research design literature, that is, the lack of analysis methods for noncontinuous data (such as counts, rates, proportions of events) that may be used in case-study designs.

An investigation of the role of parental request for self-correction of stuttering in the Lidcombe Program.

PURPOSE: The Lidcombe Program is a behavioural treatment for stuttering in children younger than 6 years that is supported by evidence of efficacy and effectiveness. The treatment incorporates parent verbal contingencies for stutter-free speech and for stuttering. However, the contribution of those contingencies to reductions in stuttering in the program is unclear. METHOD: Thirty-four parent-child dyads were randomized to two treatment groups. The control group received standard Lidcombe Program and the experimental group received Lidcombe Program without instruction to parents to use the verbal contingency request for self-correction. Treatment responsiveness was measured as time to 50% stuttering severity reduction. RESULT: No differences were found between groups on primary outcome measures of the number of weeks and clinic visits to 50% reduction in stuttering severity. CONCLUSION: This clinical experiment challenges the assumption that the verbal contingency request for self-correction contributes to treatment efficacy. Results suggest the need for further research to explore this issue.

Lateralization of brain activation in fluent and non-fluent preschool children: a magnetoencephalographic study of picture-naming.

The neural causes of stuttering remain unknown. One explanation comes from neuroimaging studies that have reported abnormal lateralization of activation in the brains of people who stutter. However, these findings are generally based on data from adults with a long history of stuttering, raising the possibility that the observed lateralization anomalies are compensatory rather than causal. The current study investigated lateralization of brain activity in language-related regions of interest in young children soon after the onset of stuttering. We tested 24 preschool-aged children, half of whom had a positive diagnosis of stuttering. All children participated in a picture-naming experiment whilst their brain activity was recorded by magnetoencephalography. Source analysis performed during an epoch prior to speech onset was used to assess lateralized activation in three regions of interest. Activation was significantly lateralized to the left hemisphere in both groups and not different between groups. This study shows for the first time that significant speech preparatory brain activation can be identified in young children during picture-naming and supports the contention that, in stutterers, aberrant lateralization of brain function may be the result of neuroplastic adaptation that occurs as the condition becomes chronic.

Clinicians' management of young children with co-occurring stuttering and speech sound disorder.

Speech sound disorders reportedly co-occur in young children who stutter at a substantial rate. Despite this, there is a paucity of scientific research available to support a treatment approach when these disorders co-exist. Similarly, little is known about how clinicians are currently working with this caseload given that best practice for the treatment of both disorders in isolation has evolved in recent years. This study used a qualitative approach to explore current clinical management and rationales when working with children who have co-occurring stuttering and speech sound disorder. Thirteen participant SLPs engaged in semi-structured telephone interviews. Interview data were analysed based on principles derived from grounded theory. Several themes were identified including multi-faceted assessment, workplace challenges, weighing-up the evidence, and direct intervention. The core theme, clinical reasoning, highlighted the participants' main concern, that not enough is known about this caseload on which to base decisions about intervention. There was consensus that little is available in the research literature to guide decisions relating to service delivery. These findings highlight the need for further research to provide evidence-based guidelines for clinical practice with this caseload.

Reduced activation of left orbitofrontal cortex precedes blocked vocalization: a magnetoencephalographic study.

UNLABELLED: While stuttering is known to be characterized by anomalous brain activations during speech, very little data is available describing brain activations during stuttering. To our knowledge there are no reports describing brain activations that precede blocking. In this case report we present magnetoencephalographic data from a person who stutters who had significant instances of blocking whilst performing a vowel production task. This unique data set has allowed us to compare the brain activations leading up to a block with those leading up to successful production. Surprisingly, the results are very consistent with data comparing fluent production in stutterers to controls. We show here that preceding a block there is significantly less activation of the left orbitofrontal and inferiorfrontal cortices. Furthermore, there is significant extra activation in the right orbitofrontal and inferiorfrontal cortices, and the sensorimotor and auditory areas bilaterally. This data adds weight to the argument forwarded by Kell et al. (2009) that the best functional sign of optimal repair in stutterering is activation of the left BA 47/12 in the orbitofrontal cortex. EDUCATIONAL OBJECTIVES: At the end of this activity the reader will be able to (a) identify brain regions associated with blocked vocalization, (b) discuss the functions of the orbitofrontal and inferior frontal cortices in regard to speech production and (c) describe the usefulness and limitations of magnetoencephalography (MEG) in stuttering research.

Syllable-timed speech treatment for school-age children who stutter: a phase I trial.

PURPOSE: This clinical trial determined the outcomes of a simple syllable-timed speech (STS) treatment for school-age children who stutter. METHOD: Participants were 10 children, ages 6-11 years, who stutter. Treatment involved training the children and their parents to use STS at near normal speech rates. The technique was practiced in the clinic and at home with the parents during everyday conversations. RESULTS: Nine months after commencing treatment, stuttering had decreased by >50% for half of the children, with 2 children attaining 81% and 87% reduction. Intention-to-treat analysis showed a clinically and statistically significant reduction in stuttering for the group even when a withdrawn participant was included. These results were mostly confirmed by self-reported stuttering severity ratings and were supported by improved situation avoidance and quality-of-life scores. There was considerable individual variation in response to the treatment. CONCLUSION: STS shows promise as a treatment for some school-age children who stutter. As a fluency technique, it is simple to learn and simple to teach, and the children in this study appeared to enjoy the treatment. The efficacy of the treatment could likely be improved with modifications.

Evidence-based practice in speech-language pathology curricula: a scoping study.

This scoping study investigated how evidence-based practice (EBP) principles are taught in Australian speech-language pathology (SLP) teaching and learning contexts. It explored how Australian SLP university programs: (1) facilitate student learning about the principles of EBP in academic and clinical settings, and (2) self-evaluate their curricula in relation to EBP. The research involved two surveys. Survey 1 respondents were 131 academic staff, program coordinators, and on-campus and off-campus clinical educators. This survey gathered information about EBP teaching and learning in SLP programs as well as future EBP curriculum plans. Survey 2 investigated how clinical educators incorporated EBP into the way they taught clinical decision-making to students. Surveys responses from 85 clinical educators were analysed using descriptive and non-parametric statistics and thematic grouping of open-ended qualitative responses. Both surveys revealed strengths and gaps in integrating EBP into Australian SLP curricula. Perceived strengths were that respondents were positive about EBP, most had EBP training and access to EBP resources. The perceived gaps included the academic staff's perceptions of students' understanding and application of EBP, respondents' understanding of research methodologies, communication and collaboration between academic staff and clinical educators, and a lack of explicit discussion by clinical educators and students of EBP in relation to clients.

Mood and substance use disorders among adults seeking speech treatment for stuttering.

OBJECTIVES: Stuttering has been associated with a range of anxiety disorders, including social phobia. In the general community, anxiety disorders are frequently associated with increased rates of mood and substance use disorders. Therefore, in the present study, the authors sought to determine the rate of mood and substance use disorders among adults who stutter. METHOD: The study employed a matched case-control design. Participants included 92 adults seeking treatment for stuttering and 920 age- and gender-matched controls. Mental health assessments were conducted via a computerized psychiatric diagnostic interview. Conditional logistic regression models were used to estimate odds ratios for the prevalence of mood and substance use disorders in both groups. RESULTS: When compared with matched controls, adults seeking treatment for stuttering had twofold increased odds of meeting criteria for a 12-month diagnosis of any mood disorder but were not found to report significantly higher lifetime prevalence rates for any substance use disorder. CONCLUSIONS: Although adults who stutter in the present study were characterized by significantly higher rates of mood disorders than matched controls, they do not appear to self-medicate with substances such as alcohol. Results are discussed in terms of treatment implications and possible reasons why adults who stutter may avoid alcohol.

The five factor model of personality applied to adults who stutter.

UNLABELLED: Previous research has not explored the Five Factor Model of personality among adults who stutter. Therefore, the present study investigated the five personality domains of Neuroticism, Extraversion, Openness, Agreeableness and Conscientiousness, as measured by the NEO Five Factor Inventory (NEO-FFI), in a sample of 93 adults seeking speech treatment for stuttering, and compared these scores with normative data from an Australian and a United States sample. Results revealed that NEO-FFI scores for the stuttering group were within the 'average' range for all five personality domains. However, adults who stutter were characterized by significantly higher Neuroticism, and significantly lower Agreeableness and Conscientiousness, than normative samples. No significant differences were found between groups on the dimensions of Extraversion and Openness. These results are discussed with reference to the relationship between personality factors among adults who stutter, their directionality, and implications for predicting treatment outcome. LEARNING OUTCOMES: The reader will be able to: (1) describe the Five Factor Model of personality, including the NEO-FFI personality domains of Extraversion, Neuroticism, Openness, Agreeableness, and Conscientiousness, and (2) discuss differences in NEO-FFI domain scores between adults who stutter and normative samples, and (3) understand the clinical implications of personality profiles in terms of treatment process and outcome for adults who stutter.

Randomized controlled trial of video self-modeling following speech restructuring treatment for stuttering.

PURPOSE: In this study, the authors investigated the efficacy of video self-modeling (VSM) following speech restructuring treatment to improve the maintenance of treatment effects. METHOD: The design was an open-plan, parallel-group, randomized controlled trial. Participants were 89 adults and adolescents who undertook intensive speech restructuring treatment. Post treatment, participants were randomly assigned to 2 trial arms: standard maintenance and standard maintenance plus VSM. Participants in the latter arm viewed stutter-free videos of themselves each day for 1 month. RESULTS: The addition of VSM did not improve speech outcomes, as measured by percent syllables stuttered, at either 1 or 6 months postrandomization. However, at the latter assessment, self-rating of worst stuttering severity by the VSM group was 10% better than that of the control group, and satisfaction with speech fluency was 20% better. Quality of life was also better for the VSM group, which was mildly to moderately impaired compared with moderate impairment in the control group. CONCLUSIONS: VSM intervention after treatment was associated with improvements in self-reported outcomes. The clinical implications of this finding are discussed.

Screening for personality disorders among adults seeking speech treatment for stuttering.

UNLABELLED: Stuttering is frequently associated with negative consequences which typically begin in early childhood. Despite this, no previous studies have investigated the presence of personality disorders among adults who stutter. Therefore, the aims of the present study were to screen for personality disorders among adults who stutter, and to compare these screening estimates with matched controls from a national population sample. Using a matched case-control design, participants were 94 adults seeking treatment for stuttering, 92 of whom completed the International Personality Disorders Examination Questionnaire (IPDEQ) as a first-stage screener, and 920 age- and gender-matched controls from the Australian National Survey of Mental Health and Well-Being (ANSMHWB). A conditional logistic regression model was used to estimate odds ratios for the primary outcome: first-stage presence of any personality disorder; as well as specific personality disorders. Based on first-stage screening, the presence of any personality disorder was significantly higher for adults in the stuttering group than matched controls, demonstrating almost threefold increased odds. This difference between groups remained significant for all specific personality disorders, with four- to sevenfold increased odds found for Dissocial, Anxious, Borderline, Dependent and Paranoid personality disorders, and two- to threefold increased odds found for Histrionic, Impulsive, Schizoid and Anankastic personality disorders. In conclusion, stuttering appears to be associated with a heightened risk for the development of personality disorders. These results highlight the need for research regarding the assessment and treatment of personality disorders among adults who stutter. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) describe the nature of personality disorders, including factors thought to contribute to their development; (2) identify some of the negative consequences associated with stuttering which may contribute to the development of personality disorders among adults who stutter; (3) describe the process involved in screening for personality disorders, including various methods of scoring; and (4) summarize findings regarding the first-stage presence of personality disorders among adults seeking speech treatment for stuttering in the present sample in comparison with age- and gender-matched controls from a national population sample.