The Impact of Time Spent in Natural Outdoor Spaces on Children's Language, Communication and Social Skills: A Systematic Review Protocol.

There has been increasing interest over the past decade with regard to the health and wellbeing implications of time spent outdoors in nature for children. Universal systematic reviews of evidence report benefits to physical health, social-emotional mental health and wellbeing, cognition and academic learning. Internationally, there is indicative evidence to suggest outdoor engagement with nature may also impact children's language and communication skills, skills that are critical to development, education, social relationships and life opportunities. Yet, at present such evidence has not been synthesised. Despite evidence for the benefits of the outdoors, the amount of time children are spending outdoors is in rapid decline, and has been further exacerbated by the COVID-19 pandemic. Alongside this are increasing numbers of children starting primary education with significant speech, language and communication needs (SLCN) which remain persistent over time. With established wide-reaching benefits of nature to children's physical and mental health and psychological development, there is a need to further explore the more specific impacts of the natural environment on children's language, communication and social skills, which could provide a unique opportunity to consider nature as a universal public health intervention for SLCN. The current review will aim to synthesise existing qualitative and quantitative evidence of the impact of time spent in natural outdoor spaces on the language, communication and social skills of 2-11-year-old children. Literature will be searched across seven databases and considered for inclusion against inclusion and exclusion criteria. Potential implications of the review include informing public health practice and policy for child development and education, informing priorities for speech, language, and communication interventions, and providing directions for future international research.

Temperament, anxiety, and depression in school-age children who stutter.

PURPOSE: The main aim of this study was to gain insight into whether temperament and/or stuttering severity were associated with anxiety and depression in children who stutter. Additionally, the study also provided an indication into the prevalence of anxiety and depression in children who stutter in a clinical cohort. METHOD: The participants were 132 English-speaking children (105 boys and 27 girls) between 9;0 and 14;11 years old (M = 11;8, SD = 1;10) and their mothers. At their first visit to a specialist center for children who stutter, mothers and children completed the relevant versions of the Early Adolescent Temperament Questionnaire-Revised (EATQ-R; Ellis & Rothbart, 2001) and a screening of children's anxiety and depression, using the Revised Children's Anxiety and Depression Scale (RCADS; Chorpita et al., 2000). Stuttering was evaluated using the Stuttering Severity Instrument Fourth Edition (SSI-4). Correlations were conducted between child and parent versions of the EATQ-R and RCADS; EATQ-R and RCADS; as well as the SSI-4 and RCADS. A comparison was made between those children who scored below the clinical threshold for anxiety and depression, and those who scored above. RESULTS: Significant correlations were found for all mother and child EATQ-R factors and RCADS scales (except for Obsessive Compulsive Disorder). Correlations were also found between the child- and mother-reported temperament factors of positive reactivity, negative reactivity, and self-regulation and anxiety and depression. Children who scored above the clinical threshold for any category of anxiety or depression had significantly lower positive reactivity and higher negative reactivity scores, compared to those who scored below the threshold. There were no differences between the two groups with regard to SSI-4 scores. CONCLUSIONS: This is the first study to evaluate associations between temperament and anxiety and depression in children who stutter. Higher negative reactivity scores and lower positive reactivity and self-regulation scores are associated with elevated levels of anxiety and depression in children who stutter. Further, those who score above the clinical threshold have significantly higher levels of negative reactivity and lower levels of positive reactivity compared to those scoring below the threshold. Findings suggest that levels of anxiety that reach clinical threshold are more prevalent in children who stutter than would be expected based on population data. Current findings have implications for both the assessment and therapy of children who stutter presenting at clinics for support.

Palin parent-child interaction therapy with children with autism spectrum disorder and stuttering.

INTRODUCTION: It is estimated that 8% of children who stutter (CWS) have autism spectrum disorder (ASD) Briley & Ellis (2018). There is evidence that interventions for CWS and interventions for children with ASD can be effective, but there is little evidence to guide clinical decision making when working with CWS with a co-existing diagnosis of ASD. Palin Parent-Child Interaction (PCI) therapy Kelman & Nicholas (2020) is an evidence-based intervention for CWS, with the authors suggesting that the approach may be beneficial for CWS with ASD. The aim of this study was to examine outcomes for three CWS with ASD who received Palin PCI at a specialist centre for stuttering in London. METHOD: The participants were three CWS with ASD aged 4;5, 6;7 and 7;7. Assessments were administered before therapy, and then at three, six and twelve months after therapy began. Outcome measures included stuttering frequency, child's communication attitude, parents' perception of the impact of stuttering on the child, the severity of stuttering and its impact on the parents, and parents' knowledge and confidence in managing stuttering. RESULTS: All three children showed improvement in three or more variables. Four out of five parents reported reduced impact of stuttering on the child and themselves following therapy, and change was maintained one year post-therapy. All five parents reported increased knowledge of stuttering and confidence in managing it after therapy, and four parents maintained these changes for a year. CONCLUSIONS: Over a one year period, these CWS with ASD who received Palin PCI showed change across multiple variables. The observed increases in parent knowledge and confidence were comparable to previously published data. These preliminary findings suggest that CWS with ASD and their parents can benefit from Palin PCI therapy and that further experimental evaluation of this approach with this client group is indicated.

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.

Consensus Guidelines for the Assessments of Individuals Who Stutter Across the Lifespan.

Purpose This project sought to develop consensus guidelines for clinically meaningful, comprehensive assessment procedures for people who stutter across the lifespan. Method Twelve expert clinicians and researchers who have written extensively about stuttering provided detailed descriptions of the type of data that they routinely collect during diagnostic evaluations of preschool children, school-age children, adolescents, and adults who stutter. Iterative content analysis, with repeated input from the respondents, was used to identify core areas that reflect common domains that these experts judge to be important for evaluating stuttering for varying age groups. Results Six core areas were identified as common components of a comprehensive evaluation of stuttering and people who stutter. These areas should be included to varying degrees depending upon the age and needs of the client or family. The core areas include the following: (a) stuttering-related background information; (b) speech, language, and temperament development (especially for younger clients); (c) speech fluency and stuttering behaviors; (d) reactions to stuttering by the speaker; (e) reactions to stuttering by people in the speaker's environment; and (f) adverse impact caused by stuttering. Discussion These consensus recommendations can help speech-language pathologists who are uncertain about appropriate stuttering assessment procedures to design and conduct more thorough evaluations, so that they will be better prepared to provide individualized and comprehensive treatment for people who stutter across the lifespan.

Contemporary issues with stuttering: The Fourth Croatia Stuttering Symposium.

PURPOSE: During the 2019 Fourth Croatia Clinical Symposium, speech-language pathologists (SLPs), scholars, and researchers from 29 countries discussed speech-language pathology and psychological practices for the management of early and persistent stuttering. This paper documents what those at the Symposium considered to be the key contemporary clinical issues for early and persistent stuttering. METHODS: The authors prepared a written record of the discussion of Symposium topics, taking care to ensure that the content of the Symposium was faithfully reproduced in written form. RESULTS: Seven contemporary issues for our field emerged from the Symposium. CONCLUSION: Effective early intervention is fundamental to proper health care for the disorder. However, as yet, there is no consensus about the timing of early intervention and how it should be managed. Currently, clinical translation is a barrier to evidence-based practice with early stuttering, and proactive strategies were suggested for junior SLPs. Apprehension emerged among some discussants that treatment of early stuttering may cause anxiety. For persistent stuttering, assessment procedures were recommended, as were strategies for dealing with childhood bullying. There was agreement that SLPs are the ideal professionals to provide basic cognitive-behavior therapy for clients with persistent stuttering. Questions were raised about our discipline standards for basic professional preparation programs for stuttering management.

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.

Introduction to the Special Issue: The 11th Oxford Dysfluency Conference.

Purpose: The purpose of this introduction is to provide an overview of the articles in this special issue of AJSLP. These articles originated from the presentations at the 11th Oxford Dysfluency Conference in September 2017.

The Most Important Therapy Outcomes for School-Aged Children Who Stutter: An Exploratory Study.

Purpose: The aim of this article was to identify what school-aged children who stutter consider to be the most important outcomes from therapy. Method: A Delphi approach was employed for the study. Eighteen participants aged 9-13 years completed a survey, generating 90 statements that would constitute successful therapy outcomes. After categorization and reduction, 79 statements were sent to participants in a second survey to seek consensus on their importance. Fifteen participants aged 8-14 years completed this second survey. Statements with the highest median ratings and smallest standard deviations were retained. Results: Twenty-one statements were retained after analysis. These reflected hopes for affective and behavioral change in the young person and in other people after therapy. Important outcomes included, but are not limited to, increased fluency, greater independence, increased confidence at school, others knowing how to support the individual, and communication situations feeling easier. Conclusions: Participants identified a range of outcomes that were important to achieve as a result of speech and language therapy. The findings suggest a need for a more holistic view of what is meant by successful therapy, incorporating improvements in the ability to communicate and participate in daily situations. The findings suggest that an integrated or holistic approach to intervention would be required to achieve these goals and should include significant others from the child's environment. The important statements identified in this study could be used to inform the content of therapy and to evaluate change over time. Supplemental Material: https://doi.org/10.23641/asha.7144205.

Palin Parent-Child Interaction Therapy: The Bigger Picture.

Purpose: Palin Parent-Child Interaction therapy (Kelman & Nicholas, 2008) is an evidence-based intervention for young children who stutter. The evidence consists of multiple single-subject replicated studies, and this demonstrates that the intervention is effective. The aim of this study was to enhance the evidence base by exploring the effectiveness of the therapy with a large cohort of children who stutter. Method: Children and parents completed a range of assessments at 4 time points: start of therapy and then 3, 6, and 12 months later. The following variables were included: stuttering frequency, child's communication attitude, parents' perception of the impact of the stuttering on the child, the severity of stuttering and its impact on the parents, and their knowledge of stuttering and confidence in managing it. Hierarchical multiple regression analyses were conducted to explore whether the variables are predictive for the outcome "parent knowledge and confidence." In addition, we sought a preliminary view of factors associated with outcome level by separating children into 2 groups according to response to treatment (more successful and less successful). Results: The results demonstrated a significant improvement in all variables, and this improvement was maintained for 1 year posttreatment. Measures collected 3 months after the start of therapy showed significant improvement in child attitude to communication, parents' knowledge and confidence in how to manage stuttering, and mothers' ratings of stuttering severity and impact the child's stuttering has on the mothers. By 6 months after therapy onset, there was a significant reduction in stuttering frequency and fathers' perception of severity and their worry about it. Furthermore, these improvements were maintained 1 year posttherapy. Several variables predicted parents' knowledge and confidence 6 months after the start of therapy. Finally, those who made greater improvements had mothers who were more negative in their ratings of severity and worry, and had less knowledge and confidence at the start of therapy. There were no differences between the groups on a range of other variables. Conclusions: The results demonstrate that, over a year, children who attend a course of Palin Parent-Child Interaction show reduced stuttering frequency and a more positive attitude to speech. In addition, parents observe these improvements in the child, feel more confident in managing the stuttering, and are less worried about it. The different times at which specific variables significantly improved provides insight to a process of change over time. Results suggest that parents' ability to notice positive change in fluency and the impact that these observations have on both the child and the family are linked to their confidence in how to support the child. The preliminary findings with regard to response to treatment suggest that children can benefit from this program even with factors that might be predicted to reduce therapy success.

The Palin Parent Rating Scales: Parents' Perspectives of Childhood Stuttering and Its Impact.

Purpose: The goal of this study is to explore the psychometric properties of the Parent Rating Scales-V1 (S. K. Millard, S. Edwards, & F. M. Cook, 2009), an assessment tool for parents of children who stutter, and to refine the measure accordingly. Method: We included 259 scales completed prior to therapy. An exploratory factor analysis determined the test constructs and identified the items that had greatest loadings on those factors. Items that did not load on the factors were removed, and normative scores calculated. Results: The resulting 19-item questionnaire measures three factors: (a) the impact of stuttering on the child; (b) the severity of stuttering and its impact on the parents; and (c) the parents' knowledge about stuttering and confidence in managing it. Reliability was demonstrated, norms established, and an automated online version constructed. Conclusions: The Palin Parent Rating Scale is a valid and reliable tool, providing a method of exploring parents' perceptions of stuttering, the impact it has on the child and themselves, and the parents' knowledge of and confidence in managing the stuttering. This is an important addition to the existing range of assessments that may be used to evaluate stuttering in children up to age 14;6 (years;months) and allows the wider targets of parent-led therapy programs to be evaluated.

Effectiveness of intensive, group therapy for teenagers who stutter.

BACKGROUND: Treatment of adolescents who stutter is an under-researched area that would benefit from greater attention. AIMS: To investigate whether an intensive treatment programme for older teenagers who stutter, aged over 16 years of age, is effective in reducing overt and covert aspects of stuttering. METHODS & PROCEDURES: A repeated-measures, single-subject experimental design was replicated across participants. The study consisted of a 5-week baseline phase, 2-week intensive treatment phase, 5-week consolidation phase and 10-month follow-up phase. Participants were asked to make ten video recordings at home during each phase, while completing a reading and a conversation task. Recordings were analysed in terms of the percentage of stuttered syllables using a simplified time-series analysis. Participants completed self-report questionnaires at predetermined times throughout the study. Data are presented for three males aged 17;7, 17;11 and 18;10. OUTCOMES & RESULTS: One participant completed all required recordings. Difficulties were encountered collecting follow-up data with the other two participants and data are available up to 5 months after the intensive therapy phase. A significant trend of reduced frequency of stuttering was found for all three participants during the intensive therapy phase. This trend continued throughout the consolidation phase and remained significant when available longer-term data were included in the analysis. Participants also reported increased self-efficacy about speaking and reduced overt and covert aspects of stammering. CONCLUSIONS & IMPLICATIONS: Findings show that this therapy programme for teenagers had a significant treatment effect for the participants studied in the short- and medium-term, however longer-term data were not available for all participants. Issues in conducting research with this client group are discussed.

Palin Parent Child Interaction and the Lidcombe Program: clarifying some issues.

PURPOSE: The authors used the "1000-bites" format (Onslow & Yaruss, 2007) to discuss two therapies used with preschool children who stutter: Palin Parent Child Interaction and the Lidcombe Program. The aim is to provide background to the therapies and to explore the differences and similarities between the approaches and research plans for them. METHOD: The format is designed to give the reader the feeling of contemporaneous observation of conversation between the authors. To that end, the format guidelines are as follows: (1) alternating responses from two authors with no response greater than 100 words, (2) a maximum of 1000 words per author, (3) when one author has used 1000 words the other may complete 1000 words in a final response or opt to not issue a final response, (4) debate may be controversial and vigorous but must be collegial, and (5) a non-contemporaneous edit by an author to a response requires the agreement of the other author. CONCLUSIONS: The "1000-bites" format achieved a collegial exchange between two discussants with differing opinions by creating a single work of shared authorship. Arguably, this format is more informative to clinicians than independent essays and rebuttals in a sequence of letters to the editor. One of its advantages is that it provides insights into the issue at stake by means of short and contemporaneous segments of spontaneous interaction. EDUCATIONAL OBJECTIVES: At the end of this activity the reader will be able to (1) outline the different theoretical backgrounds of Palin Parent Child Interaction Therapy and the Lidcombe Program, (2) describe the different goals of the two treatments, (3) contrast the different methods for the two treatments, and (4) explain any commonalities between the two treatments.

The Stammering Information Programme: a Delphi study.

PURPOSE: To find out what information children, parents and education staff feel would be important to know to support a child who stutters in the educational environment, in order to develop appropriate resources. METHOD: A Delphi study was carried out to seek the opinions of experts about the information to include. A structured six stage process was completed in order to gain consensus within four expert panels: children who stutter (CWS) aged 7-11 (n=25); young people who stutter aged 12-18 (n=27); parents of children and young people who stutter aged 2-18 (n=67); and members of the education workforce (n=35). RESULTS: In response to the questions, 538 statements were generated across the four expert panels, categorised and reduced to 276. Of the 154 rating questionnaires sent out, 99 were returned (64.2% response rate). The top 32 statements, which were those most highly rated and with the greatest consensus, were retained to inform the resources. CONCLUSIONS: This study demonstrates the value of including service users when devising materials aimed for the benefit of CWS. The methodology employed ensured that ideas, perceptions and needs were representative of a range of people who experience stuttering from different perspectives. The results indicated that each expert panel had different priorities of what should be included. The resulting resources may therefore be considered to have high content validity and would be predicted to meet the needs of those who require them. EDUCATIONAL OBJECTIVES: The reader will be able to (1) define the Delphi Approach (2) discuss the development of a user led resource for raising awareness about stuttering.

Working with young children who stutter: raising our game.

Several therapy programs have been demonstrated to be effective in supporting the development of fluency in preschool children who stutter. However, there is increasing evidence in allied fields suggesting that a positive therapy outcome cannot be entirely attributed to the therapy program itself, but also depends on what the therapist brings to the therapeutic context. This article seeks to discuss the therapist's skills and attributes that play a part in the development of the therapeutic alliance, which underpins therapy involving parents of young children who stutter. Using a model of clinical expertise development, the article discusses the attributes and skills that are necessary for the development of expertise, along with the behavioral and cognitive changes that evolve as a therapist becomes increasingly expert at using one particular program, Palin Parent-Child Interaction Therapy.

Is parent-child interaction therapy effective in reducing stuttering?

PURPOSE: To investigate the efficacy of parent-child interaction therapy (PCIT) with young children who stutter. METHOD: This is a longitudinal, multiple single-subject study. The participants were 6 children aged 3;3-4;10 [years;months] who had been stuttering for longer than 12 months. Therapy consisted of 6 sessions of clinic-based therapy and 6 weeks of home consolidation. Speech samples were videorecorded during free play with parents at home and analyzed to obtain stuttering data for each child before therapy, during therapy, and up to 12 months posttherapy. RESULTS: Stuttering frequency data obtained during therapy and posttherapy were compared with the frequency and variability of stuttering in the baseline phase. Four of the 6 children significantly reduced stuttering with both parents by the end of the therapy phase. CONCLUSIONS: PCIT can reduce stuttering in preschool children with 6 sessions of clinic-based therapy and 6 weeks of parent-led, home-based therapy. The study highlights the individual response to therapy. Suggestions for future research directions are made.