Psychosocial features of stuttering for school-age children: A systematic review.

BACKGROUND: Contemporary clinical and empirical perspectives indicate that management of the psychosocial features of stuttering is fundamental for effective treatment. Interventions that improve psychosocial outcomes for school-age children who stutter are, therefore, needed. AIMS: This systematic review identifies what psychosocial outcomes have been explored in existing school-age clinical research, the measures used and the potential treatment effects. This will provide guidance for developing interventions that reflect contemporary perspectives of stuttering management. METHODS & PROCEDURES: A total of 14 databases and three conference proceedings were searched for clinical reports of psychosocial outcomes of children aged 6-12 years. The review did not include pharmacological interventions. Psychosocial measures and outcomes were analysed in each study based on data recorded pre-treatment, immediately post-treatment and for any follow-up assessments. MAIN CONTRIBUTIONS: Of the 4051 studies identified from the databases, a total of 22 studies met criteria for inclusion in the review. From these 22 studies, the review identified four prominent psychosocial domains that have been explored in school-age clinical research to date: Impact of stuttering, communication attitude, anxiety and speech satisfaction. These domains vary in measurement and effect sizes. Two behavioural treatments were associated with anxiety reduction, even though they did not contain anxiolytic procedures. No evidence of potential treatment effects emerged for communication attitudes. Quality of life-an important psychosocial domain pertinent to health economics-did not feature in school-age clinical reports. CONCLUSIONS & IMPLICATIONS: The psychosocial features of stuttering need to be managed during the school years. Three psychosocial domains-impact of stuttering, anxiety and speech satisfaction-show evidence of potential treatment effects. This review provides direction for future clinical research so that speech-language pathologists can effectively and holistically manage school-age children who stutter. WHAT THIS PAPER ADDS: What is already known on the subject Elevated levels of anxiety are apparent for children and adolescents who stutter. Therefore, the need to assess and manage psychosocial features of stuttering are expertly regarded as clinical priorities. Clinical trials of such psychosocial features of stuttering for children aged 6-12 years are not well advanced and, therefore, do not reflect current best practice management of this disorder. What this study adds to existing knowledge This systematic review identifies four different psychosocial domains measured and reported in the literature for school-age stuttering management. For three psychosocial domains, some evidence of potential treatment effects emerged with participant numbers greater than 10: Impact of stuttering, anxiety and speech satisfaction. Though treatment effect sizes varied, there is a suggestion that cognitive behaviour therapy can improve anxiety of school-age children who stutter. There is also suggestion that two other behavioural treatments can improve anxiety of school-age children who stutter. What are the potential or actual clinical implications of this work? Given the essential need for school-age children who stutter to receive management of any speech-related anxiety they may experience, it would be productive to discover in future clinical research what interventions could contribute to that goal-behavioural or psychosocial, or both. This review reveals that cognitive behaviour therapy, and other behavioural treatments, are associated with anxiety reductions. Such approaches should be considered for future clinical trial research to help advance the evidence base for managing school-age stuttering.

Lidcombe Program translation to community clinics in Australia and England.

BACKGROUND: Early intervention is essential healthcare for stuttering, and the translation of research findings to community settings is a potential roadblock to it. AIMS: This study was designed to replicate and extend the Lidcombe Program community translation findings of O'Brian et al. (2013) but with larger participant numbers, incorporating clinicians (speech pathologists/speech anlanguage therapists) and their clients from Australia and England. METHODS & PROCEDURES: Participants were 51 clinicians working in public and private clinics across Australia (n = 36) and England (n = 15), and 121 of their young stuttering clients and their families. Outcome measures were percentage of syllables stuttered (%SS), parent severity ratings at 9 months post-recruitment, number of clinic visits to complete Stage 1 of the Lidcombe Program, and therapist drift. OUTCOMES & RESULTS: Community clinicians in both countries achieved similar outcomes to those from randomized controlled trials. Therapist drift emerged as an issue with community translation. Speech and language therapists in England attained outcomes 1.0%SS above the speech pathologists in Australia, although their scores were within the range attained in randomized trials. CONCLUSIONS & IMPLICATIONS: Community clinicians from Australia and England can attain Lidcombe Program outcome benchmarks established in randomized trials. This finding is reassuring in light of the controlled conditions in clinical trials of the Lidcombe Program compared with its conduct in community practice. The long-term impact of therapist drift in community clinical practice with the Lidcombe Program has yet to be determined. WHAT THIS PAPER ADDS: What is already known on the subject The Lidcombe Program is an efficacious early stuttering intervention. Translation to clinical communities has been studied with one Australian cohort. What this paper adds to existing knowledge A larger translation cohort is studied, comprising community clinicians and children in Australia and England. What are the potential or actual clinical implications of this work? Community clinicians from Australia and England can attain Lidcombe Program outcome benchmarks established in randomized trials. This finding is reassuring in light of the controlled conditions in clinical trials of the Lidcombe Program compared with its conduct in community practice.

Searching for Lidcombe Program mechanisms of action: Inter-turn speaker latency.

The Lidcombe Program is a well-established and efficacious treatment for early stuttering, but little is currently known about its mechanisms of action. The present report explores the possibility that inter-turn speaker latency might be associated with such mechanisms of action. Inter-turn speaker latency was measured in audio recordings of children, parents, and clinicians conversing, taken during Lidcombe Program treatment consultations. Five clinicians reduced their inter-turn speaker latencies during clinical consultations when they were speaking to children, in comparison with when they were speaking to parents. It is possible that inter-turn speaker latency is associated with the Lidcombe Program treatment process vicariously, and this possibility requires further research.

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.

After the RESTART trial: six guidelines for clinical trials of early stuttering intervention.

BACKGROUND: The Rotterdam Evaluation Study of Stuttering Therapy randomized trial (RESTART) was seminal, comparing the Lidcombe Program with RESTART Demands and Capacities Model-based treatment (RESTART-DCM) for pre-school age children who stutter. AIMS: To critique the methods of the RESTART trial to develop guidelines for its systematic replication and extension. Beyond that, to contribute to the refinement of existing methodological guidelines for early stuttering intervention. METHOD: The discussion is organized around methodological issues of primary outcomes, treatment completion, clinician allegiance, treatment fidelity, age exclusions and no-treatment control reasoning. MAIN CONTRIBUTION: We recommend six methodological guidelines to guide future clinical trials comparing the Lidcombe Program with RESTART-DCM, which can be applied to clinical trials of other early stuttering intervention methods: (1) incorporate a continuous measure of primary outcome; (2) ensure that all children in clinical trials have completed treatment; (3) eliminate potential bias due to clinician allegiance; (4) establish treatment fidelity within and beyond the clinic; (5) include children younger than 3 years in clinical trials; and (6) establish an estimate of treatment effect size at some stage of treatment development. CONCLUSION: In addition to guiding future clinical research comparing RESTART-DCM and Lidcombe Program treatment, these recommendations may extend to influence positively other treatment developments for early stuttering.

Phase I trial of a standalone internet social anxiety treatment for adolescents who stutter: iBroadway.

BACKGROUND: iGlebe is a fully automated internet treatment program for adults who stutter that has been shown, in some cases, to reduce anxiety and effectively manage social anxiety disorder for many participants. No such automated internet treatment program exists for adolescents who stutter. AIMS: The present paper reports a Phase I trial of an adolescent version of the adult program: iBroadway. METHODS & PROCEDURES: Participants were 29 adolescents in the age range 12-17 years who were seeking cognitive-behaviour therapy (CBT) for anxiety associated with stuttering. The design was a non-randomized Phase I trial with outcome assessments at pre-treatment and immediately post-treatment after 5 months of access to the program. No contact by a clinical psychologist occurred during participant use of the program. Outcomes were a range of psychological, quality-of-life and stuttering severity measures. OUTCOMES & RESULTS: The compliance rate for the seven iBroadway modules over 5 months was extremely favourable for internet CBT, at 52.4%. There was evidence of treatment effects for (1) the number of DSM-IV mental health diagnoses with the Diagnostic Interview Schedule for Children; (2) the Unhelpful Thoughts and Beliefs About Stuttering scale; (3) the Subjective Units of Distress Scale; and (4) parent-reported speech satisfaction. CONCLUSIONS & IMPLICATIONS: Further development of iBroadway, the adolescent version of iGlebe, with Phase II trialling is warranted.

Lexical tone and stuttering in Cantonese.

Cantonese is a tone language, in which the variation of the fundamental frequency contour of a syllable can change meaning. There are six different lexical tones in Cantonese. While research with Western languages has shown an association between stuttering and syllabic stress, nothing is known about whether stuttering in Cantonese speakers is associated with one or more of the six lexical tones. Such an association has been reported in conversational speech in Mandarin, which is also a tone language, but which varies markedly from Cantonese. Twenty-four native Cantonese-speaking adults who stutter participated in this study, ranging in age from 18-33 years. There were 18 men and 6 women. Participants read aloud 13 Cantonese syllables, each of which was produced with six contrastive lexical tones. All 78 syllables were embedded in the same carrier sentence, to reduce the influence of suprasegmental or linguistic stress, and were presented in random order. No significant differences were found for stuttering moments across the six lexical tones. It is suggested that this is because lexical tones, at least in Cantonese, do not place the task demands on the speech motor system that typify varying syllabic stress in Western languages: variations not only in fundamental frequency, but also in duration and intensity. The findings of this study suggest that treatments for adults who stutter in Western languages, such as speech restructuring, can be used with Cantonese speakers without undue attention to lexical tone.

Rhythmic speech and stuttering reduction in a syllable-timed language.

Speaking rhythmically, also known as syllable-timed speech (STS), has been known for centuries to be a fluency-inducing condition for people who stutter. Cantonese is a tonal syllable-timed language and it has been shown that, of all languages, Cantonese is the most rhythmic (Mok, 2009). However, it is not known if STS reduces stuttering in Cantonese as it does in English. This is the first study to investigate the effects of STS on stuttering in a syllable-timed language. Nineteen native Cantonese-speaking adults who stutter were engaged in conversational tasks in Cantonese under two conditions: one in their usual speaking style and one using STS. The speakers' percentage syllables stuttered (%SS) and speech rhythmicity were rated. The rhythmicity ratings were used to estimate the extent to which speakers were using STS in the syllable-timed condition. Results revealed a statistically significant reduction in %SS in the STS condition; however, this reduction was not as large as in previous studies in other languages and the amount of stuttering reduction varied across speakers. The rhythmicity ratings showed that some speakers were perceived to be speaking more rhythmically than others and that the perceived rhythmicity correlated positively with reductions in stuttering. The findings were unexpected, as it was anticipated that speakers of a highly rhythmic language such as Cantonese would find STS easy to use and that the consequent reductions in stuttering would be great, even greater perhaps than in a stress-timed language such as English. The theoretical and clinical implications of the findings are discussed.

The Lidcombe Program and child language development: Long-term assessment.

This study was driven by the need to understand the mechanisms underlying Lidcombe Program treatment efficacy. The aim of the present study was to extend existing data exploring whether stuttering reductions observed when children successfully treated with the Lidcombe Program are associated with restricted language development. Audio recordings of 10-min parent-child conversations at home were transcribed verbatim for 11 pre-school-age children with various stuttering severities. Language samples from three assessments-pre-treatment, 9 and 18 months after beginning treatment-were analysed using SALT software for lexical diversity, utterance length and sentence complexity. At 18 months posttreatment commencement, the children had attained and maintained statistically significant stuttering reductions. During that period, there was no evidence that Lidcombe Program treatment was associated with restricted language development. The continued search for the mechanisms underlying this successful treatment needs to focus on other domains.

The Topography of Stuttering in Cantonese.

OBJECTIVE: This is the first study to investigate the behavioral nature (topography) of stuttering in Cantonese. Cantonese, a Sino-Tibetan language, is both tonal and syllable-timed. Previous studies of stuttering topography have mainly been in Western languages, which are mainly stress-timed. METHODS: Conversational speech samples were collected from 24 native Cantonese-speaking adults who stuttered. Six consecutive stuttering moments from each participant were analyzed using the Lidcombe behavioral data language (LBDL). A complexity analysis based on the LBDL was developed to indicate the proportion of multiple-behavior stuttering moments for each participant. RESULTS: There was no significant difference in the frequency of the 7 LBDL behaviors. Almost half the stuttering moments across participants were reported as complex, containing more than 1 stuttering behavior, and stuttering complexity correlated significantly with stuttering severity. CONCLUSIONS: These preliminary findings require replication because of their important theoretical and clinical implications. Differences in topography across languages have the potential to contribute to our understanding of the nature of stuttering. Clinically, the recognition of such differences may assist practitioners in identifying stuttering, for example when screening for early stuttering. The LBDL complexity score developed in this study has the potential to be used in other languages.

Assessing attentional biases with stuttering.

BACKGROUND: Many adults who stutter presenting for speech treatment experience social anxiety disorder. The presence of mental health disorders in adults who stutter has been implicated in a failure to maintain speech treatment benefits. Contemporary theories of social anxiety disorder propose that the condition is maintained by negative cognitions and information processing biases. Consistent with cognitive theories, the probe detection task has shown that social anxiety is associated with an attentional bias to avoid social information. This information processing bias is suggested to be involved in maintaining anxiety. Evidence is emerging for information processing biases being involved with stuttering. AIMS: This study investigated information processing in adults who stutter using the probe detection task. Information processing biases have been implicated in anxiety maintenance in social anxiety disorder and therefore may have implications for the assessment and treatment of stuttering. It was hypothesized that stuttering participants compared with control participants would display an attentional bias to avoid attending to social information. METHODS & PROCEDURES: Twenty-three adults who stutter and 23 controls completed a probe detection task in which they were presented with pairs of photographs: a face displaying an emotional expression-positive, negative or neutral-and an everyday household object. All participants were subjected to a mild social threat induction being told they would speak to a small group of people on completion of the task. OUTCOMES & RESULTS: The stuttering group scored significantly higher than controls for trait anxiety, but did not differ from controls on measures of social anxiety. Non-socially anxious adults who stutter did not display an attentional bias to avoid looking at photographs of faces relative to everyday objects. Higher scores on trait anxiety were positively correlated with attention towards photographs of negative faces. CONCLUSION & IMPLICATIONS: Attentional biases as assessed by the probe detection task may not be a characteristic of non-socially anxious adults who stutter. A vigilance to attend to threat information with high trait anxiety is consistent with findings of studies using the emotional Stroop task in stuttering and social anxiety disorder. Future research should investigate attentional processing in people who stutter who are socially anxious. It will also be useful for future studies to employ research paradigms that involve speaking. Continued research is warranted to explore information processing and potential biases that could be involved in the maintenance of anxiety and failure to maintain the benefits of speech treatment outcomes.

Clinician percent syllables stuttered, clinician severity ratings and speaker severity ratings: are they interchangeable?

BACKGROUND: At present, percent syllables stuttered (%SS) is the gold standard outcome measure for behavioural stuttering treatment research. However, ordinal severity rating (SR) procedures have some inherent advantages over that method. AIMS: To establish the relationship between Clinician %SS, Clinician SR and self-reported Speaker SR. To investigate whether Clinician SRs and Speaker SRs can be used interchangeably. METHOD & PROCEDURES: Participants were three experienced speech-language pathologist (SLP) judges and 87 adults who stuttered. Adults who stuttered received a 10-min unscheduled telephone call at the conclusion of which they self-reported a SR using a nine-point scale. The SLPs measured the stuttering for these conversations with %SS and also with the SR scale. The mean scores for Clinician %SS and Clinician SR were compared with Speaker SR using appropriate indices of relative and absolute reliability. Relative reliability indices deal with the rank order of participants in a sample and whether they can be distinguished from each other. However, absolute reliability indices are related to the closeness of the measurement scores to each other and to a hypothetical true score. OUTCOMES & RESULTS: Strong correlations were found between Clinician %SS and Clinician SR, and also between Clinician %SS and Speaker SR, although with higher values in the former case. Additionally, very high correlations showed acceptable relative reliability between Clinician SR and Speaker SR. However, absolute reliability in terms of standard error of measurement and limits of agreement was poor for Clinician SR and Speaker SR. CONCLUSIONS & IMPLICATIONS: The results suggest that Clinician SR and Speaker SR cannot be used interchangeably to measure temporal stuttering severity changes for an individual client. However, researchers might use these two measures interchangeably in research contexts, such as clinical trials, where changes of the entire group are of interest to determine and compare treatment effect size across trials.

Ann Packman: Reflections on a career.

This is the fourth in a series of papers that provides an historical record in this journal of contributions made by the most influential figures in the field of stuttering. Ann Packman is an Australian researcher who will retire shortly. This paper reflects on her long and productive career, and her contributions to the field. With a background in literature, linguistics, philosophy, psychology, and the brain and language, she became well equipped to contribute to understanding stuttering causality. That work, and an accompanying collection of basic and applied clinical research, was constantly grounded with the thoughts and feelings of those who stutter in the community.

Contemporary clinical conversations about stuttering: Can intervention stop early stuttering development?

PURPOSE: To discuss whether early intervention can stop stuttering development. To inform junior clinicians and students of speech-language pathology about contemporary views on this issue. METHOD: The issue was discussed by two university researchers and two speech-language pathologists who provide public clinical services. Written conversational turns in an exchange were limited to 100 words each. When that written dialogue was concluded, each participant provided 200 words of final reflection about the issue. RESULT: Most differences that emerged centred on the clinical evidence base for early intervention, which emphasises stuttering reduction, and how it should be interpreted. CONCLUSION: The evidence base for early intervention has limitations and it should be interpreted cautiously. One interpretation is that reducing stuttering severity is a justifiable core of early management. Another interpretation focuses on ease of communication, anticipation of stuttering, and covert stuttering.

Contemporary clinical conversations about stuttering: What does brain imaging research mean to clinicians?

PURPOSE: To discuss among neuroscientists and community speech-language pathologists what brain imaging research means to clinicians. METHOD: Two university neuroscientists and two speech-language pathologists in private practice discussed the matter. Written conversational turns in an exchange were limited to 100 words each. When that written dialogue was concluded, each participant provided 200 words of final reflection about the matter. RESULT: For now, neuroscience treatments are not available for clinicians to use. But sometime in the future, a critical mass of neuroscientists will likely produce such treatments. The neuroscientists expressed diverse views about the methods that might be used for that to occur. CONCLUSION: Neuroscience does have practical clinical application at present and, in a way, that does not exclude a concurrent influence of the social model of disability. As such, the current practices of clinicians are supported by basic neuroscience research.

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

BACKGROUND: For children older than 6 years who stutter, there is a gap in clinical research. This is an issue for speech-language pathologists because the tractability of stuttering decreases and the risk of long-term psychological consequences increase with age. PURPOSE: To report a Phase II trial of a telehealth version of the Lidcombe Program with school-age children. METHODS: Participants were 37 children who stuttered, 6-12 years of age, from Australia, New Zealand, Hong Kong, and Singapore. Parents were trained by video telehealth how to deliver the Lidcombe Program to their child. Primary and secondary outcomes were stuttering severity and psychosocial functioning measured pre-treatment and at 6 months and 12 months after starting treatment. Parents submitted two 10-minute recordings of their child speaking in conversation, and three measures of anxiety, impact of stuttering, and communication attitude. RESULTS: Six months after starting treatment, seven children (18.9%) attained Lidcombe Program Stage 2 criteria, 25 children (67.6%) showed a partial response to treatment, and five children (13.5%) showed no response. By 12 months, 12 children (32.4%) had reached Stage 2 criteria. Psychosocial improvements were observed 6 and 12 months after starting treatment. CONCLUSIONS: The Lidcombe Program may eliminate or nearly eliminate stuttering for about one third of children 6-12 years of age. Randomized controlled trials with this age group involving the Lidcombe Program are warranted. In the interim, the Lidcombe Program is a clinical option clinicians can implement with this age group to reduce stuttering and its psychosocial impacts.

The Fifth Croatia Stuttering Symposium: Part I. Treatments for early stuttering.

PURPOSE: The Fifth Croatia Stuttering Symposium in 2022 continued the Fourth Croatia Stuttering Symposium 2019 theme of the connection between research and clinical practice. At the 2022 Symposium, there were 145 delegates from 21 countries. This paper documents the contents of the first of three Symposium modules. METHODS: The module topic was that three treatments for early childhood stuttering are supported by randomized controlled trial evidence. A clinical situation was considered where a parent of a 3-year-old child asked what results to expect of stuttering treatment. RESULTS: A distinguished scholar presented a 5-minute video interpretation of the research concerning the randomized controlled trial evidence for the three treatments. Three master clinicians then each presented a 2-minute video demonstration of how those research findings might be applied in a clinical situation. Following that, the convenors moderated a discussion between the distinguished scholar, master clinicians, and delegates regarding the research and how it applies to clinical practice.

Management of childhood stuttering.

Stuttering is a speech disorder that begins during the first years of life and is among the most prevalent of developmental disorders. It appears to be a problem with neural processing of speech involving genetics. Onset typically occurs during the first years of life, shortly after language development begins. Clinical presentation during childhood is interrupted and effortful speech production, often with rapid onset. If not corrected during early childhood, it becomes intractable and can cause psychological, social, educational and occupational problems. There is evidence from replicated clinical trials to support early intervention during the pre-school years. Meta-analysis of studies indicates that children who receive early intervention during the pre-school years are 7.7 times more likely to have resolution of their stuttering. Early intervention is recommended with a speech pathologist. Some children who begin to stutter will recover without such intervention. However, the number of such recoveries is currently not known, and it is not possible to predict which children are likely to recover naturally. Consequently, the current best practice is for speech pathologists to monitor children for signs of natural recovery for up to 1 year before beginning treatment.

Review of telehealth stuttering management.

OBJECTIVE: Telehealth is the use of communication technology to provide health care services by means other than typical in-clinic attendance models. Telehealth is increasingly used for the management of speech, language and communication disorders. The aim of this article is to review telehealth applications to stuttering management. METHODS: We conducted a search of peer-reviewed literature for the past 20 years using the Institute for Scientific Information Web of Science database, PubMed: The Bibliographic Database and a search for articles by hand. RESULTS: Outcomes for telehealth stuttering treatment were generally positive, but there may be a compromise of treatment efficiency with telehealth treatment of young children. Our search found no studies dealing with stuttering assessment procedures using telehealth models. No economic analyses of this delivery model have been reported. CONCLUSION: This review highlights the need for continued research about telehealth for stuttering management. Evidence from research is needed to inform the efficacy of assessment procedures using telehealth methods as well as guide the development of improved treatment procedures. Clinical and technical guidelines are urgently needed to ensure that the evolving and continued use of telehealth to manage stuttering does not compromise the standards of care afforded with standard in-clinic models.

Barry Guitar: Reflections on a career.

This is the third in a series of papers that provides an historical record in this journal of contributions made by the most influential figures in the field of fluency disorders. The paper reflects on the long and productive career of Barry Guitar, documenting his outstanding achievements. The paper is based on interviews with him during 2022. Like no one else in our field, Barry Guitar has an understanding of the experience of stuttering and how to cope with it, and, throughout his career, he has used that understanding to inspire others to cope with it.