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

PurposeThe purpose of this study was to investigate associations among behavioral and cognitive-affective features of stuttering in preschool-age children who stutter, and the extent to which participants may or may not cluster together based on multiple indices of stuttering.MethodsParticipants were 296 preschool-age children who stutter (mean age 47.9 months). Correlation and regression analyses, as well as k-means cluster analyses were conducted between and among several indices of stuttering: frequency of stuttering- and non-stuttering-like disfluencies (SLDs and NSLDs), ratios of repetitions and prolongations/blocks out of total number of SLDs, associated nonspeech behaviors, duration of stuttering events, KiddyCAT scores (Vanryckeghem & Brutten, 2007), and a TOCS parent-rated scale (Gillam et al., 2009).ResultsFor preschool-age children who stutter, most indices of overt stuttering behaviors were intercorrelated (e.g., more SLDs were associated with higher ratio of repetitions). Self-reported KiddyCAT scores (Vanryckeghem & Brutten, 2007) were largely not significantly associated with stuttering. Cluster analyses yielded two participant groupings: a larger group with less prominent stuttering features and a smaller group with more prominent features.ConclusionsThis study contributes to an increasingly comprehensive and nuanced understanding of the heterogeneous features of stuttering and their development in preschool-age children. Findings show strong intercorrelations between measures of stuttering behaviors, but more tenuous relationships between behaviors and cognitive-affective reactions to stuttering. Exploration of clusters of characteristics within this population revealed potential opportunities for future research.     

A speech and psychological profile of treatment-seeking adolescents who stutter

PurposeThe purpose of this study was to evaluate the relationship between stuttering severity, psychological functioning, and overall impact of stuttering, in a large sample of adolescents who stutter.MethodParticipants were 102 adolescents (11–17 years) seeking speech treatment for stuttering, including 86 boys and 16 girls, classified into younger (11–14 years, n = 57) and older (15–17 years, n = 45) adolescents. Linear regression models were used to evaluate the relationship between speech and psychological variables and overall impact of stuttering.ResultsThe impact of stuttering during adolescence is influenced by a complex interplay of speech and psychological variables. Anxiety and depression scores fell within normal limits. However, higher self-reported stuttering severity predicted higher anxiety and internalizing problems. Boys reported externalizing problems—aggression, rule-breaking—in the clinical range, and girls reported total problems in the borderline-clinical range. Overall, higher scores on measures of anxiety, stuttering severity, and speech dissatisfaction predicted a more negative overall impact of stuttering.ConclusionTo our knowledge, this is the largest cohort study of adolescents who stutter. Higher stuttering severity, speech dissatisfaction, and anxiety predicted a more negative overall impact of stuttering, indicating the importance of carefully managing the speech and psychological needs of adolescents who stutter. Further research is needed to understand the relationship between stuttering and externalizing problems for adolescent boys who stutter.     

Social anxiety in stuttering: measuring negative social expectancies

Much research has suggested that those who stutter are likely to be anxious. However, to date, little research on this topic has addressed the role of expectancies of harm in anxiety, which is a central construct of anxiety in modern clinical psychology. There are good reasons to believe that the anxiety of those who stutter is related to expectancies of social harm. Therefore, in the present study, 34 stuttering and 34 control participants completed the Fear of Negative Evaluation (FNE) Scale and the Endler Multidimensional Anxiety Scales-Trait (EMAS-T). The FNE data showed a significant difference between the stuttering and control participants, with a large effect size. Results suggested that, as a group, a clinical population of people who stutter has anxiety that is restricted to the social domain. For the EMAS-T, significant differences between groups were obtained for the two subtests that refer specifically to people and social interactions in which social evaluation might occur (Social Evaluation and New/Strange Situations) but not for the subtests that contained no specific reference to people and social interactions (Physical Danger and Daily Routines). These results were taken to suggest that those who stutter differ from control subjects in their expectation of negative social evaluation, and that the effect sizes are clinically significant. The findings also suggest that the FNE and the EMAS-T are appropriate psychological tests of anxiety to use with stuttering clients in clinical settings. The clinical and research implications of these findings are discussed, in terms of whether social anxiety mediates stuttering or is a simple by-product of stuttering. Possible laboratory explorations of this issue are suggested, and potential Cognitive Behavior Therapy packages for stuttering clients who might need them are discussed. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) explain why expectancy of social threat or harm may be associated with stuttering; (2) name and describe two psychological tests that are suitable for assessment of the social threat or harm that may be associated with stuttering; and (3) explain how findings for the EMAS-T test in the present results suggest that expectancy of social threat or harm, but not other kinds of negative expectancy, are associated with stuttering.     

The role of psychological processes in estimates of stuttering severity

Purpose

To examine the associations of trait anxiety (STAI), social anxiety (SIAS), depression (BDI-II), and personality features (ADP-IV) with three measures of stuttering severity: %SS, Stuttering Severity, Instrument, and the Overall Assessment of the Speaker's Experience of Stuttering.

Method

Fifty adults with a history of stuttering served as participants. Participant scores on trait, anxiety, social anxiety, depression, and personality features were entered into a regression analysis, with the criterion variables (DVs) being: %SS, SSI-3, OASES total score. In order to explore the OASES, further, each of the four OASES subscales were also examined. A separate regression was conducted for, each dependent variable.

Results

The OASES total score model was significant (p < .0001) and revealed that social anxiety and, trait anxiety were the only significant predictors, with medium effect sizes noted for both variables. In contrast, percent syllables stuttered and the SSI were not significantly associated with psychological, variables, suggesting that anxiety may not always be related to overt indicators of stuttering. Depression and personality dysfunction were not significantly associated with any measure of, stuttering severity.

Conclusion

Anxiety in the form of social and trait anxiety are significantly associated with stuttering, severity as indicated by the OASES. Traditional procedures for assigning severity ratings to individuals, who stutter based on percent syllables stuttered and the Stuttering Severity Instrument are not, significantly related to psychological processes central to the stuttering experience. Depression and, personality characteristics do not meaningfully account for stuttering.Educational objectives: The reader will be able to: (a) differentiate forms of anxiety that are likely to be associated with stuttering (b) understand the importance of determining features of stuttering that go beyond the obvious, surface characteristics of stuttering frequency, and (c) discuss the important clinical and theoretical implications for understanding the degree of psychological dysfunction that is likely to be characteristic of those who stutter.     

Avoidance of eye gaze by adults who stutter

PurposeAdults who stutter are at significant risk of developing social phobia. Cognitive theorists argue that a critical factor maintaining social anxiety is avoidance of social information. This avoidance may impair access to positive feedback from social encounters that could disconfirm fears and negative beliefs. Adults who stutter are known to engage in avoidance behaviours, and may neglect positive social information. This study investigated the gaze behaviour of adults who stutter whilst giving a speech.Method16 adults who stutter and 16 matched controls delivered a 3-min speech to a television display of a pre-recorded lecture theatre audience. Participants were told the audience was watching them live from another room. Audience members were trained to display positive, negative and neutral expressions. Participant eye movement was recorded with an eye-tracker.ResultsThere was a significant difference between the stuttering and control participants for fixation duration and fixation count towards an audience display. In particular, the stuttering participants, compared to controls, looked for shorter time at positive audience members than at negative and neutral audience members and the background.ConclusionsAdults who stutter may neglect positive social cues within social situations that could serve to disconfirm negative beliefs and fears.Educational objectives: The reader will be able to: (a) describe the nature of anxiety experienced by adults who stutter; (b) identify the most common anxiety condition among adults who stutter; (c) understand how information processing biases and the use of safety behaviours contribute to the maintenance of social anxiety; (d) describe how avoiding social information may contribute to the maintenance of social anxiety in people who stutter; and (e) describe the clinical implications of avoidance of social information in people who stutter.     

Psychological characteristics and perceptions of stuttering of adults who stutter with and without support group experience

Purpose

To compare adults who stutter with and without support group experience on measures of self-esteem, self-efficacy, life satisfaction, self-stigma, perceived stuttering severity, perceived origin and future course of stuttering, and importance of fluency.

Method

Participants were 279 adults who stutter recruited from the National Stuttering Association and Board Recognized Specialists in Fluency Disorders. Participants completed a Web-based survey comprised of various measures of well-being including the Rosenberg Self-Esteem Scale, Generalized Self-Efficacy Scale, Satisfaction with Life Scale, a measure of perceived stuttering severity, the Self-Stigma of Stuttering Scale, and other stuttering-related questions.

Results

Participants with support group experience as a whole demonstrated lower internalized stigma, were more likely to believe that they would stutter for the rest of their lives, and less likely to perceive production of fluent speech as being highly or moderately important when talking to other people, compared to participants with no support group experience. Individuals who joined support groups to help others feel better about themselves reported higher self-esteem, self-efficacy, and life satisfaction, and lower internalized stigma and perceived stuttering severity, compared to participants with no support group experience. Participants who stutter as an overall group demonstrated similar levels of self-esteem, higher self-efficacy, and lower life satisfaction compared to averages from normative data for adults who do not stutter.

Conclusions

Findings support the notion that self-help support groups limit internalization of negative attitudes about the self, and that focusing on helping others feel better in a support group context is linked to higher levels of psychological well-being.Educational objectives: At the end of this activity the reader will be able to: (a) describe the potential psychological benefits of stuttering self-help support groups for people who stutter, (b) contrast between important aspects of well-being including self-esteem self-efficacy, and life satisfaction, (c) summarize differences in self-esteem, self-efficacy, life satisfaction, self-stigma, perceived stuttering severity, and perceptions of stuttering between adults who stutter with and without support group experience, (d) summarize differences in self-esteem, self-efficacy, and life satisfaction between adults who stutter and normative data for adults who do not stutter.     

Stuttering, emotions, and heart rate during anticipatory anxiety: a critical review

Persons who stutter often report their stuttering is influenced by emotional reactions, yet the nature of such relation is still unclear. Psychophysiological studies of stuttering have failed to find any major association between stuttering and the activity of the sympathetic nervous system. A review of published studies of heart rate in relation to stressful speech situations indicate that adults who stutter tend to show a paradoxical reduction of heart rate compared with nonstuttering persons. Reduction of heart rate has also been observed in humans and mammals during anticipation of an unpleasant stimulus, and is proposed to be an indication of anticipatory anxiety resulting in a "freezing response" with parasympathetic inhibition of the heart rate. It is suggested that speech-related anticipatory anxiety in persons who stutter is likely to be a secondary, conditioned reaction based on previous experiences of stuttering. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) describe how the autonomic nervous system is modulated by emotional responses; (2) explain how anticipatory fear often results in inhibition of heart rate due to parasympathetic activation; (3) discuss why emotional reactions in persons who stutter may be secondary to negative experiences of speech problems.     

Reprint of: technology and the evolution of clinical methods for stuttering

The World Wide Web (WWW) was 20 years old last year. Enormous amounts of information about stuttering are now available to anyone who can access the Internet. Compared to 20 years ago, people who stutter and their families can now make more informed choices about speech-language interventions, from a distance. Blogs and chat rooms provide opportunities for people who stutter to share their experiences from a distance and to support one another. New technologies are also being adopted into speech-language pathology practice and service delivery. Telehealth is an exciting development as it means that treatment can now be made available to many rural and remotely located people who previously did not have access to it. Possible future technological developments for speech-language pathology practice include Internet based treatments and the use of Virtual Reality. Having speech and CBT treatments for stuttering available on the Internet would greatly increase their accessibility. Second Life also has exciting possibilities for people who stutter.Educational objectives: The reader will (1) explain how people who stutter and their families can get information about stuttering from the World Wide Web, (2) discuss how new technologies have been applied in speech-language pathology practice, and (3) summarize the principles and practice of telehealth delivery of services for people who stutter and their families.     

Technology and the evolution of clinical methods for stuttering

The World Wide Web (WWW) was 20 years old last year. Enormous amounts of information about stuttering are now available to anyone who can access the Internet. Compared to 20 years ago, people who stutter and their families can now make more informed choices about speech-language interventions, from a distance. Blogs and chat rooms provide opportunities for people who stutter to share their experiences from a distance and to support one another. New technologies are also being adopted into speech-language pathology practice and service delivery. Telehealth is an exciting development as it means that treatment can now be made available to many rural and remotely located people who previously did not have access to it. Possible future technological developments for speech-language pathology practice include Internet based treatments and the use of Virtual Reality. Having speech and CBT treatments for stuttering available on the Internet would greatly increase their accessibility. Second Life also has exciting possibilities for people who stutter.Educational objectives: The reader will (1) explain how people who stutter and their families can get information about stuttering from the World Wide Web, (2) discuss how new technologies have been applied in speech-language pathology practice, and (3) summarize the principles and practice of telehealth delivery of services for people who stutter and their families.     

Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design

Background & objectives: Social anxiety disorder (SAD) is a debilitating condition, and approximately half of adults who stutter have SAD. Cognitive-behavioral therapy (CBT) has shown promise in decreasing social anxiety symptoms among adults who stutter, but exposure, arguably the essential component for successful CBT for SAD, has been understudied and underemphasized. Aims of this study were to develop an exposure therapy protocol designed specifically for people who stutter and have SAD and evaluate its potential efficacy in reducing social anxiety and stuttering severity using a multiple baseline design.Methods: Six participants received ten sessions of exposure therapy. Participants reported daily social anxiety, and social distress and stuttering severity were evaluated at major assessment points.Results: There were substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering. No consistent change was observed for stuttering frequency. Gains were mostly maintained after six-months.Conclusions: Results suggest that the novel exposure approach may decrease social distress, but not necessarily influence speech fluency. These findings underscore the importance of the assessment and treatment of SAD among adults who stutter and suggest that the integration of care between clinical psychologists and speech-language pathologists may prove beneficial for this population.     

Effects of stuttering severity and therapy involvement on attitudes towards people who stutter

The purpose of this study was to explore whether stuttering severity or therapy involvement had an effect on the attitudes that individuals who do not stutter reported towards people who stutter (PWS). Two hundred and sixty (260) university students participated in this study. Direct survey procedures consisting of a 25-item semantic differential scale were utilized. Comparisons of the effects of stuttering severity, level of therapy involvement, and the interaction of these variables were completed. Results suggested that both stuttering severity and therapy involvement had significant effects on participants' attitudes towards PWS. Findings of this study support past research studies that has found that individuals who stutter mildly are perceived more positively than those who are severe. Similarly, the data supported past research that has found that PWS that attend therapy are perceived more positively than those who do not attend therapy. Surprisingly, the interaction of these variables was not significant. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) explain the possible effects of listeners' attitudes toward stuttering on the lives of PWS; (2) discuss how different factors might alter listeners' attitudes towards stuttering; (3) delineate how stuttering severity and involvement in therapy might impact listeners' attitudes towards PWS.     

Recurrent involuntary imagery in people who stutter and people who do not stutter

Objective

To compare intrusive memories in groups of people who do (PWS), and who do not (PWNS), stutter.

Method

Twenty-one participants who stuttered and 21 matched controls were given a semi-structured interview which explored imagery in speaking situations. The data were analyzed using a Content Analysis approach. Other outcome measures were the Beck Anxiety Inventory, the Beck Depression Inventory, the Post Traumatic Stress Disorder, PTSD, Symptom Scale: Self-Report Version.

Results

Significantly more stuttering participants than control participants indicated both recurrent imagery and associated memories. Content Analysis revealed themes of disfluency, anxiety, negative social evaluation, self-focus and pressure to speak that were common to both groups’ reports. Additional themes of helplessness, shame, sadness and frustration were found only in the images and memories of the stuttering group. No group differences were evident for the number of sensory modalities involved in images and memories, or for ratings of their vividness or strength of associated emotions, or on self-reports of depression, anxiety and trauma.

Conclusions

Recurrent imagery about events in childhood is a potent factor in the memories of PWS. It is worth modifying interventions that have been successfully applied for treating social anxiety for use with people who stutter.Educational objectives: After reading this article, participants will be able to: (a) identify the role of intrusive memories in psychiatric disorders and stuttering; (b) investigate how DSM criteria can be employed with people who stutter; (c) employ anxiety instruments used for assessing psychiatric disorders for stuttering; (d) distinguish between the intrusive memories experienced by people who stutter, and people who do not stutter; (e) apply treatments for intrusive memories in psychiatric disorders to work with people who stutter.     

Stuttering,alcohol consumption and smoking

PurposeLimited research has been published regarding the association between stuttering and substance use. An earlier study provided no evidence for such an association, but the authors called for further research to be conducted using a community sample. The present study used data from a community sample to investigate whether an association between stuttering and alcohol consumption or regular smoking exists in late adolescence and adulthood.MethodsRegression analyses were carried out on data from a birth cohort study, the National Child Development Study (NCDS), whose initial cohort included 18,558 participants who have since been followed up until age 55. In the analyses, the main predictor variable was parent-reported stuttering at age 16. Parental socio-economic group, cohort member's sex and childhood behavioural problems were also included. The outcome variables related to alcohol consumption and smoking habits at ages 16, 23, 33, 41, 46, 50 and 55.ResultsNo significant association was found between stuttering and alcohol consumption or stuttering and smoking at any of the ages. It was speculated that the absence of significant associations might be due to avoidance of social situations on the part of many of the participants who stutter, or adoption of alternative coping strategies.ConclusionBecause of the association between anxiety and substance use, individuals who stutter and are anxious might be found to drink or smoke excessively, but as a group, people who stutter are not more likely than those who do not to have high levels of consumption of alcohol or nicotine.     

Anxiety and speaking in people who stutter: An investigation using the emotional Stroop task

People with anxiety disorders show an attentional bias towards threat or negative emotion words. This exploratory study examined whether people who stutter (PWS), who can be anxious when speaking, show similar bias and whether reactions to threat words also influence speech motor planning and execution. Comparisons were made between 31 PWS and 31 fluent controls in a modified emotional Stroop task where, depending on a visual cue, participants named the colour of threat and neutral words at either a normal or fast articulation rate. In a manual version of the same task participants pressed the corresponding colour button with either a long or short duration. PWS but not controls were slower to respond to threat words than neutral words, however, this emotionality effect was only evident for verbal responding. Emotionality did not interact with speech rate, but the size of the emotionality effect among PWS did correlate with frequency of stuttering. Results suggest PWS show an attentional bias to threat words similar to that found in people with anxiety disorder. In addition, this bias appears to be contingent on engaging the speech production system as a response modality. No evidence was found to indicate that emotional reactivity during the Stroop task constrains or destabilises, perhaps via arousal mechanisms, speech motor adjustment or execution for PWS.Educational objectives: The reader will be able to: (1) explain the importance of cognitive aspects of anxiety, such as attentional biases, in the possible cause and/or maintenance of anxiety in people who stutter, (2) explain how the emotional Stroop task can be used as a measure of attentional bias to threat information, and (3) evaluate the findings with respect to the relationship between attentional bias to threat information and speech production in people who stutter.     

Real and virtual classrooms can trigger the same levels of stuttering severity ratings and anxiety in school-age children and adolescents who stutter

PurposeMany school-age children and adolescents who stutter experience the fear of public speaking. Treatment implications include the need to address this problem. However, it is not always possible to train repeatedly in front of a real audience. The present study aimed to assess the relevance of using a virtual classroom in clinical practice with school-age children and adolescents who stutter.MethodsTen children and adolescents who stutter (aged 9–17 years old) had to speak in three different situations: in front of a real audience, in front of a virtual class and in an empty virtual apartment using a head-mounted display. We aimed to assess whether the self-rated levels of anxiety while speaking in front of a virtual audience reflect the levels of anxiety reported while speaking in front of a live audience, and if the stuttering level while speaking to a virtual class reflects the stuttering level while speaking in real conditions.ResultsResults show that the real audience creates higher anticipatory anxiety than the virtual class. However, both the self-reported anxiety levels and the stuttering severity ratings when talking in front of a virtual class did not differ from those observed when talking to a real audience, and were significantly higher than when talking in an empty virtual apartment.ConclusionOur results support the feasibility and relevance of using a virtual classroom to expose school-age children and adolescents who stutter to a feared situation during cognitive behavioral therapy targeting the fear of public speaking.     

Preliminary study of self-perceived communication competence amongst adults who do and do not stutter

PurposeAdults who stutter report a significant impact of stuttering on their quality of life, including negative thoughts and attitudes toward communication. In addition to this impact, adolescents who stutter also report lower levels of self-perceived communication competence (SPCC) compared to fluent peers. The purpose of this study was to extend the investigation of SPCC to adults who do and do not stutter. Additional aims investigated included if 1) SPCC predicted overall impact of stuttering, and, 2) stuttering frequency predicted SPCC among adults who stutter.MethodsTwenty-four adults who stutter and twenty-seven adults who do not stutter matched for age, gender, and education completed the Self-Perceived Communication Competence Scale (Richmond & McCroskey, 1997). All participants who stutter completed the Overall Assessment of the Speaker’s Experience of Stuttering (OASES [ages 18+]; Yaruss & Quesal, 2006) and speaking samples to measure stuttering frequency.ResultsAdults who stutter reported significantly lower SPCC scale total scores than adults who do not stutter. For adults who stutter, lower SPCC scale scores significantly predicted more severe overall impact of stuttering as measured by the OASES. Stuttering frequency did not predict SPCC scale scores.DiscussionThis is the first study to report differences in self-perceived communication competence between adults who do and do not stutter. Results suggest adults who stutter report lower self-perceived communication competence compared to adults who do not stutter. Adults who perceive themselves to have greater communication competence reported less severe overall impact of stuttering, and stuttering frequency did not influence SPCC. Clinical implications for intervention are discussed.     

Multilingual children who stutter: clinical issues

Stuttering occurs across all languages and cultures. However, the impact of speaking more than one language on assessment and treatment of young children who stutter is not well documented. This paper discusses some of the challenges related to clinical issues pertaining to this population including (a) identifying stuttering in an unfamiliar language, (b) the influence of language proficiency, and (c) treatment of multilingual young children who stutter. The paper is written from the perspective of the author's experience treating multilingual children who stutter within the context of the linguistic and cultural diversity of Canada, notably in the French speaking Province of Quebec where many children grow up speaking two or more languages in everyday life. Clinical examples will be taken from the evidence-based literature as well as the author's clinical experience.Educational objectives: After reading this paper, the learner will be able to (1) summarize the literature regarding assessment and treatment of stuttering in young children speaking more than one language, (2) summarize some of the challenges related to this issue and (3) describe some of the findings associated with treatment of bilingual children who stutter and (4) be prepared to apply some of these suggestions in the treatment of bilingual children who stutter.