Evaluation of an integrated fluency and Acceptance and Commitment Therapy intervention for adolescents and adults who stutter: Participant perspectives

PurposeChildhood-onset stuttering is a neurodevelopmental disorder that may cause pervasive negative consequences for adults who stutter. In addition to significant challenges in personal, social, and emotional domains, stuttering has been shown to impose an economic burden on adults who stutter. Intervention for adults who stutter has historically addressed speech fluency more so than the covert psychosocial aspects of the disorder. There is an identified clinical need for holistic, efficacious, and cost-effective stuttering interventions that meet consumer needs. The purpose of the present study is to evaluate a novel, integrated intervention that combined traditional fluency techniques with Acceptance and Commitment Therapy, from the perspective of the adults who stutter who participated in the intervention.MethodTwenty-eight adults who stutter completed the intervention program. Participants were invited to complete an online post-program written survey (including qualitative comments) and a semi-structured interview to explore their evaluations of the program with respect to its authenticity, acceptability, and social validity.ResultsParticipants perceived positive psychosocial changes as a result of the program, and were satisfied with the program overall. Qualitative thematic analyses of the written survey comments and the semi-structured interviews identified two major themes: factors specific to the intervention and factors specific to the therapeutic process. Several important sub-themes were also identified.ConclusionFindings support the authenticity, acceptability, and social validity of an integrated fluency and psychosocial intervention for stuttering. Findings also highlight the need for consideration of the consumer voice in the management of stuttering disorders, in keeping with person-centred care.     

Public attitudes toward—and identification of—cluttering and stuttering in Norway and Puerto Rico

PurposeThe study sought to compare public attitudes toward cluttering versus stuttering in Norway and Puerto Rico and to compare respondents’ identification of persons known with these fluency disorders.MethodAfter reading lay definitions of cluttering and stuttering, three samples of adults from Norway and three from Puerto Rico rated their attitudes toward cluttering and/or stuttering on modified versions of the POSHA-Cl (for cluttering) and POSHA-S (for stuttering). They also identified children and adults whom they knew who either or both manifested cluttering or stuttering.ResultsAttitudes toward cluttering were essentially unaffected by rating either cluttering only or combined cluttering and stuttering on the same questionnaire in both countries. The same was also true of stuttering. Attitudes were very similar toward both disorders although slightly less positive for cluttering. Norwegian attitudes toward both disorders were generally more positive than Puerto Rican attitudes. The average respondent identified slightly more than one fluency disorder, a higher percentage for stuttering than cluttering and higher for adults than children. Cluttering–stuttering was rarely identified.ConclusionGiven a lay definition, this study confirmed that adults from diverse cultures hold attitudes toward cluttering that are similar to—but somewhat less positive than—their attitudes toward stuttering. It also confirmed that adults can identify cluttering among people they know, although less commonly than stuttering. Design controls in this study assured that consideration of stuttering did not affect either the attitudes or identification results for cluttering.Educational objectives: The reader will be able to: (a) describe the effects—or lack thereof—of considerations of stuttering on attitudes toward cluttering; (b) describe differences in public identification of children and adults who either clutter or stutter; (c) describe differences between attitudes toward cluttering and stuttering in Norway and Puerto Rico.     

Self-efficacy beliefs: Experiences of adults who stutter

PurposeChildhood-onset stuttering is a complex and multifaceted disorder. Intervention for adults who stutter has historically addressed speech fluency more so than psychosocial aspects of the disorder, including the nature of the individual’s self-efficacy beliefs concerning their confidence in their capacity to enact change. Self-efficacy is an important construct related to quality of life, resilience, and maintenance of treatment gains for adults who stutter. The purpose of this qualitative study is to explore the nature of the self-efficacy beliefs expressed by adults who stutter in order to inform efficacious and holistic intervention for these individuals.MethodSemi-structured interviews were conducted with 29 adults who stutter to describe their experiences as a person who stutters and elucidate the nature of their self-efficacy beliefs.ResultsThematic analysis identified several major themes that provided novel insight into the complex nature of the self-efficacy beliefs experienced by adults who stutter: speaker experiences shaped communicative confidence, there was a conflict between communication and fluency, stuttering was viewed as more than fluency, and individual perspectives shaped communicative confidence, as did the pervading influence of self. The notion that fluency and confidence are inextricably linked was evident within and across each major theme.ConclusionThese preliminary findings provide further support for a multidimensional approach to the treatment of adults who stutter. Findings will be used to inform a novel integrated fluency and psychosocial intervention for adults who stutter that addresses fluency and self-efficacy concurrently, with a view of engendering durable improvements in speech fluency and communicative confidence.     

A model clarifying the role of mediators in the variability of mood states over time in people who stutter

PurposeElevated negative mood states such as social anxiety and depressive mood have been found in adults who stutter. Research is needed to assist in the development of a model that clarifies how factors like self-efficacy and social support contribute to the variability of negative mood states over time.MethodParticipants included 200 adults who stutter. A longitudinal design was employed to assess change in mood states over a period of five months. Hierarchical directed regression (path analysis) was used to determine contributory relationships between change in mood states and self-efficacy, social support, socio-demographic and stuttering disorder variables. Participants completed a comprehensive assessment regimen, including validated measures of mood states, perceived control (self-efficacy) and social support.ResultsResults confirmed that self-efficacy performs a protective role in the change in mood states like anxiety and depressive mood. That is, self-efficacy cushioned the impact of negative mood states. Social support was only found to contribute a limited protective influence. Socio-demographic variables had little direct impact on mood states, while perceived severity of stuttering also failed to contribute directly to mood at any time point.ConclusionsMood was found to be influenced by factors that are arguably important for a person to cope and adjust adaptively to the adversity associated with fluency disorder. A model that explains how mood states are influenced over time is described. Implications of these results for managing adults who stutter with elevated negative mood states like social anxiety are discussed.Educational Objectives: The reader will be able to describe: (a) the method involved in hierarchical (directed) regression used in path analysis; (b) the variability of mood states over a period of five months; (c) the nature of the mediator relationship between factors like self-efficacy and social support and mood states like anxiety, and (d) the contribution to mood states of socio-demographic factors like age and education and stuttering disorder variables like stuttering frequency and perceived severity.     

Perceptions of self-efficacy in providing multidimensional school-age stuttering therapy among board certified fluency specialists in the United States

PurposeThe purpose of this study was to document fluency specialists’ self-efficacy beliefs for providing multidimensional treatment to children who stutter and to identify cognitive, affective, and behavioral correlates of self-efficacy.MethodSixty-six Board Certified Specialists in Fluency in the United States completed an online survey measuring self-efficacy in providing multidimensional stuttering therapy, perceived importance of multidimensional aspects of therapy, feelings of comfort in providing therapy, perceived treatment success, and employment and demographic questions. Open-ended questions were also asked for participants to describe why they chose to specialize and what benefits they received from it.ResultsParticipants reported high levels of self-efficacy (averages above 9 on a scale from 0 to 10) in speech-related, cognitive, emotional, and social domains of stuttering therapy, as well as high levels of comfort and clinical success. Higher ratings of overall self-efficacy were significantly correlated with beliefs about the importance of multidimensional treatment, τ = 0.27, treatment comfort, τ = 0.25, and self-reported treatment success, τ = .49. Responses indicated that many participants believed that their self-efficacy grew because of specialty certification.ConclusionAlthough not the same as treatment outcome data, self-efficacy among clinical service providers is an important variable to consider. Board Certified Specialists in Fluency in the United States report very high levels of self-efficacy for school-age stuttering treatment. The process of certification helps to increase self-efficacy and provides a means for advertising competence in stuttering treatment. This information could help in recruiting the next generation of fluency specialists.     

Elevated attention deficit hyperactivity disorder symptoms in children who stutter

PurposeThis study described the proportion of children who stutter who exhibit Attention Deficit Hyperactivity Disorder (ADHD) symptoms, manifesting in inattentive and hyperactive/impulsive behaviours. Children who stutter with these challenging behaviours may not respond as quickly and successfully to stuttering treatment. A preliminary exploration of differences in treatment responsiveness for children with and without ADHD symptoms was undertaken.MethodParticipants were 185 preschool children who stutter who had completed stuttering therapy within 3 months prior to study commencement. Differences between groups of children who stutter with and without elevated ADHD symptoms were investigated, in terms of pre-treatment stuttering features (stuttering severity and typography), demographic variables (age at onset, time between onset and commencement of therapy, family history and sex) and treatment data (post-treatment stuttering severity and number of sessions to achieve discharge criteria).ResultsOne-half (50%) of participants exhibited elevated ADHD symptoms. These children required 25% more clinical intervention time to achieve successful fluency outcomes than children without elevated ADHD symptoms. Findings suggest that more ADHD symptoms, increased pre-treatment stuttering severity, and male sex were associated with poorer responsiveness to stuttering treatment.ConclusionThe large proportion of children exhibiting elevated ADHD symptoms, and the increase in clinical contact time required in this subgroup to achieve successful fluency outcomes, is suggestive of the need for clinicians to tailor stuttering intervention to address these concomitant behaviour challenges. Findings support the use of careful caseload management strategies to account for individual differences between children, and strengthen prognostic information available to parents and clinicians.     

Stuttering treatment for a school-age child with Down syndrome: A descriptive case report

BackgroundLittle is known about optimal treatment approaches and stuttering treatment outcomes for children with Down syndrome.Aims and methodThe purpose of this study was to investigate outcomes for a child with Down syndrome who received a combination of fluency shaping therapy and parent delivered contingencies for normally fluent speech, prolonged speech, and stuttered speech.ResultsIn-clinic speech measures obtained at post-treatment and at 4 months follow-up reflected improvements in fluency of 89.0% and 98.6%, respectively. The participant's beyond-clinic follow-up sample reflected an improvement of 95.5%. Following treatment, the participant demonstrated improved self-confidence, self-esteem, and improved participation and functioning at school.ConclusionsFindings suggest that fluency shaping with parental contingencies may be a viable treatment approach to reduce stuttering in children with Down syndrome. Future research using an experimental research design is warranted.Educational objectives: Readers will be able to describe (a) prevalence estimates of stuttering in individuals with Down syndrome, (b) the main components of a fluency shaping program for a child with Down syndrome who stutters and has co-occurring speech and language delays, and (c) speech and parent-, teacher-, and self-report treatment outcomes.     

A pilot study into a possible relationship between diet and stuttering

PurposeThere are theoretical and empirical reasons to consider a potential role for copper metabolism in the brain in how it could influence stuttering. However, a link between stuttering and dietary intake has never been researched in a systematic way. This pilot study therefore aimed to explore a possible association between ingested amounts of copper and thiamine (vitamin B1) with stuttering frequency using a double blind cross-over longitudinal paradigm.Methods19 adults who stutter between 20 and 51 years old filled out an online survey for 9 consecutive weeks. The survey consisted of self-assessed fluency and mood state scales, as well as food journals. After 4 weeks, the participants consumed either copper or thiamine supplements for 2 weeks, followed by a 1-week washout period, and another period of two weeks taking the other supplement. Formal speech assessments were done pre/post baseline and at the end of each supplement intake. Participants were not informed about the nature of the supplements during the experiment and the investigators were blinded to the order of the supplements.ResultsThe results demonstrated that copper and thiamine had no measurable effect on the amount of stuttering (self and formal assessments) but there was a moderate, significant correlation between mood state and fluency.ConclusionThe findings do not support notions of dietary influences of ingested copper or thiamine on stuttering but do provide modest support for a relationship between variations in stuttering and self-perceived anxiety.     

Specific subtype of fluency disorder affecting French speaking children: A phonological analysis

PurposeClinicians working with fluency disorders sometimes see children whose word repetitions are mostly located at the end of words and do not induce physical tension. Prior studies on the topic have proposed several names for these disfluencies including “end word repetitions”, “final sound repetitions” and “atypical disfluency”. The purpose of this study was to use phonological analysis to explore the patterns of this poorly recognized fluency disorder in order to better understand its specific speech characteristics.MethodsWe analyzed a spontaneous language sample of 8 French speaking children. Audio and video recordings allowed us to study general communication issues as well as linguistic and acoustical data.ResultsWe did not detect speech rupture or coarticulation failures between the syllable onset and rhyme. The problem resides primarily on the rhyme production with a voicing interruption in the middle of the syllable nucleus or a repetition of the rhyme (nucleus alone or nucleus and coda), regardless of the position in the word or phrase.ConclusionThe present study provides data suggesting that there exist major differences in syllable production between the disfluencies produced by our 8 children and stuttered disfluencies. Consequently, we believe that this fluency disorder should be recognized as distinct from stuttering.     

Communication attitudes in children who stutter: A meta-analytic review

BackgroundThis article presents a meta-analytic review of differences in communication attitudes between children who stutter (CWS) and children who do not stutter (CWNS).MethodTo be included in this review, the studies had to include a group of CWS and CWNS between the ages of 3–18 years and a measurement of communication attitudes. The journal articles were identified by using the key words stutter*, speech disfluenc*, fluency disorder*, and stammer* cross-referenced to awareness*, reaction*, attitude*, KiddyCAT, CAT, A-19 Scale, PASS and OASES.ResultsA total of 18 studies met the inclusion criteria for this meta-analysis. The results showed that CWS exhibit more negative communication attitudes than CWNS from the preschool years. The differences between the groups increased with age, but were not influenced by gender.ConclusionThe results indicate that negative communication attitudes can be an effect of stuttering. Key issues requiring further investigation are whether communication attitudes differ as a function of age at stuttering onset and whether communication attitudes influence the development of stuttering.Educational Objectives: After reading this article, the reader will be able to: (a) summarise empirical findings with regard to the relationship between communication attitudes and childhood stuttering; (b) describe the different instruments used to measure communication attitudes; (c) discuss the relationship between communication attitudes, age and gender.     

Stuttering due to ischemic stroke

Acquired stuttering is a disorder of the fluency of speech. The mechanism underlying stuttering is unknown. It may occur after bilateral and unilateral cortical or subcortical brain damage. We report two cases who had stuttering resulting from left parietal infarction.     

Mindfulness training in stuttering therapy: a tutorial for speech-language pathologists

The use of mindfulness training for increasing psychological well-being in a variety of clinical and nonclinical populations has exploded over the last decade. In the area of stuttering, it has been widely recognized that effective long-term management often necessitates treatment of cognitive and affective dimensions of the disorder in addition to behavioral components. Yet, mindfulness based strategies and their possible usefulness in stuttering management have not been described in detail in the literature. This article seeks to engage professionals who treat stuttering in a conversation about the possible usefulness of incorporating mindfulness training into stuttering management. A review of the literature reveals that there is a substantial overlap between what is required for effective stuttering management and the benefits provided by mindfulness practices. Mindfulness practice results in decreased avoidance, increased emotional regulation, and acceptance in addition to improved sensory-perceptual processing and attentional regulation skills. These skills are important for successful long-term stuttering management on both psychosocial and sensory-motor levels. It is concluded that the integration of mindfulness training and stuttering treatment appears practical and worthy of exploration. Mindfulness strategies adapted for people who stutter may help in the management of cognitive, affective, and behavioral challenges associated with stuttering.Educational objectives: Readers should be able to: (1) describe what mindfulness is and how it is cultivated; (2) identify the benefits that can be produced from mindfulness practice; (3) summarize how the benefits of mindfulness practice parallel what is often required for effective long-term stuttering management; and (4) identify specific mindfulness techniques that can be taught in stuttering therapy and explain their rationale.     

Stuttering treatment control using P300 event-related potentials

Positron emission tomography studies during speech have indicated a failure to show the normal activation of auditory cortical areas in stuttering individuals. In the present study, P300 event-related potentials were used to investigate possible effects of behavioral treatment on the pattern of signal amplitude and latency between waves. In order to compare variations in P300 measurements, a control group paired by age and gender to the group of stutterers, was included in the study. Findings suggest that the group of stutterers presented a significant decrease in stuttering severity after the fluency treatment program. Regarding P300 measurements, stutterers and their controls presented results within normal limits in all testing situations and no significant statistical variations between pre and post treatment testing. When comparing individual results between the testing situations, stutterers presented a higher average decrease in wave latency for the right ear following treatment. The results are discussed in light of previous P300 event-related potentials and functional imaging studies with stuttering adults.Educational objectives: The reader will learn about and be able to describe the: (1) use of P300 event-related potentials in the study of stuttering; (2) differences between stuttering and non-stuttering adults; and (3) effects of behavioral fluency treatment on cerebral activity in stuttering speakers.     

Reprint of: stuttering treatment control using P300 event-related potentials

Positron emission tomography studies during speech have indicated a failure to show the normal activation of auditory cortical areas in stuttering individuals. In the present study, P300 event-related potentials were used to investigate possible effects of behavioral treatment on the pattern of signal amplitude and latency between waves. In order to compare variations in P300 measurements, a control group paired by age and gender to the group of stutterers, was included in the study. Findings suggest that the group of stutterers presented a significant decrease in stuttering severity after the fluency treatment program. Regarding P300 measurements, stutterers and their controls presented results within normal limits in all testing situations and no significant statistical variations between pre and post treatment testing. When comparing individual results between the testing situations, stutterers presented a higher average decrease in wave latency for the right ear following treatment. The results are discussed in light of previous P300 event-related potentials and functional imaging studies with stuttering adults.Educational objectives: The reader will learn about and be able to describe the: (1) use of P300 event-related potentials in the study of stuttering; (2) differences between stuttering and non-stuttering adults; and (3) effects of behavioral fluency treatment on cerebral activity in stuttering speakers.     

Effects of different attention tasks on concurrent speech in adults who stutter and fluent controls

Purpose: Motor theories indicate that focusing attention on well-practiced movements interferes with skilled performance; however, specific forms of attention (alerting vs. orienting vs. executive control) associated with this effect are not well understood. The present study explored this question in relation to stuttering, and examined whether dual task conditions that engaged sustained attention or working memory (WM) affected speech fluency in different ways. We also considered whether fluency changes were associated with changes in speech rate and language.Methods: Nineteen adults who stutter (AWS) and 20 controls produced spontaneous speech under a baseline condition and two dual task conditions: one involving a sustained attention task, the other involving WM demands.Results: Both groups produced fewer stutter-like disfluencies under dual task relative to baseline conditions and this reduction did not differ between the two dual tasks (attention vs. WM). Speech rate and language variables, which were potentially influenced by attention conditions, were not affected by dual tasks in the same way as disfluencies, and appeared to be unassociated with fluency results.Conclusions: Findings indicate that atypical disfluencies decrease when attention is divided, even when secondary task demands are minimal, as they were in the sustained attention task. For simple secondary tasks, fluency changes do not appear to be a byproduct of slowed rate and are not accompanied by observable changes in language. These results demonstrate that simple manipulations of attention can induce measurable effects on aspects of speech production, and may be a useful tool for facilitating fluency in clinical intervention.     

Toward a better understanding of the process of disclosure events among people who stutter

PurposeThe purpose of this study was to identify components of disclosure events among people who stutter, and identify possible relations between these components in order to understand how disclosure events unfold.MethodTwelve adults who stutter participated in semi-structured interviews focused on disclosure of stuttering. Participants were purposefully selected due to their self-reported history of disclosing stuttering. Qualitative content analysis using a grounded theory approach helped to identify relevant themes and subthemes related to the process of disclosure of stuttering.ResultsThe findings describe the complex process of disclosure as being comprised of antecedents (including considerations about when and why to disclose), the disclosure event itself (including the content and form of the disclosure, most and least helpful methods of disclosure, as well as immediate listener reactions), and the perceived outcomes of the disclosure at individual, dyadic, and societal/contextual levels. These components of the process are linked and affect one another, resulting in a feedback loop. Disclosure methods are context-dependent and not mutually exclusive within individuals who stutter.ConclusionProfessionals and advocates gaining a more nuanced understanding of the process of disclosure events can increase their ability to help people who stutter make optimal decisions about disclosure. Making good disclosure decisions can help PWS improve their quality of life and reduce a variety of environmental communicative barriers.     

The role of temporal speech cues in facilitating the fluency of adults who stutter

PurposeAdults who stutter speak more fluently during choral speech contexts than they do during solo speech contexts. The underlying mechanisms for this effect remain unclear, however. In this study, we examined the extent to which the choral speech effect depended on presentation of intact temporal speech cues. We also examined whether speakers who stutter followed choral signals more closely than typical speakers did.Method8 adults who stuttered and 8 adults who did not stutter read 60 sentences aloud during a solo speaking condition and three choral speaking conditions (240 total sentences), two of which featured either temporally altered or indeterminate word duration patterns. Effects of these manipulations on speech fluency, rate, and temporal entrainment with the choral speech signal were assessed.ResultsAdults who stutter spoke more fluently in all choral speaking conditions than they did when speaking solo. They also spoke slower and exhibited closer temporal entrainment with the choral signal during the mid- to late-stages of sentence production than the adults who did not stutter. Both groups entrained more closely with unaltered choral signals than they did with altered choral signals.ConclusionsFindings suggest that adults who stutter make greater use of speech-related information in choral signals when talking than adults with typical fluency do. The presence of fluency facilitation during temporally altered choral speech and conversation babble, however, suggests that temporal/gestural cueing alone cannot account for fluency facilitation in speakers who stutter. Other potential fluency enhancing mechanisms are discussed.Educational Objectives: The reader will be able to (a) summarize competing views on stuttering as a speech timing disorder, (b) describe the extent to which adults who stutter depend on an accurate rendering of temporal information in order to benefit from choral speech, and (c) discuss possible explanations for fluency facilitation in the presence of inaccurate or indeterminate temporal cues.     

The effect of manual movements on stuttering in individuals with down syndrome

PurposeStuttering may disrupt the speech of individuals with Down syndrome (DS), but standard stuttering therapies may be less adapted to these clients’ needs. This study examined if their strength in gesture use can lead to the development of a new stuttering therapy.MethodEighteen individuals with DS who stutter participated in an experimental task. During this task, they produced sentences in three different conditions: once without the ability to use gestures, once while moving the mouth of a hand puppet synchronous with their speech, and once while making beat gestures along their speech. Stuttering frequency was measured and compared between conditions while controlling for the effect of articulation rate.ResultsThe experimental hand puppet and beat condition did not affect the stuttering frequency, but the covariate articulation rate did. An exploratory posthoc analysis showed that the articulation rate decreased during the experimental hand puppet and beat condition. Manual movements in the present task might only induce fluency through articulation rate reduction. However, analyses at individual level show significant interindividual variability.ConclusionIndividual analyses show that effect on stuttering frequency cannot be attributed entirely to articulation rate reduction and that beat gestures might still play a role. However, at this point, there is not enough direct evidence to implement beat gestures in current stuttering therapy.     

Spastic dysphonia: A fluency disorder?

A case is presented for classifying spastic dysphonia, which usually is classified as a disorder of phonation, as a disorder of fluency—one that has a symptomatology and phenomenology, and possibly etiology, which is similar to stuttering. This case is based in part on a study that is reported in which listeners described speech associated with this condition as lacking in fluency. Theoretical, clinical, and research implications are discussed.