Stages of change and stuttering: a preliminary view

As a way to better understand the process of change that occurs in stuttering, Craig [Craig, A. (1998). Relapse following treatment for stuttering: a critical review and correlative data. Journal of Fluency Disorders, 23, 1-30] compared the behavioral changes that people who stutter often experience with and without treatment to those that have been observed for certain (non)addictive behavior disorders such as smoking, overeating, phobia and anxiety disorder. The process underlying these behavioral changes has been described by the transtheoretical or "stages of change" model, which is a model of behavior change that can illuminate "where" a person is in the process of change, and how this may relate to the outcome of either treatment or self-change attempts [Prochaska, J. O., & DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy. New York: Brunner/Mazel]. The purpose of the present study was to analyze the extent to which the responses of adults who stutter on a modified Stages of Change Questionnaire yield interrelations among questionnaire items that are consistent with a stage-based interpretation. Results of both confirmatory and exploratory factor analyses indicated that while the modified questionnaire was a relatively good fit for participant responses, the structure derived from the exploratory analysis provided a significantly better fit to the observed data. Results suggest that a questionnaire incorporating items that better reflect the unique behavioral, cognitive and affective variables that characterize stuttering may better discriminate stages of change in people who stutter as they move through therapy, or are engaged in self-directed change. Educational objectives: After reading this paper, the learner will be able to: (1) describe the transtheoretical or "stages of change" model; (2) describe the various processes that are associated with different stages of change; (3) summarize research findings in stages of change as they apply to a variety of clinical populations; (4) discuss the applicability of the findings from the present study to stuttering treatment, and (5) relate conventional strategies and techniques used in stuttering therapy to different stages in the process of change.     

Parent perceptions of an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering

PurposeRecent research has identified approximately half of children who stutter present with self-regulation challenges. These manifest in elevated inattentive and/or impulsive behaviours, aligned with attention deficit hyperactivity disorder (ADHD) symptoms. These symptoms have been found to influence the child’s responsiveness to their stuttering treatment, and may exacerbate the psychosocial consequences of stuttering for them and their families. Early stuttering intervention identifies parents as key agents of change in the management of their children’s stuttering. This study sought feedback from parents regarding their experiences with an integrated stuttering treatment and behavioral self-regulation program for early developmental stuttering, addressing the child’s self-regulation challenges.MethodEight parents of children who stutter who had co-occurring self-regulation challenges completed the integrated program. This incorporated the Triple P--Positive Parenting Program adapted for the developmental stuttering population, and the Curtin University Stuttering Program (CUSP). Semi-structured qualitative interviews were conducted to capture parents’ reflections on, and experiences with, the integrated program.ResultsThematic analysis identified several major themes regarding the parents’ experiences with the integrated program: emotional impact on parents, child self-regulation, link between stuttering and behaviour, parent self-regulation, impact on family dynamics, and overall positive perceptions of the integrated program. All of the parents indicated they would recommend the program to future parents of children who stutter.ConclusionThis study provides insights into parents’ perceptions regarding an integrated intervention approach for early stuttering and behavior management. It also indicates how adopting a holistic approach to stuttering intervention is positive and has social validity.     

Design of randomized controlled trials: Principles and methods applied to a treatment for early stuttering

The “gold standard” methodology for treatment efficacy research is the randomized controlled trial (RCT), which is used extensively in medical research and in other areas such as psychology. Results from a well designed and conducted RCT, which show a new treatment to be clinically and statistically superior to current standard practice, can lead to a change in clinical practice. This paper presents a tutorial on RCTs, presenting and discussing the following principles and methods: the trial protocol, choice of control treatment, eligibility criteria, random allocation, outcomes and hypotheses, sample size, subject recruitment, analysis by intention to treat, interim analysis, stopping rules, safety data monitoring/trial management, and study documentation. RCTs are a complicated and logistically involved methodology. Hence, prior to the commitment of resources to such a trial in the development of a new treatment, the safety and clinical promise of the new treatment needs to be demonstrated with preliminary studies. Such preliminary studies have been completed for the Lidcombe Program (LP) of early stuttering intervention, and an RCT of that treatment is being conducted at the time of writing. The principles and methods of RCTs are illustrated with reference to that study.

Educational objectives: The reader will understand the design principles and methods of RCTs. The reader will understand the logistics of conducting a RCT of a treatment for early stuttering.     

Childhood stuttering and speech disfluencies in relation to children's mean length of utterance: a preliminary study

The purpose of this study was to examine the influence of utterance length and complexity relative to the children's mean length of utterance (MLU) on stuttering-like disfluencies (SLDs) for children who stutter (CWS) and nonstuttering-like disfluencies (nonSLDs) for children who do not stutter (CWNS). Participants were 12 (3;1-5;11, years;months) children: 6 CWS and 6 age-matched (+/-5 months) CWNS, with equal numbers in each talker group (CWS and CWNS) exhibiting MLU from the lower to the upper end of normal limits. Data were based on audio-video recordings of each child in two separate settings (i.e., home and laboratory) during loosely structured, 30-min parent-child conversational interactions and analyzed in terms of each participant's utterance length, MLU, frequency and type of speech disfluency. Results indicate that utterances above children's MLU are more apt to be stuttered or disfluent and that both stuttering-like as well as nonstuttering-like disfluencies are most apt to occur on utterances that are both long and complex. Findings were taken to support the hypothesis that the relative "match" or "mismatch" between linguistic components of an utterance (i.e., utterance length and complexity) and a child's language proficiency (i.e., MLU) influences the frequency of the child's stuttering/speech disfluency. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to: (1) compare different procedures for assessing the relationship among stuttering, length and complexity of utterance, (2) describe the difference between relative and absolute measures of utterance length, (3) discuss the measurement and value of mean length of utterance and its possible contributions to childhood stuttering, and (4) describe how length and complexity influence nonstuttering-like disfluencies of children who stutter as well as the stuttering-like disfluencies of children who do not stutter.     

fMRI of developmental stuttering: a pilot study

The purpose of this investigation was to explore the feasibility of fMRI in the study of developmental stuttering. Speech contrasts (loud versus silent reading) and language contrasts (reading of semantically meaningful text versus nonsense words) of six developmental stutterers and six nonstutterers were compared using a commercial 1 Tesla MR-Scanner (Siemens Expert). Results indicate that mapping cortical function in persons who stutter is indeed feasible, even with a 1TMR-system. Compared to normals the stutterers seemed to employ different and particularly less differentiated auditory and motor feedback strategies in speech. They apparently rely on auditory processing and on cerebellar contribution as much during silent reading as during reading aloud. Moreover, they showed a greater involvement of the right hemisphere in language processing, activating not only the typical language areas on the left but also and with equal magnitude the right side homologues of these areas. In spite of the promising results, at present several practical problems such as possible movement artifacts and possible masking through scanner noise still hamper a more straightforward use of fMRI in the study of developmental stuttering.     

Temperament and early stuttering intervention: Two perspectives

PurposeTo discuss clinical applications of research findings about temperament and early stuttering.MethodA “1000-bytes” format (Onslow & Millard, 2012) was used to provide readers with contemporaneous observation of a “conversation” between the authors. The conversation is proceeded by a prologue and followed by concluding statements from each author.ResultsOne author contended that comprehensive, multidimensional assessment of temperament domains is essential during clinical management of early stuttering, and the results of that assessment are best incorporated into a multifactorial treatment approach. The other author contested that view, arguing that such an approach is not empirically justifiable at present.ConclusionsThe authors agree about the salience of research on temperament and early stuttering but have different perspectives about the topic when applied to providing health care for early stuttering.     

Narrative ability in school-age stuttering boys: A preliminary investigation

In a preliminary investigation, narrative ability was compared in stuttering and nonstuttering school-age boys using tasks known to be sensitive to narrative deficits. The groups were also compared on the broader domains of receptive and expressive language development using the Clinical Evaluation of Language Fundamentals - Revised (CELF-R). The results did not support the popular view that stutterers, as a group, are more vulnerable to language disorders than their nonstuttering peers. A recent hypothesis that stuttering behavior might be a causal factor in delayed expressive language development was also not supported. The importance of examining individual differences in stuttering children is emphasized for both clinical and research purposes.     

The recovery rate of early stuttering

PurposeAcross studies there is great variability in reported rates of stuttering recovery. This study examined the impact that different definitions of recovery had on calculation of recovery rates and factors associated with recovery within the same sample of children.MethodSpeech samples and parents and child reports of their experiences of stuttering were collected from 38 children who stuttered aged 2–5 years of age (Occassion-1) and again at 9–13 years of age (Occassion-2). Four different criteria for recovery that were developed representing variations in criteria reported in previous research were applied to data from these children.Results. The majority of the participants (82%) showed very little disfluent speech (<1% syllables stuttered) at Occasion 2. Recovery rate varied greatly depending on the criteria used, ranging from 13.2%–94.7%. Definitions ordered from least to greatest recovery that were (a) parent and clinician report no stuttering and no stuttering observed (13.2 %); (b) ≤1% syllables stuttered; severity rated at ≤1; parent, clinician, and child report recovery (55.3 %); (c) ≤1% syllables stuttered; severity rated at ≤1; parent and clinician report recovery (71.1 %); (d) <3.0 % syllables stuttered (94.7 %). Five participants were considered recovered and two were considered persistent stutters across all criteria. Different factors were associated with recovery from stuttering depending on the criterion used.ConclusionThe concept of recovery from stuttering is complex and estimations of recovery rate are likely to be greatly affected by differences in definitions and measurement across studies. This has a flow-on effect in determining the factors associated with recovery from stuttering.     

Evidence-based treatment of stuttering: II. Clinical significance of behavioral stuttering treatments

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.     

Systematic slowed speech: a new treatment for stuttering.

The purpose of the present study was to determine the effectiveness of a treatment for stuttering based on systematic slowing of speech and anxiety management. Subjects were six stutterers between the ages of 21 and 36. Assessment tasks consisted of recorded conversations with strangers, reading and telephone conversations with strangers, conducted pre- and post-treatment and once a month following treatment for six months. Participants were taught to read and speak progressively at 50, 70 and 90 words a minute over a two week period and received anxiety management training to facilitate maintenance of slowed speech outside of treatment sessions. The results indicated a significant treatment effect for both reading and conversation that was maintained for six months. The telephone task, which was used as a measure of generalization, improved significantly but did not maintain over time.     

Altered auditory feedback and the treatment of stuttering: a review

Several authors have suggested that devices delivering altered auditory feedback (AAF) may be a viable treatment for adults and children who stutter. This paper reviews published, peer reviewed journal papers from the past 10 years that investigate the effect of AAF during different speaking conditions, tasks and situations. A review of that literature indicates that considerable experimental evidence and limited Phase 1 treatment outcome evidence has been accumulated about the effect of AAF on the speech of people who stutter. However, critical knowledge about the effect of AAF during conversational speech and in everyday speaking situations is missing. Knowledge about how to determine the correct levels of AAF for individuals, and the characteristics of those likely to benefit from AAF, also needs to be established. At present there is no reason to accept a recent suggestion that AAF devices would be a defensible clinical option for children. In general device development and availability has occurred at a faster pace than clinical trials research. EDUCATIONAL OBJECTIVES: After reading this paper readers should be able to: (1) describe what altered auditory feedback is and common ways the speech signal is altered in stuttering; (2) describe the effects of AAF on the speech of adults who stutter; (3) provide a critical analysis of the literature in the area of AAF and stuttering.     

The separate and combined effects of GSR biofeedback and delayed auditory feedback on stuttering: A preliminary study

The separate and combined effects of galvanic skin response biofeedback low wave amplitude self regulation (GSR LW) and amplified delayed auditory feedback (DAF) upon stuttering dysfluency are examined. Two college age male stutterers who were seen on an intensive longitudinal basis were the subjects in this study.Results suggest that GSR LW, when it is accomplished, functions to moderately but significantly reduce stuttering dysfluency compared to no GSR biofeedback. This effect does not noticeably dissipate over time. There occurred a marked and sustained reduction in stuttering dysfluency under DAF compared to no DAF conditions. Without separating accomplished and not accomplished GSR LW, there occurred slightly but not statistically significantly fewer blocks under the combined DAF-GSR LW condition than under DAF alone. Nevertheless, it does seem likely, considering these findings overall, that when GSR LW is accomplished, the fluency facilitating effect of its simultaneous combination with DAF is additive i.e., greater than either alone. Possible theoretical and therapeutic implications are discussed.     

High-frequency VEP wavelets in early infancy: A preliminary study

The flash-evoked visual evoked potential (VEP) was recorded in 12 infants 0–12 weeks of age. Along with traditional low-frequency waves (1–35 Hz), high-frequency (50–100 Hz) wavelets were examined. No wavelets were apparent in records obtained from infants below 4 weeks of age, although the low-frequency waves were clearly present at all ages tested. Wavelets showed a steady increase in amplitude and a small decrease in implicit time across the time period studied. The changes in wavelet development can be interpreted as a reflection of the significant postnatal maturation of the primary visual system, particularly the maculo and visual cortex.     

Office-based vs home-based behavioral treatment for obsessive-compulsive disorder: a preliminary study

The current study investigated whether exposure with response prevention (ERP) for obsessive compulsive disorder (OCD) is more effective when administered in a participant's home or other natural environments where symptoms tend to occur, than in a therapist's office. Twenty-eight outpatients with a principal diagnosis of OCD were randomly assigned to receive ERP in their therapist's office vs. wherever their symptoms usually occur (e.g., at home, at work, in public places, in the car, etc.). Participants received 14, 90-min sessions of ERP with an individual therapist. Participants were assessed at pretreatment, post-treatment, and at 3- and 6-month follow-up. Assessments included both self-report as well as clinician-rated indicators of OCD symptom severity, depression, and functional impairment. Results suggested that participants improved significantly, regardless of where treatment occurred. There were no differences in efficacy between the home-based and office-based treatment for OCD. Implications of these findings are discussed.     

"Roadblocks" revisited: neural change, stuttering treatment, and recovery from stuttering

In light of emerging findings concerning untreated recovery and neural plasticity, this paper re-examines the viability of an NIH conference recommendation [Cooper, J. A. (1990). Research directions in stuttering: Consensus and conflict. In Cooper, J. A. (Ed.), Research needs in stuttering: Roadblocks and future directions (pp. 98-100). Rockville, MD: American Speech-Language-Hearing Association.] that adults who have recovered from stuttering might inform our understanding of the nature and treatment of persistent stuttering. It is suggested that those who have recovered could constitute a behavioral, cognitive, and neurophysiologic benchmark for evaluating stuttering treatment for adolescents and adults, while helping to identify the limits of recovery from a persistent disorder. This possibility seems especially promising because of findings from recent studies investigating untreated recovery during childhood and adulthood, the emerging evidence concerning neural plasticity and reorganization, and reports of neural system changes during stuttering treatment. Potential obstacles to applying findings from unassisted recovery to treatment do exist, but the benefits of attempts to fully understand stuttering certainly outweigh the difficulties. EDUCATIONAL OBJECTIVES: After completing this activity, the learner will be able to: (1) describe two complexities involved in determining whether recovery from stuttering was assisted or unassisted; (2) discuss the implications for stuttering research of two neural plasticity research findings from areas other than stuttering; and (3) evaluate the possible implications for stuttering treatment of a coordinated research program that addresses behavioral, cognitive, and neurological characteristics of assisted and unassisted recovery from stuttering.     

Two paradoxes in stuttering treatment

The premise of this article is that effective communication should be a central, overarching goal in the treatment of stuttering. Not focusing on communication may have some unintended negative consequences on treatment. The negative consequences are the result of two paradoxes that confront clinicians and clients: the listener paradox and the communication paradox. The listener paradox concerns the different ways that typical listeners and clinicians respond to stuttering. The communication paradox concerns the use of treatment procedures that may have negative consequences on communication. Clinicians and clients need to evaluate treatment procedures in terms of the effect they may have on communication. Understanding these two paradoxes and making effective communication the focus of treatment may improve the long-term treatment outcomes of people who stutter. EDUCATIONAL OBJECTIVES: The reader will learn about (1) why effective communication should be the central goal in the treatment of stuttering; (2) how the listener and communication paradoxes may negatively impact on communication; and (3) how understanding these paradoxes may improve the long-term outcomes of people who stutter and also improve the comfort level clinicians have in treating individuals who stutter.     

Evidence-based treatment of stuttering: III. Evidence-based practice in a clinical setting

At the heart of evidence-based practice in stuttering treatment are four issues: (1) the collection of data to inform treatment; (2) the long standing concern with maintenance of treatment gains; (3) the need to demonstrate accountability to clients, payers and our profession as service providers; and (4) the desire to advance theoretical knowledge. This article addresses the first three of these issues from a practical point of view, illustrating how data collection for stuttering treatment outcome research in a clinical setting is intimately blended with that required for clinical purposes and providing an example of a process of evaluating data for clinical and research purposes. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) differentiate between treatment outcome and treatment efficacy research, (2) describe models for integrating data collection for treatment outcome and clinical purposes, and (3) utilize guidelines for treatment efficacy that are applicable to outcome research to evaluate data for use in treatment outcome studies and to design outcome studies.     

Australian attitudes towards stuttering: A cross-sectional study

BackgroundNegative reactions experienced by people who stutter often stem from unfounded attitudes and beliefs in the community.PurposeThere is a need to better understand current public attitudes towards stuttering in Australia. The purpose of this study was to: (a) explore the attitudes and knowledge of a large sample of the Australian public using the Public Opinion Survey of Human Attitudes-Stuttering [POSHA-S], (b) identify how the reported attitudes towards, and knowledge of, stuttering compare to existing data, and (c) identify differences between groups for variables identified.MethodsA cross-sectional population study using the POSHA-S was conducted in Melbourne, Australia. Comparisons of the attitudes towards stuttering of this sample were made with data from other worldwide samples on the POSHA-S database. The influence on attitudes to stuttering of variables including age, gender, education level, country of birth, employment status and number of languages spoken was explored.ResultsThe Overall Stuttering Score (OSS) of the Australian sample was higher than the median score on the POSHA-S database. This suggests that the Australian public holds more positive attitudes than those other countries represented in the database. Being younger, more educated, employed, female, monolingual, born in Australia and not familiar with people who stutter were related to more positive attitudes for this sample. Some negative stereotypes towards stuttering were noted; people who stutter were identified as ‘shy and fearful’, and ‘nervous and excitable’.ConclusionsWhile the Australian public has generally positive attitudes towards stuttering, these attitudes still reflect some ‘stuttering stereotypes’.