Defining stuttering for research purposes

This is a response to a Letter to the Editor entitled “Stuttering prevalence, incidence and recovery rates depend on how we define it: Comment on Yairi & Ambrose’ article Epidemiology of Stuttering: 21st Century advances” by Paul Brocklehurst (2013). The criticism was directed specifically toward Yairi and Ambrose’ conclusions, based on review of recent studies, regarding the incidence and prevalence of stuttering. In this response, Brocklehurst's arguments and suggestions of criteria for incidence research are discussed and negated.     

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.     

Listener perceptions of stuttering and stuttering modification techniques

PurposeThe purpose of this study was to analyse naïve listener perceptions of speech containing unmodified stuttering, use of the pull-out technique, and use of preparatory-sets.MethodParticipants (N = 62) were randomly assigned to listen to one audio sample (unmodified stuttered speech, speech with pull-outs, or speech with preparatory-sets) and completed a survey assessing perceptions of the speaker’s speech and personality and the listener’s comfort level and willingness to social interact with the speaker.ResultsSurvey results revealed low perceptual ratings in all experimental conditions. Unmodified stuttered speech received significantly more positive ratings than the stuttering modification conditions in all measurements except for speech naturalness. Listeners reported being less willing to socially interact with those who use preparatory-sets than unmodified stuttered speech.ConclusionThe use of stuttering modification techniques did not improve listeners’ perceptions or willingness to interact with persons who stutter. Clinicians and those who stutter should be aware that the use of speech techniques will not decrease negative social interactions or stereotypes.     

Relation of motor,linguistic and temperament factors in epidemiologic subtypes of persistent and recovered stuttering: Initial findings

PurposeThe purpose of this study was to determine the presence of any patterns reflecting underlying subtypes of persistence and recovery across epidemiologic, motor, language, and temperament domains in the same group of children beginning to stutter and followed for several years.MethodsParticipants were 58 2–4-year-old CWS and 40 age and gender matched NFC from four different sites in the Midwest. At the end of the multi-year study, stuttering children were classified as Persistent or Recovered. The same protocol obtaining data to measure stuttering, motor, language and temperament characteristics was used at each site. They have not been included in previous reports.ResultsThe Persistent group performed consistently differently from the Recovered and Control groups. They performed lower on standardized language tests and in phonological accuracy, had greater kinematic variability, and were judged by their parents to be more negative in temperament.ConclusionsThe present study provides data supporting the hypothesis that subtypes of stuttering can be identified along persistency/recovery lines, but results were not definitive.Educational Objectives: Readers will be able to (a) describe the current state of subtypes of stuttering research; (b) summarize possible contributions of epidemiologic, motoric, linguistic and temperament to such subtyping with regard to persistency and recovery.     

A three-arm randomized controlled trial of Lidcombe Program and Westmead Program early stuttering interventions

PurposeTo compare two experimental Westmead Program treatments with a control Lidcombe Program treatment for early stuttering.MethodThe design was a three-arm randomized controlled trial with blinded outcome assessments 9 months post-randomization. Participants were 91 pre-school children.ResultsThere was no evidence of difference in percentage syllables stuttered at 9 months among groups. Dropout rates were substantive and may have been connected with novel aspects of the trial design: the use of community clinicians, no exclusion criteria, and randomization of children younger than 3 years of age.ConclusionThe substantive dropout rate for all three arms in this trial means that any conclusions about the 9-month stuttering outcomes must be regarded as tentative. However, continued development of the Westmead Program is warranted, and we are currently constructing an internet version.     

An exploratory factor analysis of action responses to stuttering anticipation

PurposeWe previously introduced theStuttering Anticipation Scale (SAS; Jackson, E. S., Gerlach, H., Rodgers, N. H., & Zebrowski, P. M. (2018). My Client Knows That He’s About to Stutter: How Can We Address Stuttering Anticipation during Therapy with Young People Who Stutter? Seminars in Speech and Language, 39, 356–370) – a non-standardized self-report measure for children, teens, and adults who stutter (CWS, TWS, AWS) that quantifies how often they engage in 25 commonly reported action responses to anticipation. The purpose of this study was to leverage the SAS to explore the factor structure of action responses to stuttering anticipation.MethodsA total of 121 people who stutter completed the SAS online (27 CWS, 40 TWS, 54 AWS). We used exploratory factor analysis (EFA) to determine the underlying latent variables within the 25 SAS items that characterize how people who stutter respond to anticipation.ResultsA three-factor model was most appropriate for the data with regard to factor loadings and other model fit indices. The three factors were named: avoidance (17 items), physical change (4 items), and approach (4 items).ConclusionUnderstanding these three types of action responses to anticipation can help guide clinical decision-making by providing a novel framework for clinicians and their clients who stutter to discuss how the client tends to respond to anticipation, and explore ways to facilitate productive responses to anticipation.     

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.     

The social and communication impact of stuttering on adolescents and their families

Purpose

Stuttering can cause wide ranging psychosocial impact. This is particularly the case for adolescents who may face additional physical, emotional and personality changes as they become adults. This study reports the findings of an investigation into the social and communication impacts of stuttering on Australian adolescents seeking treatment for stuttering and their families.

Method

A cross-sectional design utilising questionnaires assessed the self-perceived communication competence and apprehension, stigma and disclosure, and experiences of teasing and bullying of 36 adolescents who stutter. Additionally, the impact of stuttering on the families of these adolescents was investigated.

Results

Adolescents who stutter have below average self-perceived communication competence, heightened communication apprehension, are teased and bullied more often than fluent peers, and they try to keep their stuttering secret. The families of the adolescents in the study reported high levels of emotional strain, family conflict and difficulty managing their child's frustrations.

Conclusion

The findings from this study emphasise the wide-ranging impact of stuttering beyond the surface level behaviours. Clinicians working with adolescents who stutter should take note of both the outcomes of this study and the suggestions for more effectively coping with the condition in this population.Educational objectives: The reader will be able to: (a) summarise findings with regards to the impact of stuttering on an adolescent's social and communication skills; (b) summarise areas of impact on the families of adolescents who stutter; (c) compare these findings with previous reported data for this population; (d) discuss the clinical implications of the results for working with adolescents who stutter and their families.     

The impact of stuttering on employment opportunities and job performance

The purpose of this study was to examine the impact that stuttering has on job performance and employability. The method involved administration of a 17-item survey that was completed by 232 people who stutter, age 18 years or older. Results indicated that more than 70% of people who stutter agreed that stuttering decreases one's chances of being hired or promoted. More than 33% of people who stutter believed stuttering interferes with their job performance, and 20% had actually turned down a job or promotion because of their stuttering. Results also indicated that men and minorities were more likely to view stuttering as handicapping than were women and Caucasians. These findings suggest that people who stutter believe stuttering to be handicapping in the workplace. The results may be helpful for clinicians who work with people who stutter.

Educational objectives:

The reader will be able to: (1) describe the impact that stuttering can have on employability and job performance and (2) be better able to explain how factors such as gender, ethnicity, and stuttering severity can impact the belief that stuttering is a handicapping condition.     

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’.     

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.     

Changing adolescent attitudes toward stuttering

Purpose

Live oral or recorded video presentations on stuttering were delivered to high school students in order to determine the extent to which their attitudes toward stuttering could be improved.

Methods

A classroom teacher administered the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S) to two health classes before and after an oral live presentation by a person who stutters. She also gave the POSHA-S to two other similar classes before and after a True Life^®: I Stutter video presentation. The stuttering person in the oral condition was one of three people featured in the video. Also, following the video condition, students filled out the POSHA-S a third time after a short oral presentation by the same person who stutters.

Results

Measured attitudes improved overall on the POSHA-S and on selected items.

Conclusions

High school students hold similar attitudes toward stuttering and stutterers as adults, and these attitudes can be improved, at least temporarily, by a presentation on stuttering but more via a live presentation than a professionally prepared video.Educational objectives: (1) The reader will identify different ways to improve attitudes toward stuttering in high school students. (2) The reader will list advantages and disadvantages of live oral presentations and recorded video presentations as strategies to change attitudes toward stuttering. (3) The reader will identify characteristics of a speaker that can assist in attitude changes of high school students.     

Resilience in people who stutter: Association with covert and overt characteristics of stuttering

PurposeRecent literature stresses the importance of resilience, as a trait, for successful coping with life’s difficulties or stressors. However, only a limited number of studies were conducted on resilience among people-who-stutter (PWS). These studies did not examine the association between resilience and the specific characteristics of stuttering. This study was, therefore, aimed to directly examine the association between resilience and measures of both the covert and overt characteristics of stuttering.MethodThirty adults who stutter completed the Connor-Davidson Resilience Scale (CD-RISC) and the Overall Assessment of Speaker’s Experience of Stuttering - Adults (OASES-A). In addition, stuttering severity of all participants was quantified using the Stuttering Severity Instrument-4 (SSI-4). The associations between all measures were examined statistically.ResultsA strong and significant association was found between the participants' scores on the CD-RISC and the OASES-A (r= -.79, p < .001). In contrast, no significant correlation was found between the participants' scores in the CD-RISC and the SSI-4 (r = .02, p > .05). Within our cohort, no significant association was observed between the participants’ gender and age and their resilience levels (p > 0.05).ConclusionThis study demonstrates the role of resilience in shaping the individual's experience with stuttering. Results also show that the individuals' resilience levels do not necessarily predict stuttering severity per se, or its overt manifestations but can predict the individuals' subjective perception of his/her stuttering. This highlights the importance of addressing and promoting resilience among PWS in stuttering therapy.     

The duration component of the stress effect in stuttering

The purpose of the present study was to investigate whether there is a relationship between stuttering on stressed syllables and the duration of these syllables. Sixteen adults who stutter read a text consisting of 226 syllables. The relative stress of each syllable was rated, and syllables were categorized into long- and short-stressed syllables, unstressed syllables and intermediate syllables lying in-between. In order to isolate effects caused by within-word position from those caused by linguistic stress, syllables in initial and in subsequent positions were analyzed separately. In both word position categories stressed syllables were stuttered more often than unstressed syllables. Stuttering frequency of intermediate syllables seems to be in-between stressed and unstressed syllables, just as their stress level is rated in-between. Results regarding the duration of stressed syllables do not allow final conclusions.

Educational objectives: The reader will learn about and be able to describe (1) language factors related with stuttering events, (2) the stress effect in adults who stutter, and (3) methods to control for its confounding variables.     

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.     

Language skills of children during the first 12 months after stuttering onset

PurposeTo describe the language development in a sample of young children who stutter during the first 12 months after stuttering onset was reported.MethodsLanguage production was analysed in a sample of 66 children who stuttered (aged 2–4 years). The sample were identified from a pre-existing prospective, community based longitudinal cohort. Data were collected at three time points within the first year after stuttering onset. Stuttering severity was measured, and global indicators of expressive language proficiency (length of utterances and grammatical complexity) were derived from the samples and summarised. Language production abilities of the children who stutter were contrasted with normative data.ResultsThe majority of children’s stuttering was rated as mild in severity, with more than 83% of participants demonstrating very mild or mild stuttering at each of the time points studied. The participants demonstrated developmentally appropriate spoken language skills comparable with available normative data.ConclusionIn the first year following the report of stuttering onset, the language skills of the children who were stuttering progressed in a manner that is consistent with developmental expectations.     

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.     

The Public Opinion Survey of Human Attributes--Stuttering (POSHA-S): summary framework and empirical comparisons

Purpose

The Public Opinion Survey of Human Attributes-Stuttering (POSHA-S) was developed to make available worldwide a standard measure of public attitudes toward stuttering that is practical, reliable, valid, and translatable. Mean data from past field studies as comparisons for interpretation of POSHA-S results are reported.

Method

Means for POSHA-S items (converted to −100 to +100 scales), components comprising clusters of items, subscores comprising clusters of components, and Overall Stuttering Scores comprising two subscores for stuttering were generated from 64 samples, totaling 2876 respondents who completed experimental versions of the POSHA-S.

Discussion

Lowest, highest, and median sample values, which vary with the addition of new sample data to the growing POSHA-S database archive, provide points of comparison for any potential sample rather than predetermined values.

Conclusions

The final POSHA-S, together with an ongoing and growing archive, can provide increasingly meaningful comparisons for stakeholders measuring public attitudes toward stuttering.Educational objectives: (1) Describe the subscores and components of the POSHA-S, (2) describe the Overall Stuttering Score of the POSHA-S, and (3) describe the format for interpretation of the POSHA-S.