A randomized control trial to investigate the impact of the Lidcombe Program on early stuttering in German-speaking preschoolers

In order to investigate whether the Lidcombe Program effects a short-term reduction of stuttered speech beyond natural recovery, 46 German preschool children were randomly assigned to a wait-contrast group or to an experimental group which received the Lidcombe Program for 16 weeks. The children were between 3;0 and 5;11 years old, their and both of their parents’ native language was German, stuttering onset had been at least 6 months before, and their stuttering frequency was higher than 3% stuttered syllables. Spontaneous speech samples were recorded at home and in the clinic prior to treatment and after 4 months. Compared to the wait-contrast group, the treatment group showed a significantly higher decrease in stuttered syllables in home-measurements (6.9%SS vs. 1.6%SS) and clinic-measurements (6.8%SS vs. 3.6%SS), and the same increase in articulation rate. The program is considered an enrichment of currently applied early stuttering interventions in Germany.

Educational objectives: Readers will discuss and evaluate: (1) the short-term effects of the Lidcombe Program in comparison to natural recovery on stuttering; (2) the impact of the Lidcombe Program on early stuttering in German-speaking preschool children.     

The Lidcombe Program of early stuttering intervention for Malaysian families: Four case studies

PurposeThis study investigated the outcomes of implementing the Lidcombe Program, an evidence-based early intervention for stuttering, with four preschool children in Malaysia. Early stuttering intervention is currently underdeveloped in Malaysia, where stuttering treatment is often more assertion-based than evidence-based. Therefore, introducing an evidence-based early stuttering intervention is an important milestone for Malaysian preschoolers who stutter.MethodThe participants ranged from 3 years 3 months to 4 years 9 months at the start of the study. Beyond-clinic speech samples were obtained at 1 month and 1 week pretreatment and immediately post-Stage 1, and at 1 month, 3 months, 6 months and 12 months post-Stage 1.ResultsTwo participants, who were bilingual, achieved near-zero levels of stuttering at 12 months posttreatment. Near zero levels of stuttering were also present in their untreated languages. One participant withdrew due to reasons not connected with the research or treatment. The remaining participant, who presented with severe stuttering, completed Stage 1 but had some relapse in Stage 2 and demonstrated mild stuttering 12 months post-Stage 1.ConclusionsThe outcomes were achieved without the need to significantly adapt Lidcombe Program procedures to Malaysian culture. Further research to continue evaluation of the Lidcombe Program with Malaysian families and to estimate proportion of those who will respond is warranted.     

Experimental treatment of early stuttering: a preliminary study

This pilot study compared two treatments for stuttering in preschool-age children. Thirty children were randomly assigned to either a Lidcombe Program (LP) treatment or a Demands and Capacities Model (DCM) treatment. Stuttering frequencies and severity ratings were obtained immediately before and after treatment (12 weeks). The stuttering frequencies and severity ratings significantly decreased for both treatment groups. No differences between groups were found. Parents of children in both groups were cooperative in many respects, and there were no differences between them on scales that measured their satisfaction with the two treatments. The findings suggest that randomized controlled trials of LP versus DCM treatments are feasible, and they underline the need for experimental analyses of the two treatments. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) describe the principles and methods of Lidcombe treatment for early stuttering; (2) delineate principles and methods of Demands and Capacities Model treatment; and (3) summarize results of an investigation that compared these programs' relative effects in a pilot study.     

No other choice: Speech-Language Pathologists’ attitudes toward using telepractice to administer the Lidcombe Program during a pandemic

PurposeTelepractice has been shown to be a viable modality for the delivery of stuttering treatment. Since the advent of COVID-19, speech-language pathologists must adapt in-clinic treatments for online presentation. This research aimed to gather information from speech-language pathologists on their experiences of telepractice to deliver the Lidcombe Program to treat stuttering in young children.MethodsThis paper presents the findings of an online survey that polled the clinical experiences of 106 speech-language pathologists who were delivering the Lidcombe Program via telepractice during COVID-19.ResultsThe majority of respondents were experienced clinicians from the United States and Canada who had attended a Lidcombe Program workshop. Prior to COVID-19, 80 % had provided some clinical services online (up to 10 % of the time), and at the start of COVID-19 public lockdown orders, 77 % viewed telepractice as both a necessity and an opportunity. Three months after the public lockdown orders, the large majority, 94 %, said that they would continue to use both telepractice and in-clinic treatment in the future. Technology issues, concerns about establishing the clinical relationship, and identification of mild stuttering featured as challenges of telepractice service delivery, while benefits included time efficiency, flexibility of scheduling, and improved clinical processes.ConclusionRespondents reported that the Lidcombe Program was easily translatable to telepractice and the majority intend to continue telepractice in the future.     

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.     

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.     

Interventions for children and adolescents who stutter: A systematic review,meta-analysis,and evidence map

PurposeThis systematic review critically appraises and maps the evidence for stuttering interventions in childhood and adolescence. We examine the effectiveness of speech-focused treatments, the efficacy of alternative treatment delivery methods and identify gaps in the research evidence.MethodsNine electronic databases and three clinical trial registries were searched for systematic reviews, randomised controlled trials (RCTs) and studies that applied an intervention with children (2–18 years) who stutter. Pharmacological interventions were excluded. Primary outcomes were a measure of stuttering severity and quality assessments were conducted on all included studies.ResultsEight RCTs met inclusion criteria and were analysed. Intervention approaches included direct (i.e. Lidcombe Program; LP) and indirect treatments (e.g. Demands and Capacities Model; DCM). All studies had moderate risk of bias. Treatment delivery methods included individual face-to-face, telehealth and group-based therapy. Both LP and DCM approaches were effective in reducing stuttering in preschool aged children. LP had the highest level of evidence (pooled effect size=-3.8, CI -7.3 to -0.3 for LP). There was no high-level evidence for interventions with school-aged children or adolescents. Alternative methods of delivery were as effective as individual face-to-face intervention.ConclusionThe findings of this systematic review and evidence mapping are useful for clinicians, researchers and service providers seeking to understand the existing research to support the advancement of interventions for children and adolescence who stutter. Findings could be used to inform further research and support clinical decision-making.     

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.     

Unassisted recovery from stuttering: self-perceptions of current speech behavior, attitudes, and feelings

The purpose of this study was to investigate the nature of recovery from stuttering based on the experiences of adults who recovered without treatment. Using a semi-structured, open-ended interview format, 15 speakers verified as persons who recovered without treatment were asked to describe their status as everyday speakers. Seven speakers reported that they no longer stuttered and eight reported that they still stuttered on occasion. Interview material was coded and analyzed by the investigators and checked by independent judges. Results suggested that complete recovery was possible for speakers who reported that they no longer stuttered; whereas, those who still stuttered occasionally appeared to no longer be handicapped by stuttering, but required some vigilance to maintain their relatively fluent speech.

Educational objectives: After completing this activity, the learner will be able to: (1) describe the relevance of self-report data for evaluating the nature of recovery from stuttering without treatment; (2) describe the differences in self-perception concerning the nature of recovery for those who no longer have any tendency to stutter compared to those who still have an occasional tendency to stutter; and (3) suggest the possible implications for understanding the nature of recovery from persistent stuttering based on investigations of late recovery without treatment.     

A cross-cultural, long-term outcome evaluation of the ISTAR Comprehensive Stuttering Program across Dutch and Canadian adults who stutter

There is a need to evaluate the effectiveness of stuttering treatment programs delivered in domestic and international contexts and to determine if treatment delivered internationally is culturally sensitive. Evaluation of the effectiveness of the ISTAR Comprehensive Stuttering Program (CSP) within and across client groups from the Netherlands and Canada revealed generally positive results. At 2 years post-treatment both groups were maintaining statistically significant reductions in stuttering frequency and improvements in attitudes, confidence, and perceptions as measured by the Revised Communication Attitude Inventory (S24), Perceptions of Stuttering Inventory (PSI), and the approach scale of the Self-Efficacy Scaling by Adult Stutterers (SESAS). Data pooled across the groups on these measures gave evidence of a global treatment effect with standardized effect sizes ranging from typical to larger than typical in the behavioural sciences. Only two differences between the groups emerged: differences in speech rate and perception of self. Given that these groups represent two distinct cultures, differences were discussed in terms of whether they could be due to cultural, methodological, or other variables. Overall, results suggest that, the CSP appears to be similarly effective in both cultures and thus, sufficiently sensitive to the culture of Dutch adults who stutter.

Educational objectives: The reader will be able to (a) describe a methodology that can be used in a clinical setting to evaluate the long-term effectiveness of stuttering treatment with adults, (b) describe some of the challenges in developing a model of clinically meaningful outcome, (c) explain the rationale for the need for cross-cultural investigations of treatment outcome, and (d) summarize speech and self-report results of the cross-cultural evaluation of an integrated stuttering treatment program.     

Contemporary issues with stuttering: The Fourth Croatia Stuttering Symposium

PurposeDuring the 2019 Fourth Croatia Clinical Symposium, speech-language pathologists (SLPs), scholars, and researchers from 29 countries discussed speech-language pathology and psychological practices for the management of early and persistent stuttering. This paper documents what those at the Symposium considered to be the key contemporary clinical issues for early and persistent stuttering.MethodsThe authors prepared a written record of the discussion of Symposium topics, taking care to ensure that the content of the Symposium was faithfully reproduced in written form.ResultsSeven contemporary issues for our field emerged from the Symposium.ConclusionEffective early intervention is fundamental to proper health care for the disorder. However, as yet, there is no consensus about the timing of early intervention and how it should be managed. Currently, clinical translation is a barrier to evidence-based practice with early stuttering, and proactive strategies were suggested for junior SLPs. Apprehension emerged among some discussants that treatment of early stuttering may cause anxiety. For persistent stuttering, assessment procedures were recommended, as were strategies for dealing with childhood bullying. There was agreement that SLPs are the ideal professionals to provide basic cognitive-behavior therapy for clients with persistent stuttering. Questions were raised about our discipline standards for basic professional preparation programs for stuttering management.     

Treatment of disfluency: Future trends

Factors impeding the development of innovative stuttering treatment programs in the United States are described. The United States clinicians' obsession with employing learning paradigms to explain and treat stuttering is suggested as a major factor impeding the development of more effective treatment strategies. The perpetuation of the “frequency fallacy,” which suggests that disfluency counts are the single most valid measure of stuttering is one result of this fixation on learning models. The fear of early intervention is another. Future trends are discussed with respect to the adoption of more meaningful therapy goals, an increasing emphasis on early intervention, an awareness of the significance of metalinguistic skills to early intervention, the value of commercially produced therapy programs, an increased awareness of the limitation of short-term intensive treatment programs, the recognition of the life-long chronic stutterer, and the development of support systems for the adult stutterer.     

Clinician attitudes toward stuttering: A decade of change (1973–1983)

The attitudes of 674 speech-language pathologists toward stuttering, stutterers, stuttering therapy, parents of stutterers, and related issues were studied during the years 1973–1983. During that period, clinician attitudes were found to shift away from support of the John-sonian concepts, which suggest parental causality and dangers in early intervention. In addition, clinicians became less likely to perceive stutterers as possessing psychologic disorders and misperceptions of their problem and of their interpersonal relationships. However, a significant number of clinician's were found to continue to hold unsubstantiated beliefs regarding the personality of stutterers, their parents, and the efficacy of early intervention with very young stutterers. The results of the study were interpreted as suggesting the need to educate fluency specialists.     

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 practice in stuttering: Some questions to consider

A recent forum in JFD (28/3, 2003) evaluated the status of evidence-based practice in fluency disorders, and offered recommendations for improvement. This article re-evaluates the level of support available for some popular approaches to stuttering therapy and questions the relative value placed on some types of programs endorsed by the forum. Evidence-based practice is discussed within the context of emerging concerns over its application to non-medical interventions and suggestions are made for grounding fluency interventions by reference to empirically supported principles of change. A popular, evidence-based intervention for stuttering in young children (the Lidcombe program) is evaluated within the suggested parameters. EDUCATIONAL OBJECTIVES: After reading this article, the reader will be able to: (1) evaluate the status of evidence-based practice in fluency disorders; (2) list concerns about the impact of narrow interpretation of EBP on research and practice in the field of fluency disorders and other non-medical domains; (3) articulate the role of theory and basic research in selecting among and evaluating therapy approach options.     

The relationship between pre-treatment clinical profile and treatment outcome in an integrated stuttering program

A procedure for subtyping individuals who stutter and its relationship to treatment outcome is explored. Twenty-five adult participants of the Comprehensive Stuttering Program (CSP) were classified according to: (1) stuttering severity and (2) severity of negative emotions and cognitions associated with their speech problem. Speech characteristics (percentage of stuttered syllables, distorted speech score, and the number of correctly produced syllables on a diadochokinesis task) and emotional/cognitive states (emotional reaction, speech satisfaction, and attitudes toward speaking) were assessed before and after treatment, and at a 1- and 2-year follow-up. The results showed that: (a) there was no relationship between stuttering severity and the severity of negative emotions and cognitions, (b) the severe stuttering group had the largest treatment gains but also the highest level of regression, and (c) at post-treatment and both follow-up assessments the differences on measures of emotions between the mild and severe emotional group had disappeared, chiefly due to a large decrease in the latter group's negative emotions and cognitions. Our findings show that, based on treatment gains, specific subgroups can be identified, each requiring different treatment approaches. This underlines the necessity of developing a better understanding of how various dimensions of stuttering relate to treatment outcome. Educational objectives: The reader will be able to: (1) describe why stuttering severity and negative emotions and cognitions that are related to stuttering should be investigated separately and (2) describe how treatment outcome relates to subtypes of persons who stutter.     

A palmar sweat measure of the effect of drugs on stuttering behavior

The question is asked why drugs designed to affect physiological responses associated with anxiety do not affect stuttering if the antecedent of stuttering is anxiety? Sixteen stutterers and sixteen matched controls each participated in four conditions which were twenty-four hours apart. There were two experimental conditions where the subject received medication prior to participation. One drug was nembutal and the other benzedrine. There were also two control conditions; one in which the subject received a sugar pill and the other where he received nothing. Three simultaneous measures were made of Palmar Sweat Index (PSI), number of non-fluencies, and reading rate. The order of participation among the conditions was counterbalanced.

As a main effect the study indicated that drugs do not affect stuttering. However the interaction of drugs with the order in which drugs were administered was significant. Subjects who received nembutal as the first condition stuttered more on all four conditions than those subjects who received nembutal last. Benzedrine had little effect on stuttering. It was concluded that nembutal causes a release of stuttering and stuttering, once released, gets conditioned to the situation and continues at a high level. Theoretical explanation for such findings is presented.     

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.     

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.     

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.