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.     

Modes of understanding and mindfulness in clinical medicine

Beginning with a case vignette, this paper uses a semiotic approach to analyze several different kinds of understanding used in clinical medicine. By outlining semiotic structures, four distinct modes of understanding can be defined: (1) the representational mode, corresponding to scientific medicine; (2) the pragmatic mode, constituting the basic standpoint of medicine; (3) the hermeneutic mode, underlying the empathic, humanistic spirit of medicine; and (4) the ontologic mode, associated with both the ethical and ritual aspects of medicine. Clarifying the relationship between these modes avoids common confusions in clinical situations. Although experienced clinicians intuitively use these different modes, they do not necessarily reflect upon them. They are instead mindful of them, and this unique multi-modal consciousness, I suggest, provides a model for integrating theory and practice.This work was supported in part by the Robert Wood Johnson Clinical Scholars Program.