Anxiety and stuttering: continuing to explore a complex relationship

Reliability and validity of the unhelpful thoughts and beliefs scale for Persian-speaking adults who stutter (UTBAS-P): A cross-cultural examination of social anxiety in people who stutter

BACKGROUND AND AIM

An increasing body of research indicates that many adults who stutter (AWS) experience anxiety in social and verbal situations. The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) scales were developed to assess speech-related anxiety and negative cognitions associated with stuttering. This study aimed to translate the UTBAS into Persian, investigate its psychometric properties for Persian-speaking AWS, and compare the results with previously published UTBAS scores across various cultures.

METHOD

The UTBAS scales were translated into Persian according to the protocols of the International Quality of Life Assessment Project and the World Health Organization. Sixty-two adults with developmental stuttering, aged between 18 and 51 years, participated in this study. The psychometric properties of UTBAS-P were investigated using similar measures to those used in previous studies where valid and reliable versions were available. Additionally, UTBAS-P scores were compared to UTBAS scores previously reported for Australian, Japanese, and Turkish participants.

RESULTS

The results showed that UTBAS-P had an acceptable face, content, and construct validity. It was significantly correlated with other anxiety-related measures. Additionally, its low and negative correlations with unrelated constructs, such as the NEO-PI-R domains of openness, agreeableness, and conscientiousness, confirmed its divergent validity. Regarding reliability, the significant test-retest reliability score (Pearson r = 0.87, p < 0.001) confirmed the stability of UTBAS-P scores over time, and its internal consistency was confirmed by Cronbach's alpha of 0.99. Similarities and differences were found between participants' UTBAS scores across different cultures.

CONCLUSION

All four currently translated versions of the UTBAS have demonstrated high levels of validity and reliability, showing strong correlations with well-known anxiety measures. These findings suggest that the UTBAS has potential for use both clinically and in cross-cultural studies.

Self-inefficacy's impact on well-being indices in students self-identifying with cluttering characteristics

INTRODUCTION

Cluttering, a fluency disorder characterized by fast and irregular speech patterns, receives relatively limited research attention. Consequently, the association between cluttering and measures of well-being remains unexplored. In contrast, stuttering, another fluency disorder, has been associated with anxiety and depression. The present study examines whether an individual's experience of cluttering characteristics is related to alterations in both positive and negative measures of well-being. To achieve this, we assessed the relationship between Self-Identified Cluttering Characteristics (SICC) and measures of well-being in a sizeable sample of 1201 university students. Our main objective was to explore the potential impact of self-inefficacy on the association between SICC and well-being.

METHODS

Consistent with prior research, participants identified themselves as having cluttering characteristics (SICC) or no-cluttering characteristics (SINCC) based on a verbal and written explanation of the disorder. They also completed questionnaires on psychological well-being indices and self-inefficacy.

RESULTS

In total, 276 respondents identified themselves as having cluttering characteristics. In regression models, both SICC and self-inefficacy were predictive of greater negative well-being, increased depressive symptoms, and heightened psychosomatic symptoms. Interestingly, ADHD diagnosis was associated with less negative well-being. Positive well-being indicators (positive future orientation and subjective happiness) were solely predicted by self-inefficacy. Supporting these findings, supplementary regressions including only 56 SICC participants who reported being treated for cluttering yielded similar results. Utilizing Hayes's PROCESS computational procedures to test moderation revealed that self-inefficacy significantly moderated the association between SICC and negative well-being (depressive symptoms) as well as the association between SICC and positive well-being (positive future orientation).

CONCLUSIONS

The findings underscore alterations in well-being among individuals who identify themselves as experiencing cluttering characteristics. Primarily, heightened negative well-being was noted in those with SICC, yet individual self-inefficacy reports mitigated this effect. Overall, SICC exacerbates negative well-being rather than diminishing positive well-being. These findings point to the importance of integrating mental health assessment and intervention into clinical practice for individuals with cluttering symptoms and the potential benefits of interventions targeting self-inefficacy to improve overall well-being in this population.

Cognitive processing biases of social anxiety in adults who do and do not stutter

PURPOSE

Adults who stutter are at risk of developing high levels of social anxiety, leading to negative outcomes and contributing towards stuttering relapse post treatment. To ensure that psychological treatments for social anxiety in stuttering adults are relevant and effective, a broader empirical understanding of the mechanisms of social anxiety in stuttering populations is required. Four key cognitive processing biases identified as maintenance factors in cognitive behavioral models of social anxiety were examined: self-focused attention, safety behavior use, negative self-imagery, and interpretation bias.

METHODS

Adults who stutter and non-stuttering adults (N = 186) were assessed via an online survey. Participants were categorised into two groups based on stuttering: formally diagnosed stuttering and non-stuttering. Within those groups, participants were further categorised as having low or high levels of social anxiety. Cognitive processing bias was assessed in response to two hypothetical social scenarios (i.e., social interaction and social performance).

RESULTS

As predicted, in both adults who stutter and who are non-stuttering, high social anxiety was related to greater self-focused attention, safety behavior use and negative self-imagery compared to low social anxiety. No significant effect of social anxiety or stuttering was found in relation to interpretation bias. A significant effect of social anxiety upon negative self-imagery was observed in formally-diagnosed adults who stutter compared to non-stuttering adults.

CONCLUSION

The results support the use of cognitive behavioral models of social anxiety as a framework for research and treatment development within stuttering populations.

Psychedelics in developmental stuttering to modulate brain functioning: a new therapeutic perspective?

Developmental stuttering (DS) is a neurodevelopmental speech-motor disorder characterized by symptoms such as blocks, repetitions, and prolongations. Persistent DS often has a significant negative impact on quality of life, and interventions for it have limited efficacy. Herein, we briefly review existing research on the neurophysiological underpinnings of DS -specifically, brain metabolic and default mode/social-cognitive networks (DMN/SCN) anomalies- arguing that psychedelic compounds might be considered and investigated (e.g., in randomized clinical trials) for treatment of DS. The neural background of DS is likely to be heterogeneous, and some contribution from genetically determinants of metabolic deficiencies in the basal ganglia and speech-motor cortical regions are thought to play a role in appearance of DS symptoms, which possibly results in a cascade of events contributing to impairments in speech-motor execution. In persistent DS, the difficulties of speech are often linked to a series of associated aspects such as social anxiety and social avoidance. In this context, the SCN and DMN (also influencing a series of fronto-parietal, somato-motor, and attentional networks) may have a role in worsening dysfluencies. Interestingly, brain metabolism and SCN/DMN connectivity can be modified by psychedelics, which have been shown to improve clinical evidence of some psychiatric conditions (e.g., depression, post-traumatic stress disorder, etc.) associated with psychological constructs such as rumination and social anxiety, which also tend to be present in persistent DS. To date, while there have been no controlled trials on the effects of psychedelics in DS, anecdotal evidence suggests that these agents may have beneficial effects on stuttering and its associated characteristics. We suggest that psychedelics warrant investigation in DS.

The experience of stuttering in everyday life among adults who stutter: The impact of trait social anxiety and the social situations

PURPOSE

The purpose of this study was to investigate the emotional and stuttering experience of adults who stutter (AWS) in everyday life, and how that experience may be shaped by personal (i.e., trait social anxiety) and situational factors (i.e., social partner reaction, communication channel type, social closeness, stuttering knowledge).

METHOD

AWS completed ecological momentary assessments on their smartphones multiple times a day for up to three weeks. Data (n = 62) were analyzed with multilevel models to determine how situational factors and trait social anxiety influence the Negative Affect (NA), Positive Affect (PA), and self-reported stuttering severity of AWS.

RESULTS

Results indicated that having high (vs. low) trait social anxiety was associated with a tendency to experience high NA, low PA, and high self-reported stuttering severity among AWS. A range of situational factors significantly influenced the within-person variation of NA, PA, and self-reported stuttering severity in everyday life. In addition, interacting with distant social partners relative to being alone heightened NA, and the effect was more prominent among AWS with high (vs. low) trait social anxiety.

CONCLUSIONS

Overall, the findings suggest that the variation of affects and stuttering severity among AWS can be partly accounted for by factors from both the situational and personal levels. Clinicians should be aware of the low PA experienced by AWS who have high (vs low) trait social anxiety in everyday life.

Psychometric properties of the Persian version of the stuttering generalization self-measure tool in adults who stutter

PURPOSE

Our study aimed to translate the Stuttering Generalization Self-Measure (SGSM) into Persian and investigate its validity, reliability, and internal responsiveness in the Iranian population.

METHOD

This study was conducted on 30 adults who stutter (AWS) and 30 adults who do not stutter (AWNS). The International Quality of Life Assessment protocol (IQOLA) was applied to translate SGSM into Persian. The face and content validity were determined. Also, the discriminant validity was evaluated by comparing the scores of two groups. In addition, the internal consistency test-retest, and inter-judge reliability were assessed with Cronbach's alpha and intra-class correlation coefficients (ICC). Moreover, the mean standardized response (MSR) and the standardized effect size were measured to determine the internal responsiveness using pre- and post-treatment data.

RESULTS

All the items were comprehensible and clear. The content validity ratio (CVR) and content validity index (CVI) for all nine questions were obtained higher than.62 and.9, respectively. The internal consistency value was high (Cronbach's alpha =.98). For the test-retest reliability, ICC values were excellent, ranging from.93 to.99. The discriminant validity results revealed a significant difference between AWS and AWNS (p < .001). Pre- and post-treatment results indicated high internal responsiveness to changes for percentage of syllable stuttered (SS%) (MSR = 1.09).

CONCLUSION

The Persian version of SGSM (P-SGSM) benefits from the high values for validity and reliability. Furthermore, it distinguishes the AWS and AWNS and reflects the treatment changes significantly.

Associations between social anxiety, physiological reactivity, and speech disfluencies in autistic young adults and controls

INTRODUCTION

The aim of this study was to examine possible associations of social anxiety (SA) and speaking-related physiological reactivity with the frequencies of a) total disfluencies, b) typical disfluencies, and c) stuttering-like disfluencies, as well as d) stuttering-severity in autistic young adults and controls.

METHODS

Thirty-two autistic young adults and 35 controls participated in this study. Participants were presented with video clips (viewing condition) and were then asked to talk about the videos (narrating condition). SA was measured by the self-report Social Phobia and Anxiety Inventory (SPAI). Speaking-related physiological reactivity was measured by the electrodermal activity (EDA), an index of emotional arousal. The speech samples from the narrating condition were analyzed for type and frequency of speech disfluencies and used for determining the stuttering severity. SA and speaking-related physiological reactivity were compared between the groups. Correlation between SA, physiological reactivity, disfluency frequencies, and stuttering severity were tested separately for both groups.

RESULTS

No between-group differences were found in the overall SA, yet differences were found in SPAI subscales of social interaction, group interaction, and avoidance, as well as in agoraphobia. Both groups had higher physiological arousal in narrating condition in comparison to the video viewing condition, yet there was no between-group difference in the reactivity. No associations were found between SPAI measures, physiological reactivity, disfluency frequencies, and stuttering severity in the autistic group. In the control group, a negative association was found between physiological reactivity and total and typical disfluency frequencies.

CONCLUSIONS

SA or speaking-related physiological reactivity were not associated with disfluency frequencies or stuttering severity in autistic persons. Negative association between physiological reactivity and disfluency frequencies found in the control group may indicate that the physiological arousal may impact the speech production process by reducing the overt disfluencies.

Evaluation of an Integrated Fluency and Acceptance and Commitment Therapy Intervention for Adolescents and Adults Who Stutter

PURPOSE

Developmental stuttering is a complex and multifaceted neurodevelopmental disorder that may cause pervasive negative consequences for adults who stutter (AWS). Historically, intervention for AWS has primarily addressed speech fluency, with less focus on the covert psychosocial aspects of the disorder. The purpose of this article is to report on a feasibility trial evaluating a novel integrated intervention that combines traditional stuttering management techniques with Acceptance and Commitment Therapy (ACT) for AWS.

METHOD

Twenty-nine AWS participated in the feasibility trial. All participants successfully completed a combined fluency and ACT intervention, titled the fluency and Acceptance and Commitment Therapy for Stuttering (fACTS) Program. As this was a feasibility study, no control group was included. Intervention was administered by two certified practicing speech-language pathologists, over eight 60- to 90-min sessions.

RESULTS

Generalized linear mixed modeling was used to determine change from pre- to post-intervention and follow-up. Significant pre- and post-intervention improvements in self-efficacy, psychosocial functioning, and psychological flexibility were observed, along with significant reductions in observable stuttering behaviors (i.e., stuttered speech frequency). Intervention gains for all variables of interest were maintained 3 and 6 months post-intervention.

CONCLUSIONS

The fACTS Program was created to be a holistic and flexible intervention to promote self-efficacy beliefs and address stuttering-related psychosocial impacts and speech fluency goals of AWS. Preliminary results indicated positive improvement in all psychosocial outcomes (i.e., self-efficacy, psychosocial impact, and psychological flexibility) and observable speech fluency following completion of the program. Future clinical trials of the fACTS Program with an included control group will further investigate the mechanisms of change for the positive effects observed.

Brain response to errors in children who stutter

PURPOSE

Heightened rates of social anxiety have been reported in adults who stutter (AWS), but it is unclear whether anxiety is heightened also in children who stutter (CWS). Objective neurophysiological responses such as the error-related negativity (ERN) have been associated with anxiety, and ERN was reported to be increased in AWS. In this study, we examined whether ERN and error positivity (Pe) are increased in CWS. We further characterized ERN associations with age and anxiety in CWS relative to children who do not stutter (CWNS).

METHODS

EEG data were recorded from twenty-four CWS and twenty-four matched CWNS aged 3-9 years as they performed a Go/No-Go task. Parent-reported anxiety, and child-reported speech-associated attitude measures were collected. Linear regression models tested the effects of age, group, and their interaction, and the effects of anxiety, group, and their interaction on ERN and Pe.

RESULTS

Contrary to expectations, no ERN or Pe difference were observed between CWS and CWNS. However, larger ERN amplitudes were associated with older age in CWS but not CWNS, suggesting altered development of the error monitoring system in CWS. Association of Pe with anxiety also differed between groups: smaller Pe amplitudes were associated with higher level of parent-reported child anxiety in CWNS but not in CWS. Neither anxiety nor self-reported communication attitude differed between groups.

CONCLUSIONS

Brain responses to errors were overall comparable between CWS and CWNS. However, CWS differed in how error monitoring responses varied with age and with anxiety levels. More research is warranted to examine how these factors contribute to persistent stuttering.

Relationships Between Psychological Distress and Affective, Behavioral, and Cognitive Experiences of Stuttering

PURPOSE

People who stutter (PWS) are vulnerable to the development of various psychopathological symptoms, although prevalence data are mixed and less clarity exists about factors that potentially influence their occurrence. The current study sought to shed light on the prevalence of self-reported psychopathology in PWS and aimed to identify relationships between affective, behavioral, and cognitive (ABC) experiences of stuttering and psychological distress (PD).

METHOD

Forty-four PWS were administered the Behavior Assessment Battery (BAB) for Adults who Stutter and the Brief Symptom Inventory-18. The prevalence of clinically significant PD was calculated via BSI-18 global severity index t-score cutoffs. Regression analyses examined relationships between ABC variables of stuttering and PD.

RESULTS

Participants' BAB scores approximated normative values, while the PD score distribution was similar to that of a nonclinical sample. Nine percent of participants met thresholds for clinically significant PD. All ABC correlates of stuttering significantly and positively correlated with PD scores, capturing considerable amounts of shared variance.

CONCLUSIONS

Levels of PD in PWS approximate those of the general community, highlighting the existence of psychologically distressed subgroups of PWS. Speech situation-specific anxiety had the strongest relationship to PD, followed closely by one's report of situation-specific speech disruption. To a lesser but still significant extent, PWS' frequency to which they engage in various avoidance/escape behaviors, as well as their communication attitude, predicted levels of psychopathology. These data inform diagnostic and clinical decision making, drawing attention to factors that should be attended to in treatment.

There is more to cluttering than meets the eye: The prevalence of cluttering and association with psychological well-being indices in an undergraduate sample

BACKGROUND

Cluttering is a fluency disorder characterized by an abnormally fast or irregular speech delivery rate along with disfluencies that are frequent but are not judged to be stuttering. Data on cluttering prevalence in the general population are scarce, as well as its association with psychological well-being indices, such as anxiety, and depressive symptoms.

AIMS

To estimate cluttering prevalence among undergraduates, as well as its relationship with psychological and well-being indicators.

METHODS & PROCEDURES

To address these issues, a large sample (n = 1582) of undergraduates completed a questionnaire that provided a lay definition of cluttering and were asked to identify themselves as clutterers (SI-Clut), as well as to indicate the presence of several psychological and mental well-being indices.

OUTCOMES & RESULTS

A total of 276 respondents (23%) self-identified as clutterers (now or in the past), with 55.1% of those being male. Only 56 respondents (3.5% of the total sample; about 21% of SI-Clut) reported having received speech therapy for cluttering. Relative to students self-identifying as non-clutterers, self-identification of cluttering was associated with higher levels of psychosomatic symptoms, depressive symptoms and stress, indicating a tendency toward internalizing psychopathology, along with lower self-esteem, and lower subjective happiness.

CONCLUSIONS & IMPLICATIONS

The current findings point to the high prevalence of students self-identifying as clutterers, along with a significant link between cluttering and mental distress. Therefore, it is important to increase public awareness of cluttering, its diagnosis and treatment. From the clinical perspective, the elevated levels of somatic complaints, anxiety and depression may represent internalizing psychopathology, associated with more covert rather than overt symptomatology. Such symptom manifestation calls for special attention from the speech-language pathologists providing cluttering therapy, using designated well-being or mental health screening tools. Although data on standard cluttering treatment are limited, it should be customized to the client's unique difficulties. Speech-language pathologists' understanding of cluttering, which includes both speech characteristics as well as psychological and social aspects of well-being, may assist them in implementing effective treatments.

WHAT THIS PAPER ADDS

What is already known on the subject Cluttering is a fluency disorder characterized by an abnormally fast or irregular speech rate, along with various disfluencies and articulatory imprecision. It may co-occur with other disorders, such as learning disabilities, and attention-deficit/hyperactivity disorder. Data on cluttering prevalence and its association with psychological well-being indices, such as anxiety and depression, are limited. What this paper adds to existing knowledge A total of 276 undergraduates (23%) self-identified as clutterers, of whom 55.1% were males. A total of 56 respondents (3.5% of the total sample, and about 21% of undergraduates self-identified as clutterers) reported having received speech therapy for cluttering. Psychosomatic symptoms, depressive symptoms and stress levels were higher among these students, suggesting a tendency toward internalizing psychopathology, along with a lower sense of self-esteem and subjective happiness. What are the potential or actual clinical implications of this work? The high prevalence of students self-identifying as clutterers, along with the low percentage of respondents who received speech therapy for cluttering, emphasize the need to raise public awareness of the problem, its diagnosis and treatment (Reichel et al., 2010). The association between cluttering and mental distress requires speech-language pathologists to be aware that cluttering may have covert symptomatology, similar to stuttering, which should be addressed in therapy.

Internet searches conducted by people who stutter: association with speech-language therapy and severity of stuttering

Stuttering is a fluency disorder that is multidimensional because it involves more than speech difficulties. People who stutter can use the Internet to find out more about their condition and connect with other people in the same position, yet in Croatia, there are not nearly as many online sources on stuttering or as many possibilities to connect with other people who stutter as in the USA or Great Britain. If one does not speak English well, a lot of information about stuttering will simply be denied to them, especially to those who have never received speech therapy. The present study, the first of its kind in Croatia, was conducted in order to understand how often and for what reasons people who stutter search for Internet resources related to their condition. The study also assessed whether Internet use depended on age, experience with speech-language therapy, self-reported satisfaction with such therapy, and self-assessed severity of stuttering. An online questionnaire integrating the 9-Point Stuttering Severity Scale was developed for this study and administered to 51 individuals aged 18 years and older in Croatia. All collected data and findings on the internet searches come from the questionnaire. Age did not significantly affect the frequency or purpose of Internet searches. Individuals who were not attending speech therapy were more likely to search online sources about stuttering than those who received it before. People who rated their stuttering as severe were more likely to search online sources for stuttering than those who rated their condition as mild. These results suggest that there is a need for more useful, high-quality online content and materials in Croatian for people who stutter. Such resources would offer people who stutter a new world of support, mutual understanding, shared experiences and knowledge, and ways for them to help themselves.

"I Just Want People to Think I'm Normal": An Interview Study of Young Swedish Women With Covert Stuttering

PURPOSE

Research indicates that there is a tendency for females who stutter, more often than males, to use coping strategies that involve covering their stutter, for example, by avoiding situations that require verbal participation. The aim of the study is to increase knowledge about how covert stuttering develops and its impact on self-image and quality of life for women who stutter.

METHOD

Eleven young women who stutter covertly were interviewed, and data were subjected to qualitative content analysis. Background information was obtained from the self-report instruments measuring the impact of stuttering on different aspects of life (Overall Assessment of the Speaker's Experiences of Stuttering) and degree of perceived social anxiety (Liebowitz Social Anxiety Scale, Self-Report).

RESULTS

Three main themes were identified: (a) managing stuttering, (b) personal aspects, and (c) stuttering as a phenomenon. Shame and a desire to fit in emerged as distinct motives for covering stuttering. The women described that stuttering controlled both life choices and everyday life. Development of self-image had been strongly negatively affected, resulting in social anxiety. The women expressed a particular vulnerability of being a woman who stutters, due to societal norms of female behavior and a lack of female role models who stutter.

CONCLUSIONS

The choice of coping strategy was motivated by a desire to "be normal." As a result, stuttering had come to dominate life and affect self-image and life choices. The study highlights the importance for clinicians to be alert to and aware of the fact that the experiences of women who stutter can lead them to develop coping strategies that have far-reaching negative consequences.

Interventions That Target or Affect Voice or Speech Production During Public Speaking: A Scoping Review

OBJECTIVES

Public speaking (PS) is frequently necessary in many professional, educational, and personal settings. Mastering this communication skill is particularly important in today's society. Training techniques for PS have been described in the literature. Given that PS anxiety affects performance, especially voice characteristics and speech fluency, the purpose of this scoping review is to examine, map, and narratively summarize the available evidence on PS interventions that target or affect voice or speech.

METHODS

An extensive literature search was conducted in three bibliographic databases: Medline ALL/Ovid, PsycINFO/Ovid, and Eric/Ovid. Of the 850 studies identified, 22 met the eligibility criteria, and one was added from the reference lists of the included studies.

RESULTS

A total of 23 studies were included. The interventions identified aim to improve speaking skills either by explicitly targeting the voice or speech (direct intervention, n = 15) or by targeting the cognitive, behavioral, psychological, or physical environment impacting the speaker's production (indirect intervention, n = 8).

CONCLUSIONS

This scoping review provides the first published methodological summary of the characteristics of existing PS interventions that target or affect voice and speech. Heterogeneous characteristics were observed. Further studies are needed to determine which interventions are most effective.

Effects of behavior inhibition on stuttering severity and adverse consequences of stuttering in 3-6-year-old children who stutter

PURPOSE

The purpose of this study was to investigate whether 3- to-6-year-old children who stutter and exhibit a higher degree of behavioral inhibition (BI), a correlate of shyness, stutter more frequently and experience greater negative consequences of stuttering (per parent-report) than their peers who stutter but have lower BI.

METHOD

Forty-six children who stutter (CWS; 35 boys & 11 girls; mean age 4 years, 2 months) participated. Their degree of BI was assessed by measuring the latency to their 6th spontaneous comment during a conversation with an unfamiliar examiner (following Kagan, Reznick, & Gibbons's (1989) methodology). The frequency of stuttering and the negative impact of stuttering that CWS may have experienced was assessed using parent reports (i.e., Test of Childhood Stuttering (TOCS) Observational Rating Scale; Gillam, Logan, & Pearson, 2009).

RESULTS

We found that children's degree of BI was not associated with their speech fluency per parent report. However, children's degree of BI was significantly associated with greater negative consequences of stuttering. Specifically, among the four categories of TOCS Disfluency-Related Consequences, children's BI significantly predicted the occurrence of physical behaviors that accompany moments of stuttering (such as increased tension or excessive eye blinks). Other Disfluency-Related Consequences, such as avoidance behaviors, negative feelings, and negative social consequences, were not associated with children's behavioral inhibition tendencies. Additionally, children's stuttering severity (per the Stuttering Severity Instrument-4 scores) was significantly associated with increased physical behaviors that accompany moments of stuttering and greater negative social consequences of stuttering.

CONCLUSIONS

This study provides empirical evidence that behavioral inhibition to the unfamiliar may have salience for childhood stuttering as it predicted the development of physical behaviors associated with stuttering (e.g., tension or struggle) in 3- to 6-year-old CWS. Clinical implications of high BI for the assessment and treatment of childhood stuttering are discussed.

Sleep Problems, Social Anxiety and Stuttering Severity in Adults Who Do and Adults Who Do Not Stutter

Background: While there is sufficient evidence that children and adolescents who stutter reported more impaired sleep compared to children and adolescents who did not stutter, findings among adults who stutter (AWS) were scarce. Furthermore, stuttering is associated with issues related to verbal communication in a social context. As such, it was conceivable that AWS reported higher scores for social anxiety, compared to adults who do not stutter (AWNS). In the present study, we tested whether AWS reported higher sleep complaints compared to AWNS. We further tested whether scores for social anxiety and stuttering independently predicted sleep disturbances. Methods: A total of 110 AWS (mean age; 28.25 years, 27.30% females) and 162 AWNS (mean age; 29.40 years, 51.20% females) completed a series of self-rating questionnaires covering sociodemographic information, sleep disturbances and social anxiety. Adults with stuttering further completed a questionnaire on stuttering. Results: Compared to AWNS, AWS reported a shorter sleep duration, a lower sleep efficiency, higher scores for drug use in terms of sleep-promoting medications (significant p-values and medium effect sizes), and an overall higher PSQI score (significant p-values and large effect size), when controlling for age and social anxiety. Next, while p-values were always significant for subjective sleep quality, sleep disturbances, and daytime functioning, when controlling for age and social anxiety, their effect sizes were trivial or small. For sleep latency, the p-value was not significant and the effect size was trivial. Among AWS, higher scores for stuttering and older age, but not social anxiety, predicted higher sleep disturbances. The association between higher sleep disturbances and higher stuttering severity was greatest among those AWS with highest scores for social anxiety. Conclusions: When compared to AWNS, AWS self-reported higher sleep disturbances, which were associated with older age, and higher scores for stuttering severity, but not with social anxiety. Adults who stutter might be routinely asked for their sleep quality.

Public attitudes toward stuttering in Malaysia

PURPOSE

This study aims to: (a) measure public attitudes toward stuttering in Malaysia using the Public Opinion Survey of Human Attitudes-Stuttering [POSHA-S], (b) determine how reported attitudes and knowledge related to stuttering compare to existing data, and (c) determine whether there are differences between groups for identified variables.

METHOD

A total of 250 adults (mean age = 29 years; range = 19-60 years) completed the POSHA-S in English. We compared this sample's attitudes toward stuttering to POSHA-S data from other global samples. General linear modeling examined differences in overall stuttering score, beliefs, and self reaction subscores for demographic variables such as age, gender, marital status, parenting, education, employment status, prior exposure to a person who stutters, multilingual, race, and religion.

RESULTS

The Malaysian participants' overall stuttering score and the beliefs and self reactions subscores were all considerably lower (i.e., less positive) than the other samples around the world from the POSHA-S database median values. Being male, receiving a higher education, and knowing someone who stutters were linked to having more positive self reactions, but none of those factors was linked to positive or negative beliefs. Those who had previously been exposed to stuttering scored significantly higher than those who had not.

CONCLUSION

Malaysians may have less positive attitudes toward stuttering than Westerners. More needs to be done to make society more accepting of people who stutter. Future research should aim to find ways to educate and to raise public awareness about stuttering.

Validity and reliability of safety behaviors questionnaire for Persian adults who stutter: A cultural perspective

INTRODUCTION

Adults who stutter (AWS) are reported to have higher social anxiety compared to those who do not stutter. Previous studies have suggested that safety behaviors, which are cognitive or behavioral strategies used by people with anxiety to prevent negative consequences, are important factors in maintaining anxiety. However, the frequency and types of such behaviors might vary in different cultures. Therefore, the aim of the present study was to develop a transcultural adaptation of Safety Behaviors Questionnaire (Helgadottir et al., 2014) for Persian-speaking AWS and assess its validity and reliability.

METHODS

In the first step, the original English questionnaire was translated into Persian using the International Quality of Life Assessment (IQOLA) method. Then, 17 speech and language pathologists (SLPs) and 5 AWS evaluated all questionnaire items using Likert scales to determine face validity. Finally, 167 Persian-speaking AWS completed the questionnaire to assess its construct validity and reliability. Their responses were analyzed using factor analysis and Cronbach's Alpha.

RESULTS

Some items of the original questionnaire were modified or combined with other similar items after assessing the face validity of the Persian-translated questionnaire. Construct validity analysis categorized the remaining 29 questionnaire items into four factors: general avoidance, practice and control, rehearsal, and choosing safe and easy people. The high Cronbach's Alpha of 0.89 for all items confirmed the internal reliability of the Persian-translated questionnaire.

DISCUSSION/CONCLUSIONS

The results confirmed the psychometric characteristics of the Persian- translated version of the Safety Behaviors Questionnaire (Helgadottir et al., 2014); therefore, speech pathologists can apply it in future clinical and research settings. Similar to Australian AWS, Persian participants of this study self-reported use of various types of safety behaviors frequently.

Covert and overt stuttering: Concepts and comparative findings

PURPOSE

One way of conceptualizing stuttering is on a continuum from primarily covert to primarily overt. Assertions have been made as to how those with covert stuttering might be impacted differently to those with overt stuttering, but findings from well-controlled studies remain scarce. The principal aim of the present study was to compare the impact of stuttering and emotional distress related to two subgroups of persons who stutter: people with primarily overt stuttering and people with primarily covert stuttering. In exploring this, we also offer some preliminary thoughts on challenges with the terminology surrounding the concepts of 'overtness' and 'covertness'.

METHODS

Twenty-one adults already enrolled in a multiple, single-case treatment study (Sønsterud et al., 2019, 2020) took part in the present study, and underwent a battery of tests that assessed anxiety, depression, fear of negative evaluation, and quality of life. The sub-groups were identified on the basis of self-categorization using the Tomaiuoli, Del Gado, Spinetti, Capparelli, and Venuti (2015) classification, as well as the evaluation of speech samples from two independent SLPs (Sønsterud et al., 2020). The classifications were further explored by five independent 'lay' assessors who reviewed pre-therapy video and rated participants' speech on a 4-point Likert Stuttering Probability Scale (1 = 'fluent with no doubt', 2 = 'fluent with some doubt', 3 = 'stuttering with some doubt' and 4 = 'stuttering with no doubt').

RESULTS

No significant differences were found between the primarily overt and primarily covert groups in relation to self-reported symptoms of anxiety, depression, and fear of negative evaluation. However, investigation at item level identified a significant difference in linguistic avoidance between the two groups.

CONCLUSION

There may be fewer differences between people with primarily overt and primarily covert stuttering than previously thought with regards to emotional impact, as well as most aspects of avoidance behavior.

Speech Related Anxiety in Adults Who Stutter

Abstract. The relationship between anxiety and stuttering has always been a topic of debate with a great emphasis on research focused on examining whether speech-related anxiety can exacerbate stuttering. This investigation compares some speech-related anticipatory anxiety indices in fluent and dysfluent utterances in adults who stutter (AWS). We scored the level of cognitive speech-related anxiety (anticipatory anxiety) using a self-reporting method and also evaluated the autonomic aspects of anxiety (state anxiety) through recording changes in Galvanic Skin Response (GSR) signals. Explaining the link between stuttering and anxiety is expected to assist practitioners in stuttering assessment and subsequent treatment strategies. Phasic GSR values of six events related to answering the verbal stimuli through fluent and dysfluent responses were registered to measure sympathetic arousal as an index of state anxiety in 20 AWS ( Mage = 35 ± 4 years, range: 21–42). To quantitatively examine the cognitive aspects of speech-related anticipatory anxiety, two questionnaires were rated by participants addressing the stuttering anticipation and semantic difficulty of verbal stimuli. GSR measures of fluent events were significantly higher than dysfluent counterparts within time windows before and during answering aloud the verbal stimuli ( p < .001). Later in the experiment, GSR values of dysfluent events were found to be higher than their fluent counterparts ( p < .001). Stuttering anticipation yielded a weak negative meaningful correlation with the scores of fluency ( r = −0.283, p = .046) and a positive yet nonsignificant correlation with the stuttering scores. The semantic difficulty had a moderately significant correlation with stuttering anticipation ( r = 0.354, p = .012) but not a meaningful correlation with fluency state. Autonomic and cognitive indices of speech-related anticipatory anxiety are not robust predictors of fluency. Anxiety seems to be more of a consequence of stuttering than a cause.

The Complexity of Stuttering Behavior in Adults and Adolescents: Relationship to Age, Severity, Mental Health, Impact of Stuttering, and Behavioral Treatment Outcome

PURPOSE

This study investigated the complexity of stuttering behavior. It described and classified the complexity of stuttering behavior in relation to age, behavioral treatment outcomes, stuttering severity, anxiety-related mental health, impact of stuttering, and gender.

METHOD

For this study, a taxonomy was developed-LBDL-C7-which was based on the Lidcombe Behavioral Data Language of stuttering. It was used by five experienced judges to analyze the complexity of stuttering behavior for 84 adults and adolescents before and after speech restructuring treatment. Data were 3,100 stuttering moments, which were analyzed with nominal logistic regression.

RESULTS

The complexity of stuttering behavior appears not to change as a result of treatment, but it does appear to change with advancing age. Complexity of stuttering behavior was found to be independently associated with clinician stuttering severity scores but not with percentage of syllables stuttered or self-reported stuttering severity. Complexity of stuttering behavior was not associated with gender, anxiety, or impact of stuttering.

CONCLUSION

Clinical and research applications of these findings are discussed.

Comparison of Stuttering Severity and Anxiety During Standard and Challenge Phone Calls

PURPOSE

This study was designed to answer three questions. (a) Does percentage of syllables stuttered (%SS) differ between standard and challenge phone calls. (b) Does anxiety differ between standard and challenge phone calls. (c) Is there a relationship between %SS and anxiety during standard and challenge phone calls?

METHOD

Participants were 230 adults diagnosed with stuttering, who were participants from five clinical trials. Each participant received two 10-min phone calls at pretreatment and a further two phone calls 6 months or 20 weeks postrandomization. One phone call was standard, and the other presented challenge: occasionally disagreeing with, interrupting, and talking over participants, or asking for clarification of their views.

RESULTS

Statistically significant, but clinically minor, increases of %SS and anxiety occurred during the challenge phone calls. There was a statistically significant association between %SS and anxiety.

CONCLUSIONS

Variable phone call procedures to assess stuttering severity in clinical trials are not likely to spuriously inflate or deflate treatment outcomes to a clinically important extent. Regardless, the present results suggest that there is statistical merit in controlling the nature of phone calls during clinical trials with the simple and replicable method developed in this report. Additionally, there is procedural merit in the challenge phone call procedure; it is a more valid representation of the challenges of everyday speech than the standard procedure. However, a disadvantage of the challenge phone call procedure is the practical issues associated with its use. The clinical and theoretical applications of the results are discussed.

Cluttering in the Speech of Young Men With Fragile X Syndrome

PURPOSE

Cluttering is a fluency disorder that has been noted clinically in individuals with fragile X syndrome (FXS). Yet, cluttering has not been systematically characterized in this population, hindering identification and intervention efforts. This study examined the rates of cluttering in male young adults with FXS using expert clinical opinion, the alignment between expert clinical opinion and objectively quantified features of cluttering from language transcripts, and the association between cluttering and aspects of the FXS phenotype.

METHOD

Thirty-six men with FXS (aged 18-26 years; M = 22, SD = 2.35) contributed language samples and completed measures of nonverbal cognition, autism symptoms, anxiety, and symptoms of attention-deficit/hyperactivity disorder (ADHD). The presence of cluttering was determined by the consensus of two clinical experts in fluency disorders based on characteristics exhibited in the language sample. Cluttering features (speech rate, disfluencies, etc.) were also objectively quantified from the language transcripts.

RESULTS

Clinical experts determined that 50% of participants met the criteria for a cluttering diagnosis. Phrase repetitions were the most salient feature that distinguished individuals who cluttered. Although the presence of cluttering was not associated with autism symptoms or mean length of utterance, cluttering was more likely to occur when nonverbal cognitive ability was higher, ADHD symptoms were elevated, and anxiety symptoms were low.

CONCLUSIONS

Half of the male young adults with FXS exhibited cluttering, which supports FXS as a genetic diagnosis that is highly enriched for risk of cluttering. Cluttering was associated with increased ADHD symptoms and cognitive ability and reduced anxiety symptoms. This study contributes a new description of the clinical presentation of cluttering in men with FXS and may lead to improved understanding of the potential underlying mechanisms of cluttering and eventual refinements to treatment and diagnosis.

Anxiety and Depression Symptoms in Children and Adolescents Who Stutter: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to investigate whether there are elevated symptoms of anxiety or depression in children and adolescents (aged 2-18 years) who stutter, and to identify potential moderators of increased symptom severity.

METHOD

We conducted a preregistered systematic review of databases and gray literature; 13 articles met criteria for inclusion. A meta-analysis using robust variance estimation was conducted with 11 cohort studies comparing symptoms of anxiety in children and adolescents who do and do not stutter. Twenty-six effect sizes from 11 studies contributed to the summary effect size for anxiety symptoms (851 participants). Meta-analysis of depression outcomes was not possible due to the small number of studies.

RESULTS

The summary effect size indicates that children and adolescents who stutter present with increased anxiety symptoms (g = 0.42) compared with nonstuttering peers. There were insufficient studies to robustly analyze depression symptoms, and qualitative review is provided. No significant between-groups differences were reported in any of the depression studies.

CONCLUSIONS

Preliminary evidence indicates elevated symptoms of anxiety in some children and adolescents who stutter relative to peers. There was a tendency toward higher depression scores in this population, although reported between-groups differences did not reach statistical significance. These findings require replication in larger, preferably longitudinal studies that consider factors that may moderate risk. Nevertheless, our findings highlight a need for careful monitoring of mental health and well-being in young people who stutter. Supplemental Materials: http://osf.io/5m6zv.

Contemporary issues with stuttering: The Fourth Croatia Stuttering Symposium

PURPOSE

During 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.

METHODS

The 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.

RESULTS

Seven contemporary issues for our field emerged from the Symposium.

CONCLUSION

Effective 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.

Psychological characteristics of early stuttering

PURPOSE

The purpose of this study was to use psychological measures of pre-schoolers who stutter and their parents to inform causal theory development and influence clinical practices. This was done using data from a substantive clinical cohort of children who received early stuttering treatment.

METHOD

The cohort (N = 427) comprised parents and their children who were treated with the Lidcombe Program, the Westmead Program, and the Oakville Program. The study incorporated demographic information, stuttering severity, and child and parent psychological measures prior to treatment.

RESULT

The cohort revealed nothing unusual about behavioural and emotional functioning, or the temperaments, of pre-school children that would influence treatment, be targeted during treatment, or influence causal theory development. However, a third of parents were experiencing moderate to high life stressors at the time of seeking treatment, and half the parents failed first-stage screening for Anankastic Personality Disorder.

CONCLUSION

The present results are consistent with a number of previous reports that showed that the population of pre-schoolers who stutter have no unusual psychological profiles. Hence, these results suggest that the association between mental health and stuttering later in life is a consequence of the disorder rather than being a part of its cause. The finding of the life stress of parents who seek stuttering treatment for pre-school children has potential clinical importance and warrants further investigation. Further psychological research is required about parents of pre-school children who stutter, because half the parents in the cohort failed the screener for Anankastic Personality Disorder. This is of interest because a previous study associated screening failure for another personality disorder (Impulsive Personality Disorder) with treatment dropout for early childhood stuttering.

The Effects of Written Stuttering Disclosure on the Perceptions of a Child Who Stutters

Purpose This study measured between-groups differences in perceived speech skills and personality characteristics of a 12-year-old male child who stutters (CWS) as a function of a written factual stuttering disclosure statement, delivered by the CWS, his "mother," or his "teacher." Method Four hundred twenty-four college-age adults were assigned to one of four groups, including three experimental groups (i.e., written self-disclosure, mother-written disclosure, and teacher-written disclosure) and a control group (no written disclosure). Participants in the control conditions viewed a brief video of the CWS. In the experimental conditions, participants read a brief written disclosure statement for 30 s, followed by the same video used in the control condition. After viewing the video, all participants completed surveys relative to their perceptions of the CWS speech skills and personality characteristics. Results Results reveal that a written stuttering disclosure statement provided by the mother correlated with select significant desirable perceptual differences of the CWS, while a written disclosure statement provided by the CWS yielded insignificant or even undesirable perceptual differences of the CWS. Written stuttering disclosures provided by a "teacher" did not yield any significant between-groups differences in the perception of a CWS. Gender affiliation was found to be a source of covariance in a number of perceived speech skills and personality characteristics. Conclusions Written stuttering disclosure statements provided by the "mother" correlated with select favorable perceptual differences of speech skills and personal characteristics of a CWS. Clinically, the application of novel methods (written and oral disclosure statements) and sources (i.e., CWS advocates such as "mother" and "teacher") of stuttering disclosure statement can be integrated into a systematic therapeutic program, creating an innovative approach of scaffolding self-advocacy via stuttering disclosure in CWS. Supplemental Material https://doi.org/10.23641/asha.15505857.

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

PURPOSE

Childhood-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.

METHOD

Twenty-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.

RESULTS

Participants 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.

CONCLUSION

Findings 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.

Trait perspective-taking and need for cognition in the formation of stereotypes about people who stutter

People who stutter (PWS) suffer from stereotypes portraying them as timid and anxious, which may affect their relationships and careers. One of the mechanisms for this stereotyping is the anchoring and adjustment heuristic, whereby individuals make judgements about PWS by using previous experiences for the initial judgement and then adjust accordingly. In the current study (n = 309) we replicate previous findings that individuals stereotype PWS by anchoring to experiences with episodic stuttering and adjusting toward typical non-stuttering individuals, although insufficiently. We extend this finding by testing whether trait perspective-taking and need for cognition moderate this relationship. The results show that trait perspective-taking decreases stereotyping of non-PWS, while having no effect on PWS stereotyping. However, need for cognition exhibited no consistent moderating effect on stereotyping.

Temperament and early stuttering intervention: Two perspectives

PURPOSE

To discuss clinical applications of research findings about temperament and early stuttering.

METHOD

A "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.

RESULTS

One 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.

CONCLUSIONS

The 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.

The Role of Behavioral Inhibition for Conversational Speech and Language Characteristics of Preschool-Age Children Who Stutter

Purpose The purpose of this study was to investigate whether preschool-age children who stutter (CWS) were more likely to exhibit a temperamental trait of behavioral inhibition (BI), a correlate of shyness, than children who do not stutter (CWNS) and whether this temperamental trait affected preschool-age children's speech fluency and language complexity during a conversation with an unfamiliar adult. Method Sixty-eight preschool-age children (31 CWS, 37 CWNS) participated. The degree of BI was assessed by measuring the latency to their sixth spontaneous comment and the number of all spontaneous comments during a conversation with an unfamiliar examiner (following Kagan et al.'s [1987] methodology). Parent report of shyness from the Children's Behavior Questionnaire served as an indirect measure of BI. Children's language complexity was assessed by measuring their mean length of utterance and the number of words spoken. For CWS, the frequency of stuttering and the negative impact of stuttering were also assessed. Results First, we found no between-group differences in the degree of BI across the behavioral observation measures. However, CWS were rated shyer by parents than CWNS. Second, for CWS only, higher BI was associated with less complex utterances and fewer words spoken. Third, for CWS, higher BI was associated with fewer stuttered disfluencies produced. Conclusions This study provides empirical evidence that BI to the unfamiliar may have salience for childhood stuttering as it affected the quantity and quality of language spoken with an unfamiliar adult. Clinical implications of high BI for the assessment and treatment of preschool-age stuttering are discussed.

Autonomic Nervous System Response to Speech Production in Stuttering and Normally Fluent Preschool-Age Children

Purpose We studied speech-related sympathetic nervous system arousal of preschool-age children who do (CWS) and do not stutter (CWNS) and its association with children's proclivity to experience negative emotions and children's self-reported attitudes toward speaking. Method Electrodermal activity measures were collected from 32 preschool-age children while they engaged in a picture description and a nonword repetition task. Children's proclivity to experience negative emotions was assessed with a parent report questionnaire. Children's communication attitude was assessed with a self-report questionnaire. Results CWS did not differ from CWNS in their sympathetic arousal during a picture description task. However, during a more challenging nonword repetition task, preschool-age CWS had a higher sympathetic arousal level than CWNS. Although CWS were rated by their caregivers as more fearful and prone to sadness, children's tendency to experience stronger and more frequent negative emotions was not associated with their sympathetic arousal during speaking. Lastly, although CWS had a more negative communication attitude than CWNS, it was not associated with their level of sympathetic arousal during speaking. Conclusions Our findings suggest that age-appropriate social communication tasks are not inherently more stressful for preschool-age CWS and are not associated with state-related stress or anxiety that is often reported for adults who stutter. However, speaking tasks that place a higher demand on children's cognitive-linguistic system may be more taxing and challenging to preschool CWS than CWNS, leading to a higher level of arousal.

Temperament, Executive Functioning, and Anxiety in School-Age Children Who Stutter

The purpose of this study was to examine temperament dimensions, executive functioning ability, and anxiety levels in school-age children who stutter and their non-stuttering peers. Participants were 100 Portuguese children aged 7 to 12 years (M = 9.13; SD = 1.70), including 50 children who stutter and 50 children who do not stutter. Analyses, which were performed separately for younger and older participants, sought to identify correlations between key variables. Temperament was evaluated through a parent questionnaire, executive functioning was evaluated through children’s responses on a performance test, and anxiety level was assessed through a self-perception scale. On the temperament measure, comparisons between children who stutter and their non-stuttering peers revealed that older children who stutter exhibited significantly higher scores on the Anger/Frustration, Impulsivity, and Sadness subscales, and lower averages on the Attention/Focusing, Perceptual sensitivity, and Soothability/Falling Reactivity subscales. On the executive functioning task, comparisons revealed that the group of younger children who stutter exhibited significantly higher average execution times than their non-stuttering peers. There were no statistically significant differences in anxiety between children who stutter and children who do not stutter, and there were no statistically significant correlations between temperament factors and measures of executive functioning. Children who stutter experienced lower ability to orient attention and greater emotional reactivity compared with their non-stuttering peers. Significant correlations were found between executive functioning and age and among the temperament factors themselves. These results, which support the need for a multidimensional view of stuttering, were interpreted in the context of the Dual Diathesis – Stressor model. Findings indicate that temperament and executive functioning abilities may contribute to the development of stuttering.

In-Clinic and Standalone Internet Cognitive Behavior Therapy Treatment for Social Anxiety in Stuttering: A Randomized Trial of iGlebe

Purpose iGlebe is an individualized, fully automated Internet cognitive behavior therapy (CBT) treatment program that requires no clinician contact. Phase I and II trials have demonstrated that it may be efficacious for treating the social anxiety commonly associated with stuttering. The present trial sought to establish whether the outcomes achieved by iGlebe are noninferior to those associated with in-clinic CBT from clinical psychologists. Method Fifty adults with stuttering were randomized to receive in-clinic CBT for anxiety or 5 months online access to iGlebe. The design was a noninferiority randomized controlled trial with outcomes assessed at prerandomization and at 6 and 12 months postrandomization. Primary outcomes were CIDI-Auto-2.1 diagnoses for anxiety and mood disorders and Brief Fear of Negative Evaluation scale scores ( Carleton, McCreary, Norton, & Asmundson, 2006 ). Secondary outcomes included speech, psychology, and quality-of-life measures. Results Outcomes consistently showed clinically significant improvements of around a medium effect size for the cohort as a whole from prerandomization to 6 months postrandomization, which were maintained at 12 months postrandomization. Comparisons between the 2 treatments showed little difference between iGlebe and in-clinic treatment for all primary and secondary outcomes, with last observation carried forward for missing data. Conclusions iGlebe is a promising individualized treatment for social anxiety for adults who stutter and offers a viable and inexpensive alternative to in-clinic CBT with clinical psychologists. An issue to emerge from this trial, which requires clarification during future clinical trials of iGlebe, is the posttreatment relation between percentage of syllables stuttered and self-reported stuttering severity ratings.

Self-efficacy beliefs: Experiences of adults who stutter

PURPOSE

Childhood-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.

METHOD

Semi-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.

RESULTS

Thematic 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.

CONCLUSION

These 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.

The effect of emotion on articulation rate in persistence and recovery of childhood stuttering

PURPOSE

This study investigated the possible association of emotional processes and articulation rate in pre-school age children who stutter and persist (persisting), children who stutter and recover (recovered) and children who do not stutter (nonstuttering).

METHODS

The participants were ten persisting, ten recovered, and ten nonstuttering children between the ages of 3-5 years; who were classified as persisting, recovered, or nonstuttering approximately 2-2.5 years after the experimental testing took place. The children were exposed to three emotionally-arousing video clips (baseline, positive and negative) and produced a narrative based on a text-free storybook following each video clip. From the audio-recordings of these narratives, individual utterances were transcribed and articulation rates were calculated.

RESULTS

Results indicated that persisting children exhibited significantly slower articulation rates following the negative emotion condition, unlike recovered and nonstuttering children whose articulation rates were not affected by either of the two emotion-inducing conditions. Moreover, all stuttering children displayed faster rates during fluent compared to stuttered speech; however, the recovered children were significantly faster than the persisting children during fluent speech.

CONCLUSION

Negative emotion plays a detrimental role on the speech-motor control processes of children who persist, whereas children who eventually recover seem to exhibit a relatively more stable and mature speech-motor system. This suggests that complex interactions between speech-motor and emotional processes are at play in stuttering recovery and persistency; and articulation rates following negative emotion or during stuttered versus fluent speech might be considered as potential factors to prospectively predict persistence and recovery from stuttering.

Recovery of brain abscess-induced stuttering after neurosurgical intervention

Stuttering occurs in approximately 5% of all children and 1% of adults. One type, neurogenic stuttering, is usually attributable to strokes or other structural damages to the brain areas that are responsible for language fluency. Here, we present the first case of neurogenic stuttering caused by a brain abscess. The patient was a 60-year-old man admitted for a seizure and administered an anticonvulsant, after which he began stuttering. MRI revealed a brain abscess in the left frontal lobe that extended to the dorsolateral prefrontal cortex (BA (Brodmann's area) 9 and 46), frontal eye field (BA 8) and premotor cortex and supplementary motor area (BA 6). After neurosurgical drainage and antibiotic treatment, the symptoms had resolved. This case is unique in that the therapeutic effects and localisation of the cause of stuttering were rapidly identified, allowing for a more accurate description of the neural circuitry related to stuttering.

Evidence for a Resting State Network Abnormality in Adults Who Stutter

Neural network-based investigations of stuttering have begun to provide a possible integrative account for the large number of brain-based anomalies associated with stuttering. Here we used resting-state EEG to investigate functional brain networks in adults who stutter (AWS). Participants were 19 AWS and 52 age-, and gender-matched normally fluent speakers. EEGs were recorded and connectivity matrices were generated by LORETA in the theta (4-8 Hz), alpha (8-12 Hz), beta1 (12-20 Hz), and beta2 (20-30 Hz) bands. Small-world propensity (SWP), shortest path, and clustering coefficients were computed for weighted graphs. Minimum spanning tree analysis was also performed and measures were compared by non-parametric permutation test. The results show that small-world topology was evident in the functional networks of all participants. Three graph indices (diameter, clustering coefficient, and shortest path) exhibited significant differences between groups in the theta band and one [maximum betweenness centrality (BC)] measure was significantly different between groups in the beta2 band. AWS show higher BC than control in right temporal and inferior frontal areas and lower BC in the right primary motor cortex. Abnormal functional networks during rest state suggest an anomaly of DMN activity in AWS. Furthermore, functional segregation/integration deficits in the theta network are evident in AWS. These deficits reinforce the hypothesis that there is a neural basis for abnormal executive function in AWS. Increased beta2 BC in the right speech-motor related areas confirms previous evidence that right audio-speech areas are over-activated in AWS. Decreased beta2 BC in the right primary motor cortex is discussed in relation to abnormal neural mechanisms associated with time perception in AWS.

Transcranial direct current stimulation over left inferior frontal cortex improves speech fluency in adults who stutter

See Crinion (doi:10.1093/brain/awy075) for a scientific commentary on this article.Stuttering is a neurodevelopmental condition affecting 5% of children, and persisting in 1% of adults. Promoting lasting fluency improvement in adults who stutter is a particular challenge. Novel interventions to improve outcomes are of value, therefore. Previous work in patients with acquired motor and language disorders reported enhanced benefits of behavioural therapies when paired with transcranial direct current stimulation. Here, we report the results of the first trial investigating whether transcranial direct current stimulation can improve speech fluency in adults who stutter. We predicted that applying anodal stimulation to the left inferior frontal cortex during speech production with temporary fluency inducers would result in longer-lasting fluency improvements. Thirty male adults who stutter completed a randomized, double-blind, controlled trial of anodal transcranial direct current stimulation over left inferior frontal cortex. Fifteen participants received 20 min of 1-mA stimulation on five consecutive days while speech fluency was temporarily induced using choral and metronome-timed speech. The other 15 participants received the same speech fluency intervention with sham stimulation. Speech fluency during reading and conversation was assessed at baseline, before and after the stimulation on each day of the 5-day intervention, and at 1 and 6 weeks after the end of the intervention. Anodal stimulation combined with speech fluency training significantly reduced the percentage of disfluent speech measured 1 week after the intervention compared with fluency intervention alone. At 6 weeks after the intervention, this improvement was maintained during reading but not during conversation. Outcome scores at both post-intervention time points on a clinical assessment tool (the Stuttering Severity Instrument, version 4) also showed significant improvement in the group receiving transcranial direct current stimulation compared with the sham group, in whom fluency was unchanged from baseline. We conclude that transcranial direct current stimulation combined with behavioural fluency intervention can improve fluency in adults who stutter. Transcranial direct current stimulation thereby offers a potentially useful adjunct to future speech therapy interventions for this population, for whom fluency therapy outcomes are currently limited.

Self-efficacy and quality of life in adults who stutter

PURPOSE

Self-efficacy has emerged as a potential predictor of quality of life for adults who stutter. Research has focused primarily on the positive relationship self-efficacy has to treatment outcomes, but little is known about the relationship between self-efficacy and quality of life for adults who stutter. The purpose of this mixed- methods study is to determine the predictive value of self-efficacy and its relationship to quality of life for adults who stutter.

METHOD

The Self-Efficacy Scale for Adult Stutterers and the Overall Assessment of the Speaker's Experience with Stuttering were administered to 39 adults who stutter, aged 18- 77. Percentage of syllables stuttered was calculated from a conversational speech sample as a measure of stuttered speech frequency. Qualitative interviews with semi-structured probes were conducted with 10 adults and analyzed using thematic analysis to explore the lived experience of adults who stutter.

RESULTS

Self-efficacy emerged as a strong positive predictor of quality of life for adults living with a stuttered speech disorder. Stuttered speech frequency was a moderate negative predictor of self-efficacy. Major qualitative themes identified from the interviews with the participants were: encumbrance, self-concept, confidence, acceptance, life-long journey, treatment, and support.

CONCLUSION

Results provide clarity on the predictive value of self-efficacy and its relationship to quality of life and stuttered speech frequency. Findings highlight that the unique life experiences of adults who stutter require a multidimensional approach to the assessment and treatment of stuttered speech disorders.

How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

Purpose

We advanced a multifactorial, dynamic account of the complex, nonlinear interactions of motor, linguistic, and emotional factors contributing to the development of stuttering. Our purpose here is to update our account as the multifactorial dynamic pathways theory.

Method

We review evidence related to how stuttering develops, including genetic/epigenetic factors; motor, linguistic, and emotional features; and advances in neuroimaging studies. We update evidence for our earlier claim: Although stuttering ultimately reflects impairment in speech sensorimotor processes, its course over the life span is strongly conditioned by linguistic and emotional factors.

Results

Our current account places primary emphasis on the dynamic developmental context in which stuttering emerges and follows its course during the preschool years. Rapid changes in many neurobehavioral systems are ongoing, and critical interactions among these systems likely play a major role in determining persistence of or recovery from stuttering.

Conclusion

Stuttering, or childhood onset fluency disorder (Diagnostic and Statistical Manual of Mental Disorders, 5th edition; American Psychiatric Association [APA], 2013), is a neurodevelopmental disorder that begins when neural networks supporting speech, language, and emotional functions are rapidly developing. The multifactorial dynamic pathways theory motivates experimental and clinical work to determine the specific factors that contribute to each child's pathway to the diagnosis of stuttering and those most likely to promote recovery.

Stuttering generalization self-measure: Preliminary development of a self-measuring tool

INTRODUCTION

Generalization of treatment is considered a difficult task for clinicians and people who stutter (PWS), and can constitute a barrier to long-term treatment success. To our knowledge, there are no standardized tests that collect measurement of the behavioral and cognitive aspects alongside the client's self-perception in real-life speaking situations.

PURPOSE

This paper describes the preliminary development of a Stuttering Generalization Self-Measure (SGSM). The purpose of SGSM is to assess 1) stuttering severity and 2) speech-anxiety level during real-life situations as perceived by PWS. Additionally, this measurement aims to 3) investigate correlations between stuttering severity and speech-anxiety level within the same real-life situation.

METHOD

The SGSM initially reported includes nine speaking situations designed that are developed to cover a variety of frequent speaking scenario situations. However, two of these were less commonly encountered by participants and subsequently not included in the final analyses. Items were created according to five listener categories (family and close friends, acquaintances, strangers, persons of authority, and giving a short speech to small audience). Forty-three participants (22 PWS, and 21 control) aged 18 to 53 years were asked to complete the assessment in real-life situations.

RESULTS

Analyses indicated that test-retest reliability was high for both groups. Discriminant validity was also achieved as the SGSM scores significantly differed between the controls and PWS two groups for stuttering and speech-anxiety. Convergent validity was confirmed by significant correlations between the SGSM and other speech-related anxiety measures.

Fear of Negative Evaluation, Trait Anxiety, and Judgment Bias in Adults who Stutter

PURPOSE

Persons who stutter (PWS) and those with social anxiety disorder may exhibit fear of negative evaluation (FNE) and anxiety in social situations. However, the information processing biases that perpetuate these characteristics have had limited investigation. This study investigated judgment bias in social situations.

METHOD

Participants included 50 adults who stutter and 45 age- and gender-matched fluent persons who do not stutter (PWNS), who made up the control group. Participants completed the Interpretation and Judgmental Questionnaire (Voncken, Bögels, & deVries, 2003), and threat scores were calculated.

RESULTS

There were no significant differences between PWS and PWNS in social threat or nonsocial threat scores. When the PWS group was divided on the basis of FNE and compared with PWNS participants without heightened anxiety (n = 35), the PWS with high FNE had significantly higher total social threat scores than the PWS with low FNE. The three groups did not differ in threat ratings for ambiguous or profoundly negative social situations.

CONCLUSIONS

Judgment bias in PWS is mediated by the magnitude of FNE present; not all PWS exhibit judgment bias for social situations. Treatment implications include the need for psychosocial support addressing the negative impacts on quality of life and restrictions on social engagement that stuttering may cause in some individuals.

Maintenance of Social Anxiety in Stuttering: A Cognitive-Behavioral Model

PURPOSE

Stuttering is a speech disorder frequently accompanied by anxiety in social-evaluative situations. A growing body of research has confirmed a significant rate of social anxiety disorder among adults who stutter. Social anxiety disorder is a chronic and disabling anxiety disorder associated with substantial life impairment. Several influential models have described cognitive-behavioral factors that contribute to the maintenance of social anxiety in nonstuttering populations. The purpose of the present article is to apply these leading models to the experience of social anxiety for people who stutter.

METHOD

Components from existing models were applied to stuttering in order to determine cognitive-behavioral processes that occur before, during, and after social-evaluative situations, which may increase the likelihood of stuttering-related social fears persisting.

RESULTS

Maintenance of social anxiety in stuttering may be influenced by a host of interrelated factors, including fear of negative evaluation, negative social-evaluative cognitions, attentional biases, self-focused attention, safety behaviors, and anticipatory and postevent processing.

CONCLUSION

Given the chronic nature of social anxiety disorder, identifying factors that contribute to the persistence of stuttering-related social fears has the potential to inform clinical practice and the development of psychological treatment programs to address the speech and psychological needs of people who stutter with social anxiety.

Case file audit of Lidcombe program outcomes in a student-led stuttering clinic

PURPOSE

The current study aimed to benchmark clinical outcomes for preschool-aged clients (2;0-5;11 years old) that attended a student-led clinic and undertook the Lidcombe Program.

METHOD

A case file audit was undertaken for all preschool clients who attended the clinic between February 2008 and February 2013 and commenced the Lidcombe Program. Clients were grouped according to Stage 1 completion. A mixed ANOVA was used to test for differences between the groups in initial and final percentage syllables stuttered (%SS). Associations between case variable factors and treatment duration were investigated using Pearson correlations.

RESULT

Clients who completed Stage 1 had final %SS and severity rating (SR) scores comparable to the literature; however, the median Stage 1 duration was greater. Over half of the clients (57%) withdrew prior to completing Stage 1. These clients had a significantly higher %SS at final treatment session than their completing peers. Initial %SS and SR scores were the only case variables associated with treatment duration.

CONCLUSION

Students can achieve the same short-term treatment outcomes for children who stutter using the Lidcombe Program as the current published literature; however, treatment duration is greater and may impact completion. Implications of this for clinical education are discussed.

The role of anxiety in stuttering: Evidence from functional connectivity

Persistent developmental stuttering is a neurologically based speech disorder associated with cognitive-linguistic, motor and emotional abnormalities. Previous studies investigating the relationship between anxiety and stuttering have yielded mixed results, but it has not yet been examined whether anxiety influences brain activity underlying stuttering. Here, using functional magnetic resonance imaging (fMRI), we investigated the functional connectivity associated with state anxiety in a syllable repetition task, and trait anxiety during rest in adults who stutter (N=19) and fluent controls (N=19). During the speech task, people who stutter (PWS) showed increased functional connectivity of the right amygdala with the prefrontal gyrus (the left ventromedial frontal gyrus and right middle frontal gyrus) and the left insula compared to controls. During rest, PWS showed stronger functional connectivity between the right hippocampus and the left orbital frontal gyrus, and between the left hippocampus and left motor areas than controls. Taken together, our results suggest aberrant bottom-up and/or top-down interactions for anxiety regulation, which might be responsible for the higher level of state anxiety during speech and for the anxiety-prone trait in PWS. To our knowledge, this is the first study to examine the neural underpinnings of anxiety in PWS, thus yielding new insight into the causes of stuttering which might aid strategies for the diagnosis and treatment of stuttering.

Long-term Consequences of Childhood Bullying in Adults who Stutter: Social Anxiety, Fear of Negative Evaluation, Self-esteem, and Satisfaction with Life

PURPOSE

Psychosocial disorders have been reported in adults who stutter, especially social anxiety disorder. Social anxiety has been linked to childhood victimization. It is possible that recalled childhood victimization could be linked to psychosocial problems reported in some adults who stutter.

METHOD

Participants were 36 adults who stutter and 36 adults who do not stutter (mean age=21.9 years). The Retrospective Bullying Questionnaire was completed for primary school, secondary school and university environments for physical, verbal, relational and cyber bullying. Participants were categorized into one of five groups (bully, victim, bully-victim, bystander and uninvolved) based ontheir responses. Participants completed four psychosocial scales: social interaction anxiety, fear of negative evaluation, self-esteem and satisfaction with life scales.

RESULTS

The two groups differed with adults who stutter having higher social interaction anxiety, fear of negative evaluation and satisfaction with life. Analyses of variance revealed that victims had the highest scores among both groups on all four scales.

CONCLUSION

Adults who recalled being victimized during childhood were more likely, regardless of whether they stutter or did not stutter, to have poorer psychosocial scale scores. These results show the lingering effects of childhood victimization, common in some children who stutter, may contribute to the reported psychosocial problems in adulthood. The need for early intervention for children who are bullied and future research with larger samples is warranted.

Childhood Stuttering: Where Are We and Where Are We Going?

Remarkable progress has been made over the past two decades in expanding our understanding of the behavioral, peripheral physiologic, and central neurophysiologic bases of stuttering in early childhood. It is clear that stuttering is a neurodevelopmental disorder characterized by atypical development of speech motor planning and execution networks. The speech motor system must interact in complex ways with neural systems mediating language and other cognitive and emotional processes. During the time when stuttering typically appears and follows its path to either recovery or persistence, all of these neurobehavioral systems are undergoing rapid and dramatic developmental changes. We summarize our current understanding of the various developmental trajectories relevant for the understanding of stuttering in early childhood. We also present theoretical and experimental approaches that we believe will be optimal for even more rapid progress toward developing better and more targeted treatment for stuttering in the preschool children who are more likely to persist in stuttering.

Communication restriction in adults who stutter: Part III

This is the third article in a series examining communication restriction in adults with stuttering (AWS). The aim was to explore interpersonal communication behaviour in AWS at long-term treatment follow-up, using systemic functional linguistics (SFL) as an analytical framework. The performance of 10 AWS within 10-minute conversation samples was compared across pretreatment (T1), post-treatment (T2), and 12-month follow-up (T3), in terms of language productivity and complexity, modality, and appraisal. At T1 and T3, comparisons were also made to a control group (AWNS). Post-treatment increases in (1) language complexity, (2) frequency of modal operators, and (3) expression of appraisal were maintained in the AWS group at T3. No significant differences in these areas were found between AWS and AWNS at T3. The findings suggest that intensive comprehensive stuttering treatment can affect lasting functional change in interpersonal language use for AWS.