Comparison of Percentage of Syllables Stuttered With Parent-Reported Severity Ratings as a Primary Outcome Measure in Clinical Trials of Early Stuttering Treatment

Lidcombe Program telehealth treatment for children 6-12 years of age: A Phase II trial

BACKGROUND

For children older than 6 years who stutter, there is a gap in clinical research. This is an issue for speech-language pathologists because the tractability of stuttering decreases and the risk of long-term psychological consequences increase with age.

PURPOSE

To report a Phase II trial of a telehealth version of the Lidcombe Program with school-age children.

METHODS

Participants were 37 children who stuttered, 6-12 years of age, from Australia, New Zealand, Hong Kong, and Singapore. Parents were trained by video telehealth how to deliver the Lidcombe Program to their child. Primary and secondary outcomes were stuttering severity and psychosocial functioning measured pre-treatment and at 6 months and 12 months after starting treatment. Parents submitted two 10-minute recordings of their child speaking in conversation, and three measures of anxiety, impact of stuttering, and communication attitude.

RESULTS

Six months after starting treatment, seven children (18.9%) attained Lidcombe Program Stage 2 criteria, 25 children (67.6%) showed a partial response to treatment, and five children (13.5%) showed no response. By 12 months, 12 children (32.4%) had reached Stage 2 criteria. Psychosocial improvements were observed 6 and 12 months after starting treatment.

CONCLUSIONS

The Lidcombe Program may eliminate or nearly eliminate stuttering for about one third of children 6-12 years of age. Randomized controlled trials with this age group involving the Lidcombe Program are warranted. In the interim, the Lidcombe Program is a clinical option clinicians can implement with this age group to reduce stuttering and its psychosocial impacts.

Self-Reported Stuttering Severity Is Accurate: Informing Methods for Large-Scale Data Collection in Stuttering

PURPOSE

To our knowledge, there are no data examining the agreement between self-reported and clinician-rated stuttering severity. In the era of big data, self-reported ratings have great potential utility for large-scale data collection, where cost and time preclude in-depth assessment by a clinician. Equally, there is increasing emphasis on the need to recognize an individual's experience of their own condition. Here, we examined the agreement between self-reported stuttering severity compared to clinician ratings during a speech assessment. As a secondary objective, we determined whether self-reported stuttering severity correlated with an individual's subjective impact of stuttering.

METHOD

Speech-language pathologists conducted face-to-face speech assessments with 195 participants (137 males) aged 5-84 years, recruited from a cohort of people with self-reported stuttering. Stuttering severity was rated on a 10-point scale by the participant and by two speech-language pathologists. Participants also completed the Overall Assessment of the Subjective Experience of Stuttering (OASES). Clinician and participant ratings were compared. The association between stuttering severity and the OASES scores was examined.

RESULTS

There was a strong positive correlation between speech-language pathologist and participant-reported ratings of stuttering severity. Participant-reported stuttering severity correlated weakly with the four OASES domains and with the OASES overall impact score.

CONCLUSIONS

Participants were able to accurately rate their stuttering severity during a speech assessment using a simple one-item question. This finding indicates that self-report stuttering severity is a suitable method for large-scale data collection. Findings also support the collection of self-report subjective experience data using questionnaires, such as the OASES, which add vital information about the participants' experience of stuttering that is not captured by overt speech severity ratings alone.

Stuttering Behavior in a National Age Cohort of Norwegian First-Graders With Down Syndrome

PURPOSE

The aims of this study were to investigate the occurrence of stuttering behavior across time and to evaluate the relationship between stuttering behavior and language ability in children with Down syndrome.

METHOD

A national age cohort of Norwegian first graders with Down syndrome (N = 75) participated in the study. Speech samples from a story-retelling task and a picture book dialogue as well as standardized measures of vocabulary, grammar, and nonverbal mental ability were collected at two time points approximately 5 months apart. Stuttering behavior was evaluated through counting stuttering-like disfluencies and stuttering severity ratings. The relationship between stuttering behavior and language ability was investigated through hierarchical regression analysis.

RESULTS

The participants had stuttering severity ratings ranging from no stuttering behavior to severe and displayed all types of stuttering-like disfluencies. There were significant relationships between stuttering behavior and language ability at the first time point, whereas the relationships were not significant at the second time point. The stuttering severity ratings were significantly predicted by language ability across time, whereas the frequency of stuttering-like disfluencies was not.

CONCLUSIONS

The occurrence of stuttering behavior was high across the measures and time points; however, the relationship between stuttering behavior and language ability varied across these variables. Thus, the nature of the relationship does not seem to follow a strict pattern that can be generalized to all children across time.

Self-reported impact of developmental stuttering across the lifespan

AIM

To examine the phenomenology of stuttering across the lifespan in the largest prospective cohort to date.

METHOD

Participants aged 7 years and older with a history of developmental stuttering were recruited. Self-reported phenotypic data were collected online including stuttering symptomatology, co-occurring phenotypes, genetic predisposition, factors associated with stuttering severity, and impact on anxiety, education, and employment.

RESULTS

A total of 987 participants (852 adults: 590 males, 262 females, mean age 49 years [SD = 17 years 10 months; range = 18-93 years] and 135 children: 97 males, 38 females, mean age 11 years 4 months [SD = 3 years; range = 7-17 years]) were recruited. Stuttering onset occurred at age 3 to 6 years in 64.0%. Blocking (73.2%) was the most frequent phenotype; 75.9% had sought stuttering therapy and 15.5% identified as having recovered. Half (49.9%) reported a family history. There was a significant negative correlation with age for both stuttering frequency and severity in adults. Most were anxious due to stuttering (90.4%) and perceived stuttering as a barrier to education and employment outcomes (80.7%).

INTERPRETATION

The frequent persistence of stuttering and the high proportion with a family history suggest that stuttering is a complex trait that does not often resolve, even with therapy. These data provide new insights into the phenotype and prognosis of stuttering, information that is critically needed to encourage the development of more effective speech therapies.

WHAT THIS PAPER ADDS

Half of the study cohort had a family history of stuttering. While 75.9% of participants had sought stuttering therapy, only 15.5% identified as having recovered. There was a significant negative correlation between age and stuttering frequency and severity in adults.

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.

Stuttering, family history and counselling: A contemporary database

BACKGROUND

Information about genetic influence is useful to when counselling parents or caregivers who have infants and children at risk for stuttering. Yet, the most comprehensive family aggregate database to inform that counselling is nearly four decades old (Andrews et al., 1983). Consequently, the present study was designed to provide a contemporary exploration of the relationship between stuttering and family history.

METHODS

Data were sourced from the Australian Stuttering Research Centre, comprising 739 participants who presented for assessment, treatment, or investigation of stuttering. Reported family history data were acquired from pedigrees collected during assessment. We sought to establish the relation of the following variables to family history of stuttering: incidence, proband sex, parent sex, stuttering severity, age, reported age of stuttering onset, and impact of stuttering. Data were analysed with chi-square tests for independence, logistic and linear regression models.

RESULTS

Results were broadly consistent with existing data, but the following findings were novel. Males and females who stutter have the same increased odds of having a father who stutters relative to a mother who stutters. Males had later stuttering onset than females, with genetic involvement in this effect. There was a greater impact of stuttering for females than males with a family history of stuttering.

CONCLUSION

These findings have clinical applications. Speech-language pathologists may have infant or child clients known to them who are at risk of beginning to stutter. Information from the present study can be applied to counselling parents or caregivers of such children about stuttering and family history.

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.

Bidirectional Associations of Childhood Stuttering With Behavior and Temperament

PURPOSE

Behavior and temperament (e.g., emotional reactivity, self-regulation) have been considered relevant to stuttering and its developmental course, but the direction of this relation is still unknown. Knowledge of behavior difficulties and temperament in childhood stuttering can improve screening and intervention. The current study examined both directions of the relationship between stuttering and behavior difficulties and temperament and between persistent stuttering and behavior difficulties and temperament across childhood.

METHOD

This study was embedded in the Generation R Study, a population-based cohort from fetal life onward in the Netherlands. We analyzed data from 145 children (4.2%) with a history of stuttering (118 recovered, 27 persistent) and 3,276 children without such a history. Behavior and temperament were repeatedly assessed using parental questionnaires (Child Behavior Checklist) and Infant/Child Behavior Questionnaire between 0.5 and 9 years of age. Multiple logistic and linear regression analyses were performed.

RESULTS

Six-month-old children who were less able to "recover from distress," indicating poor self-regulation, were more likely to develop persistent stuttering later in childhood (odds ratio = 2.05, 95% confidence interval (CI) [1.03, 4.05], p = .04). In the opposite direction, children with a history of stuttering showed more negative affectivity (β = 0.19, 95% CI [0.02, 0.37], p = .03) at 6 years of age than children without such a history. Stuttering persistence was associated with increased internalizing behaviors (β = 0.38, 95% CI [0.03, 0.74], p = .04) and higher emotional reactivity (β = 0.53, 95% CI [0.09, 0.89], p = .02) at the age of 9 years.

CONCLUSIONS

Behavior and temperament were associated with stuttering persistency-seemingly as both predictor and consequence-but did not predict a history of stuttering. We suggest that children who persist in stuttering should be carefully monitored, and if behavioral or temperamental problems appear, treatment for these problems should be offered. Supplemental Material https://doi.org/10.23641/asha.16869479.

Real and virtual classrooms can trigger the same levels of stuttering severity ratings and anxiety in school-age children and adolescents who stutter

PURPOSE

Many school-age children and adolescents who stutter experience the fear of public speaking. Treatment implications include the need to address this problem. However, it is not always possible to train repeatedly in front of a real audience. The present study aimed to assess the relevance of using a virtual classroom in clinical practice with school-age children and adolescents who stutter.

METHODS

Ten children and adolescents who stutter (aged 9-17 years old) had to speak in three different situations: in front of a real audience, in front of a virtual class and in an empty virtual apartment using a head-mounted display. We aimed to assess whether the self-rated levels of anxiety while speaking in front of a virtual audience reflect the levels of anxiety reported while speaking in front of a live audience, and if the stuttering level while speaking to a virtual class reflects the stuttering level while speaking in real conditions.

RESULTS

Results show that the real audience creates higher anticipatory anxiety than the virtual class. However, both the self-reported anxiety levels and the stuttering severity ratings when talking in front of a virtual class did not differ from those observed when talking to a real audience, and were significantly higher than when talking in an empty virtual apartment.

CONCLUSION

Our results support the feasibility and relevance of using a virtual classroom to expose school-age children and adolescents who stutter to a feared situation during cognitive behavioral therapy targeting the fear of public speaking.

Validity of telephone calls to assess percentage of syllables stuttered with adolescents in clinical research

PURPOSE

Karimi, O'Brian, Onslow, and Jones (2013) reported, for adults, no systematic differences between percentage of syllables stuttered (%SS) scores during a 12-hour day and 10-minute phone calls. The present study replicated that finding with adolescents, using valid methods for the age group. The present study also extended that initial report by determining whether the gender of the caller influenced %SS scores.

METHOD

Participants were 17 adolescents with stuttering. Percentage of syllables stuttered scores were obtained from a 12-hour day of the adolescents' lives, and two 10-minute unscheduled phone calls made before and after that day. One phone call was from a male caller and the other from a female caller.

RESULTS

For adolescents, analysis of covariance (ANCOVA) and intraclass correlations (ICC) replicated the overall Karimi, O'Brian, Onslow, and Jones (2013) finding. No significant differences were found between the %SS scores of the three speech samples, and these %SS scores were found to be highly correlated. However, in contrast to the Karimi, O'Brian, Onslow, and Jones (2013) finding with adults, Bland-Altman plot results revealed a caveat to this finding when applied to individual adolescents. Additionally, there was no effect due to the gender of the caller.

CONCLUSION

A 10-minute phone call can be used confidently to assess group mean %SS scores during stuttering research with adolescents. However, a 10-minute phone call cannot be used confidently to assess %SS scores of individual adolescent participants. For the latter context, such as with data-based case studies and single-subject experimentation, we recommend supplementing %SS scores with self-reported severity scores.

Natural recovery from stuttering for a clinical cohort of pre-school children who received no treatment

PURPOSE

The natural stuttering recovery rate by adulthood is high. Community cohort studies suggest a much lower rate during the first 18 months after onset, but this may be different for clinical cohorts of pre-school aged children. The present research and case presentations add to data reported by Franken et al. by investigating early natural recovery for a clinical cohort.

METHOD

Participants were 16 pre-school children presenting to a clinic with stuttering onset 1-15 months earlier. The children were studied for a mean of 19.4 months (84.3 weeks) using parent report and clinician identification of stuttering from recorded conversations. The children received no treatment during the study. Data were obtained for each participant and are presented graphically.

RESULT

Experienced speech-language pathologists detected stuttering in the recordings of 3 of 4 children identified as recovered by their parents. Only 1 of the 16 children (6.3%) was confirmed as recovered.

CONCLUSION

There is no reason to believe that the early natural recovery rate for clinically presenting children is different from community cohorts. Parent report of natural recovery during the pre-school years needs to be confirmed by clinician observation of the child's speech; otherwise, there is risk of harmful false negative identification. The present data support the Yairi et al. different recovery pathways for children who stutter.

Verbal Contingencies in the Lidcombe Program: A Noninferiority Trial

Purpose The Lidcombe Program is an efficacious and effective intervention for early stuttering. The treatment is based on parent verbal response contingent stimulation procedures, which are assumed to be responsible for treatment effect. The present trial tested this assumption. Method The design was a parallel, open plan, noninferiority randomized controlled trial. In the experimental arm, the five Lidcombe Program verbal contingencies were removed from parent instruction. The primary outcome was beyond-clinic percentage syllables stuttered at 18-month follow-up. Seventy-four children and their parents were randomized to one of the two treatment arms. Results Findings of noninferiority were inconclusive for the primary outcome of stuttering severity, based on a margin of 1.0 percentage syllables stuttered. Conclusions The inconclusive finding of noninferiority means it is possible that verbal contingencies make some contribution to the Lidcombe Program treatment effect. However, considering all primary and secondary outcomes, an overriding impression from the trial is a similarity of outcomes between the control and experimental arms. The clinical applications of the trial are discussed, along with further research that is needed.

Pediatrician Referral Practices for Children Who Stutter

Purpose Given the marked increase in evidence-based information regarding the nature/treatment of stuttering, coupled with the fact that pediatricians tend to be one of the initial points of contact for parents who suspect their preschool-age child may stutter, this study explored pediatricians' (a) accuracy in identifying children who may stutter and (b) likelihood of referring children who present with a profile indicative of stuttering to speech-language pathologists. Method Pediatricians recruited nationally through professional organizations completed a 5- to 7-min online survey that probed stuttering identification and referral practices via responses to experimental case vignettes. Each vignette featured a 4-year-old boy with a family history of stuttering whose mother reported signs of stuttering and manipulation of two factors: stuttering during the pediatrician visit (or not) and negative communication attitude (or not). Results Our findings suggest pediatricians' identification and referral of children who may stutter is largely prompted by observation of overt speech behaviors and/or negative communication attitude. Participants' gender, years in practice, and experience working with children who stutter did not influence likelihood of referral. Conclusions Results indicate pediatricians are less likely to implement a "wait and see" approach with young children who stutter today than in the past. Unlike other common child onset diagnoses, however, parent report of atypical behavior does not yield pediatrician referral to a specialist. Future education and advocacy efforts directed toward pediatricians should emphasize inclusion of factors other than direct observation of stuttering behavior that may warrant referral (e.g., parent report).

Clinical Trials of Adult Stuttering Treatment: Comparison of Percentage Syllables Stuttered With Self-Reported Stuttering Severity as Primary Outcomes

Purpose In a companion paper, we found no statistical reason to favor percentage syllables stuttered (%SS) over parent-reported stuttering severity as a primary outcome measure for clinical trials of early stuttering. Hence, considering the logistical advantages of the latter measure, we recommended parent-reported stuttering severity for use as an outcome measure. The present report extends the prior analysis to a comparison of %SS with self-reported stuttering severity (SRSS) for use as an outcome measure in clinical trials of stuttering treatments for adults. Method We analyzed data from four randomized clinical trials for adults that incorporated %SS and SRSS data at prerandomization and at 6 months post randomization. We analyzed the distributions associated with the two measures, their agreement, and their estimates of effect sizes. Results The positively skewed distribution of %SS warrants much reservation about its value as a clinical trial outcome measure. This skew causes inherent instability because of spurious data associated with low scores, which occur commonly at the low end of such a distribution. This inherent instability is compounded by inherent problems with absolute reliability of %SS measures. These problems are reduced with the much more normal distribution of SRSS. Conclusions The logistical arguments in favor of SRSS apply similarly to adults as they do when parents report the stuttering severity of their children. However, there are statistical reasons to favor SRSS over %SS measures as a primary outcome of clinical trials with adult participants: SRSS has acceptable discriminant validity and a normal distribution, and it is less error prone than %SS. We recommend SRSS as a primary outcome for clinical trials of adults with stuttering.

After the RESTART trial: six guidelines for clinical trials of early stuttering intervention

BACKGROUND

The Rotterdam Evaluation Study of Stuttering Therapy randomized trial (RESTART) was seminal, comparing the Lidcombe Program with RESTART Demands and Capacities Model-based treatment (RESTART-DCM) for pre-school age children who stutter.

AIMS

To critique the methods of the RESTART trial to develop guidelines for its systematic replication and extension. Beyond that, to contribute to the refinement of existing methodological guidelines for early stuttering intervention.

METHOD

The discussion is organized around methodological issues of primary outcomes, treatment completion, clinician allegiance, treatment fidelity, age exclusions and no-treatment control reasoning.

MAIN CONTRIBUTION

We recommend six methodological guidelines to guide future clinical trials comparing the Lidcombe Program with RESTART-DCM, which can be applied to clinical trials of other early stuttering intervention methods: (1) incorporate a continuous measure of primary outcome; (2) ensure that all children in clinical trials have completed treatment; (3) eliminate potential bias due to clinician allegiance; (4) establish treatment fidelity within and beyond the clinic; (5) include children younger than 3 years in clinical trials; and (6) establish an estimate of treatment effect size at some stage of treatment development.

CONCLUSION

In addition to guiding future clinical research comparing RESTART-DCM and Lidcombe Program treatment, these recommendations may extend to influence positively other treatment developments for early stuttering.