Establishing the validity of recovery from stuttering without formal treatment

Recovery and Relapse: Perspectives From Adults Who Stutter

Purpose Recovery and relapse relating to stuttering are often defined in terms of the presence or absence of certain types of speech disfluencies as observed by clinicians and researchers. However, it is well documented that the experience of the overall stuttering condition involves more than just the production of stuttered speech disfluencies. This study sought to identify what recovery and relapse mean to people who stutter based on their own unique experiences to account for both the stuttering behaviors and the broader adverse impact of the condition. Method In this study, 228 adults who stutter participated in a mixed-methods exploration of the terms "recovery" and "relapse." Participants categorized themselves on whether they considered themselves to have recovered or experienced relapse. Data were analyzed thematically through the lens of the speaker self-categorizations to determine how adults who stutter define recovery and relapse regarding stuttering. Results Results indicate that, to adults who stutter, recovery from stuttering is associated with increases in positive affective/emotional, behavioral, and cognitive reactions to the condition and simultaneous decreases in associated negative constructs. These group-level definitions did not change as a function of whether respondents reported that they had experienced recovery or relapse themselves. Discussion Recovery or relapse from stuttering behaviors can occur independently from recovery or relapse from the broader adverse impact related to the condition, suggesting that researchers and clinicians should consider recovery and relapse as involving more than just a reduction or an increase in observable behaviors. These findings support recent research evidence further specifying the many individual phenotypes of stuttering, in that pathways to recovery and relapse can be experienced in different ways for people with different stuttering phenotype profiles.

"Spontaneous" late recovery from stuttering: Dimensions of reported techniques and causal attributions

PURPOSE

(1) To survey the employed techniques and the reasons/occasions which adults who had recovered from stuttering after age 11 without previous treatment reported as causal to overcome stuttering, (2) to investigate whether the techniques and causal attributions can be reduced to coherent (inherently consistent) dimensions, and (3) whether these dimensions reflect common therapy components.

METHODS

124 recovered persons from 8 countries responded by SurveyMonkey or paper-and-pencil to rating scale questions about 49 possible techniques and 15 causal attributions.

RESULTS

A Principal Component Analysis of 110 questionnaires identified 6 components (dimensions) for self-assisted techniques (Speech Restructuring; Relaxed/Monitored Speech; Elocution; Stage Performance; Sought Speech Demands; Reassurance; 63.7% variance explained), and 3 components of perceived causal attributions of recovery (Life Change, Attitude Change, Social Support; 58.0% variance explained).

DISCUSSION

Two components for self-assisted techniques (Speech Restructuring; Elocution) reflect treatment methods. Another component (Relaxed/Monitored Speech) consists mainly of items that reflect a common, non-professional understanding of effective management of stuttering. The components of the various perceived reasons for recovery reflect differing implicit theories of causes for recovery from stuttering. These theories are considered susceptible to various biases. This identification of components of reported techniques and of causal attributions is novel compared to previous studies who just list techniques and attributions.

CONCLUSION

The identified dimensions of self-assisted techniques and causal attributions to reduce stuttering as extracted from self-reports of a large, international sample of recovered formerly stuttering adults may guide the application of behavioral stuttering therapies.

School-Based Speech-Language Pathologists' Perspectives on Diagnostic Decision Making

PURPOSE

This study used a structured open interview approach to elicit information from school-based speech-language pathologists (SLPs) regarding their assessment practices for children with suspected language impairment.

METHOD

Phone interviews were conducted with 39 school-based SLPs who were employed across the United States. The interviews explored assessment topics related to assessment tool selection and rationale and the integration of assessment data to determine treatment eligibility.

RESULTS

The results of this study suggest that SLPs use both standardized testing and informal testing for their diagnostic procedures. Standardized testing appears to be the tool that drives diagnostic decisions regarding eligibility and severity. Informal measures, such as parent/teacher interviews and language sampling, were used by school-based SLPs to gather information regarding naturalistic language use; however, they seem less important in the diagnostic decision-making process. Also, SLPs reported completing language sample transcription and analysis in real time while interacting with a child.

CONCLUSIONS

School-based SLPs appear to rely on the results from standardized testing when determining treatment eligibility for children with language impairment. The reliance on standardized testing appears to be driven by institutional policies. We discuss the potential impact of federal/state/district guidelines on diagnostic decisions and consider the research-to-practice gap.

Characteristics of Fluency and Speech in Two Families With High Incidences of Stuttering

PURPOSE

This study presents data from 2 families with high incidence of stuttering, comparing methods of phenotype assignment and exploring the presence of other fluency disorders and corresponding speech characteristics.

METHOD

Three methods for assigning phenotype of stuttering were used: self-identification, family identification, and expert identification. Agreement on which individuals were assigned by each of these methods was studied. Multiple measures of fluency and speech production were obtained.

RESULTS

Self-reports and descriptions of blocking rather than self-identification as a person who stutters demonstrated the best agreement with expert identification of stuttering. Family identification showed poor agreement with both expert and self-identification of stuttering. Using binary categories of fluent or stuttering, 90% of individuals in 1 family were classified by expert consensus. Only 70% of the other family could be similarly categorized. Experts required 2 other categories, cluttering and other fluency disorders, to fully characterize dysfluency within this family. These 2 families also demonstrated differences in speech production.

CONCLUSION

Some families with high incidence of stuttering may also have high incidence of other fluency disorders and other speech-production difficulties. This finding may have ramifications for genetic studies, including criteria for defining phenotype and collapsing data across multiple families.

Integrating functional measures with treatment: a tactic for enhancing personally significant change in the treatment of adults and adolescents who stutter

PURPOSE

It is proposed that stuttering treatment, particularly for adults and adolescents who stutter, may benefit from more inventive and extensive use of functional measurement-measures that are also treatment agents. Such measures can be tailored to produce more personally significant and evidence-based treatment benefits. They may be especially useful when employed in conjunction with partial self-management and performance-contingent procedures.

METHOD

Previous approaches to the definition of stuttering treatment goals and the measurement of stuttering treatment outcomes are critically reviewed. Suggestions for improvements are presented within the framework of an evidence-based and relatively standardized stuttering treatment.

RESULTS AND CONCLUSION

Results from a review of existing literature and from 2 case studies show that 2 specific personally significant problems, saying one's name and addressing large audiences, were improved by implementing these strategies in treatment. Functional measures directly connected to treatment, and partially self-managed performance-contingent schedules, merit further research as methodologies that are suitable for conducting personally significant and evidence-based treatments with adults and adolescents who stutter.

Documenting changes in adult speakers' locus of causality during stuttering treatment using Origin and Pawn scaling

The concepts of locus of control and locus of causality are similar and refer to the degree to which a person perceives daily occurrences to be a consequence of his or her own behavior. Locus of control is considered to be a unidimensional construct indicating an inverse relationship between the polls of internality and externality. The locus of control is generally determined by using questionnaires with a limited number of items. Locus of causality is considered to be a two-dimensional construct where Origin and Pawn values, which are similar to internality and externality, respectively, are not necessarily inversely related. Locus of causality is determined by content analysis of freely spoken or written narratives. In the current study Origin and Pawn scores were obtained from twenty adults prior to and following a three-week intensive stuttering treatment program. Brief narratives written by the participants were analyzed to obtain Origin and Pawn values. These scores were compared with traditional measures of therapeutic outcome (Locus of Control, OASES, PSI, percentage of syllables stuttered). Results indicated statistically significant increases in pre- to post-treatment Origin scores (p=.001; Cohen's d=1.44) and statistically significant decreases in pre- to post-treatment Pawn scores (p=.003; Cohen's d=1.11). Origin and Pawn scores showed significant relationships with other measures of stuttering, indicating concurrent and construct validity. Origin and Pawn scaling procedures appear to provide a valid, sensitive, and nonreactive indicator of the speaker's locus of causality and ability to develop an autonomous and agentic lifestyle.

EDUCATIONAL OBJECTIVES

After reading this article, the readers will be able to: (1) distinguish between the concepts of locus of control and locus of causality, (2) describe the characteristics of individuals behaving as an Origin and a Pawn, (3) differentiate patterns of change for Origin and Pawn scores prior to and following treatment, and (4) describe the clinical advantages using Origin and Pawn scaling procedures for individuals who stutter.

How the brain repairs stuttering

Stuttering is a neurodevelopmental disorder associated with left inferior frontal structural anomalies. While children often recover, stuttering may also spontaneously disappear much later after years of dysfluency. These rare cases of unassisted recovery in adulthood provide a model of optimal brain repair outside the classical windows of developmental plasticity. Here we explore what distinguishes this type of recovery from less optimal repair modes, i.e. therapy-induced assisted recovery and attempted compensation in subjects who are still affected. We show that persistent stuttering is associated with mobilization of brain regions contralateral to the structural anomalies for compensation attempt. In contrast, the only neural landmark of optimal repair is activation of the left BA 47/12 in the orbitofrontal cortex, adjacent to a region where a white matter anomaly is observed in persistent stutterers, but normalized in recovered subjects. These findings show that late repair of neurodevelopmental stuttering follows the principles of contralateral and perianomalous reorganization.

Coping responses by adults who stutter: part I. Protecting the self and others

Using a grounded theory approach, four clusters were identified that represent patterns of coping by adults who stutter. In order to understand the complexities within the coping responses of speakers to the experience of stuttering, this first of two companion papers summarizes the literature on the human coping response to stress and the nature of two of the four main findings identified. These findings describe a coping process that emphasizes strategies of protecting both the speaker and the listener from experiencing discomfort associated with stuttering. The companion paper describes the remaining two main findings that emphasize the characteristics of self-focused and action oriented coping responses.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe, from the perspective of a select group of adults who stutter, the themes associated with the process of coping with stuttering, (2) describe the basic rationale for the procedures associated with grounded theory methods, (3) describe the factors that influence the choice to use emotion-focused and problem-focused coping strategies, and (4) explain the factors that contribute to the use of methods of escape.

Speech effort measurement and stuttering: investigating the chorus reading effect

PURPOSE

The purpose of this study was to investigate chorus reading's (CR's) effect on speech effort during oral reading by adult stuttering speakers and control participants. The effect of a speech effort measurement highlighting strategy was also investigated.

METHOD

Twelve persistent stuttering (PS) adults and 12 normally fluent control participants completed 1-min base rate readings (BR-nonchorus) and CRs within a BR/CR/BR/CR/BR experimental design. Participants self-rated speech effort using a 9-point scale after each reading trial. Stuttering frequency, speech rate, and speech naturalness measures were also obtained. Instructions highlighting speech effort ratings during BR and CR phases were introduced after the first CR.

RESULTS

CR improved speech effort ratings for the PS group, but the control group showed a reverse trend. Both groups' effort ratings were not significantly different during CR phases but were significantly poorer than the control group's effort ratings during BR phases. The highlighting strategy did not significantly change effort ratings.

CONCLUSION

The findings show that CR will produce not only stutter-free and natural sounding speech but also reliable reductions in speech effort. However, these reductions do not reach effort levels equivalent to those achieved by normally fluent speakers, thereby conditioning its use as a gold standard of achievable normal fluency by PS speakers.

A phenomenological understanding of successful stuttering management

The purpose of this investigation was to understand, from the perspective of the speaker, how seven adults have been able to successfully manage their stuttering. Individual experiences were obtained across the three temporal stages (past, transitional, and current). Recurring themes were identified across participants in order to develop an essential structure of the phenomena at each stage. The ability to make the transition from unsuccessful to successful management of stuttering was associated with six recurring themes of: (1) support, (2) successful therapy, (3) self therapy and behavioral change, (4) cognitive change, (5) utilization of personal experience, and (6) high levels of motivation/determination. Six recurring themes associated with past experiences, when stuttering was unsuccessfully managed, included: (1) gradual awareness, (2) negative reactions of listeners, (3) negative emotions, (4) restrictive lifestyle, (5) avoidance, and (6) inadequate therapy. The five recurring themes identified for the current situation where stuttering continues to be successfully managed were: (1) continued management, (2) self acceptance and fear reduction, (3) unrestricted interactions, (4) sense of freedom, (5) and optimism.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe, from the prospective of a select group of adults who stutter, the recurring themes associated with both unsuccessful and successful management of stuttering, (2) explain the recurring themes associated with how this group of seven adults achieved successful management of their stuttering, and (3) discuss the basic rationale and procedures associated with phenomenological analysis.

Evidence-based practice in stuttering: Some questions to consider

A recent forum in JFD (28/3, 2003) evaluated the status of evidence-based practice in fluency disorders, and offered recommendations for improvement. This article re-evaluates the level of support available for some popular approaches to stuttering therapy and questions the relative value placed on some types of programs endorsed by the forum. Evidence-based practice is discussed within the context of emerging concerns over its application to non-medical interventions and suggestions are made for grounding fluency interventions by reference to empirically supported principles of change. A popular, evidence-based intervention for stuttering in young children (the Lidcombe program) is evaluated within the suggested parameters.

EDUCATIONAL OBJECTIVES

After reading this article, the reader will be able to: (1) evaluate the status of evidence-based practice in fluency disorders; (2) list concerns about the impact of narrow interpretation of EBP on research and practice in the field of fluency disorders and other non-medical domains; (3) articulate the role of theory and basic research in selecting among and evaluating therapy approach options.

"Roadblocks" revisited: neural change, stuttering treatment, and recovery from stuttering

In light of emerging findings concerning untreated recovery and neural plasticity, this paper re-examines the viability of an NIH conference recommendation [Cooper, J. A. (1990). Research directions in stuttering: Consensus and conflict. In Cooper, J. A. (Ed.), Research needs in stuttering: Roadblocks and future directions (pp. 98-100). Rockville, MD: American Speech-Language-Hearing Association.] that adults who have recovered from stuttering might inform our understanding of the nature and treatment of persistent stuttering. It is suggested that those who have recovered could constitute a behavioral, cognitive, and neurophysiologic benchmark for evaluating stuttering treatment for adolescents and adults, while helping to identify the limits of recovery from a persistent disorder. This possibility seems especially promising because of findings from recent studies investigating untreated recovery during childhood and adulthood, the emerging evidence concerning neural plasticity and reorganization, and reports of neural system changes during stuttering treatment. Potential obstacles to applying findings from unassisted recovery to treatment do exist, but the benefits of attempts to fully understand stuttering certainly outweigh the difficulties.

EDUCATIONAL OBJECTIVES

After completing this activity, the learner will be able to: (1) describe two complexities involved in determining whether recovery from stuttering was assisted or unassisted; (2) discuss the implications for stuttering research of two neural plasticity research findings from areas other than stuttering; and (3) evaluate the possible implications for stuttering treatment of a coordinated research program that addresses behavioral, cognitive, and neurological characteristics of assisted and unassisted recovery from stuttering.

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

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

EDUCATIONAL OBJECTIVES

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

A thematic analysis of late recovery from stuttering

This study used thematic analysis to gain a better understanding of the experiences of individuals who reported late recovery from stuttering. Using a semistructured interview, 6 adults who reported recovering from stuttering after the age of 10 were asked to relate their recovery stories, with particular emphasis on their perceptions of factors responsible for the recovery process. The interviews were parsed into information-rich quotations that were ultimately placed into thematic categories. Three thematic categories appeared to capture the majority of the recovery attributions: (a) increased confidence; (b) increased motivation, expressed as a desire to make positive changes in speech; and (c) direct speech changes. Narrative case studies were subsequently developed to illustrate the 3 different "pathways to recovery" that were described by our participants.

Towards a functional neural systems model of developmental stuttering

This paper overviews recent developments in an ongoing program of brain imaging research on developmental stuttering that is being conducted at the University of Texas Health Science Center, San Antonio. This program has primarily used H(2)15O PET imaging of different speaking tasks by right-handed adult male and female persistent stutterers, recovered stutterers and controls in order to isolate the neural regions that are functionally associated with stuttered speech. The principal findings have emerged from studies using condition contrasts and performance correlation techniques. The emerging findings from these studies are reviewed and referenced to a neural model of normal speech production recently proposed by Jürgens [Neurosci. Biobehav. Rev. 26 (2002) 235]. This paper will report (1) the reconfiguration of previous findings within the Jürgens Model; (2) preliminary findings of an investigation with late recovered stutterers; (3) an investigation of neural activations during a treatment procedure designed to produce a sustained improvement in fluency; and (4) an across-studies comparison that seeks to isolate neural regions within the Jürgens Model that are consistently associated with stuttering. Two regions appear to meet this criterion: right anterior insula (activated) and anterior middle and superior temporal gyri (deactivated) mainly in right hemisphere. The implications of these findings and the direction of future imaging investigations are discussed.

EDUCATIONAL OBJECTIVES

The reader will learn about (1) recent uses of H(2)15O PET imaging in stuttering research; (2) the use of a new neurological model of speech production in imaging research on stuttering; and (3) initial findings from PET imaging investigations of treated and recovered stutterers.

Statistical power in stuttering research: a tutorial

The capacity to make reliable inductive statements about populations is critical for the advancement of scientific knowledge. An important contribution to that advancement of knowledge is determining that effects are either present or not present in populations. Statistical power is an important methodological qualification for any research that presents statistical results, and particularly so for research that presents null results. In this paper we describe the statistical concept of power, outline parameters of research that influence it, and demonstrate how it is calculated. With reference to selected published research, attention is drawn to the problems associated with a body of underpowered research, one being that population effects may go undetected. One way to prevent this problem is to calculate power a priori in planning research and include confidence intervals when presenting the results of research. However, it is difficult, if not impossible in many cases, to obtain high participant numbers for communication disorders of low prevalence such as stuttering. With this in mind, the paper concludes with an attempt to open discussion about ways to redress the problems associated with statistical power.

Speech-motor control and interhemispheric relations in recovered and persistent stuttering

The neurological basis of stuttering is associated with anomalies of interhemispheric relations and of the neural mechanisms of speech-motor control, specifically those involving the supplementary motor area (SMA). Stuttering typically develops through childhood and adolescence but many children will recover without formal treatment or intervention. The hypothesis that such spontaneous recovery is related to a maturation of the SMA is explored. Four experimental tasks were performed by adults whose stuttering has persisted, adults who reported having stuttered as children, and a control group of adults who reported never having stuttered. A Sequence Reproduction Finger Tapping task (Webster, 1986) and a Bimanual Crank Turning task (Preilowski, 1972) examined the functioning of the SMA, and 2 Divided Visual Field tasks examined asymmetries of hemispheric activation. The overall pattern of results for persistent stutterers compared to nonstutterers was consistent with motor-perceptual anomalies previously reported in the literature. The Bimanual Crank Turning task revealed additionally that the bimanual coordination deficits reported in adults who stutter are kinesthetically based and mediated through anterior callosal systems, including the SMA. Ex-stutterers were similar to nonstutterers in their performance of the motor control tasks, but similar to persistent stutterers in perceptual asymmetries associated with Divided Visual Field tasks. Taken together, the results from the four experimental tasks support the general hypothesis that an anomaly in interhemispheric relations and a deficit in the mechanisms of speech-motor control are each a necessary but not sufficient condition for stuttering and that recovery from childhood stuttering reflects a maturation of the mechanisms of speech-motor control.

Research on speech motor control and its disorders: a review and prospective

This paper reviews issues in speech motor control and a class of communication disorders known as motor speech disorders. Speech motor control refers to the systems and strategies that regulate the production of speech, including the planning and preparation of movements (sometimes called motor programming) and the execution of movement plans to result in muscle contractions and structural displacements. Traditionally, speech motor control is distinguished from phonologic operations, but in some recent phonologic theories, there is a deliberate blurring of the boundaries between phonologic representation and motor functions. Moreover, there is continuing discussion in the literature as to whether a given motor speech disorder (especially apraxia of speech and stuttering) should be understood at the phonologic level, the motoric level, or both of these. The motor speech disorders considered here include: the dysarthrias, apraxia of speech, developmental apraxia of speech, developmental stuttering, acquired (neurogenic and psychogenic) stuttering, and cluttering.

Adults recovered from stuttering without formal treatment: perceptual assessment of speech normalcy

The purpose of this study was to determine if the speech of adults who self-judged that they were recovered from stuttering without the assistance of treatment is perceptually different from that of adults who never stuttered. Fifteen adult speakers verified as persons who had recovered from a valid stuttering problem without the assistance of treatment were compared with 15 adult speakers verified as persons with normally fluent speech. Judges viewed videotaped speech samples of all speakers and were instructed to decide whether a speaker used to stutter or never stuttered. A separate group of judges rated the same samples for speech naturalness. Various speech behavior measures were also obtained. Results revealed that the speech of speakers who used to stutter was perceptually different from that of speakers who never stuttered. This difference was correlated with unnatural sounding speech and a high frequency of part-word repetitions.