Phase II trial of a syllable-timed speech treatment for school-age children who stutter

https://doi.org/10.1016/j.jfludis.2016.06.001Get rights and content

Highlights

  • STS in conjunction with parent verbal contingencies reduces stuttering in children.

  • Stuttering reduction was associated with improvements in satisfaction with fluency, avoidance and quality of life.

  • Following STS treatment, children did not sound rhyhmic.

Abstract

Purpose

A recent clinical trial (Andrews et al., 2012) showed Syllable Timed Speech (STS) to be a potentially useful treatment agent for the reduction of stuttering for school-age children. The present trial investigated a modified version of this program that incorporated parent verbal contingencies.

Methods

Participants were 22 stuttering children aged 6–11 years. Treatment involved training the children and their parents to use STS in conversation. Parents were also taught to use verbal contingencies in response to their child’s stuttered and stutter-free speech and to praise their child’s use of STS. Outcome assessments were conducted pre-treatment, at the completion of Stage 1 of the program and 6 months and 12 months after Stage 1 completion.

Results

Outcomes are reported for the 19 children who completed Stage 1 of the program. The group mean percent stuttering reduction was 77% from pre-treatment to 12 months post-treatment, and 82% with the two least responsive participants removed. There was considerable variation in response to the treatment. Eleven of the children showed reduced avoidance of speaking situations and 18 were more satisfied with their fluency post-treatment. However, there was some suggestion that stuttering control was not sufficient to fully eliminate situation avoidance for the children.

Conclusions

The results of this trial are sufficiently encouraging to warrant further clinical trials of the method.

Introduction

There is a pressing need to develop better treatments for school age children who stutter (Nippold, 2011, Nippold and Packman, 2012). Stuttering is most tractable during the preschool years with outcomes becoming less positive with increasing age (Bothe, 2004; Bothe, Davidow, Bramlett, Franic, & Ingham, 2006; Ingham, 1984, Ingham and Cordes, 1999, Onslow and Packman, 1997, Onslow and Packman, 1999, Prins and Ingham, 1983). As well as becoming increasingly difficult to treat, stuttering can lead to social and emotional problems as children enter formal school years (Conture & Guitar, 1993). School children who stutter are chronically bullied because of their stuttering. One report showed 11–12 year-old children who stutter have a 63% risk of bullying compared to 22% for controls (Blood & Blood, 2007). A report of 28 stuttering children aged 7–15 years found that 59% of them reported being bullied and 38% reported bullying to have occurred on most days or every day (Langevin, Bortnick, Hammer, & Wiebe, 1998). Davis, Howell, and Cooke (2002) reported that peers were far more likely to categorize stuttering school children as victims of bullying. A survey report of 332 adults (Hayhow, Cray, & Enderby, 2002) indicated that 56% of stuttering children may be affected considerably by bullying during the school years. For any child, bullying during the early school years is strongly associated with subsequent anxiety (Gladstone, Parker, & Malhi, 2006).

Social anxiety generally emerges during early adolescence, hence there are likely to be signs of its development during the school years (Smith, Iverach, O’Brian, Kefalianos, & Reilly, 2014). There are direct psychometric data to confirm that possibility (Davis, Shisca, & Howell, 2007; Messenger, Packman, Onslow, Menzies, & O’Brian, 2015). Additionally, indirect evidence of social anxiety for this age group is that stuttering children have more negative attitudes to communication than their peers and those attitudes to communication progressively worsen during the school years (DeNil and Brutten, 1991, Vanryckeghem and Brutten, 1997; Vanryckeghem, Hylebos, Brutten, & Peleman, 2001). There is also evidence of educational problems associated with stuttering, with a large-cohort report based on data from the United States National Health Interview Survey showing that stuttering school children are significantly more likely to repeat a grade than control children (Boyle, Decoufle, & Yeargin-Allsopp, 1994). Those findings about problems with school children who stutter are consistent with a report using a standard stuttering quality of life measure with 50 stuttering 8–11 year-olds and controls (Beilby, Brynes, & Yaruss 2012). The stuttering children had significantly lower quality of life than peers.

In short, it is common for school children who stutter to suffer bullying, potential social anxiety and quality of life problems. Those difficulties mean that for children who miss the preschool window of opportunity for treatment, it is critical that treatment be started as early as possible after entering school.

There is little clinical evidence to guide speech-language pathologists (SLPs) in how to treat the disorder. This situation was highlighted in a recent editorial in the journal Language, Speech and Hearing Services in Schools, where it was stated that “… during the past 10 years, NO [author’s capitals] data-based studies that focused on building fluent speech in school-age children have been published in American Speech-Language-Hearing Association journals … and only one such study (Koushik, Shenker, & Onslow, 2009) was published in the Journal of Fluency Disorders.” (Nippold, 2011, p. 99).

Historically, speech-restructuring treatments (Onslow & Menzies, 2010) have the strongest evidence for the school-age population (Boberg and Kully, 1994, Craig et al., 1996, Hancock et al., 1998, Kully and Boberg, 1991, Ryan and Van Kirk Ryan, 1995); however, there are a number of problems with this approach. First, the continued use of an unnatural speech pattern is unlikely to appeal to children. For a population at risk of social anxiety because of negative social conditioning, an unusual speech pattern that could draw attention to the speaker is clinically contraindicated. Second, the treatment notoriously is associated with relapse for all age groups. Finally, speech restructuring treatments such as the Craig et al. (1996) trial were developed for use in intensive treatment formats, which require significant clinical infrastructure and time. This presents a barrier to translation of any clinical trial results, because most SLPs would not have the infrastructure to use such a logistically challenging format.

Verbal response contingent stimulation has been shown to be of clinical value for pre-school children who stutter, particularly for the Lidcombe Program. The mechanism for the apparent clinical effects of this operant method with the Lidcombe Program are not clear, seeming not to be linguistic (Bonelli, Dixon, Bernstein Ratner, & Onslow, 2000; Lattermann, Shenker, & Thoradottir, 2005; Onslow, Stocker, Packman, & McLeod, 2002) or acoustic (Onslow et al., 2002). In fact, there is even some question about whether any such mechanisms are directly related to parent use of verbal response contingent stimulation (Donaghy et al., 2015). It has been suggested, for example, that the treatment effects my be due to the child practicing fluent speech, in response to the parental contingencies, while the brain is still highly plastic (Venkatagari, 2005). Regardless, clinical trials of verbal response contingent stimulation with school-age children show some evidence of a treatment effect (de Kinkelder & Boelens, 1998; Hewat, Onslow, Packman, & O’Brian, 2006; Lincoln, Onslow, Lewis, & Wilson, 1996; Ryan & Van Kirk Ryan, 1983) with evidence of reducing treatment effect with age (Koushik et al., 2009).

Another treatment that has received renewed attention in recent years for the school-age population is syllable-timed speech (STS). It has been known for centuries that speaking each syllable in time to a rhythmic beat reduces stuttering. The treatment was recommended as a stuttering treatment during the early 20th Century. There are three reports of STS being used as a treatment for school-age children (Alford and Ingham, 1969, Andrews and Harris, 1964, Greenberg, 1970). Andrews and Harris (1964) used STS to treat children and adults and observed the child group (five 11-year olds) responded significantly better to the treatment than either the adolescent or the adult participants. Shortly after, Alford and Ingham (1969) used STS in conjunction with negative practice and a token reinforcement system to treat nine children aged 7–10 years, again with promising results for some children in that age group. After a 3-day intensive treatment format, within-clinic scores at 3 months follow-up were from 1.3 to 10.6 “percent disfluencies”. Finally, Greenberg (1970) conducted a study with 20 children age 9–11 years. Ten were instructed to pace their speech in time to a metronome set at 98 beats per minute while the other 10 had the metronome beating in the background but with no instruction to pace their speech to this. Stuttering reduced in both groups by around 50%.

A more recent trial revisited STS as a potential treatment for school-age children. Andrews et al. (2012) investigated STS with ten children aged 6–11 years. Treatment involved training the children and their parents to use STS at normal sounding speech rates. A non-programmed treatment format was used that did not involve systematic, stepwise speech rate increases. The technique was practiced in the clinic and at home with the child and parent during everyday conversations. Prompts to use STS and reinforcement for using it were the only other techniques used. Results demonstrated a significant reduction in stuttering for four of the 10 participants although there was considerable variation in response to the treatment. Of interest though, is that nine of the participants showed a significant reduction of stuttering during the first 6 weeks of treatment indicating that STS had some merit. However, it appeared that simply practicing STS at home every day, as occurred in this trial, was not sufficient to further reduce stuttering or to maintain the initial gains for the majority of participants. Significantly, there was no evidence of any residual speech pattern following treatment. The language used by unsophisticated listeners to describe the post-treatment speech samples of a subset of the Andrews et al. participants suggested that they were not speaking with a residual rhythmic-sounding speech pattern.

In summary, evidence indicates that several treatments have resulted in decreased stuttering with school-age children. STS warrants further investigation because it is a relatively simple treatment for children to understand and use, it has the power to suppress stuttering fairly quickly and involves no residual speech pattern (Andrews et al., 2012). Being a proactive strategy, it also provides an internal locus of control for children to control their stuttering.

However, the earlier report noted that the practice of STS alone was not sufficient for the maintenance of improvements in fluency. Therefore a logical next step in the development of a new treatment was to combine the most critical features of the STS program with those of response contingent stimulation treatments in an attempt to provide a more powerful, yet simple, treatment. The present Phase II trial was designed to evaluate a hybrid treatment, which incorporated STS practice with the use of parent verbal contingencies for the child’s use of STS and for stuttered and stutter-free speech. The trial focused specifically on school children in primary or elementary school that are typically in the age range of about 6–12 years of age.

Section snippets

Participants

Participants were 22 school-age children previously diagnosed as stuttering by an expert SLP and on the treatment waiting list of a university research clinic. Inclusion criteria were (1) age from 6 years, 0 months to 11 years, 11 months; (2) no stuttering treatment during the previous 6 months; and (3) parent and child with sufficiently functional English for treatment as judged by a SLP at the time of providing informed consent.

Sixteen boys and six girls were recruited, with stuttering

Clinical progress

Twenty-two children were recruited to the trial over a 14-month period. Three children withdrew from treatment before completing Stage 1. Results are presented for the 19 participants who remained in treatment until at least the beginning of Stage 2. Of these 19, three participants (Participant 4, Participant 20 and Participant 22) did not meet their stuttering criteria for entry to Stage 2 during the subsequent year. These participants were included in the data analyses. For the children who

Discussion

The present trial investigated a modified version of the STS program for school-age children who stutter initially reported by Andrews et al. (2012). That first trial showed a 38% group reduction of stuttering from pre-treatment to 9 months follow-up and a mean 45% reduction of self-reported stuttering severity. This resulted from practicing STS on a daily basis, with no additional treatment components. However some children had difficulty further reducing their stuttering or maintaining these

Acknowledgement

This research was supported by a grant from the National Health and Medical Research Council of Australia (NHMRC), grant number 633007.

Cheryl Andrews has a private practice at the Children’s Hospital Medical Centre, Westmead, NSW specializing in the treatment of adults and children who stutter. She also works part-time at the Australian Stuttering Research Centre. Her particular interest is in the development and research of stuttering treatments for school-age children.

References (52)

  • J. Alford et al.

    The application of a token reinforcement system to the treatment of stuttering in children

    Journal of the Australian College of Speech Therapists

    (1969)
  • G. Andrews et al.

    The syndrome of stuttering

    (1964)
  • C. Andrews et al.

    Syllable-timed speech treatment for school-age children who stutter: a phase I trial

    Language, Speech, and Hearing Services in Schools

    (2012)
  • S. Arnott et al.

    Group Lidcombe Program treatment for early stuttering: a randomized controlled trial

    Journal of Speech, Language, and Hearing Research

    (2014)
  • J.M. Beilby et al.

    The impact of a stuttering disorder on Western Australian children and adults

    Perspectives on Fluency and Fluency Disorders

    (2012)
  • G.W. Blood et al.

    Preliminary study of self-reported experience of physical aggression and bullying of boys who stutter: relation to increased anxiety

    Perceptual and Motor Skills

    (2007)
  • E. Boberg et al.

    Long-term results of an intensive treatment program for adults and adolescents who stutter

    Journal of Speech and Hearing Research

    (1994)
  • P. Bonelli et al.

    Child and parent speech and language following the Lidcombe programme of early stuttering intervention

    Clinical Linguistics and Phonetics

    (2000)
  • C.A. Boyle et al.

    Prevalence and health impact of developmental disabilities in US children

    Pediatrics

    (1994)
  • A.K. Bothe

    Evidenced-based treatment of stuttering: empirical bases and clinical applications

    (2004)
  • A.K. Bothe et al.

    Stuttering treatment research 1970–2005. II. Systematic review incorporating trial quality assessment of pharmacological approaches

    American Journal of Speech-Language Pathology

    (2006)
  • K. Bridgman et al.

    Lidcombe program webcam treatment for early stuttering: a randomized controlled trial

    Journal of Speech, Language and Hearing Research

    (2016)
  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1988)
  • A. Craig et al.

    A controlled clinical trial for stuttering in persons aged 9 to 14 years

    Journal of Speech and Hearing Research

    (1996)
  • S. Davis et al.

    Sociodynamic relationships between children who stutter and their non-stuttering classmates

    Journal of Child Psychology and Psychiatry

    (2002)
  • L. DeNil et al.

    Speech-associated attitudes of stuttering and nonstuttering children

    Journal of Speech and Hearing Research

    (1991)
  • Cited by (27)

    • Speech restructuring group treatment for 6-to-9-year-old children who stutter: A therapeutic trial

      2021, Journal of Communication Disorders
      Citation Excerpt :

      The situation has improved only moderately since then if strict inclusion criteria are applied, namely two-digit sample sizes, follow-up data of at least three months, control of key variables, and reporting of effect sizes or data which allows their subsequent calculation. With these inclusion criteria, only few EBT options for school-age CWS are available (Andrews et al., 2012, 2016; Koushik, Shenker, & Onslow, 2009). Several other studies must be disregarded here because treatment results for young school children are not reported separately (Keilmann, Neumann, Zöller, & Freude, 2018; Metten, Zückner, & Rosenberger, 2007; Millard, Zebrowski, & Kelman, 2018; Senkal & Ciyiltepe, 2018) or because of other methodological deficits like missing follow-up data or insufficient sample sizes (Budd, Madison, Itzkowitz, George, & Price, 1986; Laiho & Klippi, 2007; Wolff von Gudenberg, Neumann, & Euler, 2006).

    • Auditory temporal processing assessment in children with developmental stuttering

      2020, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      Stuttering is a common childhood developmental disorder, which affects speech fluency [1]. It may recover spontaneously, otherwise requires long-term intensive therapeutic sessions, which typically have adverse impacts on the psychological and social health of children and their family [2,3]. Stuttering is characterized by repetition of a syllable or a part of a syllable, prolongation of sounds, and frequent interruptions in speech [4].

    • Bilingual children who stutter: Convergence, gaps and directions for research

      2020, Journal of Fluency Disorders
      Citation Excerpt :

      Stuttering has been found to be comorbid with other disorders in bilingual children although rates of comorbidity were ambivalent (Andrews et al., 2016; Koushik et al., 2009; Lincoln et al., 1996). In clinical studies, concomitant language, speech, and behavioral disorders (e.g., expressive language, receptive language, articulation, phonology, and attention deficit hyperactivity disorder [ADHD]) have been reported in about a third of bilingual children who stutter (Andrews et al., 2016; Koushik et al., 2009). Further, in the Baker and Cantwell (1982) study, 29% of children with speech disorders, including bilinguals who stutter (n = 4), showed concomitant psychiatric disorders (based on DSM-III) compared to children with language (95%), and mixed speech-language (45%) disorders.

    View all citing articles on Scopus

    Cheryl Andrews has a private practice at the Children’s Hospital Medical Centre, Westmead, NSW specializing in the treatment of adults and children who stutter. She also works part-time at the Australian Stuttering Research Centre. Her particular interest is in the development and research of stuttering treatments for school-age children.

    Sue O’Brian is a Senior Researcher at the Australian Stuttering Research Centre. She has extensive experience in the field of stuttering treatment and research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults who stutter and stuttering measurement.

    Mark Onslow is the Foundation Director of the Australian Stuttering Research Centre, Faculty of Health Sciences, The University of Sydney. His background is speech pathology. His research interests are the epidemiology of early stuttering in pre-schoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering.

    Ann Packman is a Senior Research Officer at the Australian Stuttering Research Centre. She has worked for more than 30 years in the area of stuttering as a clinician, teacher and researcher. One of her current interests is theories of the cause of stuttering.

    Ross Menzies is a clinical psychologist with an interest in the origins and management of anxiety. He has developed cognitive behaviour therapy packages for the treatment of obsessive compulsive disorders and published theories of the origins of phobias. He is currently the director of the Anxiety Clinic at The University of Sydney.

    Robyn Lowe is a researcher at the Australian Stuttering Research Centre. Her research interests include exploring the psychological aspects associated with stuttering and how this impacts the long-term maintenance of speech treatment benefits. Robyn is involved in the development and evaluation of online speech and anxiety treatment programs for stuttering.

    View full text