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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., Stuttering The cause of stuttering is not yet fully understood, despite decades of research and theorizing (see Packman & Attanasio, 2017). However, much recent research indicates that it is a [...]

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., A combination of self-report and objective, speech and nonspeech, measures are recommended to establish outcomes in clinical trials research for stuttering. The most frequently used method for collecting an objective [...]

Purpose: Recent research has shown that some school-age children who stutter may have speech-related anxiety. Given this, speech-language pathologists require robust measures to assess the psychological effects of stuttering during the school-age years. Accordingly, this systematic review aimed to explore available measures for assessing the psychological impacts of stuttering in young school-age children and to examine their measurement properties. Method: The systematic search protocol was registered with PROSPERO (ID: 163181). Seven online databases, in addition to manual searching and screening of reference lists, were used to identify appropriate measures for the population of children who stutter aged 7-12 years. The first two authors independently assessed the measures using the quality appraisal tool described by Terwee et al. (2007). Results: Despite the comprehensive search strategy, only six measures were identified for quality appraisal. No assessment tool was found to possess adequate measurement properties for the eight assessed domains: content validity, internal consistency, construct validity, reproducibility, reliability, responsiveness, floor and ceiling effects, and interpretability. No measure had clear evidence of responsiveness to clinical change. Based on the criterion defined by the Terwee et al. (2007) appraisal tool, the Communication Attitude Test and the Overall Assessment of the Speaker's Experience of Stuttering for School-Age Children received the highest number of ratings in support of their measurement properties. Conclusions: The results highlight a lack of available measures in this domain and poor practices in developing and testing measurement instruments. To ensure that clinicians and researchers are equipped with sound measures to meet the mental health needs of this vulnerable population, further research to establish resources is needed., Communication is a fundamental part of almost all aspects of our everyday life. Stuttering is a communication disorder that significantly impacts people across all ages, races, cultures, and languages (Van [...]

Purpose: The purpose of this review article is to provide an overview of the current evidence base for the behavioral management of stuttering and associated social anxiety. Method: We overview recent research about stuttering and social anxiety in the context of contemporary cognitive models of social anxiety disorder. That emerging evidence for self-focused attention and safety behavior use with those who stutter is considered in relation to current treatment approaches for stuttering: speech restructuring and social anxiety management. Results: The emerging information about social anxiety and stuttering suggests a conflict between the two clinical approaches. For those clients who wish to control their stuttering and where speech restructuring is deemed the most suitable approach, it is possible that speech restructuring may (a) induce or increase self-focused attention, (b) promote the use of safety behaviors, and (c) become a safety behavior itself. This conflict needs to be explored further within clinical and research contexts. Conclusions: The issues raised in this review article are complex. It appears that evidence-based speech treatment procedures are in conflict with current best-practice treatment procedures that deal with social anxiety. In this review article, we propose directions for future research to inform the development of improved treatments for those who stutter and recommendations for interim clinical management of stuttering., Stuttering, being a disorder of speech production, can have a profound effect on a person's ability to communicate. For many who stutter, verbal output and language complexity are restricted. For [...]

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 beyondclinic 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., The Lidcombe Program is a treatment for early stuttering. It has been investigated empirically during the last 3 decades (Harris et al., 2002; Onslow et al., 1994, 1990), including large-scale [...]

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., In a companion paper (Onslow et al., 2018), we argued that randomized clinical trials are generally accepted as the gold standard for evaluating health care efficacy, which includes stuttering treatment [...]

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., It has long been known that many adults who stutter experience anxiety in speaking situations, with consistent reports of this since the 1940s (Despert, 1943; Goodstein, 1958; Honig, 1947; Schultz, [...]

Purpose: This report investigates whether parent-reported stuttering severity ratings (SRs) provide similar estimates of effect size as percentage of syllables stuttered (%SS) for randomized trials of early stuttering treatment with preschool children. Method: Data sets from 3 randomized controlled trials of an early stuttering intervention were selected for analyses. Analyses included median changes and 95% confidence intervals per treatment group, Bland-Altman plots, analysis of covariance, and Spearman rho correlations. Results: Both SRs and %SS showed large effect sizes from pretreatment to follow-up, although correlations between the 2 measures were moderate at best. Absolute agreement between the 2 measures improved as percentage reduction of stuttering frequency and severity increased, probably due to innate measurement limitations for participants with low baseline severity. Analysis of covariance for the 3 trials showed consistent results. Conclusion: There is no statistical reason to favor %SS over parent-reported stuttering SRs as primary outcomes for clinical trials of early stuttering treatment. However, there are logistical reasons to favor parent-reported stuttering SRs. We conclude that parent-reported rating of the child's typical stuttering severity for the week or month prior to each assessment is a justifiable alternative to %SS as a primary outcome measure in clinical trials of early stuttering treatment., Randomized controlled trials are the gold standard of health care efficacy evaluation. As such, they make an indispensible contribution to assembling a knowledge base for evidence-based practice with stuttering. Ideally, [...]

Purpose: Those who are socially anxious may use safety behaviors during feared social interactions to prevent negative outcomes. Safety behaviors are associated with anxiety maintenance and poorer treatment outcomes because they prevent fear extinction. Social anxiety disorder is often comorbid with stuttering. Speech pathologists reported in a recent publication (Helgadottir, Menzies, Onslow, Packman, & O'Brian, 2014a) that they often recommended procedures for clients that could be safety behaviors. This study investigated the self-reported use of safety behaviors by adults who stutter. Method: Participants were 133 adults who stutter enrolled in an online cognitive-behavior therapy program. Participants completed a questionnaire about their use of potential safety behaviors when anxious during social encounters. Correlations were computed between safety behaviors and pretreatment scores on measures of fear of negative evaluation and negative cognitions. Results: Of 133 participants, 132 reported that they used safety behaviors. Many of the safety behaviors correlated with higher scores for fear of negative evaluation and negative cognitions. Conclusions: Adults who stutter report using safety behaviors, and their use is associated with pretreatment fear of negative evaluation and unhelpful thoughts about stuttering. These results suggest that the negative effects of safety behaviors may extend to those who stutter, and further research is needed., For many who stutter, the condition is associated with mental health problems (Blumgart, Tran, & Craig, 2010; Iverach, O'Brian, et al., 2009; Menzies et al., 2008). The most prevalent mental [...]

Purpose: A significant proportion of adults who stutter experience anxiety in social and speaking situations. The Unhelpful Thoughts and Beliefs About Stuttering (UTBAS) scales provide a comprehensive measure of the unhelpful cognitions associated with social anxiety in stuttering. However, reducing the number of UTBAS items would make it ideal as a brief screening instrument. Therefore, the aim of the present study was to develop a brief version of the full UTBAS scales. Method: The 66-item UTBAS scales were completed by 337 adults who stutter. Item reduction was used to determine a smaller set of items that could adequately reproduce the total score for each full UTBAS scale. Results: Item reduction resulted in the inclusion of six items for the brief UTBAS-6 scales. Decile ranges for scores on the brief UTBAS-6 provide reliable estimates of the full UTBAS scores and valuable clinical information about whether a psychological assessment is warranted. Conclusions: The brief UTBAS-6 provides a reliable and efficient means of screening the unhelpful thoughts and beliefs associated with speech-related anxiety among adults who stutter. Referral for a psychological assessment is recommended in cases where the UTBAS total score falls in or above the fifth decile., Stuttering is a speech disorder that impedes the capacity to communicate effectively. The disorder is associated with numerous negative consequences across the lifespan, many of which begin in early childhood [...]

Purpose: Those with anxiety use safety behaviors when attempting to prevent negative outcomes. There is evidence that these behaviors contribute to the persistence of anxiety disorders. Safety behaviors have been prominent in the cognitive behavior therapy literature during the last decade, particularly with social phobia management. However, nothing is known of safety behavior use by those who stutter. This is surprising given the high prevalence of social phobia in the stuttering population who seek clinical help. Method: Clinical psychologists and speech-language pathologists (SLPs) created a list of safety behaviors that might be used by adults during treatment for stuttering. Participants were 160 SLPs who were asked whether they advised adults who stutter to use any of these safety behaviors. Results: SLPs commonly recommend safety behaviors during stuttering management. Factor structures were found for the following 5 safety behavior categories: (a) general safety behaviors, (b) practice and rehearsal, (c) general avoidance, (d) choosing safe and easy people, and (e) control-related safety behaviors. Conclusions: There is a need to determine the frequency with which adults who receive stuttering treatment follow these clinician recommendations. In addition, there is a need to experimentally determine whether following such recommendations prevents fear extinction at long-term follow-up. Key Words: stuttering, adult, speech restructuring, safety behaviors, anxiety, Safety behaviors are overt or covert cognitive or behavioral strategies that those who are anxious commonly use in an attempt to prevent a negative outcome or a threatening event from [...]

Purpose: Stuttering varies between and within speaking situations. In this study, the authors used statistical process control charts with 10 case studies to investigate variability of stuttering frequency. Method: Participants were 10 adults who stutter. The authors counted the percentage of syllables stuttered (%SS) for segments of their speech during different speaking activities over a 12-hr day. Results for each participant were plotted on control charts. Results: All participants showed marked variation around mean stuttering frequency. However, there was no pattern of that variation consistent across the 10 participants. According to control charts, the %SS scores of half the participants were indicative of unpredictable, out-of-control systems, and the %SS scores of the other half of the participants were not. Self-rated stuttering severity and communication satisfaction correlated significantly and intuitively with the number of times participants exceeded their upper control chart limits. Conclusions: Control charts are a useful method to study how %SS scores might be applied to the study of stuttering variability during research and clinical practice. However, the method presents some practical problems, and the authors discuss how those problems can be solved. Solving those problems would enable researchers and clinicians to better plan, conduct, and evaluate stuttering treatments. Key Words: stuttering, variability, statistical process control chart, percent syllables stuttered, It is commonly recognized that the stuttering frequency of individual speakers varies (Andrews et al., 1983; Bloodstein & Bernstein Ratner, 2008; Van Riper, 1971; Yaruss, 1997). Evidence for that belief [...]

Purpose: Researchers have used unscheduled telephone calls for many years during clinical trials to measure adult stuttering severity before and after treatment. Because variability is a hallmark of stuttering severity with adults, it is questionable whether an unscheduled telephone call is truly representative of their everyday speech. Method: The authors studied the speech of 9 men and 1 woman for a 12-hr day during different speaking activities. On that day and 1 week prior to that day, participants received an unscheduled 10-min telephone call from a person unknown to them. The authors compared the percent syllables stuttered (%SS) for the unscheduled telephone call on the day to the %SS of the unscheduled telephone call 1 week prior to the day and to the %SS during the entire day. Results: No significant differences were found, and all confidence intervals with f tests included 0. The concordance correlation test also showed a strong positive correlation between %SS scores for the entire day and for the unscheduled 10-min telephone call. Conclusion: The authors conclude that there is no reason to doubt that 10-min unscheduled telephone calls are a representative speech sample for %SS during clinical trials of stuttering treatments. Key Words: stuttering, adult, telephone call, percent syllables stuttered, outcome measure, Valid and reliable measurement of treatment outcomes is essential for interpreting clinical trials of stuttering treatment. There seems to be a consensus that measurement of severity during trials needs to [...]

Objectives: Stuttering has been associated with a range of anxiety disorders, including social phobia. In the general community, anxiety disorders are frequently associated with increased rates of mood and substance use disorders. Therefore, in the present study, the authors sought to determine the rate of mood and substance use disorders among adults who stutter. Method: The study employed a matched case--control design. Participants included 92 adults seeking treatment for stuttering and 920 age--and gender-matched controls. Mental health assessments were conducted via a computerized psychiatric diagnostic interview. Conditional logistic regression models were used to estimate odds ratios for the prevalence of mood and substance use disorders in both groups. Results: When compared with matched controls, adults seeking treatment for stuttering had twofold increased odds of meeting criteria for a 12-month diagnosis of any mood disorder but were not found to report significantly higher lifetime prevalence rates for any substance use disorder. Conclusions: Although adults who stutter in the present study were characterized by significantly higher rates of mood disorders than matched controls, they do not appear to self-medicate with substances such as alcohol. Results are discussed in terms of treatment implications and possible reasons why adults who stutter may avoid alcohol. KEY WORDS: stuttering, mood disorders, substance use, alcohol use, anxiety, Anxiety, mood, and substance use disorders are among the most common and disabling psychiatric disorders in the general community (Kessler et al., 1994; Ormel et al., 1994; Wells et al., [...]

Purpose: In this study, the authors investigated the efficacy of video self-modeling (VSM) following speech restructuring treatment to improve the maintenance of treatment effects. Method: The design was an open-plan, parallel-group, randomized controlled trial. Participants were 89 adults and adolescents who undertook intensive speech restructuring treatment. Post treatment, participants were randomly assigned to 2 trial arms: standard maintenance and standard maintenance plus VSM. Participants in the latter arm viewed stutter-free videos of themselves each day for 1 month. Results: The addition of VSM did not improve speech outcomes, as measured by percent syllables stuttered, at either 1 or 6 months postrandomization. However, at the latter assessment, self-rating of worst stuttering severity by the VSM group was 10% better than that of the control group, and satisfaction with speech fluency was 20% better. Quality of life was also better for the VSM group, which was mildly to moderately impaired compared with moderate impairment in the control group. Conclusions: VSM intervention after treatment was associated with improvements in self-reported outcomes. The clinical implications of this finding are discussed., Behavioral control of stuttering is a core component of the clinical management of many who stutter (Onslow, 1996). To that end, there is compelling evidence in favor of treatments based [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2009.04.013 Byline: Peter F. Lovibond (a), Christopher J. Mitchell (a), Erin Minard (a), Alison Brady (a), Ross G. Menzies (b) Abstract: A laboratory autonomic conditioning procedure was used to establish fear conditioning in human participants by pairing neutral stimuli with electric shock. Participants were also trained to make a button-press response to avoid shock. A target fear stimulus was then extinguished by presenting it without shock. The experimental group was given the opportunity to make the avoidance response during extinction whereas the control group was not. When the fear stimulus was tested without the response available, the control group showed normal extinction of both shock expectancy ratings and skin conductance responses, but the experimental group showed 'protection from extinction': they continued to give high expectancy ratings and strong skin conductance responses. We interpret this effect as analogous to the role of within-situation safety behaviours in preserving threat beliefs during exposure therapy for anxiety disorders. The results support a cognitive account of learning and anxiety. The procedure provides a potential laboratory model for further examination of the cognitive and neural mechanisms underlying anxiety and its reduction. Author Affiliation: (a) School of Psychology, University of New South Wales, Sydney NSW 2052, Australia (b) Discipline of Behavioural and Social Sciences in Health, University of Sydney, Australia Article History: Received 8 December 2008; Revised 16 April 2009; Accepted 29 April 2009

Purpose: The aims of the present study were to (a) examine the rate of social phobia among adults who stutter, (b) study the effects of speech restructuring treatment on social [...]

Two research groups have raised the possibility that magical ideation may be a fundamental feature of obsessive-compulsive disorder. It has been proposed to underlie thought action fusion and superstitious beliefs. In this study, the Magical Ideation scale, the Lucky Behaviours and Lucky Beliefs scales, the Thought Action Fusion--Revised scale, the Padua Inventory, and the Obsessive Compulsive Inventory Short Version were completed by 60 obsessive compulsive patients at a hospital clinic. Of all the measures, the Magical Ideation (MI) scale was found to be the most strongly related to obsessive compulsive symptoms. Large and significant relationships between MI scores and the measures of OCD were obtained even when alternative constructs (Lucky Behaviours, Lucky Beliefs, Thought Action Fusion Revised scales) were held constant. No other variable remained significantly related to the Obsessive Compulsive Inventory--Short Version when magical ideation scores were held constant. The findings suggest that a general magical thinking tendency may underpin previous observed links between superstitiousness, thought action fusion and OCD severity. Keywords: Obsessive-compulsive disorder; Magical ideation; Thought action fusion; Superstition; Schizotypy

It is well established that many patients with obsessive-compulsive disorder have covert, or internal, compulsions. Empirical studies of this phenomenon, however, are limited. The present study followed the paradigm developed by Rachman and his colleagues for the study of overt compulsions. Patients with urges to carry out covert compulsions underwent an experimental procedure in which their compulsive urges were provoked, followed by a period of response prevention. The strength of the compulsive urges and associated discomfort were monitored. There was marked, and relatively rapid, spontaneous decay of both the compulsive urges and the discomfort. Implications of these results are discussed. Keywords: Covert compulsions; Spontaneous decay; Obsessive-compulsive disorder

This study investigated the long-term efficacy of three 45-minute sessions of live graded exposure, computer-aided vicarious exposure, or progressive muscle relaxation placebo for the treatment of spider phobia, and is a follow-up of the results previously reported by Gilroy, Kirkby, Daniels, Menzies, and Montgomery (2000). Forty-two out of 45 participants were assessed, using both subjective and behavioral assessments, at a mean of 33 months after completing treatment. The assessor was unaware of treatment group. Results showed significant improvement from pretreatment to 33-month follow-up across a range of measures in all treatment groups, although the group by time interaction was not statistically significant. Between 3-month and 33-month follow-up, no significant change was observed in any group, indicating sustained long-term improvement. The results support previous reports of the long-term efficacy of live graded exposure and indicate similar durable treatment outcome effects for computer-aided vicarious exposure.

Alleged differences between associative and non-associative perspectives are sometimes more apparent than real. The non-associative model describes a pathway to fear that is complementary to associative pathways. It does not seek to usurp conditioning models as applied to evolutionary-neutral fear. We discuss vexing definitional issues surrounding what qualifies as a conditioning event and what characterises the non-associative pathway. Genetic findings are shown to be consistent with the non-associative model of fear. Following discussion of the relation between stress-diathesis models and the non-associative position we conclude by urging a developmental, life-course approach to the understanding of fear acquisition.

It is axiomatic that the capacity to experience fear is adaptive, enabling rapid and energetic response to imminent threat or danger. Despite the generally accepted utility of functional fear, the nature of maladaptive fear remains controversial. There is still no consensus about how specific fears and phobias are acquired and modulated. Two major schools of thought are apparent: those suggesting dysfunctional fear arises largely as the result of associative-conditioning processes versus those who favour more biologically based etiological explanations. In this regard, the non-associative model of fear acquisition postulates the existence of a limited number of innate, evolutionary-relevant fears, while emphasising conditioning modes of onset for evolutionary-neutral fears. Recent retrospective and longitudinal studies have tested predictions from the non-associative model. In general, findings support non-associative hypotheses and are difficult to reconcile with neo-conditioning explanations of fear acquisition. These data suggest that four pathways to fear may provide the most parsimonious theory of fear etiology. The theoretical and practical implications of adding a fourth, non-associative path to Rachman's (Behav. Res. Ther. (1977) 15, 375-387) three `associative' pathways are discussed. Unresolved issues requiring further investigation are considered.

A longitudinal examination of the relation between separation experiences and the development of separation anxiety at age 3, 11 and 18 years was conducted. Three associative pathways (Rachman, S.J. (1978). Fear and courage. San Francisco: W.H. Freeman) were assessed. Conditioning events were not related to separation anxiety at age 3. Vicarious learning (modelling) in middle childhood (age 9 years) was the conditioning variable most strongly related to separation anxiety at age 11, accounting for 1.8% of the variance in symptoms. Separation experiences (hospitalisations) before the age of 9 were inversely correlated with separation anxiety at age 18. That is, more overnight hospital stays in childhood were related to less separation anxiety in late adolescence. However, none of these conditioning correlates remained significant predictors of separation anxiety in adjusted regression models. In contrast, certain 'planned' separations in early-mid childhood were associated with lower levels of separation anxiety at later ages. Generally, the findings were consistent with predictions from the non-associative theory of fear acquisition. That vicarious learning processes appeared to modulate, albeit to a minor degree, the expression of separation anxiety during mid-late childhood suggests that there may be critical periods during which some individuals are susceptible to the interactive effects of both associative and non-associative processes. These findings serve to illustrate the complexity of fear acquisition, the relevance of developmental factors and the likely interplay between associative and non-associative processes in the etiology of fear and anxiety.

The association between responsibility for a negative outcome, perceived severity of the outcome and perceived likelihood of the outcome was examined in a sample of 70 undergraduate students. Participants were asked to rate the likelihood and severity of 10 negative outcomes, five related to contamination and five related to checking. Thirty-eight participants completed a version of the questionnaire that presented the subject as responsible for the action that may lead to a negative outcome ('personally responsible' group). The remaining 32 completed a version of the questionnaire that presented someone else performing the actions that may lead to a negative outcome ('other responsible' group). Significant differences emerged between the personally responsible and other responsible groups for severity of outcome ratings but not for likelihood of outcome ratings. Specifically, for both washing and checking concerns, participants in the personally responsible group rated the severity of the potential negative outcome as greater than did those in the other responsible group. The results support the claimed general tendency for individuals to regard an outcome as more aversive if they are personally responsible for that outcome, rather than someone else being responsible. The results suggest that, in general, increasing perceptions of personal responsibility will increase cost or severity estimates in subjective danger calculations, and that responsibility may influence OCD phenomena in this way. Finally, the results suggest that attempts to manipulate responsibility in the laboratory may be confounded by necessarily impacting on cost estimates, and therefore on danger expectancies.

The fear dishabituation hypothesis described in the non-associative model of fear acquisition was tested in a longitudinal birth cohort study. Results were consistent with height fear and phobia dishabituation. That is, 're-emergence' of a fear of heights occurred between age 11 and 18 years among individuals who reported higher levels of non-specific stress at age 15. Interestingly, there was no evidence for dental fear dishabituation a finding consistent with the non-associative model of fear acquisition. Strengths and weaknesses of the study were considered and the results discussed in relation to laboratory-based findings on (dis)habituation.

In the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, (1994) Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: author) phobic adults and adolescents are said to 'recognize that the phobia is excessive or unreasonable' given the actual danger posed by the feared situation. The present study examined perceptions of danger in 15 spider phobic subjects and a matched set of controls before, during and after a spider-avoidance test. When detached from the phobic stimulus, phobic subjects: (1) gave higher estimates of the probability of being bitten than controls did; (2) gave higher estimates of the injuries that would result from being bitten and (3) in line with these first two findings, believed their high levels of anticipated anxiety were more reasonable and appropriate to the demands of the situation than controls did. These findings are inconsistent with the prevailing notion that when detached from the phobic situation patients can accurately evaluate the danger of potential phobic encounters. Instead, the findings suggest that phobic individuals, whether detached or in the presence of the feared object, have relatively limited insight into the irrationality of their fears. In examining the mediation of phobic phenomena, both self-efficacy and danger estimates remained significantly related to the anxiety and avoidance experienced in the spider-avoidance task. Further research designed to experimentally establish the likely causal roles of these two constructs is warranted.

Recent investigations of the aetiology and treatment of specific phobias have focussed on clarifying the concerns underlying phobic anxiety. It has been proposed that claustrophobic fear is comprised of separable confinement and suffocation components. This paper presents data from 78 general medical outpatients undergoing magnetic resonance imaging (MRI) scans in two major teaching hospitals. The findings support the two factor structure of claustrophobia, in that exposure to confinement reduced confinement subscale scores, but did not influence suffocation scores.

The Phobic Origins Questionnaire (POQ) [Ost, L.-G. & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behaviour Research and Therapy, 19, 439-447.] is the most commonly cited instrument for determining the origins of phobic anxiety and data obtained using this instrument strongly support the role of conditioning in the acquisition of fear reactions. The construct validity of the POQ in assessing episodes of conditioning has been questioned [e.g. Menzies, R. G. & Clarke, J. C. (1994). Retrospective studies of the origins of phobias: a review. Anxiety, Stress and Coping, 7, 305-318.] This paper examined the convergent validity of the POQ by comparing origins' classifications based on the POQ to classifications based on alternative instruments. The convergent validity of the POQ was found to be extremely poor. The POQ was consistently associated with a much greater likelihood of classifying the origin of fear reactions as due to direct conditioning episodes than was found using alternative instruments. The findings question the usefulness of the POQ in examining the origins of phobic anxiety.

Twenty-one OCD sufferers with washing/contamination concerns took part in a controlled treatment trial at the Anxiety Disorders Clinic, University of Sydney. Eleven of the subjects received danger ideation reduction therapy (DIRT) over eight, 1 h weekly group sessions conducted by the second author. Ten subjects were placed on a wait list and did not receive DIRT or any other treatment. DIRT procedures were solely directed at decreasing danger-related expectancies concerning contamination and did not include exposure, response prevention or behavioural experiments. Components of DIRT include attentional focusing, filmed interviews, corrective information, cognitive restructuring, expert testimony, microbiological experiments and a probability of catastrophe assessment task. All subjects were assessed at pre-treatment, post-treatment and three-month follow-up using the Maudsley Obsessional - Compulsive Inventory, Leyton Obsessionality Inventory, Beck Depression Inventory and a Self Rating of Severity Scale. Changes from pre-treatment to after treatment (post-treatment and follow-up scores averaged) were significantly greater in the DIRT condition than in the control condition for all measures. No significant differences were obtained between groups on post-treatment to follow-up change on any measure. The implications of these findings for theoretical models of OCD and its management are discussed.

Theories that fear results from previous traumatic experience (i.e. conditioning theories) have enjoyed widespread support for over half a century. Recent research, however, has cast doubt on the validity of these models in some specific phobias. Two studies on the etiology of height phobia have obtained findings consistent with a non-associative, evolutionary explanation of fear acquisition (Menzies and Clarke, 1993a, Behaviour Research and Therapy, 31, 355-365; Menzies and Clarke, 1995a, Behaviour Research and Therapy, 33, 795-805). Unfortunately, the retrospective nature of these studies limits the conclusions that can be drawn from these data. Like all retrospective research, these studies depend on adult subjects imperfect ability to recall conditioning events that may have occurred many years earlier. The present investigation overcomes these methodological shortcomings by examining the relationship between putative conditioning events before the age of 9 yr and the presence of height fear at ages 11 and 18 yr in a large birth cohort studied longitudinally. To our knowledge this is the first study that has prospectively examined the relationship between relevant traumatic events early in life and the onset of height fear in late adolescence. No positive relationship was found between a history of falls resulting in injury (i.e. fracture, dislocation, intracranial injury or laceration) before the age of 9 and fear of heights at age 11 or 18. Interestingly, falls resulting in injury between the ages of 5 and 9 occurred more frequently in those without a fear of heights at 18 (P < 0.01) - a finding in the opposite direction to that predicted by conditioning theory but consistent with non-associative theories of fear acquisition. In general, the results provide strong support for non-associative models of fear and are difficult to reconcile with conditioning theories.

The relevance of associative learning in the development of Obsessive-Compulsive Disorder (OCD) was investigated in a group of 23 OCD patients whose main concern was washing and 23 age and sex matched control subjects who did not have OCD. OC washers completed an origins instrument based on Menzies and Clarke's (1993, Behaviour Research and Therapy, 31, 355-365) Origins Questionnaire (OQ) for the phobic disorders. Control subjects completed a modified version of this measure designed to give a comprehensive picture of their experiences with relevant contamination-related stimuli. In general, the results question the relevance of associative-learning per se in the development of OC washing. Direct and indirect conditioning events were very rare in the OCD group, accounting for less than 13% of cases. No significant differences between groups were found in the proportion of subjects who knew other OC washers, or had experienced direct associative-learning events prior to onset. Contrary to expectation, significantly more non-OCD subjects had experienced vicarious learning events related to dirt and washing than OCD subjects. However, of note, associative-learning events that took place during episodes of depression were significantly more frequently reported in the OCD group than in the control group. Depression appeared to play a facilitating role in the associative-learning of OC washing. The implications of these findings for theoretical accounts of OCD are discussed.

Three obsessive-compulsive patients received Danger Ideation Reduction Therapy (DIRT) in an initial treatment trial. All three subjects presented with contamination/washing concerns but refused to participate in exposure and response prevention. DIRT is solely directed at decreasing danger-related expectancies concerning contamination. DIRT procedures do not attempt to address inflated personal responsibility. In addition, DIRT does not involve direct or filmed exposure to contamination-related stimuli, or behavioural experiments. Components of DIRT include corrective information cognitive restructuring, filmed interviews, microbiological experiments, attentional focusing and Hoekstra's (1989) probability of catastrophe estimation task. Treatment consisted of between six and ten 1-hr weekly sessions. At post-treatment, substantial reductions in scores on the Padua Inventory, Maudsley Obsessional-Compulsive Inventory and two global rating scales were apparent for all subjects. These improvements were maintained at a 3-month follow-up. The theoretical and clinical implications of these preliminary findings are discussed.

The potential mediating roles of danger expectancies, responsibility, perfectionism, anticipated anxiety and self-efficacy on obsessive-compulsive handwashing were examined. Ratings were obtained from 27 obsessive-compulsive patients before and during a behavioural avoidance test involving a compound stimulus of potting soil, animal hair, food scraps and raw meat. Correlation and partial correlation analyses were conducted to examine the relationships between the cognitive predictor variables and anxiety, urge to wash, time in task and duration of post-test washing. Large and significant relationships between danger expectancies and the dependent measures were obtained, even when alternative mediators were held constant. No other variable remained significantly related to any of the dependent measures when severity of disease ratings were held constant. Results suggest that of the cognitive variables examined, danger expectancies are the most likely mediator of washing-related behaviour in obsessive-compulsive disorder.

The acquisition of acrophobia in a large clinical sample was investigated. 148 patients from a university-based height phobia clinic and 148 age and sex matched non-phobic controls served as Ss. Subjects were assessed with a battery of measures including the Acrophobia Questionnaire [Cohen, D.C. (1977), Behavior Therapy, 18, 17-23], self-rating of severity [Marks, I. M. & Mathews, A. M. (1979) Behaviour Research and Therapy, 17, 263-267] global rating of severity [Michelson, L. (1986), Behaviour Research and Therapy, 24, 263-275], origins questionnaire [Menzies, R. G. & Clarke, J. C. (1993a) Behaviour Research and Therapy, 31, 355-365], and a height avoidance test. Results obtained question the significance of simple associative-learning events in the acquisition of fear of heights. Only 11.5% of fearful Ss were classified as directly conditioned cases. Furthermore, no differences between groups were found in the proportion of Ss who knew other height-fearfuls, had experienced relevant associative-learning events, or the ages at which these events had occurred. Finally, no relationships between mode of acquisition and severity or individual response patterns were obtained. In general, the data were consistent with the non-associative, Darwinian accounts of fear acquisition that continue to attract theorists from a variety of backgrounds [e.g. Bowlby, J. (1975) Attachment and Loss; Clarke, J. C. & Jackson, J. A. (1983) Hypnosis and behavior therapy: the treatment of anxiety and phobia; Marks, I. M. (1987) Fears, phobias and rituals: panic, anxiety and their disorders; Menzies, R. G. & Clarke, J. C. (1993a), (1993b) Behaviour Research and Therapy, 31, 499-501; Menzies, R. G. & Clarke, J. C. (1995)].

Purpose: To respond to Dr. Ingham's letter to the editor, 'Comments on Recent Developments in Stuttering Treatment Maintenance Research Using the Camperdown Program,' which appears in this issue of the Journal of Speech, Language, and Hearing Research. Method: When a treatment program has a performance-contingent maintenance schedule, as the Camperdown Program has, participants vary greatly in the time taken to complete this schedule--up to 2 years or more, in some cases. We reject Dr. Ingham's position that outcomes be measured a year after individual participants conclude their maintenance for the very reasons he has argued many times in the literature. Conclusion: We will continue to measure the outcomes of our clinical trials after a clinically meaningful period and at the same time for all participants. Key Words: Camperdown Program, outcomes, stuttering, We were taken aback by the title of Dr. Ingham's letter, Comments on Recent Developments in Stuttering Treatment Maintenance Research Using the Camperdown Program. We have not done any such [...]

The acquisition of fear of heights in an undergraduate student sample was investigated. Height-fearful (n = 50) and non-fearful (n = 50) groups were formed on the basis of extreme scores to the heights item on the FSS-III (Wolpe & Lang, Behaviour Research and Therapy, 2, 27-30, 1964). Subjects were then assessed with a battery of measures including the Acrophobia Questionnaire (Cohen, Behaviour Therapy, 18, 17-23, 1977), self-rating of severity (Marks & Mathews, Behaviour Research and Therapy, 17, 263-267, 1979), global rating of severity (Michelson, Behaviour Research and Therapy, 24, 263-275, 1986), and a new comprehensive origins questionnaire constructed by the authors. Results obtained question the significance of simple associative-learning events in the acquisition of fear of heights. Only 18% of fearful Ss were classified as directly conditioned cases. Furthermore, no differences between groups were found in the proportion of Ss who knew other height-fearfuls, had experienced relevant associative-learning events, or the ages at which these events had occurred. Finally, no relationships between mode of acquisition and severity or individual response patterns were obtained. In general, the data were consistent with the non-associative, Darwinian accounts of fear acquisition that continue to attract theorists from a variety of backgrounds (e.g. Bowlby, Attachment and loss. London: Penguin, 1975; Clarke & Jackson, Hypnosis and behaviour therapy: The treatment of anxiety and phobias. New York: Springer, 1983; Marks, Fears, phobias and rituals: Panic anxiety and their disorders. New York, Oxford Univ. Press, 1987). Differences with previous studies in which classical conditioning has accounted for the majority of cases are discussed in terms of the methodological differences across studies.

The effectiveness of in vivo exposure and vicarious exposure in reducing children's phobic anxiety and avoidance of water was investigated. Forty-eight water phobic children between the ages of 3 and 8 yr were randomly assigned to one of four groups: (1) in vivo exposure plus vicarious exposure (IVVE); (2) vicarious exposure (VE); (3) in vivo exposure (IVE); and (4) assessment only control. All subjects in the treatment groups received three individually administered treatment sessions. At the conclusion of treatment it was found that the IVE condition had produced statistically and clinically significant gains that had generalized to another situation involving water, and were largely maintained over a period of 3 months. In contrast, the VE condition did not lead to statistically greater treatment benefits than those observed in the control subjects. Furthermore, there was no significant difference between the IVVE condition and the IVE condition in their level of improvement from pre- to post-treatment. Hence, by post-treatment, vicarious exposure had not only failed to produce benefits when used on its own, but had also failed to enhance the benefits achieved through in vivo exposure. However, a tendency for the vicarious component to enhance the maintenance of treatment benefits was found at follow-up. The implications of these findings are discussed.

The origins of 50 clinical cases of childhood water phobia were investigated. All Ss had sought treatment at a university-based water phobia clinic. During screening, an origins questionnaire was administered to each attending parent. Parents were asked to indicate the most influential factor in the onset of their child's concern from a list of alternatives covering all three of Rachman's (Behaviour Research and Therapy, 15, 375-387, 1977) pathways to fear. Only one parent could recall classical conditioning episodes at the onset of their child's phobia. In contrast, the majority of parents (56%) claimed their child's concern had always been present, even on their first encounter with water. The data are taken to support a non-associative model of onset. Differences with previous studies in which classical conditioning has accounted for the majority of cases are discussed in terms of the differing definitions of conditioning used across studies.

Five intractable cases of obsessive-compulsive disorder were treated with the Danger Ideation Reduction Therapy (DIRT) program. All five cases: (1) had displayed excessive washing/cleaning behaviour for at least 10 years; (2) had failed to respond to a minimum of two separate, 12-week drug trials with serotonergic agents; (3) failed to respond to at least 15 sessions of exposure and response prevention at the beginning of the present trial, and; (4) satisfied the DSM--IV criteria for OCD with Poor Insight. DIRT was conducted in 14, weekly, individual sessions or until, in the judgement of the treating clinician: (1) clinically significant gains were apparent with minimal symptomatology remaining, and (2) clients displayed a sound grasp of the cognitive model underpinning DIRT procedures. At post-treatment, substantial reductions in scores on the Padua Inventory (PI), Maudsley Obsessional-Compulsive Inventory (MOCI), Beck Depression Inventory--II (BDI--II) and two global rating scales were apparent for four of the five subjects. These improvements were maintained at 4-to-6 month follow-up, with four of the five cases meeting Jacobson and Truax's (1991) criteria for `recovery' on the MOCI and the PI by this assessment stage. While one subject remained non-responsive, the present findings suggest that DIRT may be a viable option for treatment-resistant cases of compulsive washing. The theoretical implications, of the findings are discussed. Keywords: Obsessive-compulsive disorder; Compulsive washing; Threat-expectancy; Exposure; DIRT

The present research sought to establish a reliable and valid instrument for assessing the relevance of neoconditioning factors (e.g. latent inhibition, UCS inflation/revaluation, prior fear levels, prior expectancies of harm, fear and pain levels experienced during supposed learning events), in the development of human fear. Fifty-four undergraduate height-fearful students completed the new origins instrument (OQ-II), while 54 matched controls completed a modified version (OQM-II) that examined their prior experiences with heights. In general, few differences between groups were found. Height-fearful and control subjects did not differ on trait anxiety, the frequency of negative encounters with heights, the age at which these events had occurred, prior fear levels, prior expectancies of harm, or reports of UCS inflation/revaluation procedures. However, in a finding directly opposite to that expected from a conditioning account, the mean fear and pain scores reported by subjects who had experienced direct conditioning events were significantly higher in the non-fearful group than in the height-fearful group. These findings are discussed in terms of associative and non-associative models of fear. [C] 2001 Elsevier Science Ltd. All rights reserved.

The non-associative, Darwinian theory of fear acquisition proposes that some individuals fail to overcome biologically-relevant fears (e.g. height) because they (1) do not have sufficient safe exposure to the relevant stimuli early in life or (2) are poor habituators who have difficulty `learning not to fear'. These two hypotheses were tested in a longitudinal birth cohort study. Study 1 found evidence for reduced exposure to height stimuli in childhood for individuals with a fear of heights compared to study members without fear. Study 2 found evidence for higher levels of stress reactivity (a proxy for habituation) in childhood and adolescence among 18-year-old height phobics compared to study members with dental phobia and those with no fear. The results were discussed in relation to recent findings suggesting that some evolutionary-relevant fears may appear in the absence of traumatic `learning' experiences. The merits of adding a fourth, non-associative pathway to Rachman's [Rachman, S. (1977)]. The conditioning theory of fear acquisition: a critical examination. Behaviour Research and Therapy, 15, 375-387) three pathways model of fear acquisition were briefly considered. [C] 2000 Elsevier Science Ltd. All rights reserved.

Forty-five participants diagnosed as having specific phobia of spiders were randomly assigned to one of three treatment groups: (a) computer-aided vicarious exposure; (b) therapist-delivered live exposure; (c) relaxation placebo. Each group received three 45-minute sessions. Phobic symptom severity was measured at pretreatment, posttreatment, and at a 3-month follow-up assessment with the Spider Questionnaire, Fear Questionnaire, Phobic Targets and Work Adjustment Ratings Scale, and a Behavioral Assessment Test with Subjective Units of Distress Rating Scale. The results showed that the computer-aided vicarious exposure was an effective treatment for spider phobia and comparable to live exposure therapy in significantly reducing phobic symptoms. Both the computer and live exposure treatments were more effective than the relaxation placebo treatment.

Title: Using Statistical Process Control Charts to Study Stuttering Frequency Variability During a Single Day Journal of Speech, Language, and Hearing Research (2013), 56, part 6, 1789-1799. DOI: 10.1044/1092-4388(2013/12-0328) In [...]

A review of data concerning the uneven distribution of phobias suggests that nonassociative, ethological models can account for most of the important findings that cannot be attributed to expectancy biases. The origin of a variety of fears that appear in fixed developmental patterns across divergent cultures and species can best be explained by biological models.