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Background: Early intervention is essential healthcare for stuttering, and the translation of research findings to community settings is a potential roadblock to it. Aims: This study was designed to replicate and extend the Lidcombe Program community translation findings of O'Brian et al. (2013) but with larger participant numbers, incorporating clinicians (speech pathologists/speech anlanguage therapists) and their clients from Australia and England. Methods & Procedures: Participants were 51 clinicians working in public and private clinics across Australia (n = 36) and England (n = 15), and 121 of their young stuttering clients and their families. Outcome measures were percentage of syllables stuttered (%SS), parent severity ratings at 9 months post-recruitment, number of clinic visits to complete Stage 1 of the Lidcombe Program, and therapist drift. Outcomes & Results: Community clinicians in both countries achieved similar outcomes to those from randomized controlled trials. Therapist drift emerged as an issue with community translation. Speech and language therapists in England attained outcomes 1.0%SS above the speech pathologists in Australia, although their scores were within the range attained in randomized trials. Conclusions & Implications: Community clinicians from Australia and England can attain Lidcombe Program outcome benchmarks established in randomized trials. This finding is reassuring in light of the controlled conditions in clinical trials of the Lidcombe Program compared with its conduct in community practice. The long-term impact of therapist drift in community clinical practice with the Lidcombe Program has yet to be determined.

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.

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; and (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.

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: 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.

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.

Background: Information is available about what predicts Lidcombe Program treatment time, but nothing is known about what predicts treatment prognosis. Aims: To investigate the predictors of treatment dropout and treatment outcome for children who were treated for early stuttering with the Lidcombe Program (N = 277). Methods & Procedures: A total of 32 variables were used as predictors in regression analyses of short- and medium-term Lidcombe Program outcome, and of treatment dropout. Outcomes & Results: Regression analyses associated children who have better language skills and easy temperament with better treatment outcome, although only a small portion of the variance of treatment outcome was accounted for by these variables. There was an association between treatment dropout and parental scores on a personality screening tool relating to their impulsivity. Conclusions & Implications: Variables identified as predictors of Lidcombe Program treatment outcome were statistically significant, but not clinically significant. They did not account for a clinically substantive portion of treatment outcomes. Findings about parental impulsivity and their relationship with intervention drop-out require replication with prospective methods and comprehensive assessment of parent psychological status. This is particularly important because parents are involved in conducting all early interventions.

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

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.

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.

Background: iGlebe is a fully automated internet treatment program for adults who stutter that has been shown, in some cases, to reduce anxiety and effectively manage social anxiety disorder for many participants. No such automated internet treatment program exists for adolescents who stutter. Aims: The present paper reports a Phase I trial of an adolescent version of the adult program: iBroadway. Methods & Procedures: Participants were 29 adolescents in the age range 12-17 years who were seeking cognitive-behaviour therapy (CBT) for anxiety associated with stuttering. The design was a non-randomized Phase I trial with outcome assessments at pre-treatment and immediately post-treatment after 5 months of access to the program. No contact by a clinical psychologist occurred during participant use of the program. Outcomes were a range of psychological, quality-of-life and stuttering severity measures. Outcomes & Results: The compliance rate for the seven iBroadway modules over 5 months was extremely favourable for internet CBT, at 52.4%. There was evidence of treatment effects for (1) the number of DSM-IV mental health diagnoses with the Diagnostic Interview Schedule for Children; (2) the Unhelpful Thoughts and Beliefs About Stuttering scale; (3) the Subjective Units of Distress Scale; and (4) parent-reported speech satisfaction. Conclusions & Implications: Further development of iBroadway, the adolescent version of iGlebe, with Phase II trialling is warranted.

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: 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: 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.

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.

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, [...]

The Lidcombe Program is a well-established and efficacious treatment for early stuttering, but little is currently known about its mechanisms of action. The present report explores the possibility that inter-turn speaker latency might be associated with such mechanisms of action. Inter-turn speaker latency was measured in audio recordings of children, parents, and clinicians conversing, taken during Lidcombe Program treatment consultations. Five clinicians reduced their inter-turn speaker latencies during clinical consultations when they were speaking to children, in comparison with when they were speaking to parents. It is possible that inter-turn speaker latency is associated with the Lidcombe Program treatment process vicariously, and this possibility requires further research. [ABSTRACT FROM AUTHOR]

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: This Phase II clinical trial examined stuttering adolescents' responsiveness to the Webcam-delivered Camperdown Program. Method: Sixteen adolescents were treated by Webcam with no clinic attendance. Primary outcome was percentage of syllables stuttered (%SS). Secondary outcomes were number of sessions, weeks and hours to maintenance, self-reported stuttering severity, speech satisfaction, speech naturalness, self-reported anxiety, self-reported situation avoidance, self-reported impact of stuttering, and satisfaction with Webcam treatment delivery. Data were collected before treatment and up to 12 months after entry into maintenance. Results: Fourteen participants completed the treatment. Group mean stuttering frequency was 6.1 %SS (range, 0.7-14.7) pretreatment and 2.8 %SS (range, 0-12.2) 12 months after entry into maintenance, with half the participants stuttering at 1.2 %SS or lower at this time. Treatment was completed in a mean of 25 sessions (15.5 hr). Self-reported stuttering severity ratings, self-reported stuttering impact, and speech satisfaction scores supported %SS outcomes. Minimal anxiety was evident either pre- or post-treatment. Individual responsiveness to the treatment varied, with half the participants showing little reduction in avoidance of speech situations. Conclusions: The Webcam service delivery model was appealing to participants, although it was efficacious and efficient for only half. Suggestions for future stuttering treatment development for adolescents are discussed.

Purpose: This study adds to the Lidcombe Program evidence base by comparing individual and group treatment of preschoolers who stutter. Method: A randomized controlled trial of 54 preschoolers was designed to establish whether group delivery outcomes were not inferior to the individual model. The group arm used a rolling group model, in which a new member entered an existing group each time a vacancy became available. Assessments were conducted prerandomization and 9 months and 18 months postrandomization. Results: There was no evidence of a difference between treatment arms for measures of weeks or clinic visits required, percent syllables stuttered, or parent severity ratings. However, children in the group arm consumed around half the number of speech-language pathologist hours compared with children treated individually. In addition, children in the group progressed more quickly after the treating speech-language pathologist became more practiced with the group model, suggesting the group results are conservative estimates. Conclusions: Group delivery of the Lidcombe Program is an efficacious alternative to the individual model. Parents responded favorably to the group model, and the treating speech-language pathologists found group treatment to be more taxing but clinically gratifying.

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: Percentage of syllables stuttered (%SS) and severity rating (SR) scales are measures in common use to quantify stuttering severity and its changes during basic and clinical research conditions. However, their reliability has not been assessed with indices measuring both relative and absolute reliability. This study was designed to provide such information. Relative reliability deals with the rank order of participants in a sample, whereas absolute reliability measures the closeness of scores to one other and to a hypothetical true score. Method: Eighty-seven adult participants who stutter received a 10-min unscheduled telephone call. Three experienced judges measured %SS and also used a 9-point SR scale to measure stuttering severity from recordings of the telephone calls. Results: Relative intrajudge and interjudge reliability were satisfactory for both scales. However, absolute intrajudge and interjudge reliability were not satisfactory. Results showed that paired-judge SR and %SS procedures improved absolute reliability compared with single-judge measures. Additionally, the paired-judge procedure improved relative reliability from high to very high levels. Conclusion: Measurement of group changes of stuttering severity can be done in research contexts using either %SS or SR. However, for detecting changes within individuals using such measures, a paired-judge procedure is a more reliable method.

Purpose: The Lidcombe Program is an operant treatment for early stuttering shown with meta-analysis to have a favorable odds ratio. However, many clients are unable to access the treatment because of distance and lifestyle factors. In this Phase I trial, we explored the potential efficacy, practicality, and viability of an Internet webcam Lidcombe Program service delivery model. Method: Participants were 3 preschool children who stuttered and their parents, all of whom received assessment and treatment using webcam in their homes with no clinic attendance. Results: At 6 months post-Stage 1 completion, all children were stuttering below 1.0% syllables stuttered. The webcam intervention was acceptable to the parents and appeared to be practical and viable, with only occasional audiovisual problems. At present, there is no reason to doubt that a webcam-delivered Lidcombe Program will be shown with clinical trials to have comparable efficacy with the clinic version. Conclusion: Webcam-delivered Lidcombe Program intervention is potentially efficacious, is practical and viable, and requires further exploration with comparative clinical trials and a qualitative study of parent and caregiver experiences.

Background: At present, percent syllables stuttered (%SS) is the gold standard outcome measure for behavioural stuttering treatment research. However, ordinal severity rating (SR) procedures have some inherent advantages over that method. Aims: To establish the relationship between Clinician %SS, Clinician SR and self-reported Speaker SR. To investigate whether Clinician SRs and Speaker SRs can be used interchangeably. Method & Procedures: Participants were three experienced speech-language pathologist (SLP) judges and 87 adults who stuttered. Adults who stuttered received a 10-min unscheduled telephone call at the conclusion of which they self-reported a SR using a nine-point scale. The SLPs measured the stuttering for these conversations with %SS and also with the SR scale. The mean scores for Clinician %SS and Clinician SR were compared with Speaker SR using appropriate indices of relative and absolute reliability. Relative reliability indices deal with the rank order of participants in a sample and whether they can be distinguished from each other. However, absolute reliability indices are related to the closeness of the measurement scores to each other and to a hypothetical true score. Outcomes & Results: Strong correlations were found between Clinician %SS and Clinician SR, and also between Clinician %SS and Speaker SR, although with higher values in the former case. Additionally, very high correlations showed acceptable relative reliability between Clinician SR and Speaker SR. However, absolute reliability in terms of standard error of measurement and limits of agreement was poor for Clinician SR and Speaker SR. Conclusions & Implications: The results suggest that Clinician SR and Speaker SR cannot be used interchangeably to measure temporal stuttering severity changes for an individual client. However, researchers might use these two measures interchangeably in research contexts, such as clinical trials, where changes of the entire group are of interest to determine and compare treatment effect size across trials.

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.

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 "t" 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.

Purpose: This Phase I clinical trial explored the viability of webcam Internet delivery of the Camperdown Program for adolescents who stutter. Method and Procedure: Participants were 3 adolescents ages 13, 15, and 16 years, with moderate-severe stuttering. Each was treated with the Camperdown Program delivered by webcam with no clinic attendance. Primary outcome measures were percentage of syllables stuttered and number of treatment sessions to maintenance. Secondary outcome measures were speech naturalness, situation avoidance, self-reported stuttering severity, and parent and adolescent satisfaction. Data were collected pre treatment and at 1 day, 6 months, and 12 months post entry to maintenance. Results: Participants entered maintenance after means of 18 sessions and 11 clinician hours. Group mean reduction of stuttering from pre treatment to entry to maintenance was 83%, from pre treatment to 6 months post entry to maintenance was 93%, and from pre treatment to 12 months post entry to maintenance was 74%. Self-reported stuttering severity ratings confirmed these results. Post entry to maintenance speech naturalness for participants fell within the range of that of 3 matched controls. However, avoidance of speech situations showed no corresponding improvements for 2 of the participants. Conclusion: The service delivery model was efficacious and efficient. All of the participants and their parents also found it appealing. Results justify a Phase II trial of the delivery model.

Purpose: This clinical trial determined the outcomes of a simple syllable-timed speech (STS) treatment for school-age children who stutter. Method: Participants were 10 children, ages 6-11 years, who stutter. Treatment involved training the children and their parents to use STS at near normal speech rates. The technique was practiced in the clinic and at home with the parents during everyday conversations. Results: Nine months after commencing treatment, stuttering had decreased by greater than 50% for half of the children, with 2 children attaining 81% and 87% reduction. Intention-to-treat analysis showed a clinically and statistically significant reduction in stuttering for the group even when a withdrawn participant was included. These results were mostly confirmed by self-reported stuttering severity ratings and were supported by improved situation avoidance and quality-of-life scores. There was considerable individual variation in response to the treatment. Conclusion: STS shows promise as a treatment for some school-age children who stutter. As a fluency technique, it is simple to learn and simple to teach, and the children in this study appeared to enjoy the treatment. The efficacy of the treatment could likely be improved with modifications.

Objectives: During speech pathology professional preparation there is a need for adequate student instruction with speech-restructuring treatments for adults. An important part of that clinical educational experience is to participate in a clinical setting that produces outcomes equivalent to those attained during clinical trials. A previous report showed that this is possible with a traditional, intensive speech-restructuring treatment. Considering the treatment process advantages and time efficiency of the Camperdown Program, it is arguably a compelling prospect for clinician education. Therefore, the present study is a Phase I trial of the treatment at a student university clinic, with a similar design to a previous report. Background: During speech pathology professional preparation there is a need for adequate student instruction with speech-restructuring treatments for adults. An important part of that clinical educational experience is to participate in a clinical setting that produces outcomes equivalent to those attained during clinical trials. A previous report showed that this is possible with a traditional, intensive speech-restructuring treatment. Considering the treatment process advantages and time efficiency of the Camperdown Program, it is arguably a compelling prospect for clinician education. Aims: The present study is a Phase I trial of the treatment at a student university clinic, with a similar design to a previous report. Methods & Procedures: The design was a non-randomized Phase I clinical trial with 12 adult participants. Primary outcomes were per cent syllables stuttered (%SS) within and beyond the clinic, and speech naturalness scores from pre- and post-treatment stutter-free speech samples. Outcomes & Results: Pooled %SS scores pre-treatment were 5.7, at immediate post-treatment were 1.0, and at 12 months post-treatment were 2.4. The group speech naturalness scores post-treatment did not increase to a clinically significant extent. Conclusion & Implications: Results essentially replicate the previous study by producing similar outcomes to those attained with clinical trials. The Camperdown Program is recommended as a clinical environment for speech-restructuring speech pathology student training. (Contains 2 tables and 1 figure.)

Purpose: The relationship between anxiety and stuttering has been widely studied. However, a review conducted more than 10 years ago (Menzies, Onslow, & Packman, 1999) identified 5 methodological issues thought to preclude consistent research findings regarding the nature of this relationship. The purpose of the present review was to determine whether methodological improvements have occurred since the Menzies et al. (1999) review. Method: Literature published since the Menzies et al. review was evaluated with regard to the 5 methodological issues identified in that review: (a) the construct of anxiety, (b) trait anxiety measures, (c) participant numbers, (d) treatment status of participants, and (e) speaking tasks. Results: Despite some remaining ambiguous findings, research published since the Menzies et al. review has provided far stronger evidence of a relationship between stuttering and anxiety, and has focused more on social anxiety, expectancies of social harm, and fear of negative evaluation. Conclusion: The aims of future research should be to improve research design, increase statistical power, employ multidimensional measures of anxiety, and further develop anxiolytic treatment options for people who stutter.

Purpose: This study investigated the relationship between self-reported stuttering severity ratings and educational attainment. Method: Participants were 147 adults seeking treatment for stuttering. At pretreatment assessment, each participant reported the highest educational level they had attained and rated their typical and worst stuttering severity on a 9-point scale for a range of speaking situations. These included: (1) talking with a family member, (2) talking with a familiar person, not a family member, (3) talking in a group of people, (4) talking with a stranger, (5) talking with an authority figure such as a work manager or teacher, (6) talking on the telephone, (7) ordering food or drink, and (8) giving their name and address. Results: There was a significant negative relationship between highest educational achievement and mean self-reported stuttering severity rating for the eight situations. Conclusions: Future research is needed to investigate how this result should be addressed in educational institutions. (Contains 1 table and 2 figures.)

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.

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.

Background: Although there are treatments that can alleviate stuttering in adults for clinically significant periods, in Australia there are barriers to the accessibility and availability of best-practice treatment. Aims: This parallel group, non-inferiority randomized controlled trial with multiple blinded outcome assessments investigated whether telehealth delivery of the Camperdown Program provides a non-inferior alternative to face-to-face treatment for adults who stutter. Methods & Procedures: Forty participants who presented to a university speech clinic were randomized: 20 to the telehealth arm and 20 to the face-to-face arm. Exclusion criteria were age younger than 18 years, frequency of stuttering less than 2% of syllables stuttered and previous speech-restructuring treatment within the past 12 months. The Camperdown Program for adults who stutter was the intervention. Primary outcome measures were frequency of stuttering measured in per cent syllables stuttered (%SS) before treatment and at 9 months post-randomization and efficiency, measured by counting the number of speech pathologist contact hours used by each participant. Intention to treat analysis was conducted using last observation carried forward. Secondary outcome measures were speech naturalness, self-reported stuttering severity, and treatment satisfaction. Outcomes & Results: There was no statistically or clinically significant difference in %SS between the two groups at 9 months post-randomization. Analysis of covariance adjusting for baseline %SS showed telehealth had 0.8% absolute lower per cent syllables stuttered than face-to-face. There were also no differences in %SS between groups immediately post-treatment, or at 6 months and 12 months post-treatment (p = 0.9). In the second primary outcome measure, the telehealth group used statistically less contact time (221 min) on average than the face-to-face group (95% confidence interval = -387 to -56 min, p = 0.01). Conclusions & Implications: The results provide evidence to support the use of the Camperdown Program delivered by telehealth as an alternate to the face-to-face treatment delivery of this programme for adults who stutter. Such a model will increase accessibility to this evidence-based treatment for adults currently isolated from treatment services. Trial registration: Current Controlled Trials ISRCTN 48954432. (Contains 3 tables and 2 figures.)