Stuttering

Now you can get treatment for your child’s stuttering without all those clinic visits

4 November 2014 by David Kinnane Leave a Comment

The Lidcombe Program is an effective, evidence-based parent-administered treatment for children who stutter. Stage 1 of the standard treatment requires a parent (or other caregiver) and the child who stutters to come into the clinic every week to see the speech pathologist. This is no issue for many families. But, for some, visiting a speech pathologist weekly is not easy:

Some of us – particularly those living outside cities – don’t live anywhere near a speech pathologist.
Others are let down by a lack of public or other transport options.
For parents with several young kids, just getting everyone fed, dressed and out of the house is a multi-hour chore.
For parents and clients with physical disabilities or mental illnesses (e.g. social anxiety), coming into a speech pathology clinic poses additional obstacles that can be hard to surmount weekly.

For these families – and others who have problems making it to the clinic every week – therapy by webcam may be an option.

In June 2014, researchers at the Australian Stuttering Research Centre (ASRC) at Sydney University published the results of a small (Phase I) clinical trial. Three pre-school children who stuttered were treated with the Lidcombe Program, with the standard weekly clinic visits replaced by webcam sessions with the speech pathologist. All three children improved, with stuttering severity below 1% syllables stuttered 6 months after completion of the first stage of the treatment.

Even with the odd technical glitch with the (unnamed) webcam software, parents reported several benefits of webcam-consultations:

time and costs saved in not having to travel;
home being a more relaxed and non-threatening environment than the clinic;
no disruptions to siblings’ routines;
the speech pathologist could see the real environment in which the parent worked with their child;
trialing and practising the therapy using their own equipment; and
ability to discuss sensitive issues while the child was in another room.

Despite its positive outcomes, it took an average of 34 webcam consultations (range 26-39) for the children to complete Stage 1 of the treatment – which is around double the benchmark mean of 18 visits for children treated in the clinic (see Rousseau et al, 2007). This result sits logically with older studies showing that telephone delivery of the Lidcombe Program was also less efficient than clinic-based delivery (e.g. Lewis et al., 2008). Interestingly, webcam-delivery was almost 50% more efficient than phone delivery in the 2008 study, suggesting benefits in face-to-face interaction (albeit via webcam).

The positive results of the study justify a much bigger clinical trial with randomised controls, multiple objective outcome measures, blind assessors, and other measures designed to reduce the risk of bias. Webcam delivery has the potential to overcome many barriers we currently face delivering stuttering and other speech therapies to clients and their families, and we will follow the ASRC’s work with interest in the years to come.

Bottom Line

For time and cost reasons, we recommend families come in for clinic-based treatment consultations wherever practical. However, for those families who have limited access to treatment because of distance, transport, family factors or other obstacles, this study suggests that webcam delivery is a potentially safe, effective, viable and practical alternative.

Principal source: O’Brian, S., Smith, K., Onslow, M. (2014). Webcam Delivery of the Lidcombe Program for Early Stuttering: A Phase I Clinical Trial. Journal of Speech, Language, and Hearing Research, 57, 825-830.

Image: http://tinyurl.com/l3ga2sa

Banter Speech & Language

Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).

5 ways for teachers to help children who stutter – tips from people who stutter themselves

29 September 2014 by David Kinnane Leave a Comment

Last week I attended a public forum co-hosted by the Australian Speak Easy Association and the Australian Stuttering Research Centre. The focus was on how to help school-age children who stutter in the classroom.

The event was moderated by Professor Ross Menzies, a clinical psychologist who has been doing some great research on studying the complex relationship between anxiety and stuttering. It also featured talks from speech pathologists from the University of Sydney and the Stuttering Unit of the Bankstown Health Service.

But, for me, the highlight was hearing several adults who stutter recount some of their experiences at school. Not everyone who stutters had difficulties at school – there were some examples of people who had wonderful teachers and peers supporting them at school. But there were some harrowing stories, too, for example about:

being teased and bullied by other students;
feelings of dread while waiting for their turn to read aloud to the class or to answer a teacher’s questions;
worrying about whether teachers and the other children thought they were ‘slow’ because of their stuttering;
deciding to ‘go mute’, call in sick, or otherwise avoiding situations like presentations requiring speech; and
leaving school as soon as possible to ‘escape’.

Teachers and others who work with children who stutter at school often ask what they can do to help. And because we still don’t know exactly what causes stuttering, there is still no ‘professional’ consensus.

So here are 5 tips from the real experts – people who stuttered at school and were brave enough to share their stories:

1. Don’t think a student is less intelligent because they stutter. There is no link between intelligence and stuttering.

2. Give the student time to speak and maintain eye contact while they are talking to you. No-one likes to be interrupted or have others finish their sentences or look away mid-sentence.

3. Although anxiety doesn’t cause stuttering, it can make it worse. For some children who stutter, it can be really hard to read aloud in class, to answer questions when put on the spot, or to give a class presentation. Have a private conversation with the child and ask him or her whether there is anything you can do to make it easier. If a child is anxious about stuttering in front of the whole class, for example, you might:

allow the child to give their news or a presentation to a smaller group or just to you; or
ask the child to read aloud in unison with someone else.

4. Don’t give unsolicited advice to ‘take a deep breath’ or to ‘calm down’. This kind of advice – which is usually given with the best of intentions – can increase anxiety and make the stuttering worse.

5. Don’t pretend the stuttering isn’t there. Make sure the student is getting appropriate help. Evidence-based treatments are available, but stuttering gets harder to treat with age, with early treatment strongly recommended for school-aged children.

A student might already be in treatment. If so, ask the parents whether you can speak with the child’s speech pathologist for further advice specific to the child and to coordinate care. If not, recommend to the parents that they get in touch with a speech pathologist as a matter of priority.

More resources for teachers

Since playing a person who stutters (or ‘stammers’ as they say in the United Kingdom) in A Fish Called Wanda – and as the son of a man who stuttered and never talked about it – Michael Palin has been a fantastic public advocate for people who stutter for many years. His centre has published some terrific resources about stuttering for teachers, including this video (which could be used in class to educate children about stuttering):

and these tips, which contains a number of suggestions consistent with the tips above.

Also:

Stuttering in Schools – A Resource for Teachers (Australian Stuttering Research Centre)
8 Tips for Teachers (The Stuttering Foundation)

Image: http://tinyurl.com/qgkedp8

Banter Speech & Language

My pre-schooler stutters and has problems with speech sounds: which one should I treat first?

17 September 2014 by David Kinnane Leave a Comment

See our 2018 update about this topic.

We know that 30-40% of children who stutter also have a speech sound disorder (Gregg & Yairi, 2007).

We also know that both stuttering and speech sound disorders can lead to kids being perceived negatively by their peers at school – and even their teachers (e.g. Langevin et al, 2010; McCormack et al. 2009).

So, if your child stutters and has a speech sound disorder, which should you treat first? Or should you treat them together?

We don’t know. The research evidence to date is lousy; almost non-existent!

From a real world, clinical point of view, many factors may influence your decision, including the severity of each condition, your child’s age, and the effect each issue is having on your child’s intelligibility, participation and quality of life.

A major factor, sometimes overlooked, is the nature of the treatments involved. For example:

we advocate the Lidcombe Program for many preschoolers who stutter. The Lidcombe program is a direct parent-delivered treatment which focuses on rewarding the child for fluent speech (see here for more detail).
for speech sound disorders, we recommend a variety of different evidence-based treatments, from traditional articulation programs through to more complicated phonological treatments like Cycles, Minimal Pairs and Maximal Oppositions (we’ll explain more about these treatments in later articles). Most of these approaches also work directly on speech by rewarding correct production, often by repeating the sounds several times in isolation, syllables, words and phrases.

Our concern with treating a pre-schooler’s stuttering and speech sounds together is that you may inadvertently confuse your child (or even yourself!) about which behaviours are being rewarded, and why. For example:

in the Lidcombe Program, parents praise or otherwise encourage smooth or fluent, non-repetitive speech; and
in traditional articulation therapy, children are rewarded for saying the target sounds, syllables or words consistently and correctly.

So, if, one morning, you are praising Johnny for his fluent speech (with no repetitions) and then later on the same or the next day you are praising him for repeating a particular sound over and over, Johnny may – understandably – get confused. This may result in the treatments interfering with each other – or even (if some anecdotal evidence is to be believed) making things worse.

This is why, everything else being equal, we usually recommend “serial service delivery”: working on one goal (stuttering or speech sounds) first, before moving onto the other goal.

Depending on the age of the client and family preferences, we would normally suggest starting with stuttering treatment – especially if the child is about to start school. Our approach is consistent with the practice of a majority of Australian speech pathologists interviewed in a recent study (see citation below). But, in truth, we really don’t know enough about this group of children at this stage and need better research evidence to help guide clinical recommendations to parents.

Key source: Unicomb, R. et al. (2013). Clinicians’ management of your children with co-occurring stuttering and speech sound disorder. International Journal of Speech-Language Pathology, 15(4): 441-452.

Image: http://tinyurl.com/kppfc7z

Banter Speech & Language

Does anxiety cause stuttering?

12 September 2014 by David Kinnane Leave a Comment

No.

So why do people who stutter often feel anxious?

Here’s what some of the latest research tells us:

1. Speech is fundamental to both:

daily functioning, e.g. making an appointment on the phone, ordering dinner at a restaurant or participating in a work meeting; and
starting and maintaining relationships, e.g. meeting new people, asking someone out on a date, participating in team building exercises at work, simply chatting with friends at a BBQ, colleagues by the water cooler and acquaintances at networking or community events (Messenger et al., 2004);

2. (Somewhat obviously) many people who stutter face considerable difficulties when trying to speak (Packman et al. 2000);

3. Many people, on hearing someone stutter, react negatively to it. It can be hard not to – even pre-schoolers have been observed reacting negatively to peers who stutter (Langevion et al, 2009). This negative feedback can continue for years and decades – across a person’s lifespan. For example, people who stutter can experience:

listeners looking away, embarrassed, interrupting them, trying to finish their sentences for them, and straight out shunning;
bullying and teasing at school and in the workplace;
social isolation and rejection;
relationship problems;
educational and occupational underachievement, e.g. some people who stutter take on low paying, lowly-skilled jobs well below their aptitude levels simply so they can avoid situations requiring them to speak; and
fear of public speaking and speaking in social situations (e.g. Menzies & Onslow, 2011).

Given all these negative experiences, sometimes over very long periods of time, it’s not surprising that some people who stutter feel anxious!

So how does anxiety affect stuttering?

We know that an anxiety can exacerbate stuttering severity. From a stuttering management perspective, we also now know that untreated social anxiety and other mental illnesses can increase the risk of relapse for people who’ve been successfully treated with an evidence-based speech restructuring treatment like the Camperdown Program (e.g. Iverach et al, 2009).

Is help for social anxiety available?

Yes.

Cognitive Behaviour Therapy (CBT) is one of the most effective psychological interventions available for treating social anxiety. In 2008, a team at the University of Sydney published the results of a randomised controlled trial which showed that CBT for anxiety was associated with significant reductions in anxiety, even a year after treatment. Interestingly, CBT did not of itself reduce stuttering severity (Menzies et al, 2008), another indicator that stuttering is not caused by anxiety.

For busy people – or people who don’t want to see a clinical psychologist face-to-face – an online program for the treatment of social anxiety among adults who stutter has been developed (Helgadottir et al., 2009). The early results of this project has been promising and Associate Professor Ross Menzies and his team are currently conducting a randomised controlled trial on the program.

So watch this space.

If you would like more information about stuttering and anxiety, please contact us.

Principal source: Iverach et al. (2011). Anxiety and Stuttering: Continuing to Explore a Complex Relationship. American Journal of Speech-Language Pathology, 20, 221-232.

Image: http://tinyurl.com/mfybms7

Banter Speech & Language

33 of our best free articles to get you up to speed on child speech, language, voice and reading delays, and stuttering

6 August 2014 by David Kinnane Leave a Comment

We’ve published heaps of free information about child communication delays and problems. But who can be bothered trawling through a website? So 1990s.

Here are direct, free links to 33 of our most popular information sheets and articles. All in one convenient place.

If you find these useful, please “like” our Facebook page to get our free articles going forward. (We’re always keen to be “liked” – on Facebook, but also out in the real world!)

Free information:

1. Child Speech:

2. Child Language:

3. Child Voice:

4. Child Stuttering:

5. Literacy:

6. Child Assessments (generally):

7. Evidence-based treatments and therapy (generally):

About Banter and David

Thanks for reading. Do drop us a line if you have any comments or questions, or want more information about any aspect of your child’s communication development.

Image: http://tinyurl.com/mnnfh8u

Banter Speech & Language

Robot Talking: another evidence-based option to treat pre-schoolers who stutter

24 June 2014 by David Kinnane Leave a Comment

In Australia, there is near consensus among speech pathologists that the Lidcombe Program is the most effective treatment for pre-schoolers who stutter – especially amongst those of us who were trained at Sydney University. The Lidcombe Program is safe and, in clinical trials here and overseas – as well as in clinical practice out in the real world – it’s been proven to work for most children, time after time.

But what if it doesn’t? Is there another evidence-based option for families to consider?

Yes: the Westmead Program, known colloquially as Robot Talking.

Syllable-timed speech techniques (STS) like the Westmead Program have been used (in different forms) for hundreds of years. They involve speaking with very little difference in stress across syllables. This is achieved by saying each syllable with equal stress to a rhythmic beat – almost like – you guessed it – a robot. The Westmead Program is different from some of the older STS treatments in that it doesn’t require:

any props, e.g. metronomes, to set or maintain the beat;
the child to speak very slowly or in a monotone voice (children are instead encouraged to speak at a near-normal normal rate with pitch variation); or
the child to start with single sounds, syllables and words and work slowly up to conversation in several pre-programmed steps.

As with the Lidcombe Program, the Westmead Program has two stages and is administered by parents or other carers who measure average stuttering severity daily using the Lidcombe Program’s 1-10 scale. In line with the clinical trials, children learn and then practice the technique 4-6 times a day, for 5-10 minutes each time, until stuttering is eliminated or almost eliminated. This is followed by a period of maintenance where the treatment is slowly withdrawn under the supervision of a speech pathologist to minimise relapse risk.

Also like the Lidcombe program, we’re not sure why the Westmead Program works. The latest theory is that syllable stress variations in natural speech are a stuttering “trigger” in those with a vulnerable speech motor system. It is thought that, in children, STS may induce long-term improvements in stuttering severity before their neural pathways for speech are established (Trajkovski et al., 2009). Incidentally, the effects of STS are usually temporary for adults who stutter.

The Westmead Program does not – yet – have the same level of evidence to support its effectiveness as the Lidcombe Program, but its research base is growing. In 2011, a phase II study of a clinical trial of the Westmead Program was published (see key source citation below). The trial was conducted with 17 Australian pre-school children aged between 3 and 4.5 years of age. The key results were as follows:

Only 8 of 17 children completed the program – less than 50%. Nine dropped out for various reasons, including satisfaction with early speech gains and problems completing the program because both parents worked full-time. The researchers commented that families tended to withdraw at the point when low-level stuttering severity had been attained, but not stabilised.
For the 8 children who completed stage 1, mean stuttering severity before treatment was 6% syllables stuttered. After the treatment and at 12 months post-stage 2 entry, the mean stuttering severity had decreased to 0.2% syllables stuttered, a mean reduction of 96%.

These results, including the dramatic improvements in fluency, need to be interpreted with care because of the small sample size and the lack of randomisation and other controls. Out in the real world, the Westmead Program can be very challenging for families, particularly for time-poor parents who are both working. But it is an option, particularly for families that have been through several rounds of the Lidcombe Program without success, and for children who have been treated successfully but have relapsed.

Key source: Trajkovski, N., Andrews, C., Onslow, M., O’Brian, S., Packman, A., Menzies, R. (2011). A phase II trial of the Westmead Program: Syllable-timed speech treatment for pre-school children who stutter. International Journal of Speech-Language Pathology, 13(6): 500-509.

Image: tinyurl.com/muybcx6

Banter Speech & Language

Stuttering

Bottom Line

More resources for teachers

So why do people who stutter often feel anxious?

So how does anxiety affect stuttering?

Is help for social anxiety available?

1. Child Speech:

2. Child Language:

3. Child Voice:

4. Child Stuttering:

5. Literacy:

6. Child Assessments (generally):

7. Evidence-based treatments and therapy (generally):

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