School-age stuttering research update: mixing and matching treatments to get results

We need better treatments for school-aged children who stutter. Research groups, like the Australian Stuttering Research Centre (ASRC) and The Stuttering Center of Western Pennsylvania are working hard to develop and test new treatments. But front-line speech pathologists and families of school kids who stutter don’t have the luxury of waiting.

Why not wait for the perfect treatment?

Aside from the strong possibility that no perfect treatment will ever be found, there are at least six compelling reasons to treat stuttering for school-aged children as soon as practicable:

Pre-schoolers respond best to current best-practice stuttering treatments. Stuttering gets harder to treat with age (e.g. Bothe, 2004, Ingham & Cordes, 1999, Onslow & Packman, 1999). For children who stutter but miss the pre-school treatment “window”, the next best time to start treatment is immediately: ideally as soon as possible after starting school.
As children start school, stuttering can lead to social and emotional problems (Conture & Guitar, 1993).
School children who stutter are often bullied because of their stuttering. For example, studies have shown that:

59% of 7-15 year olds who stutter were bullied – 38% on most days or every day (Langevin et al., 1998);
11-12 year old kids who stutter were almost three times as likely to be bullied as kids who did not stutter (Blood & Blood, 2007);
school children are far more likely to see peers who stutter as victims of bullying than children who do not stutter (Davis et al., 2002); and
bullying during the early school years is strongly associated with subsequent anxiety (Gladstone et al., 2006). Social anxiety usually starts during the early teen years, meaning it’s likely to start to develop during school years (Smith et al., 2014; Messenger et al., 2015).

Children who stutter have more negative attitudes to communication than their peers, and those attitudes worsen during the school years (Denil & Brutten, 1991, Vanryckeghem & Brutten, 1997).
Children who stutter are more likely to repeat a grade than children who do not stutter (Boyle et al., 1994).
Stuttering children report a lower quality of life than children who do not stutter (Beilby et al., 2012).

A one-size-fits-all approach doesn’t work

As any parent, carer or teacher knows, school-aged kids are not all the same. Far from it.

One challenge for speech pathologists in practice is that many of the clinical trials of stuttering research are conducted on monolingual children without any other communication, mental health or other issues. While we clinicians read this research avidly, there’s always a worry in the back of our minds that the results of some of these studies may not be as easily replicated with our “real world” clients, especially for clients with multiple, sometimes complex needs.

In my practice, I come across children who stutter and are very verbal, mature, social, and intelligent. I also work with children who stutter and also have other communication issues, such as speech sound issues, language learning impairments, auditory processing disorders, working memory impairments or a combination of these. Some of my clients have a history of other issues, e.g. ADHD or anxiety issues. More than half of my clients speak more than language. Many of my recent referrals have been through more than one previous treatment, such as the Lidcombe Program or the Westmead Program (or both) without success.

Finding the right stuttering treatment for more school-age children and their families requires a good understanding of the research (and its limitations). But it also requires creativity to apply the research and discipline to measure outcomes. We also need to focus on the right outcomes – not just the percentage of syllables stuttered, but the effects of the treatment on the child’s mental health, social participation and quality of life.

New mixed treatment focused on real world outcomes

For some school-aged children who have not responded to the Lidcombe Program or the Westmead Program with previous speech pathologists, I have sometimes needed to experiment with different variables to see if I can make a difference. In consultation with the client and family, I have sometimes mixed and matched strategies from different treatments to find a combination that works for the client (and his or her family).

Although I’ve had some good results, I’ve always been concerned to ensure I stick as far as possible with treatment protocols that have been shown to be effective in peer-reviewed research. That’s why I’m so excited about a new peer-reviewed study on a mixed (or “hybrid”) stuttering treatment.

Cheryl Andrews and her colleagues from the ASRC, have just published the results of their Phase II trial of a syllable-timed speech treatment for school-aged children who stutter. (You can read more about the Phase I trial that preceded this study here.) In summary:

22 school-aged children who stuttered were studied, aged 6-11 years: 16 boys and 6 girls;
3 children withdrew before the end of Stage 1, and 3 (of the remaining 19) did not meet the requirements to graduate into Stage 2;
14 of the children had had previous treatment (6 with more than one course of treatment);
9 of the children had other issues, including language learning impairments, speech sounds issues, ADHD, literacy problems, and obsessive-compulsive disorders;
17 of the children spoke more than one language (although all were proficient in English, and none spoke a syllable-timed language, which was necessary for the trial); and
some of the children had very severe stutters (one stuttered almost 1 in 3 syllables) and others had very mild stutters (one child stuttered less than 1 in 100 syllables).

The researchers said they included a mix of children to give the study external validity. They also measured a range of outcomes including stuttering severity, satisfaction with treatment and quality of life. In other words, the researchers specifically designed the treatment for a population of real world school-aged children who stuttered, and measured success by real world outcomes that mattered to the children and their families.

Fantastic stuff!

The two-stage treatment combined:

syllable-timed speech practice as per the Westmead Program; with
verbal contingencies from the Lidcombe Program, as well as verbal contingencies for using syllable-timed speech.

For the 16 children who completed Stage 1 of the program, it took an average of 10.7 sessions over an average of 21.6 weeks (with a range of 9 to 39 weeks). Outcomes were measured at several points, including 12 months after entry into Stage 2 of the treatment.

Study Results

Percentage of syllables stuttered: This fell from an average of 8.4% to 1.9% – a 77% average reduction. But there was a wide range of individual outcomes – 2 children did not respond at all to the treatment. No child stopped stuttering completely, although 5 children stuttered less than 1 in every 100 syllables (i.e. very mildly) 12 months after the end of Stage 1.
Children’s own assessment of their stuttering severity: Consistent with the percentage of syllables stuttered, the children reported an average 64.9% reduction in their stuttering severity.
Avoidance of eight real world situations: 11/16 children reduced their avoidance in social situations compared to pre-treatment, although social avoidance remained an issue.
Children’s satisfaction with their fluency: All the children were more satisfied with their speech fluency, except for one child whose satisfaction levels remained the same.
Impact of stuttering on quality of life: On a standardised quality of life assessment, all children reported a statistically significant improvement, except for one.
How rhythmic the children’s speech was after the treatment: The children’s speech in normal conversation did not sound more rhythmic after the treatment – in fact it sounded slightly less rhythmic!

Clinical bottom line

This great study is immensely helpful for speech pathologists and families working with school-aged children who stutter:

As a Phase II trial, it showed promising results for a hybrid treatment to reduce stuttering severity and increase the quality of life of some school-aged children who stutter. It provides sufficient evidence of a possible treatment effect to warrant a randomised controlled trial of the treatment to accurately measure treatment effects (with reduced risk of bias).
It gives speech pathologists practical clinical support (and confidence) to keep working with families to tailor evidence-based treatments to the particular challenges and needs of school-age children who stutter.
It reminds us to measure outcomes that matter most to the client.

I’ll be hanging out for the Phase III randomised controlled trial!

Related articles:

Principal source: Andrews, C., O’Brian, S., Onslow, M., Packman A., Menzies, R & Lowe, R. (2016). Phase II trial of a syllable-timed speech treatment for school-age children who stutter. Journal of Fluency Disorders 48, 44-55.

Image: http://tinyurl.com/z9kejl6

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.