Banter Speech & Language

Sydney speech pathologists helping adults and children speak for themselves.

adults who stutter

Can I do stuttering therapy online via video calls?

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Yes.

From the comforts of a big city, it might not seem like there’s a shortage of speech pathologists with decent stuttering assessment and therapy experience. But there is.

Too often, simple things have stopped people who stutter from getting the help they need, when they need it. Not living in a city. Not having a car or access to public transport. Juggling multiple kids. Working 9 to 5 (or longer) and not having time to get out of the office. Physical disabilities and impairments. Social anxiety or cultural concerns about leaving the house and coming into a clinic. Given the evidence about the importance of early intervention for pre-schoolers, and some of the serious possible long-term effects of unmanaged stuttering on work, life and health outcomes, current access to services for many people who stutter is just not good enough.

Hey! It’s 2016. Technology now exists to break down some of these barriers. And we’ve decided to use it to help people who stutter to get therapy.

At Banter Speech & Language, we’re thrilled to announce the launch of My Online Stuttering Clinic. It’s an online stuttering assessment and therapy service offered by Banter Speech & Language to existing and new clients – both children and adults – who stutter or might be stuttering.

Contact us now to book an online stuttering therapy session

 

Continuous improvements

Don’t get us wrong. Despite its promise and growing evidence base, we know there are still some barriers to delivering quality speech therapy online. For example:

  • Medicare and private health insurance rebates are not yet available for clients for speech pathology services delivered online. We hope that changes soon – especially for clients living in rural and remote places and for clients who can’t afford private therapy or access speech pathology for other reasons. (Side note: This is one reason we’ll soon be announcing a pro-bono program – watch this space.)
  • The technology isn’t perfect. Sometimes, videos freeze, or the picture or sound drops out. Blame it on the NBN, the weather, or too many kids playing Minecraft, but we’ll do our best to keep things simple and to work around glitches and gremlins if and when they crop up – even if it means going old school and picking up a phone from time-to-time!

As technology improves, we’ll keep working hard to provide people who stutter with a quality tele-health service.

Evidence-based, quality service 

At Banter Speech & Language, we only provide evidence-based stuttering therapies. We offer a range of treatments, including the Lidcombe Program and Westmead Program for children who stutter, Time Out, Video Self-Modelling and the Camperdown Program – a form of prolonged speech treatment, for adults who stutter. If you stutter, we’re happy to take you through your treatment options, the evidence for and against each, and our recommendations. We’re also happy to give you evidence-based tips to help manage stuttering, e.g. for school or work. That’s why we spend so much time reading the latest research and will keep doing so.

We’re on top of the growing research base supporting online stuttering therapy, especially that published by the Australian Stuttering Research Centre (e.g. Onslow et al., 2014 and Carey et al., 2012). We’re also up-to-date on developments in tele-health and speech pathology (e.g. Hines et al., 2015, Armfield et al., 2015, Keck & Doarn, 2014, and Edwards et al., 2012) and video-based health care services, generally (e.g. Bryan, 2015).

 

So if you stutter and want help, but can’t make it in to the clinic, please get in touch with us to discuss online stuttering therapy options.

In the meantime, feel free to take a look at our free articles summarising some of the latest research about stuttering.

Related articles:

Children:

Adults:

Banter Speech & Language 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).

Not the naughty corner: time-out – a stuttering treatment for children and adults

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Lots of stuttering treatments are behavioural therapies. Evidence-based examples include the Lidcombe Program for pre-schoolers who stutter and the Camperdown Program for adults who stutter.

Some behavioural treatments – like the Lidcombe Program – are based on the idea of operant conditioning. In these treatments, rewards are given for the behaviours we want to promote (e.g. fluent speech) and a lack of rewards or ‘light’ or ‘safe’ corrections are given in response to the behaviours we want to discourage (e.g. stuttered speech).

One of the most interesting questions in stuttering research is why treatments that look to change behaviours work when stuttering is thought to be a physical problem caused by a glitch in the way the brain processes speech (rather than a learned behaviour or psychological problem). I’d certainly like this answered in my lifetime!

As we’ve said before, no stuttering treatment to date works for everyone. For example:

  • in general, school-aged children do not respond as well as pre-schoolers to the Lidcombe Program;
  • some adult clients have problems learning the Camperdown Program prolonged speech pattern;
  • some teenagers and adults clients detest prolonged speech patterns like that used in the Camperdown Program, feeling it forces them to speak in an unnatural or even “fraudulent” way;
  • some adults and children who stutter relapse after initially successful treatment; and
  • outside of broad populations divisions (e.g. pre-schoolers vs adults), there is not a lot of research about which client factors (e.g. severity, gender) speech pathologists should consider when thinking about treatment options.

So are there other evidence-based treatment options?

Yes: Time-out.

1. What is it?

Time-out is a simple operant procedure. The client pauses (i.e. takes a “time-out”) immediately after he or she stutters. Because these “time-outs” are triggered by stutters, the treatment is sometimes called “response-contingent time-out” (e.g. Franklin et al., 2008).

Time-out treatments come in a variety of flavours; and have been used to treat stuttering since at least the late 1950s (James, 2007).  There are two main kinds:

(a) Speech pathologist-led time-outs: The speech pathologist presses a button whenever the client stutters, which illuminates a light or makes a noise, or simply says “stop”. When this happens, the client stops talking.

(b) Self-administered time-outs:  Clients monitor their own speech and impose a time-out on themselves whenever they stutter.

One of the more recent versions of time-out uses a combination of these techniques: the speech pathologist initially imposes the time-out, and then trains the client to do it (Hewat et al., 2006).*

2. Who is it for?

Time-out is usually considered a stuttering treatment for teenagers and adults (e.g. Hewat et al., 2006). However, it has been used with:

  • pre-schoolers (e.g. Martin, Kuhl & Haroldson, 1972); and
  • school-aged children (e.g. Onslow et al., 1997).

3. What matters most in the treatment? 

  • Time-outs need to happen when the person stutters (and not at other times or for other reasons).
  • Self-imposed time-outs seem to help clients achieve real world gains more than speech pathologist-imposed time outs (which makes sense – it’s not as if the speech pathologist can follow the client around the clock).
  • Results seem to be best when combined with rate control and/or prolonged speech treatments.

4. What doesn’t seem to matter?

  • It doesn’t seem to matter whether the client thinks it will work!
  • The duration of the time-out seems irrelevant: short (1-5 second) time-outs seem to work as well as longer ones.

5. Does it work?

The clinical evidence-base exists though it’s patchy and sometimes contested. Although there are a number of low quality studies showing good results for some people, it’s not as well-researched as the Camperdown Program. But there’s enough research (including a non-randomised Phase II clinical trial on 22 adults) to give it a go if the Camperdown Program or other treatments don’t suit a particular client or their family’s needs or have been trialled and have not achieved the client’s desired level of fluency.

In the Phase II clinical trial (cited below), there was a wide range of responsiveness. More than half of the participants reduced their stuttering by more than 50%. Interestingly, participants with more severe stuttering tended to do better than others. The drop out rate was very high – 10/22 didn’t finish the treatment – and it’s not clear how much therapy or for how long clients need to do in the real world to maintain results. It’s been alleged that the study has a number of major flaws, e.g. there were no controls for prior treatments (James, 1997). It wasn’t randomised and neither the clinicians nor participants could be blinded as to the treatment of experiment hypothesis, meaning it’s susceptible to bias (like most Phase II trials).

Clinical bottom line

Time-out is an option with some clinical evidence to support it – particularly for teens and adults. It’s not usually my preferred option. But, for the right client, and in the right circumstances, it’s well worth a shot.

Related articles:

Principal sources:

(1) Hewat, S., Onslow, M., Packman, A., & O’Brian, S., (2006). A phase II clinical trial of self-imposed time-out treatment for stuttering in adults and adolescents. Disability and Rehabilitation, 28(1): 33-42.

(2) James, J.E. (2007). Claims of a ‘new’ stuttering treatment using time-out from speaking are exaggerated: A brief review of the literature and commentary on Hewat et al. (2006). Disability and Rehabilitation, 29(13): 1057-1060.

(3) Packman, A., Onslow, M., O’Brian, S., & Hewat, S., (2007). Down memory lane with James and time-out. Disability and Rehabilitation, 29(13): 1061-1065.

* For any speech pathologists able to peek behind journal pay-walls, there was a terrifically entertaining public squabble about the originality of the treatment described in this paper (see James, 2007; and Packman et al., 2007). My favourite quote from Packman et al.,: “The theme running through James’ commentary is that we did not accord him sufficient credit in our report for the development of the [treatment] procedure…”

I would hazard a guess that most clients are more interested in whether the treatment actually works, rather than its inventor.

Image: http://bit.ly/1SbkySx

Banter Speech & Language 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).

Stuttering treatments: what works for whom? An evidence update

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Stuttering research – though voluminous, and growing – is notoriously hard to sift through and weigh for at least three reasons:

  • with a few exceptions, different research groups tend to spend their time and funding researching and validating their own treatments, rather than comparing the effectiveness of different treatments;
  • researchers have different ways of measuring their treatment results, which makes treatments hard to compare; and
  • people who stutter are not one, uniform group of people.  They vary in age, culture, socio-economic background, temperament, stuttering severity, time since onset of stuttering, and almost every other variable you can think of.

Usually, practising speech pathologists love systematic reviews because they compare high quality evidence about the effectiveness of different treatments and help us to inform clients about their options.  But a review can only reflect the quality of the underlying research.

New review

A new systematic review has just been published (reference below).  The researchers looked at 112 peer-reviewed research papers on stuttering treatments and broke them into 7 categories:

  • speech motor interventions: these treatments work on the mechanisms of speech production, e.g. breathing, voicing and articulation systems.  They include prolonged speech treatments like the Camperdown Program for adults; and the Westmead Program for pre-school and school-aged children;
  • behaviour modification interventions: these treatments aim to change the behaviour of the person who stutters.  They include the Lidcombe Program for children;
  • cognitive interventions: these treatments aim to lead to psychological change and include cognitive behaviour therapy;
  • speech motor combined with cognitive interventions;
  • “multiple component interventions”: these include combinations of elements including smooth speech, relaxation, self-management and cognitive treatments (e.g. Hancock & Craig, 2002);
  • feedback and technology interventions: these include delayed auditory feedback and frequency altered feedback devices, electromyography and video-self modelling; and
  • papers comparing different treatments to each other, e.g. Menzies, 2008.

The researchers concluded that:

  • there is a diverse range of evidence-based treatments for stuttering, with most treatments showing some positive effect for at least some participants;
  • the evidence remains unclear about who will gain the most from which treatment;
  • treatment effects of most reviewed therapies can be maintained (although the evidence was weakest with regard to feedback and technology interventions);
  • future research should pay closer attention to variables like client and speech pathologist factors, time since stuttering began, session times, dosage (number of sessions a week, minutes per session) so treatments can be compared directly;
  • researchers should adopt standard outcome measures for assessing treatment effectiveness (e.g. stuttering severity and quality of life measures) – including measurements of things that matter most to clients; again, so speech pathologists and clients can compare treatments directly;
  • for children, there is support for the Lidcombe Program and other interventions, but the Lidcombe Program is underpinned by a “substantial body of evidence”;
  • a “one size fits all” approach is unlikely to work – no treatment is successful for everyone who receives it;
  • more input should be sought from people who stutter to assess what constitutes a “good outcome”; and
  • speech pathologists and clients need better information about how and why therapies work, and factors that may hamper the effectiveness of different treatments for particular clients.

Review limitations

The review excluded case studies and surveys because they are at a higher risk of bias.  Interestingly, the researchers sorted the papers into papers with a higher or lower risk of bias based on the Cochrane criteria for judging risk of bias, 2011, but “influenced” by what the researchers called an “aggregate approach” agreed by consensus, which seems, from the paper, to be both subjective and itself at risk of bias.  The researchers also noted that the variability in outcome measures precluded any meaningful statistical comparisons of intervention effectiveness.

Clinical bottom line

Evidence-based speech pathologists want to provide clients who stutter with good quality information about their treatment options, the risks and benefits of each treatment, and treatment recommendations that incorporate each client’s values, needs, preferences and characteristics.

At the moment, we have good research about treatments that are effective for some people, some of the time.  But, outside broad “adult” and “child” treatment classifications, we have little evidence guiding us on how to assess the suitability of a particular treatment for an individual client.  In practice, this means therapy often includes an element of trial and error.  Treatment decisions are also hampered by a lack of standardised outcome measures across the studies, which make it hard for us to compare treatments effectively.  Some outcome measures may not accord with a client’s view on what constitutes a good result.

Nothing in the review is inconsistent with my current clinical practice of offering evidence-based treatments like the Lidcombe Program and Westmead Program for children, the Camperdown Program for adults who stutter, video-self modelling as an adjunct therapy, and referring adults who may have social anxiety to psychologists for cognitive behaviour therapies.  The review is also broadly consistent with Bothe et al’s 2006 systematic review.  But, obviously, we look forward to seeing more quality research published looking at different client variables and using agreed core treatment outcomes relevant to people who stutter so we can compare studies and provide practical guidance to clients.

Source: Baxter, S., Johnson, M., Bank, L., Cantrell, A., Brumfitt, S., Enderby, P., & Goyder, E. (2015). The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness. International Journal of Language Communication Disorders, 50(5), 676-718.

Related articles:

Image: http://bit.ly/1L4swEh

Banter Speech & Language 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).

Controlling stuttering: what it feels like in the real world

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Speech restructuring or prolonged speech treatments, like the Camperdown Program can help adults who stutter to speak more fluently.  Often, after working with a speech pathologist, clients are able to speak with little or no stuttering in the clinic.  But using the technique out in the real world is not as easy.

What does it feel like?

Cream and her colleagues asked 10 adults who stutter what it feels like trying to use prolonged speech to control their stuttering.  This is the ingenious metaphor they came up with:

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playground-21277_640

 

 

 

 

 

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Those of you who are as lucky as me and grew up in regional Australia will recognise a collection of playground rockers when they see them.  Playground rockers come in three basic designs – the one way (also known as the “horse”), the two-way, and the four way.

Riding a horse: when using prolonged speech alone, there are no others to consider and riders can move up and down as fast as they want.  They feel completely in control.

Riding a two-way rocker: using prolonged speech with a supportive partner, like a family member, good friend or speech pathologist is a bit harder than alone.  But both riders share a commitment to make the ride as smooth and predictable as possible – straight up and down – to maximise the chance of an easy-ride.

Riding a four-way rocker: using prolonged speech in groups and/or with people who are not aware of the person’s stuttering or treatment is harder.  The person feels less in control, and the ride is unpredictable – they might be bounced all over the place – up and down, and side to side.  The person needs to spend more energy anticipating and processing what others are doing.  In the worst case, the person may panic, stutter, abandon the ride and refuse to get back on.

What we should take from the playground rocker idea

For people who stutter, practicing alone and with sympathetic people (like a speech pathologist, family member or good friend) is important.  But it’s not enough to prepare for rough rides out in the real world.  People need to find ways of enhancing their sense of control on that four-way rocker.  People may find it helpful to:

  • plan more (though this has its limits);
  • improve their social and conversation skills;
  • reduce social anxiety (if any), through such evidence-based treatments such as cognitive behaviour therapy; or
  • otherwise learn to accept themselves to reduce feelings of being different.

Specific skill development ideas might include training in making introductions, handling difficult people, working with difficult people, managing conflict, providing feedback to others, being interviewed and interviewing.

Of course, this is all much easier said than done!

For speech pathologists, we need to know that helping clients become fluent in the clinic is good, but not good enough.  We need to help clients tackle real world challenges – to work with clients to troubleshoot, experiment, encourage, and, when appropriate, refer on to others who can help with specific training needs or goals.  Working with a speech pathologist who understands or – better yet – has first-hand experience with some of the client’s real world challenges can help.

Source: Cream., A., Packman, A., and Llewellyn, G. (2004). The playground rocker: A metaphor for communication after treatment for adults who stutter. Advances in Speech-Language Pathology. 6(3), 182-187.

Images: http://tinyurl.com/p8gperr, http://tinyurl.com/nh8n9bj, http://tinyurl.com/nptdlkb

Banter Speech & Language 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).

Doing two things at once: empowering adults who stutter to make informed choices about their fluency

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Relapse rates for adult stuttering treatments are too high.  Even for best-in-class, evidence-based speech restructuring and prolonged speech programs like the Camperdown Program, roughly a third of people treated relapse after treatment.

Why? 

Like many things with stuttering, we don’t know for sure.  But there are some likely culprits.

For some, social anxiety and other mental health disorders get in the way.  Although they don’t cause stuttering, social anxiety and other mental illnesses can make it worse and increase the risk of relapse in adults treated with speech restructuring.

For others, the cognitive and emotional demands of everyday living may be partly to blame.  Using a new speech pattern to reduce stuttering requires constant attention.  The pattern is usually easy enough to learn and use when you are sitting in a clinic with a trusted speech pathologist.  But it’s much harder to use the pattern out in the real world – especially when your attention is split between two or more priorities.  For example, in the workplace, we are often required to dual task, e.g. to read emails while talking on the phone; or to participate in a meeting while taking notes.  It can be hard to maintain a new speech pattern when you’re thinking about something else.

Dual tasking

Doing two things at once is called “dual tasking”.  The effect of dual tasking on stuttering – speaking while doing something else at the same time – has interesting implications for stuttering treatments, which are starting to be explored in earnest:

  • some studies show that stuttering stays the same or decreases when the secondary task does not involve language; and
  • other studies (including the one cited below) have shown that stuttering increases when the second task is language-related and/or is cognitively demanding.  In other words, stuttering increases when under cognitive stress, which makes intuitive sense to people who stutter.

In a recent study, three adults who stutter practiced their new Camperdown Program speech pattern under dual task conditions.  One aim of the study was to raise each participant’s awareness of how he allocated brainpower while doing two things at once.  The participants performed category word games using a device while conversing with their speech pathologist using their new speech pattern.  They also met together as a group to dual task in conversation with each other.

The participants all reported that they found dual task practice helpful – particularly for understanding how other tasks might interfere with their ability to maintain their new speech pattern.  This knowledge in turn, enhanced their sense of control over their stuttering.

Bottom line

To find out if dual tasking stuttering therapy has real potential to reduce the risk of relapse, we need much more research.   Specifically, we need to see a randomised controlled trial with a large sample of participants split into a standalone Camperdown Program vs Camperdown Program + Dual tasking groups, with adequate follow up – at least 12 months after effective speech restructuring treatment.

Adults who stutter should be informed about this promising research and encouraged to think about how their fluency is affected by dual tasking.  In some situations, where fluency is essential, an adult may choose to dedicate all of his or her attention and brainpower to speaking fluently.  In other situations, where fluent speech is not a priority, an adult may accept some stuttering and instead focus on the more important task at hand.  Either way, for relapse rates to come down, adults who stutter must be encouraged to make their own informed decisions about how best to manage their fluency out in the real world.  This is an essential part of good therapy for stuttering.

Source: Metten, C., Bosshardt, H-G., Jones, M., Eisenhuth, J. Block, S., Carey, B., O’Brian, S. Packman, A., Onslow, M, & Menzies, R. (2011). Dual tasking and stuttering: from the laboratory to the clinic. Disability and Rehabilitation, 33(11): 933-944.

Related articles:

Image: http://tinyurl.com/ojto9p4

Banter Speech & Language 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).