Banter Speech & Language

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school children who stutter

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

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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:

  1. 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.
  2. As children start school, stuttering can lead to social and emotional problems (Conture & Guitar, 1993).
  3. 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).
  1. 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).
  2. Children who stutter are more likely to repeat a grade than children who do not stutter (Boyle et al., 1994).
  3. 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:

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

[su_service title=”Banter Speech & Language” icon=”http://www.banterspeech.com.au/wp-content/uploads/2014/02/lyrebird_rgb1-e1393567318720.jpg”]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).[/su_service]

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

[su_service title=”Banter Speech & Language” icon=”http://www.banterspeech.com.au/wp-content/uploads/2014/02/lyrebird_rgb1-e1393567318720.jpg”]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).[/su_service]

My school-age child stutters. What should I do?

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We’ve got some great, evidence-based stuttering treatments for pre-schoolers and adults.  But what about for children who are at school?

How do we treat school-age kids who stutter?

First, a few sobering facts:

1. Stuttering gets harder to treat with age.  Academics say it becomes “less tractable”, with “the chances of natural recovery diminishing significantly”.  In plain English, this means stuttering gets harder to control; and full recovery is less likely.

2. School-age kids who stutter are at risk of being bullied and teased.  One study showed that more than 80% of children who stutter were bullied about their speech during primary school (Ezrati-Vinacour et al, 2001).  Another showed that kids as young as 4 years of age start to experience negative reactions from their peers (Langevin et al., 2009).  Not surprisingly, school-aged children who stutter often develop negative attitudes to speech and communication, which gets worse over time and may include actively avoiding situations requiring them to speak (e.g. reading out loud and giving talks to the class).

3. We now know that the effects of all this negativity can have effects that outlast high-school, potentially affecting further education and job opportunities (Yaruss, 2001).  We also know that adults who stutter have 7 times the odds of having an anxiety disorder than people who don’t (Iverach et al. 2009).

So what can be done to help school-aged kids who stutter?

The first thing we can do is provide advice to teachers and others working with children who stutter, highlighting the heightened risk of bullying, teasing, anxiety and avoidance.

Obviously, the next thing we can do is try to treat the stuttering.  But, unlike with pre-schoolers, the evidence-base for treating school-aged kids successfully is limited and fairly low in quality.  To date, the best contenders for school-age stuttering treatments are:

Of these treatments, speech restructuring is probably the least desirable for school-aged kids.  Many children don’t like using the speech pattern, and relapse is common.

For younger and less mature school-age children, the Lidcombe Program has some evidence to support its use (e.g. Koushik et al., 2009).  But parents and the child (and their speech pathologist!) need to get creative and work hard to keep the child motivated, and the treatment doesn’t seem to work nearly as well as it does with pre-schoolers.

Video-self modeling has been studied with children as young as 8 years old, with some low level evidence to supports its use (e.g. Bray & Kehle, 1998).  The treatment is safe and not hard to do in the age of smart phones and tablets.  It doesn’t work for everyone.  But it’s certainly worth a try – especially if some of the other treatments haven’t worked or as an addition to another treatment.

Recently, there has been some promising (but preliminary) research conducted treating school-aged children with syllable-timed speech therapy very similar to the Westmead Program.  In 2012, Cheryl Andrews and her colleagues from the Australian Stuttering Research Centre (ASRC) at the University of Sydney and Macquarie University published the results of a clinical trial using the program to treat 10 children who stutter, aged 6-11 years.  Nine months after commencing treatment:

  • 1 child was almost free of stuttering;
  • 8 of the 10 children reduced their stuttering;
  • stuttering decreased by more than 50% for half the children, (more than 80% for two of these children); and
  • reduced stuttering outcomes were supported by measures showing reduced situation avoidance and increased quality of life for the children.

The positive results of this trial need to be read with some caution.  The study was a preliminary “Phase I” trial only: the sample size was small, and there was no control group, meaning the results appear more positive than they truly are.  There was a lot of variation.  The treatment did not eliminate stuttering completely for any participant.  Children who had never been treated and who had no family history of stuttering seemed to do better than others who had received previous treatment.  Kids with severe stuttering before treatment seemed to do better than kids with mild stuttering.  90% of the participants showed a significant and immediate improvement within 6 weeks.  And some of kids showed mixed results – with an increase in syllables stuttered (an objective measure), but a decrease in self-reported severity levels and an increased quality of life.  Importantly, the results only tracked 9 months of treatment results – the longer-term effects of the treatment are unknown.

Nonetheless, the results are encouraging.  They warrant a large randomised controlled trial.  They also warrant further exploratory studies experimenting with additional elements to the program, e.g. systematic rewards, which might increase the treatment’s effectiveness.

Bottom line

Treating school-aged children who stutter is very challenging.  Evidence-based treatment is essential.  But the current treatments all have significant limitations.

We need more and better treatment options.  We need more research.  The researchers need more funding to run quality trials.  We need good researchers (like the ASRC) to keep publishing their results with detailed treatment instructions and consideration of “real world” clinical issues.  In private and public practice we need to read the studies carefully to deliver the treatments correctly.  We need to monitor outcomes and benchmark the results against the clinical trial results.

Those of us who treat school-aged children who stutter continue to watch this space like hawks.

**September 2016 update: 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. Read about it here.

Principal Source: Andrews. C., O’Brian, S., Harrison, E., Onslow, M., Packman, A., & Menzies, R. (2012). Syllable-Timed Speech Treatment for School-Age Children Who Stutter: A Phase I Trial. Language, Speech, and Hearing Services in Schools, 43, 359-369.

Related articles:

Image: http://tinyurl.com/qye72me

[su_service title=”Banter Speech & Language” icon=”http://www.banterspeech.com.au/wp-content/uploads/2014/02/lyrebird_rgb1-e1393567318720.jpg”]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).[/su_service]

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

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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:

Related articles:

Image: http://tinyurl.com/qgkedp8

[su_service title=”Banter Speech & Language” icon=”http://www.banterspeech.com.au/wp-content/uploads/2014/02/lyrebird_rgb1-e1393567318720.jpg”]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).[/su_service]