Philosophy(PhD) / This thesis presents a randomised controlled trial of the Lidcombe Program of Early Stuttering Intervention. The Lidcombe Program was developed for the treatment of stuttering in preschool-age children. The effectiveness of the Lidcombe Program was compared to a control group in a parallel group randomised controlled trial with blinded outcome assessment. A number of supplementary studies were conducted in support of the trial; two literature reviews, two retrospective file audits and a statistical simulation study. A review of randomised studies of treatments for stuttering showed that there have been 27 such studies published in English language journals. Of these only one was devoted to a treatment for early stuttering and that was the Lidcombe Program. The randomised study showed that 3 months of this treatment was associated with a lower level of stuttering compared to a control group who received no treatment. However, with a sample size of 23, this study lacked power and the children did not receive a full course of treatment. Despite these limitations, this study provided evidence that a medium to large effect size could be anticipated in an adequately powered and properly conducted randomised controlled trial. The second review was of sample size and power in stuttering research studies that had been published in two speech pathology journals; the Journal of Speech, Language and Hearing Research (Vol 39, No. 1 to Vol 40, No, 4) and the Journal of Fluency Disorders (Vol 21, No. 1 to Vol 22, No, 3). Results suggested that the majority (73%) of the 26 studies reviewed were insufficiently powered to detect even large effects. However it was acknowledged that it is very difficult to recruit even moderate sample sizes of people who stutter. It was concluded that one way to help improve this situation is collaboration of multiple research centres or, in the case of a randomised controlled trial, inclusion of multiple recruitment sites in one study. This strategy was adopted in the randomised controlled trial reported in this thesis. Two retrospective file audit studies of children treated with the Lidcombe Program were conducted in Australia and Britain. One purpose of these file audits was to obtain information relevant to the design and conduct of the randomised controlled trial. Data from the case reports on more than 300 children from the two sites were included in a meta-analysis. Results showed that a median of 11 weekly clinic sessions were required for children to attain the criteria for low levels of stuttering for completion of Stage 1 of the Lidcombe Program. Approximately 90% of children had achieved those criteria within 6 months of beginning treatment and almost all children had achieved them within 1 year. In addition two variables were found to be associated with longer treatment duration: more severe pre-treatment stuttering and shorter times from onset of stuttering to the start of treatment. The latter was apparent in the meta-analysis but not for the individual cohorts. As a result of these findings, pre-treatment stuttering severity was stratified along with other relevant variables in the randomised controlled trial and follow up for participants was a minimum of 9 months. A simulation study was conducted prior to analysis of data from the primary outcome measure of the randomised controlled trial: percentage of syllables stuttered (%SS). The distribution of %SS scores is positively skewed. Nonetheless, simulation showed t-test to be an appropriate analysis for this primary outcome measure. There were two treatment sites for the randomised controlled trial: the University of Canterbury (Christchurch, New Zealand) and the Stuttering Treatment and Research Trust (Auckland, New Zealand). A total of 54 preschool-age children were recruited: 29 to the Lidcombe Program and 25 to the control group. Half the proposed sample size was achieved due to slower than anticipated recruitment. This occurred because, as the trial progressed, treatment with the Lidcombe Program became common knowledge among parents in New Zealand and they became increasingly reluctant to agree to have their child randomised to the trial. Analysis with t-test showed a highly statistically significant difference (p = 0.003) at 9-months post-randomisation. The mean percentage of syllables stuttered (%SS) at 9-months post-randomisation was 1.5 (SD = 1.4) for the Lidcombe Program group compared to 3.9 (SD = 3.5) for the control group, resulting in a treatment effect of 2.3 %SS (95% confidence interval: 0.8-3.9). This treatment effect was more than double the minimum clinically worthwhile difference specified in the trial protocol. These results show that the Lidcombe Program is significantly more effective than natural recovery for reducing stuttering levels in preschool children. The Lidcombe Program is the first early stuttering treatment to be shown to be more effective than natural recovery in a randomised controlled trial.

Sammanfattning Syfte och frågeställningar Det övergripande syftet med studien var att kartlägga stammande individers attityd till sin egen stamning och stamning i allmänhet. - Hur påverkar stamning individens agerande i olika sociala situationer? - Skillnader i upplevd hälsa hos individer med lätt respektive svår stamning? Metod Studien baseras på enkäter. Målgruppen bestod av stammande individet från hela Sverige. Åldersspannet låg spritt mellan <20 år till >60 år, där 21-30 år stod för störst deltagande. Enkäterna besvarades online och automatisk inlagring av data skedde i Google Docs. Resultatanalys genomfördes i Excel och SPSS, därifrån togs även figurer fram. Resultat Sociala situationer där stamningen uppfattas som särskilt hinder kunde identifieras. Den upplevda graden av stamning skiljer sig inte mellan könen eller beroende av vid vilken ålder man började stamma. Inga resultat tydde på att de som stammar svårare, i högre grad söker hjälp för sina problem. Slutsats Stamning leder i många fall till undvikande beteenden. Vid stamning uppkommer negativa känslor. Det leder till en nedåtgående spiral. Stamning kan inkräkta på hälsa och välbefinnande. Många upplever det som positivt att träffa andra som stammar. Stamningen tycks bli bättre med åren. Vad detta beror på skiljer sig mellan individerna: acceptans, negligering och talträning. Då definitionen av stamnig skiljer sig är det mycket svårt att på ett enkelt sätt beskriva vad stamning är. / Abstract Aim The overall aim of the study was to discover the attitudes towards stuttering among people who stutters. - How does stuttering influence the individual behavior in social situations? - What differences are present in perceived health among people who stutters light and severely? Method The study is a quantitative study based on surveys. The target group for the survey, both men and women, consisted of stuttering individuals from all over Sweden. The age ranged was spread over <20 and >60 years, where the age 21-30 were accounted for the largest participation. The surveys were answered online and data was automatically stored in Google Docs. Result analysis and figure presentation was performed in Excel and SPSS. Results Social situations where stuttering is perceived as especially disturbing was identified. Perceived stuttering severity was not different between genders, age at onset of stuttering. Nor did severity coincide with care seeking behavior. Conclusion In most cases, stuttering results in avoidance behavior. Stuttering emerge negative emotions. It leads to a downward spiral. Stuttering can intrude to health and wellness. Many people who stutter experience meeting with other people who stutters as positive. The stuttering seems to get better with age. Reasons for the improvement differ among individuals: acceptance, neglect and speech therapy. Because of the differences among definition of stuttering it’s hard to describe it in an easy way.

A week-long intervention for five school-age children who stutter was implemented using techniques of fluency shaping, stuttering management, and mindfulness training. The purpose of this study was to investigate if children who stutter stuttered less frequently, stuttered with less struggle, and demonstrated changes in mindfulness measures after the completion of this week-long intervention. Pre- to post-treatment measures were analyzed by individual and group-level results. A comparative analysis between reading and narrative tasks was also performed. Findings indicate that three out of five children reduced the total number of disfluencies during the reading task, and two children reduced this total during the narrative task. Four out of five children decreased the level of struggle in both tasks. Two children improved their overall mindfulness scores; however, additional changes in sub-divisions of mindfulness varied by participant. As a group, the total number of disfluencies decreased during the reading task, while the total number of disfluencies did not change from pre- to post-treatment measures during the narrative task. The group demonstrated improvements in mindfulness in the areas of communication attitudes, cognitive reappraisal, and expressive suppression. A comparison between reading and narrative tasks suggest that performance on these tasks approximated to one another by the end of the treatment. The results of this study should be interpreted with caution as this was a pilot study with clinical limitations; however, future studies are necessary to verify and support these findings.

The purpose of the present study was to examine, based on audio samples in both languages, the accuracy of diagnosis of the presence or absence of stuttering in a bilingual Spanish English (SE) child who may or may not stutter by bilingual SE speech- language pathologists (SLPs) living in Texas (n=14). This study also aimed to determine what speech characteristics (if any) influenced SLPs’ judgment of whether or not a bilingual SE child was a stutterer, as well as to explore whether personal characteristics of the bilingual SLPs who completed the ratings (i.e., years experience, confidence in diagnosing an SE child with stuttering, educational history on the topics of stuttering and/or bilingualism) uniquely impacted the accuracy of their diagnosis. Information gained from this study suggests that the atypically frequent (in comparison to monolingual children) word and phrases repetitions produced by bilingual SE children who do not stutter may put this population at risk for misdiagnosis of stuttering. Results also indicate that the accuracy of identification of a bilingual SE child who does not stutter is not influenced by any of the personal characteristics listed above. Rather, there seems to be an overall lack of knowledge regarding the speech disfluencies that differentiate bilingual SE children who do and do not stutter. Thus, the preliminary data from this investigation warrants a follow-up study of the same nature on a nationwide scale. / text

Purpose: The purpose of this study was to investigate how phonetic complexity influences the accuracy and rate of speech production in adults who do (AWS, N=15) and do not stutter (AWNS, N=15). Target words were characterized according to high phonetic complexity (HIPC) and low phonetic complexity (LIPC), and were controlled for lexical influences such as word frequency and neighborhood density. It was hypothesized that if phonetic complexity influenced speech production, there would be a difference in reaction time and accuracy for AWS during the HIPC condition. Method: Participants produced two rounds of 40 target words corresponding to specific line drawings, during a confrontational naming task. Speech reaction time (SRT) was recorded from initial presentation of picture, and fluency and accuracy of production were coded for each target. Results: There was no significant difference in SRT according to HIPC and LIPC for either AWS or AWNS. AWS participants had slower SRT recorded compared to AWNS for all conditions tested. There was no relationship found between HIPC and increased moments of disfluency. Accuracy of target word production decreased during LIPC words. Conclusion: Phonetic complexity does not affect rate or fluency of speech production for either AWS or AWNS. While there is no difference in phonetic complexity measures, AWS are consistently slower than AWNS across both groups of target productions. Increased errors for both groups on LIPC target words may indicate a motor component to accuracy of speech production. / text

The purpose of this study was to examine the awareness, perception and social preference of stuttering in children who do and do not stutter. Ten children who stutter and eleven children who do not stutter participated in this study. Each participant viewed a short DVD clip of two puppets taking turns talking. One puppet produced stuttering-like disfluencies, and the other produced typically fluent speech. The participants were then asked a series of questions formulated to examine awareness, perception, and social preference. Results indicated no significant differences between the children who stutter versus the children who do not stutter on any of the three factors examined. However, within the group of children who stutter, significant differences were discovered for two of the seven questions (“which puppet talks like you?” and “what do you call this type of talking?”) when time since onset of stuttering was considered, suggesting that the longer the child has been stuttering, the greater the awareness the child has of his/her disfluent speech both in terms of the behavior and the specific terminology used to describe the behavior. / text

This thesis extends a previous pilot study with children who stutter (CWS) to include children with specific language impairment (CSLI). The current study examines lexical-semantic organization in these two clinical populations in hopes of comparing and contrasting behavioral profiles. The study employed a list-recall task to assess the lexical-semantic organization of 9 CWS, 5 CSLI, and 20 typically developing children matched for age and vocabulary. Similar to previous investigations, our child participants demonstrated the well-documented list position effects. With regard to recall accuracy, by-participant analyses revealed significant differences between CSLI and their age-matched peers; however, they did not reveal significant differences between the CWS and either of their control groups nor between the CSLI and CWS groups. Further, inspection of error distribution suggested significant differences in the number and types of errors the CSLI and control groups produced. The prevalence of unrelated and previous list errors in CSLI suggest that deficits in inhibitory processes as well as perseveration may have affected their performance. Areas of overlap and divergence in the profiles of CWS and CSLI indicate continuity in the degree of lexical-semantic weakness as well as differences in lexical retrieval and executive functions among CSLI and CWS. / text

Purpose: Adults with stuttering (AWS) commonly demonstrate verbal avoidance behaviours as a result of speech-related anxiety. This can result in an experience of ‘communication restriction’. By nature, verbal avoidance and communication restriction are difficult to evaluate objectively, and existing evidence consists primarily of self-report data from qualitative interviews. However, recent preliminary evidence indicates the potential utility of systemic functional linguistics (SFL; Halliday, 1985) to this area of research. The SFL framework provides quantitative analyses for the objective examination of language use in sociolinguistic contexts. Recent data also suggest that the confrontation naming paradigm may be a second possible means for quantitatively evaluating aspects of functional linguistic behaviour in AWS. The purpose of the present study was to identify specific patterns of conversational language and confrontation naming behaviour in AWS using an objective methodology, and to explore these behaviours within the context of stuttering intervention and with reference to the experience of communication restriction. Method: Twenty AWS (14 males, 6 females) and 20 matched controls (AWNS), aged between 16 and 56 years, were recruited for this study. All participants were native speakers of English with no cognitive, language, motor speech, or hearing impairment (with the exception of stuttering in AWS). All participants completed: (a) self-rating scales of general and communication-related attitudes and anxiety; (b) the UC Picture ID (O’Beirne, 2011) picture naming task, designed to objectively evaluate verbal avoidance behaviour; and (c) 10 minutes of spontaneous conversation with an examiner, loosely structured around a range of set topics. For the AWS participants, these procedures were completed pre- and post-attendance at either the Naturalness Intensive Programme in Christchurch, New Zealand (NZ), or the Intensive Stuttering Clinic (Blomgren, 2009) in Salt Lake City, USA (US). All conversational samples were analysed using both conventional and SFL-based analyses. Specifically, the quantity and complexity of verbal output, as well as the frequency of use of transitivity, modality, appraisal, and thematic resources, were examined. To identify group differences on all measures between AWNS and AWS at both pre- and post-treatment, two-tailed independent samples t-tests and Mann-Whitney U-tests were conducted. To compare the performance of AWS between pre- and post-treatment, two-tailed paired t-tests and Wilcoxon matched pairs signed ranks tests were used. Group comparisons were conducted for the full participant group, as well as separately for the NZ and US subgroups. Pearson correlation matrices were also constructed, to identify linear relationships between measures. Correlations between conventional and SFL analyses of linguistic behaviour were of particular interest. Results: Group differences for each subgroup were generally consistent with those for the full participant group. (a) AWS demonstrated higher social anxiety than AWNS at pre-treatment, but self-reported anxiety levels and stuttering impact decreased following treatment. (b) No differences were found across comparisons for confrontation naming performance on the UC Picture ID task. (c) In conversation, AWS produced consistently less language than AWNS, and produced less complex language than AWNS at pre-treatment, as shown by conventional and SFL indices. Specific SFL measures revealed fewer politeness-marking modal operators, more frequent comment adjuncts, and reduced expression of appraisal in the spontaneous language of AWS. Improvements in most of these areas were seen following treatment. The results of the correlational analyses showed that self-report scale outcomes were not linearly correlated to actual performance on any linguistic measures. However, positive correlations were observed between basic linguistic indices (i.e., language productivity and complexity) from the conventional and SFL approaches. An interesting negative correlation between language productivity and frequency of use of comment adjuncts was also seen. Conclusions: The current study extends available preliminary evidence on language use in AWS. Linguistic patterns identified in the conversational language of AWS suggest a reduced openness to interpersonal engagement within communication exchanges, which may restrict the experience of such exchanges. The data indicate that conventional and SFL analyses are interchangeable at a basic level, but also exemplify the unique utility of the SFL framework for examining specific aspects of language functionality within social context. Although AWS and AWNS were not found to differ in performance on the UC Picture ID task, the observations provide insight into the conditions under which verbal avoidance behaviours may be prone to occurring. Finally, the lack of straightforward correlations between self-reported anxiety and avoidance on the one hand, and various linguistic-behavioural indicators on the other, highlights the importance of a multidimensional, holistic approach to clinical stuttering evaluation.

Philosophy(PhD) / This thesis presents a randomised controlled trial of the Lidcombe Program of Early Stuttering Intervention. The Lidcombe Program was developed for the treatment of stuttering in preschool-age children. The effectiveness of the Lidcombe Program was compared to a control group in a parallel group randomised controlled trial with blinded outcome assessment. A number of supplementary studies were conducted in support of the trial; two literature reviews, two retrospective file audits and a statistical simulation study. A review of randomised studies of treatments for stuttering showed that there have been 27 such studies published in English language journals. Of these only one was devoted to a treatment for early stuttering and that was the Lidcombe Program. The randomised study showed that 3 months of this treatment was associated with a lower level of stuttering compared to a control group who received no treatment. However, with a sample size of 23, this study lacked power and the children did not receive a full course of treatment. Despite these limitations, this study provided evidence that a medium to large effect size could be anticipated in an adequately powered and properly conducted randomised controlled trial. The second review was of sample size and power in stuttering research studies that had been published in two speech pathology journals; the Journal of Speech, Language and Hearing Research (Vol 39, No. 1 to Vol 40, No, 4) and the Journal of Fluency Disorders (Vol 21, No. 1 to Vol 22, No, 3). Results suggested that the majority (73%) of the 26 studies reviewed were insufficiently powered to detect even large effects. However it was acknowledged that it is very difficult to recruit even moderate sample sizes of people who stutter. It was concluded that one way to help improve this situation is collaboration of multiple research centres or, in the case of a randomised controlled trial, inclusion of multiple recruitment sites in one study. This strategy was adopted in the randomised controlled trial reported in this thesis. Two retrospective file audit studies of children treated with the Lidcombe Program were conducted in Australia and Britain. One purpose of these file audits was to obtain information relevant to the design and conduct of the randomised controlled trial. Data from the case reports on more than 300 children from the two sites were included in a meta-analysis. Results showed that a median of 11 weekly clinic sessions were required for children to attain the criteria for low levels of stuttering for completion of Stage 1 of the Lidcombe Program. Approximately 90% of children had achieved those criteria within 6 months of beginning treatment and almost all children had achieved them within 1 year. In addition two variables were found to be associated with longer treatment duration: more severe pre-treatment stuttering and shorter times from onset of stuttering to the start of treatment. The latter was apparent in the meta-analysis but not for the individual cohorts. As a result of these findings, pre-treatment stuttering severity was stratified along with other relevant variables in the randomised controlled trial and follow up for participants was a minimum of 9 months. A simulation study was conducted prior to analysis of data from the primary outcome measure of the randomised controlled trial: percentage of syllables stuttered (%SS). The distribution of %SS scores is positively skewed. Nonetheless, simulation showed t-test to be an appropriate analysis for this primary outcome measure. There were two treatment sites for the randomised controlled trial: the University of Canterbury (Christchurch, New Zealand) and the Stuttering Treatment and Research Trust (Auckland, New Zealand). A total of 54 preschool-age children were recruited: 29 to the Lidcombe Program and 25 to the control group. Half the proposed sample size was achieved due to slower than anticipated recruitment. This occurred because, as the trial progressed, treatment with the Lidcombe Program became common knowledge among parents in New Zealand and they became increasingly reluctant to agree to have their child randomised to the trial. Analysis with t-test showed a highly statistically significant difference (p = 0.003) at 9-months post-randomisation. The mean percentage of syllables stuttered (%SS) at 9-months post-randomisation was 1.5 (SD = 1.4) for the Lidcombe Program group compared to 3.9 (SD = 3.5) for the control group, resulting in a treatment effect of 2.3 %SS (95% confidence interval: 0.8-3.9). This treatment effect was more than double the minimum clinically worthwhile difference specified in the trial protocol. These results show that the Lidcombe Program is significantly more effective than natural recovery for reducing stuttering levels in preschool children. The Lidcombe Program is the first early stuttering treatment to be shown to be more effective than natural recovery in a randomised controlled trial.

Thesis (Ph. D.)--Columbia University, 1928. / Vita. Published also as Teachers College, Columbia University, Contributions to education, no. 314. Bibliography: p. 59.