Assessment and Outcomes
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Feeling less than confident in your assessment and treatment of fluency, particularly with the preschool set? You’re not alone. It seems to be one of those areas of practice that throws even seasoned SLPs for a loop, if we don’t encounter it often. Consider this collection of six research reviews your jump-start into EBP. The main theme of this set is assessment: How do I figure out whether this preschool kiddo’s disfluencies are actually stuttering? Is it the kind of stuttering that will get better on its own? And never fear— there is a little bit of intervention work to spice things up. Our favorite thing about this research? A lot of the procedures it describes are quick and efficient, and specifically intended to save you time, vs. what you might be doing now. So even if fluency is an area of strength for you, we bet you’ll pick up some tips on how to get through your workload a little bit quicker.
Anxiety disorders in children who stutter
Iverach et al. (2016) tested 75 children who stutter (ages 7–12 yrs) on various measures of anxiety and found that, compared to matched controls, these children “… had six-fold increased odds for social anxiety disorder, seven-fold increased odds for subclinical generalized anxiety disorder, and four-fold increased odds for any anxiety disorder.” However, in a sample of over 800 11-year-old children, Smith et al. found that only persistent stutterers (and not those who had recovered) demonstrated higher anxiety. Blood & Blood showed that people who stutter’s childhood experiences of negative social interactions and reactions contribute to their emotional wellbeing, into adulthood as well. Iverach et al. (2017) showed that, overall, SLPs need to be sensitive to the potential psychological needs of adolescents who stutter, and the complex relationship between stuttering severity, anxiety, and impact of the disorder.
In examining the available data, it appears that people who stutter aren’t more likely to have anxiety from the get-go, but instead emotional factors may build as a result of their experiences with the disorder. When looking at preschool and early elementary-aged children, Kefalianos et al. showed that stuttering and temperament (including “precursors to anxiety”) were not associated.
Examining the relationship between anxiety and stuttering is important, because though we’re fully trained to treat the communication aspect of their disorder, we need to be consulting or referring out for psychological intervention more often that many of us are. Clearly, we don't have a great handle on the link between stuttering and anxiety, and further research is needed to paint a clearer picture. But for now, we just need to be making sure our clients are getting the help they need!
Blood, G.W., & Blood, I.M. (2016). Long-term Consequences of Childhood Bullying in Adults who Stutter: Social Anxiety, Fear of Negative Evaluation, Self-esteem, and Satisfaction with Life. Journal of Fluency Disorders. doi: 10.1016/j.jfludis.2016.10.002.
Iverach, L., Jones, M., McLellan, L.F., Lyneham, H.J., Menzies, R.G., Onslow, M., Rapeea, R.M. (2016). Prevalence of anxiety disorders among children who stutter. Journal of Fluency Disorders. doi: 10.1016/j.jfludis.2016.07.002.
Iverach, L., Lowe, R., Jones, M., O'Brian, S., Menzies, R.G., Packman, A., Onslow, M. (2017). A speech and psychological profile of treatment-seeking adolescents who stutter. Journal of Fluency Disorders. doi: 10.1016/j.jfludis.2016.11.001.
Kefalianos, E., Onslow, M., Ukoumunne, O.C., Block, S., & Reilly, S. (2017). Temperament and Early Stuttering Development: Cross-Sectional Findings From a Community Cohort. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2016_JSLHR-S-15-0196.
Smith, K.A., Iverach, L., O'Brian, S., Mensah, F., Kefalianos, E., Hearne, A., & Reilly, S. (2017) Anxiety in 11-Year-Old Children Who Stutter: Findings From a Prospective Longitudinal Community Sample. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2016_JSLHR-S-16-0035.
Simplifying stuttering measurement in schools
In this article, Mirawdeli and Howell investigate whether all three elements of the commonly-used Stuttering Severity Instrument (SSI) are necessary in order to categorize children as fluent vs. dysfluent. These three measures are:
frequency of non-fluent events (percentage of stuttered syllables, %SS, from a sample of 200 syllables)
duration of the three longest non-fluent events
physical concomitants (facial and bodily movements with speech)
Data from 10–15-minute speech samples from 879 children aged 4–6 indicate that (1) alone (above) is sufficient to make this determination. The authors explain why, both statistically and clinically, it makes sense to drop the use of (2) and (3) in screening procedures. Conclusions are drawn from both the current data and previous research. The authors highlight some pros of using Riley’s SSI method of counting %SS (Riley, 1994), such as that it doesn’t include whole-word repetitions as stuttered events. This is particularly helpful in schools with English-learning students who may have word-finding difficulties, which often present in the form of whole-word repetitions. The authors also compare the newer SSI-4 to the SSI-3, and discuss why you may choose to continue using SSI-3 (see more here).
Mirawdeli, A., & Howell, P. (2016). Is it necessary to assess fluent symptoms, duration of dysfluent events, and physical concomitants when identifying children who have speech difficulties? Clinical Linguistics and Phonetics. doi: 10.1080/02699206.2016.1179345.
Help with the tricky business of diagnosing stuttering in preschoolers
Picture this: a parent asks you about her preschooler’s speech. She’s concerned that he might be stuttering. “How can I tell if it’s normal or not?” she asks. Is your heart racing just thinking about this question? Preschool stuttering can be a big ol’ gray area; it’s hard to tell when normal disfluencies cross the line into developmental stuttering. Luckily, Tumanova et al. have some evidence-based answers for us.
The authors tested a big group of preschoolers (2.5- to 5-year-olds) and classified them as children who stutter or who do not stutter using a cutoff of 3% stuttered words from a 300-word speech sample and a score of 11 or greater on the Stuttering Severity Instrument–3. Then, they looked at how well the other factors they measured classified children into one group or the other. Remember that we evaluate diagnostic accuracy by considering sensitivity (how often the test correctly identifies a disorder) and specificity (how often the test correctly identifies typical development); both should be 80% or higher.
Two measures stood out as having good diagnostic accuracy. First, percent total disfluencies—a combination of both stuttered disfluencies (e.g., prolongations, sound repetitions) and non-stuttered disfluencies (e.g., phrase repetitions, interjections)—had fair sensitivity (82%) and specificity (95%) at the cutoff of 8% disfluencies (the authors used a 300-word sample, but there is no standard recommended sample length; longer is better, and having two samples instead of one would also be better). Next, whether or not parents were concerned about their children’s stuttering had fair sensitivity (80%) and good specificity (92%) when compared to a cutoff of 3% stuttered disfluencies, “suggesting that the 3% criterion has a strong and clinically meaningful association with parental concern.” Also, boys had more non-stuttered (normal) disfluencies than girls; other factors (language ability, age) were related to how many normal disfluencies children produced, but the differences were small.
So 3% stuttered disfluencies is still our go-to for diagnosing stuttering in preschoolers, but we can supplement that by looking at (1) percent non-stuttered (normal) disfluencies and (2) whether parents report concerns about their child’s stuttering.
A parent rating scale for children who stutter
As SLPs, we don't examine communication skills in a vacuum, but instead must take into account how our clients’ speech–language impairments affect their daily lives.
This study takes data from over 259 questionnaires* completed by the parents of children who stutter between 2 ½ and 14 ½ years old. They performed careful statistical analyses in order to identify which questions best measure certain constructs, in an attempt to refine the questionnaire and remove questions that are essentially duplicates (questions that measure something another question already measured better). The constructs were described by three categories (“Impact of Stuttering on the Child”, “Severity of Stuttering and Impact on the Parents”, and “Parent’s Knowledge and Confidence in Managing the Stuttering”), resulting in a 19-item questionnaire. The researchers also compiled normative scores from the data set, which can be used to get an estimate of “degree” for each of the factors, and also to help measure progress.
And—here’s the exciting part—not only is the scale shared in the appendix of the study, but the researchers have also created a free online version, where score calculation is done for you! The online option may also help with parent participation.
*The original questionnaire was the PRS-V1.
Millard, S.K., & Davis, S. (2016). The Palin Parent Rating Scales: Parents' Perspectives of Childhood Stuttering and Its Impact. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2016_JSLHR-S-14-0137.
"Growing out of" preschool stuttering
Many of us who work with preschoolers see this situation often—you have a child under the age of three who is stuttering, and you can’t quite predict whether or not it’s a child who will “grow out of” the stuttering, or if it will persist. You wonder what to do regarding therapy, and you wonder how long to wait.
This article doesn't provide evidence regarding therapy, but it does provide us with some new information on the profile of children who do vs. do not persist with stuttering. The authors collected a large volume of language data from children ages 2 ½ to 3—some who didn’t stutter, and some who did (with a little under half who would spontaneously recover). They found that, for the children who recovered from stuttering in the preschool years, as their grammatical skills improved, their disfluencies decreased. It was not age that decreased disfluency, but rather “greater mastery of grammar and syntax.” This relationship was not present for the children who persisted in stuttering, nor for the children who did not stutter. For children who would persist in stuttering, improvement of grammatical skills did not reduce their rate of disfluency.
Also there was no significant relationship between stuttering severity and whether or not a child would recover from stuttering. So, when you’re watching to see if a preschooler’s stuttering will improve, it’s perhaps not time that you’re waiting on, but grammatical development. And stuttering severity isn’t likely to help you guess the outcome.
Hollister, J., Van Horne, A.O., Zebrowski, P. (2017). The Relationship Between Grammatical Development and Disfluencies in Preschool Children Who Stutter and Those Who Recover. American Journal of Speech-Language Pathology, 26, 44–56.
Reducing preschool stuttering with parent training
In this study, the primary caregiver of 2 ½ to 5 ½-year-old children who stutter was trained once weekly for three weeks. The primary objective of the training was to teach caregivers how to use “slow, relaxed speech” when conversing with their child. By the end of the three-week intervention, “…94% of the children increased their fluency,” even though the, “…mean articulatory rate for the children was not different across the visits…”
We could posit that training parents to speak in this manner caused the improvement in their children’s speech. However, the authors note that other factors could be at play. For example, simply increasing parents' confidence could have a positive effect their child’s fluency, not because of the caregiver's reduced speech rate, but because of other social–emotional factors that can result from parent empowerment. Why the children’s fluency improved remains to be tested.
Surprisingly, even though parent training of preschool children who stutter is very common, “…there is an astonishing lack of empirical evidence from outcome-based studies for some of the current recommendations made to parents regarding changes in communication styles.” Even though there were only 17 caregiver–child pairs in this study, it’s the, “…largest to date to examine the effect of a deliberately slower (adult) articulation rate on (childhood) stuttering.”
Sawyer, J., Matteson, C., Ou, H., & Nagase, T. (2017). The effects of parent-focused slow relaxed speech intervention on articulation rate, response time latency, and fluency in preschool children who stutter. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2016_JSLHR-S-16-0002.
Treating preschoolers for fluency? Here’s how your life can be easier
Last month we shared research showing that parent ratings of stuttering severity were related to results on the Test of Childhood Stuttering. Now, these researchers out of Australia (home of the Lidcombe Program), analyzed data from three previous randomized controlled trials of that intervention with an eye to the outcome measures. They found that there was “no statistical reason to favor” the gold-standard Percent Syllables Stuttered (PSS) over a much easier, much faster parent-reported severity rating, on a scale of 1 (no stuttering) to 10 (extremely severe stuttering), as observed over the previous week. Not only were the ratings much simpler to collect for the preschool population studied, they have the advantage of capturing the whole week vs. one quick sample. Now, the paper specifically suggests that other researchers use the ratings over PSS as a way to make stuttering intervention research easier to do, but if anyone needs a faster outcome measure, it’s practicing clinicians, amiright? Depending on where you work, you may be required to use PSS to qualify kids for services, but these findings could come in handy when special circumstances require you to “override” the eligibility criteria. You can also use severity ratings to track progress, and save a LOT of time over counting syllables.
Note that for children with fairly mild stuttering, neither measure shows progress all that well. From 3% to 2% syllables stuttered, or a parent waffling between a rating of “1” and “2”... you may have to get creative to show the results of treatment. For kids with more severe stuttering, either measure works well. Don’t use them interchangeably, though—pick a method and stick with it.
Onslow, M., Jones, M., O’Brian, S., Packman, A., Menzies, R., Lowe, R., … Franken, M.C. (2018). Comparison of Percentage of Syllables Stuttered With Parent-Reported Severity Ratings as a Primary Outcome Measure in Clinical Trials of Early Stuttering Treatment. Journal of Speech, Language, and Hearing Research. doi:10.1044/2017_JSLHR-S-16-0448.
Who needs extra time in fluency therapy?
A lot of what we know about evidence-based practice is how things work (or don’t) in general, for groups of similar clients, on average. But as we’ve all seen, even the best approaches don’t work for everyone, or don’t work to the same degree, at the same speed, or in exactly the same way in every case. Knowing how to factor individual differences into our assessment and intervention process is a huge research question (or ten thousand small ones), and it’ll take time for our field to get there. This new study is one link in that chain, addressing how self-regulation abilities relate to therapy outcomes and duration for young children who stutter.
Children who stutter often struggle with self-regulation, in a similar way to kids with ADHD. (We mentioned a study last month that addressed the importance of “effortful control” in predicting stuttering severity.) Basically, self-regulation is the ability to control your reactions (emotions AND behaviors) to changes in your environment. Kids who have a hard time self-regulating will have really big emotions, both positive and negative, and struggle to calm down when they're upset or excited. They'll also have more trouble focusing and shifting attention than other kids. Here, Druker et al. looked at 185 children between 2 and 6 years old, all of whom had been discharged or discontinued from stuttering therapy within the last three months. About half of these kids displayed “elevated” ADHD symptoms (subclinical, so not actually receiving a diagnosis), as determined by a parent-report measure. Refer back to the article for more details on how this was measured.
Now that in itself is worth knowing, but even more useful is this: the children with more ADHD symptoms needed about 24% more time in therapy (here corresponding to about 3 sessions), to meet the criteria for discharge. If you know right off the bat that your new little client struggles with attention and self-regulation (consider adding a questionnaire to your evaluation protocol or intake process so you know this!), you can take that into account in your treatment plan and expectations for progress.
What other implications do we see for practice? The authors suggest—just like the authors from the piece last month—that SLPs directly address self-regulation skills within fluency therapy. We can’t say from the current research how to do that, or how it might affect outcomes, but it’s a logical step to consider.
Druker, K., Hennessey, N., Mazzucchelli, T., & Beilby, J. (2019). Elevated attention deficit hyperactivity disorder symptoms in children who stutter. Journal of Fluency Disorders. doi: 10.1016/j.jfludis.2018.11.002.
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