Angela Cream

The relationship between mental health disorders and treatment outcomes among adults who stutter

UNLABELLED The ability to reduce stuttering in everyday speaking situations is the core component of the management plan of many who stutter. However, the ability to maintain the benefits of speech-restructuring treatment is known to be compromised, with only around a third of clients achieving this [Craig, A. R., & Hancock, K. (1995). Self-reported factors related to relapse following treatment for stuttering. Australian Journal of Human Communication Disorders, 23, 48-60; Martin, R. (1981). Introduction and perspective: Review of published research. In E. Boberg (Ed.), Maintenance of fluency. New York: Elsevier]. The aim of this study was to determine whether the presence of mental health disorders contributes to this failure to maintain fluency after treatment. Assessments for mental health disorders were conducted with 64 adults seeking speech-restructuring treatment for their stuttering. Stuttering frequency, self-rated stuttering severity and self-reported avoidance were measured before treatment, immediately after treatment and 6 months after treatment. Stuttering frequency and situation avoidance were significantly worse for those participants who had been identified as having mental health disorders. The only subgroup that maintained the benefits of the treatment for 6 months was the third of the participants without a mental health disorder. These results suggest that prognosis for the ability to maintain fluency after speech restructuring should be guarded for clients with mental health disorders. Further research is needed to determine the benefits of treating such disorders prior to, or in combination with, speech-restructuring. EDUCATIONAL OBJECTIVES The reader will (1) evaluate the impact of one or more mental health disorders on medium-term outcomes from speech-restructuring treatment for stuttering, (2) describe how this finding affects prognosis for certain groups of stuttering clients, (3) evaluate how these finding are consistent with estimates of post-treatment relapse after speech-restructuring treatment, (4) describe two test instruments for detecting mental health disorders, and (5) outline the findings about the relation between pre-treatment stuttering severity and mental health disorders.

Protection from harm: the experience of adults after therapy with prolonged‐speech

BACKGROUND It is well documented that adults can control stuttering if they use certain novel speech patterns referred to generically as prolonged-speech (PS). These speech patterns were refined in the 1960s and developed into behavioural treatment programmes. The bulk of available PS treatment research has focused on speech parameters thought to reflect favourable treatment outcome. Considering this, and that post-treatment relapse is known to be common, clinicians and researchers could be usefully informed by knowledge about the experiences of those who receive these treatments. Subsequently, they could use such information in attempts to control stuttering in their clients. Yet, at present, systematic research on this topic is scant. AIMS The continued development of PS treatments could be usefully informed by research into the experiences of those who use PS to control stuttering. Hence, that is the topic of the present report. METHODS & PROCEDURES The method used was phenomenology. Participants were a purposive sample of 10 people who had received PS treatment. During a 2-year period, a collaborative approach to the study of the topic was developed between the participants and interviewer. Interviews were from 1.5 to 2 hours, and a total of 34 interviews and discussions were undertaken with participants. Transcripts of these were used to generate text from which themes were identified using line-by-line, holistic and selective approaches. OUTCOMES & RESULTS The main findings were that even after therapy with PS there is a continued risk of stuttering occurring, and although adults have the novel experience of controlling stuttering, they also continue to experience feeling different from those who do not stutter, which may be exacerbated after therapy. Given the negative consequences associated with stuttering and feeling different, the essence of the experience after therapy with PS is that adults use their own resources to integrate behavioural skills with existing experiences in order to protect themselves from the harm of stuttering as best they can. PS changes speech, but not the dynamic and often unpredictable communication situations of everyday life. Hence, the maximum benefits of PS are attained when clients use a strategic approach to control stuttered speech and daily communication. CONCLUSIONS These findings are consistent with the results of existing outcome research as well as with other current research from the present group. Their implications are discussed in relation to the structure of PS treatments as well as in relation to future PS outcome research. The clinical implications of these findings are discussed in terms of informing prospective clients of the experiential consequences of PS, selecting clients who might benefit from PS and in terms of assisting clients to achieve optimal benefits from PS.

Beyond the divide: Comparing and contrasting aspects of qualitative and quantitative research approaches

As an introduction to this journal issue devoted to qualitative research methods in stuttering research, the present paper provides an overview of some of the underlying questions and issues arising from the use of qualitative approaches in research. The overview is written mindful of the historical domination of quantitative approaches to stuttering research and the likelihood that many readers of the present issue will have long experience and familiarity with quantitative approaches as opposed to qualitative ones. Consequently, qualitative research approaches are overviewed with particular reference to what have been, in our experiences, recurring queries about those methods from within the quantitative perspective. A broad definition of the inductive methods of qualitative approaches is offered and contrasted with the deductive methods of quantitative research. Subsequently, the issue of “bias” in qualitative approaches is considered, along with insights into ways of determining the quality of such approaches. It is concluded that there is no future in trying to understand or conceptualise either quantitative or qualitative research approaches using understandings transported from the other. Such an unproductive polemic or “paradigm clash” (Ingham, 1984) must be avoided as qualitative approaches to stuttering research grow in influence.

A comparison of aphasia therapy outcomes before and after a Very Early Rehabilitation programme following stroke

BACKGROUND Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results. AIMS To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months). METHODS & PROCEDURES This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models. OUTCOMES & RESULTS After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants. CONCLUSIONS & IMPLICATIONS A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy.

Self-modelling as a relapse intervention following speech-restructuring treatment for stuttering

BACKGROUND Speech restructuring is an efficacious method for the alleviation of stuttered speech. However, post-treatment relapse is common. AIMS To investigate whether the use of video self-modelling using restructured stutter-free speech reduces stuttering in adults who had learnt a speech-restructuring technique and subsequently relapsed. METHODS & PROCEDURES Participants were twelve adults who had previously had speech-restructuring treatment for stuttering and relapsed. They were video recorded for 1 hour within the clinic, practising their speech-restructuring technique. The videos were then edited to remove all observable stuttering. Participants then viewed the resulting video of themselves using restructured stutter-free speech each day for 1 month and were instructed to speak as they did on the video. Beyond-clinic speech samples and self-report severity data were collected before and after the intervention. OUTCOMES & RESULTS Very large effect sizes were found. The mean per cent syllables stuttered was 7.7 pre-intervention and 2.3 post-intervention. For all but one participant there was a reduction in stuttering from pre-intervention to post-intervention. These results were verified with self-report data. Speech naturalness was not compromised by the video self-modelling procedure. CONCLUSION & IMPLICATIONS Video self-modelling as a relapse management tool does not involve excessive time expenditure by the clinician or the client. The study indicates video self-modelling is potentially useful for managing relapse after speech-restructuring treatment for stuttering, and in some cases may be a stand-alone procedure to manage relapse. Phase II and III trials are warranted to determine the size and duration of the effect. It is suggested video self-modelling could also be included in a relapse management plan.

The playground rocker: A metaphor for communication after treatment for adults who stutter

In a qualitative study, 10 adults who stutter were interviewed to investigate their experience of treatment. They had all previously participated in behavioural treatments for stuttering that involved one of the variants of prolonged speech. In this type of treatment, people learn to use prolonged speech to control their stuttering. One of the themes to emerge was how difficult it is to use prolonged speech in many everyday communication contexts. The participants reported having an ongoing fear that they would lose control over their stuttering. A metaphor involving the playground rocker was developed to illustrate this experience. The metaphor also suggests strategies that might help people reduce these feelings of loss of control. These include improving conversational skills and reducing speech-related anxiety. Although developed for people who stutter, the metaphor also has implications for other communication disorders.

Constraint-induced aphasia therapy (CIAT): a randomised controlled trial in very early stroke rehabilitation

Background: Communication outcomes following stroke are improved when treatments for aphasia are administered early, within the first 3 months after stroke, and provided for more than 2 hours per week. However, uncertainty remains about the optimal type of aphasia therapy. Aims: We compared constraint-induced aphasia therapy (CIAT) with individual, impairment-based intervention, both administered early and daily after acute stroke. Methods & Procedures: This prospective, single-blinded, randomised, controlled trial recruited participants with mild to severe aphasia within 10 days of an acute stroke from acute/subacute Perth metropolitan hospitals (n = 20). Participants were allocated by computer-generated block randomisation method to either the CIAT (n = 12) or individual, impairment-based intervention group (n = 8) delivered at the same intensity (45–60 min, 5 days a week) for 20 sessions over 5 weeks (15–20 hours total). The primary outcome, measured after completing the intervention, was the Aphasia Quotient (AQ) from the Western Aphasia Battery. Secondary outcomes were the AQ at 12 and 26 weeks post stroke, a Discourse Analysis (DA) score and the Stroke and Aphasia Quality of Life Scale (SAQoL), measured at therapy completion, 12 and 26 weeks post stroke. There was a 10% (n = 2) dropout at the primary end point, both participants were in the CIAT group. The estimates for each treatment group were compared using repeated measures ANOVAs. Data from the 26-week follow-up assessment are presented, however, were not included in the between-group comparisons due to the low number of data points in each group. Outcomes & Results: Within groups analyses comparing performance at baseline, therapy completion, and 12 weeks post stroke revealed a statistically significant treatment effect for the AQ (p < .001), DA (p = .002), and SAQoL (p < .001). Between groups analysis found there was no significant difference between the CIAT and individual therapy groups on any outcome measure. Conclusions: CIAT and individual therapy produced comparable amounts of change in the very early phase of recovery suggesting a standard, intensive daily dose of therapy within this period of recovery is feasible and beneficial. There were no significant differences between the two groups demonstrating that CIAT, which is provided in a group format, may be a viable option in the very early phase of aphasia recovery. The study highlights the need for further research into the impact of therapy type in very early aphasia therapy.

A replicable, non-programmed, instrument-free method for the control of stuttering with prolonged speech

Abstract Recent research has challenged some assumptions upon which many prolonged speech programmes are based. This paper presents preliminary data from a new programme designed to redress this situation. The new programme operates without any of the following procedures: (1) a multiday, intensive treatment format; (2) formal transfer procedures; (3) programmed instruction; (4) standardized, prescriptive prolonged speech target behaviours, and (5) instrumentation for the on-line counting of stuttering rate and speech rate. The latter procedures have been replaced by the use of a severity rating scale. Data are presented for the first three clients to reach the maintenance phase of the programme. All clients reduced stuttering to very low levels both within and beyond the clinic.