Susan Block

Prevalence of anxiety disorders among adults seeking speech therapy for stuttering

The present study explored the prevalence of anxiety disorders among adults seeking speech therapy for stuttering. Employing a matched case-control design, participants included 92 adults seeking treatment for stuttering, and 920 age- and gender-matched controls from the Australian National Survey of Mental Health and Well-being. A conditional logistic regression model was used to estimate odds ratios for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases (ICD-10) anxiety disorders. Compared with matched controls, the stuttering group had six- to seven-fold increased odds of meeting a 12-month diagnosis of any DSM-IV or ICD-10 anxiety disorder. In terms of 12-month prevalence, they also had 16- to 34-fold increased odds of meeting criteria for DSM-IV or ICD-10 social phobia, four-fold increased odds of meeting criteria for DSM-IV generalized anxiety disorder, and six-fold increased odds of meeting criteria for ICD-10 panic disorder. Overall, stuttering appears to be associated with a dramatically heightened risk of a range of anxiety disorders.

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.

Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: the Camperdown Program

BACKGROUND Although there are treatments that can alleviate stuttering in adults for clinically significant periods, in Australia there are barriers to the accessibility and availability of best-practice treatment. AIMS This parallel group, non-inferiority randomized controlled trial with multiple blinded outcome assessments investigated whether telehealth delivery of the Camperdown Program provides a non-inferior alternative to face-to-face treatment for adults who stutter. METHODS & PROCEDURES Forty participants who presented to a university speech clinic were randomized: 20 to the telehealth arm and 20 to the face-to-face arm. Exclusion criteria were age younger than 18 years, frequency of stuttering less than 2% of syllables stuttered and previous speech-restructuring treatment within the past 12 months. The Camperdown Program for adults who stutter was the intervention. Primary outcome measures were frequency of stuttering measured in per cent syllables stuttered (%SS) before treatment and at 9 months post-randomization and efficiency, measured by counting the number of speech pathologist contact hours used by each participant. Intention to treat analysis was conducted using last observation carried forward. Secondary outcome measures were speech naturalness, self-reported stuttering severity, and treatment satisfaction. OUTCOMES & RESULTS There was no statistically or clinically significant difference in %SS between the two groups at 9 months post-randomization. Analysis of covariance adjusting for baseline %SS showed telehealth had 0.8% absolute lower per cent syllables stuttered than face-to-face. There were also no differences in %SS between groups immediately post-treatment, or at 6 months and 12 months post-treatment (p = 0.9). In the second primary outcome measure, the telehealth group used statistically less contact time (221 min) on average than the face-to-face group (95% confidence interval = - 387 to - 56 min, p = 0.01). CONCLUSIONS & IMPLICATIONS The results provide evidence to support the use of the Camperdown Program delivered by telehealth as an alternate to the face-to-face treatment delivery of this programme for adults who stutter. Such a model will increase accessibility to this evidence-based treatment for adults currently isolated from treatment services.

Natural History of Stuttering to 4 Years of Age: A Prospective Community-Based Study

OBJECTIVES: To document the natural history of stuttering by age 4 years, including (1) cumulative incidence of onset, (2) 12-month recovery status, (3) predictors of stuttering onset and recovery, and (4) potential comorbidities. The study cohort was a prospective community-ascertained cohort (the Early Language in Victoria Study) from Melbourne, Australia, of 4-year-old children (n = 1619; recruited at age 8 months) and their mothers. METHODS: Outcome was stuttering onset by age 4 years and recovery within 12 months of onset, defined using concurrent monthly parent and speech pathologist ratings. Potential predictors: child gender, birth weight, birth order, prematurity, and twinning; maternal mental health and education; socioeconomic status; and family history of stuttering. Potential comorbidities: preonset and concurrent temperament, language, nonverbal cognition, and health-related quality of life. RESULTS: By age 4 years, the cumulative incidence of stuttering onset was 11.2% (95% confidence interval [CI]: 9.7% to 12.8%). Higher maternal education (P = .004), male gender (P = .02), and twinning (P = .005) predicted stuttering onset. At outcome, stuttering children had stronger language (mean [SD]: 105.0 [13.0] vs 99.6 [14.6]; mean difference 5.5, 95% CI: 3.1 to 7.8; P < .001) and nonverbal cognition (mean [SD]: 106.5 [11.4] vs 103.9 [13.7], mean difference 2.6, 95% CI: 0.4 to 4.8; P = .02) and better health-related quality of life but were otherwise similar to their nonstuttering peers. Only 9 of 142 children (6.3%; 95% CI: 2.9% to 11.7%) recovered within 12 months of onset. CONCLUSIONS: Although stuttering onset is common in preschoolers, adverse affects are not the norm in the first year after onset.

Screening for personality disorders among adults seeking speech treatment for stuttering.

UNLABELLED Stuttering is frequently associated with negative consequences which typically begin in early childhood. Despite this, no previous studies have investigated the presence of personality disorders among adults who stutter. Therefore, the aims of the present study were to screen for personality disorders among adults who stutter, and to compare these screening estimates with matched controls from a national population sample. Using a matched case-control design, participants were 94 adults seeking treatment for stuttering, 92 of whom completed the International Personality Disorders Examination Questionnaire (IPDEQ) as a first-stage screener, and 920 age- and gender-matched controls from the Australian National Survey of Mental Health and Well-Being (ANSMHWB). A conditional logistic regression model was used to estimate odds ratios for the primary outcome: first-stage presence of any personality disorder; as well as specific personality disorders. Based on first-stage screening, the presence of any personality disorder was significantly higher for adults in the stuttering group than matched controls, demonstrating almost threefold increased odds. This difference between groups remained significant for all specific personality disorders, with four- to sevenfold increased odds found for Dissocial, Anxious, Borderline, Dependent and Paranoid personality disorders, and two- to threefold increased odds found for Histrionic, Impulsive, Schizoid and Anankastic personality disorders. In conclusion, stuttering appears to be associated with a heightened risk for the development of personality disorders. These results highlight the need for research regarding the assessment and treatment of personality disorders among adults who stutter. EDUCATIONAL OBJECTIVES The reader will be able to: (1) describe the nature of personality disorders, including factors thought to contribute to their development; (2) identify some of the negative consequences associated with stuttering which may contribute to the development of personality disorders among adults who stutter; (3) describe the process involved in screening for personality disorders, including various methods of scoring; and (4) summarize findings regarding the first-stage presence of personality disorders among adults seeking speech treatment for stuttering in the present sample in comparison with age- and gender-matched controls from a national population sample.

The social and communication impact of stuttering on adolescents and their families

PURPOSE Stuttering can cause wide ranging psychosocial impact. This is particularly the case for adolescents who may face additional physical, emotional and personality changes as they become adults. This study reports the findings of an investigation into the social and communication impacts of stuttering on Australian adolescents seeking treatment for stuttering and their families. METHOD A cross-sectional design utilising questionnaires assessed the self-perceived communication competence and apprehension, stigma and disclosure, and experiences of teasing and bullying of 36 adolescents who stutter. Additionally, the impact of stuttering on the families of these adolescents was investigated. RESULTS Adolescents who stutter have below average self-perceived communication competence, heightened communication apprehension, are teased and bullied more often than fluent peers, and they try to keep their stuttering secret. The families of the adolescents in the study reported high levels of emotional strain, family conflict and difficulty managing their childs frustrations. CONCLUSION The findings from this study emphasise the wide-ranging impact of stuttering beyond the surface level behaviours. Clinicians working with adolescents who stutter should take note of both the outcomes of this study and the suggestions for more effectively coping with the condition in this population. EDUCATIONAL OBJECTIVES The reader will be able to: (a) summarise findings with regards to the impact of stuttering on an adolescents social and communication skills; (b) summarise areas of impact on the families of adolescents who stutter; (c) compare these findings with previous reported data for this population; (d) discuss the clinical implications of the results for working with adolescents who stutter and their families.

Unhelpful Thoughts and Beliefs Linked to Social Anxiety in Stuttering: Development of a Measure.

BACKGROUND Those who stutter have a proclivity to social anxiety. Yet, to date, there is no comprehensive measure of thoughts and beliefs about stuttering that represent the cognitions associated with that anxiety. AIMS The present paper describes the development of a measure to assess unhelpful thoughts and beliefs about stuttering. METHODS & PROCEDURES The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) self-report measure contains 66 items that assess the frequency of unhelpful thoughts and beliefs. Items were constructed from a comprehensive file audit of all stuttering cases seen in a cognitive-behavior therapy based treatment programme over a ten-year period. OUTCOMES & RESULTS Preliminary investigations indicate that the UTBAS has high levels of test-retest reliability (r = 0.89) and internal consistency (Chronbachs alpha = 0.98). It has good known-groups validity, being able to discriminate between stuttering and non-stuttering participants on items that contain no reference to stuttering [t(38) = 8.06, p<0.0001], with a large effect size (d = 2.3). It has good convergent validity (r = 0.53-0.72) and discriminant validity (r = 0.24-0.27). The UTBAS sensitivity to change was supported by improvements in thoughts and beliefs related to social anxiety following cognitive-behavioural treatment for anxiety in stuttering [t(25) = 10.13, p<0.0001]. The effect size was large (d = 2.5). CONCLUSIONS & IMPLICATIONS Implications for the use of the UTBAS as an outcome measure and a clinical tool are discussed, along with the potential value of the UTBAS to explore the well-documented social anxiety experienced by those who stutter.

Early stuttering, temperament and anxiety: two hypotheses.

PURPOSE The topic of temperament and early stuttering and the extent to which it involves anxiety is theoretically and clinically relevant. The topic can contribute to theory development and clinical practices with early stuttering. METHOD We present a review of the empirical literature for this area with a view to determining which of two hypotheses might be true. The first is that, for the population of those who stutter, unusual temperament is a causal factor for the development of the disorder and its later association with anxiety. The second hypothesis is that for the population of those who stutter the developmental manifestation of anxiety is an effect of stuttering. Both hypotheses attempt to account for the well-known association of anxiety with chronic stuttering. RESULTS A firm conclusion about the matter would be premature at present because the literature involved is limited and contains some inconsistencies. We suggest some quantitative and qualitative directions for future research. We argue also that the only way to resolve the matter is with longitudinal studies of cohorts ascertained prior to stuttering onset. CONCLUSION Conclusive findings about the matter can only emerge when research extends beyond its modest scope of 10 interpretable publications. EDUCATIONAL OBJECTIVES The reader will be able to: (a) describe temperament and the role it plays during anxiety development, (b) explain two alternative hypotheses which implicate temperament in early childhood stuttering; (c) describe current knowledge regarding temperament similarities and differences between stuttering and control children, and (d) discuss the theoretical and clinical implications of understand the relationship between temperament, anxiety and early stuttering.

Axis I anxiety and mental health disorders among stuttering adolescents

PURPOSE The purpose of this study was to evaluate anxiety and psychological functioning among adolescents seeking speech therapy for stuttering using a structured, diagnostic interview and psychological questionnaires. This study also sought to determine whether any differences in psychological status were evident between younger and older adolescents. METHOD Participants were 37 stuttering adolescents seeking stuttering treatment. We administered the Computerized Voice Version of the Diagnostic Interview Schedule for Children, and five psychometric tests. Participants were classified into younger (12-14 years; n=20) and older adolescents (15-17 years; n=17). RESULTS Thirty-eight percent of participants attained at least one diagnosis of a mental disorder, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involving anxiety. This figure is double current estimates for general adolescent populations, and is consistent with our finding of moderate and moderate-severe quality of life impairment. Although many of the scores on psychological measures fell within the normal range, older adolescents (15-17 years) reported significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioral problems, than younger adolescents (12-14 years). There was scant evidence that self-reported stuttering severity is correlated with mental health issues. There are good reasons to believe these results are conservative because many participants gave socially desirable responses about their mental health status. DISCUSSION These results reveal a need for large-scale, statistically powerful assessments of anxiety and other mental disorders among stuttering adolescents with reference to control populations. EDUCATIONAL OBJECTIVES The reader will be able to: (a) explain the clinical importance of assessing for mental health with stuttering adolescents, (b) state the superior method for adolescent mental health assessment and (c) state a major issue with determining the genuineness of stuttering adolescent responses to psychological assessment.

Connecting stuttering management and measurement: IV. Predictors of outcome for a behavioural treatment for stuttering

BACKGROUND Clinical trials have shown that behavioural treatments based on variants of prolonged-speech (PS) are best practice for reducing the stuttering rate in adults. However, while stuttering is significantly reduced or eliminated for most adults in the short-term with such treatment, relapse in the longer-term is common. Consequently, there has been interest in attempting to establish variables that predict responsiveness to PS-based treatments. Identifying such variables would enable risk prediction and also contribute to the tailoring of treatments to suit individuals who are less likely to benefit in the long-term from the conventional PS-based treatments. Variables that have been investigated to date are the stuttering severity, the attitude to communication and the locus of control. AIMS The present study revisited this issue with methodological improvements. METHODS AND PROCEDURES Prospective, continuous measures of outcome several years after treatment, and well-powered, least-squares multivariate regression, with backwards elimination, were used to determine the best model to predict short- and long-term outcomes of a PS-based treatment. Other predictor variables were also included. The stuttering rates of 78 participants were measured immediately after the intensive stage of treatment, and during a surprise telephone call 3.5-5 years after treatment. OUTCOMES AND RESULTS Attitude to communication and locus of control were separate constructs to stuttering rate. While the stuttering rate predicted outcome, neither of the two non-behavioural variables predicted outcome in either the short- or the long-term. CONCLUSIONS The most significant finding is that the non-behavioural variables of attitude to communication and locus of control did not predict treatment outcomes. This is contrary to the findings of most previous studies.