PURPOSE:Severity ratings (SRs) of children's stuttering assigned by parents and speech-language pathologists (SLPs) have advantages over methods based on stuttering counts. They are valid, simple, and convenient; without cost; and can be used without the child's awareness. The aim of this project was to study, for the first time, the use of an SR scale by parents and SLPs to track stuttering severity for preschool children over a typical day. For that purpose, we used 10 case studies. METHOD:Participants were 10 preschool children who stuttered (3-4 years of age) and their parents. Each child's speech was audio-recorded by their parent for an entire day at home, commencing at approximately 8:00 a.m. During that day, an SLP made a randomly timed phone call, during which a 10-min sample of the child's speech was audio-recorded. At the end of the day, both before and after training in the use of a 10-point scale, parents assigned a "typical" SR score for their child's speech for the day. An independent SLP later assigned an SR to each 15-min segment of each child's recording from across the day. RESULTS:The severity of all children's stuttering varied throughout the day, and in more than half the children, it varied by as much as 4-6 SR scale values. SRs showed no consistent trend of stuttering increasing or decreasing during the day. There was close correspondence between parent- and SLP-assigned SRs for the day. Parent training in the use of the scale, which occurred at the end of the day of recording, did not change that correspondence. A random 10-min speech sample provided a reasonably valid SR score to represent typical stuttering for the entire day. CONCLUSION:These findings can be applied in clinical and research contexts where measurement of early stuttering may be used to monitor a child's speech for a substantive period.

PURPOSE:In this clinical focus article, we draw attention to the need for immediate intervention shortly after stuttering onset. More than half of stuttering onsets occur before 3 years of age. We argue that existing interventions for preschool children who stutter require varying levels of cognitive engagement from children; hence, they are not suitable for children of that age. For this reason, we argue that there is no clinical trials evidence for treatment efficacy with children younger than 3 years of age. CONCLUSIONS:There are many recommended parent strategies that do not require any active participation from children, which, therefore, may be suitable for immediate stuttering intervention. Two of these have laboratory support in their favor: parent speech rate reduction and increased interturn speaker latency. Therefore, we developed a clinical protocol based on those two parent strategies and showed the clinical viability of the protocol with three children who stuttered. We argue that automation of our proposed treatment with lifelike artificial intelligence-generated avatar clinicians will make it globally viable, and a suitable target for future Phases I-IV clinical trials.

BACKGROUND:The Unhelpful Thoughts and Beliefs About Stuttering Scale (UTBAS) is a widely used measure, available in 17 languages, designed to identify negative cognitions of adults who stutter. However, with a total of 198 response requirements (three subscales with 66 items each), it is long and impractical for use in many clinical and research settings. We conducted two studies. Study 1 investigated the correlation between the three subscales to determine if any of the scales could be removed. Study 2 sought to reduce the total number of items based on floor and ceiling effects, high levels of correlation with other items, and item-response (IRT) theory fit statistics. METHOD:We analysed UTBAS data from the Australian Stuttering Research Centre (ASRC) database. Participants were adults who stutter and who had completed the UTBAS as part of their participation in either a speech restructuring and/or cognitive behaviour therapy-based research trial. RESULTS:Study 1 (n = 316) revealed strong, positive relationships between subscale total scores (r values ≥ 0.88). This finding was consistent for pre- and post-treatment UTBAS scores and was statistically significant (P < 0.001). Study 2 (n = 431) revealed 7 of scale 1 items with floor or ceiling effects, and 6 items highly correlated with others. An initial IRT identified 11 items with poor fit. The top 20 items with the highest slope parameters were finally selected. CONCLUSION:Results demonstrate redundancy of the second and third subscales and 46 items of the UTBAS. We propose a preliminary revised version of the UTBAS (UTBAS-R) consisting of 20 items and one subscale.

PURPOSE:In our original article, we draw attention to the lifetime quality-of-life impairment that can result from childhood stuttering-hence, the need for immediate intervention after onset. We drew on existing experimental outcomes that parent speech-rate reduction and increased interturn speaker latency may reduce stuttering. We developed a two-factor treatment protocol based on those variables in combination and showed its clinical viability, suggesting that it would be a suitable target for Phase I-IV clinical trials. Chang and Bernstein Ratner wrote letters to the editor on our article, to which we respond. CONCLUSIONS:Our response to these letters to the editor covers the following issues raised by Chang and Bernstein Ratner: mechanisms of action for the proposed treatment, the evidence base for the treatment, plans to explore its treatment effects, and the need to verify its safety.

AIM:The aim of this Phase I trial was to assess the safety, compliance, and potential efficacy of iLidcombe, a standalone internet version of the Lidcombe Program for young children who stutter. METHOD:We used a prospective single-group design involving 6 months of access to iLidcombe. Assessments occurred pretreatment and after 6 months of access. Participants were 20 parents of young children who stuttered. RESULTS:There was evidence of stuttering severity reduction after using iLidcombe for 6 months. Compliance with the program was favorable, and there was no suggestion of any psychologically adverse impact on children. CONCLUSION:The results of this Phase I trial provide a roadmap for further Phases II-IV clinical trial development.

PURPOSE:Stuttering is associated with clinically significant social anxiety, which emerges during early childhood for some, but not all, children who begin to stutter. The purpose of this review article is to develop a model of social anxiety development during early childhood stuttering and to present an empirical method by which it can be tested. METHOD:We propose a mediation model of how the exposure variable of stuttering may lead to an outcome of social anxiety. Our model includes confounder and mediator variables. We explain the concepts and procedures of mediation analysis and present a method to test our model. RESULTS:We present the idea that negative peer responses to stuttering and negative self-perception of children are mediators of social anxiety development. We propose several confounder variables that involve children, their parents, and the home environment. We depict our model with a directed acyclic graph, and we present details of how it can be tested with a longitudinal research design. DISCUSSION:This is the first attempt to model the development of social anxiety shortly after stuttering onset with an empirically testable method. The intended benefit of this innovation is to direct future clinical directions for the clinical management of stuttering arising shortly after childhood onset.

Purpose eHealth treatments have been developed for a range of conditions. They provide an accessible, cost-effective, and convenient model for clients and families to access treatment. The aim of this paper is to provide details and results of user testing of an eHealth speech treatment for adults who stutter: iCamperdown. Method An iterative user-testing process was conducted using a think-aloud method and structured questionnaires. End users were adults who stutter and speech-language pathologists (SLPs). Results Based on user feedback, the program underwent several modifications. Changes made to the program included functional enhancements. These include automatic activation of audio instructions on each page to improve navigation, aesthetic modifications to improve acceptability such as rearranging of information, changes to instructions provided to users to improve clarity, and enhancing the quality of audio recordings to increase efficiency. Conclusion The iCamperdown program is now ready to be evaluated with a Phase I clinical trial, focussing on evaluating safety, compliance, and preliminary outcomes. Further clinical trialing could investigate baseline predictors and treatment moderators to identify which individuals are most likely to benefit from the program. iCamperdown has advantages and disadvantages, which we explore. We explore the prospect of automating iCamperdown with advanced machine learning techniques. Potentially, the iCamperdown Program for stuttering reduction, with translation into other world languages besides English, could be a transformative change to SLP practices internationally.

PURPOSE:To discuss how speech-language pathologists can keep up with stuttering treatment research. To inform junior clinicians and students of speech-language pathology about this matter. METHOD:The issue was discussed by two university researchers and two speech-language pathologists who provide clinical services. Written conversational turns in an exchange were limited to 100 words each. RESULT:There was agreement among the group that keeping up to date with stuttering research is essential for speech-language pathologists, and to do so requires a basic understanding of research methods. For treatment research, there are several levels of evidence, and there was agreement that they are all relevant to clinical practice. All in the group agreed that basic research is essential to inform clinical practice, particularly in five domains. The volume of stuttering research is challenging for generalist clinicians to keep up with. CONCLUSION:We make recommendations about how speech-language pathologists can keep up with stuttering treatment research in a time-efficient manner. This may be particularly useful for junior clinicians and students of speech-language pathology.

PURPOSE:The Fifth Croatia Stuttering Symposium in 2022 continued the Fourth Croatia Stuttering Symposium 2019 theme of the connection between research and clinical practice. At the 2022 Symposium, there were 145 delegates from 21 countries. This paper documents the contents of the first of three Symposium modules.METHODS:The module topic was that three treatments for early childhood stuttering are supported by randomized controlled trial evidence. A clinical situation was considered where a parent of a 3-year-old child asked what results to expect of stuttering treatment.RESULTS:A distinguished scholar presented a 5-minute video interpretation of the research concerning the randomized controlled trial evidence for the three treatments. Three master clinicians then each presented a 2-minute video demonstration of how those research findings might be applied in a clinical situation. Following that, the convenors moderated a discussion between the distinguished scholar, master clinicians, and delegates regarding the research and how it applies to clinical practice.

Purpose: The Fifth Croatia Stuttering Symposium of 2022 continued the Fourth Croatia Stuttering Symposium 2019 theme of the connection between research and clinical practice. At the 2022 Symposium, there were 145 delegates from 21 countries. This paper documents the contents of the second of three Symposium modules. Methods: The module topic was that some children with early stuttering will recover naturally. A clinical situation was considered where a parent of a 3-year-old child asked if a clinician can predict whether their child will recover from stuttering without treatment. Results: A distinguished scholar presented a 5-minute video interpretation of research about this topic. Three master clinicians then each presented a 2-minute video demonstration of how that research might be applied in a clinical situation. Following that, the convenors moderated a discussion between the distinguished scholar, master clinicians, and delegates regarding the research and how it applies to clinical practice.

The Lidcombe Program is a well-established and efficacious treatment for early stuttering, but little is currently known about its mechanisms of action. The present report explores the possibility that inter-turn speaker latency might be associated with such mechanisms of action. Inter-turn speaker latency was measured in audio recordings of children, parents, and clinicians conversing, taken during Lidcombe Program treatment consultations. Five clinicians reduced their inter-turn speaker latencies during clinical consultations when they were speaking to children, in comparison with when they were speaking to parents. It is possible that inter-turn speaker latency is associated with the Lidcombe Program treatment process vicariously, and this possibility requires further research.

Purpose: For those who stutter, verbal communication is typically compromised in social situations. This may attract negative responses from listeners and stigmatization by society. These have the potential to impair health-related quality of life across a range of domains, including qualitative and quantitative impacts on speech output, mental health issues, and failure to attain educational and occupational potential. These systematic reviews were designed to explore this matter using traditional health economics perspectives of utility measures and cost of illness. Method: Studies were included if they involved children, adolescents, or adults with stuttering as a primary diagnosis. The quality of life search strategy identified 2,607 reports, of which three were included in the quality of life analysis. The cost of illness search strategy identified 3,778 reports, of which 39 were included in the cost of illness analysis. Results: Two of the three studies included in the quality of life analysis had a high risk of bias. When measured using utility scores, quality of life for people who stutter was in the range of those reported for chronic health conditions such as diabetes mellitus, cardiovascular disease, and cancer. However, there is little such evidence of quality of life impairment during the preschool years. Studies included in the cost of illness analysis carried considerable risk of bias overall. Conclusions: For people who stutter, there are substantive direct and indirect costs of illness. These include impairment, challenges, and distress across many domains throughout life, including income, education, employment, and social functioning. Evidence of quality of life impairment using utility measures is extremely limited. If this situation is not remedied, the lifetime impairment, challenges, and distress experienced by those who stutter cannot be documented in a form that can be used to influence health policy and health care spending. Supplemental Material: https://doi.org/10.23641/asha.24168201

PURPOSE:The Fifth Croatia Stuttering Symposium of 2022 continued the Fourth Croatia Stuttering Symposium 2019 theme of the connection between research and clinical practice. At the 2022 Symposium, there were 145 delegates from 21 countries. This paper documents the contents of the third of three Symposium modules.METHODS:The module topic was mental health and early stuttering, and that pre-schoolers who stutter are at risk of developing mental health issues. A clinical situation was considered where a parent of a 3-year-old child asked a clinician what the early signs of mental health issues might be for a child who stutters.RESULTS:A distinguished scholar presented a 5-minute video interpretation of research about this topic. Three master clinicians then each presented a 2-minute video demonstration of how that research might be applied in a clinical situation. Following that, the convenors moderated a discussion between the distinguished scholar, master clinicians, and delegates regarding the research and how it applies to clinical practice.

PURPOSE This study investigated the complexity of stuttering behavior. It described and classified the complexity of stuttering behavior in relation to age, behavioral treatment outcomes, stuttering severity, anxiety-related mental health, impact of stuttering, and gender. METHOD For this study, a taxonomy was developed-LBDL-C7-which was based on the Lidcombe Behavioral Data Language of stuttering. It was used by five experienced judges to analyze the complexity of stuttering behavior for 84 adults and adolescents before and after speech restructuring treatment. Data were 3,100 stuttering moments, which were analyzed with nominal logistic regression. RESULTS The complexity of stuttering behavior appears not to change as a result of treatment, but it does appear to change with advancing age. Complexity of stuttering behavior was found to be independently associated with clinician stuttering severity scores but not with percentage of syllables stuttered or self-reported stuttering severity. Complexity of stuttering behavior was not associated with gender, anxiety, or impact of stuttering. CONCLUSION Clinical and research applications of these findings are discussed.

Background: Information about genetic influence is useful to when counselling parents or caregivers who have infants and children at risk for stuttering. Yet, the most comprehensive family aggregate database to inform that counselling is nearly four decades old (Andrews et al., 1983). Consequently, the present study was designed to provide a contemporary exploration of the relationship between stuttering and family history.Methods: Data were sourced from the Australian Stuttering Research Centre, comprising 739 participants who presented for assessment, treatment, or investigation of stuttering. Reported family history data were acquired from pedigrees collected during assessment. We sought to establish the relation of the following variables to family history of stuttering: incidence, proband sex, parent sex, stuttering severity, age, reported age of stuttering onset, and impact of stuttering. Data were analysed with chi-square tests for independence, logistic and linear regression models. Results: Results were broadly consistent with existing data, but the following findings were novel. Males and females who stutter have the same increased odds of having a father who stutters relative to a mother who stutters. Males had later stuttering onset than females, with genetic involvement in this effect. There was a greater impact of stuttering for females than males with a family history of stuttering.Conclusion: These findings have clinical applications. Speech-language pathologists may have infant or child clients known to them who are at risk of beginning to stutter. Information from the present study can be applied to counselling parents or caregivers of such children about stuttering and family history.

Background: Developmental stuttering is thought to be underpinned by structural impairments in the brain. The only way to support the claim that these are causal is to determine if they are present before onset. Materials and methods: Magnetic resonance imaging (MRI) was conducted on 18 neonates, aged 8-18 weeks, 6 of whom were determined to be genetically at risk of stuttering. Results: With tract-based spatial statistics (TBSS) analysis, no statistically significant differences were found between the at-risk group and the control group. However, fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD) in the corpus callosum of the at-risk group were lower (uncorrected) than in the control group. Automated Fiber Quantification (AFQ) yielded lower FA in the at-risk group than in the control group in the medial section of the callosum forceps minor. Discussion: The findings, albeit with a small number of participants, support the proposition that reduced integrity of white matter in the corpus callosum has a causal role in developmental stuttering. Longitudinal research to determine if children with this impairment at birth later start to stutter is needed to confirm this. The left arcuate fasciculus is thought to develop as speech develops, which likely explains why there were no abnormal findings in this area in our at-risk neonates so soon after birth. This is the first study to investigate the brains of children before the onset of stuttering, and the findings warrant further research.

PURPOSE This study was designed to answer three questions. (a) Does percentage of syllables stuttered (%SS) differ between standard and challenge phone calls. (b) Does anxiety differ between standard and challenge phone calls. (c) Is there a relationship between %SS and anxiety during standard and challenge phone calls? METHOD Participants were 230 adults diagnosed with stuttering, who were participants from five clinical trials. Each participant received two 10-min phone calls at pretreatment and a further two phone calls 6 months or 20 weeks postrandomization. One phone call was standard, and the other presented challenge: occasionally disagreeing with, interrupting, and talking over participants, or asking for clarification of their views. RESULTS Statistically significant, but clinically minor, increases of %SS and anxiety occurred during the challenge phone calls. There was a statistically significant association between %SS and anxiety. CONCLUSIONS Variable phone call procedures to assess stuttering severity in clinical trials are not likely to spuriously inflate or deflate treatment outcomes to a clinically important extent. Regardless, the present results suggest that there is statistical merit in controlling the nature of phone calls during clinical trials with the simple and replicable method developed in this report. Additionally, there is procedural merit in the challenge phone call procedure; it is a more valid representation of the challenges of everyday speech than the standard procedure. However, a disadvantage of the challenge phone call procedure is the practical issues associated with its use. The clinical and theoretical applications of the results are discussed.

Purpose: During the 2019 Fourth Croatia Clinical Symposium, speech-language pathologists (SLPs), scholars, and researchers from 29 countries discussed speech-language pathology and psychological practices for the management of early and persistent stuttering. This paper documents what those at the Symposium considered to be the key contemporary clinical issues for early and persistent stuttering. Methods: The authors prepared a written record of the discussion of Symposium topics, taking care to ensure that the content of the Symposium was faithfully reproduced in written form. Results: Seven contemporary issues for our field emerged from the Symposium. Conclusion: Effective early intervention is fundamental to proper health care for the disorder. However, as yet, there is no consensus about the timing of early intervention and how it should be managed. Currently, clinical translation is a barrier to evidence-based practice with early stuttering, and proactive strategies were suggested for junior SLPs. Apprehension emerged among some discussants that treatment of early stuttering may cause anxiety. For persistent stuttering, assessment procedures were recommended, as were strategies for dealing with childhood bullying. There was agreement that SLPs are the ideal professionals to provide basic cognitive

Purpose: Recent research has shown that some school age children who stutter may have speech-related anxiety. Given this, speech-language pathologists require robust measures to assess the psychological effects of stuttering during the school-age years. Accordingly, this systematic review aimed to explore available measures for assessing the psychological impacts of stuttering in young school-age children and to examine their measurement properties. Method: The systematic search protocol was registered with PROSPERO (ID: 163181). Seven online databases, in addition to manual searching and screening of reference lists, were used to identify appropriate measures for the population of children who stutter aged 7-12 years. The first two authors independently assessed the measures using the quality appraisal tool described by Terwee et al. (2007). Results: Despite the comprehensive search strategy, only six measures were identified for quality appraisal. No assessmenttool was found to possess adequate measurement properties for the eight assessed domains: content validity, internal consistency, construct validity, reproducibility, reliability, responsiveness, floor and ceiling effects, and interpretability. No measure had clear evidence of responsiveness to clinical change. Based on the criterion defined by the Terwee et al. (2007) appraisal tool, the Communication Attitude Test and the Overall Assessment of the Speaker's Experience of Stuttering for School-Age Children received the highest number of ratings in support of their measurement properties. Conclusions: The results highlight a lack of available measures in this domain and poor practices in developing and testing measurement instruments. To ensure that clinicians and researchers are equipped with sound measures to meet the mental health needs of this vulnerable population, further research to establish resources is needed.

Purpose The purpose of this study was to use psychological measures of pre-schoolers who stutter and their parents to inform causal theory development and influence clinical practices. This was done using data from a substantive clinical cohort of children who received early stuttering treatment. Method The cohort (N=427) comprised parents and their children who were treated with the Lidcombe Program, the Westmead Program, and the Oakville Program. The study incorporated demographic information, stuttering severity, and child and parent psychological measures prior to treatment. Result The cohort revealed nothing unusual about behavioural and emotional functioning, or the temperaments, of pre-school children that would influence treatment, be targeted during treatment, or influence causal theory development. However, a third of parents were experiencing moderate to high life stressors at the time of seeking treatment, and half the parents failed first-stage screening for Anankastic Personality Disorder. Conclusion The present results are consistent with a number of previous reports that showed that the population of pre-schoolers who stutter have no unusual psychological profiles. Hence, these results suggest that the association between mental health and stuttering later in life is a consequence of the disorder rather than being a part of its cause. The finding of the life stress of parents who seek stuttering treatment for pre-school children has potential clinical importance and warrants further investigation. Further psychological research is required about parents of pre-school children who stutter, because half the parents in the cohort failed the screener for Anankastic Personality Disorder. This is of interest because a previous study associated screening failure for another personality disorder (Impulsive Personality Disorder) with treatment dropout for early childhood stuttering.