Linguistic aspects of stuttering: research updates on the language-fluency interface.

Purpose: Although commonly defined as a speech disorder, stuttering interacts with the language production system in important ways. Our purpose is to summarize research findings on linguistic variables that influence stuttering assessment and treatment. Method and Results: Numerous topics are summarized. First, we review research that has examined linguistic features that increase stuttering frequency and influence where it occurs. Second, we tackle the question of whether or not persons who stutter exhibit subtle language differences or deficits. Next, we explore language factors that appear to influence recovery from early stuttering in children. The final topic discusses the unique challenges inherent in differentially diagnosing stuttering in bilingual children. Clinical implications for each topic are discussed. Discussion: The article concludes with a discussion of the unique differences in the integration of language and speech demands by people who stutter, when compared to people who are typically fluent, and their clinical ramifications.

Comparing evaluations of social situations for adults who do and do not stutter.

PURPOSE: Numerous research studies indicate that stuttering is associated with increased risk for social anxiety disorder (SAD). Interpretation bias is one of four cognitive biases thought to maintain symptoms associated with SAD. Interpretation bias occurs when one evaluates social situations as more negative than they actually are. The purpose of this study was to investigate if adults who do and do not stutter interpret positive, ambiguous, mildly negative, and profoundly negative social situations similarly, or-if like individuals with SAD-adults who stutter exhibit negative interpretation biases. METHOD: Forty-eight adults who stutter and 42 age-and gender-matched adults who do not stutter participated. Participants completed the Fear of Negative Evaluation (FNE) and were assigned to one of four groups: adults who stutter with high FNE (AWS-High), adults who stutter with low FNE (AWS-Low), adults who do not stutter with high FNE (AWNS-High), and adults who do not stutter with low FNE (AWNS-Low). All participants completed the trait scale of the State Trait Anxiety Inventory (STAI) and the Interpretation and Judgmental Questionnaire (IJQ). The IJQ contains descriptions of four types of social situations: positive, mildly negative, profoundly negative, and ambiguous. Within each situation type there are five different scenarios, for a total of 20 scenarios across the four situation types. Participants provided written responses to these 20 social scenarios. Qualitative analyses were used to understand how members of each group interpreted the different social scenarios. RESULTS: Thematic analysis revealed that each group responded in similar ways to each of the social scenarios, regardless of the type of situation. Adults who do and do not stutter with low and high FNE agreed on many themes related to the 20 social scenarios, and they agreed across all four types of social situations. Somewhat surprisingly, the theme "stuttering" was mentioned infrequently by the adults who stutter. CONCLUSIONS: Results suggested that adults who do and do not stutter with low and high FNE interpret social situations similarly, and that no group demonstrated a negative interpretation bias consistent with what is observed in adults with SAD. The interpretations provided by each group were appropriate to the specific scenarios being evaluated.

Consensus Guidelines for the Assessments of Individuals Who Stutter Across the Lifespan.

Purpose This project sought to develop consensus guidelines for clinically meaningful, comprehensive assessment procedures for people who stutter across the lifespan. Method Twelve expert clinicians and researchers who have written extensively about stuttering provided detailed descriptions of the type of data that they routinely collect during diagnostic evaluations of preschool children, school-age children, adolescents, and adults who stutter. Iterative content analysis, with repeated input from the respondents, was used to identify core areas that reflect common domains that these experts judge to be important for evaluating stuttering for varying age groups. Results Six core areas were identified as common components of a comprehensive evaluation of stuttering and people who stutter. These areas should be included to varying degrees depending upon the age and needs of the client or family. The core areas include the following: (a) stuttering-related background information; (b) speech, language, and temperament development (especially for younger clients); (c) speech fluency and stuttering behaviors; (d) reactions to stuttering by the speaker; (e) reactions to stuttering by people in the speaker's environment; and (f) adverse impact caused by stuttering. Discussion These consensus recommendations can help speech-language pathologists who are uncertain about appropriate stuttering assessment procedures to design and conduct more thorough evaluations, so that they will be better prepared to provide individualized and comprehensive treatment for people who stutter across the lifespan.

Introduction to the Special Issue: The 11th Oxford Dysfluency Conference.

Purpose: The purpose of this introduction is to provide an overview of the articles in this special issue of AJSLP. These articles originated from the presentations at the 11th Oxford Dysfluency Conference in September 2017.

Rates of Typical Disfluency in the Conversational Speech of 30-Month-Old Spanish-English Simultaneous Bilinguals.

Purpose: The aim of this study was to investigate the typical disfluency rates at 30 months old in a large group of simultaneous bilingual children and also investigate the relationships between disfluency rates and linguistic complexity (mean length of utterance in words [MLU-W]), vocabulary diversity (VocD), and speaking rate (utterances per unit time). Method: Fifty-three typically developing children who had been exposed to Spanish and English from birth participated in this descriptive study. The average percent input at home was 46% in English and 54% in Spanish. Outside the home, the children averaged 9 hr of exposure per week in each language. Spontaneous speech samples in both languages were obtained during play sessions between the children and a parent. Results: Nonparametric tests revealed a significant difference in typical disfluency rates across languages, with more children being disfluent in English and with a larger range of disfluency rates in English. The effect size for this difference was small. The children had significantly higher MLU-W in English; there were no differences in VocD or speaking rate between the 2 languages. Typical disfluency rate in Spanish was not significantly correlated with MLU-W, VocD, or speaking rate. Typical disfluency rates in English were correlated with MLU-W and VocD, but not with speaking rate. Conclusion: This article described the typical disfluency rates of a large group of simultaneous Spanish-English bilingual children at 30 months of age. The typical disfluency rates reported here are lower than those reported in the literature for monolingual children of similar ages. Clinical implications of these findings are addressed.

Promoting Scientist-Advocate Collaborations in Cancer Research: Why and How.

Advocates bring unique and important viewpoints to the cancer research process, ensuring that scientific and medical advances are patient-centered and relevant. In this article, we discuss the benefits of engaging advocates in cancer research and underscore ways in which both the scientific and patient communities can facilitate this mutually beneficial collaboration. We discuss how to establish and nurture successful scientist-advocate relationships throughout the research process. We review opportunities that are available to advocates who want to obtain training in the evaluation of cancer research. We also suggest practical solutions that can strengthen communication between scientists and advocates, such as introducing scientist-advocate interactions at the trainee level. Finally, we highlight the essential role social media can play in disseminating patient-supported cancer research findings to the patient community and in raising awareness of the importance of promoting cancer research. Our perspective offers a model that Georgetown Breast Cancer Advocates have found effective and which could be one option for those interested in developing productive, successful, and sustainable collaborations between advocates and scientists in cancer research. Cancer Res; 78(20); 5723-8. ©2018 AACR.

Systems Thinking and Systems-Based Practice Across the Health Professions: An Inquiry Into Definitions, Teaching Practices, and Assessment.

Phenomenon: Systems thinking is the cornerstone of systems-based practice (SBP) and a core competency in medicine and health sciences. Literature regarding how to teach or apply systems thinking in practice is limited. This study aimed to understand how educators in medicine, physical therapy, physician assistant, nursing, and speech-language pathology education programs teach and assess systems thinking and SBP. APPROACH: Twenty-six educators from seven different degree programs across the five professions were interviewed and program descriptions and relevant course syllabi were reviewed. Qualitative analysis was iterative and incorporated inductive and deductive methods as well as a constant comparison of units of data to identify patterns and themes. FINDINGS: Six themes were identified: 1) participants described systems thinking as ranging across four major levels of healthcare (i.e., patient, care team, organization, and external environment); 2) participants associated systems thinking with a wide range of activities across the curriculum including quality improvement, Inter-professional education (IPE), error mitigation, and advocacy; 3) the need for healthcare professionals to understand systems thinking was primarily externally driven; 4) participants perceived that learning systems thinking occurred mainly informally and experientially rather than through formal didactic instruction; 5) participants characterized systems thinking content as interspersed across the curriculum and described a variety of strategies for teaching and assessing it; 6) participants indicated a structured framework and inter-professional approach may enhance teaching and assessment of systems thinking. Insights: Systems thinking means different things to different health professionals. Teaching and assessing systems thinking across the health professions will require further training and practice. Tools, techniques, taxonomies and expertise outside of healthcare may be used to enhance the teaching, assessment, and application of systems thinking and SBP to clinical practice; however, these would need to be adapted and refined for use in healthcare.

Fear of Negative Evaluation, Trait Anxiety, and Judgment Bias in Adults who Stutter.

PURPOSE: Persons who stutter (PWS) and those with social anxiety disorder may exhibit fear of negative evaluation (FNE) and anxiety in social situations. However, the information processing biases that perpetuate these characteristics have had limited investigation. This study investigated judgment bias in social situations. METHOD: Participants included 50 adults who stutter and 45 age- and gender-matched fluent persons who do not stutter (PWNS), who made up the control group. Participants completed the Interpretation and Judgmental Questionnaire (Voncken, Bögels, & deVries, 2003), and threat scores were calculated. RESULTS: There were no significant differences between PWS and PWNS in social threat or nonsocial threat scores. When the PWS group was divided on the basis of FNE and compared with PWNS participants without heightened anxiety (n = 35), the PWS with high FNE had significantly higher total social threat scores than the PWS with low FNE. The three groups did not differ in threat ratings for ambiguous or profoundly negative social situations. CONCLUSIONS: Judgment bias in PWS is mediated by the magnitude of FNE present; not all PWS exhibit judgment bias for social situations. Treatment implications include the need for psychosocial support addressing the negative impacts on quality of life and restrictions on social engagement that stuttering may cause in some individuals.

Utility of virtual reality environments to examine physiological reactivity and subjective distress in adults who stutter.

PURPOSE: Virtual reality environments (VREs) allow for immersion in speaking environments that mimic real-life interactions while maintaining researcher control. VREs have been used successfully to engender arousal in other disorders. The purpose of this study was to investigate the utility of virtual reality environments to examine physiological reactivity and subjective ratings of distress in persons who stutter (PWS). METHOD: Subjective and objective measures of arousal were collected from 10PWS during four-minute speeches to a virtual audience and to a virtual empty room. RESULTS: Stuttering frequency and physiological measures (skin conductance level and heart rate) did not differ across speaking conditions, but subjective ratings of distress were significantly higher in the virtual audience condition compared to the virtual empty room. CONCLUSION: VREs have utility in elevating subjective ratings of distress in PWS. VREs have the potential to be useful tools for practicing treatment targets in a safe, controlled, and systematic manner.

Developing and Using Big Data Archives to Quantify Disfluency and Stuttering in Bilingual Children.

Worldwide, bilingualism is the rule rather than the exception, and yet we have surprisingly little research data on the fluency development of bilingual children, and even less information on their potential risk for stuttering. Many variables influence a bilingual child's language, speech, and fluency development (e.g., amount of exposure to each language); controlling these variables in research studies necessitates large numbers of bilingual participants. The frequency and types of typical disfluencies in the speech of young children are also varied. In addition, stuttering is also variable in its presentation, and when we assess bilingual children for the presence of stuttering we are adding yet another layer of complexity. This article reviews research on typical disfluencies in monolingual and bilingual speakers, and how this information might be useful clinically. We provide examples from our laboratory to illustrate how computerized language analysis (CLAN) can be used over time to track the behaviors of research participants. We also present data on the identification of stuttering in bilingual children. We discuss challenges to studying bilingual speakers and how big data initiatives such as TalkBank address these challenges to increase our understanding of bilingual fluency development.

Student self-reported communication skills, knowledge and confidence across standardised patient, virtual and traditional clinical learning environments.

BACKGROUND: Advanced communication skills are vital for allied health professionals, yet students often have limited opportunities in which to develop them. The option of increasing clinical placement hours is unsustainable in a climate of constrained budgets, limited placement availability and increasing student numbers. Consequently, many educators are considering the potentials of alternative training methods, such as simulation. Simulations provide safe, repeatable and standardised learning environments in which students can practice a variety of clinical skills. This study investigated students' self-rated communication skill, knowledge, confidence and empathy across simulated and traditional learning environments. METHOD: Undergraduate speech pathology students were randomly allocated to one of three communication partners with whom they engaged conversationally for up to 30 min: a patient in a nursing home (n = 21); an elderly trained patient actor (n = 22); or a virtual patient (n = 19). One week prior to, and again following the conversational interaction, participants completed measures of self-reported communication skill, knowledge and confidence (developed by the authors based on the Four Habit Coding Scheme), as well as the Jefferson Scale of Empathy - Health Professionals (student version). RESULTS: All three groups reported significantly higher communication knowledge, skills and confidence post-placement (Median d = .58), while the degree of change did not vary as a function of group membership (Median η (2) < .01). In addition, only students interacting with a nursing home resident reported higher empathy after the placement. Students reported that conversing with the virtual patient was more challenging than conversing with a nursing home patient or actor, and students appeared to derive the same benefit from the experience. CONCLUSIONS: Participants self-reported higher communication skill, knowledge and confidence, though not empathy, following a brief placement in a virtual, standardised or traditional learning environment. The self-reported increases were consistent across the three placement types. It is proposed that the findings from this study provide support for the integration of more sustainable, standardised, virtual patient-based placement models into allied health training programs for the training of communication skills.

Real enough: using virtual public speaking environments to evoke feelings and behaviors targeted in stuttering assessment and treatment.

PURPOSE: Virtual reality environments (VREs) are computer-generated, 3-dimensional worlds that allow users to experience situations similar to those encountered in the real world. The purpose of this study was to investigate VREs for potential use in assessing and treating persons who stutter (PWS) by determining the extent to which PWS's affective, behavioral, and cognitive measures in a VRE correlate with those same measures in a similar live environment. METHOD: Ten PWS delivered speeches-first to a live audience and, on another day, to 2 virtual audiences (neutral and challenging audiences). Participants completed standard tests of communication apprehension and confidence prior to each condition, and frequency of stuttering was measured during each speech. RESULTS: Correlational analyses revealed significant, positive correlations between virtual and live conditions for affective and cognitive measures as well as for frequency of stuttering. CONCLUSIONS: These findings suggest that virtual public speaking environments engender affective, behavioral, and cognitive reactions in PWS that correspond to those experienced in the real world. Therefore, the authentic, safe, and controlled environments provided by VREs may be useful for stuttering assessment and treatment.

Chemotherapy and targeted therapy for women with human epidermal growth factor receptor 2-negative (or unknown) advanced breast cancer: American Society of Clinical Oncology Clinical Practice Guideline.

PURPOSE: To identify optimal chemo- and targeted therapy for women with human epidermal growth factor 2 (HER2)- negative (or unknown) advanced breast cancer. METHODS: A systematic review of randomized evidence (including systematic reviews and meta-analyses) from 1993 through to current was completed. Outcomes of interest included survival, progression-free survival, response, quality of life, and adverse effects. Guideline recommendations were evidence based and were agreed on by the Expert Panel via consensus. RESULTS: Seventy-nine studies met the inclusion criteria, comprising 20 systematic reviews and/or meta-analyses, 30 trials on first-line treatment, and 29 trials on second-line and subsequent treatment. These trials form the evidence base for the guideline recommendations. RECOMMENDATIONS: Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor-positive metastatic breast cancer unless improvement is medically necessary (eg, immediately life-threatening disease). Single agent is preferable to combination chemotherapy, and longer planned duration improves outcome but must be balanced against toxicity. There is no single optimal first-line or subsequent line chemotherapy, and choice of treatment will be determined by multiple factors including prior therapy, toxicity, performance status, comorbid conditions, and patient preference. The role of bevacizumab remains controversial. Other targeted therapies have not so far been shown to enhance chemotherapy outcome in HER2-negative breast cancer.

Brief report: treating stuttering in an adult with autism spectrum disorder.

Stuttering and autism can co-occur and when they do it presents a significant communication challenge. This study examined the effectiveness of a modified version of the fluency rules program (FRP; Runyan and Runyan, Stuttering and related disorders of fluency, in 2007) to reduce stuttering frequency in a man with autism spectrum disorder (ASD). The participant's percentage of stuttered words (%SW) was calculated during conversational interactions with multiple conversation partners both within and outside of the clinic treatment sessions. Visual inspection methods revealed a reduction in %SW from an average of 14.5 %SW during baseline to 2.07 %SW during the withdrawal phase. The mean baseline reduction in %SW from baseline to the second treatment phase was 91.8 %. The FRP holds promise for reducing %SW in persons with ASD who stutter.

Formative feedback, rubrics, and assessment of professional competency through a speech-language pathology graduate program.

Professional competencies independent of discipline-specific knowledge and skills are addressed by most allied health professions. This paper presents the process of developing and testing a Graduate Student Development Profile (GSDP) in rubric format. In addition to documenting behaviors, a rubric system provides formative feedback helpful to student learning and development as a professional. A rubric for rating responsibility for learning, critical thinking, cognitive flexibility, professionalism, and communication, each with specific subcategories, was created, developed, and implemented by faculty and clinical staff to guide the three sequential evaluations each master's level student receives during the five-semester speech-language pathology program. Pilot scoring of master's students was used to calibrate and refine the GSDP before official implementation. Two evaluations were completed during faculty meetings to familiarize users with the GSDP. A third evaluation was conducted via a secured website. In each case, resulting scores and specific comments for each student were shared during a faculty meeting before being presented to students individually. The GSDP documents the speech-language pathology student's professional competency demonstrated across academic, clinical, and interpersonal settings. The web-based version brings convenience and efficiency to the often formidable, but fundamentally necessary, process of providing formative and summative feedback to students.

Public speaking attitudes: does curriculum make a difference?

In light of infamous levels of fear associated with public speaking, businesses are training staff in communication effectiveness and universities are requiring courses in public speaking. A variety of approaches to individual training are available, but few studies have assessed effectiveness of group instruction, as in academic curricula. The specific purpose of this study was to compare changes in scores on measures of self-perceived confidence, competence, and apprehension associated with public speaking after two types of courses: one focused on knowledge of the vocal mechanism and mastering vocal characteristics (pitch, volume, rate, quality), and one addressing general communication theory and public speaking. Seventy-one undergraduate students enrolled in "Voice and Diction" at George Washington University (GWU) and 68 enrolled in "Fundamental Speech" at Florida State University completed questionnaires before and after the courses. Scores on Self-Perceived Communication Competence Scale, Personal Report of Confidence as a Speaker, and Personal Report of Communication Apprehension-24, were compared within subjects (ie, prepost course) and between courses. Significant differences (p<0.05) were found on all measures: students reported less apprehension and more confidence and competence after the courses. No differences were found between the two courses when comparing the mean changes from pre- to postscore. Traditional public speaking curriculum of how to design and deliver a speech and curriculum tailored to the voice and speech mechanism succeeded in reducing public speaking apprehension and increasing feelings of confidence and competency for these undergraduate students.

Comparing judgments of stuttering made by students, clinicians, and highly experienced judges.

PURPOSE: The purpose of this study was to compare judgments of stuttering made by students and clinicians with previously available judgments made by highly experienced judges in stuttering. METHOD: On two occasions, 41 university students and 31 speech-language pathologists judged the presence or absence of stuttering in each of 216 audiovisually recorded 5-s intervals of the speech of adults who stutter. Intrajudge and interjudge agreement were calculated, and comparisons were made to judgments previously made about the same recordings by 10 highly experienced judges of stuttering. RESULTS: Students and clinicians showed similar and relatively high levels of intrajudge and interjudge agreement, but both students and clinicians identified less than half as much stuttering as the highly experienced judges had identified. CONCLUSIONS: These results replicate previous findings of high agreement coexisting with low accuracy in students' judgments of stuttering, extending those findings to show that similar problems are evident in judgments made by practicing clinicians. Implications include the need for explicit stuttering judgment training programs for both students and practicing clinicians. EDUCATIONAL OBJECTIVES: After reading this article, the reader will be able to: (1) describe different methods for identifying stuttering and possible problems associated with each method; (2) describe two different methods for reporting interjudge reliability; (3) describe how the identification of stuttering differs for student, clinician, and highly experienced judges.

Frequency of stuttering during challenging and supportive virtual reality job interviews.

UNLABELLED: This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals' time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants' subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed. EDUCATIONAL OBJECTIVES: After reading this article, the reader will be able to-(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.

An analysis of clinicians' verbal behaviors in a community reintegration program for traumatic brain injury survivors.

The authors present an analysis of clinician verbal behaviors in the Community Reintegration Program, a treatment program for traumatic brain injury survivors. Experienced clinicians from different allied health professions were videotaped as they provided group treatment. Each clinician's verbal behaviors were coded using an adaptation of the Clinical Interaction Analysis System, a reliable system for describing verbal behaviors. Clinicians then participated in a structured interview with the investigators; during the interview, clinicians reviewed their treatment tape and stated what treatment goals they were working on during each utterance. The majority of the clinicians' behaviors fell into two categories: clinician-initiated discourse and explanation. Chi-square analyses revealed that these two categories occurred significantly more frequently than other coded categories. These two verbal codes predominated regardless of the goal being addressed and regardless of the professional background of the treating clinician.