Contemporary clinical conversations about stuttering: Neurodiversity and ableism.

PURPOSE: To discuss issues about neurodiversity and ableism, and how they pertain to clinical management of stuttering, with particular reference to early childhood stuttering. METHODS: During a webinar this year, the issue emerged of how concepts of neurodiversity and ableism apply to early childhood stuttering during the pre-school years. It became apparent that this topic elicited disparate views and would be of particular interest to students of speech-language pathology. Consequently, the leaders of that webinar continued the conversation by written dialogue for the purpose of placing it on record. RESULTS: The discussants reached agreement on many points, but there was some diversity of viewpoint about how neurodiversity and ableism should apply to clinical practice with children who have recently begun to stutter.

The good, the bad, and the ugly: Unpacking the pros and cons associated with change for adults who stutter.

PURPOSE: The purpose of the current study was to document the pros and cons that adults who stutter may consider when deciding to change how they live with stuttering. METHODS: Semi-structured interviews were conducted with 11 adults who stutter and 12 speech-language pathologists who specialize in stuttering therapy. Participants were asked to identify and discuss the advantages and disadvantages of making a change to how they live with stuttering. Reflexive thematic analysis was used to generate multilevel themes. RESULTS: Meaningful units were extracted from interview transcripts to develop 37 discrete pros and 15 discrete cons. The pros of change clustered into five organizing themes: enriching one's social relationships, feeling better in social interactions, developing a healthier sense of self, gaining autonomy, and communicating easier. The cons of change clustered into three organizing themes: experiencing discomfort, expending resources, and recognizing that some things may not change. CONCLUSION: This study documented why adults who stutter may or may not seek change. Identifying the pros and cons of behavior change is an important step in understanding why some clients who stutter are ambivalent about, or resistant to, the therapeutic process.

Meet Them Where They're At: Maximizing Adolescents' Engagement in Stuttering Therapy.

Adolescents who stutter often pose a unique clinical challenge for clinicians. They are a population simultaneously striving for independence from adults and social connection with their peers at a time when social fears surge and lifelong habits take root. It is a time when they may seem "unmotivated" to learn and utilize new communication or coping skills related to stuttering. How can clinicians maximize adolescents' engagement in stuttering therapy to improve meaningful outcomes? The purpose of this article is to describe a transtheoretical approach to assessing adolescents' readiness to make positive changes to living with stuttering, and to provide motivational interviewing strategies that clinicians can employ to help propel adolescents toward personally significant change. These principles will be applied to the case study of a 14-year-old who stutters to demonstrate how clinicians can put this approach to work as they meet their adolescent clients "where they're at."

"Knowledge Without Action Means Nothing": Stakeholder Insights on the Behaviors That Constitute Positive Change for Adults Who Stutter.

PURPOSE: The aim of this study was to document the behaviors that adults who stutter (AWS) may engage in to make positive changes to living with stuttering. METHOD: We interviewed 23 key stakeholders, including 11 AWS and 12 speech-language pathologists who specialize in stuttering therapy. The semi-structured interviews began with the primary question, "If an adult who stutters was making positive changes to living with stuttering, what would they be doing?" Follow-up probing questions focused the interviews on identifying actionable behaviors that would suggest positive changes. The interviews were transcribed and qualitatively analyzed using applied and reflexive thematic analyses to develop multilevel themes. RESULTS: Meaningful units extracted from the interviews contributed to three high-order global themes: (a) noticing and adjusting physical behaviors involved in speaking, to the extent that it is personally important to do so; (b) developing neutral or positive thoughts and feelings about stuttering; and (c) participating more fully in social and professional activities, even if the person stutters or thinks they might stutter. We developed 35 low-order basic themes, which we grouped into 11 mid-order organizing themes, to richly illustrate the three global themes. CONCLUSIONS: These findings extend the ongoing discussion regarding best practices for therapy targets in stuttering intervention. We identified measurable, multidimensional actions that clinicians can integrate in their therapy plans with AWS. While these actions represent a holistic approach to making positive changes, it grants clients and clinicians space to develop individualized intentions and outcomes.

Examining the Effects of Stuttering and Social Anxiety on Interpretations of Ambiguous Social Scenarios Among Adolescents.

PURPOSE: The proclivity to construe ambiguous information in a negative way is known as interpretation bias, which has been implicated in the onset and/or maintenance of social anxiety. The purpose of this study was to examine group and individual differences in interpretation bias among young people who stutter and their typically fluent peers during the adolescent years when social fears and worries tend to escalate. METHODS: A total of 99 adolescents (13 to 19 years old) participated, including 48 adolescents who stutter (67% male) and 51 typically fluent controls (68% male). They completed a computerized vignette-based interpretation bias task in which they first read 14 short ambiguous social scenarios (half including a verbal interaction, half including a non-verbal interaction). They were then presented with four possible interpretations of each scenario including two negative interpretations (one target, one foil) and two positive interpretations (one target, one foil). Participants used a 4-point Likert scale to rate how similar in meaning each interpretation was to the original scenario. Participants also completed self-report measures of social and general anxiety, and provided a speech sample for stuttering analysis. RESULTS: There was no effect of stuttering on interpretations; the adolescents who stutter rated interpretations across both verbal and non-verbal scenarios comparably to the controls, and stuttering severity did not affect interpretation ratings. However, across groups, there was a significant effect of social anxiety such that higher social anxiety was associated with more negative interpretations, and lower social anxiety was associated with more positive interpretations. DISCUSSION: This study provides preliminary evidence that social anxiety may affect how adolescents interpret ambiguous social cues in verbal and non-verbal scenarios more than stuttering, although more research into how people who stutter process social information is warranted.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part II. Exploratory Scale Validation.

Purpose This article is the second in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. The purpose of this article was to apply and explore the validity of newly developed Transtheoretical measures for adolescents who stutter. Method The online survey was completed by a national sample of 173 adolescents who stutter between the ages of 13 and 21 years. The multipart survey included a Stage of Change scale, Decisional Balance scale, and Situational Self-Efficacy scale. Participants also completed the Overall Assessment of the Speaker's Experience of Stuttering (OASES), either the teenage or adult version depending on the participant's age, so preliminary construct validity of the new scales could be examined. Exploratory factor analyses were conducted to determine model fit and reduce the scales to the most meaningful items. External validity of the three-part survey was examined by comparing OASES scores across stage of change as well as evaluating the functional relations between the three scales. Results Adolescents' readiness to manage stuttering could be clearly described with five discrete stages, although most of the respondents reported being in the Maintenance stage. The pros of managing stuttering reliably predicted stage placement. Internal consistency of the scales ranged from good to excellent. OASES scores differed across stages of readiness in complex but predictable ways. Conclusions These findings suggest that the Transtheoretical Model fits the target behaviors involved stuttering management among adolescents. Further examination of the application of the model to validate a stage-based framework for change among individuals who stutter is warranted.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part I. Scale Development.

Purpose This article is the first in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. In this article, we describe the process of developing measures to assess stage of change (SOC) by defining behaviors of stuttering management, as well as the two primary cognitive constructs that underlie one's readiness to make behavioral change: decisional balance (DB) and situational self-efficacy (SSE). This work hinges on the ability to develop an operational definition of what it means to successfully manage or do something positive about one's stuttering. Method We used an iterative process to develop the three scales. Through qualitative analysis of key informant interview and focus group transcripts with 24 adolescents who stutter and 26 clinicians specializing in stuttering, we developed stuttering-specific SOC, DB, and SSE scales. The drafted scales were cognitively tested with nine adolescents who stutter. Results Thematic analysis yielded a three-part definition of successful stuttering management that formed the basis for the SOC scale: (a) learning and using strategies to modify speech or stuttering, (b) changing negative thoughts and attitudes regarding stuttering, and (c) talking without avoiding sounds, words, or situations. Results from this analysis support a broader view of successful stuttering management; that is, it is likely that doing so requires more than just behavior change, which has long been considered the main objective of stuttering treatment. Additional analyses yielded pros and cons of managing stuttering (62 items for the DB scale) and situations in which it is difficult to manage stuttering (39 items for the SSE scale). Conclusions Qualitative analyses provided a three-part definition of "stuttering management" and a comprehensive pool of items that would allow measurement of DB and SSE that underlie readiness to manage stuttering among adolescents. In the companion article in this two-part series, we describe the next step in scale development: exploratory scale validation of the drafted SOC, DB, and SSE scales.

Temperament is Linked to Avoidant Responses to Stuttering Anticipation.

PURPOSE: The purpose of the present study was to examine the degree to which certain temperament constructs predict individual differences in three types of behavioral responses to anticipation among children and adults who stutter (CWS and AWS, respectively): avoidance, physical change, and approach. METHODS: Participants included 64 CWS (9- to 17-years-old) and 54 AWS (18- to 50-years-old) who completed an online survey package including a temperament questionnaire (Early Adolescent Temperament Questionnaire-Revised for the CWS; Adult Temperament Questionnaire for the AWS) and the Stuttering Anticipation Scale. The data were analyzed separately for CWS and AWS using multivariate multiple regressions to assess how each temperament construct predicted avoidance, physical change, and approach responses to anticipation. RESULTS: CWS who reported higher levels of shyness were more likely to engage in avoidant behavioral responses when they anticipate an upcoming moment of stuttering. AWS who reported higher levels of orienting sensitivity were more likely to engage in avoidant behavioral responses when they anticipate an upcoming moment of stuttering. No temperament constructs predicted physical change or approach responses to anticipation among either age group. CONCLUSION: Specific aspects of temperament appear to be linked to the degree that CWS and AWS engage in avoidant behavioral responses to stuttering anticipation. These findings support the continued study of how individual differences impact the internal experience and outward manifestation of stuttering behaviors.

Attentional Bias Among Adolescents Who Stutter: Evidence for a Vigilance-Avoidance Effect.

Purpose The purpose of this study was to examine group and individual differences in attentional bias toward and away from socially threatening facial stimuli among adolescents who stutter and age- and sex-matched typically fluent controls. Method Participants included 86 adolescents (43 stuttering, 43 controls) ranging in age from 13 to 19 years. They completed a computerized dot-probe task, which was modified to allow for separate measurement of attentional engagement with and attentional disengagement from facial stimuli (angry, fearful, neutral expressions). Their response time on this task was the dependent variable. Participants also completed the Social Anxiety Scale for Adolescents (SAS-A) and provided a speech sample for analysis of stuttering-like behaviors. Results The adolescents who stutter were more likely to engage quickly with threatening faces than to maintain attention on neutral faces, and they were also more likely to disengage quickly from threatening faces than to maintain attention on those faces. The typically fluent controls did not show any attentional preference for the threatening faces over the neutral faces in either the engagement or disengagement conditions. The two groups demonstrated equivalent levels of social anxiety that were both, on average, very close to the clinical cutoff score for high social anxiety, although degree of social anxiety did not influence performance in either condition. Stuttering severity did not influence performance among the adolescents who stutter. Conclusion This study provides preliminary evidence for a vigilance-avoidance pattern of attentional allocation to threatening social stimuli among adolescents who stutter.

An exploratory factor analysis of action responses to stuttering anticipation.

PURPOSE: We previously introduced theStuttering Anticipation Scale (SAS; Jackson, E. S., Gerlach, H., Rodgers, N. H., & Zebrowski, P. M. (2018). My Client Knows That He's About to Stutter: How Can We Address Stuttering Anticipation during Therapy with Young People Who Stutter? Seminars in Speech and Language, 39, 356-370) - a non-standardized self-report measure for children, teens, and adults who stutter (CWS, TWS, AWS) that quantifies how often they engage in 25 commonly reported action responses to anticipation. The purpose of this study was to leverage the SAS to explore the factor structure of action responses to stuttering anticipation. METHODS: A total of 121 people who stutter completed the SAS online (27 CWS, 40 TWS, 54 AWS). We used exploratory factor analysis (EFA) to determine the underlying latent variables within the 25 SAS items that characterize how people who stutter respond to anticipation. RESULTS: A three-factor model was most appropriate for the data with regard to factor loadings and other model fit indices. The three factors were named: avoidance (17 items), physical change (4 items), and approach (4 items). CONCLUSION: Understanding these three types of action responses to anticipation can help guide clinical decision-making by providing a novel framework for clinicians and their clients who stutter to discuss how the client tends to respond to anticipation, and explore ways to facilitate productive responses to anticipation.

My Client Knows That He's About to Stutter: How Can We Address Stuttering Anticipation during Therapy with Young People Who Stutter?

Stuttering anticipation is endorsed by many people who stutter as a core aspect of the stuttering experience. Anticipation is primarily a covert phenomenon and people who stutter respond to anticipation in a variety of ways. At the same time as anticipation occurs and develops internally, for many individuals the "knowing" or "feeling" that they are about to stutter is a primary contributor to the chronicity of the disorder. In this article, we offer a roadmap for both understanding the phenomenon of anticipation and its relevance to stuttering development. We introduce the Stuttering Anticipation Scale (SAS)-a 25-item clinical tool that can be used to explore a client's internal experience of anticipation to drive goal development and clinical decision making. We ground this discussion in a hypothetical case study of "Ryan," a 14-year-old who stutters, to demonstrate how clinicians might use the SAS to address anticipation in therapy with young people who stutter.