LSHSS

Research Article

Webcam Delivery of the Camperdown Program for Adolescents Who Stutter: A Phase II Trial Brenda Carey,a Sue O’Brian,a Robyn Lowe,a and Mark Onslowa

Purpose: This Phase II clinical trial examined stuttering adolescents’ responsiveness to the Webcam-delivered Camperdown Program. Method: Sixteen adolescents were treated by Webcam with no clinic attendance. Primary outcome was percentage of syllables stuttered (%SS). Secondary outcomes were number of sessions, weeks and hours to maintenance, self-reported stuttering severity, speech satisfaction, speech naturalness, self-reported anxiety, self-reported situation avoidance, self-reported impact of stuttering, and satisfaction with Webcam treatment delivery. Data were collected before treatment and up to 12 months after entry into maintenance. Results: Fourteen participants completed the treatment. Group mean stuttering frequency was 6.1 %SS (range, 0.7–14.7) pretreatment and 2.8 %SS (range, 0–12.2)

12 months after entry into maintenance, with half the participants stuttering at 1.2 %SS or lower at this time. Treatment was completed in a mean of 25 sessions (15.5 hr). Self-reported stuttering severity ratings, self-reported stuttering impact, and speech satisfaction scores supported %SS outcomes. Minimal anxiety was evident either pre- or post-treatment. Individual responsiveness to the treatment varied, with half the participants showing little reduction in avoidance of speech situations. Conclusions: The Webcam service delivery model was appealing to participants, although it was efficacious and efficient for only half. Suggestions for future stuttering treatment development for adolescents are discussed.

A

(Blood & Blood, 2007; Langevin et al., 1998) that can potentially have long-term detrimental effects. Unsurprisingly, adolescents who stutter also show negative attitudes toward themselves as communicators (Blood, Blood, Tellis, & Gabel, 2003) and have a perceived lower quality of life (Beilby, Byrnes, & Yaruss, 2012). Such early negative conditioning is known to lead to psychiatric and social anxiety problems later in life (Gega, Kenwright, Mataix-Cols, Cameron, & Marks, 2005); therefore, adolescents who stutter have increasing vulnerability to developing psychological conditions as they approach adulthood. A recent study (Gunn et al., 2014) demonstrated that older adolescents seeking treatment for their stuttering, at least on some measures, appear to be more susceptible to experiencing higher levels of social anxiety and depression, although not necessarily to clinically significant levels. Therefore, it is critical for adolescents who stutter to have access to treatment to reduce their stuttering before these complications develop. Stuttering reduction may reduce the likelihood of negative peer reactions; may foster more positive attitudes toward communication; and perhaps most importantly, has the potential to prevent the development of

dolescence is a developmental stage during which there is an increasing reliance on the peer group, a strong drive to conform to group norms, and a high perceived need to “fit in” (Coleman & Hendry, 1999; Heaven, 2001). Stuttering, however, makes adolescents different. This difference can make them vulnerable to negative peer attitudes (Craig, Tran, & Craig, 2003; Doody, Kalinowski, Armson, & Stuart, 1993; Flynn & St. Louis, 2011; Hughes, Gabel, Irani, & Schlangheck, 2010; Van Borsel, Brepoels, & De Coene, 2011) and negative social consequences (Blood & Blood, 2004, 2007; Davis, Howell, & Cooke, 2002; Hearne, Packman, Onslow, & Quine, 2008; Hugh-Jones & Smith, 1999; Langevin, 2009; Langevin, Bortnick, Hammer, & Wiebe, 1998). Teasing and bullying are serious and yet common social consequences of stuttering

a

Australian Stuttering Research Centre, The University of Sydney, Australia Correspondence to Mark Onslow: [email protected] Editor: Marilyn Nippold Associate Editor: Ellen Kelly Received August 27, 2013 Revision received April 10, 2014 Accepted July 27, 2014 DOI: 10.1044/2014_LSHSS-13-0067

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Key Words: stuttering, adolescents, Camperdown Program, telehealth

Disclosure: The authors have declared that no competing interests existed at the time of publication.

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psychological conditions and educational and occupational underachievement.

Treatment for Adolescents Who Stutter It is critical then for speech-language pathologists (SLPs) to be equipped to treat adolescents who stutter presenting for treatment; however, few clinical trials have been designed specifically for this client group. Studies that have reported on adolescent participants typically either have small participant numbers (Bray & Kehle, 1996; Hearne, Packman, Onslow, & O’Brian, 2008; Hewat, Onslow, Packman, & O’Brian, 2006) or have combined adolescent data with those from school-aged or adult clients, making interpretation of the results difficult (Antipova, Purdy, Blakeley, & Williams, 2008; Craig et al., 1996; Cream et al., 2010; Euler, Von Gudenberg, Jung, & Neumann, 2009; Laiho & Klippi, 2007; Langevin & Boberg, 1993). One study that did not pool adult and adolescent data is a trial of the Comprehensive Stuttering Program (CSP; Boberg & Kully, 1994). The CSP involves teaching prolonged speech, cognitive and social training, selfgenerated home maintenance programs, and refresher clinics. Prolonged speech, which involves teaching a slow and drawling speech pattern that is gradually shaped to more natural-sounding speech, is an example of a speech restructuring treatment. Speech restructuring refers to a range of treatment variants that use a new speech pattern to reduce or control stuttering (Onslow & Menzies, 2010). The Boberg and Kully (1994) study included 25 adolescents ages 11 to 17 years who were treated initially in an intensive group format. The mean percent syllables stuttered (%SS) decreased from 14.3 pre-treatment to 1.8 immediately post-treatment and 3.9 at 12 months post-treatment. There are, however, some limitations to the CSP. For the adolescent, it is time intensive and necessitates taking time away from school. For the SLP, it is time consuming and costly in terms of clinician hours and clinical infrastructure. Positive outcomes for speech restructuring with adolescents have been observed in other trials, albeit with smaller numbers (Harrison, Onslow, Andrews, Packman, & Webber, 1998; Hearne, Packman, Onslow, & O’Brian, 2008; Langevin & Boberg, 1993). The available evidence to date suggests that speech restructuring is the most efficacious treatment for stuttering in adolescents (Onslow, Jones, Menzies, O’Brian, & Packman, 2012). The Camperdown Program (O’Brian, Carey, Onslow, Packman, & Cream, 2010) is one such speech restructuring treatment that may be particularly well suited to adolescents. The Camperdown Program can be implemented in a one-on-one delivery format (Carey et al., 2010), making it suitable for use within a generalist clinic or school environment. The program is also easily adapted for telehealth delivery (Carey et al., 2010; Carey, O’Brian, Onslow, Packman, & Menzies, 2012; O’Brian, Packman, & Onslow, 2008). Telehealth delivery of stuttering treatment may be an appealing approach for the treatment of adolescents who stutter. Adolescents are prolific users of the Internet: 87%

of adolescents in the United States use it for educational activities, games, and social networking (Lenhart, Arafeh, Smith, & Rankin MacGill, 2008). Not only is the Internet an integral part of their lives but it appears to be their preferred medium of communication for many activities (Desjarlais & Willoughby, 2010; Holtz & Appel, 2011). Telehealth delivery also has the advantage of making treatment available in the client’s home or school environment. In the school environment, where there is no regular SLP service or no specialist stuttering service, telehealth can enable regular access to an SLP at another school or center. Even in cases where there is an SLP service at a school, telehealth can enable access to support from an SLP who specializes in stuttering treatment. Preliminary evidence from a Phase I trial has demonstrated the viability of the Camperdown Program delivered using telehealth with adolescents who stutter (Carey et al., 2012). Three adolescents ages 13, 15, and 16 were treated with an adapted version of the Camperdown Program using Webcam software and the Internet. Adaptations included no clinic attendance, use of audio recording computer software programs to record and replay speech within sessions, and e-mail to receive participant home practice and everyday speech recordings. This study showed that the stuttering treatment delivered by Webcam produced a group mean stuttering reduction of 93% (range, 89–96) from pretreatment to 6 months post entry to maintenance and 74% (range, 50–89) from pre-treatment to 12 months post entry to maintenance. Reductions in stuttering were accomplished with a mean of 18 sessions and 11 clinician hours. The service delivery model was reportedly appealing to the participants and their parents. Adolescents reported the treatment was helpful and comfortable. Parents described the treatment as easy and convenient.

The Present Study Further evaluation of telehealth treatment for adolescents who stutter is now warranted. This article reports the outcomes from a Phase II trial of the Camperdown Program with adolescents who stutter delivered over the Internet with Webcam technology.

Method Design The design was a Phase II clinical trial with blinded outcome assessments pretreatment, on entry to the maintenance stage of treatment, and 6 and 12 months after entry to maintenance.

Participants Participants were 16 adolescent boys seeking treatment for stuttering, with a mean age of 14 years 6 months. See Table 1 for participant details. None of the participants in this study had taken part in the earlier Phase I study by Carey et al. (2012). Written informed consent to participate in the research was obtained from all participants and their

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Table 1. Demographic data for the 16 participants.

Participant 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15* 16*

Age (years)

Gender

Family history of stuttering

Previous treatment

Pre-treatment %SS

12 13 13 14 14 15 15 15 15 15 15 16 16 17 16 13

Male Male Male Male Male Male Male Male Male Male Male Male Male Male Male Male

Y N N Y N Y Y N Y Y N N Y Y Y N

Y Y Y Y N Y Y Y N Y Y Y Y Y Y Y

14.7 0.7 1.8 12.7 4.2 6.4 13.8 4.3 8.2 5.9 3.0 6.1 1.1 3.2 19.5 3.7

*Withdrew from the study before completing treatment.

parents. Inclusion criteria for the adolescents were (a) ages 12–17 years and (b) stuttering frequency greater than 2 %SS during a 10-min beyond-clinic telephone conversation with a stranger. Exclusion criteria were (a) limited functional English, and (b) treatment for stuttering during the preceding 12 months. Treatment for this study was provided by two SLPs located at two treatment sites. Both SLPs were experienced with stuttering treatment, had been formally trained with the Camperdown Program procedures, and used the Camperdown Program extensively in their clinical practice. The study was approved by the Human Research Ethics Committee of the University of Sydney.

and (4) maintenance, during which treatment gains are maintained and problem-solving skills are transferred from clinician to client. The Camperdown Program is a treatment that primarily aims to reduce stuttering. Although it does not incorporate standardized anxiety management procedures, it does allow for the introduction of anxiolytic procedures during the generalization stage if anxiety is felt to be a significant problem. The following adaptations were made for Webcam delivery to adolescents: (a) all treatment was conducted using Internet Webcam teleconferencing software, (b) e-mail was used to receive recorded participant speech samples, and (c) participants received all treatment away from the clinic.

Treatment The treatment used in this study was the Camperdown Program as described in the treatment manual (O’Brian et al., 2010), which can be downloaded from the Web site of the Australian Stuttering Research Centre. Conceptually, the Camperdown Program used in this trial was the same as previously published in-clinic reports of the treatment (Carey et al., 2010; Hearne, Packman, Onslow, & O’Brian, 2008; O’Brian, Onslow, Cream, & Packman, 2003; O’Brian et al., 2008). There are four treatment stages with performancecontingent progression: (1) individual teaching sessions, during which prolonged speech is taught from a model without reference to specific descriptors, and self-evaluation techniques for stuttering severity and speech naturalness are introduced; (2) instatement of natural-sounding, stutter-free speech, during which the fluency technique is practiced at more acceptable naturalness levels, and selfevaluation of stuttering severity and speech naturalness continue to be mastered; (3) generalization, during which a regular individualized speech practice routine is established, generalization of stutter-free speech is facilitated, and problemsolving strategies—including the introduction of cognitive– behavioral therapy strategies, if required—are developed;

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Assessments There were four assessment occasions: immediately pretreatment (A1), on entry into maintenance (A2), 6 months after entry into maintenance (A3), and 12 months after entry into maintenance (A4). Before progressing to the maintenance stage of the program, participants needed to meet specific criteria for 3 consecutive weeks. These criteria were (a) self-reported typical stuttering severity ratings of 1–2 on a 9-point scale where 1 = no stuttering, 2 = extremely mild stuttering, and 9 = extremely severe stuttering; (b) speech naturalness ratings (on a 9-point scale where 1 = extremely natural speech and 9 = extremely unnatural speech) that were acceptable to both participant and SLP throughout the treatment session; and (c) three beyond-clinic recordings of speech in different everyday situations with stuttering severity ratings of 1–2 and speech naturalness ratings acceptable to the participant. Participants also progressed to maintenance if no significant progress was made for 4–6 weeks. It is recognized that when stuttering is quite severe, strict progression criteria may not be appropriate or attainable. Such clients are often satisfied with a significant reduction in stuttering, although this

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may not meet stated progression criteria. This is in accordance with the Camperdown Program treatment manual (O’Brian et al., 2010).

Outcome Measures The primary outcome measure was %SS at A4. Secondary outcome measures were number of treatment sessions, weeks and hours to A2, self-reported stuttering severity, satisfaction with speech, speech naturalness, self-reported anxiety, self-reported situation avoidance, and self-reported impact of stuttering. Measures were collected at all assessment points except for self-reported anxiety, which was measured only at A1, A3, and A4, and Webcam treatment satisfaction, which was evaluated at A2. %SS. For each participant, %SS was calculated from two 10-min audio recordings of the participant conversing with a stranger by telephone. These telephone calls were clinic initiated and unscheduled. Participants could, therefore, neither predict nor prepare for their outcome telephone calls. The strangers were research assistants who were not involved with providing treatment to the participants. There is some evidence to suggest that visual stutters in young children will not be detected on audio recordings (Rousseau, Onslow, Packman, & Jones, 2008); however, this would be consistent across both pre- and post-treatment samples. Reliability. The recordings were de-identified and presented in random order to an SLP experienced in stuttering measurement but independent of the present trial. This observer counted unambiguous stutters and syllables in real time to determine %SS using a button-press timing and counting device. Unambiguous stutters were defined as stutters that the listener believed would be perceived as stutters by the majority of listeners and did not include normal disfluencies (Onslow, Packman, & Harrison, 2003). To assess intrajudge agreement, 12 speech samples (10%) were presented for re-analysis to the same observer 1 month later. These samples were chosen from different participants and across different assessment occasions. Intrajudge correlation was r = .99 (mean difference = 0.4 %SS). Twelve samples were also presented to a second observer experienced in stuttering measurement but independent of the present trial. Interjudge correlation was r = .93 (mean difference = 3.4 %SS). Number of treatment sessions, weeks and hours to maintenance. The number of treatment sessions and weeks to maintenance for each participant was counted from the first treatment session until the participant met program criteria for entry into maintenance (A2). The duration of each session varied from week to week and from participant to participant. The maximum treatment time allowable was 60 min; however, if there were few issues to be discussed, particularly toward the end of Stage 3 or during Stage 4 of treatment (see manual; O’Brian et al., 2010), the session could be as short as 30 min. Treatment time was also influenced by how much or how little parents were included in the treatment, which was typically negotiated

between the parent and child. Treatment hours were calculated by adding all time spent in treatment sessions with the SLP but did not include time participants may have spent practicing on their own, or with family and friends. Self-reported stuttering severity. Self-reported stuttering severity was measured using the 9-point severity rating scale where 1 = no stuttering, 2 = extremely mild stuttering, and 9 = extremely severe stuttering. The scale has been shown to be a valid and reliable method to evaluate stuttering severity (O’Brian, Packman, & Onslow, 2004; O’Brian, Packman, Onslow, & O’Brian, 2004). At each assessment, participants were provided with eight speaking situations representative of everyday adolescent life. The situations were (1) talking with a family member, (2) talking with best friend, (3) talking in a group of friends, (4) talking with an authority figure such as a teacher, (5) verbally providing name and address, (6) giving a class presentation, (7) talking on the telephone, and (8) ordering food or drink. Participants were asked to assign a “typical” and a “worst” severity rating score to each situation. Mean typical and worst self-reported severity ratings were calculated for each participant for the eight situations. Speech satisfaction. Speech satisfaction was measured using a 9-point scale where 1 = extremely satisfied and 9 = extremely dissatisfied. At each assessment occasion participants were asked, “How satisfied are you with your present level of speech fluency?” Speech naturalness. Speech naturalness was measured using a modified version of the 9-point speech naturalness scale developed by Martin, Haroldson, and Triden (1984). In this version, 1 = extremely natural sounding speech, and 9 = extremely unnatural sounding speech. Listeners were three postgraduate education students who were unaware of the research question or the disorder being investigated. Two 15-s stutter-free segments were randomly selected from the recordings for each participant at A2 to evaluate speech naturalness. Samples of this duration have been shown to provide valid results for this measure (Onslow, Adams, & Ingham, 1992). Two 15-s samples were also obtained from control speakers matched for age and gender to the study participants. All control speakers spoke English as a first language and were screened for any speech disorder. Files containing digital audio recordings from participants and controls were randomly presented to the listeners with no identifying information. Listeners rated each sample using the 9-point naturalness scale. Self-reported anxiety. Anxiety was measured using The Revised Children’s Manifest Anxiety Scale: Second Edition (RCMAS-2). This is a widely used self-report measure of the level and nature of anxiety symptoms in children and adolescents (Reynolds & Richmond, 2008). The RCMAS-2 includes four subscales: Physiological Anxiety, Worry/Oversensitivity, Social Concerns/Concentration, and Lie Scale. High scores indicate a higher level of anxiety. Scores above 60 are considered “cause for concern.” Situation avoidance. Situation avoidance was measured using a three-point scale where 1 = never avoided, 2 = sometimes avoided, and 3 = usually avoided. At each

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assessment, participants were asked to rate how often they avoided each of the eight speaking situations for which they assigned stuttering severity ratings. The minimum possible score indicating no situation avoidance is 8, and the maximum score indicating high situation avoidance is 24. Self-reported impact of stuttering. The Assessment of the Child’s Experience of Stuttering (ACES: Draft Version; September 27, 2006) was used to assess the impact of stuttering and overall quality of life. The ACES is an earlier draft version of the current Overall Assessment of Speaker’s Experience of Stuttering (OASES-T; Yaruss, Quesal, & Coleman, 2010) for adolescents. The ACES was used with the authors’ permission as this study was initiated before the OASES-T was published. Similar to the OASES-T, the ACES contains four subscales: (1) General Information, (2) Reactions to Stuttering, (3) Communication in Daily Situations, and (4) Quality of Life. Scores on the four sections are used to calculate the Total Impact Score, providing a measure of the overall impact of stuttering. The minimum possible score is 20, and the maximum possible score is 100. According to the scoring guide, scores between 20.0 and 29.9 indicate mild impact, 30.0–44.9 indicate mild to moderate impact, 45.0–59.9 indicate moderate impact, 60.0–74.9 indicate moderate to severe impact, and 75 or higher indicate severe impact. Satisfaction with Webcam treatment delivery. An interview was conducted with each adolescent and parent at A2 to determine the perceived benefits and disadvantages of receiving treatment via Webcam. In order to encourage transparency, interviews were conducted by an SLP independent of the trial. A separate phone call to each adolescent and each parent was arranged at a time convenient to them. Interview questions were designed to elicit opinions about the treatment’s method of delivery, acceptability, and convenience. See Appendix A and B for interview questions for the parents and adolescents.

Data Analysis Paired t tests were used to assess the differences between group means for the relevant variables at A1 and A4. An independent means t test was used to evaluate the difference between the naturalness scores of participants and controls. Cohen’s guidelines (Cohen, 1998) were used for categorizing effect size. Cohen d values of 0.80 or more indicate a large effect, between 0.50 and 0.80 indicate a medium effect, and below 0.50 indicate a small effect.

Results Clinical Progress Although 16 participants were recruited for the trial, outcomes are reported for only 14 participants. Two participants (P15, P16) withdrew from the study prior to reaching A2. P15 withdrew after 30 sessions, when self-reported typical severity ratings were 3–4. At the time, he stated that he was already satisfied with the stuttering reduction he had achieved, despite not meeting program requirements, and

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did not want any further treatment. P16 withdrew after 10 sessions because his parent reported an inability to continue the treatment program due to the time and commitment required. At the time of his withdrawal, his selfreported typical severity ratings averaged 4.

Outcomes Percentage of syllables stuttered. Table 2 shows %SS outcomes for the 14 remaining participants across the four assessment occasions. The criterion for admission to the trial was at least 2.0 %SS during a 10-min telephone call with the SLP. The data presented in Table 2 are based on the mean for the two pretreatment stranger telephone calls, as rated by an independent researcher. Hence, some pretreatment data in Table 2 are below 2.0 %SS. However, self-rated severity scores confirm the presence of significant stuttering for these participants. There was a significant difference between the group mean %SS scores at A1 and A4, with a large Cohen effect size, t (13) = 3.99, p = .001, d = 0.80. Overall the group showed an average 68% (range, 0%–96.6%) stuttering reduction at A2 and 50% (range, 0%–89.8%) and 55% (range, 0%–100%) at A3 and A4, respectively. There was, however, significant individual variation in outcomes, with seven participants (50%) having %SS scores at or below 1.2 at A4, and three (P7, P8, and P13) showing very little change. Treatment sessions, weeks and hours to maintenance. The mean number of treatment sessions to A2 was 25 (range, 14–42); weeks to A2, 30 (range, 17–42); and hours to A2, 15.5 (range, 7.5–26.3). Self-rated stuttering severity. Table 2 shows self-rated typical stuttering severity scores for participants across the four assessment occasions. There was a significant difference between the group mean self-rated stuttering severity scores from A1 to A4, with a large Cohen effect size, t (11) = 4.91, p = .001, d = 1.42. At A2, the group mean percentage reduction for typical self-reported severity was 45% (range, 3%–73%), and at the two subsequent data points, 41% (range, 0%–65%) and 43% (range, 3%–67%), respectively. At A2, the group mean percentage reduction for worst self-reported severity score was 42% (range, 13%– 60%), and at subsequent data points, 36% (range, 0%–60%) and 45% (range, 0%–71%). These scores indicate generally consistent reduction of typical and worst self-rated severity for the participants across four assessments. Speech satisfaction. At A1, the group mean satisfaction score was 6.8 (range, 4–9), at A2 it was 2.8 (range, 2–4), at A3 it was 3.4 (range, 2–6), and at A4 it was 2.7 (range, 1–6). These scores indicate a consistent and large improvement in group mean satisfaction scores for participants across the four assessments. A t test showed that overall the group significantly improved their speech satisfaction from A1 to A4, with a large Cohen effect size, t(11) = 5.92, p = .0001, d = 1.53. Whereas 8 of 14 participants assigned satisfaction scores of 7 and above (expressing very low satisfaction) at A1, no participant assigned a

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Table 2. Mean percent syllables stuttered (%SS), mean typical self-rated stuttering severity (SR), Anxiety (RCMAS-2) scores, total avoidance scores, Impact (ACES) scores, and satisfaction scores for the fourteen participants who completed maintenance. SRa

%SS Participant

Carey et al.: Camperdown Program for Adolescents Who Stutter

P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 M

Anxiety

Avoidance

A1

A2

A3

A4

A1

A2

A3

A4

A1

A3

A4

A1

A2

A3

A4

A1

A2

A3

A4

A1

A2

A3

A4

14.7 0.7 1.8 12.7 4.2 6.4 13.8 4.3 8.2 5.9 3.0 6.1 1.1 3.2 6.2

2.1 2.4 0.8 4.2 1.7 0.5 6.9 0.9 3.6 0.2 0.3 3.1 0.9 0.9 2.0

2.5 0.2 2.1 3.6 0.6 0.7 14.2 2.0 7.8 2.9 1.0 4.2 0.5 0.9 3.1

3.5 0.0 1.2 4.9 0.9 0.5 12.2 3.2 4.8 3.5 1.2 2.3 1.2 0.1 2.8*

2.9 5.0 4.1 3.3 — 4.8 3.8 3.3 6.0 4.6 2.8 5.8 3.6 4.9 4.2

2.8 — 2.5 2.4 1.4 2.3 2.1 2.4 2.3 2.0 2.3 3.4 3.5 1.3 2.4

3.0 3.0 2.3 2.6 1.0 1.8 1.6 3.0 2.1 3.3 2.1 3.0 3.6 2.0 2.5

2.8 2.8 1.4 — — 1.6 2.9 2.0 2.0 2.2 2.2 3.4 3.1 — 2.4*

35 77 54 29 67 46 28 36 50 36 42 53 31 54 41.2

37 77 45 34 53 28 28 36 36 39 44 41 31 38 37.7

35 77 45 29 29 33 33 36 50 39 48 44 27 30 36.8

15 18 17 9 19 21 16 14 14 15 17 17 9 13 15.3

11 16 11 16 15 11 10 12 8 15 14 18 8 10 12.5

16 17 11 12 10 11 12 11 9 14 12 23 11 8 12.6

14 12 13 — — 11 9 9 8 17 13 20 9 — 10.9*

42 82 79 38 81 75 52 57 57 57 55 56 46 65 60.1

32 61 28 39 55 50 33 43 41 46 46 51 38 46 43.5

27 75 27 37 45 42 34 40 34 42 35 49 40 26 39.5

25 62 34 — — 35 35 36 36 53 44 51 39 — 40.9*

5 9 5 4 9 8 8 7 7 9 5 6 5 8 6.8

2 3 3 4 3 3 2 3 3 3 2 3 3 2 2.8

2 3 2 4 — 4 4 3 4 4 3 6 4 2 3.4

1 1 3 — — 2 1 3 3 5 2 6 3 — 2.7*

Note. Em dash denotes missing data. a

Satisfactionb

Impact

1 = no stuttering; 9 = extremely severe stuttering. b1 = extremely satisfied; 9 = extremely dissatisfied. *Statistically significant ( p < .05).

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similar score at any post-treatment assessment. All but one participant (P12) were more satisfied with speech at A4 compared with A1. Participant 12 was as satisfied with his speech at A4 as at A1. Although participant satisfaction scores improved and were maintained after treatment, the wide range in satisfaction scores across participants continued across the four assessments. Speech naturalness. The group mean speech naturalness score for participants was 3.8 (range, 1.5–6.3) and for the matched controls, 3.1 (range, 1.5–6.5). The result was not significant, t(26) = 1.26, p = .22, d = 0.47. Mean listener naturalness scores for 11 of the 14 participants were within the range of the three listener naturalness scores assigned to their matched controls. The other three had scores that were slightly higher. Interestingly, nine of the stuttering participants achieved speech naturalness scores greater than 3, but so did five of the matched controls. Self-reported anxiety. RCMAS-2 scores across the four assessment occasions are shown in Table 2. Only two participants (P2 and P5) had pretreatment anxiety scores indicative of a problem (>60). Only one of these participants (P2) maintained elevated anxiety scores at subsequent assessments. He was referred for additional assessment by a psychologist but resolutely refused further help. By contrast, P5 was also referred for psychological assessment and followed through with this support. The group mean total anxiety score at all assessments was well within the acceptable range. A t test showed no significant difference between anxiety scores from A1 to A4, t(13) = 1.81, p = .09, d = 0.32. Situation avoidance. Situation avoidance scores across the four assessment occasions are shown in Table 2. At A1, all participants avoided at least one situation “sometimes,” and almost half the participants had moderately high situation avoidance scores (>16). A t test showed that overall the group significantly reduced their situation avoidance scores from A1 to A4, with a large Cohen effect size, t(10) = 2.86, p = .02, d = 1.16. However, at A2, two participants (P2 and P12) had retained their moderately high scores, and one participant (P4) had increased his avoidance scores. At A4, there were two participants (P10 and P12) with scores greater than 16. Self-reported impact of stuttering. ACES scores across the four assessment occasions are shown in Table 2. Impact of stuttering for the group pretreatment was rated as moderate to severe, with 12 of the 14 participants indicating at least a moderate (>45) degree of impact. By A4, only three participants had scores in this range. A t test showed a significant reduction in group mean impact scores from A1 to A4, with a large Cohen effect size, t(10) = 4.72, p = .001, d = 1.21, and a reduction in classification from moderate-to-severe to mild-to-moderate. Satisfaction with Webcam treatment delivery. Fourteen participants and their parents were interviewed; however, due to technical problems with one recording, data are reported for only 13. Parents commented that not needing to travel to a clinic was convenient. This reduced the amount of time they needed to take off work and the

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amount of time their child needed to take off school. Most parents noted that their child appeared to enjoy receiving treatment by Webcam. Parents reported this was due to the novelty and appropriateness of the delivery medium, the child’s familiarity and enjoyment using computers, not needing to travel to a clinic, and being in a familiar and comfortable environment in contrast to a clinic setting. Approximately one third of the parents thought the medium of delivery encouraged their child to take responsibility for treatment. All parents felt sufficiently included in the treatment. Just over half the parents commented that receiving treatment over Webcam did not affect their ability or their child’s ability to develop a relationship with the SLP. If their child needed treatment again in the future, the majority of parents expressed a preference for Webcam over inclinic treatment. They reported no disadvantages to the Webcam delivery relative to in-clinic delivery. The adolescents viewed receiving their treatment over Webcam as easy, convenient, and comfortable. In particular, most liked not needing to travel to receive their treatment. Fewer than half the adolescents expressed a preference to meet their SLP in person. Although not viewed as a disadvantage to the treatment process, for those who would have liked to meet their SLP in person, the main theme that emerged was that in-clinic contact may have facilitated getting to know the SLP better. Additionally, two participants suggested seeing the SLP a few times in person may have provided a more real-life opportunity to practice their speech technique. The majority of adolescents experienced no difficulty using the software programs. The majority expressed a preference for Webcam delivery in the event of requiring further treatment in the future. The only disadvantage reported by the adolescents was occasional technical difficulties.

Discussion Outcomes This Phase II trial investigated outcomes for the Webcam delivery of the Camperdown Program for adolescents who stutter. As a group, the adolescents significantly reduced their stuttering in terms of frequency and severity, with associated reductions in situation avoidance and impact of stuttering. Not surprisingly, there was also an associated increase in satisfaction with fluency generally. Of note was that the group as a whole did not show concerning levels of anxiety pre- or post-treatment, at least as measured by the RCMAS. However, as is typical of this age group, there was considerable individual variation in outcomes. For example, one adolescent (P7) appeared to receive minimal benefit from the program in terms of objectively measured or self-reported stuttering reduction; however, he reported a significant reduction in avoidance of speaking, presumably resulting in greater communicative engagement. This was confirmed by a substantial decrease in self-reported impact of stuttering. Although several of the participants did not

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reduce their stuttering to below 1 %SS—a frequently used indicator of success—they did reduce their stuttering by more than 50% (P1, P4, P12). Such a reduction, particularly for the two adolescents with quite severe stuttering, would likely have resulted in less impairment of their ability to communicate. Of concern is the degree of potential relapse noted. Although the trial outcomes were positive for many of the participants immediately after entry into maintenance, only around half maintained their treatment gains as measured by %SS 12 months after entry into maintenance. However, this result was not supported by self-report severity measures. According to the latter measure, only two participants had not maintained or further reduced their severity 12 months later. The self-report measure may be a more valid measure of severity across many different situations and over greater periods of time; however, it is arguably open to more bias. Therefore, whether this relapse is real or an artifact of the measurement system needs further investigation. Of interest are the results of the anxiety measures that were collected before and after treatment. As noted earlier, despite evidence to show that adolescents who stutter commonly experience teasing and bullying in the school environment, there is scant evidence that this has led to the development of generalized anxiety during this period of life. The results of this trial support the finding by Gunn et al. (2014) that generalized anxiety is not a cause for concern for most adolescents who stutter. Using the RCMAS for their group of 37 stuttering adolescents pretreatment, the 12- to 14-year-old subgroup had a mean total anxiety score of 43.8, whereas the 15- to 17-year-old subgroup had a mean total anxiety score of 52.18 compared with the present study mean of 41.2 pretreatment. This is significantly below the score of 60 that indicates cause for concern. The fact that in this trial this measure showed no improvement in response to treatment can be attributed to the fact that it was not an issue in the first place. However, this finding was not entirely replicated with the avoidance scores, which give an indication of more specific social anxiety. A mean of 15.3 pretreatment implies that the participants were at least sometimes avoiding a number of speaking situations, presumably due to speechrelated anxiety. Still, it is encouraging to note though that these avoidance scores were significantly reduced in response to treatment for half the participants, and the gains were maintained for the following 12 months. The treatment delivery model—Webcam—was investigated for two reasons: first, because it could easily be adapted for use by generalist SLPs in educational, clinical, and remote settings, and second, as the medium was thought likely to be appealing to the adolescent age group. In support of the former reason, a mean of 25 treatment sessions (15.5 hr) is a significant reduction compared with group intensive programs such as the CSP. Both programs had similar outcomes, and both showed similar problems with potential relapse (Boberg & Kully, 1994). One likely strength of the CSP is the group delivery format, which previous

research has shown adolescents prefer (Hearne, Packman, Onslow, & Quine, 2008). Although the in-clinic Camperdown Program can easily be delivered in group format, it is more difficult, although not impossible, to do so with telehealth delivery. The CSP also provided ongoing support for the adolescents in the form of weekend and 5-day refresher clinics. However, strengths of the Camperdown Program include much reduced treatment time; a program that can be provided either in the school environment or after school in the home environment, in a group or individual format; program implementation by generalist SLPs, either alone or with support from more experienced SLPs; and a treatment delivery medium that has a high level of acceptance by this age group. Ultimately, a treatment needs to be acceptable for it to have utility. Interview results showed that both the adolescents and their parents found the treatment medium convenient, easy to use, and time economical. As anticipated, the adolescents liked receiving their treatment on their computers, and most expressed a preference for this delivery medium in the future. It was interesting to note that some parents also felt that it encouraged their child to take more responsibility for the treatment. Self-empowerment can only be seen as a positive ingredient in facilitating treatment outcome.

The Future of Adolescent Stuttering Treatment This trial adds to the evidence base of treatment for adolescents who stutter. It reinforces speech restructuring as a powerful technique for immediate control of stuttering but continues to highlight the well-recognized problem of relapse even after relatively short periods of time. To maintain reductions in stuttering, speech restructuring treatments require a high degree of treatment adherence. The client needs to devote time and effort to practicing an unusual speech pattern, continually evaluate their stuttering, and problem-solve to manage fluctuations in stuttering. These tasks are difficult enough for adults and are likely to be particularly challenging for adolescents who have busy schedules, sensitive to peer appraisal, and display lower treatment adherence (Coleman & Hendry, 1999; Heaven, 2001; Taddeo, Egedy, & Frappier, 2008). Further research is needed to develop or modify treatments specifically to address these issues. Ongoing refresher courses or support groups, such as those offered with the CSP, are likely to be both motivating and supportive for adolescents. Group treatment has been shown to be popular with adolescents, and this could also be provided via Webcam. Resources are needed that are relevant and appealing for this age group. This study looked at the introduction of technology as one way to do this. It seems clear that the way forward for adolescent stuttering treatment is to incorporate the use of technologies that are familiar, motivating, accessible, and convenient. Software applications for use with smartphones, tablet computers, and other mobile devices may be used to maximize treatment compliance and maintenance. Computer-based

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simulated environments or virtual world games, if developed specifically for stuttering treatment purposes, may also be helpful in replacing or augmenting part or all of the treatment components. Finally, this study did not support the routine incorporation of anxiolytic procedures along with direct speech treatment. There is no evidence yet that adolescents suffer from the debilitating mental health problems that plague adults who stutter. That is not to say that such strategies should not be introduced when and if they are needed. We are currently trialing an on-line clinician-free cognitive– behavioral therapy program specifically designed for adolescents who stutter. However, with the adolescent population, it may be prudent to routinely introduce resilience training to promote psychological well-being and to prevent the development of later mental health problems. Regardless, whether through use of technology, group treatment, ongoing maintenance sessions, or the addition of resilience training, the need for creativity and flexibility will be paramount if we are to improve our adolescent stuttering treatment processes and outcomes.

Acknowledgment This research was supported by National Health and Medical Research Council of Australia Program Grant 633007.

References Antipova, E. A., Purdy, S. C., Blakeley, M., & Williams, S. (2008). Effects of altered auditory feedback (AAF) on stuttering frequency during monologue speech production. Journal of Fluency Disorders, 33, 274–290. Beilby, J. M., Byrnes, M. L., & Yaruss, J. S. (2012). The impact of a stuttering disorder on Western Australian children and adolescents. Perspectives on Fluency and Fluency Disorders, 22, 51–62. Blood, G. W., & Blood, I. M. (2004). Bullying in adolescents who stutter: Communicative competence and self-esteem. Contemporary Issues in Communication Science and Disorders, 31, 69–79. Blood, G. W., & Blood, I. M. (2007). Preliminary study of selfreported experience of physical aggression and bullying of boys who stutter: Relation to increased anxiety. Perceptual and Motor Skills, 104, 1060–1066. Blood, G. W., Blood, I. M., Tellis, G. M., & Gabel, R. M. (2003). A preliminary study of self-esteem, stigma, and disclosure in adolescents who stutter. Journal of Fluency Disorders, 28, 143–159. Boberg, E., & Kully, D. (1994). Long-term results of an intensive treatment program for adults and adolescents who stutter. Journal of Speech and Hearing Research, 37, 1050–1059. Bray, M. A., & Kehle, T. J. (1996). Self-modeling as an intervention for stuttering. School Psychology Review, 25, 358–369. Carey, B., O’Brian, S., Onslow, M., Block, S., Jones, M., & Packman, A. (2010). Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: The Camperdown Program. International Journal of Language and Communication Disorders, 45, 108–120. Carey, B., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2012). Webcam delivery of the Camperdown Program for

322

adolescents who stutter: A Phase I trial. Language, Speech, and Hearing Services in Schools, 43, 370–380. Cohen, J. (1998). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Coleman, J. C., & Hendry, L. (1999). The nature of adolescence (3rd ed.). London: Routledge. Craig, A., Hancock, K., Chang, E., McCready, C., Shepley, A., McCaul, A., . . . Reilly, K. (1996). A controlled clinical trial for stuttering in persons aged 9 to 14 years. Journal of Speech and Hearing Research, 39, 808–826. Craig, A., Tran, Y., & Craig, M. (2003). Stereotypes towards stuttering for those who have never had direct contact with people who stutter: A randomized and stratified study. Perceptual Motor Skills, 97, 235–245. Cream, A., O’Brian, S., Jones, M., Block, S., Harrison, E., Lincoln, M., . . . Onslow, M. (2010). Randomized controlled trial of video self-modeling following speech restructuring treatment for stuttering. Journal of Speech, Language, and Hearing Research, 53, 887–897. Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic relationships between children who stutter and their non-stuttering classmates. Journal of Child Psychology and Psychiatry, 43, 939–947. Desjarlais, M., & Willoughby, T. M. (2010). A longitudinal study of the relation between adolescent boys and girls’ computer use with friends and friendship quality: Support for the social compensation or rich-get-richer hypothesis? Computers in Human Behaviour, 26, 896–905. Doody, I., Kalinowski, J., Armson, J., & Stuart, A. (1993). Stereotypes of stutters and nonstutterers in three rural communities in Newfoundland. Journal of Fluency Disorders, 18, 363–373. Euler, H. A., Von Gudenberg, A. W., Jung, K., & Neumann, K. (2009). Computer-assisted therapy for speech disfluency: The long-term effectiveness of the Kassel Stuttering Therapy (KST). Sprache-Stimme-Gehor, 33(4), 193–202. Flynn, T. W., & St. Louis, K. O. (2011). Changing adolescent attitudes towards stuttering. Journal of Fluency Disorders, 36, 110–121. Gega, L., Kenwright, M., Mataix-Cols, D., Cameron, R., & Marks, I. M. (2005). Screening people with anxiety/depression for suitability for guided self-help. Cognitive Behaviour Therapy, 34, 16–21. Gunn, A., Menzies, R., O’Brian, S., Onslow, M., Packman, A., Lowe, R., . . . Block, S. (2014). Axis I anxiety and mental health disorders among stuttering adolescents. Journal of Fluency Disorders, 40, 58–68. Harrison, E., Onslow, M., Andrews, C., Packman, A., & Webber, M. (1998). Control of stuttering with prolonged speech: Development of a one-day instatement program. In A. Cordes & R. J. Ingham (Eds.), Treatment efficacy in stuttering: A search for empirical bases (pp. 191–212). San Diego, CA: Singular. Hearne, A., Packman, A., Onslow, M., & O’Brian, S. (2008). Developing treatment for adolescents who stutter: A phase I trial of the Camperdown Program. Language, Speech, and Hearing Services in Schools, 39, 487–497. Hearne, A., Packman, A., Onslow, M., & Quine, S. (2008). Stuttering and its treatment in adolescence: The perceptions of people who stutter. Journal of Fluency Disorders, 33, 81–98. Heaven, P. C. L. (2001). The social psychology of adolescence. New York: Palgrave. Hewat, S., Onslow, M., Packman, A., & O’Brian, S. (2006). A phase II clinical trial of self-imposed time-out treatment for stuttering in adults and adolescents. Disability and Rehabilitation, 28, 33–42.

Language, Speech, and Hearing Services in Schools • Vol. 45 • 314–324 • October 2014

Holtz, P., & Appel, M. (2011). Internet use and video gaming predict problem behavior in early adolescence. Journal of Adolescence, 34, 49–58. Hughes, S., Gabel, R., Irani, F., & Schlangheck, A. (2010). University students’ explanations for their descriptions of people who stutter: An exploratory mixed model study. Journal of Fluency Disorders, 35, 280–298. Hugh-Jones, S., & Smith, P. K. (1999). Self-reports of short- and long-term effects of bullying on children who stammer. British Journal of Educational Psychology, 69, 141–158. Laiho, A., & Klippi, A. (2007). Long- and short-term results of children’s and adolescents’ therapy courses for stuttering. International Journal of Language and Communication Disorders, 42, 367–382. Langevin, M. (2009). The Peer Attitudes Toward Children Who Stutter Scale: Reliability, known groups validity, and negativity of elementary school-age children’s attitudes. Journal of Fluency Disorders, 34, 72–86. Langevin, M., & Boberg, E. (1993). Results of an intensive stuttering therapy program. Journal of Speech-Language Pathology and Audiology, 17, 158–166. Langevin, M., Bortnick, K., Hammer, T., & Wiebe, E. (1998). Teasing/bullying experienced by children who stutter: Toward development of a questionnaire. Contemporary Issues in Communication Science and Disorders, 25, 12–24. Lenhart, A., Arafeh, S., Smith, A., & Rankin MacGill, A. (2008). Writing, technology and teens. Washington DC: Pew Internet & American Life Project. Retrieved from http://www.collegeboard.com/prod_downloads/prof/community/PIP_Writing_ Report_FINAL.pdf Martin, R. R., Haroldson, S. K., & Triden, K. A. (1984). Stuttering and speech naturalness. Journal of Speech and Hearing Disorders, 49, 53–58. O’Brian, S., Carey, B., Onslow, M., Packman, A., & Cream, A. (2010). The Camperdown Program of Stuttering: Treatment manual. Retrieved from http://sydney.edu.au/health-sciences/ asrc/docs/camperdown_manual_april13.pdf O’Brian, S., Onslow, M., Cream, A., & Packman, A. (2003). The Camperdown Program: Outcomes of a new prolonged-speech treatment model. Journal of Speech, Language, and Hearing Research, 46, 933–946.

O’Brian, S., Packman, A., & Onslow, M. (2004). Self-rating of stuttering severity as a clinical tool. American Journal of Speech-Language Pathology, 13, 219–226. O’Brian, S., Packman, A., & Onslow, M. (2008). Telehealth delivery of the Camperdown Program for adults who stutter: A phase I trial. Journal of Speech, Language, and Hearing Research, 51, 184–195. O’Brian, S., Packman, A., Onslow, M., & O’Brian, N. (2004). Measurement of stuttering in adults: Comparison of stutteringrate and severity-scaling methods. Journal of Speech, Language, and Hearing Research, 47, 1081–1087. Onslow, M., Adams, R., & Ingham, R. (1992). Reliability of speech naturalness ratings of stuttered speech during treatment. Journal of Speech and Hearing Research, 35, 994–1001. Onslow, M., Jones, M., Menzies, R., O’Brian, S., & Packman, A. (2012). Stuttering. In P. Sturmey & M. Hersen (Eds.), Handbook of evidence-based practice in clinical psychology: Vol 1. Child and adolescent disorders (pp. 185–207). Hoboken, NJ: Wiley. Onslow, M., & Menzies, R. (2010). Speech restructuring. Retrieved from www.commonlanguagepsychotherapy.org Onslow, M., Packman, A., & Harrison, E. (Eds.). (2003). The Lidcombe Program of early stuttering intervention. A clinician’s guide. Austin, TX: Pro-Ed. Reynolds, C., & Richmond, B. (2008). The Revised Children’s Manifest Anxiety Scale: Second edition (RCMAS-2). Los Angeles, CA: Western Psychological Services. Rousseau, I., Onslow, M., Packman, A., & Jones, M. (2008). Comparisons of audio and audiovisual measures of stuttering frequency and severity in preschool-age children. American Journal of Speech-Language Pathology, 17, 173–178. Taddeo, D., Egedy, M., & Frappier, J. (2008). Adherence to treatment in adolescents, Paediatrics and Child Health, 13(1), 19–24. Van Borsel, J., Brepoels, M., & De Coene, J. (2011). Stuttering, attractiveness and romantic relationships: The perception of adolescents and young adults. Journal of Fluency Disorders, 36, 41–50. Yaruss, J. S., Quesal, R. W., & Coleman, C. (2010). Overall assessment of the speaker’s experience of stuttering: Ages 13–17 (OASES-T) Response form. Bloomington, MN: Pearson Assessments.

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Appendix A Post-Treatment Questionnaire for Parents Internet Webcam delivery of The Camperdown Program for adolescents who stutter We are very interested in what you thought about your child having therapy over Skype - what you liked or didn’t like about it. Please feel free to tell as much or as little as you would like. What did you like about your child having therapy over Skype? What did you not like about your child having therapy over Skype? Do you think using the computer for therapy made the therapy any more or less enjoyable for your child in any way? What were the advantages or disadvantages for you of having your child receive therapy over Skype? Did you feel you were sufficiently included in the treatment program? How would you prefer your child to receive therapy, should it be required in the future? in-clinic □ Internet /Skype □ undecided □ Any other comments you want to add?

Appendix B Post-Treatment Questionnaire for Adolescents Internet Webcam delivery of The Camperdown Program for adolescents who stutter We are very interested in what you thought about having therapy over Skype - what you liked or didn’t like about it. Please feel free to tell as much or as little as you would like. What did you like about having therapy over Skype? What did you not like about having therapy over Skype? Did using the computer for therapy make the therapy any more or less enjoyable in any way? How did you find using the programs, e.g., Skype, Audacity? Would you have preferred to meet with your clinician face to face? Were there any advantages or disadvantages to not having met your clinician face to face? How would you prefer to receive therapy, should you require it in the future? in-clinic □ Internet /Skype □ undecided □ Any other comments you want to add?

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