European Symposium
on Fluency Disorders

The purpose of this study was to experimentally investigate the behavioral correlates of emotional reactivity (positive affect, negative affect) and emotion regulation (self-speech, off-task) and their relation to speech (dis)fluency in preschool-age children who do (CWS) and do not (CWNS) stutter during emotion-eliciting laboratory procedures.  Participants completed a neutral and a frustrating task, both of which were followed by a narrative task. Results indicated that CWS exhibited more negative emotion and more self-speech than CWNS. For CWS only, emotion regulation behaviors (i.e., off-task, self-speech) were predictive of stuttering-like disfluencies produced during the subsequent narrative tasks. Findings from this study suggest that young CWS are more emotionally reactive than CWNS and that stuttering-like disfluencies are influenced by emotional processes. Overall, findings from this study support the notion that emotions are associated with childhood stuttering and likely contribute to the difficulties that at least some CWS have establishing normally fluent speech.

A metaphor of bridges will be used to explore the client - clinician relationship in stammering therapy: client and clinician as travellers and architects working together to construct a way from the troubled present to an imagined future. The presentation will begin by considering the importance and centrality of the relationship in therapy and then move to examine the points of departure for both individuals. The key foundations, structure, and parameters of the alliance will be explored in addition to the issues involved in the building and maintenance of the relationship during a change process. Finally there will be a discussion of outcomes in relation to evidence within clinical practice and what we need to learn and develop to improve our bridge building.

Fluency therapy is a mutual process between therapist and client. It requires an awareness on the part of the therapist of what a client expects the outcome of therapy to be, and a negotiation around what is feasible and what can be delivered within the limits of the therapist's skills mix. Based on my personal experiences and results from a (non-scientific) questionnaire of adults who stammer, I will outline the most common themes in the expectations of people who stammer from fluency therapy. In addition, I will present research findings about the expectations of parents of children who stammer for their child's therapy outcomes, with a particular focus on recent findings from University College London. Based on these themes, I will end by exploring what impact clients' expectations may have on the skills mix required from a qualified fluency therapist.

The present study compared implicit sequence learning in 12 persons who stutter (PWS), 12 persons with Parkinson's disease (PPD), and 12 age-matched control subjects on a nonsense-syllable serial reaction time (SRT) task.  Subjects were required to learn and identify syllables associated with spatial locations while reaction time, accuracy, fluency, and evoked response potentials (ERPs) were recorded.  Unbeknownst to subjects, locations formed a repeating eight-item sequence.  Questionnaires confirmed learning was predominantly implicit in nature for all groups. Analysis focused on stimulus-locked ERP components following the warning stimulus (S1) and also the imperative stimulus (S2).  ERP results will reveal potential differences in patterns of cortical contribution during implicit learning for PWS, PPD and matched controls.

Dynamic interaction between participants in a dialogue is described as a process of alignment of mental representations [Pickering, M. J. & Garrod, S. (2004). Toward a mechanistic theory of dialogue. Behavioral and Brain Sciences, 27, 169-226]. To this end, aspects of planning and control of behavior become distributed between speaker and listener, potentially facilitating fluency. In the present study, conversational partners will each be provided a partially complete picture, and through dialogue, will fill in missing details of each to arrive at a composite. The composite thus functions as a shared mental representation, and the process of filling in missing details mimics alignment. Evidence of alignment may include 1) priming of lexical and syntactic information and 2) a decrease in mean length of utterance. Evidence of the effects of alignment on fluency may include decreases in both 1) hesitation frequency and 2) mean pause time between turns.

It is well known that substantial reductions in stuttering and improvements in attitudes toward communication can be achieved in the short-term; however, given the high potential for relapse there is need to investigate the degree to which such improvements are maintained in the long term. The Comprehensive Stuttering Program (CSP; Boberg & Kully, 1984; Langevin et al., 2010) is a treatment program for adults and adolescents that integrates prolonged speech and cognitive-behavioural techniques. For over 25 years its short- and long-term outcomes have been evaluated.  In this presentation the need for long-term treatment outcomes will be discussed and an overview of the components of the CSP, the methods used to investigate outcomes, and the results of our outcome studies will be presented. This session will close with a discussion of a proposed model for treatment outcomes research that may be used to guide design of future outcomes investigations.

Developing a thorough understanding of the fundamental mechanisms underlying stuttering will require a theoretical framework that accounts for the disorder's primary and associated speech characteristics, and that is consistent with empirically-verified models of sensorimotor control and neural functioning. Using a neurobiologically plausible model of the neural control of movements, our research program over the last several years has involved an integrated series of theoretically-motivated, hypothesis-driven experiments. This presentation will focus on the theoretical background and empirical data from this combined neuroimaging-psychophysical program of research. Specifically, the presentation will include our most recent data regarding stuttering children and adults' auditory and somatosensory processing; sensorimotor learning of speech and nonspeech movements; feedforward versus feedback motor control strategies; and predictive aspects of movement planning and execution, including motor-to-sensory priming. The various methodologies will be presented, and the findings will be integrated in the context of contemporary insights into the neuroscience of sensorimotor control.

To investigate the lesion-symptom correlates of neurogenic stuttering, stroke-induced brain lesions of 20 patients with neurogenic stuttering and 17 control patients were compared with voxel based-lesion-symptom mapping. A comparison of the lesions of the patients with neurogenic stuttering and controls showed that multiple left-hemispheric areas were more frequently lesioned in patients with neurogenic stuttering. These areas could be localized to both grey and white matter and most of them are commonly included in neural models of speech production. These findings are consistent with the presence of a cortical-subcortical network associated with fluent speech production and indicate that stroke-induced lesions in different locations in this network may result in neurogenic stuttering. Interestingly, many of the brain regions observed to differentiate between stroke patients with neurogenic stuttering and controls are part of the cortico-basal ganglia-cortical loop which has also been implicated in developmental stuttering.

Stuttering is hypothesized to be a disorder in the timing of activation of different brain regions. Especially the inferior frontal area, which is important for speech preparation, and the motor cortex, responsible for motor execution, are suggested to be involved. Since neurophysiological techniques have exquisite time resolution (1 ms), they are excellent tools to assess this hypothesis. Although stuttering manifests during speech production, both neuroimaging and neurophysiological research also described problems during speech perception. In addition, recent speech-language research has found increasing evidence for a perception-production link. Therefore, in the present study both processes are evaluated. Through EEG, brain activity in both stuttering and fluent speaking participants is recorded during covert reading and overt speaking of single words in different conditions. Data acquisition has been finalized. Currently, ERP and source localization analyses are being performed.

The workshop focuses on the Palin Parent Child Interaction Therapy (PCI) (Kelman & Nicholas 2008) and includes the following:

1. A brief summary of the theoretical framework on which Palin PCI is based.
2. A description of the screening procedure to determine vulnerability to persistence.
3. An outline of the detailed child assessment, parent interview and formulation process.
4. The role of the therapeutic relationship.
5. Interaction strategies: the principles, the method and the use of video feedback.
6. Family strategies: how the family can support the child's fluency.
7. Child strategies: direct fluency skills.
8. The evidence base for Palin PCI: what has been done and future directions.

‍Learning outcomes: Workshop participants will gain understanding of the theory and methods of Palin PCI, with the presentation being supported by practical exercises and video demonstrations. They will also learn about the evidence base for Palin PCI (Millard, Nicholas & Cook, 2008; Millard, Edwards & Cook, 2009).

Though emotions have been studied relative to stuttering since the 1930s and have been proposed as integral components of multi-factorial models of stuttering, little research has been devoted to the psychophysiological correlates of emotions in children who stutter. In comparison with adults, children have had little experience with, and therefore learned reactions to stuttering. Thus, physiological measures of emotions in children may allow for better understanding of how emotional processes relate to stuttering. This presentation summarizes preliminary studies of psychophysiological correlates of emotion with children who stutter and their typically-fluent peers.  Studies employing electroencephalography in preschool-aged children during emotion elicitation procedures and measures of autonomic arousal prior, during, and after speech in school-aged children will be summarized.

Narrative Therapy (Epson and White, 1990) is a component of the treatment programme Free To Stutter....Free To Speak.  It is an approach which centres the people who seek our help as the experts in their own lives.  Externalization is one of the core processes of narrative therapy.  It facilitates the realisation that the person is not the problem - the problem is the problem.  Through curious questioning, a thick description of the workings of the problem is achieved.  The relationship between the problem and the person also becomes more clearly defined.  This enables the person to take action concerning their problem using their own skills, strengths and resources.  Externalizing conversations pave the way for re-authoring conversations allowing the person who stutters to identify and establish their preferred story.  This presentation describes the process of externalizing conversations.  Activities which allow audience members to experience narrative therapy are included

The most creative aspect of language is humour and it is one of the most important topics in the study of communication. Pedagogical trends in recent decades have also shifted toward the promotion of a more relaxed learning environment emphasizing ‘making learning fun'. Research has shown that children who stutter view speaking more negatively and experience more negative speech-related emotions than do non-stuttering peers. However, while practical strategies for helping children who stutter change their feelings and beliefs about stuttering are widely available, speech language pathologists feel uncomfortable targeting such goals. Strategies are needed to use in treatment that could help clinicians help children make changes. These tools could assist the child in finding a balance between modifying speech and developing and maintaining healthier attitudes and feelings. Creativity and humor are used as tools to help children ‘problem solve' and broaden perception to develop and maintain positive attitudes towards themselves and communication. Desensitization is a behavioural intervention. By using ‘humor' in stuttering therapy, the repeated pairing of a humor response with exposure to a feared stimulus gradually diminishes the feelings of anxiety evoked by the stimulus. Current research on humour and stuttering is presented .The results of a study exploring shifts in the attitude and feelings of schoolage children who stutter following a thinking skills programme are presented. The findings of this study led to a suggested model of intervention, the ‘Smart Intervention Strategy' (SIS), with school-aged children who stutter. Included in this framework is the humor component. The use of humour as a therapeutic tool is explored and the theory and rationale for its application in therapy is discussed.

The rapid emergence of developmental cognitive neuroscience as a field of study is a timely occurrence for clinician-scientists interested in pursuing research that will establish a complete understanding of the neural bases of stuttering.  Stuttering typically has its onset between the ages of 2 and 5 years old and persistence or recovery is determined within a 6 month to 3 year window from the age of onset. Despite stuttering being a childhood disorder that potentially persists across the lifespan, the majority of attempts to understand its neural underpinnings have been restricted to investigations of adults who stutter due to the methodological limitations of early neuroimaging studies. Recent advances have made it possible to track the development of human brain structure and function from early childhood through to the twilight years. This presentation will review data from investigations of brain structure and function in children and adults who stutter. Specifically, results detailing structural abnormalities in grey and white matter, as well as anomalous auditory-motor integration during speech production in children and adults who stutter will be presented.  Results will be discussed within the context of neural development and directions for future research will be suggested.

Chronic stuttering can be a debilitating condition with significant effects on quality of life as well as limitations on other aspects of functioning. Treatment can be complex and ongoing. This has implications for management for the person who stutters, their family, and speech pathologists. Service delivery challenges and restrictions, which are often imposed by management, mean that evidence based best practice often is unable to be delivered. Furthermore, the ongoing cost of treatment can limit access to ongoing and sufficient service. Emerging evidence suggests that chronic stuttering may result in anxiety and personality attributes in adults that also warrant therapeutic attention in addition to the speech. Evidence also reveals that speech pathologists are more likely to be confident and choose to work with people with disorders with which they have had experience during their education. Thus it is imperative, if we are to ensure appropriate access to treatment for people who stutter, that those with experience and expertise provide mentoring and clinical experience opportunities for emerging members of our profession. This presentation will discuss a model for doing so.