Stuttering intervention in children: an integrative literature review

Rojas Contreras, Daniela; Saavedra Rojas, Pamela; Aravena Gallardo, Sergio Luis

doi:10.1590/1982-0216/20222427521

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REVIEW ARTICLES • Rev. CEFAC 24 (2) • 2022 • https://doi.org/10.1590/1982-0216/20222427521 copy

Stuttering intervention in children: an integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

to describe intervention methodologies implemented in recent years in stuttering children.

Methods:

a search was performed for empirical articles on interventions in stuttering children aged 2.5 to 7 years. The search was carried out in Embase, WOS, Pubmed, and Scopus, considering articles published between January 2014 and June 2020.

Literature Review:

11 articles were selected out of the 1,099 retrieved. Different approaches were observed, of which the Lidcombe program showed the most evidence. Most studies were conducted on English-speaking children and participants were assessed regarding linguistic and non-linguistic aspects. All studies considered parental involvement in the intervention. No investigation took measurements for more than 24 months. Individual interventions predominated.

Conclusion:

good therapeutic results were found in all reviewed interventions. Research comparing two types of treatments did not find one to be superior to the other.

Keywords:
Stuttering; Child, Preschool; Therapeutics; Childhood-Onset Fluency Disorder; Speech Disorders

	Embase	WOS	PubMed	SCOPUS
(Infant OR Child OR pediatrics) AND (Stuttering) AND (Therapeutic OR rehabilitation)	25, 26, 27		12, 13, 26, 27, 28, 29, 30, 31, 32	13, 27, 29
Other sources	33

Authors (Year) Language	Objective	Participants	Assessment	Number and moment of assessments
Arnott et al. (2014)²⁷ English	To investigate the effectiveness and efficiency of the standard LP treatment in comparison with the group approach to the same program.	54 children randomly allocated into 2 groups: - Control group (individual approach): 27 children: 10 were 3.0 - 3.11 years, another 10 were 4.0 - 4.11 years, and 7 were 5.0 - 5.11 years old. - Experimental group (group approach): 27 children: 13 were 3.0 - 3.11 years, 12 were 4.0 - 4.11 years, and 2 were 5.0 - 5.11 years old. The group approach had a rotating design so there were three parent-child pairs per group visit.	- The professional’s hours per child by stage 2. - Number of visits to the clinic and weeks until stage 2. - %SS obtained from two 10-minute speech samples. - Parent-reported SR. - Final questionnaire: at the end of stage 1, the parents answered a questionnaire on their experience with the treatment and satisfaction with the service. They classified the items on a 9-point scale, in which 1=totally disagree and 9=totally agree. They could also write down additional comments.	Three moments: Before randomization, 9, and 18 months after randomization.
Donaghy et al. (2015)²⁶ English	To observe the contribution of parental self-correction verbal contingencies in LP. 38 pairs distributed into 2 groups: - Experimental group: 19 parent-child pairs receiving LP, but with no self-correction verbal contingencies. - Control group: 19 parent-child pairs receiving LP as proposed. Children were 2.10 to 5.10 years old. - Number of visits to the clinic. - Number of weeks taken to reduce stuttering by 50%. - %SS. - SR. Three moments: initial, when %SS had decreased by 50% when progress had been observed for 3 consecutive weeks.
de Sonneville- Koedoot, Stolk et al. (2015)¹² Dutch	To compare the effectiveness of LP direct treatment with RESTART-DCM indirect one in stuttering preschoolers in an 18-month follow-up.	199 children randomly allocated into 2 groups: - LP treatment: 98 children; 41 were 3 years, 39 were 4 years, and 18 were 5 to 6 years old (one child was 2.11 years at inclusion). - RESTART-DCM treatment: 100 children; 37 were 3 years, 31 were 4 years, and 32 were 5 to 6 years old.	- Percentage of children who did not stutter 18 months after beginning the therapy. - %SS. - SR (8-point scale). - Professional- and child-reported stuttering severity rate (8-point scale for professionals and 4-point scale for children). - Parental assessment of their children’s health-related quality of life - Children’s attitude toward speech (KiddyCAT). - Emotional and behavioral problems (Child Behavior Checklist)	Five moments: At the beginning of the study, 3, 6, 12, and 18 months after beginning the treatment.
Guitar et al. (2015)³³ English	To investigate the duration and results of LP applied to a new sample and compare it to the original sample published by Miller and Guitar (2009). To investigate predictive factors of the duration and results of LP, combining data from both samples.	29 children divided into 2 groups: - New sample: 14 children aged 3.4 to 6.2 years. - Original sample: 15 children aged 2.5 to 5.9 years.	- %SS. - Stuttering severity instrument-3 (SSI-3)	Three moments: Pretreatment, during the treatment, and in the long run, approximately 2 years after finishing LP stage 1 (median of 26 months).
de Sonneville-Koedoot, Bouwman et al. (2015)³⁰ Dutch	To determine the incremental cost-effectiveness and cost-utility of LP in comparison with RESTART-DCM for stuttering preschoolers.	199 children randomly allocated into 2 groups: - LP treatment: 98 children; 41 were 3 years, 39 were 4 years, and 18 were 5 to 6 years old (one child was 2.11 years at inclusion). - RESTART-DCM treatment: 100 children; 37 were 3 years, 31 were 4 years, and 32 were 5 to 6 years old.	- %SS obtained from 3 conversational speech samples. - NNT: mean number of patients who need to be treated for one patient to be benefitted. - Health-related quality of life. - Direct and indirect costs measured with cost questionnaires.	Five moments: At the beginning of the study, 3, 6, 12, and 18 months after beginning the treatment.
McCulloch et al. (2016)²⁹ English	To compare LP treatment in children that attended a student-led clinic with previously published references regarding LP treatment not conducted in a student-led clinic.	40 patients.	- %SS - SR - Duration of the therapy.	Two moments: Initial and final assessment.
Bridgman et al. (2016)³¹ English	To compare LP results in in-person visits and teletherapy in early stuttering.	49 children randomly allocated into 2 groups: - Clinic: 24 children aged 3.1 to 5.11 years. - Teletherapy: 25 children aged 3.0 to 5.5 years.	- %SS - SR	Three moments: Pretreatment, 9, and 18 months after beginning LP treatment.
Sawyer et al. (2017)³² English	To investigate the effects of training on reducing the AR of caregivers of stuttering children, on the dysfluency of the children, on the AR of children and caregivers, and the RLT of children and caregivers.	17 mother/father-child pairs. The children were 31 to 66 months old.	- Percentage of stuttering dysfluencies in children per 100 syllables was assessed. - AR measured in syllables per second. - Latency time. - In home interaction, parents were expected to record the date, description of the activity, and comments or feelings.	Three moments: At the beginning of the first session, a sample of the caregiver-child interaction was taken. In the third session, samples of caregiver-child interactions were taken - for the first one, in the beginning, they were asked to “interact as usual”; then, after feedback on this interaction, they were asked to talk slowly and relaxed for the second sample.
Ferdinands et al. (2018)²⁸ English	To determine whether stuttering severity correlates with parental satisfaction with their children’s fluency in LP treatment. To demonstrate that parental satisfaction is not smaller in either teletherapy or in-person therapy in LP clinic.	49 children randomly allocated into 2 groups: - Clinic: 24 children aged 3.1 to 5.11 years. - Teletherapy: 25 children aged 3.0 to 5.5 years.	- %SS - SR - Parental satisfaction with child fluency (PSCF), based on the answer to the question: “Are you satisfied with your child’s current level of fluency?”. The answers were measured on a 10-point Likert scale.	Three moments: Pretreatment, 9, and 18 months after beginning LP treatment.
Millard et al. (2018)¹³ English	To explore the effectiveness of the Palin PCI therapy in a large cohort of stuttering children	48 children aged 2.5 to 7 years.	- %SS. - The children’s communicative attitudes (KiddyCAT). - Parental perception of stuttering and degree of impact with Palin parental rating scale.	Four moments: At the beginning of the therapy, 3, 6, and 12 months after beginning the therapy.
Druker et al. (2019)²⁵ English	To explore the effects of approaching self-regulation as a component in stuttering treatment on both the children’s fluency and the parents’ and children’s psychosocial results.	28 pairs distributed into 2 groups: - Experimental group: 14 caregiver-stuttering child pairs, who received fluency therapy with a resilience component. The children were 3 to 6 years old, with a mean of 4.25 years. - Control group: 14 caregiver-stuttering child pairs, who received only the fluency therapy. The children were 3 to 6 years old, with a mean of 4.44 years.	- Stuttered Severity Rating for children. - Parenting and Family Adjustment Scales for parents, though it analyzes both parents and children. - The Parenting and Family Adjustment Scales applied to parents. - The effortful control subscale - Curtin Early Childhood Stuttering Resilience Scale.	Two moments: Pre- and post-treatment.

Authors (Year) Language	Treatment/program or methodology employed	Individual/ group	Frequency	Conclusion/results
Arnott et al. (2014)²⁷ English	Lidcombe program In group LP (adapted), the groups had up to 4 children with their parents in weekly visits, as in standard LP. Before attending the first group visit to the clinic, the children and parents in this group attended an individual preliminary training session. In treatment stage 2, clinical visits were individual for all participants.	Individual and group	Each clinic visit lasted 45 to 60 minutes for both study groups. Both groups had a median of 18 clinic visits until stage 2. The control group took a median of 25 weeks, and the experimental group, 29 weeks until stage 2.	Group LP treatment is an effective alternative to the individual model. Results showed that children treated in groups needed half the professional’s hours to complete stage 1 than those treated individually. Parents responded favorably to the group model; professionals who applied the treatment found it more tiresome, but also more gratifying.
Donaghy et al. (2015)²⁶ English	Lidcombe program	Individual	The control group took a median of 11 clinic visits and 13 weeks, and the experimental group took a median of 9 visits and 11 weeks to decrease stuttering by 50%, with no statistical differences between the groups.	All participants in both the study and control groups reduced stuttering by 50%, which was stabilized or further reduced after 3 weeks. This study showed no significant differences in the number of clinic visits and weeks taken to reduce stuttering by 50% in both study groups.
de Sonneville-Koedoot, Stolk et al. (2015)¹² Dutch	Lidcombe program RESTART-DCM	Individual	- LP: the treatment of the 98 children lasted a mean of 22.2 sessions (standard deviation: 11.2; median: 21). -RESTART-DCM: the treatment of the 97 children lasted a mean of 19.5 sessions (standard deviation: 10.3; median: 17).	The direct treatment decreased stuttering faster in the first 3 months of intervention, though the difference was no longer significant by 18 months. LP had slightly better scores in most of the other secondary result measures, though with no significant differences between the treatment focuses. By 18 months of follow-up, both treatments are approximately equal in developmental stuttering intervention; both are commendable.
Guitar et al. (2015)³³ English	Lidcombe program	Individual	LP clinic visits to complete stage 1 ranged from 4 to 32, with a mean of 16.8 and a median of 15 visits.	Stuttering frequency decreased significantly from pretreatment to 2 years after beginning the treatment. Children with more frequent and severe stuttering take longer in LP. Pretreatment %SS and sex are long-term statistical predictors of stuttering treatment results. LP effectiveness is independent of the research being carried out by the developers of the program.
de Sonneville-Koedoot, Bouwman et al. (2015)³⁰ Dutch	Lidcombe program RESTART-DCM	Individual	During the 18-month follow-up: - The LP group had a mean of 22.2 treatment sessions (98 children). - RESTART-DCM group had a mean of 19.5 treatment sessions (97 children).	Effect and cost differences between LP and RESTART-DCM were small, slightly in favor of LP - which is a good alternative to RESTART-DCM in Dutch primary healthcare.
McCulloch et al. (2016)²⁹ English	Lidcombe program	Individual	Stage 1: Median of 19 visits in 25 weeks. stage 2: Median of 7 visits (ranging from 1 to 22) in 45.5 weeks (ranging from 16 to 120).	No differences were reported in patients who completed LP stage 1 regarding the decrease in stuttering severity or the severity scales. Stage 1 lasted slightly longer for patients who received the treatment in the student-led clinic.
Bridgman et al. (2016)³¹ English	Lidcombe program	Individual	- Clinic: median of 25 weeks and 23 sessions to complete stage 1 (37 children). - Teletherapy: median of 25 weeks and 20 sessions to complete stage 1 (37 children).	In pretreatment, stuttering severity was similar in both groups; after 9 and 18 months, no difference in severity was found between them (%SS). SR is associated with the number of sessions, which increases by 13% for each unit of severity in the LP scale. There is no difference in the number of clinic visits and weeks to complete LP stage 1, which is equally effective and economically feasible in clinic and teletherapy. However, there was a significant difference in session duration (in minutes) by 18 months; the teletherapy group took 17% less time than the clinic group.
Sawyer et al. (2017)³² English	The therapist instructed caregivers to use slow and relaxed speech, elongating vowels while maintaining suprasegmental patterns. First, a model was given for caregivers to imitate, practicing through reading and conversation, to continue doing so as they played with the children. Then, the therapist gave the necessary feedback. Caregivers were asked to continue the activity at home.	Individual	One 1-hour session a week for 3 weeks in the clinic. Caregivers were to practice at home 3 to 5 times a week, 5 to 10 minutes at a time. It was practiced a mean of 6.7 times a week.	Caregivers decreased their AR after training. Most children increased their fluency measured in % of stuttering dysfluencies in the last two samples. No statistically significant relationship was found between garegivers’ reduced AR and children’s decreased stuttering dysfluencies. Neither is there a significant relationship between AR and RLT.
Ferdinands et al. (2018)²⁸ English	Lidcombe program	Individual	- Clinic: median of 25 weeks and 23 sessions to complete stage 1 (37 children). - Teletherapy: median of 25 weeks and 20 sessions to complete stage 1 (37 children).	Parental satisfaction with their children’s fluency is parallel to decreased severity. Teletherapy is not different from clinic sessions in terms of effectiveness and efficiency; the same tendency was found for both methods regarding decreased stuttering severity and increased parental satisfaction with their children’s fluency.
Millard et al. (2018)¹³ English	Palin PCI therapy	Individual	One session per week in the clinic, for 6 weeks; then, 6 weeks for home bonding with parents.	All variables had improved results, which were maintained 1 year after the treatment.
Druker et al. (2019)²⁵ English	Beilby stuttering therapy Curtin Early Childhood Stuttering Resilience Program	Individual	23 children with 12 sessions in 12 uninterrupted weeks; 3 children with 12 sessions in 13 weeks; and 1 child with 12 sessions in 14 weeks.	Stuttering severity decreased in both treatment groups. Emotional and behavioral problems decreased, and resilience increased in stuttering children whose parents received the additional resilience component in therapy. A significant improvement in parental practices was found in this group. No changes in emotional and behavioral problems were found in children of the group that received only fluency therapy.

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[1] Corresponding address: Daniela Rojas Contreras, Avenida Independencia 1027, Independencia, Código Postal: 8380453 - Santiago, Chile, E-mail: daniela.rojas.c@uchile.cl