The authors would like to disclose no relevant financial or nonfinancial relationships within the research described in this presentation.

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2 The authors would like to disclose no relevant financial or nonfinancial relationships within the research described in this presentation. Rachael Unicomb, PhD Candidate School of Humanities and Social Science (Speech Pathology) Faculty of Education and Arts The University of Newcastle Supervisory Team: University of Newcastle, Australia: Dr Sally Hewat (Chief Investigator) Dr Elizabeth Spencer Macquarie University, Sydney, Australia: Dr Elisabeth Harrison

3 Concurrent treatment of stuttering and speech sound disorders: Phase I trial

4 Co-occurrence of stuttering and speech sound disorder (SSD) 4 Auditory processing disorders Attention deficit disorders Voice disorders Speech sound disorders Stuttering Literacy disorders Receptive language disorders Learning disabilities Expressive language disorders.reports have indicated that phonological disorders occur in 30 40% of children who stutter compared with only 2 6% of children who do not stutter. (Nippold, 2004 p. 146)

5 Impact of disorders in isolation Stuttering: less tractable with advancing age SSDs: comprise large portion of SLP caseloads Both disorders in isolation can impact negatively on individuals Early intervention CRUCIAL for both disorders

6 Perhaps the most pressing topic for research concerns the clinical management of children who stutter and have a co-occurring phonological disorder. (Nippold, 2002 p. 107)

7 Early childhood stuttering: Evidence Treatment Approach Clinical Trial Level of Evidence The Lidcombe Program (Harrison, Wilson & Onslow, 1999; Jones et al., 2005; Jones et al., 2008; Koushik et al., 2011; Lewis et al., 2008; Miller & Guitar, 2009; Onslow, Costa & Rue, 1990; Onslow, Andrews & Lincoln, 1994; Rousseau et al., 2007; Wilson, Onslow & Lincoln, 2004) Worldwide benchmarking data available Clinical effectiveness data available 3 x phase I 4 x phase II 2 x phase III (RCTs) III Ib 3 Ib Syllable Timed Speech (Trajkovski et al., 2006; Trajkovski et al., 2009; Trajkovski et al., 2011) 2 x phase I 1 x phase II III III Parent-Child Interaction Therapy (Millard et al., 2008; Millard et al., 2009) 2 x phase I III Demands and Capacities Model (Franken et al., 2005) n/a IIb Fluency Rules Program (Runyan & Runyan, 1986) n/a III

8 Speech sound disorders: Evidence Number of Studies Treatment Approach Baker & McLeod (2011)

9 Co-occurring Stuttering and SSD: Evidence Conture, Louko & Edwards (1993): Evidence level - IIb Concurrent service delivery Indirect methods Decrease in stuttering by 15% Decrease 25% or more across phonological processes

10 The treatment of co-occurring stuttering and speech sound disorder 10 What intervention approaches are clinicians using? One paper detailing specific forms of intervention used for this caseload: Speech sound disorder Stuttering PACT Nuffied Dyspraxia Program Multiple Oppositions Metaphon Maximal Contrasts Auditory discrimination Cued Articulation Prompt Eclectic mix of approaches Indirect methods Phonological based approach Minimal Pairs Traditional Articulation Therapy Unicomb et al. (2013)

11 Service delivery Sequential Sequential or Concurrent Concurrent We just don t know enough about this group of kids. Every time these children present to you you ve got to evaluate what the right thing is to do.i d love some guidelines that helped me structure it better. Unicomb et al. (2013)

12 Service delivery: More reports Arndt & Healey (2001) Concurrent - blended and discrete goals Blood et al. (2003) Concurrent - blended Nippold (2004) Concurrent Focusing on phonological disorder may indirectly improve fluency

13 Treatment options 13 Direct Therapy Indirect Therapy Concurrent Delivery Conture, Louko & Edwards (1993) Sequential Delivery February 20, 2014

14 This study. 14 Direct Therapy Indirect Therapy Concurrent Delivery Conture, Louko & Edwards (1993) Sequential Delivery February 20, 2014

15 Research question: 15 Is it safe and viable to provide concurrent, direct treatments to young children who present with co-occurring stuttering and speech sound disorder? Phase I clinical trials examine the safety of a new treatment protocol (Onslow et al., 2008) February 20, 2014

16 Method

17 Ethical considerations This research was approved by the University of Newcastle s Human Research Ethics Committee in June, 2012 (reference H )

18 Research design Quantitative methodology Phase I clinical trial Longitudinal single case study design - level III

19 Primary outcome measures Percent syllable stuttered (%SS) Within clinic Beyond clinic Percent consonants correct Single word naming test (PCC-SW) Conversation (PCC-CS)

20 Assessment occasions Pre-treatment Entry to Stage 2 of Lidcombe Program 9 months post commencement of treatment 12 months post commencement of treatment

21 Treatment Stuttering: Lidcombe Program (Onslow, Packman & Harrison, 2003) Speech Sound Disorder: Individualised based on child s independent and relational speech sound analysis Supported by research evidence Examples - Minimal Pairs Traditional Articulation Therapy

22 Procedures First 2-3 sessions LP only Then concurrent delivery: First half of session LP Second half of session SSD Average session length 77mins Visual aids utilised

23 Typical clinic visit: Session goals Goal Set 1: Visual schedule shown to child Gather baselines/speech samples LP stage 1 session format implemented Discussion of home plan Goal Set 2: Parent/child redirected to shift in goals Review of home practice SSD therapy implemented Discussion of home plan Then reiterate entire home plan Finish with rewarding task/activity carried out by child

24 Participants Child 1 Child 2 Age at entry to study 4;7 4;1 Year of schooling Preschool Preschool Age of stuttering onset 3;8 3;0 Family history of stuttering Yes maternal grandfather No Prior SLP intervention No No

25 Results

26 Stuttering Data Child 1 Child 2 Time taken to Stage 2 LP (no. clinic visits) %SS at entry into study 4.2% 3.7% %SS at entry to Stage 2 0.9% 0.1% %SS at 9mths post entry to study 0.2% 0.1% Speech Sound Data Child 1 Child 2 PCC single word at entry to study 69.4% 77.6% PCC single word at entry to Stage % 79.1% PCC single word 9mths post entry to study Number of phonological processes at entry to study Number of phonological processes 9mths post entry to study 87% 92.5%

27 Stuttering 27 Child 1 Child %SS 6 4 %SS Pre Stage 2 9months Time in Weeks 0 Pre Stage 2 9months Time in Weeks Avg. BC WC %SS Avg. BC WC %SS February 20, 2014

28 Speech sound disorder 28 PCC Child 1 Pre Stage 2 9months Assessment Occasions SW CS PCC Child 2 Pre Stage 2 9months Assessment Occasions SW CS February 20, 2014

29 Data analysis RELIABLE CHANGE INDEX Jacobson & Truax, 1991 Assessing reliable change using 95% confidence intervals for the difference in proportions

30 Reliable change in the individual: Stuttering 30 February 20, 2014

31 Reliable change in the individual: SSD 31 February 20, 2014

32 Reliable change in the individual: SSD 32 February 20, 2014

33 Statistical significance: Stuttering Stuttering 33 Post - 9months WC %SS Pre-treatment WC %SS Reference line = no change between pre and post values (scores) February 20, 2014

34 Statistical significance: Stuttering Stuttering 34 4 Post - 9months WC %SS Worsened Improved Pre-treatment WC %SS February 20, 2014

35 Statistical significance: Stuttering Stuttering 35 4 Post - 9months WC %SS Worsened Improved Child Pre-treatment WC %SS February 20, 2014

36 Statistical significance: Stuttering Stuttering 36 4 Post - 9months WC %SS Worsened Improved Child 2 Child Pre-treatment WC %SS February 20, 2014

37 Statistical significance: SSD Improved Speech Sound Disorder 110 Improved Speech Sound Disorder 100 Post - 9months PCC-SW Child 1 Child 2 Worsened Post - 9months PCC-CS Child 2 Child 1 Worsened Pre-treatment PCC-SW Pre-treatment PCC-CS February 20, 2014

38 Summary Based on clinical data: Both participants showed clinical improvements in all measures (%SS, PCC-CS, PCC-SW) Statistically significant improvement in both measures

39 Implications and future directions Safe and viable No exacerbation of either disorder Preliminary results prompting the need for more research in this area Next step phase 2 clinical trial (aim to establish treatment effect)

40 Thank you

41 Therapy protocol Child reaches Stage 2 LP schedule but weekly SSD Commence LP Stage 1 only first 2-3 sessions Concurrent delivery of LP Stage 1 and SSD Child reaches Stage 2 LP and discharged SSD Child remains in Stage 1 LP after 22 clinic visits; SSD Rx ceases

42 Outline Background Aim Rationale Method Preliminary results Future directions