Eye movement as a simple, cost-effective tool for people who stutter: A case study

Hilary D.-L. McDonagh, Patrick Broderick, Kenneth Monaghan

Received: 14 Feb. 2023; Accepted: 07 July 2023; Published: 31 Aug. 2023

Copyright: © 2023. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Access to services remains the biggest barrier to helping the most vulnerable in the South African Stuttering Community. This novel stuttering therapy, harnessing an unconscious link between eye and tongue movement, may provide a new therapeutic approach, easily communicated and deliverable online.

Objectives: This study provides both objective and subjective assessments of the feasibility of this intervention. Assessment tools holistically address all components of stuttering in line with comprehensive treatment approaches: core behaviours, secondary behaviours, anticipation and reactions.

Method: On receipt of ethical approval, this single-subject case design recruited one adult (21-year-old) male with a developmental stutter (DS). The participant gave informed consent and completed four scheduled assessments: baseline, after 5-week training, 3 months post-intervention and 24 months post-completion. The study used objective assessment tools: Stuttering Severity Instrument-4 (SSI-4); Subjective-assessment tools: SSI-4 clinical use self-report tool (CUSR); Overall Assessment of Speaker’s Experience of Stuttering (OASES-A); Premonitory Awareness in Stuttering (PAiS) and Self-Report Stuttering Severity* (SRSS) (*final assessment).

Results: The participant’s scores improved across all assessment measures, which may reflect a holistic improvement. The participant reported that the tool was very useful. There were no negative consequences.

Conclusion: This case report indicates that this innovative treatment may be feasible. No adverse effects were experienced, and the treatment only benefited the participant. The results justify the design of a pilot randomised feasibility clinical trial.

Contribution: The results indicate that this is a needed breakthrough in stuttering therapy as the instructions can be easily translated into any language. It can also be delivered remotely reducing accessibility barriers.

Keywords: stuttering; intervention; self-help; telepractice; eye movement; saccades; tongue; anticipation; holistic; accessible; affordable.

Introduction

This descriptive case report explores whether making a specific, timed, downward eye movement is effective as a holistic intervention for a young adult man with a developmental stutter (DS). This novel self-help intervention aims to enable the person who stutters to circumvent an inadvertent block or repetition, should they choose to do so. It harnesses an unconscious synchronised linking of eye movement and the posterior of the tongue, discussed by the main authors in a previously published paper (McDonagh & Monaghan, 2019). Accessibility to speech-language pathology across South Africa has always been a key barrier to helping the most vulnerable (Khoza-Shangase & Mophosho, 2018), and there has been a call for research evidence that can help facilitate a culturally, linguistically and contextually compatible service delivery, within the population and context (Khoza-Shangase & Mophosho, 2021). Current approaches to treating stuttering (Brignell et al., 2020; Connery et al., 2021) can be costly for individuals and overload speech pathology services (Meredith et al., 2023). Specifically, speech restructuring programmes such as the Comprehensive Stuttering Programme (Karani & Mupawose, 2020; Langevin et al., 2010; Scott Yaruss et al., 2012a) and the Camperdown Programme (Carey et al., 2010, 2012), which have the most empirical evidence, are difficult to maintain post-treatment. Participants frequently relapse to their original speaking patterns, which results in adults who stutter repeatedly accessing services in the form of maintenance (Blumgart et al., 2010). By expanding on this new line of research, the opportunity may exist for researchers and professionals in the speech, language and hearing professions to provide an intervention applicable to all within South Africa’s diverse stuttering population (Khoza-Shangase & Mophosho, 2018).

A DS, which typically starts as language skills develop between 3 and 5 years of age, affects an estimated 5% – 8% of children worldwide (Reilly et al., 2009). Disrupted speech, the core stuttering behaviour, is characterised by involuntary word or part-word repetitions, sound prolongations and silent blocks that actively disrupt the production of overt speech and impair communication (World Health Organization [WHO], 2016). In most cases, DS does not persist past childhood, but a lifetime prevalence has been estimated at almost 1% (Craig et al., 2002; Yairi & Ambrose, 2013). Holistically, the negative experience of a DS extends far beyond disrupted speech. For example, people who stutter (PWS) experience a range of abnormal physical movements known as concomitant or secondary behaviours. These include upper limb and body movements, facial grimaces, involuntary eye movements, blinks and shortness of breath (Didirkova et al., 2019; Kosmala et al., 2019). However, these secondary behaviours vary considerably across individuals with a study of 85 PWS from Argentina identifying 66 different abnormal movements (Riva-Posse et al., 2008).

By adulthood, most stuttering-like moments can be predicted, and a variety of linked coping responses automated: some constructive and some not. An American study of 30 adults with DS identified both action (cue to employ a speech technique or avoidance behaviour) and non-action (cognitive, emotional and affective) responses in the anticipation of stuttering (Jackson et al., 2015), with 43% of the participants reporting that anticipation produced both positive and negative results, whereas 37% reported that anticipation was not at all helpful. Specifically following the anticipation of a stuttering moment, 87% of participants avoided sounds or words, 37% avoided situations and 23% chose not to speak in preference to stuttering.

Internationally, it has been proposed that stuttering treatment should focus on facilitating productive responses to anticipation of a stuttering event (Briley, 2016; Tichenor et al., 2022). Current clinical approaches do this by addressing the three components of stuttering: overt core behaviours, secondary behaviours, and negative feelings and attitudes (Guitar, 2014). Such interventions focus on individualised (Sønsterud et al., 2020) and comprehensive interventions (Karani & Mupawose, 2020; Yaruss et al., 2012). Other clinicians advocate focusing on stuttering acceptance and communication competence (Byrd et al., 2022). As all these approaches include a focus on cognitive, emotional and affective personal reactions, they are, by linguistic design, more suitable to those accessing treatment through the private sector in South Africa.

A South African qualitative study (Barratt et al., 2012) explored whether the linguistic complexity of an assessment tool, designed in English, was equitably translated by five different local translators translating from English to isiZulu. Their findings revealed differences relating to translation of both vocabulary and semantics, key ingredients in any affective intervention, leaving speech and language professionals struggling to equitably provide services. Therefore, in the public sector, treatment provision to those who have accessed services has been challenged by the linguistic diversity of the nation. Furthermore, a 2022 study (Tar-Mahomed & Kater, 2022) highlighted that within the South African context, the geographical challenges of technological access and supportive infrastructure are not the same across the healthcare sector. These authors reported that the private healthcare sector is better resourced than the public sector.

There is a need for a new approach, and this requires a new conceptualisation of what occurs at stuttering-like moments. At a neurological level, all behaviours are first learned, then predicted and then implemented (Tenison et al., 2016). Even though we are not consciously aware of it, our eyes are constantly moving (Diaz et al., 2012). These movements are called saccades and are directly linked with our learned behaviour patterns and implemented by our unconscious. As our unconscious considers options and prepares us for action, our eyes identify the targets and required vectors of possible actions with lightning-fast movements that last between 20 milliseconds (ms) and 200 ms. Patterns of saccadic eye movement are as unique to individuals as their fingerprints (Lohr & Komogortsev, 2022). As our eyes move first, and eye and tongue movements are synchronised, this new conceptualisation contends that the most effective approach to change from an inhibited unconsciously generated movement may be a conscious eye movement. Unlike other treatment approaches, this treatment addresses only eye movement, identified as the start of all predicted actions.

If a conscious eye movement enables speech motor control, this tool could empower PWS to choose not to stutter and still speak naturally. It is not a tool to simply modify a stuttering moment. Rather, it should prevent it as, by changing the prediction, the primary symptom of stuttering should not occur. If a PWS is given the choice to voluntarily use this tool and not stutter, regardless of environment, personal reactions and the negative impact typically aligned with involuntary stuttering moments should by themselves diminish. Stuttering, also known as a stammer in India, United Kingdom and Ireland, is characterised by involuntary repetition or prolongation of sounds, syllables or words, or by voluntary hesitation or pauses, that disrupt the smooth rhythmic flow of speech (WHO, 2001), and it is classified as a disability (WHO, 2016) when its severity is such as to markedly disturb the fluency of speech. For the person who stutters, however, the experience of stuttering extends far beyond these observable dysfluencies. To address this, the International Classification of Functioning, Disability and Health (ICF) (World Health Organization [WHO], 2001) was specifically adapted to apply to stuttering (Yaruss & Quesal, 2004) and adopted as a framework for SLP practice (American Speech-Language-Hearing Association [ASHA], 2016). The experience of stuttering has been conceptualised in terms of component parts: primary symptoms, personal reactions and adverse impact, all under the influence of environmental factors (see Tichenor et al., 2022, for schematic). The primary symptom identified in this schematic is the perceived loss of speech motor control under the influence of stuttering etiology. The ICF provides additional guidelines addressing participation restriction, activity limitation and locus of control. These constructs are self-assessed by the participant throughout the study.

This is a descriptive, single-subject case study design and provides an initial platform to explore the effectiveness of this new treatment approach for the participant. Assessments are of the same individual at different time points. The core dependent variable in this study is the experimental effect making a controlled eye movement has on stuttering severity. Assessments took place at four time periods: baseline, following the 5-week intervention, 3 months post-intervention and 24 months post-intervention. As such, the data presented reflect and evaluate the generalisability of the technique, by the participant, in real life post-intervention. While a descriptive case study represents a low level of evidence (Murad et al., 2016), it is the essential starting point for a new approach, to assess its feasibility and ensure no adverse effects. Comparable evidence exists from a recently published descriptive case study describing a comprehensive stuttering intervention for DS (Karani & Mupawose, 2020).

Assessment measures used to document the value of this intervention have considered the holistic nature of the disorder and the participant’s ability to use it in real life. Core and secondary behaviours were independently assessed online because of the coronavirus disease 2019 (COVID-19) lockdown. Stuttering severity was also self-assessed by the participant. Additionally, the participant was asked to assess their anticipation of stuttering events, the overall experience of being someone who stuttered and any changes in the frequency of avoidance behaviours and perceived locus of control. The data presented reflect the participant’s ability to use the technique in real life over the 2 years following the 5-week instruction period.

The approach used in this study is to familiarise the participant with the process of using a conscious eye movement to change their posterior tongue position before commencing utterance of the next speech sound. During training, it is just this movement that is practised and the timing of it discussed. The required positioning in the back of the tongue occurs when they move their eyes downwards towards their naval. This ‘ideal’ tongue position is with the posterior of the tongue raised and as far back in the oral cavity as possible. Having the tongue positioned on the roof of the mouth has been shown to improve muscle strength (Di Vico et al., 2013) and heart rate variability (Schmidt et al., 2009). It is the tongue position that naturally coincides with putting a big silly grin on your face.

Like improving stance for a better golf swing or a pre-kick routine for taking a penalty, the purpose of the practice is to make this starting position easy to achieve under pressure. The participant is advised not to use the tool outside of practice during the 5-week training period. After the training, the participant is free to keep up the practice if they find the tool useful. Five weeks was deemed long enough time for the novelty of the movement not to be a factor when attempting to use it in stressful situations, but short enough that the technique could be easily unlearned if the participant did not find it beneficial. This was a necessary precaution given the novelty of the approach.

This novel approach may present several opportunities to effectively treat the more vulnerable in South African society. Firstly, as this is a self-help intervention, it can be delivered online cost-effectively, highlighting the outreach possibilities of using it with PWS who do not have access to the mainstream, comprehensive approach and in line with the first recently identified core component of stuttering interventions (Connery et al., 2022). It has been stated that despite the implementation difficulties associated with telepractice in South Africa, the benefits far outweigh the challenges encountered (Karrim et al., 2022). Secondly, with treatment provision to those who have accessed services challenged by the linguistic diversity within South Africa (Barratt et al., 2012), this intervention is based on instructions for physical movement, which are easily translated. Thirdly, the online nature of the training and assessments used in this research may allow researchers in Speech and Language to reimagine research in a way that is applicable to the South African Population and Context (Khoza-Shangase & Mophosho, 2021). With further replications, the evidence base for this new treatment approach would be strengthened so that this novel intervention could be a tool for Speech and Language professionals in South Africa to improve the quality of life for the stuttering community. If uncertainty and perceived lack of control are predictors of communicative participation and mental health in adults who stutter (Boyle & Chagachbanian, 2022), a tool that empowers a PWS with the conscious choice to speak freely should address stuttering in a holistic manner.

Methods

Objectives

To describe the scores obtained on the Stuttering Severity Instrument – Fourth Edition (SSI-4) for core and secondary behaviours (Phases 1, 3, 4 and 5).
To describe the scores obtained on the Overall Assessment of the Speaker’s Experience of Stuttering-Adults (OASES-A) regarding its influence on activity limitations, participation restrictions and contextual factors (personal and environmental) (Phases 1, 3, 4 and 5).
To describe any changes to the self-reported stuttering severity, avoidance behaviours and locus of control measures assessed through the SSI-4 auxiliary Clinical Use Self-Report (CUSR). These measures reflect the ICF guidelines regarding participation, avoidance behaviours and perceived locus of control (Phases 1, 3, 4 and 5).
To describe the scores obtained on the Premonitory Awareness in Stuttering (PAiS) with regard to immediate and prospective anticipation (Phases 1, 3 4 and 5).
To compare results provided on self-rated stuttering severity (SRSS) with SSI-4 scores. This measure was included only at 24 months post-intervention assessment (Phase 5).

Research design

This study used a single-subject case design including assessments at four time periods (pre-intervention, immediate post-intervention, 3 months post-intervention and 24 months post-intervention) and a 5-week intervention period (see Figure 1).

FIGURE 1: Five phases of the study procedure.

Participant description

The participant was a right-handed male Caucasian, age 21 years, who was an undergraduate student at the Institute of Technology in Sligo, Ireland. He does not know at what age he started to stutter, just that he has stuttered for as long as he can remember. He had participated in some classes for speech in childhood without much success, and at age 19, he took part in an intensive 3-day training with the Maguire programme: a self-help programme run by PWS. He still uses the techniques he learned from the programme but finds them hard to remember. He was proficient in English and had no diagnosis, needing the psychological or medical intervention of any emotional, behavioural, learning or neurological disorder. He had the cognitive ability to take part and gave informed consent.

Data collection tools

The tools used at the four testing periods (Phase 1, Phase 3, Phase 4 and Phase 5) were SSI-4, OASES-A and PAiS. The SRSS was added at 24 months follow-up (Phase 5).

The SSI-4 is the most widely used syllable-based procedure for assessing overt stuttering symptoms (Riley, 1994, 2009). The SSI-4 overall score combines the following three sections: firstly, scaled percentage of stuttered syllables (%SS); secondly, the average duration of the three longest stuttering moments, timed to nearest one-tenth of a second and converted to a scale 2–18; and finally, the physical concomitants, secondary symptoms: distracting sounds, facial grimaces, head movements and movements of the extremities converted to scale scores of 0–20, observed at the time of symptom assessment. This combination gives an overall scaled stuttering severity score and percentile ranking (Riley, 1994, 2009).

The minimum detectable change (MDC) in the percent of stuttered syllables (%SS) has been set as 1% (Jones et al., 2005), as this would be the smallest change noticeable by the participant. It has been proposed that to be clinically significant, an intervention should result in a 50% reduction in stuttering (Reddy et al., 2010), although some researchers have considered 20% (Maguire et al., 2010) clinically significant. All evaluations using SSI-4 were carried out on two consecutive days at each assessment phase, and the average of these two scores was included in this report. Assessments were carried out via Zoom by an independent psychologist available and qualified to complete the assessments during the lockdown at the start of the COVID-19 pandemic. Community Speech and Language Therapists had, at that time, been redeployed within the health sector. The same assessor was used at all phases for consistency. The total score is a scaled measure that includes %SS, duration timed to the nearest one-tenth of a second and converted to a scale score of 2–19.

The SSI-4 includes an auxiliary self-report assessing 13 items on a 9-point scale. The 13 items when subdivided yield three categories: self-assessed stuttering severity, locus of control and frequency of avoidance behaviours (Tahmasebi et al., 2018) to reflect the ICF framework. There is no established minimum clinically important difference (MCID) or MDC.

The OASES-A (Yaruss & Quesal, 2004) is a validated and reliable questionnaire designed to document improvement and evaluate treatment efficacy and is based on the WHO’s International Classification of Functioning, Disability, and Health (ICF) (World Health Organisation, 2016). The MCID and MDC have not yet been estimated. The OASES scores have been reported as remaining relatively stable over time (Constantino et al., 2020) unlike severity ratings.

The PAiS is a 12-item questionnaire assessing immediate and prospective anticipation of stuttering (Cholin et al., 2016) that was adapted from the reliable and validated Premonitory Urge for Tics Scale (PUTS) (Woods et al., 2005). Changes in PAiS are described in terms of total scores and immediate and prospective anticipation scores.

The self-rated stuttering severity (SRSS) required participants to score their typical SRSS for eight individual representative speaking situations, on a scale of 1–9 (where 1 = no stuttering and 9 = extremely severe stuttering) that represents typical, best and worst stuttering severity in that situation. The mean of the eight scores was used in the analysis. This tool was added to the assessment at phase 5 to assess whether an expert in stuttering’s self-assessment, concurred with the final independent assessment of stuttering severity. Minimum clinically important difference and MDC can be approximated based on established measures for SSI-4 using the comparison table published by Jones et al. (2004).

Study procedure

Phase 2: Eye movement training for stuttering intervention: The intervention was delivered via Zoom, at the start of the COVID-19 pandemic. The intervention took place over a 5-week period. A practice Zoom session was conducted prior to commencing the intervention schedule. Total contact time for participant and researcher over five weeks training, was 1 h 17 min (excluding time spent on assessments).

During meeting one, the participant was trained on how to use eye/tongue movement to produce non-stuttered speech. The participant was instructed to practise this movement when he experienced dysfluencies for 10 min twice per day for the next week. As a result of the lockdown, the participant did not experience stuttered speech at home alone or with family during the first week. Based on this feedback, the practice schedule was adapted in the second week, initially to an online practice schedule with the principal researcher and then back to self-directed, as it became apparent that the movement could be practised in the absence of stuttered speech.

The remaining online sessions were support sessions where the participant confirmed that he had complied with the practice schedule and the precise timing of the movement was discussed: if a stuttering-like moment started, stop talking, reposition the tongue and start again.

Key instructions from training sessions:

Attention was brought to linked eye–tongue movement – non-vision related as occurs with eyes closed.
Role of eye movement in unconscious predicting movement was discussed.
Ideal tongue position was discussed – practice to reposition quickly – like a blink.
Consider the timing of movement – before speech gesture.
The participant was reminded that this was a tool he could use if he wished to avoid a stuttering-like moment and that it would get easier with practice. It was not something he had to do, but something he could do if it helped.
First-week instructions were to practise with speech, second and subsequent weeks – no speech was required to practise eye–tongue movement.

Data analysis

Responses from SSI-4 and OASES-A were analysed based on total scores, impact scores and severity ratings using descriptive statistics. The CUSR adjunct to the SSI-4 was analysed by creating composite scores assessing self-rated stuttering severity, avoidance behaviours and locus of control (Tahmasebi et al., 2018).

Responses from the Premonitory Awareness in Stuttering were presented based on the total score of 12 validated questions. The subtotal scores for questions 1–6, commencing with ‘Right before I stutter’, and for questions 7–12 are also presented separately.

For the above assessment tools, % change from baseline is calculated for phases 3–5 using the formula:

The self-rating stuttering severity assessment tool was introduced in Phase 5 and its scores were compared to the SSI-4 based on the comparative table in O’Brian et al.’s (2004) scores to assess the internal validity of the measures and the reliability of the applicability of the SRSS in this and future studies. This also includes satisfaction with speech and frequency of avoidance behaviours measures.

Ethical considerations

Ethical clearance to conduct this study was obtained from the Institute Research Ethics Committee (IREC), the Institute of Technology Sligo (now Atlantic Technological University Sligo) and the Sligo University Hospital Research Ethics Committee (reference no.: 800).

Results

The results are presented to reflect the five study objectives described in the ‘Methods’ section.

Objective 1

To describe the SSI-4 scores for core and secondary behaviours (see Table 1).

TABLE 1: Categorical description of measurements used in the Stuttering Severity Instrument – Fourth Edition Assessment.

The SSI-4 scores (Figure 2 and Table 2) at the four testing phases are presented. The raw score of %SS decreased consistently across the four testing periods with the Phase 5 score representing a 65% change from baseline. This continuous reduction is not evident between Phase 1 and Phase 3 in the SSI-4 scaled score for %SS, which did not change (17 for both) even though there was an 11% reduction in %SS. Overall, the total SSI-4 score, and categorisation, improved from moderate (48) to very mild (17) at the final assessment. All component scores improved. Physical concomitants score (on a scale of 2–20) had decreased by 50% at Phases 4 and 5 (from 6 to 3). The scaled severity of the longest dysfluency (scale 2–18) had reduced from six to two at Phase 5 (70% change). The perceived naturalness of speech also improved changing from 7 (Phase 1) to 4.5 (Phase 5) (for full assessment, see Appendix 1).

FIGURE 2: Stuttering Severity Instrument – 4 raw %SS, scaled section scores and total scores at four testing phases (see Table 2 for summary scores).

TABLE 2: Stuttering Severity Instrument – Fourth Edition: Raw and scaled scores across all testing phases.

Objective 2

To describe the scores obtained on the Overall Assessment of the Speaker’s Experience of Stuttering – Adults (OASES-A) with regard to its influence on activity limitations, participation restrictions and contextual factors (personal and environmental).

The OASES-A scores and categorisation (Figure 3) improved from moderate–severe (3.1) at baseline to mild–moderate (2.2) at the final assessment. The improvement was not continuous as the initial gain (score 2 at Phase 3) was not fully maintained at Phase 4 (2.4); however, at Phase 5, the score (2.2) represented an overall improvement of 29% from baseline in total OASES-A score (see Appendix 2).

FIGURE 3: Overall Assessment of the Speaker’s Experience of Stuttering – Adults total impact scores.

Section 1 (general information) did not improve overall, maintaining a moderate-severe negative impact (see Table 4). This section’s score showed initial improvements, a 30% reduction (Phase 3), decreased to a 25% reduction (Phase 4) and 2% by the final assessment (Phase 5). Specifically, initial improvements in general knowledge about stuttering reverted to baseline by 24 months follow-up (see Table 3).

TABLE 3: Overall Assessment of the Speaker’s Experience of Stuttering – Adults total impact scores at four assessment phases.

TABLE 4: Overall assessment of the speaker’s experience of stuttering – Adults sectional results (% reduction in score from baseline).

Section 2 (Personal Reactions) improved from moderate–severe (3.4) to mild–moderate (2.1) at Phase 3 and then stabilised at moderate (2.8) at phases 4 and 5 (see Table 4). The final % change from baseline was 19%. Of specific relevance, the participant reported that he strongly disagreed with the statement ‘when I stutter there is nothing, I can do about it’ at phases 3, 4 and 5 – this changed from a neutral reaction in Phase 1 (see Appendix 1).

Section 3 (Communications in Daily Situations) improved from moderate to mild–moderate at phases 3, 4 and 5. Within the range of this category, the initial % change from baseline was 20% (Phase 3), which decreased to 17% at Phase 4 and again to 10% at Phase 5.

Section 4 (Quality of Life Scores) mirrored the change in the overall OASES-A score, improving from moderate–severe to mild–moderate. Four of the 25 measures in this sub-section remained at returned to baseline by Phase 5; however, 21 of the 25 measures assessing the participant’s Quality of Life improved. This was not a continual improvement. The participant’s score had reduced by 40% from baseline at Phase 3, it was 21% at Phase 4, and it had 37% change from baseline at Phase 5 (see Table 4).

Objective 3

To describe the SSI-4 CUSR measures. Composite scores of self-reported stuttering severity, avoidance behaviours and locus of control measures were assessed through the SSI-4 to reflect the ICF guidelines regarding participation and avoidance behaviours as well as the perceived locus of control.

The participant self-reported (Figure 4) that his stuttering severity had improved at Phase 3 (19% change from baseline) and that the improvement had been maintained at Phase 5 (19% change). At 3-month follow-up, perceived improvement peaked at 35%, but this level was not sustained. He also reported an initial reduction of 19% in his frequency of avoidance behaviours (Phase 3), and this reduction had further improved to 24% at phases 4 and 5. The participant reported an increased internalisation of the locus of control which improved continuously from the baseline assessment. Initial improvements were small, 10% and 11% at phases 3 and 4, but this continued to improve with a reported 31% increase in internal locus from baseline at Phase 5 (Full results are available from the corresponding author on request).

FIGURE 4: Details of composite scores from Stuttering Severity Instrument – Fourth Edition clinical use self-report tool.

Objective 4

To describe the scores obtained on the PAiS with regard to total scores and immediate or prospective anticipation scores. Coinciding with an international increase of interest in the role of anticipation in the stuttered speech, the PAiS (Cholin et al., 2016) was adapted from a validated and norm-referenced tool PUTS (Woods et al., 2005) exploring the premonitory sensations preceding Tics. The 12 questions deal with immediate and prospective awareness. When this tool was validated with PWS, there was an inverse relationship between the overall score and the percentage of stuttered syllables.

As shown in Figure 5, the overall PAiS score reduced by 50% from baseline at Phase 3. Following a slight regression to 39% change from baseline at Phase 4, there was an overall 56% reduction from the baseline score at Phase 5 (Full results are available on request from the corresponding author).

FIGURE 5: Premonitory awareness in stuttering.

Questions 1–6 are taken to reflect immediate anticipation of the stuttering event as they all commence with the words ‘right before I stutter’. The score on these questions decreased across the four testing periods, and the sub-score of immediate anticipation (Questions 1–6) was the largest contributor to the overall reduction in PAiS score having decreased 70% from baseline at Phase 5.

Objective 5

To compare results provided on self-rated stuttering severity (SRSS) with SSI-4 scores. This measure was included only at 24 months post-intervention assessment (Phase 5).

The participant rated his satisfaction with speech at 2 on a scale of 1–9 with 1 = extremely satisfied and 9 = extremely dissatisfied. He rated their level of avoidance at 1.25 on a scale of 1–3 with 1 = rarely and 3 = most of the time. He also rated their typical worst and best severity on a scale of 1–9 with 1 fluent and 9 extremely severe stuttering. These scores are converted to comparative %SS based on published analysis (Jones et al., 2005) with a typical severity of SRSS 4.6 corresponding to approximately %SS = 8.6 and ranging from 3.4 (best) to 5.6 (worst) (Full results are available on request from the corresponding author).

Comparing these to the final %SS via SSI-4, the objective assessment of %SS via SSI-4 when speaking was greater (16.55%) than self-assessed severity (12.6% approximately) and when reading the actual performance was better (0.53%) than self-assessed best (5% approximately). The average of those scores is 8.54% corresponding well with the SRSS typical severity (8.6% approximately). This supports the use of typical SRSS when expanding the research.

Discussion

The discussion elaborates on the objectives of the study and their respective findings.