INT J LANG COMMUN DISORD, JANUARY–FEBRUARY 2014,

VOL. 49, NO. 1, 113–126

Research Report
Effectiveness of intensive, group therapy for teenagers who stutter
Jane Fry, Sharon Millard and Willie Botterill
The Michael Palin Centre for Stammering, London, UK
(Received March 2013; accepted July 2013)

Abstract
Background: Treatment of adolescents who stutter is an under-researched area that would benefit from greater
attention.
Aims: To investigate whether an intensive treatment programme for older teenagers who stutter, aged over 16 years
of age, is effective in reducing overt and covert aspects of stuttering.
Methods & Procedures: A repeated-measures, single-subject experimental design was replicated across participants.
The study consisted of a 5-week baseline phase, 2-week intensive treatment phase, 5-week consolidation phase and
10-month follow-up phase. Participants were asked to make ten video recordings at home during each phase, while
completing a reading and a conversation task. Recordings were analysed in terms of the percentage of stuttered
syllables using a simplified time-series analysis. Participants completed self-report questionnaires at predetermined
times throughout the study. Data are presented for three males aged 17;7, 17;11 and 18;10.
Outcomes & Results: One participant completed all required recordings. Difficulties were encountered collecting
follow-up data with the other two participants and data are available up to 5 months after the intensive therapy
phase. A significant trend of reduced frequency of stuttering was found for all three participants during the intensive
therapy phase. This trend continued throughout the consolidation phase and remained significant when available
longer-term data were included in the analysis. Participants also reported increased self-efficacy about speaking
and reduced overt and covert aspects of stammering.
Conclusions & Implications: Findings show that this therapy programme for teenagers had a significant treatment
effect for the participants studied in the short- and medium-term, however longer-term data were not available for
all participants. Issues in conducting research with this client group are discussed.

Keywords: stuttering, treatment, single case study.

What this paper adds?

This paper outlines an integrated programme of therapy incorporating speech restructuring, cognitive behaviour
therapy and communication skills training which has been implemented at the Michael Palin Centre. It adds to the
current discussion about the use of CBT in the treatment of stuttering. It highlights some of the challenges involved
in collecting long term data with adolescent research participants, however adds to the discussion of effectiveness of
therapy with teenagers who stutter and underlines the importance of therapy resources being available for adolescents
who stutter.

Introduction
The treatment of teenagers who stutter is an under-
researched area (Bothe et al. 2006) but there are several
reasons why therapy for this age group, and research into
the effectiveness of therapy is important. Stuttering is
increasingly viewed as a chronic disorder as adolescence
progresses with the associated long-term risks of chronic
stuttering including reduced psychological, social,
vocational and economic opportunities (Blumgart et al.
2010, Yaruss 1998) and vulnerability to social anxiety
(Kraaimaat et al. 2002, Mahr and Torosian 1999)
which may persist across the lifespan (Bricker-Katz et al.
2009). There is evidence that adolescents who stutter are
already vulnerable to these risks. They have been found
to score more highly than adolescents who do not stutter
on measures of communication apprehension (Blood

Address correspondence to: Jane Fry, The Michael Palin Centre for Stammering, 13–15 Pine Street, London EC1R OJG, UK; e-mail:
janefry@nhs.net
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12051
114
et al. 2001) and social anxiety (Mulcahy et al. 2008),
and to view themselves as being less able communicators
than their fluent peers (Blood et al. 2001). Craig and
Tran (2006) concluded that adolescents who stutter are
more likely to become more shy, socially avoidant and
fearful of communication than their fluent peers, and to
develop pervasive negative attitudes and beliefs about
themselves as communicators. The teenage years are
therefore a potentially critical period for minimizing
the severity and impact of chronic stuttering.
There are also developmental reasons why therapy
may be particularly important at this time. Adolescence
is a phase of rapid physical, social, cognitive and emo-
tional change (Dahl and Gunnar 2009). Of particular
interest from a clinical point of view are developments in
executive function and construction of the sense of self.
Executive function refers to the ability to direct thoughts
and actions according to internal goals. Its develop-
ment is particularly marked during adolescence and is
demonstrated by increases in mental flexibility, ability
to self-monitor accurately, appraise personal skills and
performance, ability to plan tasks, work independently
and problem-solve (Crone 2009). The way that the sense
of self is constructed also alters during adolescence, with
a shift towards this being based on how the individual
believes that he or she is seen by others (Sebastian et al.
2008). The development of what is referred to as the
‘looking-glass self’ has a greater role during adolescence
(Sebastian et al. 2008) and is associated with height-
ened self-consciousness, increased self-evaluation, and a
greater awareness of, sensitivity to and concern about
others’ opinions (Parker et al. 2006).
The normal maturation of adolescence may there-
fore result both in greater awareness of stuttering and
increased self-consciousness about it, which can make it
more complex to treat. However, adolescents also bring
a set of cognitive skills that may help them to engage
more successfully than when younger, in a process which
requires self-monitoring, reflection and self-direction.
Finally, there is evidence that therapy with adoles-
cents can be beneficial. Several studies have reported
improvements after therapy based on speech restruc-
turing using either smooth speech (Craig et al. 1996),
prolonged speech (Hearne et al. 2008a) or gradual in-
crease in length and complexity of utterance (GILCU)
(Ryan and van Kirk Ryan 1995). Speech restructuring
has also been shown to be effective when integrated with
social skills training (Rustin and Purser 1983), avoid-
ance reduction therapy (Boberg and Kully 1994), elec-
tromyography treatment (Craig et al. 1996), cognitive–
behaviour therapy (CBT) (Blood 1995), and CBT plus
communication skills training (Fry et al. 2009).
However difficulties engaging and retaining teenage
clients in therapy, and in research projects, are often en-
Jane Fry et al.
countered and flexibility may be required in terms of
the timing, context and scope of therapy. In their quali-
tative study of teenagers’ perspectives on stuttering and
therapy, Hearne et al. (2008b) found that adolescents
reported becoming more concerned about their stutter-
ing at different ages, although there was a trend for this
to occur in later adolescence as they approached a transi-
tion to the workforce or further education. They found
that teenagers valued being able to engage in therapy
at a time of their own choosing and the camaraderie
of group therapy. Considerations such as age, maturity
and readiness for therapy may therefore influence out-
comes and, while it may not be the preferred option for
all teenagers, group work has particular developmental
relevance and may add to the appeal of therapy for this
client group.
Aim
Fry et al. (2009) investigated the efficacy of a group
therapy programme, based on the work of Rustin
et al. (1995) and also described by Fry and Cook
(2004), which consists of a 2-week, weekday only, inten-
sive course for teenagers aged 16–19 years, integrating
speech management skills, CBT and communication
skills training. These authors used a repeated-measures,
single-subject design, which is a methodology that has
been used to investigate the efficacy of therapy for chil-
dren who stutter (Matthews et al. 1997, Millard et al.
2008) and has advantages when research is conducted
in real-world clinical settings. It allows for variations in
therapy, which can be expected in response to the indi-
vidual needs and preferences of clients, and the extensive
baseline data means that the subject acts as their own
control and a control condition is not required (Kazdin
1982, Pring 2005). Fry et al. (2009) found that the sever-
ity of overt and covert features of stuttering decreased for
the subject studied, and reported self-efficacy related to
speaking increased in response to therapy. Changes were
shown to be durable, being maintained up to 10 months
after therapy. However, while single-subject studies have
high internal validity, results cannot be generalized, al-
though this limitation can be addressed, and validity
strengthened, by replication (Kully and Langevin 2005,
Pring 2005).
The aim of this study was to replicate the work of Fry
et al. (2009) and further investigate the efficacy of this
therapy programme. Specific hypotheses tested were that
teenagers attending this intensive therapy programme
would demonstrate reduced severity of stammering and
report reduced features of stammering as experienced
in day-to-day life, reduced social anxiety and increased
confidence about speaking.
Intensive group therapy for teenagers who stutter
Method
The setting
The study was conducted at a specialist, tertiary cen-
tre for stuttering that receives referrals for children and
young people from speech and language therapists in
the UK. Ethical approval for the study was granted by
the Camden and Islington Community Research Ethics
Committee.
Assessment
All adolescents aged 16 years and older complete a stan-
dard initial assessment consisting of a structured inter-
view and a within-clinic analysis of stuttering severity
using the SSI-3 (Riley 1994). Parents may request a
parent session, but it is not required, and they may al-
ternatively supply background information through a
parent questionnaire. The aim of the assessment is to as-
sess overt and covert aspects of stuttering, to understand
the client’s goals and preferences in terms of therapy,
and to agree a course of action with the client.
Participants
All clients attending either one of two groups, each of
ten young people, which took place within the 2-year
time-frame of the study, were given information about
the study and invited to take part. All those electing to
take part were included.
The criteria for selection were that participants were
aged between 16;0 and 19;0 years as this correlates with
the age range of clients attending the course. The three
participants reported on in this study could all be de-
scribed as being in ‘late adolescence’, which is typically
considered as being up to 19 years of age. All three were
living at home, in full-time education and economically
dependent, and from a lifespan perspective still prepar-
ing for emergent adult roles as is typical of adolescence.
While falling in the older range of the clinical group as
a whole, the convention of participants electing to take
part in research, or not, may inevitably limit the degree
to which specific ages can be targeted.
Selection criteria also included participants having
been diagnosed as stuttering by a specialist speech and
language therapist, having obtained a severity of stut-
tering rating on the Stuttering Severity Instrument—3
(SSI-3) (Riley 1994) of ‘mild stutter’ or higher and hav-
ing been recommended for the intensive group based
on clinical recommendations made independently of
the study.
Five participants were ultimately recruited, three
from the first year’s intensive course and two from the
second. Two withdrew during the baseline phase while
continuing with the therapy programme, leaving two
115
participants from the first year and one participant from
the second. These participants were males aged 17;7,
17;11 and 18;10, monolingual, English speakers, in full-
time education and living at home. All gave informed
consent to take part.
r Participant 1 (P1) was aged 17;11 at the start of
the study. His parents reported that he started
to stutter at 10 years of age and that there was no
family history of stuttering. He had no additional,
diagnosed, speech and language difficulties, al-
though was described, informally, as having ‘some
features’ that were consistent with Asperger’s syn-
drome. These included a tendency to interpret
information literally, a precise style of communi-
cation and a strong interest in a particular subject.
Prior to the course he had received ‘intermittent’
speech and language therapy locally with no ther-
apy in the 12 months before the course. On initial
assessment P1 obtained an SSI-3 score of 27 and
his stammer was described as moderate using the
criteria of the SSI-3.
r Participant 2 (P2) was aged 17;7 at the start of the
study. His father reported that he started to stutter
at approximately 2 years of age. There was a family
history of both recovered and chronic stuttering
paternally. P2 had no other speech and language
diagnoses. Prior to the course he had received ‘in-
termittent’ individual therapy locally between the
ages of 8 and 10 years and had also attended three
intensive, group therapy courses since the age of
10 years. He had received no substantial or regular
therapy in the 10 months before this study. On
initial assessment he obtained an SSI-3 score of
46 and his stammer was described as very severe
using the criteria of the SSI-3.
r Participant 3 (P3) was aged 18;10 at the start of
the study. He started to stutter at approximately 5
years of age and reported a family history of stut-
tering. P3 had no other speech and language dif-
ficulties and had received no speech and language
therapy, although he had tried hypnotherapy for
stuttering several years before attending the cen-
tre. On initial assessment he obtained an SSI-3
score of 9 and his stammer was described as very
mild using the criteria of the SSI-3.
Description of the programme
The programme has three components: speech manage-
ment skills, CBT and communication skills training.
The speech management component integrates speech
modification and fluency shaping skills. Speech mod-
ification focuses on identification, desensitization and
learning how to modify the moment of stuttering.
116
Therapy tasks include group discussions and reflection
on personal stuttering behaviours, practice in identifying
and describing moments of stuttering using visual feed-
back, practice in modifying stuttered moments through
controlled reduction of tension, exploring the use of vol-
untary stuttering, and increasing openness about stutter-
ing. Fluency shaping skills include rate reduction, use of
light articulatory contacts and flowing words together.
A structured programme is used to help clients gradu-
ally increase their confidence in using the skills that they
personally find most effective and appealing.
The CBT component of the programme is based
on the work of Beck (1976) and contemporary the-
ory and treatment of social anxiety (Clark and Wells
1995). CBT is increasingly referred to in the treat-
ment of stuttering and has been found to reduce so-
cial anxiety, although not overt stuttering, with adults
who stutter (Menzies et al. 2008). Participants are in-
troduced to a cognitive model that explains the links
between thoughts, feelings, physiological responses and
behaviours. They are helped to personalize the model
by identifying key mechanisms that explain their own
experience, and in particular to identify patterns of
unhelpful pre- and post-event thinking and use of
safety-seeking behaviours (Clark and Wells 1995). They
are helped to develop cognitive restructuring skills,
namely identifying and challenging negative automatic
thoughts, to explore dropping their usual safety be-
haviours and increase their problem-solving skills in re-
lation to real-life speaking situations.
The CBT component is integrated with all aspects of
therapy. For example, participants are invited to check
for negative automatic thoughts before any tasks that
might trigger heightened anxiety, such as observing
themselves on video-recorded tasks, giving a presenta-
tion to the group or completing fluency practice. The
emphasis is on real-world application of the principles
of CBT, using the group perspective whenever relevant
to provide balanced feedback or alternative perspectives.
Rustin and Purser (1983) found that communi-
cation skills training augmented treatment gains and
changes to communication style can be understood in
terms of CBT theory. When stuttering is anticipated,
people who stutter tend to use coping strategies, such
as avoiding situations or speaking less, which have an
unintended negative effect on their overall communi-
cation (Bloodstein 1995). For example, reducing eye
contact, saying less, taking longer turns when ‘on a
roll’ with fluency or scanning utterances for possible
stuttering may result in the individual being less ob-
servant of his or her conversational partner, reading
turn-taking cues less well, listening less effectively or
appearing disengaged, which may in turn result in un-
desired listener responses. In addition, a focus on flu-
ency as the communication ‘be all and end all’ may
Jane Fry et al.
result in other aspects of communication being under-
valued. A holistic awareness of communication is en-
couraged through discussion of specific skills, includ-
ing observation and eye contact, listening, turn-taking,
praise and self-reinforcement, problem-solving and ne-
gotiation. Video feedback is used to help clients iden-
tify their communication strengths as well as potential
changes that they view as desirable. These are then re-
inforced through individual and group activities. The
work is integrated with CBT, enabling participants to
understand the links between anticipated stuttering and
any associated fears, their behavioural reactions or cop-
ing strategies, and the often unintended impact these
can have on interpersonal effectiveness.
The therapeutic style throughout the programme is
collaborative, with the aim of encouraging clients to de-
fine their own goals and develop a repertoire of self-help
skills that best fit with their personal goals, decisions and
values. The group setting allows clients to share experi-
ence and support each other, as well as benefit from each
others’ perspectives and observations. Participants are
helped to reflect on the course and construct a personal
action plan that summarizes key speech, communica-
tion and CBT skills, the rationale for their use, a sched-
ule of practice activities and reflection, and guidelines
for managing setbacks. This helps clients to continue
generalizing their skills during the consolidation period
that follows the intensive component of the programme.
There are 4 follow-up days throughout the ensuing year.
These are client-led, however they typically involve a re-
fresher of all components of the course with an emphasis
on practical work and problem-solving. Additional in-
dividual therapy sessions are arranged during the year if
these are requested.
This programme is recommended for adolescents
who have sufficient language and cognitive skills to en-
able them to access the course content, who are able
to make the necessary commitment in terms of atten-
dance, completing homework assignments and attend-
ing follow-up meetings, and who find the prospect of
working in a group appealing.
Design
This was a single-subject experimental study that was
replicated across participants. It had four phases:
r Phase A consisted of a 5-week baseline during
which participants did not receive therapy.
r Phase B was a 2-week, intensive treatment phase
with therapy taking place daily excluding week-
ends.
r Phase C was a 5-week consolidation phase during
which treatment was self-managed.
Intensive group therapy for teenagers who stutter
r Phase D was a 10-month maintenance phase. Four
1-day, group follow-up sessions were held at in-
tervals during phase D.
Measures
Percentage syllables stuttered
Participants video-recorded themselves at home speak-
ing in conversation with another person for 5 min and
reading aloud for 2–3 min. Recordings were made twice
a week in phase A, each day in phase B, twice a week in
phase C and once a month in phase D, yielding a possible
40 recordings. The frequency of stuttering was measured
by calculating the percentage of stuttered syllables (%SS)
for each speaking task. Recordings were coded and ran-
domized so that first and second raters were blind to the
time of recording. Recordings for P1 were analysed by
a postgraduate, student speech and language therapist
who had been trained in identifying and counting stut-
tered syllables. Recordings for P2 and P3 were analysed
by a specialist therapist at the centre who is experienced
in assessing stuttering, and who was independent of the
treatment programme. Stuttering was defined as repeti-
tion of part-word or single-syllable whole words, prolon-
gations of sounds, and speech blocks. Phrase repetitions
and tension-free pauses were not counted as stuttered
events.
Statistical analysis of %SS was carried out using a
simplified time-series analysis (Blumberg 1984, Tryon
1982), in which Young’s C-statistic is used to deter-
mine whether or not a time-series contains any trends,
or systematic departures from random variation. It al-
lows comparison of the baseline with subsequent phases,
and enables comments to be made about the impact of
treatment. The first step is to evaluate baseline data and
determine whether or not the baseline contains a statisti-
cally significant trend. If this is ruled out, the C-statistic
is then used to determine whether or not a trend exists
across subsequent phases when these are aggregated. A
significant result at this point is interpreted as evidence
that the treatment series departs from the baseline series
or, in other words, that a treatment effect is present.
In this study, the baseline phase was analysed and then
phases A–C were aggregated. Phase D was subsequently
included in the analysis to determine the durability of
any identified trends.
A total of 30% of each participant’s recordings was
randomly selected for blind analysis by a second rater
who was a specialist speech and language therapist.
Intra-judge reliability was also examined on 25% of
P1’s recordings, on 33% of P2’s recordings and on 30%
of P3’s recordings. Intra-judge reliability was calculated
using the Smaller/Larger index or marginal agreement
index (Frick and Semmel 1978), which can be used when
117
there are two observers of a phenomena. The index is
calculated by dividing the smaller of the two values of the
occurrence of the target behaviour by the larger value,
resulting in an index ranging from 0.00 to 1.00.
Self-report questionnaires
Participants completed four self-report measures. These
were completed at the beginning of the baseline phase,
on the first and last day of the intensive phase, at the
end of the consolidation phase, and then at 3, 6 and 10
months post-treatment:
r The Self-Efficacy Efficacy Scale for Adoles-
cents (SEA-Scale) (Manning 1994) measures self-
efficacy for verbal fluency, or confidence in be-
ing able to speak fluently, in a range of everyday
situations. Both adolescents and adults who stut-
ter have both been found to have decreased self-
efficacy for verbal fluency in comparison to their
fluent peers (Manning 1994, Ornstein and Man-
ning 1985). It consists of 100 everyday speaking
situations which are scored on a scale of 1 to 10
for the degree to which self-efficacy for verbal flu-
ency is anticipated, where 1 is low and 10 is high.
Manning (2001) reported that the SEA-Scale dif-
ferentiated adolescents who stutter and those who
do not, reporting a mean score of 7.21 (SD =
1.8) for adolescents who stutter and a mean score
of 8.64 (SD = 1.2) for fluent adolescents.
r The Fear of Negative Evaluation (FNE) Scale
(Watson and Friend 1969) measures fear of neg-
ative evaluation by others. It is widely used as a
measure of this aspect of social anxiety and has
been shown to perform well as a specific mea-
sure of social evaluative concern (Stopa and Clark
2001). It consists of 30 true or false statements,
with a higher score out of 30 indicating greater
FNE. It was originally standardized on a popula-
tion of American college students, however Stopa
and Clark (2001) have established norms based on
a population of British university students. They
propose a cut-off point for low FNE at 7–8 and
below, and a cut-off point for high FNE at 20–22
and above. It has been shown to have satisfac-
tory test–retest reliability and is routinely used in
therapy and research (Musa et al. 2004).
r The Wright and Ayre Stuttering Self-Rating Pro-
file (WASSP) (Wright and Ayre 2000) measures
five aspects of stuttering: stuttering behaviours,
thoughts about stuttering, feelings about stutter-
ing, avoidance due to stuttering and disadvantage
due to stuttering. It is standardized on individu-
als who stutter aged 18 and over, although is also
widely used for older adolescents who are not yet
118
18, and has been shown to have good internal
consistency and high reliability. Norms are not
established, however, and interpretation of scores
is based on visual analysis. The authors report
‘extremely good’ test–retest reliability when the
WASSP was repeated at 1 week, followed by a
2-week interval, with Pearson’s Product Moment
Correlation above 0.8 (p < 0.005) for all sub-
tests, indicating that this measure can be used
at frequent intervals and change interpreted as
therapeutic.
r The Locus of Control of Behaviour Scale (LCB)
(Craig et al. 1984) measures the extent to which
adults perceive themselves as active agents in in-
fluencing their life experience and by implication
their stutter. Greater internality indicates that the
individual sees themselves as being an active agent
in influencing their speech. Andrews and Craig
(1998) found that a shift towards greater inter-
nality, together with increased knowledge about
fluency management skills and having a more
positive attitude about speaking, was associated
with long-term maintenance of therapy gains with
adults who stutter. However, the evidence for this
is equivocal and DeNil and Kroll (1995) did not
find an association between LOC and long-term
therapy outcomes in adults. The LCB scale con-
sists of 17 items arranged on a six-point Likert-
type scale; lower scores represent greater internal-
ity and a downward direction in scores is desirable.
Results
Participation
All three participants attended the full 10 days of the in-
tensive course. P1 attended the second and third follow-
up meetings, with attendance at the first and last meet-
ings prohibited by disruptions to air travel. He attended
a refresher day held for any teenagers who had attended a
therapy group at the centre in the previous 3 years, which
took place between the third and fourth follow-up for
his group. He did not ask for any additional individual
sessions. P2 attended the first and third follow-up days
and also attended a series of individual sessions with
his local speech and language therapist between these.
P3 attended all follow-up days and did not ask for any
additional individual sessions at the centre.
Analysis of percentage syllables stuttered
Participant 1
P1 made all requested video-recordings, although num-
ber 38 in phase D could not be analysed because of
poor recording quality. Inter-rater reliability was 0.980
for reading and 0.971 for conversation. Visual inspec-
Jane Fry et al.
tion of the data, which are shown in figure 1, shows
a marked reduction in frequency of stuttering early on
in phase B, with this remaining stable during phase C.
There is increased stuttering during phase D, at record-
ings 31–33 and 39, which corresponds to 2–4 and 9
months after the intensive course, respectively; however,
overall the frequency of stuttering appears to be less than
prior to treatment.
This is supported by statistical analysis. There was
no significant trend in phase A for either reading (z =
0.96, p = n.s.) or conversation (z = 0.46, p = n.s.),
meaning that any subsequent trend can be associated
with the effect of therapy. A significant downward trend
was found when phases A–C were aggregated in both
reading (z = 4.00, p < 0.01) and conversation (z =
4.64, p < 0.01). A significant trend was also found
when data from phase D were included for reading
(z = 3.80, p < 0.01) and conversation (z = 5.00,
p < 0.01). Analysis therefore indicated that the fre-
quency of stuttering reduced in response to treatment
and that this was maintained.
Participant 2
P2 submitted eight recordings for phase A, ten in phase
B, of which one conversation sample could not be anal-
ysed due to poor quality, eight for phase C, and four
in phase D. Inter-rater reliability was 0.957 for reading
and 0.990 for conversation. Visual interpretation of the
data, as shown in figure 2, and is less straightforward
than with P1. A downward trend is suggested when
phases A–C are examined, although clearly P2 has oc-
casions of more marked stammering in conversational
speech, notably at recordings 15, 18 and 33.
Statistical analysis established that there was no sig-
nificant trend during the baseline for either reading (z =
1.20, p = n.s.) or conversation (z = 1.32, p = n.s.). A
significant downward trend was found for both reading
(z = 2.32, p = < 0.01) and conversation (z = 1.80, p =
< 0.05) when phases A–C were aggregated, indicating
that the frequency of stuttering reduced in response to
therapy during this time frame. P2 made four record-
ings in phase D which are included in figure 2 but were
insufficient to allow an analysis of trend for this phase.
Participant 3
P3 completed 18 recordings throughout phases A–C,
and two recordings in phase D. These are included in
figure 3 but were insufficient to allow analysis of trend
in this phase. P3 was atypical in that he did not stutter
when reading, with both raters recording 0% stuttered
syllables in each speech reading sample. Analysis of trend
was therefore conducted on data from the conversation
task alone. Inter-rater reliability was 0.978 and intra-
rater reliability was 0.939. Visual inspection of the data,
Intensive group therapy for teenagers who stutter
Figure 1. P1 percentage stuttered syllables during reading and conversation.
as shown in figure 3, suggests that while P3’s stuttering
continued to vary, the range reduced, and with one ex-
ception at recording 27, the%SS remained below 2.5%
once he entered the therapy programme.
Statistical analysis established that there was no trend
in the baseline phase (z = 0.01, p = n.s.). A significant
downward trend (z = 2.77, p = < 0.01) was found
when phases A–C were aggregated, indicating a response
to treatment.
Self-report questionnaires
Participant 1
P1 scored below the mean for teenagers who stutter on
the SEA-Scale before treatment. As can be seen in figure
4, his scores increased during the intensive course, con-
tinued to increase steadily and passed the mean for fluent
adolescents 3 months after the course. P1 completed the
FNE on six assessment occasions and submitted one in-
complete form. As can be seen in table 1 his scores were
119
above the cut-off point for high FNE range prior to
the intensive course, however they fell to either below
or near the cut-off point for low FNE during the next
10 months. There was a slight increase in FNE at 3
and 10 months although this was relatively slight. P1
completed all questionnaires for the WASSP. As can be
seen in figure 5 his scores reduced sharply during the
intensive course itself and continued to do so during the
consolidation phase, remaining stable until 6 months
after the course. There was an increase in scores at 6 and
10 months, however overall his WASSP scores remained
lower following therapy than before. P1’s LOC scores
reduced during the intensive therapy phase, however,
increased after this and showed no overall shift towards
greater internality.
Participant 2
P2 completed the SEA-Scale on the first four occasions
only. He scored below the mean for teenagers who stut-
ter before treatment in phase A and showed increased
120
Figure 2. P2 percentage stuttered syllables during reading and conversation.
self-efficacy during the course itself, with his score at
the end of the course approaching the mean for fluent
adolescents. However P2’s SEA-Scale score had reduced
at the 5-week follow up and no further questionnaires
were completed. P2 completed the FNE on three oc-
casions, and one form was incomplete. His FNE scores
were all in the mid-range and while there was a reduc-
tion during the course this was also not sustained. As
before P2 completed the WASSP on the first four occa-
sions only. His scores reduced sharply during the period
of the course itself but this reduction was not sustained.
P2’s LOC scores dropped prior to starting the intensive
course and increased during the course itself.
Participant 3
P3 completed all questionnaires. His SEA-scale score
was initially below the mean for adolescents who stutter,
but increased during the course itself. While his scores
decreased after the group this was a short-term trend and
his score approached the mean for fluent adolescents
Jane Fry et al.
by the end of the study. P3 completed the FNE on
each assessment occasion. His scores before treatment
placed him at, or above, the cut-off point for high FNE,
and while his scores did not reach the cut-off point for
low FNE there was a steady decrease throughout the
period of the study. P3 completed all questionnaires for
the WASSP. These scores also reduced sharply during
the intensive period and while there was an increase
between the end of the course and the three month
follow up, overall there appears to be a stable downward
trend from 3 months post-course onward. P3’s LOC
scores increased prior to the intensive group, readjusted
during the group and overall showed no apparent shift
towards greater internality.
Conclusions and implications
The aim of this study was to investigate whether this
therapy programme was effective in reducing overt and
covert aspects of stuttering for the participants involved.
Two participants withdrew from the study during the
Intensive group therapy for teenagers who stutter
Figure 3. P3 percentage stuttered syllables during conversation.
baseline phase, and while not required to give a reason,
one volunteered that making the recordings increased
his self-consciousness about stuttering. It is assumed
that the other reconsidered the commitment involved
in the research methodology. Both withdrawees contin-
ued with therapy and there was no evidence that their
decision was linked to their engagement with the ther-
apy process. Analysis on the recordings received for the
participants who continued with the study was deemed
to have good inter- and intra-rater reliability.
P1 provided the most complete data of the three par-
ticipants and his data showed the most unequivocal, sta-
ble and durable reduction in overt stuttering behaviours
and the most evidence of change in self-reported ex-
perience of stuttering. Both visual analysis and mean
percentage stuttered syllables showed some occasions of
increased stuttering during phase D, however this was
not statistically significant in terms of overall trend. It
interesting to note that the higher frequency of stutter-
ing found at recordings 31–33 was accompanied by only
a slight increase in FNE, while SEA-Scale and WASSP
scores were unaffected. While P1’s speech may have been
somewhat less fluent at these points in time, it is possi-
ble that he gained broader skills from the therapy pro-
gramme than speech management skills alone, and as a
result was more psychologically resilient in dealing with
121
short-term variations in his fluency. Recording 39 also
showed a higher frequency of stuttering, however as it
was the final recording this cannot be placed in context.
Fluency is expected to fluctuate with chronic stuttering
and may be influenced by environmental factors, and
it is notable that this period coincides with the begin-
ning of the spring academic year when pressures with
coursework and mock examinations are often described
as high by clients within secondary education. As found
by DeNil and Kroll (1995) there is not an apparent
correlation between P1’s LOC scores and maintenance
of fluency gains, which invites consideration of the use-
fulness of this assessment. Overall, given P1’s fluency
gains, increased sense of self-efficacy, reduced FNE and
his reduced WASSP scores overall it can be concluded
that this 1-year therapy and follow-up programme was
effective for him. Of the three participants, P1 engaged
with the routine of completing homework tasks and
recordings the most consistently. His commitment to
this process may have been a reflection of his overall
commitment to therapy, which could be expected to be
a contributing factor to the outcome of therapy.
It was particularly important that a stable baseline
trend was established for P2 as he, in common with
many young people who stutter, entered the study with
extensive experience of therapy. He withdrew from the
122 Jane Fry et al.

Figure 4. SEA-Scale scores for P1, P2 and P3.

Table 1. Fear of Negative Evaluation (FNE) Scale scores for P1, P2 and P3

5 weeks First day Last day 5 weeks 3 months 6 months 10 months

Task pre-course of course of course post-course post-course post-course post-course
a
P1 25 8 8 12 7 10
a b b b
P2 13 11 17
P3 22 24 18 14 15 13 16
Notes: a Questionnaire incomplete.
b
Data not obtained.

study half-way through phase D and disengaged from
therapy, so progress beyond phase C is unknown and
the interpretation of his results needs to reflect that. His
stutter reduced significantly in frequency in the short-
term and appeared to stabilize well during phase C,
suggesting that an accumulation of skills and practise
was helpful for him in the short-term. However, data
obtained in phase D point to some destabilization of
skills at the time that he withdrew from therapy. P2 ex-
perienced increased frequency of stuttering on occasion,
as seen in figure 2 at recordings 15, 32 and 33. This
coupled with data from the other participants suggests
that fluency gains are particularly vulnerable approxi-
mately 6 months after intensive therapy, which could
be an artefact of the length of time after therapy or re-
lated to the environmental demands experienced at that
time in the academic year. P2 completed questionnaires
on the first four occasions only. In all four domains
measured his scores showed a positive shift during the
intensive course itself, however this was not sustained
Intensive group therapy for teenagers who stutter
Figure 5. WASSP scores for P1, P2 and P3.
once the group had finished. Overall, his results indi-
cate that intensive group therapy in itself was beneficial
in the short-term, but that he had difficulty maintaining
improvements beyond the context of the group, invit-
ing a consideration of why this might be, and whether
this might be related to internal or external factors. Of
the three, P2 had the most severe stutter in terms of
stuttering behaviours, and he had also received the most
therapy in the past, however his FNE and SEA-Scale
scores suggested that his stutter had less impact on his
view of himself and his confidence in speaking than it
did for P1 and P3. It may be that his stutter, while se-
vere, had less impact on his social interaction and was a
less central concern for him than might be anticipated,
and that this in turn impacted on the degree to which he
engaged in therapy in the long-term. It is also possible
that he needed more in terms of on-going follow up and
support after the course, although this is available on
request and he did not request further support.
123
The nature of P3’s stutter differed in that he was
fluent when reading and stuttered mildly in conversa-
tional speech. He had not had therapy before and his
SSI-3 score might preclude him from some clinical pro-
grammes. However, while having an overtly mild stutter
it is notable that his SEA-Scale score prior to treatment
was the lowest of all three participants, while his FNE
scores were high, suggesting that stuttering had a more
substantial impact for him than could be ascertained
by examining speech measures alone. This underlines
the importance of basing clinical decisions, and of mea-
suring change, in terms of client self-report as well as
measures of stuttered syllables, and of having sufficient
flexibility within a treatment programme to respond to
individual needs. Given the reduction in overt stuttering
behaviours, reduced FNE and increased self-efficacy and
the overall direction of WASSP scores it seems reason-
able to conclude that the year’s treatment programme
was effective for P3. P3 commented that he had learnt to
124
Figure 6. Locus of control of behaviour (LCB) scores for P1, P2 and P3.
slow down his rate of speech. While he had been aware
of this technique before he had not internalized it as a
concept. It may be that he was more ready for therapy, as
he approached transition to university, or that the group
context with its emphasis on personal responsibility for
change helped him to explore this idea in a way that he
had not done previously.
Both P1 and P3 both showed increases in stutter-
ing approximately 6 months after the intensive com-
ponent of the course and this is where P2 discontin-
ued therapy. This corresponds to a time of increased
coursework and examination demands within the UK
academic year and for this reason additional follow-up
days could be experienced as an unwanted pressure. It is
possible that distance sessions using tele-health would be
seen as a more positive option at this time as this would
minimize disruption to college schedules while provid-
ing additional support if required.
One of the challenges in studying this age group has
been a lack of robust self-report measures although this
Jane Fry et al.
more recently been addressed as new measures specific
to stuttering in adolescence have been developed. While
initially developed with an adult population, the FNE
is theoretically relevant and has apparent clinical value
in charting change. Two out of the three participants
reached the cut-off point for high FNE before therapy,
which is consistent with studies finding high scores on
measures of social anxiety amongst adults who stutter
(Kraaimaat et al. 2002, Stein et al. 1996). Both partic-
ipants then either reached, or approached, the cut-off
point for low FNE after therapy, supporting the use of
CBT and social anxiety measures in stuttering therapy.
There was no clear association between locus of control
and therapy outcomes in this study and the usefulness
of the LCB could be questioned. Finally, the importance
of measuring covert as well as overt features of stutter-
ing is highlighted by P3, who had very mild outward
stuttering but high anxiety about it.
The use of beyond-clinic measures demon-
strated that a medium-term treatment effect occurred
Intensive group therapy for teenagers who stutter
independently of the treatment setting for the partici-
pants studied. Limitations of this study include the need
for more substantive long-term follow-up although the
mobility of this age group and changing circumstances
and demands of adolescents’ lives makes this challenging
as demonstrated in the lack of complete data for P2 and
P3. The authors are mindful of this limitation and the
importance of interpreting the data with this in mind.
This study aimed to replicate a study described by
Fry et al. (2009), which used the same measures and
statistical analysis to investigate the impact of the same
intensive therapy programme on one participant. Sim-
ilarly to this study, Fry et al. found that the partici-
pant studied exhibited a trend of reduced frequency of
stuttering across treatment phases and consolidation
phases, consistently increasing SEA-Scale scores, as seen
in this study with P1. There was a similar picture when
examining LOC scores in that they moved in an un-
expected direction, with reduction in scores prior to
treatment and some increase in the B and C phases. The
participant in this initial study did not complete the
FNE and this could not be compared.
This therapy programme aims to equip clients with
skills that will enable them to manage both overt and
covert aspects of stammering more effectively. All three
participants showed a significant reduction in overt stut-
tering behaviours in the short-term, replicating the find-
ings of Fry et al. (2009). Participants who maintained
contact further through the period of the study contin-
ued to show reduced stuttering and positive changes in
those aspects of stuttering measured by self-report. On-
going engagement with the therapy process may be a
factor influencing long-term gains. While the interpre-
tation of results needs to be cautious due to the term of
data collection and the missing data for two participants,
this study adds to a previous single-subject study show-
ing evidence of the efficacy of this therapy programme.
As more data become available, it becomes possible to
examine the variability in responses to this therapy pro-
gramme and to begin to hypothesize about that factors
that may have an impact on outcome. With further con-
sideration it is hoped that in future it may be possible to
identify which young people are most likely to benefit
from this therapy programme, and what alternatives or
modifications should be considered for others.
Acknowledgements
The authors would like to acknowledge the contribution made by
Stephanie Ryder, Speech and Language Therapist for analysis of
data for P1 as part of her postgraduate degree, and the support of
Whittington Health and Action for Stammering Children. We would
also like to thank the participants for their efforts in contributing to
the study. This study was partially supported by funding from the
Rayne Foundation. The Rayne Foundation had no role in the design
of the study, collection, analysis or interpretation of data, writing up
125
or submission of this paper. Declaration of interest: The authors
report no conflicts of interest. The authors alone are responsible for
the content and writing of the paper.
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