For the speech-language pathologist who treats stuttering, telepractice holds great appeal. It allows treatment to be provided remotely to anyone, anywhere as needed. And that greatly enhances patients' access to speech-language services and helps provide equal care for equal need.
The challenge, of course, is ensuring that the quality of distance service provision is, indeed, equal to service provided in clinic. Researchers in several countries have examined the viability of telepractice as an alternative to in-clinic treatment for a variety of communication disorders, including stuttering. In particular, researchers in Australia have been working to tailor stuttering treatment for telepractice delivery. At first they tested a telephone-administered version of a treatment known as the Camperdown program (O'Brian, Onslow, Cream, & Packman, 2003). This speech restructuring treatment teaches stuttering control through use of a novel speech pattern, a strong focus on developing patient self-monitoring, and SLP-patient problem solving.
The telephone-administered program produced substantial and lasting reductions in stuttering that are comparable to those of traditionally delivered Camperdown treatment but in fewer clinician hours, according to results of a nonrandomized (O'Brian, Packman, & Onslow, 2008) and a randomized controlled trial (Carey et al., 2010). However, these studies did not use computer-based webcam options, and they didn't target any adolescents, only adults.
Why might adolescents be especially well suited for webcam-based treatment? First, from a developmental perspective, adolescents tend to crave independence (Coleman & Hendry, 1999) and seek peer acceptance (Noller & Paton, 1990). Webcam service provision allows adolescents to attend treatment independently without relying on parents for transport, and within the privacy of their homes.
Second, adolescence may be the last opportunity to treat stuttering before the verbal challenges of adulthood—which include furthering one's education, seeking jobs, and partnering—begin. Finally, most of today's adolescents are accustomed to using computers for social purposes (Desjarlais & Willoughby, 2010).
For these reasons, we decided to test the viability of using Web-based videoconferencing to deliver the Camperdown program to adolescents (Carey, O'Brian, Onslow, Packman, & Menzies, 2012).
As part of this Phase 1 trial, researchers provided treatment—entirely via Web-based videoconferencing during weekly, 30- to 60-minute sessions—to three adolescents with moderate to severe stuttering. Participants downloaded free software, including a program that permits digital audio recording and e-mailing of speech samples. After 13 to 24 sessions each, the adolescents showed marked, lasting reduction in their stuttering, and all three reported being comfortable with the technology. Here we take a closer look at their experiences.
When treatment began, Jenna was a 16-year-old girl living in Sydney, Australia, with her parents, who worked full-time, and three siblings, the youngest of whom was a toddler. Jenna reportedly began to stutter at age 4, and her stuttering was moderately severe, at 16.7% syllables stuttered (%SS) pre-treatment. Like many adolescents, Jenna led a busy life. She was in the second-to-last year of schooling, played soccer recreationally twice each week, and also worked part-time in a clothing store. As the oldest child, she often helped care for her siblings. This busy schedule resulted in some missed or postponed in-person appointments with an SLP.
Treatment sessions were held after school on a laptop Jenna took to her bedroom. Jenna established criterion stuttering reduction during the 13 sessions of Stage I Camperdown treatment, and so began Stage II, the maintenance component. Although they were supportive of Jenna's treatment, her parents had minimal active involvement in it. Jenna preferred to do the required speech practice with siblings and peers. Jenna showed an 88% reduction of stuttering severity from pre-treatment to post-treatment, and she maintained a 50% reduction 12 months later.
Her speaking-situation avoidance scores—a marker of social anxiety—showed little change from pre-treatment to post-treatment. On a scale ranging from 8 (no situation avoidance) to 24 (high situation avoidance), Jenna's score was 17 at pre-treatment and 15 at 12 months post-treatment.
In her post-treatment interview with an independent researcher, Jenna said what she liked most about the Web-based videoconferencing was that she didn't have to "race home from school and get ready and go somewhere" and could still help babysit her siblings. She said it had been "interesting" using a new program, but occasionally "frustrating" if there were Internet difficulties. Jenna said she found treatment "comfortable...because I was in my own house and in a more familiar place." She said if she attended further treatment, her preference would be for Web-based videoconferencing. Jenna's parents reported similar sentiments, saying the treatment was "convenient and time-saving."
At the start of treatment, Luca was a 15-year-old boy living in Sydney. He is a child of immigrants and has an older married brother. Luca reportedly began stuttering at age 9. The family spoke English at home, although Luca spoke Italian with some family and friends. Luca was in the second-to-last year of schooling and had high academic aspirations, describing himself as "a very capable and conscientious student." He was motivated to reduce his stuttering, which he felt might "hold him back" in the future. His preference was to practice his speech with uncles and cousins.
His pre-treatment stuttering was severe, at 21.8% SS, predominantly prolongations and blocks. Luca had his treatment sessions at home, in his bedroom. Although his parents were usually at home during his sessions, Luca preferred to attend treatment independently. When asked, he would invite a parent into the session to practice. Luca showed a 71% reduction of stuttering severity from pre-treatment to immediate post-treatment, and an 89% reduction from pre-treatment to 12 months post-treatment.
As was true for Jenna, Luca's speaking-avoidance scores showed little change from pre-treatment to post-treatment. His avoidance score was 17 at pre-treatment and 15 at 12 months post-treatment. This result highlights the potential need for anxiety management to accompany adolescent stuttering rehabilitation. He took 24 sessions to complete Stage I of the program.
In discussing his treatment experience, Luca said he found it both "convenient and comfortable," and that using a computer made treatment "more enjoyable." Luca said he enjoyed being introduced to "a new social networking system," which he looked forward to using with family and friends. Although Luca had not previously used a webcam, he described the program as user-friendly. He cited not having to travel or wait in a clinic waiting room as other advantages.
Luca said occasional Internet hiccups did not affect his progress and that he preferred Web-based videoconferencing to in-clinic treatment. Luca's father echoed these comments, saying "I think him being 16, his age is a whiz of the computer. In a way it made it enjoyable. It's like he doesn't get bored...it has become part of his everyday computer work. He doesn't mind even if a session goes for one hour. The bottom line is that, as parents, we can see that our son has improved."
Edward was a 13-year-old boy living in Canberra when treatment began. His mother reported that his stuttering onset was at age 2. Edward lived with both parents and a younger brother, age 11. His stuttering had triggered teasing and bullying from peers, and Edward reported avoiding speaking when possible. His pre-treatment stuttering severity was 9.2% SS. He had a 91% reduction of stuttering frequency from pre-treatment to post-treatment and 83% reduction from pre-treatment to 12 months post-treatment. He completed Stage I of the Camperdown program over 16 sessions, all of them attended by his father.
Consistent with reports from other participants, Edward reported occasional frustration with Internet disruptions. However, having had in-clinic treatment previously, he described the webcam treatment as "easier" because he could "just hop up on my computer instead of going to the clinic." Edward's speaking avoidance scores showed large and consistent reductions from pre-treatment to 12 months post-treatment, dropping from 19 to 9.
Edward's father said of the Web-based videoconferencing, "there was nothing that I didn't like." In particular, he said that past treatment had required much travel, which added to his son's anxiety and to financial costs. He said that Web-based videoconferencing had not diminished the therapeutic rapport: "[Edward] was just so relaxed. I think this is a big call but he is probably more relaxed with [his SLP] than he is at the school he goes to, and with his teachers. This is a big winner."
These results are encouraging, pointing to the value of testing delivery of services via Web-based videoconferencing in future clinical trials. For the three adolescents and their parents, the treatment was enjoyable, user-friendly, and convenient. It also produced substantial, lasting reductions in the adolescents' moderate to severe pre-treatment stuttering. Interestingly, the study suggested that some adolescents may retain clinically significant anxiety after treatment and require intervention for that anxiety.
We caution, however, that these results are only preliminary, and there is much work to be done. First, service delivery via Web-based videoconferencing needs to be tested in a much larger sample of adolescents, and, subsequently, randomized controlled evidence is required. To this end, we have initiated a Phase II trial of Camperdown treatment via Web-based videoconferencing with 16 adolescents. Data from this work will provide the next chapter in this ongoing story.
More information on the Australian Stuttering Research Centre and the Camperdown program can be found on the organization's website.