Introduction

Stuttering, or stammering, is a developmental speech disorder that typically appears in children between 3 and 8 years [ 1 ]. It is considered a socio-communicational problem that can negatively affect an individual's mental, emotional, and social well-being and other aspects of life. Recognizing the dimensions of quality of life (QOL) in adults who stutter can be helpful in treatment planning and in preventing later mental, emotional, and social disorders [ 2 ]. Stuttering affects individuals of all ages and disrupts speech's usual fluency and timing patterns. More male children are affected by stuttering than female children [ 3 ]. Stuttering has been associated with differences in brain anatomy, functioning, and dopamine regulation, which are thought to be related to genetic causes. Accurate diagnosis or timely referral for children is crucial, as there is growing consensus that early intervention with speech therapy for children who stutter is critical. The mainstay of treatment for both children and adults remains speech therapy.

During the COVID-19 pandemic, a study examined the effectiveness of speech-language teletherapy services for school-aged children in the United States [ 4 ]. The study focused on how school-based Speech-Language Pathologists (SLPs) maintained clinical services via teletherapy during the pandemic closures. An online questionnaire survey was used to assess the provision of teletherapy following COVID-19 school closures, the types of technologies used to deliver teletherapy, the support offered by school districts, and the challenges in providing consistent therapy. Several online speech therapy systems have been designed and proposed in the literature; however, implementing these systems is still lacking. Additionally, the technical knowledge required to use these programs remains challenging for SLPs [ 5 ].

Collaboration between computer programmers and Speech-Language Pathologists (SLPs) can contribute to developing automated programs or applications that facilitate speech rehabilitation services. The increasing use of artificial intelligence in speech-language pathology has proven effective, as it provides various treatment approaches that patients can carry out at their convenience [ 6 ]. Due to the COVID-19 pandemic, it became difficult for children who stutter (CWS) to attend regular speech therapy sessions. Although online therapy sessions were offered, parents lacked understanding of how to use specific analogies for children with stuttering effectively. Consequently, there was a need to develop a prototype that would assist parents in teaching these specific analogies easily and efficiently, thereby reducing the frequency of in-person visits to therapy centers. This study was undertaken to develop a Speech Therapy Application for CWS (STACS). The prototype was designed to facilitate therapy for children with stuttering and evaluate its usefulness among parents of children with stuttering.

Methods

This study was conducted after obtaining approval from the Sri Ramachandra Institutional Ethics Committee (Reference No: CSP/21/OCT/100/535).

Development of the App

The app was developed based on three analogies commonly used in fluency therapy for children who stutter (CWS): the Lily Pad, Finger-Thumb, and Garden Hose analogies [ 7 ]. Initially, the content for each analogy was created. This content was then reviewed and discussed with IT professionals from the communications team at SRIHER. A skilled professional in artificial intelligence developed the application. The app was created using Flutter software, with particular attention to constructing an engaging landing page featuring all three analogies. A word list was also designed for children aged 3–6.

The app includes a brief description and a video demonstration for the three analogies. The app's main domains are categorized as follows:

1. Lilly Pad Analogy

2. Garden Hose Analogy

3. Finger-Thumb Analogy

Lilly Pad Analogy

This analogy features an animated video of lily pads and a frog (see Figures 1 & 2). The child is asked to pretend to be a frog. They are then prompted to repeat words from the word list. The frog moves smoothly to the next lily pad if the child can fluently articulate a word or syllable. However, if the child exhibits dysfluencies, the frog stays on the current pad or jumps into the water. The video helps parents identify dysfluencies and guides them in assisting the child in modifying their speech behavior.

Garden Hose Analogy

This analogy (Figures 3 & 4) features an animated depiction of a garden hose connected to a faucet. This technique compares the larynx to a faucet, the tongue to a garden hose, and the lips to a nozzle. If there is an obstruction in the hose, the water flow is reduced; similarly, any obstruction in the airway disrupts airflow and interrupts speech. This animated video illustrates the underlying cause of stuttering and demonstrates how to modify the child’s speech to promote greater fluency.

Finger-thumb Analogy

This analogy (Figures 5 & 6) uses the thumb and an opposing finger. The child is instructed to say a list of age- appropriate words sequentially from the word list. If the child can say the words fluently, the thumb will move smoothly from one finger to the other. However, if there is any block or dysfluency, the fingers will become stuck to the thumb and not move to the next finger. The child will be asked to repeat the words and demonstrate that the finger and thumb move smoothly as they speak fluently. The video demonstration aims to aid in providing an effective intervention.

Figure 1. Lilly Pad Analogy (image from the app)

Figure 2. Lilly Pad Analogy (description from the app)

Figure 3. Garden Hose Analogy (image from the app)

Figure 4. Garden Hose Analogy (description from the app)

Figure 5. Finger-Thumb Analogy (image from the app)

Figure 6. Finger-Thumb Analogy (description from the app)

Content and Face Validation of the App

The content and relevance of the app were evaluated by three experts in the field of fluency disorders. Changes were made to the application based on their suggestions regarding the content and animation videos. The experts subsequently re-verified the app, after which the prototype was evaluated by the parents of children with stuttering.

Evaluation of the App among Parents

A cross-sectional study design was conducted to evaluate the effectiveness of the application among parents of children with stuttering, aged between 3 and 12 years. Thirteen parents participated in this study. Informed consent was obtained from all parents before data collection. All parents had at least an undergraduate degree and were highly proficient in English.

Data was collected at the Sri Ramachandra Faculty of Audiology and Speech Language Pathology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University). The sample size was calculated as follows: it was assumed that 90% of the parents would consider the helpful application, with a 20% relative precision and a 95% confidence level. The minimum required sample size was determined to be 11. Assuming a 20% non-response rate, the sample size was increased to 13. Data was collected using a structured questionnaire to evaluate the effectiveness of the application from June 2022 to May 2023 at SRIHER, after obtaining written informed consent from the participants.

The questionnaire was divided into two sections. The first section focused on the demographic details of the participants, while the second section contained questions that evaluated the app's contents, including clarity of instructions, user-friendliness, ease of navigation between sections, and overall usefulness. Three experts in Speech- Language Pathology verified the questionnaire. The final version of the questionnaire was administered to evaluate the effectiveness of the application on 13 parents of children with stuttering.

Initially, the principal investigator introduced "what stuttering is, its types, and causes." The parents were given a general orientation on how the application works and how it can be used with their children. Subsequently, the parents were asked to explore the contents of the application and demonstrate the analogy to their child, helping them to understand it. Parents were given adequate time to familiarize themselves with the app's flow. Later, the parents were given a demonstration on how to administer the application with their children. After the data was collected, parents provided their valuable feedback.

Statistical Analysis

Data were entered into an Excel sheet, and data analysis was performed using SPSS software. Descriptive statistics were calculated for background variables. Parent feedback on the application was presented as percentages.

Results

The results were tabulated based on the responses obtained from each parent regarding the use of the application. Findings revealed that almost all parents found the instructions provided in the app to be easily understandable. Seventy percent of the parents rated the application highly satisfying regarding its usefulness for training their children with stuttering. Nearly 77% of parents found the application's functionality highly satisfying. Approximately 85% of the parents found the app user-friendly (Table 1).

When evaluating the app, it was revealed that parents easily understood the instructions provided. Regarding user-friendliness, 85% of the study population reported being highly satisfied. Regarding the app's usefulness, 69% of the population expressed high satisfaction, while around 77% were highly satisfied with its functionality.

The responses provided by the parents for each analogy were as follows:

The Lilly pad analogy was evaluated, and the results revealed that about 85% of the parents answered both questions correctly. The parents could relate the Lilly pad analogy to their child’s speech and understand how to use it for effective communication. They also gained a fair understanding of the various types of dysfluencies present in stuttering (Table 2).

The finger-thumb analogy was evaluated, and the results revealed that about 85% of the parents answered both questions correctly. The parents understood this analogy and found it relatively easier to use with their children compared to the other analogies. They could identify specific words that were more tense and difficult to produce, as opposed to other words that were produced more easily and fluently (Table 3).

The garden hose analogy was evaluated, and the results revealed that about 92% of the parents answered both questions correctly Table 4).

Discussion

The present study revealed that parents had a very favorable opinion regarding the prognosis and treatment of their child. The results show that parents found the app user-friendly and expressed confidence in its potential for effective treatment. Existing literature on the collaboration between AI and stuttering mainly focuses on building machine learning systems to identify and classify different types of dysfluencies, such as blocks, prolongations, sound repetitions, and interjections in speech utterances. These systems are typically trained on speech samples annotated for various dysfluencies [ 8 ]. However, several other apps for stuttering, such as Delayed Auditory Feedback, Speech Easy, STAMURAI, Speech Tutor, and Fluency Corner, provide various methods of assessment and treatment for stuttering [ 3 ].

Some apps above are primarily used to detect stuttering severity and cannot be incorporated into management [ 9 ]. Other apps focus on stuttering treatment, primarily emphasizing feedback systems. In contrast, the current study's app provided training to parents of children with stuttering, enabling them to monitor their child’s fluency skills. The main goal behind the development of this app was to ensure it was user-friendly for both the child and the parent, making it possible for them to engage in interactive therapy sessions at home or in a convenient location.

A qualitative study conducted in Sri Lanka [ 10 ] revealed that parents had limited awareness about the impact of stuttering and its management. Raising awareness about the adverse effects of stuttering and the available management techniques is essential. In response to this need, a prototype application was developed to serve as a guide for parents and to support their education. Studies conducted by [ 11 ] have confirmed that parents play a significant role in managing stuttering and bear increasing responsibility for their child’s prognosis.

The current application can be further enhanced by including additional analogies related to stuttering and an integrated feedback system. A significant strength of this study is that the application is the first of its kind to teach stuttering analogies practically and interactively to children with stuttering. However, a notable limitation is the absence of AI-generated feedback within the app.

Conclusion

The primary objective of this study was to develop an application that enables children with stuttering to engage in therapy conveniently from their homes. This app aims to reduce the need for frequent in-person visits to speech- language pathologists, particularly for families facing challenges in accessing therapy services due to distance or time constraints. Future research should focus on transforming this prototype into a more advanced application featuring AI-generated feedback to support parents in monitoring and improving their child’s fluency skills effectively at home.

Acknowledgement

The authors extend their sincere gratitude to the parents and children who willingly participated in this study and the Speech-Language Pathologists who contributed to validating the app content. Special thanks to the IT experts for their invaluable support and collaboration throughout the development and execution of this project.

Author contributions

Dr. Amudhu Sankar and Mr. Janith Raj J have contributed to:

1. The study's conception, design, data analysis, and interpretation.

2. Drafting the article and critically revising it for important intellectual content.

3. Final approval of the version to be published.

Conflict of Interest

The authors declare no conflict of interest.

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