A Proof-of-Concept Study of Gamified Rhythmic Training in Preadolescents who Stutter

A Proof-of-Concept Study of Gamified Rhythmic Training in Preadolescents who Stutter | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Proof-of-Concept Study of Gamified Rhythmic Training in Preadolescents who Stutter Jamey, Kevin, Finlay, Sébastien, Foster, Nicholas E. V., Dalla Bella, Simone, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7963668/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Stuttering is a developmental speech fluency disorder linked to timing deficits in speech motor control. Given the shared neural mechanisms between rhythmic timing and speech production, rhythm-based interventions may hold promise for stuttering. This proof-of-concept study evaluated the feasibility and potential benefits of a gamified rhythmic training program, Rhythm Workers (RW), in pre-adolescents who stutter. Twenty-one children (aged 9–12) were randomly assigned to either RW or an active control game ( Frozen Bubble ) which they played at home for three weeks. We assessed feasibility as well as potential training effects on rhythmic, cognitive and speech-related abilities. Both games were well accepted, and compliance was moderate to high. Only participants trained on the rhythm game showed moderate enhancements in rhythmic synchronization, interference control, oromotor performance, and reduction of stuttering after training. The improvements (except for interference control) correlated with training dose. Moreover, some speech-related gains were associated with improved rhythmic performance, pointing to a possible causal link. While some effects did not reach statistical significance due to the limited sample size, the observed dose–response patterns and domain-specific improvements support the feasibility and promise of rhythmic gaming for young people who stutter. This study provides preliminary evidence that rhythm-based serious games can enhance speech and cognitive outcomes in adolescents who stutter. Psychology rhythm training stuttering speech sensorimotor and executive functioning Figures Figure 1 Figure 2 Figure 3 Graphical Abstract Summary This proof-of-concept study tested a gamified rhythmic-training app, Rhythm Workers, in preadolescents who stutter. Over three weeks, participants trained at home and were compared to an active control game. The rhythm group showed dose-dependent improvements in rhythmic synchronization, interference control, oromotor accuracy, and speech fluency. These findings highlight the feasibility and therapeutic promise of rhythm-based serious games to enhance speech and cognitive-motor skills in youth who stutter. Figure 3 - shows change scores (T2-T1) after training on speech tasks by game – (A) correlations between the errors as a percentage of all words produced in the diadochokinesis task (oromotor errors) and cumulative playing time, (B) correlations between inter-word-interval (in seconds) of the diadochokinesis task (oromotor speed) and cumulative playing time (C) correlation between the percentage of stuttered syllables (from overall ~300 syllables; stuttered dysfluencies) and cumulative playing time, (D) the relationship between reduction of stuttering as a function of improvement in rhythmic abilities on the Paced Tapping Index (PTI) Stuttering, also known as developmental stuttering or childhood-onset fluency disorder (DSM-V), is a neurodevelopmental speech motor disorder characterized primarily by involuntary disruptions in the flow of speech 1 . These disruptions manifest as repetitions of sounds or syllables, prolongations of sounds, and blocks (temporary inability to initiate speech despite the intention to speak). Stuttering is sometimes accompanied by secondary behaviors (e.g., facial tension, physical movements) and can vary in frequency and intensity depending on the communicative context 2 . The condition typically emerges between ages 2 and 5, with a prevalence of approximately 5-8% in early childhood 3 . Many children recover naturally without specialized intervention, and estimates suggest that around 70–80% of affected children eventually attain fluent speech, often by late childhood or early adolescence. However, stuttering persists into adulthood in the remaining 20-30% of children with initial stuttering symptoms, corresponding to about 1% of the general population 4 . While stuttering is not caused by psychological factors, it often leads to significant psychosocial consequences, including anxiety, reduced social participation, and social stigma 5 . Previous research has found that rhythm and timing play a prominent role in stuttering (see Falk, 2025, for an overview). Neuroscientific studies have converged on the basal ganglia–thalamo–cortical (BGTC) loop as a key pathway disrupted in stuttering 6–8 . The BGTC circuit, which includes the putamen, thalamus, supplementary motor area, and inferior frontal gyrus, is involved in initiating and sequencing motor actions, including speech, and in rhythmic processes beyond speech 9–15 . Altered BGTC connectivity is thought to contribute to the untimely initiation or inhibition of speech motor programs in stuttering 7,16 . Moreover, the cerebellar–thalamo–cortical pathway, which also contributes to externally paced timing tasks such as synchronizing to a metronome, has been shown to be over-recruited in people who stutter, which can be interpreted as a compensatory response to weakened BGTC function 17–20 . Importantly, speech and rhythmic timing share overlapping neural circuits for auditory-motor coupling, particularly within the BGTC system 21 . In line with this idea, individuals who stutter display weaknesses in musical rhythm tasks 22–24 . Falk et al. (2015) found that children and adolescents who stutter exhibited reduced synchronization accuracy and greater timing variability compared to controls when tapping to a metronome or music (i.e., beat synchronization). These timing alterations were more visible in those with persistent or severe stuttering and were not explained by general motor variability, suggesting specific impairments in auditory–motor integration and predictive timing mechanisms. These findings provide a compelling rationale to explore whether rhythm training can enhance speech-related motor timing in stuttering. This idea was first proposed by Fujii & Wan (2014), introducing their Sound Envelope Processing and Synchronization/Entrainment to a Pulse (SEP) hypothesis. The authors suggest that strengthening auditory-motor coupling in the BGTC via beat synchronization training may positively affect speech motor control. Rhythmic interventions built on beat synchronization may stimulate the shared neural timing network, promote temporal speech motor control, and, potentially, improve fluency outcomes in individuals who stutter 8 . However, beat synchronization tasks also engage neural systems involved in executive functioning, in particular attentional processes 13,26 . Hence, it is a possibility that rhythm training in individuals who stutter could also lead to benefits in speech production via enhanced executive functioning. In recent years, rhythm training has shown promise for enhancing motor, attentional, and other cognitive skills in various populations. Rhythm-based serious games 27 were originally tested in Parkinson’s disease 28,29 These studies showed improvements in rhythm perception and motor variability as well as a reduction of errors in manual and oromotor tasks after the training, in this group. Rhythmic skills were trained through finger-tapping to a musical beat, focusing on explicit timing precision and structured motor engagement. More recently, similar training through beat synchronization has been used to support executive functions in developmental populations, providing first evidence of increased interference and inhibitory control in typically developing children 30 , as well as in children with neurodevelopmental conditions such as ADHD 31 and autism 32 . Aims and hypotheses Building on these advances, our study applies a serious gaming approach for rhythm training to pre-adolescents with developmental stuttering. While this age group has a relatively long history of stuttering, neuroplasticity during adolescence can still lead to remissions 33 , potentially facilitated by rhythm training. Generally, music-based rhythmic training in stuttering remains largely unexplored. Given the potential overlap between timing deficits and speech fluency difficulties, such tools may hold promise for supporting speech functions in stuttering. Our goal is to conduct a proof-of-concept study, to evaluate the use of a rhythm-based serious game (Rhythm Workers, RW) in comparison to a motor control game (Frozen Bubble, FB) in developmental stuttering. Our primary goal was to assess feasibility, focusing on the compliance and acceptance of the training protocol by participants. We monitored if participants could engage with the training regularly, adhere to the sessions over the course of the protocol and whether they accept the game overall. We also verify known training effects in this age group, but unspecific to stuttering; first, whether the core training target is reached, that is, playing the rhythmic game enhances rhythmic abilities measured via a standardised mobile battery assessing rhythmic abilities 34 , 35 . Second, whether we can observe potential effects on executive functioning, in particular interference control (Flanker task), which increased in pre-adolescents with ADHD and autism after a similar rhythm training 31 , 32 . Finally, to decide whether rhythm training holds promise for stuttering, specifically, we investigate potential transfer effects of rhythm training on speech motor skills and stuttering symptoms. Here, we assess potential improvements in basic oromotor skills as well as the reduction of stuttered dysfluencies. Improvement in oromotor skills (measured through a diadochokinetic task) could be beneficial in sustaining more stable articulatory processes in stuttering 28 . Reduction of stuttered dysfluencies after rhythm training would be the most direct evidence for potential benefits. In relation to this effect, we also examined the potential basis of speech effects, by testing whether potential improvements in either speech-related skill are related to enhanced rhythmic abilities and executive functioning. Methods Participants Twenty-four French-speaking participants who stutter between 9 and 12 years were recruited in the province of Québec, Canada, between July 2022 and August 2024. According to parental reports, participants self-identified as having a stutter and did not show any speech or language difficulties aside from stuttering, nor any hearing, physical, or cognitive developmental disorders. Three participants were excluded from the training study following recruitment: two based on a parental report of comorbidities after enrollment and one withdrew after the initial testing due to lack of availability. The final sample was composed of 21 pre-adolescents who stutter (mean age 10.8 ± 1.3; 8.8–12.5 years) including 9 females. Ten of them had musical training, and 5 were left-handed. According to the Stuttering Severity Instrument–4 36 , stuttering severity in the sample was mostly very mild and mild ( n = 13), with a few participants in the moderate ( n = 5), and severe range ( n = 3). Participants were assigned to either the rhythmic game (RW) or the non-rhythmic game (FB). Initially, the first six participants were randomly assigned to either group. Thereafter, stratified randomization based on sex was implemented to ensure an even distribution of boys and girls across both groups. The groups did not differ in handedness ( p = 0.64), musical training history ( p = 1.0), video game use ( p = 0.21), and socioeconomic status ( p = 0.62), tested via χ2 tests or Fisher tests. Moreover, they were comparable in baseline cognitive abilities (IQ, short-term memory, response inhibition), as well as in stuttering severity, both subjectively (OASES-S 37 ) and objectively (% stuttered syllables on the SSI-4 36 ), as summarized in Table 1. Table 1 Comparison between the two game groups at baseline (Mann-Whitney tests) Characteristics RW group (n = 11) FB group (n = 10) M SD min max n M SD min max n p Age (month) 128.1 16.1 105 150 11 130.1 16.3 108 50 10 0.56 Stuttered dysfluencies 5.2 6.8 0.3 22.6 11 1.9 1.8 0 5.2 10 0.22 OASES-S 2.1 0.5 1.5 3.3 11 2.1 0.4 1.5 2.4 9 0.82 IQ (Raven’s Matrices) 99.2 15.3 75 124 11 101.3 11.8 86 120 10 0.61 Response inhibition (A’; Go/No-Go task) 0.92 0.03 0.87 0.96 10 0.91 0.07 0.74 0.97 8 0.76 Interference control (flanker accuracy) -0.02 0.05 -0.10 0.07 10 -0.02 0.04 -0.11 0.05 8 0.89 Interference control (flanker speed) -0.04 0.04 -0.13 0.00 10 -0.07 0.07 -0.19 0.03 8 0.32 Cognitive flexibility (Set-shifting accuracy) -0.06 0.10 -0.21 0.09 10 -0.09 0.23 -0.46 0.34 8 0.63 Cognitive flexibility (Set-shifting speed) -0.38 0.12 -0.60 -0.19 10 -0.51 0.41 -1.29 0.21 8 0.15 Short-term memory (N-back 1) 0.93 0.08 0.75 1.00 10 0.92 0.11 0.66 0.99 8 1.00 Short-term memory (N-back 2) 0.87 0.08 0.79 0.99 10 0.75 0.23 0.41 0.96 8 0.72 Abbreviations: M, mean; n, number of participants per group; SD, standard deviation of the mean. Procedure and training protocol The study included three assessment points: baseline (T0), pre-intervention (T1), and post-intervention (T2), each separated by approximately three weeks. Each testing session lasted 3 hours. Testing sessions were separated in two parts whose order was counter-balanced across participants: non-verbal testing, which included executive functioning and rhythmic abilities, and verbal testing, which included stuttering assessment and articulatory performance, among some other tasks not reported here. Testing occurred online via the online platforms Zoom (non-verbal testing), JATOS using the BRAMS online testing platform (executive functioning 31 and IRIS; verbal testing). At the end of the second testing session, a non-blinded research coordinator explained the game to the participants. Once participants understood the instructions, they started playing the game. A Samsung Galaxy Tab A 8.0” (2019 model, SM-T290) tablet was provided for the study, featuring a 2GHz processor, 1280 x 800 pixels display resolution, and 32 GB of RAM. All materials required for the study, including the tablet, which contained the game assigned to the participant and a standardized rhythmic assessment application, a gooseneck phone holder, a Samson SR850 headphones, a Marantz professional M4U microphone, paper questionnaires, game-specific instructions and sanitizing kits, were mailed to participants via postal and courier services. Participants used the touchscreen to navigate and play the applications, while the headphones were used to play the sounds and music from the applications. Participants were instructed to play their assigned game for 30 minutes a day, five days a week, for three weeks (target of 450 minutes of game engagement – how long the session is reported by participants and how much time was logged operating the game application). They were also informed that they could play more if they wished but were advised not to exceed one hour of gameplay per day. Participants were asked to log their daily gameplay in a handwritten journal. During gameplay, time is also spent navigating menus, receiving medals, and launching levels. To accurately assess active engagement, we logged cumulative playing time, defined as the total minutes spent in live gameplay within levels. Prior studies with these game versions indicate that cumulative playing time can be up to 30% lower than the total time spent within the app. To estimate training duration (dose), we adopted this more conservative metric. We considered approximately 300 minutes of cumulative gameplay as a benchmark for good compliance in this study. Rhythmic “Serious Game” This proof-of-concept study incorporated an adapted version of Rhythm Workers (RW), a rhythm-based training game originally developed for adults 27 . Specific design adjustments tailored for a pediatric population are detailed in Jamey et al. (2025). Players tap in time with the musical beat to build a virtual building with progression tied to tapping performance. For example, when players tap with perfect consistency for 8 beats, they get 100% accuracy which contributes to their general score. When the general score reaches a certain threshold, a new floor rises on the virtual building. The goal is to finish the building within a given time limit. There is a total of 32 distinct levels, each built around a unique music stimulus ranging from 2 to 4 minutes long and presented at a consistent tempo. All 32 levels must be completed to finish the game. Difficulty is increased via the rhythmic complexity of the musical stimuli. Scoring was calculated using the same accuracy metrics as described in Bégel et al. (2018). The control game was a modified version of Frozen Bubble (FB), adapted from an open-source Android build hosted on GitHub ( https://github.com/videogameboy76/frozenbubbleandroid ). This arcade puzzle shooting game challenges players to eliminate clusters of colored bubbles by launching matching ones from a cannon using touch input. The same music as RW is played in the background but players do not need to synchronize to it to progress in the game. The upper rows of bubbles steadily move downward and play ends if the bubbles reach the bottom edge of the screen. The objective is to match and clear groups of three or more identically colored bubbles, which also causes any attached lower bubbles to drop. For a visual overview of the RW and FB game environment and further details see Jamey et al. (2025). Feasibility: Evaluation of Game Compliance and Acceptance We quantitatively evaluated participant compliance by collecting data recorded on the tablet device including: the time spent per session (target ~ 450 minutes), in active gameplay (cumulative playing time, target ~ 300 minutes) and the total number of taps on the screen. A short debriefing was requested from participants and not mandatory. Children were asked to provide information about their level of enjoyment of the game on 5-point Likert scales (1 = boring, 5 = very fun). They were asked how they felt about playing the game for 3 weeks, if they would play for another 2 weeks and 4 weeks. Other items included whether they found the game difficult to play, how often they felt frustrated, how they felt time went by and whether they would recommend others play the game. Outcome measures We evaluated rhythmic, executive functioning and speech performance at baseline (T0) and (T1) and change scores by subtracting post- minus pre-training means (T2-T1). Participants whose change scores on any task construct (e.g., flanker accuracy) exceeded ± 3 standard deviations from the group mean were considered outliers and excluded from the analyses, along with their corresponding T1 and T2 scores. For example, one participant scored 100% incorrect responses on the Flanker task at T1 and 76% at T2 – a pattern that is implausible as an effect of training and suggests task disengagement or error. Sample sizes vary slightly across tasks due to remote testing constraints (such as internet interruptions), occasional participant fatigue affecting whether a task was finished, and the exclusion of outliers exceeding ± 3 SD from the group mean. Core training effect: Rhythmic abilities We evaluated rhythmic abilities using sensorimotor tasks from Battery for the Assessment of Auditory Sensorimotor Timing Abilities (BAASTA 34 , 35 ), which has been previously used in children, including those with developmental disorders 38 , 39 . In paced tapping tasks, participants tapped the index finger of their dominant hand in time with either a metronome (inter-onset intervals: 450 ms, 600 ms, 750 ms) or a musical sequence (inter-onset interval: 600 ms). We computed logit-transformed vector lengths to quantify tapping consistency—that is, the regularity and temporal alignment of taps occurring at the same rate as the cued stimuli. A value of 1 indicates perfectly isochronous tapping. For unpaced tapping tasks (regular and fast spontaneous tapping), we quantified motor variability using the coefficient of variation of the inter-tap intervals (CV-ITI). CV-ITI was calculated as the standard deviation of the inter-tap intervals divided by their mean 40 . Tapping consistency and CV-ITI subtask values at each time point were z-scored using the group mean and standard deviation from the pre-training session (T1), allowing for standardized comparisons of change over time. To align the directionality of change with other tapping consistency measures (e.g., vector length), z-scored CV-ITI values were inverted so that higher scores reflected lower variability (i.e., better performance). If T1 or T2 scores were missing for a specific task, the corresponding single T1 or T2 score was excluded from analyses. We averaged the z-scores of each task (Music, Metronome 450 ms, Metronome 600 ms, Metronome 750 ms) by time point (T1 and T2) to form a paced tapping index. Unpaced tasks were averaged similarly to calculate an unpaced tapping index. Exploratory Hypothesis: Executive functioning We administered the Eriksen flanker fish task to assess interference control. On each trial, participants saw either one or five fish aligned horizontally and indicated the direction of the central fish (left/right) by pressing a key, ignoring the surrounding (flanking) fish. Trials were either neutral (single fish), congruent (flankers swam the same direction), or incongruent (flankers swam opposite). Each trial allowed 2000 ms to respond (500 ms stimulus + 1500 ms fixation), with a 750 ms fixation cross preceding each. The task included 96 trials and lasted 3–5 minutes. After removing incorrect or premature responses, raw response times (RTs) below 200 ms and above 1000 ms were excluded, to capture performance ranges related to interference control. Following prior studies, we calculated proportional RT from RT values as a sensitive measure of change in executive functioning after intervention 41 , 42 . The proportional RT (interference control speed) was computed as (Congruent RT – Incongruent RT) / (Congruent RT), where higher (less negative) scores indicate better attentional functioning. Finally, we computed the difference between the proportional RT of congruent and incongruent trials. The same procedure was used for calculating the proportion of correct responses (interference control accuracy). Transfer to speech-related skills: Oromotor skills The oral diadochokinesis (DDK) task was used to assess articulatory performance by measuring participants’ ability to produce rapid, repetitive syllable or word sequences. DDK is a standard maximum performance task to measure articulation speed and accuracy 43 . It is widely used in speech-language pathology to assess oromotor speech function, particularly in the context of acquired motor speech disorders such as dysarthria and apraxia of speech 44 . Importantly, although the task measures aspects of speech motor control, it does not assess “fluency” in the sense of stuttering-related disfluencies. Findings regarding DDK performance in developmental stuttering are mixed, with some studies suggesting differences in sequencing or variability of rates 43 . Nevertheless, DDK remains a useful measure to explore potential transfer to oromotor skills, as it does not directly overlap with stuttering severity. Participants were first introduced to the task through a structured familiarization phase, in which they were shown the pseudo-word (/pataka/) on a screen. This classical stimulus is used in sequential DDK tasks because it combines bilabial, alveolar, and velar places of articulation in a rapid sequence 44 . Using a pseudo-word rather than isolated syllables ensures that all participants produce the sequence with a consistent prosodic pattern, including word-final accent, final lengthening, and predictable pauses, minimizing variability that could arise if syllables were produced individually. Participants were asked to read it aloud, and then prompted to repeat it progressively first once, then three times, then five times to familiarize themselves with the required task. In the test phase, they were instructed to take a deep breath and repeat /pataka/ as quickly and accurately as possible until they ran out of air, completing two recorded trials. The task was repeated if participants did not follow the instructions, experienced severe speech initiation problems due to stuttering or ran out of breath after only two or three words, and in cases where a participant could not complete it, an additional attempt was made at the end of the session or in a subsequent visit. To evaluate oromotor skills, we calculated the number of oromotor errors and oromotor speed (i.e., interword-intervals, IWI). Higher oromotor speed (i.e., shorter IWIs) and fewer errors indicate higher oromotor skills 45 . Six types of errors were coded, following guidelines provided by Yaruss & Logan (2002): (1) insertions or (2) deletions of sounds (e.g., production of incomplete sequences), (3) changes in voicing or (4) placement, (5) exchanges between sounds, and (6) perseveration of sounds. The percentage of words containing errors over all words produced was calculated to obtain a measure of oromotor errors (error %). For oromotor speed assessment, we segmented the duration of IWIs using Praat 46 , a standard approach to measuring articulation rate 47 , beginning with the burst of /p/. Oromotor speed was derived from these intervals, with shorter mean IWI duration reflecting faster production speed. It is important to note that this measure was intended to capture oromotor timing, not speech fluency in the clinical sense (i.e., absence of stuttering). Transfer to speech: Stuttered dysfluencies To assess speech dysfluencies, we measured stuttered dysfluencies using the percentage of stuttered syllables in a naturalistic speech sample, following the procedures outlined in the Stuttering Severity Instrument (SSI-4 36 ). Participants produced both a spontaneous and a read speech sample at each time point. After the testing, a research assistant counted a total number of ~ 300 syllables per sample and the number of stuttered syllables therein. The percentages of stuttered syllables for both spontaneous and read speech, were averaged to obtain a composite dysfluency score per time point. Statistical tests To evaluate changes related to game play (post-training (T2) minus pre-training (T1)) and effect size estimate between groups, we used independent samples t-tests and if assumptions for parametric testing were not met, the Mann-Whitney test from the rstatix package in R Studio 48 . Effect size interpretations were based on 49 . Normality was tested using the Shapiro-Wilk test and homogeneity of variance using Levene’s test. Spearman correlations were calculated between the outcome measures and training dose (cumulative playing time). We conducted one-tailed tests when assessing change scores based on the theoretical proposal that training rhythmic abilities would improve rhythmic, executive functioning and speech abilities 8 , 21 , 25 , and empirical evidence that rhythmic training improved some of these functions in previous studies 28 , 31 . Ethical approval The study received prior approval from the ethics board of the University of Montreal (CEREP-21-063-P) and the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (CIUSSMTL 2024 − 1926). Written informed consent was obtained from all participants’ parents and all participants assented orally. Results Pre-training comparisons for rhythmic, executive and speech functioning Participants did not differ on any of the rhythmic tasks between games at T0 (p ≥ 0.16) and T1 (p ≥ 0.34). There were no baseline differences on any of the executive functioning scores between games at T0 (p ≥ 0.14) or T1 p ≥ 0.24). We also found no statistically significant differences in baseline measure between games on any of the speech tasks (oromotor measures or dysfluencies) at T0 (p ≥ 0.14) or T1 p ≥ 0.10). Feasibility: Compliance & acceptance Participants playing RW (M = 283 minutes; SD = 131; range = 59-504) and FB (M = 279 minutes; SD = 151; range = 119-495) accumulated similar playing time, W = 56, p = 0.97, showing a satisfactory compliance. Twelve participants showed high compliance (88-168 % of the target time of 300 min of actual game play), eight participants showed moderate compliance (39-65% of the target time) and 1 participant showed poor compliance (17 % of the target). Participants in RW (M = 23819 taps; SD = 10898 taps; range = 5531- 45458 taps) and FB (M = 17884 taps; SD = 11864 taps; range = 6490- 38630 taps) showed similar total number of taps recorded on the tablet, W = 72, p = 0.25. Hence, there was a comparable amount of motor engagement with both games over the training period. Approximately 55% of participants (12/22) voluntarily provided feedback about their experience playing the game (acceptance). Overall, children in both groups reported high levels of enjoyment and engagement with the game. Ratings of global motivation after three weeks were generally positive and very high with no statistically significant differences between Rhythm Workers (M = 4.0/5) and Frozen Bubble (M = 4.6/5), p = 0.10. Willingness to continue playing for 2 or 4 more weeks, perceived difficulty, frustration, and subjective flow did not differ significantly between groups ( p > 0.80). On average, both groups rated the game as moderately difficult and reported low levels of frustration. Children also indicated that time went by relatively quickly while playing, and most participants were willing to recommend the game to others. Together, these findings suggest a generally positive user experience, with no significant differences in acceptability between groups. Effects of RW training on rhythmic abilities Here we test the hypothesis that rhythmic abilities (paced and unpaced tapping) are higher in the RW compared to FB after training. An independent samples t-test revealed that the RW group, on average, improved their rhythmic abilities more than the FB group, but this effect did not reach statistical significance, t (17) = 1.33, p = 0.10, one-tailed (Fig. 1A). As expected, for those who played RW, cumulative playing time was positively correlated with improvement in paced tapping, ρ = 0.77, p = 0.004 (Fig. 1B, one-tailed), but not FB (p = 0.36). Baseline scores were not related to change scores for paced tapping ( p > 0.46). There were no differences between games for unpaced tapping, W = 58, p = 0.14, nor was there a relation with training dose ( p > 0.56). Exploring executive functioning: Enhanced interference control after rhythmic training Fig. 2 shows the results for interference control as measured by the incongruence effect of the flanker task on speed and accuracy 31 . A one-tailed independent samples t-test revealed that the RW group (M = 0.89) performed significantly better than the FB group (M = –0.45), t (16) = 3.03, p = 0.004, with a large effect size, d = 1.43, 95% CI [0.37, 2.46] (see Fig. 2A). Cumulative playing time was not correlated with interference control speed improvement for either game ( p > 0.31, Fig. 2B). No difference or correlation was found for interference control accuracy, suggesting only speed-specific improvements in this sample. Note, that for those who played RW, baseline scores on this measure were negatively correlated with improvement on rho = -0.65, and on the cusp of statistical significance, p = 0.067. This was not the case for FB ( p = 0.27), highlighting that those with lower pre-training scores (T1) on the Flanker task tended to improve more on that task after RW training. Speech effects: improvements in oromotor skills and dysfluencies To assess whether rhythmic training is likely to transfer to speech-related skills (enhancing oromotor control and reducing stuttered dysfluencies) we compared change scores after training between RW and FB and as a function of training dose (cumulative playing time). Oromotor skills – errors and speed One participant not correctly performing the DDK task (breathing between every word) was excluded from further analyses. To test oromotor errors (%), we performed a one-tailed Wilcoxon rank-sum test to compare error percentages between RW (M = -5.60; SD = 10.58) and FB (M = 0.71; SD = 5.10) and found a significant difference ( W = 26.5, p = 0.041), with a moderate effect size ( r = 0.46). To assess oromotor speed (Inter-Word-Interval in seconds) between RW and FB we used a one-tailed Welch’s t -test and found no significant difference between games ( p = 0.741). To examine whether training dose (i.e., cumulative playing time) was associated with less oromotor errors, one-tailed Spearman’s rank-order correlations were computed between cumulative playing time and errors within each group. A negative relationship between training dose and error rate change was detected (Fig. 3A) in the RW group, ρ = –.62, p = 0.030. That is, with more RW training, participants showed a reduction of up to 23 % in oromotor errors. No such relationship was observed in the FB group ( ρ = .01, p = 0.5). For oromotor speed (Fig. 3B), no significant association was found in the RW group ( ρ = .22, p = 0.54, two-tailed since there could be speed-accuracy trade-offs in the task going in both directions). In contrast, the FB group showed a strong negative correlation ( ρ = –.76, p = 0.016 with participants speeding up their production up to 80 ms per IWI on average. Overall, this pattern of results suggests that participants playing RW were producing less oromotor errors (as expected), while participants playing FB were attaining higher oromotor rates, contrary to expectations. An ad-hoc Spearman correlation between change scores in oromotor errors and speed suggests a potential speed-accuracy trade-off in the RW group, however the correlation did not reach statistical significance, ρ = -0.62, p = 0.06. There was no sign of a speed-accuracy trade-off for FB ( p = 0.63). Stuttered dysfluencies Two participants who received speech therapy during the study were excluded from fluency analyses. A one-tailed t -test revealed that the RW group (M = –0.27) did not have significantly lower percentage of stuttered dysfluencies in naturalistic speech than the FB group (M = 0.47), t (17) = –1.28, p = 0.11, 95% CI [–∞, 0.27]. However, in the RW group, there was an association between the reduction of stuttered dysfluencies and cumulative playing time, ρ = –.72, p = 0.018, (one-tailed). As can be seen in Fig. 3C, the reduction reached 1-2 percent (~ 3-6 stuttered syllables in 300 syllables) of dysfluencies post-training. In contrast, no significant association was found in the FB group, ρ = .27, p = 0.45. Relationships between rhythmic, attentional and speech improvements Finally, we tested whether improvements in rhythmic abilities or cognitive abilities were associated with gains in oromotor skills or with reduction of stuttered dysfluencies. We found a negative association between rhythmic and dysfluency scores ( ρ = –.63, p = 0.038, one-tailed) in the RW group, but not in the FB group (Fig. 3D). That is, participants who showed greater improvement in paced tapping following RW training exhibited fewer stuttered dysfluencies during both read and spontaneous speech. This finding suggests that the relationship between motor timing and speech improvement may be specific to the rhythm-based intervention. There were no statistically significant correlations between rhythmic and oromotor improvements ( p = 0.09 for errors, and p = 0.15 for speed). In the RW group, there was an unexpected positive correlation between improvements in executive function and slowing of oromotor speed ( ρ = .74, p = 0.046, two-tailed), but nothing in the FB group ( ρ = –.22, p = 0.581). However, interpretation of this correlation remains difficult, as no clear mechanistic explanation is evident and visual inspection suggests the effect may be driven by a few influential datapoints. Additionally, there were no significant associations between improvements in attention and speech measures, nor between changes in oromotor errors and Flanker performance in either group (RW: ρ = –.24, p = .582; FB: ρ = .30, p = 0.437). Discussion In this proof-of-concept study, we used a gamified approach to examine the effect of rhythmic training to enhance speech production in pre-adolescents who stutter 8 , 25 , 50 . Here, we focused on potential benefits of rhythm training by comparing the effect of a rhythm-based training game on tablet 27 , 31 , to a non-rhythmic active control game. Training with a gamified approach for three weeks was generally successful in our sample, showing moderate to high compliance and reporting that participants generally enjoyed playing the games for 3 weeks. Hence, we conclude that feasibility goals were met and that we can recommend this approach for future studies. The present findings provide partial support for the hypothesis that rhythmic training enhances rhythmic tapping performance in children. While the RW group exhibited, on average, greater improvement in paced tapping compared to the FB group, this effect did not reach statistical significance. However, the direction of the effect and the moderate effect size suggest a potential benefit of rhythm-based gameplay on sensorimotor synchronization. Crucially, within the RW group, cumulative gameplay duration was strongly associated with improvement in paced tapping performance. This dose–response relationship suggests that extended engagement with the rhythmic game may promote entrainment and timing precision, consistent with previous literature on rhythm-based interventions (e.g., 25,31,51 . Baseline performance did not predict change, suggesting that the observed improvements were not merely due to regression to the mean or initial skill level. Together, these findings support the feasibility and potential of rhythm-based serious games to enhance synchronization abilities in preadolescents who stutter, although further studies with larger samples are needed to confirm these preliminary trends. The second finding of this study is that preadolescents who trained with RW showed gains in interference control, a subcomponent of a core executive function called inhibition control, 52 . This aligns with previous findings on the same training and outcome measure provided to ADHD and autism populations who show impairment in inhibition control 31 , 32 . In stuttering, there exists some evidence that inhibition control may be lower compared to individuals without stuttering 53 . Considering the high number of comorbidities between stuttering and ADHD 54 , it is possible that some preadolescents with stuttering are at risk of weaker inhibition control. In line with this idea and our previous results with other neurodevelopmental groups, some participants in the RW group with lower initial scores showed greater improvements after playing the game. Although regression to the mean could partly account for this finding, we did not observe the same pattern in the group playing the control game, suggesting that rhythmic training, as in our previous studies, can have a specific effect on interference control in at-risk or impaired populations. For impaired groups who have shown a similar beneficial effect in our studies 31 , 32 , we propose that the underlying mechanism lies in the nature of the training itself: RW gradually increases rhythmic complexity by making the beat less predictable and more syncopated, requiring players to ignore conflicting or misleading timing cues and to stay focused on the underlying pulse. This mirrors the cognitive demands of interference control, which involves filtering out irrelevant information to prioritize goal-relevant cues 52 . Crucially, our findings suggest that training with the rhythmic game may improve speech-motor control (i.e., oromotor skills measured by a diadochokinesis (DDK) task and reduction of stuttered dysfluencies measured in naturalistic speech). Specifically, pre-adolescents who played the rhythmic musical game, but not the control game, showed improvements in oromotor accuracy and, most notably, less stuttering symptoms as training time increased. Participants who engaged in the rhythmic game for approximately 300 minutes or more (see 3A and 3C) exhibited up to 23% reductions in oromotor errors in the DDK task and 2% in stuttered dysfluencies in naturalistic speech. Although promising, these findings should be interpreted with caution due to the small sample size and modest effect magnitude. Similar oromotor benefits following rhythmic training have been reported in clinical populations, such as individuals with Parkinson’s disease 28 . One possible explanation for the observed effects is the close functional relationship between oromotor and manual motor systems, both of which rely on finely timed sequential movements and share overlapping neural substrates, particularly in the cerebellum and basal ganglia 9 – 15 . Thus, rhythm-based training may strengthen the temporal framework that underlies both manual and speech-motor coordination. Interestingly, oromotor speed did not improve after rhythmic training, but it did in the group playing the control game. Although unexpected, this pattern may reflect the specific performance demands of the FB game. Progressing in FB requires players to shoot bubbles at increasingly rapid rates while maintaining spatial accuracy, particularly as levels become more difficult and the threat of failure becomes more imminent. Training to increase motor output speed without compromising precision may have indirectly transferred to participants’ spontaneous speed-accuracy balance adopted in the diadochokinesis task. In contrast, RW emphasizes precise temporal synchronization rather than sheer speed, which may also explain the absence of a dose–response effect in that group. Concerning stuttered dysfluencies, one may object that the observed 2.2% reduction is modest and may fall within the range of daily variability. However, the reduction associated with cumulative rhythmic training time is promising, especially as it emerged in the absence of explicit speech targets during training and after a relatively short time of training (i.e., 300–400 minutes across three weeks). Note that even traditional speech therapy often requires months or years to yield significant effects 55 , 56 . Hence, we recommend to further investigate the effects of rhythmic training in stuttering with a sufficiently high training dose, across different age groups, and with a focus on individual outcomes and predispositions. In sum, the results of this proof-of-concept study are in line with recent theoretical frameworks for rhythm-based interventions in supporting speech rehabilitation through shared sensorimotor mechanisms 21 . The speech-related improvements in our study can be interpreted through the lens of models underscoring the potential role of overlapping auditory-motor circuits for speech and musical rhythm and timing in the brain in rhythm training 25 . Participants engaging in rhythm-based training, likely strengthen the neural circuits responsible for precise timing in motor actions, a process that is crucial for fluent speech production. The absence of similar improvements in the FB group may be due to the lack of rhythmic engagement in their training, which does not target the same auditory-motor synchronization mechanisms. These promising results mark the first demonstration of gamified rhythmic training through a tablet-based serious game in developmental stuttering, warranting further investigation. Limitations and future directions While this study holds promise for the benefits of rhythm-based training in preadolescents who stutter, there are several limitations to consider. First, the sample size was relatively small, which may limit the generalizability of the findings. Future studies should aim to replicate these results in a larger sample, ideally with stratification by stuttering severity, to confirm and enhance the external validity of the effects. Another limitation concerns baseline differences between groups: although not statistically significant, the FB group showed a tendency to fewer stuttering dysfluencies than the RW group. Given the small sample size, this imbalance may have influenced change scores and limited the strength of between-group comparisons. A further important avenue for future research is exploring the underlying neural mechanisms that drive these improvements, particularly in relation to the SEP hypothesis 25 , which posits that rhythm-based interventions tap into neural circuits responsible for timing and motor coordination. Investigating these mechanisms through neuroimaging or electrophysiological methods could shed light on how rhythmic training influences brain activity and improves speech-motor control. Finally, testing the efficacy of the Rhythm Workers program in a larger randomized controlled trial (RCT) design potentially across different neurodevelopmental conditions would provide stronger evidence for its therapeutic potential and establish its place in evidence-based interventions for children and adolescents with speech as well as cognitive disorders. In conclusion, this study shows the first evidence that rhythm-based training is feasible with a young population who stutters and can potentially enhance, as a function of practice, rhythmic abilities, executive functioning and speech-motor control after 300–400 minutes of training. These results contribute to the growing body of studies discussing the therapeutic potential of rhythm training for children with various neurodevelopmental disorders. Future research combining rhythm training with established therapeutic approaches for neurodevelopmental conditions will further refine our understanding of the applications of this innovative therapeutic tool. Declarations Funding This work was supported by funding from grant RGPIN/03122-2021 (Simone Falk) and grant 05453 (Simone Dalla Bella) from the Natural Sciences and Engineering Research Council of Canada (NSERC), and from SSHRC tier 2 Canada Research Chair in interdisciplinary studies on rhythm and language acquisition (Simone Falk) as well as NSERC Tier 1 Canada Research Chair in Music Auditory-Motor Skill Learning and New Technologies (Simone Dalla Bella). Conflicts of interest/Competing interests SDB is on the board of the BeatHealth company dedicated to the design and commercialization of technological tools for assessing rhythm abilities such as BAASTA tablet and implementing rhythm-based interventions. Other authors have no competing interest to disclose. Acknowledgements We sincerely thank all our participants and their families for their precious participation as well as the speech therapists from the Centre Raymond-Dewar and the Communauté de pratique en bégaiement-bredouillement, as well as Alicia Kluth, SLP; Héloise Tangay, SLP; Judith Labonté, SLP, and the Quebec stuttering associations (AJBQ, ABC) for their help with recruitment, and Marilyne Lemire-Tremblay for her help with testing. Our special thanks to the team validating the OASES questionnaire in French, for the French translation. Author contribution Simone Falk and Simone Dalla Bella designed the overall study and hypotheses with the game design stemming from Simone Dalla Bella’s lab. All authors contributed to design the test protocol. Simone Falk secured the funding and supervised the study. Sebastien Finlay recruited participants and coordinated participants’ training and testing. Kevin Jamey and Simone Falk supervised data collection. Kevin Jamey, Simone Falk, Sebastien Finlay, and Nicholas Foster analyzed the data. Kevin Jamey and Simone Falk performed statistical analysis. All authors contributed to the interpretation of the results. Kevin Jamey wrote the first draft of the manuscript. All authors contributed to and approved the final version of the manuscript. References Bloodstein, O., Ratner, N. B. & Brundage, S. B. A Handbook on Stuttering . vol. 1 (Plural Publishing, San Diego, CA, 2021). Guitar, B. Stuttering: An Integrated Approach to Its Nature and Treatment . (Lippincott Williams & Wilkins, Philadelphia, PA, 2021). Yairi, E. & Ambrose, N. Epidemiology of stuttering: 21st century advances. J Fluency Disord 38 , (2013). Gattie, M., Lieven, E. & Kluk, K. Adult stuttering prevalence I: Systematic review and identification of stuttering in large populations. J Fluency Disord 83 , 106085 (2025). Boyle, M. P. & Fearon, A. N. Self-stigma and its associations with stress, physical health, and health care satisfaction in adults who stutter. J Fluency Disord 56 , (2018). Chang, S. E. & Guenther, F. H. Involvement of the Cortico-Basal Ganglia-Thalamocortical Loop in Developmental Stuttering. Frontiers in Psychology vol. 10 Preprint at https://doi.org/10.3389/fpsyg.2019.03088 (2020). Civier, O., Bullock, D., Max, L. & Guenther, F. H. Computational modeling of stuttering caused by impairments in a basal ganglia thalamo-cortical circuit involved in syllable selection and initiation. Brain Lang 126 , (2013). Falk, S. Music and stuttering. in The Oxford Handbook of Language and Music (ed. Sammler, D.) (Oxford Academic, Online edition, 2025). Cannon, J. J. & Patel, A. D. How Beat Perception Co-opts Motor Neurophysiology. Trends in Cognitive Sciences vol. 25 Preprint at https://doi.org/10.1016/j.tics.2020.11.002 (2021). Iversen, J. R. & Patel, A. D. The Beat Alignment Test (BAT): Surveying beat processing abilities in the general population. Proceedings of the 10th International Conference on Music Perception and Cognition (2008). Nozaradan, S., Schwartze, M., Obermeier, C. & Kotz, S. A. Specific contributions of basal ganglia and cerebellum to the neural tracking of rhythm. Cortex 95 , (2017). Grahn, J. A. & Rowe, J. B. Feeling the Beat: Premotor and Striatal Interactions in Musicians and Nonmusicians during Beat Perception. Journal of Neuroscience 29 , 7540–7548 (2009). Grahn, J. A. & Brett, M. Rhythm and beat perception in motor areas of the brain. J Cogn Neurosci 19 , (2007). Teki, S., Grube, M. & Griffiths, T. D. A unified model of time perception accounts for duration-based and beat-based timing. Front Integr Neurosci https://doi.org/10.3389/fnint.2011.00090 (2011) doi:10.3389/fnint.2011.00090. Schwartze, M. & Kotz, S. A. A dual-pathway neural architecture for specific temporal prediction. Neuroscience and Biobehavioral Reviews vol. 37 Preprint at https://doi.org/10.1016/j.neubiorev.2013.08.005 (2013). Metzger, F. L. et al. Shifted dynamic interactions between subcortical nuclei and inferior frontal gyri during response preparation in persistent developmental stuttering. Brain Struct Funct 223 , (2018). Ackermann, H. Cerebellar contributions to speech production and speech perception: psycholinguistic and neurobiological perspectives. Trends Neurosci 31 , (2008). Christensen, A. et al. An intact action-perception coupling depends on the integrity of the cerebellum. Journal of Neuroscience 34 , (2014). Frankford, S. A. et al. The neural circuitry underlying the “rhythm effect” in stuttering. Journal of Speech, Language, and Hearing Research 64 , (2021). Johnson, C. A., Liu, Y., Waller, N. & Chang, S. E. Tract profiles of the cerebellar peduncles in children who stutter. Brain Struct Funct 227 , (2022). Fiveash, A., Bedoin, N., Gordon, R. L. & Tillmann, B. Processing Rhythm In Speech And Music: Shared Mechanisms And Implications For Developmental Speech And Language Disorders. Neuropsychology 35 , (2021). Falk, S., Müller, T. & Dalla Bella, S. Non-verbal sensorimotor timing deficits in children and adolescents who stutter. Front Psychol 6 , (2015). Sares, A. G., Deroche, M. L. D., Shiller, D. M. & Gracco, V. L. Adults who stutter and metronome synchronization: evidence for a nonspeech timing deficit. Ann N Y Acad Sci 1449 , (2019). Slis, A., Savariaux, C., Perrier, P. & Garnier, M. Rhythmic tapping difficulties in adults who stutter: A deficit in beat perception, motor execution, or sensorimotor integration? PLoS One 18 , (2023). Fujii, S. & Wan, C. Y. The Role of Rhythm in Speech and Language Rehabilitation: The SEP Hypothesis. Front Hum Neurosci 8 , (2014). Chen, J. L., Penhune, V. B. & Zatorre, R. J. Listening to musical rhythms recruits motor regions of the brain. Cerebral Cortex 18 , (2008). Bégel, V., Seilles, A. & Dalla Bella, S. Rhythm Workers: A music-based serious game for training rhythm skills. Music Sci (Lond) 1 , (2018). Puyjarinet, F. et al. At-Home Training With a Rhythmic Video Game for Improving Orofacial, Manual, and Gait Abilities in Parkinson’s Disease: A Pilot Study. Front Neurosci 16 , (2022). Dalla Bella, S. Rhythmic serious games as an inclusive tool for music-based interventions. Ann N Y Acad Sci 1517 , 15–24 (2022). Zanto, T. P. et al. Digital rhythm training improves reading fluency in children. Dev Sci 27 , (2024). Jamey, K. et al. Can you beat the music? Validation of a gamified rhythmic training in children with ADHD. Behav Res Methods 57 , 303 (2025). Jamey, K. et al. Enhancing Sensorimotor and Executive Functioning in Autistic Children with a Rhythmic Videogame: A Pilot Study . Research Square https://doi.org/10.21203/rs.3.rs-5790839/v1 (2025). Koenraads, S. P. C. et al. Structural brain differences in pre-adolescents who persist in and recover from stuttering. Neuroimage Clin 27 , (2020). Dalla Bella, S. et al. Mobile version of the Battery for the Assessment of Auditory Sensorimotor and Timing Abilities (BAASTA): Implementation and adult norms. Behav Res Methods https://doi.org/10.3758/s13428-024-02363-x (2024) doi:10.3758/s13428-024-02363-x. Dalla Bella, S. et al. BAASTA: Battery for the Assessment of Auditory Sensorimotor and Timing Abilities. Behav Res Methods 49 , (2017). Riley, G. D. SSI-4: Stuttering Severity Instrument. SSI-4 : Stuttering severity instrument (2009). Scott Yaruss, J. & Logan, K. J. Evaluating rate, accuracy, and fluency of young children’s diadochokinetic productions: A preliminary investigation. J Fluency Disord 27 , (2002). Puyjarinet, F., Bégel, V., Lopez, R., Dellacherie, D. & Dalla Bella, S. Children and adults with Attention-Deficit/Hyperactivity Disorder cannot move to the beat. Sci Rep 7 , (2017). Bégel, V. et al. Rhythm as an Independent Determinant of Developmental Dyslexia. Dev Psychol 58 , (2022). Sowiński, J. & Dalla Bella, S. Poor synchronization to the beat may result from deficient auditory-motor mapping. Neuropsychologia 51 , (2013). Stuss, D. T. et al. The Trail Making Test: A study in focal lesion patients. Psychol Assess 13 , (2001). Periáñez, J. A. et al. Trail Making Test in traumatic brain injury, schizophrenia, and normal ageing: Sample comparisons and normative data. Archives of Clinical Neuropsychology 22 , (2007). Kent, R. D., Kim, Y. & Chen, L. M. Oral and Laryngeal Diadochokinesis Across the Life Span: A Scoping Review of Methods, Reference Data, and Clinical Applications. Journal of Speech, Language, and Hearing Research 65 , (2022). Duffy, J. R. Motor Speech Disorders : Substrates, Differential Diagnosis, and Management . (Elsevier/Mosby, St. Louis, Mo, 2013). Icht, M. & Ben-David, B. M. Evaluating rate and accuracy of real word vs. non-word diadochokinetic productions from childhood to early adulthood in Hebrew speakers. J Commun Disord 92 , (2021). Boersma, P. & Weenink, D. Praat: doing phonetics by computer [Computer program]. Glot International vol. 5 Preprint at (2013). Hurkmans, J., Jonkers, R., Boonstra, A. M., Stewart, R. E. & Reinders-Messelink, H. A. Assessing the treatment effects in apraxia of speech: Introduction and evaluation of the Modified Diadochokinesis Test. Int J Lang Commun Disord 47 , (2012). Kassambara, A. rstatix: Pipe-Friendly Framework for Basic Statistical Tests. Preprint at https://rpkgs.datanovia.com/rstatix/ (2023). Miles, J. (viaf)59378934 & Shevlin, M. Applying Regression and Correlation : A Guide for Students and Researchers . (London : Sage, 2001). Dalla Bella, S. & Falk, S. Rhythmic processes in stuttering and Parkinson’s disease. in Rhythms of Speech and Language (eds. Meyer, L. & Strauss, A.) (Cambridge University Press, Cambridge). Dalla Bella, S. et al. Gait improvement via rhythmic stimulation in Parkinson’s disease is linked to rhythmic skills. Sci Rep 7 , (2017). Diamond, A. Executive Functions. Annu Rev Psychol 64 , 135–168 (2013). Treleaven, S. B. & Coalson, G. A. Manual response inhibition and quality of life in adults who stutter. J Commun Disord 88 , (2020). Finlay, S. et al. Administering the Lidcombe Program to children who stutter with concomitant disorders: Insights from an exploratory retrospective chart review study. J Fluency Disord 83 , 106101 (2025). Craig, A., Hancock, K., Tran, Y., Craig, M. & Peters, K. Epidemiology of stuttering in the community across the entire life span. Journal of Speech, Language, and Hearing Research 45 , (2002). O’Brian, S., Onslow, M., Cream, A. & Packman, A. The Camperdown Program: Outcomes of a new prolonged-speech treatment model. Journal of Speech, Language, and Hearing Research 46 , (2003). Additional Declarations The authors declare potential competing interests as follows: SDB is on the board of the BeatHealth company dedicated to the design and commercialization of technological tools for assessing rhythm abilities such as BAASTA tablet and implementing rhythm-based interventions. Other authors have no competing interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:34:42","extension":"html","order_by":26,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":159600,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7963668/v1/9694908f6cb2e7226085ee22.html"},{"id":94666466,"identity":"8c8ab788-2935-4a2e-9f47-c91a787432f6","added_by":"auto","created_at":"2025-10-29 12:34:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58575,"visible":true,"origin":"","legend":"\u003cp\u003echange scores (T2-T1) of paced rhythmic tasks by game – (A) a bar graph of the mean change scores of the Paced Tapping Index (PTI), lines represent standard errors (B) correlations (Spearman) per group between mean PTI change score and cumulative playing time in minutes.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7963668/v1/baab924210f7f4ead6765c18.png"},{"id":94666465,"identity":"a6d7b390-7157-4bbc-a0ec-9299e9e9fa1f","added_by":"auto","created_at":"2025-10-29 12:34:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61924,"visible":true,"origin":"","legend":"\u003cp\u003eInterference control for the Flanker task – (A) change score means (T2-T1) after training between games interference control speed (Flanker speed), lines represent standard errors, (B) correlations (Spearman) between mean Flanker speed change scores and cumulative playing time in minutes.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7963668/v1/5cb48fae1c7384033ccb0fab.png"},{"id":94666468,"identity":"0fef0796-d8e6-4f4a-9fbf-1116f35fc80d","added_by":"auto","created_at":"2025-10-29 12:34:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":172948,"visible":true,"origin":"","legend":"\u003cp\u003eshows change scores (T2-T1) after training on speech tasks by game – (A) correlations between the errors as a percentage of all words produced in the diadochokinesis task (oromotor errors) and cumulative playing time, (B) correlations between inter-word-interval (in seconds) of the diadochokinesis task (oromotor speed) and cumulative playing time (C) correlation between the percentage of stuttered syllables (from overall ~300 syllables; stuttered dysfluencies) and cumulative playing time, (D) the relationship between reduction of stuttering as a function of improvement in rhythmic abilities on the Paced Tapping Index (PTI)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7963668/v1/4aac7da059393febc31e79d6.png"},{"id":94728507,"identity":"40def6b7-9435-49ea-ad1c-95d1dd0ed22e","added_by":"auto","created_at":"2025-10-30 07:03:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1287705,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7963668/v1/90d90f81-73f6-4fbf-9a05-66de21d2972c.pdf"}],"financialInterests":"The authors declare potential competing interests as follows: SDB is on the board of the BeatHealth company dedicated to the design and commercialization of technological tools for assessing rhythm abilities such as BAASTA tablet and implementing rhythm-based interventions. Other authors have no competing interest to disclose.","formattedTitle":"\u003cp\u003eA Proof-of-Concept Study of Gamified Rhythmic Training in Preadolescents who Stutter\u003c/p\u003e","fulltext":[{"header":"Graphical Abstract Summary","content":"\u003cp\u003eThis proof-of-concept study tested a gamified rhythmic-training app, Rhythm Workers, in preadolescents who stutter. Over three weeks, participants trained at home and were compared to an active control game. The rhythm group showed dose-dependent improvements in rhythmic synchronization, interference control, oromotor accuracy, and speech fluency. These findings highlight the feasibility and therapeutic promise of rhythm-based serious games to enhance speech and cognitive-motor skills in youth who stutter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3\u003c/strong\u003e - shows change scores (T2-T1) after training on speech tasks by game \u0026nbsp;\u0026ndash; (A) correlations between the errors as a percentage of all words produced in the diadochokinesis task (oromotor errors) and cumulative playing time, (B) correlations between inter-word-interval (in seconds) of the diadochokinesis task (oromotor speed) and cumulative playing time (C) correlation between the percentage of stuttered syllables (from overall ~300 syllables; stuttered dysfluencies) and cumulative playing time, (D) the relationship between reduction of stuttering as a function of improvement in rhythmic abilities on the Paced Tapping Index (PTI)\u003c/p\u003e\n\u003cp\u003eStuttering, also known as developmental stuttering or childhood-onset fluency disorder (DSM-V), is a neurodevelopmental speech motor disorder characterized primarily by involuntary disruptions in the flow of speech \u003csup\u003e1\u003c/sup\u003e. These disruptions manifest as repetitions of sounds or syllables, prolongations of sounds, and blocks (temporary inability to initiate speech despite the intention to speak). Stuttering is sometimes accompanied by secondary behaviors (e.g., facial tension, physical movements) and can vary in frequency and intensity depending on the communicative context \u003csup\u003e2\u003c/sup\u003e. The condition typically emerges between ages 2 and 5, with a prevalence of approximately 5-8% in early childhood \u003csup\u003e3\u003c/sup\u003e. Many children recover naturally without specialized intervention, and estimates suggest that around 70\u0026ndash;80% of affected children eventually attain fluent speech, often by late childhood or early adolescence. However, stuttering persists into adulthood in the remaining 20-30% of children with initial stuttering symptoms, corresponding to about 1% of the general population \u003csup\u003e4\u003c/sup\u003e. While stuttering is not caused by psychological factors, it often leads to significant psychosocial consequences, including anxiety, reduced social participation, and social stigma \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePrevious research has found that rhythm and timing play a prominent role in stuttering (see Falk, 2025, for an overview). Neuroscientific studies have converged on the basal ganglia\u0026ndash;thalamo\u0026ndash;cortical (BGTC) loop as a key pathway disrupted in stuttering \u003csup\u003e6\u0026ndash;8\u003c/sup\u003e. The BGTC circuit, which includes the putamen, thalamus, supplementary motor area, and inferior frontal gyrus, is involved in initiating and sequencing motor actions, including speech, and in rhythmic processes beyond speech \u003csup\u003e9\u0026ndash;15\u003c/sup\u003e. Altered BGTC connectivity is thought to contribute to the untimely initiation or inhibition of speech motor programs in stuttering \u003csup\u003e7,16\u003c/sup\u003e. Moreover, the cerebellar\u0026ndash;thalamo\u0026ndash;cortical pathway, which also contributes to externally paced timing tasks such as synchronizing to a metronome, has been shown to be over-recruited in people who stutter, which can be interpreted as a compensatory response to weakened BGTC function \u003csup\u003e17\u0026ndash;20\u003c/sup\u003e. Importantly, speech and rhythmic timing share overlapping neural circuits for auditory-motor coupling, particularly within the BGTC system \u003csup\u003e21\u003c/sup\u003e. In line with this idea, individuals who stutter display weaknesses in musical rhythm tasks \u003csup\u003e22\u0026ndash;24\u003c/sup\u003e. Falk et al. (2015)\u0026nbsp;found that children and adolescents who stutter exhibited reduced synchronization accuracy and greater timing variability compared to controls when tapping to a metronome or music (i.e., beat synchronization). These timing alterations were more visible in those with persistent or severe stuttering and were not explained by general motor variability, suggesting specific impairments in auditory\u0026ndash;motor integration and predictive timing mechanisms.\u003c/p\u003e\n\u003cp\u003eThese findings provide a compelling rationale to explore whether rhythm training can enhance speech-related motor timing in stuttering. This idea was first proposed by Fujii \u0026amp; Wan (2014), introducing their Sound Envelope Processing and Synchronization/Entrainment to a Pulse (SEP) hypothesis. The authors suggest that strengthening auditory-motor coupling in the BGTC via beat synchronization training may positively affect speech motor control. Rhythmic interventions built on beat synchronization may stimulate the shared neural timing network, promote temporal speech motor control, and, potentially, improve fluency outcomes in individuals who stutter \u003csup\u003e8\u003c/sup\u003e. However, beat synchronization tasks also engage neural systems involved in executive functioning, in particular attentional processes \u003csup\u003e13,26\u003c/sup\u003e. Hence, it is a possibility that rhythm\u0026nbsp;training in individuals who stutter could also lead to benefits in speech production via enhanced executive functioning. In recent years, rhythm training has shown promise for enhancing motor, attentional, and other cognitive skills in various populations. Rhythm-based serious games \u003csup\u003e27\u003c/sup\u003e were originally tested in Parkinson\u0026rsquo;s disease \u003csup\u003e28,29\u003c/sup\u003e These studies showed improvements in rhythm perception and motor variability as well as a reduction of errors in manual and oromotor tasks after the training, in this group. Rhythmic skills were trained through finger-tapping to a musical beat, focusing on explicit timing precision and structured motor engagement.\u0026nbsp;More recently, similar training through beat synchronization has been used to support executive functions in developmental populations, providing first evidence of increased interference and inhibitory control in typically developing children \u003csup\u003e30\u003c/sup\u003e, as well as in children with neurodevelopmental conditions such as ADHD \u003csup\u003e31\u003c/sup\u003e and autism \u003csup\u003e32\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Aims and hypotheses","content":"\u003cp\u003eBuilding on these advances, our study applies a serious gaming approach for rhythm training to pre-adolescents with developmental stuttering. While this age group has a relatively long history of stuttering, neuroplasticity during adolescence can still lead to remissions \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, potentially facilitated by rhythm training. Generally, music-based rhythmic training in stuttering remains largely unexplored. Given the potential overlap between timing deficits and speech fluency difficulties, such tools may hold promise for supporting speech functions in stuttering.\u003c/p\u003e\u003cp\u003eOur goal is to conduct a proof-of-concept study, to evaluate the use of a rhythm-based serious game (Rhythm Workers, RW) in comparison to a motor control game (Frozen Bubble, FB) in developmental stuttering. Our primary goal was to assess feasibility, focusing on the compliance and acceptance of the training protocol by participants. We monitored if participants could engage with the training regularly, adhere to the sessions over the course of the protocol and whether they accept the game overall. We also verify known training effects in this age group, but unspecific to stuttering; first, whether the core training target is reached, that is, playing the rhythmic game enhances rhythmic abilities measured via a standardised mobile battery assessing rhythmic abilities \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Second, whether we can observe potential effects on executive functioning, in particular interference control (Flanker task), which increased in pre-adolescents with ADHD and autism after a similar rhythm training \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFinally, to decide whether rhythm training holds promise for stuttering, specifically, we investigate potential transfer effects of rhythm training on speech motor skills and stuttering symptoms. Here, we assess potential improvements in basic oromotor skills as well as the reduction of stuttered dysfluencies. Improvement in oromotor skills (measured through a diadochokinetic task) could be beneficial in sustaining more stable articulatory processes in stuttering \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Reduction of stuttered dysfluencies after rhythm training would be the most direct evidence for potential benefits. In relation to this effect, we also examined the potential basis of speech effects, by testing whether potential improvements in either speech-related skill are related to enhanced rhythmic abilities and executive functioning.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eTwenty-four French-speaking participants who stutter between 9 and 12 years were recruited in the province of Québec, Canada, between July 2022 and August 2024. According to parental reports, participants self-identified as having a stutter and did not show any speech or language difficulties aside from stuttering, nor any hearing, physical, or cognitive developmental disorders. Three participants were excluded from the training study following recruitment: two based on a parental report of comorbidities after enrollment and one withdrew after the initial testing due to lack of availability. The final sample was composed of 21 pre-adolescents who stutter (mean age 10.8 ± 1.3; 8.8–12.5 years) including 9 females. Ten of them had musical training, and 5 were left-handed. According to the Stuttering Severity Instrument–4 \u003csup\u003e36\u003c/sup\u003e, stuttering severity in the sample was mostly very mild and mild (\u003cem\u003en\u003c/em\u003e = 13), with a few participants in the moderate (\u003cem\u003en\u003c/em\u003e = 5), and severe range (\u003cem\u003en\u003c/em\u003e = 3). Participants were assigned to either the rhythmic game (RW) or the non-rhythmic game (FB). Initially, the first six participants were randomly assigned to either group. Thereafter, stratified randomization based on sex was implemented to ensure an even distribution of boys and girls across both groups. The groups did not differ in handedness (\u003cem\u003ep\u003c/em\u003e = 0.64), musical training history (\u003cem\u003ep\u003c/em\u003e = 1.0), video game use (\u003cem\u003ep\u003c/em\u003e = 0.21), and socioeconomic status (\u003cem\u003ep\u003c/em\u003e = 0.62), tested via χ2 tests or Fisher tests. Moreover, they were comparable in baseline cognitive abilities (IQ, short-term memory, response inhibition), as well as in stuttering severity, both subjectively (OASES-S\u003csup\u003e37\u003c/sup\u003e) and objectively (% stuttered syllables on the SSI-4 \u003csup\u003e36\u003c/sup\u003e), as summarized in Table\u0026nbsp;1.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between the two game groups at baseline (Mann-Whitney tests)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eRW group (n = 11)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c12\" namest=\"c7\"\u003e\u003cp\u003eFB group (n = 10)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003emax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003emin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003emax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (month)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e128.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e130.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStuttered dysfluencies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOASES-S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIQ (Raven’s Matrices)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e101.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResponse inhibition (A’; Go/No-Go task)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterference control (flanker accuracy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterference control (flanker speed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive flexibility (Set-shifting accuracy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive flexibility (Set-shifting speed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShort-term memory (N-back 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShort-term memory (N-back 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"12\" nameend=\"c12\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: M, mean; n, number of participants per group; SD, standard deviation of the mean.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure and training protocol\u003c/h3\u003e\n\u003cp\u003eThe study included three assessment points: baseline (T0), pre-intervention (T1), and post-intervention (T2), each separated by approximately three weeks. Each testing session lasted 3 hours. Testing sessions were separated in two parts whose order was counter-balanced across participants: non-verbal testing, which included executive functioning and rhythmic abilities, and verbal testing, which included stuttering assessment and articulatory performance, among some other tasks not reported here. Testing occurred online via the online platforms Zoom (non-verbal testing), JATOS using the BRAMS online testing platform (executive functioning\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e and IRIS; verbal testing).\u003c/p\u003e\u003cp\u003eAt the end of the second testing session, a non-blinded research coordinator explained the game to the participants. Once participants understood the instructions, they started playing the game. A Samsung Galaxy Tab A 8.0” (2019 model, SM-T290) tablet was provided for the study, featuring a 2GHz processor, 1280 x 800 pixels display resolution, and 32 GB of RAM. All materials required for the study, including the tablet, which contained the game assigned to the participant and a standardized rhythmic assessment application, a gooseneck phone holder, a Samson SR850 headphones, a Marantz professional M4U microphone, paper questionnaires, game-specific instructions and sanitizing kits, were mailed to participants via postal and courier services. Participants used the touchscreen to navigate and play the applications, while the headphones were used to play the sounds and music from the applications.\u003c/p\u003e\u003cp\u003eParticipants were instructed to play their assigned game for 30 minutes a day, five days a week, for three weeks (target of 450 minutes of game engagement – how long the session is reported by participants and how much time was logged operating the game application). They were also informed that they could play more if they wished but were advised not to exceed one hour of gameplay per day. Participants were asked to log their daily gameplay in a handwritten journal. During gameplay, time is also spent navigating menus, receiving medals, and launching levels. To accurately assess active engagement, we logged cumulative playing time, defined as the total minutes spent in live gameplay within levels. Prior studies with these game versions indicate that cumulative playing time can be up to 30% lower than the total time spent within the app. To estimate training duration (dose), we adopted this more conservative metric. We considered approximately 300 minutes of cumulative gameplay as a benchmark for good compliance in this study.\u003c/p\u003e\n\u003ch3\u003eRhythmic “Serious Game”\u003c/h3\u003e\n\u003cp\u003eThis proof-of-concept study incorporated an adapted version of \u003cem\u003eRhythm Workers\u003c/em\u003e (RW), a rhythm-based training game originally developed for adults \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Specific design adjustments tailored for a pediatric population are detailed in Jamey et al. (2025). Players tap in time with the musical beat to build a virtual building with progression tied to tapping performance. For example, when players tap with perfect consistency for 8 beats, they get 100% accuracy which contributes to their general score. When the general score reaches a certain threshold, a new floor rises on the virtual building. The goal is to finish the building within a given time limit. There is a total of 32 distinct levels, each built around a unique music stimulus ranging from 2 to 4 minutes long and presented at a consistent tempo. All 32 levels must be completed to finish the game. Difficulty is increased via the rhythmic complexity of the musical stimuli. Scoring was calculated using the same accuracy metrics as described in Bégel et al. (2018).\u003c/p\u003e\u003cp\u003eThe control game was a modified version of \u003cem\u003eFrozen Bubble\u003c/em\u003e (FB), adapted from an open-source Android build hosted on GitHub (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://github.com/videogameboy76/frozenbubbleandroid\u003c/span\u003e\u003cspan address=\"https://github.com/videogameboy76/frozenbubbleandroid\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). This arcade puzzle shooting game challenges players to eliminate clusters of colored bubbles by launching matching ones from a cannon using touch input. The same music as RW is played in the background but players do not need to synchronize to it to progress in the game. The upper rows of bubbles steadily move downward and play ends if the bubbles reach the bottom edge of the screen. The objective is to match and clear groups of three or more identically colored bubbles, which also causes any attached lower bubbles to drop. For a visual overview of the RW and FB game environment and further details see Jamey et al. (2025).\u003c/p\u003e\n\u003ch3\u003eFeasibility: Evaluation of Game Compliance and Acceptance\u003c/h3\u003e\n\u003cp\u003eWe quantitatively evaluated participant compliance by collecting data recorded on the tablet device including: the time spent per session (target ~ 450 minutes), in active gameplay (cumulative playing time, target ~ 300 minutes) and the total number of taps on the screen. A short debriefing was requested from participants and not mandatory. Children were asked to provide information about their level of enjoyment of the game on 5-point Likert scales (1 = boring, 5 = very fun). They were asked how they felt about playing the game for 3 weeks, if they would play for another 2 weeks and 4 weeks. Other items included whether they found the game difficult to play, how often they felt frustrated, how they felt time went by and whether they would recommend others play the game.\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eWe evaluated rhythmic, executive functioning and speech performance at baseline (T0) and (T1) and change scores by subtracting post- minus pre-training means (T2-T1). Participants whose change scores on any task construct (e.g., flanker accuracy) exceeded ± 3 standard deviations from the group mean were considered outliers and excluded from the analyses, along with their corresponding T1 and T2 scores. For example, one participant scored 100% incorrect responses on the Flanker task at T1 and 76% at T2 – a pattern that is implausible as an effect of training and suggests task disengagement or error. Sample sizes vary slightly across tasks due to remote testing constraints (such as internet interruptions), occasional participant fatigue affecting whether a task was finished, and the exclusion of outliers exceeding ± 3 SD from the group mean.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCore training effect: Rhythmic abilities\u003c/h2\u003e\u003cp\u003eWe evaluated rhythmic abilities using sensorimotor tasks from Battery for the Assessment of Auditory Sensorimotor Timing Abilities (BAASTA \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e), which has been previously used in children, including those with developmental disorders \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. In paced tapping tasks, participants tapped the index finger of their dominant hand in time with either a metronome (inter-onset intervals: 450 ms, 600 ms, 750 ms) or a musical sequence (inter-onset interval: 600 ms). We computed logit-transformed vector lengths to quantify tapping consistency—that is, the regularity and temporal alignment of taps occurring at the same rate as the cued stimuli. A value of 1 indicates perfectly isochronous tapping. For unpaced tapping tasks (regular and fast spontaneous tapping), we quantified motor variability using the coefficient of variation of the inter-tap intervals (CV-ITI). CV-ITI was calculated as the standard deviation of the inter-tap intervals divided by their mean \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTapping consistency and CV-ITI subtask values at each time point were z-scored using the group mean and standard deviation from the pre-training session (T1), allowing for standardized comparisons of change over time. To align the directionality of change with other tapping consistency measures (e.g., vector length), z-scored CV-ITI values were inverted so that higher scores reflected lower variability (i.e., better performance). If T1 or T2 scores were missing for a specific task, the corresponding single T1 or T2 score was excluded from analyses. We averaged the z-scores of each task (Music, Metronome 450 ms, Metronome 600 ms, Metronome 750 ms) by time point (T1 and T2) to form a paced tapping index. Unpaced tasks were averaged similarly to calculate an unpaced tapping index.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExploratory Hypothesis: Executive functioning\u003c/h3\u003e\n\u003cp\u003eWe administered the Eriksen flanker fish task to assess interference control. On each trial, participants saw either one or five fish aligned horizontally and indicated the direction of the central fish (left/right) by pressing a key, ignoring the surrounding (flanking) fish. Trials were either neutral (single fish), congruent (flankers swam the same direction), or incongruent (flankers swam opposite). Each trial allowed 2000 ms to respond (500 ms stimulus + 1500 ms fixation), with a 750 ms fixation cross preceding each. The task included 96 trials and lasted 3–5 minutes. After removing incorrect or premature responses, raw response times (RTs) below 200 ms and above 1000 ms were excluded, to capture performance ranges related to interference control. Following prior studies, we calculated proportional RT from RT values as a sensitive measure of change in executive functioning after intervention \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. The proportional RT (interference control speed) was computed as (Congruent RT – Incongruent RT) / (Congruent RT), where higher (less negative) scores indicate better attentional functioning. Finally, we computed the difference between the proportional RT of congruent and incongruent trials. The same procedure was used for calculating the proportion of correct responses (interference control accuracy).\u003c/p\u003e\n\u003ch3\u003eTransfer to speech-related skills: Oromotor skills\u003c/h3\u003e\n\u003cp\u003e The oral diadochokinesis (DDK) task was used to assess articulatory performance by measuring participants’ ability to produce rapid, repetitive syllable or word sequences. DDK is a standard maximum performance task to measure articulation speed and accuracy \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. It is widely used in speech-language pathology to assess oromotor speech function, particularly in the context of acquired motor speech disorders such as dysarthria and apraxia of speech \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Importantly, although the task measures aspects of speech motor control, it does not assess “fluency” in the sense of stuttering-related disfluencies. Findings regarding DDK performance in developmental stuttering are mixed, with some studies suggesting differences in sequencing or variability of rates \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Nevertheless, DDK remains a useful measure to explore potential transfer to oromotor skills, as it does not directly overlap with stuttering severity.\u003c/p\u003e\u003cp\u003eParticipants were first introduced to the task through a structured familiarization phase, in which they were shown the pseudo-word (/pataka/) on a screen. This classical stimulus is used in sequential DDK tasks because it combines bilabial, alveolar, and velar places of articulation in a rapid sequence \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Using a pseudo-word rather than isolated syllables ensures that all participants produce the sequence with a consistent prosodic pattern, including word-final accent, final lengthening, and predictable pauses, minimizing variability that could arise if syllables were produced individually. Participants were asked to read it aloud, and then prompted to repeat it progressively first once, then three times, then five times to familiarize themselves with the required task. In the test phase, they were instructed to take a deep breath and repeat /pataka/ as quickly and accurately as possible until they ran out of air, completing two recorded trials. The task was repeated if participants did not follow the instructions, experienced severe speech initiation problems due to stuttering or ran out of breath after only two or three words, and in cases where a participant could not complete it, an additional attempt was made at the end of the session or in a subsequent visit. To evaluate oromotor skills, we calculated the number of oromotor errors and oromotor speed (i.e., interword-intervals, IWI). Higher oromotor speed (i.e., shorter IWIs) and fewer errors indicate higher oromotor skills \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Six types of errors were coded, following guidelines provided by Yaruss \u0026amp; Logan (2002): (1) insertions or (2) deletions of sounds (e.g., production of incomplete sequences), (3) changes in voicing or (4) placement, (5) exchanges between sounds, and (6) perseveration of sounds. The percentage of words containing errors over all words produced was calculated to obtain a measure of oromotor errors (error %). For oromotor speed assessment, we segmented the duration of IWIs using Praat \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e, a standard approach to measuring articulation rate \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e, beginning with the burst of /p/. Oromotor speed was derived from these intervals, with shorter mean IWI duration reflecting faster production speed. It is important to note that this measure was intended to capture oromotor timing, not speech fluency in the clinical sense (i.e., absence of stuttering).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTransfer to speech: Stuttered dysfluencies\u003c/h2\u003e\u003cp\u003eTo assess speech dysfluencies, we measured stuttered dysfluencies using the percentage of stuttered syllables in a naturalistic speech sample, following the procedures outlined in the Stuttering Severity Instrument (SSI-4 \u003csup\u003e36\u003c/sup\u003e). Participants produced both a spontaneous and a read speech sample at each time point. After the testing, a research assistant counted a total number of ~ 300 syllables per sample and the number of stuttered syllables therein. The percentages of stuttered syllables for both spontaneous and read speech, were averaged to obtain a composite dysfluency score per time point.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStatistical tests\u003c/h2\u003e\u003cp\u003eTo evaluate changes related to game play (post-training (T2) minus pre-training (T1)) and effect size estimate between groups, we used independent samples t-tests and if assumptions for parametric testing were not met, the Mann-Whitney test from the \u003cem\u003erstatix\u003c/em\u003e package in R Studio \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. Effect size interpretations were based on \u003csup\u003e49\u003c/sup\u003e. Normality was tested using the Shapiro-Wilk test and homogeneity of variance using Levene’s test. Spearman correlations were calculated between the outcome measures and training dose (cumulative playing time). We conducted one-tailed tests when assessing change scores based on the theoretical proposal that training rhythmic abilities would improve rhythmic, executive functioning and speech abilities \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, and empirical evidence that rhythmic training improved some of these functions in previous studies \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e The study received prior approval from the ethics board of the University of Montreal (CEREP-21-063-P) and the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (CIUSSMTL 2024 − 1926). Written informed consent was obtained from all participants’ parents and all participants assented orally.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003ch3\u003ePre-training comparisons for rhythmic, executive and speech functioning\u003c/h3\u003e\n\u003cp\u003eParticipants did not differ on any of the rhythmic tasks between games at T0 (p \u0026ge; 0.16) and T1 (p \u0026ge; 0.34). There were no baseline differences on any of the executive functioning scores between games at T0 (p \u0026ge; 0.14) or T1 p \u0026ge; 0.24). We also found no statistically significant differences in baseline measure between games on any of the speech tasks (oromotor measures or dysfluencies) at T0 (p \u0026ge; 0.14) or T1 p \u0026ge; 0.10).\u003c/p\u003e\n\u003ch3\u003eFeasibility: Compliance \u0026amp; acceptance\u003c/h3\u003e\n\u003cp\u003eParticipants playing RW (M = 283 minutes; SD = 131; range = 59-504) and FB (M = 279 minutes; SD = 151; range = 119-495) accumulated similar playing time, \u003cem\u003eW\u003c/em\u003e = 56, \u003cem\u003ep\u003c/em\u003e = 0.97, showing a satisfactory compliance. Twelve participants showed high compliance (88-168 % of the target time of 300 min of actual game play), eight participants showed moderate compliance (39-65% of the target time) and 1 participant showed poor compliance (17 % of the target). Participants in RW (M = 23819 taps; SD = 10898 taps; range = 5531- 45458 taps) and FB (M = 17884 taps; SD = 11864 taps; range = 6490- 38630 taps) showed similar total number of taps recorded on the tablet, \u003cem\u003eW\u003c/em\u003e = 72, \u003cem\u003ep\u003c/em\u003e = 0.25. Hence, there was a comparable amount of motor engagement with both games over the training period. Approximately 55% of participants (12/22) voluntarily provided feedback about their experience playing the game (acceptance). Overall, children in both groups reported high levels of enjoyment and engagement with the game. Ratings of global motivation after three weeks were generally positive and very high with no statistically significant differences between Rhythm Workers (M = 4.0/5) and Frozen Bubble (M = 4.6/5), \u003cem\u003ep\u003c/em\u003e = 0.10. Willingness to continue playing for 2 or 4 more weeks, perceived difficulty, frustration, and subjective flow did not differ significantly between groups (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.80). On average, both groups rated the game as moderately difficult and reported low levels of frustration. Children also indicated that time went by relatively quickly while playing, and most participants were willing to recommend the game to others. Together, these findings suggest a generally positive user experience, with no significant differences in acceptability between groups.\u003c/p\u003e\n\u003ch3\u003eEffects of RW training on rhythmic abilities\u003c/h3\u003e\n\u003cp\u003eHere we test the hypothesis that rhythmic abilities (paced and unpaced tapping) are higher in the RW compared to FB after training. An independent samples t-test revealed that the RW group, on average, improved their rhythmic abilities more than the FB group, but this effect did not reach statistical significance, \u003cem\u003et\u003c/em\u003e(17) = 1.33, \u003cem\u003ep\u003c/em\u003e = 0.10, one-tailed (Fig. 1A). As expected, for those who played RW, cumulative playing time was positively correlated with improvement in paced tapping, \u003cem\u003e\u0026rho;\u003c/em\u003e = 0.77, \u003cem\u003ep\u003c/em\u003e = 0.004 (Fig. 1B, one-tailed), but not FB (p = 0.36). Baseline scores were not related to change scores for paced tapping (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.46). There were no differences between games for unpaced tapping, W = 58, \u003cem\u003ep\u003c/em\u003e = 0.14, nor was there a relation with training dose (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.56).\u003c/p\u003e\n\u003ch3\u003eExploring executive functioning: Enhanced interference control after rhythmic training\u003c/h3\u003e\n\u003cp\u003eFig. 2 shows the results for interference control as measured by the incongruence effect of the flanker task on speed and accuracy \u003csup\u003e31\u003c/sup\u003e. A one-tailed independent samples t-test revealed that the RW group (M = 0.89) performed significantly better than the FB group (M = \u0026ndash;0.45), \u003cem\u003et\u003c/em\u003e(16) = 3.03, \u003cem\u003ep\u003c/em\u003e = 0.004, with a large effect size, \u003cem\u003ed\u003c/em\u003e = 1.43, 95% CI [0.37, 2.46] (see Fig. 2A). Cumulative playing time was not correlated with interference control speed improvement for either game (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.31, Fig. 2B). No difference or correlation was found for interference control accuracy, suggesting only speed-specific improvements in this sample. Note, that for those who played RW, baseline scores on this measure were negatively correlated with improvement on \u003cem\u003erho\u003c/em\u003e = -0.65, and on the cusp of statistical significance, \u003cem\u003ep\u003c/em\u003e = 0.067. This was not the case for FB (\u003cem\u003ep\u003c/em\u003e = 0.27), highlighting that those with lower pre-training scores (T1) on the Flanker task tended to improve more on that task after RW training.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eSpeech effects: improvements in oromotor skills and dysfluencies\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eTo assess whether rhythmic training is likely to transfer to speech-related skills (enhancing oromotor control and reducing stuttered dysfluencies) we compared change scores after training between RW and FB and as a function of training dose (cumulative playing time).\u003c/p\u003e\n\u003ch4\u003eOromotor skills \u0026ndash; errors and speed\u003c/h4\u003e\n\u003cp\u003eOne participant not correctly performing the DDK task (breathing between every word) was excluded from further analyses. To test oromotor errors (%), we performed a one-tailed Wilcoxon rank-sum test to compare error percentages between RW (M = -5.60; SD = 10.58) and FB (M = 0.71; SD = 5.10) and found a significant difference (\u003cem\u003eW\u003c/em\u003e = 26.5, \u003cem\u003ep\u003c/em\u003e = 0.041), with a moderate effect size (\u003cem\u003er\u003c/em\u003e = 0.46). To assess oromotor speed (Inter-Word-Interval in seconds) between RW and FB we used a one-tailed Welch\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test and found no significant difference between games (\u003cem\u003ep\u003c/em\u003e = 0.741).\u003c/p\u003e\n\u003cp\u003eTo examine whether training dose (i.e., cumulative playing time) was associated with less oromotor errors, one-tailed Spearman\u0026rsquo;s rank-order correlations were computed between cumulative playing time and errors within each group. A negative relationship between training dose and error rate change was detected (Fig. 3A) in the RW group, \u003cem\u003e\u0026rho;\u003c/em\u003e = \u0026ndash;.62, \u003cem\u003ep\u003c/em\u003e = 0.030. That is, with more RW training, participants showed a reduction of up to 23 % in oromotor errors. No such relationship was observed in the \u003cstrong\u003eFB group\u003c/strong\u003e (\u003cem\u003e\u0026rho;\u003c/em\u003e = .01, \u003cem\u003ep\u003c/em\u003e = 0.5). For oromotor speed (Fig. 3B), no significant association was found in the RW group (\u003cem\u003e\u0026rho;\u003c/em\u003e = .22, \u003cem\u003ep\u003c/em\u003e = 0.54, two-tailed since there could be speed-accuracy trade-offs in the task going in both directions). In contrast, the \u003cstrong\u003eFB group\u003c/strong\u003e showed a strong negative correlation (\u003cem\u003e\u0026rho;\u003c/em\u003e = \u0026ndash;.76, \u003cem\u003ep\u003c/em\u003e = 0.016 with participants speeding up their production up to 80 ms per IWI on average. Overall, this pattern of results suggests that participants playing RW were producing less oromotor errors (as expected), while participants playing FB were attaining higher oromotor rates, contrary to expectations. An ad-hoc Spearman correlation between change scores in oromotor errors and speed suggests a potential speed-accuracy trade-off in the RW group, however the correlation did not reach statistical significance, \u003cem\u003e\u0026rho;\u003c/em\u003e = -0.62, \u003cem\u003ep\u003c/em\u003e = 0.06. There was no sign of a speed-accuracy trade-off for FB (\u003cem\u003ep\u003c/em\u003e = 0.63).\u003c/p\u003e\n\u003cp\u003eStuttered dysfluencies\u003cbr\u003eTwo participants who received speech therapy during the study were excluded from fluency analyses. A one-tailed \u003cem\u003et\u003c/em\u003e-test revealed that the RW group (M = \u0026ndash;0.27) did not have significantly lower percentage of stuttered dysfluencies in naturalistic speech than the FB group (M = 0.47), \u003cem\u003et\u003c/em\u003e(17) = \u0026ndash;1.28, \u003cem\u003ep\u003c/em\u003e = 0.11, 95% CI [\u0026ndash;\u0026infin;, 0.27].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, in the RW group, there was an association between the reduction of stuttered dysfluencies and cumulative playing time, \u0026rho; = \u0026ndash;.72, \u003cem\u003ep\u003c/em\u003e = 0.018, (one-tailed). As can be seen in Fig. 3C, the reduction reached 1-2 percent (~ 3-6 stuttered syllables in 300 syllables) of dysfluencies post-training. In contrast, no significant association was found in the FB group, \u0026rho; = .27, \u003cem\u003ep\u003c/em\u003e = 0.45.\u003c/p\u003e\n\u003ch4\u003eRelationships between rhythmic, attentional and speech improvements\u003c/h4\u003e\n\u003cp\u003eFinally, we tested whether improvements in rhythmic abilities or cognitive abilities were associated with gains in oromotor skills or with reduction of stuttered dysfluencies. \u0026nbsp;We found a negative association between rhythmic and dysfluency scores (\u003cem\u003e\u0026rho;\u003c/em\u003e = \u0026ndash;.63, \u003cem\u003ep\u003c/em\u003e = 0.038, one-tailed) in the RW group, but not in the FB group (Fig. 3D). That is, participants who showed greater improvement in paced tapping following RW training exhibited fewer stuttered dysfluencies during both read and spontaneous speech. This finding suggests that the relationship between motor timing and speech improvement may be specific to the rhythm-based intervention. There were no statistically significant correlations between rhythmic and oromotor improvements (\u003cem\u003ep\u003c/em\u003e = 0.09 for errors, and \u003cem\u003ep\u003c/em\u003e = 0.15 for speed). In the RW group, there was an unexpected positive correlation between improvements in executive function and slowing of oromotor speed (\u003cem\u003e\u0026rho;\u003c/em\u003e = .74, \u003cem\u003ep\u003c/em\u003e = 0.046, two-tailed), but nothing in the FB group (\u003cem\u003e\u0026rho;\u003c/em\u003e = \u0026ndash;.22, \u003cem\u003ep\u003c/em\u003e = 0.581). However, interpretation of this correlation remains difficult, as no clear mechanistic explanation is evident and visual inspection suggests the effect may be driven by a few influential datapoints. Additionally, there were no significant associations between improvements in attention and speech measures, nor between changes in oromotor errors and Flanker performance in either group (RW: \u003cem\u003e\u0026rho;\u003c/em\u003e = \u0026ndash;.24, \u003cem\u003ep\u003c/em\u003e = .582; FB: \u003cem\u003e\u0026rho;\u003c/em\u003e = .30, \u003cem\u003ep\u003c/em\u003e = 0.437).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this proof-of-concept study, we used a gamified approach to examine the effect of rhythmic training to enhance speech production in pre-adolescents who stutter \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Here, we focused on potential benefits of rhythm training by comparing the effect of a rhythm-based training game on tablet \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e, to a non-rhythmic active control game. Training with a gamified approach for three weeks was generally successful in our sample, showing moderate to high compliance and reporting that participants generally enjoyed playing the games for 3 weeks. Hence, we conclude that feasibility goals were met and that we can recommend this approach for future studies.\u003c/p\u003e\n\u003cp\u003eThe present findings provide partial support for the hypothesis that rhythmic training enhances rhythmic tapping performance in children. While the RW group exhibited, on average, greater improvement in paced tapping compared to the FB group, this effect did not reach statistical significance. However, the direction of the effect and the moderate effect size suggest a potential benefit of rhythm-based gameplay on sensorimotor synchronization. Crucially, within the RW group, cumulative gameplay duration was strongly associated with improvement in paced tapping performance. This dose\u0026ndash;response relationship suggests that extended engagement with the rhythmic game may promote entrainment and timing precision, consistent with previous literature on rhythm-based interventions (e.g., \u003csup\u003e25,31,51\u003c/sup\u003e. Baseline performance did not predict change, suggesting that the observed improvements were not merely due to regression to the mean or initial skill level. Together, these findings support the feasibility and potential of rhythm-based serious games to enhance synchronization abilities in preadolescents who stutter, although further studies with larger samples are needed to confirm these preliminary trends.\u003c/p\u003e\n\u003cp\u003eThe second finding of this study is that preadolescents who trained with \u003cem\u003eRW\u003c/em\u003e showed gains in interference control, a subcomponent of a core executive function called inhibition control, \u003csup\u003e52\u003c/sup\u003e. This aligns with previous findings on the same training and outcome measure provided to ADHD and autism populations who show impairment in inhibition control \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. In stuttering, there exists some evidence that inhibition control may be lower compared to individuals without stuttering \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Considering the high number of comorbidities between stuttering and ADHD \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e, it is possible that some preadolescents with stuttering are at risk of weaker inhibition control. In line with this idea and our previous results with other neurodevelopmental groups, some participants in the RW group with lower initial scores showed greater improvements after playing the game. Although regression to the mean could partly account for this finding, we did not observe the same pattern in the group playing the control game, suggesting that rhythmic training, as in our previous studies, can have a specific effect on interference control in at-risk or impaired populations. For impaired groups who have shown a similar beneficial effect in our studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, we propose that the underlying mechanism lies in the nature of the training itself: RW gradually increases rhythmic complexity by making the beat less predictable and more syncopated, requiring players to ignore conflicting or misleading timing cues and to stay focused on the underlying pulse. This mirrors the cognitive demands of interference control, which involves filtering out irrelevant information to prioritize goal-relevant cues \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCrucially, our findings suggest that training with the rhythmic game may improve speech-motor control (i.e., oromotor skills measured by a diadochokinesis (DDK) task and reduction of stuttered dysfluencies measured in naturalistic speech). Specifically, pre-adolescents who played the rhythmic musical game, but not the control game, showed improvements in oromotor accuracy and, most notably, less stuttering symptoms as training time increased. Participants who engaged in the rhythmic game for approximately 300 minutes or more (see 3A and 3C) exhibited up to 23% reductions in oromotor errors in the DDK task and 2% in stuttered dysfluencies in naturalistic speech. Although promising, these findings should be interpreted with caution due to the small sample size and modest effect magnitude. Similar oromotor benefits following rhythmic training have been reported in clinical populations, such as individuals with Parkinson\u0026rsquo;s disease \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. One possible explanation for the observed effects is the close functional relationship between oromotor and manual motor systems, both of which rely on finely timed sequential movements and share overlapping neural substrates, particularly in the cerebellum and basal ganglia \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Thus, rhythm-based training may strengthen the temporal framework that underlies both manual and speech-motor coordination.\u003c/p\u003e\n\u003cp\u003eInterestingly, oromotor speed did not improve after rhythmic training, but it did in the group playing the control game. Although unexpected, this pattern may reflect the specific performance demands of the \u003cem\u003eFB\u003c/em\u003e game. Progressing in FB requires players to shoot bubbles at increasingly rapid rates while maintaining spatial accuracy, particularly as levels become more difficult and the threat of failure becomes more imminent. Training to increase motor output speed without compromising precision may have indirectly transferred to participants\u0026rsquo; spontaneous speed-accuracy balance adopted in the diadochokinesis task. In contrast, \u003cem\u003eRW\u003c/em\u003e emphasizes precise temporal synchronization rather than sheer speed, which may also explain the absence of a dose\u0026ndash;response effect in that group.\u003c/p\u003e\n\u003cp\u003eConcerning stuttered dysfluencies, one may object that the observed 2.2% reduction is modest and may fall within the range of daily variability. However, the reduction associated with cumulative rhythmic training time is promising, especially as it emerged in the absence of explicit speech targets during training and after a relatively short time of training (i.e., 300\u0026ndash;400 minutes across three weeks). Note that even traditional speech therapy often requires months or years to yield significant effects \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. Hence, we recommend to further investigate the effects of rhythmic training in stuttering with a sufficiently high training dose, across different age groups, and with a focus on individual outcomes and predispositions.\u003c/p\u003e\n\u003cp\u003eIn sum, the results of this proof-of-concept study are in line with recent theoretical frameworks for rhythm-based interventions in supporting speech rehabilitation through shared sensorimotor mechanisms \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. The speech-related improvements in our study can be interpreted through the lens of models underscoring the potential role of overlapping auditory-motor circuits for speech and musical rhythm and timing in the brain in rhythm training \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Participants engaging in rhythm-based training, likely strengthen the neural circuits responsible for precise timing in motor actions, a process that is crucial for fluent speech production. The absence of similar improvements in the \u003cem\u003eFB\u003c/em\u003e group may be due to the lack of rhythmic engagement in their training, which does not target the same auditory-motor synchronization mechanisms. These promising results mark the first demonstration of gamified rhythmic training through a tablet-based serious game in developmental stuttering, warranting further investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and future directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this study holds promise for the benefits of rhythm-based training in preadolescents who stutter, there are several limitations to consider. First, the sample size was relatively small, which may limit the generalizability of the findings. Future studies should aim to replicate these results in a larger sample, ideally with stratification by stuttering severity, to confirm and enhance the external validity of the effects. Another limitation concerns baseline differences between groups: although not statistically significant, the FB group showed a tendency to fewer stuttering dysfluencies than the RW group. Given the small sample size, this imbalance may have influenced change scores and limited the strength of between-group comparisons. A further important avenue for future research is exploring the underlying neural mechanisms that drive these improvements, particularly in relation to the SEP hypothesis \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, which posits that rhythm-based interventions tap into neural circuits responsible for timing and motor coordination. Investigating these mechanisms through neuroimaging or electrophysiological methods could shed light on how rhythmic training influences brain activity and improves speech-motor control. Finally, testing the efficacy of the \u003cem\u003eRhythm Workers\u003c/em\u003e program in a larger randomized controlled trial (RCT) design potentially across different neurodevelopmental conditions would provide stronger evidence for its therapeutic potential and establish its place in evidence-based interventions for children and adolescents with speech as well as cognitive disorders.\u003c/p\u003e\n\u003cp\u003eIn conclusion, this study shows the first evidence that rhythm-based training is feasible with a young population who stutters and can potentially enhance, as a function of practice, rhythmic abilities, executive functioning and speech-motor control after 300\u0026ndash;400 minutes of training. These results contribute to the growing body of studies discussing the therapeutic potential of rhythm training for children with various neurodevelopmental disorders. Future research combining rhythm training with established therapeutic approaches for neurodevelopmental conditions will further refine our understanding of the applications of this innovative therapeutic tool.\u003c/p\u003e"},{"header":"Declarations","content":"\n\u003ch3\u003eFunding\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis work was supported by funding from grant RGPIN/03122-2021 (Simone Falk) and grant 05453 (Simone Dalla Bella) from the Natural Sciences and Engineering Research Council of Canada (NSERC), and from SSHRC tier 2 Canada Research Chair in interdisciplinary studies on rhythm and language acquisition (Simone Falk) as well as NSERC Tier 1 Canada Research Chair in Music Auditory-Motor Skill Learning and New Technologies (Simone Dalla Bella).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConflicts of interest/Competing interests\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSDB is on the board of the BeatHealth company dedicated to the design and commercialization of technological tools for assessing rhythm abilities such as BAASTA tablet and implementing rhythm-based interventions. Other authors have no competing interest to disclose.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eWe sincerely thank all our participants and their families for their precious participation as well as the speech therapists from the Centre Raymond-Dewar and the Communauté de pratique en bégaiement-bredouillement, as well as Alicia Kluth, SLP; Héloise Tangay, SLP; Judith Labonté, SLP, and the Quebec stuttering associations (AJBQ, ABC) for their help with recruitment, and Marilyne Lemire-Tremblay for her help with testing. Our special thanks to the team validating the OASES questionnaire in French, for the French translation.\u003c/p\u003e\n\u003ch3\u003eAuthor contribution\u003c/h3\u003e\n\u003cp\u003eSimone Falk and Simone Dalla Bella designed the overall study and hypotheses with the game design stemming from Simone Dalla Bella’s lab. All authors contributed to design the test protocol. Simone Falk secured the funding and supervised the study. Sebastien Finlay recruited participants and coordinated participants’ training and testing. Kevin Jamey and Simone Falk supervised data collection. Kevin Jamey, Simone Falk, Sebastien Finlay, and Nicholas Foster analyzed the data. Kevin Jamey and Simone Falk performed statistical analysis. \u0026nbsp;All authors contributed to the interpretation of the results. Kevin Jamey wrote the first draft of the manuscript. All authors contributed to and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBloodstein, O., Ratner, N. B. \u0026amp; Brundage, S. B. \u003cem\u003eA Handbook on Stuttering\u003c/em\u003e. vol. 1 (Plural Publishing, San Diego, CA, 2021).\u003c/li\u003e\n \u003cli\u003eGuitar, B. \u003cem\u003eStuttering: An Integrated Approach to Its Nature and Treatment\u003c/em\u003e. (Lippincott Williams \u0026amp; Wilkins, Philadelphia, PA, 2021).\u003c/li\u003e\n \u003cli\u003eYairi, E. \u0026amp; Ambrose, N. Epidemiology of stuttering: 21st century advances. \u003cem\u003eJ Fluency Disord\u003c/em\u003e \u003cstrong\u003e38\u003c/strong\u003e, (2013).\u003c/li\u003e\n \u003cli\u003eGattie, M., Lieven, E. \u0026amp; Kluk, K. Adult stuttering prevalence I: Systematic review and identification of stuttering in large populations. \u003cem\u003eJ Fluency Disord\u003c/em\u003e \u003cstrong\u003e83\u003c/strong\u003e, 106085 (2025).\u003c/li\u003e\n \u003cli\u003eBoyle, M. P. \u0026amp; Fearon, A. N. Self-stigma and its associations with stress, physical health, and health care satisfaction in adults who stutter. \u003cem\u003eJ Fluency Disord\u003c/em\u003e \u003cstrong\u003e56\u003c/strong\u003e, (2018).\u003c/li\u003e\n \u003cli\u003eChang, S. E. \u0026amp; Guenther, F. H. Involvement of the Cortico-Basal Ganglia-Thalamocortical Loop in Developmental Stuttering. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e vol. 10 Preprint at https://doi.org/10.3389/fpsyg.2019.03088 (2020).\u003c/li\u003e\n \u003cli\u003eCivier, O., Bullock, D., Max, L. \u0026amp; Guenther, F. H. Computational modeling of stuttering caused by impairments in a basal ganglia thalamo-cortical circuit involved in syllable selection and initiation. \u003cem\u003eBrain Lang\u003c/em\u003e \u003cstrong\u003e126\u003c/strong\u003e, (2013).\u003c/li\u003e\n \u003cli\u003eFalk, S. Music and stuttering. in \u003cem\u003eThe Oxford Handbook of Language and Music\u003c/em\u003e (ed. Sammler, D.) (Oxford Academic, Online edition, 2025).\u003c/li\u003e\n \u003cli\u003eCannon, J. J. \u0026amp; Patel, A. D. How Beat Perception Co-opts Motor Neurophysiology. \u003cem\u003eTrends in Cognitive Sciences\u003c/em\u003e vol. 25 Preprint at https://doi.org/10.1016/j.tics.2020.11.002 (2021).\u003c/li\u003e\n \u003cli\u003eIversen, J. R. \u0026amp; Patel, A. D. The Beat Alignment Test (BAT): Surveying beat processing abilities in the general population. \u003cem\u003eProceedings of the 10th International Conference on Music Perception and Cognition\u003c/em\u003e (2008).\u003c/li\u003e\n \u003cli\u003eNozaradan, S., Schwartze, M., Obermeier, C. \u0026amp; Kotz, S. A. Specific contributions of basal ganglia and cerebellum to the neural tracking of rhythm. \u003cem\u003eCortex\u003c/em\u003e \u003cstrong\u003e95\u003c/strong\u003e, (2017).\u003c/li\u003e\n \u003cli\u003eGrahn, J. A. \u0026amp; Rowe, J. B. Feeling the Beat: Premotor and Striatal Interactions in Musicians and Nonmusicians during Beat Perception. \u003cem\u003eJournal of Neuroscience\u003c/em\u003e \u003cstrong\u003e29\u003c/strong\u003e, 7540\u0026ndash;7548 (2009).\u003c/li\u003e\n \u003cli\u003eGrahn, J. A. \u0026amp; Brett, M. Rhythm and beat perception in motor areas of the brain. \u003cem\u003eJ Cogn Neurosci\u003c/em\u003e \u003cstrong\u003e19\u003c/strong\u003e, (2007).\u003c/li\u003e\n \u003cli\u003eTeki, S., Grube, M. \u0026amp; Griffiths, T. D. A unified model of time perception accounts for duration-based and beat-based timing. \u003cem\u003eFront Integr Neurosci\u003c/em\u003e https://doi.org/10.3389/fnint.2011.00090 (2011) doi:10.3389/fnint.2011.00090.\u003c/li\u003e\n \u003cli\u003eSchwartze, M. \u0026amp; Kotz, S. A. A dual-pathway neural architecture for specific temporal prediction. \u003cem\u003eNeuroscience and Biobehavioral Reviews\u003c/em\u003e vol. 37 Preprint at https://doi.org/10.1016/j.neubiorev.2013.08.005 (2013).\u003c/li\u003e\n \u003cli\u003eMetzger, F. L. \u003cem\u003eet al.\u003c/em\u003e Shifted dynamic interactions between subcortical nuclei and inferior frontal gyri during response preparation in persistent developmental stuttering. \u003cem\u003eBrain Struct Funct\u003c/em\u003e \u003cstrong\u003e223\u003c/strong\u003e, (2018).\u003c/li\u003e\n \u003cli\u003eAckermann, H. Cerebellar contributions to speech production and speech perception: psycholinguistic and neurobiological perspectives. \u003cem\u003eTrends Neurosci\u003c/em\u003e \u003cstrong\u003e31\u003c/strong\u003e, (2008).\u003c/li\u003e\n \u003cli\u003eChristensen, A. \u003cem\u003eet al.\u003c/em\u003e An intact action-perception coupling depends on the integrity of the cerebellum. \u003cem\u003eJournal of Neuroscience\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e, (2014).\u003c/li\u003e\n \u003cli\u003eFrankford, S. A. \u003cem\u003eet al.\u003c/em\u003e The neural circuitry underlying the \u0026ldquo;rhythm effect\u0026rdquo; in stuttering. \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e \u003cstrong\u003e64\u003c/strong\u003e, (2021).\u003c/li\u003e\n \u003cli\u003eJohnson, C. A., Liu, Y., Waller, N. \u0026amp; Chang, S. E. Tract profiles of the cerebellar peduncles in children who stutter. \u003cem\u003eBrain Struct Funct\u003c/em\u003e \u003cstrong\u003e227\u003c/strong\u003e, (2022).\u003c/li\u003e\n \u003cli\u003eFiveash, A., Bedoin, N., Gordon, R. L. \u0026amp; Tillmann, B. Processing Rhythm In Speech And Music: Shared Mechanisms And Implications For Developmental Speech And Language Disorders. \u003cem\u003eNeuropsychology\u003c/em\u003e \u003cstrong\u003e35\u003c/strong\u003e, (2021).\u003c/li\u003e\n \u003cli\u003eFalk, S., M\u0026uuml;ller, T. \u0026amp; Dalla Bella, S. Non-verbal sensorimotor timing deficits in children and adolescents who stutter. \u003cem\u003eFront Psychol\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, (2015).\u003c/li\u003e\n \u003cli\u003eSares, A. G., Deroche, M. L. D., Shiller, D. M. \u0026amp; Gracco, V. L. Adults who stutter and metronome synchronization: evidence for a nonspeech timing deficit. \u003cem\u003eAnn N Y Acad Sci\u003c/em\u003e \u003cstrong\u003e1449\u003c/strong\u003e, (2019).\u003c/li\u003e\n \u003cli\u003eSlis, A., Savariaux, C., Perrier, P. \u0026amp; Garnier, M. Rhythmic tapping difficulties in adults who stutter: A deficit in beat perception, motor execution, or sensorimotor integration? \u003cem\u003ePLoS One\u003c/em\u003e \u003cstrong\u003e18\u003c/strong\u003e, (2023).\u003c/li\u003e\n \u003cli\u003eFujii, S. \u0026amp; Wan, C. Y. The Role of Rhythm in Speech and Language Rehabilitation: The SEP Hypothesis. \u003cem\u003eFront Hum Neurosci\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e, (2014).\u003c/li\u003e\n \u003cli\u003eChen, J. L., Penhune, V. B. \u0026amp; Zatorre, R. J. Listening to musical rhythms recruits motor regions of the brain. \u003cem\u003eCerebral Cortex\u003c/em\u003e \u003cstrong\u003e18\u003c/strong\u003e, (2008).\u003c/li\u003e\n \u003cli\u003eB\u0026eacute;gel, V., Seilles, A. \u0026amp; Dalla Bella, S. Rhythm Workers: A music-based serious game for training rhythm skills. \u003cem\u003eMusic Sci (Lond)\u003c/em\u003e \u003cstrong\u003e1\u003c/strong\u003e, (2018).\u003c/li\u003e\n \u003cli\u003ePuyjarinet, F. \u003cem\u003eet al.\u003c/em\u003e At-Home Training With a Rhythmic Video Game for Improving Orofacial, Manual, and Gait Abilities in Parkinson\u0026rsquo;s Disease: A Pilot Study. \u003cem\u003eFront Neurosci\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, (2022).\u003c/li\u003e\n \u003cli\u003eDalla Bella, S. Rhythmic serious games as an inclusive tool for music-based interventions. \u003cem\u003eAnn N Y Acad Sci\u003c/em\u003e \u003cstrong\u003e1517\u003c/strong\u003e, 15\u0026ndash;24 (2022).\u003c/li\u003e\n \u003cli\u003eZanto, T. P. \u003cem\u003eet al.\u003c/em\u003e Digital rhythm training improves reading fluency in children. \u003cem\u003eDev Sci\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, (2024).\u003c/li\u003e\n \u003cli\u003eJamey, K. \u003cem\u003eet al.\u003c/em\u003e Can you beat the music? Validation of a gamified rhythmic training in children with ADHD. \u003cem\u003eBehav Res Methods\u003c/em\u003e \u003cstrong\u003e57\u003c/strong\u003e, 303 (2025).\u003c/li\u003e\n \u003cli\u003eJamey, K. \u003cem\u003eet al.\u003c/em\u003e \u003cem\u003eEnhancing Sensorimotor and Executive Functioning in Autistic Children with a Rhythmic Videogame: A Pilot Study\u003c/em\u003e. \u003cem\u003eResearch Square\u003c/em\u003e https://doi.org/10.21203/rs.3.rs-5790839/v1 (2025).\u003c/li\u003e\n \u003cli\u003eKoenraads, S. P. C. \u003cem\u003eet al.\u003c/em\u003e Structural brain differences in pre-adolescents who persist in and recover from stuttering. \u003cem\u003eNeuroimage Clin\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, (2020).\u003c/li\u003e\n \u003cli\u003eDalla Bella, S. \u003cem\u003eet al.\u003c/em\u003e Mobile version of the Battery for the Assessment of Auditory Sensorimotor and Timing Abilities (BAASTA): Implementation and adult norms. \u003cem\u003eBehav Res Methods\u003c/em\u003e https://doi.org/10.3758/s13428-024-02363-x (2024) doi:10.3758/s13428-024-02363-x.\u003c/li\u003e\n \u003cli\u003eDalla Bella, S. \u003cem\u003eet al.\u003c/em\u003e BAASTA: Battery for the Assessment of Auditory Sensorimotor and Timing Abilities. \u003cem\u003eBehav Res Methods\u003c/em\u003e \u003cstrong\u003e49\u003c/strong\u003e, (2017).\u003c/li\u003e\n \u003cli\u003eRiley, G. D. SSI-4: Stuttering Severity Instrument. \u003cem\u003eSSI-4 : Stuttering severity instrument\u003c/em\u003e (2009).\u003c/li\u003e\n \u003cli\u003eScott Yaruss, J. \u0026amp; Logan, K. J. Evaluating rate, accuracy, and fluency of young children\u0026rsquo;s diadochokinetic productions: A preliminary investigation. \u003cem\u003eJ Fluency Disord\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, (2002).\u003c/li\u003e\n \u003cli\u003ePuyjarinet, F., B\u0026eacute;gel, V., Lopez, R., Dellacherie, D. \u0026amp; Dalla Bella, S. Children and adults with Attention-Deficit/Hyperactivity Disorder cannot move to the beat. \u003cem\u003eSci Rep\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, (2017).\u003c/li\u003e\n \u003cli\u003eB\u0026eacute;gel, V. \u003cem\u003eet al.\u003c/em\u003e Rhythm as an Independent Determinant of Developmental Dyslexia. \u003cem\u003eDev Psychol\u003c/em\u003e \u003cstrong\u003e58\u003c/strong\u003e, (2022).\u003c/li\u003e\n \u003cli\u003eSowiński, J. \u0026amp; Dalla Bella, S. Poor synchronization to the beat may result from deficient auditory-motor mapping. \u003cem\u003eNeuropsychologia\u003c/em\u003e \u003cstrong\u003e51\u003c/strong\u003e, (2013).\u003c/li\u003e\n \u003cli\u003eStuss, D. T. \u003cem\u003eet al.\u003c/em\u003e The Trail Making Test: A study in focal lesion patients. \u003cem\u003ePsychol Assess\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, (2001).\u003c/li\u003e\n \u003cli\u003ePeri\u0026aacute;\u0026ntilde;ez, J. A. \u003cem\u003eet al.\u003c/em\u003e Trail Making Test in traumatic brain injury, schizophrenia, and normal ageing: Sample comparisons and normative data. \u003cem\u003eArchives of Clinical Neuropsychology\u003c/em\u003e \u003cstrong\u003e22\u003c/strong\u003e, (2007).\u003c/li\u003e\n \u003cli\u003eKent, R. D., Kim, Y. \u0026amp; Chen, L. M. Oral and Laryngeal Diadochokinesis Across the Life Span: A Scoping Review of Methods, Reference Data, and Clinical Applications. \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e \u003cstrong\u003e65\u003c/strong\u003e, (2022).\u003c/li\u003e\n \u003cli\u003eDuffy, J. R. \u003cem\u003eMotor Speech Disorders : Substrates, Differential Diagnosis, and Management\u003c/em\u003e. (Elsevier/Mosby, St. Louis, Mo, 2013).\u003c/li\u003e\n \u003cli\u003eIcht, M. \u0026amp; Ben-David, B. M. Evaluating rate and accuracy of real word vs. non-word diadochokinetic productions from childhood to early adulthood in Hebrew speakers. \u003cem\u003eJ Commun Disord\u003c/em\u003e \u003cstrong\u003e92\u003c/strong\u003e, (2021).\u003c/li\u003e\n \u003cli\u003eBoersma, P. \u0026amp; Weenink, D. Praat: doing phonetics by computer [Computer program]. \u003cem\u003eGlot International\u003c/em\u003e vol. 5 Preprint at (2013).\u003c/li\u003e\n \u003cli\u003eHurkmans, J., Jonkers, R., Boonstra, A. M., Stewart, R. E. \u0026amp; Reinders-Messelink, H. A. Assessing the treatment effects in apraxia of speech: Introduction and evaluation of the Modified Diadochokinesis Test. \u003cem\u003eInt J Lang Commun Disord\u003c/em\u003e \u003cstrong\u003e47\u003c/strong\u003e, (2012).\u003c/li\u003e\n \u003cli\u003eKassambara, A. rstatix: Pipe-Friendly Framework for Basic Statistical Tests. Preprint at https://rpkgs.datanovia.com/rstatix/ (2023).\u003c/li\u003e\n \u003cli\u003eMiles, J. (viaf)59378934 \u0026amp; Shevlin, M. \u003cem\u003eApplying Regression and Correlation : A Guide for Students and Researchers\u003c/em\u003e. (London : Sage, 2001).\u003c/li\u003e\n \u003cli\u003eDalla Bella, S. \u0026amp; Falk, S. Rhythmic processes in stuttering and Parkinson\u0026rsquo;s disease. in \u003cem\u003eRhythms of Speech and Language\u003c/em\u003e (eds. Meyer, L. \u0026amp; Strauss, A.) (Cambridge University Press, Cambridge).\u003c/li\u003e\n \u003cli\u003eDalla Bella, S. \u003cem\u003eet al.\u003c/em\u003e Gait improvement via rhythmic stimulation in Parkinson\u0026rsquo;s disease is linked to rhythmic skills. \u003cem\u003eSci Rep\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, (2017).\u003c/li\u003e\n \u003cli\u003eDiamond, A. Executive Functions. \u003cem\u003eAnnu Rev Psychol\u003c/em\u003e \u003cstrong\u003e64\u003c/strong\u003e, 135\u0026ndash;168 (2013).\u003c/li\u003e\n \u003cli\u003eTreleaven, S. B. \u0026amp; Coalson, G. A. Manual response inhibition and quality of life in adults who stutter. \u003cem\u003eJ Commun Disord\u003c/em\u003e \u003cstrong\u003e88\u003c/strong\u003e, (2020).\u003c/li\u003e\n \u003cli\u003eFinlay, S. \u003cem\u003eet al.\u003c/em\u003e Administering the Lidcombe Program to children who stutter with concomitant disorders: Insights from an exploratory retrospective chart review study. \u003cem\u003eJ Fluency Disord\u003c/em\u003e \u003cstrong\u003e83\u003c/strong\u003e, 106101 (2025).\u003c/li\u003e\n \u003cli\u003eCraig, A., Hancock, K., Tran, Y., Craig, M. \u0026amp; Peters, K. Epidemiology of stuttering in the community across the entire life span. \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e \u003cstrong\u003e45\u003c/strong\u003e, (2002).\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brian, S., Onslow, M., Cream, A. \u0026amp; Packman, A. The Camperdown Program: Outcomes of a new prolonged-speech treatment model. \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e \u003cstrong\u003e46\u003c/strong\u003e, (2003).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Montreal","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"rhythm training, stuttering, speech, sensorimotor and executive functioning","lastPublishedDoi":"10.21203/rs.3.rs-7963668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7963668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eStuttering is a developmental speech fluency disorder linked to timing deficits in speech motor control. Given the shared neural mechanisms between rhythmic timing and speech production, rhythm-based interventions may hold promise for stuttering. This proof-of-concept study evaluated the feasibility and potential benefits of a gamified rhythmic training program, \u003cem\u003eRhythm Workers\u003c/em\u003e (RW), in pre-adolescents who stutter. Twenty-one children (aged 9\u0026ndash;12) were randomly assigned to either RW or an active control game (\u003cem\u003eFrozen Bubble\u003c/em\u003e) which they played at home for three weeks. We assessed feasibility as well as potential training effects on rhythmic, cognitive and speech-related abilities. Both games were well accepted, and compliance was moderate to high. Only participants trained on the rhythm game showed moderate enhancements in rhythmic synchronization, interference control, oromotor performance, and reduction of stuttering after training. The improvements (except for interference control) correlated with training dose. Moreover, some speech-related gains were associated with improved rhythmic performance, pointing to a possible causal link. While some effects did not reach statistical significance due to the limited sample size, the observed dose\u0026ndash;response patterns and domain-specific improvements support the feasibility and promise of rhythmic gaming for young people who stutter. This study provides preliminary evidence that rhythm-based serious games can enhance speech and cognitive outcomes in adolescents who stutter.\u003c/p\u003e","manuscriptTitle":"A Proof-of-Concept Study of Gamified Rhythmic Training in Preadolescents who Stutter","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 12:34:37","doi":"10.21203/rs.3.rs-7963668/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6b48c5c3-b805-4243-87a0-d270079c1919","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56979032,"name":"Psychology"}],"tags":[],"updatedAt":"2025-10-29T12:34:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 12:34:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7963668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7963668","identity":"rs-7963668","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}