Preliminary Study of Treatment Effectiveness

• Purpose: To assess the effectiveness of Northwestern University’s Adult Stuttering Treatment Group (ASG)– A “whole-disorder” treatment program in

use since 1970, and trained internationally

– One of the frequently “recommended,” but seldom researched treatment approaches

• Subject Pool: All clients enrolled in the ASG since 1975

Treatment Effectiveness

• Efficacy: The extent to which treatment can be shown to be beneficial under optimal (or ideal) conditions

• Effectiveness: The extent to which treatment is shown to be beneficial under typical (or real-world) conditions

• Sources: Agency for Health Care Policy and Research (AHCPR, 1994); Congressional Office of Technology Assessment (1978)

Goals of Treatment• Clients can achieve fluency when they want

to (using modification techniques)

• Clients will experience increased level of unmodified fluency (as modifications become more automatic)

• Clients accept remaining stuttering (without anxiety, fear, struggle, avoidance, etc.)

– As with other disorders that Patrick reviewed, “recovery” allows some residual stuttering

Schedule of Treatment

• Group and individual sessions with structured generalization tasks

• Extensive treatment model– 2 to 3 times per week for 2 academic

quarters (18 weeks total)

– On-going monthly maintenance and problem-solving in the “Continuation Group” following dismissal from ASG

Principles of Treatment

• Combines elements of both “speak more fluently” and “stutter more fluently” approaches to treatment with extensive counseling

• Gives client a “toolbox” of several modification techniques they can call upon to increase fluency and decrease sensitivity as necessary

Modification Techniques• “Speak more fluently” methods

– ERA-SM (Easy Relaxed Approach—Smooth Movement)

– Delayed response (pausing before utterances)– Phrasing (pausing within utterances)

• “Stutter more fluently” methods– Relaxation– Negative practice of tension and tension reduction– Voluntary Disfluency/Voluntary Stuttering– Cancellation– Pull-out

Evaluating the Clinical Records

• Data extracted from clinical records of clients who had enrolled in ASG– Observable characteristics of stuttering

– Use of modification techniques

– Situational factors affecting fluency

– Cognitive / affective aspects of clients’ recovery (attitudes, feelings, etc.)

• Data collected at diagnostic, before treatment, during treatment, and at dismissal

Observable Characteristics• Assessed via Systematic Disfluency

Analysis (SDA, Campbell & Hill, 1987, 1994)

– Examines a variety of more typical and less typical disfluency types in language context

– Measures frequency, type, duration, number of iterations, and clustering, plus qualitative features (tension, pitch changes, rhythm...)

– Five different in-clinic speaking tasks• Monologue, dialogue, reading, pressure, phone

Follow-up Questionnaire• Follow-up questionnaire sent to all

clients assessing:– Self-reported level of fluency– Use of modification techniques– Speech attitudes / comfort with speaking– Avoidance of sounds, words, situations– Occurrence of and reaction to relapse

• Asked about client’s success before treatment, immediately after treatment, and at present

Caveats

• Concerns re retrospective studies– Reliability of measurement– Accuracy of clinical files– Use of currently relevant measures

• If such issues are addressed, and results are interpreted appropriately, such studies can provide a meaningful adjunct to other studies of treatment effectiveness

Measurement Reliability• Reliability data for the SDA have not yet

been published, however:– Students participate in detailed training re

identification disfluencies and use of SDA(e.g., Campbell, Hill, Yaruss, & Gregory, 1996).

– Each SDA was reviewed by one of the authors of the SDA technique (Campbell & Hill)

– Two preliminary analyses reveal good agreement on counts (Yaruss, in press; Yaruss et al., submitted)

• Pearson Correlations: r .90 (p < .001)• Mean Differences: 0.11% (SD 1.5%)

Accuracy of Clinical Files• Clinical files are notorious for their

inaccuracy (particularly student files)• However, the NU clinic has a rigorous

review policy for all clinical reports– Reports are reviewed by the original

supervisor and by a second supervisor who “approves” all reports before they are included in the clinical files

Preliminary Results: 4 Findings

• Changes in client’s speech fluency– Average Data– Example of Individual Data

• Use of modification techniques

• Cognitive and affective changes

• Self-reported long-term changes

Finding 1a: Observable characteristics — Group Data (N = 15)

0

2

4

6

8

10

12

Fre

qu

en

cy o

f D

isfl

ue

nc

ies

Pre-Treatment Post-Treatment

Less TypicalDisfluencies (t = 5.34;p < .001)

More TypicalDisfluencies (t = 3.42;p < .004)

Finding 1b: Observable characteristics — Individual Data (Subject #1)

0

1

2

3

4

5

6

7

8

DiagnosticEvaluation

Pre-Treatment

BeforeBreak

After Break Post-Treatment

Fre

qu

en

cy

of

Dis

flu

en

cie

s

Less TypicalDisfluenciesMore TypicalDisfluencies

Treatment9 weeks

Treatment:9 weeks

No Treatment No Treatment:5 weeks

Finding 2: Use of modifications at end of treatment (N = 13)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERA-SM

DelResp

VolDisf

Canc Pull-out

Relax

% o

f S

ub

jec

ts .

Finding 3: Cognitive /affective changes at the end of treatment

• 67% of clinical records reported that clients achieved some improvement in cognitive / affective aspects– reduced fear and anxiety leading to increased

ability to enter speaking situations– improved attitudes, acceptance leading to

increased self-esteem and self-confidence

• But, no specific measures were utilized!– Judgments based only on clinician’s “feelings”

1

2

3

4

5

BeforeTreatment

ImmediatelyAfter

Treatment

CurrentlyPo

or

Go

od

Finding #4a: Self-rated Level of Fluency at Follow-up (N = 15)

Finding #4b: Self-rated Speech Attitudes at Follow-up (N = 15)

1

2

3

4

5

BeforeTreatment

ImmediatelyAfter

Treatment

CurrentlyPo

or

Go

od

Finding #4c: Self-rated Avoidance at Follow-up (N = 15)

1

2

3

4

5

BeforeTreatment

ImmediatelyAfter

Treatment

CurrentlyNe

ve

rA

lwa

ys

Finding #4d: Use of Modification Techniques at Follow-up (N = 15)

1

2

3

4

5

ERA-SM

Relax Vol.Disf.

Neg.Pract.

Del.Resp.

Canc. Pull-out

Alw

ay

sN

ev

er

S

om

eti

me

s

Implications

• All clients reported some benefits presumably associated with treatment– Increased speech fluency (impairment)– Increased ability to approach situations and

function at home and work (disability)– Increased participation in society (handicap)

• Many clients reported improvements, even though they did NOT continue to consistently use the modification techniques

Future Research• Based on these retrospective results we

can begin planning prospective studies:– Descriptive and experimental group designs to:

• Apply more rigorous assessment of measures throughout the entire treatment process

• Gain understanding of time required to establish modifications (to support development of SS study)

– Single-subject designs, e.g.,• Multiple baseline across subjects to establish

internal reliability for assessing treatment effects• Crossover design and component analyses to

directly evaluate different aspects of treatment

Conclusions

• Rather than determining that “whole-disorder” treatments should not be used because they have not yet been researched, it seems reasonable to begin to study them in a scientific fashion– If they prove to be worthless after such study, then by all

means, they should not be used– If they prove to be efficacious (whatever that means),

then they can be another acceptable means of treatment• Retrospective studies of treatment effectiveness can

help pave the way by:– providing preliminary assessment of presumed benefits– operationalizating treatment variables

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