Preliminary Study of Treatment Effectiveness

1. 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

2. 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)

3. 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 acceptremaining stuttering (without anxiety, fear, struggle, avoidance, etc.) • As with other disorders that Patrick reviewed, “recovery” allows some residual stuttering

4. 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

5. 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 fluencyand decrease sensitivity as necessary

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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%)

12. 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

13. 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

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

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

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

17. 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”

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

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

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

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

22. 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

23. 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

24. 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 Review this lecture