Treatment Effectiveness: Finding Value in Clinical Data' Part 1'

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Treatment EffectivenessFinding Value in
Clinical Data. Part 1.

• J. Scott Yaruss, Ph.D., CCC-SLPUniversity of
  Pittsburgh
• University of Georgia
• Conference on Treatment EfficacyAthens,
  GeorgiaMarch 20-22, 1997

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Purpose

• To discuss the value of supplementing treatment
  efficacy research with studies of treatment
  effectiveness
• To present preliminary results from a
  retrospective clinical study evaluating the
  effectiveness of a treatment program for adults
  who stutter

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An effective treatment is onethat successfully
addressesthe clients complaint

• Butwhat is the nature ofthe clients complaint?

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WHO (1980) Classification

• Impairment loss or abnormality of
  psychological, physiological, or anatomical
  structure or function
• Disability any restriction or lack (result-ing
  from impairment) of ability to perform an
  activity in the normal manner
• Handicap a disadvantageresulting from an
  impairment or disability that limits or prevents
  fulfillment of a normal role

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WHO and Stuttering

• Impairment (one entry)
• Impairment of speech fluency (37.0) stuttering
  events

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• Disability (dozens of possible entries)
• Disability in talking (21.0) restriction of
  ability to produce verbal messages and convey
  meaning...
• Situational coping disability (14.2)
  ...disturbance of ability to perform activities
  in specific situations...

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• Handicap (several possible entries)
• Social integration handicap (4.1)disadvantages
  that inhibit but not prevent participation in
  social activities
• Occupation handicap (4.3)restriction of career
  choice because of impairment or disability

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The complaint as Impairment

• Some treatments apparently view the clients
  complaint as the stuttering event, or the
  impairment
• Impairment disruptions in speech, including
  repetitions, prolongations, blocks, reduced
  speaking rate, etc.
• Clinicians using this approach have done a good
  job of demonstrating the efficacy of their
  treatments

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The complaint as Impairment,Disability, and
Handicap

• Some treatments view the complaint as the
  stuttering disorder, encompassing all three
  aspects (I, D, and H)
• Impairment production of disfluencies, etc.
• Disability difficulty interacting with peers,
  using the phone, entering speaking situations,
  etc.
• Handicap shame, fear, anxiety that limits
  participation in social activities, difficulty
  getting the job they want, etc.

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Clinicians using these types of whole-disorder
approaches have not done a sufficient job of
demonstrating treatment efficacy.
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Why do people use (and recommend) these unproven
treatment approaches?

• Because of a perceived differences in
• the nature of the clients complaint
• the responsibility of the clinician in addressing
  that complaint
• the scope of treatment
• However, there are problems...

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Some Problems

• With the whole-disorder approach, it can be
  difficult (but not impossible) to assess
  treatment efficacy
• Success is based on the needs of the client
• Thus, success is variable and individualized,
  both between and within clients (over time)
• The definition of success also varies depending
  upon whether youre talking about the impairment,
  the disability, or the handicap

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Consequences

• Because of the individualized nature of
  treatment, it can be difficult to apply
  traditional efficacy research methods
• Most single-subject designs require that the same
  treatment be applied across a relatively
  homogenous set of subjects
• Group designs are not as well suited to assessing
  efficacy, but they also require homogeneity
  across subjects and treatments

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Some Major Problems

• Many whole-disorder treatments are not
  well-grounded in theory, so it is difficult to
  define a framework for assessing treatment
  efficacy
• Treatment variables in these approaches are not
  sufficiently operationalized to permit rigorous
  study (at present)

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More Consequences

• Before we can meaningfully assess the efficacy of
  whole-disorder treatments, we must
• Describe the treatment programs in detail
• Operationalize the supposed outcomes of these
  treatments at all 3 levels (I, D, H)
• Determine whether clients report any benefits
  that can be associated with treatment
• We are still very much at the beginning in
  assessing whole-disorder treatments

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A first step toward efficacy...

• One way to begin asking whether whole-disorder
  treatment is effective is to study clients who
  already received treatment
• Documentation of Clinical Practice
• Such studies can help prepare us for future, more
  rigorous studies of the efficacy of
  whole-disorder treatments
• Evaluating potential benefits of treatment
• Defining treatment variables for further study