Preliminary Study of Treatment Effectiveness

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Preliminary Study of Treatment Effectiveness

• Purpose To assess the effectiveness of
  Northwestern Universitys 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

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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)

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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

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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

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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

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Modification Techniques

• Speak more fluently methods
• ERA-SM (Easy Relaxed ApproachSmooth 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

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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

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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

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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 clients success before treatment,
  immediately after treatment, and at present

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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

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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 lt .001)
• Mean Differences ? ? 0.11 (SD ? 1.5)

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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

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Preliminary Results 4 Findings

• Changes in clients speech fluency
• Average Data
• Example of Individual Data
• Use of modification techniques
• Cognitive and affective changes
• Self-reported long-term changes

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Finding 1a Observable characteristics Group
Data (N 15)
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Finding 1b Observable characteristics
Individual Data (Subject 1)
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Finding 2 Use of modifications at end of
treatment (N 13)
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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 clinicians feelings

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Finding 4a Self-rated Level of Fluency at
Follow-up (N 15)
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Finding 4b Self-rated Speech Attitudes at
Follow-up (N 15)
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Finding 4c Self-rated Avoidance at Follow-up (N
15)
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Finding 4d Use of Modification Techniques at
Follow-up (N 15)
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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

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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

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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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