LSHSS

Clinical Focus

Selecting Treatments and Monitoring

Outcomes: The Circle of Evidence-Based
Practice and Client-Centered Care in
Treating a Preschool Child Who Stutters
Nan Bernstein Ratnera

Purpose: The purpose of the present clinical forum is to I am also most comfortable recommending RESTART
compare how 2 clinicians might select among therapy demands and capacities model as the 1st treatment
options for a preschool-aged child who presents with approach, with parent consent, because its mechanism
stuttering close to onset. of action appears transparent and well-documented.
Method: I discuss approaches to full evaluation of the child’s Conclusions: There are numerous well-supported
profile, advisement of evidence-based practice options intervention options for treating preschool children who
open to the family, the need for monitoring of the child’s stutter. No single therapy can possibly work for all
response, and selection of other approaches, if the child clients. I discuss available options that I feel have sufficient
appears nonresponsive to the 1st-line approach. evidence-based support for use with young children who
Results: Although some researchers and clinicians appear stutter. I emphasize the need to consider more, not fewer,
to favor endorsement of a single recommended treatment acceptable therapy options for children who do not
for early stuttering, I do not find this approach helpful or respond positively to a selected treatment approach within
consistent with newer mandates for patient-centered care. a reasonable time frame.

L
et us review the major features of the case that his parents are quite busy at this point in their professional
appear relevant for my decision making: Our re- careers will require me to discuss the relative advantages of
ferral is a 3;6-year-old boy named David. We are working with one of the adults in David’s life to provide
seeing him less than a year post-onset of stuttering symp- short, daily, home-based interactions, which, at his age, have
toms, which is a positive prognostic indicator of spontane- the highest level of research support and should be prefera-
ous recovery (Yairi & Ambrose, 1999, 2005). The same ble to taking the child to the speech-language pathologist
body of research notes that boys achieve spontaneous re- for direct intervention during the typical work day. Home-
covery less often than girls–a negative prognostic feature. based interventions are thought to have higher generali-
The Illinois Project and others have suggested that a his- zation potential because the child and parents work on
tory of late talking and poor phonology may contribute to speaking within the child’s everyday environment. The
a negative fluency prognosis, so I would feel compelled to other symptom that concerns me is the reportedly tense
examine this aspect of the case further. quality of his stuttered speech, which implies some level
The fact that the child spends the majority of his wak- of awareness and frustration. If this child does not experi-
ing time with a caregiver other than his parents and that ence spontaneous recovery relatively soon, we will need
to find an effective program to reduce the adverse impacts
a
Department of Hearing and Speech Sciences, University of
of stuttering on his well-being and that of his parents.
Maryland, College Park
Correspondence to Nan Bernstein Ratner: [email protected]
Editor-in-Chief: Shelley Gray Further Diagnostic Concerns
Editor: Courtney Byrd Prior to parent counseling to discuss options for
Received February 2, 2017 David’s care, I would conduct a further evaluation of the
Revision received June 27, 2017 child, particularly a more in-depth analysis of his language
Accepted October 29, 2017
https://doi.org/10.1044/2017_LSHSS-17-0015
Publisher Note: This article is part of the Clinical Forum: Treatment Disclosure: The author has declared that no competing interests existed at the time
of Stuttering in Children. of publication.

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 and phonological skills. My rationale for all this is that implementation of a structured intervention is definitely an
language delays have poor prognosis for later achievement option supported by the Lidcombe consortium:
in both reading and academic performance (Dale & Hayiou-
Thomas, 2013; Paul, 2000; Rescorla, 2009; Rescorla & “Given that waiting for a year apparently does not
Dale, 2013); arguably, such delays, if not addressed, could decrease responsiveness to the program, clinicians
impose even more negative consequences on the child’s have the option of waiting for a period shorter than
a year to see if natural recovery occurs” (Lidcombe
future potential than the stuttering itself. We now know
consortium; as described in Lewis, Packman, Onslow,
that late talkers do not “catch up,” at least without inter-
Simpson, & Jones, 2008, p. 141)
vention (Rescorla & Dale, 2013). However, concerns about
the adequacy of a child’s language development may be I would explicitly guide the parents through my opin-
less easily benchmarked by parents than overt moments ion that this option is most reasonable only if the child is
of stuttering. not frustrated or adversely impacted by disfluency. Con-
More relevant to the case at hand, less well-developed trary to some perceptions that very young children are un-
language and phonological abilities also may have nega- aware of their stuttering, Langevin, Packman, and Onslow
tive prognosis for spontaneous recovery from stuttering (2010) noted frequent frustration, withdrawal from talking
(to name representative findings from two separate labs: situations, and comments about speaking difficulty in pre-
Ambrose, Yairi, Loucks, Seery, & Throneburg, 2015; schoolers who stutter. In my personal opinion, child frus-
Hollister, Van Horne, & Zebrowski, 2017; Leech, Ratner, tration should trigger immediate discussion about specific
Brown, & Weber, 2017; Spencer & Weber-Fox, 2014). Such intervention. The parents may be frustrated as well, as
work tends to suggest that children who display less-than- Langevin et al. and Plexico and Burrus (2012) note. To this
average skills in other areas of communication development end, whether or not a formal, structured intervention is
may be at increased risk for continuing to stutter. Results scheduled right away, I would begin to attempt to bind
of my further assessment are likely to shape my recommen- parental anxiety and improve parental locus of control, both
dations to David’s parents. I may also need to think about of which are associated with more positive outcomes in
additional therapy time that will need to be dedicated to children’s chronic disease management (Ros, Hernandez,
treatment of additional concerns. If there are additional Graziano, & Bagner, 2016) by discussing palliative (symp-
therapeutically relevant concerns about language ability, tom reducing) procedures for reducing the frequency of
they may interact with the child’s ability to be fluent during stuttering via what is typically termed indirect therapy
therapy tasks directed to the stuttering problem (Bernstein options.
Ratner, 2005), as well as conversational attempts having the Thus, if the family chooses to defer structured inter-
full range of linguistic and phonological complexity (Watson, vention for a few months in hopes of spontaneous recov-
Byrd, & Carlo, 2011; Wolk & LaSalle, 2015). If David also ery, in the interim, we can use parental counseling to slow
requires language intervention, the reverse is likely to be adult speech rate in conversation with the child and re-
true as well—as we try to help him with more challenging duce turn-taking challenges (both have historical published
language achievements, the child may find it more difficult support in reducing moments of disfluency in parent–child
to be fluent, as a large body of research suggests (see review interactions, as noted by Davidow, Zaroogian, & Garcia-
by Hall, Wagovich, & Bernstein Ratner, 2007). Thus, ther- Barrera, 2016; see also Sawyer, Matteson, Hua, & Takahisa,
apy “lessons” may need to scaffold language activities from 2017). I would also have the parents acknowledge moments
those that impose lower levels of challenge to those that of evident speech frustration because this principle is con-
further tax David’s speech and language formulation skills gruent with the Lidcombe Program (LP) feedback and is
in order to extend fluency into more challenging speaking consistent with guidance to adults when children have diffi-
tasks. culty with a range of functions in early development. Ac-
knowledgment plays different roles in these two approaches:
It can be viewed as providing more emotional support in
When Should Treatment Begin? the demands and capacities model (DCM) and creating shared
Given the relatively recent onset of stuttering, I would parent–child awareness of speech difficulty in LP. My pref-
discuss the possibility of waiting to initiate a structured, erence is to view acknowledgment as a hybrid of these
direct intervention. I would do this after discussing results positions—providing emotional support and the notion of
of my full evaluation and the appropriate known prog- shared work with the child in addressing his or her speech
nostic indicators to date. These include family history of difficulty that is consistent with the larger psychological
persistent stuttering, age of onset, and speech and lan- literature on the benefits of family-based treatment of de-
guage skills. As the daughter of an insurance salesman, I velopmental health problems. Finally, I would share that it
would also remind parents that prognostic indicators are, is widely recognized that parental self-efficacy in the manage-
of course, merely actuarial odds. As such, they are merely ment of childhood disorders has positive impacts on the
information that parents can mull over and balance in view child’s function (e.g., Mouton & Roskam, 2015): When
of other information or feelings that they have regarding parents are included in the treatment of their children,
their child, the dimensions of the fluency disorder, and avail- rather than relying solely on the guidance of professionals,
able time and financial commitment to therapy. Deferring outcomes tend to be superior.

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 I would also instruct the parents to chart the child’s maximally guide this process, should I select LP as the first in-
fluency profiles to gauge changes for better or worse on a tervention of choice.
daily basis, as originally developed by the LP (see examples
at Australian Stuttering Research Centre, n.d.); among
other useful outcomes, such “homework” and involve- Direct Treatment Options for David and His Family
ment increases parental self-efficacy and reduces parental I believe that the current evidence base offers multi-
anxiety (and indirectly that of the child); see Ros et al. ple options for direct treatment of preschoolers who stutter
(2016). that have reasonable levels of support, as well as two very
robustly documented treatment programs. Among the
promising approaches are Palin Parent–Child Interaction
What Is Involved in Evidence-Based Therapy (Millard, Brown, Hertsberg, Hollister, & Zebrowski,
2015; Millard, Edwards, & Cook, 2009); family-focused ther-
Practice (EBP) Decisions? apy (Yaruss, Coleman, & Hammer, 2006); and Westmead,
What Are Initial Options for Treatment of a syllable-timed speech-shaping therapy (Trajkovski et al.,
Stuttering in Preschool Children? 2011). However, because they have much larger bodies
An Overview of Parent-Administered Therapy of outcome data, the two options that I would recommend
for Preschoolers that the parents consider as first-line approaches are the
All of the major published, evidence-based pro- following:
grams to address stuttering in this age group are parent- (a) The Rotterdam Evaluation Study of Stutter-
administered or facilitated. Additionally, because of the ing Therapy in Preschool Children: A Randomized
suggested contexts of daily work, including protected talk Trial (RESTART), on the basis of a DCM of stuttering
time and scaffolded adult–child book reading, they can be (RESTART-DCM; de Sonneville-Koedoot, Stolk, Rietveld,
excellent vehicles for language enrichment for all children & Franken, 2015). This program’s authors recently pub-
(those with or without clinically relevant language con- lished a thoroughly peer-reviewed randomized clinical trial
cerns). Therefore, I might instruct how to enrich areas of (RCT) of 199 children who were randomized to a head-to-
language weakness (e.g., book reading with materials that head contrast of therapies: DCM versus LP (my second
can reinforce targets, such as growth of questions with option, described below).
popular early readers, cf., Bernstein Ratner, 2013; Zauche, DCM stands for demands and capacities model-based
Thul, Mahoney, & Stapel-Wax, 2016). therapy; its manual is available from Franken and Putker-de
Regardless of what specific fluency treatment ap- Bruijn (2007).
proach is taken, I see value in the need to strengthen lan- (b) The LP: The LP (program guide at Packman
guage for a preschooler who stutters. The difficulty of et al., 2016) clearly has abundant support in the published
language challenge is highly associated with frequency of literature. I often explicitly refer to the LP during parent
stuttered events or speech-motor instability on experimental counseling if parents demonstrate any reluctance to ac-
tasks, which can manipulate this level of challenge system- knowledge a child’s ongoing stuttering and frustration with
atically (e.g., Bernstein Ratner & Sih, 1987; MacPherson him or her because it provides strong evidence against the
& Smith, 2013; Zamani et al., 2016). This basic relation- still-popular concern that it is best to ignore stuttering in
ship is also recognized in the main tenets of the LP. The preschoolers lest this interfere with spontaneous recovery.
program asks parents to create enjoyable activities for However, I will explicitly tell the parents that this is my
verbal interaction that maximize the likelihood that the second choice because although published data are positive
optimal ratio of fluent and disfluent moments is available for this approach, how it might work to help children’s
for reinforcement and feedback (originally called punish- fluency is completely unknown, which concerns me. I will
ment when the roots of the program were more clearly ex- detail this and other concerns below.
plicated in published articles [cf., Onslow, Costa, & Rue,
1990]). The originators and researchers associated with
Why Do I Rank RESTART-DCM Above
Lidcombe understand that there are certain language task
demands associated with the general frequency of sponta- Lidcombe for This Family?
neously disfluent speech. For example, in the manual Evidence Base
(Packman et al., 2016, p. 8) the authors explicate that the First, I want to reiterate that I am pleased that I have
presence of stuttering is determined to some degree by more than one approach to recommend with some confi-
the length and complexity of the child’s attempted utter- dence and a “backup plan” should the child not respond to
ance, as shown by a large body of research. Notably, they my first choice or the parents disagree with my preference.
specify that professional supervision of the speech-language Not every person responds to one approach to care, and we
pathologist is required to enable the parent to develop are far from knowing if one form of treatment for child-
enjoyable verbal interactions that can appraise the child’s hood stuttering surpasses others or even the rate of sponta-
level of unambiguous stuttering over a range of expected neous recovery. Patient-centered care (PCC), the current
verbal demands on the child. This is why I need to do more medical mandate and guidance, emphasizes patient (and
detailed assessment of the child’s language skills in order to family) choice in the selection of health treatment options.

Bernstein Ratner: EBP and PCC in Treating a Preschooler Who Stutters 15

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 I place DCM above Lidcombe for a number of reasons, premised on a more multifactorial, individualized approach
primarily resting on the quality of its RCT evidence, as well to each child’s profile with a “mechanism of action” consis-
as its clearer mechanism of action. The recent RESTART tent with my beliefs about the nature of stuttering.
RCT used a superior and best-defended standard for treat- Although I, like others, do not know what causes
ment evaluation—equipoise design—in which two treatments stuttering, I am challenged by concerns that Lidcombe is
are compared, rather than treatment-versus-no-treatment a program without an understood mechanism of action.
design, which obviously sets a much lower standard for When I treat, I would like to be able to articulate to pa-
effects of intervention (Saxman, 2015). Lidcombe trials, tients or families how my therapy techniques are meant to
conducted on much smaller patient groups, have not con- induce behavioral change. To be sure, it may be accept-
trasted another therapy; they have only compared using LP able to have a treatment that works well, even if we do
against no therapy at all. The small individual studies are not know why—despite its wide and effective use—and we
of some concern, even when combined in retrospect: The do not know how “aspirin finds a headache” (Feldman,
major RCT (Jones et al., 2005) enrolled roughly half of 2009). Also, in medicine, psychology, and education, many
the declared recruitment goal (proposed “intent to treat” behavioral treatments that provide response-contingent
in their original approved statistical design). Currently, for feedback to change behavior make sense to me, if we are
an RCT, it is also ethically warranted to conduct clinical trying to control behaviors that are under a child’s control,
trials that include the “standard treatment” as one of the such as nail biting or tantrums.
therapy arms. It can be argued, using Lidcombe’s own Stuttering seems somewhat different to me. Large
substantial publication record, that LP rather than wait list numbers of published studies have detected both anatomi-
had to be the contrast treatment for the RESTART trial, cal and physiological differences between adults who stut-
as an ethical design (Stanley, 2007). No other published ter and those who do not (see Chang, 2014, for a cogent
research has compared two stuttering interventions for pre- summary of a rapidly growing body of literature), between
school children: RESTART performed well in this design. stuttering and fluent children, and between persistent and
In the future, this should be considered a standard practice in recovered individuals who stutter. This research suggests a
RCTs for early stuttering because we have strong evidence- complex physiological basis for stuttering, albeit one that
based options to use rather than wait-list control. can be shaped to include additional behavioral, cognitive,
The stronger RCT design for RESTART is paired and affective components as the child develops learned
with my concern that the quantity of publications report- responses to the environment (see summary by Smith &
ing LP outcomes should not be considered indicators of Weber, 2016).
superior quality of LP over DCM; despite the more than So, my dilemma is, if you do not “learn” to stutter,
85 publications authored by the original team and their how does a behavioral contingency program work to
affiliate researchers and clinicians over the years, the high- successfully obliterate the disorder? Many have suggested
est degree of adequately powered empirical support for that common factors, such as therapeutic alliance (Caughter
LP comes from a book chapter (Onslow, Jones, Menzies, & Dunsmuir, 2017), encouragement of self-efficacy in the
O’Brian, & Packman, 2012; rather than a peer-reviewed parents who stutter and their children, and even the planned
journal article) reporting a meta-analysis of 134 children and graduated imposition of language challenge built into
from the LP team’s own publications. Thus, I find the single the parent–child interactions in LP (Bernstein Ratner &
RCT by the RESTART team, reporting on 199 children Guitar, 2006; Hayhow, 2011), could be responsible for
randomized to either DCM or LP, with excellent fidelity children’s improvement. Certainly, that would explain the
checks on quality of intervention to be slightly more com- RESTART findings of no detectable difference between
pelling than the outcome data for LP reported across nu- success rates of children receiving LP and DCM therapies.
merous other publications. Some advocates of LP suggest, as an explanatory mech-
The RESTART study actually provides strong and anism, that Lidcombe praises (reinforces) fluent speech
updated support for use of either LP or DCM because and, thus, increases its frequency. This is still not a plausi-
it found no difference in 18-month outcomes in children ble account, in my opinion. LP is operant and works on
randomly assigned to the two programs and treated by contingent praise and parental feedback that was formu-
carefully trained clinicians with verified fidelity to each pro- lated as a punishment response to extinguish the disfluent
gram’s tenets and procedures. Thus, I am in the excellent speech behavior. Simply punishing, however gently, is
position of being able to offer a family multiple evidence- a behavior that research findings have led me to believe is
based options for David’s treatment; this satisfies one of grounded in poor integration among cortical systems does
the aims of true EBP, which values patient preferences in not cohere with my personal goal of understanding a treat-
therapy. ment’s mechanism of action (Turkstra et al., 2016). In LP,
the children are provided no guidance to help them figure
Mechanism of Action out how not to stutter. Moreover, there are classic refuta-
Although I consider both DCM and LP to be roughly tions of the hypothesis that parental attention to a behavior
equivalent in their likely ability to help the child and con- (such as LP does when urging parents to praise fluency) will
sider both eligible for recommendation in this case, my increase its frequency, such as Bell and Ainsworth’s clas-
preference is to start with the DCM treatment because it is sic (1972) finding that promptly responding to infants’

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 crying tends to reduce it rather than increase its likelihood. weaknesses in the motor, linguistic, and other systems in
This is undoubtedly because a large body of research over children who stutter (cf., examples in Bauerly & Gottwald,
the years has shown that the complexities of human lan- 2009; Bernstein Ratner & Sih, 1987; Gaines, Runyan, &
guage in its natural communicative contexts are not really Meyers, 1991; MacPherson & Smith, 2013).
analogous to the behaviors that can be easily conditioned I think that Lidcombe, RESTART-DCM, and simi-
in animals, let alone people. When I search for comparable lar programs may work due to common factors, such as
uses of operant conditioning in health treatment for other parent acknowledgment, protected talk time, scaffolded
health or developmental problems, I find few references language interaction, and the development of self-efficacy
past the 1970s, with the major exception of LP and severe in the child (“You can do this; try it”; Bernstein Ratner &
behavioral problems in children. Behaviors most responsive Guitar, 2006). However, it is easier for me to understand my
to operant conditioning tend to be those over which the own recommendations and counsel parents in recommend-
subject has some measure of volitional control. Stuttering ing a program, such as DCM, that works to problem-solve
does not fit this requirement, in my view. individual children’s fluency aggravators and facilitators,
Critically, recent studies additionally question LP’s using specific adjustments in environmental contexts for
purported mechanism of action. Recent work from the LP child conversation that have been individually validated as
team itself shows no relationship between the accuracy of methods for reducing the frequency of stuttered events. In
the operant contingencies and the child’s fluency outcome contrast, the only evident mechanism of action in LP is the
(Donaghy et al., 2015). More recently, Swift et al. (2016, frequency of contingent feedback. Historically, there has
p. 22), working with members of the LP team, extended been no effort to show that the child’s stuttering rate can
these finding and noted that “the results from the present be varied if the contingency schedule varies, a major pre-
study suggest that verbal contingencies for stuttering might mise of most operant interventions. The more recent reports
not be contributing to the treatment in the way in which it by Donaghy et al. (2015) and Swift et al. (2016) leave me
is assumed.” Both studies performed detailed analysis of LP even less sure how LP works, even when I see successful
parent–child interactions, using the LP team’s own primary outcomes.
data. Simply put, the parental contingencies don’t work. I hope that we will continue to add to our body of
The current research literature increasingly converges successful treatment approaches for early stuttering because
on a definition of stuttering as a neurologically based dis- of its high spontaneous recovery rate, which complicates
order that may carry a risk of genetic transmission, in- even the most positive of RCT findings. When 70%–80%
volving speech motor coordination; in people who stutter, of children appear to spontaneously recover from stuttering
speech coordination appears to be destabilized by language (Yairi & Ambrose, 2013), the sample size required to pro-
or dual task demand, among other stressors (Büchel & vide sufficient statistical power to distinguish between two
Sommer, 2004; Neef, Anwander, & Friederici, 2015; Smith treatment options is quite large. It is easy enough to find
& Weber, 2016). Thus, how do behavioral contingencies statistical calculators online to work this out in a somewhat
work to permanently reset this problem? So far, this ques- simplistic fashion. Other fields have similar problems, as
tion has not been asked, let alone answered. do our colleagues working with late-talking children and
In contrast, there is a large and diverse literature childhood seizure disorder (see Fawcett et al., 2007, for a
that has explored the benefits of component pieces of representative consideration of how hard it is to document
DCM therapy. These components are numerous but tai- intervention effectiveness when people tend to get better
lored to individual presentations of parent–child interac- even without intervention). Thus, the statistics problem for
tion. They include, as per the online manual, reducing preschool stuttering is somewhat daunting.
fluency-disrupting influences in a child’s environment What will it take to know how successful early stut-
and on task demands, in both experimental and natural tering therapies are? I will take the most conservative
settings in numerous ways (see, e.g., nonexhaustive exam- (smallest sample size) estimate I ran on a sample size
ples from LaSalle, 2015; Ryan, 2000; Sawyer et al., 2017; calculator (Kane, 2016). If we believe that either treatment
Stephenson-Opsal & Ratner, 1988). Some relate to adjust- reduces the often-proposed likelihood of about 1% that a
ments in time pressure, both in terms of conversational child will continue on to be an adult who stutters, against
flow and in terms of adult speech models. Some relate to total effectiveness (0% in treated children), we need 100 chil-
adjustments in the linguistic components of parent–child dren in a single-arm study against no treatment at all. That
interaction meant to strengthen children’s syntactic and is one reason why I consider the LP program’s self-authored
semantic skills, such as frequent use of recasting (Cleave, meta-analysis adequately powered. However, if we compare
Becker, Curran, Van Horne, & Fey, 2015). Taken together, two treatments and presume that one can boast that it
the components of the RESTART program borrow heavily halves the persistent rate to 0.5% and that the other totally
from a highly researched and productive body of parent– cures stuttering (0% likelihood as an adult), we need more
child interaction literature that has produced enormous than 2,000 children per group. All of this is to say that the
benefits when deployed in other areas of communication current debate over “best treatments” may be well ahead of
development and disorder in young children (see Bernstein our ability to know whether all current treatments may be
Ratner, 2013, for a clinically relevant summary). Addi- hastening normal recovery from stuttering and just leaving
tionally, these modifications are directly related to known high-risk children behind. In summary, because I am not

Bernstein Ratner: EBP and PCC in Treating a Preschooler Who Stutters 17

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 overjoyed with the strength of statistical evidence for even who note that “for most medical decisions, however, more
our two most strongly evidence-based treatments for young than one reasonable path forward exists.” In providing the
stuttering children, I feel that I should not limit my recom- patient with informed choice, EBP must now confront
mendations to a single option. legislatively mandated PCC and patient options (Frank,
As noted earlier, both DCM and LP are parent- Basch, & Selby, 2014).
administered programs that require parent training and Thus, I find the debate topic to recommend best
consultation, although daily activities are not lengthy and choices in treating this child to be somewhat odd. I feel
should be achievable even by parents with very busy sched- that we should have been charged to supply a list of possi-
ules. The LP has been explored in numerous permutations ble options for working with this child and options that
over the more than two decades since its first successful re- would remain available should the child not respond opti-
ports, among them a telehealth delivery option (e.g., Lewis mally to the first one chosen. I believe that our clients and
et al., 2008). Although RESTART is a much younger families need choices. They need more choices, not fewer
program, it is sufficiently similar in the scope of its parent choices, and they need to be enabled to make the right
education and counseling component, content of instruc- choices for their child and for their families. A debate for-
tion notwithstanding, that I might explore a telehealth option mat seems to presume a single winner (at least it did back
of RESTART if scheduling problems emerge, given multi- in the day when I was a collegiate debate coach). In con-
ple reports of success with LP administered via telehealth trast, modern medicine is not a zero sum game, where if
systems or webcam (O’Brian, Smith, & Onslow, 2014). one program seems effective in helping people, another
program loses its own evidence of effectiveness. Further,
treatment options are not irrevocable; if something does
The Joint Responsibility of Parents and not seem to work, there needs to be a “Plan B.”
Therapists in Selecting Therapies In my experience, choice is particularly important
when recommending the LP. Personally, having counseled
Why My Recommendations Will Include More parents for a number of decades, I know that I am not
Than One Option: Client-Centered Care alone in not understanding how Lidcombe treatment should
As noted earlier, as a therapist, as an individual, and help the child, although I gladly share with families the
as a parent myself, I am uncomfortable with any recom- large literature that it does. Research has suggested that the
mendation that does not provide choice. Virtually nowhere acceptability of behavioral treatment components may be
in modern medicine are you given a single treatment op- quite variable and that treatments endorsed by a therapist
tion for a health challenge; this is something that the med- may not necessarily be viewed as acceptable to consumers
ical profession now seriously reckons with, particularly in (Kazdin, 1980; Reimers, Wacker, Derby, & Cooper, 1995).
its evaluation of patient choice, PCC, and RCTs. The em- Reimers et al. observed that parents were generally happier
phasis on PCC across health interventions is growing daily with positive reinforcement than other aspects of operant
and promises to improve on benefits of EBP (Epstein & intervention when trying to manage child behavior prob-
Street, 2011). Current advisement cautions that lems. In addition, they noted that parental ratings of the
acceptability of behavioral interventions are influenced by
the most appropriate choice of outcome should the parents’ causal attributions of their children’s behavior.
reflect the benefit-to-harm balance for individual That is, if parents attribute their children’s problematic
patients in the population sampled, not for the behaviors to be the result of physical causes, rather than
population as a whole or by considering benefits child choice, they may view behavioral interventions as less
and harms separately. The societal value of medical acceptable. Thus, I find that some parents are not happy
decision making is determined by the potential effect with praise and correction as reasonable shapers of a be-
on individual patients, who simultaneously experience havior, such as stuttering. For these parents, I want to offer
both harms and benefits. (Kraemer, 2016, p. 7)
choices, particularly because the state of our knowledge
PCC is mindful that what seems to work for large regarding superiority of any one approach even over spon-
numbers of people in large trials (as measured by mean taneous recovery is at best preliminary.
responses) actually did not work for large numbers of indi-
vidual patients; this is increasingly evident for pharmaco-
logical agents, which, in practice, may help fewer than one No One Therapy Works for Everyone: Why
in four to 25 patients (Schork, 2015). This, in turn, has EBP Does Not Stop With the Selection
changed conversation in EBP from the primacy of the RCT
to the need for “one-person trials” (Schork, 2015). Because of a Therapy Approach
patient response to recommended therapies may vary, along I believe that it is logically impossible that one treat-
with their acceptability and side effects, increasingly, health ment works equally well for all patients, let alone all children
providers recognize that patients should be given choices, who stutter. What would you do if given only a single
both at the start and throughout a course of therapy. option for treatment of any health condition, from aller-
Shared decision making is the “pinnacle of patient gies to insomnia to cancer? What would you do if you were
centered care” (Barry & Edgman-Levitan, 2012, p. 780), told that your insurance carrier or physician had decided

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 to only offer the treatment that they deemed to be of highest EBP has worked for your client as it worked for partici-
quality according to their criteria, even though a PubMed pants followed in a published report. When things do not
search clearly revealed other successful treatments? In pos- work, it is time to investigate what has worked for other
ing this question, I am not talking about grasping at desper- participants followed in other peer-reviewed reports. No
ate straws. I am talking about clearly documented effective medical or behavioral therapy works for everyone, and
treatments that simply have fewer publications showing some patients even experience so-called paradoxical responses,
effectiveness but no studies that show lack of effectiveness. In in which a supposedly helpful intervention produces the
other words, lesser amounts of evidence that something works opposite result (as in when a tranquilizer “hypes up” the
is not evidence that something does not work. As a field, patient, as has happened to me).
I would like us to reject the conclusion that any treatment For me, the choice for this child and this family is
with the larger body of research is the best treatment, even what to recommend as a first-line approach to the problem
beyond my concern that most problems do not have a single and then what to do if, unfortunately, the child does not
best solution. That is not how EBP is supposed to work. respond optimally. I believe that to do anything less dis-
advantages our clients and does not fulfill the spirit of EBP
and its partner, PCC. I ask what you would do if you were
The Next Step is Monitoring Progress David’s parents and I had provided you with a single
Because it is reasonable to assume that no one ther- option for his care, then refused to change the approach,
apy will work for everyone equally well, EBP does not despite no improvement in his symptoms and despite duti-
end with selecting a therapy, although many diagrams of fully fulfilling the therapy’s guidelines.
the process, including the one at the American Speech-
Language-Hearing Association website (Mullen, n.d.),
suggest this closed loop. Regardless of which first-line ap- Concluding Thoughts
proach for direct therapy is chosen after mutual discussion In conclusion, my preference is to provide parents
between the therapist and the family, it is imperative to with options at all levels (when to begin structured inter-
reevaluate response to the treatment after a predetermined vention, which type of therapy might help David) to satisfy
period of time to ensure that the approach selected works the dual requirements of both EBP and PCC. For direct
for the actual client being treated (Fineout-Overholt & therapy, my first-line recommendation for this family is
Johnston, 2007). I would choose an evidence-based time either RESTART or Lidcombe, which appear to have equiv-
interval after which to reevaluate the child’s progress. alently good outcomes, according to published reports.
Based upon the RESTART trial data, which showed that As noted, I position RESTART somewhat higher in terms
children who would respond to the randomized assigned of evidence, coherence with my view of the nature of stut-
treatment primarily showed a response within 3 months (as tering, and apparent mechanism of action. Many children
measured by percentage of stuttered syllables [%SS], the respond well to both therapies, although it may remain to
primary outcome measure for LP and a major measure for be seen whether either program really does better than
DCM). extremely high rates of spontaneous recovery in the long
The benefits of reconsidering a therapy approach after run. I opt for explaining both to the family, explaining
monitoring therapy progress seem apparent to me. For my personal preference, and also mentioning that even more
example, consider data from a relatively recent published options may be available if the child does not respond well
study of the effectiveness of LP in an American program to the first one we decide to try. Some clinicians are defi-
(Guitar et al., 2015). A chart in that article showed that nitely more pessimistic about options available for treat-
the range of time that it took for children to complete just ment of early stuttering than I am (e.g., Bergþórsdóttir &
Stage 1 of the LP extended to 96 weeks (almost two years Ingham, 2016).
ago) for at least one child in the study. This is beyond my After pondering the requested debate, I am more
personal comfort zone for continuing with my original convinced than ever that what we need are better studies
plan for therapy. Even if I have faith in the evidence base of who does better with what intervention approach (i.e.,
of the LP program, something is not working optimally what works for whom; cf., Gargani & Donaldson, 2011;
in this case. In the face of less-than-optimal response from Norcross & Wampold, 2011), rather than what interven-
the child or dissatisfaction with progress on the part of par- tion approach “wins” some sort of evidentiary battle. Just
ents, I am willing to entertain other therapy options; this is because an approach has more publications does not
why I want more therapies to show good promise, not one mean it is more effective. We continually need alternatives
therapy to show best outcomes. For every average profile of in medicine for nonresponse, for paradoxical response, for
performance reported for a therapy, some clients will do bet- patient preference, for therapist adherence, for therapist
ter, and some will do less well. I feel that it is important for skill, and so on. To have alternatives and provide PCC, we
me to be able to take single-subject outcome data and change should be looking for more good therapies, not ranking
my approach to the problem. the few we have. That is how we serve our families best.
My personal opinion is that the best evidence that The real goal of EBP seeks ever more evidence of what
a clinician has is the evidence right in front of him or her works, not evidence that only one thing works. The stub-
(Bernstein Ratner, 2006, 2011). When things work, an born belief that only one approach works creates a conflict

Bernstein Ratner: EBP and PCC in Treating a Preschooler Who Stutters 19

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 of interest, in my opinion, between the clinician and the Seminars in Speech and Language, 34(4), 203–142. https://doi.
family. org/10.1055/s-0033-1353449
I am not saying that a clinician should randomly Bernstein Ratner, N., & Guitar, B. (2006). Treatment of very early
stuttering and parent-administered therapy: The state of the
flit among programs or components; well-researched ther-
art. In N. Bernstein Ratner & J. Tetnowski (Eds.), Current
apy programs have carefully motivated and developed issues in stuttering research and practice (pp. 99–124). Mahwah,
components, strategies, and sequentially ordered stages of NJ: Erlbaum.
implementation. What I am saying is that clinicians and Bernstein Ratner, N., & Sih, C. C. (1987). Effects of gradual
parents need to do what is required of EBP: pick a docu- increases in sentence length and complexity on children’s
mented approach that fits the facts of the case and coheres dysfluency. Journal of Speech and Hearing Disorders, 52(3),
with what is known about the disorder to be treated, apply 278–287.
the therapy, and then evaluate the results. When a client Büchel, C., & Sommer, M. (2004). What causes stuttering? PLoS
is not responsive within an appropriate time frame, it is Biology, 2(2), e46.
Caughter, S., & Dunsmuir, S. (2017). An exploration of the mech-
appropriate to reevaluate the choice of therapy.
anisms of change following an integrated group intervention
for stuttering, as perceived by school-aged children who stutter
(CWS). Journal of Fluency Disorders, 51, 8–23.
Acknowledgments Chang, S. E. (2014). Research updates in neuroimaging studies
The author acknowledges research funding support from of children who stutter. Seminars in Speech and Language, 35,
NIDCD: 1 R01 DC015494-01 (Brian MacWhinney, co-PI): a shared 67–79.
database for the study of the development of language fluency, and Cleave, P. L., Becker, S. D., Curran, M. K., Van Horne, A. J. O.,
NSF BCS-1626300/1626294: the development of language fluency & Fey, M. E. (2015). The efficacy of recasts in language inter-
across childhood. N. Bernstein Ratner (PI) & B. MacWhinney, vention: A systematic review and meta-analysis. American
co-PI (Collaborative Research). Thanks also to Courtney Byrd Journal of Speech-Language Pathology, 24(2), 237–255.
for inviting the original debate panel and the immense patience of Dale, P. S., & Hayiou-Thomas, M. E. (2013). Outcomes for late
reviewers who helped me (and I presume the other presenters) talkers. In P. Dale & L. Rescorla (Eds.), Late talkers: Lan-
shape our debate into something publishable. guage development, interventions, and outcomes (pp. 241–257).
Baltimore, MD: Brookes.
Davidow, J. H., Zaroogian, L., & Garcia-Barrera, M. A. (2016).
Strategies for teachers to manage stuttering in the classroom:
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