Evidence-Based Treatment of Stuttering
Evidence-Based Treatment of Stuttering
Evidence-Based Treatment of Stuttering
28 (2003) 197–207
Received 3 April 2003; received in revised form 17 April 2003; accepted 22 April 2003
Abstract
1. Introduction
0094-730X/$ – see front matter © 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0094-730X(03)00038-X
198 J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207
specializes in the treatment of people who stutter, spotlighted the topic in a recent
(2002) issue of the Division 4 newsletter when he wrote, “I believe that my task as
a clinician is to implement the most effective treatment for the people who stutter
that come through my door. I rely on research to point the way to effective treatment
today . . . . I feel that I owe my clients the best service possible. And I believe that
this means exposing them to treatments that have been researched in well-designed
outcome [or efficacy] studies” (p. 4). Power’s statements attest to his adherence
to ASHA’s Code of Ethics (2003), which states in Principles of Ethics I, Rule
A: “Individuals shall use every resource . . . to ensure that high-quality service is
provided.” An important resource, of course, is our research literature.
A different take on this topic is the position of Yaruss and Quesal (2002) in their
response to Power’s comments. They replied, “. . . Like Power, we value published
research data on the treatment of stuttering. We also value the data that we collect
during our own treatment with people who stutter. We believe that it is far from
being irrelevant simply because it is not published. Indeed, it is highly relevant to
the individuals we are treating, and it provides perhaps the most important measure
for guiding the direction of treatment. Furthermore, we do not think it appropriate
to avoid well-established treatment programs that have been helpful for countless
people who stutter simply because the data are not (yet) published” (p. 24). From
the perspective of an evidence-based treatment philosophy, one could question
how certain treatment procedures could become well established without having
the benefit of research evidence that demonstrates their effectiveness. One might
wonder as well how it can be known that such programs “have been helpful for
countless people” without systematic evidence to support that assertion.
One of the most prolific (and entertaining) writers in the arena of evidence-based
medicine is David Sackett, a Canadian physician who operates his internal medicine
practice on the principles of evidence-based medicine — and is irrepressibly en-
thusiastic about sharing these principles with others. Sackett and his colleagues
(Sackett, Straus, Richardson, Rosenberg, & Hayes, 2000) point out that we are
moving away from “opinion-based medicine,” akin to the stance taken by Yaruss
and Quesal, to “evidence-based medicine.” Traditionally in medicine, as in speech–
language pathology, knowledge has been inculcated into students by professors
and supervisors who believe that adequate treatment methods can be derived by a
common sense blending of knowledge of the nature of the particular disorder and
their personal clinical experience. However, this process becomes contradictory
and confusing because, as Paauw (2000) points out, the more experts one asks, the
more opinions one gets. He also notes that some practices are “ ‘grandfathered’
in without anyone questioning the validity of what is being taught or practiced”
(p. 13). This has most assuredly happened in regard to stuttering treatment.
What exactly is meant by evidence-based treatment? Sackett (1998, p. 1085)
describes it as the “conscientious, explicit, and judicious use of current best [re-
search] evidence” to guide the selection of treatment methods for individual clients.
He adds that clinical expertise and client values also play a role. In fact he
states, “Without clinical expertise, practice risks becoming tyrannized by evidence,
J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207 199
Efficacy Research on Stuttering (1992), these are studies: (1) that compare treated
and untreated stutterers, or stutterers receiving a standard treatment to ones receiv-
ing an experimental treatment — and, importantly, studies that randomly assign
stutterers to each group; (2) that conduct “blind” evaluations of the findings wherein
observers analyzing the data on treatment effectiveness don’t know to which group
a given stutterer belongs; (3) that use their findings to examine theories underlying
stuttering; (4) that select as participants stutterers who represent the broad range
of people who stutter, and examine enough of them to allow statistical analyses of
any group differences to be meaningful; (5) that utilize valid measures of treatment
efficacy and outcome (see below); (6) that train clinicians to deliver the treatment
in a standardized manner and obtain [fidelity] data that demonstrate this to be the
case for clinicians and participants alike; (7) that collect sufficient follow-up data
to assess the durability of the treatment; and (8) that are designed using methods
that combat sources of bias and threats to internal validity — that is, studies that
properly utilize the scientific method. Additional evaluative criteria for clinicians,
according to Friedland (1998), are to consider whether the research subjects are
similar to their own clients, whether the findings make sense in the context of other
knowledge about the disorder, and whether the treatment procedures are described
in sufficient detail to allow their replication by practitioners. Miser (2000a) re-
minds research consumers to rely on findings published in peer reviewed journals
(in contrast, for example, to information gained from the unfiltered Internet, the
credibility of which is often unknown), to look for information on dropouts as well
as those who completed the treatment, and to evaluate whether results are clinically
as well as statistically significant. In our own literature, Bloodstein (1995) listed
many of these same issues as key ones for judging the rigor of a treatment efficacy
study.
Another important factor, alluded to above, is measurement — that is, the mea-
sures researchers use to demonstrate the effectiveness of a treatment. This is where
a clinician’s judgment and a client’s values are especially relevant. Some, for ex-
ample Blood and Conture (1998), Conture (1996), and the aforementioned Yaruss
and Quesal (2002), declare that for the studies judged to be most strongly supported
by evidence, the evidence consists only of behavioral measures of stuttering fre-
quency and speech rate, and occasionally speech naturalness. In such studies, these
measures have typically been obtained repeatedly before, during, and following
the course of treatment and in a variety of speaking circumstances, including some
from the speaker’s natural environment. If a client’s goal is to become a stutter-free
speaker, or to maximally reduce occurrences of stuttering (which is surely the case
for most of our clients), these would seem to be appropriate dependent variables.
Some clinicians and authors, however, believe that equal to fluency, or even
more important, are changes that should occur in the client’s speech attitudes,
anxiety levels, locus of control, interpersonal relationships, and general quality
of life. In fact, some well-known treatment methods target these aspects of a
client’s behavior exclusively. These same people argue, though, that because these
potential outcomes of treatment are difficult to measure with validity and reliability,
J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207 201
In an ideal world the process described above would be the best-case scenario.
Unfortunately, we’re not there yet. Stuttering treatment researchers have not con-
ducted definitive randomized clinical trials, although NIDCD has expressed inter-
est of late in supporting this kind of research. In the meantime, practitioners are
left with the important responsibility of finding, reading, and critiquing individual
studies, following the guidelines listed above and elsewhere in the literature (e.g.,
Conture, 1996, 1997; Conture & Guitar, 1993; Cordes & Ingham, 1998; Costello
& Ingham, 1984; Curlee, 1993; Ingham, 1993; Ingham & Costello, 1984; Ingham
& Riley, 1998). Beyond the critical examination of individual treatment studies,
what information is available for clinicians who want to use an evidence-based
method of selecting treatments for their clients who stutter?
First, let’s talk about what’s not particularly helpful in this vein. In 1995 ASHA
published Guidelines for Practice in Stuttering Treatment, a document prepared
through the auspices of Division 4, Fluency and Fluency Disorders. At the outset
the authors wrote, “the Steering Committee felt that a set of criteria for determining
guidelines that was based entirely on empirical evidence would be too restrictive.
Some treatment practices may be quite useful even though their efficacy has not yet
been determined empirically. The committee felt that both common practice and
published data should be considered” (p. 235). Those seeking the gold standard
for stuttering treatment, or even the silver or copper or aluminum standard, might
as well quit reading immediately at that point in the document. It is perplexing
why some professionals in the area of stuttering treatment are reluctant to rely
on evidence to guide their treatments, or to prove their treatments effective. As
Sackett (1998, p. 1086) has said, “It is when asking questions about therapy that
we should try to avoid the nonexperimental approaches, because these routinely
lead to false-positive conclusions about efficacy.”
One legitimate limitation to our ability to rely on research evidence to guide our
treatments is the dearth of published treatment efficacy studies. It is bewildering,
or at least disappointing, that a discipline that exists primarily to serve people
with communication disorders hasn’t done much research on how to do just that.
Olswang (1998) acknowledges this problem and suggests several reasons why
there isn’t more treatment efficacy research. She points out that research training
in our discipline still concentrates mainly on basic research or applied research
about the nature of a disorder, rather than its treatment. This may be a partial
byproduct of the kinds of research that funding agencies call for. NIH, especially,
appears to favor research tinged with a medical flavor. Witness that in my own
family (i.e., Ingham & Ingham) we have been much more successful in obtaining
funding for our brain imaging research (e.g., Fox et al., 1996; Fox et al., 2000;
J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207 203
Ingham et al., 1996) than our treatment research (e.g., Ingham et al., 2001), even
though the clinical impact of the former is unclear and distant, at best.
Olswang (1998) also observes that group comparison statistical research de-
signs are still the mostly frequently taught, even though they are not necessarily
the most effective designs for treatment research. Many believe that single-subject
designs should at least precede group designs to prove treatments effective be-
fore they are studied on large groups of subjects. Other rationales that Olswang
provides for the relative scarcity of treatment research in our discipline are that
there are only a few qualified by research experience to serve as mentors, that such
research is difficult and time-consuming, and expensive. Nonetheless, Olswang
writes inspiringly when she says, “Treatment efficacy research is . . . at the core
of the discipline and the profession . . . In the current climate of health care and
education reform, administrators are pushing our profession to define standards
for treatment success. If the profession does not respond, most assuredly admin-
istrators will respond for us . . . Clinical researchers must take charge and build
the knowledge base for the discipline and the profession. This can be done by
recognizing the importance of clinical science for both the advancement of theory
and the advancement of practice. Treatment efficacy research is at the heart of our
future” (pp. 148–149).
As is true for our practice guidelines, another effort that does not particularly
facilitate the practice of evidence-based treatment is ASHA’s National Outcomes
Measurement System (NOMS) (http://www.professional.asha.org/resources/
noms/treatment outcomes.cfm). First, let’s address the semantics: treatment ef-
ficacy versus treatment outcomes. As Frattali (1998, pp. 16–17) explains, efficacy
is usually reserved to refer to studies that demonstrate “. . . the extent to which
an intervention can be shown to be beneficial under optimal conditions.” This is
the kind of research we’ve been discussing as useful for guiding evidence-based
treatment. Outcomes research is more typically aimed at evaluating interventions
in real world conditions, with a focus on measuring the degree of relief from dis-
ability and handicap that a treatment provides (Frattali, 1998; Olswang, 1998).
Both kinds of research have value, and both kinds of dependent variables offer
important information about the benefits of a given treatment. ASHA’s NOMS
project, however, is not designed to assess the benefits of particular treatments,
but rather of treatment offered by practitioners in our professions in general. So,
even if those findings were to indicate that stuttering treatment offered by SLPs
improves communication for people who stutter, they would not be able to indicate
which kind of treatment generates the most improvement.
There are, however, at least three reports in our literature that can serve as sys-
tematic reviews of published treatment research in stuttering — meta-analyses of
sorts. They are Andrews et al. (1980), further qualified by Andrews et al. (1983) and
Cordes (1998). These reports cover a large number of studies and stutterers. Com-
bined, their conclusions pinpoint several characteristics of stuttering treatment
that appear important to producing beneficial treatment effects: using negative
feedback contingencies for moments of overt stuttering; beginning treatment with
204 J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207
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CONTINUING EDUCATION
Evidence-based treatment of stuttering: I. Definition and application
QUESTIONS
1. The author defines evidence-based practice as depending on:
a. traditions and opinions
b. widely-used treatments
c. research evidence, clinical expertise, and client preferences
d. behavior modification
e. unpublished information
J.C. Ingham / Journal of Fluency Disorders 28 (2003) 197–207 207
2. Which of the following is not a step that clinicians should take in evidence-based
practice, as described by the author, based on the work of Sackett and col-
leagues?
a. ask a clinically relevant question
b. start by trying the treatment approach you’ve always used
c. find published evidence about relevant treatments
d. evaluate the methodological quality of the articles you find
e. integrate research evidence with your clinical expertise and your client’s
goals
3. An evidence-based approach to stuttering treatment would require the develop-
ment and use of validated measures for:
a. speech variables only
b. attitude, anxiety, and interpersonal variables only
c. within-clinic variables only
d. beyond-clinic variables only
e. any variable that is used to assess any treatment method or goal
4. The author suggested that ASHA’s (1995) Guidelines for Practice in Stuttering
Treatment are problematic because:
a. they were too restrictive
b. they did not involve the Special Interest Division for Fluency
c. they were not based on empirical evidence
d. they were based only on group-design research
e. all of the above
5. The author concluded that:
a. adequate information is available to guide evidence-based stuttering treat-
ment
b. too much information is available to guide evidence-based stuttering treat-
ment
c. clinicians should not try to practice evidence-based stuttering treatment on
their own
d. clinicians should try to practice evidence-based stuttering treatment, using
some of the steps and resources discussed in this article
e. none of the above