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 accept remaining 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 fluency and 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