Evidence-based practice in stuttering: Some questions to consider

Italian normative data for the Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) Scales for adults who stutter

PURPOSE

This study aimed to assess the reliability and validity of the Italian translation of the Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) scales for adults who stutter, as there are no assessment tools currently available in Italy. The UTBAS scales provide a comprehensive stuttering-specific measure of the unhelpful thoughts and beliefs that can be used to screen for indicators of social anxiety in adults who stutter. Additionally, the UTBAS scales also allow the identification of negative thoughts and beliefs that negatively impact speech treatment outcomes.

METHOD

The translation of the UTBAS scales into Italian (UTBAS-ITA) was completed using the forward-backward translation process and it was administered to 98 adults who stutter (AWS) and 98 adults who do not stutter (AWNS). Both groups were matched for gender and age. We also administered the UTBAS-ITA to 76 AWS a second time within a two-week interval to assess test-retest reliability. Additionally, we administered the State-Trait Anxiety Inventory and the Fear of Negative Evaluation Scale to 20 AWS to assess concurrent validity.

RESULTS

The UTBAS-ITA showed good power of discrimination between AWS and AWNS, high internal validity, high internal consistency, good construct validity, and good test-retest reliability.

CONCLUSION

Since there is a scarcity of clinical assessment tools for adults who stutter in Italy, the UTBAS-ITA could serve as an assessment tool and outcome measure for clinical and research environments.

Searching for Lidcombe Program mechanisms of action: Inter-turn speaker latency

The Lidcombe Program is a well-established and efficacious treatment for early stuttering, but little is currently known about its mechanisms of action. The present report explores the possibility that inter-turn speaker latency might be associated with such mechanisms of action. Inter-turn speaker latency was measured in audio recordings of children, parents, and clinicians conversing, taken during Lidcombe Program treatment consultations. Five clinicians reduced their inter-turn speaker latencies during clinical consultations when they were speaking to children, in comparison with when they were speaking to parents. It is possible that inter-turn speaker latency is associated with the Lidcombe Program treatment process vicariously, and this possibility requires further research.

Contemporary clinical conversations about stuttering: Neurodiversity and ableism

PURPOSE

To discuss issues about neurodiversity and ableism, and how they pertain to clinical management of stuttering, with particular reference to early childhood stuttering.

METHODS

During a webinar this year, the issue emerged of how concepts of neurodiversity and ableism apply to early childhood stuttering during the pre-school years. It became apparent that this topic elicited disparate views and would be of particular interest to students of speech-language pathology. Consequently, the leaders of that webinar continued the conversation by written dialogue for the purpose of placing it on record.

RESULTS

The discussants reached agreement on many points, but there was some diversity of viewpoint about how neurodiversity and ableism should apply to clinical practice with children who have recently begun to stutter.

Fostering Positive Stuttering Identities Using Stutter-Affirming Therapy

PURPOSE

School-age children and adolescents frequently have difficulty developing positive identities around their stuttering. Many students experience both physical and social consequences from stuttering. The great lengths that speakers go to try to hide their stuttering and to speak fluently increase their difficulty. As long as school-age children who stutter try to identify as fluent speakers, they will have difficulty lessening the negative impact of stuttering on their lives. Fortunately, many people who stutter also report positive stuttering experiences. Speech-language pathologists can use these positive experiences to help school-age children grow more comfortable with stuttering. They can also help school-age children reduce some of the speaking effort and social stigma that leads them to try to conceal their stuttering in the first place. To accomplish both these goals, I propose a stutter-affirming therapy.

METHOD

This clinical focus article summarizes previous research about identity development in stuttering. I discuss a therapy approach I call stutter-affirming therapy. In elucidating this approach, I discuss practical ways that speech-language pathologists can use to help school-age children develop positive stuttering identities through easier speaking and stuttering. I ground these examples in a case study of a 12-year-old boy who stutters.

DISCUSSION

stutter-affirming therapy focuses on conditioning the speaker's reaction to stuttering in ways that move toward and embrace stuttering (stutterphilic reactions) rather than in ways that move away from and reject stuttering (stutterphobic reactions). Speech-language pathologists can help school-age children who stutter foster positive stuttering identities using the three priorities of stutter-affirming therapy. First, reject fluency by reducing stutterphobic and increasing stutterphilic reactions to stuttering. Second, value stuttering by discovering what speakers gain from it. Third, create an environment in which it is easier to stutter through education, advocacy, disclosure, and voluntary stuttering.

Lexipontix Program: Facilitating Change toward "Best Hopes" of the School-Age Child Who Stutters and the Family

Lexipontix is a structured therapy program for school-age children who stutter. It is based on theoretical principles and clinical practices of cognitive behavioral therapy, parent-child interaction therapy, solution-focused brief therapy, fluency shaping, and stuttering modification. A case example of a school-age child who stutters and his family who participated in the Lexipontix program is illustrated to highlight the theoretical principles, structure, content, and clinical tools of the assessment and therapy process of the program. The Lexipontix program addresses the stuttering experience of the child and family in a holistic way. The child and family are assisted in facilitating changes in all components of the International Classification of Functioning, Disability, and Health model (i.e., body function, personal factors, activity and participation, environmental factors), which help them move toward their "best hopes" (i.e., personally meaningful change) from therapy. The role of the clinician in facilitating change is also considered. Therapy outcomes for the specific case example are presented and discussed in relation to data from a retrospective chart review. The mechanisms underlying the effectiveness of the program are explored and discussed.

Intensive Stuttering Therapy with Telepractice Follow-Up: Longitudinal Outcomes

PURPOSE

This study estimated the treatment outcomes of a behavioral stuttering therapy program that blended a combination of intensive face-to-face therapy with telepractice-based follow-up therapy.

METHOD

A total of 17 participants (mean age = 22 years) who stutter participated in the program, preceded by an extended baseline period. The participants completed a series of assessments conducted over multiple time points, spanning a total of 42 weeks. Growth curve modeling was used to analyze the changes participants experienced in the frequency of stuttering, stuttering severity, communication attitudes, and quality of life.

RESULTS

The participants demonstrated stability throughout the extended baseline period, and experienced positive outcomes from the intensive program and the gains in communication attitudes and quality of life were largely maintained with weekly follow-up telepractice sessions. However, stuttering frequency and severity increased when the telepractice follow-up session frequency transitioned to a biweekly basis. Neither gender nor age group predicted the treatment outcomes for frequency or severity of stuttering. Gender-based differences were found for the treatment outcomes of specific self-report measures, with male participants having demonstrated a greater proportional decline on their standard scores, relative to female participants. Outcomes were similar for both adolescents and adults.

CONCLUSIONS

Participants attending the intensive stuttering therapy program experienced positive and significant changes in their speech, attitudes toward communication, and overall quality of life, which were maintained over time with structured, weekly telepractice follow-up sessions.

What works for whom? Multidimensional individualized stuttering therapy (MIST)

PURPOSE

This study reports outcomes from a stuttering therapy approach that combines value and awareness-based elements from Acceptance and Commitment Therapy (ACT) with those of stuttering and speech modification interventions. The approach, entitled Multidimensional Individualized Stuttering Therapy (MIST), includes a combined clinician and client selection of factors across five areas: 1) general breathing patterns and body tension, 2) breathing patterns during speech production, 3) vocal features in speech production, 4) value and mindfulness-based strategies, and 5) general communication and/or presentation skills. The aims of this study were to evaluate whether the MIST a) reduces the impact of stuttering and stuttering severity, and b) has a positive impact on speaking ability, confidence in communication, avoidance-behavior, and quality of life.

METHOD

Eighteen adults, age 21-61 years took part in an A-B-A multiple case study design. Participants underwent a pre-clinic assessment phase, followed by 10 h of therapy over four sessions administered by an experienced speech-language therapist. Outcome measures examined both psychosocial and behavioral aspects of therapy three-, six- and twelve-months post-therapy.

RESULTS

Most participants chose elements from at least four of the five areas of focus. There was a significant reduction in the impact of stuttering at both 6- and 12-months post-therapy, with moderate (d = .71) to very large (d = 1.06) effect sizes. A strong association was found between overall satisfaction with MIST and improved speaking abilities. Moderate to strong associations were also found between experienced speaking abilities, confidence in communication, reduction in avoidance behaviors and improved quality of life.

DISCUSSION

Findings indicate that MIST can be effective in managing adult stuttering. The findings highlight the importance of shared decision making and personal considerations using flexible therapy approaches that integrate stuttering and speech modification interventions with value and awareness-based skills. The nature of a multidimensional individualized approach, as shown in this study, highlights the importance of adjusting the relative weighting of different subcomponents according to each individual's needs and goals.

CONCLUSION

MIST was shown to be efficacious in clinical settings and effective in real life settings. Findings were promising, despite a relatively small sample, and replication by other SLPs and with larger samples is warranted.

Verbal Contingencies in the Lidcombe Program: A Noninferiority Trial

Purpose The Lidcombe Program is an efficacious and effective intervention for early stuttering. The treatment is based on parent verbal response contingent stimulation procedures, which are assumed to be responsible for treatment effect. The present trial tested this assumption. Method The design was a parallel, open plan, noninferiority randomized controlled trial. In the experimental arm, the five Lidcombe Program verbal contingencies were removed from parent instruction. The primary outcome was beyond-clinic percentage syllables stuttered at 18-month follow-up. Seventy-four children and their parents were randomized to one of the two treatment arms. Results Findings of noninferiority were inconclusive for the primary outcome of stuttering severity, based on a margin of 1.0 percentage syllables stuttered. Conclusions The inconclusive finding of noninferiority means it is possible that verbal contingencies make some contribution to the Lidcombe Program treatment effect. However, considering all primary and secondary outcomes, an overriding impression from the trial is a similarity of outcomes between the control and experimental arms. The clinical applications of the trial are discussed, along with further research that is needed.

What do people search for in stuttering therapy: Personal goal-setting as a gold standard?

PURPOSE

Stuttering affects people in individual ways, and there are multiple factors which may influence a person's goals when seeking therapy. Even though there is a common consensus that speech-language pathologists should discuss the individual's goals and expectations for stuttering therapy and outcomes, few studies have systematically investigated this issue. The aims of the present study were to investigate individual motivations and goal-setting related factors in stuttering therapy. The associations between self-reported impact of stuttering and the participants' perceptions of stuttering interference in communication, speaking abilities, and relationships with other people were also investigated.

METHOD

This study is part of a wider-ranging treatment study of individualized stuttering management tailored to the participants' personal goals and preferences. A mixed method, multiple single-case design was used to address the research questions. Twenty-one adults, age 21-61 years, took part in a pretherapy interview, which also included two quantitative measures: the Client Preferences for Stuttering Therapy-Extended version (CPST-E) and the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A). Findings from the study sample was compared with a Norwegian reference group, in order to check for the representativeness of the study sample.

RESULTS

Quantitative data showed that most participants wanted to focus on both physical and psychological aspects of therapy, and that 95% considered 'to gain a sense of control over the stuttering' as important. Participants' perspectives on their speaking ability and stuttering interference in communication were identified as central factors, particularly in social and professional settings. These outcomes aligned well with the finding of avoidance behaviors, such as avoiding words and speaking situations. Qualitative data identified four main areas that the participants wanted to improve: speech fluency, emotional functioning, activity and participation, and understanding of their stuttering.

CONCLUSION

The study confirms that multiple and individual factors may influence the person's goals for therapy. Goals were mainly anchored in participants' wish of better coping in real world settings. A high degree of avoidance behavior was reported, suggesting that anxiety, and in particular linguistic-related anxiety needs to be taken into account when addressing social anxiety in fluency disorders.

Qualitative investigation of the speech-language therapy experiences of individuals who covertly stutter

PURPOSE

Individuals who covertly stutter have a unique experience of stuttering that involves concealing the core behaviors of stuttering (e.g., repetitions, prolongations, and blocks). From the listener's perspective, covert stuttering results in minimum typical, overt stuttering behaviors. However, from the speaker's perspective, covert stuttering often increases the cognitive and emotional impact of stuttering. This study explores the speech-language therapy experiences of individuals who covertly stutter in order to improve treatment recommendations and best practice.

METHODS

This investigation is a qualitative analysis of individuals' speech-language therapy experiences as persons who covertly stutter. Real-time video interviews were conducted with the use of open-ended phenomenological interview questions. Interviews were transcribed and thematic analysis of interview transcripts was conducted to investigate the speech-language therapy experiences of the participants.

RESULTS

The participants indicated that stuttering therapy was most impactful when it included explicit goals and activities, personalized selection of therapy techniques or strategies beyond fluency techniques, encouraged self-education, and educated those in the person's environment.

CONCLUSION

The evidence suggests individualized therapy based on each client's unique manifestation of covert stuttering is beneficial; while, fluency-focused stuttering therapy is often incongruent with the needs of persons who covertly stutter. Therapeutic implications and recommendations for speech-language pathologists are discussed.

Using critical realistic evaluation to support translation of research into clinical practice

A challenge that speech-language pathologists (SLPs) face is the translation of research into clinical practice. While randomised controlled trials (RCTs) are often touted as the "gold standard" of efficacy research, much valuable information is lost through the process; RCTs by nature are designed to wash out individual client factors and contexts that might influence the outcome in order to present the "true" impact of the intervention. However, in the area of behavioural interventions, the interaction of client factors and contexts with the treatment agent can substantially influence the outcome. This paper provides an overview of the theoretical background and methods involved in critical realistic evaluation (CRE) and discusses its current and potential application to speech-language pathology. CRE is based on the premise that a behavioural intervention cannot be evaluated without considering the context in which it was provided. While the ways in which contextual aspects and treatment mechanisms interact may seem endless, CRE methodology attempts to operationalise them into hypotheses to be empirically tested. Research based on these principles has the potential to support clinical translation of research outcomes and reduce the costs of unsuccessful treatment attempts for SLPs, clients and the service provider.

Direct versus Indirect Treatment for Preschool Children who Stutter: The RESTART Randomized Trial

OBJECTIVE

Stuttering is a common childhood disorder. There is limited high quality evidence regarding options for best treatment. The aim of the study was to compare the effectiveness of direct treatment with indirect treatment in preschool children who stutter.

METHODS

In this multicenter randomized controlled trial with an 18 month follow-up, preschool children who stutter who were referred for treatment were randomized to direct treatment (Lidcombe Program; n = 99) or indirect treatment (RESTART-DCM treatment; n = 100). Main inclusion criteria were age 3-6 years, ≥3% syllables stuttered (%SS), and time since onset ≥6 months. The primary outcome was the percentage of non-stuttering children at 18 months. Secondary outcomes included stuttering frequency (%SS), stuttering severity ratings by the parents and therapist, severity rating by the child, health-related quality of life, emotional and behavioral problems, and speech attitude.

RESULTS

Percentage of non-stuttering children for direct treatment was 76.5% (65/85) versus 71.4% (65/91) for indirect treatment (Odds Ratio (OR), 0.6; 95% CI, 0.1-2.4, p = .42). At 3 months, children treated by direct treatment showed a greater decline in %SS (significant interaction time x therapy: β = -1.89; t(282.82) = -2.807, p = .005). At 18 months, stuttering frequency was 1.2% (SD 2.1) for direct treatment and 1.5% (SD 2.1) for indirect treatment. Direct treatment had slightly better scores on most other secondary outcome measures, but no differences between treatment approaches were significant.

CONCLUSIONS

Direct treatment decreased stuttering more quickly during the first three months of treatment. At 18 months, however, clinical outcomes for direct and indirect treatment were comparable. These results imply that at 18 months post treatment onset, both treatments are roughly equal in treating developmental stuttering in ways that surpass expectations of natural recovery. Follow-up data are needed to confirm these findings in the longer term.

TRIAL REGISTRATION

isrctn.org ISRCTN24362190.

Theory-Based Practice: A Case Study of the Multifactorial Model of Stuttering

Theory concerning general processes of speech motor control can inform questions and hypothesis in stuttering research, as well as goal and activity selection in clinical practice. This paper attempts to describe the flow of information from theory to research and clinical fields, using the multifactorial model of stuttering as an example.

Temperament, emotion, and childhood stuttering

Reactivity refers to arousal of emotions, motor activity, and attention, and self-regulation refers to the ability to moderate those tendencies. In general, temperament is typically thought of as an individual's constitutionally (biologically) based behavioral proclivities. These proclivities often include emotional reactivity and self-regulation. Reactivity refers to arousal of emotions, motor activity, and attention, and self-regulation refers to the ability to moderate those tendencies. The traitlike nature of temperament makes it potentially salient to our understanding of the onset and development of stuttering because temperamental tendencies may result in greater reactivity or difficulty in coping. Emotions, which are more statelike and variable, may influence the variation of stuttering commonly observed both within and between speaking situations. Temperament and emotion may serve as a causal contributor to developmental stuttering, with empirical findings indicating that preschool-aged children who stutter (CWS) exhibit differences in temperament and emotion when compared with children who do not stutter. Given that empirical study of temperament in preschool-aged CWS is nascent, extensive discussion of clinical implications is challenging. With that caution, we present some early possibilities, including matching treatment approaches with the child's temperamental profile and using temperament as a predictor of treatment outcome.

The Clinical Applications of Acceptance and Commitment Therapy With Clients Who Stutter

The field of fluency disorders has used Cognitive Behavioral Therapy (CBT) techniques to help clients who stutter manage their thoughts about stuttering by engaging in cognitive restructuring activities. In the late ‘90s, a new form of cognitive therapy called Acceptance and Commitment Therapy (ACT) emerged, stemming from classic CBT and Relational Frame Theory (RFT). Though there is only one documented study in which ACT is used with clients who stutter, there is tremendous clinical potential to assist clients who stutter of all ages using the six core principles of ACT (contact with the present moment, acceptance, thought defusion, self as a context, defining values, and committed actions). The core principles encourage clients who stutter to live a values‐based life by assisting them in defusing adverse thoughts related to stuttering and choosing committed action behaviors and goals in accordance with their individual values through mindfulness practices. Participating in activities related to the core principles of ACT can help clients who stutter to become more psychologically flexible when managing their perceptions related to stuttering. Using ACT can further lead clients toward acceptance of all thoughts while learning to observe themselves in the present moment and make values‐based choices for future behaviors.

Theory and therapy in stuttering: a complex relationship

There are many treatments currently available for stuttering, for both children and adults. These range from direct interventions intended to reduce the severity and/or frequency of the speech behaviors of stuttering, to those intended to alleviate the anxiety and other mental health issues that can accompany the disorder. However, as there are little supporting data for many of these treatments, there is little consensus about which to use. Another way to evaluate stuttering treatments is to explore the extent to which they address the cause of the disorder. However, the cause of stuttering is not yet known. In this theoretical paper, a 3-factor causal model is presented, to which the mechanisms thought to be driving different treatments are then aligned. The model is innovative, in that it attempts to explain moments of stuttering. It is argued that all causal factors must be operating at each moment of stuttering. The model is intended as a new way of looking at cause, and how treatments may address cause. It is hoped this will stimulate discussion and lead to further lines of inquiry.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe the P&A 3-factor causal model of moments of stuttering; (b) state how indirect direct stuttering treatments relate to cause, according to the P&A model; (c) describe how direct stuttering treatments relate to cause, according to the P&A model; (d) state the purpose of cognitive behavior therapy; and (e) describe at least one suggestion for further research arising from the P&A model.

Stuttering in School-Age Children: A Comprehensive Approach to Treatment

Purpose

This letter, prepared through a close collaboration between the authors and more than 100 colleagues, responds to a paper by the editor of Language, Speech, and Hearing Services in Schools that highlighted the need for research on treatment for stuttering in school-age children.

Method

Our response addresses 3 themes: First, we offer agreement with the editor’s call for research because more evidence about treatment for children who stutter is certainly needed. Second, we provide an overview of recent literature, demonstrating that the majority of current treatments include strategies for helping children improve speech fluency in addition to helping them increase acceptance of their stuttering and diminish the negative consequences of the disorder. Third, we present several strategies designed to help clinicians respond to the individual needs of children who stutter in a data-based, comprehensive manner that focuses on minimizing the adverse impact of stuttering on children’s educational endeavors, and on their lives as a whole.

Conclusion

Much has been learned about the factors that contribute to the successful treatment of stuttering in school-age children, and evidence will continue to accumulate. Meanwhile, speech-language pathologists can help children increase their fluency while simultaneously minimizing the adverse impact of their speaking difficulties and helping them improve their overall communication.

The long term effectiveness of intensive stuttering therapy: a mixed methods study

PURPOSE

The purpose of this study was to gain a deeper understanding of client perceptions of an intensive stuttering therapy program that utilizes a multi-faceted approach to therapy. The study also proposed to gain a deeper understanding about the process involved in long-term maintenance of meaningful changes made in therapy.

METHODS

The study used a mixed methods design. The core method was a phenomenological approach using semi-structured interviews. Objective clinical data was gathered concurrently. This included archival records and current measures on a variety of assessments to evaluate stuttering severity and attitudes toward communication.

RESULTS

The major themes generated from participants' transcripts included (1) the positive effects of the Duration and Nature of the Program; (2) Speech Techniques Learned; (3) Attitude Change and Counseling; and (4) activities related to Desensitization and Transfer. The participants also reported positive effects of their personal motivation and clinician attitudes. Clinical data indicated that the participants made measurable clinical gains on all measures of stuttering severity and attitude change following the intensive clinic and these changes were maintained long after the program was completed.

CONCLUSIONS

It appears that this intensive stuttering therapy program is effective for making positive changes in behavioral measures of speech disfluencies, and attitudes. Clients reported multiple factors directly related to the program and personal factors that contributed to treatment effectiveness. Hence, future studies should explore and report on a variety of factors related to communication attitudes and overall quality of life in addition to behavioral measures of speech.

EDUCATIONAL OBJECTIVES

After reading this article, the learner will be able to: (a) identify the basic tenets of evidence-based practice; (b) summarize what we currently know about the effectiveness of behavioral treatments of stuttering; (c) identify factors that client report as important to treatment effectiveness.

Hypnotically assisted diaphragmatic exercises in the treatment of stuttering: a preliminary investigation

This preliminary study investigates the combined effect of intensive hypnotherapy and diaphragmatic exercises in the management of stuttering. Fifty-nine clients with stuttering were trained to practice abdominal weightlifting to strengthen their respiratory muscles and to improve their diaphragmatic movements. The weightlifting exercises involved lifting a dumbbell (2.0-4.0 kg) with the abdomen for 2 hours daily for 8 consecutive days. Hypnotherapy was utilized to alleviate anxiety, to boost self-confidence, and to increase motivation for weightlifting exercise. The pre- and postmeasures were statistically significant (p < .001). Results of the study provide support for the effectiveness of hypnotically assisted diaphragmatic training in the management of stuttering but should be further studied in controlled trials.

The "Iowa Way" revisited

This paper attempts to bridge the gap between past and present stuttering therapy approaches. Specifically, the ideas and methods of Wendell Johnson and Dean Williams are compared to current approaches used in treating mental illness and communication disorders in which there is an emphasis on focusing on what is "right" with the individual and spending less time focusing on the "disorder". There is particular emphasis on tying Johnson's and Williams' overall philosophy to modern psychological approaches rooted in "Positive Psychology", to highlight how these early ideas in stuttering therapy may help us to discover the common factors that underlie the success of several different stuttering therapy approaches, independent of the specific techniques employed. It is proposed that future research on clinical efficacy in stuttering should use focused hypotheses techniques to investigate common factors that make therapy effective across individuals and therapy approaches.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) summarize the basic philosophy of the "Iowa" approach to stuttering as laid out by Wendell Johnson and Dean Williams; (2) describe current therapeutic techniques that incorporate "positive psychology"; (3) discuss possible common factors that influence therapy outcome that are independent of the therapeutic technique employed.

Balancing Certainty and Uncertainty in Clinical Practice

Purpose

In this article, I question how practitioners can balance the certainty and confidence that they can help their patients with the uncertainty that makes them continually question their beliefs and assumptions.

Method

I compare the mechanisms of science and models of clinical practice that may help practitioners achieve the right balance between total acceptance of the status quo and an open willingness to explore and accept new ideas.

Conclusion

Clinical practice, unlike science, has no independent self-correction mechanism that leads to consensus about best clinical practices. Evidence-based models provide principles and guidelines for clinical practice, but ultimately, clinical decisions may be influenced most by a practitioner’s epistemology (belief systems) and propensity for rational thinking.

A nationwide survey of nonspeech oral motor exercise use: implications for evidence-based practice

PURPOSE

A nationwide survey was conducted to determine if speech-language pathologists (SLPs) use nonspeech oral motor exercises (NSOMEs) to address children's speech sound problems. For those SLPs who used NSOMEs, the survey also identified (a) the types of NSOMEs used by the SLPs, (b) the SLPs' underlying beliefs about why they use NSOMEs, (c) clinicians' training for these exercises, (d) the application of NSOMEs across various clinical populations, and (e) specific tasks/procedures/tools that are used for intervention.

METHOD

A total of 2,000 surveys were mailed to a randomly selected subgroup of SLPs, obtained from the American Speech-Language-Hearing Association (ASHA) membership roster, who self-identified that they worked in various settings with children who have speech sound problems. The questions required answers that used both a forced choice and Likert-type scales.

RESULTS

The response rate was 27.5% (537 out of 2,000). Of these respondents, 85% reported using NSOMEs to deal with children's speech sound production problems. Those SLPs reported that the research literature supports the use of NSOMEs, and that they learned to use these techniques from continuing education events. They also stated that NSOMEs can help improve the speech of children from disparate etiologies, and "warming up" and strengthening the articulators are important components of speech sound therapy.

CONCLUSION

There are theoretical and research data that challenge both the use of NSOMEs and the efficacy of such exercises in resolving speech sound problems. SLPs need to follow the concepts of evidence-based practice in order to determine if these exercises are actually effective in bringing about changes in speech productions.

Comments on Bothe, Davidow, Bramlett, Franic, and Ingham (2006)

PURPOSE

To critically assess the quality, methodology, and conclusions in A. K. Bothe, J. H. Davidow, R. E. Bramlett, D. M. Franic, and R. J. Ingham's (2006) systematic review of pharmacological approaches to stuttering.

METHOD

A. D. Oxman and G. H. Guyatt's (1988) guidelines for reading literature reviews and A. D. Oxman and G. H. Guyatt's (1991) criteria for assessing the scientific quality of systematic reviews were adopted to accomplish the purpose.

RESULTS

Bothe et al.'s review was rated on a 7-point scale from extensive flaws on the high end to minimal flaws on the low end of the scale. The ratings varied from poor to good.

CONCLUSIONS

We judged Bothe et al.'s review of the pharmacological literature as it pertains to stuttering as flawed in its methodology and conclusions. However, we agree that the existing evidence for the use of pharmacological agents with persons who stutter is insufficient to recommend them in practice. Directions for improving the quality of clinical trials are suggested. In addition, we advocate for the multimethod measurement in stuttering research, including comparison, subjective evaluation, and social impact measures.

Evidence-based practice: an examination of its ramifications for the practice of speech-language pathology

PURPOSE

The purpose of this article is to consider some of the ramifications that arise when a discipline newly endorses evidence-based practice (EBP) as a primary guiding principle. Although EBP may appear straightforward, events experienced by peer disciplines that have preceded us in the implementation of EBP raise questions about defining acceptable forms of evidence for treatment effectiveness and efficacy, the potential roles of nonspecific or common factors, therapist quality in achieving therapy outcomes, and eventual applications of EBP that may overly confine which treatments are considered acceptable and reimbursable.

METHOD

Through narrative review of the literature, the article examines valuable as well as controversial features of EBP in addition to obstacles that may impede the transition of evidence (research findings) to clinical practice.

CONCLUSION

EBP is a valuable construct in ensuring quality of care. However, bridging between research evidence and clinical practice may require us to confront potentially difficult issues and establish thoughtful dialogue about best practices in fostering EBP itself.

On the importance of scientific rhetoric in stuttering: a reply to Finn, Bothe, and Bramlett (2005)

PURPOSE

To refute the alleged practice of "pseudoscience" by P. Finn, A. K. Bothe, and R. E. Bramlett (2005) and to illustrate their experimental and systematic bias when evaluating the SpeechEasy, an altered auditory feedback device used in the management of stuttering.

METHOD

We challenged the experimental design that led to the seemingly predetermined outcome of pseudoscience rather than science: Limited preselected literature was submitted to a purposely sampled panel of judges (i.e., their own students). Each criterion deemed pseudoscientific was contested with published peer-reviewed data illustrating the importance of good rhetoric, testability, and logical outcomes from decades of scientific research.

CONCLUSIONS

Stuttering is an involuntary disorder that is highly resistant to therapy. Altered auditory feedback is a derivation of choral speech (nature's most powerful stuttering "inhibitor") that can be synergistically combined with other methods for optimal stuttering inhibition. This approach is logical considering that in stuttering no single treatment is universally helpful. Also, caution is suggested when attempting to differentiate science from pseudoscience in stuttering treatments using the criteria employed by Finn et al. For example, evaluating behavioral therapy outcomes implements a post hoc or untestable system. Speech outcome (i.e., stuttered or fluent speech) determines success or failure of technique use, placing responsibility for failure on those who stutter.

Connecting stuttering measurement and management: III. Accountable therapy

BACKGROUND

This paper is intended to contribute to the current debate in relation to persistent stuttering and evidence-based clinical practice.

AIMS

The paper will describe the authors' intervention framework for persistent stuttering, which is guided by evidence from the fields of stuttering and clinical psychology. It supports the opinion that the components of therapy should be grounded in empirically based theories that offer an explanation for the nature of stuttering, its persistence and its individual complexity. It will argue that the goals of therapy should reflect the client's personal values and experience of stuttering, as well as the knowledge and skills of the therapist.

MAIN CONTRIBUTION

The paper maintains that therapy for this disorder needs to account for the highly individual nature of the overt and covert dimensions of persistent stuttering and identify the formal and informal methods that measure progress and outcome. Current research and future directions will be touched on briefly.

The relationship between pre-treatment clinical profile and treatment outcome in an integrated stuttering program

A procedure for subtyping individuals who stutter and its relationship to treatment outcome is explored. Twenty-five adult participants of the Comprehensive Stuttering Program (CSP) were classified according to: (1) stuttering severity and (2) severity of negative emotions and cognitions associated with their speech problem. Speech characteristics (percentage of stuttered syllables, distorted speech score, and the number of correctly produced syllables on a diadochokinesis task) and emotional/cognitive states (emotional reaction, speech satisfaction, and attitudes toward speaking) were assessed before and after treatment, and at a 1- and 2-year follow-up. The results showed that: (a) there was no relationship between stuttering severity and the severity of negative emotions and cognitions, (b) the severe stuttering group had the largest treatment gains but also the highest level of regression, and (c) at post-treatment and both follow-up assessments the differences on measures of emotions between the mild and severe emotional group had disappeared, chiefly due to a large decrease in the latter group's negative emotions and cognitions. Our findings show that, based on treatment gains, specific subgroups can be identified, each requiring different treatment approaches. This underlines the necessity of developing a better understanding of how various dimensions of stuttering relate to treatment outcome.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe why stuttering severity and negative emotions and cognitions that are related to stuttering should be investigated separately and (2) describe how treatment outcome relates to subtypes of persons who stutter.