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

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Abstract

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.

Introduction

Given the current need to prove effectiveness for all kind of treatments (Sacket, Rosenberg, Gray, Haynes, & Richardson, 1996), researchers and clinicians have extensively discussed the designs and methods for efficacy research in stuttering therapy (e.g., Ansel, 1993, Bernstein Ratner, 2005, Bothe, 2003, Conture, 1996, Conture, 1997; Conture & Guitar, 1993; Conture & Yaruss, 1993; Cordes & Ingham, 1998; Costello & Ingham, 1984; Curlee, 1993, Finn, 2003a, Frattali, 1998a, Frattali, 1998b, Ingham, 2003; Ingham & Bothe, 2002; Ingham & Cordes, 1997; Thomas & Howell, 2001; Onslow, 2003, Yaruss, 1998, Yaruss, 2001). Although many studies have shown that stuttering therapy (e.g., Conture, 1996, Craig, 2002, Craig et al., 1996; Langevin & Boberg, 1993; Onslow, 2001, Perkins, 2001) is efficacious, not all people who stutter benefit from therapy equally. Stuttering therapy is not always effective. The use of fluency enhancing techniques tends to result (at least initially) in unnatural speech (Dayalu & Kalinowski, 2001; Franken, Boves, Peters, & Webster, 1995; Ingham, Gow, & Costello, 1985; Ingham, Martin, Haroldson, Onslow, & Leney, 1985; Kalinowski, Noble, Armson, & Stuart, 1994). It has also become clear that, some individuals are not able to maintain speech gains made in therapy (Boberg, 1981; Bray, Kehle, Lawless, & Theodore, 2003; Craig, 1998; Eichstaedt, Watt, & Girson, 1998; Finn, 2003b; Hasbrouck & Lowry, 1989; Ladouceur & Auger, 1980; Ryan & Van Kirk Ryan, 1995; Wagaman, Miltenberger, & Arndorfer, 1993). However, it remains unclear why some individuals benefit more from therapy than others, both in the short and long term. One method to address this issue is to explore whether or not there are different treatment outcomes for clients with differing pre-treatment stuttering profiles.

Many clinicians and researchers have attempted to characterize stuttering behaviors on the basis of various aspects, such as etiology (e.g., Blood, 1985; Poulos & Webster, 1991; St. Onge, 1963), recovery (for a review, see Seider et al., 1982, Seider et al., 1983), and stuttering characteristics (e.g., Andrew & Harris, 1964; Barber Watson, 1987, Borden, 1990; Schwartz & Conture, 1988; van Riper, 1982, Yairi, 1990). Borden (1990) reviewed a number of dimensions on which subtypes of stuttering have been differentiated in the past. Her list included among other aspects: severity (mild, moderate, severe); manifestation (covert, overt); locus of stuttering block (labial, laryngeal, respiratory); phonetic features (vowels, consonants); type of speech behaviors (prolongations, repetitions). She studied which of these classifications are useful to improve our understanding of stuttering and our ability to help those who stutter become more fluent. Borden and others argued that important differences between mild and severe stuttering (Borden, Baer, & Kenney, 1985; Watson & Alfonso, 1987) are due to reactive behaviors (secondary factors) and not to stuttering itself (primary factors). How classification or subtyping of stuttering relates to stuttering therapy remains to be investigated.

In the present study, we chose to explore the differences in treatment outcome with reference to two dimensions of stuttering: (1) stuttering severity (primary factors) and (2) the nature and severity of negative emotions and cognitions that are related to stuttering (psychosocial or secondary factors).

We included both dimensions because clinical experience suggests that they are related but independent phenomena. Although severity of stuttering tends to correlate with severity of negative introspective clinical characteristics, this is not always the case, as in instances of ‘covert’ or ‘interiorized’ stuttering where negative emotional and cognitive reactions are pronounced but overt stuttering is mild. The converse may also occur. Thus, both aspects of stuttering are investigated in this study, which allowed us to analyze the treatment-induced effects for each dimension separately.

Questions concerning the relationship between severity and the extent of treatment gains are being asked with a view to determining whether or not pre-treatment stuttering severity and the severity of negative emotions and cognitions influence response to treatment. A better understanding of how different profiles of stuttering contribute to treatment outcome might help us improve the selection of treatment strategies that address the individual needs of a client (as recommended by McClean, Tasko, & Runyan, 2004).

In the current study, the influence of the severity of stuttering and the severity of negative emotions and cognitions on the outcome of therapy is tested on a well-established treatment program that was delivered in The Netherlands: the ISTAR Comprehensive Stuttering Program (CSP; Boberg & Kully, 1985; Kully & Langevin, 1999). The CSP is an integrated therapy that addresses both speech production and related attitudinal problems, and has been shown to produce durable improvement.

In Boberg and Kully (1994), 76% (13 of 17 adults aged 18–36 years and 19 of 25 adolescents aged 11–17 years) were maintaining satisfactory (≤3% syllables stuttered [%SS]) or marginally satisfactory (3.1–6.0% SS) levels of fluency at 1 and 2 years post-treatment (adults means = 1.33 and 0.96; adolescent means = 1.11 and 1.26% SS). In Langevin and Boberg (1993), 80% of clients who attended a 3-week intensive program for adults (8 of 10 adults aged 16–38 years) were maintaining satisfactory or marginally satisfactory levels of fluency at 1-year follow-up (mean = 1.3% SS). In both studies, the outcome measure was 2 min of client talk time in telephone calls. At pre-treatment and immediately post-treatment clients made telephone calls to business. At 1- and 2-year follow-up clients received surprise telephone calls made to their home or workplace by research assistants. In addition to improvements in speech, improvements in attitudes, confidence, and perceptions of speech performance were being maintained. Eighty percent of clients in both studies rated their speech at follow-up as satisfactory.

Section snippets

Participants

Twenty-five Dutch adults who stuttered participated in this study (17 men, 8 women; mean age 29.6 years; age range 17–53 years). Their educational levels ranged from university (n = 14; 56%) to pre-university (n = 3; 12%), intermediate vocational (n = 5; 20%), and lower vocational education (n = 3; 12%). All participants were willing and able to attend the 3-week intensive CSP program which, in this study, was delivered in a residential format. The participants did not attend another treatment program

Results

Table 2 summarizes the multivariate results, organized in measures of speech and measures of introspective clinical characteristics (ICC). Because there was no significant three-way interaction, the resultant p- and F-values were not included in this table.

In Table 3, F-values, mean differences, and significance levels of the univariate results are presented.

Discussion and conclusions

In the present study, we explored whether we would find differences in the treatment outcomes of specific subgroups of stuttering individuals. Based on the pre-treatment scores on self-report questionnaires and the stuttering severity instrument (Riley, 1980), the participants were characterized as having either mild or severe negative emotions and cognitions (emotional severity, ME versus SE) associated with their stuttering and as having either a mild or a severe stuttering problem

Limitations of the study

Although dividing the participants into two groups (severe and mild) facilitated the interpretation of the results and was necessary to increase statistical power, this dichotomization was also a limitation of the study. There are two reasons for this. First, stuttering severity is not bipolar but rather a continuum and second, it is not a stable trait (see Conture, 2001; Crowe, DiLollo, & Crowe, 2000; Manning, 2001). There are of course many stuttering participants who where moderate severe

Acknowledgements

This research project was funded by The Netherlands Health Care Insurance Board (CVZ, College voor Zorgverzekeringen). The authors are grateful to Toni Rietveld and Rogier Donders for their statistical advice and to Pascal van Lieshout for his valuable comments on prior versions of this manuscript. We thank Esther Wouters for her assistance in scoring the questionnaires.
CONTINUING EDUCATION

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

Wendy J. Huinck graduated in 1995 as speech and language pathologist and graduated in 1998 with masters of science in speech-language pathology and general linguistics, at the University of Nijmegen, The Netherlands. She is doing her PhD in speech motor control and treatment efficacy in stuttering at the Department of Otorhinolaryngology, Radboud University Nijmegen Medical Centre and the Nijmegen Institute for Cognition and Information (NICI).

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  • Cited by (0)

    Wendy J. Huinck graduated in 1995 as speech and language pathologist and graduated in 1998 with masters of science in speech-language pathology and general linguistics, at the University of Nijmegen, The Netherlands. She is doing her PhD in speech motor control and treatment efficacy in stuttering at the Department of Otorhinolaryngology, Radboud University Nijmegen Medical Centre and the Nijmegen Institute for Cognition and Information (NICI).

    Marilyn Langevin is the Clinical Director at the Institute for Stuttering Treatment and Research, Faculty of Rehabilitation Medicine, University of Alberta. Her research interests centre on evidence-based practice and the social impact of stuttering on children. This focus includes outcome evaluation of stuttering treatment, clinician-training, and school-based stuttering education programs. She has authored a stuttering education and bullying prevention program titled Teasing and Bullying: Unacceptable Behavior.

    Deborah Kully is co-founder and Executive Director of the Institute for Stuttering Treatment and Research (ISTAR) in Edmonton, Alta., and associate professor in the Faculty of Rehabilitation Medicine at the University of Alberta. She has worked extensively with people who stutter, contributed journal articles and book chapters, given presentations, workshops and courses across North America and abroad, and with Einer Boberg, developed the Comprehensive Stuttering Program. Her current research interests are in developing effective treatments and service delivery models.

    Kees Graamans, MD, graduated in otolaryngology in 1978 at the Free University in Amsterdam and in 1980 he obtained his PhD at the same university. From 1980 to 2000, he worked as associate professor in the University Hospital Utrecht. Since 2000 he is professor and Chairman of the Department of Otolaryngology of the University Nijmegen Medical Centre.

    Herman F.M. Peters has worked as an associate professor in speech and language pathology at the Radboud University Medical Centre of Nijmegen, The Netherlands. His research interests centered on speech motor control and fluency disorders. He has been a member of the International Fluency Association, the International Association of Logopedics and Phoniatrics and of the Dutch Association of Voice, Speech and Language Pathology. In 1995, he received the Distinguished Service Award of the American Speech-Language-Hearing Association. In 2001 he is retired on a pension.

    Wouter Hulstijn is an experimental psychologist working since 1968 at the Nijmegen Institute for Cognition and Information (NICI) of the University of Nijmegen, The Netherlands. Since 2001 he is also employed at the Collaborative Antwerp Psychiatric Research Institute (CAPRI) of the University of Antwerpen, Belgium, as a professor in cognitive neuropsychology. His main research interests are in cognitive neuroscience of motor control and movement disorders in psychiatry, neurology and speech pathology. On the latter topic he closely collaborates with the Department of Voice and Speech Pathology of the Institute of Otorhinolaryngology of the University Hospital Nijmegen. He was the supervisor on a few PhD projects on stuttering and speech motor control, and involved in organizing the four Nijmegen speech motor conferences in 1985, 1990, 1996 and 2001.

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