WHAT STUTTERING TREATMENTS ARE EFFECTIVE? An evidence-based review of more than 200 scientific studies. Thomas David Kehoe Owner, Casa Futura Technologies Member, American Speech-Language Hearing Association This e-book can be downloaded free from http://www.casafuturatech.com/stuttering-e-book Last update: 2013 July 4 Because this e-book may be updated at any time, don’t copy or forward it to your friends. Instead, send them the link to download their own copy. Copyright (C) 2012, 2013 Thomas David Kehoe How to contact the author: [email protected] Casa Futura Technologies 720 31ST ST BOULDER, CO 80303-2402 USA This e-book is free software: you can redistribute it and/or modi- fy it under the terms of the GNU General Public License as pub- lished by the Free Software Foundation, either version 3 of the License, or (at your option) any later version. This e-book is distributed in the hope that it will be useful, but without any warranty; without even the implied warranty of merchantability or fitness for a particular purpose. See the GNU General Public License for more details. For a copy of the GNU General Public License see http://www.gnu.org/licenses/. TABLE OF CONTENTS HOW MORE THAN 200 STUDIES WERE REVIEWED ..................... 1 Trial Quality Standards ................................................................................ 2 Treatment Outcomes .................................................................................... 3 PRE-SCHOOL CHILDREN ........................................................................ 4 Indirect Therapy (a.k.a. Parent Counseling) ........................................ 4 The Lidcombe Program ............................................................................... 6 The Westmead Program .............................................................................. 7 Discussion ........................................................................................................ 7 ADULTS, TEENAGERS, AND SCHOOL-AGE CHILDREN ................... 8 Stuttering Modification Therapy .............................................................. 8 DAF, Prolonged Speech, and Fluency Shaping ..................................... 9 GILCU ............................................................................................................... 13 Regulated Breathing or Airflow ............................................................. 14 SLPs vs. Parents vs. Computers .............................................................. 14 Modifying Phonation Intervals (MPI) Therapy ................................ 16 Social, Emotional, and Cognitive Therapies ....................................... 18 Discussion ..................................................................................................... 19 ALTERED AUDITORY FEEDBACK ..................................................... 22 SpeechEasy Studies .................................................................................... 24 Casa Futura Technologies Studies ........................................................ 25 MEDICATIONS ........................................................................................ 26 REVIEWS WRITTEN BY CONSUMERS .............................................. 28 REFERENCES ........................................................................................... 49 How More Than 200 Studies Were Reviewed 1 HOW MORE THAN 200 STUDIES WERE REVIEWED This book is based on the following reviews of stuttering treatment studies: 1. A 1995 literature review of 13 studies of indirect therapy with pre- school stutterers, published in the Journal of Speech and Hearing Research (JSHR).1 2. A 2006 systematic review of 162 studies of “behavioral, cognitive, and related approaches,” published in the American Journal of Speech-Language Pathology (AJSLP).2 3. A 2006 systematic review of 31 studies of pharmaceutical treat- ments for stuttering, published in the American Journal of Speech- Language Pathology.3 4. A 2006 literature review of 17 studies of altered auditory feedback (AAF) devices, published in the Journal of Fluency Disorders (JFD).4 5. A 2006 systematic review and meta-analysis that examined 224 studies, published in Contemporary Issues in Communication Sci- ence and Disorders (CICSD).5 6. A 2008 tutorial about evaluating clinical trials for stuttering treat- ments found 21 studies that met the definition of a clinical trial, published in the American Journal of Speech-Language Pathology.6 7. A 2011 systematic review of 7 studies of pharmaceutical treatments for childhood stuttering, published in the Journal of Clinical Psy- chopharmacology.7 2 What Stuttering Treatments Are Effective? 8. A 2013 systematic review and meta-analysis of 9 childhood stutter- ing treatment studies, published in the Journal of Speech, Language, and Hearing Research.8 9. The chapter “Treatment” in the book A Handbook on Stuttering: Sixth Edition, by Oliver Bloodstein and Nan Bernstein Ratner (2008) reviewed 218 studies.9 The author also used the National Center for Biotechnology Infor- mation (NCBI) at the U.S. National Library of Medicine (NLM) to search for studies published after 2006 or otherwise missed by the above reviews, and did hand-searches of the Journal of Speech, Language, and Hearing Research, the American Journal of Speech-Language Pathology, and the Journal of Fluency Disorders since 2006. Trial Quality Standards The AJSLP systematic review measured trail quality on five criteria: 1. Quantifying and measuring something pre- and post-treatment 2. Randomized or ABA design 3. Blind or independent observers 4. Speech samples taken outside of the clinical environment 5. Controls for speech rate and speech naturalness Only 39 of 162 studies met four of these five trial quality criteria. The reviewers found that the quality of stuttering treatment research was generally poor, with the average of 162 studies scoring 2.51 out of 5 trial quality criteria. The most common missed trial quality criterion was speech samples taken outside of the speech clinics. How More Than 200 Studies Were Reviewed 3 The CICSD reviewers also noted the poor quality of stuttering treat- ment research. Of the 224 studies they examined, only twelve met their standards for trial quality. Another problem is subjects dropping out of a study. Over a year-long study subjects move away, etc. If a treatment is ineffective some subjects will drop out and skew the results. Treatment Outcomes The AJSLP systematic reviews specified four stuttering treatment out- comes: • Less than 5% stuttering • Improved social, emotional, or cognitive (SEC) measures • Follow-up after at least six months showing less than 5% stuttering • Follow-up after at least six months showing improved social, emo- tional, or cognitive (SEC) measures The AJSLP reviewers found that the results of stuttering treatment was generally poor, with the average of 162 studies scoring 1.16 out of 4 out- come criteria. The most common missed criterion was stuttering less than 5% post-treatment. 4 What Stuttering Treatments Are Effective? PRE-SCHOOL CHILDREN Indirect Therapy (a.k.a. Parent Counseling) Indirect therapy alters parents’ speech and behaviors in hopes that a child’s speech will be indirectly altered. The parents may be trained to: • Speak slower. • Not interrupt their child. • Pause after a child speaks and before the parent responds. • Ask fewer questions of their child. • Praise, encourage and agree with their child. • Not criticize or reprimand their child. A 1995 literature review of 13 studies found indirect therapy to be inef- fective with …little convincing evidence that parents of children who stut- ter differ from parents of children who do not stutter in the way they talk with their children. Similarly, there is little objec- tive support that parents’ speech behaviors contribute to chil- dren’s stuttering or that modifying parents’ speech behaviors facilitates children’s fluency.10 More recent studies have found similar results.11 A 2007 literature re- view of approximately 20 studies noted that “parent counseling” is the “primary form of advisement offered by pediatricians.…For some clini- cians…this is essentially the only important aspect of treatment.”12 The literature review continues: “…some, but relatively little, effort has been made to test the efficacy” of indirect therapy. The review noted sever- al case studies of one or two children in which indirect therapy was effec- tive. However, 80% of preschool-age children who stutter spontaneously Pre-School Children 5 recover without therapy13 so a valid clinical trial requires a large number of children. The 2007 literature review repeated the 1995 literature review’s conclu- sions that indirect interventions are “not effective by themselves in elimi- nating the problem.” The review concluded with a warning that14 …the complexity of input language is a very potent predictor of children’s later language profiles—greater sophistication in parental input language is positively associated with children’s language proficiency.15 In other words, “dumbing down” how you talk to your child might achieve nothing but dumbing down your child. Wendell Johnson originated indirect therapy between 1934 and 1939. He theorized that stuttering begins with unusually anxious or perfection- istic parents. These parents react negatively to normal childhood disflue- cies. The child then develops anticipatory avoidance reactions, i.e., tries to anticipate normal disfluencies and physically struggles