Current Issues in Stuttering Research and Practice

Nan Bernstein Ratner, John A. Tetnowski

• Publisher: Psychology Press
• Year: 2014
• eBook ISBN: 9781317777977
• Topic: Education
• Subtopic: Inclusive Education

This state-of-the art volume is a follow-up to the 1999 publication, Stuttering Research and Practice: Bridging the Gap, edited by Nan Ratner and E. Charles Healey. Like its predecessor, the current book is an edited collection of the presentations from the American Speech-Language-Hearing Association's Annual Leadership Conference in Fluency and Fluency Disorders.

Among the topics covered are evidence-based practice, impact of the self-help and support groups, meta-analyses of selected assessment and intervention programs, current theories of stuttering, and the predicted path of stuttering intervention in the future. The authoritative representation of contributors offers the reader the most up to date presentation of fluency issues, with a special emphasis placed on the practical clinical implications of fluency assessment, treatment, and evolving theories of the disorder.

The book is written for fluency specialists and graduate students in programs of fluency disorders. It will also be valuable for the clinicians who wish to upgrade their skills in treating fluency disorders.

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Stuttering Treatment in the New Millennium: Changes in the Traditional Parameters of Clinical Focus

Nan Bernstein Ratner

University of Maryland

John A. Tetnowski

University of Louisiana at Lafayette

A while back, there was a car commercial that boasted, “This is not your father’s Oldsmobile.” As we enter the new millennium, the same might be said of stuttering: from multiple perspectives, our view of stuttering, stuttering treatment, and appropriate preparation for those who provide stuttering treatment is changing. In this chapter, we discuss some challenges that face our discipline, to set the chapters that follow into current context.

Is there a growing disconnect between what SLPs actually do and what we think they do?

If one goes to the Internet to Ask Jeeves^©, “What do speech pathologists do?”, the top five answers might not seem surprising. According to the U.S. Department of Labor, Bureau of Labor Statistics:

Speech-language pathologists work with people who cannot make speech sounds, or cannot make them clearly; those with speech rhythm and fluency problems, such as stuttering; people with voice quality problems, such as inappropriate pitch or harsh voice; those with problems understanding and producing language; those who wish to improve their communication skills by modifying an accent; and those with cognitive communication impairments, such as attention, memory, and problem-solving disorders. They also work with people who have oral motor problems causing eating and swallowing difficulties. (U.S Department of Labor, retrieved from www.bls.gov/oco/pdf/ocos099.pdf)

Speech Pathology Australia answers the question, “Who do speech pathologists work with?” by answering:

A speech pathologist’s workload might include {We provide here the first five answers}:

• giving advice on feeding to a mother who has a baby with a cleft palate;

• working in a child care centre with a group of children who are hard to understand;

• working with a school child who can’t understand what his teacher says;

• working with a high school student who stutters;

• retraining a teacher who constantly loses her voice to use it more effectively… (Retrieved from www.speechpathologyaustralia.org.au/library/11_FactSheet.pdf)

To provide some sense of how state speech-language-hearing associations view the profession, we went to the Illinois Speech-Language-Hearing Association (in tribute to Bob Quesal), and found an answer to the following question, “What Do Speech-Language Pathologists Do?”:

Speech-language pathologists are specialists trained to evaluate, identify and remediate disorders of communication and swallowing. Speech-language pathologists work with people of all ages, from infants to elderly. Speech-language pathologists provide treatment to improve language, voice, stuttering, articulation, memory and swallowing. [Note the order of the disorders.] (Illinois Speech-Language-Hearing Association, retrieved from www.ishail.org)

A consumer-oriented pediatric health web site sponsored by the Pfizer company (Kidspeak) informs the public about what speech-language pathologists do:

These healthcare professionals are educated and trained to help patients overcome speech, language, and swallowing disorders. [Children who see speech-language pathologists may or may not have hearing problems.] These specialists also help treat stuttering, voice, and pronunciation disorders. (Retrieved from www.kidsears.com/kidspeak.html)

The same site prominently addresses the most common questions parents pose, including, “What should I do if my child stutters?”

Finally, our professional website (asha.org), in the area of the site providing information for prospective students, answers “Frequently Asked Questions about the Professions”:

Some Basic Facts… Speech-Language Pathologists help those who stutter to increase their fluency; help people who have had strokes or experienced brain trauma to regain lost language and speech; help children and adolescents who have language disorders to understand and give directions, ask and answer questions, convey ideas, improve the language skills that lead to better academic performance; counsel individuals and families to understand and deal with speech and language disorders. (American Speech-Language-Hearing Association; retrieved from www.asha.org/about/news/releases/faq_careers.htm)

IS THE ADVERTISING MISLEADING?

The point of what might seem like a tedious exercise in “Googling” is to note that stuttering treatment and work with people who stutter are broadly viewed as a primary focus of practice for speech-language pathologists (SLPs). Certainly a consumer seeking information about who to turn to for stuttering treatment is provided with a sense that fluency is a core professional activity. However, as we note, an emerging problem is the mismatch between perception and the statistics that characterize SLP practice. At the risk of proving the point made by a great anonymous author that, “Numbers are like people; torture them enough and they’ll tell you anything,” it is instructive to view the ASHA 2001 Omnibus Survey, specifically the caseload report for speech-language pathologists (American Speech-Language-Hearing Association, 2001a).

For SLPs in all settings combined, 65% see fluency cases. This proportion ranked above those who report treating aphasia (27%), dysphagia (37%), and voice (45%). In schools, the proportion of SLPs reporting that they have someone on the caseload who stutters rises to 78%, outranking the disorders just mentioned, as well as Specific Language Impairment (SLI), Pervasive Developmental Disorder (PDD), and children using Augmentative and Alternative Communication (AAC) devices. These numbers seem to provide support for the notion that stuttering is a disorder that SLPs commonly treat. But the numbers combine in interesting ways.

In any setting, if the absolute number of individuals seen for particular disorders is queried, the mean number of fluency clients seen per SLP falls to the absolute lowest of all conditions that SLPs treat, at 2.4% of each SLP’s caseload (schools, 2.5%) of all disorders except “communication effectiveness” (whatever that is…). When viewed against caseload statistics, SLPs see more people with hearing disorders than persons who stutter.

WHAT DOES ALL THIS MEAN?

An emerging problem with the expanding scope of practice in speech-language pathology (American Speech-Language-Hearing Association, 2001b) is that the lay public expects SLPs to be able to treat fluency disorders: In job descriptions of SLPs, treatment of stuttering is often one of the top-listed responsibilities. And, in fact, most SLPs in practice do see people in need of treatment for fluency disorders. It is one of the top-ranked disorders seen by ASHA members. However, effective fluency treatment is not a skill that can be learned “on the job,” since the absolute number of cases per clinician is among the lowest of all disorders that SLPs see, allowing little opportunity to hone skills. This is unfortunate because several surveys (e.g., Sommers & Carusso, 1995) have shown that stuttering is one of the least understood of all communicative disorders and that SLPs feel less comfortable in treating this disorder than almost any other group. This makes some sense; stuttering is a relatively low-incidence disorder (approximately 1%; Andrews, Craig, Feyer, Hoddinott, Howie, et al., 1983; Bloodstein, 1995). But its effective treatment is complex, as many have noted, and as many of the chapters in this text emphasize. Thus, we have a disconnect between a kind of fiction and reality.

Some emerging realities of clinical training

Popular novelist Tom Clancy once made the comment, “The difference between fiction and reality? Fiction has to make sense.” As noted earlier, the reality is that most SLPs are expected to, and can expect to, treat stuttering. But there is an accompanying sense in graduate curricula that it is an uncommon disorder, and thus does not merit a prominent place in the curriculum and clinical training (Yaruss & Quesal, 2002). The standards for the Certificate of Clinical Competence (CCC) in speech-language pathology have progressively loosened the requirements that programs historically impose on their students to obtain clinical and coursework expertise in fluency. These changes have had measurable consequences (Yaruss & Quesal, 2002), and the revised CCCs do insist that programs document the ability of their students to competently provide fluency services. But these standards are amorphous, and their clear implementation is still a matter of some discussion (Yaruss & Quesal, 2002). In surveys conducted over the years, stuttering consistently falls among the least understood of all the areas that speech-language pathologists encounter (Brisk, Healey, & Hux, 1997; Sommers & Caruso, 1995). In this light, it is amazing that ASHA has chosen to remove any firm clinical requirement in stuttering for students graduating with master’s degrees in speech-language pathology. It is indeed possible that a speech-language pathologist, with clinical credentials, could receive payment for treating a person who stutters without ever having had a single prior hands-on experience with stuttering. Perhaps this has contributed to the growth of the self-help movement in stuttering, where some consumers have avoided speech-language pathologists over the years and only recently are reinviting speech-language pathologists back to their groups (see Reeves, chap. 11, this volume). At this point, it is extremely unclear how competent the next generation of speech-language pathologists will feel in treating stuttering. It is evident that their predecessors, who supposedly received more rigorous training, have felt poorly equipped to work with children and adults who stutter (Brisk, Healey, & Hux, 1997; Sommers & Caruso, 1995; Quesal & Yaruss, 2002). Despite some recent improvements, stuttering remains an area of practice with which many speech-language pathologists feel less than comfortable.

Although the quality of training for speech-language pathologists to treat fluency disorders remains a serious problem, it is magnified by the emerging shortage of qualified teacher-researchers in fluency. One might ask where the new leadership in fluency treatment research will come from. A recent conference brought together most of the current Ph.D. students in fluency from throughout the country. At this conference, six doctoral students interested in fluency disorders participated and data showed that there were approximately 12 students seeking advanced degrees in fluency disorders (Eldridge, Kluetz, & Donaher, 2002). If this is an indicator of the next generation of leadership in fluency disorders in North America, consumer groups may very well start to consider alternatives to treatment by speech-language pathologists. Certainly 12 Ph.D.-level researchers will not be able to support the needs of more than 300 American SLP training programs.

One potential improvement in the U.S. model may emerge as a result of post-M.A., CCC specialization. However, it is unfortunate that there is still no compelling evidence that supports specialization as a factor in improving consumer care. In fact, the American Speech-Language-Hearing Association, together with most professional health care organizations, still faces the challenge of documenting what we certainly feel to be a fact: that certified professionals achieve better outcomes than do those with lower credentials or less rigorous training. It is extremely difficult to obtain evidence that specialization training positively affects outcomes, and certain trade-offs have been observed in medicine.

As noted, this question is not specific to fluency disorders alone. Peach (2004) has shown this trend of “specialization” is emerging in other areas of speech-language pathology. As a matter of fact, he questioned the efficacy of “required” training and specialization for well-established programs, such as the Lee Silverman Voice Training (LSVT, Ramig, Countryman, O’Brien, Hoehn, & Thompson, 1995) and PROMPT therapy (Square-Storer & Hayden, 1989). Does the training and specialization really make a difference? Can we really endorse “specialization” without any data to back up the claim that specialists are better, more efficacious, or more efficient? In the medical literature, some evidence germane to this question is both reassuring and troubling. For example, Caron, Jones, Neuhauser, and Aaron (2004) reported that, in larger organizations (we might take as analogies school systems or large clinical settings), higher level emphasis on evidence-based, continuous quality improvement seems to exert a more favorable impact on outcomes than treatment by specialists alone. Donahoe (1998) performed a meta-analysis of outcomes reported in major medical journals and concluded that specialty training appeared to confer benefits in certain circumstances, but that generalized competency in the basic concepts underlying good care might have a greater impact on outcomes. For fluency, we might say that this could amount to the difference between knowing quite a bit about stuttering and fluency techniques, and having the clinical acumen to know when, how, and how best to provide effective therapy that best matches the patient’s needs. Thus, despite the appealing notion that fluency specialization will improve care for those who stutter, is there any evidence that shows clinicians who hold specialty recognition in fluency disorders to be more competent than those who do not? Firmly documenting the value of fluency specialists through published research, or indeed, SLPs in the care of stuttering at all is but one more of the challenges that face future practitioners. Consumers, third-party payers, and school systems will justifiably continue to ask the question, “Does specialization really improve client care?”

This very question, as it relates to client care, outcomes, and treatment efficacy, is related to so many of the other issues that we face in the 21st century. The status of emerging therapies (e.g., electronic devices; see Bakker, chap. 9, this volume), the effectiveness of drug therapies for stuttering (for which SLPs will not be the primary providers; see Ludlow, chap. 10, this volume), the effectiveness of the “hotter” therapy programs (as measured by frequency of published report, e.g., the Lidcombe Program; see Bernstein Ratner & Guitar, chap. 6, this volume); intensive therapies (Montgomery, chap. 8, this volume), and specific intervention and carry-over techniques; e.g., counseling; see Ambrose, chap. 5, this volume); the role of support groups (Reeves, chap. 11, this volume) can all be linked to a trend that questions the nature of effective treatments and the documentation of efficient, successful outcomes following stuttering therapy (Pietranton, chap. 3, this volume). We additionally ask (as we measure outcomes), whether such outcomes (and even the basic understanding of what stuttering is) can be linked to a s...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• 1. Stuttering Treatment in the New Millennium: Changes in the Traditional Parameters of Clinical Focus
• 2. Communication-Emotional Model of Stuttering
• 3. An Evidence-Based Practice Primer: Implications and Challenges for the Treatment of Fluency Disorders
• 4. Measurement Issues in Fluency Disorders
• 5. Early Stuttering: Parent Counseling
• 6. Treatment of Very Early Stuttering and Parent-Administered Therapy: the State of the Art
• 7. Therapeutic Change and the Nature of our Evidence: Improving Our Ability to Help
• 8. The Treatment of Stuttering: From the Hub to the Spoke
• 9. Technical Support for Stuttering Treatment
• 10. Neuropharmacology of Stuttering: Concepts and Current Findings
• 11. The Role of Self-Help/Mutual Aid in Addressing the Needs of Individuals Who Stutter
• Author Index
• Subject Index