Treatment Efficacy: Stuttering

Transcription

1 Journal of Speech and Hearing Research, Volume 39, S18-S26, October 1996 Treatment Efficacy: Stuttering Edward G. Conture Syracuse University Syracuse, NY The purpose of this article is to review the state of the art regarding treatment efficacy for stuttering in children, teenagers, and adults. Available evidence makes it apparent that individuals who stutter benefit from the services of speech-language pathologists, but it is also apparent that determining the outcome of stuttering treatment is neither easy nor simple. Whereas considerable research has documented the positive influence of tratment on stuttering frequency and behavior, far less attention has been paid to the effects of treatment on the daily life activities of people who stutter and their families. Although it seems reasonable to assume that ameliorating the disability of stuttering lessens the handicap of stuttering, considerably more evidence is needed to confirm this assumption. Despite such concerns, it also seems reasonable to suggest that the outcomes of treatment for many people who stutter are positive and should become increasingly so with advances in applied as well as basic research. KEY WORDS: stuttering, treatment, efficacy, fluency disorders There is both scientific and clinical evidence that individuals who stutter benefit from the services of speech-language pathologists. This evidence is documented by experimental research, program evaluation data, and case studies. Olswang (1990) has observed that treatment efficacy is a broad term that can address several questions related to treatment effectiveness (Does treatment work?), treatment efficiency (Does one treatment work better than another?), and treatment effects (In what ways does treatment alter behavior?). Treatment efficacy studies have used either group or single-subject experimental designs to answer these questions; findings from both methodologies are included in this paper. Information will be used from other sources, such as case studies, to supplement experimental findings of treatment efficacy with more individualized and client-oriented accounts of treatment benefits. Thus, the specific purpose of this article is to review the efficacy of stateof-the-art treatment of stuttering in children, teenagers, and adults. Stuttering can, and often does, have significant negative effects on the academic, social, and vocational achievements and status of individuals who stutter. However, as will be shown, when treated properly and in a timely fashion, much can be done to improve the communication abilities of people who stutter. Such improvements meaningfully contribute to all facets of the person's personal and professional life. Incidence/Prevalence of Stuttering To provide some context for the scale of the disorder within the general population and, thus, the relative need for treatment, a brief review of the incidence and prevalence of stuttering is appropriate. Incidence Incidence of stuttering is typically assessed by estimating "the percentage of adults who say they have stuttered at some point in their lifetime" (Conture & Guitar, 1993, p. 258). Estimates of about 5% lifetime incidence (Andrews et al., 1983) must be tempered by estimates of a 50% recovery rate by age 6 (Andrews, 1984). In other words, only C 1996, American Speech-Language-Hearing Association S /96/3905-O 18

2 about half of the 5% (i.e., 2.5%) will still be stuttering after age 6. More recent findings (Yairi & Ambrose, 1992; Yairi, Ambrose, & Nierman, 1993), however, indicate that within the first 2 years of the onset of stuttering, recovery rates for children range between 65% and 75%, with as many as 85% of children recovering within the next several years (i.e., about 4 of 5 [85%] children who begin to stutter eventually recover). Thus, the percentage of individuals who stutter after 6 years of age is most likely closer to 1% (i.e., about 4 out of 5 will recover from a lifetime incidence rate of 5%), a figure consistent with the approximately 1% prevalence discussed immediately below. The precise influence of spontaneous recovery on treatment outcome, particularly for preschoolchildren who stutter, is unknown. However, it is believed to be an important consideration when evaluating treatment efficacy for stuttering. Prevalence Prevalence of stuttering is typically assessed by determining the number of cases present in a population (e.g., a school) during a given period of time, divided by the number of people in the population (Beitchman, Nair, Clegg, & Patel, 1986). Seventeen studies of U.S. schoolchildren cited by Bloodstein (1995) report an average prevalence of stuttering of 0.97%, with a range from 0.3% (grades 1-12: Rocky Mountain area, Hull, 1969) to 2.12% (grades 7-12: Tuscaloosa, AL, Gillespie & Cooper, 1973). Bloodstein's review of these studies suggests that the prevalence of stuttering remains relatively steady through grades 1-9 and then declines each year in grades 10, 11, and 12. Estimates of incidence and prevalence of stuttering are undoubtedly influenced by many of the same issues that affect the assessment of treatment efficacy-for example, differences in definition of stuttering, measures of stuttering, and sample sizes. Although advances in the area of measurement of stuttering are being made (e.g., time-interval judgments of stuttering: Cordes, Ingham, Frank, & Ingham, 1992; Ingham, Cordes, & Finn, 1993), Ingham (1990) correctly notes that there is still considerable need for research that will improve the reliability as well as the validity of clinician- as well as researcherjudgments of stuttering. Definition of Stuttering To provide further context for an overview of treatment efficacy for stuttering, it also seems appropriate to consider what researchers and/or clinicians typically refer to when describing stuttering or stuttered speech behavior. Although no universally acccepted definition of stuttering exists at present (operational or otherwise), certain observations can reasonably be made. Speech, like many other human behaviors, is occasionally produced by speakers with hesitations, interruptions, prolongations and repetitions. These disruptions in...ongoing speech behavior are termed disfluency and the frequency, duration, type, severity and so forth of these speech disfluencies vary greatly from person to person and from speaking situation to speaking situation. Some of these speech disfluencies, particularly those which involve within-word disruptions (such as sound or syllable repetitions), are most apt to be classified or judged by listeners as stuttering. [Conture, 1990a, p. 2] Thus, stuttering or stuttered speech typically involves part-word repetition, sound prolongation, monosyllabic wholeword repetition, or within-word pause. It has been shown, however, that stuttering events can also be perceived as occurring in the intervals between words (e.g., Cordes & Ingham, 1995; Curlee, 1981; MacDonald & Martin, 1973)-for example, on effortful-sounding or appearing disfluency perceived between words, such as a tense pause, hesitation, or block. It is safe to say that methodological advances such as the time-interval measurements reported by Ingham and colleagues (e.g., Cordes et al., 1992) will undoubtedly refine both our description as well as the measurement of those behaviors perceived as "stuttered." In brief, stuttering or stuttered speech behaviors typically involve within-word disfluencies (e.g., Boehmler, 1958; Schiavetti, 1975; Williams & Kent, 1958; Zebrowski & Conture, 1989) but sometimes can also include effortful-sounding or appearing disfluency perceived between words, such as tense pauses or hesitations (e.g., Curlee, 1981). However, it should be noted that not all withinword disfluencies are consistently perceived or judged as stuttered. For example, mothers of children who do and Conture: Treatment Efficacy in Stuttering S19 children who do not stutter infrequently (15% to 30% of the time) judge as stuttered sound prolongations of relatively brief duration (less than 300 ms) but very frequently (83% or more of the time) judge as stuttered sound/syllable repetitions of any duration (Zebrowski & Conture, 1989). Whatever the case, none of the above discussion of the disability (i.e., behavioral manifestations) features of stuttering address the handicapping (i.e., social, psychological, etc. disadvantages) aspects of stuttering. Indeed, it is fair to say that we need to know much more about the influence of treatment on the handicapping aspects of stutteringsomething to be discussed in this article. As Purser (1987) notes, the evaluation of treatment efficacy involves treatment process research (e.g., study of the methods of conducting treatment) and treatment outcome research (e.g., study of the effects of treatment), the latter being the focus of the present review. A basic challenge of treatment outcome research is determining the most relevant aspects of a stuttering disability to measure (see Curlee, 1993), because many different aspects of stuttering can be measured (e.g., frequency of occurrence, duration, severity, type of stuttering, associated behaviors). For this, as well as other reasons, St. Louis and Westbrook (1987) note that "Determining the outcome of stuttering therapy is not a simple task" (p. 235). Perhaps, as Baer (1990) suggests, treatment research would be improved if researchers were better able to discern what clients' main complaints or concerns actually are. To date, most published studies of the efficacy of stuttering treatment have relied on measures of stuttering or stuttered speech (e.g., frequency of stuttering). Thus, unless otherwise indicated, this review of treatment efficacy will rely on these kinds of objective measures of stuttering or stuttered speech. We fully realize that, as St. Louis and Westbrook suggest, "achieving healthy client attitudes or feelings, or a reduction of avoidance or anxiety, are viewed as essential ingredients in many therapies" (p. 236). Indeed, treatment outcome measures, although currently focused on changes in disability features (e.g., frequency of stuttering), should, in an ideal world, also assess changes in the degree of handicap (e.g., extent to which an individual, after treatment, enters and engages in previously avoided speaking situations).

3 S20 Journal of Speech and Hearing Research 39 S18-S26 October 1996 Definition of Effectiveness As Bloodstein (1995) notes, "The assessment of results of therapy is a process fraught with opportunities for error and self-delusion" (p. 439). Although this topic has been extensively reviewed (e.g., Curlee, 1993; Ingham, 1984, 1993; St Louis & Westbrook, 1987; Van Riper, 1973), we are still challenged to clearly, objectively, and succinctly state what we mean when we describe treatment as "effective." In other words, if we want to describe the "effectiveness" of treatment for stuttering, we need to define what we mean by "effective." Perhaps we could start by noting that effectiveness has been defined as the "ability to produce a specific result or to exert a specific measurable influence" (Dorland, 1988). This definition is not sufficient, however, because discussions of effectiveness frequently involve descriptions of whether a treatment was successful; and judgments of success, it would seem, are highly dependent on who is making the judgment. With regard to judging effectiveness or success of treatment of stuttering, we could discuss subject-independent measures of stuttering (e.g., frequency and duration of instances of stuttering) as well as subject-dependent measures of effectiveness (e.g., the client's belief that he or she can talk to anyone at any time; Conture & Wolk, 1990). And, as Conture and Wolk have stated, it simply is unclear which of these measures is more important in judging the effectiveness of stuttering treatment. Beyond the use of inferential (non)parametric statistics to assess whether pre- versus posttreatment events significantly differ, at present there are no known, one-size-fits-all objective criteria for judging effectiveness of stuttering treatment-at least none that would receive wide agreement among experienced workers in this area. In general, treatment for stuttering might be considered effective if it resulted in the individual's being able to speak with disfluencies within normal limits whenever and to whomever he or she chose, without undue concern or worry about speaking. More specifically, to quote Conture and Guitar (1993), "treatment efficacy or effectiveness [may be] maximum when [the person who stutters] as a result of treatment exhibits the ability to communicate readily and/or easily whenever, wherever, and to whomever, whatever he or she wants" (p. 254). Thus, whatever the eventual consensus definition of effectiveness of stuttering treatment, it most likely will involve some complex mix of subject-independent and subject-dependent measures of change in (a) stuttering or stuttered speech, (b) related attitudes and feelings, and (c) willingness to enter into and engage in various communication situations with various people. (For a thorough overview of representative, contemporary treatment regimens for stuttering see Peters & Guitar, 1991, pp ) Effects of Stuttering on Daily Life Activities One model for understanding the effects of stuttering on daily life activities is that of the World Health Organization. This model has been applied to stuttering by both Prins (1991) and Curlee (1993). As described by Curlee (p. 320), this model could be used to conceptualize the disorder of stuttering as follows: 1. An impairment, including all the neurophysiological and neuropsychological events that immediately precede and accompany the audible and visible events of stuttering 2. A disability, comprising all audible and visible events that are the behavioral manifestations of stuttering 3. A handicap, comprising the disadvantages that result from reactions to the audible and visible events of a person's stuttering, including those of the person who stutters Applying this conceptualization to the possible effects of stuttering on "daily life activities," one would appear to be describing the handicap of stuttering or the handicapping conditions produced by stuttering. Numerous informal observations suggest that stuttering, particularly when it is not treated properly and/or in a timely fashion, is a handicap in terms of daily life activities (e.g., children refuse to orally communicate in class, adults select professions that require little or no oral communication, individuals withdraw from social contact because of fear of speaking). Likewise, as the brief review in the following section shows, more formal observations indicate that stuttering can be a handicap, to greater or lesser degrees, within three main "venues" of daily life activities: work, school, and social interactions. Work Hurst and Cooper (1983) suggested that stuttering was a vocationally handicapping condition after they found that employers thought stuttering decreases "employability" and interferes with promotion opportunities. (For similar findings regarding negative stereotypes about people who stutter held by many groups, e.g., school administrators, see also Collins & Blood, 1990; Lass et al., 1994; Ruscello, Lass, Schmitt, & Pannbacker, 1994; Silverman & Paynter, 1990.) Craig and Calvert (1991) found that employers' perceptions of adult employees who stuttered were enhanced for those who sought treatment versus those who did not. That is, employers seemed to have less than positive perceptions of individuals who stutter; but when individuals obtained treatment for stuttering, employers' perceptions of their speech was considerably enhanced. Craig and Calvert also found that 43% of these who had maintained, on average, an 88% reduction in stuttering 10 months posttreatment reported being promoted in their jobs after treatment. Hence, assessment of treatment efficacy should not only take account of the disability aspects of stuttering but the handicap aspect of stuttering-for example, how did treatment affect "job history, employer reactions, and communication efficiency in the work place" (Craig & Calvert, p. 283). As these authors indicate, it is "very important that clinicians understand the relationship between treatment and vocation outcome" (p. 281). Indeed, Howie and Andrews (1984) suggest that a minimal requirement for stuttering treatment outcome evaluations should be the "extent of handicap" (e.g., avoidance of speaking, negative selfconcept, etc.). School Bloodstein (1995) states that there is "fairly consistent evidence that stutterers, on the whole, are poorer in educational adjustment than normal speakers" (p. 253). For example, schoolchildren who stutter are older than classmates who do not stutter in the same grade, suggest-

4 ing that children who stutter are more likely to be held back (e.g., Darley, 1955); and schoolchildren who stutter have lower achievement test scores than do those who do not stutter (Williams, Melrose, & Woods, 1969). Such findings may result from the stuttering and/or from those factors influencing the child's predisposition to stutter, the onset of stuttering, or its persistence. To the extent that stuttering affects educational adjustment, appropriate and timely treatment could be expected to improve the academic achievement and performance of children who stutter. Social Bloch and Goodstein (1971), in a review of a decade's research on personality and adjustment of stuttering children, concluded that there is no evidence of severe maladjustment in children who stutter. Bloodstein (1995) agrees that seldom, if ever, has research found stutterers, as a group, to exhibit "recognized patterns of psychoneurotic disturbance [although] signs of mild social maladjustment have been found frequently" (p. 213). What is clearly needed, however, as Bloch and Goodstein suggest, is a better understanding of how personality and social-emotional variables may influence the type, length, and outcome of treatment of stuttering and/or whether such treatment changes or leads to improvements in psychosocial adjustment and more satisfying lifestyles. (See Blood & Conture, in press, for further discussion of these issues.) As Lyon (1992) points out, with regard to aphasia, there is less than complete understanding of how disabilities, in this case stuttering, influence the mental health of "normal" personalities. Thus, the efficacy of current treatments for the handicap of stuttering will remain unclear until there are studies of how (and if) psychological well-being ("mental health") changes during and after treatment of stuttering. Although informal clinical observations suggest that people who stutter-particularly adults who have improved as a result of treatment-report varying degrees of improvement in their social interactions, the number, nature, duration, and significance of these changes in social behavior and interactions are not very well documented. Role of the Speech-Language Pathologist in Treating Stuttering Speech-language pathologists, because of their academic and clinical training, national certification examination, and state licensure (where applicable), are the professionals who usually assess and treat stuttering in children, teenagers, and adults in the United States. Academic coursework and practicum opportunities (diagnostic and treatment) in the area of stuttering are available as a part of all educational/training programs accredited by the Council on Academic Accreditation of the American Speech-Language-Hearing Association (ASHA). A Special Interest Division (SID) for fluency disorders, organized under the auspices of ASHA, is also available for speechlanguage pathologists who specialize in the study and treatment of stuttering. Further testimony to the expertise of speechlanguage pathologists in the area of stuttering is demonstrated by the fact that the editor and most associate editors and editorial consultants of one of the major journals in the area of stuttering (Journal of Fluency Disorders) are speech-language pathologists. Speech-language pathololgists, who work in various employment venues-for example, public and private schools, public and private hospitals and clinics, university and college clinics, and private practice-routinely diagnose and treat people who stutter. Although some manage a variety of communication disorders, a number of speech-language pathologists-with appropriate graduatelevel degrees (master's and/or doctorates), certification, and state licensurehave specialized experience, interest, and training in stuttering. For stuttering, as for all communication disorders, diagnosis is the gateway to treatment and may consist of initial screenings, fullscale evaluations, and subsequent reevaluations, when needed. Treatment for stuttering can be intensive (i.e., many hours every day for relatively few weeks) or extensive (i.e., one or two hours per week for several months to over a year) and can involve both individual as well as group treatment sessions. (See St. Louis & Westbrook, 1987, p. 250, for further discussion of the pros and cons of "intensive" versus "nonintensive" treatment for stuttering.) Conture: Treatmment Efficacy in Stuttering S21 With children, particularly preschoolchildren, treatment often includes considerable parental involvement-for instance, information-sharing and counseling regarding parent-child communicative and related psychosocial interactions (Zebrowski & Schum, 1993) as well as training to change parental communication and related behaviors (e.g., Kelly & Conture, 1991; Rustin & Cook, 1995; Starkweather, Gottwald, & Halfond, 1990). Treatment can also involve responsecontingent procedures (e.g., Ingham, 1982; Onslow, Andrews, & Lincoln, 1994) as well as various fluency-shaping and/ or stuttering modification approaches (e.g., Kully & Boberg, 1991). Treatment approaches used may be determined by such factors as available resources at the speech-language pathologist's place of employment, age of the person who stutters, possible exacerbation of stuttering because of inappropriate parent-child communicative interactions, nature and/ or severity of the person's stuttering, as well as the clinician's training and experience in treating stuttering. On following pages is a case study of the speech-language treatment of a typical child who stutters. This case study is not representative of all treatments for school-age children who stutter but merely one of the more typical treatments such children receive. Evidence of the Benefits of Treatment Bloodstein (1995), in his review of approximately 150 studies of treatment for stuttering, suggests several criteria for assessing whether a method of treating stuttering may be considered successful (e.g., "Have results of the treatment method been demonstrated by long-term follow-up study?"; see a similar discussion by Starkweather, 1993, pp ). However, an exhaustive review of such criteria is beyond the scope of this paper. One might also evaluate or measure the effectiveness of various treatments by using a single means of defining "stutter events." For example, one might define stutter events as involving (a) covertly perceived disruptions in speech (e.g., a sense of loss of control) and (b) overt, defensive, or coping reactions to these perceptions (e.g., muscle tensing) (Prins, 1991). Applying such a definition in evaluating the efficacy of

5 S22 Journal of Speech and Hearing Research 39 S18-26 October 1996 treatment of adults would lead to (a) "external" validation of the "defensive" reactions by people other than the stutterer-for example, the speech-language pathologist or observers in the adult stutterer's environment-and (b) "internal" validation of the covert perceptions by the stutterer-that is, validation by the stutterer him- or herself (Conture & Wolk, 1990; also see Prins, 1993). However, using such definitions with children who stutter would be problematic because of the difficulties one would have in reliably and/or validly assessing the presence of and/or changes in "internal" or "covert" perceptions of preschool and early elementary school-age children. Therefore, because both stuttering as well as its diagnosis and treatment are likely to differ across the life span in terms of frequency, length, nature, type, and rates of recovery, review of treatment efficacy is probably best considered relative to four age-groups: preschoolers, schoolage children, teenagers, and adults. Preschool Yairi (1993) and Yairi and Ambrose (1992), in their review of the efficacy of stuttering treatment in preschoolchildren, report that there is a 65% or more spontaneous recovery or natural remission rate (i.e., positive change with little or no therapeutic intervention) in the stuttering of preschool children in the first 2 years post-onset. Such remissions, however, more than likely decrease as stuttering persists. For example, Andrews (1984) estimates a spontaneous recovery of only 18% for those individuals who stutter for 5 years or more. Increasingly, clinicians appear to advocate early diagnosis and treatment of stuttering (e.g., Conture, 1990b; Onslow, 1992; Peters & Guitar, 1991; Ryan & Van Kirk Ryan, 1983); however, until the recent, relatively large-scale study of Fosnot (1993), Yairi (1993) noted that only six studies on treatment efficacy, involving a total of 14 preschool children who stutter, had been published. Fosnot's study involved 33 preschool children who stuttered and who were followed, at 6 month intervals, for a 5-year period after their initial evaluation. Fosnot reported that "of the 33 children who graduated, 30 (90.91%) have remained fluent" (p. 237). She did not include a no-treatment control group, because withholding or delaying services for stuttering in preschoolers (as Fosnot discusses, p. 246) may be fraught with various ethical and therapeutic concerns. Her findings do seem to support the efficacy of treating stuttering in preschoolers, because these children were followed for a 5-year period after their initial evaluation. However, it should be recalled that recovery rates for children who stutter (and who have received no direct treatment) may range as high as 85% (e.g., Yairi & Ambrose, 1992; Yairi et al., 1993). Therefore, it is quite possible that some ameliorative changes reported to result from treatment of preschool children who stutter are compounded by the fact that varying degrees of recovery apparently occur in the absence of direct intervention. Recently, however, Gottwald and Starkweather (1995) reported, on the basis of 2-year posttreatment telephone calls to parents, that "fluency had been maintained" for 45 of 45 preschoolers who were treated for stuttering. Likewise, following encouraging preliminary findings (Onslow, Andrews, & Lincoln, 1994), Lincoln and Onslow (in press) recently reported results of a relatively large-scale treatment study of preschoolers who stutter that employed a parent-conducted program of verbal response-contingent stimulation. Providing considerable supporting data, Lincoln and Onslow conclude that significant in-clinic as well as posttreatment reductions occurred in the preschoolers' stutterings (e.g., 7 children, who were studied 4 years posttreatment, reportedly maintained fluent speech). Thus, despite appropriate concerns for the influence of spontaneous recovery on treatment effects with preschool children who stutter, recent findings are consistent with Fosnot and are strongly suggestive of the benefits to be gained by treating the early stages of the disorder. Background Information In February 1992, 9-year-old Michael was initially evaluated at a university-based speech and hearing clinic, where he was diagnosed as a moderately severe stutterer. At that time, Michael averaged 11 speech disfluencies per 100 words of conversational speech, with his most commonly occurring disfluencies being sound/syllable repetition (e.g., "wha-wha-when") and interjections (e.g., "and [uh] she thinks"), with an average duration of 1100 ms per sound/ syllable repetitions. Michael's parents noticed that speech was becoming "effortful" for their son and expressed concern that his speech difficulties might not be resolved unless he received intervention. Treatment History Because of caseload restrictions and scheduling difficulties, treatment onset was delayed until September 1992, when Michael was initially assigned to weekly parent-child group treatment to address his speech fluency concerns. Although Michael's parents demonstrated improvement in terms of a number of communicative behaviors thought to exacerbate childhood stuttering (e.g., they spoke at a slower, more appropriate rate; and they lengthened pause time intervals), Michael made minimal progress. Consequently, in April 1993, a combination of group and individual treatment was initiated. Individual treatment targeted two main goals: (a) helping Michael learn to speak in a way that prevented or minimized the instances of stuttering, and (b) helping Michael learn to effectively and appropriately change or modify instances of stuttering when they occurred.

6 School-Age Children Conture and Guitar (1993), in their review of the efficacy of treating stuttering in school-age children, focused on the nine most recent studies (published within the past 15 years), chiefly because these nine studies (involving over 160 children) presented results that were objectified in considerable detail. These studies reported an average of 61% decrease (range: 33% to over 90%) in stuttering frequency and/or severity in school-age children. One such study (Ryan & Van Kirk Ryan, 1983), which reported a 60% average improvement during transfer (i.e., posttreatment) across four different treatment procedures, is particularly noteworthy in terms of its comprehensive study of different treatment approaches (serving as a model for how such research should be conducted) and the fact that it assessed treatment results not only in clinical settings but in the children's classrooms as well (the latter, of course, being one of the salient venues in these children's daily life activities). More recent study of treatment outcome with school-age children who stutter (Runyan & Runyan, 1993), based on a clearly explicated and seemingly reasonably motivated treatment program (i.e., the "fluency rules program"), reports significant improvement in 9 of 12 (75%) school-age children. Likewise, in a carefully conducted comparison study of two intervention programs with school-age children, Ryan and Van Kirk Ryan (1995) recently reported significant in-clinic improvement in stuttering for nearly all children studied (96%), improvement that was reportedly maintained 14-months posttreatment. Thus, although considerably more study of treatment outcome with school-age children who stutter is warranted, present findings suggest cautious optimism that many of these children have been, are being, and will continue to be helped. Teenagers Schwartz (1993), in his review of treatment efficacy studies of stuttering among teenagers, notes that the "literature available regarding specific therapy programs for adolescents is sparse" (p. 299). He says further that, unlike when dealing with preschoolers and younger schoolage children who stutter, "when dealing with adolescents we are confronted with a population who have experienced stuttering for a number of years" (p. 291). Thus, length of time stuttering or experience with the problem suggests that treatment is likely to take longer, to need modifications from those used with younger children, and to have less success than with preschool or school-age children. Daly, Simon, and Burnett-Stolnack (1995), as well as Van Riper (1971), appear to agree that the emotional, personal, and Conture: Treatment Efficacy in Stuttering S23 social aspects of teenagers' fluency problems makes them among the '"toughest clinical cases" a speech-language pathologist must manage. There is, however, some seemingly positive news in this area. Recently, Blood (1995) reported quite encouraging preliminary findings regarding a cognitive-behavioral treatment regimen designed for relapse management in teenagers who stutter. Besides minimizing relapse after treatment, in teenagers as well as adults, we may be developing some ability to make earlier predictions of the likelihood of relapse (Craig & Andrews, 1985; Craig, Franklin, & Andrews, 1984). Craig and his colleagues provide some evidence that measures of locus of control (i.e., an individual's perceived control over himor herself and the environment) are useful in predicting which individuals who stutter will relapse 10 months after completion of treatment-information that may help clinicians make appropriate adjustments in the quantity and quality of treatment for some of their teenage and adult clients who stutter. Furthermore, although outcome data were not reported, Daly et al. (1995) recently provided seemingly reasonable suggestions for the treatment of attitudes, beliefs, and perceptions of teenagers who stutter-cognitive and emotional changes that further research may show to be crucial if the teenager who stutters Treatment Progress Group treatment was gradually discontinued, and individual treatment was reduced once Michael began to consistently demonstrate easier, more relaxed speech production in a variety of speaking situations in the clinic, at home, and at school. Michael's frequency of disfluency was reduced to an average of 5 per 100 words of conversational speech, and considerable improvements were noted (by clinicians, parents, and teachers) in Michael's attitude toward speaking and speaking situations and in his abilities as a speaker. By January 1994, approximately 16 months after treatment initiation, Michael's speech-language posttreatment or "maintenance treatment" consisted of 8 sessions (approximately one session every days throughout 1994) to monitor and maintain his speech fluency skills. Observations during this time indicated that Michael continued to show decreases in frequency (average: 2 to 3 disfluencies per 100 words) and duration of disfluencies (average: 400 ms or less) as well as increased willingness and ability to speak in greater numbers and varieties of speaking situations outside the clinic-for example, in the classroom, answering the phone at home, and so forth. Cost of Treatment Given that the university-based clinic is a training as well as service facility, costs are somewhat modest in comparison to other service venues. Total cost of Michael's speech treatment services was $885, which included the cost of the initial speech-language diagnostic plus 12 group and 16 individual treatment sessions (but not including 8 maintenance treatment sessions).

7 S24 Journal of Speech and Hearing Research 39 S 18-S26 October 1996 is to maintain improvements in fluency, particularly after completion of treatment. Adults Blood (1993), in his review of the efficacy of stuttering treatment in adults, cites Bloodstein's (1987) review of over 100 studies with adults, in which Bloodstein concluded that "substantial improvement, as defined in these studies, typically occurs as a result of almost any kind of therapy in about 60 to 80% of cases" (p. 399). The literature in this area is voluminous, ranging from earlier very promising results based on responsecontingent, operant behavioral models (e.g., Ingham, 1982; Martin & Haroldson, 1982) through the use of various pharmaceutical agents to ameliorate stuttering (e.g., Andrews & Dozsa, 1977). Although the long-term effectiveness of certain behavioral approaches (e.g., R. Ingham, 1982; J. C. Ingham, 1993) seem supported by findings in carefully conducted clinical investigations, the longterm effectiveness of treating stuttering, in whole or in part, with pharmaceutical agents remains far less certain (see Brady, 1991, for a thorough overview of pharmacological approaches to stuttering). When taken as a whole, however, certain procedures (i.e., "prolonged speech" and "gentle onsets") appear to yield the greatest effectiveness for remediating stuttering in adults, according to a meta-analytical review of 42 studies of treatment of stuttering in 756 adults (Andrews, Guitar, & Howie, 1980). It is also possible, particularly for adults who stutter, that some treatments may lead to increases in speech fluency at the cost of decreases in the "naturalness of speech" (e.g., inappropriately slow speech and monoprosodic intonation). Indeed, some changes in the "naturalness" of speech do occur during and/or after certain treatments for adults (Franken, 1987; Ingham, Ingham, Onslow, & Finn, 1989); however, it is unclear what impact, if any, such changes have on long-term therapeutic effectiveness for stuttering. Clearly, however, as suggested by recent reviews of treatment efficacy research with adults who stutter (Blood, 1993; Prins, 1993), we need to expand our measurement of treatment outcome beyond basic measures of disability and at least consider such events as client attitudinal change, locus of control, the cognitive nature of cues leading to coping or defensive reactions, and so forth. Such consideration seems warranted given the possibility that these nonspeech-but-related-to-stuttering events, at least with adults, may have as much influence on long-term treatment efficacy as modification of stuttering itself. Returning to the apparent efficacy of "prolonged speech" approaches, Ingham's (1993) review of behavior modification approaches to stuttering strongly suggests that treatments involving "prolonged speech" result in short- as well as long-term reductions in stuttering frequency. Although prolonged speech and/ or gentle onset appear to be effective procedures for treatment of the disability of stuttering in adults, there is continued need for objective, peer-reviewed studies of these approaches (as well as many other approaches) regarding longterm (e.g., 5 years posttreatment) effectiveness for treating stuttering. Indeed, as Ingham's (1993) review points out, more than a few programs involve, to greater or lesser degrees, prolonged speech procedures (much the same could be said about gentle onsets). However, professionals and consumers alike can adequately and objectively evaluate the effectiveness of a treatment regimen--especially its long-term effectiveness-only if treatment outcome data are published in appropriate scholarly or professional literature. Thus, no matter what treatment regimen is employed (e.g., Webster's [1979] precision fluency shaping program, Schwartz's [1976] airflow method, and so forth) treatment outcome data published in peer-reviewed scholarly or professional journals is needed for the most complete, objective, and thorough assessment of short-, medium-, and long-term treatment outcome. Summary Across the life span, treatment for stuttering appears to result in improvement, on the average, for about 70% of all cases, ranging from a low of 33% to a high of over 90%. Although most current treatments for stuttering focus on ameliorating the disability of stuttering, it appears reasonable to assume, as the reports of people who stutter would suggest, that as the disability of stuttering decreases, the handicap of stuttering also becomes less problematic. Recovery without treatment, particularly in the preschool and school-age years, plays a role in the remission of stuttering, but much more needs to be known about the identification, at the time of initial evaluation, of those children who have "no," "low," "moderate," or "high" risk for continuing to stutter without treatment. It should be noted, however, that important strides have been made with regard to the diagnosis and evaluation of childhood stuttering (Curlee & Bahill, 1993; Riley, 1980; Riley & Riley, 1981), and encouraging treatment outcome data relative to preschoolers who stutter have been reported (e.g., Gottwald & Starkweather, 1995; Fosnot, 1993; Onslow, Costa, & Rue, 1990; Onslow, Andrews, & Lincoln, 1994; Lincoln & Onslow, in press). Likewise, studies like those of DeNil and Brutten (1991) and Miller and Watson (1992) provide us with objective insights into the self-perception of handicap by people who stutter as well as highlight the need to further our understanding of these self-perceptions. When routinely employed, these procedures and information may increase the chances that fewer treatment services will be allocated to individuals who may need them less, whereas more treatment services will be allocated to individuals who need them more. The average number of people estimated to stutter who benefit from treatment (7 of 10) undoubtedly varies with age (younger clients appear to improve somewhat more quickly and more easily than older clients), severity, type, and/or length of stuttering (longer history of stuttering appears to increase the duration of treatment and decrease likelihood of a complete recovery). Although much more needs to be known about the impairment, disability, and handicap of stuttering and how to most appropriately and effectively diagnose and treat stuttering (particularly in the preschool population), it is clear that present and future treatment outcomes for people who stutter and their families is bright and becoming more so with advances in applied as well as basic research. Current information suggests that effective treatment of stuttering is increasingly able to improve the daily life of people who stutter by increasing their ability to communicate whenever, wherever, about whatever, and to whomever they want, without undue concern and worry about speaking.

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Conture, PhD, Communication Sciences & Disorders, Syracuse University, 805 South Crouse Avenue, Syracuse, NY econture@sued.syr.edu