Stuttering research – though voluminous, and growing – is notoriously hard to sift through and weigh for at least three reasons:
- with a few exceptions, different research groups tend to spend their time and funding researching and validating their own treatments, rather than comparing the effectiveness of different treatments;
- researchers have different ways of measuring their treatment results, which makes treatments hard to compare; and
- people who stutter are not one, uniform group of people. They vary in age, culture, socio-economic background, temperament, stuttering severity, time since onset of stuttering, and almost every other variable you can think of.
Usually, practising speech pathologists love systematic reviews because they compare high quality evidence about the effectiveness of different treatments and help us to inform clients about their options. But a review can only reflect the quality of the underlying research.
A new systematic review has just been published (reference below). The researchers looked at 112 peer-reviewed research papers on stuttering treatments and broke them into 7 categories:
- speech motor interventions: these treatments work on the mechanisms of speech production, e.g. breathing, voicing and articulation systems. They include prolonged speech treatments like the Camperdown Program for adults; and the Westmead Program for pre-school and school-aged children;
- behaviour modification interventions: these treatments aim to change the behaviour of the person who stutters. They include the Lidcombe Program for children;
- cognitive interventions: these treatments aim to lead to psychological change and include cognitive behaviour therapy;
- speech motor combined with cognitive interventions;
- “multiple component interventions”: these include combinations of elements including smooth speech, relaxation, self-management and cognitive treatments (e.g. Hancock & Craig, 2002);
- feedback and technology interventions: these include delayed auditory feedback and frequency altered feedback devices, electromyography and video-self modelling; and
- papers comparing different treatments to each other, e.g. Menzies, 2008.
The researchers concluded that:
- there is a diverse range of evidence-based treatments for stuttering, with most treatments showing some positive effect for at least some participants;
- the evidence remains unclear about who will gain the most from which treatment;
- treatment effects of most reviewed therapies can be maintained (although the evidence was weakest with regard to feedback and technology interventions);
- future research should pay closer attention to variables like client and speech pathologist factors, time since stuttering began, session times, dosage (number of sessions a week, minutes per session) so treatments can be compared directly;
- researchers should adopt standard outcome measures for assessing treatment effectiveness (e.g. stuttering severity and quality of life measures) – including measurements of things that matter most to clients; again, so speech pathologists and clients can compare treatments directly;
- for children, there is support for the Lidcombe Program and other interventions, but the Lidcombe Program is underpinned by a “substantial body of evidence”;
- a “one size fits all” approach is unlikely to work – no treatment is successful for everyone who receives it;
- more input should be sought from people who stutter to assess what constitutes a “good outcome”; and
- speech pathologists and clients need better information about how and why therapies work, and factors that may hamper the effectiveness of different treatments for particular clients.
The review excluded case studies and surveys because they are at a higher risk of bias. Interestingly, the researchers sorted the papers into papers with a higher or lower risk of bias based on the Cochrane criteria for judging risk of bias, 2011, but “influenced” by what the researchers called an “aggregate approach” agreed by consensus, which seems, from the paper, to be both subjective and itself at risk of bias. The researchers also noted that the variability in outcome measures precluded any meaningful statistical comparisons of intervention effectiveness.
Clinical bottom line
Evidence-based speech pathologists want to provide clients who stutter with good quality information about their treatment options, the risks and benefits of each treatment, and treatment recommendations that incorporate each client’s values, needs, preferences and characteristics.
At the moment, we have good research about treatments that are effective for some people, some of the time. But, outside broad “adult” and “child” treatment classifications, we have little evidence guiding us on how to assess the suitability of a particular treatment for an individual client. In practice, this means therapy often includes an element of trial and error. Treatment decisions are also hampered by a lack of standardised outcome measures across the studies, which make it hard for us to compare treatments effectively. Some outcome measures may not accord with a client’s view on what constitutes a good result.
Nothing in the review is inconsistent with my current clinical practice of offering evidence-based treatments like the Lidcombe Program and Westmead Program for children, the Camperdown Program for adults who stutter, video-self modelling as an adjunct therapy, and referring adults who may have social anxiety to psychologists for cognitive behaviour therapies. The review is also broadly consistent with Bothe et al’s 2006 systematic review. But, obviously, we look forward to seeing more quality research published looking at different client variables and using agreed core treatment outcomes relevant to people who stutter so we can compare studies and provide practical guidance to clients.
Source: Baxter, S., Johnson, M., Bank, L., Cantrell, A., Brumfitt, S., Enderby, P., & Goyder, E. (2015). The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness. International Journal of Language Communication Disorders, 50(5), 676-718.
My Online Stuttering Clinic is an online therapy clinic for children and adults who stutter. We offer online stuttering assessment and therapy via video conferencing technology. My Online Stuttering Clinic is run by David Kinnane, a speech-language pathologist with post-graduate training in the Lidcombe and Camperdown Programs for stuttering.
David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).
David also owns and manages Banter Speech & Language, a ‘bricks and mortar’ independent speech pathology clinic for adults and children in Sydney, Australia.