The Impact of Identifying Preferred Treatment Outcomes on Conceptualizing, Assessing, and Treating Chronic Stuttering
About the presenters: Eugene B. Cooper has served six years on the Steering Committee of the American Speech-Language-Hearing Association's Special Interest Division for Fluency and Fluency Disorders, the last five as Division Coordinator. Crystal S. Cooper has served as ASHA Vice-President for Professional Practice in Speech-Language Pathology, president of the Public School Caucus, chair of the Interprofessional Relationships Committee, and is currently a member of ASHA's Clinical Certification Board. Both Coopers are Fellows of the American Speech-Language-Hearing Association. They are the authors of over 150 publications primarily in the area of fluency and professional issues.
The Impact of Identifying Preferred Treatment Outcomes on Conceptualizing, Assessing, and Treating Chronic Stuttering
by Eugene B. and Crystal S. Cooper
Nova Southeastern University
ABSTRACT: The American Speech-Language-Hearing Association's continuing efforts in developing a National Outcomes Measurement System (NOMS) to assess the efficacy of speech-language pathology and audiology clinical practice is one factor leading to significant changes in how chronic stuttering is conceptualized, assessed, and treated. As preferred functional outcomes of stuttering treatment become accepted by the professional community, clinicians increasingly are aware of the need to view chronic stuttering as a syndrome with affective, behavioral, and cognitive components rather than as a unidimensional disorder in the fluency of speech. Clinicians focusing primarily on measuring the frequency of their client's disfluencies are find ing that the frequency of stuttering alone is one of the least valid and reliable measures by which preferred functional outcomes of stuttering treatments can be assessed. The recognition that altering feelings and attitudes, as well as behaviors, is critical to achieving preferred stuttering therapy outcomes has strengthened the call for counseling procedures being included in the education of clinicians.
In 1993 the American Speech-Language-Hearing Association established the Task Force on Treatment Outcomes and Cost Effectiveness to create a national outcomes database for speech-language pathologists and audiologists. Obviously, the creation of the Task Force was in response to the burgeoning growth in managed health care systems designed to control escalating healthcare costs. It became evident to all that if the services of our practitioners are to be covered in health insurance plans of any nature, we must be capable of describing the preferred functional outcomes of our services and of presenting evidence of the efficacy of those services. Recognizing the need to develop a national outcomes database, the ASHA Task Force initiated the development of the National Outcomes Measurement System (NOMS). The key to the system is the use of the seven-point Functional Communication Measures (FCMs) that are scored by the clinician at the time of the client's admittance and at the time of discharge. At the same time, the Task Force invited the various disorders-related interest groups to participate in the monumental task of setting functional outcome goals for every disorder-type and in identifying and developing instruments to measure the success or failure in achieving those goals.
In response to that call, the American Speech-Language-Hearing Association's Special Interest Division for Fluency and Fluency Disorders charged its 1997 Annual Leadership Conference with reaching consensus on preferred treatment outcomes for those who stutter. The charge was extended to the 1998 Annual Leadership Conference with the additional charge of beginning to develop scaling procedures for assessing success or failure in the achievement of the preferred outcomes previously identified. The complexity of the conference charges quickly became evident to the conferees and the resulting discussions raised significant issues relative to how stuttering is conceived by the profession as well as assessed and treated.
Although conferees used the terms 'Fluency Disorder' and 'Stuttering' interchangeably, there was no question that the group's focus was on stuttering rather than on fluency disorders related to such conditions as Tourette's Syndrome, dysarthria, dyspraxia, cluttering, spasmodic dysphonia, and palilalia. Following two days of small group discussions, the 1997 the key consensus statements of preferred stuttering fluency treatment outcomes from the clinicians' and the clients' perspectives were as follows: The Clinician's Perspective: The preferred fluency treatment outcome is that the client will demonstrate feelings, behaviors, and thinking that result in improved communicative performance and satisfaction with the therapy process.
The Client's Perspective: The preferred fluency outcome is an increased feeling of fluency control with a concomitant decrease in feelings, behaviors, and attitudes that comprise the stuttering syndrome (Fluency and Fluency Disorders Newsletter, September 1997).
Participants at the 1998 Leadership Conference, referring to the previous year's conference report, identified statements that could be scaled in a variety ways. After editing the previous year's preferred outcome statements to make them compatible for use with the 7 point scale model utilized in the National Outcomes Measurement system, conferees began the task of identifying appropriate descriptors for points along a continuum from 1 to 7 for the various preferred outcome statements. Some groups focused on developing scales for adults and others focused on developing scales for children. Finally, conferees categorized each statement as to whether the statement primarily assessed affective, behavioral, or cognitive components of the stuttering syndrome. The "Prototype Scales for Assessing Preferred Functional Outcomes of Stuttering Therapy," which appears at the end of this article, is an example of one format such scales might take. It will take effort and time for researchers and clinicians to develop such scales to the point that their validity and reliability are demonstrated.
Conceptualizing Stuttering
It was evident to conferees that assessing the client's frequency of fluency failures would not suffice. Reports of various groups confirmed the observation that a significant majority of the conferees hold that the client's feelings (affect) and attitudes (cognition) need to be assessed as well as other fluency-related behaviors. This conclusion was re-affirmed in the second conference. In agreeing that the assessment of preferred fluency treatment outcomes must address changes in the clients' feeling, behavior, and attitudes, the conferees appeared to be accepting the view that chronic stuttering might best be described as being a syndrome. Such a notion has been around at least since the first quarter of the twentieth century (Bluemel, 1932, 1957). Cooper & Cooper (1985a, 1993, 1998), have suggested that the label 'stuttering' might usefully be viewed as a diagnostic label referring to a clinical syndrome characterized most frequently by abnormal and persistent disfluencies in speech, accompanied by characteristic affective, behavioral, and cognitive patterns. Such a use of the term acknowledges that not all children who are disfluent are "stutterers" because the characteristic affective, behavior, and cognitive patterns that typify the clinical problem of stuttering are not present. By viewing stuttering as a syndrome, the question of etiology becomes one of identifying a variety of causative factors rather than that of identifying a single factor. Chronic stuttering can be viewed productively, as so many of our ills are, as resulting from the interactions of multiple co-existing physiological, psychological, and environmental factors. Such an etiological statement appears to some as being simplistic and of little clinical value. To others, the focus on the interactions of variables known to be related to chronic stuttering is resulting in an increased understanding of how the interactions of such things as the child's genetic predispositions, environment, and psychic state can result in a stuttering syndrome. The move to identify and measure preferred functional outcomes for the treatment of stuttering may well result in changes in how clinicians conceptualize the clinical problem known as stuttering.
Assessing Stuttering Syndromes
The focus on functional treatment outcomes is altering how chronic stuttering is assessed. As the move to develop measures of preferred stuttering treatment outcome variables attests, clinicians increasingly will be adding instruments for assessing functional outcomes to their existing assessment protocols. For the past thirty years many stuttering assessment protocols focused primarily on the measurement of disfluencies with the assessment of the clients' feelings and attitudes being viewed as being of secondary significance. The need to provide data to 'prove' the efficacy of our treatment procedures is leading to the re-examination of stuttering therapy goals from the perspectives of the clients, their loved ones, and those who provide third party support for treatment services. The clients' feelings and attitudes can no longer be ignored. As difficult as it to measure such variables, we must do so. Fortunately, there have been many attempts to assess changes in the feelings and attitudes of clients in stuttering therapy. Examples of attempts to do so include the following: Cooper, 1966, Lanyon, 1967; Woolf, 1967; Williams, 1978, Cooper & Cooper, 1985b; Watson, 1987; and Manning, 1996. Such efforts, in conjunction with the Division of Fluency and Fluency Disorders' continuing efforts at stimulating the development of scales for assessing preferred functional outcomes will undoubtedly result in the development of an array of easily administered and scored instruments to assess preferred treatment outcomes.
Treating Stuttering
The move to identify and measure preferred functional stuttering outcomes undoubtedly will have a significant effect on stuttering treatment programs. Focusing on affective and cognitive changes as well as on behavioral changes will result in a new generation of stuttering clinicians concerned more with the counseling aspects of their client-clinician relationships than with the client's frequency of stuttering. Clinicians increasingly are being required to demonstrate the efficacy of their therapeutic intervention by providing clinical data. Such data will need to indicate how successful the clinician is in enabling the client to attain the preferred treatment outcomes sought by clients, their families, third-party payers, and society.
Unquestionably, adding the assessment of preferred functional treatment outcomes relating to feelings and attitudes to the stuttering clinician's role will result in an increased awareness of the significance of the clients' feelings and attitudes to therapeutic success. Dealing with client feelings and attitudes requires a helping relationship best described as being a counseling rather than an instructional type relationship. Such client-clinician relationships in stuttering therapy were described in detail prior to behaviorism's ascension to dominance in the 1960s (Cooper, 1966). Recently, as evidenced by the numbers of books appearing on counseling, there is a rebirth of interest in educating clinicians to be a good counselor as well as a good instructor (Cooper, 1997). Unquestionably, attending to the client's perceptions of preferred treatment outcomes will further that interest.
Summary
The drive to identify and to measure preferred functional treatment outcomes to ultimately determine the efficacy of speech-language therapy programs is having an impact in how stuttering is conceived, assessed, and treated. Indications are that counseling-type therapeutic relationships will once again become the dominant form of helping relationships for those experiencing a stuttering syndrome. In the meantime, the American Speech-Language-Hearing Association's Division for Fluency and Fluency Disorders will be continuing its efforts in facilitating the development of instruments enabling us to determine the efficacy of stuttering treatment.
REFERENCES
American Speech-Language-Hearing Association (1998). National Outcomes Measurement System. Rockville, MD: Author.
American Speech-Language-Hearing Association (1998). Preferred Fluency Therapy. Division for Fluency and Fluency Disorders Newsletter, September, p. 1.
Bluemel, C. S. (1932). Primary and secondary stuttering. Quarterly Journal of Speech, 18,187-200.
Bluemel, C. S. (1957). The Riddle of Stuttering. Danville, IL: Interstate Publishing Co.
Cooper, E.B. (1966). Client-clinician relationships and concomitant factors in stuttering therapy. Journal of Speech and Hearing Research, 9, 194-207.
Cooper, E.B. (1993). Chronic perseverative stuttering syndrome: a harmful or helpful construct? American Journal of Speech-Language Pathology. September, pp. 11-15.
Cooper, E.B. (1997). Fluency Disorders. In T.A. Crowe (Ed.), Applications of counseling in speech-language pathology and audiology. Baltimore, MD: Williams and Wilkens.
Cooper, E.B. & Cooper, C.S. (1985a). Clinician attitudes toward stuttering: A decade of change (1973-1983). Journal of Fluency Disorders, 10, 19-23.
Cooper, E.B. & Cooper, C.S. (1985b). Personalized Fluency Control Therapy ' Revised. Austin, TX: ProEd.
Cooper, E.B. & Cooper, C.S. (1996). Clinician attitudes toward stuttering: Two decades of change. Journal of Fluency Disorders, 21, 119-135.
Cooper, E.B. & Cooper, C.S. (1998). Multicultural considerations in the assessment and treatment of stuttering. In D.E. Battle (Ed.), Communication disorders in mutlticultural populations (pp.247-274). Boston, MA: Butterworth-Heinemann.
Lanyon, R.I. (1967). Stuttering severity scale (SS). Journal of Speech and Hearing Research, 10, 836-843.
Manning, W.H. (1996). Clinical decision making in the diagnosis and treatment of fluency disorders. Albany, NY: Delmar Publishers.
Watson, J. B. (1987). Profiles of stutterers' affective, cognitive, and behavioral communication attitudes. Journal of Fluency Disorders, 12, 389-405.
Williams, D. (1978). Stutterers' self-ratings of reactions to speech situations. In F. Darley & D. Spreisterbach (Eds.), Diagnostic methods in speech pathology (2nd ed.). New York, NY: Harper & Row.
Woolf, G. (1967). The assessment of stuttering as struggle, avoidance, and expectancy. British Journal of Disorders of Communication. 2, 158-171.
PROTOTYPE SCALES FOR ASSESSING PREFERRED FUNCTIONAL OUTCOMES OF STUTTERING TREATMENT
CLIENT ADULT VERSION
Directions: Clients complete the instrument at the beginning of treatment, at the conclusion of therapy, and at other times during and after therapy as deemed necessary to obtain indications of changes in the disorders' affective, behavioral, and cognitive components. Read each statement and circle the word(s) on the scale that follows, what best describes your response to the statement:
Affective Components
1. I enjoy communicating.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
2. I feel comfortable as a speaker.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
3. I like the way I sound.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
4. I feel I can modify my speech in even the toughest situations.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
5. I am satisfied with my overall speech fluency.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
Behavioral Components
1. I avoid speaking situations.
1- Never
2 - Rareley
3 - Sometimes
4- Half-the-time
5 - More than half-the-time
6 - Almost always
7 - Always
2. I avoid words.
1- Never
2 - Rareley
3 - Sometimes
4- Half-the-time
5 - More than half-the-time
6 - Almost always
7 - Always
3. My speech is becoming more fluent.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
4 I use fluency-enhancing techniques or strategies.
1- Never
2 - Rareley
3 - Sometimes
4- Half-the-time
5 - More than half-the-time
6 - Almost always
7 - Always
5. When I stutter I do things such as blink my eyes, look away, and shake my head.
1- Never
2 - Rareley
3 - Sometimes
4- Half-the-time
5 - More than half-the-time
6 - Almost always
7 - Always
Cognitive Components
1. I need speech therapy.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
2. My speech negatively affects my vocational success.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
3. My speech negatively affects my social success.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
4. I understand my stuttering problem.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
5. I am doubtful if stuttering therapy can help me.
1 - Strongly Disagree
2 - Mildly Disagree
3 - Disagree
4 - Neutral
5 - Agree
6 - Mildly Agree
7 - Strongly Agree
NOTE: The above noted statements to which clients are asked to respond were randomly selected and edited from the listing of client preferred outcomes for stuttering therapy identified at the American Speech-Language-Hearing Association Division for Fluency and Fluency Disorders' Fifth Annual Leadership Conference, Marco Island, FL, April 29-May 2, 1998. The scale is presented simply as an example of how such preferred functional treatment outcomes scales might be created and is not presented as a clinically validated assessment scale.
Editorial Correspondence To:
Eugene B. Cooper, Ed.D.
1107 Fairfield Meadows Drive
Weston, FL 33327
TEL: 954-385-1422
FAX: 954-385-0965
Email: ebcooper@msn.com
August 15, 1998
