Treatment Effectiveness: Finding Value in Clinical Data. Part 1. J. Scott Yaruss, Ph.D., CCC-SLP University of Pittsburgh University of Georgia Conference on Treatment Efficacy Athens, Georgia March 20-22, 1997

Purpose To discuss the value of supplementing treatment efficacy research with studies of treatment effectiveness To present preliminary results from a retrospective clinical study evaluating the effectiveness of a treatment program for adults who stutter

But…what is the nature of the client’s complaint? An effective treatment is one that successfully addresses the client’s complaint

WHO (1980) Classification Impairment: …loss or abnormality of psychological, physiological, or anatomical structure or function… Disability: …any restriction or lack (result-ing from impairment) of ability to perform an activity in the [normal] manner… Handicap: …a disadvantage…resulting from an impairment or disability that limits or prevents fulfillment of a [normal] role

WHO and Stuttering Impairment: (one entry) –Impairment of speech fluency (§37.0): stuttering events

Disability: (dozens of possible entries) –Disability in talking (§21.0): …restriction of ability to produce verbal messages and convey meaning... –Situational coping disability (§14.2):...disturbance of ability to perform activities in specific situations...

Handicap: (several possible entries) –Social integration handicap (§4.1):…disadvantages that inhibit but not prevent participation in social activities –Occupation handicap (§4.3):…restriction of career choice because of impairment or disability

The complaint as Impairment Some treatments apparently view the client’s complaint as the stuttering event, or the impairment –Impairment: disruptions in speech, including repetitions, prolongations, blocks, reduced speaking rate, etc. Clinicians using this approach have done a good job of demonstrating the efficacy of their treatments

The complaint as Impairment, Disability, and Handicap Some treatments view the complaint as the stuttering disorder, encompassing all three aspects (I, D, and H) –Impairment: production of disfluencies, etc. –Disability: difficulty interacting with peers, using the phone, entering speaking situations, etc. –Handicap: shame, fear, anxiety that limits participation in social activities, difficulty getting the job they want, etc.

Clinicians using these types of “whole-disorder” approaches have not done a sufficient job of demonstrating treatment efficacy.

Why do people use (and recommend) these unproven treatment approaches? Because of a perceived differences in: –the nature of the client’s complaint –the responsibility of the clinician in addressing that complaint –the scope of treatment However, there are problems...

Some Problems With the whole-disorder approach, it can be difficult (but not impossible) to assess treatment efficacy –“Success” is based on the needs of the client Thus, success is variable and individualized, both between and within clients (over time) –The definition of success also varies depending upon whether you’re talking about the impairment, the disability, or the handicap

Consequences Because of the individualized nature of treatment, it can be difficult to apply traditional efficacy research methods –Most single-subject designs require that the same treatment be applied across a relatively homogenous set of subjects –Group designs are not as well suited to assessing efficacy, but they also require homogeneity across subjects and treatments

Some Major Problems Many whole-disorder treatments are not well-grounded in theory, so it is difficult to define a framework for assessing treatment efficacy Treatment variables in these approaches are not sufficiently operationalized to permit rigorous study (at present)

More Consequences Before we can meaningfully assess the efficacy of whole-disorder treatments, we must: –Describe the treatment programs in detail –Operationalize the supposed outcomes of these treatments at all 3 levels (I, D, & H) –Determine whether clients report any benefits that can be associated with treatment We are still very much at the beginning in assessing whole-disorder treatments

A first step toward efficacy... One way to begin asking whether whole- disorder treatment is effective is to study clients who already received treatment –“Documentation of Clinical Practice” Such studies can help prepare us for future, more rigorous studies of the efficacy of whole-disorder treatments –Evaluating potential benefits of treatment –Defining treatment variables for further study