2003 IFA Congress: Montreal, Canada

Swedish Comprehensive Stuttering Program - Evaluation Two To Four Years After Treatment

Helena Foarne-Wastlund1, 2

1Department of Disability Research, The University of Orebro, Sweden
2Waslund Speech Clinic, BOA Prosodi AB, Orebro, Sweden, Sigillgaian 167SE 703 78 Orebro, Sweden

SUMMARY

The Comprehensive Stuttering Program was introduced to Sweden through a project in 1997- 2000, which included a pilot study of nine stutterers. Two years after therapy each participant was evaluated over the phone by a third person, analysing their spontaneous speech, oral reading; dysfluencies and overall impression of Stuttering Severity. They were asked to evaluate their current communication skills, rate well- being and expectations on a 0 -5 scale of positive statements concerning communication. Evaluation continues. In this section the outcome of the 2 to 4-year follow-up of 33 participants will be presented.

  1. Introduction
Evaluation of treatment efficacy is a difficult task but also an interesting challenge. The combination of both quantitative and qualitative data, and objective and subjective measurements, is outstanding and needs continuous development and improvements. Bloodstein (1981) made the following statement of criterions that should be fulfilled before a treatment should be regarded as successful.

A treatment being provided to persons that differ in terms of range of dysfluencies: very mild to very severe stuttering, should be regarded as successful when their speech is measured objectively during various occasions between 1-2 years after therapy. Moreover, the speech has to sound natural. Deviant attitudes to speech has to be normalised, and the results should not be overloaded with too many drop-outs from treatment or too many spontaneous relapses. Finally, the efficiency of treatment should be shown to be the same, when it is used by different speech pathologists at different clinics, as a part of their ongoing clinical practise.

The first two requirements regarding objective measurements of fluency and perceptual ratings of speech naturalness can be met. The following three statements concerning attitudes to speech , number of dropouts and spontaneous relapses should be a natural part of every kind of evaluation. But the last statement could involve some difficulties.

The current definitions from WHO of impairment and handicap indicate that individual ratings from the person concerned, personal feelings of cure, recovery or relapse should be an important fact in assessing outcome of therapy. Moreover, different experiences or intuitions over the years indicates that the feeling of security, confidence and pleasure in clinical work provided by the individual clinician, might be essential for a successful outcome of therapy, as much as the personal level of motivation in training for the individual person who stutters. Though, all “experiences” or intuitions does not have to be correct, but maybe we can trust on the simple common sense, telling us that probably there are individual differences between clinicians as between clients. A study detecting the efficiency of treatment to be the same, when used by different speech pathologists at different clinics, as a part of their ongoing clinical practise, should be a world-wide study at-large.

The question is whether it is necessary to do, or if it is good enough with the current Studies from different institutions indicating the percentage of successful perceptual ratings and I 90 Theory, research and therapy in fluency disorders the percentage of successful feelings of self-esteem in communicative situations, moreover the percentage of dropouts and relapses.

The aim of this follow up study is to fairly correspond to the first criterioa of Bloodstein:
  1. Clients with a pre-treatment range of dysfluencies between very mild to very severe stuttering.
  2. Objective measurement of fluency between 1-2 years after therapy.
  3. Indications of perceptual speech naturalness.
  4. Normalised attitudes to speech.
  5. Dropouts.
  6. Spontaneous relapses.
  1. Method
Evaluation, questionnaire

The evaluation for each individual two years after treatment consisted of the following:

A sudden unexpected phonecall from a third person. Tape-recorded interview and oral reading to each client, followed by a questionnaire developed from eight statements in the first pilot study, a questionnaire concerning communicative skills and self-esteem. (Forne-Wastlund, 2001) Interview of the personal outcome of therapy.

Due to economic and practical reasons, the follow up phone call procedure in this new study was carried out at the same time, in June 2003. The criterions were the Clients in the interval of between 4 to 2 years after treatment. In this sense this study shows more long-term results than was stipulated in the very beginning. The previous 9 clients of the former study (Forne- Wastlund, 2001) were excluded. A sudden unexpected phone call was performed by a 18 year old girl, a high school student not particularly familiar with people who stutter. On the other hand a skilled ear in the sense of language skills. A videotape presenting a random selection of PWS before and after treatment and follow ups from the previous study was provided to her for “calibrating “ her own cars before making the interviews over the phone. Tape-recorded interview and oral reading of each client, followed by a more elaborated questionnaire reflecting the suggestions of Bloodstein (1981) and Andrews et al. (1983), consisting of individual rating of 13 positive statements concerning sense of fluency, self -esteem in communicative situations, motivating factors and impressions of benefits out of treatment.

Participants and dropouts

During the period 1999 - 2001 in all 108 people who stutter (PWS) requested treatment with the Comprehensive Stuttering Program at the my private Clinic. Due to resistance from Speech- language pathologists only 37 clients of those were able to attend treatment. 23 payed by society by referrals from medical doctors and two from one Speech Language pathologist. The remaining 12 were paying privately. In all 37 clients completed the intensive 3 week program. During the period 2 months - 6 months four clients dropped out from the Maintenance program and follow up visits. The main reasons for dropouts were lack of motivation in using their speech targets, and preferring home-training practise.

Thus four out of 37 i.e. 9 % were dropouts from the maintenance period of treatment. The remaining 33 who had completed their 1 year-of treatment were in this study. Seven of the clients could not be reached over the phone; two had emigrated to the US and Australia, two had moved away and not registered at new addresses, three could not be reached at home during the follow up period due to summer vacations. In all 25 out of 33 were participating. That means 76% participating, which corresponds to a good level of participation. According to the Swedish bureau of Statistics, a participation level of more than 65% provides a good sample for statistic analyses.

Range of dysfluencie: methodology

All collected data, the rates of dysfluencies before and after intense treatment, were estimated by third persons. In the former pilot study (Forne-Wastlund,, 2000), the rates were measured by a listener group of 16 persons analysing speech samples of 2 minutes video recordings, spontaneous speech and oral reading, presented in random order; pre-post and follow up treatments according to the parameters of the SSI scale (Riley, 1994). One of the persons from this listeners panel, representing the main-stream values, was chosen to perform the analyses of the video speech samples from the 25 clients in this study concerning their pre- and post treatment rate of fluency. That is: rates of stuttering, duration, concomittant behaviours and overall rating of stuttering severity. The speech samples were represented in random order making it unknown for the listener whether it was a judgement of pre- or post intense treatment result.

In order to check the interjudgement reliability of the third person making the follow up interviews over the phone, the author as investigator made an analyses of the tapes independently, not being aware of the results of the other judge. A comparison of the main scores of the independent judgements shows no significant difference; Mean scores overall impression of stuttering severity: other judge: 1,62 author: 1,54.

Thus, the 25 participators in this study were found to have a pre-treatment range of dysfluencies between very mild to very severe stuttering (See Table 1) The interjudgement reliability is more than acceptable. That shows the the author was qualified for future accounts and analyses of the Stuttering Severity Instrument, the same procedure as overseas collegues perform in their daily clinical research practise.

  1. Results
Objective measurements of fluency stuttering severity

Pre-treatment: The main scores of overall impression of stuttering severity, consisting of the main score between spontaneous speech and oral reading reveils the following:
Range 0-1 Normal dysfluencies, no stuttering: 4
Range 1-2 Very mild stuttering: 5
Range 2-3 Mild stuttering: 5
Range 3-4 Moderate stuttering: 5
Range 4-5 Severe stuttering: 5
Range 5 - Very severe stuttering: 1

Mean values for the whole group: 2,6

Post-treatment: The mean values of overall impression of stuttering severity, consisting of the mean values between spontaneous speech and oral reading reveils the following:
Range 0-1 Normal dysfluencies, no stuttering: 12
Range 1-2 Very mild stuttering: 4
Range 2-3 Mild stuttering: 5
Range 3-4 Moderate stuttering: 3
Range 4-5 Severe stuttering: 0
Range 5 - Very severe stuttering: 1

Mean values for the Whole group: 1,5


Follow-up 2-4 years after: The mean values of overall impression of stuttering severity, consisting of the mean values between spontaneous speech and oral reading reveils the following:
Range 0-1 Normal dysfluencies, no stuttering: 12
Range 1-2 Very mild stuttering: 5
Range 2-3 Mild stuttering: 2
Range 3-4 Moderate stuttering: 0
Range 4-5 Severe stuttering: 3
Range 5 - Very severe stuttering: 3

Mean values for the whole group: 1,6

The mean values of the whole group indicates a significant difference, improvement of speech

during the intense treatment, a result that persists at the follow up 2-4 years after treatment. The individual results of most of the severe-very severe stutterers indicates a variety between severe to very severe stuttering. There seems to be an over - representation of relapses in this group of severe stutterers; 4 out of 6 shows during treatment difficulties in obtaining a level higher than mild stuttering , one with no improvement at all. The remaining two representing extraordinary results during treatment and afterwards, judged as no stuttering or very mild post-treatment and follow up.

Relapses

Seven out of 25 ( 27 %) had spontaneously relapsed at the follow up survey 2 to 4 years after treatment. The relapses seems to be unrelated to period posttreatment. It seems to be more linked to the achieved level of fluency during intensive treatment. In this sense the severe or very severe stutterers seem to do less well.

Indications of perceptual speech naturalness.

Regarding speech naturalness, there are only some spontaneous comments from the two investigators. Their comments shows clear preferences for speech target monitored speech rather than stuttered speech. Comments from the investigator that performed the pre-post evaluations indicate a development of a more natural speech style at the follow up study, with comments from the second investigator solely concerning stuttered speech.

Self-evaluations: Personal evaluations of outcome of treatment and sense of communicative abilities including normalised attitudes to speech.
The following 13 statements were scored 0-5 during “the third- person- follow- up- survey over the phone:

  1. The CSP treatment with partly computer training has resulted in more fluent speech of today.
  2. My opinion is that my level of fluency of today is satisfying
  3. Using the Speech targets is nowadays a natural habit.
  4. My blocks does not feel as exhausting and tedious as before.
  5. I can take a better control in communicating with others
  6. I have found a realistic level of expectations of my Speech
  7. I am a nice person that stutters sometimes
  8. I am satisfied with my own efforts of training to improve my Speech
  9. My internal and obtained experiences and knowledge has been important for my long term results.
  10. My personality and level of motivation has been important for my long term results.
  11. The Clinical experience of the treatment procedure and knowledge of the Clinician has been important for my long term results.
  12. The personality and devotion of the Clinician has been important for my long term results.
  13. I am satisfied with the Stuttering treatment I have received.
Evaluation scores by the Individual: Mean values
Range 0 - 0,8: Very satisfied communicative skills and/or treatment
Range 0,9 - 1,7: Satisfied communicative skills and/or treatment
Range 1,8 ~ 2,5: “Quite satisfied communicative skills and/or treatment
Range 2,6 - 3,4: Quite unsatisfied communicative skills and/or treatment
Range 3,5 - 4,2: Unsatisfied communicative skills and/or treatment
Range 4,3 - 5,0: Very unsatisfied communicative skills and/or treatment

Results of the whole group: Mean values for each question
  1. Improved fluency: 1,44
  2. Sufficient fluency: 1,84
  3. Speech targets natural: 2,36
  4. Blocks less exhausting: 1,32
  5. Improved control: 1,64
  6. Realistic expectations speech: 1,6
  7. Nice and stutters sometimes: 1,88
  8. Satisfied with my own training efforts: 2,48
  9. Importance of my personal experiences; 1,24
  10. Importance of my personality, motivation; 1,16
  11. Importance of Clinicians’ clinical experiences and knowledge; 0,92
  12. Importance of Clinicians’ personality and devotion; 1,0
  13. Satisfied with treatment; 0,68
Comments: All mean values less than 2.6 are positive values. The mean values are all in the range between very satisfied to quite satisfied. Though individual differences; the level of satisfaction seems in most cases being correlated to achievement of increased fluency and a sense of self esteem and confidence during intense treatment and the maintenance phase. Ten clients are in the range less than 0.8, very satisfied with their communication and fluency, and treatment. Three clients were quite unsatisfied, one was unsatisfied with their level of communication and personal outcome of treatment. They had pre-treatment severe to very severe stuttering, one moderate. The feature they had in common was less improvement in fluency during intensive treatment than the others. All participants indicated some satisfaction with treatment (question 13); 12 very satisfied, 9 satisfied and 4 quite satisfied.

Summary

The result of this follow up study shows that 12 clients out of 25 (50%) were regarded as non stutterers by the listeners, and another 7 (29%) as very mild/mild stutterers. 68% showed gains from treatment, while the remaining 32% relapsed orshowed minor improvements. The obtained level of fluency seems to be the highest predictor for increased self esteem in communicative situations, as indicated in the questionnaires. The clinicians’ clinical experiences and knowledge seems to be very important to the outcome of treatment, as to a certain extent are personality and devotion in therapy. The clients’ own personality and level of motivation is also indicated as quite important for the outcome of treatment, and to a lesser degree the clients, own knowledge and personal experiences. Less favourable is the satisfaction with their own training efforts. Some clients indicated dissatisfaction with their own efforts, specially the spontaneous relapsed clients. For most Clients the use of speech targets still felt a bit unnatural, but the benefits exceed the costs. However, all participators found the treatment mostly positive and worth while.

  1. Discussion
It is interesting to compare the findings with other clinical studies: In this study 68% showed gains from treatment. This compares with similar results from other studies. Franken (1997) reports 66% satisfied with their speech pattern two years after treatment. Webster reports 70% satisfied two years after treatment. Forne-Wastlund (2001) reports 63% are satisfied in the previous pilot study. In this study four out of 37 i.e 9 % were dropouts from the maintenance period of treatment It is difficult to estimate the other seven clients as the survey was done on a limited time period. The I94 Th.eory, research and therapy in fluency disorders

former pilot study (Forne-Wastlund, 2001) reports a dropout level of 20%. Franken reports 23% dropouts. For follow up surveys of two years, the literature indicates a dropout level of 33 % as acceptable. In other words; this kind of treatment should be regarded as corresponding to most of the demands of Bloodstein. The comparative data from the other studies indicate similar results. In other words, the data from smaller and larger scale studies are comparable.

It would be unfair to dispute a book written some 20 years back in time (Bloodstein, 1981). But still today among speech language pathologists in Northern Europe, there is this vast therapeutic tradition in stuttering therapy that opposes scientific clinical evaluation. It causes this tendency of too high demands - a dichotomy between demands of total cure or doing nothing - of the very few existing clinical evaluations, and doubt that fluency can be maintained in the long-term. In respect of the very severe and severe stutterers it would be appropriate to have a reasonable level of expectancy of outcome of treatment from clinicians. The improvement of a client from very severe stuttering to moderate should be regarded with respect. It can result in a tremendous improvement in communication. In voice training and research one would not think of having the same expectations of voice quality from a person with alaryngeal speech as of a person with slight dysphonia. There is a nice level called improvement of speech. Let us use it more often in stuttering therapy, specially in relation to the severe to very severe PWS. The results of this study indicate that they generally need much more time and consistency in feed-back training and home-training to make improvements in their speech.

Finally, I and my clients would like to thank you overseas collegues that devote your time getting involved in the professional debate. Speech-language pathology of Old Europe needs you more than ever to overcome this state of communication disorders where attempts for a fruitful debate seems to be lost in a blind alley.

References
Alm, P. (1995) Stamning. Natur och kultui, Bords, Sweden

Andrews, G., Craig, A., Feyer, A.M., Hoddinot, S., Howie, P.& Neilson, M. (1983). Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorder; 48, 226-246.

Bloodstein, O. (1981) A handbook on stuttering (3rd ed.). Chicago, IL: National Easter Seal Society,

Forne-Wastlund, H. (2000) The Swedish Comprehensive Stuttering Treatment Program. Proceedings from the 31” world Congress of Fluency Disorders, Nijrneegen University Press

Forne-Waistlund, H. (2001) Datorbaseradtaltréining for personer som stammar, Hjailpmedelsinstitutet, Stockholm, Sweden

Franken, M-C. (1997) Evaluation of stuttering therapy. Development of tools for measuring speech quality. Disertation - Katholieke Universiteit Nijmeegen, Netherlands.

Riley, G.D. (1994) Stuttering Severity Instrument for children and adults. (3rd ed. ). Examiners manual and picture plates. Austin, TX: Pro-Ed.

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